subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
17,753
| 140,298
|
19308
|
Discharge summary
|
report
|
Admission Date: [**2169-1-24**] Discharge Date: [**2169-2-9**]
Date of Birth: [**2122-3-2**] Sex: F
Service:
HI[**Last Name (STitle) 2710**]OF THE PRESENT ILLNESS: This 46-year-old white
female has a history of depression and anxiety and recently
noticed increased frequency of fluttering or palpitations. A
workup initiated by her PCP included an echocardiogram on
[**2168-12-29**] which revealed a proximal ascending aortic aneurysm
measuring 5.5 cm with no dissection. The aortic root
measured 4.1 cm. She had moderate AI, mild MR, trace PR, and
a normal EF. She was referred to Dr. [**Last Name (Prefixes) **] for Bentall
procedure. She underwent a preoperative cardiac
catheterization on [**2169-1-6**] which revealed normal coronary
arteries.
PAST MEDICAL HISTORY:
1. History of depression and anxiety.
2. History of ascending aortic aneurysm.
3. History of kidney stones.
4. History of polycystic ovaries in the [**2144**].
5. Status post left knee surgery.
6. Status post lumpectomy which was benign.
SOCIAL HISTORY: She does not smoke cigarettes. She does not
drink alcohol and is married.
ALLERGIES: She gets vomiting from anesthesia. She has no
known drug allergies.
ADMISSION MEDICATIONS:
1. Celexa 20 mg p.o. q.d.
2. Klonopin 0.7 mg p.o. q.h.s.
3. Multivitamin one q.d.
4. Calcium.
5. Colace.
6. Naproxen p.r.n.
REVIEW OF SYSTEMS: Significant for palpitations.
PHYSICAL EXAMINATION ON ADMISSION: General: She is a
well-developed, well-nourished white female in no apparent
distress. Vital signs: Stable. Afebrile. HEENT:
Normocephalic, atraumatic. The extraocular movements were
intact. The oropharynx was benign. The neck was supple.
Full range of motion. No lymphadenopathy or thyromegaly.
Carotids were 2+ and equal bilaterally without bruits.
Lungs: Clear to auscultation and percussion. Cardiovascular:
Regular rate and rhythm, normal S1, S2, no murmurs, rubs, or
gallops. Abdomen: Soft, nontender with positive bowel
sounds. No masses or hepatosplenomegaly. Extremities: No
clubbing, cyanosis or edema. Pulses were 2+ and equal
bilaterally throughout. Neurologic: Nonfocal.
HOSPITAL COURSE: On [**2169-1-24**], she underwent a Bentall
procedure with a [**Street Address(2) 11688**]. [**Male First Name (un) 923**] mechanical AV composite graft
and hemiarch replacement and a CABG times one with saphenous
vein graft to the RCA. Her cross clamp time was 252 minutes,
total bypass time 357 minutes, and she had circ arrest of 13
minutes.
She was transferred to the CSRU with an open chest due to RV
failure and she was on epinephrine. On her postoperative
night, she had postoperative bleeding which required FFP and
platelets. Her cardiac index was around 1.8. She was on
Amiodarone. She was paralyzed on ...................., epi,
and Neo. She was also on propofol, insulin, and Fentanyl.
She was also seen by the heart failure team.
On postoperative day number two, she remained sedated and
intubated and her epi was weaned slightly. She had her chest
closed on postoperative day number two. She tolerated that
procedure and still remained on Amiodarone,
...................., and epi, milrinone, Fentanyl, insulin,
and midazolam drips. She remained paralyzed.
On postoperative day number six, she had her mediastinal
chest tubes discontinued. She had her epi off. She still
had milrinone. She was also extubated on postoperative day
number five. She continued to require aggressive diuresis
and aggressive respiratory therapy. She slowly improved.
She eventually weaned off her epi and milrinone on
postoperative day number eight and had her Swan discontinued.
She had her pleural tubes discontinued on day number nine and
ten. She was transferred to the floor on postoperative day
number ten. She was transferred to the floor in stable
condition. She continued to be anticoagulated with heparin
and Coumadin. She did have a bump in her white count which
came down on Levaquin. She also had a little drainage from
the superior aspect of her sternal wound which resolved and
was being painted with Betadine. She did have a few runs of
self-limited A fib, and tolerated that well. She remains in
sinus rhythm.
On postoperative day number 16 and 14, she was discharged to
home in stable condition.
Her laboratories on discharge revealed a white count of
12,600, hematocrit 31.3, platelets 675,000. Sodium 138,
potassium 4.4, chloride 101, C02 31, BUN 19, creatinine 0.7,
blood sugar 79. Her PT is 19.4 with an INR of 2.5 and a PTT
of 31.7.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. b.i.d. times ten days.
2. Colace 100 mg p.o. b.i.d.
3. Aspirin 81 mg p.o. q.d.
4. Percocet one to two p.o. q. four to six hours p.r.n.
pain.
5. Levaquin 500 mg p.o. q.d. times two weeks.
6. Celexa 20 mg p.o. q.d.
7. Klonopin 0.5 mg p.o. q.h.s.
8. Coumadin 5 mg p.o. tonight to be checked by Dr.
[**Last Name (STitle) 46008**] tomorrow.
FO[**Last Name (STitle) **]P: She will be followed by the [**Hospital3 **] at Dr.[**Name (NI) 52581**] office and by Dr. [**Last Name (Prefixes) **] in
three weeks.
DISCHARGE DIAGNOSIS: Ascending aortic aneurysm.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2169-2-9**] 06:16
T: [**2169-2-9**] 19:36
JOB#: [**Job Number 52582**]
|
[
"429.9",
"424.1",
"E878.2",
"997.1",
"998.11",
"427.31",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"99.02",
"34.79",
"38.45",
"36.11",
"35.22",
"96.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4581, 5113
|
5135, 5425
|
2181, 4558
|
1242, 1373
|
1393, 1445
|
1460, 2163
|
798, 1043
|
1060, 1219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,360
| 119,192
|
35190
|
Discharge summary
|
report
|
Admission Date: [**2118-10-7**] Discharge Date: [**2118-10-14**]
Date of Birth: [**2047-4-26**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2118-10-8**]: ORIF Left tibia fracture
History of Present Illness:
Mr. [**Known lastname 12056**] is a 71 year old man who had a fall at home while
intoxicated on [**2118-10-6**]. He was taken to [**Hospital1 **] [**Location (un) 620**] and found
to have a tibia fracture. He was admitted and evaluated. He
was transferred to the [**Hospital1 18**] on [**2118-10-7**] for further evaluation.
Past Medical History:
Etoh abuse
HTN
GERD
Gout
Ezcema
Social History:
etoh abuse (daily, ?amt), no tob, no drugs. Lives with wife.
Family History:
NC
Physical Exam:
Upon admission
Alert
HEENT: small linear lac post head
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: Lower leg ext rotated. LE ecchymosis over proximal
tibia with avusion wounds, but no open fracture. Compartments
soft, SILT distally, + DP/PT pulses.
Pertinent Results:
[**2118-10-8**] 02:10AM BLOOD WBC-10.8 RBC-2.77* Hgb-9.1* Hct-26.6*
MCV-96 MCH-32.7* MCHC-34.1 RDW-14.5 Plt Ct-168
[**2118-10-8**] 02:10AM BLOOD PT-13.9* PTT-30.4 INR(PT)-1.2*
[**2118-10-8**] 02:10AM BLOOD Glucose-138* UreaN-20 Creat-1.1 Na-132*
K-4.1 Cl-101 HCO3-28 AnGap-7*
[**2118-10-8**] 02:10AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.1 Iron-23*
[**2118-10-13**] 06:10AM BLOOD WBC-8.0 RBC-3.05* Hgb-9.8* Hct-28.6*
MCV-94 MCH-32.2* MCHC-34.3 RDW-14.8 Plt Ct-237
[**2118-10-14**] 06:10AM BLOOD Hct-26.9*
[**2118-10-13**] 06:10AM BLOOD Glucose-66* UreaN-17 Creat-0.9 Na-137
K-3.8 Cl-100 HCO3-25 AnGap-16
[**2118-10-9**] 10:10AM BLOOD ALT-26 AST-55* LD(LDH)-208 AlkPhos-159*
TotBili-0.7
[**2118-10-13**] 06:10AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8
[**2118-10-8**] 02:10AM BLOOD calTIBC-168* Ferritn-276 TRF-129*
Imaging:
Left tibia: prox tibial/fib displaced fracture
NCHCT: negative
CT c-spine: negative
Left tibia s/p ORIF: hardware in good position
Neck CT: 1. Probable edema in the posterior laryngeal wall at
the level of the false and true vocal cords. 2. Left carotid
bulb plaque with approximately moderate stenosis. If indicated,
this may be further quantified by carotid ultrasound. 3.
Opacities at the lung apices. Please refer to the concurrent
chest CT report for further detail.
CT chest w/ w/o contrast:
1. Multifocal ground-glass opacities most likely of infectious
etiology.
Other considerations are given, and follow-up to resolution is
recommended to exclude BAC. 2. Bilateral pleural effusions and
associated atelectasis. No mediastinal hematoma. 3. Acute left
5th rib fracture, with multiple older bilateral fractures. 4.
Fatty infiltration of the liver. 5. Coronary artery
calcifications.
CXR [**10-9**]: As compared to the previous examination of [**10-8**], [**2117**], the endotracheal tube projects with its tip 3 cm above
the carina. There has been interval insertion of a nasogastric
tube which is in correct position. The size of the cardiac
silhouette is unchanged, also unchanged is the extent of the
retrocardiac atelectasis. Unchanged mild bilateral apical
pleural thickening and mild left lateral pleural thickening.
There is no evidence of overhydration and no evidence of
interval appearance of focal parenchymal opacities suggestive of
pneumonia.
Bilat upper ext LENIs: negative for DVT.
CXR pa/lat: Interval worsening of left retrocardiac opacity
might represent evolution of pneumonia, otherwise, unchanged.
Brief Hospital Course:
Mr. [**Known lastname 12056**] was a direct admission for [**Hospital1 **] [**Location (un) 620**] to the
orthopaedic surgery service.
1. Tib fracture:
He was admitted, evaluated, consented, and prepped for surgery
for displaced left proximal tibia/fibula fracture. On [**2118-10-8**]
he was taken to the operating room and underwent an ORIF of his
tibia fracture with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 101**] plate. He tolerated the procedure
well, was extubated, and transferred to the recovery room. He
was seen by physical therapy to improve his strength and
mobility. His pain was well controlled. His incisions and
wounds did not show any hard signs for infection. He was placed
in an aircast boot and instructed to partial weight bear on his
LLE until f/u in [**Hospital 80304**] clinic 2 weeks from now.
2. Post op respiratory distress:
In the recovery room he developed neck swelling with respiratory
distress and was reintubated at the bedside. He was transferred
to the TICU for further care and monitoring. There was no h/o
of any obvious trauma or difficulty during ET tube placement.
He was noted to have fat pads in his neck but no obvious source
of compromise to his airway. ENT and trauma were consulted. He
was empirically started on Decadron and unasyn x 1 dose. A CT
of his neck with and without contrast showed mild laryngeal
edema. Incidentally a left carotid bulb plaque with
approximately moderate stenosis was seen. A chest CT showed
showed multifocal ground-glass opacities most likely of
infectious etiology but BAC could not be excluded. He did not
show any other symptoms and signs of PNA and therefore will
require radiographic f/u as an outpt basis to ensure resolution
of findings. On [**2118-10-10**] he was extubated without difficulty
and his Decadron was stopped. On [**2118-10-11**] he was transferred to
the floor from the TICU. The etiology of his laryngeal edema
and respiratory distress was never clearly elucidated although
the most likely and harmful causes were adequately ruled out.
He will not require ENT follow up.
2. ETOH withdrawal:
Patient has a h/o etoh abuse. On admission he was given folate,
thiamine, mvi, and started on a valium per CIWA scale.
Postoperatively in the TSICU he continued to received ativan and
libium per CIWA. He also had episodes of tachycardia and high
blood pressure adequately controlled with standing clonidine,
hydralazine PRN, and lopressor PRN. Agitation was controlled
with soft restraints and haldol PRN with good effect. A
medicine consult was obtained to help manage his benzo and
librium tapers. By the day of discharge he was tapered off
valium, librium, ativan and clonidine. He was A&Ox3 by the day
of discharge without agitation. Please note that his home
regimen of campral for detox was held during this hospital stay.
It is advised that he discuss restarting home dose with if
campral with PCP following discharge from rehab.
3. Anemia:
Patient had blood loss in addition to anemia of chronic disease
based on iron studies. On [**2118-10-8**] he was transfused with
2units of packed red blood cells. His hematocrit was stable
prior to discharge.
4. CT chest incidental findings:
Patient found to have small bilateral pleural effusions and
ground glass opacities in the apices. Patient does not
clinically have PNA and was therefore not treated with
antibiotics. Medicine agreed with plan. A CXR the day of
discharge again showed a retrocardiac opacity, atelectasis vs
early infiltrates. He was instructed to call or go to the ED if
he develops SOB, increased chest discomfort, abdominal pain,
cough, and/or fevers/chills/sweats. He will need f/u with his
PCP to consider further imaging, specifically to r/o BAC. His
discharge summary was faxed to his primary care physician.
5. Left carotid bulb plaque:
Incidentally found on CT neck. No symptoms. He was instructed
to f/u with his PCP for further [**Name Initial (PRE) **]/u as needed.
Medications on Admission:
Prilosec 40mg daily
Toprol XL 100mg daily
lisinopril 5mg daily
Campral 666mg TID
doxepin 200mg qHS
allopurinol 100 qHS
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Doxepin 25 mg Capsule Sig: Eight (8) Capsule PO HS (at
bedtime).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 3 weeks.
11. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Insulin Regular Human 100 unit/mL Solution Sig: per SS
Injection ASDIR (AS DIRECTED).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for HTN.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**]
Discharge Diagnosis:
s/p fall
Left tibia fracture
ETOH withdrawal
Acute blood loss anemia
Left carotid artery stenosis
Discharge Condition:
Stable
Discharge Instructions:
Continue to be partial weight bearing on your left leg
Continue your lovenox injections as instructed
Please take all medications as prescribed. Please discuss
restarting campral with your primary care physician.
If you have any increased redness, drainge, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Physical Therapy:
Activity: As tolerated
Left lower extremity: Partial weight bearing
Treatments Frequency:
Staples/sutures out 14 days after surgery or at follow up
appointment.
Dry dressing daily or as needed for drainge or comfort.
Xeroform to tibial abrasion wounds until dry.
Assess for s/s of infection.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics on
Thursday [**2118-10-20**]. Please call [**Telephone/Fax (1) 1228**] to schedule that
appointment.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**12-15**] weeks.
You can discuss restarting campral at that time.
Completed by:[**2118-10-14**]
|
[
"807.01",
"V43.64",
"285.1",
"511.9",
"784.2",
"286.9",
"530.81",
"458.29",
"291.81",
"E880.9",
"274.9",
"823.02",
"478.6",
"401.9",
"303.91",
"433.10",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"99.04",
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
9029, 9079
|
3713, 7705
|
329, 374
|
9221, 9230
|
1244, 3690
|
9977, 10370
|
881, 885
|
7874, 9006
|
9100, 9200
|
7731, 7851
|
9254, 9637
|
900, 1225
|
9655, 9727
|
9749, 9954
|
281, 291
|
402, 731
|
753, 786
|
802, 865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,413
| 114,640
|
51717+59376
|
Discharge summary
|
report+addendum
|
Admission Date: [**2109-7-16**] Discharge Date: [**2109-7-26**]
Date of Birth: [**2041-2-25**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 68-year-old male
patient with a past medical history of hyperthyroidism,
hypercholesterolemia, borderline hypertension, and diabetes,
who presented with worsening exertional chest pain. He
states he has been having intermittent chest pain, however on
the night prior to admission, he had 10/10 chest pain
radiating to his neck with diaphoresis that dissipated with
aspirin and some rest. He presented to the Emergency
Department.
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2.
Borderline hypertension. 3. Diet-controlled diabetes
mellitus. 4. Hypothyroidism.
PAST SURGICAL HISTORY: Total knee replacement seven years
ago.
MEDICATIONS ON ADMISSION: 1. Levoxyl 150 mg p.o. q.d. 2.
Viagra 100 mg p.o. p.r.n. 3. Aspirin, occasional.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married, smoked one pack of
cigarettes per day for 20 years but quit 30 years ago, and
rare ETOH intake.
HOSPITAL COURSE: The patient was subsequently admitted to
the cardiology service and was taken to cardiac
catheterization, which revealed three-vessel coronary artery
disease, as well as a left ventricular ejection fraction of
45%. Cardiothoracic surgery consultation was obtained at
that time. The patient subsequently had persistent chest
pain on medical management and was taken back to the Cardiac
Catheterization Laboratory for placement of intra-aortic
balloon pump. This was done on [**2109-7-17**]. The patient was
then admitted to the coronary care unit, remained on an
intra-aortic balloon pump, and was taken to the operating
room on [**2109-7-18**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], where he underwent
coronary artery bypass grafting x 4. He had a left internal
mammary artery to the left anterior descending coronary
artery, saphenous vein graft to the posterior descending
coronary artery, saphenous vein to the obtuse marginal and
saphenous vein to the diagonal. Postoperatively the patient
was transported from the operating room to the cardiac
surgery recovery unit in stable condition. He was in normal
sinus rhythm with a heart rate in the 80s. He was on
propofol, Neo-Synephrine and IV insulin drips. On the night
of surgery the patient was weaned from mechanical ventilation
and subsequently extubated to a nasal cannula without any
difficulty. He remains on IV nitroglycerin drip. His other
drips had been discontinued.
On the morning of postoperative day one, it was noted that
his intra-aortic balloon pump had blood in the tubing and was
removed emergently at the bedside in the cardiac surgery
recovery unit with no difficulty. On postoperative day two
the patient was noted to be in atrial flutter with a
ventricular response of about 150. The patient had no
symptoms or complaints at the time. He had been on oral
Lopressor at that time and was given IV Lopressor without any
decrease in his ventricular heart rate. For that reason he
was started on IV diltiazem drip at 15 mg per hour. There
was still a fair amount of difficulty controlling his rate.
He remained on diltiazem drip until the morning of
postoperative day three, when he was placed on IV amiodarone,
however he remained in atrial flutter with a ventricular rate
of about 100. The patient remained in the cardiac surgery
recovery unit and on postoperative day four, was still in
atrial flutter, remained on amiodarone. His diltiazem drip
had been restarted and was remaining at 15 mg an hour. At
that time he was begun on IV heparin since he had remained in
atrial flutter for approximately 36 hours at that time, and
Coumadin was initiated.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Clinic consultation was obtained also on
postoperative day four, since the patient had a questionable
history of diabetes mellitus, but had never received any
treatment for such. He did require a fair amount of insulin
infusion in his postoperative course in the cardiac surgery
recovery unit. He was initially started by the [**Hospital **] Clinic
on NPH Insulin b.i.d. with sliding scale of Regular Insulin.
On postoperative day five, [**2109-7-23**], the patient remained in
atrial flutter with variable ventricular response, anywhere
from 100 to 150 per minute. His room air oxygen saturation
was 96%. His blood pressure was 140s/60s, and was otherwise
hemodynamically stable. The patient received an extra IV
dose of amiodarone that morning and was electrically
cardioverted in the cardiac surgery recovery unit, using 150
joules and one shock that converted him to normal sinus
rhythm in the 70s at that time. The patient tolerated the
procedure well and had not had any subsequent atrial
fibrillation since the time of his cardioversion on
postoperative day five. The patient was converted from IV
amiodarone to oral amiodarone. He was subsequently
transferred out of the cardiac surgery recovery unit to the
telemetry floor on postoperative day six, [**2109-7-24**], and has
remained in good condition since that time. The patient's
epicardial pacing wires were removed. He was continued on
diuretics, beta blockers and amiodarone. The patient was
also started on Coumadin, which has been increased. His
heparin infusion had been discontinued when his INR was 1.8.
He is in good condition today on postoperative day eight and
ready to be discharged home.
CONDITION ON DISCHARGE: Good.
DISPOSITION: He is to be discharged home with visiting nurse
to follow up for postoperative wound checks, vital signs
monitoring, Coumadin teaching and diabetes teaching as well.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. b.i.d. x 7 days.
2. Potassium chloride 20 mEq p.o. b.i.d. x 7 days.
3. Coumadin 2 mg p.o. today, [**2109-7-27**], [**2109-7-28**] and he is to
have an INR checked on [**2109-7-29**], Coumadin subsequently to be
dosed by Dr.[**Name (NI) 5786**] office with a target INR of 2 to 2.5.
4. Colace 100 mg p.o. b.i.d.
5. Aspirin 81 mg p.o. q.d.
6. Percocet 5/325, one p.o. q. 4 hours p.r.n. pain.
7. Protonix 40 mg p.o. q.d.
8. Synthroid 150 mcg p.o. q.d.
9. Metformin 500 mg p.o. b.i.d.
10. Lopressor 50 mg p.o. b.i.d.
11. Amiodarone 400 mg p.o. q.d. x 1 month then to be dosed
per Dr.[**Name (NI) 5786**] recommendations.
FOLLOW-UP PLANS: The patient is to follow up with Dr. [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**] within the next two weeks. He is to call his assistant
for an appointment at [**Telephone/Fax (1) 920**]. The patient is to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], cardiac surgeon, in six weeks.
The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], his
primary care physician. [**Name10 (NameIs) **] patient is also to follow up
with the [**Hospital **] Clinic as previously instructed by the [**Hospital **]
Clinic.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting.
2. Atrial fibrillation status post cardioversion.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2109-7-26**] 13:26
T: [**2109-7-26**] 13:54
JOB#: [**Job Number 107130**]
Name: [**Known lastname 15903**], [**Known firstname 33**] Unit No: [**Numeric Identifier 17506**]
Admission Date: [**2109-7-16**] Discharge Date: [**2109-7-26**]
Date of Birth: [**2041-2-25**] Sex: M
Service: CARDIOTHORACIC SURGERY SERVICE
ADDENDUM TO DISCHARGE MEDICATIONS:
The patient to administer:
1. NPH insulin 10 units subcutaneously q. a.m.
2. Humalog insulin 2 units subcutaneously before dinner each
day.
3. NPH insulin, 4 units subcutaneously q. h.s.
4. The patient is to continue his Metformin as previously
stated, 500 mg twice a day.
DISCHARGE INSTRUCTIONS:
1. He is to check his blood sugars four times a day and he
will keep a record of this.
2. He is to follow-up with the [**Hospital 616**] Clinic in
approximately two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**Name8 (MD) 5563**]
MEDQUIST36
D: [**2109-7-26**] 15:09
T: [**2109-7-26**] 15:31
JOB#: [**Job Number 17507**]
|
[
"794.39",
"401.9",
"V17.3",
"242.90",
"414.01",
"411.1",
"427.31",
"272.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"88.72",
"39.61",
"36.13",
"37.61",
"99.20",
"36.15",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7114, 7821
|
7845, 8123
|
856, 994
|
1150, 5573
|
8147, 8611
|
788, 829
|
6465, 7093
|
184, 627
|
650, 764
|
1011, 1132
|
5598, 5786
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,084
| 178,065
|
10739
|
Discharge summary
|
report
|
Admission Date: [**2133-3-6**] Discharge Date: [**2133-3-11**]
Date of Birth: [**2072-6-13**] Sex: F
Service: MEDICINE
Allergies:
Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
60F with a history of diabetes mellitus (type I vs. type II),
HTN, HLD, PVD and multiple recent hospital admissions (first for
pneumonia, requiring ICU admission with intubation) and then
earlier this month for altered mental status felt secondary to
UTI. At that time, she was initially treated with IV antibiotics
(vanco/cefepime -> ceftriaxone) but then discharged on Bactrim
to complete a 14-day course. No organism was ever isolated from
the urine. At home, she reports continued dysuria (burning) that
never resolved. For the last several days, she's been having
worsening nausea and vomiting (mulitple 6-7 episodes today prior
to presentation) as well as diarrhea/loose stool (no blood). She
has not had a bowel movement since arrival in the ED.
In the ED inital vitals were T 97.8, HR 70, BP 140/91, RR 16, O2
sat 97% RA. Initial labs returned notable for hyperkalemia in
non-hemolyzed specimen to 7.2. Subsequently, the patient was
noted to develop arrhythmia on telemetry with
bigeminy/Wenckebach and short runs of VT (~10 beats). During
runs of VT, she had palpable pulse in 40s despite rate in
110s-150s on monitor, and was symptomatic (lightheaded) with
these episodes. She was given albuterol nebs, 40 mg IV
furosemide, calcium gluconate, insulin/D50 and kayexelate. Prior
to transfer, a U/A was checked and returned dirty, so she
received a dose of ceftriaxone and also got 2g of IV magnesium.
Vitals on transfer were HR 102, BP 124/84, O2 sat 100% on RA, T
98.6.
On arrival to the ICU, she is vomiting x multiple times,
non-bloody, non-bilious. She reports having some SOB in the ED
with the arrhythmias, but no chest pain or palpitations.
Breathing is now comfortable. She denies abdominal pain but
still having nausea (especially with movement).
Past Medical History:
1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction
Social History:
The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.
Family History:
Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress. Speaking in full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear. Left pupil is
1-2 mm bigger than the right, slightly irregular, and poorly
reactive compared with the right. Patient reports prior surgery
on this eye and thinks this may be her baseline.
Neck: Supple, JVP not elevated (though difficult to assess given
body habitus), no LAD
Lungs: Clear to auscultation bilaterally (distant given body
habitus), no wheezes, rales, rhonchi
CV: Regular rate and rhythm, distant S1 + S2 but no audible
murmurs, rubs, gallops
Abdomen: Soft/obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Chronic venous stasis changes bilaterally on lower
extremities. Multiple skin lesions/ulcerations more on the right
leg which appear chronic but per patient are healing slowly.
DISCHARGE EXAM:
VS; TC 98.4 BP 137-159/74-75 HR 78-82 RR 18-20 96% RA
GENERAL - well-appearing F in NAD, comfortable, appropriate
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - ctab, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, ecchymosis at heparin shot sites
EXTREMITIES - hyperpigementation from mid-shin down bilaterally
with erythema and several draining wounds bilaterally, feet
wrapped, with weeping, raw erythema (per patient, this is
chronic), no edema
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-18**] throughout, sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
[**2133-3-6**] 06:20PM BLOOD WBC-10.5 RBC-5.11 Hgb-15.1 Hct-48.9*
MCV-96 MCH-29.6 MCHC-30.9* RDW-13.8 Plt Ct-248
[**2133-3-6**] 06:20PM BLOOD Neuts-79.7* Lymphs-15.0* Monos-2.8
Eos-1.8 Baso-0.8
[**2133-3-6**] 09:50PM BLOOD Glucose-484* UreaN-28* Creat-2.1* Na-138
K-5.6* Cl-100 HCO3-25 AnGap-19
[**2133-3-6**] 06:20PM BLOOD Glucose-359* UreaN-28* Creat-2.0*
[**2133-3-6**] 09:50PM BLOOD CK(CPK)-84
[**2133-3-6**] 06:20PM BLOOD cTropnT-0.01
[**2133-3-7**] 02:10PM BLOOD CK-MB-4 cTropnT-0.01
[**2133-3-6**] 06:20PM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8
[**2133-3-7**] 03:06AM BLOOD Osmolal-312*
[**2133-3-7**] 03:20AM BLOOD Type-ART pO2-70* pCO2-41 pH-7.41
calTCO2-27 Base XS-0
[**2133-3-7**] 03:20AM BLOOD Lactate-2.3* Na-136 K-4.4 Cl-99
[**2133-3-7**] 03:20AM BLOOD freeCa-1.13
DISCHARGE LABS:
[**2133-3-11**] 05:58AM BLOOD WBC-6.1 RBC-4.37 Hgb-12.9 Hct-42.1 MCV-96
MCH-29.6 MCHC-30.7* RDW-13.6 Plt Ct-189
[**2133-3-11**] 05:58AM BLOOD Glucose-144* UreaN-22* Creat-1.5* Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
[**2133-3-11**] 05:58AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
MICROBIOLOGIC DATA:
[**2133-3-6**] Urine culture - yeast
IMAGING STUDIES:
[**2133-3-7**] CHEST (PORTABLE AP) - Heart size and mediastinum are
unremarkable. There is no evidence of interstitial pulmonary
edema. There is no appreciable pleural effusion. Minimal
bibasal, left more than right, atelectasis is present.
STRESS [**2133-3-10**]:
INTERPRETATION: 60 yo woman with HTN, HL, DM and morbid obesity;
h/o
stage III CHD and PVD was referred to evaluate an episode of
nonsustained VT. The patient was administered 0.142 mg/kg/min of
Persantine over 4 minutes. No chest, back, neck or arm
discomforts were
reported by the patient during the procedure. No significant ST
segment
changes were noted. The rhythm was sinus with one instance of a
sinus
pause vs SA Exit block noted post-infusion; there was no blocked
sinus
or atrial premature beat noted on the ECG. The heart rate and
blood
pressure response to exercise was appropriate. Post-infusion,
the
patient was administered 125 mg Aminophylline IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Appropriate hemodynamic response to the Persantine infusion.
Nuclear
report sent separately.
MIBI [**2133-3-11**]:
The image quality is poor due to extensive soft tissue and
breast attenuation.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal probably uniform
tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 58% with an
EDV of 78 ml.
IMPRESSION:
1. Probably normal myocardial perfusion in the setting of
extensive
attenuation.
2. Normal left ventricular cavity size and systolic function.
In the setting of diabetes, normal myocardial perfusion does not
necessarily imply a low risk of adverse cardiac events.
Brief Hospital Course:
60 y/o F with diabetes (multiple complications), HTN, HLD, PVD
and two recent hospitalizations who presented with N/V/D and
found to have hyperkalemia and arrhythmia in the ED.
# HYPERKALEMIA - Patient was noted to have hyperkalemia to 7.2
on admission. The etiology of her symptoms is not entirely
clear, but it was possibly multifactorial with contributions
from ACE inhibitor use, hyperglycemia and low insulin state,
worsening renal failure in the setting of dehydration, and
recent Bactrim use. However, the relationship with bactrim seems
to be most striking as her elctrolyte imbalances were corrected
after she stopped taking the bactrim. She received multiple
treatments in the ED including calcium gluconate, furosemide,
albuterol, insulin with D50 and kayexelate. Her potassium
improved with these interventions. She was monitored via
telemetry and her EKGs remained stable. Her ACEI was held in
this setting. CK values stable without evidence of
rhabdomyolysis.
# ARRHYTHMIA - Patient was noted to have bigeminy and Wenckebach
pattern on telemetry in the ED, with multiple self-limited runs
of ? VT with rate in 100s-150s associated with palpable pulse
drop to 40s and lightheadedness (patient reports symptoms were
not severe, no LOC). This was attributed to electrolyte
imbalance. She was maintained on telemetry and her EKGs remained
reassuring. However, she continued to have brief runs of VT
(upto 11 beats) even after stabilization. She was started on
metoprolol XL 25. A percantine MIBI was performed which showed
NO ISCHEMIA and normal myocardium.
# ACUTE ON CHRONIC RENAL FAILURE - Baseline of 1.1-1.3, peaked
at 2.1. Likely partially prerenal in the setting of dehydration
from nausea and emesis. FeNA >2%, concerning intrinsic causes
such as ATN, Bactrim-induced crystal nephropathy was felt to be
msot likely. Now trending still 1.6-1.7. Patient initially
received IVF boluses. Lisinopril and HCTZ were held but HTZ was
restarted.
# POSITIVE U/A - Patient hax > 182 WBCs in urine despite
recently completing a course of Bactrim for UTI (ended day prior
to admission). No organisms were isolated from her last culture
at prior admission. Patient continues to report dysuria
(burning) never fully resolved since last admission. A urine
culture was obtained and she was treated with IV Ceftriaxone x3
days till urine culture showed yeast and no bacteria. Vaginal
estrogen for UTI prevention was started.
# VOMITING/DIARRHEA - Unclear etiology, though given presence of
diarrhea viral gastroenteritis seems likely. Diarrhea could also
be due to recent antibiotics, with N/V due to other cause such
as UTI or medications (Bactrim). Cardiac etiology is unlikely,
and troponin negative. Tolerated regular diet on discharge.
# HYPERGLYCEMIA/DIABETES MELLITUS - Possibly type I as the
patient is insulin dependent and has multiple complications. She
was hyperglycemic on arrival to 359 on labs, which may be
related to underlying illness (e.g. gastroenteritis vs. UTI).
After receiving D50 in the ED, glucose was elevated to
"critically high" on arrival to the ICU. This may represent HONK
given calculated serum osm of 313. She received 10 units of
regular insulin with improvement on arrival to the MICU.
Subsequent glucose values improved. On the floor, patient with
difficult to control blood glucose, in the 300-400s, partially
because she did not know her insulin sliding scale, which was
uptitrated rapidly.
# SKIN CHANGES - Chronic ulcerations are improving per patient.
A wound consult was obtained for guidance with dressing changes.
# HYPERTENSION - Lisinopril and HCTZ were held in the setting of
[**Last Name (un) **] (see above). SBP 130-150s off antihypertensives. Received
PO hydralazine 10mg x1 for SBP>160. Howeevr, HTZ was restarted
and she was initiated on amlodipine 5mg and metoprolol XL 25.
# HYPERCHOLESTEROLEMIA - Her statin medication was continued.
# TRANSITION OF CARE ISSUES:
Lisinopril is being held and can be restarted if Cr stable on
visit to Dr [**Last Name (STitle) 1147**]. Vaginal estrogen for UTI prevention was
started. Metoprolol XL and amlodipine were also started. Pt has
followup with [**Last Name (un) **] and PCP.
Medications on Admission:
- insulin levemir 70 units qHS
- insulin lispro sliding scale-
rough idea of: Bglc 150- 2-3U; Bglc 200- 15U; Bglc 250- 30U;
Bglc 300- 40U
- lisinopril 20 mg PO once a day
- nortriptyline 75 mg PO HS
- pantoprazole 40 mg PO Q24H
- rosuvastatin 20 mg PO DAILY
- aspirin 325 mg PO DAILY
- hydrochlorothiazide 25 mg PO DAILY
- docusate sodium 100 mg PO BID as needed for constipation
- senna 8.6 mg PO BID as needed for constipation
- sulfamethoxazole-trimethoprim 800-160 mg PO BID last dose
[**2133-3-5**]
Discharge Medications:
1. nortriptyline 75 mg Capsule Sig: One (1) Capsule PO at
bedtime.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
8. conjugated estrogens 0.625 mg/gram Cream Sig: One (1) gram
Vaginal DAILY (Daily).
Disp:*3 tubes* Refills:*0*
9. Humalog Subcutaneous
10. Levemir 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous at bedtime.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
Nausea/vomiting/diarrhea
Hyperkalemia
Pyuria
SECONDARY:
Hypertension
Diabetes Mellitus
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:
Ms. [**Known lastname 35127**],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted because you had nausea, vomiting and diarrhea. We
thought this was likely due to Bactrim. As a result of the
vomiting and diarrhea, your kidney function decreased. We
stopped your lisinopril while your kidneys are recovering. You
also had high potassium which we treated with medications.
There was a question of recurrent UTI and we treated you with
antibiotics. We stopped your antibiotics because your urine
culture did not grow bacteria. You are being started on a
vaginal cream that should help prevent UTIs in the future.
There were also some irregular heart rhythms noted while you
were admitted. We performed a stress test which ruled out any
underlying heart damage that may have been contributing to the
abnormal heart rhythm. The results of the test were normal.
We made the following changes to your medications:
- STOPPED Lisinopril: please restart after having your kidney
function assessed by Dr [**Last Name (STitle) 1147**].
- STARTED Vaginal Estrogen Cream: this cream, applied once
daily, will help prevent Urinary Tract Infections in the future.
- STARTED Metoprolol XL 25mg to alleviate irregularities in
heart beat
- STARTED Amlodipine 5mg (Norvasc) for blood pressure control
**Please bring your insulin sliding scale chart with you to your
[**Last Name (un) **] appointment**
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appt: Tuesday, [**3-17**] at 1:30pm
Department: ADULT MEDICINE
When: THURSDAY [**2133-3-26**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"584.9",
"250.62",
"791.9",
"443.9",
"713.5",
"V58.67",
"278.01",
"426.13",
"272.4",
"250.42",
"E931.0",
"403.90",
"585.9",
"V12.04",
"787.01",
"427.1",
"272.0",
"276.7",
"707.12"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13447, 13522
|
7608, 11800
|
329, 345
|
13663, 13663
|
4685, 4685
|
15300, 15922
|
2806, 2959
|
12354, 13424
|
13543, 13642
|
11826, 12331
|
13846, 14770
|
5492, 5822
|
2974, 3890
|
3906, 4666
|
14799, 15277
|
274, 291
|
373, 2141
|
4701, 5476
|
13678, 13822
|
2163, 2605
|
2621, 2790
|
5839, 7585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
200
| 186,970
|
28120
|
Discharge summary
|
report
|
Admission Date: [**2172-10-24**] Discharge Date: [**2172-11-3**]
Date of Birth: [**2148-10-12**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Crush injury
Major Surgical or Invasive Procedure:
[**2172-10-24**]:
fem-[**Doctor Last Name **] bypass graft
repair of gastrocnemius + gracilis tear
[**2172-10-25**]: RLE fasciotomies
[**2172-10-30**]: ORIF Right patella
History of Present Illness:
The patient is a 24 year old male who presented to ED via the
trauma service by medlfight. Pt was involved in a construction
accident at his work where he was pinned between a moving truck
and a stationary truck. He was medflighted in secondary to a
pulseless extremity
Past Medical History:
None
Social History:
construction worker
Family History:
NC
Physical Exam:
Upon discharge:
AVSS
NAD
A+O
CTA
RRR
S/NT/ND/+BS
RLE: incisions c/d/i
+[**Last Name (un) 938**]/FHL/AT/G/S
SILT
2+ DP/PT
brisk cap refill
Brief Hospital Course:
The patient was admitted to the trauma service. He was
emergently taken to the operating room with the vascular service
for repair of his popliteal artery injury. He tolerated the
procedure well. He was extubated and brought to the TSICU for
close monitoring. On POD#1 his compartments were closely
monitored. He developed increased swelling and some diminished
sensation over toes [**2-23**]. Vascular surgery then took him back to
the operating room for RLE fasciotomies. He tolerated the
procedure well. He was extubated and brought to the recovery
room in stable condition. Post-operatively he was transferred
to the vascular service. Once stable in the PACU he was
transferred to the floor. On the floor he did well. His pain
was well controlled. He was seen by social work for emotional
support. He was transfused 2 units PRBC's on [**2172-10-29**] for post
op anemia. On [**2172-10-30**] he was brought back to the operating
room for ORIF of his right patella with orthopedics. He
tolerated the procedure well. He was extubated and brought to
the recovery room in stable condition. Once stable in the PACU
he was transferred to the floor. On the floor he did well. He
was seen by physical therapy and progressed well. He was also
seen by chronic pain service to help control his post-operative
pain. His labs and vitals remained stable. His pain was well
controlled. His hospital course was otherwise without incident.
He is being discharged today to rehab in stable condition.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30 mg syringe
Subcutaneous Q12H (every 12 hours) for 4 weeks.
8. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
9. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
Right popliteal artery injury
Right patella fracture
Right lateral femoral condyle fracture
Right lateral tibial plateau fracture
Post operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision clean and dry. Dry sterile dressing daily
as needed. If you notice any increased redness, swelling,
drainage, temperature >101.4, or shortness of breathe please
[**Name8 (MD) 138**] MD or report to the emergency room.
Please take all medications as prescribed. You need to take the
lovenox shots to prevent blood clots. You may resume any normal
home medication.
Please follow up as below. Call with any questions.
Physical Therapy:
WBAT
ROM as tol
Treatments Frequency:
Dry sterile dressing daily
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital1 18**] orthopedic
clinic clinic in 2 weeks. Call [**Telephone/Fax (1) **] to make that
appointment.
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital1 18**] vascular
clinic in 2 weeks. Call [**Telephone/Fax (1) **] to make that appointment.
Completed by:[**2172-11-3**]
|
[
"338.11",
"822.0",
"958.92",
"285.1",
"928.11",
"E821.7",
"823.00",
"788.20",
"821.21",
"904.41",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.09",
"39.29",
"79.05",
"99.07",
"99.05",
"83.61",
"79.36",
"39.98",
"99.04",
"99.06",
"83.65"
] |
icd9pcs
|
[
[
[]
]
] |
3633, 3711
|
1089, 2600
|
334, 507
|
3907, 3916
|
4490, 4857
|
888, 892
|
2623, 3610
|
3732, 3886
|
3940, 4383
|
907, 907
|
4401, 4417
|
4439, 4467
|
282, 296
|
923, 1066
|
535, 807
|
829, 835
|
851, 872
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,441
| 133,224
|
25829
|
Discharge summary
|
report
|
Admission Date: [**2159-12-28**] Discharge Date: [**2160-1-6**]
Date of Birth: [**2108-2-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Fever, hypoxia, hypotension
Major Surgical or Invasive Procedure:
Intubation
Extubation
History of Present Illness:
Ms. [**Known lastname 64310**] is a 51 year old female with MELD 29 HCV cirrhosis
and depression who was transferred from an OSH after presenting
with cough, HA, encephalopathy, and fever to 103 at home. She
reports that she has had a [**3-6**] week prodrome of sorethroat,
non-productive cough, myalgias, and headache that has worsened
over the past few days for which she presented to an OSH last
night. Her OSH course was notable for a CXR that, per report,
was notable for bilateral pleural effusions/consolidations,
acute renal failure with a creatinine of 3.1, a leukocytosis of
20, and hyponatremia of 128. She was treated with ceftriaxone 2
grams IV and azithromycin 500 mg IV. Her OSH course was also
complicated by intermitent hypotension requiring peripheral
dopamine.
.
Of note, the patient reports that she received seasonal and H1N1
influenza vaccines this year. Per report, the patient did not
receive a influenza swab or oseltamavir at the OSH. On transfer,
the patient was reported to have a SaO2 of 93% on 6L face mask.
.
On arrival to the MICU, the patient is in respiratory distress,
tachypneic to mid-30s with an SaO2 of 88% on 15L face mask
increased to 95% NRB. She continues to complain of dyspnea and
cough, as well as increased abdominal girth.
.
Review of systems:
(+) Per HPI
(-) Denies chest pain, palpitations, n/v/d, constipation.
Past Medical History:
Past Medical History:
Hepatitis C Cirrhosis, Genotype I (Biopsy [**2156**] below); s/p
Ribavirin & Peg Interferon--non responder, stopped between [**2157**]
& [**2159**] (EGD [**12-7**], no varices).
Depression
Acne
Worsening Edema [**2159**]
.
Past Surgical History
Laminectomy x 2 in [**2135**] and [**2145**]
Social History:
Lives in [**Hospital1 6687**] with husband, 1 son and 2 daughters. [**Name (NI) **]
history of blood transfusions- IV drug use x1 at age 15.
Tobacco: Social.
Alcohol: [**5-7**] glasses wine/night.
Family History:
The patient denies any family history of liver disease.
Endorses family history of CHF. 1 sister with Breast CA,
another sister with [**Name2 (NI) **] CA.
Physical Exam:
General: Respiratory distress
HEENT: Scleral icterus. PERRL, eomi, sclerae anicteric. MMM, OP
clear. Neck supple without lymphadenopathy.
Pulm: Rhonchorous bilaterally.
CV: Nl S1+S2, no m/r/g.
Abdomen: soft, mildly distended, non-tender. +bs
Ext: No c/c/e, 1+ dp/pt bilaterally
Pertinent Results:
OSH
Cr 3.1
Na 128
WBC 20
Tbili 4.6
INR 1.9
Plt 40
[**2159-12-28**]
129 104 50
------------ 82
4.2 21 2.6
estGFR: 19/23 (click for details)
Ca: 7.3 Mg: 2.3 P: 4.3
ALT: 77 AP: 137 Tbili: 5.9 Alb: 1.8
AST: 194 LDH: 235 Dbili: TProt:
.
Hapto: 106
.
......10.1
18.8 ------ 49
......30.1
N:75 Band:5 L:8 M:5 E:0 Bas:0 Metas: 4 Myelos: 3
.
Comments: Plt-Ct: Verified By Smear
Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: 1+ Microcy: OCCASIONAL
Tear-Dr: OCCASIONAL Plt-Est: Very Low
.
PT: 20.2 PTT: 44.7 INR: 1.9
.
Fibrinogen: 313
.
[**12-28**] CXR: Patchy bilateral parenchymal consolidation.
Correlation with
history and possibly further evaluation with CT is recommended.
.
[**12-29**] US abdomen: Moderate amount of ascites, with the largest
pocket in the right lower quadrant.
.
[**1-4**] US:
IMPRESSION:
1. Patent hepatic vasculature.
2. Heterogeneous liver with no focal liver lesions identified.
3. Large gallbladder, but no gallstones and no gallbladder wall
edema
identified.
4. Mild splenomegaly.
5. Small amount of ascites but no safe pocket was located to
mark for a
paracentesis to be performed by the clinical staff.
.
CXR [**1-5**]:
REASON FOR EXAMINATION: Abnormal ventilation pattern.
Portable AP chest radiograph was compared to [**2160-1-3**].
The ET tube tip is 6 cm above the carina. The right internal
jugular line tip
is at the cavoatrial junction. The NG tube tip is in the
stomach.
Cardiomediastinal silhouette overall is unchanged, but there is
slight
dilatation of the mediastinum that in comparison with worsening
of pulmonary
edema and worsening of left lower lobe consolidation, might be
consistent with
pulmonary edema superimposed on worsening left lower lobe
pneumonia. There is
no pneumothorax.
Brief Hospital Course:
************
Patient was made CMO, family at bedside. Pain control provided.
Patient extubated. Patient expired on [**2160-1-6**].
************
Assessment and Plan: Ms. [**Known lastname 64310**] is a 51 year old female with
MELD 29HCV cirrhosis who was transferred from an OSH after
presenting with cough, HA, encephalopathy, and fever for 3 days
with a hospital course complicated by hypotension requiring
peripheral dopamine and hypoxia.
.
# Hypoxic respiratory failure: Given CXR demonstrating
bilateraly patchy infiltrates as well as her history of cough,
fever, and sore throat for 2-3 weeks, symptoms are concerning
either for influenza or a post-influenza bacterial pneumonia.
She currently meets criteria for ARDS with a P:F <100, bilateral
infiltrates, and no CHF. Other potential etiologies include IIPs
including AEP and AIP, although less likely in setting of viral
prodrome.
- Ventilate with volume-cycled AC at ARDSnet settings.
- Titrate to FiO2 and PEEP by ABG
- Sputum culture
- Bronch and BAL
- Vanco and pip/tazo for empiric HAP pneumonia given unclear
history of antibiotics and recent admissions, as well as the
fact that the patient is a hospital SW. In addition, given
suspicion for post-influenza pneumonia, S.aureus is also a
concern. Will also treat with ciprofloxacin for atypical and GNR
coverage.
- Tamiflu at 75 mg po bid dosing given renal failure
- Influenza swab
.
# Severe sepsis: Hypoxia and hypotension concerning for
infectious process with criteria sufficient for SIRS/sepsis
given leukocytosis and tachypnea. Potential infectious sources
include bacterial pneumonia or influenza as above. Alternative
infectious sources include SBP or urosepsis.
- Pan-culture including blood, urine, sputum, influenza sputum.
Consider diagnostic paracentesis if U/S demonstrates ascites.
- Tamiflu and antimicrobials as above.
- Monitor UOP, lactate for signs of end organ damage.
Vasopressors and IVF for volume rescucitation as necessary.
- Will also do a cosyntropin stimulation test to rule out
hepatoadrenal syndrome.
.
# Acute renal failure: Differential includes pre-renal azotemia,
ATN, or HRS. Given hypotension, likely secondary to inadequate
perfusion.
- Trend lytes, UOP
- Urine lytes and eos.
- Volume rescucitation as above.
.
# Liver disease: Patient with MELD 29 HCV cirrhosis with acute
decompensation, likely in setting of sepsis and ARDS.
- Consult hepatology
- Patient is not currently on lactulose and [**Last Name (LF) 64311**], [**First Name3 (LF) **] hold
off for now pending hepatology evaluation.
.
# Hyponatremia: Likely due to hypovolemia in setting of SIRS.
- Trend serum sodium
.
# Thrombocytopenia/anemia/coagulopathy: Patient with
thrombocytopenia, anemia, and coagulopathy. Chronic
thrombocytopenia likely secondary to portal hypertension and
splenic sequestration, although current platelet count worse
that baseline. Coagulopathy and anemia could also be secondary
to worsening HCV cirrhosis, although DIC is also a potential
etiology. Anemia could also be secondary to bleeding.
- Trend platelets, transfuse for plt<10 or <50 if signs of
bleeding.
- DIC and hemolysis labs.
- Guaiac stools, OGT suctioning to assess for blood
.
# Leukocytosis: Likely due to infectious process.
- Trend WBC
.
FEN: NPO, replete as necessary, IVF as above.
PPx: SCDs
Access: RIJ CVL, PIV (18, 20g)
Code: Full (confirmed)
Communication: [**Known lastname **],[**Name (NI) **] (husband)
[**Telephone/Fax (1) 64312**]
Disposition: ICU level of care
***************
[**12-29**]:
- started lactulose, rifaximin, vasopressin
- f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test --> failed [**Last Name (un) 104**] stim, started on
Hydrocortisone
- Hep recs: give alb 25g, Abd us to eval for ascites. Elevated
Tbili likely due to infxn. Would give additional 25g albumin
(done), f/u blood and urine cx's, continue hold Lasix and
Aldactone, get abd u/s (done). - Started on TF's but had high
residuals so stopped
[**12-30**]
- DFA negative so d/c'd tamiflu
- continuing vanc, zosyn, cipro empirically for now
[**12-31**]
- standing reglan and PR bisacodyl with no BM this evening still
[**1-1**]
- Sedation off
- Goal -1L
- lactulose given
- Urine lytes ordered to w/u for hepatorenal
[**1-2**]
- started tubefeeds
- sats in lower 90s most of the day
[**1-3**]
- hydrocortisone dose decreased
- hep recs: 50g albumin and vitK to see if coagulopathy d/t
deficiency
- agitation- tried Zyprexa
- patient hypertensive, tachy, and tachypneic during the night.
Tried sedation boluses with fent and midaz.
- hypernatremic
[**1-4**]
- abd US visualized small amt fluid in abd with loops of bowel
in close proximity. spoke to hepatology, felt if scant amt of
fluid and loops of bowel posed risk of perf, should hold off on
diag paracentesis.
- decreased propofol, put on zyprexa standing tid
- d5w, ngt free water flushes increased for hypernatremia
- received albumin
- back in CMV/AC
[**1-5**]:
Melena - GI aware - EGD: old clots, banded, no acute bleed
Given blood, octreotide, PPI etc.
Family aware and present
******
Patient made CMO, extubated, DNR, DNI. Family at bedside.
Patient expired.
Medications on Admission:
BUPROPION [WELLBUTRIN XL] 300mg PO daily
HYDROXYZINE HCL 50mg PO BID PRN itch
HYOSCYAMINE SULFATE [LEVSIN/SL] - 0.125 mg SL [**Hospital1 **] PRN
Ativan 0.5mg PO Q6 PRN
Omeprazole 20mg PO daily
Spironolactone 100mg PO Daily
Lasix 20mg PO PRN
Ambien 10mg PO QHS PRN
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2160-1-11**]
|
[
"038.9",
"287.5",
"571.2",
"995.92",
"486",
"789.59",
"584.5",
"518.81",
"456.20",
"286.9",
"785.52",
"070.71",
"303.90",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.72",
"96.04",
"33.23",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
10060, 10069
|
4552, 9717
|
343, 366
|
10120, 10129
|
2798, 4529
|
10181, 10307
|
2326, 2483
|
10032, 10037
|
10090, 10099
|
9743, 10009
|
10153, 10158
|
2498, 2779
|
1689, 1761
|
276, 305
|
394, 1670
|
1805, 2096
|
2112, 2310
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,895
| 188,962
|
13890
|
Discharge summary
|
report
|
Admission Date: [**2132-11-30**] Discharge Date: [**2132-12-3**]
Service: MEDICINE
Allergies:
Chocolate Flavor
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
86 M dementia, BPH, PVD, HTN, hypercholesterolemia who lives in
[**Location 14991**] NH. Developed abdominal pain 1 week prior thought [**12-26**]
constipation; treated with senna with relief. Day prior to
admission had episode of emesis noted to be coffee ground in
appearance and guiaic +. Sent to [**Location (un) 620**] ED. Tachycardic 120, BP
105/44. HCT 41.9. Noted to have erythematous scrotum concerning
for infection. Recevied unasyn, clindamycin. Underwent U/S
scrotum and abdominal films (results not available). Transfered
to [**Hospital1 18**] for management of GIB and urologic w/u for scrotal skin
infection.
.
In ED here urology evaluated pt and felt to have hydrocele and
no intervention needed. In ED, noted to be hypotensive
(100/palp), pulse 120, guiaic +, in afib, and with fever to
101.8. NG lavage attempted but pt. unable to cooperate. CT
abdomen done for concern of embolic event in setting of afib but
no evidence of mesenteric ischemia. Received 4 L NS. HCT 36.4.
Evaluated by GI who recommended admission and likely
EGD/colonoscopy.
.
Patient admitted to the ICU for continued care.
.
Review of Systems: Pt denies all complaints; no abdominal pain,
nausea, chest pain, difficulty breathing, vomiting.
Past Medical History:
Hypercholesterolemia
Afib
Dementia
PVD
HTN
BPH
Social History:
No tobacco, no etoh. Lives in [**Location **]. Baseline dementia.
Family History:
NC
Physical Exam:
Vs- 98.9, 95, 83/62, 18, 98% 1L NC
Gen- Elderly man in bed
Heent- JVP flat, dry mucous membranes, skin tenting
Chest- CTA anteriorly
Heart- RRR with occasional ectopic beat. S1, S2, no rmg
Abd- soft, ND, NT, BS+, no peritoneal signs
Ext- wwp, no edema
Neuro- A*O*1, moving all extremities
Skin- dry
Rectal- no hemorrhoids, no obvious bleeding, guiaic +
Pertinent Results:
[**2132-11-30**] 06:30PM GLUCOSE-135* UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-19* ANION GAP-12
[**2132-11-30**] 06:30PM CALCIUM-7.0* PHOSPHATE-2.2* MAGNESIUM-1.8
[**2132-11-30**] 11:33AM CORTISOL-13.8
[**2132-11-30**] 10:08AM CORTISOL-6.7
[**2132-11-30**] 06:29AM WBC-6.4 RBC-3.53* HGB-11.7* HCT-33.2* MCV-94
MCH-33.2* MCHC-35.4* RDW-13.1
[**2132-11-30**] 06:29AM PLT COUNT-120*
[**2132-11-30**] 01:40AM CK(CPK)-146
[**2132-11-30**] 01:40AM cTropnT-0.02*
[**2132-11-30**] 01:40AM CK-MB-2
[**2132-11-29**] 08:00PM LACTATE-1.8
[**2132-11-29**] 07:40PM ALT(SGPT)-12 AST(SGOT)-15 ALK PHOS-49
AMYLASE-48 TOT BILI-0.4
[**2132-11-29**] 07:40PM LIPASE-19
[**2132-11-29**] 07:40PM cTropnT-0.01
[**2132-11-29**] 07:40PM CK-MB-2
[**2132-11-29**] 07:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2132-11-29**] 07:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2132-11-29**] 07:40PM URINE RBC-[**1-26**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
.
PA AND LATERAL CHEST X-RAY: The cardiac silhouette, mediastinal
and hilar contours are normal. The pulmonary vasculature is
normal and there is no pneumothorax. There is bibasilar linear
atelectasis, most prominent at the left lung base. The lungs are
otherwise clear without consolidations or effusions. The
surrounding soft tissue and osseous structures are unremarkable.
IMPRESSION: Bibasilar linear atelectasis. No consolidations or
effusions identified.
.
CT ABDOMEN WITH ORAL, WITH INTRAVENOUS CONTRAST: There is
bilateral dependent atelectasis at the lung bases. There is a
small hiatal hernia. The liver enhances normally without focal
nodules or masses. The gallbladder, pancreas, spleen, bilateral
adrenal glands, and right kidney are normal. There is a 2.8 x
2.5 cm left parapelvic cyst. Both kidneys enhance and excrete
contrast symmetrically, and there is no hydronephrosis.
Intra-abdominal loops of large and small bowel are normal in
caliber and contour. There is no focal or segmental area of
bowel wall thickening. Scattered mesenteric lymph nodes are
prominent, but do not meet CT criteria for pathologic
enlargement. A small amount of fat stranding surrounding
mesenteric vessels. All mesenteric vessels are patent and
enhance appropriately. There is no free air and no free fluid.
CT PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: A large amount
of stool is seen within the rectum. The bladder is collapsed
around a Foley catheter. There is no inguinal or pelvic
lymphadenopathy. There is no free air and no free fluid.
BONE WINDOWS: The bones are osteopenic. There are no suspicious
lytic or sclerotic osseous abnormalities.
IMPRESSION:
1. No evidence to support mesenteric ischemia. All abdominal
vessels enhance appropriately, and there are no focal or
segmental areas of bowel wall thickening.
2. Large amount of stool within the rectal vault.
.
UPRIGHT AND SUPINE ABDOMINAL RADIOGRAPHS [**2132-12-2**].
There is slightly prominent loops of small bowel noted within
the left lower quadrant, however, no definite evidence of
obstruction or ileus. Additionally, a large amount of stool is
again identified within the rectal vault, likely implying
constipation and possibly stool impaction.
Small areas of atelectasis are again identified basally within
the lungs. No discrete opacities noted within the lung bases.
There are degenerative changes noted within the thoracic and
lumbar spine as well as the left hip joint.
IMPRESSION:
1. Mildly dilated loops of small bowel with large amount of
stool within the rectal vault likely implying severe
constipation/fecal impaction.
.
REPEAT KUB [**2132-12-3**]: Resolution of slightly prominent loops of
small bowel. Scattered air fluid levels are nonspecific in
appearance.
Brief Hospital Course:
# [**Female First Name (un) 564**] esophagitis: Patient admitted s/p episode of coffee
ground emesis with low hematocrit. He was admitted to the ICU
and underwent urgent EGD which revealed esophagitis, which
appeared likely to be [**Female First Name (un) **] based on the appearance. He was
thus treated with fluconazole 200 mg po x 1 followed by 100 mg
po qd for a total of 14 days, in addition to twice daily
protonix. He will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], a
gastroenterologist who cares for Mr. [**Known lastname 41625**] wife to discuss
follow-up EGD, as recommended to screen for Barrett's esophagus
and to discuss tapering of his protonix following a one month
treatment course. Patient is currently tolerating a regular
diet.
.
# Fever: Likely this is due to his esophagitis. Patient
remained afebrile on fluconazole. Urinalysis not consistent
with urinary tract infection and urine culture had no growth.
Blood cultures remain no growth to date. Stool negative for c
diff x 1. CXR showed no evidence of pneumonia. CT abd/pelvis
showed no acute intraabdominal pathology.
.
# Hypotension - Suspect secondary to hypovolemia +/- sepsis.
Blood pressure improved with IVF and has remained stable for
days prior to discharge without additional fluid boluses.
Patient has been restarted on his home dose of lasix.
.
# Guaic positive stool: This could be the result of his
esophagitis. Patient is also overdue for a screening
colonoscopy. He will discuss the risks vs benefits of such a
procedure with his PCP.
.
# Constipation: Patient had abdominal pain prior to admission
which resolved with senna. On admission CT he was noted to have
a large amount of stool in the rectal vault. He received enemas
in the ICU with good result and subsequent suppository and enema
on the floor, again with good effect. Rectal exam reveals no
evidence of fecal impaction. His stool is soft but sticky and
there is considerable laxity to the rectum. Recommend daily
suppository x 5 days and then prn thereafter.
.
# Drug rash: Patient developed a rash over his
chest/abdomen/arms after having received unasyn, clindamycin,
vancomycin, levofloxacin, flagyl, and fluconazole. Low
suspicion that the rash is due to fluconazole given it is
improving despite continuation of this medication. No
involvement of the mucous membranes on exam. Patient denies any
signficant pruritis.
.
# Dementia - Patient was continued on his home razadyne. He is
pleasantly demented. He required bilateral soft wrist
restraints to avoid pulling out his IVs.
.
# Afib - Patient had an initial supraventricular tachycardia
noted on his admission EKG. However, heart rate has remained
64-78 for the past 3 days without rate controlling agents. He
was continued on his home aggrenox. He will follow-up with his
new primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 7941**] and to discuss starting
coumadin, once his esophagitis resolves. Currently risk of
recurrent GI bleeding outweighs the potential benefit.
.
# Hypercholesterolemia - Patient continued on his home
simvastatin
.
# BPH - Patient continued on his home oxybutynin
.
# PVD - Patient restarted on his home aggrenox prior to
discharge.
.
# FEN: Regular diet. Patient started on [**Hospital1 **] ensure given low
albumin (3.0).
.
# PPX: Pneumoboots, PPI, patient was administered the pneumovax
prior to discharge (no record of prior administration per the
NH)
.
# Code: DNR/DNI (confirmed with pt. wife)
.
# Communication: Wife, [**Name (NI) **]
.
# Dispo: Patient discharged back to [**Hospital 14991**] Nursing Home
Medications on Admission:
Razadyne 12 [**Hospital1 **]
Simvastatin 20 qd
MVI
Oxybutynin 5 [**Hospital1 **]
Lasix 20 qod
Colace 100 [**Hospital1 **]
Aggrenox 25/200 [**Hospital1 **]
Senna
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Galantamine 4 mg Tablet Sig: Three (3) Tablet PO bid ().
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
patient to follow-up with gastroenterologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
for taper of this medication after 1 month treatment.
10. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): until groin rash resolves.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) for 5 days: THEN PRN NO BOWEL MOVEMENT X 2-3 DAYS.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14991**] - [**Location (un) 1411**]
Discharge Diagnosis:
1. [**Female First Name (un) **] esophagitis
2. constipation
3. drug rash
4. history of hypertension
5. history of paroxysmal atrial fibrillation
Discharge Condition:
good: tolerating po, afebrile, hct stable
Discharge Instructions:
Please monitor for temperature > 101, abdominal pain, vomiting,
or other concerning symptoms.
New medications: protonix, fluconazole, dulcolax suppository
Followup Instructions:
Please call to schedule follow-up with your new primary care
doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], to arrange an outpatient EGD to screen
for Barrett's esophagus and to discuss a screening colonoscopy.
Phone: ([**Telephone/Fax (1) 41626**]
|
[
"276.52",
"272.0",
"600.00",
"427.31",
"693.0",
"443.9",
"564.00",
"112.84",
"294.8",
"603.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11042, 11122
|
5925, 9571
|
246, 252
|
11312, 11356
|
2072, 5902
|
11560, 11844
|
1680, 1684
|
9782, 11019
|
11143, 11291
|
9597, 9759
|
11380, 11537
|
1699, 2053
|
1413, 1511
|
186, 208
|
280, 1394
|
1533, 1581
|
1597, 1664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,870
| 183,421
|
1842
|
Discharge summary
|
report
|
Admission Date: [**2158-11-22**] Discharge Date: [**2158-12-1**]
Date of Birth: [**2089-11-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
shortness of breath, pneumothorax
Major Surgical or Invasive Procedure:
Chest Tube Placement and Removal
Revision of T10-12 laminiecotomy incision
History of Present Illness:
69 year old woman with a history of breast and renal cell
carcinoma with metastasis into the lungs and bone and recent
CVA in [**2158-7-14**]. Pt had been complaining of several days of
shortness of breath at her rehab facility which had
progressively been getting worse. She had an outpatient CT scan
today to evaluate for recollection of recently drained pleural
effusion. CT scan today reveal large right sided pneumothorax,
thought to be causing her tachycardia and increased shortness of
breath. Per her son, she has not experienced fever, chills,
nausea, vomiting, diarrhea.
.
In the ED inital vitals were, 97.7 110 92/57 20 90% RA. Patient
fairly asymptomatic with just complaints of shortness of breath.
No chest pain. She had a right sided chest tube placed with air
and fluid return. Vital signs post chest tube place showed
103/52, 105, 19, 99% 4L nc.
.
Pt was initially diagnosed with renal cell carcinoma in [**2142**] and
breast cancer in [**2155**]. She was noted to have RCC mets to the
lung in [**2156**]. She has undergone numerous radiation and
chemotherapy treatments. She had a CT scan on [**2158-10-4**] which
showed cord compression. She had cord stablization surgery on
[**10-12**] which was complicated by continued serous drainage from her
back and recurrent pleural effusion. Her pleural fluid grew MRSA
and she was started on IV vancomycin. It is thought that her
previous surgical site is communicating with her pleural fluid
and may have been the cause of her pneumothorax.
.
On the floor, patient states that she is still short of breath
but may be her her baseline. She is very tired and would like to
be left alone.
.
Review of systems:
(+) Per HPI, back pain at site of previous surgery, + anxiety,
did have urinary retention following back surgery - she has had
foley removed for 2 days and has been voiding spontaneously
though cannot get to the bathroom independently so she is
wearing diapers.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias, no weakness or numbess. Denies rashes
or skin changes.
Past Medical History:
ONCOLOGIC HISTORY:
[**2142-6-26**]: left nephrectomy for 11 cm clear cell renal cell
carcinoma
[**2155-3-15**]: diagnosted with bilateral breast cancer
(node-positive on left, ER/PR positive, HER-2 negative). Treated
with neoadjuvant dose-dense AC and weekly taxol ending [**2155-10-3**],
bilateral mastectomy [**2155-12-25**] (after lumpectomy with positive
margins), radiation ending [**3-22**]. On arimidex since completion of
chemotherapy.
[**2156-7-14**]: CT torso (done because of elevated alk phos) showed
1.5 and 0.6 cm left upper lobe nodules.
[**2156-8-26**]: Left upper lobectomy showed two foci of clear cell
renal cell carcinoma.
[**2157-5-4**]: MRI of T/L spine with disease at T10, T11 vertebral
bodies, soft tissues T10-T12, and L3 body. CT-guided biopsy
consistent with renal cell carcinoma. Bone scan [**2157-4-18**] also
showed involvement of several left ribs. Subsequently received
XRT to thoracic spine.
[**5-/2157**]: Began sunitinib; dose reduced over time to 25 mg because
of toxicities. Sutent ended in [**2158-1-14**] because of disease
progression.
[**2158-2-7**]: MRI L-spine with T11 disease with persistent mass
effect
on thecal sac but no significant cord compression, and T9 and
T10
disease, all likely unchanged. New T12 compression fracture.
Significant progression of L3 vertebral body lesion with
pathologic fracture and retropulsion of posterior cortex.
[**2158-2-13**]: CT torso with interval marked progression of
innumerable
pulmonary mets since [**2157-8-2**]. Destructive lytic lesion within
left femoral head.
[**2158-2-14**]: XRT to lumbar spine
[**2158-4-12**]: signed consent for 08-184 trial of avastin and
temsirolimus. CT torso showed osseous mets in spine and left
ibs, with interva lincrease in size in soft tissue component at
T11 encasing thecal sac, invading cord, and invading more than
50% of the spinal canal. At L3, compression fracture with soft
tissue component extending into spinal canal. Increase in number
and size of numerous pulmonary mets bilaterally. Destructive
lytic lesion within left femoral head.
[**2158-4-19**]: C1D1 08-184 (avastin/temsirolimus)
[**2158-6-7**]: CT torso with significant decrease in size of bilateral
pulmonary lesions and stable osseous disease with decrease in
soft tissue mass at T11
- [**Date range (3) 10263**]: admitted for PNA, mental status changes, found
to have frontal CVA, taken off study
- [**2158-8-9**] CT TORSO: stable disease
-[**2158-10-4**] to have a T11 lesion causing cord compression and
underwent spine surgery [**2158-10-12**] with Drs. [**Last Name (STitle) **] and
[**Name5 (PTitle) 739**].
.
Other Past Med Hx:
- Hypertension
- Breast Cancer s/p resection
- gout
- E Coli and Klebsiella UTI both sensitive to cipro and Bactrim
[**10/2158**]
- Anemia: Likely anemia of chronic disease secondary to
underlying cancer. Received 1 unit pRBC on [**2158-10-24**] with good
response
- History of anxiety and mild delerium when in the hospital
- Wound drainage s/p Spinal Fusion
Social History:
She lives with her 3 sons who assist with her medical care. She
used to work at [**Hospital3 2568**] in the GI division. She is a
non-smoker, no alcohol or other drugs.
Family History:
Father had esophageal cancer. Her maternal grandmother had
breast cancer in her
70s.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 36.7 BP:100/53 P:104 R: 18 O2: 99% 2L
General: Alert, oriented, appear fatigued but in no acute
distress
HEENT: Sclera anicteric, pupils equal and reactive to light,
MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds on right and decreased at bases
bilaterally, no wheezes, rales, ronchi
CV: tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds, no rebound tenderness or guarding, no organomegaly, does
have diffuse bruising on abdomen with palpable hematomas from
lovenox injections
GU: no foley
Ext: warm, well perfused, 2+ pulses, bilateral non pitting pedal
edema, large dressing in place on back with some serosanguinous
drainage.
On discharge, there is a R thoracic dressing in place, otherwise
not changed.
Pertinent Results:
ADMISSION LABS:
[**2158-11-22**] 06:50PM BLOOD WBC-10.6# RBC-3.12* Hgb-9.3* Hct-28.6*
MCV-92 MCH-29.7 MCHC-32.4 RDW-17.1* Plt Ct-472*#
[**2158-11-22**] 06:50PM BLOOD Neuts-90.6* Lymphs-4.4* Monos-4.0 Eos-0.8
Baso-0.2
[**2158-11-22**] 06:50PM BLOOD Glucose-110* UreaN-16 Creat-0.8 Na-133
K-4.7 Cl-99 HCO3-23 AnGap-16
[**2158-11-23**] 03:40AM BLOOD Calcium-7.7* Phos-4.4 Mg-2.0
.
IMAGING:
CT chest [**11-22**]:
IMPRESSION:
1. Large multiloculated right hydropneumothorax, with element
of mediastinal shift to the left. Clinical correlation to
exclude local "tension" physiology is recommended.
2. Post-surgical change reflecting prior T11 corpectomy and
posterior fusion. However, in addition, the prior fluid
collection in the paraspinal soft tissues has been largely
replaced by air, with extensive air not only in the paraspinal
tissues but also also wrapping around the right aspect of the
thecal sac and extending into the T11 corpectomy bed about the
indwelling vertebral body cage device. The extensive air within
the paraspinal soft tissues and the drainage of the prior fluid
collection suggests a connection either externally or with the
adjacent right pleural space, though this cannot be definitively
identified on this study.
3. Redemonstration of extensive metastatic disease, as above.
4. New heterogeneous, diffuse ground-glass opacities
predominantly seen in the left lung. These could represent
pneumonia in the proper clinical setting. Alternatively, given
leftward mediastinal shift, a component could represent
atelectasis
5. Cholelithiasis.
6. Contrast extravasation, with 50 cc of contrast material
extravasated into the patient's right hand. The patient was
evaluated by Dr. [**Last Name (STitle) 10304**], and a plastic surgery consult was
obtained.
[**Known lastname **],[**Known firstname **] [**Last Name (NamePattern1) **] [**Medical Record Number 10305**] F 69 [**2089-11-8**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2158-11-27**] 6:40
PM
[**Last Name (LF) **],[**First Name3 (LF) **] M. MED 11R [**2158-11-27**] 6:40 PM
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN [**Name Initial (PRE) 7417**] #
[**Clip Number (Radiology) 10306**]
Reason: rule out recurrent pneumothorax.
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman with pneumothorax s/p chest tube placement
now with tube
clamped.
REASON FOR THIS EXAMINATION:
rule out recurrent pneumothorax.
Wet Read: MLHh MON [**2158-11-27**] 7:46 PM
Similar size of sml-mod R hydroPTX, with apical/lateral/basal
components.
Innumerable pulm mets. Continued LLL atelecatasis + small
effusion.
Final Report
AP CHEST 6:38 P.M., [**11-27**]
HISTORY: Pneumothorax. Chest tube placed.
IMPRESSION: AP chest compared to [**11-27**], 5:02 a.m.:
Small right apical pneumothorax is new or more readily apparent
now than it
was at 5:02 a.m. Small right pleural effusion unchanged. Lungs
full of
pulmonary nodules as before. No new collapse pneumonia or
pulmonary edema.
Small left pleural effusion stable. Right supraclavicular
central venous line
passes into the right atrium, tip is obscured by spinal
hardware. Right
pleural tube unchanged in position, crossing the mid chest
superiorly.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 10307**] HO
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: TUE [**2158-11-28**] 11:21 AM
Imaging Lab
=======
[**2158-11-24**] 8:30 am TISSUE THORACIC WOUND TISSUE.
**FINAL REPORT [**2158-11-28**]**
GRAM STAIN (Final [**2158-11-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2158-11-27**]):
Reported to and read back by BUNNIE [**Doctor Last Name 10308**] @ 11:19 AM ON
[**2158-11-25**].
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
ACINETOBACTER BAUMANNII COMPLEX. RARE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ACINETOBACTER BAUMANNII
COMPLEX
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R <=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S 8 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2158-11-28**]): NO ANAEROBES ISOLATED.
[**2158-11-24**] 02:07AM BLOOD WBC-6.3 RBC-2.46* Hgb-7.1* Hct-22.8*
MCV-93 MCH-28.9 MCHC-31.1 RDW-17.7* Plt Ct-306
[**2158-11-24**] 03:25PM BLOOD WBC-6.9 RBC-2.42* Hgb-7.1* Hct-22.3*
MCV-92 MCH-29.4 MCHC-31.9 RDW-17.5* Plt Ct-300
[**2158-11-25**] 04:43AM BLOOD WBC-9.7 RBC-2.32* Hgb-6.9* Hct-21.5*
MCV-93 MCH-29.7 MCHC-32.1 RDW-17.6* Plt Ct-277
[**2158-11-26**] 04:15AM BLOOD WBC-12.3* RBC-2.80* Hgb-8.4* Hct-25.7*
MCV-92 MCH-29.9 MCHC-32.6 RDW-17.3* Plt Ct-303
[**2158-11-27**] 03:41AM BLOOD WBC-13.1* RBC-2.74* Hgb-8.2* Hct-25.8*
MCV-95 MCH-30.1 MCHC-31.9 RDW-17.1* Plt Ct-337
[**2158-11-28**] 04:21AM BLOOD WBC-10.3 RBC-2.69* Hgb-8.0* Hct-25.2*
MCV-94 MCH-29.6 MCHC-31.7 RDW-17.4* Plt Ct-307
[**2158-11-24**] 03:25PM BLOOD PT-14.6* PTT-41.9* INR(PT)-1.3*
[**2158-11-24**] 03:25PM BLOOD Plt Ct-300
[**2158-11-25**] 04:43AM BLOOD PT-17.5* PTT-50.8* INR(PT)-1.6*
[**2158-11-25**] 04:43AM BLOOD Plt Ct-277
[**2158-11-26**] 04:15AM BLOOD PT-15.6* PTT-42.5* INR(PT)-1.4*
[**2158-11-28**] 04:21AM BLOOD PT-16.1* PTT-150* INR(PT)-1.4*
[**2158-11-28**] 08:53AM BLOOD PT-16.0* PTT-62.5* INR(PT)-1.4*
[**2158-11-29**] 09:46AM BLOOD PT-14.3* PTT-58.1* INR(PT)-1.2*
[**2158-11-22**] 06:50PM BLOOD Glucose-110* UreaN-16 Creat-0.8 Na-133
K-4.7 Cl-99 HCO3-23 AnGap-16
[**2158-11-23**] 03:40AM BLOOD Glucose-87 UreaN-16 Creat-0.8 Na-134
K-4.5 Cl-102 HCO3-23 AnGap-14
[**2158-11-24**] 02:07AM BLOOD Glucose-104* UreaN-14 Creat-0.7 Na-136
K-4.4 Cl-102 HCO3-25 AnGap-13
[**2158-11-25**] 04:43AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-135
K-4.6 Cl-105 HCO3-21* AnGap-14
[**2158-11-27**] 03:41AM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-135
K-4.9 Cl-107 HCO3-19* AnGap-14
[**2158-11-29**] 05:13AM BLOOD Glucose-86 UreaN-18 Creat-0.8 Na-134
K-4.6 Cl-106 HCO3-21* AnGap-12
[**2158-11-25**] 04:43AM BLOOD Hapto-430*
[**2158-11-26**] 11:34AM BLOOD Vanco-23.8*
[**2158-11-25**] 04:43AM BLOOD Vanco-27.5*
[**2158-11-29**] 05:13AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.3 Mg-2.0
Brief Hospital Course:
69 yo female with extensive medical history now with pulmonary
and osseous mets, admitted for pneumothorax noted on outpatient
CT scan , admitted to [**Hospital Unit Name 153**] for hemodynamic monitoring and
surgical wound revision.
.
# pneumothorax: Pt with evidence of pneumothorax on chest CT,
thought to be secondary to possible communication between
surgical site and pleural fluid. R chest tube was place in ED
with good relief. Chest tube was originally placed to suction
with good result. The patient went for revision of the surgical
site on [**2158-11-23**] where the ffascia was closed and debrided.
Returned to the [**Hospital Unit Name 153**] in stable condition. Chest tube placed to
water seal the following day althouhg evidence on cxr of
enlarging pneumothorax was noted. Tube returned to suction.
After discussing goals of care with patient, the decision was
made to place the chest tube back on water seal with the hopes
of being able to d/c the tube and send the patient home. On
[**2158-11-27**] the chest tube was removed. She expressed a desire to
be home soon, so with those goals in mind, we allowed for slight
re-accumulation of PTX as long as she remained hemodynamically
stable.
.
# MRSA pleural fluid: Pt was continued on vancomycin for MRSA
noted in pleural fluid [**10-26**]. Given possible open communication
to surgical site, patient was taken back to the OR by
neurosurgery for wound irrigation and fascial closure. Tissue
cultures grew sparse growth of MRSA and rare growth of
acinetobacter, but given that her goals of care were to go home
on hospice and she did not appear to be clinically infected, we
decided not to treat with long-term antibiotics.
.
# metastatic RCC: Originally diagnosed in [**2142**] with lung mets in
[**2156**] and bony mets [**2157**] complicated by spinal cord compression
requiring stablization. She has had numerous radiation therapies
and chemotherapies but has not received any treatment since her
CVA in [**Month (only) 205**] of this year. Patient is currently not interested in
aggressive life sustaining measures and is DNR/DNI. Patient was
kept comfortable with home pain regimen augmented by additional
dilaudid following neurosurgery revision. On discharge, her oral
regimen of dilaudid and oxycontin was continued.
.
# pain control: patient's current pain regimen includes
oxycontin 40mg TID with dilaudid 4-6mg q3hr for pain. Per her
oncologist, she gets confused with too much opiates so use
dilaudid sparingly.
.
# hypertension: on valsartan at home, holding in setting of
hypotension. Goal BP per previous neurology notes SBP<140 given
recent stroke. Upon transfer to the floor, Ms. [**Known lastname 10309**] BP
remained in the 100-110/70-80 range and valsartan was not
restarted.
Medications on Admission:
anastrozole 1mg daily
enoxaparin 30mg q12 hr
hydromorphone 4-6 mg q3hr prn
levothyroxine 50mcg daily
ativan 0.5-1mg q6hr prn
ondansetron 4mg q8hr prn
oxycontin 40mg TID
prochlorperazine 10mg q6hr prn
simvastatin 10mg daily
valsartan 160mg daily
vancomycin 1g daily
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for breakthrough pain.
Disp:*120 Tablet(s)* Refills:*0*
3. ondansetron 8 mg Tablet, Rapid Dissolve Sig: [**1-15**] Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
4. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
Disp:*120 Tablet Extended Release 12 hr(s)* Refills:*0*
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Disp:*90 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stool.
Disp:*90 Tablet(s)* Refills:*2*
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. lorazepam 0.5 mg Tablet Sig: 0.5-2 Tablets PO Q4H (every 4
hours) as needed for anxiety/insomnia.
Disp:*90 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Hypertension
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 10265**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with shortness of breath which was discovered to be due
to air in the area around your lungs. This in turn was found to
be due to a communication between the pleural space (the space
between your lungs and chest wall) and your surgical wound from
early [**Month (only) 462**]. The neurosurgeons sealed this leak, and the
interventional pulmonologists drained as much air as they could
out of your chest. You still have some air within your chest,
but it is much decreased.
The following medication changes have been made:
STOP Valsartan
STOP Simvastatin
START Senna
START Colace
START bisacodyl as needed for
START tylenol 1000mg three times daily on a scheduled basis
INCREASE ativan to 0.25 to 1mg as needed every 4 hours for
anxiety
STOP LOVENOX
STOP Anastrozole
You will need to have the sutures on your back removed in 1
month
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2158-12-13**] at 2:30 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**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: WEDNESDAY [**2158-12-13**] at 2:30 PM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V15.3",
"V10.52",
"V12.54",
"511.89",
"285.22",
"E878.8",
"998.59",
"512.1",
"198.5",
"998.32",
"197.2",
"197.0",
"300.00",
"V10.3",
"998.6",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"83.44"
] |
icd9pcs
|
[
[
[]
]
] |
18918, 18988
|
14417, 17183
|
339, 416
|
19082, 19082
|
7038, 7038
|
20242, 20875
|
6042, 6129
|
17499, 18895
|
9316, 9403
|
19009, 19061
|
17209, 17476
|
19265, 20219
|
6144, 7019
|
2118, 2819
|
266, 301
|
9435, 14394
|
444, 2099
|
7055, 9276
|
19097, 19241
|
2841, 5838
|
5854, 6026
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,482
| 182,796
|
51983
|
Discharge summary
|
report
|
Admission Date: [**2195-5-30**] Discharge Date: [**2195-6-5**]
Date of Birth: [**2125-8-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 F DM2, CAD s/p mult stents, ischemic CM EF 25%, asthma,
recent admission to [**Hospital Unit Name **] in [**5-28**] was brought in by family after
a fall. Per husband. She fell face down on ground around 3 AM
and took her 2 hours to get up in bed stayed at home until this
AM. This AM granddaughter checked BS and was 79 at 10 AM and
was given her usual dose of 75/25 insulin.
On presentation to [**Hospital1 18**] ER, T 96.5 BP 114/44 HR 88 O2 95%4L,
inital BG was 8, 16, 65 and after eating 68. Given Medications
[**2-22**] amps of glucose, ASA 325, pancultured and started on D5 gtt.
At time of transfer to the ICU patient denied any complaints.
Patient not oriented to place or time.
Past Medical History:
# CAD s/p MI ([**2190**])
- known total occlusion of LAD and ramus w/ R->L collaterals
- aborted CABG ([**2190**]) d/t extensive calcification making it
impossible to cross clamp aorta
- s/p stents to LAD, LCx, OM, D2, ramus and RCA
# CHF: last echo [**3-28**] with EF 25%, 1+MR, infero-lateral and
distal LV/apical akinesis
- s/p dual chambered ICD [**2191-7-4**] for primary prevention
([**Company 1543**] [**Last Name (un) 24119**] DR)
# Hypertension
# Diabetes type 2
# Hyperlipidemia
# COPD (has been labelled as asthma, however CXR and ABGs more
c/w COPD along w/ long smoking hx)
# Depression
# h/o LV thrombus
# Carotid artery disease
- s/p R catorid artery stenting [**2189**]
# h/o cerebral infarction by MR in [**2190**]
# s/p ccy
# Likely dementia (?-Alzhemer's vs. Vascular)
Social History:
Originally from [**Location (un) 4708**]. She never knew her father and her
mother left her when she was very young. She grew up with a
[**Doctor Last Name **] family. She immigrated to America in the [**2157**]. She has 7
children and 13 grandchildren used to live with many of them in
a large 3-family house, but most recently was at NH. She used to
smoke about 1/2ppd for unclear amount of time and currently has
an occassional cigarette. She doesn't currently use alcohol
(previously used to only when "partying" - cannot quantify). She
has never used illicit drugs.
Family History:
Unknown hx of parents.
Physical Exam:
Flowsheet Data as of [**2195-5-30**] 11:57 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 35.3 ??????C (95.5 ??????F)
Tcurrent: 35.3 ??????C (95.5 ??????F)
HR: 67 (65 - 75) bpm
BP: 100/48(68) {91/48(59) - 100/60(68)} mmHg
RR: 23 (12 - 27) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 99%
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Wheezes : )
Abdominal: Soft, Non-tender, No(t) Distended
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Admit Labs/Studies:
--------------------
[**2195-5-30**] 01:30PM WBC-8.3 RBC-3.62* HGB-10.3* HCT-31.2* MCV-86
MCH-28.6 MCHC-33.2 RDW-17.1*
[**2195-5-30**] 01:30PM NEUTS-80* BANDS-0 LYMPHS-13* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-15*
[**2195-5-30**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2195-5-30**] 01:30PM PLT SMR-NORMAL PLT COUNT-253
[**2195-5-30**] 12:50PM GLUCOSE-16*
[**2195-5-30**] 01:30PM CK(CPK)-371*
[**2195-5-30**] 01:30PM CK-MB-12* MB INDX-3.2 cTropnT-0.08*
[**2195-5-30**] 10:45PM CK(CPK)-375*
[**2195-5-30**] 10:45PM CK-MB-9 cTropnT-0.17*
[**2195-5-31**] 04:31AM BLOOD CK-MB-8 cTropnT-0.16*
[**2195-5-31**] 04:31AM BLOOD CK(CPK)-351*
CT C-SPINE WITHOUT CONTRAST: Images were obatined from the skull
base through T1. There is essentially normal alignment with mild
grade I anterolisthesis of C3 on C4 and mild loss of
intervertebral disc space height at C6. There are no fractures
and no dislocation. Prevertebral soft tissues are normal. There
is no central canal stenosis.
IMPRESSION: No fracture or dislocation; minor degenerative
changes.
CT HEAD WITHOUT IV CONTRAST: There is no acute intracranial
hemorrhage, mass effect, or evidence of acute infarction.
Hypoattenuation and encephalomalacia within the right parietal
and occipital lobe are unchanged and consistent with old
infarcts. The ventricles and sulci are prominent, consistent
with age- related involutional changes. Osseous structures and
soft tissues are unremarkable.
IMPRESSION: No acute intracranial hemorrhage or infarction.
PORTABLE AP AND LATERAL CHEST RADIOGRAPHS: The heart size
remains enlarged, without evidence of pulmonary edema,
atelectasis or pneumonia. The lungs remain hyperinflated with
flattening of the diaphragms. No pneumothorax or pleural
effusion is seen. A left axillary pacemaker is again seen, with
continuously transvenous right atrial pacer lead and right
ventricular pacer defibrillator lead in unchanged position. The
patient is status post CABG, with unchanged appearance to median
sternotomy wires. Calcifications are again noted along the
aortic arch.
IMPRESSION: Stable moderate cardiomegaly and hyperinflation,
without evidence of acute intrathoracic process.
.
Other labs/Studies:
===================
[**2195-6-5**] 10:30AM BLOOD WBC-6.3 RBC-3.50* Hgb-9.5* Hct-30.6*
MCV-88 MCH-27.2 MCHC-31.0 RDW-16.6* Plt Ct-324
[**2195-6-2**] 06:40AM BLOOD WBC-5.9 RBC-3.39* Hgb-9.3* Hct-30.0*
MCV-88 MCH-27.5 MCHC-31.1 RDW-16.5* Plt Ct-269
[**2195-6-5**] 10:30AM BLOOD Neuts-65.5 Lymphs-25.2 Monos-7.5 Eos-1.3
Baso-0.4
[**2195-6-5**] 07:05AM BLOOD Glucose-147* UreaN-20 Creat-0.8 Na-133
K-4.9 Cl-99 HCO3-28 AnGap-11
[**2195-6-2**] 06:40AM BLOOD Glucose-175* UreaN-33* Creat-1.0 Na-138
K-5.2* Cl-98 HCO3-33* AnGap-12
[**2195-5-31**] 04:31AM BLOOD CK(CPK)-351*
[**2195-5-30**] 10:45PM BLOOD CK(CPK)-375*
[**2195-5-30**] 01:30PM BLOOD CK(CPK)-371*
[**2195-5-31**] 04:31AM BLOOD CK-MB-8 cTropnT-0.16*
[**2195-5-30**] 10:45PM BLOOD CK-MB-9 cTropnT-0.17*
[**2195-5-30**] 01:30PM BLOOD CK-MB-12* MB Indx-3.2 cTropnT-0.08*
[**2195-6-5**] 07:05AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1
[**2195-6-4**] 06:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.2
[**2195-6-3**] 06:35AM BLOOD Albumin-3.2* Calcium-8.2* Phos-2.6*
Mg-2.3
[**2195-5-30**] 03:55PM BLOOD Lactate-2.3*
[**2195-5-30**] 12:50PM BLOOD Glucose-16*
[**2195-5-30**] 01:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2195-5-30**] 01:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
[**2195-5-30**] 04:42PM URINE Hours-RANDOM UreaN-665 Creat-67 Na-28
TotProt-21 Prot/Cr-0.3*
[**2195-5-30**] 01:50PM URINE Hours-RANDOM
Blood Cx ([**5-30**]) - negative x 2
Urine Cx ([**5-30**]) - negative x 2
.
ECG ([**6-1**]):
Sinus rhythm
Left axis deviation - may be left anterior fascicular block but
is
nondiagnostic
Prior anterior myocardial infarction
Borderline prolonged/upper limits of normal Q-Tc interval - is
nonspecific
Clinical correlation is suggested
Since previous tracing of [**2195-5-31**], no significant change
.
CT Head ([**6-1**]):
FINDINGS: Comparison is made to [**2195-5-30**].
There are no intracranial hemorrhages or masses. The [**Doctor Last Name 352**]/white
matter
differentiation is maintained. Again seen is an old posterior
watershed
infarct of the right occipital lobe. There is a minimal amount
of
periventricular white matter hypodensities consistent with
chronic
microangiopathic change.
The visualized orbits are normal. The visualized paranasal
sinuses and
mastoid air cells are clear. Calcifications of the carotid
arteries are seen
bilaterally. There are no suspicious bony abnormalities.
IMPRESSION: No acute intracranial abnormalities. Old right
posterior
watershed infarct and minimal amount of chronic microangiopathic
change.
Brief Hospital Course:
69F h/o CAD s/p multiple stents, ischemic cardiomyopathy (EF
25%), DM2, asthma here with hypoglycemia, ARF after fall. She
was initially admitted to the ICU and then transferred to the
medicine floor.
.
1. Hypoglycemia
2. DM-2 Uncontrolled, with complications
Most likely etiology of hypoglycemia is from continuing to take
her baseline insulin in setting of acute renal insufficiency.
Also likely that she was getting more insulin than required as
she is not on steroids now and her dose was increased during her
last admission when she was on steroids. No evidence of
infection. She was given dextrose initially with improvement of
her blood sugar and mental status. Her home insulin was held
and she was placed on an insulin sliding scale. Patient
initially presented with hypoglycemic episode in setting of
increased insulin dose with some evidence of renal failure.
Started on Lantus during this admission, with dose titrated up
to 15 units. Also kept on humalog sliding scale. Fingersticks
were reasonably controlled on this regimen, however she did have
some values in the low 200s, and will need further monitoring
and adjusting of her dosage as an outpatient.
.
3. Acute Renal Failure
Likely in setting of volume depletion. Admission FeUrea < 35%
in setting of decreased urine output. Subsequently resolved
with hydration. Lisinopril and Lasix had been held, now
restarted. Cr continued to remain stable.
.
4. Heart Failure - chronic systolic and chronic diastolic
Last TTE showed EF of 25% w/ grade III diastolic dysfunction.
Did not appear volume overloaded. O2 sats well maintained on
room air. She was continued on Lasix, ACE-i, and B-blocker.
.
5. COPD - stable
Labelled as having asthma and previously denied heavy smoking
hx. However, last PFTs seemed more c/w emphysematous picture.
CXRs show large lung volumes and flattening of diaphragms. Also,
ABG shows evidence of chronic retainer. Has scattered wheezes.
She was continued on Albuterol and Atrovent nebs. While on the
medical floor, she remained off oxygen with O2 sats in the mid-
to high-90s. Given that she is a likely CO2 retainer, O2 sats
should not be kept high.
.
6. Coronary Artery Disease
Long/complex cardiac hx. Has had failed CABG in past. Currently
asymptomatic w/o chest pain/sob. Had troponin leak in setting of
demand and renal failure during this admission, however did not
have ACS. She was continued on ASA 325, [**Doctor Last Name **], Statin, and
B-blocker
.
7. LUE DVT - catheter associated
Had been on Lovenox/Coumadin on discharge from previous
admission. These were held on presentation to [**Hospital Unit Name 153**]. Was on
heparin gtt in [**Hospital Unit Name 153**] due to initial concern for ACS picture.
This was subsequently stopped. Plan had been to do one-month
course of anticoagulation for UE DVT. However, given patient's
waxing/[**Doctor Last Name 688**] mental status, tendency to pull out lines, recent
fall, and the fact that DVT was in the upper extremity, risk of
anticoagulation would likely outweigh any benefit. She was
maintained on prophylactic SC Heparin.
.
8. Depression
Stable. Continued on Paxil
.
9. Altered Mental Status/Likely dementia w/ recent fall and
episode of being non-verbal
Do not suspect there has been an acute change in mental status.
Given vascular hx, would consider multi-infarct dementia (vs.
early Alzheimer's dementia) as possible etiology for overall
confusion. Head CT did not show acute bleed or evidence of new
infarct. On the day of transfer to the floor, the patient was
non-verbal. She was able to follow commands, however seemed to
be more lethargic than usual and seemed unable to speak. A
repeat head CT did not show any acute findings. She
subsequently returned back to her baseline. Given the overall
poor mental status over the past few months, the patient would
benefit from outpatient neuropsychological testing and possibly
further imaging of her head.
.
10. Question of Paroxysmal A-fib
Patient was generally in sinus rhythm at a well controlled rate
while in house. However, per notes, has had episodes of A-fib
in the past. Anticoagulation issue discussed as above. Issue
of anticoagulation will have to be addressed as an outpatient.
She may benefit from an assessment of her disease burden (if
any) of the A-fib.
.
Disposition:
Patient failed at home given readmission. PT consult
recommended rehab. Discussed issue with patient's daughter,
[**Name (NI) 107611**]. [**Name2 (NI) 227**] strong family support and possibility of increased
services, along with family and patient's preference for patient
to go home, patient was discharged home with 24-hour
supervision.
Medications on Admission:
Clopidogrel 75 mg PO daily
Atorvastatin 20 mg PO daily
Paroxetine HCl 20 mg Tablet PO daily
Albuterol 90 mcg/Actuation Aerosol 2 puffs q4h:prn
Ipratropium Bromide 17 mcg/Actuation Aerosol 4 puff prn
Metoprolol Succinate 25 mg PO daily
Docusate Sodium 100 mg PO BID
Aspirin 325 mg PO daily
Enoxaparin 90 mg [**Hospital1 **]
Warfarin 5 mg daily
Furosemide 40 mg PO daily
Lisinopril 10 mg PO daily
Insulin 75/25, 32 units in AM and 10 units in PM
Fluticasone 220 mcg 2 puffs [**Hospital1 **]
Discharge Medications:
1. Hospital Bed Sig: as directed as directed: One hospital
bed for home.
Disp:*1 bed* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
6. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Lantus 100 unit/mL Solution Sig: as directed Subcutaneous
at bedtime: Take 15 units daily at night (unless directed
otherwise).
Disp:*1 vial* Refills:*2*
14. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
qAC qHS: Take as per sliding scale.
Disp:*1 vial* Refills:*2*
15. Insulin Syringes (Disposable) 1 mL Syringe Sig: as
directed Miscellaneous as directed.
Disp:*30 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypoglycemia
Type II Diabetes Mellitus
Acute Renal Failure
Heart Failure - chronic systolic and chronic diastolic
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Deep Venous Thrombosis (Left Upper Extremity)
Depression
Delirium with Likely Dementia
Discharge Condition:
Afebrile, vital signs stable. AAOx1.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
It is very important that you follow your blood glucose level
very carefully and record these. Your insulin was changed from
Insulin 75/25 twice daily to Insulin Glargine once daily (at
night) along with a sliding scale of insulin (Humalog) to be
given prior to meals. You should check your fingerstick 30
minutes prior to meals and give the insulin based on this. Keep
a log of these sugars and bring this to your doctor's visit.
.
You were on coumadin and Lovenox previously. However, since you
had a fall and the blood clot you were being treated for was in
the upper part of your body, these medications have been stopped
since the risk of the medication is likely greater than the
likely benefit.
.
It is very important that you take in an adequate amount of
fluid, particularly water, so that you do not get dehydrated.
.
Please call your doctor or return to the emergency room if you
should develop very low blood sugar, increased confusion, chest
pain, shortness of breath, high fever, or any other concerning
symptom.
Followup Instructions:
Primary Care: Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 3581**]. Tuesday [**6-9**] at 2:15pm.
|
[
"493.20",
"401.9",
"414.8",
"428.42",
"414.01",
"294.8",
"584.9",
"276.51",
"V45.02",
"272.4",
"293.0",
"250.82",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15240, 15297
|
8532, 13203
|
322, 328
|
15603, 15642
|
3610, 8509
|
16823, 16975
|
2469, 2493
|
13742, 15217
|
15318, 15582
|
13229, 13719
|
15666, 16800
|
2508, 3591
|
274, 284
|
356, 1054
|
1076, 1865
|
1881, 2453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,682
| 123,277
|
14545
|
Discharge summary
|
report
|
Admission Date: [**2131-9-5**] Discharge Date: [**2131-9-18**]
Date of Birth: [**2062-1-18**] Sex: M
Service:
DIAGNOSIS:
1. Ruptured abdominal aortic aneurysm.
2. Acute renal failure.
3. Respiratory insufficiency.
OPERATIONS: Repair of ruptured abdominal aortic aneurysm
[**2131-9-5**].
SUMMARY: This 69-year-old man was transported to [**Hospital1 346**] by helicopter. He had been seen at
another hospital for hypotension and CT scan demonstrated an
8 cm abdominal aortic aneurysm. The patient arrived in the
operating room at [**Hospital1 69**]
intubated with tachycardia of 110 and a blood pressure of
approximately 100 with intravenous fluids running.
HOSPITAL COURSE: The patient underwent immediate repair of
the ruptured abdominal aortic aneurysm. He was severely
hypotension throughout the procedure. The aneurysm involved
the origin of the renal arteries. Postoperatively, he was
transferred to the Intensive Care Unit and was there for the
remainder in the stay in the hospital.
Postoperatively, he was started on CVAD and efforts were
made to reduce the volume load. In addition, he required
intensive pulmonary support with initial PEEP of 20 and over
the next two weeks, constant efforts were made to improve
pulmonary function and remove excess volume. This was
difficult because at times cardiac function was compromised.
The patient required pressor agents through most of his
hospital stay.
At approximately day 18 of hospitalization, he developed
sepsis and became very difficult to sustain cardiac function.
His family expressed a very strong wish to provide comfort
measures only, and this was instituted on [**2131-9-17**], and the
patient expired on [**2131-9-18**].
A postmortem was obtained that showed the abdominal aortic
graft intact with intact suture lines. There was a large
retroperitoneal hematoma. There were pulmonary findings
consistent with diffuse alveolar damage. The left kidney was
infarcted and there was a perisplenic abscess.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern4) 27015**]
MEDQUIST36
D: [**2131-12-11**] 14:37
T: [**2131-12-12**] 04:48
JOB#: [**Job Number 30365**]
|
[
"458.2",
"518.81",
"996.73",
"038.49",
"997.5",
"441.3",
"584.5",
"276.2",
"482.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"38.44",
"96.72",
"88.72",
"38.95",
"89.64",
"96.6",
"99.15",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
698, 2290
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,228
| 151,469
|
54411
|
Discharge summary
|
report
|
Admission Date: [**2186-5-31**] Discharge Date: [**2186-6-2**]
Date of Birth: [**2124-6-6**] Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
EtOH Intoxication
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The patient is a 61 y/o M with PMHx of polysubstance abuse, who
is quite well known to the emergency department, who presented
to the ED in the setting of alcohol intoxication. Per report,
the patient was most recently in the emergency department this
morning with alcohol intoxication. He represented to the
emergency department this evening in a similar fashion.
In the ED, he was noted to have vomit in his airway. He was
intubated for airway protection with no complications. In the
ED, labs were significant for EtOH level of 494. Chem 7 did
reveal an AG. He was given clindamycin out of concern for
potential aspiration. CXR was unremarkable. Head CT was
remarkable for minimally displaced comminuted fractures of the
right maxillary sinus involving the anterior wall and right
inferior orbital floor as well as the posterior and medial
walls; also bilateral anterior nasal bone fractures. Plastic
surgery was consulted who recommended sinus precautions as well
as augmentin.
Of note, in the ED, he also underwent Wood's lamp exam given eye
erythema, which was negative.
Unable to obtain ROS on arrival to the ED as pt is intubated and
sedated.
Past Medical History:
ETOH abuse w/ reported history of seizures and DTs
Polysubstance abuse (heroin remotely, and cocaine more recently)
Chronic HCV infection
Remote history of vertebral osteomyelitis
Low Back Paim / Degenerative disease / Vertebral compression
fractures
Pseudo-seizures
Hypertension
Depression
Left parietal bone lesion NOS - ?atypical hemangioma
Calf injury [**2175**] with left gluteal transplant to left calf
Social History:
The patient is homeless, and drink half pint vodka daily. He
reports smoking [**1-27**] cigarettes daily for many years, could not
quantify. Denies any drug use.
Family History:
Reports family history of diabetes
Physical Exam:
Physical Exam:
Vitals: : 98.8 BP: 124/89 P: 94 R: 14 O2: 96% on CMV 500x16,
FiO2 50%, PEEP 5
General: Intubated, Sedated
HEENT: PERRL, c-collar in place, evidence of facial trauma
Neck: cervical collar in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses
Neuro: sedated, not responding to verbal or painful stimuli on
my exam
Pertinent Results:
[**2186-5-31**] 02:45PM BLOOD WBC-9.2 RBC-4.81 Hgb-13.5* Hct-41.2
MCV-86 MCH-28.2 MCHC-32.8 RDW-17.0* Plt Ct-384
[**2186-6-2**] 03:01AM BLOOD WBC-6.8 RBC-4.18* Hgb-11.6* Hct-35.2*
MCV-84 MCH-27.8 MCHC-33.0 RDW-17.0* Plt Ct-244
[**2186-6-2**] 03:01AM BLOOD Neuts-59.9 Lymphs-30.9 Monos-4.1 Eos-4.6*
Baso-0.5
[**2186-5-31**] 02:45PM BLOOD PT-11.1 PTT-30.9 INR(PT)-1.0
[**2186-5-31**] 02:45PM BLOOD Glucose-107* UreaN-9 Creat-0.9 Na-140
K-4.0 Cl-99 HCO3-24 AnGap-21*
[**2186-6-2**] 03:01AM BLOOD Glucose-103* UreaN-5* Creat-0.7 Na-138
K-3.2* Cl-98 HCO3-28 AnGap-15
[**2186-6-1**] 03:26AM BLOOD Calcium-7.6* Phos-3.8 Mg-1.6
[**2186-6-2**] 03:01AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.4*
[**2186-5-31**] 02:45PM BLOOD ASA-NEG Ethanol-494* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2186-5-31**] 03:02PM BLOOD Type-[**Last Name (un) **] Temp-37.1 pO2-82* pCO2-52*
pH-7.34* calTCO2-29 Base XS-0 Comment-GREEN TOP
[**2186-5-31**] 03:02PM BLOOD Lactate-3.3*
[**2186-5-31**] 03:14PM BLOOD O2 Sat-97
Brief Hospital Course:
HOSPITAL COURSE:
This is a 61 year old gentleman with PMHx of polysubstance
abuse, who is quite well known to the emergency department, who
presented to the ED in the setting of alcohol intoxication,
status post intubation for airway protection. He was admitted
to the medical intensive care unit for management of his airway.
He was extubated within 24 hours. Due to his frequent
admissions for alcohol detoxication and significant risk of
death associated with his frank inability to care for himself
secondary to severe alcohol dependance, a section 35 was
obtained to evaluate for mandated medical detox and substance
abuse rehabilitation.
.
ALCOHOL INTOXICATION: The patient was intubated in the field
for alcohol detoxication. He was extubated withing 24 hours. A
psychiatric evaluation was performed, there was no evidence of
mental illness other than severe alcohol dependance. The
patient was treated with valium for management of alcohol
withdrawal symptoms and was medically stable at the time of
discharge. He was given a multivitamin, folic acid and thiamine
prior to discharge.
.
DISPOSITION: Since [**2185-5-25**], the patient was seen in the
[**Hospital1 18**] emergency department 33 times for alcohol related visits
with 24 admissions to a medical unit for management of alcohol
dependance, withdrawal symptoms. In the last week (starting
[**5-26**]) he was seen in the ED 3 times with 3 admissions for
alcohol intoxication, the last resulting in intubation. The
patient has been seen by social work during his multiple
admissions where there documented that the patient has no
insignt into his alcohol depenance, does not admit that his
intoxication led to this admission. The patient has repeatedly
rejected any SW intervention to deal with substance abuse and
refuses to speak or commit to any other support for sobriety.
Given the frequency of admissions for alcohol dependance and his
high risk of death due to consequences of his substance abuse.
A section 35 was obtained, and the patient was transported by
police escort to court. It is strongly recommended that the
patient have medical detox and prolonged substance abuse
rehabilitation.
.
FACIAL FRACTURE: CT sinus revealed a new minimally displaced
comminuted fractures involving the right maxillary sinus and the
right orbital floor and junction of the maxilla and zygomatic
arch. Plastic surgery was consulted who recommended treatment
with Augmentin for 7 days and follow-up in plastic surgery
clinic. He was recommended to use afrin twice daily and
sudafed daily for four days as sinue precautions.
.
HYPERTENSION: Home dose of amlodipine initially held and then
restarted.
.
TRANSITIONS OF CARE:
- Section 35 court
- Continue Augmentin x 7 days, afrin twice daily and sudafed
daily for 4 days
Medications on Admission:
Medications (per OMR)
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
Discharge Medications:
1. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Capsule(s)
7. Afrin 0.05 % Aerosol, Spray Sig: One (1) Nasal twice a day
for 2 days.
Disp:*qS * Refills:*0*
8. Sudafed 30 mg Tablet Sig: One (1) Tablet PO once a day for 2
days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol Intoxication, Facial Fracture
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital for alcohol intoxication. You
were found after a fall. You required intubation (mechanical
ventilation) to assist you with breathing given the degree of
your intoxication. You were able to come off the ventilator
soon after admission to our intensive care unit. You were found
to have a facial fracture in the setting of your fall that was
evaluated by our plastic surgeons. You were started on a 7 day
course of antibiotics for treatment of this facial fracture.
Because of your recurrent admissions for alcohol intoxication
that is clearly interfering with your ability to function and
take care of your health, you were placed on a Section 35. This
is a court ordered mandate for professional detoxication. A
psychiatric evaluation was performed while you were here and
there was no evidence of mental illness other than severe
alcohol dependance. You are at high risk of death due to
consequences of your substance abuse.
You are strongly recommended to have medical admission for
professional detox.
CONTINUE Augmentin 875/125mg three times a day for 5 days
CONTINUE afrin twice daily for 2 additional days
CONTINUE sudafed daily for 2 additional days
Followup Instructions:
Plastic Surgery
Please call [**Telephone/Fax (1) 4652**] to schedule a follow-up for your facial
fracture.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"802.0",
"801.01",
"V60.0",
"401.9",
"293.0",
"305.1",
"303.01",
"276.2",
"802.6",
"802.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8115, 8121
|
3739, 3739
|
284, 296
|
8206, 8296
|
2722, 3716
|
9577, 9779
|
2112, 2149
|
7316, 8092
|
8142, 8185
|
6556, 7293
|
3756, 6410
|
8357, 9554
|
2179, 2703
|
226, 246
|
324, 1482
|
8311, 8333
|
6431, 6530
|
1504, 1915
|
1931, 2096
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,651
| 169,663
|
26482+26483
|
Discharge summary
|
report+report
|
Admission Date: [**2183-10-26**] Discharge Date: [**2183-10-30**]
Date of Birth: [**2103-3-30**] Sex: M
Service: CME
CHIEF COMPLAINT: Transfer from [**Hospital3 **] for cardiac
catheterization.
MAJOR SURGICAL/INVASIVE PROCEDURES:
1. Cardiac catheterization with stenting x 2.
2. Intra-aortic balloon pump.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
male with a history of diabetes presenting the sudden onset
of nausea, vomiting and chest pain that started the evening
prior to admission. The patient chest pain was prominent on
the left side, nonradiating, not associated with diaphoresis,
but kept the patient awake all night.
He presented in the morning to [**Hospital3 **] at 10 a.m.
where EKG revealed ST elevations in his inferior leads with
reciprocal elevations in V1-V6 and ST depressions in I and
AVL. At the outside hospital, his troponin I was 12.43.
He was transferred to [**Hospital6 256**]
for emergent cardiac catheterization.
On transfer he was on heparin drip and Integrilin drip. He
received Lopressor 5 mg IV x 3, Nitroglycerin drip, aspirin
and Plavix.
In the catheter lab, there was elevated right- and left-sided
filling pressures. Cardiac catheterization revealed two-
vessel coronary artery disease with thrombotic total
occlusion of the proximal RCA, 50% lesion at the mid LAD and
a totally occluded left circumflex which appeared to be
chronic disease with collaterals from the right and left. The
elevated left- and right-sided filling pressures were
indicative of RV infarct physiology.
During the procedure, the patient developed atrial
fibrillation and was hypotensive requiring intra-aortic
balloon placement, and a dopamine drip was started. A Cypher
stent was placed in the RCA.
On transfer to the CCU, the patient's blood pressures were
stable with maps in the 70s. On arrival he denied chest pain,
shortness of breath or recent dyspnea on exertion. He only
complained of back discomfort from lying flat.
PAST MEDICAL HISTORY: Diabetes on Glucotrol and Avandia.
CURRENT MEDICATIONS: Glucotrol and Avandia.
SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **]
is a former smoker. He denies illicit drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.3, heart
rate 91, respiratory rate 18, blood pressure 100/63 on
dopamine drip, O2 saturation 100% on 2 L nasal cannula.
General: The patient is an elderly male lying flat in bed,
breathing comfortably with nasal cannula, in no acute
distress. HEENT: Oropharynx clear. JVP flat. Cardiovascular:
Regular rate and rhythm. Normal S1 and S2. No murmurs,
gallops or rubs. Respiratory: Lungs clear to auscultation
bilaterally anteriorly. Abdomen: Normoactive bowel sounds.
Soft, nontender, nondistended. Extremities: 2+ DP pulses, 1+
PT pulses, no edema. Groin: Left Swan sheath and intra-aortic
balloon pump in place. No hematoma. No bruits.
PERTINENT RESULTS: Cardiac catheterization on [**2183-10-26**]:
1. Right dominant system with thrombotic total occlusion on
the right proximal RCA. Acute marginal and PDA were free
of disease. LMCA was unobstructed. Mid LAD had a 50%
lesion. LCX was totally occluded with chronic occlusion
in its mid course and received collaterals from the right
and left.
2. Left ventriculography was deferred.
3. Limited hemodynamics showed elevated left and right-sided
filling pressures with equalization consistent with RV
infarct physiology. The patient developed atrial
fibrillation and was hypotensive requiring intra-aortic
balloon placement.
4. Successful stenting of RCA with a 3.5 mm Cypher drug-
alluding stent.
[**2183-10-27**], portable chest x-ray: Intra-aortic balloon
pump tip present terminating approximately 2 cm below the
superior aspect of the aortic knob. A Swan-Ganz catheter was
present with the tip terminating in the region of the
pulmonary artery. The cardiac silhouette is in the upper
limits of normal size for technique. There is some crowding
of the pulmonary vascularity related to low lung volumes.
Mild atelectatic changes are observed in the right perihilar
region, with otherwise grossly clear lungs. A small amount of
fluid is seen in the minor fissure versus focal fissural
thickening.
[**2183-10-29**], cardiac catheterization:
1. Coronary angiography of this right dominant circulation
showed single-vessel CAD. The LMCA was free of disease.
The LAC had mild diffuse disease. The LCX was occluded in
the midvessels and fills the abridging collaterals. The
RCA had a widely patent stent.
2. Resting hemodynamics showed normal central aortic
pressure.
3. Successful stenting of the LCX with a 2.5 mm Cypher drug-
alluding stent, post dilated to 2.75 mm.
4. The left CFA arteriotomy site was closed with a 6 French
angio seal.
LABORATORY DATA: CBC on [**2183-10-26**], showed a WBC of
30.7, RBC 3.2, hemoglobin 10.8, hematocrit 32.1, MCV 100, MCH
33.6, platelets 119. CBC on [**2183-10-30**], showed a white
count of 30.3, hematocrit 28.1, MCV 100, platelets 113.
Admission INR was 1.1. Discharged INR on [**2183-10-30**],
was 1.1.
Cardiac enzymes starting on [**2183-10-26**], showed a CK of
2153 at 5:40 p.m. On 11:13 p.m., [**2183-10-26**], CK was
2259. On [**10-27**], 4:18 a.m., CK was 2295. On [**10-27**],
4:11 p.m., CK was 1817. On [**2183-10-28**], 4:20 a.m., CK
was 1158. On [**10-29**], 4:20 p.m., CK was 294. On [**2183-10-26**], 5:40 p.m., CKMB was 264, MB index 12.3, troponin
12.03. On [**2183-10-27**], 4:18 am, CKMB 153, MB index 6.7,
troponin 9.28; same day 4:11 p.m., CKMB 79, MB index 4.3,
troponin 6.20. On [**2183-10-28**], 4:20 a.m., CKMB 31, MB
index 2.7, troponin 4.8. On [**2183-10-29**], 4:20 p.m.,
CKMB 6. [**2183-10-30**], 5:22 a.m., CKMB 4, troponin 9.01.
LFTs on [**2183-10-30**], showed an ALT of 33, AST 41,
alkaline phosphatase 44, total bilirubin 0.5.
Chemistries on discharge showed a sodium of 139, potassium
4.7, chloride 104, bicarb 27, BUN 25, creatinine 1.5, glucose
154.
HOSPITAL COURSE: This is an 80-year-old male with diabetes
and right ventricular inferior MI status post stent to the
RCA and chronic left circumflex occlusion status post cardiac
catheterization with stenting to RCA and left circumflex,
status post intra-aortic balloon pump placed after
hypotensive episode during first cardiac catheterization, on
a dopamine drip, started on amiodarone for atrial
fibrillation.
1. Coronary artery disease, status post Cypher stents to RCA
and left circumflex: On admission the patient was on
heparin, Integrilin, Plavix, aspirin and statin. First
cardiac catheterization was complicated by hypotension
and atrial fibrillation. The patient was placed on a
dopamine drip which was weaned by the following day.
Intra-aortic balloon pump remained in place as we planned
for second cardiac catheterization for a left circumflex.
The patient remained in atrial fibrillation for the entire
time the intra-aortic balloon pump was in place. It was
removed after the second cardiac catheterization at which
time the atrial fibrillation resolved. The patient was
started on Coumadin for anticoagulation. He was also started
on amiodarone for rate control.
He was started on a beta-blockade and ACE inhibitor after
being weaned off the dopamine drip and tolerated this well.
He will be continued on aspirin, Plavix, Lipitor 8 mg p.o.
daily, Metoprolol 25 mg p.o. daily, and lisinopril 10 mg p.o.
daily. He will follow up with a cardiologist in [**12-8**] weeks.
1. Rhythm: The patient was in atrial fibrillation but
converted to normal sinus rhythm after removal of intra-
aortic balloon pump as mentioned above. He will continue
on amiodarone 400 mg p.o. daily for 2 weeks and then 200
mg daily thereafter. He will follow up with a
cardiologist as mentioned above. He will also continue on
anticoagulation with Coumadin and will have his INR
monitored by his cardiologist.
1. Diabetes: The patient was well controlled on insulin
sliding scale during his admission; however, he was
restarted on his oral medications as an outpatient.
1. Chronic renal insufficiency: The patient's baseline
creatinine is 1.5 per his primary care physician. [**Name10 (NameIs) **]
remained stable during his admission.
1. Increased white blood cell count: The patient has known
CLL per his primary care physician. [**Name10 (NameIs) **] baseline white
blood cell count is in the 30s. Currently he is not
receiving any treatment, and his white count remained at
his baseline in the low 30s throughout his admission.
CONDITION ON DISCHARGE: Chest-pain free, normal sinus
rhythm, hemodynamically stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSIS: Myocardial infarction status post
Cypher stents to right coronary artery and left circumflex.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. daily,
Atorvastatin 80 mg p.o. daily, Plavix 75 mg p.o. daily,
Warfarin 5 mg p.o. q.h.s., pantoprazole 40 mg p.o. daily,
Metoprolol succinate 25 mg sustained release 1 tablet p.o.
daily, lisinopril 10 mg p.o. daily, amiodarone 200 mg 2
tablets p.o. daily x 2 weeks, then 200 mg p.o. daily
thereafter, Glucotrol, Avandia.
DISCHARGE PLANS: Please call your primary care physician
immediately for follow up within 1 week. This follow up
should include rechecking your thyroid function, INR and
liver function tests. We will call you for a cardiology
follow up. If you have any problems at all, please call the
CCU at [**Telephone/Fax (1) 65432**]. If you do not hear from us regarding
follow up cardiology appointment tomorrow, please call this
number as well.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 65433**], [**MD Number(1) 65434**]
Dictated By:[**Last Name (NamePattern1) 65435**]
MEDQUIST36
D: [**2183-11-24**] 10:44:43
T: [**2183-11-24**] 12:29:21
Job#: [**Job Number 65436**]
Admission Date: [**2183-10-26**] Discharge Date: [**2183-10-30**]
Date of Birth: [**2103-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
transfer from [**Hospital **] hosp for cath
Major Surgical or Invasive Procedure:
1. Cardiac catheterization with stenting x 2.
2. Intra-aortic balloon pump.
History of Present Illness:
The patient is an 80-year-old male with a history of diabetes
presenting the sudden onset of nausea, vomiting and chest pain
that started the evening
prior to admission. The patient chest pain was prominent on the
left side, nonradiating, not associated with diaphoresis,but
kept the patient awake all night.
He presented in the morning to [**Hospital3 **] at 10 a.m. where
EKG revealed ST elevations in his inferior leads with reciprocal
elevations in V1-V6 and ST depressions in I and VL. At the
outside hospital, his troponin I was 12.43.He was transferred to
[**Hospital6 256**] for emergent cardiac
catheterization.
On transfer he was on heparin drip and Integrilin drip. He
received Lopressor 5 mg IV x 3, Nitroglycerin drip, aspirin and
Plavix. In the cath lab, there was elevated right- and
left-sided filling pressures. Cardiac catheterization revealed
two vessel coronary artery disease with thrombotic total
occlusion of the proximal RCA, 50% lesion at the mid LAD and a
totally occluded left circumflex which appeared to be chronic
disease with collaterals from the right and left. The elevated
left- and right-sided filling pressures were
indicative of RV infarct physiology. During the procedure, the
patient developed atrial fibrillation and was hypotensive
requiring intra-aortic
balloon placement, and a dopamine drip was started.
On transfer to the CCU, the patient's blood pressures were
stable with MAPs in the 70s. On arrival he denied chest pain,
shortness of breath or recent dyspnea on exertion. He only
complained of back discomfort from lying flat.
Past Medical History:
Diabetes Mellitus -on glucotrol, avandia
Social History:
The patient lives at home with his wife. [**Name (NI) **]
is a former smoker. He denies illicit drug use.
Family History:
non-contributory
Physical Exam:
Vital signs: Temperature 98.3, heart rate 91, respiratory rate
18, blood pressure 100/63 on dopamine drip, O2 saturation 100%
on 2 L nasal cannula.
General: The patient is an elderly male lying flat in bed,
breathing comfortably with nasal cannula, in no acute distress.
HEENT: Oropharynx clear. JVP flat.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No
murmurs,
gallops or rubs.
Respiratory: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Normoactive bowel sounds. Soft, nontender,
nondistended. Extremities: 2+ DP pulses, 1+ PT pulses, no edema.
Groin: Left Swan sheath and intra-aortic balloon pump in place.
No hematoma. No bruits.
Pertinent Results:
Cardiac catheterization on [**2183-10-26**]:
1. Right dominant system with thrombotic total occlusion on
the right proximal RCA. Acute marginal and PDA were free
of disease. LMCA was unobstructed. Mid LAD had a 50%
lesion. LCX was totally occluded with chronic occlusion
in its mid course and received collaterals from the right
and left.
2. Left ventriculography was deferred.
3. Limited hemodynamics showed elevated left and right-sided
filling pressures with equalization consistent with RV
infarct physiology. The patient developed atrial
fibrillation and was hypotensive requiring intra-aortic
balloon placement.
4. Successful stenting of RCA with a 3.5 mm Cypher drug-
alluding stent.
.
[**2183-10-29**], cardiac catheterization:
1. Coronary angiography of this right dominant circulation
showed single-vessel CAD. The LMCA was free of disease.
The LAC had mild diffuse disease. The LCX was occluded in
the midvessels and fills the abridging collaterals. The
RCA had a widely patent stent.
2. Resting hemodynamics showed normal central aortic
pressure.
3. Successful stenting of the LCX with a 2.5 mm Cypher drug-
alluding stent, post dilated to 2.75 mm.
4. The left CFA arteriotomy site was closed with a 6 French
angio seal.
LABORATORY DATA:
CBC on [**2183-10-26**], showed a WBC of 30.7, hematocrit 32.1,
MCV 100, platelets 119.
CBC on [**2183-10-30**], showed a WBC 30.3, hematocrit 28.1,
MCV 100, platelets 113.
Admission INR was 1.1. Discharged INR on [**2183-10-30**],
was 1.1.
Cardiac enzymes:
[**2183-10-26**]:
CK of 2153 at 5:40 p.m., 2259 11 p.m.
On [**10-27**], CK was 2295 4:18 a.m., and CK was 1817 at 4 pm.
On [**2183-10-28**], 4:20 a.m., CK was 1158, On [**10-29**],
4:20 p.m., CK was 294.
CK-MBs trended as follow 264 with an index of 12.3 and a
troponin of 12.03 at 5:40 pm on [**10-26**] to CKMB 153, MB index 6.7,
troponin 9.28 on the morning of [**10-27**] to CKMB 79, MB index 4.3,
troponin 6.20 that afternoon and continued to trend down the
following day [**10-28**] to CKMB 31, MB
index 2.7, troponin 4.8. to CKMB 4, troponin 9.01 on [**10-30**].
LFTs on [**2183-10-30**], showed an ALT of 33, AST 41,
alkaline phosphatase 44, total bilirubin 0.5.
Chemistries on discharge showed a sodium of 139, potassium
4.7, chloride 104, bicarb 27, BUN 25, creatinine 1.5, glucose
154.
Brief Hospital Course:
This is an 80-year-old male with diabetes and right ventricular
inferior MI status post staged procedure with stent to the RCA
followed by repeat catheterization with stenting to the left
circumflex, and status post intra-aortic balloon pump placed
after hypotensive episode during first cardiac catheterization,
started on amiodarone for atrial fibrillation.
1. Coronary artery disease, status post Cypher stents to RCA and
LCX: On admission the patient was on heparin, Integrilin,
Plavix, aspirin and statin. First cardiac catheterization was
complicated by hypotension and atrial fibrillation requiring
IABP placement, doapamine drip and then amiodarone loading for
atrial fibrillation. The dopamine drip was weaned by the
following day but IABP remained in place for second cardiac
catheterization for a left circumflex lesion. The second
catheterization was uncomplicated and a cypher stent was placed
in the LCX. The patient remained in atrial fibrillation for the
entire time the intra-aortic balloon pump was in place. It was
removed after the second cardiac catheterization at which
time the atrial fibrillation resolved. The patient was started
on Coumadin for anticoagulation. He was also started on
amiodarone for rate control. In addition, he was started on a
beta-blockade and ACE inhibitor after being weaned off the
dopamine drip and tolerated this well. He will be continued on
aspirin, Plavix, Lipitor 80 mg p.o. daily, Metoprolol 25 mg p.o.
daily, and lisinopril 10 mg p.o. daily. He will follow up with a
cardiologist in [**12-8**] weeks.
2. Rhythm: The patient was in atrial fibrillation but converted
to normal sinus rhythm after removal of intra- aortic balloon
pump removal as mentioned above. He will continue on amiodarone
400 mg p.o. daily for 2 weeks and then 200 mg daily thereafter.
He will also continue on anticoagulation with Coumadin and will
have his INR monitored by his cardiologist.
3. Diabetes: The patient was well controlled on insulin sliding
scale during his admission. He was restarted on his oral
medications as an outpatient.
4. Chronic renal insufficiency: The patient's baseline
creatinine is 1.5 per his primary care physician. [**Name10 (NameIs) **] remained
stable during his admission.
5. Increased white blood cell count: The patient has known CLL
per his primary care physician. [**Name10 (NameIs) **] baseline white blood cell
count is in the 30s. Currently he is not
receiving any treatment, and his white count remained at his
baseline in the low 30s throughout his admission.
Medications on Admission:
Glucotrol, avandia
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Name10 (NameIs) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name10 (NameIs) **]:*30 Tablet(s)* Refills:*6*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name10 (NameIs) **]:*30 Tablet(s)* Refills:*6*
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
[**Name10 (NameIs) **]:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Name10 (NameIs) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
[**Name10 (NameIs) **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name10 (NameIs) **]:*30 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 weeks: Take two per day for two weeks followed by one per
day until changed by your doctor.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
9. Glucotrol Oral
10. Avandia Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial infarction
Discharge Condition:
Good
Discharge Instructions:
Take all of your medications as directed.
.
Keep all of your follow up appointments.
.
The following changes have been made to your medications:
1. You are now taking amiodarone for your heart rate. You should
take 400 mg once per day for 14 days and then 200 mg once per
day thereafter.
2. You are also on coumadin 5 mg once per day at bedtime.
Followup Instructions:
Please call your PCP immediatley for followup within one week.
This followup should include rechecking your thyroid function
tests, INR and liver function tests.
We will call you for cardiology followup.
If you have any problems at all, please call the CCU at
[**Telephone/Fax (1) 65432**]. If you do not hear from us regarding a followup
cardiology appointment tommorow, please call this number.
|
[
"410.71",
"250.00",
"414.01",
"427.31",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"37.22",
"88.55",
"00.66",
"99.20",
"00.40",
"37.61",
"88.52",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
19326, 19332
|
15399, 17941
|
10375, 10455
|
19397, 19403
|
12987, 14557
|
19797, 20199
|
12266, 12284
|
18010, 19303
|
19353, 19376
|
17967, 17987
|
6083, 8687
|
19427, 19774
|
12299, 12968
|
2276, 2941
|
14574, 15376
|
10292, 10337
|
2070, 2094
|
10483, 12063
|
12085, 12127
|
12143, 12250
|
8712, 8815
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,019
| 102,960
|
51395
|
Discharge summary
|
report
|
Admission Date: [**2125-8-16**] Discharge Date: [**2125-9-8**]
Date of Birth: [**2073-11-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old
male with end stage liver disease secondary to hepatitis C
cirrhosis and end stage renal disease secondary to membranous
proliferative glomerulonephritis who presented for
simultaneous liver and kidney transplant. The patient has
had some reported episodes of hepatic encephalopathy although
none directly prior to admission. The patient was also on
hemodialysis three times a week. The patient denies fevers
or chills, nausea, vomiting, chest pain, shortness of breath.
PAST MEDICAL HISTORY:
1. End stage liver disease secondary to hepatitis C.
2. End stage renal disease secondary to membranous
proliferative glomerulonephritis.
3. Hepatitis C cirrhosis.
4. Hypertension.
5. Esophageal varices, although no bleeds.
6. Gastroesophageal reflux disease.
7. Peripheral neuropathy.
8. History of VRE.
PAST SURGICAL HISTORY: Significant for right arm AV graft,
cholecystectomy.
MEDICATIONS ON ADMISSION:
1. Mycelex.
2. Tums.
3. Metoprolol 100 b.i.d.
4. Prevacid 30 b.i.d.
5. Amitriptyline 30 q.h.s.
6. Epogen.
7. Coumadin 4 q.h.s.
8. Celexa 10 q day.
9. Norvasc 10 q day.
10. Lactulose 30 prn.
11. Milk of Magnesia 30 prn.
SOCIAL HISTORY: Significant for alcohol use, intravenous
drug use, and 13 pack year history of smoking.
PHYSICAL EXAMINATION: The patient was in no acute distress.
Alert and oriented times three. Neck was supple. No JVD.
Regular rate and rhythm. No murmur. Clear to auscultation
bilaterally. Abdomen was soft, nontender, nondistended.
Positive bowel sounds. Extremities no lower extremity edema.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2125-8-16**]. Attending surgeon Dr. [**Last Name (STitle) **], assistant Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. For complete account please see
operative reported dated [**2125-8-16**] for both orthotopic liver
transplant and cadaveric kidney transplant. Postoperatively,
the patient was admitted to the Intensive Care Unit per
protocol. Intensive Care Unit course was unremarkable. The
patient was transferred to the floor on postoperative day
number eight. Delay in transfer was only due to bed
availability issues. Upon transfer to the floor the patient
had a creatinine of 2.2, ALT 105, AST 32, alkaline
phosphatase 104 and total bilirubin 2.3. On postoperative
day number ten the patient's immunosuppression regimen went
as follows, Cyclosporin 100 mg b.i.d., Prednisone 20 mg q
day, CellCept [**Pager number **] mg b.i.d. Cyclosporin levels were being
adjusted daily per level. On postoperative day number 11 the
patient's JP output picked up to 180 cc and JP output
creatinine was noted to be 15.5. The patient was examined by
CT to evaluate for possible leak. CT scan was normal.
Ultrasound, however, approximately 7 by 2 by 2 cm fluid
collection superomedial to the transplanted kidney.
Treatment at that time was decided to be leave the JP drain
in until output was minimal as well as the Foley.
Contributing to this treatment plan was the fact that the
patient suffers from benign prostatic hypertrophy.
On postoperative day number 13 the patient began to get
increasingly agitated and began to have mental status
changes. A sitter was written for in order to watch the
patient. Psychiatric consult was also obtained recommending
Haldol to treat the patient's agitation. By postoperative
day number 15 the patient became increasing agitated,
actively hallucinating and frankly delirious and psychotic.
The patient requiring 4 point leather restraints at times.
Haldol seemed to have no effect. Later on postoperative day
fifteen the patient began to have respiratory difficulties
and the patient was transferred to the Intensive Care Unit
and was intubated and sedated. The patient remained
intubated in the Intensive Care Unit for a day and a half at
which time CT scan revealed a right lower lobe consolidation.
The patient received bronchoscopy to reopen atelectally
collapsed right lower lobe. Cultures from that consolidation
had been negative to date. The patient was placed on Zosyn
for a ten day course for empiric treatment of pneumonia. The
patient was then taken off Cyclosporin for a presumptive
Cyclosporin induced psychosis and delirium. After extubation
the patient quickly returned to baseline mental status. He
remembered vividly his episodes of confusion. The patient
was started on Prograf and got to a therapeutic level of 10.
On postoperative day number 20 the patient was found to have
on ultrasound duplex of the central veins a nonocclusive
thrombus on the right IJ. On [**2125-9-5**] the patient went back
to the Operating Room for ligation of right arm AV fistula
prior to which the patient had marked right upper extremity
edema. Postoperative day number 21 from the liver kidney
transplant the patient returned to the floor doing well. The
patient's staples were removed and Steri-Strips were applied.
Postoperative day number 22 status post kidney liver
transplant and on Zosyn day eight for right lower lobe
pneumonia the patient remained afebrile, vital signs were
stable. JP drain was discontinued for minimal output.
Creatinine was 1.1, AST 20, ALT 27, alkaline phosphatase 82,
total bilirubin 0.7. The patient's mental status was at
baseline. The patient was therapeutic on Prograf 2 mg b.i.d.
dose being adjusted daily for levels. Also postoperative day
number 22 hepatitis C viral load continued to be negative.
The patient's wound was clean, dry and intact and preliminary
read of an ultrasound of the transplanted kidney revealed no
detectable fluid collection. The patient's Foley still in
place. The Foley is to remain in place for one to two weeks.
The patient at this time was deemed well enough and go be
discharged to a rehabilitation center and then to home
thereafter with close follow up with the transplant center.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital3 **].
DISCHARGE DIAGNOSES:
1. Status post cadaveric renal transplant.
2. Status post orthotopic liver transplant.
3. Hepatitis C cirrhosis.
4. End stage renal disease secondary to membranous
proliferative glomerulonephritis.
5. Hypertension.
6. Right lower lobe pneumonia.
DISCHARGE MEDICATIONS:
1. Tacrolimus 2 mg po b.i.d.
2. Percocet one to two tabs po q 4 to 6 hours prn.
3. Protonix 40 mg po q day.
4. Diflucan 200 mg po q day.
5. Multivitamins once a day.
6. Valcyte 450 mg po q day.
7. Metoprolol 100 mg po b.i.d.
8. Ipratropium bromide MDI q 4 to 6 hours prn.
9. Albuterol q 6 hours prn.
10. Prednisone 15 mg po q day.
11. Doxazosin 2 mg po q.h.s.
12. Amlodipine 5 mg po q day.
13. CellCept [**Pager number **] mg po b.i.d.
14. Bactrim single strength one tab po q day.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] on
[**2125-9-12**] at 9:50, with Dr. [**Last Name (STitle) 497**] on [**2125-9-19**] at 9:40 a.m. Both
appointments at the Transplant Center.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name (STitle) 106550**]
MEDQUIST36
D: [**2125-9-7**] 11:33
T: [**2125-9-7**] 11:57
JOB#: [**Job Number 106551**]
|
[
"571.2",
"V45.1",
"486",
"585",
"581.2",
"570",
"518.82",
"070.54",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"39.53",
"55.69",
"39.95",
"99.15",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6142, 6395
|
6418, 6915
|
1104, 1335
|
1759, 6046
|
1024, 1078
|
6927, 7399
|
1464, 1741
|
160, 664
|
686, 1000
|
1352, 1441
|
6071, 6121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,460
| 176,627
|
49047
|
Discharge summary
|
report
|
Admission Date: [**2131-9-23**] Discharge Date: [**2131-9-25**]
Date of Birth: [**2060-9-5**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Chief Complaint: "Droop"
.
Reason for MICU transfer: DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 year old female w/ diabetes, htn, on ASA/plavix p/w
experssive aphasia x 2-3 days brought back by EMS after being
signed out AMA earlier today. earlier today she had been
evaluated for aphasia which neurology thought at that time not
to be an acute neurological problem. However patient was found
to be hyperglycemic to FSBG 440. She has had similar
presentations in the past, seen by neuro and attributed to
hyperglycemic episodes. Now, pt states her speech is more
garbled than normal and her daughter also noticed the same over
the telephone. Denies HA, cp/sob, numbness, weakness, tingling,
gait problems or other symptoms.
.
In the ED, initial vitals were 99.4 108 124/46 22 99%. Physical
exam showed no clear neuro deficits and patient had a
fluctuating level of consciousness. Labs were significant for a
glucose of 705 and 136/4.4/99/17/31/1.1
.
Seen earlier today for expressive aphasia by neurology who felt
unlikely to be stroke. Hyperglycemia with waxing/[**Doctor Last Name 688**]
consciousness but she left AMA. Now BS 700's with AG. No
insight into medical condition currently. 8 SC regular insulin
and then on insulin drip. Clear CXR. No other symptoms. Given
2L IVF.
Past Medical History:
--HTN
--hyperlipidemia
--DM Type 1 ([**First Name8 (NamePattern2) **] [**Last Name (un) **] notes): has had problems with
hypoglycemia unawareness, last HgbA1C 10.8 in [**10-26**], missed last
[**Last Name (un) **] appointment [**2128-3-4**]
--CAD:
[**11-21**] cath:LAD stent
[**2-22**] cath: LAD stent with 95% instent restenosis, successful
ptca
[**10-22**]: cath LAD stent widely patent, 50% L cx lesion, RCA
diffusely diseased to 60%
Per Dr. [**Last Name (STitle) **] [**1-23**] discussion - will need to stay on plavix
indefinitely.
[**5-25**] ETT MIBI: EKG changes and some throat tightness, mod inf
wall ref defect.
Per Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] continue medical management of CAD.
--?TIA: admitted for dysarthria in [**2124**], MRI/MRA brain normal,
EEG w/ no epileptiform activity
--glaucoma of right eye
--prosthetic left eye
Social History:
Lives with her husband who she cares for. In the past (per OMR)
she denies cigarette smoking and illicit drug use. She had
drunk
EtOH daily but had not for many years. She reportedly has lost
significant weight [**2-21**] husband's illness
Family History:
Family history is negative for strokes, seizures, or
peripheral nerve palsies. Diabetes is present in her sister and
aunt. [**Name (NI) **] sister also had stomach cancer.
Physical Exam:
Admission Physical Exam:
Vitals: Tcurrent: 37.5 ??????C (99.5 ??????F), HR: 102, BP: 155/70(91)
mmHg, RR: 22 insp/min, SpO2: 100%
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, III/VI holosystolic
murmur heard best LUSB, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema .
Exam on Discharge:
VS: 97.7, 110/52, 62, 14, 100% RA
General: AAOx3, in NAD
HEENT: MMM, PEERLA
Lungs: CTAB, no wheezes, rales or rhonchi
Cardiac: RRR, 3/6 systolic mumur heard best at LUSB radiating to
the carotids. NO rubs or gallops
Abdomen: soft, nontender, nondistended
Extremities: Warm, well perfused, 2+ DP pulses bilaterally, no
edema.
Neuro: CN II-XII intact, 5/5 strength in UE bilaterally and
lower extremities bilaterally. Gait stable.
Pertinent Results:
Images:
.
[**2131-9-23**] CTA Head/neck: No hemorrhage large territorial infarct or
acute process on non-contrast scan. Small vessel ischemic
changes. CTA and perfusion imaging in progress.
[**2131-9-23**] CT head w/o contrast: No acute intracranial process.
[**2131-9-23**] CXR: Limited study with low lung volumes, but otherwise
no acute pulmonary process noted.
EKG: NSR, poor R wave progression
TTE [**2131-9-25**] The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. There is moderate
(non-obstructive) focal hypertrophy of the basal septum. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). There is no left
ventricular outflow obstruction at rest or with Valsalva. Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Labs on Admission:
[**2131-9-22**] 05:15PM BLOOD WBC-10.7# RBC-4.49 Hgb-12.7 Hct-37.8
MCV-84 MCH-28.2 MCHC-33.5 RDW-13.0 Plt Ct-274
[**2131-9-22**] 05:15PM BLOOD Neuts-81.5* Lymphs-14.0* Monos-3.6
Eos-0.7 Baso-0.2
[**2131-9-22**] 05:15PM BLOOD UreaN-27* Creat-1.1
[**2131-9-22**] 05:19PM BLOOD Type-[**Last Name (un) **] pH-7.41 Comment-GREEN-TOP
[**2131-9-22**] 05:19PM BLOOD Glucose-460* Lactate-1.9 Na-142 K-4.8
Cl-99 calHCO3-27
[**2131-9-22**] 05:19PM BLOOD freeCa-1.20
Labs on Discharge:
[**2131-9-25**] 06:30AM BLOOD WBC-6.4 RBC-3.94* Hgb-11.3* Hct-32.9*
MCV-84 MCH-28.8 MCHC-34.5 RDW-12.7 Plt Ct-205
[**2131-9-25**] 06:30AM BLOOD Neuts-51.3 Lymphs-39.7 Monos-6.3 Eos-2.4
Baso-0.3
[**2131-9-25**] 06:30AM BLOOD Glucose-282* UreaN-13 Creat-0.6 Na-139
K-4.3 Cl-103 HCO3-29 AnGap-11
[**2131-9-25**] 06:30AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
Pertinent labs:
[**2131-9-23**] 05:50AM BLOOD ALT-22 AST-19 LD(LDH)-246 CK(CPK)-208*
AlkPhos-140* TotBili-1.2
[**2131-9-23**] 01:50AM BLOOD cTropnT-<0.01
[**2131-9-23**] 05:50AM BLOOD CK-MB-4 cTropnT-<0.01
[**2131-9-23**] 08:27AM BLOOD VitB12-1060*
[**2131-9-23**] 05:50AM BLOOD TSH-0.88
[**2131-9-23**] 08:27AM BLOOD Ethanol-NEG
[**2131-9-23**] 05:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2131-9-23**] 06:11AM BLOOD Type-ART Temp-37.3 Rates-/18 FiO2-20
pO2-84* pCO2-34* pH-7.44 calTCO2-24 Base XS-0 Intubat-NOT INTUBA
[**2131-9-23**] 06:11AM BLOOD Glucose-311* Lactate-1.1 Na-146* K-3.9
Cl-109*
Microbiology:
[**2131-9-22**] URINE CULTURE (Final [**2131-9-25**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
[**2131-9-23**] RAPID PLASMA REAGIN TEST (Final [**2131-9-25**]):
NONREACTIVE.
Reference Range: Non-Reactive.
Brief Hospital Course:
71 y/o F w/ CAD, HTN, TIA, HLD presenting to ED w/ AMS and
glucose of 704 and found to be in DKA.
#DKA: On presentation to the ED, FSBG 705 with 40 ketones/1000
glucose in urine. She was admitted to the ICU where she was
aggressively given IVF for hypovolemia, repleted with potassium,
and contiued on insulin drip + dextrose until her anion gap was
within normal limits at which time the patient was given her
usual basal dose of 15U humalog and put onto lantus sliding
scale. She was transferred to the floor where she seen by
[**Hospital1 **] physicians who helped in adjusting her sliding scale.
After one day on the floor her BS were under better control. She
no longer had a gap and was tolerating PO.
It is unknown what the percipiting event for this patient's DKA
was. CXR clear, WBC wnl, U/A clean. LFTs/trop/lipase
unremarkable. Now with leukocytosis this AM and low grade fever,
but still no clear source of infection. Patient endorses full
compliance with home insulin regimen. After discharge, it was
noted on her Microbiology results that she had 10,000 GPC in
her urine culture. Her UA was negative for infection; suspect
colonization or contamination. As she denied any dysuira or
urinary symptoms and had a negative UA she was not treated
inpatient for a UTI, and was afebrile throughout her stay. She
will follow up with PCP [**Last Name (NamePattern4) **] [**2131-9-28**].
#Neuro/Aphasia/Altered Mental Status: Upon presentation, the
patient had an expressive aphasia in which she was unable able
to follow commands but would answer questions inappropriately
and with repetitive words and phrases. Altered mental status
likely [**2-21**] to hyperglycemia as it has markedly improved now with
decrease in glucose. NCHCT shows no acute infarct/hemorrhage.
Her CTA was negative at the time of discharge. As her blood
sugars were brought under control her speech improved. Neurology
was consulted when she was in the emergency room and felt that
this was most likely due to her hyperglycemia.
#Leukocytosis: The patient did have a transient leukocytosis of
15.9 which resolved at time of admission which was thought to be
a result of stress response.
#Pulmonary HTN: A TTE was performed to evaluate finding
concerning for pulmonary hypertension including loud [**3-25**]
systolic murmur at LUSB, large R pulmonary artery on CXR, and
poor R wave progression on EKG. The findings were consistent
with previous TTE, and did not require any further interventions
during this admission.
#Chronic Issues: Patient was continued on home medications
amlodipine 5 mg, isosorbide mononitrate 30 mg, lisinopril 40 mg,
and metoprolol 25mg for hyptertension, atorvastatin 40 mg for
hyperlididemia, aspirin 325 mg/clopidogrel 75 mg for
vasculopathy.
Transitional Issues:
Patient has follow up with a certified diabetes educator at 2pm
on [**2131-9-27**] at [**Hospital1 **]
Patient has follow-up with her PCP [**Last Name (NamePattern4) **] [**9-28**]
Pending tests- [**2131-9-22**]- Blood culture- PENDING
-Sliding scale was changed, and she was increased to 16U Lantus
qhs per [**Hospital1 4087**]
-Patient was found to have positive urine culture after
discharge. This will need to be addressed by her PCP [**Last Name (NamePattern4) **] [**9-28**]
whether or not she needs treatment as she is asymptomatic.
Medications on Admission:
Medications:
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
daily
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - one Tablet(s) by mouth
once
a day no substitutions - No Substitution
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 16 units at bedtime 3 month supply
INSULIN LISPRO [HUMALOG KWIKPEN] - 100 unit/mL Insulin Pen -
take
per sliding scale qid up to 64 units per day
ISOSORBIDE MONONITRATE [IMDUR] - 30 mg Tablet Extended Release
24
hr - one Tablet(s) by mouth daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
.
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use as
directed four times a day and as needed
LANCETS,THIN - Misc - USE AS DIRECTED FOUR TIMES A DAY
ONE TOUCH ULTRA SYSTEM - Kit - AS DIRECTED FOR TESTING BLOOD
SUGAR
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Sixteen
(16) Subcutaneous at bedtime.
9. insulin lispro 100 unit/mL Insulin Pen Sig: please take per
sliding scale Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: DKA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 102927**],
It was a pleasure taking care of you while you were admitted
here at [**Hospital1 18**].
You were brought into the hospital for concern that your speech
was not making sense and that you might be having a stroke. You
were found to have an elevated blood sugar of 704. Neurology
saw you and felt that these symptoms were from your elevated
blood sugar and not from a stroke. As your blood sugar improved
your speech improved to normal. You were admitted to the
intensive care unit for diabetic ketoacidosis which can be a
life threatening condition when your blood sugar gets too high.
After your condition improved and was no longer critical you
were transferred to the general medical floor and we continued
to monitor your blood sugars and blood tests. You were
tolerating eating and drinking well at the time of discharge and
able to walk around well. We were unable to figure out why you
had such high blood sugars (sometimes it can be caused by
infections or not taking medications however you did not have
anything on our workup to indicate you have an infection).
Transitional issues:
Your blood sugars have been high and need to be checked while
you are at home.
- Check your blood sugar 4 times per day, pre-breakfast,
pre-lunch, pre-dinner, post-dinner.
The following changes were made to your insulin treatment plan
while you were here (per [**Hospital1 **]).
1.We increased your nighttime lantus to 16U
2.Your sliding scale should be as follows (see attached sheet to
use for your sliding scale)
Comments: IF BLOOD GLUCOSE < 150 AT BEDTIME HAVE 4 PEANUT BUTTER
CRACKER SNACKS.
If skip meal but BG over 250 - take 1/2 dose Humalog
-Please continue to take all of your other medications as
directed.
Appointments:
It is very important that you make your follow-up appointment
with your primary care doctor [**First Name8 (NamePattern2) **] [**9-28**]. [**2131**]
-We made an education appointment for you at [**Hospital1 **] so that you
can go over your new treatment plan after you have been
discharged from the hospital- this is on Thursday [**2131-9-27**]
-Pending tests- blood culture [**2131-9-23**]- still pending
Followup Instructions:
[**Hospital6 30927**]
Appointment with Certified Diabetes Educator
Thursday [**9-27**]. [**2131**] at 2pm
At [**Hospital6 30927**]
Department: [**Hospital3 249**]
When: FRIDAY [**2131-9-28**] at 10:50 AM
With: [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**], MD. [**Company 191**] POST [**Hospital 894**] CLINIC
[**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
|
[
"401.9",
"414.01",
"V45.82",
"V58.67",
"250.12",
"416.9",
"272.4",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12284, 12342
|
7058, 8480
|
325, 331
|
12399, 12399
|
4010, 5210
|
14758, 15503
|
2720, 2895
|
11488, 12261
|
12363, 12378
|
10413, 11465
|
12549, 13668
|
2935, 3541
|
13689, 14735
|
245, 287
|
5699, 6051
|
359, 1557
|
3560, 3991
|
5224, 5680
|
12414, 12525
|
6068, 7035
|
9586, 9824
|
1579, 2445
|
2461, 2704
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,599
| 134,028
|
45617
|
Discharge summary
|
report
|
Admission Date: [**2192-9-16**] Discharge Date: [**2192-9-19**]
Date of Birth: [**2109-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
EGD [**2192-9-17**]
EGD [**2192-9-19**]
History of Present Illness:
Mr. [**Known lastname 97280**] is an 82 yo M with h/o CAD s/p CABG, moderate AS,
and distant h/o PUD who acutely presents with coffee ground
emesis and is being transferred to the MICU for further
management. The patient was recently discharged from [**Hospital1 18**] on
[**9-14**] after been admitted for chest pain and he underwent a
cardiac catheterization. Cath showed native 3 vessel disease,
patent grafts, and moderate aortic stenosis. No intervention
performed at this time. He was NPO for the procedure but took a
full dose aspirin (4 baby aspirin's). He was discharged home and
immediately started to feel nauseous with multiple episodes of
coffee ground emesis and intermittent lower abdominal pain. He
denies any BRBPR or melena at this time.
In the ED, NG lavage was attempted but the patient vomited up
coffee grounds during the attempt so it was aborted. He was
guaiac negative in the ED. GI was [**Name (NI) 653**], and he was started
on Pantoprazole 40mg IV BID and then transferred to CC-7 for
further work-up.
This evening after eating a liquid meal he vomited up [**Date range (1) 61126**]
cup of bright red blood with clots. His vitals at this time were
BP 180/90 AR 94 RR 18 O2 sat 97% RA. He was then transferred to
the MICU for closer monitoring.
Patient denies any dizziness, chest pain, or SOB. He does admit
to some mild lower abdominal pain. He denies any BRBPR or
melena. He denies taking any NSAIDs on a chronic basis.
Past Medical History:
CAD, s/p CABG x 4 (LIMA-large diag, SVG-LAD, SVG-OM, SVG-PDA
from dominant RCA)in [**2188**]
Moderate aortic stenosis
Hearing loss
Peptic ulcer disease diagnosed approximatley 20 years ago, does
not recall if treated for H. pylori
Left eye loss now with prosthesis
S/P kidney stones
Inguinal hernia repair x 2
Spinal stenosis
Anxiety
S/P rotator cuff
BPH, s/p TURP, recurrent BPH
Social History:
He is married with two grown children and remains very active
walking on a regular basis and working with son in the
construction business he used to own. He does not smoke or
drink.
Family History:
Non-contributory
Physical Exam:
vitals T 98.7 BP 165/86 AR 84 RR 11 O2 sat 97% on 2L NC
Gen: Awake and alert, responsive to commands
HEENT: Dry mucous membranes, anicteric sclera, L eyelid closed
Heart: RRR, + 3/6 systolic murmur with radiation to carotids
Lungs: CTAB, few scattered crackles at posterior lung bases
Abdomen: Soft, NT/ND, +BS, no epigastric tenderness elicited
Extremities: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
[**2192-9-19**] 06:50AM BLOOD WBC-7.7 RBC-3.88* Hgb-11.3* Hct-33.7*
MCV-87 MCH-29.1 MCHC-33.5 RDW-14.3 Plt Ct-306
[**2192-9-18**] 05:03AM BLOOD WBC-9.8 RBC-3.46* Hgb-10.4* Hct-29.6*
MCV-86 MCH-30.1 MCHC-35.2* RDW-14.3 Plt Ct-272
[**2192-9-17**] 04:14AM BLOOD WBC-13.7* RBC-3.64* Hgb-10.8* Hct-31.1*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.0 Plt Ct-314
[**2192-9-16**] 08:06PM BLOOD WBC-14.4* RBC-3.69* Hgb-11.1* Hct-31.4*
MCV-85 MCH-30.1 MCHC-35.4* RDW-14.0 Plt Ct-326
[**2192-9-16**] 07:15AM BLOOD WBC-14.9* RBC-4.16* Hgb-12.3* Hct-36.1*
MCV-87 MCH-29.5 MCHC-34.1 RDW-14.0 Plt Ct-372
[**2192-9-16**] 01:15AM BLOOD WBC-17.3*# RBC-4.59* Hgb-13.7* Hct-38.8*
MCV-85 MCH-29.9 MCHC-35.3* RDW-14.0 Plt Ct-369
[**2192-9-17**] 04:14AM BLOOD PT-13.3 PTT-26.5 INR(PT)-1.1
[**2192-9-16**] 08:06PM BLOOD PT-14.0* PTT-28.1 INR(PT)-1.2*
[**2192-9-16**] 01:15AM BLOOD PT-13.3 PTT-24.9 INR(PT)-1.1
[**2192-9-19**] 06:50AM BLOOD Glucose-84 UreaN-19 Creat-1.2 Na-138
K-4.0 Cl-102 HCO3-27 AnGap-13
[**2192-9-18**] 05:03AM BLOOD Glucose-101 UreaN-24* Creat-1.1 Na-137
K-3.9 Cl-105 HCO3-26 AnGap-10
[**2192-9-17**] 04:14AM BLOOD Glucose-114* UreaN-31* Creat-1.1 Na-138
K-4.3 Cl-106 HCO3-26 AnGap-10
[**2192-9-16**] 08:06PM BLOOD Glucose-132* UreaN-25* Creat-1.1 Na-135
K-4.2 Cl-102 HCO3-24 AnGap-13
[**2192-9-16**] 07:15AM BLOOD Glucose-117* UreaN-15 Creat-1.2 Na-138
K-4.2 Cl-101 HCO3-26 AnGap-15
[**2192-9-16**] 01:15AM BLOOD Glucose-155* UreaN-15 Creat-1.3* Na-137
K-4.4 Cl-98 HCO3-26 AnGap-17
[**2192-9-16**] 01:15AM BLOOD TotBili-1.0
[**2192-9-16**] 07:15AM BLOOD PEP-ABNORMAL B IgG-1314 IgA-277 IgM-82
IFE-MONOCLONAL
Endoscopy
[**9-19**] EGD:
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Diffuse friability, erythema and superficial erosion of
the mucosa with stigmata of recent bleeding were noted in the
fundus. Cold forceps biopsies were performed for histology.
Diffuse erythema, friability and congestion of the mucosa with
no bleeding were noted in the stomach body and antrum, less
prominent when compared to the fundus. Cold forceps biopsies
were performed for histology.
Duodenum: Normal duodenum.
Impression: Friability, erythema and erosion in the fundus
(biopsy)
Erythema, friability and congestion in the stomach body and
antrum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Routine post procedure orders
Avoid all NSAIDS and [**Doctor Last Name **]-2 inhibitors. Take tylenol for pain.
Hold on restarting aspirin for 3-5 days and if/when restarted,
minimize dose.
Will inform patient of biopsy results and direct treatment
accordingly.
[**9-17**] EGD:
Findings: Esophagus:
Contents: Refluxed blood was seen in the esophagus.
Mucosa: Localized erythema with superficial ulceration of the
mucosa was noted in the gastroesophageal junction.
Stomach:
Contents: Red blood was seen in the fundus and stomach body.
Mucosa: Multiple diffuse erythematous linear superficial
erosions of the mucosa with oozing and fresh adherent clot were
noted in the fundus and stomach body. Due to the diffuse nature
of these findings, no one area could be localized for cautery.
Duodenum: Normal duodenum.
Impression: Blood in the esophagus
Erythema with superficial ulceration in the gastroesophageal
junction
Blood in the fundus and stomach body
Erythematous linear superficial erosions in the fundus and
stomach body
Otherwise normal EGD to second part of the duodenum
Recommendations: Routine post procedure orders
Supportive measures with continued HCT monitoring and PRBC's as
needed to maintain HCT >30.
Repeat endoscopy in [**3-11**] days to assess for resolution.
Avoid aspirin and all NSAIDS.
Brief Hospital Course:
A/P: Mr. [**Known lastname 97280**] is an 82yo m with PMH significant for CAD and
remote history of PUD who is presenting with a several day
history of coffee ground emesis who is being transferred to the
MICU for closer monitoring, HCT stable now and transferred back
to medical floor.
.
# GI bleed: Mr. [**Known lastname 97280**] presented [**9-16**] with several day
history of coffee ground emesis. On admit to CC7, pt had
hematemesis and was transferred to the MICU for closer
monitoring. Hct on admission was 39, which then dropped to 31
after episode hematemsis. He was transfused 1u PRBC (HCT
28->31) and his HCT has remained stable thereafter. Concerned
about esophagitis, gastritis, or PUD given his prior history and
recent Aspirin use. He does not have BRBPR or melena to suggest
a lower source. GI consulted and recommended EGD. EGD done
[**9-17**] which showed gastritis, esophagitis without bleeding.
H.pylori positive on serology from [**9-17**], EGD with biopsy planned
for today to verify H.pylori. No abd pain. EGD repeated [**9-19**]
which showed no active bleeding. Biopsies taken without
complications. Continued on PPI.
.
# CAD s/p CABG - With recent cardiac cath for evaluation of
exertional chest pain that revealed patent grafts. No signs on
EKG suspicious for ACS. Cardiac enzymes during this admission
were negative. ASA held during admission, statin continued
.
# HTN: Patient's blood pressure was significantly elevated on
admission in the ED. Not on any anti-hypertensives as an
outpatient. SBP on transfer to the MICU was in the 140's. SBP
on floor after MICU transfer was well controlled, off
anti-hypertensives.
.
# Asymptomatic Bactiuria: Patient with +UA for UTI from [**9-16**]
with pan sensitive Enterococcus. Repeat U/A [**9-18**] positive
again, cultures pendign. Patient asymptomatic but given high
level of WBC in urine, decision made to treat. Patient given 5
day course of Macrobid.
.
# Aortic stenosis - Valve area 1.0 cm2 with pressure gradient 33
mmHg on recent cath. No interventions.
.
# Elevated Cr - Baseline Cr 1.0 - 1.3. Baseline during
admission.
.
# BPH: Hold Flomax for now given concern for acute bleed and
possibility of BP dropping. SBP stable at this point.
Restarted on flomax without difficulty.
.
# FEN: Tolerated regular diet after EGD without complications.
.
# PPx: No heparin SQ given for acute bleed; maintained on
pneumoboots. Maintained on PPI as above.
.
# Code: Full
.
# Communication: with patient and wife [**Name (NI) **] [**Telephone/Fax (1) 97281**]
[**Name2 (NI) **]ter in [**Name2 (NI) **] [**Doctor First Name **] would also like to know of any changes in
status ([**Telephone/Fax (1) 97282**]
.
# Dispo: Home with services
Medications on Admission:
Lipitor 20 mg 1 tab daily
Nitroglycerin 0.4 mg 1 tab sl q 5 min x 3 prn (does not use)
Flomax 0.4 mg 1 tab daily
ASA 81 mg 1 tab daily
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Do not start until
[**9-24**].
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Macrobid 100 mg Capsule Sig: One (1) Capsule PO twice a day
for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Upper GI bleeding
Discharge Condition:
Stable in good condition
Discharge Instructions:
You were admitted to the hospital with a concern for bleeding
from your upper gastrointestinal tract because of a history of
"coffee grounds" in your vomitus after you had taken aspirin at
home. Initially you were admitted to the general medical floor,
but after an episode of vomiting, your blood count dropped and
you were transferred to the Intensive Care Unit for closer
observation. The Gastroenterologists did an Upper Endoscopy
which showed that you had some irritation of your esophagus and
stomach, but there was no bleeding found. Your blood counts
remained stable and you were transferred back to the general
medical floor where you remained without bleeding. A follow-up
Upper Endoscopy was done on [**9-19**] during which time biopsies were
taken of the area that was likely the cause of the original
bleeding. You were stable after the procedure and deemed stable
and ready for discharge home.
You were found to have bacteria in your urine. The decision was
made to treat you with an antibiotic called Macrobid for 5 days.
Call your primary doctor if you start to have any pain with
urination, burning with urination or increasing frequency of
urination.
You will be started on a new medication called Omeprazole which
you will take twice a day.
You should call your regular doctor or return to the Emergency
Room if you have have more episodes of vomiting blood or coffee
ground like material, any fevers, abdominal pain not relieved
with pain medication, respiratory difficulty or blood in your
stool.
Followup Instructions:
Follow-up with your primary doctor, Dr. [**Last Name (STitle) **] on [**9-27**] at
11:10AM. Please call [**Telephone/Fax (1) 1579**] if there are any problems.
Follow-up with the Gastroenterologists for your biopsy results
with Dr. [**First Name (STitle) 3037**] on [**2192-10-10**] at 3PM. Call [**Telephone/Fax (1) 463**] for any
problems.
Follow-up with provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D.
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2192-9-26**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"531.40",
"599.0",
"285.1",
"535.41",
"530.19",
"414.01",
"424.1",
"041.86",
"V45.81",
"041.04",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
10210, 10285
|
6575, 9298
|
336, 378
|
10347, 10374
|
2928, 6552
|
11950, 12595
|
2478, 2496
|
9484, 10187
|
10306, 10326
|
9324, 9461
|
10398, 11927
|
2511, 2909
|
276, 298
|
406, 1857
|
1879, 2260
|
2276, 2462
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,781
| 197,858
|
39597+58307
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-9-26**] Discharge Date: [**2121-10-8**]
Date of Birth: [**2056-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tuberculin,Ppd,Multi-Puncture
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2121-9-30**] - Coronary artery bypass grafting to one vessel, Aortic
valve replacement (21mm St. [**Male First Name (un) 923**] Mechanical valve)
History of Present Illness:
65 year old female with a history of diabetes, hypertension, and
known aortic stenosis-followed by serial echocardiograms- was
found to be in atrial fibrillation with worsening Aortic
stenosis and decreased LVEF of 45% during
an echo on [**9-22**]. She was told to go tho the ED and presented to
OSH complaining of worsening dyspnea on exertion, fatigue and
lower extremity edema. Cardiac cath revealed multivessel
coronary disease. She was transferred to [**Hospital1 18**] for cardiac
surgery evaluation of operative candidacy for Aortic Valve
replacement/
coronary artery revascularization.
Past Medical History:
DMII, dyslipidemia, hypertension, Aortic stenosis, PAF since
[**2121-9-22**], scarlet fever, migraines
Social History:
Last Dental Exam:1 year ago
Lives with:alone
Occupation:RN->med/[**Doctor First Name **]
Tobacco:denies
ETOH:denies
Family History:
Father +MI->deceased 75yo, Mother->AAA, sister->Dibetes/leukemia
Physical Exam:
Pulse: 54 Resp:18 O2 sat: 99% R/A
B/P Right:113/64 Left:
Height: 66 Weight: 270
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmurx- SEM IV/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit -SEM transmitted Right: 2+ Left:2+
Pertinent Results:
[**2121-9-27**] ECHO
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic arch is mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is severe mitral annular
calcification with moderate thickening of the valve chordae.
There is mild functional mitral stenosis (mean gradient 3 mmHg)
due to mitral annular calcification. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Critical calcific aortic
stenosis. Mild calcific mitral stenosis.
[**2121-10-7**] 04:30AM BLOOD WBC-10.1 RBC-3.50* Hgb-10.8* Hct-31.7*
MCV-90 MCH-30.9 MCHC-34.2 RDW-13.9 Plt Ct-277
[**2121-10-8**] 04:54AM BLOOD PT-37.4* INR(PT)-3.9*
[**2121-10-7**] 04:30AM BLOOD Glucose-142* UreaN-18 Creat-0.6 Na-135
K-3.9 Cl-97 HCO3-36* AnGap-6*
Brief Hospital Course:
Ms. [**Known lastname 87383**] was admitted to the [**Hospital1 18**] on [**2121-9-26**] for surgical
management of her coronary artery disease and aortic valve
stenosis. She was worked-up in the usual preoperative manner.
Dental clearance was obtained. Heparin was continued as she was
in atrial fibrillation. She had a urinary tract infection for
which ciprofloxacin was started. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] diabetes consult was
obtained as her hemoglobin A1c was 10.8%. On [**2121-9-30**], Ms.
[**Known lastname 87383**] was taken to the operating room where she underwent
coronary artery bypass grafting to her right coronary artery and
an aortic valve replacement using a 21mm St. [**Male First Name (un) 923**] mechanical
valve. 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. She had atrial fibrillation and was placed on
amiodarone. Coumadin was started for her mechanical AVR and
atrial fibrillation. Her chest tubes were removed and she was
transferred to the surgical step down floor. Her epicardial
wires were removed. She was seen in consultation by the
physical therapy service. She continued to make steady progress
and was discharged to home on postoperative day eight. INR was
arranged to be followed by Dr. [**Last Name (STitle) 84113**]. All follow-up
appointments were advised.
Medications on Admission:
Lisinopril 40(1), Glyburide 5(2), ASA 81(1), Simvastatin that
she recently stopped 2' cost, Vit D/Calcium, Prilosec 20 (1)
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. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
6. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg daily for 1 week, then decrease to 200mg daily
ongoing.
Disp:*60 Tablet(s)* Refills:*2*
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
9. 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*
10. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: or
as directed by the office of Dr. [**Last Name (STitle) 84113**]. .
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Labs: PT/INR for Coumadin for Mechanical AVR and atrial
fibrillation
Goal INR [**1-29**]
First draw [**10-9**]
Results to Dr. [**Last Name (STitle) 84113**] at ([**2121**]
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Aortic stenosis
Coronary artery disease
Diabetes
Dyslipidemia
Hypertension
Paroxysmal atrial fibrillation
Obesity
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg, Right - 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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2121-10-23**] 1:30
Cardiologist: Dr. [**Last Name (STitle) 4922**] on [**10-31**] at 1:15pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name **] [**0-0-**] in [**3-31**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin for Mechanical AVR and atrial
fibrillation
Goal INR [**1-29**]
First draw [**10-9**]
Results to Dr. [**Last Name (STitle) 84113**] at ([**2121**]
Completed by:[**2121-10-8**] Name: [**Known lastname 13861**],[**Known firstname 13862**] Unit No: [**Numeric Identifier 13863**]
Admission Date: [**2121-9-26**] Discharge Date: [**2121-10-8**]
Date of Birth: [**2056-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tuberculin,Ppd,Multi-Puncture
Attending:[**First Name3 (LF) 741**]
Addendum:
Pt also prescribed 40 units Lantus q AM for better BS control.
At the time of discharge blood sugar was ranging 72-185.
Patient was instructed about the importance of strict blood
sugar control.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 1066**], [**First Name3 (LF) **]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2121-10-8**]
|
[
"414.01",
"E878.2",
"285.9",
"424.1",
"427.32",
"272.4",
"311",
"521.00",
"250.00",
"E849.7",
"401.9",
"599.0",
"278.00",
"V15.82",
"998.89",
"346.90",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"23.09",
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
9546, 9750
|
3370, 4854
|
315, 466
|
7026, 7227
|
2091, 3347
|
8150, 9523
|
1366, 1433
|
5028, 6741
|
6868, 6984
|
4880, 5005
|
7251, 8127
|
1448, 2072
|
256, 277
|
494, 1090
|
1112, 1216
|
1232, 1350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,585
| 182,644
|
34471
|
Discharge summary
|
report
|
Admission Date: [**2196-8-4**] Discharge Date: [**2196-8-15**]
Date of Birth: [**2134-6-29**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Quinolones / Clonidine / Atenolol / Lipitor /
Digoxin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Right Femoral CVL
Right Internal Jugular CVL
Right axillary arterial line
Left radial arterial line
Right PICC line
History of Present Illness:
Ms. [**Known lastname 20948**] is a 62F with a PMH s/f COPD (home O2 2-3L) on
chronic prednisone, DM, CAD, s/p MI, VF s/p ICD, Chronic
diastolic heart failure, with a recent hospitalization at [**Hospital 79221**] hospital in Main ([**2196-6-9**]) for CHF exacerbation and
unstable angina.
Her hospitalzation was complicated by respiratory failure,
pseudomonas tracheal-bronchitis, severe c. diff colitis and
subsequent toxic megacolon leading to abdominal compartment
syndrome. Patient underwent tracheotomy / PEG tube placement
after prolonged hospitalization and failure to wean off
mechianical ventilator.
Patient was recently discharged to a rehab facility where on
arrival she was noted to be in respiratory distress with an ABG
of 7.24/59/80. She was sent to the [**Hospital1 2177**] ED where a repeat ABG
was 7.38/23/73. She was empirically started on Vancomycin /
Levaquin and sent back to rehab. On the morning of admission,
patient desaturated to the 80s, requiring FiO2 of 100% and an
increase in her PEEP to 10, and was sent to the [**Hospital1 18**] ED as the
[**Hospital1 2177**] ICU was on diversion.
In the emergency department her initial vital signs were 96.9,
SBP's 70-90, HR= 108-120. A right femoral line (patient has a
left subclavian clot, and a right PICC placed in [**Month (only) 596**]) and
arterial line were placed, and the patient was started on
levophed (was volume overloaded on CXR).
Current ventilator settings are tidal volume of 550, PEEP of 10,
and an FiO2 of 100%, where she is satting 100% with an ABG of pH
7.31 pCO2
50 pO2 109 HCO3 26 .
She was given albuterol and atrovent nebulizers for COPD. CXR
revealed volume overload vs. PNA, so the patient was given 40mg
of IV lasix, and vancomycin/zosyn for presumed VAP. Urine and
blood cultures were obtained. She was sent for a CTA prior to
coming to the MICU, but heparin was not started as her
tracheostomy site is bleeding.
Past Medical History:
1)COPD (baseline 3L NC at home)
2)CAD
-- s/p MI
-- s/p BMS to mid RCA ([**2189-10-5**])
3)Diastolic heart failure, EF 45-50% with basal and mid inferior
hypokinesis, impaired diastolic function (E to A reversal)
-- Stress test [**2192-8-6**] with fixed inferolateral wall defect
and global hypokinesis.
4)V Fib (out of hospital arrest)
-- s/p ICD placement ([**2193-2-5**])
-- [**Company 1543**] GEM III DR [**Last Name (STitle) **] #7275
5)C diff colitis / Toxic megacolon / Abdominal compartment
syndrome
-- S/P Exploratory lap [**2196-6-22**]
6)Subclavian DVT: coumadin held from bleeding complications
7)Morbid obesity
8)RUL pulmonary nodules
9)Respiratory failure ([**2196-6-30**])
10)VRE from wound (Enterococcus Faecalis)
11)Diabetes Mellitus
12)h/o Breast Cancer
Social History:
Married, Currently in a rehab facility in [**Location (un) 86**] (no vent
facilities near her home in [**State 1727**]). Daughter very involved.
Family History:
NC
Physical Exam:
T = 100.3 BP = 98/68 HR = 119 RR= 22 O2= 99%
GENERAL: Intubated, very pleasant elderly woman, comfortable.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. Tracheotomy site clean/dry,
no blood visible.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Diffuse rhonchi and mildly decreased breath sounds.
ABDOMEN: NABS. Soft, midline wound with mild erythema, dressing
clean / dry/ intact. PEG site also c/d/i.
EXTREMITIES: 3+ pitting edema of lower extremities. 2+ dorsalis
pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Appropriate. CN 2-12 grossly intact.
Pertinent Results:
==================
ADMISSION LABS
==================
[**2196-8-4**] 07:45AM BLOOD WBC-15.0* RBC-3.28* Hgb-9.9* Hct-32.1*
MCV-98 MCH-30.2 MCHC-30.8* RDW-18.6* Plt Ct-409
[**2196-8-4**] 07:45AM BLOOD Neuts-89.3* Lymphs-5.5* Monos-4.7 Eos-0.4
Baso-0.1
[**2196-8-4**] 07:45AM BLOOD Glucose-180* UreaN-52* Creat-0.8 Na-144
K-4.2 Cl-108 HCO3-25 AnGap-15
[**2196-8-4**] 07:45AM BLOOD ALT-24 AST-28 CK(CPK)-29 AlkPhos-308*
TotBili-0.9
[**2196-8-4**] 07:45AM BLOOD CK-MB-NotDone cTropnT-0.13* proBNP-[**Numeric Identifier 63314**]*
[**2196-8-4**] 07:45AM BLOOD Albumin-4.1 Calcium-10.3* Phos-5.9*
Mg-2.5
[**2196-8-9**] 09:46AM BLOOD Phenyto-16.4
[**2196-8-4**] 09:53AM BLOOD Type-ART pO2-109* pCO2-50* pH-7.31*
calTCO2-26 Base XS--1 Comment-RADIAL LEF
[**2196-8-4**] 07:48AM BLOOD Lactate-1.5
=============
RADIOLOGY
=============
CHEST X-RAY ([**2196-8-4**])
SINGLE AP SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: There is diffuse
bilateral
pulmonary edema, right more than left with associated small
right pleural
effusion and probable left pleural effusion. There is mild
cardiomegaly.
Aortic calcifications are evident. There is no pneumothorax.
Right chest wall AICD device with right ventricular lead in
standard location and another shorter lead with distal anchoring
device projecting over the right lung apex. There is a third
lead, which is not definitely visualized, and best visualized up
to the upper portion of right atrium. The PICC line is
terminating within the proximal right subclavian. Tracheostomy
tube is noted. Visualized osseous and soft tissue structures are
otherwise unremarkable.
IMPRESSION:
1. Severe bilateral pulmonary edema, right more than left, with
associated
small pleural effusions.
2. AICD device with right ventricular lead in standard location
and second
lead not seen in its entirety is best visualized up to the upper
atrium. Third redundant lead is seen to project over the right
lung apex.
3. Right PICC line terminating in the proximal subclavian
-------------------
CTA CHEST ([**2196-8-4**])
-------------------
The pulmonary arteries are well opacified with no filling defect
suspicious for pulmonary embolism. The aorta shows mild
atherosclerotic calcification, but the size is within normal
limit, and there is no evidence of aneurysmal dilatation or
dissection.
The heart size is moderately enlarged. There is no pericardial
effusion.
Bilateral left more than right moderate pleural effusions are
seen.
Diffuse airspace disease with ground-glass opacities, septal
thickening, and areas of consolidation are seen in both lung
fields.
In the mediastinum, there are multiple enlarged lymph nodes;
11.2-mm right
paratracheal lymph node, 7-mm left prevascular lymph node,
8.8-mm left
paratracheal lymph node, and 1-cm right lower paratracheal lymph
node.
A tracheostomy tube terminates in the midthoracic portion of the
trachea. A right-sided dual-leaded pacemaker is seen with the
right atrial lead projects beyond the boundaries of the right
atrium and terminates in the IVC.
The evaluation of the abdomen shows diffuse atherosclerotic
calcification of The aorta, celiac artery, SMA, renal arteries,
and iliacs. The patient is status post aorto-[**Hospital1 **]-iliac bypass.
The weak contrast material within the circulation system of the
abdomen and pelvis cannot exclude or confirm the presence of
underlying DVT involving the iliac veins.
There is no evidence of contrast excretion from both kidneys.
The liver, spleen are unremarkable. The pancreas is unremarkable
as well.
A small stone is seen in the Gallbladder. One of the cruses of
the right
adrenal gland has a speckle of calcification without soft tissue
masses.
A hypodense lesion likely a cyst is seen arising from the
inferior pole of the right kidney.
The small and large bowels demonstrate normal caliber with no
evidence of wall thickening, pneumatosis, or adjacent
inflammation.
Trace amount of free fluid is seen in the right upper quadrant
and left upper quadrant and in the pelvis in close proximity to
an atrophic uterus.
a Foley catheter is seen in the bladder which does not contain
any opacified contrast material.
Extensive fatty stranding of the subcutaneous fatty structures
of the anterior abdominal and pelvic wall as well as the flanks
and the lateral margins of the chest wall.
IMPRESSION:
1. Negative examination for pulmonary embolism or aortic
dissection.
2. Diffuse airspace disease which could represent pulmonary
edema either from a cardiogenic cause or non-cardiogenic cause
like renal failure. Other possibiltis would include pneuomonia
or hemmorage.
------------------
ECHO
-----------
Very limited image quality (patient on ventilator). The left
atrium is dilated. The right atrium is moderately dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is moderate global left
ventricular hypokinesis (LVEF = 30-40 %). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. with depressed free wall contractility. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-13**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The
supporting structures of the tricuspid valve are
thickened/fibrotic. There is no pericardial effusion. There is
an anterior space which most likely represents a fat pad.
----------
KUB [**2196-8-14**]
----------
Two radiographs of the chest and abdomen are submitted. The
bilateral apices are excluded. Assessment of the pulmonary
parenchyma is markedly limited by technique and respiratory
motion. The cardiomediastinal contours are similar to that seen
on [**2196-8-13**]. No pneumoperitoneum is evident. There are multiple
air-filled distended loops of small and large bowel. Air is
present within the stomach. Air and stool are identified within
the descending colon. Surgical staples project over the mid
abdomen as does a radiopaque catheter. Single-lead cardiac
pacemaker is again noted. The aorta is calcified and tortuous.
IMPRESSION:
Nonspecific bowel gas pattern. Close clinical followup is
recommended.
-----------------
Labs [**2196-8-14**]
-----------------
14.6* \______/ 111
/ 32.1*\
141 | 108 | 21 /
--------------- 114
4.2 | 25 | 0.7 \
PT: 17.7 PTT: 28.0 INR: 1.6
Brief Hospital Course:
Ms. [**Known lastname **] is a 62yo female with severe COPD, CAD, and long
hospital course c/b VAP with hypoxemic respiratory failure s/p
tracheostomy, toxic megacolon from C. diff and abdominal
compartment syndrome, presented on [**8-4**] with hypotension and
respiratory distress. Patient however continued to decompensate
and family requested transition to comfort measures only after
she acutely worsened. Patient expired shortly therafter. Details
are listed by problem below:
1)Hypotension: Patient initially presented with hypotension
requiring pressors. The differential included sepsis, adrenal
insufficiency, and cardiogenic shock. Possible sources of
infection included ventilator associated pneumonia although she
was completing course with amikacin and doripenem. Patient
required short course of pressors on admission with prompt wean.
There was no evidence of adrenal insufficiency and although an
organism was not isolated, patient was empirically treated for
VAP with meropenem and amikacin. PICC line placed at OSH was
removed and sent for culture. Patient however continued to have
transient episodes of hypotension without known etiology or
organism isolation. Patient was agressively cultured and placed
back on broad spectrum antibiotics and placed on pressors after
an aspiration event, but patient continued to have refractory
hypotensive episodes.
After prolonged hospitalization and lack of improvement (for
full list see below) family meeting was arranged, where decision
to transition to comfort measures only was made. The patient
expired shortly thereafter, with her family at the bedside.
#. Digitalis toxicity: Due to tachycardia in setting of
hypotension, patient was loaded with digoxin. After completion
of load however, high degree of ectopy was noted and patient
exhibited signs of digitalis toxicity with an accelerated
junctional escape rhythm. Digitalis level of 4 was noted and
patient experienced seizures. Although it is not clear that the
latter were caused by digitalis, given the ECG changes patient
was given digibind, with good resolution back to baseline sinus
rhythm. Due to narrow therapeutic window in spite of appropiate
dosing, would avoid using digoxin in the future.
#. Possible Cardiogenic shock: Although it was not clear that
patient was in cardiogenic shock, strong cardiac history,
hypotension at presentation and gross volume overload were
concerning for this.
Echocardiogram was obtained and revealed globally depressed
systolic function and diastolic failure. Cardiac enzymes were
obtained and although mild elevation in troponins were noted, CK
remained normal. Troponin leak likely secondary to rapid hear
rate and demand ischemia.
.
#. Possible Adrenal insufficiency: Given critical illness,
patient was pulsed with stress dose steroids, however this was
not continued after it AI was ruled out.
.
#. Respiratory distress: As above, likely a combination of
diastolic heart failure and pneumonia, with possible cardiogenic
shock. Patient treated broadly for possible ventilator
associated pneumonia, however respiratory status worsened after
witnessed vomiting and aspiration of tube feeds (given via PEG
tube). Patient was transitioned over to full assist control and
remained unable to return to CPAP.
.
#. COPD: No evidence of acute exacerbation, although continued
on steroids.
.
# Subclavian DVT: Unclear etiology, likely iatrogenic from line
placement at OSH. Due to Upper extremity location, low risk of
propagation/ pulmonary embolization and recent peri-trach
bleeding, No anticoagulation was given.
.
Seizure activity: Patient was noted to have twitching of the
right upper and lower extremities. She was immediately loaded
with Fosphenytoin and then started on Dilantin 100mg IV TID. CT
head was unrevealing. Neurology was immediately consulted. The
etiology was unclear but was thought to be secondary to digoxin
toxicity. As a result, he was given Digibind to try and reverse
the toxic effects. She also underwent an EEG which was
consistent with moderate to severe global encephalopathy.
She was continued on Dilantin and was started on Keppra.
Atrial fibrillation: Rate controlled at first with Digoxin,
until toxicity noted. Rate controlled with beta blocker
thereafter.
.
#. SVC ICD lead: Per cardiology report, this appears to have
been a placement issue and not a dislodgement issue.
Medications on Admission:
Amikacin 1300mg Q36H (last day [**8-4**])
Ascorbic acid 500mg PO daily
Diltiazem 30mg PO daily
Doripenem 500mg Q8H
NPH 40u QAM, 25u QPM
Atrovent 6 puffs Q4H
Isosorbide 60mg PO Q12
Prevacid 30mg PO daily
Lopressor 50mg PO BID
Prednisone 5mg PO daily
Vitamin A [**Numeric Identifier 389**] units daily
Zinc sulfate 220mg PO daily
Ambien 5mg PO QHS PRN
Combivent
ASA 325mg PO daily
Lovenox 40mg SQ daily
Paxil 20mg PO daily
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"785.52",
"276.0",
"496",
"444.89",
"V45.02",
"V10.3",
"428.0",
"411.1",
"V44.1",
"995.92",
"V46.2",
"560.1",
"428.33",
"412",
"038.9",
"427.1",
"255.41",
"507.0",
"V44.0",
"285.9",
"518.81",
"278.01",
"427.31",
"250.00",
"780.39",
"707.07",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"99.04",
"96.72",
"38.93",
"38.91",
"89.49"
] |
icd9pcs
|
[
[
[]
]
] |
15380, 15389
|
10493, 14869
|
351, 468
|
15448, 15465
|
4119, 10470
|
15529, 15547
|
3388, 3392
|
15340, 15357
|
15410, 15427
|
14895, 15317
|
15489, 15506
|
3407, 4100
|
291, 313
|
496, 2416
|
2438, 3210
|
3226, 3372
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,404
| 194,458
|
40552
|
Discharge summary
|
report
|
Admission Date: [**2145-5-4**] Discharge Date: [**2145-5-10**]
Date of Birth: [**2121-7-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
pericarditis, DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 23yo M with no known prior past medical history who
presents with one week of chest pain and worsening dyspnea on
exertion and hyperglycemia with possible DKA. Pt was initially
seen at [**Hospital6 3105**] for 1 week of reflux type
symptoms with burning substernal chest discomfort, which he
though was possibly reflux (though he has never had this
before). Pt states that he tried some tums with no relief. He
denies having any chest pain and no real positional change of
symptoms, though he does note the burning was wakening him up at
night. He also reports dyspnea on exertion worsening over the
past 3-4 days, with sensation of heart racing. Pt denied any
recent fever but did note some chills over the weekend. He also
has been very fatigued and weak with anorexia and has lost
7-8lbs over the past week. He has had a dry cough, and had some
nausea last week with 1 episode of emesis on Thursday bringing
up food, and 1 episode of emesis on Saturday, clear liquids
only. He otherwise denies URI symptoms, myalgias, arthralgias or
sick contacts.
Pt also had 3 weeks of polydipsia and polyuria prior to this
chest discomfort with no previous history of diabetes.
.
At LGH, he had an initialy ECG which was not particularly
remarkable. A D-dimer was done, and was elevated, thus give
concern for PE, CTA done. There was some concern per radiology
read there that there was a possible small segmental PE and
question pneumomediastinum. Given that, he was sent here for
thoracics evaluation.
.
In the ED, initial vs were: T 97.7 P 90 BP 134/90 R 20 O2 sat
99% 2LNC. On presentation to the ED here, his ECG was remarkable
for diffuse STE changes, concerning for pericardititis. No
cardiac enzymes were yet sent. CT was read by radiology here,
and there was no concern for PE or pneumomediastinum. He was
found to be quite hyperglycemic & had an AG, and DKA was thought
to be possible. Attempted to get UA in ED, but pt was unable to
void yet, and hesitant to straight cath, so unknown if ketones.
Given that pt looked so well initially, thought was that pt
could get insulin, and recheck. However, after 10 units insulin
and 2L IVF's with potassium, AG still present, so he was started
on insulin gtt and admitted to MICU for DKA. Of note, bedside
u/s done, and no evidence of pericardial effusion, though
windows not great. He was given one dose of toradol for
pericarditis, and started on D5W with potassium.
ABG was done which showed 7.14/14/210/5.
Prior to transfer VS were afebrile, BP 150/85, RR 18 HR 90 O2
sats 100% RA.
.
On the floor, he describes feeling very weak and fatigued. He
still has some of the mild burning sensation in his chest that
is occasionally worse with breathing. He denies any chest pain
or pressure.
.
Review of systems:
(+) Per HPI. Also notable for 28lb weight loss, unintentional
over the last several 2 months. Positive also for constipation
without BM for 3 days.
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, palpitations currently. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, or hematuria. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
none
Social History:
Lives at home with his mother, her boyfriend, and his 21yo
brother.
- Tobacco: smokes [**3-19**] ppd for 5-6 years
- Alcohol: recently quit 2-3 weeks ago, prior to that socially,
up to 3 drinks of hard alcohol and 3 beers at one sitting
- Illicits: Marijuana use, last used 4 days ago, but usually
smokes once daily. Denies any IVDU
Family History:
Pt has GM with DM and HLD. GF with HTN. Paternal uncle and aunt
also have DM. Mother is alive and healthy. 21yo brother healthy
with no medical problems.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 97 BP: 148/62 P: 96 R: 16 O2: 100%RA
General: Alert, oriented, no acute distress, appears fatigued
HEENT: EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities,
no gross deficits
DISCHARGE PHYSICAL:
VS: Tc 97.7, BP 123/77, HR 92, RR 16, O2Sat 100, BS 91.
Overnight BS low at 79.
General: Alert, oriented, no acute distress
HEENT: EOMI, Sclera anicteric, mucous membrane slightly dry,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly, 1
large ecchymotic area below the umbilicus
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities,
no gross deficits
Pertinent Results:
ADMISSION LABS:
[**2145-5-3**] 09:04PM BLOOD WBC-14.0* RBC-5.16 Hgb-15.8 Hct-41.4
MCV-80* MCH-30.5 MCHC-38.1* RDW-13.1 Plt Ct-332
[**2145-5-3**] 09:04PM BLOOD Neuts-73.9* Lymphs-19.6 Monos-4.2 Eos-1.6
Baso-0.7
[**2145-5-3**] 09:04PM BLOOD PT-13.1 PTT-28.9 INR(PT)-1.1
[**2145-5-3**] 09:04PM BLOOD Glucose-372* UreaN-13 Creat-1.1 Na-125*
K-3.7 Cl-96 HCO3-9* AnGap-24*
[**2145-5-3**] 09:04PM BLOOD ALT-43* AST-22 LD(LDH)-122 AlkPhos-118
TotBili-0.7
[**2145-5-3**] 09:04PM BLOOD Lipase-201*
[**2145-5-3**] 11:55PM BLOOD CK-MB-2 cTropnT-<0.01
[**2145-5-3**] 10:33PM BLOOD Type-[**Last Name (un) **] pO2-210* pCO2-14* pH-7.14*
calTCO2-5* Base XS--22 Comment-GREEN TOP
[**2145-5-3**] 11:55PM BLOOD CK(CPK)-56
.
Pertinent labs:
[**2145-5-4**] 05:45AM BLOOD Lipase-1279*
[**2145-5-4**] 03:10PM BLOOD ESR-14
[**2145-5-4**] 02:55AM BLOOD CK(CPK)-51
[**2145-5-4**] 05:45AM BLOOD ALT-33 AST-17 CK(CPK)-53 AlkPhos-85
TotBili-0.5
[**2145-5-4**] 05:45AM BLOOD Lipase-1279*
[**2145-5-4**] 02:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2145-5-4**] 05:45AM BLOOD CK-MB-2 cTropnT-<0.01
[**2145-5-4**] 11:20AM BLOOD Calcium-8.3* Phos-0.6* Mg-1.8
[**2145-5-4**] 03:10PM BLOOD Iron-179*
[**2145-5-4**] 03:10PM BLOOD calTIBC-203 Ferritn-918* TRF-156*
[**2145-5-4**] 04:32AM BLOOD %HbA1c-11.8* eAG-292*
[**2145-5-4**] 03:10PM BLOOD CRP-32.3*
[**2145-5-4**] 03:10PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2145-5-4**] 05:45AM BLOOD RheuFac-6
[**2145-5-4**] 05:45AM BLOOD HIV Ab-NEGATIVE
[**2145-5-4**] 05:45AM BLOOD TSH-1.5
[**2145-5-4**] 03:10PM BLOOD ESR-14
[**2145-5-4**] 03:10PM BLOOD Amylase-217*
[**2145-5-5**] 06:57PM BLOOD Fibrino-261
[**2145-5-5**] 05:40PM BLOOD Ret Aut-1.0*
[**2145-5-5**] 05:40PM BLOOD LD(LDH)-109
[**2145-5-5**] 05:40PM BLOOD proBNP-13
[**2145-5-5**] 04:35AM BLOOD Triglyc-161*
[**2145-5-5**] 05:40PM BLOOD Hapto-103
[**2145-5-5**] 05:40PM BLOOD Glucose-281* UreaN-5* Creat-0.6 Na-135
K-2.4* Cl-106 HCO3-18* AnGap-13
[**2145-5-6**] 02:00AM BLOOD Cortsol-10.3
[**2145-5-7**] 03:52PM BLOOD HEREDITARY HEMOCHROMATOSIS MUTATION
ANALYSIS-Test
[**2145-5-7**] 06:30AM BLOOD VitB12-1209* Folate-12.3
[**2145-5-6**] 06:18PM BLOOD WBC-5.4 RBC-3.14* Hgb-9.7* Hct-24.6*
MCV-78* MCH-30.8 MCHC-39.2* RDW-13.4 Plt Ct-226
[**2145-5-6**] 10:20AM BLOOD Hgb A-PENDING Hgb S-PND Hgb C-PND Hgb
A2-PND Hgb F-PND
[**2145-5-6**] 02:00AM BLOOD Lipase-157*
.
DISCHARGE LABS:
[**2145-5-10**] 07:25AM BLOOD WBC-5.5 RBC-3.28* Hgb-9.8* Hct-27.8*
MCV-85 MCH-29.8 MCHC-35.1* RDW-15.4 Plt Ct-264
[**2145-5-10**] 07:25AM BLOOD Glucose-79 UreaN-7 Creat-0.8 Na-140 K-3.9
Cl-104 HCO3-30 AnGap-10
[**2145-5-5**] 04:35AM BLOOD ALT-30 AST-19 AlkPhos-76 TotBili-0.6
[**2145-5-10**] 07:25AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.1
.
STUDIES:
CT CHEST AT OSH [**2145-5-3**]:
IMPRESSION:
1. Suboptimal evaluation of the segmental and subsegmental
pulmonary arterial branches due to contrast bolus and patient
respiratory motion, and PE can not be excluded in these vessels.
No evidence of central PE. No acute aortic syndrome.
2. No pericardial effusion or evidence of pneumomediastinum.
3. Small hiatal hernia.
4. Possible gastric diverticulum, as described above, not well
evaluated; correlate with prior imaging if available or
consider dedicated abdomen CT.
5. Fatty liver.
.
TTE [**2145-5-4**]:
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
minimal resting left ventricular outflow tract obstruction.
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. The pulmonary artery systolic
pressure could not be determined. There is a trivial/physiologic
pericardial effusion.
.
CXR [**2145-5-5**]:
IMPRESSION: No evidence of pneumonia or other acute
cardiopulmonary disease.
.
MRCP [**2145-5-5**]:
IMPRESSION:
1. Peripancreatic edema, most notably around the tail,
consistent with the
provided history and suggestive of pancreatitis. Notably, there
is no
evidence of pancreatitis-related complications.
2. Significant and diffuse hepatic steatosis.
.
TTE [**2145-5-6**]:
The left ventricular cavity is small. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is small. There is a trivial/physiologic pericardial effusion.
There are no echocardiographic signs of tamponade. Compared
with the findings of the prior study (images reviewed) of [**2145-5-4**], both ventricles now appear small (?underfilled) and
hyperdynamic.
.
MICRO:
BCX x3 [**2145-5-3**]: No growth
UCX [**2145-5-4**] & [**2145-5-6**]: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
23 yo M with no known PMH presented with 1 week of chest burning
and DKA from the OSH for concern of PE and pneumomediastinum,
found to have pericarditis, pancreatitis, and anemia.
#. Acute pericarditis. Supported by symptoms as well as ECG
findings of diffuse STE. Myocarditis was considered but CE were
negative. It was thought this is likely [**2-17**] viral.
Rheumatological causes are less likely with normal [**Doctor First Name **], RF, ESR.
HIV was negative. TTE was performed which showed trivial
pericardial effusion. He was started on Ibuprofen and Colchicine
to prevent recurrence in the MICU but colchicine was
discontinued upon transferring to the floor. On the floor, he
continued with ibuprofen for a planned total of 7 day course.
He was discharged on ibuprofen to complete the rest of the
course on [**2145-5-11**]. This can be followed up in the outpatient
setting by his new primary care doctor.
#. DKA/Diabetes mellitus. Pt is without previous history of
diabetes, though with several week history of polydipsia and
polyuria, new onset diabetes with presentation of DKA most
likely. Pt had significant AG and ketones in the urine. He was
started on insulin gtt, with aggressive fluids and electrolytes
repleted. Once his AG closed, he was started on SC insulin and
[**Last Name (un) **] was consulted. An A1c was 11.8 was found. Given new
onset diabetes and elevated lipase as below, structural causes
of new onset diabetes were considered. MRCP showed some
peripancreatic edema but no structural abnormalities. Iron
studies were checked given new-onset diabetes and consideration
of hemochromatosis. Ferritin was elevated, but difficult to
interpret in the setting of acute illness, but saturation was
elevated. Given insulin resistance, ethnicity, body habitus,
and family history, it is likely that he has type 2 DM, although
further work-up will be done in the outpatient setting. He was
given nutritional education and insulin teaching while in the
hospital. His discharge glargine was set to be 30 units of
glargine and 1000 mg of metformin [**Hospital1 **] with [**Last Name (un) **] follow up
appointment.
#. Electrolyte disturbance with hypokalemia and
hypophosphatemia. Initially with severe AGMA, most likely [**2-17**]
DKA. Lactic acidosis possible though lactate checked in MICU was
1.3. His AG closed once he was treated for DKA as above.
However, he continued to have an acidosis, non-anion gap on
HOD#2. This was thought in part due to large volume NS for DKA
treatment, though Cl was not particularly high. RTA possible
given continued acidosis until transfer to medicine floor team
but urine lytes shows minimal phosphate and potassium,
suggesting that patient was retaining the electrolytes while
getting the aggressive repletion. It is most likely that he was
severely dehydrated and depleted total body store. He continued
to get aggressive repletion while on the general medicine floor.
His electrolytes normalized by the time of his discharge. This
can be followed up in the outpatient setting.
# Anemia: Pt's Hct dropped while in the ICU. He had no s/s
bleeding. Hemolysis and DIC labs were negative. Peripheral smear
showed no schistocytes. Hemoglobin electrophoresis was sent
given microcytic anemia with low retic count, which was pending
at the time of discharge. His Hct dropped to mid-20s but remain
stable and appeared to be on the up-trend by discharge. It is
possible that he has anemia of chronic disease given the
diabetes (although iron studies was difficult to interpret) and
was very hemoconcentrated on presentation. His primary care
provider will have to discuss with him the result of the
hemoglobin electrophoresis.
# Elevated lipase/pancreatitis: Pt found to have initially mild
elevation in lipase to 200 on admission. On repeat, this level
was 1200. MRCP showed inflammation of the pancreas, but patient
was asymptomatic throughout. It is possible that this is
related to his DKA. He was monitored clinically and his lipase
downtrended.
# Sinus tachycardia: Pt was tachycardic during his MICU stay.
Most likely [**2-17**] acute illness, and initially due to dehydration
given DKA. However, after volume resuscitated, he continued to
be tachycardic. Tachycardia was attributed to anemia, and
appropriate physiologic response. Repeat TTE showed hyperdynamic
function with relatively small ventricles, c/w physiologic
response to anemia. It improved to the 90s and low 100s upon
discharge. This can continue to be monitored in the outpatient
setting.
# Hyponatremia: Most likely [**2-17**] hypovolemia and DKA. Na
corrected for glucose was normal. After DKA treated, pt had mild
hyponatremia, likely [**2-17**] multiple infusions of D51/2NS given DKA
protocol. Na and lytes were trended and normalized prior to
discharge.
# Mild ALT elevation: Pt with fatty liver per OSH read. LFT's
were trended and normalized. Importance of weight loss with
stressed to the patient. Pt should have outpatient follow-up to
monitor this.
# Abnormal iron studies: transferrin saturation is about 88% by
calculation. Patient has elevated iron in addition to ferritin
(acute phase reactant) and relatively lower [**Name (NI) 59658**] raised the
question of hemachromatosis although his ethnicity makes it less
likely. Given his young age for onset of diabetes, fatty liver
disease (per OSH), pericarditis, pancreatitis, the HFE gene
mutation was sent. The result was not finalized by the time
patient was discharged. Therefore, the result will be discussed
with the patient upon his follow up with his primary care
physician.
# Peripheral eosinophilia. This will be followed up in the
outpatient setting. There was question of allergic reaction to
the contrast used in MRCP, with cough. This subsided by the
time of discharge. The peripheral eosinophilia can be monitored
in the outpatient setting.
Medications on Admission:
none
Discharge Medications:
1. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous see below: Use the kit 4 times a day to check your
blood sugar, before meals and at bed time.
Disp:*1 kit* Refills:*1*
2. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for through [**2145-5-11**]. days: take with food.
Disp:*6 Tablet(s)* Refills:*0*
3. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for allergy.
Disp:*60 Tablet(s)* Refills:*3*
4. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
5. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime: Please record your blood sugar 4 times
a day (before meals and at bedtime).
Disp:*900 units* Refills:*2*
6. Humalog 100 unit/mL Solution Sig: [**6-26**] unit Subcutaneous
before meals and at bed time per your insulin sliding scale.
Disp:*900 units* Refills:*2*
7. insulin sliding scale
Humalog.
At meal time (breakfast, lunch, dinner)
Blood sugar: Humalog dose
121-160: 6 units
161-200: 7 units
201-240: 8 units
241-280: 9 units
281-320: 10 units
321-360: 11 units
> 360: call your doctor
Bedtime
Blood sugar: Humalog dose
201- 240: 3 units
241- 280: 4 units
281- 320: 5 units
321- 360: 6 units
> 360: call your doctor
8. Lancets,Ultra Thin Misc Sig: One (1) lancet Miscellaneous
four times a day.
Disp:*120 lancets* Refills:*2*
9. insulin syringe-needle,dispos. 1 mL 29 x [**1-17**] Syringe Sig:
One (1) syringe-needle Miscellaneous four times a day: at meal
time and before bed time.
Disp:*120 syringe-needle* Refills:*2*
10. glucometer strip
check blood sugar with 1 strip after lancet use 4 times a day
(before meals and at bed time).
Dispense: 120 strips
Refills: 2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Type 2 diabetes mellitus, uncontrolled
- Diabetic ketoacidosis
- Pericarditis, resolved
- Acute pancreatitis, resolved
Secondary diagnoses:
- Microcytic anemia
- Fatty liver disease
- Anion gap metabolic acidosis, resolved
- Hyponatremia, resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1071**],
It was a pleasure to take care of you in [**Hospital1 827**].
You were admitted for concern for a clot in your lung. However,
repeat scan did not suggest it. Your chest discomfort was
thought to be related to inflammation of the lining of the
heart. This could be from a viral infection and you were
treated with medications. At the same time, you were also found
to have high blood sugar, so insulin was started, and you
received aggressive electrolyte repletion. Furthermore, it was
also noted that you have very high lipase, which is a marker for
pancreatitis. You were treated conservatively for that, and the
value improved. It was noted that you are also anemic.
***Some of the labs are still pending at this time, so you
should talk to your doctor about the results in your follow up
appointment***
Please note the following changes in your medications:
- Start Lantus 30 units, subcutaneous injection, at bed time
- Start metformin 500 mg tab, 2 tabs, by mouth, twice a day
- Start Humalog insulin sliding scale 6-11 units depending on
your blood sugar. This sliding scale is listed on the next
page.
- Start ibuprofen 800 mg, 1 tab, by mouth, every 8 hours. Take
with food. This is for your pericarditis. You will finish the
7 day course at the end of [**2145-5-11**].
- Start fexofenadine, 60 mg tab, 1 tab, by mouth, twice a day as
needed for allergy.
It is VERY IMPORTANT for you to follow up with your new primary
care provider and your diabetes provider in the scheduled
appointments below.
Followup Instructions:
Department: [**Hospital3 249**]
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. This appointment is with a hospital-based
doctor as part of your transition from the hospital back to your
primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your
regular primary care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **] in follow up.
When: FRIDAY [**2145-5-14**] at 9:40 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**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: Endocrinology
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**], NP
When: Thursday [**2145-5-20**] at 12:30 to complete your
registration, 1 PM for your Eye Exam, and 1:30 to meet with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**], NP
Address: [**Last Name (un) 3911**], [**Location (un) 551**], [**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2384**]
Completed by:[**2145-5-11**]
|
[
"285.9",
"553.3",
"275.3",
"571.8",
"250.12",
"577.0",
"420.90",
"276.1",
"V58.67",
"427.89",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18248, 18254
|
10525, 16424
|
321, 327
|
18567, 18567
|
5572, 5572
|
20298, 21434
|
4002, 4159
|
16479, 18225
|
18275, 18416
|
16450, 16456
|
18717, 20275
|
7921, 10502
|
4174, 5553
|
18437, 18546
|
3116, 3604
|
263, 283
|
355, 3097
|
5588, 6277
|
18582, 18693
|
6293, 7905
|
3626, 3632
|
3648, 3986
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,183
| 189,730
|
9883
|
Discharge summary
|
report
|
Admission Date: [**2196-2-1**] Discharge Date: [**2196-2-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Pt is a 82 y/o M w/ h/o COPD, CAD, TIA who p/w progressive
dyspnea over the last few weeks. Pt. admits to not taking his
medications for the last month b/c "he ran out". He has had
worsening SOB and today he couldn't tolerate it.
.
Denied chest pain/n/v/d/urinary or bowel sx.
.
In [**Name (NI) **], pt. tight w/ min. air movement. O2 sat in 79% on RA.
Rec'd combivent nebs, steroids. Pt. w/ some improvement on nebs,
continued to desat off continous nebs.
Additionally in ED, EKG w/ < [**Street Address(2) 4793**] elevation in V1/2 w/ +
troponin-. Per cardiology intervention was limited to aspirin
and heparin was deferred no BB b/c copd; cycle enyzymes, call
them if pain recurs, repeat EKG.
.
Patient was given ceftriaxone, azithro due to multilobar pna
seen on cxr. Sputum and blood cultures were obtained. He was
given lasix 10 IV and continuous combivent nebs.
Past Medical History:
HTN
hypercholesterolemia
NQWMI ca. [**2182**]
TIA/aphasia [**10-1**]
s/p L CEA [**2-2**]
COPD (FEV1 1.57 per [**7-1**] PFTs)
BPH s/p TURP [**5-31**]
balanitis s/p circumcision [**5-31**]
remote nephrolithiasis
former tobacco use (80 pack/year Hx)
Social History:
lives with wife. 2- children, daughter very involved. Works as
case manger at [**Hospital1 18**]. 80 pack years of smoking, quit 5 years
ago. Has generally been pretty resistant to medical care, last
PCP [**Name Initial (PRE) **] ~ 2 years ago.
Family History:
Non-contributory
Physical Exam:
T 97.2, BP: 94/58 HR 93 RR: 25 89% on 6L neg >800cc for the day
GEN: NAD, speaking in full sentences, A & O X 3, no accessory
muscle use
HEENT: L CEA surgical scar, well-healed; no thyromegaly
LUNGS: poor air movement, + expiratory wheezes, minimal
expiratory rhonchi, no crackles, decreased bs at bases
HEART: RRR, nls1s2 no MRGs
ABD: sl. distended, soft, NTND +bs
EXT: 2+ pulses, no C/C/E
NEURO: nl MS; CN II-XII grossly intact, nl strength and
sensation grossly
Pertinent Results:
Portable CXR [**2-8**]: A small right pleural effusion has decreased.
Small bilateral pleural effusions persist. Mild opacification at
the lung bases is probably atelectasis. Upper lungs clear. No
pulmonary edema. Heart size normal.
.
Echo [**2-2**]: There is moderate symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated. There is
mild global right ventricular free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
No mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
This 82 year old gentleman with COPD and CAD, and TIA's
presented with progressive dyspnea over several weeks was
admitted to the ICU for hypoxia and need for continuous nebs.
Given wheezes and history of smoking, this was believed to be
secondary to COPD exacerbation. In addition, there was evidence
of bilateral opacities on chest X-ray suggesting a concurrent
pneumonia and pt was initially covered broadly. He was ruled
out for MI and pulmonary embolus disease.
#hypoxia/PNA: On HD 3 the patient was found to be hypercarbic
with pCO2 of 83 and was therefore intubated. His respiratory
function improved and he was extubated on HD 5 Sputum culture
revealed strep pneumonia and antibiotic coverage was narrowed to
levofloxacin.
After extubation, the patient had a persistently high oxygen
requirement requiring face mask with nasal cannula. He was
weaned off face mask but continued to require 6 L nasal cannula
to maintain oxygen saturations at 88-92% (which is baseline per
patient). When attempts were made to increase o2 saturatino, he
became hypercarbic, so the goal was made to keep his sats in the
88-92% range. He was not in respiratory distress after
extubation. He was transferred on HD 8 to the floor.
He was continued on nebs around the clock and required 6L NC or
35% FM intitially, with continued desats on ambulation with PT.
Over his five day stay on the floor, his lung exam improved and
his oxygenation status improved such that he could tolerate 4L
o2 while ambulating with desats onlt to 85% on discharge. We
strongly recommended pulmonary rehab, but patient repeatedly
refused. Through this time, we continued levofloxacin and
discharged him with a prescription to take him through a full 14
day course.
.
He was discharged home with home oxygen, albuterol nebulizers
and tiotroprium, salmeterol, fluticasone
.
# Cardiac:
Pt. also had elevated trops with flat CK in context of
hypovolemic ARF, which has now resolved to baseline. Also had a
brief run of sinus arrest and junctional escape (several
seconds), so cardiology recommended avoid nodal agents for BP
control and pt. was started on lisinopril. Had Echo showing
moderate LVH, normal EF, moderate RV dilitation, hypertrophy,
and mild hypokinesis.
We started asa, continued lipitor and initially started ACE-I,
which he initially tolerated in ICU, but had to be titrated down
due to hypotension on the floor. We ended up discontinuing it,
with plans to readress whether his blood pressures could
tolerate ACE-I as an outpatient. Of not he was asymptomatic
during these episodes of hypotension to systolics in the 90s.
.
# Volume overload:
He also was aggressively volume resuscitated resulting in a max
of 12L positive in ICU, after which he has been aggressively
diuresed with lasix. He responded nicely with no need for
further diuretics upon discharge
.
#CRI- baseline 1.0, admission 1.7. likely elevated in the
setting of infection.
--Resolved with fluids, clearing of infection
.
Medications on Admission:
ALBUTEROL 90MCG--2 puffs four times a day as needed
ASPIRIN 325MG--One by mouth every day
ATROVENT 18MCG--2 puffs four times a day
LIPITOR 10MG--One tablet by mouth every day
LISINOPRIL 5 mg--One (1) tablet po once a day
**per pt.'s daughter, the pt really only taking lipitor.**
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
[**Month/Day (2) **]:*180 neb* Refills:*2*
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
[**Month/Day (2) **]:*100 neb* Refills:*0*
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
[**Month/Day (2) **]:*30 Cap(s)* Refills:*2*
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*1 disk* Refills:*2*
7. Oxygen-Air Delivery Systems Device Sig: One (1) system
Miscellaneous once.
[**Hospital1 **]:*1 kit* Refills:*0*
8. home oxygen
home oxygen. Titrate on face mask or nasal cannula to oxygen
saturation of 88-91%
9. Nebulizer Device Sig: One (1) device Miscellaneous once.
[**Hospital1 **]:*1 unit* Refills:*0*
10. Nebulizer Accessories Kit Sig: One (1) kit Miscellaneous
once.
[**Hospital1 **]:*1 kit* Refills:*0*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety.
[**Hospital1 **]:*50 Tablet(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: take 3 tabs po per day (30mg) for 7 days then 2 tabs per
day (20mg) for another 7 days. After than start taper using 5mg
tablets.
[**Hospital1 **]:*35 Tablet(s)* Refills:*0*
14. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a
day: after finishing 20 mg taper, start taking 3 tabs/day(15mg)
for 1 week, then 2 tabs/day until further notice from your PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
15. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
[**Name Initial (NameIs) **]:*90 Capsule(s)* Refills:*0*
16. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
[**Name Initial (NameIs) **]:*1 bottle* Refills:*0*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid:prn as needed
for constipation.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
[**Name Initial (NameIs) **]:*60 Capsule(s)* Refills:*0*
19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
[**Name Initial (NameIs) **]:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
COPD exacerbation
Multilobar Pneumonia
Acute Renal Failure
_______________
Hypertension
Discharge Condition:
good, tolerating POs, ambulating without assistance, satting 88%
on Room air, desatting to low 80s on 4L NC with ambulation
Discharge Instructions:
please seek medical attention should you develop increasing
shortness of breath or desaturations to less than 85%. Please
also seek medical attention should you develop fevers, chills,
chest pain, abdominal pain, or increased weight gain, swelling.
You have two more days of antibiotics which you should finish.
Take all other medications exactly as prescribed. You should
attempt to adhere to a diet of <2g salt per day. Weigh yourself
daily and call your doctor should you gain > 3 pounds or >5
pounds from today's weight.
You should follow up with Dr. [**Last Name (STitle) 5717**] within a week, as below
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5717**] within the next week. His number is
[**Telephone/Fax (1) 250**].
|
[
"518.81",
"403.90",
"585.9",
"788.20",
"412",
"584.9",
"428.0",
"486",
"491.21",
"112.0",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9364, 9422
|
3149, 6131
|
270, 295
|
9554, 9680
|
2265, 3126
|
10343, 10461
|
1745, 1763
|
6462, 9341
|
9443, 9533
|
6157, 6439
|
9704, 10320
|
1778, 2246
|
223, 232
|
323, 1196
|
1218, 1467
|
1483, 1729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,642
| 115,417
|
39733
|
Discharge summary
|
report
|
Admission Date: [**2120-6-26**] Discharge Date: [**2120-7-2**]
Date of Birth: [**2073-12-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Headache for 2-3 days and s/p unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. [**Known lastname 29425**] is a 46 yoF with polymyositis who was admitted
to the neuro ICU with right temporal lobe intraparenchymal
hemorrhage, SDH and SAH on [**6-26**]. She was found down at home
after several days of HA, and it is suspected she fell from the
IPH and then sustained a SDH/SAH. She was originally taken to an
OSH, but then transferred her after head CT showed the IPH.
.
She was transferred to the floor on [**6-27**], and her head bleeds
have been stable clinically and radiographically. She had
elevated troponins noted in the ED (peaked at 4.15). She has
been followed by cardiology. TTE showed moderate to severe TR
and pulmonary HTN, and she is scheduled for a cath on Monday for
further workup. There is concern this may be early ILD from the
polymyositis.
.
ROS is negative for CP, PND, orthopnea, [**Location (un) **], weight changes,
N/V, change in BM, F/C, NS, and arthralgias. She does encorse
SOB with climbing stairs, which she feels is worse over the last
few years. She had attributed this to muscle weakness with her
polymyositis. She continues to have a frontal headache, though
it is better than on admission, and she has mild back pain over
her tailbone.
Past Medical History:
Polymyositis
Chronic headache
Social History:
Lives in [**Location (un) 5503**] with her two children. No EtOH, smokes
1ppd, no illicits.
Family History:
No history of aneurysm, intracranial bleeding
Physical Exam:
Physical Exam on admission:
T: 96.9 HR: 97 BP: 106/77 RR:18 Sat: 98
Gen: comfortable, anxious
HEENT: Pupils: 4->3 EOMs - full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to
3 mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5- 5 5 3- 4 4 5 5 5
L 5- 5 5 3- 4 4 5 5 5
Motor: Normal bulk and tone bilaterally. No pronator drift
Sensation: Reports numbness to light touch in bilateral lower
extremity - calf up to thighs. Also reports numbness in abdomen
up to chest.
Physical exam on discharge:
VS on transfer: 98.8, 125/74, 90, 16, 99% RA
General: comfortable,laying in bed
HEENT: OP clear, no LA, conjunctiva non-icteric
LUNGS: LCTA bil, no wheezing
CARDIO: rate regular, no murmurs appreciated
ABD: soft, NTND
SKIN: no rashes, no ecchymoses
NEURO: AA, Ox3, CNII-XII in tact, speech normal, strength 5/5
throughout, reflexes 2+ throughout, gait deferred
Pertinent Results:
[**2120-6-26**] 02:30AM BLOOD WBC-11.2* RBC-4.21 Hgb-14.8 Hct-40.9
MCV-97 MCH-35.1* MCHC-36.1* RDW-13.1 Plt Ct-226
[**2120-7-1**] 05:27AM BLOOD WBC-4.4 RBC-3.93* Hgb-13.4 Hct-38.6
MCV-98 MCH-34.1* MCHC-34.7 RDW-13.5 Plt Ct-201
[**2120-6-26**] 02:30AM BLOOD PT-14.2* PTT-22.1 INR(PT)-1.2*
[**2120-6-26**] 02:30AM BLOOD Glucose-187* UreaN-5* Creat-0.6 Na-138
K-3.6 Cl-101 HCO3-21* AnGap-20
[**2120-7-1**] 05:27AM BLOOD Glucose-88 UreaN-4* Creat-0.5 Na-134
K-3.4 Cl-100 HCO3-26 AnGap-11
[**2120-6-26**] 02:30AM BLOOD ALT-56* AST-69* LD(LDH)-438*
CK(CPK)-6134* AlkPhos-75 TotBili-0.7
[**2120-6-28**] 05:15AM BLOOD CK(CPK)-2972*
[**2120-7-1**] 05:27AM BLOOD CK(CPK)-1294*
[**2120-6-26**] 07:52PM BLOOD cTropnT-4.15*
[**2120-6-28**] 05:15AM BLOOD CK-MB-48* MB Indx-1.6 cTropnT-1.87*
[**2120-7-1**] 05:27AM BLOOD cTropnT-0.35*
[**2120-6-26**] 02:30AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.5*
[**2120-7-1**] 05:27AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.0 Mg-2.0
[**2120-6-28**] 05:15AM BLOOD Phenyto-7.8*
[**2120-7-1**] 05:27AM BLOOD Phenyto-9.3*
.
CT HEAD [**6-26**] AM
1. Possibly mildly increased IPH centered in the R temporal
lobe, now
measuring 3.2 x 2.0 cm.
2. Unchanged 5mm leftward shift. Effacement of the RIGHT-sided
sulci.
3. Unchange RIGHT-sided SDH, with max thickness of 5 mm.
4. Small amount of RIGHT-sided SAH.
5. No intraventricular hemorrhagic extension. No developing
hydrocephalus.
.
CTA HEAD [**6-26**]
Overall stable appearance of R temporal hematoma with slight
increased edema but stable mild left shift. No herniation.
Stable R frontal SDH and stable amount of SAH. No new focus of
hemorrhage. COW vessels patent without large aneurysm. [**Doctor Last Name **] x pg
[**Numeric Identifier 27921**]
.
MRI HEAD W and W/O [**6-26**]
IMPRESSION: Right-sided temporal intraparenchymal hemorrhage
identified with extension to the subarachnoid space and subdural
space. Post-gadolinium images are limited for evaluation of any
enhancement in the area. There is no evidence of abnormal
vascular structures in the region. It is recommended that if
clinically indicated the post-gadolinium imaging should be
repeated if necessary with sedation.
.
CT Head [**2120-6-27**]:
Stable appearance of bleed and midline shift.
.
L-spine [**2120-6-28**]: Mild degenerative changes. Grade 1
anterolisthesis of L4 over L5.
.
CTA chest w/ w/o contrast [**2120-6-28**]: No segmental, subsegmental
pulmonary embolism or acute aortic syndromes. Punctate left
lower lobe pulmonary nodule. In the absence of risk factors, no
further followup is necessary.
.
ECHO [**2120-6-28**]:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate to severe tricuspid regurgitation. Severe pulmonary
hypertension. Calcified mitral and aortic valve. Mild to
moderate aortic regurgitation.
.
Right-sided cardiac catherization [**2120-7-1**]: Coronary arteries
are normal. Normal ventricular function.
Brief Hospital Course:
# Intracranial hemorrhage: Prior to admission, patient had been
complaining of worsening headaches for 2 -3 days accompanied by
nausea and vomiting. On [**2120-6-25**] she was found down in the
bathroom by family members after a presumed fall from standing.
The patient reports headaches were common for her but the recent
headaches were much more severe. She initially presented to an
OSH where a noncontrast CT scan of the head was obtained which
showed a right temporal intraparenchymal hemorrhage, a Right
subdural hematoma, and a small Right subarachnoid hemorrhage.
Following the results of the imaging she was transferred to
[**Hospital1 18**] for further care. Upon arrival in the emergency room she
was evaluated and found to have slight proximal muscle weakness
secondary to her polymyositis. She also complained of numbness
in both calves, thighs, and on her abdomen up to her mid chest.
She was admitted to the intensive care unit for monitoring. A
neurology consult was also called in order to better evaluate
her presenting symptoms. On the morning of [**2120-6-26**] she was
evaluated on rounds and found to be neurologically intact. In
order to attempt to determine the etiology of her IPH in
conjunction with recommendations from neurology, a CTA of the
head and MRI with and without contrast of the head were
obtained. The CTA showed that there was a stable appearance of
her intracranial blood and that there were no aneurysms
appreciated. Her MRI showed stable appearance of her bleed and
no underlying mass but motion artifact resulted in non-ideal
study. While in the ICU she exhibited periods of confusion and
impulsiveness, which resolved. She was transferred to the
medical floor on [**2120-6-30**]. Patient was started on Dilantin for
seizure prophylaxis and levels were appropriate after adjustment
with albumin.
.
# Cardiac: On admission, Troponin was elevated. An
echocardiogram was obtained which showed tricuspid and atrial
regurgitation as well as severe pulmonary hypertension
([**2120-6-27**]). After the Echo final read was done, Cardiology was
[**Month/Day/Year 4221**] on [**2120-6-28**] and recommended a CTA to rule a PE. The CTA
was performed which did not show a PE. A right-sided cardiac
catherization was performed, which showed normal biventricular
filling pressures, normal cardiac output, and normal systemic
blood pressure. No further studies were recommended by the
Cardiology service.
.
# Polymyositis: On admission patient had elevated CK up to 6490,
which continued to trend down throughout the hospital course to
1294. She did not report flare of her polymositis and was not
currently on steroid treatment. Followup appointment with
outpatient rheumatologist was made prior to discharge.
Medications on Admission:
Aspirin prn
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Intraparenchymal Hemorrhage
Right Subdural hemorrrhage
Right Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 29425**], you were admitted to the [**Hospital1 **]
Hospital because you were found down. When you got here, we got
CT scan of your head which showed bleeding inside and around
your brain. You were admitted to the Neurosurgery service, where
they decided not to treat you surgically. Instead, you were
given a medication called dilantin to prevent seizures, which
can happen in the setting of a brain bleed. When you got the
hospital blood tests showed that you heart enzymes were
elevated, which can be due to damage to the heart. We got an
ultrasound of your heart which suggested that you might have
high blood pressure in the your lung vessels. Thus the
cardiology doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**] and they threaded a catheter
into your heart to take a closer look. The results of the
right-catherization was normal. You should follow up with your
neurosurgeon, rheumatologist, and primary care physician after
discharge. We have made those appointments for you.
You should also remember to:
- Take your pain medicine as prescribed.
- Exercise should be limited to walking; no lifting, straining,
or excessive bending.
- Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
- Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
- If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
We made the following changes to your medication:
1. Phenytoin Sodium Extended 100 mg by mouth three times a day
Followup Instructions:
Please follow up with your primary care doctor - Dr. [**Last Name (STitle) 47242**]
508-993-00 with in [**11-18**] weeks. You will need your primary care
doctor to order a repeat cardiac echocardiogram.
It is very important to have a doctor that you have a good
relationship. If you Dr. [**Last Name (STitle) 47242**] is no longer available would
be happy to see you at our clinic at [**Hospital6 733**].
Please give us a call to set up an appointment at [**Telephone/Fax (1) 250**]
if you would prefer to transfer your care to [**Hospital1 **].
Please call [**Telephone/Fax (1) 1669**] and make a follow up appointment for
4-6 weeks with a non-contrast Head CT with Dr. [**Last Name (STitle) 548**], your
neurosurgeon.
Please also make an appointment with your rheumatologist Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by calling [**Telephone/Fax (1) 9674**] within the next month.
Completed by:[**2120-7-2**]
|
[
"710.4",
"401.9",
"724.5",
"784.0",
"852.06",
"852.26",
"424.0",
"431",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
9460, 9466
|
6497, 9240
|
361, 368
|
9601, 9601
|
3516, 6474
|
11691, 12635
|
1780, 1827
|
9302, 9437
|
9487, 9580
|
9266, 9279
|
9752, 11668
|
1842, 1856
|
3135, 3497
|
275, 323
|
396, 1600
|
2280, 3107
|
1870, 2028
|
9616, 9728
|
1622, 1653
|
1669, 1764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,589
| 101,114
|
8618
|
Discharge summary
|
report
|
Admission Date: [**2111-12-17**] Discharge Date: [**2112-1-21**]
Date of Birth: [**2052-7-24**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
increased work of breathing
Major Surgical or Invasive Procedure:
- Intubation/ventilation
- Tunneled HD catheter placement
- Central line
History of Present Illness:
The patient is a 59y/o WW w/ a PMH significant for DM1 (c/b CRF,
neuropathy, and retinopathy), morbid obesity, and HTN who was
recently hospitalized for an episode of ARF [**1-14**] ATN. This
occurred in the setting of a osteomyelitis [**1-14**] an ankle fx. She
was sent back to her Rehab center following this admission and
there she developed dyspnea and anuria. Her Cr rose to 4.8 and
she had a leukocytosis at 16. She was admitted and noted to have
troponins in the 3 and was seen to have a NSTEMI but was not
anticoagulated [**1-14**] the feeling that her presentation represented
a subacute event. She required a NRB during her early admission
that was quickly weaned but, considering her fluid overload,
renal was consulted and decided to proceed to HD. During this
time, she also was noted to have a UTI that was initially
treated w/ levo/flagyl (b/c of a presumed aspiration PNA at this
time as well) but this was later changed to linezolid when it
grew VRE. On the floor, she had an episode of unresponsiveness
for which a code blue was called. She was initially pulseless
but returned to NSR w/ CPR. She was intubated during this code
during which she was also noted to have a 12b run of VT.
.
During MICU stay, pt's vent settings were weaned quickly. She
received very little sedation and was comfortable on the vent.
She was maintained on the vent for the first two days in the
MICU for her tunneled HD catheter placement and for initiation
of HD. Her line was placed on MICU day #2 in IR without
complications. HD was done the same day through the line and 1kg
was removed. Pt tolerated HD well. ON MICU day #2, she was
changed to PS 5/5 and a RSBI on MICU day #3 was 28. She was
extubated on MICU day #3 and maintained her O2 sats in high 90s.
An insulin gtt was briefly started for high blood sugars but
this was titrated off. A c. diff infection was treated w/
flagyl.
.
On ROS today, the patient complains of "labored breathing" but
denies any CP, abdominal pain, N/V, HA, weakness, paresthesias,
visual changes, or palpatations.
Past Medical History:
s/p laser, neuropathy manifestation, diabetic nephropathy. crf
1.7 1 year ago. pcr [**12-15**]. prot. for 5 years. [ACEI cough, high K
on [**Last Name (un) **]]
- Hyperlipidemia, NOS
- Obesity
- Anemia of Other Chronic Illness - on procrit for 2 years. on
q 3 wk. large dose. only on procrit once every 3 weeks now,
small dose.
- Hypothyroidism primary
- Hypertension, essential NOS:
- Hyperparathyroidism (secondary) now on hectorol at hospital.
- CVA - [**2111**]5, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30210**]. of the Left Internal Cap.
Social History:
Married and lives with her husband. 2 children, retired school
teachers. No tob, no EtOH.
Family History:
Father died of Colon Cancer
Physical Exam:
PE: 96.2, 133/36, 75, 100% 40%FM
Gen: Obese woman lying in bed in NAD, foley and rectal tube in
place
HEENT: EOMI, PERRLA, MMM, O/P clear
Lungs: Diffusely rhonchi
Cardiac: Difficult to hear w/ coarse breath sounds but
Abdomen: Obese, S/NT/ND, +BS, - HSM appreciated
Extremities: 2+ LE edema bilaterally w/ trace UE edema as well
Skin: no rashes. L heel wrapped
Neuro: CN and strenght exam limited by lack of cooperation by
patient, AAO x3
Pertinent Results:
Admission Labs:
[**2111-12-17**] 05:32PM BLOOD WBC-15.1* RBC-3.67* Hgb-10.2* Hct-31.5*
MCV-86 MCH-27.8 MCHC-32.4 RDW-16.5* Plt Ct-283
[**2111-12-17**] 05:32PM BLOOD Neuts-92.1* Bands-0 Lymphs-3.7* Monos-2.0
Eos-2.0 Baso-0.2
[**2111-12-19**] 06:30AM BLOOD Neuts-86.3* Bands-0 Lymphs-7.5* Monos-2.2
Eos-3.7 Baso-0.3
[**2111-12-17**] 05:32PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
Stipple-OCCASIONAL
[**2111-12-17**] 05:32PM BLOOD Plt Smr-NORMAL Plt Ct-283
[**2111-12-30**] 06:33PM BLOOD ESR-115*
[**2111-12-17**] 09:58PM BLOOD CK(CPK)-9140*
[**2111-12-29**] 05:46PM BLOOD Lipase-10
[**2111-12-17**] 09:58PM BLOOD CK-MB-118* MB Indx-1.3 cTropnT-2.86*
[**2111-12-17**] 05:32PM BLOOD Calcium-8.4 Phos-6.9* Mg-2.0
[**2111-12-30**] 06:33PM BLOOD VitB12-600 Folate-10.5
[**2111-12-30**] 06:33PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
[**2112-1-9**] 03:45AM BLOOD TSH-6.7*
[**2111-12-31**] 02:08PM BLOOD Cortsol-27.1*
[**2111-12-31**] 02:08PM BLOOD Cortsol-38.2*
[**2111-12-31**] 04:20PM BLOOD Cortsol-41.8*
[**2111-12-20**] 04:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2111-12-30**] 06:33PM BLOOD CRP-216.0*
[**2111-12-30**] 06:33PM BLOOD PEP-NO SPECIFI
[**2112-1-1**] 12:26AM BLOOD Vanco-13.4*
[**2111-12-22**] 05:04PM BLOOD HCV Ab-NEGATIVE
[**2111-12-17**] 04:05PM BLOOD Glucose-180* Lactate-2.0 Na-138 K-6.4*
Cl-104 calHCO3-22
[**2111-12-17**] 05:32PM BLOOD Glucose-206* K-5.4*
[**2111-12-17**] 04:05PM BLOOD pH-7.19* Comment-GREEN TOP
[**2111-12-17**] 07:24PM BLOOD Type-ART Temp-38.3 Rates-/14 pO2-113*
pCO2-41 pH-7.31* calHCO3-22 Base XS--5 Intubat-NOT INTUBA
Comment-ROOM AIR
-CXR [**12-30**] - Lretrocardiac, R base, R upper lobe above minor
fissure opacities suggestive of atelectasis but could be
aspiration.
-EKG: at time of event unchanged, sinus tach
-Abd XR - [**12-29**] - Non-diagnostic bowel gas pattern. No evidence
of small bowel obstruction.
-TTE [**2111-12-18**]: mild sym LVH. LV size normal. EF >55% with no
obvious wall motion abnormality (due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded). Mild pulm artery systolic HTN.
.
EMG: Complex, abnormal study. There is electrophysiologic
evidence for a severe,
ongoing, proximal myopathy with denervating features (as can be
seen in
inflammatory myopathy, critical illness myopathy or toxic
myopathy). In
addition, there is evidence for a severe, chronic, sensorimotor,
generalized
polyneuropathy with both axonal and demyelinating features, as
can be seen in
diabetics, although other causes of neuropathy cannot be
excluded
.
Micro -
[**12-17**] Urine - VRE, yeast (resolved)
[**12-21**] Stool + for C diff (resolved)
[**12-24**] Urine - yeast (resolved)
.
MRI:
1. There is moderate cerebral and cerebellar atrophy.
2. There are areas of abnormal signal intensity in the brain
parenchyma, the distribution of which suggests ischemic lesions
including old lacunes in the thalami, probable small, old
brainstem infarcts, and a probable old infarct in the right
internal capsule. Given the patient's age, demyelinating disease
is a consideration but the [**Doctor Last Name 352**] matter lesions are unusual.
3. There is good flow in the distal internal carotid arteries,
the distal vertebral arteries and the basilar artery. The major
branches of the cerebral arteries are normal.There is no
evidence of a significant stenosis.
Brief Hospital Course:
59F multiple ICU admissions for problem[**Name (NI) 115**] respiratory function
including repiratory arrest requiring intubation who was most
recently transferred back to the MICU on [**1-3**] with increased
secretions and decreased functional respiratory reserve,
concerning for neurologic induced weakness. She had been
transferred out of the MICU 2 days prior ([**1-1**]) and while on
the floor was noted to have marked increased purulent sputum on
suctioning as well as increased residuals in her NG tube
concerning for obstruction. Furthermore, while on the floor she
was continuing work-up for her subacute weakness which included
an MRI showing no cervical cord compression. Her other medical
problems include DM type 1 (c/b CRF, neuropathy, and
retinopathy), osteomyelitis s/p fracture, morbid obesity, HTN,
CRF. She was originally admitted for this admission from rehab
w/ volume overloaded and in renal failure. This early part of
the hospitalization was also c/b NSTEMI which was medically
managed, as well as a UTI (VRE), which was treated.
.
During her first MICU stay ([**12-21**]), pt's vent settings were
weaned. She had a tunnelled HD line placed and dialysis was
initiated. Also the patient was found to have Cdiff and started
on flagyl. She was transferred to the floor on [**2111-12-23**].
.
On the floor the patient had persistent hypoxia at times
requiring a non rebreather. This was thought to potentially be
due to vol overload vs muscular weakness. The patient has
seemed to improve with HD. Of note on [**2111-12-28**] the patient was
having abdominal pain with tube feeds and had 1 episode of
coffee ground emesis in NGT suction. This cleared quickly and
did not recur. Hct has remained stable. Other ongoing problems
include ulcers on both feet, followed by Wound Care. A sacral
decubitus ulcer developed and was treated by Wound Care.
.
Pt had an episode of hypotension to the 80's, hypoxia to the
70's, and unresponsiveness on [**12-30**] prompting code blue &
transfer back to MICU. Anesthesia required an oral airway and
bag mask ventilation transiently but the patient quickly
regained consciousness spontaneously. Her BP normalized 120's
and she was satting in the high 90's on NRB mask. EKG was
unchanged and ABG during the episode was 7.44/36/223. In MICU
she was started on Zosyn for pneumonia, was transferred to the
floor on [**1-1**] after stabilization.
.
Weakness: Pt has had subacute (over wks) progression of profound
muscular weakness and CKs were as high as 9000s (w/low CK-MB).
CKs resolved spontaneously. An LP was done and was normal with
negative culture. Methylmalonic acid from the CSF was normal and
IgG was nondiagnostic. Her NIFs were followed and approximately
-40. An EMG was done and c/w critical illness myopathy and DM
neuropathy. An MRI was done which showed nothing specific. Pt
never on steroids during this admission. DiffDx also includes
rheumatologic cause such as polymyositis. Muscle Bx ([**1-8**]) c/w
ICU myopathy as well as more chronic changes, but special stains
are still pending. Neuro plans for outpt follow up. During
course, a GJ tube was placed and tube feeds begun because of
concern for pt's ability to swallow [**1-14**] weakness (NOTE:
fasteners will need to be removed [**2112-1-24**] similar to sutures per
Radiology who placed GJ tube). At time of discharge, patient
lifting L arm > R, minimal movement of legs (none against
gravity).
.
Hypotension: She had several episodes of hypotension in the ICU
which initially resolved with fluids. No evidence of sepsis.
On [**1-10**], pt's BP was persistently in the 90s/30s with MAPs in
the 50s that didn't respond to 500cc bolus so she was started on
low-dose Levophed. Renal evaluated the patient, and felt that
the hypotension seemed to occur post-dialysis, and recommended a
trial of mitodrine. She was started on this medication and was
titrated Levophed to off [**1-13**]; BP was stable afterwards. Prior
to discharge, patient restarted on beta blocker tx, particularly
in light of recent NSTEMI, once BP was stable. BB should be held
on AM of dialysis.
.
Diabetes: Patient with poorly controlled DM. Was transiently on
insulin drip during 1st MICU stay and then transitioned to
Lantus 50U [**Hospital1 **]. On [**1-9**], pt noted to have a blood sugar of 11
so Lantus discontinued and [**Last Name (un) **] consulted. Now stable and
titrating up Lantus doses, with SS insulin as needed. Glucoses
ranging in high 100s-low 200s of late (110-261).
.
C. diff colitis: Treated with flagyl, repeat toxin testing
negative.
.
Respiratory compromise: likely due to increased secretions from
tracheobronchitis. Pt was requiring sunctioning every [**12-14**]
hours. She was continued on Zosyn x 10 days, last dose 1/28.
Glycoperolate nebs were started to help with secretions but
stopped as they may have been thickening the secretions.
Weakness may have a component of her respiratory compromise.
Continues to be stable on NC with clear lung exam & CXR. A CTA
was performed which was negative for PE; did reveal some mild
hilar lymphadenopathy.
.
CAD: h/o severe CAD, and ?NSTEMI (peak CK 9000s but peak MB only
173 so may be more noncardiac skeletal muscle) in early [**Month (only) 404**].
Cardiology followed peripherally and would consider cardiac cath
in future. Started on ASA, now added beta blocker. Intolerant of
ACE-I and [**Last Name (un) **] by hx.
.
Acute on Chronic Renal Failure: Patient now with ESRD on HD
likely from diabetes. Cont renagel, phoslo. Renal following. Pt
will require dialysis while in Rehab.
.
FEN: On Tube Feeds via G-J tube. NOTE: fasteners will need to be
removed [**2112-1-24**] similar to sutures per Radiology who placed GJ
tube.
.
PPX: On PPI, Heparin sub Q.
.
Medications on Admission:
Insulin Glargine 40 U hs
Bowel reg.
Renagel 1600 qac
Bethanechol 10 tid
Metoprolol XL 150
Insulin (Lispro) SS
Prozac 40
ASA 81
Simvastatin 80
Synthroid 100
Plavix 75
MVI
Bowel Reg: senna, colace, mineral oil, dulcolax
Ciprofloxacin 500 daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
10. Aloe Vesta 2-n-1 Skin Cond 3 % Lotion Sig: One (1) Topical
qday () as needed for to periwound tissue.
11. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
16. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
21. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for pain.
22. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every
6 hours) as needed.
23. Insulin Glargine 100 unit/mL Solution Sig: 68 Units
Subcutaneous at lunch.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
- Critical illness myopathy
- Respiratory arrest/hypotension
- Congestive heart failure
- Renal failure on HD
- Urinary Tract Infection (VRE, treated, neg cx [**2112-1-1**])
- C diff colitis (treated, negative toxin)
- Diabetes mellitus, triopathy
[Intolerant of ACE (cough) and [**Last Name (un) **] (hyperkalemia)]
- Non-ST-Elevation Myocardial Infarction
- Hyperlipidemia
- Obesity
- Anemia chronic disease on procrit
- Hypothyroidism
- Hypertension
- Secondary hyperparathyroidism
- CVA [**7-16**] left internal capsule
Discharge Condition:
Fair
Discharge Instructions:
- Take the medications as prescribed.
- You will be working with Physical Therapy while at Rehab. You
will follow up with Neurology regarding your muscle weakness and
the results of the special biopsy muscle stains as scheduled
below.
- Call a doctor, return to ED for:
* fever
* chest pain
* shortness of breath
* other concerns.
Followup Instructions:
1. NEUROLOGY: Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 1038**], M.D.
Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2112-4-14**] 9:30
2. With your primary care doctor, call to schedule an
appointment for a convenient time.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"428.0",
"410.71",
"707.03",
"728.88",
"585.6",
"518.82",
"707.14",
"276.7",
"507.0",
"359.81",
"356.9",
"112.2",
"008.45",
"403.91",
"250.61",
"278.01",
"427.89",
"V58.67",
"250.41",
"599.0",
"V54.16",
"427.5",
"458.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"38.95",
"44.32",
"00.17",
"03.31",
"99.60",
"83.21",
"00.14",
"96.04",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15129, 15199
|
7120, 12868
|
297, 372
|
15768, 15775
|
3672, 3672
|
16157, 16513
|
3167, 3197
|
13160, 15106
|
15220, 15747
|
12894, 13137
|
15799, 16134
|
3212, 3653
|
230, 259
|
400, 2451
|
3689, 7097
|
2473, 3043
|
3059, 3151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,011
| 175,689
|
33245
|
Discharge summary
|
report
|
Admission Date: [**2160-11-28**] Discharge Date: [**2160-12-7**]
Date of Birth: [**2101-6-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Ileo-right colectomy.
3. Ileostomy/Hartmann procedure.
4. Liver biopsy.
History of Present Illness:
59M recently diagnosed with sclerosing cecal adenocarcinoma on
routine colonoscopy at [**Hospital1 1774**] presented with acute onset
abdominal pain/vomiting to [**Hospital6 5016**]. KUB positive
for free air. Patient transferred to [**Hospital1 18**].
Past Medical History:
Path at [**Hospital1 1774**]: mod differentiated sclerosing adenocarcinoma
Social History:
Pt is married with children and one grandchild. Pt is an avid
swimmer. He denies all tobacco, ethanol, and recreational drug
use.
Family History:
Non-contributory
Physical Exam:
On discharge:
98.7 87 118/64 18 94%RA
Gen: NAD
CVS: RRR, nl S1S2
Pulm: CTA b/l
Abd: soft, NT, ND, +BS, wound healing well s erythema/drainage,
ostomy pink & viable with brown stool & gas in bag
Ext: 2+ pitting edema b/l LE, warm & well perfused
Pertinent Results:
On admission:
[**2160-11-27**] 10:50PM BLOOD WBC-1.5* RBC-5.10 Hgb-14.3 Hct-42.6
MCV-84 MCH-28.1 MCHC-33.6 RDW-16.6* Plt Ct-480*
[**2160-11-27**] 10:50PM BLOOD PT-16.1* PTT-29.1 INR(PT)-1.5*
[**2160-11-27**] 10:50PM BLOOD Gran Ct-1100*
[**2160-11-27**] 10:50PM BLOOD Glucose-168* UreaN-19 Creat-1.1 Na-139
K-3.7 Cl-102 HCO3-25 AnGap-16
.
On discharge:
[**2160-11-28**] 04:08AM BLOOD calTIBC-173* VitB12-174* Ferritn-20*
TRF-133*
[**2160-11-29**] 02:12AM BLOOD ALT-20 AST-40 LD(LDH)-192 AlkPhos-33*
Amylase-42 TotBili-0.8
[**2160-11-29**] 02:12AM BLOOD Lipase-10
[**2160-12-1**] 04:03AM BLOOD Glucose-59* UreaN-10 Creat-0.8 Na-137
K-3.6 Cl-105 HCO3-28 AnGap-8
[**2160-12-1**] 04:03AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.8
[**2160-12-2**] 06:30AM BLOOD CEA-4.6*
[**2160-12-2**] 04:53PM BLOOD PT-16.3* PTT-29.4 INR(PT)-1.5*
[**2160-12-2**] 04:53PM BLOOD Folate-7.6
[**2160-12-3**] 06:40AM BLOOD WBC-10.2 RBC-3.14* Hgb-8.8* Hct-26.4*
MCV-84 MCH-28.1 MCHC-33.4 RDW-16.9* Plt Ct-318
.
Pathology:
1. Right colon and terminal ileum, hemi-colectomy (A-S):
A. Adenocarcinoma, see synoptic report.
B. Evidence of perforation with surgical repair; acute
serositis and granulation tissue with pigmented and polarizable
material.
2. Liver biopsy (T):
Metastatic adenocarcinoma consistent with colonic primary.
Colon and Rectum: Resection Synopsis
MACROSCOPIC
Specimen Type: Colonic resection. Location: Right colon
(hemicolectomy).
Specimen Size
Greatest dimension: 31.5 cm.
Tumor Site: Cecum.
Tumor configuration: Exophytic.
Tumor Size
Greatest dimension: 5 cm. Additional dimensions: 3 cm x
0.8 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: Low-grade (well or moderately
differentiated).
EXTENT OF INVASION
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues.
Regional Lymph Nodes: pN2: Metastasis in 4 or more lymph
nodes.
Lymph Nodes
Number examined: 18.
Number involved: 7.
Distant metastasis: pM1: Distant metastasis: Liver.
Margins (See comment.)
Proximal margin:
Uninvolved by invasive carcinoma. Distance of tumor
from closest margin: 110 mm.
Distal margin:
Uninvolved by invasive carcinoma. Distance of tumor
from closest margin: 135 mm.
Circumferential (radial) margin:
Uninvolved by invasive carcinoma. Distance of tumor
from closest margin: 45 mm.
Lymphatic Small Vessel Invasion: Present.
Venous (large vessel) invasion: Absent.
Additional Pathologic Findings: Adenomas (0.7 cm, 0.6 cm,
distant from margin).
Comments: Tumor directly extends to peritoneal surface and is
present associated with granulation tissue on the serosa.
.
[**12-5**] CT ABDOMEN:
IMPRESSION:
1. Status post ileal/right colectomy and ileostomy/Hartmann
pouch. Again seen is bowel wall thickening in particularly
involving the ileum, which may be related to anasarca and large
amount of intraabdominal fluid.
2. The small bowel is mildly dilated, likely representative of
ileus. No
evidence of bowel obstruction.
3. Multiple low-density lesions within the liver, which is
concerning for
metastases.
4. Moderate-sized bilateral pleural effusion and adjacent
atelectasis.
Indeterminate nodular opacities in the lungs, which may
represent atelctasis however cannot exclude metastatic lesion.
Recommend reevaluation with CT chest with better inspiratory
effort after resolution of pleural effusions.
5. Large amount of intraabdominal fluid , which limits
evaluation for omental lesions. No intraabdominal abscess is
identified.
.
[**12-5**] LENIS
No evidence of DVT.
.
CT torso:
1. Status post ileal/right colectomy and ileostomy/Hartmann
pouch. There is bowel wall thickening, in particular involving
the ileum, which may be related to anasarca/large amount of
intrabdominal fluid.
2. Multiple incompletely characterized low-density lesions
within the liver for which metastatic lesion cannot be excluded.
Geometric wedge-shaped defect is seen within the right posterior
lobe of the liver consistent with biopsy.
3. Moderate-sized bilateral pleural effusion and adjacent
atelectasis.
Indeterminate nodular opacity in the right lower lobe, which may
be related to atelectasis/inflammatory process. Recommend
reevaluation after resolution of atelectasis and effusion.
4. Large amount of intrabdominal fluid which limits evaluation
for omental lesions.
Brief Hospital Course:
Pt transferred from OSH with perforated viscus and taken to the
OR emergently. Pt had colonoscopy on [**11-4**] for unexplained
weight loss/ This study demonstrated polps and adenocarcinoma
of the cecum. On the day of admission, pt presented to [**Hospital 40796**] with marked RUQ abdominal pain and vomiting. He
received a CT scan demonstrating free air.
.
Neuro: In the immediate post-operative period, the patient was
receiving propofol 50 for sedation. The patient's pupils were
equal and reactive and his EOMI. By the following day, the
patient was extubated and was AxOx3 and was being given dilaudid
IV for pain control. He was converted to PO pain medication on
POD 4 and has tolerated it well with eventually transitioning to
PO tylenol at the time of discharge.
.
CVS: During patient's stay in ICU, he became intermittently
hypotensive. This required intermittent levophed and
vasopressin for support. In addition, pt received more than 20
liters of fluid resusciation in the first 24 hours after
arrival. On POD# 1, levophed was weaned off and vasopressin was
weaned to halve its previous dose. Pt never required lasix for
this robust fluid resuscitation. He has since had excellent
urine output, and was hep locked on POD 3, taking a regular
diet.
.
Pulm: Initially, pt was transferred to SICU on AC with FIO2 of
60% rate of 18, peep of 5 without pressure support. Pt was soon
extubated and maintained on a face tent with high sats until
being transferred to the floor. At the time of discharge the
pt's breath sounds were clear with Sats greater than 95 percent
on room air only. Sats have been stable during ambulation.
.
GI: Surgery demonstrated gross fecal contamination and a 3 cm
perforation in the cecum. Pathology obtained from outside
hospital was consistent with moderately differentiated
sclerosing adenocarcinoma. During surgery, liver biopsy was
sent. Pt was also seen by our oncology service to discuss
outpatient management of disease. Pt also received stool
softeners with his narcotics.
.
Renal: Pt with stable BUN and creatinine throughout stay. Pt
with consistent and strong urinary output.
.
ID: Pt begun on cipro, flagyl, vanco at OSH and continued during
hospital admission. All antibiotics were stopped prior to
discharge following a nine day course beginning with IV
medication and concluding on PO's.
.
Heme: Pt with stable crit throughout surgery and postop period.
However, pt's INR at admission was noted to be 1.5 and
increased to 2.5 directly post-op. The last INR for this
patient was 1.5 on [**12-2**].
.
Endo: Pt maintained on ISS with QID finger-sticks throughout his
hospitalization.
.
FEN: Electrolytes were repleted as necessary.
.
Medications on Admission:
Aspirin
Saw [**Location (un) **]
Discharge Medications:
1. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
1 months: To prevent constipation while taking narcotics for
pain relief.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Perforated Cecal Adenocarcinoma
Discharge Condition:
Afebrile, vital signs stable, tolerating regular diet,
functioning ostomy, ambulating, pain well controlled on PO
medication. VNA services arranged for wound care.
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 skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
The following appointments have been made for you for follow-up
care.
.
Hematology Oncology
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3150**] Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-12-26**] 11:00
.
GI Hematology Oncology:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2160-12-26**]
11:00
.
Please call Dr. [**Last Name (STitle) **], Trauma Surgery, at ([**Telephone/Fax (1) 22750**] to
schedule an appointment within 1-2 weeks.
.
Please call Dr. [**Last Name (STitle) **], Hepatobiliary Surgery, at ([**Telephone/Fax (1) 3618**]
to schedule an appointment within 1-2 weeks.
|
[
"038.9",
"995.91",
"569.83",
"197.7",
"153.4",
"288.00",
"276.2",
"285.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"50.12",
"46.23",
"38.93",
"46.75",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9090, 9173
|
5735, 8444
|
330, 434
|
9249, 9416
|
1283, 1283
|
10506, 11214
|
979, 998
|
8528, 9067
|
9194, 9228
|
8470, 8505
|
9440, 10483
|
1013, 1013
|
1635, 5712
|
276, 292
|
462, 717
|
1297, 1621
|
739, 815
|
831, 963
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,008
| 144,377
|
4736
|
Discharge summary
|
report
|
Admission Date: [**2109-10-25**] Discharge Date: [**2109-10-31**]
Date of Birth: [**2025-12-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History obtained via pt.'s family at bedside as pt. sleeping and
unable to answer questions with any consistency. This is a 83
year-old man with a history of myeloma who presents from [**Hospital 100**]
Rehab with fever to 100.1, lethargy, tachypnea. He has been on
vanc/zosyn for known health-care associated PNA since [**10-18**] and
flagyl for C. difficile colitis, which was restarted [**10-18**] after
a period off of it. He received one dose of imipenum at [**Hospital1 5595**]
prior to being sent to [**Hospital1 18**]. Apparently had known C. diff.
treated for two weeks, with recrudescence of diarrhea about a
week after flagyl stopped. His family reports confusion,
difficulty putting sentences together, lethargy, decreased
appetite and diarrhea over the last week. Diarrhea has improved.
He has had a stable unproductive cough, only associated with
taking pos over the last few weeks. Wife [**Name (NI) 19913**] multiple
episodes of liquid-associated coughing. In addition, he has
sacral decub stage 2 on coccyx. He received one dose of imipenem
and was transferred to ED.
.
In the ED, he had initial vitals of 98.6 BP 134/76 HR 110 RR 32
96% on 3L, 91%RA. He had WBC to 17.9 with 3% bands, Cr to 1.3
(nl BL<1.0), lactate 3.2 and had blood cx. drawn. U/A negative
and received 2L IVFs and stress-dose steroids given chronic
prednisone for myeloma.
.
ROS: + weight change (weight loss over last year), no nausea,
vomiting, abdominal pain, + diarrhea, as above that is
improving, constipation, melena, hematochezia, chest pain, mild
shortness of breath. no orthopnea, PND, lower extremity edema,
urinary sx. no HA rash.
Past Medical History:
- Hypertension
- BPH
- Hypercholesterolemia
- B12 def dx'd 2y ago by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**]
- Grade I diastolic dysfunction by echo in [**10-26**]
- Myeloma/MDS: Kappa light chain myeloma. Presented with MGUS
[**2100**] without evidence of end organ damage. Initially observed
until [**2102**] when monoclonal protein rose and patient treated with
6 cycles melphalan/prednisone. Patient remained stable until
[**2104**] when protein rose again and was treated with 8 cycles
melphalan/prednisone finishing [**9-25**]. He then remained off
treatment until [**9-26**] when began to develop anemia/bone pain.
Found to have smear consistent with MDS involving all 3
lineages. Began treatment with velcade/revalmid and epo, then
mephalan/prednisone d/c'd earlier this year due to inability to
tolerate. Also had T9 and T11 involvement s/p radiation in [**2107**].
He was receiving treatment for his Myeloma until [**Month (only) **]
[**2108**]/dexamethasone/revlamide/alkaran but it was dc'ed [**12-22**] to
inability to tolerate regimen.
- h/o hyponatremia
- h/o multiple PNAs requiring hospitalization
- h/o C.Diff.
Social History:
Retired accountant, lives at [**Hospital **] rehab. No tobacco now or
previously, no etoh now or previously.
Family History:
No FH of malignancies.
Physical Exam:
Vitals: T: 97.8 BP: 96/47 HR: 94 RR: 19 O2Sat: 98%/3L
GEN: elderly man, sleeping, cachetic, follows commands, AA&Ox1.
Answers some questions clearly, but mumbled rambling for others
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP with thrush
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs with decreased BS at R base., sl. crackles at bases,
improve with cough
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, multiple ecchymoses over arms and legs
bilaterally
NEURO: CN II ?????? XII grossly intact. Moves all 4 extremities.
Skin: stage 2 decub over coccyx
Pertinent Results:
Admission Labs
[**2109-10-25**] 03:50PM
PT-17.6* PTT-32.1 INR(PT)-1.6*
PLT SMR-VERY LOW PLT COUNT-53*#
HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL
MICROCYT-NORMAL POLYCHROM-1+
NEUTS-55 BANDS-3 LYMPHS-29 MONOS-0 EOS-0
BASOS-0 ATYPS-10* METAS-1* MYELOS-2*
WBC-17.9*# RBC-3.51* HGB-10.7* HCT-30.3*
MCV-86# MCH-30.5 MCHC-35.4* RDW-16.8*
OSMOLAL-312* ALBUMIN-1.9* CALCIUM-9.3
PHOSPHATE-3.0 MAGNESIUM-1.9
LIPASE-18
ALT(SGPT)-7 AST(SGOT)-30 ALK PHOS-45 TOT BILI-0.4
estGFR-Using this
GLUCOSE-144* UREA N-35* CREAT-1.3* SODIUM-138 POTASSIUM-4.9
CHLORIDE-112* TOTAL CO2-21* ANION GAP-10
LACTATE-3.7*
[**2109-10-25**] 04:54PM URINE
AMORPH-MANY CA OXAL-OCC
RBC-0 WBC-0 BACTERIA-MOD YEAST-NONE EPI-0
BOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
CXR [**10-25**]
IMPRESSION: Moderate pulmonary edema and more focal
consolidation in the
right lower lobe, which may represent superimposed pneumonia
Brief Hospital Course:
Altered mental status: Patient initially admitted to ICU for
close monitoring before being transferred to the inpatient floor
the following day. Initially it was thought the patient may
have a worsening pneumonia. Patient was noted to be aspirating
with copious secretions. The patient failed speech and swallow
evaluation. Work up for altered mental status was done,
including cultures, head CT, metabolic problems was all
neagtive. In the end the altered mental status was believed to
be a result of severe deconditioning from multiple acute medical
problems on top of his multiple myeloma/MDS. There was not much
else that we could do for the patient. The family did not want
to put the patient through any uncomfortable procedures such as
an LP. They did not want a feeding tube placed. The patient
was not a candidate for any treatment for his myeloma.
Palliative care consult was obtained and after careful
discussion the family made the decision to make the patient CMO.
All nonessential meds were stopped and the patient expired
peacefully on [**2109-10-31**].
.
Medications on Admission:
- vancomycin IV 1gq12h
- zosyn q6h, switched to imipenem as above
- flagyl 500tid
- prednisone 15mg qdaily
- lactobacillus
- Caco3 650 [**Hospital1 **]
- VitD 1000 U qdaily
- cyanocobalamin 500mcg qod
- atrovent
- lactobacillus
- Mg oxide 400bid
- Megace 400 [**Hospital1 **]
- omeprazole 40bid
- KCL 20meQ tid po
- NaCl 1g qdaily
- Bactrim DS 1 tab q MWF
- tylenol PRN
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2109-11-3**]
|
[
"707.03",
"428.32",
"266.2",
"275.42",
"600.00",
"287.5",
"584.9",
"428.0",
"203.00",
"401.9",
"008.45",
"112.0",
"707.22",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
6680, 6689
|
5134, 5142
|
340, 346
|
6748, 6765
|
4092, 5111
|
6829, 7017
|
3331, 3355
|
6640, 6657
|
6710, 6727
|
6245, 6617
|
6789, 6806
|
3370, 4073
|
279, 302
|
374, 2008
|
5159, 6219
|
2030, 3188
|
3204, 3315
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,066
| 155,634
|
29770
|
Discharge summary
|
report
|
Admission Date: [**2169-1-21**] Discharge Date: [**2169-1-26**]
Date of Birth: [**2090-6-5**] Sex: F
Service: SURGERY
Allergies:
Oxycodone/Acetaminophen
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal pain
Nausea/vomiting x2 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo female with 2 days of vomiting and diarrhea, no blood
in the stool. No fever. Passing flatus. Developed abdominal
pain on [**2169-1-21**]. Presented to OSH where a CT scan reported to
have air in the portal system, WBC was 6.9, vital signs were
stable. She as then transferred to [**Hospital1 18**].
labs at OSH showed WBC of 6.9 with 77% PMNS.
Past Medical History:
HTN
CAD
IDDM
Colon cancer s/p colectomy (likely on left) x2 (one revision)
'[**57**], '[**58**] w/ colostomy s/p reversal.
Social History:
Denies tobacco, EtOH, illicit drugs.
Family History:
Noncontributory
Physical Exam:
Discharge Exam:
Tm 97.6 Tc 96.4 HR 68 BP 137/65 RR 16 SPO2 99%RA
NAD, A&Ox3
RRR
CTAB
Abd soft, NT, ND. +BS
LE: +1 nonpitting edema
Pertinent Results:
Admission labs:
[**2169-1-21**] 01:56AM BLOOD WBC-8.6 RBC-4.71 Hgb-13.8 Hct-38.7 MCV-82
MCH-29.4 MCHC-35.8* RDW-14.1 Plt Ct-178
[**2169-1-21**] 01:56AM BLOOD Glucose-74 UreaN-67* Creat-2.3* Na-133
K-4.2 Cl-96 HCO3-23 AnGap-18
[**2169-1-21**] 02:48PM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1
[**2169-1-21**] 02:17AM BLOOD Lactate-1.1
Discharge Labs:
[**2169-1-26**] 06:20AM BLOOD WBC-6.8 RBC-5.06 Hgb-14.0 Hct-42.4 MCV-84
MCH-27.7 MCHC-33.0 RDW-13.4 Plt Ct-200
[**2169-1-26**] 06:20AM BLOOD Glucose-103 UreaN-25* Creat-1.3* Na-138
K-5.2* Cl-100 HCO3-31 AnGap-12
[**2169-1-26**] 06:20AM BLOOD Phos-4.0 Mg-2.1
Digoxin monitoring:
[**2169-1-24**] 06:45AM BLOOD Digoxin-0.3*
[**2169-1-23**] 06:15AM BLOOD Digoxin-<0.2*
[**2169-1-21**] 01:56AM BLOOD Digoxin-0.2*
Admission CT ([**2169-1-21**]):
INDICATION: 78-year-old female with bowel ischemia on outside
CT. Patient has a elevated creatinine of 2.3. Oral contrast
only.
COMPARISON: None.
TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed
without
intravenous contrast. No intravenous contrast was administered
for elevated creatinine. Coronal and sagittal reformatted
images were obtained.
CT ABDOMEN WITH ORAL, WITHOUT INTRAVENOUS CONTRAST: The lung
bases are clear. A nasogastric tube is in place with the tip in
the stomach antrum. The patient is status post pacemaker
placement with a lead in the coronary sinus. Dense coronary
artery calcifications and calcifications along the mitral valve
are noted.
Imaging of the abdomen is limited by the lack of intravenous
contrast.
Allowing for this, the abdominal aorta and mesenteric branches
are densely
calcified. The liver is normal in attenuation. A few scattered
foci of
peripheral gas are seen in the nondependent portions of the
liver. There is a small amount of perihepatic free fluid. The
gallbladder is not clearly seen and may have been removed. The
pancreas is atrophic. The spleen is not enlarged. The left
adrenal gland and both kidneys are normal. There is a 15 x 15mm
right adrenal adenoma. Tiny calcification or stones are seen in
the kidneys bilaterally.
Proximal loops of small bowel measure upper limits of normal.
Several loops of jejunum within the left mid abdomen appear
thick walled with a few scattered foci of intramural air. There
more proximal loops of small bowel are prominent, but not
frankly distended. Contrast extends through to the rectum.
There is a small amount of intra-abdominal free fluid. There is
no free air. Multiple clips along the anterior abdominal wall
are most consistent with prior hernia repair.
CT PELVIS WITH ORAL, WITHOUT INTRAVENOUS CONTRAST: Foley
catheter is seen
within a collapsed bladder. The distal sigmoid, rectum, and
pelvic loops of small bowel are unremarkable. There is no
inguinal or pelvic lymphadenopathy. There is no free air.
BONE WINDOWS: There are no suspicious lytic or sclerotic
osseous
abnormalities. Degenerative changes are seen along the lumbar
spine.
IMPRESSION:
1. Small amount of peripheral portal venous gas within the
liver. Scattered tiny foci of intramural free air within
multiple thickened small bowel loops in the left mid abdomen.
This constellation of findings is concerning for mesenteric
ischemia in this patient with dense atherosclerosis involving
all proximal mesenteric vessels.
2. Calcifications in bilateral kidneys likley represent stones,
but may be vascular.
3. Right adrenal adenoma.
Brief Hospital Course:
At time of ED consult, HR 120 SBP 90-85. Temp 99. Tachycardia
improved with 500cc NS bolus. Due to CT suggestive of
mesenteric ischemia and pneumatosis, patient was initially
admitted to the ICU. She was started on ampicillin,
ciprofloxacin, and flagyl. She had an uneventful course
overnight and given a lack of physical findings suggesting
peritonitis, lack of fever, and normal WBC count, she was
transferred to the floor on HD2.
On HD3 she was advanced to sips and her foley catheter was
removed. She continued to have [**2-11**] loose bowel movements per
day. She was restarted on her home medications with the
exception of lasix, which was held to [**1-10**] her home dose of 40mg
PO BID and spironolactone, which was held.
On HD4 she had [**2-11**] loose BM. C. diff toxin screen was sent and
returned positive. The ampicillin and cipro were d/c'd and the
flagyl was changed to 500MG PO TID. Diet was advanced to
cleras.
HD5: diet was advanced to regular diabetic diet.
HD6: Patient tolerated regular diet. Continued to have [**2-11**]
loose BM per day but had no abdominal pain for 2-3 days. Felt
ready to go home. Morning of discharge her creatinine rose to
1.3 from 0.8 and her K was 5.2. Discharged home with
instructions to discontinue taking her lasix and spironolactone.
Discharged with 10d of PO flagyl.
Medications on Admission:
Imdur 30'', Iron 325', Lasix 40'', Lipitor 20', Protonix 20',
Digoxin 0.25', ASA 81', Norvasc 5', aldactone 25'', atenolol
200', diovan 320'
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Mesenteric ischemia
Clostridium difficile colitis
Discharge Condition:
Good
Discharge Instructions:
Do not take your lasix or spironolactone until further
instructed by your PCP or cardiologist. Resume your other
medications. Take all new medications as directed. You may
resume your regular diabetic diet.
Contact your MD if you experience:
* Increasing abdominal pain
* Worsening diarrhea or diarrhea that continues past your
antibiotic regimen
* Fever (>101.5 F)
* Other symptoms concerning to you
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5189**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 13553**] Call to schedule
appointment
Please follow-up with your PCP [**Name Initial (PRE) 176**] 2-3 days.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2169-1-26**]
|
[
"V10.05",
"557.1",
"008.45",
"414.01",
"276.51",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6236, 6242
|
4564, 5900
|
322, 329
|
6336, 6343
|
1109, 1109
|
6795, 7270
|
926, 943
|
6092, 6213
|
6263, 6315
|
5926, 6069
|
6367, 6772
|
1452, 4541
|
958, 958
|
974, 1090
|
244, 284
|
357, 710
|
1125, 1436
|
732, 856
|
872, 910
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,660
| 159,603
|
29540
|
Discharge summary
|
report
|
Admission Date: [**2144-7-14**] Discharge Date: [**2144-8-7**]
Date of Birth: [**2093-11-21**] Sex: F
Service: MEDICINE
Allergies:
Codeine / onions
Attending:[**First Name3 (LF) 13891**]
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
I and D of right gluteal abscess
b/l nephrostomy tube exchange by IR
History of Present Illness:
50 yo w/MMP, significant for HIV, sacral decubitus ulcer,
chronic vaginal discharge and hydronephrosis with bilateral
nephrostomy tubes and urinary incontinence presents with 1 day
of R thigh pain and swelling. Pt reports that pain is [**6-23**] feels
"like my leg is going to burst", constant, worse with touch or
movement, non-radiating. Leg is more swollen than usual, hot to
touch and red. She has had fever for 7 days w/temp ranging from
101-102. Denies SOB, CP, abd pain, change in nephrostomy or
colostomy output. She has had an increase in her chronic vaginal
discharge, no vaginal pain, no new sexual partners. Chronic
nausea is unchanged.
All other ROS negative
Past Medical History:
ONCOLOGIC HISTORY:
1) Rectal cancer:
- late [**2139**]: 6 months of intermittent rectal bleeding, rectal
pressure and a sensation of incomplete emptying.
- [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and
a 2.5 cm distal rectal mass arising from the anal verge in the
posterior rectum with a large area of induration.
- [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring
4.8 x 3.8 cm, bulging posteriorly into the presacral space and
anteriorly towards the uterus. There were enlarged lymph nodes
in the perirectal fat adjacent to the mass, a 9-mm enhancing
lymph node in the left pelvic sidewall, and enhancing lymph
nodes in the right external iliac region. There was also a 7-mm
hypodensity in the caudate lobe of the liver. Rectal ultrasound
on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3
disease. There were at least four abnormal perirectal lymph
nodes seen on MRI, in addition to multiple bilateral enlarged
pelvic sidewall lymph nodes, concerning for extensive disease.
- [**2141-2-20**]: began chemoradiation
- [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia,
and abdominal cramping
- [**2141-3-13**]: 5-FU was restarted at a reduced dose
- [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal
skin changes, diarrhea, and electrolyte abnormalities.
- [**Date range (3) 70844**]: Radiation was also held
- [**2141-3-27**]: 5-FU was restarted at a further reduced dose
- [**2141-3-31**]: completed radiation
- [**2141-4-3**]: completed chemotherapy
- [**Date range (3) 70845**]: hospitalized for bowel rest and the
initiation of TPN due to presumed radiation enteritis.
- [**2141-5-31**]: found to be HIV positive and began on HAART
- [**Date range (1) 70846**]: required hospitalization for an SBO, underwent
laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed
severe radiation-induced acute ischemic enteritis. She recovered
from this surgery, but continued to require TPN.
- [**7-/2141**]: Once her CD4 count had recovered, she underwent
laparotomy, lysis of adhesions, ileal resection,
proctosigmoidectomy, colonic jejunal pouch to near-anal
anastomosis with EEA, takedown splenic flexure, resection of
ileostomy and creation of new end-ileostomy. Pathology from the
surgical specimen revealed no residual carcinoma and all 14
lymph nodes sampled were free of disease.
- [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis
showed no evidence of recurrence.
- [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen
near the anastomatic site, new since the earlier study. Local
recurrence cannot be excluded, although possibly the appearance
is associated with endoluminal debris."
.
OTHER MEDICAL HISTORY:
2) HIV CD4 count CD4 263 in [**1-26**]
3) Short gut syndrome secondary to bowel surgery for CA.
4) Obstructive renal failure from radiation fibrosis, in the
past necessitating b/l nephrostomy tubes which have required
multiple revisions.
5) Lower extremity neuropathy, likely secondary to radiation
fibrosis, uses a wheelchair since 4/[**2141**].
6) Pancreatic insufficiency.
7) Anemia.
8) Chronic pain.
9) DVT in LE X2: requires lifelong coumadin, most recent [**4-24**].
Social History:
Lives in [**Location 17566**] with her husband and several children. No
tobacco or EtOH use. Used to be account manager, now on
long-term disability. Has [**First Name9 (NamePattern2) 269**] [**Location (un) 5871**], with skilled nursing 1h X
3/week + aid 1h X2/week. She is wheelchair bound.
Family History:
Father died at age 72 from MI. Mother is alive and well. Remote
family history of breast cancer. Daughter with ulcerative
colitis.
Physical Exam:
ADMITTING EXAM
VS: 98.8 99/54 122 20 95% on RA
GEN: mild distress, laying in bed
HEENT: no scleral icterus
SKIN: R thigh w/red, hot, indurated, tender, stage 4 sacral
decubitus ulcer, stage 2 R heel ulcer
CHEST: ctab
CV: tachy, regular, no m/r/g
ABD: nabs, soft, nt/nd
EXT: pitting edema to groin +DPs
GENITALIA: mons red (acute), firm (chronic)
NEURO: alert, answering questions appropriately
PSYCH: pleseant, appropriate
DISCHARGE EXAM
Pertinent Results:
[**2144-7-14**] 06:24PM LACTATE-1.3
[**2144-7-14**] 01:15PM GLUCOSE-82 UREA N-13 CREAT-1.2* SODIUM-131*
POTASSIUM-3.4 CHLORIDE-91* TOTAL CO2-29 ANION GAP-14
[**2144-7-14**] 01:15PM WBC-33.4*# RBC-3.15* HGB-9.1* HCT-29.2*
MCV-93# MCH-29.1 MCHC-31.3 RDW-18.6*
[**2144-7-14**] 01:15PM PLT COUNT-492*
CT A/P/Thigh [**2144-7-14**]: 1. Focal fluid collection posterior to the
right ischium is new since the prior exam measuring 8.6 x 3.7
cm. Additionally there is skin thickening, soft tissue
reticulation involving the right hemipelvis and the right thigh
with no evidence of necrotizing fascitis. 2. Unchanged air-fluid
level within the bladder likely secondary to
nephrostomy tubes, howeverconhowever infection with gas-forming
organisms
cannot be excluded in the correct clinical setting. 3.
Extensive radiation changes within the pelvis including findings
compatible with radiation cystitis, possible radiation colonic
stricture and enteritis. 4. Diffuse dilation of the small bowel,
without a definite transition point, which is chronic, and
essentially unchanged from [**2144-2-16**]. 5. Bilateral
nephrostomy tubes in place without hydronephroureter. 6.
Collapsed gallbladder, containing a small punctate gallstone.
Gas identified within the renal collecting systems bilaterally,
possibly introduced from the patient's nephrostomy tubes
unchanged from the prior exam. Stable left mid-ureter 4 mm
stone. 7. Similar appearance of sacral decubitus ulcer, with
erosive changes at the coccyx concerning for osteomyelitis. 8.
Hepatic steatosis.
CT Thigh [**2144-7-19**]: 1. No significant change in the appearance of
the previously packed and drained right gluteal abscess. No new
drainable collections. 2. New locules of air in the right groin
are of unclear significance and may be due to a prior injection
site or a new region of infection. There is no organized fluid
collection adjacent to the air to suggest a new abscess. 3.
Stable skin thickening and significant subcutaneous edema in the
thighs, worse on the right than the left. 4. Stable sacral
decubitus ulcer with probable osteomyelitis of the coccyx.
CTAP [**2144-7-23**]: IMPRESSION: 1. New moderate-to-large left
perinephric and left renal subcapsular hematoma. Small amount of
complex upper abdominal ascites suggestive of intraperitoneal
extension of hemorrhage. 2. Bilateral percutaneous nephrostomy
tubes in place. A small amount of air
in the kidneys relate to the recent tube change. 3. Moderate
distension of the stomach and proximal small bowel loops, may
relate to ileus or partial small bowel obstruction, evaluation
of which is limited due to lack of oral contrast. 4. Interval
drainage of a previously seen right gluteal abscess with small
amount of residual air and fat stranding in this region. A
large coccygeal decubitus ulcer. 5. Hepatic steatosis.
WOUND CULTURE (Final [**2144-7-19**]):
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 +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2144-7-19**]): NO ANAEROBES ISOLATED.
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Brief Hospital Course:
Ms. [**Known lastname 70847**] is a 50 year old woman with h/o rectal ca s/p
radiation, chemotherapy, and surgery, radiation-induced damage
s/p ileostomy, HIV on HAART (last CD4 263 in [**1-26**], vital load
[**6-/2144**] 413), obstructive renal failure from radiation fibrosis
with b/l nephrostomy tubes and h/o recurrent obstructions, DVTs
on Coumadin, chronic sacral ulcer with coccygeal osteomyelitis
(noted previously, being managed conservatively). The patient
was initally admitted to the floor and then quickly transfered
to the ICU for sepsis secondary to MRSA bacteremia. She then
improved with antibiotics and was transferred back to the
general medical floor. While on the floor, she underwent IR
guided change of her percutaneous nephrostomy tubes complicated
by perineprhic bleed leading to hypovolemic shock requiring ICU
transfer. She stabilized and was again transferred to the
medical floor and developed healthcare associated pneumonia.
This was treated with antibiotcs. She was also found to have a
likely bowel obstruction. She and her family refused invasive
treatments. After discussion, her family decided to focus on
comfort and her status was changed to comfort measures only on
[**2144-8-4**]. Her symptoms were managed aggressively with the help of
the palliative care team. The evening of [**2144-8-7**] after
discussion with palliative care, pain management and the
patient's family, a decision was made to start palliative
sedation. Full details of this discussion can be seen in the
paper chart and in the palliative care note from [**8-7**]. The
patient died [**8-7**] at 23:30.
For full details of her hospitalization please see below:
---------
# SEPSIS/SHOCK: Patient presented to ICU with mild hypotension
responsive to IV fluids. She had a R thigh cellulitis. A CT
showed a focal fluid collection posterior to the right ischium
with no evidence of necrotizing fascitis. The thigh abscess
spontaneously drained several hundred milliliters of purulent
fluid. General surgery was consulted regarding cellulitis and
abscess. They did not recommend any surgical intervention at
this time aside from packing the abscess pocket. Patient's bps
improved after resuscitation, and remained stable. She was
transferred to the floor awaiting nephrostomy tube exchange as
well as for further management of her abscess. She underwent
nephrostomy tube exchange on [**7-21**]. On [**7-23**], she was noticed
to have increasing flank pain, hypotension, and a falling
hematocrit. She was transferrred back to the MICU for
management of perinephric hemorrhage (described below). Patient
was maintained initially on linezolid and zosyn, then
transitioned to vancomycin after abscess cultures showed MRSA.
This was then transitioned to daptomycin once enterococcus grew
in urine (see below), though moved back to IV Vanco when she
required treatment for HAP on [**2144-7-29**]. This and wound care
continued. All antibiotics were discontinued when goals of care
were changed to comfort.
# PERINEPHRIC/PSOAS/intraabdominal HEMORRHAGE: Patient returned
to MICU after undergoing nephrostomy tube change and developing
pain at site of tube change. Patient became hypotensive and
hematocrit dropped from 25 to 18. Upon transfer to MICU, patient
became unresponsive and was pulseless to palpation. Patient was
stimulated and few chest compressions were performed prior, and
then became responsive but with barely palpable pulse. Patient
was bolused IVFs wide open, and received 4 units of pRBC, 1 unit
FFP, and 1 unit platelets. Levophed was transiently started, and
intraosseus access was obtained. After initial resuscitation,
patient remained hemodynamically stable, requiring another 1
unit pRBC for downward trending hematocrit. Anticoagulation was
held. HCT dropped again [**2144-7-29**] to 22 requiring 2 more PRBC.
Hct has remained largely stable since that time, with slight
decrease likely relating to ongoing phlebotomy. Bleeding
appeared to stop without intervention.
# OXYGEN REQUIREMENT/VOLUME OVERLOAD: Patient developed volume
overload, small effusions on CXR after initial MICU
resuscitation. Required 6L NC initially, but was titrated down.
She was given iv lasix to help with volume removal. Though
recurrent VTE was entertained, she was not a candidate for
systemic re-anticoagulation, and she and husband refused DVT/PE
eval or IVC filter after discussion.
# NEPHROSTOMY/ENTEROCOCCAL UTI: U/A on admission showed
positive leuks, WBC 56, and positive nitrite, few bacteria.
[**Month/Day/Year 159**] concerned for possible pyocystitis. Foley catheter
placement is difficult due to extensive radiation and scaring in
the area. The patient was scheduled to have nephrostomy tubes
changed on [**2144-7-16**] as an outpatient, underwent routine exchange
on [**7-21**] as an inpatient. On [**7-24**], patient was found to have
enterococcus growing in urine. Given extensive hospital history,
patient was transitioned from vancomycin to daptomycin given
concerns for [**Month/Year (2) **]. Final culture results revealed vancomycin
sensitive enterococci, and vancomycin continued for healthcare
associated pneumonia, starting on [**2144-7-29**]. As above,
antibitotics were discontinued.
# Anemia: Hct was initially in the low 20s despite 1 unit [**Date Range **]
on D1 of hospitalization. Her INR was reversed and there were
no signs bleeding on imaging. Her stool output was not bloody.
Her crit rose to around 24-25 by the time she was transferred to
the floor, without the need for transfusions. After her
nephrostomy tube placement and perinephric hemorrhage, she
required several more units of pRBCs.
# [**Last Name (un) **]: Cr 1.2-1.5 over the last 2 months. Went as high as 1.8 in
the setting of hypovolemia/shock. Responded to fluid
resuscitation.
# b/l DVTs: Supratherapeutic INR of 8.9 was reversed with FFP
and coumadin was held. She was then started on a heparin drip
and received 2 doses of oral coumadin with the plan to
discontinue the heparin drip for discharge. The patient then
developed hemorrhage as described above. She declined possible
IVCfilter, when, as result of increasing hypoxemia,
consideration of recurrent VTE was discussed.
# HIV: Chronic, last CD4 263 in [**Month (only) 956**]. Repeat CD4 this
admission 174. Home norvir, [**Month (only) **], prezista were continued, as
well as dapsone, however pt. largely unable to tolerate po
medications given bowel obstruction. Currently off all oral
medications.
# Ulcers: chronic, sacral and L heel. Wound care was consulted
recommendations were followed. Currently changing dressings only
for comfort as movement causes pain.
# Peripheral neuropathy/Chronic pain: Her home dose of Lyrica
and nortriptyline was continued. She was followed by the
palliative care service who made recommendations of pain
medications. She was transitioned to IV methadone.
# Rectal ca: No e/o disease per heme/onc progress note in [**1-25**],
but has not been seen in follow-up since that time.
# Recurrent small bowel obstruction. This occured on [**2144-7-31**].
Husband and healthcare proxy [**Name (NI) **] refused nasogastric
decompression. Discussions were ongoing with family about a
transition to comfort-oriented care as above.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. [**Name (NI) 70848**] *NF* (abacavir-lamivudine) 600-300 mg Oral daily 8am
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Darunavir 800 mg PO BID Start: In am
4. Vitamin D 50,000 UNIT PO LUNCH
5. fentaNYL citrate *NF* 200 mcg Buccal q30min pain
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. HYDROmorphone (Dilaudid) 32 mg PO Q4H:PRN pain
9. Lorazepam 1 mg PO Q4H:PRN anxiety
10. Magnesium Sulfate 2 gm IV 3X/WEEK (TU,TH,SA)
11. Methadone 20 mg PO TID
12. Mirtazapine 15 mg PO HS
13. Nortriptyline 25 mg PO HS
14. Ondansetron 4-8 mg PO Q8H:PRN nausea
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. Phenytoin Infatab 100 mg PO DAILY
dose not take PO. Crush tab, mix with saline and apply to wound
bandage
17. Pregabalin 50 mg PO TID
18. RiTONAvir 100 mg PO BID
19. Warfarin 4 mg PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
21. Loperamide 4 mg PO QID:PRN diarrhea
22. Multivitamins W/minerals 1 TAB PO DAILY
23. sodium chloride 0.45 % *NF* 1 L Injection 3x/week
Discharge Disposition:
Expired
Discharge Diagnosis:
x
Discharge Condition:
x
Discharge Instructions:
x
Followup Instructions:
x
[**Name6 (MD) 3130**] JUPITER MD [**MD Number(2) 13893**]
Completed by:[**2144-8-8**]
|
[
"707.03",
"285.1",
"599.0",
"785.59",
"682.6",
"V08",
"263.0",
"V10.06",
"V12.51",
"682.5",
"730.28",
"585.3",
"785.52",
"459.0",
"355.8",
"276.2",
"V44.2",
"995.92",
"038.9",
"990",
"041.04",
"707.24",
"486",
"707.07",
"579.3",
"E879.2",
"V58.61",
"041.12",
"584.9",
"276.1",
"707.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"55.93"
] |
icd9pcs
|
[
[
[]
]
] |
18056, 18065
|
9661, 16918
|
287, 357
|
18111, 18115
|
5384, 9638
|
18165, 18284
|
4774, 4906
|
18086, 18090
|
16944, 18033
|
18139, 18142
|
4921, 5365
|
239, 249
|
385, 1059
|
1081, 4447
|
4463, 4758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,049
| 198,778
|
25526+57458
|
Discharge summary
|
report+addendum
|
Admission Date: [**2198-11-17**] Discharge Date: [**2198-12-14**]
Date of Birth: [**2144-10-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Infected right ileo femoral graft
Major Surgical or Invasive Procedure:
right AKA [**2198-11-19**]
flex bronchoscopy x 2
intubation x 2
VATS
History of Present Illness:
54y/o female well known to Vascular Surgery service, recently
hospitalized from [**Date range (1) 63758**] for rt. groin pain. Evaluated
with tagged WBC which showed uptake at ileo-fem graft site.
Patient treated in hsopital with Vancomycin, flagyl, cipro
started [**11-7**], cipro d/c'd [**11-8**] aztreoman added [**11-8**]. ID
recommended [**3-10**] week course. Leg amputation was recommended,
patient defered surgery until after the holidays. She was
discharged home [**2198-11-16**] VNA services and IV vanco/aztreoman and
po flagyl to finish the 4-6 weeks as recommended by ID. Returns
now for amputation.
Past Medical History:
history of PVD, s/p rt. ileo-fem bpg [**12-10**] complicated by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
histroy of chronic pancretieis s/p Pestow,J-tube,ccy1998,Expl
lap [**2189**]
history of ETOH cirrhosis/chronic pancreatitis
history of left breast cyst s/p excision
history of GERD,pud
histroy of esophgitis with stricure
history of small bowel obstruction
history of PV,SMV thrombosis
histroy of asthma
history of cervical ca s/p multiple d/c's
history of DM2 insulin dependant
history of entero-colonic fistula
Social History:
former ETOH use
tobacco use , current
married and lives with spouse
Family History:
noncontributory
Physical Exam:
vital signs:97.5-96-18 B/P 124/69 )2 sat 94% room air
cachectic female who Ox3 but nods off during interview
HEENT: nonicteric, no LAD, no carotid bruits or JVD
Lungs: clear to ausculation bilaterally
Heart: RRR
ABd: BS present , soft c/w ascities with mild distention
EXT: rt. foot cool with 3+edema, hyperemic, firm, tense rt. leg
rt. groin with open wound with purulent drainage and warm
to touch to above the rt. knee. Pain with passive plantar
flection
Pulses: dopperable femoral and [**Doctor Last Name **] pulses with absent pedal
pulses rt.
palpable femoral and [**Doctor Last Name **] pulses and dopperable pedal
pulses on left.
Neuro: grossly intact
Pertinent Results:
[**2198-11-17**] 04:39PM GLUCOSE-187* UREA N-20 CREAT-0.6 SODIUM-146*
POTASSIUM-3.8 CHLORIDE-113* TOTAL CO2-28 ANION GAP-9
[**2198-11-17**] 04:39PM WBC-8.0 RBC-2.30* HGB-7.2* HCT-23.5* MCV-102*
MCH-31.3 MCHC-30.7* RDW-17.4*
[**2198-11-17**] 04:39PM NEUTS-72.4* LYMPHS-21.9 MONOS-4.8 EOS-0.6
BASOS-0.3
[**2198-11-17**] 04:39PM PLT COUNT-544*
[**2198-11-17**] 04:39PM PT-14.5* PTT-23.7 INR(PT)-1.3*
.
at discharge
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-12-14**] 06:19AM 8.3 2.67* 8.5* 26.6* 100* 31.8 31.9 17.7*
868*
Source: Line-PICC
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos NRBC
[**2198-12-10**] 04:45PM 77.9* 15.9* 4.2 1.7 0.3
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-12-14**] 06:19AM 88 24* 0.6 149* 4.0 113* 30
.
[**2198-12-13**] ECHO
.
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%) There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. Abnormal flow consistent
with a patent ductus arteriosus is identified. There is no
pericardial effusion.
.
[**2198-12-10**] LUNG PATHOLOGY
.
Lung wedge, right lower lobe (A-B):
a. Organizing pneumonitis, see note.
b. Mild subpleural fibrosis.
II. Lung wedge, right middle lobe (C-D):
a. Marked accumulation of hemosiderin-laden macrophages, see
note.
b. Septal fibrosis.
III. Lung wedge, right lower lobe (E-G):
a. Organizing pneumonitis, see note.
b. Accumulation of hemosiderin-laden macrophages.
c. Subpleural fibrosis.
d. Rare giant cells seen.
Note: The changes are patchy and not well-developed. The
morphology of the organizing pneumonitis is suggestive of
bronchiolitis obliterans / organizing pneumonia (BOOP/COP). The
accumulation of macrophages in alveolar spaces in a smoker are
consistent with respiratory bronchiolitis - interstitial lung
disease (RBILD). Clinical correlation is recommended.
.
[**12-3**] CTA CHEST
.
On the current examination, there is increasing interstitial
prominence, predominantly at the upper lobes bilaterally.
Additionally, increasing confluence is identified within the
right upper lobe as well as at the left base. Differential
considerations for the increase in interstitial markings include
pulmonary edema superimposed on a background of chronic lung
disease. Worsening of the patient's interstitial lung disease is
also a differential consideration. However, on the current
examination, there is increase in multifocal patchy airspace
disease, predominantly identified within the right lung. Several
of these areas do appear somewhat peripheral. Therefore, the
differential considerations do include septic embolism. Other
considerations do include a diffuse infectious process. Findings
are discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at the time of dictation.
There is no evidence of main, central, or segmental pulmonary
embolism. There is increasing mediastinal and right hilar
lymphadenopathy, which appears most prominent in a subcarinal
location on the current study.
On the current exam, new small bilateral pleural effusions are
noted.
IMPRESSION:
1. Increasing interstitial prominence as noted above, which may
represent congestive failure and/or worsening of the patient's
interstitial lung disease.
2. No evidence of pulmonary embolism.
3. Patchy airspace opacities as noted. The differential
considerations are as discussed above and include septic
embolism and diffuse infection. The imaging findings are fairly
nonspecific.
4. Increasing mediastinal and right hilar lymphadenopathy.
.
[**11-29**] CT ABDOMEN PELVIS
.
FINDINGS: Direct comparison is made to prior examination dated
[**2198-11-21**]. As on a prior examination, there is evidence of
diffuse interstitial abnormality with interlobular septal
thickening and areas of honeycombing. Overall, the degree of
superimposed pulmonary edema as evidenced by areas of
ground-glass opacity, appear improved since the prior exam.
Also, there has been resolution of previously described pleural
effusions. There is a somewhat more confluent opacity within the
right upper lobe which likely also represents similar disease
process of pulmonary edema superimposed on interstitial lung
disease, however, infectious etiology cannot be definitively
excluded based on these imaging appearances.
There is evidence of intra- and extra-hepatic biliary dilatation
as previously described on CT dated [**2198-4-25**]. There is
narrowing of the distal common bile duct, suggesting possibility
of a stricture, possibly related to the patient's history of
chronic pancreatitis which is evidenced by the scattered
pancreatic parenchymal calcifications. The spleen and adrenal
glands are unremarkable. Remaining liver parenchyma is otherwise
grossly unremarkable. The kidneys are grossly unremarkable.
Diffusely stool filled colon is noted. Small bowel loops are
fluid filled throughout with areas of fecalization more
distally.
The pelvic structures are grossly unremarkable with Foley
catheter in place.
Significant diffuse atherosclerotic calcification is noted.
Again, there is evidence of thrombosis of the right-sided iliac
arteries. Bilateral common iliac artery stents are noted. The
left-sided stent does appear to be patent.
There is evidence of thrombosis of right-sided iliac and femoral
veins as previously described.
There is no evidence of intravenous contrast extending into the
right superficial femoral artery. Evidence of recent above the
knee amputation is noted with atrophy of the musculature of the
anterior compartment of the thigh.
No suspicious lytic or blastic bony lesions are identified.
Evaluation of the mediastinum again reveals mediastinal
lymphadenopathy in the subcarinal, pretracheal and prevascular
distributions with lymph nodes measuring up to 12 mm in short
axis dimension.
IMPRESSION:
1. Findings of pulmonary edema superimposed on interstitial lung
disease. Pulmonary edema appears improved since the
aforementioned prior examination. More confluent opacity is
noted and infection within the right upper lobe cannot be
definitively excluded.
2. Interval resolution of bilateral pleural effusions.
3. Intra- and extra-hepatic biliary dilatation is again
identified as detailed above. There is suggestion of a possible
stricture within the distal common bile duct.
4. Significant vascular pathology as noted.
5. Mediastinal lymphadenopathy as noted above.
Brief Hospital Course:
The patient was admitted [**11-18**] with pain RLE with nonhealing
ulcer and osteo requiring AKA on 12/17th [**2197**] by vascular
surgery. This was complicated with hypoxia requiring two
intubations and MICU stay, a fiberoptic visualization of pharynx
for extravasation of contrast in neck (resolved on its own), c
difficile colitis, bronchoscopy by pulmonary and VATs by
thoracics for persistent hypoxia after extubation, and renal
failure secondary to diuresis. At the time of discharge, all
these issues are resolved and creatinine is 0.6 (baseline
0.4)and trending down after diuresis stopped. She has had and
still has persistent asymptomatic hypernatremia wich is likely
to resolve in a few days as the patient's PO intake continues to
be stable.
.
Hypoxia: this was the main post op complication, with the
patient requiring 3 liters n/c for most of her stay, and
re-intubation in the MICU after her PACU stay post AKA. She is
comfortable on room air at discharge. CTA was negative for PE.
CTA and CXRs revealed an interstitial disease that was
attributed partially to noncardiogenic pulmonary edema, as her
echo showed normal EF. Pulmonary consult was obtained and PFT
revealed a restrictive disease. She was diuresed numerous times
with subjective relief of dyspnea but minimal change in oxygen
requirement. She underwent bronchoscopy with BAL and cultures
were negative for atypical infections, also galactomanan and B
glucan were negative (equivocal b glucan). Eventually Thoracic
Surgery was consulted for VATS, and biopsy revealed underlying
RB-ILD (Respiratory Bronchiolitis- Interstitial Lung Disease).
She was counseled to stop smoking. She will be followed up at
pulmonary clinic for serial PFTs and DLCO. Steroids were
discussed and ultimately decided against, as they have not been
shown to significantly improve outcomes. In addition, in her
case, prednisone would further complicate her glycemic control.
.
C difficile: she has 3 more days of Flagyl to complete 14 days
plus one additional week beyond discontinuation of other abx.
She has had intermittent diarrhea the past few days and she was
started on imodium prn yesterday.
.
AKA: she had no complications from the stump. She was on a 3
week course of aztreonam and vancomycin which she completed and
she remained afebrile. The staples need to be d/c in 3 days. She
developed intermittent erythema on the LLE and this was treated
with topical mupirocin with resolution of sx. Doppler for DVT
were negative.
.
ARF: With daily diuresis, her creatinine rose to 0.9 from 0.3,
from pre-renal causes, and she also had hyperphosphatemia >7.
Diuresis was discontinued and she received gentle hydration;
creatinine is trending down at discharge. She is taking adequate
PO food and liquids. Today creatinine is 0.6. The patient
appears to not need any diuresis and did very well off diuretics
for the past 3 days. She was on sevelamer for 2 days and
hyperphosphatemia resolved. She also received calcium
supplementation for 2 days.
.
Hypernatremia: The patient has been intermittently
hypernatremic. This has been treated with D5W with resolution,
however she quickly reverted to hyperNa. This will likely
resolve once her PO intake normalizes completely. She has stated
that at times she was very thirsty but did not drink due to pain
(either at the AKA stump or at the VATs site).
.
Diabetes Mellitus: Her sugars seem to have stabilized on 30
units glargine for breakfast (HS was tried with worse results)
and the attached sliding scale. During her stay she was at times
hyper and at times hypo (lowest recorded sugar in the 40s). This
quickly resolved with half an amp of D50. She is very non
compliant with the diabetic diet and needed constant reassurance
and teaching that she needed to eat regularly and adhere to a
diabetic diet. She has improved on this at discharge.
.
SMV thrombosis, with presumed hypercoagulable state. She was on
coumadin 2.5-5 mg with therapeutic INR. This was discontinued
and a heparin drip bridge was started for procedures. At
discharge, she remained on heparin bridge to coumadin and there
will need to be an overlap of 2 days before heparin can be d/c.
She had no clotting events during her stay.
.
Depression: she was briefly on celexa and is discharged on
duloxetine 60 mg daily. Her mood improved during her stay on
medication. SW also visited and worked with the patient.
.
The patient was evaluated by and worked with PT during her stay.
She is very weak and deconditioned and will need aggressive
rehab.
.
Anemia: this was worked up and was consistent with chronic
disease. She received one unit of blood 1/10 to help her
oxygenation and her Hct bumped 4 points to>26 at discharge.
.
The patient remained FULL CODE. She is discharged stable from
all her medical issues and ready to begin aggressive rehab.
Medications on Admission:
Albuterol inh q6
Amylase-Lipase-Protease iii TID
Aspirin 325mg qd
Clopidogrel 75mg qd
Duloxetine 30mg qd
Ergocalciferol (Vitamin D2)50,000u i qd
Hexavitamin i qd
Insulin Glargine 12u qhs, HISS
Nicotine 14mg/24 hr Patch qd
Oxycodone 5mg prn
Pantoprazole 40mg qd
Spironolactone 25mg qd
Tiotropium Bromide 18mcg qd
Warfarin 4mg qd
Discharge Medications:
1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. Medium Chain Triglycerides Oil Sig: Fifteen (15) ML PO
TID (3 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
10. 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.
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
13. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
17. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
20. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
21. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
22. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
23. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
24. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
25. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
26. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
27. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
28. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
29. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
30. glargine 30 units at breakfast
And sliding scale insulin attached
31. heparin drip IV
For goal PTT 60-80.
After INR therapeutic for 2 days, d/c the heparin drip
32. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Infected right. Ileo femoral graft( enterobacter cloacae )
S/p right Above the Knee Amputation
Respiratory Bronchiolitis-Interstitial Lung Disease
chronic obstructive pulmonary disease
Diabetes Type II, uncontrolled with complications
SMV thrombosis
cirrhosis
Discharge Condition:
Stable. Afebrile. Breathing on room air. Ambulatory
Discharge Instructions:
Admitted for severe infection in leg that needed amputation
above the knee. You received antibiotics and the infection
resolved. The staples need to come out in 3 days.
.
Shortness of breath developed which was due to a disease called
Respiratory Bronchiolitis-Interstitial Lung Disease. We could
diagnose this because a bit of tissue and fluid was taken from
your lung during an operation. It is essential that you stop
smoking.
.
You need to be on coumadin for an INR [**1-6**] due to clots. Please
make sure your INR is checked frequently. Follow your rehab
doctor's instructions.
.
Take your medications as prescribed and return if you have any
worrisome concerns.
.
You have appointments with your vascular doctor and your lung
doctor. They are below. Please keep these appointments.
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) 1391**] , call for an appointment [**Telephone/Fax (1) 1393**]
Call your primary care [**First Name8 (NamePattern2) **] [**Doctor Last Name 5448**] as needed.
See a pulmonologist (lung doctor) regularly:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Name: [**Known lastname 10645**],[**Known firstname **] M Unit No: [**Numeric Identifier 11351**]
Admission Date: [**2198-11-17**] Discharge Date: [**2198-12-14**]
Date of Birth: [**2144-10-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1472**]
Addendum:
The patient must not be further diuresed, as she has been in
renal failure and no longer has pulmonary edema. In addition,
she has marked hypoalbuminemia which is contributing to her
peripheral edema.
.
She is scheduled to see a new PCP here at [**Hospital1 8**], per her
request. See discharge instructions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**]
Completed by:[**2198-12-14**]
|
[
"997.5",
"571.2",
"440.23",
"996.62",
"250.60",
"707.15",
"557.0",
"516.8",
"452",
"276.0",
"285.9",
"008.45",
"357.2",
"584.9",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"34.21",
"38.93",
"33.24",
"96.04",
"32.29",
"84.17"
] |
icd9pcs
|
[
[
[]
]
] |
19856, 20078
|
9408, 14226
|
308, 379
|
17920, 17974
|
2540, 9385
|
18811, 19833
|
1814, 1831
|
14605, 17523
|
17637, 17899
|
14252, 14582
|
17998, 18788
|
1846, 2521
|
235, 270
|
407, 1021
|
1043, 1713
|
1729, 1798
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,943
| 133,483
|
53443
|
Discharge summary
|
report
|
Admission Date: [**2116-5-20**] Discharge Date: [**2116-5-25**]
Date of Birth: [**2049-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Cardizem / Morphine / Vancomycin
Attending:[**Known firstname 922**]
Chief Complaint:
positive stress test- asymptomatic
Major Surgical or Invasive Procedure:
coronary artery bypass x 4 (LIMA-LAD, SVG-Dx2, SVG-OM, SVG-LPDA)
[**2116-5-20**]
History of Present Illness:
66 yo M with history of MI s/p PCI to
LAD in [**2099**] who was recently noted to have an abnormal stress
test during workup for right total hip replacement. Cardiac
catheterization reveals coronary artery disease. The patient is
referred for surgical revascularization.
Past Medical History:
DM-II on lantus (intermittently takes FS)
CAD s/p MI [**2096**]
HTN
Low back pain
glaucoma
impotence
current smoking
peripheral neuropathy
trivial MR
Obesity
Social History:
Smokes 1+ ppd, at least 50 pack years, no etoh, no IVDU, used to
work for the post office and the city. Lives with his wife in
[**Name (NI) 4310**]. On disability after having work related injury
Family History:
[**Name (NI) 46425**]
Mother-DM
Physical Exam:
Physical Exam
Pulse:73 Resp:16 O2 sat: 97%RA
B/P Right:173/77 Left:161/93
Height:5'[**17**]" Weight:252 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:+2 Left:+2
Carotid Bruit -none Right: +2 Left:+2
Pertinent Results:
[**2116-5-22**] 06:00AM BLOOD WBC-20.7* RBC-3.19* Hgb-8.0* Hct-24.1*
MCV-76* MCH-25.1* MCHC-33.3 RDW-19.7* Plt Ct-262
[**2116-5-22**] 07:59AM BLOOD Glucose-228* UreaN-25* Creat-1.2 Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
[**2116-5-24**] 04:30AM BLOOD WBC-15.7* RBC-3.34* Hgb-8.4* Hct-25.7*
MCV-77* MCH-25.1* MCHC-32.6 RDW-19.8* Plt Ct-379
[**2116-5-24**] 04:30AM BLOOD Glucose-52* UreaN-25* Creat-1.2 Na-140
K-3.5 Cl-102 HCO3-30 AnGap-12
Pre Bypass: The left atrium is mildly dilated. No mass/thrombus
is seen in the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. [**Location (un) 109**] calculates to 1.9 cm2 by
continuity, but appears widely patent and has a plainemtery area
of 2.4 cm2, limiting factor is likely LVOT diameter, which only
measures 2.0-2.1 cm. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post Bypass: Patient is on Phenylepherine and in sinus rhythm.
Biventricular function is preserved, LVEF >55%, MR is 1+. Aoritc
contours intact. Remaining exam is unchanged. All findings
discussedd with surgeons at the tiem of the exam.
Brief Hospital Course:
The patient was admitted and brought to the operating room on
[**2116-5-20**] where he underwent coronary artery bypassx4 as detailed
in the operativen note. Intraoperatively, the patient developed
a reaction (rash and hypotension) to (likely) propofol. He was
treated with pressors, steroids and benadryl and recovered
appropriately. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in critical
but stable condition for observation and recovery. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. He was neurologically intact and hemodynamically
stable, on no inotropic or vasopressor support. He does have a
history of diabetes mellitus, and [**Last Name (un) **] was consulted for
assistance with blood glucose management. We appreciate their
recommendations. The patient was transferred to telemetry on
POD 1. Chest tubes and pacing wires were discontinued without
complication. On POD 4 the patient developed some serous
sternal drainage without erythema. He remained afebrile and WBC
were decreasing from steroid load. Keflex and cipro were
started and drainage significantly decreased by POD 5. He will
be maintained on antibiotics for a 10 day course with
instructions to call for fever, erythema, or increased drainage.
He was cleared by PT and discharged to home with VNA services
and appropriate follow up instructions on POD 4.
Medications on Admission:
Metformin 1000mg [**Hospital1 **]
roxicet PRN for back pain
Tiramcinolone acetonide cream PRN (eczema)
Atenolol 25mg daily
Lisinopril 40mg daily
Glyburide 5mg 3 tablets in the am
Simvastatin 20mg daily
HCTZ 25mg daily
Lantus 20 Units at hs
Xalatan eye gtt 1 gtt OU
Aspirin 325mg-on hold pre surgery
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. 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*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for sternal drainage for 9 days.
Disp:*36 Capsule(s)* Refills:*0*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 9 days.
Disp:*36 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
13. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
14. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: SLIDING SCALE.
Disp:*QS * Refills:*2*
15. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous breakfast.
Disp:*qs * Refills:*2*
16. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
coronary artery disease, s/p coronary artery bypass this
admission
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, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 1579**] in 1 week -keep a log of your
blood sugars and bring to appt. with Dr. [**Last Name (STitle) **]
Dr. [**Last Name (STitle) **], [**First Name3 (LF) 122**] P., MD [**Telephone/Fax (1) 5068**] in [**12-24**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2116-5-25**]
|
[
"272.4",
"696.1",
"E938.3",
"693.0",
"V45.82",
"250.60",
"357.2",
"724.2",
"424.0",
"V45.4",
"414.01",
"458.29",
"401.9",
"365.9",
"412",
"607.84",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7249, 7324
|
3602, 5037
|
360, 443
|
7435, 7442
|
1901, 3579
|
7982, 8530
|
1160, 1193
|
5387, 7226
|
7345, 7414
|
5063, 5364
|
7466, 7959
|
1208, 1882
|
286, 322
|
471, 745
|
767, 928
|
944, 1144
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,641
| 104,243
|
21912
|
Discharge summary
|
report
|
Admission Date: [**2165-6-4**] Discharge Date: [**2165-6-14**]
Date of Birth: [**2094-1-2**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
1. Open treatment thoracic fracture dislocation.
2. Posterior instrumentation T10 through L2.
3. Posterolateral fusion T10 through L2.
4. Local autograft for fusion augmentation.
History of Present Illness:
Reason for Consult: C1 fx
HPI: 71M w hx CHF, AF on coumadin, tfr from [**Hospital3 **] for
C1 fracture. Pt sustained mechanical fall backwards from 6ft
ladder around 4pm today. +LOC for ~30sec. Ambulated at Neck
pain.
Neuro intact in ED and complained only have neck and back pain.
No reports of numbness/tingling. HD stable. CT head showed no
ICH. CT c-spine showed C1 fx. He then vomited x2 and was
intubated for airway protection. CT chest, abd, pelv deferred
to [**Hospital1 **]. INR 1.4.
PMH: DM2, HTN, HLD, schizophrenia, AFIB, CAD s/p 2 cardiac
stents, Ischemic CMP, multi-infarct dementia, mood disorders
MED: Aldactone, Crestor, Coumadin 5 mg daily, Janumet,
Lasix, Niaspan, Risperdal, Toprol, Trilipix, aspirin, glipizide,
lisinopril, Augmentin
ALL: nkda
SH: denies smoking & drugs admits to social etoh, married lives
with wife, has 4 children, retired
PE:
AVSS
Intubated, sedated
Opens eyes to command
Superficial occiptal abrasion
c-collar in place
Moving all extremities x 4 spontaneously
BUE skin clean and intact
No deformity, erythema, edema, induration or ecchymosis
Arms and forearms are soft
2+ radial pulses
BLE skin clean and intact
No deformity, erythema, edema, induration or ecchymosis
Thighs and legs are soft
1+ pitting edema BLE
1+ PT and DP pulses
No step-offs or deformities to T,L spine
Superficial abrasion over L-spine and perianal
LABS: Hct 38, INR 1.4
IMAGING: CT c-spine: C1 fx through right lateral mass and
posterior arch, minimally-displaced
CT
IMPRESSION & RECOMMENDATIONS:
71M s/p mech fall off ladder with C1 anterior and posterior arch
fractures. Ambulatory at scene and NVI in OSH ED prior to
intubation.
-Recommend CT scan T,L,S spine to assess for additional spine
injury
-Log roll precautions
-[**Location (un) 2848**] J c-collar at all times
-Stable c-spine injury pattern - will treat conservatively with
non-operative management
CT scan TL Spine
1. Acute transverse fracture across a T12 vertebral body
hemangioma and
coursing into the left lamina, with minimal retropulsion. MR
should be
considered for further evaluation to assess for cord injury.
2. Hepatic steatosis.
3. Trace bilateral pleural effusions. Area of left lower lobe
consolidation
may reflect mild aspiration.
4. 21 mm cystic lesion arising from the lower pole of the right
kidney is
indeterminate on this single phase study. Further outpatient
evaluation with
ultrasound could be considered in six months to assess for
stability.
5. Minimally displaced left 12th rib and left L2 and right L3
(2:81)
transverse process fractures.
MRI
1. No evidence of spinal cord edema/contusion. There is no
significant
spinal canal narrowing seen.
2. T12 vertebral body fracture with minimal anterior epidural
swelling as
described above. Also seen is an acute compression fracture of
C7 and T1.
Fractures of C1 and posterior element fractures are better seen
on the recent
CT study.
3. Multilevel degenerative changes without significant canal
stenosis. There
is narrowing of the subarticular recesses bilaterally at L4-L5
contacting the
traversing [**Name (NI) 13032**] nerve roots.
See prior CT Torso.
Past Medical History:
- afib
- HTN
- Hypercholestremia
- DM Type II
- CAD s/p 2 cardiac stents
- [**10-15**] Cath: LAD 80% prox stenosis followed by 90% apical
lesion. LCx mild-mod diffuse disease. Cypher stent placed to LAD
- ischemic CMP w/ h/o flash pulmonary edema; CHF (EF 35%), mod
MR
- PSYCHIATRIC HISTORY:
- Multi-infarct dementia
- Mood Disorder NOS; r/o BPAD vs. MDD with psychotic
features with h/o of multiple hospitalizations
- - Carried dx of schizophrenia x 25yrs; previous trial of
Stelazine
Social History:
Pt was born in [**Country 2559**], has lived in US since his 20s. Married
with 4 living children. Has degrees in both visual arts and
architecture. And, though currently retired continues to work
with iron and other sculpture mediums. Lives [**Location 6409**] with
wife. Denies h/o illicit drug use, admits to social EtOH use.
Denies tobacco use currently.
Family History:
Denies
Physical Exam:
see HPI
Pertinent Results:
[**2165-6-4**] 08:42PM TYPE-ART RATES-/14 TIDAL VOL-500 O2-100
PO2-170* PCO2-62* PH-7.27* TOTAL CO2-30 BASE XS-0 AADO2-474 REQ
O2-81 -ASSIST/CON INTUBATED-INTUBATED
[**2165-6-4**] 10:12PM FIBRINOGE-214
[**2165-6-4**] 10:12PM PLT COUNT-230
[**2165-6-4**] 10:12PM PT-15.1* PTT-27.4 INR(PT)-1.4*
[**2165-6-4**] 10:12PM WBC-11.8* RBC-3.90* HGB-12.1* HCT-35.9*
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.8
[**2165-6-4**] 10:12PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-6-4**] 10:12PM cTropnT-<0.01
[**2165-6-4**] 10:12PM LIPASE-50
[**2165-6-4**] 10:12PM estGFR-Using this
[**2165-6-4**] 10:12PM UREA N-15 CREAT-1.1
[**2165-6-4**] 10:24PM freeCa-0.85*
[**2165-6-4**] 10:24PM HGB-12.1* calcHCT-36 O2 SAT-92 CARBOXYHB-7*
MET HGB-0
[**2165-6-4**] 10:24PM GLUCOSE-130* LACTATE-1.4 NA+-141 K+-4.7
CL--107 TCO2-21
[**2165-6-4**] 10:24PM PH-7.51* COMMENTS-GREEN
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service. He was
brought intubated from OSH and admitted to ICU. CT scan and MRi
spinI scans of the spine revealed T12 unstable fracture in
addition to C1 fracture (stable). Neurological status was
difficult to assess. He was and taken to the Operating Room for
the above procedure for T12 fracture. Refer to the dictated
operative note for further details. The surgery was without
complication and the patient was transferred to the ICU in a
stable condition. TEDs/pnemoboots were used for postoperative
DVT prophylaxis. Intravenous antibiotics were continued for
24hrs postop per standard protocol. Initial postop pain was
controlled.
No HVAC drains were used.
Events in the hospital
[**6-6**]: Extubated
[**6-7**]: Difficult to arouse, does not move UE and LE adequately.
Only some movement in fingers and toes. Requested limited scan
of the spine.
[**6-8**]: No evidence of ongoing cord compresison on MRI.
[**6-10**]: Moving better, dressing changed, Incision CDI, okay to
anticoagulate.
Foley was removed on POD#2.
Physical therapy was consulted for mobilization OOB to ambulate.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
Coumadin 2.5, Spironolactone 25, Rosuvastatin 40 HS,
Sitagliptin-Metformin (Janumet) 1 tab'', Lasix 80, Niaspan ER
500, Risperdal 50 IM twice weekly, Toprol XL 50, Fenofibric acid
135, ASA 81, Glipizide 10, Lisinopril 20
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
13. diltiazem HCl 120 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
14. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
15. Janumet 50-1,000 mg Tablet Sig: One (1) Tablet PO bid ().
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Target INR [**3-15**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
C1 anterior and posterior arch fractures ([**Location (un) 26524**]) - Stable
T12 extension distraction fracture (Unstable)
Ankylosing Spondylitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
- Activity: As tolerated in brace.
- Rehabilitation/ Physical Therapy:
o You can walk as much as you can tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You have been given a brace (TLSO and [**Location (un) 2848**] J).
This brace is to be worn when you are walking. You may take TLSO
off when sitting in a chair or while lying in bed. Keep [**Location (un) 2848**] J
at all times.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
PLease follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] 2 weeks from the date of
discharge
Completed by:[**2165-6-14**]
|
[
"295.30",
"720.0",
"854.02",
"401.9",
"276.2",
"412",
"272.4",
"437.0",
"805.2",
"428.0",
"V45.82",
"427.31",
"V58.61",
"414.8",
"250.00",
"805.01",
"290.40",
"228.09",
"E881.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"96.71",
"03.53",
"81.63",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
8718, 8788
|
5538, 6833
|
311, 492
|
8979, 8979
|
4605, 5515
|
11232, 11393
|
4554, 4562
|
7105, 8695
|
8809, 8958
|
6859, 7082
|
9117, 9185
|
4577, 4586
|
9203, 9682
|
10719, 11209
|
267, 273
|
9694, 10708
|
520, 3647
|
8994, 9092
|
3669, 4157
|
4173, 4538
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,273
| 123,414
|
16722
|
Discharge summary
|
report
|
Admission Date: [**2188-9-25**] Discharge Date: [**2188-10-8**]
Service: MEDICINE
Allergies:
Penicillins / Sulfur
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Fevers, fatigue, and falls
Major Surgical or Invasive Procedure:
[**9-28**] Incision and debridement of bursa around posterior spinal
fusion; abcess drainage.
[**9-30**] Right Knee tap
[**10-1**] Right knee tap
History of Present Illness:
87 year old female with Parkinson's disease who presents from a
nursing facility with 2 days of fever to 101.5 and frequent
falls. Ms. [**Known lastname 1313**] reports feeling generally weak and complains
of significant pain in her mid-back, the latter of which is
chronic and thought to be related to ??????rods?????? she has in her back.
She denies chest pain, abdominal pain, cough, urinary frequency
or dysuria. She has fallen several times recently, although she
does not recall the last time she fell. She has baseline poor
mobility from her Parkinson's disease and does not walk.
Past Medical History:
Parkinson's disease: per most recent neurology notes, patient is
not walking, has significant motor disability
Hypertension
High Cholesterol
Osteoporosis
Depression
Anemia
Peptic Ulcer disease--but on chronic NSAIDs
Rectal prolapse--s/p repair
Social History:
She currently lives in an [**Hospital3 **] facility ([**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 410**] [**Hospital3 400**] in [**Location (un) **]).
Family History:
N/A
Physical Exam:
Vitals: 97.8, 159/65, 108, 28, 100% RA
General Appearance: Thin, NAD, A&Ox3
Eyes / Conjunctiva: PERRL, no jaundice, well-hydrated
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right DP pulse: Present), (Left DP
pulse:present
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : RLL, Bronchial: RLL)
Abdominal: Soft, Non-tender, Bowel sounds present
Skin: Not assessed, Rash: scalp (chronic)
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): place, time, self, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
On Admission:
[**2188-9-25**] 08:00AM WBC-9.8 RBC-3.68* HGB-11.1* HCT-34.0* MCV-92
MCH-30.2 MCHC-32.7 RDW-12.8
[**2188-9-25**] 08:00AM NEUTS-89* BANDS-1 LYMPHS-4* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-9-25**] 08:00AM GLUCOSE-118* UREA N-22* CREAT-0.8 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15
CT L-spine ([**2188-9-26**])
1. Interval development of compression deformity at the T10
vertebral body. The previous seen T11 compression deformity is
again noted and there is associated kyphosis centered at this
area.
2. Well-defined, corticated soft tissue collection located
posterior to the
T8 to T10 vertebral levels. This is 8 cm x 3 cm in largest cross
sectional
diameter. [**Month (only) 116**] represent abscess or seroma and must be clinically
correlated.
3. Posterior lumbar spinal fusion hardware noted to be in place
with no sign of loosening. Anterior migration of the disc fusion
material at L1-L2 and L2-L3 levels, stable from previous
examination.
4. Bilateral pleural effusions and associated atelectasis, this
would be
better characterized with dedicated imaging of the lung if
clinically
indicated.
5. Abdominal, arterial calcification, stable from the study of
[**2186**].
CXR: Patchy opacity in the right lung base, which may represent
developing area of infection.
ECHO:
The left atrial volume is markedly increased (>32ml/m2). The
left atrium is dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. Mild to moderate ([**2-13**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension.
IMPRESSION: No vegetations or abscess seen. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Moderate tricuspid and mitral
regurgitation.
Knee XR: There are advanced degenerative changes in the knee,
with significant tricompartmental joint space narrowing and
spurring. There also appears to be a lucency within the lateral
knee compartment which may be related to mass effect or vacuum
phenomenon. There are additional ossific/calcific densities
within the knee, largest posteriorly measuring 1.2 cm, which
likely represent loose bodies within the joint. There is no
acute fracture or dislocation. Suprapatellar joint effusion is
present.
CT Head: No acute intracranial hemorrhage.
Microbiology Data:
Blood cultures
[**2188-9-25**] MRSA ([**3-15**])
[**2188-9-26**] MRSA ([**3-15**])
[**2188-9-27**] MRSA (2/2
[**2188-9-28**] MRSA ([**3-15**])
[**Date range (1) 47308**] negative
Joint fluid: [**2188-9-30**] MRSA;
Joint fluid: [**2188-10-1**] MRSA
Brief Hospital Course:
In the ED, vitals were initially 98.2, 181/85, 110, 16, 98% RA.
She did develop a fever of 102 and was given 1 gram of Tylenol.
CXR with RLL infiltrate (early) and she was given levofloxacin.
However, her BP dropped to 100 (from 180) and, at that point,
her abx were broadened to Vanc/Cefepime. The ED team felt she
might have also had early zoster on her left buttock and she was
ordered for valcyclovir. In the ED, she was persistently
tachycardic with HR 105-115. She received approx 2L IVF. Her
labs were notable for a Na 132 and CK 1000s (nml trop). Head CT
& cspine CT were done after hx of falls elicited??????no acute
pathology seen.
Patient was admitted to the MICU, where she was contnued on
vancomycin/ceftazidime, aggresive IVF, CT scan to assess for
cyst & hardware, CXR, CK, UA. CT of neck showed degenerative
changes in cervical spine, and collection of fluid in soft
tissue in L8-L10. Ortho tried draining fluid and obtained
purulent material on [**9-26**]. However, patient decided not to
pursue surgical management of the abscess. Patient grew [**7-18**]
Staph Aureus (MRSA). Since patient persistent patient she got
incision and debridement of bursa around posterior spinal
fusion, leaving hardware in place ([**9-28**]). She was tranfered
back to the ICU. Patient stable in ICU afterwards, afebrile for
24 hours, normal BP, then was transfered to the floor. ID was
consulted after surgery and agreed to continue antibiotics.
In the floor patient had persistent productive cough and CXR
without improvement. However, cough improved within the
following 2 days and dissapearead. On [**9-30**] patient complained
of right knee pain, and on physical exam there was inflammation
of the joint. Ortho was consulted again, as well as
rheumatology. R knee was tapped and fluid with 67,000 WBC (90%
PMNs), normal glucose and protein, positively birefringent
crystals, negative gram stain, but grew MRSA in culture a couple
of days later. Patient declined surgical wash out of the knee
and decided medical management. The following day the knee was
tapped again; fluid had 41,500 WBC (95% PMNs). Meeting took
place between paliative care, attending, daughters and patient
who decided not to proceed with any further aggresive treatment.
Antibiotics were stopped on [**6-5**] and patient status was changed
to CMO. Since then, patient has been stable and comfortable in
the floor.
Medications on Admission:
Fosamax 70 mg weekly
Prozac 10 mg daily
Lasix 20 mg daily
Bupropion SR 150 mg [**Hospital1 **]
Salsalate 750 mg [**Hospital1 **]
Omeprazole 20 mg daily
Sinemet 25/100 2 tab qid
Detrol LA 2 mg qhs
Aricept 10 mg daily
Trazodone 25 mg qhs:prn
Gluc/[**Doctor Last Name **]
CaCO3/Vit D
FeSO4 325 mg daily
Lactobacillus
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO 10
X DAILY (APPROX Q1-2HR DURING WAKING HOURS) ().
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
7. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
8. Ropinirole 8 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. 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*
12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*2*
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12HR ON & OFF ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
16. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Disp:*1 Tube* Refills:*0*
17. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
Primary
MRSA sepsis
Osteomyelitis in toraco-lumbar spine with rod placement
Septic arthritis (R knee)
Secondary
Parkinson's disease: per most recent neurology notes, patient is
not walking, has significant motor disability
Hypertension
High Cholesterol
Osteoporosis
Depression
Anemia
Peptic Ulcer disease--but on chronic NSAIDs
Rectal prolapse--s/p repair
Discharge Condition:
Stable, DNR/DNI, CMO, off antibiotics.
Discharge Instructions:
You were seen at [**Hospital1 18**] for fever, chills. You were found to have
a bacterial infection in your blood and spine that required you
to be in the ICU for a few days due to low blood pressure. You
declined surgery at the begining, but on [**9-28**] you had the
articulation washed and drained.
Then you developed an infection in the articulation of the right
knee with some crystales (pesudo-gout). You received pain
control and had 2 knee taps (1 to make diagnosis and 1 as follow
up and therapeutic).
A discussion took place about the possibility of doing a washout
of the knee +/- of the spine and to continue antibiotics.
Between you and your healthcare proxy, [**Name (NI) **], and Dr. [**Last Name (STitle) 410**]
(your PCP) it was decided to provide you with comfort measures
only. You were able to understood the consequences of stopping
antibiotics and not having the knee drained.
Paliative care spoke with you and you family to help and support
all the things that are going on.
You are being discharge to the hospice you and your family
selected.
Followup Instructions:
Follow up with your primary care as needed.
|
[
"727.3",
"737.30",
"998.59",
"E849.7",
"V09.0",
"733.00",
"272.0",
"707.03",
"518.0",
"511.9",
"995.92",
"785.52",
"038.11",
"599.7",
"711.06",
"727.89",
"332.0",
"311",
"285.9",
"E878.8",
"486",
"533.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.5",
"88.72",
"03.09",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
10114, 10180
|
5378, 7768
|
254, 404
|
10580, 10621
|
2156, 2156
|
11740, 11787
|
1492, 1497
|
8132, 10091
|
10201, 10559
|
7794, 8109
|
10645, 11717
|
1512, 2137
|
188, 216
|
432, 1023
|
5051, 5355
|
2170, 5042
|
1045, 1290
|
1306, 1476
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,057
| 189,742
|
54616
|
Discharge summary
|
report
|
Admission Date: [**2173-6-23**] Discharge Date: [**2173-6-30**]
Date of Birth: [**2095-7-27**] Sex: M
Service: OMED
Allergies:
Niacin
Attending:[**Doctor First Name 18856**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 77M with h/o metastatic RCC with mets to lung, thyroid,
COPD, diastoic CHF, sleep apnea, restrictive lung disease,
remote MI, presents with acute onset resp failure; intubated in
ED, became hypotensive following sedation requiring 6L NS
boluses and levophed. WBC 21 with 9%bands. CT angio-> L
infrahilar mass compressing L main bronchus and L pulm art but
stable, interval increase in parenchymal nodes and masses,
increased b/l pleural effusions, stable RLL ground glass
opacity, no PE.
[**Hospital Unit Name 153**] course: treated with steriods, nebs, Zosyn->Levoflox.
Weaned off pressors and extubated [**6-25**]; presumed mucus plugging
v COPD flare v RLL infiltrate (bronchitis). On arrival on floor
(5S on [**6-26**]), experienced some tachycardia due to frequent PAC's
and non-sustained A-tach, and was given IV Dilt, 10 mg and 30
po, with successful rate control response.
Past Medical History:
PMH: metastatic RCC, COPD, OSA, h/o prostate CA, CAD s/p MI,
hyperlipidemia, Afib, 4+MR
Social History:
Lives at home with wife; works as a heavy equipment operator.
Family History:
Leukemia, brain cancer
Physical Exam:
PE:
T 97; BP 151/58; P 111; R 16; Sat 99% on 4 lpm
I/O +6155 LOS good UOP
Gen - NAD
Heent - PERRLA, EOMI, O/P clear
Neck - 8-9 cm JVD
Lungs - LLL crackles, no wheezes
CV - Tachy, [**Last Name (un) **] [**Last Name (un) **]
Abd - Soft, NT, + BS, mod. distension
Ext - 2+ edema t/o
Neuro - A + O, moves all extremities
Pertinent Labs -
Cr 1.8, up from 1.4 on admission; blood and urine cx. neg.
Pertinent Results:
[**2173-6-23**] 06:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+
[**2173-6-23**] 06:15PM NEUTS-60 BANDS-9* LYMPHS-25 MONOS-2 EOS-1
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2173-6-23**] 06:15PM WBC-21.1* RBC-5.09 HGB-13.8* HCT-47.1 MCV-92
MCH-27.1 MCHC-29.3* RDW-14.5
[**2173-6-23**] 06:15PM TOT PROT-6.9 ALBUMIN-3.3* GLOBULIN-3.6
CALCIUM-7.2* PHOSPHATE-5.5*# MAGNESIUM-0.9*
[**2173-6-23**] 06:15PM CK-MB-15* MB INDX-4.3 cTropnT-0.01
[**2173-6-23**] 06:15PM ALT(SGPT)-53* AST(SGOT)-50* CK(CPK)-348* ALK
PHOS-143* AMYLASE-57 TOT BILI-0.4
[**2173-6-23**] 06:15PM GLUCOSE-166* UREA N-20 CREAT-1.5* SODIUM-142
POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-23 ANION GAP-19
[**2173-6-23**] 06:25PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0
[**2173-6-23**] 06:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2173-6-23**] 06:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2173-6-23**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2173-6-23**] 07:00PM ALBUMIN-3.1* CALCIUM-6.8* PHOSPHATE-6.6*
MAGNESIUM-0.8*
[**2173-6-23**] 07:00PM CK-MB-15* MB INDX-4.2 cTropnT-0.03*
[**2173-6-23**] 07:00PM ALT(SGPT)-50* AST(SGOT)-50* CK(CPK)-357* ALK
PHOS-136* AMYLASE-62 TOT BILI-0.4
[**2173-6-23**] 07:00PM GLUCOSE-175* UREA N-20 CREAT-1.6* SODIUM-144
POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-26 ANION GAP-17
[**2173-6-23**] 08:56PM HGB-11.0* calcHCT-33
[**2173-6-23**] 08:56PM LACTATE-1.0 K+-5.3
[**2173-6-23**] 08:56PM TYPE-ART PO2-378* PCO2-52* PH-7.21* TOTAL
CO2-22 BASE XS--7
[**2173-6-23**] 10:03PM PT-14.3* PTT-24.4 INR(PT)-1.4
[**2173-6-23**] 10:28PM TYPE-ART PO2-229* PCO2-41 PH-7.28* TOTAL
CO2-20* BASE XS--6
Brief Hospital Course:
Mr. [**Known lastname 32090**] was transfered to the OMED service from the [**Hospital Unit Name 153**]
after a one day stay which had required intubation. Initially,
he required 4 LPM O2 via nasal cannula, and on arrival on the
floor, he experienced and episode of irregularly irregular
tachycardia, with rates b/t 100 and 150. An EKG was ordered, an
interpreted as MFAT vs. ATACH with occasional PVC's. Mr.
[**Known lastname 32090**] remained stable throughout this episode, and was
asymptomatic. He was given 10 mg of Diltiazem, IVP, with
immediate rate control to the 70's. He was followed with 30 of
Dilt PO, and then put on a regular schedule of 90 mg Dilt tid.
He was monitored on telemetry while on the floor. He was
diuresed with Lasix IV 20 mg 1-2 doses/day, with occasional need
for K, Ca, and Mg repletion. His SOB continued to improve
through this interval, with lessening O2 requirements, finally
needing only 2 lpm via NC. On [**6-29**], after walking to the
bathroom without assistance, he was noted to have another
episode of atach with RVR with rates of approx 100-150. He was
again asymptomatic and stable during this episode. No Afib was
noted. He was managed at this time with rest and an additional
po dose of Dilt, 30mg. Later in the day of the 29th, his rhythm
was stable, and he completed a video swallow study. The
recommendations of the SLP were for no gulping, and sitting bolt
upright for any po. He was d/c'd on the following day with F/U
in heme/onc clinic, home O2, and home PT. His Dilt was
prescribed in ER form, at one 240 mg capsule qd.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*6 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Prednisone 10 mg Tablet Sig: 10 mg Tablets PO as instructed
for as instructed doses: Take five tablets once a day for three
days, then 4 tablets once a day for three days, then 3 tablets
once a day for three days, then 2 tablets once a day for three
days, then one tablet once a day for three days.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*6 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Prednisone 10 mg Tablet Sig: 10 mg Tablets PO as instructed
for as instructed doses: Take five tablets once a day for three
days, then 4 tablets once a day for three days, then 3 tablets
once a day for three days, then 2 tablets once a day for three
days, then one tablet once a day for three days.
Disp:*45 Tablet(s)* Refills:*0*
7. Diltiazem ER 240 mg Capsule,Degradable Cnt Release Sig: One
(1) Capsule,Degradable Cnt Release PO once a day.
Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Bronchitic pneumonia/COPD flare.
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Followup Instructions:
Heme/onc clinic. Please call Dr.[**Name (NI) 47540**] office to schedule
[**Name6 (MD) 6337**] [**Name8 (MD) **] MD [**MD Number(1) 6342**]
|
[
"428.0",
"198.89",
"518.81",
"V10.52",
"197.0",
"428.32",
"416.9",
"491.21",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7413, 7484
|
3696, 5284
|
269, 276
|
7561, 7569
|
1858, 3673
|
7653, 7825
|
1401, 1425
|
6277, 7390
|
7505, 7540
|
5310, 6254
|
7593, 7630
|
1440, 1839
|
226, 231
|
304, 1195
|
1217, 1306
|
1322, 1385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,990
| 143,874
|
49134
|
Discharge summary
|
report
|
Admission Date: [**2170-12-18**] Discharge Date: [**2170-12-21**]
Date of Birth: [**2098-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 13386**]
Chief Complaint:
dyspnea x 12 hours
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
72-yo-woman w/ DM2, ESRD on HD presents w/ dyspnea x 12 hours.
She has been feeling unwell w/ increasing fatigue for 2 days.
Last night around 7pm, she developed L sided neck pain described
as "sharp, shooting," [**6-19**] severity, non-radiating, no assoc
symptoms, unrelieved by tylenol. Over the next few hours, the
pain became more severe, [**11-19**] severity radiating down the L
neck to the L shoulder. It became associated w/ nausea,
vomiting, diaphoresis, and dyspnea. This became progressively
worse until 4am, when the pt was so dyspnic that she could not
speak, prompting call to EMS for transport to ED. She denies any
recent fever, weight loss, palpitations, dietary indiscretion,
abd pain, melena, and hematochezia. She has had cough, runny
nose, and nasal congestion for a few days. There is no history
of CAD or smoking. Of note, the pt did not take her medications
yesterday as she was feeling unwell.
In the ED, the pt was severely dyspnic w/ BP 224/99, HR 120, O2
sat 100% on NRB. She was placed on CPAP 10, ABG was
7.32/46/233/25. She was given NTG SL x 1 and then started on
nitro gtt, w/ SBP decreasing to 177/82 and HR decreasing to 96.
She was also treated w/ ASA 325mg, morphine 4mg IV x 2, anzemet
12.5mg IV, lasix 100mg IV, and levoflox 500mg IV.
Currently, her dyspnea has resolved, but CP is persistent at
[**6-19**] severity in the L shoulder.
Past Medical History:
1. DM2: c/b retinopathy, nephropathy
2. ESRD: on HD Tues/Th/Sat through L AV fistula, makes some
urine
3. HTN
4. Anemia: [**3-14**] ESRD, baseline HCT 36-39
5. OA
6. Vascular dementia: mild short-term memory loss
7. CHF: by report, ECHO [**5-12**] w/ EF 67%
Social History:
The patient lives with her husband. She
denies alcohol, tobacco, or drug use. She goes to adult
daycare at [**Last Name (un) **] [**Doctor Last Name **] three days per week and has Visiting
Nurses Association the other four days of the week.
Family History:
Non contrib
Physical Exam:
PE: T HR 82 BP 158/86 RR 14 O2 sat 99% 5L/m NC
Gen: chronically ill appearing elderly woman lying in bed in
NAD, speaking in full sentences
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, 4mm firm nodule
at R EJ (attempted venous access site), no LAD, JVP 10cm
CV: reg s1/s2, no s3/s4/m/r
Pulm: decreased BS w/ dullness to percussion to 1/2 up B,
crackles to 3/4 up B, no wheezes
Abd: obese, +BS, soft, minimal tenderness diffusely, no rebound
tenderness
Ext: warm, faint DP B, + non-pitting edema to mid-leg B, L AV
fistula intact w/ palpable thrill
Neuro: a/o x 3, CN 2-12 intact, strength 4/5 throughout UE/LE B,
sensation to fine touch intact throughout
Pertinent Results:
[**2170-12-18**] 02:19PM CK(CPK)-265*
[**2170-12-18**] 02:19PM CK-MB-8 cTropnT-0.27*
[**2170-12-18**] 09:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2170-12-18**] 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2170-12-18**] 09:15AM URINE RBC-[**4-14**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2170-12-18**] 07:13AM TYPE-ART O2-100 PO2-233* PCO2-46* PH-7.32*
TOTAL CO2-25 BASE XS--2 AADO2-450 REQ O2-75
[**2170-12-18**] 07:13AM LACTATE-2.9*
[**2170-12-18**] 07:05AM GLUCOSE-309* UREA N-41* CREAT-8.2*#
SODIUM-140 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-24 ANION GAP-24*
[**2170-12-18**] 07:05AM CK(CPK)-99
[**2170-12-18**] 07:05AM cTropnT-0.06*
[**2170-12-18**] 07:05AM CK-MB-NotDone
[**2170-12-18**] 07:05AM WBC-12.8*# RBC-3.08* HGB-10.2* HCT-31.5*
MCV-102* MCH-33.0* MCHC-32.3 RDW-15.1
[**2170-12-18**] 07:05AM NEUTS-81.4* LYMPHS-13.6* MONOS-3.5 EOS-1.4
BASOS-0.1
[**2170-12-18**] 07:05AM HYPOCHROM-3+ MACROCYT-2+
[**2170-12-18**] 07:05AM PLT COUNT-253
[**2170-12-18**] 07:05AM PLT COUNT-253
.
Admission EKG: sinus tach @ 120, LAD, nl intervals, poor
baseline, no obvious ST changes, ? hyperacute T waves in V2-V4
.
CXR [**2170-12-18**]: heart enlarged similar to prior cxr, perihilar
haziness and large bilateral pleural effusions c/w moderate CHF.
.
TTE [**2170-12-18**]: [**2-11**]+MR, [**2-11**]+ TR, moderate [**Last Name (un) 6879**], mildly thickened MV
leaflets, E:A 1.14
.
UA [**11-17**] neg
.
CE: CK [**Age over 90 **]m 281m 282
Tpn: 0.06, 0.27, 0.13
Brief Hospital Course:
Briefly, this is a 72 yo woman with DMW, ESRD on HD who p/w a
h/o L sided neck pain radiating down L shoulder, associated
n/v/diaphoresis/ dyspnea for 12 hrs PTA. The pt was found to
have sinus tachy and hypertensive urgency on admission with BP
224/99--likely due to BP medication noncompliance. CXR revealed
moderate CHF and Echo revealed mild LVH, EF>55%, and moderate
pulmonary artery HTN. The pts presentation was most c/w LV
overload/pulmonary edema secondary to hypertensive urgency. In
[**Name (NI) **] pt was started on nitro gtt and given Lasix 100 mg IV. She
was admitted initialy to the MICU and then transferred to the
floor unit the following day.
.
1. Dyspnea: Her dyspnea was likely due to pulmonary edema
induced by hypertensive urgency, as well as demand ischemia.
She was also probably fluid overloaded by a CRI state as well.
The pts Tpn peaked at 0.27, likely secondary to both demand
ischemia and renal insufficiency. Nitro gtt was titrated on day
of admission to the pt being chest pain free, and it was
discontiued on [**12-19**]. The pt received HD on [**12-18**] and [**12-20**],
alleviating much of her fluid overload. Repeat portable CXR on
[**12-20**] revealed interval improvement in her CHF. The pt was
maintained on ASA. Her metoprolol was ultimately titrated to
Toprol XL 300 mg po qd.
.
2. Chest pain/Elevated Cardiac Enzymes: Pt again c/o chest pain
today [**12-20**], but no EKG changes and no elevation in CE from
prior (Tpn 0.08). The pt presented with c/o chest pain in the
setting of hypertensive urgency. While in the MICU, her Tpn
peaked at 0.27, CK peak 282, MB peak 8; likely due to renal
insufficiency and demand ischemia. There was probably some
element of demand ischemia in the setting of volume overload,
tachycardia, and hypertensive urgency. Nitro gtt was titrated
in MICU for CP, and discontinued [**12-18**]. A heparin gtt was
started on admission, but discontinued on [**12-18**] as it was felt
the pt did not have an ACS. The pt was continued on aspirin.
She was started on lipitor 80 mg po qd in the setting of
elevated cardiac enzymes. Her lipid profile was as follows: LDL
60, T Chol 135, HDL 65. Lisinopril was started on [**12-18**] at 10 mg
po qd and was titrated up to 20 mg po qd prior to discharge.
Metoprolol was titrated up to Toprol XL 300 mg po qd. The pt
has several likely episodes of chest pain on [**12-20**] (due to
language barrier, there was some confusion as to the pts
symptoms), however all EKGs were unchanged and her cardiac
enzymes were unchanged from prior. The pt seemed to have some
chest wall tenderness to palpation at this time. Consideration
may be given to a cardiac stress test in several months as an
outpatient once the pt is in a less debilitated state.
.
2. ESRD: The pts ESRD is felt to be secondary to diabetic
nephropathy. The pt normally receieves HD Tues/Th/Sat. She
received 2 HD treatments while in-house. The pts pulmonary edema
(in setting of hypertensive urgency) was felt to be partially
induced by being in an overall volume overloaded state (from
CRI). The pt was continued on nephrocaps, calcium acetate,
cinacalcet.
.
3. CHF: The pt has mild diastolic dysfunction in the setting of
long-standing HTN. The pts diastolic dysfunction likely
compromised the pts ability to expedite forward flow in the
setting of hypertensive urgency. The pt received HD while
in-house to decrease her overall fluid volume. Her metoprolol
was titrated to Toprol XL 300 mg po qd to assist with rate
control and filling time. She was started on lisinopril as well
to assist with preload/afterload reduction. Repeat portable CXR
on [**12-20**] revealed interval improvement in her CHF.
.
4. Anemia: baseline Hct 36-39 [**3-14**] ESRD. The pts hct remained
stable during this admission. She did not require transfusion.
.
5. HTN: The pt was previously on metoprolol as an outpt. The pt
did not take her meds PTA secondary to feeling unwell, likely
contributing to her hypertensive urgency. Her blood pressure
was better controlled w/ nitro gtt on admission. The pts
metoprolol was titrated to Toprol XL 300 mg po qd for easier
medication compliance. She was also started on lisinopril 20 mg
po qd. Following titration of these medications and
hemodialysis, the pts blood pressure was well-controlled prior
to discharge.
Medications on Admission:
1. metoprolol 100mg [**Hospital1 **]
2. lantus 14 units qhs
3. RISS
4. calcium acetate 667mg TID
5. cinacalcet 30mg daily
6. nephrocaps 1 daily
.
Transfer Meds:
ASA 325 mg po qd
Atorvastatin 80 mg po qd
Calcium acetate 667 mg TID
Cinacalcet 30 mg qd
Heparin Sq
Lisinopril 10 mg po qd
Metoprolol 100 mg po TID
Morphine prn
Nephrocaps
Protonix
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 tablets* Refills:*2*
2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO qd ().
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lantus 100 unit/mL Solution Sig: Seven (7) units Subcutaneous
qam and qhs.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection as directed: For fingerstick of: 150-199 take 2 units;
200-249 take 4 units; 250-299 take 6 units; 300-349 take 8
units; 350-400 take 10 units; >400 call your doctor.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive Urgency
Diastolic Heart Dysfunction
End Stage Renal Disease
Diabetes Mellitus II
Discharge Condition:
stable, maintains oxygen saturation greater than 88% on room air
while walking, blood pressure improved
Discharge Instructions:
1) Please take all medications as prescribed
2)Please return to the ER or call your doctor if you experience
chest pain, shortness of breath, or any other concerning
symptoms
Followup Instructions:
1)Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next week
(call [**Telephone/Fax (1) 250**] to make an appointment)
2) Dialysis: Please continue Tuesday, Thursday, Saturday
dialysis as previously scheduled
|
[
"428.30",
"428.0",
"402.91",
"285.21",
"585.6",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10617, 10674
|
4599, 5950
|
295, 310
|
10812, 10918
|
2982, 4576
|
11141, 11404
|
2275, 2288
|
9326, 10594
|
10695, 10791
|
8959, 9303
|
10942, 11118
|
2303, 2963
|
5967, 8933
|
236, 257
|
338, 1715
|
1737, 1997
|
2013, 2259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,795
| 170,872
|
36518
|
Discharge summary
|
report
|
Admission Date: [**2169-10-3**] Discharge Date: [**2169-10-13**]
Date of Birth: [**2124-1-22**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Clindamycin /
Prochlorperazine / Penicillins / Quinolones
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Wrist and ankle pain
Major Surgical or Invasive Procedure:
I&D of left wrist abscess on [**2169-10-5**] in the operating room
History of Present Illness:
Mr. [**Known lastname 82685**] is a 45 y/o M with HIV, HCV and prior cellulitis
episodes presents with 4 days of fevers, night sweats shaking
chills and left wrist and ankle pain. He reportedly gives
himself IM injetions of norflex in his thighs daily and has had
thigh cellulitis in the past requiring drainage in the OR in the
past and a left thigh cellulitis in [**7-/2169**] for which he was sent
home with a PICC line for IV vancomycin. He denies IV drug use
recently (last in [**1-/2169**]) and his PICC line was pulled in
8/[**2169**]. He has had some recent nasal congestion and has been on
azithromycin but denies sore throat, cough, SOB, dysuria,
frequency, CP, palpitations. Given his joint pain and fevers he
presented to his PCP who sent him to the ED.
VS on arrival to ED: T 100 HR 108 BP 124/74 R 18 o2 sats 99% on
RA. Pt was given Vanc 1gram IV x 1 and oxycodone. CXR, wrist and
ankle films were unremarkable. On arrival to the floor patient
reports improvement in the pain in his ankle but worsening
redness, warmth, swelling and pain in his wrist over the course
of the day. He was taking extra oxycodone and oxycontin over
the past 4 days for the pain with little relief. He has been
taking all of his medications. He denies sick contacts. [**Name (NI) **]
[**Name2 (NI) 82686**] to [**State **] 2 weeks ago, but denies any other
travel. He denies trauma to the joints, IV drug use.
Past Medical History:
HCV-plans to start theapry in near future per patient
DM -on lantus and aspart sliding scale
HIV per pt last CD4 in 500s (per patient), VL undectable
chronic sinusitis s/p surgery [**4-20**]
migraines
Thigh cellulitis
Social History:
Smokes 1 ppd, no etoh, remote history of IV drug use (had a 2
day relapse in [**2-/2169**]), but denies any drugs currently,
unemployed, used to work in catering management. Lives with
roommates.
Family History:
[**Doctor First Name **] any medical problems in his family.
Physical Exam:
ROS: Denies weight loss, fatigue, visual changes,
lightheadedness, worsening of his HA, diarrhea, constipations,
bledding, bruising, hematuria, orthopnea, PND, LE edema, skin
rash
Vitals:T 101.3 BP 158/86 HR 105 R 20 O2 sata 93 % on RA
General: Flushed but otherwise comfortable appearing middle aged
male
HEENT:OP clear, MMM, sclera anicteric, scattered excoriations on
face
LN: No cervical or axillary LAD
CV: tachycardic, RR, nl S1S2, I could not appreciate m/g/r
Pulm: Lung CTA b/l
Back: no spinal, paraspinal or CVA tenderness
Abd: Obese, soft, NT/ND, I could not appreciate
hepatospelnomegaly
EXT: Left hand and wrist are edematous and erythamtous and warm,
erythema extend halfway up forearm and the dorsum of the hand.
Most of the erythema is located over the left wrist. The area
was outlined patient has severe pain in wrist on active and
passive motion. Right wrist is unremarkable. Left foot is
erythematous. He has full ROM of the ankle and is able to bear
weight. The erythmatous area was outlined. No LE edema.
Skin: No petechiae, splinter hemmhorhages, osler nodes or
[**Last Name (un) **] lesions
Neuro: AAOx3
Pertinent Results:
CXR: The lungs are clear without consolidation or edema. The
mediastinum is unremarkable. The previously noted right upper
extremity PICC line has been removed in the interval. The
cardiac silhouette is within normal limits for size. No effusion
or pneumothorax is noted. The osseous structures are
unremarkable.
IMPRESSION: No acute pulmonary process.
Left wrist x-ray: 1. No visible acute fracture.
2. Some displacement of the pronator quadratus fat pad volar to
the radius is seen. If there is high degree of clinical
suspicion for fracture, further assessment with MRI is
suggested.
Left ankle x-ray: IMPRESSION: No evidence of traumatic injury or
significant underlying degenerative joint disease. Essentially
normal exam. Please note this is the third in a series of normal
ankle x-rays dating back to [**2169-8-5**].
ECG: sinus rhythm, rate 97, normal PR, no ST-T wave changes.
[**2169-10-11**] 04:34AM BLOOD WBC-6.3 RBC-4.53* Hgb-12.7* Hct-37.9*
MCV-84 MCH-28.1 MCHC-33.5 RDW-14.3 Plt Ct-321
[**2169-10-3**] 01:00PM BLOOD WBC-6.3 RBC-3.97* Hgb-11.3* Hct-33.7*
MCV-85 MCH-28.6 MCHC-33.7 RDW-15.2 Plt Ct-233
[**2169-10-4**] 06:25AM BLOOD Neuts-60.7 Lymphs-26.2 Monos-7.0 Eos-5.1*
Baso-0.9
[**2169-10-4**] 06:25AM BLOOD PT-13.4 PTT-30.9 INR(PT)-1.1
[**2169-10-4**] 06:00PM BLOOD ESR-31*
[**2169-10-11**] 04:34AM BLOOD Glucose-86 UreaN-17 Creat-0.9 Na-138
K-4.4 Cl-102 HCO3-25 AnGap-15
[**2169-10-3**] 01:00PM BLOOD Glucose-148* UreaN-9 Creat-0.8 Na-135
K-4.0 Cl-100 HCO3-26 AnGap-13
[**2169-10-11**] 04:34AM BLOOD ALT-49* AST-27 LD(LDH)-179 AlkPhos-106
TotBili-0.2
[**2169-10-4**] 06:25AM BLOOD ALT-237* AST-211* AlkPhos-122 TotBili-0.4
[**2169-10-11**] 04:34AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.3
[**2169-10-9**] 06:35AM BLOOD Vanco-16.3
BLOOD CULTURES X 2 ON [**10-6**] AND [**10-7**] NO GROWTH. FINAL.
[**2169-10-5**] 1:28 pm SWAB LEFT WRIST.
GRAM STAIN (Final [**2169-10-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2169-10-7**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2169-10-11**]): NO GROWTH.
ACID FAST SMEAR (Final [**2169-10-6**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final [**2169-10-5**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
[**2169-10-5**] 11:40 am SWAB LEFT WRIST DORSAL TISSUE.
GRAM STAIN (Final [**2169-10-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2169-10-7**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2169-10-11**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2169-10-5**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2169-10-6**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2169-10-4**] 6:00 pm IMMUNOLOGY
**FINAL REPORT [**2169-10-7**]**
HIV-1 Viral Load/Ultrasensitive (Final [**2169-10-7**]):
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test.
Detection range: 48 - 10,000,000 copies/ml.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
[**2169-10-4**] 9:46 am URINE Site: CLEAN CATCH Source: CVS.
**FINAL REPORT [**2169-10-5**]**
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
[**2169-10-5**]): Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final [**2169-10-5**]): Negative for Neisseria Gonorrhoeae by
PCR.
[**2169-10-4**] 6:00 pm IMMUNOLOGY
**FINAL REPORT [**2169-10-5**]**
HCV VIRAL LOAD (Final [**2169-10-5**]):
56,800 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
[**2169-10-5**] LEFT WRIST PATHOLOGY
1. Soft tissue, left wrist volar ulna, biopsy (A):
A Soft tissue, most likely synovium, with acute and chronic
inflammation, reactive change and focal necrosis. See note.
B. Fibrinopurulent exudate.
2. Soft tissue, left wrist dorsal, biopsy (B):
Synovium with focal fibrosis, otherwise unremarkable.
Note:
GMS, Gram and [**Doctor Last Name 6311**] stains performed on block A are negative
for fungal and bacterial organisms.
H&E slides reviewed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **].
Brief Hospital Course:
WRIST AND DORSAL FOOT TENOSYNOVITIS: culture negative, biopsy of
L hand synovium was largely unrevealing. The patient's urine GC
was negative. He was treated empirically with vancomycin
initially and symptoms did not completely improve, given GC was
still a possibility he was sent to the ICU for ceftriaxone
desensitization and treated with an empiric 2 week course of
vanc/ceftriaxone. Discharged on [**10-13**] with 8 remaining days.
Afebrile for > 2 days prior to discharge. He was set up with
PCP/ID follow up and will follow up with rheumatology in case
his symptoms do not improve.
Diabetes: home medications continued
Anxiety: Continued effexor and clonazepam
HTN, benign: Continued verapamil
Medications on Admission:
Venlafaxine XR 150 mg PO DAILY
Oxycodone SR (OxyconTIN) 40 mg PO Q12H
OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
Pseudoephedrine 30 mg PO Q6H:PRN sinus congestion
Omeprazole 40 mg PO DAILY
Lantus 30 units QHS and novolog SS
Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
Cyclobenzaprine 10 mg PO/NG HS
Gabapentin 600 mg PO/NG Q8H
Norflex *NF* (Orphenadrine Citrate) 30 mg/mL Injection Q6H
migraine
Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Atorvastatin 40 mg PO/NG DAILY
Verapamil SR 240 mg PO Q24H
Clonazepam 2 mg PO/NG [**Hospital1 **]
ValACYclovir 1 gram PO QDAILY
Darunavir 800 mg PO DAILY
RiTONAvir 100 mg PO DAILY
Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Benadryl 25-50 mg PRn sleep
ASA 81 mg po daily
Trazadone 100mg Po HS prn sleep
Allergies: Bactrim/sulfa-rash, PCN-rash, clindmycin
-anaphylaxis, compazine-seizure, quinolones-rash
Discharge Medications:
1. Outpatient Lab Work
CBC with differential, Chem 7 (Na, K, Cl, HCO3, BUN, Cr,
glucose), LFTs (AST, ALT, Alk phos, total bilirubin). To be
drawn [**2169-10-19**]. Results to be faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (fax#
[**Telephone/Fax (1) 34420**]) (phone# [**Telephone/Fax (1) 5723**])
2. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 8H (Every 8 Hours) for 12 days.
Disp:*36 doses* Refills:*0*
3. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours) for 12 days.
Disp:*12 doses* Refills:*0*
4. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
6. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for sinus congestion.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
10. Novolog 100 unit/mL Solution Sig: as directed units
Subcutaneous QAC AND QHS: per sliding scale.
11. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
13. Norflex 30 mg/mL Solution Sig: One (1) injection Injection
four times a day as needed for migraine.
14. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
15. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. verapamil 120 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q24H (every 24 hours).
17. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO QDAILY ().
18. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
19. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
20. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Benadryl 25 mg Capsule Sig: [**1-7**] Capsules PO at bedtime as
needed for insomnia.
22. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
23. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
24. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
25. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB.
26. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) pen
Intramuscular once as needed as needed for allergic reaction
characterized by feeling like you are going to faint or throat
closing / trouble breathing for 1 doses.
Disp:*1 epi pen* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Left wrist cellulitis with multiple abscesses
Left ankle cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for infection involving your left wrist and
left ankle. There were pockets of infection around your left
wrist which were incised and drained by Orthopedics on
[**2169-10-5**]. You were treated with intravenous Vancomycin and
Ceftriaxone.
MEDICATION CHANGES:
START taking VANCOMYCIN and CEFTRIAXONE (IV antibiotics)
OXYCODONE dose has been INCREASED temporarily to 10mg every 4
hours as needed for pain
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
Appointment: Friday [**2169-10-20**] 2:30pm
Department: RHEUMATOLOGY
When: TUESDAY [**2169-10-31**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4900**], 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
|
[
"682.4",
"V08",
"682.6",
"070.54",
"346.90",
"250.00",
"305.1",
"711.03",
"401.9",
"V07.1",
"682.3",
"727.05",
"727.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"80.73",
"38.93",
"80.33",
"80.83",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
14325, 14394
|
9805, 10514
|
384, 453
|
14506, 14506
|
3596, 5784
|
15103, 15749
|
2367, 2429
|
11420, 14302
|
14415, 14485
|
10540, 11397
|
14657, 14915
|
2444, 3577
|
7156, 9782
|
7094, 7117
|
14935, 15080
|
324, 346
|
481, 1895
|
14521, 14633
|
1917, 2136
|
2152, 2351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,778
| 184,237
|
19193
|
Discharge summary
|
report
|
Admission Date: [**2113-1-13**] Discharge Date: [**2113-1-20**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Chief Complaint: nausea/vomiting
.
Reason for MICU transfer: hyperkalemia, [**Last Name (un) **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old male with PMH DM2, CAD, parkinsons is admitted with
nausea and vomiting and deyhdration and is admitted to the
intensive care unit with hyperkalemia.
According to the patient and home attendant, the patient
developed nausea and vomiting two days prior to admission. The
vomiting worsened, he was unable to tolerate oral intake and the
attendant called his PCP who recommended that he come to the ED
for evaluation. He had also noted elevated finger sticks in the
last three days.
In the ED, initial vitals were T97.0 p59 bp132/69 rr18 96% RA
labs were remarkable for Cr 5.1 K 7.3, Na 125, HCO3 21. He was
given Ca Gluconate 2g IV, 1 amp of D50, albuterol, and
keyexylate. He did not have a bowel movement, repeat K was 6.5.
He was seen by nephrology who recommended IV fluids and MICU
admission. Vitals on transfer were afebrile HR 52 128/68 rr
18-24, 96% RA.
.
On arrival to the MICU, he was somnolent stating that he had not
slept the last few nights. He denied recent sick contacts. [**Name (NI) **]
reported that his last bowel movement was four days prior to
admission. Othewise reported breathing is comfortable.
Past Medical History:
1) DM2
2) Depression
3) Chronic Anxiety
4) Chronic Low Back Pain s/p ruptured intervertebral disk at the
age of 52
5) Dyspepsia on PPI
6) Osteoarthritis
7) BPH s/p TURP
8) HTN
9) Gout
10) OSA
11) Abnormal stress test, medically managed
12) Periodic limb movement disorder of sleep.
Social History:
Retired Longshoreman. Has had Caregroup
VNA in the past. Quit smoking 50 years ago. No ETOH.
Family History:
Non-contributory.
Physical Exam:
Admission Exam:
Vitals: T:98.9 BP:128/83 P:102 R:18 O2: 100% RA
General: Somnolent, elderly male oriented, no acute distress
HEENT: Mucous membs moist EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds active
GU: no foley
Ext: L>R cogwheel rigidity in upper extremities. warm, well
perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge Exam:
VS: T 96-97 BP 110-150/50-60s HR 50-60s RR 18 95% RA
UOP: 2000cc/24h
GENERAL - Elderly man in NAD
HEENT - NC/AT, PEERL, MMM
LUNGS - Diffuse expiratory wheezing, no increased WOB
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ pitting edema of the BLEs to the shin,
hyperpigmentation of the BLEs, 1+ pulses b/l
NEURO - A/Ox3, CNs II-XII grossly intact, non focal
Pertinent Results:
Admission Labs:
[**2113-1-13**] 08:10PM BLOOD WBC-5.6 RBC-3.95* Hgb-12.4* Hct-35.2*
MCV-89# MCH-31.5 MCHC-35.3* RDW-13.7 Plt Ct-178
[**2113-1-13**] 08:10PM BLOOD Neuts-85.4* Lymphs-8.6* Monos-5.2 Eos-0.6
Baso-0.3
[**2113-1-13**] 08:10PM BLOOD Glucose-80 UreaN-98* Creat-5.1*# Na-125*
K-7.3* Cl-87* HCO3-21* AnGap-24*
[**2113-1-13**] 08:10PM BLOOD cTropnT-0.06*
[**2113-1-14**] 02:14AM BLOOD cTropnT-0.07*
[**2113-1-14**] 11:38AM BLOOD CK-MB-4 cTropnT-0.09*
[**2113-1-14**] 02:14AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.9
Discharge Labs:
[**2113-1-20**] 07:40AM BLOOD WBC-6.6 RBC-3.79* Hgb-11.9* Hct-34.2*
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.9 Plt Ct-211
[**2113-1-20**] 07:40AM BLOOD Glucose-113* UreaN-81* Creat-4.6* Na-141
K-4.8 Cl-104 HCO3-25 AnGap-17
[**2113-1-20**] 07:40AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8
[**2113-1-15**] 05:28AM BLOOD Cortsol-9.0
.
CXR [**2113-1-15**]:Heart size is normal. A confluent opacity has
developed medially at the right lung base and is accompanied by
mild volume loss. This may reflect atelectasis, aspiration, and
less likely a developing focus of pneumonia. Followup
radiographs may be helpful in this regard. Left-sided calcified
pleural plaque is noted.
.
TTE ([**2113-1-16**]):
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is high
(>4.0L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Moderate
pulmonary artery systolic hypertension. Mild aortic valve
stenosis.
CLINICAL IMPLICATIONS:
The patient has mild aortic valve stenosis. Based on [**2107**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 3 years. Based on [**2108**] 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.
.
Renal Ultrasound ([**2113-1-16**]):
1. Normal renal ultrasound exam.
2. Small amount of ascites.
Brief Hospital Course:
Primary Reason for Admission: [**Age over 90 **] year old male with PMH DM2,
CAD, parkinsons is admitted with nausea and vomiting and
deyhdration to the MICU with hyperkalemia and acute renal
failure, found to be ATN, subsequently called out to the floor.
.
Active Problems:
.
# [**Last Name (un) **]: The patient came in with a Cr of 5.1 in the setting of
persistent nausea, vomiting and taking an ACEI and NSAIDs at
home. Looking at the urine, multiple muddy brown casts were
seen, suggesting ATN secondary to hypovolemia. The patient was
given IVF, his BP meds were held as were his NSAIDs. Renal was
consulted. He continued to make good urine and his electroyltes
were trended. In the MICU he was started on Midodrine 5mg tid to
help augment his BP and renal perfusion; this was stopped upon
arrival to the floor. On the floor, his Cr continued to trend
down with IVF. His home Lasix was restarted and IVF was stopped.
He was started on Nephrocaps and NaHCO3. At discharge, his Cr
was 4.6. He will follow up with renal in [**1-2**] weeks and will see
his PCP early next week for lab check. He has 24 hour home care.
.
# Hyperkalemia: The patient's potassium was 7.3 on admission,
due to renal failure from ATN. There were no EKG changes on
admission to the MICU. He was given Kayexelate and IV hydration
and his hyperkalemia resolved at the time of MICU callout. On
the floor, his K was elevated to 5.3, for which he received
Kayexalate x1. His K remained normal thereafter and he was
discharged on his home Lasix dose. He will follow up with his
PCP next week for K/Cr check.
.
# Hyponatremia: Pt initially demonstrated hypovolemic
hyponatremia in the setting of recent vomiting and [**Date Range 7968**] PO
intake. He did not have any altered consciousness, and showed
improvement with gradual fluid resuscitation. At tht time of
MICU callout, his Na was normal and remained normal for the
remainder of his hosptial course.
.
# Nausea/Vomiting: Patient denies eating raw meat, new or
spoiled foods, denies sick contacts. Viral gastroenteritis seems
most likely. Pt's caretaker states that he may have also
consumed a significant quantity of lactulose several days prior
to admission, which represents another significant etiology for
his diarrhea, though this would not account for his vomiting.
The patient continued to endorse nausea on the floor, and his
bowel regemin was increased. On [**2113-1-19**] the patient had several
large bowel movements with resolution of his nausea.
.
Chronic Issues
.
# Coronary Artery Disease: two vessel disease seen on cath in
[**2110**], medically managed.
-- cont Isosorbide Mononitrate 60 mg PO DAILY
-- cont Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
-- cont Aspirin 325 mg PO/NG DAILY
-- cont Simvastatin 40 mg PO/NG DAILY
# Parkinson's disease: patient with cogwheeling on exam.
-- Continue Carbidopa-Levodopa (25-100) 2 TAB PO/NG TID
# Restless legs syndrome
-- Conitnue pramipexole 0.375 mg Oral daily at 21:00
.
Transitional Issues: Pt was d/c'ed home with instrucitons to
hold [**Hospital1 **] and Allopurinol and take a reduced dose of
[**Hospital1 43510**] given [**Hospital1 7968**] CrCl. These medications can be
restarted per renal. He will follow up with his PCP for [**Name Initial (PRE) **]/Cr
check next week and in renal clinic shortly thereafter.
Medications on Admission:
Allopurinol 300 mg Tablet every other day
Carbidopa-levodopa 25 mg-100 mg Tablet, 2 tabs PO TID
Ergocalciferol (vitamin D2) 50,000 unit Capsule every other week
Furosemide 40 mg Tablet daily
[**Name Initial (PRE) 43510**] 100 mg QAM, 200mg 4pm, 300mg 8pm
Isosorbide mononitrate 60 mg Tablet Extended Release 24 hr daily
[**Name Initial (PRE) **] 2.5 mg Tablet daily
Metoprolol succinate 25mg daily
Nitroglycerin 0.3 mg Tablet, Sublingual prn chest pain
Oxycodone-acetaminophen 5 mg-325 mg Tablet TID
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]
Pramipexole [Mirapex] 0.25 mg Tablet, 1.5 Tablet(s) at 9 pm
Simvastatin 40mg daily
Tolterodine [Detrol] 2 mg Tablet [**Hospital1 **]
Ascorbic acid 1,000 mg Tablet daily
Aspirin 325mg daily
Calcium citrate-vitamin D3 315 mg-200 unit Tablet, 2 tabs [**Hospital1 **]
Docusate sodium [Stool Softener] 50 mg Capsule [**Hospital1 **]
Famotidine-Ca carb-mag hydrox 10 mg-800 mg-165 mg Tablet
Guaifenesin [Mucinex] 600 mg Tablet Extended Release 1 tab [**Hospital1 **]
Multivitamin daily
Polyethylene glycol 3350 [Miralax] 17 gram prn constipation
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO every other
day: HOLD - do not take until told to restart by the renal
clinic.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) Nasal once a day: alternating nosrils.
5. Caltrate 600 + D 600 mg(1,500mg) -400 unit Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Detrol 2 mg Tablet Sig: One (1) Tablet PO twice a day.
8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO every other week.
9. [**Hospital1 **] 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
10. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. [**Hospital1 21177**] 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
HOLD until renal clinic [**Hospital1 648**].
13. melatonin 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
14. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
15. pramipexole 0.125 mg Tablet Sig: Three (3) Tablet PO daily
at 21 ().
16. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO at bedtime.
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual every 10 minutes prn as needed for chest pain: do not
take more than 3 in 30 minutes.
19. oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for pain.
20. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
21. Pepcid Complete 10-800-165 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day: at midnight.
22. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
24. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
25. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
26. magnesium citrate Solution Sig: One (1) PO once a day
as needed for constipation.
27. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Hyperkalemia
Secondary Diagnosis:
Acute on Chronic Renal Failure
Parkinsons Disease
DM II
Gout
OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname 50388**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for renal failure and
hyperkalemia. You spent a night in the ICU and then a few nights
on the medicine floor, where you were cared for by medicine
doctors. You are now safe to return home.
Please note the following changes to your medications:
HELD Allopurinol - do not take this until your [**Hospital1 648**] with
the Renal Doctors
[**First Name (Titles) **] [**Last Name (Titles) **] - do not take this until your [**Last Name (Titles) 648**] with
the Renal Doctors
[**First Name (Titles) **] [**Last Name (Titles) 43510**] to 300mg by mouth every other day - discuss
increasing the dose with the renal doctors at your [**Name5 (PTitle) 648**]
STARTED Nephrocaps 1 cap by mouth daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2113-1-25**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC/NEPHROLOGY
When: THURSDAY [**2113-2-2**] at 1 PM
With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2113-5-30**] at 11:40 AM
With: DR. [**Last Name (STitle) **] / DR. [**Last Name (STitle) 3172**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.9",
"276.50",
"300.00",
"584.5",
"414.01",
"333.94",
"332.0",
"276.1",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12691, 12749
|
5688, 8664
|
348, 355
|
12911, 12911
|
3127, 3127
|
14012, 14979
|
1970, 1989
|
10170, 12668
|
12770, 12770
|
9038, 10147
|
13094, 13426
|
3661, 5147
|
2004, 2663
|
2679, 3108
|
5170, 5665
|
8685, 9012
|
13455, 13989
|
228, 310
|
383, 1534
|
12823, 12890
|
3143, 3644
|
12789, 12802
|
12926, 13070
|
1556, 1840
|
1856, 1954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,027
| 187,899
|
23453
|
Discharge summary
|
report
|
Admission Date: [**2175-6-24**] Discharge Date: [**2175-6-27**]
Date of Birth: [**2127-2-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 60118**] is a 48 year old man with a history of pancreatitis,
alcohol abuse, and type II diabetes. He drinks about 1 pint of
brandy every other day (although sometimes everyday). He reports
his family wants him to stop drinking alcohol. He initially
stopped two days prior to presentation. Yesterday afternoon
around four PM he developed nausea and emesis (non-bloody). He
states that he thought it was related to not drinking. He then
tried to drink some alcohol, but was unable to do so. He denied
any pain, but reports that he felt slightly unstable on his
feet. He reports not sleeping very well throughout the night.
This morning he was able to drink some soda and V8. However, he
continued to feel very bad and his wife brought him to the [**Name (NI) **].
He reports his main symptoms are feeling his heart go fast,
"high blood bressure," and "high cholesterol." He did not take
his heart rate or blood pressure.
He generally has poor glucose control. He takes glargine 16
units [**Name (NI) **] along with 10 units of humalog with meals. His blood
glucose generally ranges in the 150's-300's. His glucose the day
prior to presentation was 324-194-284.
Initial vitals in the ED were: 98.2 135 153/87 18 99%. In the ED
he received two liters of normal saline. His initial labs were
significant for a glucose of 360, creatinine of 2.2, and anion
gap of 40. He was started on an insulin gtt and his glucose
prior to leaving the ED was 203. He was switched over to D5NS
with 40 mEq of KCl. Vitals on transfer were: 20 g 110 155/85 20
100% RA.
On arrival to the MICU, he appeared comfortable. He had a slight
headache (denied any trauma). He denied any other pain,
shortness of breath, cough, dysuria, back pain, fever, chills,
night sweats, recent weight loss or gain. Denies sinus
tenderness, rhinorrhea, jaw pain, or congestion. Denies chest
pain, chest pressure, palpitations. Denies constipation,
abdominal pain. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes. He also
denies any over the counter medications or ingestions such as
methanol, ethylene glycol, etc.
Past Medical History:
Anxiety
DM II on insulin
Alcohol abuse
Hypertension
Hyperlipidemia
Acute-on-Chronic pancreatitis
Social History:
He lives at home with his wife, daughter, and three grand
children. Reports cigarette use 15 years ago (about [**2-17**]
cigarettes per day). Denies drug use. Drinks 1 pint of brandy
every 1-2 days.
Family History:
Reports hypertension and anxiety in multiple family members.
Physical Exam:
ADMISSION EXAM:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
[**Month/Day (3) **]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
VS: 98.2 106/70-144/93 80-101 18 100% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no cervical lymphadenopathy
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3
Pertinent Results:
admission labs
[**2175-6-24**] 12:25PM BLOOD WBC-13.5*# RBC-4.68 Hgb-13.4* Hct-41.9
MCV-90 MCH-28.7 MCHC-32.1 RDW-13.2 Plt Ct-231
[**2175-6-24**] 12:25PM BLOOD Neuts-89.1* Lymphs-6.1* Monos-4.2 Eos-0.5
Baso-0.2
[**2175-6-25**] 01:48AM BLOOD PT-11.2 PTT-27.4 INR(PT)-1.0
[**2175-6-24**] 12:25PM BLOOD Glucose-360* UreaN-32* Creat-2.2*#
Na-131* K-4.2 Cl-81* HCO3-10* AnGap-44*
[**2175-6-24**] 12:25PM BLOOD ALT-89* AST-145* AlkPhos-99 TotBili-0.6
[**2175-6-24**] 12:25PM BLOOD Lipase-15
[**2175-6-24**] 12:25PM BLOOD CK-MB-4
[**2175-6-24**] 12:25PM BLOOD cTropnT-<0.01
[**2175-6-25**] 11:45AM BLOOD CK-MB-3 cTropnT-<0.01
[**2175-6-24**] 12:25PM BLOOD Albumin-5.4* Calcium-10.5* Phos-2.3*
Mg-2.6
[**2175-6-24**] 12:25PM BLOOD ASA-4.0 Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-6-24**] 06:49PM BLOOD Type-ART pO2-108* pCO2-31* pH-7.39
calTCO2-19* Base XS--4
[**2175-6-24**] 06:49PM BLOOD Glucose-127* Lactate-1.0 Na-137 K-4.2
Cl-103
.
discharge labs
[**2175-6-27**] 06:00AM BLOOD WBC-4.3 RBC-3.86* Hgb-10.7* Hct-33.6*
MCV-87 MCH-27.7 MCHC-31.8 RDW-12.8 Plt Ct-176
[**2175-6-27**] 06:00AM BLOOD Glucose-289* UreaN-4* Creat-0.9 Na-134
K-3.3 Cl-99 HCO3-27 AnGap-11
[**2175-6-27**] 06:00AM BLOOD Calcium-9.1 Phos-2.3* Mg-1.4*
.
urine
[**2175-6-25**] 12:58PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2175-6-25**] 12:58PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2175-6-25**] 12:58PM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
.
micro
URINE CULTURE (Final [**2175-6-27**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
blood culture pending at time of discharge
.
studies
CXR: No acute cardiopulmonary process.
.
Brief Hospital Course:
Mr. [**Known lastname 60118**] is a 48 year old man with a history of alcohol abuse
presenting with with anion gap metabolic acidosis now improved
.
# Anion gap metabolic acidosis: Likely multifactorial and
related to DKA vs starvation vs ETOH. Gap closed with IV fluids
and improved blood glucose control. Workup for inciting events
including ischemia and infection were negative (final blood
cultures pending at time of discharge). [**Last Name (un) **] was consulted and
adjusted his insulin regimen. His blood sugars improved to low
200s. He was discharged with plans to take 24 units of lantus
every evening and sliding scale humalog QACHS. He is [**Last Name (un) 1988**]
for PCP and [**Name9 (PRE) **] follow up.
.
# Alcohol Dependence with Withdrawal: Given significant abuse
history, he was at high risk for withdrawal. Patient was placed
on valium CIWA scale and required only 1 dose while in the ICU
but did not require any further benzodiazepines while on the
floor. Patient reported motivation to stop drinking. He met with
the social worker who provided him with resources to help him
stop drinking. He was continued on multivitamin, thiamine, and
folate.
.
# Acute Kidney Injury: Creatinine up to 2.2 on admission likely
prerenal in etiology. Creatinine improved with intravenous
fluids.
.
# Hypertension: Initially held lisinopril in the setting of [**Last Name (un) **].
This was restarted when creatinine improved to baseline.
.
# Elevated LFT's: likely in the setting of ETOH use as AST/ALT
2:1 ratio. LFTs should be rechecked at outpatient follow up.
.
# difficulty with swallowing: On day of transfer from the MICU
to the floor, the patient reported some discomfort with
swallowing. This was thought to be due to irritation from
frequent vomiting the day prior to presentation. He was started
on a PPI and underwent a speech and swallow evaluation which was
unrevealing. Symptoms improved and patient was able to tolerate
full diet without difficulty prior to discharge.
.
# Hx of Pancreatitis: Lipase within normal limits. Denied pain
consistent with his prior episodes.
.
# depression - continued citalopram, gabapentin. Gabapentin was
renally dosed.
.
# HLD - held simvastatin in the setting of elevated LFTs.
Patient will need to have his LFTs checked at follow up with his
PCP and discuss whether it is safe to restart this medication.
.
transitional issues:
-statin held at discharge for elevated LFTs. patient will need
to have LFTs checked at follow up.
-patient provided with information regarding the Choices group
for his alcohol abuse
-patient will need to monitor and record blood sugars after
discharge, and insulin regimen may need further alteration
Medications on Admission:
CITALOPRAM - 20 mg Tablet
FOLIC ACID - 1 mg
GABAPENTIN - 100 mg Capsule 3 Capsule(s) by mouth three times
per day
INSULIN GLARGINE 16 units [**Last Name (un) **]
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - per sliding scale protocol per sliding scale
protocol
LISINOPRIL - 20 mg Tablet
SIMVASTATIN - 40 mg Tablet
ASPIRIN - 325 mg Tablet
MULTIVITAMIN WITH MINERALS
THIAMINE HCL - 100 mg Tablet
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
4. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
5. Humalog 100 unit/mL Solution Sig: as directed by sliding
scale units Subcutaneous four times a day: please take as
directed by sliding scale .
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. omeprazole 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*
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
4. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
5. Humalog 100 unit/mL Solution Sig: as directed by sliding
scale units Subcutaneous four times a day: please take as
directed by sliding scale .
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. omeprazole 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
Discharge Diagnosis:
primary diagnosis: diabetic ketoacidosis, acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 60118**],
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted because you were having nausea and
vomiting and were unable to tolerate oral intake. You were found
to have high sugars and concern for diabetic ketoacidosis. You
were given intravenous fluids and insulin to improve your blood
sugars. You were evaluated by the [**Last Name (un) 387**] team who helped modify
your insulin regimen.
.
The following changes were made to your medication regimen.
Please START taking
- omeprazole 20 mg daily
.
Please CHANGE
- lantus to 24 units at bedtime (on evening of [**6-27**] take 4 units
of lantus, start 24 units at bedtime on [**6-28**])
- humalog before meals and bedtime according to sliding scale
- gabapentin from 300 mg three times daily to twice daily
- aspirin from 325 to 81 mg daily
.
Please STOP taking your simvastatin as your liver function is
abnormal. This is likely related to your alcohol use. You should
stop drinking alcohol. Please have your liver function checked
at follow up and discuss if it is safe to restart this
medication.
.
Please take the rest of your medications as prescribed and
follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Followup Instructions:
Name:[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP
Location: [**Hospital **] CLINIC
Address: ONE [**Last Name (un) **] PLACE, SECOND FL, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 60119**]
When:Thursday, [**6-29**] at 8:30am
Department: [**Hospital3 249**]
When: THURSDAY [**2175-7-3**] at 1:00 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC with Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Phone:[**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
Completed by:[**2175-6-27**]
|
[
"V58.67",
"787.20",
"V15.82",
"355.9",
"291.81",
"250.12",
"584.9",
"272.4",
"300.00",
"303.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10942, 10948
|
5912, 8276
|
312, 318
|
11054, 11054
|
4086, 5889
|
12497, 13470
|
2848, 2910
|
9088, 10919
|
10969, 10969
|
8627, 9065
|
11205, 12474
|
2925, 3581
|
3597, 4067
|
8297, 8601
|
266, 274
|
346, 2494
|
10988, 11033
|
11069, 11181
|
2516, 2615
|
2631, 2832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,196
| 168,106
|
43396
|
Discharge summary
|
report
|
Admission Date: [**2170-3-19**] Discharge Date: [**2170-3-26**]
Date of Birth: [**2098-2-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Zestril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2170-3-19**] - Aortic valve replacement with a 21 mm [**Doctor Last Name **] Magna
ease bioprosthesis.
History of Present Illness:
71yo female with known aortic stenosis. Serial echocardiograms
have shown worsening gradients. Part of her pre-kidney
transplant evaluation included a stress test which was not fully
completed due to severe shortness of breath. Current symptoms
include dyspnea on exertion and decreased exercise tolerance.
She denies chest pain, syncope, pre-syncope, orthopnea, PND and
pedal edema. She is able to perform routine ADL without much
difficulty. She occasionally
requires a cane for balance, and frequently requires a
wheelchair for walking long distance. Cardiac surgery consulted
for surgical correction.
Past Medical History:
Past Medical History
- Hypertension
- Dyslipidemia
- Diabetes Mellitus Type II
- History of renal cell carcinoma status post nephrectomy
resulting in ESRD, requires peritoneal dialysis since [**2164**]
- History of peritonitis over five years ago
- History of herpes Zoster several years ago
- History of C. difficile colitis
- Anemia
- Arthritis, History of Gout
- Hyperparathyroidism
Past Surgical History
- s/p Bilateral Nephrectomy
- s/p Hernia Repair
- s/p Dialysis Catheter Placement
Social History:
Lives: Alone
Tobacco: Quit over 40 years ago
ETOH: Denies
Family History:
non contributory
Physical Exam:
Pulse:99 Resp: 16 O2 sat: 98/RA
B/P Right: 121/74 Left: 91/77
Height: 4'9" Weight: 139 lbs
General: Elderly female in no acute distress
Skin: Dry [x] intact [x] - dialysis catheter noted lower abd
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - 4/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
[x]
Extremities: Warm [x], well-perfused [x]
Edema - trace Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs
Pertinent Results:
[**2170-3-19**] ECHO
PRE-CPB:
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
There is moderate 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 simple atheroma in the descending thoracic aorta. No
thoracic aortic dissection is seen.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Two AI jets are seen: one
central, the other at the commissure between the left and
non-coronary cusps. Mild to moderate ([**1-21**]+) aortic regurgitation
is seen.
The mitral valve leaflets are mildly thickened. There appears to
be mild mitral stenosis. Mild to moderate ([**1-21**]+) mitral
regurgitation is seen. The MR jet is central.
POST-CPB:
There is a bioprosthetic valve in the aortic position. The
leaflets are freely mobile, the valve is well-seated. No
paravalvular leaks are seen. There is no AI.
The LV is hypertrophied, the chamber size is small, consistent
with hypovolemic state. The LV systolic function is normal,
estimated EF 55-60%. [**Male First Name (un) **] is seen with evidence of LVOTO and
increased MR. Pt was treated with volume loading and
phenylephrine with gradual resolution.
MR remains mild to moderate. The gradient across the mitral
valve is increased, peak gradient is 16mmHg, mean gradient is
7mmHg. The cardiac output remains comparable to pre-op.
The RV systolic function remains normal.
There is no evidence of aortic dissection.
[**2170-3-26**] 04:53AM BLOOD WBC-7.9 RBC-3.47* Hgb-10.4* Hct-31.4*
MCV-91 MCH-30.1 MCHC-33.1 RDW-14.8 Plt Ct-169
[**2170-3-24**] 04:53AM BLOOD WBC-8.6 RBC-3.31*# Hgb-10.2* Hct-29.7*
MCV-90 MCH-30.7 MCHC-34.3 RDW-15.0 Plt Ct-152
[**2170-3-26**] 04:53AM BLOOD Glucose-104* UreaN-56* Creat-8.2* Na-137
K-4.3 Cl-93* HCO3-26 AnGap-22*
[**2170-3-25**] 05:34AM BLOOD Glucose-58* UreaN-54* Creat-7.7* Na-135
K-4.5 Cl-93* HCO3-28 AnGap-19
[**2170-3-26**] 04:53AM BLOOD Calcium-8.4 Phos-6.3* Mg-2.4
[**2170-3-25**] 05:34AM BLOOD Calcium-8.6 Phos-6.0* Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname 3271**] was admitted to the [**Hospital1 18**] on [**2170-3-19**] for surgical
management of her aortic valve disease. She was taken to the
operating room where she underwent an aortic valve replacement
using a pericardial tissue valve. Please see operative note for
details. Postoperatively she was transferred to the intensive
care unit for recovery. The nephrology service followed her
closely for her continuous peritoneal dialysis. Over the next
several hours, Ms. [**Known lastname 3271**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. On postoperative day one, blood tinged peritoneal
dialysate was noted and the transplant surgery service was
consulted. Her hematocrit was stable and aspirin was held.
Peritoneal dialysis was resumed without issue. Later on
postoperative day one, she was trnasferred to the step down unit
for further recovery. The physical therapy service was consulted
for assistance with her postoperative strength and mobility. The
goal was to make her a liter negative per day through her
peritoneal dialysis. She did have a burst of rapid atrial
fibrillation which converted to sinus rhythm with amiodarone and
an increase in beta blockade. She continued to make steady
progress and was discharged to [**Hospital1 **], [**Location (un) 701**] for
rehabilitation on postoperative day 7. Her follow-up
appointments have been scheduled.
Medications on Admission:
Allopurinol 150mg PO daily
Atoarvastatin 10mg PO daily
Cinacalcet 90mg PO daily
Doxrecalciferol 2.5mcg PO daily
Epogen 7500units MWF
Fluticasone 50mcg spray in each nostril daily
Gabapentin 100mg PO prn qhs
Glyburide 5mg PO daily
Ranitidine 150mg PO daily
Docusate 100mg PO BID
Ferrous sulfate 325mg daily
Magnesium 200mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. gentamicin 0.1 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
7. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. epoetin alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-21**] Sprays Nasal
QID (4 times a day) as needed for dry nares.
10. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation .
14. 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*
15. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. hydralazine 10 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for SBP>140mmHg.
17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing, sob.
19. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
20. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
21. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x 1 week, then 200mg daily until further
instructed.
22. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
- Aortic valve stenosis
- Hypertension
- Dyslipidemia
- Diabetes Mellitus Type II
- History of renal cell carcinoma status post nephrectomy
resulting in ESRD, requires peritoneal dialysis since [**2164**]
- History of peritonitis over five years ago
- History of herpes Zoster several years ago
- History of C. difficile colitis
- Anemia
- Arthritis, History of Gout
- Hyperparathyroidism
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
trace edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] #:[**Telephone/Fax (1) 170**] Date/Time:[**2170-4-17**] 1:45
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 93402**]: appointment on [**2170-4-24**] at
2pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 3314**] in [**4-24**] weeks. Please call
[**Telephone/Fax (1) 3183**] to schedule your appointment.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2170-3-26**]
|
[
"518.81",
"V10.52",
"585.6",
"272.4",
"424.1",
"427.31",
"V45.11",
"403.91",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"54.98",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8668, 8750
|
4697, 6113
|
307, 416
|
9183, 9358
|
2420, 4674
|
10332, 10993
|
1657, 1676
|
6492, 8645
|
8771, 9162
|
6139, 6469
|
9382, 10309
|
1691, 2401
|
248, 269
|
444, 1051
|
1073, 1565
|
1581, 1641
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,336
| 119,603
|
32626
|
Discharge summary
|
report
|
Admission Date: [**2197-12-22**] Discharge Date: [**2197-12-26**]
Date of Birth: [**2135-10-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Dyspnea, hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 62 yoF w/ a h/o multiple sclerosis x 28 years now
quadraplegic and bedbound who presented to [**Hospital3 **]Hospital with shortness of breath. Patient began to notice
shortness of breath beginning 4 days prior to presentation. She
denies any chest pain, subjective fevers, chills, or night
sweats. Denies any cough, nasal congestion, sputum, hemoptysis,
weight loss, palpitations. No worsening of her chronic lower
extremity swelling and no lower extremity discomfort. No prior
history of heart disease. On presentation, she did note a
sensation of chest heaviness over the last 4 days. Denies any
nausea, diaphoresis, or lightheadedness.
.
Of note, at baseline, she does have some difficulty breathing
while laying flat and wears O2 at night but has never had a
formal sleep study. No PND. She noted steady progression of her
symptoms over the 4 days PTA. In the past she has required
hospitalization for respiratory distress in the setting of URIs,
however she had not been hospitalized for 3 years prior to this.
She has never required intubation.
.
Upon arrival to [**Hospital3 17031**], VS 97.4, 117, 156/68, 24, 85%
on 3LNC. Patient reported to have made 1600 cc or UOP following
lasix in route to ED. Exam was significant for moderate
respiratory distress and decreased BS over R lung fields. CXR
was obtained showing what was thought to be a large R sided
pleural effusion. ECG showed sinus tachycardia. ABG was
7.42/45/53/29 on 3LNC. Patient placed on 50% ventimask w/ O2
sats increasing to 94% and improvement in SOB. BNP was normal at
68. D-dimer was mildly elevated at 524. First set of cardiac
enzymes were negative. Patient was transferred to [**Hospital1 18**] for
potential thoracentesis and intensive care monitoring.
.
In transit, patient O2 sats remained 87-92% on 50% ventimask.
HRs remained tachycardic in 120s. Upon arrival to [**Hospital1 18**], O2 sats
high 80s on 50% ventimask --> mid 90s on NRB.
.
She was admitted to the MICU at [**Hospital1 18**] for further management of
her respiratory distress. During her course there, she underwent
TTE which showed preserved LVEF, no significant valvular dz and
no intracardiac shunt. A CTA chest was obtained out of concern
for PE which was negative for PE, but did show extensive mucoid
impaction in the distal trachea and the lower lobe bronchi with
complete collapse of the right lower lobe and segmental collapse
of the left lower lobe. Thus, she underwent aggressive pulmonary
toilet with chest vest and deep suctioning with significant
improvement in her O2 sats so that she is maintaining O2 sats on
2.5L NC prior to transfer to the floor. She reports she is
nearly back to her respiratory baseline.
Past Medical History:
# Multiple sclerosis x 28 years
- functionally quadraplegic
- bedbound with transfers to wheelchair
- on 2L home O2 at night
# h/o stage 1 breast cancer found on mammogram s/p biopsy, not
pursued per patient preference (thinks was on Left)
# chronic LE edema
# chronic indwelling foley on suppressive antibiotics
# s/p oopherectomy
# s/p T+A as child
Social History:
SH: Lives in [**Location **] with her husband. [**Name (NI) **] home health aides.
She is quadriplegic and bedbound. Former 2 ppd smoker. Quit 20
years ago. 40 pk/yr hx. No EtOH or drugs.
.
Family History:
FH: Father had emphysema. Also had CAD s/p MI in 50s and CABG.
Died of MI in 70s. No fam hx of cancer
Physical Exam:
PE: T: 97.8 BP: 112/68 HR: 108 RR: 20 O2 sat 97% 2.5L
Gen: Pleasant, laying in bed, no accessory muscle use or
retractions, speaking in full sentences
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD.
CV: regular, do not appreciate mrg
LUNGS: rhonchi anteriorly likely transmitted upper airway moreso
ABD: Obese. + BS. Baclofen pump in LLQ. Soft, NT, ND. No HSM
EXT: WWP. [**1-24**]+ LE edema. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. No spontaneous motor activity. Increased
tone in L shoulder. 0/5 strength throughout. Muscle atrophy of
intrinsic muscles of the hand. Plantar contraction of feet
bilat.
Pertinent Results:
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with quadriplegia secondary to multple
sclerosis with poor peripheral IV access
REASON FOR THIS EXAMINATION:
Pls place PICC for access
PICC LINE PLACEMENT
INDICATION: IV access needed.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGISTS: Dr. [**First Name (STitle) 1022**] and Dr. [**First Name (STitle) 3175**] performed the procedure.
Dr. [**First Name (STitle) 3175**], the Attending Radiologist, was present and
supervised the entire procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
right basilic vein was punctured under direct ultrasound
guidance using a micropuncture set. Hard copies of ultrasound
images were obtained before and immediately after establishing
intravenous access. A peel-away sheath was then placed over a
guidewire and a single-lumen PICC line measuring 45 cm in length
was then placed through the peel-away sheath with its tip
positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the
chest.
The peel-away sheath and guide wire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
4 French single-lumen PICC line placement via the right basilic
venous approach. Final internal length is 45 cm, with the tip
positioned in SVC. The line is ready to use.
-------------------
CTA CHEST W&W/O C&RECONS, NON-
Reason: eval for PE, eval for anatomic cause of elevated R
hemidiaph
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with chronic multiple sclerosis, bedbound p/w
4 days increasing SOB
REASON FOR THIS EXAMINATION:
eval for PE, eval for anatomic cause of elevated R hemidiaphragm
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 62-year-old female with chronic multiple sclerosis, bed
bound now presenting with 4 days of increasing shortness of
breath to rule out a pulmonary embolism.
TECHNIQUE: CT of the chest was performed without intravenous
contrast followed by CT of the chest post-administration of
intravenous contrast, reconstructions were performed in the
axial, sagittal and coronal planes.
COMPARISON: Chest radiograph of [**2197-12-22**].
FINDINGS:
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There is a 7 mm low-attenuation focus in the left lobe of the
thyroid gland, this may be assessed further with a thyroid
ultrasound. There is atelectasis present at the lung bases with
almost complete collapse of the right lower lobe and
subsegmental collapse of the left lower lobe. There are
bronchial secretions almost completely occluded in the bronchus
intermedius and the bronchus supplying the right lower lobe.
There are secretions also present in the collapsed segments of
the left lower lobe as well as distal trachea.
There are ill-defined patchy opacities present in both lungs
likely infectious or inflammatory. There are scattered
mediastinal lymph nodes.
There is no central pulmonary embolism, however, given the
extent of lower lobe collapse, a subsegmental pulmonary embolism
cannot be excluded in the lower lobes.
There are multiple hepatic hypodensities, these are too small to
characterize and likely represent cysts and hemangiomas. There
are multiple bilateral renal hypodensities, again these are too
small to characterize and likely represent cysts.
MUSCULOSKELETAL: There are multilevel degenerative changes
present in the spine.
CONCLUSION:
1) Extensive mucoid impaction in the distal trachea and the
lower lobe bronchi with complete collapse of the right lower
lobe and segmental collapse of the left lower lobe.
2) No central pulmonary emboli, however, given the extent of the
lobar collapse, subsegmental pulmonary emboli cannot be
excluded.
TTE
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast at rest. Left ventricular wall thickness, cavity size,
and systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis or regurgitation. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is an anterior space which most likely represents
a fat pad.
IMPRESSION: No intracardiac shunting seen. Preserved global
biventricular systolic function. No significant valvular
disease.
Brief Hospital Course:
62 yoF w/ h/o MS, untreated breast cancer who was transferred to
[**Hospital1 18**] for worsening SOB found to extensive mucous plugging and
lobar collapse.
.
# Respiratory distress: Secondary to mucous plugging and lobar
collapse. The patient was initally admitted to the ICU for
aggressive pulmonary toilet and significantly improved in
respiratory status maintaining O2 sats on 1-2L NC which is her
baseline. Pt was continued on supplemental O2, and should wean
off oxygen during day (uses 2.5 L at night as outpatient). She
was continued on standing alb/atrovent nebs and levofloxacin
(day [**5-29**] on day of discharge). Discharged to rehabilitation
hospital for further optimization of aggressive pulmonary
toilet.
.
# UTI: evidence of UTI on OSH U/A. Here with many bacteria,
+nitrites, no leuk est, 9RBCs, 9WBCs; colonization vs true
infection. On Macrodantin suppression at home. Levofloxacin was
continued for both UTI and possible PNA for 7 days as above (day
[**5-29**] on day of discharge).
.
# Multiple Sclerosis: Quadriplegic. Has baclofen pump with only
minimal spasticity on exam. Continued baclofen pump, po
baclofen and diazepam prn.
.
# Stage 1 breast cancer: Patient did not pursue further
treatment after biopsy. No records regarding this in our system.
Outpatient follow up.
.
# CODE: DNR/DNI. Confirmed w/ patient.
.
# COMM: [**First Name8 (NamePattern2) **] [**Known lastname **], daughter/HCP. [**Telephone/Fax (1) 76049**]
Medications on Admission:
Baclofen 20 mg TID
Diazepam 2 mg Q4H prn
Prozac 20 mg [**Hospital1 **]
Macrodantin 100 mg Qday
miacalcin nasal spray qam
lasix 20 mg [**Hospital1 **]
albuterol Q4H prn
ibuprofen prn
MOM prn
dulcolax QOD
metamucil qpm
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Diazepam 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
4. Macrodantin 100 mg Capsule Sig: One (1) Capsule PO once a
day.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: last day [**12-28**].
6. Miacalcin 200 unit/Actuation Aerosol, Spray Sig: One (1)
Nasal once a day.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Metamucil Powder Sig: One (1) PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Respiratory failure
Multiple sclerosis
Discharge Condition:
Stable, baseline oxygenation status
Discharge Instructions:
You were admitted with respiratory failure secondary to mucuc
plugging. CAT scan did not show clots in your lung. You were
treated for a lung and urine infection with antibiotics. You are
being discharged to a rehab facility to optimize your
respiratory status before you return home.
Return the the ER if any further worsening respiratory distress
which does not respond to suctioning and oxygen, or any
worrisome symptoms.
Followup Instructions:
Follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**] [**Telephone/Fax (1) 22629**] within
the next 2-4 weeks for post hospitalization follow up.
|
[
"344.00",
"934.9",
"486",
"599.0",
"340",
"518.0",
"174.8",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12428, 12507
|
9349, 10802
|
333, 339
|
12590, 12627
|
4519, 4519
|
13101, 13325
|
3650, 3753
|
11069, 12405
|
6245, 6331
|
12528, 12569
|
10828, 11046
|
12651, 13078
|
3768, 4500
|
277, 295
|
6360, 9326
|
367, 3051
|
3073, 3426
|
3442, 3634
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,727
| 134,531
|
51959
|
Discharge summary
|
report
|
Admission Date: [**2157-2-11**] Discharge Date: [**2157-2-16**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Shortness of Breath and Chest Pain
Major Surgical or Invasive Procedure:
Hemodialysis on [**12-17**], [**2-15**]
History of Present Illness:
60 y/o M ESRD on HD, CAD, CHF, atrial arrhythmia presenting with
shortness of breath and chest pain of one day duration. Patient
missed HD today and yesterday used cocaine. Chest pain is
constant, [**7-23**] in severity, squeezing in nature and similiar to
recent episode following cocaine use. Today patient became short
of breath while lying down, improves when sitting up. Describes
cough of 1 day duration, but denies fever, chills or sputum
production. Shortness of breath similiar to prior episodes when
missing HD. Describes mild headache, no vision changes or
photophobia. Describes one episode of vomiting.
.
In the ED, initial vs were: 97.9 96 154/82 28 99%. For chest
pain patient was given ativan, fentanyl with no relief. Patient
received ASA from EMS, but refused nitro. Due to possibility of
PNA patient was given vancomycin and zosyn. Also given albuterol
for wheezing. For hyperkalemia (no peaked t waves on EKG) given
calcium gluconate, no documentation that kayexalate was given.
Patient was admitted to ICU due to concern of oxygenation status
and tachycardia.
.
Patient was recently admitted [**Date range (3) 107554**] for chest pain
following missed HD sessions and cocaine use. ECG on admission
demonstrated new TWIs in V2 and V3 and new partial RBBB,
troponin mildly elevated from baseline 0.55, however cycled
troponins flat and cards felt EKG changes due to demand. Hypoxia
was secondary to volume overload and patient improved following
three sessions of HD. Hospital course complicated by Atrial
fib/flutter (controlled on amiodarone and diltiazem).
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
sinus tenderness, rhinorrhea or congestion. 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:
- ESRD on HD T/Th/Sa at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] [**Last Name (NamePattern1) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**],
[**Telephone/Fax (1) 69669**]
- Type 2 diabetes mellitus c/b peripheral neuropathy
- CAD: on review of records, he had demand ischemia in [**9-/2155**]
with no flow-limiting stenoses on cardiac cath. MIBI in [**11/2152**]
showed reversible defects inferior/lateral. baseline troponin
0.2-0.4. Cath in [**2155**] - normal coronaries.
- Chronic systolic CHF with EF 30% ([**10/2156**] TTE)
- Atrial fibrillation/AFlutter s/p ablation [**2153**]; h/o atrial
tachycardia s/p EPS [**9-21**] and ablation x 2. not on coumadin due
to history of GIBs.
- Hypertension
- Dyslipidemia: [**9-/2155**] TC 101, LDL 54, HDL 29, TG 112
- History of GI bleeds: Duodenal, jejunal, and gastric AVMs s/p
thermal therapy; diverticulosis throughout colon
- Chronic pancreatitis
- Possible Hepatitis C infection, HCV Ab + [**10/2150**], but neg [**2154**]
- GERD
- Gout
- s/p arthroscopy with medial meniscectomy [**5-/2149**]
- Depression with multiple hospitalizations due to SI
- Polysubstance abuse: crack cocaine, EtOH, tobacco
- frequent bouts of chest pain following crack/cocaine use
- Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**]
- h/o C diff in [**2156-8-14**]
Social History:
42 pack-year smoking history, denies current smoking but per
notes he is currently smokes [**2-16**] cigarettes per day. He has a
history of alcohol abuse, with DTs and detoxification, with last
drink reportedly > 1 year ago. Pt has used crack cocaine for
years, approx 2-3x/wk. Lives with his girlfriend.
Family History:
Mother had ESRD on HD, died from MI at the age of 58. 4 Brothers
and 2 sisters, nearly all with DM2.
Physical Exam:
General: Oriented X 3. Able to speak in full sentances without
respiratory distress.
HEENT: Sclera anicteric, PERRL 3->2, MM slightly dry, oropharynx
clear.
Neck: supple, JVD elevated at least to ear.
Lungs: Bilateral ronchi 1/2 up lung.
CV: Tachycardic, normal S1 + S2, no appreciated murmurs, rubs,
gallops.
Abdomen: soft, mildly distended, bowel sounds present, no
tenderness or guarding, no organomegaly.
Ext: well perfused, 2+ pulses, no clubbing, cyanosis, 1+ bilat
LE edema. LUE with fistula vs. graft, good bruit and thrill.
Neuro: CN II-XII intact. Strength 5/5 in distal UEs and LEs.
Pertinent Results:
Labs on Admission:
[**2157-2-11**] 05:30PM BLOOD WBC-9.5# RBC-3.70* Hgb-10.3* Hct-32.6*
MCV-88 MCH-27.9 MCHC-31.6 RDW-15.3 Plt Ct-202
[**2157-2-11**] 05:30PM BLOOD Neuts-87.8* Lymphs-6.4* Monos-4.3 Eos-1.3
Baso-0.2
[**2157-2-11**] 05:30PM BLOOD PT-13.0 PTT-29.3 INR(PT)-1.1
[**2157-2-11**] 05:30PM BLOOD Glucose-140* UreaN-56* Creat-9.4*# Na-135
K-6.4* Cl-96 HCO3-21* AnGap-24*
[**2157-2-11**] 05:30PM BLOOD CK(CPK)-88
[**2157-2-11**] 05:30PM BLOOD cTropnT-0.21*
[**2157-2-12**] 04:16AM BLOOD Calcium-9.4 Phos-5.3*# Mg-2.3
-------------------
Labs on Discharge:
[**2157-2-16**] 05:30AM BLOOD WBC-4.4 RBC-3.77* Hgb-10.8* Hct-33.9*
MCV-90 MCH-28.7 MCHC-31.9 RDW-15.0 Plt Ct-277
[**2157-2-16**] 05:30AM BLOOD Glucose-63* UreaN-25* Creat-4.6* Na-137
K-4.8 Cl-92* HCO3-32 AnGap-18
[**2157-2-16**] 05:30AM BLOOD Calcium-10.9* Phos-5.4* Mg-2.1
--------------------
Cardiac enzymes:
[**2157-2-11**] 05:30PM BLOOD CK(CPK)-88
[**2157-2-12**] 04:16AM BLOOD CK(CPK)-109
[**2157-2-12**] 04:33PM BLOOD CK(CPK)-85
[**2157-2-13**] 03:13AM BLOOD CK(CPK)-71
[**2157-2-11**] 05:30PM BLOOD cTropnT-0.21*
[**2157-2-12**] 04:16AM BLOOD CK-MB-4 cTropnT-0.23*
[**2157-2-12**] 04:33PM BLOOD CK-MB-NotDone cTropnT-0.43*
[**2157-2-13**] 03:13AM BLOOD CK-MB-4 cTropnT-0.42*
-------------------
Micro:
blood culture [**2-11**]: no growth
-------------------
Studies:
.
CHEST (PORTABLE AP) Study Date of [**2157-2-11**] 5:42 PM
IMPRESSION: Bilateral airspace opacities, likely pulmonary edema
with superimposed infection involving the right lower and left
mid lungs. Unchanged right pleural effusion.
.
CHEST (PORTABLE AP) Study Date of [**2157-2-12**] 3:12 PM
Relatively symmetric perihilar infiltration has progressed in
the left lung, stabilized on the right most likely pulmonary
edema. Moderate cardiomegaly is stable, but small right pleural
effusion has decreased. No pneumothorax.
.
CHEST (PORTABLE AP) Study Date of [**2157-2-13**] 4:32 AM
Moderately severe pulmonary edema has improved and change in
distribution, now more dependent. Mild cardiac enlargement
stable. Pleural effusion, minimal if any. No pneumothorax.
Brief Hospital Course:
Assessment and Plan: 60M with ESRD on HD, CAD, DM, atrial
arrhythmia, CHF, presenting with shortness of breath and chest
pain in setting of cocaine abuse and missing hemodialysis.
.
# Chest pain: Differential includes ACS, cocaine induced chest
pain, pericarditis versus costocondiritis. Unlikely ACS as
recent cath [**2155**] no CAD (however could be cocaine induced
ischemia), no acute changes on EKG and he was ruled out with
flat cardiac enzymes. Pain is not positional and no changes on
EKG to suggest pericarditis. Pain is not reproducible to
palpation to suggest costacondritis. Most likely cocaine induced
chest pain based on recent use and prior history. Patient was
continued on statin, aspirin and ACEI. Beta-blocker was avoided
due to recent cocaine abuse. Patient's chest pain improved, but
he continued to have his chronic dull chest pain on discharge.
.
# Hypoxia: Patient was volume overloaded with pulmonary edema
and effusions in setting of not getting HD. His EF is 30% on
most recent echo in [**10-22**]. There was no evidence of pneumonia,
though patient did have productive cough. Patient was taken to
urgent HD on [**2-12**] with 4.5L removed, and another makeup HD
session on Monday [**2-14**]. Patient's respiratory symptoms resolved
on discharge.
.
# Tachycardia/Aflutter: Patient with baseline Aflutter and
atrial tachycardia, followed by Dr. [**First Name (STitle) 437**] in cardiology.
Patient required diltiazem 10 mg IV for HR 170s on admission to
MICU. Amiodarone and diltiazem were continued. Beta-blocker
was avoided because of cocaine use. Patient continued to be in
atrial tachycardia, with HR around 100.
.
# End-stage renal disease: Patient missed 2 HD sessions prior
to admission, which accounts for his volume overload and
respiratory distress on admission. He underwent HD sessions on
[**12-17**] and [**2-15**]. He also had a AV fistulogram which was
ordered as outpatient but he never showed up for appointment.
Some narrowing was noted at the fistula, so fistula revision was
performed by IR.
.
# Pain control: Patient has pain at AV fistula site during
[**Month/Day (2) 2286**], which should improve now that his AV fistula has been
revised. Dr. [**First Name (STitle) 216**] would like to give him no more than 6
tablets of percocet per week, i.e., up to 2 tablets of percocet
per [**First Name (STitle) 2286**] session. Four week supply of percocet (24 tablets)
was provided to him at the time of discharge.
.
# Hyperkalemia: Patient presented with K of 6.4, secondary to
missing 2 HD sessions. No peaked t waves on EKG, but patient
received calcium gluconate in the ED, and he underwent HD
sessions on [**12-17**] and [**2-15**]. His potassium was within normal
range during the rest of his hospital stay.
.
# Hypertension: Secondary to volume overload. After HD sessions,
patient's blood pressure improved, as well as his volume status.
Diltiazem was continued.
.
# Depression: Patient was seen by social work. Sertraline was
continued.
.
# Cocaine abuse: [**Last Name **] problem for patient. Patient was again
see by addiction service for his cocaine abuse problem. [**Name (NI) **]
was urged to stop using cocaine.
.
# Metabolic acidosis: Admission anion gap was 18, likely
secondary to renal failure from CKD. After HD sessions,
patient's anion gap resolved.
Medications on Admission:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
2. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
5. Aspirin 81 mg Tablet, One (1) Tablet, Chewable PO DAILY
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY.
7. B Complex-Vitamin C-Folic Acid 1 mg One (1) Cap PO DAILY.
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-15**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
9. Diltzac ER 240 mg Capsule One (1) Capsule, Sustained Release
PO once a day.
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO at
bedtime.
11. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for itching.
12. Insulin Sliding scale
13. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day:
14. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO once a day
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-15**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
11. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for itching.
12. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q [**Month/Day (2) 2286**] as needed for pain for 4 weeks: Patient gets
[**Month/Day (2) 2286**] every Tue/[**Last Name (un) **]/Sat, so should get 6 percocet tabs per
week .
Disp:*24 Tablet(s)* Refills:*0*
14. Insulin Glargine 100 unit/mL Cartridge Sig: Fourteen (14)
unit Subcutaneous at bedtime.
15. Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Cocaine Induced Chest Pain
End-state renal disease
.
Secondary diagnoses:
Atrial tachycardia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
chest pain and shortness of breath. It is likely that your
chest pain was caused by cocaine use and your shortness of
breath was cuased by missing hemodialysis. You were initially
admitted to the intensive care unit. Hemodialysis was performed
and more than 4 liters of fluid was removed. You had another
make-up hemodialysis session on Monday [**2157-2-14**], followed by your
regular [**Month/Day/Year 2286**] schedule of Tue/[**Doctor First Name **]/Sat. Your chest pain
significantly improved but you continue to have your chronic
chest pain. Your shortness of breath resolved. You also had an
AV-fistulogram on [**2-15**] since you missed your outpatient
appointment for this study. The AV fistula was revised because
of some narrowing.
.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
.
Please also note that you need to stop using cocaine. Please do
not miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] sessions.
.
Your medications were not changed. As Dr. [**First Name (STitle) 216**] indicated to
you, you should not take more than 6 tablets of percocet per
week for [**First Name (STitle) 2286**], i.e., up to 2 tablets per [**First Name (STitle) 2286**] session.
You're given 4 week supply of percocet.
Followup Instructions:
We attmpted to make an appointment for you to see your hand
surgeon, Dr. [**Last Name (STitle) **], but the staff in Dr.[**Name (NI) 4213**] office said someone
from the office will call you at home to let you know the date
and time of the appointment.
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP in Cardiology, Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2157-3-30**] 10:00
Please make a follow up appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"427.31",
"357.2",
"403.91",
"V45.11",
"E980.4",
"970.8",
"414.01",
"305.90",
"276.7",
"428.0",
"250.60",
"786.50",
"276.2",
"276.6",
"427.32",
"585.6",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12805, 12811
|
6851, 10181
|
303, 345
|
12967, 12967
|
4728, 4733
|
14498, 15130
|
3997, 4099
|
11288, 12782
|
12832, 12904
|
10207, 11265
|
13144, 14475
|
4114, 4709
|
12925, 12946
|
1974, 2269
|
5603, 6828
|
229, 265
|
5290, 5586
|
373, 1955
|
4747, 5271
|
12981, 13120
|
2291, 3658
|
3674, 3981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,872
| 140,301
|
35143
|
Discharge summary
|
report
|
Admission Date: [**2170-7-4**] Discharge Date: [**2170-7-8**]
Date of Birth: [**2091-4-7**] Sex: M
Service: MEDICINE
Allergies:
Phenothiazines / Heparin Agents
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
massive hemoptysis, OSH transfer
Major Surgical or Invasive Procedure:
bronchial artery embolization x 2
intubation
central line placement
arterial line placement
multiple bronchoscopies, flex and rigid
History of Present Illness:
Mr. [**Known lastname 16590**] is a 79 yo male with severe copd, who has been in
[**Hospital 16843**] Hospital for the past 12 days getting treatment with
steroids for a COPD flare after presenting with SOB and yellow
sputum production, SOB, wheezing, and chest tightness, now being
transferred for management of hemoptysis. He was started on IV
steroids (40 to 80mg during his OSH stay), nebs, and antibiotics
(vanc/zosyn initially). He was started on fondaparinux for
history of HIT. He was also diuresed. He has a very slow course
of improvement and actually worsened in terms of his dyspnea in
the past few days. His steroids were increased.
.
24 hrs prior to transfer, Mr. [**Known lastname 16590**] developed hemoptysis,
initially mild, but then more significant. He was transferred to
the ICU and intubated for bronchoscopy, which he underwent on
the morning of transfer. Significant bleeding was found from the
posterior segment of the RUL, though there was no endobronchial
lesion identified. Epinephrine and saline irrigation was not
successful successful in controlling the bleeding, however it
subsequently bleeding improved prior to transfer. His HCT was
reported as stable at 35.9 on the day of transfer and he has not
required transfusion. He is stable on PRVC TV 450, PEEP 5, FiO2
80%, RR 14. He was also placed got vancomycin for MRSA found in
a [**6-29**] sputum culture. BCx have been negative and he has been
afebrile. Before the bronch, his WBC was 18-21, afterwards it
was 31, in the setting of steroids. His CXR shows an infiltrate
on RUL.
.
.
On the floor, he is intubated. He opens eyes to voice and
responds to simple commands.
Past Medical History:
- COPD on home O2, frequent exacerbations/intubations
early [**2170**] PFTs: FEV1 37%. severely reduced DLCO of 18% of
predicted.
- cor pulmonale with peripheral edema
- muliptle admission sin the past year with COPD exacerbations
- CHF: dCHF vs cor pulmonale
- pulm HTN
- hiatal hernia
- ventral hernia
- prostate CA
- cholelithiasis
- pancreatitis
Social History:
married, lives with his wife. has 2 sons. history of heavy etoh
and tobacco use, none currently - quit tobacco 10 yrs ago. he
was a professional boxer and owns his own painting business
Family History:
NC, no history of lung disease
Physical Exam:
Vitals: T: 97.6 BP: 90/53 P: 123 R: 26 O2: 95% on 80% FiO2
General: intubated, sedated. opens eyes to voice and squeezes
hands and wiggles toes to command
HEENT: Sclera anicteric, MMM, oropharynx clear. pupils pinpoint
and minimally reactive
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse expiratory rhonchi, no wheezes, rales
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: [**3-7**]+ LE edema. warm, well perfused, 2+ pulses, no clubbing,
cyanosis
Pertinent Results:
[**2170-7-4**] 10:46PM BLOOD WBC-38.6* RBC-4.27* Hgb-12.9* Hct-38.8*
MCV-91 MCH-30.2 MCHC-33.1 RDW-17.7* Plt Ct-232
[**2170-7-5**] 08:26AM BLOOD WBC-41.0* RBC-3.64* Hgb-11.0* Hct-33.0*
MCV-91 MCH-30.2 MCHC-33.3 RDW-17.8* Plt Ct-184
[**2170-7-5**] 02:25PM BLOOD Hct-29.7*
[**2170-7-5**] 09:31PM BLOOD Hct-26.4*
[**2170-7-6**] 03:06AM BLOOD WBC-27.4* RBC-2.82* Hgb-8.7* Hct-25.6*
MCV-91 MCH-30.7 MCHC-33.9 RDW-18.2* Plt Ct-138*
[**2170-7-6**] 09:05AM BLOOD Hct-25.4*
[**2170-7-6**] 04:00PM BLOOD Hct-25.9*
[**2170-7-6**] 10:26PM BLOOD Hct-23.2*
[**2170-7-7**] 06:01AM BLOOD WBC-24.2* RBC-3.00* Hgb-9.2* Hct-27.1*
MCV-90 MCH-30.5 MCHC-33.8 RDW-18.0* Plt Ct-116*
[**2170-7-8**] 04:31AM BLOOD WBC-14.3* RBC-2.22*# Hgb-6.7*# Hct-19.7*#
MCV-89 MCH-30.3 MCHC-34.1 RDW-18.2* Plt Ct-86*
[**2170-7-8**] 05:35AM BLOOD WBC-14.6* RBC-2.20* Hgb-6.8* Hct-20.0*
MCV-91 MCH-30.8 MCHC-33.7 RDW-19.1* Plt Ct-77*
[**2170-7-8**] 10:59AM BLOOD Hct-32.0*#
[**2170-7-8**] 02:37PM BLOOD WBC-16.1* RBC-3.36*# Hgb-10.3*# Hct-29.6*
MCV-88 MCH-30.8 MCHC-35.0 RDW-18.0* Plt Ct-99*
[**2170-7-4**] 10:46PM BLOOD PT-11.7 PTT-22.7 INR(PT)-1.0
[**2170-7-8**] 04:31AM BLOOD Fibrino-400
[**2170-7-8**] 02:37PM BLOOD Fibrino-425*
[**2170-7-4**] 10:46PM BLOOD Glucose-196* UreaN-30* Creat-1.0 Na-141
K-4.6 Cl-102 HCO3-32 AnGap-12
[**2170-7-5**] 08:26AM BLOOD Glucose-155* UreaN-41* Creat-1.2 Na-142
K-4.6 Cl-106 HCO3-29 AnGap-12
[**2170-7-6**] 03:06AM BLOOD Glucose-124* UreaN-48* Creat-1.5* Na-141
K-4.2 Cl-105 HCO3-29 AnGap-11
[**2170-7-7**] 06:01AM BLOOD Glucose-154* UreaN-57* Creat-1.5* Na-138
K-4.3 Cl-104 HCO3-31 AnGap-7*
[**2170-7-8**] 04:31AM BLOOD Glucose-137* UreaN-54* Creat-1.2 Na-141
K-4.4 Cl-106 HCO3-31 AnGap-8
[**2170-7-8**] 02:37PM BLOOD Glucose-112* UreaN-51* Creat-1.1 Na-141
K-4.3 Cl-104 HCO3-31 AnGap-10
.
CHEST (PORTABLE AP) Study Date of [**2170-7-4**] 10:51 PM
Cardiomediastinal contours are unchanged. NG tube tip is 8 cm
above the
carina. There is no evidence of pneumothorax. Of note the lungs
were not
totally included in the radiograph. In the visualized portions
of the lungs
radiolucency of the left upper lobe is due to emphysema. Large
right mid lung
opacity could be hemorrhage or pneumonia. There is interstitial
bilateral
basal opacities larger on the right side.
.
ECHO
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. The right ventricular
cavity is mildly dilated The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Overall borderline normal
left ventricular systolic function. Right ventricular
hypertrophy, dilation, at least moderate pulmonary artery
systolic hypertension.
.
CT-A CHEST:
MPRESSION:
1. No evidence of pulmonary embolism to the subsegmental levels.
Small area
of outpouching of contrast, immediately adjacent to
atherosclerotic plaque is
seen in the descending aorta, most likely representing an area
of penetrating
atherosclerotic ulceration, unchanged since [**2170-6-29**].
2. Significant progression of infectious process, now with
extensive airspace
consolidation involving the entire right hemithorax with
multiple air-fluid
levels, most compatible with a component of necrotizing
pneumonia in addition
to severe emphysema.
3. Likely aspiration/hemorrhage or secretions within the right
lower lobe
bronchi with associated atelectasis.
.
CXR [**7-8**]
omparison is made with prior study performed five hours earlier.
New opacities in the left lower lobe are consistent with
aspiration. Dense
consolidations in the right mid and opacities in the right lower
lobe are
unchanged. Right IJ catheter tip is in the mid-to-lower SVC. NG
tube tip is
out of view below the diaphragm.
ET tube tips are in the carina and left main bronchus.
Brief Hospital Course:
Mr. [**Known lastname 16590**] was transferred from an OSH with massive hemoptysis
and MRSA PNA. He was intubated prior to transfer. On arrival to
[**Hospital1 18**], he was sent urgently to IR for angioembolization of his
bronchial artery. This was successful. He then went to the OR
for rigid bronchoscopy and washout of the R lung, which was
filled with blood. CT-A was negative for PE, but confirmed
necrotizing PNA, c/w his known MRSA infection. Over the next
several days, he remained intubated with extremely poor
oxygenation, requiring Fi02 of 80-100%. On the morning of [**7-8**],
he had a significant 8 point hematocrit drop with associated
hypoxia and BRB from his ET tube. A flex bronch was performed,
showing bubbling blood at the RMS bronchus, sp[illing over in to
the left lung. He was urgently switched over to a double lumen
ET tube to protect the L lung. He was rushed back to the IR
suites were repeat embolization was attempted, but no further
source could be identified. A discussion between the MICU team,
IR, IP, and thoracic surgery ensued, during which emergency
lobectomy was considered, but ultimately considered too risky. A
family meeting ensued and it was decided that the patient would
be transitioned to CMO. His family gathered at the bedside and
the ventilator was turned off, with ETT in place to prevent
hemopysis. He was kept comfortable with fentanyl and versed. He
expired peacefully within an hour of the ventilator being turned
off.
Medications on Admission:
Medications on Transfer:
wellbutrin
advair diskus 250/50 one puff q 12h
lasix 40mg qday
ISS
xopenix q 6hrs pnr
solumedrol 40mg IV q 8
nasonex
protonix 40mg IV daily
tiotropium 1 puff daily
vancomycin 1.25g IV q 12hr
lasix
.
Home Meds:
lasix 40mg qday
protonix 40mg qday
reglan
wellbutrin
potassium chloride
spiriva
advair
albuterol neb
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
necrotizing MRSA PNA, hemopysis, respiratory failure
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"416.8",
"428.0",
"V10.46",
"515",
"786.3",
"289.84",
"518.81",
"491.21",
"482.42",
"428.30",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"88.43",
"33.24",
"33.22",
"39.79",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9560, 9569
|
7670, 9145
|
321, 454
|
9665, 9674
|
3394, 7647
|
9726, 9732
|
2731, 2763
|
9532, 9537
|
9590, 9644
|
9171, 9171
|
9698, 9703
|
2778, 3375
|
249, 283
|
482, 2138
|
9196, 9509
|
2160, 2512
|
2528, 2715
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,976
| 162,866
|
38300
|
Discharge summary
|
report
|
Admission Date: [**2165-6-22**] Discharge Date: [**2165-7-1**]
Date of Birth: [**2083-3-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
CHB s/p RCA occlusion and stenting
Major Surgical or Invasive Procedure:
Pacemaker explant
Central Line placement
PICC line placement
History of Present Illness:
82yoM w/ PMH DM II, HTN, HL, [**Hospital 2091**] transferred from [**Hospital3 12748**] after admission with CHB s/p RCA occlusion and
stenting and c/b hypotension requiring IABP. He was initially
admitted on [**2165-6-20**] with weakness/dizziness and Vfib arrested in
the ED there. He required 1 shock, epinephrine, and amiodarone.
He subsequently had a temporary pacemaker placed after he was
found to have complete heart block, and he was intubated. This
was replaced with a single chamber cardiac pacemaker ([**Company 1543**]
bipolar pacing lead, Model 4092-58CM) under fluoro on [**2165-6-20**].
He was successfully extubated at 10am on [**2165-6-21**] with no
complications, and was mentating well afterwards. He continued
to have intermittent hypotension to SBP's 70's and continued to
require dopamine.
.
Febrile to 101.4 on [**6-20**]. Sputum on [**6-21**] showed 4+ GN
coccobacilli, 2+ GP cocci, 1+ GNR, 1+ GPR. Treated for
aspiration PNA with IV levaquin and flagyl. Received three doses
of ancef post-procedure.
.
This AM, patient began complaining of chest pain with a bump in
his troponin (54-->93.94). He had ECG changes, he was taken
emergently to the cath lab where his RCA was found to have 99%
stenosis. Right and left heart cath was done and showed PCWP 7,
left main normal, left circ normal, LAD with 70% proximal
lesion, RCA with 99% mid and 80% distal disease s/p placement of
two bare metal stents and post-dilation with good results. Due
to hypotension, Intraortic balloon pump was subsequently placed
and he was transferred to [**Hospital1 18**].
.
On the [**Location (un) 7622**] ride over to [**Hospital1 18**], patient had received 100mcg
of fentanyl for [**9-17**] chest/back pain. Per EMS report, this
improved his pain and he was talking/smiling/interactive. Then,
20 minutes later, he became unresponsive and had left-deviated
gaze with no tracking. He had no arrhythmia and VSS during this
time as per EMS report. After 5 minutes of unresponsiveness, he
was intubated (given another 150mcg fentanyl and also given
etomidate). On arrival to the CCU, MAPs are in mid-50's. He was
initially quite somnolent, but opened his eyes on request (in
[**Month/Year (2) 8003**]). Approximately 30 min later, he is following all
commands.
.
Review of systems could not be obtained as patient is intubated.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: Denies
3. OTHER PAST MEDICAL HISTORY:
-Osteoporosis
-CKD on on procrit, baseline Cr 1.3 in [**2164-2-9**], Cr=1.97 on
[**6-20**], Cr=1.59 on [**6-21**]
-CEA in [**2162-7-9**] with repeat imaging [**5-17**] showing plaque L w/
50% stenosis, no stenosis on R
-s/p TURP in [**2137**]
-Cataracts
-Echo [**7-/2161**] "normal", but on home lasix so unclear if CHF hx
-Stress (Cardiolite) in [**4-/2162**] "normal"
Social History:
Lives with wife, two sons and grandson. [**Name (NI) 482**] [**Name2 (NI) 8003**] only.
Previously independent with ADL's.
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: WDWN M in NAD. Intubated, following commands.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: Supple with JVP to mandible in supine position.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. Sounds of IABP heard.
LUNGS: CTAB in anterior fields, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
NEURO: PERRL, moving all four extremities, strength appears
equal when asked to squeeze hands b/l and wiggle toes b/l
ACCESS: Right cordis/R IJ. Left arterial sheath (femoral), Right
arterial sheath w/ balloon and venous sheath (femoral).
Pertinent Results:
[**2165-6-22**] 03:38PM TYPE-ART PO2-148* PCO2-23* PH-7.36 TOTAL
CO2-14* BASE XS--10
[**2165-6-22**] 03:38PM LACTATE-1.4
[**2165-6-22**] 02:37PM GLUCOSE-251* UREA N-47* CREAT-2.3* SODIUM-133
POTASSIUM-6.5* CHLORIDE-106 TOTAL CO2-16* ANION GAP-18
[**2165-6-22**] 02:37PM estGFR-Using this
[**2165-6-22**] 02:37PM ALT(SGPT)-772* AST(SGOT)-1057* CK(CPK)-946*
ALK PHOS-58 TOT BILI-1.5
[**2165-6-22**] 02:37PM CK-MB-17* MB INDX-1.8 cTropnT-7.15*
[**2165-6-22**] 02:37PM ALBUMIN-2.7* CALCIUM-6.7* PHOSPHATE-3.8
MAGNESIUM-1.6
[**2165-6-22**] 02:37PM WBC-14.1* RBC-3.24* HGB-9.4* HCT-29.0* MCV-90
MCH-29.1 MCHC-32.5 RDW-12.8
[**2165-6-22**] 02:37PM PLT COUNT-236
[**2165-6-22**] 02:37PM PT-26.7* PTT-94.8* INR(PT)-2.6*
.
Labs at discharge:
.
Abdominal ultrasound [**6-27**]:
IMPRESSION:
1. Moderately distended gallbladder containing sludge, but no
specific
findings of acute cholecystitis.
2. Right pleural effusion.
.
EKG: [**6-26**]
Sinus rhythm and marked A-V conduction delay with atrial
bigeminy. Compared to
the previous tracing of [**2165-6-26**] no diagnostic interim change.
Clinical
correlation is suggested.
.
ECHO [**6-23**]:
The left atrium is normal in cavity size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe regional left ventricular systolic dysfunction with
severe hypokinesis of the inferior septum, inferior, and
inferolateral walls. The remaining segments contract well (LVEF=
30-35%). The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Regional left and right ventricular systolic
dysfunction c/w CAD (proximal RCA distribution involving RV and
PDA territories).
Brief Hospital Course:
82yoM w/ PMH IDDM, HTN, HL presents s/p RCA occlusion and BMS x
2 c/b complete heart block, hypotension w/ intraaortic balloon
pump in place, and also w/ episode unresponsiveness during
transport today.
.
# Cardiogenic Shock: Transferred from OSH with intraaortic
balloon pump (IABP) felt likely secondary to RV infarct given
low PCWP and high right-sided pressures. Patient remained
intubated while IABP used due to concerns with position. He was
weaned off of the IABP and dopamine drip, then subsequently
successfully extubated.
.
# Hospital Acquired Pneumonia: Patient had been treated for
aspiration PNA at OSH with levo/flagyl. On admission here, he
was broadened to vanc/cefepime/flagyl for possibility of HAP.
Blood cultures grew coag negative staph in one out of four
bottles, thought to be a contaminant. Patient was transitioned
back to PO levo/flagyl for total of 8 day course, with the last
day being [**6-29**].
.
# Coronary Artery Disease: Status bare metal stent x 2 to
mid-RCA at outside hospital prior to transfer. Upon arrival, he
was continued on ASA, plavix, lipitor and integrillin gtt. Beta
blocker and ACE-inhibitor were initially held given hypotension
and use of pressors, and continue to be held because of AV nodal
block and resolving ARF. Pt was on Carvediolol and Lisinopril
prior to admission and should be restarted in the future.
.
# Cholecystitis: The patient developed intermittent right upper
quadrant abdominal pain on [**2165-6-27**] that on exam initially was
mild without [**Doctor Last Name **] sign. A RUQ ultrasound showed biliary sludge
but no stones or signs of obstruction. The following day his RUQ
became more tender, now with positive [**Doctor Last Name **] sign and worsening
leukocytosis and LFT. A HIDA scan was performed that showed
non-visualization of the gallbladder c/w acute cholecystitis.
General surgery was consulted. A percutaneous chole drain was
placed by IR on [**2165-6-30**]. He was started on Unasyn with plans for
a 7 day course, last day [**7-5**]. He will have the tube in place
for a total of 6 weeks and will then cap the tube for 48 hours.
If the patient develops a fever or the abdominal pain returns,
he should leave the tube in place and call interventional
radiology. Please see detailed care instructions on page 1. As
of discharge, his WBC is normal, no fevers or upper abdominal
pain.
.
# Acute Systolic Dysfunction EF 30%: Per OSH records, normal
echo in [**2161**], but patient on lasix as outpatient so unclear if
has history of CHF. No evidence of pulmonary edema on CXR, and
PCWP was low during cardiac cath at OSH. Patient transiently
required IABP. Bedside Echo on [**2165-6-23**] showed EF 30-35% with
moderate to severe regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior septum,
inferior, and inferolateral walls. Currently, pt does not appear
to be fluid overloaded, has minimal peripheral edema and no O2
requirement. Given his new low EF, he should have daily weights
and be assessed for signs of fluid retention. His home dose of
lasix was restarted. Long acting Metoprolol was started at
discharge, Lisinopril being held because of high K over weekend,
will need to restart soon if K stable.
.
# Complete heart block: Pt initially presented with CHB and had
a single chamber [**Company 1543**] pacer with permanent lead placed at
OSH. On admission here, EP evaluated pacemaker and noted that
there was lead dislodgement with poor sensing of R waves and
increasing thresholds. As patient's cardiac perfusion improved
following cardiac catheterization, patient's rhythm improved to
normal sinus rhythm with prolonged PR interval, which was also
seen on EKG's 2 years prior. EP removed the pacer and lead on
[**2165-6-24**].
.
# Neuro deficits: Patient had a reported episode
unresponsiveness in the setting of having received fentanyl, but
episode described appears to be very focal in nature. Patient
now with nonfocal neurological exam and interactive. Head CT
was negative for intracranial hemorrhage. Following extubation,
patient had an intact neurological status, and so EEG was
deferred.
# Elevated Coags: Unclear etiology of elevated coags as patient
not on coumadin, though it is most likely secondary to shock
liver. INR, PTT and LFT's were monitored and were downtrending
at discharge.
# Acute on Chronic Renal Failure: Baseline Cr appears to be
1.6-1.9. On admission, creatinine was 2.3, likely prerenal in
setting of MI. Patient was monitored closely, given IV fluids
as needed. Creatinine improved to 1.3.
.
# Non gap metabolic acidosis: Initially presented with an anion
gap of 11, likely compensating for acidosis. Was losing bicarb
possibly due to renal failure. ABGs were followed and lactated
ringers used for IV fluids with closing of his anion gap.
# DM II: Normally on Arcabose and Glipizide at home with lantus
25 units. Arcabose and Glipizide were held here and lantus was
decreased to 12 units as pt was NPO with Humalog Sliding scale.
Now increasing lantus as pt starts to eat. Will need to restart
oral meds at some point and increase Lantus to maintain Bs< 150.
Continue Humalog sliding scale before meals.
# Hyperlipidemia: Intially maintained on atorvastatin 40mg daily
given his elevated LFTs, however was increased to 80mg daily
following improvement of his liver functions.
.
# Hypertension: Anti-hypertensives were initially held given
hypotension, and have continued to be held because of renal
status. His Lisinopril was held 2 days ago because of increasing
K, now normalized. Pt will need to have Lisinopril restarted
soon if potassium is stable.
# Anemia: Baseline Hct 30. On Epogen for CKD as outpt. Was
noted to have gradually downtrending hematocrit for which he
received 1 unit of pRBCs with appropriate response from 23.8 to
28.3.
Medications on Admission:
-Vicodin 5-500 PRN
-Acarbose 50mg TID prior to meals
-Lisinopril 5mg daily
-Lipitor 40mg daily
-Lasix 40mg daily
-Carvedilol 25mg [**Hospital1 **]
-Lantus 25mg SQ daily
-Folic Acid 1mg daily
-Glipizide 5mg [**Hospital1 **]
-Epogen
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take every day for one month.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation: Hold for diarrhea.
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
10. 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.
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for low
calcium.
12. Ampicillin-Sulbactam 3 gram Recon Soln Sig: One (1) Recon
Soln Injection Q6H (every 6 hours): last day [**7-5**].
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO three times
a day as needed for pain.
14. Oxycodone 5 mg Capsule Sig: [**2-9**] Capsules PO four times a day
as needed for pain.
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Hold
SBP < 100, HR < 55.
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Lab Work
Please check CBC and Chem 7 on Thursday [**7-4**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Complete Heart Block
Acute on Chronic Kidney Disease
Acute Systolic dysfunction: EF 35%
Hypertention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for the opportunity to participate in your care. You
had a large heart attack which affected the electrical system of
your heart. You had a cardiac catheterization at [**Hospital 5987**]
[**Hospital3 **] and two bare metal stents were placed in your
right coronary artery. You will need to take Plavix and aspirin
every day for at least one month, do not stop taking Plavix and
aspirin unless Dr. [**Last Name (STitle) 61478**] tells you to. You also had a
pneumonia and finished a course of antibiotics on [**6-29**] to treat
this. A pacemaker was placed at [**First Name4 (NamePattern1) 5987**] [**Last Name (NamePattern1) **] but we did not
feel you needed this long term and took it out. We think your
heart rhythm is now the same as it was before the heart attack.
You had some abdominal pain that was due to some blockages in
your gallbladder. You have a tube that is draining bile and
should stay in for 6 weeks. You will need to cap off the tube
after 6 weeks and see if you develop a fever or if the pain
comes back. Please call [**Telephone/Fax (1) 85346**] if you have any questions
about the tube.
You will be on antibiotics for one week to treat the infection.
Your kidney function worsened during your illness but is
improving slowly.
You twisted your right ankle transferring to the bed. There is
no evidence of a fracture. Please use an ACE bandage and pain
medicine as needed.
.
Medication changes:
1. Discontinue Lisinopril, your potassium level was too high.
This medicine should be restarted at a later date.
2. Start Aspirin and Plavix. It is extremely important that you
take these medications every day to prevent the stents from
clotting off and giving you another heart attack. Do not stop
taking this medicine unless Dr. [**Last Name (STitle) 61478**] tells you to.
3. Increase Lipitor to 80 mg
4. Start Colace, senna and Miralax to treat your constipation
5. Start heparin injections to prevent blood clots while you are
at rehabilitation
6. Change Vicodin to tylenol every 8 hours and oxycodone as
needed for your back and abdominal pain
7. Discontinue Arcabose and Glipizide. These should be restarted
before you go home
8. Continue taking Epogen as per Dr. [**First Name (STitle) **].
9. Start Ampicillin-Sulbactam, an antibiotic for total of 7
days.
10. Start Metoprolol to lower your heart rate, this takes the
place of the Carvedilol.
11. Start Calcium to treat low calcium levels
12. Decrease lantus to 16 units. This will probably be increased
as you start to eat more food.
.
Your heart is weak after the heart attack. You will need to
weigh yourself every day and call Dr. [**First Name (STitle) **] if you notice
that your weight increases more than 3 pounds in 1 day or 6
pounds in 3 days.
Watch for increasing swelling in your legs and trouble
breathing, call Dr. [**First Name (STitle) **] if you notice this too.
Followup Instructions:
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
[**First Name8 (NamePattern2) **]
[**Hospital1 487**], [**Numeric Identifier 85347**]
Phone: ([**Telephone/Fax (1) 71045**] Ext.6829
Please make an appt after you get out of rehab to see her.
.
Cardiology:
[**Doctor Last Name 4922**], [**Name8 (MD) **] MD
Location: ASSOCIATES IN CARDIOVASCULAR MEDICINE
Address: [**Location (un) 85348**], [**Location **],[**Numeric Identifier 21918**]
Phone: [**Telephone/Fax (1) 84020**]
Fax: [**Telephone/Fax (1) 85349**]
Date/time: Friday [**7-26**] at 1:15pm
.
Interventional Radiology:
Phone: [**Telephone/Fax (1) 85346**] Please call if you have any questions about
the tube.
Surgery:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 2723**] Date/Time: Please call to
make an appt in 6 months unless you hear from the office.
|
[
"426.0",
"790.7",
"276.7",
"410.71",
"285.21",
"V45.01",
"403.90",
"575.0",
"E878.1",
"410.41",
"250.00",
"275.41",
"287.5",
"486",
"570",
"414.01",
"584.9",
"996.01",
"V45.82",
"272.4",
"585.9",
"733.00",
"V12.53",
"276.2",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.07",
"38.93",
"38.91",
"37.77",
"51.01",
"37.89"
] |
icd9pcs
|
[
[
[]
]
] |
14196, 14284
|
6451, 12281
|
349, 412
|
14464, 14464
|
4417, 5150
|
17504, 18409
|
3509, 3624
|
12563, 14173
|
14305, 14443
|
12307, 12540
|
14615, 16021
|
3639, 4398
|
2880, 2887
|
16041, 17481
|
275, 311
|
5170, 6428
|
440, 2772
|
14479, 14591
|
2918, 3290
|
2794, 2860
|
3306, 3493
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,590
| 166,945
|
54385
|
Discharge summary
|
report
|
Admission Date: [**2124-9-8**] Discharge Date: [**2124-9-15**]
Date of Birth: [**2055-7-14**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
nausea, vertigo, ataxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 69 year-old man with history of severe
peripheral
vascular disease who was transferred to our ED after he
experienced several symptoms last night and this morning and an
OSH head CT revealed a hyperintense lesion in his right
dorsolateral medulla/inferior cerebellar peduncle. He was in his
USOH yesterday afternoon, and
remembers sitting in his recliner [**Location (un) 1131**] a paper in his den.
During that time, he began to feel "dizzy" (denies spinning,
endorses lightheaded). It was not sudden-onset, and not
accompanied by any other symptoms he can recall (denies
headache,
nausea, weakness, vision/hearing change). He stood up and walked
to his living room to lie on the rug, which he often does when
he
gets a headache or feels unwell. He remembers getting a "sour
stomach" at this time, and didn't have an appetite for dinner
when called by his wife. His wife supplied an antacid and ice
packs for his head. He was feeling better after an hour or two
in
this position, after which he walked to the kitchen and ate some
toast and drank a small amount of milk without any difficulty.
He
remained asymptomatic for another 45min or so, watched TV, and
went to bed. He remembers feeling a bit unsteady changing his
clothes for bed, but shaved and showered and dried off without
any difficulty, and then slept well for several hours.
Around midnight, he awoke to urinate. When he arose to walk to
the bathroom, he recalls walking "like a drunk," stumbling into
walls and furniture. He did not fall. He endorses a spinning
dizzy sensation in addition to recurrence of lightheadedness at
that time, but denies headache, speech change, weakness, sensory
change, and vision/hearing change. He returned to bed and slept
well til around 4am. He awoke then, feeling nauseous, stumbled
again to the bathroom, and vomited a small amount, after which
he
felt better. He stumbled back to the bed, and, felt normal lying
down, and went back to sleep. Around 06:30am, he awoke (usual
time), feeling fine in bed, but became nauseous when he sat up.
He stumbled back to the bathroom, where he vomited, urinated,
brushed his teeth. At that time, he noticed a mild headache,
which was diffuse (holocephalic, perhaps worse in front), achy,
non-positional, and not sudden in onset. His nausea and a
spinning sensation returned. He was still walking "like a
drunk,"
and had difficulty dressing and walking downstairs. He decided
with his wife to go to the [**Name (NI) **].
He was evaluated at the [**Hospital3 8834**] ED. There, a
NCHCT (now uploaded in our PACS) revealed what was reported to
me
verbally as a "PICA aneurysm." On my review of the images, it
looks like a round, moderately hyperintense mass (just under a
centimeter in diameter) in or immediately atop the dorsolateral
aspect of the mid-to-caudal medulla (near or at the caudal end
of
the inf cb peduncle, perhaps overlying the vestibular and
rostral
dorsal-column nuclei and extending medially to or near the
rostral DMV/NTS/AP complex). He denies any history of cerebral
infarction, aneurysm, tumor, or vascular malformation. He has
never had any symptoms like this before.
He was transferred to our ED at [**Hospital1 18**], where his sBP on arrival
was 210/100. First dose of IV labetalol 10mg reduced this to
194,
and he came down to 166 following a second dose of 10mg IV
labetalol. Neurosurgery was called to evaluated, and recommended
MRI/MRA with contrast (ED had planned to get CTA, which was
cancelled). Nsgy also requested Neurology evaluation, so we were
called to consult.
Review of Systems: negative except as above -- On neuro ROS, the
pt denies current headache. Never any change in vision. Endorses
diplopia (but says that it is old, x20 years -- when I point out
that he is squinting his left eye, his wife says this is new).
Denies dysphagia, tinnitus and hearing difficulty. Denies
difficulties producing or comprehending speech. He acknowledges
that his voice sounds a bit slurred, but he insists that it is
only because of dry throat. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention. On
general review of systems, the pt denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies diarrhea, constipation or abdominal pain
(just "sour stomach" y/d and earlier this morning). No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias
or myalgias. Denies rash.
Past Medical History:
1. CAD, cerebrovascular and peripheral vascular disease:
- bilateral carotid endarterectomies circa [**2102**] (Left was
revised
once, due to "scarring") due to "90% blockage." Denies h/o
stroke. Says may have had TIA once before the CEAs (episode of
vertigo at a barbershop).
- CABG (five-vessel) in [**2102**] at [**Hospital1 18**]
- Renal artery stent (which improved his BP and allowed him to
stop two anti-HTN agents)
- bilateral femoral artery stents for PAD
2. "retinal tear causing chronic double-vision especially when
looking left" per pt. (per wife, his double-vision seems worse
since yesterday).
3. Diabetes on MTF/Januvia
4. Hypertension on HCTZ/BB (says A1c was 6.5% [**2124-1-23**])
5. Anxiety on BDZ
6. Gout on allopurinol
7. Hyperlipidemia on statin (says TC was 114 recently)
>>Denies h/o stroke/MI, denies any neurologic disease history
besides carotid atherosclerotic disease
Social History:
Lives at home with wife, independent in
ADLs/iADLs, normally walks without assistance. Supportive family
(three adult children and wife) present on exam. Family contacts
-- daughter cell [**Telephone/Fax (1) 111330**]; son cell [**Telephone/Fax (1) 111331**], wife cell
[**Telephone/Fax (1) 111332**]. Smoked in remote past, but quit many years ago.
Denies EtOH/illicits.
Family History:
NC at this time. No remarkable
aneurysmal/cerebrovascular Hx.
Physical Exam:
Vital signs in ED:
Time Pain Temp HR BP RR Pox
Triage 10:22 0 97.6 73 210/67 18 99%
Today 10:33 0 61 157/73 12 100%
Today 11:50 70 [**Telephone/Fax (2) 111333**]%
Today 13:06 0 61 194/87 16 100%
Today 13:08 70 166/81 18 100%
Today 13:50 0 64 172/62 16 100%
Today 14:41 69 186/85 18 90%
Today 15:11 0 77 180/100 16 98%
General: Awake, talkative, cooperative, in NAD. Says he has no
current headache or dizziness, and only mild lightheadedness
currently.
HEENT: Bilater carotid bruits (prominent on R / faint on L). No
bruits appreciated elsewhere (e.g. over orbits/temples).
Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are dry. No lesions noted in oropharynx.
Neck: Supple, with full range of motion and no nuchal rigidity.
No carotid bruits. No lymphadenopathy.
Chest: midline sternotomy scar.
Pulmonary: Lungs CTA bilaterally with reduced BS at bases.
Non-labored.
Cardiac: Distant, sharp HS, RRR, no loud M/R/G appreciated.
Abdomen: Soft, non-obese, non-tender, and non-distended, +
normoactive bowel sounds.
Extremities: Warm and well-perfused. Slightly pale. No clubbing,
cyanosis, or edema. 2+ radial, 1+ DP pulses bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Oriented to person, year, month, date, day of week, season,
city,
location, reason for treatment. Able to relate history without
difficulty. Attentive. Speech was mildly dysarthric (pt denies,
says it is dry throat). Language is fluent with intact
repetition
and comprehension, normal prosody, and normal affect. There were
no paraphasic errors. Able to read and write without difficulty.
Naming is intact. Able to follow both midline and appendicular
commands quickly and reliably. There was no evidence of apraxia
or neglect or ideomotor apraxia or left-right confusion.
-Cranial Nerves:
II: PERRL, 3.5 to 2.5mm, brisk. Visual fields are FTC in each
eye. Disc margins are sharp and vessels/fundui appear normal.
III, IV, VI: EOMs are abnromal with variable nystagmus. There is
occasional subtle nystagmus at rest, and the lower eyelids
twitch
a bit (more prominent on the Left). Cannot ABduct the left eye
full (can on the right). No INO. There is mixed
rotatory/vertical
nystagmus (vertical most prominent looking up and right;
rotatory
most prominent looking right and up/right). Saccades are not
grossly abnormal. Patient says he sees double in all directions
except possibly to the right and up. IT is primarily
side-by-side, goes away when covering the left eye (or right),
and the separation increases with increasing left-[**Hospital1 **] gaze
angle.
V: Facial sensation intact and subjectively symmetric to light
touch and cold metal V1-V2-V3.
VII: No ptosis, no flattening of either nasolabial fold, but
very
subtle assymetry of [**Location (un) 67019**] border (down towards right).
Normal, symmetric facial elevation with smile. Brow elevation is
symmetric. Eye closure is strong and symmetric. Cheek-puff full
bilaterally.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevation IS symmetric with phonation. Mallampati
I-II airway.
[**Doctor First Name 81**]: [**5-27**] equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline and strength full to both
sides.
-Motor:
No drift. No asterixis. Normal muscle bulk. Slightly paratonic
in
both legs. Mild rest/intention tremor in RUE, which pt holds
flexed 90deg up in the air frequently for no apparent reason.
Full strength throughout:
Delt Bic Tri WE FF FE IO | IP Q Ham TA [**Last Name (un) 938**] Gastroc
L 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
-Sensory:
No deficits to light touch, cold sensation, or vibratory
sensation in any extremity. Joint position sense is normal in
both upper (5th digits) and lower extremities (great toes).
Eyes-closed Finger-to-[**Last Name (un) **] testing revealed no proprioceptive
deficit (did not miss [**Last Name (Titles) **]), despite gross RUE ataxia.
-Reflexes (left; right):
Biceps (++;++)
Triceps (+;+)
Brachioradialis (++;++)
Quadriceps / patellar (++;++)
Gastroc-soleus / achilles (0;0), no clonus
Plantar response was Flexor (down-going) bilaterally.
-Coordination:
Right UE grossly ataxic on FNF (dysmetric and consistently
misses) and mirroring (overshoot). Left UE with very mild
end-reach tremor on FNF, but not clearly ataxic and mirroring is
normal. No dysdiadochokinesia noted on rapid-alternating
movements. FFM essentially normal bilaterally. HKS not ataxic on
either side.
-Gait:
Stands slowly, but without difficulty. Wide base, very unsteady
(ataxic gait), becomes rapidly nauseous and vomits x1. Back in
bed, HR stable in 80s, BP stable in 160s.
Pertinent Results:
[**2124-9-9**] 02:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2124-9-9**] 02:52AM BLOOD Triglyc-40 HDL-56 CHOL/HD-1.9 LDLcalc-45
[**2124-9-9**] 02:52AM BLOOD %HbA1c-6.3* eAG-134*
[**2124-9-9**] 02:52AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.5 Mg-1.8
Cholest-109
[**2124-9-10**] 05:35AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
[**2124-9-15**] 04:20AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1
[**2124-9-9**] 02:52AM BLOOD CK-MB-2 cTropnT-<0.01
[**2124-9-9**] 02:52AM BLOOD ALT-15 AST-17 CK(CPK)-84 AlkPhos-55
TotBili-0.3
[**2124-9-9**] 02:52AM BLOOD Glucose-141* UreaN-18 Creat-1.1 Na-138
K-3.4 Cl-99 HCO3-33* AnGap-9
[**2124-9-10**] 05:35AM BLOOD Glucose-161* UreaN-22* Creat-1.0 Na-138
K-3.0* Cl-100 HCO3-25 AnGap-16
[**2124-9-12**] 04:45PM BLOOD Glucose-230* UreaN-17 Creat-0.8 Na-134
K-3.5 Cl-96 HCO3-28 AnGap-14
[**2124-9-15**] 04:20AM BLOOD Glucose-133* UreaN-24* Creat-1.0 Na-141
K-3.5 Cl-102 HCO3-28 AnGap-15
[**2124-9-14**] 04:30AM BLOOD Glucose-141* UreaN-21* Creat-0.9 Na-139
K-3.9 Cl-104 HCO3-28 AnGap-11
[**2124-9-13**] 11:35PM BLOOD Glucose-141* UreaN-22* Creat-0.9 Na-137
K-3.8 Cl-101 HCO3-29 AnGap-11
[**2124-9-8**] 06:25PM BLOOD PT-12.3 PTT-25.6 INR(PT)-1.1
[**2124-9-9**] 02:52AM BLOOD PT-11.6 PTT-25.4 INR(PT)-1.1
[**2124-9-9**] 02:52AM BLOOD Plt Ct-171
[**2124-9-11**] 05:30AM BLOOD Plt Ct-145*
[**2124-9-9**] 02:52AM BLOOD Neuts-81.4* Lymphs-13.3* Monos-5.1
Eos-0.1 Baso-0.1
[**2124-9-13**] 04:25AM BLOOD Neuts-70.1* Lymphs-21.8 Monos-7.0 Eos-0.8
Baso-0.2
[**2124-9-15**] 04:20AM BLOOD Neuts-68.7 Lymphs-24.4 Monos-5.2 Eos-1.5
Baso-0.1
[**2124-9-9**] 02:52AM BLOOD WBC-9.5 RBC-4.17* Hgb-12.6* Hct-37.2*
MCV-89 MCH-30.3 MCHC-34.0 RDW-14.4 Plt Ct-171
[**2124-9-10**] 05:35AM BLOOD WBC-9.9 RBC-4.24* Hgb-12.7* Hct-38.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-14.6 Plt Ct-162
[**2124-9-9**] 02:53AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-70 Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2124-9-9**] 02:53AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2124-9-9**] 02:53AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
************
MRI, MRA of kidney:
1. Left main renal artery stent. No flow-limiting renovascular
stenosis or
Preliminary Reportthrombosis.
Preliminary Report2. Severe atherosclerosis at the aortoiliac
bifurcation, with distal
Preliminary Reportreconstitution.
Preliminary Report3. Prominent adrenals, without discrete
nodules.
Kidney US:
1. No evidence of renal size discrepancy. Bilateral kidneys
demonstrate
normal size.
2. Mild, bilateral increased resistive indices in the
interlobar arteries,
may reflect intrinsic kidney disease. The right main renal
artery peak
systolic velocity is 130 cm/s in comparison to left main renal
artery,
measuring 69 cm/s. This is a small discrepancy and may be
related to technical
difficulties. If clinical concern remains, CT or MR angiogram
would be
beneficiary as tests of choice.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 69 year old man multiple vascular risk factors
came in with vertigo, nausea and vomiting and found to have a
posterior lateral medullary/inferior cerebellar peduncle
hemorrhage on the right. The etiology is cavernoma versus
HTN-related hemorrhage. An underlying lesion is unlikely, but
can't be completely ruled out. The plan is for an MRI in about 6
months. While here he was determined to need rehab given his
severe functional impairment secondary to vertigo. His ASA was
initially stopped and restarted 2 days ago along with heparin
SQ. He developed severe refractory hypertension with hypokalemia
(we began investigation for hyperaldosteronism). We had tried
hydralazine, captopril, and finally started to react to the
clonidine. He requires active titration of the medication to be
normotensive. His hypokalemia has been stable with about 20 meq
of potassium given per day (HCTZ). We sent off serum renin and
aldosterone which are still pending. Renal MRA/US did not show
significant stenosis of the renal arteries nor clear adrenal
mass. He will have follow up with nephrology.
Medications on Admission:
1. atenolol 50mg qAM
2. hydrochlorothiazide 25mg qAM
3. simvastatin 40mg QHS
4. aspirin 325mg qAM
5. alprazolam 0.25mg qAM
6. metformin 500mg QID
7. Januvia
8. multivitamin
Discharge Medications:
1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety (home med)
hold for sedation or RR<12 or SaO2<96%
2. Amlodipine 10 mg PO DAILY
HOLD for SBP<100
3. Aspirin 81 mg PO DAILY
4. Clonazepam 0.75 mg PO TID:PRN nausea, vertigo
5. CloniDINE 0.1 mg PO TID
hold for SBP less than 120
6. Docusate Sodium 100 mg PO BID inpatient bowel regimen
7. Heparin 5000 UNIT SC TID
8. Labetalol 100 mg PO TID
hold for SBP<120
9. Lisinopril 40 mg PO DAILY
HOLD for SBP<100
10. Multivitamins 1 TAB PO DAILY home med
11. Omeprazole 20 mg PO DAILY
12. MetFORMIN (Glucophage) 500 mg PO QID
13. Januvia *NF* (sitaGLIPtin) 00 Oral as before
as you take prior to admission
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
1.Right Medulla Hemorrhage
2.Hypertension
3. Hyperlipidemia
4. Diabetes
5.Left renal stenosis s/p stent
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: Awake, alert and oriented x3, mild facial droop on
the right side. No focal deficit in motor or sensory. Dysmetria
in right hand. Tilting to right when sits.
Discharge Instructions:
Dear Mr [**Known lastname **] .
You were admitted to hospital as your symptoms were concerning
for stroke. In performed tests we found that you have bleeding
in your brain stem which caused you vertigo, imbalance and
worsened your double vision. During your hospital stay you
developes high blood pressure , we performed multiple tests to
make sure that your kidney stent is working well and you have no
abnormality in your adrenal , as some time adrenal problem can
cause high blood pressure. All test results so far came back
normal so you do not have any adrenall mass and your stent is
working well . We change your Blood pressure medication :
1. Add labetalol 100 mg every 8 hours.
2. Add clonidine 0.1 mg every 8 hours.
3. Add lisinopril 40 mg daily.
4.
We stopped HCTZ as you developed low potassium level and this
medication can worsen that.We also stopped atenolol.
You were evaluated by physical therapy service and they
recommended inpatient rehabilitation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2124-11-2**] 9:00
Please call ([**Telephone/Fax (1) 22692**] to schedule an appointment with Dr
[**Last Name (STitle) 1693**] in 2 months.
As you need MRI in [**2124-12-27**], to get information about exact
day of your MRI please call [**Telephone/Fax (1) 91972**] at least 1 week before
[**2124-12-27**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2124-9-15**]
|
[
"440.1",
"272.4",
"250.00",
"V15.82",
"V10.46",
"275.3",
"V45.81",
"781.3",
"276.8",
"274.9",
"368.2",
"401.9",
"431",
"780.4",
"300.00",
"414.00",
"443.9",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16309, 16381
|
14279, 15415
|
329, 336
|
16529, 16529
|
11243, 14256
|
17868, 18435
|
6261, 6325
|
15647, 16286
|
16402, 16508
|
15441, 15624
|
16875, 17845
|
8296, 11224
|
6340, 7665
|
3978, 4927
|
265, 291
|
364, 3959
|
16544, 16851
|
7690, 7690
|
4949, 5855
|
5871, 6245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,875
| 151,329
|
35791
|
Discharge summary
|
report
|
Admission Date: [**2119-4-20**] Discharge Date: [**2119-5-10**]
Date of Birth: [**2058-9-11**] Sex: M
Service: SURGERY
Allergies:
Iodine-Iodine Containing / Wasp Venom / Heparin Agents / Ativan
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Abdominal colectomy w/ ileostomy/hartmann's
History of Present Illness:
60-y.o. male with metastatic pancreatic cancer and laryngeal
cancer p/w abdominal pain. Please refer to oncology progress
notes for full oncologic history. In short, he initially
developed chronic low abdominal pain with intermittent nausea
and
vomiting in [**2116**]. Symptoms did not improve, and CT abdomen
showed pancreatic mass. EUS with FNA showed pancreatic
adenocarcinoma. CT abdomen with pancreatic protocol showed
tumor
invasion of the portal vein and SMV. He was treated with chemo-
and radiotherapy with stable disease until 3/[**2118**]. A cecal mass
was identified, and he underwent diagnostic laparoscopy on
[**7-/2118**]
with biopsy showing metastatic peritoneal implants and spread to
the falciform ligament. Last chemotherapy was 10 days ago.
He presented to [**Hospital3 **] Hospital with acute onset dull LUQ
abdominal pain this afternoon, no exacerbating or ameliorating
factors, no identifiable triggers, without radiation. Pain has
been intermittent. Denies fever, chills, nausea, vomiting,
diarrhea, and constipation
Past Medical History:
PAST MEDICAL HISTORY:
1. Pancreatic cancer complicated by metastatic recurrence
mainly
in the perineum and anterior abdominal wall.
2. Locally advanced vocal cord carcinoma status post
cisplatin-based definitive chemoradiation.
Social History:
SOCIAL HISTORY: His son is going to turn 21 pretty soon. His
daughter is contemplating a college education in [**State **].
His supportive wife [**Name (NI) **] was by his side and they all live in
[**Hospital3 15516**] ([**Location (un) **]).
Family History:
FAMILY HISTORY: Sister had breast cancer at age 52. Father had
skin cancer and died in his 60s.
Brief Hospital Course:
He was admitted to the ACS service and taken to the operating
room for abdominal colectomy with ileostomy and Hartmann
closure. There were no complications; postoperatively he was
transferred to the ICU intubated/sedated and requiring multiple
vasopressors to support an adequate pressure. This was continued
and the patient was also resuscitated with scheduled albumin,
with a vigileo monitor in place to follow his cardiac output and
fluid status. Tube feeding via nasogastric tube were initiated
early. Additionally, by POD 3 the patient was having notable
mental status changes; was not responding appropriately to
commands and was consistently pulling at tubes and lines.
Because of concern for benzo or alcohol withdrawal he was
started on antipsychotic, as well as Ativan per CIWA protocol.
Additionally he was started on Precedex at night for his severe
agitation. By POD 4 the patient was no longer requiring
pressors, but because of a consistently altered mental status, a
CT scan of his head was obtained which demonstrated no acute
pathology. On [**4-26**], a repeat echo was taken and showed no
concerning findings. On [**4-28**] a HIT panel was sent because of
dropping platelets and this was positive; Hematology was
consulted and he was started on lepirudin. By [**4-30**] his
agitation and altered mental status had resolved, he was
hemodynamically stable and was transferred to the regular
nursing unit.
Once transferred to the floor he progressed slowly. His tube
feedings were continued despite patient removing the Dobbhoff on
[**1-15**] occasions. As his mental status continued to improve he was
trialed on an oral diet only after consultation form
Speech/Swallow an oropharyngeal video swallow which showed no
evidence of gross aspiration. Patient was considered to still be
at high risk for aspiration and was initially recommended for
honey-thick liquids and soft solids. He was re-evaluated and
upgraded to a regular diet. because his intake was did not
provide adequate calories the decision was made with patient and
his family to initiate TPN; he may still continue with an oral
diet. A PICC was placed on [**5-6**] and TPN started.
During his stay he required intermittent transfusions with
PRBC's for falling hematocrits; his HCT's have ranged between
21-25.9. He was transfused most recently on [**5-6**] when his HCT
was 21 (post transfusion 24->22.2).
He has been intermittently noted with increased ostomy output
requiring replacement cc/cc with IV fluids. His output has
averaged approximately 2 liters/24 hour period.
His abdominal wound has been noted with increased leakage,
several sutures were placed to control the leakage.
Palliative care became involved during his stay for assistance
with end of life issues and discharge planning. After several
family meetings the decision was made that he would benefit from
rehab short term. Discussion regarding hospice after discharge
from rehab was also initiated. Case manangement intiatedth
escreening process and he was discharged to rehab after a
lengthy hosptial course.
Medications on Admission:
Citalopram 20 mg daily, dronabinol 2.5 mg daily, lorazepam 2 mg
Q6H PRN nausea or insomnia, ondansetron 4-8 mg PRN nausea,
prochlorperazine 5-10 mg Q6H PRN nausea, tamsulosin 0.4 mg
daily.
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale.
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q4H (every 4 hours) as
needed for wheezing.
4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
5. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for heartburn.
6. fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 MG Subcutaneous
DAILY (Daily).
7. Medication
Sodium Citrate 4% soultion - 5 ML flush to DWELL AND PRN flush
*(patient has heparin allergy, but heparin dependent port)
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
10. Ondansetron 4 mg IV Q8H:PRN nausea
11. TPN
See Attached TPN recommedations:
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 23638**]
Discharge Diagnosis:
Bowel perforation
Acute blood loss anemia
Malnutrition
Secondary diagnosis:
Metastatic pancreatic cancer with peritoneal metastases,
laryngeal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with a perforation in your intestine that
required an operation to repair. During the operation an
ileosotmy was created and you have a bag that collects your
stool output. Because of your extensive surgery your nutritional
status has been compromised and you are now receiving nutrition
through a centrally placed intravenous catheter - this special
nutrition is called TPN. You are allowed to eat foods for
comfort at your discretion; in the meantime you are receiving
adequate calories through the TPN.
Followup Instructions:
Follow up in Acute Care Surgery clinic in [**1-15**] weeks, call
[**Telephone/Fax (1) 600**] for an appointment.
You have appointments with the following providers that wwere
scheduled prior to your hospital stay:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2119-5-22**] 3:30
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2119-5-22**] 4:00
Provider: [**Name10 (NameIs) 706**] CARE,THREE [**Name10 (NameIs) 706**] CARE UNIT
Phone:[**Telephone/Fax (1) 446**] Date/Time:[**2119-6-21**] 7:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2119-5-10**]
|
[
"V10.21",
"560.89",
"287.5",
"780.09",
"V49.87",
"995.92",
"038.9",
"197.6",
"569.83",
"E849.7",
"567.9",
"785.52",
"V49.86",
"157.9",
"E878.3",
"787.01",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.93",
"96.6",
"45.79",
"96.71",
"38.91",
"46.20"
] |
icd9pcs
|
[
[
[]
]
] |
6527, 6616
|
2120, 5191
|
337, 382
|
6810, 6810
|
7512, 8312
|
2014, 2096
|
5431, 6504
|
6637, 6693
|
5217, 5408
|
6960, 7489
|
283, 299
|
410, 1463
|
6714, 6789
|
6825, 6936
|
1507, 1717
|
1750, 1981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,376
| 135,573
|
1081
|
Discharge summary
|
report
|
Admission Date: [**2185-3-5**] Discharge Date: [**2185-3-9**]
Date of Birth: [**2140-5-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
ST elevation Myocardial infarction
Major Surgical or Invasive Procedure:
Cardiac catheterization with Cypher stent placed in the right
coronary artery
History of Present Illness:
Patient is a 44 yo man with PMH of borderline hypertension,
borderline hypercholesterolemia, presented to ED with 7/10
substernal chest pain. Patient states that his chest pain began
suddenly at work, started with noted diaphoresis, then felt
sub-sternal chest "burning". Initially thought it might be
gastric reflux, so he took some maalox which did not relieve the
pain. The chest pain worsened and therefore patient called 911
and was brought to [**Hospital1 18**]. He otherwise denied radiation of the
pain to jaw or arm, denied N/V, SOB, any other complaints.
Denies having had this pain before.
In ED, patient was afebrile, HR 86, BP 168/70, O2 sat 100% on
2L. EKG was performed that demonstrated ST elevation with
tombstoning in leads II, III, aVF with recipricol ST depression
in leads I, aVL, V1-V5. A right sided EKG was performed that
demonstrated ST elevation with tombstoning in leads rV3-rV6.
Patient was given NS fluid bolus x 2, 4 baby aspirin, morphine,
lopressor 5mg IV x 1, and started on integrillin and heparin
drips, then transferred to cath lab for emergent cardiac cath.
Patient had onset of symptoms at 4:30PM, arrived in cath lab at
6:30PM.
In Cath lab, demonstrated 100% RCA occlusion, 40-50% stenosis in
left main, 50-60% stenosis in LAD, 90% long lesion in long diag.
Had Cypher stent placed to RCA, across AM origin into PL, then
had balloon dilation of AM, with residual 70-80% stenosis of AM.
Post-cath course c/b onset of atrial fibrillation. Therefore
patient was given amiodarone 150mg IV x 1 for loading and sent
to CCU.
Currently patient reports being very tired. Denies any chest
pain/pressure, SOB. + N/V x 1 upon arrival in CCU, resolved
spontaneously.
Past Medical History:
Borderline hypertension
Borderline hypercholesterolemia
S/p basilar skull fracture s/p MVA
Social History:
Works as a counseler at a hospital. Denies tobacco (current or
past), EtOH, drug use.
Family History:
Mother had HTN, DM. Father had CVA at age 55. Brother has HTN.
Sister has HTN.
Physical Exam:
Vitals - afebrile, HR 89, BP 115/86, RR 20, O2 99% 2L NC
General - awake, alert, lying flat in bed, appropriate, NAD
HEENT - PERRL, MMM, EOMI
Neck - JVP flat, no noted hepato-jugular reflex, although
difficult to evaluate because patient lying flat, no carotid
bruit's b/l
CVS - irregularly irregular, nl S1,S2, no M/R/G
Lungs - CTA anteriorly and laterally. Could not assess
posterior lung fields as patient lying supine
Abd - soft, NT/ND, + BS, no HSM
Groin - Sheath in place in R groin, no tenderness to palpation
Ext - no LE edema b/l, 2+ DP pulses b/l
Pertinent Results:
Labs on admission:
[**2185-3-5**] 06:00PM BLOOD WBC-17.3* RBC-5.51 Hgb-15.5 Hct-44.6
MCV-81* MCH-28.1 MCHC-34.7 RDW-13.9 Plt Ct-265
[**2185-3-5**] 06:00PM BLOOD Neuts-79* Bands-8* Lymphs-7* Monos-3
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2185-3-5**] 06:00PM BLOOD PT-12.4 PTT-24.1 INR(PT)-1.1
[**2185-3-5**] 06:00PM BLOOD Glucose-153* UreaN-17 Creat-1.1 Na-139
K-3.4 Cl-99 HCO3-26 AnGap-17
[**2185-3-5**] 06:00PM BLOOD ALT-28 AST-24 LD(LDH)-128 CK(CPK)-176*
AlkPhos-48 TotBili-0.4
[**2185-3-5**] 06:00PM BLOOD Albumin-5.0* Calcium-9.7 Phos-2.2* Mg-2.0
[**2185-3-7**] 05:14AM BLOOD calTIBC-251* VitB12-424 Folate-17.5
Hapto-72 Ferritn-283 TRF-193*
[**2185-3-6**] 04:00AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
[**2185-3-5**] 09:13PM BLOOD Triglyc-67 HDL-46 CHOL/HD-4.1 LDLcalc-128
[**2185-3-5**] 06:00PM BLOOD TSH-1.1
[**2185-3-5**] 06:00PM BLOOD Free T4-1.3
[**2185-3-6**] 04:45AM BLOOD CRP-2.3
[**2185-3-5**] 07:56PM BLOOD Type-ART pO2-162* pCO2-40 pH-7.38
calHCO3-25 Base XS-0 Intubat-NOT INTUBA
[**2185-3-7**] 05:14AM BLOOD Ret Aut-1.6
.
Cardiac labs:
[**2185-3-5**] 06:00PM BLOOD ALT-28 AST-24 LD(LDH)-128 CK(CPK)-176*
AlkPhos-48 TotBili-0.4
[**2185-3-5**] 09:13PM BLOOD CK(CPK)-1789*
[**2185-3-6**] 04:45AM BLOOD CK(CPK)-[**2191**]*
[**2185-3-6**] 01:40PM BLOOD CK(CPK)-1704*
[**2185-3-7**] 05:14AM BLOOD LD(LDH)-455* CK(CPK)-959* TotBili-0.6
[**2185-3-5**] 06:00PM BLOOD cTropnT-<0.01
[**2185-3-5**] 06:00PM BLOOD CK-MB-3
[**2185-3-5**] 09:13PM BLOOD CK-MB-157* MB Indx-8.8*
[**2185-3-6**] 04:45AM BLOOD CK-MB-191* MB Indx-9.5* cTropnT-4.64*
[**2185-3-6**] 01:40PM BLOOD CK-MB-133* MB Indx-7.8* cTropnT-4.81*
[**2185-3-7**] 05:14AM BLOOD CK-MB-31* MB Indx-3.2 cTropnT-2.86*.
.
Labs on Discharge:
[**2185-3-9**] 07:35AM BLOOD WBC-8.8 RBC-4.56* Hgb-12.6* Hct-36.5*
MCV-80* MCH-27.7 MCHC-34.6 RDW-13.9 Plt Ct-285
[**2185-3-9**] 07:35AM BLOOD PT-12.8 PTT-27.5 INR(PT)-1.1
[**2185-3-9**] 07:35AM BLOOD Glucose-93 UreaN-16 Creat-1.0 Na-141
K-4.2 Cl-103 HCO3-28 AnGap-14
[**2185-3-9**] 07:35AM BLOOD Calcium-9.5 Phos-5.1*# Mg-1.9
.
Microbiology: None
.
Imaging:
Cardiac Catheterization [**2185-3-5**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery diease. The left main coronary
artery had
a distal 40-50% lesion. The left anterior descending artery is
a small
vessel with diffuse disease (50-60% stenoses). The first
diagonal
branch (2.0 mm vessel) has a tubular 90% lesion. OM1 has a 60%
ostial
stenosis. The right coronary artery was the dominant vessel and
was
totally occluded proximally.
2. Right heart catheterization revealed normal right and left
sided
filling pressures. Cardiac output and cardiac index were
normal.
3. The mid RCA lesion was predilated with a 2.0 X 20 mm sprinter
balloon, stented with a 2.5 X 28mm Cypher stent and post dilated
with a
3.0 X 13mm high sail balloon with lesion reduction from 100% to
0%,
also jailing and stenosing the ostium of the AM.
4 rescue angioplasty of the jailed AM/PDA.
.
The final angiogram showed TIMI III flow with no residual
stenosis in
the stented segment with no embolisation or dissection. (see
PTCA
comments)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal right and left sided filling pressures.
3. Successful stenting of the mid/distal RCA lesion
4. Rescue angioplasty of the jailed AM
.
ECHO [**2185-3-5**]:
Overall left ventricular systolic function is mildly depressed
with inferior and inferoseptal hypokinesis (focused views only)
estimated LVEF ?50%. Right ventricular systolic function is
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. Trivial mitral regurgitation is
seen is focused views (parasternal long axis); valvular
regurgitation was not fully assessed. There is no pericardial
effusion. No evidence of pericardial tamponade.
.
CT Abd/Pelvis [**2185-3-7**]:
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Bilateral small pleural effusions with associated
atelectasis.
3. Severe coronary artery calcifications.
.
ECHO [**2185-3-7**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction. Overall
left ventricular systolic
function is mildly depressed. Tissue velocity imaging
demonstrates an E/e' <8 suggesting a normal left ventricular
filling pressure. Resting regional wall motion abnormalities
include inferior hypokinesis and basal inferoseptal hypokinesis.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
Brief Hospital Course:
Patient is a 44 year old man with past medical history of
borderline hypertension, borderline hypercholesterolemia, who
presented to the emergency department with an ST elevation
myocardial infarction.
.
Upon presentation to the ED, the patient was noted to have ST
elevations in the inferior leads on EKG (II, III, aVF) and
right-sided EKG demonstrated ST elevation in the Right sided
precordial leads, including lead rV4. These findings indicated
an infero-posterior MI with RV involvement. The patient was
immediately taken to the cardiac catheterization lab, and time
from onset of symptoms to intervention was estimated at
approximately 2 hour (onset of symptoms at 4:30pm, in cath lab
by 6:30pm). The cardiac catheterization demonstrated proximal
RCA total occlusion, that was rescued by wire stent placement.
The catheterization also demonstrated evidence of diffuse
disease, with left main coronary artery with a distal 40-50%
lesion, the left anterior descending artery noted to be a small
vessel with diffuse disease (50-60% stenoses), the first
diagonal branch (2.0 mm vessel) with a tubular 90% lesion, and
the OM1 has a 60% ostial stenosis. The RV was noted to be
functioning well. Following cardiac cath, patient was started
on plavix 75mg qd, aspirin 325mg qd, lipitor 80mg qd, metoprolol
which was titrated up and changed to toprol xl on discharge.
Nitroglycerin was avoided in setting of likely RV involvement.
In terms of other ischemic management, patient's cardiac enzymes
were trended, demonstrating a CK peak of [**2191**].
.
Post-cath course complicated immediately by atrial fibrillation,
noted in the cath lab following the case. He was started on
amiodarone (given 150mg bolus in cath lab, followed by 1mg/hr
drip) and patient spontaneously converted to NSR a couple hours
later. It was believe that his atrial fibrillation was
secondary to peri-MI, peri-cath circumstances and may have been
contributed to by his PA catheter in place during the
catheterization. Therefore, upon converting to NSR, his
amiodarone was discontinued. Patient remained on telemetry
without event throughout remainder of hospital course.
His post-cath course was also complicated by nausea/vomiting and
hypotension, which was treated with PRN anti-emetics and fluid
boluses with subsequent good control.
Later in hospital course, patient noted to have a slight Hct
drop from 35->32->31. Therefore a chest/abd/pelvis CT was
obtained to rule out a bleed which was negative.
.
Given his lack of risk factors for cardiac disease, HgA1C was
checked which was normal at 5.4, CRP was checked which was
elevated at 2.3. Homocysteine will plan to be checked as an
outpatient (could not check as an inpatient).
.
Patient underwent post-cath ECHO that demonstrated EF > 55%,
mildly depressed LV function, resting regional wall motion
abnormalities include inferior hypokinesis and basal
inferoseptal hypokinesis, nl RV function, trivial MR [**First Name (Titles) **] [**Last Name (Titles) **].
.
Patient was discharged on above medications with instructions to
follow up with his cardiologist and primary care physician.
Medications on Admission:
Gingko baloba
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. 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:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease with ST-elevation myocardial infarction
Discharge Condition:
Good. Patient chest pain free, ambulating without difficulty.
Discharge Instructions:
Please contact physician if develop chest pain/pressure,
shortness of breath, lightheadedness/dizziness, any other
questions/concerns.
.
Please take medications as directed. It is VERY IMPORTANT that
you take your aspirin and plavix EVERY DAY.
.
Please follow up with appointments as directed.
.
Please refrain from heavy lifting or vigorous activity for 2
weeks.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] ([**Telephone/Fax (1) 920**]) on [**2185-3-25**]
at 3:15 PM, [**Hospital Ward Name 23**] 7, [**Hospital Ward Name **].
.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 7056**], in 2 weeks.
|
[
"997.4",
"458.29",
"410.11",
"285.9",
"787.01",
"427.31",
"V17.4",
"401.9",
"V18.0",
"414.01",
"997.1",
"272.0",
"E879.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"00.66",
"99.20",
"00.41",
"36.07",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
11768, 11774
|
7992, 11119
|
347, 427
|
11882, 11947
|
3078, 3083
|
12361, 12810
|
2397, 2481
|
11183, 11745
|
11795, 11861
|
11145, 11160
|
6244, 7969
|
11971, 12338
|
2496, 3059
|
273, 309
|
4782, 6227
|
455, 2161
|
3097, 4763
|
2183, 2276
|
2292, 2381
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,115
| 118,302
|
46564
|
Discharge summary
|
report
|
Admission Date: [**2124-1-28**] Discharge Date: [**2124-2-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Esophagoduodenoscopy
Transfusion (7 units packed RBCs)
History of Present Illness:
87 year old M Alzheimers, prostate cancer, chronic kidney
disease who presents with shortness of breath. Limited history
from patient due to advanced dementia, consequently following
history is mostly from caregiver. After dinner patient appeared
pale and fatigued. While waking to bathroom he become
diaphoretic and weak (fell to knees, no LOC). No chest pain or
any other compliants. Was brought in to ED for further
evaluation.
.
In ED physical exam notably for dark stool grossly heme
positive. NGT was placed which returned coffee grinds with 500cc
flush. Unfortunately patient pulled NGT before seeing if
cleared. Labs notable for HCT 26 (prior baseline 30-37). GI was
consulted who felt EGD only necessary if hemodynamically
unstable. Patient's VS on presentation to ED were T 97.1 HR 92
BP 122/72 RR 16 SaO2 100%. Protonix 40 mg IV and 2 L NS given.
Active type and screen sent. BP ranged from 96-133/60-72, HR
80-103. VS prior to transfer BP 138/75 HR 103 16 98% RA.
.
On arrival patient complains of abdominal pain, unable to
specify further. No other compliants.
Past Medical History:
- AD -- Ox1 at baseline
- Prior episodes of syncope, seen in [**Hospital1 18**] ED in [**2119**],
determined vasovagal, had Holter monitor
- H/O UGIB: Per discharge summary [**2107**] EGD demonstrated small
superficial ulcer in the antrum which was biopsied. Mild
gastritis. Question of peptic ulcer disease.
- PVD
- Prostate CA, BPH
- Depression
- Spinal stenosis
- per prior discharge summaries:
HTN
RENAL FAILURE
? DIABETES
Social History:
Originally from Poland. Lives with female partner. Independent
in ADLs, requires assistance with some aADLs. He is a retired
dentist. Holocaust survivor. Denies any EtOH or cigarette use.
Family History:
Mother with congenital heart defect
Physical Exam:
General: Alert, oriented X 1, no acute distress
HEENT: pale conjunctiva, sclera anicteric, dryMM, 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, mild tenderness throughout, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2124-1-28**] 08:20PM PT-12.1 PTT-21.0* INR(PT)-1.0
[**2124-1-28**] 08:20PM PLT COUNT-200
[**2124-1-28**] 08:20PM WBC-11.3*# RBC-2.84*# HGB-9.1*# HCT-26.3*#
MCV-92 MCH-32.2* MCHC-34.8 RDW-13.5
[**2124-1-28**] 08:20PM GLUCOSE-252* UREA N-74* CREAT-1.9* SODIUM-141
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-20* ANION GAP-20
[**2124-2-4**] 05:50AM BLOOD WBC-8.8 RBC-3.12* Hgb-9.6* Hct-28.9*
MCV-93 MCH-30.6 MCHC-33.0 RDW-18.2* Plt Ct-255
[**2124-2-2**] 01:10AM BLOOD WBC-9.6 RBC-3.10* Hgb-9.3* Hct-27.7*
MCV-89 MCH-30.1 MCHC-33.6 RDW-20.3* Plt Ct-141*
[**2124-2-1**] 03:05PM BLOOD Hct-23.6*
[**2124-2-1**] 11:12AM BLOOD Hct-20.3*
[**2124-1-31**] 09:37AM BLOOD Hct-27.2*
[**2124-2-4**] 05:50AM BLOOD Glucose-100 UreaN-29* Creat-1.5* Na-146*
K-3.9 Cl-114* HCO3-21* AnGap-15
[**2124-2-3**] 05:48AM BLOOD Glucose-86 UreaN-30* Creat-1.6* Na-144
K-4.6 Cl-115* HCO3-19* AnGap-15
[**2124-1-28**] 08:20PM BLOOD Glucose-252* UreaN-74* Creat-1.9* Na-141
K-4.5 Cl-106 HCO3-20* AnGap-20
[**2124-1-29**] 12:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2124-1-29**] 07:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2124-1-28**] 08:20PM BLOOD cTropnT-<0.01
[**2124-2-4**] 05:50AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2
[**2124-1-29**] 07:20AM BLOOD %HbA1c-6.5* eAG-140*
[**2124-2-2**] 07:26AM BLOOD Triglyc-105
[**2124-1-31**] 02:52PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019
[**2124-1-31**] 02:52PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2124-1-31**] 02:52PM URINE RBC-[**10-7**]* WBC-[**1-21**] Bacteri-FEW Yeast-NONE
Epi-0-2
.
.
Time Taken Not Noted Log-In Date/Time: [**2124-2-3**] 12:05 pm
SEROLOGY/BLOOD CHEM# [**Serial Number 98865**]B.
**FINAL REPORT [**2124-2-4**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2124-2-4**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
.
.
.
Final Report
INDICATION: 87-year-old man with dyspnea.
COMPARISON: [**2122-6-24**].
SINGLE UPRIGHT VIEW OF THE CHEST AT 9:10 P.M.: Lungs are clear
without
consolidation or pleural effusion. Linear opacities at the left
lung base are
unchanged dating back to [**2119**], likely reflecting scarring. This
results in a
slightly blunted appearance of the left costophrenic angle.
There is no clear
left pleural effusion. There is no right pleural effusion. There
is no
pneumothorax. The heart size is normal. The aorta remains
tortuous. There
is no hilar or mediastinal enlargement. Pulmonary vascularity is
normal.
IMPRESSION: No acute cardiopulmonary abnormality.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 2671**] [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2483**]
Approved: SAT [**2124-1-29**] 1:27 AM
.
.
.
Brief Hospital Course:
#) Anemia--patient had grossly bloody and melenotic stools in ED
and in MICU. NG lavage positive (coffee grounds). Maintained on
protonix drip and transfused in total 7U packed RBCs to maintain
Hct >25. On HD4 had EGD which showed multiple bleeding duodeunal
ulcers which were clotted. Transitioned to Protonix 40mg [**Hospital1 **]. On
HD6 Hct dropped from stable 24-25 to 20, he had a melenotic
bowel movement, and he was transfused one more unit. Thereafter
his Hct remained stable at 27-28. Home lasix and flomax held in
setting of ongoing blood loss, although he remained
hemodynamically stable. He was then transferred to the medical
floor where his HCT and vitals continued to be stable. His H
pylori was negative and he was to be discharged on 40mg PO BID
protonix. GI team did not recommend any routine follow up unless
he becomes symptomatic given the patient has severe dementia and
would not likely benefit.
.
#) Alzheimer's dementia--continued on home dose of Namenda and
on seroquel 12.5mg [**Hospital1 **] for agitation. Also received olanzapine
PRN for agitation and had 1:1 sitter. speech and swallow team
assessed pt and did video swallow, recommending a thin liq and
pureed diet with 1:1 sitter, crushed meds.
.
#) Acute on chronic renal failure--baseline creatinine at 1.7.
Patient remained at his baseline but on HD4 there was a
creatinine bump to 2.6 and patient had poor urine output. A
Foley was placed which quickly drained 1-2L urine and creatinine
began to down-trend. Cr also improved in setting of blood
transfusion. We restarted the patient's flomax upon discharge
(initially held in concern for hypotension). We also started the
pt's home lasix 20mg upon discharge and he should have his
electrolytes monitored in the next 2-3 days.
.
# Depression: continued home seroquel
.
# BPH: pt sent home with foley due to retention in setting of
holding flomax for concern for hypotension with GIB. the pt was
discharged with a foley in place and started on his home flomax.
.
# Prostate cancer: No recent record. Appears to have been
treated and not currently active.
.
# Pain: Continue gabapentin. Hold tramadol as may cause
hypotension. Can continue tylenol.
.
# Communication: son [**Name (NI) 3788**] [**Name (NI) **] [**Telephone/Fax (1) 98866**], HCP is son [**Name (NI) **]
[**Name (NI) **] [**Telephone/Fax (1) 98867**], home [**Telephone/Fax (1) 98868**]
# Code: Full Code (confirmed with son [**Name (NI) 3788**] [**Name (NI) **]) HCP is son
[**Name (NI) **] [**Name (NI) **]
Medications on Admission:
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule -
1
Capsule(s) by mouth at bedtime
MEMANTINE [NAMENDA] - 10 mg Tablet - 1 Tablet(s) by mouth twice
daily, no later than 2pm
QUETIAPINE [SEROQUEL] - 25 mg Tablet - [**11-20**] Tablet(s) by mouth
twice daily
TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg
Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth daily
TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth once a day as needed for needed
Medications - OTC
Ambien 5 mg prn qhs
ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth daily as needed
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider)
-
Dosage uncertain
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth daily as needed
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- Dosage uncertain
PYRIDOXINE [VITAMIN B-6] - (Prescribed by Other Provider) -
Dosage uncertain
Discharge Medications:
1. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed for agitation.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
12. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] health care
Discharge Diagnosis:
Primary:
upper GI bleed - duodenal ulcer, cauterized
acute anemia
.
Secondary:
end stage alzheimer's dementia
BPH
depression
Discharge Condition:
afebrile, stable vitals
.
Mental Status: Confused - always
Level of Consciousness: Lethargic but arousable
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted due to an upper GI bleed from a duodenal ulcer
which was cauterized. You were in the ICU initially requiring
numerous units of blood but you ultimately stabilized your blood
counts and your vitals. You were started on a medication called
protonix. You should stop taking all NSAIDs and aspirin
permanently as this may cause another bleeding ulcer. Please
stop taking tramadol for now and take tylenol instead.
.
Please take all medications as prescribed.
Please follow up with all appointments.
Please do not hesitate to return to the hospital with any
concerning symptoms at all.
Followup Instructions:
Please follow up with your primary care provider as needed. Dr.
[**Last Name (STitle) 38274**],[**First Name3 (LF) **] X. [**Telephone/Fax (1) 3530**]
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"294.10",
"311",
"V10.46",
"403.90",
"584.9",
"331.0",
"285.1",
"532.40",
"585.3",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
10633, 10690
|
5573, 8084
|
280, 336
|
10859, 10885
|
2693, 5550
|
11682, 11966
|
2114, 2151
|
9526, 10610
|
10711, 10838
|
8110, 9503
|
11059, 11659
|
2166, 2674
|
221, 242
|
364, 1440
|
10900, 11035
|
1462, 1890
|
1906, 2098
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,862
| 144,919
|
3680
|
Discharge summary
|
report
|
Admission Date: [**2128-7-18**] Discharge Date: [**2128-8-10**]
Date of Birth: [**2054-5-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine / Ativan / A.C.E Inhibitors
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
R hip arthroplasty for R femoral neck fracture on [**2128-7-21**]
Blood transfusions
History of Present Illness:
Mr [**Known lastname 16642**] is a 74-y/o gentleman with CAD (s/p CABG), h/o
mechanical AVR for aortic regurgitation (on home Coumadin),
chronic systolic/diastolic CHF [**1-24**] ischemic cardiomyopathy s/p
ICD placement for primary prevention, chronic a-fib, who now
presents from [**Hospital6 33**] after he was admitted there
after a fall.
Patient reports he was walking his dog at night, after his usual
4oz alcoholic beverage, when he began to feel "dizzy". When
asked about what this means, he reported "things just went
black" and he felt as though he was going to pass out. He tried
to find a place to sit but stumbled and fell inside his garage
with concrete floor. Denies any loss of consciousness or head
trauma. Reports he tried to protect his head with his hands but
has no pain anywhere other than his hip. Denies any preceeding
chest pain, nausea, vomiting, headache, double vision or
difficulty breathing.
Of note, patient had gone to see his cardiologist 3 dayst PTA
and had been re-started on Digoxin and had his dose of
metoprolol decreased to 50mg daily.
In [**Hospital6 **], patients vitals were Temp 98.6, HR 70,
BP 76/50 and RR 14, O2 Sat 99% on room air. Portable AP films of
the hip revealed an acute, subcapital hip fracture on the right,
with significant proximal migration of the femur with respect to
the femoral head. INR at admission was 4.3, Hct 27.3, Creatinine
1.8. EtOH level of 78mg/dl. CK 180, CK MB 4.1 and Tn T 0.02.
Patient received 2 units of PRBC, total 7.5mg Vitamin K. Has not
received pressors, #18 and #20 gaugue PIV. Foley catheter was
placed. CT Scan of head and abdomen were obtained, with the
latter only pertinent for a small hernia in the periumbilical
region containing a short segment of small intestine. CT pelvis
revealed acute right hip fracture with extensive soft tissue
contussion adjacent to the right hip with small associated
hematoma. Orthopedic surgery was consulted and decision to
pursue hip arthoplasty once coagulopathy was resolved was
formulated. Patient requested transfer to [**Hospital1 18**] as he has
obtained most of his care here.
Past Medical History:
Cardiac History:
CABG in [**2102**]: SVG-LAD, SVG-LCX --occluded
CABG in [**2116**]: LIMA->LAD, Y graft to D1 and OM, and SVG->RCA.
.
Pacemaker/ICD, in [**2123**], s/p battery change in [**2126**] (complicated
by pocket hematoma)
.
Other Past History:
Skin cancer removed from back [**2123**]
Persistent AF s/p multiple cardioversions
Ischemic cardiomyopathy with EF of 30-40% on ECHO from [**4-28**] s/p
ICD [**2123**]
CAD
-- s/p CABG x3 [**2116**] at [**Hospital1 18**]
-- s/p CABG x2 [**2102**] at [**University/College **] Presbyterian
Aortic Regurgitation
-- s/p mechanical, bileaflet valve AVR [**2116**]
Hypertension
CRF
Sleep apnea (BiPAP)
Pulmonary hypertension
Hyperlipidemia
s/p cholecystectomy and appendectomy
Ischemic colitis
-- s/p colectomy with diversting colostomy, now repaired
Gout
Social History:
He grew up in the [**Location (un) 86**] area. Married with two grown adopted
children. Lives with his wife. [**Name (NI) **] currently works part time as a
researcher/field interviewer. He drinks [**12-24**] alcoholic beverages
per week. He denies any tobacco history.
Family History:
He has a strong family history of cancer. His mother died of
colon cancer, his father had lung cancer. He also had multiple
grandparents with colon cancer.
Physical Exam:
Vital signs, Temp: 99.2 HR: 80 BP: 98/53 O2 Sat: 91% RA
GEN: Appears comfortable, sedated, somnolent. Arousable
HEENT: EOMI, PERRL with 1 mm pupils bilaterally. Dry MM.
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, Normal S1, loud mechanical S2 with systolic
ejection murmur, loudest at RUSB.
LUNGS: Clear to auscultation bilaterally, no rales, rhonchi,
wheezes
ABD: Soft, mildly distended. Well healed mid-abdominal scar and
peri-hepatic scar.
MSK: Right hip with tenderness to palpation, ecchymoses along
buttocks. Strong distal pulses.
Pertinent Results:
[**2128-7-18**]
Na 135 / K 4.9 / Cl 102 / CO2 21 / BUN 69 / Cr 1.6 / BG 119
CK 281 / MB 3 / Trop T .01
Alb 4 / Ca 8 / Mg 2.2 / Phos 4.3
WBC 10.4 / hct 29.9 / Plt 217
INR 2.9 / PTT 30.8
[**2128-8-10**]
Na 142 / K 4.1 / Cl 104 / CO2 29 / BUN 17 / Cr .9 / BG 98
WBC 8.9 / Hct 29.8 / Plt 544 / INR 1.6
SPIROMETRY 8:24 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.55 4.15 61
FEV1 1.83 2.75 67
MMF 1.17 2.47 47
FEV1/FVC 72 66 109
[**2128-7-18**] Pelvis AP XR - Single frontal radiograph of the pelvis
demonstrates a displaced and angulated fracture of the right
femoral neck. Fracture is displaced 0-25% of the width of the
femoral neck. There is external rotation of the distal fracture
fragment and proximal displacement of the distal fracture
fragment. The left hip is unremarkable. The sacroiliac joints
and symphysis pubis are normal.
Surgical staples project over the right groin and vascular
calcifications
project over the low pelvis and left thigh.
[**2128-7-19**] Echo - The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild global left
ventricular hypokinesis (LVEF = 45 %). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
borderline normal free wall function. There is abnormal septal
motion/position. A mechanical aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2128-7-19**] CXR - No acute cardiopulmonary process.
[**2128-7-19**] Lumbosacral spine - Marked lumbar spondylosis without
spondylolisthesis. Right femoral neck fracture, better seen on
recent hip radiographs.
[**2128-7-19**] CT Head - IMPRESSION: No evidence of fracture or
hemorrhage.
[**2128-7-20**] Stress MIBI - No anginal symptoms or ECG changes noted
from baseline. Nuclear report sent separately. ; 1. Fixed,
severe perfusion defects at the inferior and inferolateral
walls. Global hyponkinesis and septal dyskinesis 2. The
calculated LVEF is 36% and the LV-EDV is 149mL.
[**2128-7-22**] CT Abd / Pelvis -
1. Moderate hematoma involving the right gluteal muscles in this
patient
status post right hip replacement.
2. Thickening of the cecum and ascending colon. Differential
diagnosis
includes ischemia, infection and inflammatory causes.
3. Small epigastric hernia containing small bowel. No evidence
for small-
bowel obstruction.
4. Small bilateral pleural effusions and septal thickening are
consistent
with CHF.
CT Right Lower Extremity - [**2128-7-28**] - Large predominantly
intramuscular hematoma involving the right gluteal muscles and
anterior thigh musculature as above. Without IV contrast, we
cannot
assess for active bleeding/extravasation.
Brief Hospital Course:
In summary, Mr [**Known lastname 16642**] is a 74 y/o M w h/o CAD (s/p CABG), aortic
regurg (s/p mechanical valve replacement), chronic combined
systolic/diastolic CHF (LVEF 45%) [**1-24**] ischemic CMP s/p ICD
placement for primary prevention, chronic a-fib, who originally
presented w fall and was diagnosed with R hip fracture. He was
transferred to BIMDC on [**2128-7-18**] for R hip ORIF. His course has
been complicated by post-op bleeding in the setting of required
anticoagulation for the presence of a mechanical valve. The
bleeding resulted in a R gluteal hematoma, hypotension (resolved
with fluid resuscitation), acute anemia (treated with
transfusions), ARF and transaminits (likely [**1-24**] to hypoperfusion
of kidney/liver).
.
#. Hip Fracture / Trauma / Hematoma: Imaging was repeated on
arrival to [**Hospital1 18**], which confirmed right hip fracture. Due to
complain of neck pain, CT c-spine was performed and did not
reveal any concerning findings. Given history of mechanical
aortic valve, anticoagulation with heparin drip was re-initiated
and cardiology consult was obtained for pre operative
assessment. Stress test was obtained and revealed fixed deficits
without reversible ischemia. Patient underwent successful hip
arthroplasty on [**2128-7-21**], and heparin drip was restarted 6 hours
post procedure. While in the ICU, the patient did have a
noticeable Hct drop following anticoagulation, but had an
appropriate Hct bump after being transfused 2UPBRCs. Following
this, the patient was transferred to the floor with stable Hct's
until the morning of [**2128-7-28**] when the patient's Hct was noted to
drop from 27.3 --> 23.3. In addition to this, the patient's
blood pressure was lower than usual (baseline SBP in the 90's).
On examination, R gluteal hematoma was found and confirmed with
CT imaging. The pt was transferred back to the MICU and received
total of 4units pRBCs while in MICU. Hct has been stable, thus
restarted heparin gtt on [**2128-7-31**]. [**Date Range 1957**] has been following to
eval for compartment syndrome and wound infection, doing serial
exams to ensure no foot drop or other concerning findings. On
discharge, surgical wound healing well with no complications.
Followup with Dr [**Last Name (STitle) 1005**] scheduled.
.
#. Fall / Syncope: History was very suggestive of syncopal
episode, with prior history of orthostatic hypotension and
recent medication change (may have predisposed to medication
error). Differential diagnosis however includes non perfusing
arrhythmia, myocardial infarction (leading to arrhytmia), acute
valvular disease (although highly unlikely with normal exam),
massive pulmonary embolus, and seizure. Patient was ruled out
for MI, had a CT with old cerbellar infarct and ECHO without
significant change from prior. ICD was interrogated and no VT/VF
episodes had been detected. Fall likely secondary to orthostatic
hypotension. Nitrates, [**Last Name (un) **] (ACE-I allergic) were held, low-dose
BBl was continued.
.
#. Acute anemia: In setting of fracture and extensive hematoma,
as above, patient responed appropiately to blood transfusions.
.
#. Ischemic Cardiomyopathy: Appears stable. Given relative
hypotension on admission, we held antihypertensives with
exception of metoprolol. We continued aspirin 81mg and statin,
but held nitrate, [**Last Name (un) **] and spironolactone.
.
#. Coronary Artery Disease: Extensive burden of disease,
although patient is currently asymptomatic. pMIBI negative for
reversible ischemia. Aspirin, atorvastatin and metoprolol
continued.
.
# Chronic syst/diast CHF, fluid overload: Pt received copious
amounts of IVFs while hypotensive and became severely volume
overloaded (dependent edema), which made physical therapy
difficult. Pt was started on bumetanide and treated with a dose
of 2mg PO BID for aggressive diuresis. His heart failure regimen
metoprolol 12.5mg PO BID, spironolactone 12.5mg PO daily,
atorvastatin 80mg PO daily were continued. No ACE for now given
ACE allergy/no [**Last Name (un) **] given ARF earlier, consider restarting as an
outpatient. No nitrates for now.
.
# Mechanical Aortic Valve: Heparin drip restarted in the MICU,
after pt's Hct stabilized. Coumadin restarted very cautiously on
[**2128-8-2**], however, having trouble increasing INR, so Coumadin
increased to 6mg PO daily for now. Needs to be increased to an
INR goal of 2.5-3.5, with heparin bridge to cover in the interim
period.
.
#. Afib: Patient's rate has been controlled with a low dose beta
blocker and he has not had a significant bp drop from this
either. We discussed possibly starting Coreg as it would be
better for his cardiac health, however, we deferred this change
until his anti-coagulation and bleeding issues have been further
resolved. He is currently on heparin. Coumadin was held for
bleeding issues and surgery, restarted on [**8-2**].
.
#. Acute Renal failure: Baseline Cr ~1, pt developed ARF [**1-24**]
hypoperfusion vs ATN in the setting of hypotension from
hemorrhage. Peak Cr 2.1, downtrended gradually to baseline of 1.
ARF resolved completely by discharge.
.
#. RUQ Pain/Transaminitis: On POD #3, RUQ tenderness on exam in
the MICU. LFTs elevated ALT-82, AST-104, ALKPHOS-301 on [**7-26**],
downtrending afterwards, but peaking again ALT=165, AST=137,
ALK=402. Possible shock liver from hypotension from bleeding.
RUQ U/S showed absent GB (s/p cholecystectomy), no ductal
dilation/stones. Pt has no abd pain and no tenderness on exam,
LFTs downtrending on discharge.
.
# Delirium/Confusion: After the operation, the pt became
disoriented with slowed speech, waxing and [**Doctor Last Name 688**] mental status.
Etiology likely drug related (pt very susceptible to narcotics
per wife) vs possible ICU delerium. Head CT on [**8-14**], [**7-19**]
with no evidence of bleed or interval change. All cultures are
NGTD, unlikely infectious process. Pt's mental status improved
since transfer to floor, however, still waxing and [**Doctor Last Name 688**]. AOx3
on discharge. Recommend avoidance of narcotics/sedative (used
tramadol prn for pain and haldol prn for hyperactivity or
agitation).
.
# Fever/Leukocytosis: After the surgery, the pt had low grade
temps to 99-100. Unlikely PE (pt not tachycardic, on heparin
drip, R unilateral LENIs negative), CXR neg for aspiration,
blood and urine cx's show NGTD. RUQ U/S neg for
choledocholithiasis. Patient finished levo/vanc 10 day course on
[**2128-7-31**]. He was also started on keflex for ?cellulitis around
groin site. He then spiked a fever on [**2128-8-1**] to 100.5. He was
pan-cultured and had no change in his CXR from [**2128-7-28**]. He has
had a RIJ line since [**2128-7-21**] and this may be source, so it was
d/c after peripheral access was attained. Pt also developed an
asymptomatic UTI by UA and culture (growing pan-sensitive
Pseudomonas), however, he was not started on abx given that he
did not spike a fever and did not become hemodynamically
unstable.
Medications on Admission:
Digoxin 0.125mg daily (started [**7-16**])
Aldactone 25mg
Aspirin 81mg daily
Atorvastatin 80mg daily
Bumetanide 2mg twice a day
Isosorbide Mononitrate SR 30mg daily
Toprol XL 50mg daily
Nitroglycerin SL PRN
K-Dur 10mg daily
Sertraline 100mg daily
Clonazepam PRN
Allopurinol 100mg daily
Colchicine 0.6mg PRN
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 H
on, 12 H off on R hip.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
18. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
19. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary diagnosis:
R hip fracture s/p arthroplasty
Acute renal failure
Transaminitis likely [**1-24**] ischemia
Delerium
Orthostatic Hypotension
.
Secondary diagnosis:
Ischemia cardiomyopathy
Chronic sys/diastolic CHF
Chronic atrial fibrillation
coronary artery disease
hypertension
hyperlipidemia
obstructive sleep apnea
Discharge Condition:
Hemodynamically stable, oxygenating at room air, alert and
oriented to person, place and date
Discharge Instructions:
You were admitted to the hospital after you fell. We found that
you have a right hip fracture, which was treated with surgery.
After the surgery you developed bleeding in your right hip in
the setting of anticoagulation that you received for your
mechanical valve. Because of the bleeding, you were transferred
into the intensive care unit and were treated for the
complications. Your condition has now stabilized.
.
We have changed your medications, please take them as
prescribed. Please follow up with your primary care physician
within [**Name Initial (PRE) **] week, so he can continue to optimize your medications.
We have made the following changes:
- metoprolol - please take this medication 12.5mg twice daily
- bumetanide - we have increased this medication to 2mg twice
daily
- dofetilide - we have discontinued this medication
- losartan - we have discontinued this medication while your
kidneys were injured. You may restart this medication within the
next 1-2 weeks.
- allopurinol - we have discontinued this medication while your
kidneys were injured. You may restart this medication within the
next 1-2 weeks.
- sertraline - we have discontinued this medication while you
were hospitalized. If you need it, you can restart this
medication at rehab.
- bisacodyl / senna / docusate / magnesium oxide - we have
started this medication to help keep your bowel movements
regular
- Vitamin D and calcium - we have started these medications to
strengthen your bones.
- tylenol and tramadol - we have started these medications to
help your pain control.
- multivitamin and ferrous sulfate - we have added these
supplements.
- Famotidine - we have added this medication to help your acid
reflux.
.
You should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L per day
.
Should you have fever > 101, dizziness, shortness of breath,
chest pain, abdominal pain, bleeding or any other symptoms that
concern you, please call your physicians immediately.
Followup Instructions:
Please call your primary care physcian, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
[**Telephone/Fax (1) 250**] within a week of your discharge from the hospital.
.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2128-8-31**] 8:55
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2128-8-31**] 9:15
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2128-9-21**]
10:30
.
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2128-9-21**] 11:00
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2128-10-8**] 10:40
Completed by:[**2128-8-10**]
|
[
"403.90",
"780.2",
"599.0",
"V45.81",
"820.09",
"327.23",
"585.9",
"E935.8",
"428.42",
"584.9",
"682.6",
"292.81",
"998.59",
"V45.02",
"276.2",
"E885.9",
"272.4",
"V43.3",
"V58.61",
"414.8",
"428.0",
"041.7",
"998.11",
"285.1",
"427.31",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
16716, 16813
|
7646, 14612
|
315, 402
|
17179, 17275
|
4421, 7623
|
19350, 20247
|
3672, 3831
|
14972, 16693
|
16834, 16834
|
14638, 14949
|
17299, 19327
|
3846, 4402
|
271, 277
|
430, 2543
|
17002, 17158
|
16853, 16981
|
2565, 3368
|
3384, 3656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,154
| 100,742
|
32927
|
Discharge summary
|
report
|
Admission Date: [**2166-3-4**] Discharge Date: [**2166-3-18**]
Date of Birth: [**2105-2-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Hmg-Coa Reductase Inhibitors (Statins) / Compazine / Oxycodone
Hcl/Acetaminophen / Morphine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
exertioanl angina, DOE, fatigue
Major Surgical or Invasive Procedure:
[**3-10**] AVR (19mm St-[**Male First Name (un) 923**])
History of Present Illness:
61 yo F with known AS and recent increase in symptoms.
Past Medical History:
MS, R breast CA-s/p lumpectomy/XRT-completed [**1-11**], glucose
intollerance, dyslipidemia, Hashimoto Thyroiditis, AS.
Social History:
works in OR booking at [**Hospital6 **]
no tobacco
rare etoh
Family History:
NC
Physical Exam:
HR 62 RR 14 BP 123/68
Well appearing F in NAD
Lungs CTAB
Heart RRR 3/6 SEM radiation to carotids
Abdomen benign
Extrem warm, no edema, 2+ pulses t/o
No varicosities
Pertinent Results:
[**2166-3-18**] 04:20AM BLOOD WBC-5.4 RBC-2.75* Hgb-8.6* Hct-26.1*
MCV-95 MCH-31.5 MCHC-33.1 RDW-14.2 Plt Ct-394
[**2166-3-18**] 04:20AM BLOOD PT-24.9* INR(PT)-2.4*
[**2166-3-17**] 10:25AM BLOOD PT-24.6* PTT-32.9 INR(PT)-2.4*
[**2166-3-16**] 06:25AM BLOOD PT-22.7* PTT-89.8* INR(PT)-2.2*
[**2166-3-15**] 12:14AM BLOOD PT-14.5* PTT-57.7* INR(PT)-1.3*
[**2166-3-14**] 04:00PM BLOOD PT-12.8 PTT-40.9* INR(PT)-1.1
[**2166-3-18**] 04:20AM BLOOD Plt Ct-394
[**2166-3-18**] 04:20AM BLOOD Glucose-101 UreaN-13 Creat-0.8 Na-133
K-3.9 Cl-98 HCO3-31 AnGap-8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76619**] (Complete)
Done [**2166-3-10**] at 9:19:46 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2105-2-4**]
Age (years): 61 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: avr
ICD-9 Codes: 786.05, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2166-3-10**] at 09:19 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *56 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 51 mm Hg
Aortic Valve - LVOT pk vel: 0.74 m/sec
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
Before final separation from bypass, the tissue valve was tested
and found to have unacceptably high regurgitation associated
with the right cusp. The aorta was re-clamped and the valve
inspected. Tried to wean again, and again too much AI at the
right cusp. Finally re-clamped and placed a mechanical valve.
Post-CPB: A mechanical aortic valve is in place. No AI, no
peri-valvular leak. Mean gradient = 11. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 66799**]r systolic fxn. Aorta intact. Other parameters as
pre-bypass.
Brief Hospital Course:
She was transferred from MWMC to cardiac surgery. She was
cleared for surgery by dental. She was taken to the operating
room on [**3-10**] where she underwent an AVR. She was transferred to
the ICU in stable condition. She was extubated later that same
day. She was given 48 hours of vancomycin since she was in the
hospital preoperatively. She was started on coumadin for her
mechanical valve.She was transfused 1 unit for HCT 24 with
oliguria and hypotension. She continued to require a neo gtt.
Her chest tubes had air leaks and were dc'd on POD #3. She was
weaned from her neo and transferred to the floor. She had SVT
and was seen by electrophysiology. She was started on
amiodarone. Her INR was therapeutic and she was ready for
discharge home. Pre-discharge xray showed a moderate left
effusion. Thoracentesis for 500 cc bloody fluid was performed.
Post-tap xray was improved and she was ready for discharge home.
Coumadin will be followed by the [**Hospital1 **] heart center coumadin
clinic.
Medications on Admission:
Arimidex1, atenolol 50 hs, ASA 81', trazadone prn, rhinocort,
zetia 10', protonix 40', HCTZ, niaspan 1500', norvasc 5',
meloxican 15', mirapex 0.25', diasynenide, lipitor 5', ambien
prn.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. 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*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily ().
6. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
10. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day.
14. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO ONCE (Once) for 2
days: 3 mg [**3-18**] and [**3-19**] and then check INR [**3-20**] with results to
MWMC coumadin clinic.
Disp:*60 Tablet(s)* Refills:*0*
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
AS now s/p AVR
MS, R breast CA-s/p lumpectomy/XRT-completed [**1-11**], glucose
intolerance, dyslipidemia, Hashimoto Thyroiditis
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions,creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 5448**] 2 weeks
Dr. [**Last Name (STitle) 32255**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2166-3-18**]
|
[
"V15.3",
"245.2",
"790.29",
"V10.3",
"272.4",
"788.5",
"285.9",
"997.5",
"996.02",
"746.3",
"458.29",
"427.31",
"340",
"698.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"35.22",
"99.04",
"34.91",
"99.05",
"89.60",
"39.61",
"34.03",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
8237, 8299
|
5077, 6079
|
388, 446
|
8472, 8480
|
972, 5054
|
767, 771
|
6316, 8214
|
8320, 8451
|
6105, 6293
|
8504, 8755
|
8806, 8962
|
786, 953
|
317, 350
|
474, 530
|
552, 673
|
689, 751
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,219
| 104,398
|
31563
|
Discharge summary
|
report
|
Admission Date: [**2175-10-9**] Discharge Date: [**2175-10-18**]
Date of Birth: [**2115-6-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Aspirin / Codeine
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Increased headache, seizure
Major Surgical or Invasive Procedure:
[**2175-10-13**]: Right frontal craniotomy for tumor resection
History of Present Illness:
60 year-old female with metastatic renal cell carcinoma to the
lung and brain, now presents with worsening L-sided weakness and
headaches. She reports headaches began this morning in
association with dizziness and mild nausea. No vomiting, blurry
vision, or lightheadedness. No fever, chills, or mental status
changes. The patient called [**First Name4 (NamePattern1) 25897**] [**Last Name (NamePattern1) **], RN and was
instructed to take decadron 10mg and come to the emergency room.
Of note, the patient has experienced R-sided headaches, L-sided
weakness and numbness, incoordination, muscle stiffness, and
fatigue since [**Month (only) 958**] and has gradually deteriorated since then,
becoming hemiparetic requiring a walker. She has undergone
biopsies of the
brain lesion and cyberknife SRS. Recent MRI
([**2175-9-22**])demonstrated an increased lesion (2 x 3 x 2cm) with
extensive edema and mass effect on the motor strip. She was
scheduled for resection with Dr [**First Name (STitle) **] on [**2175-10-13**].
In the [**Hospital1 18**] ED, she had a seizure, witnessed by her family,
lasting approximately 2 minutes. Prior to onset, she complained
of worsening R-sided head discomfort. She was observed to have
eye deviation to the right and tonic-clonic movements of UE and
LE, bilaterally. She was given 2mg ativan; the seizure stopping
during administration. No post-ictal behavior. No history of
seizure.
Past Medical History:
1. Renal cell cancer with left nephrectomy, lung metastasis, and
thalamic metastasis.
s/p left nephrectomy for RCC on 1/[**2171**].
s/p radiofrequency ablation of the right upper lung met
s/p brain biopsy [**2174-8-4**] by Dr. [**Last Name (STitle) **], renal cell ca
s/p cyberknife SRS on [**2174-8-19**] to right thalamus to 22 Gy
s/p thalamic biopsy [**2175-6-7**] by Dr. [**Last Name (STitle) **], necrosis
2. History of PNA in late [**2174**], treated successfully with
levofloxacin.
3. Seasonal allergies
Social History:
She lives with her husband. She is originally from [**Male First Name (un) 1056**]
and is Spanish speaking. She has five children and 13
grandchildren. She formerly worked as a supervisor at a hotel.
She denies tobacco, alcohol or illicit drug use.
Family History:
Her mother died of lung cancer at 81 years. She
was a nonsmoker. Her father died of either colon or prostate
cancer at 82 years. He also had a history of coronary artery
disease. She has 12 siblings and five children, none of whom
have had cancer.
Physical Exam:
On Admission
T: 97.7 HR: 73 BP:135/63 R: 18 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
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
Orientation: Oriented to person, place, and date.
Language: Speech slurred but understandable (no change from
previous per family) - speaks Spanish, some English. Translator
at bedside.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally
V, VII: left lower facial droop with decreased sensation to
light
touch and temperature
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Decreased left SCM.
XII: Tongue midline without fasciculations.
Motor: LUE 0/5. LLE [**4-13**] at quad. 0/5 at gastroc. RUE and RLE
[**6-13**].
Sensation: decreased in left hemi-body
Cannot ambulate
Exam on Discharge:
Oriented x 3. PERRL. Left facial droop. Left sided plegia with
some withdrawal to noxious. Full strength on the right side.
Incision clean, dry, and intact.
Pertinent Results:
Labs on Admission:
[**2175-10-9**] 06:50PM BLOOD WBC-5.2 RBC-4.74 Hgb-13.4 Hct-40.7 MCV-86
MCH-28.2 MCHC-32.9 RDW-13.1 Plt Ct-268
[**2175-10-9**] 06:50PM BLOOD Neuts-82.3* Lymphs-15.8* Monos-1.3*
Eos-0.1 Baso-0.5
[**2175-10-9**] 06:50PM BLOOD PT-11.7 PTT-23.0 INR(PT)-1.0
[**2175-10-9**] 06:50PM BLOOD Glucose-126* UreaN-13 Creat-0.8 Na-141
K-4.6 Cl-107 HCO3-23 AnGap-16
[**2175-10-9**] 06:50PM BLOOD CK(CPK)-57
[**2175-10-9**] 06:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2175-10-9**] 06:50PM BLOOD Calcium-9.4 Phos-3.6# Mg-2.5
[**2175-10-10**] 04:00AM BLOOD Phenyto-4.5*
Labs On Discharge:
Dilantin 11.7
IMAGING:
CT HEAD W/O CONTRAST [**2175-10-9**]
FINDINGS: Again seen is a right superior frontal mass with a
hyperdense rim, grossly similar in size compared to [**2175-9-22**]
allowing for differences in modalities. However, the extent of
vasogenic edema associated with the mass has increased. There is
also a slight interval increase in leftward mildline shift from
7 to 9 mm. Partial compression of the right lateral and third
ventricles is again seen. The temporal [**Doctor Last Name 534**] of the left lateral
ventricle may have increased in size since [**2175-9-22**].
The known right thalamic mass is poorly visualized, as it
demonstrates only minimal hyperdensity. Edema in the right deep
white matter, thalamus,
midbrain and pons is not significantly changed since [**9-22**]
allowing for
differences in modalities. A right frontal burr hole is again
seen. Visualized paranasal sinuses are unremarkable.
IMPRESSION:
1. Increased vasogenic edema associated with known right frontal
mass is
increased since [**2175-9-22**]. Slightly increased leftward midline
shift.
2. Persistent partial compression of the third and right lateral
ventricles. Possible increase in the size of the temporal [**Doctor Last Name 534**]
of the left
lateral ventricle.
3. Right thalamic mass is poorly seen. Associated mass effect is
grossly
stable.
4. Recommend MRI for further evaluation.
MR HEAD W/CNTRST [**2175-10-10**]
FINDINGS: Right frontal lobe mass is identified with surrounding
edema as on the previous MRI of [**2175-9-22**]. Additional enhancing
lesion is seen in the right basal ganglia with surrounding
edema.
IMPRESSION: Limited study by motion. Enhancing masses in the
right frontal
lobe and right thalamic regions are seen as before. Mass effect
is seen on
the right lateral ventricle.
MR HEAD W/ CONTRAST [**2175-10-12**]
FINDINGS: There is a large heterogeneously enhancing mass in the
right
frontal lobe which measures 3.8 x 3 cm. There is a second right
thalamic mass which measures 1.6 x 1.7 cm. There is associated
perilesional edema causing 1-cm leftward subfalcine herniation.
Three burr hole tracks are noted in the right frontal calvarium
with enhancement along the burr hole tract. There are no other
areas of abnormal enhancement.
There is also hypoattenuation extending into the right pons
which does not
demonstrate enhancement and could reflect extension of the edema
from the
thalamic lesion.
IMPRESSION: Heterogeneously enhancing right frontal and thalamic
lesion with perilesional edema and leftward subfalcine
herniation in the setting of known malignancy suspicious for
metastases.
CT HEAD W/O CONTRAST [**2175-10-13**]
FINDINGS: There has been interval resection of the right frontal
mass with
postoperative pneumocephalus and small amount of cortical
hyperattenuation
which could reflect minimal postoperative blood products.
There is right thalamic edema, corresponding to the known second
metastatic lesion. There is persistent vasogenic edema spanning
the right frontoparietal convexity and extending into the right
thalamic, mid brain, and anterior temporal regions, the extent
of edema is minimally larger than the prior study and may relate
to recent intervention.
There is minimal mass effect causing 6-mm leftward deviation of
the septum
pellucidum, unchanged since the prior study. There are bilateral
basal
ganglia calcifications.
IMPRESSION:
1. Expected post surgical changes following resection of the
right frontal
mass with postoperative pneumocephalus and minimal resection bed
blood
products. Persistent mass effect with 6-mm leftward deviation of
the septum
pellucidum.
2. Right thalamic edema, likely reflects known underlying
thalamic lesion.
MR HEAD W & W/O CONTRAST f [**2175-10-13**]
FINDINGS: Since the previous study, the patient has undergone
resection of
the right frontal lobe enhancing mass. Blood products are seen
in this region with small amount of air from recent surgery.
Following gadolinium, mild residual enhancement is seen at the
margin of the surgical cavity in the frontal lobe medial aspect.
There is no acute infarct seen in this region.Surrounding edema
has remained unchanged. There is slight decrease in the mass
effect on the right lateral ventricle. The previously noted
right thalamic lesion is again identified and is unchanged with
unchanged
surrounding edema extending to the midbrain. There is mild
prominence of the ventricles which is also unchanged from
previous study.
IMPRESSION:
Status post resection of the right frontal lobe enhancing lesion
with mild
residual enhancement at the surgical margin seen. Expected
post-surgical
changes are seen at the surgical bed. Enhancing right thalamic
lesion again identified. No acute infarct seen.
Brief Hospital Course:
Patient was admitted to the hospital on [**10-9**] after complaining
of increased headache in the setting of known intracranial
lesion. While in the emergency department she was given a
decadron bolus(10mg). She was also observed to have had a
seizure, which was treated with ativan and resolved. She was
then admitted to the neurosurgical ICU for ongoing managment.
She was stabilized on the steroid regimen, and further seizures
did not occur, so surgery was semi-electively pursued for
[**2175-10-13**]. On [**10-13**] she went to operating room for a right sided
craniotomy for tumor resection. Post-operatively she had a head
CT and she returned to the ICU. She remained neurologically
stable on [**2175-10-14**]. She was transfered to the floor and her
Decadron taper was initiated and to continue to a resting dose
of 2mg twice daily. She continued to revieve Dilantin for
seizure prophylaxis. PT and OT evaluated the patient and agreed
that she was an appropriate candidate for rehab. She was
discharged on [**2175-10-18**] with plans to follow-up in the Brain [**Hospital 341**]
Clinic.
Medications on Admission:
Duloxtine 30mg [**Hospital1 **], Omeprazole 20mg daily, Dilantin 300mg daily,
Lyrica 200mg TID
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
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. 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).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
11. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO tid ()
for 2 days.
12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO tid () for
2 days.
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 99 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Multiple Brain Masses
Seizure
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-18**] days (from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic with Dr. [**Last Name (STitle) 724**]
on [**2175-11-13**] at 11:30 am. The Brain [**Hospital 341**] Clinic is located on
the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization
Completed by:[**2175-10-18**]
|
[
"V15.3",
"V45.73",
"780.39",
"197.0",
"V10.52",
"198.3",
"342.00",
"348.5",
"V15.88",
"198.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
11906, 11967
|
9536, 10635
|
325, 390
|
12073, 12097
|
4165, 4170
|
14147, 14970
|
2670, 2920
|
10781, 11883
|
11988, 12052
|
10661, 10758
|
12121, 14124
|
2935, 3146
|
258, 287
|
4758, 9513
|
418, 1837
|
3403, 3969
|
3988, 4146
|
4184, 4739
|
3161, 3387
|
1859, 2386
|
2402, 2654
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,450
| 163,777
|
30198+57679
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-11-1**] Discharge Date: [**2180-11-20**]
Date of Birth: [**2137-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2180-11-1**] Redo Sternotomy, Aortic Valve Replacement utilizing a
19mm St. [**Male First Name (un) 923**] Mechanical on IABP
[**2180-11-4**] Re-exploration with Evacuation of Pericardial Hematoma.
History of Present Illness:
Ms. [**Known lastname 496**] is a 43-year-old woman with a history of
bioprosthetic aortic valve replacement 6-years-ago for aortic
insufficiency/endocarditis. According to patient, she had been
doing well until this summer when she moved down to [**State 108**] and
noticed worsening shortness of breath. She initially attributed
these symtpoms to humidity, but eventually returned to
[**State 350**] where she was supposedly diagnosed with a
respiratory tract infection and treated with antibiotics. Ms.
[**Known lastname 496**] somewhat better and went to [**Location (un) **] to visit her uncle;
during this trip developed worsening shortness of breath and was
hospitalized for a CHF exacerbation. At this time, she was told
that her "valves were failing"; she was eventually stabilized
and returned to [**State 350**], where she went to see her
cardiologist Dr. [**Last Name (STitle) 11493**] on the day of admission. She was
subsequently told to go to the ED for treatment of CHF
exacerbation. Ms. [**Known lastname 496**] complains of progressive dyspnea
since this summer, worse in the last month. She cannot think of
any precipitating event. She endorses symptoms of orthopnea,
cough, and hemoptysis. She states that she has had some fever
and chills for the past week, though hadn't taken her
temperature. Ms. [**Known lastname 496**] reports that she hasn't been taking
her medications as she ran out of them in [**State 108**]. On further
review of systems, patient denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
History of AV Endocarditis, s/p AVR with bioprosthetic valve
Bipolar Disorder
Obsessive Compulsive Disorder
Depression
Hypothyroidism
Hypertension
Cervical spine surgery
Appendenctomy
Cesarean Section
Social History:
Currently smokes and has a 20 pack-year-history. Used to be a
heavy drinker but now has 1-2 drinks on occassion. No IV drug
use. Patient is close to her mother and 20-year-old son. Used
to work as a sign language instructor.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission: VS:96.1, 103, 91/66, 100% on BiPAP with FI02 of 80%
and 5 of PEEP.
GENERAL: Thin woman, on CPAP, moderate distress, cooperative
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mucous membranes
difficult to appreciate with CPAP
NECK: Supple with JVP of ~7cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. [**4-11**] holosystolic murmur best heard at left sternal border,
[**4-11**] diastolic murmur best heard at right upper sternal border
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations were somewhat labored. Crackles [**1-8**] way up both
lung fields.
ABDOMEN: +BS, soft, non-tender. Slightly distended.
EXTREMITIES: No edema bilaterally; warm and well-perfused.
SKIN: Warm and dry
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2180-10-31**] WBC-22.0*# RBC-4.05* Hgb-12.6 Hct-37.2 RDW-13.9 Plt
Ct-233
[**2180-10-31**] PT-12.6 PTT-23.5 INR(PT)-1.1
[**2180-10-31**] Glucose-114* UreaN-19 Creat-1.2* Na-137 K-3.3 Cl-91*
HCO3-31
[**2180-10-31**] CK-MB-4 proBNP-[**Numeric Identifier 71957**]*
[**2180-11-1**] Calcium-8.4 Phos-4.2 Mg-1.6
[**2180-11-1**] Cardiac Cath:
1. Coronary angiography in this right dominant system revealed
no significant coronary artery disease. The LMCA was normal
without angiographically apparent coronary disease. The LAD was
normal. The LCx was normal. The RCA was normal.
2. Limited resting hemodynamics revealed severely elevated left
sided filling pressures with an LVEDP of 40 mmHg and low central
aortic pressures 66/47 with a mean of 57 mmHg. There was severe
aortic stenosis with a peak to peak gradient of 97 mmHg.
3. Supravalvular aortography revealed 3+ aortic regurgitation.
4. A 30 cc IABP was inserted via the left femoral artery with
satisfactory augmentation
[**2180-11-2**] Intraop TEE:
PRE-BYPASS: The left atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. with mild global free wall
hypokinesis. There are focal calcifications in the aortic arch.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Moderate
to severe (3+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric directed jet of
Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.
POST-BYPASS: On Milrinone, epinephrine, vasopressin, levophed,
IABP
Mild global RV hypokinesis. LVEF 45%. The aortic mechanical
valve is stable, fucntioning well with a transaortic mean
gradient of 20mm of Hg. Thoracic aortic contour is intact. 2+
eccentric MR jet. Cardiac output is 5.2L/min. IABP location is
appropriate.
[**2180-11-11**] Postop ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular cavity is
mildly dilated with normal free wall contractility. A bileaflet
aortic valve prosthesis is present. The transaortic gradient is
normal for this prosthesis. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] 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.
[**2180-11-20**] 04:55AM BLOOD WBC-7.9 RBC-2.96* Hgb-8.7* Hct-27.1*
MCV-92 MCH-29.3 MCHC-32.0 RDW-15.4 Plt Ct-440
[**2180-11-16**] 05:20AM BLOOD WBC-12.7* RBC-3.50* Hgb-10.6* Hct-31.0*
MCV-89 MCH-30.4 MCHC-34.4 RDW-15.6* Plt Ct-510*
[**2180-11-15**] 04:30AM BLOOD WBC-11.6* RBC-3.76* Hgb-11.0* Hct-34.0*
MCV-90 MCH-29.3 MCHC-32.5 RDW-15.6* Plt Ct-516*
[**2180-11-20**] 04:55AM BLOOD PT-21.8* PTT-86.7* INR(PT)-2.0*
[**2180-11-19**] 04:31AM BLOOD PT-18.2* PTT-130.2* INR(PT)-1.6*
[**2180-11-18**] 04:34AM BLOOD PT-15.0* PTT-70.6* INR(PT)-1.3*
[**2180-11-17**] 01:54PM BLOOD PT-15.7* PTT-84.8* INR(PT)-1.4*
[**2180-11-17**] 12:50AM BLOOD PT-16.9* PTT-56.8* INR(PT)-1.5*
[**2180-11-16**] 05:20AM BLOOD PT-17.8* INR(PT)-1.6*
[**2180-11-15**] 04:30AM BLOOD PT-21.1* PTT-28.3 INR(PT)-2.0*
Brief Hospital Course:
This is a 43-year-old woman with a medical history significant
for aortic valve replacement 6 years ago who presented now with
signs/symptoms of acute systolic heart failure. She was admitted
under cardiology and underwent endocarditis work-up, along with
ID consult. Broad spectrum antibiotics with Vancomycin,
Cefepime, and Gentamicin were initiated. The patient was placed
on BiPAP, and given mild diuresis. Despite medical therapy, she
continued to decompensate. Anesthesia was called to intubate the
patient. She continued to clinically deteriorate and required
increased pressors. The decision was made to take the patient to
the catheterization lab. There, severe aortic stenosis with a
peak to peak gradient of 97 mm Hg was discovered. The
supravalvular aortography revealed 3+ aortic regurgitation. The
patient returned to the CCU briefly, where she decompensated
further and required four pressors. At that time, the patient
was taken emergently to the operating room where Dr. [**First Name (STitle) **]
performed redo sternotomy and aortic valve replacement with a
St. [**Male First Name (un) 923**] mechanical size 19 mm valve. For surgical details,
please see operative report. Following the operation, she was
brought to the CVICU for invasive monitoring. She experienced a
postoperative coagulopathy, receiving large amounts of blood
products. She went on to develop hypotension with escalating
pressor requirements. Echocardiogram was consistent with
tamponade and she eventually required re-exploration with
significant improvement in hemodynamics. Also developed oliguric
acute renal insufficiency secondary to acute tubular necrosis,
and was started on CVVH. Due to prolonged ventilation period,
tube feedings were initiated. Once volume status started to
improve, she was successfully extubated on postoperative day
seven. Once her hemodynamics improved, she was transitioned from
CVVH to hemodialysis. She remained stable on medical therapy and
maintained on intravenous Heparin for her mechanical aortic
valve. Warfarin was eventually resumed and dosed for a goal INR
between 2.0 - 3.0. Due to hyponatremia, she was placed on fluid
restriction. She tolerated hemodialysis and was noted to have
gradual improvement in renal function. Due to improving renal
function, hemodialysis was eventually discontinued. Her postop
creatinine peaked to 4.9, and by discharge creatinine improved
to 1.7mg/dL. She continued to make clinical improvements and
was eventually cleared for discharge to rehab on postoperative
days 19 and 16.
Medications on Admission:
levothyroxine 75mcg daily
esomeprazole 40mg daily
clonazepam 1mg 4 times daily
combivent inhaler
budesonide inhaler
mirapex 0.5mg daily
albuterol inhaler
furosemide 40mg twice daily
amphetamine-dextroamphetamine XR 30mg 3 times daily
mirtazapine 15mg daily
trazadone 200mg daily
Discharge Medications:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Dose daily for goal INR [**2-9**] for mechanical AVR.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
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 DAILY
(Daily).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
13. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Itching.
16. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every four (4) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Prosthetic Aortic Valve Endocarditis
Prosthetic Aortic Stenosis/Aortic Insufficiency
Acute Systolic Congestive Heart Failure
Postop Cardiac Tamponade, s/p Re-exploration
Hyponatremia
Acute Renal Failure
Hypertension
History of ETOH abuse
Bipolar disorder/Obsessive Compulsive Disorder
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. No Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**2180-12-4**] @ 1PM [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 71958**] in [**4-10**] weeks. Dr. [**Last Name (STitle) 71958**] will refer to
another cardiologist. Patient does not want to followup with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**].
**Prior to discharge from rehab, please arrange coumadin
followup with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 71958**]** Goal INR 2.0 - 3.0 for
mechanical AVR.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2180-11-20**] Name: [**Known lastname **],[**Known firstname 850**] C Unit No: [**Numeric Identifier 12038**]
Admission Date: [**2180-11-1**] Discharge Date: [**2180-11-20**]
Date of Birth: [**2137-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
The patient was also discharged on Clonazepam as below:
Discharge Medications:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Dose daily for goal INR [**2-9**] for mechanical AVR.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
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 DAILY
(Daily).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
13. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Itching.
16. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every four (4) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
17. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2180-11-20**]
|
[
"287.5",
"276.1",
"428.0",
"493.90",
"300.3",
"599.0",
"428.21",
"286.9",
"401.9",
"296.80",
"584.5",
"998.12",
"996.61",
"244.9",
"424.1",
"423.3",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"35.22",
"39.95",
"38.93",
"39.61",
"37.22",
"37.61",
"96.6",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
16441, 16656
|
7338, 9885
|
341, 544
|
12224, 12439
|
3846, 7315
|
13363, 14724
|
2873, 2960
|
14747, 16418
|
11916, 12203
|
9911, 10191
|
12463, 13340
|
2975, 3827
|
282, 303
|
572, 2386
|
2408, 2611
|
2627, 2857
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,213
| 181,977
|
34657
|
Discharge summary
|
report
|
Admission Date: [**2105-3-11**] Discharge Date: [**2105-4-5**]
Date of Birth: [**2064-7-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Motrin / Tylenol / Codeine / Plavix /
Percocet / Zofran / Morphine / Optiray 320 / Visipaque /
Tramadol / Ketorolac
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Endoscopy, bialteral femoral cathether placement TPA
administatration, power PICC placement
History of Present Illness:
Ms. [**Known lastname **] is a 40 year old woman with a history of type 1
diabetes, htn, protein C deficiency s/p PE not currently on
anticoagulation who presents with severe stabbing RUQ pain,
N/V/D x 1 day. Patient notes acute onset of RUQ sharp, stabbing
abdominal pain while watching TV. No radiation. Nonpleuritic.
Cannot say if changes with food as she has not been able to
tolerate any po intake since onset of pain as also associated
with nausea and vomiting of all po intake. Vomitus described as
brown, bilious, without blood. She does note subjective fevers,
with temp of 101.3 yesterday. Denies chills or nightsweats. She
notes watery diarrhea for the last day as well but denies any
melena, or hematochezia.
.
Of note, she was last admitted [**Date range (1) 79480**] for chest pain.
During that admission she was ruled out for MI with serial
enzymes. She had a CTA that was negative for PE. She had a
normal BNP despite LE edema and crackles. Her peripheral edema
was eventually attributed to renal dysfunction given >100
protein on U/A. During her admission she also had unexplained
anemia requiring blood transfusion. GI evaluated the patient and
recommended EGD and colonoscopy but she refused to have done as
an inpatient. During that admission she also had IJ CVL placed
as she did not have access. She eventually left the hospital
AMA. During that admission she was also found to have diffuse
ground-glass opacities in the lung apices and a right lower lobe
ground glass nodule with some mildly enlarged mediastinum lymph
nodes of unclear significance.
.
In the ED, 98.1, 197/90->122/44, 107->92, 18, 99% RA. Labs
significant for normal WBC of 9 without left shift, 4.8% eos.
Hct was 30.7 (up from low 20s during her last admission). LFTs
normal. Lipase elevated at 63 (last normal 10/[**2104**]).
Electrolytes normal with exception of glu of 209, BUN of 30 (cr
1.1), and elevated K 5.8 which improved to 4.9 with kayexalate,
Cagluc, bicarb, and humalog. U/A not c/w infection but 100
protein and 1000 glucose. Ketones negative. Normal AG. RUQ u/s
was WNL. CT abdomen (w/o contrast d/t reported allergy) showed
no abnormalities with exception of known lung abnormalities seen
on most recent admission, and were stable. On ECG, ED concerned
about [**Street Address(2) 4793**] depression in V5/V6 felt to be new and her first
set cardiac enzymes were negative.
.
On the floor, she is sleeping comfortably but upon arousal,
complains of significant abdominal pain. Otherwise denies chest
pain, SOB, other pain. On further ROS, she notes 1 wk of dysuria
as well as 2 wks of foul smelling urine. She states her sugars
had been running low at home. Also notes new LE edema over the
last day although review of OMR notes LE edema at the time of
her last admission. Denies cough, SOB, orthopnea, PND.
Past Medical History:
# DM, type I
# CAD s/p NSTEMI per pt report
# Hypertension
# Protein C deficiency
# h/o PE [**4-/2104**]
- self d/c'ed coumadin
- s/p IVC filter
# Hyperlipidemia
# ? h/o CHF, ECHO [**2105-1-14**] w/o LVH or sys dysfunction (EF>55%)
# s/p cholecystectomy
# anemia
- reportedly normal EGD and colonscopy in [**5-/2104**] at an outside
hospital per patient report
Social History:
Denies TObacco or ETOH Lives at home with husband. [**Name (NI) **] children.
Reports prior employment as pharmacist, currently undergoing
court case for technicians filling fake prescriptions
Family History:
M CAD, died MI at 55. F first MI at 50, DM prostate CA
Physical Exam:
On discharge:
98.5, 134/69, 89, 18, 93% RA
GEN: Obese, middle aged female, NAD
HEENT: PERRL, EOMI, sclera anicteric, OP clear, MMM
NECK: no LAD
CV: RRR, [**3-13**] sys murmur at LUSB
CHEST: CTA bilaterally. No resp distress
ABD: Obese. +BS. Soft. minimal RUQ TTP, No rebound or guarding.
EXT: WWP. 1+ edema to sacrum, decreased LE sensation and pulses.
SKIN: No rashes, lesions.
NEURO: A+Ox3. CNs [**3-19**] grossly intact. Moving all extremities.
Strength normal throughout, decreased sensation to touch at
feet. Answers questions and follows directions appropriately.
Pertinent Results:
CT abdomen [**2105-3-11**]:
no appy, diverticulitis, or bowel obstruction. 13mm ground
glass nodule in the right lung base, which has been stable since
[**2104-11-3**]. continued follow up is recommended as
Bronchoalveolar cell carcinoma is not excluded.
RUQ u/s [**3-11**]:
Liver displays normal echogenic pattern and architecture without
focal mass lesion identified. Patient is status post
cholecystectomy. There is no intra- or extra-hepatic biliary
ductal dilatation with the common duct measuring 6 mm (may be
normal in a post cholecystectomy patient). The main portal vein
is patent with normal hepatopetal flow. No right upper quadrant
ascites is present. The right kidney appears unremarkable
without hydronephrosis. The pancreas is not well evaluated given
overlying bowel gas.
IMPRESSION: No findings to explain patient's pain. S/p
cholecystectomy without evidence of retained stone.
L LE ultrasound [**2105-3-12**]:
No evidence of DVT in the left lower extremity. Subcutaneous
edema in the left calf.
Renal US [**2105-3-16**]:
Grossly normal renal ultrasound.
Endoscopy [**2105-3-18**]:
Small amount of solid was found in the stomach body. This
finding is compatible with gastroparesis.
Localized erythema, congestion and erosion of the mucosa with no
bleeding were noted in the antrum. These findings are compatible
with erosive gastritis. Two cold forceps biopsies were performed
for histology at the stomach antrum.
RUS [**2105-3-19**]:
1. Normal kidneys and bladder.
2. No evidence of renal artery stenosis. Elevated resistive
indices of the
intraparenchymal vessels suggest chronic parenchymal disease.
MRV [**2105-3-21**]:
Thrombosis of the inferior vena cava below the IVC filter,
extending into both common iliac veins. Thrombus does extend
into the right internal iliac vein and into the left external
iliac vein as described.
IVC Gram [**2105-3-24**]:
Large amount of thrombus in the IVC extending to the external
iliac veins
bilaterally. During this procedure, the patient developed throat
tightness
and hypoxia after infusion of TPA through the AngioJet and
dropped O2
saturations to the low 80s. She responded to 100% O2
non-rebreather.
Infusion catheters were placed and TPA and heparin were both
started. It is believed that her symptoms during the case
represented either PE or contrast reaction.
Echo [**2105-3-25**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no valvular aortic
stenosis. The increased transaortic velocity is likely related
to high cardiac output. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. 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 [**2105-3-20**], no change.
CT ab/pelvis [**2105-3-26**]:
1. No retroperitoneal hemorrhage.
2. Trace ascites. Anasarca.
3. Small bilateral pleural effusions, atelectasis, and
ground-glass opacity, most consistent with pulmonary edema.
4. Unchanged infrarenal IVC filter. Known IVC thrombus below the
level of
the filter is better depicted and described on recently
performed MRV from
[**2105-3-21**].
CXR [**2105-3-27**]:
CHF and underlying infectious infiltrate cannot be totally
excluded.
Bilateral LENI [**2105-3-30**]:
No evidence of deep vein thrombosis in either leg.
___________________________________
Hypercoagubility workup:
Prothrombin mutation - neg
Factor V Leiden mutation - neg
BETA-2-GLYCOPROTEIN 1 antibodies - neg
EPO - high
Lead - low
SPEP - IgG low at 510, no monoclonals
Protein C and S function - normal
___________________________________
Microbiology:
C Diff positive [**2105-3-27**]
UCx positive for E Coli and alpha hemolytic gram positives
[**2105-3-15**]
H Pylori neg [**2105-3-14**]
Blood cultures and sputum cultures neg
___________________________________
Other:
Cortisol - normal
TSH - 1.7
HCG - neg
Cholestrol - TC 303, LDL 225, HDL 39, TG 280
Hgb A1C - 7.9
Anemia panel - Iron 31, TIBC 334, Ferritin 46, B12 415, Folate
8.5, Hapto 180, Fibrinogen 220, Retic count 3, DAF (CD55) and
MIRL (CD59) normal
LFTs - AST, ALT, Alk phos, total bili, amylase, lipase all
normal
Cardiac Enzymes - neg x 12
Chemistries: WNL except creatinine (peaked at 2.5 on [**2105-3-15**], 1.3
at discharge)
CBC: WBC peaked at 16 on [**3-25**], Hct nadired at 20.2 on [**3-26**], MCV
80s with elevated RDW, Plt WNL
Coags: INR 1.9 at discharge on 7.5mg Coumadin
Brief Hospital Course:
40 y/o F with PMHx of DM1, HTN, IVC filter for PEs and
misdiagnosed protein C deficiency, presented initially with
abdominal pain, thought to be due to gastroparesis and
gastritis. Course complicated by peripheral edema, hypotension,
prerenal ARF due to large IVC filter clot, s/p attempted
thrombolysis and initiation of anticoagulation.
# RUQ abd pain/nausea: Pt had extensive workup, including
noncontrast CT, abdominal ultrasound and labs which were
nonconclusive. GI was consulted and performed EGD, which showed
findings consistent with diabetic gastroparesis and erosive
gastritis. Pt was treated with IV dilaudid, PPI, phenergan,
reglan and ativan, quicktly transitioned to PO. Pt had
persistent symptoms of pain, nausea/vomiting thoughtout the
admission, with fluctuating ability to tolerate POs. At
discharge pt, was tolerating >1L liquids plus minimal solids.
# IVC thrombus: During pt's workup for abdominal pain, she was
noted to have worsening peripheral edema. Heart failure and
liver disease were ruled out, as were amlodipine, thyroid
abnormalities, hypoalbuminemia, and nephrotic syndrome.
Abdominal ultrasound showed patent renal and portal vasculature.
Pt then underwent MRI which confirmed large IVC filter clot
extending to bilateral iliacs. Pt was started on heparin drip
and after premedication underwent attempted IR thrombolysis.
[**Name (NI) 79481**] pt suffered from respiratory distress
peri-procedure concerning for anaphylaxis (although received
prophylactic solumedrol, benadryl) vs showering of emboli
(although filter in place). IR was unable to complete procedure,
and the clot burden likely persists. Pt was then monitored in
the ICU while her SOB and hypoxia spontaneously improved. Pt
underwent bilateral LENIs without visualization of femoral clots
or revascularization. Once pt stabilized, IR determined no need
for inpt reattempt, and pt was started on PO warfarin. This was
initially dosed at 3mg (for interaction with concurrent flagyl),
increased to 5mg when switched to PO vanco, and increased to
7.5mg daily for several days at discharge. Pt was set up for
following at the [**Hospital 191**] [**Hospital 2786**] clinic to commence on
[**2105-4-8**].
# Acute Renal Insufficiency: In the setting of repeated
hypotension (thought to be due to poor venous return in the
setting of IVC filter clot), pt developed prerenal acute renal
failure, peaking at a Cr of 2.5. Attempted fluid repletion
worsened peripheral edema, but seemed to not improve pt's
hypotension. Cr worsened with attempted diuresis, but did not
appear to develop ATN per urine sediment examination. At no
point during pt's severe [**Doctor First Name **] sarca, did pt develop pulmonary
edema or respiratory distress and thus sht was allowed to self
regulate and slowly improved her blood pressure and then renal
function. Blood pressure eventually provided room for diuresis,
which was done with daily Lasix 20mg IV. Renal function returned
to baseline prior to discharge and was 1.3 on [**2105-4-5**].
#. Hypoxia - Pt's baseline oxygen saturation was mid 90s on room
air. This was thought to be due to known ground glass opacities,
obesity hypoventilation, and likely OSA. She remained
comfortable at her baseline throughout the admission with the
exception of during her attempted thrombolysis and for several
days afterwards.
Differential included showering of emboli in setting of
thrombolysis, vs anaphylaxis to contrast exposure. Pt showed no
signs of infections on CXR or symptomatically thus was only
treated with antibiotics very shortly. She was not thought to be
in pulmonary edema.
As per prior plan, pt should have follow up imaging of her
ground glass opacities in [**2104-7-6**], 6 month after their initial
diagnosis.
# Hypercoagulability: Pt carried the diagnosis of protein C
deficiency from [**Hospital 1474**] hospital. After records were obtained,
it was confirmed that this diagnosis was made in the context of
anticoagulation. Heme-onc was consulted and hypercoagulability
workup was repeated while on heparin, but OFF warfarin. Pt was
confirmed to NOT be protein C deficient, or have any other
hypercoagulability syndrome. However, due to pt's large IVC
filter clot, she was started on heparin drip, and ultimately on
warfarin. As pt's filter has been in place for approximately 9
months, and is not possible to remove, she will likely need
lifelong anticoagulation to prevent clot extension or
reformation. Workup did incidentally note a slightly low IgG,
which may be due to current infection and heme-onc recommended
repeat in 6wks.
# Anemia: Pt was known to be anemic on admission, with prior
requirement for transfusion. Her anemia studies showed normal
MCV, elevated RDW with severe iron deficiency, and inappropriate
retic count. Etiology of iron deficiency remained unclear, and
pt was recommended to under go an outpatient colonoscopy once
able to tolerate bowel prep. Pt required pRBC transfusion for
several episodes of Hct drop <21, which she tolerated well. She
was also treated with IV ferrlicit x3, and PO iron. On
discharge, Hct had remained stable at ~24 for approximately 1
week.
# Diarrhea: Over pt's long course, she was exposed to broad
spectrum antibiotics in the ICU for concern of pneumonia. Pt
then developed diarrhea, was found to be positive for C diff,
and broad antibiotics were stopped. She was treated initially
with flagyl, and then due to worsened nausea and vomiting was
switched to PO vancomycin to complete the 14 day course. She was
also put on the BRAT diet and ordered TID yogurt for probiotics,
Pt remained afebrile, without leukocytosis and with benign
abdomen throughout the course of the C diff infection.
# Guaic positive stools: Pt was noted to have guaiac positive
stools in setting of epistaxis, c diff, gastritis and iron
repletion. Given known iron deficiency anemia, recommended for
pt to have a colonoscopy. However due to inability to tolerate
POs, and poor renal function, pt was unable to tolerate
colonoscopy prep as an inpt. Pt was treated and discharged on a
proton pump inhibitor.
# CAD: Pt had had recent admission for workup of chest pain. She
was thus known to have non-obstructive CAD on recent cath. Also
recent normal ECHO and stress test. Pt had recurrent, almost
nightly, chest pain, not thought to be cardiac in origin
(repeated EKG unchanged, CEs neg). Pt was continued on her
statin, and BP meds restarted as blood pressure allowed.
# DM1: Pt's type 1 diabetes was monitored with QID finger sticks
and treated with escalating doses of lantus and sliding scale to
parallel her increasing PO intake. On discharge she was taking
70U on Lantus daily.
Medications on Admission:
Furosemide 80 mg DAILY
Clonazepam 0.5 mg [**Hospital1 **]
Metoprolol 25 mg [**Hospital1 **]
Simvastatin 40 mg DAILY
Amlodipine 10 mg [**Hospital1 **]
Lisinopril 20 mg DAILY
Lantus 80 units nightly (states this was decreased from 110
units at her last admission here although documented as 110
units on discharge)
humalog 20 units before meals
humalog insulin sliding scale
Trazodone 150 mg HS as needed.
Isosorbide Mononitrate 10 mg [**Hospital1 **]
Discharge Medications:
1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Insulin
Continue home insulin: Lantus 110 units at night with humalog 20
units pre-meal and sliding scale.
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-11**]
hours as needed for pain.
Disp:*42 Tablet(s)* Refills:*0*
12. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for nausea.
Disp:*64 Tablet(s)* Refills:*0*
14. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
twice a day. Tablet(s)
15. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: take 3 tablets (7.5mg) daily for 2 days, then decrease
to 2 tabs (5mg).
Disp:*30 Tablet(s)* Refills:*2*
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic Gastroparesis
IVC thrombosis
C Difficile colitis
Urinary tract infection
Secondary:
DM I
Hypertension
Discharge Condition:
Stable, INR 1.9
Discharge Instructions:
You were admitted with nausea, vomiting, abdominal pain and
diarrhea. We think this is likely due to gastroparesis, a
complication of long-standing diabetes, where your stomach does
not contract as it should and your food does not pass, causing
nausea/vomiting and pain. To make a definite diagnosis of this,
you should be seen by gastroenterology as an outpt and have a
study called "gastric emptying study".
You also developed severe peripheral edema, thought to be due to
a large clot on your IVC filter. Interventional radiology
attempted but was unable to lyse the clot. You were managed with
blood thinners with gradual improvement of the edema. You will
need to continue your coumadin and follow up in the coumadin
clinic at [**Hospital3 **] to manage your doses. This will prevent
further growth of your clot, or formation of a new clot.
You also developed a diarrhea that is called C. Difficile. This
needs to be treated for 14 days with an antibiotic. You have
received 8 days while in the house and need to finish the last 6
at home.
You also had multiple repeated episodes of chest pain. These
were evaluated and cardiac causes were ruled out. The most likey
cause is GI disease such as heart burn, esophageal spasm or
gastritis.
You were also noted to have bloody stools as well as severe iron
deficiency anemic. Although we repleted your iron, you will need
to continue iron at home, and follow up with gastroenterology to
have a colonoscopy in the near future.
We made multiple changes to your medications as listed below.
Please take everything as prescribed.
If you develop lightheadeness/dizziness, coolness of your feet,
worsened nausea/vomiting or any other concerning symptoms,
please call your PCP or return to the hospital.
It was a pleasure taking care of you, we wish you the best!
Followup Instructions:
PCP:
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday, [**4-7**] @ 10am at [**Hospital **], [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] 1, Atrium Suite ([**Telephone/Fax (1) 250**]).
Please call your insurance prior to this appointment to let them
know that you are switching your PCP.
Interventional radiology:
[**Hospital **] clinic on Wed 3/11at 11am on [**Location (un) 470**] of the Clinical Center
on [**Hospital Ward Name 517**]. Check in at the Radiology front desk.
GI:
Dr. [**First Name (STitle) **] [**Name (STitle) 79482**] on Tuesday, [**4-14**] @ 4pm at
Gastroenterology, [**Hospital Ward Name 516**], [**Hospital Unit Name 1825**] [**Location (un) 453**]
([**Telephone/Fax (1) 463**])
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
Completed by:[**2105-4-5**]
|
[
"008.45",
"362.01",
"518.81",
"250.61",
"996.74",
"E849.8",
"E879.8",
"578.1",
"995.0",
"583.81",
"E878.8",
"250.41",
"453.2",
"401.9",
"V64.1",
"041.4",
"250.51",
"289.81",
"584.9",
"536.3",
"507.0",
"599.0",
"996.79",
"E947.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.07",
"45.16",
"99.10",
"88.51",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18464, 18470
|
9402, 16068
|
413, 507
|
18635, 18653
|
4625, 9379
|
20515, 21444
|
3962, 4019
|
16569, 18441
|
18491, 18614
|
16094, 16546
|
18677, 20492
|
4034, 4034
|
4048, 4606
|
359, 375
|
535, 3350
|
3372, 3735
|
3751, 3946
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,563
| 190,933
|
6262
|
Discharge summary
|
report
|
Admission Date: [**2179-4-29**] Discharge Date: [**2179-5-7**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall with C1 and C2 fractures
Major Surgical or Invasive Procedure:
trach and PEG on [**2179-5-6**]
History of Present Illness:
Mr. [**Known lastname 24347**] is an 87M with a history of stroke who presented
on [**2179-4-29**] with light-headedness. The patient fell 2 days prior
to admission after drinking a [**Doctor Last Name 6654**]. He developed
light-headedness on the day of admission and his wife noticed
his breathing was shallow. He denied any complaints on arrival
in ED. Denies headache, dizziness, numbness, weakness, tingling,
neck or back pain, chest pain, dyspnea, nausea, vomiting,
blurred vision, double vision, bowel
or bladder incontinence.
Past Medical History:
A-fib, HTN, depression, h/o seizures , hearing loss, osteopenia,
s/p CVA, sleep apnea, hx bezor, Hx Bell's Palsy, GERD
Social History:
works with wife and works as an artist.
Tobacco:neg, EtOH:occasional, IVDA:neg
Family History:
CAD, Depression
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 98.7 HR: 68 BP: 149/85 RR: 16 Sat: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: irregular b/l EOMs intact
Neck: hard collar in place
Extrem: Warm and well-perfused, except for bruising and pain in
left forefinger/knuckle
Neuro:
Mental status: Awake and [**Doctor Last Name 3584**], cooperative with exam
Orientation: expressive aphasia but can communicate via writing
etc. oriented to month/year
Right nasal labial fold flattened
no pronator drift
Motor:
D B T WE WF G IP Q H AT [**Last Name (un) 938**]
G
R 5 5 5 5 5 5 5 5 5 5 5
5
L 5 5 5 5 5 4 5 5 5 5 5
5
Sensation: Intact to light touch
Reflexes: Br Pa Ac
Right 2 2 2
Left 2 2 2
no clonus, no hoffmans
PHYSICAL EXAMINATION ON DISCHARGE:
Awake and [**Last Name (un) 3584**], nods head appropriately, follows simple
commands, full strength.
CTO brace in place
Pertinent Results:
[**2179-4-29**] Non-contrast Head CT:
1. Fracture of the anterior arch of C1 and probable fractures
involving the posterior arches. Recommend CT C-spine for
further evaluation.
2. No acute intracranial hemorrhage. Continued
encephalomalacia of the left frontal and parietal lobes
consistent with prior MCA infarct. Atrophy and chronic small
vessel disease.
[**2179-4-29**] CXR: No acute cardiopulmonary process.
[**2179-4-29**] Non-contrast Cervical Spine:
1. Acute fractures in the anterior and posterior arches of C1
consistent with [**Location (un) 5621**] fracture with superior displacement of
the posterior arch fragment. Associated widening of the C1 and
occipital condyle articulation on the right, concerning for
ligamentous injury.
2. Type 2 dens fracture with retropulsion of the superior
fragment into the spinal canal. MRI is recommended for further
evaluation of ligamentous injury or spinal cord compromise.
3. Old compression deformities of T2 and T3.
[**2179-4-29**] Left hand x-ray: Dorsal dislocation of second MCP joint
[**2179-4-30**] CT Thoracic spine:
Interval progression in the previously demonstrated compression
fractures at T3 and T5 vertebral bodies with associated kyphotic
angulation and mild retropulsion. Diffuse osteopenia and disc
degenerative changes are identified, more significant at T7/T8
level. Bilateral pleural effusions and areas of consolidation
in both lung bases.
[**2179-4-30**]: CT Lumbar:
1. No evidence of lumbar spine fractures. Mild-to-moderate
multilevel disc degenerative changes as described above.
Diffuse osteopenia is noted throughout the lumbar spine.
Schmorl's nodes are present at the level of L3/L4 and L4/L5
levels.
2. Renal cystic formation is noted on the upper pole of the
left kidney,
partially evaluated in this examination, possibly slightly
larger in
comparison with the prior CT of the chest dated [**2176-1-1**], correlation with renal ultrasound is recommended if
clinically warranted.
C-SPINE (PORTABLE) [**2179-4-30**]: Initiation of traction
There is again seen a fracture involving the dens of C2. There
is some
separation measuring approximately 5 mm at the more anterior
aspect of the
site of the fracture. There are degenerative changes, worst at
C3-C4 with
disc space narrowing. No abnormal antero- or retro-listhesis is
seen.
[**5-1**] C-SPINE NON-TRAUMA [**12-25**] VIEWS PORT without traction
There is separation of fracture by 6 mm. The dens and the
anterior arch of C1 appear adjacent to one another. There is
slight subluxation of the dens fragment in relation to the body
of C2. Degenerative changes at C3-C4 are also present.
[**5-2**] C-spine Xray portable without traction:
There is separation of the fracture fragments by 5mm with
increased posterior displacement of the dens fragment in
relation to the base of C2
measuring 8 mm, previously 4 mm.
[**5-2**] Chest xray for line placement:
Comparison is made to previous study from [**2179-5-2**].
There is an endotracheal tube whose distal tip is 2.2 cm above
the carina. The side port of nasogastric tube is again at the
GE junction. The right-sided central venous catheter has been
pulled back with the distal lead tip in the mid SVC. There is a
persistent left retrocardiac opacity. This is stable. There is
mild atelectasis at the right base.
[**5-3**] C-spine Xray portable with traction:
Evaluation of the C2 dens fracture is limited. There is
persistent separation of the fracture fragments. The dens
fragment appears in improved alignment with the base of C2,
although the evaluation is limited.
[**5-3**] CT Cspine with and without traction 10:00:
IMPRESSION:
1. No angulation or subluxation in or out of traction. This is
significantly improved from the prior exam.
2. Stable [**Location (un) 5621**] fracture of the C1 vertebral body.
3. Stable mild distraction of the type 3 dens fracture.
[**5-3**] CT C-spine without traction 14:30:
IMPRESSION:
1. Since the prior CT at 10 a.m. on the same day, there has been
a slight
increase in the posterior angulation of the fracture through the
body of C2.
2. Stable appearance of the [**Location (un) 5621**] burst fracture through
the anterior and posterior arches of C1.
3. Probable incidental osteochondroma extending off the left
lateral mass of C1.
4. Ossified fragment medial to the lateral mass of C1 is likely
ossification of the transverse ligament or less likely a
fracture fragment. This is stable from the prior exams.
[**5-4**] C-spine Xray in traction, in CTO brace:
Improved alignment of dens fracture which remains minimally
seperated
[**5-4**] Chest Xray: PORTABLE SUPINE CHEST RADIOGRAPH: Endotracheal
tube terminates 4.4 cm above the carina. Nasogastric tube
terminates in the proximal stomach slightly higher than on the
prior study and as mentioned previously can be advanced for more
optimal positioning.
Right subclavian catheter terminates in the mid SVC. Left basal
opacity and mild vascular congestion are improved with calcified
granuloma seen in the right apex.
[**5-4**]: CT Cspine without traction:
IMPRESSION: No interval change in the alignment of the
fractures of C1 and C2.
[**5-5**]: CT Abdomen:
IMPRESSION:
1. Bilateral small nonhemorrhagic pleural effusion with
secondary
subsegmental atelectasis.
2. Cholelithiasis without signs of cholecystitis.
3. No findings to suggest prior abdominal surgery
[**5-6**] CXR:
Semi-upright portable chest radiograph was obtained.
Endotracheal tube
terminates 3.2 cm above the carina. Nasogastric tube is again
seen with side hole at the level of GE junction. Right
subclavian catheter terminates in the mid SVC. Bibasilar left
greater than right atelectasis is unchanged with slight decrease
in edema. A right midlung opacity is more apparent given the
decreased edema and may reflect an early pneumonia. Cardiac
size and tortuosity of the aorta is unchanged.
IMPRESSION: Slightly decreased edema with bibasilar atelectasis
and newly
evident right midlung opacity which may reflect a developing
pneumonia.
Finding was discussed by phone with Dr. [**Last Name (STitle) 24348**] by Dr. [**First Name (STitle) **] at
1050 on
[**2179-5-6**].
[**5-6**] repeat CXR: There is a new tracheostomy tube, turned to the
left, tip facing the left tracheal wall. There is no
pneumothorax or mediastinal widening. Small right pleural
effusion is new. Heart size is normal. Thoracic aorta is
tortuous, but not focally dilated. Right subclavian line ends
low in the SVC.
Brief Hospital Course:
Mr. [**Known lastname 24347**] was admitted to the Trauma/Surgical ICU on [**2179-4-29**]
after presenting to the ED with lightheadedness in the setting
of a recent fall. Imaging revealed fractures of C1 and C2 for
which the patient was initially treated with a cervical collar
and monitored with hourly neuro checks. He was also found to
have a dorsal dislocation of the left second metacarpal joint.
On [**2179-4-30**], the patient was intubated and found to have irregular
pupils bilaterally. His INR was reversed with 2 units of FFP and
vitamin K. He was found to have a UTI and was bacteremic with
GPC, started on vancomycin. MRI c-spine was done to evaluate for
cord involvement and c-spine x-ray obtained pre-traction for
baseline studies. Patient was placed in traction. The weight of
traction was increased by 5 lbs each time c-spine imaging was
completed and showed no change in subluxation. He was at 15lbs
of traction when c-spine x-ray showed reduction of subluxation.
Hand was consulted for dislocation of 1st MCP joint who reduced
dislocation and recommended a splint and follow up in hand
clinic in [**11-23**] weeks. On [**5-1**], patient was taken out of traction,
pins remained in place, and he was elevated. C-spine imaging
showed stable C1/C2. Overnight he was febrile and full
cultures were sent.
Morning portable AP and Lateral C-spine xrays on [**5-2**]
demonstrated increased posterior displacement of the dens
fragment in relation to the base of C2 and so the patient was
placed back in cervical traction to 15lbs. He remained
intubated with an unchanged neurological exam.
On [**5-3**],The patient's hematocrit was 26 from 31 the day prior.
The patient was transfused with 1 unit of PRBC. The post
transfusion Hct was 28.1. The patient had a CT of the neck in
traction and out of traction with minimal displacement and a
Cervial hard collar with thoracic extension was ordered. The
brace was fitted and the patient had another CT out of cervical
traction that demonstrated posterior displacement of the dens
fragment and subluxation. The patient was placed back in
cervical traction. On exam, the patient was able to move his
extremities antigravity to command off sedation.
On [**5-4**] C-spine Xray in traction and CTO demonstrated good
alignment of the fragment with minimal displacement. The
orthotic team was called to adjust the brace to place the
patient in more flexion in order to maintain alignment. His
exam and respiratory status improved and he was following
commands in all 4 extremities with good strength, very attentive
and interactive.
On [**5-6**] a trach and PEG was placed.
On [**5-7**] he weaned from the vent. He remains interactive,
attentive. Follows simple commands. Moves all extremities full
strength. He was screened and accepted to rehab and was
discahrged.
Medications on Admission:
-coumadin
-keppra 500mg [**Hospital1 **]
-tamsulosin 0.4mg qhs
-metoprolol succinate 100mg daily
-citalopram 20mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, T>38.5
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Citalopram 20 mg PO DAILY
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. LeVETiracetam Oral Solution 500 mg PO BID seizure d/o
13. Metoprolol Tartrate 50 mg PO BID HTN/hx of afib
hold if SBP<100
14. Piperacillin-Tazobactam 4.5 g IV Q8H
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Tamsulosin 0.4 mg PO HS
17. Warfarin 3 mg PO DAILY
goal INR [**12-25**]
18. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
19. Vancomycin 750 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Respiratory failure
C1/2 fracture
atrial fibrilation
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:
Dr. [**Last Name (STitle) 14354**] [**Name (STitle) **]
?????? Do not smoke
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Wear your hard cervical collar with thoracic extension vest at
ALL TIMES. sponge bath around the vest and collar.
?????? YOU [**Month (only) **] NOT take the collar OFF at any time
?????? 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.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Coumadin may start [**2179-5-7**] at a dose of 3 mg qd.
The goal INR is [**12-25**] for intermittent Atrial Fibrillation which
has been approved by Dr [**Last Name (STitle) **](neurosurgery) and Dr [**Last Name (STitle) **]
(primary care physician).
The INR should be rechecked on Monday [**2179-5-10**] and the primary
care physician should be notified. The contact information is
Name: [**Name (NI) **],[**First Name3 (LF) **] S.
Location: PERSONAL [**Hospital **] HEALTH CARE, P.C.
Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1408**]
Fax: [**Telephone/Fax (1) 18702**]
Email: [**University/College 24349**]
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 3 months.
??????You will need CT of the cervical spine-scan prior to your
appointment.
The INR should be rechecked on Monday [**2179-5-10**] and the primary
care physician should be notified. The contact information is
Name: [**Name (NI) **],[**First Name3 (LF) **] S.
Location: PERSONAL [**Hospital **] HEALTH CARE, P.C.
Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1408**]
Fax: [**Telephone/Fax (1) 18702**]
Email: [**University/College 24349**]
Completed by:[**2179-5-7**]
|
[
"041.49",
"790.7",
"584.9",
"530.81",
"E885.9",
"790.92",
"834.01",
"438.11",
"599.0",
"401.9",
"V49.86",
"805.02",
"E879.8",
"997.31",
"733.90",
"458.9",
"427.31",
"V58.61",
"345.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"31.1",
"79.74",
"96.6",
"96.04",
"43.11",
"93.44",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12746, 12817
|
8705, 11538
|
288, 321
|
12914, 12914
|
2187, 2216
|
15179, 15919
|
1141, 1158
|
11709, 12723
|
12838, 12893
|
11564, 11686
|
13094, 15156
|
1173, 1194
|
2045, 2168
|
215, 250
|
349, 885
|
2225, 8682
|
1208, 1454
|
12929, 13070
|
907, 1028
|
1044, 1125
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,616
| 176,734
|
9104
|
Discharge summary
|
report
|
Admission Date: [**2113-3-18**] Discharge Date: [**2113-3-19**]
Date of Birth: [**2034-2-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Morphine
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Chest pain
Reason for transfer to MICU: ?sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 yo woman w/ h/o known CAD s/p RCA stent [**2103**] and [**2105**], severe
MR, A fib, tachy/brady s/p PM, h/o GIB, and chronic urinary
retention s/p recent cystectomy with ileal loop who presents as
transfer from OSH ED after being evaluated there for c/o CP.
While at rehab following recent surgery, patient has had
constant pain in abdomen since her surgery, as well as nausea
over the last several days. She then noted onset of intermittent
SSCP yesterday, ~[**5-21**]. This continued most of the day, but
improved w/ percocet administered by her rehab. Patient then
reports waking up this AM with 10/10 chest pain. CP described as
"heaviness," similar to prior MI. This was associated with
radiation of pain to her stomach, and legs. Also associated with
nausea, but denies associated SOB. CP continued, so she was
taken to the OSH ED.
.
On arrival to OSH ED, BP 120/51, HR 125. EKG revealed sinus tach
with lateral ST depressions. Given Zofran 4mg x1, ASA 162mg x1,
and Morphine 4mg IV x1 initially. Started on heparin gtt. CP not
controlled, so patient given Nitro drip, then Lopressor 5mg IV
x1. Per ED records, she is also noted to have a WBC count of
22.1 w/ 9% bands. Afebrile per records at OSH ED w/ temp 96.8.
+UA per ED records, however, patient has urostomy bag. Given
ceftriaxone 1mg IV x1 at OSH. Given concern for ACS, patient
transferred to [**Hospital1 18**] cardiology service for further management.
On transfer, ED records indicate "disposition vital signs" with
a blood pressure of 87/42.
.
On arrival to [**Hospital Ward Name 121**] 6, patient normotensive w/ BP 104/54, HR 96.
Patient denies chest pain, but c/o [**4-20**] abdominal pain. Of note,
she reports having abdominal pain every day since her surgery on
[**2113-2-16**]. Reports subjective fevers, and nausea x several days.
Denies dysuria or diarrhea, stating "I have a bag." Unsure if
increased output from ostomy bags."
.
While on [**Hospital Ward Name 121**] 6 her blood pressure dropped into the 80's. Given
the overall picture of hypothermia, elevated white count, low
BP, and tachycardia, MICU was called to assess the patient.
.
On interview patient says she has not felt truly well since
having her surgery on [**2-16**]. She says she's had unremitting
abdominal since that time, which has gotten acutely worse over
the past 2-3 days. The worsening pain has been accompanied by
nausea and a desire to vomit but says she hasn't been able to
bring anything up. She says she's lost about 30 pounds in teh
past 2-3 years.
Past Medical History:
- CAD s/p IMI - s/p RCA stenting in [**2103**] and [**2106-5-13**]
- Chronic atrial fibrillation
- Diabetes
- Severe MR
- Cardiomyopathy w/ evere systolic and diastolic ventricular
dysfunction on last cath (no EF on file here)
- Hx of chronic urinary retention, w/ indwelling foley catheter
many years with recurrent UTI's; s/p recent cystectomy with
ileal loop at [**Hospital3 **] Hosp by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29848**]
- Carotid artery disease, s/p right CEA
- [**2-13**] permanent pacemaker implantation due to tachy-brady
syndrome
- Hx of recurrent GIB's, most recently in [**8-17**], s/p
cauterization of bleeding ulcer [**5-17**]
- s/p ileocolectomy for a cecal polyp
- Pancreatic cyst
- s/p cholecystectomy
- s/p appy
- TAH (patient believes that she might have had some form of
cancer)
- Bladder suspension
- Prior MVA (hit by a car)
Social History:
Patient is widowed and lives alone in [**Hospital3 4634**]. She has
four children. One son, [**Name (NI) **] lives in the area and is her
HCPShe is followed by VNA in the [**Name (NI) **] area. +h/o tobacco use
(~60 years), quit 2 months ago. Denies EtOH.
Family History:
"whole family" has heart disease
Physical Exam:
VS: 81/22 88 24 98%
Gen: elderly female, laying in bed, sleeping, NAD.
HEENT: NCAT. Sclera anicteric. EOMI. very dry MM, OP clear
Neck: Supple with flat JVP.
CV: RR, normal S1, S2. +2/6 systolic murmur at apex.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: +urostomy bag RLQ, +colostomy bag LLQ - under appliance no
visuble ostomy; NABS, Soft, diffusely tender to palpation, no
HSM, no guarding. neg [**Doctor Last Name **] sign.
Ext: No c/c/e. +1 DP pulses
Neuro: alert, oriented
Pertinent Results:
[**2113-3-18**] 11:34PM TYPE-ART PO2-92 PCO2-39 PH-7.38 TOTAL CO2-24
BASE XS--1
[**2113-3-18**] 11:34PM K+-4.7
[**2113-3-18**] 06:53PM GLUCOSE-294* UREA N-65* CREAT-3.2*#
SODIUM-128* POTASSIUM-GREATER TH CHLORIDE-88* TOTAL CO2-23
[**2113-3-18**] 06:53PM estGFR-Using this
[**2113-3-18**] 06:53PM ALT(SGPT)-49* AST(SGOT)-177* CK(CPK)-164* ALK
PHOS-227* AMYLASE-200* TOT BILI-1.1
[**2113-3-18**] 06:53PM CK-MB-3 cTropnT-0.20*
[**2113-3-18**] 06:53PM CK-MB-3 cTropnT-0.20*
[**2113-3-18**] 06:53PM CALCIUM-9.0 PHOSPHATE-9.3*# MAGNESIUM-4.3*
[**2113-3-18**] 06:53PM DIGOXIN-1.8
[**2113-3-18**] 06:53PM WBC-22.2* RBC-3.59* HGB-11.4* HCT-35.8*
MCV-100*# MCH-31.8# MCHC-31.9 RDW-17.8*
[**2113-3-18**] 06:53PM NEUTS-89* BANDS-5 LYMPHS-0 MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2113-3-18**] 06:53PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SPHEROCYT-1+
BITE-OCCASIONAL
[**2113-3-18**] 06:53PM PLT COUNT-653*#
[**2113-3-18**] 06:53PM PT-14.5* PTT-48.0* INR(PT)-1.3*
Brief Hospital Course:
Patient arrived in the MICU. She was mentating beautifully
despite BP in the 80-90's, with two peripheral IV's, 1 of which
was running the heparin gtt for her ACS and the other running
the remaining IVF which had been ordered for her on the floor.
Initially she seemed to be responding to the IVF, with her
pressures up into the high 80's-90's. While getting the ICU
consent, she refused several things on the consent form
including A-lines, LP, etc. There was a fairly involved
discussion about central lines because there was a high
liklihood that she might need one, and she did agree to one if
necessary. Her pressures/MAPS did not improve and the RN's
couldn't get any further PIV's. Her mentation remained
excellent but there was some concern as her BP wasn't
stabilizing, and we also needed more access for IV antibiotics.
The RN's also discovered that her ostomy appeared very strange
when they removed her ostomy appliance - it didn't look like a
normal round, ostomy - it appeared sunken, more like a natural
fistula than a surgically created ostomy.
Her abdominal exam was somewhat tender to palpation but no
rebound or guarding.
The MICU attending was called and there were multiple failed
attempts at placing a central line. The patient's BP dwindled
after the fluid was completed and did not respond to another
bolus, staying in the low eighties and then dropping further to
the seventies. Patient was started on periheral dopamine to
support her blood pressure. Her mental status began to
deteriorate and We (Attending, primary RN, other RNs, and
resident) stopped and discussed the overall situation. We had
failed to get any central access and the patient was requiring a
supratherapeutic dose of peripheral dopamine to maintain any
kind of BP/MAP. Her stat labs had come back and were overall
worse with notable ARF. We discussed whether there was any
utility in calling a surgery consult. During the initial
interview, the patient had made it clear that she did not want
any aggressive interventions and was very specific about not
wanting any further surgeries. Given her HD instability, active
ACS, her ARF, and previously stated wishes, the attending spoke
to the patient, who was sleepy but mentating to some degree,
explaining that she was extremely ill, and that we were going to
stop all invasive aggressive procedures and try to treat her
with IV antibiotics. The patient agreed. Her son was
[**Name (NI) 653**] and it was explained that his mother had multiple
system failure and that all interventions except medications had
been stopped.
IV antibiotics were started. Her BP remained low but stable on
peripheral dopa. She remained rousable for a while, but
eventually become somnolent. She went into V tach, then V fib,
and became asystolic. She was pronounced dead at 2:17 AM. The
family declined an autopsy.
Medications on Admission:
Prilosec 20mg daily
Sandostatin 100mcg SC TID
Mag Oxide 500mg PO BID
Digoxin 0.125mg PO daily
Captopril 6.25mg PO TID
Lasix 20mg PO daily
Nystatin S&S
Toprol XL 100mg PO daily
Maalox prn
Tylenol prn
Percocet prn
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"V45.01",
"276.7",
"995.92",
"428.40",
"V44.3",
"V44.6",
"V45.82",
"788.29",
"584.9",
"414.01",
"428.0",
"038.9",
"401.9",
"424.0",
"790.6",
"427.31",
"250.00",
"427.5",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8989, 8998
|
5828, 8694
|
355, 361
|
9049, 9058
|
4756, 5805
|
9114, 9124
|
4104, 4138
|
8957, 8966
|
9019, 9028
|
8720, 8934
|
9082, 9091
|
4153, 4737
|
267, 317
|
389, 2905
|
2927, 3815
|
3831, 4088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,507
| 122,101
|
25781
|
Discharge summary
|
report
|
Admission Date: [**2160-12-12**] Discharge Date: [**2160-12-17**]
Date of Birth: [**2089-5-18**] Sex: F
Service: SURGERY
Allergies:
Chlorhexidine Gluconate/Brush
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Metastatic adenocarcinoma of the
colon to the liver.
Major Surgical or Invasive Procedure:
[**2160-12-12**] extended right hepatic lobectomy, cholecystectomy
History of Present Illness:
Per Dr.[**Name (NI) 1369**] operative note: 71-year-
old female who underwent a right hemicolectomy with
ileocolostomy primary anastomosis performed on [**2160-7-10**], by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] for a high-grade poorly-
differentiated adenocarcinoma of the right colon. Tumor was a
pT3, pN1, pMX. CT scan on [**2160-6-18**], demonstrated no
evidence of metastatic disease to the liver. Postoperatively,
she developed right upper quadrant abdominal pain as an
outpatient and underwent an MRI that demonstrated multiple
rim enhancing lesions in the right lobe of the liver. The
largest lesion within segment 5 measured 2.5 x 1.7 with an
additional lesion in the dome in segment 8 measuring 1.4 x
1.1 cm. A liver biopsy on [**7-23**] demonstrated focus of
poorly-differentiated carcinoma consistent with colon
primary. She underwent a course of modified FLOX chemotherapy
that was started on [**2160-9-22**]. A follow-up CT scan on
[**11-10**] demonstrated progression of disease with a 3.7 x
3.3 cm lesion in the dome of the liver in segment 8, a
segment 5 lesion measuring 6.3 x 5.3 cm, a segment 7 lesion
measuring 4.1 x 3.7 cm and a new segment 7 lesion measuring
1.4 cm in diameter. We have discussed with her the potential
benefit of the hepatic resection for her metastatic disease.
We also discussed the risks and potential complications. She
has provided informed consent and is brought to the operating
room for right hepatic lobectomy, cholecystectomy and
intraoperative ultrasound.
Past Medical History:
PXE, diagnosed at age 42 c/b retinal hemorrhage OU, legally
blind
PVD, s/p bilateral SFA stenting
Hypertension
Hyperlipidemia (patient denies)
Diastolic heart failure
Mitral regurgitation, MVP
Atrial fibrillation
Polymalgia rheumatica
Endometrial cancer, s/p TAHBSO
Left carpal tunnel release
Eczema
Osteoporosis
S/P fungal infection of right toes
.
Cardiac History:
CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD placed: none
.
PMH:
1. PXE (pseudoxanthoma elasticum) a rare hereditary connective
tissue disorder: legally blind
2. A fib (has been holding Coumadin for ~1 month starting with
colonoscopy)
3. Eczema
-Last mammogram [**7-25**]: normal
-Colonoscopy [**2-23**]: normal
4. [**2160-12-12**] ex lap, extended right hepatic lobectomy,
cholecystectomy
OB/GYN HISTORY: She has had NSVD x2. She reports regular
menstrual cycles until her ? early 50s. She denies history of
abnormal Pap smears, STDs, cysts, or fibroids.
Social History:
She is married with two adult children. She does not smoke or
drink alcohol. She is a homemaker.
Family History:
No family history of CAD.
Physical Exam:
height 157cm, wt 75kg
97.2 69 121/69 20 O2 95% RA
pleasant female, legally blind
A&O
lungs clear
cor irreg rhythm
Pertinent Results:
[**2160-12-12**] 01:22PM BLOOD WBC-16.5*# RBC-3.96* Hgb-13.5 Hct-36.6
MCV-93 MCH-34.0* MCHC-36.8* RDW-16.6* Plt Ct-253
[**2160-12-16**] 05:08AM BLOOD WBC-10.7 RBC-3.09* Hgb-10.4* Hct-29.1*
MCV-94 MCH-33.6* MCHC-35.7* RDW-16.7* Plt Ct-239
[**2160-12-16**] 05:08AM BLOOD PT-13.8* PTT-28.3 INR(PT)-1.2*
[**2160-12-17**] 05:47AM BLOOD Glucose-113* UreaN-16 Creat-0.6 Na-129*
K-4.0 Cl-92* HCO3-28 AnGap-13
[**2160-12-12**] 01:22PM BLOOD ALT-225* AST-324* AlkPhos-86 TotBili-2.3*
[**2160-12-13**] 03:32AM BLOOD ALT-512* AST-603* CK(CPK)-739* AlkPhos-83
TotBili-2.7*
[**2160-12-14**] 04:41AM BLOOD ALT-623* AST-346* AlkPhos-100
TotBili-2.4*
[**2160-12-15**] 02:22AM BLOOD ALT-416* AST-139* LD(LDH)-361* AlkPhos-92
Amylase-83 TotBili-1.7*
[**2160-12-16**] 05:08AM BLOOD ALT-283* AST-68* AlkPhos-109 TotBili-2.1*
Brief Hospital Course:
On [**2160-12-12**], she underwent extended right hepatic
lobectomy,cholecystectomy, and intraoperative ultrasound for
metastatic adenocarcinoma of the colon to the liver. Surgeon was
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative report for
complete details. Operative findings revealed several large
masses in the right lobe of the liver with the lesion in the
dome of the liver in segment 8 extending into the segment 4A and
abutting the middle hepatic vein. There were no lesions in the
left lateral segment or the caudate lobe. At the completion of
the extended right
hepatic lobectomy, the lesions were completely excised. The
closest margin on the second lesion in segment 8 was 0.5 cm.
Pathology results were as follows: Right lobe liver, lobectomy
(A-I):
1. Metastatic poorly differentiated adenocarcinoma, consistent
with colonic primary origin.
2. The surgical margin is free of tumor.
II. Gallbladder (J-L):
1. Cholesterolosis.
2. No calculi or tumor.
Postop, she remained in the PACU overnight due to low bp and
pain control issues. She received IV fluid boluses, a neo drip
and 2 units of PRBC for a drop in hct with improvement in her
bp/hct. She remained in afib with rates in the 60-90s. Urine
output dropped but responded to lasix. Atenolol was started for
rate control with good results. She was transferred to the SICU
for monitoring/management. Neo was weaned off. She transferred
out of the SICU.
LFTs increased initially postop but trended down. Diet was
advanced slowly and tolerated. She was passing flatus. Home
meds (except alendronate, ativan & simvastatin) were resumed
including coumadin.
The JP output was non-bilious. This was removed on [**12-17**].Foley
was removed without problems. Abdomen was non-distended, soft.
Incision was clean, dry and intact.
Pain was initially managed with iv morphine then switched to
oxycodone once tolerating pos.
She was discharged to [**Hospital 11851**] Rehab with stable vital signs,
ambulating with a [**Name6 (MD) **] and RN assist as she was functioning
below her baseline. For this, PT recommended rehab. A message
was left with her PCP's answering service (Dr. [**Last Name (STitle) 5292**]
[**Telephone/Fax (1) 64222**]regarding patient transfer to [**Hospital1 11851**] and need
for INR/coumadin management.
A one week follow up with Dr. [**Last Name (STitle) **] should be scheduled.
Medications on Admission:
Alendronate 70 Qwk, Atenolol 25'', Clopidogrel 75', Furosemide
80', Lorazepam 0.5 prn, Omeprazole 20'', Ondansetron 8 Q8prn,
Potassium Chloride 10 mEq', Prednisone 5', Prochlorperazine 10
Q4-6prn, Simvastatin 5', Valsartan-Hydrochlorothiazide 160
mg-12.5', Warfarin 2.5' (afib), ASA 81, Iron 325'', MVI
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: inr goal [**12-23**]
Dr. [**Last Name (STitle) 5292**], [**Telephone/Fax (1) 5294**] manages coumadin.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
10. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
13. Valsartan-Hydrochlorothiazide 160-12.5 mg Tablet Sig: One
(1) Tablet PO once a day.
14. Outpatient Lab Work
INR every Monday and Thursday
Call Dr. [**Last Name (STitle) 5292**] [**Telephone/Fax (1) 5294**] with results
15. Outpatient Lab Work
Monday [**12-21**] labs: chem 7
16. Insulin Regular Human 100 unit/mL Solution Sig: follow
printed slliding scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Metastatic poorly differentiated adenocarcinoma, colon
legally blind due to pseudo xamthmo elasticum
HTN
Hyperlipidemia
Diastolic heart, chronic
MR
Afib
h/o DVT/PE
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, jaundice, worsening abdominal pain, incision
redness/bleeding or drainage.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please call [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator for Dr. [**First Name (STitle) **] W.
[**Doctor Last Name **] (surgeon) for 1 week follow up ([**Telephone/Fax (1) 17195**])
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2161-1-20**] 11:00
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2161-3-23**]
10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2160-12-17**]
|
[
"424.0",
"V10.05",
"710.8",
"401.9",
"725",
"575.6",
"428.32",
"428.0",
"427.31",
"V10.42",
"733.00",
"272.4",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.3",
"99.04",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
8383, 8467
|
4091, 6545
|
344, 413
|
8675, 8682
|
3263, 4068
|
9013, 9680
|
3081, 3108
|
6898, 8360
|
8488, 8654
|
6571, 6875
|
8706, 8990
|
3123, 3244
|
251, 306
|
441, 1974
|
1996, 2950
|
2966, 3065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,759
| 135,728
|
4374
|
Discharge summary
|
report
|
Admission Date: [**2161-9-15**] Discharge Date: [**2161-9-22**]
Date of Birth: [**2100-9-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 F with Type II DM, primary hyperPTH, HTN; admitted with
hyperglycemia. Patient with one week of nausea, vomiting,
anorexia, watery diarrhea. Thought it may be related to starting
high dose weekly vitamin D. In the last few days, unable to hold
down most food/drink (attempts followed quickly by vomiting.
Reports thirst, polydipsia and polyuria for a week as well. Also
mild cough, nonproductive, and mild dyspnea, no chest pain. No
fever, headache, abdominal pain, hemetemesis,
hematochezia/melena, dysuria, joint pains. Does report that
thought process slightly "foggy" though improved since ED
course; also with slightly blurry vision that has also improved
somewhat. Reports that she has been taking metformin daily
rather than twice daily in the last week. No recent travel, no
antibiotics, no sick contacts.
.
She went to her endocrinologist today with the above complaints
and was referred to the ED. In the ED, T96.3, HR 82, BP 120/95,
R18, O2 sat 95% RA. FSBG critically high, then 975 on chem 7.
EKG with TWI in III, given ASA 325 mg. CXR, UA negative. Patient
received 2 L NS, insulin SC and then gtt started. She was
initially admitted to the ICU for further care.
Past Medical History:
1. Diabetes mellitus - last HgA1C 7.0 [**2159-3-16**]
2. Hypertension - poorly controlled in the past
3. Chronic kidney disease - basline Creatine 1.0-1.4
4. Hyperlipidemia
5. History of chest pain with negative stress
6. Hx of Ventral Hernia
7. Pancreatic mass on prior abdominal imaging
Social History:
The patient lives in [**Location 686**] with her husband. She is a
retired school librarian.
Tobacco: None
ETOH: None
Illicit drugs: None
Family History:
Mother: + CAD, Died age 66 of CVA.
Father: Died age 42 of accident
Siblings: 4 deceased, + CAD.
Physical Exam:
Vitals: T97.2, P81, 129/94, R15, 96% RA
General: Obese female, pleasant, nontoxic appearing. NAD. Not
tachypneic or Kussmauling.
HEENT: NC/AT, PERRL, sclera anicteric. MM dry. OP clear.
Neck: supple, no adenopathy.
Chest: CTA bilat.
Heart: RRR S1 S2, no m/r/g
Abdomen: soft, +BS, reports diffuse mild TTP but greatest in
epigastrium (in LLQ in ED), no rebound/guarding.
Extrem: Warm, no edema. 2+ DP pulses. Feet without ulcers or
lesions.
Neuro: A/O x3. Moving all extremities.
Pertinent Results:
TWO-VIEW STUDY OF THE CHEST
INDICATION: 60-year-old woman with nausea and vomiting, cough
with clear
sputum. Evaluate for infiltrate.
COMPARISON: Chest x-ray [**2160-4-2**].
FINDINGS: PA and lateral views of the chest are obtained. The
lungs are
clear, without focal airspace consolidation or pleural effusion.
Cardiac size
is stable and within normal limits. The aorta is ectatic, but
stable in
comparison to the prior study. Pulmonary vasculature and hila
are within
normal limits. Visualized osseous structures are normal.
There is stable elevation of the left hemidiaphragm in
comparison to the prior
study.
.
GASTRIC EMPTYING STUDY: Normal gastric emptying.
.
URINE CULTURE (Final [**2161-9-19**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. PAN SENSITIVE
.
[**2161-9-21**] 7:39 pm SEROLOGY/BLOOD
HELI ADDED TO ACC#[**Serial Number 18860**]B [**9-21**] @ 19:39.
HELICOBACTER PYLORI ANTIBODY TEST (Pending):
.
INSULIN ANTIBODIES Results Pending
.
ISLET CELL ANTIBODY SCREEN NEGATIVE NEGATIVE
[**2161-9-15**] 11:00AM BLOOD Glucose-975* UreaN-28* Creat-1.9* Na-129*
K-4.4 Cl-93* HCO3-20* AnGap-20
[**2161-9-22**] 06:50AM BLOOD Glucose-126* UreaN-10 Creat-1.2* Na-141
K-4.0 Cl-107 HCO3-29 AnGap-9
[**2161-9-17**] 12:07PM BLOOD %HbA1c-12.6*
[**2161-9-16**] 03:59PM BLOOD GLUTAMIC ACID DECARBOXYLASE-Test
Brief Hospital Course:
ASSESSMENT AND PLAN: 60 F with DM type II, HTN, primary
hyperparathyroidism, admitted with mild DKA/significant
hyperosmolar hyperglycemia.
.
# Hyperglycemia. Patient had presenting serum glucose of > 900
with AG of 16 in the ED, a little acetone in blood, negative
ketones in urine. Unclear trigger for the above picture.
Possibilities include med noncompliance (though would not expect
this with holding or decreasing dose of metformin alone),
infection (initial urine, CXR negative), MI (ruled out x 2),
pancreatitis (pain but enzymes negative), thyrotoxicosis (TSH
wnl), EtOH (denies), renal failure (has some acute on chronic,
but likely related to dehydration). HbA1c of 12.6 suggests
long-standing poor glucose control. Picture consistent
predominantly with HONK but does also showed very mild ketosis,
suggesting possible DM type 1 component. Glutamic acid
decarboxylase and anti-islet cell antibodies were negative, but
anti-insulin antibodies were pending on discharge and should be
followed up by her outpatient endocrinologist. Patient was
started on insulin gtt in the ED, admitted to the ICU and and
then transitioned to a sliding scale with Lantus and Humalog. By
the end of her night in the unit, patient's AG had closed.
Patient was transferred to the floor where her blood sugar
remained in the high 200s and gradually came down to the 100s
with titration of her sliding scale. Metformin was held
throughout her hospitalization. Patient was volume repleted with
1/2 NS given hyperosmolarity and electrolytes were repleted.
Patient was discharged on 32 units glargine qHS and Glyburide
5mg [**Hospital1 **]. Metformin was discontinued.
.
# Nausea/vomiting/diarrhea/abdominal pain. No recent travel,
unusual food exposures, sick contacts, fevers. [**Name2 (NI) 116**] be worsened
by HONK/DKA picture, but more likely preceded the hyperglycemia.
Given lack of signs of infection on presentation, bacterial
gastroenteritis unlikely, though viral GE possible.
Gastroparesis was evaluate as a possible etiology with a gastric
emptying study performed with normal results. Patient
experienced several episodes of "chest pain" and burning that
improved with maalox/lidocaine/Benadryl. She was started on
omeprazole 20mg just prior to discharge for gastroesophageal
reflux. Peptic ulcer disease was evaluated as a possible source
of her abdominal symptoms and H. pylori studies were pending on
discharge and should be followed up by her primary care
physician. [**Name10 (NameIs) **] the time of discharge patient was tolerating POs
without nausea and abdominal pain was largely resolved.
.
# Chest pain. Patient experienced two episodes of acute chest
pain with radiation to abdomen without palpitations, shortness
of breath, diaphoresis or radiation to the neck or arm. There
was concern for possible ischemia given patient's echo from
[**2160-10-27**], which showed an inferior infarct not visible on [**3-19**]
Persantine MIBI. EKGs remained stable from her baseline on
admission and she was ruled out with serial enzymes x3 for each
episode. Patient's symptoms improved with
Maalox/lidocaine/Benadryl, suggesting a GI rather than cardiac
origin. Would consider outpatient repeat stress echo.
.
# ARF on CKD. Baseline creatinine 1.1-1.5 but was more elevated
on admission at 1.9, likely due to dehydration/hypovolemia.
Creatinine trended towards baseline with hydration.
.
# UTI. Patient developed dysuria and incontinence with urine
culture positive for E. coli. She was treated with Ciprofloxacin
for 3 days, and symptoms resolved.
.
# Hypercalcemia. History of primary hyperPTH (though not
entirely clear yet per endocrine notes). Mildly elevated
initially, with improvement with hydration. Vitamin D
supplements were held.
.
# Hypophosphatemia. Likely related to hyperglycemia and baseline
low phosphate considering history of ? primary hyperPTH.
Improved with repletion.
.
# HTN. Remained normotensive during hospital stay. Was continued
on atenolol while in the hospital, while spironolactone was held
due to hypovolemia. Patient was instructed to hold
spironolactone until she followed up with primary care physician
[**Last Name (NamePattern4) **] [**2161-9-23**].
.
# Hyponatremia. Pseudohyponatremia that resolved with correction
of hyperglycemia and hydration.
.
# FEN. Patient was given 1/2 NS while she was taking poor POs.
Diet was advanced as tolerated and by the time of discharge she
was able to eat without nausea.
# Ppx. She was maintained on HSQ TID for DVT prophylaxis
.
She remained hemodynamically stable and afebrile throughout her
admission. She was discharged home with follow-up scheduled
with her PCP, [**Name10 (NameIs) **] endocrinologist, and her diabetologist within
two weeks of discharge.
Medications on Admission:
atenolol 50 mg daily
- vitamin D 50,000 units weekly
- metformin 1000 [**Hospital1 **]
- simvastatin 40 mg daily
- spironolactone 100 mg daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Thirty Two
(32) units Subcutaneous at bedtime.
Disp:*30 pens* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
HONK
Nausea, vomiting
Urinary tract infection
Discharge Condition:
Stable, tolerating food and fluid without nausea/vomiting with
adequate control of blood sugar.
Discharge Instructions:
You were admitted with critically high blood sugar. You also
had symptoms of nausea/vomiting and diarrhea. It was found that
you did NOT have a heart attack. You were treated for a urinary
tract infection antibiotics.
.
Your hemoglobin A1C was found to be markedly elevated to 12.6%
suggesting poor diabetes control recently. You were seen by
nutrition to review appropriate diabetic diet. You were
followed by [**Last Name (un) **] team and have been started on an insulin
regimen with improved control in your blood sugar. While you
were in the hospital we also stopped your home medication
metformin. Please DO NOT take metformin when you go home. We are
sending you home with a new prescription for glyburide. Please
take this medication as instructed.
.
You were started on a new medication to try and help your
abdominal pain and possible reflux disease. Please take this
and all of your medications as instructed. We have held your
spironolactone, please do not restart this medication until you
are seen by your primary care physician.
.
Please call your doctor or return to the emergency department if
you develop nausea/vomiting, worsening abdominal pain, inability
to tolerate food/fluid, difficult to control blood sugar, chest
pain, palpitations, shortness of breath or any other symptoms
that concern you.
Followup Instructions:
Please keep all of the following appointments:
.
You will need to see your primary care physician to [**Name9 (PRE) 702**] on
the H. Pylori tests at the following time:
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9613**], MD
Phone:[**Telephone/Fax (1) 7477**] Date/Time:[**2161-9-23**] 12:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD
Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2161-9-25**] 4:00
.
Please follow up your diabetic test results that have not come
back with Dr. [**Last Name (STitle) 3617**]:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 4375**] [**Name (STitle) 3617**] (@ the [**Last Name (un) **])
Phone: [**Telephone/Fax (1) 13733**]
Date/Time: [**2161-10-9**] 9:30
|
[
"287.5",
"275.42",
"584.9",
"041.4",
"403.90",
"599.0",
"250.20",
"585.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9524, 9530
|
4041, 8780
|
323, 329
|
9620, 9718
|
2636, 4018
|
11093, 11880
|
2024, 2121
|
8975, 9501
|
9551, 9599
|
8807, 8952
|
9742, 11070
|
2136, 2617
|
275, 285
|
357, 1539
|
1561, 1851
|
1867, 2008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,857
| 184,481
|
24654
|
Discharge summary
|
report
|
Admission Date: [**2111-8-30**] Discharge Date: [**2111-9-24**]
Date of Birth: [**2085-2-4**] Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Central Line Placement
[**8-31**] removal of tunneled catheter
[**8-31**] placement right internal jugular catheter
[**9-5**] Intubation for lumbar puncture
[**2111-9-17**] removal right internal jugular catheter
[**2111-9-19**] Left PICC line placement
[**2111-9-20**] Left PICC removal
History of Present Illness:
Mr. [**Known lastname 33419**] is a 26 yo M with history of CLL s/p Allo SCT (donor
brother), cardiomyopathy, bigeminy/trigeminy who presented to 7
[**Hospital Ward Name 1826**] outpatient area today for routine lab check. He was in
his usual state of health and had no complaints. His CVL was
flushed with 20 mL of NS prior to infusion but after his nurse
tried to withdraw blood from the line his eyes rolled to the
left side, he became extremely somnolent and was not able to
move his left side. A code blue was code was called. Upon
arrival to the bedside the patient was very somnolent but
responsive to stimuli and was not able to move his extremities
on the left side. The stroke team was called and upon their
arrival the patient was less somnolent and able to move his left
side but to a lesser degree than the right side. He was taken
emergently for CTA head which showed no focal abnormality of
transit time or blood flow to suggest a focus of
infarction/ischemia and no ICH. He was then taken to MRI and
this was unremarkable. He was AO x3 and following comands prior
to the MRI.
.
Upon arrival to the [**Hospital Unit Name 153**], he became acutely confused and would
answer [**2085-2-4**], which is his birthday, to every question. He can
also say he is in pain but cannot say where the pain is located.
.
Past Medical History:
ONCOLOGIC HISTORY:
* Diagnosed in [**2106**] with CLL/SLL and bulky cervical
lymphadenopathy
*Pentostatin/Cytoxan x 1 with transient response and disease
progression prior to 2nd cycle
*R-CHOP x 2 cycles with decline in ejection fraction and
atypical chest pain, resolved over a period of months
*[**1-/2109**] R-CVP x 4
*[**5-/2109**] [**Hospital1 **] (Adriamycin given as thought to be less
cardiotoxic when given in an infusional way)
*[**12/2109**] Rituxan x 1
*[**9-/2110**] R-[**Hospital1 **] x 2 for increasing cervical adenopathy, with
modest response
*[**11/2110**] Bendamustine x 1 with poor response
*[**12/2110**] FCR x 2
*[**2111-5-1**] Reduced intensity allogeneic stem cell transplant
with TLI, ATG, clofarabine as conditioning regimen. Brother is
donor.
.
POST TRANSPLANT COMPLICATIONS:
*CMV first noted [**2111-5-20**], viral load rose on oral valcyte but
resolved on IV ganciclovir. Currently on maintenance Valcyte,
last CMV viral load on [**6-29**] negative.
*BK viruria, viral load trending down and symptoms now
resolved-received IVIG on [**2111-6-11**].
.
PAST MEDICAL/SURGICAL HISTORY: Asymptomatic cardiomyopathy,
bigeminy/trigeminy, positive PPD [**2100**]- 12 months of therapy, s/p
tonsillectomy [**2107**].
Social History:
Former heavy drinker (20 beers/week on average) but has stopped
altogether with current treatment. Lives at home with his
girlfriend. Denies drug use. No smoking. Has worked various
jobs, was most recently employed as a machinist but has been
laid off since 2/[**2110**]. He currently receives unemployment
compensation, and hopefully will be eligible for disability
soon. Of note, his mother was his only parent he had a
relationship with. She passed away when [**Known firstname 1116**] was 20 yo after
sustaining a stroke which was witnessed by family.
Family History:
Mother had stroke at age 48. Patient does not know his father
well. [**Name2 (NI) **] has 2 brothers.
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.2 BP: 138/86 P: 115 RR: 21 O2: 98% 2L
General: AOx1 (self), agitated
HEENT: Sclera anicteric, 3 mm pupils and reactive, MMM
Neck: supple, JVP not elevated, no LAD, R Hickmans with erythema
around the inscision site.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, 2+ edema up to the knee
Pertinent Results:
Admission Labs:
[**2111-8-30**] 12:55PM WBC-4.6 RBC-3.50* HGB-10.8* HCT-32.1* MCV-92
MCH-31.0 MCHC-33.8 RDW-16.1*
[**2111-8-30**] 12:55PM CALCIUM-8.7 PHOSPHATE-2.6* MAGNESIUM-1.5*
[**2111-8-30**] 12:55PM ALT(SGPT)-26 AST(SGOT)-17 ALK PHOS-75 TOT
BILI-0.6
[**2111-8-30**] 12:55PM GLUCOSE-101* UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-3.1* CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
[**2111-8-30**] 02:36PM PT-11.6 PTT-21.4* INR(PT)-1.0
[**2111-8-30**] 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2111-8-30**] 05:13PM CYCLSPRN-343
[**2111-8-30**] 06:40PM LACTATE-3.2*
.
Pertinent Imaging:
.
CT w/out Contrast Torso [**2111-9-6**] 1. Pancolonic wall thickening
and pericolonic fat stranding compatible with colitits. 2. New
opacities in bilateral lungs may reflect developing infection.
.
MRI w/and w/out constrast head [**2111-9-5**]: Interval development
of non-enhancing white matter abnormalities predominantly in the
right parietal and occipital lobes. Differential diagnosis would
include venous ischemia versus encephalitis or vasculitis.
Sulcal FLAIR
hyperintensity is also noted along the vertex of the brain .
There is slow flow in the left transverse sigmoid sinus.
Consider MRV to exclude the possibility of venous sinus
thrombosis.
.
CT w and w/o Contrast of HEAD on [**2111-8-30**]: 1. No acute
intracranial hemorrhage, mass effect, or obvious hypodense area
to suggest an acute infarct. However, if there is continued
clinical concern
given the symptoms and signs, consider MR of the head if not
contraindicated. 2. Patent major arteries of the head and neck
without focal flow-limiting stenosis or occlusion. 3. Small
amount of gas noted in the right internal jugular vein, external
jugular vein, right cavernous sinus, and two tiny foci of gas
noted in the
right parietal lobe. Please note that the head is not completely
included on the CT angiogram study. Consider followup with CT/MR
depending on the clinical presentation and concern.
.
MRI w/o contrast of HEAD [**2111-8-30**] 1. No acute infarction or
mass effect. 2. Two tiny foci of negative susceptibility
correlate with tiny hypodense foci noted in the right parietal
lobe on the concurrent CT study. These may represent tiny foci
of gas, with accurate assessment of the attenuation value on the
prior CT being limited due to volume averaging artifact. 3.
Maxillary retention cysts
.
ECHO: [**2111-8-31**] No atrial septal defect or patent foramen ovale
is seen by 2D, color Doppler or saline contrast with maneuvers
.
MRI w/o contrast of Head [**2111-9-5**]: Interval development of
non-enhancing white matter abnormalities predominantly in the
right parietal and occipital lobes. Differential diagnosis would
include venous ischemia versus encephalitis or vasculitis.
Sulcal FLAIR hyperintensity is also noted along the vertex of
the brain . There is slow flow in the left transverse sigmoid
sinus. Consider MRV to exclude the possibility of venous sinus
thrombosis.
.
CT torso w/out contrast [**2111-9-6**] 1. Pancolonic wall thickening
and pericolonic fat stranding compatible with colitits. 2. New
opacities in bilateral lungs may reflect developing infection.
.
Ultrasound Left upper extremity [**2111-9-19**]:
1. Non-occlusive clot around the PICC line in the left brachial
vein
extending approximately 3 cm into the left axillary vein.
2. Patent left IJ and subclavian veins.
3. No fluid or hematoma around the PICC insertion site near the
antecubital
fossa.
.
Bilateral upper extremity ultrasound [**2111-9-24**]:No evidence of
thrombus in the internal jugular and visualized portions of the
subclavian veins. This study is unable to completely rule out
SVC syndrome. The vena cava was not directly visualized
Brief Hospital Course:
#. Altered mental status: Mr. [**Known lastname 33419**] is a gentleman with small
lymphocytic leukemia status post stem cell transplant on
[**2111-5-1**] who had an episode of unresponsiveness and left sided
hemiplegia at a routine clinic blood draw from his tunneled
central line. He was transferred to the [**Hospital Unit Name 153**] after a Code
Stroke where he was witnessed to be altered but had [**Hospital Unit Name 48752**]
movement in all extremities. MRI and CT of his brain did not
show evidence of infarct but raised question of air emboli in
right parietal lobe which was thought to be the cause of the
initial event. His treatment course in the [**Hospital Unit Name 153**] included work-up
for infectious and toxic causes of his acute mental status
changes were all unremarkable. On HD 6 he was transferred
briefly to the floor after which he was transferred back to the
[**Hospital Unit Name 153**] after a code purple for aggression during an attempted LP.
In the [**Hospital Unit Name 153**], Mr. [**Known lastname 33419**] was intubated and an LP was performed
which was unremarkable. Infectious diseases was consulted, an
infectious encephalopathic picture was felt to be less likely,
viral studies pending. He was treated empirically with IVIG for
BC/[**Male First Name (un) 2326**] and Foscarnet briefly for herpes virus. A 24 hour EEG
demonstrated slow right sided sharp waves which may have served
as epilogenic focus, but no seizures. Repeat MRI imaging
demonstrated white matter lesions in the right parietal and
occipital lobes with slow flow through the left transverse sinus
which were not visualized on the first MRI. An MRA/MRV was
suggested but not completed due to the requirement of medication
to have the study completed. Mr. [**Known lastname 33419**] was transferred back to
the Bone Marrow Transplant floor on HD 9 with improving mental
status. He was consistently oriented, following commands with
normal tone. His hallucinations of people, voices and events
had resolved by HD 15.
.
# Questionable Bacteremia: There was concern that Mr. [**Known lastname 33419**]
suffered from bacteremia following manipulation of his tunneled
line. His tunneled line was removed, and access was placed in
his right IJ. He was started on Vancomycin empirically given
his prior history of MRSA infection. He was continued on home
prophylaxis with micafungin and valacyclovir. He was
hemodynamically stable throughout his stay. Vancomycin was
discontinued on HD 11.
.
#. Coagulase negative Staphylococcus bacteremia: Blood cultures
from [**9-14**], [**9-15**], and [**9-16**] grew three different strains of
coagulase negative staph aureus, all sensitive to vancomycin.
The likely source was an infected right IJ catheter, which was
removed on [**2111-9-17**] due to persistently positive cultures. The
tip culture likewise was positive for the same organisms. He
was begun on vancomycin from [**Date range (1) 31971**], after which he lost
venous access which could not be reestablished. He received 48
hours of linezolid before discharge. He remained afebrile and
asymptomatic throughout.
.
# New pulmonary infiltrate on chest CT: A chest CT on HD 7
demonstrated new pulmonary infiltrates concerning for an
aspiration event while Mr. [**Known lastname 33419**] was altered. He was restarted
on Vancomycin and started on Cefepime. Vancomycin was
discontinued on HD 11 and Cefepime was changed to cefpodoxime on
HD 12. Mr. [**Known lastname 62232**] pulmonary exam was persistently
unremarkable.
.
#. GI GVHD: Patient has a history of GI GVHD being treated with
cyclosporine and prednisone. Because of concern that the
cyclosporine could be contributing to his altered state, Mr.
[**Known lastname 62232**] home cyclosporine levels were decreased and his home
prednisone was increased. He continued to have [**3-19**] loose bowel
movements daily with mild LLQ abdominal pain on exam.
Prednisone was eventually tapered to 10mg Qam and 5mg Qpm. He
was given instructions to restrict his diet to bland foods and
lean meats.
.
#. CLL status post Allo SCT: Mr. [**Known lastname 33419**] was well over 100 post
transplant on admission. He was continued on cellcept. His
cyclosporine dosing was decreased with concern for
neurotoxicity. Prednisone was concommitantly increased on
admission but was slowly tapered as Mr. [**Known lastname 33419**] [**Last Name (Titles) 48752**] his
baseline mental status. He was continued on prophylaxis,
valgancyclovir and micafungin. micafungin was changed to oral
posaconazole on HD 12 and LFTs were trended. He underwent
pentamidine inhalation for PCP prophylaxis prior to his
admission.
.
#. PICC thrombus: Patient received left PICC line on [**2111-9-19**] for
parenteral antibiotics due to his bacteremia. It thrombosed on
[**2111-9-20**] with pain and swelling of the left upper extremity. The
clot was in the superficial venous system, in the basilar vein,
and so the PICC was removed without anticoagulation.
.
#. HTN: During his admission, Mr. [**Known lastname 33419**] was noted to have
elevated blood pressures, with diastolic pressures over 100. He
was started on amlodipine on HD 14 which was increased on HD 15
to 10mg. On HD 16, Mr. [**Known lastname 33419**] complained of bilateral pedal
edema. Amlodipine was discontinued in favor of metoprolol 25mg
[**Hospital1 **]. Of note several EKGs during his admission were significant
for evidence of bigemy and trigemy, which was consistent with
Mr. [**Known lastname 62232**] past medical history.
.
# Edema: Patient was noticeably edematous on the day of
discharge with notable swelling of the neck, face, and upper
extremities. Upper extremity U/S demonstrated no evidence of
SVC syndrome. No upper extremity venous engorgement or
Pembertons sign was noted on exam.
Medications on Admission:
Tylenol 325-650 PO Q4PRN fever
Micafungin 100mg IV q24hrs
Cellcept 500mg PO BID
Olanzipine 5mg PO BIDPRN agitation
Omeprazole 40mg PO Daily
Budenoside 3mg PO TID
CSA Neoral 50mg PO q12hrs
Folic acid 1 mg PO qDaily
Prednisone 30mg PO BID
Ursoidiol 300/600 mg PO BID
Valgancyclovir 900 mg PO BID
Vancomycin 1250 mg IV q12hrs
Discharge Medications:
1. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
2. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day: Until this
prescription is completed. .
3. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
8. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO every morning.
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO every evening.
10. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual three times a day as needed for abdominal cramping:
To be taken NO MORE than three times a day.
Disp:*90 tablets* Refills:*0*
11. Mepron 750 mg/5 mL Suspension Sig: Ten (10) mL PO once a
day.
12. Posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Five (5)
mL PO TID (3 times a day).
13. Maginex Sig: One (1) tablet PO once a day: Take one tablet
Discharge Disposition:
Home
Discharge Diagnosis:
1. Altered mental status
2. CLL
3. coagulase negative staphylococcus bacteremia
4. Graft versus host disease
Discharge Condition:
Stable, afebrile, ambulatory.
Discharge Instructions:
Dear Mr. [**Known lastname 33419**],
You were initially admitted to the hospital because of confusion
and a difficulty moving the right side of your body. A CT scan
and MRI of your brain did not show any signs of stroke, and we
tested you for a possible infection of the brain which was also
negative. You [**Known lastname 48752**] your normal mental status and were
transferred out of the ICU and to the [**Location (un) 436**]. You
unfortunately developed a blood infection from an infected
catheter in your neck that we removed. We treated you with IV
and then oral antibiotics until this infection went away. We
also kept you on a higher dose of steroids in the hospital
because of your worsening "GVH" disease. These steroids made
you very puffy, which should likely resolve as we decrease their
dose slowly and as you resume your normal activity.
Please keep track of your stools and call Dr. [**Last Name (STitle) **] if they
become very frequent and very loose.
Followup Instructions:
Please keep the following appointments:
1) BED 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2111-9-26**]
12:00
2) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2111-9-29**]
2:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2111-9-29**]
2:30
|
[
"996.74",
"276.8",
"342.90",
"453.9",
"292.11",
"279.50",
"995.91",
"427.89",
"204.10",
"E879.8",
"E939.2",
"276.4",
"795.5",
"E947.9",
"V58.65",
"345.40",
"038.12",
"348.30",
"999.31",
"996.85",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"03.31",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15702, 15708
|
8328, 8339
|
299, 589
|
15861, 15893
|
4521, 4521
|
16920, 17340
|
3789, 3892
|
14526, 15679
|
15729, 15840
|
14179, 14503
|
15917, 16897
|
3932, 4502
|
238, 261
|
617, 1940
|
4537, 8304
|
8354, 14153
|
1962, 3199
|
3215, 3773
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,138
| 128,014
|
5246
|
Discharge summary
|
report
|
Admission Date: [**2171-4-1**] Discharge Date: [**2171-4-13**]
Date of Birth: [**2122-3-19**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
CC: Brought in by wife with increase in lethargy
Major Surgical or Invasive Procedure:
Paracentesis [**4-1**], [**4-3**], [**4-8**]
EGD/colonoscopy [**4-8**]
History of Present Illness:
HPI: This is a 49 y male with h/o of Hep C, DM2, presenting with
2 weeks of increasing lethargy, new scleral icterus, dark urine
and abdominal distention. Saw his PCP (noted + Asterixis) last
Tuesday ([**3-26**]) and was evaluated at BHW and admitted for hepatic
encephalopathy. Work up per wife was a [**Name (NI) 5283**] U/S showing "enlarged
liver", elevated ammonia level and low platelets. Was placed on
Lactulose with improvment in MS and and d/c'd on Friday. Over
the weekend, wife noted increasing lethargy again with worsening
MS and only 3 BM since Sat, while taking lactulose qid.
.
No prior H/O GIB, Cirrhosis, hepatic encephalopathy, SBP,
ascites. No F/C/N/V. Decreased PO intake [**1-10**] to poor MS. [**Name13 (STitle) **]
wife, increased use of NSAIDs last 2 weeks for back pain
.
NG lavage in ED negative.
.
ROS as above
Past Medical History:
PMH:
1. Lumbar degenerative spine disease,
2. Depression/anxiety, (PTSD) related to bagging bodies between
[**2139**]-[**2140**].
3. Cellulitis in his lower limb followed by staphylococcal
septicemia and bilateral septic arthritis of the hip. This has
resulted in replacement as well as 2 revisions of his right hip,
while his left hip also has accelerated osteoarthritis and may
need replacement.
4. Hep C dx in "[**2154**]'s - [**1-10**] IVDU
5. DM2
6. HTN
7. EtOH abuse (now sober for 20+ years)
8. Chronic pain, h/o IVDU - on methadone
Social History:
Social Hx: He has been on disability since [**2157**]. Prior to that,
he worked as a heavy equipment operator between [**2142**]-[**2157**]. He
has had a steady significant other for the last 18 years and has
a daughter, age 15.[**Name2 (NI) **] smokes [**12-10**] pack of
cigarettes a day since the age of 17 years. He quit alcohol 20
years ago, and had an alcohol problem for approximately 3 years
only.
Family History:
Family Hx: Mother with HTN, CAD s/p CABG, NIDDM. Father with CHF
and NIDDM.
Physical Exam:
Physical Exam:
Vitals: T P: R: BP: SaO2:
General: Ill-appearing, jaundiced male who is alert and oriented
to self, person, time. Appears very encephalopathic.
HEENT: NC/AT, PERRL, EOMI without nystagmus, + scleral icterus
noted. MM dry, with dried blood noted around gums and oral
mucosa without any obvious lesions/source visualized.
Neck: supple, no JVD or LAD appreciated
Pulmonary: CTA-B, no w/r/r/
Cardiac: RRR, s1 s2 normal, no m/g/r
Abdomen: soft, very distended with shifting dullness to
percussion. +fluid wave. Few BS. Non-tender to palpation. Liver
edge approx 5 cm below right costal margin. Spleen not palpated.
Guiac + in ED.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l. +chronic venous stasis changes.
Neurologic: +asterixis. Following commands intermittently,
easily distracted. +persveration.
Pertinent Results:
[**2171-4-1**] 04:00PM PLT SMR-VERY LOW PLT COUNT-50*#
[**2171-4-1**] 04:00PM MACROCYT-1+
[**2171-4-1**] 04:00PM NEUTS-61.2 LYMPHS-29.5 MONOS-5.1 EOS-3.7
BASOS-0.6
[**2171-4-1**] 04:00PM WBC-9.1 RBC-3.65*# HGB-12.0*# HCT-34.6*#
MCV-95# MCH-32.8*# MCHC-34.6 RDW-16.0*
[**2171-4-1**] 04:00PM AMMONIA-131*
[**2171-4-1**] 04:00PM TOT PROT-6.9 ALBUMIN-2.7* GLOBULIN-4.2*
CALCIUM-10.1 PHOSPHATE-2.2* MAGNESIUM-1.8
[**2171-4-1**] 04:00PM ALT(SGPT)-98* AST(SGOT)-204* ALK PHOS-344*
AMYLASE-58 TOT BILI-5.5*
[**2171-4-1**] 04:00PM GLUCOSE-191* UREA N-22* CREAT-0.9 SODIUM-130*
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-14
[**2171-4-1**] 04:06PM LACTATE-2.8*
[**2171-4-1**] 04:45PM URINE HYALINE-[**2-10**]*
[**2171-4-1**] 04:45PM URINE RBC-[**5-18**]* WBC-0-2 BACTERIA-0 YEAST-NONE
EPI-0-2
[**2171-4-1**] 04:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2171-4-1**] 04:45PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2171-4-1**] 08:00PM ASCITES WBC-163* RBC-128* POLYS-8* LYMPHS-20*
MONOS-0 MESOTHELI-1* MACROPHAG-71*
[**2171-4-1**] 08:00PM ASCITES ALBUMIN-LESS THAN
[**2171-4-1**] 08:37PM PT-22.2* PTT-40.5* INR(PT)-2.2*
[**2171-4-1**] 10:39PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2171-4-1**] 10:39PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
Brief Hospital Course:
Assessment and Plan: This is a 49 y/o male with Hep C, NIDDM,
h/o IVDU and EtOH abuse, p/w new-onset ascites, encephalopathy.
.
#. Fever - patient finishing 10 day course of levo/flagyl [**4-10**],
but with new fever and leukocytosis. Chest X-ray shows new
white out of L lung and multiple alveolar opacities in R lung,
suggesting multifocal, possibly aspiration pneumonia. No
evidence of free air on CXR. MICU consult called. Lactate of
4.2. Concern also for SBP given low AFTP 0.3 and recent
EGD/colonoscopy. Has R hip stage I decub ulcer, but no erythema
or warmth surrounding lesion, so not suspicious for cellulitis
- Bcx x 2
- UA and urine cx
- paracentesis today p 2 units FFP for emergent INR reversal
- increase abx coverage to vanc, ceftazidime, flagyl (in
discussion with ID) for broad spectrum coverage.
.
#. Desaturation - ABG 7.46/27/88/20, A-a gradient 120. Patient
with anion gap metabolic acidosis with compensatory respiratory
alkalosis. Lactate 4.2.
- supplement with O2
.
#. Hepatitis C/Alcoholic Cirrhosis - active, with VL 84,300.
The patient was encephalopathic with abdominal distention
suggesting ascites. On [**4-1**], the patient had an ultrasound
which showed a nodular liver consistent with cirrhosis, patent
hepato-pedal flow within the portal vein, ascites, sludge within
the gallbladder, and no stones. The read initially stated that
there may be intrahepatic biliary ductal dilatation, and a MRCP
was ordered given his rising direct hyperbilirubinemia.
However, he failed to remain still [**1-10**] to pain and agitation x 5
attempts. In discussion with the attending ultrasound
radiologist, the intrahepatic biliary ductal dilatation seen on
the [**4-1**] ultrasound was likely an overcall, with ductal
measurements of [**1-12**] mm being within normal limits, making an
MRCP unwarranted. An AFP was measured on the patient, and was
found to be mildly elevated to 8.9 (nl up to 8.7), with negative
peritoneal fluid cytologies. This is of uncertain significance
and will require outpatient follow-up. His MELD score is 26,
and he will need a workup for a possible liver transplant. Per
wife, he has quit using heroin for approximately 1 year, and has
had no EtOH for 20 years. Not very compliant per Dr. [**Last Name (STitle) 21448**] and
Dr. [**Last Name (STitle) 21449**], though wife says that he has been compliant
with methadone clinic and that she could improve his compliance.
No known workup for transplant before in past per his doctors
and wife. [**Name (NI) **] with increasing bilirubin today and
ultrasound showing reversal of portal vein flow to hepatofugal,
indicating further decompensating liver failure.
- Liver team aware
- Hep serologies positive for recovery period of Hep B (HBsAg
neg, HBsAB pos, HbcAB pos); past exposure to Hep A (HAV Ab
positive, IgM negative) and positive HCV Ab with VL of 84,000
- Nadolol 20 mg QD for portal HTN and gastropathy
- continue lactulose and rifaximin
- continue protonix 40 Q12 for PPX
.
#. New-onset ascites - This was felt to be from
portal-hypertension [**1-10**] to decompensated liver disease. A
paracentesis on [**4-1**] showed SAAG>1.1, AFTP 0.3, LDH 52, Amylase
19, WBC 76, RBC 114, polys 9, lymphs 32. No evidence of SBP on
both taps [**4-1**] and [**4-3**]. [**4-6**] paracentesis unsuccessful.
Patient was sent for marking by ultrasound, but not enough
ascites to be marked. Repeat ultrasound from [**4-9**] shows
reaccumulating ascites, primarily in RLQ. Patient with new
fever [**4-10**] and s/p EGD/colonoscopy with high risk of SBP
- Diagnostic/therapeutic tap today. 2 units FFP prior to tap
- continue aldactone 50 QD for ascites. Had almost no ascites
seen on U/S [**4-6**]. Physical exam unchanged regarding possible
ascites, though difficult to tell given soft distention.
- fluid restriction to < 2 L
.
#. Encephalopathy - Patient admitted with likely hepatic
encephalopathy. tox screens negative except for methadone.
Mental status appears to have acutely worsened today, though may
have been slowly declining last 2 days. Patient at first not
responding to name, then woke up more and is able to say that he
is in a hospital, but was A&Ox3 morning of [**2171-4-9**].
- lactulose qid, titrate to >3BM's daily + rifaximin. Has had
multiple BMs.
- NPO for now x meds until patient's mental status improves
- low-dose methadone (to prevent withdrawal; see below)
increased to 60 mg QD after discussion with patient's methadone
clinic doctor, all other sedating meds to be held
- outpatient home methadone program set up.
.
#. Guaiac + stool/melena - likely [**1-10**] combination of
NSAID-induced gastritis, thrombocytopenia, liver dysfunction.
Has had a negative NG lavage. [**4-9**] EGD showed 3 cords grade I
varices, portal gastropathy and colonoscopy showed diffuse
continuous congestion with no bleeding consistent with
nonspecific mucosal edema.
- s/p 2 units PRBCs [**4-6**] for decreased Hct since admission
- hct now stable at 28.
- continue protonix [**Hospital1 **]
- nadolol 20 QD for portal gastropathy
- NPO for now given decreased mental status
- active T&S, pt consented for tx
.
#. Hyponatremia - Initially [**1-10**] hypervolemic hyponatremia from
ascites. Stable. Though patient may now be slightly hypovolemic
given that he was mistakenly NPO most of yesterday, despite
having orders for a diet.
- fluid restriction <2 L
- monitor daily Na
- continue aldactone
.
#. NIDDM - exact dose of NPH unknown per wife, will cover with
[**Name (NI) **] and add NPH depending on amount of [**Name (NI) **] needed
- pt with minimal po now
.
#. Chronic pain/h/o IVDU - on high-dose of methadone through
clinic, followed at CAB (Pat-[**Telephone/Fax (1) 21450**]). Cannot continue this
high dose for now given MS/encephalopathy. However, also need to
be concerned about withdrawal. 20 mg methadone qd is the minimum
dose needed to prevent withdrawal (per tox curbside).
- increased methadone to 60 mg qd -> hold/decrease depending on
MS, increase dose if signs of withdrawal.
- patient sinus tachy, BP stable, no other signs of withdrawal
- watch for signs of withdrawal
.
#. Tachycardia - patient with tachycardia throughout this
admission. Does have dry MM, blood crusted mouth, which suggest
some amount of hypovolemia. Patient also complaining of rib
pain (has chronic pain issues), which may be causing
tachycardia. Also, may have some slight withdrawl from
methadone.
- Received 2 units of FFP [**4-9**] prior to scoping
- aldactone decreased back to 50 mg QD.
.
*Prophylaxis: PPI IV bid, pneumoboots, lactulose
*FEN: diabetic/low Na/low protein diet when patient awake and
with supervision
*Access: PICC line
*Code Status: Full
*Dispo: to ICU
*Comm: HCP: [**Name (NI) **] [**Name (NI) 21451**] (h) [**Telephone/Fax (1) 21452**]; (c)[**Telephone/Fax (1) 21453**] -
family made aware of transfer to ICU
Dr. [**Last Name (STitle) 21454**] [**Telephone/Fax (1) 21455**] (beeper), [**Telephone/Fax (1) 13553**] (office) -
methadone program medical director
MICU course:
A/P: 49 y/o male with PMHx of HepC cirrhosis, who intially
presented with hepatic encephalopathy and was transferred to
MICU for worsening mental status and possible aspiration PNA.
Now pt. hypotension requring pressor, increased lactate and
respiratory distress.
.
## Hypotension/Sepsis - o/n pt. with hypotension and increased
lactate. Pt. likely w/ sepsis requring large amounts of fluid
and pressors to maintain adequate blood pressure. Pt. w/ known
pneumonia - likely aspiration - this may be the source. Pt. w/
recent paracentesis that did not show SBP.
- bllod ctx, urine ctx, stool c. diff sent
- cont. aggressive fluid management to maintain pressure
- will need central access to monitor CVP for adequate
resuscitation
.
## Respiratory Distress - Pt. w/ new wheezing this a.m. w/ no
evidence of fluid overload. On rounds, pt. w/ increased work of
breathing (accessory muscles in use w/ low sats )and decreased
mentation. Discussed w/ team and decided to intubate pt. for
hypoxic respiratory failure
- cont. to monitor gas and adjust vent settings as necessary.
.
## Metabolic Acidosis - pt. w/ acidosis, likely in setting of
sepsis. Pt. w/ increased lactate that will not be cleared
easily [**1-10**] to liver failure
.
## HepC/Alcohol Cirrhosis - Based on patient U/S and reversal of
flow it appears that patient with progressively worsening liver
failure. Patient [**Name (NI) **] continue to rise and MELD > 26, and will
need workup for possible liver transplant. Recent paracentesis
w/o SBP
- Consider repeat paracentesis give septic picture
- Will continue to follow with liver
- Will continue lactulose and refaximin
- Will continue nadolol, protonix, aldactone
.
## Altered Mental Status - Was resoloving and was most likely
encephalopathic from liver failure. However, this is now
exacerbated by septic picture
- Will treat for infection
- Will continue lactulose and refaximin as above
.
## PNA - Chest xray suggests worsening opacities consitent with
aspiration PNA. Patient increased altered mental status or
recent EGD may have caused patient to aspirate. Will
empiracally treat for nosocomial infection with
vanc/ceftaz/flagyl.
- Will send blood cx, sputum cx (if possible), urine cx
.
## HTN - Patient currently on ACEI, nadolol, aldactone. Will
monitor BP closely, if BP drop will first d/c ACEI
.
## Anemia - Patient Hct currently stable. Most likely secondary
to liver failure. Patient with EGD and c-scope this admission
which showed no active bleeding.
.
## DM2 - Will cover patient with [**Name (NI) **] and monitor blood sugar
closely given worsening liver failure.
.
## History of drug use - Patient was getting methadone 60mg
daily on floor to prevent withdrawal, however given new altered
mental status will hold methadone for now.
.
## PPx - INR > 2, PPI
.
## Access: R PICC line.
.
## Code: Full at this time, floor team discussed with wife.
.
## Communication: [**First Name8 (NamePattern2) **] [**Known lastname 21451**] (c)[**Telephone/Fax (1) 21453**]; (h)[**Telephone/Fax (1) 21452**]
(Health Care Proxy)-------
Circumstances around Death:
Called by nsg for deterioration of status. Pt's SBP continued
to drop, and failed to come up with fluid boluses. Levophed was
started, but it was still not enough to keep MAPs > 60. AVP was
added as well. MAPs were still in the high 50s, so
neosynepherine was added as well. At that point, the patient
was not looking good and chance for recovery was slim. Family
meeting with Dr. [**Last Name (STitle) **] and Family took place and it was decided
that no further aggressive measures, such as dialysis would be
undertaken. The patient's status continued to deteriorate with
bleeding from NGT, and increasing lactic acidosis on 3 pressors
(lactate 10.4). Another discussion with the family took place
and a decision was made to change pt's code status to CMO.
Morphine drip was started, the patient was weaned off pressors
and vent settings were decreased to minimal support. The
patient was then terminally extubated and subsequently expired
peacefully.
Medications on Admission:
Medications:
Lactulose 30mg QID
Methadone 215mg po qd
Insulin NPH 10 [**Hospital1 **], [**Hospital1 **]
Lisinopril 5mg po qd
Folate 1mg po qd
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt. expired
Discharge Condition:
Pt. expired
Discharge Instructions:
Pt. expired
Followup Instructions:
Pt. expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"286.7",
"250.00",
"995.92",
"507.0",
"570",
"571.2",
"038.10",
"304.01",
"303.93",
"E935.9",
"456.21",
"401.9",
"287.5",
"276.2",
"V58.67",
"518.81",
"572.3",
"280.0",
"V43.64",
"535.41",
"707.04",
"070.44"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.34",
"96.6",
"96.71",
"45.23",
"45.13",
"99.04",
"96.04",
"38.93",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
15967, 15976
|
4690, 15775
|
329, 403
|
16031, 16044
|
3220, 4667
|
16104, 16244
|
2274, 2351
|
15997, 16010
|
15801, 15944
|
16068, 16081
|
2381, 3201
|
241, 291
|
431, 1271
|
1293, 1834
|
1850, 2258
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,530
| 113,333
|
48623
|
Discharge summary
|
report
|
Admission Date: [**2173-11-15**] Discharge Date: [**2173-11-18**]
Date of Birth: [**2112-8-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
ONCO-MED HOSPITALIST ADMISSION NOTE
.
61 year old gentleman with COPD, stage IV NSCLC mucinous
adenocarcinoma and recent PE who presents with dyspnea. He
reports sudden-onset worsening of respiratory status on the
morning of admission without associated productive cough,
fevers/chills, CP, or other symptoms.
.
Of note, patient was recently readmitted in early [**2173-10-28**]
for SOB/dyspnea, at which time a new LLL consolidation was seen.
He was provided with one dose of Vanc/Cefepime, and started on
a morphine drip in concert with patient's HCP as well as patient
wishes. Improvement in clinical status was noted overnight and
his morphine drip was discontinued. His acute respiratory
decompensation was attributed to a mucus plug, aspiration,
perhaps with contributing atalectasis. He was continued
albuterol/ipratropium nebulizers, as well as enoxaparin [**Hospital1 **] for
his recent PE's. Antibiotics were not resumed at time of
discharge. After discharge, blood cultures from [**2173-11-3**] grew
Fusobacterium Nucleatum in one out of two bottles. The patient
was contact[**Name (NI) **] on [**2173-11-6**] regarding this lab result, and did not
feel any different since discharge from the hospital. Repeat
blood cultures at his outpatient oncologist failed to reveal
positive cultures. Since his recent discharge, discussion
regarding hospice care has been continued with his oncologist
Dr. [**Last Name (STitle) 45322**], given the patient's poor prognosis.
.
In the ED, initial vitals recorded were a RR of 32. Labs showed
hyponatremia with a sodium of 129, otherwise unremarkable CMP.
CBC with WBC count of 16.0 with 97.3 PMN's and 2.4 %
lymphocytes. HCT of 30.6, platelets of 508. Coags showed INR of
1.2, PTT of 31.8. CXR showed Stable right-sided pleural effusion
and post-obstructive consolidation, increasing left pleural
effusion with basal atelectasis. Patient had his pleurex
catheter drained with 300 cc's of straw colored fluid aspirated.
He was administered albuterol/ipratropium nebs,
vancomycin/zosyn, as well as lorazepam and methylprednisolone.
.
In MICU, VS: 96.9 103 131/74 14 90%4L NC. He endorsed feeling
hungry. His respiratory status stabilized after clearing mucous
plug, but still requiring 4-5L NRB. No antibiotics were given as
low suspicion for acute infection. He improved with time,
albuterol/ipratropium nebs. He was continued on lovenox for
recent PE. In addition, as a large component of dyspnea was
anxiety, patient was placed on standing clonazepam 1mg TID.
Palliative care was consulted for assistance with pain control
and was made DNR/DNI. Of note, he was found to be growing G+
cocci in 1 of 2 Bcx bottles, was started on IV vancomycin and
was transferred out of ICU.
.
ROS: He denies F/C/S, N/V, headache, dizziness, chest pain,
abdominal pain, back pain, constipation, diarrhea, hematochezia,
urinary symptoms, or rash. All other ROS were negative.
Past Medical History:
1. Metastatic NSCLC to [**Last Name (LF) 500**], [**First Name3 (LF) **], with malignant effusion,
Pleurex placed [**2173-9-16**], s/p carboplatin/paclitaxel x2 cycles,
then pemetrexad x2 cycles (last given [**2173-11-11**]).
2. PE, 9/[**2172**].
3. CVA.
4. Carotid stenosis s/p CEA [**2173-7-31**].
5. Hypertension.
6. Ocular migraine.
7. Alcohol abuse.
8. Hyperlipidemia.
Social History:
- Tobacco: Smoked 2 PPD age 20 to 61.
- Alcohol: Former heavy drinker, drinks [**11-29**] bottle of wine per
night.
- Illicits: Denies.
- Occupation: ECG engineer.
- Exposures: Denies.
Family History:
Mother - colon cancer at 83 s/p resection, still alive at 88,
hypertension.
Father - died of multiple myeloma at age 80, high cholesterol.
Sister 1 - died of malignant brain tumor at age 24.
Sister 2 - hypertension.
No FH of stroke, diabetes.
Physical Exam:
Admission to Floor Physical Exam
Vitals: 97.8 108/62 111 21 97%NC 5L, 0/10 pain
General: Alert, oriented, no acute distress, dyspnia
occasionally interferes with his ability to complete sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Diminished BS at bases b/l, R>L
CV: Tachycardic ~110, regular rhythm, normal S1 + S2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2173-11-15**] 11:30AM WBC-16.0*# RBC-3.16* HGB-9.3* HCT-30.6*
MCV-97 MCH-29.6 MCHC-30.5* RDW-17.8*
[**2173-11-15**] 11:30AM NEUTS-97.3* LYMPHS-2.4* MONOS-0.2* EOS-0.1
BASOS-0
[**2173-11-15**] 11:30AM PLT COUNT-508*
[**2173-11-15**] 11:30AM PT-12.9* PTT-31.8 INR(PT)-1.2*
[**2173-11-15**] 11:30AM GLUCOSE-124* UREA N-12 CREAT-0.4* SODIUM-129*
POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-31 ANION GAP-10
.
Thoracentesis Fluid
[**2173-11-15**] 12:00PM PLEURAL WBC-50* RBC-2725* POLYS-67* LYMPHS-24*
MONOS-7* MESOTHELI-2*
.
[**2173-11-15**] CTA CHEST: IMPRESSION:
1. Extensive right lung mass with post obstructive collapse of
the right upper and middle lobes.
2. No pulmonary emboli. The right upper and middle lobe
pulmonary arteries are attenuated by the mass.
3. Pleural effusions increased since the preceding exam 14 days
ago.
4. Extensive sclerotic metastases to the spine and sternum.
5. Ground glass opacity in left apex is non-specific but could
represent infectious process.
.
[**2173-11-15**] CXR: IMPRESSION: Stable appearance of right-sided
pleural effusion and post-obstructive consolidation in the
setting of a known right chest mass; increasing left pleural
effusion with basal atelectasis.
.
[**2173-11-15**] CXR: IMPRESSION: Interval decrease in left pleural
effusion with associated atelectasis and no pneumothorax.
.
DISCHARGE LABS:
[**2173-11-17**] 07:25AM BLOOD WBC-10.0 RBC-2.87* Hgb-8.9* Hct-28.7*
MCV-100* MCH-31.2 MCHC-31.2 RDW-17.6* Plt Ct-382
[**2173-11-16**] 06:36AM BLOOD Neuts-96.7* Lymphs-2.3* Monos-0.6*
Eos-0.2 Baso-0.1
[**2173-11-17**] 07:25AM BLOOD PT-12.2 PTT-27.8 INR(PT)-1.1
[**2173-11-17**] 07:25AM BLOOD Glucose-93 UreaN-9 Creat-0.2* Na-129*
K-4.0 Cl-92* HCO3-31 AnGap-10
[**2173-11-17**] 07:25AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.5*
Brief Hospital Course:
61yo man with metastatic NSCLC to ribs, malignant effusion, and
encasement of right hilum, on enoxaparin for PE, Pleurex
catheter for malignant effusion, hx of CVA admitted to the ICU
for acute dyspnea. He initially required non-rebreather O2m byt
after expectorating a mucous plug, his O2 requirement decreased
to 5L. Palliative care consulted. Clonazepam added for
anxiety. Code status changed to DNR/DNI. Blood cultures grew
GPC in clusters and GPC in chains, two separate species.
Started on vancomycin. He continued to decline requiring more
oxygen again despite suctioning. He was placed on a morphine
gtt for comfort and died [**2173-11-18**] at 16:20PM.
.
# Dyspnea/hypoxia: Due to malignancy and malignant effusion +/-
post-obstructive pneumonia. Required non-rebreather in ICU, but
improved after mucous plug expectorated. Blood cultures growing
GPC in clusters and GPCs in chains. Started vancomycin [**2173-11-16**]
for GPC bacteremia, leukocytosis, increased mucous production,
leukocytosis, tachycardia, and tachypnea --> sepsis. Continued
albuterol prn, fluticasone-salmeterol. Tiotropium changed to
ipratropium nebs. Continued guaifenesin/codeine and benzonatate
for cough. O2 support as needed. Morphine for dyspnea.
Lorazepam for respiratory distress. Suctioned for worsening
hypoxia, but no improvement. Trigger for hypoxia 88% on 6L
[**2173-11-18**]. Mr. [**Known lastname **] and his girlfriend agreed to comfort care
only and inpatient hospice. He was placed on a morphine gtt for
comfort and died [**2173-11-18**] at 16:20PM.
.
# Metastatic NSCLC: Last given pemetrexad [**2173-11-11**]. Palliative
care consulted. Stopped folate considering goals of care.
.
# Leukocytosis: Due to sepsis. No labs considering goals of
care.
.
# Anemia: Likely chemo induced and anemia of inflammation. No
labs.
.
# Chronic PE: Stopped enoxaparin for [**Month/Day/Year 3225**].
.
# HTN: Held metoprolol and hydralazine due to hypotension.
.
# Anxiety: Added clonazepam.
.
# Pain (rib): Continue MSContin. Increased morphine IV PRN for
pain and dyspnea.
.
# FEN: Regular diet. Hyponatremia possibly SIADH stable.
Repleted hypomagnesemia.
.
# GI PPx: PPI and bowel regimen.
.
# DVT PPx: Enoxaparin for PE stopped for [**Month/Day/Year 3225**].
.
# Precautions: None.
.
# Lines: Peripheral.
.
# CODE: DNR/DNI, [**Month/Day/Year 3225**].
Medications on Admission:
Benzonatate 100 mg Capsule Sig: [**11-29**] Capsules PO TID prn
Metoprolol succinate 50 mg Tablet Extended Release 1 tab po BID
Morphine 30 mg Tablet Extended Release 1 po q12hrs
Docusate sodium 100 mg Capsule 1 po BID
Tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: 1
cap qday
Oxycodone 5 mg Tablet 1 po q6hrs prn
Folic acid 1 mg Tablet 1 po qday
Fluticasone-salmeterol 100-50 mcg/dose Disk 1 inh [**Hospital1 **]
Enoxaparin 80 mg/0.8 mL Syringe 1 SC q12 hrs
Albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler PRN SOB
Dexamethasone 4 mg Tablet daily
Lorazepam 0.5 mg Tablet 1 po q4 hours as needed for anxiety.
Hydralazine 50 mg Tablet 1 PO TID
Megestrol 20 mg 1 po qday
Ondansetron 8 mg Tablet ODT PO three times a day PRN
Prochlorperazine maleate 10 mg Tablet 1 PO three times PRN
Pantoprazole 40 mg Tablet 1 tab PO twice a day.
Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Transdermal qday
Discharge Medications:
N/A.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Sepsis (severe blood infection)
Hypoxia (low oxygen levels)
Shortness of breath
Non-small cell lung cancer
Malignant effusion (fluid in the lungs from cancer)
Anxiety
Death
Discharge Condition:
Deceased.
Discharge Instructions:
N/A. Deceased.
Followup Instructions:
N/A. Deceased.
|
[
"511.81",
"198.3",
"272.4",
"V49.86",
"486",
"995.91",
"V15.82",
"518.0",
"162.9",
"198.5",
"285.3",
"V12.51",
"E933.1",
"401.9",
"253.6",
"E915",
"933.1",
"V66.7",
"038.9",
"496",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
9891, 9910
|
6535, 8900
|
314, 321
|
10126, 10137
|
4718, 4718
|
10201, 10219
|
3880, 4124
|
9862, 9868
|
9931, 10105
|
8926, 9839
|
10161, 10178
|
6091, 6512
|
4139, 4699
|
266, 276
|
349, 3265
|
4734, 6075
|
3287, 3662
|
3678, 3864
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,090
| 176,240
|
45028
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 96276**]
Admission Date: [**2192-4-11**]
Discharge Date: [**2192-4-19**]
Date of Birth: [**2144-9-11**]
Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
female with a history of intravenous drug abuse who has been
treated for multiple episodes of endocarditis in the past
with her most recent episode in [**2182**]. At that time she had
been informed that she has tricuspid regurgitation and
recommended a repair of her tricuspid valve which she
declined. Over the last several years she is becoming more
symptomatic complaining of fatigue, dyspnea on exertion,
palpitations and chest tightness and Dr. [**Last Name (STitle) **], her
cardiologist, referred her for surgical evaluation. She
currently describes dyspnea on exertion with chest tightness
and stabbing pain which will resolve spontaneously. She has a
history of varicose veins and has bled from the varicose
veins requiring transfusions but otherwise no new symptoms
are noted.
PAST MEDICAL HISTORY: Significant for asthma, hepatitis C
with active titers, fibromyalgia, Raynaud's, chronic fatigue
syndrome, bipolar disorder, endocarditis times five, history
of intravenous drug abuse, varicose veins, renal calculi,
ectopic pregnancy.
PAST SURGICAL HISTORY: Is significant for a right
thoracotomy secondary to emphysema in [**2182**] and right carpal
tunnel release.
MEDICATIONS ON ADMISSION: Include Ultram 60 mg q 4 hours
p.r.n., methadone 40 mg daily, OxyContin 5 mg as needed,
Ventolin 3 puffs daily, meclozine as needed.
ALLERGIES: Are to penicillin which is anaphylaxis. Codeine
which is gastrointestinal upset.
Last dental examination was on [**2192-3-24**], she had several
extractions and was cleared for surgery by Dr. [**First Name (STitle) **].
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She is currently not working. She lives with
her mother. She smokes one pack a day, just has an occasional
drink with meals. Denies any current intravenous drug use.
PHYSICAL EXAMINATION: Preoperatively her examination
includes she is 5 foot 1 inches tall, weight is 147, heart
rate is 87, regular, blood pressure of 146/78. She is anxious
appearing. The neck is supple with no jugular venous
distension. The heart is regular with a IV/VI systolic
ejection murmur, a II/VI diastolic murmur. The lungs are
clear. The abdomen is soft, nontender. Lower extremities have
bilateral varicosities. She has 2+ distal lower extremity
pulses.
PREOPERATIVE LABORATORY DATA: Included hematocrit of 37.2,
platelets of 128, INR of 1.3. Urinalysis significant for 25
red cells, 2 white cells, less than 1 epithelial. BUN and
creatinine of 12 and 0.7. Hemoglobin A1C of 5.3.
Echocardiogram from [**2192-2-24**] showed an ejection of 60 to 65
percent, 4+ tricuspid regurgitation, mild left atrial
enlargement, moderately dilated right atrium and moderate
pulmonary artery systolic hypertension. Cardiac
catheterization on [**2192-3-16**] demonstrated severe tricuspid
regurgitation, normal coronaries.
HOSPITAL COURSE: The day of admission the patient was taken
to the operating room where she underwent a tricuspid valve
replacement with a 29 mm pericardial valve. Intraoperatively
she tolerated the procedure well but there was an episode of
complete heart block and by the end of the case this had
evolved to block with junctional escape rhythm. Due to the
dysrhythmia a permanent epicardial pacing wire was placed at
the end of the case and its lead remained in the subcutaneous
tissue of the abdomen. The typical electrocardial wires were
placed as well. She was transported to the Cardiac Intensive
Care Unit stable and intubated with a little bit of pressor
support. Over the next day she was extubated, pressor support
weaned and pain service and the electrophysiological service
were consulted. She remained hemodynamically stable by
postoperative day one. She remained in a first degree AV
block. Her beta blocker was dosed initially but then was
stopped due to worry that this might precipitate complete
heart block. She was transferred to the floor on
postoperative day #2 and since then on postoperative day #3
had a temperature spike. She was pancultured, started on
empiric levofloxacin. There have been no positive cultures to
date but she is continued on a full course of antibiotics and
she has defervesced. She has received physical therapy and at
this current time has completed level 4 with the plan of
completing a level 5 prior to discharge. She had a
postoperative anemia which was treated with iron sulfate and
vitamin C. Initially she was on a Dilaudid PCA and the acute
pain service has helped manage her pain regimen and has
evolved down back to the pre-hospitalization regimen. On
postoperative day six her epicardial wires were removed. She
has remained hemodynamically stable in a sinus rhythm with a
first degree block and the EP service is continuing to
follow. The pain service will continue to follow her as an
outpatient as before. She is now currently stable and ready
for discharge to home.
DISCHARGE DIAGNOSES:
1. Severe tricuspid regurgitation, status post tricuspid
valve replacement with a porcine valve.
2. Hepatitis C.
3. Prior intravenous drug abuse.
4. History of edema.
5. Varicose veins.
6. Raynaud's.
7. Fibromyalgia.
8. Bipolar.
9. Chronic fatigue syndrome.
10. Renal calculi.
MEDICATIONS ON DISCHARGE: Lasix 20 mg p.o. daily for two
weeks, potassium chloride 20 mEq p.o. daily for two weeks,
aspirin 81 mg p.o. daily, Colace 100 mg p.o. b.i.d.,
methadone 40 mg p.o. in the morning and methadone 10 mg p.o.
in the evening, albuterol activation aerosol 1 to 2 puffs q 6
hours as needed, vitamin C 500 mg p.o. b.i.d. for one month,
ferous sulfate 325 mg p.o. daily for one month, Neofloxacin
500 mg p.o. daily for seven days. She will follow up with the
[**Hospital 409**] Clinic in two weeks, Dr. [**Last Name (STitle) **] in four weeks. She will
follow up with Dr. [**Last Name (STitle) 770**] in the urology clinic for the
hematuria that she has had.
DISCHARGE CONDITION: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 8958**]
MEDQUIST36
D: [**2192-4-18**] 21:13:59
T: [**2192-4-18**] 21:52:45
Job#: [**Job Number 96277**]
|
[
"426.11",
"070.70",
"397.0",
"998.11",
"428.0",
"518.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.27",
"88.72",
"37.78",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6076, 6357
|
1812, 1830
|
5089, 5376
|
5403, 6054
|
1427, 1795
|
3056, 5068
|
1290, 1400
|
2037, 3038
|
190, 1007
|
1030, 1266
|
1847, 2014
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,815
| 179,756
|
52163
|
Discharge summary
|
report
|
Admission Date: [**2109-6-28**] Discharge Date: [**2109-7-15**]
Date of Birth: [**2039-10-22**] Sex: F
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
chest pain
shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization
pericardiocentesis
pericardial drain placement
History of Present Illness:
69 yo with metastatic cancer to lung, with unknown primary had
chemo today and then developed acure onset of chest pain at 2 am
that woke her from sleep, described as [**7-5**] with diaphoresis,
nausea and SOB with STE inferiorly and laterally she notes that
it was simlar to her previous episodes of CP that she has had in
the past, but never had an MI. She still had CP on arrival to
ED and was taken to cath lab directly after head CT neg for
bleed or mass effect with concern for mets. She was started on
nitro, heparin and integrillin gtt. Cath with normal coronaries
except 40%ostial LCX, elevated right and left heart pressures
and low cardiac output, thought to have pericarditis. Currently
she feels alright, pain is gone, but it comes and goes. She
hasn't noticed a difference or improvement with NTG. She had
started her first dose of chemo today as well, and notes she has
been losing some weight, but otherwise denies any URI,
f/c/sweats/SOB besides with the pain or pain anywhere else.
*****
Briefly, 69yo woman with h/o HTN, hyperlipidemia, DM2, bladder
CA, metastatic lung cancer who had chemo on DOA with
carboplatin/gemcytobene, then developed acute onset chest pain,
SOB that woke her from sleep, found to have pericarditis with
pericardial effusion but no tamponade. A head CT was neg for
bleed or mass effect but with concern for metastatic disease.
She was taken to cath lab for concern about MI, had no flow
limiting lesions (40%ostial LCX), evidence of left heart
diastolic dysfunction and moderate pulmonary HTN with increased
right sided filling pressures. Also had a TTE ([**2109-6-28**]) that
showed normal regional left ventricular wall motion,
hyperdynamic LV (EF>75%), and a small pericardial effusion that
was stable on repeat TTE ([**2109-6-30**]).
.
Over the weekend, the patient had acute worsening of her
shortness of breath in the setting of receiving a blood
transfusion for her anemia, with chest xray revealing pulmonary
edema consistent with a flash from her known hypertrophic
cardiomyopathy. Also of note, the patient developed cough
productive of copious yellow sputum, and given her
immunosuppression from chemotherapy as well as the CTA findings,
was started on Ceftaz/Flagyl and diuresed with Lasix. The CTA
showed: no PE, multiple pulmonary nodules c/w metastases,
multiple pleural-based metastases with adjacent invasion into
the ribs, a loculated hydropneumothorax in the proximal left
lower lobe, compressive atelectasis or consolidation in the left
lower lobe, a loculated pleural fluid collection in the
posterior left base, and a small to moderate pericardial
effusion. In talking with her Oncologist, Dr. [**Last Name (STitle) **] at [**Hospital 10596**], the [**Hospital Unit Name **] resident confirmed that most of these findings
were not new. The Oncologist did not feel that a transfer to DF
was warranted as it seemed the patient might be able to be
discharged soon from [**Hospital1 18**].
.
Since undergoing diuresis and starting on Ceftaz/Flagyl, the
patient's shortness of breath has improved dramatically, and her
sputum production has decreased as well. Of note, she is also
developing pancytopenia but has remained afebrile with ANC 1000
today. She also has a climbing sodium concentration and BUN/Cr
ratio, taking in only tube feeds and occassion ice.
Past Medical History:
metastatic ca with mets to lung, unknown primary s/p chemo two
cycles, but with esophageal mass s/p PEG [**2109-5-29**]
bladder ca s/p urostomy [**2084**]'s
type II diabetes mellitus
hypertension
hyperlipidemia
Social History:
lives with her daughter, son-in-law
no [**Name2 (NI) **], etoh, illicits
Family History:
non-contributory
Physical Exam:
VS: P 91 BP 127/66 Sat 93%on 2LNC
GEN aao, lethargic, in nad
HEENT PERRL, MMM, clear OP, Right IJ triple lumen in place
CHEST CTAB no crackles
CV RRR no murmurs
ABD Soft NT/ND, +BS
EXT trace LE edema
Pertinent Results:
[**2109-6-28**] 03:15AM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TARGET-OCCASIONAL PENCIL-OCCASIONAL
[**2109-6-28**] 03:15AM NEUTS-85.7* BANDS-0 LYMPHS-12.8* MONOS-1.3*
EOS-0.1 BASOS-0
[**2109-6-28**] 03:15AM WBC-5.3 RBC-3.86* HGB-8.8* HCT-28.8* MCV-75*
MCH-22.7* MCHC-30.4* RDW-21.0*
[**2109-6-28**] 03:15AM CK-MB-NotDone cTropnT-0.01
[**2109-6-28**] 03:15AM CK(CPK)-31
[**2109-6-28**] 03:15AM GLUCOSE-153* UREA N-33* CREAT-1.1 SODIUM-141
POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-18* ANION GAP-19
[**2109-6-28**] 04:20AM PT-13.7* PTT-23.2 INR(PT)-1.3
[**2109-6-28**] 05:55AM HGB-7.5* calcHCT-23 O2 SAT-94
[**2109-6-28**] 05:55AM K+-4.1
[**2109-6-28**] 05:55AM TYPE-ART PO2-71* PCO2-32* PH-7.35 TOTAL
CO2-18* BASE XS--6
[**2109-6-28**] 07:00AM PLT COUNT-206
[**2109-6-28**] 07:00AM WBC-4.5 RBC-3.21* HGB-7.2* HCT-24.1* MCV-75*
MCH-22.4* MCHC-29.8* RDW-21.2*
[**2109-6-28**] 07:00AM CALCIUM-8.5 PHOSPHATE-4.5 MAGNESIUM-2.1
[**2109-6-28**] 07:00AM CK-MB-NotDone cTropnT-<0.01
[**2109-6-28**] 07:00AM GLUCOSE-131* UREA N-32* CREAT-0.9 SODIUM-142
POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-17* ANION GAP-17
Brief Hospital Course:
69 yo woman with presumed metastatic lung CA, possible
post-obstructive pna, transferred to the CCU with pericarditis
and tamponade s/p pericardial drain placement and fungemia.
.
1) Pericarditis/pericardial effusion: THis is felt to be a
malignant effusion from metastatic disease. She underwnet
pericariocentesis and pericardial drain placement on [**2109-7-10**].
THoracic surgery was consulted to place a window but she was too
sick as there was concern for collapsing a lung during the
procedure and that she would not have enough lung reserve to
survive that. Pericardial fluid sent grew yeast. Drainage
diminished and the drain was pulled given infection and no
re-accumulation.
.
2) ID: She was transferred with fungemia ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]) on
voriconazole that was swtiched to caspofungin. Her blood was
also positive enterococcus faecium and she was started on
vancomycin. Her post obstructive pneumonia was treated with
ceftazidime and zosyn initially, then meropenum.
.
3) Hypotension:
She became septic with initial SVR 450. She was started on
vasopressin on [**7-10**] and levophed. She was pressor dependent from
then on.
.
4) Resp:
She had a post-obstructive pna and pleural effusion:
She was treated with Ceftaz/Flagyl and then meropenum. CT chest
showed loculated effusions that were not amenable for
throacentesis. She was intubated on [**7-10**] for respiratory failure
secondary to fatigue. The posivtive pressure helped to open
collapsed L lung.
She had a bronchoscopy on [**7-9**], with no frank obstruction,
extrinsic compression of L lower bronchus.
.
5) Metastatic lung CA: followed by Dr. [**Last Name (STitle) **] at [**Company 2860**], spoke to
him on [**7-10**],per records it is a squamous cell pathology, likely
lung. He said given poor prognosis would not favor aggressive
treatment.
.
6) Pancytopenia:
-Anemia: felt to be secondary to recent chemotherapy. SHe was
transfused for hematocrits less than 27.
-Thrombocytopenia: Her platelets dropped, likely from
chemotherapy. Her HIT antibody was negative.
7) CV:
Rhythm - She was in intermittent atrial flutter, initially
treated with diltiazem but that was discontinued when she became
septic.
8) Metabolic acidosis: Non anion gap, likely ARF from ATN and
RTA given + urine anion gap.
9) Goals of care: Given her multiple organ failure and inability
to wean from the ventilator, and her poor prognosis with the
metastatic cancer, her code status was changed to DNR. After
several days of no improvement and continued septic picture and
dependence on pressors and ventilator, additinal family meetings
were held. She was made CMO and passed away comfortably with her
family at her side on [**2109-7-15**].
Medications on Admission:
ferrous sulfate
lipitor
macrodantin
protonix
folate
B12
MVI
lantus
zofran
compazine
lorazapam
fentanyl
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic cancer
Pericadial effusion
Sepsis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"427.31",
"284.8",
"197.0",
"518.84",
"038.8",
"785.52",
"V55.6",
"584.9",
"199.1",
"112.5",
"486",
"198.5",
"041.04",
"276.5",
"420.90",
"428.30",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"88.53",
"38.93",
"99.04",
"88.56",
"37.0",
"37.12",
"89.64",
"96.72",
"00.17",
"37.23",
"96.04",
"88.73"
] |
icd9pcs
|
[
[
[]
]
] |
8482, 8488
|
5557, 8300
|
319, 392
|
8577, 8586
|
4342, 5534
|
8638, 8644
|
4088, 4106
|
8454, 8459
|
8509, 8556
|
8326, 8431
|
8610, 8615
|
4121, 4323
|
249, 281
|
420, 3748
|
3770, 3982
|
3998, 4072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,275
| 109,751
|
33508
|
Discharge summary
|
report
|
Admission Date: [**2120-7-8**] Discharge Date: [**2120-7-12**]
Date of Birth: [**2060-8-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo F with widely metastatic breast cancer including likely
leptomeningeal spread on cycle 2 of taxol and avastan admitted
with subacute, progressive unresponsiveness and a hypotensive
episode.
.
The patient has reportedly had 2 weeks of confusion and
lethargy. She was admitted to [**Hospital3 **] for altered mental
status and increasing unresponsiveness within the past week. At
that time she was found to be hypokalemic to K of 2.6 and
dehydrated. After IV fluid rescucitation and potassium repletion
she was discharged home.
.
On the day of admission, she came to clinic for a scheduled XRT
treatment. She was found to be hypokalemic with severely
depressed mental status. At that visit she opened her eyes to
her name but was not speaking or following commands. She did
respond to painful stimulus. On arrival to the oncology floor,
the patient had vitals of 96.0 92 108/64 22 97% RA. She was
noted to be minimally responsive. Out of concern for mass effect
and/or seizure activity, the patient received 10mg dexamethasone
and 1mg IV ativan. Subsequently her blood pressure declined to
sbp 80 and then 60. She received a 1L NS bolus with return of
sbp to 107. The patient also became bradypneic with this
episode. She was transferred to the ICU for further care.
.
After transfer, the patient's primary oncologist had a
discussion with the patient and her family. The decision was
made for no further invasive tests or imaging studies. The
patient will receive IV fluids, antibiotics and other IV
medications as well as have lab draws.
.
ROS: Unable to obtain.
Past Medical History:
- Metastatic breast cancer. Initially presented in [**2119-11-14**]
with a lytic lesion in the left leg and a breast mass. Biopsy
revealed infiltrating carcinoma. HER-2/neu negative, ER
positive. S/p cyberknife radiation therapy to an 8mm left
cerebellar lesion. Known bony mets. Likely leptomeningeal spread
on MR brain [**2120-4-30**]. Received palliative XRT to the thoracic
spine. She is on cycle 2 of Taxol and Avastin.
- Multiple episodes of severe malignancy associated
hypercalcemia and altered mental status.
- S/p surgical repair of left tibia on [**2120-1-2**]
- Prior hysterectomy and bilateral salpngo-oophorectomy in [**2115**]
for benign causes.
- Surgery for ectopic pregnancy in [**2090**].
Social History:
Married. Previous associate principal in a middle school. 2
daughters in their 40's. Lifetime nonsmoker with rare alcohol
use.
Family History:
Half-sister with breast CA at age 63. No other known cancers in
the family.
Physical Exam:
PE 79 102/38 6 99% RA
Gen: Unresponsive. Moans once. Not following any commands. Not
responding to painful stimulus.
HEENT: PERRL. Eyes pointing upwards.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally.
Abd: Soft, nontender. No distention or organomegaly.
Ext: Trace left lower extremity edema. No right lower extremity
edema.
Neuro: Unresponsive to commands or painful stimulus. PERRL.
Flexed right upper extremity slowly improved with movement.
Unable to ilicit reflexes at the patella. Upgoing toes
bilaterally.
.
Pertinent Results:
Labs: Na 143, K 2.9, Cl 110, Bicarb 22, BUN/Cr 5/0.5, Ca 9.0, Mg
1.7, Phos 2.1, WBC 4.3 (76% N, 14% L), Hct 32.0, platelets 259.
.
ALT 14, AST 43, AP 339, LDH 539, T Bili 0.6, Alb 3.1.
.
CEA 97, CA 27.29 pending.
.
EKG: None available.
.
Micro:
Blood culture
([**2120-6-24**]): No growth.
([**2120-7-8**]): Pending.
Urine culture
([**2120-6-24**]): No growth.
.
Imaging:
MR brain with and without contrast ([**2120-4-30**]): 1. New metastatic
involvement of the leptomeninges, most notable of the posterior
fossa. 2. Stable minimal residual enhancement at the site of
treatment of the left cerebellar metastasis. No new brain
parenchymal lesions. 3. Interval slight worsening in calvarial
metastases including infiltration of the skull base and upper
cervical vertebra.
Brief Hospital Course:
Mr [**Known lastname 77692**] is a 59 yo woman with history of metastatic breast
cancer presenting with two weeks duration of confusion and
icreasing lethargy.
Ms. [**Known lastname 77692**] was admitted to the [**Hospital Unit Name 153**] for subacute, progressive
unresponsiveness and a hypotensive episode likely due to volume
depletion. Her unresponsiveness was likely secondary to
progression of her widely metastatic breast cancer, including
possible leptomeningeael spread. Also, considered was seizure
activity with post-ictal state and toxic-metabolic mediated
altered status in the setting of hypercalcemia and hypocalemia.
On admission to the [**Hospital Unit Name 153**], initially, the goals of care were
discussed, and it was decided not to pursue further chest
x-rays, MRI brain, EEG or lumbar puncture. She was volume
resuscitated, and her electrolytes were repleted. The next
morning, [**2120-7-9**], both palliative care and social work met with
the family to continue to discuss goals of care, which included
being able to take her home with comfort (but not CMO). Per her
neuro-oncologist, however, CT head and MRI of head and neck as
well as EEG were ordered with agreement from family. She was
given a Keppra load and will start on maintenance doses on the
oncology floor. She was deemed stable for transfer to the
oncology floor on [**2120-7-9**].
On the floor the patient remained stable hemodynamically and
neurolgically. The patient received phenytoin and was continued
on levitiracetam on Neuro/onc recomendation. The MRI showed no
evidence of leptomeningeal disase with stable CNS disease.
Continous EEG was obtained which showed evidence of
encephalopathy.
The patient was noted electrolyte abnomalities suggestive of non
anion gap metabolic acidosis which improved on IVF.
The patient's discomfort was managed with IV morhine which was
transitioned to concerntrated elixir at discharge. After a
discusion with the family regarding the goals of care a decision
was made to transition care at home with comfort care.
Palliative care was involved in the management of this patient
and family discussions.
Medications on Admission:
Meds, Inpatient:
- Heparin 5000U subq
- Pantoprazole 40mg Daily
.
Meds, Outpatient:
- Oxycodone prn
- Compazine
- Zofran
- Oxycontin
- Colace prn
- Prilosec prn
- Ativan prn
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1hrs
as needed for pain, discomfort, agitation, shortness of breath.
Disp:*30 ccs* Refills:*0*
2. Ativan 1 mg Tablet Sig: 1-2 Tablets PO q2-4hrs as needed for
agitation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary: encephalopathy
Discharge Condition:
Comfortable
Discharge Instructions:
You were admitted because of altered mental status. This is
probably from progression of your cancer.
Unfortunately, this was not from a reversible process.
Followup Instructions:
None
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
Completed by:[**2120-7-17**]
|
[
"311",
"276.51",
"174.8",
"458.9",
"198.5",
"198.3",
"276.8",
"348.30",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.14"
] |
icd9pcs
|
[
[
[]
]
] |
6910, 6983
|
4255, 6400
|
323, 330
|
7051, 7065
|
3461, 4232
|
7271, 7433
|
2821, 2898
|
6624, 6887
|
7004, 7030
|
6426, 6601
|
7089, 7248
|
2913, 3442
|
275, 285
|
358, 1929
|
1951, 2661
|
2677, 2805
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,215
| 134,424
|
26008+57475
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-4-7**] Discharge Date: [**2107-4-12**]
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 yo F, Russian, aphasic h/o CAD, CVA [**1-/2106**] (on ASA, no PPI),
PEG tube presents from [**Hospital 100**] rehab on [**2107-4-7**] with
melena and coffee-ground emesis. In ED, G tube lavage with
clots/coffee-grounds. HCT 26, Received 2 units PRBC, HCT now
stable at 30. GI consulted, felt likely [**2-25**] gastritis and
decided not to scope unless HCT dropped further. Course also
notable for ucx/bcx growing enterococcus. Was initially on
linezolid (?VRE), but now on vancomycin. ?why not amp. Ordered
for TTE. Pt is DNR, but OK to intubate for short-term, central
line, pressors.
Past Medical History:
Past Medical History - from chart
- Afib - detected on [**11/2103**] admission, on coumadin
- HTN
- dyslipidemia
- DM - on lantus at [**Hospital 100**] Rehab
- anemia - iron deficiency
- hiatal hernia - EGD on [**3-/2105**]: hiatus hernia, mild gastritis.
- mild gastritis
- [**2107-1-24**] admitted to [**Hospital1 **] with NSTEMI
- L MCA stroke: residual R hemiparesis, aphasia, dysphagia. PEG
placed.
- thrombocytopenia
- glaucoma
- hemorhoids
- CAD NSTEMI [**2105**] with BMS to proximal LAD
Social History:
Social History: patient is originally from [**Location (un) 3155**], [**Location (un) 3156**]. Moved
to the United States in [**2093**]. Lives with her husband. She is
geologist by training. Denies any tobacco history. No EtOH use.
She has one child, [**Doctor First Name 335**].
Family History:
.
Family History: NC, most of her family were killed in WWII.
Physical Exam:
Vitals - 96.0; hr 68-75; 145/78; [**1-6**]; 96% ra
Gen - elderly female, nad, asleep, but arousable, does not
really follow commands, unable to speak. less responsive than
usual per family.
HEENT - oropharyngeal secretions (audible); no scleral icterus;
no thyroid megaly or thyroid fullness
CVS - regular S1 and S2, 2/6 systolic murmur best audible at
apex. no rubs or gallops.
Lungs - scattered crackles at bases. otherwise clear
Abd - PEG in place. bruises from Sq heparin. soft, not-tender,
non-distended
Rectal - grossly guiac positive, melenotic stool per ED
Ext - no edema.
Neuro: R sided hemiplegia. Does not follow commands. L sided
clonus.
Pertinent Results:
[**2107-4-7**] 09:18PM GLUCOSE-138* UREA N-57* CREAT-0.7 SODIUM-135
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-30 ANION GAP-11
[**2107-4-7**] 09:18PM CK(CPK)-16*
[**2107-4-7**] 09:18PM CK-MB-4 cTropnT-0.02*
[**2107-4-7**] 09:18PM CALCIUM-8.0* PHOSPHATE-4.2 MAGNESIUM-2.1
[**2107-4-7**] 09:18PM URINE HOURS-RANDOM CREAT-44 SODIUM-43
[**2107-4-7**] 09:18PM URINE OSMOLAL-635
[**2107-4-7**] 09:18PM HCT-27.5*
[**2107-4-7**] 09:18PM PT-13.3* INR(PT)-1.2*
[**2107-4-7**] 09:18PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2107-4-7**] 09:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2107-4-7**] 09:18PM URINE RBC-0 WBC-7* BACTERIA-MANY YEAST-NONE
EPI-3
[**2107-4-7**] 02:07PM LACTATE-2.2*
[**2107-4-7**] 02:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2107-4-7**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2107-4-7**] 11:30AM GLUCOSE-195* UREA N-62* CREAT-0.7 SODIUM-128*
POTASSIUM-5.0 CHLORIDE-91* TOTAL CO2-29 ANION GAP-13
[**2107-4-7**] 11:30AM estGFR-Using this
[**2107-4-7**] 11:30AM ALT(SGPT)-91* AST(SGOT)-49* CK(CPK)-21* ALK
PHOS-329* AMYLASE-37 TOT BILI-0.4
[**2107-4-7**] 11:30AM LIPASE-32
[**2107-4-7**] 11:30AM CK-MB-5 cTropnT-0.03*
[**2107-4-7**] 11:30AM ALBUMIN-2.9*
[**2107-4-7**] 11:30AM WBC-13.2*# RBC-3.07* HGB-9.5* HCT-26.8*
MCV-87 MCH-31.0 MCHC-35.5* RDW-16.6*
[**2107-4-7**] 11:30AM NEUTS-81.2* LYMPHS-12.7* MONOS-5.0 EOS-1.0
BASOS-0.1
[**2107-4-7**] 11:30AM ANISOCYT-1+
[**2107-4-7**] 11:30AM PLT COUNT-318#
[**2107-4-7**] 11:30AM PT-12.5 PTT-22.0 INR(PT)-1.1
.
TTE:
Preserved global biventricular systolic function. Trace aortic
regurgitation. Mildly thickened mitral leaflets without
pathologic mitral
regurgitation or definite echocardiographic evidence for
endocarditis.
If clinically suggested, the absence of a discrete vegetation
does not exclude
clinical endocardits.
.
pCXR: No acute cardiopulmonary process. Possible moderate-sized
hiatal hernia; lateral view would be helpful in confirming this
finding
.
Brief Hospital Course:
# GIB: Likely upper GI source, possible [**2-25**] PEG tube
manipulation by the patient vs. norovirus-associated vomiting.
Hct remains stable. Gastritis (pt on asa and not ppi at heb reb)
also possible. GI consulted and stated no need for endoscopy
given stable Hct, clearing of output from PEG. Will continue to
hold ASA for now, cont. PPI [**Hospital1 **]. Hct remained stable.
.
# Bacteremia: 4/4 bottles GPC in pairs and chains. Likely source
is urine, which is growing enterococcus, however concern for
endovascular infection. Vanc changed to linezolid given possible
VRE. No fevers, normal WBC count. Hemodynamically stable.
Surveillance cultures remained negative. Was sensitive to vanco,
will plan for 4 week course, day 1=[**4-10**].
.
# CAD: s/p BMS to LAD 12/[**2105**]. Initally was on asa/plavix. No
evidence of ischemia. Negative cardiac enzymes x 2. EKG with
resovled TWI, no ST changes. Continue holding ASA. On lower dose
of beta blocker given bleed, this can be titrated up as
necessary.
.
# AFib: h/o PAF since [**2103**]. Never anti-coagulated due to high
fall risk and h/o GIB. Was on heparin during [**2105**] admission,
never started on coumadin; well rate-controlled. Currently in
nsr 68. Restarted digoxin, on lower dose BB.
.
# Pump: TTE showed preserved function, no overt evidence of
endocarditis.
.
#h/o L MCA CVA. s/p recent debilitating stroke, which left her
aphasic, dysphagic and confused. Has been at rehabs since the
stroke. Did not do well with speech and rehab therapy. Follow up
with PCP regarding restarting ASA/plavix.
.
# DM: Was on lantus at heb reb. Well controlled. Cont
RISS.Restarted lantus, cont. SSI.
.
# Glaucoma: Cont outpatient eye gtt
.
# FEN: Speech and swallow eval failed again, recommended cont.
TF, if family wants to give po nutrition give nectar thick liqs
and pureed solids.
# PPX: venodynes (holding sc heparin), colace, senna, ppi
# Code: DNR. Disucssed with daughter-[**Name (NI) **] (HCP) and confirm DNR
and would accept endoscopy and BLD transfusion. Pls call
[**Telephone/Fax (1) 64618**] with questions. Would not want CPR or shocks. Would
be ok to intubate short-term, but no long term intubation.
Daughter ([**Doctor First Name **]) and son (ilya) are both HCP, and disagree with
how much should be done.
[**Telephone/Fax (1) 64619**] (H)
[**Telephone/Fax (1) 64620**] (W)
[**Telephone/Fax (1) 64621**] (c)
.
Medications on Admission:
1. ASA 325 mg daily
2. Digoxin 0.125 qod
3. Latanoprost eye gtt
4. Timoptic eye gtt
5. Lisinopril 40 mg daily
6. Lopressor 200 mg [**Hospital1 **]
7. Celexa 30 mg daily
8. Norvasc 10 mg daily
9. Lantus 12 units daily
10. Glucerna tube feeds 80cc/hr
11. MVI po daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
sliding scale Injection ASDIR (AS DIRECTED).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
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.
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
13. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Omega-3 Fatty Acids 550 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day).
15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO once a day: by G tube.
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 24H (Every 24 Hours) for 4 weeks: d1=[**4-8**].
Disp:*28 g* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Enterococcal bacteremia
UTI
Dysphagia
Discharge Condition:
stable
Discharge Instructions:
Continue your medications as listed. Continue tubefeeds, if
supplementing with oral intake please use honey thick liquids
and pureed solids with continued aspiration precautions. Please
make sure you follow up with your PCP [**Last Name (NamePattern4) **] [**2-27**] weeks regarding
restarting your aspirin.
Followup Instructions:
1. Please follow up with your PCP in the next 2-4 weeks.
Name: [**Known lastname 11403**],[**Known firstname 11404**] Unit No: [**Numeric Identifier 11405**]
Admission Date: [**2107-4-7**] Discharge Date: [**2107-4-12**]
Date of Birth: [**2023-5-15**] Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 7264**]
Addendum:
Curbsided ID regarding course of vanco, they recommended 2 weeks
from last positive culture. Will plan 2 week course of vanco.
TTE negative for overt endocarditis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7267**] MD [**MD Number(2) 7268**]
Completed by:[**2107-4-12**]
|
[
"578.9",
"414.01",
"041.04",
"790.7",
"285.9",
"V45.82",
"438.12",
"427.31",
"599.0",
"438.11",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
9890, 10113
|
4625, 7008
|
221, 228
|
8931, 8940
|
2433, 4602
|
9296, 9867
|
1701, 1747
|
7324, 8760
|
8870, 8910
|
7034, 7301
|
8964, 9273
|
1762, 2414
|
175, 183
|
256, 847
|
869, 1368
|
1400, 1667
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,626
| 182,272
|
29027
|
Discharge summary
|
report
|
Admission Date: [**2188-10-8**] Discharge Date: [**2188-10-27**]
Date of Birth: [**2125-1-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Bactrim
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
CP, DOE
Major Surgical or Invasive Procedure:
[**2188-10-10**] CABG x 3 (LIMA->LAD, SVG->OM, SVG->RCA)
History of Present Illness:
HPI: 63M PMH CAD, DM2, OSA, [**Hospital 69943**] transferred from [**Hospital 1514**]
Hospital, NH, for high-risk LMCA cath after being denied
surgical intervention due to multiple co-morbidities. While at
[**Location (un) 1514**], pt reported CP with movement to and from wheelchair,
and was initially treated with nitropaste, then nitro gtt, which
was weaned off by the time of arrival at [**Hospital1 18**]. Pt describes a
long history of chest pain/SOB with exertion, relieved by rest
or by SL NTG. He had apparently been having CP for the past few
months, with multiple ED admissions and per the patient normal
stress tests. Last time he had CP prior to this admission was
this summer, when he took NTG SL and it went away.
*
He had initially presented to [**Location (un) 1514**] on [**2188-10-5**] after feeling
chest pressure in the setting of hypoglycemia. He reported that
the chest pain waxed and waned throughout the day; no radiation;
some associated SOB. No diaphoresis, N/V, palpitations, F/C/NS.
Past Medical History:
PMH:
-CAD, ? MI [**91**] years ago at [**Location 1268**] VA; ETT 2 yrs ago
[**Hospital **] Med Ctr with "tiny" lateral basilar defect and EF 50%
-?MS [**First Name (Titles) **] [**Last Name (Titles) **] neuropathy; wheelchair-bound, bladder
spasms
-DM2
-Obesity
-BPH
-Anxiety
-HTN
-PTSD
-Osteoporosis
-OSA, on CPAP at home
Social History:
Social: Married, wife cares for him at home. Quit smoking in
[**2176**] after 3 PPD for "many years." Denies ETOH. No exercise.
*
Family History:
FH: Father MI > 60. Son MI age 18, also with Muscular dystrophy.
*
Physical Exam:
Vitals: T 97.3
BP 147/47
HR 53
R 18
Sat 95% RA
*
PE: G: Obese male, NAD, gets somewhat flushed and dyspneic with
movement for exam (sitting up)
HEENT: Clear OP, MMM
Neck: Supple, No LAD, No JVD, no carotid bruits
Lungs: Fine bibasilar late-peaking crackles R>L, no W/R
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT. Distended, tympanic. NL BS. No HSM.
Ext: 1+ pitting edema BL. 2+ DP pulses BL.
Neuro: A&Ox3. Appropriate. Grossly normal.
*
Pertinent Results:
[**2188-10-14**] 05:45AM BLOOD WBC-6.4 RBC-2.81* Hgb-8.7* Hct-25.7*
MCV-91 MCH-30.8 MCHC-33.7 RDW-14.9 Plt Ct-166
[**2188-10-14**] 05:45AM BLOOD Plt Ct-166
[**2188-10-13**] 02:45AM BLOOD PT-13.6* PTT-26.5 INR(PT)-1.2*
[**2188-10-16**] 05:40AM BLOOD WBC-7.6 RBC-2.84* Hgb-8.8* Hct-25.6*
MCV-90 MCH-31.1 MCHC-34.5 RDW-15.0 Plt Ct-212
[**2188-10-16**] 05:40AM BLOOD Plt Ct-212
[**2188-10-15**] 11:25AM BLOOD Glucose-120* UreaN-20 Creat-0.9 Na-139
K-3.8 Cl-98 HCO3-32 AnGap-13
[**2188-10-9**] ECHO
The left atrium is elongated. The inferior vena cava is dilated
(>2.5 cm).
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-10**]+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
[**2188-10-15**] Lower Extremity U/S
No evidence of left lower extremity deep venous thrombosis.
[**2188-10-15**] CXR
Pulmonary vascular congestion is worsened slightly since
[**10-12**]. Large postoperative cardiomediastinal silhouette is
stable. Small left pleural effusion or pleural thickening is
unchanged. No right pleural abnormality and no pneumothorax
noted.
Brief Hospital Course:
Mr. [**Known lastname 1182**] was admitted to the [**Hospital1 18**] on [**2188-10-8**] via transfer
from [**Hospital 1514**] Hospital for surgical management of his coronary
artery disease. He was placed on heparin for anticoagulation.
The cardiac surgical service was consulted and Mr. [**Known lastname 1182**] was
worked-up in the usual preoperative manner. Ciprofloxacin was
started for a urinary tract infection. As he had an episode of
chest pain, intravenous integrillin and nitroglycerin were
started. On [**2188-10-10**], Mr. [**Known lastname 1182**] was taken to the operating room
where he underwent coronary artery bypass grafting to three
vessels. Please see operative note for details. Postoperatively
he was taken to the cardiac surgical intensive care unit for
monitoring. He developed atrial fibrillation which was treated
with amiodarone. On postoperative day one, Mr. [**Known lastname 1182**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. CPAP was used given his
history of sleep apnea and severe COPD. On postoperative day
three, Mr. [**Known lastname 1182**] 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. On
postoperative day four, Mr. [**Known lastname 1182**] had a reaction to percocet
which caused him to be profoundly sedated. Narcan was given with
complete resolution of his symptoms. Mr. [**Known lastname 1182**] developed a left
leg cellulitis and keflex was started. An ultrasound was
performed which was negative for a deep vein thrombosis. As his
urine culture remained positive on ciprofloxacin, macrodantin
was used in its place. As his diet improved, his oral diabetes
agents were resumed.
Mr. [**Known lastname 1182**] continued to make steady progress and was discharged
home on [**2188-10-27**]. He will follow-up with Dr. [**Last Name (STitle) 914**], his
cardiologist and his primary care physician.
Medications on Admission:
tums, nystatin, nabumetone, xanax, buspar,NTG, finasteride,
terazosin, halcion, ativan, asa, glyburide, elavil, zantac,
vistaril, baclofen, oxybutinin, antivert, actos, quinine,
prilosec, zocor, colace
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Nabumetone 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
8. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO TID:PRN.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
as needed.
13. Triazolam 0.25 mg Tablet Sig: Two (2) Tablet PO qhs prn ().
14. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
16. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Flovent 110 mcg/Actuation Aerosol Sig: One (1) Inhalation
twice a day.
18. Albuterol-Ipratropium Inhalation
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care Inc
Discharge Diagnosis:
CAD
MI
MS [**First Name (Titles) 151**] [**Last Name (Titles) **] neurophathy
DM2
BPH
HTN
PTSD
anxiety
osteoporosis
CVA [**2176**]
bladder spasm
hemorrhoids
obesity
anxiety
OSA on CPAP
R rotator cuff
L knee arthroscopy
prostate surgery
appy
LLE fracture
tobacco abuse
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving until follow up with surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] (PCP at the VA) 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2188-10-28**]
|
[
"427.31",
"309.81",
"401.9",
"682.6",
"V15.82",
"250.00",
"414.01",
"423.9",
"411.1",
"292.81",
"692.9",
"412",
"278.00",
"599.0",
"E935.2",
"496",
"997.1",
"780.57",
"340"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"89.60",
"37.0",
"39.61",
"36.12",
"93.90",
"54.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7864, 7973
|
4076, 6121
|
292, 351
|
8285, 8293
|
2529, 4053
|
8578, 8743
|
1913, 1982
|
6373, 7841
|
7994, 8264
|
6147, 6350
|
8317, 8555
|
1997, 2510
|
245, 254
|
379, 1400
|
1422, 1748
|
1764, 1897
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,884
| 105,595
|
25113
|
Discharge summary
|
report
|
Admission Date: [**2125-11-25**] Discharge Date: [**2125-12-4**]
Date of Birth: [**2050-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
75 year old with intermittent substernal chest pain, STE 7mm in
leads II,II, aVF, and 3mm STD V2-V3. Patient was evaluated at
[**Hospital1 **] with cardiac cath and subsequently had IABP placement
and transferred to [**Hospital1 18**] for cardiac cath.
Major Surgical or Invasive Procedure:
s/p cabg x4
s/p Cypher stent to SVG to ramus
History of Present Illness:
75 year old male with HTN, GERD, hypercholesteremia, TIA x 9yrs
ago no deficits. PTA Pt reported several day of intermittent
episodes of substernal chest pain, which worsened one day PTA.
Pt saw Dr. [**Last Name (STitle) 3549**] c/o [**6-12**] substernal chest pain. EKG revealed
STE in inferior leads, and STD in V2-V3. Pt treated with ASA,
Plavix, Loperssor, SL NTG, Heparin, and Integrelin. Cardiac
Cath showed RCA 50% prox, 80%PDA, LAD mid occlusion, RAMUS 90%
prox, LCx and Left main without significant disease. Patient
had IABP placed and was transferred to [**Hospital1 18**] for CABG.
Past Medical History:
Hypertension, GERD, TIA x 9 years ago no deficit,
Hyperlipidemia.
Social History:
Patient admits to Etoh use, history of smoking, has quit.
Denies IVD abuse.
Family History:
Denies early CAD, otherwise noncontributory
Physical Exam:
Vital signs stable
HEENT, EOMI
trachea midline, no jvd, or carotid bruits
breath sounds CTA, respirations unlabored
I/ VI holosystolic murmur (likely due to IABP), regular rate and
rhythm, S3 present
No peripheral edema, distal pulses 2+ x4 extremities
Neuro grossly intact
pleasant affect cooperative with exam
Pertinent Results:
[**2125-12-3**] 09:35AM BLOOD WBC-12.9* RBC-4.75# Hgb-14.9# Hct-43.7#
MCV-92 MCH-31.3 MCHC-34.0 RDW-14.5 Plt Ct-361#
[**2125-11-30**] 03:38AM BLOOD WBC-15.1* RBC-3.49* Hgb-11.0* Hct-30.9*
MCV-88 MCH-31.6 MCHC-35.8* RDW-14.6 Plt Ct-86*
[**2125-12-3**] 09:35AM BLOOD Plt Ct-361#
[**2125-12-3**] 09:35AM BLOOD Glucose-106* UreaN-18 Creat-1.2 Na-135
K-3.9 Cl-96 HCO3-26 AnGap-17
Brief Hospital Course:
75 year old male with substernal chest pain admitted for CABG
for CAD, triple vessel disease demonstrated on cardiac cath.
Patient underwent CABGx4(LIMA to Diag, SVG to distal LAD, SVG
to Ramus, SVG to PDA) on [**2125-11-27**] with Dr. [**Last Name (STitle) 2230**] and Dr.
[**Last Name (STitle) 8420**]. Patient had post operative hypotension with EKG
changes and was taken to the cath lab for evaluation. Grafts
patent, pressors weaned to diminish vasospasm gradually. IABP
continued for pressure support. On POD#2 IABP was weaned to
1:2, patient started on Vancomycin. WBC decreased to 21.3(down
from 23.2). Diuresis continued with lasix. On POD #3 SBP 159,
captopril increased to 12.5, lopressor begun, vancomycin 1g q12
continued, WBC decreased to 15. Patient eval 'd by PT,
considered not yet ready. On POD #4 pacing wires d/c'd.
Lipitor 10mg started, SBP 100, Urine culture showed Klebsiella,
E.Coli>100,000 sensitive to Bactrim, vancomycin d/c'd. On POD#6
patient to be evaluated and treated by PT. Bactrim for 7 days
for UTI. On POD #7 patient will be transferred to rehab
facility.
Medications on Admission:
asa, nexium, inderal, detrol
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
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:*2*
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] hospital/TCU
Discharge Diagnosis:
s/p cabg x4
s/p CVA [**30**] years ago
HTN
GERD
s/p stent to SVG to ramus
acute MI
Discharge Condition:
good
Discharge Instructions:
shower over wounds and pat dry
no lotions, creams or powders to incisions
no lifting greater than 10# for 10 weeks
no driving for one month
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**2-4**] weeks
follow up with [**Last Name (un) 11427**] in [**2-4**] weeks
follow up with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2125-12-4**]
|
[
"599.0",
"287.5",
"750.3",
"414.01",
"414.02",
"427.89",
"997.1",
"458.29",
"041.3",
"530.81",
"041.4",
"272.4",
"401.9",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"88.56",
"00.66",
"39.64",
"36.07",
"36.15",
"37.22",
"36.13",
"00.40",
"00.45",
"39.61",
"88.53",
"97.44"
] |
icd9pcs
|
[
[
[]
]
] |
5121, 5208
|
2194, 3299
|
529, 576
|
5335, 5342
|
1795, 2171
|
5530, 5731
|
1402, 1447
|
3378, 5098
|
5229, 5314
|
3325, 3355
|
5366, 5507
|
1462, 1776
|
236, 491
|
604, 1204
|
1226, 1293
|
1309, 1386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,947
| 199,058
|
46191
|
Discharge summary
|
report
|
Admission Date: [**2144-1-7**] Discharge Date: [**2144-1-15**]
Date of Birth: [**2080-7-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 63 year old male underwent
an exercise tolerance test as part of a routine physical
examination which was positive. He was referred for cardiac
catheterization which revealed a 30 to 40% left main
stenosis, three vessel coronary artery disease and an left
ventricular ejection fraction of 40%. He is now referred for
coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. History of diverticulosis.
2. Mild asthma.
3. Hypercholesterolemia.
4. Chronic prostatitis with no active problems at this
point.
5. Carotid ultrasound [**8-14**], which revealed less than 40%
stenosis bilaterally.
MEDICATIONS ON ADMISSION:
1. Flovent two puffs twice a day.
2. Nasacort one puff each nostril twice a day.
3. Aspirin 325 mg p.o. q.o.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He does not smoke cigarettes and he does not
drink alcohol.
REVIEW OF SYSTEMS: The review of systems is unremarkable.
PHYSICAL EXAMINATION: On physical examination, he is a well
developed, well nourished white male in no apparent distress.
Vital signs are stable, afebrile. Head, eyes, ears, nose and
throat examination - normocephalic and atraumatic.
Extraocular movements are intact. The oropharynx is benign.
The neck is supple, full range of motion, no lymphadenopathy
or thyromegaly. Carotids are 2+ and equal bilaterally
without bruits. The lungs are clear to auscultation and
percussion. Cardiovascular examination is regular rate and
rhythm, normal S1 and S2, with no murmurs, rubs or gallops.
The abdomen was soft, nontender, with positive bowel sounds,
no masses or hepatosplenomegaly. Extremities were without
cyanosis, clubbing or edema, pulses 2+ and equal bilaterally
throughout. Neurologic examination was nonfocal.
HOSPITAL COURSE: The patient was admitted on [**2144-1-7**], and
underwent a coronary artery bypass graft times three with
left internal mammary artery to the left anterior descending,
reversed saphenous vein graft to the obtuse marginal and
right coronary artery, cross-plant time 44 minutes, total
bypass time 70 minutes. He was transferred to the CSRU on
Neo-Synephrine and Propofol in stable condition. He did have
labile blood pressure swings immediately postoperative and
required volume for this. He was extubated on postoperative
night.
Postoperative day number one, his chest tubes were
discontinued and he remained on Neo-Synephrine. This was
slowly weaned off and on postoperative day three, he was
transferred to the floor in stable condition. He had his
epicardial pacing wires discontinued. He continued to have a
stable postoperative course. He did have some tachycardia
which responded well to beta blocker. He got very anxious
and got combative and was seen by psychiatry who recommended
low dose Ativan which eventually his anxiety subsided. He
continued to progress and, on postoperative day number eight,
he was discharged to home in stable condition.
His laboratories on discharge included a hematocrit of 32.4,
white blood cell count 7.2, platelet count 390,000. Sodium
141, potassium 4.1, chloride 105, CO2 25, blood urea nitrogen
13, creatinine 0.9, blood sugar 95.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Zantac 150 mg p.o. twice a day.
3. Ecotrin 325 mg p.o. once daily.
4. Percocet one to two p.o. q4-6hours p.r.n.
5. Flovent two puffs twice a day.
6. Flomax 0.4 mg p.o. q.h.s.
7. Lopressor 50 mg p.o. twice a day.
8. Nasacort one puff each naris twice a day.
FOLLOW-UP: He will be followed by Dr. [**Last Name (STitle) **] in one to two
weeks and by Dr. [**Last Name (STitle) 70**] in six weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Postoperative tachycardia.
3. Anxiety.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 98222**]
MEDQUIST36
D: [**2144-1-15**] 17:46
T: [**2144-1-15**] 17:57
JOB#: [**Job Number 98223**]
|
[
"562.10",
"272.0",
"997.1",
"300.00",
"785.0",
"414.01",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3794, 4142
|
3330, 3773
|
786, 939
|
1918, 3304
|
1100, 1899
|
1037, 1077
|
159, 514
|
536, 760
|
956, 1017
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,485
| 153,303
|
23435+57354
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-1-12**] Discharge Date: [**2159-1-26**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Tranferred from [**Hospital Unit Name 153**] for acute mental status change/somnolence,
now with NSTEMI medically managed
Major Surgical or Invasive Procedure:
placement of right IJ central venous catheter.
History of Present Illness:
83yo woman with history of HTN, dyslipidemia, COPD and
breast CA s/p mastectomy presented with acute mental status
change,
found by her husband unresponsive on morning of admission.
She had been in her usual state of health up to this event.
Family denied any recent complaints of chest pain, shortness of
breath, palpitations, cough, abdominal pain, dysuria,
headache/weakness/numbness.
There was some concern for potential medication adverse effects,
as the patient was on an extensive array of medications, many of
them
sedatives and many with anticholinergic side effects.
Additionally, she and
her husband manage their medications independently, and the
husband was
recently admitted for amantidine toxicity.
Past Medical History:
1) HTN
2) dyslipidemia
3) COPD
4) Breast CA, s/p mastectomy
Social History:
- lives with husband at home
- just recently moved from long-time home in
[**State 531**] to [**Location (un) 86**] to be closer to son and daughter-in-law
- no history of etoh, smoking, drugs.
Physical Exam:
Temp 97 2
BP 130/78
Pulse 70s
Resp 18
O2 sat 100% 4 L o2
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - diminished BS throughout, some wheezes diffusely
CV - Normal S1/S2, RRR, [**3-17**] HSM heard at apex and aortic area,
no rubs or gallops
Abd - Soft, nontender, distended, with normoactive bowel sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-23**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - ecchymoses
Pertinent Results:
CXR [**1-20**]: The cardiac silhouette is enlarged, but unchanged.
There is improvement in appearance of the vasculature and no
overt CHF is seen at the present time. There is patchy density
at the bases which could represent
atelectasis/pneumonia/aspiration. There are no large pleural
effusions.
Echo [**1-15**]: Regional left ventricular systolic dysfunction c/w
CAD (mid-LAD
lesion). Moderate pulmonary artery systolic hypertension.
Moderate mitral
regurgitation. Mild aortic valve stenosis.
MRI/A [**1-15**]: negative
CTA Head [**1-12**]: no hemmorhage
Labs:
Micro:
Brief Hospital Course:
Admitted to the [**Hospital Unit Name 153**] intially. Mental status thought to be
related to polypharmacy and toxic-metabolic state with a tox
screen positive for TCA's. In addition, UTI plays a roll as well
as PNA and NSTEMI. Neurology consult confirmed this and pt
briefly on tegretol for 5 days and then stopped b/c it was
deemed pt did not have seizure. UTI and S. pneumonia PNA treated
with 7 days of levoquin. While in the unit, pt had NSTEMI, cards
consulted and decided to plan cath once stable. Medically
managed with [**Hospital Unit Name **], BB, ACE I, heparin gtt and enzymes trended
downward during unit stay. Hypoxia was thought to be [**3-13**]
pulmonary edema adn pt was intially intubated, then extubated
but failed [**3-13**] laryngeal edema treated with racemic epi, heliox
and solumedrol, then reintubated rested on AC ventilation, given
steroids, and then extubated [**1-21**] prior to transfer to [**Hospital Ward Name **] to await to decision to cath.
1) Encephalopathy: Multifactorial, clearing. Infection,
toxic-metabolic are all part of picture. Pts mental status was
oriented x 3 while on the floor. Pt was given haldol PO once for
agitation but did not need it for any further episodes. Cont ot
monitor MS and consider seroqel for aggitation/sleep.
2) UTI, pneumonia: compelted 7 day course of abx. Currently
afebrile. With elevated WBC ct but no fever or other symptoms,
will send UA. urine cx, stool cx and sputumm cx if prod cough.
Dr [**Last Name (STitle) 1266**] to f/u results in rehab. If spikes, would consider
longer txt of levoquin or consider ventilator associated PNA if
worses.
3) NSTEMI: Pt was maintaned on herpain gtt x 5 days. Cards input
was to cont [**Last Name (STitle) **]/BB/captopril titrated upward. Family and pt
decision to not do cardiac cath at this time. Heparin gtt d/c'd
and CK's trending downward. Pt pain free. EKG showed no further
changes after intial event. Will need titration of cardiac meds
as outpt while in rehab. Monitor cardiac status. Readdress
further eval in future.
4) Hypoxia/respiratory failure: From fluid overload and PNA.
EF=30%. Lasix 40 mg qd given once on trasnfer to flor with good
effect. Pt maintained on RTC nebs/IH and racemic epi. AFter 36
hrs on floor oxygenation improved with [**Month (only) **] in supplimental
oxygen to 2 L with 98-100% sats. Pt reports shortness of breath
however improving hypoxia. CXr rechecked on [**1-23**] which showed
interval improvement. Would cont racemic epi, nebs and IH while
laryngeal edema improves. No evidence for PNA now but would keep
in mind over next few weeks if pt has fever. Maintain on 20 mg
lasix qd, fludi restrictionn, daily wts, and check for sxs of
vol overload.
5)Renal Failure, prerenal in [**Hospital Unit Name 153**]: now at baseline, monitor Cr.
6)Anemia: [**3-13**] to chronic disease, stool guaic negative. [**Name (NI) 60084**] pt
remained in house overnight, one unit blood was transfused after
consent was obtained. Small dose lasix given after transfusion.
Hct increased appropriately.
7)Nutrional consulted for aspriation risk with pt who has
laryngeal edeam and thy reccomended ground mechanical diet with
thin liquids with a staw.
8)Maintain on prevacid.
9)Diarrhea: On day prior to discharge, pt 's WBC ct remained
elevated, afebrile and began haivng foul smelling diarrhea.
Given recent course of abx and hospitalizaiton for >1 week,
emperically began treatment for C Diff. C dif studies were sent
and were negative. Flagyl 500 mg Po tid x 7 days started. Dr
[**Last Name (STitle) 1266**] to f/u culture results.
9)Code: FULL, HCP is son
Pt was d/c to [**Hospital 550**] rehab in good condition. Afebrile, improving
hypoxia.
Medications on Admission:
(on transfer from [**Hospital Unit Name 153**])
atrovent, captopril, metoprolol, racemic epi, prednisone,
haldol, albuterol, nystatin, bisacodyl, senna, heparin gtt,
[**Last Name (LF) 17339**], [**First Name3 (LF) **], sucralfate, levaquin, insulin
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-10**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing.
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
11. Racepinephrine HCl 2.25 % Solution Sig: 0.5 ML Inhalation
Q4H (every 4 hours) as needed.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB/wheezing.
13. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
1. Congestive heart failure
2. Myocardial infarction
3. Diabetes
4. Hypertension
5. Hyperlipidemia
6. [**Last Name (un) **]. sleep apnea
7. Resporatory failure
Discharge Condition:
Good.
Discharge Instructions:
If you have fevers/chills, shortness of breath, chest pain, or
difficulty breathing, please call your PCP Dr [**Last Name (STitle) 1266**] or come
to the ED.
1. Take medications as directed
Followup Instructions:
Follow up per nursing home/Dr. [**Last Name (STitle) 1266**].
Dr [**Last Name (STitle) 1266**] to follow up UA/cx, stool for C Diff, would repeat
WBC ct in a few days.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Name: [**Known lastname 11006**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 11007**]
Admission Date: [**2159-1-12**] Discharge Date: [**2159-1-26**]
Date of Birth: [**2075-8-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 473**]
Addendum:
Results from hospital stay.
Pertinent Results:
[**2159-1-12**] 11:15AM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2159-1-12**] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-1-12**] 11:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 418**]-1.019
[**2159-1-12**] 11:15AM PT-12.9 PTT-28.7 INR(PT)-1.1
[**2159-1-12**] 11:15AM PLT COUNT-145*
[**2159-1-12**] 11:15AM MACROCYT-1+
[**2159-1-12**] 11:15AM NEUTS-88.2* LYMPHS-8.1* MONOS-3.3 EOS-0.3
BASOS-0.1
[**2159-1-12**] 11:15AM WBC-11.0 RBC-3.38* HGB-11.0* HCT-33.0* MCV-98
MCH-32.6* MCHC-33.3 RDW-14.8
[**2159-1-12**] 11:15AM URINE GR HOLD-HOLD
[**2159-1-12**] 11:15AM URINE HOURS-RANDOM
[**2159-1-12**] 11:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2159-1-12**] 11:15AM PHENOBARB-<1.2*
[**2159-1-12**] 11:15AM THEOPHYL-2.3*
[**2159-1-12**] 11:15AM TSH-0.63
[**2159-1-12**] 11:15AM calTIBC-333 VIT B12-864 FERRITIN-62 TRF-256
[**2159-1-12**] 11:15AM ALBUMIN-4.4 CALCIUM-9.4 PHOSPHATE-5.3*
MAGNESIUM-2.6
[**2159-1-12**] 11:15AM IRON-42
[**2159-1-12**] 11:15AM CK-MB-4 cTropnT-<0.01
[**2159-1-12**] 11:15AM ALT(SGPT)-18 AST(SGOT)-64* CK(CPK)-116 ALK
PHOS-142* TOT BILI-0.4
[**2159-1-12**] 11:15AM GLUCOSE-146* UREA N-47* CREAT-2.5* SODIUM-139
POTASSIUM-7.1* CHLORIDE-106 TOTAL CO2-22 ANION GAP-18
[**2159-1-12**] 11:48AM K+-5.7*
[**2159-1-12**] 11:48AM TYPE-ART PO2-86 PCO2-49* PH-7.28* TOTAL
CO2-24 BASE XS--3 COMMENTS-SOURCE NOT
[**2159-1-12**] 03:15PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0
LYMPHS-30 MONOS-70
[**2159-1-12**] 03:15PM CEREBROSPINAL FLUID (CSF) PROTEIN-28
GLUCOSE-103
[**2159-1-12**] 08:34PM LACTATE-0.6 K+-4.6
[**2159-1-12**] 03:15PM CEREBROSPINAL FLUID (CSF) PROTEIN-28
GLUCOSE-103
[**2159-1-12**] 08:34PM freeCa-1.22
[**2159-1-12**] 08:34PM TYPE-ART PO2-111* PCO2-47* PH-7.32* TOTAL
CO2-25 BASE XS--2 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 807**]
[**2159-1-12**] 09:38PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2159-1-12**] 09:38PM URINE OSMOLAL-536
[**2159-1-12**] 09:38PM URINE HOURS-RANDOM UREA N-771 CREAT-103
SODIUM-66 POTASSIUM-46 CHLORIDE-63 PHOSPHATE-74.5 TOTAL CO2-<5
[**2159-1-12**] 09:45PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.3
[**2159-1-12**] 09:45PM CK-MB-5 cTropnT-<0.01
[**2159-1-12**] 09:45PM CK(CPK)-118
[**2159-1-12**] 09:45PM GLUCOSE-90 UREA N-39* CREAT-1.9* SODIUM-146*
POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-25 ANION GAP-14
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2159-1-26**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
AEROBIC BOTTLE (Final [**2159-1-21**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2159-1-21**]): NO GROWTH.
**FINAL REPORT [**2159-1-16**]**
URINE CULTURE (Final [**2159-1-16**]): NO GROWTH.
**FINAL REPORT [**2159-1-18**]**
GRAM STAIN (Final [**2159-1-14**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2159-1-18**]):
RARE GROWTH OROPHARYNGEAL FLORA.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
BETA STREPTOCOCCI, NOT GROUP A. SPARSE GROWTH.
**FINAL REPORT [**2159-1-15**]**
RAPID PLASMA REAGIN TEST (Final [**2159-1-15**]):
NONREACTIVE.
Reference Range: Non-Reactive.
CXR:FINDINGS: Single AP upright view. Comparison study dated
[**2159-1-20**]. The heart shows moderate left ventricular
enlargement. The pulmonary vessels do not indicate any left
ventricular failure. There is no pleural effusion. The lungs are
better inflated than before. The right IJ central line remains
in satisfactory position. Minor linear atelectasis is noted in
the left mid zone laterally. No other abnormalities are
identified.
IMPRESSION: 1) Improved lung inflation. 2) No acute
cardiopulmonary abnormality. LV enlargement of the heart noted.
MRI head:
FINDINGS: Examination is somewhat limited by patient motion.
There is no evidence of acute mass effect or hemorrhage. There
is no displacement of normally midline structures. There is no
evidence of a focal extra-axial lesion or fluid collection.
Ventricles and sulci are not remarkable. An empty sella is
noted. There is no evidence of abnormal diffusion. Gadolinium
was not administered at this time. There are few scattered high
signal intensity foci best visualized on the repeat FLAIR
sequence consistent with microvascular angiopathy.
IMPRESSION:
No evidence of acute infarction, mass effect or hemorrhage. Note
made of an empty sella.
MRA OF THE CIRCLE OF [**Location (un) 243**] AND ITS MAJOR TRIBUTARIES:
FINDINGS: There is no evidence of aneurysm or flow abnormality.
IMPRESSION:
Negative MRA of the circle of [**Location (un) **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - Acute Rehab
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 475**]
Completed by:[**2159-1-26**]
|
[
"285.29",
"458.9",
"493.20",
"276.7",
"787.91",
"401.9",
"410.71",
"518.81",
"428.0",
"276.2",
"349.82",
"287.5",
"481",
"780.09",
"276.0",
"584.9",
"599.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"93.90",
"99.04",
"03.31",
"88.41",
"88.91",
"38.93",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
14222, 14445
|
2754, 6450
|
341, 389
|
8271, 8278
|
9203, 14199
|
8517, 9184
|
6749, 7971
|
8088, 8250
|
6476, 6726
|
8302, 8494
|
1445, 2134
|
180, 303
|
417, 1134
|
1156, 1218
|
1234, 1430
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,866
| 152,392
|
26488
|
Discharge summary
|
report
|
Admission Date: [**2118-9-1**] Discharge Date: [**2118-9-8**]
Date of Birth: [**2054-6-13**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Lipitor
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
increased somnolence
Major Surgical or Invasive Procedure:
Left sided Internal jugular line.
History of Present Illness:
64 year old African American woman with HTN, DM, ESRD (on
dialysis MWF), CVA in [**2114**] on Coumadin, CAD presented to ED for
increased somnolence. This morning, home aide noted that she was
more sleepy than usual and called the ambulance. Per daughter in
the [**Name (NI) **], she is almost back to her baseline currently in terms of
her orientation and level of alertness, but has slightly slurred
speech. Patient complains of a headache and abdominal pain for
the past few days. No focal deficits were noted by her home aide
or daughter. Pt. denies LOC, weakness, diplopia, dysphagia,
falls. At baseline, she is disoriented to time, inattentive and
has impaired memory.
She has a history of lethargy and confusions after dialysis
sessions and was last admitted for somnolence in [**2118-6-19**]. At
that time, it was thought that she experienced post-dialysis
hypoperfusion, which caused encephalopathy [**12-21**] small ischemic
episodes that were not appreciated on imaging given her existing
extensive pathology.
Based on her complaints of lethargy the patient had a CT scan,
on
the scan it was noted that the patient had basal ganglia bleed
in
the right caudate head with some intraventricular extension and
layering. The patient was also noted to have very high blood
pressures. After an attempt to get an a-line the patient was
upset and then again appeared slightly more somnolent. She was
taken back to the scanner and did not have a change in her CT.
She appeared improved on return. An a-line was eventually
placed
and she was started on nicard for blood pressure management and
admitted to the unit.
Of note the patient was on Coumadin and had an INR of 2.5. She
had been placed on Coumadin because of multiple infarcts and the
presence of a complex atheromatous aortic plaque. In the ED she
was given Profilnine and vitK as well as 2 units of FFP.
Past Medical History:
1. Coronary artery disease
- s/p cath ([**8-24**]): Mild epicardial disease, collalateral flow
to distal inferior wall, no intervention
2. Hypertension
3. Hyperlipidemia
4. Diabetes: complicated by retinopathy, neuropathy, and
nephropahy
5. Chronic kidney disease, on dialysis
6. Stroke: left frontal MCA and occipital PCA stroke
7. Impaired memory s/p MVA
8. Anemia
9. History of MSSA PNA, [**3-25**]
10. Treated for presumptive endocarditis, [**12-27**]
11. H/o Upper GI bleed NOS, gastritis, duodenitis
Social History:
Lives independently but has visiting aids come home x3/day. Her
two daughters also stop by a few times a week. She is able to
toilet and shower independently. Meds are prepared by care
takers. Meals are also prepared by aids and family.
Family History:
-Father died in his 70's with heart disease
-Siblings (two sisters) with diabetes mellitus (type II).
Physical Exam:
NC/AT, no scleral icterus noted, MMM, false teeth out of
place
Neck: Supple,
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert & oriented x 2 (answered [**2104-6-1**];
disoriented to time at baseline), inattentive (able to name days
of the week forward, but difficulty reciting backwards),
impaired
calculations with serial 7s. Language is fluent with intact
repetition, follow some commands, sl dysarthria. Able to follow
some commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally
XII: Tongue protrudes in midline.
-Motor: Normal bulk, paratonia BL, slightly increased on L side.
Pronator drift bilaterally. No neglect.
Delt Bic Tri WrE FE IP Quad Ham PLex PLflex
L 5 5 5 5 4 5 5 4+ 5 5
R 5 5 5 5 4+ 5 5 5- 5 5
-Sensory: No deficits to light touch. Sensation to pinprick,
temperature and vibration decreased on feet bilaterally
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally
-Coordination: Slight tremor on FNF bilaterally.
Pertinent Results:
[**2118-9-1**] 01:00PM PT-25.6* PTT-28.4 INR(PT)-2.5*
[**2118-9-1**] 05:39PM PT-15.3* PTT-38.6* INR(PT)-1.3*
[**2118-9-1**] 10:40AM GLUCOSE-156* UREA N-28* CREAT-4.5*#
SODIUM-134 POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-27 ANION GAP-19
[**2118-9-1**] 10:40AM CK(CPK)-74
[**2118-9-1**] 10:40AM WBC-8.7 RBC-4.16* HGB-12.7 HCT-39.8 MCV-96
MCH-30.6 MCHC-32.0 RDW-14.5
[**2118-9-1**] 10:40AM PLT COUNT-221
CT head [**2118-9-1**]: IMPRESSION:
1. Intraparenchymal hemorrhage and intraventricular hemorrhage
as described
above are stable. No shift of normally midline structures or new
hemorrhage
identified.
2. Chronic infarcts of the left frontal and left occipital lobe
as well as
left thalamus are also stable. Chronic small vessel ischemic
changes are
stable.
CXR [**2118-9-1**] IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Ms. [**Known lastname 64426**] is a 64 year old woman with a history of ESRD (HTN,
DM), left MCA stroke(complex aortic arch atheroma, on
coumadin),who presented with a depressed mental status and was
diagnosed with a CNS hypertensive bleed.
CT head which demonstrated bleeding into her right caudate with
interventricular extension (ICH score 1). She was hypertensive
in the setting of a theraputic INR on coumadin for a complex
atheroma/stroke history. Hemorrhage was attributed to small
vessel disease and hypertension.
She had a anticoagulation reversed with vitamin K, and with
factor IX. She was initially placed on a nicardipine gtt for
blood pressure control over the first day. She remained stable
over the first two days in the ICU then succesfully transitioned
to step down, then the floor service. Coumadin was stopped along
with ASA.
Her examination on the floor was notable for disorientation
(thought in "house", did not know date). She had a mild left
sided facial droop. Tone was increased in legs bilaterally.
Power was reduced in finger extensors (i.e. upper motor neuron
pattern) worse on left than right. Relexes were symmetric with
mute left toes and downgoing right toes.
She continued hemodialysis while an inpatient and Renal followed
(Dr. [**Last Name (STitle) **] followed her progress). She will be started on plavix
on [**2118-9-11**].
She was discharged to rehabilitation on [**2118-9-8**] - [**Location (un) **],
[**Location (un) 169**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Medications on Admission:
LISINOPRIL 10 mg QD
METOPROLOL SUCCINATE 150 mg QD
PRAVASTATIN 80 mg QD
SEVELAMER CARBONATE [RENVELA] 800 mg Tablet TID
WARFARIN [COUMADIN] 5.5mg QD
Medications - OTC
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] 100 unit/mL (70-30)
Suspension - 14 units in am and 6 units in pm
SENNOSIDES-DOCUSATE SODIUM [PERI-COLACE]
ASA 325mg QD
Discharge Medications:
1. lisinopril 40 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO once a day.
2. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
[**Last Name (NamePattern1) **]: One (1) Tablet Sustained Release 24 hr PO once a day.
3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
[**Last Name (NamePattern1) **]: One (1) Tablet Sustained Release 24 hr PO once a day.
4. pravastatin 80 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO once a day.
5. sevelamer HCl 800 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO three
times a day: With meals.
6. INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] 100 unit/mL
(70-30)
7. Suspension - 14 units in am and 6 units in pm
8. Colace 100 mg Capsule [**Last Name (NamePattern1) **]: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. insulin regular human 100 unit/mL Solution [**Last Name (NamePattern1) **]: Per sliding
scale. Injection ASDIR (AS DIRECTED).
11. Nephrocaps 1 mg Capsule [**Last Name (NamePattern1) **]: One (1) Capsule PO once a day.
12. On [**2118-9-11**] - please start Plavix 75mg
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) **]
Discharge Diagnosis:
Primary
- Intercranial hemorrhage
Secondary (past diagnosis)
- CAD
- s/p cath ([**8-24**]): mild epicardial disease, collateral flow to
distal inferior wall, no intervention
- HTN
- HL
- DM: c/b retinopathy, neuropathy, nephropathy
- CKD, on dialysis
- Stroke: L frontal MCA and occipital PCA stroke [**2114**]
- Impaired memory s/p MVA
- Anemia
- MSSA PNA in [**3-25**]
- Treated for presumptive endocarditis, [**12-27**]
- Upper GI bleed NOS, gastritis, duodenitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness:alternates from Alert and interactive to
Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after your complaint of
headache and drowsiness led us to scna your head and we found
bleeding. The bleeding was stable when we repeated the head
scan. You were given medication to reverse your anticoagulation
and you were given medication to better control your blood
pressure. You were first placed in the ICU and then transferred
to the step down unit. Your coumadin and aspirin were stopped -
Plavix needs to be started on ([**2118-9-11**])
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **]. date/time: Tuesday [**10-11**]
at 1:30 pm.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"362.01",
"414.01",
"V58.61",
"357.2",
"V58.67",
"440.0",
"V45.11",
"250.60",
"403.91",
"432.9",
"585.6",
"272.4",
"250.50",
"250.40",
"V12.54",
"285.21",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8884, 8962
|
5742, 7283
|
299, 334
|
9474, 9474
|
4886, 5719
|
10204, 10413
|
3039, 3142
|
7666, 8861
|
8983, 9453
|
7309, 7643
|
9701, 10181
|
3899, 4867
|
3157, 3503
|
239, 261
|
362, 2238
|
9489, 9677
|
2260, 2768
|
2784, 3023
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,207
| 180,402
|
47681
|
Discharge summary
|
report
|
Admission Date: [**2152-3-15**] Discharge Date: [**2152-3-21**]
Date of Birth: [**2092-5-14**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Psychosis (auditory and visual hallucinations)/tachycardia
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
59 yo woman with h/o depression, anxiety, asthma who presents
sectioned from therapist. She was noted to be very disorganized,
psychotic, and hallucinating at therapy and sent in for
evaluation. She reportedly had a fall yesterday and no LOC.
.
In the ED, initial VS were: 97.6 108 183/85 20 97. She was
tachycardic 108 which improved after fluids to 80 (1 Liter).
Labs notable for WBC 13.4, nl chemistry, D-dimer 488, AST 42,
LDH 293, Valproate 85 negative cardiac enzymes. U/A negative.
EKG showed sinus tachycardia, NA/NI and no ST/T changes. CXR
negative, CT Head with no bleed, sinus retention cyst. Pt
subsequently pulled out IV. She was agitated and got 1mg ativan
POx2.
.
She remained intermittently tachycardic and felt to need
evaluation of this prior to admission to psych.
.
Of note, psychiatry spoke to pts friend who felt that she has
not been doing well and has been depressed: not going out of the
house, not getting up, crying, not answering the phone but had
never known her to hallucinate.
.
Per patient's primary care doctor's office, patient has baseline
leukocytosis and was previously seen by a hematologist in the
[**Hospital1 **] system who did not find
underlying pathology. She has also been documented with
tachycardia on medical visits, HR110 in [**2152-2-14**]; she also
frequently misses appointments due to severe anxiety and
depression (predominantly of hoarding, isolating nature - no
previous history of hallucinations/psychosis).
.
Currently unable to obtain good history from patient, as she is
intermittnetly falling asleep. When aroused, patient is
disorganized in her speech, asking about the difference between
apple cinnamon and apple cider, tangential but alert and
oriented X3.
Past Medical History:
Anxiety
Depression
PTSD
Allergic rhinitis
Esophageal reflux
Tension headaches
Asthma
Hypertension
Atopic dermatitis
Cholelithiasis
Fatty liver
Obesity
Social History:
Works for dry cleaner, rare etoh, denies smoking
Family History:
Noncontributory
Physical Exam:
Vitals: T:98.8 BP:126/60-140/78 P:120-125 R:16 O2: 94-95%RA
General: Alert, oriented x3 but mumbling and difficult to focus.
Would awaken to verbal stimuli and attempt to answer question in
somewhat pressured/garbled speech and falls asleep quickly
thereafter. Also with apneic episodes and loud snoring. Some
tangential thoughts this morning (ex: what is the difference
between apple cinnamon and apple cider?)
HEENT: NCAT, EOMI without nystagmus, dry mucus membranes, mucus
crusting around eyes (L>R), nasal congestion (audible)
Neck: Soft, supple, no JVD, no nuchal rigidity
Lungs: CTAB, no wheezing/rhonchi/rales
CV: Regular rhythm, tachycardia, no murmurs/gallops/rubs, normal
S1/S2
Abdomen: Soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, +DP/PT pulses, no
clubbing/cyanosis/edema
Neuro: Strength and sensation grossly intact, moving all
extremities, gait unable to assess
Pertinent Results:
D-Dimer: 488
.
Trop-T: <0.01
.
Chem 7
141 102 17 90 AGap=11
4.0 32 0.7
.
ALT: 30 AP: 95 Tbili: 0.5
AST: 42 LDH: 293 Lip: 24
.
Valproate: 85
.
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
.
CBC
13.4 12.3 433
38.4
N:64.4 L:25.0 M:6.1 E:3.9 Bas:0.7
.
Urinalysis neg
.
B12 486
TSH 1.0
Ammonia 29
.
CSF
Gram stain, bacterial and viral cultures neg
HSV PCR negative
WBC 2 RBC 6 Polys 3
TotProt Glucose LD(LDH)
37 61 19
.
ABGs:
pO2 pCO2 pH TCO2 AG
79* 50* 7.40 32* 4
70* 59* 7.35 34* 4 NOT INTUBA2
84* 54* 7.37 32* 3
62* 48* 7.43 33* 6 NOT INTUBA2
.
CTA chest:
1. No evidence of pulmonary embolism or other acute pulmonary
pathology.
2. Cholelithiasis.
3. Hepatic hypodensity, incompletely characterized.
.
EKG: Sinus tachycardia. Possible left ventricular hypertrophy.
No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 142 70 344/431 61 -12 28
.
CXR: no acute cardiopulmonary processes
.
CT head: no intracranial processes
Brief Hospital Course:
MICU Course: Admitted tachycardic and apneic, determined to be
OSA c/b enlarged tongue. Started on nasal CPAP, resolved.
Still tachycardic, CTA negative for PE. Mental status cleared
significantly.
.
59 year old female with h/o depression, anxiety, HTN, asthma
presents for section 12 from therapist for psychotic symptoms
and tachycardia
.
# Altered mental status: Initially unclear and thought likely
due to progressing psychiatric illness and ativan received in
ED. Psychiatry initially felt her presentation was consistent
with psychotic depression or previously subclinical bipolar or
psychotic disorder. Patient has been on depakote, suggesting the
need for some mood stabilization as target of pharmacotherapy.
In further discussions with family, however, her recent
hallucinations were felt to be inconsistent with what would be
expected with psychotic depression, and inconsistent with her
past mental health manifestations. Head trauma was also felt
less likely given negative CT head. Infectious etiology less
likely, despite leukocytosis which is apparently close to
baseline. CXR, urinalysis, LFTs all negative and patient does
not have localizing symptoms/fevers; no nuchal rigidity or
significant concern for CSF infection and ultimate lumbar
puncture analysis was negative for bacterial, fungal, viral
etiologies. Other toxic metabolic etiologies include
B12/thiamine deficiency, hypo/hyperthyroidism psychosis,
syphillis, illicit drug use work up for which were all negative.
Given neurological exam grossly intact, lower suspicion for
these etiologies as well. Patient became progressively
somnolent, altered on the floor, responding only to noxious
stimuli and unsafe to take PO medications. She was started on
thiamine and underwent lumbar puncture as aforementioned.
Patient was noted to be audible obstructing while sleeping. On
continuous pulse oximetry, patient was noted to desaturate
frequently while sleeping to <88% O2.Serial ABGs were performed
which showed progressive hypoxia, hypercarbia. Sleep was
ultimately consulted and recommended BiPap settings. Patient
then had a 20 second apneic episode and was transferred to the
MICU. There, she was transitioned to CPAP with face mask. As she
could not tolerate the face mask, she was switched to nasal CPAP
with good effect. Her mental status improved dramatically
thereafter and upon return to the general Medical Floor, patient
was conversant, interactive and asking intelligent, informed
questions about her medical conditions. Throughout this, patient
was continued on her home psych and other medications.
Psychiatry followed patient throughout this hospitalization and
eventually felt her presenting symptoms not due to psychiatric
illness, but likely severe sleep depression secondary to
obstructive sleep apnea. Patient was discharged straight to her
follow-up Pulmonary appointment and will also have close
followup with her psychiatrist (psychiatry NP) and primary care
doctor. Social work also saw patient in-house.
.
# Tachycardia - Most likely dehydration in the setting of recent
poor PO intake (given mental status/psychiatric issues) and per
physical exam (dry mucus membranes). Pulmonary Emboli was lower
on the differential in the setting of no hypoxia and D Dimer
488. Eventual CTA for pulmonary emboli was also negative.
Cardiac etiology also felt to be unlikely given normal EKG and
negative cardiac enzymes X2. TSH was within normal limits and no
events were noted on telemetry. Patient was on intravenous
fluids when altered and transitioned to PO intake with some
improvement in her tachycardia to 90-100s.
.
# HTN- Continued home Lisinopril/HCTZ & Nifedipine per home
regimen. Although blood pressures were high (SBP140s), patient's
home regimen was not altered during this admission in setting of
her other issues. She was encouraged to discuss this further
with her primary care doctor, especially since initiation of
CPAP may help with hypertension management.
.
# Asthma- Continued home inhalers
.
# GERD- Continued Pantoprazole
.
# Code: presumed full
.
# Emergency Contact: Daughter [**First Name8 (NamePattern2) **] [**Name (NI) 77095**] [**Telephone/Fax (1) 100714**]
Psychiatrist - [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 100715**] [**Telephone/Fax (1) 100716**]
PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 17**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2261**] and [**Telephone/Fax (1) 100717**]
Medications on Admission:
(Per [**Location (un) 2274**] records, unable to confirm from pt)
Tobramycin/dexamethaone 0.3%-0.1% drops. I drop to ea eye daily
through [**2152-3-25**].
Paxil 40 mg daily
Divalproex sr 1250 mg po qhs
klonopin 0.5 mg po bid
pantoprazole delayed release 40 mg po daily
Proair HFA 90 mcg/actuation inh 1-2 puffs q 4-6 hrs prn
Fluticasone 50 mcg/actuation - 2 sprays ea nostril daily
Loratadine 10 mg po daily prn
Lisinopril/HCTZ 5/12.5mg daily
Ketoconazole topical cream apply to affected areas [**Hospital1 **]
Nifedipine 90 mg po daily
Trazodone 25 - 100 mg po qhs prn
.
Allergies: sulfa, tetracycline, tomatoes
Discharge Medications:
1. Non-invasive Positive Pressure Ventilation
Home Phone: [**Telephone/Fax (1) 100714**] / Work Phone: [**Telephone/Fax (1) 100718**]
Next of [**Doctor First Name **]: [**First Name8 (NamePattern2) **] [**Known lastname 77095**] [**Telephone/Fax (1) 100714**] (daughter)
Insurance: NHP COMMCARE [**Name (NI) 100719**] ID#: NHP0163117
Type: Autoset Bipap Machine with Nasal Mask; PSV 0, pressure
range 5-15
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler (MDI)* Refills:*0*
6. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
Disp:*30 Tablet(s)* Refills:*0*
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
8. Ketoconazole 2 % Cream Sig: One (1) application Topical twice
a day: To affected skin areas.
Disp:*1 tube* Refills:*2*
9. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puffs
Inhalation twice a day.
Disp:*1 inhaler (MDI)* Refills:*2*
11. Depakote ER 250 mg Tablet Sustained Release 24 hr Sig: Five
(5) Tablet Sustained Release 24 hr PO once a day.
Disp:*150 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Nystatin 100,000 unit/mL Suspension Sig: Fifteen (15) mL PO
four times a day as needed for oral pain.
Disp:*240 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: Sleep deprivation, severe obstructive sleep apnea,
depression/anxiety, hypertension
Secondary: Asthma, allergic rhinitis, GERD, post-traumatic
stress disorder
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
-You were admitted with hallucinations and found to be delirious
(very sleepy, difficult to wake, confused). It was felt that you
were suffering from severe sleep deprivation due to obstructive
sleep apnea (when your airways get blocked while sleeping,
causing you to wake briefly, repeatedly gasping for air). You
were started on a CPAP breathing machine, which uses high
pressure air to keep your airways open. You responded very well.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> STOP Klonopin 0.5mg twice daily
--> STOP Trazodone 25-100mg before bed as needed
--> START Flovent inhaler twice daily
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Appointment #1
Department: NEUROLOGY (SLEEP CLINIC)
When: TUESDAY [**2152-3-21**] at 11:20 AM
With: DR [**Last Name (STitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Appointment #2
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 100715**]
Therapist
Wednesday, [**3-22**] at 8 am
* Review your depression/anxiety medications and discuss whether
there are other regimens that could work better for you (less
weight gain, more management of symptoms)
.
Appointment #3
Dr. [**First Name4 (NamePattern1) 17**] [**Last Name (NamePattern1) **]
Primary Care
Friday, [**3-24**] at 2:40pm
* Discuss whether your blood pressure medications should be
increased
|
[
"427.89",
"276.51",
"309.81",
"327.23",
"780.1",
"477.9",
"530.81",
"493.90",
"300.4",
"401.9",
"V69.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11583, 11640
|
4496, 4849
|
377, 394
|
11852, 11852
|
3408, 4436
|
12948, 13779
|
2401, 2418
|
9628, 11560
|
11661, 11831
|
8991, 9605
|
12000, 12925
|
2433, 3389
|
279, 339
|
422, 2145
|
4445, 4473
|
11867, 11976
|
2167, 2319
|
2335, 2385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,687
| 165,763
|
7173
|
Discharge summary
|
report
|
Service: Vascular Surgery Discharge Date: [**2120-7-25**]
Date of Birth: [**2074-6-22**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
CHIEF COMPLAINT: Ischemic, chronic right heel ulcer.
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
white female with type I diabetes, coronary artery disease,
end stage renal disease, status post renal transplant in
[**9-/2117**], status post left below the knee amputation, status
post right distal popliteal to anterior tibial artery bypass,
status post right common femoral to popliteal anterior tibial
left arm vein graft. She has been followed by Dr. [**Last Name (STitle) **],
Podiatry, since [**6-/2119**] for a chronic right plantar heel
ulcer. The patient has had multiple Apligraf applications.
The wound has gotten small but still has not healed.
The patient was referred back to Dr. [**Last Name (STitle) **]. The patient
underwent an outpatient arteriogram on [**2120-7-15**] which
showed a stenosis in her distal right vein graft. The
patient was scheduled for revision of her right vein graft.
PAST MEDICAL HISTORY: Coronary artery disease: Myocardial
infarction, coronary artery bypass graft.
Type I diabetes since age 12; with triopathy and
gastroparesis.
Cerebrovascular accident times two.
End stage renal disease, status post renal transplant in
09/[**2117**].
Hypertension.
Hypercholesterolemia.
Anemia.
Peripheral vascular disease.
PAST SURGICAL HISTORY: Coronary artery bypass graft times
three in [**7-/2116**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 190**].
Left lower extremity bypass graft in [**2112**].
Left below the knee amputation in [**1-/2117**] by Dr. [**Last Name (STitle) **].
Jump graft from right common femoral artery to popliteal
anterior tibial vein graft with left arm vein on [**2118-12-2**]
by Dr. [**Last Name (STitle) **].
Hand surgery.
Renal transplant in 09/[**2117**].
FAMILY HISTORY: The patient's family history is
noncontributory.
SOCIAL HISTORY: The patient lives with her husband. She is
a current cigarette smoking with an 80-pack-year history.
She ambulates with a left lower extremity prosthesis and a
boot for her right leg prescribed by the Podiatry Service.
ALLERGIES: Intravenous contrast dye causes nausea and
vomiting.
Augmentin causes a rash.
Demerol causes a rash.
Irritation from silk/ribbon tape.
PHYSICAL EXAMINATION: Vital signs: The patient was afebrile
with stable vital signs. Her heart had a regular rate and
rhythm. Her lungs were clear bilaterally. Her abdomen was
benign. The right foot had a deep plantar heel ulcer. A
pedal pulse was not palpable. Left below the knee amputation
incision was well healed. Neurological exam: The patient
was alert and oriented times three; nonfocal.
LABORATORY DATA: On [**2120-7-16**], white blood count was 9.2,
hemoglobin 12.9, hematocrit 39.2, platelets 274,000. Sodium
140, potassium 3.9, chloride 103, bicarbonate 32, BUN 7,
creatinine 0.6, glucose 46. Chest x-ray on [**2120-7-16**] showed
no acute pulmonary disease. Electrocardiogram on [**2120-7-8**]
showed a normal sinus rhythm at a rate of 67. Interval
improvement in anterolateral ischemia seen since previous
tracing of [**2120-7-6**].
MEDICATIONS: Her medications on admission were levofloxacin
500 mg p.o. q.day, prednisone 5 mg p.o. q.d., tacrolimus 2 mg
p.o. q.12 hours, CellCept [**Pager number **] mg b.i.d., Bactrim one tablet
p.o. q.d., glargine 25 units subcutaneously q.h.s., regular
insulin sliding scale q.i.d., metoprolol 50 mg p.o. b.i.d.,
aspirin 325 mg p.o. q.d., famotidine 20 mg p.o. b.i.d.,
paroxetine 20 mg p.o. q.d., alprazolam 1 mg p.o. b.i.d.,
Colace 100 mg p.o. b.i.d., Senna p.r.n., morphine sustained
release 30 mg p.o. b.i.d., MSIR 15 mg p.o. q.4-6 hours
p.r.n., .................... 400 mg p.o. q.4 hours, Lactulose
30 mg p.o. q.8 hours p.r.n., nitroglycerin p.r.n.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2120-7-22**] following an uneventful jump graft from the right
femoral to below the knee popliteal vein graft to the right
below the knee to anterior tibial vein graft using right arm
basilic vein. At the end of surgery, the patient had a
Doppler signal at the right anterior tibial and dorsalis
pedis.
The patient received Kefzol perioperatively. The Renal
Transplant Service followed the patient during her
hospitalization. They recommended holding the patient's
metoprolol perioperatively while on bed rest if the patient's
systolic blood pressure was low. Target systolic blood
pressure was greater than 110. The patient reported that her
average blood pressure was in the 90/60 range. On
postoperative day three, the patient's blood pressure was
87/39. The patient appeared sedated but was easily
arousible. She stated that when she was on bed rest, her
blood pressure was frequently in that range. The patient was
asymptomatic.
The Podiatry Service was consulted to adjust the patient's
right leg boot in order to off load as much weight from her
right heel as possible. This was done on [**2120-7-25**], and the
patient can be full weight bearing on the right.
At the time of dictation, the patient's right arm and leg
incisions are clean, dry, and intact. Her right dorsalis
pedis pulse is dopplerable. Her right plantar heel ulcer is
deep but clean. Her right elbow ulceration is stable. The
patient will continue to have Adaptic and a dry, sterile
dressing applied to her right foot and right elbow ulcers
q.d. She may have a dry, sterile dressing to her right arm
and leg incisions p.r.n.
The patient will follow-up with Dr. [**Last Name (STitle) **] in the office in
about two weeks for surgical staple removal. She will
continue on levofloxacin for her plantar ulcer until
follow-up with Dr. [**Last Name (STitle) **] and then per further instructions.
DISCHARGE MEDICATIONS:
Prednisone 5 mg p.o. q.d.
Bactrim single strength one tablet p.o. q.Monday, Wednesday,
Friday.
Tacrolimus 2 mg p.o. b.i.d.
Mycophenolate mofetil 1000 mg p.o. b.i.d.
Metoprolol 50 mg p.o. b.i.d.
Paxil 20 mg p.o. q.d.
Pepcid 20 mg p.o. b.i.d.
Aspirin 325 mg p.o. q.d.
Colace 100 mg p.o. b.i.d.
Lactulose 30 mg p.o. q.8 hours p.r.n. constipation.
Senna one tablet p.o. b.i.d. p.r.n.
Neurontin 400 mg p.o. q.6 hours.
Alprazolam 1 mg p.o. b.i.d. p.r.n.
Morphine sulfate sustained release 30 mg p.o. q.12 hours.
MSIR 15 mg p.o. q.4-6 hours p.r.n.
Nitroglycerin sublingual 0.3 mg p.r.n. chest pain.
Glargine 25 mg p.o. q.h.s.
Regular insulin sliding scale q.i.d.
CONDITION AT DISCHARGE: Satisfactory.
DISPOSITION: Home with [**Hospital6 407**] services.
PRIMARY DIAGNOSIS:
Ischemic right chronic plantar heel ulcer and distal right
vein graft stenosis.
Jump graft from right femoral popliteal vein graft to right
popliteal anterior tibial vein graft using right arm basilic
vein on [**2120-7-22**].
SECONDARY DIAGNOSIS:
Type I diabetes with triopathy and gastroparesis.
End stage renal disease, status post renal transplant.
Coronary artery disease.
Status post cerebrovascular accident times two.
Hypertension.
Hypercholesterolemia.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2120-7-25**] 15:52
T: [**2120-7-25**] 16:04
JOB#: [**Job Number 26639**]
|
[
"V45.81",
"996.74",
"250.01",
"401.9",
"414.01",
"272.0",
"440.23",
"707.14",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
6246, 6914
|
4173, 6223
|
1591, 2574
|
2597, 2914
|
6929, 6999
|
2934, 4155
|
248, 1567
|
7272, 7768
|
7018, 7251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,298
| 111,341
|
7805
|
Discharge summary
|
report
|
Admission Date: [**2123-1-12**] Discharge Date: [**2123-1-19**]
Date of Birth: [**2047-9-27**] Sex: F
Service: MEDICINE
Allergies:
Tape [**12-14**]"X10YD / Morphine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
- Cardiac catheterization [**2123-1-14**]
History of Present Illness:
75 F with CAD s/p to stent to RCA [**2116**], COPD recently started on
home oxygen, HTN, PVD who inititally presented to [**Hospital 1474**]
Hospital after for ongoing SOB since the beginning of [**Month (only) 404**].
Pt states that since early [**Month (only) 404**], she has been experiencing
worsening shortness of breath that has occurred on exercise & at
rest. She has been unable to sleep or tolerate recumbency. She
has had an ongoing cough productive of clear-white sputum
without hemoptysis. She experienced one episode of chest
thightness/sharp chest pain roughly 3 weeks ago. This pain was
non-radiation; it was not associated with diaphoresis, nausea,
vomiting.
.
She was seen by her PCP and started on inhalers for concern
regarding possible URI. On Monday, she was started on
azithromycin yesterday as well as home oxygen with a plan to
increase her prednisone.
.
Early on the morning of admission, she had worsening SOB/DOE so
she called 911 & was brought to [**Hospital 1474**] Hospital. There was
iniital concern for a COPD exacerbation; she was given 250 mg
azithro, 1 gm cftx, albuterol/ipratropium nebs, IV solumedrol
125 mg IV. CXR showed bilateral effusions. CTA was negative for
PE.
.
Pt ruled in for NSTEMI (trop 2.76 -> 4.02). She was given 325
mg ASA, plavix 75 mg, & she was started on heparin gtt. She was
also given 40 mg IV lasix and subsequently transferred to [**Hospital1 18**]
for possible cath.
.
REVIEW OF SYSTEMS: As per HPI. No headache, dizziness, abdominal
pain, nausea, vomiting, diarrhea, constipation, melena,
hematochezia, dysuria, myalgias, or arthralgias. No history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery. No recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
PND, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis
Social History:
- Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits.
Family History:
No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T= 95.6 BP= 135/69 HR= 105 RR= 18 O2 sat= 95% RA
GENERAL: thin elderly female, resting comfortably but fatigued
appearing, NAD
HEENT: NCAT. Sclera anicteric. Pupils equal, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. Slightly dry mucous membranes/
NECK: Supple with JVD to mandible.
CARDIAC: RRR, normal S1, S2. No m/r/g. Distant heart sounds.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
breath sounds with bibasilar crackles, no wheezing or rhonchi.
ABDOMEN: Bowel sounds present, soft, non-tender, non-distended,
no organomegaly, no guarding or rebound tenderness.
EXTREMITIES: Warm, DPs 2+ bilaterally, no edema
SKIN: No stasis dermatitis or other rashes.
NEURO: AAOx3, CN 2-12 grossly intact, strength 5/5 throughout,
sensation grossly intact to light touch
PSYCH: Calm, appropriate
DISCHARGE PHYSICAL EXAM:
Tm: 98.5 100(70-100) 97/50(80-120/40-80) 18 98/2L
24 I/O: 1170/1100
GEN: Appears frail.
HEENT: NCAT.
NECK: No JVD
COR: +S1S2, RRR, no m/g/r.
PULM: Crackles at bases, do not clear with cough.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND.
EXT: WWP, no leg edema. R groin with hematoma stable.
NEURO: MAEE, weak.
Pertinent Results:
ADMISSION LABS & STUDIES:
[**2123-1-13**] 06:55AM BLOOD PT-13.2* PTT-VERIFIED B INR(PT)-1.2*
[**2123-1-13**] 06:55AM BLOOD WBC-9.4 RBC-3.95* Hgb-11.8* Hct-33.9*
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.2 Plt Ct-290
[**2123-1-13**] 06:55AM BLOOD Glucose-100 UreaN-23* Creat-1.3* Na-140
K-3.6 Cl-100 HCO3-26 AnGap-18
[**2123-1-13**] 12:34AM BLOOD CK-MB-9 cTropnT-0.33*
[**2123-1-13**] 06:55AM BLOOD Calcium-8.8 Phos-5.8*# Mg-2.1
CXR ([**2123-1-14**]):
FINDINGS: Comparison is made with the most recent study at this
institution of [**2118-6-16**]. The cardiac silhouette remains somewhat
enlarged and there is increased opacification at the bases
consistent with small pleural effusions and associated
compressive atelectasis. There is engorgement of ill-defined
pulmonary vessels, consistent with elevated pulmonary venous
pressure, as suggested in the clinical history
CT ABDOMEN & PELVIS ([**2123-1-14**]):
IMPRESSION:
1. Left groin hematoma, deep to the left common femoral artery.
There is
mild stranding surrounding the right common femoral artery,
though no evidence of hematoma.
2. Diverticulosis.
3. New bilateral pleural effusions and smooth intralobular
septal thickening, likely indicating volume overload.
4. Extensive atherosclerosis.
5. Calcified granulomata in the liver and spleen.
DISCHARGE LABS & STUDIES:
[**2123-1-19**] 08:55AM BLOOD Glucose-104* UreaN-25* Creat-1.1 Na-139
K-4.2 Cl-100 HCO3-28 AnGap-15
[**2123-1-18**] 07:05AM BLOOD proBNP-9710*
[**2123-1-19**] 08:55AM BLOOD WBC-8.0 RBC-3.28* Hgb-9.9* Hct-29.1*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.4 Plt Ct-291
TTE ([**2123-1-13**]):The left atrium is mildly dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25-30
%) secondary to akinesis of the entire septum and apex, and
moderate global hypokinesis of the remaining segments. The
basal-mid lateral wall contracts best. Right ventricular chamber
size is normal. with focal hypokinesis of the apical free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction
c/w multivessel CAD. Moderate mitral and tricuspid regurgitation
with moderate pulmonary artery systolic hypertension.
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
75 F w CAD s/p RCA stent [**2116**], COPD, RA, seizure disorder, HTN,
PVD, p/w several weeks of worsening SOB. Ruled in for STEMI at
OSH & subsequently transferred to [**Hospital1 18**] for cath.
ACUTE DIAGNOSES:
# NSTEMI: Found to have peak troponin to 2.76 at OSH with T wave
changes in V2-V5.
Transferred on heparin gtt. Pt was continued on metoprolol,
statin, ASA. Loaded with plavix prior to cath on [**2123-1-14**] which
showed minimal in-stent restenosis of RCA stent, as well as a
tight ostial LAD on which PCI could not be performed (too
difficult). Pt had radial access for arterial cath; venous
access in groin difficult to obtain. Patient hypotensive during
case, requiring dopamine gtt temporarily (now off pressors).
Afterward, patient developed rapidly expanding left groin
hematoma. She was given protamine. Hematoma now stable,
hematocrit 29 on discharge (stable for days). Patient also
dyspnea, requiring O2 4L per NC, and appears somewhat volume
overloaded. Patient admitted to CCU for diuresis and observation
overnight. B/L LE US were negative for hematoma, non-contrast CT
abdomen and pelvis were negative for RP bleed. In the CCU,
patient was continued on ASA 325mg PO, Atorvastatin 80mg PO
daily, Metoprolol tartrate 50mg PO BID, plavix. Amlodipine was
discontinued and lisinopril was held due to hypotension/low
urine output. On the floor, patient started on diovan 40 mg,
which should be held if her blood pressure is less than 100.
Discharged on full ASA, plavix, metoprolol succinate 100 mg QD.
# LEFT GROIN HEMATOMA: Developed apparent right groin hematoma
which was treated with protamine. CT [**Last Name (un) 103**] showed pt actually had
left groin hematoma, none on right. No pseudoaneurysm/RP bleed.
Hematoma and hematocrit remained stable throughout CCU & floor
course. DPs dopplerable BL. Patient was maintained on
pneumoboots instead of heparin sq prophylaxis.
# Acute on Chronic Systolic CHF: CXR showed pulmonary
engorgement & bilateral effusions with compressive atelectasis.
Pt was given IV lasix prior to going to the cath lab. A TTE was
performed that showed severe global hypokinesis & akinesis of
entire septum & apex. LVEF 25-30%. Prior ECHO shows EF 40-45%
in [**2116**]. During catheterization, pt was hypotensive & required
dopamine gtt. She was transferred to the CCU for transient
hypotension requiring dopamine in the catheterization lab. Ms.
[**Known lastname 13143**] was normotensive on the floor. Diovan was started on
the floor as above. Lasix will not be reinitiated on discharge.
CHRONIC DIAGNOSES:
# COPD/Emphysema: Pt was continued on her course of
azithromycin. There was no concern for acute exacerbatin given
good air movement & lack of wheeze.
# PVD: continued on aspirin & plavix.
# Seizure disorder: Last seizure was on [**2120**]. He was continued
on home keppra 1500mg [**Hospital1 **], but pharmacy recommended switching
her dose based on her renal function. The recommended dose
(based on creatinine clearance) is 750 mg [**Hospital1 **]. This was
explained to the patient as she was nervous about the change in
dose.
# Rheumatoid arthritis: He was continued on prednisone 5mg PO
daily. Her celebrex was held due to NSTEMI.
# Osteopenia: He was continued on calcium, vitamin D.
TRANSITIONAL ISSUES:
# Follow-Up: Upon leaving rehab, the patient should schedule
follow up appointments with her cardiologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
and her primary care doctor.
# Code Status: DNR/DNI. Daughter is HCP: [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 28220**]
Medications on Admission:
Aspirin 81mg daily
Celebrex 100mg daily
Simvastatin 20mg nightly
Prednisone 5 mg daily
Metoprolol 25mg daily
Omeprazole 20mg daily
Amlodipine 5mg daily
Vitamin D 400 units daily
Calcium carbonate - 6 tabs daily
Keppra 1500mg [**Hospital1 **]
B12 injection once per month
Timolol 0.5% one drop to each eye daily in AM (not recently
taking)
Brimodidine 0.15% one drop left eye [**Hospital1 **] (not recently taking)
Optive dry eye solution, both eyes TID (not recently taking)
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-14**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Please hold for sBP < 100 or HR < 60.
7. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please hold for sBP < 100.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough for 2 weeks.
12. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane five times a day as needed for sore throat for 1 weeks.
13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. calcium citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet
PO three times a day.
16. Medication
B12 injections one per month
17. timolol maleate (PF) 0.5 % Dropperette Sig: One (1) drop
Ophthalmic QAM.
18. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
19. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
20. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO HS
(at bedtime) as needed for cough for 1 weeks: Do not administer
this medication if patient sedated.
21. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for congestion for 2 days.
22. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 27838**] Rehabilitation & [**Hospital **] Care Center - [**Hospital1 1474**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Non-ST Elevation Myocardial Infarction
SECONDARY DIAGNOSES:
- Congestive Heart Failure
- Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 13143**], it was a pleasure to participate in your care
while you were at [**Hospital1 18**]. You came to the hospital for shortness
of breath over hte past month. You were transferred from
[**Hospital 1474**] Hospital after it was found that you had a small heart
attack. While you were here, you had a cardiac catheterization
which showed a blockage. We were unable to treat the blockage
because your blood pressure was low during the procedure and you
need to go to the cardiac intensive care unit. While you were
there, you were treated with some intravenous diuretics. Your
urine output temporarily dropped, but by the time you were
transferred back to the medical floor, your urine production
improved. You had an ultrasound of your heart that showed
slight worsening of your heart failure.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
MEDICATION INSTRUCTIONS:
- Medications STARTED:
---> Please start taking celexa 10 mg daily
---> Please start taking diovan 40 mg daily
---> Please start taking atorvastatin 80 mg daily
---> Please start taking plavix 75 mg daily
---> Please start taking nasal saline spray as needed for dry
nose
---> Please start taking calcium citrate (instead of calcium
carbonate)
---> Please start taking your inhaler as indicated
- Medications STOPPED:
---> Please stop taking lisinopril
---> Please stop taking amlodipine
---> Please stop taking simvastatin
---> Please stop taking calcium carbonate
- Medications CHANGED:
---> Please decrease your dose of Keppra from 1500 mg twice a
day to 750 mg twice a day (this medication is now dosed safely
according to your kidney function)
---> Please increase your dose of aspirin from 81 mg to 325 mg
daily
---> Please increase your dose of metoprolol from 25 mg daily to
100 mg daily
Followup Instructions:
After you leave rehab, please call Dr.[**Name (NI) 5452**] office to schedule
a follow-up appointment.
|
[
"V49.86",
"E944.4",
"V15.82",
"410.71",
"E878.8",
"458.29",
"799.02",
"345.90",
"714.0",
"V45.82",
"428.23",
"V58.65",
"788.5",
"281.0",
"E879.0",
"998.12",
"V46.2",
"365.70",
"733.90",
"V45.79",
"440.21",
"362.50",
"996.72",
"365.9",
"428.0",
"414.01",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
13458, 13573
|
7189, 10489
|
314, 357
|
13752, 13752
|
4506, 7166
|
15796, 15902
|
3145, 3252
|
11351, 13435
|
13594, 13594
|
10851, 11328
|
13935, 14850
|
3292, 4145
|
13676, 13731
|
10510, 10825
|
1844, 2308
|
255, 276
|
385, 1825
|
13613, 13655
|
14875, 15773
|
13767, 13911
|
2330, 3010
|
3026, 3129
|
4170, 4487
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,023
| 199,189
|
27338
|
Discharge summary
|
report
|
Admission Date: [**2180-6-12**] Discharge Date: [**2180-6-21**]
Date of Birth: [**2126-2-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SOB and cough for 3 weeks
Major Surgical or Invasive Procedure:
AVR on [**2180-6-13**] ( [**Street Address(2) 17167**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] pericardial valve)
History of Present Illness:
54 yo female with known AS, admitted to [**Hospital 1474**] Hosp. on [**6-1**]
for SOB and cough for three weeks. This was thought to be a COPD
exacerbation and was treated with steroid taper and inhalers. A
swab for pertussis was also sent. She was also treated for a
UTI/ trichomonas with flagyl. Cardiac cath at [**Hospital1 1474**] revealed
nl. cors. echo showed [**Location (un) 109**] 0.4 cm2 with mean gradient of 58 mm.
Referred to Dr. [**Last Name (STitle) **] for AVR.
Past Medical History:
AS
COPD
UTI
anxiety
bipolar disorder ( newly diagnosed at [**Hospital1 1474**])
Hepatitis B and C
Social History:
smoker, [**2-7**] ppd for 40 years
ETOH abuse, but none in 3 months
lives with brother ( has been homeless)
Physical Exam:
NCAT, PERRLA, EOMI, OP : edentulous, pierced tongue
NAD, AVSS 98.3, 96% RA sat, 119/70, Hr 99 RR 18
CTAB
RRR, 4/6 SEM
+ BS, soft, NT, ND, no masses or HSM
no c/c/e, pulses 2+ bilat. throughout
no lymphadenopathy or thyromegaly
carotids 2+ with radiating murmur bilat.
neuro nonfocal
62" 58.9 kg
Pertinent Results:
[**2180-6-15**] 05:56AM BLOOD WBC-12.1* RBC-3.10* Hgb-10.2* Hct-29.3*
MCV-95 MCH-32.9* MCHC-34.8 RDW-16.3* Plt Ct-98*
[**2180-6-16**] 06:00AM BLOOD Hct-26.9* Plt Ct-PND
[**2180-6-12**] 07:10PM BLOOD WBC-10.7 RBC-3.58* Hgb-12.2 Hct-35.6*
MCV-99* MCH-34.1* MCHC-34.3 RDW-12.7 Plt Ct-201
[**2180-6-15**] 05:56AM BLOOD Plt Smr-LOW Plt Ct-98*
[**2180-6-15**] 05:56AM BLOOD Glucose-89 UreaN-23* Creat-0.8 Na-138
K-4.7 Cl-102 HCO3-33* AnGap-8
[**2180-6-16**] 06:00AM BLOOD UreaN-22* Creat-0.8 K-4.5
[**2180-6-12**] 07:10PM BLOOD ALT-18 AST-13 LD(LDH)-169 AlkPhos-45
Amylase-54 TotBili-0.2
[**2180-6-12**] 07:10PM BLOOD Lipase-18
[**2180-6-15**] 05:56AM BLOOD Mg-2.3
[**2180-6-12**] 07:10PM BLOOD Albumin-4.1
[**2180-6-19**] CXR
New ill-defined opacities in the right middle and lower lobes.
Considering history of fever, this could represent an
early/evolving pneumonia. Followup radiographs may be helpful.
[**2180-6-13**] ECHO
PRE-BYPASS:
1) The left atrium is normal in size. 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.
2) A patent foramen ovale is present.
3) There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4) Right ventricular chamber size and free wall motion are
normal.
5) The aortic valve is bicuspid. The aortic valve leaflets are
severely
thickened/deformed. There is severe aortic valve stenosis. No
aortic
regurgitation is seen.
6) The mitral valve appears structurally normal with trivial
mitral
regurgitation.
7) There is no pericardial effusion.
Postbypass:
Preserved biventricular systolic function. Overall LVEF 60%.
Ascending aorta is free of any free dissection flaps. There is a
small hematoma noted during the aortic cannulation and it has
not increased in size. The hematoma is probably 1 X 1cm. Aortic
arch and descending thoracic aorta are free of any dissection
flaps. A bioprosthesis is seen in the native aortic position,
stable in postion and functioning well with a peak and a mean of
20 and 10mm of HG.
Brief Hospital Course:
Ms. [**Known lastname 67002**] was admitted to the [**Hospital1 18**] on [**2180-6-12**] for surgical
management of her aortic valve disease. She was worked-up in the
usual preoperative manner and deemed suitable for surgery. On
[**2180-6-13**], Ms. [**Known lastname 67002**] was taken to the operating room where she
underwent an aortic valve replacement utilizing a 19mm St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) **] pericardial tissue valve. Postoperatively she was taken
to the cardiac surgical intensive care unit for monitoring. She
was weaned from sedation and awoke neurologically intact. A
steroid taper was continued for her preoperative COPD
exacerbation. Aspirin, beta blockade and a statin were resumed.
She was then transferred to the cardiac surgical step down unit
for further recovery. Ms. [**Known lastname 67002**] was gently diuresed toward
her preoperative weight. The physical therapy service was
consulted for assistance with her postoperative strength and
mobility. During the early hours of postoperative day three, Ms.
[**Known lastname 67002**] fell. Work-up was negative and an ice pack was applied
to her knee. A On postoperative day 6, Ms. [**Known lastname 67002**] developed a
fever. She was pan cultured which was negative and a lower
extremity ultrasound was negative for a deep vein thrombosis.
Antibiotics (dicloxacillin and vancomycin)were prophylactically
started. She defervesced and her cultures remained negative. On
potoperative day seven, Ms. [**Name14 (STitle) 67003**] was discharged from the
hospital in stable condition to her home. She will follow-up
with Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician
as an outpatient.
Medications on Admission:
ECASA 81 mg daily
prednisone 35 mg daily(tapering doses)
lopressor 25 mg [**Hospital1 **]
seroquel 25 mg qAM, 50 mg HS
colace 100 mg [**Hospital1 **]
albuterol MDI
atrovent MDI
advair 250/ 50 mg [**Hospital1 **]
nicotine patch 21
SL NTG prn
ativan prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. 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*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
12. 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:*0*
13. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
Disp:*QS 1 Month* Refills:*0*
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*QS 1 month* Refills:*0*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
5 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p AVR [**2180-6-13**]
COPD
UTI
anxiety
bipolar disorder ( newly diagnosed at [**Hospital 1474**] Hosp.)
+ HEP. B and Hep.C
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams, or powders on [**Doctor First Name **] incision
no driving for one month
call for fever greater than 100, redness or drainage
no lifting greater than 10 pounds for 10 weeks
may shower over incision and pat dry
Followup Instructions:
see Dr. [**Last Name (STitle) 67004**] in [**2-7**] weeks
See Dr. [**Last Name (STitle) **] in [**3-10**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2180-7-21**]
|
[
"496",
"070.54",
"724.5",
"424.1",
"300.00",
"428.0",
"296.7",
"E884.2",
"719.46",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7940, 7995
|
3749, 5479
|
318, 469
|
8166, 8175
|
1560, 3726
|
8453, 8671
|
5783, 7917
|
8016, 8145
|
5505, 5760
|
8199, 8430
|
1239, 1541
|
253, 280
|
497, 977
|
999, 1098
|
1114, 1224
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,695
| 125,617
|
396
|
Discharge summary
|
report
|
Admission Date: [**2176-7-2**] Discharge Date: [**2176-7-7**]
Date of Birth: [**2115-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3513**]
Chief Complaint:
Abdominal pain, nausea, and vomiting.
Major Surgical or Invasive Procedure:
ERCP x 2.
History of Present Illness:
60 year-old male with history significant for severe nonischemic
hypertensive cardiomyopathy (EF 20%), ICD placement,diabetes who
presents with abdominal pain, nausea, and vomiting since the
morning of admission. The patient states he ate breakfast at 9
am, and approximately one hour later, the pain began and
continued to wax and wane throughout the day, often reaching
[**11-6**]. The pain was described as bandlike across his abdomen,
without radiation to the back. No aggravating factors other than
eating. The pain was alleviated with Morphine in the ED. The
patient has never had this type of pain in the past. The patient
also complained of nausea and vomiting, nonbilious/nonbloody.
The patient denied diarrhea, melena or hematochezia. He denies
any recent changes in his medications, recent travel, recent
alcohol use, history of gallstones or symptoms of biliary colic.
.
In the ED, the patient received one liter NS, morphine, and a
dose of levofloxacin. The patient was admitted to the MICU.
.
In the MICU he was given NS at 150cc/hr. Antibiotics were not
continued. The biliary team saw the patient and recommended
ERCP. The procedure was deferred due to the patient's INR. The
patient's pain was improved on transfer.
Past Medical History:
1. Diabetes mellitus type 2, insulin dependent x 8 years
2. Cardiomyopathy, EF 20%
3. ICD placement
4. Elevated transaminases, unknown etiology
5. Chronic atrial fibrillation
6. Chronic renal failure, most recent creatinine 1.7
7. Umbilical hernia repair, [**8-/2175**]
Social History:
Lives with his wife, has four grown children. Not currently
working, on disability. Used to work in contruction. No tobacco,
alcohol, or illicits.
Family History:
No family history of heart disease.
Physical Exam:
VS: T 98.2 HR 74 BP 125/71 RR 18 O2sat 98% RA
GEN: Awake, lying flat in bed, NAD, well developed
HEENT: Atraumatic, mild scleral icterus, dry mucosa
NECK: No JVD, no LAD
CV: Soft [**3-5**] holosystolic murmur, LSB, irregular rhythm, regular
rate
LUNGS: CTA B/L w/ good inspiratory effort
ABD: Mildly distended, soft, tender to palpation in upper
quadrants B/L and periumbilical. Negative [**Doctor Last Name **] sign, no
rebound
EXT: Warm, dry, no LE edema
NEURO: AAOX3, follows commands, answers questions appropriately,
no focal deficits
Pertinent Results:
Labwork on admission:
[**2176-7-2**] 08:20PM WBC-9.3 RBC-4.95 HGB-14.6 HCT-40.5 MCV-82
MCH-29.5 MCHC-36.0* RDW-17.1*
[**2176-7-2**] 08:20PM NEUTS-58 BANDS-0 LYMPHS-32 MONOS-8 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2176-7-2**] 08:20PM PLT SMR-NORMAL PLT COUNT-149*
[**2176-7-2**] 08:20PM DIGOXIN-1.0
[**2176-7-2**] 08:20PM TRIGLYCER-165*
[**2176-7-2**] 08:20PM CK-MB-3 cTropnT-<0.01
[**2176-7-2**] 08:20PM CALCIUM-9.9
[**2176-7-2**] 08:20PM ALT(SGPT)-272* AST(SGOT)-485* LD(LDH)-594*
CK(CPK)-135 ALK PHOS-188* AMYLASE-1472* TOT BILI-3.8* DIR
BILI-2.0* INDIR BIL-1.8
[**2176-7-2**] 08:20PM GLUCOSE-140* UREA N-25* CREAT-1.9* SODIUM-134
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-28 ANION GAP-17
[**2176-7-2**] 08:20PM LIPASE-6160*
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2176-7-2**]
FINDINGS: The liver displays normal echotexture and
architecture. No focal liver lesions are identified. The
hepatic veins are dialated consistent with congestive heart
failure. The main portal vein is patent with normal hepatopetal
flow. The gallbladder demonstrates mild wall thickening without
without intraluminal stone. There is a negative son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign. There is no pericholecystic fluid or gallbladder
wall edema. There is no intra- or extra- hepatic biliary duct
dilatation with the common bile duct measuring 5 mm. There is no
right upper quadrant ascites. Partially visualized portion of
the pancreatic head and neck demonstrate no acute abnormality.
IMPRESSION:
1. No evidence of cholecystitis.
2. Prominent hepatic veins consistent with venous congestion.
.
CHEST (PORTABLE AP) [**2176-7-2**]
FINDINGS: There is stable cardiomegaly. Left-sided AICD device
noted with leads unchanged. No pleural effusion or pneumothorax
identified. There is pulmonary vascular congestion although
slightly decreased when compared to previous. There is no
evidence of free intra-abdominal air.
.
ECG Study Date of [**2176-7-2**]
Atrial fibrillation
Indeterminate axis
Low limb lead QRS voltages
Delayed R wave progression with late precordial QRS transition
Nonspecific T wave abnormalities
Findings are nonspecific but clinical correlation is suggested
for possible in
part chronic pulmonary disease
Since previous tracing of [**2175-11-10**], no significant change
.
ERCP [**2176-7-5**]
Impression: A plastic stent placed in the pancreatic duct was
found in the major papilla.
Evidence of a previous incomplete sphincterotomy was noted in
the major papilla.
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique.
A mild dilation was seen at the biliary tree.
There was a filling defect that appeared like sludge at the
biliary tree.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome.
Sludge was extracted successfully using a balloon catheter.
The plastic stent was removed.
.
Labwork on discharge:
[**2176-7-6**] 08:15AM BLOOD WBC-6.7 RBC-3.67* Hgb-11.0* Hct-30.3*
MCV-83 MCH-29.9 MCHC-36.3* RDW-17.5* Plt Ct-104*
[**2176-7-7**] 07:40AM BLOOD Glucose-131* UreaN-17 Creat-1.4* Na-139
K-3.8 Cl-103 HCO3-24 AnGap-16
[**2176-7-6**] 08:15AM BLOOD ALT-100* AST-62* LD(LDH)-251*
AlkPhos-137* Amylase-37 TotBili-4.1*
[**2176-7-7**] 07:40AM BLOOD TotBili-3.4*
[**2176-7-6**] 08:15AM BLOOD Lipase-20
Brief Hospital Course:
60 year-old male with congestive heart failure (EF 20%), status
post ICD placement, atrial fibrillation on coumadin, chronic
renal failure presenting with abdominal pain, nausea, vomiting
for 24 hours prior to admission and found to have pancreatitis.
.
1. Pancreatitis: Elevated amylase/lipase consistent with
pancreatitis as the cause of the patient's abdominal pain. The
elevated alkaline phosphatase/bilirubin was suggestive of a
gallbladder etiology. There were no obvious gallstones seen on
ultrasound; ERCP showed abundant sludge, however. The pancreatic
duct was stented during the first ERCP but the common bile duct
was unable to be cannulated; this was achieved with the second
ERCP. During the second ERCP it was noted that the stent
initially placed in the pancreatic duct had migrated and this
was subsequently removed. Amiodarone is known to rarely cause
pancreatitis; the patient's amiodarone was held and was not
restarted on discharge. The patient remained afebrile, without
leukocytosis, and with normal lactate. Antibiotics were
therefore not indicated. The patient was initially maintained
NPO with intravenous hydration but tolerated clear liquids and
then a regular diet soon after the second ERCP. The patient's
pancreatic enzymes trended down quickly. The patient's coumadin
was held and the patient was transfused one unit fresh frozen
plasma prior to ERCP. Coumadin should be held for ten days
following ERCP and can be restarted [**7-15**].
.
2. Elevated transaminases: The patient has a history of elevated
transaminases and recently had an appointment in liver clinic;
etiology remains unknown. Recent hepatitis panel negative. The
patient's acute transaminase elevation was likely due to
gallbladder sludge. The patient's amiodarone and statin were
held and were not restarted prior to discharge. The patient had
follow-up scheduled with Hepatology for further outpatient
work-up.
.
3. Cardiac:
a. Vessels: Clean coronary catheterization in [**2165**]. The patient
had no EKG changes and cardiac enzymes were within normal limits
on this admission. The patient's statin was held in the setting
of elevated transaminases, although unlikely secondary to
statin.
b. Pump: Hypertensive non-ischemic cardiomyopathy, EF 20%. The
patient's lasix was initially held and he was hydrated with
intravenous fluids. The patient was subsequently hypervolemic
but diuresed well with lasix. The patient was euvolemic on
discharge. The patient was continued on coreg. Diovan was
initially held for concern for acute renal failure but was
restarted when the creatinine was confirmed to be at baseline.
c. Rhythm: Chronic atrial fibrillation, rate controlled with
digoxin and coreg. The patient's digoxin level was within normal
limits on admission and digoxin was continued. The patient was
continued on coreg. Diovan was initially held for concern for
acute renal failure but was restarted when the creatinine was
confirmed to be at baseline. Coumadin should be held for ten
days following ERCP and can be restarted [**7-15**].
.
4. Diabetes mellitus, type II: Insulin-dependent, moderate
control. The patient was given 1/2 dose of insulin 70/30 while
NPO but restarted on his home dose when taking a regular diet.
The patient was maintained on a humalog insulin sliding scale.
.
5. Chronic renal insufficiency: Recent baseline 1.4-1.7; at
baseline. Likely secondary to diabetes and hypertension. Diovan
was initially held for concern for acute renal failure but was
restarted when the creatinine was confirmed to be at baseline.
.
6. Thrombocytopenia: Recent baseline 93-157. The patient's
platelet count remained stable during admission. Unknown
etiology. [**Month (only) 116**] be due to liver disease. Further work-up deferred
to the outpatient setting.
.
7. Anemia: Recent baseline low-30s. The patient's hematocrit
remained stable during admission. Likely component of chronic
renal failure. Recent iron studies were within normal limits.
B12 and folate within normal limits on this admission. Further
work-up deferred to the outpatient setting.
.
Code: Full
.
Disposition: Home
Medications on Admission:
Lasix 80 mg daily
Coreg 12.5 mg [**Hospital1 **]
Diovan 80 mg daily
Digoxin 125 mcg daily
Coumadin - dosed per clinic
Amiodarone 200 mg daily
Insulin 70/30, 30 units daily
Zocor 20 mg daily
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Thirty (30) units Subcutaneous once a day.
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO 2X/DAY () as
needed for gout.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Gallstone pancreatitis status post stents to the common bile
duct and pancreatic duct
2. Elevated liver function tests
3. Anemia
4. Thrombocytopenia
.
Secondary:
1. Diabetes mellitus type 2, insulin dependent x 8 years
2. Cardiomyopathy, EF 20%
3. ICD placement
4. Elevated transaminases, unknown etiology
5. Chronic atrial fibrillation
6. Chronic renal failure, most recent creatinine 1.7
7. Umbilical hernia repair, [**8-/2175**]
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were hospitalized with pancreatitis. This was due to
gallstones occluding the pancreatic and common bile ducts. You
had two procedures to stent open the ducts responsible. You
should discuss follow-up with gastroenterology with your primary
care physician.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, black stools or blood in your stools, or any
other concerning symptoms.
.
For your congestive heart failure:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: One liter per day
.
Please take your medications as prescribed.
- You should hold coumadin for ten days after your ERCP (until
[**7-15**]).
- You should hold amiodarone and zocor until follow-up with your
primary care doctor.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Previously scheduled appointments:
Follow-up with your primary care physician: [**Name Initial (NameIs) 2169**]:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Last Name (NamePattern1) 3514**]Date/Time:[**2176-7-9**] 1:00
.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2176-7-9**]
4:00
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2176-8-13**]
3:30
|
[
"V45.02",
"287.5",
"427.31",
"574.20",
"285.21",
"404.91",
"585.9",
"428.0",
"425.8",
"577.0",
"276.1",
"272.0",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"97.05",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
10870, 10876
|
6041, 10142
|
350, 362
|
11364, 11396
|
2711, 2719
|
12351, 12864
|
2098, 2135
|
10383, 10847
|
10897, 11343
|
10168, 10360
|
11420, 12328
|
2150, 2692
|
5625, 6018
|
273, 312
|
390, 1625
|
2733, 5611
|
1647, 1918
|
1934, 2082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,455
| 149,367
|
36047
|
Discharge summary
|
report
|
Admission Date: [**2139-1-20**] Discharge Date: [**2139-1-29**]
Date of Birth: [**2077-4-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Celecoxib / Singulair /
Accolate / Prilosec / Coumadin
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
tachypnea/hypotension in [**First Name3 (LF) 13042**] after ERCP
Major Surgical or Invasive Procedure:
ERCP
central line placement
PICC line placement
History of Present Illness:
61F referred for ERCP for choledocholithiasis, found to be
tachypneic in [**Last Name (LF) 13042**], [**First Name3 (LF) **] transferred to [**Hospital Unit Name 153**] for closer monitoring
o/n. She had presented to [**Hospital 5871**] Hospital on [**1-17**] with fever,
nausea, and elevated bilirubin, where an MRCP was equivocal for
filling defects in the CBD--she is s/p CCY on [**2139-1-16**]--and so
was referred here for ERCP, which was completed evening of [**1-20**]
with removal of gallstones. The recovery area, her blood
pressures were stable 110s, but she was tachypneic and confused,
so the anesthesia staff requested ICU monitoring. On arrival in
the ICU, she remained confused but BP was then 80/40.
Also at [**Hospital3 **], she was diagnosed with an ESBL E coli
UTI (she has had recurrent UTIs for the past 2 years, which
"never get better" according to her daugther) and a possible
pna/right sided opacity on CXR, although the discharge summary
does not indicate if she ever had any pulmonary symptoms.
ROS: Pt unable to provide. Daughter reports that pt has felt
nauseaous and fatigued since recent CCY and had not been
progressing very much at rehab. Also, she thinks her mothers
dementia has been steadily progressing over the past few months.
Past Medical History:
myasthenia [**Last Name (un) 2902**]
DVT in [**2132**]
chronic pain
lupus
hypothyroidism
pancytopenia, has been treated with B12 shots and IVIG before
Past Surgical History:
Gastric bypass
Lap CCY [**2139-1-15**]
ORIF of R and L hips, TKR, rotator cuff repairs
Breast reduction surgery
Social History:
Has been in and out of nursing homes for the past two years;
daughter describes that pt lives at home with VNA, HHA, etc, but
then an infection, such as UTI, leads to delirium, hospital
stay, rehab/[**Hospital1 **], then back to home with maximal services in
cycles.
Family History:
Noncontributory
Physical Exam:
Vitals: T:98.6 BP:86/50 HR:98 RR:19 O2Sat:100% 2L
GEN: obese, elderly woman, appears older than stated age
HEENT: EOMI, PERRL, sclera mildly icteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: JVP 10 cm, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: normal S1 S2, radial pulses +2
PULM: Lungs CTAB but poor airmovement, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: Grossly edematous, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. Ecchymoses on
arms.
Pertinent Results:
[**2139-1-21**] 01:06AM BLOOD WBC-5.8 RBC-2.12* Hgb-8.1* Hct-24.1*
MCV-114* MCH-38.2* MCHC-33.6 RDW-17.8* Plt Ct-82*
[**2139-1-21**] 01:06AM BLOOD Neuts-82.9* Lymphs-11.7* Monos-4.5
Eos-0.5 Baso-0.4
[**2139-1-21**] 01:06AM BLOOD PT-17.4* PTT-31.6 INR(PT)-1.6*
[**2139-1-21**] 01:06AM BLOOD Glucose-97 UreaN-14 Creat-0.5 Na-138
K-3.9 Cl-106 HCO3-23 AnGap-13
[**2139-1-21**] 01:06AM BLOOD ALT-23 AST-43* LD(LDH)-132 AlkPhos-164*
TotBili-3.2*
[**2139-1-21**] 01:06AM BLOOD Calcium-7.2* Phos-1.9* Mg-1.7
[**2139-1-21**] 03:10AM BLOOD Type-ART pO2-188* pCO2-24* pH-7.40
calTCO2-15* Base XS--7
[**2139-1-21**] 03:10AM BLOOD Lactate-0.3*
OSH Labs:
WBC 6, Hct 9.3, Plts 85. INR 1.4. AST 67, ALT 29, Alk Phos 182,
Tbili 4.5, Dbili 2.7; urine culture grew ESBL E coli (no UA
available), Bld Cx NGTD.
Imaging:
CXR: No previous images. Left subclavian catheter extends to the
lower
portion of the SVC. No evidence of pneumothorax. Extremely low
lung volumes may account for some of the prominence of the
transverse diameter of the heart. No gross evidence of acute
pneumonia.
Brief Hospital Course:
61F s/p gastric bypass and more recently, lap CCY, with
choledocholithiasis, ESBL E coli UTI, and also question of
pneumonia who transferred from OSH for ERCP. ERCP done done, no
pus seen. Patient developed hypotension day after ERCP and
transiently required pressor support. Sepsis thought to be
secondary to ESBL UTI as no pus seen on ERCP.
# Sepsis: Thought to be secondary to ESBL UTI which is from
urine culture from outside hospital. Known from cultures at
outside hospital. After transfer, became hypotensive requiring
levophed for blood pressor support. Was weaned off pressor
support successfully. On admission covered broadly with
antibiotics with meropenem, flagyl and vancomycin. Flagyl and
vancomycin were discontinued given negative cultures. Her
hypotension was thought to be partially chronic, as she had
documented systolic blood pressures in the 70s at [**Hospital1 34**] and she
remained asymptomatic after being weaned off Levophed.
# Biliary Obstruction: At the outside hospital, patient had
elevated Tbili, slightly elevated alk phos, and vague abd
complaints which was c/w choledocholithiasis. Patient underwent
ERCP on admission here and was initially covered broadly given
hypotension with meropenem for known UTI with ESBL E. coli,
flagyl for GI anaerobes, and vancomycin for gram positive
coverage. Flagyl and vancomycin were discontinued as above as
sepsis thought to be secondary to UTI given no pus was seen on
ERCP.
# ESBL E. coli UTI: From outside hospital culture. Meropenem as
above. A PICC was placed to finish a 14 day total course of
meropenem at rehab.
# Malnutrition: Patient needs frequent encouragement to
increase her food and protein intake. This is contributing to
her anasarca. Patient had been refusing high protein
nutritional supplements of ensure.
# Anasarca: Secondary to low albumin, lack of mobility. On many
occassions, Patient was firmly instructed to increase her
nutritional intake and cooperate with physical therapy.
# Chronic pain: Patient on numerous pain meds at home--fentanyl
transdermal, oxycodone, ultram, as well as lidoderm and
methocarbamol. She initially required IV morphine but was
quickly resumed on her home pain regimen.
# Pancytopenia: Based on records from [**Location (un) 5871**], this has been
long standing, with WBC [**2-5**], Hct high 20s, and plts ~100,
unresponsive to IVIG in the past, and has also received B12
supplementation as she is s/p gastric bypass, without apparent
effect. Followed counts. Continue folate
# Hypothyroidism: continued levothyroxine 200mcg daily
# Code: DNR/DNI was transiently reversed for ERCP. Discussed
with daugther who states she would want intubation/heroic
measures only if patient would be likley to return to at or near
her current functional status.
# Comm: with daughter and proxy, [**Name (NI) **] [**Name (NI) 5345**] [**Telephone/Fax (1) 81801**] (h)
or [**Telephone/Fax (1) 81802**] (c).
Medications on Admission:
oxycodone 20mg po Q4hrs
fentanyl 25mcg patch
lidoderm patch
zofran 4mg po prior to each meal
compazine 5mg po tid prn
ambien 10mg hs prn
ultram 50mg qid prn
seroquel 75mg qhs
K dur 20 mEq [**Hospital1 **]
Robaxin 500mg tid
levothyroxine 200mcg po daily
tums prn
protonix 40mg daily
folic acid 1mg daily
albuterol q4 hrs prn
magnesium oxide 400mg [**Hospital1 **]
has also been on zosyn 3.375gm Q6h since [**1-18**]
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
17. Oxycodone 5 mg Tablet Sig: Four (4) Tablet PO Q3H (every 3
hours) as needed for pain: HOLD FOR RR<10, CONFUSION.
18. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 7 days.
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
20. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
21. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) grams PO
three times a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Continuing Care Center at [**Location (un) 34422**]
Discharge Diagnosis:
Sepsis
Discharge Condition:
good, stable
Discharge Instructions:
You were transferred to [**Hospital1 18**] for ERCP during which gallstones
were removed. You had low blood pressure that may have been from
your urinary tract infection but you improved with antibiotics
and IV fluids.
Return to the hospital for fevers, chills, chest pain, shortness
of breath, worsening abdominal pain, inability to tolerate food
or liquid, episodes of loss of consciousness, or any other
concerning symptoms.
Followup Instructions:
Follow up with your primary care provider after discharge from
rehab.
|
[
"358.00",
"599.0",
"244.9",
"V45.86",
"574.51",
"486",
"V12.51",
"284.1",
"782.3",
"995.91",
"576.1",
"041.4",
"710.0",
"V45.79",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.88",
"51.85",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9649, 9727
|
4149, 7090
|
413, 463
|
9777, 9791
|
3058, 4126
|
10268, 10340
|
2371, 2389
|
7556, 9626
|
9748, 9756
|
7116, 7533
|
9815, 10245
|
1957, 2070
|
2404, 3039
|
309, 375
|
491, 1761
|
1783, 1934
|
2086, 2355
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 128,755
|
15318
|
Discharge summary
|
report
|
Admission Date: [**2138-4-16**] Discharge Date: [**2138-4-19**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Seizures
Elevated blood pressures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 20 year old female with h/o ESRD secondary to
SLE. She is currently on HD through a L IJ tunnelled catheter on
MWF @ [**Hospital1 1426**]. She was dialysed on the day of admission and at
the end of dialysis her her post HD BP was 230-240s and she
also experienced a bitemporal headache with blurry vision.
Also, she described transient CP sensation for 1 minute at HD.
.
In ED she was noted to have SBP to 250s and was given
phentolamine X2, clonopine PO and patch, hydralazine with
minimal effect. A CT head showed no evidence of bleed. A
nipride gtt was started with some effect with SBP falling
transiently to 190.
.
On arrival to MICU, pt was switched to labetalol gtt out of
concern for potential toxicity on nipride. Labetalol was
effective initially but pt did have SBP to 230. Pt had
witnessed, tonic clonic seizure for 30 seconds with + tongue
biting and spontaneous resolution + post-ictal state. Pt had
repeat head CT negative and neuro eval who found pt
neurologically intact and recommended holding on dilantin and
getting MR head with GAD in AM to r/o posterior
leukoencephalopathy
.
Pt had second seizure lasting 2-3 minutes and was given 2mg IV
ativan with good effect. Dilantin IV 1gm load given.
Additional labs returned with phos at 1.1 so PO and IV repletion
started.
*
Past Medical History:
ESRD [**2-12**] lupus on HD since [**11-14**] through left tunneled cath
SLE
HTN- with hx hypertensive crisis
HOCM
hx TTP
pregnancy termination in [**Month (only) **]
TTP
Social History:
lives with Mom and 14 year old brother
occasional EtOH, no tobacco, heroin, cocaine
Family History:
aunts with hypertension
grandmother died of myeloma
several men with prostate cancer
Physical Exam:
T 95.7 HR 93-110 BP 185-234/100-155 RR11-20 O2 Sat 99-100%
Gen: Sleeping in bed, NAD, easily arousable
Neck: supple, normal ROM, no thyromegaly, no bruit
CV: RRR, Nl S1 and S2, 2/6 SEM
Lung: Clear to auscultation bilaterally
aBd: +BS, soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam. Oriented
to person, place, and date. She has mild attention problems,
can
say [**Name (NI) 1841**] backwards-but takes several attempts and made one
mistake
on last try. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. Registers [**3-13**], recalls
[**1-13**] at 5min. No evidence of apraxia or neglect
Fundus exam: No papilledema and no retinal hemorrhages
bilaterally.
CN II-XII symmetrical and intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout.
Reflexes:
B T Br Pa Ach
Right 2 2 2 2 2
Left 2 2 2 2 2
Grasp reflex absent
Toes were downgoing bilaterally
Coordination: normal on finger-nose-finger, heel to shin
Pertinent Results:
[**2138-4-16**] 08:44PM PT-14.8* PTT-40.3* INR(PT)-1.4
[**2138-4-16**] 05:27PM PT-14.1* PTT-150 IS HIG INR(PT)-1.3
[**2138-4-16**] 11:40AM GLUCOSE-94 UREA N-16 CREAT-3.9* SODIUM-141
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-32* ANION GAP-18
[**2138-4-16**] 11:40AM CK(CPK)-97
[**2138-4-16**] 11:40AM CK-MB-4 cTropnT-0.02*
[**2138-4-16**] 11:40AM HCG-<5
[**2138-4-16**] 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2138-4-16**] 11:40AM WBC-6.0 RBC-5.15 HGB-15.7 HCT-47.8 MCV-93
MCH-30.5 MCHC-32.8 RDW-17.8*
[**2138-4-16**] 11:40AM NEUTS-75.7* LYMPHS-18.0 MONOS-5.1 EOS-0.6
BASOS-0.6
[**2138-4-16**] 11:40AM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-1+
[**2138-4-16**] 11:40AM PLT COUNT-141*
*
Admission Head CT:
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
*
Admission chest X ray:
no abnormalities
*
ECG:
Sinus tachycardia with slowing of the rate as compared to the
previous tracing
of [**2138-4-16**]. Biatrial enlargement and new T wave inversion in lead
aVL with
dissociated ST-T wave flattening in lead I.
*
Head MRI:
Abnormal T2 and FLAIR signal within both occipital and parietal
lobes in a pattern suggestive of posterior reversible
encephalopathy syndrome
*
Knee X ray:
Normal L knee.
Brief Hospital Course:
A/p 20 yo F with ESRD on HD who p/w hypertensive crisis and has
new onset seizure
.
1) Hypertensive emergency
Her blood pressure was controlled with a labetaolol drip and she
was then transitioned to po labetalol. She was also continued on
the clonidine patch. In light of her complaints of chest pain we
were reassured by her ECG and by her flat cardiac enzymes.
.
2) New onset seizure
We thought that her new onset seizures were probably due to her
severely elevated blood pressure but other diagnoses including
lupus cerbritis were also considered.
An MRI with gadolinium was obtained. It demonstrated abnormal
T2 and FLAIR signal within both occipital and parietal lobes in
a pattern suggestive of posterior reversible encephalopathy
syndrome. We consulted the rheumatology service who thought that
her presentation was more consistent with hypertensive
encephalopathy rather lupus cerebritis. She was loaded with
dilantin. With dilantin loading and control of her blood
pressure she did not have a recurrence of her seizures.
.
3) Lupus:
She was continued on her plaquenil and prednisone.
.
4) ESRD
She continued to receive regulary scheduled hemodialysis.
.
5) Knee Pain:
On the day of discharge the patient complained of L knee pain.
On physical exam she was afebrile, the knee was slightly warm
and tender to the touch without obvious effusion. An X ray of
the knee was read as normal. She had full range of motion but it
was painful but she was able to bear weight on it. She was
instructed to use tylenol prn for pain and to return o the
clinic or emergency room should she develop worsening knee pain,
fevers or chills.
.
Communicaton:
The patient and the patient's mother were extensively counselled
about the patient's disease. She demonstrated an understanding
of the importance of good medical compliance with therapy and
keeping appointments.
Medications on Admission:
1. Clonidine TTS 1 Patch 1 PTCH TD QWED started in ED
2. Folic Acid 1 mg PO DAILY
3. Heparin 5000 UNIT SC TID
4. Prednisone 10 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Labetalol HCl 200 mg PO TID Start: In am
wean labetalol gtt as tolerated, Hold for SBP<150
7. Lisinopril 40 mg PO DAILY Start: In am Order date: [**4-16**] @
1712
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lidocaine-Aloe [**Doctor First Name **] 0.5 % Gel Sig: [**1-12**] APPL Topical every
six (6) hours as needed for pain.
Disp:*1 VIAL* Refills:*0*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*10 Patch Weekly(s)* Refills:*2*
6. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Labetalol HCl 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Naproxen 500 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Hypertensive encephalopathy and new onset seizures
Lupus Nephritis
End Stage Renal Disease on hemodialysis
Secondary:
H/o Thrombotic Thrombocytopenic Purpura.
Discharge Condition:
Good, without headaches or blurry vision, blood pressure well
controlled and at her baseline.
Discharge Instructions:
Please take all of your medications as prescribed. Please
attend all of your follow up appointments. As we discussed it is
extremely important that you take all of your blood pressure
medications as instructed.
*
Please return to the emergency room of your PCP's office if you
have severe headache, blurry or worsening vision or seizures.
*
It is CRUCIAL TO YOUR HEALTH that you attend ALL of your follow
up appointments!!!!
*
Please return to the emergency room or your PCP's office or
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 44523**] office at [**Telephone/Fax (1) 44524**]
if you experience worse knee pain, swelling, fevers or chills.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2138-5-8**] 11:20
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2138-6-12**] 1:45
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2138-6-25**] 10:00
Test for consideration post-discharge: Beta-2 Microglobulin.
Please call [**Telephone/Fax (1) 2100**] for a follow up appointmnt with
neurology in [**2-13**] months.
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 44524**] for an appointment
in 10 days.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"780.39",
"437.2",
"403.91",
"710.0",
"285.9",
"425.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8203, 8209
|
4717, 6578
|
312, 319
|
8420, 8515
|
3421, 4173
|
9225, 10274
|
1974, 2061
|
6978, 8180
|
8230, 8399
|
6604, 6955
|
8539, 9202
|
2076, 2342
|
239, 274
|
347, 1662
|
4182, 4694
|
2381, 3402
|
2366, 2366
|
1684, 1856
|
1872, 1958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,551
| 129,696
|
16043+16044
|
Discharge summary
|
report+report
|
Admission Date: [**2150-3-5**] Discharge Date: [**2150-3-19**]
Date of Birth: [**2103-4-25**] Sex: F
Service: ONCOLOGY
CHIEF COMPLAINT: Fevers and hypoxia.
HISTORY OF PRESENT ILLNESS: A 46-year-old female with
history of HIV (diagnosed two years ago, [**2150-1-7**], CD4
count equals 214 with an undetectable viral load), hepatitis
[**Holiday **] developed headaches. In [**Month (only) 404**] she started to
have balance problems. [**Name (NI) 6**] MRI on [**2150-1-30**],
demonstrated an enhancing mass in the vermis. She underwent
a suboccipital craniotomy by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2150-1-30**]. The pathology was consistent with adenocarcinoma, she
did not have a primary carcinoma identified at the time. She
underwent stereotactic surgery on [**2150-2-16**].
She has a known history of a lung nodule in the right middle lobe
for the past year. A recent CT scan on [**2150-1-31**],
demonstrated hilar lymphadenopathy and a stable right middle
lobe nodule. Following this surgery her Decadron was rapidly
tapered. She was noted by her significant other to have a
rapid decline in function concurrent with steroid taper, with
difficulty walking, and progressive shortness of breath
approximately two weeks prior to admission. On [**2150-3-5**], she presented to the Thoracic Clinic for evaluation of
a cervical nodule, however, was found to be febrile with a
room air oxygen saturation of 84% (temperature was 104
Fahrenheit, pulse 100-110, blood pressure 80/60), and she was
admitted to [**Hospital1 69**] for further
management.
Her primary care physician had started levofloxacin on [**2150-3-4**], for one week history of a cough productive of clear
sputum (blood cultures from that time were negative). She denies
prior PPD testing or tuberculosis exposure. Her last Pap smear
was within this past year and was reportedly negative as well as
mammogram. She denies any chest pain or abdominal pain or dysuria
or odynophagia on presentation.
PAST MEDICAL HISTORY:
1. HIV; since two years. CD4 count equals 214 with an
undetectable viral load in [**2150-1-7**]. On HAART therapy.
2. Hepatitis C since two years.
3. Status post cholecystectomy.
4. Oral Candidiasis history.
ALLERGIES: Penicillin and Bactrim cause hives.
Amphotericin-B causes a rigors.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. q. day.
2. Diflucan 100 mg q. day.
3. Decadron 2 mg p.o. q.o.d.
4. Ativan 0.5 mg p.o. q. 6h. p.r.n.
5. Kaletra three capsules b.i.d.
6. Combivir one tab b.i.d.
7. Dapsone 100 mg p.o. q. day.
SOCIAL HISTORY: The patient is a former accountant and has a
23-year-old child who is healthy. Her significant other is
[**Name2 (NI) **]. She smokes half a pack to one pack of cigarettes per
day for the past 20 years. There is no history of alcohol
consumption. No history of intravenous drug abuse within the
past nine years.
FAMILY HISTORY: Significant for gallbladder carcinoma.
PHYSICAL EXAMINATION ON PRESENTATION: General: Pleasant
female in mild to moderate respiratory distress, not in any
pain. Vital signs: Temperature 100.1 degrees Fahrenheit,
blood pressure 100/62, heart rate 88, respiratory rate 20.
Oxygen saturation 95% on four liters nasal cannula. HEENT:
Pupils equal, round and reactive to light bilaterally.
Extraocular movements intact. Moist mucus membranes.
Oropharynx clear. Neck: Supple, no jugular venous
distention or bruits. Patient had significant bilateral
supraclavicular adenopathy. Cardiac: Regular rate and
rhythm, normal S1, S2, no murmurs, rubs or gallops.
Pulmonary: Dry crackles to the mid lungs bilaterally.
Scattered wheezes. Abdomen: Soft, non-tender,
non-distended, normoactive bowel sounds. Extremities: No
clubbing, cyanosis or edema, 2+ pedal pulses bilaterally.
Pelvic examination: Nodular cervix with white liquid
exudate. No masses felt. No cervical motion tenderness.
Breasts: No masses or areolar discharge. Neuro: Alert and
oriented times three. Cranial nerves II through XII grossly
intact. Strength and sensation symmetric and within normal
limits throughout. Normal Babinski. Finger-nose-finger
intact. ? shin-heel-shin abnormality. Reflexes
hyporeflexive throughout.
LABORATORY FINDINGS ON ADMISSION: White blood cell count
7.2, hematocrit 38.5, platelet count 120. Sodium 130,
potassium 3.3, chloride 94, bicarbonate 19, BUN 22,
creatinine 0.5, glucose 80. PT 14, PTT 24.1, INR 1.3. ALT
23, AST 14, alkaline phosphatase 57. Total bilirubin 0.8,
albumin 3.3, calcium 8.4, phosphorus 4.0, magnesium 1.9.
RADIOLOGIC DATA: CT of the chest on [**2150-1-31**],
demonstrating bilateral supraclavicular, anterior mediastinal
and right hilar adenopathy. Also notable for diffuse
emphysema with a small right middle lobe pulmonary nodule.
Several low attenuation areas in the left kidney consistent
with a cyst and large bilateral adnexal cysts.
PATHOLOGIC DATA: [**2150-1-7**] cerebellar mass, status post
craniotomy, was consistent with adenocarcinoma felt to be
metastatic.
HOSPITAL COURSE: A 46-year-old female, HIV positive, on
antiretroviral medications, hepatitis C positive, recently
diagnosed with brain metastases found to be adenocarcinoma of
unknown primary, admitted with fevers, hypoxia and large
cervical lymph node.
1. Oncology: The patient underwent several studies to
further differentiate the primary source of her
adenocarcinoma. She underwent a fine needle aspiration of
the left cervical lymph node. This was done in concert with
General Surgery consultants. The final biopsy results showed
poorly differentiated adenocarcinoma. Further investigation
was obtained with bronchoalveolar lavage cytology that
demonstrated atypical cells, however, was nonspecific. A CT
with contrast of the chest was obtained on [**3-7**] that was
consistent with a picture suggestive of bronchoalveolar
spread of carcinoma that was highly suspicious for a lung
primary.
Taking these investigations as a whole, she has a
poorly differentiated adenocarcinoma with metastatic disease
to the brain that is likely a primary pulmonary carcinoma.
Pulmonary service was consulted (attending is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 575**]) who facilitated the BAL that was obtained without
incident, and did not require intubation (patient was
monitored closely overnight in the Intensive Care Unit). In
discussions with the Pulmonary and Oncology services, the
decision was made that a VATS procedure to obtain a tissue
diagnosis of the lung was not necessary given the above data
to support a lung primary. Additionally, patient had a
normal mammogram and Pap smear to argue against other sources
of primary carcinoma. In view of the later findings of
Aspergillus infection (see below), the decision was made to
wait on pursuing chemotherapeutic interventions empirically
and to see whether her Aspergillus infection (which has a
high mortality) will clear with a four week course of
ampicillin. Plan will be to reassess infectious status after
a total of four weeks of ampicillin and decide on further
chemotherapeutic interventions at that time.
2. Infectious Disease: Presenting with hypoxia, fevers.
Found to have diffuse pulmonary process. BAL culture data
and multiple sputum samples consistent with Aspergillus
fumigatus infection. All other culture data from the BAL
including acid fast cultures and viral cultures were
negative. Blood cultures times ten were negative throughout
this admission. Urine cultures times two were negative.
Stool ova and parasite cultures were negative. Cryptococcus,
toxoplasma, Legionella also negative. She was initially
treated with amphotericin-B for her Aspergillus infection,
however, had a rigorous reaction to this medication requiring
Demerol. She was switched to AmBisome. On AmBisome fever
curve persistently decreased as well as her oxygen
requirement. Given her good respond to AmBisome, it argues
against concurrent infections with the Aspergillus. The plan
is to continue antifungal therapy for a total of four weeks
and reassess status at that time. Regarding her HIV, a
repeat CD4 count was 48. The patient was continued on
prophylactic Dapsone. Her antiretroviral agents (Kaletra,
Combivir) were discontinued secondary to inconsistent p.o.
intake. Patient was also noted to have Clostridium difficile
infection for which she was treated with Flagyl. She was
also noted to have gardnerella infection also treated with
Flagyl. On [**3-19**] this is day nine of AmBisome and day
11 of Flagyl.
3. Neurology: Status post craniotomy/stereotactic surgery
for cerebellar vermis metastases. She was initially
continued on her Decadron taper. Once the fungal infection
was identified, the steroids were discontinued.
4. Hematology: We transfused two units of packed red blood
cells on [**3-15**] for a low hematocrit secondary to
polyphlebotomy.
5. Pulmonary: Supplemental oxygen requirement continued to
decrease with AmBisome therapy for Aspergillus. At the time
of this dictation on [**3-19**] she was breathing comfortably
with five liters of nasal cannula oxygen supplementation.
The remainder of pulmonary history as above in Oncology and
Infectious Disease sections.
6. Fluids, Electrolytes and Nutrition: Intermittently poor
p.o. intake throughout. Does tolerate solids with aspiration
precautions. Noted to be hypokalemic frequently as her
potassium is being wasted by the AmBisome therapy. She
requires supplementation daily.
7. Access: The patient has a PICC line in place.
8. Code: The patient is DNR/DNI. This is confirmed with
her health care proxy, [**Name (NI) 717**] [**Name (NI) **] (who is also her
sister).
9. Social: The patient was married to her significant
other, [**Name (NI) **], during this admission.
DISCHARGE DIAGNOSES:
1. Metastatic lung carcinoma.
2. Aspergillus fumigatus infection of the lung.
3. Brain metastases status post craniotomy/stereotactic
surgery for cerebellar vermis metastases.
4. HIV infection.
5. Hepatitis C.
6. Clostridium difficile.
DISCHARGE MEDICATIONS: Medications will be dictated
separately in the addendum when the date of discharge is
determined.
FOLLOW UP: Patient will be discharged to an extended care
facility where she will continue on her course of AmBisome.
At the time of this dictation, [**3-19**], day nine of a four
week course of AmBisome. Patient will require Clostridium
difficile precautions as well as oxygen supplemental therapy.
[**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], M.D. [**MD Number(1) 7074**]
Dictated By:[**Name (STitle) 45071**]
MEDQUIST36
D: [**2150-3-19**] 14:43
T: [**2150-3-19**] 15:02
JOB#: [**Job Number 45913**]
Admission Date: [**2150-3-5**] Discharge Date: [**2150-3-25**]
Date of Birth: [**2103-4-25**] Sex: F
Service:
ADDENDUM:
Subsequent to the time of the last dictation, the patient
experienced increasing mental status changes and delirium.
This was attributed to her chronic hypoxia at first, however,
out any other causes for her mental status changes. This
magnetic resonance scan showed confluent cortical T2
hyperintensity and slight enhancement involving the medial
temporal lobes in both insula. The pattern is suggestive of
herpes simplex encephalitis versus perineoplastic limbic
encephalitis. To determine which of these causes is
responsible for the patient's mental status changes, a lumbar
cell count mainly lymphocytic in origin. Therefore, the
patient was begun on Acyclovir intravenous for presumptive
HSV encephalitis. A HSV PCR was sent which later returned
positive!!
The patient was also managed supportively at this
time. A few days later, the laboratory called with the
results of the CMV antigen and her BAL returned positive.
For this, the question was whether the patient should be
started on intravenous Ganciclovir to treat for CMV. A CMV
serum antigen was also sent to exclude any possibility of
contamination. This also returned positive with a CMV serum
antigen level in the 3000s. Therefore, the patient was
switched from Acyclovir to Ganciclovir intravenously.
The patient was continued on her AmBisome and her Flagyl which
had been discontinued secondary to the presumed treatment of
her Clostridium difficile infection was restarted.
The patient experienced increasing episodes of confusion during
this time, increasing shortness of breath with an increased
oxygen requirement, an episode of desaturation down to the
70s and temperature decreasing to 95 to 96 range. Therefore,
for presumed sepsis, the patient was begun on Vancomycin
empirically. Her Ganciclovir was
continued as was the Dapsone. The patient was also started
initially on Ceftriaxone but secondary to Penicillin allergy
was switched to Ciprofloxacin intravenously to cover for
pseudomonas aeruginosa. The patient had a repeat chest x-ray
performed which suggested possible pneumonia in addition to
her other disease. She had a repeat urinalysis sent which
returned positive for Staphylococcus aureus. Subsequently,
her blood cultures returned positive for Methicillin
resistant Staphylococcus aureus. The patient was treated
aggressively with antibiotics during this time.
She required the use of a nonrebreather mask. She had to have a
one to one sitter for her increasing delirium and given her
overall
prognosis and her increasing distress, on these treatments,
the family as health care proxy, [**Name (NI) 717**] [**Name (NI) **] and her
husband [**Name (NI) **] [**Name (NI) 4709**] were approached to discuss plans for her
care. At that time, the family felt that the patient had
undergone enough intervention and was suffering with the
treatment that she was undergoing. Therefore, the decision
was made to make the patient comfortable rather than to
pursue any further aggressive intervention. The patient was
begun on Morphine empirically to control her pain and
dyspnea. She also received Ativan for increasing agitation.
Her oxygen was continued but her antibiotics were
discontinued. The patient who was a very pleasant female
passed away on the night of [**2150-3-27**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 569**] 11-970
Dictated By:[**Name8 (MD) 10249**]
MEDQUIST36
D: [**2150-3-29**] 14:23
T: [**2150-3-29**] 14:47
JOB#: [**Job Number 45914**]
|
[
"484.6",
"198.3",
"070.54",
"707.0",
"042",
"162.8",
"117.3",
"054.3",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.28",
"33.24",
"03.31",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
2958, 4287
|
9886, 10133
|
10157, 10256
|
2385, 2607
|
5097, 9865
|
10268, 14483
|
156, 177
|
206, 2037
|
4302, 5079
|
2059, 2359
|
2624, 2941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,631
| 193,788
|
32231
|
Discharge summary
|
report
|
Admission Date: [**2186-5-21**] Discharge Date: [**2186-6-9**]
Date of Birth: [**2145-11-13**] Sex: F
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis
Chest tube placement by IP
Intubation
Radial atrial line placement
History of Present Illness:
40F w/ metastatic breast cancer (liver, lungs, pleural space,
brain) who presented to [**Hospital3 **] on [**5-20**] with shortness
of breath and increased LE edema. Pateint reports she awoke on
Saturday at 2-3am not feeling herself with increased SOB,
orthopnea, and LE edema, associated with cough and mild chest
pain with coughing but none at rest or with exertion. Cough is
rarely productive of white sputum and she has noted wheezing as
well but no fever or chills. She has significant orthopnea to
the point where she has been sleeping in a recliner. Report
symptoms dissimilar from previous episodes where she has had to
have pericardial effusions drained.
.
At [**Hospital1 **], she was initially hypoxic and required bipap. She
diuresed quite well with lasix and was weaned down to 3L NC. She
was transferred here as her oncologic care is here. She also had
a head CT with brain mets and vasogenic edema (although
improved) as below so decadron dosng was increased to [**Hospital1 **].
Currently, she reports that her breathing and edema are much
improved although not yet back to her baseline. Her chest pain
has improved. ROS is remarkable for right sided facial droop
over the last week and left sided headache. Denies N/V, visual
changes. Has also had hoarse voice x 2 months. Also reports
right arm numbness related to an IV placed several months ago.
ROS otherwise negative in detail.
Past Medical History:
Past Medical Hx:
1. Metastatic breast cancer: Oncology History: Initially
diagnosed in [**1-29**] when she found a breast mass in her left
breast. Biopsy revealed a poorly differentiated tumor,
ER/PR/Her2neu all negative, underwent
neoadjuvant chemotherapy, and subsequently bilateral mastectomy
with reconstruction in [**7-29**], and subsequently with radiation
post operatively. She was then diagnosed in [**11-28**] with brain
metastases, and underwent whole brain radiation. MRI completed
in [**1-30**] showed increased size of her brain mets. She was also
diagnosed in [**1-30**] with a malignant pericardial effusion when she
presented with tamponade, and was admitted to the CCU. She was
started on xeloda and avastin, which were stopped when liver
mets were seen on imaging. At that time, she was started on
adriamycin. She again developed a pericardial effusion which was
drained in the cath lab in [**3-30**]. After that, her adriamycin was
switched to navelbine. She also developed a malignant pleural
effusion which was drained.
.
Social History:
Lives with husband, works as a program coordinator for WGBH. H/o
cigarettes one-half to one pack per day x 10 years, quite appx
[**2173**]. ETOH or drugs - none. She also has a son who is now 21.
Family History:
There is no family history of breast cancer. There is a paternal
grandmother who had colon cancer and maternal grandfather who
might have had prostate or colon cancer. The patient has no
siblings.
Physical Exam:
Vitals: T 97.2 BP 129/82 P 124 R 24 98% 3L NC
Gen: chronically ill appearing female, speaking in half
sentences due to dyspnea but not in acute distress
HEENT: MMM. Cushingoid
Neck: JVP difficult to appreciate but appeasr flat
Lungs: Decreased breath sounds diffusely on the R ([**1-24**] way
up)and at left base with dullness to percussion in these areas
CV: tachycardic, regular, no murmur or rub
Abd: soft, nt/nd, +bs
Ext: 2+ BLE edema with cracking of skin on feet bilaterall, mild
erythema
Neuro: Right peripheral facial droop with decreased forehead
wrinkling. EOMI but not fully yoked. Mild 4+/5 RUE weakness.
Pertinent Results:
OSH Labs: coags normal
Na 137, K 3.5, Cl 101, Bicarb 26, BUN 6, creatinine 0.5, glucose
104, calcium 9.1, CK 34
WBC 2.1, Hct 35.7, Plt 468 (PMNs 19%, Lymphs 62%, Monos 18%)
.
LABS ON ADMISSION:
[**2186-5-22**] 01:00AM BLOOD WBC-2.4*# RBC-3.85* Hgb-13.1 Hct-38.2
MCV-99* MCH-34.0* MCHC-34.2 RDW-16.6* Plt Ct-437
[**2186-5-22**] 01:00AM BLOOD Neuts-58 Bands-0 Lymphs-32 Monos-10 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2186-5-22**] 01:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Fragmen-OCCASIONAL
[**2186-5-22**] 03:30AM BLOOD PT-13.3 PTT-23.8 INR(PT)-1.1
[**2186-5-22**] 01:00AM BLOOD Gran Ct-1210*
[**2186-5-22**] 01:00AM BLOOD Glucose-110* UreaN-7 Creat-0.5 Na-137
K-4.9 Cl-100 HCO3-27 AnGap-15
[**2186-5-22**] 01:00AM BLOOD ALT-149* AST-96* AlkPhos-385* TotBili-0.4
[**2186-5-22**] 01:00AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.0
.
URINE:
[**2186-5-28**] 03:45PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.026
[**2186-5-28**] 03:45PM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2186-5-28**] 03:45PM URINE RBC-41* WBC-296* Bacteri-NONE Yeast-NONE
Epi-0
.
MICROBIOLOGY:
[**5-31**] BAL - Staph aureus coag +, MSSA
[**5-28**] Sputum - MSSA
[**6-7**] BAL - Staph aureus coag +
.
Expiration labs-
[**2186-6-9**] 04:56AM BLOOD WBC-9.1 RBC-3.22* Hgb-10.8* Hct-32.5*
MCV-101* MCH-33.4* MCHC-33.1 RDW-17.5* Plt Ct-347
[**2186-6-9**] 04:56AM BLOOD Glucose-149* UreaN-39* Creat-1.0 Na-143
K-3.9 Cl-104 HCO3-26 AnGap-17
[**2186-6-9**] 04:56AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.0
[**2186-6-9**] 04:56AM BLOOD Phenyto-7.2*
[**2186-6-9**] 05:01AM BLOOD Type-ART pO2-95 pCO2-47* pH-7.41
calTCO2-31* Base XS-3
.
CARDIOLOGY:
TTE ([**5-24**]):
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is a small pericardial
effusion (?loculated). There are no echocardiographic signs of
tamponade. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling. Pericardial constriction cannot be
excluded.
Compared with the prior study (images reviewed) of [**2186-4-22**], no
change. If indicated, a cardiac MRI or CT may be better to
assess for pericardial constriction/pericardial thickness.
.
[**Year (4 digits) 706**]:
CXR [**5-22**]:
FINDINGS: Comparison is made to [**2186-5-17**], and multiple priors.
Lung volumes remain very low, but allowing for this,
cardiomediastinal
contours appear unchanged. Bilateral small-to-moderate pleural
effusions are not significantly changed, right greater than
left. Known pleural and
parenchymal metastases are not well visualized by radiographs,
better
demonstrated on recent CT of [**2186-4-19**].
.
CTA Chest:
IMPRESSION:
1. No evidence pulmonary embolus.
2. New right lower lobe consolidative opacity consistent with
pneumonia.
3. Bilateral pleural effusions (increased on left) and
persistent pericardial effusion.
4. No short interval change in widespread metastatic disease.
.
CT Head:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Slightly increased amount of vasogenic edema compared to
prior MR,
however, difficult to assess due to difference in techniques. If
direct
comparison is required, consider repeating MR.
.
CRX [**6-9**]
Mild pulmonary edema has worsened, left lower lobe is
chronically collapsed, no appreciable right pleural effusion,
pigtail pleural drain still in place, small left pleural
effusion stable, heart size is normal. Since the chin is down,
tip of the endotracheal tube less than 15 mm from the carina is
acceptable. Nasogastric tube passes into the stomach and out of
view.
Brief Hospital Course:
In short, Ms [**Known lastname **] is a 40F w metastatic breast cancer and
malignant pleural effusions, admitted with shortness of breath,
transferred to the ICU in the setting of seizure and PEA arrest.
# Dyspnea/Respiratory failure: Dyspnea felt to be multifactorial
and related to reaccumulation of large R sided pleural effusion,
documented as malignant in [**2186-3-22**]. CT chest on admission
showed increase pleural effusions with large loculated right
effusion. IP evaluated her and performed a thoracentesis on
[**2186-5-23**]. Her symptoms improved with this procedure as well as
with diuresis prior to transfer to [**Hospital Unit Name 153**]. She was continued on
Lasix 40mg PO BID for component of heart failure as well given
association with lower extremity edema. TTE was obtained which
showed EF of 55-60% and no change since prior [**2186-4-22**]. In the
[**Hospital Unit Name 153**] she had IP place a pig tail chest catheter placed to drain
her infusion. She required intubation with her PEA arrest
advent. In the [**Hospital Unit Name 153**] she was repeatedly attempted to wean from
the ventilator on a daily basis. She had a attempted extubation
but quickly became too tachypneic and required reintubation. She
later that day self-extubated and again required reintubation.
She was diagnosed with a HAP MSSA PNA and was treated with a
course of vanco and Zosyn initially and then continued on Zosyn.
Significant effort was made to diuresis the patient to improve
her chance of extubation, but despite this she continued to fail
repeat spontaneous breathing trials due to poor tidal volumes
and tachypnea. Despite aggressive and repeated treatment of
pneumonia, pleural effusion, volume overload, daily
wake-ups/SBTs the patient was unable to been weaned from the
ventilator. During her last week of the hospital stay, her
weaning difficulty was further complicated by a decline in
mental status which likely reflected a neurologic complication
of the intra-cranial tumor (see below). Thus, despite
aggreessive and repeated attempts toward extubation, she
remained intubated until expiration. Please note also that the
extended period of time with intubation instead of moving toward
a tracheostomy or change in the goals of care reflected the
wishes of the husband. After she had been intubated for over 2
weeks and it was clear that this was not improving despite
aggressive attempts toward extubation, the situation was
discussed extensively with the husband. We had proposed either
tracheostomy and long-term care or pursuing palliative care
(extubation, comfort care). The husband did not want either
pathway and held out hope that she would come of the ventilator.
Thus, patient remained on mechanical ventilation for extended
period of time.
.
# Metastatic breast cancer: Patient has widely metastatic breast
cancer including brain, liver, and pleural fluid mets with poor
prognosis. This was reinforced with patient by primary
oncologist Dr. [**Last Name (STitle) **] but she wishes to maintain an aggressive
approach to care. She was continued on home Decadron 8mg daily
as well as Keppra and dilantin for seizure prophylaxis.
Malignant pleural and pericardial effusions addressed as above.
Palliative care was consulted and recommended starting Dilaudid
for pain control which was done. On night of transfer to [**Hospital Unit Name 153**]
she had a witnessed seizure event followed by PEA arrest
requiring <1 minute of CPR. Then had agonal breaths requiring
intubation (see above for resp course). Her anti-seizure
medications were increased, however, her dilantin level was very
labile during her admission due to concern about PO absorption.
3 days prior to expiration she was changed to IV dilantin. Five
days prior to expiation she had a change in mental status and
became less responsive. There was concern that she had a
progression of her brain mets or had a CVA. Despite medical
advise of a head CT to evaluate the patient, her husband refused
this procedure. See below for day of expiration events.
# Facial droop: Pt reported a new facial droop and had facial
weakness with peripheral Bell's palsy on exam. She had
previously discussed this with Dr. [**Last Name (STitle) 79**] and plan was to obtain
further imaging, however, it was decided that it would not
change management since neurosurgeon would not consider her a
surgical candidate. Neurooncology was following and recommended
palliative care.
# Social Family issues: During the pt??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] stay there had been
concern over the husband??????s interactions with the staff. He had
expressed some paranoia and distress over the care of his wife.
There had been repeat family meetings with the husband and the
attending to listen to his concerns and explain her course. He
was very concerned that she was still requiring intubation.
There had been daily efforts to try to wean the vent, but had
been unsuccessful. The husband wanted transfer of his wife to
[**Name (NI) **], but there was not an accepting physician available
there. Attending had a family meeting with ethics on [**6-8**] to
discuss options of further pt care. Pt??????s husband had [**Name2 (NI) 75353**] to
consider hospice, but was still unsure. Today after death of
patient, husband expressed his appreciation to the staff.
During the final week of the [**Hospital **] hospital course, the patient's
mental status appeared depressed, and we were concerned for a
neurologic complication. Given that the patient had
intracranial tumor, the differential including bleeding into
that area, edema, expansion, early herniation - to determine
this, we attempted to perform a head CT scan but the husband
refused for the reason that he felt it would not change her
management. We attempted this a couple times but he refused.
He also began to refuse simple procedures such as a PICC line
for access as the patient was running out of adequate access for
medications. On the day of the patient's death (see event
below), it appeared that she had a neurologic catastrophe.
Thus, our suspicions that the patient had a complication related
to the intra-cranial tumor at the beginning of the week were
likely accurate. Whatever process had evolved likely then lead
to complete neurologic catastrophe on the final day of the
hospital course likely reflective of brain herniation given the
neurologic examination revealing fixed, dilated pupils with no
corneal reflexes and no response to any stimuli (verbal,
painful).
Events of expiration:
11:30 AM, pt's SBP dropped suddenly to 43. She was given IVF
bolus and Epi 0.2mg. SBP up to 200s briefly, then in 100s, and
tachy to 140s. Pulse was still present. Neuro exam showed mildly
dilated and fixed pupils. No gag reflex, no response to painful
stimuli, no limb movement, no corneal reflex, and eyes did not
move with dolls head maneuver. Pts husband was notified and no
other heroic measures were indicated. SBP then slowly declined
over the morning. Attending was present.
At 1340 pt had PEA arrest. Ventilator was stopped. Pt has no
heart beat or pulse. Was warm. Pupils fixed and dilated. No
response to pain. Time of death 1340, family at bedside. Husband
declined autopsy. Admitted and attending notified. Cause of
death was metastatic breast cancer with immediate cause
neurologic catastrophe likely secondary to complication of
intracranial mass.
Medications on Admission:
Medications at [**Hospital1 **]:
decadron 8 mg [**Hospital1 **] (increased from 8mg daily home dose)
keppra 1000 mg [**Hospital1 **]
protonix 40 mg daily
dilantin extended release 200 mg qhs
dilaudid 1 mg IV q4h prn
zofran 4 mg IV q4h prn
.
Home Medications
Also on metoprolol XL 50 mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Breast cancer
Cardiac arrest
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2186-6-10**]
|
[
"285.22",
"780.39",
"V67.2",
"197.7",
"351.0",
"511.81",
"790.4",
"198.3",
"V67.1",
"518.0",
"584.9",
"V16.0",
"V66.7",
"V15.82",
"782.3",
"V10.3",
"482.41",
"198.5",
"518.81",
"420.90",
"427.5",
"V45.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"33.24",
"96.04",
"99.25",
"34.91",
"96.07",
"96.6",
"38.91",
"99.60",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
15938, 15947
|
8129, 15567
|
324, 406
|
16031, 16040
|
3981, 4161
|
16093, 16128
|
3131, 3329
|
15909, 15915
|
15968, 16010
|
15593, 15886
|
16064, 16070
|
3344, 3962
|
277, 286
|
434, 1835
|
7478, 8106
|
4175, 7469
|
1857, 2901
|
2917, 3115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,835
| 168,091
|
33789
|
Discharge summary
|
report
|
Admission Date: [**2180-11-15**] Discharge Date: [**2180-11-27**]
Service: SURGERY
Allergies:
Penicillins / Clinoril
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
abdominal pain, free air
Major Surgical or Invasive Procedure:
Exploratory laparotomy, oversew and [**Location (un) **] patch
of perforated duodenal ulcer [**2180-11-15**]
History of Present Illness:
Ms [**Known lastname **] is a very pleasant woman transferred from [**Hospital3 1280**]
with a diagnosis of free air on CT scan in the setting of
abdominal pain. She states she has had off and on abdominal
pain
for the past week and was seen at [**Hospital3 1280**] 2 days prior to
admisison where she was found to have mild cardiac enzyme
elevation, and she was admitted there for the past few days.
She
was also having abdominal discomfort, all over but focused in
the
RLQ, and had a CT scan that she states was normal. She was
admitted for cardiac work-up, which was essentially negative and
discharged home this morning feeling well. When she got home at
11am however, she noticed a severe increase in her RLQ pain that
became much more diffuse, [**9-30**], pain with any movement, nausea,
no vomiting. No fevers, +chills. She returned to [**Hospital3 1280**]
where at CT scan showed a significant amount of free air and
extravasation of contrast in ther RLQ.
She currently is complaining of ongoing pain, although improved
a
bit with some morphine. No chest pain or shortness of breath,
+nausea, no fevers/chills
Past Medical History:
Peripheral vascular Disease - non-healing L 3rd toe ulcer, 1
vessel runoff (peroneal)
Hypertension
Hypercholesterolemia
bronchitis
arthritis
history of Right Lower Extremity trauma
glaucoma
anxiety
chronic back pain
Left superficial femoral artery PTA on [**2179-3-22**]
Social History:
quit smoking 30 years ago, no ETOH, lives alone w son nearby
Family History:
N/C
Physical Exam:
T99 83 120/68 16 95%RA
Gen: pleasant thin elderly woman laying in bed in NAD, A+0x3
HEENT: dry MM, scerla anicteric
CV: RRR
Lungs: CTAB
abd: distended, rigid, diffusely tender with rebound and
guarding
Guaiac neg
ext: well-perfused, no c/c/e
Pertinent Results:
[**2180-11-15**] 08:35PM WBC-11.1* RBC-4.02* HGB-12.6 HCT-38.1 MCV-95
MCH-31.4 MCHC-33.1 RDW-13.4
[**2180-11-15**] 08:35PM NEUTS-61 BANDS-28* LYMPHS-7* MONOS-1* EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2180-11-15**] 08:35PM PLT COUNT-387
[**2180-11-15**] 08:35PM ALT(SGPT)-19 AST(SGOT)-55* LD(LDH)-646*
CK(CPK)-138 ALK PHOS-40 AMYLASE-92 TOT BILI-0.3
[**2180-11-15**] 08:35PM CK-MB-3 cTropnT-<0.01
[**2180-11-15**] 08:35PM GLUCOSE-152* UREA N-23* CREAT-0.9 SODIUM-134
POTASSIUM-6.0* CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
[**2180-11-15**] 10:14PM PT-13.0 PTT-26.2 INR(PT)-1.1
Brief Hospital Course:
[**2180-11-15**] Pt admitted to the surgical ICU s/p ex-lap revealing
perforated anterior duodenal ulcer repair with [**Location (un) **] patch. She
was kept intubated overnight, NPO/ IVF, NGT to LWS on [**Hospital1 **]
protonix, and IV abx
[**11-16**]: Transfer from the OR intubated, extubated in AM, wbc
trending up, tranisent episdoe of afib resolved with lopressor
[**11-17**]: Episodes of acute hypoxia with tachycardia and dyspnea,
Bronch done mucus plugging on RLL, CTA done to r/o PE, possibly
flash pulmonary edema. B/L Pleural effusions on CXR, afib
overnight: rate controlled with Lopressor
[**11-18**]: CTA neg for PE, She had CHF respiartorty distress ABG
respiratory acidosis, started on Lasix drip, Hydralzyne PRN and
lopressor increased, Intubated due to respiratory failure. Left
tlc placed
[**11-19**] 2 units transfused, continued lasix gtt, hpylori ag sent.
[**11-20**] Decreased fio2 to 40%, bedside echo WNL. Dig started
[**11-21**]: IR for NJ tube. TF started. TTE EF>55%. CT showing bil
pleural effusions.
[**11-22**] :diastolic hypotension 30's.MAP mid 50,s.started low dose
neo infusion.
[**11-23**]: Weaning vent to [**4-25**], Dcd amlosipine due to diastolic
hypotension. Tachypneic and hypertnesive given hydral/
labetalol.
[**11-24**]: extubated. Stable o/n. lasix gtt. Contraction alkalsois
from overdiuresis. Still DNR/DNI (if pt deteriorates, will be
CMO)
[**11-25**]: Extubated on NRB. cont with albumin and lasix gtt
[**11-26**]: Made CMO by family per patient's request. Transferred to
private room on floor.
[**11-27**]: Expired at 4:00 AM
Medications on Admission:
ALENDRONATE 70 mg q week, AMLODIPINE-ATORVASTATIN 5 mg-20 mg''
Atenolol 25''LUMIGAN 0.03 % 1 gtt ou qpm, ALPHAGAN P 0.15 % 1
gtt ou twice a day, COSOPT 0.5 %-2 % Drops - 1 gtt ou twice a
day
FOLIC ACID 1, HCTZ 25, LIDODERM 5 % (700 mg/patch) on in the am
off in pm, ASPIRIN 81, MVI, VITAMIN E 400 unit Capsule q am
Discharge Medications:
None - patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated duodenal ulcer, respiratory failure, atrial
fibrillation
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
|
[
"934.8",
"V45.89",
"707.15",
"620.2",
"272.0",
"276.3",
"E878.8",
"300.00",
"365.9",
"567.89",
"532.10",
"716.90",
"427.31",
"790.6",
"276.2",
"112.89",
"218.9",
"997.1",
"428.0",
"724.5",
"440.23",
"401.9",
"112.0",
"410.71",
"518.5",
"338.29",
"535.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"44.42",
"96.04",
"96.6",
"99.15",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
4817, 4826
|
2822, 4402
|
264, 374
|
4937, 4946
|
2206, 2799
|
4999, 5147
|
1917, 1922
|
4770, 4794
|
4847, 4916
|
4428, 4747
|
4970, 4976
|
1937, 2187
|
200, 226
|
402, 1527
|
1549, 1822
|
1838, 1901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,338
| 147,143
|
9335
|
Discharge summary
|
report
|
Admission Date: [**2159-8-24**] Discharge Date: [**2159-8-27**]
Date of Birth: [**2097-9-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic
and diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea.
Pt states that yesterday evening he noted sudden onset of
shortness of breath. He denies any fevers, chills, nausea,
vomiting, chest pain, melena, hemetemesis, hematochezia,
diarrhea, constipation.
In the [**Name (NI) **] pt's initial VS were noted to be T96.2, HR 68, BP
118/84, RR 24, Sat 96%. His initial EKG was concerning for
possible V tach however on further review it was noted to be A.
fib with aberrancy, pt was given 5mg IV Lopressor which resulted
in decrease of HR from 130s to the low 100s, SBP down to the mid
90s. Pt underwent CXR which showed fluid overload and he was
thus given Furosemide 40mg x 1. He was also given Vancomycin 1gm
IV x 1 due to concern for possible PNA. His labs were notable
for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST were
noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was
noted to be 42 with an anion gap acidosis. His INR was noted to
be 3.4, Digoxin level 0.3, BNP 6682. He received a RUQ U/S which
showed edematous gallbladder wall but no cholecystitis, pt also
had cholelithiasis. He also had a right IJ placed and underwent
a CT abdomen/pelvis without contrast to eval for source of high
lactate. CT scna was negative for bowel wall thickening,
pneumotosis but did showed ground glass opacities in the lung.
Prior to the CT scan he was given Levofloxacin and Zosyn given
his acutely ill appearance and elevated lactate.
Past Medical History:
CAD s/p CABG
Anterior MI [**2144**]
h/o massive UGIB in [**2154**] [**1-1**] gastritis [**1-1**] NSAIDs and
coumadin(intubated, c/b MRSA VAP, had tracheostomy)
CHF (EF 25% by last echo) with BiV pacer and ICD placement
L hip arthritis
Hyperlipidimia
Hypothyroidism
h/o Afib in past (not currently on coumadin)
Social History:
Married > 25 years. Has three adult children. Lives with his
wife. Used to work in computers but on disability for health
reasons. Denies tobacco, occasional etoh. No illicits.
Family History:
FH: Father died of MI at age 52
Physical Exam:
At Admission:
General: Chronically sick appearing Male, appears jaundices
lying down in NARD.
HEENT: Left Sclera icteric, EOMI, PERRL
Neck: JVP noted at mandible
Lungs: Crackles noted over right hemithorax and left base.
CV: Distant S1, S2, irregularly irregular, no murmurs, rubs,
gallops
Abdomen: Soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly, no
murphys
Ext: Lower extremities cool to touch, sensation intact, movement
intact. Healing wound noted on LLE.
Pertinent Results:
[**2159-8-24**] 12:10AM PT-33.9* PTT-35.9* INR(PT)-3.4*
[**2159-8-24**] 12:10AM PLT COUNT-234
[**2159-8-24**] 12:10AM NEUTS-68.8 LYMPHS-24.3 MONOS-6.2 EOS-0.2
BASOS-0.5
[**2159-8-24**] 12:10AM WBC-12.3* RBC-4.98# HGB-12.2* HCT-42.1
MCV-84# MCH-24.4*# MCHC-28.9*# RDW-18.3*
[**2159-8-24**] 12:10AM DIGOXIN-0.3*
[**2159-8-24**] 12:10AM CALCIUM-8.8
[**2159-8-24**] 12:10AM CK-MB-6 proBNP-6682*
[**2159-8-24**] 12:10AM cTropnT-0.05*
[**2159-8-24**] 12:10AM LIPASE-25
[**2159-8-24**] 12:10AM ALT(SGPT)-133* AST(SGOT)-243* CK(CPK)-116 ALK
PHOS-257* TOT BILI-5.1* DIR BILI-2.0* INDIR BIL-3.1
[**2159-8-24**] 12:10AM GLUCOSE-42* UREA N-22* CREAT-1.5* SODIUM-137
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-17* ANION GAP-31*
[**2159-8-24**] 12:19AM K+-4.2
[**2159-8-24**] 01:10AM URINE HYALINE-0-2
[**2159-8-24**] 01:10AM URINE RBC-0-2 WBC-[**2-1**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2159-8-24**] 01:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-NEG
[**2159-8-24**] 01:10AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2159-8-24**] 01:36AM LACTATE-13.7*
[**2159-8-24**] 05:42AM PT-43.7* PTT-42.5* INR(PT)-4.7*
[**2159-8-24**] 05:44AM PLT COUNT-182
[**2159-8-24**] 05:44AM WBC-11.5* RBC-4.54* HGB-10.8* HCT-38.0*
MCV-84 MCH-23.7* MCHC-28.3* RDW-18.6*
[**2159-8-24**] 05:44AM ALBUMIN-3.5 CALCIUM-8.1* PHOSPHATE-4.4#
MAGNESIUM-2.0
[**2159-8-24**] 05:44AM CK-MB-NotDone cTropnT-0.05*
[**2159-8-24**] 05:44AM ALT(SGPT)-284* AST(SGOT)-770* LD(LDH)-1290*
CK(CPK)-90 ALK PHOS-219* TOT BILI-5.2*
[**2159-8-24**] 05:44AM GLUCOSE-90 UREA N-24* CREAT-1.4* SODIUM-134
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-17* ANION GAP-27*
[**2159-8-24**] 05:53AM O2 SAT-73
[**2159-8-24**] 05:53AM LACTATE-11.2*
[**2159-8-24**] 07:18AM TSH-2.8
[**2159-8-24**] 07:18AM OSMOLAL-291
[**2159-8-24**] 07:23AM O2 SAT-96 CARBOXYHB-2
[**2159-8-24**] 07:23AM LACTATE-9.0*
[**2159-8-24**] 07:23AM TYPE-ART PO2-106* PCO2-33* PH-7.39 TOTAL
CO2-21 BASE XS--3 COMMENTS-ADD ON CAR
[**2159-8-24**] 08:33AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL ELLIPTOCY-OCCASIONAL
[**2159-8-24**] 09:23AM URINE RBC-[**5-9**]* WBC-[**5-9**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2159-8-24**] 09:23AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG
[**2159-8-24**] 09:23AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2159-8-24**] 12:49PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2159-8-24**] 12:49PM ALT(SGPT)-589* AST(SGOT)-[**2160**]* LD(LDH)-2362*
ALK PHOS-185* TOT BILI-3.8*
[**2159-8-24**] 12:49PM GLUCOSE-99 UREA N-27* CREAT-1.3* SODIUM-135
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
[**2159-8-24**] 12:59PM HGB-10.7* calcHCT-32 O2 SAT-59
[**2159-8-24**] 12:59PM LACTATE-4.8*
[**2159-8-24**] 12:59PM TYPE-[**Last Name (un) **] PO2-37* PCO2-41 PH-7.37 TOTAL CO2-25
BASE XS--1
[**2159-8-24**] 01:33PM O2 SAT-63
[**2159-8-24**] 07:31PM PLT COUNT-138*
[**2159-8-24**] 07:31PM WBC-10.0 RBC-4.22* HGB-10.4* HCT-34.4* MCV-82
MCH-24.7* MCHC-30.2* RDW-19.7*
[**2159-8-24**] 07:31PM CALCIUM-8.0* PHOSPHATE-2.6*# MAGNESIUM-1.9
[**2159-8-24**] 07:31PM ALT(SGPT)-711* AST(SGOT)-2094* LD(LDH)-1775*
ALK PHOS-201* TOT BILI-3.4*
[**2159-8-24**] 07:31PM GLUCOSE-75 UREA N-28* CREAT-1.4* SODIUM-135
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
[**2159-8-24**] 08:36PM LACTATE-3.4*
Brief Hospital Course:
Patient was admitted on [**2159-8-24**] for acute onset dyspnea.
Patient is a 61 yom with h.o. of severe systolic and diastolic
function s/p AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w
acute onset dyspnea, elevated lactate, transaminitis and fluid
overloaded on exam.
##. Elevated Lactate: Pt noted to have an elevated lactate of
13.7 on admission. Unclear as to the exact etiology of the
Lactate level. Initial workup included osmolar gap (1), serum
tox (negative), co-oximetry (negative), and cyanide (pending).
Level was followed an rapidly trended down to 3.4 with fluids
and diuresis. Infection was considered however in the setting of
a mild leukocytosis and lack of fever and unconvincing history,
this seemed less likely. Patient was pan cultured and a CXR was
performed demonstrating substantial fluid overload. It was later
felt that the lactate resulted from hypoperfusion stemming from
prolonged SVT with abberancy. Lactate level was 1.7 on the day
of discharge.
##. Dyspnea/CHF exacerbation: Pt presented to ED with complaint
of SOB of sudden onset with no chest pain. On physical
examination pt noted to have JVP, elevated elevated BNP and CXR
which suggest fluid overload. CHF exacerbation was immediately
suspected, flash pulmonary edema during episode of AF with RVR.
Cardiac enzymes were cylced and were negative and dyspnea
quickly resolved with diuresis. He responded well to IV lasix
(negative > 3 liters on [**2159-8-26**]), and given the concern for
further excess fluid, he was instructed to take 60 mg PO daily
for two days after returning home instead of his usual 40 mg.
##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated
AST, ALT, TB on admission in the ED. In the ED he received a RUQ
ultrasound which showed cholelithiasis with GB wall edema, per
Radiology was not cholecystitis, as well as moderate ascites. Pt
does have cholelithiasis although no mention is made of any CBD
or prominence. Pt also fluid overloaded on examination,
transaminitis was thought to have resulted from congestive
hepatopathy with possible component of shock liver in setting of
hypoperfusion. Hepatitis serologies were drawn and statin was
held. Liver enzymes trended down over the course of the
admission. Therefore, medications with caution in hepatic
failure were held at discharge (including lorazepam, clonazepam,
simvastatin, midodrine, and zolpidem).
##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis
with an AG of 26. Likely due to lactic acidosis given his
lactate of 13.7. The gap resolved completely as lactate trended
down.
##. A. fib with RVR: Pt noted to go into A. fib with RVR in the
ED. Although he received 10 of IV Lopressor, no response noted.
Pt has history of A. fib, not anticoagulated due to a prior GI
bleed whilst on Coumadin. Coumadin was held and sotalol was
continued. EP was consulted and pacer was interrogated
demonstrating no ventricular arrhythmias and multiple episodes
of SVT with aberrancy. They recommended starting amiodarone;
however, patient had allergic reaction to this [**Date Range 4085**] in
past. At discharge, patient was in a paced rhythm at 72 bpm.
##. Hypothyroidism: patient was continued on synthroid
##. Systolic/diastolic dysfunction: Pt received an Echo in
[**11/2158**] which was notable for an EF of 20% as well as Grade
III/IV LV diastolic dysfunction. Patient was continued on
digoxin.
##. Depression: Patient continued on home regimen of Citalopram
and Bupropion.
##. Insomnia: Patient was taking lorazepam and zolpidem QHS at
home. As these medications should be used with caution in
hepatic impairment, they were held during this admission. The
patient received a single dose of trazodone 25 mg PO. He was
discharged with a prescription for 14 days of trazodone 25 mg to
assist with insomnia until his LFTs can be re-evaluated and a
decision made about a long-term sleeping aid.
*** FOLLOW UP CARE ***
Mr. [**Known lastname 31930**] will return home with visiting nurse services to
attend to his wound care as well as to monitor his vitals (low
blood pressure 90s/60s during this admission, but asymptomatic)
and fluid status (assess for volume overload). Mr. [**Known lastname 31930**] will
see a health provider [**Last Name (NamePattern4) **] 1 week, and should have his LFTs,
electrolytes and CBC assessed at that time given the
abnormalities noted prior to discharge to confirm that these
values continue to stabilize. If LFTs have returned to [**Location 213**],
consider restarting prior home medications which were held in
the setting of transaminitis (statin, zolpidem, clonazepam,
lorazepam, midodrine). He should also have BP checked
(orthostatics performed, given his history) and volume status
assessed - he may require increase in baseline lasix.
Medications on Admission:
Bupropion 100 mg po bid
Citalopram 10 mg daily
Clonazepam 0.5 mg po bid
Digoxin 125 mcg, 1 tab/2 tabs alterating
Lasix 40 mg daily
Levothyroxine 50 mcg daily
Lorazepam 4 mg qhs
Midodrine 1 mg po tid
Simvastatin 40 mg daily
Sotalol 120 mg po bid
Spironolactone 12.5 mg daily
Triamcinolone 0.1% ointment
Zolpidem 10 mg qhs
Discharge Medications:
1. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Digoxin 125 mcg Tablet Sig: 1-2 Tablets PO Alternate 1 or 2
tabs every other day.
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take 1.5 tablets on [**2159-8-28**] (tomorrow) and [**2159-8-29**] (Wednesday),
then resume 1 tablet per day.
6. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Triamcinolone Acetonide 0.1 % Ointment Topical
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnosis:
CHF exacerbation
Congestive hepatopathy
Paroxysmal atrial fibrillation with rapid ventricular rate
Secondary Diagnosis:
Hypothyroidism
Orthostatic hypotension
Discharge Condition:
good, respiratory status back to baseline
Discharge Instructions:
You were admitted to the hospital because you developed acute
shortness of breath and weakness. Upon admission we discovered
that your heart was in an abnormal rhythm called atrial
fibrillation with rapid ventricular response. This means that
your heart was not able to pump blood appropriately because of
this and because of your congestive heart failure. This allowed
fluid to fill your lungs and made you feel short of breath. You
were initially admitted to the ICU were it was discovered that
this had not only affected your heart and lungs but also your
liver. You were treated with a [**Hospital 4085**] called lasix which
helped you cleared this fluid from your lungs. Your condition
improved with just one dose of this [**Hospital 4085**]. You were
subsequently transfered to the medical floor. We continued your
lasix and your condition improved even more. As a result of this
treatment your liver also recovered and it is now recovering.
We made the following changes to your medications:
1. STOP TAKING simvastatin until directed to resume use by your
doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this
time.
2. STOP TAKING clonazepam until directed to resume use by your
doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this
time.
3. STOP TAKING lorazepam until directed to resume use by your
doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this
time.
4. STOP TAKING zolpidem until directed to resume use by your
doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this
time.
5. STOP TAKING midodrine until directed to resume use by your
doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this
time.
6. INCREASE DOSE of Lasix (furosemide) to 60 mg (1.5 tablets) by
mouth daily for 2 days (tomorrow and Wednesday). Then resume
your usual dose of 40 mg by mouth daily starting on Thursday.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 mL of fluid per day
If you at any point experience chest pain, shortness of breath,
weakness, nausea, vomiting, abnormal heart beats, increased leg
swelling, defibrillator firing, fevers, chills or any other
symptom that concerns you please return to the hospital or
contact your PCP or your [**Name9 (PRE) 31931**] for further evaluation.
Please keep the follow-up appointments as outlined below.
Followup Instructions:
Please keep the following appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**]
Date/Time: [**2159-9-5**] at 2:10 pm
Provider: [**Doctor Last Name 31929**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time: [**2159-9-21**] at 2:50 pm
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**]
Date/Time: [**2159-9-27**] 9:30 am
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time: [**2159-9-27**] 10:20 am
Completed by:[**2159-8-27**]
|
[
"573.3",
"425.4",
"440.23",
"272.4",
"300.4",
"707.15",
"458.0",
"428.0",
"244.9",
"276.2",
"428.43",
"V45.81",
"427.31",
"607.84",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12518, 12581
|
6575, 11356
|
280, 286
|
12804, 12848
|
2975, 6552
|
15477, 16080
|
2379, 2413
|
11728, 12495
|
12602, 12602
|
11382, 11705
|
12872, 13843
|
2428, 2956
|
13872, 15454
|
233, 242
|
314, 1835
|
12742, 12783
|
12621, 12721
|
1857, 2168
|
2184, 2363
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,627
| 131,679
|
36846
|
Discharge summary
|
report
|
Admission Date: [**2160-6-30**] Discharge Date: [**2160-7-4**]
Date of Birth: [**2081-5-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2160-6-30**] Coronary artery bypass grafting x3
(LIMA-LAD,SVG-PDA,SVG-OM1)
History of Present Illness:
This is a 79 year old female with known coronary artery disease
who presented with recurrent chest discomfort in [**2159-12-10**].
Cardiac catheterization in [**2159-12-10**] showed severe three
vessel coronary disease with moderate mitral regurgitation. Her
coronary anatomy has remained relatively unchanged compared to
[**2153**]. Given her recurrent angina, she was referred for surgical
evaluation. Current symptoms include mostly exertional shortness
of breath and diaphoresis. Occasional chest pressure. She denies
chest pain, orthopnea, PND and syncope.
Past Medical History:
Coronary Artery Disease
Hypertension
Dyslipidemia
Osteoarthritis
Obesity
Hysterectomy for precancerous tumor
Appendectomy
Right Hip Replacement
Social History:
Occupation: Seamstress
Last Dental Exam: 3 weeks ago
Lives with: Lives alone
Race: Caucasion
Tobacco: Non-smoker
ETOH: occasional, no h/o abuse
Family History:
Mother and father suffered/died MI at ages 65 and 50. Sister
died
of MI at age 64.
Physical Exam:
ADmission:
Pulse: 87 Resp: 16 O2 sat: 97% RA
B/P Right: Left: 150/80
Height: Weight:
General: Elderly female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur soft 2/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
?abdominal bruit
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
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: none Left: none
Pertinent Results:
[**2160-6-30**] Echo: PRE-BYPASS: The left atrium and right atrium are
normal in cavity size. No spontaneous echo contrast or thrombus
is seen in the body of the left atrium/left atrial appendage or
the body of the right atrium/right atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. 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. There are complex (>4mm) atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is mild to moderate aortic valve stenosis
(varying valve areas obtained 1.1-1.4cm2). There was no cath
comment. By planimetry, [**Location (un) 109**] was 2. The non coronary cusp was the
calcified cusp. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen at
worst. There is no pericardial effusion. Dr.[**Last Name (STitle) **] was notified
in person of the results on [**Known lastname 83230**] before incision.
Post_bypass: Intact thoracic aorta. Preserved biventricular
systolic function. LVEF 55%. MR was mild to moderate. Aortic
valve velocity profile remained similar to prebypass.
[**2160-7-3**] 05:30AM BLOOD WBC-11.3* RBC-2.95* Hgb-9.5* Hct-27.0*
MCV-92 MCH-32.2* MCHC-35.2* RDW-13.4 Plt Ct-194
[**2160-7-3**] 05:30AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-139
K-4.0 Cl-104 HCO3-27 AnGap-12
Brief Hospital Course:
Ms. [**Known lastname 83230**] was a same day admit after undergoing
pre-operative work-up as an outpatient. On the day of admission
she was brought directly to the Operating Room where she
underwent coronary artery bypass graft x 3. Please see operative
report for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition on no pressors. Within 24 hours
she was weaned from sedation awoke neurologically intact and was
extubated. On post-op day one she was transferred to the
telemetry floor for further care. Chest tubes and epicardial
pacing wires were removed per protocol on POD 2 and 3
respectively.
Physical therapy worked with her for strength and mobilization.
She was begun on beta blockers and diuresed towards her
preoperative weight. Diuretics were continued after discharge
for two weeks as she was still above her preop weight.
Discharge instructions were discussed with her as well as
medications and followup care prior to discharge home.
Medications on Admission:
Aspirin 81 qd, Atenolol 100 qd, Simvastatin 80 qd,
Glucosamine/Chondroitin, Vitamin D, Lysine, Lipo-Falvonoid
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 * Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary artery bypass grafting x 3
Hypertension
Dyslipidemia
Osteoarthritis
Obesity
s/p Hysterectomy for precancerous tumor
s/p Appendectomy
s/p Right Hip Replacement
Discharge Condition:
Good
Discharge Instructions:
Report any redness of, or drainage from incisions.
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 until it has healed.
Shower daily. No bathing or swimming for 1 month.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month and while taking narcotics for pain.
Take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 29070**] in [**2-12**] weeks
Dr. [**Last Name (STitle) **] in [**1-11**] weeks ([**Telephone/Fax (1) 17355**])
[**Hospital Ward Name 121**] 6 for wound check in 2 weeks
Please call for appointments
Completed by:[**2160-7-4**]
|
[
"413.9",
"424.0",
"272.4",
"401.9",
"V43.64",
"V45.89",
"715.90",
"414.01",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61",
"39.64",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6080, 6155
|
3834, 4852
|
293, 373
|
6395, 6401
|
2127, 3811
|
6882, 7207
|
1309, 1393
|
5013, 6057
|
6176, 6374
|
4878, 4990
|
6425, 6859
|
1408, 2108
|
234, 255
|
401, 964
|
986, 1131
|
1147, 1293
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,570
| 128,532
|
9674
|
Discharge summary
|
report
|
Admission Date: [**2170-6-9**] Discharge Date: [**2170-6-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Hip fracture
Major Surgical or Invasive Procedure:
OPERATIVE PROCEDURE:
1. Closed reduction of right hip with open placement of
dynamic hip screw, right hip.
2. Examination under anesthesia with placement of splint,
right elbow.
PROCEDURE #2 :
1. Exploratory laparotomy with drainage of intra-abdominal
abscess and peritonitis with gross soilage with bile and
gastric contents.
2. Exposure and wide drainage of perforated posterior
duodenal ulcer with internal and external drainage.
3. Feeding jejunostomy.
4. Tube gastrostomy.
5. Placement of a right femoral arterial line.
History of Present Illness:
[**Age over 90 **] yo F with MMP (see below) who sustained a mechanical fall
down stairs resulting in a hip and arm fracture. Fall was
witnessed by daughter. [**Name (NI) **] seizures, no LOC, no head or neck
trauma. Patient denies CP, SOB, light headedness, or dizziness
prior to of after the fall. She fell on her R side and had a
great deal of pain in her R arm and hip. Presented to [**Location (un) **]
and found to have R humerus and R hip fx. Ct of head and neck
neg for fx, bleed, and dislocation.
Past Medical History:
1. Coronary artery disease status post non-ST-elevation
myocardial infarction in [**2166-5-27**], status post cardiac
catheterization with left anterior descending artery stent
placement in 05/[**2166**].
2. CHF with an ejection fraction of 40-45% [**3-3**]
3. Diabetes type 2.
4. Anemia, transfusion dependent every three months. Hct 28 b/l
5. Polymyalgia rheumatica.
6. Hypertension.
7. Hypothyroidism.
8. Chronic renal insufficiency with a b/l creatinine of 1.4.
9. History of syncope and first degree A-V heart block with
beta blocker therapy.
10. History of lower gastrointestinal bleed in [**2166-6-27**].
11. spinal stenosis
12. Pacemaker- DDD dual chamber rate response pacemaker [**2168-9-12**]
for symptomatic bradycardia
Social History:
Lives alone in [**Hospital3 4634**], a daughter in the area, two
children and exercises two times a week by walking and
stretching.
no, tob, no etoh, no drugs
Family History:
Noncontributory
Physical Exam:
at admission
T 96.0 BP 177/61 P 70 R 18 O2 97 on RA
Gen - somnolent, confused
HEENT - PERRL, OP clear, EOMI
Cor - rrr, no m/r/g
Chest - CTAB anteriorly
Abd - s/nt/nd +BS
Ext - 2+ edema to knees, warm 2+ pulses, pain in R arm and R hip
Pertinent Results:
[**2170-6-9**] 06:00PM GLUCOSE-188* UREA N-48* CREAT-1.3* SODIUM-138
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
[**2170-6-9**] 06:00PM CK(CPK)-32
[**2170-6-9**] 06:00PM CK-MB-NotDone
[**2170-6-9**] 06:00PM WBC-14.9*# RBC-2.91* HGB-8.5* HCT-24.7*
MCV-85 MCH-29.3 MCHC-34.5 RDW-14.6
[**2170-6-9**] 06:00PM NEUTS-87.9* BANDS-0 LYMPHS-6.3* MONOS-5.7
EOS-0.1 BASOS-0
[**2170-6-9**] 06:00PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2170-6-9**] 06:00PM PLT SMR-NORMAL PLT COUNT-216
[**2170-6-9**] 06:00PM PT-13.3 PTT-26.4 INR(PT)-1.2
.
EKG - NSR 64, 1st deg block, LAD, new TWI inf/lat leads, new ST
depressions V4-6
.
Echo [**3-3**]
1. The left atrium is moderately dilated. The left atrium is
elongated.
2. The left ventricular wall thicknesses are normal. The left
ventricular
cavity size is normal. There is mild regional left ventricular
systolic
dysfunction. Overall left ventricular systolic function is
mildly depressed. Resting regional wall motion abnormalities
include inferolateral , inferior and mid septal hypokinesis.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation present.
5.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
6.There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2166-6-27**], the LV function has improved with an improvementt in
function of the apex, septal and anterior walls. New inferior
and inferolateral wall motion abnormalities with more severe
mitral regurgitation present.
.
Cath [**2166**]
1. Coronary angiography demonstrated single vessel disease in a
right
dominant system. The left main was normal. The LAD had serial
90%
lesions proximally, involving the origin of the first diagonal,
which
was occluded and filled via left to left collaterals. The
mid-distal LAD
was underfilled initially but was without obstructive disease.
The
non-dominant circumflex system had no hemodynamically
significant
stenoses. The dominant RCA was a large vessel with no
significant
disease.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with a mean RA pressure of 12 mm Hg and a mean wedge
pressure
24 mm Hg. Moderate pulmonary hypertension was present with a PA
of
52/28. The cardiac index was preserved at 3.0 L/min/m2.
3. Left ventriculography was not performed due to the presence
of
moderate renal insufficiency (creatinine 1.6).
4. Successful PTCA and stenting of the proximal LAD with
overlapping
2.25x13mm and 2.25x18mm Hepacoat stents with no residual
stenosis or
dissection and normal flow (see PTCA comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderately elevated right and left sided filling pressures.
3. Successful stenting of the proximal LAD.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2170-6-15**] 09:40AM 19.3* 4.46 13.1 39.2 88 29.4 33.5 14.4
159
[**2170-6-15**] 12:52AM 19.8*# 4.73 13.8 42.1# 89 29.3 32.9 14.3
147*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2170-6-13**] 06:15AM 90.0* 0 5.6* 4.2 0.1 0.2
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2170-6-13**] 06:15AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2170-6-15**] 09:40AM 159 1+
[**2170-6-15**] 09:40AM 14.9*1 31.9 1.5
1 NOTE NEW NORMAL RANGE AS OF 12 AM [**2170-5-26**]
[**2170-6-15**] 12:52AM 147*
[**2170-6-15**] 12:52AM 14.6*1 33.8 1.4
1 NOTE NEW NORMAL RANGE AS OF 12 AM [**2170-5-26**]
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2170-6-15**] 09:40AM 192* 87* 2.4* 146* 5.1 114* 16* 21*
[**2170-6-15**] 12:52AM 160* 86* 2.6* 148* 4.4 115* 14*1 23*
1 VERIFIED BY DILUTION
NOTIFIED [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-TSICU 140 AM [**2170-6-15**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2170-6-15**] 07:40AM 628*
[**2170-6-15**] 12:52AM 22 65* 739* 52 81 1.0
OTHER ENZYMES & BILIRUBINS Lipase
[**2170-6-15**] 12:52AM 17
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2170-6-15**] 07:40AM 15* 2.4
[**2170-6-15**] 12:52AM 14* 1.9 0.12*1
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2170-6-15**] 09:40AM 8.3* 5.4* 2.1
[**2170-6-15**] 12:52AM 2.1* 7.7* 5.1*# 1.6
LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc
[**2170-6-10**] 09:20AM 1[**Telephone/Fax (2) 32710**] LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
LAB USE ONLY GreenHd
[**2170-6-9**] 06:00PM HOLD1
1 HOLD
DISCARD GREATER THAN 4 HOURS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calHCO3 Base XS AADO2 REQ O2 Intubat Vent
[**2170-6-15**] 07:58AM ART 102 36 7.26* 17* -9
[**2170-6-15**] 04:31AM ART 36.4 16/ [**Telephone/Fax (2) 32711**]4* 7.26* 16*
-10 ASSIST/CON1 INTUBATED
1 ASSIST/CONTROL
[**2170-6-15**] 12:58AM ART 147* 39 7.22*1 17* -11
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2170-6-15**] 07:58AM 4.5*1
1 VERIFIED
[**2170-6-15**] 04:31AM 5.1*1
1 VERIFIED
[**2170-6-15**] 12:58AM 6.2*1
1 VERIFIED
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat COHgb
MetHgb
[**2170-6-14**] 09:36PM 11.4* 34 73 1 1
[**2170-6-14**] 01:08PM 10.9* 33 96
CALCIUM freeCa
[**2170-6-14**] 09:36PM 1.00*
[**2170-6-14**] 01:08PM 1.22
RADIOLOGY Final Report
CT ABDOMEN W/O CONTRAST [**2170-6-14**] 5:46 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: Please eval for perf/ischemic bowel
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with MS changes, abd pain hypotension and
bloody lavage on Lovenox+ASA
REASON FOR THIS EXAMINATION:
Please eval for perf/ischemic bowel
CONTRAINDICATIONS for IV CONTRAST: renal failure
INDICATION: [**Age over 90 **]-year-old woman with mental status changes, now
with abdominal pain and hypertension.
TECHNIQUE: A multidetector scanner was used to obtain contiguous
axial images from the lung bases to the pubic symphysis. Neither
IV nor oral contrast were used.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are bilateral
pleural effusions, right greater the left; there is compressive
atelectasis at the left lung base. There are coronary vascular
calcifications. A nasogastric tube is seen coiling in the
stomach. A dual chamber pacemaker is seen with leads terminating
in the right atrium and right ventricle. Nasogastric tube is
seen coiling in the stomach, with its tip at the pylorus.
Allowing for the limitations of this noncontrast study, the
liver, pancreas, adrenals, stomach are unremarkable. A 1.8 cm
exophytic renal cyst is seen on the left. A similar lesion is
seen on the right, measuring 2.2 cm. The aorta is normal in
caliber, with vascular calcifications. A small amount of free
fluid is seen tracking around the liver, right pericolic gutter,
along the mesentery and surrounding the right colon, which is
collapsed. A small amount of nondependent free air is seen in
the anterior aspect of the abdomen. The remainder of the bowel
loops are fluid filled, and nondilated.
CT OF THE PELVIS WITHOUT IV CONTRAST: As previously noted, there
is a small amount of free fluid surrounding the right colon,
tracking along the mesentery and into the pelvis. A small amount
of free air is seen in the nondependent portion of the pelvis.
Vascular calcifications are seen in the abdominal aorta and
iliac arteries. Subcutaneous edema is noted in the lower abdomen
and pelvis. A catheter is seen entering the left inguinal region
and coursing along the iliac vessels, terminating in the left
pelvis.
Osseous structures are remarkable for degenerative changes of
the spine, and a fracture of the proximal right humerus, with
orthopedic hardware causing beam hardening artifact.
IMPRESSION:
1. A small amount of free air and free fluid in the pelvis and
abdomen, mostly along the right pericolic gutter and surrounding
the ascending colon, concerning for perforation. Other bowel
loops are unremarkable on this limited study. This was discussed
with Dr. [**First Name8 (NamePattern2) 32712**] [**Name (STitle) **] at approximately 6:30 p.m., [**2170-6-14**].
2. Bilateral pleural effusions, right greater than left, with
left-sided compressive atelectasis.
3. Right proximal humeral fracture status post fixation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: FRI [**2170-6-15**] 4:01 PM
Brief Hospital Course:
[**Age over 90 **] yo F with MMP who sustained a mechanical fall down stairs
resulting in a hip and arm fracture.
.
1) s/p Fall - unlikely to be mechanical in nature. Patient has
injuries to her shoulder and hip.
.
2) CV - Patient has CAD and CHF with a low hct and major trauma.
She also has new changes on EKG.On pressor to hold mean 60.
.
3) Anemia - patient transfusion dependant with a baseline of 28.
- transfuse 2 units today, with lasix
.
4) GERD - PPI
.
5) DM- glipizide, ISS
.
6) PMR - cont prednisone
.
7) GI:Ms. [**Known lastname 174**] is an unfortunate [**Age over 90 **] year old woman,
status post a recent fall necessitating right ORIF of the hip
and right wrist fracture ORIF, who was in the hospital for
this event, when it was noted that she had abdominal pain,
distention and coffee ground emesis with worsening mental
status and renal failure. CT scan was obtained and this
revealed free air and massive ascites.Pt underwent surgery on
[**6-14**] 1. Exploratory laparotomy with drainage of intra-abdominal
abscess and peritonitis with gross soilage with bile and
gastric contents.
2. Exposure and wide drainage of perforated posterior
duodenal ulcer with internal and external drainage.
3. Feeding jejunostomy.
4. Tube gastrostomy.
Continue to deteriorate spiking fevers with ventilatory support
on pressors to hold the bp. with no improvement in mental staus
was made CMO 5/20/5. Expired at 5pm
Medications on Admission:
lasix alt 40mg and 20mg qday
levothyrox 50mcg qday
lisinopril 5mg qday
famotidine 20 mg qday
fe so4 325mg qday
asa 325mg qday
toprol xl 25mg qday
glipizide 5mg qday
imdur 60mg qdau
prednisone 5mg qday
tylenol
Discharge Disposition:
Expired
Discharge Diagnosis:
MULTIORGAN FAILURE
DUODENAL PERFORATION
MULTIPLE TRAUMA
Discharge Condition:
deceased
Followup Instructions:
none
Completed by:[**2170-6-15**]
|
[
"584.9",
"532.60",
"E849.6",
"V45.82",
"E880.9",
"995.92",
"250.00",
"428.0",
"285.1",
"244.9",
"401.9",
"820.21",
"410.71",
"412",
"414.01",
"812.40",
"276.5",
"725",
"V45.01",
"567.2",
"285.9",
"593.9",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.71",
"79.15",
"45.01",
"99.04",
"93.54",
"54.19",
"43.19",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
13418, 13427
|
11737, 13159
|
273, 800
|
13526, 13536
|
2582, 5422
|
13559, 13594
|
2290, 2307
|
8644, 8749
|
13448, 13505
|
13185, 13395
|
5439, 8607
|
2322, 2563
|
221, 235
|
8778, 11714
|
828, 1341
|
1363, 2098
|
2114, 2274
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,294
| 119,734
|
34145+57899
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-8-7**] Discharge Date: [**2173-8-13**]
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Ms. [**Known lastname 78709**] is an 89 y/o with a history of gait disorder
with recurrent falls, HTN, peripheral vascular disease, and ESRD
on HD, presents as a transfer from an OSH for further mangament
of ICH after a fall. The patient was reportedly in her USOH
until earlier today, when she reportedly had a fall at her
assited living facility while walking to the bathroom. The
patient does not recall the event. She was taken to [**Hospital 6451**] Hospital,where she was reportedly found to have a left
frontal SDH and left frontal intraprenchymal hemorrhage on
non-contrast head CT. She was placed in a soft cervical collar,
though CT C-spine reportedly showed spondylosis without
fracture. While there, she was reportedly alert and fully
oriented, though a full neurologic examination was
notdocumented. She was loaded with Cerebyx. She was
transferred to [**Hospital1 18**] for further neurosurgical assessment. Here
she was initially noted to be fully oriented,but taking longer
to answer questions, and doing so with slurred speech.
Neurology was consulted with interval change in the patient's
examination.
Past Medical History:
Past Medical History:
-HTN
-Gait disorder with falls
-ESRD on HD Tu/Thurs/Sat
-Hypothyroidism
-CHF
-Infected right leg hematoma
-GERD
-Hyperparathyroidism, s/p subtotal parathyroidectomy
-Hypocalcemia
-PVD
-Restless legs syndrome
-Depression
-Arthritis
-COPD
Social History:
Works as a librarian. Lives in [**Hospital3 **] housing.
Family History:
Non contributory.
Physical Exam:
Physical Exam
Vitals: T 98.0 F BP 145/42 P 73 RR 18 SaO2 95 2LNC
General: frail elderly woman, sleepy
HEENT: has extensive ecchymosis under left eye with small
abrasion above, sclera hemorrhagic on left, dry MM, no exudates
in oropharynx
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, + SEM over apex
Abdomen: soft, thin, non-tender, non-distended, bowel sounds
present
Ext: cool, no edema, pedal pulses appreciated, toes gnarled, has
bandaged medial tibial wound with surrounding erythema on right
leg, bruising throughout extremities
Neurologic Examination:
Mental Status:
Sleepy, unable to relay much history, cooperative with exam
while awake, oriented to person, and time, though states she is
at [**Hospital3 417**], quite sleepy and inattentive, fluent,
dysarthric speech while awake, no paraphasic errors,
comprehension to commands intact while awake
Cranial Nerves:
Optic disc margins appear sharp; visual fields are full to
confrontation. Pupils equally round and reactive to light, 2 to
1 mm bilaterally. Reports diplopia in each eye individually.
Extraocular movements intact, no nystagmus. Facial sensation
intact bilaterally. Facial movement normal and symmetric.
Hearing intact to finger rub bilaterally. Palate elevates
midline. Tongue protrudes midline, no fasciculations. Trapezii
full strength bilaterally.
Motor:
Diffusely reduced bulk throughout and increased tone in legs.
No tremor, positive asterixis. Generally impersistent due to
lethargy, but seems to have full power in all muscle groups
tested. Did not comply with testing in toes.
D T B WE FiF [**Last Name (un) **] IP Q H TA G
Right 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5
Sensation: No deficits to light touch, pin prick, but somnolence
limits examination of other modalities.
Reflexes: B T Br Pa Pl
Right 2 1 2 1 0
Left 2 1 2 1 0
Toes were mute bilaterally.
Coordination: Slowed with minor intention tremor noted
bilaterally on on FNF. Too somnolent to follow commands for
HKS.
Gait: Deferred given lethargy
Pertinent Results:
Head CT [**8-7**]: There is a large left frontal parenchymal
hemorrhage with associated left subdural measuring upto 8 mm
along the frontoparietal and temporal convexity. There is no
shift of midlline structures or herniation.
Head CT [**8-9**]: IMPRESSION: No interval change in left subdural
hematoma and left intraparenchymal hemorrhage. No new areas of
hemorrhage are identified.
CXR [**8-11**]:
1. Interval improvement in now moderate pulmonary edema and
decrease in size of pleural effusions.
2. Improved aeration of the left lower lobe.
EKG [**8-7**]
Ectopic atrial rhythm. Short P-R interval. Consider left
ventricular
hypertrophy by voltage criteria. Compared to the previous
tracing of [**2173-6-28**] the rate has increased. The rhythm is now
ectopic atrial in origin.
Laboratory investigations
[**2173-8-8**] 12:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2173-8-8**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2173-8-8**] 12:00AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2173-8-7**] 09:05PM GLUCOSE-170* UREA N-18 CREAT-2.7*#
SODIUM-146* POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-28 ANION GAP-15
[**2173-8-7**] 09:05PM WBC-11.4*# RBC-3.96* HGB-12.4 HCT-40.0#
MCV-101* MCH-31.2 MCHC-30.9* RDW-16.0*
[**2173-8-7**] 09:05PM NEUTS-88.5* LYMPHS-6.3* MONOS-4.2 EOS-0.6
BASOS-0.4
[**2173-8-7**] 09:05PM PLT COUNT-253
[**2173-8-7**] 09:05PM PT-12.9 PTT-22.5 INR(PT)-1.1
Brief Hospital Course:
Ms [**Known lastname 78709**] was admitted after a fall with a left subdural
hematoma and a frontal interparenchymal hemorrhage. The
hemorrhage was slightly larger on the second serial CT head
scan. She was monitored closely in ICU. On the [**6-9**],
she became more drowsy, and had fevers. The CT head was stable,
however, her CXR showed pulmonary edema and bilateral pleural
effusions. She was started on Ceftriaxone and received a five
day course with improvement in CXR and WBC and no fever. She
received hemodialysis via her left AV fistula, and her usual
schedule is: Sat/Tues/Thurs, note that she is not anuric. She
transferred out of ICU [**8-11**]. She was at her neurological
baseline with exception of difficulty hearing (baseline). On
[**8-13**] she was reassessed by Speech and swallow, who recommended
that she have: nectar thickened liquids, pills crushed with
puree, supervision to assist with feedings, and alternating
between small bites and sips. PT recommended gait, endurance and
strength training, however, she still has significant balance
impairment.
Her neurological exam prior to discharge was the following:
1. Awake, alert, oriented to time/person/place
2. Follows commands.
3. Eyes open (please note the left hematoma around her eye is
resolving)
4. the rest of the cranial nerve examination was unremarkable.
5. No pronator drift.
6. Full power in her arms and legs.
Medications on Admission:
Medications (per [**Hospital3 **] sheet):
-Lasix
-Hydralazine
-Clonidine
-Lopressor
-Isordil
-Lisinopril
-Norvasc
-Lactulose
-Prevacid
-Colace
-Flonase
-Paxil
-Melatonin
-Procrit
-Sennokot
-Calcitriol
-Calcium carbonate
-Nephrocap
-Reglan
-Renagel
-Singulair
Allergies:
Sulfa- anaphylaxis
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
10. Lasix 20 mg Tablet Sig: Five (5) Tablet PO once a day.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Other medications
Please note that in addition, she can contine on her medications
prior to admission such as: Renagel, Singulair, Reglan,
Nephrocap, Calcium carbonate, Calcitriol, Procrit.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Left Frontal Subdural Hematoma and Frontal Intraparenchymal
Hemorrhage
Discharge Condition:
Neurological exam was stable.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, 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.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **]. [**Doctor Last Name 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2173-8-13**] Name: [**Known lastname 12681**],[**Known firstname 11416**] Unit No: [**Numeric Identifier 12682**]
Admission Date: [**2173-8-7**] Discharge Date: [**2173-8-13**]
Date of Birth: [**2083-8-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1698**]
Addendum:
Pt has been followed by wound care for right lower leg wound -
treated with saline cleansing, duoderm and moist gauze daily.
Should follow up with PCP or vascular surgeon upon discharge
from rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2173-8-13**]
|
[
"486",
"530.81",
"244.9",
"E885.9",
"443.9",
"333.94",
"428.0",
"707.12",
"853.02",
"585.6",
"781.2",
"852.22",
"496",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10622, 10817
|
5485, 6885
|
236, 242
|
8591, 8623
|
3959, 5462
|
9658, 10599
|
1776, 1795
|
7225, 8381
|
8497, 8570
|
6911, 7202
|
8647, 9635
|
1810, 2414
|
192, 198
|
270, 1403
|
2754, 3940
|
2453, 2738
|
2438, 2438
|
1447, 1685
|
1701, 1760
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,783
| 144,368
|
15099
|
Discharge summary
|
report
|
Admission Date: [**2193-9-11**] Discharge Date: [**2193-9-18**]
Date of Birth: [**2149-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Malaria in returning traveler
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 44080**] is a 44 [**Initials (NamePattern4) **] [**University/College **] anthropolgy PHD candidate who
returned from a 6 week stay in [**Country 15800**] on [**8-27**]. He reports feeling
well throughout his trip but developed malaise, fevers to 103,
chills, sweats, diffuse mylagias/arthralgias, HA, cough 2-3 days
after returning to [**Location (un) 86**]. He was seen at the [**University/College **] Health
Services [**Doctor Last Name **] Infirmary where he was admitted for IV
hydration and blood work showed a thrombocytopenia of 40 ,
elevated LFTs with AST 85. ALT 126, AP 84, Tbili 1.7. A parasite
smear returned positive for likely P. falciparum malaria with
ring forms seen in 2% of RBC's and he was transferred to our ER.
Here he was febrile to 102.9, further hydrated and repeat
parasite smear fshowed likely P. falciparum in 0.9% of RBCs. He
was started on oral Quinidine Sulfate and Doxycycline but
experienced nausea and vomiting. While in the ED he complained
of worsening SOB, tachypnea to >35 and CXR showed new b/l
pulmonary edema. A CXR done at HHS done on [**9-10**] had been clear.
At that point he was transferred to the ICU for IV Quinidine
Gluconate and Doxycycline therapy along with telemetry
monitoring.
.
Given his complaints of HA and malaise an LP was warranted but
patient declined. He reports spendng most of his time in an
urban setting in [**Country 15800**] interviewing citizens. He recalls
sporadic moquito bites. He did not take any Malaria prphylaxis
before or during his trip. he has spent much time in [**Country 15800**]
including a recent 17 month stay. In total, he has been to [**Country 15800**]
7 times in the last 10 years. He has never taken malaria
prophylaxis and has never had malaria.
Past Medical History:
Bunion removal
Social History:
EtOH: {X}N {}Y Amount:
Tobacco: {X}N {}Y Amount:
Drugs: {X}N {}Y Amount:
Married: {X}N {}Y Divorced {} SO {}
Occupations: [**University/College **] Anthropology PHD Candidate
Exposures: 6 week stay in [**Country 15800**]
Travel: [**Country 15800**]- returned on [**8-27**]
Pets: None
HIV Risk: Sexually active with women- no recent/new/unknown
partners. no known HIV exposures
Born and raised in [**State 4565**]
Family History:
FAMILY HISTORY: Noncontributory
Physical Exam:
Tm102.9 Tc:101.3 P:109 R:32 BP:109/63 Drips- Quinine Gluconate
0.02mg/kg/hr
General:ill appearing, tachypnic, NAD
HEENT: {X}WNL Anicteric, non-injected sclera, no LAD, no
photphobia
Neck: {X}WNL- supple , no meningismus
Cardiovascular: Tachycardic, regular rhythm, no M/R/G
Respiratory: decreased BS at bases bilaterally, no wheezing, no
rales or rhonchi
Back: {X}WNL
Gastrointestinal:Soft NTND + BS, no hepatomegaly, ?spleen tip
felt 2 cm below costal margin
Genitourinary: {X}WNL
Musculoskeletal:{X}WNL
Skin: {X}WNL- no rashes
Neurological: {X}WNL
Psychiatric: {X}WNL
Access: peripheral IVs
Pertinent Results:
Thick and thin parasite smears
[**9-10**]- [**University/College **] Health Services: P. falciparum- 2% parasitemia
[**9-11**]- Likely P. falciparum 0.9% parasitemia
[**9-12**]- 9% parasitemia
[**9-12**]- 8% parasitemia
[**9-13**]- 6%
8/22- 0.2%
8/23- 0.2%
8/24- negative
[**9-16**]- negative
CXR [**9-11**]: Bilateral pulm edema
[**2193-9-11**] 07:05PM BLOOD WBC-4.2 RBC-4.50* Hgb-14.0 Hct-40.3
MCV-90 MCH-31.1 MCHC-34.7 RDW-12.6 Plt Ct-37*
[**2193-9-11**] 07:05PM BLOOD PT-14.0* PTT-36.7* INR(PT)-1.2*
[**2193-9-11**] 07:05PM BLOOD Glucose-107* UreaN-5* Creat-1.0 Na-132*
K-3.4 Cl-99 HCO3-25 AnGap-11
[**2193-9-11**] 07:05PM BLOOD ALT-73* AST-80* LD(LDH)-382* AlkPhos-82
TotBili-2.2*
[**2193-9-11**] 07:05PM BLOOD Lipase-45
[**2193-9-11**] 07:05PM BLOOD proBNP-980*
[**2193-9-11**] 07:11PM BLOOD Lactate-1.7
[**2193-9-12**] 01:11AM BLOOD WBC-10.6# RBC-4.38* Hgb-13.8* Hct-38.6*
MCV-88 MCH-31.5 MCHC-35.8* RDW-12.8 Plt Ct-28*
[**2193-9-12**] 01:11AM BLOOD PT-14.0* PTT-36.8* INR(PT)-1.2*
[**2193-9-12**] 01:11AM BLOOD Glucose-105 UreaN-7 Creat-0.9 Na-127*
K-3.5 Cl-97 HCO3-21* AnGap-13
[**2193-9-12**] 01:11AM BLOOD Hapto-171
[**2193-9-12**] 05:01AM BLOOD Osmolal-263*
[**2193-9-13**] 03:15AM BLOOD WBC-9.3 RBC-4.01* Hgb-12.6* Hct-35.7*
MCV-89 MCH-31.4 MCHC-35.2* RDW-12.9 Plt Ct-24*
[**2193-9-14**] 07:30AM BLOOD Neuts-64 Bands-6* Lymphs-15* Monos-4
Eos-1 Baso-0 Atyps-10* Metas-0 Myelos-0
[**2193-9-14**] 07:30AM BLOOD PT-12.2 PTT-33.6 INR(PT)-1.0
[**2193-9-14**] 07:30AM BLOOD Glucose-97 UreaN-14 Creat-1.1 Na-129*
K-3.7 Cl-94* HCO3-27 AnGap-12
[**2193-9-14**] 07:30AM BLOOD ALT-102* AST-109* AlkPhos-92 TotBili-1.6*
[**2193-9-14**] 07:30AM BLOOD Calcium-7.1* Phos-2.4* Mg-2.1
[**2193-9-15**] 07:20AM BLOOD WBC-10.8 RBC-3.55* Hgb-11.4* Hct-31.3*
MCV-88 MCH-32.0 MCHC-36.2* RDW-13.7 Plt Ct-46*
[**2193-9-16**] 06:10AM BLOOD WBC-10.9 RBC-3.43* Hgb-11.0* Hct-31.1*
MCV-91 MCH-32.2* MCHC-35.4* RDW-13.5 Plt Ct-61*
[**2193-9-17**] 06:20AM BLOOD WBC-11.8* RBC-3.53* Hgb-11.0* Hct-31.6*
MCV-89 MCH-31.2 MCHC-34.9 RDW-14.3 Plt Ct-102*#
[**2193-9-18**] 06:20AM BLOOD WBC-11.4* RBC-3.55* Hgb-11.1* Hct-32.0*
MCV-90 MCH-31.1 MCHC-34.6 RDW-14.4 Plt Ct-160#
[**2193-9-17**] 06:20AM BLOOD ALT-93* AST-54* AlkPhos-118* TotBili-1.0
[**2193-9-18**] 06:20AM BLOOD ALT-100* AST-66* AlkPhos-113
Brief Hospital Course:
1. Malaria:
Symptoms of high fevers, chills, sweats, myalgias/arthralgias,
cough and SOB are consistent with malaria. Smear from [**University/College 44081**]clinic confirmed this suspicion and suggested
Plasmodium falciparum was the parasitic [**Doctor Last Name 360**]. Severe pulmonary
involvement and high parasitemia also make falciparum likely.
Initial parasitemia measured at 2%, but a repeat smear was 8%.
Tylenol was used for high fevers. Given chloroquine resistance
in [**Country 15800**], IV quinine gluconate and doxycycline regimen was
initiated. Because of side effects of quinine including
prolonged QTc and associated arrhythmias and hypoglycemia, he
had serial EKGs and electrolytes and glucose were tightly
regulated. He was monitored for complications of malaria,
including anemia (with serial hct's), thrombocytopenia (with
splenic exams and serial platelet counts), DIC (with PT, PTT,
and fibrinogen), ARF (with BUN and Cr), and cerebral malaria (by
symptoms, mental status, and neuro exams). Parasite smears were
followed q12h. ID was consulted and followed the patient
throughout his stay. At the time of transfer off of the MICU his
parasitemia was falling from a high of 8% and he was switched to
oral doxycycline.
.
Upon transfer the medicine floor on [**9-13**], pt was continued on IV
Quinine and PO Doxycycline until parasite counts dropped to <1%
per ID recommendations. He was then switched to oral Quinine
and continued on oral Doxycycline and finished a 7 day course of
both. He had occasional nausea with the PO quinine and was
treated with Zofran PRN for this. He had daily EKGs to monitor
for side effects of Quinine which were normal. He was monitored
on telemetry and had no abnormal rhythms during this
hospitalization. His blood glucose was checked every 6 hours
for possible hypoglycemia side effects of quinine and these were
normal. Significant complications of malaria including his
pulmonary edema, thrombocytopenia, anemia, transaminitis, and
coagulopathy were monitored and treated as described below.
These were stable or resolved at the time of discharge as
described. On discharge, he was told to follow in the
Infectious Disease clinic on [**10-14**]. He was instructed to have
his blood checked on day 3, 7 and 28 after discharge per ID
recommendations.
.
2. ARDS/Pulmonary Edema:
Pt felt markedly SOB upon light exertion and at times could not
speak in continuous sentences without becoming SOB. He meets
ARDS criteria based on fairly rapid development of respiratory
distress, bilateral infiltrates consistent with pulmonary edema,
PaO2/FiO2=99/. His chest x-ray shows diffuse, bilateral
haziness, worse in the lower lung fields. EKG was unremarkable,
save for mild QTc prolongation. Echo showed only mild (1+) MR.
His pulmonary pathology thus is likely due to his malaria, in
which adherent red blood cells and inflammatory mediators can
damage pulmonary vasculature leading to pulmonary edema and
hemorrhage. He was supported with O2 by nasal cannulae. He was
given one 20mg dose of lasix for symptomatic SOB prior to
transfer to the medicine floor.
.
Upon transfer out of the MICU on [**9-13**], pt became acutely short
of breath. His respiratory rate was approximately 40
breaths/min and his O2 saturations were 95% on 5L NC. He was
given 40mg IV Lasix [**Hospital1 **] with nitropaste and morphine for
treatment of his SOB and pulmonary edema. He responded to the
Lasix with appropriate urine output and was diuresed 2-3L
negative each day. He improved with aggressive diuresis and
respiratory status improved. His oxygen was gradually weaned
down as tolerated. He was able to get out of bed on [**9-17**]. On
[**9-18**], the day of discharge, he was off of oxygen and able to
ambulate without become hypoxic. His electrolytes were replete
as needed. His renal function with Lasix was stable. He was
instructed not to fly for several weeks after discharge.
.
3. Hyponatremia:
Pt was hyponatremic on [**8-6**] with a sodium of 127 and Urine
osms = 330. Pt appeared euvolemic, thus causes of hyponatremia
include SIADH, hypothyroidism, and adrenal insufficiency. Of
these, SIADH in the setting of diffuse lung injury is most
likely. TSH checked to rule out thyroid disease and was normal.
As diuretics corrected pulmonary edema and functional lung
status improved, sodium corrected. By [**9-16**], sodium was within
the normal range and was 134. On discharge, sodium was normal.
Pt had no symptoms of hyponatremia and did not experience
complications of this.
.
4. Tachycardia:
Pt was in the 110s for the majority of [**9-12**]. His tachycardia was
likely due to combination of fever and SOB. No signs of ischemia
or other cardiac dysfunction on EKG or echo. As stress of acute
illness resolved, tachycardia also resolved and pt had normal HR
of 70-80 during the end of his hospitalization.
.
5. Thrombocytopenia:
On admission PLTs were low and continued to fall to a low of
20k. There were no signs of bleeding and he was not transfused
PLTs. It is believed that his thrombocytopenia is [**2-23**]
hypersplenism. His spleen was possibly palpable on admission.
As his acute illness resolved, his thrombocytopenia resolved.
By [**9-16**], his platelet count was 61. By [**9-17**] it was 102 and on
the day of discharge [**9-18**], it was 160. He had one episode of
nose bleed on [**9-15**] which was brief and did not reoccur.
.
6. Anemia:
Pt became anemic over the first few days of his hospitalization
with a low HCT of 31.1 on [**9-16**]. He had a elevated total
bilirubin initially with a normal haptoglobin. The cause of his
anemia was possibly due to hemolysis but more likely was an
effect of the parasite on his RBCs. He had no bleeding episodes
and on discharge HCT was stable at 32.0, which was stable for
the prior 5 days before discharge. He will follow-up with his
PCP and [**Hospital **] clinic with future blood draws for any persistent
anemia.
.
7. Coagulopathy:
On admission, coags were slightly elevated with a PT of 14.0,
PTT of 36.7, INR of 1.2. This was likely from some liver damage
secondary to malaria vs. coagulation factor deficiency from
malaria. Coags were monitored and levels returned to [**Location 213**]
values on [**2193-9-14**].
.
8. Transaminitis:
On admission, ALT, AST and Alk phosphatase were elevated with a
high total bilirubin. ALT and AST continued to trend up with a
peak of ALT=115 and AST=109. His LFTs then started to trend
down and on discharge ALT was 100 with AST of 66. He had no
hepatomegaly and no jaundice. He did not complain of RUQ pain
and had no signs of acute liver failure. Most likely cause of
his transaminitis was due to toxic effect of malaria parasite.
He should have his LFTs rechecked upon follow-up with his PCP.
.
9. Fluids, Electrolytes, Nutrition:
Pt was given a regular diet and tolerated this well. His
electrolytes were repleted as needed. IV fluids were not needed
during this hospitalization.
.
10. Hospital Prophylaxis:
Pt was given SC Heparin for DVT prophylaxis. He was given
Colace and Senna for a bowel regimen.
.
11. Code Status: FULL
.
12. Discharge:
On discharge, pt was no longer hypoxic at rest or with
ambulation. He was evaluated by physical therapy and able to
ambulate on his own. He felt clinically well and was
hemodynamically stable. He was given an appointment to
follow-up with his PCP the following week. He was given an
appointment in the Infectious Disease clinic for 4 weeks. He
was told to have his blood drawn for follow-up parasite smears
in 3, 7 and 28 days. He was instructed to come to [**Hospital1 **] to have these labs done.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Falciparum Malaria, Severe
Discharge Condition:
Afebrile, hemodynamically stable.
Discharge Instructions:
You were admitted to the hospital with severe malaria requiring
an ICU stay. The parasite affected your lungs and caused fluid
to accumulate in the lungs. You were treated with diuretics and
improved over the course of your hospitalization. You were
treated with antibiotics and Quinine which were completed before
discharge. Your liver tests were still mildly elevated at the
time of discharge and you should have these checked again in [**4-28**]
weeks.
You were not discharged on any medications. You should
follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44082**] next week as detailed below.
You should follow-up with the Infecious Disease clinic in 1
month. You should have your blood drawn on Friday, [**2193-9-20**],
Wednesday, [**2193-9-25**] and Wednesday [**2193-10-16**].
You should seek immediate medical attention for any persistent
fevers > 101 Farenheit, headaches, vomitting, chills, night
sweats, diarrhea, shortness of breath, yellowing of the skin,
darkening urine, abdominal pain, or other symptoms that concern
you.
Followup Instructions:
Dr. [**Last Name (STitle) 44082**] [**Name (STitle) 25203**]Health Services [**2193-9-27**] at 10:40am.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2193-10-14**] 10:00
Please have your blood drawn for parasite counts on [**2193-9-20**],
[**2193-9-25**] and [**2193-10-16**].
|
[
"790.4",
"790.92",
"584.9",
"785.0",
"518.82",
"283.9",
"564.00",
"287.5",
"084.4",
"514",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13395, 13401
|
5599, 13233
|
345, 352
|
13472, 13508
|
3292, 5576
|
14634, 15002
|
2646, 2663
|
13288, 13372
|
13422, 13451
|
13259, 13265
|
13532, 14611
|
2678, 3273
|
276, 307
|
380, 2145
|
2167, 2183
|
2199, 2614
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,727
| 123,143
|
10764
|
Discharge summary
|
report
|
Admission Date: [**2173-11-8**] Discharge Date: [**2173-11-16**]
Date of Birth: [**2095-6-5**] Sex: M
Service:
DIAGNOSIS:
1. Febrile neutropenia.
2. Hypotension.
3. AML and CLL. - BICLONAL
HISTORY OF PRESENT ILLNESS: This is a 78 year old man with a
history of AML and CLL who has been treated with supportive
care and now presents with febrile neutropenia, unclear
etiology, with abrasion on his right arm, right hand and a
cut. He developed bacteremia and was sent to Intensive Care
Unit secondary to hypotension, which did not require pressors
and resolved with fluids. He was then transferred to the BMT
Service for further care and that is how he was admitted.
His vital signs were stable when admitted to BMT Service.
Vital signs when admitted, afebrile, normotensive, saturating
well on room air.
PAST MEDICAL HISTORY:
1. AML, CLL in bone marrow diagnosed in 09/[**2172**]. Getting
supportive treatment for both.
2. Hypertension.
3. Bilateral cataract repair surgery.
ALLERGIES: Penicillin which causes rash.
MEDICATIONS AS OUTPATIENT:
1. Prednisone 40 q. day.
2. Prilosec q. day.
3. Multivitamin q. day.
He denies any over-the-counter medications or any herbal
medications.
SOCIAL HISTORY: Retired engineer; lives with wife. [**Name (NI) **]
tobacco history, no intravenous drug history. Rare ethanol
use.
PHYSICAL EXAMINATION: On examination, the patient was in no
acute distress. Pupils equally round and reactive to light
and accommodation. Extraocular movements are intact. Neck
supple, no bruits, no jugular venous distention.
Cardiovascular is regular rate and rhythm, II/VI systolic
ejection murmur at apex; no rubs, no gallops. Chest was
clear to auscultation bilaterally. Abdomen soft, nontender,
nondistended. Extremities with no cyanosis, clubbing or
edema. Neurologically alert and oriented. Cranial nerves II
through XII intact. No focal deficits.
LABORATORY: On day of admission, white blood cell count 2.7,
with a differential of 3% neutrophils, 84% lymphocytes, zero
percent monocytes, zero eosinophils, one band, and 11 blasts.
Hematocrit 30.2, platelets 12, sodium 129, potassium 4.0,
chloride 94, bicarbonate 23, BUN 26, creatinine 1.2, glucose
123, lactate 2.7. Negative urinalysis.
When transferred from the Surgical Intensive Care Unit to
Bone Marrow Transplant, his labs were white blood cell count
of 2.0.
HOSPITAL COURSE: When transferred from Intensive Care Unit
he was improved. His hypotension had resolved. Pertinent
positives on the examination were right sided fourth
metacarpal abrasion, positive for erythema. There was no
fluctuants. His hypotension had resolved when transferred to
Bone Marrow Transplant.
While in the Unit, he was found to have bacteremia which was
later on found to be a group B strep G which was treated
since he has been there in the unit with Cefepime and
Vancomycin. The patient did well and follow-up results were
all negative.
The patient was then transferred to Bone Marrow Transplant
but he was continued on the Cefepime and Vancomycin until the
day before his discharge at which time he was switched from
Vancomycin and cefepime to ceftriaxone for the remainder of
six days to complete a fourteen day course.
The patient was also given stress dosed steroids in the unit
and he was continued with that when he was transferred to the
Bone Marrow Transplant, but after a couple of days, he was
then switched to Prednisone 20 q. day. He had done well
while on that regimen.
On the day of discharge he was sent home with Fluconazole and
Bacitracin Ointment to be applied to his right hand. Also,
he had cefepime and Vancomycin discontinued. He was
continued on ceftriaxone intravenously. His labs on the day
of discharge were white blood cell count up to 2.9, and
stable. Hematocrit was stable at 29.7, platelets 38 and
stable. Sodium was 133, potassium 3.8, bicarbonate 30,
calcium 7.8, phosphorus 3.0, magnesium 2.2, INR 1.0, glucose
109, BUN 22 and creatinine of 0.8. ALT 17, AST 8, alkaline
phosphatase 52, total bilirubin 0.6.
The patient was discharged to home with services.
DISCHARGE INSTRUCTIONS:
1. The patient was instructed to follow-up with N.P. and Dr.
[**Last Name (STitle) **] late this week on Thursday, [**11-18**], at 12:30 at the
[**Hospital 23**] Clinic.
2. The patient was instructed to continue medications as
prescribed below and by primary clinician.
3. The patient was instructed to eat cooked foods only and
the only fruits that were allowed were those that were
peeled.
4. To follow neutropenic precautions.
DISCHARGE DIAGNOSES:
1. AML, CLL.
2. Febrile neutropenia.
There were no major surgical interventions done.
CONDITION AT DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Fluconazole 100 q. day for the next seven days and
discuss continuation with Dr. [**Last Name (STitle) **].
2. Peridex 15 cc twice a day, gargle.
3. Prednisone 10 mg q. day; discuss continuation with Dr.
[**Last Name (STitle) **].
4. Ceftriaxone 2 grams q. day for the next six days and then
will stop.
5. Protonix 40 q. day.
6. Multivitamin q. day.
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], M.D. [**MD Number(1) 7775**]
Dictated By:[**Name8 (MD) 6112**]
MEDQUIST36
D: [**2173-11-17**] 14:43
T: [**2173-11-17**] 17:35
JOB#: [**Job Number 35195**]
|
[
"276.5",
"458.9",
"205.00",
"038.0",
"288.0",
"205.10",
"287.5",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4606, 4706
|
4752, 5384
|
2415, 4126
|
4150, 4585
|
1379, 2396
|
4722, 4729
|
238, 829
|
851, 1220
|
1237, 1356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,186
| 117,900
|
47878
|
Discharge summary
|
report
|
Admission Date: [**2160-6-10**] Discharge Date: [**2160-6-21**]
Date of Birth: [**2097-8-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Leaking from old G tube site
Major Surgical or Invasive Procedure:
[**2160-6-11**] Gastrostomy takedown
[**2160-6-17**] Incision opened and wound vac applied
History of Present Illness:
Mr. [**Known lastname **] is a 62 year old gentleman well known to the
transplant surgery service. In brief, he is s/p renal transplant
in [**2137**] for post-streptococcal glomerulonephritis. This failed
after several years and he underwent transplant nephrectomy in
[**2143**]. He was recently admitted in [**3-/2160**] for
increased drainage and irritation from his G tube(originally
placed in [**2156**] as
part of a re-do ex. lap for mesenteric ischemia following
subtotal colectomy
for pneumatosis intestinalis). During his latest admission, his
G tube was
removed and his overlying cellulitis was treated with IV
antibiotics and
thought to be secondary to gastrocutaneous fistula. He has since
had increased
output from his former G tube site, and is here today for
preoperative
anticoagulation management prior to his gastrostomy takedown.
Past Medical History:
(Per record & patient)
ESRD on HD (secondary to post-streptococcal
glomerulonephritis, Renal transplant '[**37**] failed, transplant
nephrectomy in [**2143**]), Hyperparathyroidism, Hypertension, Atrial
fibrillation (started on warfarin [**Date range (1) 101024**]), CAD, Diastolic CHF
with remote history of systolic CHF [**Date range (1) 8974**], Endocarditis w/ Aortic
and Mitral valve involvement, Repeated episodes of pneumonia,
VRE
septic arthritis, L wrist [**Date range (1) 8974**] infective arthritis, Right hip
fracture s/p Right hip hemiarthroplasty, [**2157-1-11**], Right
Prosthetic Hip infection s/p explantation [**2-18**], Ischemic
colitis/ileitis s/p subtotal colectomy and terminal ileal
resection, followed by ileocolonic anastomosis with diverting
loop ileostomy and gastrostomy tube placement [**2156**]
.
PAST SURGICAL HISTORY: (Per record or patient)
[**2158-11-7**]: Aortic valve replacement(21 mm ON-X, Mitral valve
replacement 25/33 On-X Conform-X mechanical valve)
[**2158-10-5**]: Right heart catheterization
[**2158-10-3**]: Paracentesis
[**2158-7-13**]: Fistulogram, 6-mm balloon angioplasty of
juxta-anastomotic segment
[**2157-6-16**]: Washout and drainage right hip wound infection.
[**2157-6-14**]: Revision left radiocephalic arteriovenous fistula,
endarterectomy radial artery.
[**2157-2-22**]: Evacuation drainage of right hip deep hematoma-abscess.
[**2157-2-18**]: Removal right hip hemiarthroplasty.
[**2157-2-3**]: Irrigation, debridement and evacuation of hematoma of
right septic hemiarthroplasty.
[**2157-1-26**]: Right hip revision of hemi arthroplasty due to
dislocation.
[**2157-1-15**]: Exploratory laparotomy, gastrostomy tube, ileocolonic
anastomosis and diverting loop ileostomy.
[**2157-1-14**]: Exploratory laparoscopy, subtotal colectomy.
[**2157-1-13**]: Exploratory laparotomy, Subtotal colectomy, Resection
of terminal ileum, Temporary abdominal closure.
[**2157-1-11**]: Right hip hemiarthroplasty.
[**2156-12-10**]: Left wrist incision and drainage.
[**2156-2-17**]: Right ring finger closed reduction percutaneous pinning
for mallet finger. Left index and long ring finger PIP joint
manipulation under anesthesia.
[**2155-12-16**]: Left carpal tunnel release and left index, long and
ring finger trigger releases
Social History:
SH: H/o ~3 p-y tob, occ etoh.
Family History:
Father with prostate CA.
Physical Exam:
Vitals: 100-110/70, R 14-16, afebrile
Gen: Elderly male
HEENT: pallor present, no icterus, NG tube with biliary drain
Neck: Supple, no LAD
Chest: CTA b/l
CVS: audible mechanical valves, afib,
Abd: Soft, wound vac in place
Ext: no edema
Pertinent Results:
[**2160-6-10**] 01:05PM BLOOD WBC-4.5 RBC-2.99* Hgb-9.3* Hct-30.9*
MCV-103* MCH-31.1 MCHC-30.1* RDW-16.7* Plt Ct-134*
[**2160-6-10**] 01:05PM BLOOD PT-20.7* PTT-36.7* INR(PT)-2.0*
[**2160-6-10**] 01:05PM BLOOD Glucose-105* UreaN-13 Creat-5.6* Na-138
K-4.3 Cl-98 HCO3-29 AnGap-15
[**2160-6-10**] 01:05PM BLOOD ALT-10 AST-22 AlkPhos-155* TotBili-0.3
[**2160-6-10**] 01:05PM BLOOD Albumin-2.8* Calcium-9.5 Phos-4.8* Mg-1.6
[**2160-6-20**] 06:20AM BLOOD PT-59.5* INR(PT)-5.9*
[**2160-6-19**] 06:45AM BLOOD WBC-7.3 RBC-3.09* Hgb-9.2* Hct-31.0*
MCV-101* MCH-29.9 MCHC-29.7* RDW-16.9* Plt Ct-176
[**2160-6-21**] 06:05AM BLOOD PT-49.5* INR(PT)-4.9*
[**2160-6-21**] 06:05AM BLOOD Na-133 K-4.2 Cl-95*
Brief Hospital Course:
62 y/o male with complicated PMH who is admitted for
preoperative anticoagulation management prior to his gastrostomy
takedown. The patient is on warfarin for an existing St Jude
valve. Patient was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
takedown of the gastrocutaneous fistula. Per the operative
report the fistula tract was taken down completely to the
stomach. The surgery was without complication and he was
transferred to the PACU in stable condition.
He had an NG tube in place and was kept strictly NPO through
post op Day 3.
On POD 2 the patient had fever to 101.1, and on subsequent days
he has run a low grade fever. Blood cultures have been sent on
[**4-12**], [**6-16**] and [**6-18**] in response to low grade fevers. They are
no growth to date but have not yet been finalized.
Hemodialysis was continued per routine schedule.
On POD 2, the patient had an episode of hypotension into the
80's and desaturation. He was also having a lot of pain at the
incision site, and as such was transferred to the SICU, where he
was able to receive hemodialysis, and increased monitoring.
Blood pressures improved and with fluid removal, the patient had
improved respiratory status.
He was transfered back out of the ICU the following day, and has
maintained adequate blood pressures thereafter.
Heparin drip was restarted following surgery, and when
appropriate, coumadin was restarted with the heparin bridge. He
was therapeutic on POD 7 and the heparin drip was discontinued.
On POD 5, the incision was opened due to drainage, and on POD 6
the incision was further opened and a wound VAC was placed for
assistance with wound healing.
Ostomy output has remained stable from 300 -700 cc daily. He was
evaluated by the wound consult service who noted some maceration
at the stoma, changed the dressing to better fit stoma. He was
see by physical therapy who determined he would need rehab
services. His pain was well controlled on PO pain medication.
On POD 7, his INR was 5.9 and he received 1 unit of FFP and
coumadin was held. His wound vac changed. At this time a 1 cm
fascial dehiscence was noted over medial aspect of incision. It
appeared amenable to wound vac, so a vac was replaced.
On POD8, [**2160-6-21**], he was discharged to rehab. He was afebrile
with stable vital signs, tolerating a regular diet, and pain was
controlled. He was discharged to [**Hospital **] Healthcare center and
will resume his regular [**Hospital 2286**] schedule.
Medications on Admission:
warfarin 5.5mg daily, aspirin 81 daily,
Digoxin 0.125mg 2x/wk (Tues &Thurs), pantoprazole 40 [**Hospital1 **],
Sensipar 20mg (3-4 times/week), Renvala 2.4g q day, oxycodone
unknown dose but patient states he usually takes 3 tabs per day,
lisinopril unknown dose, cipro daily (dose unkmown to patient)
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUTHUR
(TU,TH).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for spasms.
8. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day:
Start on [**2160-6-22**].
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Gastrocutaneous fistula s/p gastrostomy takedown
Non-healing abdominal incision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You will be transferring to [**Hospital **] [**Hospital **] Rehab
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
temperature of 101 or greater, shaking chills, nausea, vomiting,
increased abdominal distension/pain, ostomy output decreases or
stops, incision redness/bleeding/drainge,
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Blood draw Monday [**6-23**] for inr/Coumadin management
Hemodialysis to continue every Monday-Wed-Friday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2160-6-26**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2160-7-3**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2160-8-18**]
9:00
Completed by:[**2160-6-21**]
|
[
"V45.73",
"V55.2",
"428.0",
"998.83",
"998.31",
"414.01",
"V15.51",
"305.1",
"V45.11",
"458.29",
"585.6",
"996.80",
"588.81",
"799.02",
"E878.4",
"V43.3",
"790.92",
"V45.72",
"V02.53",
"537.4",
"428.32",
"723.0",
"V88.21",
"403.91",
"E934.2",
"427.31",
"580.0",
"557.9",
"V55.1",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.63",
"39.95",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
8374, 8457
|
4686, 7199
|
331, 424
|
8581, 8581
|
3971, 4663
|
9318, 9794
|
3672, 3698
|
7551, 8351
|
8478, 8560
|
7225, 7528
|
8757, 9295
|
2179, 3608
|
3713, 3952
|
263, 293
|
452, 1302
|
8596, 8733
|
1324, 2154
|
3624, 3656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,752
| 115,932
|
8119
|
Discharge summary
|
report
|
Admission Date: [**2198-4-29**] Discharge Date: [**2198-5-3**]
Date of Birth: [**2143-9-10**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin Hcl / Rocephin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
flank pain, fever
Major Surgical or Invasive Procedure:
A-line placement
changing of R mid-line over guidewire
History of Present Illness:
This is a morbidly obese 54 female w/DM1 complicated by
retinopathy, neuropathy and nephropathy s/p cadaveric kidney
transplant in [**2193**] on immunosuppression who p/w fever and flank
pain to OSH ([**Hospital3 **]), now being transferred here with
sepsis on pressor.
.
Pt initially presente on [**4-27**] to OSH with fevers up to 102.6,
b/l flank pain and difficulty urinating. Stable BP, RR of 26 on
admission. Her skin revealed a reddened area over her right
breast as well as an oozing opening over her morbidly obese
abdomen. Lactate was 4.8 on admission to the ICU for IVF
resuscitation. CT abdomen/pelvis showed inflammation over the
lower anterior abdominal wall.
.
Pt was initially started empirically on ceftazidime and
levofloxacin (allergic to Vanco and CTX), then switched to
penicillin and kept on levofloxacin after culture data came
back; urine culture was positive for proteus (nearly
pan-sensitive per verbal signout from OSH) and Bcx came back
positive for beta-hemolytic strep B (sensitive to penicillin).
She was later found to be in septic shock requiring
Neosynephrine drip. She was also started on stress dose steroids
(hydrocortisone), but switched to prednisone on transfer. Her BP
was 90/41 on tapering doses of Neo on transfer. She wa initially
somewhat obtunded but responded appropriately to questions after
initial resuscitation.
.
Her respiratory status remained stable with 93% on 2-3L NC. BNP
was 143. CXR was unremarkable. Latest ABG on day of transfer was
7.30/37/62. Lactate came down to 1.5. WBC was 23.3 with 48%
bands on transfer. Hct was 27.3. There were no signs of bleeding
but pt has h/o GIB. Patient received 1U pRBC on day of transfer
with Hct coming up to 30.6. R triple PICC is in place after
unsuccessful TLC attempt. Last BUN/Cr of 50/1.5. I/Os: 3610 in
and 500 out + additional 700 out on day of transfer. BGs in 200s
on ISS and standing insulin.
.
On arrival to ICU, pt is still on Neo, mentating well, without
pain, fever or SOB.
.
ROS: Denies any CP, abdominal pain, F/C/N, SOB.
Past Medical History:
1. Type 1 Diabetes mellitus c/b nephropathy, s/p cadaveric
renal transplant [**2193**]
2. Diabetic neuropathy.
3. Diabetic retinopathy, legally blind.
4. Hypertension.
5. Cervical cancer status post radiation.
6. Depression.
7. Status post appendectomy.
8. Status post cholecystectomy.
9. Constipation.
10. Right upper extremity AV fistula.
11. Right axillary vein thrombosis [**2193**] w/ SVC sydrome
12. wound seroma and infection which progressed to septic shock
and respiratory arrest requiring intubation [**12-19**].
13. s/p nephrostomy tube placement and capping [**2-19**]
14. morbid obesity walks with walker
15. obstructive sleep apnea, uses BiPAP at night
16. colitis proctitis with lower GI bleeding
Social History:
Lives with her husband, has 2 kids both married and out of the
house. Formerly worked with Alzheimer's patients now on
disability. Uses a walker to get around, unable to use the
stairs in her house. Denies alcohol, illicits, IVDU. Quit
smoking 5 years ago had smoked 1ppdx15 yrs prior.
Family History:
+for DM, neg for cancer, neg for heart disease or clot disorder
Physical Exam:
Vitals: T: 97.2 BP: 70/27 -> 123/76 HR: 97 RR: 19 O2Sat: 98% on
2L NC
GEN: Morbidly obese female in NAD, responding to all questions
HEENT: EOMI, cornea b/l scarred, no epistaxis or rhinorrhea,
very dry MM, OP Clear
NECK: JVD unable to assess to due obese neck
COR: RRR, no M/G/R, normal S1 S2
PULM: Lungs CTAB anteriorly, no W/R/R
ABD: Soft, NT, ND, sparse BS
EXT: No C/C/trace LE edema, palpable pulses
NEURO: alert, oriented to person, place, and time. Responds
appropriately to all questions. Strength 5/5 in upper and lower
extremities.
SKIN: Erythema below both breasts and in both groins. No
jaundice or cyanosis. RUE fistula and R PICC in place.
Pertinent Results:
OSH labs:
WBC 25 (18% bands). Hct 29.3. Plt 168.
Na 136, K 4.6, Cl 108, CO2 21, BUN 53, Cr 1.6. Glc 229.
.
Micro data from OSH:
Bcx [**4-29**]: NGTD
Wound cx (abdomen) [**4-28**]: preliminary growth with proteus,
enterococcus, GNR, beta hemolytic strep B
UCx [**4-27**]: Proteus mirabilis, pan-sensitive except for
Ampicillin, Cephalothin, Gent, Nitrofurantoin, Tetracycline and
Tobramycin.
Bcx [**4-27**] (4/4 bottles): Beta hemolytic Strep B in anearobic and
aerobic bottles.
.
Imaging:
CXR at OSH: no acute process
.
CT abdomen/pelvis at OSH on [**4-27**]:
Severely limited study. Small shrunken kidneys b/l. Transplanted
kidney on right without gross hydro.
.
Echocardiogram on [**2197-12-12**]:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2194-1-14**],
there is no definite change.
Renal u/s on admission: Very limited study due to patient's body
habitus and clinical condition. The transplanted kidney is not
clearly visualized..
TTE: IMPRESSION: Extremely difficult windows, cannot assess
ventricular function or valvular abnormalities. A TEE is
indicated if clinically suggested
TEE: unable to perform as patient's soft tissue around neck will
not support the level of sedation necessary for study without
intubation for airway maintenance.
Brief Hospital Course:
54 female w/DM1 complicated by retinopathy, neuropathy and
nephropathy s/p cadaveric kidney transplant in [**2193**] on
immunosuppression who p/w fever and flank pain to OSH ([**Hospital 28941**]), was transferred here with sepsis on pressor which could
be weaned off the same night.
.
# Mental status: The patient was quite drowsy on various
occasions likely due to a combination of her severe infections,
hypercarbia when she refused her nocturnal bipap, and renal
function. The day prior to discharge she returned to her
baseline mental status, and remained responsive to questions and
oriented x 3, although somewhat drowsy.
# septic shock: The patient was started on neosynephrine for
blood pressure support at the outside hospital, however on
arrival to our MICU, seh received several liters of fluid and
arterial line was placed which showed stable blood pressures.
She was found to have three infectious sources for her sepsis:
1. Beta hemolytic group A streptococcus bacteremia: The patient
was followed by the infectious disease team. No clear source was
found, however she may have some abdominal cellulitis in her
pannus which may be the source for this. She was started on
Penicillin G IV and dose was adjusted as her renal function
improved. We attempted TTE and TEE to rule out endocarditis,
however TTE was not able to visualize her valves due to habitus
and TEE could not be performed due to inability to protect her
airway if sedated given her habitus. She will therefore be kept
on Penicillin G 4 million units IV q 4 hours for a total of 4
weeks of therapy. Day 1 is [**2198-4-29**]. After this course is
completed her R midline should be removed.
2. Proteus UTI: Teh patient had a urine infection with proteus
which was sensitive to ciprofloxacin and she was started on
ciprofloxacin therapy 400mg IV BID for a total of 14 days. Day
one was [**4-29**].
3. Coagulase negative staphalococcus bacteremia: The patient had
[**2-19**] blood cultures which returend positive for CNS. Due to
vancomycin allergy she was started on linezolid 600mg IV q24
hours and should remain on this for 2 weeks. Day 1 was [**5-1**]. The
likely source for this was believed to be her R PICC line. On
the day of discharge, this line was pulled and replaced over a
wire with a new R midline. This is not ideal given the
infectious site, however after repeated failed attempts at
central venous access, and inability to place PICC line in her
left arm given this is [**Month/Year (2) **] only site for accurate blood pressure
measurements, the best scenario was to remove the suspected
infected PICC from the R arm and change over a wire for a new
midline. This line should be used to give IV antibiotics. Her
linezolid is used for a 2 week course to cover the line itself
as a likely infectious source. After two weeks of linezolid is
complete, the patient will still have 2 weeks left of her PCN G,
and thus will have the line in place. Thus, surveillance blood
cultures should be drawn three times per week after linezolid is
stopped until the R midline is pulled.
In total, the patient is on penicillin G 4 million units IV
q4hours for total of 4 weeks (day 1 [**4-29**]), ciprofloxacin 400mg
IV bid for total of 2 weeks with day 1 [**4-29**], and linezolid 600mg
IV q24hours for 2 weeks with day 1 being [**5-1**]. After linezolid
is finished blood cultures should be drawn three times per week
for surveillance while line is in place. midline should be
pulled after the final day of PCN G.
# respiratory distress: The patient has known sleep apnea nad
uses oxygen intermittently at night. She remained on 2 L NC
throughout her stay. She also uses bipap at night at setting of
14/6 and should continue to do so.
# Acute renal failure: this was likely prerenal in etiology and
in the setting of sepsis. She received kayexelate three times
for potassium elevation to the mid-5s. Her creatinine level
returned to her usual baseline level of 1.1 on the day of
discharge. She was followed by the renal transplant team while
here. She continued on her dose of cellcept and prednisone. Her
tacrolimus dose was decreased to 3 mg po bid due to elevated
tacro level of [**8-25**], and levels were checked daily for goal FK506
level of about 5. Please continue to follow FK 506 levels at
trough three times per week for goal level of 5. The patient's
renal transplant attending Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is available for
questions.
# hematuria: this has been a problem for [**Name2 (NI) **] patient in [**Name2 (NI) **] past
and she has been seen by urology for this. On the day of
discharge she began having blood in her foley catheter. This was
chagned to a three way catheter and continues bladder irrigation
was begun. After several hours, she began to have much more
clear urine from her foley. Please continue CBI only until she
is clear, and at that time foley may be removed or changed to a
smaller (single lumen) catheter. The patient should follow up
with her prior [**Name2 (NI) **] for evaluation.
# diastolic CHF: The patient has history of diastolic CHF with
EF of 50%. As she was relatively hypotensive during her stay,
and required fluids on arrival, we held her ACE inhibitor and
her lasix. Fluid status and blood pressure should be monitored
as an outpatient with an eye to restarting these meds at her
prior doses. She continues on ASA 81mg po qday for primary
prevention of heart disease.
# anemia: the patient has a baseline hematocrit of 30. On
arrival she received one unit of PRBCs for Hct of 27. Thereafter
her hct was stable and was followed daily.
# diabetes mellitus: The patient was initially put on half of
her home dose of lantus (home dose is 52 units qhs), however due
to high finger sticks this was rapidly titrated up. On the day
of discahrge she was to receive 50 units of glargine at hs. This
may be uptitrated as warranted by finger sticks in rehab. She
should also continue with regular insulin slide scale per
protocol.
# Neuro/Psych: we continued her outpatient doses of gabapentin
and citalopram. These should continue as an outpatient as well.
# nausea: the patinet was treated with prn zofran and Reglan for
her intermittent nauea. In general, Reglan seemed to work better
for her.
# chronic pain: the patient was treated with prn PO percocet for
her chronic back pain.
# abdominal wall cellulitis: wound care was continued to her
panus as there was erythema there possibly representing [**Name2 (NI) **]
source of her group A strep. She was continued on penicillin as
above.
# general care: note that the patient's blood pressure can be
gotten with an extra large cuff on her Left arm only. Although
this is eomwhat difficult to read, we did get accurate reads
which coincided with her arterial line. Note taht her forearms,
and both legs did not produce accurate BP reads (she appeared
hypotensive when she was not).
# Access: Access was a difficult issue for this patient. Despite
her R AV fistula, R triple lumen PICC was placed at OSH on [**4-27**]
after unsuccessful CVL placement at OSH. After many attempts at
a Left subclavian line which were unsuccessful, we decided to
have her R PICC replaced over a guidewire to a R midlin, which
is in place at present. This line was placed on the day of
discharge and should be ckept in place only until her 4 week
antibiotic course is finished. After that, please d/c her
midline access as it is a possible infectious source. A-line
placed on [**4-29**] on arrival to ICU to monitor blood pressures was
pulled several days later.
.
# PPx: she was given protonix and subcutaneous heparin
throughout her stay in the ICU.
.
# Code: Full code
.
# Communication: patient; husband [**Name (NI) **] [**Name (NI) 28942**] [**Telephone/Fax (1) 28943**]
Medications on Admission:
Home Medications per patient:
#. Prednisone 5mg daily
#. Ativan 1mg q8H PRN
#. Pantoprazole 40mg daily
#. Mycophenolate Mofetil 500mg [**Hospital1 **]
#. Lisinopril 2.5mg daily
#. Citalopram 20mg daily
#. Acetaminophen 500mg q6H PRN pain or fever
#. Insulin Glargine 52 Units qHS
#. Gabapentin 300mg TID
#. Insulin Regular sliding scale
#. Furosemide 40mg daily
#. Oxycodone 5 mg q4H PRN
#. Tacrolimus 4mg q12H
#. ASA 81 daily
.
Medications on transfer:
- Neosynephrine drip at 0.8
- Nexium 40 IV daily
- Cellcept [**Pager number **] [**Hospital1 **]
- Tacrolimus 4 [**Hospital1 **]
- Neurontin 300 [**Hospital1 **]
- Prednisone 10 PO daily [Hydrocortisone 50 IV q8h (started Fri,
stopped Sat)]
- RISS
- Levemir Insulin 18U qHS
- Levaquin 750 q48h (d1 = [**4-27**])
- Penicillin 4 [**Last Name (un) **] IV q6h (d1= [**4-28**])
- Atrovent 0.5 q5h
- Miconazole [**Hospital1 **] to groin
PRN Meds:
- Reglan
- Zofran
- Tylneol
- Percocet
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection Q8H (every 8 hours).
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed: apply to abdomen, pannus folds.
9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
10. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q12H (every 12 hours) for 10 days:
total fo 14 days, day 1 was [**4-29**].
11. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
13. Metoclopramide 10 mg Tablet Sig: Ten (10) mg PO QID (4 times
a day) as needed.
14. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4
million units Injection Q4H (every 4 hours) for 4 weeks: total
of 4 weeks, day 1 was [**4-29**].
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
17. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous Q12H (every 12 hours) for 2 weeks: total of
14 days, day 1 was [**5-1**].
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ML of NS followed
by 2ML of heparin solution daily and prn to each lumen of
midline.
19. Outpatient Lab Work
please check surveillance blood cultures three times per week
after linezolid is discontinued but while patient still has line
in place. (weeks [**3-20**])
20. insulin
50 units of glargine qhs.
check FS qid and treat with standard regular ISS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
group A streptococcus bacteremia with sepsis
pseudomonas UTI
coag negative staph bacteremia
acute renal failure
confusion
respiratory distress
nausea
Discharge Condition:
blood pressure stable, afebrile, renal function back to normal
with Cr 1.1. Oriented and alert.
Discharge Instructions:
Please be sure to give all meds as directed.
Pt is to continue penicillin G 4 million units q4 hours IV for
total of 4 weeks (day 1: was [**4-29**]). Please pull R midline as
soon as this is completed. Ciprofloxacin 400mg [**Hospital1 **] IV q12 hours
for total of 2 weeks (day 1: [**4-29**]). Linezolid 600mg IV q24hrs
for total of 2 weeks. (day 1: [**5-1**]). **After linezolid finishes,
patient will have midline in for two more weeks to complete PCN.
Please check surveillance blood cultures three times per week
for those two weeks. Please run all antibiotics through her
midline. Pull midline as soon as penicillin G course is
finished.
Please check BP only in her left upper arm, as this is [**Month/Year (2) **] only
accurate measurement for her.
Please continued wound care to abdominal cellulitis.
Please continue continuous bladder irrigation until clears, then
may change foley catheter to single lumen, or pull foley
catheter.
Please check FK 506 (tacrolimus) levels three times per week for
goal level at trough of 5. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] if
needed for assistance.
Please follow up with your renal transplant physician, [**Name10 (NameIs) **]
and primary care physician within the next 2 weeks.
If you have fever, hypotension, or other concerning symptoms
please call your primary care physician or come to the emergency
room.
Followup Instructions:
Please follow up with your renal transplant physician, [**Name10 (NameIs) **]
and primary care physician within the next 2 weeks.
Completed by:[**2198-5-3**]
|
[
"250.40",
"250.50",
"682.2",
"038.0",
"285.9",
"785.52",
"995.92",
"583.81",
"787.02",
"584.9",
"599.0",
"362.01",
"041.19",
"599.7",
"250.60",
"428.32",
"357.2",
"V10.41",
"293.0",
"518.82",
"V42.0",
"327.23",
"041.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
17299, 17399
|
6274, 6562
|
303, 359
|
17593, 17691
|
4245, 5796
|
19149, 19309
|
3489, 3555
|
15071, 17276
|
17420, 17572
|
14098, 14541
|
17715, 19126
|
3570, 4226
|
246, 265
|
387, 2424
|
5810, 6251
|
6577, 14072
|
14566, 15048
|
2446, 3169
|
3185, 3473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
175
| 176,764
|
54122
|
Discharge summary
|
report
|
Admission Date: [**2184-1-21**] Discharge Date: [**2184-1-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Lethargy, hypoxia.
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
The pt. is a [**Age over 90 **] year-old gentleman with multiple medical
problems, recently discharged from [**Hospital1 18**] after a hospital stay
for CHF exacerbation and aspiration pneumonia, who presented
from rehab with increasing lethargy. Pt. was noted to be
"obtunded" at rehab facility on day of admission and ABG was
performed which was consistent with hypercarbic and hypoxemic
respiratory failure (7.25/96/26). Intubation was attempted at
rehab without success. Pt. was also noted to be hypothermic
(T=94F) and was given 1 gram of IV vancomycin and 1 gram of IV
unasyn prior to transfer to the [**Hospital1 18**] ED. He was also given
100mg of IV lasix before transfer.
In the ED, the pt. was noted to be tachypneic with respiratory
rate in the upper 20's and ABG on presentation was 7.31/87/130.
He was intubated and placed on mechanical ventilation shortly
after presentation. He received a dose of levofloxacin and
metronidazole for presumed aspiration pneumonia. He was also
given a total of 2 liters of IV fluid and 40mg of IV lasix to
which he put out approximately 800 cc of urine.
According to the pt's. daughter, the pt. had been increasingly
confused and lethargic for three to four days PTA. She also
noted that his lasix dose had been recently reduced as it was
felt that the pt. was "dry."
Upon presentation to the MICU, the pt. was intubated and
sedated.
Past Medical History:
-CAD s/p CABG x1 venous ([**2165**])
-PVD w/ RLE bypass
-HTN
-chronic afib s/p pacemaker
-AVR (porcine [**2165**])
-AAA (7cm), awaiting repair
-diastolic CHF; TTE ([**11-2**] at OSH) EF 55%, LAE, severe LVH,
global HK esp. RV, MR, TR, severe pulmonary HTN
-anemia of chronic inflammation
-h/o aspiration pneumonia
-S/P PEG placement, [**12-3**]
-chronic subdural hematomas vs subdural hygromas of
undeterminate age.
-gastritis
-Type III odontoid fx
-cholelithiasis w/ hyperbilirubinemia
-small septated cyst and granuloma in left liver lobe
-cataracts
Meds:
-toprol XL 75mg po daily
-lasix 60mg po daily
-isordil 10mg po bid
-heparin 5000units sc tid
-lisinopril 10mg po daily
-ASA 325mg po daily
-digoxin 125mcg po daily
-pantoprazole 40mg po daily
-pramipexole 0.125mg po daily
-docusate 100mg po bid
-acetaminophen prn
-albuterol prn
-loperamide prn
-senna prn
Social History:
The pt. is a resident of [**Hospital3 **]. He is married. No
use of tobacco or alcohol.
Family History:
Father (died of MI [**Age over 90 **]yo)
Mother unknown
Physical Exam:
Vitals: T: 100.3F P: 84 R: 15 BP: 145/61 SaO2: 97% on 70% FIO2
Vent: Mode: AC Vt: 500 RR: 16 PEEP: 5 FiO2: 0.7
General: elderly, cachectic male, intubated and sedated
HEENT: PERRL, EOMI, MMdry, ETT in place
Neck: C-collar in place
Pulmonary: coarse breath sounds bilaterally
Cardiac: RRR, S1S2, V/VI (+parasternal heave) HSM at LSB to
axilla
Abdomen: soft, NT/ND, hypoactive bowel sounds, no masses noted,
PEG tube insertion site without erythema or drainage
Extremities: warm, trace LE pitting edema bilaterally, 1+ DP
pulses bilaterally
Neurologic: Sedated, moving all extremities. Normal tone in all
extremities. 1+ biceps and patellar DTRs bilaterally. Mute
plantar response bilaterally.
Skin: No rashes noted. Right heel ulcer noted with scant
serosanguinous drainage.
Pertinent Results:
Labs on Admission:
EKG: NSR at 66bpm, LAD, LBBB, no ST-T changes noted
CXR: bilateral pleural effusions, marked cardiomegaly, perihilar
haziness, apparent worsening of CHF in interval since [**12-3**]
Brief Hospital Course:
1. Respiratory failure: Multifactorial and due to CHF
exacerbation with possible aspiration event. ABG on admission
c/w compensated chronic respiratory acidosis, improved with
ventilatory support.
2. Hypotension: Differential includes sepsis vs. cardiogenic
shock. The patient was maintained on pressors during his stay in
the [**Hospital Unit Name 153**].
3. Axis (C2) fx.: maintain hard collar at all times, pt. has f/u
with orthopaedics in early [**Month (only) 404**].
4. CAD: continue ASA
5. Comm: Daughter [**Name (NI) 2155**] [**Telephone/Fax (1) 110927**], son Dr. [**Known lastname 8993**]
(internist, pg. [**Telephone/Fax (1) 110930**])
6. Care plan: The paitne was clearly in pain and without a good
prognosis given his aspiration risk and his C2 fracture. The
family relied on the primary team and the ethics consult service
for guidance in planning for Mr. [**Known lastname 110931**] care. In addition, Mr.
[**Known lastname 8993**] had expressed to his wife the desire to not have his life
prolonged by "machines". He was made CMO on [**2184-1-30**] and placed
on a T-piece while still intubated. The patient passed away at
10:30 [**2184-1-31**]. Post-mortum was declined.
Medications on Admission:
-toprol XL 75mg po daily
-lasix 60mg po daily
-isordil 10mg po bid
-heparin 5000units sc tid
-lisinopril 10mg po daily
-ASA 325mg po daily
-digoxin 125mcg po daily
-pantoprazole 40mg po daily
-pramipexole 0.125mg po daily
-docusate 100mg po bid
-acetaminophen prn
-albuterol prn
-loperamide prn
-senna prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Congestive heart failure
Discharge Condition:
expired
|
[
"518.81",
"V54.17",
"427.31",
"507.0",
"V45.81",
"428.31",
"273.8",
"V42.2",
"707.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"38.93",
"96.72",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
5365, 5374
|
3813, 5008
|
279, 291
|
5442, 5452
|
3586, 3591
|
2719, 2777
|
5395, 5421
|
5034, 5342
|
2792, 3567
|
221, 241
|
319, 1707
|
3606, 3790
|
1729, 2596
|
2612, 2703
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,577
| 179,387
|
52797
|
Discharge summary
|
report
|
Admission Date: [**2129-5-16**] Discharge Date: [**2129-6-3**]
Date of Birth: [**2052-12-16**] Sex: F
Service: MEDICINE
Allergies:
Diflucan
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
mental status changes, fever and poor po intake at home
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Mrs. [**Known lastname 9480**] is a 76 yo AA female with PMH significant for IgD
multiple myeloma diagnosed [**3-/2129**] (presented with a creatinine
of 6.8 and a calcium of 12.5), s/p plasmapheresis x 5 and pulse
steroids, also h/o parafalcine intracranial hemorrhage/seizure
who is now presents with a 4 day hsitory of generalized
weakness, fatigue, and poor po intake at home. The patient is a
poor historian and history is obtained primarily from her
husband.
Per patient's family, she had an appointment and was seen in
Heme/[**Hospital **] clinic on [**2129-5-12**]. She was in her usual state of health
until [**2129-5-13**] when she started complaining of diffuse pain not
localizing to any particular place in her body. No nausea,
vomiting, chest pain or SOB. No cough. Over the next few days
she has become progressively more confused from already poor
baseline. Family reports minimal po intake. Patient has had no
BM over the last 2-3 days. In the ED patient febrile 101.5, HR
80, BP 117/74. She was given Tylenol 650 mg daily and treated
with Kayexalate for hyperkalemia (K 5.8, Cr 3.4 up from 2.9 on
[**3-14**]). The [**Last Name (un) **]
ROS negative for melena, hematochezia, urinary complaints.
Patient at baseline has significant problems with short term
memory, ambulates with a walker. Per PCP and her family, this is
a singnificant change in her mental status and baseline.
Past Medical History:
1. IgD multiple myeloma, dignosed [**3-/2129**] when the patient
presented with actue renal failure Cr 6.8 and hypercalcemia
2. Colon CA Duke's C2 s/p resection in [**2111**]; normal C-scope in
[**2125**] except for diverticulosis
3. Thalassemia trait, microcytic anemia
4. HTN
5. Gout
6. Seizure [**2129-4-3**] [**3-2**] right parafalcine parietal hemorrhage.
Etiology for bleed was not clear as location is atypical for HTN
bleeding. There was concern for intracranial mass and the
patient was scheduled for outpatient f/u with neurosurg [**5-16**].
Has been in rehab at [**Hospital1 41724**] hospital until a few weeks prior
to this admission.
7. Polycystic kidney disease and polycystic liver disease
8. Enhancing nodule, 5 mm, within the cyst, upper pole of left
kidney
Social History:
She is married for the last 14 years. Lives with her husband.
She has two living daughters, though she had one daughter who
died because of a CNS aneurysm. Her daughter had polycystic
kidney disease. Mrs. [**Known lastname 9480**] does not smoke tobacco or alcohol
and has never done so significantly in her life. She is a
retired [**Location (un) 86**] public school administrator. She retired in [**2122**].
Family History:
Daughter had CNS aneurysm
Diabetes
Lung CA
Physical Exam:
VITAL SIGNS: 99.4, 142/80, 96, 20, 95% RA
GENERAL: chronically ill appearing female, alert, oriented to
self, place, but not date. Able to choose correct year from
three choices.
HEENT: NC, AT, sclera non-icteric, PERRL, OP clear, no lesions
NECK: Supple, with no JVD, lymphadenopathy or thyromegaly.
PULMONARY: Clear to auscultation bilaterally.
HEART: RRR, nl S1S2, no m/g/r
GI: decreased BS, soft, NT, mildly distended, marked
hepatomegaly
EXTREMITIES: 3+ lower extremity edema.
Neuro/Psych: oriented to self and place only, but selects [**2129**]
from 3 choices, poor attention, + perserverence, able to answer
some questions appropriately but at times does not make sense,
looses train of thought
Pertinent Results:
[**2129-5-16**] 07:50AM WBC-9.9 RBC-4.32 HGB-11.5* HCT-37.0 MCV-86
MCH-26.7* MCHC-31.1 RDW-16.2*
[**2129-5-16**] 07:50AM PLT COUNT-422
[**2129-5-15**] 09:54PM LACTATE-2.1*
[**2129-5-15**] 09:22PM GLUCOSE-125* UREA N-55* CREAT-3.4* SODIUM-142
POTASSIUM-5.8* CHLORIDE-110* TOTAL CO2-19* ANION GAP-19
[**2129-5-15**] 09:22PM ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-310* ALK
PHOS-194* AMYLASE-66 TOT BILI-0.6
[**2129-5-15**] 09:22PM LIPASE-33
[**2129-5-15**] 09:22PM NEUTS-90.7* BANDS-0 LYMPHS-7.0* MONOS-2.2
EOS-0 BASOS-0
IgD level [**5-12**] pending (60 on [**2129-4-18**])
Urinalysis:
[**2129-5-16**] 06:04AM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.015
[**2129-5-16**] 06:04AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2129-5-16**] 06:04AM URINE RBC-36* WBC-38* BACTERIA-NONE YEAST-MANY
EPI-0
NCHCT [**5-16**]: Resolving hemorrhage with area of decreased
attneuation in the right medial parietal lobe. No areas of acute
hemorrhage. No evidence of acute territorial infarction or
hydrocephalus. Unchanged left parafalcine meningioma at cranial
vertex.
KUB (supine) [**5-16**]: No evidence of stool impaction. Soft tissue
masses occupying the upper abdomen displacing bowel inferiorly,
unchanged from previous study.
CXR [**5-16**]: No evidence of pneumonia.
MRI abd [**2129-3-29**]:
1. A 5 mm enhancing nodule within the 7 cm upper pole left renal
cyst, concerning for an intracystic neoplasm.
2. Numerous complex nonenhancing cystic liver lesions and
biliary ductal
dilatation in the left lobe, most likely secondary to
compressive effects of these cysts.
3. Bilateral adrenal adenomas.
4. Small ascites, bibasilar pleural effusions and compressive
atelectasis.
5. Vertebral body changes, which may be consistent with multiple
myeloma.
Brief Hospital Course:
1. C diff colitis. As part of work up for fever, the patient had
CXR on admission w/o infiltrate. WBC WNL. Urine culture did not
grow anything. The patient was empirically on Levaquin very
briefly for presumed UTI but it was discontinued when cultures
showed no growth. The patient then developed diarrhea and her
stool culture return positive for c diff toxin and she was
started on Flagyl po. She had no hisotry of recent outpatient
antibiotic use. She defervesced on Flagyl. Her abdominal exam
remained benign. CT abd/pelvis showed findings thickening of
bowel wall in the transverse, descending, sigmoid, and mildly in
the rectum that are most suggestive of colitis. The patient
diarrhea improved.
2. Multiple myeloma with leptomeningeal involvement. The patient
was noted to have urinary retention, progressive leg weakness
and decreased rectal tone. Leg weakness progressed to the point
that the patient was unable to move her legs or get out of bed.
She had MRI of the lumbar spine to evaluate for cauda equina
which revealed a nodule at L3 that enhanced with gadolinium. LP
was pursued and revealed CSF protein markedly elevated at 166,
glc normal. CSF Tube 1: WBC 58, 4P, 82L, 5M, 9% other; RBC 20.
Cytospin results returned as atypical plasmacytoid cells and
blood; suspicious for involvement by myeloma. The Radiation
Oncology and Neuro Oncology teams were consulted. The patient
also had brain, as well as T- and C- spine MRIs to evaluate for
extend of disease. The patient started radiation treatment on
[**2129-5-27**]. and was thought to be a candidate for intrathecal MTX
and ARA-C until her clinical status began to decline (see
below).
3. Mental status changes. The etiology for the patient's mental
status changes were presumed to be likely multifactorial due to
infection with c diff, dehydration, constipation. Ammonium level
was normal. Because of h/o seizures secondary to intracranial
bleed in [**2129-3-29**], EEG was pursued per suggestion of Neuro
Oncologist and revelaed increased stage II sleep concerning for
early encephalopathy.
Decadron was slowly tapered from 4 mg po daily on admission and
she was continued on Keppra. Then, on [**5-30**] patient became
minimally responsive with bp drop to low 80's sbp with transient
response to fluids. She was transfered to MICU for pressores as
patient was full code. On admission to ICU, etiology of altered
mental status and hypotension was attributed to hypovolemia +/-
?infection in addition to leptomeningeal spread of her disease.
She was placed in stress dose steroids (althoiugh her am
cortisol was 34 and adrenal insifficency was unlikley), levo/
flagly and placed on levophed. Patient found to be growing
pseudomonas in her urine. Patient expressed her desire to be
comfortable and for no agressive measure to be taken.
Eventually family meeting was held and decision to make her dnr/
dni and the CMO pending arrival of her brother from out of town.
She was then transfered back to the floor for comfort care.
3. Hyperkalemia. Likely due to worsened renal fx and
constipation. Improved.
4. Acute on chronic renal failure (Cr 2.9 on [**2129-5-12**] and 3.4 on
admission). likely combination of prerenal from poor po intake
and from nephropathy secondary to MM. The patient was originally
treated with gentle hydration.
5. Anemia. Procrit per Heme/Onc.
6. HTN. The patient has been hypotensive during this admissino.
Norvasc, Metoprolol were held. She was given IVF for BP support
and eventually was transfered to the unit (see section under
altered mental status).
7. Renal lesion seen on MRI [**2129-3-29**] concerning for malignancy
8. Metabolic acidosis - likely secondary to diarrhea, tubular
disease and inability to reabsorb bicarb, large amounts of NS
given for hydration. Metabolic disturbances were corrected with
bicarb as needed.
9. Hypernatermia. Na was as high as 150. This was presumed to be
due to free water deficit from decreased po intake. Serum Na was
slowly corrected with hypotonic IV fluids.
Medications on Admission:
Norvasc 7.5 mg [**2-2**] po daily
Dexamethasone 4 mg po daily
Prevacid 30 mg po daily
KCl 20 MEq daily
Bactrim [**1-30**] tab M, W, F
Bicitra 10 ml [**Hospital1 **]
Keppra 500 mg [**Hospital1 **]
Lopressor 100 mg [**Hospital1 **]
Nystatin 5 ml tid
Epogen 40,000 every two weeks
Fluconazole daily
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*15 Patch 72HR(s)* Refills:*2*
2. Morphine Concentrate 20 mg/mL Solution Sig: [**6-7**] mg PO Q1-2H
() as needed: titrate to comfort.
Disp:*500 mg* Refills:*1*
3. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed.
Disp:*100 Tablet(s)* Refills:*1*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: use while patient is on narcotics.
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Multiple Myeloma
Discharge Condition:
Stable
Discharge Instructions:
Please let you caretaker know if you are in increasing pain or
discomfort
Followup Instructions:
Goal of care is comfort
Completed by:[**2129-6-3**]
|
[
"008.45",
"285.9",
"599.0",
"584.9",
"276.5",
"203.00",
"282.49",
"593.9",
"780.39",
"401.9",
"274.9",
"V10.05",
"753.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10565, 10623
|
5662, 9670
|
323, 341
|
10684, 10692
|
3795, 5639
|
10814, 10868
|
3013, 3058
|
10016, 10542
|
10644, 10663
|
9696, 9993
|
10716, 10791
|
3073, 3776
|
228, 285
|
369, 1771
|
1793, 2569
|
2585, 2997
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,484
| 143,436
|
48753
|
Discharge summary
|
report
|
Admission Date: [**2166-4-12**] Discharge Date: [**2166-4-23**]
Date of Birth: [**2114-8-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Confusion, dizziness
Major Surgical or Invasive Procedure:
Liver biopsy [**2166-4-18**]
History of Present Illness:
51 year-old male with history of newly diagnosed metastatic lung
cancer to liver, bones, and brain via PET imaging, stigmata of
chronic liver disease probably from alcoholism based on history,
presenting with one day history of confusion and dizziness in
addition to worsening LFTs. Patient has not established with
oncology given lack of tissue diagnosis. Patient's labs drawn by
Thoracic Surgery [**2166-4-3**] were as follows: Tbili 10.8, ALP 283,
AST 220, ALT 81, so he was called by primary care NP and asked
to present to the ED.
In the ED, initial vs were: T 97.6 P 104 BP 142/70 R 18 Sat 96%
RA. Patient was noted to be jaundiced. Labs were notable for Na
131, Ca [**69**], Cr 1.6 from baseline of 0.8. LFTs were remarkable
for AST 352, ALT 76, TBili 15.8, Direct Bili 12, Alk Phos 229.
Ammonia was 105. INR was noted to be 1.5. Blood and urine
cultures were sent, with urinalysis unremarkable. 2 liters IVF
were given in ED for hypercalcemia with some improvement in
mental status. Head CT was performed and showed no acute process
with known cerebellar lesion on MRI not visualized. Right upper
quadrant U/S showed CBD with 2 mm diameter and no intrahepatic
biliary dilation, with no evidence of cholecystitis or focal
liver lesions seen on limited images obtained. Vitals in ED
prior to transfer were as follows: T98.4 HR 103 166/79 93% RA.
On the floor, patient is in no acute distress, but unable to
answer questions appropriately.
Review of systems:
(+) Per HPI. Patient has had some weight loss but difficult to
cooperate in answering questions at this time. Endorses
constipation.
(-) Denies headache, sinus tenderness. Denied shortness of
breath. Denied chest pain. Denied abdominal pain. Denied
arthralgias or myalgias.
Past Medical History:
Lung cancer
Hypertension
Back pain
Social History:
Tobacco: Reports [**12-8**] ppd for many years.
ETOH: Former heavy drinker, now drinks daily. Per brother [**Name (NI) **],
with whom he lives, last drink was about a week prior to
admission
Illicits: denies, but per brother [**Name (NI) **] last used cocaine night
prior to admission
Lives with brother [**Name (NI) **], but also has another brother [**Doctor Last Name **]
and sister involved in her care.
Family History:
Father with CAD/PVD, diabetes, HTN, mother with stroke. Brother
with diabetes mellitus.
Physical Exam:
Admission
T: 98.5 BP: 151/78 P: 109 R: 14 O2: 94% 2L NC
General: easily arousable, no acute distress, jaundiced
HEENT: Sclera icteric, very dry mucus membranes
Neck: supple, visble carotid pulsations
Lungs: Limited air movement bilaterally, no
rhonchi/wheezes/crackles appreciated
CV: Regular rhythm, rapid rhythm, very hyperdynamic heart
Abdomen: Hypoactive bowel sounds, soft, non-tender, mild to
moderately distended, no rebound tenderness or guarding
GU: Foley with icteric urine
Ext: Warm, well perfused, 1+ DP pulses, no peripheral edema
Skin: Spider angiomata
Neuro: oriented to name, but not year or place; PERRLA;
symmetric DTR's globally; no clonus
Pertinent Results:
ADMISSION LABS:
ALT-76* AST-352* CK-330* ALK PHOS-229* TOT BILI-15.8* DIR
BILI-12* INDIR BIL-3.8
ALBUMIN-3.8 CALCIUM-15* PHOSPHATE-3.9 MAGNESIUM-2.4
ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
WBC-10.3 RBC-4.47* HGB-14.6 HCT-41.4 MCV-93 MCH-32.6* MCHC-35.2*
RDW-17.3*
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS
amphetmn-NEG mthdone-NEG
URINE COLOR-AMBER APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017 URINE BLOOD-NEG
NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD
UROBILNGN-8* PH-5.0 LEUK-NEG
CK-MB-2 cTropnT-<0.01 CK(CPK)-315
PTH-9*
LAST SET OF LABS: [**2166-4-20**]
WBC-8.7 Hgb-11.0* Hct-32.5* MCV-95 Plt-88*
PT-30.6* PTT-43.3* INR(PT)-3.0*
Glucose-70 UreaN-71* Creat-1.6* Na-140 K-3.9 Cl-104 HCO3-15*
Calcium-7.3* Phos-4.9*# Mg-1.6
ALT-126* AST-871* LD(LDH)-4180* AlkPhos-212* TotBili-18.1*
MICROBIOLOGY:
BLOOD CULTURES: NEGATIVE
URINE CULTURE: NEGATIVE
MRSA SCREEN: NEGATIVE
HCV VIRAL LOAD: 800,000
PATHOLOGY:
LIVER CORE BX [**2166-4-18**]: Metastatic carcinoma with
neuroendocrine features. The morphologic and immunophenotypic
features are consistent with a lung primary.
RADIOLOGY:
PET SCAN [**2166-4-9**]:
1. Large left lower lobe FDG avid mass with multiple osseous and
hepatic metastases as well as large metastatic lymph nodes in
the aortocaval and portocaval regions.
2. Asymmetric FDG avidity in the left vocal chord which may be
due to tumor involvement of the right recurrent laryngeal nerve.
MRI HEAD [**2166-4-9**]:
3-mm lesion within the left cerebellar hemisphere with
enhancement seen on
only axial post-gadolinium images are not clearly visualized on
the
post-gadolinium MP-RAGE images as described above. The presence
of the lesion on the FLAIR and T2 images is suggestive of
metastatic lesion. However, given the small size of this
solitary if further confirmation is clinically required (for
therapeutic purposes), repeat T1 post-gadolinium axial and
coronal images of the posterior fossa with 3-mm section
thickness would help.
CT HEAD [**2166-4-11**]:
1. No acute intracranial process. Known left cerebellar lesion
is not
apparent on unenhanced CT.
2. Aerosolized secretions and mucosal thickening in the left
maxillary sinus.
RUQ U/S [**2166-4-12**]:
1. No intrahepatic biliary ductal dilation. The common bile duct
measures 2 mm.
2. The gallbladder is decompressed, likely accounting for wall
thickening,
with no evidence of cholecystitis.
3. Limited images demonstrating no focal liver lesion, though
correlation
with recent PET-CT (reportedly showing focal liver lesions
concerning for
metastases) is advised.
CXR [**2166-4-12**]:
There is again seen an area of consolidation projecting over the
left base
compatible with known infiltrate in the left lower lobe abutting
the major
fissure. The cardiac silhouette is within normal limits. There
is no
pneumothoraces or pleural effusions identified.
Brief Hospital Course:
51 year-old male with h/o newly diagnosed metastatic cancer with
lung, liver, brain, and bone lesions via PET imaging, presented
with altered mental status, liver failure, and hypercalcemia.
Patient was treated for hypercalcemia and hepatic encephalopathy
in the ICU; IV fluids, calcitonin, and pamidronate for
hypercalcemia and lactulose and rifaximin for hepatic
encephalopathy. CXR revealed PNA for which the patient was
treated initially with levofloxacin and metronidazole and later
broadened to cefepime and metronidazole. His mental status
improved and patient was transferred to the floor on hospital
day 2.
Diagnostic paracentesis and liver biopsy were performed. Liver
biopsy pathology revealed findings consistent with lung cancer.
The patient's liver failure progressively worsened with MELD
score reaching 34 when labs stopped being drawn. Because of the
extremely grave prognosis of widely metastatic lung cancer (mets
to the brain, liver nad bones) and hepatic failure, the patient
opted to transition to hospice care. His chief request was that
he be made comfortable and that any pain related to cancer will
be treated promptly and adequately. He designated his brother,
[**Name (NI) **] [**Name (NI) 102482**], to be his healthcare proxy.
On [**2166-4-23**], he was noted to have worsening in his mental
status and to be more labored in his breathing. He appeared to
be near death. His family was notified of his change in status.
However, soon after notifying the family, this writer was
notified that he had died. He was reassessed and was noted to
have unreactive pupils and no evidence of cardiopulmonary
activity. The family was notified of his death. Time of death
was 8:34 AM. The patient's brother declined post-mortem exam.
Medications on Admission:
Acetaminophen-Codeine 300-30 mg 1 tab q4h PRN pain
Hydrochlorothiazide 25 mg PO daily
Cyclobenzaprine 10 mg PO daily PRN muscle spasm
Lisinopril 10 mg PO daily
Naproxen 500 mg PO BID PRN pain
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
eight (8) hours: titrate to 3 bowel movements daily.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Expired
Discharge Diagnosis:
Lung cancer, metastatic to brain, liver, and bones
Hepatic failure with encephalopathy, coagulopathy, anasarca
Coma from hepatic encephalopathy and hypercalcemia
Hepatitis C
Acute kidney injury
Pneumonia, community acquired versus aspiration
Cancer-related pain
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"401.9",
"198.5",
"584.9",
"198.3",
"572.2",
"338.3",
"789.59",
"782.3",
"303.91",
"571.2",
"197.7",
"196.2",
"276.8",
"162.5",
"276.1",
"286.9",
"724.5",
"275.42",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
8544, 8553
|
6324, 8091
|
325, 355
|
8859, 8869
|
3410, 3410
|
8926, 8937
|
2625, 2714
|
8333, 8521
|
8574, 8838
|
8117, 8310
|
8893, 8903
|
2729, 3391
|
1850, 2126
|
265, 287
|
383, 1831
|
3426, 6301
|
2148, 2184
|
2200, 2609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,444
| 144,642
|
26144
|
Discharge summary
|
report
|
Admission Date: [**2114-12-2**] Discharge Date: [**2115-1-1**]
Date of Birth: [**2057-10-3**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
ICU Tx from OSH for GTC sz
Major Surgical or Invasive Procedure:
Brain Biopsy
Tracheostomy
PEG tube placement
Intubation
PICC line placement
Lumbar puncture
IVC filter placement
History of Present Illness:
The patient is a 57 yo ?-handed woman with a history of
obesity and Crohn's disease who presented to OSH [**11-30**] with GTC
seizure (first time). History is per chart as patient is
currently intubated.
Weeks prior she had developed a slight headaches (no information
regarding quality and location of HA available), mainly in the
mornings. These would occur daily without any accompanying
symptoms. One day prior to presentation to OSH, the patient
developed blurred vision, HA, a strange sensation in her mouth
and she had to vomit. On the day of presentation she was feeling
fine until she had troubles getting words out. She then fell to
the floor and had a GTC seizure that lasted for about 5 minutes
(witnessed by her husband). At the ED of OSH, a head CT was
negative and she was discharged home with appointments for
further workup as outpatient. The same evening she had 3 more
GTC
seizures. These started focally with L-arm numbness followed by
L-arm shaking. Postictally, weakness was noted in the L-arm. She
also was incontinent for urine. A repeat CT was negative and an
LP showed 1WBC and 52 RBC, glc 96, prot 33. She had a normal
WBC,
was afebrile at that point and did not have meningismus. She was
loaded on dilantin (1g), given maintenance of 100mg TID (with
trough [**12-2**] of 12). She was noted to have twitching of the
L-arm
and L-leg, with interictally altered consiousness and L-sided
weakness. She was emperically given acyclovir, vanco,
gentamycin,
and CTX on [**12-1**]; all d/c-ed on [**12-2**].
MRI on [**12-1**] showed parasagittal, bihemispheric infarcts on DWI
(along the falx), periventricular white matter changes on FLAIR.
She was given solumedrol 1gram for ? of vasculitis.
CTA/CTV head [**12-1**] showed some small filling defects in the
superior sagittal sinus. An MRV was not performed.
Later that day she was intubated as she became increasingly
lethargic in between the seizures (airway protection). She was
then maintained on propofol until transfer. On the day of
transfer ([**12-2**]) she developed a low grade fever 100.2. Her
dilantin trough [**12-2**] was 12, after which she was given another
500mg dilantin iv.
Upon transfer, the patient had a temp of 101.3. She was noted to
have trhythmic movements involving her L-arm more than her R-arm
and some internal rotation of her legs (also rhythmically).
Prior
to transfer she received 2mg of ativan. Shortly after transfer
she received 2mg ativan x3 and received another dose of dilantin
(10mg/kg, i.e. 900mg).
Of note the patient is allergic to shellfish and had undergone a
CT with contrast.
Review of systems
-could not be obtained; patient intubated
Past Medical History:
-Crohns disease: currently not on anti-inflammatory therapy; s/p
ileostomy; s/p fistula repair; short bowel syndrome
-GTC seizures [**11-30**]; no prior history
-no history of CAD or DM
-obesity
Social History:
Pt is a nurse. She lives with her husband. They have 4
children who live in other areas. She doesn't smoke. No drugs.
No recent supplements/weight loss remedies.
Family History:
No history of stroke or seizure.
Physical Exam:
Vitals: T101.3 HR110 BP130/60 (later 94/50) RR12 (vent) sO2
100%
on vent
Gen: intubated; diffuse rash in face and upper body
HEENT: mmm, red conjunctivae
Neck: no LAD; no carotid bruits; full range neck movements
Lungs: coarse breathing sounds bilaterally
Cardiovascular: Regular rate and rhythm, normal S1 and S2, no
murmurs, gallops and rubs.
Abdomen: normal bowel sounds, soft, nontender, nondistended
Extremities: no clubbing, cyanosis, ecchymosis, or edema
Mental Status:
intubated, had recently received ativan, propofol had been held
for 20 minutes; does not open eyes to sensory stimuli; does not
follow commands
Cranial Nerves: PERL 2mm; corneal reflexes present, but weak
bilaterally; dulls eyes present; no gag reflex
Motor System: decreased tone in all 4 extremities; moves all 4
extremities during seizures; no spontenous movement
Sensory system: does not respond to noxious stimuli in any of
the
extremities.
Reflexes:
brisk in UE bilaterally; normal over knee tendon and Ach tendon
Toes: upgoing bilaterally.
Coordination: could not be tested
Pertinent Results:
[**2114-12-2**] 07:40PM BLOOD WBC-9.9 RBC-4.17* Hgb-11.4* Hct-33.4*
MCV-80* MCH-27.2 MCHC-34.0 RDW-14.1 Plt Ct-248
[**2114-12-2**] 07:40PM BLOOD PT-13.0 PTT-19.5* INR(PT)-1.1
[**2114-12-2**] 07:39PM BLOOD ESR-29*
[**2114-12-2**] 07:40PM BLOOD Fibrino-315
[**2114-12-2**] 07:39PM BLOOD Lupus-NEG AT III-90 ProtCFn-121
ProtCAg-105 ProtSFn-87 ProtSAg-121 ACA IgG-10.2 ACA IgM-10.3
[**2114-12-2**] 07:40PM BLOOD Glucose-132* UreaN-14 Creat-0.7 Na-143
K-4.1 Cl-107 HCO3-27 AnGap-13
[**2114-12-2**] 07:40PM BLOOD ALT-8 AST-16 LD(LDH)-165 AlkPhos-68
Amylase-64 TotBili-0.3
[**2114-12-13**] 06:15PM BLOOD CK-MB-2 cTropnT-<0.01
[**2114-12-14**] 02:41AM BLOOD cTropnT-<0.01
[**2114-12-14**] 10:00AM BLOOD CK-MB-1 cTropnT-<0.01
[**2114-12-2**] 07:40PM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.5 Mg-2.3
[**2114-12-4**] 09:41PM BLOOD Cryoglb-NO CRYOGLO
[**2114-12-2**] 07:39PM BLOOD Homocys-5.6
[**2114-12-2**] 07:40PM BLOOD TSH-0.46
[**2114-12-4**] 08:38PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2114-12-4**] 08:38PM BLOOD ANCA-NEGATIVE B
[**2114-12-2**] 07:40PM BLOOD RheuFac-8
[**2114-12-2**] 07:39PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40
[**2114-12-2**] 07:39PM BLOOD CRP-22.7*
[**2114-12-3**] 02:52AM BLOOD C3-152 C4-46*
[**2114-12-4**] 08:38PM BLOOD HCV Ab-NEGATIVE
[**2114-12-2**] 08:06PM BLOOD Glucose-141* Lactate-1.2
--
PTGM neg
B2-microglobulin neg
Factor V Leiden neg.
---
[**12-2**]:MRI/A/V of head:There is no mass effect, hydrocephalus, or
shift of the normally midline structures. There are multiple
bilateral regions of subacute infarction with regions of
cortical restricted diffusion and T2 hyperintensity. The most
extensive region involves the right insular cortex and the
parietal cortex, more posteriorly, on the right. There is also a
smaller infarct in the left middle cerebral artery territory as
well. In addition, there are bilateral subacute infarcts in the
medial frontal lobes bilaterally, more extensive on the right
than the left, involing portions of both anterior cerebral
artery territories. The posterior cerebral artery territories
appear spared. All of the infarcted regions show subtle gyriform
enhancement following gadolinium administration.
Both cerebral hemispheres also demonstrate scattered foci of T2
hyperintensity without associated restricted diffusion or
enhancement. These are probably more chronic in character. There
are also multiple tiny bilateral punctate foci of susceptibility
artifact, which could possibly represent hemorrhagic residua
from prior small-vessel infarctions. The cerebellum and
brainstem are spared. The surrounding osseous and soft tissue
structures are unremarkable.
MR ANGIOGRAM: The major tributaries of the circle of [**Location (un) 431**]
appear patent. There are no areas of significant stenosis or
aneurysmal dilatation. No sign of arteriovenous malformation is
apparent within the limits of coverage of the study. There is a
small right vertebral artery, which probably ends as a posterior
inferior cerebellar artery.
MR VENOGRAM: The major intracranial venous sinuses, cerebral
vein of [**Male First Name (un) 2096**], and internal cerebral vein appear patent.
----
[**12-7**]:MRI/A of head:There is no extra-axial fluid collection.
There is no mass effect, hydrocephalus, or shift of the normally
midline structures. The ventricles, cisterns, and sulci are
unremarkable, without effacement.
The areas of previously noted acute infarction in the bilateral
middle and anterior cerebral artery territories now show T2
hyperintensity, consistent with anticipated ongoing evolution of
the infarcts.
In addition, there are new foci of T2 hyperintensity in the
lentiform nuclei bilaterally and the right thalamus. There is a
gap in the diffusion- weighted images in this area, so that the
basal ganglia regions are not fully assessed with respect to
diffusion. However, the new FLAIR abnormality in the right
thalamus is shown to correspond to a region of new restricted
diffusion. These areas correspond to new infarcts since the
prior study.
There are new air fluid levels in the sphenoid and maxillary
sinuses, which could be related to intubation. The surrounding
osseous and soft tissue structures are within normal limits.
MR ANGIOGRAM: The quality of MR angiogram of the circle of
[**Location (un) 431**] is improved since the prior study. Again, it demonstrates
no significant stenosis or aneurysmal dilatation. A small right
vertebral artery, ending as a posterior inferior cerebellar
artery, is again noted.
----
CT abd-pelv to r/o retroperitoneal hematoma [**12-15**]:
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Consolidation is again
noted at both lung bases, unchanged from the prior study. An NG
tube is present within the stomach. The spleen, liver,
gallbladder, pancreas, adrenals, kidneys, and intraabdominal
small bowel are unremarkable in appearance. The colon is again
noted to be distended and full of stool. No bowel wall
thickening is seen. There is no free air, free fluid, or
pathologic lymphadenopathy in the abdomen.
CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid, and
bladder are unremarkable. A Foley catheter is present, and some
air is again noted within the bladder. There is no free fluid or
lymphadenopathy.
Osseous structures demonstrate minor degenerative changes in the
thoracolumbar spine. Soft tissues are unremarkable.
IMPRESSION:
No evidence of retroperitoneal hematoma. No significant change
in the appearance of bibasilar consolidation or prominent stool
filled colon compared to one day earlier.
----
UE u/s [**12-17**]
LEFT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler
ultrasound of the left internal jugular, subclavian, axillary,
brachial, basilic, and cephalic veins was performed. There is
normal flow, compressibility, waveforms, and augmentation. No
intraluminal thrombus is identified.
IMPRESSION: No left upper extremity DVT.
----
LAST HEAD CT [**12-28**]
FINDINGS: Since the prior study, there has been evolution of the
multifocal right greater than left bilateral areas of
intraparenchymal hemorrhage. The extent of cerebral edema
appears unchanged. The ventricles are not dilated. The basal
cisterns are patent. No new areas of hemorrhage are visible.
Changes in the right frontal bone related to the craniotomy are
stable. The mastoid air cells are opacified bilaterally, as
before. Fluid and/or secretions layer within the ethmoid and
sphenoid sinuses bilaterally, also unchanged.
IMPRESSION: No new areas of intracranial hemorrhage. Similar
extent of brain edema compared to the prior study.
Last CXR [**12-30**]:
There is probable cardiomegaly, with an unfolded aorta. No CHF
or effusion is identified. There is patchy opacity in right and
left infrahilar regions. While this may represent atelectasis,
infectious infiltrates cannot be excluded. Allowing for
differences in positioning, the appearance is unchanged compared
with [**2114-12-28**]. Tracheostomy tube noted.
Last EEG [**12-20**]:
FINDINGS:
PUSHBUTTON ACTIVATIONS: There were none.
AUTOMATED SEIZURE DETECTIONS: There were two. Neither of these
represented a true electrographic seizure.
AUTOMATED SPIKE DETECTIONS: There were 1,000 entries in these
files.
Most were artifactual but some right frontal and bifrontal sharp
waves
were seen.
ROUTINE TIME SAMPLING: Showed a slow and disorganized background
throughout most of the recording mostly in the delta and theta
frequency
ranges. Frequent and nearly continuous polymorphic delta
frequency
slowing was seen focally in the bifrontal regions throughout
much of the
recording and mixed alpha and beta frequency activity was seen
bifrontally, as well.
SLEEP: No clear state changes were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This 24-hour video EEG telemetry captured no
pushbutton
activations. No electrographic seizures were seen. Interictally,
however, right frontal and bifrontal epileptiform discharges
were seen.
The background was very slow and disorganized throughout the
recording,
suggestive of a moderate encephalopathy, and focal slowing in
the
bifrontal regions suggested the additional possibility of
subcortical
dysfunction in frontal lobes.
Brief Hospital Course:
1.Neuro:The initial etiology of the patient's problems was not
clear. The initial priority was to control her seizures. This
was accomplished using dilantin, phenobarbital, and a propofol
drip. She was monitored during this propofol coma on a
continuous EEG and burst suppression was achieved. She had no
further clinical evidence of seizure. A extensive work-up
included a repeat MRI showing numerous bilateral apparently
ischemic areas as well as multiple microhemorrhages. All of
this was in the anterior circulation, with no posterior
involvement. An MRV showed no evidence of venous sinus
thrombosis which had been suspected initially. An MRA did not
suggest any pathology. A repeat MRA which was deemed a better
study was equally unhelpful in establishing a diagnosis.
Possibilities for her multiple areas of restricted diffusion on
MR included the sequelae of prolonged status epilepticus,
infectious encephalitis, non-infectious encephalitis/vasculitis,
multiple embolic strokes, segmental vasospasm. An LP was done
which showed 6 WBCs(monocytes and lymphocytes), 1 RBC, normla
protein and glucose. This was sent for a number of infectious
agents which all returned negative(HSV,VZV,CMV,EBV,Crypto,
vial/fungal/bacterial cultures). Oligoclonal bands were also
negative. While these studies were pending, she was continued
on broad spectrum antibiotics and acyclovir. She was also put
on 4 days of pulse dose solumedrol given the possibility of
vasculitis and then switched to prednisone 60 mg daily for
several weeks. The ID service was consulted and agreed with the
above studies. She was intermittently febrile, often to
temperatures of 104. The source was investigated thoroughly
multiple times and she was intermittently on various
antibiotics, including vancomycin, levofloxacin, and flagyl.
She had a possible pneumonia at one point. TLENIs were negative
for DVT, but a CTA of the chest revealed a large PE. Drug fever
was considered, especially to Dilantin, but this was a diagnosis
of exclusion. She continued to spike intermittent fevers during
her course. These were investigated each time with blood,
urine, and sputum cultures. Her sputum grew yeast multiple
times, but per the ID service, this was considered a respiratory
contaminant. At the time of discharge, she had completed a
course of vancomycin and continued to have either low-grade
temperatures or fevers to 101. These were not felt by
infectious disease to represent a specific source of infection,
and cultures continued to be negative.
In further working to rule out causes of her condition,
vasculitis was considered. She was on steroids as above. A brain
biopsy was undertaken which showed no evidence for vasculitis or
any evidence for inflammation in general, but did show extensive
amyloid angiopathy. Her case was discussed with many of the
senior staff and there was no clear consensus as to the cause
and how amyloid angiopathy could be related to ischemic injury.
There are case reports suggesting that amyloid can cause
vasculitis leading to infarction but the biopsy results as
stated did not support vasculitis. Non-inflammatory
vasconstriction syndromes were also entertained but this
condition would not be explained by amyloid angiopathy.
Nevertheless, she was placed on calcium channel blockers as
well. Eventually, as her blood pressure continued to be
tenuous, the calcium channel blocker was discontinued (after at
least two weeks of therapy) with no substantial difference in
her neurological state/function. However, Verapamil was
restarted at 80 mg by G-tube [**Hospital1 **] near the end of hospitalization
because her blood pressure was more stable (with SBP 110s-140s).
Multiple emboli were considered. A TTE and then a TEE were
performed. They showed no clear source of a proximal embolus
that may have caused a shower of embolic phenomenon. She did
have a small PFO, but nothing significant enough to account for
her symptoms.
She was quickly weaned from the propofol after ~1 week and
had no new seizure activity on the EEG. However, despite being
off of all sedating medications for a prolonged time, she did
not regain consciousness. The reason for this was not fully
known, but was presumed to be due to the extensive damage she
had suffered from the initial insult. Despite multiple
therapeutic approaches, she continued to show new areas of
restricted diffusion on MRI.
Later in the hospitalization, a repeat CT scan to assess
for progression showed an increase in cerebral edema, thought to
be due to natural progression of her multiple strokes. She was
briefly placed on mannitol, decadron, hypothermia and a
pentobarbital coma. A repeat scan was improved and she was
taken off of the above therapies slowly.
There were several episodes of shivering/shaking that did not
appear to be seizures by EEG, but were concerning clinically.
She had several EEGs with attempts to characterize these events,
which later included nystagmoid eye movements that were
bidirectional on forward/resting gaze, with occasional gaze
deviation to either the left or right. EEG showed no
electrographic correlate. The epilepsy specialists felt that
the eye twitching was likely to be peripheral/muscle activity
rather than seizure, or perhaps a myoclonic equivalent. She was
continued on dilantin and reloaded on multiple occassions. She
was also on phenobarbital, but as her LFTs rose, the epilepsy
consultants recommended switching to Keppra, which is renally
cleared. Keppra was titrated up to goal dose of 1500mg [**Hospital1 **], and
at that point, Phenobarb was to be weaned by 40 mg every two
days, with careful attention to the dilantin level (which should
be checked at least every other day), as this can rise suddenly
as phenobarbital is decreased. Corrected dilantin levels were
therapeutic at the end of her admission. Her exam at discharge
was stable over one week - eye blinking and nystagmoid movements
as noted above, occasional shivering-like movement of the right
or left arm, sometimes in response to noxious stimuli and more
often spontaneously. She withdrew very slightly to deep noxious
stimuli in her lower limbs, and grimaced (and once opened eyes)
to deep sternal rub. Reflexes were brisk throughout, and both
toes were upgoing. At the time of discharge, she had no
directed responsiveness and blinked non-purposefully and not to
threat. Brainstem reflexes were intact. There were no
movements of her limbs and toes were bilaterally upgoing. The
biopsy showed that she had extensive loss of neocortical
neurons.
2.Heme: She had a slowly drifting hematocrit initially that
stabilized on its own. However, after receiving heparin for her
PE, she had a significant hematocrit drop. This was
investigated by a torso CT which showed no obvious source of
bleeding. Her hematocrit then stabilized. It is unclear where
this lab abnormality originated. She continued to have low but
stable hematocrit levels, probably due to her chronic illness.
Se received several units of packed red blood cells, with some
mild improvement of her hematocrit. As she diuresed, her
hematocrit increased, leading the team to believe that the
anemia was perhaps partly dilutional. For the last week of
admission, the hematocrit was stable, in the 27-30 range. She
was also taken off the heparin drip two weeks prior to admission
because of increased bleeding in the brain. She underwent IVC
filter placement to prevent recurrence of PEs; the risks of
remaining on heparin were considered to be greater than the
benefit to her PE. For further prophylaxis, she was started on
subcutaneous heparin injections and pneumoboots.
3.CV: She initially had fairly good blood pressure and heart
rates. She then developed tachycardia and hypotension,
requiring multiple fluid boluses and eventually pressors for BP
support. At this time, her PE was discovered and felt to be the
cause of her hemodynamic instability. This was treated with
heparin and thrombectomy was considered. The IR service was
consulted but felt that this was too risky a procedure at this
time so it was not performed. She continued to require pressors
for several days and eventually was taken off the calcium
channel blockers, as noted above. Her blood pressure stablized
and has been in the 120-140 range (systolic) since, with regular
heart rate.
4.Pulm: She was ventilated fairly easily until she developed her
PE as aboe. This was a large right main pulmonary artery
embolus. LENIs from the day before were free of DVT, but it is
possible that her clot came from a pelvic vein. As above, she
was treated with heparin. This was briefly off given her
hematocrit drop, but was restarted when her levels stabilized
and no sourceof bleeding was identified. When she was
stabilized, an IVC filter was placed. She alternated between
CMV and pressure support as an inpatient. At discharge, she was
on PSV with a pressure of 12, PEEP 10, on 40%FIO2 achieving
adequate tidal volumes for her size.
6.Renal: Her urine output and renal function were stable
throughout her stay despite multiple possible nephrotoxic
medications. She was initially net positive and developed
anasarca (though was thought to be intravascularly depleted);
during the last few weeks of her hospital stay, she diuresed [**1-7**]
to 1 L per day, with improvement of both the hematocrit and
appearance of anasarca.
7.ID: As above, she spiked multiple fevers for the majority of
her stay here. An infectious source was sought aggressively
given the fact that she was on steroids and therefore
immunosuppressed. No obvious source was found in her blood,
urine, sputum, or CSF. Other considerations were her PE and
possible drug fever. Other than contaminant yeast, no clear
answer was found for her fever. In addition, her WBC count was
normal for much of her stay, but this was clouded by the
steroids she was receiving. As mentioned above, her sputum grew
yeast multiple times, but per the ID service, this is always a
respiratory contaminant. She had completed a course of
vancomycin and continued to have either low-grade temperatures
or fevers to 101. These were initially not felt by infectious
diseases to represent a specific source of infection, and
cultures continued to be negative. However, nearer the end of
her hospital course, the sputum grew gram positive cocci and the
white blood cell count went up; with these factors (as well as
fever) she was started on a course of Vancomycin to treat a
presumed tracheobronchitis (versus pneumonia - as chest xray
showed bilateral hilar infiltrates vs atelectasis). Another
possibility for her infection source was thought to be c-diff;
stools were somewhat loose daily but not liquid. CDiff toxin
was sent and was still pending at discharge. However, the
vancomycin (though not PO/Gtube) should also treat this type of
stool infection. The white count went down, and she was less
febrile 24 hours after starting the vancomycin.
8. Per ongoing discussions with her family (and per their
discussions with the patient that predated this admission), she
remains full code. She was discharged to a rehab facility for
further vent weaning.
Medications on Admission:
-MVI
-cholesta
Upon transfer from OSH:
-dilantin 100mg 4 times daily
-propofol
-ativan PRN
Discharge Medications:
1. Acetaminophen 650 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day (2) **]: [**1-7**]
Drops Ophthalmic PRN (as needed).
3. Artificial Tear Ointment 0.1-0.1 % Ointment [**Month/Day (2) **]: One (1) Appl
Ophthalmic QID (4 times a day) as needed.
4. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
5. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Ibuprofen 100 mg/5 mL Suspension [**Month/Day (2) **]: One (1) PO Q8H (every
8 hours) as needed for fever.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
11. Phenytoin 100 mg/4 mL Suspension [**Month/Day (2) **]: Two [**Age over 90 1230**]y
(250) mg PO QAM AND QAFTERNOON ().
12. Phenytoin 100 mg/4 mL Suspension [**Age over 90 **]: Three Hundred (300) mg
PO QPM (once a day (in the evening)).
13. Levetiracetam 500 mg Tablet [**Age over 90 **]: Three (3) Tablet PO BID (2
times a day).
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Verapamil 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12
hours).
16. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous
twice a day for 10 days: for presumed mrsa tracheobronchitis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
multiple ischemic strokes with hemorrhagic transformation
Seizures, status epilepticus
Pulmonary embolism
MRSA pneumonia
Possible diagnosis of Call-[**Doctor Last Name 8271**] syndrome (unproven)
Discharge Condition:
Unresponsive; grimace or eye opening occasionally to deep
noxious stimuli. Please see discharge summary for details of
most recent exams.
Discharge Instructions:
Pt has had multiple ischemic strokes with hemorrhagic
transformation
Followup Instructions:
F/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (stroke specialist) on discharge from
rehab. Otherwise, please f/u with rehab physicians.
Completed by:[**2115-1-1**]
|
[
"E849.8",
"415.11",
"277.3",
"555.9",
"401.9",
"E878.8",
"486",
"780.39",
"348.39",
"434.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.19",
"89.19",
"38.93",
"38.7",
"31.1",
"88.72",
"38.91",
"03.31",
"01.14",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
26199, 26269
|
12924, 24154
|
311, 426
|
26509, 26650
|
4664, 12901
|
26767, 26967
|
3529, 3563
|
24296, 26176
|
26290, 26488
|
24180, 24273
|
26674, 26744
|
3578, 4042
|
245, 273
|
454, 3113
|
4218, 4645
|
4057, 4202
|
3135, 3331
|
3347, 3513
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,004
| 121,157
|
41332
|
Discharge summary
|
report
|
Admission Date: [**2171-3-1**] Discharge Date: [**2171-3-8**]
Date of Birth: [**2118-9-11**] Sex: M
Service: MEDICINE
Allergies:
Gentamicin / Seroquel / Latex
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname 89987**] is a 54 year old gentleman with a PMH significant
for polysubstance abuse, CAD s/p PCI, and seizure disorder
admitted for possible seizures. Per report, the patient was
noted today to have chest pain clutching his chest. At that
time, EMS was called with report of seizure activity. He
received 2 mg IM ativan in EMS without resolution of seizure
activity.
.
In the [**Hospital1 18**] ED, initial VS 99.8 70 156/113 100% AC 500x14, 10,
1.0 with ABG 7.34/48/165. The patient had a urine tox screen
positive for amphetamines and had a negative CTA chest and
NCHCT. [**Hospital1 878**] evaluation in the ED was non-localizing, and
the patient was admitted to the MICU for further management.
.
The patient was initially admitted to [**Hospital3 3583**] on [**2-21**]
for SI and depression. At that time, the admission note states
that he had recently been discharged from [**Hospital **] Hospital 2
weeks prior for depression, and that he has a history of abuse
of pain medications. In addition, the patient has a history of
suicide attempts via OD and car crash. His Daughter states that
he has a history of addiction to morphine, hydromorphone, and
valium due to his chronic pain, and that he has been admitted to
an inpatient substance abuse facility since [**2-21**].
.
Currently, the patient is intubated, and sedated.
Past Medical History:
HTN
HLD
CAD s/p PCI
Depression
Polysubstance abuse on suboxone
Left parietal tumor
Seizure disorder - has not had a seizure in 5 years.
Neck and back pain s/p C5-7 fusion
Social History:
Lives with daughter. [**Name (NI) 1139**] - 1 ppd x5 years. EtOH - none per
daughter. [**Name (NI) **] illicit or herbal drugse except for pain medication
addiction.
Family History:
non-contributory
Physical Exam:
ADMISSION:
VS: 98.1 54 147/88 100%AC 500x16, 10, 1.0
Gen: Intubated, sedated
HEENT: ETT in place
CV: Nl S1+S2, no m/r/g
Pulm: CTAB
Abd: S/ND +bs
Ext: No c/c/e.
Neuro: pupils 2->1 mm bilaterally. 1+ biceps, brachioradialis,
patellear reflexes bilaterally. No evidence of rigidity or
clonus. Downgoing toes bilaterally.
.
DISCHARGE:
VS: 98.8 98.6 122/88 109-162/75-100 70 62-76 18 95%RA
8H 60/750
24H 480/675+ not saved, +BMx1
Gen: awake, alert, appears fatigued, NAD
HEENT: NCAT, EOMI, right eye deviated to right, dry MM, no
scleral icterus, OP clear
CVS: RRR, nl S1 S2, no m/r/g
Pulm: no use access mm of breathing, CTAB without wheezes or
crackles
Abd: +BS, soft, NTND
Ext: warm, dry, no [**Location (un) **], slight erythema and edema of RUE around
PICC site, slight tenderness to palpation
Neuro: A&Ox3, awake, alert, 4/5 strength RUE, though difficult
to assess if related to effort, gait not assessed
Pertinent Results:
ADMISSION LABS:
[**2171-3-1**] 03:28PM BLOOD WBC-5.6 RBC-4.42* Hgb-14.2 Hct-39.3*
MCV-89 MCH-32.2* MCHC-36.2* RDW-13.4 Plt Ct-305
[**2171-3-1**] 03:28PM BLOOD Neuts-66.8 Lymphs-26.7 Monos-4.9 Eos-1.2
Baso-0.4
[**2171-3-1**] 03:28PM BLOOD PT-14.4* PTT-29.5 INR(PT)-1.2*
[**2171-3-1**] 03:28PM BLOOD Glucose-118* UreaN-23* Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-28 AnGap-14
[**2171-3-2**] 04:39AM BLOOD Glucose-82 UreaN-18 Creat-0.6 Na-143
K-3.3 Cl-110* HCO3-23 AnGap-13
[**2171-3-1**] 03:28PM BLOOD ALT-14 AST-13 AlkPhos-49 TotBili-0.4
[**2171-3-1**] 03:28PM BLOOD Lipase-25
[**2171-3-1**] 03:28PM BLOOD cTropnT-<0.01
[**2171-3-1**] 11:34PM BLOOD CK-MB-3 cTropnT-<0.01
[**2171-3-2**] 04:39AM BLOOD CK-MB-3 cTropnT-<0.01
[**2171-3-1**] 03:28PM BLOOD Albumin-4.4 Calcium-10.0 Phos-3.7 Mg-2.0
[**2171-3-1**] 03:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2171-3-1**] 03:28PM BLOOD Valproa-106*
.
PERTINENT LABS:
[**2171-3-6**] 01:35AM BLOOD CK-MB-2 cTropnT-<0.01
[**2171-3-6**] 04:49AM BLOOD calTIBC-254* VitB12-1163* Folate-6.6
Ferritn-116 TRF-195*
[**2171-3-2**] 04:39AM BLOOD Valproa-89
[**2171-3-2**] 04:40PM BLOOD Phenyto-7.5*
[**2171-3-3**] 02:19AM BLOOD Phenyto-6.0*
[**2171-3-4**] 03:28AM BLOOD Phenyto-5.7*
[**2171-3-4**] 11:47PM BLOOD Phenyto-10.9 Valproa-92
.
DISCHARGE LABS:
[**2171-3-8**] 05:25AM BLOOD WBC-4.4 RBC-3.75* Hgb-11.8* Hct-32.9*
MCV-88 MCH-31.4 MCHC-35.7* RDW-13.5 Plt Ct-258
[**2171-3-8**] 05:25AM BLOOD Glucose-93 UreaN-15 Creat-0.6 Na-142
K-3.5 Cl-108 HCO3-26 AnGap-12
.
MICRO:
BCx [**2171-3-4**]:
[**2171-3-4**] 9:12 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2171-3-5**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**Doctor First Name **] BEAVER AT 8PM ON
[**2171-3-5**].
Aerobic Bottle Gram Stain (Final [**2171-3-7**]):
GRAM POSITIVE COCCI.
IN CLUSTERS.
.
Blood Cx [**2171-3-1**]: no growth
Blood Cx [**3-5**], [**3-6**], [**3-7**]: pending
.
STUDIES:
ECG: Sinus with 1:1 conduction, bradycardic. NA-NI. No acute
ST-T wave changes.
.
CTA: No PE/dissection. no fx identified. cervical anterior
fusion hardware not visualized.
.
CTH: no ich. no acute process.
CXR:
1. Endotracheal tube in appropriate position. Nasogastric tube
coursing below the level of the diaphragm, inferior aspect not
included.
2. Clear lungs
.
C-spine [**2171-3-5**]:
FINDINGS: C1 through the mid-body of C6 are visualized. There is
preservation of the cervical lordosis. There has been prior
anterior fusion at C5 through C7 with metallic plate and two
sets of screws. There is loss of disc height at C4-C5, but the
remainder of the disc spaces are preserved.
There is no fracture or spondylolisthesis between flexion and
extension.
There is no prevertebral soft tissue edema. Visualized lung
apices are clear. A right-sided central venous catheter is
incompletely evaluated.
.
MRI [**2171-3-6**]:
IMPRESSION:
1. Status post spinal fusion from C5 to C7.
2. Moderate severe spinal stenosis at C4-5 level above the level
of fusion
due to disc osteophyte and thickening of the ligaments with
indentation on the spinal cord without abnormal signal seen
within the spinal cord. Severe left-sided and moderate-to-severe
right-sided foraminal narrowing is seen at this level.
3. Degenerative changes at other levels as described above.
4. No evidence of epidural abscess, discitis or osteomyelitis.
.
RUE U/S [**2171-3-7**]:
IMPRESSION: Occlusive thrombus seen within the right cephalic
vein, which is a superficial vein. No thrombus is seen within
any of the deep veins of the right arm. Note is made of a PICC
line in one of the two brachial veins.
Brief Hospital Course:
HOSPITAL COURSE:
Mr. [**Known lastname 89987**] is a 54 year old gentleman with a PMH significant
for polysubstance abuse, CAD s/p PCI, and seizure disorder
admitted for possible seizures. Pt was intubated in the ED for
airway protection. Pt was monitored in the ICU and was followed
closely by [**Known lastname 878**] who did not see EEG activity consistent
with seizures. He was extubated and transferred to the medical
floors for further management. He had some right arm and neck
pain, and MRI showed spinal stenosis. He had fevers, but no
source of infection. One blood culture grew CONS and was
initially started on Vancomycin which was discontinued. Pt was
evaluated by Psychiatry and he did not meet inpatient criteria
for follo-up. Pt was discharged with Psychiatric follow-up, and
continued on home medications.
Pt was discharged with the ride to assist with getting to
appointments.
.
ACTIVE ISSUES:
# Seizure-like activity: He was followed by [**Known lastname **] and
monitored on 24-hour EEG monitoring. He did have several
episodes of myclonic jerking that were not associated with any
EEG evidence of seizures. The EEG was negative over several days
but did show epileptiform activity consistent with history of
epilepsy. In the setting of medication non-compliance he may
have had a seizure prior to admission. He did have urine
toxicology positive for amphetamines and toxicology was
consulted but they did not feel that his presentation was
concerning for amphetamine overdose. MRI brain was negative.
Initially, was loaded on dilantin and was also started on
depakote. When his depakote level was therapeutic, the dilantin
was stopped and he was continued on his home depakote dose. He
was transferred to the medicine floors and had no further
seizure-like activity. He was continued on his home dose of
Depakote and instructed to follow-up with [**Known lastname 878**] as an
outpatient.
.
# Chest pain: Patient has a history of CAD s/p PCI. Per report,
was complaining of chest pain this afternoon at rehab. ACS was
ruled out with serial cardiac biomarkers and repeat ECG.
Carvedilol, ASA, plavix, and statin were restarted when began to
take POs. On the medicine floors, he had an episode of chest
pain, though ECG was unchanged and cardiac markers were again
negative. Pt was hypertensive at the time, and his chest pain
improved as his BP was better controlled.
.
# Respiratory: Patient underwent RSI in the ED for airway
protection in the setting of possible seizures. He was extubated
without complications.
.
# FEVER: Fevers in ICU, though no clear source. Pt had 1 bottle
growing GPC's, and was speciated to coag negative staph, likekly
contaminate. Started on Vancomycin initially, and then
discontinued once speciated as CONS. Pt defervesced and had no
fevers for 48hrs prior to discharge.
.
# SUBSTANCE ABUSE: Positive for amphetamines on admission. Pt
has long-history of substance abuse, and was taking narcotics
prior to admission at [**Hospital1 1680**]. At [**Hospital1 1680**] he was in treatment for
detox. Pt was given fentanyl for concern for withdrawal in ICU.
On the floors, narcotics were held. Psych was consulted, and pt
decided he wanted to go home and was enthusiastic about
attending AA.
He was set up with the ride to help with getting rides to
meetings and oupatient psychiatry.
Pt was counseled on avoidance of narcotics and valium.
.
# Depression: Continued on Fluoxetine in MICU. Remeron was
restarted on the floors. Pt was evaluated by Psychiatry, and
recommended continuing Fluoxetine and Remeron. Pt to follow-up
closely with psychiatry. As above, SW consulted for issues as
outlined above, pt reports unable to make it to previous appts
given difficulty with rides.
.
# Right upper extremity weakness, neck pain: Exam inconsistent
as reportedly able to perform tasks without weakness. MRI
demonstrated severe spinal stenosis, which may have been
contributing to his pain and some right upper arm weakness. Per
[**Hospital1 **] this is a chronic condition and recommended outpatient
follow-up with Spine.
.
# Anemia: Normocytic. Stable since admission. Vitamin B12,
folate normal. Fe on low end of normal, ferritin not elevated,
with low transferrin saturation suggestive of iron deficiency.
Hct was stable and he had no symptoms or signs of bleeding.
Started on iron supplementation. He was instructed to follow-up
with his PCP for further management to have appropriate colon
cancer screening with colonoscopy.
.
# Superficial thrombophlebitis: Pt had some right arm swelling
at site of PICC, found to have thrombosis of superficial vein.
PICC removed, pt treated symptomatically.
.
# HTN: Antihypertensives were initially held in the MICU. On the
floors he was hypertensive, and home medications were restarted:
HCTZ 25 mg daily, Hydralazine 100 mg po tid, Amlodipine 5mg
daily, and Lisinopril 40mg daily. Pt's BP better controlled
after starting home meds.
.
# HLD: Pt was discharged on home dose of Crestor.
.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP
- PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **]
[**Name Initial (NameIs) **] PSYCHIATRY
- SPINE
3. Contact: [**Name (NI) 13788**] [**Name (NI) 89987**] ([**Telephone/Fax (1) 89988**] (daughter)
4. MEDICAL MANAGEMENT:
- START Aspirin 81mg, Colace, Ferrous sulfate, potassium for
hypokalemia here with labs to be checked as outpatient on
discharge
- Counseled on avoiding all illicits
5. Barrier to rehospitalization: history of substance abuse,
concern for non-compliance with follow-up
6. Needs outpatient screening colonoscopy for concern of
iron-deficiency anemia.
Medications on Admission:
Pharmacy: [**Telephone/Fax (1) 89639**], last filled there [**2171-2-20**]
- coreg 25mg po bid
- valproate ER 500mg 2 tabs [**Hospital1 **]
- fluoxetine 40mg daily
- hctz 25mg daily
- hydral 100 tid
- imdur 30 daily
- crestor 40mg daily
- lisinopril 40 daily
- Amlodipine 5 daily
- plavix 75 mg daily
- Remeron 45mg qhs
- valium 5mg tab, [**12-2**] tid:prn
- fiorect-codeine 50-325 APAP-40mg caffeine-30mg codeine
- dilaudid 4mg tid:prn pain
- morphine sulfate ER 30mg [**Hospital1 **]
- fentanyl patch filled 50mcg [**2171-1-8**]
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
4. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. hydralazine 100 mg Tablet Sig: One (1) Tablet PO three times
a day.
8. divalproex 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO BID (2 times a day).
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. mirtazapine 45 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
13. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
14. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Physical Therapy
Please evaluate and treat.
16. Outpatient Lab Work
Please have chem 7 for electrolytes, BUN/Cr checked on [**2171-3-12**]
and bring or fax results to primary care doctor, Dr. [**Last Name (STitle) 80583**], at
[**Telephone/Fax (1) 89989**].
17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Seizure like activity
2. Fevers
3. Substance abuse
4. Anemia
5. Chest pain
Secondary Diagnoses:
1. Depression
2. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 89987**],
You were admitted to the hospital for seizure like activity. You
were observed closely in the ICU and required intubation. You
were evaluated by [**Known lastname **] and EEG was done, but showed no
seizures. You also had fevers and were initially started on
antibiotics, however, this was discontinued as there was no
infection in the blood. You had chest pain, but the cardiac
enzymes were normal and ECG was normal. You had some neck pain
and right upper arm weakness, and MRI showed some cervical spine
narrowing. You should follow-up with spine specialists for this.
You also had a small blood clot in one of your veins. You should
use warm packs for this to help with the discomfort.
You were evaluated by the physical therapists, who recommended
outpatient physical therapy.
The following medications were changed during this admission:
- STOP Dilaudid, Morphine, Valium, Vistaril, Fiorcet-Codeine,
and Fentanyl
*** You had prescriptions for these medications prior to
admission at [**Hospital1 1680**]. DO not take these medications.
- START Aspirin 81mg by mouth daily
- START Ferrous sulfate 325mg by mouth daily
- START Docusate sodium 100mg by mouth twice daily
**The ferrous sulfate (iron) can cause some constipation. The
Docusate is a stool softener that will help you have bowel
movements.
- START Potassium chloride tablets 20mEQ by mouth daily
**Your potassium levels were low here. This medication is to
help replace your potassium. Please discuss this with your
primary care doctor. You should have your labs checked at your
appointment with her on Tuesday of next week ([**2171-3-12**], see
below) to make sure that your potassium levels are normal.
Please continue all other medications you were on prior to this
admission.
It is important that you avoid ALL illicit drugs. These can be
very harmful and even life-threatening to your health.
It is very important that you make it to all your appointments.
We tried to arrange for the Ride for you. However, you will need
to re-apply when you are discharged. In the mean time, please do
make it to your appointments. This is very important for your
long-term health.
You were found to have anemia here. Your iron was on the low
normal range. We saw no evidence of bleeding here. However, you
should discuss with your PCP further workup such as
age-appropriate colon cancer screening with colonoscopy.
Followup Instructions:
Please follow-up with the following appts:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: ROUTE 44 MEDICAL
Address: 106 ROUTE 44, [**Location (un) **],[**Numeric Identifier 89990**]
Phone: [**Telephone/Fax (1) 89991**]
Appt: [**3-12**] at 11:45am
***NOTE-At this appt please discuss with Dr [**Last Name (STitle) 80583**] obtaining a
psychiatrist for medication managemenet and counseling needs
Department: [**Last Name (STitle) **]
When: WEDNESDAY [**2171-3-13**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3292**] [**Last Name (NamePattern1) 3293**], MD [**Telephone/Fax (1) 3294**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: THURSDAY [**2171-3-28**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2171-3-8**]
|
[
"345.91",
"E879.8",
"276.2",
"305.1",
"272.4",
"280.9",
"401.9",
"296.80",
"V45.82",
"338.29",
"786.50",
"786.04",
"723.0",
"780.60",
"999.31",
"V45.4",
"451.82",
"304.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14789, 14795
|
6949, 6949
|
297, 322
|
14981, 14981
|
3060, 3060
|
17572, 18710
|
2098, 2116
|
13124, 14766
|
14816, 14913
|
12569, 13101
|
6966, 7846
|
15132, 17549
|
4378, 4683
|
2131, 3041
|
14934, 14960
|
4727, 6926
|
249, 259
|
7861, 12543
|
350, 1705
|
3076, 3987
|
14996, 15108
|
4003, 4362
|
1727, 1899
|
1915, 2082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,879
| 101,388
|
4274
|
Discharge summary
|
report
|
Admission Date: [**2150-3-7**] Discharge Date: [**2150-3-13**]
Date of Birth: [**2100-1-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline /
Wellbutrin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Pancreatitis, AMS, respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 55 year-old female with a PMH of HTN, PVD,
seizure disorder, chronic pain on oxycodone, methadone, OSA who
presented to an OSH on [**2150-3-6**] after being found stuporous with
white foam and white poweder around her mouth at home. Her son,
whom she lives with, reviewed her [**Date Range 4085**] boxes and verified
that no medications were missing or overconsumed. EMS brought
her to the ED and en route she was given Narcan with some
effect. On presentation, she was found to be hypoxic to 74% on
RA with rhonchi and had a Glascow of 4. She was noted to have a
depressed mental status with an absent gag and some secretions
at the glottic opening. She was intubated for airway protection
(7.34/60/322). A CXR was performed and was negative for
pneumonia per report. Her labs were significant for a lipase of
3882 and WBC of 15 and serum and urine tox were significant for
positive TCA, methadone, and THC, but negative for tylenol,
phenobarbital, and alcohol. Creatinine and LFTs were normal with
a mildly elevated Alk phos. An EKG was also NSR. The
differential was thought to include seizure versus aspiration vs
overdose. She was transferred to [**Hospital1 18**] for further mgmnt and her
ventilator settings at the time were Vt 500, 90% PEEP 5 RR 18.
There was difficulty noted in weaning the FiO2. She was
intermittently sedated with ativan.
.
On arrival, her VS were T 102.6 P 110 100%ra BP 170/100. She was
intubated but awake and alert, following simple commands. A RSBI
was performed and was 150, with a RR of 25 and Vt of ~200. She
was also witnessed to aspirate.
.
Review of systems is otherwise unremarkable per report.
Past Medical History:
- pulmonary htn
- OSA - pt refuses CPAP.
- COPD - PFTs in [**6-20**] showed FEV1/FEV 87% predicted
- AS - s/p AVR with 21mm [**Company 1543**] Mosaic valve [**2149-4-1**] ([**Doctor Last Name **])
- hypertension
- high cholesterol
- Crohn's disease since age 19, no surgeries, treated with
prednisone off and on
- prednisone induced hyperglycemia
- gastritis/GERD, h/o GI bleed
- one seizures in the setting of emesis in [**12-20**], no AEDs
- basal cell skin cancer on nose
- inflammatory [**Last Name **] problem periodically
- pyoderma gangrenosum-on L calf and R ankle, tx with Prednisone
- osteopenia
- all teeth extracted secondary to prednisone
- right arm arterial bypass when she presented with right arm
pain and pulselessness
Social History:
completed 12th grade, currently on disability but formerly
worked in an airplane factory, divorced, lives with son, active
[**Name2 (NI) 1818**] - 1-1.5 ppd x 32 years. No drinking or drug use (IVDA).
Family History:
mother deceased age 62 of stroke, HTN, high chol, father
deceased age 56 of MI and also had low back pain, sisters x 4
one with diabetes and neuropathy, one brother deceased (in
army), and another alive with HTN, high chol, and prostate
cancer, one son healthy.
Physical Exam:
T 102.6 P 110 100%ra BP 170/100
PHYSICAL EXAM
GENERAL: intubated, agitated, awake, alert, responds to commands
HEENT: Normocephalic, atraumatic, ETT. No conjunctival pallor.
No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. [**2-20**]
ejection murmur at RUSB. No JVD.
LUNGS: coarse B b/l.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Follows commands. Moves all extremities. CN 2-12 grossly
intact.
Pertinent Results:
[**3-9**] echo: The left atrium is dilated. 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. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. A bioprosthetic aortic valve
prosthesis is present. The transaortic gradient is higher than
expected for this type of prosthesis. No masses or vegetations
are seen on the aortic valve, but cannot be fully excluded due
to suboptimal image quality. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal regional and global systolic function.
Bioprosthetic AVR with higher than expected gradients.
Endocarditis cannot be excluded on the basis of this study.
Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2150-3-8**],
inferior hypokinesis is not seen on the current study. The apex
is well seen and contracts normally.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
CXR [**3-9**]: Left moderately severe left lower lobe atelectasis has
progressed, mild interstitial edema is new accompanied by
increasing small bilateral pleural effusions and increase in top
normal heart size as well as congestion of the hilar and
mediastinal vessels. ET tube, right internal jugular line,
nasogastric tube in standard placements. No pneumothorax.
.
MRI head [**3-9**]:
1. No acute infarction.
2. Contour irregularity of the left middle cerebral artery, and
some of the branches of the right middle cerebral artery with
minimal decrease in caliber of the left middle cerebral artery
in the interval since the prior study, with mild narrowing.
Vasculitis related changes or other etiology cannot be excluded.
Interventional neuorradiology consult can be consdiered for
further management decision.
3. No flow-limiting stenosis or occlusion or aneurysm more than
3 mm within the resolution of MR angiogram.
.
CXR [**3-10**]: Lateral aspect of the right chest is excluded from the
examination. Mild pulmonary edema and small right pleural
effusion increased. Heart size top normal. Mediastinal venous
engorgement unchanged. Left lower lobe largely airless probably
due to atelectasis. ET tube, nasogastric tube and right internal
jugular line in standard placements. No pneumothorax.
.
CXR [**3-12**]
1. Improved CHF.
2. Multifocal patchy and linear opacities in mid and lower
lungs, many of
which may be due to atelectasis, but coexisting pneumonia should
be considered considering clinical suspicion for infection.
3. Right middle lobe atelectasis, for which followup radiographs
are
suggested to document resolution.
4. Small bilateral pleural effusions.
.
EEG [**3-9**] This is an abnormal portable EEG recording due to the
background activity which was at times slow and disorganized and
at
other times showed a burst suppression pattern. These
abnormalities are
suggestive of encephalopathy. The first one of moderate
encephalopathy
and the second one with a more severe encephalopathy. The fact
that the
patient's background was viable throughout the recording is
suggestive
of the possibility of a better prognosis of encephalopathy.
Metabolic
disturbances, medications, infection, and ischemia are among the
most
common causes of encephalopathy. There are no clear epileptiform
features seen in this recording. Of note is the tachycardia.
Brief Hospital Course:
55 year-old female with a PMH of HTN, PVD, seizure disorder,
chronic pain on oxycodone, methadone, OSA who presented with
after being found down with inability to be roused by her son.
.
#. Acutely altered mental status: intubated for airway
protection from MS changes, cause was unclear, possibilities
included toxic metabolic encephalopathy, delirium, [**Month/Year (2) 4085**]
effect (hx of seroquel, cyclobenzaprine, methadone, trazadone),
seizure, CVA, infection (pancreatitis, aspiration pna,
meningitis). She was prescribed seroquel on [**3-6**], tox screen
positive for TCA (Duloxetine, cyclobenz, and seroquel can cause
false positives), opiate (methadone hx), THC, and phenobarbital
(in Donnatal), but negative for alcohol. Also hypercapnia in
setting of COPD and aggravating factor also possible. She had
no nuchal rigidity, photophobia, or focal neural deficits.
Her sedatives were initially held, she was pancultures and
treated for an aspiration pna, and her metabolic work-up was
negative. Upon extubation, she continued to show an atypical
affect, but was alert and oriented x3, and tolerating the
reinitiation of her SSRI and percocet for pain.
.
The etiology of the episode was unclear, but thought possibly
due to polypharmacy after EEG was negative, and MRI was without
acute changes. Seroquel was discontinued as possible cause for
decompensation. Given the episodes, she was advised not to
drive until cleared by the neurologists.
.
#. Acute Hypoxemic respiratory failure: thought liklely
respiratory acidosis with metabolic compensation at baseline
secondary to COPD. CXR showed right base atelectasis and scant
infiltrates. She was on stress dose steroids for airway and
relative hypotension, as she was on budesonide at baseline. As
above, she was intubated for respiratory failure, then extubated
two days prior to transfer to floor, and demonstrated good
respiratory mechanics. She was transferred to the floor with
stable oxygen saturations on low O2 requirement (3L NC). Upon
transfer, she was transitioned back to her budesonide dosing.
She ultimately stabilized from a respiratory perspective,
although she had a cough, and finding on her CXR of possible
infiltrate. She was discharged to complete a course of
levofloxacin.
.
#. Pneumonia: She presented with leukocytosis. CXR ultimately
showed likely infiltrate. She was pan cultured, as above, her
only positive cultures were GPC in her sputum. She was
initially on vanco, levo, flagyl, then transitioned to
levofloxacin as monotherapy, with plan to complete 7d course on
[**3-14**].
.
# EKG changes/?Takasubo's cardiomyopathy: while intubated on
hospital day 2, pt was noted to have t wave inversions in 7 of
12 leads, predominantly in lateral leads, cardiac
enzymes/troponin was elevated at OSH, cks flat upon admit here.
Cardiology was consulted, bedside echo performed, with mild
hypokinesis, concern for takayasu's cardiomyopathy, started on
beta blockade, and mild diuresis while on ventilator. A repeat
echocardiogram was performed, which showed improved systolic
dysfunction without apical ballooning, but her EKG continued to
show t wave inversions at discharge. She has close follow up
with Dr. [**Last Name (STitle) 171**] for further evaluation. On his review of her
echocardiograms, there was no apical ballooning seen.
.
# Acute renal failure: She developed acute renal failure while
in the ICU, likely due to diuresis. She was rehydrated, her
lisinopril was held, and her renal function was still elevated
at baseline. Her urine eos were negative. Her Cr was still
elevated at 1.2 at discharge, and her lisinopril was held until
she sees Dr. [**Last Name (STitle) **].
.
#. pancreatitis: Pt had elevated lipase secondary to possibly
gallstone pancreatitis (alk phos elevated at 190), alcohol
(though tox neg), or other less common etiologies such as
hypertriglycerides, pancreatic carcinoma, medications, viral
infections, abdominal trauma. Enzymatic analysis of
pancreatitis resolved, pt denies abd pain on exam, and her diet
was advanced without issue.
.
#. Crohns Disease: pt followed by Dr. [**First Name (STitle) 572**]; diagnosis was
mainly symptom based with little objective evidence, on chronic
budesonide. EGD and colonoscopy normal in 1/[**2150**].
.
# chronic pain: She has a history of chronic pain and has been
on methadone. Given concern for polypharmacy, the methadone was
discontinued on discharge, and she was discharged on dialudid.
.
#. HTN: Patient's lisinopril and atenolol were initially held
due to infection.
.
#. Obstructive sleep apnea: notes indicate pt use BiPap at home,
pt refused to wear bipap in the icu.
.
#. Depression/anxiety: her anxiolytics were initially held in
icu as per work-up of mental status changes, then restarted at
lower doses upon transfer to floor. She was discharged on her
home doses, and Dr. [**Last Name (STitle) 18529**] will continue to work with her on
other anxiety management. She may consider psychotherapy as an
outpatient, at a facility close to her home.
.
#. COPD: On baseline home O2 of 3L and has a long smoking
history. She did not require oxygen at discharge, with O2 sat of
95% with ambulation, and will only use O2 at night. She was
also urged to stop smoking.
.
# Follow up: Given the unclear etiology of the episode, she
will have close outpatient follow up with Dr. [**Last Name (STitle) **] ([**3-24**]), Dr.
[**Last Name (STitle) 171**] (first week of [**Month (only) 958**]), Dr. [**Last Name (STitle) 18529**] (psychiatry - 2 weeks)
and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18530**]/[**Doctor Last Name **] of neurology. Dr. [**Last Name (STitle) **], precepting
Dr. [**First Name (STitle) **], is aware of all events and will continue to coordinate
care for this complex patient.
.
EMERGENCY CONTACT: HCP is sister: [**Name (NI) **] [**Name (NI) 18531**] at
[**Telephone/Fax (5) 18532**] and secondary HCP is son [**Name (NI) 6644**] [**Name (NI) 18533**]
at same #.
.
Medications on Admission:
Albuterol inhaler 1-2puffs QID prn
Atenolol 25mg daily
Atorvastatin 20mg daily
Budesonide 6mg daily
Cyclobenzaprine 10mg TID prn
Duloxetine 50mg [**Hospital1 **]
Folic acid 1mg daily
Abandronate 150mg monthly
Lisinopril 20mg daily
Methadone 5mg Q4H, 10mg QHS
Nicotine patch 21
Pantoprazole 40mg [**Hospital1 **]
Donnatal (phenobarbital/belladonna)
Pregabalin 225mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Sulfasalazine 1g TID
Tiotropium 18mcg daily
Trazodone 100-200mg QHS prn
ASA 81mg daily
Calcium 500mg [**Hospital1 **]
Vitamin B12 100mcg daily
Ferrous sulfate 160mg daily
MVI
Seroquel 6.125-12.5mg [**Hospital1 **] prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Fifty
(50) mg PO BID (2 times a day).
13. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for muscle spasm.
15. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
17. Lyrica 75 mg Capsule Sig: Three (3) Capsule PO twice a day.
18. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
19. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*45 Tablet(s)* Refills:*0*
20. Nocturnal O2, 3L
21. Levofloxacin 500 mg daily, for 3 more days
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Acute altered mental status
Acute respiratory failure
EKG changes
Chronic pain syndrome
Severe anxiety
Oxygen dependent COPD
Obstructive sleep apnea
Acute renal failure
Discharge Condition:
stable, tolerating diet, on home oxygen supplementation.
Discharge Instructions:
You were admitted after your son found you and could not awaken
you. You were having trouble breathing, and needed to be
intubated. You got agitated and were in the ICU for several
days. Your MRI did not show an acute stroke, and your EEG did
not show an obvious seizure. It is possible that the seroquel
caused this problem, or some combination of all of your
medications.
.
You should continue to talk to your doctors about your
[**Name5 (PTitle) 4085**] regimen, which is extremly complicated, and may be
causing problems. DO NOT DRIVE UNTIL YOU SEE THE NEUROLOGISTS.
Do not change any of your medications without talking to your
doctors.
.
You need a repeat chest xray
.
Return to the ED if you have trouble breathing, get confused or
agitated again, develop high fevers or chills, or chest pain.
.
Changes to your medications:
Seroquel was discontinued.
Levofloxacin was added (for possible pneumonia).
Followup Instructions:
Provider: [**Name10 (NameIs) **],TEACHING [**Hospital **] CLINIC-CC2 (SB)
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2150-3-17**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-3-24**] 6:20
Provider: [**First Name8 (NamePattern2) 18534**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2150-3-30**] 9:00
.
Repeat chest xray in [**3-18**] weeks.
Repeat basic metabolic panel with Dr. [**Last Name (STitle) **].
|
[
"787.20",
"482.41",
"300.4",
"780.09",
"E932.0",
"794.31",
"V12.54",
"V46.2",
"401.9",
"507.0",
"276.4",
"577.0",
"307.9",
"338.4",
"E939.3",
"305.1",
"249.00",
"416.9",
"724.2",
"255.0",
"458.8",
"345.90",
"V42.2",
"275.42",
"518.81",
"555.9",
"790.5",
"276.51",
"584.9",
"440.21",
"349.82",
"272.4",
"496",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16194, 16250
|
7824, 8030
|
366, 372
|
16462, 16520
|
3966, 7801
|
17481, 18033
|
3064, 3327
|
14509, 16171
|
16271, 16441
|
13853, 14486
|
16544, 17352
|
3342, 3947
|
13098, 13827
|
17381, 17458
|
288, 328
|
400, 2069
|
8045, 13086
|
2091, 2829
|
2845, 3048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,425
| 125,355
|
28274
|
Discharge summary
|
report
|
Admission Date: [**2159-5-1**] Discharge Date: [**2159-5-5**]
Date of Birth: [**2109-1-23**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Flexeril / Tricyclic Compounds
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Nasogastric tube
History of Present Illness:
Ms. [**Known lastname 68459**] is a 50F with HCV cirrhosis, DM, and adrenal
insufficiency who presents with altered mental status. Of note,
she was just recently admitted [**Date range (1) 66383**] with the same
complaints, felt at that time to be due to hepatic
encephalopathy and she cleared on rifaximin and lactulose. Her
spironolactone was initially held in setting of hyponatremia to
125, but restarted at discharge. She was also restarted on
prophalactic bactrim at discharge for her history of LE
cellulitis.
.
Per discussion, mother thought she was still confused, weak,
unsteady on feet, and disoriented. She would fall asleep in the
middle of eating. Had a unwitnessed fall 4am on Sunday. Patient
was taking her rifaximin and lactulose, had two BMs yesterday.
She had a "rattling" cough. Was running low grade temps in the
99.8. Blood sugars were under good control 100's, as low as 78
good for her.
.
In the emergency department, vitals were T 99 P 97 BP 140/89 RR
16 O2 93% on RA. Fingerstick glucose was 98. Serum Na was 112,
down from 137 on [**4-27**], WBC 14k. CT head was negative. Abdominal
ultrasound showed a patent TIPS and NO ascites. Wrist films
showed ?periosteal reaction. Blood cultures were obtained, but
no antibiotics given Mental status wakes to sternal rub. 84
133/72 14 96% on 4L. access PIV 20guage. ER reports discussion
with liver fellow.
Past Medical History:
* HCV Cirrhosis, diagnosed [**2151**], nonresponder to interferon /
ribavirin, s/p TIPS [**11-9**] for ascites. Course has been
complicated by encephalopathy, thrombocytopenia, ascites, and
hydrothorax. Currently on [**Month/Year (2) **] list.
* Hyponatremia baseline 128-133
* Secondary adrenal insufficiency
* asthma
* DM
* GERD
* Anxiety
* h/o UTI's
* Hip fx and L4 compression Fx on [**2157-11-6**] s/p ORIF of hip fx.
Susequently she had coag neg Staph abscess w/ joint involvement
- washout [**6-/2158**]
- Vancomcyin 7/2~[**7-22**] --> Bactrim 1 tab TID
- E.coli, enterococcus, coag neg Staph
- hardware removal [**9-19**]
- vancomycin + meropenem, [**2158-9-6**]
* LE Cellulitis
* h/o UTIs
* ?prolactinoma suggestion of microadenoma [**5-13**] MRI
* hypercalcemia thought due to aggressive vitamind D repletion
Social History:
Currently lives with her mother.
Smoking: 1ppd for years, quit ~[**2154**]. Currently sober, unclear
when last drank alcohol but maybe as recently as a year ago.
IVDU: h/o IV heroin use in the remote past
Family History:
F-COPD, alcohol cirrhosis
M-diabetes, HTN, HL
Daughter-congenital heart dz
Physical Exam:
Upon arrival to the MICU
Vitals 98.1 89 162/78 16 97% on RA
General Chronically ill appearing, twitching occasionally
HEENT PEARL, sclera anicteric, MMM
Neck No JVD, supple
Pulm Lungs with few rales R base persist after cough, no
wheezing
CV Regular S1 S2 systolic murmur at apex
Abd Soft nondistender mild RUQ tenderness to palpation
GU guiac negative in ER
Extrem Warm no edema palpable distal pulses
Neuro Opens eyes to voice but shuts them again soon after,
sleepy, does follow commands intermittently, verbalizing but
speech not coherent. Does not follow commands to track finger
but EOMI spontaneous movement. No facial weakness. Able to raise
upper extremities and feet off of bed. +clonus, not cooperative
with asterixis testing.
Derm Jaundiced with multiple spider angiomas
Lines/tubes/drains foley in place draining yellow urine
Pertinent Results:
CBC 14>38<58 N 83 no bands E 0.3
Chem 112/5.5/94/18/26/0.9<77
Ca [**60**].4 Mag 1.0 Phos 2.3
ALT 47, AST 107, ALKP 160, Tbil 4.2, Alb 3.3
INR 1.5, PTT 37
lactate 1.3
UA mod bld tr ket, 0-2 rbc, 0 wbc
.
Micro:
[**5-1**] blood cx NGTD
.
ECG: SR @93, nl axis and intervals, peaked T's more prominent
[**4-26**]
.
STUDIES:
CT head
1. No acute intracranial pathology identified. If clinical
concern warrants however, would recommend repeat imaging of the
posterior fossa.
.
Abdominal ultrasound
no ascitic fluid. wall to wall flow seen in TIPS. stable
appearance to cirrhotic liver.
.
CXR no infiltrate L elevated hemidiaphragm, atelectasis, small
bowel appears dilated
.
Plain films R wrist periosteal reaction distal radius,
nonspecific finding but could be c/w subacute fracture
.
CXR:Unchanged position of the nasogastric tube. The pre-existing
right lower lobe opacity shows moderate decrease in extent.
Unchanged left basilar atelectasis. No newly occurred focal
parenchymal opacities. Unchanged bilateral healed rib fractures.
Unchanged size of the cardiac silhouette.
Brief Hospital Course:
This 50F with hepatitis C cirrhosis, DM, and secondary adrenal
insufficiency with recent hospitalization for hepatic
encephalopathy returns with altered mental status and is found
to be profoundly hyponatremic now called out from MICU.
.
#)Altered mental status: Improved throughout admission, likely
multi-factorial including, hyponatremia, hypercalcemia, hepatic
encephalopathy, and multiple sedating meds. No other signs of
decompenstation such as ascites to tap. No evidence of GIB.
Electrolytes improved with repletion. Tolerated PO now, blood
and urine cultures NGTD. Held neurontin but restated prior to
admisison. Cont rifaximin and lactulose. She was AAOX3 prior to
discharge.
.
#)Hyponatremia: 112 on admission, improved with NS. 130 upon
discharge. Likely [**1-8**] poor PO intake in setting of restarting
spironolactone at too high a dose. Restarted
lasix/spironolactone at half doses.
.
#)?Aspiration Pneumonia: patient had leukocytosis on admission,
improved without fever right lower lobe opacity seen on CXR.
Patient with new nonproductive cough. Treated with 5 day course
of levo/flagyl plus nebs for aspiration pneumonia. Blood, Urine,
NGTD. Legionella negative.
.
#)Cirrhosis: C/b encephalopathy, MELD 16 upon admission,
continued rifaximin and lactulose at increased dose, trended
LFTs, INR, restarted Bactrim ppx once levo/flagyl finishes.
.
#)Hypercalcemia: Improved. Free ionized calcium normal this am.
Has been ongoing,(seen in endocrinology clinic and thought to be
[**1-8**] high doses of calcitriol). Patient was hypercalcemic at last
admit, with improvement with holding calcium supplements per DC
summary. PTH appropriately down at 13. Continued to hold
calcium/D, should be monitored by endocrine/PCP.
.
#)Ileus: [**Month (only) 116**] have had in setting of narcotics, poor PO intake
and electrolyte abnormalities. NGT placed but once she tolerated
PO with +BS and stool output, d/ced it.
.
#)Wrist pain: Question of wrist fracture on plain films that was
re-read as unlikely to be fracture. Pt with known osteoporosis.
Continued splint per [**Month (only) **]
.
#)Thrombocytopenia: [**1-8**] spenomegaly/sequestration, remained at
baseline in 40-60s, monitored
.
#)DM: Covered with insulin sliding scale, diabetic diet
.
#)Adrenal insufficiency: continued home prednisone in addition
to adding florinef for mineralicorticoids.
.
#)Asthma: Continued home inhalers
.
#)Chronic pain: continued home narcotics at a smaller dose
.
#)General Care: FEN: low sodium diet, follow and replete elytes,
Access 2PIV, PPX: PPI, boots, strict aspiration precautions,
Dispo: pending electrolyte repletion, Code: full, Comm with
mother [**Name (NI) 2048**] Phone: [**Telephone/Fax (1) 68660**]
Medications on Admission:
Lasix 80mg daily
Spironolactone 100mg daily
Rifaximin 400mg TID
Prednisone 5mg daily
Bactrim DS 1tab [**Hospital1 **]
Insulin lantus 21 units at bedtime
Humalog sliding scale
Advair 250/50mg [**Hospital1 **]
Albuterol prn
Singulair 10mg daily
Venlafaxine 75mg [**Hospital1 **]
Oxycodone 5mg q8h prn
Oxycontin 10mg q12h
Neurontin 100mg [**Hospital1 **]
Nepro
Lidoderm patch
MVT
Folate 1mg daily
L-lysine 500mg [**Hospital1 **]
Triamcinolone cream
Senna prn
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty One (21)
units Subcutaneous at bedtime.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Humalog 100 unit/mL Cartridge Sig: as directed per sliding
scale units Subcutaneous four times a day.
6. Triamcinolone Acetonide 0.1 % Paste Sig: One (1) Dental
twice a day.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q8H (every 8
hours) as needed for pain.
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-8**] IH Inhalation every six (6) hours.
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): Please titrate to 4 bowel movements a day.
Disp:*3600 ML(s)* Refills:*2*
14. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
15. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
19. L-Lysine 500 mg Capsule Sig: One (1) Capsule PO twice a day.
20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care Services
Discharge Diagnosis:
Primary:
Hepatic Encephalopathy
Aspiration Pneumonia
Hyponatremia
Ileus
Hyperkalemia
Hypercalcemia
.
Secondary:
Cirrhosis due to Hepatitis C
Diabetes
Discharge Condition:
vitals signs stable, cleared by physical therapy
Discharge Instructions:
You were admitted because of confusion which we believe was
because of your encephalopathy and electroyltes abnormalities.
We treated you with fluids and replaced your electrolytes. Your
bowels also slowed down but improved with hydration. We also
treated you for an aspiration pneumonia.
.
We STOPPED your tube feeds, oxycontin, and senna.
We STARTED florinef 0.1mg by mouth daily.
We decreased your sprionolactone to 50mg by mouth daily.
We decreased your lasix to 40mg by mouth daily.
We decreased your oxycodone to 2.5-5mg PO every 8 hours as
needed.
We increased your lactulose to 30mL by mouth 4 times a day.
.
Please follow up in the liver clinic on [**2159-5-23**] at 8:40am.
.
If you develop chest pain, shortness of breath, cough, fever,
chills, nausea, vomiting, diarrhea, abdominal pain, confusion,
falls, headaches, or dizziness please call your primary care
doctor or go to your local emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2159-9-6**] 10:00
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2159-9-6**] 9:40
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2159-5-23**] 8:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2159-5-6**]
|
[
"250.00",
"287.5",
"560.1",
"276.1",
"493.90",
"070.44",
"255.41",
"V15.82",
"276.7",
"300.00",
"338.29",
"530.81",
"507.0",
"719.43",
"571.5",
"275.42"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9875, 9945
|
4874, 5122
|
323, 342
|
10139, 10190
|
3778, 4851
|
11154, 11694
|
2827, 2904
|
8092, 9852
|
9966, 10118
|
7612, 8069
|
10214, 11131
|
2919, 3759
|
262, 285
|
370, 1746
|
5137, 7586
|
1768, 2589
|
2605, 2811
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,297
| 137,410
|
9875
|
Discharge summary
|
report
|
Admission Date: [**2147-1-24**] Discharge Date: [**2147-1-25**]
Date of Birth: [**2069-7-14**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
gentleman with a history of coronary artery disease (status
post coronary artery bypass graft), congestive heart failure
(with an ejection fraction of 35%), hypertension, and known
abdominal aortic aneurysm who was admitted for a workup of
his aortic aneurysm in the setting of ongoing abdominal pain.
The patient reports initial imaging of his aneurysm
approximately one year ago with an approximate diameter of 3
cm at that time. For the past two months, the patient has
been complaining of some bilateral lower quadrant/suprapubic
abdominal pain that has been crampy and intermittent with no
associated nausea, vomiting, diarrhea, hematochezia, fevers,
chills, or weight loss.
A computerized axial tomography of his abdomen on [**2147-1-12**] showed an abdominal aortic aneurysm of 4.5 cm X 5.8
cm; which was increased in size since one year ago.
Over the last several weeks, the patient has had persistent
intermittent abdominal symptoms, but no acute exacerbation.
After a discussion with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] yesterday
morning, the patient was admitted to the hospital for blood
pressure monitoring and repeat computerized axial tomography
given his ongoing symptoms and possible symptomatic abdominal
aortic aneurysm.
The patient denied chest pain, but he did note some chronic
dyspnea. No cough. No orthopnea. No lower extremity edema.
The patient does reports a history of gastroesophageal reflux
disease which is unlike his current symptoms. No peptic
ulcer disease or gallstones. The patient reports having had
a prior colonoscopy which was negative (by report).
PAST MEDICAL HISTORY:
1. Abdominal aortic aneurysm.
2. Coronary artery disease; status post coronary artery
bypass graft at [**Hospital6 1708**] in the early
[**2123**].
3. History of congestive heart failure (with an ejection
fraction of 35% by echocardiogram in [**2146-12-26**]).
4. Status post ventral hernia repair.
5. History of osteoarthritis.
6. Hypertension.
7. Hypercholesterolemia.
8. Asbestosis.
9. Gastroesophageal reflux disease.
10. Status post bilateral corneal surgeries.
ALLERGIES: No known drug allergies; question of a reaction
to PERCOCET.
MEDICATIONS ON ADMISSION:
1. Triamterene 75 mg by mouth once per day.
2. Mevacor 20 mg by mouth once per day.
3. Zestril 10 mg by mouth once per day.
4. Atrovent inhaler as needed.
5. Azmacort inhaler as needed.
6. Theophylline.
7. Aspirin 325 mg by mouth once per day.
SOCIAL HISTORY: The patient is widowed. He drinks
approximately two to three drinks per week. He has a history
of prior tobacco, but he has quit.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed vital signs with a temperature of 97
degrees Fahrenheit, his heart rate was 93, his blood pressure
was 125/64, and his pulse oximetry was 99% on room air.
General appearance revealed the patient was
comfortable-appearing and in no acute distress. Head, eyes,
ears, nose, and throat examination revealed the mucous
membranes were moist. The oropharynx was clear. There were
bilateral surgical pupils. The sclerae were anicteric. The
neck was supple with no jugular venous distention.
Cardiovascular examination revealed distant first heart sound
and second heart sound. No murmurs. The lungs were clear to
auscultation bilaterally. The abdomen was soft and obese.
He had a vertical periumbilical scar. He had some mild
tenderness to palpation in the suprapubic area. There was no
rebound or guarding. There were active bowel sounds.
Extremity examination revealed he had prominent varicosities
with no edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed the patient's white blood cell count was 6.8, his
hematocrit was 42.2, and his platelets were 239. His INR was
1.1. Sodium was 142, potassium was 4.4, chloride was 105,
bicarbonate was 28, blood urea nitrogen was 19, creatinine
was 1, and his blood glucose was 98.
PERTINENT RADIOLOGY/IMAGING: A computerized axial tomography
of the abdomen revealed a 5.8-cm X 4.5-cm in diameter
abdominal aortic aneurysm which was unchanged from prior.
There was no evidence of extravasation of contrast. There
was also a thrombosed aneurysm involving the left renal
artery which was also unchanged. The patient had extensive
bilateral pleural plaques which were chronic.
An electrocardiogram on admission revealed a normal sinus
rhythm at 94 beats per minute, with some intraventricular
conduction abnormalities. Left axis with occasional
premature atrial contractions.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: The patient with a history of
coronary artery disease. He was continued on his aspirin and
his ACE inhibitor. It was unclear why he was not on a beta
blocker, but this might be secondary to bronchospasm in the
setting of his known pulmonary disease. He also has a
history of congestive heart failure but appeared well
compensated and was continued on his ACE inhibitor.
For blood pressure control, the patient was initially started
on a Nipride drip after placement of an arterial line. He
remained on the Nipride overnight with a goal systolic blood
pressure of 120 to 130. The Nipride was weaned off as we
increased the dose of his lisinopril to 40 mg by mouth once
per day and started him on Norvasc at initially 5 mg and then
10 mg by mouth once per day.
2. VASCULAR ISSUES: The patient with a known abdominal
aortic aneurysm with persistent abdominal pain. By history,
the patient's abdominal symptoms had not acutely worsened. A
repeat computed tomography scan of his abdomen was
essentially unchanged. He was evaluated by Vascular surgery who
felt that his abdominal pain was not related to his abdominal
aortic aneurysm per se, and that he would best benefit from
an elective outpatient stenting procedure within the next
several weeks.
3. RENAL ISSUES: Given the addition of an increased ACE
inhibitor, his triamterene was discontinued. His potassium
was within normal limits during this hospitalization.
4. GASTROINTESTINAL ISSUES: Regarding the patient's chronic
abdominal pain, it was unclear whether this was secondary to
his aortic aneurysm. He does have a history of
gastroesophageal reflux disease; although, he stated that his
symptoms now were different. Also considered peptic ulcer
disease. Of note, there was no other bowel pathology noted
on the computerized axial tomography. The patient's liver
function tests were within normal limits.
On the morning of discharge, the patient had no appreciable
abdominal pain or tenderness to palpation. He was discharged
on a dose of Protonix. It was possible his gastroesophageal
reflux disease symptoms could be worsened by his
theophylline.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) 487**]
[**Last Name (NamePattern1) **] as scheduled.
2. The patient will initiate Norvasc and go out on a higher
dose of lisinopril.
3. The patient was also instructed to stop his triamterene.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Lovastatin 20 mg by mouth once per day.
3. Flovent 110-mcg inhaler 2 puffs inhaled twice per day.
4. Atrovent inhaler 1 puff inhaled q.4-6h. as needed.
5. Theophylline (as previously dosed).
6. Protonix 40 mg by mouth once per day.
7. Norvasc 10 mg by mouth at hour of sleep.
8. Lisinopril 40 mg by mouth once per day.
As noted, the patient was to stop his triamterene. The
patient also instructed to minimize his use of alcohol, as it
may effect his blood pressure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2147-1-25**] 10:38
T: [**2147-1-28**] 14:22
JOB#: [**Job Number 33147**]
|
[
"789.00",
"414.01",
"272.0",
"V45.81",
"428.0",
"501",
"401.9",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7380, 8183
|
2431, 2683
|
7075, 7354
|
4821, 6991
|
7006, 7042
|
156, 1822
|
1845, 2405
|
2700, 4787
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,369
| 103,344
|
40078
|
Discharge summary
|
report
|
Admission Date: [**2192-9-28**] Discharge Date: [**2192-10-2**]
Date of Birth: [**2107-7-26**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Latex
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
From [**Hospital Unit Name 153**] admission note:
85 year old man with known history of cryptogenic cirrhosis with
hypersplenism, portal hypertension, and esophogeal varices along
with chronic LGIB due to known AVMs and pancytopenia presents
transferred from OSH for BRBPR. Patient has had chronic blood
per stool since [**Month (only) 116**], and has been followed closely with serial
hematocrits and transfusions. Previous colonoscopies have shown
bleeding AVM's treated with cauterization. Presents to OSH after
having 5 bloody bowel movements yesterday morning. Stools
decscribed as loose and dark with bright red blood mixed in.
Denies abdominal pain, nausea or vomiting. Denies dizziness or
syncope. No chest pain or SOB. Last bowel movement was this
morning with smaller amount of BRB mixed with stool.
.
Patient remained normotensive at OSH. HCT showed HCT 21.5
(baseline 25). Received 2 units pRBC with increase to 24.3.
Received one additional unit prior to transfer. On arrival to
the floor, patient is comfortable and without complaint except
for being hungry.
Past Medical History:
- recurrent GI bleeding (see above)
- Grade II esophageal varicies s/p endoscopic band ligation,
[**First Name9 (NamePattern2) 67469**] [**Last Name (un) 88105**] injection
- Diverticulosis
- Internal hemorrhoids
- CAD s/p CABG approximately 30 years ago
- Moderate to severe mitral regurgitation
- Severe pulmonary artery hypertension
- History of atrial fibrillation
- Biventricular Pacemaker (inserted ~[**2188**], unknown indication)
- Osteomyelitis at 8 y/o resulting in shortening of his left leg
- Hearing impairment
- Bilateral hip replacement
- Anti-K antibody. Patient should receive K-antigen negative
products for all red cell transfusions.
Social History:
Mr. [**Known lastname 88104**] is one of 9 children. Only he, his brother, and
his oldest sister are still living. He currently lives with his
wife in a senior apartment complex in [**Location (un) 38**]. He retired
10-15 years ago from a career as a professional accordian player
when his hearing began to decline. He shops for food, cooks, and
helps care for his wife who has spinal stenosis. He performs his
ADLs without problem and uses a cane at basleline.
TOBACCO: smoked cigarettes occasionally; last smoked 20-25 years
ago
ALCOHOL: denies
ILLICITS: denies
Family History:
His father had a history of alcohol abuse and died from heart
disease. His mother died from heart disease in her 90s. One of
his sons died at 52 y/o from sudden cardiac death. His other son
died at 53 y/o in [**Country 3992**], where he was working as a physician's
assistant. There is no family history of colon cancer.
Physical Exam:
Admission exam(from [**Hospital Unit Name 153**] note)
Vitals: T:97.9 BP:144/81 P:60 R:14 18 O2: 99%
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, II/VI holosystolic
murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Notable posterior displacement of rt tibia from knee with
shortening of right leg.
Neuro: AAOx4. CNII-XII intact. 4+/5 strength throughout except
at rt knee, likely due to chronic deformity. FTN intact. Gait
deferred.
Discharge Exam
VSS
GEN: Patient lying comfortably in bed nad a+ox3
HEENT: MMM oropharynx clear
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: ctab no w/r/r
ABD: soft nt nd bs+
EXTR: no le edema good pedal pulses bilaterally
DERM: no rashes, ulcers or petechiae
neuro: cn 2-12 grossly intact non-focal
PSYCH: normal affect and mood
Pertinent Results:
[**2192-9-28**] 07:56PM HCT-31.8*
[**2192-9-28**] 04:00PM GLUCOSE-85 UREA N-17 CREAT-1.0 SODIUM-144
POTASSIUM-3.3 CHLORIDE-111* TOTAL CO2-24 ANION GAP-12
[**2192-9-28**] 04:00PM estGFR-Using this
[**2192-9-28**] 04:00PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2192-9-28**] 04:00PM WBC-2.3* RBC-3.68*# HGB-11.6*# HCT-33.5*#
MCV-91 MCH-31.4 MCHC-34.5 RDW-19.3*
[**2192-9-28**] 04:00PM NEUTS-63.5 LYMPHS-23.7 MONOS-8.8 EOS-3.7
BASOS-0.3
[**2192-9-28**] 04:00PM PLT COUNT-86*
Discharge labs
[**2192-10-2**] 11:15AM BLOOD WBC-2.1* RBC-3.13* Hgb-10.1* Hct-28.4*
MCV-91 MCH-32.4* MCHC-35.6* RDW-19.3* Plt Ct-77*
[**2192-10-2**] 11:15AM BLOOD PT-14.3* INR(PT)-1.2*
Colonoscopy [**10-2**]:
Impression: Angioectasia in the ascending colon (thermal
therapy)
Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
.
#BRBPR/melena: Patient was initially transferred to the ICU and
monitored overnight. He did not require any further
transfusions(got three at OSH). He underwent colonoscopy on
[**10-2**] which showed an angioectasia in the ascending colon which
was coagulated. Diverticulosis was also noted. His hct on
[**10-2**] was 28.4. He was discharged on po iron and will f/u with
his PCP [**Last Name (NamePattern4) **] [**10-8**]. PLEASE REPEAT A CBC AT THIS VISIT.
.
#cryptogenic cirrhosis: no report of hemoptysis, coffee-ground
emesis. He will follow up with Dr. [**First Name (STitle) **] for an EGD on [**10-9**].
#afib: Patient was paced through hospitalization. His nadolol
was restarted on discharge.
.
Medications on Admission:
-Crestor 5 daily
-Nadolol 40 daily
- Flomax 0.4 daily
- Omeprazole 20 daily
- Ascorbic acid 500 daily
- Ferrous sulfate 325 daily
-MVI
Discharge Medications:
1. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
5. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for bloody and black stool. Initially you
required a blood transfusion, no further bleeding was noted. A
colonoscopy was performed and an abnormal blood vessel
(angioectasia) was found in your colon and treated. On
discharge your blood counts had been stable for >48 hours
without transfusion. Please follow up with your primary care
physician and your gastroenterologist.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**] O.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
When: Monday, [**10-8**], 3:30PM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2192-10-9**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage
*This appointment is for an Endoscopy. If you have not already
received preparation instructions from Dr. [**Last Name (STitle) 88107**] office, please
call the number above.
|
[
"284.19",
"V43.64",
"V45.81",
"572.3",
"571.5",
"569.85",
"562.10",
"414.00",
"V45.01",
"456.21",
"455.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
6458, 6464
|
5040, 5755
|
280, 293
|
6522, 6522
|
4144, 5017
|
7091, 7963
|
2671, 2993
|
5940, 6435
|
6485, 6501
|
5781, 5917
|
6672, 7068
|
3008, 4125
|
235, 242
|
321, 1397
|
6537, 6648
|
1419, 2073
|
2089, 2655
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,594
| 105,434
|
15706+15520
|
Discharge summary
|
report+report
|
Admission Date: [**2128-10-29**] Discharge Date: [**2128-11-10**]
Date of Birth: [**2070-9-2**] Sex: M
Service: Bloomgart
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
male transferred from [**Hospital 86**] Hospital with no known past
medical history. He was found unconscious at home by his
brother on [**2128-10-20**]. The patient had last been seen
two days prior to this and was well at that time.
In the Emergency Room at [**Hospital 86**] Hospital, the patient had a
temperature of 95.2 rectally, blood pressure was 119/90,
pulse was 84, respiratory rate was 26, oxygen saturation was
96% on 100% nonrebreather. The patient received 2 liters of
normal saline and was intubated for airway protection.
Arterial blood gas on 100% FIO2 ventilator showed a pH of
7.43, PCO2 of 21, PO2 of 342.
Laboratory values sent on presentation revealed sodium was
142, glucose was 110, calcium was 6.3, white blood cell count
was 14, albumin was 2.1. Creatine phosphokinase was 746 with
a troponin of less than 0.3. Serum and urine toxicology
screens were negative. INR was 1.8.
The patient required no sedation while on the ventilator. A
head CT was obtained which showed a large 2-cm intercellular
mass consistent with a pituitary macroadenoma. A chest x-ray
showed no acute abnormalities.
At [**Hospital 86**] Hospital, the patient was admitted directly to the
Intensive Care Unit where he initially required pressor
support with dopamine. The patient was hydrated and given
stress-dose steroids with hydrocortisone given pituitary
macroadenoma seen on head CT. Of note, the patient did not
require any sedation while intubated. The patient was
extubated 48 hours later without incident.
The patient's hematocrit on admission was 31 which decreased
to 25 while on hydration. The patient was transfused with
packed red blood cells. The patient subsequently sent out
coffee-grounds emesis from a nasogastric tube with
maroon-colored stools. An esophagogastroduodenoscopy was
performed which revealed mild distal esophagitis as well as a
moderate-sized hiatal hernia. In the first portion of
duodenum there was noted to be a large ulcer with a clean
white base with no stigmata of recent bleeding. The patient
was started on intravenous Protonix and a Helicobacter pylori
antibody was sent which returned negative. Serial
hematocrits remained stable over the next several days.
Given the large pituitary macroadenoma seen on head CT and
hypothermia and hypotension on presentation, a workup for
panhypopituitarism was initiated. The patient's initial
sodium was 142 with a potassium of 3.1. Total T3 was 44
(normal 45 to 137). Free T4 was 0.8 (normal 0.8 to 1.5).
Follicle-stimulating hormone was 7 (normal 1.1 to 8). LH was
1.35 (normal 2 to 12). Periactin level was 1.86 (normal 1.61
to 18.7). Initial cortisol level drawn prior to the
administration of hydrocortisone was 11 (normal range 3 to
17). Given low-normal free T4 and total T3 and relative
hypotension the patient was started on intravenous
levothyroxine and hydrocortisone.
The patient underwent a follow-up magnetic resonance
imaging/magnetic resonance angiography approximately six days
following presentation. Magnetic resonance imaging revealed
a 5-cm X 2-cm X 2.5-cm enhancing lobulated soft tissue mass
originating in the sella turcica and extending superiorly
into the supracellular cistern; most likely representing a
pituitary macroadenoma. There was no evidence of hemorrhage
or infarct on diffusion-weighted images. A magnetic
resonance angiography of the surface of [**Location (un) 431**] and posterior
circulation was normal.
Following extubation, the patient was noted to be hypoxic on
a shovel mask. A CT of the chest with CT spiral angiography
was obtained which showed no evidence of pulmonary embolism.
There were small bilateral lobe airspace infiltrates;
otherwise, lung parenchyma was clear. The patient was
started on ceftazidime and Flagyl for a presumed aspiration
pneumonia. Given liver function abnormalities on
presentation, and abdominal CT was done which showed evidence
of cirrhosis with a small amount of ascites. Given liver
abnormalities and hypoxia, a concern for hepatopulmonary
syndrome was considered.
A workup of cirrhosis was initiated at the outside hospital.
Hepatitis A, hepatitis B, and hepatitis C panels were
negative. Ceruloplasmin level was normal. Alpha-fetoprotein
was negative.
The patient was transferred to [**Hospital1 188**] for evaluation by Neurosurgery following medical
stabilization.
The patient's brother was [**Name (NI) 653**] and revealed that the
patient had been feeling unwell for several years prior to
admission. The patient's brother reports the patient
appeared jaundiced and had progressive fatigue and decreased
energy levels. The patient had not seen a physician prior to
presentation at the outside hospital.
PAST MEDICAL HISTORY: None; per report from brother the
patient had not seen a physician prior to presentation to the
outside hospital.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is single. He has never been
married with no children. The patient lived with his mother
until approximately one year ago when she passed away. He
denied any history of alcohol use, tobacco use, or
intravenous drug use.
PHYSICAL EXAMINATION ON TRANSFER: Temperature was 97.2,
blood pressure was 98/60, pulse was 74, respiratory rate was
20, oxygen saturation was 93% on 70% scoop mask. In general,
a very pale and chronically ill-appearing male. No secondary
sexual characteristics. Largely unresponsive and nonverbal.
He followed simple commands; would nod "yes" or "no" to
questions. Head, eyes, ears, nose, and throat examination
revealed pupils were equal, round, and reactive to light.
Mucous membranes were dry with crusted blood in his mouth.
Poor dentition. Cardiovascular examination revealed a
regular rate, normal first heart sound and second heart
sound. No murmurs, rubs, or gallops. Lungs revealed
crackles at the bases, right greater than left. No stridor.
Abdomen was soft and nontender. Positive distention with
fluid wave. Extremities were diffusely edematous, pitting.
Clotting noted on hands. Neurologically, as above unable to
assess cranial nerves as the patient could not follow finger
directions properly.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
obtained during this admission.
1. ENDOCRINE: Prolactin was 9.6 (normal 2 to 20).
Cortisone stimulation test (no prednisone given 24 hours
prior to test) was 22, 27, and 23. Aldosterone was 90, 103,
103. Adrenocorticotropic hormone was pending.
Follicle-stimulating hormone was 1.7 (normal 2 to 10). LH
was 1.4 (normal 2 to 10). Thyroid-stimulating hormone was
less than 0.05. Free testosterone was less than 0.05.
Testosterone was 19 (normal 270 to 1100). Growth hormone and
insulin-like growth factor levels were pending at the time of
this dictation.
2. LIVER STUDIES: Hepatitis A, hepatitis B, and hepatitis C
serologies were negative. AST was 38, ALT was 33, alkaline
phosphatase was 61, total bilirubin was 1.5, amylase was 43,
lipase was 36, Helicobacter pylori negative. Albumin was
1.8. INR was 1.8. Antimitochondrial antibody was negative.
Anti-smooth muscle antibody positive. Antinuclear antibody
positive. Alpha-fetoprotein was 2.6. IgG was normal. Iron
level was 14. Ferritin was 22. Total iron-binding capacity
was 202.
3. HEMATOLOGY: Platelets were 113. Fibrinogen was 97. SBP
was 10 to 40. D-dimer was 500 to 1000. LDH was 390.
Reticulocyte count was 4.6. Ammonia was 41. Human
immunodeficiency virus negative.
4. MICROBIOLOGY:
(a) Urine on admission with no white blood cells.
(b) Blood cultures 1/4 bottles from [**2128-10-30**] drawn
from subclavian central line were positive for Staphylococcus
aureus coagulase-positive oxacillin resistant. Follow-up
blood cultures on [**11-1**], [**11-3**], and [**11-4**]
showed no growth to date.
(c) Peritoneal fluid on [**2128-11-1**] revealed no
growth.
(d) Pleural fluid from [**11-4**] revealed no growth.
(e) Sputum culture from [**2128-11-3**] with moderate
growth of methicillin-resistant Staphylococcus aureus.
(f) Blood cultures for fungal and acid-fast bacillus with no
fungus or macrobacteria isolated. Stool for Clostridium
difficile negative on [**11-1**] and [**11-4**].
RADIOGRAPHIC IMAGING:
1. A portable chest x-ray on [**2128-10-29**] revealed low
lung volumes with bibasilar atelectasis, left greater than
right.
2. A CT scan of the abdomen and pelvis on [**2128-10-31**]
showed a large amount of abdominal pelvic ascites as well as
significant soft tissue edema, bilateral pleural effusions.
The liver was small without focal masses. Pancreas, spleen,
adrenal glands, and kidneys were unremarkable. The main
portal and splenic vein was patent.
3. A chest CT on [**2128-10-31**] with contrast revealed no
enlarged lymph nodes and small pleural effusions (left
greater than right). No focal lung consolidations,
pneumothorax, or nodule.
HOSPITAL COURSE BY SYSTEM:
1. HYPOXIA: The patient presented with oxygen saturations
of 93% to 97% on 100% nonrebreather. An arterial blood gas
was obtained on admission which showed pH was 7.45, PCO2 was
33, PAO2 was 80, with A:A gradient of over 300.
A review of the chest CT obtained at the outside hospital
revealed small bilateral pleural effusions with otherwise
clear lung parenchyma. No evidence of pneumonia. In
addition, a CT angiogram obtained at the outside hospital
showed no evidence of pulmonary embolism.
A Pulmonary consultation was obtained. Given cirrhosis seen
on abdominal CT, concern for hepatopulmonary syndrome was
addressed. A echocardiogram with bubble study was obtained
which indicated a marked right-to-left shunt strongly
suggestive of pulmonary arterial venous shunting.
A CT of the chest with contrast was repeated; and on review
with Radiology, there was no large pulmonary arteriovenous
malformation which would be amenable to embolization.
During his hospital course, the patient's oxygen saturations
continued to decline. A repeat arterial blood gas on
[**11-2**] showed pH was 7.51/26/53 on 100% nonrebreather.
The patient was transferred to the Intensive Care Unit for
further management. The etiology of hypoxia was again
thought to be secondary to hepatopulmonary syndrome.
The patient underwent a right-sided therapeutic thoracentesis
on [**11-4**] with removal of 1400 cc of clear serous fluid.
The pleural fluid was transudative with 11 white blood cells
and [**Pager number **] red blood cells. Fluid culture showed no growth.
The etiology of fluid was thought to be from massive ascites.
Following thoracentesis, the patient's oxygenation did not
improve.
The patient was evaluated by the Liver Service for a possible
liver transplant, but was not a candidate secondary to
profound hypoxia. Therefore, treatment for hepatopulmonary
syndrome remained supportive with supplemental oxygen.
2. SUPPRESSED MENTAL STATUS: On admission, the patient
responded mainly to commands but remained largely
unresponsive. A CT scan done on admission at the outside
hospital showed a large pituitary macroadenoma. A follow-up
magnetic resonance imaging/magnetic resonance angiography did
not show any evidence of ischemic or hemorrhagic stroke. PA
CO2 on arrival to the floor was 31 on arterial blood gas.
A Neurology consultation was obtained. The patient underwent
electroencephalogram which showed slow background maximum
frequency 6 hertz versus delta frequency consistent with
encephalopathy.
The etiology of suppressed mental status was thought to be
secondary to structural lesion (pituitary mass versus toxic
metabolic state), hepatopulmonary syndrome. On discharge,
the patient was able to answer simple questions and nod "yes"
and "no."
3. ENDOCRINE SYSTEM: The patient presented with known
pituitary macroadenoma with suppressed thyroid-stimulating
hormone, follicle-stimulating hormone, LH, and normal
cortisol. The Endocrinology Service was consulted. The
patient was initially started on stress-dose hydrocortisone
which was tapered to 30 mg intravenously q.a.m. and 15 mg
intravenously q.p.m. In addition, he was started on
levothyroxine 100 mcg p.o. q.d.
Given the relative hypoxia and poor medical condition, the
patient was unstable to go to the operating room for surgical
resection of the pituitary mass.
4. HEMATOLOGY: The patient presented with a platelet count
of 113. Given the use of subcutaneous heparin for deep
venous thrombosis prophylaxis at the outside hospital a
hemagglutination-inhibition test antibody was sent and was
positive. In addition, a disseminated intravascular
coagulation panel was sent on hospital day two, which
revealed a platelet count of 80, INR was 1.8, fibrinogen was
102, D-dimer was 500 to 1000, and SBP of 52, 110.
A Hematology consultation was placed. It was unclear if
coagulation abnormalities were secondary to liver disease
versus disseminated intravascular coagulation. The patient
was supported with cryo to maintain fibrinogen greater than
100, and fresh frozen plasma was given prior to procedures.
The etiology of disseminated intravascular coagulation
included sepsis. Blood cultures drawn on admission grew
methicillin-resistant Staphylococcus aureus in [**12-26**] bottles.
The patient's central line was removed, and the patient was
started on vancomycin. However, heparin products were
avoided. The patient continued to have low platelets,
elevated INR, and low fibrinogen which was thought to be
likely secondary to progressive liver disease.
5. GASTROINTESTINAL SYSTEM: The patient presented with
evidence of cirrhosis with an elevated INR, large ascites, an
albumin of 2.1, and a bilirubin of 1.2.
The patient's family denied any history of alcohol use, and
toxicology screen on admission was negative. Hepatitis A,
hepatitis B, and hepatitis C panels were negative.
Ceruloplasmin and iron levels were both normal. Liver
function tests on admission were within normal limits. In
addition, an antinuclear antibody and anti-smooth muscle
antibody returned positive; consistent with possible
autoimmune hepatitis.
The patient underwent a diagnostic paracentesis to rule out
spontaneous bacterial peritonitis in the setting of
disseminated intravascular coagulation of unknown etiology.
This revealed 10 white blood cells with [**Pager number 45264**] red blood cells;
and the culture showed no growth. Fluid was transudative.
Ascites albumin level was less than 1.
The Liver Service and Gastrointestinal Service were consulted
regarding the management of a new diagnosis of cirrhosis.
The Gastrointestinal Service indicated no role for steroids.
In addition, the Liver Service evaluated the patient for a
possible liver transplant; but given pronoun hypoxia, the
patient was not a candidate.
At the outside hospital the patient had an upper
gastrointestinal bleed with coffee-grounds emesis and maroon
stools. Esophagogastroduodenoscopy revealed a duodenal
ulcer. A Helicobacter pylori was sent and was negative. The
patient was kept on Protonix 40 mg intravenously b.i.d. On
[**2128-11-8**] the patient had bright red blood per rectum
with a drop in his hematocrit from 27.2 to 21.6. The patient
was transfused 2 units of packed red blood cells. Per
discussions with family, management was to be supportive care
only.
6. FAMILY DISCUSSION: Given large pituitary macroadenoma,
progressive hypoxia secondary to hepatopulmonary syndrome,
with no available medical therapy, a family discussion was
held with the patient's brother and friend.
Given progressive medical illnesses, it was decided that the
patient would be do not resuscitate/do not intubate and
supportive care only. At discharge, the patient was
transferred to nursing home with hospice care.
DISCHARGE DIAGNOSES:
1. Pituitary macroadenoma.
2. Cirrhosis likely secondary to autoimmune hepatitis.
3. Hepatopulmonary syndrome.
4. Upper gastrointestinal bleed secondary to peptic ulcer
disease.
5. Disseminated intravascular coagulation.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2128-11-9**] 16:11
T: [**2128-11-9**] 16:33
JOB#: [**Job Number 19281**]
Admission Date: [**2128-10-29**] Discharge Date: [**2128-11-17**]
Date of Birth: [**2070-9-2**] Sex: M
Service: [**Location (un) **]/INTERNAL MEDICINE
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] was a 50-year-old
gentleman with a history of hepatopulmonary syndrome,
hypoxemia, end-stage liver disease, and DIC who was
transferred from an outside hospital after being found down
and apneic.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit at the [**Hospital6 2018**] and aggressive measures were made to support the
patient's respiratory status. Unfortunately, however, the
patient succumbed to his hepatopulmonary syndrome and
continued active bleeding to his lungs and gastrointestinal
tract from fistulae in his lungs and from his DIC. He
expired on [**2128-11-17**] after being made comfort
measures only by his family, specifically his brother.
DISCHARGE DIAGNOSIS:
1. Hepatopulmonary syndrome.
2. Disseminated intravascular coagulation.
3. Hypoxemia.
4. Gastrointestinal bleed.
5. Panhypopituitarism.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2129-1-13**] 02:00
T: [**2129-1-13**] 16:03
JOB#: [**Job Number **]
|
[
"571.5",
"511.9",
"286.6",
"287.5",
"253.2",
"789.5",
"227.3",
"255.4",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
15970, 16903
|
17416, 17832
|
5083, 5128
|
16921, 17395
|
9152, 11090
|
172, 4918
|
11106, 15949
|
4941, 5056
|
5145, 9124
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,271
| 115,393
|
1577
|
Discharge summary
|
report
|
Admission Date: [**2144-4-14**] Discharge Date: [**2144-5-18**]
Date of Birth: [**2068-6-9**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
75yo woman w T cell lymphoma, s/p CHOP D11, presents to clinic
with 1 day of fatigue and subjective fevers. Noted to have T
101.2 in clinic. Denies any symptomatic focus of infection. Had
one day of loose watery diarrhea x 4 episodes 2 days prior to
admission but none since. She is also complaining of poor po
intake due to oral mucositis. Denies cough, SOB, dysuria,
sputum.
.
ROS
Apart from mouth sores, otherwise negative in detail.
Past Medical History:
1. Lumbar spinal spondylosis.
2. Hypertension
3. Bronchiectasis.
4. Hyperlipidemia.
5. History of pancreatic cyst.
6. Elevated 5-HIAA, without further w/u
7. Irritable Bowel Syndrome
8. spinal stenosis
9. Newly diagnosed T cell lymphoma s/p 1 cycle of CHOP
Social History:
Originally from [**Country 5881**], moved here 40 years ago. Now splits time
in homes in [**Location (un) 2624**] and [**Location (un) 9188**]; also goes to [**Hospital3 **], but not
recently. No recent travel; has mostly stayed indoors in the
last few months. Denies tobacco use, social drinker, no IVDU.
Family History:
Father died of complications of EtOH use. Mother died of TB of
spine when pt was 3 yo, and sister had TB ~60-70 years ago, when
they were in [**Country 5881**]. Does not recall ever having TB herself.
Physical Exam:
On admission -
Exam: T99.3 BP 150/86 HR 80 RR 18 sats 98% RA
Gen: resting comfortably, NAD
HEENT: Anicteric MMM OP clear
Neck: no palp LAD. Healed mediastinoscopy scar. JVP NE
Lungs: L basal crackles
Cards: RRR no MGR
Abd: BS+ NT ND soft, no HSM
Ext: no edema
Pertinent Results:
==========
Labs
==========
admission -
[**2144-4-13**] 12:00PM BLOOD WBC-0.5*# RBC-3.51* Hgb-10.3* Hct-29.5*
MCV-84 MCH-29.2 MCHC-34.8 RDW-15.2 Plt Ct-117*
[**2144-4-13**] 12:00PM BLOOD Glucose-140* UreaN-12 Creat-0.8 Na-134
K-3.7 Cl-100 HCO3-26 AnGap-12
[**2144-4-14**] 11:30AM BLOOD ALT-15 AST-11 LD(LDH)-164 AlkPhos-44
TotBili-0.4
[**2144-4-14**] 11:30AM BLOOD Albumin-2.6* Phos-1.9* Mg-1.1*
===========
Microbiology
===========
Urine [**4-14**] and [**4-15**]
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
=============
Radiology
=============
CT Head [**4-18**]
Extensive chronic microvascular infarct without evidence of
neoplastic or infectious process; however, MRI remains more
sensitive for this indication.
.
CT Torso [**4-18**]
1. Prominent mediastinal and hilar adenopathy is slightly less
bulky along
the right paratracheal region but unchanged in the subcarinal
region.
Adenopathy in the abdomen is improved.
2. Since [**2144-3-31**], there has been interval near-complete
resolution of right
pleural effusion but the patient now has new small to moderate
left pleural
effusion with adjacent compressive atelectasis. However, no
evidence of new
pneumonia.
3. Distended gallbladder with cholelithiasis, but no wall
thickening or
pericholecystic fluid.
4. Small hiatal hernia. Sigmoid diverticulosis.
.
MRI Head [**4-21**]
1. No acute infarction. No focal lesions in the brain parenchyma
to suggest
neoplastic or infectious etiology. Nonspecific white matter
changes in the
cerebral white matter on both sides, likely due to sequelae of
chronic small vessel occlusive disease, with other etiologies
being less likely, due to lack of IV contrast enhancement.
.
CT Head [**4-23**]
IMPRESSION:
1. No intracranial hemorrhage.
2. Periventricular white matter changes, stable from prior,
likely
representing chronic microvascular disease.
.
CT head [**5-2**]
IMPRESSION:
1. No acute intracranial process. Meningeal inflammation cannot
be excluded on this non-contrast study.
2. Stable extensive microvascular disease.
.
MR head [**5-13**]
IMPRESSION:
1. Stable patchy confluent nonenhancing T2/FLAIR
hyperintensities within the subcortical white matter, centrum
semiovale, corona radiata, and periventricular regions. This is
nonspecific and likely represents chronic microangiopathic small
vessel ischemic changes.
2. No evidence for acute infarct or hemorrhage.
Brief Hospital Course:
# Fever and Neutopenia: Patient initially covered with broad
spectrum antibiotics including Vancomycin and Cefepime. Culture
data only revealed Eneterococcus in the urine sensitive to
Vancomycin. Counts recovered with Neupogen but patient remained
febrile. CT Torso was unremarkable and blood cultures were
negative. As mental status progressively deteriorated (see
below) antibiotics were changed to Ceftriaxone, Ampicillin,
Vancomycin and Acyclovir for meninigitis coverage.
.
# Altered mental status: Patient's mental status worsened and
eventally became non-responsive. LP was not consistent with
bacterial meningitis, but since WBC was poly predominant
meningitis doses of antibiotics were administered. Viral studies
and CSF culture data were negative. An EEG revaled that patient
was in nonconvulsive status epelepticus. Patient was started on
Keppra and Ativan, and mental status cleared. An MRI head
revealed signs consistent with CNS lymphoma and CSF revealed
atypical cells. Goals of care were changed to comfort measures
only on [**4-23**], and confirmed on [**4-24**], but family decided to
discontinue CMO order on [**4-25**]. After further conversations with
family, the decision was made to make her FULL CODE and to
proceed with further chemotherapy.
.
Events in chronological fashion:
[**4-27**]: Pt received a one-time administration of high dose
methotrexate intravenously on the night of [**4-27**]. She was given
aggressive hydration with bicarb solution to keep her urine
alkalinized (pH>8.0), promoting elimination of methotrexate.
Despite this, serial levels showed that the clearance of
methotrexate was delayed. In the first few days after
methotrexate, pt remained alert and oriented x 3, although her
mentation did wax and wane at times for unclear reasons.
[**4-28**]: Keppra was uptiratred from 750 mg to 1000 mg IV BID
[**4-29**]: New hives on back. Derm consult was obtained. NOT thought
to be due to any medications, more likely dermatographism. Pt
c/o itchiness however only topical sarna lotion was used in
favor of avoiding sedating medications.
[**4-30**]: Pt became febrile to 100.5 early morning of [**4-30**]. Cefepime
was started. In the afternoon of [**4-30**], pt was noted to be more
somnolent and yet more irritable. Pt appeared very
uncomfortable. Pt did not answer questions or follow commands
consistently. She failed to make eye contact. She was noted to
have body tremors, which subsided briefly after 1 mg of Ativan
then returned.
[**5-1**]: Overnight of [**2050-4-29**] pt continued to be somnolent and
tremulous. Multiple doses of ativan were given to little effect.
Acyclovir was started for concern of HSV encephalitis.
Infectious work up was initiated.
[**5-2**]: CT scan did not show any acute changes. Vancomycin was
started. 24hr video EEG monitoring was begun.
[**5-3**]: Pt was noted to be back in status epilepticus. Keppra was
increased to 1 g TID. Pt was loaded with phenytoin 1 g followed
by 100 mg IV Q8 hrs, Dexamethasone 10 mg IV then 4 mg IV BID.
EEG monitoring was continued. All antimicrobials were continued
although microbiology data so far had been negative. A lumbar
puncture was performed for interval check of lymphoma in CNS and
pt was also given IT Ara-C.
[**5-4**]: Pt remained in status despite the multiple anti-epileptics
and pt was transferred to the ICU for phenobarbital
administration.
MICU course:
She was transferred to [**Hospital Unit Name 153**] for elective intubation for
initiation of phenobarbital
# Sedation/ Unresponsiveness: Her mental status continued to be
nonresponsive for >1 week. This was likely secondary to
persistent phenobarbital, as levels were high. This trended
down from a peak of 35 but has persisted in the low 20s for
days. Portions of her neuro exam improved slowly, and when her
level fell to 16 she was able to follow simple commands. She
had a repeat MRI that was unchanged. . Neuro has said that
there is no role for rpt imaging.
.
# Seizures/Status Epilepticus: She was initially on continuous
EEG monitorring. She stopped seizing, so EEG was discontinued.
Keppra and fosphenytoin were continued. Phenobarbital levels
trended down. Neurology trended down.
.
# Ventilatory support.: Intubated electively for phenobarb
initiation without underlying acitve pulmonary issues. She was
initially apneic when on PSV but later had spontaneous
breathing.
# Bacteremia: On [**4-14**], patient developed leukocytosis and
low-grade fever. Vanc/Zosyn were started for possible VAP. On
[**4-15**], blood cultures grew gram positive cocci in short chains
and pairs, suspicious for VRE. Goals of care were revised, so
all antibiotics were stopped.
.
# Hyponatremia: Urine lytes and osms were consistent with SIADH,
likely secondry to her intracranial process. Free water was
restricted.
# T Cell Lymphoma: BMT service followed her. She was s/p CHOP,
MTX, and IT cytaribine. Leukovorin was stopped given
undetectable MTX levels. Dexamethasone and PCP/HSV ppx were
continued.
# Hypertension: well controlled on metoprolol
# Goals of care: Given poor prognosis of her T-cell lymphoma as
well as the complicated ICU course including bacteremia, the
patient's family elected to extubate and move toward comfort
measures. All medications including antibiotics were stopped,
dexamethasone was continued given chronic steroid use, morphine
was started PRN. She was extubated and called out to the BMT
service. Pt was given morphine drip for comfort and valium to
suppress any seizure activity. Pt passed the morning of [**2144-5-18**].
Medications on Admission:
Acyclovir
Clotrimazole Troche
Fluconazole
Folic Acid
Levofloxacin [[**Date Range **]]
Lorazepam
Metoprolol Tartrate
Omeprazole
Ondansetron [ZOFRAN ODT]
Cholecalciferol (Vitamin D3) [Vitamin D-3]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
T cell lymphoma with CNS involvement
Sepsis
Pneumonia
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2144-5-19**]
|
[
"584.9",
"995.92",
"272.4",
"V09.80",
"708.3",
"599.0",
"041.04",
"288.00",
"494.0",
"345.3",
"112.0",
"E933.1",
"202.10",
"401.9",
"564.1",
"997.31",
"348.30",
"250.00",
"253.6",
"287.4",
"038.0",
"780.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"03.31",
"96.72",
"03.92",
"99.25",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10402, 10462
|
4562, 5051
|
277, 295
|
10568, 10573
|
1879, 4539
|
10625, 10659
|
1382, 1584
|
10374, 10379
|
10483, 10547
|
10155, 10351
|
10597, 10602
|
1599, 1860
|
232, 239
|
323, 761
|
5066, 10129
|
783, 1041
|
1057, 1366
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,023
| 111,603
|
38967+58251
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-8-11**] Discharge Date: [**2146-8-18**]
Date of Birth: [**2067-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] Porcine Aortic Stenosis
History of Present Illness:
78 year old gentleman with a long history of cardiac murmur. He
has been followed by echo recently. He resides in [**State 108**], and
AVR was recommended. He has come to [**Location (un) 86**] for another opinion.
Echo done today reveals [**Location (un) 109**] 0.8-1cm2. He does have SOB but
denies chest pain, dizziness or syncope. Other medical history
includes relapsing polychondritis, for which he is on chronic
steroid therapy. Additionally, he has an abscess on his right
elbow that is being treated with azithromycin and I&D
periodically with dressing/wick changes.
Past Medical History:
- Aortic Stenosis s/p Aortic Valve Replacement
- Coronary artery disease, ?MI [**2137**]
- Hyperlipidemia
- Congestive heart failure
- Relapsing polychondritis
- Compression fracture of thoracic spine following traumatic
fall
- Diabetes Mellitus
- Hypothyroid
- Episcleritis/iritis
- saddle nose deformity
- Resection of left mainstem hamartoma
Social History:
Race: Caucasian
Last Dental Exam: 3mos ago
Lives with: Wife in [**State 86434**]
Occupation: Retired physician
[**Name Initial (PRE) 1139**]: Quit smoking >10 years ago. 120 pack years
ETOH: Occassional use
Family History:
mother died 91 h/o CVA
father died 91 h/o CAD, MI, CHF
brother with CAD, s/p CABG
Physical Exam:
Pulse: 78 Resp: 16 O2 sat: 98%
B/P Right: 151/60 Left: 130/60
Height: Weight:
General:
Skin: Dry [x] intact [x] well healed left thoracotomy incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema- pedal
Varicosities: None [] early venous stasis changes
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: radiation of cardiac murmur
Pertinent Results:
[**2146-8-12**] Pre CPB: The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The descending thoracic aorta is mildly dilated.
There are complex (>4mm) atheroma in the descending thoracic
aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen.
Due to co-existing aortic regurgitation, the pressure half-time
estimate of mitral valve area may be an OVERestimation of true
mitral valve area. Mild (1+) mitral regurgitation is seen.
[**2146-8-11**] Cath: 1. No significant CAD. 2. Moderate systemic
arterial hypertension.
[**2146-8-11**] 08:30AM BLOOD WBC-11.5* RBC-4.05* Hgb-12.4* Hct-38.8*
MCV-96 MCH-30.7 MCHC-32.0 RDW-16.8* Plt Ct-112*
[**2146-8-18**] 04:40AM BLOOD WBC-8.4 RBC-2.81* Hgb-8.6* Hct-25.6*
MCV-91 MCH-30.5 MCHC-33.4 RDW-16.4* Plt Ct-82*
[**2146-8-11**] 08:30AM BLOOD PT-12.2 PTT-25.2 INR(PT)-1.0
[**2146-8-16**] 01:24AM BLOOD PT-12.7 PTT-28.2 INR(PT)-1.1
[**2146-8-11**] 08:30AM BLOOD Glucose-112* UreaN-41* Creat-1.2 Na-145
K-4.3 Cl-110* HCO3-25 AnGap-14
[**2146-8-18**] 04:40AM BLOOD Glucose-79 UreaN-50* Creat-1.5* Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2146-8-14**] 01:45AM BLOOD Calcium-7.7* Phos-3.9 Mg-2.2
[**2146-8-17**] 04:40AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
[**2146-8-11**] 08:30AM BLOOD ALT-34 AST-30 AlkPhos-65 Amylase-65
TotBili-0.3
Brief Hospital Course:
Dr. [**Known lastname 86435**] was admitted to the [**Hospital1 18**] on [**2146-8-11**] for
surgical management of his aortic valve stenosis. He underwent a
diagnostic cardiac catheterization in preparation for his
surgery which revealed less then 50% stenosis of the left
anterior descending artery and right coronary artery. A
rheumatology consult was obtained due to his history of
polychondritis and steroid dependence. It was recommended that
he continue prednisone with the possibility of adding CellCept
in the future in the event that his symptoms worsen despite his
daily prednisone. Dr. [**Name (NI) 86435**] was worked-up in the usual
preoperative manner. On [**2146-8-12**], he was taken to the operating
room where he underwent an aortic valve replacement using a [**Street Address(2) 68430**]. [**Hospital 923**] Medical Epic Biocor tissue valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. He required continuous
pacing for underlying asystole. On postoperative day one, he
awoke neurologically intact and was extubated. He required
intravenous medication to control his hypertension. He was
transfused for postoperative anemia. On postoperative day three,
his underlying rhythm was complete heart block alternating with
a junctional rhythm. The electrophysiology service was consulted
for assistance in his care. As his underlying rhythm did not
i\improve, a pacemaker was placed on [**2146-8-16**]. He was then
transferred to the stepdown 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. Interrogation of his
pacemaker showed it to be functioning properly. He continued to
make steady progress and was discharged to [**Hospital1 86436**] on [**2146-8-18**]. He will follow-up with Dr. [**Last Name (STitle) **],
his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
azithromycin 500mg daily
glimepiride 2mg daily
Aspirin 81 daily
Toprol XL 100 daily
Prednisone 15 daily
famotidine 20 daily
vytorin 10/40 QOD
Januvia 50 daily
Synthroid 50 daily
Centrum Silver
Vitamin D
Vytorin,
Flomax 0.4
Tylenol
Sudafed
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Sitagliptin 100 mg Tablet Sig: 0.5 Tablet PO daily ().
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal once a day.
11. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Potassium Chloride 10 % Liquid Sig: Ten (10) meq PO once a
day for 1 weeks.
16. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 1
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation Center of [**Location (un) 1121**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Past medical history
- Coronary artery disease, ?MI [**2137**]
- Hyperlipidemia
- Congestive heart failure
- Relapsing polychondritis
- Compression fracture of thoracic spine following traumatic
fall
- Diabetes Mellitus
- Hypothyroid
- Episcleritis/iritis
- saddle nose deformity
- Resection of left mainstem hamartoma
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2146-9-8**] 1:00
Cardiologist:
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 34384**] in [**3-7**] weeks [**Telephone/Fax (1) 86437**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-8-18**] Name: [**Known lastname 13687**]-[**Known lastname 13688**],[**Known firstname **] Unit No: [**Numeric Identifier 13689**]
Admission Date: [**2146-8-11**] Discharge Date: [**2146-8-18**]
Date of Birth: [**2067-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 741**]
Addendum:
Pacemaker follow up
[**2146-8-25**] 10:30a DEVICE [**Doctor Last Name 13690**]-CC7
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
CC7 CARDIOLOGY (SB)
Please wear sling at night until follow up in device clinic
You might have slight itching at the incision. Try not to
scratch the incision or rub it.
Do not apply lotion or powder to the incision.
Bruising into the underarm area may be seen.
Let someone in the device clinic ([**Telephone/Fax (1) 337**] ) know right away
if you note any of the following:
&#[**Numeric Identifier **]; redness, swelling, or drainage near your incision
&#[**Numeric Identifier **]; temperature of 101 or more (fever)
&#[**Numeric Identifier **]; pain that is getting worse instead of better
&#[**Numeric Identifier **]; any opening in the skin at the site of device
[**Month (only) 412**] I go back to my usual activities?
Please follow these guidelines regarding activity. Ask questions
about any other activities you aren??????t sure about.
You may be asked not to drive for a certain amount of time
during your recovery. This is different for everyone. Please ask
your doctor when you may drive.
For six weeks, [**Male First Name (un) **]??????t lift, carry, push, or pull anything
weighing more than five pounds using the arm on the side where
your pacemaker is inserted.
During the first six ?????? eight weeks, you will need to watch how
you use the arm on the side where your pacemaker was inserted.
You may wash your face, brush your teeth, shave, and comb your
hair. But do not raise your elbow above the height of your
shoulder. You may not swim or play tennis or golf. Now is a good
time to ask for help with things like raking leaves, cleaning,
painting, ironing, vacuuming, or walking a dog.
Call for help if:
Call for help if you have:
?????? redness, swelling, drainage, or any opening at the area of
your incision
?????? temperature of 101 or more
?????? pain from the incision that is getting worse instead of better
?????? a return of symptoms you had before your pacemaker insertion
or any other symptom that concerns you
Discharge Disposition:
Extended Care
Facility:
[**Hospital 345**] Rehabilitation Center of [**Location (un) 95**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2146-8-18**]
|
[
"682.3",
"244.9",
"250.00",
"272.0",
"530.81",
"428.32",
"426.0",
"401.9",
"V58.65",
"412",
"V15.51",
"V45.82",
"733.99",
"424.1",
"285.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"37.83",
"39.61",
"88.56",
"35.21",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
12583, 12799
|
4229, 6231
|
299, 393
|
8448, 8614
|
2449, 4206
|
9537, 12560
|
1613, 1696
|
6520, 7926
|
8062, 8427
|
6257, 6497
|
8638, 9514
|
1711, 2430
|
240, 261
|
421, 1005
|
1027, 1373
|
1389, 1597
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,366
| 154,193
|
35868
|
Discharge summary
|
report
|
Admission Date: [**2132-1-22**] Discharge Date: [**2132-2-1**]
Date of Birth: [**2066-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypoxemic respiratory failure
Major Surgical or Invasive Procedure:
intubation
CVVH
History of Present Illness:
Mr. [**Known lastname **] is a 65M with alcoholic cirrhosis on HD transferred
from [**Hospital2 **] [**Hospital3 6783**] in [**Hospital1 1559**] [**1-22**], after being admitted to
the OSH on [**2131-1-14**]. After a cardiac stress test, patient had
become dyspneic and hypotensive to 60/30, resulting in emergent
intubation and transfer to ICU. Had MRSA sepsis with the
suspected source a right femoral line. He had been empirically
treated with vanz/ceftaz, extubated [**1-17**]. On the floor, he had
continued labored breathing and therefore underwent
thoracentesis of right hydrothorax.
.
Got HD [**1-23**] at [**Hospital1 18**] where his right thoracic HD line was
utilized.
During HD, became confused with desaturation to the 70's --
subsequently improving to 90's on NRB. ABG was 7.40/48/73 on
NRB. BP dipped from 120's systolic initially to 80's but then
improved to 90's. He underwent urgent intubation and was
transferred to the MICU for further management. No volume was
removed during the dialysis session.
.
On evaluation in the HD unit patient denied any pain but was too
confused to cooperate with further history.
Past Medical History:
* Cirrhosis, presumably due to EtOH, diagnosed in [**5-/2129**];
complicated by ascites, likely SBP following a dental procedure
[**2131-9-10**] (not started on ppx), encephalopathy
***Per records, [**2130-11-9**] endoscopy with bleeding ulcers, no
report of varices in records, but on nadolol
* ATN on hemodialysis, following hernia repair [**11-16**]
* Dupuytren's contracture x 4 to 5 years
* s/p strangulated umbilical hernia repair [**11-16**]
* Hypertension
* gout
* Peptic ulcer disease with history of GI bleed
Social History:
He drank approximately half a gallon of alcohol water (?) each
week for about 20 years; however, over the last 6 years the
level of alcohol consumption decreased significantly and he
stopped drinking all together a year and half ago when he was
told that he had cirrhosis. Former smoker, quit 25 years ago. He
is married and has 3 children.
Family History:
There is no family history of liver disease. His father died at
age of 72 of prostate cancer. His mother died at the age of 76
of breast cancer with metastases.
Physical Exam:
Vitals on arrival to MICU 94.8 102 156/88 19 92% on AC 500x14,
1.0
General Chronically ill appearing, now intubated and sedated
HEENT anicteric, dry mm
Neck no JVD
Pulm lungs with decreased breath sounds right hemithorax nearly
to apices, no rales/rhonchi
CV tachycardic regular s1 s2 no m/r/g
Abd distended +fluid wave nontender +bowel sounds
Extrem warm 1+ bilateral edema palpable distal pulses palmar
erythema +dupuytrens contractures
Neuro prior to intubation responds to voice able to answer
yes/no questions, no asterixis, moving all extremities
Pertinent Results:
[**2132-1-22**] 09:35PM GLUCOSE-95 UREA N-26* CREAT-4.4* SODIUM-140
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
[**2132-1-22**] 09:35PM estGFR-Using this
[**2132-1-22**] 09:35PM ALT(SGPT)-28 AST(SGOT)-36 LD(LDH)-320* ALK
PHOS-217* TOT BILI-3.4*
[**2132-1-22**] 09:35PM ALBUMIN-2.4* CALCIUM-9.0 PHOSPHATE-3.3
MAGNESIUM-1.9 IRON-44*
[**2132-1-22**] 09:35PM calTIBC-111 VIT B12-GREATER TH FOLATE-11.4
FERRITIN-252 TRF-85*
[**2132-1-22**] 09:35PM WBC-14.6* RBC-4.32* HGB-13.0* HCT-39.0*
MCV-90 MCH-30.0# MCHC-33.3 RDW-23.6*
[**2132-1-22**] 09:35PM NEUTS-85.7* LYMPHS-9.3* MONOS-3.6 EOS-0.8
BASOS-0.6
[**2132-1-22**] 09:35PM PLT COUNT-89*
[**2132-1-22**] 09:35PM PT-20.7* PTT-42.2* INR(PT)-1.9*
Brief Hospital Course:
65M with presumed EtOH cirrhosis transferred from OSH for
management of dyspnea and expedited workup for consideration of
combined liver - kidney transplant transferred to the MICU
following increased respiratory distress during HD
.
1. Respiratory distress
The acute precipitant for his respiratory distress is uncertain
- most likely may be ARDS in the setting of his sepsis. ?Whether
fluid shift during HD may have been an issue. An aspiration
event is also a possibility. MI or PE seem less likely. Of note,
his pulmonary reserve is very limited by his increasing right
sided pleural effusion and his distended abdomen. Unknown
whether he has pulmonary shunts. Treated line sepsis as listed
below. Thoracentesis was not attempted, as was likely to occur
quickly. Remained ventilated for duration of hospital stay.
.
2. Hypotension
BP initially stable on ICU transfer, then hypotensive to 80's
responding to fluids and levophed. Most likely septic shock. Use
of HD catheter today may have resulted in bacteremia setting off
septic response. Vanc and Zosyn started empirically given acuity
of decompensation and recent hospitalization allowing for
possibility of gram negative infection. All old lines removed
and new triple lumen placed. Cultures remained negative at time
of death. Patient was given fluids, albumin and started on
pressors including above and vasopressin and neosynephrine.
Patient remained extremely labile with slightest movement
causing a pressure drop. On hospital day 10, the patient's
spouse elected to stop all pressure support. The patient was
extubated 2 hours later after his blood pressure was 30/20. 10
minutes later he was noted to be asystolic and apneic. Time of
death was 1508.
.
3. Confusion
Likely secondary to current infection exacerbated by hypoxia, as
well as hepatic encephalopathy.
- Treated infection as above
- Continued lactulose
.
4. Cirrhosis
- Holding diuretics and beta blockers in setting of hypotension
- Transplant workup per hepatology
.
5. Renal failure thought sequelae of ATN post surgery [**11-16**]
- patient started on CVVH after transfer, however, this was
stopped secondary to low blood pressures. His renal function
then continued to worsen.
.
6. HTN holding antihypertensives given shock
FEN-patient started on Tube feeds but was noted to have high
residuals throughout stay. These were eventually halted.
Access PIV, HD line -> new line as above
PPX pneumoboots, PPI
Dispo ICU
Code FULL
Comm with family
Medications on Admission:
MEDICATIONS ON TRANSFER:
Lactobacillus 1 tablet daily
Multivitamin
Pantoprazole 40mg daily
Ceftriazone 1 gram with HD
Vancomycin 1gram with HD
.
MEDICATIONS AT HOME (per OMR note [**12-16**] -- need to confirm)
Renagel 400 mg daily
omeprazole 20 mg daily
Nadolol 20 mg twice a day
Celexa 1 tablet daily
Iron
Vitamins
Lactulose
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary failure secondary to Sepsis of unknown source
and complicated by end stage liver disease and renal failure
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2132-2-1**]
|
[
"560.1",
"572.2",
"518.81",
"785.52",
"038.12",
"995.92",
"585.6",
"584.9",
"996.62",
"507.0",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"86.05",
"39.95",
"96.6",
"88.72",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6817, 6826
|
3926, 6412
|
341, 358
|
6992, 7001
|
3185, 3903
|
7052, 7084
|
2434, 2596
|
6790, 6794
|
6847, 6971
|
6438, 6438
|
7025, 7029
|
2611, 3166
|
272, 303
|
386, 1518
|
6463, 6767
|
1540, 2060
|
2076, 2418
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,256
| 184,499
|
49022
|
Discharge summary
|
report
|
Admission Date: [**2187-10-12**] Discharge Date: [**2187-10-17**]
Date of Birth: [**2137-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
hypertensive emergency and acute pulm edema
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
50 yo M with ESRD on HD and malignant HTN presents with dyspnea
x 2 hours. He was feeling well until 2 hrs before presentation
when he developed increased pruritis and dyspnea at rest.
Dyspnea has progressively worsened. ? if pt took medications
yesterday. Per report pt noted to be gurgling blood prior to
intubatoin, currently with bld in his ET tubing. He has been
getting HD regularly, last HD Wednesday w/ full session
completed. Denies fever, chest pain, cough, abd pain.
.
In the ED, BP was 269/166, HR 135. He was tachypnic at 40 bpm,
w/ O2 sat 88% RA. CXR demonstrated diffuse pulm edema. He was
treated w/ lasix 80mg IV, nitro gtt, and morphine 4mg IV
resulting in decreased BP. He was started on BiPAP resulting in
increased O2 sat to 100%. However, he remained tachypnic in the
40s, breathing w/ accessory muscles. He was intubated for for
vent support as there was no immediate access to HD. Renal
service was consulted.
Past Medical History:
1. Alport's Syndrome: c/b ESRD on HD and deafness
2. ESRD: s/p failed renal transplant x 2 ([**2152**] and [**2168**]), now on
HD M/W/F
3. Malignant hypertension
4. h/o CHF w/ dilated cardiomyopathy: now w/ recovered fxn, ECHO
[**3-22**] w/ EF>55%, 1+ MR
5. SVT s/p ablation [**3-22**]
6. h/o seizures: likely metabolic etiology per notes
7. Restless legs syndrome
8. Anemia of chronic disease
9. h/o respiratory failure secondary to pulmonary edema
10. Pruritis: treated w/ prednisone, mirapex
Social History:
divorced w/2 children, ages 10 and 13. used to work with
computers. 3 pack yr hx. Occ EtOH. hx marijuana and cocaine,
none x 2 yrs. No IVDU.
Family History:
mother with alport's syndrome, father with CAD and CABG at age
60, brother died at 16 yrs old from ESRD
Physical Exam:
PE: Tc 96.2, BP 126/78, HR 86, O2 sat 100%
Vent: AC 400/16 (breathing at 20)/50%/5. No ABG.
Gen: thin man lying in bed, intubated and sedated
HEENT: anicteric, PERRL, OP clear w/ MMM, JVD to earlobe at 90
degrees
CV: RRR, nl s1/s2, +S3, no M/R/G
Pulm: crackles diffusely through all lung fields, no wheezing
Abd: scaphoid, +BS, soft, NT, ND
Ext: warm, faint DP B, no edema
Neuro: was following commands before intubation by report, now
sedated
Pertinent Results:
Admission Labs:
[**2187-10-12**] 07:14AM BLOOD WBC-14.6*# RBC-3.21* Hgb-10.4* Hct-33.4*
MCV-104* MCH-32.3* MCHC-31.0 RDW-22.4* Plt Ct-258
[**2187-10-12**] 07:14AM BLOOD Neuts-68 Bands-0 Lymphs-25 Monos-4 Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-2*
[**2187-10-12**] 07:14AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL
Target-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**Name (STitle) 16494**]
[**2187-10-12**] 07:14AM BLOOD Plt Ct-258
[**2187-10-12**] 07:14AM BLOOD PT-12.4 PTT-23.4 INR(PT)-1.0
[**2187-10-12**] 07:14AM BLOOD Glucose-133* UreaN-87* Creat-14.5*#
Na-144 K-4.8 Cl-94* HCO3-23 AnGap-32*
[**2187-10-12**] 07:14AM BLOOD CK(CPK)-370*
[**2187-10-12**] 07:14AM BLOOD CK-MB-7
[**2187-10-12**] 07:14AM BLOOD cTropnT-0.15*
[**2187-10-12**] 07:14AM BLOOD Calcium-10.2 Phos-8.6*# Mg-2.2
[**2187-10-12**] 10:28AM BLOOD Type-ART Rates-16/2 Tidal V-400 PEEP-5
FiO2-50 pO2-112* pCO2-51* pH-7.33* calHCO3-28 Base XS-0
-ASSIST/CON Intubat-INTUBATED Vent-CONTROLLED
.
[**10-12**] CXR: Interval worsening of congestive heart failure.
.
[**10-12**] CXR: There has been interval placement of an endotracheal
tube, which terminates at the thoracic inlet level, about 5 cm
above the carina. The cuff of the tube may be very slightly
over-distended. A nasogastric tube has also been placed, coiling
within the stomach, with the distal tip directed cephalad.
Cardiac silhouette remains enlarged. There has been a change in
distribution of bilateral alveolar pattern, which is now more
prominent centrally and was previously more prominent basally,
likely reflecting changes in distribution of pulmonary edema
related to patient positioning. Bilateral pleural effusions are
again demonstrated.
.
[**10-14**] CXR: Comparison is made with the prior film from [**10-13**]. The endotracheal tube and nasogastric tube have been
removed. Heart remains enlarged and an interstitial alveolar
pattern is still present consistent with failure, not
significantly changed since the prior chest x-ray but still
considerably improved from the films of [**10-12**].
.
Interval Labs/Discharge Labs:
[**2187-10-17**] 05:30AM BLOOD WBC-9.1 RBC-2.89* Hgb-9.0* Hct-28.4*
MCV-98 MCH-31.3 MCHC-31.8 RDW-22.0* Plt Ct-192
[**2187-10-13**] 03:50AM BLOOD Neuts-67 Bands-0 Lymphs-23 Monos-5 Eos-3
Baso-2 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2187-10-17**] 05:30AM BLOOD Plt Ct-192
[**2187-10-17**] 05:30AM BLOOD Glucose-57* UreaN-64* Creat-13.5*# Na-138
K-5.3* Cl-95* HCO3-23 AnGap-25*
[**2187-10-12**] 07:14AM BLOOD CK(CPK)-370*
[**2187-10-15**] 10:50AM BLOOD CK(CPK)-311*
[**2187-10-15**] 05:37PM BLOOD CK(CPK)-381*
[**2187-10-16**] 03:41AM BLOOD CK(CPK)-245*
[**2187-10-12**] 07:14AM BLOOD cTropnT-0.15*
[**2187-10-15**] 10:50AM BLOOD cTropnT-0.24*
[**2187-10-15**] 05:37PM BLOOD CK-MB-4 cTropnT-0.23*
[**2187-10-16**] 03:41AM BLOOD CK-MB-2 cTropnT-0.20*
[**2187-10-17**] 05:30AM BLOOD Calcium-8.7 Phos-6.4* Mg-2.1
Brief Hospital Course:
Patient is a 50 yo man w/ Alport's, ESRD s/p two renal tx,
labile HTN admitted [**10-12**] with hypertensive emergency and flash
pulmonary edema. Patient presented with c/o 2 hrs of dyspnea
getting progressively worse. There was question of medical non
compliance or dietary indiscretion. Patient is a very poor
historian but denies missing any meds and he received his last
episode of HD. Patient was initially managed in the [**Hospital Unit Name 153**] where
he was intubated for worsening respiratory status. Initially he
had BPs of 269/166 HR 135, tachypneic to the 40s, O2 sat 88% RA.
CXR showed pulmonary edema. Patient was started on nitro gtt, 80
IV lasix x 1 and Morphine 4 mg IV. Patient was initially
maintained on BiPAP with improvement in O2 sat to 100% but
remained tachypneic with use of accessory muscles and therefore
the patient was semi-electively intubated for airway protection.
The renal service was consulted for urgent HD which was
performed for rapid fluid removal. The patient was extubated the
following day on [**10-13**] w/out complications. Patient was then
transferred to the medical floor on the evening of [**10-14**] with
persistently elevated BP to 160s-190s but dramatically improved
from admission, stable respiratory status, sating 94% RA. On
exam, however, the patient was difficult to arouse. On the
floor, patient's BP was very difficulty to control increasing
from 190->209/98 despite additional beta blocker and ACEI. He
was changed to Captopril q6 for titration and Metoprolol TID for
titration, Hydral 10 mg IV x2, NTG SL, nitropaste 1 inch. The
patient was transferred back to the MICU for aggressive BP
management including nitro gtt. In the ICU he was dialyzed that
evening and again the next day. He is transferred back to the
floor s/p x2 HD with dramatic improvement in SBP 140-160s with
clear mental status. He is able to recount his story and says
that his shortness of breath came on very suddenly. He remembers
coming into the ED but nothing after that until waking up
yesterday morning. Yesterday he ate three meals and feel much
better. He believes that he ate too much over [**Holiday 1451**] which
could have let to this exacerbation. He denies any chest pain,
difficulty breathing, no headache, no N/V/D or any other
complaints. In terms of his individual medical problems:
.
Hypertension. Very difficult to manage as per notes in OMR,
patient has presented several times with hypertensive emergency
in the past requiring intubation for flash pulmonary edema.
Patient has also presented with altered mental status in setting
of elevated BP. Patient was continued on HD for fluid management
and then recommended to continue with HD on Monday, Wednesday
and Friday as he was doing previously. Patient states that he
usually dialysed to a weight of 61 kg. During this admission he
was dialysed to a weight of 57 kg. The patient states that he
feels much better at this weight. He was discharged with a blood
pressure ranging 140-150/80s with close follow up. His discharge
medications include Toprol XL 50 mg daily and Lisinopril 10 mg
daily.
.
Respiratory failure. S/p intubation for flash pulmonary edema,
symptoms came on quickly in setting of uncontrolled BP to >220.
Patient was extubated the following day without complications.
He is discharged saturating well on room air, breathing
comfortably and ambulating without problems.
.
Subendocardial Ischemia. Patient had EKG changes consistent with
subendocardial ischemia, Troponin 0.15->0.20, CK 370->245 likely
[**12-20**] to demand ischemia in setting of tachycardia and severe
hypertension on presentation as well as acute CHF exacerbation.
Repeat EKG was unchanged and did not show resolution of these
changes. Patient was continued on a beta blocker and ASA. He is
discharged with close follow up in the heart failure clinic.
.
ESRD. Patient is s/p two renal transplants now with ESRD again
awaiting transplantation. Patient was aggressively dialysed for
hypertensive emergency. He was followed by the renal service
throughout. Recommendations were to continue with HD three times
weekly.
.
Anemia. Hct stable, 26.6. Likely multifactorial.
.
Pruritis. Patient continued on sarna lotion, diphenhydramine,
hydroxyzine for itching.
.
Patient was maintained on a renal diet, no IVF, electrolytes
were monitored and replaced as needed.
.
Prophylaxis. OOBTC, PO diet, bowel regimen, Hep SC
.
Patient was a full code throughout this admission.
Medications on Admission:
1. ASA 325mg daily
2. Toprol XL 50 mg PO daily
3. ?Lisinopril 5 mg DAILY
4. Sevelamer 1600 mg PO TID
5. Prednisone 5 mg PO DAILY
6. Pantoprazole 40 mg daily
7. Mirapex 0.125 mg qhs, 2 hours before HD
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs ().
Disp:*30 Tablet(s)* Refills:*2*
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pruritis.
Disp:*30 Tablet(s)* Refills:*0*
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs 1* Refills:*2*
7. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
Disp:*30 Capsule(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*1*
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Flash pulmonary edema requiring intubation
Alport's disease
End Stage Renal Disease
Hypertension
Discharge Condition:
Good - blood pressure stable ranging 140-150/80
Discharge Instructions:
Please take all of your medications as directed
Please follow up as listed below
Please return to the hosptial or contact your doctor if you have
any shortness of breath, very high blood pressure, chest pain,
dizziness or any other problems.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L
Followup Instructions:
1. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2187-10-29**] 8:30
2. Provider: [**Name10 (NameIs) 3833**] Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2187-11-5**] 9:00
3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-11-22**] 2:00
PLEASE CALL TO MAKE AN APPOINTMENT IN THE HEART FAILURE CLINIC
AT
[**Telephone/Fax (1) 3512**] (PLEASE MENTION THAT YOU HAVE BEEN THERE IN THE
PAST), THEY ARE AWARE THAT YOU ARE TO HAVE AN APPOINTMENT WITH
THEM IN THE NEAR FUTURE
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2187-10-23**]
|
[
"333.99",
"996.81",
"428.0",
"411.89",
"285.29",
"425.4",
"780.39",
"403.01",
"585.6",
"759.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12023, 12029
|
5616, 10073
|
360, 383
|
12170, 12220
|
2639, 2639
|
12638, 13458
|
2054, 2159
|
10324, 12000
|
12050, 12149
|
10099, 10301
|
12244, 12615
|
4786, 5593
|
2174, 2620
|
276, 322
|
411, 1355
|
2655, 4770
|
1377, 1874
|
1890, 2038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,381
| 156,834
|
48145
|
Discharge summary
|
report
|
Admission Date: [**2126-10-18**] Discharge Date: [**2126-10-25**]
Date of Birth: [**2061-9-22**] Sex: F
Service: MEDICINE
Allergies:
Tetanus & Diphtheria Tox,Adult / Methotrexate / Avelox /
Infliximab
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Central Line placement (L IJ)
Arterial Line placement (R radial)
History of Present Illness:
This pt is a 65 y/o WF w/ h/o RA treated with enbrel (stopped
2-3months ago) on prednisone, pulmonary fibrosis believed [**3-12**]
MTX, chronic bronchitis, 50 pk-year ex-smoker admitted for
hypoxemia. Pt had two admissions in the last 2 months, most
recently on [**8-30**] for CAP. She was treated initially with
ceftx and azithromycin and was discharged on [**10-10**] w/ cefpodoxime,
azithro and on home O2 2L NC. she has been on Bactrim for PCP
[**Name Initial (PRE) **]. She states that since d/c she has been feeling unwell with
low grade temp around 99. She also has non-productive cough that
makes her vomit at times. She also has increase shortness of
breath worse than from her baseline (which is 1 block) on
exertion at home. She denies having any chest pain, upper resp
symptoms, chills. No changes in bowel or bladder pattern. She
denies missing any doses of her antibiotics.
.
In the ED her vitals were 98 120 113/70 16, oxygen saturation
83% on RA. Pt had oxygen saturaiton in the 80%s with 6L
supplemental oxygen by nasal cannula then up in 90%s with a
non-rebreather mask. Her cxray showed findings consistant with
fibrosis and LUL infiltrate, which is new since last admission.
She was started on vanco and on clindomycin for HAP. Blood
cultures were sent and she was admitted to the ICU for hypoxia.
On transferred to the ICU her vitals were afebrile, HR 107,
145/56, 32, 92% NR.
.
On arrival to the [**Name (NI) 153**], pt appears overall confortable breathing
at mid 20s to low 30s on non-rebreather mask with oxygen
saturation at 100%. She was not using accessory muscles. She has
occ dry cough. Her daughter was by her bed side and while I was
drawing ABG her daughter fainted, falling and hiting her head on
the floor. She loss councious for 5 secs. She was taken to the
ED by EMS for further evaluation.
.
Of note as per recent pulm note, pt has a hx of pulmonary
fibrosis from methotrexate which she took for a duration of 1
year, approximately ten years ago. She subsequently developed
the exertional dyspnea and states that it has gotten
progressively worse over the past 10 years. She has not returned
to her pulmonologist at [**Hospital1 112**] in two years because she felt her
disease was stable. She does not use her perscribed albuterol or
flovent inhalers.
Past Medical History:
-Rheumatoid arthritis, on embril/prednisone (followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 112**])
-Hypertension
-Diabetes mellitus type II
-HLD
-IPF (RA-associated)
-Obesity
-Osteopenia
-B12 Deficiency
-Anxiety disorder
-Chronic bronchitis
-Breast nodule
-Pulmonary nodule
-Eosinophilic urticarial syndrome with possible AIN [**8-17**],
thought to be possibly related to fluoroquinolone
Social History:
Was born in [**Location (un) 2030**], MA. Lives with husband in [**Name (NI) 3786**]. Have
2 [**Name (NI) **]. Former secretary on disability. No Etoh or drugs.
Quit tobacco [**2097**], prior 2.5 ppd x20 yrs.
Family History:
No autoimmune disease. Father with ILD. Sister with asthma.
Daughter with frequent allergic rxns to medications.
No family hx of MI, stroke, diabetes, HTN, cancers.
Physical Exam:
Time of Death Physical Exam 17:40
-Heart asystolic on tele
-No heart sounds on cardiac exam
-Pupils non-reactive
-No response to sternal rub
-No pulse
Brief Hospital Course:
ID: Ms [**Known lastname 101493**] is a 65 yr caucasian female with PMH of RA
treated with enbrel (stopped 2-3months ago), currently on
prednisone, pulmonary fibrosis believed [**3-12**] Methotrexate,
chronic bronchitis, 50 pk-year ex-smoker admitted for hypoxemia
Presenting chest xray showed LUL opacity consistent with an
infectious process. In context of elevated WBC, tachypnea, low
O2 sats, and [**Month/Day (2) **] findings, pt was started on IV antibiotics. She
was placed on non-invasive positive pressure vent because of
poor saturations on air mask. Saturations improved but pt still
very tachypnic with RR 35-50. Decision was made that she could
not sustain this indefinitely and pt was intubated. Before
intubation pt expressed desire to not stay on vent indefinitely
and to be taken off vent if no quick resolution of problem could
be reached. She was intubated and a central line was placed. She
was continued on IV Abx but developed ARDS shortly after
intubation. Also developed acute renal failure. Pressors were
required to support blood pressure. Treated over the next [**6-13**]
days in the ICU with only marginal improvement in her WBC, [**Month/Day (3) **]
appearance, and vent settings. Pt was very hard to ventilate and
required very high levels of PEEP and FiO2 to maintain O2 sats
>90%. Multiple attempts made to wean down on vent settings were
only marginally successful. Multiple vent maneuvers including
inverse ratio were attempted with little improvement in
saturations. After a few days the family started talking about
withdrawing care. The decision to make pt [**Name (NI) 3225**] was made on [**10-25**].
Pt was placed on a morphine gtt with additional ativan for
comfort. All other medications were stopped and pt was
extubated. [**Name6 (MD) 23835**] and MD [**First Name (Titles) **] [**Last Name (Titles) 22157**]. Pt became aystolic at
1733 and was pronounced dead at 1740 [**2126-10-25**] from hypoxic
respiratory failure due to pneumonia. Family declined autopsy.
Medications on Admission:
1. Prednisone 5 mg daily
2. glyburine 10 mg [**Hospital1 **]
3. metformin 1000 mg qam, 1500 mg qhs
4. actos 45 mg daily
5. simvastatin 20 mg daily
6. HCTZ 25 mg daily
7. fluticasone 110 mcg inhaler - not using
8. albuterol 90 mcg HFA inhaler - not using
9. fluticasone 50 mcg nasal spray - not using
10. enalapril 20 mg [**Hospital1 **]
11. fluoxetine 20 mg daily
12. MVI
13. citracal
14. Vit D 400 IU
15. folate 1 mg daily
16. TMP-SMX 1 DS daily
17. Enbrel (has not received in 8 weeks)
18. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**6-17**]
MLs PO Q6H (every 6 hours) as needed for cough.
19. Benzonatate 100 mg Capsule PO TID
20. Cefpodoxime 200 mg Tablet PO Q12H (every 12 hours)
21.Azitrhomycin 250mg PO Qday
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt died during hospitalization
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"486",
"266.2",
"584.9",
"250.00",
"714.0",
"038.9",
"518.81",
"401.9",
"285.9",
"995.92",
"708.8",
"799.02",
"278.00",
"785.52",
"515",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6589, 6598
|
3771, 5779
|
350, 428
|
6672, 6682
|
6734, 6740
|
3415, 3581
|
6561, 6566
|
6619, 6651
|
5805, 6538
|
6706, 6711
|
3596, 3748
|
291, 312
|
456, 2749
|
2771, 3172
|
3188, 3399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,276
| 191,814
|
40282
|
Discharge summary
|
report
|
Admission Date: [**2142-8-20**] Discharge Date: [**2142-9-5**]
Date of Birth: [**2083-3-22**] Sex: F
Service: ORTHOPAEDICS
Allergies:
percocdan / nylon sutures
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
L3-S1 anterior fusion
Anterior fusion and decompression of T12-L3
Posterior decompression and fusion T9-S1 w/ instrumentation and
bone graft.
History of Present Illness:
Ms. [**Known lastname 88392**] has a long history of scoliosis. She has attempted
conservative treatment but has failed. She now presents for
surgical intervention.
Past Medical History:
HLD, GERD, Barrett's esophagus, asthma, migraines, scoliosis,
anxiety, mitral valve prolapse
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2142-9-1**] 08:55AM BLOOD WBC-11.3* RBC-3.19* Hgb-9.5* Hct-27.3*
MCV-85 MCH-29.7 MCHC-34.8 RDW-14.2 Plt Ct-689*
[**2142-8-31**] 05:15AM BLOOD WBC-13.4* RBC-3.40* Hgb-10.3* Hct-29.5*
MCV-87 MCH-30.1 MCHC-34.7 RDW-14.1 Plt Ct-671*#
[**2142-8-29**] 01:13AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.2* Hct-26.3*
MCV-86 MCH-30.0 MCHC-34.9 RDW-14.6 Plt Ct-435
[**2142-8-27**] 01:53AM BLOOD WBC-6.7 RBC-3.35* Hgb-10.2* Hct-29.6*
MCV-88 MCH-30.3 MCHC-34.3 RDW-14.2 Plt Ct-244
[**2142-9-1**] 08:55AM BLOOD Glucose-113* UreaN-8 Creat-0.4 Na-137
K-3.8 Cl-100 HCO3-30 AnGap-11
[**2142-8-30**] 01:46AM BLOOD Glucose-93 UreaN-14 Creat-0.5 Na-134
K-4.0 Cl-98 HCO3-28 AnGap-12
[**2142-8-28**] 12:25PM BLOOD Glucose-124* UreaN-28* Creat-1.2* Na-139
K-4.1 Cl-98 HCO3-28 AnGap-17
[**2142-8-27**] 01:53AM BLOOD Glucose-95 UreaN-13 Creat-0.6 Na-140
K-3.1* Cl-99 HCO3-31 AnGap-13
Brief Hospital Course:
Ms. [**Known lastname 88392**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2142-8-20**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T12-L3 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. On HD#3 she
returned for a scheduled T10-S1 posterior fusion with
instrumentation. A bupivicaine epidural pain catheter placed at
the time of the posterior surgery remained in place until postop
day one.
She developed a post-operative ileus and an NG tube was placed.
The ileuse was slowly resolving and NG tube was removed with
diet advanced.
She developed acute distension and was transferred to the TICU
for monitoring. There, an NG tube was placed and her abdomen was
decompressed. CT scan showed no sign of blockage.
She was subsequently transferred out of the TICU and monitored.
She was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley remained in place due
to post-op urinary incontenance. This will be managed by her
PCP. [**Name10 (NameIs) **] was fitted with a TLSO brace for ambulation. Physical
therapy was consulted for mobilization OOB to ambulate. Hospital
course was otherwise unremarkable. On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet.
Medications on Admission:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
contipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for dyspepsia.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
contipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for dyspepsia.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
10. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 805**] [**Last Name (NamePattern1) **] Care
Discharge Diagnosis:
Scoliosis
Urinary incontenance
Post-op ileus
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Ambulate with brace
Treatment Frequency:
Please perform leg bag teaching. Inspect the incision for
drainage daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2142-9-5**]
|
[
"300.00",
"738.4",
"424.0",
"518.0",
"722.52",
"722.4",
"E878.1",
"998.89",
"785.0",
"E849.7",
"737.30",
"276.3",
"413.9",
"729.73",
"721.3",
"493.90",
"997.49",
"560.1",
"285.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"81.64",
"80.51",
"77.71",
"81.63",
"77.79",
"81.05",
"81.04",
"03.90",
"96.6",
"84.51",
"81.06"
] |
icd9pcs
|
[
[
[]
]
] |
6127, 6265
|
2208, 4243
|
299, 442
|
6385, 6391
|
1334, 2185
|
8535, 8613
|
794, 799
|
5139, 6104
|
6286, 6364
|
4269, 5116
|
6415, 6521
|
814, 1315
|
8371, 8415
|
6557, 6750
|
250, 261
|
6786, 7241
|
7253, 8353
|
470, 638
|
8436, 8512
|
660, 754
|
770, 778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,517
| 115,777
|
25503
|
Discharge summary
|
report
|
Admission Date: [**2189-7-27**] Discharge Date: [**2189-8-12**]
Date of Birth: [**2116-9-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Jaundice and pruritis
Major Surgical or Invasive Procedure:
Whipple procedure [**2189-7-28**]
Evacuation of retroperitoneal hematoma [**2189-8-1**]
History of Present Illness:
72 year old female with 10 day history of pruritis and jaundice.
Seen by her primary care physician where labs revealed
increased bilirubin. A CT was then performed which showed a
mass in the pancreas. The patient then underwent two ERCPs that
both failed to cannulate the bile duct.
Past Medical History:
-Adenocarcinoma of left chest wall s/p resection and
radiation/chemotherapy
-Hypothyroidism
-Hypercholesterolemia
-S/P tonsillectomy
Social History:
Past history of 30 pack years tobacco; quit 6 years ago
(-)ETOH. Housewife.
Family History:
Father, brother w/ CAD, MI
Mother w/ HTN
Physical Exam:
Gen: Pleasant elderly femal in no acute distress
Alert and oriented x3
HEENT: Pupils equal, round and reactive to light and
accommodation, extraocular movements intact, skin jaundiced,
mild scleral icterus
CV: Regular rate and rhythm, no murmur appreciated
Pulm: Clear to auscultation bilaterally, no wheeze/rales/rhonchi
Abd: Soft, non-tender, non-distended, no masses appreciable,
+normoactive bowel sounds
Ext: No clubbing, cyanosis, or edema
Pertinent Results:
[**2189-7-27**] 09:15PM GLUCOSE-116* UREA N-6 CREAT-0.7 SODIUM-141
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
[**2189-7-27**] 09:15PM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-1.7
[**2189-7-27**] 08:13AM ALT(SGPT)-411* AST(SGOT)-188* ALK PHOS-449*
AMYLASE-65 TOT BILI-6.7* DIR BILI-5.0* INDIR BIL-1.7 LIPASE-96*
ALBUMIN-3.8
[**2189-7-27**] 08:13AM WBC-8.0 RBC-4.34 HGB-12.5 HCT-38.4 MCV-89
MCH-28.8 MCHC-32.5 RDW-14.7 PLT COUNT-253
[**2189-7-27**] 08:13AM PT-11.8 PTT-24.1 INR(PT)-0.9
[**2189-7-28**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2189-7-27**]
ERCP: Fifteen spot fluoroscopic images are provided from ERCP
performed by Dr. [**Last Name (STitle) **]. The pancreatic duct is nondilated.
Images demonstrate periductal opacification secondary to
extramucosal injection with extraluminal air. The common bile
duct is not opacified. A plastic pancreatic duct stent is
placed.
IMPRESSION: Extramucosal injection of contrast and small amount
of extraluminal air. Nondilated pancreatic duct with plastic
pancreatic duct stent placed.
CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST [**2189-7-27**]
1 A 1.3-cm rounded hypoattenuating lesion in the periampullary
region of the pancreatic head concerning for an early pancreatic
head or periampullary tumour.
Secondary dilatation of the intra- and extrahepatic biliary
tree,non distended pancreatic duct with stent in situ. 2. No
evidence of metastatic disease. 3. Cholelithiasis
Pathology report, pancreatic specimen
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G3: Poorly differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes: pN1b: Metastasis in multiple regional
lymph nodes.
Brief Hospital Course:
Patient was admitted on [**2189-7-27**] with jaundice and pruritis from
a pancreatic mass obstructing the common bile duct. An ERCP
performed the day of admission had failed to cannulate the bile
duct due to distal obstruction. A CTA of the abdomen was done
to further define the mass in anticipation of surgical excision.
A chest x-ray, electrocardiogram, and U/A were performed with
no abnormalities noted. Labs revealed elevated liver function
tests with a total bilirubin of 6.7. The patient underwent a
Whipple procedure on [**2189-7-28**] and the pancreatic mass was
successfully resected. The patient tolerated the surgery
without complications intraoperatively. An epidural was placed
pre-operatively for pain control. The common protocol for
patients following a whipple procedure was followed. She was
placed on subcutaneous heparin, venodynes, and thigh-high [**Male First Name (un) **]
stockings for DVT prophylaxis. She remained NPO on IV fluids
with a nasogastric tube in place. Nutrition was consulted for
recommendations post-whipple procedure. Her JP drain was noted
to be draining serosanguinous fluid of appropriate volume. The
patient was out of bed to a chair on POD1 and ambulated with
assistance on POD2. The patient's urine output decreased
slightly on POD3 and she required 2 normal saline boluses of
500cc. Her blood pressure and heart rated remained stable. The
epidural catheter was removed on POD3 by pain service with the
tip intact and the patient was placed on a PCA for pain control.
The nasogastric tube was also discontinued on POD3. The
patient had an episode of coffee ground emesis and continued to
have low urine outputs. Overnight on POD3 the patient's
hematocrit was noted to decrease from 27.9 to 22.8 then 20.5 and
the JP output was noted to be more sanguinous than previously
with a larger volume draining. INR was 2.5. At this time the
patient also began experiencing abdominal pain and was noted
have tenderness on exam. Her heart rate was in the 60s and her
blood pressure was stable at this time. The patient was
transferred to the SICU and transfused 3units PRBCs and 4units
FFP. The JP amylase level at this time was 253. The patient
continued to have a decreasing hematocrit despite transfusions
and the patient was taken to the operating room for a presumed
post-operative bleed after discussion with the patient's son.
She was found to have a retroperitoneal hematoma commented in
the operative note as "right upper quadrant bleeding presumably
from the mesopancreas of uncinate process with acute-dissection
deep into retroperitoneum down to pelvis". The patient
tolerated the procedure well and was noted to have a hematocrit
increasing to 28.8. She remained intubated in the SICU and was
monitored closely. She recovered well and had no evidence of
further bleeding. TPN was initiated due to the patient's
prolonged NPO status. The patient was extubated on POD7/3. She
was transferred to the floor on POD9/5. The patient's diet was
advanced beginning on POD [**10-19**] and TPN was discontinued when she
was on a regular diet ([**2189-8-10**]). Physical therapy evaluated and
followed the patient on the floor and recommended continuation
of therapy upon discharge. The patient was discharged to rehab
on [**2189-8-12**] (POD 15/11) in good condition.
Medications on Admission:
Lipitor
Synthroid
Folic Acid
Fosamax
Discharge Medications:
1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please continue until ambulating
frequently.
3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Pancreatic mass
Discharge Condition:
Good
Discharge Instructions:
Please call if you experience new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also call if your wound becomes red, swollen, warm, or produces
pus.
You may resume your regular diet as tolerated.
Followup Instructions:
Please call Dr.[**Name (NI) 9886**] office for an appointment on Monday,
[**8-24**]. ([**Telephone/Fax (1) 14347**].
|
[
"244.9",
"198.89",
"285.1",
"196.2",
"560.1",
"998.12",
"286.7",
"574.11",
"272.0",
"157.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"54.12",
"38.91",
"51.22",
"99.15",
"99.04",
"38.93",
"52.7",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
7620, 7667
|
3432, 6775
|
335, 425
|
7727, 7734
|
1530, 3409
|
8017, 8136
|
1007, 1049
|
6862, 7597
|
7688, 7706
|
6801, 6839
|
7758, 7994
|
1064, 1511
|
274, 297
|
453, 741
|
763, 897
|
913, 991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,563
| 190,897
|
41784
|
Discharge summary
|
report
|
Admission Date: [**2157-3-9**] Discharge Date: [**2157-3-16**]
Date of Birth: [**2087-6-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
[**2157-3-9**]
1. Esophagogastroduodenoscopy.
2. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy.
3. Feeding jejunostomy tube placement.
4. Buttressing of intrathoracic anastomosis with
intercostal muscle.
History of Present Illness:
The patient is a 69-year-old gentleman with locally advanced
adenocarcinoma of the GE junction. In [**2156-10-28**] he
underwent an EGD and laparoscopic J-tube placement. He was
discharged [**Last Name (un) **] on [**2156-11-9**] with visiting nursing for tube
feeding, and the plan was to start chemoradiation. He has since
completed chemotherapy on the [**11-20**], and apparently
has had a good oncologic response per radiologic critiers.
Still has diminished appetite. Strong gag reflex, everytyhing
from saliva to the smell of his urine can make him gag.
Currently he is tolerating tube feeds cycled from 7pm to 5:30,
2kCal HN. Occasionally he will have reflux with this but it is
sporadic. He presents now for surgical resection
Past Medical History:
PMH: HTN, radiation proctitis, PAF
PSH: S/P prostatectomy [**2144**] for Ca with XRT to bed of prostate
[**2147**]
due to increased PSA
Social History:
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:____
quit: ______
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [ ] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:Retired laborer
Marital Status: [x] Married [ ] Single
Lives: [ ] Alone [x] w/ family [ ] Other:
Other pertinent social history:Very active
Travel history:none
________________________________________________________________
Family History:
No Ca
Physical Exam:
BP: 117/77. Heart Rate: 90. Weight: 160.7. Height: 71.5. BMI:
22.1. Temperature: 98.6. Resp. Rate: 16. Pain Score: 3. O2
Saturation%: 98.
Gen: AOx3 NAD
Cor: RRR without mRG
Res: CTAB, normal WOB
Abd: Soft, NT/ND, J-tube site C/D/I
Ext: No edema
Pertinent Results:
[**2157-3-9**] 04:00PM WBC-8.4 RBC-3.30* HGB-9.1* HCT-28.8* MCV-88
MCH-27.5 MCHC-31.5 RDW-15.0
[**2157-3-9**] 04:00PM PLT COUNT-157
[**2157-3-9**] 04:00PM PT-14.1* PTT-27.8 INR(PT)-1.3*
[**2157-3-9**] 04:00PM GLUCOSE-158* UREA N-27* CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2157-3-15**] Ba swallow :
1. No evidence of extraluminal leak.
2. Narrowed and irregular appearance of the anastomosis, without
obstruction, likely representing postoperative changes.
Brief Hospital Course:
Mr. [**Known lastname 634**] was admitted to the hospital and taken to the
Operating Room where he underwent an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **]
esophagogastrectomy. He tolerated the procedure well and
returned to the SICU in stable condition. He maintained stable
hemodynamics and his pain was controlled with an epidural
catheter.
Following transfer to the Surgical floor he continued to
progress. His pain was controlled with an epidural catheter and
he remained free of any pulmonary problems by using his
incentive spirometer effectively. He developed 2:1 atrial
flutter on post op day #2 and required rate control with a
Diltiazem drip along with scheduled IV Lopressor. He converted
to NSR in the 80's and maintained it. He remained on the IV
preparations until his barium swallow was completed on [**2157-3-15**].
At that time he was converted to Diltiazem 30 mg PO QID and
Lopressor 50 mg PO BID. He remained in NSR in the 80 range and
will continue this regime until he is evaluated by Dr. [**First Name (STitle) **],
his cardiologist in [**State 1727**].
From a surgical standpoint he continued to do well. His
incisions were healing well and his chest tube and JP drain were
removed after his swallow demonstrated no anastomotic leak. He
subsequently began a liquid diet and tolerated it well in
moderation. His cyclic tube feedings were resumed and he
noticed that he had occasional loose bowel movements once they
were restarted. He had the same problem pre op but didn't
mention it to anyone. He was able to control the diarrhea with
occasional Imodium. Due to the fact that he has many cases of 2
cal HN at home, he prefers to continue the same preparation as
it should be short term.
He was up and walking independently and his pain was controlled
with Tylenol and Oxycodone. His staples were removed prior to
discharge and VNA services were set up. He was discharged to
home on [**2157-3-16**] and will return to the Thoracic Clinic in 2
weeks.
Medications on Admission:
Metoprolol 100 mg QD
Ranitidine 150 mg [**Hospital1 **]
Discharge Medications:
1. diltiazem HCl 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day): Crush and take with applesauce.
Disp:*120 Tablet(s)* Refills:*2*
2. metoprolol tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day): Crush and give with applesauce.
Disp:*60 Tablet(s)* Refills:*2*
3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
4. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Twenty (20) mls PO
Q6H (every 6 hours) as needed for pain.
Disp:*500 mls* Refills:*2*
5. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 mls PO Q4H (every 4
hours) as needed for pain.
Disp:*500 mls* Refills:*0*
6. Nutrition
Tube feedings 2 cal HN at 90 mls/hr x 12 hours
4 [**11-29**] cans daily
Dispanse 1 case with refills for 6 months
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] HOME HEALTH AND HOSPICE
Discharge Diagnosis:
Esophageal cancer
PAF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting (take anti-nausea medication)
-Increased abdominal pain
-Incision develops drainage
-Remove chest tube and j-tube site bandages Friday and replace
with a bandaid, changing daily until healed.
-Your steri strips will fall off within a few weeks
Pain
-Oxycodone via J-tube or orally as needed for pain
-Tylanol is also effective
-Take stool softners with narcotics
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Tube feeds: 2 cal HN Full Strength 90 mL x 12 hrs from 6pm to
6am OR whatever 12 hour time frame works for you.
Flush J-tube with 30 cc's water of water, before and after
starting tube feeds and giving medications through tube and
every day at noon.
Full liquid diet, may increase to soft solids over the next few
days as tolerated.
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Danger signs
Fevers > 101 or chills
Increased shortness of breath, cough or chest pain
Incision develops drainage
Nausea, vomiting (take anti-nausea medication)
Increased abdominal pain
Call if J-tube falls out (save the tube and bring with you to
the hospital to be re-placed) or suture breaks
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2157-3-29**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinicla
Center for a chest xray.
Dr.[**Doctor Last Name 90756**] office will notify you of a follow up appointment
towards the end of [**Month (only) 116**].
Completed by:[**2157-3-16**]
|
[
"401.9",
"V87.41",
"150.8",
"427.31",
"V45.77",
"427.32",
"V15.82",
"V15.3",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"42.42",
"46.39",
"45.13",
"42.52"
] |
icd9pcs
|
[
[
[]
]
] |
5913, 5986
|
2838, 4850
|
319, 559
|
6052, 6052
|
2310, 2815
|
7907, 8551
|
2022, 2029
|
4956, 5890
|
6007, 6031
|
4876, 4933
|
6203, 7884
|
2044, 2291
|
270, 281
|
587, 1329
|
6067, 6179
|
1351, 1490
|
1907, 2006
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.