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53,939
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45908
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Discharge summary
|
report
|
Admission Date: [**2140-6-16**] Discharge Date: [**2140-6-21**]
Date of Birth: [**2058-2-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Lethargy, hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 82 year old male with chief complaint of near
syncope. He states that several days ago he fell into the side
of his car while he was working on it. He has had bruising on
his right hip. He had been feeling fatigued for the last several
days, and was told to come into [**Hospital1 **] by his PCP. [**Name10 (NameIs) **] [**Name Initial (NameIs) **]
near syncopal episode today at home getting ready to come to
hospital, EMS called and he was hypotensive with 90's systolic.
Taken to [**Hospital1 18**] [**Location (un) 620**].
The patient's wife does not know anything about the patient
falling or bumping into a car. Patient has very large right
sided hip hematoma which extends to his knee, with firm leg and
significant edema. + pulses. The patient's wife reports that the
patient has been especially fatigued and lethargic over the last
few days and has been getting somewhat confused.
As reported by the Emergency Department, the patient has a
history of myeloproliferative disease with [**First Name9 (NamePattern2) **] [**Doctor First Name **] and
thrombocytosis. Patient's normal hematocrit is around 43, WBC
around 50, and platlets of 1.5 million.
At [**Location (un) 620**], the patient was afebrile, 89, 99/55, RR 18, O2 sat
95
Labs: WBC 155.8; HCT 26.2; Lactate 6.9; Potassium 6.8 The
patient received 2.5L of crystalloid, insulin, glucose, calcium
gluconate, sodium bicarb, kayexalate for hyperK. He also
received cefepime and vancomycin. The patient further received 2
units pRBCs. Peripheral smear slides sent over, to go to lab;
reported to show no immature cells. LENI negative at [**Location (un) 620**].
In the ED, initial vital signs were T afebrile P 103 BP 113/43 R
16 O2 sat 100% on 2L.The patient received calcium gluconate,
bicarbonate, dextrose, and 1.5 L normal saline.
Past Medical History:
Polycythemia
Hypertension
Social History:
- Tobacco: Has not smoked in many years
- Alcohol: 1 drink per week
Family History:
No conditions run in the family, according to patient.
Physical Exam:
On Admission:
Vitals: BP: 98/53 P: 120 R: 28 100% on 2L:
General: Follows simple commands, oriented only to self
HEENT: Sclerae anicteric, MMM, oropharynx clear, partly
edentulous
Neck: Supple, no LAD
Lungs: Clear to auscultation bilaterally
CV: S1, S2, no murmurs auscultated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding; significant hematoma on right
flank/back
GU: Foley in place
Ext: Significant swelling of right lower extremity, pitting
edema of right foot, bullae forming on pre-tibial surface.
Pulses palpable and patient capable of moving foot.
Pertinent Results:
On Admission:
[**2140-6-16**] 02:25PM BLOOD WBC-119.3* RBC-3.95* Hgb-8.7* Hct-29.7*
MCV-75* MCH-21.9* MCHC-29.1* RDW-20.2* Plt Ct-868*
[**2140-6-16**] 02:25PM BLOOD Neuts-97* Bands-1 Lymphs-0 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2140-6-16**] 02:25PM BLOOD PT-16.4* PTT-30.7 INR(PT)-1.4*
[**2140-6-16**] 02:25PM BLOOD Glucose-48* UreaN-70* Creat-3.6* Na-133
K-7.4* Cl-97 HCO3-16* AnGap-27*
[**2140-6-16**] 09:22PM BLOOD ALT-30 AST-66* LD(LDH)-341* CK(CPK)-694*
AlkPhos-252* TotBili-1.3
On Discharge:
Studies:
CT Abd/Pelvis [**6-16**]-IMPRESSION: 1. Large intramuscular hematoma
in the right buttock extending into the medial right thigh.
Active bleeding cannot be excluded on this noncontrast CT. 2.
Small right pelvic and presacral hematoma. No large RP hematoma.
3. Splenomegaly - please correlate clinically. 4. Incompletely
characterized renal cysts - US may be obtained to further
assess. 5. Left adrenal nodule, which is not compatible with
adenoma due to attenuation of 25 [**Doctor Last Name **] - consider MRI to further
assess.
CT Head [**6-16**]-IMPRESSION: No acute intracranial process. If CVA
is suspected, please note MRI is more sensitive.
Brief Hospital Course:
The patient is an 82-year-old man with a myeloproliferative
disorder who is presenting with altered mental status and
electrolyte disturbances.
.
# Electrolyte disturbances: The patient presented to an OSH
with an elevated potassium and phosphate. Received Ca++-gluc,
kayexalate, insulin and IVF at OSH for hyperkalemia with ?ECG
changes. Transferred to [**Hospital1 18**] with initial K+ of 7.4 and Cr 3.6.
Continued to receive runs of kayexalate, bicarb and repeated
insulin-dextrose with some improvement in hyperkalemia. Renal
consulted and did not feel urgent HD was necessary. Initial
differential was for tumor lysis syndrome vs. rhabdo. Heme
consulted and though rhabdo most likely etiology. Over
subsequent days, the patient's K+ returned to baseline without
further intervention.
.
Right Sided Hematoma: patient was found to have very large
right sided hematoma and swelling in the entirity of his right
leg, abdomen, and right upper extremity as well as scrotal
swelling and hematoma. This was reportedly related to a fall
the patinent had several days prior to admission. He was seen
by surgery who did not find evidence of compartment syndrome
given intact pulses, strength, sensation and abssence of severe
pain nor did they feel evacuation of the hematoma was indictated
given its age. His CK, AST, K and uric acid were elevated at
admission and improved to baseline over the course of his stay.
LENIs were done on the lower extermity that did not show
evidence of DVT. Asprin and heparin were initially held for
fear of rexpansion of hematoma, but were restarted prior to
transfer from the ICU.
.
# Altered mental status: On presentation the patient was
oriented only to self. Likely secondary to his electrolyte
disturbances although also considered hyperviscosity syndrome
given large number of WBCs (see below). Head CT was obtained
given reccent history of fall and did not show an acute
intracranial process. Heme consult did not believe leukostasis
to be playing a role. Over the subsequent hospital stay, the
patient's MS improved and was nearly back to baseline on [**6-19**]
per family.
.
# Acute kidney injury: Baseline creatinine unknown, although
given home medications that include daily colchicine, likely has
normal kidney function. CT scan of abdomen showed no suggestion
of hydronephrosis/post-renal problems. The patient's Cr trended
downwards from a peak of 3.8 around admission to 1.7 presently.
Likely a mixed pre-renal and ATN etiology.
.
# Blood Dyscrasia: The patient presented with WBC >100 with 96%
neutrophils. Unclear etiology although the patient's wife
reports that he sees Dr. [**Last Name (STitle) **] in [**Hospital1 1474**] for a blood dyscrsia
and is receiving radiation therapy. Neither the patient nor the
wife understands him to have a diagnosis of leukemia. He takes
anagrelide and low dose aspirin therapy at home for his
thrombocytosis. Heme/onc did not see any immature forms on
peripheral smear and did not find this to be either a blast
crisis or tumor lysis syndrome. His anagrelide was discontinued
in the hospital for subtherapeutic dosing as well as hydroxyurea
being the clinically indicated treatment for polycythemia [**Doctor First Name **].
Anagrelide was restarted at time of discharge; the decision to
restart hydroxyurea will be pending outpatient hematology.
.
# Afib with RVR: patient was predominately in sinus rhythm with
heart rates in the 80s, but was seen to have frequent ectopy and
conversion to afib with spontaneous resolution on telemetry.
Bouts of afib were never seen to last more than a few minutes
and rate control was attempted with metoporolol, though doses of
12.5mg [**Hospital1 **] caused hypotension to the 80s systolic. His
pressures were stable in the 110s on 6.25 mg metoporolol. At
time of discharge he was maintained on metoprolol 6.25 daily.
.
# Raspy Voice: Patient remarked to have "soar voice" unclear
etiology, was seen by speech and swallow team who recommended he
be placed on thin liquids and ground foods.
.
# Hypertension: Anti-hypertensives were restarted at time of
discharge
.
# Gout: Holding colchicine, given kidney injury.
.
# Dispo: to rehab with instructions to follow up with primary
care and outpatient hematology
Transitional Issues:
Will need:
(1) Daily abdominal / flank assessment to make sure hematoma is
not expanding
(2) Daily CBC to ensure HCTs are stable
(3) Daily INR checks to keep < 2.0
(4) Daily BMP to ensure potassium does not increase
(5) Telemtry for atrial fibrillation - can d/c metoprolol if no
further episodes
(6) Can restart SC heparin if INR remains < 2.0
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
(1) Right sided buttock and right thigh hematoma
(2) Rhabdomyolysis (with renal failure and high potassium)
(3) Polycythemia [**Doctor First Name **]
(4) Paroxysmal atrial fibrillation
Discharge Condition:
Able to sit up in bed with assistance; improvement in WBC count,
resolution of electrolyte abnormalities
Discharge Instructions:
Dear Mr [**Known lastname 26735**],
You were admitted after a recent fall. The fall caused bleeding
around the right buttock and right thigh area. Because of
bleeding, your potassium was very high and it also led to your
kidneys to fail. To treat this, you needed to be in the ICU,
where you received lots of fluid. We had the general surgery
team see you who felt you had no need for surgery. The hematoma
should improve on its own. The most important priority at this
time is physical therapy to ensure that you can regain your
strength.
We made the following medication changes during your
hospitalization:
(1) Stop colchicine - you should only restart this when your
kidneys are back to normal.
(2) Change allopurinol to 100 mg every other day. This medicine
can be taken normally again when your kidneys return to normal.
(3) Start metoprolol - this is a medicine for your heart that
protects it from a fast heart rate that you had called atrial
fibrillation.
Followup Instructions:
Please schedule an appointment with your primary care doctor and
outpatient hematologist following discharge from the rehab
center.
|
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12,532
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13996
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Discharge summary
|
report
|
Admission Date: [**2168-4-14**] Discharge Date: [**2168-4-27**]
Date of Birth: [**2120-2-18**] Sex: M
Service: BMT
Mr. [**Known lastname 7710**] is a 48 year-old man with no significant past
medical history who was previously well until [**2168-1-1**].
At that time, he started developing high fevers up to 103.0
F, drenching night sweats and crampy left upper quadrant
abdominal discomfort. The pain in his epigastrium became
progressively worse to the point where he was unable to eat
or continue working in his job as a construction worker. He
was evaluated in the [**Hospital 8**] Hospital Emergency Department
and discharged with a diagnosis of gastroenteritis at that
time. However his abdominal discomfort persisted and after
searching the internet, he questioned his PCP as to whether
he had pancreatitis. Amylase level drawn in [**2168-2-29**] was
in the 900s. An ultrasound on [**3-21**] confirmed
pancreatitis and abdominal CT Scan demonstrated marked
retroperitoneal lymphadenopathy. He underwent MRI of the
abdomen on [**4-4**] which raised the concern of pancreatic
stricture and noted extensive peripancreatic lymphadenopathy
that was thought to be consistent with lymphoma versus
metastatic disease.
He continued to suffer from abdominal discomfort which was
associated with rising bilirubin and fevers. He was
diagnosed with obstructive cholangitis. He was initially
admitted to an outside hospital and treated with intravenous
antibiotics. An ERCP was attempted with gastric biopsy, but
they were unable to cannulate the common bile duct. He is
transferred to [**Hospital1 69**] for ERCP
and further management.
PAST MEDICAL HISTORY:
1. L4-5 laminectomy.
2. Left rotator cuff repair.
3. Left orchiectomy for "fibrous epididymitis".
4. History of left lung pneumonia in [**2167-7-1**].
5. History of left chest shingles in [**2168-1-1**].
MEDICATIONS ON ADMISSION:
1. Pantoprazole 40 mg q. day.
2. Metoprolol 50 mg b.i.d.
3. Morphine p.r.n.
4. Lorazepam 0.5 mg t.i.d. p.r.n.
5. Fentanyl 25 mcg patch.
6. Ceftriaxone 1 gram q. day.
7. Metronidazole 500 mg t.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He has worked as a construction worker for
the past 30 years. He lives in [**Hospital1 3494**] with his
significant other.
FAMILY HISTORY: His mother has hypertension and his father
has prostate cancer.
PHYSICAL EXAMINATION: Temperature 100.3 F, heart rate 92,
blood pressure 140/90, respiratory rate 18. He was a
jaundiced man in no acute distress. Pupils are equal, round
and reactive to light and accommodation. Extraocular muscles
are intact. Scleral icterus. Oropharynx clear. Neck was
supple without lymphadenopathy. Heart was regular rate and
rhythm with normal S1, S2. There are no murmurs, rubs, or
gallops. Lungs were clear to auscultation and percussion
bilaterally. The abdomen was soft and distended. There was
tenderness in the epigastric and right upper quadrant. There
are active bowel sounds. There is no evidence of rebound or
guarding. There is no CVA tenderness. Extremities are
without cyanosis, clubbing or edema. There are 2+ peripheral
pulses bilaterally. He is alert and oriented to person,
place and time. Cranial nerves II through XII are intact.
Motor strength was 5/5 times four extremities. Sensation was
intact to light touch.
LABORATORY: White count 14.1 with 57% neutrophils, 3% bands,
11% lymphocytes, 9% monocytes, 18% atypicals, hemoglobin
13.7, platelets 129. PT 13.2, PTT 34.8. Sodium 134,
potassium 4.5, chloride 95, bicarbonate 15, BUN 21,
creatinine 0.7, glucose 40. ALT 314, AST 413, alkaline
phosphatase 1,087, total bilirubin 11.9, albumin 2.8, calcium
8.4, phosphorus 2.0, magnesium 2.0.
HOSPITAL COURSE: Mr. [**Known lastname 7710**] is admitted to this hospital for
further management of his disease. He underwent an ERCP
which demonstrated cholangitis, choledocholithiasis. His
gastric mucosa was biopsied. He had a successful
sphincterotomy with successful extraction of small stone
fragments and sludge. Pathology of his gastric biopsy and
bone marrow biopsy demonstrated a monoclonal population of
cells which were [**Last Name (un) **] positive, surface CD3 negative,
cytoplasmic CD positive, CD56 positive, weekly CD2 positive,
CD20 negative. These biopsy findings were consistent with a
NK cell lymphoma / leukemia.
Following his sphincterotomy, he was transferred to the
Intensive Care Unit for further management due to concerns of
a rising lacticacidosis and hypoglycemia. He remained in the
Intensive Care Unit for four days during which time he was
treated with intravenous antibiotics and intravenous cortical
steroids as well as Allopurinol for tumor lysis prophylaxis.
His clinical status improved during his ICU stay and he was
transferred to the Oncology Service for initiation of
chemotherapy.
He completed the first course of chemotherapy in-house with a
cycle of Phosphoamide, Dexamethasone, ARA-C and Cisplatin.
He tolerated the chemotherapy well without major toxicities.
He did develop some acute upper GI bleeding with melena. An
EGD was performed and demonstrated no signs of active
bleeding. The melena resolved on its own. He was discharged
to home in stable condition and close follow up in the
[**Hospital **] Clinic was arranged.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: He will follow up in the [**Hospital **] Clinic
within two days of discharge for further management.
DISCHARGE MEDICATIONS:
1. Lorazepam p.r.n.
2. Oxycodone p.r.n.
3. Allopurinol.
DISCHARGE DIAGNOSES:
1. Natural killer cell lymphoma / leukemia status post
chemotherapy.
2. Obstructive cholangitis status post sphincterotomy.
3. Upper GI bleed of uncertain etiology.
4. Transient hypoglycemia and lacticacidemia likely
secondary to hepatic dysfunction.
5. Acute renal failure secondary to intervascular volume
depletion.
6. Anemia secondary to GI blood loss requiring blood
transfusion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], M.D. [**MD Number(1) 7782**]
Dictated By:[**Last Name (NamePattern1) 7787**]
MEDQUIST36
D: [**2169-1-3**] 10:16
T: [**2169-1-4**] 14:24
JOB#: [**Job Number 41805**]
|
[
"276.5",
"401.9",
"276.2",
"576.1",
"577.0",
"574.50",
"202.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85",
"41.31",
"51.10",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2319, 2384
|
5584, 6252
|
5503, 5563
|
1917, 2160
|
3758, 5327
|
2407, 3740
|
1681, 1891
|
2177, 2302
|
5352, 5480
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,469
| 126,534
|
10270
|
Discharge summary
|
report
|
Admission Date: [**2174-8-18**] Discharge Date: [**2174-9-21**]
Date of Birth: [**2124-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Bronchoalveolar lavage
TEE
[IR-guided PICC placement]
History of Present Illness:
The patient is a 50 year old man with history of non-ischemic
cardiomyopathy (EF 10%), afib, DM2, obesity presenting after
being found down. He was found by his girlfriend "flailing" at
~1am on [**2174-8-18**]. EMS was called. EMS found him to be in afib
with RVR (120s) and with gurgling in his chest. A fingerstick
was normal. He was found to be hyperventilating. He was
intubated for airway protection (ETT 7.5). Per report the
initial rhythm was afib with rate of 120.
Upon arrival to [**Hospital3 **], a RIJ TLC was placed. Dopamine
gtt was begun for hypotension as well as IVF. He remained
sedated with versed gtt. His BNP was 310 on admission, a digoxin
level was 2.1, his peak troponin was 0.56. Given vancomycin and
imipenem after he spiked a fever to 101. A head CT was
unremarkable (per discharge note).
Past Medical History:
Monischemic cardiomyopathy (EF 25%)
Morbid obesity
Diabetes mellitus
Atrial fibrillation
Cellulitis (abd and lower extremities)
Social History:
Negative for tobacco, alcohol, illicit substance use. Not
married, lives with family. Currently on disability.
Family History:
Two brothers, both of whom are healthy to his knowledge.
Physical Exam:
VS: 101 100 102/65 22 96% (dopamine 3mcg/kg/min)
Vent: AC 600 x 12 0.4 PEEP 5 PIP 29
Gen: obese middle aged male in NAD, resp or otherwise. intubated
and sedated
HEENT: ETT in place. NCAT. Sclera anicteric. PERRL (4->2mm
bilat), oculocephalics intact. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple. JVP not seen (CVP 8)
CV: PMI located in 5th intercostal space, midclavicular line.
irreg irreg, distant heart sounds
Chest: No chest wall deformities, scoliosis or kyphosis. No
crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits. warm abdominal pannus
Ext: No c/c/e. No femoral bruits.
Skin: skin breakdown on right shin with stasis dermatitis with
super-imposed cellulitis
Pulses:
- Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP
- Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP
Neuro: Intubated and sedated. Normal tone. Withdraws all 4
extremities to painful stimuli
Exam at discharge:
Pt expired
No pupillary or corneal reflexes
No heart or breath sounds heard in 60 sec
No withdrawing to pain
Pertinent Results:
[**2174-8-18**] 07:48PM BLOOD WBC-13.2* RBC-4.16* Hgb-12.5* Hct-37.8*
MCV-91 MCH-29.9 MCHC-33.0 RDW-17.9* Plt Ct-282
[**2174-8-18**] 07:48PM BLOOD Neuts-83.9* Lymphs-7.8* Monos-7.7 Eos-0.3
Baso-0.3
[**2174-8-18**] 07:48PM BLOOD PT-37.9* PTT-38.3* INR(PT)-4.1*
[**2174-8-18**] 07:48PM BLOOD Glucose-136* UreaN-62* Creat-1.4* Na-141
K-3.5 Cl-102 HCO3-27 AnGap-16
[**2174-8-18**] 07:48PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.3
[**2174-8-18**] 07:48PM BLOOD ALT-48* AST-37 CK(CPK)-549*
[**2174-8-25**] 05:15AM BLOOD ALT-40 AST-38 LD(LDH)-215 AlkPhos-120*
Amylase-116* TotBili-1.1
[**2174-8-26**] 04:10AM BLOOD Lipase-80*
[**2174-8-19**] 03:03AM BLOOD CK(CPK)-1021*
[**2174-8-19**] 03:01PM BLOOD CK(CPK)-1077*
[**2174-8-19**] 11:20PM BLOOD CK(CPK)-990*
[**2174-8-20**] 04:55AM BLOOD CK(CPK)-922*
[**2174-8-19**] 03:03AM BLOOD CK-MB-5 cTropnT-0.12*
[**2174-8-19**] 03:01PM BLOOD CK-MB-3
[**2174-8-19**] 11:20PM BLOOD CK-MB-3 cTropnT-0.13*
[**2174-8-20**] 04:55AM BLOOD CK-MB-3 cTropnT-0.13*
[**2174-8-25**] 05:15AM BLOOD ESR-100*
[**2174-8-25**] 05:15AM BLOOD CRP-24.6*
[**2174-8-20**] 04:26PM BLOOD Fibrino-932*
[**2174-8-20**] 04:26PM BLOOD Hapto-374*
[**2174-8-18**] 09:06PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2174-8-18**] 09:06PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2174-8-18**] 09:06PM URINE RBC-27* WBC-21* Bacteri-NONE Yeast-NONE
Epi-<1
[**2174-8-23**] 03:32AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test
Name
RESPIRATORY CULTURE (Final [**2174-8-23**]):
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP. UNABLE TO DEFINITIVELY DETERMINE THE PRESENCE OR
ABSENCE OF
OROPHARYNGEAL FLORA.
PROTEUS MIRABILIS. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
[**2174-8-25**] 07:02PM BAL WBC-0 RBC-0 Polys-97* Lymphs-1* Monos-2*
EKG [**2174-8-18**]
Atrial fibrillation. Intraventricular conduction delay. Vertical
axis.
Intraventricular conduction delay. Late R wave progression. ST-T
wave
abnormalities. No previous tracing available for comparison.
TTE [**2174-8-19**]
The left atrium is markedly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The right atrial pressure is indeterminate. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. There is severe global left
ventricular hypokinesis (LVEF = 10 %). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. with moderate global free wall hypokinesis. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
CT CHEST [**2174-8-20**]
1. Left lower lobe and upper lobe consolidation.
2. Right lower lobe collapse consolidation.
3. Cardiomegaly.
4. Gynecomastia.
CT CHEST/ABD/PELVIS [**2174-8-24**]
1. No detectable paraspinal abscess; however in the absence of
OV contrast, this cannot be ruled out with certainity.
2. Persistent multifocal pneumonia with bilateral pleural
effusion.
B/L TIB/FIB AP/LAT [**2174-8-24**]
Nonaggressive periosteal new bone formation along the tibiae
bilaterally. Tiny lucency in distal right tibia of uncertain
etiology, but considered unlikely to represent a focus of
osteomyelitis. If clinically indicated, MRI or CT could help to
further assess this finding.
Brief Hospital Course:
Pt is a 50 year old man with history of non-ischemic
cardiomyopathy (EF 10%), afib, DM2, obesity presenting after
being found down on [**2174-8-18**]. EMS found him to be in afib with
RVR (120s) and in respiratory distress. He was intubated for
airway protection and brought to OSH. RIJ placed and started on
dopamine gtt for hypotension and sedated with versed. EKG
showed a.fibb with RVR, Peak troponin 0.56.
Initial workup at the OSH showed an elevated BNP of 310,
elevated WBC to 14. He did spike a temp to 101 and was started
on vancomycin and imipenem after blood and urine cultures
obtained. He was subsequently transferred to [**Hospital1 18**] CCU.
CCU course: Pt was weaned off dopamine and antibiotics were
changed to vanco and zosyn for suspected pneumonia. ECHO done
showed stable cardiomyopathy (EF 10%) and CXR with infrahilar
opacification. Sputum cultures grew proteums with GS + GPC
(pairs/clusters), GPR and GN diploccci. Pt was persistently
febrile despite vanc/zosyn and thus ID called.
Pulmonary also consulted and underwent BAL. BAL showed viral
inclusions on cytology.
# RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **])
Pts failure likely multifactorial. From an infectious
standpoint, multi-lobar pneumonia is contributing, cultures
postitive on [**8-18**] as listed above, then on [**8-25**] positive HSV1 on
BAL. Sputum positive for MSSA. However, pt also has severe CHF
(EF 10%). Pt remained intubated and unable to wean from vent. Pt
felt to be severely volume overloaded and wt as droped over 30
kg since coming to CCU. He was aggressively diuresed, first with
bolus lasix, escalating to lasix gtt @ 20mg/hr and metalazone,
and diamox. The process was complicated by hyponatremia
requiring frequent free water balances. On [**9-5**] pt underwent
trach and PEG. By [**9-10**] it was believed that we have overdiuresed
the pt, Cr increaseing, BP dropping and fluid resesitant was
began. Fluid status remains a challange to assess given the pt
body habitus. The pt's habitus also contributes to the resp
distress and he becomes tachypnic and hypotensive when laying
flat. Pt often has chennes [**Doctor Last Name 6056**] repiration with RR in 40s and
periods of apnea. Does better on vent settings as follows:
Vt600/rate24/peep10/fi0240%. Pt thought to be dry thus lasix was
held. He was continued on atrovent nebs prn. [**9-8**] sputum showed
MSSA, therefore vanco was d/c'ed. Had added flagyl for concern
of aspiration pna. As per ID switched to clindamycin 450mg IV
q6h for MSSA and anerobe coverage. However, follwoing clinda
sensitivities, clinda was d/c'd on [**2174-9-11**]. Antibiotics switched
to Ceftazidime 1gm Q12H on [**2174-9-11**]. Pt completed 14 day course
of antibiotics and they were d/c'd. Patient subsequently
developed higher fevers and was re-started on vanc/zosyn on
[**2174-9-19**] per ID recs. On [**9-21**], in the setting of worsening
respiratory status with metabolic acidosis, fever, tachycardia,
and hypotension, it was decided that antibiotics were not
helping and all were d/c'ed. His breaths became markedly
irregular and agonal, with short, gasping inhalations. Discussed
pt's situation with his brother and his fiancee (in person) and
with his other borhter (on the phone) and it was decided on [**9-21**], [**2174**] to make Mr. [**Known lastname 5395**] [**Last Name (Titles) **] measures only. He was
pronounced dead at 20:[**2086-9-15**] from respiratory failure
secondary to pneumonia and CHF>
# FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)
Despite finishing course of abx cefepime, levofloxacin, flagyl
for [**8-18**] positive cultures, pt continued to spike fevers. The
WBC remained stable, sputum cultures + for pan-sensitive
proteus, urine legionella Ag neg, sputum legionella cx neg to
date, CT/CXR with b/l lower lobe consolidations. RIJ cath tip
neg. Ucx to date neg. Tib/Fib film no evidence of osteomyelitis.
TEE w/o evidence of endocarditis. The source of fevers remained
unclear. On [**8-25**] Initial cytology from BAL showing HSV
inclusions and HSV1 culture positive. Completed coarse of
Acyclovir 1000mg IV q8h
but continued to spike fevers up to 102. A [**9-7**] WBC scan [**Last Name (un) **]
only minor chest wall focus with no major chest or abd finding.
HIV negative. On [**9-11**] culture + MSSA in sputum and +
pseudomonas in urine, and fever increased to 104. Now on Ceftaz,
flagyl and nafcillin (first dose [**2174-9-13**]). BP remains low, HR
high, febrile, unclear at this time if picture is septic or
cardiogenic shock. On [**9-19**] pt spiked fever to 103.1, which was
higher than the fevers that he had previously been spiking
frequently. On [**9-20**] his fevers climbed to 104.5 despite
continued q6h tylenol. They remained unexplained; LUQ ultrasound
showed no evidence of abscess near PEG tube site, TEE had no
vegetations, chest/abdomen/pelvis CT showed no abscess or other
concerning intrabdominal process. Thus, in a final attempt to
bring his fevers down a triple lumen foley catheter was placed
for bladder lavage with cooling liquids, ice cold gastric was
tried, and he was aggressively cooled by the Arctic Sun
protocol. Despite this, his temperature rose to 106.9 so after a
6 hour trial these measures were d/c'ed. On day of death, max
temp was 107.1 F.
# HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC
Pt with severe cardiomyopathy and EF of only 10%. Volume status
difficult to access, have been aggressively diureising. Very
resistant to lopressor. Had tolerated Captopril, but now held in
setting of low BP and rising Cr. Currently on dig as well. Pt
currently not tolerating PO in setting of ileus, thus will
give IV Metoprolol until PO can be resumed. Continue Digoxin at
current dose once PO intake can be resumed. BB Changed from
Metoprolol to Carvedilol per Cardiology; will restart when
tolerating PO. Cards suggested starting heparin, will hold for
now given recent oozing of PEG and possibility of procedures in
near future. Given 5% risk of event per year and limit expected
pt lifespan, do not feel strongly on starting heparin.
throughout course patient was extremely dependent on CO. When HR
increased because of fever or tachyarrythmia uop would
subsequently and reliably drop. Patient was started on pressors
for inotropy with good effect on his CO and uop. By [**9-20**], in the
setting of marked fever and metabolic acidosis pt was
tachycardic and hypotensive despite maximum dose of
norepinephrine (0.45 mcg/kg/min). Carvedilol was d/c'ed.
Throughout [**9-21**], pt's SBP remained low with SBP consistently in
50s.
#GI:
PEG in place for fear of poor PO intake with trach. Pt had large
bilious return from PEG tube/ET tube and an ileus on CT that
resolved after TF were held. TF were subsequently re-started
with no further ileus. On [**9-19**] some concern was raised over the
possibility of a peg site infection so a abdominal u/s was
ordered, but was unrevealing. Surgery commented that they felt
the oozing secretions around the PEG tube site was only leaking
tube feeds. Abdominal CT on [**9-20**] showed dilated bowel loops
concerning for c. difficile colitis, but no obstruction or
abscess.
# RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)- Likely
pre-renal [**3-5**] severe CHF. Cr improved with diuresis and then
began to creep back up with max 3.4 on [**2174-9-13**]. Believe now
intravascularly dry [**3-5**] intense diuresis. FeNa suggestive of
pre-renal etiology. Renal following. Renally dosed meds. Giving
fluid boluses and monitoring UOP, which was noted to be
exquisitely sensitive to blood pressure. Urine output and Cr
improved by [**9-19**], however by [**9-21**], in the setting of very high
fevers and hypotension his urine output dropped to zero for
multiple hours.
# Metabolic Alkalosis
pH up to 7.6 on [**9-12**]. Originally attributed to contraction
alkalosis [**3-5**] aggressive lasix diuresis. However, met alk
continues dispite lack of further diuresis. Thought be be [**3-5**] to
GI losses with large NG output. Aggressively giving KCL today
and continue Diamox. TTKG calculated [**9-12**] = 12.7, suggesting
renal K loss. Pt was aggressively given KCL, goal K > 4.5.
Alkalosis resolved with hydration.
# DELIRIUM / CONFUSION
Pt becomes aggitated at times, and has managed to pull out an
A-line, and IJ. Stable on Zyprexa
# ATRIAL FIBRILLATION (AFIB)
Admitted with Afib and RVR. Pt has been poorly responsive to BB.
Also on dig. Moderate response with IV dilt. Cardiology
consulted; transitioned from metoprolol to carvedilol.
Anti-coagulation held at first because of coagulopathy and then
re-started with goal INR [**3-6**]. On 8
# COAGULOPATHY
Possible sources since the last coumadin was given on [**8-24**]
include hepatic and nutritional. Hepatic possible given poor CO
and episodic hypotension, however would expect higher LFTs if
cause was ischemia. Of note LFT are elevated. Nutrition possible
since no Vit K in tube feeds but near normal alb. a source could
be levaquin, as this effects coumadin metabolism. DIC unlikely
since platelets are rising. Held Heparin. Gave Vit K 10mg QD X 3
daysfibrinogen and haptoglobin high so likely not DIC. Resolved.
# Nutrition: PEG inplace, Nutren Renal with benefiber TF at
45mL/hr
# Glycemic Control: Insulin SS with q6h then q4h checks. Raised
standing NPH to 12U q12H
# Prophylaxis:
DVT: Pneumoboots then heparin SC
Stress ulcer: Famotidine
VAP: Head of bed elevated.
# Communication: With brothers and girlfriend.
Medications on Admission:
Spironolactone 25 mg b.i.d.
Furosemide 80 mg b.i.d.
Simvastatin 80 mg daily
Diovan 40 mg daily
Levothyroxine 100 mcg daily
Metolazone 2.5 mg every other day
Loratadine 10 mg daily
Allopurinol 300 mg daily
Digitek 250 mcg daily
Aspirin 81 mg daily
Prilosec 20 mg daily
Humalog 40 units b.i.d.
Lantus 50 units at 9 p.m.
Advair 250/50 b.i.d.
Albuterol t.i.d. p.r.n.
Klor-Con 20 mEq b.i.d.
Warfarin 5 mg tablets daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
COngestive heart failure
Hospital-acquired Pneumonia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2174-9-22**]
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icd9cm
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icd9pcs
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[
[
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16451, 16460
|
6459, 15954
|
333, 399
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16556, 16565
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2747, 6436
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16621, 16659
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1543, 1601
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16481, 16535
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15980, 16396
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2618, 2728
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273, 295
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427, 1246
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1268, 1397
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1413, 1527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,958
| 197,081
|
40771
|
Discharge summary
|
report
|
Admission Date: [**2176-3-13**] Discharge Date: [**2176-3-13**]
Date of Birth: [**2107-3-24**] Sex: M
Service: MEDICINE
Allergies:
indomethacin
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
intubation
pacer wire placement
balloon pump placement
History of Present Illness:
68 yo M with HTN, HLD, DM, no known CAD s/p SFA stent for RLE
non-healing ulcer, who presented to Caritas [**Hospital3 **] for resting
ischemia with ulcer of the right foot, with plans to undergo
diagnostic angiography, atherectomy, angioplasty, and possible
stenting. Patient underwent angio for mapping that showed below
the knee multiple vessel disease, had a bump in creatinine going
from 1.3->1.9 and was held in house for observation. The patient
underwent an SFA stent on the right on [**2176-3-10**]. In the AM of
[**2176-3-13**] he appeared well, but around per the wife had been
complaining of some chest pain the night before; a rapid
response team was called at 7:54, and at 815 code was intitated
for an unclear prior rhythm. There was a thought he might be in
complete heart block, with ventricular response in the 20's. He
received a shock of 100 [**Doctor First Name **] at 835 for presumed VT (strip not
available), and underwent epi x 1 and atropine x 1, and 2 amps
of calcium. He was then transferred from the floor to the ICU,
but int he ICU coded again at 848, and the code lasted until
0955 for [**Doctor First Name **]. At this time, he received 4 rounds of CPR, and
received 1 amp of epi, 1 amp vasopressin, 1 amp atropine, and 3
amps of calcium, 2 g of magnesium, and started a dopamine gtt.
Also initated insulin and D50. During this code, he was charted
as having alternative [**Last Name (LF) **], [**First Name3 (LF) **], and VT. A temporary pacer was
placed in the R subclavian [**Last Name (un) **]. Bedside echo was performed and
showed large wall motion abnormality, Trop I during the code was
9.6 during the code. Given the finding of positive Trop,
complete heart block with new LBBB morphology, and large wall
motion abnormalities, he was taken to cath lab for presumed CAD
leisions. While in cath lab, he was had a intra-arterial SBP of
66 while on Dopa, IABP was placed. His cath report showed 3VD,
but was noted to have noted to have TIMI 3 flow. The patient
also had an external trancutaneous pace placed. He was
transferred to [**Hospital1 18**] for a question of further management with
potential bypass surgery, transffered on heparin gtt, dopamine
gtt.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: Currently transcutaneous as well as temporary
right subclavian [**Last Name (un) **]
3. OTHER PAST MEDICAL HISTORY:
HTN
DM
HLD
Depression
Diverticulitis
CKD Stage II
Hx knee problems
Hx L [**Name (NI) 89116**] in [**2173**]
Gout
Social History:
Retired, married
- Tobacco history: None
- ETOH: None
- Illicit drugs: Unkown
- Occupational exposure to asbestos
Family History:
DM and CKD runs in the family
Physical Exam:
Vitals: T: 98 F BP 90/50 HR 90 RR 24
Gen: not responsive to commands, intubated and sedated,
myoclonic jerking at times
HEENT: No conjunctival pallor. No icterus. MMM. OP with ETT and
OGT. R pupil 3 mm, L pupil 5 mm, no reaction to light
NECK: Supple, No LAD. + JVD ~ 12 cm . Normal carotid upstroke
without bruits. No thyromegaly.
CV: PMI in 5th intercostal space, mid clavicular line. RRR.
normal S1,S2. III/VI holosystolic murmur at apex
LUNGS: Coarse breath sounds with crackles anteriorly R>L. End
expiratory wheezes noted.
ABD: NABS. Soft, obese. No HSM. Abdominal aorta was not enlarged
by palpation. No abdominal bruits.
EXT: Feet cold, legs cool, NO CCE. Difficult to appreciate pedal
pulpses bilaterally, bilateral popliteal pulses intact
SKIN: mottled in the lower extremities
NEURO: Not responding to commands, corneal reflexes and gag
intact. Myoclonus noted in lower extremities.
Pertinent Results:
Laboratory Data:
CBC:
[**2176-3-13**] 04:09PM BLOOD WBC-24.1* RBC-3.04* Hgb-10.4* Hct-32.5*
MCV-107* MCH-34.1* MCHC-31.9 RDW-15.7* Plt Ct-284
Coagulation:
[**2176-3-13**] 04:09PM BLOOD PT-21.4* PTT-146.2* INR(PT)-2.0*
Chemistry:
[**2176-3-13**] 04:09PM BLOOD Glucose-100 UreaN-42* Creat-3.1* Na-137
K-5.4* Cl-104 HCO3-11* AnGap-27*
[**2176-3-13**] 08:14PM BLOOD Glucose-22* UreaN-46* Creat-3.7* Na-141
K-6.2* Cl-103 HCO3-10* AnGap-34*
LFTs:
[**2176-3-13**] 04:09PM BLOOD Calcium-11.1* Phos-8.3* Mg-2.8*
[**2176-3-13**] 08:14PM BLOOD Calcium-11.6* Phos-9.5* Mg-2.8*
Elementals:
[**2176-3-13**] 04:09PM BLOOD Calcium-11.1* Phos-8.3* Mg-2.8*
[**2176-3-13**] 08:14PM BLOOD Calcium-11.6* Phos-9.5* Mg-2.8*
Blood gases:
[**2176-3-13**] 04:23PM BLOOD Type-ART pO2-200* pCO2-33* pH-7.19*
calTCO2-13* Base XS--14
[**2176-3-13**] 06:13PM BLOOD Type-ART Temp-36.7 Rates-20/7 Tidal V-500
PEEP-5 FiO2-100 pO2-204* pCO2-32* pH-7.17* calTCO2-12* Base
XS--15 AADO2-493 REQ O2-81 Intubat-INTUBATED Vent-CONTROLLED
[**2176-3-13**] 08:27PM BLOOD Type-ART pO2-80* pCO2-33* pH-7.13*
calTCO2-12* Base XS--17
Lactate:
[**2176-3-13**] 04:23PM BLOOD Lactate-8.8*
[**2176-3-13**] 08:27PM BLOOD Lactate-14.3*
Microbiology:
None
Imaging:
Portable TTE (Complete) Done [**2176-3-13**] at 5:11:35 PM FINAL
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Aorta - Sinus Level: *4.0 cm <= 3.6 cm
Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *22 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 16 mm Hg
Aortic Valve - LVOT diam: 2.5 cm
Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2
TR Gradient (+ RA = PASP): 14 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Moderate regional LV systolic dysfunction. No
resting LVOT gradient.
RIGHT VENTRICLE: RV not well seen.
AORTA: Mildy dilated aortic root.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS (area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Moderate (2+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - bandages,
defibrillator pads or electrodes. Suboptimal image quality -
body habitus.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Basal InferoseptalBasal AnteroseptalBasal Anterior
Basal InferiorBasal InferolateralBasal Anterolateral Mid
InferoseptalMid AnteroseptalMid Anterior
Mid InferiorMid InferolateralMid Anterolateral Septal
ApexAnterior Apex
Inferior ApexLateral Apex Apex
N = Normal, H = Hypokinetic, A = Akinetic, D =
Dyskinetic
Conclusions
The left atrium is mildly dilated. There is moderate regional
left ventricular systolic dysfunction with focal hypokinesis of
the mid to distal anterior wall, anterior septum, inferior wall,
and apex. There is dyskinesis of the distal inferior wall. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Focused views. Regional
left ventricular dysfunction c/w probable multivessel CAD.
Moderate mitral regurgitation. At least mild aortic stenosis.
- CHEST (PORTABLE AP) Study Date of [**2176-3-13**] 3:59 PM
IMPRESSION:
1. The distal tip of the pacemaker device projected over the
expected
location of the mid right ventricle. The nasogastric tube and
intra-aortic
balloon pump are malpositioned as described above.
2. Moderately severe acute pulmonary edema and probable
bilateral moderately large pleural effusions.
- CHEST (PORTABLE AP) Study Date of [**2176-3-13**] 5:45 PM
IMPRESSION: Low position of intra-aortic balloon pump, proximal
position of
orogastric tube, and change in positioning of transvenous pacing
lead.
Brief Hospital Course:
68 yo M with HTN, HLD, DM, no known CAD s/p SFA stent for RLE
non-healing ulcer, who coded x 2 at [**Hospital3 **], found to have
diffuse 3 vessels disease, presenting to [**Hospital1 18**] for further
management with possible surgical intervention.
# PUMP: The patient was felt to be in cardiogenic shock on
arrival, initially on dopamine gtt, ultimately uptitrated to 3
pressors with dopamine, levophed, and vasopressin. The patient's
bedside echos both at OSH as well as in-house showed focal
hypokinesis of the mid to distal anterior wall, anterior septum,
inferior wall, and apex, as well as dyskinesis of the distal
inferior wall. Cardiogenic shock as also presumed given the
global hypoperfusion indicated by the patient's elevated lactate
and anion gap acidosis. The inciting factor for cardiogenic
shock was not clear, but the patient in the cath lab at OSH was
noted to have 3VD, and there were comments in OSH regarding
arrhythmia, which seems to be the two most likely factors to
have instigated cardiogenic shock. The patient was supported
with 3 pressors, and balloon pump was continued at 1:1. Lactates
were trended with bicarbonate provided to keep pH greater than
7.15 in order to maintain effectiveness of pressors.
.
# CAD: The patient has diffuse 3VD not amenable to stenting; at
OSH, it was not felt feasible or safe to perform stenting
procedures. The patient was evaluated by Cardiac Surgery, but
given the patient's very tenous status was not made a candidate
for surgery. Patient was continued on heparin gtt, ASA,
Atorvastatin, and Plavix for a presumed myocardial infarction.
The plan was for cardiac enzymes to be cycled.
# RHYTHM: The patient was noted by OSH reports to have been in
3rd degree heart block, and during his codes was noted to have a
wide complex tachycardia, with variations between [**Hospital1 **]. The
patient was paced intra-venously, but on arrival was having
difficulty maintaing its position and having the heart capture
said beats, results in occasional need for transcutaneous
pacing. The EP fellow was able to guide the pacer wire under
floroscopy. The patient does not have any history of any
underlying rhythm abnormalities, but is is very possible that a
rhythm distrubance precipitated hypoperfusion of the heart,
causing it to become ischemic, causing poor EF causing global
hypoperfusion. The patient's rhtyhm was paced during his
hospitalization.
# Neuroprotection s/p arrest: Patient is not a candidate for
Artic Sun Cooling protocol given the amount of time since his
event and start of cooling. He was noted to have poor neurologic
signs, such as occasional lower limb jerking, unresponsiveness,
and a lack of pupillary response to light. He was sedated with
fentanyl and midazolam, and
# [**Last Name (un) **]: Creatinine is 3.1, up from a baseline of around 1.3 per
OSH records. Likely secondary to poor renal perfusion secondary
to cardiogenic shock
# Transamitinits: Likely secondary to poor hepatic perfusions
# Leukocytosis: Likely secondary to an inflammatory resposne
secondary to patient's global hypoperfusion. The patient is not
currently febrile, and CXR shows diffuse bilateral infilitrates
not consistent with a PNA.
# Goals of care: The patient's prognosis was very poor on
arrival given his his focal wall motion abnormalities, his poor
neurologic status, his rise in creatinine, and the rise in his
lactate, and rise in his LFTs. The family was gathered, and HCP
(wife) agreed to make the patient DNR. Subsequently during the
night, as the patient requiring continued pressor support, the
family was called to discuss the patient's clinical status, and
elected to withdraw care. The patient passed away at 9:30 PM on
[**2176-3-13**].
Medications on Admission:
Venlafaxine 37.5 [**Hospital1 **]
Allopurinol 300 mg Daily
Lovastatin 40 mg Daily
Gabapentin 300 mg TID
Aspirin 81 mg Daily
Lantus 36 U SQ in AM
Vicodin 5/500 (2 tablets)PO Q4H PRN Pain
Tylenol 1000 mg PO PRN pain
Stool softenser
Plavix 75 mg PO Daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"785.51",
"584.9",
"V49.86",
"250.00",
"V43.65",
"410.91",
"414.01",
"276.2",
"272.4",
"585.2",
"403.90",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12601, 12610
|
8542, 12267
|
292, 348
|
12661, 12670
|
4092, 6756
|
12726, 12829
|
3132, 3163
|
12569, 12578
|
12631, 12640
|
12293, 12546
|
12694, 12703
|
6799, 8519
|
3178, 4073
|
2684, 2840
|
234, 254
|
376, 2574
|
2871, 2985
|
2596, 2664
|
3001, 3116
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,796
| 109,906
|
13368
|
Discharge summary
|
report
|
Admission Date: [**2177-10-1**] Discharge Date: [**2177-10-14**]
Service: HEPATOPANCREATIC BILIARY SERVICE
HISTORY OF PRESENT ILLNESS: The patient is status post
extensive lysis of adhesions secondary to recurrent adhesive
small bowel obstruction and status post anticoagulation from
left upper extremity deep venous thrombosis.
PHYSICAL EXAMINATION: Vital signs: T-max 100.4??????, T-current
100.1??????, blood pressure 104/64, pulse 90, respirations 22,
current oxygen saturation 95% on room air. General: The
patient is an 84-year-old female with appearance appropriate
for age. The patient was in no acute distress. HEENT: No
evidence of scleral icterus. Extraocular movements intact.
Moist mucous membranes. No evidence of ulcers. No cervical
lymphadenopathy. Cranial nerves II-XII intact. Chest:
Clear to auscultation bilaterally. Cardiovascular:
Irregularly, irregular beats without evidence of cardiac
murmurs. Abdomen: Vertical incision noted with staples
intact. Inferior aspect of the wound site is currently
packed with new gauze. There was mild erythema along the
inferior aspect of the wound. There were small and resolving
indurations also noted on palpation. The patient's abdomen
is soft and nondistended and minimally tender to palpation
with no evidence of rebound or hepatosplenomegaly or masses
palpated. Bowel sounds present on auscultation in all four
quadrants. Extremities: Bilateral pretibial edema extending
up to one-eight above the ankle with 2+ pedal edema present.
LABORATORY DATA: White count 9.7, hematocrit 34.3, platelet
count 313; sodium 134, potassium 4.1, bicarb 28, chloride
100, BUN 6, creatinine 0.4, glucose 121; PT 17, PTT 101.4,
INR 2.0; magnesium 1.7, phosphate 3.1.
Upper extremity duplex on [**2177-10-8**], showed
occlusive thrombus in the subclavian axillary and brachial
veins. PICC line was seen at the center of the thrombus.
HOSPITAL COURSE: The patient is an 84-year-old female with a
history of atrial fibrillation, status post low anterior
resection, radiation therapy for T3N1 rectal cancer,
presenting to our service for exploratory laparotomy after
being nutritionally supplemented times two weeks. The
patient's operative course was remarkable for an extensive
adhesive bowel which required six hours to lyse. During the
postoperative course in the PACU, the patient's pressure
remained persistently low between the 80s/50s with
tachycardia heart rates greater than 120 and atrial
fibrillation. The patient was aggressively resuscitated with
fluids and received concomitant evaluation by the Cardiology
Service regarding the patient's status.
An emergent echocardiogram done by the cardiologist revealed
an ejection fraction greater than 50%, and a recommendation
was made to continue to aggressively fluid resuscitate the
patient. When urine output continued to remain low with low
pressures, the decision was made to transfuse 2 U packed red
blood cells. The patient's pressure rose to 120/70 without
any pressors, and the patient was then transferred to the
Intensive Care Unit for continuous cardiac and fluid
management.
After adequately resuscitating the patient in the Intensive
Care Unit, the patient was transferred to the floor for
continued diuresis. On postoperative day #7, the patient
began complaining of asymmetric edemas, left arm greater than
the right despite the heavy diuresis. The patient underwent
an emergent ultrasound which revealed an occlusive thrombus
in the subclavian, axillary, and brachial veins with PICC
line at the center. The PICC line was removed, and the
patient was immediately initiated on Heparin anticoagulation.
After the patient achieved adequate anticoagulation level
with subsequent Coumadin therapy and was able to tolerate
adequate p.o. intake without difficulty, the patient was
discharged to rehabilitation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post extensive lysis of adhesions.
2. Status post 2 U transfusion secondary to hypotension.
3. Status post left upper extremity deep venous thrombosis.
4. Status post occlusive thrombus in the subclavian,
axillary, and brachial veins on the left.
5. Atrial fibrillation with rapid ventricular response.
6. Nutritional support with total parenteral nutrition.
7. Hypokalemia.
DISCHARGE MEDICATIONS: Keflex 500 mg p.o. q.i.d., Warfarin 2
mg p.o. q.h.s., Digitalis 0.125 mg p.o. q.d., Lopressor 10 mg
IV q.6 hours, Albuterol nebulizer, Furosemide 20 mg q.a.m.,
10 mg q.p.m., Dilaudid p.r.n. for pain, Protonix.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 468**] in
[**11-3**] days in his surgical office.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 40628**]
MEDQUIST36
D: [**2177-10-14**] 12:56
T: [**2177-10-14**] 13:16
JOB#: [**Job Number 40629**]
|
[
"453.8",
"560.81",
"276.8",
"996.74",
"V10.06",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"45.02",
"54.59",
"45.91"
] |
icd9pcs
|
[
[
[]
]
] |
4392, 4993
|
3975, 4368
|
1937, 3872
|
366, 1919
|
148, 343
|
3897, 3954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,514
| 108,459
|
5701
|
Discharge summary
|
report
|
Admission Date: [**2151-5-19**] Discharge Date: [**2151-6-7**]
Date of Birth: [**2081-11-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Diarrhea, Weakness, Anemia
Major Surgical or Invasive Procedure:
Port-a-cath placement.
History of Present Illness:
69 yo F with h/o Anaplastic large cell lymphoma and granuloma
annulare who presents with fatigue and weakness x 2-3 days. Pt
is poor historian but notes weakness x 2-3 days. She also notes
loose stools over this time period. She denies fevers, chills,
night sweats. She denies chest pain, shortness of breath, cough.
She denies melena, hematochezia, brbpr. She denies dysruia. Per
the patient's son, she has had no PO intake and has not got OOB
x 2 weeks. She also has occcassional urinary/fecal incontinence.
In the am of admission, she slipped and fell on leg. No LOC,
head trauma.
In [**Name (NI) **], pt was found to have diarrhea and poor rectal tone, neuro
consulted.
--CT head-multiple lytic lesions seen in the right parietal and
both occipital bones.
--CT C-spine - Multiple lytic lesions seen in the occipital
bones bilaterally and lateral mass of C1
--MRI L-spine - Degenerative changes seen in the lower lumbar
spine with no evidence of nerve root compression. Diffuse
mottled appearance seen within the vertebral bodies, the sacrum,
and both iliac bones is nonspecific in etiology. This can be
seen in diffuse osteopenia, myeloproliferative or lymphomatous
involvement of the osseous structures.
She also had a hematocrit of 19 and then 15 with fluids with LDH
380, I. Bili 1.3, INR 1.6. The patient was transfused 1 U PRBC.
She also had elevated LFTs:
--RUQ US - Multiple ill-defined small hypoechoic lesions
throughout the right lobe of the liver and surrounding the
gallbladder fossa.
--CT ABD - Diffuse stranding in the mesentery, which could
suggest infiltration by neoplastic process or fluid. Progressive
retroperitoneal and inguinal lymphadenopathy.
.
Pt admitted to MICU for ? cord compression and hypotension with
anemia. Found to be OB neg, received 4 units PRBC and ruled out
for cord compression. Transfered to medical floor once HD
stable. In addition, pt found to have PNA with hx of exposure to
Pertussis.
Past Medical History:
HTN
Anxiety
No Hx of skin sensitivity to sun or creams.
Granuloma Annulare
Social History:
Smokes [**12-20**] ppd x 60 years
No Etoh
Lives at home with son
Family History:
Mother died of ruptured appendix
Father died of EToh abuse
No hx of CA in family
Physical Exam:
Vitals: T99.8, BP: 130/50, HR: 107, RR: 26, O2 98% RA.
GEN: Moderately ill appearing female in NAD, mildly tachypneic,
no use of accessory muscles, speaking in full sentences.
HEENT: Pupils equal and reactive, MM dry, neck is supple with no
LAD.
CV: Tachy, reg, 1/6 SEM at axilla.
CHEST: Decreased BS at b/l bases. No rales or wheezes
appreciated.
ABD: NDNT, normoactive BS, soft. No masses appreciated.
EXT: trace pedal edema, warm and well perfused. L inguinal LAD
with skin changes. 4-5 cm ulcerative lesion on R calf with
surrounding erythema and lichenifcation of skin. Pt also has
mult areas on both upper ext with scaly lesions.
Neuro: A&Ox3 and appropriate. Moving all ext with normal
strength.
Pertinent Results:
CXR [**2151-5-20**]: FINDINGS: There is interval increase in the left
retrocardiac opacity with associated left pleural effusion. This
is consistent with an evolving pneumonia. There is prominence of
the pulmonary vasculature, suggestive of mild CHF. The soft
tissue and osseous structures are unchanged. No pneumothorax is
seen.
IMPRESSION: Left retrocardiac opacity and associated left
pleural effusion, which is increased in comparison to the prior
study, likely representing an evolving pneumonia. There is mild
prominence of the pulmonary vasculature, suggestive of
associated mild CHF.
.
.
CT Head: FINDINGS: No previous examination available for
comparison.
White and [**Doctor Last Name 352**] matter differentiation is preserved. No
intracranial masses effect and no hemorrhage is seen. Midline
structures are normal in position. Ventricles and subarachnoid
spaces are within normal limits. No findings to suggest an acute
territorial infarction are noted. MRI is more sensitive to
detect acute infarction, consider this if clinically indicated.
Bone windows demonstrated lytic lesion seen in the left parietal
skull measuring approximately 1 cm in diameter. Multiple
additional lytic lesions are seen in the occipital bones
bilaterally. Clinical correlation is necessary..
.
.
RUQ ultrasound: IMPRESSION:
1) No evidence of cholecystitis, cholelithiasis, or
choledocholithiasis. Tiny comet tail artifact likely secondary
to an adherent crystal versus a small cholesterol polyp.
2) Multiple ill-defined small hypoechoic lesions throughout the
right lobe of the liver and surrounding the gallbladder fossa.
These may be secondary to focal fatty sparing, however, given
the history of lymphoma a CT or MRI is recommended for
definitive characterization.
.
.
CT pelvis:
IMPRESSION:
1) No evidence of retroperitoneal hematoma.
2) Diffuse stranding, likely related to third-spacing.
3) Progressive retroperitoneal and right inguinal
lymphadenopathy, concerning for relapsed lymphoma; slight
improvement in size of left inguinal adenopathy. This unexpected
finding was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the morning of [**5-20**], [**2150**].
4) Diverticulosis.
5) Similar appearance of left adnexal cyst.
6) Liver lesions not assessed without intravenous contrast.
Mild mucosal thickening is seen involving both posterior ethmoid
sinuses. Small fluid level is seen within the left sphenoid
sinus and inferior left maxillary sinus.
INTERPRETATION:
1) No acute intracranial abnormalities.
2) Multiple lytic lesions seen in the right parietal and both
occipital bones, clinical correlation is necessary.
.
.
[**2151-5-21**] 04:39AM BLOOD WBC-14.2* RBC-3.07* Hgb-9.4* Hct-28.7*
MCV-93 MCH-30.5 MCHC-32.6 RDW-18.7* Plt Ct-492*
[**2151-5-21**] 04:39AM BLOOD Neuts-92.6* Bands-0 Lymphs-2.8* Monos-2.3
Eos-2.1 Baso-0.1
[**2151-5-21**] 04:39AM BLOOD Glucose-105 UreaN-13 Creat-0.6 Na-136
K-3.8 Cl-106 HCO3-23 AnGap-11
[**2151-5-21**] 04:39AM BLOOD ALT-34 AST-41* LD(LDH)-164 AlkPhos-122*
TotBili-1.7*
[**2151-5-20**] 02:59AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
.
.
Pelvic U/S:
Transabdominal ultrasound demonstrates a uterus measuring 5.7 x
3.1 x 5.7 cm. No fibroids are identified. The endometrium is
heterogeneous and thickened as it is seen transabdominally,
measuring 1.4 cm. There are echogenic foci within the
myometrium. The right ovary is not identified. A rounded left
adnexal cyst is seen, measuring approximately 2.4 cm in
diameter. This corresponds to a left adnexal cyst seen on the
recent CT exam. The left ovary itself is not clearly identified.
Transvaginal examination was declined by the patient.
IMPRESSION:
1. Thickened heterogeneous endometrium. The differential
diagnosis includes endometrial hyperplasia, carcinoma,
adenomyosis, or polyp. Further evaluation with MRI could be
considered. This exam is limited as the patient declined
transvaginal exam.
2. Left adnexal cyst. The ovaries are not clearly identified
Brief Hospital Course:
A 69-year-old female with past medical history significant for
anaplastic large cell lymphoma, granuloma annulare, who
presented with weakness, anemia, and hypertension.
.
BRIEF HOSPITAL COURSE BY PROBLEM:
.
1. Anaplastic large cell lymphoma: The patient has been
treated in the past with methotrexate successfully. During this
admission, she was found to have a white blood cell count that
was consistently trending upwards, even with broad-spectrum
antibiotics. After the patient had received approximately 14
days of broad-spectrum antibiotics, it was felt that this rising
white blood count was likely secondary to reactive leukocytosis.
The patient did not have any abnormal cells on blood smear;
however, it was noted that she had new lymphadenopathy on the
right side in the inguinal region per pelvic CT. In addition,
progression of her left-sided inguinal adenopathy was noted as
the patient developed open draining sores, which she had had on
prior admissions prior to treatment with methotrexate. It was,
therefore, felt that the patient's rising white blood counts and
symptoms were likely secondary to reactive leukocytosis from her
underlying lymphoma. The patient was, therefore, started on
CHOP chemotherapy on [**2151-6-1**], after placement of a right
subclavian Port-A-Cath. The patient successfully received 5
days of CHOP chemotherapy. She had some nausea and vomiting on
the first day, which was treated with antiemetics. The patient
did not receive any further hydration during this chemotherapy
as she was already quite anasarcous. After treatment with CHOP
chemotherapy, her white blood cell count begin to trend down
from 55 and is now at 16 after chemotherapy. The plan will
continue with CHOP chemotherapy as the patient will be unable to
take methotrexate with pleural effusion seen on CT scan. The
plan for the next dose of chemotherapy will be [**2151-5-31**]. Pt
with need twice weekly CBC and chem 7 during rehab admission as
Nadir will likely be around [**2151-6-23**]. Pt will follow-up with Dr.
[**Last Name (STitle) **] prior to next dose of chemo. Please communicate lab values
to Dr. [**Last Name (STitle) **].
.
2. Fevers: The patient was transferred to the medicine floor
and subsequently developed fevers up to 101. The patient's
symptoms included tachypnea without shortness of breath. She
denied nausea, vomiting, abdominal pain, lightheadedness,
dizziness, or headache. The patient also had a rising white
blood cell count associated with fevers with a maximum while
blood cell count of 55,000. The patient was initially started
on Levaquin, Flagyl and azithromycin while in MICU. She was
started on the azithromycin for an exposure to pertussis per the
patient's son. When the patient spiked again, she was started
on vancomycin. There was also a ? of asp pna due to altered MS
on admission. The patient did continue to spike through these
antibiotics. Infectious disease was consulted at this point.
The patient was persistently febrile through these
broad-spectrum antibiotics. They recommended coverage for
Pseudomonas, which would be the only thing that was not covered.
The patient was, therefore, started on Zosyn. The patient
developed diarrhea. Her stools were cultured and all cultures
were negative. All blood cultures, sputum cultures, and urine
cultures were negative. However, on hospital day 10, the
patient was found to have white blood cells in her urine and
grew out yeast. The patient was started on a 7-day course of
fluconazole. In addition to this, Histoplasma, Brucella, and
Bartonella were all sent per recommendation by the ID team. A CT
scan was performed which showed bilateral large pleural
effusions. It was felt that the left-sided pleural effusion
should be tapped to rule out empyema. A thoracentesis was
performed and the fluid was a transudate with no bacteria seen
on Gram stain and no growth on culture. Wound cultures were
also performed on the draining wounds in her left groin. These
grew out both yeast and staph, coagulase negative. However, it
was felt that these were likely secondary to normal skin flora.
The patient's fevers defervesced and all antibiotics were
discontinued after a full 14-day course for suspected pneumonia.
The patient remained afebrile and at the time of dictation,
both Brucella and Bartonella results were negative. Histoplasma
was still pending. The patient was also ruled out for pertussis
by PCR and cultures. After fevers defervesced, the patient's
white blood cell count continued trending up. Therefore, it was
felt that her fevers and leukocytosis were secondary to a
reactive leukocytosis from her lymphoma. The patient was
afebrile after her CHOP chemotherapy and white blood cell count
trended down.
.
3. Neuro: On admission, the patient was felt to be weak and
there was a question of cauda equina syndrome. The patient was
assessed by neurology who felt that her symptoms of weakness and
fatigue were likely associated with infection versus metabolic
dysfunction. The patient was found to have a hematocrit of 15
at the time of admission, and after transfusions and treatment
with broad-spectrum antibiotics, the patient's symptoms
resolved. The patient had an MRI as above which showed no
evidence of compression. Neurology signed off as they felt that
the patient's symptoms were not secondary to neurologic
dysfunction. The patient was seen and evaluated by physical
therapy. They felt that her weakness is secondary to
deconditioning. The patient will need aggressive physical
therapy and rehabilitation after discharge.
.
4. Anemia: Most likely secondary to inflammatory process with a
background of lymphoma. The patient had no clear source of
bleeding initially on admission as well as stools were guaiac
negative. DIC labs were sent and were negative. Haptoglobin
was normal on admission. Hematocrit was stable after receiving
4 units of PRBCs on admission. The patient received 2
additional transfusions after CHOP chemotherapy for hematocrit
less than 25. Pt found to have vaginal bleeding on [**6-4**]. HCT
remained stable. See below for details.
.
5. Vaginal bleeding: The patient was noted to have small
amounts of vaginal bleeding after the CHOP chemotherapy. The
patient is postmenopausal and has never had the symptoms before.
She denied pain. She was afebrile. A transvaginal ultrasound
was ordered; however, the patient refused this ultrasound. She
did allow a pelvic ultrasound, which showed a thickened
heterogeneous endometrium and a left adnexal cyst was also
noted. The ovaries were not clearly identified. OB/GYN was
consulted, but the patient refused a pelvic exam and refused
further workup at this time. The patient stated that she wanted
to discuss the issue with her family members. The patient was
educated and counseled about the risks of possible endometrial
cancer. She felt that she did not want any further intervention
at this time. After further discussion with the patient she
agreed to had biopsy and further work-up as an outpatient. GYN
agreed to this plan and an appointment was scheduled for [**6-30**], [**2150**].
.
6. Tachycardia: The patient was found to be tachycardic between
100 and 120 during the entire admission. Old records were
reviewed which showed that her heart rate had been in this range
since her first admission in 11/[**2149**]. It was noted in her prior
records that the patient had been on both beta-blockers and
calcium channel blockers in the past; however, her granuloma
annulare seemed to worsen with these medications and they were
therefore stopped. An Pt has a normal EF, but did have an
element of diastolic dysfunction. The patient received Lasix
with transfusions and her heart rate did improve to between 80
and 90 after chemotherapy and decrease in white blood cell
count. The patient should be started on a beta-blocker or
calcium channel blocker for another trial after her lymphoma is
stabilized.
.
7. Pneumonia: It was felt that the patient had a pneumonia on
initial admission to the MICU. She was started on antibiotics
as described above. The patient's respiratory status improved
after pleural effusion tapped on the left. Sputum cultures were
negative. Pertussis PCR neg. It is likely that her bilateral
pleural effusions were secondary to volume overload as the
patient was anasarcic after fluid resuscitation and
transfusions. The patient's respiratory status was back to
baseline at the time of discharge.
.
8. Diarrhea: The patient noted on admission that she was having
frequent loose bowel movements. The patient had C. diff checked
x3 and all were negative. She also had stool cultures sent for
ova and parasites, Salmonella, Cyclospora, and Giardia, all of
which were negative. The patient was on Flagyl for 14 days.
.
9. Nutrition: The patient was found to have an elevated INR on
admission, which was felt to be nutritional. The patient has
had a difficult time with nutrition since her diagnosis. She
states that she is simply not hungry. The patient received subq
vitamin K and oral vitamin K x5 days. Her INR then trended back
down to normal. She was noted to have hypoalbuminemia to 2.
The patient seemed to do well with encouragement while eating.
Nutrition was consulted and added a high-calorie shake to all of
her meals. The patient did well with this plan and was eating
more with encouragement and assistance with eating. The patient
is able to feed herself.
.
10. Anxiety: The patient has a history of anxiety and was
continued on her Valium during this admission.
.
11. FEN. Nutrition as above. Electrolytes: The patient had a
creatinine that was trending up during this admission. Checked
FeNa which was 0.9 suggesting dehydration. The patient received
gentle hydration plus transfusion to increase her forward flow.
She was also encouraged p.o. fluid intake for hydration.
Creatinine trended back down to 0.8. The patient also noted to
have chronic hyponatremia. The highest sodium that had been
documented over the past year was 136. Baseline appears to be
closer to 131. The patient has likely been equilibrated. She
was placed on a fluid restriction initially, which did bring the
sodium back up to the low 130s.
.
12. Prophylaxis. The patient was maintained on subq heparin
and PPI.
.
13: Granuloma Annulare: Pt is being followed by dermatology as
an outpatient. Skin lesions are actually much improved after MTX
treatment. Used to have open draining wounds.
.
Contact: The patient gave her son [**Name (NI) **] at phone number
[**Telephone/Fax (1) 22753**].
.
Code status was full during this admission. The patient states
she would like to talk to her family further about her code
status.
Medications on Admission:
HCTZ (not taking)
Valium 5 qd
Prozac - not taking
Folic Acid
Doxacin - ? taking
Aranesp
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
Disp:*90 ml* Refills:*2*
2. 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*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Diazepam 2 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*2 cannisters* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1)
flush Intravenous DAILY (Daily) as needed.
9. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection every eight (8) hours as needed for nausea.
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Recurrent lymphoma
Granulomata Annulare
Discharge Condition:
Stable to rehab
Discharge Instructions:
Please return to the hospital if you experience chest pain,
shortness of breath, severe nausea/vomiting or any other severe
symtoms.
1. Please follow-up with your appointments as below
Followup Instructions:
1. Please follow up with Gynecology on [**6-30**] with Dr. [**Last Name (STitle) **] at
2:30; Please go to [**Location (un) **], [**Hospital Ward Name 23**] 8. ([**Telephone/Fax (1) 22754**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM. Where: CUTANEOUS ONCOLOGY
Date/Time:[**2151-6-30**] 9:45
|
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"627.1",
"286.7",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.91",
"99.28",
"86.07",
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] |
icd9pcs
|
[
[
[]
]
] |
19425, 19504
|
7392, 7570
|
339, 363
|
19588, 19605
|
3347, 3944
|
19839, 20177
|
2526, 2608
|
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|
19525, 19567
|
18161, 18251
|
19629, 19816
|
2623, 3328
|
273, 301
|
7598, 18135
|
391, 2329
|
3953, 7369
|
2351, 2427
|
2443, 2510
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,037
| 185,684
|
45893+58864
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-11-4**] Discharge Date: [**2190-12-27**]
Date of Birth: [**2114-3-4**] Sex: F
Service: PLASTIC
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female, admitted to [**Hospital1 69**] for
composite definite resection of a large expanding verrucous
carcinoma in the right floor of the mouth, adjacent to the
body of the right mandible.
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypothyroidism
PAST SURGICAL HISTORY:
1. Left breast biopsy
2. Cholecystectomy
3. Left eye enucleation
MEDICATIONS:
1. Levoxyl
2. Aspirin
3. Hydrochlorothiazide/triamterene
ALLERGIES: Percodan, Demerol, morphine, adhesive tape
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2190-11-4**], and taken to the
operating room, where she had (1) tracheostomy; (2) composite
resection of floor of mouth and alveolar ridge for right side
of mandible in continuity with a modified right radical neck
dissection; (3) left radial forearm fasciocutaneous flap to
floor of the mouth and left cheek (microvascular); (4) full
thickness skin graft to left volar forearm, 8 x 6 cm.
The patient's postoperative course was complicated by neck
hematoma and thrombosis of the venous outflow from the left
radial free flap, requiring multiple returns to the operating
room. The patient remained intubated with a #6 Shiley
tracheostomy due to copious secretions and drainage following
surgery, as well as edema of perioral tissues, including
tongue. Tube feeds were initiated by nasogastric tube on
[**11-5**]. The patient was taken to the operating room on [**11-15**]
for placement of a gastrostomy tube for continued feeding,
with debridement of her radial free flap also being
performed. Sputum was sent for culture [**11-11**]. Treatment was
initiated with vancomycin. A swab taken from deep neck
hematoma [**11-15**] also grew methicillin resistant staphylococcus
aureus, alpha strep and enterococcus.
Over the next two weeks, the patient remained in the Surgical
Intensive Care Unit, and efforts were made to wean her off
her ventilator. A cuffed tracheostomy tube remained in
place, with frequent suctioning performed for secretions.
By [**11-20**], the patient was able to spend periods of time out
of bed in a chair. She had developed a sacral decubitus
ulcer that was managed. Her radial free flap was monitored
and required multiple debridements for nonviable tissue, with
resulting eventual exposure of the mandible. A bronchoscopy
performed with suctioning of considerable volume of
secretions was prematurely terminated for bradycardia.
Sputum culture from lavage grew methicillin resistant
staphylococcus aureus and Enterobacter.
On [**11-29**], a trial of a Passy Muir valve was initiated by
Speech Therapy for verbal communication by the patient. By
[**2190-12-3**], the patient had a large defect of her left neck and
chin with approximately 7 cm of mandible exposed. The
patient's lip incision was also noted to be somewhat necrotic
in the right, and was dehisced. The patient was taken to the
operating room for right pectoralis muscle flap to right
neck, split thickness skin graft to right neck (18 x 12 cm),
and debridement and closure of full thickness lower lip
wound. The patient had an uneventful recovery thereafter,
although her lip incision dehisced on [**12-14**].
The patient remained in the Surgical Intensive Care Unit
until [**12-16**], by which time the patient was better able to
manage her secretions and her pectoral flap appeared stable.
The patient received a brief course of Diflucan for yeast in
her urine. The patient underwent a swallow evaluation on
[**12-17**], with recommendations and teaching given over about
three sessions. The patient was made nothing by mouth on
[**12-17**] for some spillage through the defect in her lower lip
with contamination of her chest wound. The patient was taken
to the operating room on [**12-22**] for repair of the defect and
irrigation and debridement of her chest wound.
The patient's tracheostomy was down-sized to a #4 Shiley
cuffless on [**12-24**]. Her tracheostomy was capped successfully
on [**2190-12-26**], with the patient tolerating the procedure well.
By the time of discharge, the patient was just being
restarted on sips of clears and ice chips for comfort by
mouth, with aspiration precautions. She will need to undergo
further speech and swallow evaluation following discharge.
Her respiratory function will need to be monitored, with
suctioning provided as needed. The patient will also need
continued physical therapy.
DISCHARGE CONDITION: Stable
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg once daily
2. Dilaudid .5 to 1 mg intravenously every four to six hours
as needed
3. Albuterol one to two puffs every four to six hours as
needed
4. Dulcolax as needed
5. Colace elixir 100 mg per gastrostomy tube twice a day
6. Levothyroxine 250 mcg Sunday, Tuesday, Thursday, Saturday
7. Levothyroxine 125 mcg Monday, Wednesday and Friday
8. Sertraline 50 mg PG once daily
9. Heparin 5000 units subcutaneously twice a day
10. ProMod with fiber full strength at 130 cc/hour 8 P.M. to
8 A.M.
11. Miconazole powder
FOLLOW UP: The patient was to follow up with Dr. [**Last Name (STitle) 5385**] in
one week. The patient was also to follow up with Dr. [**First Name (STitle) **]
of ENT in one to two weeks at [**Telephone/Fax (1) 97743**]. The patient was
also to follow up with Occupational Therapy and her primary
care physician.
DISCHARGE DIAGNOSIS:
1. Oral cancer
2. Methicillin resistant staphylococcus aureus pneumonia
3. Methicillin resistant staphylococcus aureus bacteremia
4. Urinary tract infection, fungal
5. Sacral decubitus ulcer
6. Respiratory failure
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7738**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2191-1-17**] 19:10
T: [**2191-1-18**] 01:04
JOB#: [**Job Number 97744**]
Name: [**Known lastname 9090**], [**Known firstname 3989**] M Unit No: [**Numeric Identifier 15596**]
Admission Date: [**2190-11-4**] Discharge Date: [**2190-12-28**]
Date of Birth: [**2114-3-4**] Sex: F
Service: Plastic Surgery
HOSPITAL COURSE: The patient was discharged to
rehabilitation on [**2190-12-28**] with the status listed above.
Discharge condition, discharge medications, and discharge
followup all is listed on previous dictation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3988**]
Dictated By:[**Name8 (MD) 2504**]
MEDQUIST36
D: [**2191-4-13**] 14:54
T: [**2191-4-14**] 04:40
JOB#: [**Job Number 15597**]
|
[
"998.32",
"144.8",
"996.79",
"482.41",
"998.6",
"285.9",
"E878.2",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.69",
"76.31",
"06.09",
"86.22",
"31.1",
"27.59",
"43.11",
"40.41",
"27.56",
"83.82",
"38.02"
] |
icd9pcs
|
[
[
[]
]
] |
4617, 4625
|
4648, 5188
|
5528, 6276
|
6294, 6753
|
471, 670
|
5200, 5507
|
169, 389
|
411, 448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,716
| 114,110
|
48903
|
Discharge summary
|
report
|
Admission Date: [**2147-7-23**] Discharge Date: [**2147-8-11**]
Date of Birth: [**2077-11-4**] Sex: F
Service: MEDICINE
Allergies:
Plavix / Heparin Agents
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
CC: Hypotension, fever, tachypnea.
Major Surgical or Invasive Procedure:
Paracentesis, G-J tube placement with flouroscopy.
History of Present Illness:
HPI: 69 y/o female with a h/o pansensitive TB on 3 drug regimen,
MDS with pancytopenia, respiratory failure s/p trach placement
and revision [**5-/2147**], recently discharged [**2147-6-30**] with sepsis
presumed [**12-23**] PNA (by MDR E coli, pseudomonas) who comes in from
[**Hospital3 **] with tachycardia, tachypnea, and hypotension.
Two days ago the patient's G-tube fell out and she had it
replaced yesterday. She also had a new PICC tube placed
yesterday for additional access as her one PICC line was deemed
inadequate. The patient had known intermittent fevers with a
negative workup for anything other than her TB ever since she
was first diagnosed with TB in [**2146-11-21**], however yesterday
she was noted to have increased fevers. In addition, she was
also noted to have a decreased hct and was transfused 2PRBC
overnight. This morning she was then noted have tachycardia,
tachypnea, and hypotension with BP as low as the 60s systolic.
She received vanco/cefepime and flagyl and a 500cc NS bolus. She
then was transported to the [**Hospital1 18**] for further management.
.
In the ED: Initial VS 100.0 T, HR 130, BP 40/21, RR 22, O2 Sat
87%. Old left PICC pulled. 2L NS given. Levophed started and
MAPs maintained >55. She remained on AC, no increased support
requirements. CXR with new LLL consolidation. Labs: Lactate
3.1, CBC 20.1, INR 1.7, Plt 20. She also was noted to have K
5.3 and Cr 3.2 (up from baseline 1.2-1.7). Peaked T waves noted
on EKG: given calcium, HCO3, insulin, and dextrose as well as
Kayexylate. Also administered 2U of FFP. CT abd was obtained
which showed no sign of abdominal abscess and normal positioning
of the G-tube. ID was curbsided and advised to give Meropenem
iv, Tobramycin IH, Cipro iv, and Dapto iv was started. On
transfer to [**Hospital Unit Name 153**], VS 100.2 t, HR 105, BP 92/50, RR 36, 99%.
Past Medical History:
Recent ID course summarized as:
Prior cultures significant for MDR pseudomonas sensitive to
Cipro from sputum [**6-10**] and MDR E coli sensitive (ESBL) to
Meropenem from sputum [**6-9**]. Also, VRE from cath tip on [**6-21**],
started on Daptomycin, however, daptomycin was discontinued due
to negative blood cx for VRE on [**6-23**]. Tobramycin was added on
[**6-19**] for double coverage of resistent pseudomonas given poor
lung penetration of Cipro. The full course of meropenem was
completed on [**7-2**] and of tobramycin on [**7-3**].
.
Past Medical History:
x [**Date range (1) 102693**] admission for presumed PNA sepsis. ID course as
above
x Pulm TB (pan sensitive) with liver/spleen granulomas
- s/p R sided vats, r supraclavic LN, liver bx +
- h/o +PPD w/o tx
- AFB on BAL [**2147-1-2**]
- tx continuous since 2/1 per prior dc summ
x Diabetes mellitus
x OSA - previously on BiPAP
x Cataract left eye
x CVA/TIA (positive MRI) - right frontal with L arm/hand
hemiparesis; etiology likely moderate degree stenosis of the ICA
in the cavernous region, stable on recent CTA, hx of watershed
infarcts during acute illness in the setting of acute disease
x Asthma
x Hypercholesterolemia
x Seizure- uncertain diagnosis - L arm involuntary movements
[**2144**], not on anti-seizure medications
x Chronic renal insufficiency due to recurrent exposures to
nephrotocxic medications/ contrast and hemodynamic instability
in the context of recurrent sepsis, Creat on last discharge 2.6.
x Likely anoxic brain injury: nonverbal, withdraws to pain, eyes
open; presumptively from recurrent hypotensive insults
x MDS: on bone marrow biopsy with borderline transformation to
AML
x hx of HIT
.
Social History:
(per last discharge summary) Has been living in [**Hospital **] rehab
getting tx for disseminated TB. Previosly lived alone in
[**Location (un) 86**]. Supportive family nearby. Remote history of tobacco use.
One-two glasses of alcohol per week. Retired, used to work in a
post office.
.
Family History:
(per last discharge summary) Diabetes in son, sister, and
brother. [**Name (NI) 102689**] with epilepsy. [**Name (NI) **] brother with
possible lung cancer. Uncle with TB.
Physical Exam:
Physical Exam:
VS: 99.3 110 127/75 100% on AC 600cc/[**10-25**]
GEN: NAD, unresponsive, not following commands
NEURO: nonverbal, minimally withdraws to pain, eyes open,
reflexes
HEENT: PEERLA, 4mm pupils, L cataract, mmm, R tongue lesion,
thrush
CARDS: S1S2, RR, tachycardic, no m/r/g
CHEST: rhonchorus breath sounds throughout, decreased breath
sounds in L base, bloody secretions
ABD: s/nt/nd/scarse positive bowel sounds, PEG in place with
bilious secretions
EXT: +DP, warm, minimal movement with pain, reflexes
Skin: erythema and increased warmth in R armpit and on L thigh,
PICC in R arm
.
Pertinent Results:
Imaging Studies:
[**2147-7-23**]. CT abdomen/pelvis.
IMPRESSION:
1. Limited study given lack of IV contrast and streak artifact.
Opacification
of the G-tube demonstrates normal positioning of the G-tube. No
intra-
abdominal abscesses are identified although difficult to
evaluate given lack
of IV contrast.
2. Enlarged bilateral inguinal lymph nodes and left flank
subcutaneous
nodules.
3. Left lower lobe consolidation.
4. Heterotopic new bone formation surrounding the left proximal
femur,
unchanged.
5. Anasarca.
.
[**2147-7-23**]. Chest X-ray.
IMPRESSION: Increased airspace density within the left lung
base, which may reflect pneumonia or aspiration.
.
[**2147-7-26**]. CT abdomen/pelvis.
IMPRESSION:
1. Multiple ill-defined areas of low attenuation within an
enlarged spleen, suspicious for infarction.
2. Interval progression of bilateral lower lobe consolidation,
with stable small pleural effusions.
3. New simple appearing abdominal and pelvic ascites.
4. Malposition of the gastrostomy tube in the subcutaneous
tissues.
5. No significant interval change in abdominal and pelvic
lymphadenopathy, compatible with known diagnosis of disseminated
TB.
.
[**2147-8-7**]. Renal Ultrasound.
IMPRESSION:
Limited ultrasound of the kidneys shows no hydronephrosis or
perinephric
abscess. Heterogeneous appearance of the kidneys could relate
to infection, though this is uncertain.
Enlarged spleen with infarcts.
Peritoneal ascites with some complexity in the left upper
quadrant adjacent to the spleen. It is uncertain if this
represents hemorrhage or other debris and infection cannot be
excluded.
.
Microbiology:
GRAM STAIN (Final [**2147-7-23**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2147-7-27**]):
OROPHARYNGEAL FLORA ABSENT.
SERRATIA MARCESCENS. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
.
URINE CULTURE (Final [**2147-8-8**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.
Sensitive to Zosyn, Meropenem, Imipenem.
.
ACITES FLUID ([**2147-8-10**]):
1+ PMNS, NO ORGANISMS, CULTURE PENDING
.
Significant Laboratory Values:
Admission Laboratories [**2147-7-23**]:
Hematology:
CBC WBC-20.1*# RBC-4.19*# Hgb-13.2# Hct-36.6# MCV-87 MCH-31.4
MCHC-36.0* RDW-16.6* Plt Ct-20*#
Differential: Neuts-96* Bands-1 Lymphs-0 Monos-3 Eos-0 Baso-0
Atyps-0 Metas-0 Myelos-0
Coags: PT-17.7* PTT-32.7 INR(PT)-1.7*
DIC Labs: Fibrino-441*# D-Dimer-9993* FDP-80-160*
Lactate-3.1*
ABG: Type-ART pO2-412* pCO2-23* pH-7.43 calTCO2-16* Base XS--6
-ASSIST/CON Intubat-INTUBATED
.
Chemistries:
Glucose-90 UreaN-113* Creat-3.2* Na-146* K-5.3* Cl-118* HCO3-12*
AnGap-21*
ALT-4 AST-35 AlkPhos-101 Amylase-68 TotBili-1.5
LD(LDH)-787* Hapto-50
Albumin-1.6* Calcium-8.0* Phos-8.2*# Mg-2.5
freeCa-1.20
Urine elctrolytes: BUN: 560 Na: 27 Creatinine 27
.
Urinalysis:
COLOR-LtAmb APPEAR-SlHazy SP [**Last Name (un) 155**]-1.015 BLOOD-LGE NITRITE-NEG
PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1
PH-5.0 LEUK-SM RBC-9* WBC-14* BACTERIA-NONE YEAST-MANY EPI-0
GRANULAR-4*
.
Discharge Laboratories:
Hematology:
WBC-8.0 RBC-3.17*# Hgb-10.0*# Hct-28.3*# MCV-89 MCH-31.5
MCHC-35.3* RDW-15.3 Plt Ct-63*#
ABG: pO2-105 pCO2-27* pH-7.50* calTCO2-22 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
.
Chemistries:
Glucose-75 UreaN-38* Creat-1.2* Na-147* K-3.5 Cl-117* HCO3-21*
AnGap-13
Lactate-1.6
.
Other Laboratories:
Cortsol-14.0
[**2147-8-1**]: Urine electrolytes Na 34 Cr 46 K 24 Cl 41
Peritoneal Fluid: Protein 2.9 Glucose 69 Albumin: <1.0
WBC 2967 Poly 48% Lymph 20% Mono 30% EOs
Brief Hospital Course:
Ms. [**Known lastname **] is a 69 yo female with a history of disseminated TB,
significant brain injury from ischemia, vent dependency with
tracheostomy, and MDR pneumonia who presented to the ED on
[**2147-7-23**] with fever, hypotension and tachycardia.
.
PNEUMOSEPSIS: The patient presented with fevers, tachycardia,
tachypnea and hypotension. She was found on admission to have a
new LLL infiltrate on CT and CXR and a mild lactic acidosis. Of
note, she had a history of MDR pseudomonas and ESBL E. coli for
which she completed a 14-day course of meropenem, ciprofloxacin,
and inhaled tobramycin on [**2147-7-3**]. In the emergency room she
was started on vancomycin, cefepime, and Flagyl; on transfer to
the MICU, the ID consult service recommended a switch to
daptomycin for a potential line infection, meropenem and inhaled
tobramycin for her previous MDR lung pathogens, and Flagyl for
empiric coverage of Clostridium difficile. Her PICC line was
also removed. Her blood pressure in the ED was initially as low
as a systolic in the 60's. She briefly required Levophed for
pressure support but was quickly weaned after arrival in the
MICU. Sputum sample from [**2147-7-23**] grew out pan-sensitive Serratia
and 2 strains of Pseudomonas, for which she was started on a
3-week course of inhaled tobramycin and ciprofloxacin that
completed on [**8-11**]. Blood and urine cultures taken at the time
of admission were negative. All repeat sputum cultures have
been negative.
.
ARF: On admission, the patient was noted to have an elevated
creatinine of 3.2 with concurrent hyperkalemia and
hyperphosphatemia. At the time of her most recent discharge it
was noted to be 2.6 and it was felt that the patient had renal
damage secondary to recurrent exposures to nephrotoxic
medications and hemodynamic instability. On admission, the
worsening from this baseline was thought to be due to acute
renal failure from hypotension; her creatinine improved with IV
hydration to 1.3. Her hyperkalemia and hyperphosphatemia have
also resolved.
.
URINARY TRACT INFECTION: The patient was found on [**2147-8-5**] to
have a positive UA and urine culture with 10-100,000 colonies of
E. Coli sensitive to Zosyn, meropenem, and imipenem. She was
started on meropenem on [**8-6**] with plans to complete a two week
course for a complicated infection; the finish date is [**8-20**].
.
METABOLIC ACIDOSIS: The patient was noted to have a persistently
decreased serum bicarbonate and a blood gas consistent with a
non-anion gap metabolic acidosis. Urine electrolytes were
consistent with renal loss of bicarbonate. Her picture was felt
to be most consistent with a type I renal tubular acidosis,
although the etiology is not entirely unclear. Bicarb losses
from chronic loose stools is also possible. On admission, she
was taking sodium bicarbonate 650 mg PO QID with a resultant
bicarb of approximately 13. Attempts were made to increase her
bicarbonate (and thus hopefully decrease her elevated
respiratory rate) by tripling her replacement; her bicarb
improved to 20 but she became alkalemic to a pH of 7.50 and had
no improvement with her hyperventilation. Her bicarb
replacement was decreased to her original dose.
.
PERSISTENT INTERMITTENT FEVERS: Throughout this hospital course
Ms. [**Known lastname **] has had persistent intermittent fevers. Based on
prior notes and communication with [**Hospital **] Rehab, these
intermittent fevers have existed since [**Month (only) 404**]. Intense prior
workups during her prior hospitalizations at [**Hospital1 **] have failed to
find a source other than TB. Workup during this hospitalization
has included blood, urine, and sputum cultures, chest
radiographs, abdominal CT scans, and a diagnostic paracentesis.
As noted above, she was found to have pneumonia from Pseudomonas
and a urinary tract infection from E. coli. Pathogen-directed
antibiotics appear to have resolved these infections; they have
not, however, significantly affected her fever curves. An
abdominal paracentesis on [**2147-8-10**] shows a WBC count of 3000
cells per microliter without any organisms on gram stain.
Cultures from this fluid will be followed by the patient's PCP
and if necessary, further recommendations will be sent to the
rehab hospital.
.
RESPIRATORY FAILURE: Patient with persistent respiratory
failure throughout this admission. She has a permanent
tracheostomy since around [**Month (only) 958**] of this year. It is likely that
her respiratory failure is multifactorial. Her dead space
ventilation during this admission was calculated to be greater
than 75%. She also presented with evidence of pneumonia and
mild pulmonary edema. During this admission, she has
persistently required assist control ventilation. She has been
able to tolerate trials of pressure support for only short
periods of time, but eventually becomes tachypneic over her
already elevated baseline. On discharge, her ventilation is
stable on assist control with a tidal volumes of 440, a rate of
20, an FiO2 of 30%, and a PEEP of 10. We attempted to decrease
her respiratory rate by increasing her bicarb supplementation.
While her bicarb level did improve towards normal (up to 20),
her respiratory rate never slowed even though she became
alkalemic. This finding points towards a central (brain) cause
for her hyperventilation.
.
G-J TUBE: Two days prior to her admission, the patient's G-tube
fell out and was replaced with a Foley catheter. On admission,
it was noted that the G-tube tract was widened. She underwent
an abdominal/pelvic CT scan and it showed no signs of
intraabdominal pathology. Her G-tube was replaced by the
surgical consult service. This balloon from this G-tube,
however, was found to be eroding through the canal a few days
after placement. She underwent a filling study of her G-tube by
CT scan; extravasation of contrast into the subcutaneous tissues
around the entry site was noted. The G-tube was replaced by
interventional radiology with a G-J tube. A few days prior to
discharge, the balloon from this tube was found to be outside of
the abdominal skin. The balloon was deflated and re-inserted
into the stomach; the G-J tube was stitched to the outside
abdominal skin. The balloon was left deflated to prevent
further erosion of the tract. Significant drainage is exiting
from the tract site. Thoracic surgery has recommended that this
drainage be controlled by placing an ostomy bag over the tract
site until the canal heals itself and re-seals against the G-J
tube.
.
LACTIC ACIDOSIS: Patient noted to have an elevated lactic acid
on admission of 3.3. This was initially attributed to sepsis
given her presentation. Her lactic acidosis, however, did not
clear as her clinical presentation improved. She was started on
thiamine out of concern that nutritional deficiency might be
contributing. Her lactate level, however, continued to
fluctuate throughout her hospital course. On discharge, it is
1.3, the lowest value recorded since admission.
.
ASCITES: The patient was noted on abdominal ultrasound to have
free fluid in her pelvis. She underwent ultrasound guided
paracentesis on [**8-10**]. Analysis of her peritoneal fluid revealed
a SAAG > 1.1 with 1400 PMNs. Gram stain of her peritoneal fluid
showed 1+ PMNs with no organisms. Samples were sent for
bacterial and mycobacterial culture. At the time of discharge,
cultures are still pending. The patient is completing a two
week course of meropenem for her urinary tract infection and
completed a three week course of ciprofloxacin and inhaled
tobramycin for pneumonia. She is also taking tuberculosis
medications. After discussion with the ICU team, it was decided
that increasing antibiotic coverage at this time in not
appropriate. The cultures from the peritoneal fluid will be
followed by the patient's primary care doctor. If a pathogen is
discovered on culture and a change in treatment is needed, the
[**Hospital 4487**] hospital will be informed.
.
ELEVATED INR: The patient has had an elevated INR throughout
this admission ranging from 1.3 to 2.0 with a normal PTT. Her
fibrinogen level has remained normal to high, however, making
DIC unlikely. Her increased INR has been attributed to
malnutrition and prolonged antibiotic use. Vitamin K was given
for 5 days during this admission, but only provided minimal
improvement. She has had no evidence of active bleeding. Stool
heme occults have all been negative. She did have mild
hemoptysis at admission, but this was attributed to bleeding
from earlier tongue bites.
.
TACHYCARDIA: Throughout this hospitalization the patient has
been noted to have intermittent episodes of tachycardia to the
150s. Her rhythm has always been sinus. She has tended to
become more tachycardic when febrile or agitated. The
tachycardia has not seemed to correlate with her blood pressure
and is not responsive to fluid administration. The etiology of
her tachycardia is unclear at the time of discharge but does not
appear to cause hemodynamic instability. Echocardiogram on
[**2147-7-26**] showed improvement of her global left ventricular
systolic function from a prior study in [**Month (only) **], but worsening of
her mitral regurgitation and pulmonary artery hypertension. No
further workup was pursued.
.
MYELODYSPLASTIC SYNDROME: The patient has a history of
thrombocytopenia and anemia and is transfusion dependent for
platelets and red blood cells. Her anemia and thrombocytopenia
are thought to be secondary to her myelodysplastic syndrome.
Past studies indicated that she may be progressing to AML, but
the hematology/oncology service felt that she was not a
candidate for chemotherapy due to her otherwise poor health.
During this hospitalization, she received numerous blood
products for transfusion goals of platelets greater than 10 and
hematocrit greater than 21. She has tolerated these well and
will continue to need blood products at her rehab facility on a
regular basis.
.
DISSEMINATED TB: The patient was diagnosed with disseminated TB
in [**12-28**] with lung, liver, and spleen involvement. She is
currently taking isoniazid, ethambutol, and pyrazinamide since
[**2146-12-22**]. During her last hospitalizations, she was ruled out
for active tuberculosis infection with three negative induced
sputum samples. During this hospitalization, she was continued
on her three medications. Per ID's recommendations, she will
require continued therapy with these three medications until
[**2147-9-20**] and will not require a follow up ID visit. Her
outstanding acid fast bacteria cultures, including blood,
sputum, and peritoneal fluid, will be followed by the patient's
PCP. [**Name10 (NameIs) **] positive cultures are found, the rehabilitation hospital
will be notified. It is unlikely that TB will be found after 7
months of triple therapy.
.
ALTERED MENTAL STATUS: Patient has a baseline decreased mental
status secondary to multiple watershed infarcts of the brain,
particularly of the right frontal lobe, and possible anoxic
injury due to episodes of hypotension and/or hypoventilation.
She is able to track with her eyes and move her right upper
extremity spontaneously, but she does not appear to be able to
follow commands.
.
SWOLLEN RUE: During her MICU course, the patient has been noted
to have a warm, erythematous right upper extremity near the site
of her original PICC line. Ultrasound of her right arm was
negative for DVT.
.
POSSIBLE SPLENIC INFARCTION: Patient has had two abdominal CTs
and an abdominal ultrasound that have shown changes consistent
in her spleen consistent with infarction. The etiology of this
is unclear. [**Name2 (NI) **] further workup has been initiated at this time.
.
ASTHMA: The patient a past medical history of asthma. She was
continued on albuterol and Atrovent MDIs during this admission
with good effect.
.
DIABETES MELLITUS: The patient has a history of type two
diabetes. During this hospitalization, she was maintained with
success on insulin sliding scale.
.
PROPHYLAXIS: The patient has a history of heparin induced
thrombocytopenia. For this reason, she did not receive
subcutaneous heparin for DVT prophylaxis. Instead, she was
given pneumoboots. She has been maintained on a PPI for GI
prophylaxis.
.
FULL CODE: The patient's code status was discussed at length
with her guardian [**Name (NI) **] [**Name (NI) **]. She is full code.
.
COMM: [**Name (NI) **] [**Name (NI) **] ([**Hospital **] Health care proxy) [**Telephone/Fax (1) 102690**],
[**Telephone/Fax (1) 102691**].
Medications on Admission:
Current Meds:
Lansoprazole 30 mg PO DAILY
Albuterol 90 mcg/Actuation Aerosol 1-2 Puffs Q6H as needed
Ipratropium Bromide 17 mcg/Actuation 2 Puff Inhalation QID
Insulin QID per sliding scale
Insulin Glargine 7 units Subcutaneous at bedtime
Isoniazid 300 mg PO DAILY
Pyrazinamide 500 mg PO DAILY
Pyridoxine 50 mg PO DAILY
Sucralfate 1 g PO QID
Ethambutol 400 mg 3tbl PO Q36H
Nystatin S+S
Acetaminophen 160 mg/5 mL Solution [**Telephone/Fax (1) **] PO Q6H
Lactulose 10 g/15 mL 30ml PO Q8H as needed for constipation.
Senna 8.6 mg PO BID as needed for constipation.
Docusate Sodium 100 mg PO BID
Sodium Bicarbonate 650 mg PO Q6H (every 6 hours).
Fentanyl Citrate 25-100 mcg IV Q6H:PRN
Midazolam 2-4 mg IV Q4H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Pneumonia
Disseminated TB
MDS
Peritonitis
Discharge Condition:
Stable, at baseline
Discharge Instructions:
You were seen and evaluted for your fevers, high heart rate and
low blood pressure. You were found to have a pneumonia and were
started on antibiotics. You were also found to have a urinary
tract infection and were treated with antibiotics for this
infection. Your feeding tube was replaced with a G-J tube.
Followup Instructions:
Need to follow-up:
- urine metanephrines
- Cdiff toxin B
- cultures of peritoneal fluid
[**Month (only) 116**] need reimaging of peritoneal cavity depending on what grows
from peritoneal fluid culture
|
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[
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icd9pcs
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8813, 19690
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22295, 22316
|
5105, 5105
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22675, 22879
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,275
| 140,840
|
36137
|
Discharge summary
|
report
|
Admission Date: [**2164-1-3**] Discharge Date: [**2164-1-7**]
Date of Birth: [**2100-5-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Heartburn
Major Surgical or Invasive Procedure:
s/p Coronary artery bypass graft x 4 (Left internal mammary
artery -> left anterior descending, saphenous vein graft ->
diagonal, saphenous vein graft -> obtuse marginal, saphenous
vein graft -> posterior descending artery) [**1-3**]
History of Present Illness:
63 year old male with symptoms he describes as heartburn with
abnormal stress test. Referred for cardiac catherization that
revealed coronary artery disease and was evaluated for surgical
intervention.
Past Medical History:
Coronary artery disease
Carotid Stenosis Left (80-99%)
Elevated lipids
Hypertension
Avascular necrosis in hips s/p right hip replacement
Anxiety
Depression
s/p hernia repair
s/p lumbar laminectomy
Social History:
Sales manager for dairy company
Married and lives with spouse
[**Name (NI) 1139**] - 10 pack year history, quit 7 years ago and recently
restarted [**12-23**] pack per day
Alcohol: 6 beers per week
Family History:
Noncontributory
Physical Exam:
66 sr 16 123/70 128/77 70" 165
GEN: NAD
LUNGS: Clear
HEART: RR, Nl S1-S2, No murmur
ABD: Soft, nontender, nondistended, normoactive bowel sounds
EXT: 2+ pulses throughoout, no varicosities, no edema
NEURO: Nonfocal
Pertinent Results:
[**2164-1-3**] ECHO
PREBYPASS
1. No atrial septal defect or PFO is seen by 2D or color
Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. The right ventricular cavity is moderately dilated.
4. There are simple atheroma in the aortic arch and descending
thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
7. There is no pericardial effusion.
8. Dr. [**Last Name (STitle) **] was notified in person of the results during the
surgery.
POST-BYPASS: the patient is on phenylephrine infusion
1. Left ventricular function is similar to prebypass with an EF
60%
2. Trace MR is again seen
3. Aortic contours are smooth after decannulation
[**2164-1-7**] 07:50AM BLOOD WBC-10.0 RBC-2.78* Hgb-8.9* Hct-26.5*
MCV-95 MCH-32.0 MCHC-33.6 RDW-13.2 Plt Ct-275#
[**2164-1-3**] 11:30AM BLOOD WBC-11.1* RBC-2.77*# Hgb-9.0*# Hct-26.0*#
MCV-94 MCH-32.6* MCHC-34.7 RDW-12.8 Plt Ct-239
[**2164-1-7**] 07:50AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-136
K-4.3 Cl-100 HCO3-25 AnGap-15
[**2164-1-3**] 12:52PM BLOOD UreaN-21* Creat-0.8 Cl-110* HCO3-27
[**2164-1-6**] 07:00AM BLOOD Mg-2.1
[**2164-1-3**] 08:49PM BLOOD Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname 68224**] was admitted to the [**Hospital1 18**] on [**2164-1-3**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. Within 5 hours, he awoke
neurologically intact and was extubated. Aspirin, beta blockade
and a statin were resumed. On postoperative day one he was
transferred to the step down unit for further recovery. The
physical therapy service was consulted to assist with his
strength and mobility. He was gently diuresed towards his
preoperative weight. He was cleared for discharge on POD 4.
Medications on Admission:
ASA 325', imdur 30', citalopram 20', propanolol 80', alprazolam
0.25" prn, darvocet 2 tabs"
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-23**]
Tablets PO Q8H (every 8 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Arthrotec 50 50-0.2 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
Carotid Stenosis Left (80-99%)
Elevated lipids
Hypertension
Avascular necrosis in hips s/p right hip replacement
Anxiety
Depression
s/p hernia repair
s/p lumbar laminectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**First Name (STitle) 5936**] in 1 week ([**Telephone/Fax (1) 6699**])
Dr [**Last Name (STitle) 7047**] in [**1-24**] weeks
Dr [**Last Name (STitle) **] in 1 month (for carotid stenosis)
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2164-1-7**]
|
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2865, 3625
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285, 521
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|
1476, 2842
|
5982, 6423
|
1204, 1221
|
3767, 5140
|
5235, 5443
|
3651, 3744
|
5495, 5959
|
1236, 1457
|
236, 247
|
549, 753
|
775, 973
|
989, 1188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,513
| 124,864
|
4020
|
Discharge summary
|
report
|
Admission Date: [**2153-1-16**] Discharge Date: [**2153-1-23**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 2.
History of Present Illness:
83 y/o male with longstanding h/o stable anginia, s/p MI approx.
25 yrs agp. On [**1-15**] he had CP with minimal relief from his usual
SL NTG & called 911. EMS brought him to [**Hospital 4199**] Hospital. AT
OSH, pt had an increase in cardiac enzymes and was transferred
to [**Hospital1 18**] for cardiac cath. This revealed 60% LM and 3VD with an
EF of 40%. He is now reffered for CABG.
Past Medical History:
Coronary artery disease, s/p coronary artery bypass graft x 2.
Remote MI
PVD, +claudication L leg
Gout
Prostate CA s/p XRT
s/p TURP
s/p L CEA 04
s/p facial mass removal (Basal cell CA)
s/p bil. hernia repair
+hearing aide
Social History:
Lives alone. Has 4 sons who are involved in pt's care. -ETOH,
never smoked tobacco.
Family History:
Non-contributory
Physical Exam:
Well-appearing 83 y/o male in NAD
Neuro: Grossly intact
Pulm: CTAB, -w/r/r
Cor: RRR, +S1S2, =c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, -c/c/e, -varicosites, good pulses
Pertinent Results:
[**2153-1-16**] 02:00PM BLOOD WBC-5.3 RBC-3.64* Hgb-10.1* Hct-30.4*
MCV-84 MCH-27.9 MCHC-33.4 RDW-14.0 Plt Ct-159
[**2153-1-20**] 04:30AM BLOOD WBC-8.7 RBC-3.08* Hgb-9.4* Hct-26.6*
MCV-86 MCH-30.4 MCHC-35.3* RDW-14.3 Plt Ct-126*
[**2153-1-16**] 02:00PM BLOOD PT-13.1 PTT-39.2* INR(PT)-1.1
[**2153-1-16**] 02:00PM BLOOD Plt Ct-159
[**2153-1-20**] 04:30AM BLOOD PT-12.8 PTT-29.9 INR(PT)-1.0
[**2153-1-20**] 04:30AM BLOOD Plt Ct-126*
[**2153-1-16**] 02:00PM BLOOD Glucose-127* UreaN-27* Creat-1.1 Na-138
K-3.8 Cl-104 HCO3-27 AnGap-11
[**2153-1-22**] 06:30AM BLOOD Glucose-120* UreaN-31* Creat-1.6* Na-143
K-4.3 Cl-103 HCO3-30* AnGap-14
[**2153-1-16**] 02:00PM BLOOD ALT-9 AST-15 AlkPhos-68 Amylase-79
TotBili-0.4
[**2153-1-16**] 09:37PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.027
[**2153-1-16**] 09:37PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Brief Hospital Course:
After being seen by csurg, pt. had a carotid ultrasound
secondary to carotid stenosis/L CEA in the past. U/S revealed no
significant stenosis bilat. Pt. was prepared for surgery the
next day. On HD #2, pt was brought to the OR and after general
anesthesia pt underwent CABG x 2. Please see surgical summary
for full details. Pt. tolerated the operation well. CPB time was
42 minutes. XCT was 30 minutes. He was transferred to CSRU in
stable condition being A-paced with a rate of 80, MAP 78, CVP 9,
PAD 11, [**Doctor First Name 1052**] 16. He had a propofol infusion for anesthesia and
neo infusion for BP support.
Later on OP day, pt's propfol was weaned, ventilator was also
weaned and pt was extubate. Following extubation pt was awake,
oriented and moving all extremities.
POD #1 - Pt. doing well. Swan was removed. PT. was transferred
to telemetry floor.
POD #2 - Pt. went into RAF last eveing. He was treated with
Amiodarone and lopressor and currently in SR - Heparin started.
. Both Chest tube and pacing wires removed. Pharynx mildly
erythematous with whitish plaques - Nystatin started. Pt. also
slightly confused - psych. consult was done and pt. had delerium
secondary to meds, haldol started. Foley removed.
POD #3 - Foley reinserted secondry to inability to
void/delerium. Later today, removed and pt. voiding well on own.
Otherwise pt. doing alright with some rales bilat. Hemodynam.
stable.
POD # 5 - Pt. progressing well. Post-op confusion now cleared.
Some r. hand phlebitis a old IV site.
POD # 6 - Pt. at level 5. Has not had AF for greater than 72
hours. D/C'd home today with VNA services.
PE on day of D/C:
Neuro: Alert, oriented, non-focal
Pulm: CTAB -w/r/r
Caridac: RRR, +S1/S2, -c/r/m/g
Sternum: Incision C/D/I, -erythema/drainage
Abd: Soft, NT/ND, +BS
Ext: Warm, trace edema, inc. c/d/i
Medications on Admission:
1. Inderal 80 mg TID
2. Isordil 40 mg TOD
3. Lipitor 10 mg QD
4. ASA 81 mg QD
5. Allopurinol 300 mg QD
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. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: To begin when [**Hospital1 **] dosing complete.
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
8. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 6 days.
Disp:*18 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease, s/p coronary artery bypass graft x 2.
Remote MI
PVD, +claudication L leg
Gout
Prostate CA s/p XRT
s/p TURP
s/p L CEA 04
s/p facial mass removal (Basal cell CA)
s/p bil. hernia repair
+hearing aide
Discharge Condition:
Stable.
Discharge Instructions:
Wash incisions daily with soapy water -- rinse well. Do not
apply ANY creams, lotions, powders, or ointments.
No driving x 6 weeks.
No heavy lifting greater than 10pounds for at least 6 weeks.
No swimming or bathing in a tub.
Followup Instructions:
Make appointment to follow-up with Dr. [**Last Name (STitle) 70**] in 4 weeks.
Make appointment to follow-up with Dr. [**Last Name (STitle) 1270**] in [**11-19**] weeks.
Completed by:[**2153-2-15**]
|
[
"E849.7",
"414.01",
"999.2",
"412",
"274.9",
"401.9",
"E879.8",
"427.31",
"185",
"411.1",
"272.4",
"451.84",
"293.0",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"37.22",
"88.53",
"99.04",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5236, 5294
|
2264, 4079
|
280, 315
|
5559, 5568
|
1316, 2241
|
5843, 6044
|
1095, 1113
|
4232, 5213
|
5315, 5538
|
4105, 4209
|
5592, 5820
|
1128, 1297
|
230, 242
|
343, 733
|
755, 978
|
994, 1079
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,646
| 199,424
|
9203
|
Discharge summary
|
report
|
Admission Date: [**2126-4-8**] Discharge Date: [**2126-4-25**]
Date of Birth: [**2061-12-3**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
weakness, SOB, orthostatic hypotension
Major Surgical or Invasive Procedure:
s/p wound closure in OR
History of Present Illness:
64yo M w/ PMH of CAD and cryptogenic cirrhosis s/p 3v CABG and
simultaneous liver transplant in [**4-3**], with a post-op course
complicated by peritonitis, sternal wound infection, ? MI, and
orthostatic hypotension. Completed a [**Hospital 11728**] rehab program at
[**Hospital3 7**] which had enabled him to walk again and get
back on his feet. He was doing well until 3-4 weeks ago when he
developed progressive fatigue, SOB, and postural hypotension
(he'd get lightheaded when standing quickly). His sx began to
get worse over the last week. He fell at home last Wednesday,
landing on his R side and injuring his ribs. EMS was called but
the pt refused transport to the ER at that time. He denied LOC,
no head trauma, no bleeding. His SOB has begun to occur at rest,
while he's sitting in a chair. He is asx when laying flat (no
LH, no SOB).
.
He experienced this previously while hospitalized in [**State 108**],
but felt he had been doing better up until now. At that time, he
was started on midadrine once daily. He was then started on
lasix, and then coreg. Over the last month, coreg and lasix have
had to be discontinued, and his outpt provider has gradually
gone up on his midadrine to his current dose, 10mg PO TID, with
no improvement in his sx (if anything, his sx have gotten
worse).
.
ROS:
denies fevers, chills, night sweats or weight loss
denies URI sx of rhinorrhea, cold, sinus congestion; + cough
productive of clear sputum
denies dysphagia, difficulty swallowing, or odynophagia
denies anorexia, abdominal pain, n/v/d/constipation
denies numbness or tingling in his hands or feet
+ mild swelling in his toes [**1-31**] [**Male First Name (un) **] stockings
+ black stools since starting Fe supplements
+ cloudy urine, denies dysuria, decreased urinary frequency
+ "funny feeling" in his back, in his kidney area
denies back pain
Past Medical History:
1) s/p 3v CABG and concurrent liver transplant in [**4-3**]
- complicated by sternal wound infxn
2) cryptogenic cirrhosis (s/p liver transplant as above)
3) DM type II
- complicated by neuropathy
4) h/o sinusitis
5) h/o depression
Social History:
Married, 3 children. Lives in [**Location **], MA. Is retired plant
manager (chemical engineer). Retired in [**2120**] when dx w/
cirrhosis.
No tob, no EtOH, no IVDU.
Family History:
F + DM, M/F both died of MIs
Physical Exam:
VS - T 97.8, BP 130/78, HR 80, RR 16, sats 97% on RA
GEN - Thin, elderly male, appears older than stated age, lying
on stretcher, in NAD. Pleasant, conversant.
HEENT - NCAT, sclera anicteric. PERRL, EOMI. OP clear, no
exudates or erythema. Neck supple, no evidence of LAD or JVD.
CHEST - Sternal wound packed w/ dry gauze. Mild serosanguinous
drainage at its base. Has small area, 2x4 cm, of streaking
erythema that extends laterally to the R. No flocculence, but +
warmth. Nontender, no pustular drainage.
CV - RR, normal S1, S2. No m/r/g.
LUNGS - CTAB, no crackles/wheezes/rhonchi.
ABD - Soft, NTND. + BS. No masses. Multiple scars (horizontal)
across his abdomen, one under each costal margin, and one
(vertical) in the suprapubic area, all well-healed. +
hepatomegaly (10-12cm span).
EXT - 2+ DP/radial pulses bilaterally. No c/c, mild edema across
dorsum of feet bilaterally. Feet are cool, but w/ good cap
refill. TEDS in place.
NEURO - AAOx3. CN II-XII grossly intact.
Pertinent Results:
LABS on admission:
WBC 6.5#, Hct 42.1#, MCV 77*#, Plt 180
PT 11.3, PTT 26.4, INR(PT) 0.9
Na 137, K 4.4, Cl 103, HCO3 25, BUN 41, Cr 2.4, Glu 182
ALT 53*, AST 37, AlkPhos 131*, Amylase 49, TBili 0.2
TotProt 6.7, Albumin 3.9, Globuln 2.8, Calcium 11.3*, Mg 2.2
rapmycn 23.4*
Lactate 1.5
%HbA1c-6.5*#
Triglyc-545* HDL-33 CHOL/HD-6.9 LDLmeas-113
.
URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025 Blood-TR
Nitrite-NEG Protein-100 Glucose-1000 Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-NEG RBC-0 WBC-31* Bacteri-MANY
Yeast-NONE Epi-1 CastGr-19*
.
MICRO:
fluid from abdominal wound drains x 3 and tissue from OR sample
of wound on closure:
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ 8 I
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
.
CXR [**2126-4-8**] - No evidence of CHF or pneumonia.
.
CT head [**2126-4-8**] - No intracranial hemorrhage or mass effect.
.
RENAL US [**2126-4-9**] - Re-demonstration of large right renal cyst.
Otherwise, unremarkable renal ultrasound without evidence of
hydronephrosis.
.
ECHO [**2126-4-12**] - The left atrium is elongated. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is severe global left ventricular hypokinesis
(ejection fraction 20-30 percent). No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right ventricular chamber size is normal. Right ventricular
systolic function appears depressed. The aortic root is
moderately dilated. The ascending aorta is mildly dilated. The
aortic arch
is moderately dilated. 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. Moderate (2+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion. Compared with the
findings of the prior study (images reviewed) of [**2125-12-14**], the left ventricular ejection fraction is further reduced.
KUB [**2126-4-19**]: Gas is present within a prominent transverse colon,
but air in soles present throughout the colon. There is no
evidence for obstruction. Findings are most consistent with
ileus. Degenerative disease is present throughout the lumbar
spine.
Brief Hospital Course:
Mr. [**Known lastname 9035**] is a 64yo man status post 3V CABG and concurrent
liver transplant last year in [**Location 14660**] FL, complicated by
sternal wound infection. He presented to cardiology clinic for
the first time with weakness, shortness of breath, and
orthostatic hypotension and was admitted to the inpatient
medicine service.
.
ORTHOSTATIC HYPOTENSION: The etiology of his symptoms were
unclear on admission. Our differential was broad and included
autonomic neuropathy secondary to DM, deconditioning given his
long ICU stay, and dehydration. He was given IVF for 48 hrs
which improved his orthostasis, but began to lead to volume
overload, with slight pedal edema and crackles on lung exam.
Neurology was consulted for the evaluation of his autonomic
dysfunction. A tilt table test was performed and found him to
have true orthostatic hypotension, likely multifactorial in
etiology. We continued his home midodrine and increased his
dose to 12.5mg qam, 10mg at noon and 10mg at 4pm. He was also
started on florinef daily, then increased to [**Hospital1 **] to aid with his
orthostasis. We encouraged the patient to wear TEDS stockings
around the clock as well as keeping his bed in reverse
Trendelenberg, however hte patient refused to wear 24 hour TEDS
stockings, repeatedly insisting that he take them off to sleep
at night for comfort. The patient remained orthostatic
throughout his stay, with some days better than others although
with no clear precipitants for these differences. We ultimately
encouraged that he dirnk caffeine as well, up to three times per
day to aid with his orthostasis. He was able to walk with PT
with a walker prior to discharge, but continued to report
dizziness on standing. He was repeatedly instructed in sitting
up slowly, then standing slowly while holding on to a chair or
counter until dizziness passes, then attempting to walk.
Ultimately, it was recommended that the patient be discharged to
rehab for further PT work, however the patient and his wife
refused, saying that they preferred discharge to home with PT.
The patient was discharged to home with PT, but also with a
wheelchair as he was strictly instructed by our inpatient
physical therapist that he is not to walk around alone at home.
He was also given a prescription for a walker with seat for
future work with PT at home. He will schedule a follow up
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of autonomics (neuro) for his
orthostatic hypotension. Dr.[**Name (NI) 19469**] office will contact the
patient.
.
WOUND CLOSURE: The patient's wound was closed by thoracic and
plastic surgery during his stay. This was complicated by
enterobacter positive cultures from all three JP drains as well
as tissue sampled in the OR from the wound site. The patient
remained afebrile and was initially started on vancomycin and
ceftazidime, later switched to levofloxacin after culture and
sensitivity data returned for a total 14 day course. The wound
erythema decreased steadily on this antibiotic regimen. Drains
were all removed prior to discharge to home. After wound
closure, the patient's immunosuppression regimen was changed to
prednisone 10mg/tacrolimus/cellcept, as it was felt that
tacrolimus is better than rapamune for wound healing. The
patient's prograf levels were monitored by the liver team and
the dose was adjusted accordingly. Post operative course was
also complicated by ileus and urinary retention, likely both due
to dilaudid use for pain control, and both of which resolved
after dilaudid was changed to oxycodone. The patient has a
follow up appointment with Dr. [**First Name (STitle) **] of plastics after
discharge to follow up.
.
ACUTE ON CHRONIC RENAL FAILURE: Mr. [**Known lastname 9035**] has had CRI with
baseline Cr about 2.0 since his ICU admission in [**State 108**].
Etiology of this chronic renal insufficiency is unknown. In
house, his Cr initially seemed to improve slightly with IVF.
Bactrim dose was decreased given renal function and maintained
at single strength prophylactic dose. After the wound closure,
the patient again experienced acute renal failure. This was
felt to be multifactorial in nature. The patient had urinary
retention postoperatively likely secondary to dilaudid and
placement of a foley catheter released 900cc of urine. Renal
ultrasound showed no hydronephrosis. Dilaudid was changed to
oxycodone with improved spontaneous urination. Renal consult
was called and believed ARF to be due to transient hypotension
(of unknown etiology) the day prior, initiation of Prograf and
an initial elevated Prograf level, and post operative urinary
retention. As each of these issues were resolved the patient's
creatinine returned to his baseline of 2. His prograf levels
were titrated by the liver team, with goal level [**5-5**] in this
patient. Prograf levels will be followed as an outpatient by
[**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in the liver center.
.
S/P LIVER TRANSPLANT: Mr. [**Known lastname 31620**] transaminases were elevated
on admission, but they quickly returned to baseline. The liver
team was consulted on admission and followed his course. As
noted above, rapamycin was held after wound closure and the
patient's immunosuppressant regimen was changed to cell cept,
Prograf, and increased prednisone to 10mg qday. His levels were
follwoed by the liver team, who will continue to follow him as
an outpatient. He will have blood drawn on Monday with results
sent to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in hte liver center and he has a follow up
appointment with Dr. [**Last Name (STitle) 497**] there.
.
DM2: Mr. [**Known lastname 9035**] sees an endocrinologist as an outpatient for
his diabetes management. He states that his FS have been under
good control. His HgbA1C is 6.5. He was continued on his home
regimen of insulin sliding scale and lantus, and his FS remained
in good control throughout his stay.
.
ANEMIA: On admission, his Hct was normal, but dropped slightly
after fluid resuscitation. He has a h/o iron deficiency anemia
and was already on iron supplementation. Iron studies were
performed and revealed an anemia of chronic disease. We
discontinued his iron supplementation. His Hct remained stable
for the rest of his hospital course.
.
CAD: Mr. [**Known lastname 9035**] has a h/o CAD, now s/p 3v CABG one year ago,
yet on admission he was taking none of the expected secondary
prevention medications like [**Known lastname **], bblocker, statin, ACE-i. After
his wound closure, we started him on low dose aspirin, as well
as statin, which should not interact with any of his
immunosuppressant medications and per the liver team is safe s/p
liver transplant.
Cardiology consulted on him and recommended an ACE-i if
possible, however his blood pressure in house was unable to
tolerate this. He received one dose of perioperative beta
blocker, however due to baseline hypotension, this medication
was otherwise held as the patient could not tolerate it. ECHO
did reveal a worsening in his LVEF, without any focal WMA or new
findings other than global hypokinesis. Prior to going to the
OR, it was decided to perform a p-MIBI, which showed no
reversible defects and the patient was cleared for the OR. He
will follow up with Dr. [**Last Name (STitle) **] in cardiology as an outpatient
and can pursue wehther an ACE inhibitor can be added to his
regimen.
.
DYSPNEA: He complained of dyspnea on admission, and throughout
[**Last Name (un) 8692**] stay with exertion, but he was not hypoxic, only had an
intermittent productive cough, and a clear CXR. There was no
evidence for pneumonia, CHF, or asthma. An ECHO was performed to
r/o a PFO and was negative, without any signs of a shunt. The
neurologists felt that his symptoms were most consistent with
orthostatic dyspnea. There was likely also a component of
deconditioning to his dyspnea, and this should improved with
further work with PT and mobility.
.
DEPRESSION: The patient has a history of depression and on
admission was taking mirtazipine. Throughout his stay he was
noted to be depressed, not eating much, often times making poor
eye contact and not wishing to speak with providers, as well as
expressing feeling depressed. He denied suicidal ideation. He
was seen by social work repeatedly throughout his stay. On the
day prior to discharge he stated that in the past Wellbutrin
worked better to control his depression. He was instructed to
follow up with his PCP to discuss his depression and wehther his
medications should be so changed, as it is unknown to us why his
Wellbutrin was discontinued in the past and changed to
mirtazipine.
.
HYPERCALCEMIA: He was hypercalcemic on admission, but it
corrected with fluid resuscitation. His PTH was checked, prior
to fluid resuscitation, and was actually low. No further
intervention or workup was performed.
.
As stated above the patient was discharged to home with home PT
after a prolonged conversation between the patient, his wife,
social work and PT. Our unanimous recommendation was for the
patient to be discharged to rehab, however he and his wife
refused nad he was discharged to home. He has follow up
appointments with Dr. [**Last Name (STitle) **], [**Doctor Last Name 497**], and [**Location (un) **]. He will be
called by Dr.[**Name (NI) 19469**] office for a follow up appointment. The
patient will call his primary care provider to make [**Name Initial (PRE) **] follow up
appointment as well to discuss his depression.
Medications on Admission:
Lactinex 1 tablet PO BID
EPO 20,000u every other Wed (last dose [**2126-4-3**])
Colace 100mg PO BID
Fe 325mg PO QD
Neurontin 300mg PO QHS
Lantus 6u QHS
Novolog insulin sliding scale
Synthroid 50mcg PO QD
Midodrine 10mg PO TID
Prednisone 5mg PO QD
Rapamune 10mg PO QD
Bactrim DS 1 tab PO QD
Prevacid 30mg PO BID
MVI
Remeron 30mg PO QHS
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*3*
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*3*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*3*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*3*
10. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*3*
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Disp:*30 Capsule(s)* Refills:*3*
12. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*3*
13. Midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day: please take 12.5 mg when you wake up (this pill and a
smaller 2.5 pill), 10mg at noon (this pill only), and 10mg at
4pm (this pill only).
Disp:*90 Tablet(s)* Refills:*3*
14. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO qAM: please
take 12.5mg total every morning (this pill and larger 10mg
pill).
Disp:*30 Tablet(s)* Refills:*3*
15. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
16. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please take 1.5mg total twice per day (this pill
and one larger 1mg pill). dose will be adjusted by levels.
Disp:*180 Capsule(s)* Refills:*3*
17. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day:
please take 1.5mg total twice per day (this pill and one 0.5mg
pill). dose will be adjusted by levels.
Disp:*180 Capsule(s)* Refills:*3*
18. insulin
please continue your previous insulin regimen of lantus 6 units
every night and novolog insulin slide scale.
19. epoetin
please continue your previous 20,000 units of epoetin SC
injection every other wednesday
20. walker with seat
please dispense one walker WITH SEAT for patient to use
21. Outpatient Lab Work
Please check CBC, chem 7, calcium, mg, phos, ALT, AST, alk phos,
Total bili, albumin, and FK506 level (prograf level) on Monday
[**2126-4-29**] and weekly on each Monday thereafter.
Please fax results to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary diagnosis:
Orthostatic hypotension
Open sternal wound
Acute on chronic renal failure
Mild transaminitis
.
Secondary diagnosis:
CAD s/p 3V CABG in [**4-3**]
Cryptogenic cirrhosis s/p liver transplant [**4-3**]
Depression
Diabetes mellitus type II
Discharge Condition:
Good
Discharge Instructions:
MEDICATION CHANGES:
1. LIPITOR: please take this pill once per day for your
cholesterol.
2. ASPIRIN: please take one baby aspirin [**Name2 (NI) 31621**] day for heart
protection.
3. CELLCEPT: please take this pill twice per day for your liver
transplant (immune suppression).
4. MIDODRINE: we increased your morning midodrine to 12.5 mg,
then 10mg at noon and 10mg at 4pm. This medication should only
be taken while awak and at these times, do not take before bed
as it only works if you'll be sitting up or standing.
5. PREDNISONE: we increased your dose to 10mg every day.
6. PROGRAF (also called tacrolimus): please take 1.5 mg twice
per day (one big and one small pill of tacrolimus). Please have
your blood drawn weekly and faxed to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] to adjust your
dose.
7. BACTRIM: we decreased you to single strength bactrim. Please
take one every day.
8. STOP taking your rapamycin.
.
Please be sure to go to your follow up appointments with Dr.
[**Last Name (STitle) 497**], Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) **], and Dr. [**First Name (STitle) **]. Please call our
primary doctor for an appointment to discuss your depression and
whether you should be on new antidepressant medication.
.
Please work with physical therapy at home often. Use your
wheelchair. Drink plenty of fluids. Please go from lying to
sitting slowly and adjust to dizziness before attempting to
stand. Please go from sitting to standing slowly, holding on to
something secrue until dizziness passes before you start
walking.
.
Please call your primary care physician or go to the nearest ER
if you develop any of the following symptoms: fever, chills,
chest pain, shortness of breath, dizziness, lightheadedness,
swelling in your legs, difficulty walking or doing your usual
activities, or any other worrisome symptoms.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-5-1**] 10:40
2. CARDIOLOGY: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2126-5-6**] 1:15. [**Hospital1 18**] [**Hospital Ward Name 23**] Center [**Location (un) 436**].
.
3. AUTONOMIC DYSFUNCTION/NEUROLOGY: Please follow-up with Dr.
[**First Name (STitle) **] (of neurology) for your orthostatic hypotension. His
secretary will call you with a time and date. [**Telephone/Fax (1) 8139**]
.
4. PLASTIC SURGERY: Dr. [**First Name4 (NamePattern1) **] [**5-9**] at 10:00am. [**Street Address(2) 31622**]. [**Location (un) **], MA
.
5. Please call your primary doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1474**] in the next two
weeks for a follow up appointment to discuss your depression
Completed by:[**2126-5-1**]
|
[
"V45.81",
"458.0",
"997.5",
"428.0",
"428.20",
"276.51",
"250.00",
"584.9",
"414.00",
"560.1",
"788.20",
"998.59",
"682.2",
"585.9",
"V42.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
19303, 19374
|
6486, 16075
|
319, 345
|
19672, 19679
|
3726, 3731
|
21606, 22542
|
2684, 2714
|
16461, 19280
|
19395, 19395
|
16101, 16438
|
19703, 19703
|
2729, 3707
|
19723, 21583
|
241, 281
|
373, 2226
|
19530, 19651
|
19414, 19509
|
3745, 6463
|
2248, 2483
|
2499, 2668
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,424
| 186,214
|
23768
|
Discharge summary
|
report
|
Admission Date: [**2118-7-29**] Discharge Date: [**2118-8-27**]
Date of Birth: [**2058-9-11**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Clindamycin / Warfarin / Ativan / Zosyn
Attending:[**First Name3 (LF) 30158**]
Chief Complaint:
hyperkalemia and fever of unknown origin
Major Surgical or Invasive Procedure:
Tunneled dialysis catheter placed by interventional radiology
History of Present Illness:
59M with hx of Alport's syndrome, ESRD on HD three times a week
who presented to the ED with hyperkalemia. Patient was sent
here due to hyperkalemia noted at [**Hospital **] rehab. This was most
likely due to the fact he skipped a dose of dialysis (missed
friday). At the hospital pt. with EKG changes (EKG showed
peaked T waves and a widened QRS). Per renal notes, pt receives
HD at [**Hospital3 **] three times a week. On [**7-4**] (?), pt was
noted to be lethargic at HD. he was sent to the [**Hospital3 **]
ER and admitted. He was found to be febrile and hypotensive with
a leukocytosis. Bld cx were drawn and antibiotics were started.
Bld cx returned negative. During that time, pt's AV fistula in
his right arm clotted off and remained so despite a thrombectomy
so a temporary? HD catheter was placed. Sources of infection
included osteomyelitis/discitis verses AVF. Per notes, pt
completed course of Vancomycin for presumed bacteremia.
.
The patient was given one amp of IV calcium gluconate and sent
to [**Hospital1 18**] ER. In the ER, a hemolyzed K returned at 9.1. He
received Calcium gluconate, Insulin/D50, one amp of bicarb and
Kayexalate.
.
Patient's brief hospital course in the ICU is below. For his
hyperkalemia he was dialyzed and his EKG was followed. For his
fever, cultures were drawn from his dialysis catheter, cdiff
sent and he was on vancomycin dosed by levels for < 15. He
developed Afib with rates to 150's, he was given an additional
beta-blocker which helped. All of his other medical problems
were stable on home meds.
.
On the floor, patient without complaints. Denies CP, SOB,
abdominal pain, N, V, confusion, palpitations, melena, diarrhea
or constipation. He has no complaints now.
Past Medical History:
* Alport's syndrome leading to ESRD and hearing impairment
* s/p failed renal transplant at age 16
* Diabetes
* adrenal insufficiency
* hx of L1/L2 discitis and epidural abscess
* hx of subacute cerebral infarcts
* squamous cell carcinoma
* CHF (per [**Hospital3 **] records EF 20%)
* Hypertension
* diverticulosis
Social History:
ALL: ACE-I, Clindamycin, Lorazepam, Warfarin ?
.
Patient lives at home with his wife, recently transferred to
[**Hospital **] rehab. Has no children and is cared for by his wife. [**Name (NI) **]
denies ETOH, tobacco or drugs.
Family History:
mother has diabetes, father had [**Name2 (NI) 499**] cancer and died in [**2082**], 2
sisters with Alport syndrome and two aunts with [**Name (NI) 60693**].
Physical Exam:
In ICU
Exam: 100.4 -->97.3, BP 115/47, HR 90, R 20, 100% on 2L
Gen: NAD, pleasant
HEENT: MMM, no JVD, EOMI
CV: regular with frequent ectopy, no murmurs appreciated
Chest:
Abd: +BS, soft, nontender, nondistended
ext: no edema, 2+ PT, warm
neuro: CN 2-12 intact, strength 4/5 throughout
.
On floor
97.1, BP 98/40, P 72, RR 16, 99%RA
Gen: NAD, pleasant
HEENT: MMM, no JVD, no LAD
CV: RRR murmur noted though faint
Chest: CTAB
Abd: +BS, soft, nontender, nondistended
ext: no edema, 2+ PT, warm
neuro: CN 2-12 intact, AAO
Pertinent Results:
Initial EKG: baseline RBBB, widened QRS, peaked T waves
.
EKG after HD: RBBB, QRS and T waves improved
.
Admission CXR IMPRESSION:
1. Plate like atelectasis, left lower lobe. No evidence of
pneumonia.
2. Probable compression deformity and narrowing of
intervertebral disc space, upper lumbar spine. Clinical
correlation is recommended.
.
ECHO: Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with
normal cavity size and systolic function (LVEF>55%). Regional
left ventricular
wall motion appears normal (in some views the inferior wall
appears
hypokinetic but this may be due to frequent ectopy/irregular
rhythm). Right
ventricular chamber size and free wall motion are normal. The
aortic root is
mildly dilated. The ascending aorta is mildly dilated. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation
is seen. The left ventricular inflow pattern suggests impaired
relaxation.
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I
(mild) left ventricular diastolic dysfunction. The estimated
pulmonary artery
systolic pressure is normal. No vegetation/mass is seen on the
pulmonic valve.
There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen.
.
MR L spine [**8-4**]: FINDINGS: No comparisons are available.
.
There is large area of destruction involving the L1/2 disc with
destructive end plate changes of L1 and L2. There is
heterogeneously increased T2 signal as well as diffuse
enhancement of these vertebral bodies and disc, consistent with
spondylitic discitis. There is paraspinal and epidural phlegmon
without a discrete abscess.
At T12/L1, there is a left lateral disc bulge extending from the
foramen to the extraforaminal region. There is no significant
central canal or neural foraminal narrowing at this level.
Note is made of a 1 cm gallstone.
IMPRESSION: L1/2 spondylodiscitis with paraspinal and epidural
phlegmon without a discrete abscess. The epidural phlegmon is
causing 25-50% central canal narrowing
.
Left venous upper extremity ultrasound: IMPRESSION: Intraluminal
thrombus within the left IJ vein. The remainder of the right
upper extremity veins are patent. There is a small soft tissue
fluid collection adjacent to the left shoulder, which may
represent a small post-procedure hematoma
.
CT chest [**8-7**]: IMPRESSION:
1. Osseous destruction at L1-2 with paravertebral soft tissue
consistent with osteomyelitis/discitis, better demonstrated on
recent MR [**First Name (Titles) **] [**2118-8-4**]. Evaluation of the central canal is
limited on CT.
2. Bilateral pulmonary consolidation and pleural effusions,
likely representing pulmonary edema, although superimposed
pneumonia is not excluded.
3. No evidence of intra-abdominal abscess.
4. Gallstones, without evidence of cholecystitis.
5. Absent bilateral native kidneys and atrophic-appearing
transplant kidney, right pelvis.
.
CXR [**8-9**]: There has been a substantial increase in perihilar
pulmonary consolidation which is seen on the lateral view to lie
in the upper and middle lobes, less so in the lower. In
addition, there are discretely nodular opacities seen in the
lower lungs particularly on the right, all of which points to
disseminated infection, alternatively progressive pulmonary
hemorrhage, rather than pulmonary edema as suggested previously.
Mild-to-moderate cardiomegaly is stable and there is no
appreciable pleural effusion. There has been interval increase
in thickness of the right paratracheal and mediastinal soft
tissue probably combination of azygos vein distention,
mediastinal fat deposition, and some increase in central
adenopathy. Left supraclavicular dual-channel dialysis catheter
has been advanced to the lower third of the SVC. There is no
pneumothorax
.
CT chest: IMPRESSION: Worsening multilobar pneumonia, much less
likely pulmonary hemorrhage.
.
Bone scan: IMPRESSION:
1. Abnormal focal osseous uptake along the right aspect of the
L1 and L2
vertebral bodies which may represent osteomyelitis, though
non-specific. This
will be correlated to the results of the white blood cell scan
when available.
2. Marked diffuse cardiac uptake, which could be consistent
cardiac
amyloidosis.
.
WBC scan: IMPRESSION: 1. Pneumonia 2. No convincing evidence for
spinal osteomyelitis although In-111 white blood cells may have
some decrease in sensitiviy in the spine.
.
Mr of right shoulder: IMPRESSION:
1. Extremely limited examination. The patient could not complete
the study and the submitted images are degraded by significant
motion artifact. There is a loculated high T2 signal collection
anterior to the scapula extending anterior to the shoulder.
Several round low signal lesions are present in this collection.
Findings are nonspecific but most likely represent severe
glenohumeral degenerative changes with an effusion containing
degenerative loose bodies. Further evaluation could be made with
either a dedicated CT through the shoulder or if the patient
clinically stabilizes, an attempt at a repeat MR with more time
sensitive sequences. Correlation with plain x- rays is
suggested.
2. Bilateral upper lobe lung consolidations
.
Admission labs:
[**2118-7-29**] 03:30PM WBC-10.2 RBC-3.73* HGB-10.1* HCT-32.8* MCV-88
MCH-27.1 MCHC-30.8* RDW-18.5*
[**2118-7-29**] 10:30PM GLUCOSE-178* UREA N-28* CREAT-3.3*#
SODIUM-138 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-25 ANION GAP-19
[**2118-7-29**] 10:30PM CALCIUM-8.4 PHOSPHATE-4.3# MAGNESIUM-1.5*
Brief Hospital Course:
59 year old male with history of ESRD [**2-24**] Alport's syndrome who
presented initially with K of 7.7 and EKG changes, and now is
with fever of unknown origin.
.
1) Fever of unknown origin/discitis/osteomyelitis/pneumonia:
The patient presented with high fever spikes. Patient had
recently finished a three week course of vancomycin from
presumed bacteremia from AV fistula, but per [**Hospital3 **],
all blood cultures sent were negative. During that hospital
course at [**Hospital3 **] he had a temporary HD catheter placed.
On admission, it was thought initially that the patient had a
HD catheter infection. The patient was maintained on vancomycin
had his catheter replaced and the tip sent for culture. During
hospital course, the patient continued to have fever spikes.
All blood cultures and catheter tip culture returned negative/no
growth to date. Therefore infectious disease was consulted
regarding fever of unknown origin. Infectious disease,
recommended removal of HD catheter x 48 hours (after it was
already changed on admission, given continued fever spikes), but
patient refused.
.
Patient also had a known history of discitis and osteomyelitis
of L1-L2/epidural abscess in [**3-28**]. After evaluation at [**Hospital 2586**] he was evaluated for this problem again at [**Name (NI) 112**] in
[**2118-5-23**]. He has had CT guided biopsies of this area in the
past, from which the cultures have been negative. A new MR of
spine was obtained during his hospital course that demonstrated
continued L1/2 spondylodiscitis with paraspinal and epidural
phlegmon without a discrete abscess. Another CT guided biopsy
was considered, and therefore the orthopedic spine team was
consulted. They felt once all other infectious etiologies were
ruled out, we could consider an incision and drainage of the
phlegmon and/or a debridement.
.
Other infectious work up during hospital course included a
trans-thoracic echocardiogram which was negative for valvular
vegetations, ultrasound of chest wall (where HD catheter was)
which was negative for absess, ultrasound of left upper
extremity deep veins that demonstrated DVT in left IJ, initial
CT thorax that did not demonstrate any absesses, but revealed
bilateral pulmonary consolidation and pleural effusions, which
likely represent fluid overload (although are considering other
etiologies on differential), bone scan, WBC scan (revealing
pneumonia), bronchoscopy, and an MR of the shoulder (possible
effusion noted).
.
A repeat CXR was performed later in his course, which raised the
possibility of disseminated infection or septic emboli. This
led to a pulmonary consult, and per their suggestions, we
rechecked his Chest CT after dialysis, sent sputum samples and
sent out an anti-GBM antibody. Later in his course, the CT of
the chest and the white cell scan revealed a multilobar
pneumonia, so a bronchoscopy was performed. As the patient's
fever curve worsened, while waiting for bronchoscopy results, he
was empirically started on vancomycin, cefepime and flagyl.
With these antibiotics on board, the patient had an episode of
hypotension. This, with his fever and tachycardia was worrisome
for sepsis, so he was transferred to the ICU for fluid
resuscitation.
.
Initially per infectious disease, patient was maintained on
vancomycin, but was not broadened as to not mask etiology of
infection. Later in his course all antibiotics were stopped such
that the patient's fever curve and cultures could be followed
off antibiotics. Eventually with a source of pneumonia, and the
patient having increased fevers, it was decided the patient
needed to be covered and was started on broad spectrum
antibiotics while cultures were pending.
.
2) Atrial fibrillation: In the ICU, the patient converted into
atrial fibrillation with a rate of 140-150 following
hemodialysis. The patient denies atrial fibrillation in the
past, but this could be related to the stress of infection. In
the ICU, he was started on metoprolol, and converted back to
normal sinus rhythm. The patient remained on telemetry, and was
only noted to have ventricular bigeminy. He was maintained on
metoprolol throughout hospital course. Initially,
anticoagulation was held due to possible coumadin allergy. Then
patient was noted to not have this allergy, and started on
heparin. Deferred initiation of coumadin to outpatient setting
(as patient was only in atrial fibrillation for short time
period). The patient remained in normal sinus rhythm
throughout remainder of hospital course.
.
3) Hyperkalemia: His hyperkalemia resolved status post dialysis,
kayexylate, calcium/bicarb and insulin. His EKG improved
post-intervention and we continued to monitor for re-occurrance.
His hyperkalemia on admission was attributed to the fact that
he had recently missed dialysis and that his dialysis catheter
was not functioning properly. Patient's potassium level
remained stable throughout remainder of hospital course.
.
4) Left Internal Jugular Vein clot: The patient was noted to
have a clot of Left internal jugular vein on ultrasound. There
was a questionable allergy to coumadin noted in the chart, so
while this was being confirmed, anticoagulation was postponed.
We felt that the patient's allergy to coumadin was unlikely
(after further investigation) and therefore started a heparin
drip. He should start coumadin as well in the future prior to
hospital discharge. He will likely need only 1 month of
anticoagulation for left IJ DVT.
.
5) ESRD: Patient was continued on hemodialysis, three days per
week (MWF) and was followed by nephrology. He did well with
nephrocaps, renal diet, and hemodialysis.
.
6) Hypertension: Patient's blood pressures remained controlled
on metoprolol, and the dose was adjusted for optimal control.
We did not restart hydralazine as the patient's blood pressures
were normal, and we were unsure if this was needed (he is on
hydralazine and not isosorbide at home, so less renal benefits).
.
7) adrenal insufficiency: We continued his prednisone, and he
did not require any stress doses.
.
8) Hypothyroidism: We continued his home dose of levoxyl. Based
on the thyroid studies, he can go up on his dose, but he is
clinically euthyroid so this can be adjusted as an outpatient.
.
9) Diabetes: We continued to increase his sliding scale insulin,
until he maintained good blood glucose control.
MICU course [**Date range (1) 9459**]: Pt arrived to the MICU with a bp in the
80s-90s. He refused central line placement, so his HD catheter
was used for central access. He received a one liter fluid
bolus and his bp remained stable in the 120s for the rest of his
MICU stay. He was covered with broad spectrum antibiotics
(vanc, flagyl, ceftaz -- due to cefepime allergy, and
levofloxacin) per ID recommendations. His steroids were
increased to prednisone 40 mg given hx adrenal insufficiency.
He remained afebrile. His cultures remained negative, and he
was transferred back to the floor on [**8-19**].
On the Floor - The medicine team was called to the ICU to admit
the patient to floor. The patient at that time decided with his
family to discontinue further aggressive medical care, and be
made comfort measures only. The implications of this desicion
were discussed at length, and it was made clear that it woudl
likely result in his death. He understood the implications, and
despite the slim chance that continued aggressive treatment
might have resulted in significantly prolonging his life, he
wished to be made Comfort Measures Only. The decision was
discussed with his wife, who was supportive. He passed away on
the floor shortly after.
Medications on Admission:
* recently finished course of Vanc on [**7-27**]
* metoprolol 100mg [**Hospital1 **]
* MVI
* Zolpidem prn
* tylenol prn
* Nephrocaps
* ASA 81mg qd
* Nexium 40mg qd
* Lidoderm patch
* prednisone 10mg qd
* Levoxyl 75mcg qd
* colace 100mg [**Hospital1 **]
* hydralazine 10mg qd
* RISS
* Soriatane 10mg qd
Discharge Medications:
expired
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"585.6",
"996.62",
"324.1",
"486",
"995.91",
"403.91",
"722.93",
"173.6",
"427.31",
"410.71",
"038.9",
"453.8",
"250.02",
"759.89",
"263.9",
"255.4",
"780.6",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"39.95",
"38.95",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
17196, 17262
|
9162, 16810
|
361, 424
|
17313, 17322
|
3499, 8827
|
17378, 17388
|
2786, 2944
|
17164, 17173
|
17283, 17292
|
16836, 17141
|
17346, 17355
|
2959, 3480
|
279, 323
|
452, 2184
|
8843, 9139
|
2206, 2523
|
2539, 2770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,658
| 171,768
|
27228+57529
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-12-23**] Discharge Date: [**2132-12-28**]
Date of Birth: [**2075-9-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Beet
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
heartburn
Major Surgical or Invasive Procedure:
Emergency coronary artery bypass graft x5: Left internal
mammary artery to left anterior ascending artery and saphenous
vein graft to posterior descending artery diagonal and saphenous
vein sequential grafting to obtuse marginal 2 and 3. [**2132-12-23**]
History of Present Illness:
Over past 2 weeks have been noticing increased heartburn. Last
night woke patient from sleep and did not go away, so he went to
emergency room at [**Hospital3 1280**]. He underwent cardiac cath which
revealed: LM 50%, LAD90%, Cx 90%, OM1 TO-culprit, RCA 100%. An
IABP was placed and he was transferred to [**Hospital1 18**] for emergency
CABG.
Past Medical History:
Hypertension
Hyperlipidemia
Renal Insufficiency
Social History:
Lives with wife and is a real estate attorney.
Family History:
father died MI at 55 yo. Mother also had MI at 58yo
Physical Exam:
Pulse: 98 Resp: 18 O2 sat: 100% 2LNP
B/P 125/87:
Height: 5'[**32**]" Weight: 223 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-no
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- A&Ox3-nonfocal exam
Pulses:
Femoral Right: IABP Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 1+ Left: 1+
Carotid Bruit- no Right: Left:
Pertinent Results:
[**2132-12-26**] 04:57AM BLOOD WBC-10.8 RBC-3.84* Hgb-11.4* Hct-34.1*
MCV-89 MCH-29.7 MCHC-33.4 RDW-13.3 Plt Ct-220
[**2132-12-24**] 05:43AM BLOOD PT-13.1 PTT-26.8 INR(PT)-1.1
[**2132-12-25**] 05:38AM BLOOD Glucose-125* UreaN-12 Creat-1.0 Na-133
K-4.1 Cl-99 HCO3-30 AnGap-8
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on Mr.[**Known lastname 66773**]
before surgical incision..
POST-BYPASS:
Normal RV systolic function.
LVEF 45%.
Intact thoracic aorta.
Moderate MR still present and surgeon notified.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2132-12-25**] 13:42
Brief Hospital Course:
Transferred in from [**Hospital1 **] on [**12-23**] and underwent surgery with
Dr. [**First Name (STitle) **]. Transferred to the CVICU in stable condition on
titrated phenylephrine.Extubated in the early AM on POD #1. IABP
weaned and removed and transferred to the floor to begin
increasing his activity level. Gently diuresed toward his preop
weight. Chest tubes and pacing wires removed per protocol.
Continued to make good progress and was cleared for discharge to
home with VNA on POD #4. All f/u appts were advised.
Medications on Admission:
Lisinopril
Lipitor
ASA 325'
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**] VNA
Discharge Diagnosis:
Hypertension
Hyperlipidemia
Renal Insufficiency
CAD, s/p CABGx5 [**2132-12-23**]
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
trace.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] (for Dr. [**Last Name (STitle) **] at [**Hospital1 **] Heart
Center Thursday [**1-15**] @ 9 AM
PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) 4640**] [**2133-1-30**]@ 1:15PM
Please call for appt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] (Cardiologist at
[**Hospital1 **]) in 3 weeks [**Telephone/Fax (1) 6256**]
**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:[**2132-12-27**] Name: [**Known lastname 11594**],[**Known firstname **] Unit No: [**Numeric Identifier 11595**]
Admission Date: [**2132-12-23**] Discharge Date: [**2132-12-28**]
Date of Birth: [**2075-9-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Beet
Attending:[**First Name3 (LF) 265**]
Addendum:
Patient required one additional day to clear physical therapy.
Discahrged home on [**2132-12-28**] POD # 5 in stable condition.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 11596**] VNA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2132-12-28**]
|
[
"V17.3",
"414.01",
"530.81",
"403.90",
"585.9",
"410.71",
"414.8",
"424.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"36.15",
"39.61",
"38.93",
"97.44"
] |
icd9pcs
|
[
[
[]
]
] |
6399, 6581
|
3287, 3810
|
283, 541
|
4095, 4323
|
1808, 3264
|
5164, 6376
|
1069, 1123
|
3970, 4053
|
3836, 3866
|
4347, 5141
|
1138, 1789
|
233, 244
|
569, 917
|
939, 989
|
1005, 1053
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,411
| 100,718
|
1018
|
Discharge summary
|
report
|
Admission Date: [**2187-8-23**] Discharge Date: [**2187-8-26**]
Date of Birth: [**2141-5-14**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Biaxin / Vancomycin / Haldol / Heparin Agents
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. hemodialysis
2. cauterization of bleeding from tooth extraction site
History of Present Illness:
46 yo AA woman with h/o SLE, ESRD on hemodialysis, htn,
hyperlipidemia, and cardiomyopathy, CHF, and recent
immunosuppression
with tacrolimius/cellcept/IVIG in an attempted preparation for
receiving a kidney transplant from her sister presented
initially
on [**8-23**] with atypical chest pain. She had no ischemic EKG
changes, and her initial set of cardiac enzymes was flat. She
also complained
of epigastric/RUQ pain. Finally, she had subacute complaints of
subjective fever and bronchitis symptoms. In the ED, her
vitals were T = 97.5, (T@ dialysis = 99.2), BP = 191/97, HR =
70, RR = 20 and 100% RA.
.
She had severe hyperkalemia to 8.1, and underwent urgent
hemodialysis.
In hemodialysis, she developed significant bleeding from a site
of recent tooth extraction, and then arterial bleeding from her
AV fistula site when the HD line was disconnected. She was
managed with
DDAVP 15mcg IV x i, 10units of cryoprecipitate; additionally,
ENT
stopped the oral bleeding with Ag local tx, and AV fistula
bleeding
stopped after 55min of continuous pressure. The working
suspicion
is that she was suffering from uremic platelet dysfunction.
.
She was admitted to MICU after she had developed persistent
bleeding from the site of her recent tooth extraction as well
as arterial bleeding from her AV fistula site. The bleeding
from her tooth extraction site stopped after she was seen by ENT
and this was treated with local Ag therapy. The bleeding from
her AV fistula site stopped after continuous pressure for 55min,
and DDAVP.
.
Overnight, several events took place. First, she remained chest
pain
free, but her troponin trended from 0.06 to 0.26 and then back
down
to 0.06 with the only EKG changes of new TWI in V6 and
borderline
Twave flattening in lead I. Her CK and MB remained flat
throughout.
Secondly, she was ruled out for AAA and PE by CTangiogram.
Next,
she had a Tmax of 101.6, and repeat blood cultures were drawn.
She additionally underwent CTangiogram of torso: No evidence of
PE; no aortic aneurysm/dissection; no pathologic LAD;
non-specific
thickening of the pylorus. Also, her labs were significant for
the following:
.
- evidence of hemolysis with hapto < 20, elevated LDH
- no evidence of TTP, no schistocytes on peripheral smear,
and no evidence of DIC (nl coags, fibrinogen elevated)
.
- platelets remained stable in 50's range
- DIC Ab returned positive; heme/onc consulted re:
anticoagulation
strategy in setting of recent significant bleeding
.
- transaminitis trending downward
- elevated amylase/lipase - now trending downward.
.
Past Medical History:
PMHx:
1) End-Stage Renal Disease on hemodialysis Tues, Thurs, Sat; L
dialysis fistula
2) SLE: dx [**2173**], h/o lupus cerebri, membranous
glomerulonephritis, BOOP [**9-/2179**], Raynaud's, DIP arthritis
3) HTN
4) Dyslipidemia
5) Cardiomyopathy & CHF: normal cath in [**2183**]; TTE in [**9-9**] showed
EF 45%, 1+ MR, mild global left ventricular hypokinesis, LVH;
Exercise MIBI in [**9-9**] showed EF 62%
6) History of salmonella bacteremia
7) Gastritis: dx by EGD [**10/2185**]
8) Anemia: ? thallesemia, autoimmune hemolytic anemia
9) TTP/HUS
10) Thrombocytopenia/ITP
11) HSV [**2184-10-5**]
12) Cervical dysplasia LGSIL [**2180**]-[**2181**]
13) Breast DCIS
14) Uterine Prolapse
15) Fibroids s/p TVH
16) Adrenal crisis [**2184**] (was on chronic prednisone- finished in
[**8-9**])
17) Osteoporosis
18) Hypothyroidism
19) Cataracts
20) Seizures
21) S/p hysterectomy for dysfunction uterine bleeding of [**Last Name (un) 6722**]
etiolgoy.
22) Pancreatitis [**2-7**] pancreatic divisum
23) status post cholecstectomy in [**2184-7-5**],
24) adrenal crisis in [**2184-6-5**]
.
.
PSHx:
1) CCY [**2184**]
2) D&C/HSC [**2186**]
3) Breast excision x 3, [**2186**]
4) TVH [**5-/2187**]
.
Social History:
Currently on disability. Denies any alcohol nor tobacco use.
Supportive contacts / friends in area.
Family History:
She reports a family history of lupus and autoimmune diseases.
Physical Exam:
PE
Tm 101.6, Tc 100.1, 130-170/60-80, 78-98, 100% RA
.
gen: a/o, no acute distress; overall appears well, pleasant
heent: no scleral icterus, perrla; no OP lesions/ulcers. Last
molar tooth on left with no evidence of active bleeding
after treatment by ENT
neck: supple, full range of motion
cv: RRR, [**3-11**] holosystolic murmur throughout precordium
(unchanged
since admission)
resp: CTA bilaterally throughout
abd: soft, NABS, minimal epigastric tenderness; no peritoneal
signs
extr: -few scattered dark, pigmented 2x2cm nodular lesions in
bilateral proximal lower extremities
-No evidence of conjunctival/palatal petechiae,
Oslers/[**Last Name (un) 1003**],
or splinter hemorrhages
neuro: no focal deficits appreciated
Pertinent Results:
[**2187-8-23**] 11:00PM PT-12.7 PTT-27.7 INR(PT)-1.1
[**2187-8-23**] 08:54PM GLUCOSE-98 UREA N-23* CREAT-6.2*# SODIUM-142
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-31 ANION GAP-14
[**2187-8-23**] 08:54PM ALT(SGPT)-305* AST(SGOT)-286* LD(LDH)-431*
CK(CPK)-41 ALK PHOS-381* AMYLASE-321* TOT BILI-0.5
[**2187-8-23**] 08:54PM LIPASE-251*
[**2187-8-23**] 08:54PM CK-MB-NotDone cTropnT-0.25*
[**2187-8-23**] 08:54PM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.6
[**2187-8-23**] 08:54PM WBC-2.4* RBC-3.66* HGB-10.7* HCT-33.6* MCV-92
MCH-29.2 MCHC-31.8 RDW-22.6*
[**2187-8-23**] 08:54PM PLT COUNT-51* LPLT-3+
[**2187-8-23**] 11:20AM POTASSIUM-2.2*
[**2187-8-23**] 11:20AM ALT(SGPT)-246* AST(SGOT)-451* LD(LDH)-488*
ALK PHOS-376* AMYLASE-276* TOT BILI-0.8 DIR BILI-0.5* INDIR
BIL-0.3
[**2187-8-23**] 11:20AM LIPASE-712*
[**2187-8-23**] 11:20AM ALBUMIN-3.4
[**2187-8-23**] 11:20AM HAPTOGLOB-<20*
[**2187-8-23**] 11:10AM POTASSIUM-5.0
[**2187-8-23**] 09:17AM K+-8.1*
[**2187-8-23**] 07:58AM GLUCOSE-84
[**2187-8-23**] 07:45AM GLUCOSE-88 UREA N-80* CREAT-12.4*# SODIUM-134
POTASSIUM-7.2* CHLORIDE-95* TOTAL CO2-24 ANION GAP-22*
[**2187-8-23**] 07:45AM CK(CPK)-74
[**2187-8-23**] 07:45AM CK(CPK)-74
[**2187-8-23**] 07:45AM cTropnT-0.06*
[**2187-8-23**] 07:45AM CK-MB-NotDone
[**2187-8-23**] 07:45AM WBC-3.4* RBC-4.21 HGB-12.5 HCT-39.1 MCV-93#
MCH-29.6# MCHC-31.9 RDW-22.4*
[**2187-8-23**] 07:45AM NEUTS-48* BANDS-1 LYMPHS-45* MONOS-5 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2*
[**2187-8-23**] 07:45AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
[**2187-8-23**] 07:45AM PLT SMR-VERY LOW PLT COUNT-50*#
[**2187-8-23**] 07:45AM PT-11.8 PTT-28.8 INR(PT)-0.9
[**2187-8-23**] 07:45AM FIBRINOGE-443*
[**2187-8-23**] 07:45AM RET AUT-3.4*
Brief Hospital Course:
A/P: 46 yo AA woman with h/o SLE, ESRD on hemodialysis, htn,
hyperlipidemia, and cardiomyopathy, CHF, recent immunosuppresion
presented with atypical chest pain, abdominal pain, and
severe hyperkalemia; now stable from MICU after uremic bleeding.
.
1. Chest Pain:
Presentation was atypical for angina, and she ruled out for
acute MI. Over her MICU course, there was concern for aortic
dissection or other etiology for her chest pain, and she
underwent
a CTangiogram of the torso. This showed no evidence of any
aortic dissection, aneurysm, or a pulmonary embolism.
Her chest pain resolved.
.
2. Abdominal Pain/Diarrhea:
This was a non-specific abdominal pain. On
review, it turns out that this is a chronic complaint.
Her abdominal CT did not demonstrate any acute pathology.
She does have chronically elevated amylase/lipase and LFT's
that date back several years. It may be that this is related
to her SLE or potentially autoimmune hepatitis. Her
abdominal pain had resolved by time of discharge. She
will need to f/u with her PCP and nephrologist for further
management.
.
3. Fever:
She defervesced over her hospital course, and
her infectious workup was unrevealing. She had no evidence
of any pulmonary infiltrates, and her blood cultures
remained no growth to date. No empiric abx coverage was
initiated and she remained well throughout.
.
4. Hyperkalemia/ESRD:
On presentation, she had an elevated Creatinine at 12, and
a markedly elevated K at 8.1. She underwent urgent hemodialysis,
with her hyperkalemia and uremia improving. She did have peaked
T waves on admission EKG, but no other worrisome findings.
She did have what was suspected to be uremic bleeding on
day of admission with bleeding from her AV fistula site,
as well as oral mucosal bleeding from the site of her
recent tooth extraction. This resolved with DDAVP, pressure,
and an ENT procedure. She had no further bleeding.
.
5. Heme:
She has chronic pancytopenia, but on admission her platelets
had dropped from a baseline of 100's to 50's. She had no
evidence of DIC. Given her history of TTP, this was considered
as a potential etiology. Heme/Onc and transfusion medicine were
involved. There was no definitive evidence of TTP, as there were
not pathologic levels of schistocytes on her peripheral smear.
Her HIT Ab did come back positive, but this was felt to be a low
titer and of questionable significance. She has potentially
received
heparin in low quantity in her hemodialysis sessions. However,
it
was felt that this Ab positivity may be the result of her recent
IVIG treatment. Given her recently controlled uremic bleeding,
it
was decided that she would be anticoagulated with argatroban
only
if she developed a thrombotic complication. She remained stable
and required no anticoagulation.
.
6. CHF/Cardiomyopathy:
TTE in [**9-9**] showed EF 45%, 1+ MR, mild global left ventricular
hypokinesis, LVH.
Monitored her volume status closely; there was no evidence of
CHF.
.
7. Hypertension:
Continued her home regimen; bp improved after
hemodialysis. Held her ace-i in setting of hyperkalemia.
.
Medications on Admission:
Meds:
ativan .5mg 1-2x/day prn
serax 15mg qhs prn
fosamax 35mg qweek
nifedipine 90mg qd
atenolol 100mg qd
zestril 40mg qd
nephrocap 1 cap qd
folic acid 1 tab qd
***Immunosuppression (tacrolimus, cellcept, IVIG) recently
stopped
.
All: biaxin, sulfa, vancomycin, haldol
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*1*
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
Discharge Disposition:
Home
Discharge Diagnosis:
1. SLE
2. ESRD, hemodialysis dependent
3. Hyperkalemia
4. uremic bleeding, s/p DDAVP treatment
5. chest pain - ruled out for ACS
6. pancytopenia
7. worsening thrombocytopenia, HIT Ab positive
8. hypertension
9. h/o TTP
10. s/p immunosuppression in preparation for kidney transplant
Discharge Condition:
fair
Discharge Instructions:
1. Continue to take your usual medications
2. Call your Nephrologist to schedule a follow up appointment
within the next week
3. Call your doctor or return to the emergency room for any
further
chest pain, shortness of breath, fever, chills, nausea/vomiting,
or
any other concerning symptoms.
4. If you have any bleeding you should call your PCP and return
to the closest ED.
5. You are scheduled for HD next Tuesday [**2187-8-28**] at the Kidney
Center.
Followup Instructions:
Call your Nephrologist, Dr [**Last Name (STitle) 1860**], to schedule a follow up
appointment
within the next week
Please call your PCP and make [**Name Initial (PRE) **] follow up appointment for [**1-7**]
weeks.
Appointment Reminders:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2187-8-28**] 2:20
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-8-29**] 9:00
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:[**2187-9-21**] 2:00
|
[
"424.0",
"428.0",
"272.4",
"286.6",
"413.9",
"733.00",
"E934.2",
"284.8",
"425.4",
"998.11",
"996.73",
"710.0",
"403.91",
"276.7",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11336, 11342
|
7039, 10143
|
331, 405
|
11668, 11675
|
5198, 7016
|
12178, 13020
|
4335, 4399
|
10462, 11313
|
11363, 11647
|
10169, 10439
|
11699, 12155
|
4414, 5179
|
281, 293
|
433, 2995
|
3017, 4200
|
4216, 4319
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
631
| 168,097
|
14065
|
Discharge summary
|
report
|
Admission Date: [**2124-1-10**] Discharge Date: [**2124-1-18**]
Date of Birth: [**2049-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
endotracheal intubation
Upper Endoscopy
Colonoscopy
History of Present Illness:
This 74 year old gentleman has been experiencing abdominal
discomfort, weight loss, and diarrhea since [**Month (only) **] around the
time when he was diagnosed with a myocardial infarction. He was
admitted to [**Hospital3 **] Medical Center for his MI and was
elected for medical management in view of CRI. Pt was seen in
[**Month (only) **] by GI for his complaint of diarrhea, decreased food
intake and weight loss. At that time he denied hematemesis,
melena, hematochezia. He reports having been evaluated by Dr.
[**First Name4 (NamePattern1) 71**] [**Last Name (NamePattern1) 41956**] at [**Hospital3 **] Medical Center, where a CT scan
of the abdomen revealed diverticular disease of the colon, there
was no evidence of inflammatory changes in the wall of the
colon, extensive vascular calcification was seen, the liver was
not enlarged, the patient is status post nephrectomy for kidney
stones and a small cyst was found in the remaining right kidney.
Upper endoscopy was done, mild gastritis was seen as well as a
hiatal hernia, because of the fact that he is on aspirin and
Plavix no biopsies were done at that time. The patient was being
followed by Dr. [**Last Name (STitle) 41956**] but became somewhat frustrated for the
lack of clinical improvement and came to [**Hospital1 18**] for a second
opinion. Pt had barium study around the same time which revealed
a transient lower esophageal spasm, no hiatal hernia was found,
a small bowel x-ray was not done at that time. He is known to
have an elevated creatinine which is 3.1 at baseline. He was
also known to have mild anemia with a hematocrit of 31.6 and a
hemoglobin of 10.9.
.
Mr. [**Known lastname 41957**] presented to the emergency room with essentially
the same complaint of diffuse abdominal pain and diarrhea. He
could not provided a good description of the abdominal pain. He
does state however that it was diffuse without radiation to the
back and was not related to meal. He continues to have diarrhoea
and has lost 30 pounds in the past 3 months. Recently he has
noticed some melaena and BRBPR. In ER stool was brown in colour
but guiac positive. Pt also complains of sour brash without
actual heart burn. He states he was placed on PPI with mild
relief. He was also given empirical treatment of flagyl and
mesalamine with mild relief and has now stopped taking them. In
ER he was noted to have a hct of 27 but was hemodynamically
stable without postural bp drop. He was admitted for further
evaluation of his symptoms.
Past Medical History:
PMH:
1. Recent MI in [**2123-10-13**] managed medically.
2. CRI status post nephrectomy for renal stone. Baseline Cr 3.1
3. Iron def anaemia.
4. HTN.
5. Gastritis.
6. PPM inserted for presumed sick sinus syndrome.
Social History:
He is a smoker, no alcohol intake at this time
Family History:
Positive for coronary artery disease, negative
for inflammatory bowel disease or colon cancer.
Physical Exam:
per Dr. [**First Name (STitle) **] [**Name (STitle) **] on admission
Vital: temp 98.6, hr 80/min, rr 16/min, bp 140/60
General: appears comfortable at rest.
Neck: supple, no jvd, no lymphadenopathy.
CVS: RRR, nl s1+s2, 3/6 SEM RSB radiating to carotids
Chest: CTAB, nl effort.
[**Last Name (un) **], diffuse discomfort, no rebound/guarding/regidity, nl bs.
Extreme: no o/c/c.
Neuro: alert and oriented x 3, nl mood and affect.
Pertinent Results:
Admission CBC:
[**2124-1-12**] 03:18PM BLOOD WBC-8.4 RBC-3.29* Hgb-9.9* Hct-30.3*
MCV-92 MCH-30.0 MCHC-32.6 RDW-14.0 Plt Ct-245
.
CBC Trends:
Hct 30.3 - 26.5 - 23.4 - 27.0
.
Admission Chem panel
[**2124-1-10**] 05:10PM BLOOD Glucose-108* UreaN-30* Creat-3.1* Na-137
K-3.9 Cl-106 HCO3-20* AnGap-15
.
Cardiac enzymes:
[**2124-1-11**] 09:15AM BLOOD CK-MB-2 cTropnT-0.08*
[**2124-1-13**] 11:19PM BLOOD CK-MB-5 cTropnT-0.19*
[**2124-1-14**] 05:09AM BLOOD CK-MB-9 cTropnT-0.46*
[**2124-1-14**] 01:02PM BLOOD CK-MB-7 cTropnT-0.42*
[**2124-1-11**] 09:15AM BLOOD CK(CPK)-25*
[**2124-1-13**] 11:19PM BLOOD CK(CPK)-110
[**2124-1-14**] 05:09AM BLOOD CK(CPK)-155
[**2124-1-14**] 01:02PM BLOOD CK(CPK)-136
.
Imaging:
Echo:[**2124-1-12**]
Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2.There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed with apical and mid
lateral and inferolateral akinesis with basal hypokinesis.
3. Right ventricular chamber size is normal.
4.The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated.
5.There is moderate aortic valve stenosis (area 0.8-1.19cm2)
Moderate(2+)aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7.There is moderate pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
.
RUQ US:
IMPRESSION: No dilated intrahepatic ducts. Normal hepatic
texture
CT [**Last Name (un) 103**]:
limited by lack of iv contrast, no evidence of obstruction or
mass.
.
CXR:
1. Evidence of early pulmonary vascular congestion and
interstitial edema.
2. Probable scarring at the medial aspect of the right lung
base, with no definite consolidation.
.
CHEST (PORTABLE AP) [**2124-1-15**] 5:36 AM
Single frontal radiograph of the chest again demonstrates a
dual- lead cardiac pacer, unchanged. The heart is enlarged,
unchanged. There is no evidence of pneumothorax or pleural
effusion. The pulmonary vasculature appears less indistinct and
there is decreased cephalization since the prior examination
consistent with improving pulmonary edema. There is improving
airspace opacity at the right lung base. Unchanged retrocardiac
airspace disease is seen. There is atherosclerotic calcification
of the aortic arch and the aorta is tortuous.
IMPRESSION:
1. Enlarged cardiac silhouette and improving pulmonary edema.
Improving right base airspace disease and persistent unchanged
left lower lobe airspace disease.
.
Echo [**2124-1-14**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.7 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.7 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aortic Valve - Peak Velocity: *3.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 47 mm Hg
Aortic Valve - Mean Gradient: 25 mm Hg
Aortic Valve - Pressure Half Time: 698 ms
TR Gradient (+ RA = PASP): *50 mm Hg (nl <= 25 mm Hg)
This study was compared to the prior study of [**2124-1-12**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Mild regional LV systolic dysfunction. Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
inferolateral - hypo; mid inferolateral - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Moderate AS (AoVA 0.8-1.19cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Moderate PA systolic hypertension.
.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with inferolateral
hypokinesis. Overall left ventricular systolic function is
mildly depressed. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is probably moderate aortic valve stenosis
(area 0.8-1.19cm2) ; aortic valve area was not fully assessed.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2124-1-12**],
left ventricular systolic function appears similar.
Brief Hospital Course:
74 you M with pmh of MI, CRI, HTN, pacemaker [**1-14**] sick sinus
syndrome initially presented for w/u of 3mo. of abd. complaints.
Hospital course by problem:
.
# GI: The patient was made NPO and was treated with IVF,
antiemetics and pain meds. GI recommended a small bowel capsue
endoscopy and colonoscopy. EGD showed Nodularity and atrophy of
the mucosa with contact bleeding noted throughout the duodenum.
Cold forceps biopsies were performed for histology. Colonoscopy
showed multiple diverticula with medium openings were seen in
the whole colon. Diverticulosis appeared to be of moderate
severity. Ischemic bowel disease as well as a partial SBO
diagnoses were entertained given prior CT scans with mesenteric
calcificaion.
- Per GI recommendations the patient was placed on Protonix 80mg
[**Hospital1 **] and Sucralfate.
- The patient required 2 units of PRBC's during his MICU stay
with stable hematocrit thereafter. The source of the hematocrit
drop was thought secondary to Upper GI bleeding given the EGD
findings.
- An abdominal MRI/MRA was considered but not obtained per GI
given the lack of recurrent symptoms.
- Patient had Guaiac negative stool x2 prior to discharge.
- He did not experience any further abdominal discomfort for
three days prior to discharge.
- He will follow up with Dr. [**Last Name (STitle) 1940**] at [**Hospital 18**] [**Hospital **] clinic for
further evaluation should abdominal pain return.
.
# Respiratory failure/pulm edema:
Shortly after the EGD and colonoscopy, a code blue was called
when the patient was found unresponsive with shallow
respirations. He was intubated for airway protection and
transferred to the MICU-East. CXR showed evidence of pulmonary
edema and he was treated iwth lasix and nebs. He was extubated
the following day, on [**2124-1-14**].
- Transferred to Cardiology-Medicine Service on [**Hospital1 18**] [**Hospital Ward Name **] where he was stable for 72 hours without any oxygen
requirement. He did not require further diuresis.
.
# Cards vascular:
During the episode of pulmonary edema, the patient had an EKG
with ST depressions in V3-V6. He has a known history of an
NSTEMI in [**10-17**] that was medically managed at [**Hospital3 **]
Medical Center related to his severe renal insufficiency. His
cardiac enzymes were cycled and he had a troponin elevation to
0.46 without CK elevation. His EKG changes resolved when his
heart rate normalized. We treated his NSTEMI medically with
aspirin, plavix, lopressor, as well as a nitro gtt. We
transitioned him to hydral and imdur which he tolerated well
post-extubation.
- The cardiology service was formally consulted upon transfer
back to the medical floor with recommendations for medical
management at this time. Consider stress imaging in a period of
6 weeks. This decision was discussed with Mr. [**Known lastname 41958**]
primary cardiologist at [**Hospital3 **] Med Ctr.
.
# Anemia: The patient had iron studies which showed a mixed
picture of both iron deficiency and anemia of chronic
inflammation. Post-MI, we treated with 2u PRBCs to maintain his
HCT at or near 30. Hematocrit was uptrending at time of
discharge to 35.3
.
# ID:
Spiked temp to 101 overnight on [**2124-1-14**]. Blood and urine
cultures sent. No evidence of infection prior to spike, WBC
has been trending downwards. We did not treat with antibiotics.
He was afebrile for the remainder of the admission.
.
# Renal:
Patient is s/p nephrectomy with baseline Cr 2.8-3.1. His renal
function was stable at time of discharge.
.
# HTN:
He was weaned from his nitroglyerin gtt, we increased his
metoprolol (as he is paced) and continued with hydral and imdur.
Hydralazine was stopped on the Cardiology medicine floor.
- discharged with Toprol XL 300mg daily (pt is paced), with good
BP control.
- On outpatient follow-up the patient can be switched to
Carvedilol if he is feeling significant side affects from the
metoprolol. He tolerated the regimen well for a period of 3 days
on the inpatient service.
.
The patient was discharged to his home where he lives with his
daughter.
Medications on Admission:
Plavix 75 qd
Nexium 40 qd
Lipitor 80 qd
Atrovent 1 puff qid
Flovent 1 puff [**Hospital1 **]
Lexapro 20 qd
Imdur 60mg qd
atenolol 100mg qd
mirtazipine 15mg qhs
colace 100mg [**Hospital1 **]
docusate 2 tab [**Hospital1 **]
Lasix 40mg qd
Asa 325mg qd
Buspirone 5mg [**Hospital1 **]
alfuzosin 10mg qhs
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 * Refills:*3*
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulosis
Coronary Artery Disease
NSTEMI
Hypertension
Hiatal hernia
Discharge Condition:
stable
Discharge Instructions:
You were admitted for evaluation of your abdominal pain. You
developed trouble breathing after colonoscopy and suffered a
heart attack. You were evaluated by cardiologists here at [**Hospital1 18**]
who also consulted with your cardiolgist at [**Hospital3 **]. We
maximized your medical therapy for heart disease.
Please take all of your medications as prescribed
.
Call Dr. [**Last Name (STitle) **] or 911 if you experience any chest pain,
Shortness of breath, worsening abdominal pain, uncontrolled
bleeding, fevers, nausea, vomiting or any other concerning
symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in the next two weeks
.
Please follow up with Dr. [**Last Name (STitle) 1940**] (gastroenterology) in the next
week for further evaluation.
|
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icd9cm
|
[
[
[]
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[
"99.04",
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"96.04",
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] |
icd9pcs
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,369
| 125,230
|
37203
|
Discharge summary
|
report
|
Admission Date: [**2188-12-5**] Discharge Date: [**2188-12-10**]
Date of Birth: [**2131-6-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
type A aortic dissection
Major Surgical or Invasive Procedure:
graft repair ascending dissection, aortic valve
resuspension,vein graft to right coronary artery [**2188-12-5**]
History of Present Illness:
57 year old white male presented to [**Hospital1 **] on [**12-4**] with back
and chest pain and shortness of breath. He was found to have a
creatinine of 2.7 and no CT scan was done. He was treated for a
pulmonary embolism. He was stable by report. A transthoracic
echocardiogram the next morning demonstrated a flap in the aorta
and he was transferred here as a Type A dissection.
Past Medical History:
hypertension
hyperlipidemia
Social History:
Nonsmoker, no ETOH
Works as equity trader
lives with his wife
Family History:
Mother died of cancer age 57
Physical Exam:
Admission:
PE: mild distress
BP 120's/60's HR 90's temp 98
CTA B/L
Neuro: grossly intact, moves 4 ext. appropriate. L handed
RRR
Abd: benign
Vasc: palp pulses everywhere B/L (radial, fem, D.P, PT)
TEE: no evidence of tamponade but + pericardial effusion
WBC 20K, Ht 40.3. K 5.3, Cr 2.7. INR 1 PTT 52, trop 0.02
Pertinent Results:
[**2188-12-10**] 11:00AM BLOOD WBC-14.8* RBC-3.02* Hgb-9.1* Hct-28.0*
MCV-93 MCH-30.0 MCHC-32.3 RDW-15.9* Plt Ct-310
[**2188-12-5**] 05:42AM BLOOD WBC-20.2* RBC-4.40* Hgb-13.9* Hct-40.3
MCV-92 MCH-31.6 MCHC-34.5 RDW-13.2 Plt Ct-275
[**2188-12-10**] 11:00AM BLOOD Plt Ct-310
[**2188-12-10**] 11:00AM BLOOD PT-17.9* INR(PT)-1.6*
[**2188-12-5**] 05:42AM BLOOD PT-11.8 PTT-52.5* INR(PT)-1.0
[**2188-12-5**] 05:42AM BLOOD Plt Ct-275
[**2188-12-10**] 11:00AM BLOOD Glucose-130* UreaN-22* Creat-1.2 Na-138
K-3.9 Cl-99 HCO3-33* AnGap-10
[**2188-12-5**] 05:42AM BLOOD Glucose-153* UreaN-32* Creat-2.7* Na-142
K-5.3* Cl-102 HCO3-25 AnGap-20
[**2188-12-10**] 11:00AM BLOOD Mg-2.1
[**Last Name (LF) **],[**First Name3 (LF) **] [**Doctor First Name 147**] FA6A [**2188-12-9**] 2:53 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 83768**]
Reason: f/u RT pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with Type A repair
REASON FOR THIS EXAMINATION:
f/u RT pneumothorax
Provisional Findings Impression: SP TUE [**2188-12-9**] 5:05 PM
Right-sided apical pneumothorax absorbed. No new pulmonary
abnormalities.
Observed that mediastinal prominence still remains.
Final Report
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: Followup of small right-sided pneumothorax. Status
post type-A
aortic dissection repair.
FINDINGS: PA and lateral chest view were obtained with patient
in upright
position. Available for comparison is the next previous AP
single chest view
of [**2188-12-8**]. Previously described right internal
jugular approach
central venous line remains in unchanged position. The previous
small right-
sided apical pneumothorax cannot be identified any more. Status
post
sternotomy is unchanged. Also still present is the mediastinal
widening with
aortic ascending contour still prominent as it was prior to the
operation. It
is, however, slightly less marked in comparison with the
pre-operative chest
findings of [**2188-12-5**]. The lateral view discloses a mild
degree of
displacement of the subepicardial fat line, consistent with some
remaining
pericardial effusion. This finding existed already on the first
pre-operative
study. The mild degree of posterior pleural sinus blunting is
postoperative
as it was not present on the initial study. No new pulmonary
infiltrates or
atelectasis are seen.
IMPRESSION: Status post sternotomy and aortic dissection repair.
Remaining
upper mediastinal prominence compatible with non-evacuated
extra-aortic
hematoma. Compare with events described in O.R. report.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: TUE [**2188-12-9**] 5:27 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83769**]
(Complete) Done [**2188-12-5**] at 1:29:50 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
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: [**2131-6-14**]
Age (years): 57 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic dissection. Aortic valve disease. Left
ventricular function. Mitral valve disease. Pericardial
effusion. Right ventricular function. Valvular heart disease.
ICD-9 Codes: 786.51, 440.0, 441.00, 423.3
Test Information
Date/Time: [**2188-12-5**] at 13:29 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: *4.1 cm <= 3.4 cm
Findings
Emergency TEE for rule out dissection. Large sized pericardial
effusion with echocardiographic signs of tamponade.
Echocardiographic guidance provided for placement of femorally
placed arteraila nd venous access cannulae
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size.
RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta. Simple atheroma in ascending aorta.
Ascending aortic intimal flap/dissection.. Aortic arch intimal
flap/dissection. Descending aorta intimal flap/aortic
dissection.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Moderate to large pericardial effusion. Effusion
circumferential. RV diastolic collapse, c/w impaired
fillling/tamponade physiology.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses and cavity
size are normal. The right ventricular cavity is mildly dilated
with borderline normal free wall function. The ascending aorta
is moderately dilated. There are simple atheroma in the
ascending aorta. A mobile density is seen in the ascending aorta
consistent with an intimal flap/aortic dissection. A mobile
density is seen in the aortic arch consistent with an intimal
flap/aortic dissection. A mobile density is seen in the
descending aorta consistent with an intimal flap/aortic
dissection. There are three aortic valve leaflets. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is a moderate to
large sized pericardial effusion. The effusion appears
circumferential. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology.
POST CPB:
1. Preserved LV systolci function
2. Imorioved global RV systolci function.
3. A tube graft in ascending aortic position identified.
4. Trace A!.
5. No other change in valvular structure and function
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2188-12-5**] 15:19
Brief Hospital Course:
In the ED a transesophageal echo revealed a Type A dissection
with pericardial effusion and cardiac compression. He was taken
emergently to the Operating Room for surgical repair. See
operative report for further details. He was transferred to the
intensive care unit for hemodynamic monitoring. He required
pressors but they were weaned off. He awoke intact and was
extubated the following morning, having been kept intubated
overnight due to some difficulty intubating him. His urine
output was adequate and his renal numbers improved. Beta
blockade was begun and ACE inhibitor resumed to control his
hypertension. He developed rapid atrial fibrillation and
Amiodarone was given with conversion to sinus rhythm. He
continued to have intermittent episodes of atrial fibrillation
and coumadin was started for anticoagulation. Physical therapy
worked with him on strength and mobility. Ultrasound of right
arm due to edema revealed non occlusive venous clot, continues
on coumadin. He was ready for discharge home on [**2188-12-10**].
Medications on Admission:
lisinopril 20mg [**Hospital1 **]
lipitor 10 mg daily
ASA 81 mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): take 1 tablet twice a day then decrease to 1 tablet
daily on [**12-17**] and follow up with cardiologist .
Disp:*67 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for severe pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing indication Atrial fibrillation goal
INR 2.0-2.5 results to Dr [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 8052**] fax
[**Telephone/Fax (1) 8053**] attn [**Female First Name (un) 55288**] - First draw [**12-12**]
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Warfarin 2 mg Tablet Sig: goal INR 2.0-2.5 Tablets PO once a
day: take 2mg on [**12-11**] then [**Month/Year (2) **] draw [**12-12**] for further dosing -
dose to adjust based on INR results .
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Type A aortic dissection
Acute renal failure on admission
Hypertension
hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming
Monitor wounds for infection and report any redness, warmth,
swelling, tenderness or drainage
Please take temperature each evening and Report any fever 100.5
or greater
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Monitor Right arm please call for increase edema or pain, please
elevate at or above heart level
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 8051**] in [**1-18**] weeks please call to schedule
Wound Check [**12-18**] at 2pm [**Hospital Ward Name **] 6 [**Telephone/Fax (1) 3071**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2189-1-5**] 1:00
Labs: PT/INR for coumadin dosing indication Atrial fibrillation
goal INR 2.0-2.5 results to Dr [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 8052**] fax
[**Telephone/Fax (1) 8053**] attn [**Female First Name (un) 55288**] - First draw [**12-12**]
CT scan chest in three months - please arrange at follow up
visit with Dr [**First Name (STitle) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2188-12-10**]
|
[
"441.01",
"584.9",
"272.4",
"746.85",
"423.3",
"427.31",
"453.83",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.11",
"38.45",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
11805, 11864
|
9128, 10170
|
346, 461
|
11994, 12001
|
1402, 2268
|
12727, 13490
|
1021, 1051
|
10289, 11782
|
2308, 2343
|
11885, 11973
|
10196, 10266
|
12025, 12704
|
7495, 8722
|
1066, 1383
|
282, 308
|
2375, 7446
|
489, 875
|
897, 926
|
942, 1005
|
8732, 9105
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,150
| 189,980
|
27802
|
Discharge summary
|
report
|
Admission Date: [**2137-8-13**] Discharge Date: [**2137-8-20**]
Date of Birth: [**2066-8-20**] Sex: F
Service: GU
DIAGNOSIS: Angiomyolipoma.
CHIEF COMPLAINT: Right lower quadrant abdominal pain.
HISTORY OF PRESENT ILLNESS: She is a 70-year-old woman with
pain in the right lower quadrant that has subsequently gotten
worse over the day. She was taken to [**Hospital 1474**] Hospital where
a CT scan showed a right renal mass. Then, at that point, it
was discovered that ten years ago she was diagnosed with
angiomyolipoma, however, she had been asymptomatic until this
day, [**2137-8-13**]. She was subsequently brought to [**Hospital1 **] for further care. She has no history of any
renal procedures or surgeries.
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS: Metformin b.i.d., verapamil 80
t.i.d., sulfazine b.i.d., 81 mg aspirin daily, and ibuprofen
600 mg b.i.d. to t.i.d.
PAST MEDICAL HISTORY: Diabetes mellitus type 2,
hypertension, rheumatoid arthritis.
PAST SURGICAL HISTORY: Hernia repair and appendectomy when
she was approximately 3 years old.
SOCIAL HISTORY: No history of smoking or heavy drinking.
FAMILY HISTORY: Her mother died of ovarian cancer.
INPATIENT MEDICATIONS: Acetaminophen 325 to 650 p.o. q.4-6
hours p.r.n., captopril 25 mg t.i.d., famotidine 20 p.o.
b.i.d., furosemide 40 mg p.o. b.i.d., insulin sliding scale,
morphine 2-4 mg q.2 hours p.r.n. pain, oxycodone 5 mg p.o.
q.4 hours.
HOSPITAL COURSE: The patient was admitted on [**8-13**], and
she was taken to the surgical ICU where she was transfused 3
units. Her angiomyolipoma was embolized on [**8-15**].
Subsequently the next morning, she began to experience
desaturations and complained of chest pain. A CTA and chest x-
ray showed signs of CHF. EKG showed normal sinus rhythm and
she was given 20 of hydralazine as well as Lasix. She
subsequently stabilized and was transferred to the floor on
[**8-16**]. While she was on the floor, her blood pressure
continued to remain elevated. A medicine consult was obtained
and she was also maintained on hydralazine 20 and 40 p.o. of
Lasix per medicine's recommendations. Her hydralazine was
used only in cases of elevated blood pressure when the Lasix
and her verapamil did not decrease her systolic blood
pressure to less than 150. Throughout her hospital stay, her
verapamil was discontinued and she was begun on 12.5 mg of
captopril p.o. t.i.d. She was ruled out for a myocardial
infarction by having negative cardiac enzymes and negative CK
MB and negative troponin x3. A repeat EKG was also normal. An
echocardiogram was obtained on her third postoperative day,
sixth hospital day, and that was negative. A stress test was
also obtained 2 days later and that was also negative for any
heart disease. Her postoperative course remained
uncomplicated. Her blood cultures, urine cultures showed no
growth through her day of discharge and she had mild fevers
which was expected secondary to her embolization procedure.
She was discharged on hospital day eight, postprocedure day
5, in good condition. She was sent home with her captopril,
her oxycodone 5 mg and her Cipro b.i.d. for 7 days. She was
also instructed to visit her family physician prior to coming
to the hospital for procedure for radical right nephrectomy
so that her primary care physician was aware of her new blood
pressure medication and changes. She was consented for a
right radical nephrectomy which is to take place on Monday,
[**8-26**], and she was instructed to call if she had any
further questions or concerns.
[**Name6 (MD) **] [**Last Name (NamePattern4) 8918**], [**MD Number(1) 19072**]
Dictated By:[**Name8 (MD) 560**]
MEDQUIST36
D: [**2137-8-25**] 18:50:15
T: [**2137-8-26**] 11:53:12
Job#: [**Job Number 67781**]
|
[
"714.0",
"568.81",
"401.9",
"786.59",
"223.0",
"785.0",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.45",
"88.42",
"99.04",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
1180, 1465
|
1483, 3813
|
1032, 1104
|
805, 922
|
182, 220
|
249, 780
|
945, 1008
|
1121, 1163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,727
| 114,887
|
51925
|
Discharge summary
|
report
|
Admission Date: [**2155-8-16**] Discharge Date: [**2155-8-20**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Hyperkalemia, AFIB RVR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57yo M with a h/o systolic (EF 20-25) and grade 4 diastolic
heart failure, ESRD [**2-15**] DM on HD, atrial fibrillation with RVR,
severe depression, crack cocaine use presents with hyperkalemia
to 7.4 and atrial fibrillation with RVR to 150s in setting of
missing dialysis for the past week, of note patient with long
history of missing dialysis sessions. Patient recently
discharged on [**8-10**] with c.diff colitis, claims did crack cocaine
2 days ago and has had persistent diarrhea. He has missed
dialysis for the past week, he states he was told not to go to
HD since he was having active diarrhea.
In the ED, was treated for hyperkalemia with 2 grams calcium
gluconate, dextrose, IV regular insulin, 30g kayexalate, bicarb.
Renal was consulted and will plan on HD tomorrow a.m. Cards was
consulted for afib RVR and rec IV labetalol which converted him
back into SR in the 110s.
.
ROS: patient with depressed mental status
Past Medical History:
ESRD on hemodialysis (Tues/Thurs/Sat, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis,
[**Location 1268**], [**Telephone/Fax (1) 69669**])
Type II diabetes mellitus
CAD s/p MI (pt does not recall), MIBI in [**11-19**] showed reversible
defects inferior/lateral
CHF with EF 20-25% (from echo in [**6-/2155**]) and severe global
hypokinesis
Hypertension
Dyslipidemia
Atrial fibrillation
History of gastrointestinal bleed: Duodenal, jejunal, and
gastric AVMs, s/p thermal therapy; sigmoid diverticuli.
Chronic pancreatitis
Hepatitis C
GERD
Gout s/p arthroscopy with medial meniscectomy [**5-/2149**]
Depression s/p multiple hospitalizations due to SI
Polysubstance abuse: crack cocaine, EtOH, tobacco
Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**]
Social History:
Smokes 3 cigarettes/day. 42 pack year history. Hx of alcohol
abuse, with DTs and detoxification. Last crack cocaine use was
day prior to admission. Lives with a female partner.
Family History:
Father with alcoholism. Cousin with [**Name2 (NI) 14165**] cell. Mother with
renal failure, d. 58. Son with diabetes.
Physical Exam:
VS- 95.7 115 (Afib) 135/88 24 95%4L NC
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
ADMISSION LABS
.
[**2155-8-16**] 09:00PM PT-17.8* PTT-33.6 INR(PT)-1.6*
[**2155-8-16**] 09:00PM PLT COUNT-335
[**2155-8-16**] 09:00PM WBC-5.1 RBC-5.38 HGB-16.1# HCT-49.7 MCV-92
MCH-29.8 MCHC-32.3 RDW-16.6*
[**2155-8-16**] 09:00PM NEUTS-74.0* LYMPHS-17.5* MONOS-6.0 EOS-0.4
BASOS-2.1*
[**2155-8-16**] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-8-16**] 09:00PM CALCIUM-11.1* PHOSPHATE-6.9*# MAGNESIUM-2.9*
[**2155-8-16**] 09:00PM CK-MB-12* MB INDX-11.8*
[**2155-8-16**] 09:00PM cTropnT-0.34*
[**2155-8-16**] 09:00PM LIPASE-39
[**2155-8-16**] 09:00PM ALT(SGPT)-45* AST(SGOT)-69* CK(CPK)-102 ALK
PHOS-153* TOT BILI-1.8*
[**2155-8-16**] 09:00PM GLUCOSE-117* UREA N-85* CREAT-10.4*#
SODIUM-137 POTASSIUM-7.4* CHLORIDE-99 TOTAL CO2-19* ANION
GAP-26*
[**2155-8-16**] 09:02PM freeCa-1.13
[**2155-8-16**] 09:02PM HGB-17.5 calcHCT-53 O2 SAT-85 CARBOXYHB-3.8
MET HGB-0.0
.
CXR [**2155-8-16**]
IMPRESSION: Increased moderate-to-large right pleural effusion
and slightly decreased small left effusion. Slightly worsened
pulmonary edema.
.
At time of transfer frm ICU to medical floor on [**2155-8-19**] the
patient's K+ was 4, Na 139, Cl 98, Bicarb 26, BUN 37 and Cr 7
and Glu 172 and CBC showed wbc 4.7, Hgb 14.2, Hct 44.3, Plts 246
and 2 sets Blood Cultures drawn [**8-16**] are still pending.
.
Discharge Labs:
[**2155-8-20**] 06:15AM BLOOD WBC-4.1 RBC-4.24* Hgb-13.1* Hct-39.6*
MCV-94 MCH-30.9 MCHC-33.0 RDW-15.9* Plt Ct-217
[**2155-8-20**] 06:15AM BLOOD Glucose-127* UreaN-42* Creat-8.0* Na-138
K-4.3 Cl-102 HCO3-25 AnGap-15
[**2155-8-18**] 07:20AM BLOOD ALT-64* AST-76* CK(CPK)-69 AlkPhos-111
TotBili-1.0
Brief Hospital Course:
58yo M with a hx of systolic (EF 20-25%) and grade 4 diastolic
heart failure, ESRD [**2-15**] DM on HD, atrial fibrillation with RVR,
severe depression, and recent crack cocaine use presents with
hyperkalemia to 7.4 and atrial fibrillation with RVR to 150s in
the setting of missing dialysis for the past week. Of note,
patient has had a long history of missing dialysis sessions.
.
Upon presentation to ED, patient was treated for hyperkalemia
with 2 grams calcium gluconate, dextrose, IV regular insulin,
30g kayexalate, and bicarb. Renal was consulted and urgent HD
was [**Month/Day (2) 1988**] for [**8-18**] in the early a.m. hours and approximately
1 Liter of fluid was removed. Cardiology was also consulted for
afib with RVR and recommended IV labetalol, which converted him
back into SR in the 110s. During his stay in the unit, pt
remained rate controlled in the 90s-110s and was NSr at time of
transfer to the general medical floor. Patient was resumed on
his home dose of Labetalol.
.
Lisinopril was initially held due to hyperkalemia setting but
plan was to resume his oupatient dose once discharged. Potassium
this morning, [**8-19**], was K 4.0 and team felt comfortable
switching patient back to his Ace-inhibitor. Additional ESRD
medications, cinacalcet and sevelamer were also continued for
electrolyte/Phos level control.
.
During admission, the patient also complained of intermittent
non-radiating chest pressure. SL Nitro was given with no effect.
Pain episodes would eventually resolve without intervention.
Repeat EKGs showed no change from admission, and no new
ischemia/infarction. The pain was reproducible on physical exam
at the lower edge of xiphoid and epigastric region and responded
to Maalox and it was felt that these complaints were large GI
related vs. cardiac. He continued to have chest pain while on
the floor, and again it was relieved with tylenol and maalox,
thought to be more GI related at that time.
.
Patient was discharged from recent hospital stay on [**8-10**] with C.
Diff colitis and still has about a week left of his Flagyl
therapy. Patient continues to c/o daily diarrhea at this time
but the frequency has decreased. Flagyl was continued during
this admission. He had three days left of treatment at the time
of discharge.
.
The patient has a history of DM-2 and was initially placed on
Humalog sliding scale after acute presentation. Now that patient
has stabilized he can return to his usual NPH daily schedule of
15 Units a.m. and 10 Units p.m.
.
For his history of depression he was continued on daily Zoloft
home dose.
.
On the floor, he was seen by a social work to address his
absence from dialysis the week before admission. He obviously
has insight into the medical problems it causes, but continues
to do crack cocaine and miss his sessions. He has an
appointment at the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to follow up his substance
abuse and was discharged with goals of staying sober and
attending all his dialysis sessions. He will continue his Tues,
Thurs, Sat schedule as an outpatient.
Medications on Admission:
Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
Pantoprazole 40 mg Tablet, Delayed Release (E.C.)
Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
Senna 8.6 mg Tablet
Diphenhydramine HCl 25 mg Capsule q6h prn
Camphor-Menthol 0.5-0.5 % Lotion
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-15**] Sublingual
Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO
Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID
Insulin Lispro 100 unit/mL Solution sliding scale
Metronidazole 500 mg Tablet Sig: TID x 14 days started [**8-10**]
Insulin NPH Human Recomb 15 qam and 10 qpm
Discharge Medications:
1. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Month/Year (2) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
[**Month/Year (2) **]:*9 Tablet(s)* Refills:*0*
10. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous QAM.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous every morning.
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for chest/abdominal
discomfort.
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
17. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
18. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Ten
(10) units Subcutaneous every night.
[**Month/Year (2) **]:*1 pen* Refills:*2*
19. Insulin Lispro 100 unit/mL Insulin Pen Sig: One (1) unit
Subcutaneous as directed by sliding scale.
[**Month/Year (2) **]:*1 pen* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. End Stage Renal Disease on hemodialysis
2. Type II diabetes mellitus
3. Congestive Heart Failure
.
Secondary:
3. CAD s/p MI
4. CHF with EF of 20-25%
5. Hypertension
6. Atrial fibrillation
7. Polysubstance abuse: crack cocaine
Discharge Condition:
vital signs stable, afebrile, breathing room air comfortably,
ambulating without difficulties, normal mentation.
Discharge Instructions:
You were admitted for high potassium levels in the setting of
missed dialysis visits. You were dialyzed here in the hospital
and we continued treatment for your c difficile colitis.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
Please return to the hospital for worsening chest pain,
shortness of breath, abdominal pain, fainting, nausea, vomitting
or any other concerns. Call 911 if it is an emergency.
Followup Instructions:
Please follow up in hemodialysis, it is very important that you
continue to make these appointments. Your schedule is Tues,
Thursday, Saturday at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis. Their phone number
is [**Telephone/Fax (1) 69669**].
.
Please see your PCP:
[**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2155-8-27**]
10:10
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2155-8-22**]
|
[
"276.7",
"427.31",
"V15.81",
"008.45",
"304.20",
"530.81",
"577.1",
"428.40",
"250.40",
"584.9",
"428.0",
"585.6",
"403.91",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10986, 10992
|
4872, 8003
|
291, 298
|
11274, 11389
|
3177, 4534
|
11901, 12472
|
2291, 2411
|
8986, 10963
|
11013, 11253
|
8029, 8963
|
11413, 11878
|
4551, 4849
|
2426, 3158
|
229, 253
|
326, 1259
|
1281, 2080
|
2096, 2275
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,323
| 156,685
|
47472
|
Discharge summary
|
report
|
Admission Date: [**2173-5-12**] Discharge Date: [**2173-5-14**]
Date of Birth: [**2109-6-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
1. Cardiac catheterization and ethanol septal ablation of the
septum with temporary pacemaker wires placed.
2. ECHO
History of Present Illness:
Pt initially presented with an episode of syncope
approximatley two years earlier. At the time, he had just
finished eating dinner when he suddently became diaphoretic and
nauseous. He rushed to the bath room where he had an episode of
emesis as well as defecation. He subsequently lost
consciousness and his next memory was being surrounded by EMS.
At the time, he was found to have Hypertrophic cardiomyopathy
and during evaluation for CAD was also found to have CAD with
3VD. He underwent a CABG and a myomectomy in [**March 2173**] and since
reports he had been doing well. The one week since surgery he
was able to ambulate up and down stair without difficulty, but
the week prior to admission, he was significantly short of
breath walking up one flight of stairs. He also reports
frequent dizzy spells and dyspnea when he exerts himself. His
wife also reports he has been appearing slightly "grayish". He
denies any further syncopal episodes, although states that he
has had one episode of presyncope. He denies ever having had
chest pain or palpitations. He denies fever, chills, rigors,
HA, runny nose, cough, sputum, BRBPR, weight gain, weight loss.
Past Medical History:
1. Hypertrophic cardiomyopathy dx in '[**71**] presented with syncope
2. CAD s/p 4V CABG and myomectomy on [**2173-3-23**].
3. Hypertension
4. Hyperlipidemia
5. benign prostatic hypertrophy
6. Sleep apnea
7. History of cholecystectomy.
Social History:
Married, works as a sales manager for modular/mobile homes.
Tob: Remote history of tobacco - smoked <1ppd/day x 5 years but
quit 30+ years ago.
EtOH: Pt admits to occasional alcohol use - 1 beer every couple
of months.
Illicit drug: denies ever using illicit drug - specifically
denies cocaine, heroine.
Family History:
Brother: MI in his early 40's
Brother: prolonged course of lupus
Father and Mother: both with colon CA
Physical Exam:
VS: BP: 158/89 HR: 64 RR: 14 SaO2:99% on RA
Gen: well nutritioned caucasian male lying in bed in NAD. Pt
conversing fluently in full sentences.
HEENT: PERRLA, EOMI, anicteric, mmm, op clear
Neck: JVP 5cm, no cervcal, submandibular LAD
CV: RRR, S1, S2, 2/6 systolic ejection murmur
Chest: well healed vertical midline sternotomy scar, CTA
anteriorly
Abd: soft, NT, ND, BS+
Ext: wwp, no c/c/e, PT +1 bilaterally
Neuro: A+O x3, CN II-XII grossly intact
Pertinent Results:
[**2173-2-24**] Stress echo:
[**Doctor First Name **] protocol: 5'[**94**]" with 2mm ST segment depression in the
inferior and lateral leads. Negative for chest pain or
ventricular arrythmias.
Echo: negative for ischemia. Baseline Outflow gradient 68mmHg,
with a velocity of 4.1m/sec. Immediately post exercise it was
92mmHg with a velocity of 4.8m/sec. Post valsalva (Post
exercise), it was 4.7m/sec with a gradient of 88mmHg. The septum
was slightly thicker than the posterior wall.
.
[**2173-3-10**] Echo: moderately dilated left atrium, EF 65%, severe LVH,
1+MR, trivial pericardial effusion.
.
[**2173-3-10**] Cath: 3VD with 70% proximal LAD, 80% stenosis in D1, 70%
stenosis in D2, 80% LCX proximal stenosis with a large
aneurysmal dilatation of the mid vessel (which may have included
a walled off rupture). RCA TO of proximal vessel. No left
ventricular outflow tract noted at rest but a gradient of
40-50mmHg was noted post PVC. With Valsalva, a small increase
in the gradient of 10mmHg was noted. EF 58%. Trivial to 1+MR
noted.
.
[**2173-3-23**] CABG: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2230**] LIMA to LAD, SVG to OM1, SVG
to OM2, SVG to RCA. Septal myomectomy
.
[**2173-5-12**] TTE:
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated. Severe symmetric LVH. LV cavity size is
normal. There is a mild resting LV outflow tract obstruction.
The gradient increased with the Valsalva manuever. Overal LV
systolic function appears preserved. The basal to mid septum is
hypokinetic. RV chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no systolic anterior motion of the mitral
valve leaflets. Mild (1+) mitral regurgitation is seen. Mitral
inflow pattern was not assessed. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (tape reviewed) of [**2173-3-10**], the
basal to mid septum is now hypokinetic.
.
.
Cardiac Catheterization [**2173-5-12**]:
"Right Heart Catheterization: was performed by percutaneous
entry of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through a 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French angled pigtail catheter,
advanced
to the left ventricle through a 7 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 catheter, with manual contrast
injections.
Graft Angiography: of 3 saphenous vein bypass grafts was
performed using
a 7 French right [**Last Name (un) 2699**] and a Multipurpose catheter, with
manual
contrast injections.
Arterial Conduit Angiography: of a left internal mammary artery
graft
was performed using a preformed [**Female First Name (un) 899**] catheter, with manual
contrast
injections.
Temporary pacing: was secured by placement of a 4 French bipolar
Electrode catheter in the right ventricle.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.04 m2
HEMOGLOBIN: 13.1 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 13/11/10
RIGHT VENTRICLE {s/ed} 35/13
PULMONARY ARTERY {s/d/m} 35/16/24
PULMONARY WEDGE {a/v/m} 13/14/11
LEFT VENTRICLE {s/ed} 168/13 210/22
AORTA {s/d/m} 148/84/110 160/83/100
**CARDIAC OUTPUT
HEART RATE {beats/min} 60 80
RHYTHM SINUS SINUS
O2 CONS. IND {ml/min/m2} 125 125
A-V O2 DIFFERENCE {ml/ltr} 48 42
CARD. OP/IND FICK {l/mn/m2} 5.3/2.6 6/2.9
**% SATURATION DATA (NL)
SVC LOW 60
PA MAIN 60
AO 94
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 100
3) DISTAL RCA DIFFUSELY DISEASED
4) R-PDA DIFFUSELY DISEASED
4A) R-POST-LAT DIFFUSELY DISEASED
4B) R-LV DIFFUSELY DISEASED
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 50
6) PROXIMAL LAD DIFFUSELY DISEASED
6A) SEPTAL-1 NORMAL
7) MID-LAD DIFFUSELY DISEASED 70
8) DISTAL LAD DIFFUSELY DISEASED
9) DIAGONAL-1 DIFFUSELY DISEASED 80
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX DISCRETE 80
13) MID CX DIFFUSELY DISEASED
13A) DISTAL CX DIFFUSELY DISEASED
14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED
15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED
17) LEFT PDA DIFFUSELY DISEASED
17A) POSTERIOR LV NORMAL
**PTCA RESULTS
PTCA COMMENTS: Detailed rest and dobutamine hemodynamics
revealed a
mid cavitary gradient of 20mm Hg at baseline and 70mm Hg with
20mcg/kg/min of dobutamine and 100mm Hg with Valsava maneuver. A
pacer
was placed in the RV prophylactically and 2,000 U of Heparin
were given
intravenously. A 6 French XBLAD 3.5 guide provided good support.
A
Choice PT XS guide crossed in the distal part of the second
septal and
position was confirmed with dye injection and with echo
(optison).
Ethanol injections were performed with the 1.5mm balloon
occluded under
echo guidance. We then repeated the same sequence on first
septal with
resolution of the gradient to less than 10mm Hg on dobutamine.
At the
end of the procedure the arteriotomy site was successfully
closed with a
6 French Angioseal device. The patient developed transient chest
pain
during the procedure and an episode of nausea and vomiting that
resolved
with antiemetic medications. The patient was transferred to the
CCU
(with the pacer in placer) pain free and in stable condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 2 hours 29 minutes.
Arterial time = 2 hours 23 minutes.
Fluoro time = 32.6 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 125 ml
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin [**2168**] units IV
Other medication:
Fentanyl 25mcg IV bolus
Midazolam 0.5mg IV bolus
Diltiazem 5mg IV bolus
Dolasetron 12.5mg IV bolus
Cefazolin 1gm IV bolus
Cardiac Cath Supplies Used:
.014 [**Company **], CHOICE PT XS, 300CM
.014 [**Company **], CHOICE PT XS, 300CM
1.5 [**Company **], MAVERICK, 9
6F CORDIS, XBLAD 3.5
5F BARD, PACING WIRE
6F [**First Name8 (NamePattern2) **] [**Male First Name (un) **], ANGIOSEAL STS, 6F
200CC MALLINCRODT, OPTIRAY 200CC
COMMENTS:
1. Selective coronary angiography revealed a co-dominant system
with
three vessel coronary artery disease and patent SVGs and LIMA.
The LMCA
had a 50% distal stenosis. The LAD was small and diffusely
diseased with
70% proximal stenosis. A large D1 branch had a discrete 80%
stenosis.
The LCx had an 80% proximal stenosis. The rest of the LCx was
diffusely
diseased. The RCA had total occlusion proximally.
The LIMA to LAD was patent. The SVGs to upper and lower poles
of OM1
and to RCA were patent with valves and somewhat sluggish flow.
2. Hemodynamics with a 5 French pigtail catheter placed at the
apex of
the LV revealed a mid cavitary gradient of approximately 20mm
Hg. Post
VPC gradient was up to 60mm Hg. With infusion of dobutamine at
20mcg/kg/min, a gradient of 70mm Hg was induced and increased to
almost
100mm Hg with Valsalva. The cardiac index increased
appropriately in
response to dobutamine. There was no gradient across the aortic
valve on
pull back of the catheter.
3. Left ventriculography was not performed.
4. Successful ethanol ablation of the septum (See PTCA
comments).
5. Successful closure of the arteriotomy site with a 6 French
Angioseal
device.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. LIMA and 3 vein grafts all patent.
3. Mid-cavitary gradient of 20mm Hg at rest increasing to 70mm
Hg with
dobutamine and 100mm Hg with dobutamine and Valsalva.
4. Preserved cardiac index and slightly elevated LVEDP.
5. Successful ethanol ablation of the septum."
.
.
[**2173-5-12**] TTE:
"MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.4 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: *2.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.8 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Left Ventricle - Peak Resting LVOT gradient: *16 mm Hg (nl <= 10
mm Hg)
Left Ventricle - Peak Inducible LVOT gradient: 25 mm Hg
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
TR Gradient (+ RA = PASP): 24 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2173-3-10**].
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Mild resting LVOT gradient. LVOT gradient increases with
Valsalva.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No
systolic anterior motion of mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views.
Conclusions:
The left atrium is moderately dilated. There is severe symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is a mild resting left ventricular outflow tract
obstruction. The gradient increased with the Valsalva manuever.
Overal left ventricular systolic
function appears preserved. The basal to mid septum is
hypokinetic. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no systolic anterior motion of the mitral
valve leaflets. Mild (1+) mitral regurgitation is seen. Mitral
inflow pattern was not assessed. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (tape reviewed) of [**2173-3-10**], the
basal to mid septum is now hypokinetic."
.
.
TTE [**2173-5-12**]:
"Conclusions:
Left ventricular cavity and outflow tract gradient were assessed
while
dobutamine 25 mcg/kg/min was infused with a peak gradient of 60
mmHg. After infusion of Optison into the 2nd septal branch of
the left anterior descending coronary artery, increased
echogenicity was noted in the mid interventricular septum."
.
.
TTE [**2173-5-12**]:
"Conclusions:
Following serial infusion of ethanol doses into the second
septal branch of the left anterior descending coronary artery,
there was a growing region of increased echogenicity of the mid
interventricular septum. The left ventricular cavity/outflow
tract gradient fell to 36 mmHg, then to 16 mmHg. Dobutamine 25
mcg/kg/min was infused throughout all gradient measurements.
Mild mitral regurgitation was detected."
.
.
TTE [**2173-5-13**]:
"Conclusions:
There is moderate symmetric left ventricular hypertrophy.
Overall left
ventricular systolic function is mildly depressed.. There is
borderline left ventricular outflow obstruction (peak 16 mmHg)
at rest and with Valsalva. Resting regional wall motion
abnormalities include hypokinesis of the basal to mid anterior
septum. There is a region of increased echogenicity in the mid
anteroseptum. There is no aortic valve stenosis. There is mild
mitral regurgitation. There is no pericardial effusion."
.
.
[**2173-5-12**] 07:37PM CK-MB-100* MB INDX-19.6*
[**2173-5-12**] 07:37PM CK(CPK)-510*
[**2173-5-12**] 07:37PM POTASSIUM-3.5
[**2173-5-12**] 07:37PM MAGNESIUM-1.8
[**2173-5-12**] 07:37PM PLT COUNT-186
Brief Hospital Course:
A/P: 63yo M with Hypertrophic Obstructive Cardiomyopathy, CAD
s/p CABG who presents with progressive DOE and is admitted for
elective septal ablation with EtOH.
.
1. CV:
A). CAD: Pt with known CAD s/p CABG. Cath on admission reveals
significant 3VD. Now with septal ablation creating a "controlled
MI". Daily ECG demonstrated an evolving and resolving septal MI
in the appropriate leads. CE were cycled until they peaked and
trended down. Goal for management during this admission
involved rate and pressure control with HR <80 and SBP <140.
The patient was successfully controlled on his outpatient
regimen of metoprolol 50mg [**Hospital1 **], ASA and Pravastatin 20mg once
daily. He was discharged in stable condition without changes in
his CAD medications.
.
B). HOCM/Pump: Pt with hx of HOCM s/p myomectomy. TTE on
admission did not demonstrate a large outflow tract obstruction,
however with the administration of dobutamine a large gradient
became apparent (for details, please see pertinent results). He
subsequently underwent cardiac catheteriztaion with EtOH septal
ablation to improve the outflow tract obstruction. He also
received a temporary pacing wire for back up in case he
developed complete heart block or other arrhythmias. Daily
thresholds were checked to ascertain placement of leads and were
deemed appropriate with threholds of 0.3. The pacer wires were
removed 48hours after the septal ablation. The patient was
stable without any signs of complications. Recommend follow up
TTE in near future.
.
C). Rhythm: Pt was admitted with NSR. However, due to the
possibility of nodal/His ablation with the procedure, the
patient had temporary pacer wires in place for back up in case
he develops CHB or other arrhythmias. As above, daily threshold
were checked and found to be 0.3 which indicated appropriate
placement of temporary pacer wires. The leads were removed
without complications and the patient was discharged after
72hours of observation.
.
.
2. Nausea/Sedation: Pt reported significant nausea overnight and
this AM with some emesis. Pt was given anzmet twice overnight
without much effect. This AM, the patient was given compazine
IV with some evidence of sedation. This may have been secondary
to the MI which was induced, or due to the medications he
received in the cath lab. This was controlled with compazine
which induced some sedation.
.
.
3. Psych: Pt was continued on his outpatient Paroxetine 20mg
once daily
.
4. BPH: cont. Tamsulosin 0.4mg QHS
.
5. FEN: cardiac heart healthy, low salt diet. Electrolytes were
repleted to keep K > 4 and Mg >2.
.
6. PPx: Pt was continued on heparin sub Q TID for DVT
prophylaxis during his stay.
.
Medications on Admission:
1. Aspirin, 81 mg po daily.
2. Flomax, 0.4 mg po daily.
3. Pravastatin, 20 mg po daily.
4. Paroxetine, 10 mg po daily.
5. Lopressor, 50 mg po bid.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
3. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypertrophic cardiomyopathy s/p ethanol septal ablation in
[**5-11**].
2. CAD s/p 4V CABG and myomectomy on [**2173-3-23**].
3. Hypertension
4. Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
You should call or return if you develop lightheadedness,
dizziness, chest pain, shortness of breath or difficulty
breathing.
Followup Instructions:
1. You should follow-up with your primary care physician and
your cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**] [**Telephone/Fax (1) 11254**] in 1
week. She will determine the need for further interventions
with you.
Completed by:[**2173-5-15**]
|
[
"414.01",
"780.57",
"401.9",
"600.00",
"412",
"425.4",
"272.4",
"V45.81",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"37.34",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
18397, 18403
|
14950, 17641
|
335, 453
|
18609, 18615
|
2860, 8604
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18789, 19109
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2259, 2364
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18639, 18766
|
2379, 2841
|
8623, 10716
|
276, 297
|
484, 1654
|
1676, 1921
|
1937, 2243
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,429
| 155,381
|
31642
|
Discharge summary
|
report
|
Admission Date: [**2134-4-14**] Discharge Date: [**2134-4-22**]
Date of Birth: [**2090-9-14**] Sex: F
Service: SURGERY
Allergies:
Morphine / Latex
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Chronic Pancreatitis
Pancreatic Head Mass
Major Surgical or Invasive Procedure:
1. Pylorus preserving Whipple pancreaticoduodenectomy.
2. Open liver wedge biopsy.
History of Present Illness:
This 43-year-old woman is well-known to me as I first took care
of her close to a year ago for pancreatitis of unknown etiology.
She had previously had
a cholecystectomy in the past through an open approach. She had
a very severe episode of pancreatitis at that time, was
transferred to my care and she recovered quite well. However, in
the recovery period imaging found her to have a mass in the head
of the pancreas. This has been followed for close to
a year now and has resolved a little bit in size but still
remains troublesome in its characteristics. Alternatively it
looked solid and cystic. Multiple biopsies have taken place
through endoscopic ultrasound guidance and these have all been
nondiagnostic to date. Most recently she returned to the
hospital with a severe attack of abdominal pain and evidence of
pancreatitis once again.
This patient is a very anxious lady and is extremely concerned
as to why she may or may not have a pancreatic pathology. She is
troubled by the fact that she has had recurrent episodes of pain
and problems and she is very
uncomfortable with the process of observing this lesion which
continues to persist. Furthermore, she has had persistent
diarrhea which has all started in the last year. This was
refractory to major doses of pancreatic enzymes.
Past Medical History:
HTN, morbid obesitY (BMI 43), asthma, bronchitis, IDDM
PSH: c-section ('[**12**] and '[**13**]), open chole '[**13**], appy '[**11**], hernia
repair '[**22**]
Social History:
Occasional EtOH
Denies Smoking
Family History:
Father: CAD
Mother, Aunt: DM, CAD
Physical Exam:
AVSS
Gen: NAD, anicteric, morbid obesity
HEENT: MMM, PERRLA
Chest: constricted lung sounds, diminished at bases
CV: RRR
ABD: large, round, soft, nondistended, nontender
Ext: obese, +pulses bilat.
Pertinent Results:
[**2134-4-14**] 05:37PM BLOOD WBC-15.5*# RBC-3.90* Hgb-12.1 Hct-37.3
MCV-96 MCH-31.0 MCHC-32.5 RDW-13.2 Plt Ct-271
[**2134-4-17**] 04:18AM BLOOD WBC-9.7 RBC-2.90* Hgb-9.4* Hct-28.6*
MCV-99* MCH-32.3* MCHC-32.7 RDW-13.1 Plt Ct-198
[**2134-4-20**] 04:19AM BLOOD WBC-6.4 RBC-2.83* Hgb-9.1* Hct-26.5*
MCV-94 MCH-32.1* MCHC-34.3 RDW-13.1 Plt Ct-237
[**2134-4-14**] 05:37PM BLOOD Glucose-187* UreaN-11 Creat-0.9 Na-141
K-4.5 Cl-102 HCO3-22 AnGap-22*
[**2134-4-20**] 04:19AM BLOOD Glucose-79 UreaN-8 Creat-0.8 Na-144 K-3.4
Cl-105 HCO3-30 AnGap-12
[**2134-4-15**] 12:56PM BLOOD CK(CPK)-2218*
[**2134-4-16**] 08:22AM BLOOD CK(CPK)-1783*
[**2134-4-16**] 08:22AM BLOOD CK-MB-3 cTropnT-<0.01
.
SPECIMEN SUBMITTED: Jejunum, Whipple Specimen, Liver Wedge
Biopsy.
Procedure date Tissue received Report Date Diagnosed
by
[**2134-4-14**] [**2134-4-14**] [**2134-4-19**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma??????
DIAGNOSIS:
I. Jejunum (A-C):
Within normal limits.
II. Pancreaticoduodenectomy (D-U):
1. Nodule of healing pancreatitis with organizing fat necrosis
and hemorrhage, and fibrosis.
2. Single focus of pancreatic intraepithelial neoplasia,
low-grade (PanIN-I).
3. No exocrine carcinoma or endocrine tumor identified.
4. Duodenum and bile duct, within normal limits.
5. Regional lymph nodes; no tumor.
III. Liver, wedge biopsy (V):
1. Mild portal and lobular inflammation, including neutrophils
and lymphocytes.
2. Moderate steatosis involving 60% of hepatocytes, without
intracytoplasmic hyalin.
.
CHEST (PORTABLE AP) [**2134-4-17**] 7:47 AM
A single AP view of the chest is obtained [**2134-4-17**] at 08:00 hours
and is compared with the prior morning's radiograph. No
significant adverse interval change has occurred. There is low
lung volumes bilaterally. Increased retrocardiac density on the
left side is stable and likely represents subsegmental
atelectasis. No large pleural effusions seen. Right-sided IJ
line and nasogastric tube unchanged in position.
.
CHEST (PORTABLE AP) [**2134-4-18**] 7:40 AM
A single AP view of the chest is obtained [**2134-4-18**] at 0745 hours
and compared with the prior morning's radiograph. No significant
adverse interval change. Lung volumes remain low with elevation
of the right hemidiaphragm. Minimal bibasilar atelectasis is
present. Right-sided IJ line is unchanged.
Brief Hospital Course:
This is a 43 year old female with chronic pancreatitis and a
pancreatic head mass who went to the OR on [**2134-4-14**] for:
Pancreaticoduodenectomy (Whipple procedure).
She did well post-operatively, only having ppost-op hypoxia
related to her Asthma and followed the "Whipple" pathway.
Pain: She had a PCA for pain control and was followed by APS.
She was transitioned to oral pain medications once tolerating a
diet.
GI/ABD: She was NPO, with a NGT and IVF. The NGT, per the
pathway, was removed on POD 3. Her diet was slowly advanced as
she had return of bowel function. She was tolerating clears
liquids by POD 5. On POD 6, a JP Amylase was measured and was
... The drain was subsequently removed the next day.
Her abdomen was soft, nondistended and the incision with staples
was C/D/I. The staples were removed prior to discharge and steri
strips placed.
/She was tolerating regular food and reported +flatus and +BM
prior to discharge.
Post-op Hyperglycemia: She is a diabetic and takes Lantus and
Metformin at home. She continued to have elevated blood sugars
and [**Last Name (un) **] was consulted to help manage her blood sugars.
Post-op Hypoxemia: She has severe Asthma and Bronchitis. On POD
1, she was tachycardic and hypoxic with O2 sats in the 60's when
transferring from the chair to the bed. A Chest CT was negative
for a PE. On POD 2, she was transferred to ICU following acute
desat to 60's; on 15L BIPAP and satting only 88-90. She received
nebs and her O2 sats improved. She returned to the floor the
next day and continued with her home inhalers and nebs and had
no further desaturation of O2.
She was on all of her home meds and stable and discharged home
on POD... in good condition.
Medications on Admission:
singulair 10', cardia 240", diovan 160", [**Doctor First Name 130**] 180', lasix
40", metformin 750' 10pm, lantis 26u 10pm, humilin SSI, flovent
220 4puffs", serevent 1puff", MVI'
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
16. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DINNER (Dinner).
17. 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*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Chronic pancreatitis
Discharge Condition:
Good
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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**10-27**] lbs) for 6 weeks.
* Keep incision clean and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Please call
[**Telephone/Fax (1) 1231**] to schedule an appointment.
|
[
"V58.65",
"577.1",
"250.00",
"493.20",
"278.01",
"V58.67",
"276.3",
"571.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"50.12",
"52.7"
] |
icd9pcs
|
[
[
[]
]
] |
8370, 8389
|
4614, 6331
|
317, 401
|
8454, 8461
|
2238, 4591
|
9949, 10085
|
1972, 2007
|
6561, 8347
|
8410, 8433
|
6357, 6538
|
8485, 9926
|
2022, 2219
|
236, 279
|
429, 1725
|
1747, 1908
|
1924, 1956
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,959
| 140,992
|
31812
|
Discharge summary
|
report
|
Admission Date: [**2109-8-28**] Discharge Date: [**2109-9-4**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Dobhoff tube placement
History of Present Illness:
Mr. [**Known lastname 5872**] is an 83 year-old man s/p unwitnessed fall down 8
stairs, found by wife at bottom of stairs. His GCS 15 at scene
he was transfered from referring institution, having been
intubated several hours prior to arrival, to [**Hospital1 18**] for further
care. He arrived with a known C6 facet fracture.
Past Medical History:
Diabetes Mellitus
Chronic Renal Insufficiency
Coronary Artery disease
Hyperlipidemia
s/p CVA with Right hemiparesis
Sick sinus syndrome s/p pacemaker
Atrial Fibrillation
Social History:
Married
Family History:
Noncontributory
Physical Exam:
Upon admission:
102.1 60paced 91/51 23 100% on AC 1.0/600x20/5
7.26/49/94/23/-5
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2mm bilaterally, moves eyes to examiner
Neck: Supple.
Lungs: CTAB.
Cardiac: RRR. nl S1/S2.
Abd: +BS, S, NT/ND
Extrem: Warm and well-perfused. No c/c/e.
Neuro:
Mental status: Awake, attempting to cooperate with exam.
Orientation: Oriented to person and date.
Unable to test language, pt intubated.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
No abnormal movements or tremors detected.
No pronator drift.
Toes downgoing bilaterally.
Pertinent Results:
Non-contrast Head CT [**2109-8-28**]- 6-mm high-dense focus posterior to
the right side of the pons, which appears to be within the
subarachnoid space, which could represent small focus of
subarachnoid hemorrhage. Generalized brain atrophy and chronic
small vessel ischemia.
.
CT C-spine [**2109-8-27**]- IMPRESSION: Non-displaced fracture through
the left C6 lamina extending to the facet joint. Rotation of C1
upon C2, probably rotational. Degenerative changes. Emphysema.
.
CT Torso [**2109-8-27**]- Impression:
1. Small area of abnormal soft tissue density/stranding in the
posterior mediastinum/right paraesophageal region, likely
representing a small mediastinal hematoma. However, there is
mild adjacent esophageal wall thickening and traumatic injury to
the esophagus cannot be excluded. Aorta and great vessels are
intact.
2. Nonspecific, ill-defined right middle lobe airspace
opacities, which could represent atelectasis, infection or
aspiration. Followup is recommended.
3. No traumatic injury in the abdomen or pelvis. Extensive
colonic diverticulosis without evidence for diverticulitis.
.
Wrist (3 views) [**2109-8-27**]- IMPRESSION: Irregular appearance of the
scaphoid. Correlate clinically in regards to the presence of
pain. If indicated, dedicated scaphoid views can be obtained.
Otherwise no fracture or subluxation.
.
Carotid Duplex [**2109-8-27**]- IMPRESSION: There is a widely patent
right internal carotid artery and a widely patent left internal
carotid artery with antegrade flow in both vertebral arteries.
This is a normal carotid duplex
.
ECG [**2109-8-27**]- Ventricular paced rhythm. Ventricular couplet.
Atrial mechanism uncertain. Baseline artifact makes assessment
difficult. No previous tracing available for comparison.
.
Echo [**2109-8-28**]- The left atrium is mildly dilated. The right atrium
is moderately dilated. A small secundum atrial septal defect is
present. The estimated right atrial pressure is 11-15mmHg. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 50 %) with global
hypokinesis (most prominent in the basal inferior wall). There
is no ventricular septal defect. Right ventricular systolic
function is borderline normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is moderately
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets aremildly thickened. There is no
mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2109-8-28**] 02:36PM PT-18.4* PTT-30.4 INR(PT)-1.7*
[**2109-8-28**] 08:53AM GLUCOSE-208* UREA N-27* CREAT-1.4* SODIUM-142
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13
[**2109-8-28**] 08:53AM CALCIUM-8.1* PHOSPHATE-1.9*# MAGNESIUM-2.1
[**2109-8-28**] 08:53AM TSH-0.81
[**2109-8-28**] 08:53AM WBC-20.2*# RBC-3.70* HGB-11.6* HCT-32.6*
MCV-88 MCH-31.2 MCHC-35.4* RDW-14.0
[**2109-8-28**] 08:53AM PLT COUNT-177
[**2109-8-28**] 08:53AM PT-22.0* PTT-30.4 INR(PT)-2.2*
[**2109-8-28**] 08:31AM LACTATE-2.3*
[**2109-8-28**] 03:30AM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-2.4
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery and
Orthopedic Spine Surgery were consulted given his injuries. He
was managed operatively for his injuries. Initially he was
loaded with Dilantin and remained on this tid for the next
several days; he was also started on Nicardipine to prevent
vasospasm. Serial head CT scans were followed and were stable.
Follow up will be need in 4 weeks with Dr. [**Last Name (STitle) 548**] for repeat head
imaging. His cervical spine injury was managed with a hard
cervical collar which will need to be worn for the next 6 weeks.
He will follow up in 2 weeks with Dr. [**Last Name (STitle) 1352**] for repeat spine
imaging.
His blood sugars were intermittently elevated during his
hospital stay; he is usually followed by Endocrinologist Dr.
[**Last Name (STitle) 74648**] for his insulin regimen ([**Telephone/Fax (1) 74649**]. He was contact[**Name (NI) **]
and his home dose of NPH was restarted 42 units in the morning
and 22 units in the evening.
On HD #7 he was noted to have an elevated sodium (153) and was
also borderline hypokalemic (3.6); he was given free water
boluses via his Dobbhoff and his K+ was repleted via the
Dobbhoff as well. His Na on the following day remained at 154,
his free water boluses were increased to 200 cc's every 4 hours.
He also did have an elevated Creatinine during his hospital stay
which has actually trended downward from 3.2 on [**9-3**] to 2.2 on
[**9-4**]. He will need to have his elcetrolytes followed closely
while at rehab.
He is also being treated for a pneumonia; likely aspiration,
with a 10 day course of Vancomycin and Zosyn.
He underwent a Speech and Swallow evaluation at bedside and was
deemed a high aspiration risk. He was kept NPO; a Dobbhoff was
placed and tube feedings were subsequently started. His
swallowing will need to be re-evaluated once in rehab.
Physical and Occupational therapy were also consulted and have
recommended an acute level rehab stay after discharge.
Medications on Admission:
Coumadin
Lescol XL
Insulin
Univasc
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, headache, fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP <110; HR <60.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO twice a day
as needed for constipation.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Five (5) ML
Miscellaneous Q6H (every 6 hours).
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: 0.83 ML
Inhalation Q6H (every 6 hours).
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to affected areas [**Hospital1 **].
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) GM
Intravenous once a day for 10 days: Monitor levels and adjust
dose accordingly.
14. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 GM
Intravenous Q8H (every 8 hours) for 10 days.
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty
Two (42) Units Subcutaneous BREAKFAST (Breakfast).
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Two (22) Units Subcutaneous QPM.
17. Protonix 40 mg Recon Soln Sig: Forty (40) MG Intravenous
once a day.
18. Regular Insulin Sliding Scale Sig: One (1) dose four times
a day as needed for per sliding scale: BS 150-200 2 units
BS 201-250 4 units
BS 251-300 6 units
BS 301-350 8 units
BS 351-400 10 units
BS >400 notify MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
s/p Fall
Left C6 lamina fracture extending to facet
Posterior mediastinal/Right paraesophageal hematoma
Subarachnoid hemorrhage
Secondary diagnosis:
Pneumonia
Dysphagia
Discharge Condition:
Good
Discharge Instructions:
You will need to continue the hard cervical collar for the next
6 weeks.
Followup Instructions:
Follow up in 2 weeks with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**], Orthopedic Spine
Surgery; inform the office that you will need AP/Lat cervical
spine films for this appointment. Call [**Telephone/Fax (1) 1228**] for an
appointment.
Please also follow up with the Neurosurgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**],
in 4 weeks; inform the office that you will need a head CT
without contrast for this your appointment. Please call ([**Telephone/Fax (1) 18865**] to arrange for the head CT and to schedule your
follow-up appointment.
If a PEG tube placement is required please contact the office of
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 6439**] to have an outpatient
appointment scheduled.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2109-9-10**]
|
[
"507.0",
"V45.01",
"805.06",
"250.00",
"585.9",
"427.31",
"272.0",
"414.01",
"852.06",
"438.20",
"862.22",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9389, 9469
|
5363, 7349
|
269, 294
|
9683, 9690
|
1917, 5340
|
9811, 10788
|
885, 902
|
7436, 9366
|
9490, 9619
|
7375, 7411
|
9714, 9788
|
917, 919
|
221, 231
|
322, 651
|
1361, 1898
|
9640, 9662
|
933, 1206
|
1221, 1345
|
673, 844
|
860, 869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,453
| 142,004
|
50565+50566
|
Discharge summary
|
report+report
|
Admission Date: [**2147-5-10**] Discharge Date:
Date of Birth: [**2069-3-18**] Sex: F
Service: MICU
CHIEF COMPLAINT: Found down.
HISTORY OF PRESENT ILLNESS: A 78-year-old woman, with past
medical history of hypertension on hydrochlorothiazide,
pulmonary nodule of the right middle lobe, angina, who was
found down at home by her family members on the evening of
her admission. She last spoke with the family at 8:00 pm the
night prior. She was brought to the Emergency Room where she
was intubated for airway protection, and received 1 gm of
ceftriaxone and 900 mg of clindamycin IV. She was started on
a propofol drip for sedation; however, blood pressure dropped
to 81/43. The patient's drip was changed to versed and
fentanyl, with improvement of blood pressure, and given an
additional bolus of 500 cc.
In addition, the patient's family noticed that she had lost
30 pounds in the last year, has increased labored breathing,
with a chronic cough, and decreased energy level. At
baseline, the patient is alert and oriented x 3. She is
independent of her ADL, and has occasional confusion.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Increased cholesterol.
3. ETOH.
4. Restrictive lung disease.
5. Arthritis.
6. Depression.
7. Known pulmonary nodule.
8. Angina.
9. COPD.
10.History of bleeding, ?[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] factor deficiency.
ALLERGIES: Unknown.
MEDS:
1. Aspirin 325 mg.
2. Calcium carbonate tid.
3. Cardizem 180 mg [**Hospital1 **].
4. Hydrochlorothiazide 50 mg qd.
5. Isordil 20 mg tid.
6. Potassium chloride 40 mg qd.
7. Klonopin 0.5 mg [**Hospital1 **].
8. Lactulose prn.
9. Zestril 20 mg qd.
10.Lovastatin 20 mg qd.
11.Paxil 20 mg qd.
12.Prilosec 20 mg qd.
13.Evista 60 mg qd.
14.Sublingual Nitroglycerin prn.
15.Vioxx prn.
16.Seroquel.
SOCIAL HISTORY: Greater than 50 pack years of smoking. A
history of alcohol use in the past. The patient is a widower
who lives alone, independent.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 100.8, pulse
77, blood pressure 95/52, 99% on 100% oxygen.
GENERAL EXAMINATION: Intubated, moving extremities.
HEENT: Pupils equal, round, reactive to light. ETT tube is
in place.
CARDIOVASCULAR: Regular rate and rhythm. Rhonchi
anteriorly.
PULMONARY: Bilateral breath sounds on the ventilator.
ABDOMEN: Soft, nontender, nondistended, scaphoid.
EXTREMITIES: No cyanosis, clubbing, or edema.
NEURO: The patient grimaces to pain, withdraws. Moves all 4
extremities.
LABS ON ADMISSION: ABG on assist control - 500, 17, 5 and
0.6. ABG - 7.34, PCO2 61, PO2 89. White count 31.1,
hematocrit 45.1, platelets 301. Sodium 112, potassium 2.9,
bicarbonate 32, lactate 4.7. CK 5,123, CK-MB 40, troponin-T
less than 0.01. Urine tox and serum tox negative.
CT CHEST, ABDOMEN AND SPINE: Showed no fracture. Right
middle lobe nodule. Consolidation in the left lower lobe.
No aneurysm or dissection. CT of the head showed no
bleeding.
HOSPITAL COURSE: The patient's hyponatremia was treated with
sodium repletion. The patient was thought to have possible
pneumonia and was started on levofloxacin and Flagyl for a
left lower lobe pneumonia. The patient was thought to have
loss of consciousness secondary to hyponatremia. The source
of the hyponatremia was unclear at the time, but most likely
secondary to excessive diuretic use, particularly
hydrochlorothiazide in the setting of poor PO intake.
However, SIADH was also entertained, but based on urine
electrolytes, this was not confirmed.
After aggressive hydration, the patient developed metabolic
acidosis and was repleted with bicarb. The patient's
respiratory failure gradually improved. At the time of
dictation, the patient is able to have spontaneous breathing
on ventilator and anticipate extubation.
During the hospital course, the patient became hypotensive
shortly after arrival to the floor. An emergent femoral line
was placed to resuscitate with pressors. Shortly thereafter,
a subclavian line was attempted in order to remove the
femoral line. The patient subsequently developed a
left-sided pneumothorax during subclavian line placement.
The patient's blood pressure acutely decreased, requiring
needle decompression and subsequent chest tube placement.
The patient also had bronchoscopy performed to evaluate a
right middle lobe nodule. Bronchial washings were performed
and sent off for cytology which is pending at the time of
this dictation.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Name8 (MD) 10402**]
MEDQUIST36
D: [**2147-5-13**] 14:07
T: [**2147-5-13**] 14:09
JOB#: [**Job Number 105266**]
Admission Date: [**2147-5-10**] Discharge Date: [**2146-5-22**]
Date of Birth: [**2069-3-18**] Sex: F
Service: [**Hospital Unit Name 153**]
THIS IS A DISCHARGE SUMMARY ADDENDUM FROM THE DATES OF [**2147-5-14**] UP UNTIL DATE OF DISCHARGE, [**2147-5-23**].
HOSPITAL COURSE:
1. Fluid and electrolytes: The patient was initially found
to be severely hyponatremic of unclear etiology. She was
free water restricted and her sodium slowly increased. She
later became hypernatremic and was recorrected with free
water. Throughout the rest of her hospital course, her
sodium remained stable within a normal range. She had some
mild evidence of heart failure during her stay and received
very small doses of Lasix, which she responds vigorously too.
She then auto-diuresed during the later part of her hospital
stay.
2. Pulmonary function: She had a pneumothorax thought to be
related to left subclavian line placement. She had an
initial chest tube placed, which was pulled after
pneumothorax had resolved on chest x-ray and there was
minimal chest tube output. During follow-up chest x-ray's
there was no evidence of pneumothorax. She was initially
intubated for respiratory support, and then extubated.
Because of questions of her neurological status, she was
reintubated to facilitate brain imaging and was later
extubated. She did well post extubation, but did have
occasional episodes of desaturations into the low 90s. Her
desaturations were thought to be likely due to mucous
plugging as she has significant secretions. During her
desaturation, she was ruled out for pulmonary embolism and
has been on deep vein thrombosis prophylaxis. She was
aggressively suctioned and continued on albuterol and
ipratropium plus Mucomyst nebulizers and continued with chest
Physical Therapy. She likely has chronic emphysematous
changes due to chronic obstructive pulmonary disease and will
continue with nebulizers and chest Physical Therapy at
rehabilitation.
3. Infectious Disease: She was initially treated with a ten
day course of levofloxacin and Flagyl for a suspected
pneumonia. She also received several days of vancomycin for
a [**2-10**] positive blood culture bottles with enterococcus sensitive
to vancomycin from her arterial line. Her arterial line
was later discontinued and she no longer had growth in
follow-up blood cultures bottles and her vancomycin was then
discontinued.
4. Mental status/neurological: As she was initially found
down, there was concern for a CVA, but her initial CAT scan
of the brain was negative. Later in the hospital course, she
was noted to have anisocoria, and there was concern that she may
have a CVA or other brain stem injury and/or brain metastases.
Neurology was consulted and a MRI was done showing no significant
abnormalities. There was a question of possible seizure
activity, which may possibly affect her occasional respiratory
desaturations. She was placed on Dilantin and an
electroencephalogram was done showing findings consistent with
metabolic etiology, however, she was continued on Dilantin and
will follow-up with Neurology as an outpatient for outpatient
electroencephalogram and reassessment of her Dilantin therapy.
5. Lung nodule: She has a history of a right middle lobe
lung nodule prior to admission, as well as some associated
weight loss. Bronchoscopy was performed which was negative
for malignant cells. She will follow-up with her primary
care physician for further evaluation of this lung nodule.
6. Cardiac function: Patient was found to have an
intermittent left bundle branch block during her admission
which was initially confused for non-sustained ventricular
tachycardia on telemetry and electrocardiogram. Her
outpatient cardiologist was [**Month/Day (2) 653**] and prior
electrocardiograms did not show these changes. She was noted
to have an initial elevated troponin during her admission,
but this was felt to be in the setting rhabdomyolysis after
she was found down and not thought to be related to
myocardial ischemia. During her hospital stay, she had
several repeat enzymes drawn showing no evidence of
myocardial infarction. Cardiology was consulted. It was
thought that patient's left bundle branch block was likely
rate related. She did have evidence of some T wave
inversions in the inferior and lateral leads. There was
questions of angina or ongoing ischemia. She had a
transthoracic echocardiogram, as well as a stress dobutamine
echocardiogram that did not show evidence of wall motion
abnormalities or reversible defects. Her ejection fraction
echocardiogram was 50% and on her dobutamine echocardiogram
was 45%. It was thought that she did not have evidence of
significant ischemia on cardiac imaging and she should
continue with medical management with an aspirin,
beta-blocker and statin. She will follow-up with her
cardiologist as an outpatient.
7. Chest pain: Patient complained of constant chest pain
during her hospital course, which is sharp and substernal.
This pain is reproducible on deep palpation of her sternum
and thought to be related to her history of arthritis. It is
likely chronic costochondritis. It was not thought to be
related to cardiac ischemia. She will continue treatment
with Tylenol and NSAIDs for this chronic chest pain.
8. Depression: Patient was evaluated by Psychiatry who
agreed that patient likely had elements of depression. She
was continued on her SSRI. It is thought that her
medications may be changed to Remeron if her depression does
not improve as an outpatient.
9. Code status: The physician covering for patient's
primary care physician was [**Name (NI) 653**], who established that
patient had prior wishes of "Do Not Resuscitate" and "Do Not
Intubate" prior to her hospital admission. These wishes were
not known at the time of admission. After the patient was
extubated and her mental status returned to baseline, she
then stated her wishes of "Do Not Resuscitate" and "Do Not
Intubate." Psychiatry was consulted who felt that patient's
depression was not effecting her judgement and she was stated
to be "Do Not Resuscitate/ "Do Not Intubate."
10. Access: A left arm PICC was placed on [**2147-5-23**]
which is followed into the SVC.
11. Nutrition: Patient was initially placed on tube feeds
while intubated and they were slowly advancing her diet. She
had been followed by Nutrition throughout her hospital
course.
12. Glaucoma: Patient was placed on her previous eye drops
after her outpatient ophthalmologist was [**Year (4 digits) 653**]. She will
have her blood pressure and heart rate monitored, as well as
systemic blood pressure medications have beta-blocking
activity.
13. Prophylaxis: The patient was placed on a proton pump
inhibitor, given Maalox prn, placed on a bowel regimen, as
well as subcutaneous heparin for deep vein thrombosis
prophylaxis. She will continue on subcutaneous heparin until
fully ambulatory.
14. Severe deconditioning: Patient had a prolonged hospital
course with severe weakness and deconditioning. She will need
several weeks to months of Physical Therapy to return to a
functional status with even minor activity, she notes
worsened complaints of costochondritis chest pain and
worsening shortness of breath thought to be related to this
sever deconditioning.
CONDITION OF DISCHARGE: Stable.
DISCHARGE STATUS: Extended care facility, [**Hospital **]
rehabilitation.
DISCHARGE DIAGNOSES:
1. Hyponatremia.
2. Rhabdomyolysis.
3. Pneumothorax.
4. Pneumonia.
5. Lung nodule.
6. Chronic obstructive pulmonary disease.
7. Mild congestive heart failure.
8. Depression.
9> Glaucoma.
10. Non cardiac chest pain.
11. Hypertension.
12. Arthritis.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg po t.i.d.
2. Regular insulin sliding scale.
3. Albuterol nebulizers q. 6 hours.
4. Ipratropium nebulizers q. 6 hours.
5. Tylenol 325-650 mg po q. 6 hours prn.
6. Milk of Magnesia 30 mL po q. 6 hours prn constipation.
7. Docusate 100 mg po b.i.d.
8. Protonix 40 mg po q.d.
9. Senna 1 tablet po b.i.d. prn constipation.
10. Lovastatin 20 mg po q.d.
11. Paroxetine 20 mg po q.d.
12. Raloxifene 60 mg po q.d.
13. Bisacodyl 10 mg po q.d.
14. Ibuprofen 400 mg po q. 8 hours.
15. Aspirin 81 mg po q.d.
16. Betaxolol .25% drops, 1 drop b.i.d.
17. Latanoprost .005% drops, 1 drop at bedtime.
18. Mucomyst nebulizers q. 6 hours. Please give with
albuterol.
19. Metoprolol 25 mg po b.i.d.
20. Subcutaneous heparin 5000 units q. 8 hours. Please give
until patient fully ambulatory.
21. Maalox 15-30 mL po q.i.d. prn dyspepsia.
22. Nystatin swish and swallow 5 mL po q.i.d. prn dysphagia.
23. Simethicone 40-80 mg tablets po q.i.d. prn bloating.
24. Ativan .5-1 mg po q. 6 hours prn anxiety.
FOLLOW-UP PLANS: The patient will follow-up with her primary
care physician within one to two weeks time. She will also
follow-up with her outpatient cardiologist. She has an
appointment with Dr. [**Last Name (STitle) **] of Behavioral Neurology on [**6-5**] at 10 a.m. She also has an outpatient
electroencephalogram on [**6-5**] at 1 p.m. She was told to
continue all medications as prescribed and be sure to
follow-up with her outpatient appointments for evaluation of
her pulmonary nodule and Dilantin use. She was told that if
she had any severe worsening shortness of breath, significant
lightheadedness, arm or leg numbness, or had any other
concerning symptoms, that she should notify her primary care
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 6289**]
MEDQUIST36
D: [**2147-5-23**] 01:34
T: [**2147-5-23**] 12:47
JOB#: [**Job Number 105267**]
|
[
"996.62",
"492.8",
"728.88",
"349.82",
"428.0",
"512.1",
"276.1",
"518.82",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"96.04",
"99.15",
"38.93",
"34.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12154, 12412
|
12435, 13445
|
4978, 12133
|
13463, 14453
|
138, 151
|
180, 1122
|
2526, 2972
|
1144, 1831
|
1848, 2004
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,771
| 161,788
|
15335
|
Discharge summary
|
report
|
Admission Date: [**2196-9-27**] Discharge Date: [**2196-10-3**]
Date of Birth: [**2125-3-9**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 44555**] is a 71 year old male
with past medical history significant for longstanding
insulin dependent diabetes mellitus who originally presented
with a progressive decline in his activity tolerance.
According to the patient he has now been able to walk more
than [**Age over 90 **] yards without feeling short of breath and fatigued.
The patient denied any history of chest pain. He has no
symptoms of claudication, orthopnea, edema, paroxysmal
nocturnal dyspnea or lightheadedness. He had a stress test
performed in [**2196-6-6**] during which he experienced chest
pain. His baseline electrocardiogram shows a possible old
inferior wall myocardial infarction with poor R wave
progression. A recent echocardiogram revealed a large severe
partially fixed and partially reversible defect involving the
inferoposterolateral wall. In addition, there was akinesis
of the basal aspect of the inferior wall with left
ventricular ejection fraction of approximately 46%. The
patient was consequently referred for cardiac catheterization
to further evaluate abnormal findings. Cardiac
catheterization performed on [**2196-9-8**] revealed three
vessel coronary artery disease and mildly decreased left
ventricular systolic function. Specifically, the left
anterior descending was 80% stenosed, the left circumflex was
50% stenosed, obtuse marginal 1 was 90% stenosed as was the
obtuse marginal 2. The right coronary artery had 90%
stenosis just before getting off the posterior descending
artery. Apical and inferior hypokinesis was noted with the
estimated left ventricular ejection fraction of 44%.
PAST MEDICAL HISTORY: 1. Diabetic neuropathy; 2. Insulin
dependent diabetes mellitus times 30 years; 3. Prostate
cancer, status post radiation treatment three years ago; 4.
Arthritis; 5. Hemorrhoids.
PAST SURGICAL HISTORY: Cholecystectomy (laparoscopic).
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Enteric coated Aspirin 325 mg p.o. q. day
2. Insulin NPH 25 units q. AM, 35 units q. PM
3. Zestoretic 40/25 mg q. day at 2 PM
4. Lipitor 5 mg p.o. q. day
PHYSICAL EXAMINATION: Afebrile, heartrate 70, blood pressure
187/99, respiratory rate 18, 96% on room air. General
examination, elderly male in no apparent distress. Head,
eyes, ears, nose and throat examination was within normal
limits, no bruits, no jugulovenous distension. Cardiac
examination, regular rate and rhythm with normal S1 and S2,
no murmurs. Lung examination, clear to auscultation
bilaterally. Abdomen soft but obese, nontender,
nondistended, bowel sounds present. No hepatosplenomegaly.
A well healed abdominal laparoscopic scar from
cholecystectomy present. Extremities, warm and well
perfused. Pulses, bilateral lower and upper extremity pulses
present throughout.
LABORATORY DATA: White blood cell count 6.2, hematocrit
43.1, platelets 181, sodium 139, potassium 4.2, BUN 22,
creatinine 1.3. INR 1.1. Urinalysis negative. Glucose 138,
BUN 21, creatinine 1.0, sodium 136, potassium 4.0, ALT 27,
AST 28, alkaline phosphatase 168, total bilirubin 0.8. Chest
x-ray showed no evidence of congestive heart failure. There
were bilateral upper lobe calcific foci.
SUMMARY OF HOSPITAL COURSE: Given the patient's symptoms and
three vessel coronary artery disease according to the cardiac
catheterization, a surgical intervention was proposed. On
[**2196-9-27**], the patient underwent coronary artery
bypass grafting times 5. Please see the full operative
report for detail. The procedure was without any
complications. The patient tolerated the procedure well.
The patient was transferred to the Intensive Care Unit. He
remained intubated. Upon arrival to the Intensive Care Unit,
the patient's blood pressure was noted to be very labile. He
became rather hypotensive and required large amounts of
volume for stabilization. Metabolic acidosis was noted. The
patient continued to produce adequate urine. He remained in
sinus rhythm. He was extubated on postoperative day #1
without complications. The patient had diminished lung
sounds but no obvious infiltrate was noticed. Extensive
pulmonary toilet was initiated. The patient's blood pressure
and heartrate remained stable during his stay in the
Intensive Care Unit. He was diuresed and started on a beta
blocker. His chest tube was removed. His urine catheter was
removed. Physical therapy was consulted which followed the
patient throughout his hospitalization. The patient was
transferred to the regular floor on postoperative day #2.
His pacing wires were removed. The patient was ambulating.
After the removal of the Foley catheter the patient was noted
to have difficulty urinating. The Foley catheter was put in
again. When the catheter was removed on postoperative day
#4, the patient started urinating on his own. The diabetes
consult was contact[**Name (NI) **] given unstable blood sugar levels. In
fact, the patient was noted to have a blood sugar level of 34
on postoperative day #4. His insulin regimen was adjusted
accordingly. The patient continued to do well. His incision
was clean, dry and intact. The patient was discharged to
rehabilitation facility on [**2196-10-3**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Three vessel coronary artery disease, status post
coronary artery bypass grafting times five.
2. Insulin dependent diabetes mellitus.
3. Prostate cancer.
4. Arthritis.
5. Diabetic neuropathy.
6. Decreased vision.
DISCHARGE MEDICATIONS:
1. Insulin NPH 20 units at breakfast and 30 units at dinner.
2. Lipitor 10 mg p.o. q. day
3. Protonix 40 mg p.o. q. day
4. Milk of magnesia 30 ml p.o. h.s. prn constipation
5. Percocet 1 to 2 tablets p.o. q. 4 hours prn pain
6. Tylenol 650 mg p.o. q. 4 hours prn pain
7. Aspirin, enteric coated 325 mg p.o. q. day
8. Colace 100 mg p.o. b.i.d.
9. Potassium chloride 20 mEq p.o. b.i.d. times ten days
10. Lasix 20 mg p.o. b.i.d. times ten days
11. Lopressor 25 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS:
1. The patient is to see his cardiac surgeon, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in approximately four weeks.
2. The patient is to see his cardiologist, Dr. [**Last Name (STitle) **] in
approximately three weeks.
3. The patient is to see his primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] in approximately one to two weeks.
[**Last Name (STitle) **] DR.[**Last Name (STitle) **] [**Last Name (Prefixes) 44556**],[**First Name3 (LF) 412**] 02-351
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2196-10-2**] 20:12
T: [**2196-10-2**] 21:37
JOB#: [**Job Number 25416**]
|
[
"362.01",
"414.01",
"357.2",
"276.2",
"250.81",
"250.61",
"458.2",
"250.51",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.15",
"39.61",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
5448, 5474
|
5741, 6225
|
5495, 5718
|
2128, 2290
|
6249, 6977
|
2031, 2102
|
3412, 5392
|
2313, 3383
|
176, 1801
|
1824, 2007
|
5417, 5424
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,417
| 150,147
|
37584
|
Discharge summary
|
report
|
Admission Date: [**2108-12-6**] Discharge Date: [**2108-12-21**]
Date of Birth: [**2046-1-21**] Sex: M
Service: NEUROLOGY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Severe Headache, altered mental status
Major Surgical or Invasive Procedure:
[**2108-12-6**]: Diagnostic Angiogram, placement of external
ventricular drain
History of Present Illness:
62 yo man with a history of poorly controlled HTN, presenting
with AMS, found to have large IVH. Reportedly on [**12-5**], he
started to not feel well, with symptoms of headache and
dizziness. He mentioned this to his family on the am of [**12-6**],
at which point they called EMS to his house. At that time he
was
reportedly alert and oriented, moving all extremities. He was
taken to an OSH, where he was given Dilauded for his headache,
and underwent a head CT, which showed a large intraventricular
hemorrhage. Shortly after receiving the second mg of Dilaudid,
he reportedly became 'altered' at which point he was intubated.
He was loaded with 1g of Dilantin and transferred to [**Hospital1 18**] for
definitive neurosurgical care
Past Medical History:
Hypertension
Social History:
unknown
Family History:
unknown
Physical Exam:
On Admission:
O: T: BP: 144/70 HR: 60 R 18 O2Sats 100%
Gen: Intubated, NAD
Pupils: 2->1mm
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated, sedated
Cranial Nerves: Pupils 2mm->1mm. - oculocephalics - corneal
+gag
Motor: Normal bulk and tone bilaterally. Spontaneous movement of
all extremities noted off sedation.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: Unable to assess
Exam on Discharge:
XXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2108-12-6**] 08:45PM BLOOD WBC-9.7 RBC-3.92* Hgb-12.3* Hct-36.4*
MCV-93 MCH-31.3 MCHC-33.7 RDW-14.1 Plt Ct-199
[**2108-12-6**] 04:10PM BLOOD Neuts-91.5* Lymphs-6.1* Monos-2.2 Eos-0
Baso-0.2
[**2108-12-6**] 08:45PM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1
[**2108-12-6**] 08:45PM BLOOD Glucose-104 UreaN-16 Creat-1.0 Na-135
K-4.3 Cl-106 HCO3-21* AnGap-12
[**2108-12-6**] 04:10PM BLOOD CK(CPK)-183*
[**2108-12-6**] 04:10PM BLOOD cTropnT-<0.01
[**2108-12-6**] 04:10PM BLOOD CK-MB-5
[**2108-12-6**] 08:45PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.6
Labs on Discharge:
XXXXXXXXXXX
IMAGING:
CTA Head:
Impression:
No definite aneurysm or AVM seen on this limited CTA.
Intraventricular
hemorrhage as described
Head CT [**12-8**]:
IMPRESSION: Unchanged intraventricular hemorrhage. Now apparent
is a
hypodensity in the right cerebellum which is approximately 1.5
cm in size.
Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] for definitive neurosurgical
intervention after being found to have intraventricular
hemorrhage. Upon arrival to [**Hospital1 18**] his head ct demonstrated
hydrocephalus, so an emergent external ventricular drain was
placed. He then went for emergent angiogram to evaluate for
possible aneurysm. Angio was negative for such a finding. He was
then returned to the intensive care until for ongoing
management, and frequent neurological examinations. His ICU
treatment consisted of mannitol therapy in conjunction with
external ventricular drain. On [**12-11**], his mannitol therapy wean
was initiated.
On a follow up MRI on [**12-12**] the patient was noted to have
multiple small infarcts involving both cerebellar hemispheres
and also in the deep white matter of both cerebral hemispheres.
There was a concern for an embolic source however the workup was
negative (including a TEE). This occurred after the angiogram
and may have been secondary to that procedure. While in the ICU
he was noted to be febrile. The source was presumed to be a
cellulitis on the patient's left arm at the site of an old IV.
Vancomycin was started and the fevers and rash improved. A
Trans-esophageal echo did not show any source of emboli or
infection.
During his stay he was noted to be persistently hypertensive and
it required multiple agents to control. He had a workup for
secondary causes of hypertension including a urine metanephrine
study (still pending), and a renal ultrasound which did not show
any evidence of renal artery stenosis. During this workup the
patient was found to be hypo-thyroid and was started on thyroid
hormone replacement.
He was transferred to the floor on [**12-18**] and his confusion slowly
resolved. He was seen by PT numerous times while an inpatient
and he was discharged home. Due to insurance difficulties he
was given free care medications, and was set up with a PCP on
discharge to manage his hypertension. He will be followed by
the stroke service and neurosurgery as an outpatient.
Medications on Admission:
ASA 81mg (not taking)
Lotrel 40mg (not taking)
Discharge Disposition:
Home
Discharge Diagnosis:
Intraventricular Hemorrhage
HTN
Discharge Condition:
Neurologically Stable
MS: intact, oriented to person, place, time, mild
inattentiveness, but able to name [**Doctor Last Name 1841**] backward, per family and
translators -> language intact.
CN: no deficits
Motor: no deficits
Sensory: intact to all modalities
Gait: slightly unsteady, narrow base, normal stride length
Discharge Instructions:
You were admitted with an episode of headache and confusion. As
a result you were taken to a local hospital were you were found
to have a large amount of bleeding in your brain involving all
of the ventricles. You were then intubated and then sent to
[**Hospital3 **] Medical Center for further care. Here you had a
drain placed in the ventricles of your brain to relieve excess
pressure. You were sent to the Neuro-ICU for intensive care.
You also had a CT scan and a test called an angiogram to rule
out any vascular abnormalities, and both of these tests were
normal. You were also stared on a medication called Mannitol to
help decrease the pressure in your brain. While in the ICU you
were noted to have had fevers. The soruce was presumed to be an
infection that was on your left arm at the site of an old IV.
You were started on an antibiotic Vancomycin and your fevers and
rash improved. We also obtained an echo of your heart (a
Trans-esophageal echo) that did not show any source of emboli or
infection.
Your mental status improved and you became less confused. You
were also noted to have some small strokes, and the workup for
the cause of these strokes was unrevealing. Your hypertension
was also difficult to control. We have you on a number of blood
pressure agents currently with good control over your blood
pressure now. You had a workup of other causes of high blood
pressure, and there was no problems in the arteries of your
kidneys, and we have a test of your urine that is still pending
(urine metanephrines. During this workup wer noted that you had
low thyroid function and you were started on synthroid a thyroid
replacement medication.
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.
Please take all medications as prescribed. Please make all
follow up appointments. If you experience any of the symptom
including intractable headache, weakness on one side of your
body, vision loss, vertigo or dizziness, intractable nausea or
vomiting, loss of sensation on one side of your body, seizures
or any symptoms that concern you, please call your doctor or
return to the nearest emergency room.
Followup Instructions:
Please follow with:
[**Hospital6 733**], [**Hospital Ward Name 23**] Clinical Center, at [**Hospital1 771**] - [**Hospital Ward Name 516**]
with:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2109-1-25**]
2:45
Please follow up with the stroke clinic on
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **], at [**Hospital1 827**] - [**Hospital Ward Name 516**]
with:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2109-1-22**] 3:00
Neurosurgery:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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icd9cm
|
[
[
[]
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] |
[
"96.71",
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"88.48",
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icd9pcs
|
[
[
[]
]
] |
4936, 4942
|
2768, 4838
|
308, 389
|
5018, 5339
|
1866, 1871
|
7863, 8894
|
1237, 1246
|
4963, 4997
|
4864, 4913
|
5363, 7840
|
1261, 1261
|
230, 270
|
2440, 2745
|
417, 1160
|
1535, 1815
|
1834, 1847
|
1885, 2421
|
1500, 1519
|
1182, 1196
|
1212, 1221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,044
| 191,061
|
23529+23530
|
Discharge summary
|
report+report
|
Admission Date: [**2133-7-30**] Discharge Date: [**2133-8-9**]
Date of Birth: [**2069-3-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
generalized weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 1391**] is a 64 year old male with Type 2 DM, HTN, atrial
fibrillation on coumadin, CAD s/p CABG [**2127**] (4-vessel at [**Hospital1 336**]),
chronic surgical wound of left foot complicated by osteomyelitis
and status post debridement on intravenous vancomycin, who was
sent to the ED after evaluation in the podiatry clinic for HTN
and feeling unwell. At podiatry clinic he was noted to be pale
and weak.
.
The patient stated he has "not been feeling well" for the last
one week. Last week, he was trying to get up out of his recliner
and noticed that it felt like his legs were giving out
underneath him. He hit his hip on the sofa but otherwise had no
injuries. He denies any other associated symptoms especially
Lightheadedness or dizziness. Still states that he continued to
feel weak in his legs, occasionally he felt jittery. His
greatest difficulty comes with attempting to rise from a chair.
His knees ache constantly. Two nights ago he had some
discomfort/weakness while lifting a few folders from his kitchen
table. These light objects felt as though they were 12 pounds
heavy.
.
His sleep has also been poor over the last two to three weeks.
His wife thinks it is because he is short of breath but no PND
and stable 2 pillow orthopnea. He also noted increase in his
abdominal girth over the last one week.
.
His SOB has been ongoing since [**Month (only) 116**]. He says over all he thinks
it is about the same. It s more pronounced with walking; he only
walk small distance with a walker in his home. The patient had a
cough while on lisinopril. His wife described his breathing as
"labored." She also noted more lower extremity edema. This
evening he states it is easier for him to sit up to breath.
Denies CP/pressure, LH/dizziness.
.
Overall he feels unwell and has a difficult time honing in on
the exact nature of his symptoms.
.
In the [**Hospital1 18**] ED, he was afebrile, HR 80, BP 167/89, RR 18,
saturation of 94 % on Room Air. He was given Aspirin and Beta
Blocker, NS and TUMs in the ED. Head CT for history of a recent
fall at home was negative. Cardiology was consulted in ED.
.
Admitted for workup of muscle weakness, elevated troponin, and
SOB.
.
ROS: no F/C/+night sweats x a few months, no N/V/D/C/change in
stool or blood in stool, no LH/dizziness, no numbness/tingling,
no change in vision
Past Medical History:
IDDM, Htn, Afib w/ anticoagulation therapy
Gout, hypercholesterolemia, arthritis
CAD
PSH:
s/p L 5th ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]
Social History:
retired postal worker, married, 4 children, no tobacco, no drugs
use, ETOH qweek, wife involved
Family History:
Mother died of liver cancer in her 70's
Physical Exam:
PHYSICAL EXAM -
VS: 150/90, HR 77, RR 22, 89% RA, 94% 2L oxygen
Gen - Alert, no acute distress, some SOB with talking for
several minutes
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVP difficult to assess, no cervical lymphadenopathy
Chest - [**Month (only) **] BS in LL, no crackles, no wheezing, some [**Month (only) **] BS on
right LL, surgical scar
CV - distant HS, nl S1/S2, IRRR
Abd - obese, nontender, +distended, with normoactive bowel
sounds, ?+fluid wave
Back - No costovertebral angle tendernes, no sacral edema
Extr - No clubbing, cyanosis, 1+ edema to mid shin on R, [**1-26**]+ in
LLE. 1+ DP pulses in right
Left leg: surgical scar on left leg, dressed left foot wound
Neuro - Alert and oriented x 3, cranial nerves [**3-8**] intact, UE
strength 5/5 except for deltoid ([**4-29**]), LE [**5-29**] except for hip
extensors ([**3-29**])
Skin - No rash
MSK- no thigh, bicep, calf tenderness
Pertinent Results:
Labs: see below, notable for elevated CK/MB/troponin,
transaminitis, elevated BNP
.
EKG unchanged, low voltage - a fib, no ST changes.
.
[**2133-7-30**] CT head (prelim): No acute intracranial hemorrhage. Small
vessel ischemic changes and evidence of prior left parietal lobe
infarction.
.
[**2133-7-30**] CXR: Cardiomegaly without pulmonary edema. Left lower
lobe
atelectasis versus consolidation.
[**2133-7-30**] 04:10PM CK(CPK)-[**Numeric Identifier 60242**]*
[**2133-7-30**] 04:10PM CK-MB-100* MB INDX-0.8 cTropnT-0.27*
proBNP-1510*
[**2133-7-30**] 04:10PM VIT B12-188* FOLATE-8.2
[**2133-7-30**] 04:10PM TSH-3.0
[**2133-7-30**] 01:00PM GLUCOSE-69* UREA N-22* CREAT-1.1 SODIUM-143
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-28 ANION GAP-12
[**2133-7-30**] 01:00PM ALT(SGPT)-373* AST(SGOT)-433* CK(CPK)-[**Numeric Identifier 12181**]*
AMYLASE-41 TOT BILI-0.5
[**2133-7-30**] 01:00PM LIPASE-28
[**2133-7-30**] 01:00PM CK-MB-96* MB INDX-0.8 cTropnT-0.24*
[**2133-7-30**] 01:00PM ALBUMIN-3.7 CALCIUM-8.0* PHOSPHATE-3.3
MAGNESIUM-1.7
[**2133-7-30**] 01:00PM WBC-7.1 RBC-4.11* HGB-12.4* HCT-36.1* MCV-88
MCH-30.2 MCHC-34.3 RDW-15.9*
[**2133-7-30**] 01:00PM NEUTS-77.4* LYMPHS-15.4* MONOS-4.8 EOS-2.0
BASOS-0.3
[**2133-7-30**] 01:00PM PLT COUNT-195
[**2133-7-30**] 01:00PM PT-26.3* PTT-26.7 INR(PT)-2.7*
[**2133-8-8**] 06:04AM BLOOD WBC-8.6 RBC-4.38* Hgb-13.0* Hct-38.0*
MCV-87 MCH-29.6 MCHC-34.2 RDW-16.3* Plt Ct-216
[**2133-7-30**] 01:00PM BLOOD Neuts-77.4* Lymphs-15.4* Monos-4.8
Eos-2.0 Baso-0.3
[**2133-8-8**] 06:04AM BLOOD Plt Ct-216
[**2133-8-8**] 06:04AM BLOOD Glucose-119* UreaN-25* Creat-1.2 Na-140
K-4.1 Cl-100 HCO3-30 AnGap-14
[**2133-8-8**] 06:04AM BLOOD ALT-511* AST-525* CK(CPK)-[**Numeric Identifier 60243**]*
[**2133-8-7**] 05:58AM BLOOD ALT-474* AST-501* CK(CPK)-9940*
AlkPhos-48
[**2133-8-6**] 05:23AM BLOOD ALT-490* AST-535* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-46
[**2133-8-3**] 04:59PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2133-8-6**] 05:23AM BLOOD HCV Ab-NEGATIVE
[**2133-7-31**] 06:30AM BLOOD HCV Ab-NEGATIVE
[**2133-8-6**] 05:23AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
Brief Hospital Course:
Mr. [**Known lastname 1391**] is a 64 year old gentleman with DM2, HTN, AF, CAD
s/p CABG, and PVD who is admitted with diastolic CHF and
elevated CK's.
.
1. Rhabdomyolysis/Proximal muscle weakness-
Admission Creatine Kinase enzymes were found to be 11,419, this
value peaked 3 days later at 12,300 and reached a nadir of 9,200
during the hospitalization. His admission urinalysis was
supportive of rhabdomyolysis with the finding of large Heme
positivity with only scant RBC's. The patient was immediately
taken off his lipid lowering agents ezetimibe and tricor. The
patient had only a distant history of treatment with statins.
At first the patient was given gentle hydration to prevent renal
dysfunction in the setting of elevated CK's. However his kidney
function remained relatively stable throughout the
hospitalization with creatinine on admission at 1.1 peaking at
1.4 and reaching a nadir of 0.8. In this setting it was decided
to institute gentle diuresis with IV lasix to improve the
patient's respiratory status. With a net diuresis of [**1-25**].5
liters per day the patient reported improvement in his sensation
of shortness of breath. It was later felt that the patient may
have had diaphragmatic weakness in the setting of a thus far,
occult intraabdominal process. In the two weeks prior to
hospitalization the pt and his wife noted nearly a doubling in
the size of his abdomen. This in itself may explain a mechanical
deficit in the patient's ability to respire. Abdominal
ultrasound did not reveal any ascites, could not adequately
assess the patient's liver, but did note a mildly enlarged
spleen to 13.6cm. Hepatitis B and C were negative, neurology
consultation was obtained at it was felt that the patient's long
term use of tricor in combination with the recent addition of
Ezetemibe were likely at cause for the patient's CK elevation.
Low vitamin B12 was treated with B12 injection for 7days. As
noted above, the patient's CK's fluctuated around 10,000
throughout the hospitalization without any clear alteration in
renal function. Daily physical therapy also greatly improved the
pt's functional status and he was soon ambulating with a walker
and able to climb a flight of stairs without difficulty.
Creatinine values exhibited some fluctation from 1.1-1.4-0.8 At
time of discharge it was thought the patient's CK elevation
could be due to lingering effects of Tricor/Zetia combination,
however an intrabdominal process that may explain the patient's
clinical picture could be be ruled out. MR scan with gadolinium
contrast was attempted, but the patient was unable to fit into
the MR machine due to his abdominal girth. An outpatient open
MRI is suggested to further evaluate the abdomen and
specifically the liver to assess for possible vascular or
intrahepatic process. CT abdomen with contrast was not obtained
due to the patient's baseline mild renal insufficiency.
.
2. Diastolic CHF/CAD/AFib-
Cardiology consultation was obtained on admission for evaluation
of elevated CK-MB and Troponin. The patient was not having an
acute coronary syndrome, but rather a demand mediated ischemia.
CK-MB enzymes trended down moderately, but remained elevated in
the setting of his general CK eleavtion. Transthoracic
Echocardiography revealed LVEF of 55%, and mildly dilated
[**Doctor Last Name 1754**], no wall motion abnormalities. Given the patient's body
habitus it was thought diastolic dysfunction may be a component
of his symptoms of shortness of breath. He was titrated to 50mg
PO BID of Metoprolol in this setting, and was tolerating the
therapy well. He was switched to his home dose of lasix 40mg PO
daily and continued on avapro, coumadin, aspirin, and fish oil.
Of note, the patient's chest xray was never fully consistent
with a picture of heart failure, but rather demonstrated low
lung volumes. Pulmonary consultation was obtained to assess for
possible obstructive sleep apnea. They suggested an outpatient
sleep study with follow up by the sleep clinic at [**Hospital1 **] (or other facility of the PCP's choosing). Pulmonary
consult did concur with the fact that the patient seemed to be
exhibiting signs of diaphragmatic weakness. Further cause for
the need for abdominal evaluation
.
4. Transaminitis:
The patient AST was around 500 and ALT mid-high 400's.
Transaminase enzymes remained stable, but persistently elevated
throughout the admission. Hep B was negative, hep C was
negative.
.
5. Status post left foot debridement/osteomyelitis:
The patient was examined by podiatry for recommendations on
optimum care of pt's L TMA. The patient should continue to
follow up with podiatry as an outpatient. The patient's PICC
line used for IV vancomycin with his history of osteomyelitis
was removed just prior to discharge.
.
6. DM2:
The patient's blood glucose levels were optimally maintained on
NPH 18 U in AM, 12 U in the evening, in combination with a
humalog sliding scale.
Medications on Admission:
actos 45 mg qd
allopurinol 300 mg qd
amytriptilene 1 mg qd
avapro 300 mg qd
ASA 81 mg qd
catapress 0.3 qweek, changes on Sat.
diltizem CR 300 mg qd
lasix 40 mg qd
neurontin 600 mg [**Hospital1 **]
tricor 145 mg qd
coumadin 5 mg qhs x 6 days
zetia 10 mg qd
lopressor 25 mg [**Hospital1 **]
insulin: novolog 24 u qam/18qpm
fish oil 2 gm [**Hospital1 **]
.
Discontinued:
lisinopril 40 mg [**Hospital1 **]
glucophage 500 mg, pravacol 10 mg, indapamide 2.5 mg qd, norvasc
10 mg qd, zocor?
Temp meds:
rocephine, zyvox, zosyn, flagyl, levoquin, vancomycin (9 weeks)
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
4. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO qd ().
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Omega-3 Fatty Acids 550 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
DAILY (Daily) for 7 days.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Follow Insulin flow sheet attached Subcutaneous twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: rhabdomyolysis
Secondary:
Diabetes Mellitis
Peripheral Vascular Disease
Diastolic Heart Dysfunction
Discharge Condition:
Good
Discharge Instructions:
You have been diagnosed with rhabdomyolysis that may be related
to the cholesterol lowering drugs Zetia and Tricor. There is
also a possibility that this could be related to an abnormality
with your liver or gastrointestinal tract and it is important
you follow up as an outpatient for an abdominal MRI.
Please contact your doctor or call 911 if you should experience
shortness of breath, chest pain, severe muscle pain or worsening
weakness, dizzyness, uncontrollable bleeding, increasing
abdominal girth, or any other concerning symptoms.
Followup Instructions:
1)You should follow up with Dr. [**First Name (STitle) 745**] within the next Thursday
to follow up on your condition after discharge. It is
recommended you have further evaluation of your liver, with an
MRI scan, as an outpatient. This will need to be scheduled at a
facility with an open MRI scanner.
2)You have been taken off of Zetia and Tricor and it is
important you follow up with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name (STitle) 745**] to discuss alternative management of your cholesterol.
3)The pulmonary doctors have recommended [**Name5 (PTitle) **] have schedule a
sleep study due to their concern for obstructive sleep apnea and
how it may be affecting your heart. You can follow up with the
sleep clinic at [**Hospital1 18**] with the results from your sleep study if
you choose.
4)You should see your podiatrist for follow up care of your
foot.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Admission Date: [**2133-8-13**] Discharge Date: [**2133-9-10**]
Date of Birth: [**2069-3-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Weakness, increased abdominal girth,
Major Surgical or Invasive Procedure:
1. Tracheostomy Placement
2. PEG tube placement
History of Present Illness:
Pt is a 64 yo M with h/o DM2, CAD s/p recent hospitalization for
rhabdomyolyis and myopathy presenting with weakness. Pt states
that since d/c on [**8-9**] he has experienced progressively
worsening weakness. He states that he has the most difficulty
getting out of chair, changing clothes, not as much weakness at
the wrists or ankle. No diplopia or blurry vision, no dysphagia,
no headache or jaw pain. Pt denies any myalgias, no
paraesthesis. On the previous hospitalization his cholesterol
lowering agents were discontinued as it was thought that these
could be the possible culprits for rhabdomyolysis. During that
hospitalization neurology was consulted, and work up included nl
TSH, elevated ESR, negative [**Doctor First Name **]. Pt's health has been
deteriorating over the past year in the setting of a chronic
post surgical would infection at the left foot requiring most
recently vancomycin. He was started on zyvox 4 days prior to
this presentation. Of note, during his prior hospitalization he
complained of SOB and had an oxygen requirement. Echo
demonstrated an EF of % and it was felt that he possibly had
diastolic heart failure. He responded to gentle diuresis with
subjective improvement in symptoms. Pulmonary was consulted at
that time and recommended outpt sleep study. His hospital course
results were also remarkable for persistently elevated LFTs. An
MRI was planned to further evaluate but pt was unable to fit in
MRI due to abdominal girth.
.
In the ED his labs were notable for elevated CK to < [**Numeric Identifier 4731**]. This
was higher than the CK max at the prior hospitalization. He was
given 1L NS.
.
ROS: positive for mild SOB which he says is unchanged since
discharge - overall improved over the past month since starting
diuretics; denies CP/palp/cough/diarrhea/rash.
Past Medical History:
IDDM, Htn, Afib w/ anticoagulation therapy
Gout, hypercholesterolemia, arthritis
CAD
PSH:
s/p L 5th ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]
Social History:
retired postal worker, married, 4 children, no tobacco, no drugs
use, ETOH qweek, wife involved
Family History:
Mother died of liver cancer in her 70's
Physical Exam:
VS: 130/80, HR 87, RR 16, 89% RA, 96% 2L oxygen
Gen - NAD
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVP 8cm, no cervical lymphadenopathy
Chest - CTA bl
CV - irrg/irreg nl s1 s2 no mrg
Abd - obese, nt, nd, nabs
Back - No costovertebral angle tendernes, no sacral edema
Extr - No clubbing, cyanosis, 1+ edema to mid shin bl
Left - foot surgical scar wound
Neuro - Alert and oriented x 3, cranial nerves [**3-8**] intact, UE
strength 5/5 except for deltoid ([**4-29**]), LE [**5-29**] except for hip
extensors ([**4-29**]); sensation intact
Skin - No rash
Pertinent Results:
[**2133-8-13**] 05:30PM GLUCOSE-120* UREA N-43* CREAT-1.4* SODIUM-138
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-28 ANION GAP-14
[**2133-8-13**] 05:42PM LACTATE-1.5
[**2133-8-13**] 05:30PM ALT(SGPT)-542* AST(SGOT)-573* CK(CPK)-[**Numeric Identifier 37476**]*
ALK PHOS-63 TOT BILI-0.5
[**2133-8-13**] 05:30PM LIPASE-39
[**2133-8-13**] 05:30PM WBC-8.5 RBC-4.15* HGB-12.3* HCT-35.8* MCV-86
MCH-29.6 MCHC-34.4 RDW-16.4*
[**2133-8-13**] 05:30PM NEUTS-79.3* LYMPHS-14.2* MONOS-4.6 EOS-1.6
BASOS-0.4
[**2133-8-13**] 05:30PM ANISOCYT-1+ MICROCYT-1+
[**2133-8-13**] 05:30PM PLT COUNT-192
.
CXR--Bibasilar atelectasis, cardiomegaly
.
.
FINAL DIAGNOSIS:
RIGHT DELTOID MUSCLE BIOPSY (including snap-frozen tissue):
Acute, recent, and chronic myopathy (chronic active myopathy)
Acute myofiber necrosis.
Scattered degenerating and regenerating myofibers and scattered
myophagocytosis, indicative of recent myofiber injury.
Increased endomysial connective tissue, increased frequency of
internalized nuclei, and scattered split myofibers, indicative
of chronic myopathy.
Scattered CD4 and CD8 T-lymphocytes, without direct association
with pathologic changes.
Coarse lipid and mitochondrial staining in degenerating
myofibers.
NOTE:
In addition to the findings identified in the preliminary
report, these special stains identify coarse lipid staining in
many of the degenerating myofibers, along with corresponding
changes in mitochondria. While not specific, they are consistent
with a metabolic myopathy affecting lipid metabolism, as can be
induced by toxic agents and several drugs. They are consistent
with effects of some cholesterol lower agents, especially
combinations of agents in elderly patients. Diagnostic changes
of an inflammatory myositis are not identified in this biopsy.
MICROSCOPIC DESCRIPTION:
H&E stain: increased internalized nuclei and split myofibers;
scattered myophagocytosis and frequent degenerating and
regenerating myofibers, including atrophic basophilic fibers;
moderate to marked variation in myofiber size; frequent small,
round or angulated myofibers; scattered acutely necrotic
myofibers having pale eosinophilic staining
Gomori trichrome stain: increased endomysial connective tissue
in sites of greatest degeneration; no ragged red fibers;
degenerating myofibers often show coarse staining of
sarcoplasmic mitochondria
PAS stain: normal distribution of glycogen
PAS + diastase stain: no diastase-resistant glycogen
Oil red "O" stain: coarse staining of degenerating myofibers
NADH histochemistry: coarse staining of degenerating myofibers
in a mitochondrial pattern (mitochondrial clumping)
ATPase (pH 4.3, 4.6, 9.5) histochemistry: type I myofiber
predominant; atrophic myofibers of both types - predominantly
type II; no diagnostic type grouping.
CD3 immunoperoxidase: non-contributory
CD4 immunoperoxidase: scattered T4 lymphocytes throughout
specimen; not directly associated with individual myofiber
injury
CD8 immunoperoxidase: scattered T8 lymphocytes throughout
specimen; not directly associated with individual myofiber
injury
CD68 immunoperoxidase: non-contributory
Factor VIII immunoperoxidase: normal numbers of vessels,
including endomysial capillaries
Brief Hospital Course:
A/P:
64yo man with h/o TIIDM, CAD, Afib, and Gout, presenting with
myositis vs rhabdomyalysis, transferred now with tachypnea and
hypercapnia and acidemia.
.
# Respiratory failure Poor ventilation due to progressive
muscle weakness. Rising PCO2 and respiratory acidemia
progressed to hypercarbic respiratory failure. No evidence of
primary pulmonary process.
- Pt intubated for worsening ventilation/oxygenation in setting
of worsening weakness
- Remained intubated due to poor NIFs. Very brief SBT failed
when pt had no respiratory effort.
-Given continued poor respiratory muscle strength, likelihood of
lengthy intubation, percutaneous tracheostomy performed on
[**2133-9-1**] and trach placed. Complicated trach placement due to
subcutaneous emphysema on same day of trach placement. Incision
site was widened and subcutaneous emphysema and swelling
decreased over the next two days. No pneumothorax or
pneumomediastinum seen on CXR.
.
# Myospathy: rhabdomyolysis/myopathy, pathololgy from muscle
biopsy suggests myopathic changes, possibly drug-induced.
Rheumatology and neurology consulted. Not thought that steroids
will help this disease process. Off statins, will follow CK and
clinical picture, await gradual recovery.
.
# ARF: contrast nephropathy, ATN on chronic diabetic
nephrophathy. patient briefly anuric. Hemodialyzed, but now
with improving renal function, increased urine output, no
further need for dialysis at this time.
.
# Transaminitis: LFTs returned to NL; likely due to rhabdo.
hepatitis serologies negative. CTA abdomen nondiagnostic
.
# Foot wound: patient completed 10days Linezolid per podiatry
recc's. Podiatry following.
.
# TIIDM: RISS + NPH for elevated blood sugars.
.
# HTN: metoprolol
.
# FEN: diabetic, cardiac diet; PEG placed on [**9-8**]
.
# PPx: SC heparin, po diet
.
# Access: PICC
.
# Full Code
Medications on Admission:
Allopurinol 200 mg PO DAILY
Aspirin 81 mg PO DAILY
Clonidine 0.3 mg/24 hr Patch Weekly QSAT
Irbesartan 300 mg PO qd
Warfarin 5 mg PO 6X/WEEK (MO,TU,WE,TH,FR,SA)
Docusate Sodium 100 mg PO BID
Omega-3 Fatty Acids 550 mg PO BID
Gabapentin 300 mg PO BID
Folic Acid 1 mg PO DAILY
Cyanocobalamin 1,000 mcg/mL for 7 days.
Furosemide 40 mg PO DAILY
Metoprolol Tartrate 50 mg PO BID
Insulin NPH-Regular
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
10. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
11. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP>155.
18. Vancomycin HCl 1000 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Myopathy
2. Respiratory Failure
Discharge Condition:
Good
Discharge Instructions:
- Please take all medications as prescribed.
- Return if you have any worsening weakness, any worsening
muscle cramping, chest pain, dizziness, faintness, or any other
concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of discharge.
|
[
"427.31",
"599.0",
"518.84",
"428.31",
"401.9",
"585.9",
"428.0",
"790.4",
"272.0",
"V45.81",
"274.9",
"E942.2",
"584.5",
"584.9",
"997.62",
"403.91",
"728.88",
"443.9",
"414.01",
"V58.61",
"250.40",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.21",
"39.95",
"33.22",
"96.72",
"93.90",
"96.6",
"31.1",
"43.11",
"99.07",
"38.93",
"38.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
25141, 25220
|
21283, 23158
|
15056, 15106
|
25299, 25306
|
18033, 18669
|
25543, 25646
|
17361, 17402
|
23603, 25118
|
25241, 25278
|
23184, 23580
|
18689, 21260
|
25330, 25520
|
17417, 18014
|
14980, 15018
|
15134, 16946
|
16968, 17231
|
17247, 17345
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,513
| 151,433
|
8245
|
Discharge summary
|
report
|
Admission Date: [**2155-10-31**] Discharge Date: [**2155-11-7**]
Date of Birth: [**2095-10-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
referred for elective cardiac cath
Major Surgical or Invasive Procedure:
cardiac catheterization
PCI with angioplasty and drug eluting stents
History of Present Illness:
60 year old woman with prior history of anterior MI, s/p lysis
with subsequent cath revealing only 45% LAD, CHF (EF 30%),
severe COPD who presented with several days of increasing DOE.
She indicates that these symptoms, as well as some epigastric
burning pain, have all been worseing over the past several
weeks. The epigastric burning is usually at night, and is
relieved with maalox / rolaids
.
She had an ETT as an outpatient two months ago that showed a
fixed apical defect. Two months ago admitted with CHF. Echo
revealing an LVEF of 35% with severe pulmonary HTN and apical
WMA. Diuresed. Had been stable at home for the past months on
diuretics, admitted on the 27th with two episodes of severe SOB
and chest burning. Ruled out for MI.
.
Underwent dobutamine echo at the OSH and had similar chest
burning with elevation of HR during dobutamine infusion.
Anterior wall remained AK, other walls fine.
.
Patient was transferred to the ICU at 3am on [**2155-10-31**] after she
went in to flash pulmonary edema. BP 174/100, she was started on
a Nitro gtt and given 80mg IV lasix. Patient diuresed 2100cc. Of
note, at that time, a chest xray did not reveal pulmonary edema.
At 5am BP 92/58- Nitro gtt off. She is currently stable, able to
lay flat without difficulty. She has heparin @ 1100units/hr.
[**10-30**] INR 0.9
.
Review of Systems: Otherwise she has been feeling fine. She
endorses PND, orthopnea, but no edema. She can walk less than
one city block at baseline before getting SOB.
Past Medical History:
Congestive Heart Failure, EF 30%
Non-Hodgkin's Lymphoma
Severe Emphysema (s/p intubation in [**2155-7-1**])
CAD ([**2147**] anterior myocardial damage s/p lysis; cath with
45%LAD)
Pulmonary hypertension
Hypertension
Schizophrenia
DM type 2
Pneumonia in [**2155-7-1**] (rx with levofloxacin)
Tobacco use
Prior DVT
Social History:
Lives with her parents. Recently retired from housekekeping work
at a hospital. She quit tobacco 4 months ago (smoked for 30
years). She denies EtOH use.
Family History:
Brother with pacemaker.
.
Physical Exam:
Upon arrival to the medicine floor:
Vs- 97.3 100 116/77 24 96% 2L
Gen- Female lying flat in bed, appearing older than stated age,
in mild distress with breathing
Heent- MMdry, dry blood on tongue and nares, anicteric
Neck- supple, JVP 9cm
Cor- Regular, tachy, distant heart sounds, no M/R/G
Chest- Mild decreased breath sounds, expiratory wheezes, no
rales
Abd- obese, distended, NT, pos bs
Ext- No edema, good pulses, right groin with ooze, no hematoma
Neuro- AAO 3
Skin- seborrheic keratoses
Pertinent Results:
Laboratory:
CK peak 56 ([**2155-11-1**])
TnT peak 0.02 ([**Date range (1) 29270**])
ABG at transfer to CCU: pH 7.49/pCO2 36/pO2 54
.
Microbiology:
[**2155-11-2**]: Blood Cx: 3/4 bottles: GNR (quinolone, cephalosporin
[**Last Name (un) 36**])
.
Cardiac Catheterization: [**2155-10-31**]
1. Selective coronary angiography in this left dominant system
revealed three vessel coronary artery disease. The LMCA was
normal.
The LAD had a 70% stenosis in the mid segment, mild disease
throughout,
and a very small D1 with a 90% lesion. The LCx was subtotally
occluded
just before the lPDA. The RCA was a small nondominant artery
with
diffuse disease.
2. Limited hemodynamic assessment demonstrated elevated left
sided
filling pressures with an LVEDP of 25. There was systemic
arterial
hypertension with an SBP of 160 mmHg and DBP of 93 mmHg.
3. Successful direct stenting was performed of the mid LAD with
a 2.5x13
mm Cypher stent. Final angiography revealed 0% residual
stenosis, no
dissection, and normal flow. (see PTCA comments)
4. Successful PTCA and stenting was performed of the distal CX
with a
2.5x23 mm Cypher stent. Final angiography revealed 0% residual
stenosis, no dissection, and normal flow. (see PTCA comments)
5. Right femoral arteriotomy site closed with a 6F Angioseal
device.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated left sided filling pressures.
3. Successful PTCA and stenting of the mid LAD and distal CX
with drug
eluting stents.
.
[**2155-11-2**]: CTA chest - 1. Severe emphysema. 2. No evidence of
pulmonary embolism. 3. Coronary artery calcifications.
.
[**2155-11-3**]: ECHO (TTE) -
The LA is normal in size. LV wall thicknesses and cavity size
are normal. There is mild regional LV systolic dysfunction with
focal severe hypokinesis of the distal half of the septum,
distal anterior wall, basal inferior wall and apex. The
remaining LV segments contract normally. RV chamber size and
free wall motion are normal. The AV leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The MV leaflets are structurally normal.
There is no MV prolapse. Mild to moderate ([**12-2**]+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Regional LV systolic dysfunction c/w multivessel
CAD. Mild-moderate mitral regurgitation.
.
[**2155-11-4**] CXR: The heart is normal in size. The cardiac
silhouette, mediastinal and hilar contours, and pleural surfaces
are normal. The pulmonary vasculature is normal and there is no
pneumothorax. The lungs are hyperinflated, similar to [**2155-11-4**].
The lungs are clear. There are no pleural effusions or
pneumothorax.
IMPRESSION: 1. No evidence of pneumonia, unchanged compared to
[**2155-11-4**]. 2. Hyperinflation indicating emphysematous disease
shown to be extensive on CTA [**2155-11-2**].
Brief Hospital Course:
In brief, the patient is a 60F CAD, severe COPD, DM who was
referred for cardiac catheterization who underwent PCI, however
her course was complicated by respiratory distress and GNR
bacteremia.
.
1. Respiratory distress: The patient developed sudden onset
respiratory distress and new oxygen requirement this was thought
c/w a COPD exacerbation. Pt had a h/o severe emphysema with FEV1
of 0.8. Wheezing has remained the predominant finding on exam.
Despite her multiple episodes of SOB here and at [**Location (un) 620**], her
CXRs have all remaied clear. However the cath showed LVEDP of
25, which raises the possibility that some pulmonary vascular
congestion may be contributing to the bronchospasm. Another
possibility is dye allergy given the shellfish allergy, although
this did not seem likely given the contrast load during the cath
that was tolerated well. She was treated with steroids,
bronchdilators, and antibiotics. She did receive a dose of
lasix and was briefly placed on a nitroglycerin gtt for
presumptive pulmonary edema, but much of her recovery was
thought secondary to the COPD therapy. Her home dose of
beta-blocker was held until her respiratory status improved. She
will complete a 2 week course of steroids, as well as
levofloxacin for 14 days. At the time of discharge, she was
feeling very comfortable, but still requiring two liters of
oxygen via nasal cannula. She would desaturate to SpO2 87% with
ambulation. She was discharged with home oxygen and visiting
nurse to monitor lung exam, oxygenation.
.
2. Cardiac
a. Coronary artery disease: The patient was referred for
elective cardiac cath after having an indeterminate dobutamine
stress echo at the OSH. The cath revealed 3-vessel disease. As
her severe COPD (FEV1 <1 L) would limit the safety of CABG, an
LAD lesion and LCx lesion were treated with angioplasty and DES
(please see full cath report for details). Her CK peak was only
56. She will continue on aspirin 325, plavix, statin, and ACE
inhibitor. Her beta-blocker was held temporarily and was resumed
by time of discharge.
.
b. Pump:
The patient has a history of CHF with EF 30%. She had been
treated for CHF exacerbation on her prior episodes however it is
unclear why she seemed to respond to diuresis although her chest
xray never revealed pulmonary edema. A repeat TTE revealed
essentially unchanged LV function c/w 3-vessel coronary disease.
By time of discharge, she will be stable on her ACE inhibitor
and beta-blocker regimens.
.
c. Rhythm: When the patient developed her respiratory distress
requiring CCU transfer, the patient was in a regular narrow
complex tachycardia c/w sinus tachycardia. The rate was steady
at 145 which was suspicious for atrial flutter, however
following carotid massage (after hearing no carotid bruits)
distinct P-waves were appreciated prior to each QRS complex. The
sinus tachycardia was attributed to the respiratory distress and
relative hypovolemia following diuresis. The heart rate resolved
toward her baseline.
.
3. Fever: During the respiratory distress the patient was
febrile to ~103F. There was no overt source of infection as the
patient had clear chest imaging, no evidence of UTI on
urinalysis, no GI symptoms. However blood cultures resulted
with 3 of 4 bottles with GNR (Klebsiella pneumonia) that was
sensitive to quinolones and cephalosporins. She was started on
antibiotics as above. She should complete a 14 day course of
antibiotics.
.
4.) Diabetes mellitus type 2 uncontrolled - With the initiation
of the steroid therapy for the COPD exacerbation, her blood
sugars were difficult to control. Her sugars were initially
managed with an insulin drip. As her steroids were tapered she
was converted to her home oral anti-hyperglycemic regimen with
supplemental insulin. She had several episodes of low AM blood
sugars (to the 40s), so she was not discharged on insulin, but
this could be needed as an outpatient as determined by her PCP.
.
.
PPX: hep SC; PPI
Code: Full
Medications on Admission:
Lasix 80 p.o. [**Hospital1 **]
Aldactone 12.5mg qd
glipizide 10 mg p.o. daily
metformin 2 grams p.o. daily
albuterol
Advair
Spiriva
Prilosec 20 mg
Risperdal 20 mg p.o. qhs
prednisone 10mg qd
thyroxine 0.112 mg
lipitor 40
Discharge Medications:
1. Supplemental oxygen
Please use 2L continuous oxygen via nasal cannula.
Disp quantity sufficient for one month.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
5. Risperidone 1 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
Disp:*150 Tablet(s)* Refills:*2*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
15 days: Please continue while on prednisone.
Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*60 Cap(s)* Refills:*2*
10. Metformin 500 mg Tablet Sustained Release 24HR Sig: Four (4)
Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*60 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day
for 15 days: Please take 5 tabs (50mg) for three days
([**Date range (1) 29271**]); then 4 tabs for three days ([**Date range (1) 29272**]); then
take three tabs for three days ([**Date range (1) 18319**]); then two tabs for
three days ([**Date range (1) 29273**]); and then one tab for three days
([**Date range (1) 5530**]).
Disp:*50 Tablet(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QOD ().
Disp:*30 Tablet(s)* Refills:*2*
16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Coronary artery disease
COPD exacerbation
Bacteremia
.
Secondary:
Diabetes mellitus type 2 uncontrolled
Discharge Condition:
Good, ambulating, tolerating PO meds, stable on 2L oxygen
Discharge Instructions:
If you experience any chest pain, difficulty breathing, fevers,
bleeding, or any other concerning symptom, please seek immediate
medical attention.
.
Please follow up with Dr. [**Last Name (STitle) 5057**] on Tuesday, [**2155-11-11**] at 2pm.
YOu will need to discuss this hospitalization, your new
medications, as well as your ongoing need for oxygen and the
possible need of home insulin therapy.
.
Please take all medications as directed.
.
You should have your visiting nurse check your oxgen level, your
lung exam, as well as your blood sugar. If you are consistently
having readings over 250, you should notify your doctor.
Followup Instructions:
Dr. [**Last Name (STitle) 5057**] on [**11-11**] at 2pm.
.
Dr. [**Last Name (STitle) 22882**] before [**Month (only) 404**]. Please call [**Telephone/Fax (1) 28634**].
|
[
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"244.9",
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"00.46",
"36.07",
"88.56",
"37.22",
"00.41",
"99.20",
"00.66",
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] |
icd9pcs
|
[
[
[]
]
] |
12617, 12666
|
5934, 9927
|
309, 379
|
12823, 12883
|
2983, 4284
|
13562, 13734
|
2425, 2453
|
10199, 12594
|
12687, 12802
|
9953, 10176
|
4301, 5911
|
12907, 13539
|
2468, 2964
|
1749, 1901
|
235, 271
|
407, 1730
|
1923, 2238
|
2254, 2409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,738
| 180,834
|
36157+58062
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-10-15**] Discharge Date: [**2103-10-24**]
Date of Birth: [**2030-3-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2103-10-17**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
Diagonal, Saphenous vein graft to Obtuse marginal, Saphenous
vein graft to Posterior descending artery)
History of Present Illness:
73 y/o female with several months of exertional chest
discomfort. Was admitted to OSH in [**8-22**] but was ruled out for
myocardial infarction and had a negative stress test. Since then
she was been noticing increasing frequency of chest pain.
Admitted to OSH where she underwent cardiac cath which showed
severe three vessel coronary artery disease.
Past Medical History:
Hypertension, Hypothyroidism, Obstructive airway disease
Social History:
Retired nurse. Denies tobacco and ETOH use.
Family History:
Non-contributory
Physical Exam:
At discharge:
VS: 98.8, 125/60, 73SR, 18, 95%RA
Gen: NAD
Skin: no rash
Chest: crackles bilateral bases, o/w clear
Heart: RRR, no murmur or rub
Abd: NABS, soft, non-tender, non-distended
Ext: trace edema
Neuro: grossly in-tact
Incisions: [**Doctor Last Name **]- c/d/i, no erythema or drainage, LEVH- minor
erythema about the edges, no drainage, wound well approximated
Pertinent Results:
[**2103-10-16**] CT: 1. Elevation of right hemidiaphragm secondary to
eventration, without evidence of pleural tumor or hepatic tumor.
2. Single kidney identified on the right. This is likely due to
embryologic variant, although left-sided pelvic kidney is not
excluded (as the pelvis was
not scanned on this examination). 3. Ascending aortic arch
appears essentially void of vascular calcifications; however,
mild vascular calcifications are seen along the entire course of
the descending thoracic and abdominal aortic. 4. Marked vascular
calcifications, particularly involving the coronary arteries.
[**2103-10-16**] Carotid U/S: 1. Less than 40% stenosis in the right
internal carotid artery. 2. 40-59% stenosis in the left internal
carotid artery.
[**2103-10-17**] Echo: Prebypass: 1. No atrial septal defect is seen by
2D or color Doppler. 2. Left ventricular wall thicknesses are
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). 3.
Right ventricular chamber size and free wall motion are normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 6. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. 7. Dr. [**Last Name (STitle) **] was notified in person of
the results on [**2103-10-17**] at 1030 am. POSTBYPASS: 1. The patient
is on phenylephrine and epinephrine infusions. 2. The left
ventricular function remains good, EF 65%. 3. The mitral
regurgitation immediately after bypass appeared moderate to
severe (3+) but improved to prebypass levels of moderate MR. 4.
Aortic contours are smooth after decannulation.
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname **] [**Known lastname 52014**] was transferred from
OSH for surgical revascularization. She was worked-up in the
appropriate manner and brought to the operating room on [**10-17**]
where she underwent a coronary artery bypass graft x 4. Please
see operative report for surgical details. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one she was
started on beta-blockers and diuretics and gently diuresed
towards her pre-op weight. The patient was transferred to the
step-down unit where she made good progress. Chest tubes and
pacing wires were discontinued without complication. Hematocrit
was 24 on POD 5 and the patient was feeling weak. She was
transfused two units of packed red blood cells with improvement
in her symptoms. Hematocrit rose to 30. A short course of
keflex was given for sternal drainage which promptly cleared.
Hospital course was otherwise uneventful and the patient was
discharged home on POD 7.
Medications on Admission:
Lopressor 50mg [**Hospital1 **], Prilosec 20mg qd, Levothyroxine 100mcg qd,
Symbicort 160/4.5 2 puffs [**Hospital1 **], MVI, Lasix 20mg qd, Diovan 160mg
qd, Pravachol 20mg qd, Aspirin 81mg qd, Isosorbide 10mg [**Hospital1 **]
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. 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*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
9. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. 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*
11. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Hypertension, Hypothyroidism, Obstructive airway disease
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Take lasix and potassium for 1 week and then stop.
8) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] in 4 weeks
Dr. [**Last Name (STitle) 5017**] [**Telephone/Fax (1) 5424**] in [**12-17**] weeks
Dr. [**Last Name (STitle) 12593**] [**Telephone/Fax (1) 12597**] in [**11-15**] weeks
Please call all providers to schedule appointments.
Completed by:[**2103-10-24**] Name: [**Known lastname **] [**Known lastname 13138**],[**Known firstname 13139**] M Unit No: [**Numeric Identifier 13140**]
Admission Date: [**2103-10-15**] Discharge Date: [**2103-10-24**]
Date of Birth: [**2030-3-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 741**]
Addendum:
The patient was also discharged on Keflex 500 QID for 1 week for
sternal and leg redness.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2103-10-24**]
|
[
"244.9",
"327.23",
"695.9",
"519.8",
"427.31",
"401.9",
"E931.9",
"458.29",
"784.2",
"414.01",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.13",
"36.15",
"39.61",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
7989, 8119
|
3283, 4412
|
292, 530
|
6339, 6345
|
1491, 3260
|
7176, 7966
|
1068, 1086
|
4688, 6144
|
6194, 6318
|
4438, 4665
|
6369, 7153
|
1101, 1101
|
1115, 1472
|
242, 254
|
558, 911
|
933, 991
|
1007, 1052
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,587
| 102,683
|
35383
|
Discharge summary
|
report
|
Admission Date: [**2124-4-10**] Discharge Date: [**2124-4-17**]
Date of Birth: [**2072-10-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Vicodin / Codeine / Opium
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Ataxia,gait instability
Major Surgical or Invasive Procedure:
[**4-14**]: Right Posterior Fossa Craniotomy/craniectomy for mass
resection
History of Present Illness:
Ms. [**Known lastname 80652**] was well until last week or two when she had noticed
increasing headaches. The headaches were worse when she was
straining with bowel movements or laughing, but often it also
came with or without any precipitating factors. She was also
noticed being clumsy and having loosing her balance as well.
She has not had any visual disturbances. No other signs of
intracranial tensions like headache, nausea, vomiting, or other
motor, sensory, or neurological deficits. She had a head CT,
which showed right lateral CP angle mass
measuring about 4.8 x 4.7 cm. This was heterogeneously
enhancing. An MRI confirmed this mass also.
Past Medical History:
-s/p 4 left ovarian cystectomies
-reports that one cyst "fell out" into the toilet that was
greyish in appearance
-s/p hysterectomy and bilateral oophorectomies [**2107**]
-left foot cyst
-3 left hip lipomas removed
-kidney stones
-s/p cholecystectomy [**27**] years ago
-left shoulder ganglion cyst
-s/p "bladder sling" [**2123-9-13**]
-emphysema
-hypercholesterolemia
Social History:
Has several family members with her that are supportive, +
tobacco, has tried to quit 6 times
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM Upon Admission:
T:97.5 BP:127/81 HR:74 RR:12 O2Sats:97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERRL EOMs-intact
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, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-21**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-23**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: Slowed on finger-nose-finger. Normal rapid
alternating movements, heel to shin.
+ Rhomberg test
Upon Discharge:
Pertinent Results:
Labs on Admission:
[**2124-4-10**] 04:53PM BLOOD WBC-8.1 RBC-4.99 Hgb-14.6 Hct-41.7 MCV-84
MCH-29.2 MCHC-35.0 RDW-13.9 Plt Ct-330
[**2124-4-10**] 04:53PM BLOOD Neuts-70.3* Lymphs-25.4 Monos-2.1 Eos-1.6
Baso-0.7
[**2124-4-10**] 05:51PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2124-4-10**] 04:53PM BLOOD Glucose-96 UreaN-20 Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-24 AnGap-16
[**2124-4-11**] 05:01AM BLOOD Calcium-10.4* Phos-3.7 Mg-2.4
Labs on Discharge:
[**2124-4-16**]
07:25a
136 101 22 127 AGap=10
-------------/
4.6 30 0.7
Ca: 9.0 Mg: 2.4 P: 3.3
Wbc: 14.6 Hgb:11.7 PLT: 333 Hct:32.2
PT: 12.1 PTT: 22.8 INR: 1.0
CT head [**2124-4-10**]:
FINDINGS: Centered in the right lateral posterior fossa,
adjacent to the
cerebellopontine angle, there is an apparent extra-axial, 4.8 x
4.7 cm,
heterogeneous, avidly-enhancing mass with small foci of
calcification along
the rim. On non- contrast images, this lesion is slightly
hyperdense compared to brain parenchyma, particularly along the
rim, with central hypodense region. There is resulting mass
effect and compression of right cerebellar hemisphere. There is
no erosion or definite hyperostosis identified of the adjacent
bone. There is mass effect resulting in compression of the right
perimesencephalic cistern, and leftward displacement of the
fourth ventricle, which still appears patent. There is evidence
of tonsillar herniation. Overall, the ventricles have a slightly
enlarged appearance, which could reflect a mild degree of
outflow obstruction. The right jugular vein appears patent as
well as part of the sigmoid sinus. However, the tumor effaces
the sigmoid sinus within its groove at the level of the fourth
ventricle. The sigmoid and transverse sinus cephalad to this
region appear patent. Elsewhere, there is no intracranial
hemorrhage, edema, shift of normally midline structures or
evidence of major vascular territorial infarcts. The remaining
basilar cisterns are patent. The [**Doctor Last Name 352**]-white differentiation in
the cerebral cortex is preserved. There is no fracture. Mastoid
air cells and paranasal sinuses are well aerated. Soft tissues
are normal.
IMPRESSION: Large right posterior fossa extraaxial, enhancing,
heterogeneous mass resulting in tonsillar herniation,
compression of the right perimesencephalic cistern and
displacement of fourth ventricle, likely causing a mild degree
of outflow obstruction. The adjacent sigmoid sinus appears
effaced. The imaging findings are most consistent with a large
meningioma. A contrast-enhanced MRI could provide further
information, including the patency of the adjacent sigmoid
sinus.
MRI head [**2124-4-10**]:
FINDINGS: In comparison with a prior examination, again on the
right side of the posterior fossa, there is a large apparently
extra-axial mass lesion, measuring approximately 5.0 x 4.5 cm in
transverse dimensions x 4.5 x 4.5 cm in the coronal MP-RAGE
projection. This lesion demonstrates mild hyperintense signal in
comparison with the rest of the brain parenchyma on T1 without
contrast. No restricted diffusion is identified. Several
heterogeneous signal areas are visualized on the FLAIR sequence
within this mass lesion, possibly related with punctate
calcifications and hyperintensity signal areas on T2, possibly
related with small areas with cystic transformation. With
gadolinium contrast, this lesion enhance avidly, mild vasogenic
edema is identified and significant mass effect and shifting of
the fourth ventricle towards the left. The prepontine cistern
apparently is preserved, mild effacement of the inferior right
collicular cistern is demonstrated. Supratentorially, there is
no evidence of abnormal enhancement and both cerebral
hemispheres are grossly normal, no diffusion abnormalities are
detected. The ventricles are slightly prominent, however no
significant transependymal migration of CSF is demonstrated.
Multiple areas of hyperintensity signal are visualized in the
periventricular white matter, likely consistent with chronic
areas of gliosis or small vessel disease. Normal flow void is
identified in the major vascular structures, the right posterior
fossa mass lesion lesion is in close contact with the right
trasverse sinus. The coronal and sagittal images demonstrate
right tonsillar herniation, approximately 1.5 cm of tonsillar
herniation is demonstrated on the sagittal image. The orbits,
the paranasal sinuses, and the mastoid air cells appear within
normal limits.
IMPRESSION:
1. Large extra-axial right posterior fossa mass lesion, with
significant pattern of enhancement and areas of heterogeneous
signal, more
likely consistent with a large meningioma, resulting in right
tonsillar
herniation, mass effect, and compression of the fourth ventricle
as described in detail above.
2. Multiple areas of hyperintensity signal are visualized in the
periventricular white matter, likely consistent with chronic
areas of gliosis or small vessel disease, however, nonspecific.
No other lesions or areas with abnormal enhancement are
demonstrated.
CT Torso [**4-13**]:
CT OF THE CHEST WITH CONTRAST, FINDINGS: No pulmonary
parenchymal
abnormalities are appreciated. The aorta appears unremarkable as
well as its major branches. There is no hilar, mediastinal or
axillary adenopathy. No breast masses. Bone windows show no
abnormalities.
Initial wet read to raised the question of a filling defect
involving the left pulmonary artery which is felt to be
extrinsic to the artery or due to partial volume effect. Note of
a cyst involving the left pericardium.
CT OF THE ABDOMEN WITH CONTRAST AND WITHOUT CONTRAST, FINDINGS:
The patient
is status post cholecystectomy. The liver is unremarkable with a
patent
portal vein, no focal mass lesions, and no dilated ducts. The
kidneys,
adrenal glands, spleen, pancreas, and visualized loops of large
and small
bowel appear normal. The aorta as well as its branches also
appears
unremarkable.
CT OF THE PELVIS WITH CONTRAST, FINDINGS: The visualized loops
of large and
small bowel appear normal. There is no free fluid, no
adenopathy. The
patient is status post hysterectomy. Bone windows demonstrate no
suspicious lytic or blastic change.
IMPRESSION:
1. No findings to suggest a primary source of this patient's
intracranial
pathology.
2. Simple pericardial cyst.
3. No evidence of acute pulmonary embolism.
EKG [**4-13**]:
Normal sinus rhythm, rate 71. Normal tracing. No previous
tracing available
for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 160 110 386/405 47 22 48
MRI [**4-15**]:
FINDINGS: Since the previous study, the patient has undergone
resection of
right-sided posterior fossa meningioma. Blood products are seen
with a large surgical cavity in the region. Mild surrounding
edema is identified. No acute infarcts are seen. No residual
enhancement is identified. There is no evidence of
hydrocephalus. The previously noted subtle periventricular
signal abnormalities are unchanged. Of concern is filling defect
within the right transverse sinus extending from torcula to the
region of the sigmoid sinus. The left transverse sinus as well
as the superior sagittal sinus, and deep venous system are
patent.
Fluid is seen within the soft tissues in the right parietal
region related to surgery. Inferior position of the cerebellar
tonsils is again identified and is unchanged.
IMPRESSION:
1. Postoperative changes in the posterior fossa with blood
products, air, and surrounding edema unchanged with a downward
position of the cerebellar tonsils as before. Mass effect on the
fourth ventricle is seen without hydrocephalus with a mass
effect decrease since the previous study.
2. Filling defect is seen in the right transverse sinus
concerning for
thrombosis within the sinus. Further evaluation with the MRV is
recommended.
CTA/V of Head [**4-16**]:
CTV OF THE BRAIN WITH CONTRAST
HISTORY: Suspected venous sinus thrombosis right transverse
sinus.
Comparison is made with study performed on [**2124-4-15**].
There is a post-operative cavity in the right cerebellum with a
hemorrhagic
focus along its margins. There is a mesh cranioplasty at the
operative site. Corresponding to the findings seen on the MRI,
there is lack of normal flow in the mid to distal transverse and
sigmoid sinus concerning for thrombosis. The remaining venous
structures are normally opacified.
IMPRESSION:
Findings suggestive of right distal transverse and sigmoid sinus
thrombosis.
Brief Hospital Course:
The patient was admitted to the ICU for Q 1 hour neuro checks
due to the large size of the posterior fossa mass and due to the
mass effect on the 4th ventricle. She was symptomatic such that
she was experiencing headaches and difficulty with balance. The
patient was scheduled to have a craniectomy with resection of
the mass which occurred on [**2124-4-14**]. She went to the ICU
post-operatively for observation. Her neuro exam was stable
without any focal deficit. She was continued on a decadron
medication with a every other day taper to off. She was given
arrangements to follow up with her PCP [**Last Name (NamePattern4) **] [**4-18**] for continued
monitoring of her blood sugars while the dosing is tapered. She
was further seen and evaluated by PT and OT who determined that
she would be appropriate for home discharge with the use of a
walker. She was discharged accordingly on [**4-17**] with follow up
instructions for a brain tumor apptointment and MRV of the head.
Medications on Admission:
Vytorin, Etodolac
Discharge Medications:
1. Docusate Sodium Oral
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
4. 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:*0*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Dexamethasone 4 mg Tablet Sig: Taper dose PO Q6H (every 6
hours): 4mg QIDx2 dys, 3mg QIDx2 dys, 2mg QIDx2dys, 1mg
QIDx2dys. then off.
Disp:*QS Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Right Cerebellar Mass
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.
?????? You may wash your hair only after sutures staples have been
removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You 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 [**7-28**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2124-5-15**] @
2:00pm. 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 need an MRI/V of the brain (prior to your brain tumor
appointment). MRI Phone:[**Telephone/Fax (1) 327**] MRI/V is scheduled for
[**2124-5-15**] @ 11:55am
Completed by:[**2124-4-17**]
|
[
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"225.2",
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icd9cm
|
[
[
[]
]
] |
[
"02.04",
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icd9pcs
|
[
[
[]
]
] |
13399, 13433
|
11450, 12434
|
315, 393
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13499, 13523
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1102, 1474
|
1490, 1586
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,271
| 122,869
|
10995
|
Discharge summary
|
report
|
Admission Date: [**2159-6-1**] Discharge Date: [**2159-6-4**]
Date of Birth: [**2110-12-25**] Sex: M
Service: OMED
CHIEF COMPLAINT: Fever and neutropenia.
HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old
male with a history of esophageal cancer with metastases to
liver, bone, and choroid of the left eye status post
radiation therapy to eye and to esophagus, iliac crest and
status post chemotherapy with CPT11, cisplatin, Taxol, VEGF
and most recently 5FU who ended second cycle of 5FU on
[**2159-5-18**], which resulted on pancytopenia. The patient
presented with a chief complaint of fever and neutropenia on
[**5-31**]. The patient was started on Ceptaz. On hospital day
number two the had acute onset of dysphagia and hematemesis.
The patient had an esophagogastroduodenoscopy in the
Endoscopy Suite and a large obstructing clot was visualized
in the esophagus. Because of large clot burden and no airway
protection, clot was not removed for fear of massive
bleed/aspiration. The patient was then transferred to the
[**Hospital Ward Name 332**] Intensive Care Unit for elective intubation for a
second esophagogastroduodenoscopy. A 20 cm clot was
visualized and pushed into the stomach with the endoscope.
No active bleed was visualized. The patient was started on
Carafate one gram po q.i.d. and Protonix 40 mg intravenous
b.i.d. The patient was also noted to have grade four
esophagitis thought secondary to [**Female First Name (un) **]. Since admission,
the patient has been transfused four units of packed red
blood cells.
PAST MEDICAL HISTORY: 1. Metastatic esophageal cancer
diagnosed [**7-2**] with metastases to liver, bone, choroid, lungs
status post radiation to eye and to bone. Status post CPT11
and cisplatin from [**9-2**] to [**12-2**], status post Taxol from
[**12-2**] to [**3-3**]. VEGF receptor trial on [**3-3**], 5FU cycle number
two ended [**2159-5-18**]. 2. Mild psoriasis.
ALLERGIES: Questionable Penicillin allergy as a child. Has
tolerated Cephalosporins in house.
MEDICATIONS ON TRANSFER FROM THE [**Hospital Ward Name **] INTENSIVE CARE UNIT:
Protonix drip, Nystatin swish and swallow, Carafate 1 gram po
q 4 hours, Neupogen 300 micrograms subQ q day, Ceptaz 2 grams
intravenous q 8, Fluconazole 100 mg intravenous q 24, Ambien
prn.
LABORATORIES ON ADMISSION FROM INTENSIVE CARE UNIT: White
blood cell count 5.8, hematocrit 29.7, platelets 129,
PTT/PT/INR within normal limits. Chem 7 remarkable for a
sodium of 130, ionized calcium .98 and phosphate of 1.0. ALT
62, AST 150, alkaline phosphatase 373, T bili 2.7.
Results of esophagogastroduodenoscopy from [**6-1**], blood in the
esophagus, mass in the gastroesophageal junction and lower
third of the esophagus, ulcers in the lower third of the
esophagus, grade four esophagitis in the whole esophagus,
otherwise normal esophagogastroduodenoscopy the third part of
duodenum. Clotted blood of about 20 cm in size in the
esophagus was pushed into stomach with endoscope. The
esophagus is patent and free of clots post procedure.
PHYSICAL EXAMINATION: Vital signs 97.8, heart rate 110,
respiratory rate 18. Blood pressure 114/72. HEENT no thrush
noted on examination. Heart normal S1 S2. No murmurs, rubs
or gallops. Lungs clear to auscultation bilaterally.
Abdomen soft, liver margin 4 cm below costal margin.
Palpable epigastric mass. Extremities no clubbing, cyanosis
or edema.
HOSPITAL COURSE: In summary, this is an unfortunate 48
year-old male with metastatic esophageal cancer now status
post removal of an obstructive esophageal clot.
1. Gastrointestinal: Grade four esophagitis was noted on
esophagogastroduodenoscopy, however, there was no active
bleeding vessel noted. The patient was started on Protonix
40 mg po b.i.d. and Carafate was continued 1 gram q.i.d. The
patient was also started on Fluconazole 100 mg po q day to
finish a seven day course. The patient's hematocrit was
checked b.i.d. after admission from the Intensive Care Unit
and remained stable. The patient did not need any more
transfusions.
2. Hematology: The patient was transfused 4 units of packed
red blood cells in the Intensive Care Unit. The patient was
neutropenic on admission on [**2159-5-31**] and was started on
Neupogen. On the day of discharge the patient is no longer
neutropenic and Neupogen was discontinued.
3. Oncology: Metastatic esophageal adenocarcinoma status
post 5FU, the patient will follow up with his oncologist Dr.
[**Last Name (STitle) 3274**] two to three days after discharge. A plan for
further treatment will be decided upon at that time.
4. Infectious disease: The patient came in with a fever and
neutropenia. When the patient was no longer neutropenic and
afebrile, Ceptaz was discontinued. The patient was treated
for his presumed [**Female First Name (un) **] induced esophagitis with 100 mg po
Diflucan to finish a seven day course.
5. FEN: The patient's phosphate was 1.0 on the day of
discharge, however, the patient is taking inadequate po
without difficulty. The patient will be discharged on
Neutrophos one capsule or packet q.i.d.
6. Physical therapy: The patient states that he feels weak
and fatigue at baseline. Physical therapy was consulted and
the patient will have a home safety evaluation as an
outpatient.
DISCHARGE DIAGNOSES:
1. Metastatic esophageal cancer.
2. Esophagitis secondary to [**Female First Name (un) **].
3. Status post removal of obstructive esophageal clot.
DISCHARGE MEDICATIONS: 1. Fluconazole 100 mg po q day times
three more days. 2. Protonix 40 mg po b.i.d. 3. Carafate
1 gram po q.i.d. 4. Neutrophos one capsule po q.i.d.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 3274**] on
Thursday [**2159-6-7**] as an outpatient. The patient will
also have a physical therapy home safety evaluation.
MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3282**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2159-6-4**] 10:41
T: [**2159-6-5**] 09:36
JOB#: [**Job Number 35650**]
|
[
"197.7",
"198.5",
"578.0",
"198.4",
"288.0",
"V10.03",
"112.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"96.04",
"96.71",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5341, 5492
|
5516, 5671
|
3447, 5136
|
5155, 5320
|
5683, 6139
|
3093, 3429
|
150, 174
|
203, 1572
|
1595, 3070
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,178
| 112,505
|
27343
|
Discharge summary
|
report
|
Admission Date: [**2159-6-27**] Discharge Date: [**2159-7-24**]
Date of Birth: [**2134-1-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
Exploratory Laparotomy [**2159-6-27**]
Bialteral chest tubes
Bronchoscopy [**2159-6-29**] [**2159-7-11**]
Percutaneous tracheostomy [**2159-7-11**]
History of Present Illness:
24 yo male helmeted driver, s/p motorcycle crash; ? LOC.
Transported to [**Hospital1 18**] for continued trauma care.
Past Medical History:
Seizure Disorder
Family History:
Noncontributory
Physical Exam:
VS upon admission to trauma bay:
HR 150's BP 60's RR 30
GCS 14
Gen: color ashened
HEENT: EOMI, PERRL 3->2; TM's clear
Neck: c-collar
Chest: CTA bilat
Cor: reg tachy
Abd: soft, NT, ND FAST positive for fluid around liver
Rectum: nl tone
Back: no stepoffs
Pertinent Results:
[**2159-6-27**] 10:49PM TYPE-ART PO2-98 PCO2-75* PH-7.07* TOTAL
CO2-23 BASE XS--10
[**2159-6-27**] 10:49PM GLUCOSE--251* LACTATE-7.8* NA+-138 K+-5.3
CL--103
[**2159-6-27**] 10:49PM HGB-13.2* calcHCT-40 O2 SAT-95 CARBOXYHB-1
MET HGB-1
[**2159-6-27**] 10:00PM PT-19.1* PTT-57.6* INR(PT)-1.8*
CHEST (PORTABLE AP) [**2159-7-16**] 10:31 AM
CHEST (PORTABLE AP)
Reason: eval: R CT placement
[**Hospital 93**] MEDICAL CONDITION:
25 year old man s/p R CT placement
REASON FOR THIS EXAMINATION:
eval: R CT placement
EXAMINATION: AP CHEST 10:45 A.M., [**7-16**].
HISTORY: Chest tube placement.
IMPRESSION: AP chest compared to [**7-10**] and 7:
New right apical pleural tube. No pneumothorax. Decrease
moderate size right pleural effusion. Left lung clear aside from
mild vascular congestion. Heart is normal size. Widening of the
upper mediastinum due to fat deposition and vascular
engorgement. Nasogastric tube ends in the stomach.
CT ABDOMEN W/CONTRAST [**2159-7-15**] 11:29 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval for abcess, loculated fluid collection
Field of view: 48 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with s/p motorcycle accident, h/o chest tubes,
s/p ex lap for liver lac, now with fevers
REASON FOR THIS EXAMINATION:
eval for abcess, loculated fluid collection
CONTRAINDICATIONS for IV CONTRAST: None.
25-year-old male status post motorcycle accident with multiple
fractures and hepatic lacerations, now with fever and concern
for intra-abdominal abscess.
COMPARISON: [**2159-7-3**].
TECHNIQUE: MDCT continuously acquired axial images of the chest,
abdomen and pelvis were obtained after 130 mL Optiray IV as well
as oral contrast.
CT OF THE CHEST WITH IV CONTRAST: The tracheostomy remains in
appropriate position. There has been interval removal of a right
chest tube. A nasogastric tube terminates in the stomach. The
heart and pericardium as well as aorta are unremarkable. There
is no pathologic mediastinal, hilar or axillary lymphadenopathy.
There has been interval worsening in a now very large right
pleural effusion with associated total atelectasis of the right
middle and lower lobes. There has been improvement in left
basilar consolidation with residual patchy nodular opacities
more peripherally, possibly representing areas of contusion.
CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated is
extensive laceration of the right hepatic lobe, primarily
segments V, VI and VII. This is not significantly changed. The
gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach,
duodenum, and intra-abdominal loops of large and small bowel are
unremarkable. The kidneys enhance and excrete contrast
symmetrically, and the ureters are of normal caliber. There has
been interval resolution of the small bowel obstruction, and
there is free passage of oral contrast through to the ascending
colon. There is a small amount of fluid along the inferior edge
of the liver. There has been resolution of ascites seen
previously to track into the pelvis. No intra-abdominal fluid
collection or abscess is identified.
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter
within the decompressed urinary bladder. The rectum, prostate
gland, seminal vesicles and intrapelvic loops of bowel are
unremarkable. There is no significant free pelvic fluid or
lymphadenopathy.
BONE WINDOWS: Again demonstrated are multiple bilateral
posterior rib fractures as well as fractures of the posterior
spinous processes from T2 through T5 as well as the right
scapula.
IMPRESSION:
1. Interval worsening in now large right pleural effusion with
associated total atelectasis of the right middle and lower
lobes.
2. Improvement in left basilar consolidation with residual
patchy nodular peripheral left lung opacities, probably
representing contusion.
3. No significant change in right hepatic laceration.
4. Multiple fractures as previously described.
5. Near resolution of intra-abdominal free fluid with only a
small amount of residual fluid along the inferior edge of the
liver.
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Height: (in) 68
Weight (lb): 228
BSA (m2): 2.16 m2
BP (mm Hg): 106/67
HR (bpm): 116
Status: Inpatient
Date/Time: [**2159-6-28**] at 15:36
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W014-1:08
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 2.6 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 160 msec
TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Aortic valve not well seen. No AS. No AR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal
tricuspid valve supporting structures. Normal PA systolic
pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views. Suboptimal image quality - poor subcostal views.
Suboptimal image
quality - bandages, defibrillator pads or electrodes. Suboptimal
image quality
as the patient was difficult to position. Suboptimal image
quality -
ventilator.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Overall left ventricular systolic function appears grossly
normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic
valve is not well seen. There is no aortic valve stenosis. No
aortic
regurgitation is seen. The estimated pulmonary artery systolic
pressure is
normal. There is no pericardial effusion.
CT T-SPINE W/O CONTRAST [**2159-6-28**] 5:02 PM
CT T-SPINE W/O CONTRAST
Reason: trauma
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with
REASON FOR THIS EXAMINATION:
trauma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 25-year-old man with trauma.
TECHNIQUE: T-spine CT without contrast.
No comparison.
FINDINGS: There is no evidence of subluxation. The prevertebral
soft tissue is unremarkable. Note is made of minimally displaced
fracture of the spinous processes from T2-T5. Note is made of
rib fractures bilaterally at T1, on the righta t T3-8, and
possibly on the left at T8. Note is made of opacities in the
lungs, which was described in detail in torso CT report.
IMPRESSION: No subluxation. Minimally displaced fractures of the
spinous processes of T2-T5. Multiple rib fractures. Please also
refer to the official report of the CT torso study.
Brief Hospital Course:
Patient admitted to the trauma service. FAST exam positive in
the emergency department; he was intubated and immediately taken
to the operating room for exploratory lap, repair of liver
laceration and placement of bilateral chest tubes for pulmonary
contusions. His chest tubes were eventually removed; follow up
chest xray after removal of right chest tube reveals tiny apical
pneumothorax. Neurosurgery was consulted for ICP bolt
placement given his mechanism of injury and decreased mental
status; initial pressures were 28. The bolt was eventually
removed several days later.
Orthopedic spine surgery was consulted because of minimally
displaced fractures of spinous processes T2-T5. he was treated
non operatively for these injuries and was fitted for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36323**]
brace to be worn while out of bed.
Infectious disease was consulted for persistent fevers; he was
cultured; central line tip cultured as well; blood cultures grew
out staph caog negative; catheter tip grew Acinetobacter and
Klebsiella; sputum grew Klebsiella. He was treated with
Vancomycin, which completed on [**7-23**]; Meropenem and Gentamicin,
which will continue through [**7-31**] & Bactrim po, which will also
continue through [**7-31**].
Speech and Swallow was consulted to evaluate swallowing and
Passy Muir valve. He was eventually able to tolerate the PMV;
his diet was upgraded to regular solids with thin liquids. His
tracheostomy was downsized on HD #28 with the plan to follow up
in Trauma Clinic in 1 week to decannulated.
Physical and Occupational therapy have worked with patient
throughout his hospital course; at time of discharge he is
independent with ambulation and ADL's; will require some
assistance for donning his [**Location (un) 36323**] brace.
Medications on Admission:
"Antiseizure" meds
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Gentamicin 40 mg/mL Solution Sig: One (1) Injection Q 12 for
7 days: 250 mg.
Disp:*24 * Refills:*0*
3. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 7 days.
Disp:*28 Recon Soln(s)* Refills:*0*
4. Bactrim 400-80 mg Tablet Sig: 1.5 Tablets PO three times a
day for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: Two (2) Tablet
PO every 6-8 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. PICC
PICC line care per protocol
9. Carbamazepine 100 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO four times a day.
Disp:*180 Tablet, Chewable(s)* Refills:*2*
10. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
s/p Motorcycle crash
Liver laceration
Lung contusions
Respiratory failure
Right scapula fracture
Spinous process fractures T2-T5
Bacteremia
Multiple rib fractures
Discharge Condition:
Good
Discharge Instructions:
Return to the emergency department if you develop fevers,
chills, headache, dizziness, increased shortness of breath,
nausea, vomiting, diarrhea and/or any other symptoms that are
concerning to you.
You must continue to wear your brace when out of bed.
Your antibiotics will continue until [**7-31**].
Followup Instructions:
Follow up in Trauma Clinic in 2 weeks. Call [**Telephone/Fax (1) 6439**] for an
appointment.
Follow up with Dr. [**Last Name (STitle) 363**], Orthopedic Spine Surgery in 4 weeks,
call [**Telephone/Fax (1) 3573**] for an appointment. Inform the office that you
may need a repeat MRI scan for this appointment.
Follow up with Dr. [**Last Name (STitle) **], Neurosurgery in 3 months, call
[**Telephone/Fax (1) 1669**] for an appointment.
Completed by:[**2159-7-31**]
|
[
"486",
"998.2",
"518.5",
"996.62",
"811.00",
"276.6",
"861.21",
"493.90",
"864.04",
"850.11",
"482.2",
"285.1",
"958.4",
"E812.2",
"790.7",
"805.2",
"807.4",
"560.1",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.72",
"99.07",
"96.04",
"99.05",
"99.04",
"46.75",
"96.6",
"38.93",
"50.22",
"33.24",
"01.18",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
11860, 11912
|
8849, 10656
|
335, 485
|
12119, 12126
|
996, 1393
|
12479, 12947
|
688, 705
|
10725, 11837
|
8073, 8094
|
11933, 12098
|
10682, 10702
|
12150, 12456
|
5088, 8036
|
720, 977
|
275, 297
|
8123, 8826
|
513, 632
|
654, 672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,715
| 140,337
|
3096
|
Discharge summary
|
report
|
Admission Date: [**2100-9-1**] Discharge Date: [**2100-9-2**]
Date of Birth: [**2030-9-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Hypotension s/p DCCV.
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
DC Cardioversion
History of Present Illness:
This is a 69 year old female with a past medical history of DM,
htn, hyperlipidemia, AF on coumadin who was was recently
admitted to [**Hospital1 18**] last week and underwent a TEE cardioversion
for a.fib with RVR. She was transitioned from propafenone to
sotalol after being found to have newly depressed EF to 45-50%
with anterior and anterior-septal HK concerning for CAD. She
returned for an outpatient stress test yesterday and was found
to be back in AF. INR was 1.7. Coumadin dose was increased and
she returned for TEE/DCCV today after an increase in sotalol to
120 mg [**Hospital1 **]. INR now 2.0. TEE cardioverted but complicated by
persistent hypotension requiring phenylephrine gtt, SBPs to the
60s with HR initially in the 40s-50s. She did received
significant amounts of sedation for the procedure (2.5mg versed,
50mcg fentanyl, 50mg propofol) She received 2L of IVF and had a
foley placed with only 300 cc of urine (had not urinated all
day). On arrival to CCU she was quickly weaned off of
phenylephrine. She is asymptomatic. She denies any
lightheadedness, chest pain, visual changes, shortness of
breath, abd. pain, N/V/D, dysuria, focal weakness, numbness or
tingling.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation on coumadin and propaphenone
- hypothyroid
- Type II DM
- GERD
- Hyperlipidemia
- Hypertension
- Depression
- Thyroid nodule
- Osteoarthritis
- Iron deficiency anemia
PAST SURGICAL HISTORY:
s/p left total knee replacement [**2091**]
s/p C-section
s/p two thyroid surgeries (said she had "cold lumps")
s/p tummy tuck 32 years ago
Social History:
- Portugese is first language
- works as caregiver [**First Name (Titles) **] [**Last Name (Titles) **]
- spent several months in [**State **] and [**Location 652**] recently
working as caregiver, which she reports was very stressful
- lives with Daughter in apartment
- No ETOH
- No smoking
Family History:
Father - stoke, HTN
Mother - stroke, diabetes
Children - healthy
No family history of breast or GI cancer
Physical Exam:
VS: 97.5, 72, 96/51, 98% RA
GENERAL:in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
EKG 10/14/9:
Sinus bradycardia. Occasional atrial premature beats. Compared
to
tracing #1 the patient is now back in sinus rhythm. There are
persistent
anteroseptal ST-T wave abnormalities. Cannot rule out myocardial
ischemia
.
EKG 10/15/9:
Probable irregular ectopic atrial rhythm. Compared to tracing #2
ectopic atrial rhythm is new. There are persistent anteroseptal
ST-T wave abnormalities. Clinical correlation is suggested.
.
2D-ECHOCARDIOGRAM [**2100-8-24**]:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with focal hypokinesis of the distal half of the
anterior septum and anterior walls. The remaining segments
contract normally (LVEF = 45-50 %). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w CAD (mid-LAD distribution). Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2099-5-26**], the
regional left ventricular systolic dysfunction and atrial
fibrillation are new.
.
TEE [**2100-9-1**]:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
.
Labs on day of discharge (10/15/9):
WBC-7.6 RBC-3.81* Hgb-10.7* Hct-33.1* MCV-87 MCH-28.0 MCHC-32.3
RDW-14.3 Plt Ct-402
PT-24.7* PTT-24.8 INR(PT)-2.4*
Glucose-122* UreaN-20 Creat-0.8 Na-137 K-5.3* Cl-109* HCO3-24
AnGap-9
Calcium-8.6 Phos-3.6 Mg-2.5
.
Brief Hospital Course:
69 yo woman with DM, htn, HL, suspected CAD, PAF on sotalol now
s/p TEE/DCCV with post procedure hypotension - presents to the
CCU post-procedure.
# Hypotension: Pt reports poor po intake day prior to procedure
and was then NPO. Minimal urine output despite fluid bolus,
prior to arrival in the CCU, argues for some level of
hyovolemia. [**Month (only) 116**] also have some contribution of sedation from
procedures or stunning from cardioversion. Patient on pressors,
and unable to be weaned off of them in the procedure location,
so was transferred to the CCU. In the CCU, came off of pressors,
and although BP was on the lower side of normal, patient was
without symptoms throughout (no lightheadedness, chest pain,
sob). Pressors remained off throughout the rest of her
hospitalization and patient continued to be asymptomatic. Fluid
boluses of 250cc NS, were given, and po intake was highly
encouraged. The patient's BP did rise higher overnight and into
the next day (up to SBP in the 80s-90s); patient with good urine
output and continued to be asymptomatic. Given the patient's
lack of symptoms, and her ability to keep her blood pressure up
off of pressors, she was discharged. Antihypertensives were
held, and her sotalol was held intermittently and then restarted
on the day of discharge. Close follow-up appointment with PCP
for the day following discharge was ensured. Due to hypotension
and prolonged QT interval, patient was monitored on telemetry -
no events.
.
# Atrial fib: S/P second DCCV, was in NSR throughout time in the
CCU. Patient on coumadin. Sotalol held initially and then
restarted the day after the DCCV.
.
# H/o hypertension: d/t hypotension, held lisinopril until
patient sees PCP on the day following discharge. sotalol
restarted on day of discharge.
.
#. Type II Diabetes: ISS while inpatient, restart PO meds on
discharge.
#. Hypothyroid: Continue on her home levothyroxine
#. Hyperlipidemia. Continue on atovastatin.
#. Depression. Continue on paroxetine.
.
FEN: Diabetic, heart healthy, low sodium diet. Encouraged PO
intake.
.
ACCESS: PIV's
.
PROPHYLAXIS:
-DVT ppx with warfain
-Bowel regimen
.
CODE: full
Medications on Admission:
1. Sotalol 120 mg PO BID
2. Atorvastatin 20 mg PO DAILY
3. Levothyroxine 175 mcg PO DAILY
4. Paroxetine HCl 40 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Omeprazole 40 mg PO DAILY (Daily).
7. Metformin 500 mg PO BID
8. Finasteride 1 mg PO once a day.
9. Warfarin 5mg PO Once Daily at 4 PM.
10. Mobic 15 mg PO once a day
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Finasteride 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Mobic 15 mg Tablet Sig: One (1) Tablet PO daily ().
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
atrial fibrillation s/p cardioversion
hypotension
hypovolemia
Discharge Condition:
All vital signs stable, in normal sinus rhythm, ambulatory. AOx3
Discharge Instructions:
You were admitted with some low blood pressure after your heart
was shocked out of atrial fibrillation. This was likely due to a
combination of dehydration and the sedating medications your
received for the procedure. Please ensure that you drink some
extra fluids over the next few days to ensure that you stay
hydrated.
You will continue on the increased dose of the sotalol.
Please do not take your lisinopril until you follow up with your
primary care physician.
Please call your doctor or come the emergency room if you feel
lightheaded, dizzy, chest pain, shortness of breath, nausea, or
any other symptoms that concern.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2100-9-3**] 4:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2100-10-15**] 1:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2100-10-22**] 3:20
Completed by:[**2100-9-3**]
|
[
"311",
"250.00",
"427.31",
"272.4",
"458.29",
"530.81",
"244.9",
"401.9",
"276.52",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
9106, 9112
|
5890, 8041
|
334, 384
|
9218, 9285
|
3478, 5867
|
9963, 10448
|
2504, 2611
|
8413, 9083
|
9133, 9197
|
8067, 8390
|
9309, 9940
|
2038, 2178
|
2626, 3459
|
1736, 1794
|
273, 296
|
412, 1606
|
1825, 2015
|
1650, 1716
|
2194, 2488
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,412
| 117,391
|
50961
|
Discharge summary
|
report
|
Admission Date: [**2176-1-21**] Discharge Date: [**2176-3-20**]
Date of Birth: [**2124-9-13**] Sex: M
HISTORY OF PRESENT ILLNESS: Briefly, this is a 51-year-old
male who was recently discharged in [**Month (only) 404**] for diabetic
ketoacidosis who had a known history of cirrhosis with
multiple episodes of spontaneous bacterial peritonitis and
He had been admitted multiple times, and at this time was
being admitted for his high [**Month (only) **] sugars. He presented with
nausea, vomiting, and a sour taste in his stomach and started
vomiting. He denied any [**Last Name (LF) **], [**First Name3 (LF) 691**] diffuse abdominal pain,
or changes in bowels.
significant for)
1. Hepatitis C and alcohol abuse with cirrhosis (he was a
Child class C).
2. He had portal gastropathy.
3. Grade II varices.
4. Ascites.
5. Multiple episodes of spontaneous bacterial peritonitis.
6. He had multiple episodes of encephalopathy.
7. Type 1 diabetes.
8. Gastroparesis.
9. Chronic renal insufficiency.
10. Osteoporosis.
11. Diverticulitis.
12. Status post hemicolectomy.
MEDICATIONS ON ADMISSION: (His medications on admission
were)
1. NPH insulin 32 units subcutaneously q.a.m.
2. Humalog sliding-scale.
3. Folate.
4. Protonix 40 mg p.o. q.d.
5. Spironolactone 100 mg p.o. q.d.
6. Lasix 80 mg p.o. q.d.
7. Thiamine 100 mg p.o. q.d.
8. Lactulose 30 cc p.o. q.i.d.
9. Reglan 10 mg p.o. q.i.d.
10. Neutra-Phos four times per day.
11. Multivitamin one tablet p.o. q.d.
12. Colace.
ALLERGIES:
SOCIAL HISTORY: He lives with his wife and two sons. [**Name (NI) **]
quit alcohol 13 years ago. He also had been a bartender.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, he was afebrile. His vital signs were stable.
He was alert and oriented times three and appeared
comfortable. His pupils were equally round and reactive to
light. Extraocular muscles were intact. He had icterus and
generalized jaundice. His neck was supple. His lungs had
crackles at the bases but were otherwise clear. His heart
was regular in rate and rhythm with a 2/6 systolic ejection
murmur. His abdomen was distended, diffusely tender (left
greater than right), with ascites, and with rebound. His
extremities had bilateral edema. His neurologic examination
was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: His
laboratories upon admission evaluated he had a white [**Name (NI) **]
cell count of 6.3, hematocrit was 29.7, and platelet count
was 89. Chemistries revealed sodium was 125, potassium was
5.3, chloride was 98, bicarbonate was 18, [**Name (NI) **] urea nitrogen
was 91, creatinine was 1.8, and [**Name (NI) **] glucose was 142. His
prothrombin time was 15, partial thromboplastin time was
32.3, and his INR was 1.5. His ALT was 70, AST was 110,
alkaline phosphatase was 247, total bilirubin was 2.4,
albumin was 3.2, amylase of 52, and lipase was 44.
HOSPITAL COURSE: He was admitted to the Medicine Service at
that time for a question of spontaneous bacterial peritonitis
versus gastritis and was managed at that time. He stayed in
the hospital with great difficulty managing his sugars as
well as a question per bacterial peritonitis.
On [**2176-1-29**], the patient received a cadaveric liver
transplant with a primary end to end bile duct anastomosis with
no T- tube. The patient was transferred to the Intensive Care
Unit postoperatively where he stayed through postoperative day
15.
At this time, he continued to be afebrile throughout his
Intensive Care Unit course. His [**Year (4 digits) **] pressure was good. He
was started on oral food on postoperative day six as well as
continued on intravenous fluids. He was also started on tube
feeds on postoperative day 12. His urine output continued to
improve, and after postoperative day one he required no more
[**Year (4 digits) **] transfusions. His urine output was excellent
throughout his Intensive Care Unit stay, and his
[**Location (un) 1661**]-[**Location (un) 1662**] output slowly decreased. His left
[**Location (un) 1661**]-[**Location (un) 1662**] drain was discontinued on postoperative day 10.
His laboratories revealed his white [**Location (un) **] cell count stayed
normal. His hematocrit was stable after an original
transfusion, and his platelet count stayed less than 100
(which required multiple platelet transfusions). His
chemistries were within normal limits. His creatinine, which
rose to a high of 3, slowly began to return to normal at that
time. His liver function tests slowly reduced to normal, and
he continued to improve. His bilirubin, which rose to a high
of 19, returned slowly back down to his normal range of
approximately 2.6, and his INR slowly corrected. The patient
did well from that standpoint. His liver ultrasound was
normal, and he was continued on MMF Solu-Medrol which was
slowly tapered, and prednisone, and cyclosporin.
The patient had OK T3 until the end of his Intensive Care
Unit course and was only started on CSA on postoperative day
seven. The patient did well from a transplant point of view,
and he was transferred to the floor.
It was noted during his hospital stay that his left knee had
become swollen, and Orthopaedics consulted on postoperative
day 18. He was taken to the operating room for a left knee
washout which he tolerated well. At that time, the joint
fluid showed 53,000 white [**Location (un) **] cells, with many polys, with
4+ white [**Location (un) **] cells, and no organisms on Gram stain. His
cultures ultimately did not growth anything; however, he did
have the washout for a septic joint.
On postoperative day 16, an endoscopic retrograde
cholangiopancreatography was done which showed no bile leak.
The [**Location (un) 1661**]-[**Location (un) 1662**] drain in the bile was approximately 1.9.
Chest x-rays continued to show small pleural effusions which
slowly improved over time. The patient continued to improve
on the floor postoperatively from his washout as well as from
his liver transplant. His white [**Location (un) **] cell count continued
to remain normal. His chemistries were all within normal
limits, and his creatinine slowly dropped to within normal
limits. His alkaline phosphatase and liver enzymes were
slightly elevated postoperatively, and he continued to
fluctuate (upwards of 800).
A biopsy was done on postoperative day 22 which showed no
evidence of acute rejection. His ultrasound also showed
patent vessels with good flow. He was continued on his MMF,
his prednisone, and his CSA. His levels were all within
normal limits (around 300).
He continued to do well. His total bilirubin continued to
normalize, and his Foley was removed on postoperative day 25.
On postoperative day 26, a magnetic resonance imaging of the
brain was done for episodes of confusion and showed no focal
lesions with generalized atrophy (no more than expected for
his age). His immunosuppressants were continued at that time
at the same doses. His oxycodone was stopped at that time
for his confusion.
His [**Location (un) **] sugars, which continued to fluctuate throughout his
course, required an insulin drip occasionally as well as
management by the [**Hospital **] [**Hospital 982**] Clinic. He had multiple
episodes in which his [**Hospital **] sugars were upwards of 400 and
also dropped very low down to the 30s.
He continued to have excellent urine output and was given
minor diuresis. Due to his positive vancomycin-resistant
enterococcus cultures, and other bacterial cultures from his
knee washout, he was started linezolid, levofloxacin, and
meropenem, as well as the regular antibiotics as Bactrim,
fluconazole, and Valcyte for his graft.
On postoperative day 29, another biopsy was done which showed
cholestasis, but no evidence of acute rejection. It also
showed some mononuclear infiltrations around his portal vein.
A repeat endoscopic retrograde cholangiopancreatography was
done the next day which showed a small bile leak which was
stented at that time. A computed tomography scan of the
abdomen showed an increasing right pleural effusion, but no
focal collections. His ascites was drained at that time for
2.4 liters. Vicodin was restarted after the paracentesis for
pain control. Due to a rise in his bilirubin, a repeat
endoscopic retrograde cholangiopancreatography was done which
showed a continued leak as well as obstruction of the stent
which had been placed. A new stent was placed at that time,
and meropenem was started.
Two days later, on postoperative day 35, his bilirubin
continued to rise. Therefore, another endoscopic retrograde
cholangiopancreatography was performed which again showed a
leak as well as pus around the major papilla and a question
of a right hepatic duct abscess, and the stent again being
occluded. The stent was replaced. A computed tomography
angiogram of the liver was done which showed no intrahepatic
collections, with good flow in the right hepatic artery.
The next day a HIDA scan was performed which was normal with
no leak and normal bile transit. Due to his increased
pleural effusions, which had been noted from before, a
pleural tap was done on postoperative day 37.
On postoperative day 42, another repeat endoscopic retrograde
cholangiopancreatography was done, and the stent was
replaced. An ultrasound at that time was also normal for
liver flow. His bilirubin, which had reached a maximum of
8.1, slowly began to decrease at that time.
At the time of the last endoscopic retrograde
cholangiopancreatography, on postoperative day 42, a Dobbhoff
tube was placed. That tube required Interventional Radiology
for placement into the postpyloric into the duodenum; after
which time, tube feeds (which had been stopped due to the
bile leak) were restarted at a goal of 50 cc per hour of
Nepro.
After the final endoscopic retrograde
cholangiopancreatography on postoperative day 42, the
patient's bilirubin returned to [**Location 213**]. It was noted that
the patient had some slight abdominal pain on postoperative
day 41, and a computed tomography scan was done which showed
fluid collection in the abdomen. The fluid collection
throughout the abdomen were drained and were found to be
frankly bilious. Therefore, a repeat endoscopic retrograde
cholangiopancreatography on postoperative day 42 was done,
and a new stent was placed. At that time, the drain output
of the abdominal drain slowly decreased and also changed in
character from bilious to more ascitic.
The patient's abdominal drain was removed and antibiotics
were stopped. First the meropenem was stopped, and then the
levofloxacin. Linezolid was also stopped. The drain site
was stitched, and the patient was doing well. His was at
goal tube feeds as well as taking oral intake. He was making
adequate urine, and his white [**Location **] cell count was normal.
His cyclosporin levels were stabilized, and he was planned to
be discharged to a rehabilitation facility with taking Neoral
at approximately 150 mg p.o. b.i.d.
MEDICATIONS ON DISCHARGE: (The patient's discharge
medications at that time included)
1. Neoral 150 mg p.o. b.i.d.
2. Insulin sliding-scale as well as a fixed dose. He was
to receive 18 units of NPH in the morning and 18 units of NPH
at night.
3. Lasix 40 mg p.o. b.i.d.
4. Prednisone 50 mg p.o. q.d.
5. MMF 1000 mg p.o. b.i.d.
6. Nystatin swish-and-swallow 5 mg p.o. q.i.d.
7. Vicodin one to two tablets p.o. q.4h. as needed.
8. Fluconazole 400 mg p.o. q.d.
9. Trazodone 7.5 mg p.o. q.h.s.
10. Actigall 300 mg p.o. t.i.d.
11. Valcyte 450 mg p.o. q.d.
12. Protonix 40 mg p.o. q.d.
13. Bactrim one tablet p.o. q.d.
DISCHARGE DISPOSITION: Upon discharge, the patient's
creatinine had normalized. His liver function tests were all
within normal limits, and his white [**Location **] cell count had
stabilized, and his hematocrit had hovered approximately at
30 throughout his hospital course after his initial
transfusion.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility on [**2176-3-20**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 497**] in one week.
2. The patient was also to follow up with the [**Hospital 1326**]
Clinic in one week.
3. His levels and [**Hospital **] tests were to be done twice per week
and reported back to Dr. [**Last Name (STitle) 497**] as well as the [**Hospital 1326**]
Clinic for modifications.
4. The patient was discharged with tube feeds (Nepro 50 cc
per hour continuous through a Dobbhoff tube). He was also
instructed to continue that until such time as it is deemed
that he is able to take enough adequate oral intake in order
to discontinue the Dobbhoff.
DISCHARGE DIAGNOSES:
1. Hepatitis C alcoholic cirrhosis.
2. Status post orthotopic liver transplant.
3. Insulin-dependent diabetes mellitus.
4. Chronic renal insufficiency.
5. Gastroparesis.
6. Diverticulitis.
7. Status post colectomy.
8. Spontaneous bacterial peritonitis on multiple occasions.
9. Grade II varies.
10. Status post left knee washout for a septic joint.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 105899**]
MEDQUIST36
D: [**2176-3-19**] 21:44
T: [**2176-3-20**] 01:35
JOB#: [**Job Number 105900**]
|
[
"790.7",
"711.06",
"572.4",
"998.12",
"567.2",
"070.41",
"789.5",
"997.4",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"80.86",
"80.6",
"38.93",
"54.12",
"50.59",
"50.11",
"99.15",
"51.87",
"80.76",
"00.14",
"50.12"
] |
icd9pcs
|
[
[
[]
]
] |
11722, 12114
|
12848, 13478
|
11086, 11698
|
1134, 1549
|
2956, 11059
|
12198, 12826
|
12129, 12165
|
151, 1107
|
1566, 2938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,130
| 106,375
|
30910
|
Discharge summary
|
report
|
Admission Date: [**2200-8-1**] Discharge Date: [**2200-8-3**]
Date of Birth: [**2132-6-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
cardiac arrest at home this AM
Major Surgical or Invasive Procedure:
s/p cabg x3/MV repair [**2200-7-21**]
History of Present Illness:
68 yo male who was discharged home on [**7-29**] after cabg x3/MV
repair with Dr. [**Last Name (STitle) **]. Had cardiac arrest at home this AM and
was resuscitated from apparent asystole to a junctional rhythm.
Had decreased level of responsiveness since his arrest this
morning and hyperkalemia with worsening renal function.He was
transferred into [**Hospital1 18**] for further management.
Past Medical History:
Ischemic Cardiomyopathy, Systolic Congestive Heart Failure,
Coronary Artery Disease, Mitral Regurgitation, Prior MI [**2198**]
complicated by cardiac arrest, Chronic Renal Insufficiency,
COPD, History of Upper GI Bleed secondary to esophogeal varices
- s/p cauterization, History of ETOH abuse
[**2200-7-21**] cabg x3/MV repair
Social History:
Former smoker, 50 pack year history of tobacco. Former heavy
alcohol abuse, none since [**2198**]. He is a former carpenter and
Marine Corp Veteran. Lives in [**State 4565**] and is here visiting
for the summer. Currently living with his daughter.
Family History:
Denies premature coronary artery disease.
Physical Exam:
eyes open with decorticate posturing when being suctioned
occasional twitching of eyes and mouth
no spontaneous movement of extremities noted
lungs coarse bilat.
RRR with holosystolic murmur
abd softly distended, no BS noted
extrems cool,no edema;knees mottled
Pertinent Results:
[**2200-8-3**] 07:55AM BLOOD WBC-24.5* RBC-3.10* Hgb-9.8* Hct-29.0*
MCV-94 MCH-31.6 MCHC-33.8 RDW-18.1* Plt Ct-284
[**2200-8-3**] 07:55AM BLOOD PT-24.6* PTT-83.1* INR(PT)-2.5*
[**2200-8-3**] 07:55AM BLOOD Plt Ct-284
[**2200-8-3**] 07:55AM BLOOD UreaN-41* Creat-2.2* Na-132* Cl-105
HCO3-15*
[**2200-8-3**] 02:11AM BLOOD Glucose-77 UreaN-54* Creat-3.2* Na-131*
K-5.1 Cl-97 HCO3-20* AnGap-19
[**2200-8-3**] 02:11AM BLOOD ALT-491* AST-694* LD(LDH)-1216*
AlkPhos-111 Amylase-286* TotBili-1.8*
[**2200-8-3**] 02:11AM BLOOD Lipase-14
[**2200-8-3**] 02:11AM BLOOD CK-MB-20* cTropnT-1.06*
[**2200-8-3**] 07:55AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9
Cardiology Report ECG Study Date of [**2200-8-2**] 1:08:56 AM
Sinus tachycardia. Poor R wave progression with loss of R waves
in
lead V4. Possible prior anterior myocardial infarction. Compared
to tracing
of [**2200-7-17**] no significant change is seen except heart rate is
now faster.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] F.
RADIOLOGY Final Report
MR HEAD W/O CONTRAST [**2200-8-3**] 11:59
MR HEAD W/O CONTRAST
Reason: Anoxic injury of brain?
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with post CPR stroke
REASON FOR THIS EXAMINATION:
Anoxic injury of brain?
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Status post CPR stroke. Evaluate for anoxic injury to
the brain.
Routine MRI of the brain without gadolinium was performed.
There are no comparison studies.
FINDINGS:
There is abnormal signal throughout the supra- and
infratentorial brain specifically, in the frontal and parietal
cortex, bilateral thalami and caudate nucleus and in the
cerebellum. The deep [**Doctor Last Name 352**] and cortical abnormalities likely
represent sequela of hypoxic ischemic injury. The cerebellar
diffusion abnormalities could represent watershed or embolic
ischemia. Abnormal signal is also seen in the right putamen.
There are also probable scattered small vessel ischemic sequela
in the subcortical white matter.
Intracranial flow voids appear to be maintained.
Bilateral mastoid opacification is seen. There is fluid pooling
in the nasopharynx and the nasal cavities, which may be related
to intubation.
IMPRESSION:
Findings likely relating to hypoxic ischemic injury and
watershed ischemia.
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: SUN [**2200-8-3**] 6:01 PM
Brief Hospital Course:
Admitted [**2200-8-1**] to CSRU intubated and unresponsive with a poor
neurological status. Renal and neuro consults done as prognosis
was poor on triple pressor support. Dr. [**Last Name (STitle) **] discussed the
prognosis with the family and CVVHD was started initially for
continued support. On [**8-2**], he showed signs of anoxic brain
injury with possible ischemia. Cardioverted on the morning of
[**8-3**] for rapid AFib. MRI of the head on [**8-3**] showed diffuse
areas of infarct. He remained hypotensive despite pressor
therapy, and a family discussion was held with neurology and Dr.
[**Last Name (STitle) **]. Family decided to make the pt. DNR and he expired at
14:17 on [**8-3**].
Medications on Admission:
at home:
lasix 20 mg daily
KCl 20 mEq daily
colace 100 mg [**Hospital1 **]
ASA 81 mg daily
lipitor 40 mg daily
paroxetine 20 mg daily
toprol XL 12.5 mg [**Hospital1 **]
at transfer:
dopamine drip
heparin drip ( for ? PE)
combivent MDIs
protonix 40 mg IV daily
rocephin one gram IV daily
ASA 325 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p cardiac arrest [**8-1**]
s/p cabg x3/MVrepair [**7-21**]
multi-organ system failure
Discharge Condition:
expired
Completed by:[**2200-10-20**]
|
[
"584.5",
"276.7",
"427.31",
"428.20",
"V45.81",
"496",
"410.91",
"414.8",
"428.0",
"348.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"39.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5248, 5257
|
4195, 4893
|
349, 388
|
5390, 5429
|
1785, 2903
|
1446, 1489
|
2940, 2977
|
5278, 5369
|
4919, 5225
|
1504, 1766
|
279, 311
|
3006, 4172
|
416, 811
|
833, 1163
|
1179, 1430
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,463
| 140,575
|
16486+56770+56771
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2186-11-21**] Discharge Date: [**2186-11-27**]
Date of Birth: [**2123-6-23**] Sex: M
CHIEF COMPLAINT: Painless jaundice.
HISTORY OF PRESENT ILLNESS: This is a 63 year old man with
a history of diabetes mellitus type 2, coronary artery
obstructive sleep apnea, sent to [**Hospital 1263**] Hospital with one day
of painless jaundice on [**2186-11-17**]. The patient also
had noted one month of pruritus at that time without any
fever, chills, shortness of breath, nausea, vomiting,
diaphoresis or abdominal pain.
At the [**Doctor Last Name 1263**] he had a total bilirubin of 12.0, direct of
ultrasound revealed two lesions in the liver, each 2
centimeters, consistent with metastases. An endoscopic
retrograde cholangiopancreatography was attempted but was
unsuccessful secondary to infiltration/edematous folds over
the ampulla. The patient cannot have his duct cannulated,
and the patient was transferred to [**Hospital1 190**] for further evaluation.
At the [**Hospital1 69**], the patient had
no endoscopic retrograde cholangiopancreatography and
underwent sphincterotomy, however, the duct still cannot be
cannulated and the plan was made for a repeat endoscopic
retrograde cholangiopancreatography at another time. He was
then transferred to the Medical Floor.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2 for 20 years, insulin dependent
15 years with mild retinopathy.
2. Coronary artery disease status post coronary artery
bypass graft in [**2181**] for three vessel disease.
3. [**Last Name (un) **]-vesicular fistula.
4. Peripheral vascular disease status post right
aortofemoral bypass.
5. Nephrotic syndrome, unknown etiology, diagnosed in
[**10/2186**] with 3.6 grams of protein q. 24 hours, positive
P-ANCA and positive [**Doctor First Name **] per outside hospital.
6. Anemia of unclear etiology.
ALLERGIES: No known drug allergies.
MEDICATIONS AS AN OUTPATIENT:
1. Lasix 40 mg p.o. q. day.
2. Zestril 10 mg p.o. q. day.
3. Iron sulfate 325 mg p.o. three times a day.
4. Pravachol 40 mg p.o. q. day.
5. Toprol XL 100 mg p.o. q. day.
6. Glucophage 500 mg p.o. twice a day.
7. Aspirin 81 mg p.o. q. day.
8. NPH 50 units q. a.m. and 20 units q. h.s.; Regular 10
units q. a.m.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient lives alone with a dog. He
drinks alcohol on occasion. He smokes occasionally after
meals. He denies any drug use. His sister [**Name (NI) **] [**Name (NI) 46850**] is
his only family member. [**Name (NI) **] phone number is [**Telephone/Fax (1) 46851**],
work at [**Telephone/Fax (1) 46852**].
PHYSICAL EXAMINATION: Blood pressure 100/palpable; heart
rate 53, 14 and 97% on room air. 170 pounds. In general, he
is lethargic and jaundiced in no acute distress. Cor:
Regular rate and rhythm, no murmurs, rubs or gallops. Lungs
clear to auscultation bilaterally with poor effort. Abdomen
soft, nontender, nondistended, positive bowel sounds.
Extremities with trace edema bilaterally; no dorsalis pedis
pulses bilaterally.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient was admitted for further
evaluation of his painless jaundice. The patient was
lethargic and mildly hypotensive on arrival on the floor from
ERCP Suite. The patient responded with intravenous fluids in
time. The patient's course was complicated by acute renal
failure which will be discussed, however, repeat Endoscopic
retrograde cholangiopancreatography under general anesthesia
which had been planned for the next day was unable to be
performed. The patient could not have an abdominal CT scan
with contrast secondary to a rise in creatinine.
He was evaluated for MRCP however, he could not undergo this
procedure secondary to his excessive movement and agitation.
The patient's transaminases remained slightly elevated. ALT
was 69, now 251, AST 48 and now 267. LDH has remained
normal. Alkaline phosphatase was 86 and now increased to
1211, amylase started at 39 and increased to 109. Total
bilirubin started at 0.4, which was probably a false [**Location (un) 1131**]
and now elevated at 6.6 with direct of 4.5, indirect 2.1.
The patient will have a repeat endoscopic retrograde
cholangiopancreatography on admission whenever he is
medically stable enough to undergo this further evaluation.
Also of note, the patient had a highly elevated CA19-9 up to
27,834 at the outside hospital, concerning for malignancy.
Other possibilities include other biliary disease.
2. Acute renal failure: The patient had underlying renal
disease of nephrotic syndrome of unclear etiology. The
patient's urine output dropped to oliguric level on hospital
days one and two. BUN increased from 50 up to 65 and
creatinine rose from 2.5 to 5.0. Potassium also increased to
hyperkalemic levels. Bicarbonate initially was 12 which
increased to 15 with bicarbonate therapy. He remained with
hypodynamic acidosis. Due to the patient's underlying renal
disease and new acute renal failure, Renal was consulted.
Work-up of this likely acute glomerular nephritis or
post-Streptococcal glomerular nephritis was pending at this
time with antibodies.
He also underwent a renal ultrasound which was essentially
negative with no signs of hydronephrosis.
3. Anemia: The patient has a ferritin of 10 with TIBC of
312 near his admission time. He was already on iron
replacement and continued on this. He did have occasional
guaiac positive stools and it is unclear the reason for this.
4. Diabetes mellitus: The patient was admitted on insulin
as well as oral hypoglycemics. Oral medications were
initially held. The patient's insulin was cut in half while
he was n.p.o.. The patient's glucose continued to drop and
he became hypoglycemic into the 60s for his renal failure.
Due to longer instance of insulin renal failure, the patient
was taken off his insulin and placed on a Regular insulin
sliding scale.
5. Neurological: Per report the patient was alert and
oriented prior to the endoscopic retrograde
cholangiopancreatography. Following the procedure, he became
agitated and confused. It was unclear initially if this was
due to the medication effect or his underlying medical
issues. The patient required p.r.n. Haldol for sedation as
well as a one-to-one sitter which he still requires. His
attention has waxed and waned consistent with delirium from a
toxic metabolic encephalopathy.
6. Swallowing; The patient has been noted by Nursing to
have difficulty swallowing where he chokes and turns" purple.
His sister noted some difficulty eating at home but not to
this extent. It is unclear if this is due to his confusion
or if he has underlying mechanical problem. This will need
to be explored by Speech and Swallow.
The rest of this dictation will be completed at a later
point.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2186-11-26**] 15:58
T: [**2186-11-26**] 21:05
JOB#: [**Job Number 46853**]
Name: [**Known lastname 8642**], [**Known firstname 63**] Unit No: [**Numeric Identifier 8643**]
Admission Date: [**2186-11-21**] Discharge Date: [**2186-12-2**]
Date of Birth: [**2123-6-23**] Sex: M
Service: [**Company 112**]
ADDENDUM:
HOSPITAL COURSE: (CONTINUED)
1. GASTROINTESTINAL: The patient's condition stabilized and
his bilirubin decreased following sphincterotomy of initial
endoscopic retrograde cholangiopancreatography. The patient
returned for endoscopic retrograde cholangiopancreatography
on [**2186-11-28**], which revealed successful chemoablation
of the biliary duct and irregular stricture of malignant
appearance of 20 millimeters in length was noted in the lower
post-obstructive dilatations compatible with malignance of
biliary obstruction.
The area was stented successfully and the patient was sent to
the floor on Levaquin and Vancomycin for a seven day course.
Cytology samples were obtained with brushings which were
pending at the time of this dictation. Based on all of the
data accumulated including CA [**02**]-9 of 27,000, it was felt by the
endoscopic retrograde cholangiopancreatography team that he
most likely has metastatic pancreatic carcinoma and would not
be amenable to further treatment.
2. ACUTE RENAL FAILURE: The patient's creatinine continued
to climb into the fives with hypercalcemia and metabolic
acidosis that continued. The patient underwent renal biopsy
of the right kidney on [**2186-11-30**], and the results of this
are pending at this time. It was felt that he also had
positive ASO titer as well as positive [**Doctor First Name **] and positive
double stranded DNA antibodies. He had negative ANCA
antibodies which was a mixed picture consistent with either
post-Streptococcal glomerular nephritis or an auto-immune
glomerular nephritis and it was felt that the biopsies will
be determining factor. His pathology initially showed diabetic
nephropathy without active inflammation, but the IF and EM are
pending at the time of discharge.
The patient will follow-up with Dr. [**Last Name (STitle) 2955**] in [**Hospital 8644**]
Clinic.
Prior to the patient's discharge, his creatinine stabilized
at approximately 5.0 with stable electrolytes on multiple
medications prior to discharge medications.
3. ANEMIA: The patient's iron studies revealed iron
deficiency anemia. The patient remained on iron sulfate 325
mg p.o. three times a day. The patient was also transfused
one unit of packed red blood cells following the kidney
biopsy. His hematocrit remained stable and he was ready for
discharge.
4. DIABETES MELLITUS: The patient was transiently taken off
os his NPH over concern of aspiration. Speech and Swallow
evaluated the patient and the patient did not have any signs
of aspiration on the bedside. The patient was then restarted
on his NPH with gradual titration upward.
5. NEUROLOGICAL: The patient's mental status continued to
improve mildly as the patient's bilirubin came down. The
patient remained to have mild changes consistent with
delirium in his mental status which was felt likely to go on
for it to completely resolve.
6. PULMONARY: The patient experienced respiratory distress
and desaturation to 70% following his endoscopic retrograde
cholangiopancreatography. The patient required re-intubation
and transient stay in the Intensive Care Unit. The patient
was rapidly extubated and transferred back to the floor
without any complications.
DISPOSITION: The patient was discharged to rehabilitation
with follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and
nephrologist Dr. [**Last Name (STitle) 2955**]. No gastrointestinal follow-up was
arranged as there was a question of utility to this.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Jaundice, likely secondary to pancreatic malignancy,
awaiting final biopsy.
2. Acute renal failure from acute glomerular nephritis;
awaiting biopsy for a final interpretation.
3. Iron deficiency anemia.
4. Diabetes mellitus.
5. Delirium.
DISCHARGE MEDICATIONS:
1. Calcium carbonate 1500 mg p.o. three times a day with
meals.
2. Metoprolol 25 mg p.o. twice a day.
3. Levaquin 250 mg p.o. q. four to eight hours to complete a
seven day course.
4. Vancomycin one gram intravenous for level less than 15,
to complete a one week course.
5. Sodium bicarbonate 650 mg p.o. four times a day.
6. Protonix 40 mg p.o. q. day.
7. Miconazole 2%, one application to perineum twice a day.
8. Iron sulfate 325 mg p.o. three times a day.
9. Acetaminophen 325 to 650 mg p.o. q. four to six hours
p.r.n.
10. Insulin, NPH to be titrated for blood sugars, currently
12 units q. a.m. and 8 units q. h.s.
11. Regular insulin sliding scale.
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Name8 (MD) 8510**]
MEDQUIST36
D: [**2186-12-1**] 17:02
T: [**2186-12-1**] 17:16
JOB#: [**Job Number 8645**]
Name: [**Known lastname 8642**], [**Known firstname 63**] Unit No: [**Numeric Identifier 8643**]
Admission Date: [**2186-11-21**] Discharge Date: [**2186-12-4**]
Date of Birth: [**2123-6-23**] Sex: M
Service: [**Company 112**]
HOSPITAL COURSE:
1. GI. The patient's biopsy results following ERCP are
still pending. These will likely reflect pancreatic CA. The
patient's primary care doctor, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] deal with the
results of this. He will be informed about pathology
results.
2. Acute renal failure. The patient underwent kidney biopsy
demonstrating only diabetic nephropathy. Patient was
restarted on an ACE inhibitor which was slowly titrated up.
Patient's creatinine decreased upon discharge to a level of
3.7. Patient may have his sodium bicarbonate and calcium
carbonate discontinued as his acute renal failure continues
to resolve. He should follow up with Dr. [**Last Name (STitle) 2955**] in
nephrology clinic.
3. Anemia. Patient continues to exhibit iron deficiency
anemia, although his hematocrit did stabilize. He remained
on iron sulfate 325 mg p.o. t.i.d. This should continued to
be followed at the rehab facility.
4. Diabetes mellitus. The patient's finger sticks continued
to remain out of control after patient was restarted on his
diet. He was eating additional candy. Patient's NPH was
titrated up and this will be continued to titrated at rehab.
5. Neurological. Patient remains mildly delirious, although
his mental status has improved significantly. It will likely
take weeks to months for him to completely return to his
baseline.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to [**Hospital **]
Healthcare and followed by Dr. [**Last Name (STitle) **].
DISCHARGE DIAGNOSES:
1. Jaundice likely secondary to pancreatic malignancy,
awaiting final biopsy.
2. Acute renal failure from diabetic nephropathy.
3. Iron deficiency anemia.
4. Diabetes mellitus.
5. Delirium.
6. Hypomagnesemia.
DISCHARGE MEDICATIONS:
1. Calcium carbonate 1500 mg p.o. t.i.d. with meals.
2. Metoprolol 25 mg p.o. b.i.d.
3. Sodium bicarbonate 650 mg p.o. q.i.d.
4. Protonix 40 mg p.o. q.d.
5. Miconazole 2% one application to scrotum b.i.d.
6. Iron sulfate 325 mg p.o. t.i.d.
7. Acetaminophen 325 to 650 mg p.o. q.four to six hours
p.r.n.
8. NPH insulin 22 units q.a.m., 18 units q.h.s.
9. Regular insulin sliding scale.
10. Heparin 5000 units subcu b.i.d.
11. Lisinopril 10 mg p.o. q.d.
12. Mag oxide 400 mg p.o. times four doses.
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Name8 (MD) 8510**]
MEDQUIST36
D: [**2186-12-4**] 13:11
T: [**2186-12-4**] 15:15
JOB#: [**Job Number 8646**]
|
[
"581.9",
"250.40",
"276.2",
"584.5",
"197.7",
"518.5",
"280.9",
"157.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"51.14",
"96.71",
"51.87",
"51.85",
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
2278, 2288
|
13969, 14185
|
14208, 14975
|
12405, 13786
|
2643, 3052
|
142, 162
|
192, 1316
|
1338, 2260
|
2306, 2619
|
13811, 13948
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,876
| 102,451
|
5841
|
Discharge summary
|
report
|
Admission Date: [**2180-1-12**] Discharge Date: [**2180-1-28**]
Date of Birth: [**2131-3-13**] Sex: F
Service: SURGERY
Allergies:
Iodine Containing Agents Classifier / Iron Derivatives
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Gangrene of the right fourth toe.
Major Surgical or Invasive Procedure:
A jump graft from femoral anterior tibial vein graft to dorsalis
pedis artery with non reversed lesser saphenous vein and right
fourth toe open amputation.
History of Present Illness:
This 48-year-old lady with juvenile diabetes
and long history of peripheral vascular disease has
previously undergone a right femoral anterior tibial bypass
to the proximal anterior tibial artery. She subsequently
developed 2 episodes of recurrent ischemia in her right foot
with a patent graft, and was found to have disease in her
anterior tibial artery [**First Name3 (LF) 22594**] to the vein graft, but proximal
to the dorsalis pedis artery. This area has been
angioplastied twice due to severe ischemia of her foot. The
second time we did it we decided to revise this with a
bypass, since the recurrence rate of stenosis between the 2
episodes was quite short. She has gangrene of her toe and
requires toe amputation at the same time
Past Medical History:
(1) CAD s/p CABG ([**2164**]) s/p PTCA/PCI (Stenting of LAD in [**1-21**]),
(2) TIA; occluded L ICA ([**2174**]); Min plaque R ICA.
(3) DMI (since age 6) with Triopathy/Gastroparesis.
(4) HTN
(5) Hypercholesterolemia
(6) H/O Pneumonia.
(7) Iron deficiency anemia
(8) H/O Kidney stones
(9) H/O DVT
(10)PVD s/p L 4th toe amp, s/p SFA Bypass Graft and LFA
(11)Thrombectomy([**2166**])
(12)hx pericarditis
(13)I&D lt. buttocks abcess [**11/2171**]
Cath [**8-23**]: Report Unavailable.
Cath [**11-24**]:
(1) 3VD.
(2) Patent SVG-Diagonal
(3) Patent SVG-PDA
(4) Patent LIMA-LAD
(5) Occluded SVG-OM. COMMENTS: LMCA patent. LAD had a mid total
occlusion. LCX mild diffuse disease. Occluded OM. RCA proximal
100% stenosis. SVG-PDA 40% mid stenosis. [**Month/Year (2) **] LAD beyond the
touchdown patent w/ mild 30-40% in-stent restenosis.
ECHO: Not available.
pMIBI ([**4-/2173**]): EF51%. Apical akinesis. Mod min rev [**First Name (Titles) 22594**] [**Last Name (Titles) **]
and apical perf defect.
Social History:
Lived with husband and two children. Worked as a nurse??????s aid for
two women with MS. [**First Name (Titles) **] [**Last Name (Titles) 1818**]: 20+ p-y. [**12-25**] drinks
ETOH/week. No drugs/IVDU.
Family History:
No CAD/MI/DM. Mother and father healthy. [**Name2 (NI) **] son (age 21) has
high chol.
Physical Exam:
VITAL SIGNS: Her blood pressure is 130/80, pulse was 78 and
regular, and her weight was stable at 135 pounds.
SKIN: Without rash, lesions, or nodules. She did have erythema
of her right foot / open wound on fore foot is C/D/I.
HEENT: Pupils are equal, round, and reactive. Conjunctivae,
nose, and throat were clear. Hearing intact to finger rubbing.
NECK: Without mass or thyromegaly without cervical or
supraclavicular lymphadenopathy.
CHEST: Clear to percussion and auscultation.
HEART: Showed normal PMI without S3, S4, or murmurs.
ABDOMEN: Soft, without masses, tenderness, or organomegaly.
She
had tenderness in the right inguinal area. There was tender
lymphadenopathy.
EXTREMITIES: Exam of the leg and foot was as above. Her ulcers
appear dry and her skin is erythematous. There is no edema.
Pulses: R DP/PT dopp / palp graft, L DP/PT dopp / palp graft
Pertinent Results:
[**2180-1-25**] 06:20AM BLOOD
WBC-9.3 RBC-3.21* Hgb-9.0* Hct-28.4* MCV-88 MCH-28.2 MCHC-31.9
RDW-14.8 Plt Ct-513*
[**2180-1-25**] 06:20AM BLOOD
PT-13.1 PTT-30.4 INR(PT)-1.1
[**2180-1-25**] 06:20AM BLOOD
Glucose-89 UreaN-16 Creat-1.4* Na-141 K-4.6 Cl-104 HCO3-29
AnGap-13
[**2180-1-24**] 04:50AM BLOOD
Calcium-9.1 Phos-4.2 Mg-2.0
[**2180-1-12**] 08:54PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-[**4-30**]* WBC-[**1-24**] Bacteri-FEW Yeast-NONE Epi-0-2
[**2180-1-21**] 10:10 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2180-1-22**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2180-1-19**] 1:30 pm SWAB Site: TOE RIGHT 4TH TOE.
GRAM STAIN (Final [**2180-1-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2180-1-21**]):
BETA STREPTOCOCCUS NOT GROUP A OR B. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2180-1-23**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Pt admitted on [**1-12**]
pre-op'd / foot xrays show osteo of 4th digit / AB started /
cx's taken
[**1-12**]
Underwent a A jump graft from femoral anterior tibial vein graft
to dorsalis pedis artery with non reversed lesser saphenous vein
and right fourth toe open amputation.
Tolerated the procedure well. No complications
Recovered in the PACU. Once recovered from the PACU sent to the
VICU in stable condition.
Bedrest
[**1-14**]
HLIV / regualr diet
[**1-15**] - [**1-18**]
low u/o and decrease o2 sats / responeded to lasix / PRBC given
[**1-17**]
c/o chest pressure / diagnosis of CHF and NSTEMI / tx to CCU
Cardiology is consulted - pt has been complaining of recurrent
CP. There was no ECG changes but cardiac enzymes returned
positive (TnT 0.16 with CPK 94), and cardiology was consulted on
[**1-17**], and pt was taken to cath lab for intervention. Cath showed
diffuse severe disease of LMCA, LAD, LCx, RCA. SVG to RCA was
patent with [**Month/Year (2) 22594**] RCA which had 90% lesions in the PLB
unchanged from previous angiography. LIMA to LAD was patent.
Origin Left subclavian had 70% and left subclavian was stented
with a Genesis stent and the final residual was 0% with normal
flow. LVEDP was elevated at 32 with PCW mean 29. Pt is getting
admitted to CCU overnight for observation and diuresis.
[**1-18**]
Transfer back to VICU
[**1-19**]
Pt undergoes a incision and debridement of r fourth toe
amputation site under local
[**Date range (1) 23163**]
wound watched with VAC dressing changes
AB tailored to treat strep b
[**1-27**]
VAC DC / changed to wet to dry dressing changes
PT / case management
Pt stable for DC
Home on PO AB
Creat stabalized from ARF
Medications on Admission:
Plavix 75', ASA 325', diltiazem 120', isosorbide 120',
lisinopril 10', toprol 100', pravastatin 80', percocet
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*0*
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*15 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Insulin
Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose
Bedtime
Glargine 15 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-70 mg/dL [**11-23**] amp D50
71-100 mg/dL 0 Units 0 Units 0 Units 0 Units
101-120 mg/dL 2 Units 2 Units 2 Units 0 Units
121-140 mg/dL 3 Units 3 Units 3 Units 0 Units
141-160 mg/dL 3 Units 3 Units 3 Units 0 Units
161-180 mg/dL 4 Units 4 Units 4 Units 0 Units
181-200 mg/dL 5 Units 5 Units 5 Units 0 Units
201-220 mg/dL 6 Units 6 Units 6 Units 2 Units
221-240 mg/dL 7 Units 7 Units 7 Units 4 Units
241-260 mg/dL 9 Units 9 Units 9 Units 5 Units
261-280 mg/dL 10 Units 10 Units 10 Units 6 Units
281-300 mg/dL 13 Units 13 Units 13 Units 7 Units
> 300 mg/dL Notify M.D. .
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Ischemic toe
PAD
ARF - creat 0.8 on admission / 1.5 on DC / High
Discharge Condition:
Stable
Discharge Instructions:
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
OTHER INFORMATION:
You may shower immediately upon coming home. No bathing. keep
your open wound dry. Dressing changes twice a day
Avoid taking a tub bath, swimming, or soaking in a hot tub
untill your wound is completely healed
Limit strenuous activity and or heavy lifting until the wound
is well healed. Activity may prevent the wound from healing.
Do not drive a car unless cleared by your Surgeon.
Try to keep your affected limb elevated when not in use, This
decreases swelling to the affected wound and helps in the
healing process.
You may have an ace wrap around the affected limb with the
wound. This helps prevent swelling to the area. You may take
this off at night. But when you are doing activity the ace wrap
should be worn.
ANTIBIOTICS:
You may have a prescription for antibiotics. Take as directed.
Be sure you take the full course even if the wound looks well
healed. Failure to do so may lead to infection.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2180-4-25**] 11:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2180-6-20**] 11:10
Call Dr [**Last Name (STitle) **] office and schedule am appointment for one
week. He can be reached at [**Telephone/Fax (1) 3121**]
Completed by:[**2180-1-28**]
|
[
"440.24",
"401.9",
"536.3",
"357.2",
"250.51",
"362.01",
"583.81",
"428.0",
"250.61",
"997.1",
"250.41",
"410.71",
"584.9",
"998.59",
"730.07",
"428.23",
"V45.81",
"272.0",
"447.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.68",
"00.40",
"84.11",
"37.23",
"88.56",
"39.29",
"88.53",
"39.50",
"39.90",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
8824, 8899
|
4689, 6393
|
349, 507
|
9008, 9017
|
3528, 4666
|
10470, 10932
|
2530, 2618
|
6553, 8801
|
8920, 8987
|
6419, 6530
|
9041, 9041
|
2633, 3509
|
275, 311
|
9054, 10447
|
535, 1276
|
1298, 2295
|
2311, 2514
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,099
| 115,426
|
3023
|
Discharge summary
|
report
|
Admission Date: [**2150-11-6**] Discharge Date: [**2150-11-11**]
Date of Birth: [**2093-8-2**] Sex: F
Service: MEDICINE
Allergies:
Oxycontin
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD
Angiography with embolization
Central line placement
History of Present Illness:
Pt is a 57 yo F w/ metastatic ampullary carcinoma of pancreas
admitted [**11-6**] for thrombocytopenia and trace guiaic + emesis,
now transferred from [**Hospital Unit Name 153**] for CMO. She failed systemic therapy
with irinotecan, and began rx one wk ago with
oxaliplatin/avastin/5FU. She had increased bruising, emesis x 3
[**11-5**], and fell night of [**11-5**] on L buttock into dresser. She was
sent to ED from [**Hospital **] clinic after found emesis heme + (pt brought
sample of emesis), hct 25, plt 9. In ED couple hours later, hct
24, plt 5. Transfused 2 units pRBCs and 2 packs of platelets;
repeat hct 24 and plt 18. Sent to floor [**11-6**] afternoon.
.
ROS: +Chronic LBP since ERCP in [**7-12**]. No melena or blood in
stool. nl BM [**11-6**]. able to take in POs. no dysuria, gum
bleeding, vaginal bleeding, swelling/pain in joints. no F/C/S.
no confusion, dizziness, LOC. +Memory loss on chemotherapy (pain
meds).
Past Medical History:
metastatic ampullary carcinoma - lung nodules
h/o SBO in [**8-11**] s/p duodenal stent
HTN
internal hemorrhoids
DCIS of breast [**2141**] s/p excision and XRT
osteoarthritis
history of positive PPD in [**2115**] - tx c anti-TB tx x 1 yr
hyperlipidemia
LBP- prior hx unrelated to new LBP
Social History:
Lives with mentally disabled daughter in [**Name (NI) 4047**]. Former ICU
nurse, on disability for LBP x 10 yrs. Tob 28 pk yrs and quit 15
years ago. No EtOH. HCP [**Name (NI) **] [**Name (NI) 14407**], nurse friend, at
[**Telephone/Fax (1) 14408**].
Family History:
Her father had multiple myeloma. A non-smoker paternal aunt had
lung cancer.
Physical Exam:
Vitals: T 96.5 BP 128/67 P 58 R 12 O2 97% 3L NC
Gen: Pale female in no acute distress lying in bed, lethargic
appearing
HEENT: Anicteric. PERRL, EOMI. Pale mucous membranes. Palatal
petechiae
Heart: Regular rate and rhythm. Normal s1,s2. III/VI SEM at LUSB
Lungs: Decreased breath sounds on right, left lung clear to
ausculation.
Abd: Soft, nondistended, normal active bowel sounds, tender to
palpation in epigastrium with minimal involuntary guarding, no
rebound
Ext: warm and well perfused, without cyanosis or edema.
Skin: 2x3 cm bruises noted on her left buttock. Multiple bruises
on both arms
Neuro: Awake, alert and oriented x 3. Moving all extremities
equally and spontaneous
Pertinent Results:
[**Age over 90 **]|99|14/104
3.4|32|0.7\
>9.624.0<5
N:91 B:0 L:5 M:4 E:0 Bas:0
Granct:[**Numeric Identifier 14409**]
PT:12.9 PTT:25.7 INR:1.1
...........
[**2150-11-6**] 07:36AM PLT SMR-RARE PLT COUNT-9*#
[**2150-11-6**] 07:36AM WBC-14.0*# RBC-2.99* HGB-8.1* HCT-25.1*
MCV-84 MCH-27.0 MCHC-32.2 RDW-16.2*
[**2150-11-6**] 09:55AM PT-12.9 PTT-25.7 INR(PT)-1.1
[**2150-11-6**] 09:55AM WBC-9.6 RBC-2.83* HGB-7.9* HCT-24.0* MCV-85
MCH-27.8 MCHC-32.8 RDW-16.2*
[**2150-11-6**] 09:55AM GLUCOSE-104 UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-32 ANION GAP-10
[**2150-11-6**] 03:33PM PLT COUNT-18*#
[**2150-11-6**] 03:33PM HCT-23.9*
Brief Hospital Course:
57 year-old female with metastatic pancreatic ampullary
carcinoma who presented with hematemesis, anemia, and
thrombocytopenia. On first night of admission the patient had 2
episodes of hematemesis, 70cc and ~100cc - the first episode
during plt transfusion and associated with diffuse abdominal
pain and hypotension to SBP 70s. KUB revealed no free air.
Surgery was called and did not eval the patient. GI recommended
adequate access, PPI, volume resuscitation. She was transferred
to [**Hospital Unit Name 153**] after 2nd episode of hematemesis on [**11-7**].
.
In the [**Hospital Unit Name 153**], she underwent EGD for which she was electively
intubated, which revealed large amounts of blood and clot in the
stomach. There was no evidence of active bleeding. Three
lesions at the gastroesophageal junction were cauterized
although these lesions had a low probability to be contributing
to her hematemesis. Shortly after the EGD, she developed
massive amounts of hematemesis (1.5 L) and became
hemodynamically unstable. She required a total of 13 units of
red cells, 6 L of crystalloid, 2 units of platelets, 2 units of
fresh frozen plasma. She was taken to IR for embolization. On
angiography, she had a clear bleed in the pacreatoduodenal
branch of the SMA that was successfully embolized. While she
remained hemodynamically stable over the next 12 hours, her
hematocrit trended down and she continued to have 100 cc/hr
output from her OG tube. IR was ready to take the patient back
for another angiography; however, the health care proxy decided
not to pursue further treatments. At that point the patient was
extubated and made comfort measures only.
.
The patient was transfered back to the floor on MSO4 and ativan
drips at 160 mg/hr and 2 mg/hr respectively to control her pain.
Her HCP, [**Name (NI) **], was at patient's side. At 4:30 am the night
float resident was called to evaluate the patient because she
had stopped breathing. The patient was found to have no
pupillary reaction to light, no breath sounds, and no pulse.
.
The patient was maintained NPO. Her calcium, magnesium, and
potassium were repleted before she was made comfort measures
only. She was maintained on pneumoboots and PPI before she was
made comfort measures only.
.
Initially the patient was DNR, but once she continued to bleed
post-embolization, she was made comfort measures only.
Medications on Admission:
dilaudid 4 mg Q4
fentanyl 250 mcg Q3 days
protonix 40 iv BID
lorazepam 1 mg Q4 prn
neurontin 300 TID,
naprosyn [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
UGIB
metastatic ampullary carcinoma - lung nodules
........
HTN
internal hemorrhoids
DCIS of breast [**2141**] s/p excision and XRT
osteoarthritis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
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"197.0",
"V10.3",
"157.9",
"518.81",
"287.4"
] |
icd9cm
|
[
[
[]
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[
"99.07",
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icd9pcs
|
[
[
[]
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5984, 5993
|
3384, 5777
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282, 340
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6184, 6193
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2696, 3361
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1897, 1977
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6014, 6163
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5803, 5932
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6217, 6223
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1992, 2677
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231, 244
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368, 1302
|
1324, 1613
|
1629, 1881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,089
| 115,298
|
7304
|
Discharge summary
|
report
|
Admission Date: [**2115-7-4**] Discharge Date: [**2115-7-19**]
Date of Birth: [**2052-12-23**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
R-sided chest pain, SOB
Major Surgical or Invasive Procedure:
Left-sided thoracentesis
History of Present Illness:
62M with T3, N0, M0 (stage IIb) recurrent esophageal
adenocarcinoma s/p neoadjuvant chemoradiation [**2114-1-4**], then
esophagectomy 5/[**2113**]. He had a positive margin on the surgical
resection and has undergone palliative chemo with
epirubicin/oxaliplatin/5FU x 5cycles starting 5/[**2113**]. Started
palliative taxotere [**2115-1-24**] - C5D1 [**2115-5-30**], C6D1 held today. Pt
admitted from clinic for R-sided chest pain and SOB. Pt with h/o
of bilateral pleural effusions s/p L thoracentesis [**5-29**],
cytology neg. Pt on lasix after thoracentesis and did better for
a period of time, but worsening the past couple of weeks. Pt
sent for CTA chest today: neg for PE, showed reaccumulation of
large bilateral pleural effusions.
Pt reports R-sided chest pain x2-2.5wks. Reports pain constant,
[**4-11**] at baseline and increases with movement and deep
inspiration. Pain [**9-11**] with [**Month/Year (2) **]. Pt reports chest pain
located over R anterior chest with radiation around to the back.
Pt also with dry [**Month/Year (2) **] for same time period. Pt reports SOB at
rest, worse with exertion. Pt also reports PND, orthopnea. No LE
edema or pain. No fevers/chills, n/v, abdominal pain. Eating
poorly but enough to maintain weight. Pt reports seen in clinic
[**6-27**] and given robitussin but no improvement in [**Last Name (LF) **], [**First Name3 (LF) **] no
longer taking it. Pt also recently treated for thrush with
nystatin swish and swallow, but no longer taking.
On arrival to the floor, pt reports continued R-sided chest pain
and SOB.
Past Medical History:
ONCOLOGIC HISTORY:
Mr. [**Known lastname 26973**] presented with a sensation of food getting stuck in
his chest in the fall of [**2112**]. Barium swallow demonstrated a
stricture in the distal esophagus. ECG demonstrated
circumferential narrowing and thickening at the GE junction (40
cm), and extended proximally to 35 cm. Biopsies were performed
and pathology demonstrated adenocarcinoma, mucin-producing with
few signet ring cells, moderately differentiated. He underwent
PET/CT scan [**2113-12-31**], which showed FDG uptake in the GE junction
but no evidence of regional or distant metastases. He was
referred for EUS staging, performed on [**2114-1-5**], which
demonstrated
a mass at the distal esophagus/GEJ consistent with known
adenocarcinoma, maximum depth 1 cm, with extension beyond the
muscularis propria. There were no concerning lymph nodes
identified. By EUS, the tumor was staged as T3N0Mx, Stage IIB
esophageal adenocarcinoma.
.
He began concurrent chemoradiation with cisplatin/5-FU on
[**2114-1-23**]. He had a J-tube placed prior to treatment. His last
radiation treatment was on [**2114-3-1**], total dose 5040 cGy. His
last
cycle of chemotherapy (C2D1) was [**2114-2-19**]. He underwent
[**Month/Day/Year 12351**]-[**Doctor Last Name **] esophagectomy [**2114-4-25**] which demonstrated residual
disease, including a positive proximal margin. Surveillance
endoscopy demonstrated friable and nodular distal esophagus and
biopsy demonstrated adenocarcinoma.
.
[**2114-9-3**] C1D1 Epirubicin, Oxaliplatin, 5-fluorouracil (5-FU given
by continuous infusion pump Mon-Fri x96 hours given his
difficulty swallowing pills)
[**2114-9-24**] C2D1 Epirubicin, Oxaliplatin, 5-fluorouracil
.
PAST MEDICAL HISTORY:
-Myocardial infarction in [**2101**] treated with plain old balloon
angioplasty to one vessel and a stent in another vessel.
-Open gall bladder surgery
-Kidney stones
-Osteoarthritis: mainly neck and right knee
-Low back injury
-GERD
Social History:
Married to his wife of 40 years. two children, & two
grandchildren.
He works in software and customer teaching for an electronic
access device maker.
Smoked half a pack to pack a day for approximately 30 years, but
quit in [**2101**] with his heart attack. He does not drink alcohol
regularly.
Family History:
Parents both died of heart attack. He has a sister who has had
breast cancer twice and a brother with diabetes.
Physical Exam:
Admission PE:
Vitals - T: 98.3 BP: 114/68 HR: 98 RR: 18 sat: 100% RA
GENERAL: sitting up in bed, pleasant, in NAD
HEENT: AT/NC, PERRLA, anicteric sclera, pink conjunctiva, patent
nares, MMM, a few small white plaques on R side inside mouth,
nontender supple neck, no cervical/supraclavicular/axillary LAD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: speaking in short sentences, tachypneic, inspiratory rales
on R > L, decent air movement bilaterally
CHEST: anterior chest tender to palpation around ribs [**2-3**] on the
right
ABDOMEN: nondistended, decreased BS, nontender
EXTREMITIES: no LE edema or tenderness
NEURO: 5/5 strength in UE and LE bilaterally, sensation to light
touch intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge PE:
VS: Tc-98, HR 110-120s, BP 98-110s/60-70s, RR 20-22, 94-100% RA
I/O: 770(PO) + 737(IV)/1575 + 525 from L pleurex
GENERAL: Chronically ill appearing gentleman, pleasant, in no
acute distress
HEENT: thrush resolved, dry MM
CHEST: inpsiratory rales at L base but improved BS on L
compared to prior, coarse inspiratory rales on the R throughout,
decent air movement, pigtail on L capped
CARDIAC: Tachycardic, regular rhythm, no MRG
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: 1+ LE edema with support stockings on; edema of L
arm slightly increased with clear demarcation just proximal to
the elbow
Pertinent Results:
Admission Labs:
[**2115-7-4**] 08:50AM UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-3.9
CHLORIDE-102 TOTAL CO2-29 ANION GAP-11
[**2115-7-4**] 08:50AM ALT(SGPT)-7 AST(SGOT)-19 ALK PHOS-77 TOT
BILI-0.7
[**2115-7-4**] 08:50AM CALCIUM-8.4 PHOSPHATE-2.1* MAGNESIUM-1.8
[**2115-7-4**] 08:50AM WBC-13.5* RBC-4.10* HGB-11.3* HCT-35.3*
MCV-86 MCH-27.6 MCHC-32.0 RDW-16.4*
[**2115-7-4**] 08:50AM PLT COUNT-347
[**2115-7-4**] 08:50AM GRAN CT-[**Numeric Identifier 26974**]*
MICRO
Pleural [**Numeric Identifier 26975**]:
[**2115-7-4**] 6:13 pm PLEURAL [**Month/Day/Year **] **FINAL REPORT [**2115-7-10**]**
GRAM STAIN (Final [**2115-7-4**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2115-7-7**]): NO GROWTH.
[**2115-7-5**] 11:35 am PLEURAL [**Month/Day/Year **] **FINAL REPORT [**2115-7-10**]**
GRAM STAIN (Final [**2115-7-5**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2115-7-10**]):
LACTOBACILLUS SPECIES. RARE GROWTH.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. RARE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # 352-0143D [**2115-7-6**].
ANAEROBIC CULTURE (Final [**2115-7-10**]): NO ANAEROBES ISOLATED.
[**2115-7-6**] 4:00 am BLOOD CULTURE No growth x2
[**2115-7-6**] 2:52 pm PLEURAL [**Year (2 digits) **]
GRAM STAIN (Final [**2115-7-6**]):
Reported to and read back by [**First Name8 (NamePattern2) 26976**] [**Last Name (NamePattern1) **] @ 7PM [**2115-7-6**] .
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
[**Month/Day/Year **] CULTURE (Preliminary):
LACTOBACILLUS SPECIES. MODERATE GROWTH.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE
GROWTH.
Susceptibility testing requested by [**First Name9 (NamePattern2) **] [**Doctor Last Name **] #[**Numeric Identifier 26977**]
[**2115-7-12**].
ANAEROBIC CULTURE (Final [**2115-7-10**]): NO ANAEROBES ISOLATED.
[**2115-7-8**] 1:35 pm PLEURAL [**Month/Day/Year **] **FINAL REPORT [**2115-7-13**]**
GRAM STAIN (Final [**2115-7-9**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2115-7-13**]):
LACTOBACILLUS SPECIES. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2115-7-13**]): NO ANAEROBES ISOLATED.
IMAGING:
TTE [**2115-7-19**]: Moderate circumferential pericardial effusion. No
clear-cut evidence of tamponade physiology. However, the
presence of tachycardia and relatively small chamber sizes along
with hyperdynamic left ventricular systolic function is
suggestive of poor diastolic filling. Compared with the prior
study (images reviewed) of [**2115-7-9**] and [**2115-7-8**], the findings are
similar.
CT Chest [**2115-7-18**]:
Moderate layering nonhemorrhagic left pleural effusion is larger
today than on [**7-11**]. Left pleural catheter enters laterally,
traverses the major fissure and ends superiorly alongside the
spine at the level of the fourth posterior interspace. No left
pneumothorax:
Moderate-to-large right pleural effusion is larger, particularly
in the right lower and anterolateral hemithorax where [**Month (only) **] now
replaces previous air component. Fissural and paramediastinal
components of the moderate-to-large right pleural effusion have
also increased. More extensive ground-glass opacification in the
upper aspect of the right lower lobe which is still consolidated
at the base could be edema associated with pleural [**Month (only) **]
interfering with lymphatic milking due to pleural restriction
that prevents ventilatory change in lobar volume, however, could
also be progression of pneumonia even though cavitation present
previously has not worsened. The residual esophagus or upper
neoesophagus is still distended above the alimentary stent,
which though unchanged in position, roughly from the level of
the T5-T9 is still largely occluded with semisolid material.
Large pericardial effusion, also nonhemorrhagic, is larger. The
superior vena cava above the pericardial reflection is larger
than the intrapericardial segment, and the right atrium and
ventricle are both smaller today than on [**7-11**], warranting
evaluation for possible early cardiac tamponade.
Mild atelectasis in the lingula and left lower lobe are probably
due to
ventilatory compromise by the larger left pleural effusion.
Left-sided central venous line ends at the superior cavoatrial
junction.
Atherosclerotic coronary calcification is heavy in the left
main, anterior descending and circumflex vessels.
Discharge Labs:
[**2115-7-19**] 06:12AM BLOOD WBC-7.6 RBC-3.58* Hgb-9.5* Hct-29.5*
MCV-82 MCH-26.6* MCHC-32.3 RDW-18.2* Plt Ct-328
[**2115-7-19**] 06:12AM BLOOD Glucose-112* UreaN-7 Creat-0.4* Na-137
K-3.5 Cl-101 HCO3-34* AnGap-6*
[**2115-7-19**] 06:12AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7
Brief Hospital Course:
62M with T3, N0, M0 (stage IIb) recurrent esophageal
adenocarcinoma s/p neoadjuvant chemoradiation [**2114-1-4**], then
esophagectomy [**4-/2114**] admitted from clinic with R-sided CP and
SOB. CTA showing reaccumulation of large bilateral pleural
effusions.
.
Active diagnoses:
#Bilateral pleural effusions, R-sided empyema: CT on admission
showed large bilateral pleural effusions, with the right one
being loculated, which had reaccumulated from prior drainage
6/[**2114**]. Pigtail placed on L [**2115-7-4**] by IP with pleural [**Month/Day/Year **]
exudative, cytology neg, no growth from culture. Pt had R
pigtail placed [**2115-7-5**] by IP with pleural [**Month/Day/Year **] exudative,
cytology neg, culture with rare growth of lactobacillus and
STREPTOCOCCUS ANGINOSUS. Pt transferred to [**Hospital Unit Name 153**] for hypotension
(SBP to 80s) and tachycardia [**2115-7-5**]. Pt started on Vanc and
ceftriaxone initially. Because of the potential for sepsis,
Ceftriaxone was broadened to Cefepime. Bl cultures from [**2115-7-6**]
negative x2. A repeat gram stain of the right pleural [**Month/Day/Year **] was
sent, which showed polymicrobial results. Flagyl was added.
This repeat pleural [**Month/Day/Year **] culture from R on [**2115-7-6**] with moderate
growth of lactobacillus and STREPTOCOCCUS ANGINOSUS. Chest tube
placed on R [**2115-7-8**] with pleural [**Month/Day/Year **] culture without growth.
Given the concern for an esophageal-pleural fistula, a CT thorax
with PO contrast was done on [**7-7**] which was inconclusive, so an
esophagram was performed on [**7-9**] that did not show evidence of
esopahgeal leak. R sided pleural effusion loculations and
bacterial growth concerning for empyema. In pt with h/o
bilateral effusions with reaccumulation, seems that pt likely
infected preexisting effusions. Bacteria are consistent from
oral flora per ID. This suggests microaspiration caused
infection and organization of R pleural effusion. Cytology has
been repeatedly negative. R sided effusion/empyema concerning
for abscess or necrotizing pneumonia per CT chest [**2115-7-11**].
Initial etiology of pt's pleural effusions still unclear since
cytology consistently negative but known to reaccumulate. L
effusion exudative but does not appear infected on pleural [**Month/Day/Year **]
culture. Bl cx neg. The patient was seen by Thoracic Surgery as
well as Interventional Pulmonology. The tubes continued to
[**Month/Day/Year 19843**] serosanguinous [**Month/Day/Year **] with intermittent instillations of
alteplase and dronase. Thoracic surgery felt intervention would
not be beneficial given his overall clinical picture. ID was
consulted and pt was switched to meropenem monotherapy [**2115-7-11**]
with plan for 4wk IV ABX course (starting [**2115-7-8**]). Pt to be
discharged on IV ertapenem q24h with plan to follow-up with ID
and complete at minimum of 4wk course ([**2115-8-5**]). On [**2115-7-14**], L
pigtail exchanged for pleurex. [**2115-7-15**] smaller R pigtail removed
by IP. On [**7-17**], pt accidentally pulled remaining R chest tube.
Pt had CT chest to evaluate if repeat pigtail needed to be
placed. IP reported no need for placing another chest tube on
the R. They want to follow-up with repeat chest CT and then appt
in clinic to evaluate if reaccumulation occurs to require a
chest tube. Pt with small PTX after L tube exchanged. Persisted
for many days. L tube capped with plan for intermittent drainage
M, W, F up to 1L each time. Again, thoracic surgery was
contact[**Name (NI) **] regarding possibility of intervention based on CT
chest [**7-17**]. They reported they did not feel he would benefit
from decortication based on mainly parenchymal abnormalities on
imaging.
.
#Pericardial effusion: The patient had a TTE that noted an
approximately 1cm effusion located posteriorly but had no
echocardiographic signs of tamponade. His pulsus paradoxus
remained approximately 6-8 mmHg during his ICU stay. Cardiology
recommended following the effusion with a repeat echo in 2 weeks
(~[**2115-7-23**]). Pt found to have slight increase in pericardial
effusion on chest CT [**7-17**], so TTE completed [**7-18**]. Showed
moderate effusion without clear tamponade physiology. Talked to
cardiology about poor diastolic filling on repeat TTE from [**7-18**]
and they said that without clear tamponade physiology they did
not want to do a pericardiocentesis. Patient will follow-up with
cardiology on [**8-1**] as an outpatient.
.
#Hypotension: The patient occasionally became hypotensive with
systolics in the high 80s. His hypotension responded well to
boluses of NS. His antihypertensive medications were held. His
SBPs came up to 100-120 range. BP meds continue to be held on
discharge.
.
#Tachycardia: Pt remained tachycardic throughout hospital stay.
HR in 100-110s mostly with occasional elevation to 120s.
.
#Thrush: pt put on fluconazole on admission because of inability
to tolerate nystatin secondary to severe worsening of GERD.
Thrush resolved during hospital stay.
.
#Edema: from IVF, pt was positive during admission resulting in
LE edema. Pt also developed asymmetric edema of L arm distal to
the elbow. Pt had duplex U/S on [**7-14**] which was neg for DVT. L
arm edema worsened, so pt had repeat duplex U/S on [**7-18**]. ACE
wraps started on L arm to mobilize [**Month/Year (2) **].
.
Chronic diagnoses:
# Recurrent esophageal adenocarcinoma: s/p C5D1 [**2115-5-30**], cycle 6
held [**7-4**]. Continued pain mgmt, nausea mgmt, home ativan.
# CAD s/p MI: Continued home [**Month/Day (2) **], atenolol held for low BPs.
# GERD: continued home PPI
Transitional issues:
# Pt to f/u with ID in [**Hospital 4898**] clinic, IP with plan for repeat
chest CT prior to appt, cards for pericardial effusion f/u
# Pt will also f/u with OP oncologist, Dr. [**Last Name (STitle) 3274**]
# Pt will require weekly lab draws: CBC with diff, Chem7, AST,
ALT; please fax results to ([**Telephone/Fax (1) 4591**]. All questions
regarding outpatient parenteral antibiotics should be directed
to the Infectious Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the
on-call ID fellow when the clinic is closed.
# Full Code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Aspirin 325 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Fentanyl Patch 25 mcg/hr TP Q72H
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
5. FIRST-Mouthwash BLM *NF* (lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **])
200-25-400-40 mg/30 mL Mucous Membrane TID
6. Lorazepam 0.5 mg PO Q4H:PRN nausea, insomnia
7. Ondansetron 8 mg PO Q12H:PRN nausea
8. Naproxen 500 mg PO Q12H:PRN pain
Discharge Medications:
1. Fentanyl Patch 25 mcg/hr TP Q72H
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
3. Lorazepam 0.5 mg PO Q4H:PRN nausea, insomnia
4. Naproxen 500 mg PO Q12H:PRN pain
5. Aspirin 325 mg PO DAILY
6. FIRST-Mouthwash BLM *NF* (lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **])
200-25-400-40 mg/30 mL Mucous Membrane TID
7. Ondansetron 8 mg PO Q12H:PRN nausea
8. ertapenem *NF* 1 gram Intravenous daily
end date earliest [**2115-8-5**] - or longer per ID recommendation
9. Docusate Sodium 100 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR <12
11. Senna 1 TAB PO BID:PRN constipation
12. HYDROmorphone (Dilaudid) 1-2 mg IV QMWF PRN for pain from
chest tube drainage
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Bilateral Pleural effusions
Right empyema
Secondary diagnosis:
Recurrent esophageal cancer
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:
Dear Mr. [**Known lastname 26973**],
It was a pleasure taking care of you at [**Hospital3 **]. You came
into the hospital because of right-sided chest pain and
shortness of breath. Your pleural effusions were found to be
increased on the CT scan of your chest. We had the lung doctors
[**Name5 (PTitle) 19843**] the [**Name5 (PTitle) **] from your left lung and leave in a [**Name5 (PTitle) 19843**]. They
then drained the right lung as well and left a [**Name5 (PTitle) 19843**] in place. A
repeat CT scan on [**7-11**] showed that the infection in your lung had
not gotten better. You had a third drainage tube placed in your
right lung. Your two right lung drains were removed. The chest
tube in your left chest will remain in place and will be drained
every M, W, F up to 1L each time.
Your home medications were not changed. Please see the attached
list for new medications added to your regimen.
Please follow-up at the appointments listed below.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2115-8-1**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2115-8-6**] at 10:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2115-8-9**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2115-8-16**] at 9:45 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY/Interventional Pulmonology
When: THURSDAY [**2115-8-22**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You will get a repeat chest CT on this same day [**2115-8-22**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2115-7-19**]
|
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"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
18548, 18624
|
11049, 11310
|
298, 325
|
18779, 18779
|
5790, 5790
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|
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18664, 18707
|
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|
11328, 16665
|
3675, 3910
|
3926, 4223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,213
| 197,986
|
34658
|
Discharge summary
|
report
|
Admission Date: [**2106-1-31**] Discharge Date: [**2106-2-7**]
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 / Metoclopramide
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Pericardiocentesis with placement of a pericardial drain
History of Present Illness:
41 y/o woman w/type I diabetes, HTN, HL, dCHF, history of PE
([**4-12**]) s/p IVC filter and IVC filter clot who has been off
coumadin since [**11-13**] (patient says a doctor told her to but has
not been to see her PCP) who presents with 3 days of increasing
lower extremity edema and 3 days of sharp left-sided substernal
chest pain that radiates to the back which is the same as her
previous chest pain. Patient also reports shortness of breath,
mild cough, nausea and one episode of emesis. Patient denies
dizziness, confusion, slurred speech, vision change, headache,
palpitations, radiation of the pain to her jaw or arm,
Of note she had an admission in [**2105-3-8**] for LE edema (at
this time patient had also stopped taking her coumadin) and was
found to have a IVC filter clot, IR attempted thrombectomy but
the patient developed respiratory distress thought to be due to
anaphyaxis vs. PE despite being premedicated with steroids and
benadryl and she was d/c'd on lovenox bridge to coumadin. During
that admission she was evaluated by heme/onc and had a negative
hypercoagulable work up. She has also had multiple previous
admissions for similar chest pain, work ups unrevealing and the
patient has left AMA due to not receiving IV dilaudid. It is
documented in OMR that she has multiple hospital admissions in
the [**Location (un) 86**] Hospitals but has DNKd multiple PCP in our system.
In the ED, initial vitals were 98.4 110 175/72 22 96%on RA. On
labs troponin 0.03, INR 1.2. EKG looks like left bundle,
consistent with past. T max 100, got levaquin b/c ?consolidation
on CXR. Also could not get CTA due to dye allergy and can't do a
VQ scan logistically. So she was started her on heparin gtt.
Guaiac positive brown stool. Also got lasix 100mg po daily and
1mg Dilaudid. Current VS, HR 104, on 2L02 (for chest pain).
On the floor the patient reports severe chest pain, unrelenting,
and nausea. No reported improvement in the ED with pain meds,
patient requests phenergan.
Past Medical History:
# DM type I - since age 12
# CAD s/p NSTEMI
- recent cath [**3-/2304**] at [**Hospital1 2177**] w/ 50% LCX lesion, 40% RCA lesion
(though original reports not available)
# Migraines
# HTN
# ? of TIA
# h/o PE in [**4-/2104**], [**7-/2104**] at [**Hospital 1474**] Hospital
- s/p IVC filter in [**4-/2104**] but date unclear (? [**2104-4-28**]).
# [**Name2 (NI) **]onic chest pain: Patient also had multiple admissions for
chest pain at [**Hospital1 18**], [**Hospital1 2177**] and other hospitals with chest pain of
undiagnosed etiology (not PE-related)
# Hyperlipidemia
# Erosive Gastritis
# Gastroparesis
# h/o dCHF - ? flash pulm edema [**8-/2104**] normal ECHO in [**1-/2105**]
# s/p ccy [**2104-5-3**]
# s/p ovarian cyst removal in [**2097**]
- c/b staph infection
- was a 3 month hospitalization
# anemia - s/p several transfusions, dates back to [**2099**]
# Rentinal Hemmorahge w/ initation of laser treatment
Social History:
She is married and lives with her husband [**Name (NI) 6409**]. She is
on disability due to her diabetes. She previously worked as a
pharmacist. She denies any tobacco use or EtOH use ever. She
does not have any children but did have one spontaneous
miscarriage at 2 months in [**2097**].
Family History:
Father has a history of MI, is s/p 4V CABG, and has a pacer. Her
mother died at age 56 of cardiac arrest. She also had DM and was
on dialysis. Her mother's dialysis line was "blocked" and during
the attempt to clear the blockage, she arrested and died. She
has one sister who is in good health. A paternal uncle had a
blood clot to his heart and died. She has one cousin who died of
a stroke at age 47. She does not know any medical history about
her grandparents on either side.
Physical Exam:
Vitals: 99.8 181/91 101 20 96% on 2L
GEN: Obese female in no acute distress, anxious appearing but
not using accessory muscles.
HEENT: PERRL, Sclera anicteric, MMM
CV: S1+, S2+, RRR, 2/6 systolic blowing murmur at LSB
RESP: Right sided mild crackles at the base, mild end expiratory
wheeze. Left CTAB
ABD: Soft, NT/ND +BS, obese
EXT: Warm, 2+ edema to knees bilaterally.
NEURO: Awake, conversive, appropriate. Gait deferred due to
pain.
Pertinent Results:
[**2106-1-31**] 08:15PM BLOOD WBC-5.6 RBC-3.51* Hgb-9.4* Hct-29.2*
MCV-83 MCH-26.8* MCHC-32.3 RDW-15.5 Plt Ct-473*
[**2106-1-31**] 08:15PM BLOOD PT-13.6* PTT-20.3* INR(PT)-1.2*
[**2106-1-31**] 08:15PM BLOOD Glucose-240* UreaN-33* Creat-1.6* Na-139
K-4.2 Cl-107 HCO3-22 AnGap-14
[**2106-2-1**] 10:30AM BLOOD ALT-11 AST-12 CK(CPK)-323* AlkPhos-79
TotBili-0.2
[**2106-1-31**] 08:15PM BLOOD CK-MB-3 proBNP-1391*
[**2106-1-31**] 08:15PM BLOOD cTropnT-0.03*
[**2106-2-1**] 10:30AM BLOOD CK-MB-2 cTropnT-0.04*
[**2106-2-3**] 12:36AM BLOOD CK-MB-3 cTropnT-0.02*
[**2106-2-3**] 04:52AM BLOOD CK-MB-3 cTropnT-0.03*
[**2106-2-1**] 07:55PM BLOOD Albumin-3.3* Mg-1.5*
REPORTS:
LE U/S BL [**2106-1-31**]:
IMPRESSION: No evidence of DVT in the bilateral lower
extremities within
limits of exam.
CXR [**2106-1-31**]:
1. Patchy opacity at the lung bases may represent atelectasis or
infection.
2. Stable cardiomegaly without overt pulmonary edema.
ECHO [**2106-2-1**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is a moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade. No right
atrial [**Month/Day/Year 7216**] collapse is seen.
IMPRESSION: Moderate circumferential pericardial effusion
without evidence of tamponade. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Probable [**Month/Day/Year 7216**] dysfunction. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2105-4-16**],
the size of the pericardial effusion has increased.
MRI CHEST/ABDOMEN [**2106-2-1**]:
Limited examination as the patient was not able to hold her
breath.
1. No central pulmonary emboli, however, segmental PE cannot be
excluded.
2. Moderate-to-large bilateral pleural effusions with
atelectasis in the
lower lobes. Moderate-to-large pericardial effusion.
3. No evidence of an aortic dissection.
4. Susceptibility artifact is seen from the IVC filter. No
thrombus seen in the visualized IVC below and above the filter.
A wet read was placed in the CCC at the time of the MRI
examination on
[**2106-2-1**].
CXR PA/LA [**2106-2-2**]:
IMPRESSION: Moderate cardiac enlargement, most likely
representing
pericardial effusion, mild-to-moderate bilateral pleural
effusions regressing. No new infiltrates.
ECHO [**2106-2-3**]:
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. 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. The tricuspid valve leaflets are
mildly thickened. There is a small to moderate sized pericardial
effusion. There is right ventricular [**Month/Day/Year 7216**] collapse,
consistent with impaired fillling/tamponade physiology.
Compared with the prior study (images reviewed) of [**2106-2-1**],
right ventricular collapse is now present.
Brief Hospital Course:
41 y/o woman with h/o CAD (s/p NSTEMI in [**2104**]), type I diabetes,
HTN, HL, dCHF, history of PE ([**4-12**]) s/p IVC filter and IVC
filter clot who has been off coumadin since [**11-13**] (patient says
a doctor told her to but has not been to see her PCP) who
presents with 3 days of increasing lower extremity edema and 3
days of sharp left-sided substernal chest pain that radiates to
the back which is the same as her previous chest pain.
.
# Chest pain: Patient has had several hospitalizations for
similar chest pain, twice revealing pulmonary embolism. ACS
ruled out by neg EKG, enzymes, and poor story for angina. Pt was
also found to be in severe acute dCHF with frank anasarca. MRI
of chest/abdomen was negative for dissection and PE, however
poor image quality and heparin was continued. Initial echo
showed mild to moderate pericardial effusion, which, on repeat
echo, was worsening, associated with wider pulsus paradoxus (see
below). Please see below, ultimately it was felt that her chest
pain was a result of recurrent pericarditis. She was treated
with colchicine and PO hydromorphone with good response.
.
# Pericarditis and pericardial effusion: Patient was found to
have pulsus paradoxus and tamponade physiology on echo. She
underwent pericardiocentesis on [**2-3**]. Post-pericardiocentesis,
the patient was transferred to CCU for close monitoring. She
intermittently continued to experience left sided, pleuritic
chest pain, requiring opioids for adequate relief. Repeat
bedside TTEs daily x 2 days following pericardiocentesis
revealed only trivial pericardial effusion. Pericardial drain
was pulled on [**2-4**]. Given patient's multiple allergies,
including to NSAIDS, patient was put on colchicine for
pericarditis. On transfer back to the floor on [**2-5**], patient's
chest pain was better controlled. Workup for etiology of
pericardial effusion included negative RF and [**Doctor First Name **]. dsDNA is
pending. Furthermore, patient had no viral prodrome prior to
admission. On [**2-6**] the patient had normal vital signs and
negative pulsus.
.
# Anemia: Likely secondary to anemia of inflammation. SPEP,
elevated erythropoetin, elevated haptoglobin. Given patient is
guaiac positive, concern for GI bleed if HCT dropping rapidly,
however pt is having her period, and HCTs have been stable.
Patient did not require any transfusion during this admission.
.
# Chronic Kidney Disease: Likely HTN and DM induced. Baseline
between 1.2 and 2.0. She had acute kidney injury with Cr to 2.3
in the setting of diuresis and tamponade likely causing prerenal
kidney injury. Diuretics were held then gently restarted on a
lower dose (40 mg daily from 80 mg [**Hospital1 **]) at discharge.
.
# DM: Pt with elevated BS on admission, no gap. Home regimen of
50units of glargine and ISS were continued.
.
# HTN: Patient's home regimen was continued with reasonable
control of blood pressure.
# Hyperlipidemia: Simvastatin was switched to pravastatin after
colchicine was started to redue the risk of rhabdomyolysis.
.
# Psych: Citalopram and clonazepam were continued per outpatient
regimen.
The patient received a diabetic/heart healthy/low salt diet.
She received SC heparin for DVT prophylaxis. She was full code.
[**Telephone/Fax (3) **]
TO BE FOLLOWED OUTPATIENT
1) INR - patient restarted on coumadin on [**2106-2-6**]
2) BMP - patient restarted on lasix, had ARF
3) Acute Renal Failure - patient had ARF in the setting of
tamponade, evaluate for resolution
4) Pericarditis/Tamponade - patient had rheumatologic labs drawn
in idiopathic tamponade workup (dsDNA and ANCA), pending at [**Telephone/Fax (3) 79488**]
Medications on Admission:
1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Insulin Glargine 100 unit/mL Solution Sig: Fifty
Subcutaneous at bedtime.
7. Insulin Lispro 100 unit/mL Solution Sig: Ten (10)
Subcutaneous three times a day: with [**Telephone/Fax (3) 16429**] and applied sliding
scale.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
start tomorrow on [**2105-2-8**].
Disp:*30 Tablet(s)* Refills:*1*
6. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous at bedtime.
7. Insulin Lispro 100 unit/mL Solution Sig: As directed units
Subcutaneous QIDACHS: restart insulin sliding scale as
previously instructed.
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO four times a
day as needed for pain for 3 days.
Disp:*15 Tablet(s)* Refills:*0*
9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pericardial effusion, concern for constrictive pericarditis
Acute exacerbation of chronic [**Date Range 7216**] congestive heart failure
Secondary Diagnoses
History of venous thromboembolic disease
Hypertension
Gastroparesis
Discharge Condition:
Good, tolerating PO, Pain reduced
Ambulating independently
Mental status alert and oriented *3
Discharge Instructions:
You were admitted to the hospital because you were having pain
in your chest. We did tests that showed you seemed to have
fluid overload so some fluid was removed. You also were found
to have fluid around your heart that caused low blood pressures
and problems with your heart's pumping. This fluid was drained
and you improved. It is unclear what caused this fluid to
accumulate. It will be important to follow up with your primary
care doctor to finish the evaluation of this problem.
Your medications have been changed. Your WARFARIN (COUMADIN)
has been restarted to help prevent blood clots. Your should
continue to take this medication unless told to stop by your
physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 79489**] been started on colchicine, a medication to
help reduce the inflammation in the pericardium and help your
pain. You have been given a small amount of HYDROMORPHONE
(DILAUDID) pills to help deal with your pain over the next
couple days. Your SIMVASTATIN (ZOCOR) has been switched to
PRAVASTATIN as this medication is safer to use with colchicine.
Otherwise your medications have not been changed.
Followup Instructions:
You should follow up in [**Company 191**] in the next week or two to see how
you are doing and help set you up for further necessary
follow-up. Our [**Hospital 1944**] clinic will call you next week to
set up an appointment. You should also re-establish care with
the [**Hospital 620**] [**Hospital3 **] to help follow your coumadin
levels.
It will be important for post discharge clinic to check your
electrolytes and fluid balance in the context of the reduced
dose of water pills. They can also monitor your pain, check to
make sure your blood pressure is stable, and make sure you have
follow up to monitor your coumadin levels.
Completed by:[**2106-2-7**]
|
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icd9cm
|
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[
[]
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[
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13468, 13474
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,569
| 146,083
|
45654
|
Discharge summary
|
report
|
Admission Date: [**2160-11-26**] Discharge Date: [**2160-12-13**]
Date of Birth: [**2091-12-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / ibuprofen
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer for respiratory failure
Major Surgical or Invasive Procedure:
Intra-abdmonial abscess drainage
History of Present Illness:
68 yo male with history of PE, recurrent bowel obstructions, a
fib who was transfered to [**Hospital1 18**] for worsening respiratory
distress.
Pt initially presented to [**Hospital **] [**Hospital 1459**] Hospital on [**2160-11-6**]
for elective abdominal wall reconstruction and lysis of
adhesions given multiple recurrences of bowel obstructions. Pt
did well following procedure and was on zosyn post-operatively.
On [**2160-11-11**], pt developed respiratory distress. CXR showed
possible LLL pneumonia. He was started on moxifloxicin. CTA
showed no evidence PE. Pt initially improved, however on [**11-16**]
pt had episode of tachycardia to 130-140s associated wtih
increased respiratory distress. Given worsening renal status, pt
was evaluated with V/Q scan which again showed no evidence of
PE. The following day, CT abdomen showed ilieus with no bowel
obstruction and LLL pneumonia. Sputum cultures returned positive
on [**11-18**] for Klebsiella and the patient was noted to be febrile.
He was continued on moxifloxicin. Repeat CT scan did not show
e/o abscess or other intra-abdominal source. On [**11-19**], WBC
increased from 11.9-->22.4 and the patient was febrile. Repeat
CXR showed worsening LLL consolidation. On [**11-24**], WBC count
peaked at 35.1, sputum grew yeast, MRSA and klebsiella. Abx were
changed to ticarcillin and diflucan. Given a penicillin allergy,
he was changed from ticarcillin to tigecyclin. On morning of
[**11-25**], pt was intubated for worsening respiratory failure. He
was started on Vancomycin, underwent bronchoscopy and
transferred here on [**11-26**].
.
The patient arrives to the floor intubated but otherwise HD
stable. Not on pressors. Grandaughter at bedside.
.
Review of systems: Unable to obtain. Patient intuabted and
sedated.
Past Medical History:
- [**Month/Year (2) **] in the past requiring ex-lap
- Colonic resection in past (unclear if related to [**Name (NI) **])
- [**Name (NI) **] SBOs; 3 in past year
- H/o PE now s/p IVC filter
- A Fib not on coumadin
- COPD
- HTN
- HL
- OCD and depression
- H/o alcohol abuse
Social History:
Past history of alcoholism, quit 35 years ago. No current
tobacco use.
Family History:
Father with lung cancer
Physical Exam:
On Admission:
Vitals: T: 98.6 BP: 109/71 P: 66 Intubated
General: Intubated, not responsive to voice
HEENT: PERRLA, Sclera anicteric, ET tube
Neck: supple, JVP not elevated, no LAD
Lungs: Limited exam secondary to patient positioning. Rhoncorous
breath sounds throughout
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
large staple line in midline. Wound is intact and without
surrounding erythema.
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Sedated
On Discharge:
General: Lying in bed in NAD
HEENT :PERRLA, Sclera anicteric
Lungs: Still rhoncorous but improved. No major change since
yesterday.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, NT/ND.
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Awake, alert and oriented. Diffusely weak.
Pertinent Results:
On Admission:
[**2160-11-26**] 02:30PM BLOOD WBC-15.7* RBC-2.74* Hgb-7.9* Hct-25.6*
MCV-93 MCH-28.8 MCHC-30.9* RDW-13.9 Plt Ct-339
[**2160-11-26**] 02:30PM BLOOD PT-14.9* PTT-34.2 INR(PT)-1.3*
[**2160-11-26**] 02:30PM BLOOD Glucose-113* UreaN-32* Creat-0.9 Na-143
K-4.3 Cl-106 HCO3-33* AnGap-8
[**2160-11-26**] 02:30PM BLOOD ALT-17 AST-28 LD(LDH)-274* AlkPhos-126
TotBili-0.2 DirBili-0.1 IndBili-0.1
Studies:
.
ECHO [**11-26**] - The left atrium is mildly dilated. The right atrium
is moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
CT chest/abd/pelvis [**11-30**] - IMPRESSION: 1. Rim enhancing,
air-containing fluid collection in the lower abdomen / upper
pelvis. Although this collection was present on [**11-24**], the rim
enhancement and gas are new and concerning for abscess. Despite
proximity to old small bowel anastamosis, no extravasation or
oral contrast. The location is ammenable for CT guided drainage.
Two smaller rim-enhancing collections below the liver and in the
pelvis are not suitable for drainage. 2. Common bile duct
dilation with a smooth taper towards the pancreatic head.
Differential enhancement of the pancreatic head and punctate
calcifications are consistent with sequela prior acute or
chronic pancreatitis. 3. Persistent pneumonia with improved
aeration of the left lower lobe.
.
CT Sinus [**11-20**] - IMPRESSION: 1. Extensive paranasal sinus
disease is likely secondary to both chronic sinusitis and
patient's recent intubation. While there is no definite evidence
of acute sinusitis, this diagnosis cannot be excluded. 2.
Complete obstruction of the left maxillary sinus.
.
CT chest [**12-5**]: IMPRESSION:
1. Collapse of the right lower quadrant abdominal collection
with a sliver of remaining fluid and drainage catheter located
within.
2. Unchanged appearance to tiny pelvic and subhepatic fluid
collections.
3. Slightly improved multifocal ground glass opacities likely
reflect
infectious process with improved aeration in left lower lobe.
4. Hypodensities in the pancreatic head could reflect prominent
side
branches, and if indicated can be assessed by MRI.
.
CT chest [**12-9**]: IMPRESSION:
1. No evidence of pulmonary embolism.
2. Prominent main pulmonary artery, again suggesting underlying
pulmonary
arterial hypertension.
3. Multifocal consolidative and ground-glass opacities,
demonstrating
variable progression and improvement compared to [**2160-12-5**], as detailed above. These remain most consistent with
multifocal pneumonia.
4. Secretions within the trachea, suggesting aspiration.
5. Coronary artery calcifications.
6. Trace pleural effusions.
.
CT Abdomen: IMPRESSION: 1. Slight interval reexpansion of a
right lower quadrant fluid collection. Decreased subhepatic and
perirectal fluid collections. 2. Mildly improved bilateral
bibasilar multifocal opacities compatible with a resolving
pneumonia. Small left pleural effusion increased since [**12-9**], [**2160**]. 3. Stable slight intrahepatic biliary duct dilation. 4.
Bilateral renal cysts, stable. 5. IVC filter.
Brief Hospital Course:
Mr. [**Name13 (STitle) 49985**] is a 68 year-old man transferred to [**Hospital1 18**] with
pneumonia and worsening respiratory failure s/p intubation.
.
Hospital Course
-----------
The patient was admitted at [**Hospital **] [**Hospital 1459**] Hospital from
[**2160-11-6**] until [**2160-11-26**], initially for an elective surgery and
subsequently for a worsening pneumonia. Sputum cultures there
were ploymicrobial including klebsiella/yeast/MRSA implicating
aspiration as a possible etiology. On transfer to [**Hospital1 18**], the
patient was intubated and on a high level of FiO2. He was
initially continued on broad spectrum antibiotics (vancomycin,
cefepime, flagyl). On HOD #1, the patient was hypotensive. A
central line was placed and levophed started. Tobramycin was
added for double pseudomonal coverage. Sputum cultures revealed
MRSA and corynebacterium. By HOD #3, the patient was able to
come off pressors however was persistently febrile. A CT torso
was performed that showed an organizing intra-abdominal abscess
with communication to the bowel. An additional peri-hepatic
fluid collection was seen. The patient went for IR drainage of
the communicating abscess. Surgery saw the patient regarding
the communication with the bowel and felt this was a low output
fistula and declined intervention. Following drainage of the
abscess, the patient's fever curve improved. Cultures of the
drained fluid revealed [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 97334**] and the patient was
placed on micafungin. Radiographically his pneumonia was
improving as well. Despite resolving infectious processes and
agressive diuresis, the patient remained difficult to wean from
the ventilator. On [**12-7**], the patient passed his RSBI and was
able to be extubated uneventfully. He did well following
extubation although oxygen saturations remained in the 90-92%
range (unclear baseline). The abdominal drain was removed on
[**12-9**]. He was continued on meropenem and micofungin. On [**12-10**],
the patient had a likely aspiration event causing a transient
desat and leukocytosis. Post-pyloric tube placed and given tube
feeds. Remains NPO. On [**12-11**] the patient underwent repeat
abdominal CT scan that showed a small interval increase in size
of the perihepatic collection and a decrease in size in other
collection. Plan was made for the patient to continue
micafungin and meropenem to complete a 2 week course on
[**2160-12-26**] and undergo repeat CT scan at that time. On [**11-13**]
the patient was clinically improved and ready for discharge to a
rehabilitation facility.
.
#. Anemia - The patient had a baseline hematocrit and [**Location (un) **]
[**Location (un) 1459**] of ~35. In admission here his hematocrit was ~25. No
obvious bleeding source and hemolysis labs were negative. Over
the course of the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 153**] stay his hematocrit remained
stable at 25-30. He did not require any blood transfusions.
.
#. Urinary retenetion - The patient reports having a history of
urinary retention for which he sees a urologist. Does not take
any medications for this. Unknown diagnosis. Following foley
removal here the patient failed to put out urine and a bladder
scan revealed >600ml in the bladder. Foley replaced. Given
tamsulosin and voiding trial repeated successfully. Tamsulosin
d/c'ed due to blockage of the dobhoff tube. Continued to have
good urine output without the foley.
.
#. Atrial Fibrillation - The patient has a history of afib fow
which he is rhythym controlled with amiodarone. On presentation
here he was in sinus. He was continued on amiodarone. He is not
an AC at baseline most likely due to a low CHADS2 score.
.
#. COPD - The patient has a history of COPD. Unclear baseline
PFTs or oxygen saturation. Stable on albuterol and ipratropium
at discharge.
.
#. HTN - Held his home lisinopril in the setting of severe
infection. Restarted due to hypertension.
.
#. HL - Changed simvastatin 80mg to atorvastatin 40mg daily
.
#. Bipolar d/o - Initially held all psychoactive medication
including seroquel, amytriptiline, and welbutrin. Seroquel was
added back in preperation for extubation and sedation weaning.
Added back amitriptiline and wellbutrin prior to discharge.
Transitional Issues:
Pt is full code.
1) Continue Micafungin and Meropenem until [**2160-12-26**]
2) Follow-up on [**Female First Name (un) 564**] sensitivities and consider switching
micofunging to fluconazole.
3) Follow-up on pending blood culture results. Microbiology lab
at [**Hospital1 18**] ([**Telephone/Fax (1) 97335**].
4) Reccomend CT abd/pelvis to evaluate for itnerval change in
fluid collections after completing antibiotic course on
[**2160-12-26**]
5) Speach and swallow evaluation. Has been on tube feeds while
in the ICU due to aspiration event.
6) Chem-7 on Monday [**12-15**] to check creatinine. Recent contrast
exposure.
Medications on Admission:
HOME MEDS:
amiodarone 200 mg daily
amitripyline 10 mg qhs
aspirin 325mg daily
combivent two puffs [**Hospital1 **]
colace 100mg [**Hospital1 **]
lisinopril 10mg daily
seroquel 100 mg qhs
simvastatin 80mg qhs
wellbutrin SR 200mg daily
.
Medications from OSH:
zyrtec 10mg daily
celexa 20mg qhs
combivent PRN
benadryl 25 mg IV q4hr PRN
diflucan 200mg q24hr
flovent 2 puffs [**Hospital1 **]
dilaudid 0.5-1mg q3hr
haldol 1mg q4hr
heparin SQ
insulin SS
reglan 10mg IV q8hr
zofran 4mg IV q 6hr PRN
protonix 40mg IV q24 hr
phenergan IM q6hr PRN
propofol
seroquel 100mg qhs
tygacil 50mg IV
vancomycin 1gm q12hr
wellbutrin 75 mg [**Hospital1 **]
solumedrol 40 mg IV q 8hr
percocet 1-2 tablets q4-6 hr PRN
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. quetiapine 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
6. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for Fever.
7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
10. micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
11. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Wellbutrin 100 mg Tablet Sig: Two (2) Tablet PO once a day.
13. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
15. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary: Aspiration Pneumonia, Intra-abdominal abscess
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!
You were transferred to our hospital due to a worsening
pneumonia. At this hospital you were treated with strong
antibiotics and your breathing was supported on a ventilator.
Additionally, you were found to have an abscess in your abdomen
that was drained by interventional radiologists. You are now
ready to be discharged to a rehabilitation center to continue
your physical therapy and antibiotic therapy.
See below for changes to your home medication regimen:
1) Please CONTINUE Meropenem 500mg IV every 6 hours until
[**12-26**]
2) Please CONTINUE Micafungin 100mg daily until [**12-26**]
3) Please CHANGE Simvastatin to Atorvastatin 40mg daily
4) Please CONTINUE Fluticasone nasal spray once daily
5) Please CONTINUE Senna 1 tab twice daily
See below for instructions regarding follow-up care:
Followup Instructions:
Please follow-up with your primary care provider, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 46310**]
MD, within 2 weeks of discharge from your rehabilitation center.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2160-12-13**]
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[
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,919
| 115,286
|
28752
|
Discharge summary
|
report
|
Admission Date: [**2144-9-6**] Discharge Date: [**2144-9-15**]
Date of Birth: [**2070-1-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Altered mental status and CT scan at outside hospital with
colonic abcess, right renal artery embolus
Major Surgical or Invasive Procedure:
[**2144-9-7**] PICC line placed RUE
History of Present Illness:
74 y/o F with a h/o HTN, RA, hypercholesterolemia who presents
from OSH for further w/u of R renal artery embolus and sigmoid
diverticulosis with intramural abscess, and slurred speech. Pt.
is delirious and is unable to relay a history; history is
obtained from her daughter and EMS reports.
.
Per report she fell at home 3 days PTA. She does not remember
the fall. She says that her friend found her beside the bed
yesterday morning and called EMS. She reports L lower back pain
since the fall. She reports that she has felt "generally down
and punk" for several days, and that her speech has been "heavy,
thick and boozy" for about 2 weeks. She denies numbness
anywhere, has noticed generalized weakness but no focal
weakness, denies dysphagia, word finding difficulties, bowel or
bladder incontinence. She denies fevers, chills, N/V, abd pain,
or dysuria at home.
.
Per EMS records they were called to pt's house on [**9-5**] at 18:00.
Pt. was complaining of lower back pain and LUQ abd pain. Family
reported to them that pt. fell 3 days ago, that she has been
increasingly confused over the past few days, that her speech
has been "slightly slurred," and that she has had generalized
weakness for several days.
.
Pt. was brought to an OSH, where head CT showed age-related
atrophy but no infarcts. CT abd performed and showed R renal
artery embolus and diverticulosis with chronic-appearing
intramural abscess. CEs negative x 1, WBC Ct 18. Pt. received
Clindamycin, transferred here for further w/u.
.
In the ED she underwent evaluation by the neurology, vascular
surgery, and general surgery teams. CXR showed a hilar mass.
Vascular surgery recommended medical management of renal embolus
due to new finding of hilar [**Hospital3 **] surgery recommended
antibiotics and NPO status to manage diverticular abscess. She
received 1 mg of ativan in the ED, mucomyst, ASA, and
levo/flagyl.
.
ROS (per family): Pt is s/p fall 6 mos ago and experienced a
vertebral fracture. Denies fever or chills. 10 pound weight loss
over past 6 months. Denied headache, cough, chest pain. Denied
nausea, vomiting, diarrhea, or abdominal pain. No dysuria. No
rash.
Past Medical History:
HTN
Hypercholesterolemia
Rheumatoid arthritis
Vertebral fracture
Multiple falls per pt., etiology unclear
spont pneumothorax - [**2097**]
Social History:
lives alone in [**Location (un) 4047**] with home health asst several times a
week. Tobacco: 1.5 PPD since age 16. No EtOH, no illicits.
Family History:
emphysema - mother
glomerulonephritis - son
Physical Exam:
Vitals: T: 97.8 ax P: 86 BP: 120/60 RR: 18 SaO2: 95% on 2L O2
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MMM, OP without
lesions
Neck: supple, no JVD or carotid bruits appreciated
Pulm: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Ext: No clubbing cyanosis or edema.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert & Oriented x [**2-10**] (occaisionally correctly
identifies this as a hospital).
-cranial nerves: intact except unable to protrude tongue.
-motor: reduced bulk. Able to hold limbs against gravity but
would not resist. So [**4-12**] throughout. Possibly confounded by
effort.
-sensory: No deficits to light touch detected.
-cerebellar: dysarthric.
-DTRs: 2+ biceps, triceps.
Pertinent Results:
CBC:
[**2144-9-6**] 02:00AM WBC-15.1* RBC-4.35 HGB-10.9* HCT-32.3*
MCV-74* MCH-25.0* MCHC-33.7 RDW-16.3*
[**2144-9-6**] 02:00AM PLT COUNT-364
[**2144-9-6**] 02:00AM NEUTS-87.9* LYMPHS-9.5* MONOS-2.0 EOS-0.5
BASOS-0.1
.
Chemistries:
[**2144-9-6**] 02:00AM GLUCOSE-112* UREA N-10 CREAT-0.8 SODIUM-142
POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-29 ANION GAP-13
[**2144-9-6**] 02:00AM ALT(SGPT)-25 AST(SGOT)-21 ALK PHOS-107
AMYLASE-17
[**2144-9-6**] 02:00AM LD(LDH)-767*
[**2144-9-6**] 02:00AM ALBUMIN-2.4* CALCIUM-11.1* PHOSPHATE-2.2*
MAGNESIUM-2.4
[**2144-9-6**] 02:00AM TSH-2.3
[**2144-9-6**] 09:00PM PTH-13*
[**2144-9-6**] 09:00PM calTIBC-203* FERRITIN-252* TRF-156*
.
Serum Tox:
[**2144-9-6**] 02:00AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
.
Coags:
[**2144-9-6**] 04:25AM PT-13.9* PTT-20.7* INR(PT)-1.2*
.
Urine studies:
[**2144-9-6**] 04:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2144-9-6**] 04:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
.
CXR [**9-6**]: Right hilar mass, with associated airspace opacity
within the right upper lobe. These findings are concerning for
malignancy within the right hilum, and secondary
post-obstructive pneumonia or consolidation. Further evaluation
with a CT scan is recommended.
.
CT Pelvic [**9-6**]: 1. Tubular filling defect measuring 1.2 cm in
proximal right renal artery with hypoperfusion of right kidney,
most likely representing right renal artery emboli. Persistent
non-perfusion areas seen in the right kidney on delayed images.
2. Inflammatory changes in sigmoid colon with fat stranding, and
1.3 cm fluid collection versus small abscess.
3. Compression fracture of lower thoracic vertebra.
4. Right hilar mass noted on chest x-ray was not imaged on this
abdominal CTA.
.
Renal US [**9-6**]: 1. No hydronephrosis.
2. The renal vein was difficult to assess.
3. The resistive indices are slightly less within the right
kidney compared to the left. Further evaluation with a CTA study
is recommended.
.
CAROTID U/S [**9-8**]: No plaque or wall thickening of either carotid
artery. Diffuse low velocity seen b/l suggesting low cardiac
output.
.
CHEST CT [**9-7**]: 1. A very large heterogeneous right hilar mass
measuring 7 cm with multiple areas of central necrosis extending
to the level of the thyroid with associated mediastinal
adenopathy. The mass extends into the SVC as well as the right
mainstem bronchus with a short segment demonstrating 50%
occlusion. 2. Lack of perfusion of right kidney secondary to
previously identified thrombus. 3. Multiple hypodensities in the
liver, the largest representing a simple cyst, the smallest too
small to characterize, but may also represent cysts. 4.
Compression deformity of T9 of indeterminate age.
.
Echo [**9-8**]: The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There a moderate-sized
(1.2 cm-thick) echogenic anterior space which most likely
represents an epicardial fat pad, though a loculated, organized
anterior pericardial effusion cannot be excluded.
.
L-spine film [**9-10**]: 1. Chronic-appearing L1 vertebral body
compression fracture. 2. Likely small fusiform abdominal aortic
aneurysm which was seen on the prior CTA abdomen of [**2144-9-6**].
.
FNA, Right supraclavicular lymph node [**9-10**]: POSITIVE FOR
MALIGNANT CELLS
consistent with non-small cell carcinoma.
.
CT Head with Contrast [**9-12**]: Single focus of low density within
the white matter of the right frontal lobe likely representing
chronic microvascular infarct. No evidence of enhancing lesions
to suggest metastatic disease.
.
CXR [**9-14**]: 1. Worsening right upper lobe post-obstructive
pneumonia secondary to right hilar mass. Increased right lung
volume loss.
2. Bilateral pleural effusions
.
RUQ US [**9-14**]: No evidence of acute cholecystitis.
Brief Hospital Course:
Ms. [**Known lastname 19961**] is a 74 year old female with a history of HTN, RA,
hypercholesterolemia, who presents from OSH for work up of R
renal artery embolus and sigmoid diverticulosis with intramural
abscess, delirum and slurred speech, now with hypercalcemia and
likely nephrogenic DI. Hospital course outlined by problem
below:
.
1. Right hilar mass - This was concerning for malignancy given
history of tobacco and appearance on imaging. The CT scan found
a 7cm mass in the right lung which invades into the SVC and
right mainstem bronchus. Intervential pulmonology was consulted
for possible stenting of right mainstem bronchus. They did not
feel it was necessary at the time. Thoracic surgery was
consulted for a fine needle aspiration of the supraclavicular
node for diagnosis and to see if she was a surgical candidate.
The FNA preliminarily showed malignant cells consistent with
non-small cell carcinoma. Hematology/oncology and radiation
oncology were consulted and treatment options were discussed the
with the patient and the family. Outpatient appointments were
established. A bone scan was to be performed to look for bony
mets on day of discharge, but this was discontinued secondary to
a change in the patient's treatment goals (see below). On the
last night of admission, the patient had an acute increased need
for oxygen therapy (she was on room air prior). A chest x-ray
showed pulmonary effusions and a RUL infiltrate suggestive of
post-obstructive pneumonia vs lobe collapse. The patient
remains afebrile but her WBC was elevated to 20K on discharge
from 16K and 18K a fews days prior. She was already receiving
levofloxacin and metronidazole for the diverticular abscess, and
she was given furosemide to help with the pleural effusions. In
a family discussion with the medical team, the patient and her
daughter decided that no further aggressive treatment was
wanted. Hospice consult was placed per Ms. [**Known lastname 19961**]' request.
Extensive conversations had been held with the patient and the
daughter throughout her stay regarding her code status and
wishes towards treatment and this decision is consistent with
those prior conversations.
.
2. Hypercalcemia - The patient presented with delirium and
slurred speech. She was found to have hypercalcemia and
hypernatremia which was thought to be a paraneoplastic syndrome.
Her PTHrp was found to be elevated at 8.6. Her hypercalcemia
was causatively linked to nephrogenic diabetes insipidus. Renal
consult was placed and she was agressively treated with IVF,
furosemide, calcitonin, and pamidronate to decrease her calcium
levels. She spent one night in the ICU mostly for nursing
issues regarding her frequent lab checks and electrolyte
monitoring. Once they were within normal limits, her sodium
levels dropped to normal range and she was no longer delirious.
.
3. Hypernatremia - secondary to nephrogenic diabetes insipidus.
See above.
.
4. Diverticulitis with localized abscess - surgery consult was
obtained and they recommened conservative treatment given her
comorbidities. She was placed on levofloxacin and
metronidazole. She was initially NPO, but as her delirium
resolved, surgery recommended normal diet. She was cleared by a
speech and swallow evaluation and placed on soft foods and thin
liquids along with Boost supplementation per nutrition
recommendations.
.
5. Right renal emboli - Normal renal function on admission but
large renal artery emboli noted. At first this was thought to
be likely due to cholesterol emboli per the renal team given h/o
hypercholesterolemia and did not require anticoagulation. At
discharge it was unclear whether this thrombus is secondary to
cholesterol emboli or to her hypercoagulable state secondary to
malignancy. Her renal function is still within normal limits.
.
6. Leukocytosis - The patient's WBC was stable around 16K on
levofloxacin and metronidazole for her diverticular abscess. A
few days prior to admission, her WBC rose to 18K, but she
remained afebrile. Work up showed no urinary tract infection
(patient had foley cath in place for close monitoring of
ins/outs for DI treatment) and a RUQ ultrasound showed no
cholecystitis (patient had RUQ pain on exam on the day prior to
discharge. The chest x-ray the night prior to admission showed
possible post-obstructive pneumonia which may account for her
increased WBC. She was discharged on oral antibiotics.
.
7. Anemia - iron studies are consistent with anemia of chronic
disease. Her Hct remained stable throughout admission. No
transfusion was required.
.
8. Rheumatoid arthritis - The patient was not taking medications
at admission and treatment was defered. She was given
acetaminophen for pain. During admission, the patient
complained of lower back pain and a lumbar spine x-ray showed
only an old compression fracture of L1. No new fractures. A
bone scan was to be performed to look for bony mets on day of
discharge, but this was discontinued secondary to a change in
the patient's treatment goals.
.
*FEN: eating soft foods and thin liquids with boost after
cleared by speech and swallow.
*Comm: daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 69496**] cell [**Telephone/Fax (1) 69497**]
home
*Code Status: DNR/DNI per HCP (daughter) and per patient
Medications on Admission:
(not taking any of these medications)
atenolol
prednisone
folic acid
fosamax
methotraxate
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily) for 6 weeks.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2-3H (every 2-3 hours).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
8. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4
to 6 hours) as needed for dyspnea/pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
Lung cancer- cytology consistent with NSCLC
Hypercalcemia causing nephrogenic diabetes insipidus
Right renal artery embolus
Intramural sigmoid abscess
.
Secondary diagnosis:
Anemia
Rheumatoid arthritis
Discharge Condition:
stable, on 5L oxygen via nasal canual
Discharge Instructions:
You have been diagnosed with lung cancer and are being
discharged to a hospice facility to make you comfortable.
.
You have been prescribed antibiotics for a pneumonia. You have
also been given morphine and lorazepam to help with the back
pain and shortness of breath.
Followup Instructions:
none
Completed by:[**2144-9-15**]
|
[
"197.0",
"588.1",
"196.0",
"198.89",
"714.0",
"276.0",
"569.5",
"275.42",
"162.8",
"593.81",
"285.9",
"562.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14527, 14542
|
8329, 13647
|
415, 453
|
14807, 14847
|
3880, 8306
|
15165, 15201
|
2962, 3008
|
13788, 14504
|
14563, 14563
|
13673, 13765
|
14871, 15142
|
3583, 3861
|
3023, 3464
|
274, 377
|
481, 2630
|
14756, 14786
|
14582, 14735
|
3479, 3566
|
2652, 2792
|
2808, 2946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,140
| 167,570
|
32157
|
Discharge summary
|
report
|
Admission Date: [**2128-7-7**] Discharge Date: [**2128-7-30**]
Date of Birth: [**2074-10-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin / Lasix
Attending:[**First Name3 (LF) 20640**]
Chief Complaint:
left hand weakness
Major Surgical or Invasive Procedure:
Cervical embolization
C7 Corpectomy
PICC line placement
bronchial artery embolization
History of Present Illness:
This is a 53 yo female with a past medical history metastatic
RCC, diagnosed 2 years ago, with brain and lung mets s/p
nephrectomy and chemo, most recently on experimental protocol,
s/p bronchial stenting on [**2128-6-30**], now with respiratory
decompensation, hemoptysis, found to have occlusion of right
side of stent by tumor growth, brought to IR today for bronchial
artery embolization.
.
Prior to this admission, the patient presented with LUE weakness
after a visit to her chiropractor, s/p nephrectomy and
chemotherapy, and was found to have a pathologic fracture of C7.
She was brought for embolization of tumor and C7 corpectomy
(received solumedrol for cord compression), however, after this
procedure, her course was c/b post-op inability to move any
extremities. MRI showed no compression but edema of C2-T1. On
[**7-12**], she was intubated for respiratory distress with SBP 70s, HR
130s, and she was started on Diltiazem gtt with Neo for SVT with
hypotension. She also underwent a right sided thoracentesis on
[**7-14**] with 700cc removed, and broad spectrum antibiotics were
started for fevers and empiric tx for VAP. She was extubated on
[**7-15**], but then had a witnessed localized motor seizure and was
started on dilantin which was transitioned to keppra. Over the
next several days, her respiratory status appeared worse, and
underwent another bronchoscopy on [**7-18**] secondary to right lung
collapse. At this time, the patient was considering transition
to hospice, but then her respiratory status began to improve,
and she regained some mobility in her arms and legs and decided
she preferred to proceed to rehab instead.
.
She was to be discharged on [**7-27**], when she suddenly began to
have increasing respiratory distress. She was taken by IP for
flexible bronch for therepeutic aspiration of secretions and
visualization of Y stent, where it was discovered that, after
therapeutic aspiration was performed, the left limb of the
Y-stent was patent without endobronchial lesions or active
bleeding, however, on the right side, there was a tumor ingrowth
to the distal end of the stent which was approximately 90%
occlusive. This area was extremely friable and was the source of
bleeding. She was then taken by IR for [**Doctor Last Name **] out of concern for
continued bleeding.
.
She was then transferred to the MICU from IR for monitoring s/p
[**Doctor Last Name **]. At night has anxiety induced dyspnea where she is placed on
NRB and given ativan. On [**7-28**] a CXR showed complete
opacification of right hemithorax, likely a combination of
atelectasis and fluid due to lack of signicicant midline shift
(overall slight leftward shift) concerning for blood as patient
is status-post embolization. IP then spirated long obstructing
blood clot from R main stem beginning at level of tumor. She was
then stable in the ICU and transferred to OMED for further
observation.
Past Medical History:
[**2126-8-4**]: Intermittent hematuria with urinalysis positive
for e.coli and was treated with antibiotics
[**2126-9-4**]:Symptoms recurred and a CT was performed on
[**10-3**] which revealed a 13.8 cm mass in the right
kidney with cystic and solid components. CT of
chest revealed multiple bilateral lung nodules,
highly concerning for metaastic disease &
retroperitoneal adenopathy
[**2126-10-5**]: Right nephrectomy, clear cell histology,
[**Last Name (un) 19076**] nuclear G3, LVI present with gross
invasion into renal vein, invades renal capsule
but not beyond capsule, 12 cm, pT3b, Nx M1
[**2126-11-4**]: CT torso with pulmonary disease progression;
head CT negative. [**Hospital1 18**] consult with Dr.
[**Last Name (STitle) **]; HD IL-2 therapy recommended.
Cardiology consult obtained due to h/o SVT &
bigemingy and cleared for treatment; signed
consent for 06-149 in [**12-11**]; HD IL2 Select
[**2126-12-16**]: C1 Wk 1 HD IL2; [**12-18**] doses; low-dose diltizaem
with telemetry monitoring due to h/o SVT.
Doses held for GI issues, confusion & fatigue.
Additional side effects included rash, flu
symptoms, arthralgias, headache, rigors,
mucositis, ARF, metabolic acidosis responsive
to repletion, hyperbilirubinemia, transaminitis
& anemia/thrombocytopenia without transfusion
requirement. Developed hives from Lasix after
discharge
[**2126-12-30**]: C1 Wk 2 HD IL2; [**11-17**] doses with doses held for
fatigue, flu symptoms, GI side effects,
mucositis & fatigue. Additional side effects
included N/V/D, rash, ARF, oliguria,
hyperbilirubinemia & anemia. Telemetry
monitoring throughout admission with SR noted
and occasional PVC
[**1-/3227**]: CT with decrease (30%) in pulmonary disease;
small pericardial effusion
[**2127-3-4**]: CT with stable disease (wk 11 CT)
[**2127-3-17**]: C2 Wk 1 HD IL2; [**12-18**] doses with doses held for
shock, flu symptoms & pt request for cumulative
side effects. She also developed hypotension
r/t CLS requiring vasoprssor BP support, N/V,
rash, fatigue, mucosiits, ARF, oliguria,
metabolic acidosis responsive to repletion,
hyperbilirubinemia, anemia & thrombocytopenia.
Telemetry monitoring demonstrated occasinal PVC
[**2127-3-31**]: C2 Wk 2 HD IL-2; [**9-17**] doses with doses held for
shock, & recurrent hypotension r/t CLS requiring
Neo-synephrine support. Telemetry demonstrated
NSR with occasional APCs & a short 5 beat run
of SVT. She also developed mucositis, bilateral
shoulder pain, fatigue, pruritis, rash, rigors,
N/V, malaise, ARF, oliguria, metabolic acidosis
responsive to repletion, mild confusion, mild
hyperbilirubinemia & anemia without transfusion
support
[**2127-5-5**]: CT with mixed response-pulmonary disease
decreased with increased mediastinal adenopathy
[**2127-6-2**]: CT without significant change; slight increase
in mediastinal disease
[**2127-7-21**]: CT with mixed results; new pulmonary nodules;
referred to thoracic oncology for possible
removal of pretrachael node
[**2127-8-13**]: Endobronchial U/S with transbronchial needle
aspiration; cytology positive for RCC
[**2127-12-29**]: CT stable pulmonary disease; slight increase in
right nephrectomy bed
[**2128-3-29**]: New onset hemoptysis 3 weeks ago with interval
progression of pulmonary disease; pericardial
effusion; referred to pulmonary to evaluate
hemoptysis; signed consent for 04-393 in hopes
of stable pulmonary evaluation
[**2128-3-31**]: Flexible bronchoscopy revealed endobronchial
mass which was erythematous & friable & nearly
occluding the RUL bronchus. Photodynamic
therapy scheduled followed by debridement with
rigid bronchoscopy
[**2128-4-7**]: Rigid bronchoscopy; flexible bronchoscopy, RUL
tumor destruction with cryo probe; tumor
ablation with argon plasma coagulation
[**2128-4-9**]: Flexible bronchoscopy; mechanical debridement &
cryotherapy of RUL
[**2128-4-16**]: Echo revealed small to moderate pericardial
effusion with right atrial mass at the IVC-RA
junction most likely representing tumor;
admitted for evaluation & further w/u to
determine if mass is a blood clot or tumor. CT
torso revealed no evidence of right atrial
thrombus/mass but a conglomerate nodal mass in
the azygo-esophageal recess near the junction
of the IVC & RA. She was hemodynamically
stable & d/c home on [**4-22**] wtih a plan to
perform cardiac MRI to determine location of
thrombus/mass
[**2128-4-21**]: Cardiac mass identified in RA & in IVC; started
on Sutent therapy soon after (~ [**2128-4-23**])
[**2128-5-26**]: Flexible bronchoscopy for cough & hemoptysis
[**2128-5-28**]: Signed consent for 08-313; RAD Biomarker trial
[**2128-6-14**]: Cycle 1 Day 1 RAD001 (Everolimus)
.
PSH: c-section, right nephrectomy, multiple bronchs with RUL and
tracheal cryotherapy and ablations, left knee surgery
Social History:
The patient is a school nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1157**]. She is married with
two children, a son aged 24 and a daughter aged 21. She is a
former smoker having smoked approximately one to one and a half
packs per day for 10 years but quit 25 years ago. She drinks
alcohol very rarely. She denies illicit drug use.
Family History:
The patient says that one of her first cousins was diagnosed
with a renal cell carcinoma. Her father died of testicular
cancer in his late 20s. Her mother died of lymphoma at age 68.
Her maternal grandfather died of lung cancer but he was a
smoker. A paternal aunt has breast cancer and died at the age of
44. The paternal cousin had breast cancer at age 40
Physical Exam:
Vitals: T:97.5 BP:118/70 P:98 R: 18 O2: 92NRB
General: Alert, oriented, mild respiratory distress
HEENT: Sclerae anicteric, MM dry, oropharynx clear with dried
blood on teeth
Neck: supple, JVP not elevated, no LAD
Lungs: Loud upper airway rhonchi with obvious secretions
CV: Regular rate and rhythm, normal S1 + S2
Abdomen: soft, non-tender, non-distended, bowel sounds quiet, no
rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulse in right, 1+ in left, no
clubbing, cyanosis. 1+ edema b/l
Neuro: Pt unable to move left leg, can wiggle toes on right foot
only. Can move proximally fairly well in the upper extremities
with 4-/5 strength on the left and 4/5 strength on the right.
Sensation in tact bilaterally. CN II-XII in tact bilaterally.
Mood appropriate.
Pertinent Results:
MRI [**2128-7-7**]: 1. Pathological compression fracture of C7 with
associated retropulsion causing moderate spinal canal narrowing
and mild compression of the cord with no abnormal cord signal
intensity.2. Extensive enhancement in the left anterolateral
epidural space extending from C6-T1 with associated involvement
of the left C6/C7 and C7/T1 neural foramina
Pathology Examination
SPECIMEN SUBMITTED: C7 Tumor, posterior longitudunal ligament.
Procedure date Tissue received Report Date Diagnosed
by
[**2128-7-8**] [**2128-7-9**] [**2128-7-13**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies: [**-1/2068**] TRACHEAL TUMOR.
[**Numeric Identifier 75223**] tracheal mass.
[**Numeric Identifier 75224**] right upper lobe tumor.
[**Numeric Identifier 75225**] right upper lobe tumor.
(and more) DIAGNOSIS: 1. C7 tumor, resection (A-B):
Clear cell neoplasm consistent with known metastatic renal cell
carcinoma.
2. Ligament, posterior longitudinal (C):Collagenous material
invaded by clear cel neoplasm consistent with known metastatic
renal cell carcinoma.Clinical: Collapsed C7 vertebrae.
Gross: The specimen is received fresh in two parts, both labeled
with the patient's name, "[**Known firstname 72523**] [**Known lastname **]" and the medical
record number.
Part 1 is additionally labeled "C7 tumor." It consists of
multiple fragments of bone and attached soft tissue that measure
3.5 x 3.0 x 1.0 cm in aggregate. The specimen is represented in
A-B which are submitted for decalcification prior to processing.
Part 2 is additionally labeled "posterior longitudinal
ligament." It consists of a 2.0 x 1.2 x 0.5 cm piece of pink
soft tissue with focal hard areas that are entirely submitted in
C prior to processing.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2128-7-12**] 9:06 PM Final Report
EXAM: CT of the chest, [**2128-7-12**].
INDICATION: Metastatic renal cell carcinoma, with increasing
hypoxia and
hypotension. ? PE.
COMPARISON: Multiple priors, most recently torso CT from
[**2128-6-8**].
CTA CHEST: There is no pulmonary embolism. Thoracic aorta is
normal in
caliber and contour throughout. There is no dissection.
Right pleural effusion has increased in size, now moderate.
Small left
pleural effusion is new. Extensive mediastinal lymphadenopathy
is not significantly changed. Large conglomerate nodal mass in
the right upper paratracheal area is grossly unchanged, now
measuring 6.2 x 4.8 cm (previously 6.2 x 5.1 cm). Large
subcarinal and bulky right hilar lymphadenopathy is not
significantly changed. AP window lymph node is stable in size.
Partial occlusion/invasion of the superior vena cava is
unchanged. A tracheal Y-stent has been placed since previous CT,
which is patent. There is apparent slight narrowing of the right
upper lobe bronchus (3, 44) which appears increased since
previous exam. Right main pulmonary artery passes directly
through the conglomerate lymphadenopathy, but is not attenuated.
Small pericardial effusion is unchanged.
Multiple parenchymal nodules and pleural-based nodules are not
significantly changed. Moderate right basilar atelectasis is
new. Scattered small centrilobular ground-glass and semi-solid
nodules in the left lower lobe, and in portions of the anterior
right upper lobe, and superior segment of the right lower lobe
may represent small foci of infection or aspiration. This study
is not specifically tailored for subdiaphragmatic evaluation.
Limited views of the upper abdomen show multiple foci of early
arterial hyperenhancement in the liver parenchyma which have not
been visualized on previous imaging (though there is no prior
imaging) which includes an early arterial phase for direct
comparison. Partially imaged hardware is seen at the site of
recent C7 corpectomy, bone graft, and plating, at the location
of known pathologic fracture, which is better evaluated on
recently performed MRI of the cervical spine. There is no other
definite osseous lesion suspicious for malignancy. IMPRESSION:
1. No pulmonary embolism. 2. Increased pleural effusions, right
greater than left. 3. No significant change in widespread
pulmonary/pleural, and mediastinal metastases. 4. Unchanged
thrombus/partial occlusion of the superior vena cava. 5.
Multiple small foci of early arterial hyperenhancement in the
liver. Given absence of prior arterial phase imaging for
comparison, it is unclear if
this is a new finding. Most likely, these represent hemangiomas,
but if there are liver function abnormalities, or clinical
concern for liver metastases, abdominal ultrasound could be
performed for correlation.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**First Name3 (LF) **] [**Hospital1 18**] [**Numeric Identifier 75226**]Portable TTE
(Complete) Done [**2128-7-12**] at 4:02:43 PM FINAL
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Stroke Volume: 48 ml/beat
Left Ventricle - Cardiac Output: 3.87 L/min
Left Ventricle - Cardiac Index: 2.00 >= 2.0 L/min/M2
Aortic Valve - LVOT VTI: 19
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.29
Mitral Valve - E Wave deceleration time: 199 ms 140-250 ms
Findings
Patient hypotensive on Phenylephrine 1 mcg/kg/min
RIGHT ATRIUM/INTERATRIAL SEPTUM: RA mass.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Normal regional
LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild
mitral annular calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Indeterminate
PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
GENERAL COMMENTS: The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). The patient appears to be in sinus rhythm. Results
Left pleural effusion.
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Regional left
ventricular wall motion is normal. 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. 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 a small pericardial effusion. There are no
echocardiographic signs of tamponade. A homogeneous mass
measuring 2.2x1.9 cm is seen in the IVC/right atrium junction.
Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of
[**2128-7-9**] 1:09 PM
Final Report
FINDINGS: Previously seen spinal cord edema expansion, spanning
C2 through 7 levels has increased in the interval. At C4-5
level, there is a focal area of restricted diffusion with low
signal on ADC map, highly concerning for cord infarction. The
appearance of the cervical spine with the corpectomy is not
changed from the recent prior study.
IMPRESSION: Findings concerning for cord infarction at C4-5
level. Increased cord edema.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 75227**] F 53 [**2074-10-13**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2128-7-17**] 4:31
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] SICU-A [**2128-7-17**] 4:31 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 75228**]
Reason: Resolution of PNA?
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with vent associated PNA- now extubated
REASON FOR THIS EXAMINATION:
Resolution of PNA?
Provisional Findings Impression: MLKb SAT [**2128-7-17**] 10:59 AM
New collapse of RUL. Unchanged LLL collapse. Interval
improvement of right
lower lung opacity.
Final Report
HISTORY: 53-year-old female with vent-associated PNA, now
extubated.
Resolution of PNA?
COMPARISON: Multiple prior studies, most recent chest radiograph
on [**2128-7-16**].
PORTABLE AP CHEST RADIOGRAPH: Interval development of collapse
of the right upper lobe. Previously seen mediastinal mass
contours are obscured by the lung collapse. Interval left lower
lobe collapse is unchanged. Right basilar opacity has improved.
A small right pleural effusion is unchanged. Left pleural
effusion appears to have improved.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 75229**] [**Name (STitle) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
[**Known lastname **],[**Known firstname **] [**Medical Record Number 75227**] F 53 [**2074-10-13**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2128-7-21**] 3:00
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] SICU-A [**2128-7-21**] 3:00 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 75230**]
Reason: Assess lung fields
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with metstatic renal cell CA with lung mets
REASON FOR THIS EXAMINATION:
Assess lung fields
Final Report
REASON FOR EXAMINATION: Evaluation of the patient with
metastatic renal cell
cancer to mediastinum and lungs.
Portable AP chest radiograph was compared to [**2128-7-20**].
There is slight interval improvement in the right basal opacity.
Mediastinal widening has increased most likely due to a
combination of mediastinal lymphadenopathy and recurrent partial
atelectasis of the right upper lung. The bilateral pleural
effusions and left retrocardiac opacity are unchanged. The NG
tube tip is in the stomach.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: WED [**2128-7-21**] 1:39 PM
[**Known lastname **],[**Known firstname **] [**Medical Record Number 75227**] F 53 [**2074-10-13**]
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2128-7-22**] 9:11 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] SICU-A [**2128-7-22**] 9:11 AM
VIDEO OROPHARYNGEAL SWALLOW Clip # [**Clip Number (Radiology) 75231**]
Reason: evaluate swallow
[**Hospital 93**] MEDICAL CONDITION:
53yF p/w LUE weakness after visit to chiropractor, h/o
metastatic RCC diagnosed
2y ago, w/pulmonary, trachea, & brain lesions, s/p
nephrectomy and
chemotherapy, recently found to have pathologic fracture of
C7 s/p embolization
of tumor and C7 corpectomy (received solumedrol for cord
compression) c/b
post-op inability to move any extremities, MRI showed no
compression but edema
of C2-T1.
REASON FOR THIS EXAMINATION:
evaluate swallow
Final Report
HISTORY: Evaluate swallowing in patient status post C7
corpectomy with postop
inability to move any extremities. Edema from C2-T1.
VIDEO OROPHARYNGEAL SWALLOW
COMPARISONS: None.
FINDINGS: In collaboration with speech and swallow pathology,
barium of
various consistencies was orally administered to the patient
during continuous fluoroscopic evaluation. There is free passage
of orally administered material from the oropharynx into the
proximal esophagus without evidence for holdup. There was trace
penetration and aspiration of thin liquids. A nasogastric tube
is present in the patient's esophagus, which may have slightly
impaired swallow function.
IMPRESSION: Trace penetration and aspiration of thin liquids.
For full
details including treatment recommendations, please refer to
speech and
swallow pathology note from the same day.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: FRI [**2128-7-23**] 12:38 PM
PULMONARY ANGIO Study Date of [**2128-7-28**] 3:12 PM
Right mediastinum metastatic tumor fed by branches of right
bronchial artery, which was completely embolized with 300-500
micrometer Embospheres and three 2 mm x 4 cm coils.
CXR
Final Report
REASON FOR EXAMINATION: Shortness of breath.
Portable AP chest radiograph was compared to prior study
obtained the same day earlier at 04:26 a.m.
There is no change in the right upper lobe collapse accured in
the meantime interval. The multiple pulmonary nodules, bilateral
pleural effusions, and bibasal consolidations are unchanged as
well.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2128-7-30**] 3:42 PM
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2128-7-30**] 04:00AM 8.1 3.72* 9.4* 30.2* 81* 25.3* 31.3 22.6*
583*
[**2128-7-28**] 05:30AM 6.5 3.26* 8.5* 27.1* 83 26.0* 31.3 21.1*
674*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2128-7-30**] 04:00AM 118* 6 0.5 138 3.6 100 26 16
Source: Line-PICC
[**2128-7-29**] 04:42AM 108* 5* 0.3* 140 3.9 103 27 14
Source: Line-picc
[**2128-7-28**] 07:41PM 105 5* 0.5 138 4.1 102 25 15
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2128-7-28**] 07:41PM 9.1 3.1 2.0
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent
[**2128-7-30**] 10:21AM ART 50*1 37 7.51* 31* 5
[**2128-7-17**] 06:06AM ART 79* 48* 7.44 34* 6
Brief Hospital Course:
Pt was admitted to neurosurgery service after complaints of [**4-7**]
weeks of progressive weakness in the left hand. After
hospitalization it was revealed that the pt had an outpt
bronchoscopy that left her with some upper extremity weakness x
1 week. She then sought chiropractic care for neck pain that
left her with some LUE weakness. Imaging of the cervical spine
revealed C7 pathological fracture [**3-8**] renal cell mets.
After she was admitted she was placed in a hard collar. She was
readied for the OR and on [**7-8**] went to neuro interventional
radiology for pre-op embolization prior to OR. After the
embolization she remained intubated but appeared to have left
leg weakness. Her sedation was lightened on the way to the OR
and she was unable to move all 4 extremities. She was then
placed in traction in OR and underwent C7 corpectomy. She was
also started on solumedrol protocol for spine injury.
She tolerated the procedure and was kept intubated and
transferred to PACU where she remained overnight for close
monitoring. She also underwent MRI of brain which demontrated
the following: metastasis in the left frontal lobe and left
occipital lobe. Tiny areas of acute infarct in the cerebellum
seen as restricted diffusion. Normal MRA of the head. She also
underwent MRI c-spine which showed increased signal within the
spinal cord from C2-T1 level could be due to ischemia or cord
edema. Status post corpectomy of C7 with normal alignment of the
vertebral bodies. Decrease in size of the left paraspinal mass
related to surgery and embolization.
On the first post-op morning her motor exam improved slightly
and she was moving her right arm with slight movement left
hand/wrist. Dressing was clean and dry.
On [**7-12**] pt. was extubated and then re-intubated secondary to
failure to clear secretions. Two days later she was started on
broad spectrum antibiotics for fevers and empiric coverage of
VAP. Family meeting held to decide on another trial of
extubation and then trach if needed. No further oncological
treatment offered. Pt aware and agrees with this plan.
The patient was successfully extubated a few days later and is
tolerating a face tent for oxygenation. On [**7-16**] the patient was
observed to have some focal motor seizures characterized by arm
tremmors. She required frequent bolus' of dilantin and was
transition to Keppra for sz control.
She was seen by speech therapy and was ultimately cleared for a
diet after extubation and when she was able to tolerate it
safely. In the meantime she was fed via NGT.
Her respiratory status was fluctuating and there was some
discussion as to if the pt should be electively trached if she
required reintubation. Ultimately she did not require
reintubation so this became a mute point. She did express that
she did not want hospice and that she would like to pursue
agressive therapy and be transferred to rehab. She was bronch'd
on the [**7-19**] for increasing RLL infiltrates and right
lung collapse.
Neurologically she improved in her upper extremity exam with
more stength proximally than distally. Her lower extremity exam
has remained poor. Ultimately her respiratory status improved
so that she could tolerate a video swallow eval. Her NGT was
removed and she was placed on thin liquids and moist ground
solids. Nutrition consult was obtained to assess caloric
intake.
She was re-seen by Interventional Pulmonary to assist in
clearing of her secretions on [**2128-7-26**]. During their procedure
they noted that the right mainstem bronchus was 50% occluded
around the 13th and now is 60-80% occluded with blood clots
overlying the protruding mass. No intervention was performed
during the procedure.
The IP attending discussed course of action with pt, husband and
children. They would like to move forward with treatment of
bronchial obtruction. Her lovenox was discontinued in prep for
intervention. IR consult for embolization was called as well as
RT consult for RT to mass. This was discussed with family and
performed [**7-28**]. Pt and family also decided upon DNR/DNI after
long discusssion. Pt was transferred to MICU after the
procedure. After much thought, the family reconsidered code
status and made the patient full code. She then had a bronchial
artery embolization and was then transferred to the MICU from IR
for monitoring. At night has anxiety induced dyspnea where she
is placed on NRB and given ativan. On [**7-28**] a CXR showed complete
opacification of right hemithorax, likely a combination of
atelectasis and fluid due to lack of signicicant midline shift
(overall slight leftward shift) concerning for blood as patient
was status-post embolization. IP then spirated long obstructing
blood clot from R main stem beginning at level of tumor. She was
then stable in the ICU and transferred to OMED for further
observation. She again had respiratory distress and was
transferred back to the ICU, until finally, she decided to be
CMO and was transferred back to the OMED service. She then had
respiratory depression/failure and passed away at 5:59PM on
[**2128-7-30**].
Medications on Admission:
BENZONATATE - 100 mg Capsule - 1 (One) Capsule(s) by mouth twice
a day as needed for cough - No Substitution
BENZONATATE [TESSALON PERLES] - 100 mg Capsule - 1 (One)
Capsule(s) by mouth three times a day as needed for cough - No
Substitution
CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 Tablet(s) by mouth
DILTIAZEM HCL - (Prescribed by Other Provider) - 240 mg Capsule,
Sust. Release 24 hr - 1 Capsule(s) by mouth daily
LORAZEPAM - 0.5 mg Tablet - [**2-6**] Tablet(s) by mouth every six
hours as needed for nausea/sleep
LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 0.5 mg
Tablet - 0.5-1 Tablet(s) by mouth twice a day as needed
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - [**2-6**]
Tablet(s) by mouth every 6 hours as needed for pain
RAD 001 - (Prescribed by Other Provider) - Dosage uncertain
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours as needed for pain
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider; Pt reports
taking.) - 325 mg Tablet - [**2-7**] Tablet(s) by mouth as needed for
discomfort.
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 100 mg Capsule(s) by mouth as needed for constipation
GUAIFENESIN [MUCINEX] - 1,200 mg Tab, Multiphasic Release 12 hr
-
1 (One) Tab(s) by mouth twice a day - No Substitution
IBUPROFEN [ADVIL] - (Prescribed by Other Provider) - 200 mg
Tablet - 200-400 mg Tablet(s) by mouth as needed for pain
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
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30070, 30079
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30130, 30140
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9670, 17533
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8501, 8860
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30100, 30109
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28590, 30047
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8875, 9651
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257, 277
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20742, 23417
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431, 3343
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3365, 8116
|
8132, 8485
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,389
| 109,644
|
51688
|
Discharge summary
|
report
|
[** **] Date: [**2164-2-2**] Discharge Date: [**2164-2-7**]
Date of Birth: [**2108-8-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / erythromycin (bulk) / Compazine / Bactrim DS /
Sulfa (Sulfonamide Antibiotics) / Dapsone / Levaquin /
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Left ear pain and hearing loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 55 year old woman with h/o restrictive lung
disease (bleomycin toxicity), sarcoidosis, systolic CHF (EF 10%,
adriamycin toxicity), Factor V Leiden, s/p trach and PEG
placement, here with recurrent fevers. She was admitted to [**Hospital1 18**]
last year for respiratory distress was intubated and unable to
wean off the [**Last Name (un) **]. She then got a trach and PEG tube. Her
hospitalization was complicated by pna, recurrent fevers, and
C.diff. She was then discharge to [**Hospital 100**] rehab. In [**Month (only) **] she was
transferred to [**Hospital3 105**] for continued [**Hospital3 **] weaning. She
has had a complicated course since then w/ pneumomediastinum, R
pneumothorax with CT placement in [**Month (only) **], worsening CHF with EF
decreased from 30% to 10%, [**Last Name (un) **] requiring temporary HD, anemia of
chronic disease requiring blood transfusions (last on [**1-31**] for
Hct of 25). Recurrent C-diff with extended course of flagyl and
vanco and resistant pseudomonas pna most recently + sputum cult
on [**1-30**] for which pt was being treated with colistimethate and
aztreonam.
.
Pt was being weaned off the [**Month/Year (2) **] with 20hours off the [**Month/Year (2) **] on
trach mask and only requiring 4 hours of [**Month/Year (2) **] support. However,
in the last 2 days, she was only able to tolerate respiratory
trial off the [**Month/Year (2) **] for most of 1.5 hours. She had increased
sputum and became febrile to 102. She also c/o increase L ear
pain and decrease hearing. She had a CT scan of maxillofacial
sinuses from [**1-30**] that showed mastoiditis and otitis media. As
per note, there was concern for cholesteatoma and she was
transfer here for ENT eval.
.
On arrival to the ED, her initial vitals were Temp of 97.6, 115,
99/75, 30, 100% on trach on [**Month/Year (2) **]. Patient was given vanc and
cefepime and receiced 2L of NS. Her BP responded by increasing
to 110s/60s. She has reamined sinus tachy in 110s. She had a
femoral line placed which the patient was pulled as per nursing
report. She had some of of the fluid and vanco infiltrated into
her tight. Her CT of her maxillofacial sinuses in OHS was
evaluated by our radiologist and the prelim reports that there
is no new findings when compared to prior CT done in [**Month (only) **].
.
On arrival to the MICU, pt is on [**Month (only) **] via trach with pressure
control Fio2 35%, PEEP 5, PIP 35, rate of 14 sating 100%. Pt is
overall comfortable. She is sleepy, but responsive. Answering
appropriately to questions. She had just received some ativan
prior to my evaluation.
.
Review of systems: Unable to fully assess ROM given that she is
non-verbal due to trach and sleepy on arrival.
(+) Per HPI. She c/o increase L side ear pain and decrease
hearing on L side, mild L facial edema as per OHS note. Occ
diarrhea
Past Medical History:
- s/p trach/PEG [**9-1**]
-Sarcoidosis: treatment History: methotrexate [**12-31**], stopped [**1-31**]
due to reaction, prednisone 10-20-10-7.5mg [**Date range (1) 107077**] stopped due
to Cushingoid side effects in [**10-31**].
- Non-Hodgkin's lymphoma (27 years ago) s/p chemotherapy c/b
bleo lung tox, autologous BMT, and high-dose myeloablative total
body irradiation.
- Pulmonary embolism with Factor-5 Leiden- long term coumadin
goal INR [**1-26**] therapy
- Status post CVA with memory deficit.
- Stage III-IV chronic kidney disease.
- Systolic CHF- [**1-25**] adriamycin from large cell lymphoma several
years ago. Recent Echo 30%.
- Hypertension.
- Hyperlipidemia
- Mild sleep apnea.
- Anxiety
- Gout.
- Anemia - on Aranesp
- Iron overload.
- Multiple environmental allergies
Social History:
Currently living at [**Hospital 100**] Rehab x2 weeks. She has been on
disability for the past 15 years, but used to work in a hotel as
a reservations consultant.
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
- Maternal: clots, PE, TIA, Factor V Leiden, dementia at 92
- Paternal: CAD, pancreatic CA
- Siblings: sister died [**2162-12-24**] from complications of DM,
another sister with thyroid problems and high cholesterol
- Children: one healthy daughter without [**Name2 (NI) **] V Leiden
- Uncle: colon cancer
Physical Exam:
Vitals: 115, 129/77, RR 26, 100% on [**Name2 (NI) **]
General: sleepy but responsive to verbal stimuli. Non-verbal due
to trach, but answering appropriately to questions. No acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, Mild left facial edema and non tender L ear or
mastoid process. L tympanic membrane with yellowish opacity,
bulging. R with pearl white membrane.
Lungs: rhochorus through out, no increase in WOB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present (hyperactive), no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses on bil LE, no clubbing,
cyanosis or edema.
Pertinent Results:
Head CT [**2-2**]: FINDINGS: There is complete opacification of the
left mastoid air cells and the left middle ear. This is similar
in appearance to the [**2163-9-16**] study. There is no
underlying bony destruction. Opacification of the left mastoid
air cells are seen as far back as [**2162-11-21**]. Remaining
visualized paranasal sinuses and right mastoid air cells are
clear.
.
IMPRESSION: Chronic opacification of the left mastoid air cells
and left
middle ear with no evidence of underlying bony destruction.
.
Chest X-Ray [**2-2**]: IMPRESSION: Overall, there is slight increased
opacity of the interstitial markings and ultimately it is
difficult to determine whether there is a superimposed process
on the extensive background of abnormal lungs. Consider, if
clinically feasible, a trial of diuresis with repeat radiography
to discern whether there is an element of superimposed pulmonary
edema.
.
[**2164-2-2**] 10:20PM BLOOD WBC-16.5*# RBC-3.31* Hgb-10.6* Hct-32.2*#
MCV-97 MCH-32.1* MCHC-33.0 RDW-19.8* Plt Ct-209#
[**2164-2-7**] 03:51AM BLOOD WBC-12.1* RBC-2.91* Hgb-9.6* Hct-29.3*
MCV-101* MCH-32.9* MCHC-32.8 RDW-18.9* Plt Ct-266
[**2164-2-4**] 06:05AM BLOOD Neuts-54 Bands-4 Lymphs-12* Monos-15*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-13*
[**2164-2-2**] 10:20PM BLOOD Glucose-66* UreaN-29* Creat-1.3* Na-135
K-5.2* Cl-98 HCO3-29 AnGap-13
[**2164-2-7**] 03:51AM BLOOD Glucose-117* UreaN-61* Creat-1.4* Na-141
K-4.0 Cl-108 HCO3-25 AnGap-12
[**2164-2-3**] 03:57AM BLOOD Cortsol-7.9
[**2164-2-6**] 06:30AM BLOOD Vanco-18.3
[**2164-2-2**] 10:30PM BLOOD Lactate-1.1
Brief Hospital Course:
Ms. [**Known lastname **] is a 55 year old woman with h/o restrictive lung
disease (bleomycin toxicity), sarcoidosis, systolic CHF (EF 10%,
adriamycin toxicity), Factor V Leiden, s/p trach and PEG
placement who was sent from [**Hospital3 **] due to concern for
mastoiditis. Also noted to have fevers and being treated for
pseudomonal pneumonia.
.
# ? Mastoiditis: The OSH was concerned for possible infection
and sent her to [**Hospital1 18**] for ENT evaluation. After review by our
radiologist, there was no significant change in the CT scan when
compared to in [**Month (only) 359**]. Seen by ENT- felt no clinical or
radiological evidence of acute mastoiditis, and fluid likely
chronic. No clear evidence of cholesteotoma on CT scans. They
recommend outpatient follow up with Dr. [**Last Name (STitle) 3878**] [**Telephone/Fax (1) 2349**].
She was briefly started on IV vancomycin which was discontinued
prior to discharge.
.
#. Fevers: On her last [**Telephone/Fax (1) **] in [**Month (only) 359**] she presented with
fevers which were not thought to be due to infection. She was
started on Vanc and meropenam however they were discontinued
prior to discharge. She presents now with a leukocytosis and
increased difficulty weaning off [**Month (only) **] concerning for a pulmonary
process. She was recently found to have pseudomonas growing in
her sputum on [**2164-1-30**] (2 strains that were multi-drug resistant
that was sensitive to amikacin. However there has been state
shortage of Amikacin and he was started on colistimethate and
had aztreonam added on [**2164-1-30**]). She was on aztreonam and
colistin upon [**Date Range **]. She has also been receiving flagyl and
vancomycin for c.diff and had multiple + C-diffs and has on and
off diarrhea. She was afebrible and was tolerating being
capped. Viral panel, legionella negative as were blood
cultures. Her aztrenoam was stopped and started on Meropenam and
continued on Colistin for pseudomonas, plan for 2 week course
per ID with an end date of [**2-16**]. She will need her creatnine
checked at least every other day while she is on colisitin.
.
#. Respiratory failure: Secondary to bleomycin toxicity and
reccurent pna. She failed to be extubated and has trach.
Currently has increase amounts of sputum and has hx of
pseudomonas pna. She arrived trached and on [**Date Range **]. She has a
history of becoming anxious when on the trach mask in which
Ativan was effective for relief. Chest x-ray showed some
bilaterally intertitial opacities which may be due to some
pulmonary edema. She also has a history of sarcoidosis and is on
chronic steroids for this. She is on HD for fluid removal given
hx of CHF and poor renal tolerance of diuresing. Currently doing
well on and tolerated trach collar. she was capped during the
day and was ventilated overnight.
.
# Chronic Systolic Congetive Heart Failure: Hx of cardiomyopathy
due to adriamycin. Pt had prior EF of 30% during prior
hospitalizations. As per OHS notes, her EF was decreased to 10%
on [**2163-10-19**] with severe L ventricular systolic dysfx, dilated
hypokinetic R ventricle. Repeat Echo in [**Month (only) **] and in [**Month (only) **] her EF
remained at 10%. Her Lisinopril 20mg and carvedilol 25mg.
.
# CKI: Pt had creatine peaked at 3.2 in [**Month (only) **] with aggressive
diuresing to help with weaning off [**Month (only) **]. She also developed
hyperK and as per note was started on HD to help with fluid
removal, she is currently receiving HD for volume status
management (last on [**1-30**] and [**2-2**]. Current creatine at 1.8. she
may require dialysis when returns to LTAC as is starting to show
signs of volume overload, but respiratory status doing well.
.
# Chronic Anemia: Pt with hx of anemia of chronic disease that
was fully worked up. Last iron 92, TIBC of 126. Her hct
decreased from 33.8 in [**Month (only) **] to 25.1 on [**1-30**] and she received 2
units of PRBCs. Current Hct now stable at low 30s.
.
# Upper Ext DVT: pt was on lovenox which appear to have stop.
Uncertain the dates on the lovenox. No UE edema noted. She was
restarted lovenox- will continue for long term course given
history of DVT and factor V leiden. Her creatinine has been
stable around 1.5 however if her creatinine worsens she should
be switched to lovenox one a day.
.
# Code: Full (discussed with patient).
Daughter, HCP, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 107085**]
Medical Facility: floor- [**Telephone/Fax (1) 88287**]
PA page- [**Telephone/Fax (1) 107086**]
Medications on [**Telephone/Fax (1) **]:
1. Acetaminophen 650 mg PO/NG Q6H:PRN Fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/Wheezing
3. Ascorbic Acid (Liquid) 500 mg PO/NG DAILY
4. Aztreonam [**2152**] mg IV Q6H
5. NPH 5 Units Daily
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
7. Lisinopril 20 mg PO/NG DAILY
8. Calcium Acetate 667 mg PO/NG TID W/MEALS
9. Lorazepam 1 mg PO/NG Q6H:PRN Anxiety
10. Carbamide Peroxide 6.5% 5-10 DROP AD [**Hospital1 **] Duration:
11. Metoclopramide 5 mg PO/NG QIDACHS
12. Carvedilol 25 mg PO/NG [**Hospital1 **]
13. MetRONIDAZOLE (FLagyl) 500 mg PO/NG Q6H
14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
15. PredniSONE 5 mg PO/NG DAILY
16. Cholestyramine 4 gm PO BID
17. Simethicone 40-80 mg PO/NG QID:PRN Abdominal Discomfort
18. Colistin 75 mg IH [**Hospital1 **]
19. Vancomycin Oral Liquid 250 mg PO/NG Q6H
20. Estrogens Conjugated 1 gm VG DAILY
21. Venlafaxine 37.5 mg PO TID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Fever.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/Wheezing.
3. ascorbic acid 500 mg/5 mL Syrup Sig: One (1) PO DAILY
(Daily).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q
12H (Every 12 Hours).
9. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
10. NPH insulin human recomb 100 unit/mL Suspension Sig: Five
(5) UNITS Subcutaneous once a day.
11. insulin lispro 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous three times a day.
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
14. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for Abdominal
Discomfort.
16. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
17. colistimethate sodium 150 mg Recon Soln Sig: One (1) Recon
Soln Injection [**Hospital1 **] (2 times a day).
18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
19. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Anxiety.
20. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
22. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnosis
Serous Otitis
Pneumonia (pseudomonas)
C. diff
Secondary Diagnosis
Chronic Systolic Congestive Heart failure
Chronic Renal Failure
Anemia
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 were admitted to the ICU because there was concern that you
had an infection deep in your left ear. You had the ears, nose
and throat specialist evaluate you and they did not think that
you had a significant infection.
You were also evaluated by the infectious disease doctors during
your [**Name5 (PTitle) **]. There were a few changes to your antibiotics.
The IV Vancomycin, Aztreonam and Fagyl were discontinued however
your meropenam and colisitin were continued. They recommended a
2 week course with an end date of [**2-16**].
Medications changed during your [**Date Range **]
STOP Aztreonam
STOP Flagyl
Start Meropenam End [**2-16**]
Change Colisitin 150mg [**Hospital1 **] subcutaneous End [**2-16**]
Start Ranitidine 150mg daily
Followup Instructions:
Please follow up with ENT as an outpatient with Dr. [**Last Name (STitle) 3878**] as
an outpatient [**Telephone/Fax (1) 2349**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"V58.61",
"383.9",
"585.3",
"V44.1",
"272.4",
"V44.0",
"008.45",
"428.22",
"403.90",
"428.0",
"285.29",
"289.81",
"493.90",
"381.4",
"135",
"482.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14592, 14675
|
7063, 12541
|
421, 428
|
14875, 14875
|
5463, 7040
|
15820, 16088
|
4381, 4688
|
12564, 14569
|
14696, 14854
|
15051, 15797
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4703, 5444
|
3105, 3326
|
351, 383
|
456, 3085
|
14890, 15027
|
3348, 4135
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4151, 4365
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,868
| 175,710
|
52916
|
Discharge summary
|
report
|
Admission Date: [**2163-1-21**] Discharge Date: [**2163-1-23**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Fluid overload
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Pt is a 73 yo female w/ pmhx DM, HTN, PVD, afib, hyperlipidemia,
ESRD on HD who presents today with acute shortness of breath. Pt
was last dialyzed on wednesday and she reports that was given
back all of the fluid that was taken off. Per dialysis nurse she
is actually below her dry weight. Last night she reports waking
up feeling palpatations and sob when laying on her side, no LE
edema although she has b/l BKAs. At that point had no
diaphoresis, cp, nausea or vomiting. Patient reports eating
cheese and crackers and having chinese for dinner last night. No
changes to her medications that she knows of. Pt denies URI
symptoms, fever, chills, cough, cp, abd pain, nausea, vomiting,
diarrhea. She occasionally has constipation.
.
EMS had a difficult time getting an O2 sat and placed her on
cpap and brought her to the ED whree she was weaned to 4 liters
nasal cannula. She received 1 sl nitro. On exam in ED, she was
noted to have crackles on lung exam and she received Asa 325 mg
x 1, 100 IV lasix and she put out 400 cc which per patient made
her feel better. Renal was consulted and recommended emergent
dialysis in the ICU. She was also placed on nitro gtt because
her initial blood pressure in ED was 210/104 and pressures is
now down to 150/80s. EKG showed st elevation V1-V4 c/w prior ekg
and recent prior cath 8 days ago was negative.
.
Of note, she had a recent admission to [**Doctor Last Name 1263**] with acute dyspnea
and fluid overload and was dialyzed emergently there. She was
then transferred from osh with elevated troponins and negative
stress test to [**Hospital1 18**]. Pt had coronary catheterization which
showed patent arteries at [**Hospital1 **] last week. She was thought to have
elevated troponins in setting of renal failure and demand
ischemia with aflutter. She underwent caval-isthmus atrial
flutter ablation which was unsuccessful and she was put on
coumadin and rate controlled.
.
In the ICU, patient's initial vs were: T 97.4, HR 81, BP 124/62,
R 23, O2 sat 100% on 4 l nc. She felt much better after the
lasix given in the ED. Denied dizziness, cp, palp, sob, abd
pain, nausea, etc.
Past Medical History:
-Hypertension
-Diabetes
-Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
-GERD
-Hypercholesterolemia
-ESRD on hemodialysis M,W,F. Right IJ Permanent Catheter in
place. Receives dialysis at [**Location (un) **] hemodialysis center in
[**Location (un) **].
-Paroxysmal atrial flutter, refused anticoagulation
-Peptic ulcer disease
-Hypertrophic Obstructive Cardiomyopathy.
-Mild mitral stenosis (MVA 1.5-2.0 cm2)
-Secondary Hyperparathyroidism
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
Social History:
Social history is significant for the presence of current
tobacco use, [**12-22**] PPD x 50 years. There is no history of alcohol
abuse. Lives in [**Hospital3 **] facility and uses a mobile
wheelchair.
Family History:
Her father died in his 90's and mother at the age of 102.
Patient unable to specify cause of death. She has one living
sister at the age of 75 and 6 sisters and one brother who passed
away. Her family history is significant for coronary artery
disease, cancer, and diabetes.
Physical Exam:
VS: Temp: 97.4 BP: 124 /62 HR: 81 RR: 23 O2sat 100% on 4 l nc
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: mild bibasilar crackles
CV: RR, S1 and S2 wnl, 2/6 sem at lusb and harsher hsm at apex
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: b/l bka, warm, no rashes
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: deferred
Pertinent Results:
Admission Labs:
[**2163-1-21**] WBC-18.8* RBC-3.99* Hgb-12.4 Hct-39.5 MCV-99* MCH-31.1
MCHC-31.4 RDW-19.8* Plt Ct-366 Neuts-83.4* Lymphs-12.9*
Monos-2.6 Eos-0.9 Baso-0.2
[**2163-1-21**] PT-40.7* PTT-43.9* INR(PT)-4.4*
[**2163-1-21**] Fibrino-506*
[**2163-1-21**] Glucose-119* UreaN-35* Creat-6.8* Na-139 K-5.0 Cl-101
HCO3-25 AnGap-18 Calcium-8.9 Phos-5.7*# Mg-2.3
[**2163-1-21**] CK(CPK)-48 Amylase-108*
[**2163-1-21**] CK-MB-4 proBNP-9533* cTropnT-0.12*
[**2163-1-21**]
AP PORTABLE CHEST: Dual-lumen catheter via right internal
jugular approach terminates near the cavoatrial junction. Heart
size is normal. Aorta is tortuous. The interstitial markings are
prominent and multiple peripheral septal lines are noted. Both
costophrenic sulci are blunted. There is no pneumothorax or
focal airspace consolidation. The bones are somewhat
demineralized.
IMPRESSION: Interstitial edema and small bilateral pleural
effusions.
[**2163-1-21**] EKG:
Sinus rhythm. Left atrial abnormality. Q waves in leads V1-V2
with poor
R wave progression. Suggest old anteroseptal myocardial
infarction.
Borderline left ventricular hypertrophy. ST-T wave
abnormalities, most likely related to secondary repolarization
abnormalities from left ventricular hypertrophy. Compared to the
previous tracing of [**2163-1-11**] there is no significant diagnostic
change.
Brief Hospital Course:
Patient is a 73 yo female with pmhx afib s/p failed ablation on
coumadin, htn, hyperlipidemia, DM and ESRD on HD who presented
with acute dyspnea and pulmonary edema, treated in the MICU with
urgent dialysis, called out to the floor on HD#2 euvolemic.
#. Dyspnea - Resolved quickly with hemodialysis, likely
secondary to volume overload from being underdialyzed and
dietary non-complaince. No evidence of PNA on admission CXR,
with resolved leukocytosis and afebrile. Anticoagulated so PE is
unlikely.
She was discharged to continue her dialysis on regular M/W/F
schedule. Patient was educated about a low salt, heart healthy
diet.
#. HTN- Patient hypertensive to 200s when she came to ED and was
started on nitro gtt. On admission to MICU, SBP 120s and
nitroglycerin gtt was quickly weaned off. This episode is likely
secondary to fluid overload and sob [**1-22**] fluid overload. Patient
was normotensive on transfer to the floor and remained
normotensive on the day of discahrge. She was discharged on her
home regimen with the uptitration of her beta blocker to
continue dialysis regimen as above.
#. ESRD- On dialysis M/W/F. Per report, patient was under
dialyzed on wednesday, two days prior to admission, because she
was under her dry weight. She received HD on the evening of
admission emergently and was sent home to continue HD on M/W/F
when she was euvolemic. The renal followed during her stay and
we continued sevelemer and nephrocaps. On the day of discharge,
patient was mildly hyperkalemic and received kayxalate prior to
discharge with plan for HD on the morning following discharge.
#. Leukocytosis- Patient's [**Known lastname **] count 18.8 on admission with no
localizing signs of infection or fever. [**Month (only) 116**] be stress related.
Resolved on transfer to the floor. Urine culture negative on
admission. Blood cultures x2 with no growth to date still
pending at time of discharge.
#. PAF- S/P failed ablation last admission on warfarin. INR
supratherapeutic on admission at 4.4. Her warfarin was held as
INR was supratherapeutic and resumed on discharge once INR fell
into therapeutic range. She was continued on metoprolol with
uptitration to 100mg [**Hospital1 **] and diltiazem at home dose for rate
control. Telemetry showed continued paroxysmal atrial
fibrillation during her stay.
#. Hyperlipidemia- Continued simvastatin 80 mg qd.
#. PVD- continued aspirin.
#. DM - Most recent A1c in [**11-27**] was 6.9. She was maintained on
NPH 16 units qam as per home regimen. QACHS finger sticks with
sliding scale coverage and diabetic diet were provided during
her stay.
#. Glaucoma- continued home meds.
#. GERD/PUD - continued ranitidine per home regimen.
# F/E/N: HD, Replete lytes PRN. diabetic/renal/cardiac diet
# PPx: Bowel regimen, H2 blocker, supratherapeutic INR
# Access: PIV, dialysis line
# Dispo: to home with HR and BP controlled and patient euvolemic
on exam.
# Code Status: Full
Medications on Admission:
from discharge summary on [**2163-1-13**]- pt reports no changes
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Diltiazem HCl 120 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily): Right eye.
11. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Left eye.
12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily): Left eye.
13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): Left eye.
14. Vigamox 0.5 % Drops Sig: One (1) drop Ophthalmic TID (3
times a day): Left eye.
15. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Sixteen
(16) units Subcutaneous once a day.
17. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days. (finished course)
Disp:*5 Tablet(s)* Refills:*0*
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Sixteen
(16) units/ml Subcutaneous once a day.
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
15. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Outpatient Lab Work
please check INR on [**1-25**] and fax results to [**Company 109100**] Anticoagulation
Management Service (ACMS)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Pulmonary Edema from volume overload
end-stage renal disease on hemodialysis
hypertensive urgency
atrial fibrillation
insulin dependent diabetes mellitus
Discharge Condition:
hemodynamically stable, saturating well on room air with no
signs of volume overload on exam.
Discharge Instructions:
You have been treated for your SOB with dialysis. Please adhere
to a low salt diet and take your medications as prescribed.
Your metoprolol was increased to 100mg twice daily from 75mg
during your stay.
During your stay, your coumadin was held because your INR was
elevated. Please resume your 5mg daily dose and have your INR
checked on [**1-25**] by the VNA. Your result should be faxed to [**Company 109100**]
Anticoagulation Management Service (ACMS).
Please resume your Monday, Wednesday, Friday dialysis schedule.
Please call your primary care provider or return to the
emergency department if you have any chest pain, shortness of
breath, fevers >100.8 or any other concerning symptoms.
Followup Instructions:
Please resume dialysis on [**2163-1-24**] and have your INR checked this
week by the VNA.
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2163-1-27**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-2-1**] 12:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2163-2-16**]
10:40
|
[
"V17.3",
"V18.0",
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"588.81",
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"585.6",
"427.32",
"530.81",
"443.9",
"V49.75",
"425.1",
"427.31",
"V12.71",
"365.9",
"272.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11668, 11725
|
5593, 8543
|
329, 343
|
11923, 12019
|
4226, 4226
|
12767, 13353
|
3319, 3596
|
10286, 11645
|
11746, 11902
|
8569, 10263
|
12043, 12744
|
3611, 4207
|
275, 291
|
371, 2497
|
4243, 5570
|
2520, 3083
|
3099, 3303
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
310
| 142,159
|
1547+1548
|
Discharge summary
|
report+report
|
Admission Date: [**2139-5-6**] Discharge Date: [**2139-5-10**]
Date of Birth: [**2096-7-16**] Sex: M
Service: NSU
CHIEF COMPLAINT: Chiari type II malformation with
hydrocephalus.
PHYSICAL EXAMINATION: The exam of the patient on admission
is as follows: Vital signs: The blood pressure is 118/70 and
the heart rate is 60. In general, he is a mildly anxious man
but well appearing. He has no visible rashes. He has a large
head with anicteric sclera, moist mucous membranes. His neck
was supple. His chest reveals a normal respiratory pattern
and is clear to auscultation. Cardiovascularly, he has
regular rate and rhythm without murmurs. Abdomen is soft and
nontender. His extremities reveal no edema and are warm and
well perfused. On his back exam, he is noted to have some
scoliosis and an old scar at the L2-L3 level. His neurologic
exam is as follows: He is alert and oriented x3. He is mildly
anxious. His cranial nerves are fully intact without any
visible deficits. His sensory exam is fully intact. His motor
exam is fully intact. His reflexes are quite brisk
throughout, 3+/4, with bilaterally positive Babinskies and
positive [**Doctor Last Name **] sign bilaterally. His coordination exam
reveals mild end target dysmetria bilaterally on finger to
nose but normal heel to shin and rapid alternating movements.
His gait is normal but he is unable to do tandem gait well
and is noted to rotate his feet internally while walking on
his toes.
HOSPITAL COURSE: The patient was admitted on the same day of
his surgery which was [**2139-5-6**], and underwent a bilateral
suboccipital craniotomy, Chiari compression, C1 laminectomy
and duraplasty. Please refer to the operative note of [**5-6**]/[**2139-5-7**], for further details of operative procedure.
He was taken to recovery to the surgical intensive care unit
on postoperative day zero where he made a good recovery. In
the immediate postoperative period, he underwent a CT scan
which revealed postoperative changes but was unconcerning for
any abnormalities or hematomas. He had no neural deficits on
exam. He was noted, however, in the immediate postoperative
period to have some sinus bradycardia which readily resolved
when the patient was awakened. His EKG was checked and was
normal. Cardiac enzymes were checked and were found to be
normal as well. He did have a large volume of urine output
and serum osmolality was checked and found to reveal a mildly
reduced serum sodium which eventually restored itself on
postoperative day #2. Also on postoperative day 1, the
patient was noted to have right eye erythema and was
diagnosed with a right corneal abrasion for which he was
treated with erythromycin. He was kept in the intensive care
unit until postoperative day 3 when he was transferred to the
floor with hemodynamic stability. A physical therapy
consultation was obtained to evaluate the patient for his
back pain. He was started on cyclobenzaprine for back spasms
and he was continued on the erythromycin ophthalmic ointment
for his corneal abrasion. He made a good recovery and,
because physical therapy deemed him as not a candidate for
home physical therapy, he was discharged home without
services on postoperative day 5 in good condition, and he was
to follow-up with Dr. [**Last Name (STitle) **] in clinic in 2 weeks after his
discharge.
DISCHARGE MEDICATIONS:
1. Lithium carbonate 300 mg twice a day.
2. Duloxetine 60 mg daily.
3. Docusate sodium 100 mg twice a day.
4. Percocet 1-2 tablets q.4 hours as needed for pain.
5. Erythromycin ophthalmic ointment to be applied to the
right eye 4 times a day for 5 days.
DISCHARGE DIAGNOSES:
1. Chiari II malformation.
2. Major depression.
3. Generalized anxiety disorder.
4. Corneal abrasion.
5.
Sinus bradycardia.
6. Hyponatremia.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 9031**]
Dictated By:[**Doctor Last Name 9032**]
MEDQUIST36
D: [**2139-6-10**] 14:58:42
T: [**2139-6-10**] 16:26:17
Job#: [**Job Number 9033**]
Admission Date: [**2139-5-6**] Discharge Date: [**2139-5-10**]
Date of Birth: [**2096-7-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Suboccipital decompressive craniotomy, C1 laminectomy,
duraplasty
History of Present Illness:
The patient is a 42-year-old
patient who is well known to the [**Hospital1 **] neurosurgical
service. He has been seen in Dr.[**Name (NI) 9034**] office multiple times
on an
outpatient basis. He has been diagnosed with a Chiari II
malformation in the setting of a previously operated spinal
meningeal viral series. The patient has classic signs of
headaches that are positional and aggravated by coughing. The
patient has been worked up with an MRI scan that shows the
tight posterior fossa with inferior displacement of parts of
the cerebellum to the level of C1. He was counseled. He
wished to proceed with elective decompression today. The
patient was consented in the office. He was taken to the
operating room on the evening of [**2139-5-6**].
Past Medical History:
PAST MEDICAL HISTORY:
1. Anxiety/depression.
2. Chiari II malformation with hydrocephalus.
Family History:
not obtained
Physical Exam:
GENERAL: mildly anxious man but well appearing.
NEUROLOGIC EXAM:
Mental status:
Patient is alert, awake, mildly anxious affect with some
tangential speech. Good attention, tells a coherent story.
Language is fluent with good comprehension, repetition, able to
read. He naming intact. No dysarthria. No neglect or
left/right
mismatch. Cranial Nerves:I-XII-intact.
Sensory: Normal touch, vibration, proprioception, pinprick
sensation.
Motor: Slightly increased tone in the legs. No pronator drift.
Mild postural tremor, fine, low amplitude with arms
outstretched.
Full strength.
Reflexes: brisk throughout 3+ with crossed adductors and
bilaterally upgoing toes. + [**Doctor Last Name **] bilaterally.
Coordination: finger-to-nose slowwer on L, but normal heel to
shin, rapid alternating movements.
Gait:Gait appears normal but unable to tandem.
Brief Hospital Course:
Pt was admitted and brought to the OR electively on [**2139-5-6**] for
decompressive suboccipital craniotomy and C1 laminectomy and
duraplasty under general anesthesia. Post op he was transferred
to SICU for close neurological monitoring. He remained
neurologically intact. He was intermittently bradycardic. Post
op head CT showed good appearance. He was transferred to the
floor. His diet and activity were advanced. His dressing was
clean and dry.
Medications on Admission:
lithium bicarbonate (generic) 300/150/300,
cymbalta 60mg daily.
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari malformation
Discharge Condition:
neurologically stable
Discharge Instructions:
Keep incision dry. Call for fever or any signs of infection
-redness, swelling or drainage from wound.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] for suture removal in 10 days - call
[**Telephone/Fax (1) 2731**]- for appt.
Completed by:[**2141-5-19**]
|
[
"918.1",
"E878.8",
"300.4",
"276.1",
"724.8",
"741.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.24",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
6835, 6841
|
6265, 6720
|
4377, 4445
|
6905, 6929
|
7080, 7233
|
5357, 5371
|
3654, 4312
|
3369, 3633
|
6862, 6884
|
6746, 6812
|
1493, 3346
|
6953, 7057
|
5386, 5434
|
225, 1475
|
4329, 4339
|
4473, 5224
|
5739, 6242
|
5466, 5724
|
5451, 5451
|
5268, 5341
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,025
| 146,848
|
37196
|
Discharge summary
|
report
|
Admission Date: [**2168-11-4**] Discharge Date: [**2168-11-9**]
Date of Birth: [**2125-1-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
OSH transfer from [**Hospital **] [**Hospital 83761**] hospital for HD access and possible
need for TIPS
Major Surgical or Invasive Procedure:
Tunneled right subclavian hemodialysis line placement
History of Present Illness:
43 yoM with EtOH liver disease and recent initiation of HD, who
is being admitted from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for poor venous access in
the setting of coagulopathy and possible TIPS procedure. He was
was admitted on [**10-30**] after his HD catheter "slipped out" while
sleeping and had some bleeding. On [**11-1**], he had a tunneled HD
cath placed by IR on the right, which was subsequently removed
for bleeding. HD was attempted on [**11-2**] but could not be
comleted due to poor flow thorugh the line. The line was
heparinized and then had some oozing requiring "multiple units"
of RBC, plts, FFP and DDAVP. The catheter was removed and a
suture was placed on [**11-3**]; the bleeding subsequently stopped.
He was hypotensive with SBP to the 60's around this time for
which he was transiently on phenylephrine.
.
Prior to transfer on [**11-4**], he had two units FFP at 8 am for INR
1.9. He has not had HD in 8 days, though he has been stable on
room air and has had stable electrolytes.
.
On [**11-3**], he was started empirically on ceftazidime for possible
SBP (no tap done; benign exam always; added to vanco that was
previously started for for line infection; numerous blood and
urine cultures have been negative).
.
Of note, he had blood cultures from HD drawn on [**2168-10-22**] that
grew MRSA and was started on vancomycin. At a clinic
appointment on [**2168-10-24**] with Dr. [**Last Name (STitle) 10285**], he reported low BP and
temp to 103; he was started on a z-pack, though subsequently had
blood cultures that grew out MRSA. He was changed from lactulose
to rifaximin 400mg TID at this appointment given the degree of
his diarrhea.
.
Note that WBC noted to be 30.2 in an OMR note from GI on [**10-26**]
(this is from outside labs drawn at HD).
.
Also of note, patient was recently admitted from [**Date range (1) 83762**]
with acute EtOH hepatitis and hematemesis, at which point he was
started on HD (though does have some residual urine function).
EGD showed [**Last Name (un) 27191**], erosive esophagitis and portal gastropathy
but no varices.
Past Medical History:
(#) Recent bacteremia per above (12/5 blood cultures from HD)
(#) EtOH abuse with h/o seziures ? during intoxication
(#) EtOH Liver disease-- acute EtOH hepatitis in [**8-26**] (was not
started on corticosteroids due to GI bleed, UTI and [**Last Name (un) **]); was
started on pentoxyphyline to prevent HRS with a planned 4 week
course from [**2168-9-26**] (last day [**2168-10-24**]); negative hepatitis A and
B serologies, as well as a hepatitis C serology
(#) Hemodialysis dependent-- since last admission, dx
multifactorial with ATN +/1 NSAIDs +/- HRS; getting HD through
tunneled line (until this admission) with HD MWF
(#) Gastroesophageal Reflux Disease
(#) Seizures in setting of heavy alcohol consumption, seen by a
neurologist who did not feel that it was a primary seizure
disorder (first [**12-27**])
(#) MVA [**3-/2153**] - Right femur fracture with [**Male First Name (un) **] placement, pelvic
fracture
(#) Asthma
Social History:
Never smoker, Drank [**11-23**] Vodka daily until 3 weeks ago. Never has
used IV drugs. Lives with girlfriend, [**Name (NI) 5627**] [**Name (NI) 83758**]
[**Telephone/Fax (1) 83759**]. Has 2 children, daughter 17, son, 16 who live with
their mother who the patient is still very close to. Pt formerly
worked at Mass Electric.
Family History:
Mother - Deceased [**12-21**] alcoholic liver disease
Father - Deceased [**12-21**] [**Name2 (NI) 499**] cancer, diagnosed in his 40s. No
other family history of [**Name2 (NI) 499**] cancer.
Physical Exam:
VS on arrival to the ICU: Temp 95.9, HR 101, BP 88/39, RR 17,
98% on room air
General: awake, conversant
HEENT: iceteric sclera, good dentition, OP clear
Lungs: crackles at bases that cleared with deep inspiration,
otherwise clear b/l
Cardio: RR, II/VI SEM at RUSB, no r/g, no JVD
Abd: + BS, soft, somewhat obese and distended with slight fluid
wave, liver marin [**12-22**] inches below costal margin, no
splenomegaly appreciated
Extremities: 3+ LE edema symmetric to mid-calf, no erythema or
TTP
Skin: jaundiced, dry with some lotion on extremities, no
petechiae or rashes; ecchymoses right anterior chest from
tunneled line, one suture (placed [**11-3**]); PIV in forearms b/l
Neuro: AA, oriented but slight cognitive deficits with somewhat
increased speech latency, CN II - XII normal, slight resting
tremor in UE, no asterixis or myoclonus, moving all extremities
Pertinent Results:
On transfer from OSH, notable for WBC 16.0, Hct 24 (after 1 unit
pRBC), INR 1.9 (then 2 units FFP), plts , K 3.8, Cr 9.3
On arrival, notable for
.
MICROBIOLOGY:
[**2168-11-4**] BCx x 1: pending (needs to be followed up as
outpatient)
[**2168-10-30**] BCx; negative ([**11-4**]; telephone [**Telephone/Fax (1) 83763**])
.
[**2168-11-4**] 4:55p
135 101 54
------------ 81
3.8 18 8.4 ∆
.
Ca: 9.0 Mg: 2.1 P: 7.2 ∆
ALT: 36 AP: 132 Tbili: 38.6 Alb: 2.6
AST: 96
Vanco: 28.0
.
.........8.1
10.5 ------ 69
........21.9
N:81.4 L:13.6 M:4.0 E:0.8 Bas:0.3
PT: 19.0 PTT: 54.8 INR: 1.7
Brief Hospital Course:
43 yoM with EtOH liver disease and coagulopathy, on HD with no
access currently [**12-21**] line dysfunction and inability to replace
prior to transfer from OSH on [**2168-11-4**].
#. HEMODIALYSIS-DEPENDENT: Throughout hospitalization, legs
remained edematous but was breathing and speaking comfortably on
room air and electrolytes remained stable. Right subclavian
tunnelled line was replaced by IR on [**2168-11-7**]. There was some
slight oozing around the site, but hematocrit remained stable
s/p 2 units total PRBC during hospitalization. Patient last had
HD on [**2168-11-9**], next dialysis planned for Saturday [**2168-11-12**].
Continued on nephrocaps, Epogen. Held sevelemer on discharge.
Pentoxyfilline also stopped as no further indication for use per
renal (had finished one month course).
#. Elevated WBC: WBC had been elevated for several weeks now;
slightly hypothermic on admission although no localizing
symptoms and line had been pulled for a few days on admission.
Nonfocal exam; Ceftazidime was started empirically at OSH which
was not continued. He was otherwise afebrile and HD stable
throughout hospitalization (note his SBP's were in low 90's and
asymptomatic during his stay, likely his baseline). On
discharge, WBC was 11.3, patient asymptomatic and afebrile. He
has a blood culture from [**2168-11-4**] that is still pending and
should be followed up as outpatient.
#. MRSA BACTERMIA: Per blood cultures from hemodialysis line on
[**10-22**]; has been on vanco HD dosing starting in early [**Name (NI) 1096**]
(unclear exactly when). Line now pulled and completed 14 days of
Abx. Vancomycin was discontinued on discharge.
#. ETOH LIVER DISEASE: Also with h/o GIB (portal hypertensive
gastropathy and erosive esophagitis on recent EGD's; no
varices). Appeared to have slight encephalopathy on exam this
admission. No indication for TIPS acutely. Cont PPI, lactulose,
rifaximin.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Vancomycin 1 g IV (last given [**11-3**]; trough on ?[**11-4**] 26)
Ceftazidime 2 g QOD (started 1217 --> written to be given for
one week for c/f SBP)
Desmopressin 25 mcg x 2 on [**11-3**]
Epo
Nephrocaps
Morphine PRN
Hydromorphone IV Q3 hours PRN
Lactulose 30 ml [**Hospital1 **]
Midodrine 7.5 mg TID
Protonix 40 mg PO/IV BID
Pentoxyphylline 400 mg PO TID
Vitamin K SQ (given [**11-3**])
Ambien PRN
.
HOME MEDICATIONS:
Sucralfate
Protonix 40 mg [**Hospital1 **]
Lactulose
Midodrine 7.5 mg TID
Nephrocaps
Trental 200 mg QD
Ambien QHS
Folate
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for titrate to BM's.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
4. Epoetin Alfa Injection
5. Sucralfate Oral
6. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
End stage renal disease
Need for dialysis catheter
Alcoholic Cirrhosis and Coagulopathy
.
Secondary:
ETOH Hepatitis
Discharge Condition:
Mental Status:Clear and coherent but profoundly jaundiced
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires walker or cane
Discharge Instructions:
You were admitted due to difficulty obtaining dialysis access
and you have had a tunneled hemodialysis line placed in your
right subclavian vein. It is important for you to monitor the
line site for any signs of bleeding, inflammation, redness or
increasing pain. You have received hemodialysis here and you
should return to your dialysis home site on Saturday at 6am.
It is essential for you to avoid all alcohol in order to prevent
further liver injury.
.
Please note the following changes to your medications:
1. Stop the Trental (pentoxifylline)
2. Stop the Sevelamer until otherwise instructed at HD
.
Followup Instructions:
Please keep your follow up appointments as listed below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2168-11-28**]
10:00
Please call Dr. [**Last Name (STitle) 50167**] at [**Telephone/Fax (1) 83764**] to schedule a follow up
appointment in the new year.
|
[
"493.90",
"286.9",
"041.12",
"303.91",
"571.2",
"585.6",
"276.2",
"530.81",
"584.9",
"E879.1",
"567.23",
"790.7",
"996.73",
"403.91",
"571.1",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8610, 8681
|
5645, 7556
|
419, 475
|
8850, 8850
|
5029, 5622
|
9666, 10005
|
3933, 4125
|
8172, 8587
|
8702, 8829
|
7582, 7582
|
9032, 9518
|
4140, 5010
|
8027, 8149
|
9547, 9643
|
275, 381
|
503, 2622
|
8864, 9008
|
7607, 8009
|
2644, 3574
|
3590, 3917
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,396
| 154,455
|
16831
|
Discharge summary
|
report
|
Admission Date: [**2183-12-29**] Discharge Date: [**2184-1-8**]
Date of Birth: [**2107-6-15**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient presented with six
to seven week history of increased gait disturbance, leg
weakness and numbness on the soles of the feet.
PHYSICAL EXAMINATION: Initial physical examination showed
alert and oriented times three. Speech clear. Cranial
nerves intact. Mild weakness to lower extremities with a
slowed gait. There was also decreased vibration sense to the
lower spine, decreased position sense to the knees and
decreased sharp and temperature sensation to about the level
of T10. The patient also had decreased anal tone. Ankle
reflexes were absent. Findings are consistent with an upper
spinal cord lesion. MRI revealed compression of the cord and
around T10 by an epidural mass involving the vertebral body
and paraspinal tissue.
PAST MEDICAL HISTORY: Melanoma with resection of the left
temple in [**2183-11-4**], multiple squamous cell CA, basal
cell CA, thyroidectomy twenty years ago for a benign tumor
and vitamin B-12 deficiency.
HOSPITAL COURSE: On the [**11-30**] the patient was
taken to the Operating Room for decompression of a thoracic
lesion, which was biopsied and later found to be metastatic
thyroid cancer. On the 30th he began experiencing decreased
movement of bilateral lower extremities. Solu-Medrol
protocol initiated and was taken back to the Operating Room
for evacuation of an epidural hematoma and a thoracic
laminectomy. His strength in the lower extremities has
slowly improved since then with the right being slightly
stronger then the left. On the [**11-5**] he began
experiencing some bradycardia. Cardiology was consulted and
it was believed to be due to autonomic instability related to
cord compression. Symptoms resolved slowly on their own.
MEDICATIONS: Heparin 5000 units subQ q 12, Dexamethasone 2
mg po q 8, Pantoprazole 40 mg po q 24, Oxycodone,
acetaminophen one to two tablets po q 4 to 6 prn and Tylenol
325 to 650 po q 4 to 6 prn.
DISCHARGE STATUS: The patient is to be discharged to rehab.
FOLLOW UP INSTRUCTIONS: Arrangements will be made for follow
up with an oncologist and a radiation oncology on [**Location (un) **].
The patient needs to return for a follow up visit with Dr.
[**Last Name (STitle) 1327**] around [**1-17**] for staple removal.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2184-1-8**] 10:59
T: [**2184-1-8**] 12:53
JOB#: [**Job Number 47471**]
|
[
"198.5",
"V10.83",
"336.3",
"344.1",
"198.3",
"998.12",
"997.09",
"V10.82",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4",
"93.59",
"03.02",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
1139, 2658
|
320, 913
|
160, 297
|
936, 1121
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,755
| 127,216
|
28573+57599
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-9-11**] Discharge Date: [**2116-9-30**]
Date of Birth: [**2073-2-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
anoxic encephalopathy, aspiration pneumonia
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
The pt. is a 43 year-old right-handed woman with a history
of alcoholism, pancreatitis, and diabetes who was brought by her
boyfriend to an outside hospital on [**2116-9-9**], unresponsive.
Boyfriend said that pt was in her usual state of health until
2:30 in the afternoon on the day of admission. At that time she
went to take a nap. Two hours later at 4:30 boyfriend noticed
that pt was foaming at the mouth (green fluid)and was
unresponsive. He did not notice any abnormal movements.
Boyfriend positioned pt on her stomach at that time. Two hours
later at 6:30, boyfriend noticed that pt was aspirating fluid
and brought her to the ED of OSH. Pt had not complained of
headache or fever prior to her nap. Boyfriend noticed pt had 2
fentanyl patches on and removed one. According to pt's family,
boyfriend is not a good historian and was probably intoxicated
himself. Family suspects that pt was probably abusing both
alcohol and Klonopin on day of admission.
At OSH, pt was unresponsive and work-up revealed urine tox
positive for opiates and hypoglycemia but Narcan and glucose did
not change pt's mental status. Alcohol level was 1.0 .Ammonia
level
was 71. Temperature was 102 on admission and decreased after
levofloxacin was started. CK was initially 3495 (index 0.9) and
decreased to [**2131**]. No growth from 2 blood cultures. No acute
bleeds or masses on head CT, normal EEG. LP was negative for
organisms (glucose 45, protein 13, color clear, 0 wbc, 0 rbcs).
U/A showed 2-5 wbcs, 0-2 rbcs, nitrate pos, spec [**Last Name (un) **] 1.020, ket
> 80, mod bilirubin, no blood.
Neuro consult at OSH found increased tone (l>r), hyperreflexia,
pinpoint pupils, gaze deviation to the right. Neurologist was
concerned about brainstem stroke/bleed. She ordered a MRI/MRA
but their scanner could not safely handle an obtunded pt so pt
was transferred, intubated, to [**Hospital1 18**].
Patient was unresponsive and not following commands on admission
to [**Hospital1 18**]. Further neurologic workup was done, and clinical
picture and EEG were thought to be most suggestive of
hypoxic-ischemic encephalopathy due respiratory depression from
the fentanyl/opiate/alcohol overdose with which she presented to
OSH. The patient was unresponsive for three days in the [**Hospital1 18**]
MICU but woke on [**9-15**] and was able to follow commands. She was
extubated at 5:00pm on [**9-16**] and has done well: is more alert,
follows commands, speaks a few words, and smiles and makes eye
contact.
Past Medical History:
1. Pancreatitis - hospitalized in [**Month (only) 205**] for kidney, liver and
pancreas problems (left AMA).
2. Alcoholism
3. Diabetes (on insulin)
4. Anxiety/agoraphobia
5. Chronic back pain
Social History:
Long history of EtOH abuse. Her three children were
raised by husband. Narcotic abuse, Klonopin abuse. Smokes 2 ppd.
Unemployed on disability. Lives with brother and boyfriend.
Ex-husband had hep C.
Family History:
Pt was adopted. Hx of "kidney disease" in birth family.
Physical Exam:
Vitals: T 98.1, P 69, RR 18, BP 106/76, 97% on RA
General: Slender woman, unresponsive to verbal stimuli, eyes
open.
HEENT: NC/AT, slight scleral icterus noted, clear secretions
foaming from mouth, NG tube in place. Telangectasias noted
bilaterally on cheeks.
Pulmonary: Lungs CTA except for transmitted upper airway sounds
Cardiac: nl S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Fecal bag intact and draining.
GU: Normal external genitalia, foley in place and draining.
Extremities: No C/C/E bilaterally
Skin: healed abrasion on right knee and left hip; scratches on
hands and wrists.
Neurologic:
-mental status: Moderately responsive to verbal stimuli. Can
grasp your fingers with her hand, lift legs when asked, moves
head from one side to the other in response to voice calling her
name. Mutters unintelligibly at times but verbally
unresponsive.
-cranial nerves: PERRL 4 to 2mm and brisk. Unable to track.
+VOR. Corneal reflexes present bilaterally. Face symmetric.
-motor: Normal bulk. Tone increased throughout (LE>UE). Pt
moves
all extremities slowly flexing and extending feet at ankles and
flexing and extending legs at knees. Legs are rigid most of the
time during these movements.
-Plantar response: flexor bilaterally.
Pertinent Results:
CBC:
[**9-17**]: WBC 4.3 (60.6N, 29.7 L, 6.6 monos, 2.8 eos, 0.3 basos),
Hgb 9.9, Hct 28.3, MCV 106, Plt 161
[**9-16**]: WBC 4.7, Hgb 9.7, Hct 27.2, MCV 105, Plt 144
[**9-15**]: WBC 4.5, Hgb 9.9, Hct 27.4, MCV 105, Plt 122
[**9-14**]: WBC 6.2, Hgb 9.9, Hct 27.5, MCV 105, Plt 103
[**9-13**]: WBC 6.2, Hgb 10.3, Hct 29.4, MCV 105, Plt 113
[**9-12**]: WBC 3.7, Hgb 9.0, Hct 26.7, MCV 107, Plt 84
[**9-11**]: WBC 4.2, Hgb 10.1, Hct 28.5, MCV 105, Plt 72
Coagulation Studies:
[**9-16**]: PT 18.5, PTT 33.6, INR 1.7
[**9-15**]: PT 19.3, PTT 34.4, INR 1.8
[**9-12**]: PT 18.6, PTT 33.2, INR 1.8, fibrinogen 187, Ddimer 1379
[**9-11**]: PT 15.8, PTT 29.7, INR 1.4
Chemistries:
[**9-17**]: Na 140, K 3.4, Cl 110, HCO3 25, BUN 7, Cr 0.4, Glu 131*,
Ca 7.8* Ph 3.2 Mg 1.9
[**9-16**]: Na 141, K 3.5, Cl 109, HCO3 25, BUN 6, Cr 0.4, Glu 135,
Ca 7.7* Ph 2.7 Mg 1.7
(see OMR for more results. Generally, K has trended in the low
3's, Mg from 1.7-1.9, Phos 2.7-3.2, Ca 7.7-8.0).
Liver enzymes:
[**9-17**]: ALT 44* AST 57* AP 94 Total bili 1.8*
[**9-15**]: ALT 45, AST 49, Alk Phos 109, Total bili 1.6
[**9-12**]: ALT 75, AST 164, AP 105, Total bili 1.8
[**9-11**]: ALT 91, AST 235, AP 127, Total Bili 3.0
Iron/B12/Folate studies
[**9-11**]: calTIBC 130*, VitB12 1433*, Folate 13.7, Ferritin 309*,
TRF 100*
Urine tox:
[**9-11**]: negative for benzos, barbiturates, opiates, cocaine,
amphetamines, methadone
EKG: sinus rhythm with PACs, nl axis, poor R-waves, no ischemic
changes
Micro:
[**9-17**]: C. diff stool culture pending
[**9-13**]: Sputum culture: Gram positive cocci in chains and clusters
shown on gram stain from ET tube; culture of respiratory
secretions showed sparse growth of oropharyngeal flora.
[**9-13**]: Urine culture: no growth. Blood cx pending
[**9-12**]: Stool culture negative for salmonella, shigella, campy, c.
diff
[**9-12**]: Sputum culture: Gram positive cocci in chains and clusters
and gram positive rods shown on gram stain from ET tube; culture
of respiratory secretions showed moderate growth of
oropharyngeal flora.
[**9-11**]: Urine cultures negative.
[**9-11**]: Blood cultures: no growth.
Radiologic Data:
[**9-15**]:
CXR: The heart size and mediastinal contours are unremarkable.
The lungs are clear. The pleural surfaces are smooth with no
pleural effusion.
[**9-13**]:
CXR: Accounting for the shallow level of inspiration which
creates more crowded appearance to the lung markings, there is
no definite evidence for new infiltrate.
EEG: This is an abnormal EEG due to the persistent background
slowing. This is consitent with an encephalopathy, which may be
seen
with ischemia, infections, and toxic metabolic abnormalities.
[**9-12**]:
CXR: There is no evidence of new consolidation and the heart,
mediastinum and pulmonary vascular markings are normal.
MRI of head: Subtle area of signal abnormality within the pons
could be due to an incidental capillary telangiectasia. No
acute infarcts are seen.
[**9-11**]:
CXR: Heart size top normal. Lungs clear. No pleural
abnormality or evidence of central adenopathy. Nasogastric tube
ends in the stomach.
ECG: Sinus rhythm. Frequent atrial ectopy. Poor R wave
progression - consider old anteroseptal myocardial infarction.
Brief Hospital Course:
AA/P: 43 yo female with history of alcoholism, anxiety found
down [**1-9**] to ETOH and fentanyl patch overdose who was intubated
and sucessfully extubated and now has a anoxic brain injury
improving daily.
# AMS: Neurologic symptoms and EEG consistent with
encephalopathy, likely due to anoxic brain injury secondary to
Fentanyl/opiate overdose at initial presentation. Neurology has
investigated several alternative explanations, including NMS and
seratonin syndrome, but no clear history of insulting meds. MRI
of the brain not suggestive of infarct. EEG did not support
status. Pt able to follow commands and make noises, improving
daily and no longer neglecting her right side. Pt is an
excellent canidate for rehab. Needs intensive daily rehab.
#UTI/yeast infection: pt c/o burning with urination and vaginal
irritation, exam by attending over weekend showed erythema and
d/c c/w yeast infection. UA was sent which is postive for
infection. Pt started on miconazole and cipro. Cx grew MRSA
sensitive to macrodantin and abx was changed, repeat UA sent.
Finish [**10-5**].
#Anxiety: Pt has h/o anxiety and asked to start back on klonopin
for anxiety. Pt restarted on klonopin at half dose from home
meds with good response, pt was seen by social work for someone
to talk to which per pt, helped her. Will need continued social
work services at rehab.
# Aspiration Pneumonia - Extubated [**2116-9-15**], on levoflox since
OSH [**9-9**] ([**Hospital1 **] [**9-11**]), flagyl started on [**9-13**]; completed a 10 day
course; however, CXRs remain unremarkable and sputum, while GS
positive for GNRs, has grown only oral flora.
.
# Coagulopathy - INR has ranged from 1.4 to 1.8, and cause has
been hypothesized to be secondary to EtOH liver disease and poor
nutrition. No signs of bleeding and HCT remained stable.
#Elevated blood sugar: No h/o of DM or steroids, given that pt
was not taking in regular PO intake, we did not start
hypoglycemic medications. HAIC was 4.9. Will need to be follow
by her PCP or the rehab attending once she is eating regularly.
#Liver disease: Transaminitis and mild thrombocytopenia most
likely related to ETOH use, stable at this time.
.
# Macrocytic Anemia - pt HCT holding stable in high 20's
throughout course, continue B12/Thiamine/Folate, and follow
daily HCT.
.
# Alchoholism: patient with known long history of alchoholism.
Unclear of amount/duration. EtOH positive at OSH. Ativan was
given PRN. Pt also started thiamine, folate and MVI. Will need
outpt counseling on alcohol abuse/cesation.
# Elevated CK: initial elevation likely due to trauma or
increased tone; downward trend made this issue inactive.
.
# Chronic back pain: Once pt able to communicate, she started to
c/o imtermitten back pain, relieved with tylenol or motrin.
.
# FEN:
-S&S study was repeated and pt able to tolerate thin/pureed
foods with ensure for supplementation.
# Code: Full.
# Contact: Next of [**Doctor First Name **] is daughter x2 and son x 1, brother [**Name (NI) **].
Phone: [**Telephone/Fax (1) 69186**] or [**Telephone/Fax (1) 69187**].
Medications on Admission:
Meds on admission to OSH [**9-9**]:
Klonopin 4mg dial
Folate: 1mg PO daily
Thiamine: 100mg PO daily
Protonix: 40mg PO daily
Duragesic patch: 150mcg Q72
Insulin
Medications on admission to [**Hospital1 18**] [**9-11**]:
Ciprofloxacin HCl 500 mg PO Q12H
Folic Acid 1 mg PO DAILY
Potassium Phosphate 15 mmol / 500 ml NS IV ONCE
Potassium Chloride 20 mEq / 250 ml NS IV ONCE
Lactulose 30 ml PO TID Titrate to 3 BM per day
Lansoprazole Oral Suspension 30 mg NG DAILY
Lorazepam 2 mg IV Q4H:PRN CIWA>10
Thiamine HCl 100 mg PO DAILY
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) dose PO BID (2 times a day).
5. Miconazole Nitrate 200 mg Suppository Sig: One (1) Appl
Vaginal HS (at bedtime) for 3 days.
6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 3 days.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for anxiety.
9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for insomnia, anxiety.
10. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) for 5 days.
11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until ambulating regularly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary: anoxic brain injury
Secondary: alcohol abuse, aspiration pneumonia, back pain,
urinary tract infection
Discharge Condition:
stable
Discharge Instructions:
You are being discharged to a rehab facility where they will be
able to work with you on speech and strength.
You also have a urinary tract infection for which you need to
take antibiotics.
Take you vitamins as directed. You need to stop drinking and
there are ways to get help through your local AA or in drug
treatment programs.
Followup Instructions:
You will be seen by doctors at the rehab center.
You can also follow up with Dr. [**Last Name (STitle) 12982**] at [**Telephone/Fax (1) 69188**] as
needed.
Name: [**Known lastname **],[**Known firstname **] J Unit No: [**Numeric Identifier 11807**]
Admission Date: [**2116-9-11**] Discharge Date: [**2116-9-30**]
Date of Birth: [**2073-2-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 653**]
Addendum:
Pt seen and examined with house officer. Agree with plan above.
See my note in the paper chart as well.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**]
Completed by:[**2116-9-30**]
|
[
"728.88",
"287.5",
"250.80",
"303.01",
"996.64",
"348.1",
"572.2",
"281.9",
"507.0",
"599.0",
"E850.2",
"112.1",
"965.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14030, 14258
|
7943, 11019
|
316, 335
|
13014, 13023
|
4709, 7920
|
13402, 14007
|
3318, 3377
|
11595, 12763
|
12879, 12993
|
11045, 11572
|
13047, 13379
|
4322, 4690
|
3392, 4051
|
233, 278
|
363, 2870
|
4066, 4305
|
2892, 3085
|
3101, 3302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,016
| 106,607
|
11091
|
Discharge summary
|
report
|
Admission Date: [**2179-4-15**] Discharge Date: [**2179-5-15**]
Date of Birth: [**2103-10-19**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 75-year-old male who
was transferred from [**Hospital6 2561**] to [**Hospital1 346**] on [**2179-4-15**] for evaluation of a
basilar artery aneurysm.
The patient has a significant history of coronary artery
disease, status post coronary artery bypass graft, mitral
valve regurgitation, hypertension, peripheral vascular
disease, and stroke, as well as a history of rectal cancer
(status post resection and colostomy).
The patient was at his Winter home in [**State 108**] when he
experienced two weeks of worsening shortness of breath,
orthopnea, and chest pain. Because his family lives in
[**Hospital1 3494**], [**State 350**] the patient requested transfer to
[**Hospital6 2561**] for mitral valve surgery.
As part of his presurgical evaluation, the patient underwent
a head computed tomography which was worrisome for fusiform
basilar artery aneurysm which was confirmed by magnetic
resonance angiography to be 1.3 cm X 2.1 cm in diameter
aneurysm.
The patient was subsequently transferred to [**Hospital1 346**] for definitive treatment prior to
mitral valve replacement.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft and mitral valve disease.
2. Hypertension.
3. Hypothyroidism.
4. Gout.
5. Peripheral vascular disease.
6. Rectal cancer; status post colostomy.
7. History of burns as a child; he has had bilateral upper
extremity with skin grafting.
MEDICATIONS ON ADMISSION: Home medications included Zocor,
Elavil, Synthroid, Lasix, potassium chloride, Colace,
lactulose, amiodarone, Protonix, allopurinol, and captopril.
ALLERGIES: ASPIRIN (which produces a rash).
SOCIAL HISTORY: He lives in [**Hospital1 3494**] with his wife.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission revealed the patient was afebrile with stable vital
signs. General examination revealed an elderly male in no
apparent distress. Head and neck examination demonstrated
normocephalic and atraumatic. The neck was supple with
proptotic eyes. Cardiovascular examination demonstrated a
regular rate with a systolic murmur. The lung examination
demonstrated good air movement with bibasilar crackles.
Abdominal examination was soft, nontender, and nondistended
with a functional colostomy noted in the left lower quadrant.
Extremity examination demonstrated 2 to 3+ edema; right
greater than left. Pulses were palpable throughout. Old
burn injuries were noted in both bilateral upper extremities.
The patient was noted to be missing the fifth digit on his
right hand and had a .................... left hand.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 1444**] on [**2179-4-15**] under the
Neurosurgery Service directed by Dr. [**Last Name (STitle) 1132**].
Shortly following angiography to fully study the extent of
his basilar artery aneurysm on hospital day two, the patient
experienced an episode of acute respiratory distress
requiring emergency reintubation and was subsequently
transferred to the Coronary Care Unit on [**2179-4-17**].
In the Intensive Care Unit, the patient's pulmonary status
was responsive to aggressive diuresis. The patient was
successfully extubated on [**2179-4-18**] and continued to
demonstrate improving failure signs with aggressive diuresis.
With continued with improvement in his respiratory status,
the patient was able to be transferred back to the regular
floor on [**4-19**] where he remained until the day of his
surgery.
An Infectious Disease consultation was obtained given reports
of a positive catheter tip culture at [**Hospital6 2561**]
which reportedly demonstrated Pseudomonas and Escherichia
coli, as well as a reported recent history of Clostridium
difficile colitis. Although no evidence of bacteremia was
noted at that time, the patient was prophylactically begun on
perioperative Flagyl for Clostridium difficile prophylaxis
beginning on [**2179-4-19**].
A cardiac catheterization conducted on [**2179-4-22**]
demonstrated elevated left-sided and right-sided filling
pressures and preserved cardiac output. In addition,
moderate pulmonary hypertension with large V waves and
pulmonary capillary wedge pressure tracing was noted. 40% to
50% serial stenoses in the proximal and medial portions of
the left anterior descending artery were noted. Nonselective
renal angiography demonstrated only mild bilateral stenosis
(less than 40%).
Following stabilization of the patient's respiratory status,
extensive conversations were held with the patient and his
family with regard to the risks of additional cardiac surgery
given his fusiform basilar artery aneurysm. Following
extensive discussions surrounding the risks of potential
stroke during the course of his procedure, the patient and
his family agreed to mitral valve replacement on [**4-26**],
and the patient was subsequently scheduled for a mitral valve
replacement on [**2179-4-27**].
On [**4-27**], the patient underwent a right thoracotomy with
mitral valve replacement with a 31 Mosaic porcine valve. The
patient tolerated the procedure well with a bypass time of
100 minutes. The patient's pericardium was reapproximated.
Lines placed included a right radial arterial line, a right
internal jugular with a Swan-Ganz catheter. Two atrial wires
were placed and two right pleural tubes were additionally
placed during the course of the procedure. On transfer to
the Recovery Room, the patient's mean arterial pressure was
60. His central venous pressure was 12. His PAD was 28, and
his [**Doctor First Name 1052**] was 36. The patient was noted to be a normal sinus
rhythm at a rate of 80. Drips on transfer included Milrinone
and Levophed.
The patient was initially weaned and extubated shortly
following his procedure; however, he required reintubation
for respiratory distress and atrial fibrillation on
postoperative day one. A follow-up chest x-ray demonstrated
evidence of volume overload with questionable acute
respiratory distress syndrome.
An Infectious Disease consultation obtained at that time
recommended starting the patient on empiric Zosyn coverage in
addition to his standing Flagyl dosage. Further consultation
with Pulmonary Medicine resulted in continued aggressive
diuresis of the patient with good effect. Further evaluation
of the patient's chest film demonstrated the presence of
bilateral pleural effusions with increasing evidence of
underlying newly diagnosed pulmonary fibrosis. Intermittent
temperature spikes resulted in the addition of vancomycin to
the patient's antibiotic regimen with continued aggressive
respiratory care.
A screening transesophageal echocardiogram obtained on [**5-5**] demonstrated no evidence of endocarditis as a potential
source of the patient's elevated temperature.
The patient demonstrated gradual improvement in his
respiratory status with aggressive diuresis and continued
antibiotic therapy through [**5-6**], at which point he was
successfully extubated while in the Cardiothoracic Surgery
Recovery Unit.
Following extubation, an oropharyngeal speech and swallowing
study was obtained which cleared the patient for oral intake
on [**5-6**].
The patient continued to demonstrate an improving clinical
examination and diminishing signs of respiratory distress
through postoperative day 13 ([**5-10**]), at which point he
was transferred to the floor and admitted to the
Cardiothoracic Service under the direction of Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **].
Extensive review by Physical Therapy recommended the patient
for rehabilitation placement following discharge.
On the floor, the patient continued to demonstrate a
gradually improving clinical examination with continued
aggressive diuresis. A follow-up chest computed tomography
demonstrated no evidence of a pulmonary infectious process;
however, it did demonstrate evidence of progressive pulmonary
fibrosis; right greater than left.
On postoperative day 17 ([**2179-5-14**]), the patient was being
planned for transfer to rehabilitation when he demonstrated
an episode of tachypnea with associated diaphoresis. An
electrocardiogram and chest x-ray at this time demonstrated
no evidence of acute myocardial event or flash pulmonary
edema. At this time, the emergence of a left facial tick was
also noted, and a Neurology consultation was obtained.
On further review, the patient described a history of
intermittent left facial ticks; however, a head computed
tomography was obtained at this time under the advice of the
Neurology Service which demonstrated no evidence of acute
cerebrovascular injury. The patient was noted to demonstrate
increasing respiratory status once again with aggressive
diuresis and was subsequently cleared for discharge to a
rehabilitation facility on [**2179-5-15**].
DISCHARGE DISPOSITION: The patient was to be discharged to a
rehabilitation facility for further care and management with
instructions for followup.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Levothyroxine sodium 25 mcg p.o. once per day.
2. Docusate sodium 100 mg p.o. twice per day.
3. Plavix 75 mg p.o. once per day.
4. Ranitidine 150 mg p.o. twice per day.
5. Amitriptyline 10 mg p.o. q.h.s.
6. Flagyl 500 mg p.o. three times per day (times seven
days).
7. Percocet 5/325 one to two tablets p.o. q.4h. as needed
(for pain).
8. Vancomycin 1 g intravenously q.24h. (times seven days).
9. Potassium chloride 20 mEq p.o. twice per day.
10. Lasix 80 mg p.o. twice per day.
11. Captopril 18.75 mg p.o. three times per day.
12. Lopressor 12.5 mg p.o. twice per day.
13. Procainamide 500 mg p.o. twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to maintain his incisions clean and dry
at all times.
2. The patient may shower but should pat dry his incisions
afterwards. No bathing or swimming until further notice.
3. The patient was to complete an entire prescribed course
of vancomycin and Flagyl.
4. The patient may resume a regular diet.
5. The patient was to limit physical activity; no heavy
exertion.
6. No driving while taking prescription pain medications.
7. The patient was to follow up with his primary care
provider within one to two weeks following discharge.
8. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] from
Neurosurgery within one to two weeks following discharge for
further neurosurgical evaluation.
9. The patient was to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
within four weeks following discharge for re-evaluation.
10. The patient was to call to schedule all follow-up
appointments.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2179-5-15**] 04:24
T: [**2179-5-15**] 04:49
JOB#: [**Job Number 35806**]
|
[
"515",
"518.5",
"424.0",
"437.3",
"427.31",
"511.9",
"507.0",
"996.62",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.57",
"88.42",
"96.6",
"39.64",
"88.56",
"88.41",
"96.04",
"88.72",
"39.61",
"38.93",
"37.23",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
8996, 9133
|
9211, 9851
|
1637, 1832
|
2792, 8972
|
9885, 11139
|
9148, 9184
|
185, 1278
|
1300, 1610
|
1849, 2773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,950
| 179,616
|
48069
|
Discharge summary
|
report
|
Admission Date: [**2172-12-5**] Discharge Date: [**2172-12-18**]
Date of Birth: [**2090-8-9**] Sex: F
Service: SURGERY
Allergies:
Cephalexin Hcl
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
abdominal pain, SBO
Major Surgical or Invasive Procedure:
[**2172-12-6**]
1. Exploratory laparotomy.
2. Small-bowel resection.
3. Ileocolic anastomosis.
4. Abdominal washout.
5. Closure abdominal wall defect.
6. post op ileus
History of Present Illness:
82-year-old female who underwent laparoscopic robot assisted
TAHBSO, LOA for endometrial cancer and reduction of hernia on
[**2172-11-17**]. She was seen by the Acute Care service afterwards
for a small bowel obstruction which resolved with conservative
management. She has had a RLQ ventral hernia for the past nine
years since her right hip replacement. This was reduced during
her surgery but became reincarcerated post-operatively and was
thought to be the likely source of her obstruction. She was
ultimately discharged to home on [**2172-11-27**]. She returned to the
[**Hospital1 18**] ED after presenting to an OSH with an acute abdomen.
Past Medical History:
Past Medical History: asthma, HTN, chronic sinusitis, LE
edema/cellulitis, laparoscopic robot assisted TAHBSO, LOA for
endometrial cancer ([**2172-11-17**])
Past Surgical History: right hip replacement ([**2163**]), bladder
neck suspension, open appy, ovarian cystectomy,
cytoscele/rectocele repair, thyroid surgery
Social History:
Denies smoking, alcohol, or drug abuse. She is a 20-pack-year
smoker who quit over 20 years ago.
Family History:
Two sisters had breast cancer. Uterine cancer in her youngest
daughter. [**Name (NI) **] history of ovarian or colon cancer.
Physical Exam:
In the ED:
98.7 99 122/50 18 97RA
GEN: A&O, NAD, NGT in place
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: large R sided ventral hernia, minimally tender to
palpation,
feels firm and indurated, rest of abdomen is soft, minimally
distended, no rebound or guarding
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
CT Abd/Pelvis [**2172-12-5**] :
1. New/increased fluid in the right lower quadrant hernia sac
with ill-defined small bowel loops and mesenteric edema within
the sac, as well as increased intermesenteric fluid in the
peritoneal cavity, raises concern for bowel ischemia.
Extraluminal gas in the hernia sac, while seen previously, it is
now more remote from patient's surgery, and perforation can not
be excluded.
2. Relative caliber change of small bowel at the hernia neck,
but only mildy dilated proximal bowel loops, may be due to
early/partial obstruction.
3. Increased/new pelvic fluid which appears to be organizing and
with peritoneal enhancement; while findings may be reactive with
peritonitis, underlying infection is not excluded.
4. Unchanged postsurgical soft tissue densities between the
urethra and the rectum and between the right ischial tuberosity
and the anus.
5. Small right renal hypodensity, too small to further
characterize on this study, but which could be further evaluated
on non-urgent ultrasound.
[**2172-12-5**] 07:40PM WBC-20.6*# RBC-3.79* HGB-11.5* HCT-34.5*
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.9
[**2172-12-5**] 07:40PM NEUTS-56 BANDS-38* LYMPHS-0 MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2172-12-5**] 07:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-1+
[**2172-12-5**] 07:40PM PLT SMR-NORMAL PLT COUNT-290
[**2172-12-5**] 07:40PM PT-15.7* PTT-25.9 INR(PT)-1.4*
[**2172-12-5**] 07:40PM GLUCOSE-129* UREA N-30* CREAT-2.2*#
SODIUM-140 POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-20* ANION
GAP-18
[**2172-12-5**] 07:45PM LACTATE-2.1*
[**2172-12-6**] 12:28 am PERITONEAL FLUID
GRAM STAIN (Final [**2172-12-6**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83986**] @ 5:41A [**2172-12-6**].
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2172-12-10**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2172-12-10**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2172-12-7**]):
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Brief Hospital Course:
Mrs. [**Known lastname 101374**] was evaluated by the Acute Care service in the
Emergency Room as well as the GYN service given her recent
surgery. She had a WBC of 20K and her CT scan demonstrated an
incarcerated hernia with evidence of ischemia on exam. She was
admitted to the ICU for vigorous fluid resuscitation and broad
spectrum antibiotics.
On [**2172-12-6**] she was taken to the Operating Room and underwent an
exploratory laparotomy with repair of a strangulated, perforated
ventral hernia. She tolerated the procedure well and returned
to the ICU in stable condition. She maintained stable
hemodynamics and her pain was well controlled with IV Dilaudid.
She remained intubated overnight and was successfully weaned and
extubated on post op day #1. Due to her extensive surgery her
nasogastric tube remained in for decompression until her bowel
function returned.
Following transfer to the Surgical floor on [**2172-12-9**] she remained
stable but her nasogastric tube was removed. She was taking only
a small amount of liquids over the next few days and she became
more distended and tympanic on exam. She stopped passing flatus
and her KUB showed a dilated large bowel. She was treated with
Methylnaltrexone which was immediately effective. She was
passing flatus and had a normal bowel movement. Her narcotics
were discontinued and her pain was effectively managed with
Tylenol. Her diet was advanced to regular but her appetite was
only fair. Eventually she improved with Carnation Instant
Breakfast supplements along with the addition of Megace.
The Physical Therapy service evaluated her on numerous occasions
and due to her prolonged hospitalization and decreased mobility
a short term rehab was recommended prior to her return home. She
was dischargaed on [**2172-12-18**].
Medications on Admission:
diovan 160', prevacid 30', lasix 20', ibuprofen,
percocet
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO BID (2 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] home
Discharge Diagnosis:
Strangulated, perforated ventral hernia.
.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-18**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
* Your staples will be removed at rehab.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-12**] weeks.
Completed by:[**2172-12-18**]
|
[
"569.83",
"V15.82",
"997.4",
"V14.1",
"473.9",
"552.29",
"518.81",
"995.92",
"493.90",
"567.21",
"557.0",
"274.9",
"530.81",
"560.1",
"401.9",
"V43.64",
"038.9",
"272.4",
"V10.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.15",
"53.59",
"96.71",
"54.59",
"54.25",
"96.07",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
7887, 7935
|
5114, 6920
|
294, 464
|
8023, 8023
|
2159, 4731
|
10042, 10181
|
1616, 1744
|
7029, 7864
|
7956, 8002
|
6946, 7006
|
8206, 9664
|
9680, 10019
|
1347, 1484
|
1759, 2140
|
4764, 5091
|
235, 256
|
492, 1142
|
8038, 8182
|
1187, 1323
|
1500, 1600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,122
| 176,368
|
6463
|
Discharge summary
|
report
|
Admission Date: [**2134-5-2**] Discharge Date: [**2134-5-8**]
Service: MEDICINE
Allergies:
Ciprofloxacin / Ambien
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Left Subclavian line
Left Arterial LIne
History of Present Illness:
82 yr old female w/hx of gout, CAD s/p PCTA of in-stent
restenosis of prox LAD lesion [**2134-4-26**], diastolic dyfunction, AF
s/p successful DCCV [**4-18**] on amidoronone, who has been admitted
twice last month for CHF exac. At [**Hospital 100**] rehab, pt was noted to
be short of breath with increased orthopnea. Initial story was
that pt was given fluid bolus as well as signficant amount of
fluid via heparin bolus, as precipitant for heart failure.
[**Hospital 100**] rehab physician denies this. Transferred to [**Hospital1 18**] for
eval. Also, was being bridged on heparin and coumadin for
recent AF. PTT >200 and INR >10 at [**Hospital 100**] Rehab, so she was
given PO and IV vit K. In the ED, given 2mg IV morphine, lasix
80mg IV X 1, and ntg gtt started. Given her resp distress she
was also started on BiPAP 10/10. Pt's BP dropped from SBP 180's
to 80's. She remained assymptomatic during this episode.
Febrile to 101 on admission. NTG stopped, and BiPAP stopped.
She was taken to the CCU. Of note, she c/o abd pain that lasted
~30 minutes, relieved with defecation. No bloody diarrhea or
persistent belly pain.
Past Medical History:
1. Atrial fibrillation status post DCCV on [**2133-3-18**] and again on
[**2134-3-23**] (still in AF) - chronically on coumadin. Successfully
cardioverted [**4-18**]. Being bridged with hep and coumadin at
[**Hospital 100**] Rehab.
2. Hypercholesterolemia/HTN
3. UTI: Klebsiella in past (pansensitive)
4. Diastolic congestive heart failure. Hemodynamic evaluation
revealed moderately to severely elevated right-sided pressures
(mean RA was 17 and RVEDP was 22 mmHg), severely elevated
left-sided pressures (mean PCW was 29 and LVEDP was 31), and
severely elevated pulmonary pressures (PA was 67/33 mmHg).
There were prominent V waves on the PA tracing up to 50 mmHg,
2+MR.
5. CAD: s/p PCI of the proximal LAD on [**2130-2-23**], then had
NSTEMI and in-stent restenosis treated with PTCA [**2134-4-26**] and PTCA
of mid-LAD 70% lesion
6. Gout.
7. Obesity.
8. Obstructive sleep apnea on CPAP (setting of 12).
9. Status post cholecystectomy.
10. History of spinal stenosis
Social History:
Very functional, lives alone. She is able to shop, drive, all
ADLS. She does not smoke or drink. Her daughter is her health
care proxy. She has three children.
Family History:
n/c
Physical Exam:
Gen: NAD, obvious distress
HEENT: MMM, no dentures, 11cm JVP
CV: RRR, no m/r/g though distant HS
Lungs: L>R crackles up 1/2 bilaterally
Abd: + BS, soft, Nt, ND obese. No peritoneal signs. Skin shows
mild breakdown and erythema.
Ext: 1+ pedal edema to knees. Preserved peripheral pulses.
Neuro: A&Ox3. non-focal
Pertinent Results:
Admission labs:
[**2134-5-4**] 04:19AM BLOOD WBC-9.4 RBC-3.79* Hgb-10.5* Hct-31.3*
MCV-83 MCH-27.8 MCHC-33.6 RDW-15.7* Plt Ct-279
[**2134-5-4**] 04:19AM BLOOD Neuts-63.9 Lymphs-27.7 Monos-4.2 Eos-3.2
Baso-1.0
[**2134-5-4**] 04:19AM BLOOD Hypochr-1+ Poiklo-1+ Microcy-1+
[**2134-5-3**] 04:31AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+
Stipple-OCCASIONAL
[**2134-5-4**] 04:19AM BLOOD Plt Ct-279
[**2134-5-4**] 04:19AM BLOOD PT-14.6* PTT-99.2* INR(PT)-1.4
[**2134-5-4**] 04:19AM BLOOD Glucose-97 UreaN-45* Creat-1.4* Na-140
K-4.5 Cl-102 HCO3-28 AnGap-15
[**2134-5-3**] 04:31AM BLOOD CK(CPK)-28
[**2134-5-2**] 11:53PM BLOOD CK(CPK)-38
[**2134-5-2**] 01:30PM BLOOD CK(CPK)-40
[**2134-5-2**] 11:53PM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2134-5-2**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2134-5-4**] 04:19AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.8*
[**2134-5-3**] 04:31AM BLOOD Albumin-2.9* Calcium-7.6* Phos-3.6 Mg-1.7
[**2134-5-2**] 08:29PM BLOOD calTIBC-308 Ferritn-541* TRF-237
[**2134-5-3**] 08:16AM BLOOD Cortsol-60.6*
[**2134-5-3**] 04:31AM BLOOD Cortsol-30.8*
[**2134-5-2**] 02:52PM BLOOD Lactate-3.3*
[**2134-5-2**] 06:49PM BLOOD Lactate-1.3
.
EKG: Sinus rhythm
[**Month (only) 116**] be Normal ECG but baseline artifact makes assessment
difficult
Since previous tracing of [**2134-4-29**], prolonged Q-Tc interval and T
wave changes absent
.
ECHO ([**5-3**]): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is mild to moderate
aortic valve stenosis (area 1.1 and grad 24, mean) . Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic
signs of tamponade.
.
Brief Hospital Course:
82 y/o female with PMH CAD (s/p recent PCI), diastolic
dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit
w/acute decompensated CHF.
.
1. Hypotension/Hypertension: Developed hypotension the ED,
requiring admission to CCU,likely secondary to overaggressive
preload inhibition in setting of moderate AS and increased
atenolol levels in setting of ARF. Pt required inotrop/pressor
support for ~24 hours with dop gtt at 4-5. She was easily
weaned off pressors. No evidence of CNS or cardiac ischemia. No
evidence of distributive shock. Blood cultures neg. Does have
UTI, but not uroseptic. Lactate improved from 3.3 to 1.3.
Antihypertensives were held in the setting of hypotension; they
were continued to be held on transfer to the floor. Within 24
hours of being on the floor, pt developed hypertension to 200s
systolic, during which she developed flash pulmonary edema. See
next issue for details. Pt was started on nitro drip and
restarted on po lopressor w/ improved blood pressure.
Hydralazine was subsequently added and nitro drip was titrated
down. Pt was subsequently restarted on imdur and valsartan;
nitro drip and hydralazine were discontinued. Pt's home
antihypertensive regimen of lopressor, valsartan, and imdur were
titrated for optimal bp control.
.
2. Pump: 82 y/o female with PMH CAD (s/p recent PCI), diastolic
dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit
w/acute decompensated CHF. Possible etiologies include high
output failure in setting of UTI/fever, hypertension in setting
of diastolic dysfunction. Pt was admitted cold and wet in class
IV HF, secondary to recent fluid boluses in the form of heparin
bolus and IVF bolus. She diuresed very well with IV lasix. She
was transiently on dopamine drip in the CCU for blood pressure
support, which helped with diuresis. Pt was hypoxic on admission
and required positive pressure vent with BiPAP for ~24 hours.
She was continued on CPAP at night. On floor day 1, pt developed
flash pulmonary edema in the setting of severe hypertension off
antihypertensives. She was noted to be hypoxic to 70s on 4L,
with increase to mid 90s on 100% NRB. She was started on nitro
gtt, lopressor, and hydralazine for BP control. CXR confirmed
worsened pulmonary edema. She was given lasix for diuresis.
After adequate diuresis and BP control, pt was able to be weaned
down on her oxygen requirement. Pt was restarted on heart
failure regimen of lopressor, valsartan, imdur; nitro gtt was
weaned and hydralazine discontinued. Pt was diuresed with IV
lasix daily for goal 1L daily, with signficant respiratory
improvement. Pt should continue to be diuresed w/ IV lasix for
48 hours for goal negative 500cc daily prior to being switched
to a po lasix regimen.
.
3. CAD: Pt is s/p NTSEMI last month and is s/p PTCA to prox
and mid LAD [**4-26**]. Pt was continued on asa, plavix, and statin.
On admission was noted to have a slight troponin bump likely
from demand ischemia and decompensated heart failue. She was
restarted on bb, [**Last Name (un) **], and imdur, which were titrated.
.
4. Rhythm: S/P sucessful DCCV [**4-18**]. Pt remained in sinus.
Dopamine drip did not cause reversion to AF. Amiodarone was
held initially in the setting of bradycardia, but was restarted.
She recieved oral and IV vit K at [**Hospital 100**] Rehab for INR of 10.
Subsequently had suptherapeutic INR. She was restarted on
heparin gtt and restarted coumadin 5mg daily for goal INR
2.0-3.0. Pt is being discharged on lovenox bridge
.
5. Resp: Initially presented with large Aa gradient,
attributed to pulmonary edema. She was hypoxic on admission,
requiring BiPAP for ~24 hours. With diuresis, she had
decreasing O2 requirements. Supplemental oxygen should continue
to be weaned down, with further diuresis.
.
6. ID: Pt was febrile to 101 in ED. Pt was noted to have UTI
by UA. On day of last discharge she was noted to have >100,000
Staph aureus, which was attributed to contamination and not
treated. Admission urine culture once again grew out >100,000
Staph aureus, found to be MRSA sensitive to vanco, gent,
tetracyclin, and nitrofurantoin. Pt initially received emperic
ceftriaxone and vancomycin. Ceftriaxone was subsequently
discontinued. Pt was continued on vancomycin (renally dosed,
q48h dosing) to complete a 10 day course. Vanco trough levels
should be checked 30 minutes prior to 3rd dose of vanco. She
should get a trough level on [**5-7**]. Pt's blood cultures remained
negative. Repeat UA on the day before discharge is negative,
with a urine culture that is negative to date.
.
7. Renal: Pt has had ARF since [**2134-4-27**], secondary to contrast
nephropathy vs. CHF (poor forward flow). Baseline is 1.0 to 1.3.
She received 240mL contrast at time of cath. Creatinine
improved with dopamine drip and treatment of heart failure.
.
8. Anemia: She has a severe iron deficency anemia without
evidence of acute bleed. Last C-scope 3-4 years ago, by report.
Received 1U PRBC for goal hct >30. Hct remained stable.
.
9. Gout: Stable. Continued on allopurinool
.
10. OSA: CPAP at night at outpt settings. Pt was seen by
pulmonary consult service who stated that pt has secondary
pulmonary hypertension in the setting of left heart failure. Pt
should follow up with Dr. [**Last Name (STitle) **] for outpatient sleep study.
.
11. Cerumen impaction: Pt was noted to have bilateral cerumen
impaction preventing her from inserting her hearing aides. She
was started on [**Hospital1 **] hydrogen peroxide.
Medications on Admission:
Allopurinol 100mg qd
amiodarone 200mg qd
asa 325mg qd
atenolol 50mg qd
plavix 75mg qd
simvastatin 80mg qd
Valsartan 40mg qd
Trazodone prn
warfarin 5mg qhs
lasix 40mg qd
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED): until INR is 2.
7. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q48H (every 48 hours) for 5 days.
8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
15. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
17. Lasix
Please give Lasix 40mg IV qd x 3-4 days for diuresis of goal
negative 500cc daily.
Please restart appropriate po dosing of Lasix in a few days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Shock
Decompensated CHF
UTI
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
If you have these symptoms, call your doctor:
- shortness of breath
- cough
- fevers
- dizziness
- chest pain
- visual changes
- palpitations
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX) [**Hospital Ward Name 1947**] Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2134-5-19**] 9:20
Provider: [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2134-7-1**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2134-5-17**]
10:30
Follow-up with Dr. [**Last Name (STitle) **] on [**6-10**] at 4:15pm located on
[**Hospital Ward Name 23**] floor 7.(call [**Telephone/Fax (1) 612**] to reschedule)
|
[
"584.9",
"428.33",
"478.29",
"398.91",
"427.31",
"458.29",
"780.57",
"414.01",
"041.11",
"V45.82",
"272.0",
"278.00",
"E947.8",
"V58.61",
"V09.0",
"E934.2",
"790.92",
"380.4",
"280.9",
"274.9",
"401.9",
"396.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"93.90",
"96.52",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12458, 12531
|
5172, 10678
|
248, 290
|
12603, 12609
|
3008, 3008
|
12925, 13800
|
2654, 2659
|
10898, 12435
|
12552, 12582
|
10704, 10875
|
12633, 12902
|
2674, 2989
|
189, 210
|
318, 1460
|
3024, 5149
|
1482, 2457
|
2473, 2638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,205
| 179,265
|
1268
|
Discharge summary
|
report
|
Admission Date: [**2174-12-30**] Discharge Date: [**2175-1-6**]
Date of Birth: [**2107-9-15**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old
woman with dilated cardiomyopathy and depressed left
ventricular ejection fraction to less than 25% by last
echocardiogram in [**2172-12-30**], who has resided at a
rehabilitation facility for most of the interval prior since
her discharge from [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] in
[**2174-7-31**] for dehydration and congestive heart failure.
The patient now presents from rehabilitation with a complaint
of one month of an increased size of abdomen, weight gain and
lightheadedness, and orthostatic symptoms. She also reports
some shakiness and tremor for the last few days. On
admission, the patient denied any fever or chills prior to
admission, and denied any chest pain or shortness of breath.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Congestive
heart failure (echocardiogram [**2172-12-30**] revealed mild
aortic stenosis, mild mitral regurgitation, left ventricular
dilatation, left ventricular ejection fraction less than 25%,
diffuse hypokinesis, decreased right ventricular ejection
fraction). 3. Status post cholecystectomy. 4. Coronary
artery disease.
MEDICATIONS ON ADMISSION: Digoxin 0.25 mg p.o.q. Tuesday,
Thursday, Saturday and Sunday and 0.125 mg p.o.q.d. Monday,
Wednesday, Friday, lisinopril 5 mg p.o.b.i.d., and Protonix.
ALLERGIES: Zomax, codeine, sulfa and carvedilol.
FAMILY HISTORY: Family history is significant for congestive
heart failure and coronary artery disease on the patient's
mother's and father's side.
SOCIAL HISTORY: The patient is a widow. She denies smoking
or alcohol abuse.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 99.2, heart rate 70, blood
pressure 123/70 and oxygen saturation 98% in room air.
General: Patient in no acute distress, speech slurred,
patient inattentive with bilateral asterixis and stigmata of
liver disease. Head, eyes, ears, nose and throat: Anicteric
sclerae, moist mucous membranes. Neck: Positive jugular
venous distention, no bruits. Cardiovascular: S1 and S2,
III/VI holosystolic, old. Lungs: Bibasilar crackles.
Abdomen: Distended with ascites, mild right upper quadrant
tenderness. Rectal: Guaiac negative. Extremities: 2+
pitting edema. Neurologic examination: Patient very
inattentive, oriented to month only and place, positive
asterixis but no focal deficit.
HOSPITAL COURSE: The patient had been admitted for weight
gain and shakiness and dizziness. She had been found to have
ascites in the Emergency Room and, since she appeared
encephalopathic, a diagnostic paracentesis was done in the
Emergency Room to rule out spontaneous bacterial peritonitis,
which did not confirm spontaneous bacterial peritonitis.
1. Gastrointestinal: The patient was admitted and found to
have worsening ascites. This had been noted in the past but
her weight gain over the period of three weeks had been about
30 pounds. She also noted enlargement of her abdomen. A CT
scan of the abdomen was performed to rule out venous
thrombosis, which was negative. Her liver appeared cirrhotic
on CT scan, with ascitic fluid, which was increased in the
amount in comparison with previous CT scan of the abdomen
several months ago.
The patient received a prophylactic dose of ciprofloxacin
after admission for spontaneous bacterial peritonitis but,
since she remained without signs of infection, this was
discontinued. She was worked up for etiology of liver
cirrhosis. She denied alcohol use, which would be the most
common cause. She had previously had hepatitis C and B
serologies were negative. These were repeated during this
hospital course and also turned out to be negative.
The patient was seen by the liver service, who recommended
workup for cirrhosis, including her hepatitis serologies,
which were negative. The majority of the tests for her
cirrhosis were still pending at the time of dictation. A
liver biopsy and esophagogastroduodenoscopy were not
indicated at this time. She was started on Aldactone and her
dose of Lasix had been increased to help with the ascites.
The patient had a therapeutic paracentesis with removal of
three liters of fluid, with improvement of her weight. On
[**2175-1-8**], the day of tentative discharge, the patient
developed abdominal discomfort and her weight increased by
several pounds. Clinically, there was worsening of the size
of the ascites and the decision was made to retap her
abdomen.
On Monday, [**2175-1-9**], the patient had a repeat
paracentesis with 3,800 cc of peritoneal fluid was taken off
with subsequent receiving of albumin. She was doing very
well after the tap and had no abdominal discomfort. The
liver service recommended increasing the dose of diuretics,
Aldactone 200 mg daily and Lasix 40 mg daily.
It was felt that the patient will need a repeat paracentesis
in the future and a follow-up appointment was scheduled for
mid-[**Month (only) 404**] by the liver service. In the meantime, her
electrolytes should be checked on a regular basis, at least
once a week.
2. Cardiovascular: The patient has known dilated
cardiomyopathy. She ruled out for a myocardial infarction.
A repeat echocardiogram was performed, which was unchanged
from the previous study. It was felt that her ascites is
mainly related to liver cirrhosis rather than congestive
heart failure.
The patient was diuresis but, on hospital day number four,
after increasing her diuretic doses and after a therapeutic
paracentesis, she became hypotensive and required an
overnight Medical Intensive Care Unit stay. During the
hypotension, she was lethargic and felt lightheaded. It was
felt that the reason for her hypotension is most likely due
to fluid shift, and she responded well to fluid boluses and
did not require any pressors.
Since then, she remained with a low systolic blood pressure
in the range of 70 to 110/palpable to 50. She, however
remained very stable and was not symptomatic. Her diuretic
doses were decreased and the patient had been doing well.
3. Encephalopathy: Initially, the patient was admitted with
encephalopathy, but improved after starting lactulose.
4. Laboratory data: White blood cell count 6.2, hematocrit
33, hemoglobin 10.9, platelet count 119,000, glucose 79,
sodium 133, potassium 4.5, chloride 102, bicarbonate 27, BUN
24, creatinine 0.7, calcium 7.7, phosphorous 3.7, INR 1.3,
alkaline phosphatase 171, amylase 20, lipase 9, ALT 29, AST
50, total bilirubin 0.5 and ammonia 68.
DISCHARGE DIAGNOSES:
Liver cirrhosis of unclear etiology, status post paracentesis
times two.
Dilated cardiomyopathy.
Congestive heart failure.
DISCHARGE MEDICATIONS:
Lasix 40 mg p.o.q.d.
Aldactone 100 mg p.o.q.d.
Trazodone 50 mg p.o.q.d.p.r.n.
Lactulose 30 cc p.o.b.i.d.
Digoxin 0.125 mg p.o.q. Tuesday, Thursday, Saturday and
Sunday and 0.25 mg p.o.q.d. Monday, Wednesday, Friday.
Protonix 40 mg p.o.q.d.
Darvocet N-100 one p.r.n. pain.
DISCHARGE STATUS: The patient will be discharged to a
rehabilitation facility in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 6063**]
MEDQUIST36
D: [**2175-1-12**] 13:04
T: [**2175-1-14**] 12:29
JOB#: [**Job Number 7889**]
|
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icd9cm
|
[
[
[]
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] |
[
"38.91",
"54.91"
] |
icd9pcs
|
[
[
[]
]
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1613, 1746
|
6744, 6868
|
6891, 7542
|
1391, 1596
|
2631, 6723
|
1849, 2486
|
166, 989
|
2511, 2613
|
1012, 1364
|
1763, 1826
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,045
| 132,164
|
7742
|
Discharge summary
|
report
|
Admission Date: [**2126-12-15**] Discharge Date: [**2126-12-25**]
Date of Birth: [**2050-2-11**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
direct admit for CHF management s/p cath
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old gentleman with a history of 3 vessel
CAD s/p redo CABGx3 and multiple stents, systolic and diastolic
CHF, HTN, HLD, CRF with exacerbations following cath who
presented to [**Hospital1 18**] with dyspnea. The patient was admitted last
week on [**12-11**]. At that time he had a cardiac cath where he was
found to have instent restenosis of LM to LCx and ostial LAD.
His LIMA and SVG to OM were patent at that time. At that time
he had balloon angioplasty was performed to the ostial LAD as
well as LM to LCx with cutting balloon. The patient was
discharged without a change in creatinine. Last night at 2am,
the patient experienced chest pain and dyspnea.
.
While at home, he denied having fevers, was compliant with all
his medications (confirmed with the wife). He denied any
excessive fluids. The only recent medication changes doubling of
his metoprolol to 50, doubling of lisinopril to 5, and stoppage
of zantac.
.
In the ED, the patient was hypoxic requiring 100% NRB. He
received 40mg IV lasix and symptoms improved marginally. Crn
was increased to 1.7 from prior at 1.4. He was taken back to
the cath lab on [**12-15**] and found to have 50% recoil in the LCx and
LAD with competitive flow from the LIMA. No intervention was
done. He continued to require 100% NRB, received 100mg IV
lasix. As he continued to require 100% NRB he was sent to the
CCU for monitoring.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
[**7-/2109**]: CABG with SVG-OM2CAD
[**3-11**]: CABG with LIMA-LAD and SVG-?diagonal
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**9-/2109**] PTCA
[**7-/2114**] PTCA of RCA
[**3-13**] BMS to SVG-OM2
[**10-13**] 3 DES to SVG-OM2
[**9-14**]: DES to LMCA and RCA
[**9-15**]: Repeat DES to LMCA into LCx
[**11-16**]: POBA of LAD and LCx
[**2-19**]: PTCA of in-stent restenosis of his left main into the
proximal circumflex stent.
-PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY:
-Chronic Kidney disease stage III
-Carotid stenosis 60-69% right ICA stenosis, 70-79% left ICA
stenosis in [**7-/2125**]
-DMII- last HgA1C 7.7
-Gout
-PVD s/p aortobifemoral bypass
-Depression and Anxiety
Social History:
Retired. Machine operator in [**Last Name (un) 27903**] stethoscope factory.
Married with three children. Stopped smoking 30 years ago.
Smoked 2-3 packs per day. No EtOH. No drugs. He typically is
able to walk short distances in his house. He just recently
started going for daily walks.
Family History:
B: Died of MI at 42, B: had multiple MIs; F, M: died. Whole
mothers side diabetes mellitus
Physical Exam:
On admission: HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple, JVP=12cm
CARDIAC: PMI located in 5th ICS near anterior axillary line. RR,
normal S1, S2. [**2-16**] Holosystolic murmur at LUSB. No thrills,
lifts. No S3 or S4.
LUNGS: crackles heard 2/3 up,
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. R groin site w/o hematoma, TTP. Bilateral
femoral bruits present (chronic). Chronic hyperpigmentation of
ankles bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On discharge:
same as above except:
NECK: JVP=8cm
LUNGS: Crackles heard [**1-13**] of the way up
Pertinent Results:
Admission Labs:LABS
.
139 | 99 | 41
-------------< 314
4.5 | 25 | 1.7
TropT:0.13
.
12.9> 10.4/32.2<352 N:93.2, L 4, M: 2.2, E 0.3
.
PT 13.1, PTT 24.4 INR: 1.1
.
Admission EKG: Sinus rythm at 92, RBBB, Left axis deviation
.
[**2126-12-16**] ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. There is
severe global left ventricular hypokinesis (LVEF = 25-30 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
inferolateral and inferior walls are thinned and akinetic. The
function of the anterior wall and lateral wall is relatively
preserved. Right ventricular chamber size is normal. with mild
global free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2126-11-4**],
the degree of mitral regurgitation has increased and the degree
of aortic regurgitation has decreased. Estimated pulmonary
artery systolic pressures are higher on the current study.
.
[**12-17**] CXR : As compared to the previous radiograph, there is
minimal improvement with improved ventilation of the lung bases.
The overall extent of the pre-described bilateral and
predominantly mid and lower lung
parenchymal opacities, however, are unchanged. The opacities are
likely to
represent a combination of infection and pulmonary edema, as
emphasized in the previous written report. Moderate
cardiomegaly, presence of a small left pleural effusion cannot
be excluded. No evidence of pneumothorax.
.
===================HISTORICAL DATA===================
[**11-4**] Echo:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate to
severe global left ventricular hypokinesis (LVEF = 25 %). No
masses or thrombi are seen in the left ventricle. Right
ventricular cavity size is normal with borderline normal free
wall motion. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-12**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-12**]+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
IMPRESSION: Left ventricular cavity enlargement with marked
global hypokinesis. Mild-moderate mitral regurgitation.
Mild-moderate aortic regurgitation.
Compared with the prior study (images reviewed) of [**2126-3-12**], the
severity of aortic regurgitation is increased (may be related to
much higher systemic blood pressure). The estimated pulmonary
artery systolic pressure is now lower. Bieventricular sizes and
systolic function are similar.
.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2123**] 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.
.
CARDIAC CATH: [**12-15**]: 1. Two vessel coronary artery disease,
minimally changed from prior catheterization. 2. Normal systemic
blood pressure. 3. Patent SVG-OM 4. Patent LIMA by competative
flow in LAD. 5. Successful RRA TR band. 6. Clinical signs of
heart failure with hypoxia, admit to CCU for CHF managment.
.
Discharge Labs:
[**2126-12-25**] 06:10AM BLOOD WBC-9.9 RBC-3.57* Hgb-9.1* Hct-28.6*
MCV-80* MCH-25.6* MCHC-31.9 RDW-18.3* Plt Ct-363
[**2126-12-23**] 06:25AM BLOOD PT-13.1 PTT-26.8 INR(PT)-1.1
[**2126-12-25**] 06:10AM BLOOD Glucose-112* UreaN-130* Creat-2.2* Na-136
K-4.1 Cl-93* HCO3-31 AnGap-16
[**2126-12-25**] 06:10AM BLOOD Calcium-9.1 Phos-4.4 Mg-3.0*
[**2126-12-24**] 06:10AM BLOOD Cortsol-21.8*
Brief Hospital Course:
76 y/o M with h/o CAD s/p CABG, multiple PCIs, DM, HTN, HLD, CHF
(last EF 25%), CKD (baseline Cr 1.6-1.8), here with worsening
CHF symptoms and chest pain s/p balooning in the cath lab.
Presented with clinical signs of heart failure and was admitted
to the CCU for CHF management and found to have had MI. Had
several epsides of CP in the CCU relieved with nitro.
# CHF: On arrival, patient was dyspneic, tachypenic and with a
high oxygen requirement. He was treated with a furosemide drip,
morphine, and then added nitro drip with improvement in
symptoms. Last echo in [**10/2126**] showing EF of 25%. Echo on
admission shows LVEF 25-30% ?????? worse AR, MR, akinesis of
inferolateral and inferior walls. Fluid overload related to
congestive heart failure with diastolic dysfunction, myocardial
ischemia with myocaridial stunning and acute on chronic renal
insufficiency from IV contrast during cath. Furosemide drip was
augmented with metolazone with improved diuresis and improvment
in respiratory status. At discharge, his diuretic regimen was
the same as admission, 160mg PO Lasix [**Hospital1 **]. He was asked to hold
his PM dose on day of discharge.
.
# CORONARIES: Patient complained of CP on admission and may have
had ischemia prior to cardiac cath. CKMB and Trops elevated on
admission and up trended. Myocardial ischemia likely related to
vascular recoil following previous cath. Patient underwent
cardiac cath with kissing balloon dilation in LAD and LCx. Right
coronaries not clearly visualized on cath, ischemia may be due
to right coronary or LIMA disease. Trops are elevated likely [**2-12**]
to renal failure, as well as a possible coronary event. While in
the CCU, he had angina at rest and dynamic EKG changes. The
option of repeat cath was discussed however the patient and
family declined further interventions. His symptoms were managed
medically with changing metoprolol to carvediol and Imdur 30mg
daily. We continued his home aspirin, plavix, metoprolol, and
nitroglycerin SL. Atorvastatin was increased to 80mg.
.
# CKD: Has CKD stage III with baseline Cr 1.6-1.8. Cr on
admission was 1.8. He received post-cath hydration. We renally
dosed his medications and avoided nephrotoxins. He was on a
lasix drip for diuresis. Vitamin D was started.
.
# Peripheral vascular disease: continued pentoxifylline,
aspirin, lipitor, antihypertensives.
.
# HTN: he was normotensive while in hospital. Antihypertensive
and rate control medical management as above.
.
# DM: Has a long-standing history of insulin dependent DM2. Last
A1c 7.7 in 07/[**2126**]. He was managed with FS QACHS and home
lantus was increased to 54 units QHS and he was corrected with
HISS.
.
# Anemia: His HCT of 28.6 at discharge is near his baseline for
the past year or so, though still inexplicably low. Perhaps
driven down by renal failure, though also overdue for repeat
colonoscopy after polyp seen in [**2119**]. Fe studies showed low iron
during last admission, normal b12 and folate, normal ferritin,
TRF. Patient will likely benefit from outpatient colonoscopy.
.
# Gout: stable. Continued allopurinol. We stopped his
colchicine, given his renal function.
.
# Depression: stable. continued celexa.
.
# Insomnia: continued trazodone prn.
.
# Transitional Issues:
-Goals of care: The patient initially expressed his wish to be
DNR/DNI and to have no further invasive measures taken. However,
after discussion with palliative care, SW, and Dr. [**Last Name (STitle) **], he
decided to switch his code status to full.
-He has a reported history of silent aspiration. He was
evaluated by swallow team and was graduated up to full diet
without signs or symptoms of aspiration.
-Colonoscopy as outpatient to explain anemia
Medications on Admission:
- aspirin 325 mg daily
- atorvastatin 40 mg daily
- clopidogrel 75 mg daily
- allopurinol 100 mg daily
- citalopram 10mg daily
- metoprolol succinate 50 mg daily
- isosorbide mononitrite 30mg Daily
- lisinopril 2.5mg daily
- trazodone 75mg daily prn insomnia
- pentoxifylline 400 mg [**Hospital1 **]
- furosemide 160mg [**Hospital1 **]
- Humalog Sliding Scale
- Lantus 40 units Qhs
- colace 100mg qhs
- nitroglycerin 0.4mg tab prn CP
- senna [**Hospital1 **] prn
Discharge Medications:
1. Outpatient Lab Work
Please check chem-7, Mag and phos, CBC on Friday [**12-27**] and
call results to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 250**]
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
10. pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
11. insulin glargine 100 unit/mL Solution Sig: Fifty Four (54)
units Subcutaneous once a day.
12. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day.
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
as directed.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
16. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day: [**Month (only) 116**] take capsule.
17. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
18. furosemide 80 mg Tablet Sig: Two (2) Tablet PO twice a day:
Do not take in the evening on [**12-25**], start taking twice daily
again on [**12-26**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Acute on Chronic Kidney Failure
Coronary Artery disease s/p NSTEMI
Hypertension
Dyslipidemia
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:
You had an exacerbation of your congestive heart failure and
your kidneys are not working as well as before because of this.
We found som blockages in your heart arteries but we did not
have to place a stent. We had discussions with you and your
family about your goals of care and what you would want us to do
if your heart were to stop or if you were to become very sick
again. At this time, you have decided that you would want us to
do everything to help you recover from a life threatening
illness. We got rid off a lot of fluid with medicines here. You
will need to follow your fluid status carefully and take all of
your medicines every day to prevent the fluid from coming back.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight
at discharge is 150 pounds.
.
Medication changes:
1. Start Vitamin D daily
2. Increase Atorvastatin to 80 mg daily
3. Discontinue Metoprolol
4. Start Carvedilol to keep your heart rate and blood pressure
low
5. Increase Lantus (Glargine) to 54 units daily, please check
your blood sugars before meals and use the humalog sliding scale
that you have at home.
6. Continue Furosemide 160 mg twice daily but please do not take
the evening dose tonight [**12-25**].
Followup Instructions:
Rheumatology:
Department: RHEUMATOLOGY
When: WEDNESDAY [**2127-1-15**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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
.
Primary Care:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2127-1-1**] at 11:10 AM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**]/[**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**
AND
Department: [**Hospital3 249**]
When: FRIDAY [**2127-2-7**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Nephrology:
Name: [**Last Name (LF) 118**], [**First Name7 (NamePattern1) 429**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] NEPHROLOGY ADMINISTRATION
Address: [**Street Address(2) 7160**], [**Hospital Ward Name **] 8, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 721**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 118**]
within 2-4 weeks. You will be called at home with the
appointment. If you have not heard from the office within 2 days
or have any questions, please call the number above.**
AND
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2127-4-2**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: MONDAY [**2126-12-30**] at 1 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
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|
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4260, 4260
|
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232, 274
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366, 2253
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2858, 3063
|
11985, 12440
|
2297, 2359
|
3079, 3368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,798
| 189,840
|
8569
|
Discharge summary
|
report
|
Admission Date: [**2119-5-2**] Discharge Date: [**2119-5-5**]
Date of Birth: [**2065-9-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy [**2119-5-3**]
History of Present Illness:
(via Portugese Creole interpreter)
53M h/o CVA and CRI (b/l Cr ~1.3) admitted to the MICU [**5-2**] with
vomiting and diarrhea. Had been taking ibuprofen for low back
pain (~800mg daily x4 days). In the ED, triage BP 88/70s with HR
80s on betablocker with subsequent SBP's recorded in 100s. Brown
guaiac+ stool on rectal exam. NG lavage showed tiny specs of
clot thought by GI to be most consistent with NGT trauma.
Therefore, deferred urgent EGD. Transferred to MICU for closer
observation. Hematocrit remained stable.
.
In the emergency department, initial vitals were 98.7 79 88/57
18 95% on RA. Got 40mg IV protonix. Had NG lavage with red blood
initially, [**1-10**] "specks of coffee grounds". Stools were heme
positive. GI saw him in the ER, felt did not have an upper GI
bleed. Vitals 82, 113/75, 95% on RA. Has 1 PIV, going to place
2nd PIV. Given 1L of normal saline. GI fellow saw him in ER felt
given improvement in BP and brown stools no emergent endoscopy
required.
Past Medical History:
s/p hemorrhagic CVA [**2110**]
CRI b/l Cr ~1.3
HTN
BPH
ED
Low back pain
Social History:
He is separated from his wife. Lives with his son and sees his
daughter daily. [**Name2 (NI) **] continues to be intermittently in
relationships. He is on disability s/p CVA. Prior heavy drinker.
Family History:
Denies h/o colon CA or other GI disease
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals 97.8 81 128/96 17 93% on RA
General Pleasant appears comfortable in no distress
HEENT Sclera anicteric, conjunctiva pink, MMM
Neck No JVD
Pulm Lungs clear bilaterally, no rales or wheezing
CV Regular S1 S2 soft systolic RUSB
Abd Soft nontender well healed midline surgical scar +bowel
sounds no HSM or masses
GU guiac+ brown stool in ER per report
Extrem warm no edema palpable distal pulses
Neuro alert and interactive, answering appropriately
Pertinent Results:
[**2119-5-2**] 12:55PM BLOOD WBC-6.7 RBC-3.96* Hgb-11.3* Hct-33.8*
MCV-85 MCH-28.6 MCHC-33.6 RDW-12.1 Plt Ct-154
[**2119-5-2**] 04:41PM BLOOD Hct-35.0*
[**2119-5-2**] 09:55PM BLOOD Hct-34.4*
[**2119-5-3**] 03:54AM BLOOD WBC-6.5 RBC-3.89* Hgb-11.7* Hct-33.6*
MCV-86 MCH-30.0 MCHC-34.9 RDW-12.0 Plt Ct-143*
[**2119-5-3**] 05:05PM BLOOD Hct-35.8*
[**2119-5-4**] 07:00AM BLOOD WBC-7.1 RBC-4.17* Hgb-11.9* Hct-36.0*
MCV-86 MCH-28.4 MCHC-32.9 RDW-11.9 Plt Ct-163
[**2119-5-5**] 08:55AM BLOOD WBC-7.1 RBC-4.19* Hgb-12.0* Hct-35.5*
MCV-85 MCH-28.7 MCHC-33.9 RDW-12.2 Plt Ct-150
[**2119-5-2**] 12:55PM BLOOD Neuts-77.7* Lymphs-13.1* Monos-6.4
Eos-2.3 Baso-0.4
[**2119-5-2**] 12:55PM BLOOD Glucose-102 UreaN-36* Creat-2.3*# Na-141
K-4.1 Cl-106 HCO3-24 AnGap-15
[**2119-5-3**] 03:54AM BLOOD Glucose-89 UreaN-24* Creat-1.6* Na-143
K-4.1 Cl-108 HCO3-25 AnGap-14
[**2119-5-4**] 07:00AM BLOOD Glucose-93 UreaN-18 Creat-1.5* Na-141
K-3.9 Cl-107 HCO3-24 AnGap-14
[**2119-5-5**] 08:55AM BLOOD UreaN-17 Creat-1.3* Na-141 K-3.8 Cl-104
HCO3-27 AnGap-14
[**2119-5-2**] 12:55PM BLOOD ALT-19 AST-24 CK(CPK)-339* AlkPhos-36*
TotBili-1.0
[**2119-5-3**] 03:54AM BLOOD CK(CPK)-274*
[**2119-5-2**] 12:55PM BLOOD Lipase-39
[**2119-5-2**] 12:55PM BLOOD CK-MB-5 cTropnT-0.04*
[**2119-5-2**] 12:55PM BLOOD cTropnT-0.05*
[**2119-5-3**] 03:54AM BLOOD CK-MB-4
[**2119-5-2**] 12:55PM BLOOD Iron-57
[**2119-5-4**] 07:00AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.7
[**2119-5-2**] 12:55PM BLOOD calTIBC-300 Ferritn-142 TRF-231
.
[**2119-5-2**] 03:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2119-5-2**] 03:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2119-5-2**] 03:45PM URINE Eos-NEGATIVE
[**2119-5-3**] 03:54AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2119-5-3**] 03:54AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG
.
Cardiology Report ECG Study Date of [**2119-5-2**] 12:42:20 PM
Sinus rhythm. A-V conduction delay. Left atrial abnormality.
Compared to the previous tracing of [**2111-9-9**] no diagnostic
interim change. The ST-T wave abnormalities have improved.
.
[**2119-5-2**] CXR
FINDINGS: PA and lateral chest views were obtained with patient
in upright
position. The heart size is within normal limits. No typical
configuration
abnormalities identified. Thoracic aorta unremarkable in
position. No local contour abnormality identified. No
mediastinal abnormalities are seen. The pulmonary vasculature is
not congested. No signs of acute or chronic parenchymal
infiltrates are present and the lateral and posterior pleural
sinuses are free. No pneumothorax on frontal view in the apical
area and the azygos vein shadow is within normal limits.
Skeletal structures grossly within normal limits.
IMPRESSION: Chest findings within normal limits. No evidence of
CHF,
cardiomegaly or gross mediastinal abnormalities or pneumothorax.
No pleural effusion.
.
EGD [**5-3**] - Mild erythema and several small erosions in the
antrum (biopsied). Otherwise normal EGD to third part of the
duodenum.
.
Pathology Examination
SPECIMEN SUBMITTED: GI BIOPSY (1 JAR)
Procedure date Tissue received Report Date Diagnosed
by
[**2119-5-3**] [**2119-5-3**] [**2119-5-5**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/ie??????
Previous biopsies: [**-5/2623**] GI BX 2 HF, MID TRANS.
DIAGNOSIS:
Gastric mucosal biopsy:
1. Antral and fundic mucosa with chronic, predominantly inactive
gastritis.
2. Bacteria morphologically consistent with H. pylori
identified.
.
[**2119-5-3**] FINDINGS: Comparison made to [**2119-5-2**]. Lung volumes are
slightly lower, but allowing for this, cardiomediastinal
contours are not significantly changed. Lungs are clear. There
is no pleural effusion or pneumothorax.
IMPRESSION: No acute intrathoracic process.
.
[**2119-5-4**] 11:57 am Influenza A/B by DFA
Source: Nasal swab . R/O H1N1.
DIRECT INFLUENZA A ANTIGEN TEST (Preliminary):
Positive for Influenza A viral antigen.
Specimen sent to State Laboratory for further testing.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2119-5-4**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
Brief Hospital Course:
#Influenza A - Maintained on droplet precautions. Treated with 5
days of oseltamivir. Recommended that he wear a mask while on
antiviral therapy. Informed patient of warning symptoms to watch
for in his family members, and recommended that he notify family
members' school/workplace if feeling sick.
.
#H. pylori gastritis - Hematocrit remained stable. Treated with
PPI followed by prevpac x 2 weeks when pathology returned.
Instructed to avoid NSAIDs. Recommended outpatient colonoscopy
to ensure that guaiac positive stools not coming from lower GI
source.
.
#Acute on chronic renal insufficiency - Improved with IVF. Urine
sediment unremarkable, urine eosinophils negative.
.
#Hypertension - Well-controlled on labetalol. Discontinued
amlodipine, terazosin, HCTZ.
Medications on Admission:
amlodipine 10mg [**Hospital1 **]
enalapril 40mg daily
HCTZ 25mg daily
labetalol 400mg [**Hospital1 **]
sildenafil prn
terazosin 5mg qhs
aspirin 81mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
4. Oseltamivir Phosphate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day) for 3 days.
Disp:*6 Capsule(s)* Refills:*0*
5. Prevpac 500-500-30 mg Combo Pack Sig: One (1) tablet PO twice
a day for 14 days.
Disp:*1 prevpac* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Influenza A
2) H. pylori gastritis
3) Acute on chronic renal insufficiency
4) Hypertension
Discharge Condition:
Clinically improved with stable vital signs.
Discharge Instructions:
You were admitted to the hospital with influenza (flu). This
infection was partially treated with antiviral medication.
Please continue taking the medication through [**Last Name (LF) 766**], [**5-8**].
Please continue to wear a mask that covers your nose and mouth
while you are still taking this medication.
Please contact your family members' school or place of work if
they develop any of the following symptoms: fever, chills,
cough, sore throat, stuffy nose, body aches, or headache.
You were also found to have irritation in the stomach, called
gastritis, that may be due to ibuprofen. You also tested
positive for a bacteria called H. pylori that causes
inflammation in the stomach. For this reason, you were started
on a 2-week course of antibiotics to get rid of this bacteria.
Please avoid taking non-steroidal anti-inflammatory medications
(NSAIDs) such as ibuprofen, advil, motrin, etc.
It was also recommended that you have a colonoscopy as an
outpatient to ensure that the small amount of bleeding is not
coming from lower down in the GI tract.
The following medication changes were recommended:
1) Prevpac was started, to be taken for 2 weeks.
2) Amlodipine was discontinued due to low blood pressure.
3) Hydrochlorothiazide was discontinued due to low blood
pressure.
4) Terazosin was discontinued due to low blood pressure.
Please discuss restarting these medications with your doctor.
Please attend all of your follow-up appointments.
Please call your physician or return to the Emergency Department
if you experience fever, chills, sweats, dizziness,
lightheadedness, chest pain, palpitations, cough, shortness of
breath, abdominal pain, vomiting, diarrhea, bloody or dark
stools, rash, or other worrisome symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2119-5-9**] 4:00
Please follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD [**First Name (Titles) **] [**Last Name (Titles) 18**]
Gastroenterology (GI) on [**2119-5-30**] at 3:30 PM. The phone number is
[**Telephone/Fax (1) 463**] if you wish to reschedule.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2119-6-8**] 10:20
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2119-12-13**] 10:00
Completed by:[**2119-5-5**]
|
[
"008.8",
"403.90",
"600.00",
"041.86",
"535.40",
"724.2",
"487.1",
"276.51",
"584.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.33",
"45.13",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
8051, 8057
|
6543, 7312
|
340, 384
|
8195, 8242
|
2273, 6520
|
10034, 10809
|
1720, 1761
|
7518, 8028
|
8078, 8174
|
7338, 7495
|
8266, 10011
|
1776, 2254
|
274, 302
|
412, 1394
|
1416, 1490
|
1506, 1704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
827
| 135,487
|
542
|
Discharge summary
|
report
|
Admission Date: [**2174-1-4**] Discharge Date: [**2174-2-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
hip fracture and subsegmental PE
Major Surgical or Invasive Procedure:
L HIP ORIF
History of Present Illness:
[**Age over 90 **] year old female with h/o hypothyroidism, anemia,
osteoporosis, multiple falls including [**2-20**] and [**3-23**], [**5-23**] who
presents [**1-4**] s/p fall on left hip. Per ambulance report, pt was
behind her apartment door with walker, when her physical
therapist opened the door which hit her, causing her to fall.
She landed on left hip. She denies LOC, dizziness, palpitations
and confusion. X-ray confirmed L hip fracture.
.
Pt taken to OR [**1-6**] for L ORIF. Intraoperatively she dropped her
O2 sats from 100 to 90 and was noted to have an elevated A-a
gradient. Hip procedure went well without complications.
Post-operatively, the pt left ventilated on SIMV and ortho
requested transfer to MICU for further evaluation and treatment.
Past Medical History:
Frequent falls [**4-21**], [**11-21**]
GERD
Hypothyroidism
Hearing loss on Left
B12-deficiency, Iron deficiency, Anemia
osteoporosis
T3 compression fracture
UTI
Anxiety
ECHO [**11-21**] EF>55%, with 1+ AR, normal LV wall motion.
Social History:
Social History:
- lives in own apartment on [**Location (un) 470**]
- walks with walker
- has lifeline
- has very actively involved family (niece/HCP) in the area who
helps with [**Name (NI) 4461**]. She has strong feelings as to how her aunt
should be taken care of.
- Remote tobacco use, no etoh
- NOK/HCP is patient's niece (is a social worker) [**Name (NI) 17**] [**Name (NI) **] -
[**Telephone/Fax (1) 4462**] (#1 daughter's room), [**Telephone/Fax (1) 4463**] (#2 cell phone).
Does not want to work with [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], RN CM.
- PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**]
Family History:
NC
Physical Exam:
Vitals: T 99.2
BP 142/65
HR 84
R 26
Sat 91% 5LNC
*
PE: G: Elderly female, NAD
HEENT: Dry MM
Neck: Supple, No JVD
Lungs: BS BL, diffuse rhonchi
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT, ND. NL BS. No HSM.
Ext: No edema.
Neuro: Alert, but thinks she's on a ride ("when does this ride
stop?")
*
Pertinent Results:
ADMISSION LABS:
[**2174-1-4**] 07:02PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2174-1-4**] 07:02PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2174-1-4**] 07:02PM URINE RBC-[**2-20**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2174-1-4**] 05:40PM GLUCOSE-101 UREA N-34* CREAT-1.2* SODIUM-142
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
[**2174-1-4**] 05:40PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0
[**2174-1-4**] 05:40PM WBC-6.8 RBC-4.26 HGB-12.1 HCT-35.6* MCV-84
MCH-28.5 MCHC-34.1 RDW-13.3
[**2174-1-4**] 05:40PM NEUTS-75.1* LYMPHS-20.4 MONOS-2.8 EOS-1.1
BASOS-0.6
[**2174-1-4**] 05:40PM PLT COUNT-300
[**2174-1-4**] 05:40PM PT-12.0 PTT-24.1 INR(PT)-0.9
IMAGING:
Admission Hip Film ([**1-5**]): IMPRESSION: Proximal left femoral
fracture.
Admission CXR ([**1-5**]): IMPRESSION: No acute pulmonary process.
Low lung volumes with right basilar atelectasis. Previously
identified right retrocardiac nodular density, not clearly
visualized in this study.
Gross Path on L Hip Fx: Clinical: Fracture left hip.
The specimen is received fresh labeled with "[**Known firstname **] [**Known lastname 4464**]" and
"left femoral head" and consists of a femoral head measuring 6.5
x 4.5 x 3.8 cm. The additional separate fragment of bone
measuring 2.3 x 1.5 x 1.3 cm. The shape of the femoral head is
unremarkable, however, there is extensive eburnation across most
of the surface. There is mild, focal osteophytic growth on the
edge. It is sectioned to reveal large area of hemorrhage
measuring up to 3 cm, and the inferior surface of the femoral
head is jagged and hemorrhagic. The bone trabecula are firm
and no tumors or other mass lesions are noted on sectioning.
Representative sections are submitted in A-B following
decalcification.
CTA Chest (post-op) [**1-7**]:
IMPRESSION:
1. Single PE visualized in the apical segment of the right lower
lobe.
2. Small bilateral pleural effusions. Associated atelectasis. No
other areas of consolidation are visualized.
3. Mild/early CHF.
CT Abd/Pelvis ([**1-9**]):
IMPRESSION:
1. Patient is status post ORIF of the left proximal femur. There
is marked streak artifact from this within the pelvis, however,
no definite hematomas are identified.
2. Bilateral small pleural effusions with associated
atelectasis.
3. The gallbladder appears full, and contains sludge. If there
is clinical concern for acute cholecystitis, evaluation with
ultrasound is recommended.
US liver/GB ([**1-10**]):
IMPRESSION: Gallbladder sludge and pericholecystic fluid. No
gallbladder wall edema or other evidence to suggest acute
cholecystitis. Given the presence of hypoalbuminemia, normal
LFTs, and the absence of a white count, the gallbladder sludge
and gallbladder distention likely reflect a fasting state.
CXR [**1-12**]: IMPRESSION: Improvement of pulmonary edema. Unchanged
right pleural effusion.
Brief Hospital Course:
[**Age over 90 **] year old female with h/o hypothyroidism, anemia,
osteoporosis, multiple falls including [**2-20**] and [**3-23**], [**5-23**] who
presented [**1-4**] s/p mechanical fall with subsequent L hip fx.
She was taken to OR [**1-6**] for L ORIF. Intraoperatively she
dropped her O2 sats from 100 to 90 and was noted to have an
elevated A-a gradient. Hip procedure went well without
complications. Post-operatively, the pt left ventilated on SIMV
and ortho requested transfer to MICU for further evaluation and
treatment. In the ICU, she was found to have a subsegmental PE
and BL pleural effusions. She developed a fever to 101.9, and
was treated empirically for hospital-acquired PNA with
CTZ/flagyl (plan for 10 days). She was also started on heparin,
and was noted to have had a Hct drop of 10 points on [**1-9**], which
was stable after transfusion. No obvious source was found and
her Hct was stable following. During this time ([**1-9**]), she was
also empirically started on Vancomycin for the fevers, but it
was d/c'd on [**1-13**]. No other etiology for the fevers was found,
including negative RUQ U/s and CT a/p. Once extubated, the
patient failed speech and swallow evaluation, but refused NGT
placement. A PICC line was placed for temporary nutrition via
TPN.
.
1. PE: The patient was anticoagulated initially with heparin gtt
then switched to lovenox. Once a PEG was placed, the patient was
transitioned over to coumadin with lovenox bridge. Last INR was
2.1 on [**2174-2-2**], stopped lovenox, discharged on Coumadin 3mg PO
qd, please check INR in 2 days and adjust dose of coumadin as
needed. At time of discharge, her SaO2 ranged from 92-95 on RA.
.
2. ID: The patient was treated empirically with CTZ and Flagyl
for a nosocomial/aspiration PNA and remained afebrile while on
the floor. However, pt's WBC elevated so Vanco was added to
regimen for a 7 day course. A sputum cx from [**1-10**] grew sparse
yeast. The foley was changed and a urine sent for culture; the
initial sample was contaminated and grew yeast; the second urine
cx grew enterococcus resistant to Vanco 10,000-100,000 colonies.
A repeat urine was sent and the foley was removed; cx grew only
yeast. She remained afebrile, with a normal WBC, throughout the
remainder of her hospitalization. A pCXR on [**2173-1-31**] showed a
question of a new L medical base infiltrate; however, in absence
of fever and stable WBC, did not treat with abx, followed
clinically. There was a concern that the patient may have
experienced an aspiration event; however she did not worsen
clinically so no further treatment provided other than measures
to reduce aspiration risk.
.
3. L Hip fracture, s/p ORIF: The patient was followed by
Orthopedics and did well, cleared for WBAT and work with PT/OT;
will need PT/OT at rehab when physically able. The patient will
f/u with Dr. [**Last Name (STitle) 1005**] 2 weeks from discharge date (number in
discharge paperwork).
.
4. Delirium/Dementia: The patient had a waxing/[**Doctor Last Name 688**] mental
status. At one point the patient pulled her IV lines including
her PICC line, occasionally requiring the use of soft restraints
for her safety. Olanzapine was used on a prn basis for
agitation. Frequent reorientation was used. Pt has periods of
apparent lucidity and makes insightful comments and
conversation.
.
5. FEN: The patient failed multiple speech & swallow
evaluations. The patient was initially on TPN via the PICC line
for nutrition. Extensive discussions were had with the [**Hospital 228**]
healthcare proxy regarding options for enteral nutrition. An
albumin was 2.7. A PEG was placed on [**2174-1-27**] and tube feeds were
begun and the patient achieved her TF goal. Electrolytes were
stable. There was concern on [**2174-1-30**] that the patient was
aspirating some of her TF [**1-20**] reflux, despite no residuals when
checked; a CXR was unchanged. A day later a repeat CXR showed a
question of a new L medial base infiltrate (poor quality film).
Reglan was started, and TF were restarted at a slower rate. A
PPI was also administered. HOB kept elevated >30-45 degrees at
all times. The patient was followed on a sliding scale insulin
regimen with good effect.
.
6. Hypothyroidism: The patient was initially treated with IV
levoxyl since she was NPO; a TSH was checked: 8.5, difficult to
interpret in an ill, hospitalized patient. A free T4 was WNL, so
pt was maintained on same dose of levoxyl. Once PEG in place, PO
levoxyl started at same dosing per Pharmacy recs.
.
7. Anemia: Stable during remainder of hospitalization. Baseline
Hct appears to be in the low to mid 30s.
.
.
Medications on Admission:
Meds on transfer:
Propofol gtt
Multivitamins 1 CAP PO DAILY
Olanzapine prn
Oxycodone 5 mg PO Q4-6H:PRN pain
Acetaminophen 650 mg PO/PR Q6H
Pantoprazole 40 mg PO Q24H
Calcium Carbonate 500 mg PO TID
Cefazolin 1 gm IV Q8H Duration: 6 Doses
Docusate Sodium 100 mg PO BID:PRN
Enoxaparin Sodium 40 mg SC Q24H
Levothyroxine Sodium 88 mcg PO DAILY
Senna 1 TAB PO BID
Metoprolol 5 mg IV Q6H
Morphine Sulfate 1-2 mg IV Q4-6H:PRN
Vitamin D 400 UNIT PO DAILY
.
Allergies: NKDA
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: via
PEG. Tablet(s)
6. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily): via PEG.
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): via PEG.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): via PEG, fold for HR<60, SBP<115.
9. Outpatient Lab Work
Please check INR in 2 days and adjust coumadin level as needed
for goal INR [**1-21**].
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily)
as needed for PE.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
1. L hip fracture s/p ORIF
2. PE
3. Dementia/delirium
4. Pneumonia (resolved)
5. Anemia (stable)
6. Hypothyroidism
Discharge Condition:
Fair
Discharge Instructions:
-Take medications as prescribed
-Work with physical therapy as able
-Tube feeds via PEG (nothing by mouth until re-evaluation by
Speech/Swallow)
-Notify your doctor or return to the ER for:
* fever>101.4
* chest pain, shortness of breath, abdominal pain
* other concerns
Followup Instructions:
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Date/Time:[**2174-3-7**] 1:30
- Orthopedics Dr. [**Last Name (STitle) 1005**] -- Call [**Telephone/Fax (1) 4466**] to schedule
appointment at a time conveneient for you 2 weeks from your
discharge date.
|
[
"518.5",
"584.9",
"415.11",
"507.0",
"820.09",
"997.3",
"E888.9",
"530.81",
"486",
"244.9",
"263.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"38.93",
"99.15",
"81.52",
"79.35",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11648, 11722
|
5409, 10038
|
293, 305
|
11881, 11888
|
2432, 2432
|
12208, 12504
|
2085, 2089
|
10555, 11625
|
11743, 11860
|
10064, 10064
|
11912, 12185
|
2104, 2413
|
221, 255
|
333, 1099
|
2449, 5386
|
1121, 1352
|
1384, 2069
|
10082, 10532
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,490
| 185,398
|
2874
|
Discharge summary
|
report
|
Admission Date: [**2185-8-17**] Discharge Date: [**2185-8-23**]
Date of Birth: [**2126-8-24**] Sex: F
Service: MEDICINE
Allergies:
Soybean
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58yo F with COPD on 3L at baseline who presented with right
sided CP with radiation to the back that began when she woke up
this morning. Her pain got worse throught the day and pleuritic
in nature (worse with inspiration). Pt has felt dizzy whenever
she attempted to walk today. Also reports chills, shivering, and
HA. Pt called Dr [**Last Name (STitle) 575**] who was concerned for PE, PTX, or
dissection and sent her to the ED. Initial ED vitals: 100.2 110
112/65 18 95%. While in the ED, she became hypotensive to the
80s. Initially, pressures did not improve with 2L IVF. Bedside
FAST was negative. A right IJ was placed. CVP was measured at
[**3-4**] and she got another 2L IVF with improvement of pressures to
the low 100s (total 4L given in the ED). CTA was negative for PE
or dissection. Given new RLL opacities, she was given 750mg of
Levoflox. She never required pressors. She got morphine x 1 for
pain. Per the ED, she transiently desatted to 73% on 6L
approximately 30mins before ICU transfer; per nursing report,
this occured in the setting of having recieved 4mg of morphine.
Currently, T100, 98, 102/68, RR 22, 93% on 6L.
On the floor, pt still feels "lousy," but somewhat better than
before presentation to the ED. Having some cough since volume
resucitation in the ED.
Past Medical History:
CHRONIC PAIN - Related to low back degenerative changes,
cervical spinal stenosis, s/p surgery, and fibromyalgia.
SYSTEMIC LUPUS ERYTHEMATOSUS (severe ophthalmopathy, diffuse
arthropathy)
DEPRESSION
MITRAL VALVE PROLAPSE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
LUNG NODULE
OSA (on CPAP)
Social History:
Single (divorced) former nurse who currently works as a
receptionist at her local Catholic church. She currently lives
alone with 2 cats.
- Tobacco: Last cigarette 6m ago, previously smoked for 40+ pack
years
- Alcohol: no significant Hx
- Illicits:denies
Family History:
Significant for an uncle with diabetes
Physical Exam:
Admission Exam:
T100, 98, 102/68, RR 22, 93% on 6L.
General: Alert, oriented, no acute distress. CPAP in place
HEENT: Sclera anicteric, MMM
Lungs: Coarse right basilar crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
Admission Labs:
[**2185-8-16**] 08:40PM BLOOD WBC-13.3*# RBC-4.65 Hgb-14.9 Hct-42.4
MCV-91 MCH-32.2* MCHC-35.3* RDW-13.5 Plt Ct-282
[**2185-8-16**] 08:40PM BLOOD Neuts-92* Bands-3 Lymphs-5* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2185-8-16**] 08:40PM BLOOD PT-13.4 PTT-28.3 INR(PT)-1.1
[**2185-8-16**] 08:40PM BLOOD Glucose-160* UreaN-17 Creat-1.2* Na-138
K-4.0 Cl-101 HCO3-25 AnGap-16
[**2185-8-16**] 08:40PM BLOOD cTropnT-<0.01
[**2185-8-16**] 08:40PM BLOOD Calcium-9.2 Phos-2.2* Mg-1.6
[**2185-8-16**] 08:40PM BLOOD D-Dimer-2613*
[**2185-8-16**] 08:53PM BLOOD Lactate-3.0*
.
CXR [**2185-8-16**]: Severe emphysema with new bibasilar ill-defined
opacities which may reflect infection or aspiration.
.
Echo [**2185-8-17**]: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2183-5-20**], pulmonary pressures can now be quantified and are
in the mild range. Right ventricular size is mildly dilated with
preserved systolic function. Left ventricular regional and
global systolic function is normal.
Brief Hospital Course:
58yo F with COPD on 3L O2 at home who presents with pleuritic
right CP and new RLL on chest imaging.
.
# PNA: On presentation, fevers, leukocytosis with left shift,
hypoxia, and infiltrates on CT and CXR. She was initially
covered with vanc/ceftriaxone/levofloxacin for CAP requiring ICU
admission. Vanc was stopped after a few days after pt had become
afebrile with no fever spike. Urine legionella negative. She
completed a 5 day course of levoflox and continued on CTX. Prior
to discharge, she was switched to cefpodoxime for a planned
total 14 day course (to end [**2185-8-29**]). Pleuritic chest pain
improved; patient not requesting PRN pain medication prior to
d/c. Supplemental O2 was weaned as tolerated, 90-92% on 6L at
the time of d/c.
.
# Afib with RVR: Pt developed afib with rates in the 140s/150s
with chest discomfort, no ischemic EKG changes. Required
digoxin load, but converted back to sinus and dig was d/ced.
Felt to be [**2-2**] stress of PNA. Pt in NSR in the 70s-80s at the
time of d/c.
.
# COPD: Uses 3L O2 at baseline. Increased Advair to 500-50.
Iprtroprium nebs q6 hours, held Spiriva, can resume this upon
d/c.
.
# Flash pulmonary edema: One time occurance. Given Lasix
intermittently. Echo did not show any major abnormalities. Upon
d/c would give Lasix PRN to keep Is and Os even, but no need for
standing diuresis.
.
# Delerium: Pt developed visual hallucinations during her ICU
stay. Does not use EtOH, but does take a fair amount of BZDs and
Vicodin at home, particularly at HS. Poor sleep during her
hospital course. ICU delirium vs. Benzo withdrawal. Mental
status at baseline and resolution of hallucinations prior to
d/c. Pt should resume her home dose of Klonopin upon d/c. She
may continue Zyprexa at HS PRN.
.
# OSA: CPAP at night with home settings.
.
# CAD: Con't simvastain
.
# Smoking cessation: Continue nicotine replacement.
.
# HTN: Held lisinopril in the setting of diuresis, can resume
upon d/c.
.
# Chronic pain: Continued home gabapentin. Held home Vicodin
given AMS and hallucinations.
.
DNR/DNI (confirmed with pt, she has discussed this with her
psychiatrist)
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs orally up to qid for asthma flare as directed
CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - 1 mg
Tablet - [**2-4**] Tablet(s) by mouth
DIAZEPAM - (Prescribed by Other Provider) - 5 mg Tablet - 0.5
(One half) Tablet by mouth in the AM and 1 tab in the PM
DULOXETINE [CYMBALTA] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 20 mg Capsule, Delayed Release(E.C.) -
4 Capsule(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril once a day pharmacy please deliver
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 actuation(s) orally once or twice a day
GABAPENTIN [NEURONTIN] - (Prescribed by Other Provider) - 800 mg
Tablet - 4 (Four) Tablet(s) by mouth at bedtime
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - [**1-2**] Tablet(s)
by
mouth every six (6) hours as needed for pain limit 4 tabs per
day
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth once a day
NAPROXEN SODIUM - 550 mg Tablet - 1 Tablet(s) by mouth twice a
day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 (Two)
Capsule(s) by mouth once a day please deliver
OXYGEN - - 2L/min cont flow at night via CPAP; 2L/min cont flow
with exertion at home; Evaluate for pulse dose 02 with exertion
outside home; Dxs: COPD; OSA
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth Once a Day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaed orally once a day
CETIRIZINE - (Prescribed by Other Provider; OTC) - 10 mg Tablet
- 1 (One) Tablet(s) by mouth once a day as needed for allergy
symptoms
NICOTINE - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 14 mg/24 hour Patch 24 hr - 1 patch daily daily
NICOTINE (POLACRILEX) - 4 mg Gum - chew 1 piece as directed at
each significant urge to smoke
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
3. nicotine (polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q2H
(every 2 hours) as needed for craving.
4. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every
4 hours).
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
6. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. gabapentin 400 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
11. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
12. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
hold for SBP < 100.
14. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sedation.
15. Klonopin 2 mg Tablet Sig: 1-2 Tablets PO at bedtime: hold
for sedation.
16. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
17. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: community-aquired pneumonia
.
Secondary: COPD
sleep apnea
atrial fibrilation, resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname **],
.
It has been a pleasure taking care of you here at [**Hospital1 771**]. You were admitted to the ICU with a
pneumonia. We treated you with antibiotics and were slowly able
to decrease the amount of oxygen you needed. Your heart went
into an abnormal rhythm (atrial fibrilation), likely from the
stress of the pneumonia. Your heart was back in normal sinus
rhythm before discharge.
.
We made the following changes to your medications:
- Please start taking cefpodoxime for 6 more days
- Please change your Advair to 500-50, 1 puff twice a day
- Please stop taking Vicodin for now. As you might remember, you
were confused for a few days in the ICU. You appeared
comfortable without this medication.
- You may take guaifenasin as needed for cough
- You may take Zyprexa (olanzipine) 5mg at bedtime as needed to
help you sleep
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2185-8-30**] at 11:00 AM
With: [**Last Name (NamePattern4) 13952**] RRT/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
.
Department: NEUROLOGY
When: WEDNESDAY [**2185-8-31**] at 4:00 PM
With: DRS. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 249**]
When: TUESDAY [**2185-9-6**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2185-8-23**]
|
[
"V49.86",
"401.9",
"496",
"414.01",
"518.81",
"368.16",
"327.23",
"486",
"721.3",
"427.31",
"338.29",
"518.4",
"710.0",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10147, 10213
|
4482, 6601
|
279, 285
|
10353, 10353
|
2626, 2626
|
11412, 12370
|
2203, 2244
|
8549, 10124
|
10234, 10332
|
6627, 8526
|
10536, 10969
|
2259, 2607
|
10998, 11389
|
229, 241
|
313, 1604
|
2642, 4459
|
10368, 10512
|
1626, 1913
|
1929, 2187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,177
| 166,808
|
38541
|
Discharge summary
|
report
|
Admission Date: [**2142-8-6**] Discharge Date: [**2142-8-16**]
Date of Birth: [**2067-8-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Barbiturates / Tricyclic Compounds /
Phenothiazines
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
intubation, central line placement, PICC line placement
History of Present Illness:
75 year old man with PMH significant for advanced
dementia (nonverbal at baseline), hypothyroidism, pituitary
adenoma s/p resection, with multiple prior episodes of
hypothermia who was transfered from his nursing home today with
dysphagia and found to have hypoxia and hypotension. Pt has had
multiple admissions, most recently for urosepsis ([**7-11**]), coag
negative staph bacteremia and autonomic dysregulation with
hypothermia, low blood pressure, and bradycardia ([**5-25**]).
.
Nursing home documentation states that the pt has been having
new difficulty swallowing, and he was transfered here for
evaluation.
.
[**Name (NI) 1094**] sister reports that the pt was at baseline state of health
1 week prior to admission, but he was having problems eating his
food.
.
In the ED, initial vs were: T30.7 rectal P43 BP123/65 R20 O288%.
He was triggered for hypoxia. Patient was given 3L NS, 100mg
hydrocort, vanc 1g, cefepime 2g, flagyl 500mg. Also, the pt was
given 0.5mg atropine for bradycardia/hypotension. CXR taken and
Foley was placed. O2 went to 95% in 4L NC.
Past Medical History:
- Dementia (Alzheimer's) in NH since [**2136**]
- Hypothyroidism
- Far-advanced pituitary adenoma s/p resection with subsequent
adrenal insufficiency
- History of CVA
- Renal insufficiency
- Anemia
- H/o syphilis
- Prostatic enlargement
- Depression
- Hyperlipidemia
- GERD
- Amputation of fingers of left hand
Social History:
Tobacco, ETOH and IVDU history unavailable. Lives at [**Hospital 10246**]
nursing home. Health care proxy and legal guardian is sister
([**Telephone/Fax (1) 85722**]) [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Per report, at baseline patient is nonverbal with
occasional grunting or answering "yes". He does not maintain
eye contact and is not ambulatory at baseline. He is able to eat
a modified diet.
Family History:
nc
Physical Exam:
Vitals: T: BP:100/63 P:62 R: 18 O2:97% 4LNC
General: Alert, not able to communicate at baseline, withdraws
to painful stimuli
[**Last Name (NamePattern1) 4459**]: Sclera anicteric, Dry MM, oropharynx clear
Neck: supple, 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, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU: foley in place draining clear urine
Ext: slightly cool, cap refill <2 seconds, 2+ pulses, no
clubbing, cyanosis or edema
Pertinent Results:
Admission labs:
[**2142-8-6**] 04:10PM WBC-3.7*# RBC-3.25* HGB-9.5* HCT-31.2* MCV-96
MCH-29.3 MCHC-30.5* RDW-16.6*
[**2142-8-6**] 04:10PM NEUTS-49* BANDS-17* LYMPHS-23 MONOS-6 EOS-1
BASOS-0 ATYPS-1* METAS-2* MYELOS-1* NUC RBCS-13*
[**2142-8-6**] 04:10PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-OCCASIONAL
[**2142-8-6**] 04:10PM PLT SMR-LOW PLT COUNT-130*
[**2142-8-6**] 04:10PM PT-12.6 PTT-35.7* INR(PT)-1.1
[**2142-8-6**] 04:10PM GLUCOSE-117* UREA N-32* CREAT-1.3* SODIUM-134
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-22 ANION GAP-15
[**2142-8-6**] 04:10PM cTropnT-<0.01
[**2142-8-6**] 04:15PM LACTATE-2.3* NA+-135 K+-5.2 CL--103 TCO2-23
Discharge labs:
[**2142-8-16**] 04:47AM BLOOD WBC-11.0 RBC-2.58* Hgb-7.7* Hct-23.6*
MCV-91 MCH-30.0 MCHC-32.8 RDW-17.3* Plt Ct-146*
[**2142-8-16**] 04:47AM BLOOD Plt Ct-146*
[**2142-8-16**] 04:47AM BLOOD Glucose-91 UreaN-31* Creat-1.0 Na-139
K-4.9 Cl-106 HCO3-27 AnGap-11
[**2142-8-15**] 04:58AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.8
[**2142-8-6**] CXR: FINDINGS: In the interval, the left-sided PICC line
has been removed. There is increased interstitial opacity in the
right upper lobe, new compared to prior exam. There is
essentially unchanged right infrahilar and left retrocardiac
interstitial prominence, likely chronic and related to
atelectasis, since unchanged compared to [**2142-7-12**]. The
cardiomediastinal silhouette is normal. There is no pleural
effusion and no pneumothorax.
IMPRESSION: New right upper lobe hazy reticular opacification
might represent early consolidation, ?? aspiration pneumonia.
Unchanged bibasilar opacification, likely related to
atelectasis.
[**2142-8-8**] EEG: IMPRESSION: This telemetry showed a low voltage
slow encephalopathic background throughout, with infrequent
generalized sharp waves. Encephalopathy appeared severe. It was
unchanged over the record. There were no areas of prominent
focal slowing, but encephalopathies may obscure focal findings.
The frequent sharp waves were isolated and did not include
simple spike or sharp and slow wave complexes, and there were no
repetitive discharges or electrographic seizures.
[**2142-8-8**] CT Head: IMPRESSION:
1. No acute intracranial hemorrhage or mass effect in the
supratentorial
compartment. However, MR (if not contra-indicated) should be
considered for further evaluation if there is a high clinical
suspicion of an acute
infarction. Evaluation of posterior fossa structures including
brainstem is limited due to artifacts and hence, not well
assessed.
2. Markedly enlarged ventricles suggestive of communicating
hydrocephalus such as normal-pressure hydrocephalus versus
central volume loss or possibly a combination of both. MR (if
not CI)can be helpful to assess the cerebral aqueduct and better
distinction.
3. Markedly dilated temporal horns of lateral ventricles which
could suggest Alzheimer's disease.
Brief Hospital Course:
75-year-old male with advanced dementia and pan-hypopituitarism
who presented with acute respiratory distress.
He was started on stress dose steroids, vancomycin, meropenem,
and ciprofloxacin for double coverage of GNRs. He required
dopamine for pressure support for 2 days while intubated. His
mental status was altered from baseline, and he was not opening
eyes or following commands. Neurological exam was notable for
pinpoint pupils briefly (off narcotics) and neurology was
consulted. CT head showed no evidence of stroke. Antibiotics
were narrowed to levofloxacin only after culture data revealed
no growth. Several days into treatment of his pneumonia his
mental status improved (opens his eyes and responded to his
name). Pt was extubated on [**8-9**] without complication. Family
meeting regarding goals of care was had at that time and family
was entertaining home hospice. Prognosis of patient's advanced
dementia is poor and death is likely to be a result of an
infectious complication such as pneumonia from aspiration,
decubitus ulcer, or other causes.
He was transferred to the floor [**2142-8-10**]. On [**2142-8-11**] there was
concern that his white count was rising and that there were
increasing opacities on chest x-ray. His Levaquin was changed to
cefepime, ciprofloxacin and vancomycin in case of worsening
pneumonia. A PICC was placed to give antibiotics. He remained
clinically stable, and his antibiotics were changed back again
to Levaquin alone. He completed antibiotics [**2142-8-16**].
There were multiple family meetings through his stay, first to
inform the family of goals of care, and then to shape his goals
of care. Palliative care was consulted and there are multiple
notes from them in OMR. His sister [**Name (NI) **] is his HCP, and she
consulted extensively with his other siblings. Understanding
that his severe dementia is irreversible, she wanted to focus on
comfort. She did not want a permanent feeding tube placed and
wanted him to get food by mouth for comfort, understanding that
this may lead to aspiration. They did still want him to get CPR
if needed, even if that meant that he would be transferred back
to the hospital.
Medications on Admission:
Levothyroxine
Furosemide
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Prednisone 5 mg Tablet Sig: As directed Tablet PO once a day
for 9 days: Take 3 tablets for 3 days, then 2 tablets for 3
days, then 1 tablet daily for 3 days, finishing [**2142-8-24**].
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Roscommon on the Parkway - [**Location 1268**]
Discharge Diagnosis:
Pneumonia
Respiratory failure
Severe dementia
Discharge Condition:
Mental Status: Confused - always. Non-verbal
Level of Consciousness: Lethargic but arousable. Sometimes will
track eyes to voice and follow basic commands.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 284**] was admitted with severe pneumonia. He went to
the intensive care unit and had to be intubated. His pneumonia
has stabilized and he is now back to his baseline. Because of
his severe dementia, he is not going to recover his ability to
talk, eat or go to the bathroom normally. Severe dementia has a
very poor prognosis, so he is being discharged to hospice.
.
Changes were made to his medications:
- He STOPPED furosemide
- He was STARTED on a prednisone taper. He should take 20mg
daily for 3 days, then 10mg daily for 3 days, then 5mg daily for
3 days, then stop.
- He was STARTED on stool softeners. He should take colace every
day, and Senna and Dulcolax as needed to prevent constipation.
- He completed antibiotics the day of discharge.
His code status is DO NOT INTUBATE, but he CAN still be
resuscitated and transferred back to the hospital.
Followup Instructions:
You will be seen by your doctor at the nursing home
|
[
"276.7",
"244.9",
"272.4",
"333.90",
"787.20",
"294.10",
"995.92",
"530.81",
"V66.7",
"276.0",
"255.41",
"507.0",
"585.9",
"253.2",
"348.30",
"331.0",
"276.4",
"518.81",
"285.9",
"584.9",
"038.9",
"564.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"38.93",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8734, 8807
|
5906, 8096
|
345, 402
|
8897, 8897
|
2922, 2922
|
10010, 10065
|
2298, 2302
|
8171, 8711
|
8828, 8876
|
8122, 8148
|
9106, 9987
|
3680, 5154
|
2317, 2903
|
285, 307
|
430, 1501
|
5163, 5883
|
2938, 3664
|
8912, 9082
|
1523, 1836
|
1852, 2282
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,564
| 115,411
|
11017
|
Discharge summary
|
report
|
Admission Date: [**2144-11-19**] Discharge Date: [**2144-11-20**]
Date of Birth: [**2095-12-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Transfer from [**Hospital **] Hospital
for interventional coronary catheterization. A 48-year-old
male with past medical history with end-stage renal disease
on hemodialysis, hepatitis C, coronary artery disease, status
post coronary artery bypass graft x2 vessels in [**2143-6-28**],
transferred from outside hospital for interventional
catheterization. Admitted to [**Hospital **] Hospital on [**2144-11-15**] with chest discomfort and dyspnea. Had laboratories
there which showed a CK of 300, MB of 10, and troponin of 43.
The patient underwent cardiac catheterization which showed a
cardiac output of 8.7, wedge pressure 24, PA pressure of
65/30, a 70% stenosis in the left main coronary artery, and a
totally occluded left circumflex artery, right coronary
artery dominant system with 90% stenosis in the right
coronary artery at the bifurcation of the PDA and PL
branches. The patient had [**Female First Name (un) 899**] to left anterior descending
artery graft and saphenous vein graft to OM-2 graft which
were patent.
The patient was then transferred for interventional cardiac
catheterization at [**Hospital1 69**] and
possible stent placement. At catheterization at [**Hospital1 346**], the patient had a cardiac output of
3.5, a wedge pressure of 32, PA pressure of 78/36, right
coronary artery showed diffuse calcification, distal 90%
lesion at the bifurcation of the PDA/PL. A stent was then
placed in the distal right coronary artery. The patient was
transferred to the CCU for further care because he continued
to have searing 10/10 chest pain after stent placement.
PAST MEDICAL HISTORY:
1. Chronic renal failure on hemodialysis on Monday,
Wednesday, Friday reportedly secondary to hypertension.
2. Congestive obstructive pulmonary disease. The patient
continues to smoke one pack per day.
3. Hepatitis C, open sores secondary to pruritus.
4. Coronary artery disease.
5. History of flash pulmonary edema.
6. Hypertension.
7. Gastritis.
SOCIAL HISTORY: Smoking greater than one pack per day.
History of intravenous drug abuse.
ALLERGIES: Aspirin leads to bleeding. Norvasc leads to
unknown reaction.
MEDICATIONS AT HOME:
1. Nitroglycerin.
2. Lasix unknown dose.
VITAL SIGNS: Temperature 96.5, temperature max of 98.4,
heart rate 110-78, blood pressure 90-132/50-73. Pulse
oximetry is 95-99% on room air. Patient on a ReoPro drip 0.1
mcg/minute.
PHYSICAL EXAMINATION: General, deconditioned, belligerent
male verbally abuse. Cardiovascular: 3/6 systolic murmur at
the precordium, regular, rate, and rhythm. Patient refused
rest of the examination.
INITIAL LABORATORIES: White blood cell count is 7.2,
hematocrit 29.3, platelets 163, 88% neutrophils, 5.1%
lymphocytes, INR 1.3. Chem-7: Sodium 130, potassium 5.3,
chloride of 98, bicarb of 25, BUN of 45, creatinine 5.2,
glucose of 118, magnesium of 2.0. CPK of 45, AST 17, ALT 6,
alkaline phosphatase 281.
INITIAL ASSESSMENT: A 48-year-old male with a past medical
history of end-stage renal disease, hepatitis C, substance
abuse, coronary artery disease status post coronary artery
bypass graft x2 here in CCU after a successful stent
placement to the distal right coronary artery.
HOSPITAL COURSE: Patient was extremely combative initially
during hospital course, and he required several doses of
Haldol 5 mg IV as well as Ativan. Patient slept only
intermittently requested to leave the hospital to smoke
cigarettes. Extremely belligerant to team. Finally
requesting to sign out against medical advice. The patient
refused his morning dialysis, assisted in signing out. The
patient underwent an extensive discussion with the medical
team, and understood that he was at risk at sudden cardiac
death, congestive heart failure, and complications leading to
skipping dialysis. All of this was discussed in detail. He
remained adamant upon leaving.
We spoke to his nephew, who then spoke to the patient.
Patient continued to refuse to remain in the hospital, and
insisted on signing out against medical advice, which the
patient eventually did.
A phone call was placed to his local pharmacy to have Plavix
prescription filled for the patient, and his wife was
[**Name (NI) 653**] and the importance of taking the Plavix as he had a
recent stent placement was stressed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 8279**]
MEDQUIST36
D: [**2144-12-28**] 10:43
T: [**2144-12-31**] 04:42
JOB#: [**Job Number 35681**]
|
[
"V45.81",
"496",
"428.0",
"403.91",
"414.01",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"88.55",
"88.52",
"37.22",
"39.95",
"99.20",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
3362, 4705
|
2317, 2546
|
2569, 3344
|
163, 1756
|
1778, 2128
|
2145, 2296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,904
| 148,441
|
46927
|
Discharge summary
|
report
|
Admission Date: [**2176-6-11**] Discharge Date: [**2176-6-12**]
Date of Birth: [**2112-11-25**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Toradol / Talwin Nx / Vancomycin
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Shortness of breath and neck pain.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 63-year-old woman with approximately 9 year history of
airway stenosis of unknown etiology. The patient has had 2
laryngotracheal resections, as well as several procedures to
treat subglottic and tracheal stenosis. She underwent a rigid
bronch, balloon dilation, microdebridement and stent placement
on [**2176-5-22**]. A 14 mm silicone stent was placed 8-9mm below the
cords. The patient returned to the hospital on [**5-28**] c/o SOB. A
repeat bronch showed that the stent was in place. She was
recently readmitted again on [**6-2**] for SOB and neck pain. She
underwent flexible bronchoscopy which showed a significant
arytenoid fold covering the vocal cords. Despite multiple
attempts and additional instillations of lidocaine, they were
unable to pass the vocal cords due to severe coughing. A CT was
therefore performed to assess the stent and reassess the issue
of surgical correction of her tracheal stenosis. CT airway
showed patent stent with swelling above the stent. No further
interventions were performed at that time as the patient
improved and was discharged to home.
The patient presents to with cough and throat pain. She states
that her pain is from the cough and localized to her throat.
Presented to OSH for cough where that did a fiberoptic bronch
and were able to pass through her cords. Showed edema above the
stent. Pt transfered here for further management. On
presentation to the [**Name (NI) **], pt was found to be tachypneic. She
received 6mg Morphine and humidified O2 and symptoms resolved.
The patient gets most of her ENT care at [**Hospital 13128**].
Past Medical History:
Carotid stenosis and cerebrovascular accident, diabetes
mellitus, lupus, hypothyroid, bilateral mastectomies for cystic
disease
Social History:
The patient is married and lives with her husband. She is a
former office secretary. She is a former smoker with 60 pack
year history who quit 10 years ago. She has no known asbestos
exposure.
Family History:
Her mother died due to complications related to coronary artery
disease, and her father of cerebrovascular accident (CVA).
Physical Exam:
GEN: anxious, but comfortable. no acute distress. Speaking in
full sentences, no accessory muscles. Tearful.
VITALS: 98.7, 77, 94/59, 22, 98% RA
HEENT: MMM, pupils equal, well healed trach scar. No LAD
CHEST: Bibasilar rhonchi, no wheeze, no stridor.
CV: RRR, no murmurs appreciated.
ABD: soft nontender nondistended, normoactive BS
EXT: no clubbing or edema. Warm and well perfused.
NEURO: No focal findings.
Pertinent Results:
[**2176-6-11**] 06:39PM GLUCOSE-58* UREA N-14 CREAT-1.1 SODIUM-142
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15
[**2176-6-11**] 06:39PM WBC-10.9 RBC-4.26 HGB-11.1* HCT-33.7* MCV-79*
MCH-26.1* MCHC-33.0 RDW-13.7
[**2176-6-11**] 06:39PM NEUTS-68.6 LYMPHS-21.8 MONOS-3.8 EOS-5.5*
BASOS-0.3
[**2176-6-11**] 06:39PM HYPOCHROM-1+ MICROCYT-1+
[**2176-6-11**] 06:39PM PLT COUNT-384
.
CT ([**2176-6-4**]): IMPRESSION:
1. There is near complete occlusion of the airway in the
glottic region just above the stent.
2. The stent is patent. There is a slight size discrepancy
between the stent and size of the trachea in the inferior aspect
of the stent. There is thickening of the trachea around the
stent.
3. The trachea and main stem bronchi below the stent are
unremarkable.
Brief Hospital Course:
63 y.o female well known to Thoracic and IP teams, s/p stent
presents with SOB and neck pain.
HPI: This is a 63-year-old woman with approximately 9 year
history of
airway stenosis of unknown etiology. The patient has had 2
laryngotracheal resections, as well as several procedures to
treat subglottic and tracheal stenosis. She underwent a rigid
bronch, balloon dilation, microdebridement and stent placement
on [**2176-5-22**]. A 14 mm silicone stent was placed 8-9mm below the
cords. The patient returned to the hospital on [**5-28**] c/o SOB. A
repeat bronch showed that the stent was in place. She was
recently readmitted on [**6-2**] for SOB and neck pain. She underwent
flexible bronchoscopy which showed a significant arytenoid fold
covering the vocal cords. Despite multiple attempts and
additional instillations of lidocaine, we were unable to pass
the vocal cords for severe coughing. A CT was therefore
performed to assess the stent and reassess the issue of surgical
correction of her tracheal stenosis. CT airway showed patent
stent with swelling above the stent. No further interventions
were performed at that time as the patient improved and was
discharged to home.
The patient gets most of her ENT care at [**Hospital 13128**].
.
1)Tracheal stenosis: Pt has an extensive history of tracheal
stenosis and is s/p mult interventions. Plan fromlast discharge
was to reassess surgical intevention at [**Hospital 13128**] as the
stent is patent and the IP service does not feel that there is
anything more that they can do at this time. Pt's resp status
improved in ED with humidified air and morphine. However, per IP
service, pt should not receive narcotics. Pt has just finished a
course of levaflox for ? bronchitis and has not required
steroids since discharged on [**2176-6-5**].
- Will give alb/ atro nebs to heplopen airways.
- Cont acetylcysteine for mucolytics.
- Humidified O2 for comfort.
- Pt discussed with Dr. [**Last Name (STitle) **] on admission and would prefer to
have patient seen at [**Hospital 13128**] as this is where she gets
most of her care. Further interventions would likely be surgical
at this point.
- No further imaging at this time as the patient is comfortable
and last CT on [**6-4**].
- If resp status worsens can give steroids to decrease known
edema. Can also consider azythromycin for Bronchitis as this
also has anti-inflammatory effects.
- If decompensates consider Heliox.
- Consult IP (Dr. [**Last Name (STitle) **] in the am.
.
2)Neck pain: Pt has a history of narcotic abuse. Per prior notes
and Dr [**Last Name (STitle) **] the patient should not receive narcotics. Will
treat pain with alternating tylenol and ibuprofen.
.
3) DM: Will hold metformin for possible CT. Will cover with
RISS.
.
4) FEN: Pt tolerating PO. Mildly hypotensive in ED after
receiving 6mg morphine. Diabetic diet, no IVF at this time, will
recheck lytes in am.
.
5) PPx: Famotidine. Will start bowel reg as needed. SC heparin.
.
6) Access: PIV
.
7) Code: FULLChief complaint: SOB and Stridor
.
[**2176-6-12**]: HD 1 patient w/ no respiratory distress. Primary
complaint of pain in throat. VSS with CXR indicative of no
pneumonia, mild left lower lobe atelectasis.
Medications on Admission:
Albuterol
Mucomyst
Atrovent
Trazodone 100Qhs
Effexor sustained release 75mg QD
Zonisamide 100mg Qhs
Glyburide/Metformin 5-500 PO BID
Famotidine 20 [**Hospital1 **]
Lopressor 25mg [**Hospital1 **]
Loarazepam 1mg Q6
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- shortness of breath
- subglottic and tracheal stenosis s/p stent
SECONDARY:
- carotid stenosis
- h/o CVA
- lupus
- hypothyroidism
- diabetes mellitus
- s/p bilateral mastectomies
Discharge Condition:
no shortness of breath, oxygenating well, discharged to home
with outpatient follow-up
Discharge Instructions:
- Take medications as scheduled.
- Follow up as scheduled. Call Dr. [**Last Name (STitle) **] of [**Hospital 13128**]
immediately after discharge for a follow-up appointment.
- Seek immediate medical attention for shortness of breath,
difficulty swallowing, vomiting, cough with sputum, fevers,
chills, or other concerning symptoms.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] of [**Hospital 13128**] immediately after discharge
for a follow-up appointment.
|
[
"710.0",
"250.00",
"244.9",
"478.74",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7196, 7202
|
3731, 6723
|
338, 345
|
7436, 7525
|
2919, 3708
|
7907, 8026
|
2349, 2474
|
7223, 7415
|
6958, 7173
|
7549, 7884
|
2489, 2900
|
6740, 6932
|
373, 1971
|
1993, 2122
|
2138, 2333
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
806
| 149,888
|
16590+16614+16591+16592
|
Discharge summary
|
report+report+report+report
|
Admission Date: [**2103-1-19**] Discharge Date: [**2103-1-25**]
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is an 83 year old male
transferred from [**Hospital3 23439**] Hospital in [**Location (un) 8973**] with a
past medical history of diabetes mellitus, chronic renal
insufficiency with baseline of 2.1 creatinine and
hypertension who presented with chest pain and shortness of
breath and ruled in for non-Q wave myocardial infarction with
troponin of 14.5 at an outside hospital. There he was found
to be in congestive heart failure and diuresed with a
subsequent bump in his creatinine from 2.1 baseline to 2.6.
At the outside hospital an echocardiogram showed severe
aortic stenosis with valve area of 0.5 cm squared and an
ejection fraction of 35%.
The patient presented with mid sternal chest pain radiating
to both arms, arm heaviness and overwhelming sense of fatigue
and shortness of breath. It was relieved when he sat upright
and worse when he was lying down. The patient went to the
Emergency Department and his chest pain was relieved after
one sublingual nitroglycerin. The patient has had increase
in chest pressure with exertion over the past one and a half
years. He has also had increased chest pressure, status post
eating which occurs about 15 minutes after a meal. He has no
fever and chills. He sleeps on one pillow with no increase,
no paroxysmal nocturnal dyspnea, no coughing, no lightheaded
and no syncope. He has a history of five to six years of
chronic lower extremity edema. No abdominal pain after
meals, no melena, no hematochezia, no dysuria, no transient
ischemic attack symptoms.
PAST MEDICAL HISTORY: No prior cardiac history. Diabetes
mellitus for 14 years. Chronic renal insufficiency, baseline
creatinine 2.1. Stroke ten years ago with a question of a
right facial droop, now on Coumadin. Echocardiogram at [**Hospital3 38921**] Hospital, [**Location (un) 8973**], showing ejection fraction of
35%, severe atrial fibrillation, hypertension,
hypercholesterolemia, cataract surgery, tonsillectomy,
appendectomy.
MEDICATIONS ON ADMISSION: (At outside hospital/admission
here) Aspirin 81 mg p.o. q.d.; Glucotrol 20 mg p.o. q.d.;
Prevacid; Lasix 40 mg intravenously b.i.d.; Lopressor 12.5 mg
b.i.d.; Mucomyst 600 mg p.o. b.i.d.; Heparin drip;
Nitroglycerin drip. The patient took Coumadin at home 5 mg
q.d. and Nifedipine 60 mg q.d. at home.
ALLERGIES: Sulfa ? reaction; statins with myopathy.
SOCIAL HISTORY: Lives with daughter in [**Location (un) 8973**], quit
tobacco in [**2070**] and smoked [**2-15**] pack per day for 40 years,
worked as a custodian, no alcohol, no drugs.
FAMILY HISTORY: Mother with diabetes in her 70s.
PHYSICAL EXAMINATION: Examination on admission revealed
temperature 98.4, blood pressure 114/60, pulse 72,
respirations 18, 140 lbs by patient report. General: Alert
and oriented in no acute distress. Head, eyes, ears, nose
and throat, extraocular movements intact, pupils equal, round
and reactive to light, anicteric sclera, mucous membranes
moist. Neck, no jugulovenous distension, no lymphadenopathy.
Chest, bibasilar rales. Cardiac, regular rate and rhythm,
S1 and S2, harsh III/VI systolic ejection murmur, loudest at
apex, radiating to carotids and to femoral vessels. Abdomen,
nontender, nondistended, normoactive, no organomegaly.
Rectal, large prostate guaiac negative stool. Extremities,
no cyanosis, clubbing or edema. Vascular, bilateral femoral
bruits, likely radiated from heart. Bilateral carotid
bruits, questionably radiating from heart as well. 2+
dorsalis pedis pulses bilaterally. Neurologic, cranial
nerves II through XII intact. Strength, [**6-18**] in upper and
lower extremities. Left arm with slight intention tremor.
Sensory grossly intact. Patellar reflexes equal bilaterally.
Babinski downgoing bilaterally.
LABORATORY DATA: Laboratory studies at the outside hospital
on admission on [**1-19**], white blood cell count 10,
hematocrit 37.8, platelets 145, LDL in 200s. Sodium 136,
potassium 4.5, chloride 96, bicarbonate 30, BUN 51,
creatinine 2.6, platelets 202, calcium 8.5 and INR 1.8.
Electrocardiogram, normal sinus rhythm, 70, left axis
deviation, positive left atrial abnormality, positive left
ventricular hypertrophy, positive left ventricular strain
pattern in V4 through V6 and one in AVL.
HOSPITAL COURSE: This is an 83 year old male without
significant past cardiac history with a history of
hypercholesterolemia, diabetes mellitus, and hypertension who
was transferred from an outside hospital after ruling in for
non-Q wave myocardial infarction, congestive heart failure
and found to have critical aortic stenosis by echocardiogram.
The patient was also found to have increase in his creatinine
from 2.1 to 2.6 after diuresis of his congestive heart
failure. On presentation he was asymptomatic with
Nitroglycerin drip and status post diuresis.
1. Cardiac - A. Coronary artery disease, the patient with
increasing exertional chest pressure over the past few months
with more recent increased angina when lying down flat,
relieved when sitting upright. This is likely due to
elements of congestive heart failure when lying flat. He
ruled in for non-Q wave myocardial infarction by positive
troponins at outside hospital. He likely has both coronary
artery disease and subendocardial ischemia with his critical
aortic stenosis. On admission here he was continued on his
heparin drip, weaned off of his Nitroglycerin drip because of
his critical aortic stenosis and continued on his beta
blocker and Aspirin.
Cardiac catheterization was done after his renal function
showed some improvement. This showed: Three vessel cardiac
disease with calcified left anterior descending and moderate
diffuse disease throughout with stenosis of 60% in the mid
segment. The dominant circumflex had 50% proximal disease
and 80% distal disease. An obtuse marginal had a proximal
90% stenosis. The nondominant right coronary artery also had
a stenosis of 80% at its mid segment.
Because of his three vessel disease, this patient was thought
to be a candidate for coronary artery bypass graft. The
patient was awaiting coronary artery bypass graft and had
multiple episodes of chest pain during this time. This chest
pain was relieved on occasion by merely sitting the patient
upright. Other times it required one to two sublingual
nitroglycerins administered judiciously to try to prevent too
much preload reduction with his critical aortic stenosis. On
occasion this chest pain was associated with flash pulmonary
edema and desaturations to 85% which was relieved by
sublingual nitroglycerin and Lasix.
B. Pump, this is a patient with critical aortic stenosis
seen by cardiac catheterization and echocardiogram with
increasing angina, and dyspnea. He has no history of
syncope.
Cardiac catheterization showed hemodynamics with normal
right-sided filling pressures and mildly elevated left-sided
filling pressures with a mean gradient of 35.5 mg of mercury
across the aortic valve and a calculated valve area of 0.79
cm squared. The cardiac index was mildly reduced at 2.3.
The patient had echocardiogram as well this admission which
showed ejection fraction of 40%. The severe aortic stenosis
was seen with symmetric left ventricular hypertrophy and
regional dysfunction of his inferolateral and inferior walls
with hypo and akinesis in this region consistent with
coronary artery disease. He also had mild to moderate mitral
regurgitation and moderate pulmonary artery hypertension by
this study.
The patient was continued on his Metoprolol 25 mg p.o. b.i.d.
and cautious use of Nitroglycerin was used during his
episodes of flash pulmonary edema.
CEP, the patient was in normal sinus rhythm throughout this
hospitalization with evidence of left ventricular strain on
his electrocardiogram with no significant event on telemetry.
The patient has a history of hypertension and has blood
pressure ranged from 120 to 160 systolic during this
hospitalization.
2. Carotid artery disease - The patient was thought to be a
candidate for coronary artery bypass graft and aortic valve
repair. Prior to his surgery he did receive a carotid artery
duplex evaluation which showed 80 to 99% stenosis of the
right internal carotid artery and occlusion of the left side.
He was then given an magnetic resonance imaging scan,
magnetic resonance angiography of his head and neck which
confirmed these ultrasound studies. It did show a patent
circle of [**Location (un) 431**] and flow in the vertebral arteries. The
patient was thought to benefit most from right coronary
artery stenting prior to his coronary artery bypass graft and
aortic valve repair surgery. At the time of this dictation
he will be undergoing this procedure today. He had no signs
of acute stroke by his magnetic resonance imaging scan.
3. Renal - The patient had acute and chronic renal failure,
status post diuresis for his congestive heart failure on
admission.
The patient's creatinine fluctuated between 2.1 and 2.6
during this hospitalization with an increase 48 hours after
cardiac catheterization and slight increases after his
diuresis in the setting of his flash pulmonary edema.
Overall, however, it has ranged in the 2.4 to 2.5 range with
good urine output.
4. Hematology - The patient had been anticoagulated for his
history of stroke. He was continued on his heparin GGT
during this admission for his acute coronary syndrome as well
as his cardiovascular disease. His Coumadin was held. His
platelets remained stable in the low 100s on heparin
throughout this stay.
5. Diabetes mellitus - His blood sugars ranged from 170 to
250 during his stay on the floor on a regular insulin sliding
scale. He was kept on the sliding scale and his Glucotrol
was discontinued because of his multiple catheterizations and
during this week.
6. Hypercholesterolemia - The patient could not tolerate
statins and develops myopathy with these. He was continued
on a low cholesterol diet.
DISPOSITION: The patient will have his carotid stent and go
to the Coronary Care Unit. He will then be transferred to
the Cardiothoracic Surgery Team for coronary artery bypass
graft and aortic valve repair.
This dictation encompasses the hospital stay from [**1-19**]
to [**2103-1-14**].
MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Metoprolol 25 mg p.o. b.i.d.
4. Insulin sliding scale
5. Nitroglycerin 0.3 mg sublingual times one prn
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Last Name (NamePattern4) 47047**]
MEDQUIST36
D: [**2103-1-25**] 15:36
T: [**2103-1-25**] 16:33
JOB#: [**Job Number 47048**]
Admission Date: Discharge Date: [**2103-2-2**]
Service:
ADDENDUM
The patient was kept for two additional days, and was
discharged on [**2103-2-2**] in order to observe the patient and
follow the patient's creatinine. On [**2103-2-2**], the patient's
creatinine was decreased appropriately from 3.2 to 3.1, and
it was agreed upon by the primary team to discharge the
patient in light of the patient's plateauing creatinine,
which was thought to be secondary to diuresis by using
furosemide as well as hypotension intraoperatively. The
patient is to follow up with the [**Hospital 10701**] Clinic as well as
the primary care physician and Dr. [**Last Name (STitle) **] in four weeks.
DISCHARGE MEDICATIONS:
1. Norvasc 2.5 mg by mouth once daily
2. Ciprofloxacin 500 mg by mouth once daily for seven days
3. Glipizide 10 mg by mouth once daily
4. Plavix 75 mg by mouth once daily
5. Aspirin 325 mg by mouth once daily
6. Zantac 150 mg by mouth twice a day
7. Colace 100 mg by mouth twice a day
8. Lopressor 12.5 mg by mouth twice a day
9. Tamsulosin 0.4 mg by mouth daily at bedtime
10. Percocet one to two tablets by mouth every four to six
hours as needed for pain
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 17480**]
MEDQUIST36
D: [**2103-2-4**] 18:06
T: [**2103-2-5**] 01:02
JOB#: [**Job Number **]
Admission Date: [**2103-1-19**] Discharge Date: [**2103-2-2**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old
male transferred from [**Hospital6 14576**] with a past
medical history of diabetes mellitus, CRI, hypertension
presenting with shortness of breath, chest pain and ruled in
for a non Q wave myocardial infarction with troponin highs of
14.5. The patient was found to be in congestive heart
failure, was diuresed, creatinine increased from 2.1 to 2.6.
Echocardiogram showed severe aortic stenosis, 0.5 cm squared
and an ejection fraction of 35%. The patient presented with
mid sternal chest pain radiating to both arms, arm heaviness,
and fatigue, question short of breath. Relieved when he sat
upright and worse when lying. The patient went to the
Emergency Department and chest pain was relieved after one
nitro and has been chest pain free since. He has had
increased chest pain with exertion for the past one and a
half years. Also increased chest pain with eating, fifteen
minutes after eating. No fevers or chills. The patient
sleeps on one pillow. No paroxysmal nocturnal dyspnea, no
cough, no lightheadedness, no syncope. History of five or
six years of chronic lower extremity edema. No abdominal
pain after meals. No melena. No hematochezia, polyuria. No
transient ischemic attack symptoms.
PHYSICAL EXAMINATION: The patient's vital signs are stable.
Neck no JVD. No lymphadenopathy. Chest bibasilar rales.
Cardiovascular regular rate and rhythm. S1 and S2. 3 out of
6 systolic ejection murmur loudest at apex, radiates to
carotids. Abdomen nontender, nondistended. No organomegaly.
Rectal large prostate, guaiac negative stool. Extremities no
clubbing, cyanosis or edema. Vascular bilateral femoral
bruits, bilateral carotid bruit, question radiating from
aortic stenosis. 2+ dorsalis pedis pulses. Neurological
cranial nerves II through XII intact. Strength 5 out of 5
upper extremities and lower extremities. Left arm slight
intention tremor. Sensory grossly intact. Patella reflexes
equal bilaterally. Babinski downward.
LABORATORY: Hematocrit 37.8, creatinine 2.6, calcium 8.5,
INR 1.8. Electrocardiogram normal sinus rhythm at 70, left
axis deviation down sloping ST depressions in 1 through AVL,
V4 through V6 versus left ventricular strain.
HOSPITAL COURSE: The patient is admitted to the [**Hospital Unit Name 196**] Service
on [**2103-1-19**] for complaints of chest pain at which time the
patient ruled in and was transferred to [**Hospital1 190**] from [**Hospital3 **]. The patient was started on
a heparin drip, nitro drip and sublingual nitroglycerin prn,
beta blocker and aspirin. Cardiac catheterization was also
recommended. The patient's kidney function was also assessed
as acute on chronic renal failure, which at that time was
attributed to prerenal failure. Subsequent cardiac
catheterization showed left main coronary artery with no
significant obstructive disease, left anterior descending
coronary artery with 60% stenosis in the mid portion, left
circumflex 70% proximal, 90% stenosis at the obtuse marginal
one, 90% distal obstruction and right coronary artery with
small nondominant 70% mid vessel stenosis. Aortic valve
gradient was 15 mmHg. At that time it was thought that
because of the patient's three vessel disease that he should
proceed to Cardiothoracic Surgery for coronary artery bypass
graft. In addition, the patient was worked up for his
carotid disease and the vascular laboratory reported carotid
stenosis of 80 to 99% of the right coronary artery and no
flow detected in the left internal carotid.
A renal consult was obtained for the patient's acute
on chronic renal failure at which time the following
recommendations were made, to hold off on the patient's
diuretics, review urinary sediment and to hold on the
patient's ace inhibitor and to avoid nephrotoxins. It is
believed that the patient's acute renal insufficiency was due
to redo contrast nephrotoxicity. The chronic renal disease
was secondary to diabetes. The patient had no evidence of
atheroemboli. On hospital day five the patient was noted to
have flash pulmonary edema. The Stroke Service was consulted
in order to place a stent in the right internal carotid
artery before the patient's aortic valve replacement and
coronary artery bypass graft. The findings on duplex
ultrasound were confirmed by MRA. The patient was found to
have severe right coronary artery stenosis. On [**2103-1-25**] the patient had a 30 mm carotid stent placed in the
right ICA. The patient was seen by cardiac surgery at which
time possible risks and complications were explained to him
and consent was signed.
The patient was taken to the Operating Room on [**2103-1-26**] at
which time coronary artery bypass graft times three was
performed. The patient's left internal mammary coronary
artery was taken to the left anterior descending coronary
artery, saphenous vein graft to the posterior descending
coronary artery, saphenous vein graft to the obtuse marginal.
The patient was cross clamped for 115 minutes and
cardiopulmonary bypass times 147 minutes. In addition, he an
aortic valve replacement was performed. A #19 mm CE Bovine
pericardial valve was placed. Postoperative day number one
the patient did well on CPAP and pressure support of 10 to
15. The patient's blood gases were normal at that time and
on postoperative day number two the patient continue to
resolve without neurological deficits. He was continued on
his aspirin and Plavix for patency of the carotid stent. On
postoperative day number three the patient was felt to be
stable and was subsequently transferred to the cardiac
surgical floor.
On the floor the patient's Foley was discontinued, but had to
be replaced secondary to a 12 hour lack of urination. Post
void residual was 700. The patient's creatinine continued to
creep up to approximately 3.1. The patient's blood pressure
also elevated and renal recommended Norvasc 2.5 mg po q day.
The patient also received 1 unit of packed red blood cells
for a hematocrit of 26, which was on repeat hematocrit 30.7.
On postop day seven the patient's AV wires were taken out and
the patient was found to be stable for rehab. Urology had
seen the patient and has recommended starting the patient on
Flomax .4 for the patient's urinary retention. The patient
is to have voiding trial in one week and is leaving with a
urinary leg bag. The patient is to follow up with nephrology
and with the Neurological Stroke service.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSES:
Status post right internal carotid artery stent and status
post coronary artery bypass graft with aortic valve
replacement.
DISCHARGE MEDICATIONS: Norvasc 2.5 mg po q day,
Ciprofloxacin 500 mg po q 24 hours, Glipizide 10 mg po q day,
Plavix 75 mg po q day, aspirin 325 mg po q day, Zantac 150 mg
po q day, Colace 100 mg po b.i.d. and Lopressor 25 mg po
b.i.d.
FOLLOW UP PLANS: The patient is to follow up with the
Neurology Stroke Service in two weeks. The patient is to
follow up with Dr. [**Last Name (STitle) **] in four weeks and should follow up
with the Nephrology Service in two weeks as well.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 8455**]
MEDQUIST36
D: [**2103-2-2**] 10:36
T: [**2103-2-2**] 10:44
JOB#: [**Job Number 19515**]
Admission Date: [**2103-1-19**] Discharge Date: [**2103-2-2**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old
male transferred from [**Hospital6 14576**] with a past
medical history of diabetes mellitus, CRI, hypertension
presenting with shortness of breath, chest pain and ruled in
for a non Q wave myocardial infarction with troponin highs of
14.5. The patient was found to be in congestive heart
failure, was diuresed, creatinine increased from 2.1 to 2.6.
Echocardiogram showed severe aortic stenosis, 0.5 cm squared
and an ejection fraction of 35%. The patient presented with
mid sternal chest pain radiating to both arms, arm heaviness,
and fatigue, question short of breath. Relieved when he sat
upright and worse when lying. The patient went to the
Emergency Department and chest pain was relieved after one
nitro and has been chest pain free since. He has had
increased chest pain with exertion for the past one and a
half years. Also increased chest pain with eating, fifteen
minutes after eating. No fevers or chills. The patient
sleeps on one pillow. No paroxysmal nocturnal dyspnea, no
cough, no lightheadedness, no syncope. History of five or
six years of chronic lower extremity edema. No abdominal
pain after meals. No melena. No hematochezia, polyuria. No
transient ischemic attack symptoms.
PHYSICAL EXAMINATION: The patient's vital signs are stable.
Neck no JVD. No lymphadenopathy. Chest bibasilar rales.
Cardiovascular regular rate and rhythm. S1 and S2. 3 out of
6 systolic ejection murmur loudest at apex, radiates to
carotids. Abdomen nontender, nondistended. No organomegaly.
Rectal large prostate, guaiac negative stool. Extremities no
clubbing, cyanosis or edema. Vascular bilateral femoral
bruits, bilateral carotid bruit, question radiating from
aortic stenosis. 2+ dorsalis pedis pulses. Neurological
cranial nerves II through XII intact. Strength 5 out of 5
upper extremities and lower extremities. Left arm slight
intention tremor. Sensory grossly intact. Patella reflexes
equal bilaterally. Babinski downward.
LABORATORY: Hematocrit 37.8, creatinine 2.6, calcium 8.5,
INR 1.8. Electrocardiogram normal sinus rhythm at 70, left
axis deviation down sloping ST depressions in 1 through AVL,
V4 through V6 versus left ventricular strain.
HOSPITAL COURSE: The patient is admitted to the [**Hospital Unit Name 196**] Service
on [**2103-1-19**] for complaints of chest pain at which time the
patient ruled in and was transferred to [**Hospital1 190**] from [**Hospital3 **]. The patient was started on
a heparin drip, nitro drip and sublingual nitroglycerin prn,
beta blocker and aspirin. Cardiac catheterization was also
recommended. The patient's kidney function was also assessed
as acute on chronic renal failure, which at that time was
attributed to prerenal failure. Subsequent cardiac
catheterization showed left main coronary artery with no
significant obstructive disease, left anterior descending
coronary artery with 60% stenosis in the mid portion, left
circumflex 70% proximal, 90% stenosis at the obtuse marginal
one, 90% distal obstruction and right coronary artery with
small nondominant 70% mid vessel stenosis. Aortic valve
gradient was 15 mmHg. At that time it was thought that
because of the patient's three vessel disease that he should
proceed to Cardiothoracic Surgery for coronary artery bypass
graft. In addition, the patient was worked up for his
carotid disease and the vascular laboratory reported carotid
stenosis of 80 to 99% of the right coronary artery and no
flow detected in the left internal carotid.
A renal consult was obtained for the patient's acute
on chronic renal failure at which time the following
recommendations were made, to hold off on the patient's
diuretics, review urinary sediment and to hold on the
patient's ace inhibitor and to avoid nephrotoxins. It is
believed that the patient's acute renal insufficiency was due
to redo contrast nephrotoxicity. The chronic renal disease
was secondary to diabetes. The patient had no evidence of
atheroemboli. On hospital day five the patient was noted to
have flash pulmonary edema. The Stroke Service was consulted
in order to place a stent in the right internal carotid
artery before the patient's aortic valve replacement and
coronary artery bypass graft. The findings on duplex
ultrasound were confirmed by MRA. The patient was found to
have severe right coronary artery stenosis. On [**2103-1-25**] the patient had a 30 mm carotid stent placed in the
right ICA. The patient was seen by cardiac surgery at which
time possible risks and complications were explained to him
and consent was signed.
The patient was taken to the Operating Room on [**2103-1-26**] at
which time coronary artery bypass graft times three was
performed. The patient's left internal mammary coronary
artery was taken to the left anterior descending coronary
artery, saphenous vein graft to the posterior descending
coronary artery, saphenous vein graft to the obtuse marginal.
The patient was cross clamped for 115 minutes and
cardiopulmonary bypass times 147 minutes. In addition, he an
aortic valve replacement was performed. A #19 mm CE Bovine
pericardial valve was placed. Postoperative day number one
the patient did well on CPAP and pressure support of 10 to
15. The patient's blood gases were normal at that time and
on postoperative day number two the patient continue to
resolve without neurological deficits. He was continued on
his aspirin and Plavix for patency of the carotid stent. On
postoperative day number three the patient was felt to be
stable and was subsequently transferred to the cardiac
surgical floor.
On the floor the patient's Foley was discontinued, but had to
be replaced secondary to a 12 hour lack of urination. Post
void residual was 700. The patient's creatinine continued to
creep up to approximately 3.1. The patient's blood pressure
also elevated and renal recommended Norvasc 2.5 mg po q day.
The patient also received 1 unit of packed red blood cells
for a hematocrit of 26, which was on repeat hematocrit 30.7.
On postop day seven the patient's AV wires were taken out and
the patient was found to be stable for rehab. Urology had
seen the patient and has recommended starting the patient on
Flomax .4 for the patient's urinary retention. The patient
is to have voiding trial in one week and is leaving with a
urinary leg bag. The patient is to follow up with nephrology
and with the Neurological Stroke service.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSES:
Status post right internal carotid artery stent and status
post coronary artery bypass graft with aortic valve
replacement.
DISCHARGE MEDICATIONS: Norvasc 2.5 mg po q day,
Ciprofloxacin 500 mg po q 24 hours, Glipizide 10 mg po q day,
Plavix 75 mg po q day, aspirin 325 mg po q day, Zantac 150 mg
po q day, Colace 100 mg po b.i.d. and Lopressor 25 mg po
b.i.d.
FOLLOW UP PLANS: The patient is to follow up with the
Neurology Stroke Service in two weeks. The patient is to
follow up with Dr. [**Last Name (STitle) **] in four weeks and should follow up
with the Nephrology Service in two weeks as well.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 8455**]
MEDQUIST36
D: [**2103-2-2**] 10:36
T: [**2103-2-2**] 10:44
JOB#: [**Job Number 19515**]
|
[
"427.31",
"584.9",
"428.0",
"433.10",
"593.9",
"424.1",
"414.01",
"410.71",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.41",
"88.56",
"35.21",
"36.12",
"39.50",
"36.15",
"39.61",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
2696, 2730
|
26452, 26577
|
26601, 27338
|
2133, 2491
|
22170, 26369
|
21198, 22152
|
19932, 21175
|
1689, 2106
|
2508, 2679
|
26394, 26431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,454
| 120,237
|
47711
|
Discharge summary
|
report
|
Admission Date: [**2136-7-18**] Discharge Date: [**2136-8-1**]
Service: MEDICINE
Allergies:
Pronestyl / Quinidine / Clonidine / A.C.E Inhibitors /
Spironolactone / Flagyl / Levaquin / Compazine / Keflex
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Decreasing hematocrit, right thigh hematoma and decreased urine
output.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PT is an 86 y.o female with h.o CAD, systolic CHF, AS/AR, afib,
s/p pacemaker, HL, DM, dementia, s/p CEA who was recently
admitted on [**7-4**] to the [**Hospital Unit Name 153**] then transferred to [**Hospital Ward Name 121**] 3/[**Hospital1 **]
service.
.
At [**Name (NI) 16962**], pt was found to have a HCT of 21, 27 2 days ago and and
INR of 4.7. Pt was given 1u PRBCs and 2 units of FFP. Pt was
also noted to have a K of 5.6 for which she was given 10 units
of reg insulin SC, 1 amp bicarb, D50, kayexylate. Pt was also
noted to have a Ck of 529, MB 60, index 11.3, and troponin of
30.18. R.femoral line was placed. Vitals noted to be T 97, BP
108/55, finger stick 155.
.
Pt's daughter reports that she felt her mother was more "weak",
"pale" and had decreased urine output. Pt and daughter deny
recent trauma or falls. Of note, pt c/o L.hip pain at last admit
and plan films were neg for fx.
.
Currently pt denies pain, LH/dizziness, headache, chest
pain/palpitations, SOB, abd pain/N/V/D/C, joint pain, rash.
.
On review of symptoms, - stroke, -TIA, +deep venous
thrombosis/L.arm, -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. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
1. CAD - s/p PCI with BMS [**8-20**]
2. CHF (LVEF 25% 10/06)
3. Rheumatic, multivalvular disease (mod AS, mod-severe AR)
4. Afib
5. CHB s/p pacemaker placement
6. IDDM
7. Hyperlipidemia
8. Dementia
9. HTN
10. h/o GI bleed
11. Hypothyroidism
12. Temporal arteritis
13. s/p R CEA
14. chronic c. diff colitis
15. CKD - b/l Cr. ~1.6
Brief Hospital Course:
Pt is an 86 year old female with a history of CAD, CHF, s/p
pacemaker implantation, who presented with a left thigh
hematoma, HCT drop and elevated INR, with acute renal failure.
She was admitted to the CCU on [**2136-7-18**].
#Acute renal failure: The patient had a baseline Cr of 1.4-2.0.
was 1.4 on [**7-15**]. Likely etiology is ATN (muddy-brown casts).
Pt's daughter reporting poor urine output at home. There was no
suspicion of obstructive physiology. The Patient's fluid status
was initially unclear. She appeared to be dry and was given
fluid however she did not make urine appropriate to the fluid
bolus. She became fluid overloaded and diuresis was attempted.
She did not respond well to Lasix and continued to retain fluid.
Nephrology was consulted and recommended holding Lasix and that
the only remaining treatment options for her was dialysis.
Lasix drip was attempted for fluid removal as family did not
want to put patient on dialysis. The patient's creatinine
continued to rise and was 4.1 on [**7-29**].
.
# CAD: Pt with a h/o MI, s/p stenting [**2128**] to LAD. Originally
report was that pt had a Troponin of 30 at [**Year (4 digits) 16962**]. However, trop T
on admission was 1.40. Elevated enzymes could have been due to a
cardiac event but it was felt that the patient was a poor
candidate for any intervention. ECG was unchanged and the
patient was without cardiac symptoms. Cardiac enzymes trended
down over admission.
.
# CHF: The patient had a history of Systolic HF. Last echo with
EF 15-20%. The pati net initially received fluid boluses to help
determine etiology of renal failure, however she was unable to
remove volume and not candidate for dialysis. Patient comfort
made main goal of therapy.
.
# A-FIB: The patient had a history of afib and was s/p pacemaker
placement.She was vpaced (VVI) at the time of admission. Her
Pacer rate increased to attempt to help cardiac output however
this did not have an effect on urine output.
.
# Anemia: The patient had a history of anemia. Baseline HCT
34-38 but was noted to be 22 on admission. Likely etiology is
from suspected bleed-in the area of the L.thigh, likely
spontaneous in the setting of supratherapeutic INR. CT
abd/pelvis/L.thigh ruled out RP and rectus sheath bleed, thigh
hematoma seen. The patient was not transfused blood as
hematocrit stabilized and patient already in heart failure.
.
#history of C.diff- The patient was initially continued on her
suppressive vancomycin therapy, but was stopped with negative
C.diff toxins.
.
# Pain/Palliation/End of life: A family meeting was held on [**7-29**]
and the options/goals of care were discussed. It was felt that
the patient's renal failure required dialysis and the family was
clear that this was not a therapy they wished to pursue. It was
agreed that patient would stop medications that were only
present because of long term benefit and that patient comfort
would be the goal of care. Patient moving towards CMO, no oral
medications and the patient was started on Dilaudid for pain
control. She was continued on telemetry for family comfort.
Over the next 3 days, the patient's mental status declined and
she became less responsive. On [**8-1**], the patient was surrounded
by her daughters and care givers when she was noted to become
asystolic. No intervention was attempted. The patient appeared
to die peacefully and without pain. She was pronounced dead at
4:24pm.
Medications on Admission:
ASA 81 mg daily
CALCIUM-CHOLECALCIFEROL 500 mg (1,250 mg)-400 unit- [**Unit Number **] daily
CALCITONIN 200 U 1 spray once a day
CARVEDILOL 6.25 mg [**Hospital1 **]
COUMADIN 5 mg daily
DIGOXIN .0625 mg daily
DONEPEZIL 10 mg daily
FERROUS SULFATE 325 mg daily
FUROSEMIDE 60 mg daily
INSULIN NPH - 12 units once a day
INSULIN LISPRO [HUMALOG] daily before breakfast per SS
LATANOPROST [XALATAN] - 0.005 % - 1 drop both eyes at bedtime
LEVOTHYROXINE 112 mcg daily
LIPITOR 10 mg daily
LOSARTAN 25 mg daily
METOLAZONE 2.5 mg daily
POTASSIUM CHLORIDE 70 mEq
PROTONIX 40 mg daily
SACCHAROMYCES BOULARDII - 500 mg [**Hospital1 **]
SERTRALINE [ZOLOFT] 75 mg qHS
VANCOMYCIN 250 mg daily (was increased to 250 mg QID)
.
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest
Systolic Heart Failure
Renal Failure
Discharge Condition:
Expired
Completed by:[**2136-8-3**]
|
[
"426.0",
"E934.2",
"V53.31",
"427.31",
"998.2",
"396.8",
"584.5",
"599.0",
"V45.82",
"428.22",
"250.00",
"276.52",
"285.1",
"V58.61",
"244.9",
"414.01",
"428.0",
"272.4",
"403.90",
"728.89",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6350, 6359
|
2159, 5590
|
388, 394
|
6462, 6499
|
6380, 6441
|
5616, 6327
|
277, 350
|
422, 1775
|
1797, 2136
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,795
| 173,748
|
36404
|
Discharge summary
|
report
|
Admission Date: [**2130-4-27**] Discharge Date: [**2130-7-4**]
Date of Birth: [**2084-6-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
new acute low back pain w/ bilateral leg spasms associated w/
obliterated T4 vertebrae on CT chest
Major Surgical or Invasive Procedure:
[**5-15**]: Median Sternotomy for anterior approach T1-T7 fusion.
Placement of 3 chest tubes and a lumbar drain.
History of Present Illness:
45F w/ multiple medical problems including alcohol abuse, c/b
pancreatitis, CRI, DM2 was d/c'd on [**2130-4-25**] from [**Hospital **] hospital
after EtOH detoxification since [**2130-3-31**] and returning for
atypical chest pain on [**2130-4-22**] (negative cardiac workup). One day
after she returned to [**Hospital1 **] w/ new acute new acute low back
pain w/ bilateral leg spasms. Back pain was constant, leg
spasms were intermittent and varied b/w sharp and dull and had
associated tingling. She also c/o weakness in her
arms/shoulders and legs when walking. CTA chest demonstrated
destruction of T4 vertebral body.
Past Medical History:
atypical chest pain, h/o ETOH abuse, hypercoagulopathy
secondary to ETOH abuse, depression, DM2, h/o hepatic
encephalopathy, CRI, h/o anemia, hepatic cirrhosis, GERD, h/o
ETOH pancreatitis
Social History:
ETOH for 15 yrs w/ at least 3 "heavy" drinks daily, detox on
[**2130-3-31**], Smoked for ~15yrs, quit w/ detox, denies illict/IVDU,
married, lives w/ husband, currently unemployed.
Family History:
non-contributory
Physical Exam:
On admission:
BP: 147/96 HR: 80 RR: 20 O2Sats: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL; EOMI
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, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5- 5- 5 5 5 5
L 5 5 5 5 5 5 5- 5 5 5 5
Sensation: Intact to light touch, pinprick bilaterally but
decreased below knees bilaterally
Reflexes: B T Br Pa Ac
Right 2---------->
Left 2---------->
Rectal exam normal sphincter control, rash at perineum
On Discharge:
VS: Tm 101.5 P 100-120 BP 120-140/60-90 RR 18 Sat 99/RA
GEN alert, confused
ENT dry OP
CV tacycardia
P mildly decreased breath sounds at right base
GI soft, mildly tender, non distended
EXT warm, no edema
NEURO RLE weakness 1-2/5
Pertinent Results:
Labs On Admission:
[**2130-4-26**] 09:30PM BLOOD WBC-4.2 RBC-3.22* Hgb-10.9* Hct-31.3*
MCV-97 MCH-33.8* MCHC-34.8 RDW-15.5 Plt Ct-81*
[**2130-4-26**] 09:30PM BLOOD Neuts-57 Bands-0 Lymphs-29 Monos-13*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2130-4-26**] 09:30PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2130-4-26**] 09:30PM BLOOD PT-18.3* PTT-32.4 INR(PT)-1.7*
[**2130-4-27**] 09:35AM BLOOD ESR-43*
[**2130-4-26**] 09:30PM BLOOD Glucose-81 UreaN-13 Creat-1.2* Na-132*
K-4.0 Cl-98 HCO3-23 AnGap-15
[**2130-4-26**] 09:30PM BLOOD ALT-71* AST-110* LD(LDH)-408*
AlkPhos-140* TotBili-1.8*
[**2130-4-27**] 09:35AM BLOOD Calcium-8.3* Phos-5.6* Mg-1.2*
[**2130-4-27**] 09:35AM BLOOD CRP-7.3*
Labs on Discharge ([**2130-7-4**]):
Iron: Pnd
Ferritn: Pnd
TRF: Pnd
133 95 14 AGap=13
-------------< 105
3.2 28 2.9 D
Ca: 8.0 Mg: 1.4 P: 0.7 D
WBC: 4.8
PLT: 39
HCT: 20.1
Imaging:
CTA Chest [**4-26**]:
IMPRESSION:
1. No central, lobar, or segmental pulmonary embolus.
2. Complete destruction of T4 vertebral body with a soft tissue
mass
circumferentially involving this level and extending into the
central canal as
described above. Further evaluation with a dedicated CT and MR
should be
performed.
3. Ascites.
CT T-Spine [**4-27**]:
MPRESSION: Complete destruction of T4 vertebral body with a
circumferential
soft tissue mass extending into the spinal canal as described
above.
Evaluation of [**Month/Day (4) **] is significantly limited, but appears to be
displaced and possibly compressed by this complex. Overall, this
could represent
consequence of infection such as Potts' disease or neoplastic
process. It is unclear if there is concomitant history of
trauma. Overall, clinical
correlation is recommended. (counting based on L5 from the
scout)
CXR [**4-27**]:
FINDINGS: The hemidiaphragms are in normal position, there is no
pleural
effusion. The structure and transparency of the lung parenchyma
is
unremarkable. No focal parenchymal opacity suggestive of
pneumonia, normal
size of the cardiac silhouette, normal hilar and mediastinal
appearance.
MRI C/T/L-Spine [**4-27**]:
FINDINGS:
The completely destroyed collapsed T4 vertebral body, with focal
kyphotic
deformity and increased signal, is visualized with
ffacement/discontinuity of the ventral thecal sac, and extension
into the spinal canal causing
compression on the [**Month/Day (4) **]. The outline of the [**Month/Day (4) **] is not clearly
traceable.
Hence, the effect on the [**Month/Day (4) **] cannot be adequately assessed.
Given the lack of continuity of the [**Last Name (LF) **], [**First Name3 (LF) 691**] injury to the [**First Name3 (LF) **]
like transection cannot be completely excluded.
IMPRESSION:
Uninterpretable study, due to marked patient motion artifacts.
Please see the CT performed on the same day. There appears to be
extension of the collapsed and destroyed T4 vertebral body into
the spinal canal, with displacement and compression of the [**First Name3 (LF) **].
As the continuity of the [**First Name3 (LF) **] cannot be traced, transection of
the [**First Name3 (LF) **] cannot be completely excluded if there is history
related to trauma.
EKG [**5-1**]:
Sinus rhythm. There is a late transition with Q waves in the
anterior leads consistent with possible prior anterior
myocardial infarction. Low voltage in the limb leads. Compared
to the previous tracing there is no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 114 88 426/445 69 0 56
Abdominal Ultrasound [**5-2**]:
More images from this ultrasound examination became available
after the
original report was dictated. The visualized portion of the
pancreatic head and proximal body is normal in contour and
echotexture. The distal pancreatic body and tail are obscured by
overlying bowel gas. Kidneys are normal in contour and
echotexxture without hydronephrosis. Right kidney measures 1.9
cm. Left kidney measures 10.8 cm. Spleen is enlarged.
[**5-15**]: CT of T-Spine:
TECHNIQUE: MDCT axially acquired images of the thoracic spine
were obtained. No IV contrast was administered. Coronal and
sagittal reformats were performed.
FINDINGS: There has been interval placement of anterior spinal
fusion plate with two screws inserting in the T3 and T5
vertebral bodies. There is persistent kyphosis at this level,
improved in appearance compared to the prior exam. Extensive
streak artifact from the hardware limits full
evaluation, but there appear to be several tiny calcifications
within the
central canal, decreased in appearance when compared to prior
exam. The extent of canal encroachment is difficult to assess
with CT. Evaluation of the [**Month/Year (2) **] integrity at this level is
markedly limited. The remainder the spine is unremarkable.
Incidental note is made of left- sided posterior rib fractures,
unchanged. Imaged portions of the lung demonstrate a large right
pleural effusion with associated atelectasis or consolidation.
The patient is intubated. Two metallic wires are identified
within the thoracic spinal canal, incompletely imaged. There is
a small amount of free fluid surrounding the spleen,
incompletely imaged.
IMPRESSION:
1. Interval t4 vertebrectomy with placement of the anterior
spinal fusion
with screws spanning T3 through T5.
2. Right pleural effusion and associated
atelectasis/consolidation.
3. Free fluid surrounding the spleen.
MRI T-spine [**5-18**]:
FINDINGS: There are post-surgical changes at the T4 and T5
vertebral bodies with overlying susceptibility artifact. There
is a focal kyphotic deformity at this level that appears stable
when compared to the prior exams. There is packing material
posterior to the vertebral body of T4 with severe [**Month/Year (2) **]
compression, [**Month/Year (2) **] edema, and increased T2 signal surrounding the
vertebral body at this level consistent with CSF leak or
postoperative fluid. There is increased T2 signal within the
[**Month/Year (2) **] at the T4 and T5 levels. The remainder of the visualized
portion of the thoracic [**Month/Year (2) **] demonstrates no disc bulge, central
canal or neural foraminal stenosis. There is a small right
pleural effusion and associated lung consolidation.
IMPRESSION:
1. Stable angulation of the spine at T4 after fusion.
2. Spinal [**Month/Year (2) **] edema at T4 and T5 bodies with postoperative
change including packing material causing severe [**Month/Year (2) **]
compression at this level.
3. Right pleural effusion with associated
atelectasis/consolidation.
CT Torso [**5-18**]:
FINDINGS: Since [**2130-4-26**], diffuse anasarca increased. A
recent surgery of the spine was performed for a large T4 mass
extending in the spinal canal. Sternotomy was performed with a
minimal less than 1 mm AP misalignement between the fragments.
Subcutaneous gas collections are new on the right, related to
placement of two right chest tubes, one ending at the apex and
one at the base. The ETT tip is in the right main stem bronchus.
A nasogastric tube ends in the stomach. A right central venous
catheter ends in expected position. A right pneumothorax is
small. Minimal pneumomediastinum is associated with fat
stranding, expected in this recent postop status. Small right
pleural effusion is heterogeneous, with dependent denser
portions due to clot. The effusion is mostly layering but also
loculated, especially along the mediastinal border and at the
apex. Pericardial effusion is small. There is no left pleural
effusion. Multifocal ground-glass opacities and consolidation
are throughout both lungs, not associated with significant
septal thickening. The main pulmonary artery measures 3.6 mm
wide. 19 mm soft tissue nodularity is new in the anterior chest
wall (2:34). Coronary artery calcifications are minimal. Airways
are patent to the subsegmental level. The right middle lobe and
the right lower lobe are almost completely collapsed. This study
was not tailored for subdiaphragmatic evaluation except to note
ascites.
Recent surgery was performed in the upper thoracic spine. Left
tenth and
eleventh rib fractures are chronically non-united. A catheter is
in the
spinal canal. Healed right rib fractures are present.
IMPRESSION:
1. ETT tip in the right main stem bronchus.
2. Increase in diffuse anasarca, persistence of ascites, and new
right
pleural effusion.
3. Heterogeneous right pleural effusion, likely containing some
blood, partly layering and partly loculated along the
mediastinal border and at the apex. Two chest tubes in place.
Small right pneumothorax.
4. Tiny pneumomediastinum and fat stranding of the anterior
mediastinum,
expected in this recent postoperative period. Subcutaneous gas
collections.
5. Multifocal bilateral ground-glass opacities and
consolidation, could be
multifocal pneumonia, developping ARDS or hemorrhage, given the
reported
coagulopathy.
6. Small pericardial effusion.
7. Enlargement of pulmonary artery, could be pulmonary
hypertension.
8. New soft tissue in the anterior chest wall, probable small
hematoma.
9. Recent T4 surgery with metallic hardware, non-united left and
healed right rib fractures, not fully evaluated by this study.
Port Chest s/p PICC [**5-24**]:
The right PICC line tip is at the level of mid SVC. There is no
change in the right basal opacity consistent with a combination
of high level of the
diaphragm due to ascites and liver enlargement as well as
pleural effusion and atelectasis. The right chest tube is in
unchanged position. Cardiomediastinal silhouette is unchanged as
well as there is no change in minimal left basal opacity, most
likely due to atelectasis.
LENIS [**5-24**]:
BILATERAL LOWER EXTREMITY ULTRASOUND: The right and left common
femoral,
superficial femoral and popliteal veins demonstrate normal
compressibility, waveforms, augmentation and flow. The calf
veins are unremarkable.
IMPRESSION: No lower extremity DVT.
CXR [**5-25**]:
FINDINGS: A portable upright AP view of the chest was obtained.
The
cardiomediastinal silhouette is stable in appearance. There is
stable
elevation of the right hemidiaphragm. There is persistent
collapse of the
right middle and right lower lobe with a small right pleural
effusion. There is a right apical lateral pneumothorax
identified, not significantly changed from the prior study.
There is increased lucency noted at the right lung base which
may represent slight interval increase in the basilar aspect of
the right-sided pneumothorax. The right sided chest tube is
unchanged in position. The left lung is unchanged. Again noted
are median sternotomy wires and spinal fixation hardware.
IMPRESSION:
Interval increase in right basilar lucency which may represent
an increase in the basilar aspect of the right pneumothorax.
Persistent collapse of the right middle and right lower lobes
with a small stable right pleural effusion.
CXR [**5-26**]:
Right chest tube still in place. Right basilar pleural gas
collections are
unchanged. Complete collapse of the right middle lobe and right
lower lobe is unchanged. Right pleural effusion is unchanged,
overlying the lower half of the right lung. Small left pleural
effusion is unchanged.
[**2130-6-25**] Radiology MR THORACIC SPINE W/O C
[**Last Name (LF) **],[**First Name3 (LF) **] B.
1. New severe compression of T3 with retropulsed fragments
resulting in [**First Name3 (LF) **] compression. 2. Right posterior mediastinum
fluid collection with enlarged loculated right pleural fluid
collection. Increased T2 signal within T3 and T5. Findings may
be secondary to infection. 3. These findings were discussed with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by Dr. [**Last Name (STitle) **] on [**2130-6-26**] at 10:00 a.m.
[**2130-6-25**] Radiology CT CHEST W/CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] B.
[**2130-6-25**] Radiology CT ABDOMEN W/CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **]
B. [**2130-6-25**] Radiology CT PELVIS W/CONTRAST
[**Last Name (LF) **],[**First Name3 (LF) **] B.
1. Large right hemothorax which appears more organized and
reduced in volume compared to prior CT on [**2130-5-27**].
Superimposed infection of this
hemothorax is not excluded. 2. Right lower lobe collapse with
interval partial reexpansion of right upper and middle lobes. 3.
Fluid containing tract in the right chest wall at site of prior
chest tube placement. 4. Interval wedge compression of the T3
vertebral body with increased soft tissue and calcific/osseous
material projecting into the spinal canal causing severe spinal
canal stenosis at the level of T4. 5. Evidence of cirrhosis. 6.
Mild-to-moderate ascites. 7. No drainable or organized
intra-abdominal or pelvic fluid collection. 8. Bilateral femoral
head AVN.
[**2130-6-25**] Radiology BILAT LOWER EXT VEINS [**Last Name (LF) **],[**First Name3 (LF) **]
B.
No evidence lower extremity DVT.
[**2130-6-22**] Radiology US ABD LIMIT, SINGLE OR [**Last Name (LF) 2416**],[**First Name3 (LF) 2415**] V.
Approved
1. No evidence of biliary dilatation or cholecystitis. 2. Small
ascites.
Brief Hospital Course:
Ms. [**Known lastname **] is a 45 year old woman with a significant history of
alcohol abuse and presumed alcoholic cirrhosis who was initially
trasnferred from [**Hospital **] Hospital to the [**Hospital1 18**] neurosurgery
service on [**2130-4-27**] with a destructive T4 spinal mass causing [**Date Range **]
compression and back pain. At the time, she had an essentially
intact neurologic exam (except for possibly decreased light
touch/pinprick sensation below both knees). The etiology of her
spinal mass was unclear (infectious versus neoplastic) and she
was started on empiric vancomycin, ceftriaxone, and
metronidazole; she did have a single blood culture bottle from
admission grow Corynebacterium so ID was consulted and
recommended discontinuation of antibiotics and biopsy of her T4
lesion.
.
On [**2130-5-15**], she was taken to the OR for vertebrectomy and spinal
fusion via an anterior median sternotomy approach. Due to the
approach, she had a chest tube placed perioperatively. The
surgery was also complicated by a dural tear requiring a dural
drain. Post-operatively, she received multiple blood products
for her coagulopathy. Her chest tube was initially draining to
gravity (rather than to suction) given the dural tear. Her
lumbar drain was discontinued on [**2130-5-20**], however, and the
chest tube was able to be placed to suction. She has continued
to have high output of blood-tinged pleural fluid from this
tube, and one theory has been that her abdominal ascites has
simply been migrating to her pleural space.
.
Of note, the operative pathology/microbiology from her T4 lesion
was nondiagnostic. Neurosurgery thought the leasion was likely
traumatic with poor healing and there was no strong evidence of
infection or malignancy. A sputum culture from [**2130-5-20**] grew
sparse GNRs and she was put on vancomycin and pip/tazo for
empiric therapy of VAP.
.
On [**2130-5-22**], she was initially extubated but had to be quickly
reintubated due to respiratory distress. That same day, she
underwent ultrasound-guided paracentesis by IR to assist with
her repiratory mechanics in the hopes of facilitating
extubation. 5.6 liters of fluid were removed, though it was not
sent for laboratory analysis; she did not receive any
periprocedure albumin. She also underwent pleurodesis with
doxycycline. She was extubated on [**2130-5-23**] and was sent to the
floor (under neurosurgery) on [**2130-5-24**]. On the floor, she had
been requiring only about 2 liters/min of oxygen. She underwent
a second doxycycline pleurodesis on [**2130-5-25**].
.
Her renal function began to decline. Initially this was thought
to be related to non-oliguric ATN in setting of large volume
paracentesis and furosemide treatment. Over time this became
more consistent with hepato-renal syndrome. She was started on
an octreotide and mididrine and bolused with albumin.
.
She then was noted on chest x-ray to have "white out" of her
right lung in spite of relatively well-compensated pulmonary
function (requiring only 2 liters of oxygen by nasal cannula). A
chest CT also showed an increase in the size of her right
pleural effusion and complete collapse of the right lung. It was
thought that she could be having recurrent mucous plugging of
the right lung, so she was transferred back to the T-SICU in
preparation for a bronchoscopy to try and relieve the
obstruction.
.
During the bronchoscopy, she had secretions (described as
purulent) suctioned from her right mainstem bronchus. These
secretions were noted to spill over to her left mainstem
bronchus, however, and she experienced an acute episode of
hypoxia to the 80s with bradycardia to the 30s; she never lost a
pulse, by report. She was given 1 mg of atropine with an
increase of her heart rate to the 50s. Due to the hypoxia, she
was emergently intubated. Suctioning was then completed from
both the right and left mainstem bronchi.
.
Post-procedure, she was noted to be hypotensive with SBPs in the
80s and was started on phenylephrine (in addition to propofol
for sedation). A post-intubation CXR demonstrated some
improvement in the aeration of her right lung, though still with
a right-sided loculated effusion in both the apical and basilar
portions of the right lung. A post-procedure ABG was 7.26/44/202
(unclear what her FiO2 was at this time) and her ventilator rate
was increased from 14 to 16 (Vt of 500 cc). She was then
transferred to the MICU for further care.
.
In the MICU, she was noted to have a am cortisol at 1.8 and was
started on stress dose steroids. Family wanted to pursue HD, so
dialysis catheter was placed by IR. She continued to have
bleeding from the chest tube sites. She recieved multiple
transfusions, FFP, cryo and DDAVP. She underwent a bronchoscopy
by thoracics, was given more blood and had more chest tubes
placed. Eventually it was felt that instead of having the chest
tubes to suction that they be placed on waterseal and allow the
bleeding to essentially tamponade itself. Chest tube output
decreased. Patient eventually self extubated on [**6-3**]. She
continued to need some blood products and was given more DDAVP
and amikar. Over time her transfusion requirement decreased. Her
diet was advanced and she was called out to the floor after
being stable for over 48 hours.
.
On the medical floor she was initially stable and her remaining
chest tubes were able to be pulled. She slowly began to have
mental status changes. These were waxing and [**Doctor Last Name 688**]. She was
found to have positive blood cultures and overnight pulled out
her PICC. She was started on Linezolid for VRE. Because of the
positive blood cultures her temporary HD cath was pulled. She
had a second set of positive blood cultures so a second
temporary line had to be put in for HD. Her lactulose was also
increased as her mental status was in part due to hepatic
encephalopathy. The Liver team was reconsulted and it was
determined that she was not currently a candidate for transplant
and that she would need supportive care and continued HD. Per
liver, consideration for transplant would require that she be
stable out of a medical facility for 3 months with abstenence
from alcohol and regular visits, that there be no evidence of
infection and that any potentially infected hardware be removed.
She would also need to be evaluated by transplant psyciatry.
.
From [**Date range (1) 16463**], patient had low grade fevers up to 100.4. ID was
reconsulted for evaluation of these fevers and recommended a CT
scan and serial cultures. CT scan showed enhacement around
hemothorax with a small amount of air, concerning for infection.
Thoracentesis of hemothorax showed Enterococcus. Further
imaging was suggestive of a possible connection between
hemothorax and peri-spinal space, and enhancement concerning for
a spinal empyema. IR and neurosurgery were consulted about
getting a biopsy of this vertebral tissue, but neither service
felt that it could be done safely. The decision was made with
ID and the family to continue with emperic gram positive
coverage for 6 weeks and then reassess.
.
She developed vague numbness and weakness on [**6-25**]. Her exam
showed progressive lower extremity weakness. A repeat CT showed
interval narrowing of spinal canal and MRI showed impingement on
[**Month/Day (4) **]. Neurosurgery was reconsulted. Her findings were
concerning for T3 osteomyelitis and possible connection between
epidural space and hemathorax. She was treated with one dose of
solumedrol, but managed expectantly for progressive paralysis.
As this progression was highly concerning for progressive
osteomyelitis. Although this problem would require surgical
intervention, she is was felt unlikely to survive a further
surgery per neurosugery.
.
*** ACTIVE MEDICAL ISSUES ***
. # GOALS OF CARE: There were several family meetings with
primary team, neurosurgery team and palliative care team with
the family regarding goals of care with her family. The most
recent team meeting was with the mother, [**Name (NI) **], who is the HCP,
and sisters [**Name (NI) **] and [**Name (NI) **]. [**Known firstname **] has had an extensive protracted
hospital course for >90 days now with multiple complications.
She has end stage liver disease, end stage renal disease, a new
T3 fracture with [**Known firstname **] compression which is inoperable - these
medical problems cannot be reversed and will decrease [**Known firstname **] life
expectancy. In the more immediate setting, we have concerns over
an infected pleural effussion and spine but there is no way left
to biopsy the spine anymore. Family is very emotionally
exhausted and troubled over the impending loss of their loved
one. After several family meetings, we have come to the
following decision. The most important thing currently for the
family is for [**Known firstname **] to be closer to home. They agree with
DNR/DNI/DNH. They would like dialysis to be continued for now as
without it she would likely pass in a few days and they would
like more time with her if possible. They agree to only
essential medications and essential lab draws. With regards to
treatment of pleural effussion and empiric treatment of possible
osteo, currently they want antibiotic continued with hopes of
giving [**Known firstname **] more time with them. They agree with not re-imaging
her chest or spine to see if anything is changing. If [**Known firstname **],
continues to decline on antibiotics, they will consider stopping
it entirely. If [**Known firstname **] is signficantly better toward the end of
the currently projected abx course of 6 weeks, they can consider
ID consultation/re-imaging. [**Known firstname **] has delirium and varying
degrees of clarity into what is going on. She does seem to
understand that "she is dying" and is happy about being closer
to home.
.
T4/T3 MASS LESION: Although there was no evidence of infection
on pathology of T4 and the new T3 lesion is not amenable to
surgery or biopsy according to NSG and IR, this is likely
osteomyelitis with a presumably gram positive organism. She has
lower extremitiy neurologic symptoms from [**Known firstname **] compression
caused by this lesion. She is not a candidate for neurosurgery.
- antibiotics as below
- TSLO for any activity out of bed
.
INFECTED HEMOTHORAX and BACTEREMIA: Patient found to have
enteroccus in hemothorax that may connect with perispinal space.
Linazolid may have lowered her cell counts. Antibiotic plan
per ID is below. Consider reimaging with CT thorax (with
contrast) and T-spine MRI at end of antibiotic course if there
has been significant improvement in overall picture. Please see
the Goals of Care discussion above.
Prescribed Antibiotic Information:
Daptomycin 8mg/kg (600mg) IV q48hr.
If dose falls on HD day, please give after HD.
Duration: minimum of 6 weeks ([**Date range (1) 82483**])
laboratory monitoring required:
Weekly: CBC/diff, chem 7, LFTs, CPK, ESR/CRP
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**]
Follow-up:
MRI of T-spine, 2-3 weeks
CT of chest w/ contrast, 2-3 weeks
[**Hospital **] clinic, 4 weeks
.
END STAGE RENAL DISEASE: Patient is now HD dependent.
- HD per renal, labs as needed.
.
ALTERED MENTAL STATUS: Patient has delerium likely from hepatic,
renal, and bacterial processes as well as underlying
alcohol-related dementia. She continues to have intermittant
hallucinations.
- continue olanzapine as needed.
- rifamixin and lactulose titrated to 4 BM/day if desired for
further clarity.
.
ALCOHOL-RELATED CIRRHOSIS: Has been evaluated by liver and not a
transplant candidate. Could not consider outpatient evaluation
for transplant until [**Month (only) 205**] when she might be 4-6 months sober and
in alcohol rehab. Infectious issues would need to be settled by
then as well.
.
ANEMIA: Iron studies consistant with anemia of chronic disease.
.
.
Medications on Admission:
FoLIC Acid 1 mg PO DAILY, Furosemide 40 mg PO DAILY, GlipiZIDE 5
mg PO BID, Lactulose 30 mL PO TID, Nadolol 20 mg PO DAILY,
Eplerenone 50 mg PO DAILY, Omeprazole 20 mg PO BID, Sertraline
50 mg PO DAILY, Thiamine 100 mg PO DAILY, traZODONE 50 mg PO
HS:PRN, ASA 81mg PO Daily
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] unit
dwell Injection PRN (as needed) as needed for line flush:
DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL
NS followed by Heparin as above according to volume per lumen. .
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day) as needed for confusion: Hold for > 4 bowel
movements daily.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Patient with liver failure. Do not
exceed 2gm per day.
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Neutra-Phos Sig: Two (2) packets three times a day as
needed for phosphate < 2.0.
8. Sodium Phosphate 3 mMole/mL Solution Sig: One (1) dose
Intravenous once: 30 mmol / 250 ml NS IV ONCE on arrival.
9. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for indigestion.
10. Daptomycin 450 mg IV Q48H
On HD days, give dose after HD.
11. Heparin Flush (10 units/ml) 2 mL IV PRN As needed for PICC
12. Ondansetron 4 mg IV Q8H:PRN nausea
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
T4 Vertebral Body Distruction
Acites
Acute Renal Failure
Hepatic coagulopathy
Respiratory distress
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the [**Hospital1 18**] with a spinal mass. You had a
surgical procedure to remove this tissue. You developed blood
in your lungs that became infected. You also had continued
degereration of the area in your spine for unclear reasons.
This [**Last Name **] problem is causing you to have numbness and weekness
in your legs. Neurosurgery does not feel that further surgical
procedures could help improve this situation. You also have
renal and liver failure. You were started on dialysis for your
liver failure. You are being treated with antibiotics for the
infected blood in your lungs. You may also have an infection in
your spine bones, although we are not able to do a biopsy to
determine what infection is there.
Please call your PCP if you have new or concerning symptoms or
have questions about your goals of care.
Followup Instructions:
Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in [**6-28**] weeks.
Please follow up with infectious disease in [**4-24**] weeks ([**Telephone/Fax (1) 82484**]
Completed by:[**2130-7-9**]
|
[
"285.1",
"733.13",
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"518.5",
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"250.00",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"03.53",
"34.04",
"99.09",
"81.04",
"99.05",
"96.72",
"83.21",
"96.04",
"88.73",
"81.62",
"34.91",
"34.92",
"99.21",
"99.07",
"03.59",
"99.06",
"38.93",
"96.05",
"99.04",
"54.91",
"86.59",
"33.24",
"84.51",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
29584, 29684
|
15792, 27183
|
413, 533
|
29827, 29835
|
2706, 2711
|
30735, 30993
|
1614, 1632
|
28170, 29561
|
29705, 29806
|
27871, 28147
|
29859, 30712
|
1647, 1647
|
2451, 2687
|
274, 375
|
561, 1186
|
2725, 15769
|
27198, 27845
|
1208, 1399
|
1415, 1598
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,367
| 127,877
|
30296
|
Discharge summary
|
report
|
Admission Date: [**2155-4-29**] Discharge Date: [**2155-5-14**]
Date of Birth: [**2085-7-25**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
Pelvic mass
Major Surgical or Invasive Procedure:
- Exploratory laparotomy, total abdominal hysterectomy,
bilateral salpingo-oophorectomy, omentectomy, cystotomy repair
- Transfusion of 5 units of PRBC
History of Present Illness:
The patient is a 69-year-old G0 sent by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for a
GYN-oncology consultation regarding a pelvic mass. The patient
has a several-week history of reflux symptoms, dysuria
associated with slightly worse stress incontinence, alternating
constipation and diarrhea, and most prominently increasing
abdominal girth with associated shortness of breath. She had a
CT of the abdomen and pelvis on [**2155-4-15**], which revealed a 2.4-cm
nodular density in epicardial fat on the right side near the
diaphragm consistent with a lymph node. There was a large
amount of ascites. There was a 4.6-cm lesion in the medial
aspect of the right lobe of the liver suspicious for metastatic
disease. There were two adjacent 2.4 cm low attenuation lesions
in the left lobe consistent with liver cysts. There were a few
small periaortic lymph nodes. There was a large pelvic mass
measuring 10 cm.
Past Medical History:
PAST MEDICAL HISTORY: Negative.
*
PAST SURGICAL HISTORY: Facial cosmetic surgery [**2151**].
*
OB HISTORY: Negative.
*
GYN HISTORY: Last Pap smear and mammogram were both recently
normal.
Social History:
The patient does not smoke or drink. She is retired. She lives
with her husband, who has metastatic prostate cancer.
Family History:
Significant for mother who died of pancreatic cancer at age 62.
Physical Exam:
GENERAL APPEARANCE: Well developed, well nourished, in no acute
distress.
HEENT: Sclerae anicteric.
LYMPHATICS: Lymph node survey was negative.
LUNGS: Clear to auscultation.
HEART: Regular without murmurs.
BREASTS: Without masses.
ABDOMEN: Tensely distended with obvious ascites. There were no
palpable abdominal masses.
EXTREMITIES: Without edema.
PELVIC: The vulva and vagina were normal. The cervix was
normal but very anterior. Bimanual and rectovaginal examination
was somewhat limited by the ascites. However, there was a large
mass filling the cul-de-sac which was firm and irregular and
associated with cul-de-sac nodularity. The rectum was
intrinsically normal.
Pertinent Results:
*
[**4-29**] LENI
IMPRESSION: Bilateral calf (peroneal) venous thrombosis.
*
[**5-5**] LENI
IMPRESSION: Redemonstration of bilateral calf vein thrombosis,
involving the peroneal veins bilaterally, totally occlusive on
the left, and partially occlusive on the right. There is no
evidence of extension into the popliteal, femoral or common
femoral veins.
*
[**5-9**] LENI
IMPRESSION: No flow seen within the left peroneal vein,
consistent with known thrombosis. No evidence of propagation of
clot to the popliteal, superficial femoral, or common femoral
vein.
*
[**5-6**] KUB
IMPRESSION: Findings are consistent with small bowel
obstruction.
*
[**5-7**] Chest X ray
Nasogastric tube is seen coiling in the stomach, with the tip
terminating over the expected location of the stomach. Again
noted are
bilateral pleural effusions and left lower lobe collapse.
*
[**5-12**] Abdominal CT: IMPRESSION: Bilateral pleural effusions. No
evidence of bowel obstruction. Multiple liver lesions.
*
[**2155-4-29**] 06:01PM BLOOD WBC-10.6 RBC-3.62* Hgb-10.7* Hct-30.2*
MCV-83 MCH-29.4# MCHC-35.3*# RDW-14.4 Plt Ct-255
[**2155-4-30**] 12:30PM BLOOD Hct-23.8*
[**2155-5-5**] 03:42AM BLOOD WBC-12.4* RBC-3.07* Hgb-8.5* Hct-26.1*
MCV-85 MCH-27.6 MCHC-32.5 RDW-14.7 Plt Ct-511*
[**2155-5-6**] 01:30AM BLOOD WBC-18.2* RBC-3.61* Hgb-10.1* Hct-30.8*
MCV-85 MCH-27.9 MCHC-32.8 RDW-14.8 Plt Ct-702*
[**2155-5-7**] 06:55AM BLOOD WBC-12.6* RBC-3.49* Hgb-9.6* Hct-28.8*
MCV-83 MCH-27.5 MCHC-33.4 RDW-14.6 Plt Ct-809*
[**2155-5-13**] 07:40AM BLOOD WBC-8.5 RBC-3.11* Hgb-8.7* Hct-27.0*
MCV-87 MCH-28.1 MCHC-32.4 RDW-15.1 Plt Ct-775*
[**2155-5-13**] 07:40AM BLOOD Plt Ct-775*
[**2155-5-13**] 07:40AM BLOOD Glucose-111* UreaN-16 Creat-0.6 Na-135
K-3.8 Cl-104 HCO3-27 AnGap-8
[**2155-5-13**] 07:40AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.2
*
[**5-6**] Cath tip culture
WOUND CULTURE (Final [**2155-5-8**]): No significant growth.
*
[**5-6**] urine culture
URINE CULTURE (Final [**2155-5-7**]): NO GROWTH.
*
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2155-5-7**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
*
URINE CULTURE (Final [**2155-5-3**]): NO GROWTH.
*
BLOOD CULTURE (Final [**2155-5-12**]): NO GROWTH.
Brief Hospital Course:
This patient is a 69 year old woman who was admitted s/p an
exploratory laparotomy, total abdominal hysterectomy, bilateral
salpingo-oophorectomy, omentectomy, and cystotomy repair for
ovarian cancer. Please see operative report for full details.
*
Post-operatively, she was initially transferred to the ICU for
hemodynamic monitoring where she remained for two days.
Intraoperatively and in the ICU, she received 5U PRBC. A central
line was placed. She was extubated on post-op day #1. On post-op
day #2, she was transferred to the floor. The remainder of her
postoperative course was complicated by
1. Blood loss anemia
2. Fever
3. Ileus
4. Small bowel obstruction
5. Bilateral peroneal vein thromboses
*
1. Blood loss: The patient received a total of 5u PRBC. The
lowest measured Hct was 23% post-op. At the time of her
discharge, her Hct remained stable in the range of 26-28%.
*
2. Fever: On post-op day #3 (100.4) and post-op day #6 (101.3),
the patient had two episodes of fever. Clinical exam and work-up
did not suggest infection. She was not started on antibiotics.
She remained afebrile for the remainder of her hospital stay.
*
3. Ileus/?SBO: On post-op day #3, the patient noted nausea and
abdominal distension. She was thought to have an ileus and was
made NPO. On post-op day #6, the patient reported improvement in
her symptoms and she was started on a clear diet. On post-op day
#7, she noted resumption of her nausea. An abdominal X-ray
revealed dilated loops of small bowel and no air in the colon.
She was diagnosed with a small bowel obstruction. She was made
NPO and a nasogastric tube was placed. On post-op day #8, she
was noted to have minimal output from the NGT and following
several chest X-rays, proper placement was confirmed. She was
also started on PPN to ensure adequate nutrition for a total of
7 days. The NGT remained in place until post-op day #13. At the
time of her discharge, she was tolerating a regular diet.
*
4. Peroneal vein thromboses: In the ICU, the patient was found
to have bilateral peroneal vein thromboses. No anticoagulation
therapy was instituted. Instead, she underwent twice weekly
lower extremity ultrasound evaluations. These did not reveal any
progression in the thromboses on [**5-5**] and [**5-9**]. She received
heparin 5000U SC TID during her hospital stay.
*
5. s/p Cystotomy repair: The patient had a Foley in place until
post-op day #10. The foley was removed and the patient voided
without difficulty.
*
6. Oncology: The pathology returned as endometrioid
adenocarcinoma of the ovary. She was started on Carboplatinum
chemotherapy on POD#14 ([**2155-5-13**]). She will receive Paclitaxel as
an outpatient.
*
7. Social: A social work consult was obtained for the patient's
anxiety in the setting of her new diagnosis. She was
administered Lorazepam as needed for anxiety.
Medications on Admission:
Prilosec
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Compazine 10mg PO q6 hours prn nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Ovarian cancer
Blood loss anemia
Ileus
Bilateral peroneal vein thromboses
Discharge Condition:
Good
Discharge Instructions:
vomiting, worsening abdominal pain, difficulty with urination or
any other worrisome symptoms.
*
No driving while taking narcotics.
*
Nothing in your vagina and no heavy lifting for 4 weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Date/Time: [**2155-6-5**] 2:45
|
[
"286.9",
"518.0",
"560.1",
"183.0",
"198.89",
"E870.0",
"569.49",
"799.02",
"998.11",
"E849.7",
"530.81",
"444.22",
"198.0",
"197.6",
"560.9",
"198.1",
"511.9",
"197.7",
"276.2",
"V16.0",
"280.0",
"573.8",
"998.89",
"780.6",
"553.3",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93",
"57.81",
"99.04",
"68.49",
"99.15",
"45.41",
"34.81",
"48.35",
"46.75",
"03.90",
"96.07",
"54.4",
"54.3",
"45.33",
"99.77",
"65.61",
"57.59",
"48.23",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
8119, 8125
|
4885, 7731
|
340, 494
|
8243, 8250
|
2624, 4862
|
8489, 8600
|
1838, 1904
|
7790, 8096
|
8146, 8222
|
7757, 7767
|
8274, 8466
|
1550, 1685
|
1919, 2605
|
289, 302
|
522, 1469
|
1514, 1526
|
1701, 1822
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
477
| 191,025
|
13508
|
Discharge summary
|
report
|
Admission Date: [**2156-7-20**] Discharge Date: [**2156-7-28**]
Date of Birth: [**2084-3-29**] Sex: M
Service: MED
Allergies:
Iodine / Inderal
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
1. Acute bleed
2. Acute on chronic renal failure
3. Hypernatremia/Diabetes Insipidus
Major Surgical or Invasive Procedure:
Thoracentesis, Left pleral space
History of Present Illness:
72yo male with h/o A Fib, HTN, AAA, CRI, L renal cysts, recent
urosepsis treated with levofloxacin, who p/w an acute bleed from
L kidney when INR was 4.6. Since admission, pt??????s INR and Hct
have stabilized, has had acute on chronic renal failure which is
resolving, had hypernatremia which is resolving, and had a L
pleural effusion which was tapped on [**7-26**], results c/w tracking
of L renal bleed. Elevated WBC, chronic cough.
Past Medical History:
?????? Atrial Fibrillation/Flutter: rate controlled?????? Hypertension??????
AAA (6 x 6.5cm): being watched?????? CRI: baseline Cr ~2.5?????? Bipolar
D/O: tx??????d w/Li for many yrs?????? Renal cysts/unidentified lesions:
dx??????d 3y PTA by Dr. [**Last Name (STitle) 9125**], pt refused further w/u?????? Gout??????
Urosepsis (recent): treated with levofloxacin
Social History:
SH: lawyer
[**Name (NI) 1139**] 50 pack-year habit
EtOH 14 drinks/week
Family History:
FH
Brother ?????? ? RCCFather ?????? CVA
Physical Exam:
PE
Vitals T 9 P 71, reg BP 140/80 Resp 20, 98% on RA
Gen Obese patient lying in hospital bed with mild SOB, A+O x 3
HEENT PERRL, EOMI
Neck Obese, no LAD
Thorax Bibasilar rales, cough
CV RRR, nl s1s2, no murmurs/gallops/rubs
Abd Obese, nondistended, normoactive BS, no rebound/guarding
Ext No clubbing/cyanosis/edema, nontender
Neuro Nonfocal; pleasant affect, A+O x 3
Pertinent Results:
[**2156-7-28**] 07:47AM BLOOD WBC-14.7* RBC-3.35* Hgb-10.2* Hct-31.9*
MCV-95 MCH-30.4 MCHC-32.0 RDW-15.4 Plt Ct-393
[**2156-7-28**] 07:47AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND
Baso-PND
[**2156-7-28**] 07:47AM BLOOD Plt Ct-393
[**2156-7-28**] 07:47AM BLOOD PT-15.0* PTT-32.1 INR(PT)-1.5
[**2156-7-28**] 07:47AM BLOOD Glucose-111* UreaN-53* Creat-3.0* Na-145
K-4.5 Cl-111* HCO3-23 AnGap-16
[**2156-7-26**] 07:20AM BLOOD LD(LDH)-241
[**2156-7-26**] 07:20AM BLOOD TotProt-5.2*
[**2156-7-27**] 07:50AM BLOOD VitB12-358 Folate-GREATER TH
[**2156-7-24**] 07:00AM BLOOD TSH-1.8
Brief Hospital Course:
A/P 72yo Caucasian male with h/o Afib, HTN, AAA, CRI, left renal
cysts and unidentified lesions, recent urosepsis treated with
levofloxacin, who p/w left flank and abdominal pain, Hct 22 and
INR 4.6 and evidence of an acute bleed into his left kidney.
Since admission, pt??????s INR and Hct have stabilized, has had acute
on chronic renal failure which is resolving, had hypernatremia
which is resolving, and had a L pleural effusion which was
tapped on [**7-26**], results c/w tracking of L renal bleed. Slightly
elevated WBC, chronic cough.
1.Increased WBC, cough with sputum, no F/C: possible mild
tracheobronchitis, cont to follow
2. ARF: resolving
3. Neuro: gait disturbance, unchanged since [**2156-7-18**]. Suggest MRI
for eval of head and spine, as per neuro consult; pt refuses
3. ? Bipolar D/O: hold Li, f/u with outpt psych
4. AAA (last measured at 6.5cm x 6.3cm): f/u as outpt with cards
5. Hypernatremia: resolving
9. FEN: liberal PO fluid intake; D5W
10. Dispo: short term rehab facility will be required prior to
return to home; possible d/c home tomorrow if stable, WBC
decreases
Medications on Admission:
Meds
?????? RISS?????? Pantoprazole 40 mg PO Q24H ?????? Acetaminophen 650 mg PO Q6H
?????? Docusate Sodium 100 mg PO BID ?????? Senna 1 TAB PO BID:PRN ??????
Diazepam 5 mg PO Q6H:PRN ?????? Morphine Sulfate 2 mg IV Q4H:PRN ??????
Metoprolol 25 mg PO TID ?????? 1000 ml D5W Continuous at 100 ml/hr
for [**2152**] ml?????? Lithium (held)
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
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. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q HS PRN ().
6. Diazepam 2 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5344**] Knoll Nursing & Rehabilitation - [**Location (un) 5344**]
Discharge Diagnosis:
1. Acute blood loss
2. Acute on chronic renal failure
3. Pleural effusion
4. Hypernatremia
5. Gait disturbance
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in one month.
Followup Instructions:
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in one month.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
"427.31",
"112.0",
"585",
"511.9",
"599.0",
"593.81",
"285.1",
"588.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
4474, 4583
|
2398, 3497
|
358, 392
|
4737, 4745
|
1795, 2375
|
4896, 5132
|
1350, 1392
|
3885, 4451
|
4604, 4716
|
3523, 3862
|
4769, 4873
|
1407, 1776
|
234, 320
|
420, 859
|
881, 1246
|
1262, 1334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,449
| 187,354
|
9517
|
Discharge summary
|
report
|
Admission Date: [**2192-12-23**] Discharge Date: [**2192-12-26**]
Date of Birth: [**2168-10-28**] Sex: M
Service: MEDICINE
Allergies:
Cozaar / Spironolactone
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
SOB/DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 32362**] is a 24 year old man with a history of non-ischemic
cardiomypathy (EF 15-20%) and morbid obesity who presents with
shortness of breath, lower extremity edema and abdominal
distention for the past 2 weeks. He states that on the day of
admission ([**2191-12-24**]) he felt short of breath and a chest tightness
described as "pulling" sensation in the center of his chest,
worse with deep inspiration. He reports decreased expercise
tolerance and is only able to ambulate [**12-22**] a block (previously
could ambulate several blocks). He can climb 1 flight of stairs.
He denies dietary indiscretion and states he has been taking all
medications as prescribed. He has 3 pillow orthopnea which has
worsened in the past few weeks. He denies overt chest pain, PND,
diarrhea, constipation, fever, chills, night sweats, nausea,
vomiting, dysuria. ROS is positive for chronic cough x 1 year.
He was supposed to have an EP study with or without AICD
placement on [**11-20**] that was postponed to [**2193-1-2**] for symptoms
akin to a cold. (No record in chart)
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
In the ED, initial vitals were 99.6 63 146/95 32 95% RA. He
triggered in the ED for tachypnea with a RR of 32 and his HR was
110-120s and sinus during his ED stay. He received 1 SL NTG, ASA
325mg and Lasix 40mg IV x 1, to which he put out 850ml of urine
and reported feeling improvement in symptoms
Past Medical History:
1. Presumed Idiopathic dilated cardiomyopathy, EF 15-20% (echo
[**9-28**])
- diagnosed [**11-27**] when he presented to [**Hospital1 18**] with cough, fever,
and increasing SOB. Chest CT showed bilateral lung infiltrates
and enlarged mediastinal lymph nodes consistent with multifocal
pneumonia, and echocardiography showed moderate to severe
global left ventricular hypokinesis (LVEF = 25-30 %), with
normal valve function, and no pericardial effusion. Lab work
for RSV was positive, while HIV, influenza, EBV, CMV, Lyme and
multiple blood cultures were unremarkable. Repeated echo 10
months later confirms severely depressed and dilated LV with
LVEF of [**10-4**]%, and LVEDD of 7.8 cm
- last hospitalized [**5-29**] for CHF exacerbation, treated with IV
lasix
- evaluated [**2192-11-1**] by ED (Dr. [**Last Name (STitle) **] for ICD placement,
recommended general anesthesia for EPS and ICD placement
2. Childhood asthma
3. Morbid obesity
4. Sleep apnea - on CPAP but has not been using it
5. Moderate, Worsening pulmonary hypertension (46 mmHg [**9-28**])
(20-28 in [**4-28**])
6. Fatty Liver by CT. Obese and hx of EtOH. INR 1.4-1.7 since
[**5-29**]; Bili 1.7; HCV neg; HBV immune.
Social History:
He is unmarried and lives at home with his parents. He works as
a high school wrestling coach and in security. He never smoked.
He drank "a lot" in college, previously quoting 6 beer/weekend
but not elaborting this time; started drinking in [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32363**]
high school. He has a history of cocaine use, "a great deal" in
sophmore year. Drinks an occasional glass of wine.
Family History:
Father is 65 year-old and mother is 55 year-old.
Both have diabetes. He has 4 healthy older sisters. There is no
family history of SCD or cardiomyopathy.
Physical Exam:
VS: T= 97.3 BP= 136/61 HR=114 RR= 23 O2 sat= 97% 3L
GENERAL: Obese African-American man in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without appreciable JVP, although cannot currently
assess due to body habitus. Dark Acanthosis nigricans
bilaterally
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, crackles at Right
base, no wheezes or rhonchi.
ABDOMEN: Obese with diffuse anasarca and tense skin. No pain on
palpation. Positive bowel sounds.
EXTREMITIES: 3+ pitting edema to mid-abodmen. Dry skin of lower
extremities with changes of venous stasis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Skin: dry, cool. Acanthosis as above.
Neurologic: Cn 2-12 intact, full strength globally
Pertinent Results:
ADMISSION LABLS
WBC-12.3* RBC-5.33 Hgb-12.7* Hct-38.8* MCV-73* MCH-23.8*
MCHC-32.8 RDW-19.1* Plt Ct-284
Glucose-136* UreaN-15 Creat-1.0 Na-136 K-4.2 Cl-102 HCO3-23
AnGap-15
ALT-15 AST-25 CK(CPK)-97 AlkPhos-82 TotBili-1.7*
PT-17.3* PTT-27.9 INR(PT)-1.6*
CK-MB-2 cTropnT-<0.01 proBNP-2319*
CK-MB-NotDone cTropnT-0.01
Digoxin-0.3*
[**2192-12-24**] 03:52AM BLOOD Calcium-8.9 Phos-4.7* Mg-1.9 Iron-PND
IRON
calTIBC-503* Ferritn-47 TRF-387* Iron-36*
Liver
[**2192-12-23**] PT-17.3* PTT-27.9 INR(PT)-1.6*
[**2192-12-25**] PT-16.1* PTT-28.9 INR(PT)-1.4*
[**2192-12-23**] ALT-15 AST-25 CK(CPK)-97 AlkPhos-82 TotBili-1.7*
[**2192-12-26**] TotBili-1.9* DirBili-1.0* IndBili-0.9
Brief Hospital Course:
Mr. [**Known lastname 32362**] is a 24 year old man with a history of non-ischemic
cardiomyopathy, NYH Class II CHF, EF 15-20% who presents with
DOE/SOB over one month, acutely over one week. He was treated
for acute on chronic CHF exacerbation. He was diuresed with IV
and then PO lasix, achieving a net negative balance of ~ 7
litres. He was discharged to optimize his fluid status prior to
an AICD placement
By Problem
1. Acute on Chronic CHF Exacerbation: Underlying etiology for
patient's chronic heart failure was presumed to be viral in
origin, could also be related to cocaine use in years prior to
diagnosis or alcohol abuse. All lab testing negative except for
RSV, including HIV, EBV, CMV, Lyme, RPR. Current exacerbation
likely due to poor dietary compliance as patient does not weigh
himself daily and could easily become overloaded particularly in
the context of the Holidays. He denied any medication
noncompliance. The patient was aggressively diuresed with iV
furosemide and by time of discharge he was 7 litres net negative
and sent home on 40 mg of PO furosemide [**Hospital1 **].
2. Tachycardia: The patient had CHF with rates around 100-130 at
presentation. This appears to be a chronic problem per previous
notes. This improved somewhat with diuresis and improvement of
his respiratory status. Doses of metoprolol were increased over
hospitalization without change in heart rate (100-120 on
telemetry). The patient should have an AICD for purposes of
primary prevention given his low EF. Plans are underway to
finish this as an outpatient. He was discharged on 100 mg
Toprol XL [**Hospital1 **]
3. Iron Deficiency Anemia: The patient continued to be
microcytic with indices suggestive of iron deficiency. He is
also hemoglobin AC which could explain some microcytosis. No
signs of active bleeding and previous CT [**Last Name (un) **] was negative. He
was discharged on iron TID with ascorbic acid for absorption and
senna/colace for constipation
4: Hyperbilirubinemia/ Liver Dysfunction: Patient had a slightly
elevated INR and bilirubin at presentation with normal
transaminases. Both of these parameters were slightly above his
previous values though he doe have a known element of
non-alcoholic steatohepatitis (defined by ALT/AST and US/CT
evidence of fatty infiltration). Given his two presumptive
diagnoses (NAFLD/NASH and Congestive Hepatolpathy) he is at
increased risk of fibrosis. His negative transaminases and
elevated bilirubin (half direct, half indirect) were likely in
the setting of hepatic congestion and decreased cardiac output
during his heart failure exacerbation. His bilirubin was
elevated at the time of discharge, but this would not be
expected to fall quickly. It ought to be followed.
5. Pulmonary Hypertension: The patient was mildly hypoxic at
presentation presumably due to exacerbation of his CHF. With
diuresis this improved. ULtimately, plan is for outpatient
right heart cath. The patient was also encouraged to use his
CPAP at home and continue the diuresis begun in house.
6. Leukocytosis: The patient had a mild leukocytosis that was
trending down at the time of discharge. He had no fevers or
signs of acute infection.
[**Telephone/Fax (3) 32364**]
TO BE FOLLOWED IMMEDIATELY
1) Needs BMP to evaluate response to Lasix 40 mg [**Hospital1 **]
2) Needs Weight Check, was 192 Kg standing on scale at d/c
EVENTUALLY
3) CBC, iron studies to follow progress on iron repletion
4) Ultimately, follow bilirubin, INR, assess liver status
[**Telephone/Fax (3) **]
Medications on Admission:
Diovan 40mg PO qday
Acetaminophen + Codeine 300mg/30mg PO q4H PRN cough
ASA 325mg PO qday
Furosemide 20mg PO BID - of note, pt is not sure if he takes
20mg or 40mg [**Hospital1 **]
Digoxin 250mcg PO qday
Metoprolol Succinate ER 75mg PO BID - pt is not sure of dose
(this is per Dr.[**Name (NI) 8996**] last note)
Discharge Medications:
1. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day: Take one pill in
the morning and one at night.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
for constipation.
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
10. Outpatient Lab Work
Check Na, K, BUN, Cr on Monday [**2192-12-31**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute exacerbation of chronic systolic congestive heart failure
Iron Deficiency Anemia
Morbid obesity
Discharge Condition:
Good, not hypoxic on room air
Ambulating without assistance
Alert and Oriented *3
Discharge Instructions:
Mr [**Known lastname 32362**], it was pleasure to participate in your care. You were
admitted because you had increased swelling in your legs and
difficulty breathing. This was due to an exacerbation of your
heart failure. The reasons for this exacerbation are unclear
though it may have been partially driven by more salty food over
the Holidays or more subtle diet changes. In the hospital you
received IV diuretics to help remove this fluid. You lost more
than 7 litres of fluid by the time you were discharged. This is
more than 15 pounds! It is crucial that you continue this
progress at home by being very careful with diet, fluid intake
and medication use.
Your medications have been changed. You have been started on
iron supplementation as your low iron seems to be contributing
to your persistently low blood counts. Take your iron pills with
vitamin c or fruit juice. If you get constipated on iron, you
can take Colace twice daily or Senna; these are medications that
you can get at the pharmacy. Please continue to take your other
medications as previously described.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
MEDICATIONS
1) LASIX/FUROSEMIDE - Take 40mg tablets in the morning when you
wake and again at 4pm, or a few hours before you go to sleep.
You must take it twice daily. Your cardiologist may change this
dose. You must follow up with your PCP for [**Name Initial (PRE) **] lab test while on
this dose
2) Toprol XL - 100 mg, twice daily - this is a new dose of your
heart rate medication. TAKE THIS MEDICATION TONIGHT.
3) Aspirin 325 mg, this is to prevent a clot in your heart
4) Iron, Vitamin C - you are very low on iron and vitamin c aids
in absorption
5) Colace and Senna - medications for constipation, if that
becomes an issue
Followup Instructions:
You need to have your labs checked at your PCP office
We have scheduled an appointment for monday
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2192-12-31**]
12:30
You have a pre-op evaluation on the [**1-2**].
Provider: [**Name10 (NameIs) **] RM 1 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2193-1-2**]
9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2193-1-10**] 11:20
Completed by:[**2192-12-26**]
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icd9cm
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[] |
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|
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19,029
| 113,848
|
13493
|
Discharge summary
|
report
|
Admission Date: [**2110-6-17**] Discharge Date: [**2110-6-25**]
Date of Birth: [**2066-10-31**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ceftazidime / Carbamazepine / Cephalosporins /
cefepime
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Chief Complaint: Increased seizures
Major Surgical or Invasive Procedure:
Left PICC line placed by IR
History of Present Illness:
Ms. [**Known lastname **] is a 43F with a past medical history of [**Doctor Last Name **]
encephalitis, epilepsy, right hemiparesis, global aphasia,
tracehal stenosis, tracheobronchomalacia, chronic tracheostomy,
and recent ICU admissions for pneumonia and UTI in [**Month (only) **] for with
urosepsis and seizures. She was recently discharged on [**6-11**] from
the neurology service for increased seizures and Burkholderia
bacteremia. Patient presents today after being found at her
group home with increased seizure frequency and febrile to 103.
CXR there showed R infiltrate, and she was started on
vancomycin. Patient was initially tachycardic and hypotensive
but this reportedly resolved with tylenol and IVF.
.
In the ER, initial vitals were 101, 89, 102/55, 27, 100% on 35%
humidified trach mask. She was seen by neurology who
recommended admission to MICU with plans for transition to
neurology service once hemodynamically stable. Per neuro recs,
she received additional keppra 500mg IV and ativan 1mg IV. She
also received 1.5L NS and IV levaquin (despite taking PO
levaquin since d/c) and had SBP in the 90s. No pressors were
required. EKG showed sinus tachycardia and CXR here was poor
quality with questionable R infiltrate. She was admitted to
MICU for monitoring given SBP in 90s. Vitals on transfer were
99/54, 87, 25, 100% 15L track mask.
She was admitted to the MICU around and was started on
linezolid, tobramycin and aztreonam because of her multiple drug
allergies.
.
She had a PICC line placed on [**2110-6-18**], but her course has also
been complicated by frequent seizures. Her seizures are her
usual semiology of R facial twitching. Her zonisamide was
increased to 500mg QHS and her pheyntoin was increased to 100mg
TID. She was then transferred to the neurology floor service
for further management of her seizures.
Past Medical History:
1. [**Doctor Last Name **] encephalitis
2. Epilepsy
3. Partial left hemispherectomy at age 19 complicated by right
hemiparesis and partial aphasia
4. Mental retardation
5. Left thoracolumbar scoliosis
6. Vagal nerve stimulator implanted [**12-7**], needs battery change
7. h/o Aspiration pneumonias, now on scopolamine patch
8. S/p PEG placement using T tube
9. S/p tracheostomy
10. MRSA line infection in the past
11. Hx multiple UTIs, Urosepsis (enterococcus, other)
12. Difficult venous access requiring femoral sticks
13. Constipation
14. Mood disorder, on SSRI; also Zyprexa
- dense global aphasia w/ right hemiparesis
- right spastic hemiplegia
- tracheal stenosis and tracheobroncomalacia (trach dependent)
- recent h/o Pseudomonas aspiration PNA requiring
hospitalization
- major depression
Social History:
No history of tobacco, alcohol, illicit drug use. Lives in a
group home.
Family History:
No family history of seizures or [**Doctor Last Name **].
Physical Exam:
On ADMISSION:
General: Non-verbal but following commands
HEENT: NC/AT, EOMI in L eye, R eye with disconjugate eye
movements, sclera anicteric, MMM, oropharynx clear
Neck: supple, trach in place
Lungs: Clear to auscultation bilaterally anteriorly with coarse
breath sounds, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, GI tube in place, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, trace BLE edema, no
clubbing or cyanosis
ON DISCHARGE:
VITALS: T97,5 (ax), BP 87/33, HR 51, RR 18, 100% on 35% trach
mask
GEN: somnolent, opened eyes to voice, able to follow simple
commands
HEENT: MM mildly dry, OP clear, trach in place
NECK: No nuchal rigidity
PULM: Diffuse rhonchourous breath sounds bilaterally
CARDS: RRR no m/r/g
ABD: soft, NT, ND, no guarding or rebound
EXT: trace non-pitting edema to knees bilateraly, bilateral
contractures at fingers, on R has wrist contracture
SKIN: no rashes, scar on R chest for VNS
.
NEUROLOGICAL EXAM:
Mental Status: somnolent, but arousable to sternal rub, but was
not able to follow commands except for "lift this arm" while
touching her L arm. She is non-verbal.
.
Cranial Nerves:
I: Olfaction not tested
II: PERRL 4->2mm and brisk
III, IV, VI: patient has R eye exotropia, so eye movements are
disconjugate. V: pt unable to cooperate/respond to testing
VII: mild L sided facial droop
VIII: pt unable to cooperate/respond to testing
IX, X: not visualized
[**Doctor First Name 81**]: pt unable to cooperate/respond to testing
XII: tongue protrudes in midline
.
Motor: normal bulk, tone increased in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**] and RUE.
Able to lift her L arm fully off the bed, but only able to move
distal RUE up off bed. Unable to move either LEs, but does
withdraw bilaterally on LE's to pain. Fingers flexed and
contracted bilaterally.
.
Sensory: pt was unable to cooperate with the sensory exam
.
Reflexes: [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
R 0 0 0 0 0
L 0 0 0 0 0
.
Coordination and Gait: patient bedbound, unable to test
Pertinent Results:
ADMISSION LABS:
[**2110-6-17**] 08:14PM LACTATE-0.7
[**2110-6-17**] 07:09AM URINE RBC-1 WBC-90* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2110-6-17**] 06:31AM GLUCOSE-104* UREA N-11 CREAT-0.7 SODIUM-131*
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-23 ANION GAP-13
[**2110-6-17**] 06:31AM PHENOBARB-28.0 PHENYTOIN-7.1*
[**2110-6-17**] 06:31AM WBC-10.6 RBC-2.35* HGB-7.3* HCT-22.6* MCV-96
MCH-31.3 MCHC-32.5 RDW-15.9*
[**2110-6-17**] 01:18AM WBC-14.9*# RBC-2.76* HGB-8.7* HCT-25.4*
MCV-92 MCH-31.6 MCHC-34.3 RDW-15.9*
[**2110-6-18**] 04:00 6.4 2.39* 7.4* 23.4* 98 31.0 31.6 15.8* 265
[**2110-6-18**]: Feces negative for C.difficile toxin A & B by EIA.
DISCHARGE LABS:
[**2110-6-25**] 03:26AM BLOOD WBC-2.3* RBC-2.52* Hgb-7.6* Hct-23.5*
MCV-93 MCH-30.1 MCHC-32.3 RDW-15.9* Plt Ct-218
[**2110-6-25**] 03:26AM BLOOD Neuts-26* Bands-0 Lymphs-61* Monos-7
Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2110-6-25**] 03:26AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2110-6-25**] 03:26AM BLOOD Glucose-101* UreaN-17 Creat-0.7 Na-140
K-4.2 Cl-105 HCO3-28 AnGap-11
[**2110-6-25**] 03:26AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.2
[**2110-6-25**] 03:26AM BLOOD Phenoba-27.2 Phenyto-10.0
IMAGING:
CXR [**2110-6-17**]: IMPRESSION: No evidence of pneumonia. Low lung
volumes with resultant bronchovascular crowding
ECHO [**2110-6-20**]: IMPRESSION: normal study; no vegetations seen
Brief Hospital Course:
Ms. [**Known lastname **] is a 43F with a past medical history of [**Doctor Last Name **]
encephalitis, epilepsy, right hemiparesis, global aphasia,
tracehal stenosis, tracheobronchomalacia, chronic tracheostomy,
and recent admission for bacteremia and pneumonia, who presented
with MRSA bacteremia.
# Sepsis: She was reportedly febrile to 103 at her group home
with tachycardia and hypotension that responded to IV fluids.
Had a Postivie UA, elevated white count, with blood cultures
positive for MRSA from an OSH, but no lactate. Given her
history of VRE UTI last month, MRSA and prior resistant
Pseudomonas in sputum in [**Month (only) **], treated broadly with linezolid,
aztreonam, tobramycin and added levofloxacin for coverage of
BURKHOLDERIA (PSEUDOMONAS) CEPACIA. Narrowed to linezolid only
on [**6-17**]. Completed course of levo for pseudomonas on [**6-19**].
Tunneled catheter pulled and new PICC line placed by IR. We
planned to continue linezolid + vancomycin until Vanc level was
therepeutic, but pt developed neutropenia on linezoolid (see
below), and this was D/C'd early. Patient was continued on
vancomycin for a 2 week course from her first negative blood
culture, for a course that finishes on [**7-4**]. She was sent back
to her group home with VNA to complete the course.
# Hem/Onc: pt developed neutropenia on linezolid on [**6-20**]. Her
linezolid was then stopped and her neutropenia improved, and she
was no longer neutropenic on [**6-23**].
# Recent hypotension: Patient was reportedly hypotensive at
OSH/group home and responded to IVF. She was admitted to the
MICU for hemodynamic monitoring given SBP in the 90s in the ED.
Upon review of prior notes, her SBP seemed to range from the
90s-120s on previous admission. EKG was without signs of acute
concern and prior normal TTE in [**4-16**] was reassuring against
cardiac cause as well. Patient recived fluid bolusus as needed.
Lactates have been WNL, and her blood pressures remained
relatively stable throughout her admission despite some
fluctuations into the mid-80's.
# Seizures: Patient has very difficult to control seizures and
was just discharged from the neurology service for this on [**6-11**].
Had intermittent seizure activity with rapid eye movements and
facial twitching felt to be above her baseline. Neurology was
consulted recommended increasing zonisamide to 500QHS, dilantin
to 100 TID after 300bolus, and if breathing stably to give
phenobarb bolus 5mg/kg. After this, patient was transferred to
the neurology service, where her dilantin was further changed to
100/150/100 TID. Her seizures improved on this regimen but they
also likely improved as her bacteremia was treated.
Medications on Admission:
1. phenobarbital 20 mg/5 mL Elixir Sig: Thirty (30) mg PO HS (at
bedtime).
2. phenobarbital 20 mg/5 mL Elixir Sig: Sixty (60) mg PO BID (2
times a day).
3. levetiracetam 100 mg/mL Solution Sig: 1500 (1500) mg PO BID
(2 times a day).
4. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO NOON
(At Noon).
5. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
6. phenytoin 50 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables
PO TID (3 times a day).
7. fluoxetine 20 mg/5 mL Solution Sig: Five (5) cc PO DAILY
(Daily).
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
9. montelukast 5 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO DAILY (Daily).
10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every four (4) hours.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours.
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
14. scopolamine base 1.5 mg Patch 72 hr Sig: 1.5 Patch 72 hrs
Transdermal Q72H (every 72 hours).
15. senna 8.8 mg/5 mL Syrup Sig: Two (2) Tablet PO DAILY
(Daily).
16. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 9 days: Last day = [**6-19**].
Disp:*9 Tablet(s)* Refills:*0*
Discharge Medications:
1. phenobarbital 20 mg/5 mL Elixir Sig: Thirty (30) mg PO HS (at
bedtime).
2. phenobarbital 20 mg/5 mL Elixir Sig: Sixty (60) mg PO BID (2
times a day).
3. levetiracetam 100 mg/mL Solution Sig: 1500 (1500) mg PO BID
(2 times a day).
4. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO NOON
(At Noon).
5. zonisamide 100 mg Capsule Sig: Five Hundred (500) mg PO DAILY
(Daily).
6. fluoxetine 20 mg/5 mL Solution Sig: Twenty (20) mg PO DAILY
(Daily).
7. phenytoin 50 mg Tablet, Chewable Sig: One Hundred (100) mg PO
BID (2 times a day): Dose is 100/150/100 at TID dosing.
8. phenytoin 50 mg Tablet, Chewable Sig: One [**Age over 90 1230**]y (150)
mg PO QDAY (): Dose is 100/150/100 at TID dosing.
9. olanzapine 10 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO DAILY (Daily).
10. montelukast 5 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO DAILY (Daily).
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every four (4) hours.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H.
14. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
15. vancomycin in 0.9% sodium Cl 1.25 gram/150 mL Solution Sig:
1.25 grams Intravenous every twenty-four(24) hours: Last dose is
[**2110-7-4**].
Disp:*9 doses* Refills:*0*
16. senna 8.8 mg/5 mL Syrup Sig: Two (2) tabs PO once a day.
17. miconazole nitrate 2 % Powder Sig: One (1) application
Topical four times a day as needed for rash.
Discharge Disposition:
Home With Service
Facility:
Infusion Resource
Discharge Diagnosis:
Primary: MRSA bacteremia
Secondary: Epilepsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
NEURO EXAM: Somnolent, but arousable, can follow simple
commands, will move UE's spontaneously, and withdraw LE's
minimally to painful stimuli
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were seen in the hospital for an infection of your blood.
You were treated with intravenous antibiotics and repeat blood
tests showed that your infection was clearing. You will need to
complete a 14 day course of vancomycin, to finish on [**2110-7-4**].
We made the following changes to your medications:
1) We INCREASED your PHENYTOIN to 100mg, 150mg, 100mg three
times a day.
2) We INCREASED your ZONISAMIDE to 500mg once a day
3) We STARTED you on VANCOMYCIN 1250mg every 24 hours with last
dose on [**2110-7-4**].
4) We STOPPED your SCOPALAMINE PATCH, however, your doctors [**First Name (Titles) **] [**Name5 (PTitle) 40837**] [**Name5 (PTitle) **] decide to restart this, depending on your secretions.
Please continue to take your other medications as previously
presbribed.
If you experience any of the below listed Danger Signs, please
call your doctor or go to the nearest Emergency Room, or have
one of the aides at your group home assist you with getting
medical attention.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2110-8-4**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD [**Telephone/Fax (1) 2928**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2110-8-4**] at 11:15 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 857**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"995.91",
"E879.8",
"276.1",
"V44.0",
"038.12",
"V49.86",
"342.90",
"999.31",
"784.3",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12778, 12826
|
6968, 9666
|
369, 398
|
12915, 12915
|
5541, 5541
|
14310, 14920
|
3216, 3275
|
11191, 12755
|
12847, 12894
|
9692, 11168
|
13198, 13512
|
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|
3290, 3290
|
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|
13541, 14287
|
4394, 4394
|
310, 331
|
426, 2286
|
4577, 5522
|
5557, 6190
|
3304, 3883
|
12930, 13174
|
2308, 3109
|
3125, 3200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,313
| 167,037
|
28822+57608
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-7-16**] Discharge Date: [**2191-7-22**]
Service: MEDICINE
Allergies:
Ampicillin / Aldactone / Percocet / Simvastatin / Codeine /
Motrin
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
s/p fall and dyspnea/hypoxia
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
This is an 88 yo female w/ hx of AS, Afib, HTN, and dementia who
was transferred from the MICU after presenting to the ED the day
before with SOB secondary to CHF and s/p unwitnessed fall. On
the day of ED presentation, pt was found down by son at [**Hospital 4382**] home; pt was reportedly diaphoretic, increasingly
confused, and in respiratory distress. There was no associated
fever, chills, or cough. There was no LOC evident. The son, who
is the primary historian and HCP, reported that the pt had
increasing mental status changes in the last week, secondary to
changing medications, and was noted to have increasing falls by
ALH staff. Last hospitalization for CVA was [**4-26**], in which
medications were titrated.
.
In the [**Name (NI) **], pt had 02 sats in 70s on RA, which improved to 99 on
NRB, rectal T of 102 w/ lactate of 2.9. A foley catheter was
placed and pt received levaquin 500 mg IV, ceftaz 1 g IV, 10 mg
Decadron, and 20 IV lasix IV x2. She was subsequently admitted
to the MICU.
Past Medical History:
DM
A fib, w/ coumadin, rate controlled with BB and ditalizem
Osteoperosis
HTN
AS, no hx of syncope
Dementia, s/p CVA [**4-26**]
Temporal Arteritis
Recurrent falls
Social History:
Pt. lives at [**Hospital3 **] community after CVA [**4-26**]. Son is
HCP and makes major decisions for mother.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
VS: Temp: 96.5 BP: 130/72 HR: 119 RR: 22 O2sat: 93% on 3L NC
GEN: elderly woman in NAD
HEENT: MMM, neck supple
RESP: diffuse crackles but good air movement
CV: irregular, [**1-24**] sys murmur at RUSB, late peaking
ABD: soft, NT, ND, + BS
EXT: trace edema to shin BL, 2+ DP pulses, erythema over
bilateral knees with abrasions
Pertinent Results:
[**7-16**] Head CT :
IMPRESSION:
1. No hemorrhage or mass effect.
2. Severe periventricular and subcortical white matter
hypodensities
consistent with chronic microvascular ischemia.
[**7-16**] CT spine:
IMPRESSION:
1. No fracture or abnormal alignment.
2. Moderate degenerative change of the cervical spine.
[**7-16**] CXR:
There are bilateral pleural effusions, left greater than right.
There are moderates sized perihilar opacities. There is some
mild cephalization of the pulmonary vasculature. These findings
are consistent with moderate CHF. Aortic knob calcifications are
present. Impression: Moderate CHF with bilateral pleural
effusions. Cannot exclude underlying pneumonia within the lower
lobes.
[**7-17**] CXR:
FINDINGS: Comparison is made to the previous study from [**7-16**], [**2190**].
Cardiac silhouette is enlarged. There is calcification of the
thoracic aorta, unchanged. Mitral annulus calcification is also
seen. There are again seen persistent pleural effusions, right
side greater than left, which are unchanged. There is pulmonary
edema which is also stable.
[**7-18**] CXR:
PORTABLE AP CHEST RADIOGRAPH: Compared to prior radiograph from
[**2191-7-17**], given difference in technique, there is no
significant change of the right-sided pleural effusion. Small
left-sided pleural effusion remains unchanged. Stable appearance
of bibasilar atelectasis. No new consolidations. Heart size
remains mildly enlarged with upper zone redistribution of
pulmonary blood flow consistent with mild CHF. The mediastinal
and hilar contours are stable. IMPRESSION: Unchanged right-sided
pleural effusion and cephalization of pulmonary blood flow
consistent with mild CHF.
Lab Results:
CBC --> [**2191-7-16**]
WBC-14.0* RBC-3.64* Hgb-10.3* Hct-30.3* MCV-83 MCH-28.2
MCHC-33.9 RDW-15.3 Plt Ct-334; BLOOD Ddx Neuts-84.6* Lymphs-9.9*
Monos-4.7 Eos-0.7 Baso-0
[**2191-7-21**]
WBC-9.4 RBC-4.79 Hgb-13.0 Hct-39.5 MCV-82 MCH-27.0 MCHC-32.8
RDW-15.1 Plt Ct-331, DDx: Neuts-89.1* Bands-0 Lymphs-7.1*
Monos-3.7 Eos-0.1 Baso-0.1
Coagulations -->
PT-15.7* PTT-26.7 INR(PT)-1.4*
PT-19.6* PTT-25.9 INR(PT)-1.9*
Chemistries -->
[**2191-7-16**] Glucose-174* UreaN-26* Creat-0.9 Na-141 K-4.0 Cl-102
HCO3-25 AnGap-18
[**2191-7-21**] Glucose-147* UreaN-33* Creat-0.9 Na-133 K-4.3 Cl-94*
HCO3-28 AnGap-15
[**2191-7-16**] CK(CPK)-444*
[**2191-7-16**] CK(CPK)-393*
[**2191-7-16**] CK-MB-8 cTropnT-<0.01
[**2191-7-16**] CK-MB-8 proBNP-[**Numeric Identifier 19337**]*
[**2191-7-21**] proBNP-5690*
[**2191-7-16**] Calcium-9.4 Phos-3.1 Mg-2.0
[**2191-7-20**] Calcium-9.8 Phos-2.6* Mg-1.9
[**2191-7-16**] Lactate-2.9*
Brief Hospital Course:
1. CHF/SOB: Pt. presented w/ dyspnea upon admission. The
causes of her dyspnea was likely due to both an infectious
etiology (PNA)given her leukocytosis and acute CHF exacerbation.
On physical exam, pt had elevated JVP w/ trace edema, decreased
breath sounds, dullness to precussion, and diffuse crackles;
pleural effusions and pulmonary edema on CXR. The CXR could not
exclude a PNA give the pleural effusions. Her lab values
included elevated BNP levels ([**Numeric Identifier 19337**]) and WBC at 15.4. These
finding suggest an infectious etiology as well as CHF. Therfore,
given her UA and blood cultures were negative, she was treated
empirically for CAP.
The CHF is secondary to HTN and aortic stenosis (last measured
on [**2191-4-21**] at [**Hospital1 2025**] at 0.6); the cause of her CHF exacerbation
is still unclear although a dx of PNA or a run of her atrial
fibrillation may have contributed. Upon admission, the pt was
gently diuresed with Lasix 20 mg PO daily that was subsequently
increased to 40 mg PO daily. Pt. responded well to the diuresis
with decreased JVP, maintained BPs, and was oxygenating at 94%
on 2L on discharge. Pt's lasix dosage was reduced to 20 mg PO
daily to prevent overdiuresis and should be continued on that
dosage s/p discharge. Pt. should also be discharged w/ O2,
which can be titrated off as tolerated by [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
.
2. Leukocytosis: This is likely due to CAP. UA was negative with
negative urine and blood cultures. CXR could not exclude PNA
given effusions. The patient was treated empirically with
levofloxacin 250 mg QD for a ten day course. Upon discharge the
patient's WBC ct had fallen to 9.4 and she was afebrile.
.
3. Afib: Pt. was dx with Afib after [**2191-4-21**] admission at [**Hospital1 2025**]
for CVA. Pt. had an irregularly irregular heart rate w/ 3/6 SEM
in RUSB that was unchanged. Pt was continued on outpatient
medications of metoprolol 100 mg [**Hospital1 **] and diltizem. Dilt was
originally 180 XR PO daily, but was increased to 300 XR PO daily
because of increases in her heart rate. Her heart rate
continued to trend upwards, thus prompting increases in her dilt
(highest dose 360); the pt. then bradyed down to 40s and was
restarted at her outpt dose of 180 mg Diltiazem. metoprolol was
continued at 100 mg [**Hospital1 **]. Upon discharge, pt. had atrial
fibrillation and heart rate of 80s. She should continue to
receive 100 mg [**Hospital1 **] metoprolol and 180 mg XR PO daily dilt. Per
attending recs, we will start the patient on digoxin 0.25 mcg QD
x 2 days then 0.125 mg QD ongoing. We called the patient's PCP's
office to make a follow up appointment and were informed that
she will be followed by the [**Last Name (un) 2299**] house physicians and then by
her PCP's attending group when she return to her [**Hospital3 **]
facility.
.
3. Aortic Stenosis: Pt. was admitted w/ AS of 0.6 sqcm and a
3/6 SEM, heard best in the RUSB. Records from the [**Hospital 2025**] hospital
from [**2191-4-21**] confirm diffuse valvular disease in the MR, TR,
and AS; ejection fraction at this time is 69%. No repeat echo
was done considering her last echo was in [**Month (only) **]. Pt. is preload
dependent and should be carefully monitored for volume
depletion. Upon discharge, she was maintained on 20 mg PO lasix.
.
4. DM: Pt. had outpatient issue of DM and was continued on a
sliding scale of insulin as well as metformin at her outpatient
dosage.
.
5. Temporal Arteritis: Pt. had outpatient issue of temporal
arteritis and was continued on 1 mg prednisone.
Medications on Admission:
Medications:
Diltiazem XR 180 QD
Metoprolol 100 [**Hospital1 **]
Mag ox 400 qd
Ranitidine 150mg QD
Prednisone 1mg QD
Trazadone 50 mg Qd
Lasix 20mg QD
Metformin 500 qd
Lipitor 10mg qd
Coumadin 4mg qhs
Fosamax 40mg Qweek
Brimonidine 0.2% ou [**Hospital1 **]
Travatan one drop ou qd
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
3. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime)
as needed.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Alendronate 40 mg Tablet Sig: One (1) Tablet PO once a week:
please dose on wednesday.
11. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
12. Travoprost 0.004 % Drops Sig: One (1) Drop Ophthalmic QHS
(once a day (at bedtime)).
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID WITH MEALS ().
16. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day for
1 days: Please give this dosage on [**7-23**] then take 0.125 mcg/day
ongoing.
17. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day:
Please start this medication on [**7-24**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Pneumonia and Congestive Heart failure exacerbation.
Discharge Condition:
Good.
Discharge Instructions:
Please return to the ER or call your PCP if you experience
increasing shortness of breath, high fever, or any other
symptoms that concern you.
Followup Instructions:
Please follow up with your PCP within one week of discharge.
[**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 608**]
Completed by:[**2191-7-22**] Name: [**Known lastname 11833**],[**Known firstname 11834**] Unit No: [**Numeric Identifier 11835**]
Admission Date: [**2191-7-16**] Discharge Date: [**2191-7-22**]
Date of Birth: [**2102-8-15**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Aldactone / Percocet / Simvastatin / Codeine /
Motrin
Attending:[**First Name3 (LF) 2191**]
Addendum:
The patient came into the hospital on coumadin for her AFib.
After a discussion with her attending and the patient's son, it
was decided that given her fall risk, the coumadin would be
discontinued. Therefore, the patient was not discharged on
coumadin for her atrial fibrillation.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **]
[**First Name11 (Name Pattern1) 732**] [**Last Name (NamePattern4) 2192**] MD [**MD Number(2) 2193**]
Completed by:[**2191-7-22**]
|
[
"397.0",
"486",
"294.8",
"396.2",
"402.91",
"446.5",
"V58.61",
"733.00",
"250.00",
"398.91",
"707.03",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11418, 11674
|
4714, 8326
|
303, 310
|
10339, 10347
|
2075, 4691
|
10538, 11395
|
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|
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|
8352, 8633
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235, 265
|
338, 1349
|
1371, 1535
|
1551, 1664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,422
| 192,883
|
46785
|
Discharge summary
|
report
|
Admission Date: [**2138-9-3**] Discharge Date: [**2138-9-6**]
Date of Birth: [**2067-3-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nsaids / Bactrim DS / adhesive
tape
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Paroxysmal atrial fibrillation & Osler [**Doctor Last Name 11586**] Rendu syndrome.
Major Surgical or Invasive Procedure:
[**2138-9-3**]: 1. Bilateral mini thoracotomies with pulmonary vein
isolation using the AtriCure Synergy bipolar RF device with
resection of left atrial appendage.
History of Present Illness:
The patient is a 71-year-old woman referred to me by Dr. [**Last Name (STitle) **]
[**Name (STitle) **] for consideration of minimally invasive Maze procedure
with resection of left atrial
appendage due to her Osler [**Doctor Last Name 11586**] Rendu syndrome prohibiting her
from being anticoagulated. The patient has been relatively well
controlled with antiarrhythmics but has breakthrough atrial
fibrillation even on antiarrhythmics and has had to be
cardioverted several times.
Past Medical History:
1. Paroxysmal atrial fibrillation, status post two
cardioversions, most recently on [**2137-11-15**] and prior to that in
10/[**2135**].
- Pt can only take ASA for anticoagulation due to OWR syndrome
2. Paroxysmal atrial flutter.
3. LLE Lymphedema secondary to skin lesion removal.
4. Asthma.
5. In [**2116**], an episode of congestive heart failure secondary to
presumed viral cardiomyopathy, this was the first onset of
atrial
fibrillation.
6. Mild mitral valve regurgitation, severe tricuspid
regurgitation by echocardiogram in 10/[**2135**].
7. Hypertension and LVH.
8. Osler-[**Doctor Last Name 11586**]-Rendu syndrome.
9. Squamous cell CA s/p multiple excisions
10. Pulmonary HTN
11. Esophagitis
12. Ganglion cysts
13. s/p L TKR
14. s/p tonsillectomy
15. s/p TAH/SO on prempro
Social History:
Anesthesia nurse [**First Name (Titles) 767**] [**Last Name (Titles) **], retired 2.5 years ago. Exercises and
does low-impact aerobics 30 min/3x week. Lives with husband.
Denies tobacco use or recreational drug use. Patient 2 glasses
of wine per night.
Family History:
Pt is adopted and therefore there is no family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
.
Physical Exam:
Discharge exam
VS:T: 98.1 HR: 78 SBP: 135/71 Sats: 92% RA WT: 189
General: 71 year-old female who appears well
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: decreased breath sounds otherwise clear
GI: benign
Extr: warm no edema
Incision: bilertal minithoracotomy site clean dry intact, no
erythema
Neuro: awake, alert oriented
Pertinent Results:
[**2138-9-6**] WBC-6.4 RBC-3.82* Hgb-11.1* Hct-33.5* MCV-88 MCH-29.0
MCHC-33.0 RDW-15.9* Plt Ct-229
[**2138-9-3**] WBC-7.1# RBC-3.83* Hgb-11.1* Hct-34.1* MCV-89 MCH-28.9
MCHC-32.5 RDW-15.8* Plt Ct-179
[**2138-9-6**] Glucose-91 UreaN-9 Creat-0.6 Na-136 K-4.2 Cl-102
HCO3-25
[**2138-9-3**] UreaN-10 Creat-0.6 Na-141 K-3.4 Cl-110* HCO3-20*
[**2138-9-6**] Mg-2.2
[**2138-9-3**] MRSA SCREEN (Final [**2138-9-6**]): No MRSA isolated.
CXR: [**2138-9-5**]: There is no evidence of pneumothorax. The rest
of the examination is unchanged from one hour prior with mild
vascular congestion and cardiomegaly.
Brief Hospital Course:
The patient was brought to the operating room on [**2138-9-3**] where
the patient underwent Bilateral mini thoracotomies with
pulmonary vein isolation using the AtriCure Synergy bipolar RF
device with resection of left atrial appendage.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Her pain was not well control and
anesthesia performed on [**9-3**] bilateral T6 paravertebral blocks
x2 and repeat on [**9-4**] bilateral T4, T7, T10 paravertebral block
with better pain control. Dofetilide was restarted. She transfer
to the floor on POD1. She had brief episodes of self limiting
atrial fibrillation 120's. She was gently diuresed toward the
preoperative weight. Chest tubes and pacing wires were
discontinued without complication. She was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on [**2138-9-6**] the patient was
ambulating freely, bilateral wounds were healing and pain was
controlled with oral analgesics. The patient was discharged
home in good condition with appropriate follow up instructions.
Medications on Admission:
Amlodipine 5 mg daily, Tikosyn 125 mcg twice daily, Premarin
0.625 mg daily, Fenofexadine 60mg twice daily, Flovent 110mcg -
2 puffs twice daily, Lisinopril 40 mg daily, Medroxyprogesterone
5 mg daily, Prilosec 20 mg daily, Calcium and Vitamin D daily,
Aspirin 325 mg daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. conjugated estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. indomethacin 25 mg Capsule Sig: One (1) Capsule PO three
times a day.
Disp:*90 Capsule(s)* Refills:*2*
9. medroxyprogesterone 5 mg Tablet Sig: One (1) Tablet PO once a
day.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-12**]
hours as needed for pain, fever.
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. potassium chloride 8 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
14. Senna-S 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a day:
hold for loose stool.
Disp:*60 Tablet(s)* Refills:*2*
15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Paroxysmal Atrial Fibrillation, s/p multiple DCCV, Hypertension,
Multinodular Goiter, Osler-[**Doctor Last Name 11586**]-Rendu syndrome, History of
Melanoma s/p excision, complicated by Lymphedema, Squamous cell
carcinoma of the leg, s/p 5FU cream, Asthma, Episode of
congestive heart failure secondary to presumed viral
cardiomyopathy, this was the first onset of atrial fibrillation,
GERD, s/p melanoma excision [**2132**], s/p sentinel node procedure
complicated by persistent seroma
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]: the office
will call you for a follow-up appointment
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time:[**2138-10-14**] 2:45 in the
[**Last Name (un) 2577**] Building [**Hospital Unit Name **] [**Last Name (NamePattern1) **]
Cardiologist Dr. [**Last Name (STitle) **]. Please call for a follow-up
appointment
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 2204**] in [**3-11**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2138-9-6**]
|
[
"401.9",
"493.90",
"427.31",
"424.0",
"397.0",
"V10.82",
"241.1",
"448.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.36",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
6621, 6670
|
3394, 4776
|
418, 584
|
7201, 7357
|
2766, 3371
|
8229, 8987
|
2200, 2355
|
5100, 6598
|
6691, 7180
|
4802, 5077
|
7381, 8206
|
2370, 2747
|
294, 380
|
612, 1097
|
1119, 1911
|
1927, 2184
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,920
| 171,509
|
52410
|
Discharge summary
|
report
|
Admission Date: [**2114-9-22**] Discharge Date: [**2114-9-27**]
Date of Birth: [**2064-2-26**] Sex: M
Service: [**Hospital Ward Name 332**] Intensive Care Unit
CC:[**CC Contact Info 98817**]
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
gentleman with advanced amytrophic lateral sclerosis who is
ventilatory dependent and presented with respiratory
distress.
This history was obtained primarily from the patient's wife
and was confirmed with the patient who is able to speak
minimally around his tracheostomy.
Approximately five days prior to admission, the patient
started spiking temperatures to 102. Three days prior to
admission, his wife empirically started him on a course of
levofloxacin for a presumed pneumonia when she noted
increased thick blood-tinged pulmonary secretions. The
fevers did decrease on the antibiotics.
However, one day prior to admission, the patient and his wife
were watching television and afterwards the patient's wife
had difficulty transferring the patient to a wheelchair and
had to lower him to the floor. He then started complaining
of shortness of breath and asked his wife to call 911. She
attempted to suction him as well as to bag him without
improvement in his symptoms, so she called Emergency Medical
Service. The patient also complained of some pleuritic chest
pain (typical of his pneumonia episodes according to his
wife). He denies dysuria, but his wife reports dark urine
recently.
In the Emergency Department, he was found to have a blood
pressure of 195/98 with a heart rate of 150. His initial
arterial blood gas revealed a pH of 7.05, a PCO2 of 51, and a
PO2 of 324; consistent with a mixed respiratory and metabolic
alkalosis. With improved ventilation, his arterial blood gas
improved to a pH of 7.22, a PCO2 of 38, and a PO2 of 151.
The Emergency Department did a computed tomography angiogram
which was negative for pulmonary embolism but showed a
question of bibasilar consolidation versus atelectasis. He
was given ceftriaxone 1 g intravenously and then transferred
to the Intensive Care Unit for further care.
PAST MEDICAL HISTORY:
1. Amytrophic lateral sclerosis diagnosed in [**2111**]; status
post tracheostomy and percutaneous endoscopic gastrostomy
tube in [**2113-5-17**]. He has been ventilator dependent since
[**2113-5-17**].
2. Depression.
3. Hypertension.
4. History of prostatitis.
5. Coronary artery disease; status post non-Q-wave
myocardial infarction in [**2113**] at [**Hospital6 1130**].
6. History of pneumonia (Pseudomonas and Serratia).
7. Nephrolithiasis.
8. History of alcoholism.
MEDICATIONS ON ADMISSION:
1. Lactulose 30 mL by mouth twice per day.
2. Ativan as needed.
3. Clonazepam 1.5 mg by mouth twice per day.
4. Celebrex 200 mg by mouth twice per day.
5. Reglan 10 mg by mouth twice per day to three times per
day.
6. Celexa 80 mg by mouth once per day.
7. Allopurinol 100 mg by mouth once per day.
8. Rilutek 50 mg by mouth twice per day.
9. Detrol 2 mg by mouth twice per day
10. Temazepam 45 mg by mouth q.h.s.
11. Trazodone 200 mg by mouth q.h.s.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer. Father had
coronary artery disease and a myocardial infarction in his
50s. Brother has hypertension. Grandfather had early
coronary artery disease.
SOCIAL HISTORY: The patient is married and lives with his
wife who is his primary caretaker. [**Name (NI) **] is a past alcoholic;
and according to his wife drinks socially now. No history of
tobacco use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed vital signs with a temperature of 99.1
degrees Fahrenheit, his heart rate was 92, his blood pressure
was 164/79, his respiratory rate was 20, and his oxygen
saturation was 100% on 40% FIO2. In general, he was alert
and answered questions appropriately. Head, eyes, ears,
nose, and throat examination revealed tracheostomy in place.
Cardiovascular examination revealed heart sounds obscured by
loud breath sounds. Lungs revealed loud rhonchorous upper
airway sounds bilaterally with decreased breath sounds in the
bases. The abdomen was distended and nontender. Bowel
sounds were present. Gastrojejunostomy tube was in place.
Extremity examination revealed 3+ pitting edema throughout.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed his white blood cell count was 21. Chemistry-7 was
significant for a bicarbonate of 16, with an anion gap of 17,
and a glucose of 296. Acetone was negative. A urinalysis
showed 6 to 10 red blood cells, 6 to 10 white blood cells, a
few bacteria, and no ketones. A lactate on his initial
arterial blood gas was 3.8.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed patchy
bibasilar density (left greater than right).
A computed tomography angiogram was a limited study due to
central intravenous access, but no pulmonary embolism was
seen. Focal patchy consolidation or atelectasis with
associated bronchiectasis in the bilateral bases.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The patient is chronically
ventilator dependent due to advanced amytrophic lateral
sclerosis. He presented with acute hypercapnic
decompensation as well as an increased A:A gradient which was
presumed secondary to pneumonia.
He was started on Zosyn and gentamicin due to his history of
Pseudomonas pneumonia. The Zosyn was also coverage for
consideration of aspiration pneumonia.
Three days after admission, a sputum culture became positive
for methicillin-resistant Staphylococcus aureus, and the
patient was switched to vancomycin. After being on
vancomycin for a couple of days, his fever curve trended
down. The time of discharge, the patient was stable on his
ventilatory settings, and his secretions were much decreased.
2. ACIDOSIS ISSUES: On admission, the patient had a
profound acidosis due to respiratory and metabolic elements.
His respiratory acidosis resolved with changes in his
ventilatory settings which increased ventilation. His
metabolic acidosis was presumed to be lactic acidosis also
resolved within a few hours of admission. It was unclear
what caused this, but may have been due to an undocumented
hypotensive event prior to his presentation.
3. ENDOCRINE ISSUES: The patient had a glucose of
approximately 300 on presentation. He had no history of
diabetes. His glucose levels normalized within the first
couple of days of admission. A hemoglobin A1c was checked
and was 5. This was likely a stress event and does not need
further treatment at this time; however, this may suggest
that the patient has an increased risk of developing diabetes
in the future.
4. CARDIOVASCULAR ISSUES: The patient did have positive
troponin levels with a peak of 0.36 in the setting of
negative creatine kinase levels during this admission. He
does have a history of a non-Q-wave myocardial infarction in
the past. This likely represented demand ischemia and was
treated with the initiation of aspirin and a beta blocker
(which the patient had previously been on at home in the
past).
5. PSYCHIATRIC ISSUES: The patient was on a large amount of
chronic benzodiazepines as well as antidepressants. These
were continued while he was in house.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient does
take food by mouth and is supplemented by tube feeds through
his gastrojejunostomy tube.
7. ACCESS ISSUES: A peripherally inserted central catheter
line was placed by Interventional Radiology for home
antibiotics.
8. CODE STATUS: The patient is already chronically
ventilation dependent. However, he is do not resuscitate
status and this was confirmed with the patient and his wife
during this hospitalization.
CONDITION AT DISCHARGE: Condition on discharge was stable on
ventilator with improved pulmonary secretions.
DISCHARGE STATUS: Discharge status was to home. The
patient's primary caretaker is his wife who is a registered
nurse. They also have [**Hospital 5065**] home health care services.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to
complete a 2-week course of vancomycin through his
peripherally inserted central catheter line.
DISCHARGE DIAGNOSES: Methicillin-resistant Staphylococcus
aureus pneumonia.
MEDICATIONS ON DISCHARGE:
1. Lactulose 30 mL by mouth twice per day.
2. Ativan as needed.
3. Clonazepam 1.5 mg by mouth twice per day.
4. Celebrex 200 mg by mouth twice per day.
5. Reglan 10 mg by mouth twice per day to three times per
day.
6. Celexa 80 mg by mouth once per day.
7. Allopurinol 100 mg by mouth once per day.
8. Rilutek 50 mg by mouth twice per day.
9. Detrol 2 mg by mouth twice per day
10. Temazepam 45 mg by mouth q.h.s.
11. Trazodone 200 mg by mouth q.h.s.
12. Vancomycin 1 g intravenously twice per day (for 10
days).
13. Aspirin 325 mg by mouth once per day.
14. Metoprolol 12.5 mg by mouth twice per day.
15. Albuterol and Atrovent meter-dosed inhalers.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 15468**]
MEDQUIST36
D: [**2114-9-26**] 12:06
T: [**2114-9-27**] 12:34
JOB#: [**Job Number 108305**]
|
[
"335.20",
"V46.8",
"599.0",
"276.4",
"V44.0",
"V09.0",
"518.83",
"482.41",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3187, 3379
|
8260, 8316
|
8343, 9298
|
2645, 3170
|
8121, 8237
|
5110, 7801
|
7816, 8086
|
237, 2114
|
2136, 2618
|
3396, 5076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,040
| 120,255
|
54694
|
Discharge summary
|
report
|
Admission Date: [**2183-8-29**] Discharge Date: [**2183-9-12**]
Date of Birth: [**2102-8-1**] Sex: M
Service: SURGERY
Allergies:
clindamycin / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
exploratory laparotomy, right hemicolectomy, descending loop
colostomy, end ileostomy, rectal biopsy
History of Present Illness:
Admitted on [**2183-8-29**]:
The patient is an 81M with remote h/o prostate cancer s/p XRT
and radiation-induced proctitis who is presenting with
increasing abdominal pain and distention x 1 months. According
to Gerontology notes in OMR, the patient has been evaluated for
these symptoms as recently as [**8-26**]. At the time, his abdominal
bloating was attributed to fecal impaction, and his laxative
regimen was escalated to include miralax. The patient states
that he has not had a normal BM during the past month, as all of
his stools have been small volume and containing mucous. He also
endorses decreased PO intake over past several months. His wife
reports that he has been steadily losing weight since [**Month (only) 547**], up
to 40 lbs. His most recent BM was last [**2183-8-28**], very little
stool. Passing flatus today. Denies history of prior abdominal
surgeries or hernias.
With respect to his radiation proctitis, the patient has
developed
leakage of stool and occasionally some blood in the stool over
the past few years. A sigmoidoscopy in mid-[**Month (only) 205**] showed abnormal
mucosa up to 19 cm, consistent with radiation proctitis. There
was also a mass versus hypertrophic mucosa in the distal rectum,
for which he was scheduled to be biopsied next week.
In the ED, initial VS were: 97.9 63 132/78 16 100% RA. His
abdomen was TTP diffusely on the left without rebound. Labs were
significant for Cr 1.6 and HCT 31.4. CT A/P showed segment of
descending colon with bowel wall thickening with small-moderate
ascites, colitis (infectious/inflammatory/ischemic) cannot be
excluded. Moderate bilateral hydronephrosis with full column
hydroureter extending all the way to the bladder with no
obstructive calculi noted which may represent radiation induced
stricture of ureter. VS prior to transfer were: 98.3 hr 60 b/p
166/79 rr 20.
Past Medical History:
1. Prostate cancer six years ago, status post XRT currently on
Lupron q6mo - apparently recently rising PSA.
2. Radiation proctitis per reports of prior colonoscopy.
3. Mild COPD.
4. Obstructive sleep apnea, uses CPAP.
5. CAD status post stent many years ago, no recurrent symptoms.
6. Pacemaker.
7. Spinal stenosis and DJD.
8. Hypertension.
9. Total hip replacement in [**2180**].
10. Submucosal gastric lesion, likely GIST tumor status post EUS
in [**2183**] - plan to follow conservatively.
Social History:
He is a former smoker and drinks only occasional alcohol.
He lives with his wife and as I mentioned, his daughter is a
nurse, who is very involved with his care.
His daughter is getting married in the near future and they hope
he feels well enough for the wedding.
Family History:
There is no family history of inflammatory bowel disease or any
other GI conditions as far as he is aware. His father died in
his 70s with an MI and his mother died in her 80s of a stroke.
Physical Exam:
VITALS: 98.1, 67, 137/72, 20, 100% RA
GENERAL: NAD, pleasant elderly caucasian gentleman
HEENT: PERRL, EOMI, mucous membranes dry
NECK: no carotid bruits, no lymphadenopathy
LUNGS: CTAB, no wheezing rhonchi, or rales
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: no abd distention, soft, nontender to palpation, open
abdominal wound packed with gauze, erythema around wound due to
fungal infection, ileostomy on right, colostomy on left, both in
place, +BSs
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
Pertinent Results:
([**2183-8-29**]) CT ABDOMEN:
1. Significant fecal loading involing entire colon.
2. Diverticulitosis witout diverticulitis.
3. Segment of descending colon with bowel wall thickening with
small-moderate ascites;colitis
(infectious/inflammatory/ischemic) cannot be excluded. Given
fecal loading, stercoral colitis remains in the differential.
Recommend correlation with lactate.
4. Moderate bilateral hydronephrosis with full column
hydroureter extending all the way to the bladder with no
obstructive calculi noted. Findings may be secondary to
radiation induced stricture of ureter.
5. Renal hypodensities in right upper and mid pole likely cysts
6. Small -moderate ascites.
7. Presacral thickening likely sequela of prostate cancer
treatment.
KUB [**2183-9-1**]
Dilated right and transverse large bowel loops. Distal large
bowel obstruction with competent ileocecal valve cannot be
excluded.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 111849**],[**Known firstname **] [**2102-8-1**] 81 Male [**-1/3566**] [**Numeric Identifier 111850**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/DR. [**Last Name (STitle) **]. PATWARDHAN/DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/DR.
[**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **],E/mtd
SPECIMEN SUBMITTED: RUSH...GI BX (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
[**2183-9-5**] [**2183-9-5**] [**2183-9-9**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rna
DIAGNOSIS:
Rectal mass, mucosal biopsies:
Adenocarcinoma of the prostate involving the colonic
mucosa; confirmed by immunopositivity for prostate specific
antigen and prostate specific acid phosphatase.
Immunostain for CDX-2 highlights background colonic
epithelial cells and is negative within the tumor.
Clinical: Large bowel obstruction. Rectal mass lesion on
previous sigmoidoscopy.
Gross: The specimen is received in one formalin-filled
container labeled with the patient's name, "[**Known lastname **], [**Known firstname 3613**]", the
medical record number, and is additionally labeled "rectal
mass". It consists of multiple tissue fragments measuring up to
0.3 cm which are entirely submitted in cassette A.
Brief Hospital Course:
Mr [**Known lastname **] is a 81 caucasian Male with remote h/o prostate cancer
s/p XRT and radiation-induced proctitis who is presenting with
increasing abdominal bloating and distention. Pt has not had a
substantial BM x 1 month. He recently had a sigmoidoscopy with
Dr. [**First Name (STitle) 908**] on [**2183-8-11**] that showed: Abnormal mucosa up to 19cm,
consistent with radiation proctitis; mass versus hypertrophic
mucosa in the distal rectum. - ABD CT on admission showed fecal
impaction through the entire colon, without obvious transition
point.
CV:
There was some concern for intraoperative ischemia, but
troponins were negx3, and ECG was unchanged from pre-op. On
[**2183-9-6**] (POD #1), he was admitted to the SICU for hypotension
and low UOP. This resolved with aggressive fluid resuscitation
and 2U PRBC, and he was transferred back to the floor POD #2
([**2183-9-7**]). He was restarted on his antihypertensives when
tolerating PO, and his BP remained around 130-140s systolic.
After consultation with cardiology, his aspirin was restarted
[**2183-9-8**], and it was decided he no longer needed plavix.
Pulm:
Patient had some dyspnea with exertion POD #5 and a CXR was
obtained, showing clear lung fields and no acute pulmonary
process. His dyspnea resolved. He has a history of obstructive
sleep apnea, uses CPAP at setting PS 7, used during this
admisison.
GI: For his original constipation/impaction, pt was first tried
with an aggressive bowel regimen with little improvement. GI was
consulted and recommended even more aggressive regimen. Manual
disimpaction was first tried by primary team intern on [**2183-9-1**]
without success. Surgery was consulted, tried another manual
disimpaction on [**2183-9-3**] without any success again. GI performed
sigmoidoscopy on [**2183-9-5**] that showed almost completely
obstructing mass in the rectum ~4cm from the anal verge.
Differential includes malignancy vs. severe inflammation and
hyperplasia in the setting of radiation proctitis. Colorectal
surgery consulted and an ex-lap, right hemicolectomy, end
ileostomy, descending loop colostomy, and rectal biopsy was
performed on [**2183-9-5**]. There was some fecal spillage
intraoperatively. He tolerated the procedure well and was
transferred to the PACU in stable condition. Upon discharge, he
was at goal ileostomy output (between 500 and 1200cc/day), with
gas in his ileostomy and colostomy bag. His wound was opened
[**2183-9-11**] due to increased drainage and was being packed with
moist to dry tid.
Nut/FEN: He was advanced to a CLD POD #3, which he tolerated
well, and then advanced to a regular diet POD #4, which he again
tolerated well. He had repeated hypokalemia post-operatively,
and needed repletion daily. K 2.5 on [**2183-9-8**], improved to 3.7
upon admission.
GU: Upon admission he had low UOP with hydronephrosis on CT and
elevated Cr to 1.6, which resolved rapidly and returned to
baseline within 2-3 days. He had a foley placed [**8-30**] with
cystoscopy by urology. The foley was cut accidentally in the OR
and replaced without difficulty on [**2183-9-5**]. He again had
increased Cr to 1.3 POD [**1-27**], but again resolved with hydration
and has remained at baseline 1.0 with good UOP. Rectal biopsy
[**2183-9-5**] showed adenocarcinoma of the prostate involving the
colonic mucosa; confirmed by immunopositivity for prostate
specific antigen and prostate specific acid phosphatase. PSA
[**2183-9-6**] was 16.8 from PSA [**2183-1-27**]. Patient was diagnosed with
recurrent/metastatic prostate cancer that failed lupron
treatment, and was seen by heme/onc and was recommended to
undergo hormone therapy, without further surgery. He will
follow-up with heme/onc 2 weeks after discharge. Urology will
also see the patient Wed [**2183-9-17**] to do a voiding trial. The
foley should remain until then. He remained on tamsulosin 0.4 mg
qd during his admission.
ID: No issues.
Psych: Patient has a long history of depression, starting
depression medication a few years ago. He now takes Mirtazapine
15mg at bedtime and duloxetine ER 60mg daily
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of VNA services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for VNA/ Rehab services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Albuterol Inhaler [**1-27**] PUFF IH Q6H:PRN wheeze
2. Atenolol 12.5 mg PO BID
Hold for SBP<100, HR<60
3. Duloxetine 60 mg PO DAILY
4. fenofibrate *NF* 145 mg Oral daily
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Hydrocortisone Acetate 10% Foam 1 Appl PR HS
7. Mesalamine 400 mg PO TID
8. Mesalamine (Rectal) 1000 mg PR DAILY
9. Mirtazapine 15 mg PO HS
10. Montelukast Sodium 10 mg PO DAILY
11. Fish Oil (Omega 3) Dose is Unknown PO BID
12. Tamsulosin 0.4 mg PO HS
13. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Albuterol Inhaler [**1-27**] PUFF IH Q6H:PRN wheeze
RX *albuterol 1-2 puffs every six (6) hours Disp #*1 Inhaler
Refills:*1
2. Duloxetine 60 mg PO DAILY
RX *Cymbalta 60 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
RX *Flovent HFA 110 mcg/actuation 2 puff ih twice a day Disp #*1
Inhaler Refills:*1
4. Mirtazapine 15 mg PO HS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. Montelukast Sodium 10 mg PO DAILY
RX *Singulair 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
7. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
9. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
10. Loperamide 2 mg PO BID
RX *Imodium A-D 2 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*1
11. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
12. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN rash
posterior to abdominal wound yeast rash
RX *miconazole nitrate 2 % 1 application twice a day Disp #*1
Unit Refills:*1
13. Nitroglycerin SL 0.3 mg SL PRN chest pain
page HO prior to giving
RX *Nitrostat 0.3 mg 1 tablet sublingually once, MR1 Disp #*10
Tablet Refills:*0
14. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*40 Tablet Refills:*0
15. Psyllium Wafer 2 WAF PO BID
RX *Metamucil 2 wafer by mouth twice a day Disp #*60 Unit
Refills:*0
16. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram/10 mL 10 milliliter by mouth twice a day
Disp #*600 Milliliter Refills:*1
17. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*30
Tablet Refills:*0
18. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] nursing and therapy center [**Hospital3 4414**]
Discharge Diagnosis:
advanced prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a right colectomy for
surgical management of your obstructing rectal mass. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
regarding these results they will contact you before this time.
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor Movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 1-2 days. After anesthesia it is not
uncommon for patient??????s to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are expected however, if you notice that you are passing bright
red blood with bowel your bowel function closely. If you are
passing loose stool without improvement please call the office
or go to the emergency room if the symptoms are severe. If you
are taking narcotic pain medications there is a risk that you
will have some constipation. Please take an over the counter
stool softener such as Colace, and if the symptoms does not
improve call the office. If you have any of the following
symptoms please call the office for advice or go to the
emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or
constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise for 6 weeks.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
you find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if you notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If you notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. You may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to you by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. You
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until you are comfortable caring
for it on your own.
You have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. You should have [**1-27**]
bowel movements daily. If you notice that you have not had [**First Name8 (NamePattern2) 691**]
[**Doctor Last Name 3945**] from your stoma in [**1-27**] days, please call the office. You
may take an over the counter stool softener such as Colace if
you find that you are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if you notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as you
have been instructed by the wound/ostomy nurses. You will be
able to make an appointment with the ostomy nurse in the clinic
7 days after surgery. You will have a visiting nurse at home for
the next few weeks helping to monitor your ostomy until you are
comfortable caring for it on your own.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 770**] at his general urology clinic
on Wednesday [**2183-9-17**]. Call ([**Telephone/Fax (1) 7707**] to make an appointment
for a voiding trial.
Please follow up with Dr. [**Last Name (STitle) **] (oncology) in 2 weeks. Call
([**Telephone/Fax (1) 31163**] to make an appointment.
Please call the colorectal surgery department at [**Telephone/Fax (1) 160**] to
make an appointment with [**First Name4 (NamePattern1) 1123**] [**Last Name (NamePattern1) 111851**], NP or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
for follow-up 7-14 days after surgery. At this visit an
appointment will be made for you with Dr. [**Last Name (STitle) 1120**] for your second
post-operative visit.
|
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"327.23",
"403.90",
"276.8",
"560.89",
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"458.29",
"909.2",
"496",
"E879.2",
"197.5",
"285.9",
"787.60",
"414.8",
"V43.64",
"789.59",
"788.20",
"V45.82",
"783.21",
"569.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"48.24",
"57.94",
"46.03",
"99.15",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
14270, 14361
|
6324, 11303
|
325, 428
|
14430, 14430
|
3855, 6301
|
21384, 22142
|
3134, 3325
|
12012, 14247
|
14382, 14409
|
11329, 11989
|
14613, 21361
|
3340, 3836
|
273, 287
|
456, 2316
|
14445, 14589
|
2338, 2835
|
2851, 3118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,710
| 100,852
|
9318
|
Discharge summary
|
report
|
Admission Date: [**2129-3-9**] Discharge Date: [**2129-3-14**]
Date of Birth: [**2075-4-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Oxaliplatin
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Right Cerebellar Mass
Major Surgical or Invasive Procedure:
[**3-10**]-Posterior Fossa Craniotomy for right sided brain mass
History of Present Illness:
Patient is a 53F electively admitted on [**3-9**] to undergo a
posterior fossa craniotomy for resection of right cerebellar
mass
Past Medical History:
colon Ca with metastatic disease
pulmonary wedge rection [**2123**]
colectomy [**2121**]
Social History:
Social History: She is a computer programmer. She does not
smoke cigarettes or drink alcohol.
Family History:
Family History: Her mother died of colon cancer. Her father
died of old age. She has a brother who is healthy. She does
not
have any children.
Physical Exam:
On Discharge:
Alert, Oriented. full strength and power throught. no dysmetria
or drift noted.
Pertinent Results:
Labs on Admission:
[**2129-3-9**] 03:45PM BLOOD WBC-11.9* RBC-3.68* Hgb-10.5* Hct-31.5*
MCV-86 MCH-28.5 MCHC-33.3 RDW-16.2* Plt Ct-216
[**2129-3-9**] 03:45PM BLOOD Neuts-75.6* Lymphs-19.5 Monos-3.5 Eos-1.1
Baso-0.3
[**2129-3-9**] 03:45PM BLOOD PT-13.4 PTT-25.9 INR(PT)-1.2*
Labs on Discharge:
[**2129-3-12**] 06:02AM BLOOD WBC-14.0* RBC-2.95* Hgb-8.6* Hct-25.4*
MCV-86 MCH-29.0 MCHC-33.7 RDW-16.0* Plt Ct-247
[**2129-3-12**] 06:02AM BLOOD PT-12.3 PTT-33.6 INR(PT)-1.0
[**2129-3-12**] 06:02AM BLOOD Glucose-114* UreaN-20 Creat-0.8 Na-140
K-4.1 Cl-103 HCO3-29 AnGap-12
[**2129-3-12**] 06:02AM BLOOD Phenyto-9.0*
Imaging:
Head CT [**3-9**](post-op):
There are again seen is a left occipital craniectomy site. A
right
intraventricular catheter has been removed. There is new and
more pronounced edema in the left parietal lobe towards the
vertex where there is some effacement of the adjacent sulci. A
right frontal burr hole is again seen. There is no shift of
midline structures, loss of [**Doctor Last Name 352**]-white matter junction
differentiation and osseous structures are otherwise
unremarkable with mastoid air cells and visualized paranasal
sinuses being clear.
IMPRESSION:
1. Expected postoperative changes at right the occipital
craniectomy site.
2. Apparently new edema with mild effacement of sulci towards
the vertex
raises the possibility of a new metastatic lesion.
MRI Head [**3-12**]:
FINDINGS: Again postoperative changes are seen in the right
posterior fossa with small amount of blood products at the
surgical bed and a small
craniectomy defect. Small area of edema is seen in this region.
Small air
bubble is identified secondary to recent surgery and mild
surrounding slow
diffusion is seen which could be related to surgery. There is no
definite
residual enhancement identified in this region. Again, a linear
enhancement in the left cerebellum and multiple enhancing brain
metastatic lesions are identified involving both frontal lobes,
left parietal lobe. These findingsare not significantly changed
and surrounding edema has also not changed. Mild diffuse
hyperintensity in the white matter indicate post-radiation
change.
IMPRESSION: No residual enhancement is seen at the site of
post-surgical
changes and blood products in the right cerebellum. Other
enhancing brain
lesions are again identified, and are unchanged compared with
[**2129-3-10**].
Head CT [**3-10**]:
COMPARISON: [**2129-3-9**].
NON-CONTRAST HEAD CT: Patient is status post right occipital
craniectomy,
with expected post-surgical changes seen at the surgical site.
Underlying
edema and minimal superficial blood products are noted, but
there is no
evidence for new hemorrhage or increased mass effect. Effacement
of the 4th ventricle is decreased. Again seen is a prior left
occipital craniectomy. There is edema seen within the left
frontal and parietal lobes, which has not changed compared to
study performed one day prior. There is no change in the size of
the ventricles and sulci. The basilar cisterns appear normal.
[**Doctor Last Name **]-white differentiation is preserved. There is no shift of
normally midline structures.
There is a prior right frontal burr hole. The visualized
paranasal sinuses
and mastoid air cells are normally pneumatized and clear.
IMPRESSION:
1. Expected postoperative changes at the site of right occipital
craniectomy,with decreased mass effect upon the 4th ventricle.
2. Unchanged edema in the left parietal and frontal lobes.
Brief Hospital Course:
Patient was electively admitted on [**3-9**] for a suboccipital
craniotomy to resect a right cerebellar mass. Post operatively,
the patient was monitored in the ICU for 48 hours due to
lethargy and slight right sided arm weakness. MRI did not show
any increase ventricular size and subtotal resection of
cerebellar mass. On Post OP day 2 she was more awake, orientated
X3 with slight right arm weakness. Her diet was advanced and PT
and OT evaluated the patient was felt [**Last Name (un) **] appropriate for
discharge with home services. She was discharged on [**3-14**] with
appropriate follow up in the brain tumor clinic.
Medications on Admission:
Decadron 3mg Daily
MVI
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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain. Tablet(s)
7. Outpatient Physical Therapy
please perform PT per recommendations
8. Outpatient Occupational Therapy
per occupational therapy
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Right Sided brain mass
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.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You 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 [**7-15**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**4-11**],[**2129**] at 2pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] 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:[**2129-3-14**]
|
[
"198.3",
"348.5",
"V10.05",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6118, 6137
|
4533, 5160
|
296, 363
|
6204, 6228
|
1043, 1048
|
8268, 9188
|
782, 914
|
5233, 6095
|
6158, 6183
|
5186, 5210
|
6252, 8245
|
929, 929
|
943, 1024
|
235, 258
|
1337, 3484
|
391, 521
|
3493, 4510
|
1062, 1318
|
543, 635
|
668, 749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,283
| 181,873
|
53247
|
Discharge summary
|
report
|
Admission Date: [**2151-6-9**] Discharge Date: [**2151-6-18**]
Date of Birth: [**2073-9-21**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Examine under anesthesia with anoscopy
Colonoscopy
EGD
History of Present Illness:
This is a 77-year-old Spanish-speaking Jehovah's witness with
multiple medical comorbidities (HTN, hyperlipidemia, diabetes,
anxiety/depression, Parkinson's and dementia) who underwent
hemorrhoidal surgery on [**6-4**], developed BRBPR 2 days later and
was found to have Hct of 24 and INR on 10 (not on coumadin),
stabilized in MICU and now transferred to the floor for further
w/u of anemia.
.
The patient had outpatient hemorrhoidectomy without
complications on [**6-4**] under the care of Dr. [**Last Name (STitle) 109605**] [**Name (STitle) **] here
at [**Hospital1 18**] for chronic symptomatic hemorrhoids. Per OP note, there
were large partially prolapsing hemorrhoids with a significant
external component in the right posterior and left lateral
position which were removed with a electrocautery and LigaSure
and a small right anterior hemorrhoid which was
electrocoagulated because it was internal. Three days afer the
surgery, she began to develop BRBPR and rectal pain and
presented to the ED for this on [**6-9**].
.
On arrival to the ED, VS were T98.2 HR87 BP137/56 RR13 99%. Her
INR was found to be 9.9 although the patient reports to never
having been on coumadin and was not taking any herbal
medications or rat poison. She was given 10 mg PO vitamin K. Hct
on arrival was 33.9 (baseline ~39) after passing ~250cc BRBPR,
dropped to 25 prompting transfer to ICU. On transfer, patient
was asymptomatic (HR 80s, SBP 130s).
.
In the ICU, patient was seen by heme/onc, colorectal surgery,
and GI. Heme-onc felt that her presentation and labs were
consistent with ingestion of vitamin-K antagonist (found that
factors 2,7,10 were low, 5,8,9, normal). Mixing studies were
negative. She was taken to the OR on [**6-11**] for [**Month/Day (4) **] with anoscopy
where her hemorrhoids were noted to appear clean, although
melena was found and her rectum was packed with Surgicell. GI
felt that her BRBPR was likely [**1-7**] lower GI but recommended
endoscopy and colonoscopy to look for origin. Endoscopy was
unremarkable other than a polyp in the stomach and colonoscopy
was remarkable for diverticulosis of the whole colon, several
small (2-5 mm) polyps and ulceration in the rectum, the latter
of which was thought to be the source of the patient's recent
bleeding. Her Hct on transfer from the MICU was 21.9 and the
patient remained asymptomatic throughout.
.
On arrival to the floor, patient continues to feel well though
complains of rectal pain.
Past Medical History:
- Type 2 diabetes mellitus, diet controlled
- Hypertension
- Hyperlipidemia
- Osteoarthritis
- Chronic low back pain
- Somatoform disorder
- Depression/anxiety
- Dementia
- Parkinsonism, tremor
- Glaucoma
- GERD
- s/p appendectomy
- s/p total knee replacement x 2
- s/p post left wrist spur removal
- Cesarean section x 3
- History of back surgery:
--L4-S1 decompression and fusion
--removal of broken hardware at S1 with a revision
arthrodesis
--repeat CT scan shows pseudoarthrosis at L5-S1, with
decompression down S2, and L3-L4 arthropathy
--L4-S1 anterior lumbar interbody fusion followed by
posterior stabilization
--revision decompression with iliac screws
- right humerous fracture [**6-13**]
Social History:
Home: Lives alone in [**Location (un) 686**].
Family: Originally from D.R. Divorced. 3+ children, closest ==
son [**Name (NI) 11805**] (visits ~[**2-7**]/wk). Is pt's HCP.
[**Name (NI) **]: Retired housekeeper.
Functional: pt requires help with IADLs and bathing but
independent in other ADLs. Son [**Name (NI) 11805**] visits [**2-7**]/wk, son's
girlfriend [**Name (NI) **] calls to check daily.
Tob: never smoked
EtOH: none
Illicits: denies
Family History:
Sister with breast cancer. (+) hx depression, (-) hx diabetes.
Physical Exam:
Admission:
VITALS: T 98.9| BP 142/55| HR 77| RR 18| Satting 98% on RA [**5-16**]
abdominal pain.
GENERAL: Tearful, complaining of abdominal pain.
HEENT: PERRL, EOMI. Left eye with medial plaque.
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, TTP without rebound, worse in epigastric/RUQ
region, NABS, no organomegaly. NBS. Negative [**Doctor Last Name 515**]/Cullen
sign
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3. MAE. No CN deficits.
Discharge:
Vitals: Tc:98.4, BP:130/64, P:80, RR:18, O2:93%RA
General: elderly woman lying in bed in NAD
HEENT: bilateral conjunctival pallor, skin normal tone per
patient
Neck: supple, JVD flat, no LAD
Lungs: CTAB, no murmur/rubs/gallops
CV: not tachy, [**1-11**] holosystolic murmur in LUSB
Abdomen: soft, non-distended, diffusely tender to palpation
Ext: 2+ DP pulses, feet are warm, trace edema and varicose veins
bilaterally
Pertinent Results:
Admission labs:
[**2151-6-9**] 09:10PM BLOOD WBC-9.3 RBC-3.73* Hgb-11.4* Hct-33.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-13.4 Plt Ct-234
[**2151-6-9**] 09:10PM BLOOD Neuts-45.0* Lymphs-48.3* Monos-4.4
Eos-1.7 Baso-0.6
[**2151-6-9**] 09:10PM BLOOD PT-96.4* PTT-55.9* INR(PT)-9.9*
[**2151-6-10**] 01:31AM BLOOD D-Dimer-1104*
[**2151-6-10**] 05:48PM BLOOD PT-19.6* PTT-40.3* INR(PT)-1.9*
Anemia workup:
[**2151-6-10**] 06:35PM BLOOD Fibrino-264 Thrombn-15.2
[**2151-6-10**] 06:35PM BLOOD Fact II-32* Fact V-79 FactVII-36*
FacVIII-115 Fact IX-58 Fact X-30*
[**2151-6-11**] 04:10AM BLOOD Ret Aut-1.8
[**2151-6-13**] 05:53AM BLOOD Ret Aut-2.4
[**2151-6-10**] 06:35PM BLOOD Inh Scr-NEG
[**2151-6-10**] 06:35PM BLOOD calTIBC-250* VitB12-303 Ferritn-30
TRF-192*
[**2151-6-10**] 06:35PM BLOOD Homocys-4.1
[**6-14**] H. pylori negative
[**6-10**] KUB: No evidence of obstruction or free air.
[**6-14**] KUB: No evidence of SBO, volvulus, or pneumoperitoneum.
[**6-16**] RUQ U/S:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. No gallstones and no biliary dilatation.
3. Bilateral simple renal cysts.
[**6-15**] Colonoscopy:
Findings:
Mucosa: Localized ulceration including 1 large ulcer was noted
in the rectum in the area of recent hemorrhoidectomy.
Protruding Lesions Several 2-5mm small polyps were noted
throughout the colon,
Excavated Lesions Multiple small diverticula were seen
throughout the colon. Diverticulosis appeared to be of mild
severity.
Other No fresh or old blood seen in the colon.
Impression: Ulceration in the rectum, which is likely the source
of the patient's recent bleeding.
Small 2-5mm polyps in the colon
Diverticulosis of the whole colon
No fresh or old blood seen in the colon.
[**6-15**] EGD:
Esophagus: Normal esophagus.
Stomach:
Protruding Lesions A single polyp of benign appearance was
found in the stomach.
Duodenum: Normal duodenum.
Impression: Polyp in the stomach
Otherwise normal colonoscopy to third part of the duodenum
Brief Hospital Course:
77-year-old Spanish-speaking Jehovah's witness with multiple
medical comorbidities (HTN, hyperlipidemia, diabetes,
anxiety/depression, Parkinson's and dementia) who underwent
hemorrhoidal surgery on [**6-4**], developed BRBPR 2 days later and
was found to have Hct of 24 and INR on 10 (not on coumadin),
stabilized in MICU then transferred to the floor for further w/u
of anemia and management of rectal and abdominal pain.
.
Acute Issues
# BRBPR: patient presented to the ED with several days of BRBPR.
In the ED, she had a further episode of bleeding leading to Hct
drop to 25 prompting transfer to the MICU. [**Month/Year (2) **] with anoscopy
showed "absolutely no evidence of bleeding at any of the
[hemorrhoid] sites." EGD was unremarkable with the exception of
a polyp in the stomach. However, colonoscopy was remarkable for
diverticulosis of the whole colon, several small (2-5 mm) polyps
and ulceration in the rectum, the latter thought to be the most
likely cause of the patient's bleeding, although it is unclear
why [**Name (NI) **] did not mention the rectal ulcers. Patient is a
Jehovah's witness thus wishes to not receive any blood products.
Throughout her stay, she had 2 peripheral IVs, was on
continuous telemetry and we checked [**Hospital1 **] Hct, which remained in
the low 20s. She never developed any symptoms of hemodynamic
instability (HR 80s, SBPs 120s-130s) although did feel quite
fatigued. We gave her senna, colace, miralax and an XXX enema
to help her to continue having bowel movemenents. She had
several BMs during her time on the medical floor, none of which
were bloody. She will follow-up with GI as an outpatient
regarding further management of her rectal ulcers. We explained
to her the importance of eating fiber and staying hydrated to
prevent constipation leading to the development of more
hemorrhoids or of anal fissures.
.
# Rectal pain: the patient developed severe rectal pain after
her colonoscopy and anoscopy such that she had difficulty
sitting and going to the bathroom. She was already on oxycodone
and morphine for back pain, which we continued. We also started
her on lidocaine and hydrocortisone cream, with minimal effect.
The colorectal team performed a rectal exam which was
unremarkable and suggested giving her low dose gabapentin. On
discharge, her rectal pain had improved slightly.
.
# Coagulopathy: on admission, the patient's INR was 9.9.
Etiology was unclear as the patient denied taking warfarin, any
herbal medications or ingesting rat poison. Factor deficiencies
(2, 7, 10 low) and correction of INR with vitamin K were
consistent with ingestion of vitamin-K antagonist. Her son
brought in all of her medications, none of which included
warfarin. We have sent for a lab test to look for warfarin in
her initial blood samples, resuls pending.
.
# Anemia: the patient's Hct hovered in low 20s, lowest was 19.9.
As described above, she remained largely asympomatic. Of note,
she appears to have a baseline anemia with low/normal RBCs
(mid-low 30s over past 10 years). We thought her anemia was
likely multifactorial in cause, include BRBPR and coagulopathy
as described previously. Her MCV was 94 but RDW was elevated,
suggesting a combination of iron-deficiency from bleeding
(though transferrin and were TIBC low, perhaps because there was
not enough time to equilibrate) with macrocytic anemia. She was
found to have an innappropriately low reticulocyte count,
although platelet and WBC count were normal thus not
pancytopenic. We explored several causes of normocytic
hypoproliferative anemia including endocrine disorders (hypo/
hyperthyroidism, panhypopituitarism, hyperPTH all associated
with mild proliferative anemia. The patient never had elevated
calcium and we checked her TSH which was normal. Heme-onc
thought the most likely cause was nutrition deficiency thus she
was started on folate and B12 supplementation. We gave her 2
doses of PO iron after which she developed nausea and vomiting
thus we switched this to IV iron, which the patient tolerated
well. On discharge, her Hct was 22.3. She should have retic
count rechecked as outpatient once stable and consider heme/onc
referral if persistently low.
.
# Systolic murmur: patient has a [**1-11**] holosystolic in LUSB, newly
heard during this admission. Likely flow murmur due to anemia,
but would recommend oupatient f/u for TTE
.
# Abdominal pain: the patient had abdominal pain and abdominal
exam was remarkable for diffuse tenderness without any
peritoneal signs. Had KUB x 2 since admission which showed no
evidence of obstruction. Labs were notable for slightly
elevated AST, ALT, Alk-phos, GGT which did not provide a clear
picture of the etiology bilirubin was normal). Of note, she had
an abdominal CT in [**2148**] which was normal (but did not have
elevated LFTs then). On this admission, she underwent a RUQ u/s
which showed no stones in the gallbladder but was remarkable for
fatty infiltration of the liver. She is at risk for NAFLD given
several risk factors (DM, HTN, HLD). We also sent an H. pylori
which was negative. On discharge, abdominal pain was improved
and LFTs were normal with the exception of slightly elevated alk
phos at 118. She will have outpatient GI follow-up.
.
# Genital herpes: on the last day of your admission, you pointed
out several small erythematous papules near your vagina, which
appeared to be genital herpes. These lesions were causing you
minimal pain but were quite itchy and bothersome. You told us
that you had these lesions in the past inside of your vagina but
had never been treated for them. We prescribed you with 3 days
of Valtrex for treatment of your genital herpes.
.
Chronic Issues
.
#Diabetes mellitus: diet controlled.
.
#HLD: continued on simvastatin 10 mg qhs
.
#Parkinsonism: continued on pramipexole
.
Transitional Issues:
1) Will f/u with colorectal, GI, PCP and [**Name9 (PRE) 478**] (for monthly
IV iron infusions)
2) Please f/u warfarin levels
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Amlodipine 5 mg PO DAILY Start: In am
hold for SBP<100
2. Atenolol 25 mg PO BID
hold for SBP<100/HR<60
3. Famotidine 20 mg PO DAILY
4. Mirtazapine 30 mg PO HS
5. Morphine SR (MS Contin) 15 mg PO Q12H
6. Omeprazole 20 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
pain
hold for sedation/RR<10
8. pramipexole *NF* 0.75 mg Oral [**Hospital1 **]
9. Simvastatin 10 mg PO QHS
10. zolpidem *NF* 6.25 mg Oral qhs
Extended release multiphase tablet [**12-7**] po at bedtime
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qday
13. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID
for rectal pain
14. Biotene Oralbalance *NF* (lactoperoxi-gluc oxid-pot
thio;<br>saliva stimulant agents comb.2) 30 cc Mucous Membrane
QID
swish and spit
15. Senna 1 TAB PO BID:PRN constipation
16. Simethicone 80 mg PO QID:PRN gas/bloating
17. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] *NF* 200-25-400-40 mg/30 mL
Mucous Membrane QID prn mouth pain
swish and spit
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
hold for SBP<100
2. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID
for rectal pain
3. Morphine SR (MS Contin) 15 mg PO Q12H
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
pain
hold for sedation/RR<10
5. pramipexole *NF* 0.75 mg Oral [**Hospital1 **]
6. Senna 1 TAB PO BID:PRN constipation
7. Simethicone 80 mg PO QID:PRN gas/bloating
8. Simvastatin 10 mg PO QHS
9. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
10. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Gabapentin 300 mg PO HS
RX *gabapentin 300 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
12. Iron Dextran 1000 mg IV ONCE Duration: 1 Doses
13. Lidocaine 5% Ointment 1 Appl TP PRN rectal pain
RX *lidocaine HCl 3 % please apply around rectal area prn Disp
#*1 Tube Refills:*0
14. Atenolol 25 mg PO BID
hold for SBP<100/HR<60
15. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
16. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qday
17. Famotidine 20 mg PO DAILY
18. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] *NF* 200-25-400-40 mg/30 mL
Mucous Membrane QID prn mouth pain
swish and spit
19. Mirtazapine 30 mg PO HS
20. Omeprazole 20 mg PO BID
21. zolpidem *NF* 6.25 mg Oral qhs
Extended release multiphase tablet [**12-7**] po at bedtime
22. ValACYclovir 500 mg PO Q12H Duration: 5 Days
day 1 = [**6-18**]
RX *valacyclovir 500 mg 1 tablet(s) by mouth twice per day Disp
#*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Rectal ulcer
Anemia, acute blood loss
iron deficiency
Coagulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 73793**],
It was a pleasure taking care of you during your recent
admission at [**Hospital1 18**]. You came to the hospital several days after
having hemorrhoid surgery because you were bleeding from your
rectum. Several hours after arriving to the emergency room, you
passed more blood from your rectum and your hematocrit dropped
to a very low level, prompting your transfer to the medical
intensive care unit. Your INR, which is a measure of the
clotting function of your blood, was very high, although you
were not taking any anti-coagulants. We remain unclear of
exactly why this happened. You had an exam under anesthesia
with anoscopy which showed that the sites of the excised
hemorrhoids were not bleeding. An esophagogastroduodenoscopy
(EGD) was unremarkable, however a colonoscopy showed that you
had a rectal ulcer, which we thought was the source of your
bleeding. You were transferred to the general medical floor
about 1 week into your hospitalization where we continued to
manage your anemia and also tried to help you with your rectal
and abdominal pain. For your anemia, you were started on B12,
folate and iron supplementation. We did a right upper quadrant
ultrasound for your abdominal pain, which showed some changes in
your liver (fatty infiltration) that we recommend you follow-up
as an outpatient. For your rectal pain, we gave you lidocaine
and steroid cream and also started you on gabapentin. Upon
discharge, you were having less pain in your rectum and abdomen.
Medication Changes
1) Please start taking 300 mg gabapentin daily for your rectal
pain
2) Please use lidocaine and hydrocortisone cream as needed for
your rectal pain
3) Please continue to get monthly IV infusions of iron for your
anemia. This will be done at the hematology/oncology clinic.
4) Please start taking B12 and folate supplementation for your
anemia
Follow-up appointments:
Please see below
Followup Instructions:
Department: Gastroenterology
When: [**2151-7-7**] 1:00
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 79190**], MD, [**Telephone/Fax (1) 463**]
Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
Department: [**Hospital3 249**]
When: THURSDAY [**2151-6-24**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2151-7-13**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 9645**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2151-7-20**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14117**], NP [**Telephone/Fax (1) 160**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2151-6-19**]
|
[
"724.2",
"785.2",
"715.90",
"272.4",
"332.0",
"285.1",
"054.19",
"281.9",
"V49.86",
"211.1",
"569.41",
"250.00",
"294.20",
"300.4",
"401.9",
"286.9",
"211.3",
"562.10",
"569.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"49.21",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
16062, 16068
|
7173, 13013
|
273, 330
|
16179, 16179
|
5034, 5034
|
18290, 19557
|
4029, 4093
|
14417, 16039
|
16089, 16158
|
13186, 14394
|
16330, 18225
|
4108, 5015
|
18249, 18267
|
13034, 13160
|
228, 235
|
358, 2827
|
5051, 7150
|
16194, 16306
|
2849, 3552
|
3568, 4013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,621
| 144,925
|
7872+55887+55888
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-21**]
Date of Birth: [**2082-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
67 yo male sp cadaveric kidney transplant, with complicated post
operative course with an unrine leak. Comes back to the
emergency department with change in mental status, and hx of low
grade fevers 100.2. For evaluation.
Major Surgical or Invasive Procedure:
CT DRAINAGE OF RIGTH PERINEPHIC COLLECTION
CISTOSCOPIC REMOVAL OF STENT
CT GIDED PLACEMNET OF NEPHOSTOMY TUBE
History of Present Illness:
67 yo male sp cadaveric kidney transplant, with complicated post
operative course with an unrine leak. Comes back to the
emergency department with change in mental status, and hx of low
grade fevers 100.2. For evaluation.
Past Medical History:
PAST MEDICAL HISTORY: Significant for diabetes x32 years
requiring insulin. He has associated retinopathy, nephropathy,
and neuropathy. He has a history of coronary artery bypass
grafting in [**2143**] by Dr. [**Last Name (STitle) **] at this facility, but no history
of
myocardial infarction.
Social History:
SOCIAL HISTORY: Significant for distant use of tobacco. He quit
in [**2143**]. No history of alcohol use or IV drug abuse. His wife
died of bone cancer. He has 6 children, all adults with an
eldest son with a history of diabetes. He has supportive family
in the area. He currently lives alone.
Physical Exam:
PHYSICAL EXAMINATION:
MUSCULOSKELETAL: Right lower extremity, there is a BKA on that
side. The stump is well vascularized. No evidence of fractures.
He has staples in his right iliac groin area. He has externally
rotated right lower extremity. He complains of pain in the
groin. Exam once again demonstrates well-vascularized right
lower extremity stump. He has capillary refill of 2 seconds
distally. His knee cannot fully extend. He lacks about 15
degrees of extension. He can flex to about 85 degrees.
GENERAL: Awake alert MAC FC oriented X2
VITAL SIGNS: He stands about 5 feet 9 inches. He weighs 180
pounds. VS satble t 99 hr 75 140/72
RESP Lungs CTA b bs
HEART RRR NM NG
ABD SOFT NT ND
Pertinent Results:
[**2150-2-3**] 12:50PM URINE RBC-[**1-24**]* WBC->50 BACTERIA-MOD YEAST-MANY
EPI-0 TRANS EPI-<1
[**2150-2-3**] 12:50PM PT-13.4 PTT-27.9 INR(PT)-1.1
[**2150-2-3**] 12:50PM HYPOCHROM-2+
[**2150-2-3**] 12:50PM NEUTS-93.5* LYMPHS-4.8* MONOS-1.3* EOS-0.2
BASOS-0.2
[**2150-2-3**] 12:50PM GLUCOSE-343* UREA N-66* CREAT-3.7* SODIUM-136
POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-19* ANION GAP-21*
[**2150-2-3**] 01:12PM LACTATE-1.6
[**2150-2-3**] 03:00PM GLUCOSE-409* UREA N-67* CREAT-3.7* SODIUM-135
POTASSIUM-7.1* CHLORIDE-105 TOTAL CO2-18* ANION GAP-19
[**2150-2-3**] 08:40PM CALCIUM-6.0* PHOSPHATE-4.8* MAGNESIUM-1.6
Brief Hospital Course:
67-year-old gentleman, who is 2 months status post cadaveric
renal transplantation. His postoperative course has been
complicated by a postoperative hemorrhage requiring re-operation
and delayed graft function. He is also presumed to have a small
urine leak based on a high JP creatinine. He is currently on a
Prograf-based immunosuppressive regimen. On [**2150-2-10**], the
patient underwent a cystoscopy and a ureteric stent removal. He
had a percutaneous nephrostomy tube, which was internalized into
the bladder. He also had a percutaneous drain as well as a
ureteric stent. He tolerated that procedure well. He was noted
to have an intertrochanteric hip fracture. This appeared to have
occurred while he was at a rehabilitation facility, recovering
from his transplantation. Patient had Open reduction, internal
fixation of
right intertrochanteric hip fracture.On [**2-13**]. 2 days after
surgery patient became dyspneic CTA of the chest was done with
the following results:
1) No evidence of pulmonary embolus.
2) Small bilateral pleural effusions, left greater than right,
with
associated atelectasis.
3) Small areas of atelectasis of the right upper and right lower
lobes.
During this episode pt needed to be transferred to ICU for
monitoring of respiratory status.
Remain the the ICU for 2 days and after stabilization came back
to the floor.
Patient at this point is doing well from all His multiple
medical problems. Was evaluated by physical therapy
recommendation include rehabilitation placement.
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Fluoxetine HCl 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Four (4)
Tablet, Chewable PO QIDACHS (4 times a day (before meals and at
bedtime)).
10. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
15. Valganciclovir HCl 450 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
16. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day) for 2 doses.
17. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
ONCE (once) for 1 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab
Discharge Diagnosis:
SP RENAL TRANPLANT
URINE LEAK
SP LEFT BKA
Discharge Condition:
SLEF EATING NON WIGTH BEARING ON BKA, MOBILIZING WITH ASSISTANCE
Discharge Instructions:
NEEDS ASSISTANCE FOR SITTING, AND MOBILIZATION
Followup Instructions:
Scheduled Appointments :
Provider [**Name9 (PRE) 2106**],[**Name9 (PRE) 2105**] TRANSPLANT CENTER-MEDICINE Where: LM
[**Hospital Unit Name 5628**] CENTER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-3-3**] 1:00
Provider BONE DENSITY TESTING Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2150-3-3**] 2:40
Provider [**Name9 (PRE) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2150-3-12**] 10:00
Completed by:[**2150-2-19**] Name: [**Known lastname 4971**],[**Known firstname **] Unit No: [**Numeric Identifier 4972**]
Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-21**]
Date of Birth: [**2082-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2800**]
Addendum:
Right intertrochanteric hip fracture was noted on
abdominal/pelvic CT [**2150-2-5**]. This fracture may have occurred on
prior hospital stay when he suffered a fall while transferring
independently from wheelchair to bed. At that time he complained
of right knee pain. The right knee was xrayed and revealed no
fracture or dislocation.
Post ORIF on [**2150-2-13**] he received morphine. He was given flexeril
for muscle spasms. He became somewhat confused and required a
sitter for one evening [**2150-2-17**]. Mental status cleared with
cessation of morphine, and flexeril. He has been receiving
tylenol with fair relief of pain. He was followed by PT.
Rehabilitation was recommended for further PT to increase
strength, mobility and safety. Vital signs were stable.
LaCOMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2150-2-20**] 06:20AM 9.0 3.24* 9.1* 28.8* 89 28.0 31.5 15.7*
601*#1
N
1 DOUBLE CHECKED
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2150-2-3**] 12:50PM 93.5* 4.8* 1.3* 0.2 0.2
RED CELL MORPHOLOGY Hypochr
[**2150-2-3**] 12:50PM 2+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2150-2-20**] 06:20AM 601*#1
N
1 DOUBLE CHECKED
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2150-2-16**] 03:23AM 667*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2150-2-20**] 06:20AM 103 7 0.8 138 3.9 108 20* 14
N
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2150-2-16**] 09:40AM 2 12 186* 225* 0.4
[**2150-2-16**] 03:23AM 105
CK CPIS TNT ADDED @ 0555 [**2150-2-16**]
OTHER ENZYMES & BILIRUBINS Lipase
[**2150-2-16**] 09:40AM 9
CPK ISOENZYMES CK-MB cTropnT
[**2150-2-16**] 03:23AM 3 0.06*1
CK CPIS TNT ADDED @ 0555 [**2150-2-16**]
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2150-2-19**] 06:10AM 7.4* 1.9* 1.6
TOXICOLOGY, SERUM AND OTHER DRUGS FK506
[**2150-2-20**] 06:20AM 8.21
N
bs on discharge were as follows:
Major Surgical or Invasive Procedure:
CT DRAINAGE OF RIGHT PERINEPHIC COLLECTION
CYSTOSCOPIC REMOVAL OF STENT
CT GIDED PLACEMENT OF NEPHOSTOMY TUBE
R ORIF [**2150-2-13**] for R intertrochanteric fx s/p fall
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**2150-2-20**] Name: [**Known lastname 4971**],[**Known firstname **] Unit No: [**Numeric Identifier 4972**]
Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-21**]
Date of Birth: [**2082-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4973**]
Addendum:
Please note that the patient's tacrolimus will be increased to
6mg PO BID. This information will be communicated to the
transplant coordinator and the patient will be D/C to rehab
[**2150-2-21**].
Major Surgical or Invasive Procedure:
CT DRAINAGE OF RIGHT PERINEPHIC COLLECTION
CYSTOSCOPIC REMOVAL OF STENT
CT GIDED PLACEMENT OF NEPHOSTOMY TUBE
R ORIF [**2150-2-13**] for R intertrochanteric fx s/p fall
Past Medical History:
PAST MEDICAL HISTORY: Significant for diabetes x32 years
requiring insulin. He has associated retinopathy, nephropathy,
and neuropathy. He has a history of coronary artery bypass
grafting in [**2143**] by Dr. [**Last Name (STitle) 690**] at this facility, but no history
of
myocardial infarction.
Social History:
SOCIAL HISTORY: Significant for distant use of tobacco. He quit
in [**2143**]. No history of alcohol use or IV drug abuse. His wife
died of bone cancer. He has 6 children, all adults with an
eldest son with a history of diabetes. He has supportive family
in the area. He currently lives alone.
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Fluoxetine HCl 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Four (4)
Tablet, Chewable PO QIDACHS (4 times a day (before meals and at
bedtime)).
10. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Valganciclovir HCl 450 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
15. Tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO BID (2 times
a day) for 2 doses.
16. Reg Insulin S.S
Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose [**Known lastname 4971**],[**Known firstname **] [**Numeric Identifier 4972**]
Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose
Fingerstick QACHSInsulin SC Fixed Dose Orders
Breakfast Dinner
Humalog 75/25 10 Units Humalog 75/25 10 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL [**11-23**] amp D50 [**11-23**] amp D50 [**11-23**] amp D50 [**11-23**] amp D50
71-160 mg/dL 0 Units 0 Units 0 Units 0 Units
161-200 mg/dL 2 Units 0 Units 0 Units 0 Units
201-240 mg/dL 4 Units 2 Units 2 Units 0 Units
241-280 mg/dL 6 Units 4 Units 4 Units 2 Units
281-320 mg/dL 8 Units 6 Units 6 Units 4 Units
> 320 mg/dL Notify M.D. Notify M.D. Notify M.D. Notify M.D.
Instructons for NPO Patients: USE HS SCALE
17. Metronidazole 500 mg Tablet Sig: 500MG Tablets PO every
eight (8) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
S/P RENAL TRANPLANT
URINE LEAK
S/P LEFT BKA
Discharge Condition:
gOOD. PATIENT [**Month (only) **] AMBULATE ON LEFT LEG. MOBILIZING WITH
ASSISTANCE
Discharge Instructions:
Patient or facility needs to call immediately at [**Telephone/Fax (1) 242**]
if any fevers, chills, nausea, vomiting, any weight loss,
abdominal pain-NEEDS ASSISTANCE FOR SITTING, AND MOBILIZATION
Followup Instructions:
Scheduled Appointments :
Provider [**Name9 (PRE) **],[**Name9 (PRE) **] TRANSPLANT CENTER-MEDICINE Where: LM
[**Hospital Unit Name 4918**] CENTER Phone:[**Telephone/Fax (1) 242**]
Date/Time:[**2150-3-3**] 1:00
Provider BONE DENSITY TESTING Where: [**Hospital6 189**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 4974**] Date/Time:[**2150-3-3**] 2:40
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 853**], MD Where: LM [**Hospital Unit Name 4975**] CENTER Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2150-3-12**] 10:00
Patient needs labs drawn every Monday and Thursday starting [**2-23**].
Patient needs a CHEM 7, CBC, CA, PO4, AST, T. BILI, U/A AND
PROGRAF LEVEL. THE RESULTS NEED TO BE SENT IMMEDIATELY TO
[**Telephone/Fax (1) 2858**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 3765**] MD [**MD Number(1) 3766**]
Completed by:[**2150-2-21**]
|
[
"584.9",
"112.2",
"996.81",
"250.61",
"250.51",
"357.2",
"V45.81",
"997.5",
"276.7",
"507.0",
"362.01",
"414.00",
"820.21",
"997.3",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.02",
"79.35",
"55.03",
"57.32",
"97.62"
] |
icd9pcs
|
[
[
[]
]
] |
13823, 13871
|
2903, 4423
|
10472, 10643
|
13959, 14046
|
2255, 2880
|
14292, 15189
|
11298, 13800
|
13892, 13938
|
14071, 14269
|
1542, 1542
|
1564, 2236
|
273, 496
|
674, 897
|
10687, 10964
|
10996, 11275
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,022
| 155,140
|
43960
|
Discharge summary
|
report
|
Admission Date: [**2155-10-1**] Discharge Date: [**2155-10-23**]
Service: SURGERY
Allergies:
Cephalosporins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Abdominal pain
2. Nausea
3. Vomiting, and weakness
Major Surgical or Invasive Procedure:
[**2155-10-15**] ERCP:
Impression: Cannulation of the biliary duct was initially
somewhat difficult with the sphincterotome.
A small pre-cut was made with a needle knife in order to
facilitate biliary access.
Successful biliary cannulation.
Normal cholangiogram with no filling defects.
Successful biliary sphincterotomy with immediate release of a
small amount of sludge.
Otherwise normal ERCP to 3rd portion of duodenum
History of Present Illness:
86yM transferred from [**Hospital 189**] Hospital with abdominal pain,
nausea/vomiting, and CT findings concerning for a small bowel
obstruction. Per OSH records, on [**9-28**] Mr. [**Known lastname 94417**] was taken by
ambulance from his nursing home to [**Hospital 189**] hospital for a 2-day
history of abdominal pain, nausea, vomiting, and weakness. He
also had fallen and hit his head shortly prior to the onset of
his symptoms.
Upon admission there he was afebrile and his labs showed WBC
19.1, Hct 56.8, amylase [**2143**], lipase 1370, ALT 88, AST 94, alk
phos 106, LDH 375, total bilirubin 3.1. OSH read of an
abdominal/peliv CT noted enlargement of the pancreatic head with
associated stranding. There was fluid in the mesentary,
paracolic gutters, and in the pelvis. An U/S showed gallstones
in the gallbladder, however the common bile duct was note
identified. He was started on IVF resuscitation and given a
dose each of ciprofloxacin and flagyl. A head CT was also
obtained in light of his recent fall which showed no acute
process. A CXR was found to show bilateral pleural effusions
and bibasilar
infiltrates consistent with atelectasis. He was subsequently
transferred to [**Hospital1 18**] for further management.
Past Medical History:
PMH: HTN. GERD. CKD Stage I. Seizure d/o. Depression d/o. Venous
insufficiency. Hypothyroidism. Osteoarthritis. Contact
dermatitis. Hx of syncope, falls.
PSH: none known
Social History:
Lives in nursing home. Brother is health care proxy.
Family History:
unknown
Physical Exam:
ON ADMISSION:
Vitals: T 97.2, P 101, BP 174/99, RR 26, O2sat 99% 4L NC
Gen: Appears uncomfortable. Alert. Oriented to person only.
HEENT: PERRL, EOMI. Sclerae non-icteric. Mucous membranes dry.
Neck: JVP visualized at mandibular angle.
CV: Tachycardic. Regular rhythm.
Resp: Scattered crackles bilaterally.
Abd: Abdomen soft but tense. Very distended. Very tender to
light palpation w/ rebound tenderness.
Ext: Cap refill 4 sec. Venous stasis changes b/l LE. Feet cool.
Legs warm. DP pulses palpable.
ON DISCHARGE:
VS: 98.4, 77, 135/69, 18, 95% RA
Gen: Confused, AO x 1 (self), follows simple commands, moves all
extr. spontan.
CV: RRR
Lungs: Scattered crackles bilaterally
Abd: Soft, nondistended, LUQ tenderness to deep palpation
Extr: Minimal pitted edema b/l LE, RUE PICC line with occlusive
dressing
Pertinent Results:
IMAGING:
CT Abdomen/Pelvis--OSH read
1. Enlargement of pancreatic head with stranding extending to
mesenteric root, consistent with pancreatitis.
2. Mesenteric fluid and moderate amount of fluid extending along
paracolic gutters and into upper quadrants.
3. Calcified pleural plaques at bases with areas of peripheral
pulmonary fibrosis and small effusions.
4. Small to moderate amount of free fluid in pelvis.
Abdominal U/S--OSH read
1. Multiple gallstones found in gallbladder, with gallbladder
wall measuring 4mm. No pericholecystic fluid.
2. Common hepatic duct 6-8mm. CBD not identified.
Head CT--OSH read
1. Atrophy
2. Periventricular and subcortical findings consistent with
small
vessel disease
CXR--OSH read
1. Bilateral pleural effusions
2. Bibasilar infiltrates consistent with atelectasis
CXR [**2155-10-1**]:
FINDINGS: No previous images. Bibasilar opacifications, more
prominent on
the left, are consistent with atelectasis and effusion. In the
appropriate
clinical setting, the possibility of superimposed pneumonia
would have to be considered. No evidence of vascular congestion
or pneumothorax. There is a prosthesis in the right shoulder.
CXR [**2155-10-3**]:
1. Stable left moderately large pleural effusions, mild
cardiomegaly,
bibasilar atelectasis.
2. New upper lobe opacity which either represents pleural fluid
in this
semi-upright radiograph or developing left upper lobe infection.
This can be further evaluated on a repeat upright radiograph.
CXR [**2155-10-4**]:
There is no fluid overload. Bibasilar opacities left greater
than right
consistent with atelectasis, mild cardiomegaly and left pleural
effusions are unchanged. The upper lobes are clear. Left
subclavian catheter remains in place. There is no pneumothorax
or new lung abnormalities. Right shoulder arthroplasty is
present.
CXR [**2155-10-5**]:
There are persistent low lung volumes. There is no fluid
overload. Bibasilar opacities left greater than right are
consistent with atelectasis. Cardiomegaly and small bilateral
pleural effusions are unchanged. There is no pneumothorax. Left
subclavian catheter remains in place. Right shoulder hardware is
seen.
RUQ ultrasound [**2155-10-1**]: The liver is diffusely hypoechoic with
scattered punctate areas of echogenicity ("starry [**Hospital Ward Name **]"
appearance), suggestive of acute hepatitis. There is trace
perihepatic ascites and a small right pleural effusion, likely
reactive. There is normal hepatopetal flow in the portal vein.
The gallbladder is partially distended, with equivocal wall
thickening and nonmobile calcified stones measuring up to 7 mm.
The common duct is nondilated at 4 mm. The pancreas was not well
visualized.
Impression:
1. Diffusely hypoechoic liver with "starry [**Hospital Ward Name **]" appearance,
suggestive of
acute hepatitis. Please correlate clinically. Trace perihepatic
ascites and
right pleural effusion, likely reactive.
2. Cholelithiasis and equivocal gallbladder wall thickening,
which may be
reactive. Findings are nonspecific for acute cholecystitis, but
this
diagnosis could be considered in the appropriate clinical
setting.
3. No biliary ductal dilatation.
KUB [**2155-10-5**]: There is no evidence of ileus or obstruction. The
ascending colon has residual barium. The transverse colon, part
of the descending colon, and rectum are air filled. Mild
degenerative changes are in the lumbar spine.
ABD CT [**2155-10-7**]:
1. Further evolution of pancreatitis, including marked
inflammatory changed, with a small developing rim-enhancing
peripancreatic fluid collection inferior to the body of the
pancreas.
2. Cholelithiasis in a nondistended gallbladder.
3. Bibasilar patchy opacities which may represent pneumonia or
aspiration.
HEAD CT [**2155-10-9**]: Chronic small vessel ischemic disease,
age-related volume loss. No acute process to explain the
patient's new neurologic deficits.
CHEST PORT [**2155-10-9**]:
1. Small right pleural effusion and moderate left pleural
effusion,
unchanged.
2. Left retrocardiac opacity may represent atelectasis, pleural
fluid or
pneumonia, if clinically appropriate.
KUB [**2155-10-11**]:
Residual contrast material is seen in non-dilated colon.
Relative
paucity of small bowel without evidence of dilatation to suggest
obstruction.
No definite gas is seen within the stomach.
The current examination is essentially within normal limits.
However, if
there is strong clinical suspicion of dilated completely
fluid-filled loops of small bowel, CT could be considered.
CHEST PORT [**2155-10-15**]:
No pleural effusions, focal consolidations or pulmonary edema is
present.
Hilar mediastinal and cardiac silhouettes are unchanged.
Persistent right
basal opacity silhuetting right hemidiaphram likely represents
atelectasis.
Right basal pleural calcifications are unchanged.
Right PIC catheter tip projects over low SVC. NG tube has been
removed.
Right shoulder prosthesis is noted.
ERCP [**2155-10-15**]: IMPRESSION: Contrast seen within the colon
perhaps related to recent CT scan. The biliary tree is normal in
caliber and contour without evidence of filling defects.
Gallbladder fills with patent cystic duct.
[**2155-10-18**] RIGHT UPPER EXTREMITY ULTRASOUND:
No evidence of fluid collection in the
right antecubital fossa or right arm. PICC is noted in situ in
the brachial vein with normal flow around the PICC.
ABD CT [**2155-10-19**]:
1. Continued slight interval decrease in the peripancreatic
inflammation with interval decrease in size to peripancreatic
fluid collections as well as free fluid within the pelvis. No
large organized fluid collections identified to suggest abscess
formation. Slightly heterogeneous enhancement of the pancreatic
parenchyma at the body-tail junction, consistent with pancreatic
necrosis (less than 25% of the gland). No other secondary
complications including no thrombosis or pseudoaneurysm.
2. Short-term progression in patchy lower lobe opacities from
the [**10-7**] and [**10-1**] CT examinations, consistent with
probable superimposed
pneumonitis/pneumonia. Baseline pleural plaques and fibrotic
changes are
suggestive of underlying asbestos exposure with secondary
asbestosis. If
alteration in care will occur, a dedicated HRCT could be
obtained on a
non-emergent basis to better characterize
KUB [**2155-10-21**]: IMPRESSION: Normal bowel gas pattern without
evidence of obstruction. No free air is seen.
MICRO:
[**2155-10-5**] 9:29 am URINE Source: Catheter.
**FINAL REPORT [**2155-10-7**]**
URINE CULTURE (Final [**2155-10-7**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
The patient was transferred and admitted directly to the [**Hospital1 18**]
ICU from [**Hospital6 204**].
His hospital course is as follows by systems:
NEURO: An OSH head CT was obtained given the patient's history
of fall, the results of which were negative for any acute
process. On arrival, he was alert and could answer questions
pertaining to his symptoms appropriately but oriented only to
person. However, over the next few days, his mental status began
to deteriorate. On HD 5, patient's mental status improved and he
was transferred to the floor. Patient was waxing and weaning on
the floor, and on HD 8 patient's mental status changed again.
Patient became lethargic, AO x O, and he was transferred back to
the ICU. Head CT was obtained, which was grossly normal. In ICU
patient's mental status stabilized and he was transferred to the
floor in stable condition. Prior discharge, patient's status
improved, he is AO x 2, less confused and following all
commands. Patient has remote history of seizure disorder and he
continued to receive Depakote daily. During hospitalization no
any signs or symptoms of seizure were noticed.
CVS: On admission, the patient was tachycardic with a HR in the
100s-110s, occasionally up into the 120s. He was also
hypertensive. A CVL and A-line were placed and beta blockade was
initiated. Patient continue to be tachycardic during
hospitalization and he continue to receive Metoprolol for rate
control. Patient's cardiac status was monitored with telemetry
device. Patient remained stable from cardiac standpoint with
occasional SVTs during hospital stay.
PULM: The patient initially had high O2 requirements and had
scattered rhonchi on physical exam. His CXR on admission showed
bibasilar atelectasis and small effusions. These remained stable
over his hospital course. Despite aggressive fluid
resuscitation, serial CXRs did not show the development of fluid
overload. Patient was weaned off from supplemental O2 and he
remained stable on room air with O2 Sats within normal limits.
Baseline pleural plaques and fibrotic changes on CTs are
suggestive of underlying asbestos exposure with secondary
asbestosis, patient recommended to follow up with his PCP on
these findings.
FEN/GI: The patient was made NPO and aggressive IVF
resuscitation was initiated upon his admission to the ICU. He
was bolused a total of 3.5L within the first 24 hours in
addition to getting LR @ 150cc/hr to maintain adequate urine
output. His abdomen was distended and extremely tender to
palpation. A RUQ ultrasound was obtained, which showed a
diffusely hypoechoic liver suggestive of acute hepatitis and
cholelithiasis with equivocal gallbladder wall thickening
without biliary ductal dilation. Over the next few days, his
abdominal pain resolved but he was still tender to palpation.
His abdominal distention improved. A KUB obtained on HD 5 showed
no evidence of ileus or obstruction. An NGT was placed and he
was started on tube feeds later that day. He was transferred out
of the unit to the floor on HD 6. However, in the AM of HD 7, he
was noted to have increased abdominal distention and pain.
Therefore, his tube feeds were held and his NGT was put to wall
suction. A stat CT abdomen was obtained which showed findings of
acute pancreatitis, including diffuse enlargement of the
pancreas, extensive peripancreatic stranding, and stranding and
fluid extending into the SB mesentery, paracolic gutters, LUQ
and pelvis. However, the pancreas enhanced homogeneously and the
splenic vein, SMV and portal vein were patent. The patient was
not restarted on tube feeds and instead his NGT was left to
suction and he was started on TPN the next day. Patient was
continued on TPN and kept NPO, on HD 12 patient underwent
bedside swallow evaluation and was started on nectar thick
liquids and pureed solids with the aspiration precautions.
Patient was noted to have intermittent coughing on pureed solids
and nectar thick liquids, and he was reevaluated by
speech/swallow team. After reevaluation, patient was made NPO
and continued TPN. On HD # 17, patient was scheduled for GJ
feeding tube placement, attempt was aborted s/t difficult
anatomy, Dobbhoff tube was placed and patient was started on TF.
On HD 21, GI services tried to place PEG tube, but s/t abdominal
distention, PEG tube placement was aborted. Patient refused
Dobbhoff tube placement. On HD # 23, patient was restarted on
TPN and discharged in acute rehab. Patient needs to be followed
by Speech/Swallow, and he needs to be reevaluated when his
mental/physical status will improve.
GU: The patient's admission showed he had acute kidney injury
with a Cr of 1.4. As previously noted, the patient was
aggressively hydrated. Initially he was bolus ed to maintain a
goal urine output of 50cc/hr. His Cr trended down to normal by
the evening of HD 2. Patient's Cre continue to be within normal
limits during hospitalization, urine output was monitored daily,
and fluid intake was adjusted when necessary.
HEME: The patient's hct at the OSH was 56 suggesting that the
patient was dehydrated. On admission here at [**Hospital1 18**] it was 47.8.
After aggressive fluid hydration, his hct trended down and
stayed stable in the mid- to high- 30s.
ID: The patient's WBC on admission was 17.9. This trended down
over the next few days. Blood cultures drawn on the day of
admission showed no growth. Urine culture drawn on [**2155-10-5**]
showed >100,000 proteus mirabilis so the patient was started on
Bactrim. However, sensitivities later showed resistance to
amp/Cipro/Bactrim and intermediate sensitivity to gent.
Therefore, the patient's antibiotics were changed to Unasyn
given his allergy to cephalosporins. Patient's Unasyn was
discontinued on [**10-17**]. Patient underwent ERCP on [**10-15**] and per
ERCP recommendations, he was started on 7 days course of
Ciprofloxacin. Cipro was discontinued on [**10-21**]. Patient
temperature and WBC curves were monitored throughout
hospitalization.
ENDO: Hypothyroidism was listed under the patient's PMH.
However, the patient did not take thyroid hormone replacements
at home and was this was not initiated while he was in the
hospital. Blood glucose was monitored routinely and FS was
within normal limits, no insulin administration was required.
During this hospitalization, the patient was evaluated by
Physical Therapy and was recommended to be discharge in long
term medical facility. The patient received subcutaneous heparin
and venodyne boots were used during this stay. The patient's
blood sugar was monitored regularly throughout the stay; sliding
scale insulin was administered when indicated. Labwork was
routinely followed; electrolytes were repleted when indicated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient is currently NPO and
continued on TPN, he requires assistance to transfer from bed to
chair, voiding without assistance, and pain was well controlled.
Medications on Admission:
-Mirtazapine 30 qHS
-Depakote 125mcg daily
-Pepcid 40mg daily
-Senna 805mg daily
-Ca carbonate 1250mg daily
-Oxazepam 10 PRN insomnia
Colace 100mg PO BID
-Cyanocolbalamin 500mg daily
-Triamcinolone 0.1% cream [**Hospital1 **]
-Folic acid 1 tab daily
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
2. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
3. Valproate Sodium 500 mg/5 mL (100 mg/mL) Solution Sig: Two
[**Age over 90 1230**]y (250) mg Intravenous three times a day.
4. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q6H (every 6 hours): hold if SBP < 100, or HR < 60.
5. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day) for 3 days.
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
7. 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.
8. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: [**3-24**]
units Subcutaneous every six (6) hours: as directed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] HOSPITAL
Discharge Diagnosis:
1. Gallstone pancreatitis
2. Urinary tract infection
3. Delirium
4. Dysphagia
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:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-23**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
PEG tube care: Flush with tap water 30 cc [**Hospital1 **].
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office at [**Telephone/Fax (1) 1231**] if you have
questions, no formal follow up needed
.
Please follow up with your PCP [**Last Name (NamePattern4) **] [**3-19**] weeks after discharge
Completed by:[**2155-10-23**]
|
[
"403.90",
"287.5",
"276.51",
"518.82",
"V15.88",
"288.60",
"535.50",
"530.81",
"577.0",
"244.9",
"584.9",
"459.81",
"511.9",
"112.0",
"599.0",
"507.0",
"518.0",
"787.20",
"692.9",
"345.90",
"294.8",
"715.90",
"574.20",
"585.1",
"V45.61",
"V45.79",
"293.0",
"041.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"96.6",
"51.85",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
18593, 18660
|
10348, 17320
|
275, 701
|
18782, 18782
|
3112, 10325
|
19626, 19881
|
2256, 2265
|
17621, 18570
|
18681, 18761
|
17346, 17598
|
18962, 19603
|
2280, 2280
|
2801, 3093
|
182, 237
|
729, 1974
|
2294, 2787
|
18797, 18938
|
1996, 2169
|
2185, 2240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,826
| 118,418
|
39458
|
Discharge summary
|
report
|
Admission Date: [**2178-1-20**] Discharge Date: [**2178-2-7**]
Date of Birth: [**2107-2-15**] Sex: M
Service: OME
HISTORY OF PRESENT ILLNESS: This patient is a 70-year-old
male with extensive locally recurrent melanoma involving his
face, status post excision, neck dissection and radiation
therapy. Initial staging was consistent with stage III C
disease but now with mets to the lung, bone and soft tissue.
He was due to be started on high-dose IL-2 but in clinic on
[**2178-1-12**], he was noticed to have erythema in an area of
recent lymph node dissection felt consistent with cellulitis,
and was started on oral Keflex, and now is presenting with
worsening erythema. The patient reports that in the week
since he started antibiotics, the erythema has enlarged and
become more red. In clinic today, his white blood cell count
was up to 20,000 and he was admitted to OMED service.
PAST MEDICAL HISTORY: Hypertension, metastatic melanoma with
original diagnosis in [**2177-6-5**]. On [**2177-8-21**] he underwent
wide local excision and sentinel lymph node biopsy, with
melanoma present in 1 left intraparotid node. On [**2177-8-28**]
he had re-excision of the left temple and cheek area and a
left radical neck dissection, with melanoma in 7 of 69 total
lymph nodes. He underwent radiation therapy to the forehead
area, completing 20 fractions over 4 weeks. He then
developed soft tissue nodule superior to the graft, that
might have represented residual melanoma and appeared to have
reduced in size with radiation.
In late [**2177-10-6**] a PET CT showed increased glucose
uptake at sites of surgery on his thigh and around the
superior edge of the graft on his face. He was seen in
follow-up one of three weeks after completion of radiation.
Follow up head MRI and torso CT on [**2178-1-7**] revealed no
metastatic brain lesions, but metastatic disease in his
chest, left axilla, mediastinum and lung, as well as a T12
sclerotic focus felt consistent with melanoma. The BRCA
mutation testing on his tumor was negative. He has passed
screening tests to begin high-dose IL-2 therapy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Enalapril 20 mg p.o. daily,
pravastatin 20 mg p.o. daily, Keflex 500 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Reveals an elderly male
in no apparent distress. HEENT: Pupils equal, round,
reactive to light. Left temporal and buccal graft without
erythema. NECK: Well-healed scar from posterior auricular
area to the left upper chest. No signs of wound dehiscence.
Broad area of erythema and corresponding area warm to touch.
No palpable masses or fluid collections. No cervical,
supraclavicular or axillary lymphadenopathy. HEART: Regular
rate and rhythm, S1, S2. CHEST: No dullness to percussion
and clear to auscultation bilaterally. ABDOMEN: Positive
bowel sounds, soft, nontender. EXTREMITIES: Warm and well
perfused, 1+ edema to [**12-8**] the way up shins bilaterally, 2+ DP
and PT pulses. NEUROLOGIC EXAM: Nonfocal.
ADMISSION LABS: WBC 20.9, hemoglobin 11.7, hematocrit 33.7,
platelet count 206,000, BUN 20, creatinine 1.2, sodium 134,
potassium 6.1, chloride 101, CO2 23, glucose 117.
HOSPITAL COURSE: The patient was admitted with cellulitis
and was placed on IV vancomycin. Doxycycline was added when
he did not appear to be improving. Unasyn was added when the
cellulitic area continued to worsen. He also became short of
breath and was treated with Lasix. Transthoracic echo
revealed diastolic heart failure and he was continued on
enalapril and Lasix. He had an ID consult on [**1-28**] who
suggested stopping the Unasyn, changing to cefepime and
adding vancomycin back. Blood cultures remained negative and
he was afebrile throughout this time. Derm consult on [**1-28**]
was obtained due to persistent rash, and a biopsy was
performed consistent with melanoma. He was subsequently
transferred to the biologic service on [**2178-1-30**] to begin
high-dose IL-2 therapy.
During this week he received 7 of 14 doses with 7 doses held
related to tachycardia and pulmonary edema. On treatment day
#4, he was tachypneic with hypoxia to the mid 80s. Chest x-
ray was consistent with bilateral pleural effusions.
Throughout the day he became increasingly more tachypneic and
fatigued, and was transferred to the ICU. He was treated
with Lasix with improvement in his respiratory status. An
echocardiogram on [**2178-2-3**] showed a small pericardial
effusion with question tamponade physiology. Cardiology was
consulted and felt they were not able to tap the effusion.
He underwent a cardiac MRI on [**2178-2-4**] revealing no cardiac
metastases and no tamponade physiology.
He developed SVT to the 140s on [**2178-2-4**], which
spontaneously improved with a fluid bolus. His respiratory
status improved with continued diuresis, and he was
transferred back to the floor on [**2178-2-5**]. Lasix and
enalapril were continued and he was weaned to room air with
O2 saturations in the mid 90s.
Physical therapy consult was initiated and he was ambulating
short distances with a steady gait. He was discharged to
home on [**2178-2-7**] with a plan to follow up in clinic on
[**2178-2-10**].
Other side effects related to IL-2 included rigors improved
with Demerol; fatigue; and hypotension on treatment day 3,
requiring fluid boluses. During this week he developed acute
renal failure with a peak creatinine of 3.0 with associated
oliguria. He developed metabolic acidosis with a minimum
bicarb of 18, improved with bicarbonate boluses.
Electrolytes were monitored and repleted per protocol.
Strict I & Os and serum chemistries were maintained. IV
fluids were continued given acute renal failure.
During this week he had mild ST elevation to 54, which
improved prior to discharge. He had no hyperbilirubinemia,
myocarditis or coagulopathy noted. He was thrombocytopenic
to a platelet count low of 68,000 without evidence of
bleeding. He was anemic and was transfused with packed red
blood cells with discharge hemoglobin of 9.1. By [**2178-2-7**]
he had recovered from side effects to allow for discharge to
home.
CONDITION ON DISCHARGE: Alert, oriented and ambulatory.
DISCHARGE STATUS: To home with his family.
DISCHARGE DIAGNOSES:
1. Metastatic melanoma status post cycle 1, week 1, high-
dose IL-2 therapy complicated by pulmonary edema, and
bilateral pleural effusions from IL-2 induced capillary
leak, with respiratory distress.
2. Acute renal failure related to IL-2 therapy.
DISCHARGE MEDICATIONS: Enalapril 20 mg p.o. daily, Lasix 20
mg p.o. daily, lorazepam 0.5 mg q. 6 hours p.r.n. nausea,
pravastatin 20 mg p.o. daily, Compazine 5 to 10 mg q.i.d.
p.r.n. nausea.
FOLLOW-UP PLANS: The patient will return to clinic on
[**2178-2-10**] for assessment of his clinical status prior to
consideration for treatment with week #2 of therapy.
I have reviewed the discharge summary and agree with the hospital
course and disposition as dictated by [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) 17265**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 66804**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2178-2-24**] 12:32:55
T: [**2178-2-25**] 15:33:12
Job#: [**Job Number 87177**]
cc:[**Numeric Identifier 87178**]
|
[
"511.9",
"196.1",
"423.3",
"196.0",
"172.3",
"584.9",
"E933.1",
"196.3",
"197.0",
"428.0",
"287.49",
"198.2",
"428.31",
"402.91",
"423.9",
"276.2",
"198.5",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"00.15",
"38.97",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
6289, 6551
|
6575, 6744
|
2190, 2296
|
3231, 6165
|
6762, 7403
|
164, 911
|
3058, 3213
|
2311, 3012
|
3030, 3041
|
934, 2163
|
6190, 6268
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,766
| 193,931
|
54588
|
Discharge summary
|
report
|
Admission Date: [**2184-9-18**] Discharge Date: [**2184-9-24**]
Date of Birth: [**2131-12-31**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Levaquin / Morphine
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2184-9-18**]
1. Exploratory laparotomy.
2. Reduction of common channel intussusception.
3. Small-bowel resection with primary anastomosis.
History of Present Illness:
52F with history of gastric bypass in [**2182**] at [**Hospital1 112**] presents
with one day of epigastric abdominal pain and nausea. Patient
noticed pain last night, felt deep in epigastrium. Pain has
worsened since with associated nausea. She has not passed flatus
or had a BM since her pain started. She denies fever, chills,
vomiting, diarrhea, and malaise. She denies recent NSAID or
alcohol use. She takes pantoprazole daily since her surgery.
Since arrival in ED, her pain has been stable. She had one
episode of coffee ground emesis and an NGT was placed. She
received 2L over 7 hours in the ED and no urine output (no foley
in place).
Past Medical History:
# HIV positive (viral load less than 50) [**4-17**]--contracted after
a sexual assault
# HTN
# Fatty liver
# Asthma
# Hypercholesterolemia
# Neuropathy
# Depression
# h/o MRSA abscesses/cellulitis
# s/p hysterectomy
# Obesity
# Chronic pain
Social History:
Pt lives at home with her two children. She does not work. She
has a 15 pack year smoking history (still smokes [**3-16**] cigarettes
per day), rare alcohol and no IV or other drug use. Brother is
healthcare proxy [**Numeric Identifier 111657**].
Family History:
HTN widespread in family
Mom alive and well
Hx of Breast CA and Stomach CA in family
DM grandfather
Sister has Ulcerative Colitis
Physical Exam:
Temp 97.6 HR 56 BP 123/84 RR 18 O2 sat 100% RA
Gen: Appears uncomfortable, NAD
CV: RRR
Resp: CTAB
Abd: Soft, nondistended, tender in epigastrium, no rebound, no
guarding, +BS
Ext: Warm, no edema
Pertinent Results:
[**2184-9-17**] 05:05PM WBC-7.3 RBC-4.57 HGB-14.8 HCT-42.3 MCV-93
MCH-32.5* MCHC-35.1* RDW-12.6
[**2184-9-17**] 05:05PM NEUTS-87.0* LYMPHS-9.5* MONOS-2.3 EOS-0.9
BASOS-0.4
[**2184-9-17**] 05:05PM PLT COUNT-317
[**2184-9-17**] 05:05PM ALT(SGPT)-16 AST(SGOT)-20 ALK PHOS-111* TOT
BILI-0.4
[**2184-9-17**] 05:05PM LIPASE-15
[**2184-9-17**] 05:05PM ALBUMIN-4.4
[**2184-9-17**] 05:05PM GLUCOSE-126* UREA N-12 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
[**2184-9-17**] KUB :
Findings concerning for early small-bowel obstruction. Mild
fecal loading.
[**2184-9-18**] CT Abd/pelvis :
1. Intussusception at the Roux en Y anastomosis site with
associated small-bowel obstruction with dilatation of the entire
efferent limb and the mid and distal end of the afferent limb.
2. No abnormal bowel wall enhancement.
3. No free air and no free fluid.
Brief Hospital Course:
Mrs [**Last Name (STitle) 9404**] was admitted on [**2184-9-18**] and taken emergently to the
OR for exploratory laparotomy, reduction of intussusception and
small bowel resection with primary anastomosis. She tolerated
the procedure well and was transferred to the ICU, intubated to
receive further care. She was able to be extubated within a few
hours. The patient was able to be transferred to the floor on
post op day #2.
Following her transfer she continued to make good progress. She
remained NPO for 48 more hours and gradually began a liquid
diet. She slowly progressed to her stage 5 bariatric diet once
her bowel function returned. Her abdominal wound was healing
well without erythema or drainage.
The pain service followed her closely as she had been on
methodone and oxycodone for years. Once her pain medication
could be taken orally she was placed on her pre op doses with
additional oxycodone given for incisional pain. Her PCP agreed
with this regime and a notation was placed on her record as she
has a narcotic contract.
She was up and walking independently, using her incentive
spirometry effectively and tolerating regular food. She was
discharged home on [**2184-9-24**] with VNA services and will follow up
in the [**Hospital 2536**] Clinic in 2 weeks for staple removal.
Medications on Admission:
Albuterol 90 prn, Efavirenz-emtricitabin-tenofov
[**Telephone/Fax (3) 111658**]', Fluticasone 110 mcg'', Methadone 10'', oxycodone
15, pantoprazole 20', valacyclovir 1,000 prn herpes, varenicline
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
Disp:*1 MDI* Refills:*1*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
10. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. oxycodone 15 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain: start [**2184-9-29**] when medication
available.
Disp:*56 Tablet(s)* Refills:*0*
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
13. methadone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Common channel intussusception causing intestinal obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-20**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at your follow-up appointment.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appoint,ment on [**2184-9-30**] for staple remonal.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2184-9-30**] 5:00
Provider: [**First Name11 (Name Pattern1) 3679**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3680**], RD Phone:[**Telephone/Fax (1) 3681**]
Date/Time:[**2184-10-6**] 9:00
Completed by:[**2184-9-24**]
|
[
"V45.86",
"557.9",
"042",
"356.8",
"560.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.81"
] |
icd9pcs
|
[
[
[]
]
] |
5847, 5910
|
2954, 4260
|
309, 453
|
6017, 6017
|
2046, 2931
|
8024, 8571
|
1675, 1807
|
4508, 5824
|
5931, 5996
|
4286, 4485
|
6168, 7626
|
7642, 8001
|
1822, 2027
|
255, 271
|
481, 1128
|
6032, 6144
|
1150, 1393
|
1409, 1659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,434
| 113,836
|
27262
|
Discharge summary
|
report
|
Admission Date: [**2128-2-11**] Discharge Date: [**2128-2-17**]
Date of Birth: [**2055-10-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
substernal chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 72 y/o M with h/o CAD (known 3VD, declined bypass x5
yrs), CKD (cr 3.5), dCM (EF 25%, declined ICD previously), DM,
BRBPR (not yet worked up) p/w 1 week SOB, substernal chest
discomfort and left arm pain, also with bloody stools. Pt was
admitted to floor where he received 1u pRBC, O2, morphine, lasix
and NTG. Pt then went into acute respiratory distress and was
admitted to the ICU. Found to be hypotensive, tachycardic and
diaphoretic and agitated. given SL NTG then on IV NTG gtt.
received total of 6mg IV morphine and was calmer. For his
tachycardia he was given IV lopressor. CXR done at that time
showed RLL infiltrate that was worsening on followup CXR with
"intermittent infiltrate" (not always seen) in left lung. Pt
only put out 300ccs of urine to 280 IV lasix (40mg IV bolus
followed by gtt). Trop T 0.11 and went up to 0.67. FSG in the
600s, GAP unknown at presentation but down to 13 prior to
transfer (glucose in 200s by then). pt placed on insulin gtt
with resolution of blood sugars to 200s. Pt hyperkalemic with K
6.4 --> 7.2 --> 6.1, 1 dose kayexelate given. Pt was taken off
bipap and nitro gtt but developed acutely worsening SOB, BP down
to 70/40 and levophed was started. Pt started on azithro/unasyn
out of c/f PNA. Pt had fever last week but was afebrile at OSH.
EKG showed LBBB, wide QRS with elevated K. TTE yesterday showed
mildly dilated LV, LVEF 30% akinesis of anterior wall, apex,
septum, inf/inferolateral wall, moderate MR, mod TR, mild pHTN
PAP 40, small effusion. Pt also received steroids. Pt was
transferred to [**Hospital1 18**] for further management. Vitals prior to
transfer were HR 91, BP 85.46 SpO2 99%.
.
On arrival pt was on levophed 20, insulin 6u/hr, protonix drips
and bipap. Vital signs were AF T97.4 HR 93 Bp105/50 (63) RR19
100% on nonrebreather (50%FIO2).
.
ECG showed NSR at 100bpm with no ST changes suggestive of
ischemia but with peaked T waves in antero-lateral leads. Labs
showed: trop 1.46 CKBM 49, Cr of 4.1 up from b/l 3.5, K of 6.1,
bicarb 19, sodium 134, glucose 285. WBC 10, HCT 30. Lactate
0.6. Pt was placed on bipap at 40% for ABG of 7.11/60/318. Was
given lasix 200mg IV without much urine output, placed on lasix
gtt of 20 and metolazone 5mg given. After 30 minutes ABG showed
7.14/54/93.
.
Of note, family very conflicted about goals of care, pt has
refused multiple interventions in the past and recurrently
noncompliant with therapy. Conversations with family through the
language line were extensive. Daughter in law speaks English and
knows medical terminology and stated that the interpreter??????s
accent was difficult to understand. Pt refused to make decision
regarding dialysis, code status, and HCP. At first refused
anticoagulation and PR medications but bipap was removed to make
him more comfortable and have a conversation effectively and he
agreed to these measures.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
OTHER PAST MEDICAL HISTORY:
- asthma
- BPH
Social History:
pt is egyptian, arabic speaking only. former smoker.
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
Tcurrent: 36.3 ??????C (97.4 ??????F)
HR: 96 (91 - 105) bpm
BP: 119/50(69) {90/44(0) - 119/50(69)} mmHg
RR: 16 (11 - 21) insp/min
SpO2: 99% on nonrebreather
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 109 kg (admission): 109.7 kg
GENERAL: moderate distress, incr WOB. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP halfway up the neck
CARDIAC: heart sounds difficult to auscultate over lung rhonchi
and wheezes. Normal S1, S2 no m/r/g.
LUNGS: labored breathing, on NRB. Diffusely wheezy and
rhonchorous.
ABDOMEN: protuberant. Soft, NTND. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
AT DISCHARGE:
Tmax: 37.2 ??????C (99 ??????F)
Tcurrent: 36.7 ??????C (98 ??????F)
HR: 108 (101 - 122) bpm
BP: 108/47(64) {84/35(49) - 121/54(73)} mmHg
RR: 22 (16 - 33) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 97.5 kg (admission): 109.7 kg
GENERAL: moderate distress, incr WOB. Not able to orient. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Shallow ~1cm ulcer
on nasal bridge [**2-19**] BiPAP, nonpurulent. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP halfway up the neck
CARDIAC: heart sounds difficult to auscultate over lung rhonchi
and wheezes.
Normal S1, S2 no m/r/g.
LUNGS: labored breathing, on shovel mask with humidified O2.
Diffusely rhonchorous and coarse.
ABDOMEN: protuberant. Soft, NTND. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Pulses 2+
SKIN: No stasis dermatitis, scars, or xanthomas.
Pertinent Results:
- ECHO:
[**2122**] at [**Hospital1 18**] TTE: EF 25%
1. The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed. No masses or thrombi are seen in
the left ventricle. Resting regional wall motion abnormalities
include akinesis of the lower third of the LV with inferolateral
akinesis.
3. Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion.
6.The mitral valve leaflets are mildly thickened. Mild mitral
regurgitation is seen.
7. No pericardial effusion seen.
.
TTE [**2128-2-11**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= 25 %) secondary to severe
hypokinesis/akinesis of the inferior and posterior walls, and
extensive apical akinesis with focal dyskinesis. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. An eccentric, posteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. Due to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2122-5-8**], inferior wall contractile dysfunction is more
extensive, with consequent worsening of mitral regurgitaton.
.
CXR [**2128-2-14**]
Diffuse right lung opacities have minimally improved,
differential still
include hemorrage, infection, asymmetric edema. Left upper lobe
atelectasis is unchanged. Left mid lung atelectasis and aeration
of the left lower lung have improved. There is no evident
pneumothorax. Right PICC tip is in the lower SVC.
cardiomediastinal contours are stable.
Brief Hospital Course:
# hypercarbic respiratory failure - Pt presented with
respiratory acidosis and elevated CO2 on ABG in 60s range. Pt
had become acutely dyspneic [**2-10**], most likely [**2-19**] cardiogenic
edema in setting of MI with MR. CXR showed pulmonary edema and
consolidation of right lung fields greater than left, pt had a
significant wet cough, reported fevers at home, and out of c/f
CAP pt was started on ceftriaxone/azithro.ers at home).
Bronchospasm/some component of COPDlikely played a role(pt
longtime smoker w/ history of asthma, on
albuterol/fluticasone/ipratropium at home). Pt was maintained
initially on facetent at 30-50% with 4L NC, but gas showed PCO2
up to 60s and was started on bipap. Pt remained stable with
improvement of CO2 to 55 on bipap. Pt was again taken off bipap
and CO2 went up to 79 on [**2128-2-15**].
Xopenex was given along with standing nebs. PT was aggressively
diuresed, with eventual succes. Goals of care discussions were
murky and ongoing, on [**2128-2-15**] the family requested that we
attempt to wean pressors and DC antibiotics. Pt was given
morphine prn for increased WOB with good effect. On [**2128-2-17**],
another goals of care discussion occured and at that point it
was decided that Mr. [**Known lastname 66855**] would be made comfort measures only.
At this point, pressors and all non-comfort focused medications
were discontinued. Mr. [**Known lastname 66855**] passed on [**2128-2-17**].
.
#decompensated heart failure - presented with shortness of
breath [**2-19**] pulmonary edema/fluid overload in setting of [**Month/Day (2) 7792**].
EF of 25% and severe global LV hypokinesis and MR. At OSH
diuresis was attempted with total 280mg IV lasix without
success. Once transferred, pt was put on a lasix gtt which was
run between 20-30 mg per hour for 2 days with success after
addition of metolazone. Pt was net negative several liters by
[**2128-2-15**]. Lasix was stopped on [**2128-2-17**] consistent with his goals
of care.
.
#[**Name (NI) 7792**] - pt p/w several days of epigastric pain and SOB. Acute
decompensation with evidence of fluid overload also with
elevated cardiac enzymes MB of 49. Likely inferior infarct
associated with mitral regurgitation. Echo [**2128-2-11**] showed EF of
25% with severe global hypokenesis/akenesis of left ventricle
with moderate mitral regurg. In setting of goals of care cath
was deferred. Pt was given aspirin and plavix load, started on
heparin gtt for 48 hours.
#hypotension - pt was unable to maintain BP on his own, off
pressors would drop to 70s systolic. Was started on levophed and
failed attempts to wean. Hypotension [**2-19**] decreased cardiac
output in setting of LV hypo/akinesis. Levophed was continued
until he was made CMO on [**2128-2-17**], and Mr. [**Known lastname 66855**] passed on
[**2128-2-17**].
.
#anemia - pt with HCT drop on arrival s/p transfusion of 1u
PRBCs at OSH. On admission HCT 30 which went down to 25. pt with
history of reported melena for 6 months not worked up, but no
signs of obvious bleeding. Pt had no stools and therefore no
witnessed melena during this hospitalization. No BRBPR. Hct was
trended, remained stable s/p 1u pRBCs at [**Hospital1 18**]. There was some
concern that pt was bleeding into lung parenchyma as he began
coughing up thick bloody mucous on [**2128-2-14**]. Initially pt was
continued on heparin, plavix, ASA, in setting of [**Date Range 7792**], but
after 48 hours heparin gtt was discontinued.
.
# hyperkalemia - K up to 7.1 at OSH on presentation. Resolving
on transfer s/p kayexelate at OSH but still in 6 range with
peaked T waves on ECG. With kayexelate, insulin gtt, bicarb,
beta agonist nebs, lasix gtt, K corrected to normal range. [**2-19**]
pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] on CKD, see below.
.
# ESRD - [**Last Name (un) **] on CKD, most likely cardiac in origin in setting
of poor perfusion to kidneys. On transfer pt was found to be
hyperkalemic, acidotic (respiratory acidosis with metabolic
component). Nephrology was consulted for concern that pt would
need dialysis. Dialysis was not initiated as patient was made
CMO.
.
#metabolic acidosis - Pt presented with metabolic component of
acidosis with AG of 17. Likely in setting of renal failure [**2-19**]
decreased perfusion, FSG was monitored and remained in the 200
range, then controlled with insulin gtt, and pt was transitioned
to SQ regimen without issues.
.
#goals of care - family discussions were held in depth every day
of hospitalization. on [**2128-2-15**] they were informed we had tried
everything we could do, and agreed to wean pressors and DC
antibiotics. Mr. [**Known lastname 66855**] was made CMO on [**2128-2-17**], and Mr. [**Known lastname 66855**]
passed on [**2128-2-17**].
.
# DM - poorly controlled, p/w FSG of 600 to OSH but no AG. BS
down to high 100s on insulin gtt, stabilized and pt transitioned
to subcu insulin. This was stopped on [**2128-2-17**] as patient was
made CMO.
.
#Nutrition - pt initially kept NPO c/f aspiration (audible
gurgling/choking noises). Family fed the pt chicken and
respiratory status worsened, felt that he developed aspiration
pneumonitis. Goals of care were clarified and family wanted to
feed the pt which was fine as we were not escalating care.
.
#communication - pt is arabic speaking only.
.
#contact: [**Name (NI) **] [**Telephone/Fax (1) 66856**] ([**Name2 (NI) **]er in law)
[**Name (NI) **]: [**Telephone/Fax (1) 66857**] (son)
Medications on Admission:
proair
fluticasone-propionate (flovent) 2 puffs by mouth [**Hospital1 **]
lasix 60po daily
lisinopril 20mg daily
simvastatin 20 mg po daily
glyburide 5mg daily
metoprolol succinate 50 mg daily
vitamin D 5000u 1x per wk
doxazosin 2mg qhs
allopurinol 100mg tab daily
atrovent 2 puffs 4times daily
aspirin 81mg
Discharge Medications:
None, patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Non-ST Segment Elevation Myocardial Infarction
Decompensated Systolic Heart Failure
End Stage Renal Disease
Diabetes Mellitus Type II
Hypoxemic and Hypercarbic Respiratory Failure
Discharge Condition:
Deceased
Discharge Instructions:
Dear Mr. [**Known lastname 66855**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with a heart attack and decompensated systolic
congestive heart failure with resultant respiratory distress and
renal failure. We initially treated your heart attack with blood
thinners and your heart failure with diuretics. Unfortunately
however, your condition was too severe to be treated with
medical management alone. With your healthcare proxies, we
decided to focus on comfort focused care, and arranged for you
to be sent home with hospice care.
The following medication changes were made:
STOP all medications except:
sublingual morphine 2-8mg as needed for comfort
liquid atropine drops as needed for secretions
All other pre-hospital medications should be discontinued as we
are focusing on comfort measures.
Followup Instructions:
None
|
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"410.71",
"276.7",
"428.0",
"V66.7",
"584.9",
"416.8",
"428.23",
"585.6",
"425.4",
"507.0",
"518.81",
"785.51",
"493.20",
"578.1",
"414.01",
"403.91",
"V49.86",
"275.3",
"276.4",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14433, 14442
|
8564, 14027
|
327, 333
|
14666, 14677
|
6021, 8541
|
15566, 15574
|
3974, 3992
|
14386, 14410
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14463, 14645
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14053, 14363
|
14701, 15543
|
4007, 4007
|
5013, 6002
|
266, 289
|
361, 3762
|
4021, 4999
|
3871, 3888
|
3904, 3958
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,745
| 118,272
|
47599
|
Discharge summary
|
report
|
Admission Date: [**2157-3-16**] Discharge Date: [**2157-4-18**]
Date of Birth: [**2075-5-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Epigastric/RUQ pain
Major Surgical or Invasive Procedure:
Laparoscopic converted to open
cholecystectomy plus liver biopsy
History of Present Illness:
81M with MMP and hx of recurrent cholecystitis who presents
[**2157-3-16**] with a one day history of RUQ/epigastric pain
Past Medical History:
PMH:
CRI, baseline 2.5-3.5
NIDDM
[**11/2139**] AMI
PVD: s/p RLE bypass [**7-/2143**], [**5-/2148**] left Fem [**Doctor Last Name **] bypass, [**2-3**]
angioplasty of left Fem-AT bypass stenosis
Hyperlipidemia
Gallstones s/p [**2156-1-2**] ERCP w/ CBD [**Month/Day/Year **] placement needs
[**Month/Day/Year 100581**]
AAA (3cm stable sine [**2145**])
Elevated Alk Phos
[**9-/2147**] embolic CVA, seven CVA's since most recently in [**10-7**].
Afib/flutter s/p Ablation [**11-5**], EPS [**11-7**]
Syncope
HTN
renal arteries no stenosis by cath [**2154-5-17**]
[**5-8**] s/p TTE w/ EF to be newly depressed at 30-35% with left
ventricular hypertrophy and [**12-7**]+MR. [**Name14 (STitle) **] w/ reversible defect
PSH:
[**2142**] R Fem [**Doctor Last Name **] in situ
[**2147**] L Fem [**Doctor Last Name **] in situ
[**2150**] vein angioplasty L Fem artery
Social History:
Married for 53 years with three sons. They have assistance with
cleaning and cooking at home through elderly affairs assistance.
His son manages all their bills and mail and lives upstairs.
Wife is legally blind and is a care taker for Mr. [**Known lastname 100582**]. The
patient walks unassisted now. He is very hard of hearing. +80
ppy history, quit [**2145**]. No EtOH or illicits.
Family History:
NC
Physical Exam:
Admission Physical Exam- [**2157-3-16**]
97.1 51 148/44 18 98%RA
HEENT: sleep, arousable, AAOx2, anicteric, mm dry, no JVD
Car: reg S1S2, brady, II/VI SEM
Resp: Decreased BS w/ occ rhonchi
Abd: soft, ND, not specifically tender over the the aneurysm
site, +RUQ tender + distented GB; no hernia
Ext: 1+ ext edema, col, dry,, +cap refill [**2-6**] sec
Rectal: guaiac (-)
Brief Hospital Course:
[**Known firstname 122**] [**Known lastname 100582**] was evaluated in the emergency department on
[**2157-3-16**]. WBC count was 12.0;Amylase 169; Lipase 89; Alk Phos
150. AST/ALT/T.Bili were WNL. RUQ ultrasound showed moderately
distended and mildly edematous thickened gallbladder wall,
shadowing gallstones, not overtly changed in appearance since
[**2157-1-6**]. He was admitted to the surgery service under the
care of Dr. [**Last Name (STitle) 5182**]. He was made NPO. Levofloxacin/Flagyl
were given for empiric coverage. Plavix was stopped. At HD 3 he
was afebrile and his pain was improved. Amylase/Lipase/Alk phos
were 81/28/137. WBC count was elevated at 16.9. He remained NPO
and on IV antibiotics. AT HD 5 the diet was advanced. At HD 6
his LFTs were trending up. He was made NPO. ERCP was completed
on HD 7 which showed an open previous spinchterotomy with bile
drainage into the duodenum. A balloon was passed to clear
sludge from the common duct. He tolerated the procedure well
and was returned to the floor after recovery. At HD 8 he had an
episode of ? aspiration with medications. A CXR was performed
which showed a small right pleural effusion and consolidation at
the medial aspect of the right lung base. His O2 sats were
maintained without distress with NC oxygen with no sequelae. At
HD 9 he was tolerating a regular diet. LFTs were trending down.
Operative date was planned for the following week. At HD 11 he
was tolerating a diet and denied pain. He was found to have UTI
with psotive UCx for Proteus. [**Last Name (un) **] was consulted for blood
glucose control and Lantus was added to his sliding scale. At HD
16 he was taken to the operating room where he underwent a
laparoscopic converted to open cholecystectomy. He was found to
have liver cirrhosis despite only a mildly elevated alk phos
preoperatively at 129. AST/ALT/Bili were WNP. There was a
moderate amount of bleeding from the liver bed r/t to the
cirrhosis with a loss of approximately 1200ml. A liver biopsy
was obtained. He tolerated the procedure and was taken to the
ICU intubated and sedated. At POD 1 he was on Levophed to
maintain pressure. Urine output was low. Hct was 25.4. At POD 2
he failed to extubate and was reintubated. Urine output was
marginally improved. At POD 4 cardiac enzymes were cycled for
new BBB with (+) elevation of troponin. Cardiology was
consulted. He was transfused for a Hct of 22.7. He was afebrile
and hemodynamically stable off pressors. Urine output was WNL.
He was draining a moderate amount of ascitic fluid from JP
drain. TPN was started. Neurology was consulted on [**2157-4-9**] for an
episode of bradycardia and desaturation. They did not find any
focal problems. [**Name (NI) 6**] MRI was done. The patient contunied to
progress well. On [**2157-4-14**] a video swallow was done. The patient
was placed on a thin liquids and ground diet. His drain was
removed. The patient was transferred to the floor. On [**2157-4-18**]
the patient was discharged to rehab in stable condition
Medications on Admission:
Amiodarone 200'; ASA 81'; Flomax 0.4'; Lasix 20'; Hydralizine
25'; Isosorbide 30'; Levoxyl 50mcg'; Lipitor 80'; Lopressor
25''; Plavix 75'
Discharge Medications:
1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
Disp:*qs qs* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*0*
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
acute calculous cholecystitis
Discharge Condition:
stable
Discharge Instructions:
If you have fever>101.4, nausea, vomitting, increased abdominal
pain or any other concerns please call you doctor.
Please take medications as prescribed. We are discontinuing your
lasix.
Followup Instructions:
Please call Dr[**Name (NI) 6045**] office for a follow up appointment
([**Telephone/Fax (1) 15350**]
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2157-4-18**]
|
[
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"428.0",
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"518.5",
"369.4",
"998.11",
"511.9",
"412",
"789.5",
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icd9cm
|
[
[
[]
]
] |
[
"51.22",
"96.72",
"96.6",
"88.72",
"99.15",
"99.04",
"51.10",
"50.11",
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] |
icd9pcs
|
[
[
[]
]
] |
6535, 6614
|
2269, 5297
|
334, 400
|
6688, 6697
|
6933, 7172
|
1852, 1856
|
5486, 6512
|
6635, 6667
|
5323, 5463
|
6721, 6910
|
1871, 2246
|
275, 296
|
428, 551
|
573, 1431
|
1447, 1836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,819
| 170,583
|
29208
|
Discharge summary
|
report
|
Admission Date: [**2111-10-12**] Discharge Date: [**2111-10-23**]
Date of Birth: [**2059-10-18**] Sex: M
Service: MEDICINE
Allergies:
Imipramine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
This is a 51 yo male with PMH of Hep B/C and EtOH abuse induced
cirrhosis transferred to [**Hospital1 18**] from OSH for hepatic transplant
work up and implantable defibrillator evaluation.
Major Surgical or Invasive Procedure:
Thoracentesis
Central Venous Access
History of Present Illness:
This is a 51 yo male with PMH of Hep B/C and EtOH abuse induced
cirrhosis transferred to [**Hospital1 18**] from OSH for hepatic transplant
work up and implantable defibrillator evaluation.
.
Initially, the patient was admitted to the OSH s/p fall x 2 with
loss of consciousness and bladder function following an episode
of chest pain and dizziness. After the second fall, he was found
by his son and brought to the hospital. In the ED, he was found
to be dyspneic and hypoxic and a CXR showed a right sided
pleural effusion.
.
He underwent a 1.4L thoracentesis on [**10-8**] which was consistent
with a transudate with a diff showing 12 polys, 41 lymphs, 21
eos and 41 monos, total protein of 1.9 and LDH 76. Cultures were
negative. Following the procedure, his sats improved.
.
His hospitalization was complicated by an episode of TdP on [**10-8**]
attributed to hypomagnesemia and prolonged QT, which required
CPR and 2 shocks, amiodarone loading/drip and magnesium bolus.
Although he did rule out for MI by CE, repeat surface echo
indicated a hyperdynamic LVEF from 59 to 84%. Additionally, the
patient had blood cultures + for GPC's and was started on
vancomycin.
.
On transfer, the patient is stable and complains of pain over
his chest in the location of rib fractures secondary to CPR. He
denies n/v/d, abd pain, chest pressure, palpitations, and
although he feels mildly dyspneic, he notes that he feels much
improved.
Past Medical History:
-long QT syndrome
-h/o TdP
-Hepatitis B
-Hepatitis C
-H/o hepatitis A
-EtOH abuse (sober 10 yrs)
-viral/alc cirrhosis
-thrombocytopenia with coagulopathy
-DM2
-GERD
-h/o cholelithiasis
-Anxiety
-Depression
Social History:
admits to IVDU (sober for "20 years), EtOH abuse (sober for "30
years"), and is a current tobacco smoker at 1/3ppd. Patient has
6 children, lives at home with his teenage son; divorced.
Patient is on habit management and stable to take 13-day
take-home doses. Worked for [**Company **] as a repairman for
the electrical poles. Is currently on disability for his anxiety
and depression.
Family History:
non-contributory
Physical Exam:
VS: 96.5 113/55 74 20 94%high flow 02
General: 51 yo M appearing older than his stated age, arousable
but sedated.
Skin: mildly jaundiced, warm and well perfused with venous
stasis changes in the lower extremities and multiple tattoos
over upper extremities. Spider angiomata on chest.
HEENT: Normocephalic, PERRL, EOMI but sluggish, mild scleral
icterus. OP clear. Ecchymosis over chin on left side. No JVD.
Chest: gynecomastia. Ecchymosis over sternum with significant
TTP.
Cardiac: RRR III/VI SEM heard best at RUSB radiating to right
carotid and across the precordium, louder with inspiration. No
rubs/gallops.
Lungs: Diffuse expiratory wheeze/mild rhonchi.
Abd: Distended with faint fluid wave. Hepatomegaly to 3cm below
costal margin. +BS, nontender, negative [**Doctor Last Name **].
Ext: venous stasis changes, 2+DP pulses. no edema.
Neuro/Psych: strength 5/5, follows commands. Asterixis.
Pertinent Results:
[**2111-10-12**] 10:01PM GLUCOSE-93 UREA N-21* CREAT-0.7 SODIUM-131*
POTASSIUM-3.8 CHLORIDE-89* TOTAL CO2-38* ANION GAP-8
[**2111-10-12**] 10:01PM ALT(SGPT)-23 AST(SGOT)-49* LD(LDH)-308* ALK
PHOS-82 AMYLASE-20 TOT BILI-9.3*
[**2111-10-12**] 10:01PM LIPASE-19
[**2111-10-12**] 10:01PM ALBUMIN-2.4* CALCIUM-8.0* PHOSPHATE-2.0*
MAGNESIUM-1.9
[**2111-10-12**] 10:01PM WBC-12.5* RBC-3.15* HGB-10.4* HCT-29.7*
MCV-94 MCH-33.0* MCHC-35.0 RDW-17.1*
[**2111-10-12**] 10:01PM NEUTS-83.0* LYMPHS-9.1* MONOS-7.4 EOS-0.5
BASOS-0.1
[**2111-10-12**] 10:01PM ANISOCYT-1+ MACROCYT-1+
[**2111-10-12**] 10:01PM PLT SMR-VERY LOW PLT COUNT-33*
[**2111-10-12**] 10:01PM PT-24.8* PTT-46.1* INR(PT)-2.5*
Brief Hospital Course:
51 yo M with MMP including viral and alcoholic cirrhosis
transferred s/p thoracentesis for hydrothorax complicated by
decompensated TdP requiring CPR/shock resuscitation.
.
Viral/EtOH Cirrhosis and ARDS: Gastroenterologist at OSH (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 55386**]) evaluated the patient and felt that he may be a
candidate for liver transplant. There was no evidence of ascites
on CT or US, but patient's presentation was consistent with
hepatic encephalopathy. Hepatology was on board throughout the
patient's course in the MICU, but did not feel that he was a
candidate for liver transplant secondary to his septic picture.
The patient continued to decompensate, requiring intubation for
hypoxic respiratory failure and pressors for what was believed
to be possible ARDS/sepsis and ended up going into fulminant
hepatic failure, despite maximum supportive measures and
antibiotics. His coagulopathy was unable to be controlled even
with receiving maximum blood products and support with pressors.
His family decided to withdraw blood products and the patient
passed away on [**2111-10-23**].
Medications on Admission:
Protonix 40mg PO BID
Amiodarone 400mg PO BID
Spironolactone 100mg PO daily
Methadone 110mg PO QAM
Clonazepam 0.5mg TID
Clonazepam 1mg QHS
Neutraphos 1 packet with meals TID
Lactulose 30ml PO QID
Vancomycin 1.5g IV Q12h
Lasix 20mg PO BID
RISS
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver failure
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
"276.3",
"428.0",
"518.81",
"518.0",
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"250.00",
"303.93",
"305.1",
"511.9",
"571.2",
"286.6",
"785.52",
"070.22",
"486",
"584.5",
"038.11",
"570",
"577.0",
"572.4",
"070.44",
"426.82",
"578.0",
"287.5",
"304.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"99.07",
"99.15",
"96.72",
"39.95",
"38.93",
"99.06",
"96.04",
"93.90",
"99.04",
"34.91",
"96.6",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
5738, 5747
|
4279, 5417
|
464, 501
|
5804, 5814
|
3557, 4256
|
5867, 5874
|
2606, 2624
|
5709, 5715
|
5768, 5783
|
5443, 5686
|
5838, 5844
|
2639, 3538
|
235, 426
|
529, 1958
|
1980, 2187
|
2203, 2590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,687
| 153,005
|
55089
|
Discharge summary
|
report
|
Admission Date: [**2162-5-13**] Discharge Date: [**2162-5-17**]
Date of Birth: [**2144-2-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Medication overdose (lithium, thorazine, atenolol)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
18-year-old female with significant psychiatric history
presenting s/p overdose on lithium, thorazine, and atenolol. She
was in a verbal altercation with her mother on day of
presentation regarding a friend who her mother felt was a poor
influence. During this argument, pt was becoming agitated and
mother was calling her crisis counselor. In order to retaliate,
pt proceeded to take all of the pills left in her pill bottles,
including 48 pills of lithium 300mg, 10 pills of atenolol 25mg,
10 pills of thorazine 50mg, and 12 pills of thorazine 100mg.
Prior to this, she had been taking all medications as prescribed
and denies illicit drug or alcohol use. Pt states that this was
not a suicide attempt.
Her mother called EMS, and she was taken to [**Hospital3 **] ED.
At [**Hospital3 **] ED, initial vitals were: 98.5 119/79 95 14
99%RA. Toxicology consult was obtained. She was given 50grams
charcoal, polyethylene glycol. Lithium level was 3. WBC 17.7,
Hct 37.7, plts 400. She was then transferred to [**Hospital1 18**] ED for
further evaluation, including possible need for dialysis.
.
In the ED, initial VS were: 89 114/72 16 100%. Lithium level was
3.3. She was given 2L NS. Toxicology and renal were consulted.
They recommended q1-2 lithium/Cr checks with initiation of
dialysis if lithium levels rose above 4, q1h EKG and fingerstick
checks. She remained hemodynamically stable at ED with no focal
neurologic deficits and no concerns for mental status changes.
.
Review of systems:
(+) Per HPI; reports rhinorrhea, cough
(-) Denies fever, chills. Denies headache, sinus tenderness.
Denies shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency.
Past Medical History:
Anxiety
Bipolar disorder
PTSD
Asthma
Social History:
She is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] in high school. She had been living in a group
home until 2.5 weeks ago. Since then she has been living with
her mother. Denies smoking or alcohol. Reports hx of marijuana
use, last use one year ago.
Family History:
Mother: anxiety, depression, fibromyalgia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5 P 95 BP 119/79 RR 14 O2Sat 99%RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, mouth and tongue covered with
black film from charcoal, oropharynx clear, EOMI, pupils dilated
and equal, reactive to light
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
.
DISCHARGE PHYSICAL EXAM:
VS: Tm98.7 Tc98.0 P87(85-108) BP125/71(118-130/66-80) RR20
O2Sat97-99%RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, mouth and tongue covered with
black film from charcoal, oropharynx clear, EOMI, pupils dilated
and equal, reactive to light
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
[**2162-5-13**] 09:15PM BLOOD WBC-13.2* RBC-3.96* Hgb-11.9* Hct-35.9*
MCV-91 MCH-30.0 MCHC-33.1 RDW-11.9 Plt Ct-393
[**2162-5-13**] 09:15PM BLOOD Neuts-73.0* Lymphs-20.6 Monos-3.2 Eos-3.0
Baso-0.3
[**2162-5-13**] 09:15PM BLOOD PT-11.3 PTT-24.1* INR(PT)-1.0
[**2162-5-13**] 09:15PM BLOOD Glucose-93 UreaN-9 Creat-0.8 Na-140 K-3.7
Cl-107 HCO3-22 AnGap-15
[**2162-5-13**] 09:15PM BLOOD HCG-<5
[**2162-5-13**] 09:15PM BLOOD Lithium-3.3*
[**2162-5-13**] 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2162-5-13**] 09:20PM BLOOD Lactate-1.8
.
MICROBIOLOGY DATA:
[**2162-5-14**] 12:22 am MRSA SCREEN
**FINAL REPORT [**2162-5-16**]**
MRSA SCREEN (Final [**2162-5-16**]): No MRSA isolated.
.
RADIOLOGICAL STUDIES:
NONE
.
DISCHARGE LABS:
[**2162-5-16**] 05:35AM BLOOD WBC-10.0 RBC-4.33 Hgb-12.6 Hct-40.1
MCV-93 MCH-29.1 MCHC-31.3 RDW-12.1 Plt Ct-423
[**2162-5-16**] 05:35AM BLOOD Glucose-78 UreaN-6 Creat-0.7 Na-139 K-4.4
Cl-106 HCO3-22 AnGap-15
[**2162-5-16**] 05:35AM BLOOD ALT-24 AST-26 AlkPhos-101
[**2162-5-16**] 05:35AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.8
[**2162-5-15**] 04:18AM BLOOD Lithium-1.2
.
PENDING LABS:
NONE
Brief Hospital Course:
Patient is a 18-year-old female with significant psychiatric
history presenting after overdose on lithium, thorazine, and
atenolol.
# Suicidal Ingestion with Lithium, throazine, atenolol:
Patient was initially taken to an outside hospital emergency
department, where she receieved activated charcoal and
Polyethylene Glycol. She was then transferred to [**Hospital1 18**] for
consideration for hemodialysis given patient's lithium overdose.
Patient was evaluated in the emergency department and then
admitted to the medical ICU. Toxicology and nephrology were
consulted and the medical team monitored patient closely for
signs and symptoms of drug toxicity. Over the course in the
medical ICU, lithium level in patient's blood decreased from a
supratherapeutic level of 3.3 to a therapeutic level of 1.2.
Patient continued to show no signs or symptoms of medication
toxicity evident on physical exam, vital signs, and EKG. After
stabilization, patient was transferred to a regular inpatient
medicine floor, where she continued to be asymptomatic and
medically stable. She was monitored with 1:1 sitter for
suicidality. She was transferred to inpatient psychiatry.
# Transitional Issues:
1) Psychiatric evaluation
2) Restart psychiatric medications
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy.
1. guanFACINE *NF* 1 mg Oral at noon
2. ChlorproMAZINE 50 mg PO QAM
3. ChlorproMAZINE 100 mg PO QHS
4. Lithium Carbonate 600 mg PO BID
5. Atenolol 25 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH QHS
7. Clonazepam 0.25 mg PO BID
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
2. ChlorproMAZINE 50 mg PO QAM:PRN agitation
3. ChlorproMAZINE 100 mg PO QHS:PRN agitation
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1) Lithium overdose
2) Thorazine overdose
3) Atenolol overdose
.
SECONDARY DIAGNOSES:
1) Asthma
2) Anxiety NOS
Discharge Condition:
Alert and oriented to time, place, person.
Independently ambulatory.
Stable and asymptomatic.
Discharge Instructions:
You were admitted to the hospital after ingesting excessive
doses of lithium, thorazine, and atenolol. Before you arrived
at [**Hospital1 18**], you receieved activated charcoal and GoLYTELY at
another hospital emergency room. Then, you were transferred to
[**Hospital1 18**] where you were evaluated in the emergency department and
then admitted to the medical ICU. While you were in the medical
ICU, specialists from toxicology and nephrology were consulted
and the medical team monitored you closely for signs and
symptoms of drug toxicity. Over the course in the medical ICU,
lithium level in your blood decreased to therapeutic level and
you continued to show no signs or symptoms of medication
toxicity. Afterwards, you were transferred to a regular
inpatient medicine floor, where you continued to be asymptomatic
and medically stable. Your home medications including
guanfacine, lithium, clonazepam, atenolol, oral contraceptive
pills were held. Per psychiatry team's recommendation, we
started you on thorazine again.
.
MEDICATION CHANGES:
STOP Guanfacine
STOP Buspirone
STOP Lithium
STOP Clonazepam
STOP Atenolol
STOP OCP (Ortho-Novum 7/7/7)
Followup Instructions:
Please follow up with your primary care physician within one
week of going home after psychiatric evaluation and treatment.
|
[
"296.80",
"969.1",
"309.81",
"493.90",
"E950.3",
"E950.4",
"969.8",
"971.3",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6942, 7012
|
5129, 6299
|
354, 361
|
7186, 7282
|
3932, 3932
|
8487, 8614
|
2583, 2626
|
6778, 6919
|
7033, 7117
|
6410, 6755
|
7306, 8340
|
4720, 5106
|
2666, 3263
|
7138, 7165
|
1880, 2216
|
8360, 8464
|
264, 316
|
389, 1861
|
3948, 4704
|
6322, 6384
|
2238, 2276
|
2292, 2567
|
3288, 3913
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,506
| 117,108
|
41083
|
Discharge summary
|
report
|
Admission Date: [**2178-2-20**] Discharge Date: [**2178-2-22**]
Date of Birth: [**2141-7-4**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
fall, headache after fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
36M with history of one seizure last year who per report had a
seizure
and fell from standing height. No LOC, but immediately had a
headache after fall. No changes in vision. No nausea/vomiting.
Pain was initially worse behind right ear and now is global.
Past Medical History:
one seizure last year
status post gastric bypass 5 years ago
psychiatric mood disorder
Social History:
SOCIAL HISTORY: He lives with his girlfriend and works in snow
removing/masonry. He completed high school education. He smokes
[**5-26**] cigarettes per day and has done so for 4 years.
Occasionally
drinks alcohol. He does not own a vehicle but he does seldomly
drive.
Family History:
FAMILY HISTORY: His half-brother used to have epilepsy as a
child
but now seizure-free. His father is alive and healthy. His
mother
passed away due to occupational lung disease; she had a history
of diabetes.
Physical Exam:
On the day of admission [**2178-2-20**]
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Gross blood in right ear canal.
Pupils: 3mm, bilaterally reactive
EOMs: intact
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, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-19**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-21**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On the day of discharge:
Neurologically intact
Pertinent Results:
[**2178-2-20**] 03:15PM GLUCOSE-102* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
[**2178-2-20**] 03:15PM estGFR-Using this
[**2178-2-20**] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2178-2-20**] 03:15PM WBC-8.7 RBC-4.96 HGB-13.5* HCT-41.4 MCV-84
MCH-27.2 MCHC-32.5 RDW-15.6*
[**2178-2-20**] 03:15PM NEUTS-81.1* LYMPHS-15.3* MONOS-2.4 EOS-0.9
BASOS-0.4
[**2178-2-20**] 03:15PM PLT COUNT-164
[**2178-2-20**] 03:15PM PT-11.9 PTT-22.1 INR(PT)-1.0
[**2178-2-22**] 07:55AM BLOOD WBC-4.9 RBC-4.19* Hgb-11.3* Hct-34.8*
MCV-83 MCH-27.1 MCHC-32.6 RDW-15.7* Plt Ct-150
[**2178-2-22**] 07:55AM BLOOD Plt Ct-150
[**2178-2-22**] 07:55AM BLOOD PT-12.0 PTT-22.7 INR(PT)-1.0
[**2178-2-22**] 07:55AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-139 K-4.0
Cl-106 HCO3-26 AnGap-11
[**2178-2-22**] 07:55AM BLOOD ALT-11 AST-14 LD(LDH)-122 AlkPhos-53
TotBili-0.3
[**2178-2-22**] 07:55AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.8 Mg-2.0
[**2178-2-22**] 07:55AM BLOOD Phenyto-3.8*
CT HEAD W/O CONTRAST Study Date of [**2178-2-22**] 12:45 PM
COMPARISON: CTA of the head from [**2178-2-20**].
FINDINGS:
Since [**2178-2-20**] there has been slight interval decrease
of size and
density of the thin left subdural hematoma, layering along the
left
frontotemporal convexity. No acute intracranial hemorrhage, mass
effect, or large acute territorial infarction is seen. The
ventricles and sulci are normal in size and configuration. The
[**Doctor Last Name 352**]-white matter differentiation is well preserved. The
extensive longitudinal fracture of the right temporal bone,
involving that middle ear cavity and carotid canal, and exiting
at the right sphenoid air cell, is better-demonstrated on the
thin-section CTA of [**2178-2-20**]; there are persistent layering blood
products in the right sphenoid air cell.
IMPRESSION:
Significant interval decrease in size and density of the left
subdural
hematoma, NOTE ADDED IN ATTENDING REVIEW: The thin left-sided
subdural hematoma is now poorly-seen, likely due to interval
resorption/redistribution. No new hemorrhage is demonstrated.
CTA HEAD W&W/O C & RECONS Study Date of [**2178-2-20**] 4:43 PM
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3239**] EU [**2178-2-20**] 4:43 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
FINDINGS: HEAD CT:
Comparison was made with the previous outside CT of [**2178-2-20**].
There is a
small subdural hematoma seen in the left frontal and temporal
region. No
fracture seen in this region. There is no mass effect, midline
shift, or
hydrocephalus. No intraparenchymal hematoma or subarachnoid
hemorrhage seen. Bone images demonstrate fracture in the right
parietal region extending to squamous temporal bone and to the
mastoid and petrous temporal region. There is a longitudinal
fracture of the right petrous temporal bone extending through
the skull base and involving portion of the carotid canal and
extending to the right side of the sphenoid sinus with a small
fluid level in the right sphenoid sinus. There are soft tissue
changes likely secondary to blood seen in the external auditory
canal as well as in the middle ear. The ossicles appear intact
without displacement. However, a detailed CT of the temporal
bone can help for further assessment.
CT CERVICAL SPINE:
The cervical spine CT demonstrate no fracture or subluxation.
There is no
evidence of prevertebral soft tissue abnormality. CT ANGIOGRAPHY
OF THE NECK: CT angiography of the neck demonstrates no evidence
of vascular injury or dissection. No stenosis or occlusion seen.
Postoperative changes are seen in the right clavicle.
CT ANGIOGRAPHY HEAD:
CT angiography of the head and skull base demonstrate no
evidence of vascular injury or dissection. The arteries of the
anterior and posterior circulation are well maintained without
stenosis or occlusion.
IMPRESSION:
1. Head CT demonstrates longitudinal fracture of the right
temporal bone
extending to the carotid canal and right side of the sphenoid
sinus with a
blood fluid level in the right sphenoid sinus. Small left-sided
subdural
hematoma is seen.
2. No cervical spine fracture identified.
3. CT angiography of the neck demonstrate no evidence of
vascular injury in the neck. Postoperative changes are seen in
relation with the right clavicle.
4. CT angiography of the head demonstrate no evidence of
vascular injury in relation with the right carotid artery. In
particular, no dissection or
stenosis seen or occlusion identified in the arteries of
anterior and
posterior circulation. The study and the report were reviewed by
the staff radiologist.
Brief Hospital Course:
This is a 36 year old male with history of one seizure last
year who per reports that he had a seizure and fell from
standing height on [**2178-2-20**]. The patient denied loss of
consciousness, but immediately had a headache after fall. The
head Ct was consistent with significant interval decrease in
size and density of the left subdural hematoma and extensive
longitudinal fracture of the right temporal bone, involving that
middle ear cavity and carotid canal, and exiting at the right
sphenoid air cell. The patient was admitted for 24 hrs
observation to neurosurgery ICU. Seizure prophylaxis was
intitated with a dilantin load and Dilantin 100mg TID was
started. The neurological exam was intact but there was a
possible csf leak noted from the right ear.
On [**2178-2-21**], ENT was consulted and the recommendations included to
initiate CSF leak precautions (HOB elevation, stool softeners,
sneeze with mouth open, no nose blowing).There was no need for
systemic antibiotics. (Start floxin otic / decadron ophthalmic
drops: 4gtt / 2gtt AD/AS TID x 10 days.).instructions to keep
ear dry until follow up (Cotton ball in ear, then vaseline
smeared over ear and cotton when washing hair).with instructions
for the patient to call [**Telephone/Fax (1) 41**] to schedule audiogram and
follow-up ENTappointment. The patient's neurological exam
continued to be intact and the patient was transfered to the
floor.
Neurology was consulted and recommended a urine analysis which
was negative, urine toxicity screen which was positive for
opiates and barbituates,chest xray,LFTs which were within normal
limits,routine EEG as an outpatient with outpatient follow-up
with Epilepsy Dept. and no driving for 6 months as per Mass.
law.
On [**2178-2-22**], the patient was neurologically intact. He was
changed from Dilantin to keppra for seizure prophylaxis.The
patient was able to tolerate a regular diet and was ambulating
independedntly.
Medications on Admission:
none
Discharge Medications:
1. ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic QID (4
times a day).
Disp:*1 * Refills:*0*
2. dexamethasone 0.1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
Disp:*1 * Refills:*0*
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-18**]
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*40 Tablet(s)* Refills:*0*
4. oxycodone 20 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:*0*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: do not drive while on this medication .
Disp:*60 Tablet(s)* Refills:*0*
6. levetiracetam 500 mg Tablet Sig: as directed PO DAILY
(Daily): 500 mg PO/NG DAILY Duration: 5 Days
then 500 mg po bid x 5 days, then 1000mg am/500mg PM x 5days,
then 1000mg po bid
.
Disp:*150 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
Subdural hematoma
conductive hearing loss / right ear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
Per Mass. law, you are not allowed to drive for 6 months
following
a seizure.
?????? 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.
***** You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
You do NOT need to be seen in the neurosurgery clinic as you
will be seen in the [**Hospital 878**] clinic. If they have concerns
from a surgical standpoint they will direct you to see us in the
clinic. If you have any questions for Dr. [**First Name (STitle) **] or need
tocontact us - our phone number is [**Telephone/Fax (1) 1669**]
The Neurology team would like to see you in the [**Hospital 875**] clinic
in 2 weeks at [**Telephone/Fax (1) **] / please call their office for an
appointment - you will also need a PROLONGED EEG WITH
SPHENOIDALS
While in the hospital you were seen the the ENT service for the
fluid draining from your right ear. They are requesting that
you be seen in their clinic in one month at ([**Telephone/Fax (1) 6213**]
You will also need to schedule an out patient hearing test.
This can be scheduled when you call their office.
Completed by:[**2178-2-22**]
|
[
"801.21",
"388.61",
"345.10",
"E885.9",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10410, 10416
|
7474, 9417
|
332, 339
|
10522, 10522
|
2770, 5161
|
11824, 12755
|
1056, 1251
|
9472, 10387
|
10437, 10501
|
9443, 9449
|
10673, 11801
|
1321, 1554
|
266, 294
|
367, 625
|
1847, 2751
|
5170, 7451
|
10537, 10649
|
647, 736
|
769, 1024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,317
| 126,656
|
28468
|
Discharge summary
|
report
|
Admission Date: [**2123-11-27**] Discharge Date: [**2123-12-12**]
Date of Birth: [**2064-5-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Sternal wound infection
Major Surgical or Invasive Procedure:
[**2123-11-29**] Sternal Wound Debridement with VAC placement/bil. chest
tubes
History of Present Illness:
59 y/o female s/p CABGx3/MV Repair on [**2123-10-29**] transferred to
[**Hospital1 18**] d/t sternal wound infection.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3,
Mitral Regurgitation s/p Mitral Valve Repair ([**2123-10-28**]), Diabetes
Mellitus, Hypertension, Hyperlipidemia, Cholelithiasis, Anemia,
s/p Appendectomy, s/p Left Knee Replacement
Social History:
The patient works as a food service worker in a high school. She
lives with her husband. The patient quit smoking 15 years ago;
previously smoked 1ppd x 30 years. Rare alcohol use.
Family History:
No early heart disease. Father with MI in 70s. Brother with CAD
s/p at 58. History of DM, HTN.
Physical Exam:
Sedated, intubated BP 130/54 90
CTAB -w/r/r
RRR -c/r/m/g
Chest wound open in uppper-middle and lower pole of incision.
Necrotic tissue present along with small amount of purulent
drainage.
Abd soft NT/ND, +BS
Ext. warm, +pulses
Discharge
General No acute distress
Pulmonary CTA decreased at bases
Cardiac RRR, No murmur/rub/gallop
Abd Soft, nontender, nondistended, +BS
Ext warm pulses palpable
Inc: left leg EVH healed
Sternal with VAC intact changed [**12-7**]
Pertinent Results:
CXR [**11-27**]: Comparison with [**2123-10-31**]. There is interval increase in
bilateral pleural effusions. There is probably development of
underlying pulmonary vascular congestion, but the lungs are
somewhat obscured. The patient is status post median sternotomy
and CABG as before. An endotracheal tube has been inserted and
ends at the thoracic inlet. A nasogastric tube has been placed
and ends below the diaphragm, off of the bottom of the image. A
PICC line has been placed and terminates in the region of the
superior vena cava.
CXR [**12-1**]: New bibasilar opacities and associated atelectasis
with lung volume loss suggestive of either aspiration versus a
new infectious process such as pneumonia.
CT [**11-28**]/: 1. Large bilateral pleural effusions, right greater
than left with adjacent bibasilar compressive atelectasis. 2.
Small pericardial effusion. 3. Diffuse coronary artery
calcifications. 4. No evidence of sternal
osteomyelitis/parasternal fluid collections. 5. Cholelithiasis,
without evidence for cholecystitis.
ECHO [**11-29**]: Mild spontaneous echo contrast is present in the left
atrial appendage. A left atrial appendage thrombus cannot be
excluded. A left- to-right shunt across the interatrial septum
is seen at rest. A small secundum atrial septal defect is
present. There is moderate regional left ventricular systolic
dysfunction. Overall left ventricular systolic function is
moderately depressed. Resting regional wall motion abnormalities
include hypokinetic mid and apical portions of the septum,
anterior septum, inferior septum, inferior wall and anterior
wall. Right ventricular chamber size and free wall motion are
normal. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. There is moderate aortic valve
stenosis (area 0.8-1.19cm2) Trace aortic regurgitation is seen.
A mitral valve annuloplasty ring is present. No mass or
vegetation is seen on the mitral valve. Mild mitral
regurgitation is seen.
[**2123-11-27**] 09:56PM BLOOD WBC-6.2 RBC-3.96* Hgb-11.6* Hct-33.1*
MCV-84 MCH-29.2 MCHC-34.9 RDW-15.2 Plt Ct-306
[**2123-12-1**] 05:40AM BLOOD WBC-7.5 RBC-4.39 Hgb-12.6 Hct-37.5 MCV-85
MCH-28.6 MCHC-33.5 RDW-14.6 Plt Ct-298
[**2123-11-27**] 09:56PM BLOOD PT-14.5* PTT-26.8 INR(PT)-1.3*
[**2123-11-30**] 02:42AM BLOOD PT-13.7* PTT-24.8 INR(PT)-1.2*
[**2123-11-27**] 09:56PM BLOOD Glucose-130* UreaN-22* Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-23 AnGap-15
[**2123-12-1**] 05:40AM BLOOD Glucose-157* UreaN-10 Creat-0.5 Na-139
K-4.1 Cl-101 HCO3-30 AnGap-12
[**2123-12-3**] 10:50AM BLOOD WBC-7.7 Hct-39.3
[**2123-12-3**] 10:50AM BLOOD K-3.9
[**2123-11-30**] 02:42AM BLOOD ALT-46* AST-40 AlkPhos-123* Amylase-63
TotBili-0.3
[**2123-12-9**] 06:08AM BLOOD WBC-6.4 RBC-3.80* Hgb-10.9* Hct-32.7*
MCV-86 MCH-28.8 MCHC-33.4 RDW-16.0* Plt Ct-560*
[**2123-12-7**] 05:42AM BLOOD Neuts-79.4* Lymphs-10.0* Monos-4.3
Eos-6.2* Baso-0.2
[**2123-12-9**] 06:08AM BLOOD Plt Ct-560*
[**2123-12-9**] 06:08AM BLOOD UreaN-25* Creat-2.0*
[**2123-12-7**] 05:42AM BLOOD ALT-27 AST-20 AlkPhos-80 TotBili-0.3
[**2123-12-8**] 05:40AM BLOOD Calcium-8.5 Phos-4.7* Mg-2.2
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 30929**] was admitted for sternal wound
infection. She was continued on antibiotics and wound cultures
were taken. Multiple radiologic studies were performed and she
was ultimately taken to the operating room on [**11-29**] for sternal
wound debridement and bil. chest tube placement for pleural
effusions. Please see operative report for surgical details.
Following procedure she was transferred to the CSRU. VAC
dressing was placed by Plastics on this day. Infectious Disease
was consulted and antibiotics were changed to Nafcillin. Patient
was stable on post-op day one and was transferred to SDU in
stable condition. Chest tubes were removed per protocol and she
continued to receive antibiotics over the next several days. Her
creatinine rose on nafcillin, so this was discontinued and
vancomycin was started. On post op day #10 she was ready for
discharge to rehab with Vac dressing and continued IV
antibiotics for 6 weeks.She is to make her follow-up appts. with
ID and plastics as per discharge instructions. Creatinine should
be followed.
Medications on Admission:
Vanco, Ceftriaxone, Heparin, Nexium, Aspirin, Lipitor, Lasox,
Lopressor, RISS, Lantus, Propofol
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*0*
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation every six (6) hours.
Disp:*1 1* Refills:*0*
8. Outpatient [**Hospital1 **] Work
Labs: CBC with Diff, LFT, BUN/Cr, ALT/AST, vanco trough -results
to ID fax# [**Telephone/Fax (1) 1419**]
please check with 3rd dose after discharge
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
13. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Vancomycin in Normal Saline 1 g/250 mL Solution Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours): to see in [**Hospital **] clinic on
[**2124-1-11**] discontinuing .
15. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Sternal Wound Infection s/p Debridement with VAC placement/ bil.
chest tube placement for pleural effusions
PMH: Coronary Artery Disease s/p Coronary Artery Bypass Graft x
3, Mitral Regurgitation s/p Mitral Valve Repair ([**2123-10-28**]),
Diabetes Mellitus, Hypertension, Hyperlipidemia, Cholelithiasis,
Anemia, s/p Appendectomy, s/p Left Knee Replacement
Discharge Condition:
Good
Discharge Instructions:
Continue wound care with VAC dressing changes every three days -
to follow up with plastics at wound clinic on Friday [**12-17**]
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
No lifting more than 5 pounds
Please call with any questions or concerns
Followup Instructions:
Dr. [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Plastics - follow up in wound clinic on friday please call for
appointment ([**Telephone/Fax (1) 5343**])
Infectious disease - DR. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2124-1-11**] 9:30
Labs: CBC with Diff, LFT, BUN/Cr qweekly with results to ID fax#
[**Telephone/Fax (1) 1419**] first draw [**12-16**]
|
[
"518.81",
"285.9",
"998.59",
"414.00",
"272.4",
"V43.65",
"584.9",
"998.32",
"511.9",
"E930.0",
"401.9",
"574.20",
"428.0",
"787.91",
"041.11",
"250.00",
"V45.81",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"93.57",
"34.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7768, 7835
|
4801, 5898
|
299, 379
|
8235, 8241
|
1603, 4778
|
8764, 9234
|
1007, 1103
|
6044, 7745
|
7856, 8214
|
5924, 6021
|
8265, 8741
|
1118, 1584
|
236, 261
|
407, 526
|
548, 793
|
809, 991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,280
| 185,514
|
35828
|
Discharge summary
|
report
|
Admission Date: [**2122-2-4**] [**Month/Day/Year **] Date: [**2122-2-9**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male s/p fall after complaiing of 2 days of feeling dizzy.
He went to an area hospital where found to have a drop in his
hematocrit with hypotension and an INR of 15. He received FFP
and was then transferred to [**Hospital1 18**] with an illiacus hematoma.
Past Medical History:
Afib, GERD, TIA's, macular degeneration
Social History:
Married, lives with wife who he reportedly cares for
Family History:
Noncontributory
Pertinent Results:
[**2122-2-4**] 10:08PM GLUCOSE-122* UREA N-56* CREAT-1.0 SODIUM-145
POTASSIUM-2.8* CHLORIDE-109* TOTAL CO2-25 ANION GAP-14
[**2122-2-4**] 10:08PM ALT(SGPT)-13 AST(SGOT)-35 LD(LDH)-259* ALK
PHOS-121* TOT BILI-1.2
[**2122-2-4**] 10:08PM ALBUMIN-3.1* CALCIUM-7.4* PHOSPHATE-2.2*
MAGNESIUM-2.4
[**2122-2-4**] 08:05PM HCT-28.8*
[**2122-2-4**] 08:05PM PT-42.8* PTT-73.9* INR(PT)-4.7*
[**2122-2-4**] 05:11PM cTropnT-<0.01
[**2122-2-4**] 05:11PM CK(CPK)-196*
[**2122-2-4**] 05:11PM WBC-15.6* RBC-2.77* HGB-10.0* HCT-28.4*
MCV-102* MCH-36.0* MCHC-35.1* RDW-14.3
Cardiology Report ECG Study Date of [**2122-2-4**] 10:35:50 PM
Atrial fibrillation. Right bundle-branch block with left
anterior fascicular
block. Delayed precordial R wave progression. Non-specific ST
segment
abnormalities. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 0 146 398/455 0 -52 47
CHEST (PA & LAT) [**2122-2-7**]
Three radiographs of the chest again demonstrate left-sided
pleural effusion and left basilar atelectasis. There is evidence
of a small right-sided pleural effusion as well.
Cardiomediastinal contours are unchanged from [**2122-2-5**]. The
hilar contours are unremarkable.
A nodular density is again seen to project over the left mid
lung on the PA view. A second nodular density is seen along the
right infrahilar region.
Neither of these findings is well localized on the lateral view.
No
pneumothorax. Trachea is midline. Multilevel degenerative
endplate change
involves the thoracic spine.
IMPRESSION:
Persistent left-sided effusion and left basilar atelectasis.
Pneumonia is not excluded.
Nodular densities as described. Findings are not well localized
on the
lateral view. Further characterization with CT examination of
the chest is recommended.
Brief Hospital Course:
He was admitted to the Trauma Service. His INR was rechecked
upon arrival to [**Hospital1 18**] and was 4.8 (last INR [**2-6**] was 1.5). His
Coumadin and ASA were withheld. Geriatric Medicine was consulted
given his age, co-morbidities and mechanism of injury. Several
recommendations were made pertaining to his medications
including to restart ASA at a lower dose (81 mg) and Coumadin
restart should be at discretion of his PCP. [**Name10 (NameIs) **] primary care
doctor, Dr. [**Last Name (STitle) **], was contact[**Name (NI) **] regarding his admission INR and
his Coumadin being withheld. Per his records his INR has been
within therapeutic range from previous lab reports in his office
records. ASA 81 mg was started at time of [**Name (NI) **] and will
defer restart of Coumadin to PCP.
There was an incidental finding on CXR revealing a pulmonary
nodule on left middle lobe. This was discussed with patient's
primary care doctor. Patient is recommended to follow up after
[**Name (NI) **] with his PCP from rehab regarding this. A copy of the
chest xray report is being forwarded to Dr.[**Name (NI) 31668**] office.
Social work was also consulted given that patient was previously
living at home caring for his wife who is of ill mental health.
A conversation with patient's daughter took place who is now
resuming the care of his wife in the interim.
He was evaluated by Physical and Occupational therapy and is
being recommended for rehab after his acute hospital stay.
Medications on Admission:
Coumadin 7.5mg/3d-5mg/4d; Nadolol 20mg qd; Methimazole 5mg qd;
Brimonidine tartrate drops; Bimatoprost 0.03% 1 drop L
eye',Flonase, Ocuvite 1tab", Fosamax liq 70mg po qsun
[**Name (NI) **] Medications:
1. Methimazole 5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Apply to both eyes.
8. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic daily
(): Apply to left eye.
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily): Each nostril.
10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
11. Citalopram 20 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
12. Ocuvite 100-15-2-100 mg-unit-mg-mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
13. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for HR<60; SBP<110.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Location (un) **] centre,[**Location (un) **]
[**Location (un) **] Diagnosis:
s/p Fall
Illiacus hematoma
Secondary diagnosis:
Pulmonary nodule left middle lobe
[**Location (un) **] Condition:
Hemodynamically stable, hematocrit and INR stable, pain
adequately controlled.
[**Location (un) **] Instructions:
DO NOT restart Coumadin until follow up with his priamry care
doctor (Dr. [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 16827**])
Followup Instructions:
Follow up in 2 weeks for your illiacus hematoma with Dr. [**Last Name (STitle) **],
Trauma Surgery. Call [**Telephone/Fax (1) 6429**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab regarding a finding on your chest xray showing a pulmonary
nodule on your left middle lung. You will need to call for an
appointment as soon as you are discharged for further follow up
of this nodule.
Completed by:[**2122-3-9**]
|
[
"E880.9",
"V58.61",
"362.50",
"242.90",
"790.92",
"E888.9",
"959.12",
"427.31",
"276.0",
"511.9",
"E934.2",
"311",
"518.89",
"707.03",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2610, 4096
|
279, 285
|
778, 2587
|
6226, 6716
|
742, 759
|
4122, 5657
|
5794, 5822
|
231, 241
|
5911, 5991
|
5687, 5762
|
6026, 6203
|
313, 593
|
5843, 5879
|
615, 656
|
672, 726
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,438
| 192,240
|
34985
|
Discharge summary
|
report
|
Admission Date: [**2159-10-13**] Discharge Date: [**2159-10-23**]
Date of Birth: [**2112-7-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
TIPS [**2159-10-16**]
Gastric varix embolization [**2159-10-16**]
History of Present Illness:
47M with HepC cirrhosis who underwent esophageal and gastric
variceal banding on day prior to admission who, on day of
admission, had a large bout of hematemesis, and was brought to
[**Hospital 8641**] Hospital ED where his pressure was noted to be 60/20.
Hct was 26. He was given 2U of pRBCs and 2L saline. He
immediately went to endoscopy and was noted to be bleeding from
banded gastric varix and this bleeding was not able to be
stopped. Injection with Na- Morrhate was attempted but was not
successful. Patient received an additional 4U pRBCs, 2FFP, and
2L NS during endoscopy. A [**State **] tube was placed under
flouroscopy and the patient was transferred to [**Hospital1 18**] for
possible TIPS.
Past Medical History:
-HepC cirrhosis likely 2/2 blood transfusion after car accident
30 yrs ago in which he had sign liver damage. Diagnosed [**2-27**] yrs
ago. Had endoscopy on diagnosis, was started on IFN which he
took for 3 yrs PTA. S/p recent endoscopy with esophageal and
gastric variceal banding at OSH.
-Motorcycle accident in [**2137**] s/p transfusions.
Social History:
Lives in [**Location 8641**] NH with wife and 2 daughters. [**Name (NI) 1403**] as a
janitor. Has large extended family nearby. No EtOH use in
several mo, prior to this occassional EtOH use. Denies h/o
tobacco or IVDU.
Family History:
No FH of liver disease
Physical Exam:
GENERAL: intubated and sedated, [**State **] tube in place
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, tattoos on both hands, midline abdominal scar
HEENT: AT/NC, PERRLA, anicteric sclera, pale conjunctiva,supple
neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: sedated, no cyanosis clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: sedated
Discharge VS: T 97.8 BP 134/70 HR 73 RR 20 Sat 100% on RA
Pertinent Results:
Admission labs:
[**2159-10-13**] 04:14PM BLOOD WBC-3.7* RBC-3.56* Hgb-11.4* Hct-31.5*
MCV-88 MCH-31.9 MCHC-36.1* RDW-16.7* Plt Ct-27*
[**2159-10-13**] 04:14PM BLOOD PT-18.2* PTT-48.0* INR(PT)-1.7*
[**2159-10-13**] 06:13PM BLOOD Glucose-117* UreaN-17 Creat-0.7 Na-137
K-6.8* Cl-113* HCO3-21* AnGap-10
[**2159-10-13**] 06:13PM BLOOD ALT-94* AST-169* AlkPhos-34* TotBili-2.0*
[**2159-10-13**] 06:13PM BLOOD Calcium-6.6* Phos-2.8 Mg-1.3*
[**2159-10-13**] 04:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**10-21**] liver US - IMPRESSION: TIPS patent, with wall-to-wall flow
demonstrated within the TIPS and the portal veins.
Brief Hospital Course:
47M with HepC cirrhosis with iatrogenic gastric variceal bleed
s/p TIPS placed on [**10-16**].
UGIB/cirrhosis: His upper GI bleed was likely due to his recent
gastric variceal banding, as seen on OSH EGD on day of
admission, s/p TIPS [**10-16**]. He remained hemodynamically stable
after receiving 5pRBC, 4FFP, 3PLT. Patient also received
~4uPRBC and 2U FFP at outside hospital. CBCs here have been
stable. Patient was treated with an IV PPI and has received 7
days of Ceftriaxone. He also to received 5 days of Octreotide
which was stopped on [**2159-10-18**]. As per IR, the patient will need
an US of his TIPS q3 months indefinitely. On [**10-21**] he had an US
of his TIPS which showed that his TIPS was patent. He was
discharged on protonix 40 mg daily and lactulose. He will
follow up in the pretransplant clinic with Dr. [**Last Name (STitle) 497**].
Respiratory Failure: The patient was intubated for airway
protection and extubated on [**2159-10-17**] without event. His
respiratory status improved as he was diuresed and he was
satting normally on room air by discharge.
Micro: The patient was treated with Ceftriaxone for his variceal
bleed. He was also transiently treated with Vanc while his
A-line grew out Staph epi. As per pathology, the patient had
received a contaminated platelet product on [**10-13**] and a patient
at another hospital had a GPC (unspeciated) bacteremia from the
same sample of contaminated platelets. Surveillance cultures
were sent to assess for bacteremia, but he continued to have no
signs of infection.
Possible line infection: The patient was found to have gram +
cocci from BCx taken from his central line on [**10-21**]. He had no
fevers or clinical signs of infection. His line was pulled and
the tip sent for culutre which showed no significant growth.
This speciated to be coag-neg strep, so it was thought to be a
cotaminant and not a true line infection. All other blood
cultures were no growth or no growth to date. Prior to
discharge the patient was told that if he developed warning
signs including fever, chills, or pain at the site of his
previous line that he should come to the emergency room.
Medications on Admission:
(pt is unsure of dosages)
Nadolol
INF SC Q week
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for confusion.
Disp:*1 500mL* Refills:*3*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: take 30 minutes
prior to first meal of the day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Gastric Varix Bleed
Hepatitis C Cirrhosis
Discharge Condition:
Stable, ambulatory
Discharge Instructions:
You were admitted with a significant upper gastrointestinal
bleed from a gastric varix. A TIPS procedure was performed to
reduce the pressure flowing through the varices. You were
transferred out of the MICU and continued to do well on the
floor.
.
Please be sure to make all of your follow up appointments.
.
One of the side effects to watch for is increasing confusion.
With liver disease, any disruption to the system, including new
bleeding, infection or kidney disease can first manifest as
confusion. You should administer lactulose (the only side effect
of which is diarrhea) which helps with confusion and you can
start with administering 30-45mL three to four times a day,
titrating to 3 bowel movements per day. Also, at the first sign
of confusion, please call the Liver Center at ([**Telephone/Fax (1) 1582**] and
ask to speak to Dr. [**Last Name (STitle) 497**].
.
If you experience fevers or chills at home, or any other
symptoms that are concerning to you, please return to the
hospital.
Followup Instructions:
Right Upper Quadrant Ultrasound with dopplers every 3 months
(next due in [**2159-12-27**])
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2159-11-12**] 1:00pm
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2159-10-23**]
|
[
"456.8",
"571.5",
"070.54",
"998.11",
"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"44.44",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
5675, 5730
|
3038, 5212
|
321, 389
|
5816, 5837
|
2357, 2357
|
6888, 7289
|
1746, 1770
|
5310, 5652
|
5751, 5795
|
5238, 5287
|
5861, 6865
|
1785, 2338
|
277, 283
|
417, 1128
|
2373, 3015
|
1150, 1494
|
1510, 1730
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,232
| 141,775
|
10283
|
Discharge summary
|
report
|
Admission Date: [**2154-5-22**] Discharge Date: [**2154-5-25**]
Date of Birth: [**2098-9-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ([**2154-5-22**])
History of Present Illness:
Pt is 55 yo f with chronic constipation, who presented to [**Hospital 26580**]
Hospital on [**5-18**] with sudden onset epigastric pain radiating to
back and chest. Pt also had nausea at that time. She had CTA
chest which was negative for PE. She was ruled out for MI. She
had an elevated Alk Phos, LDH, ALT, and AST, and underwent an
abdominal CT which showed duct dilation of 13mm. Pt also had
MRCP, which showed duct size up to 16mm with nonobstructing
multiple common bile duct stones. Pt underwent ERCP
w/sphincterotomy last PM, and upon returning to the floor had
new [**11-13**] sub-sternal chest pressure (also felt in her back).
She was given pain medications, and started on a nitro gtt. Trop
I rose to 2.2. CT reportedly was done and ruled out PE. She says
the pain has been constant since last PM. She was transferred to
[**Hospital1 18**] for further evaluate of her chest pain early this morning.
.
Upon arrival to the floor pt had SBP in 100's, however she then
had SBP in 80's. Nitro gtt was turned off, and pt was given
500cc NS bolus. SBP increased to 100's. She initially denied
CP/SOB, however shortly after nitro gtt was turned off, pt c/o
[**8-13**] crushing sub-sternal CP. A stat echo was performed which
showed anteroseptal WMA. Her cardiac enzymes returned postive;
she was started on IV heparin given ASA 325mg and Plavix 600mg
x1, and then taken to the cath lab. On initial visualization of
her coronaries, no coronary abnormality was noted, but a focal
anterobasal dyskinetic focal area. After repeated CP in the
holding area, review of the cath films showed a possible kink in
the diagonal branch. She was taken back to the cath lab which
showed a widely patent diagonal with no significant stenosis,
but again demonstrated the focal wall motion abnormality.
.
On arrival to the CCU, patient still c/o of [**11-13**] abd pain, but
denied any chest pain, shortness of breath, difficulty
breathing, pruritis, nausea or vomiting. She denied any
palpitations. She was given 1mg of Ativan, 1 mg of dilaudid and
her pain decreased.
Past Medical History:
1)neuropathy s/p MVA
2)s/p lap chole in [**2150**]
3)s/p abdominal hysterectomy
4)chronic constipation
5)rectocele
6)s/p knee and back surgery
7)s/p colon polypectomy
8)s/p breast biopsy
9)tubal sterilization
10)cholecystitis s/p recent ERCP [**5-21**]
Social History:
significant for the absence of current tobacco use. There is no
history of alcohol abuse. Lives with husband of 7 years.
Family History:
Father died of MI at age 57. Mother died from complications of
cardiac cath.
Physical Exam:
VS: T 98.0 BP 143/85 HR 72 RR 16 O2 99% 2L
Gen: WDWN middle aged female, initially agitated and thrashing
around in pain. Appeared more comfortable with pain medications.
Oriented x1-2.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly.
Abd: Soft, nd, +BS. Epigastric region and periumbilical region
mildly tender to palpation, no rebound or involuntary guarding.
No HSM. Abd aorta not enlarged by palpation. No abdominial
bruits. R groin with bandaged groin.
Ext: No c/c/e. No femoral bruits.
Skin: Mildly diffuse maculopapular rash across trunk and back.
.
Pertinent Results:
Cardiac Cath [**2154-5-22**]:
1. Coronary angiography of this right dominant system
demonstrated no
angiographically apparent flow-limiting coronary artery disease.
There
was one view that suggested a focal kink in the proximal
diagonal artery
that would match the focal anterobasal wall motion abnormality.
However, on repeat views, the diagonal artery appeared widely
patent.
Possibilities for her myocardial abnormalities include coronary
vasospasm, intermittent kinking of the diagonal vessel,
intermittent
small thrombus, and focal myocarditis.
2. Limited resting hemodynamics revealed elevated left sided
filling
pressure with a LVEDP of 23 mmHg. Systemic arterial pressure
was
high-normal with a BP of 139/84 mmHg. There was no transaortic
valve
gradient on pullback of the catheter from the LV to the aorta.
3. Left ventriculography demonstrated no mitral regurgitation.
The
calculated LVEF was 56% with a focal anterobasal dyskinetic
region.
.
Thin Barium Swallow:
IMPRESSION: No evidence of esophageal rupture on this limited
study. Patient could not stand upright and mobility was limited
for oblique views. Optimal luminal distention was not
established. Study had to be terminated early due to new onset
arrythmias.
.
TTE [**5-24**]:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is low normal (LVEF 50%) secondary
to focal hypokinesis of the midventricular segment of the
anterior free wall and lateral wall. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated athe
sinus level. The ascending aorta is mildly dilated. The aortic
arch is mildly dilated. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are mildly
thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2154-5-22**], the overall ejection fraction is increased due
to less extensive hypokinesis of the anterior free wall. A
bicuspid aortic valve is now recognized (mild aortic stenosis).
.
CT abd/pelvis [**5-24**]:
1. Status post ERCP, with biliary stent in place. Mild
pneumobilia is expected post-ERCP finding. Mildly dilated common
bile duct.
2. Normally enhancing pancreas, without evidence of
peripancreatic fat stranding, fluid collection or pseudocyst.
3. Two noncalcified 4-mm pulmonary nodules. In the absence of
any known malignancy or risk factors such as smoking, no
followup is necessary. If there are known risk factors, a
12-month followup chest CT is recommended.
Brief Hospital Course:
55 yo f with fam hx of CAD, who presented with crushing SSCP s/p
ERCP with new anteroseptal WMA with normal coronary anatomy and
possible kinked Diagonal vessel.
.
1. CAD:
No previous history of CAD with episode of SSCP s/p ERCP. Now
with new anteroseptal WMA, normal EKG but biomarkers c/w NSTEMI,
and normal cath without evidence of coronary disease or
thrombosis except for possible kinked diagonal vessel. This
likely represented a stress related cardiomyopathy (similar to
Takatsubo's) that may resolve on repeat TTE in several weeks
time. Given the lack of CAD seen on cardiac cath, no change in
her medication regimen was made at this time. Pt was discharged
to follow up with her PCP as needed.
2. [**Name (NI) **]
Pt with a mildly diminshed EF of 50% with a new anterobasal
hypokinetic area which is thought to correlate with her stress
related NSTEMI. This may resolve with time, and patient was
advised to have a repeat TTE in [**4-7**] weeks' time after discharge.
An appointment was requested to follow up our cardiologist, Dr.
[**Last Name (STitle) **] in 8 weeks time to follow up on resolution of this
WMA.
.
3. Valves
A new bicuspid aortic valve was found during this admission with
a mild aortic valve stenosis. She was advised to use antibiotic
prophylaxsis during dental procedures (given scrip for
azithromycin given her ? PCN allergy).
.
4. Choledocholithiasis s/p ERCP c/b mild pancreatitis:
She was transferred to [**Hospital1 18**] after her ERCP with sphincterotomy
and biliary stent placement. Apparent difficult procedure likely
led to post-ERCP mild pancreatitis (lipase 125 -> 87 --> 27) as
well as abdominal pain from sphincter manipulation. Epigastric
pain likely all due to manipulation of sphincter as this
resolved completely during her hospitalization. A follow up CT
abd/pelvis was obtained during this admission which showed
resolution of CBD dilatation and no residual stones.
Ciprofloxacin was continue for post-ERCP ppx although this had
to be discontinued due to a possible allergy leading a diffuse
maculopapular rash. She was advised to follow up with the
physician who performed the ERCP to have her biliary stent
removed in 4 weeks time. Pt was pain free and tolerating
regular diet at time of discharge.
.
5. Chronic Pain:
She was continued on her chronic MS contin 30 [**Hospital1 **] and lyrica for
her chronic pain. She was to follow up with her PCP regarding
further issues.
.
DISPO: She is to follow up with her PCP as well as her GI
physician to have her biliary stent removed in 4 weeks time.
Please follow up with Dr. [**Last Name (STitle) **] from cardiology in 8 weeks
time (after obtaining a follow up TTE).
Medications on Admission:
Lyrica 50mg [**Hospital1 **]
MVI
morphine sulfate 30mg [**Hospital1 **] prn
Levsin (Hyoscyamine) 0.125mg [**Hospital1 **]
Discharge Medications:
1. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual [**Hospital1 **] (2 times a day).
2. Benadryl 25 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for itching.
Disp:*30 Tablet(s)* Refills:*0*
3. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical TID:PRN as needed for itching.
Disp:*1 large tube* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Lyrica 150 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once as
needed for antibiotic prophylaxis prior to dental procedure:
Take 1 hour prior to dental procedure.
Disp:*5 Tablet(s)* Refills:*0*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once as needed for chest pain: Take 1 tablet every 5
minutes as needed for chest pain, maximum 3 tablets.
Disp:*30 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Post ERCP pancreatitis
Hypotension, resolved
Probable coronary artery vasospasm
Bicuspid aortic valve with mild aortic stenosis
Discharge Condition:
Stable condition, normotensive, eating full diet.
Discharge Instructions:
We believe that you probably had spasm of one of your coronary
arteries, resulting in chest pain and slightly depressed heart
function. We believe that this will improve over time, and
recommend a repeat echocardiogram in [**7-12**] weeks to assess
interval change.
While in the hospital, you were given a medication called
Ciprofloxacin following placement of a biliary stent. You
subsequently developed a rash, and we believe that Ciprofloxacin
may have been the culprit. We have added this medication to your
list of allergies. It may take several weeks for the rash to
resolve.
Please note that you were also found to have a bicuspid aortic
valve (2 leaflets instead of 3). Because of this condition, we
recommend that you take antibiotic prophylaxis prior to any
dental procedure to prevent infection of the heart valve. We
have prescribed Azithromycin, 500 mg by mouth 1 hour before
procedure. You should also talk to your doctor prior to any
other procedure to see if you need antibiotics.
Please return to the ED or call your PCP if you develop fever or
chills, worsening abdominal pain, or chest pain or shortness of
breath.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (cardiology) in [**7-12**] weeks.
Please call his office at ([**Telephone/Fax (1) 5862**].
Please follow-up at [**Hospital3 3583**] with the physician that
performed your ERCP. You will need the biliary stent removed in
several weeks.
Please follow-up with your primary care doctor, Dr. [**First Name (STitle) 5656**], this
week to discuss your hospital admission.
Previously scheduled appointments:
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-7-30**] 10:10
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-7-30**] 10:30
Completed by:[**2154-5-25**]
|
[
"424.1",
"413.1",
"E930.8",
"693.0",
"746.4",
"458.9",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.53",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10876, 10882
|
6928, 9606
|
298, 342
|
11054, 11106
|
3901, 6905
|
12291, 13053
|
2862, 2940
|
9780, 10853
|
10903, 11033
|
9633, 9757
|
11130, 12268
|
2956, 3882
|
248, 260
|
371, 2430
|
2453, 2708
|
2724, 2846
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,998
| 162,050
|
32862
|
Discharge summary
|
report
|
Admission Date: [**2133-3-2**] Discharge Date: [**2133-3-26**]
Date of Birth: [**2076-3-6**] Sex: M
Service: NEUROLOGY
Allergies:
Latex
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Hemorrhage
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
56 yo with unknown medical history was found down and presented
to [**Hospital **] Hospital. At around 4pm today, the notes say that he
went to the car to "de-stress" and collapsed next to the car.
EMS was called and he presented to [**Hospital1 **] (EMS note not
available). At [**Hospital1 **], his SBP was in the 200s and blood
glucose 44. He was noted to have slurred speech, flaccid on the
left side, eyes deviated to the right, right mouth droop, left
neglect, and not following commands. A head CT was done, which
showed a right basal ganglia bleed 5.6 x 2.2 cm with edema and
midline shift. He was intubated (unclear if deteriorated for
because of CT findings) and sedated with Feantanyl 50 mcg,
Versed 6mg, Ativan 2mg, Vec 10mg, Succ 100, and Etomidate 20mg.
He was also loaded with Dilantin 1gm. He was then transferred
to [**Hospital1 18**] ED.
Since arrival, he has had repeat imaging, which shows that the
hemorrhage is a little larger at 6.2 x 2.6cm. His SBP has been
in the 130s. He remains intubated and sedated on Propofol.
Past Medical History:
Unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
Vitals: AF HR 72 BP 135/79 RR 14 100% on vent
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, ND, +NABS.
Extrem: Warm and well-perfused. No C/C/E.
Neuro : Off Propofol, he is not following commands. Pupils are
2mm and reactive bilaterally, eyes midline, unable to perform
OCR due to cervical collar, facial movements appear relatively
symmetrical (difficult to tell due to tape and ET tube in
place), intact gag, intact cough. With painful stimulation, he
has posturing of the left arm (stereotyped movement with
extension and internal rotation), purposeful movement of left
lower extremity, right upper extremity, and right lower
extremity. There are more spontaneous movements of his right
lower extremity compared to the left. Reflexes are [**3-9**] and
symmetric. Right toe down, left toe up.
Pertinent Results:
[**2133-3-2**] 06:55PM BLOOD WBC-10.1 RBC-5.46 Hgb-17.1 Hct-46.8
MCV-86 MCH-31.3 MCHC-36.5* RDW-13.8 Plt Ct-185
[**2133-3-4**] 02:08AM BLOOD WBC-5.8 RBC-4.60 Hgb-14.3 Hct-39.4*
MCV-86 MCH-31.0 MCHC-36.2* RDW-14.0 Plt Ct-135*
[**2133-3-6**] 03:54AM BLOOD WBC-5.9 RBC-4.33* Hgb-13.3* Hct-37.9*
MCV-87 MCH-30.7 MCHC-35.1* RDW-13.7 Plt Ct-130*
[**2133-3-3**] 11:17AM BLOOD PT-15.1* PTT-29.1 INR(PT)-1.3*
[**2133-3-5**] 03:57AM BLOOD PT-14.1* PTT-30.6 INR(PT)-1.2*
[**2133-3-2**] 06:55PM BLOOD Fibrino-322
[**2133-3-2**] 06:55PM BLOOD Glucose-108* Na-142 K-3.6 Cl-103 HCO3-28
AnGap-15
[**2133-3-6**] 03:54AM BLOOD Glucose-110* UreaN-21* Creat-0.8 Na-141
K-3.7 Cl-107 HCO3-31 AnGap-7*
[**2133-3-3**] 11:17AM BLOOD ALT-46* AST-35 LD(LDH)-214 CK(CPK)-131
AlkPhos-43 TotBili-1.2
[**2133-3-3**] 11:17AM BLOOD CK-MB-5 cTropnT-<0.01
[**2133-3-2**] 06:55PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
[**2133-3-3**] 11:17AM BLOOD %HbA1c-4.8
[**2133-3-3**] 11:17AM BLOOD Triglyc-110 HDL-34 CHOL/HD-4.4 LDLcalc-95
[**2133-3-4**] 08:58AM BLOOD TSH-0.18*
[**2133-3-5**] 12:21PM BLOOD T4-5.1 T3-53* Free T4-0.77*
[**2133-3-3**] 04:29AM BLOOD Phenyto-7.6*
[**2133-3-6**] 03:54AM BLOOD Phenyto-14.8
[**2133-3-2**] 06:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-3-21**] 03:00PM BLOOD WBC-10.2 RBC-4.80 Hgb-14.8 Hct-40.2
MCV-84 MCH-30.8 MCHC-36.8* RDW-13.3 Plt Ct-188
[**2133-3-17**] 05:00AM BLOOD Glucose-109* UreaN-38* Creat-0.9 Na-141
K-4.2 Cl-105 HCO3-27 AnGap-13
[**2133-3-3**] 11:17AM BLOOD %HbA1c-4.8
[**2133-3-3**] 11:17AM BLOOD Albumin-3.6 Cholest-151
[**2133-3-3**] 11:17AM BLOOD Triglyc-110 HDL-34 CHOL/HD-4.4 LDLcalc-95
[**2133-3-6**] 08:45PM BLOOD FSH-<1.0* LH-<1.0* TSH-0.75
[**2133-3-6**] 08:45PM BLOOD T4-5.7 T3-68* calcTBG-1.16 TUptake-0.86
T4Index-4.9
[**2133-3-17**] 05:10PM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.024
[**2133-3-17**] 05:10PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2133-3-17**] 05:10PM URINE RBC->1000 WBC-[**7-14**]* Bacteri-MANY
Yeast-FEW Epi-0
Renal Ultrasound:[**2133-3-9**]
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for renal artery stenosis.
2. Normal-sized kidneys. 5 cm septated right upper pole cyst,
and 1.2-cm left interpolar cystic lesion with minimal internal
echogenicity, six-month followup study is advised to document
stability.
CT Torso:
1. No evidence of acute bony or soft organ injury.
2. Multifocal consolidation within the lungs, atypical in
appearance for aspiration, and most likely representing
aspiration, though other pneumonia cannot be excluded.
3. Possible bladder wall thickening.
CT Head [**3-2**]:
1. Large right lenticular nucleus intraparenchymal hemorrhage
with slight surrounding edema, slightly larger since the recent
OSH study; the findings suggest an underlying hypertensive
etiology. If more detailed evaluation is needed, recommend
scanning the outside study into PACS for side-by-side
comparison.
2. Slight effacement of the right lateral ventricular atrium and
occipital [**Doctor Last Name 534**] and leftward shift of the midline structures, by
approximately 3 mm.
CT/CTA [**3-4**]:
1. Right basal ganglia hemorrhage which is not significantly
changed compared to the prior CT of [**2133-3-3**].
2. CT angiography demonstrates no evidence of aneurysm or
abnormal vascular structures or evidence of stenosis or
occlusion.
CT [**2133-3-20**]:
IMPRESSION: Decrease in the amount of hyperdense blood with
persistent surrounding edema and mass effect consistent with
evolving hemorrhage. No new intraparenchymal hemorrhage
identified.
Cardiac ECHO [**2133-3-6**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
moderately dilated. Moderate (2+) aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate aortic regurgitation. Dilated thoracic aorta.
Brief Hospital Course:
Mr. [**Known lastname 14611**] was admitted to the ICU for further manegement. His
hospital course by problem is as follows:
1) R Basal Ganglia bleed:Felt to be due to untreated
hypertension.
Mr. [**Known lastname 14611**] remained very hypertensive during his initial course,
and he was treated with IV antihypertensives. The patient was
transitioned to PO blood pressure medications including
hydrochlorothiazide, metoprolol and lisinopril. A CTA was done
to look for an underlying AVM or aneurysm as he could not get an
MRI. This study showed no vascular anomaly. His other secondary
stroke risk factors including LDL and A1c were checked and were
WNL. It was felt that the mechanism for his bleed was likely
hypertensive. He was gradually started on standing metoprolol
which was titrated. He was also treated with Mannitol to reduce
the intracerebral edema. This was tapered on day #4. He was also
treated with thiamine. He was ruled out for an MI with CE on
admission and a TTE was done which showed LVH.
He was initially started on dilantin. This was stopped, however
several days into his course, he was noted to have shaking
movements. He was therefore restarted on Dilantin and then
transitioned to Keppra for relative thrombocytopenia. The
certainty that his abnormal movements were seizures was brought
into question after his EEG (see below). The patient is
currently involved in a keppra taper.
He remained very drowsy for much of his [**Hospital **] hospital course.
An EEG was done to r/o subclinical status epilepticus. The EEG
did not show any seizure like activity. He was montiored and
Thyroid studies were done as well. Finally over 10 days into his
course, he finally started to follow simple commands. He was
extubated a few days later. Two days prior to discharge the
patient began to speak. He subsequently passed a speech and
swallow evaluation for ground solids and nectar thickened
liquids.
2) Hypothyroidism:
Given his hypertension, a TSH was checked which was low. His FT4
and T3 were also low. An endocrinology consult was called. They
did not feel that his mildly low thyroid function could explain
his altered mental status, and as stated above he was speaking
and much more alert prior to discharge.
3) PNA:
On admission, he was found to have aspiration on his CT chest.
He then developed fevers and was empirically started on vanco
and zosyn for PNA. He was then stopped as his WBC was normal but
he had persistent spiking fevers. He was recultured multiple
times and finally grew ecoli from his sputum. He was therefore
started on bactrim for a 7 day course. bactrim d/c'd by arrival
to floor. pt afebrile with normalized WBC by arrival to floor.
4) UTI:
The patient also had a 7 day course of ceftriaxone for a UTI.
Medications on Admission:
Omega 3 (per OSH records)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 doses.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right Basal Ganglia Hemorrhage.
Hypertension
Thrush
Discharge Condition:
Vital signs are stable. The patient speaks rarely, but in
complete sentences and his topics are appropriate to his
situation. He has a left sided facial droop. He has a right
gaze preferance. Left hemiparesis. Passed speech and swallow.
Discharge Instructions:
Please take your medication as prescribed.
Please follow up with your appointments as documented below.
Please return to the hospital if you have any concerning
symptoms. These include, but are not limited to, difficulty
moving your limbs beyond your deficits at this time and
difficulty with speech.
Blood pressure should be monitored and maintained <135/80.
Followup Instructions:
Please make a follow up appointment with your primary care
doctor.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2133-5-12**] 11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2133-3-26**]
|
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"518.81",
"244.9",
"707.03",
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] |
icd9cm
|
[
[
[]
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] |
[
"96.72",
"97.49",
"33.24",
"88.72",
"96.6",
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] |
icd9pcs
|
[
[
[]
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|
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|
277, 288
|
10960, 11204
|
2465, 6916
|
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|
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|
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|
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|
9736, 9764
|
11228, 11592
|
1464, 2446
|
226, 239
|
316, 1368
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1390, 1399
|
1415, 1424
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,545
| 127,841
|
48222
|
Discharge summary
|
report
|
Admission Date: [**2118-3-24**] Discharge Date: [**2118-4-1**]
Date of Birth: [**2049-10-26**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
Central venous line placement ([**3-26**]).
History of Present Illness:
68 y/o woman with PMHx of treated nasopharygeal carcinoma who
presents from her [**Hospital3 **] with lethargy, decreased po
intake, incontinence, reported fever, and decreased
responsiveness.
In ED, initial vital signs: T 98.6 HR 64 BP 132/72 RR 20 O2sat
99%. Pt was noted to be speaking nonsense without specific motor
or sensory loss. She was found to have a marked hyponatremia
with Na 112. CT head showed bitemporal hypodensity suggestive of
either HVS encephalitis, post-irradiation or recurrence of
tumor. Neuro was consulted and felt there was evidence of mild
neck rigidity. She underwent lumbar puncture and fourth tube
revealed 0 WBCs, 1 RBCs, Protein 80, glucose 74. She received
acyclovir 500mg, ceftriaxone 2g, vancomycin 1g and ampicillin
1g. Pt is now being admitted for hyponatremia and work-up of
mental status changes and question of new bilateral brain
lesions. On transfer vitals temp 98.2, HR 82, BP 170/80, O2sat
100% RA.
Pt arrived to the MICU in no acute distress. On exam, she was
responding "yah" to all questions. Unable to illicit any other
response, not following commands or opening eyes without
stimulation. Nursing home notes report mental status changes
were seen earlier in the day and possibly began the day prior to
presentation per fellow residents.
Past Medical History:
1. Nasopharyngeal carcinoma [**2106**], s/p chemotherapy & proton beam
therapy at [**Hospital1 2025**]. Per ENT note-pt completed treatment for a
nasopharyngeal cancer in 04/[**2113**]. She had recurrence and
underwent salvage concurrent proton beam radiation and weekly
cisplatin. She has also undergone hyperbaric oxygen therapy for
radiation-induced necrosis of the temporal lobes. She did
receive 23 out of 30 planned treatments through the
[**Hospital6 1129**] and due to mental status changes
this was terminated on [**2115-10-2**].
2. Hypercholesterolemia.
3. Sixth nerve palsy.
4. Impaired vision secondary to her cancer.
5. Hearing loss.
6. Hypothyroidism
Social History:
The patient was born and raised in [**Country **]. Lives in [**Hospital **] and HCP is her sister who lives in [**Name (NI) 4565**].
Family History:
Non-contributory.
Physical Exam:
Vitals: T: 99 BP: 182/93 P: 74 R: 14 18 O2: 99% on RA
General: NAD, eyes closed, not following commands or answering
questions appropriately
HEENT: sclera anicteric, PERRLA, erythematous/bloody nasal
mucosa bilaterally, TM not visualized on L, frank purulence in
otic canal on right with some pain on manipulation
Neck: supple, asymetric matted lesion palpable in precervical
region, R>L, no clear adenopathy
Lungs: Clear to auscultation bilaterally, though pt is not
compliant with exam
CV: Regular rate and rhythm
Abdomen: soft, non-tender, mild distension, bowel sounds
present, no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses
Neuro: confused but alert, unable to assess orientation, does
not answer questions appropriately, withdraws to pain
appropriately in all four extremities, toes upgoing bilaterally,
increased tone throughout.
Pertinent Results:
Labs at Admission:
[**2118-3-24**] 04:50PM BLOOD WBC-10.3 RBC-4.26 Hgb-10.0* Hct-30.4*
MCV-71* MCH-23.6* MCHC-33.0 RDW-14.9 Plt Ct-438
[**2118-3-24**] 04:50PM BLOOD Neuts-75.2* Lymphs-15.8* Monos-7.5
Eos-1.2 Baso-0.4
[**2118-3-24**] 04:50PM BLOOD PT-12.1 PTT-32.5 INR(PT)-1.0
[**2118-3-24**] 04:50PM BLOOD Glucose-122* UreaN-12 Creat-0.6 Na-112*
K-5.4* Cl-78* HCO3-27 AnGap-12
[**2118-3-26**] 05:22AM BLOOD ALT-14 AST-29 LD(LDH)-168 AlkPhos-59
TotBili-0.3
[**2118-3-25**] 12:33AM BLOOD Calcium-8.7 Phos-2.4* Mg-1.8 Iron-37
[**2118-3-25**] 12:33AM BLOOD calTIBC-368 Ferritn-42 TRF-283
[**2118-3-24**] 04:50PM BLOOD TSH-3.0
[**2118-3-24**] 04:50PM BLOOD Free T4-1.1
[**2118-3-26**] 05:22AM BLOOD Cortsol-16.9
Serial Sodium measurements:
[**2118-3-25**] 11:13PM BLOOD Glucose-105 Lactate-1.2 Na-118* K-3.2*
Cl-87*
[**2118-3-26**] 01:28AM BLOOD Na-119*
[**2118-3-26**] 03:41AM BLOOD Na-121*
[**2118-3-26**] 07:59AM BLOOD Na-125*
[**2118-3-26**] 12:14PM BLOOD Na-129*
Imaging Studies:
CT Head ([**3-24**]):
IMPRESSION:
Vasogenic edema-like pattern and relatively symmetric in both
temporal lobes extending cephalad into the bilateral parietal
lobes. There are rounded foci of slight hyperattenuation in the
basal portions of both temporal lobes. These may reflect tumor
or possibly foci of hemorrhagic transformation. Diagnostic
considerations, in light of the osseous erosion identified along
the more cephalad aspects of the clivus and of the central
sphenoid bone is tumoral invasion. Given a history of fever and
altered mental status with the findings relatively symmetric in
the temporal lobes, infection also must be considered and a
leading candidate would be herpes encephalitis. No
hydrocephalus. Posted to ED dashboard immediately on
interpretation prior to dictation and discussed with Dr.
[**Last Name (STitle) 72672**] at approximately 5:50 p.m. on the day of study.
MRI Brain ([**3-25**]):
in bilateral anterior inferior temporal lobes there are T2
bright, T2*
intermediate intraxial collections with fluid levels that may
represent blood products. There is slight enhancement around
these collections, suggesting that there may be local tumor
recurrance, but no restricted diffusion to suggest that these
are abscess cavities, although infection
cannot be fully excluded. enhancement of the nasal and ethmoid
mucosa may be due to infection, although post surgical changes
may cause similar findings. fluid in bilateral mastoids may
indicated mastoiditis. no meningeal enhancement to suggest
meningitis. bilateral high flair signal in the temporal lobes
compatible with post radiation changes. normal COW apart from
hypoplastic right A1 segment, likey congenital. no restricted
diffusion to suggest acute infarct. comparision to more recent
MR imaging would be useful in further evaluation of these
findings. osseous component better evaluated on CT performed
same day.
CT Chest ([**3-26**]):
1. Radiation fibrosis noted medially along the bilateral lung
apices.
Otherwise no lung, mediastinal or hilar mass seen.
2. 3.9 cm segment VI hepatic lesion is incompletely assessed.
Dedicated
imaging of the liver will be recommended for further evaluation.
Also
comparison with prior imaging would be useful in establishing
time course of this lesion. Trace perihepatic ascites.
3. Tiny hiatal hernia.
4. Tiny bilateral pleural effusions with adjacent atelectasis.
CTA chest [**3-31**]
FINDINGS:
There is satisfactory contrast opacification of the pulmonary
arteries, no
pulmonary embolism or acute aortic pathology. Subtle
ground-glass nodules in the left perihilar region of the left
upper lobe are new since the recent CT in [**2118-3-26**] and most
likely infectious. The remaining lungs are clear with mild
bibasilar atelectasis. No pathologically enlarged mediastinal or
axillary lymph nodes by CT size criteria. The central airways
are widely patent to subsegmental level bilaterally. Heart size
is normal. No pericardial effusion.
The examination was not designed for subdiaphragmatic evaluation
except to
note a hypodensity in the right lobe of the liver, better
appreciated on the recent CT chest.
IMPRESSION:
1)No pulmonary embolism or acute aortic pathology.
2)Subtle ground-glass opacities in the left perihilar region of
the left upper lobe could be infectious or inflammatory.
The findings are otherwise unchanged since the recent chest CT
on [**3-26**],
reference to this study is recommended for a report.
The study and the report were reviewed by the staff radiologist.
CT head [**3-31**]
FINDINGS: In comparison to the prior CT of [**3-24**], there is
little change in the bitemporal hyperdense lesions. Extensive
confluent areas of low attenuation of the temporal lobe white
matter extending cephalad into the parietal lobes are unchanged.
The basal cisterns are preserved, without evidence of uncal or
transtentorial herniation. There is no shift of midline
structures. There is no hydrocephalus.
Osseous destruction is better evaluated on the prior CT orbits.
Air-fluid
level in the sphenoid sinus is unchanged, as well as
opacification of the
ethmoid air cells. The mastoid air cells remain opacified, and
as before,
fluid/soft tissue density surrounds the ossicles of the left
middle ear.
IMPRESSION: Unchanged examination in comparison to head CT [**3-24**], [**2117**],
including bilateral hyperdense temporal lobe lesions, confluent
bilateral
temporal lobe white matter hypoattenuation, osseous destruction
and sinus and mastoid opacification.
Please refer to reports of MRI brain and CT orbits [**2118-3-25**] for further details.
Labs on discharge [**2118-4-1**]:
5.9>24.7<298
134/4.0/95/20/14/1.0<88
Blood cultures 5/1 negative
5/2-3 pending
B12, folate, UPEP, SPEP pending
Brief Hospital Course:
68 yo female with pmh of treated nasopharygeal carcinoma
admitted for change in mental status, found to be hyponatremic
and with bilateral temporal lobe lesions initially of unknown
duration, subsequently found to be present from [**2115**], but with
significant change. She was initially admitted to the MICU as
she was found to be severely hyponatremic.
.
# Mental status change: The patient's mental status has improved
greatly with correction of her hyponatremia. This was felt to be
the greatest contributant to her mental status changes followed
by infection and then the MRI changes in the brain parenchyma.
At discharge the patient was sleepy, but easily arounded, and
quite HOH which often contributed to an underappreciation that
she was actually oriented to person, place and time.
.
# Bilateral temporal lobe lesions: MRI was concerning for local
tumor reoccurance. She was initially consulted by neurosurgery
and neurology. Films were compared to those from [**2115**] at [**Hospital 86999**] revealing (per oral report): evolution of enhancing
temporal lobe findings which were previously c/w radiation
induced changes now with cystic components and fluid levels
concnerning for further radition-induced changes versus
malignany. Osteonecrosis of the skull base vs residual tumor
was also evident with increased destruction of the petrious into
the clivus and changes in the appears of the nasopharynx
concerning for tumor of the sphenoid. These findings were
thought most c/w malignancy versus radiation necrosis and felt
not to be communicating with the OM and infectious components. A
f/u was scheduled for the patient with her oncologist the
following week.
.
# Hyponatremia: Patient's urine sodium was >400, consistent with
SIADH. She was corrected with hypertonic saline (about 20 hours)
which was stopped mid-day on [**3-26**]. Her sodium has continued to
correct with fluid restriction 112 ??????> 134 (over 48 hours). She
was initially followed by renal.
.
# hypotensive episode: Patient was hypotensive to 70s with
presyncope on [**3-31**], likely due to hypovolemia and orthostasis as
CT head unchanged, CTA chest neg for PE, EKG without
significiant changes. No events on tele o/n. She was ambulating
well around her room with assistance on day of discharge.
.
# Left Otitis media with h/o myringotomy: There was frank
purulent material from the left canal during the patient's ICU
stay. She was seen by ENT and ID. She was placed on
Ciprofloxacin 0.3% Ophth Soln 4 DROP RIGHT EAR QID and
Dexamethasone Ophthalmic Soln 0.1% 2 DROP RIGHT EAR QID. She was
transitioned from Vancomycin to Nafcillin for a planned course
through [**4-28**] until confirmed with Infectious Disease. The patient
will need weekly labs as stated in her discharge planning.
.
# Hepatic lesion: Seen on chest CT. This should be followed as
an outpatient. Given possibility of worsening brain lesions,
?malignancy.
.
# Anemia: Patient's Hct has remained below her baseline of mid
30's in the low 30's to high 20's. No clinical evidence of
bleeding. B12, folate and SPEP were pending at discharge. The
patient should have a UPEP as an outpatient.
.
# Nasopharyngeal carcinoma [**2106**]: s/p chemo and photon beam
radiation, unclear current status of disease. Per
neuroradiology, may be biopsiable area of brain. This will need
to be discussed as an outpatient as goals of care will likely
need to be addressed.
.
# Hypothyroidism: Restarted on Synthroid 50mcg daily after ICU
stay.
.
# FEN: regular diet with free water restriction
.
# Prophylaxis:
-Heparin SC as brain lesion likely chronic
-Bowel regimen
.
# Access: PICC
.
# Code: Full Code, MICU team confirmed with sister/HCP
.
# Emergency Contact: Sister, [**Name (NI) **] [**Telephone/Fax (1) 101631**] in [**State 4565**].
Medications on Admission:
Ipratropium Bromide nasal spray TID
Levothyroxine 50 mcg daily
Mirtazapine 15 mg daily
Calcium Carbonate 500 mg Tablet Twice a Day
Ergocalciferol 1,000 unit daily
Multivitamin daily
Senna prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: Five (5) mL
Injection TID (3 times a day).
5. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic QID
(4 times a day).
6. Dexamethasone 0.1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic QID (4 times a day).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nafcillin 2 g IV Q4H
day 1 [**3-29**]
9. Outpatient Lab Work
weekly LFTs, CBC/differential, BMP, ESR/CRP
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
10. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
11. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO once a day.
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
- hyponatremia
- otitis medial
Secondary:
- nasopharygeal carcinoma
- hypothyroidism
Discharge Condition:
sleepy, easily aroused, oriented X 3, hard of hearing
ambulating with assistance only
Discharge Instructions:
You were admitted to the hospital for treatment of confusion and
altered mental status. During this admission, your sodium levels
were found to be very low. Additionally, you had an infection in
your right ear which was treated with anitbiotics. You were in
the intensive care unit for a period of time. Your sodium
levels resolved and you were treated with antibiotics for your
ear infection which should be continued through your appointment
with infectious disease on [**4-28**] unless told otherwise.
You also had changes on your brain MRI. You need to follow-up
with your oncologist about this at the appointment below.
You should continue the medications as listed on the following
page. You should have weekly lab tests as specified on the
following page.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
Followup Instructions:
Department: [**Hospital1 2025**] Head and Neck
When: Thursday, [**4-7**], 9am.
With: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone: [**Telephone/Fax (1) 12267**]
Department: [**Hospital1 **] MRI (MOBILE)
When: TUESDAY [**2118-5-10**] at 10:35 AM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2118-5-10**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GERONTOLOGY
When: WEDNESDAY [**2118-6-15**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2118-4-28**] at 1:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"V10.02",
"382.9",
"322.9",
"323.9",
"253.6",
"280.9",
"378.54",
"573.8",
"348.89",
"458.0",
"244.9",
"389.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
14619, 14691
|
9193, 12983
|
291, 336
|
14830, 14918
|
3446, 4411
|
15966, 17397
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2513, 2532
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13225, 14596
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14712, 14809
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13009, 13202
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14942, 15943
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2547, 3427
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229, 253
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364, 1658
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1680, 2347
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|
4429, 9170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,061
| 188,807
|
32923
|
Discharge summary
|
report
|
Admission Date: [**2184-12-21**] Discharge Date: [**2184-12-22**]
Date of Birth: [**2107-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Exertional dyspnea
Major Surgical or Invasive Procedure:
Coronary angioplasty
Bare metal stent to left circumflex OM1
Stent graft
History of Present Illness:
77 yo M with HTN, hypercholesterolemia, PVD admitted after
cardiac catheterization with a complication of coronary
perforation.
.
The patient underwent echo stress testing on [**2184-12-13**] in advance
of elective right knee surgery. The test revealed 3-4mm ST-T
wave changes in II, III, V4-6 with anterior HK and AK at peak
stress. Follow-up cardiac cath today revealed LMCA 30%, LAD 100%
after septals fill via the RCA, LCx 95% lesion in OM1, RCA 70%
mid lesion. A bare metal stent was placed in the LCx OM1 with
high pressure post-dilation complicated by perforation
successfully treated with stent graft. He was noted to have a
tiny effusion by immediate echo. There was no change in right
heart cath. He developed chest pain [**3-26**] with bradycardia and
realtive hypotension succesfully treated with transient atropine
and dopamine. Subsequent repeat echo revealed unchanged trivial
effusion. The patient is admitted for further monitoring.
.
On review of symptoms, he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. All of
the other review of systems were negative.
.
Cardiac review of systems is notable for exertional dyspnea for
several years limiting activity such as lifting furniture or
climbing [**11-17**] flights of stairs. Denies chest pain, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- PVD s/p bilateral lower extremity angioplasties for
claudication (at [**Hospital3 **]??????s) s/p stent to right leg only.
S/p gene therapy to left leg for PVD
- Hypertension
- Hypercholesterolemia
- TIA approximately 12 years ago-loss of speech x 1 day
Social History:
Married. + Tobacco use. Denies EtOH.
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.4 44 139/62 20 100% RA
Gen: Well-appearing. NAD.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: Distant heart sounds. RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally.
Abd: Soft, nontender, no masses or organomegaly.
Ext: Palpable distal pulses on the left. Dopplerable pulses
distally on the right. Right femoral cath site clean and dry
without bruit or hematoma.
Neuro: A&Ox3
Pertinent Results:
ADMISSION LABS:
[**2184-12-21**] 09:41PM BLOOD Hct-38.5*
[**2184-12-22**] 04:31AM BLOOD WBC-8.0 RBC-4.08* Hgb-13.8* Hct-37.8*
MCV-102* MCH-33.8* MCHC-33.1 RDW-12.1 Plt Ct-220
[**2184-12-21**] 09:41PM BLOOD UreaN-25* Creat-1.6*
[**2184-12-22**] 04:31AM BLOOD Glucose-103 UreaN-24* Creat-1.6* Na-141
K-4.2 Cl-100 HCO3-32 AnGap-13
[**2184-12-22**] 04:31AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.2
CARDIAC ENZYMES:
[**2184-12-22**] 04:31AM BLOOD CK(CPK)-166
[**2184-12-21**] 09:41PM BLOOD CK-MB-4 cTropnT-0.03*
[**2184-12-22**] 04:31AM BLOOD CK-MB-8 cTropnT-0.05*
EKG ([**2184-12-21**]): Normal sinus rhythm. Normal axis. Downgoing T's
in V2-6. No acute ST or T wave changes. No prior available for
comparison.
CARDIAC CATH ([**2184-12-21**]): LMCA 30%, LAD 100% after septals fill
via the RCA, LCx 95% lesion in OM1, RCA 70% mid lesion. Bare
metal stent placed in the LCx OM1 with high pressure
post-dilation complicated by perforation successfully treated
with stent graft. Tiny effusion by echo. No change in right
heart cath. Chest pain [**3-26**], bradycardia treated with atropine
and dopamine.
Echo ([**2184-12-21**]): LV systolic function appears depressed with
septal and apical hypokinesis/akeins. The mitral valve leaflets
are mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
Ms. [**Known lastname 10595**] was admitted after cardiac catheterization with a
complication of coronary perforation. Repeat echo revealed
unchanged trivial effusion. Aspirin, clopidogrel and
simvastatin were continued. Home beta-blocker and calcium
channel blocker were held until discharge the day after
admission.
Medications on Admission:
Atenolol 25mg Daily
Amlodipine 2.5mg Daily
Simvastatin 10mg Daily
Aspirin 81mg Daily
Clopidogrel 75mg Daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain: Up to
three sublingual pills, 5 minutes apart.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Angina
Coronary artery disease
Discharge Condition:
Stable, ambulating, chest pain free
Discharge Instructions:
You were admitted to the hospital because of an abnormal stress
test. You uderwent a heart catheterization which showed severe
disease. A stent was placed and you will need to be sure to take
Plavix daily.
Please keep all scheduled appointments and take all medications
as prescribed. If you experience new chest pain, shortness of
breath, fever, or drainage from the groin, please seek medical
attention.
You should not take your amlodipine for now. You will follow-up
with Dr. [**Last Name (STitle) **] in 2 weeks, his office will call you with an
appointment. At that time you will discuss resuming your
amlodipine or adjusting your other medications.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 5435**] ([**Telephone/Fax (1) 76615**] within 2 weeks
You should follow-up with Dr. [**Last Name (STitle) **] within 2 weeks to discuss your
medications. His office will call you with your appointment.
|
[
"V12.54",
"997.1",
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"E870.0",
"401.9",
"443.9",
"272.0",
"998.2",
"458.29",
"414.01",
"V15.82",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.46",
"36.06",
"37.23",
"88.56",
"00.66",
"00.40"
] |
icd9pcs
|
[
[
[]
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] |
5276, 5282
|
4239, 4562
|
337, 412
|
5357, 5395
|
2804, 2804
|
6100, 6352
|
2314, 2334
|
4720, 5253
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5303, 5336
|
4588, 4697
|
5419, 6077
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2349, 2359
|
2381, 2785
|
3210, 4216
|
278, 299
|
440, 1964
|
2820, 3193
|
1986, 2244
|
2260, 2298
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,539
| 178,324
|
50446
|
Discharge summary
|
report
|
Admission Date: [**2202-12-5**] Discharge Date: [**2202-12-8**]
Date of Birth: [**2159-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Bleeding from trach site
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 yo male with a history of anoxic brain injury living at a
rehab, who is trach and PEG dependent, with recent admission for
tongue laceration, who presents from his rehabilitation facility
with concerns for bleeding from trach. Staff from rehab report
about 400cc bright red blood from trach site over the last 12
hours.
Of note, patient had a recent admission from [**Date range (1) 105118**] for a
tongue laceration. During that hospital course he had total
teeth extraction. He also had a high grade MRSA bacteremia and
was started on 4 week course of Vancomycin (last day [**12-19**]). TEE
was negative. He also completed a 7 day course of Cefepime and
Cipro for VAP. LUE US developed thrombus, and patient was
discharged on lovenox [**Hospital1 **] (day 1 = [**11-30**]).
In the ED, initial vs were: T 97.5 P 86 BP 114/90 R 16 O2 sat
100. He recieved midazolam and fentanyl while IP did a bronch.
The bronch was clean without evidence of bleeding from the trach
or lower. The airways were reportedly free of lesions other than
mild, non-bleeding granulation tissue near the tracheostomy
tract. They thought that despite the inflated balloon he may be
aspirating blood from his bleeding gums. A CTA did not reveal a
PE but did show new nodular ground glass opacities in the right
lung and left apex compared to a CT from [**2202-9-2**] abdominal
CT. Because of this he was given Levofloxacin and Cefepime. He
was admitted for further work-up of new ground glass opacity,
and sent to the ICU given his trach. Prior to transfer vitals
were HR 75-85 BP 110s/80s RR 16 100% on vent.
On the floor, patient is alert, but not interactive.
Review of systems:
(+) Per HPI
(-) Unable to complete
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Systolic CHF: EF 20%
S/p STEMI [**6-/2193**], w/ large thrombus in the proximal LAD
complicated by cardiogenic shock w/ DES to prox LAD
[**11/2193**]: [**Month/Year (2) 3941**] placement for Low EF, runs of NSVT.
H/o alcohol and substance abuse
H/o deep vein thrombosis partially treated with Coumadin
Positive hepatitis B serologies in the past
S/p PEA arrest in [**9-/2202**] with resulting anoxic brain injury
during VT ablation in EP lab. At baseline, the pt is responsive
only to deep painful stim (such as deep suctioning), although he
does appear alert and open his eyes (no tracking). He is
completely dependent for all ADLs.
Social History:
He had been on disability for 10 years since his first heart
attack. Prior to that he was a manager at [**Company **]'s. He
reported smoking approximately one pack of cigarettes per week.
He also reported history of ETOH but denied any IVDA. Now
unresponsive to all but deep painful stim, and completely
dependent for all ADLs. Baseline GCS of 9.
Family History:
Non-contributory
Physical Exam:
Vitals: T: BP:114/70 P:88 R:[**10-23**] O2: 93-99% on trach collar
FiO2 40%
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, patient refuses to open mouth for
a prolonged period of time. Tongue appears intact and non
bloody. Lower gums appear to be oozing. Trach collar in place.
No bleeding around site.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2. 2/6 systolic murmur
loudest at apex.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. PEG tube in
place.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2202-12-5**] 04:40AM WBC-9.7 RBC-2.90* HGB-8.4* HCT-27.3* MCV-94
MCH-28.8 MCHC-30.6* RDW-17.5*
[**2202-12-5**] 04:40AM PLT COUNT-290
[**2202-12-5**] 04:40AM PT-17.0* PTT-38.8* INR(PT)-1.5*
[**2202-12-5**] 04:40AM GLUCOSE-128* UREA N-30* CREAT-1.0 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
Studies:
[**2202-12-5**] Chest Xray: Stable position of tracheostomy. Stable
cardiomegaly.
[**2202-12-5**] CTA Chest:
1. No evidence for pulmonary embolus or acute aortic syndrome,
although the evaluation of subsegmental pulmonary arteries is
technically limited.
2. Mild enlargement of the main pulmonary artery suggests
underlying
pulmonary hypertension.
3. There are diffuse nodular and ground-glass densities
throughout the right lung and at the left apex. These appear new
compared to [**2202-9-20**], when they were not seen on lung
bases on the CT of the abdomen and pelvis. There is associated
bronchial wall thickening and hilar adenopathy. Overall, this is
most conssitent with a infectious bronchopneumonia. Given the
clinical history, alvealar hemorrhage should also be considered.
Close imaging follow-up is recommended with radiography as well
as chest CT follow-up, particularly given lymphadenopathy,
within three months, if clinically indicated.
4. Trace pericardial effusion.
5. Small-to-moderate ascites.
[**2202-12-6**] Left upper extremity ultrasound:
No evidence of left upper extremity DVT. Mildly abnormal
subclavian venous waveform.
Brief Hospital Course:
43 year old male with anoxic brain injury, s/p PEG & trach,
after a PEA arrest in [**9-/2202**] (pt was undergoing VT ablation)
who was readmitted with bleeding from trach site.
#. Bleeding: This was his second admission for bleeding from his
trach site. The first admisison, it was felt that he was
gnawing at his tongue with his teeth and his teeth were
subsequently pulled. This time, it appeared his bleeding was
coming from his gums in the areas where his teeth had been
recently pulled. His Lovenox was stopped and he was started on
clonazepam 0.25mg po TID to prevent gnawing behaviors. His
hematocrit remained stable and he continued to have minimal
low-grade bleeding from his gums.
#. Aspiration pneumonitis: On admission he had ground glass
opacities seen on CT scan that were felt to represent likely
aspiration of blood. He had a bronchoscopy that was not notable
for thick secretions or alveolar hemorrhage. He was given a
dose of Levofloxacin and cefepime in the ED but antibiotics were
stopped on admission due to low clinical suspicion for pneumonia
(with the exception of Vancomycin for which he is completing a
course for prior bacteremia). He did not have any fevers,
cough, or new oxygen requirement.
#. MRSA Bacteremia: At his last hospitalization he had
high-grade MRSA bacteremia with 6/6 bottles positive on [**11-20**].
He continued a 4-week course of Vancomycin to end on [**2202-12-19**].
#. L UE Thrombus: He had a previous LUE thrombus of brachial
vein. Repeat ultrasound on this admission showed no evidence of
thrombus. Due to his bleeding, his Lovenox was discontinued.
His PICC line should be removed when he finishes his course of
Vancomycin on [**2202-12-19**].
#. S/p anoxic brain injury: He continues to be trach and PEG
dependent. He appearesd at his baseline mental status. His tube
feeds were restarted.
#. Diabetes: He was continued on an insulin sliding scale.
#. Hypertension: His antihypertensives were held due to low
blood pressure and bleeding on admission. These were restarted
at lower doses at discharge (lisinopril, carvedilol), and his
Lasix was restarted at full dose. His lisinopril can be
titrated up to 10mg daily and his carvedilol can be titrated up
to 25mg po bid if needed for hypertension.
#. Cardiovascular disease: His aspirin was initially held but
was restarted at discharge at a lower dose. He was continued on
atorvastatin.
#. Code Status: He was full code during this hospitalization.
Goals of care discussions were continued with the family during
this admission and should be continued after discharge.
Medications on Admission:
1. Bisacodyl 10 mg po daily PRN constipation
2. Senna 8.6 mg po bid PRN constipation
3. Aspirin 325 mg po daily
4. Atorvastatin 10 mg po daily
5. Acetaminophen 160 mg/5 mL Solution [**Date Range **]: Ten (10) mL PO Q6H
(every 6 hours) as needed for pain, discomfort.
6. Multivitamin 1 po daily
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Furosemide 20 mg po daily
9. Ciprofloxacin 750 mg po q12h: Last dose on [**2202-12-3**].
10. Insulin Sliding Scale
11. Carvedilol 25 mg po bid
12. Lorazepam 2 mg/mL Syringe [**Year (4 digits) **]: One (1) mg Injection Q8H
(every 8 hours) as needed for anxiety.
13. Pantoprazole 40 mg IV q24h
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Year (4 digits) **]: One (1)
Intravenous every twenty-four(24) hours: Last Dose 1/17.
16. Cefepime 2 gram IV q12h Last dose on [**12-3**].
17. Lovenox 80 mg sc bid day 1 = [**11-30**]
18. Lisinopril 10 mg po daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Aspirin 81 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
4. Atorvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: Ten (10) ml PO Q6H
(every 6 hours) as needed for pain, fever.
6. Multivitamin Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Year (2) **]: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Furosemide 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
9. Insulin Lispro 100 unit/mL Solution [**Month/Day (2) **]: One (1) Injection
Subcutaneous ASDIR (AS DIRECTED): Please use insulin sliding
scale as prior to admission.
10. Pantoprazole 40 mg Recon Soln [**Month/Day (2) **]: Forty (40) mg Intravenous
once a day.
11. Carvedilol 6.25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a
day.
12. Vancomycin 1,000 mg Recon Soln [**Month/Day (2) **]: 1000 (1000) mg
Intravenous Q 24H (Every 24 Hours): Last dose [**2202-12-19**].
13. Lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
14. Clonazepam 0.5 mg Tablet [**Year (4 digits) **]: 0.5 Tablet PO TID (3 times a
day).
15. Outpatient Lab Work
Needs vanc trough [**2202-12-10**] with goal 15-20. Needs hematocrit
daily x 2 days, then needs weekly Chem10 and CBC.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary Diagnosis:
Bleeding from mouth
Secondary Diagnosis:
Anoxic brain injury
Congestive heart failure
Diabetes Mellitus
Discharge Condition:
Mental Status: Nonverbal due to anoxic brain injury
Level of Consciousness: Responsive to pain/verbal stimuli by
opening eyes
Activity Status: Bedbound
Discharge Instructions:
You were admitted to the hospital with bleeding from your mouth.
Your blood count (hematocrit) remained stable and your bleeding
decreased. Your blood thinner (Lovenox) was stopped.
Changes to your medications:
STOPPED Lovenox
Continued vancomycin
Started Clonazepam 0.25mg by mouth three times daily
Changed aspirin from 325mg daily to 81mg by mouth daily
Decreased carvedilol to 6.25mg by mouth twice daily
Decreased lisinopril to 5mg by mouth daily
Since you also have a diagnosis of heart failure, you should be
weighed every morning, and notify your doctor if your weight
goes up more than 3 lbs.
You need to have a vancomycin trough level drawn the morning of
[**2202-12-10**] prior to your dose. Goal trough levels are 15-20.
Followup Instructions:
You have the following appointments scheduled:
Department: Cardiology
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-1-19**]
9:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-1-19**]
10:00
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2203-1-19**] 11:00
|
[
"414.01",
"272.4",
"528.9",
"428.0",
"250.00",
"280.0",
"V46.11",
"507.0",
"V44.0",
"V45.02",
"V45.82",
"401.9",
"V12.51",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
10791, 10846
|
5455, 8052
|
339, 345
|
11014, 11014
|
3930, 3930
|
11955, 12403
|
3146, 3164
|
9105, 10768
|
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|
8078, 9082
|
11192, 11377
|
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|
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|
2036, 2072
|
275, 301
|
373, 2017
|
10928, 10993
|
3946, 5432
|
10886, 10907
|
11029, 11168
|
2094, 2765
|
2781, 3130
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,238
| 104,407
|
51760
|
Discharge summary
|
report
|
Admission Date: [**2156-3-7**] Discharge Date: [**2156-3-10**]
Date of Birth: Sex:
Service: CARDIOLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 11075**] is a pleasant 74
year-old man with no clear history of coronary artery
disease, but positive electrocardiograms changes on recent
stress echocardiogram as well as history of hypertension and
hypercholesterolemia, who presented with complaint of chest
pain. The patient is a very active man who spends
approximately forty minutes on a treadmill every other day.
Approximately three weeks prior to presentation he noted
chest pain during his treadmill exercises. The patient
characterized the pain as substernal pressure that originated
in the center of his chest. It did not radiate elsewhere and
was not pleuritic. Mr. [**Known lastname 11075**] [**Last Name (Titles) **] these episodes as
approximately 3 out of 10 in severity, and said they
initially occurred after about fifteen minuets of exercise.
When these episodes occurred during exercise the patient
would stop exercising and take some nitro spray (prescribed
"years ago" by Dr. [**Last Name (STitle) **], though the patient cannot recall
why). The nitroglycerin did not seem to help the patient's
symptoms appreciably, but the pain would abate somewhat and
he would then resume exercising. The pain would disappear
completely after about an hour and a half.
Because of these exercise related episodes of chest pressure,
the patient saw his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. The stress echocardiogram was done on [**2156-3-3**]. The echocardiogram portion of the examination was
normal, however, during exercise 1 to 1.5 mm horizontal down
sloping ST segment depressions were noted and isolated to
leads V2 through V3. Additionally, T wave inversions were
noted at lead V2. These changes resolved slowly post
exercise and were not absent until ten minutes post exercise.
The rhythm was sinus with frequent atrial irritability noted
throughout exercise. No palpitations were reported and the
patient remained hemodynamically stable.
On the day prior to admission at about 5:00 p.m., shortly
after finishing dinner, the patient noted the above chest
pressure symptoms, though this time he was sitting and at
rest. He took some Pepcid, which alleviated the discomfort
somewhat and then took nitroglycerin and Atenolol. The pain
lasted approximately an hour and a half. The pain occurred
again on the morning of presentation while the patient was
sitting, [**Location (un) 1131**] on line. He then decided to present to the
Emergency Department.
REVIEW OF SYSTEMS: The patient denied recent illness and
injury (aside from his chronic fatigue syndromes). The
patient denied prior history of angina, orthopnea, paroxysmal
nocturnal dyspnea, lower extremity edema and claudication.
He also denies fevers or chills, nausea, vomiting, melena,
hematochezia, dysuria or hematuria.
In the Emergency Department the patient was without
significant electrocardiogram changes, however, his troponin
was noted to be elevated to 8.9. He was given aspirin, beta
blocker and started on a heparin drip as well as Integrilin
and the nitro drip. The patient was subsequently taken to
cardiac catheterization.
PAST MEDICAL HISTORY: Stress echocardiogram ([**2156-3-3**])
ejection fraction 60% with no wall motion abnormalities or
inducible echocardiogram ischemia, however, there were
notable electrocardiogram changes as described above.
Hypertension. Hypercholesterolemia. Symptom cluster deemed
chronic fatigue syndrome. Status post appendectomy. Status
post tonsillectomy. Status post ring finger trigger finger
release complicated by infection.
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS: Atenolol 25 mg q.d., Zoloft 100 mg
q.d., Proscar 5 mg q.d., Modafinil, Hytrin, Naproxen prn,
aspirin 325 mg q.d.
SOCIAL HISTORY: The patient lives in [**Location 5344**],
[**State 350**] with his wife. They have no children. The
patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] professor [**First Name (Titles) **] [**Last Name (Titles) **] art. He quit
smoking approximately thirty five years ago after a ten pack
year history. He drinks one glass of wine per day. He
denies history of elicit drug use.
PHYSICAL EXAMINATION: Vital signs, heart rate 61, blood
pressure 112/61. Respirations 18. Sating 96% on 1 liter and
98% on room air. General, awake, and in no acute distress.
HEENT normocephalic, atraumatic. Sclera anicteric. Pupils
are equal, round, and reactive to light and accommodation.
Extraocular movements intact bilaterally. Mucous membranes
are moist without lesions. Neck supple. No JVD or left
anterior descending coronary artery. No carotid bruits.
Cardiovascular regular rate and rhythm. Normal S1 and S2
without murmurs, rubs or gallops. Chest clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended, positive normoactive bowel sounds. No
hepatosplenomegaly or pulsatile masses. Rectal examination
revealed normal sphincter tone with brown stool that was
guaiac negative. Extremities 2+ dorsalis pedis pulses
bilaterally. No clubbing, cyanosis or edema. Neurological
examination revealed the patient to be alert and oriented
times three. His speech was normal and appropriate. Cranial
nerves II through XII were intact bilaterally. The patient's
right upper extremity had some weakness, approximately 4 out
of 5 strength both proximally and distally, which the patient
attributes to his chronic fatigue, otherwise, strength
testing was both 5 out of 5 both proximally and distally.
LABORATORY DATA: CBC revealed a white count of 8.8,
hematocrit 39.7, platelets 212. Cardiac studies revealed an
INR of 1.1, PT 12.8, PTT 24.8. Chem 7 revealed sodium 138,
potassium 4.1, chloride 105, bicarb 24, BUN 24, creatinine
1.0, glucose 118. Initial CK was 253 with an MB fraction of
28 and an MB index of 11.1. Troponin was 8.9. Urinalysis
was negative. Electrocardiogram revealed normal sinus rhythm
at a rate of 60 beats per minute, old Q wave in lead 3.
There were no acute ST or T changes. There were no changes
versus prior study of [**2155-6-3**]. Chest x-ray no evidence
of pleural effusions, infiltrates or congestive heart
failure.
HOSPITAL COURSE: The patient was initially admitted to the
[**Hospital Unit Name 196**] Service for further evaluation and treatment for his
above noted conditions. On the evening of admission the
patient went to cardiac catheterization. At the time of this
dictation no official report is available on the computer
regarding the catheterization. However, preliminary report
reveals that the system was right dominant. There was no
significant obstructive disease in the LMCA. There was no
moderate disease in the left anterior descending coronary
artery with 40% mid stenosis in the right coronary artery.
There was total occlusion of the distal left circumflex. The
obtuse marginal one and obtuse marginal two were stented.
The left circumflex was jailed and subsequently rescued.
This event was complicated by bradycardia and hypotension as
well as chest pain. Thus, the patient required a brief
course of Dopamine and was transferred briefly to the Cardiac
Care Unit. He was quickly weaned off Dopamine following
admission to the Cardiac CAre Unit and was transferred back
to the Medicine Floor the following day.
Aside from the above noted catheterization and interventions
the patient was treated medically with aspirin, Plavix, beta
blocker and an Ace inhibitor. As his LDL was found to be
elevated to 129 he was started on Lipitor. The patient did
well during the remainder of his hospitalization
CONDITION ON DISCHARGE: Vital signs stable, afebrile. Free
of chest pain and shortness of breath. Fully ambulatory.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post stent placement to
obtuse marginal one and obtuse marginal two. Complicated by
jailing of left circumflex artery, which was subsequently
rescued.
2. Hypertension.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS: The patient was discharged on his
above noted outpatient medication regimen. He was given
prescriptions for Captopril 6.25 mg t.i.d., as well as
Lipitor 10 mg po q.d. and Plavix 75 mg po q.d.
FOLLOW UP: The patient is to follow up with his primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2156-3-12**] 16:47
T: [**2156-3-15**] 07:55
JOB#: [**Job Number 107208**]
|
[
"272.0",
"427.89",
"E879.0",
"410.71",
"998.12",
"401.9",
"458.2",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"37.61",
"88.53",
"88.56",
"37.22",
"36.02"
] |
icd9pcs
|
[
[
[]
]
] |
7950, 8182
|
8206, 8400
|
6409, 7809
|
8412, 8863
|
3860, 3974
|
4420, 6391
|
2720, 3350
|
159, 2700
|
3373, 3835
|
3991, 4397
|
7834, 7929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,467
| 138,979
|
41858
|
Discharge summary
|
report
|
Admission Date: [**2117-9-14**] Discharge Date: [**2117-9-30**]
Date of Birth: [**2057-2-9**] Sex: M
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
Percutaneous Liver biopsy [**2117-9-21**]
History of Present Illness:
60 year old gentleman with hypertension, peripheral artery
disease, coronary artery disease and IDDM was admitted on
[**2117-8-25**] with abdominal pain and was eventually diagnosed with
appendicitis for which he had open appendectomy and found to
have perforated appendix.
He tolerated the surgery well per report. Post-operatively, he
was treated with Zosyn. Subsequent pathogens fragilis and
anerobic gram postive rods for which meropenem and flagyl was
initiated (brief period on levo [**2117-8-29**]).
.
His hospital course was complicated by fever, respiratory
insufficiency that required intubation ([**Date range (1) 90900**]; resolved) (no
PE per CT per OSH dc summary), acute renal failure (oliguric, Cr
was 5+ from baseline of 1.0; improving), need for pressors, with
elevated tpn up to 8.8, hepatic failure and possible
pancreatitis. He slowly improved and was extubated on [**2117-9-5**]
when he was noted to have icteric sclera and evidence of
obstructive jaundice as per report.
.
Right PICC placed at OSH [**2117-8-31**] FOR tpn and antibiotics
.
vital signs prior to transfer from OSH: T 98.7, HR 87, BP
116/57, Pulse oxy 100%. Hgt 5'7, Wt 210 lb.
.
On the floor he was lying flat in bed comfortably. Very
interactive, pleasant, answers questions appropriately. Denies
abd pain nausea or vomiting. Denies chest pain or shortness of
breath. (see ROS please)
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting. Reports having brown regular stool once
daily for the last two days.Denies abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Open appendectomy [**8-/2117**]
ISDDM
HL
HTN
PVD fem-[**Doctor Last Name **] bypass bilaterally
CAD - stent in [**2107**].
h/o MRSA
Social History:
- Works as CPA
- Married Lives with family.
- Tobacco: Denies
- Alcohol: 6 beer per day, starts afternoon
- no blood transfusions, no acupuncture, no tatoos
- Illicits: did not ask
Family History:
strong for Diabetes. Mother had [**Name2 (NI) 3495**] disease in her 50's. No
liver disease in the family.
Physical Exam:
Admission physical exam:
Vitals: T: 96.8 BP: 105/54 P: 70's R: 13 O2: 97% RA
General: Alert but slightly sleepy (new per wife, was not this
way prior to surgery), orientedx3, no acute distress
HEENT: Sclera icteric, MM dry, oropharynx clear
Skin: spider nevi on chest
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 1/6 systolic murmur
at right mid-sternal [**Last Name (un) **], rubs, gallops
Abdomen: soft, non-tender, negative [**Doctor Last Name **] sign, fatty
distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly appreciated. Laparoscopic surgical
scars with steristrips. Appendectomy scar with steristrips.
echymosis at the suprapubic region that is non-tender.
GU: on foley
Ext: warm, well perfused, 2+ pulses, fem-[**Doctor Last Name **] scar bilaterally.
no clubbing, cyanosis or edema, no asterixis or duputryen's
contracture. He has palmar erythema.
.
Physical exam on discharge:
Vitals: 97.1, 152/67, 73, 20, 99RA
General: AAOx3, sitting in the chair watching TV
HEENT: Sclearal icterus, MMM
Cardiac: RRR, no MRG appreciated, no elevated JVP
Lungs: CTAB
Abd: Distended abdomen, soft, not rigid no rebound or guarding,
good bowel sounds. Port sites and RLQ incision are crusted over
wihtout erythema or exudate.
Extremities: 2+ edema bilaterally, trace DP pulses bilaterally.
Pertinent Results:
Labs on Admission:
[**2117-9-14**] 09:46PM BLOOD WBC-11.0 RBC-3.17* Hgb-9.7* Hct-29.2*
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.9 Plt Ct-244
[**2117-9-14**] 09:46PM BLOOD Neuts-86.0* Lymphs-7.9* Monos-2.7 Eos-2.9
Baso-0.5
[**2117-9-14**] 09:46PM BLOOD PT-20.3* PTT-34.3 INR(PT)-1.9*
[**2117-9-15**] 04:19AM BLOOD Ret Aut-3.1
[**2117-9-14**] 09:46PM BLOOD Glucose-161* UreaN-33* Creat-1.4* Na-137
K-4.9 Cl-112* HCO3-16* AnGap-14
[**2117-9-14**] 09:46PM BLOOD ALT-171* AST-251* LD(LDH)-325*
AlkPhos-370* Amylase-226* TotBili-12.0*
[**2117-9-14**] 09:46PM BLOOD Lipase-322*
[**2117-9-14**] 09:46PM BLOOD Albumin-2.0* Calcium-7.8* Phos-2.7 Mg-1.9
.
Pertinent labs:
[**2117-09-15**] 11:24AM BLOOD calTIBC-98* Hapto-208* Ferritn-620*
TRF-75*
[**2117-9-15**] 11:24AM BLOOD TSH-1.4
[**2117-9-15**] 11:24AM BLOOD Free T4-0.99
[**2117-9-15**] 04:19AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2117-9-17**] 11:50AM BLOOD Smooth-NEGATIVE
[**2117-9-15**] 11:24AM BLOOD AMA-NEGATIVE
[**2117-9-15**] 11:24AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2117-9-17**] 05:02AM BLOOD IgG-1595
[**2117-9-15**] 11:24AM BLOOD IgA-427*
[**2117-9-15**] 11:24AM BLOOD tTG-IgA-7
[**2117-9-15**] 04:19AM BLOOD HCV Ab-NEGATIVE
[**2117-9-19**] 09:40PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2117-9-19**] 09:40PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-LG
[**2117-9-19**] 09:40PM URINE RBC-<1 WBC-128* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-1
[**2117-9-18**] 04:12PM URINE Hours-RANDOM UreaN-569 Creat-86 Na-13
K-47 Cl-15
[**2117-9-15**] 11:24AM BLOOD calTIBC-98* Hapto-208* Ferritn-620*
TRF-75*
[**2117-9-15**] 11:24AM BLOOD TSH-1.4
[**2117-9-15**] 11:24AM BLOOD Free T4-0.99
.
Discharge labs:
[**2117-9-30**] 05:00AM BLOOD WBC-12.7* RBC-2.80* Hgb-8.4* Hct-26.2*
MCV-94 MCH-30.2 MCHC-32.2 RDW-18.4* Plt Ct-269
[**2117-9-30**] 05:00AM BLOOD PT-14.3* PTT-25.0 INR(PT)-1.2*
[**2117-9-30**] 05:00AM BLOOD Glucose-105* UreaN-30* Creat-0.9 Na-134
K-4.3 Cl-101 HCO3-21* AnGap-16
[**2117-9-30**] 05:00AM BLOOD ALT-195* AST-259* AlkPhos-270*
TotBili-10.1*
[**2117-9-30**] 05:00AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.7 Mg-1.8
Micro:
[**2117-9-19**] URINE CULTURE (Final [**2117-9-21**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
Imaging:
CXR [**2117-9-15**]: No previous images. Low lung volumes may account
for much of the prominence of the transverse diameter of the
heart. No definite vascular congestion or acute focal pneumonia.
Right subclavian catheter tip lies in the mid-to-lower portions
of the SVC.
.
RUQ U/S [**2117-9-15**]: IMPRESSION: Cholelithiasis with thick-walled
gallbladder; gallbladder wall thickening can be present in the
setting of gallbladder contraction and ascites.
.
RUQ U/S [**2117-9-19**]: 1. Marked gallbladder wall thickening and
edema. Although a gallstone is present, a cause rather than
cholecystitis, such as hepatitis, is most likely. 2. No evidence
for biliary dilatation.3. Findings suggesting pancreatitis. 4.
Splenomegaly. 5. Small quantity of ascites, but increased;
however, insufficient for paracentesis.
.
Renal U/S [**2117-9-21**]: CONCLUSION: Normal-sized kidneys without
evidence of obstruction. Two tiny nonobstructing stones seen in
the left kidney.
.
KUB [**2117-9-22**]: IMPRESSION: No evidence of free air. No evidence
of obstruction.
.
KUB [**2117-9-23**]: IMPRESSION: Probable ileus which has mildy
improved compared to prior study on [**2117-9-22**].
.
KUB [**2117-9-26**]: FINDINGS: Interval reduction in degree of
distention of small and large bowel loops. Scattered air-fluid
levels persist on the upright view. Findings are most consistent
with an improving ileus.
.
EKG Sinus rhythm with ventricular premature beats. Borderline
low voltages
throughout. Consider cardiomyopathy. No previous tracing
available for
comparison.
.
Liver Biopsy pathology [**2117-9-21**]:
1. Established cirrhosis with prominent sinusoidal fibrosis
(Stage 4 fibrosis). Trichrome stain evaluated.
2. Mild predominantly macrovesicular steatosis with ballooning
degeneration and numerous intracytoplasmic hyalin.
3. Moderate lobular predominantly neutrophilic inflammation.
4. Mild to moderate septal mixed inflammation including
neutrophils and plasma cells with focal acute cholangitis.
5. Hepatocellular and canalicular cholestasis.
6. Immunohistochemistry for CMV is negative.
7. Iron stain shows no stainable iron stain.
Note: These findings are consistent with the patient's history
of severe toxic injury. The presence of increased plasma cells
is unusual and clinical correlation is suggested. In addition,
given the clinical history and presence of acute cholangitis,
correlation is suggested to rule out sepsis or ascending
cholangitis.
Brief Hospital Course:
60 yo M with history of HTN, HL, DM, PAD and CAD was transferred
from an OSH where he had undergone a openappendectomy for
perforated appendicitis that was complicated by sepsis,
requiring intubation and associated renal failure, transferred
here for jaundice and found to have alcoholic hepatitis.
.
#Alcoholic hepatitis: patient was jaundice on admission with no
evidence of obstruction on imaging from [**Hospital1 18**] to give elevated
bilirubin. Total bilirubin continued to rise while inpatient
despite ursodiol and peaked at 17.5. He underwent a
percutaenous liver biopsy which showed cirrhosis and evidence of
alcoholic hepatitis. It was then determined that he was
drinking 6beers/day for many years. He was started on
prednisone and showed a brisk response with decreasing bilirubin
which was 10.0 at the time of discharge. He was then switched
to a prednisone taper of 10mg per week. He remained jaundice at
the time of discharge. He was seen by nutrition who recommended
a 2000kcal diet. He has follow-up scheduled with Dr. [**Last Name (STitle) **] on
[**10-6**] to follow-up his progress with the prednisone taper. He
was counseled on abstaining from alcohol, and did not feel that
he would require any assistance in this.
.
#Cirrhosis: patient was found to have cirrhosis on his liver
biopsy. He has mild ascites. He will require outpatient
follow-up for this, which may require an EGD to look for
evidence of varices. At no point during this admission did he
had any signs of hepatic encephalopathy. His ALT and AST were
climbing at the time of discharge in the setting of being on the
steroids, however his Bilirubin was decreasing. Work-up for
other causes of cirrhosis (hepatitis panel, EBV etc) were all
negative.
.
#Acute renal failure: patient had ATN during this admission,
likely due to his hypotensive episode while he was at the OSH.
Renal saw the patient and spun his urine and saw muddy brown
casts. While hydration and monitoring, his Cr retured to
baseline at the time of discharge. He had a renal U/S which
showed no evidence of obstruction or hydronephrosis and his
urine lytes showed a pre-renal picture.
.
# Nutrition: Patient was transferred from the outside hospital
on TPN. This was stopped on arrival and he was started on a
regular diet. He had some intermittent abdominal distention and
increased stool output. He was negative for CDiff toxin, and he
had improvement of his gas/bloating with simethicone. He was
seen by nutrtion who encouraged him to continue to a 2000kcal
diet to help with his liver disease.
.
# HTN/CAD/HLP: patient has history of HTN, however on transfer
he had low blood pressure, so his home medications were stopped.
After his renal failure improved and he was improving
clinically, he was restarted only on his atenolol at the time of
discharge. He will need to restart his valsartan as an
outpatient if he continues to have elevated blood pressures
while on the atenolol. His statin and niacin were held during
this admission and at the time of discharge. Once his liver
function resolves these can be considered to be restarted.
.
#Diabetes: Patient's home actos was held while he was inpatient.
He was started on lantus with increasing requirement while on
the prednisone. He will be discharged on Lantus qhs and a
sliding scale of lispro. The patient will need to continue with
the insulin until his liver function has improved.
.
#Urinary tract infection: the patient had a urinalysis which was
suggestive of a UTI, however the urine culture showed mixed
flora. Given his worsening renal function and recent urinary
catheter from the OSH, he was treated with a course of
ceftriaxone.
.
#Transitional Issues:
Pending labs: None
Medications started:
1. Lantus Insulin 22Units at bedtime
2. Insulin sliding scale
3. Pantoprazole
4. Ursodiol
5. Folic acid
6. Thiamine
7. Multivitamin
8. Colace
9. Prednisone 30mg by mouth once a day until [**10-6**] (then
decrease to 20mg by mouth once a day until [**10-13**], then decrease
to 10mg by mouth once a day until [**10-20**])
10. As needed medications for rehab include: tylenol, trazodone,
senna, metoclopromide, simethicone
Medications stopped:
1. Pioglitazone (hold this for the time being until you discuss
with your primary care doctor)
2. Valsartan (this can be restarted if you are hypertensive)
3. Diltiazem (this can be restarted if you are hypertensive)
4. Ezetimibe
5. Lipitor
6. Niacin
Follow-up
You have follow-up scheduled with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] will need to have your blood pressures checked regularly at
rehab and they can adjust your blood pressure medications as
needed
Medications on Admission:
Home medications- verified with patient:
Valsartan 320 mg po daily
Atenolol 50mg po daily
Diltiazem 180mg po daily
Ezetimibe 10mg po daily
Lipitor 80mg po daily
Niacin ER 500mg po daily
Pioglitazone 15mg po daily
Aspirin 325mg po daily
Discharge Medications:
1. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas, bloating.
7. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. insulin glargine 100 unit/mL Cartridge Sig: Twenty Two (22)
units Subcutaneous at bedtime.
9. insulin lispro 100 unit/mL Cartridge Sig: see attached
sliding scale Subcutaneous three times a day: per sliding
scale.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not exceed 2g in 24 hour period.
11. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea/vomiting.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for consitpation.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary: Alcoholic hepatitis, Cirrhosis, acute renal failure,
urinary tract infection
Secondary: Diabetes, Hypertension
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 90901**],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**].
You were transferred here from another hospital for concern
about your liver as it was not working properly causing your
skin to turn yellow (jaundice). Your bilirubin (the substance
that causes the yellowing of the skin) continued to rise while
you were here despite no obvious signs of something causing a
blockage in your liver to make this go up. You underwent a
liver biopsy which showed changes consistent with cirrhosis
(scarring of the liver) from alcohol use. You were started on a
course of oral steroids and your bilirubin came down and is
still decreasing. It is also important to get a lot of calories
in your diet to help heal your liver. You were seen by nutrition
who made recommendations of how you can maintain a 2000calorie
diet.
You also had worsening kidney function while you were here. You
were seen by the kidney specialists who looked at your urine and
saw signs of acute kidney injury that they feel was most likely
due to your low blood pressures and illness prior to being
transferred. We gave you fluids and monitored the kidney
function and it returned to [**Location 213**] at the time you were
discharged.
You were also found to have a urinary tract infection, which was
most likely due to the fact that you had a urine catheter in
place while you were in the ICU at the outside hospital. This
was treated with a course of IV antibiotics.
As you had been in the hospital for an extended amount of time
you were seen by the physical and occupational therapists who
worked with you to get you stronger, and this will be an ongoing
process as you continue to improve.
Your diabetes was controlled here with Insulin instead of your
home actos. The oral steroids that you were started on for your
liver treatment make your blood sugars worse. For the time being
you will need to remain on insulin, and check your blood sugars
regularly.
While you were here we stopped most of your cholesterol
medications as they can affect the liver. Please discuss with
Dr. [**Last Name (STitle) **] and your PCP about when it will be appropriate to
restart these medications.
For your blood pressure, we only kept you on your atenolol as
your pressures were not very high. While you are at rehab they
can monitor your blood pressure and decide if the valsartan and
the diltiazem should and when to be restarted.
Transitional Issues:
Pending labs: None
Medications started:
1. Lantus Insulin 22Units at bedtime
2. Insulin sliding scale
3. Ursodiol 300mg by mouth twice a day
4. Prednisone 30 mg by mouth once a day until [**10-6**]- (then
decrease to 20mg by mouth once a day until [**10-13**], then decrease
to 10mg by mouth once a day until [**10-20**]
5. Simethicone (for gas/bloating)
As needed medications for rehab include: tylenol, trazodone,
senna, colace, metoclopromide
Medications changed: None
Medications stopped:
1. Pioglitazone (hold this for the time being until you discuss
with your
2. Valsartan (this should be held until your liver has fully
recovered)
3. Diltiazem
4. Ezetimibe
5. Lipitor
6. Niacin
Follow-up
You have follow-up scheduled with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] will need to have your blood pressures checked regularly at
rehab and they can adjust your blood pressure medications as
needed
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: LIVER CENTER
When: WEDNESDAY [**2117-10-6**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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icd9cm
|
[
[
[]
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,962
| 177,035
|
40586
|
Discharge summary
|
report
|
Admission Date: [**2142-6-23**] Discharge Date: [**2142-6-27**]
Date of Birth: [**2084-3-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58M w/ PMH of hx of lung CA (BAC) with liver mets on gemcitabine
who presents with 2 days of worsening cough productive of white
sputum, subjective low grade fevers, shortness of breath. The
history is provided via translation by the son. [**Name (NI) **] reports that
he told his father he needed to go the [**Name (NI) **] on [**2142-6-23**] and drove
him in to [**Hospital1 18**] after speaking with his oncologist. Pt has had
chest pain with coughing, non-exertional, non-pleuritic. No leg
swelling, chills. No recent hospitalizations. On further
questioning, patient does endorse history of wheezing with cold
air. Denies orthopnea or PND. Of note, according to OMR patient
was seen [**2142-6-5**] for chemo and was c/o cough and congestion. He
was noted to be wheezy, with good oxygen sat on RA, and was
ordered for bronchodilators.
.
In the ED, initial VS: 99.4 125 138/84 96% RA. He was triggered
for being tachy to 130s and tachypneic to 30s, hypoxic to low
90s on RA. Tight breath sounds with wheezes on exam. More cough
and rhonchi after nebs. Considered PE in differential but given
infiltrate decided no CTA. Labs notable for lactate 2.2, WBC 8.5
with 86%N, Hct 35 (baseline), phos 1.8, AP 389 (had been
increasing recently). PCXR showed RLL infiltrate c/f PNA. EKG
showed sinus tachycardia. Blood cultures drawn. He was given
cefepime, ipratropium neb x2, albuterol nebs x3, vancomycin 1
gram, 1.5L NS.
.
Pt was transferred directly to the MICU from the ED because of
worsening tachypnea and tachycardia. On arrival to the MICU, he
stated he was breathing a little bit better.
Past Medical History:
- metastatic lung cancer (pt not a smoker)
** See onc note form [**2141-11-7**] for entire oncology hx
- benign sigmoid polyps
- Hernia repair on [**2141-5-19**].
metastatic lung cancer (pt not a smoker)-history below
--[**6-1**] CXR that revealed a 4 x 4 cm right middle lobe nodule.
---[**7-1**] CT scan revealed a 4.5 x 4.8 cm right perihilar mass as
well as numerous confluent right upper lobe nodules and
subcarinal lymphadenopathy. There were tiny contralateral
nodules noted in the left lower lobe, none larger than 3 mm.
--[**7-1**] needle core biopsy of the right lung mass, which revealed
adenocarcinoma, moderately differentiated, consistent with
non-mucinous bronchoalveolar carcinoma. EGFR mutation status
unknown. He was started on Tarceva.
--[**2137**]-[**2139**] He did well on Tarceva. Subsequent scans in
[**Month (only) **] as well as [**2138-11-24**] revealed a marked
improvement in his disease. He was scanned serially
approximately every three months while on Tarceva with no
evidence of worsening disease until [**10/2140**]
--[**11-3**] CT scan right perihilar mass was again noted to be as
large as 4 x 4 cm. Also in [**10/2140**], he developed visual changes
in the right eye. He was subsequently noted to have a large
detachment of the macula with an oval choroidal lesion
underneath the superior temporal arcade in the right eye,
presumably due to metastatic disease.
--[**12-3**] He subsequently underwent radiation up to 20 Gy at [**Hospital 88830**] Infirmary and has done well with good control of the
lesion per outside hospital reports.
--[**2-/2141**] CT scan revealed persistent right perihilar lung mass
measuring 4.1 cm, multiple nodules in a right perihilar
distribution GGO RML, 8 mm nodule in the right hepatic lobe, a
1.5 cm nodule immediately adjacent in the right hepatic lobe in
a subcapsular location, as well as a stable hepatic cyst,
suspicious lymph node in the region of the gastrohepatic
ligament measuring 9 mm in short axis. He continued on Tarceva.
--[**2141-5-5**] worsening periumbilical pain. CT scan revealed
abnormal increased density in the inferior right hilum with a
small right pleural effusion, a round area of decreased
attenuation in the right lobe of the liver, which had the
appearance of a cyst, and three rounded areas of decreased
attenuation in the right lobe of the liver, which appeared to
have increased in size when compared to the CAT scan done on
[**2141-3-8**]. There were also small lesions in the left lobe of
the liver.
--[**2141-5-19**] by Dr. [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 19122**] for repair of an umbilical
hernia. Pathology revealed a metastatic well-to-moderately
differentiated adenocarcinoma in the hernia sac and contents
with strong positivity for CK-7 and TTF-1 and negative for
CK-20. The sample was sent for EGFR testing, which was
negative.
---[**2141-5-29**] ultrasounded-guided core biopsy of the liver
revealed a metastatic adenocarcinoma consistent with a lung
primary of a bronchoalveolar type. No EGFR mutation was
detected. insufficient tissue for ALK testing.
--[**2141-6-14**] PET CT: FDG avid right perihilar coalescent
pulmonary mass with satellite lesions and moderate pleural
effusion. Avid supraclavicular, mediastinal and retroperitoneal
adenopathy as detailed. Left adrenal and multiple (at least 5)
hepatic metastases. Extensive omental caking. Osseous
metastases involving C3 vertebral body, posterior left 10th rib,
proximal femurs, left iliac [**Doctor First Name 362**], and sacrum.
--[**2141-6-14**] MRI brain: Proliferation of intraconal fat in the
right orbit, with mild mass effect on the optic nerve, likely
representing a sequela of known radiotherapy to this site. No
suspicious parenchymal, meningeal or bone lesion to suggest
metastatic disease.
--[**2141-8-8**]: started 5 cycles of carboplatin/alimta
--[**2141-9-21**]: CT torso: Interval improvement in the size of the
right lung nodules; perihilar mass 2.1 x 1.8 cm previously 4.2 x
3.4. Stable appearance of liver, adrenal and omental metastatic
disease. Significant interval worsening of multiple sclerotic
bony lesions, mild interval worsening of moderate-to-large
hyperenhancing right pleural effusion.
--[**2141-11-7**] started alimta maintenance
--[**2142-1-19**] CT torso:
Interval worsening hepatic metastatic lesions with increase in
size and number of the metastatic deposits. Stable to slightly
decreased pulmonary disease. Decrease in omental masses. Stable
right pleural effusion. Stable osseous metastatic tumor.
--[**2142-5-16**] CT torso, no appreciable change in the diffuse
multiple bilateral small pulmonary nodules or right-sided
pleural effusion or mediastinal adenopathy. There has been an
increase in the size and number of hepatic metastasis, the
largest now to 44 mm from 31 and now there is a new lesion from
segment III.
There is diffuse omental thickening and stranding consistent
with metastatic disease, which is present on prior study, but
subjectively appears to have increased. Bone windows again
demonstrate metastatic disease with potentially a new 3 mm
sclerotic focus at T8 and possibly L4.
--[**2142-5-8**] started gemcitabine 1000 mg/m2. week 3 held for
thrombocytopenia.
- benign sigmoid polyps
- Hernia repair on [**2141-5-19**]
- h/o duodenitis
- h/o thrombocytopenia
Social History:
The patient is married with three children, ages18 to 36, all in
the US. The youngest child still lives with himand his wife.
Family is very supportive. The patient isSpanish-speaking only.
He comes to clinic with his nephew. [**Name (NI) 88831**] until recently
worked in a factory, which made radiators.The patient has never
smoked. The patient takes no alcohol. [**Name (NI) 88831**] denies
illicits.
Family History:
No family history of lung cancer or other malignancies.
Physical Exam:
INITIAL
VS: T 98.7 HR 111 BP 115/80 O2sat 94% on 1L RR 22
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, OP clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Fast but regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diffuse inspiratory and expiratory wheezes, no stridor,
poor air entry throughout, no rales or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
VS: T 98.7 HR 111 BP 115/80 O2sat 94% on 1L RR 22
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, OP clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Fast but regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diffuse inspiratory and expiratory wheezes, no stridor,
poor air entry throughout, no rales or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Pertinent Results:
[**2142-6-27**] 07:50AM BLOOD WBC-10.9 RBC-3.46* Hgb-10.6* Hct-32.4*
MCV-94 MCH-30.8 MCHC-32.9 RDW-17.2* Plt Ct-130*
[**2142-6-24**] 03:33AM BLOOD Neuts-80.9* Lymphs-15.8* Monos-2.9
Eos-0.1 Baso-0.3
[**2142-6-23**] 12:15PM BLOOD Neuts-86.2* Lymphs-9.6* Monos-1.4*
Eos-2.2 Baso-0.5
[**2142-6-27**] 07:50AM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.3*
[**2142-6-26**] 07:00AM BLOOD PT-12.9* PTT-27.1 INR(PT)-1.2*
[**2142-6-25**] 07:06PM BLOOD PT-13.2* PTT-28.0 INR(PT)-1.2*
[**2142-6-26**] 07:00AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2142-6-25**] 07:05AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-142
K-4.1 Cl-107 HCO3-28 AnGap-11
[**2142-6-25**] 07:05AM BLOOD ALT-26 AST-20 LD(LDH)-313* AlkPhos-298*
TotBili-0.5
[**2142-6-25**] 07:05AM BLOOD cTropnT-<0.01 proBNP-521*
[**2142-6-23**] 12:15PM BLOOD proBNP-787*
[**2142-6-25**] 07:05AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.2
[**2142-6-24**] 03:33AM BLOOD Albumin-3.5 Calcium-7.7* Phos-1.8* Mg-2.3
.
Chest CT:
1. Extensive bilateral pulmonary emboli as described.
2. Right upper opacity is mostly likely infectious with lower
lobe
atelectasis.
3. Right juxtahilar lesion and innumerable pulmonary metastases
are increased with accompanying increased moderate pleural
effusion.
4. Increased compression and possible invasion of left main
stem bronchus by increased subcarinal soft tissue.
Head CT [**6-24**]:
1. Limited evaluation for hemorrhage given recent IV contrast
bolus through prior study. No definite acute hemorrhage.
2. No definite mass lesion to suggest intracranial metastatic
disease. If there is ongoing clinical concern, MRI of the brain
is recommended for
increased sensitivity for detection.
NOTE ADDED AT ATTENDING REVIEW: There are two tiny cortical
foci, one left frontal, one right parietal (series 2 image 22
and series 2 image 23), that are hyperdense and appear cortical.
There is no associated edema. It is possible these are normal
vessels on end, but in the setting of metastatic disease, the
possibility of metastases should be considered. Since contrast
was given for a Chest CTA, the high density may reflect contrast
enhancement, rather than hemorrhage or calcifictation. These
findings would be best pursued with an MR examination including
contrast.
Radiology Report BILAT LOWER EXT VEINS [**2142-6-26**]
IMPRESSION: Bilateral femoral vein deep venous thrombosis,
partially
occlusive.
MR HEAD [**2142-6-26**]
IMPRESSION: 1. Punctate focus of abnormal enhancement noted on
the right cerebellar hemisphere and two small ring-enhancing
lesions in the left cerebellar hemisphere, with no significant
mass effect or edema.
2. Supratentorially, there are two small foci of abnormal
enhancement in the left and right frontal lobes, with no
evidence of mass effect or edema, these lesions are highly
suspicious for metastatic disease.
IMPRESSION: AP chest compared to [**6-23**] and [**6-24**]:
[**2142-6-24**] CXR
Previous mild pulmonary edema has improved, most evident in the
left lung.
Small right pleural effusion is larger. Opacification at the
base of the
right lung could be the residual of edema and atelectasis, but
there is a
heterogeneous quality to it that raises concern for pneumonia.
Heart size is normal. This is confirmed in the right upper lobe
on the chest CTA performed
nearly concurrently. The small lung nodules seen on that study
are barely visible on this conventional bedside radiograph.
.
Discharge labs:
[**2142-6-27**] 07:50AM BLOOD WBC-10.9 RBC-3.46* Hgb-10.6* Hct-32.4*
MCV-94 MCH-30.8 MCHC-32.9 RDW-17.2* Plt Ct-130*
[**2142-6-26**] 07:00AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
Brief Hospital Course:
In summary this is a 58 male with metastatic NSCLC who presented
with cough, fevers, and dyspnea and found to have evidence of
multiple central PEs confirmed by CTA on [**2142-6-24**], as well as DVT
and endobronchial lesion, requiring stenting by IP.
.
# Pulmonary emboli: Was Confirmed on CTA. Pt was started on
Heparin and then bridged to Lovenox. LE Ultrasound revealed
bilateral DVTs. Troponin was negative and BNP were negative.
EKG did not show strain. Pt continued to be very wheezy on
exam, not moving air well which implied element of bronchospasm
also contributing to his respiratory symptoms. He was discharged
on long term lovenox given his malignancy. He will have an IVC
filter placed as below - given his need for endobronchial stent
next week.
.
#Possible Pneumonia: pt received broad spectrum antibiotics for
HCAP and was later switched to Levofloxacin when his pneumonia
was no longer concerning for HCAP. He did meet SIRS criteria
with tachypnea and tachycardia but had no evidence of septic
shock.
.
# Lung cancer with obstructive endobronchial lesion: pt has
broncheoalveolar carcinoma, known metastatic disease, and
currently is receiving gemcitabine. Head CT and Brain MRI
revealed metastatic diesease. Pt had elevated alk phos which was
likely from bony metastases. Mr [**Known lastname 34030**] will also follow up with
interventional pulmonary next week, and as he has an
endobronchial lesion that will require treatment to avoid lung
collapse.
.
# Anemia: Patient's hematocrit was stable and did not trend
downward. Hct had been steadily decreasing over the past month
(i.e. Hct on [**2142-5-29**] was 40 and today [**2142-6-27**] is 32). Likely
related to malignancy and/or Fe deficiency.
.
# Code: Confirmed Full code
Follow up plans:
Mr. [**Known lastname 34030**] will follow up next week for IVC filter placement
and endobronchial lesion stenting with interventional pulmonary.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Ondansetron 8 mg PO TID:PRN nausea
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
4. Benzonatate 100 mg PO TID:PRN cough
5. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
6. Ferrous Gluconate 325 mg PO DAILY
7. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
Hold for sedation, RR<10
8. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q6H:PRN
SOB
2 puffs
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 80mg twice a day Disp #*60 Syringe
Refills:*0
2. Benzonatate 100 mg PO TID:PRN cough
3. Ferrous Gluconate 325 mg PO DAILY
4. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
5. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
Hold for sedation, RR<10
6. Levofloxacin 750 mg PO DAILY Duration: 4 Doses
7. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
8. PredniSONE 40 mg PO DAILY Duration: 1 Days
9. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q6H:PRN
SOB
2 puffs
10. Ondansetron 8 mg PO TID:PRN nausea
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Emboli
Deep venous thrombosis
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 34030**],
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted because of fevers and increased shortness of breath.
During your hospital stay it was discovered that you had blood
clots in your lungs. Therefore you were started on medicine
(Lovenox) to help so the clots would not grow any larger. You
will need to follow the instructions you received from the nurse
and inject this medicine after going home. You will need to
follow up with the Interventional Pulmonary Service for possible
stenting of a possible blockage in the lung airways. They will
give you a call at home for a followup visit. If you do not hear
from the, please call Phone: [**Telephone/Fax (1) 3020**] to book an appointment
with the Lung (Pulmonary) doctors.
Please also follow up with your oncologist Dr. [**Last Name (STitle) **].
Details are mentioned below on your followup appointments.
Followup Instructions:
You will need to follow up with the [**Hospital1 18**] Interventional
Pulmonary Service for possible stenting of one of the closing
airways in your lungs. They will give you a call at home for a
followup visit.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2142-7-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], RN [**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: TUESDAY [**2142-7-17**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2142-7-17**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) 610**] [**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
|
[
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"415.19",
"785.0",
"198.3",
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"280.9",
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"285.22",
"453.41",
"287.5",
"198.5",
"197.7",
"486",
"V58.69",
"799.02",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16006, 16012
|
12835, 14753
|
320, 326
|
16106, 16106
|
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|
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|
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|
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|
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1970, 7320
|
7336, 7742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,237
| 149,775
|
6526
|
Discharge summary
|
report
|
Admission Date: [**2112-1-12**] Discharge Date: [**2112-1-16**]
Date of Birth: [**2034-7-19**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Levaquin / Nafcillin / ceftazidime
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
cough, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 year old gentleman with a history of CHF, AF on coumadin,
severe peripheral vascular disease s/p multiple bypasses and
procedures, polymicrobial left foot osteomyelitis (CoNS, MSSA,
Stenotrophomonas) and associated MSSA BSI who is transferred
from [**Hospital **] hospital for new onset cough, dyspnea and fever.
Per records patient developed fever to 100.8, chills, increased
respiratory rate and dyspnea. He was going to be sent to [**Hospital1 18**]
but then he deteriorated quickly with sats down to 70% on 2L NC.
He was briefly started on CPAP and sent to [**Hospital **] Hospital.
.
On arrival at [**Location (un) **] his VS were 99.2, hr 96, BP 125/70. He was
tachypnic to 40 with sats 96% on NRB. He was given 80mg IV lasix
(at 5:15 AM) and then 180mg IV lasix (at 6:00 AM) as well as 1
gram IV vanco and 600mg IV [**Last Name (un) 2830**]. O2 sats improved on 40%
ventimask. Per record only put out 250 cc to 260 total lasix at
OSH.
.
He denies any chest pain, orthopnea, PND. He does have some
shortness of breath.
.
Noted to have new onset ascites on recent admission ([**10-11**]) with
a negative paracentesis.
.
In the ED inital vitals were, 96.2 66 120/77 20 96% 40% venti
mask. Initial labs showed a WBC of 25 with 10% bandemia. He was
subsequently transferred to the ICU. At the time of transfer his
vital signs were 97.9 106/54 99/4L 82.
.
On arrival to the ICU he was comfortable but appeared to have
somewhat labored breathing. His only complaint was a cough.
.
He was discharged [**12-10**] after being hospitalized for left foot
osteomyelitis and gangrene with MRSA and E. cloacae s/p left 2nd
toe amputation ([**11-30**]) and debridement of 2nd and 3rd Metatarsal
heads ([**12-3**] and [**12-9**]). Discharged on vanc/[**Last Name (un) 2830**] being followed by
Dr. [**First Name (STitle) **] in OPAT, planning for 6 week course to end [**1-20**].
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-Diabetes Mellitus
-Hypercholesterolemia
-Hypertension
-Aortic Stenosis (area 1.2-1.9 cm2)
-Atrial Fibrillation (on coumadin)
-CHF (EF > 55%)
-CRI (baseline Cr 2.2-2.9)
-Obesity
-Hypothyroid
-Gout
-BPH
-Dieulafoy's Lesion duodenum with GIB- [**8-10**]
-H. pylori PUD with GIB- [**2103**]
-Peripheral vascular disease
-MSSA BSI associated with left foot osteomyelitis; cx grew MSSA,
CoNS, Stenotrophomonas- [**1-9**]
-s/p right malleolar ulcer- [**2111**]
-s/p L THR- [**5-9**]
-s/p L CEA- [**2108**]
-s/p radical prostatectomy- [**2108**]
-s/p L3-4 laminectomy- [**1-31**]
-s/p LLE Bypass Graft (LLE fem to peroneal, LLE vein patch
angioplasty)- [**2101**]
-s/p LLE jump graft from fem-peroneal to distal peroneal with
cephalic vein- [**1-9**]
-s/p Balloon angioplasty of distal anastomosis of right common
femoral to below-knee popliteal artery vein bypass graft- [**6-10**]
-s/p I&D R hallux abscess [**8-2**], [**10-3**]
-s/p Left metatarsal head resection [**1-9**]
Social History:
lived with wife until recent admission, now at rehab facility.
Quit smoking in [**2083**]; denies alcohol or recreational substance
use.
Family History:
non-contributory
Physical Exam:
Admission exam:
Vitals: T 97.3 P 95 R 22 O2 sat 99/RA
General: Alert, oriented, no acute distress
HEENT: dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diminished at bases, scattered bibasilar crackles, faint
expiratory wheeze
CV: irregular, no R/G/M appreciated
Abdomen: distended but soft and nontender, bowel sounds present,
no rebound tenderness or guarding, no organomegaly appreciated
GU: foley
Ext: 2+ pitting edema bilaterally, left 2nd toe packed, right
medial malleolus superficial
.
Discharge Physical Exam:
96.3 143/63 57 20 95%RA
FSBS: 109-205
GA: Awake and alert, sitting on edge of bed.
Cards: Irregularly, irregular. II/VI systolic murmur.
Pulm: Decreased breath sounds at bases and minimal crackles.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: Both feet in dressing which are c/d/i. Venous
stasis changes on both shins. Scars from multiple prior bypass
surgeries/interventions. Toe amputated on right. [**2-1**]+ pitting
edema. On removal of dressing wounds look good without
surrounding erythema or draining pus.
Neuro/Psych: Awake, alert and oriented.
Pertinent Results:
Admission labs:
WBC-24.4*# RBC-2.85* Hgb-8.6* Hct-29.5* MCV-103* MCH-30.2
MCHC-29.2* RDW-19.5* Plt Ct-230
Neuts-83* Bands-10* Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
PT-39.4* PTT-42.4* INR(PT)-3.9*
Glucose-169* UreaN-43* Creat-2.2* Na-142 K-3.9 Cl-106 HCO3-29
AnGap-11
ALT-19 AST-28 LD(LDH)-262* AlkPhos-161* TotBili-0.4
proBNP-[**Numeric Identifier 25033**]*
Albumin-3.4* Iron-19*
calTIBC-260 VitB12-366 Folate-GREATER TH Ferritn-195 TRF-200
Lactate-1.4
.
Discharge labs:
[**2112-1-16**] 06:59AM BLOOD WBC-7.7 RBC-2.97* Hgb-8.9* Hct-29.9*
MCV-101* MCH-30.0 MCHC-29.8* RDW-19.7* Plt Ct-215
[**2112-1-16**] 06:59AM BLOOD Glucose-118* UreaN-54* Creat-2.3* Na-144
K-3.9 Cl-106 HCO3-29 AnGap-13
[**2112-1-16**] 06:59AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1
[**2112-1-16**] 06:59AM BLOOD Vanco-20.8*
.
Microbiology:
Blood culture ([**2112-1-12**])- NGTD, pending x 2
Urine culture ([**2112-1-12**])- no growth, final
Rapid Respiratory Viral Screen & Culture ([**2112-1-12**])-
Respiratory Viral Culture (Preliminary): NEGATIVE
Respiratory Viral Antigen Screen (Final [**2112-1-13**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
MRSA ([**2112-1-12**]): NEGATIVE
.
Imaging:
CXR [**2112-1-13**]- The tip of a right-sided PICC line is difficult to
visualize but is probably unchanged. The lung volumes remain
low. There is an extensive consolidation in the right lower
lung, probably in the right lower lobe. The appearance is fairly
similar to the more recent prior radiographs allowing for
differences in technique although pulmonary vasculature is
somewhat less prominent. It is difficult to exclude small
pleural effusions but no definite pleural effusion is seen. The
cardiac, mediastinal and hilar contours appear unchanged,
including cardiac enlargement.
IMPRESSION:
1. Persistent consolidation in the right lower lung worrisome
for pneumonia. Follow-up radiographs are recommended to show
resolution within eight weeks.
2. Findings suggesting mild vascular congestion but seemingly
improved.
.
Foot Xray [**2112-1-13**] -
1. Osseous erosive changes are noted at the right first
interphalangeal joint at the base of the distal right first
phalanx may represent changes of inflammatory or crystalline
arthritis or osteomyelitis in the appropriate clinical setting.
If there is clinical concern for osteomyelitis, consider
correlation with right foot or forefoot MRI.
2. Prior fracture deformity through the distal diaphysis of
right second
metatarsal.
3. Prior resection changes involving distal third left
metatarsal and proximal portion of third proximal phalanx and
prior amputation of the mid shaft second metatarsal and
phalanges and partial metatarsal and proximal
first left phalangeal digit amputation. Interval decreased soft
tissue gas at prior resection site involving the left forefoot
without signs of periostitis or new osseous erosion. If clinical
concern for left foot osteomyelitis, consider left forefoot MRI.
.
Video Swallow [**2112-1-14**] - IMPRESSION: No gross aspiration, but
penetration was seen with thin liquids. For full detail, please
see the speech and swallow note in OMR.
.
ECHO - IMPRESSION: Moderate biatrial enlargement. Mild symmetric
left ventricular hypertrophy with normal cavity size and
rpreserved global and regional biventricular systolic function.
Dilated right ventricle with impaired systolic function. Mildly
dilated aortic root and ascending aorta. Mild aortic stenosis.
Mild to moderate mitral regurgitation. At least moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
.
RUE U/S [**2112-1-14**] - FINDINGS: Grayscale and Doppler son[**Name (NI) **] of
the right internal jugular, subclavian, axillary, and brachial
veins were performed. There is normal compressibility, flow, and
augmentation throughout. A PICC is seen in the right brachial
vein. The right cephalic and basilic veins are patent.
IMPRESSION: No DVT in the right upper extremity.
Brief Hospital Course:
77M CHF, s/p R toe amp + osteomyelitis, history of afib on
coumadin, recent admission for toe amputation with long course
of antibiotics for osteo presenting from OSH for new onset
respiratory distress.
.
.
ACTIVE ISSUES:
# Respiratory Distress: Patient initially presented with
leukocytosis of 24 with banemia of 10%, in addition to
tachypnea. Lactate was normal at 1.8 and patient was
hemodynamically stable. Most likely source of infection was
aspiration pneumonia given frequent observed aspirations. Rapid
respiratory viral screen negative but culture pending. Also
patient has several risk factors for developing transient
bacteremia including osteo and PICC site. However, on arrival
to the ICU, he stabilized very quickly. Lactate never
increased, and leukocytosis/bandemia resolved by HD 1. Patient
was continued on vancomycin and meropenem to cover HCAP as well
as osetomyelitis. Diuresed agressively. Likely diagnosis is
flash pulmonary edema in the setting of aspiration PNA. His
cultures remained negative. The patient was HD stable and was
transferred to the medical floor. On the medical floor the
patient continued to do well. Vancomycin was held due to
elevated troughs. At the time of discharge, trough was 20.8.
After discussion with ID and pharmacy, decision was made to
restart vancomycin 500 mg IV q48 hours, with plan to check level
on Monday, [**1-18**]. He will have close follow up with Dr.
[**First Name (STitle) **] in ID for adjustment of medication.
.
# Osteomyelitis: Patient has chronic osteomyelitis s/p
amputation and multiple debridements. Prior to admission, he was
undergoing a course of vanc/meropenem via PICC followed by Dr.
[**First Name (STitle) **] at OPAT. Xray of the feet done here as described prior and
will be followed by ID. Vancomycin dosing was changed, as
described above.
.
# CKD: stage 4, baseline ~2.5, briefly on HD during recent
admission which was stopped on discharge. Patient's creatinine
was at his baseline throughout admission. He was continued on
home renagel and medications were all renally dosed.
.
# Anemia: HCT ~30 with elevated MCV (103). Labs consistent with
anemia of chronic disease, and B12 and folate levels normal.
Therefore, unclear why he has a macrocytosis. Further eval on
an outpatient basis.
.
# AF: Coumadin held on admission for supratherapeutic INR of 3.9
This rose to 5.0 on HD1, likely due to underlying poor liver
function. Would be less likely that this is related to
antibiotics as patient has been on this regimen for several
weeks. Patient was given vitamin K on HD1 and INR improved.
Coumadin restarted at 2.5mg on day of discharge.
.
# Swallowing: Concern for aspiration PNA given presentation. Was
initally made NPO. Underwent swallow study which the patient did
well on. Recommended regular diet with thin liquids and PO meds
with puree.
.
.
TRANSITIONAL ISSUES:
# Vancomycin dosing has been reducsed by half. Patient should
have level checked on Monday, [**1-18**], with results faxed
Dr. [**First Name (STitle) **] in ID.
# Please continue to monitor patient's INR.
Medications on Admission:
Allopurinol 100 mg PO/NG EVERY OTHER DAY
Aspirin 81 mg PO/NG DAILY
Digoxin 0.125 mg PO/NG MWF QAM
Ferrous Sulfate 325 mg PO/NG DAILY
Metoprolol Tartrate 100 mg PO/NG [**Hospital1 **]
Heparin 5000 UNIT SC TID
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Calcitriol 0.25 mcg PO DAILY
Levothyroxine Sodium 100 mcg PO/NG DAILY
Meropenem 500 mg IV Q8H
Simvastatin 20 mg PO/NG QHS
Pantoprazole 40 mg PO Q24H
Senna 1 TAB PO BID:PRN Constipation
sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO MWF QAM ().
5. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours).
8. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One
(1) Tablet PO once a day.
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
17. Outpatient Lab Work
Have VANCOMCYIN level lab checked in the morning on Monday,
[**1-18**], with results faxed to Dr. [**First Name (STitle) **] (fax: [**Telephone/Fax (1) 1419**]
phone: [**Telephone/Fax (1) 457**]).
18. vancomycin 500 mg Recon Soln Sig: One (1) recon soln
Intravenous q48 hours.
Disp:*3 recon soln* Refills:*0*
19. 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.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 511**] Siani
Discharge Diagnosis:
Primary: Pneumonia
Secondary: Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted due to cough, fever and
shortness of breath. It appears that you had a pneumonia that
caused an exacerbation of your heart condition. In the hospital
you were treated with antibiotics for the pneumonia and a
diuretic to help remove excess fluid from your body. Your
symptoms have now greatly improved and we believe you are ready
to be discharged.
See below for changes to your medication regimen:
1) Please CHANGE vanocmycin dose to: vancomycin 500 mg IV every
48 hours
2) Have vancomycin level lab checked on Monday, [**1-18**],
with results faxed to Dr. [**First Name (STitle) **] (fax: [**Telephone/Fax (1) 1419**] phone:
[**Telephone/Fax (1) 457**]).
Also: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Wishing you all the best!
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2112-1-20**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2112-1-17**]
|
[
"V45.77",
"507.0",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
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14555, 14611
|
9076, 9283
|
318, 324
|
14710, 14710
|
4986, 4986
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3826, 4344
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|
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|
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352, 2227
|
5002, 5459
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14725, 14837
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
133
| 191,817
|
24424
|
Discharge summary
|
report
|
Admission Date: [**2165-5-6**] Discharge Date: [**2165-5-16**]
Date of Birth: [**2088-1-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
intermittent chest pain for 1-2 months, but worse in last few
days prior to admission with associated arm pain
Major Surgical or Invasive Procedure:
cabg x3 [**5-7**]
History of Present Illness:
77 yo male with 1-2 months , but worsening in past few days.
Also has associated arm pain. Admitted to [**Hospital **] Med Ctr. in
RI [**5-2**]. Ruled in for NSTEMI by exzymes. Cath performed there
revealed EF 70%, 90% LAD, CX 90-95%, 90% PDA. He has significant
COPD with reported hx of FEV1 0.6/ FVC 1.2L.
Transferred here for CABG with Dr. [**Last Name (STitle) **].
Past Medical History:
CAD
COPD
HTN
gout
depression
PVD s/p right CEA
Social History:
smoked 1 ppd for 55 years, quit 1 year ago
uses alcohol, but none in 2 months
wife died last year
Family History:
no family hx of CAD or CVA
Physical Exam:
5'6" 58.2 kg 99.3 125/91 SR 83 92% on 2L
NAD
AT/NC no JVD, lymphadenopathy, or bruits bilat. Healed Right
CEA scar.
distant heart sounds RRR no murmur
distant breath sounds without wheezes
abd. soft, NT, ND
extrems. without C/C/E, bilat erythema over medial malleoli, +
TTP
pulses: 2+ bil. carotid, radial; pops. not palpable
1+ bilat. femoral, DP and PT
Pertinent Results:
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-16**] 06:35AM BLOOD WBC-18.0* RBC-3.79* Hgb-11.4* Hct-34.4*
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 Plt Ct-295
[**2165-5-6**] 08:55PM BLOOD WBC-7.0 RBC-3.65* Hgb-11.6* Hct-33.7*
MCV-92 MCH-31.7 MCHC-34.3 RDW-12.2 Plt Ct-199
[**2165-5-16**] 06:35AM BLOOD Neuts-89.6* Lymphs-5.3* Monos-4.4 Eos-0.6
Baso-0.1
[**2165-5-16**] 06:35AM BLOOD Plt Ct-295
[**2165-5-6**] 08:55PM BLOOD PT-12.1 PTT-40.9* INR(PT)-1.0
[**2165-5-14**] 10:30AM BLOOD Glucose-110* UreaN-17 Creat-1.0 Na-134
K-4.2 Cl-92* HCO3-31* AnGap-15
[**2165-5-6**] 08:55PM BLOOD ALT-13 AST-21 LD(LDH)-183 AlkPhos-77
TotBili-0.4
[**2165-5-13**] 02:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.9
[**2165-5-6**] 08:55PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2165-5-8**] 12:24PM BLOOD Cortsol-29.0*
Brief Hospital Course:
Carotid u/s done pre-op showed no signif. stenoses. Underwent
CABG x3 on [**5-7**] with Dr. [**Last Name (STitle) **]. Plaque was found in thoracic
aorta during intraop TEE. Transferred to CSRU on titrated
neosynephrine and propofol drips. Remained on neo on POD #1 on
ventilator for weaning. Vascular surgery ([**Doctor Last Name **])
consulted about plaque and CTA of chest was negative for
dissection. Hemodynamically stable on neo 0.3. Extubated on POD
#2 and chest tubes removed. Transferred back to CSRU after one
hour on the floor. Not reintubated, but moitored carefully for
respiratory issues/COPD. Transferred back to floor on POD #4.
Seen and eval. by PT. Beta blockade and lasix diuresis started.
Had some confusion and wheezing. Treated with haldol and
restarted on pulmonary toilet. Anxiety and confusion has
resolved. Betablockade was increased on POD #7. He continued to
increase his ambulation. UTI diagnosed on [**5-15**] with rising WBC
to 20. WBC decreased to 18 today on day 2 of a 7 day course of
cipro. Afebrile today, VS 98.5 67 SR 166/63 RR 20 92% on 2L ,
55.5 kg today ( down from pre-op weight 2.5 kg). Alert and
oriented, wounds healing well. Patient is on 2L O2 via NC at
home. Will require O2 therapy. Transferred to rehab on POD # 9.
Medications on Admission:
Combivent 2 puffs QID
Heparin IV 800 u /he
Tiotropium 1 puff qd
ECASA 81 mg qd
Advair 50/100 1 puff [**Hospital1 **]
Flomax 0.4 mg qd
NTG paste prn
Bisoprolol 2.5 mg qd
lipitor 10 mg qd
lexapro 10 mg qd
atenolol 50 mg qd
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 1 months.
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer IH
Inhalation Q4WA ().
8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
[**12-2**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
10. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
11. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Formoterol Fumarate 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Capsule, w/Inhalation Device Inhalation [**Hospital1 **] (2 times a
day).
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6930**] Skilled Nursing
Discharge Diagnosis:
s/p cabg x3
CAD
COPD
elev. chol
HTN
UTI
gout
depression
MI
PVD s/p Right CEA
Discharge Condition:
stable
Discharge Instructions:
may shower over wounds; pat dry
no powders, creams or lotions on incisions
may not drive for one month
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
follow up with PCP [**Last Name (NamePattern4) **] [**12-2**] weeks post discharge
follow up with Dr. [**Last Name (STitle) **] for postop visit in 4 weeks
[**Telephone/Fax (1) 170**]
Completed by:[**2165-5-16**]
|
[
"274.9",
"496",
"V15.82",
"272.0",
"293.9",
"410.71",
"440.0",
"414.01",
"443.9",
"599.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"89.60",
"36.13",
"39.61",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5809, 5876
|
2715, 3985
|
430, 451
|
5997, 6005
|
1476, 2692
|
6203, 6419
|
1053, 1081
|
4257, 5786
|
5897, 5976
|
4011, 4234
|
6029, 6180
|
1096, 1457
|
280, 392
|
479, 851
|
873, 922
|
938, 1037
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,583
| 130,348
|
24603
|
Discharge summary
|
report
|
Admission Date: [**2164-9-12**] Discharge Date: [**2164-9-18**]
Date of Birth: [**2118-5-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Pollen/Hayfever
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
" not acting quite right "
Major Surgical or Invasive Procedure:
[**9-14**]: Left frontal Craniotomy and tumor resection
History of Present Illness:
46 yo M with h/o metastatic esophageal cancer was brought to
[**Hospital 792**]hospital by his wife who felt he was not acting
quite right. She notes a chance in his affect for the past
week. The patient complains of cloudy thinking and occasional
difficulty saying what he intends to say. He was found to have
a left frontal mass at [**State 792**]hospital and sent here for
further evaluation.
Past Medical History:
Stage III esophageal cancer s/p MIE [**2162-11-5**] after adjuvant
chemoradiation therapy.
Diverticulitis w/ colovesicle fistula s/p repair,
Ventral Hernia,
Dilated aortic root
Marfans Traits
Tonsil and adenoidectomy
Social History:
lives with wife and 2 daughters. Employed by [**Company 33655**]. no
tobacco, etoh or drugs
Family History:
Maternal grandfather died of squamous cell esophageal cancer at
age [**Age over 90 **]. Maternal aunt had breast cancer.
His mother has melanoma.
His paternal uncle and a paternal grandmother had [**Name2 (NI) 499**] cancer.
His eldest daughter has a [**Name (NI) 62108**] syndrome and [**Last Name (un) 62109**]
syndrome. She was initially found to have aortic root dilation
and carried the FBN1 gene, which
lead to identification of these problems in Mr. [**Known lastname 62107**] as
well.
Physical Exam:
O: T 96.7, BP 110/66, HR 76, RR 18, O2 Sats 95%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2mm bilat EOMs intact
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, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech with occasional word finding difficulty, very
mild expressive aphasia with good comprehension and repetition.
Naming intact. No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-4**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
PHYSICAL EXAM UPON DISCHARGE
awake, a+ox3
PERRL, EOMI
face symmetric, tongue midline
no drift
MAE's with full strengths
following all commands
Pertinent Results:
CT/CTA Head [**9-13**]
1. Large left frontal intraxial mass with surrounding edema in
close
proximity of anterior carotid arteries and deep cerebral veins;
however no
definite evidence of invasion. Both ACA are displaced to the
right.
2. Mass effect on bilateral frontal horns of lateral ventricles,
subfalcine
herniation, and 10-mm rightward shift of midline structures from
mass effect.
CT head [**9-14**]
1. Patient is newly status post superior left frontal craniotomy
and
resection of previously seen large left frontal lobe mass, with
expected
postoperative changes as delineated above. No large intracranial
hemorrhage
seen. Thin rim of hyperdense material seen in the resection bed,
probably
represent small amount of blood product and post-surgical
debris. This thin
rim is contiguous with more rounded hyperdense area which
apparently extends
into the mildly dilated left frontal [**Doctor Last Name 534**].
2. Substantially decreased
rightward mass effect and resolved effacement of frontal horns
after resection
of previously seen large left frontal mass.
MRI [**9-16**]
1. done. read PND
Brief Hospital Course:
Pt was admitted from the emergency room to the neurosurgery
service on [**9-13**]. He was started on decadron and cont on his
Keppra. He underwent a CTA to evaluate the vasculature around
the mass and a WAND MRI for intra op guidance.
On [**9-14**] he was taken to the operating room and underwent a left
frontal craniotomy and tumor resection. Post operatively he was
admitted to the ICU for close neurological monitoring and strict
blood pressure control. On post op exam he was doing well. He
was AOx3, following commands, his speech was intact and he moved
all ext with 5/5 strength. He did have a post operative head ct
that showed no new hemorrhage and good resection of tumor.
On [**9-15**] pt was transfered to the floor in stable condition. He
was mobilized OOB and his foley catheter was removed. He had no
trouble voiding on his own or tolerating a PO diet. On [**9-16**] &
[**9-17**] He remained neurologicaly intact and was seen by the
physical therapists who cleared him for discharge home. His
decadron was started on a wean.
On [**9-18**] the patient felt comfortable ambulating independently
and was without complaint. He was discharged home.
Medications on Admission:
chemotherapy meds, decadron, morphine, protonix, keppra
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. 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. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO taper: Take
4mg every 8 hrs x2 days, then
2mg every hrs x3 days, then 2mg every 12hrs and cont. until
appt.
Disp:*100 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Left Frontal Brain Mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
[**Month/Year (2) 2729**] are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, you
should not resume taking this until cleared by your doctor.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? If 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.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**6-9**] days (from your date of
surgery) for removal of your staples/[**Date Range 2729**] and a wound check.
Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or
staples. Be sure to point out any incisions, which may be
covered by clothing at the time of suture/staple removal. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2164-9-24**]
at 1PM. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. This is a
multi-disciplinary appointment. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2164-9-18**]
|
[
"401.9",
"759.82",
"348.4",
"197.0",
"311",
"198.3",
"348.5",
"V10.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6346, 6352
|
4293, 5455
|
307, 365
|
6420, 6420
|
3163, 4270
|
10278, 11397
|
1159, 1656
|
5561, 6323
|
6373, 6399
|
5481, 5538
|
6571, 6592
|
1671, 1916
|
241, 269
|
6604, 10255
|
393, 793
|
2210, 3144
|
6435, 6547
|
815, 1033
|
1049, 1143
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,010
| 199,960
|
49937
|
Discharge summary
|
report
|
Admission Date: [**2178-3-23**] Discharge Date: [**2178-3-27**]
Date of Birth: [**2124-7-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy
hemorhoidectomy
History of Present Illness:
This is a 53yo woman with history of Barrett's esophagus
followed by serial EGDs and prior h/o internal hemorrhoids on a
'[**76**] colonoscopy who presented with bright red blood per rectum x
6 wks. She also complained of worsening shortness of breath and
fatigue.
Upon evaluation in ED, she was found to have guaiac positive
bright red blood per rectum. Her initial vitals were as follows:
99.4, 87, 100/75, 16, 97% RA. She had no abdominal tenderness.
She had a Hct drop to 19.7 (from prior baseline of 28 to 37).
INR was 1.0. Platelets were 325. She refused NG lavage. She was
typed/crossed for red cell transfusion. Two Lg bore peripheral
IVs were placed. The GI fellow was made aware. She remained
hemodynamically stable throughout her ED stay with BP of (99 -
119)/(47 - 70). She was transfused 2units in total of PRBC.
Also got Seroquel 200mg, Trazadone 200mg, Morphine 2mg. The
patient was transferred to the MICU for further workup.
On interview on admission to the ICU, she confirmed that she has
had an ongoing history of blood per rectum over the past six
weeks. She reported ongoing rectal pain as well. She saw her
provider at [**Name9 (PRE) 882**], who prescribed topical Lidocaine. She had
some relief with her rectal pain, but described ongoing bloody
bowel movements on near daily basis. Over this time period, she
also describes symptoms of lightheadedness with no frank loss of
consciousness and exertional dyspnea. Denies any chest pain.
Otherwise, ROS negative. She specifically denied any n/v or
hematemesis. She denied any active ETOH abuse; she reports
having been abstinent x 8wks. She denied any NSAID use.
Past Medical History:
1. EtOH abuse - 20+ years history of drinking. Pt denies hx of
withdrawal seizures, however as per previous medical records she
has had episodes of seizures.
2. Depression
3. ? Esophageal/Gastric varices
4. Grade 2 internal hemorrhoids on colonoscopy [**2175-5-8**]
5. Psychiatric condition - currently not fully diagnosed per
OMR notes
6. History of a left breast mast excision (which was diagnosed
as metaplasia and fibrosis.
Social History:
The pt is a former elementry school teacher.
EtOH: more than [**2-13**] of vodka per day for over 20+ years
Tobacco: 1ppd x 7+ years continuing to smoke
Illicit drugs: As per prior d/c summaries, the pt has a histor
of cocaine abuse x 15 years (snorting only; no injection). She
is reported to have quit 10 years ago. She currently denies any
hx of cocaine use.
IVDU: None.
Family History:
M: died of anaplastic thyroid cancer at 65y/o
Maternal aunt: died of lung cancer
Physical Exam:
vs: AF, 72, 112/52, 20, 98% RA
gen a/o, nad
heent moist mucous membranes, anicteric
neck no JVD
cv rrr, no m/r/g
resp CTA bilaterally with no rales
abd soft, nt, nd, rectal (in ED) with guiaiac pos mucous
extr no c/c/e
Pertinent Results:
[**2178-3-23**] 10:32PM HGB-5.4* calcHCT-16
[**2178-3-23**] 05:25PM GLUCOSE-95 UREA N-17 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16
[**2178-3-23**] 05:25PM WBC-7.5 RBC-2.82*# HGB-6.2*# HCT-19.7*#
MCV-70* MCH-22.1* MCHC-31.6 RDW-16.5*
[**2178-3-23**] 05:25PM NEUTS-67.5 LYMPHS-25.6 MONOS-3.8 EOS-1.8
BASOS-1.3
[**2178-3-23**] 05:25PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MICROCYT-3+
[**2178-3-23**] 05:25PM PT-11.5 PTT-19.0* INR(PT)-1.0
Colonoscopy [**2178-3-25**]- internal hemorrhoids
[**2178-3-27**] 02:29PM BLOOD Hct-30.6*
[**2178-3-27**] 04:35AM BLOOD WBC-5.8 RBC-3.44* Hgb-9.2* Hct-27.0*
MCV-79* MCH-26.8* MCHC-34.0 RDW-20.0* Plt Ct-271
Upon discharge:
[**2178-3-27**] 04:35AM BLOOD Glucose-91 UreaN-15 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-28 AnGap-11
Brief Hospital Course:
This is a 53yo woman with h/o Barrett's esophagus and
internal/external hemorrhoids who presented with progressive
symptomatic bright red blood per rectum x 6 wks and a Hct drop
from 28 to 19.7.
.
1. Lower GI bleed- The patient was transferred to the MICU and a
total of three units of blood was transfused during her
hospitalization. She had a colonoscopy that showed large Grade 2
internal hemorrhoids or possible rectal varix with recent
stigmata of bleeding. The patient refused an NG lavage and EGD
as she had an EGD recently that did not show any signs of PUD or
source of bleeding. Therefore, the source of her bleeding was
presumed to be her hemorrhoids. The patient Hct had stabilized
after the blood transfusions and she was transferred to the
floor. A surgical consult was called and the patient underwent a
hemorhoidectomy. She was discharge after the procedure as her
Hct had been stable for > 48hrs. She was advised to return to
the ER if her bleeding recurred. She was also advised to follow
up with her surgeon, Dr. [**Last Name (STitle) 1120**] upon discharge and to have a CBC
checked in one week and sent to her PCP
.
2. depression/anxiety: The patient was continued on her home
regimen.
.
3. h/o ETOH abuse: The patient was continued on antabuse.
Medications on Admission:
ANTABUSE 250 mg--1 tablet(s) by mouth po qd
PROTONIX 40 mg--one tablet(s) by mouth qday
SEROQUEL 200 mg--1 tablet(s) by mouth po tid
TRAZODONE 100 mg--4 tablet(s) by mouth po qhs
Discharge Medications:
1. Disulfiram 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
3. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. Trazodone 100 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Please have a CBC checked in one week. Please send results to
Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] fax #([**Telephone/Fax (1) 8137**].
Discharge Disposition:
Home
Discharge Diagnosis:
Hemorrhoidal Lower GIB
Discharge Condition:
Good.
Discharge Instructions:
Please return to the ER or call your physician if you experience
red blood per rectum, lightheadedness, shortness of breath, or
any symptoms that concern you.
.
Please follow up with Dr. [**Last Name (STitle) 1120**].
.
Dr. [**Last Name (STitle) 1120**] recommends warm water soaks to the surgical area.
.
Please get your blood drawn in one week. Have the results sent
to your PCP at fax # ([**Telephone/Fax (1) 8137**].
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], upon discharge.
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1670**] [**Last Name (un) 1671**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2178-4-2**] 12:10
.
Please follow up with Dr. [**Last Name (STitle) 1120**] on [**4-9**] at 1pm at [**Hospital1 18**], [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] building, [**Location (un) 10043**]. [**Telephone/Fax (1) 274**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 23733**], M.D. Date/Time:[**2178-5-22**] 12:10
Completed by:[**2178-4-1**]
|
[
"285.1",
"455.1",
"455.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"49.49"
] |
icd9pcs
|
[
[
[]
]
] |
6260, 6266
|
4070, 5338
|
343, 373
|
6333, 6341
|
3245, 3933
|
6811, 7466
|
2908, 2990
|
5567, 6237
|
6287, 6312
|
5364, 5544
|
6365, 6788
|
3005, 3226
|
275, 305
|
3949, 4047
|
401, 2040
|
2062, 2498
|
2514, 2892
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,993
| 190,528
|
2327
|
Discharge summary
|
report
|
Admission Date: [**2175-9-11**] Discharge Date: [**2175-9-14**]
Date of Birth: [**2092-8-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lisinopril / Shellfish Derived
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
Tachycardia, shortness of breath
Major Surgical or Invasive Procedure:
PleurX abdominal catheter placement [**2175-9-14**]
History of Present Illness:
Patient is an 83 year-old [**Location 7979**] speaking female with a
history of recently diagnosed gastric adenocarcinoma with mets
to the peritoneum, recurrent abdominal ascites, atrial flutter,
who presented [**9-11**] for elective pleurex catheter placement into
the peritoneum. Her ascites was drained 5 days prior to
admission, and since that procedure, she has had increasing poor
appetite and fluid intake. In the intake suite, she was found
to be tachycardic to 160s. At that time, she was completely
asymptomatic without chest pain, palpitations, and had only mild
shortness of breath comparable to her baseline. She was taken
to the ER for further management.
.
In the ED, initial vs were: HR 161 134/71 20 100% 4L. ECG showed
atrial flutter at 154. Patient was given 2L NS, HR remained in
150s. She was given 15 mg IV diltiazem with initial improvement
of HR into 80s, then resturned to 100s. placed on a diltiazem
drip. She was then given 30 mg PO diltiazem, another 15 IV dilt,
then started on diltiazem drip at 10 cc/hr, still in atrial
flutter. CTA showed bilateral PE, no RV strain. After discussion
with the family, decision was made to start a heaprin drip and
she was transferred to the ICU for rate control. In the ICU,
after initial attempt to transition to oral diltiazem was
unsuccessful, a second attempt was effective, and she was able
to be transferred to the floor without any incident. At that
time, she felt well and was stable. Of note, after discussion
with the patient and her family about the risks and benefits of
anticoagulation for PEs including need for blood tets for
monitoring, they elected to not pursue anticoagulation therapy.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Gastric adenocarcinoma, stage IV.
2. Hypertension.
3. Hypercholesterolemia.
4. Atrial flutter - Docum,ented once in [**Month (only) 205**] during
hospitalization, resolved, was on coumadin, then discontinued
5. Ocular hypertension.
6. Hyponatremia.
Social History:
denies EtOH, tobacco, or illegal drugs
Family History:
The patient's granddaughter recently died of colon cancer at 36
years. Her father died of an MI in his 70s. Her mother died of
CHF in her 90s. She has one sister who has allergies and history
of scarlet fever. She has 12 children, 11 currently living.
Physical Exam:
FEX ON ADMISSION
Vitals: Afebrile, HR 77 bp 126/61 RR 18, SaO2 100% RA ICU
stay +2.4 liters
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no lesions or edema
Neuro: no focal deficits
Psych: cooperative, pleasant
FEX ON DISCHARGE (Prior to PleurX placement)
VS: Tm 98.2 Tc 96.8 110/54 91 18 99%RA
General: Pleasant elderly woman. Alert, oriented, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Moderately distended and tense. Nontender. Several
poorly defined hard non tender masses palapted over abdomen
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2175-9-11**] 10:57AM BLOOD WBC-8.7 RBC-4.69 Hgb-13.4 Hct-38.5 MCV-82
MCH-28.6 MCHC-34.9 RDW-14.2 Plt Ct-357
[**2175-9-13**] 05:45AM BLOOD WBC-7.3 RBC-4.27 Hgb-12.2 Hct-36.8 MCV-86
MCH-28.5 MCHC-33.1 RDW-14.8 Plt Ct-272
[**2175-9-11**] 10:57AM BLOOD PT-12.8 INR(PT)-1.1
[**2175-9-14**] 06:05AM BLOOD PT-12.7 INR(PT)-1.1
[**2175-9-11**] 10:57AM BLOOD Glucose-124* UreaN-16 Creat-0.6 Na-126*
K-4.8 Cl-90* HCO3-28 AnGap-13
[**2175-9-13**] 05:45AM BLOOD Glucose-102* UreaN-16 Creat-0.6 Na-133
K-4.1 Cl-99 HCO3-23 AnGap-15
[**2175-9-11**] 10:57AM BLOOD ALT-8 AST-18 AlkPhos-62 TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2175-9-11**] 10:57AM BLOOD Albumin-3.0*
[**2175-9-13**] 05:45AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.4
[**2175-9-11**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2175-9-11**] 12:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
[**2175-9-11**] 12:00PM URINE RBC-0-2 WBC-0-2 Bacteri-0 Yeast-NONE
Epi-0-2
REPORTS
EKG [**2175-9-11**]: Atrial fibrillation with a rapid ventricular
response, although there is some organized atrial activity. The
variable ventricular response suggests atrial fibrillation
(atrial flutter). No significant change compared to the previous
tracing except that the current ventricular response is more
variable suggesting the combination of atrial fibrillation and
flutter.
EKG [**2175-9-11**]: The rate is much slower with persistent
flutter/fibrillation waves with a regular ventricular response
suggesting conducted atrial fibrillation.
CXR [**2175-9-11**]: IMPRESSION: Bibasilar atelectasis and small
bilateral pleural effusions. Stable cardiomegaly.
CTA Chest [**2175-9-11**]: IMPRESSION: Pulmonary emboli involving the
right middle and lower lobar as well as left lower lobar
pulmonary arteries without evidence of right heart strain. Small
bilateral simple pleural effusions are slightly increased.
Brief Hospital Course:
83 year old female with end stage gastric adenocarcinoma with
metastases to peritpneum and a history of atrial flutter
requesting comfort measures only who presents with atrial
flutter and PE prior to placement of PleurX abdominal catheter.
ACTIVE ISSUES
1. Atrial Flutter: Patient presented with palpitations and HR
>150 prior to placement of adbominal catheterization. Because
she was symptomatic from her atrial flutter, it was deemed
reasonable to rate control her. Patient initially controlled
with IV diltiazem drip and transitioned to 90mg diltiazem qid.
Rate was controlled to the 70's-100's with one asymptomatic runs
back to 150. Patient was discharged on 360mg diltiazem ER. No
anticoagulation prophylaxis on discharge as per patient's goals
of care.
.
2. PE: Bilateral PE was visualized on CTA, likely precipitated
in setting of end-stage malignancy. There was no evidence of
hemodynamic compromise or RV strain. Patient was briefly started
in heparin drip. However, discussed with patient and her family
that treatment of a PE consists of heparin and 3-6 months of
coumadin or lovenox shots. Also explained that because of her
cancer, she has a high risk of developing more clots even while
on coumadin. Thus, because coumadin requires frequent blood
draws and carries a risk of bleed, this would not be consistent
with her goals of care. Heparin drip was discontinued on
transfer to floor
.
3. Recurrent ascites: Likely secondary to malignancy. Patient
underwent PleurX abdominal catheter placement [**2175-9-14**] for
palliation.
.
4. Stage IV gastric adenocarcinoma. No further treatment under
current goals of care.
OUTSTANDING STUDIES
-None
Medications on Admission:
OXYCODONE - 5 mg Tablet - [**1-15**] Tablet(s) by mouth every 4-6 hours
as needed for pain
Zofran 4mg PO q8 PRN nausea
PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 10
mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed
for nausea (take with oxycodone).
TIMOLOL - 0.5 % Drops - one drop [**Hospital1 **] ou per [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD here
for
pt record
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth every six
(6) hours as needed for pain
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
POLYETHYLENE GLYCOL 3350 [MIRALAX] - 17 gram Powder in Packet -
1
Powder(s) by mouth once a day as needed for constipation
SENNOSIDES [SENNA] - 8.6 mg Tablet - 2 Tablet(s) by mouth twice
a
day as needed for constipation
SODIUM CHLORIDE - 0.65 % Aerosol, Spray - 1 spray per nostril
twice daily
Mylanta 30 cc PO q6 PRN heartburn
Tums 500mg PO TID
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea, anxiety, or sleeplessness.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. oxycodone 5 mg Capsule Sig: [**1-15**] Capsules PO every 4-6 hours
as needed for pain.
4. OxyContin 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every twelve (12) hours.
5. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
7. timolol 0.5 % Drops Sig: One (1) Ophthalmic twice a day.
8. triamcinolone acetonide 0.1 % Ointment Sig: One (1)
application Topical twice a day.
9. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
12. Miralax 17 gram Powder in Packet Sig: [**1-15**] packet PO once a
day as needed for constipation.
13. sennosides 8.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for constipation.
14. sodium chloride 0.65 % Aerosol, Spray Sig: One (1) spray
Nasal twice a day.
15. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
16. diltiazem HCl 360 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary: Recurrent ascites
Secondary: Gastric adenocarcinoma, atrial flutter, pulmonary
embolism.
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 12129**],
You were admitted to the hospital because you were about to have
a catheter placed in your abdomen to drain extra fluid, you
developed an abnormal heart rhythm called atrial fibrillation.
We controlled you heart rhythm with medications, and placed the
catheter.
While you were here we found blood clots in your lungs. After
discussing treatment options, which include frequent blood draws
or injections, you decided this did not fit with your goals of
care and declined treatment.
Ultimately the PleurX catheter was placed on [**2175-9-14**]. You
tolerated the procedure well. Your hospice team will come to
drain your abdomen as needed to help you feel comfortable.
Please note the following changes to your medications:
- START Diltiazem 360mg once a day.
- START Zofran 4mg every 8 hours as needed for nausea
- STOP Amlodipine
- STOP Hydrochlorothiazide
- STOP Furosemide (Lasix)
No other changes were made to your medications. Please follow up
with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**] as needed. It has
been a pleasure taking care of you.
Followup Instructions:
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**] as
needed.
|
[
"151.4",
"415.19",
"789.51",
"427.32",
"276.1",
"272.0",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10620, 10671
|
6332, 7996
|
338, 392
|
10813, 10813
|
4371, 6309
|
12152, 12270
|
2894, 3147
|
8998, 10597
|
10692, 10792
|
8022, 8975
|
10996, 11730
|
3162, 4352
|
11760, 12129
|
266, 300
|
420, 2546
|
10828, 10972
|
2568, 2822
|
2838, 2878
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,678
| 180,173
|
35062
|
Discharge summary
|
report
|
Admission Date: [**2115-10-15**] Discharge Date: [**2115-10-25**]
Date of Birth: [**2045-7-28**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Bee Pollens
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Obstructive jaundice
Major Surgical or Invasive Procedure:
Exploratory laparotomy, hepaticojejunostomy, bile duct biopsy.
History of Present Illness:
70 year old male with h/o Whipple in '[**01**] for duodenal
adenocarcinoma and esophagectomy for esophageal squamous cell ca
in [**2108**] who became jaundiced with fever in [**9-2**]. MRCP on [**9-2**]
showed diffuse dilatation of intrahepatic biliary tree. [**9-5**]
Cholangiogram demonstrated a high-grade stricture in the common
hepatic duct, with dilation in both R and L hepatic duct.
Placement of an 8.5 French 25 cm ultra thin [**Location (un) 2617**]-[**Doctor Last Name 2418**]
biliary drain in the left hepatic duct. MRCP on [**9-10**] showed a
1.9 x 2.8 x 2.8 cm mass concering for cholangiocarcinoma,located
centrally in Klatskin location, causing obstruction of R and
left hepatic bile ducts. On [**9-16**], he had internalization of
existing left-sided biliary catheter and a R internal-external
biliary catheter was placed. He is now admitted for Exploratory
laparotomy, hepaticojejunostomy, bile duct biopsy.
Past Medical History:
Duodenal adenocarcinoma (Whipple surgery in [**2101**]), esophageal
squamous cell cancer with esophagectomy in [**2108**], dental abscess
with drainage in [**5-2**], left incisional hernia repair in [**2109**],
right incisional hernia repair [**2113**].
ECHO (PMG Internal Medicine and Cardiology, [**2115-8-13**]):
normal LV and RV size and systolic function
mild thickening of the aortic and mitral valves without
vegetations or stenosis
trace AR, MR, and TR.
Stress ECHO (Dr. [**First Name (STitle) **], [**2113-8-5**])
Social History:
No alcohol or tobacco use. No history of recreational drug use.
He is happily married in [**Location (un) 3320**].
Family History:
N/C
Physical Exam:
Post Op
T-101, 84, 96/57, 18, 98%2L, 68.7 kg
Gen: Drowsy but arousable, c/o pain with movement
HEENT: temporal wasting noted, dry mucous membranes
Card: RRR, no M/R/G
Lungs: CTA bilaterally
Abd: 3 PTC drains in place with bilious appearing fluid and 1
JP. Abdomen soft, tender on palpation non-distended
Extr: No edema, 2+ DPs
Neuro: no focal deficits
Skin: warm and dry
GU: Foley in place, 400 cc in bag
Pertinent Results:
On Admission: [**2115-10-15**]
WBC-9.1 RBC-3.73* Hgb-11.0* Hct-32.3* MCV-87 MCH-29.5 MCHC-34.1
RDW-20.6* Plt Ct-487*
PT-15.8* PTT-34.4 INR(PT)-1.4*
Glucose-102 UreaN-11 Creat-0.4* Na-136 K-4.0 Cl-101 HCO3-26
AnGap-13
ALT-119* AST-183* AlkPhos-226* TotBili-3.5*
On Discharge [**2115-10-25**]
WBC-5.7 RBC-3.52* Hgb-10.6* Hct-30.4* MCV-86 MCH-30.1 MCHC-34.8
RDW-18.5* Plt Ct-468*
Glucose-84 UreaN-11 Creat-0.7 Na-135 K-3.6 Cl-102 HCO3-26
AnGap-11
ALT-30 AST-33 AlkPhos-600* TotBili-2.2*
Brief Hospital Course:
70 y/o male admitted following Exploratory laparotomy,
hepaticojejunostomy, bile duct biopsy. He was taken to the OR
with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. In Summasry:
The hilum was densely scarred with extensive sclerotic reaction.
No tumors or
malignancies demonstrated within the metastatic deposits within
the abdominal cavity or on the liver itself. On the distal
aspect of bile duct there appeared to be a large amount of
sclerotic tissue and possibly intraluminal mass. A
piece of this was sent for frozen section analysis which came
back benign fibrosis tissue. A number of attempts were made to
try to peel the common bile duct off the portal vein; but at
each time, ultimately created a large venotomy in the portal
vein. After several attempts at this and requiring suture
closure of the manner of the venotomy in the portal vein, we did
not believe that we could safely complete
the resection. Extending further up into the hilum, there was
extensive sclerotic reaction, and at this time patient was
deemed unresectable. The hepaticojejunostomy was reapproximated.
Please see the operative note for full details.
In the post op period in the PACU the patient became hypotensive
and was febrile to 101.9. He received a fluid bolus, was
cultured and was transferred to the SICU for monitoring. Blood
and urine cultures reported as no growth. He was started on
Cipro which continued through the hospitalization.
He was slowly transitioned to POs
On [**10-21**] he underwent tube cholangiogram which showed evidence
of a small leak at the level of the hepaticojejunostomy
anastomosis. Contrast is demonstrated to slowly enter the
surgically placed JP drain in the right upper abdominal
quadrant. As well, he has redemonstration of hilar, right and
left biliary strictures as before.
CT of abdomen on [**10-22**] shows:
Four drainage catheters are in place, including: the
external-internal biliary drain, a right lateral drain coursing
through the liver and terminating at the hepaticojejunostomy
(2:23), a drain entering the skin at the right lower abdomen and
coursing superiorly and terminating medial to the left lobe of
liver near the
diaphragm, and a drain entering the left mid abdomen, coursing
medially,
possibly through the left lobe of liver into the hepatic hilum.
The second mentioned drain located in the right lateral abdomen
posterior to the external-internal biliary drain is well
positioned adjacent to the hepaticojejunostomy, at the site of
demonstrated leak. No significant collection is seen surrounding
this drainage tube.
The internal/exernal biliary drain was capped during the course
of the hospitalization, however, the JP drain exhibited an
increase in the bilious appearance of the fluid, and the
decision was made to uncap all drains and PTCs.
Patient to have cholangiogram during the following week and
follow up with DR [**First Name (STitle) **] to determine plan of care.
He remained afebrile and was discharged home on PO Cipro. He was
tolerating diet and using supplements and was ambulating.
Medications on Admission:
Viokase (4 tablets) TID, mvi 1 qd, colace 100mg [**Hospital1 **], senna 1 prn
[**Hospital1 **], Vicodin 1 tab prn (~ 3 tabs per day for last 2 weeks)
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig:
3-4 Tablets PO TID (3 times a day): with meals.
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**] intake
Discharge Diagnosis:
hepatic cholangiocarcinoma vs sclerotic tissue s/p radiation
therapy
Biopsy not definitive
Discharge Condition:
Good
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea,
vomiting, diarrhea, inability to take or keep down medications,
increased fatigue, yellowing of skin or eyes or any other
concerning symptoms.
The drains will be left open to bag drainage for now. Measure
and record drainage twice daily or more often as necessary,
bring copy with you to clinic visit.
Note the color of the drainage, especially in the JP drain.
Please call if this becomes a darker yellow or brownish/green
color, has blood in the drain or develops a foul odor.
You will be scheduled for a repeat cholangiogram for the middle
of next week. Dr [**Last Name (STitle) 9411**] office will be in touch regarding the
scheduling of this test.
Monitor the incision for redness, drainage or bleeding. The
staples will come out next week.
No heavy lifting
No driving if taking vicodin or any other narcotic pain
medication
Followup Instructions:
Cholangiogram week of [**10-28**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], week of [**10-28**]. [**Telephone/Fax (1) 673**] Office will
be in contact for appointment
Completed by:[**2115-10-29**]
|
[
"155.1",
"576.2",
"997.4",
"V10.09",
"V10.03",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.37",
"51.13",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
6906, 6964
|
2993, 6072
|
321, 386
|
7099, 7106
|
2485, 2485
|
8057, 8284
|
2040, 2045
|
6275, 6883
|
6985, 7078
|
6098, 6252
|
7130, 8034
|
2060, 2466
|
261, 283
|
414, 1344
|
2499, 2970
|
1366, 1891
|
1907, 2024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,378
| 172,149
|
39633
|
Discharge summary
|
report
|
Admission Date: [**2100-7-31**] Discharge Date: [**2100-8-1**]
Date of Birth: [**2073-5-6**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 27 YOF with history of opiate abuse and bipolar
disorder on lamictal who was found "altered" on the subway. A
supervisor removed her from the train and EMS was called. Upon
EMS arrival she was found to be unresponsive and an oral airway
was placed. When she arived to the ED she was apneic.
.
She was given 2 mg intranasal narcan by EMS, then 2 mg IV when
access established. Became responsive. In the ED the patient was
restrained due to combative behavior/thrashing. VS were 98.8 HR
52 BP 112/52 sat 86% on RA. She was placed on 4 L nc and her sat
came up to 100%. CO2 monitor was 47. O2 was decreased to 2 L and
the CO2 went to 39. FS was 85. Head CT and CXR were both normal.
Tox screen was positive for benzodiazepines and methadone. EKG
showed QtC prolongation to 455 with HR now in the 70s. In the ED
she also received 2 L NS. She was able to protect her airway but
very sedated so she was transferred to the ICU. She reportedly
denied ingestion, but was able to state that she takes lamictal.
Pt had [**Hospital1 2025**] blue card on person and ED resident talked with
access nurse [**First Name (Titles) **] [**Last Name (Titles) 2025**] who confirmed history of recent admission
[**7-21**] at [**Hospital1 2025**] for opiate OD. Also had klonipin overdose in [**Month (only) 116**]
with fetal demise.
.
On the floor, the patient is nonresponsive to verbal stimulus
but minimally arrousable to sternal rub. Her VS were 118/74, 49,
rr 9-12, 100% 2 L nc. ABG revealed hypercarbia and pt was given
0.4 mg narcan with good effect.
.
Review of systems:
Unable to obtain as pt minimally responsive and not accompanied
by family or friends.
.
Past Medical History:
1. Bipolar disorder
2. opiate abuse - on methadone
3. previous history Benzodiazepine toxicity (presumably with
klonipin) [**2100-5-6**] at [**Hospital1 2025**] complicated by fetal demise of 8 wk
intrauterine pregnancy. Pt denied SI but claimed it was
accidental ingestion in setting of multiple psychosocial
stressors. Was enrolled in [**Hospital 1680**] Hospital for substance
recovery prior to discharge.
4. Heroin use - hospitalized [**Hospital1 2025**] [**2100-7-21**] and given narcan
5. hepatitis C
6. Asthma
7. hx of PNA
8. Head Trauma-x2 from abuse
9. Seizures- states she had a w/d seizure in jail 2 weeks ago
from benzos
Social History:
Substance use:
Tobacco-1 ppd
ETOH- drinks once a year now, but had hx of binging in her
teens,
no hx of treatment or ETOH w/d.
Illicit- initially addicted to oxycontin in teens, then
transitioned to heroin at age 19. Used IV heavily until age 25,
when she enrolled at Habit Co-op. States her last use was 2
weeks
ago after leaving jail because she could not get her methadone
(she used twice). Also has hx of cocaine use 5 x month in the
past, but now uses rarely (last 3 weeks ago). Admits to taking
more benzos than prescribed in the past. Denies other illicits.
SH:
Origin- b/r in [**Hospital1 **]. parents divorced at age 2. lives with
roommate in [**Location (un) **] currently.
Childhood/Parents- has 9 siblings
Abuse-chaotic upbringing w/ physical and sexual abuse
School- completed through 11th grade
Employment- unemployed, on SSI
Relationships- has BF [**Doctor First Name **], off and on x6 years, though recently
had been in abusive relationship with another man from [**Month (only) **]-[**Month (only) **]
Legal-has court date upcoming for possession of class C
substance
with intent to distribute.
Family History:
sister with substance abuse issues; Mother and grandmother
have bipolar per her report
Physical Exam:
Vitals: 118/74, 49, rr 9-12, 100% 2 L nc
General: lethargic, mildly arousable to vigorous rub and loud
verbal stimuli
HEENT: pupils reactive to light, mildly constricted, Sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: bradycardic, 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
Pertinent Results:
[**2100-7-31**] 01:06PM BLOOD WBC-7.1 RBC-4.15* Hgb-12.1 Hct-35.2*
MCV-85 MCH-29.2 MCHC-34.5 RDW-14.4 Plt Ct-233
[**2100-7-31**] 06:00PM BLOOD Na-140 K-4.8 Cl-106
[**2100-7-31**] 01:06PM BLOOD UreaN-11 Creat-0.9
[**2100-7-31**] 06:00PM BLOOD Albumin-4.2 Calcium-9.0 Phos-4.2 Mg-2.1
[**2100-7-31**] 06:00PM BLOOD ALT-18 AST-23 AlkPhos-64 TotBili-0.3
[**2100-7-31**] 01:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2100-7-31**] 06:12PM BLOOD Type-ART pO2-67* pCO2-61* pH-7.30*
calTCO2-31* Base XS-1 Intubat-NOT INTUBA
[**2100-7-31**] 01:18PM BLOOD Glucose-57* Lactate-2.1* Na-144 K-4.5
Cl-101 calHCO3-29
[**2100-7-31**] 06:12PM BLOOD Lactate-0.7
UA: negative
.
Micro:
none
.
Images:
[**2100-7-31**] CT head: No acute foci of hemorrhage.
.
[**2100-7-31**] CXR: normal
.
EKG:
NSR, 79 bpm, nml axis, no PR or QRS prolongation, but QTc
prolonged at 455 ms, no q waves, TWI, or ST changes.
Brief Hospital Course:
27 YOF with history of previous benzodiazepine and heroin
overdose who presents with likely toxic overdose with altered
mental status, bradycardia, decreased respiratory rate, and tox
screen positive for both methadone and benzodiazepines.
.
# methadone/benzodiazepine overdose: The patient initially
presented with polonged QTc, bradycardia and decreased
respiratory drive with a rate of 8. ABG revealed hypercapnea
with pCO2 61. Initial labs did not reveal electrolyte
abnormalities. She responded to narcan in the ED and was
administered another dose of 0.5 mg on the floor (one time) with
good effect. Her ventilation improved as the patient became
more alert and after 4 hours she was conversant. Her vital
signs normalized. She was placed on suicide precautions with a
1:1 sitter although she denied intentional overdose. She was
evaluated by psychiatry who did not feel that she needed
inpatient hospitalization and provided her with a referral to an
outpatient substance abuse clinic at [**Hospital 1680**] Hospital. The
pateint was given one dose of 100 mg of methadone and 1 mg
Ativan for anxiety. She was not provided with prescriptions for
narcotics or benzodiazepines upon discharge.
Follow up:
- Pt should follow up with [**Hospital 1680**] Hospital at 9 am on [**2100-8-2**]
- Pt should contact PCP for follow up appointment
Medications on Admission:
1. Methadone 109 mg (provided by Habit)
Discharge Medications:
1. Methadone 109 mg (provided by Habit)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Benzodiazepine overdose
Methadone overdose
Secondary diagnosis:
Hepatitis C
bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were brought to the hospital unconscious after accidentally
overdosing on benzodiazepines and narcotics. Your breathing was
dangerously low and you were given medication to treat the
overdose. You were admitted to the Intensive Care Unit and
monitored overnight. You recovered overnight and were able to
eat food without problems. [**Name (NI) **] were evaluated by psychiatry who
did not think this was an intentional overdose. They recommend
that you seek treatment in an outpatient substance abuse clinic.
It is important that you go to your appointment and seek help
to prevent you from dying from your drug problem in the future.
Followup Instructions:
We have set up an appointment for you at the [**Hospital 1680**] Hospital,
located at:
[**Street Address(2) **].
[**Location (un) 538**], [**Numeric Identifier 7023**]
The [**Hospital 1680**] Hospital is located in [**Location (un) 538**] off the 'Green
st' T stop on the [**Location (un) **] line. Your appointment is set for
tomorrow ([**2100-8-2**]) at 9 am. The phone number to the clinic is
([**Telephone/Fax (1) 87419**]
You should also follow up with your primary care doctor. Please
call your primary care doctor, Dr. [**First Name (STitle) 1557**] ([**Telephone/Fax (1) 87420**], to set
up an appointment in the next week.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"427.89",
"296.80",
"304.01",
"969.4",
"070.70",
"E858.3",
"965.02",
"426.82",
"E850.1",
"493.90",
"799.1",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6989, 6995
|
5484, 6690
|
323, 330
|
7152, 7152
|
4538, 5273
|
7972, 8749
|
3841, 3930
|
6925, 6966
|
7016, 7016
|
6861, 6902
|
7303, 7949
|
3945, 4519
|
6701, 6835
|
1946, 2036
|
262, 285
|
358, 1927
|
5282, 5461
|
7100, 7131
|
7035, 7079
|
7167, 7279
|
2058, 2693
|
2709, 3825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,276
| 133,382
|
38418+58212+58213
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2189-7-17**] Discharge Date: [**2189-7-23**]
Date of Birth: [**2133-12-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2189-7-19**] Coronary artery bypass grafting x5, left internal
mammary artery, left anterior descending coronary artery;
reverse saphenous vein single graft from aorta to the first
diagonal coronary artery; as well as reverse saphenous vein
single graft from the aorta to the first obtuse marginal
coronary artery; reverse saphenous vein single graft from the
aorta to the distal right coronary artery, as well as a reverse
saphenous vein graft from the [**Doctor Last Name **] of the first obtuse marginal
coronary artery vein graft to the third obtuse marginal coronary
artery
History of Present Illness:
55 year old [**Doctor Last Name 8003**] speaking male with new onset angina at rest
which began 3 months ago. Recently was on vacation in [**Doctor First Name 85554**] and developed chest pain and was started on ASA and
"another medicine" and developed peptic ulcer requiring
hospitalization for one month and multiple transfusions (patient
states 5 UPRBC).
Past Medical History:
Hypertension
Diabetes
Peptic ulcer disease d/t ASA
Social History:
Race:hispanic
Last Dental Exam:5 months ago- no issues
Lives with: wife- also [**Name2 (NI) **] speaking
Occupation: retired in [**2173**] loom weave inspector
Tobacco:none
ETOH:none
Family History:
father and mother deceased with CHD and father with CVA
Physical Exam:
Pulse: 68 Resp: 18 O2 sat:98%
B/P Right: 122/64 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right:+2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2189-7-19**] Echo: Prebypass: No atrial septal defect is seen by 2D
or color Doppler. There is moderate regional left ventricular
systolic dysfunction with hypokinesia of the apex, apical and
mid portions of the inferior, inferoseptal and inferolateral
walls. The mid and apical portions of the septal wall were also
hypokinetic during some portions of the prebypass period.
Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results on [**2189-7-19**] at 845am. Post bypass: Patient is in sinus
rhythm and receiving an infusion of phenylephrine. The inferior
wall is contracting better. There is hypokinesia of the apical
and mid portions of the septal and anteroseptal walls. LVEF=40%.
RV function is normal. Trivial mitral regurgitation present.
Aorta is intact post decannulation.
[**7-18**] Chest CT: 1. No focal lung consolidation. No pleural
effusion, or pneumothorax. 2. Foci of calcification in the wall
of the aorta, at the ascending aorta and arch. 3. Nonspecific
punctate calcification at the liver with suboptimal evaluation
of the liver due to lack of IV contrast, could be nonspecific
tiny calcified granuloma. 4. Small nonobstructing renal stone in
the left kidney. 5. Incidental thickenning of esophagus,
correlate with history.
[**7-22**] CXR: 1. Small left apical pneumothorax has slightly
decreased. 2. Small bilateral pleural effusions and mild
bibasilar atelectasis are
unchanged.
[**2189-7-17**] 05:05PM BLOOD WBC-7.9 RBC-4.49* Hgb-12.0* Hct-36.2*
MCV-81* MCH-26.8* MCHC-33.3 RDW-17.2* Plt Ct-288
[**2189-7-23**] 04:40AM BLOOD WBC-13.2* RBC-3.35* Hgb-9.1* Hct-27.0*
MCV-81* MCH-27.3 MCHC-33.8 RDW-17.0* Plt Ct-291
[**2189-7-17**] 05:05PM BLOOD PT-13.8* PTT-28.1 INR(PT)-1.2*
[**2189-7-19**] 02:22PM BLOOD PT-14.4* PTT-30.8 INR(PT)-1.3*
[**2189-7-17**] 05:05PM BLOOD UreaN-10 Creat-0.9 Na-138 K-3.7 Cl-104
HCO3-26 AnGap-12
[**2189-7-23**] 04:40AM BLOOD UreaN-12 Creat-0.8 Na-134 K-4.7 Cl-96
[**2189-7-17**] 05:05PM BLOOD ALT-16 AST-14 LD(LDH)-109 AlkPhos-51
TotBili-0.6
Brief Hospital Course:
Mr. [**Known lastname 28942**] was transferred from outside hospital after presenting
with chest pain and undergoing a cardiac cath which revealed
severe three vessel coronary artery disease. Upon transfer he
was medically managed and underwent all appropriate
pre-operative work-up. On [**7-19**] he was brought to the operating
room where he underwent a coronary artery bypass graft x 5.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one beta-blockers and diuretics were initiated and he was
diuresed towards his pre-op weight. Also on this day he was
transferred to the telemetry floor for further care. Chest tubes
and epicardial pacing wires were removed per protocol. Post
chest tube removal x-ray revealed small left apical
pneumothorax. He continued to progress well during his post-op
period and worked with physical therapy for strength and
mobility. On post-op day four he appeared suitable for discharge
home with VNA services and the appropriate medications and
follow-up appointments.
Medications on Admission:
Metoprolol XL 12.5mg
Lisinopril 10mg daily
Metformin 850mg [**Hospital1 **]
Folic acid
Protonix 40 daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
Past medical history:
Hypertension
Diabetes
Peptic ulcer disease d/t ASA
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage. Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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**] on [**2189-8-25**] at 1:15PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6043**] in [**2-7**] weeks
You need to get a referral from your PCP to [**Name Initial (PRE) **] Cardiologist.
Should see Cardiologist in [**3-11**] weeks.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2189-7-23**] Name: [**Known lastname 11701**],[**Known firstname 13554**] R Unit No: [**Numeric Identifier 13555**]
Admission Date: [**2189-7-17**] Discharge Date: [**2189-7-23**]
Date of Birth: [**2133-12-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
In addition to the patients discharge medications he was placed
on Atorvastatin 20 mg QD
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) 102**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2189-7-24**] Name: [**Known lastname 11701**],[**Known firstname 13554**] R Unit No: [**Numeric Identifier 13555**]
Admission Date: [**2189-7-17**] Discharge Date: [**2189-7-23**]
Date of Birth: [**2133-12-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Lipitor is not covered by the patients insurance, therefore his
statin prescription was changed to Simvastatin 40mg QD
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) 102**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2189-7-24**]
|
[
"401.9",
"250.00",
"512.1",
"414.01",
"411.1",
"E935.3",
"412",
"533.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
10635, 10872
|
4773, 5975
|
332, 915
|
7683, 7901
|
2293, 4750
|
8740, 9830
|
1592, 1649
|
6130, 7408
|
7527, 7588
|
6001, 6107
|
7925, 8717
|
1664, 2274
|
282, 294
|
943, 1302
|
7610, 7662
|
1392, 1576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,848
| 177,913
|
4049
|
Discharge summary
|
report
|
Admission Date: [**2143-7-29**] Discharge Date: [**2143-8-3**]
Date of Birth: [**2087-12-8**] Sex: M
Service: SURGERY
Allergies:
Garlic Oil
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Right lower leg pain
Major Surgical or Invasive Procedure:
1. [**2143-7-30**] Lower extermity catheterization
2. [**2143-7-30**] Lower extermity catheterization(2nd of day)
3. [**2143-7-31**] evacuation fo right calf hematoma, right lower
extremity fasciotomies
History of Present Illness:
55 y/o M / physician, [**Name10 (NameIs) 151**] history of hodkins lymphoma s/p
chemotheraphy now in remission for 10 years, crohn's disease who
presented to his PCP with right calf claudication. He was
admitted for angiogram.
Past Medical History:
-Hodgkin lymphoma s/p ABVD, radiation to torso -- now remission
-Crohn's disease
-Hypothyroidism
-Exercise-induced asthma
Social History:
Works as rheumatologist at BU
Tob: Denies all use
EtOH: Occasional
Illicits: Denies all use
Family History:
Father with MI at age 55, other uncles with [**Name2 (NI) **] at later ages,
no
known sudden death.
Physical Exam:
GENERAL: Appears well in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. R medial and lateral
incisions c/d/i witout erythema or purulent drainage
SKIN: Site of cath insertion is clear and dry. No are no
hematomas or bleeding. No bruits heard.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP and PT dopplerable
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2143-7-30**] Cardiac Cath:
Right Lower Extremity: The previously described right popliteal
occlusion was moderately improved with reduction in the thrombus
in the proximal popliteal with a funnel shaped occlusion at the
takeoff of the AT. Very little flow could be seen to the foot
via the popliteal. The PFA supplied collaterals filling the
peroneal vessel but the AT and PT were presumable occluded with
thrombus. An 0.014" wire was directed into the distal popliteal
but intraluminal position in the AT could not be obtained and
only entry of an accessory vessel could be made. The wire was
redirected into a high-takeoff PT/accessory popliteal artery
which was occluded at the knee. The wire passed into what
appeared to be a small PT vessel that filled to the distal calf.
A 2.0 mm balloon was used to dilate and restore flow into the
vessel. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7336**] wire was then directed into the true popliteal
and an additional course of tPA was planned.
[**2143-7-30**] Cardiac Cath (2nd of the day):
The previously imaged popliteal artery no longer had flow in the
portion of the popliteal collateralizing the PT. The popliteal
was now occluded at the knee while flow was previously noted to
below the knee. Profunda collaterals, however, were seen to
fill
the peroneal artery more proximally than previously noted.
[**2143-7-30**] Cardiac Echo:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. There is no pericardial effusion.
IMPRESSION: No ASD or left ventricular thrombus seen. Normal
global and regional biventricular systolic function.
[**2143-7-30**] Vein mapping
VENOUS STUDY
HISTORY: Right popliteal artery occlusion, vein mapping.
FINDINGS: The greater saphenous veins are patent bilaterally,
see digitized image on PACS for sequential measurements.
[**2143-7-30**] arterial duplex
ARTERIAL STUDY.
HISTORY: Right popliteal occlusion, now on TPA.
FINDINGS: Limited portable assessment of the popliteal artery
on the right was performed. There is patency of the right
popliteal artery, though velocities are low. Some residual
thrombus versus plaque marginating the arterial walls is
appreciated.
[**2143-7-30**] 09:20AM BLOOD WBC-5.5 RBC-4.28* Hgb-10.5* Hct-32.9*
MCV-77* MCH-24.5* MCHC-31.9 RDW-18.5* Plt Ct-241
[**2143-7-30**] 09:20AM BLOOD PT-13.0* PTT-102.2* INR(PT)-1.2*
[**2143-7-30**] 05:22PM BLOOD CK(CPK)-31*
[**2143-7-30**] 05:35PM BLOOD Lactate-0.7
Brief Hospital Course:
55 y/o M with history of hodkins lymphoma s/p chemotheraphy now
in remission for 10 years, crohn's disease who presented to his
PCP with right calf claudication and found to have right
popiteal artery occulsion that was complicated by compartment
syndrome.
Right Popiteal Occulsion: The patient had several weeks of right
lower extermity pain of several weeks which prompted an ABI that
showed 0.65 on the right with monophasic arterial wave forms
from the right popliteal distally. He was taken to the cardiac
cath lab on [**2143-7-29**] and found to have a right popiteal artery
blockage. The interventional team was unable to pass the wire. A
TPA drip and heparin was started and he was admitted to the CCU
for observation. He was taken back the the cardiac cath lab on
HD#2 and continued to have the obstruction. He was maintained on
TPA and heparin throughout the day but was noted to have
increasing pain and swelling of his right lower extermity. He
was taken back the cath lab where it was noted the obstruction
was still in place but there was no bleeding seen.
Right lower extermity compartment syndrome: Pt was brought to
the endovascular suite for evacuation of hematoma and
fasciotomies. He tolerated this procedure well and was recovered
in the ICU without signigficant difficulty. The following day he
was transfered to the VICU and then to the floor.
His lateral fasciotomy was closed on post op day # 2. The
medial fascitomy was Closed on POD #3. His diet was advanced as
appropriate and he was seen by PT. At the time of discharge his
pain was well controlled and he was tollerating a regular diet.
He was discharged on POD #4 with follow up scheduled for [**2143-8-19**]
Medications on Admission:
Levothyroxine 50 mcg daily
theophylline 300 mg daily
B12 - 1000 mcg daily
Advair 100/50 mcg inh [**Hospital1 **] prn exercise
Albuterol 90 mcg HFA INH Q6H prn exercise
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Enoxaparin Sodium 80 mg SC BID
RX *enoxaparin 80 mg/0.8 mL Please inject one syringe twice a
day Disp #*20 Not Specified Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Not Specified Refills:*0
4. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth Qday Disp #*30 Not
Specified Refills:*0
5. Omeprazole 40 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth Qday Disp #*30 Not
Specified Refills:*0
7. Theophylline SR 300 mg PO DAILY prior to exercise
8. Albuterol Inhaler [**12-24**] PUFF IH Q4H:PRN wheezing
9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
10. Cyanocobalamin 1000 mcg PO DAILY
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Qday Disp #*30 Not
Specified Refills:*0
12. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN Pain
RX *Endocet 5 mg-325 mg [**12-24**] tablet(s) by mouth Q6hrs Disp #*30
Not Specified Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right popliteal occlusion
Right calf hematoma
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right lower extremity
pain and were found to have an occlusion of right popliteal
artery. You underwent an angiogram of the right lower extremity
and were given tPA to dissolve the clot. Your postoperative
course was complicated by a right lower extremity hematoma. You
needed to return to the operating room for removal of the blood
clot. You also needed to make incisions (fasciotomies) on your
right lower extremity to relieve the pressure which we were able
to close at the bedside.
We started you on several new medications to treat his blood
clot.
1. Aspirin
2. Plavix
3. Lovenox (only until your INR is in range on coumadin)
4. Coumadin
Your INR levels and coumadin dosing will be monitored by the
[**Hospital3 **] here at [**Hospital1 18**]. They will contact you on
[**2143-8-5**] with the details of the program. They can be reached at
[**Telephone/Fax (1) 2173**].
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart with pillows
every 2-3 hours throughout the day and night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
?????? When you go home, you may walk and use stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
Followup Instructions:
Department: VASCULAR SURGERY
When: MONDAY [**2143-8-19**] at 1 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2143-8-19**] at 1:45 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2143-8-19**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2143-8-3**]
|
[
"V58.61",
"998.89",
"724.5",
"V10.79",
"E879.8",
"244.9",
"729.72",
"493.81",
"444.22",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.48",
"99.10",
"00.40",
"83.14"
] |
icd9pcs
|
[
[
[]
]
] |
7966, 7972
|
4976, 6671
|
290, 494
|
8062, 8109
|
1960, 4953
|
10910, 11725
|
1021, 1122
|
6889, 7943
|
7993, 8041
|
6697, 6866
|
8213, 10887
|
1137, 1941
|
230, 252
|
522, 751
|
8124, 8189
|
773, 896
|
912, 1005
|
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