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Discharge summary
|
report
|
Admission Date: [**2154-3-3**] Discharge Date: [**2154-3-8**]
Date of Birth: [**2112-11-25**] Sex: F
Service: MEDICINE
Allergies:
Nsaids / Peppermint
Attending:[**First Name3 (LF) 15237**]
Chief Complaint:
Anemia. Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 99778**] is a 41 year old female a history of warm
autoantibody hemolytic anemia diagnosed in [**2150**] who recently
underwent laparoscopic splenectomy on [**2154-2-20**] for disease
refractory to steroids, and refractory to rituximab and
cyclosporin. She tolerated the procedure well but has been
fatigued but has been experiencing abdominal pain since surgery
which is poorly controlled with Percocet. She has also felt
fatigued and dyspneic, consistent with prior episodes of
hemolysis. Because of her abdominal pain and fatigue she has not
been eating well and has not taken her cyclosporin for
approximately 2 days.
She initially presented with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital with
abdominal pain. She was found to have a WBC count of 30 and a
hematocrit of 10. On [**2154-2-26**] her WBC count was 13.4 with a
hematoctit of 25.1. She underwent a CT scan of the abdomen which
showed no evidence of acute bleeding or other etiology of her
abdominal pain. She received 4 units of non-crossmatched PRBCs
and solumedrol 125 mg IV x 1. She was transferred to [**Hospital1 18**] for
further management.
On arrival to the emergency room her initial vitals were T: 98.1
BP: 118/55 HR: 97 RR: 21 O2: 99% RA. She was evaluated by the
surgical service who reviewed the OSH CT scan and did not feel
that there was a surgical cause of her pain. She received 6 mg
IV Dilaudid for pain and 4 mg IV zofran.
On review of systems she endorses chills at home but did not
take her temperature. She denies chest pain or pressure. She
endorses dyspnea with exertion, lightheadedness, and fatigue.
She endorses diffuse severe abdominal pain with nauesa, no
vomiting. She has had diarrhea x 1 day but cannot describe
stools. She denies melena or hematochezia. She endorse decreased
urine output and dark urine. She has worsening jaundice. She has
no lower extremity edema or swelling. All other review of
systems negative in detail.
Past Medical History:
1. Idiopathic autoimmune hemolytic anemia: Diagnosed in [**3-4**]
admitted to the ICU with Hct 9.6, given high dose steroids and 6
units pRBC, developed steroid psychosis and tapered off. Refused
splenectomy then received 4 cycles Rituximab and has been on
cyclosporin since [**9-/2152**] and finally unwent splenectomy on
[**2154-2-20**].
2. Anxiety disorder: on benzodiazepines
3. Psoriasis with psoriatic arthritis
4. Crohn's disease, history of leukocytoclastic vasculitis by
biopsy in [**Month (only) 359**] Per pt this is inactive.
5. Basal Cell Carcinoma of Leg
6. Osgood-Schlatter (osteochondritis of the tibial tuberosity)
Social History:
Occasional ETOH use, no tobacco or illicit drug use.
Family History:
Mother with hemolytic anemia at 6 mth of age, uncle with
hemolytic anemia in infancy causing his demise. No family h/o
SLE or Crohn's. Brother has new onset atrial fibrillation.
Physical Exam:
On admission:
Vitals: T: 99.7 HR: 85 BP: 102/63 RR: 20 O2: 99% on RA
General: Tan, jaundiced, tearful and easily aggitated
Skin: Tanned skin, mild jaundice, no petechiae or rashes
HEENT: PERRL, EOMI, sclera icteric, MM moist, oropharynx clear
Cardiac: Regular rate and rhythm, normal s1 and s2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezez, rales,
ronchi
Abdomen: Soft, non-distended, +BS, well healing LUQ laparoscopic
sites, + voluntary guarding, no rebound
Extremities: Warm and well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: Alert and oriented x 3, strength 5/5 in upper and lower
extremities, sensation intact to light touch
=======================================
At time of discharge:
BP=160s-170s/80s-90s, HR=50-60
Abdomen: non-distended, soft, tolerating deep palpation with
minimal discomfort, normal bowel sounds.
Remainder of physical exam unchanged
Pertinent Results:
Labs on admission:
[**2154-3-3**] 04:30AM BLOOD WBC-28.0*# RBC-1.73*# Hgb-5.3*#
Hct-15.8*# MCV-91# MCH-30.9 MCHC-33.8 RDW-19.5* Plt Ct-1481*#
[**2154-3-3**] 04:30AM BLOOD Neuts-84* Bands-1 Lymphs-8* Monos-5 Eos-0
Baso-1 Atyps-0 Metas-1* Myelos-0 NRBC-5*
[**2154-3-3**] 04:30AM BLOOD PT-17.2* PTT-28.6 INR(PT)-1.6*
[**2154-3-3**] 04:30AM BLOOD Ret Man-11.2*
[**2154-3-3**] 04:30AM BLOOD Glucose-193* UreaN-39* Creat-1.3* Na-135
K-5.5* Cl-105 HCO3-17* AnGap-19
[**2154-3-3**] 04:30AM BLOOD ALT-33 AST-57* LD(LDH)-472* AlkPhos-254*
TotBili-2.8* DirBili-1.4* IndBili-1.4
[**2154-3-3**] 04:30AM BLOOD Lipase-22
[**2154-3-3**] 04:30AM BLOOD UricAcd-8.3*
[**2154-3-3**] 04:30AM BLOOD Hapto-261*
[**2154-3-4**] 04:00AM BLOOD Cyclspr-128
CT abdomen/pelvis [**2154-3-3**]:
1. Heterogeneous perfusion of the liver related to thrombosis of
the right portal vein, main portal vein, splenic vein, and SMV.
Note is made of thrombus extending into extensive
retroperitoneal collaterals.
2. Abnormal bowel wall thickening involving the sigmoid colon,
which may
relate to venous congestion.
3. Patent hepatic veins, in arterial system. No IVC thrombosis.
4. Gas in the soft tissues of the left anterior abdominal wall.
Recommend clinical correlation with recent surgery.
CXR:
Bilateral pleural effusions, right greater than left, are new,
are associated with adjacent atelectasis. The upper lungs are
clear. Moderate cardiomegaly is unchanged.
Discharge Labs:
[**2154-3-8**] 07:15AM BLOOD WBC-17.5* RBC-3.88* Hgb-11.9* Hct-36.6
MCV-94 MCH-30.8 MCHC-32.6 RDW-18.8* Plt Ct-985*
[**2154-3-8**] 07:15AM BLOOD PT-20.7* PTT-96.7* INR(PT)-1.9*
[**2154-3-8**] 07:15AM BLOOD Glucose-140* UreaN-21* Creat-1.0 Na-144
K-4.6 Cl-104 HCO3-27 AnGap-18
[**2154-3-8**] 07:15AM BLOOD LD(LDH)-346*
[**2154-3-5**] 03:45AM BLOOD Mg-2.1
[**2154-3-3**] 04:30AM BLOOD Hapto-261*
[**2154-3-3**] 08:17PM BLOOD Hapto-239*
[**2154-3-4**] 04:00AM BLOOD Hapto-243*
[**2154-3-5**] 03:45AM BLOOD Hapto-233*
Brief Hospital Course:
Ms. [**Known lastname 99778**] is a 41 year old female with warm autoimmune
hemolytic anemia who presented ten days status-post splenectomy
with abdominal pain and dyspnea with a hematocrit of 11 and some
evidence of hemolysis.
Anemia: Her laboratories at OSH were consistent with but not
diagnostic of hemolysis; she did not display signs of active
bleeding. The haptoglobin at [**Hospital1 18**] was elevated pointing against
hemolysis. Given her low hematocrit. She was initially managed
in the ICU. A CT scan at [**Hospital1 18**] showed extensive clot burden in
her portal system, likely related to her prior surgery. She
received four units of major antibody crossmatched blood, and
additional tubes were sent to the Red Cross for further
crossmatching.
Hematology saw the patient in the emergency room, and
recommended treatment with steroids and cyclosporine. She was
started on Solumedrol 80mg IV daily and Cyclosporine 150mg PO
q12hours. Hemolysis labs were monitored as well as Cyclosporine
levels. The Surgical team also followed the patient in the ICU.
After transfer to the medical floor, Hct gradually rose daily to
36.6 at time of discharge. Solumedrol was tapered and converted
to prednisione. Cyclosporine was also tapered to 75mg [**Hospital1 **]. LDH
was persistently elevated likely secondary to abdominal clot
process. F/u was scheduled with her hemtologist, Dr. [**Last Name (STitle) 2148**].
Abdominal Pain/Portal thrombus: The pain was diffuse, severe,
and out of proportion to exam. CT scan of abdomen did show large
portal clot burden. Empiric metronidazole was started until a
C.diff could be obtained, but as pt did not have a BM, it was
continued until day of discharge. Her pain was controlled with
Dilaudid as needed. Her diet was advanced to regular, but on
the day of discharge (against medical advice), she did not
tolerate jello without IV dilaudid. Plan was for pt to remain
until able to tolerate clears with only po pain meds, but she
chose to leave AMA (form signed). She has f/u scheduled with Dr.
[**Last Name (STitle) **] within one week. Expressed understanding of need to
return if abdominal pain increases. Given 5 days worth of home
dose of percocet.
Thrombocytosis: Likely related to recent splenectomy, improved
from 1.5 million to 900K at time of d/c.
Leukocytosis: Likely reactive process + related to high dose
steroids. No fevers. No localizing sources of infection with
the exception of abdominal pain. She was started on empiric
Flagyl which was discontinued at time of discharge. White count
peaked at 36 and fell to 17.5 at time of discharge.
Acute Kidney Injury: Creatinine 1.3 from baseline < 1.0. The
was felt to most likely be prerenal from dehydration. This
returned to baseline prior to d/c.
.
Hypertension: likely secondary to steroids and cyclosporine. not
stating anti-htn at this time, continue to monitor; should
improve with taper. BPs peaking in the 170/80 range at time of
discharge.
.
Anxiety: The patient was noted to be very anxious, and this
seemed to worsen after the initiation of steroids. There is
concern that the steroid is causing side effects, including
psychosis, as it had done in the past according to the patient.
She was continued on home benzodiazepines (Klonopin), as well as
Haldol PRN. Disscharged on home klonopin dose.
***PT DISCHARGED AMA. Our recommendation was that she stay
until being able to tolerate po with only percocet for pain
control. She signed AMA form and expressed understanding of
risks.
Medications on Admission:
Benzoyl Peroxide cleanser
Clobetasol cream
Clonazepam 1 mg [**Hospital1 **]:PRN
Cyclosporin 150 mg [**Hospital1 **]
Folic Acid 6 mg daily
Omeprazole 40 mg daily
Percocet 7.5-325 mg tablet 1-2 tabs Q6H:PRN
Paroxetine 30 mg daily
Calcium-Vitamin D
Magnesium [**Hospital1 **]
Multivitamin
Discharge Medications:
1. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day:
prophylaxis.
Disp:*30 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
8. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO twice a
day.
Disp:*180 Capsule(s)* Refills:*0*
9. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
11. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Multivitamins Oral
13. Percocet 7.5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
autoimmune hemolytic anemia
portal vein thrombosis
thrombocytosis
anxiety
Discharge Condition:
Discharged against medical advice. Is not tolerating solid food
without IV dilaudid at the time of discharge.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] with severe abdominal pain and a very
low blood count. You received a blood transfusion at an outside
hospital and another one here. At the time of discharge, your
blood counts were nearing the normal range. A scan of your
abdomen showed a large amount of blood clots in the vessels that
drain your intestines. For this, you will need to be
anticoagulated for some time.
You are being discharged against medical advice. We strongly
advise you to stay until you were able to tolerate food without
IV pain medication. There is a risk that advancing your diet
without medical supervision may lead to an acute abdomen process
requiring urgent intervention.
Please return to the hospital if you develop: severe abdominal
pain, fevers, chills, sweats, dizziness, blood in your stool,
tarry stools, any other form of bleeding, severe headache,
chenage in vision, or any other symptom which seriously concerns
you.
Several changes were made to your medications:
- cyclosporin has been reduced to 75mg twice daily
- prednisone 30mg daily has been started
- warfarin 5mg daily has been started
- bactrim (single strength) has been started
- omeprazole, paroxeteine, clonazepam, calcium/vitamin D, and
folic acid have been continued at previous doses.
Followup Instructions:
We have scheduled you an appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **],
MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2154-3-14**] at 11:45am
Please call Dr.[**Name (NI) 7750**] office today and make an appointment
for Tuesday [**3-12**]. It is very important that you make this
appointment, you will need to have your INR (blood thinning)
checked.
Completed by:[**2154-3-8**]
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]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11190, 11196
|
6175, 9688
|
303, 310
|
11314, 11426
|
4190, 4195
|
12796, 13221
|
3063, 3242
|
10024, 11167
|
11217, 11293
|
9714, 10001
|
11450, 12773
|
5636, 6152
|
3257, 3257
|
241, 265
|
338, 2322
|
4209, 5619
|
2344, 2977
|
2993, 3047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,216
| 188,030
|
9436
|
Discharge summary
|
report
|
Admission Date: [**2118-2-9**] Discharge Date: [**2118-2-11**]
Date of Birth: [**2056-10-30**] Sex: M
Service: MICU
CHIEF COMPLAINT: Respiratory failure.
HISTORY OF PRESENT ILLNESS: A 61-year-old male with
metastatic renal carcinoma status post multiple rigid bronchs
for multiple pulmonary metastases. The patient came today
the OR at the procedure and was subsequently extubated, but
remained hypoxic on O2 sats at about 82%. He remained
agitated, confused, diaphoretic, and required reintubation.
Of note, the patient has had one more complication in the
past requiring reintubation.
1. Renal cell carcinoma diagnosed in [**2115-3-5**] status
post right nephrectomy.
2. Excision of the right atrium as well as multiple pulmonary
metastases.
3. Diabetes mellitus type 2.
3. Hypertension.
MEDICATIONS:
1. Lopressor 25 [**Hospital1 **].
2. Norvasc 10 q day.
3. Terazosin 10 [**Hospital1 **].
4. Glucotrol 20 q day.
5. Tylenol.
6. Ativan.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married, consultant, former smoker.
PHYSICAL EXAMINATION: Afebrile, heart rate 100, blood
pressure 100/50, sedated and intubated. No jugular venous
distention. Tachycardic, S1, S2 with no murmurs, rubs, or
gallops. Lung examination: Coarse breath sounds with
decreased breath sounds at the bases bilaterally. Abdomen
was soft, nontender, nondistended with normoactive bowel
sounds, no edema, [**2-3**]+ pulses.
BRIEF HOSPITAL COURSE: The patient is admitted to Medical
Intensive Care Unit for further observation of respiratory
distress. On hospital day #2, the patient underwent
bronchoscopy which revealed multiple hemorrhagic metastases
extending through the large portion of the bronchial tree.
At this point, a discussion with the family was initiated with
the presence of medical oncology, interventional pulmonology and
critical care. As there were no more therapeutic options
available from an oncologic or airway standpoint, all were in
agreement that it would be in the best interest for
the patient to pursue a nonaggressive approach. Therefore,
the patient was made comfort measures only, and was started
on a Morphine drip. He expired the same day in the Medical
Intensive Care Unit.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 5094**]
MEDQUIST36
D: [**2118-2-13**] 14:15
T: [**2118-2-16**] 07:31
JOB#: [**Job Number 32189**]
|
[
"401.9",
"250.00",
"V10.52",
"518.81",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.01",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1461, 2474
|
1078, 1437
|
150, 172
|
201, 1001
|
1018, 1055
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,866
| 129,702
|
22892+57328
|
Discharge summary
|
report+addendum
|
Admission Date: [**2164-1-30**] Discharge Date: [**2164-2-27**]
Date of Birth: [**2095-7-20**] Sex: M
Service: VSU
CHIEF COMPLAINT: Left foot ischemia.
HISTORY OF PRESENT ILLNESS: This is a 58 year-old gentleman
who is transferred from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36688**] Hospital. Patient is well
known to our service and he recently underwent right and left
vascular bypasses with revision. His last surgery was [**2163-9-24**] where he underwent a left femoral popliteal revision
with bovine patch for graft stenosis. He returns now with
left leg ischemia. He has had a right femoral popliteal in
[**2163-4-24**], a right femoral anterior tibial bypass with PTFE
and a right femoral endarterectomy and right profunda femoris
plasty secondary to failing graft in [**2163-8-25**]. Patient
on [**2164-1-29**] in the morning after going to church had
onset of acute left foot pain most of the day and by bed time
the pain had progressed and the foot had become cool. The
patient was admitted to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36688**] Hospital and transferred
here for further evaluation and treatment. Patient's last
hemodialysis was on Sunday.
PAST MEDICAL HISTORY: Past illnesses include peripheral
vascular disease, carotid disease, status post bilateral
carotid endarterectomy, coronary artery disease, status post
myocardial infarction at the age of 36, status post coronary
artery bypass graft x4 in [**2160**] at [**Hospital6 1130**]. History of hypertension, controlled. History of
type 2 diabetes mellitus with neuropathy and nephropathy. End
stage renal disease on hemodialysis via Quinton catheter
Monday, Wednesday and Friday. At the time of discharge he
returned to peritoneal dialysis. Renal artery stenosis by
arteriogram. History of methicillin resistant Staphylococcus
aureus. History of PMIBI on [**1-29**] which showed moderate
severe left ventricular dysfunction.
PAST SURGICAL HISTORY: Left femoral PFA endarterectomy with
bone patch angioplasty, left common femoral artery to below
knee popliteal with PTFE [**2163-1-25**]. Right femoral below
knee popliteal in [**2163-4-24**]. Angiogram diagnostic via the left
brachial artery in [**2163-8-25**]. Exploration of the right
femoral popliteal bypass with thrombectomy, a right femoral
anterior tibial with PTFE, right femoral endarterectomy and
right profundoplasty in [**2163-8-25**]. Revision of the left
femoral below knee popliteal bypass angioplasty with bovine
patch in [**2163-9-24**]. Quinton catheter in [**2162**]. Hemodialysis
catheter in [**2163-7-25**].
ALLERGIES: No known drug allergies.
MEDICATIONS: Include Coumadin for his graft.
PHYSICAL EXAMINATION: This is an alert white male with left
foot rest pain. Head, eyes, ears, nose and throat examination
with bilateral carotid bruits. The wound sites are well
healed. The carotid pulses are 1+ bilaterally with no jugular
venous distension or thyromegaly. Lungs are clear to
auscultation. Heart has a regular rate and rhythm without
murmur, gallop or rub. Abdominal examination is soft,
nontender, nondistended. Bowel sounds are present x4 with a
left iliac bruit. Peripheral vascular pulses show left foot
with rubrous cyanotic changes the toes to the ankle. Foot is
cool to touch. Motor is intact. Sensory is intact. Pulse
examination shows on the right a Dopplerable femoral with
absent pulses below the femoral artery. The left femoral is
palpable 2+. The popliteal is Dopplerable and the dorsalis
pedis and posterior tibial are Dopplerable. Neurologic
examination: The patient is oriented x3, is nonfocal.
HOSPITAL COURSE: The patient was admitted to the vascular
service. He was begun on IV heparinization. He had serial
coagulations monitored for goal PTT of 60 to 80. Renal
service was consulted for peritoneal dialysis management. The
patient underwent on [**2164-1-31**] an arteriogram which
showed a patent right femoral anterior tibial bypass graft
with a proximal common femoral artery 90% stenosis. The left
iliac was with disease and the left common femoral was with
disease. The profunda femoris was the sole runoff on the left
side. On [**2-4**] cardiology was consulted in anticipation
for revascularization. His beta blockade was increased to
maintain a goal heart rate between 60 and 70. A PMIBI was
done which showed moderate fixed deficit with global
hypokinesis and ejection fraction of 27%. On [**2-7**] the
patient had mental status changes with hypotension and he was
transferred to VICU. His CKs and troponins were cycled. The
patient was begun on Levophed which required him to be
transferred to the surgical intensive care secondary to
vasopressive use. Initial CK was 312 with an MB of 11. The
patient was pancultured. TSH was done which was normal at 4.4
with free thyroid T4 of 0.9. An echocardiogram was repeated.
There was no significant change. Hemodialysis was instituted.
On [**2-9**] there was a significant drop in the patient's
hematocrit from 30.6 to 26.0. The patient was transfused.
Patient was noted to have melanotic stools. The patient had a
poor response of his hematocrit post transfusion. A
gastrointestinal consult was placed. An upper
esophagogastroduodenoscopy was done which demonstrated
esophageal erosions with duodenitis and gastritis. His H
pylori was negative. The patient was then transferred to the
VICU for continued care and serial hematocrits were monitored
with stabilization of his hematocrit. Cardiology was
reconsulted on [**2-12**] because of the patient was going
into paroxysmal atrial fibrillation. He was started on
amiodarone which converted him to normal sinus rhythm. IV
heparinization was begun and recommendations were long term
anticoagulation with Coumadin. The outside cardiac
catheterization studies were reviewed and they felt the
patient was not a candidate for any cardiac intervention. The
patient underwent on [**2-13**] a left common iliac artery
and external iliac artery stenosis with a left femoral patch
angioplasty and removal of his peritoneal dialysis catheter.
The patient tolerated the procedure well. The patient was
noted to have persistent left foot ischemia and they felt he
would probably wind up requiring a below knee amputation. It
was also noted that the right foot was ischemic. The patient
underwent a right femoral endarterectomy with patch
angioplasty and a graft thrombectomy. The patient had a full
graft pulse at the end of the procedure. The patient's
amiodarone was increased secondary to increase in atrial
fibrillation. IV heparinization was continued.
The patient underwent on [**2-17**] a left below knee
amputation. He tolerated the procedure well. He continued to
do well and on [**2-19**] he was transferred to the regular
nursing floor. On [**2-20**] the patient had an episode of
bradycardia with supraventricular tachycardia. His total CK
was 194 with an MB of 17 and a troponin of .51. The second
set showed a total CK of 1553 with a troponin of 22. The
patient was therapeutic on his Coumadin and his heparin was
discontinued. Physical therapy was requested to see the
patient. There were no significant ischemic
electrocardiographic changes on the bradycardia
supraventricular tachycardia episode. On [**2-22**] the
patient's INR was noted to be 7.7. The Coumadin was
discontinued. A repeat showed progressive elevation in his
INR. A hematology consult was placed. PT/INR the following
day was 2.2 after 5 mg of vitamin K. Recommendations were to
hold the Augmentin which we had started for the patient's
stump cellulitis and to continue to monitor his coagulations
carefully, reconsider another antibiotic given that the
Augmentin would synergize the effect of Warfarin. Case
management was consulted for discharge planning. Physical
therapy felt the patient would require rehabilitation prior
to the patient being discharged home. The patient will be
discharged to rehabilitation when medically stable.
DISCHARGE MEDICATIONS: Coumadin for a goal INR of 2.0 to
3.0. This was reinitiated on [**2-23**] at 1 mg. Dosing will be
adjusted according to PT/INR. Metoprolol 12.5 mg b.i.d.,
lisinopril 10 mg daily, acetaminophen 650 mg q 4 hours around
the clock, Protonix 40 mg q 12 hours, amiodarone 400 mg
daily, allopurinol 100 mg daily, albuterol nebulizer q 6
hours, arvistatin 80 mg daily, gabapentin 300 mg q 4 to 8
hours, amitriptyline 25 mg at h.s., hold for excessive
sedation, Sucralfate 1 gram q.i.d., Bisco 10 mg tablets or
suppositories p.r.n. MiraLax 17 grams q.d. p.r.n. for
constipation, insulin sliding scale - please see enclosed
copy of insulin sliding scale, temazepam 50 mg h.s. p.r.n.,
aspirin 325 mg daily, Colace 100 mg b.i.d.
DISCHARGE DIAGNOSES:
1. Left foot ischemia secondary to peripheral vascular
disease with rest pain.
2. Bilateral carotid disease, status post CEAs,
asymptomatic.
3. History of coronary artery disease with myocardial
infarction at the age of 36, status post coronary artery
bypass graft x4.
4. History of hypertension, controlled.
5. History of diabetes mellitus type 2 with neuropathy and
nephropathy.
6. End stage renal disease on peritoneal dialysis,
discontinued with removal of the PD catheter and begun
hemodialysis.
7. Renal stenosis by arteriogram.
8. History of methicillin resistant Staphylococcus aureus
wound infection.
9. PMIBI shows moderate severe left ventricular dysfunction.
10. Postoperative blood loss anemia, transfused, corrected.
11. Postoperative esophagitis, gastritis and esophageal
erosions by esophagogastroduodenoscopy with H pylori
negative.
12. Postoperative hypotension requiring vasopressor support
secondary to gastrointestinal bleed,corrected.
13. Status post left common iliac, external iliac stenting
with left femoral patch angioplasty on [**2-13**],
failed.
14. Status post left below knee amputation on [**2-15**].
15. Status post foot ischemia secondary to embolectomy.
16. Status post right femoral endarterectomy with patch
angioplasty and graft thrombectomy with return of
circulation.\
17. Postoperative paroxysmal atrial fibrillation requiring
amiodarone.
18. Postoperative hypocoagulation secondary to nutritional
depletion, corrected.
DISCHARGE INSTRUCTIONS: The patient should follow up with
Dr. [**Last Name (STitle) 1391**] in 3 to 4 weeks. No stump shrinkers. Skin clips
remain in place for a total of 2 weeks in the right leg and
in the left leg the below knee amputation stump skin clips
remain in place until seen in follow up. Patient's INR should
be monitored on a daily basis until he in a steady
therapeutic state with a INR of 2.0 to 3.0. If patient's INR
drops below 2 IV heparin should be begun for a total PTT 60
to 80. Dr.[**Name (NI) 1392**] office should be called if the patient
develops a temperature greater than 101.5, if the amputation
site or the incisions on the right leg become erythematous or
drain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2164-2-23**] 13:57:21
T: [**2164-2-23**] 15:18:44
Job#: [**Job Number 59173**]
Name: [**Known lastname 8390**],[**Known firstname **] Unit No: [**Numeric Identifier 10878**]
Admission Date: [**2164-1-30**] Discharge Date: [**2164-2-24**]
Date of Birth: [**2095-7-20**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 231**]
Addendum:
Continued from [**2-23**]. On [**2164-2-24**], patient passed an uneventful
night. He had hemodialysis on [**2-24**]. He was discharged to your
rehabilitation facility in good condition and looking forward to
working hard at reconditioning.
Major Surgical or Invasive Procedure:
diagnostic angiogram with right leg runoff via left CFA [**2164-1-31**]
EGD [**2-10**]
D/c pretoneal dialysis catheter, left CIA/EIA stenting and left
fem patch angioplasty [**2164-2-13**]
rt. femoral endartectomy, graft thrombectomy with femoral patch
angioplasty [**2-15**]
left BKA [**2164-2-17**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1)
Packet PO QD PRN () as needed for Constipation.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Coumadin 1 mg Tablet Sig: Titrate Tablet PO once a day:
Start with 1mg. If increase is needed, increase by only 0.5 mg
increments. PATIENT IS VERY SENSITIVE TO WARFARIN.
19. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Five (5) ml Intravenous qhour: 1. Please check PTT 6 hours
after beginning drip
2. Goal PTT is 60-80. Please titrate heparin drip up to goal
PTT.
3. Please check PTT 6 hours after each dose change.
4. Please discontinue when INR from warfarin is therapeutic -
between [**1-27**].
Disp:*QS ml* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1933**]
Discharge Diagnosis:
left foot ischemia with rest pain
ESRD on PD, converted to HD [**2164-2-8**]
CHF
Hypotension
Iron deficiency anemia
Atrial fibrillation
left iliac stenosis s/p stenting [**2-12**]
rt foot ischemia, acute secondary to arterial embolus
left foot persistant ischemia s/p BKA
hypercoaguable state secondary to malnutrition, reversed
Discharge Condition:
stable
Discharge Instructions:
No stump shrinkers
Skin clips remain in place until seen in followup with Dr.
[**Last Name (STitle) **]
[**Name (STitle) **] if patient developes fever >101.5 or if wounds appear
infected
Moniter INR qd for goal of 2.0-3.0 for atrial fibrillation and
graft. If INR fall below 2.0 start IV heparin for goal PTT
60-80.
Please dose warfarin nightly according to INR. THE PATIENT IS
EXTREMELY SENSITIVE TO WARFARIN. Increase as needed by 0.5mg at
a time.
Followup Instructions:
2-4 weeks Dr. [**Last Name (STitle) **]. call for appointment. [**Telephone/Fax (1) 236**]. Pt.
will get staples removed at this time.
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2164-2-24**]
|
[
"998.11",
"427.31",
"285.1",
"458.29",
"535.61",
"276.6",
"996.74",
"707.15",
"403.91",
"250.40",
"440.1",
"276.51",
"263.9",
"535.41",
"997.1",
"997.62",
"410.91",
"414.8",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"99.04",
"00.17",
"84.15",
"88.42",
"38.93",
"97.82",
"45.13",
"39.95",
"39.90",
"00.40",
"00.46",
"54.98",
"38.18",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
14159, 14206
|
11873, 12178
|
14579, 14588
|
15087, 15381
|
8737, 10276
|
12201, 14136
|
14227, 14558
|
3667, 7974
|
14612, 15064
|
2001, 2718
|
2741, 3649
|
154, 175
|
204, 1236
|
1259, 1977
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,996
| 135,999
|
5682
|
Discharge summary
|
report
|
Admission Date: [**2200-4-14**] Discharge Date: [**2200-4-17**]
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 22705**] is an 89-year-old
seen on [**3-18**] with increased difficulty ambulating,
incontinence, headache, falls and left sided weakness. She
was found to have right sided subdural hematoma on the [**3-20**] and she continued to have left facial and upper
of [**Month (only) 116**] from the rehabilitation and she was doing well.
Secondary to increased lethargy and mild headache, she was
noted to be holding her right arm in a flex position and was
noted to have soft voice and increasing lethargy. The CT
scan in the Emergency Room showed increased volume of the
subdural hematoma on the left side with compression of the
lateral ventricles and subfalcial herniation with increased
signs at this time are blood pressure 188/93, saturations 97%
on room air and pulse was 80 and regular.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft
2. Congestive heart failure, ejection fraction of 30%
3. Atrial fibrillation
4. Hypertension
5. Pacemaker
MEDICATIONS:
1. Lisinopril 10
2. Atorvastatin 10
3. Levoxyl 15
4. Lasix 20
5. Glipizide 5
6. Atenolol 75
7. Zantac 150
8. She has also been on Coumadin, the dose of which we are
not sure of.
9. Insulin
EXAM:
VITAL SIGNS: The pulse was irregular.
ABDOMEN: Soft.
NECK: Supple. There are no bruits.
NEUROLOGIC: She is alert and oriented to name and states she
is in [**Hospital6 1708**] and that it is [**2198-1-31**].
She is mildly anxious. Repetition is intact. Attention
directed. Motor right downward drift. Mild right facial.
Right triceps, deltoids, wrist extensors and flexors are 4 to
4+/5. Full strength on all the other extremities. Sensory
is intact.
CNS: Pupils are post surgical bilaterally. Extraocular
muscles are intact. Trapezius 5 and 5. The rest of the
cranial nerves are fine. Gait - walks unassisted.
LAB TESTS: White cells 6.8, platelets 272 and hematocrit of
37. Her INR was 1.2, PT 13.4, PTT 23.6. Sodium 138,
potassium 3.8, chloride 99, bicarbonate 28, urea 16,
creatinine 0.8 and blood sugar was 158.
IMAGING: Her electrocardiogram demonstrated atrial
fibrillation and head CT showed acute hemorrhagic competence
in the prior subdural collection.
HOSPITAL COURSE: The plan was to admit her to Neurosurgery
Intensive Care Unit for blood pressure control and also
drainage of the right subdural hematoma and this was done by
bedside. The left scalp was prepared, draped in a sterile
fashion and after some intravenous sedation, a drain was
placed and some blood was drained. The drain was left in for
48 hours and then it was removed. Repeat head scan shows a
reduction in the amount of subdural collection and reduction
in mass effect since placement of catheter. Her hematocrit
at the time of discharge was 32.7 and white cells 6.4,
platelets 237. Sodium is 139, potassium 3.9, chloride 102,
bicarbonate 26, urea 12, creatinine 0.6 and glucose 150.
DISCHARGE CONDITION: She is awake, alert, oriented. She has
a very mild drift to her left upper extremity, but otherwise
the neurological exam is intact and she is oriented x2. She
is stable neurologically at present and she is being screened
for rehabilitation. Physical therapy and occupational
therapy and they have suggested to continue.
DISCHARGE DIAGNOSES:
1. Impaired mobility
2. Impaired balance
She has risk for falls
The rest of the details of the physical therapy evaluation
can be found in their discharge papers.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Doctor Last Name 22706**]
MEDQUIST36
D: [**2200-4-17**] 12:17
T: [**2200-4-17**] 14:30
JOB#: [**Job Number 22707**]
|
[
"V45.81",
"427.31",
"432.1",
"401.9",
"428.0",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
3075, 3399
|
3420, 3859
|
2362, 3053
|
124, 938
|
960, 2344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,786
| 132,435
|
6788
|
Discharge summary
|
report
|
Admission Date: [**2152-9-12**] Discharge Date: [**2152-9-14**]
Date of Birth: [**2106-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
"I'm having withdrawal"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 25747**].
HPI: 45 yo M with h/o polysubstance abuse and ? h/o alcohol
withdrawal seizures who was found in his hotel room drunk and
naked sitting in stool after calling 911. He stated he was
using heroin. Initial blood sugar 123, BP 140/P, HR 106, 97%
NRB. Per report he had a Sz in the ED lobby. In the ED he
received Ativan 2 mg x2. Head CT and CXR unremarkable.
.
Currently he is sedated but arousable to sternal rub. O2 sat
decreased to 87% on 2L NC while asleep, increased to 95% on 4L
NC. He reports he is uncomfortable secondary to withdrawel
symptoms. He admits to drinking 2 liters of Vodka today and
using morphine and dilaudid. Urine and serum tox screen in ED
revealed EtOH level of 317, otherwise negative. He reports
being sober for 3 yrs [**Known lastname **] to recent binge. Pt was last seen
at [**Hospital1 18**] in [**2149-8-27**]. At that time he was evaluated by neuro
and psych; he had several episodes of arm and leg shaking which
were not thought to be seizures.
.
He reports he started drinking again secondary to depression.
He admits to suicidal ideation with a plan to "drink himself to
death".
.
Past Medical History:
1. EtOH abuse
2. Cocaine abuse
3. Heroin abuse
4. ?h/o Hepatitis C (negative HCV Ab in [**3-29**])
5. + ppd s/p INH x6 months
6. Depression treated at [**First Name9 (NamePattern2) 3782**] [**Location (un) 86**] VA
Social History:
Reports drinking 2 liters of vodka today. He was incarcerated
for vehicular homicide (DUI) in [**2139**]-[**2147**]. Started drinking age
13. Enlisted in army age 17. Joined army rangers. 6 children
in his family. Living with mother at home; in and out of most
[**Location (un) 86**] Hospitals. Recently admitted in [**6-1**] to ICU at
[**Hospital1 1474**] VA for multiple seizures. Then inpt psych stay,
completed 6 wk [**Hospital1 3782**] detox program at [**Location (un) 86**] VA (completed Labor
Day). In [**2148**] committed to [**Hospital3 12678**] for 30 days.
Family reports he was missing since 5 days [**Known lastname **] to admission.
Was living with his mother since completed VA program.
.
Family History:
unknown
Physical Exam:
Upon arrival to ICU:
Tc 98.7 BP 130/69 HR 101 RR 9-18 Sat 89-96% 4L NC
Gen: initially sleeping, then awakes with arm shaking, refusing
to open eyes or mouth
HENNT: anicteric
CV: RRR, nl S1S2, No M/R/G
Lungs: anteriorly CTAB
Abd: soft, NT/ND, +BS, No HSM
Ext: no edema, strong DP/PT pulses bilaterally
Neuro: spontaneously moving UE's x 10 seconds while awake
Skin: no rash
Pertinent Results:
Labs on admission:
[**2152-9-12**] 09:13PM GLUCOSE-86 UREA N-20 CREAT-0.9 SODIUM-136
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-20* ANION GAP-24*
CALCIUM-8.5 PHOSPHATE-1.9*# MAGNESIUM-2.5 ALT(SGPT)-100*
AST(SGOT)-67* LD(LDH)-184 ALK PHOS-66 AMYLASE-72 TOT BILI-0.6
[**2152-9-12**]: serum tox: ASA-NEG ETHANOL-317* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2152-9-12**]: urine tox: URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
10/18-19/06: cardiac enzymes TnT < 0.01 x 3 sets
.
Studies:
CXR [**9-12**]: No evidence for acute cardiopulmonary abnormality.
.
Head CT [**9-12**]: No evidence of intracranial hemorrhage, injury or
other acute process.
.
[**2152-9-12**] 09:13PM GLUCOSE-86 UREA N-20 CREAT-0.9 SODIUM-136
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-20* ANION GAP-24*
[**2152-9-12**] 09:13PM CALCIUM-8.5 PHOSPHATE-1.9*# MAGNESIUM-2.5
[**2152-9-12**] 02:56PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2152-9-12**] 02:40PM ASA-NEG ETHANOL-317* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2152-9-12**] 09:13PM GLUCOSE-86 UREA N-20 CREAT-0.9 SODIUM-136
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-20* ANION GAP-24*
[**2152-9-12**] 09:13PM GLUCOSE-86 UREA N-20 CREAT-0.9 SODIUM-136
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-20* ANION GAP-24*
[**2152-9-12**] 02:40PM ALT(SGPT)-100* AST(SGOT)-67* LD(LDH)-184 ALK
PHOS-66 AMYLASE-72 TOT BILI-0.6
Brief Hospital Course:
A/P: 45 yo M with h/o polysubstance abuse admitted with EtOH
intoxication.
.
1.) EtOH Intoxication with EtOH level of 317: The patient
presented acutely intoxicated and was showing early evidence of
tremulousness suspicious for alcohol withdrawal. As the patient
has a history consistent with very high risk for severe delerium
tremens, he received a benzodiazepine load with valium and
ativan. He received a total of 350 mg of valium and 24 mg of
ativan while in the ICU. His vital signs remained stable
without evidence of autonomic instability. He received IVF with
folate/thiamin/multivitamins. In collaboration with the
psychiatry consult service, he was started on a low dose
methadone taper to manage symptoms of opiate withdrawal as his
dilated pupils were more consistent with this withdrawal
syndrome as well. He was recommended to be transferred directly
to an inpatient detox program at the [**Hospital1 1474**] VA. However, he
decided that he would leave against medical advice and pursue a
detox program on his own. It was explained to him multiple
times by ICU staff, psychiatry staff, and social work staff that
this was not in keeping with sound medical care as the health
care staff was concerned that he would simply resume drinking
upon leaving the hospital. Furthermore, he was reminded that if
he left, he would be homeless as there was no time to arrange
housing. He proceeded with leaving AMA.
.
2.) Depression with SI. He initially stated that he was trying
to kill himself. He was placed on a 1:1 supervision while he
was intoxicated. Upon becoming sober, he denied suicidal
ideation. The psychiatry consult evaluated him and confirmed
that the patient was not actively suicidal. He continued to
receive lexapro at low dose.
.
3.) Atypical muscular skeletal movements: The patient had
periodic episodes of arm and leg moving. These were evaluated
by the neurology consult and thought to be not consistent with
seizure and a low probability for a positive EEG. No
anti-convulsants were indicated.
4.) Chest pain: The patient had a brief episode of chest pain
in the left side of his chest. This was not associated with
diaphoresis or shortness of breath. An EKG showed no evidence
of myocardial ischemia and he had 3 sets of negative cardiac
enzymes. Upon discharge, it was recommended that he take a baby
aspirin daily for primary cardiac prevention.
.
5.) Leukocytosis (WBC 14) likely stress response. No evidence of
infection. The white count resolved on follow-up.
.
6.) Anemia: The patient had a normocytic anemia. This developed
after fluid resusistation. There was no evidence of acute blood
loss. Iron studies were consistent with anemia of chronic
disease. The anemia could not be completely evaluated as the
patient left AMA. The anemia should be further evaluated as an
outpatient.
.
7.) FEN. The patient received IVF with Thiamine, Folate, MVI in
1L of normal saline daily for 2 days. Replete lytes prn. Once he
was sober, he tolerated a regular diet.
8.) Heme positive stool. Iron studies were not consistent with
iron deficiency. Will need [**Hospital1 3782**] workup for occult blood loss.
.
9.) PPX. SC heparin, H2 blocker while not taking po's
.
10.) Code: Full
.
11.) Access: PIV
.
12.) Dispo: patient left against medical advice. psychiatry
consult confirmed that patient had capacity to make medical
decisions once he was sober.
.
13.) Communication: Sister - [**Name (NI) **] [**Name (NI) 3003**] is health care proxy.
[**Telephone/Fax (1) 25748**] (h); [**Telephone/Fax (1) 25749**] (c)
Medications on Admission:
Lexapro (unknown dose)
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
Primary:
Ethanol Intoxication and withdrawal
.
Secondary:
Polysubstance abuse
Atypical musculoskeletal jerking
Non-cardiac chest pain
Discharge Condition:
stable vital signs. no evidence of alcohol withdrawal.
ambulating. tolerating oral nutrition and medication.
You are leaving against medical advice. You were evaluated by
psychiatry and and felt to have the capacity to make medical
decisions.
Discharge Instructions:
You have been evaluated and treated for your alcohol
intoxication and withdrawal symptoms. The episodes of shaking
were not related to seizure activity. The brief episode of
chest pain was evaluated as well and there was no evidence of
heart damage.
.
It is essential that you attend the recommended alcohol detox
program. Your drinking is very detrimental to your health and
persistant drinking will very likely ultimately kill you.
.
You were given medications to manage the alcohol withdrawal
symptoms and a short course of methadone to manage opiate
withdrawal. These medications were not continued once you left
the hospital.
.
If you experience any concerning symptoms, particularly chest
pain, persistant nausea/vomiting or worsening withdrawal
symptoms contact your primary doctor.
Followup Instructions:
Please call your primary [**Hospital **] clinic at [**Telephone/Fax (1) 9075**] to set up a
detox program.
.
Contact your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up appointment
for as soon as possible. (Dr. [**First Name8 (NamePattern2) 2127**] [**Last Name (NamePattern1) 9780**] [**Telephone/Fax (1) 9075**])
|
[
"303.01",
"285.9",
"291.81",
"305.50",
"305.91",
"V62.84",
"288.60",
"780.39",
"786.59",
"311",
"291.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8208, 8256
|
4418, 7984
|
339, 346
|
8434, 8681
|
2953, 2958
|
9523, 9875
|
2522, 2531
|
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|
8277, 8413
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8010, 8034
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8705, 9500
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2546, 2934
|
276, 301
|
374, 1536
|
2972, 4395
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1558, 1775
|
1791, 2506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,058
| 115,024
|
49906
|
Discharge summary
|
report
|
Admission Date: [**2179-9-14**] Discharge Date: [**2179-10-7**]
Date of Birth: [**2128-8-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Zoloft / Tetracyclines / Prozac / Paxil
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2179-9-15**] Cardiac Catheterization
[**2179-9-21**] Cartotid Stent to [**Doctor First Name 3098**]
[**2179-9-22**] PICC line insertion
[**2179-9-28**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to OM, SVG to RCA), Aortic Valve Replacement (19mm St.
[**Male First Name (un) 923**] Mechanical), Mitral Valve Replacement (27mm St. [**Male First Name (un) 923**]
Mechanical), Aortic Root Enlargement with Pericardial Patch
History of Present Illness:
51 y/o F w/hx of HTN and PVD, was in her USOH on Sunday night
until she woke up at midnight severely SOB. She was intubated in
the filed and brought to [**Hospital3 **]. Upon intubation they
noted pink frothy sputum coming from the ETT. At the [**Hospital1 189**] ICU,
her bp was controlled and she was diuresed with lasix. She was
extubated on Monday [**9-13**]. She had a CTA to r/o PE, which
demonstrated only interstitial opacities c/w CHF (no PE). She
had a TTE which showed MR, AR, and an akinetic anterior wall.
Her initial ECG upon arrival yest AM showed <[**Street Address(2) 4793**] depressions
in II/III/aVF with 1 mm STE in V1-2. By this AM, her ECG showed
deep TWI in I, aVL, II, and V2-6. Her cardiac enzymes showed CK
62-> 278 -> 380, with MB 0.6 ->5 -> 3.7, trop <0.04 -> 0.88 ->
0.94 (from yest at 1 am to 9 am to 5 pm). She was then
transferred from OSH to [**Hospital1 18**] for cardiac cath and further care.
Past Medical History:
Hypertension, Hypercholesterolemia, Peripheral Vascular Disease,
Varicose Veins, Congestive Heart Failure, Congenital hip
dysplasia with chronic low back pain, s/p Appendectomy, s/p
cholecystectomy, s/p left finger reattached, s/p stents to left
leg and angioplasty to right leg, s/p left hip replacement
Social History:
patient is married with one grown daughter. previously worked as
a medical assistant. 1 ppd smoking since age 16, quit 6/[**2178**]. No
alcohol/drug abuse.
Family History:
Father with Diabetes and CVA in his late 60s, mother with MI at
age 53.
Physical Exam:
T: 98.3 BP: 130/54 P: 77 R: 18 97%RA
Gen: alert and oriented pleasant female in NAD
HEENT: pupils 2 mm and minimally reactive, eomi, sclerae
anicteric, MMM, no OP lesions
Neck: supple, bilateral carotid bruits, JVD not elevated
Lungs: minimal bibasilar crackles, dullness to percussion at
bilateral bases
CV: RRR, normal S1/S2, no m/r/g
Abd: soft, nt/nd, normoactive bowel sounds
Ext: no edema, 2+ dp bilaterally
Neuro: CN II-XII intact, MAEW
Pertinent Results:
Cath [**9-15**]: 3VD. The LMCA had diffuse 50% stenosis. The LAD had
had diffuse proximal disease without critical lesions. The
distal LAD was intramyocardial with the distal D2 being the
predominant vessel to the apex. The LCx was a non-dominant
vessel with 80% stenosis in its origin. The RCA was a dominant
vessel with 80% stenosis at its origin.
CNIS [**9-21**]: Significant plaque with bilateral 80-99% carotid
stenosis. Of note, the plaque extends fairly high in both
cervical internal carotid arteries.
Echo [**9-28**]: PRE-BYPASS: Preserved biventricular systolic
function. The intrinsic LV systolic function may be depressed
given the degree of mitral regurgitation. Overall LVEF 55%.
Thickened mitral leaflets at commisures, no prolapse or flail
segments reflecting a probable rheumatic disease in origin.
There is shortened chordae and a thickened subvalvular
apparatus. There is mild mitral stenosis with moderate to severe
mitral regurgitation. The regurgitant jet is mostly central with
a vena contracta of 0.57cm and mitral annulus of 30mm and a
dilated left atrium. Thickened aortic leaflets especially at
commissures with a mild aortic stenosis and a central
regurgitant jet c/w with moderate aortic regurgitation. There is
no flow reversal of flow in the thoracic aorta. Mild tricuspid
and pulmonic regurgitation. POST-BYPASS: Suboptimal images due
to double mechanical valves A mechanical prosthesis is seen in
the native mitral position, stable and functioning well and
regurgitant jets are typical for the type of prosthesis. No
mitral stenosis is appreciated. Mean gradient of 3 mm Hg. A
mechanical prosthesis is seen in the native aortic position,
stable and functioning well and the regurgitant jets are typical
of the prosthesis with a mean gradient of 7 mm Hg.
CXR [**10-2**]: Bilateral pleural effusions, worse on the left than
the right. There is interval worsening of the left-sided pleural
effusion. Bibasilar atelectasis.
[**2179-9-14**] 05:29PM BLOOD WBC-13.6* RBC-4.21 Hgb-13.5 Hct-37.8
MCV-90 MCH-32.2* MCHC-35.8* RDW-12.9 Plt Ct-209
[**2179-9-27**] 06:45AM BLOOD WBC-5.0 RBC-2.75* Hgb-8.9* Hct-25.5*
MCV-93 MCH-32.2* MCHC-34.7 RDW-14.2 Plt Ct-174
[**2179-10-5**] 07:32AM BLOOD WBC-12.1* RBC-2.99* Hgb-9.4* Hct-27.2*
MCV-91 MCH-31.4 MCHC-34.5 RDW-17.0* Plt Ct-262
[**2179-9-14**] 05:29PM BLOOD PT-12.9 PTT-31.4 INR(PT)-1.1
[**2179-9-25**] 06:35AM BLOOD PT-12.4 PTT-32.3 INR(PT)-1.1
[**2179-10-2**] 12:54PM BLOOD PT-64.4* PTT-30.8 INR(PT)-8.1*
[**2179-10-5**] 07:32AM BLOOD PT-16.5* PTT-72.4* INR(PT)-1.5*
[**2179-9-14**] 05:29PM BLOOD Glucose-94 UreaN-14 Creat-0.6 Na-142
K-3.6 Cl-101 HCO3-30 AnGap-15
[**2179-9-27**] 06:45AM BLOOD Glucose-100 UreaN-7 Creat-0.7 Na-141
K-4.1 Cl-104 HCO3-30 AnGap-11
[**2179-10-5**] 07:32AM BLOOD Glucose-109* UreaN-9 Creat-0.5 Na-130*
K-4.8 Cl-97 HCO3-27 AnGap-11
[**2179-9-16**] 10:10AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-MOD
[**2179-9-16**] 10:10AM URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE
Epi-0
[**2179-9-23**] 12:36PM URINE RBC-0-2 WBC-[**11-8**]* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2179-9-26**] 05:43PM URINE RBC-2 WBC-18* Bacteri-OCC Yeast-NONE
Epi-6
Brief Hospital Course:
Ms. [**Known lastname 104253**] was transferred from OSH to [**Hospital1 18**] and underwent
cardiac cath on [**9-15**] which revealed severe 3 vessel disease.
Also on this day she underwent an Echo which revealed moderate
MR [**First Name (Titles) **] [**Last Name (Titles) **]. Pre-operative work-up was performed which first
revealed a UTI. She was treated with appropriate antibiotics and
then definitive once cultures were completed. She also underwent
a carotid ultrasound which revealed bilateral stenosis. On [**9-21**]
she underwent stenting of her [**Doctor First Name 3098**]. Please see procedure note.
On [**9-22**] she underwent PICC line placement for definitive IV
therapy. Please see procedure note. Over the next several days
she was medically managed and treated for her UTI. Her operation
was cancelled several times due to her UTI. She was finally
cleared for surgery and on [**9-28**] she was brought to the
operating room where she underwent a coronary artery bypass
graft x 4, aortic valve replacement, and mitral valve
replacement. Please see operative report for surgical details.
She tolerated the procedure well and was transferred to the CSRU
for invasive monitoring in stable condition. She remained
intubated and on pressors through post-op day one. She also
required multiple transfusions for bleeding and low HCT. By
post-op day two pressors were weaned and she now required
Labetalol for hypertension. This was slowly weaned off and she
was then started on beta blockers and diuretics. She was gently
diuresed towards her pre-op weight. And beta blocker was
titrated for maximum hr and bp control. She was weaned from
sedation, awoke neurologically intact and was extubated. Also on
this day her chest tubes were removed. She was started on
Coumadin (d/t mechanical valves) with a Heparin bridge until INR
therapeutic. Epicardial pacing wires were removed on post-op day
three and she was transferred to the SDU. On post-op day three
her INR dramatically rose to over 8 and Coumadin was stopped.
She was treated with FFP and over the next several days her INR
trended down and she was again titrated with Coumadin for a goal
INR 3-3.5. On post-op day six Amiodarone was started for episode
of atrial fibrillation. She was ready for discharge on
[**2179-10-7**].
Medications on Admission:
Medications at home: plavix, toprol 50, lisinopril 20, oxycontin
80 mg tid, oxycodone 5 mg prn, aspirin, protonix
Medications on transfer: Lasix 40 IV x1, Oxycontin 160mg tid,
Toporol 50mg qd, Protonix 40mg qd, Plavix 75mg qd, Aspirin 325mg
qd, Reglan prn, lopressor 5 IV x 1, Labetalol 5mg IV x 1,
Nitropaste 1 inch, Dilaudid prn, Lipitor 10mg qd, Lisinopril
20mg qd, Lovenox
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*1*
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): 1
mg alternating with 2 mg. 1 mg today [**10-7**]. Check INR [**10-8**] with
results to Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day) for 1
weeks.
Disp:*56 Capsule, Sustained Release(s)* Refills:*0*
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 [**Hospital1 **] x 4 days, then 400 QD x 7 days then 200 QD
ongoing.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Aortic Insufficiency s/p Aortic Valve Replacement
Mitral Regurgitation s/p Mitral Valve Replacement
PMH: Hypertension, Hypercholesterolemia, Peripheral Vascular
Disease, Varicose Veins, Congestive Heart Failure, Chronic low
back pain, s/p Appendectomy, s/p cholecystectomy, s/p left
finger reattached, s/p stents to left leg and angioplasty to
right leg, s/p left hip replacement
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions and pat dry. Do not take bath.
Do not apply lotions, creams or ointments to incisions
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
If you develop a fever, notice redness or drainage from
incision, please contact office immediately.
Call to schedule all follow-up appointments.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks.
Dr. [**First Name (STitle) **] in [**1-22**] weeks.
Dr. [**Last Name (STitle) **] in [**12-21**] weeks and for coumadin follow up
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2179-10-7**]
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|
1756, 2062
|
2078, 2235
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
860
| 176,225
|
46685
|
Discharge summary
|
report
|
Admission Date: [**2161-2-9**] Discharge Date: [**2161-2-25**]
Date of Birth: [**2100-6-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Dysphagia and weight loss
Major Surgical or Invasive Procedure:
pericardiocentesis
gastric feeding tube placement by interventional radiology
History of Present Illness:
60 yo F with newly diagnosed metastatic NSCLC was admiteed from
clinic for worsening dyphagia, dehydration, neutropenia, and
ARF. Mrs. [**Known lastname 99102**] presented to clinic today for an unscheduled
urgent visit due to an inability to swallow and extreme fatigue.
She has chronic low-back pain and was also unable to take her
Percocet today. Her nutrition has been worse over the last
couple of days and her husband fears she has lost even more
weight (98 lbs 10 days ago). Otherwise, she has had no fevers
at home, no chills or night sweats. Constipation remains an
issue as she has not had a bowel movement in about 3 days.
Past Medical History:
1. Smoked until 2 weeks ago, on nicotine patch until [**9-6**].
2. Rheumatoid Arthritis
3. PCI to LAD in [**2152**] (95% LAD, 40%RCA, 50% PDA)
4. Hypercholesterolemia
5. HTN
Social History:
Lives w/ her husband of 38 [**Name2 (NI) 1686**]. Has daughter and son. Smoked
1ppd for 40 [**Name2 (NI) 1686**], quit 3 weeks ago. Drinks about 10 drinks per
week. Works for her sons asphalt company doing office work.
Family History:
CAD in brother/sister
[**Name (NI) **] brother w/ prostate cancer
Physical Exam:
Vital signs: Temperature 96.6, blood
pressure 142/86, pulse 102, oxygen saturation 96% on room air,
weight is 90 pounds, height is 61 inches. ECOG performance
status is 2. In general, Ms. [**Known lastname 99102**] is a thin, pleasant 60-
year-old woman in no acute distress. HEENT: Pupils are equal,
round, and reactive to light. Sclerae are anicteric. Neck is
supple with approximate 1-cm bilateral cervical lymph nodes.
Heart: Tachycardic rate, regular rhythm with no appreciable
murmurs, rubs, or gallops. Lungs are clear to auscultation
bilaterally with no wheezes or crackles. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities: There is no edema, clubbing, or cyanosis.
Pertinent Results:
[**2161-2-9**] 11:53AM UREA N-77* CREAT-2.8*# SODIUM-131*
POTASSIUM-3.8 CHLORIDE-91* TOTAL CO2-30* ANION GAP-14
[**2161-2-9**] 11:53AM ALT(SGPT)-32 AST(SGOT)-31 LD(LDH)-300* ALK
PHOS-77 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4
[**2161-2-9**] 11:53AM ALBUMIN-4.1 CALCIUM-9.6
[**2161-2-9**] 11:53AM CEA-5107*
[**2161-2-9**] 11:53AM WBC-1.4*# RBC-3.96* HGB-13.1 HCT-36.8 MCV-93
MCH-33.0* MCHC-35.5* RDW-12.2
[**2161-2-9**] 11:53AM NEUTS-8* BANDS-1 LYMPHS-52* MONOS-31* EOS-3
BASOS-0 ATYPS-5* METAS-0 MYELOS-0
[**2161-2-9**] 11:53AM PLT SMR-LOW PLT COUNT-85*#
ECHO [**2161-2-20**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is a large, circumfirential pericardial
effusion with pericardial thickening (2.0-3.0 cm anteriorly
from subcostal view). There is respiratory variation in the
mitral and tricuspid inflow that is non-diagnostic. There is
right atrial and right ventricular early diastolic invagination
without definite collapse. There appears to be occasional,
prolonged RV free wall diastolic invagination (respiratory
change?) that likely represents early tamponade.
IMPRESSION: Large circumfirential pericardial effusion with
probable early tamponade.
ECHO [**2161-2-25**]
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is a small
pericardial effusion subtending primarily the right atrial and
right ventricular free wall. There are no echocardiographic
signs of tamponade. No right atrial diastolic collapse is seen.
No right ventricular diastolic collapse is seen.
Compared with the findings of the prior report (tape unavailable
for review) of [**2161-2-23**], the pericardial effusion is
smaller.
Brief Hospital Course:
# Dysphagia: Pt with known significant LAD compressing the
esophagus. This has caused substantial weight loss and is
likely contributing significantly to her weakness as she was
unable to take PO's. GI was consulted for placement of PEG tube
for initiation of tube feeds. They performed EGD however were
unable to pass the scope past the upper esophagus due to
stricture likely from external source. IR was then called and
they placed PEG tube under flouroscopy. Attempted to start
using the PEG tube 24 hours after placement with 4 boluses per
day of nutritional supplement. With this method pt had
residuals of 100 and was requesting use of pump. She was then
started on cycling which was adjusted until she was able to
tolerate with minimal residuals. She was also started on reglan
and erythromycin for enhamced GI motility. Pt continued to have
problems with nausea and phlegm production. GI was reconsulted
in reagrds to possible esophageal stent for comfort measures.
Pt decided against esophageal stent and patient was discharged
home on cycling tube feeds, tolerating it well with reglan.
.
# Pericardial effusion: Pt had a small pericardial effusion seen
on recent CT scan. She developed progressive SOB in the setting
of aggressive hydration for her ARF due to dehydration. CXR
showed small bilateral effusion with pulmonary edema. At this
point she was diuresed with minimal effect. Her SOB and O2
requirement continued to worsen. Repeat CXR now showed moderate
szized effusion on the left with increase size of silhoutte of
heart. Pulsus was 15 at this time. She was then sent for ECHO
which demonstrated large pericardial effusion with tamponade
physiology. Pt was tachycardic but BP stable at this time.
Cardiology was consulted and patient was sent to the west for
urgernt pericardiocentesis. They drained the effusion and
performed a balloon pericardiotomy. After the drainiage her
heart rate decreased and patient clinicallyy improved however
still required O2. After the procedure she was monitored in the
CCU for 1 day then on the floors by cardiology for 2 more days.
Follow up ECHOs showed no evidence of reacculmulation 5 days
later.
.
# Volume status: Pt was very dry at admission & labs c/w
prerenal. Rec'd aggressive IV hydration. Now with pleural
effusion in the setting of pericardial effusion. Pleural
effusion was present on discharge. Disucussed possibility of
thoracentesis, pt refused and wanted to go home.
.
# ARF: Pt presented with creatinine of 2.8 and BUN of 77. Her
baseline creatinine was 0.8. Her FENA at this time was <1% and
renal failure felt to be secondary to dehydration. She was
aggressively hydrated with gradual improvement in her renal
function. After several days creatinine had returned to
baseline.
.
# Hypoxia: Pt with bilateral effusion left greater then right.
Also likely has lymphangetic spread of the tumor. Disucussed
possibility of tapping the effusion but the pt refused. Also
not sure if tapping would help with hypoxia anyway given
lymphangetic spread. Pt sent home with O2 for comfort.
.
# CAD: No chest pain during stay. Was on BB for most part. Had
stop for for short period when pt was hypotensive. Did not
restart statin as would have no benefit to patient in short
term.
.
# Hyponatremia: Was likely due to volume depletion, this
resolved with IVF.
.
# Non-small-cell lung ca: Did not actively treat as inpatient.
However started on Tarceva prior to discharge.
.
# [**Name (NI) 25933**] Pt had isolated fever on [**2161-2-21**] after
pericardiocentesis. She was emipirically started on Levo/vanco.
Blood cultures and UA thus far negaitve. Since pt had been
afebrile otherwise we stopped the abx.
.
# Dispo- Discharged home with VNA services and likely transition
to hospice.
Medications on Admission:
Inderal, Benicar, Lipitor, Percocet one tablet q.6h. p.r.n.
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-14**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*QS * Refills:*2*
3. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: 15-30 ml Mucous membrane every four (4) hours as
needed for mouth pain.
Disp:*QS * Refills:*2*
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for nausea/anxiety: Please take 0.5mg qhs and
then use q6hr prn otherwise.
Disp:*120 Tablet(s)* Refills:*1*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-20 MLs
PO Q6H (every 6 hours) as needed.
Disp:*QS ML(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) mL PO
BID (2 times a day).
Disp:*900 mL* Refills:*2*
11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-21**]
MLs PO Q6H (every 6 hours) as needed.
Disp:*QS ML(s)* Refills:*2*
12. Oxygen
Pt requires 4L of continuous oxygen via NC
13. Probalance Liquid Sig: Four (4) cans PO once a day.
Disp:*120 8 oz Cans* Refills:*2*
14. Tube feed supplies
Pt will need a tube feed pump, pole, and G tube supplies(tubing,
bag for tube feeds, etc.)
Discharge Disposition:
Home With Service
Facility:
Healthcare [**Hospital 94111**] Hospice
Discharge Diagnosis:
non-small cell lung cancer
dehydration
dysphagia due to lymphadenopathy
pericardial effusion with tamponade
Discharge Condition:
stable, tolerating tubefeeds and small amounts of POs, breathing
comfortably
Discharge Instructions:
Take all medications as instructed.
Please contact Dr. [**Last Name (STitle) 3274**] if you develop fever/chills,
worsening shortness of breath, worsening pain, or other
concerning symptoms.
Followup Instructions:
You will need to follow-up with Dr. [**Last Name (STitle) 3274**] and Dr. [**First Name (STitle) **] please
call their office at [**Telephone/Fax (1) 15512**] to set up an appointment for
next Thursday.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"284.8",
"564.00",
"780.6",
"530.3",
"162.9",
"198.3",
"196.1",
"276.5",
"198.89",
"276.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"37.0",
"99.04",
"42.24",
"43.11",
"99.05",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10275, 10345
|
4646, 8426
|
340, 420
|
10497, 10575
|
2366, 4623
|
10815, 11132
|
1543, 1610
|
8537, 10252
|
10366, 10476
|
8452, 8514
|
10599, 10792
|
1625, 2347
|
275, 302
|
448, 1090
|
1112, 1288
|
1304, 1527
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,814
| 171,527
|
52779
|
Discharge summary
|
report
|
Admission Date: [**2163-9-4**] Discharge Date: [**2163-9-8**]
Date of Birth: [**2079-1-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Respiratory Distress, Hypotension
Major Surgical or Invasive Procedure:
Right internal jugular (CVL) (discontinued)
Arterial line (discontinued)
PICC (placed [**2163-9-8**])
History of Present Illness:
84 year old male with multiple co-morbidities, including rectal
cancer s/p resection and radiation in [**2157**], coronary artery
disease s/p stents, systolic CHF, dilated cardiomyopathy, atrial
fibrillation, history of cardiac arrest and complete heart blood
s/p AICD/pacemaker, recent trach/peg who presented with
respiratory distress, fevers and hypotension. The patient
desaturated one day before admission to 85% at [**Hospital 100**] Rehab
although improved to 92% with suctioning out copious amounts of
thick yellow, brown secretions. Per his wife and daughter, he
had been doing well with the trach, often having it capped in
the last week - up until 2-3 days ago when he needed to be on
the vent more frequently. He reportedly had a fever to 103.0
yesterday and 102.0 today at rehab and had a CXR performed there
showing LLL pneumonia; he was treated with Vancomycin 1 gram X1
there.
.
On arrival to the [**Hospital1 18**] ED, the patient was being bagged by EMS
upon arrival, hypotensive to SBP80s, not tachypneic, never
febrile, satting stably on his trach settings. He was mentating
well, complaining only of buttocks pain (stable) and answering
questions appropriately. CXR [**Last Name (un) **] ED similar to priors and he was
treated with Levofloxacin and Cefepime. Given persistent
hypotension SBP80s and decreased UOP (50cc/4-5 hours) despite
1.5L IVF, a RIJ CVL was placed and levophed started at 0.06. He
also had a midline IV from before and 18 gauge PIV. His troponin
was 0.11 so he was also given aspirin 325mg. VS on transfer to
MICU: Afebrile, HR70, BP86/40, RR16, 95% on PEEP5, FiO2 60%,
TV500.
.
Upon arrival to the MICU, the patient was resting comfortably in
bed.
.
Review of systems:
(+) Per HPI
(-) [**Last Name (un) 4273**] headache, sinus tenderness, congestion. [**Last Name (un) 4273**] chest
pain, chest pressure, palpitations, or weakness. [**Last Name (un) 4273**] nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits.
Past Medical History:
- Rectal cancer s/p excision and XRT ([**2157**])
- CAD s/p stents
- Complete heart block s/p pacemaker
- h/o cardiac arrest (now with AICD)
- Afib
- Systolic CHF (EF 40-45%)
- s/p Fall with multiple rib fractures ([**2163-6-23**])
- h/o GI bleed
Social History:
Resident of [**Hospital 100**] Rehab w plans to return home; previously had
lived in [**Location 745**] with his wife, now w some depression about
moving out of their 42 year home. Has two children. Retired
computer science professor.
- Tobacco: 5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol: Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**]
Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.
Physical Exam:
Admission Exam:
Vitals: T: Afebrile BP: 105/47 P: 61 R: 13 O2: 100%
General: oriented, no acute distress, sleepy
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, RIJ CVL
Lungs: Diffusely rhonchorous, rales; no wheezes
CV: RRR, [**3-20**] holosystolic murmur heard best over apex with
dulling of S1 and S2 over apex. Otherwise S1 S2 clear and of
good quality over rest of precordium.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding; ostomy bag in place
GU: three way irrigation foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; dry stasis changes on bilateral lower extremities
Discharge Exam:
VS 98.9 73 133/69 24 95% trach collar 50%F1O2
General Appearance: No acute distress, breathing comfortably on
trach collar.
HEENT: PERRL, Conjunctiva pale, Normocephalic, Poor dentition
Cardiovascular: RRR, [**3-20**] holosystolic murmur heard best over
Respiratory: mild rhonchi throughout all lung fields with
occasional expiratory wheezes
Abdominal: Soft, non-tender, colostomy, PEG, + BS
Extremities: Bilateral LE edema L>R, Chronic skin changes over
bilateral LE suggestive of chronic venous stasis, right knee
tender to palpation
Skin: Warm, well perfused
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal, localizes
pain. Able to point out letters on chart for communicating,
appropriate
Pertinent Results:
Blood Counts
[**2163-9-4**] 08:00AM BLOOD WBC-28.2*# RBC-2.71* Hgb-7.9* Hct-24.0*
MCV-88 MCH-29.1 MCHC-33.1 RDW-16.6* Plt Ct-148*
[**2163-9-5**] 02:30PM BLOOD WBC-11.6* RBC-3.00* Hgb-8.8* Hct-26.6*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.6* Plt Ct-109*
[**2163-9-8**] 02:53AM BLOOD WBC-8.0 RBC-2.81* Hgb-8.3* Hct-25.0*
MCV-89 MCH-29.4 MCHC-33.0 RDW-16.1* Plt Ct-80*
Electrolytes
[**2163-9-4**] 08:00AM BLOOD Glucose-139* UreaN-45* Creat-1.5* Na-136
K-5.0 Cl-99 HCO3-29 AnGap-13
[**2163-9-6**] 02:57AM BLOOD Glucose-106* UreaN-50* Creat-1.3* Na-138
K-4.4 Cl-107 HCO3-25 AnGap-10
[**2163-9-8**] 02:53AM BLOOD Glucose-144* UreaN-48* Creat-1.2 Na-139
K-4.3 Cl-103 HCO3-29 AnGap-11
Brief Hospital Course:
HOSPITAL COURSE
84yo PMHx rectal cancer s/p resection and XRT w ostomy, systolic
CHF (LVEF40-45%), recent trach/peg who presented with
respiratory distress, found to have a pnuemonia, with blood and
sputum cultures growing out MRSA, now improved to baseline
respiratory status being discharged to MACU on 2 week course of
IV antibioitics
.
ACTIVE
# Healthcare Associated Pnuemonia and MRSA Bacteremia - Patient
presented with increasing O2 requirements, leukocytosis and
hypotension; CXR demonstrated LLL PNA; accompanying elevated
Lactate, High SvO2 (93%), hypotension and tachycardia suggested
sepsis; blood and sputum cultures grew out MRSA. Patient was
initially fluid resuscitated and briefly required vasopressors.
He was treated with vancomycin (initially with cefepime and
levofloxacin as well, which were stopped based upon culture
data). Patient respiratory status improved, and patient was
able to be weaned off vent to trach collar. Given MRSA
bacteremia, patient had PICC line changed and underwent TTE that
did not demonstrate signs of valvular lesions; patient was
planned for 2 week course with IV vancomycin.
.
# Sacral decubitus ulcer: Significant, likely stage IV.
Appropriate wound care was provided and his pain regimen was
increased to Oxycodone to 5-10 mg q4 PRN for pain which
successfully curbed decubitus pain.
.
# Coronary artery disease: Stable, continued carvedilol; held
lisinopril given hypotension and will need to be restarted;
started ASA (had been held previously given history of GI
bleeds).
.
# Afib: CHADS4, but off anticoagulation [**2-16**] hemothorax 6/[**2163**].
Discussed with primary cardiologist who recommended considering
restarting [**Year (4 digits) **] as outpatient.
INACTIVE
# Anemia - Continued iron supplementation
.
# Systolic CHF: EF 40-45%, continued lasix
.
Transitional Issues:
- Patient is full code
- Will need primary care doctors to discuss [**Name5 (PTitle) **] as
outpatient
- Continue vancomycin for 2 weeks total course
Medications on Admission:
Medications (per D/C summary and [**Hospital 100**] Rehab records):
* Acetaminophen 650mg q8 hours PRN pain
* Acetaminophen 325mg q8 hours PRN pain
* Lidocaine patch X2
* Trazodone 25mg qHS
* Carvedilol 3.125mg twice daily
* Citalopram 20mg daily
* Docusate 10mL twice daily
* Ferrous sulfate 325mg elixir daily
* Folate 1mg daily
* Lasix 40mg daily
* Gabapentin 300mg twice daily
* Lisinopril 2.5mg daily
* Multivitamin daily
* Omeprazole 20mg
* Protein supplements daily
* Albuterol HFA inhaler
* Simethicone 80mg every 8 hours
* Oxycodone 5 every four hours PRN tracheal pain, dressing
changes
* Miconazole powrder qHS
* Levofloxacin 750mg daily, completed course [**2163-7-21**]
* Gentamicin nebulizer 80mg q12 hours nebulizer
Discharge Medications:
1. acetaminophen 325 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Year (4 digits) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
3. trazodone 50 mg Tablet [**Year (4 digits) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
4. citalopram 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: Ten (10) mL PO BID (2
times a day).
6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Year (4 digits) **]: One (1)
dose PO DAILY (Daily).
7. folic acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
8. multivitamin Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Year (4 digits) **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob,
wheeze.
11. simethicone 80 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet,
Chewable PO TID (3 times a day).
12. miconazole nitrate 2 % Powder [**Year (4 digits) **]: One (1) Appl Topical HS
(at bedtime).
13. oxycodone 5 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO every four (4)
hours as needed for pain: Hold for Sedation or RR<12.
14. aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Lasix 40 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
16. Please change and care for lines per nursing routine
17. carvedilol 6.25 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO twice a
day.
18. vancomycin 750 mg Recon Soln [**Year (4 digits) **]: One (1) solution
Intravenous twice a day for 24 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY
Healthcare Associated Pneumonia
Staph Bacteremia
SECONDARY
Systolic CHF
Atrial Fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 108855**]--
It was a pleasure treating you at [**Hospital1 18**]. You were admitted with
difficulty breathing and low blood pressure. You were found to
have a pneumonia and an infection in your blood. You were
treated with antibiotics and improved. You will need to
continue your antibiotics for 2 weeks total.
The following changes to your medications were made:
- STARTED vancomycin (continue until [**2163-9-18**])
- STARTED aspirin
- STOPPED inhaled gentamycin
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2163-9-28**] at 11:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2163-9-28**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"V12.54",
"425.4",
"486",
"V15.3",
"707.24",
"427.31",
"V10.06",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10309, 10375
|
5610, 7431
|
392, 495
|
10520, 10520
|
4914, 5587
|
11174, 11765
|
3286, 3438
|
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|
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|
3453, 4118
|
4134, 4895
|
7452, 7603
|
2236, 2513
|
319, 354
|
523, 2217
|
10535, 10635
|
2535, 2783
|
2799, 3270
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,770
| 198,787
|
5764
|
Discharge summary
|
report
|
Admission Date: [**2160-1-18**] Discharge Date: [**2160-2-12**]
Date of Birth: [**2093-10-4**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
Massive hemoptysis
Major Surgical or Invasive Procedure:
1. Rigid Bronchoscopy
2. Pulmonary angiography, s/p bilateral bronchial artery
embolization
3. Right hip long stem bipolar hemiarthroplasty
4. Curretage right proximal and distal femur lesions
History of Present Illness:
66 yo M with history of thyroid ca metastatic to lungs
bilaterally and to brain and bone, presents to the ED after
presenting to OSH with hemoptysis. He was transferred
immediately to [**Hospital1 18**] and once arrived had multiple cupfuls of
hemoptysis. He was intubated and taken to the OR for rigid
bronch to locate the source of bleeding. Will need angio for
embolization once source is localized. He was recently given a
prescription for sorafenib, but it is unclear if he actually had
started this treatment. Of note, he was admitted to [**Hospital1 18**] in
[**7-28**] with hemoptysis (two small episodes) for which he underwent
bronchoscopic evaluation which demonstrated a likelihood of
suspicious lesions in the right upper lobe and left superior
lingula with no active bleeding. He was discharged at that time
with therapeutic INR. Ortho was consulted to evaluate patient's
current status of known lytic lesions in C1.
On review of his past oncologic history, he was diagnosed in
[**2149**] when he developed significant snoring related problems that
required seeking medical attention. He saw an
otorhinolaryngologist who at that time reported that he had neck
swelling which was contributing to his snoring and which was
likely related to a thyroid process. He then reported that he
had this swelling for about 10 years prior to this presentation,
but a workup had not been performed at that time. A surgical
resection demonstrated a papillary carcinoma. He subsequently
received radioactive iodine therapy for this disease and
appeared to have tolerated it well. His treatment was
complicated by atrial fibrillation, and was placed on atenolol.
He subsequently required repetition of his radioactive iodine
treatments because of elevated thyroglobulin levels as well as
because of the appearance of new lung metastases. In the last
few months, the patient developed right-sided chest discomfort
on exertion localized to the right rib cage. He was started on
coumadin in [**1-28**] for a PE and in the summer of [**2159**], the patient
had two episodes of hemoptysis during exertion, which required a
bronchoscopic evaluation and ablation of the lesion. Pathology
from this lesion demonstrated metastatic carcinoma of a thyroid
origin. He was subsequently admitted with hemoptysis and
underwent a bronchoscopic evaluation and control of his
bleeding. PET scan evaluation revealed a significant increase in
his disease burden, as well as multiple sites of uptake in the
skeleton. A Thyrogen scan did not reveal Iodine uptake.
He was admitted to the MICU for further work-up and management
after rigid bronchoscopy.
Past Medical History:
Metastatic Thyroid Ca
HTN
Atrial Fibrillation
Pulmonary Embolus [**1-28**] - Anticoagulated with coumadin; has
two small lesions on MRI head c/w mets but not contraindications
to anticoag.
Hypothyroidism
Social History:
Lives with wife. [**Name (NI) 1403**] part time in real estate building and
development and is still currently working. Retired from full
time work in [**2157-9-22**].
Smoked approximately 30 years ago (quit in [**2126**])
EtOH: drinks 1 glass wine/day
Family History:
Mother with h/o emphysema.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp: 96.0 (oral) BP: 102/51 HR: 64 RR: 15 O2sat 100% on A/c
550x15 FiO2 1, peep 5
GEN: intubated, sedated
HEENT: PERRL, anicteric, MM dry, dried blood around nares
NECK: hard collar in place - unable to assess JVP
RESP: Diffuse rhonchi and insp/exp wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: mildly distended, +b/s, soft, tympanitic to percussion
RLE: [**Last Name (un) 938**]/DF/PF intact, [**Last Name (un) 36**] intact to LT over tib/sp/dp,
palpable DP
SKIN: no rashes/no jaundice, pale
NEURO: bilateral downgoing babinski. will reassess when sedation
is weaned.
Pertinent Results:
ADMISSION LBAS:
[**2160-1-18**] 03:15AM BLOOD WBC-11.3*# RBC-4.03* Hgb-12.3* Hct-37.9*
MCV-94 MCH-30.6 MCHC-32.4 RDW-13.3 Plt Ct-135*
[**2160-1-18**] 03:15AM BLOOD Neuts-58.9 Lymphs-34.2 Monos-5.0 Eos-1.6
Baso-0.3
[**2160-1-18**] 03:15AM BLOOD PT-13.8* PTT-30.3 INR(PT)-1.2*
[**2160-1-18**] 03:15AM BLOOD Plt Ct-135*
[**2160-1-18**] 04:04AM BLOOD Glucose-261* UreaN-21* Creat-1.0 Na-141
K-4.3 Cl-107 HCO3-26 AnGap-12
CARDIAC ENZYMES:
[**2160-1-18**] 03:15AM BLOOD cTropnT-0.03*
[**2160-1-18**] 04:04AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2160-1-18**] 04:04AM BLOOD CK(CPK)-68
[**2160-1-18**] 04:04AM BLOOD Calcium-8.4 Phos-5.5* Mg-2.0
[**2160-1-18**] 06:43AM BLOOD Type-[**Last Name (un) **] pO2-64* pCO2-93* pH-7.08*
calTCO2-29 Base XS--5 Intubat-INTUBATED
EKG: Sinus tachycardia with ST depressions in anteroseptal
leads.
IMAGING:
CXR: Inumerable small nodules c/w mets with marked progression
since [**7-28**], fluffy hilar infiltrates bilaterally c/w hemorrhage
given clinical scenario of hemoptysis. Tip of ET tube not
visualized.
[**2160-1-18**] Pulmonary Angiography:
No active extravasation but multiple hypervascular masses,
likely metastases. Bronchial artery embolization was performed
bilaterally.
PET [**11-28**]: IMPRESSION: Diffuse abnormal FDG uptake in the lungs
and bone consistent with metastatic disease, which compared to
prior exam shows slight increase in disease burden. Again noted
are the large lytic lesions in the right femoral head/neck and
C1 which remains high risk for fracture.
Brief Hospital Course:
# Hemoptysis:
Mr. [**Known lastname 20598**] was admitted from an outside hospital with massive
hemoptysis. Pulmonary angiogram on [**2160-1-18**] showed no active
extravasation but multiple hypervascular masses, likely
metastases. Bilateral bronchial artery embolization was
performed without complication, and he was extubated several
hours after the procedure. Hematocrit remained stable
overnight, and he was hemodynamically stable without further
episodes of hemoptysis. Of note, as an outpatient he was on
lovenox at treatment doses for a PE that he had in [**1-28**]. In
addition, he was recently started on sorafenib, a VEGF pathway
inhibitor that carries a bleeding risk; he had two doses of the
medicine, the last of which was taken around [**2160-1-8**]. Per Dr.
[**Name (NI) **], pt will likely not be a candidate for continued sorafenib
therapy. He will need further oncologic options discussed as his
health improves.
.
The patient underwent pulmonary angiogram [**2160-1-18**] which showed
no active extravasation but was notable for multiple
hypervascular masses, thought to likely represent metastases.
Bilateral bronchial artery embolization was performed without
complication, and he was extubated several hours after the
procedure. Post-procedure, he was hemodynamically stable except
for an episode of difficult to control Afib with [**Month/Day/Year 5509**] (max rate
200's) thought to be precipitated by beta-blocker withdrawal
that converted with esmolol gtt, digoxin, and reinstitution of
metoprolol. As his hematocrit remained stable and he was without
further episodes of hemoptysis x 48 hours, he was transferred to
OMED for consideration of chemotherapy. Before transfer he did
spike a fever to 101 and was pan-cultured but no antibiotics
were started. Of note, he required no blood product transfusions
this admission.
.
On the floor, the patient began again to have small volume
hemoptysis (dark blood mixed with sputum per report) and was
noted to be hypoxic to 76-77% on 4L NC which improved to the 90%
on NRB. He also was febrile to 102.0 but otherwise
hemodynamically stable and in NAD. Labs notable for Hct decrease
trend from 29.5->28.5->26.5. CXR prelim read with slight
increase in diffuse fluffy bilateral opacities but otherwise
unchanged. He was transferred to the [**Hospital Ward Name 332**] ICU for close
monitoring and consideration of repeat rigid bronchoscopy, which
was ultimately not pursued (his more significant problem in the
[**Name (NI) 153**] was [**Name (NI) 5509**] as below).
.
As his admission proceeded and he was otherwise stable in the
[**Hospital Unit Name 153**], he continued to have some low-volume hemoptysis which
suggested that some portion of his prior hemoptysis was due to
the malignancy itself rather than other factors.
# Papillary Thyroid Cancer:
Mr. [**Known lastname 20598**] is a patient of Dr. [**Last Name (STitle) **]. Despite widespread and
progressive metastasis, he has been able to maintain a fairly
active lifestyle. He was starting sorafenib therapy rather than
chemotherapy (tumor is iodine neg) as of [**11-28**]; he had two doses
of the medicine, the last of which was taken around [**2160-1-8**]. On
[**2160-1-19**] after embolization of the bronchial arteries, he was
transferred from the MICU to the oncology service, but then had
to return to the MICU after going to [**Date Range 5509**] once again. After
eventually being stabilized in the MICU he was again called out
to the floor for consideration of his oncology plan.
# Atrial Fibrillation:
Mr. [**Known lastname 20598**] has a history of AFib and was on atenolol 25 mg [**Hospital1 **]
for rate control (as well as BP control). Atenolol was held
upon admission for relative hypotension in teh setting of
hemoptysis. It was restarted on [**2160-1-19**] when he developed
tachycardia with HR > 200. His HR improved to the 130 - 140 BPM
range with 25 mg IV of lopressor and 20 mg IV of diltiazem;
atenolol 25 mg [**Hospital1 **] was then restarted. The pt remained
asymptomatic during this time beyond complaints of palpitations
and SBPs did not drop lower than 87. HR remained in the 140-150s
range and esmolol gtt was started. The pt was also started on a
po digoxin load and spontaneously broke out of afib in NSR in
the 70s. Atenolol was also switched to metoprolol to allow
better in house titration of his HR.
.
When transferred to the [**Hospital Unit Name 153**], he had a number of additional
episodes of atrial fibrillation with [**Hospital Unit Name 5509**] which were controlled
with IV diltiazem or IV metoprolol. Early in his [**Hospital Unit Name 153**] admission
he actually had to be intubated given his unstable hemodynamics;
we attempted electrical cardioversion on [**1-21**], but this was
only very briefly successful. We continued to use digoxin and
metoprolol but we were initially concerned about the possibility
of using amiodarone because of its iodine content. Ultimately
after much discussion with endocrine and oncology, we judged use
of the amiodarone to be worth the potential cost (namely,
decreasing the possibility of radioactive iodine, a treatment
which had already failed him). As we loaded him on amiodarone we
ultimately discontinued the digoxin, without any further
significant episodes while in the [**Hospital Unit Name 153**]. Metoprolol was
discontinued because of some intermittent hypotension. He was to
switch from his loading dose to [**Hospital1 **] dosing on [**2160-1-31**].
Anticoagulation was not started because of his hemoptysis.
.
# h/o PE: The pt was on lovenox as an out-patient, which was
held on admission in the setting of the bleed. The risk vs.
benefits of restarting the pt on lovenox will need to be
determined.
.
# Cytopenia: Patient with anemia (baseline Hct 30) and
thrombocytopenia, possibly from bone marrow supression from
malignancy and chemo. Pt had not recieved heparin, so HIT was
judged to be a very unlikely cause of thrombocytopenia. Low Hct
is also likely due to marrow suppression, and prior hemoptysis.
.
#Pain - Seen by pain service. He has significant pain secondary
to bony mets and pathologic fracture of R femoral neck.
Currently on gabapentin, fentanyl patch and dilaudid PRN.
.
# Femoral fracture: Likely while undergoing attempts at
electrical cardioversion, Mr [**Known lastname 20598**] [**Last Name (Titles) 18095**] a pathologic R
femoral neck fracture. Orthopedics followed and towards the end
of his MICU stay began to plan for a possible surgery to
stabilize the fracture. For the patient, the most troubling
issue with the fracture is that it caused him significant pain
with any movement.
.
#. Hypotension: pt had multiple episodes of hypotension during
his [**Hospital Unit Name 153**] stay requiring fluid bolus, though has been stable x 72
hours. Possible etiologies included sepsis, adrenal
insufficiency, or fentanyl/midazolam causing hypotension. Sepsis
seems less likely given negative BCx and no clear source.
Adrenal insufficiency has been evaluated with cortisol level,
and given low albumin, endo feels a cortisol level of 20.5 rules
out adrenal insufficiency. Therefore, most likely cause is
iatrogenic [**2-23**] sedatives. In the latter part of his [**Hospital Unit Name 153**] stay
his pressure was stable, and he had not required further fluid
bolus.
.
Cervical spine metastasis followed by Dr [**Last Name (STitle) 548**] of Neurosurgery.
Follow up will be arranged by their service. C-collar at all
times until follow up.
.
Patient was taken to the OR on [**2160-2-4**] for R hip long stem
bipolar hemiarthroplasty, tolerated the procedure well without
complications. EBL: 500cc. He was transferred to the
Orthopedic service post-operatively. On POD 1 his Hgb was found
to be 7.4, he was transfused 2 units of pRBC's. Re-check of the
Hgb on POD 2 found it to be 7.0, he was again transfused 2 units
of pRBC's. On POD [**3-26**] his Hgb was stable at 8.5. At discharge
he was tolerating PO, voiding spontaneously, and his pain was
well controlled. He was hemodynamically stable and afebrile at
discharge. He was cleared for safe discharge to rehab by PT.
Medications on Admission:
ATENOLOL 50 mg--0.5 (one half) tablet(s) by mouth twice a day
GABAPENTIN 100 mg--
Levothyroxine 200 mcg--1 (one) tablet(s) by mouth once a day
Levothyroxine 25 mcg--0.5 (one half) tablet(s) by mouth mon,
wed, fri
OXYCONTIN 40 mg--1 (one) tablet(s) by mouth three times a day
SORAFENIB 800 mg once a day to be administered at 400 mg b.i.d.
doses (script given [**11-28**])
LOVENOX
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day for every Mon, Wed, Fri days.
9. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO
SUN,TU,TH,SAT ().
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 40 mg Tablet [**Month/Year (2) **] Release 12 hr Sig: One (1)
Tablet [**Month/Year (2) **] Release 12 hr PO Q8H (every 8 hours).
12. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Metastatic thyroid cancer
Discharge Condition:
Stable
Discharge Instructions:
1. C-collar at all times
2. Lovenox daily for 4 weeks
3. Change right thigh dressings daily until no drainage on guaze
4. Weight bearing as tolerated right lower extremity
5. Daily physical therapy to work on gait, strengthening and
range of motion
6. You may shower, no bathing
7. Please check weekly thyroid function tests (TSH, free T4),
report results to Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 1803**])
8. Please call if you develop fevers/chills, increasing pain,
redness and/or drainage from the incision sites
Physical Therapy:
Weight bearing as tolerated right lower extremity
C-collar at all times
Treatments Frequency:
Daily dry sterile dressing changes right lower extremity
Followup Instructions:
1. Follow up with Dr [**First Name (STitle) 4223**] in [**Hospital Ward Name 23**] [**Location (un) **] [**Hospital **]
clinic in 2 weeks with AP pelvis and AP and Lat of the R femur.
2. Follow up with Neurosurgery (Dr [**Last Name (STitle) 548**] by calling
[**Telephone/Fax (1) 1669**] to schedule an appointment.
3. Follow up with your primary care physician (Dr [**Last Name (STitle) 22933**] by
call ing [**Telephone/Fax (1) 22934**] to schedule an appointment in 1 week.
4. Dr [**Last Name (STitle) **] will call you with follow up time and date.
5. Follow up with Oncology medicine (Dr [**Last Name (STitle) **] by calling
[**Telephone/Fax (1) 13006**] to schedule an appointment in 2 weeks.
|
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"197.0",
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"198.5",
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icd9cm
|
[
[
[]
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[
"99.04",
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icd9pcs
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[
[
[]
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15833, 15933
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5892, 14033
|
309, 503
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16002, 16010
|
4348, 4766
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16756, 17458
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3687, 3715
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16034, 16563
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3755, 4329
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16581, 16653
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16675, 16733
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4783, 5869
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251, 271
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531, 3170
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3192, 3398
|
3414, 3671
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,038
| 103,987
|
6839
|
Discharge summary
|
report
|
Admission Date: [**2137-11-24**] Discharge Date: [**2137-12-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Thoracentesis
Paracentesis
History of Present Illness:
81yo man with h/o CLL c/b malignant pleural effusion, primary
resected melanoma, type II diabetes mellitus, and Gout presented
to [**Hospital1 18**] ED after mechanical fall and found to have subdural
hematoma.
.
The patient reports he tripped and fell on his oxygen cord at
home. He was started on supplemental oxygen after his last d/c
from NEBH on [**2137-11-22**]. On initial presentation to ED T 98.8 HR
96 BP 99/43 RR 19 92% 2.5L. He was admitted to the MICU for
further evaluation and treatment, and neurosurgery was
consulted. Head CT showed multiple high density nodules
concerning for metastatic disease. He was loaded with dilantin
and monitored overnight without any detioration in neurologic
status. Repeat head CT showed stable appearance of the SDH.
Hematology/Oncology was consulted. He was transfused 6units
platelets in the ED, and underwent leukopheresis in the MICU.
Of note, patient was recently hospitalized [**Date range (1) 25864**]/05 on
Oncology service for leukopheresis and chemo for his CLL after
presenting with dyspnea and WBC 678K.
.
On presentation now his is oriented x3 and complains only of
pain in his right shoulder. He denies headache, dizziness,
confusion, vision changes, nausea. On ROS he denies fever,
chills, sweats, palpitations, chest pain, SOB, abdominal pain,
nausea, vomiting, diarrhea, constipation, bloody stools,
dysuria, hematuria. He notes some skin changes in his arms c/w
small bruises.
Past Medical History:
1. T cell CLL/PLL; previously treated with pentostatin,
cyclophosphamide, fludarabine, cytoxan. currently getting
regular leukopharesis and Campath. c/b left malignant pleural
effusion requiring thoracentesis
2. h/o left chest wall melanoma s/p resection, no nodal
dissection
3. type II diabetes mellitus
4. Gout
5. Hypertension
6. H/o right knee arthritis
7. H/o small bowel obstruction
Social History:
married, lives with his wife
retired construction worker, originally from [**Country 2559**]
Tob: previously smoked 2ppd, quit 21yrs ago
EtOH: avg 1/week
illicits: none
Family History:
Mother died at 86 of [**Name (NI) 2481**]
Father died at 52 of an accident
Brother died at 67 of lung cancer
Physical Exam:
T 99.3 HR 90 BP 101/55 RR 20 95%5Lnc
Gen: comfortable, alert, NAD
HEENT: anicteric, PERRL, EOMI, OP with petechia posteriorly,
MMM
Neck: supple, no LAD, R SC pheresis catheter in place, JVP
nondistended
CV: RRR, II/VI SEM, PMI nondisplaced
Resp: decreased BS B bases with mild crackles
Abd: +BS, soft, NT, ND, liver palp 2cm below costal margin,
spleen not palpable
Ext: [**1-2**]+ pitting edema BLE, nontender
Skin: petechiae arms, abdomen, legs
Neuro: A&Ox3, answers questions appropriately and follows
commands, CN II-XII intact, strength 5/5
biceps/triceps/grip/quads/dorsi&plantar flexion, sensation
intact to fine touch BUE and BLE, coordination intact FTN, no
plantar deviation. gait and romberg not assessed
Pertinent Results:
[**11-24**] Head CT:
1. High density nodules and multiple ill-defined hypodensities
scattered
throughout the brain, suggestive of a metastatic process.
2. Very small (approximately 1 mm) right extra-axial fluid
collection, with associated mild edema of the right hemisphere,
but without midline shift.
An MRI of the brain is recommended for further evaluation of
these findings.
.
[**11-24**] CXR:
New moderate-sized right pleural effusion, with underlying
collapse and/or consolidation. Atelectasis at left base.
Prominent right
hium --
.
[**11-25**] Head CT:
No interval change in the appearance of the brain. Stable tiny
right subdural hemorrhage. Unchanged appearance of multiple
high attenuation lesions scattered within the brain concerning
for metastasis.
.
[**12-1**] CXR: There is a right-sided IJ central venous catheter, with
the distal tip in the SVC, unchanged. There is again seen a
large right-sided pleural effusion likely layering and a
left-sided pleural effusion which is moderated sized. These are
unchanged from previous. There is no evidence for overt
pulmonary edema. There is a left retrocardiac opacity. This
finding is unchanged. Underlying pneumonia would be difficult to
exclude given the retrocardiac opacity and the large pleural
effusions.
.
ECHO: [**12-6**]:
Conclusions:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (LVEF>55%). Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. Trivial mitral
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
.
CT Head [**2137-12-5**]:
FINDINGS: There is a new moderate sized mixed density subdural
fluid collection on the right. The lateral ventricle is
completely compressed indicating mass effect from the subdural
fluid collection as well as a 3 mm shift of the normally midline
structures. The mixed intensity of the collection likely
consists of blood and other fluid given the mixed densities. The
previously identified high-density lesions are subsiding
indicating that these were most likely hemorrhages rather than
amyloid angiopathy.
.
CT Head [**2137-12-6**]:
There is no change in the size or configuration of the
right-sided subdural hemorrhage. Denser blood products are
layering posteriorly. The hematoma extends under the right
temporal lobe, which is slightly elevated and medially
displaced. However, the basal cisternal spaces retain their
normal configuration. There is mild shift of midline structures
to the left, unchanged since the previous day's examination.
Brain parenchymal attenuation is also stable.
.
CT Head [**2137-12-9**]:
IMPRESSION: Stable right subdural hematoma with slight
progression of mass effect and shift of midline structures.
.
CT Head: [**2137-12-18**]:
IMPRESSION: Slightly improved right subdural hematoma and
associated mass effect, with lessened contralateral shift of
normally midline structures.
.
[**2137-11-24**] 08:17PM GLUCOSE-144* UREA N-56* CREAT-2.2* SODIUM-137
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11
[**2137-11-24**] 08:17PM CALCIUM-7.9* PHOSPHATE-2.0* MAGNESIUM-2.1
[**2137-11-24**] 08:17PM WBC-665.6* HCT-22.5*#
[**2137-11-24**] 08:17PM PLT COUNT-51*#
[**2137-11-24**] 08:17PM PT-14.4* INR(PT)-1.4
[**2137-11-24**] 12:00PM GLUCOSE-171* UREA N-54* CREAT-2.2*#
SODIUM-136 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12
[**2137-11-24**] 12:00PM CK(CPK)-63
[**2137-11-24**] 12:00PM CK-MB-NotDone cTropnT-0.07*
[**2137-11-24**] 12:00PM CALCIUM-8.1* PHOSPHATE-1.4* MAGNESIUM-2.2
[**2137-11-24**] 12:00PM WBC-846.7*# HCT-35.0*#
[**2137-11-24**] 12:00PM NEUTS-0* BANDS-0 LYMPHS-19 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-81*
[**2137-11-24**] 12:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2137-11-24**] 12:00PM PLT SMR-RARE PLT COUNT-15*#
[**2137-11-24**] 12:00PM PT-13.9* PTT-21.2* INR(PT)-1.3
Brief Hospital Course:
81yo man with h/o CLL c/b malignant pleural effusion, primary
resected melanoma, type II diabetes mellitus, and gout presented
to [**Hospital1 18**] ED after mechanical fall and found to have subdural
hematoma. During his hospitalization the following issues were
addressed:
.
#. Subdural hematoma: Hemorrhage occurred in the setting of
mechanical fall. He was seen by neurosurgery who recommended
keeping SBP <140 and loading with Dilantin. He was admitted to
the MICU for frequent neuro checks, and remained there for one
day. On day two, his Dilantin level was subtherapeutic, and he
was reloaded. On day three he developed neurologic changes of
increased lethargy and dysarthria. Findings were consistent
with Dilantin toxicity. His AM dose was held on day four, and
symptoms resolved. He was continued on Dilantin 100mg po TID.
His head CT showed multiple lesions concerning for mets disease.
It was unclear whether these lesions could be due to his
CLL/PLL or due to his remote history of nonmetastic resected
melanoma. He had a brain MR that showed a single parietal
lesion concerning for mets. The other lesions were read as
consistent with amyloid angiopathy. Neuro-oncology was
consulted, and did recommend LP for staging, and that patient
may benefit from XRT.
.
A repeat head CT on [**2137-12-5**] showed new midline shift and rebleed
(unclear of duration) without herniation. Hence, an LP was held.
Neurosurgery was consulted and patient was not a surgical
candidate because of his comorbidities and the size of the
lesion. In addition, his thrombocytopenia introduced a
substantial bleeding risk if any drains were placed in his head.
On [**2137-12-9**], another head CT showed no interval changes in the
midline shift, but worsening mass effect. Follow up CT on [**12-18**]
showed stable midline shift.
.
Throughout the hospitalization, he was transfused platelet
products for counts <50 to minimize worsening of his
intracranial hemorrhage.
.
#. CLL: The patient is followed by oncology attending Dr. [**Last Name (STitle) **]
at NEBH; but has been admitted to the BMT service at [**Hospital1 18**]
previously. He underwent leukopharesis three times prior to
transfer to BMT for hyperleukocytosis. His last dose of Campath
was at NEBH [**2137-11-22**]. He was transfused both PRBC and platelets
without much increase. In the MICU, he was followed by the BMT
fellow and BMT attending with the OMED resident/intern team
following. He underwent leukophoresis several times here with
reductions in his WBC to usually < 300K.
.
Because of his previously failed chemotherapy experiences, he
was offered to be treated with the anti-CD52 antibody, Campath.
While the family was advised about the significant risks
(inlcuding worsening of his ascites and the mass effect in his
brain) regarding the administration of this drug in the face of
his multiple medical comorbidities, they still requested that
this drug be given.
.
4 doses of Campath were given from [**Date range (1) 25865**] (with an initial test
dose of 3mg).He experienced small WBC count decrements, but soon
started to rebound. At this time, his WBC count consisted
predominantly of prolymphocytes. A short wait period was done to
assess his response to the campath. And in the face of
continuing rises in his WBC count, the family requested to have
another trial of campath. Hence, he continued to receive campath
on [**2-15**] and [**12-16**] and [**12-18**].
.
# ID issues:
- Bacteroides and Citrobacter in 2 different blood cultures
- on Vanco and ceftaz/flagyl and caspo, ganciclovir
- [**12-10**]: switched [**Last Name (un) 2830**] to ceftaz
- CMV VL [**Numeric Identifier 961**] on [**2137-12-4**]: started on Ganciclovir -> [**12-7**]: VL 7670
- CMV VL on [**12-14**]->2050
- patient was cultured significant temperature spikes.
.
# Bilateral malignant pleural effusions.
- Thoracentesis [**2137-12-3**]: 1.5L by IP service
- CXR: [**2137-12-9**]: A moderate right and small left pleural effusion
are stable.
- CXR: [**12-12**]: b/l layering pleural effusions and perihilar edema
.
# DIC: as per previous labs, pt. in chronic DIC. On [**11-16**]
pt developed persistent bleeding at site of phereis catheter.
Transfused 3 u platelets, 2 u FFP, 2 u cryoprecipitate c
improvement in clinical symptoms and improvement in DIC labs.
Plat cnt up to 60 from 20 s/p transfusions. This likely
accounts for his petechial rash. Throughout his hospitalization,
patient was transfused to keep his fibrinogen >100 for suspected
chronic DIC.
.
#. ARF: baseline creat 1.0; elevated on admission 2.1.
allopurinol and [**Last Name (un) **] held. creatinine improved daily. FeNA
calculated < 1%; appeared dry on exam. Likely prerenal in
etiology. Renal ultrasound obtained to r/o post renal etiology.
baseline creatinine of 1. Unclear cause - possibly secondary to
leukemic infiltration vs. previous TLS. Dry on physical exam;
may represent some component of pre-renal azotemia.
.
- U Na - 28, U Cr - 124, FeNA = .21%; c/w prerenal azotemia
- renal u/s showing no obstruction
- Cr 2.9 on [**2137-12-7**]: decreased ganciclovir on [**12-6**]; decreased
spironolactone on [**2137-12-7**] -> Cr 2.7 on [**12-16**]
.
#. HTN: Dyazide and Cozaar held given relative hypotension.
goal SBP <140 per neurosurgery recc's.
.
#. Skin: patient has rash [**1-2**] lymphoma per oncology; also with
diffuse petechiae.
.
#. TIIDM: maintained on sliding scale insulin with good
control.
.
# End of life issues: The hematology team had several
discussions with the [**Known lastname **] family regarding the state of health
of the patient. It was reiterated multiple times that he had
multiorgan failure and that there was only a small chance that
he could recover from his illness. It was reiterated that
campath could worsen his condition and they accepted this risk.
He continued to be a DNR/DNI during the last days of his life.
In the AM of [**12-19**], the patient passed after worsening
respiratory status for the last few days of his life. He had
become more and more unresponsive and was increasing his O2
requirements over the last few days of his life. The daughter
(proxy) was offered an autopsy, but refused.
Medications on Admission:
Meds on Admission:
Allopurinol 60mg daily
Dyazide 37.5/25 daily
Cozaar 50mg daily
Campath
supplemental O2
previously on metformin; stopped during last hospitalization
Discharge Medications:
Patient passed away in hospital
Discharge Disposition:
Expired
Discharge Diagnosis:
CLL/PLL
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2138-1-5**]
|
[
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"428.0",
"348.8",
"286.6",
"790.7",
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"401.9",
"274.9",
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"511.9",
"204.10",
"584.9",
"873.0",
"V10.82",
"250.00",
"292.81",
"V15.82",
"202.80",
"E936.1",
"E885.9",
"078.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"54.91",
"99.06",
"99.72",
"86.59",
"99.05",
"99.07",
"99.04",
"38.93",
"99.28"
] |
icd9pcs
|
[
[
[]
]
] |
13799, 13808
|
7324, 13526
|
273, 301
|
13859, 13869
|
3281, 3293
|
13921, 13954
|
2405, 2516
|
13743, 13776
|
13829, 13838
|
13552, 13557
|
13893, 13898
|
2531, 3262
|
225, 235
|
329, 1783
|
6120, 7301
|
3845, 6111
|
13571, 13720
|
1805, 2201
|
2217, 2389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,724
| 110,296
|
10762
|
Discharge summary
|
report
|
Admission Date: [**2178-12-30**] Discharge Date: [**2179-1-6**]
Date of Birth: [**2101-5-27**] Sex: F
Service: #58
ADMISSION DIAGNOSIS:
Coronary artery disease.
DISCHARGE DIAGNOSIS:
Coronary artery disease status post coronary artery bypass
graft times three ([**2179-1-1**]).
HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old
woman who had repeated episodes of chest pain radiating to
the left chest without nausea, vomiting, diaphoresis. She
had two recent admissions for chest pain to the [**Hospital3 **] at which time she ruled out for myocardial
infarction. The patient did rule in for myocardial
infarction at this admission to [**Location (un) **] and the patient was
transferred to the [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Peripheral vascular disease.
3. Increased cholesterol.
4. Breast cancer.
5. Status post lumpectomy.
MEDICATIONS: Atenolol 50 mg po q day, Imdur 30 mg po q day,
aspirin 325 mg po q day, Benadryl prn.
PHYSICAL EXAMINATION: The patient is an elderly Hispanic
woman in no acute distress. She appears comfortable. Vital
signs are stable. Afebrile. Chest is clear to auscultation
bilaterally. Cardiovascular is regular rate and rhythm
without murmurs, rubs or gallops. Abdomen is soft,
nontender, nondistended. No masses or organomegaly.
Extremities are warm, noncyanotic, nonedematous times four.
Neurological is grossly intact.
LABORATORIES ON ADMISSION: 8.4/32.8/243. Chemistry
136/4.0/103/23/16/0.7/181/calcium 8.4. PT 29.3, INR 1.2.
ALT 16, AST 19, alkaline phosphatase 64, total bilirubin 0.3,
amylase 98, albumin 3.3.
HOSPITAL COURSE: The patient was transferred from the
[**Hospital3 **] to the [**Hospital1 69**].
Upon arrival the patient had cardiac catheterization, which
revealed severe coronary artery disease of all vessels with
large dominant left anterior descending coronary artery that
collateralizes large posterior descending coronary artery.
Subsequent to this the patient was begun on nitroglycerin
drip. Cardiac consultation was obtained. Cardiac surgery
consultation was obtained. The patient was then added on for
revascularization. The patient had a coronary artery bypass
graft times three performed on [**2179-1-1**]. Anastomoses were as
follows left internal mammary coronary artery to left
anterior descending coronary artery, saphenous vein graft to
RPL, saphenous vein graft to ramus intermedius. The patient
was transferred to the Recovery Room on neo and Propofol
drips. In the Intensive Care Unit setting the patient was
found to have significant bloody chest tube output and the
patient was emergently taken back to the Operating Room for
reexploration.
In the reexploration, small chest wall bleeder was found and
hemostasis was achieved. The patient subsequently went back
to the Intensive Care Unit after the reexploration. At that
time the chest tube drainage continued to be thin and bloody
and a unit of packed red blood cells was given for a
hematocrit of 27. The patient at that time was hypertensive
even on a nitroglycerin drip. The Nipride drip was added.
Insulin drip was also added. On postoperative day number one
the patient remained on a Nipride drip, but was otherwise
comfortable. The patient was given 500 cc of Hespan for
hypertension and low filling pressures. The patient
tolerated extubation after being given Presidex. Subsequent
to this the patient's Intensive Care Unit stay was
essentially unremarkable. The patient was then transferred
to the floor on postoperative day number three. Chest tubes
were removed on postoperative day number three. The patient
continued to work with physical therapy and had no
difficulties progressing with her conditioning. The patient
was then subsequently discharged to home on postoperative day
number five, tolerating a regular diet and adequate pain
control on po pain medications and having no anginal symptoms
or significant arrhythmia.
PHYSICAL EXAMINATION ON DISCHARGE: No acute distress. Vital
signs are stable, afebrile. Regular rate and rhythm without
murmurs, rubs or gallops. There is no sternal click. There
is no incisional drainage. Abdomen is soft, nontender,
nondistended. Extremities are warm, noncyanotic with 1+
bilateral pedal edema. Neurologically intact.
DISCHARGE MEDICATIONS: 1. Percocet 5/325 prn. 2. Colace
100 mg po b.i.d. 3. Aspirin 325 mg q.d. 4. Lopressor 75
mg po b.i.d. 5. Lasix 20 mg b.i.d. times five days. 6.
Potassium chloride 20 milliequivalents b.i.d. times five
days.
DISCHARGE CONDITION: Good.
DISPOSITION: To home, which is an [**Hospital3 **] facility.
She will be sent with VNA.
DIET: Cardiac.
INSTRUCTIONS: The patient is to follow up with her
cardiologist in one to two weeks. She is to follow up with
Dr. [**Last Name (STitle) 70**] in six weeks. The patient was only given five
days worth of diuretics. The need for diuretics and
adjustment to cardiac medications should be addressed at
first cardiology visit.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 14041**]
MEDQUIST36
D: [**2179-1-6**] 12:36
T: [**2179-1-6**] 12:43
JOB#: [**Job Number 27708**]
|
[
"414.01",
"272.0",
"443.9",
"401.9",
"998.11",
"V10.3",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"36.15",
"34.03",
"37.22",
"39.61",
"88.56",
"36.12",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4576, 5320
|
4336, 4554
|
204, 300
|
1649, 3988
|
1021, 1445
|
157, 183
|
4003, 4312
|
329, 749
|
1460, 1631
|
771, 998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,912
| 178,857
|
52914
|
Discharge summary
|
report
|
Admission Date: [**2133-5-24**] Discharge Date: [**2133-5-31**]
Date of Birth: [**2070-6-27**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
TIPS
Endotracheal intubation
Placement of central venous catheter
History of Present Illness:
Patient is a 63 y/o female with UC s/p colectomy and colostomy
20 yrs
ago and recently diagnosed cirrhosis after a variceal bleed in
early [**Month (only) 547**] requiring ICU stay and a total of 11 units of PRBCs.
She presented at that time with bright red blood in her ostomy.
The bleeding was eventual stopped when the surgery team put
sutures in an actively bleeding vessel at the ostomy site on
[**2133-4-26**]. Afterward, a tagged RBC scan failed to reveal any
extravazation of blood. GI scoped the ostomy and found no
further sites of bleeding. She was discharged home on [**2133-5-2**]. 5
days ago she had the sutures removed from her stoma. She now
represents with recurrent bright blood in her ostomy starting at
11 PM last night. She reported lightheadedness at the time of
the bleeding. She denies CP, SOB, N/V, hematemesis, abdominal
pain, fevers. She [**Last Name (un) 25177**] had a mild nose bleed. She was taken to
[**Hospital3 **] and then transferred to [**Hospital1 18**]. In ED at [**Hospital1 18**] she
was transiently hypotensive to SBP 70s. She received 7 Liters
normal saline and 2 units PRBCs. NG lavage in ED negative.
Currently she complains of chills, but denies lightheadedness,
SOB.
Past Medical History:
Hypothyroidism
Ulcerative colitis
GI Bleed: Bleeding vessel at ostomy
Cirrhosis, likely [**2-26**] ETOH
Anemia of blood loss and [**Month/Day (2) **] deficiency
Lower extremity cellulitis vs venous stasis
Social History:
Reports no alcohol since last admission. Prior heavy intake - 2
bottles wine/day.
No tobacco, but husband smokes 3 ppd
Family History:
NC
Physical Exam:
VS: T 99.0 HR 96 BP 85/48 (in ED: low of SBP 70--> 96/60) RR 15
97% 4L
GEN: Pale appearing, NAD
HEENT: OP clear, anicteric, MMM, PERRL
Neck: Supple
CV: RRR, no m/r/g
PUL: bibasilar crackles, o/w clear
ABD: Soft, NT, midline scar, ileostomy in RLQ recently emptied
without stool or blood present.
Ext: 3+ tense pitting edema, areas of erythema over b/l medial
shins, +warmth, no tenderness.
Neuro: A&Ox3, speech fluent, moves all extremities. no focal
deficits.
Pertinent Results:
TIPS procedure:
After risks and benefits were explained to the patient and
patient's family, written informed consent was obtained. The
patient was placed supine on the angiographic table. The
bilateral necks were prepped and draped in the standard sterile
fashion. A preprocedure timeout was performed to confirm the
patient's name, procedure, and site. Using sterile technique,
general anesthesia, and local anesthesia, an access was
established to the right internal jugular vein using
ultrasonographic guidance and micropuncture site. The access
site was dilated and a 10-French vascular sheath was placed over
the wire with the tip positioned in the superior vena cava under
fluoroscopic guidance. A 5-French modified C2 catheter was then
advanced through the sheath over the wire with its tip engaged
into the hepatic vein under fluoroscopic guidance. The catheter
was then advanced distally and venogram was performed. The
catheter was then exchanged for a balloon occlusion catheter
over the wire and CO2 portogram was performed after inflation of
the balloon. This was done in the frontal and lateral
projections. The portogram confirmed the position of the balloon
catheter within the right hepatic vein. A TIPS puncture site was
then advanced through the sheath into the hepatic vein and the
branch of the right portal vein was entered after several
attempts with the needle. A guide wire was then advanced into
the main portal vein and a multihole straight catheter was then
placed over the wire with the tip in the main portal vein.
Pressure gradient was measured at the main portal vein, which
was 34 mmHg. The venogram was performed through the catheter,
which demonstrated multiple large collateral vessels. The liver
parenchyma track was dilated with an 9-mm balloon with an
inflation pressure up to 12 atm. A 10 mm x 94 mm Wallstent was
then deployed, extending from the main portal vein into the
hepatic vein. The stent was then dilated with 10-mm balloon.
Pressure gradient decreased to 2 mmHg between the portal vein
and the right atrium. The catheter was then repositioned into
the main portal vein and followup venogram was performed. This
demonstrated patent shunt, and decreased collateral vessels. The
catheter and the sheath were then withdrawn into the IVC and
then removed. Hemostasis was achieved by direct manual pressure
for 15 minutes.
By the request of anesthesiologist, a triple-lumen central line
was placed before the procedure through left internal jugular
vein. The tip of the catheter is within the superior vena cava.
The patient tolerated the procedure well and there were no
immediate complications.
IMPRESSION:
1. Successful transjugular intrahepatic portosystemic shunt
placement with reduction of a pressure gradient between portal
vein and right atrium at approximately 2 mmHg after the TIPS
placed.
.
F/u Day 1 post-TIPS Doppler U/S:
FINDINGS:
The liver is normal in size, no focal lesions. No intrahepatic
biliary dilatation. The TIPS stent is demonstrated between the
posterior branch of the right portal vein and right hepatic
vein. The stent appears patent with wall-to-wall flow on color
Doppler. Doppler interrogation along the stent shows a velocity
of 71 cm per second in its proximal portion, an elavated
velocity of 210 and 256 cm in the mid portion and 142 cm at the
distal end. These velocities above 200 cm per second require
close followup.
Main portal vein is patent with a velocity of 41 cm per second.
There is normal hepatopetal directional flow in the main and
right portal vein towards the TIPS stent.
Inferior vena cava appears patent on color Doppler as is the
right hepatic vein. Normal arterial waveform in the left hepatic
artery.
Small amount of intra-abdominal ascites around the liver in the
right upper quadrant.
CONCLUSION:
1. Patent TIPS stent with expected hepatopetal directional flow
in the main portal vein. Elevated velocities in the mid portion
of the TIPS stent over 200 cm per second. Short interval
followup with Doppler is advised.
2. Small amount of intra-abdominal ascites.
.
F/u Day 3 Post-TIPS Doppler U/S:
TIPS ULTRASOUND: 2D, color flow, and Doppler examination of the
abdomen was performed and compared with [**2133-5-28**]. There is a
TIPS stent in the posterior branch of the right portal vein and
right hepatic vein. The stent appears patent with wall-to-wall
color flow on Doppler exam. Doppler interrogation along the
stent shows velocity of 107 cm per second in the proximal
portion, 116 to 160 cm per second in the mid portion and 129 cm
per second in the distal portion. These velocities are
appropriate and have decreased in comparison to [**2133-5-28**]. The
main portal vein is patent with velocity of approximately 59 cm
per second. There is normal hepatopetal directional flow in the
main and right portal vein toward the TIPS stent. The inferior
vena is patent. There is appropriate flow in the main hepatic
and left hepatic veins. There is normal arterial waveform in the
common hepatic and anterior right hepatic arteries. There is a
small amount of intra- abdominal ascites around the liver in the
right upper quadrant.\
IMPRESSION:
1. Patent TIPS stent with appropriate velocities ranging from
107 to 160 cm per second. This is improved in comparison to the
prior study.
2. Small amount of intra-abdominal ascites.
.
Bilateral LENIs:
FINDINGS: Grayscale, color, and Doppler images of the right and
left common femoral, superficial femoral, and popliteal veins
were obtained. Normal flow, compressibility, augmentation, and
waveforms are demonstrated. No intraluminal thrombus is
identified.
IMPRESSION: No deep venous thrombosis in right or left common
femoral, superficial femoral, or popliteal veins.
.
[**5-27**] AP CXR:
Cardiac, mediastinal, and hilar contours are unchanged. The lung
fields are clear. Bilateral small pleural effusions have
slightly improved. No evidence of CHF or pneumonia.
.
[**5-28**] AP CXR:
Compared to yesterday's portable film, there is now new opacity
in the right middle lobe, which may represent pneumonia.
Bilateral pleural effusions may be slightly decreased. Vertical
left basilar atelectasis now slightly obscures the descending
aorta and some consolidation may be present here as well.
Cardiac size is unchanged. A left subclavian central venous
catheter has been placed and the tip is located at the level of
the proximal superior vena cava. TIPS stent is identified in the
right upper quadrant, new since yesterday's exam. Lumbar
dextroscoliosis is noted.
CONCLUSION:
1. New opacities in right middle lobe and left retrocardiac
region, which could represent pneumonia or atelectasis.
2. Decreased pleural effusions.
3. Interim placement of left subclavian central venous catheter
and TIPS stent.
.
[**5-29**] PA/Lat CXR:
FINDINGS: Left internal jugular venous access catheter appears
in unchanged position with tip terminating in upper SVC. The
heart size and mediastinal contours are within normal limits.
There are bilateral pleural effusions, right greater than left,
and bibasilar atelectasis, slightly increased from the previous
examination. TIPS stent in place in right upper quadrant. No
pneumothorax.
IMPRESSION:
1. Bilateral pleural effusions and bibasilar atelectasis,
slightly increased. No definite evidence of pneumonia.
2. Left internal jugular venous access catheter in satisfactory
position.
.
[**5-31**] PA/Lat CXR:
There has been no significant change since the prior film of [**5-29**], 06, other than removal of the left jugular CV line. No
pneumothorax. Bilateral pleural effusions and associated
bibasilar atelectasis are again demonstrated and no new lung
lesions are identified.
.
[**5-24**] WBC-11.2 Hct-20.0 MCV-98 Plt Ct-273
[**5-25**] WBC-9.4 Hct-28.0 Plt Ct-201
[**5-28**] WBC-15.1 Hct-29.6 Plt Ct-190
[**5-31**] WBC-13.3 Hct-26.4 Plt Ct-207
.
[**5-24**] PT-16.1* PTT-28.9 INR(PT)-1.5*
[**5-31**] PT-15.4* PTT-32.8 INR(PT)-1.4*
[**5-28**] Fibrino-169 D-Dimer-3003*
.
[**5-24**] Glucose-99 UreaN-10 Creat-0.7 Na-135 K-3.7 Cl-105 HCO3-20
[**5-31**] Glucose-138* UreaN-13 Creat-0.8 Na-138 K-4.2 Cl-112
HCO3-18
Calcium-8.0* Phos-2.7 Mg-2.3
.
[**5-28**] ALT-21 AST-61* AlkPhos-63 TotBili-2.7* DirBili-1.5*
IndBili-1.2
[**5-31**] ALT-16 AST-34 LD(LDH)-225 AlkPhos-85 TotBili-1.4
.
[**5-28**] 05:45AM BLOOD Cortsol-10.0
[**5-28**] 08:11AM BLOOD Cortsol-9.0
[**5-28**] 08:35AM BLOOD Cortsol-9.9
.
[**5-24**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Urine Cx: GRAM POSITIVE BACTERIA. 10,000-100,000
ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
Brief Hospital Course:
Patient is a 63 y/o female with UC s/p colectomy and colostomy
20 yrs ago and recently diagnosed cirrhosis after a variceal
bleed in early [**Month (only) 547**] requiring ICU stay and a total of 11 units
of PRBCs. She presented at that time with bright red blood in
her ostomy. The bleeding was eventually stopped when the surgery
team sutured an actively bleeding vessel at the ostomy site on
[**2133-4-26**]. Afterward, a tagged RBC scan failed to reveal any
extravazation of blood. GI scoped the ostomy and found no
further sites of bleeding. She was discharged home on [**2133-5-2**]. On
[**5-20**], she had the sutures removed from her stoma. She
represented with recurrent bright blood in her ostomy starting
at 11 PM on [**5-24**]. She reported lightheadedness at the time of
the bleeding. She denied CP, SOB, N/V, hematemesis, abdominal
pain, fevers. She also had a mild nose bleed. She was taken to
[**Hospital3 **] and then transferred to [**Hospital1 18**]. In ED at [**Hospital1 18**] she
was transiently hypotensive to SBP 70s. She received 7 Liters
normal saline and 2 units PRBCs. NG lavage in ED negative. On
presentation to the MICU, she complained of chills, but denies
lightheadedness or SOB.
.
During her [**4-30**] admission, Ms. [**Known lastname **] was also diagnosed with
alcoholic cirrhosis, with EGD demonstrating portal gastropathy
with grade I varices in the lower [**1-27**] of her esophagus. She
adamantly denied any resumption of her alcohol use during the
intercedent time between hospital admissions. On initial exam in
the MICU, she had no evidence of ascites, and diuretics were
held. Vitamin K was given for INR 1.5. On arrival to the MICU,
Ms. [**Known lastname **] was transfused a total of 5U PRBC. She had an
ileoscopy on [**5-26**], which found friable tissue at the ioeostomy
site exteriorly, with nonbleeding periileostomy varices. The
first ileal portion showed portal hypertension ileopathy. The
remainder of the examined ileum was normal. She was started on
octreotide, and maintained on IV protonix [**Hospital1 **]. Per GI and liver
staff, IR consulted for TIPS procedure and possible embolization
of prominent ileocolic vein. On [**5-27**], she had a 1L BRB bleed
via ostomy requiring an additional 2U PRBC and tamponade against
liver via foley. She had a successful TIPS procedure done on
[**5-27**], and fall in pressure gradient to 2mmHg. She was extubated
post-procedure without difficulty. L IJ placed by IR on [**5-27**] at
time of TIPS as well. She was started on prophylactic Rifaximin
on [**5-28**]. F/u US demonstrated resultant expected hepatopetal
flow, but with elevated velocities to >200cm/sec. She remained
stable, and octreotide was d/c'ed on [**5-29**]. She had no further
episodes of bleeding since her TIPS. Her hct has continued to
slowly trend down, but was been generally stable.
.
Ms. [**Known lastname **] has also been treated for LE erythroderma, possible
cellulitis, for which she had been treated as an outpatient with
tw weeks of Keflex. She states that her legs improved somewhat,
but remained erythematous and edematous at time of admission,
and she was switched to vancomycin on [**5-25**]. She had LENIs on
[**5-26**], which showed no evidence of DVT. Her vanc was d/c'ed on
call-out to floor on [**5-29**] since LEs did not appear cellulitic,
and unclear whether initial appearance was due to cellulitis or
venous stasis changes. She had no worsening of symptoms after
d/c'ing vancomycin.
.
Ms. [**Known lastname **] ran a low-grade temp while in the MICU, to 100.6 on
[**5-27**], and then to 102.7F with rigors on [**5-28**] after her TIPS,
with increased O2 requirements. [**5-28**] CXR demonstrated a new RML
and L retrocardiac infiltrate, c/w PNA or atelectasis. She was
started on Zosyn, and transiently required O2 by 75% FT, again,
the day after TIPS. She was placed transiently on neosynephrine
for MAPs in 50s, which was weaned off. Her AM [**Last Name (un) 104**] stim test was
abnormal (10.0 to 9.0 to 9.9), and was started on hydrocort and
fludrocort. She has been receiving finger sticks and being
maintained on a diabetic diet for blood sugars elevated to 190s,
possibly in setting of infection vs steroids. On call-out to the
medicine floor, Ms. [**Known lastname **] had been afebrile for 24 hours, and
was feeling very well. She did have one transient episode of
relative hypotension to SBP 70s on the morning of transfer,
which responded well to 500mL LR. Her baseline BBP is 90s, and
she had no further episodes of hypotension below this level.
.
Once called out to the floor, a PA/Lateral CXR was done to
better characterize opacities seen on AP film, which were read
as more consistent with atelectasis. She was diligent about
using incentive spirometry, and her O2 was quickly weaned to
off. As Ms. [**Known lastname **] was doing extremely well clinically and
afebrile, her Zosyn and vancomycin were d/c'ed. She had no
increase in oxygen requirement or new fevers after being
observed for 48 hours. She did have an elevation in her wbc,
matching the initiation of steroid therapy. Primary team
believed that episode of fever/rigors was [**2-26**] transient
bacteremia in setting of TIPS, and transiently increased O2
requirement was [**2-26**] atelectasis, which resolved with use of
incentive spirometry. Since it was not believed that Ms. [**Known lastname **]
was truly septic, but did not have appropriate response to [**Last Name (un) 104**]
stim test, she was d/c'ed home on 1 week prednisone taper. She
was instructed to f/u with her hepatologist, with whom she had
an appointment in two weeks. As she was not volume overloaded
and had a recent TIPS procedure, she was not sent out on her
home diuretic therapy. However, she was instructed to call her
physician if she had increasing LE edema or abdominal swelling
to discuss reinitiation of diuretics. She was also instructed to
return to the ED with any recurrence of fevers, shortness of
breath, or for any other concerns.
Medications on Admission:
1. Pantoprazole 40 mg Tablet
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325mg Tablet Sig: One Tablet PO DAILY
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
9. Keflex
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days: [**5-31**]: 3 pills once a day
[**6-2**]: 2 pills once a day
[**6-4**]: 1 pill once a day
[**6-6**]-14: [**1-26**] pill once a day
[**6-8**]: stop.
Disp:*10 Tablet(s)* Refills:*0*
9. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
10. ostomy supplies
ConvaTec Active Life Drainable Pouch
precut 1 [**1-28**]"
#[**Numeric Identifier 109096**]
Dispense: qs one month
Refills: 2
11. ostomy supplies
[**Last Name (un) **] Wafer
#002
Disp:qs one month
Refills: 2
12. ostomy supply
Adhesive Remover Wipes
#[**Numeric Identifier 109097**]
Disp: qs one month
Refills: #2
13. ostomy supplies
No Sting Barrier wipes
Disp: qs one month
Refills:#2
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Portal ileopathy
Cirrhosis
Discharge Condition:
Good
Discharge Instructions:
You were admitted with a GI bleed. You had a TIPS procedure to
decrease the pressure in the blood vessels in your GI tract. You
should follow-up in liver clinic in [**1-26**] weeks and the number is
listed below. You should return to the ED with any bleeding from
your ostomy, fever, chills, shortness of breath, or for any
other problems that concern you. You should not take your lasix
or spironolactone for now. If you experience increased leg or
abdominal swelling, you should contact your physician regarding
whether you should restart these medicines.
Followup Instructions:
An appointment was scheduled with Dr. [**Last Name (STitle) **] in the Liver
Clinic, but we have decided you should see Dr. [**Last Name (STitle) **] instead.
Please call [**Telephone/Fax (1) 2422**] on Monday to make an appointment with
Dr. [**Last Name (STitle) **] in [**1-26**] weeks. When you call that number, please ask
them to cancel your appointment with Dr. [**Last Name (STitle) **] (originally
scheduled for [**6-10**]).
|
[
"556.9",
"456.21",
"682.6",
"285.1",
"584.9",
"571.2",
"038.9",
"995.91",
"V44.2",
"456.8",
"255.4",
"572.3",
"244.9",
"537.89",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
19109, 19115
|
11241, 17236
|
293, 360
|
19195, 19202
|
2486, 11218
|
19808, 20245
|
1985, 1989
|
17753, 19086
|
19136, 19174
|
17262, 17730
|
19226, 19785
|
2004, 2467
|
231, 255
|
388, 1604
|
1626, 1833
|
1849, 1969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,247
| 172,679
|
35513
|
Discharge summary
|
report
|
Admission Date: [**2121-7-21**] Discharge Date: [**2121-7-23**]
Date of Birth: [**2048-1-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
tracheostomy bleeding
supratherapeutic INR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 yo male hospitalized in [**5-24**] for AVR/MVR/CABG, subsequent
trach/PEG and acute renal failure. Transferred to rehab on [**7-14**].
Readmitted to CVICU [**7-21**] for bleeding from tracheostomy site and
INR 9.1. Had vitamin K and FFP at rehab prior to ER transfer.
Past Medical History:
Aortic stenosis
mitral regurgitation
coronary artery disease
s/p coronary artery stent
insulin dependent diabetes mellitus
hypercholesterolemia
h/o prostate cancer
depression
degenerative joint disease
s/p bilateral knee replacements
s/p transurethral resection of prostate
s/p femeral rodding
A Fib
prior heparin induced thrombocytopenia
respiratory failure
prior acute renal failure
Social History:
Patient lives with daughter, son and grandaughter. He is
retired. He is a non smoker.
Currently at rehab.
Family History:
non-contributory
Physical Exam:
98.8 T HR 103 92/56 RR 32 99% sat CPAP/PSV
130.7 kg 70"
[**Last Name (un) **]
sternal incision C/D/I , small area of eschar left side of
incision
rhonchorus upper lobes Bil.
dimin. BS bibasilar
+ BS soft, NT, ND, obese
BLE 1+ edema with peripheral pulses present
neuro follows commands, MAE
Pertinent Results:
[**Hospital 93**] MEDICAL CONDITION:
73 year old man s/p avr/mvr/cabg with bleeding from trach
REASON FOR THIS EXAMINATION:
assess for effusions/aspirations
Final Report
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: S/P AVR, MVR, and CABG with bleeding from
tracheostomy.
Comparison is made with prior study, [**2121-7-20**].
Tracheostomy tube is in standard position. Right PICC is in
place with tip in
the lower SVC. Cardiomegaly is unchanged. Ill-defined opacity in
the right
mid lung is new. Mild pulmonary edema has slightly worsened.
Small-to-moderate bilateral pleural effusions, larger on the
right side, have
increased. There are low lung volumes.
IMPRESSION: Worsened pulmonary edema and increasing pleural
effusions.
Ill-defined opacity in the right mid lung could represent fluid
in the
fissure, atelectasis, and/or area of aspiration. Sternal wires
are aligned.
There is no pneumothorax.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: MON [**2121-7-21**] 5:30 PM
Imaging Lab
[**2121-7-23**] 03:41AM BLOOD WBC-8.9 RBC-3.20* Hgb-9.2* Hct-29.3*
MCV-92 MCH-28.8 MCHC-31.5 RDW-15.6* Plt Ct-328
[**2121-7-20**] 11:00PM BLOOD Neuts-74.6* Lymphs-16.7* Monos-4.4
Eos-4.2* Baso-0.2
[**2121-7-23**] 03:41AM BLOOD Plt Ct-328
[**2121-7-23**] 03:41AM BLOOD PT-24.3* PTT-29.9 INR(PT)-2.3*
[**2121-7-23**] 03:41AM BLOOD Glucose-116* UreaN-76* Creat-1.7* Na-146*
K-4.3 Cl-111* HCO3-26 AnGap-13
[**2121-7-21**] 03:15AM BLOOD ALT-60* AST-56* AlkPhos-73 Amylase-99
TotBili-0.6
[**2121-7-20**] 11:00PM BLOOD CK(CPK)-16*
[**2121-7-21**] 03:15AM BLOOD Lipase-144*
[**2121-7-20**] 11:00PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2121-7-21**] 03:15AM BLOOD Albumin-2.9* Mg-3.1*
Brief Hospital Course:
Transferred [**7-21**] early AM from [**Hospital3 **] ER and INR allowed to
drift down. Evaluated by Dr. [**Last Name (STitle) **] for trach site bleeding.
Bleeding stopped as INR decreased. Bronchoscopy deferred until
INR in therapeutic range, but ultimately determined to be
unnecessary. Cipro started [**7-21**] for UTI. Coumadin restarted for A
Fib and HITT target range 2.0-2.5. Cleared for discharge to
rehab on [**7-23**]. INR should be closely followed at rehab.
Medications on Admission:
chlorhexidine mouthwash [**Hospital1 **]
colace 100 mg [**Hospital1 **]
ASA 325 mg daily
tramadol 50 mg prn
digoxin 0.125 mg every other day
amiodarone 200 mg [**Hospital1 **]
zantac 150 mg daily
ativan prn
lipitor 10 mg daily
combivent IH q4h
albuterol nebs
bacitracin ointment
lopressor 75 mg [**Hospital1 **]
ipratropium
coumadin daily
paroxetine 60 mg daily
humalog insulin SS
lantus 15 units daily
lasix 20 mg IV daily
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: Four (4) ml PO Q6H
(every 6 hours) as needed for pain/fever.
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY-PRN () as needed for constipation.
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO DAILY
(Daily).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**4-21**]
Puffs Inhalation Q4H (every 4 hours).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: last dose PM [**7-23**].
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO provider to
order daily dose for 1 doses: dose 7/8 is 2 mg, then daily per
rehab provider- [**Name10 (NameIs) **] INR 2.0-2.5
please check INR mon/wed/fri until on steady dose for 2 weeks .
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb IH
Inhalation Q6H (every 6 hours) as needed for wheezing.
15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. 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.
17. Insulin Glargine 100 unit/mL Cartridge Sig: Fifteen (15)
units Subcutaneous once a day: daily at breakfast.
18. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day: QID humalog per attached sliding
scale.
19. Paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO once a
day: total dose 60 mg .
20. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
s/p AVR/MVR/ CABG x3 [**2121-6-11**]
s/p trach /PEG [**7-1**]
tracheostomy bleed [**7-21**]
supratherapeutic INR
A Fib
IDDM
depression
osteoarthritis
hypercholesterolemia
obesity
CAD
UTI
right scapular pressure ulcer
prior heparin-induced thrombocytopenia
degenerative joint disease
Discharge Condition:
fair
Discharge Instructions:
no lotions, creams or powders on any incision
no driving at this time
no lifting greater than 10 pounds for 4 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
bathe daily and pat incisions dry
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**2-18**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2121-7-23**]
|
[
"790.92",
"250.00",
"V43.65",
"272.0",
"427.31",
"E934.2",
"V44.1",
"V43.3",
"V10.46",
"V58.67",
"519.09",
"599.0",
"V58.61",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6415, 6491
|
3306, 3779
|
323, 330
|
6819, 6826
|
1530, 1530
|
7137, 7388
|
1178, 1196
|
4254, 6392
|
1570, 1628
|
6512, 6798
|
3805, 4231
|
6850, 7114
|
1211, 1511
|
241, 285
|
1660, 3283
|
358, 630
|
652, 1038
|
1054, 1162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,289
| 137,952
|
35170
|
Discharge summary
|
report
|
Admission Date: [**2174-9-22**] Discharge Date: [**2174-9-28**]
Date of Birth: [**2116-7-14**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
GTC seizure and R occiptal hemorrhage
Major Surgical or Invasive Procedure:
Cerebral angiogram
History of Present Illness:
The pt is a 58 year-old man (handedness unknown) who was
transferred from [**Hospital3 **]. This history is obtained
from his transfer records and his girlfriend as he was intubated
for agitation prior to transfer.
It appears from the record that Mr. [**Known lastname 11622**] had presented to the
ED with complaints of seeing "flashing lights" associated with a
headache today. It is documented that he would only "look to the
left with the head turned". He also complained of nausea and
vomiting. Per his girlfriend, the symptoms started around 9am
this morning. He waited all day and she was finally able to
convince him to go to the ED. On arrival he had a "Grand Mal"
seizure in triage for which he was given 3mg of ativan.
His BP at the OSH was recorded as 175/117. The nursing notes are
difficult to read, however it appears that he had vomiting while
there prior to his CT. The image showed a 2cm R occipital bleed
and a repeat study 3 hours later was stable.
Over the next few hours he was given ativan 1mg, 2mg, 2mg,
dilantin 1gm and then another ativan 2mg. In one of the notes,
he was described as unresponsive but moving extremities and head
but not purposefully, "thrashing in bed". He was reportedly in
restraints at this time and his behavior was attributed to a
post-ictal state. At 2200 he was given versed 1mg x 2 and then
another dose of ativan (?). Prior to transfer he was given
another dose of versed and intubated.
His labs at [**Hospital1 2436**] showed a metabolic acidosis with a low
HCO3 and an anion gap of 19. His INR was 1.1 and his platelet
were 197. His tox screen was positive for THC.
These symptoms occur in the context of a fall 3 weeks ago. He
was sitting and fell forward striking his forehead. He had LOC
for a few seconds but was reportedly back to baseline
immediately without evidence of being post-ictal.
Past Medical History:
Hepatitis C - reports receiving treatment but details unknown
Social History:
-heavy and longstanding tobacco use
-No EtOH or drug use per girlfriend
-works from home as a currency exchanger
Family History:
Father with [**Name2 (NI) 499**] cancer.
Physical Exam:
Vitals: T: AF P: 80 R: 20 BP: 132/75 MAP: 91 SaO2: 100% on EG
General: intubated, sedated
HEENT: NC/AT, no scleral icterus noted, ET in place
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: nl S1, S2, regular
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No peripheral edema
Skin: + petechia on chest and shoulders, no splinter hemorrhages
Neurologic:
-Mental Status: intubated, sedated, does not follow grimaces to
nox stim but does not have consistently purposeful movements
CN
I: not tested
II,III: pupils 1mm but reactive, unable to visualize fundi due
to
pupil size
III,IV,V: no dolls
V: + corneals with head turning away to stimulus, + V1-V3 to LT
VII: face grossly symmetrical w/ ET in place
VIII: UA
IX,X: + gag
[**Doctor First Name 81**]: UA
XII: UA
Motor: Normal bulk and tone; withdraws symmetrically to nox stim
in all extremities
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 1 1 1 2 0 Flexor
R 1 1 1 2 0 Flexor
-Sensory: withdraws to nox stim in all extremities
-Coordination: NA
-Gait: NA
Physical exam at discharge was essentially normal, with normal
visual field to confrontation test. Gait was stable.
Pertinent Results:
[**2174-9-22**] 01:00AM BLOOD WBC-9.6 RBC-4.13* Hgb-13.4* Hct-37.6*
MCV-91 MCH-32.5* MCHC-35.6* RDW-13.3 Plt Ct-167
[**2174-9-22**] 01:00AM BLOOD Glucose-106* UreaN-11 Creat-1.0 Na-141
K-3.5 Cl-108 HCO3-24 AnGap-13
[**2174-9-22**] 01:00AM BLOOD ALT-27 AST-29 LD(LDH)-276* CK(CPK)-762*
AlkPhos-54 Amylase-30 TotBili-0.8
[**2174-9-22**] 01:00AM BLOOD TSH-2.5
[**2174-9-22**] 03:47PM BLOOD Phenyto-13.6
[**2174-9-22**] 04:45AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2174-9-22**] 04:45AM BLOOD HCV Ab-POSITIVE
MR/MRA/MRV of head:
1. Hyperacute parenchymal hemorrhage with small amount of
surrounding edema in the right occipital lobe as described
above. No findings are detected to explain the etiology. If the
hemorrhage was secondary to a small AVM, this would not be
detectable on MRI, and if clinical concern present, a
conventional arteriogram is recommended.
2. Intensely enhancing lesion with irregular borders in the
atrium of the
left lateral ventricle with associated cystic component
indenting into the
superior ventricular. Given that similar enhancement
characteristics are
noted and a focus of choroid plexus appears to extend towards
this region,
this most likely represents a focus of ectopic choroid plexus.
Correlation
with CT and continued followup is recommended.
3. Sinusitis.
Cerebral Angiogram official report pending.
Brief Hospital Course:
Patient was admitted to NSICU and successfully extubated the
next day - initially was quite agitated requiring several doses
of haloperidol, possibly due to the R occipital hemorrhage but
soon improved with redirection provided per 1:1 sitter. He was
also loaded with Dilantin and was continued on Dilantin for
seizure prophylaxis.
His MRI with gadolinium was unrevealing. He underwent angiogram
per Dr. [**Last Name (STitle) **] on [**9-23**] without complications, which raised the
possibility of an occipito-temporal arteriovenous fistula. A
repeat angiogram on [**9-27**] under anesthesia was negative, however.
During the admission he was noted to have progressive CK
elevations, and had mild rash around his neck. It was felt to
be due to dilantin hypersensitivity syndrome. Dilantin was
dicontinued and keppra was started. CK went down. He tolerated
well Keppra.
He was discharged with plans for repeating his MRI with
gadolinium in 4 weeks. Consideration for additional studies,
such as CT torso, will be determined after his repeat MRI by
[**Month/Day (4) **]. [**Name5 (PTitle) **] & [**Doctor Last Name 78537**] upon follow up. Dr. [**Last Name (STitle) **] will also
discuss the results of his angiogram with Dr. [**First Name (STitle) **], our
interventional vascular neurosurgeon, who is currently out of
the country when he returns.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
3. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right parietal-occipital intracerebral hemorrhage
seizures
Discharge Condition:
stable with mild residual visual changes
Discharge Instructions:
You were admtted to this hospital because you developed visual
changes and headache, while in the outside hospital you had a
generalized seizure. You underwent a head CT which showed
bleeding in the posterior aspect of your brain. To evaluate the
cause for this bleeding you had a brain angiogram, the first
test showed a possible fistula in your vessels but because of
the amount of the bleeding and movement artifact a second
angiogram was required.
To prevent further seizures you need to continue taking Keppra
1000mg twice a day. The most common side effect is behavior
changes.
While in the hospital your muscles enzymes levels were levated,
and this might be related to the shaking movements during the
seizure. Before your discharges the CK level was going down.
Please call Dr [**First Name (STitle) **] or return to the emergency department if
you have visual changes, persistent headache, mental status
change, weakness, dizziness or seizures.
You will need to call Dr [**First Name (STitle) **] [**Numeric Identifier 80273**] to obtain a referal
to see neurology on [**2174-10-19**]
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2174-10-17**]
3:15
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2174-10-19**] 1:30 PLEASE CALL THE OFFICE TO PROVIDE
GENERAL INFORMATION
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
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69,293
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48481
|
Discharge summary
|
report
|
Admission Date: [**2185-7-21**] Discharge Date: [**2185-8-9**]
Date of Birth: [**2106-11-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Methyldopa / Clindamycin / Sulfamethoxazole /
Trimethoprim / Tylenol
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest Pain --> NSTEMI
Major Surgical or Invasive Procedure:
Cardiac cath
Pacemaker placement
Pericardiocentesis and drain placement/removal
Intubation and mechanical ventilation
s/p left SFA thrombectomy, femoral endarterectomy, right
fasciotomy
Right femoral line
RIJ CVL
Left brachial A-line
Right radial A-line
History of Present Illness:
78F h/o PAF (not on coumadin due to fall risk), O2- and
steroid-dependent COPD transferred for cardiac catheterization
for treatment of NSTEMI. Presented to OSH on [**7-20**] with chest
pain rated [**11-19**], sharp, non-radiating, and constant in nature.
The patient was found to be in rapid AFib with HR in the 150's
and was treated with a diltiazem gtt and eventually transitioned
to PO dilt and digoxin. Initial troponin in the ED was 0.16, BNP
1080. While on the floor, troponin rose to 19.32 -> 112.2 ->
116.6 while on the floor (CK 1113 -> 2417 -> 2165, CK-MB 255 ->
392 -> 264). The patient was started on a Heparin gtt, Aspirin,
and the patient received a plavix load of 600mg for her NSTEMI.
Chest pain resolved and prior to transfer for cardiac cath, the
patient was chest pain-free, V/S 98.5, 107/64, 60-70s, 18,
94%2L.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: No Diabetes, No Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: Unknown
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation (not anticoagulated due to prior fall)
MVP
Carotid stenosis
COPD, oxygen (2.5L) and steroid-dependent
Restrictive lung disease
s/p RUL lobectomy
SCC
HTN
Positive PPD s/p INH treatment
Vertebral compression fractures
Social History:
Lives in an assisted housing community. She has a son and is
widowed. Ambulates at home with a walker and a cane.
-Tobacco history: 52 pk year history of tobacco, quit 1 year ago
-ETOH: none
-Illicit drugs: none
Family History:
Mother with MI (age 78), cerebral aneurysm and AVM. Father
unknown.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T=95.8 BP=103/53 HR=64 RR=21 O2 sat=88% on RA
GENERAL: Cushingoid appearing elderly female. Oriented x3.
Affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with flat JVP.
CARDIAC: Heart sounds difficult to auscultate due to diffuse
wheezing. Normal rhythm, No murmurs or extra heart sounds
appreciated.
LUNGS: Barrel chested with severe pectus excavatum.
Respirations labored, shallow, audible inspiratory wheezes with
some accessory muscle use. Bilateral diffuse expiratory wheezes
and poor air movement. Left lower and middle lobe with
scattered crackles, right lower lobe clear.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Right femoral catheter site with clean dressing in
place and mild tenderness. No femoral bruits. Right leg
immobilizer in place.
SKIN: Warm and well perfused, no rashes.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP doppler PT doppler
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP doppler PT doppler
Pertinent Results:
[**2185-7-21**] 10:25PM
9.5
10.3>---<154 RBC-3.01*
27.9
PT-13.4 PTT-29.2 INR(PT)-1.1
Glucose-105 UreaN-17 Creat-0.8 Na-136 K-3.5 Cl-98 HCO3-27
AnGap-15
CK(CPK)-666*
[**2185-7-22**] 05:39AM BLOOD CK(CPK)-458*
[**2185-7-26**] 01:17AM BLOOD CK(CPK)-97
[**2185-7-21**] 10:25PM BLOOD CK-MB-31* MB Indx-4.7 cTropnT-4.41*
[**2185-7-22**] 05:39AM BLOOD CK-MB-24* MB Indx-5.2 cTropnT-2.82*
[**2185-7-21**] 10:25PM BLOOD Calcium-8.1* Phos-3.7 Mg-1.8
[**2185-7-26**] 09:58AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2185-7-26**] 09:58AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
[**2185-7-26**] 09:58AM URINE RBC-[**7-20**]* WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
Sputum:
[**2185-7-26**] 1:33 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2185-7-28**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] REQUESTED ADDITIONAL SENSITIVITIES
[**2185-7-31**].
SENSITIVITIES: MIC expressed in
MCG/ML
PSEUDOMONAS AERUGINOSA
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**7-21**] Cardiac Cath
COMMENTS:
1. Selective coronary angiography in this right dominant system
revealed
one vessel coronary disease. The LMCA was very short. The
proximal LAD
had a 99% stenosis. The RCA and LCX were free of
angiographically
apparent disease.
2. Resting hemodynamics revealed low systemic blood pressure and
high LV
filling pressure.
3. Unsuccessful attempt at PCI of the ostial LAD stenosis was
performed.
(See PTCA comments.)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Unsuccessful PCI attempt of the ostial LAD.
[**7-22**] TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60-70%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. 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. Moderate
(2+) mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**7-25**] TTE
There is normal left ventricular wall thickness and cavity size.
Right ventricular chamber size and free wall motion are normal.
There is a very small, echodense inferolateral pericardial
effusion c/w blood, inflammation or other cellular elements. No
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2185-7-25**],
the inferolateral effusion is identified (prior study only had
subcostal views and this may not reflect a true change).
Serial evaluation is suggested.
[**7-27**] TTE
Left ventricular wall thicknesses and cavity size are normal.
There is mild global left ventricular hypokinesis (LVEF = 45 %).
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2185-7-26**], the
pericardial findings are similar. The LVEF may be slightly
improved.
[**7-27**] Carotid U/S
Right ICA 1-39% stenosis. Left ICA 40-59% stenosis with bulky
plaque noted bilaterally. No available studies for comparison.
[**8-3**] CXR
There is probably a small right pneumothorax
primarily lateral and anterior, stable since [**8-2**] at 2:06
p.m.
Moderate cardiomegaly and small bilateral pleural effusions and
pulmonary vascular congestion are also stable but there appears
to be developing consolidation in the right upper lobe,
particularly when compared to [**7-21**], concerning for pneumonia.
Brief Hospital Course:
RV Perforation: The patient underwent pacemaker placement on
[**7-25**]. The EP procedure was complicated by RV perforation, and
subsequent tamponade. She had a brief loss of pulses (~20s)
that returned upon drainage of her pericardial effusion and
placement of catheter (600cc in the OR and then an additional
450cc in the ICU). The patient's Hct dropped to 17 and she
emergently transfused a total of 5U pRBC. The patient was also
emergently intubated and an arterial line was placed in the
right femoral artery. It was noted that after placment of the
a-line that dopplerable pulses were lost on the right foot. Her
arterial line was removed, but distal pulses were still not
dopplerable. She was seen by vascular surgery and taken to the
OR. Please see below for full course. The patient underwent
serial TTE that did not show tamponade and her drainage of her
catheter stopped within 24hrs. Her drain was removed on [**7-26**] and
repeat TTE did not show further accumulation. The patient's Hct
remained stable and no further evidence of tamponade. Pt's IJ
was d'c and PICC placed on [**2185-8-4**].
R LEG ISCHEMIA: During the patient's EP procedure on [**7-25**] a
femoral a-line was placed. After placement of the line pulses
were lost in her right leg. The a-line was immediately removed
and femoral pulses returned, but distal pulses were not
doplerable. Vascular surgery was called and the patient was
taken to the OR for left SFA thrombectomy, femoral
endarterectomy, and right fasciotomy. The procedure was
successful and she had dopperable pulses post-procedure. The
patient did not show evidence of comparment syndrome and CK
remained wnl. Wound care was consulted for the right groin site,
the site was kept dry with desitin. Per Vascular Surgery,
staples in the Rt LE are to stay in until 4 weeks from [**7-24**]
([**8-23**]-15).
HAP: The patient had a CXR that showed left retrocardiac
opacity. Sputum cultures were sent that initally grew GNR and
GPC. She was empirically started on vancomycin/aztreonam/cipro
given her PCN allergy and for double coverage of pseudomonas.
Her sputum culture subsequently grew pseudomonas and was changed
to meropenem for a planned 14 day course. Additionally, her
cultures also grew stenotrophomonas sensitive to levofloxacin,
which was not treated initially as her respiratory status seemed
gradually improving. However, daily CXR began to show increased
RUL consolidation and treatment with Levofloxacin was started
[**8-3**] for a full 10 day course. CXR's then remained stable and
she remained afebrile until discharge; WBC started to drift down
steadily to the 7s by the time of discharge.
CORONARIES: Patient presented to OSH on [**7-20**] with chest pain and
found to be in rapid AFib with HR in the 150's and was treated
with a diltiazem gtt and eventually transitioned to PO dilt and
digoxin. Her initial troponin in the ED was 0.16, BNP 1080.
However, while on the floor, her troponin rose to 19.32 -> 112.2
-> 116.6 (CK 1113 -> 2417 -> 2165, CK-MB 255 -> 392 -> 264). The
patient was started on a Heparin gtt, Aspirin, and the patient
received a plavix load of 600mg for her NSTEMI. Chest pain
resolved prior to transfer for cardiac cath. She underwent
cardiac cath on [**7-21**], which showed a focal LAD lesions that
appeared calcified that was not thrombotic or ulcerated in
appearance. Percutaneous intervention attempted but unsuccessful
and given patient's other comorbitidities, patient was not a
surgical candidate. TTE showed that the right ventricular cavity
was moderately dilated with mild global free wall hypokinesis,
EF 45%. She was medically optimized and continued on ASA 325mg,
plavix 75mg, atorvastatin 80mg. She was restarted on metoprolol
and lisinopril after her blood pressures had stablized.
.
PUMP: Patient with elevated BNP on arrival to OSH and some
crackles at the lung bases on physical exam. Her EF was
reportedly 60-65% on TTE at OSH on [**2185-6-21**]. serial TTE
performed during her admission showed an EF 45%. She was
transfused 5U pRBC and given ~3L IVF after her RV perforation
and right leg ischemia. Her CXR [**7-27**] showed volume overload and
she was given 40mg IV lasix x2. She continued to have worsening
edema and started on a lasix gtt for diuresis. She was net
negative 2.5L the first day and then 1-2L negative the following
days, her gtt was stopped on [**7-30**]. The patient was transiently
hypotensive after aggressive diuresis and required neo
intermittently. She then received Lasix PRN to maintain
euvolemic status and then started on a standing dose. BNP was in
the 13,000s the day of discharge but goal remained to keep her
euvolemic. This was due to increasing bicarb and minimal
improvement in respiratory status on standing dose of Lasix.
.
RHYTHM: The patient has a history of paroxysmal AFib and was not
anti-coagulated due to high risk for falls. The patient was in
a-fib w/ RVR at the OSH and required IV diltiazem and digoxin at
OSH for rate control. The patient ECG showed RBBB and LAFB with
concern for AV disassociation. She underwent EPS and pacemaker
placement that was complicated by RV perforation and right leg
ischemia on [**7-25**]. See above for management. The patient went
into a-fib with RVR on [**7-28**] with rates 100-140's. She was
treated with IV/po metoprolol then IV amio on [**7-29**] followed by
PO loading. The patient returned to sinus/a-pacing. She again
had a-fib with rates in the 100-120's, so that her amiodarone
was increased to 400mg [**Hospital1 **]. She will continue amiodarone 200 mg
PO daily and metoprolol 25 mg PO TID as an outpatient.
Anti-coagulation was not started given her RV perforation as
well as her fall risk.
RESPIRATORY FAILURE: The patient was intubated after RV
perforation during her EP procedure. She was initally very
acidotic with ABG: 7.17/61/198/23 immediately post-procedure.
Her vent setting were adjusted and acid/base status improved to
7.36/36/163/21. Her respiratory status was complicated by her
baseline COPD (on 2-3L at home), HAP and pulmonary edema. She
was aggressively diuresed with lasix gtt and volume overload
improved. She was weaned and eventually extubated on [**7-30**]. The
patient eventually improved to 02 sats>95% on 2.5 L NC (her
baseline home 02 setting), with occassional desaturations to
80%'s when eating or coughing. She was initially maintained on
TF for adequate nutrition to prevent aspiration/desat's, but was
cleared by S/S on [**8-4**]. Pt continued to have episodic
desaturations to 88% on 2-3L face mask/nasal cannula. She
responded well to repositioning, sleep and suctioning and was on
2-3L O2 at home; thus, pt was transferred out to [**Hospital Ward Name 121**] 3. She
triggered on the floor X2, however, and was returned to the CCU.
Pt continued to fare variably when placed in chair, often citing
fatigue, respiratory fatigue. Pulmonary was re-consulted on [**8-8**]
re: pt's respiratory issues. By the end of her stay, her
episodes of desaturation had decreased and pt responded well to
repositioning, sleep (decreasing anxiety), suctioning. Pt on 3L
O2 at home, at baseline.
.
COPD: The patient with severe COPD on home O2 (2-3L). The
patient also has a cushingoid habitus that is likely secondary
to chronic steriod use. On admission she had diffuse wheezes
and poor air movement. She was started on IV solumedrol 80mg q8
for COPD flare. She was also continued on nebs. Her resp status
improved, but continued to have diffuse wheezes. She was
transitioned to po prednisone on [**7-22**]. However, after her
intubation she started back on IV solumedrol 40mg q24. After
extubation, she was started on 60mg PO prednisone daily, to be
tapered extremely slowly. A pulmonary consultation earlier in
the admission recommended a non-contrast chest CT for evaluation
of the right hilum, which can be done outpatient.
Medications on Admission:
Carvedilol 3.125 mg Tablet
1 (One) Tablet(s) by mouth twice a day
Citalopram 20 mg Tablet
1 (One) Tablet(s) by mouth once a day
Clopidogrel [Plavix] 75 mg Tablet
1 (One) Tablet(s) by mouth once a day
Digoxin 250 mcg Tablet
1 (One) Tablet(s) by mouth once a day
Diltiazem HCl 240 mg Capsule, Sustained Release
1 (One) Capsule(s) by mouth once a day
Famotidine 20 mg Tablet
1 (One) Tablet(s) by mouth once a day
Furosemide 20 mg Tablet
1 (One) Tablet(s) by mouth once a day
Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
1 (One) Tablet(s) by mouth once a day
Salmeterol [Serevent Diskus] 50 mcg Disk with Device
1 (One) inhaled twice a day 1 puff twice a day
Tiotropium Bromide [Spiriva with HandiHaler] 18 mcg Capsule,
w/Inhalation Device 1 (One) inhaled once a day 1 puff once a day
* OTCs *
Aspirin 325 mg Tablet
1 (One) Tablet(s) by mouth once a day (Not Taking as Prescribed)
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 days: Tapering Prednisone.
30 mg daily next week (week of [**8-14**]), 20 mg daily week of [**8-21**], 10 mg daily week of [**8-28**]. Pt should be completely done
[**9-4**].
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
17. 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.
18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Pt to discuss w/ cardiologist Dr. [**Last Name (STitle) **] within a month
re: stopping this medication.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary: Heart attack (NSTEMI)
Secondary: Abnormal heart rhythm, pacemaker placed; right leg
thrombosis; hospital acquired pneumonia
Discharge Condition:
Improved. Vital signs have been stable, patient able to sit in
chair.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of a heart attack.
You underwent cardiac cath that showed an occlusion of your
blood vessel in your heart. We attempted to open the vessel
with a balloon, but were unsuccessful. It was deemed you were
not a cardiac surgery candidate because of your other medical
issues so you were treated with medications.
You also had a slow rate on your ECG and there was concern for
an abnormal rhythm. You underwent an EP study and placement of
a pacemaker. The placement of the pacemaker was complicated by
perforation of your heart. You underwent drainge of the blood
surrounding your heart. Additionally, you had a clot in your
right leg that compromised blood flow. You underwent surgery to
restore blood flow to your leg. You required intubation and
medications to maintain your blood pressure.
You also went into a fast heart rhythm that required the
initiation of a medication called amiodarone.
Please follow the medications prescribed below.
* STOP taking your Prednisone 60mg daily, Coreg 3.125 mg twice a
day, Diltiazem SR 240 mg daily, Imdur 30 mg daily.
* CONTINUE taking your Advair 250/50 one puff daily, Spiriva 18
mcg two puffs daily, Plavix 75 mg daily, Celexa 20 mg daily
* CONTINUE also, your lidocaine patch 5% twice a day (every 12
hours)
* START Amiodarone 200mg daily until you see Dr. [**Last Name (STitle) **] and
discuss with him whether you can stop taking it
* Start Prednisone 40mg daily until the end of this week. Take
Prednisone 30mg daily the week after (week of [**8-14**]). Then
decrease to Prednisone 20 mg daily the week after (week of [**8-21**]). Finally decrease to Prednisone 10 mg daily the final week
(week of [**8-28**]). You should be done with Prednisone completely
by [**9-4**].
* START Furosemide 40 mg daily (water pill for fluid on your
lungs)
START Toprol XL 75 mg daily (controls your heart rate and blood
pressure
START Atorvastatin 80mg daily (for your cholesterol)
START Famotidine 500 mg daily (for heart burn control)
START Lisinopril 10 mg daily (also controls your blood pressure)
START Aspirin 325 mg daily (helps blood flow through your
arteries)
* You should take your antibiotic, Levofloxacin 500 mg daily for
three more days
Please follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. An
appointment has been made for you for Monday, [**8-29**] at 11:45
AM. His office has moved from [**Location (un) 583**] to [**Location (un) **], [**State 350**].
You can reach his office at: [**Telephone/Fax (2) 8725**]l. Please make sure to
discuss your new medication Amiodarone with Dr. [**Last Name (STitle) **],
especially regarding whether you can stop taking it after your
appointment with him.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Please follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. An
appointment has been made for you for Monday, [**8-29**] at 11:45
AM. You can reach his office at: [**Telephone/Fax (2) 8725**]l. Please make sure
to discuss stopping new medication Amiodarone with Dr. [**Last Name (STitle) **].
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-11**] weeks.
You can reach his office at: [**Telephone/Fax (1) 6699**]
|
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"444.22",
"424.0",
"428.22",
"998.2",
"427.31",
"518.81",
"V58.65",
"440.20",
"038.9",
"426.51",
"491.21",
"397.0",
"410.71",
"997.2",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"88.48",
"38.16",
"96.04",
"38.18",
"37.26",
"37.73",
"83.14",
"00.41",
"38.93",
"37.82",
"38.91",
"88.42",
"37.0",
"88.55",
"37.22",
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] |
icd9pcs
|
[
[
[]
]
] |
19416, 19488
|
8703, 16587
|
365, 621
|
19665, 19737
|
3701, 6031
|
22778, 23336
|
2529, 2598
|
17532, 19393
|
19509, 19644
|
16613, 17509
|
6048, 8680
|
19761, 22755
|
2613, 2613
|
1937, 2013
|
2635, 3682
|
304, 327
|
649, 1824
|
2044, 2282
|
1846, 1917
|
2298, 2513
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,993
| 103,633
|
10368
|
Discharge summary
|
report
|
Admission Date: [**2180-4-30**] [**Month/Day/Year **] Date: [**2180-5-11**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
[**5-1**] Exploratory lap; repair of anastomosis; repair of bladder;
loop ileostomy
History of Present Illness:
83 yo female with history of colon CA who underwent a resection
of a large right perforated right cecal tumor which infiltrated
the bladder, 12 days ago. She represented to the ED with signs
of sepsis and presumed leak on CT
scan. She was taken to the operating room for treatment of this.
Past Medical History:
1)Hypertension
2)Distant ovarian carcinoma-s/p THA BSO and ? brachy therapy
3)s/p cholecystectomy
4)s/p ORIF Le Fort I and II fracture [**1-3**] after fall
5)s/p ORIF L 4th MCP
6)RLE DVT on Coumadin
Social History:
Widowed for 30 yrs from husband who dies of bladder CA. Lives
with her daughters with good functional status. No smoking or
EtoH. Immigrated from [**Country 6171**] in [**2121**].
Family History:
Father and brother with HTN, no hx of breast, ovarian or colon
CA.
Pertinent Results:
Blood Urine CSF Other Fluid Microbiology
Recent
Last Day Last Week Last 30 Days All Results Hide Comments
From Date To Date
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2180-5-11**] 10:00AM 8.3 3.46* 9.7* 30.3* 88 28.0 32.0 16.7*
355
[**2180-5-11**] 05:45AM 6.4 3.02* 8.4* 26.5* 88 27.9 31.7 16.9*
302
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2180-4-30**] 11:52PM 95.5* 0 1.9* 2.5 0.1 0
[**2180-4-30**] 05:45PM 83* 8* 3* 6 0 0 0 0 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Burr
[**2180-4-30**] 11:52PM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
[**2180-4-30**] 05:45PM NORMAL NORMAL 1+ NORMAL NORMAL 1+ 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2180-5-11**] 10:00AM 355
[**2180-5-11**] 05:45AM 302
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2180-5-11**] 10:00AM 116* 10 0.5 143 3.9 115* 21* 11
[**2180-5-11**] 05:45AM 88 10 0.5 141 3.5 114* 21* 10
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2180-5-8**] 05:20AM Using this1
[**Numeric Identifier **] PICC W/O PORT [**2180-5-8**] 12:43 PM
Reason: please place PICC
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with need for long term antibiotics
REASON FOR THIS EXAMINATION:
please place PICC
PICC LINE PLACEMENT
INDICATION: 83-year-old woman need for long term antibiotics.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGIST: Drs. [**First Name (STitle) 3175**] and [**Doctor Last Name **] Dr. [**First Name (STitle) 3175**] the attending
radiologist was present and supervising throughout.
TECHNIQUE: Using sterile technique and local anesthesia, the
left brachial vein was punctured under direct ultrasound
guidance using a micropuncture set. Hard copies of ultrasound
images were obtained before and immediately after establishing
intravenous access. A peel-away sheath was then placed over a
guidewire and a single lumen PICC line measuring 36 cm in length
was then placed through the peel-away sheath with its tip
positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the
chest.
The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
single lumen PICC line placement via the left brachial venous
approach. Final internal length is 36 cm, with the tip
positioned in SVC. The line is ready to use.
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2180-5-11**] 10:00AM 6.6* 2.0* 2.2
[**2180-5-11**] 05:45AM 6.3* 2.1* 2.1
HEMATOLOGIC calTIBC Ferritn TRF
[**2180-5-8**] 05:20AM 108* 255* 83*
PITUITARY TSH
[**2180-5-2**] 01:25PM 2.5
LAB USE ONLY EDTA Ho HoldBLu RedHold
[**2180-5-2**] 01:25PM HOLD1
1 HOLD
DISCARD GREATER THAN 8 HOURS OLD
[**2180-5-2**] 01:25PM HOLD1
1 HOLD
DISCARD GREATER THAN 24 HRS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Comment
[**2180-5-4**] 02:37AM ART 100 38 7.44 27 1
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2180-5-2**] 10:05AM 70
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT
[**2180-5-1**] 09:42AM 7.5* 23
[**2180-5-1**] 08:24AM 8.0* 24
CALCIUM freeCa
[**2180-5-1**] 11:43AM 1.16
[**2180-5-1**] 09:42AM 1.19
[**2180-5-1**] 08:24AM 1.05*
CYSTOGRAM ([**Numeric Identifier 34386**], [**Numeric Identifier 34387**])
Reason: please evaluate for proper storage of urine, leak.Please
rep
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with invasion of colon Ca into bladder, s/p
partial cystectomy
REASON FOR THIS EXAMINATION:
please evaluate for proper storage of urine, leak.Please replace
foley under guidance
CLINICAL HISTORY: 82-year-old female with history of colon
cancer with invasion into the bladder status post partial
cystectomy. Evaluate for leak.
COMPARISON: None.
TECHNIQUE/FINDINGS: Scout view demonstrates multiple surgical
suture and clips projecting within the pelvis. A JP drain is
seen within the right hemipelvis.
650 cc of Cysto-Conray contrast was administered via Foley
catheter into the bladder under fluoroscopic guidance which
demonstrates extravasation of contrast along the right superior
aspect of the bladder. Contrast was noted to be draining from
patient's drain.
IMPRESSION: Extravasation of contrast along the right superior
aspect of the bladder. Findings were discussed with Dr.
[**Last Name (STitle) 34388**] at the time of dictation.
CHEST (PORTABLE AP)
Reason: eval for pna, chf
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with recent surgery, here with hypotension and
decreased UOP
REASON FOR THIS EXAMINATION:
eval for pna, chf
STUDY: Portable AP chest x-ray.
INDICATION: 82-year-old female with a recent surgery presenting
with hypotension and decreased urine output. Assess for
pneumonia/CHF.
COMPARISONS: None.
FINDINGS: The heart is normal in size. The mediastinal and hilar
contour is unremarkable. The lungs are clear. There are no
pleural effusions. The soft tissues and osseous structures are
grossly unremarkable aside from degenerative change of the
thoracic and upper lumbar spine.
IMPRESSION: No evidence of acute cardiopulmonary disease.
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: PO contrast ONLY (not IV)
Field of view: 35
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with abd pain, elevated WBC.
REASON FOR THIS EXAMINATION:
PO contrast ONLY (not IV)
CONTRAINDICATIONS for IV CONTRAST: creat
INDICATION: 82-year-old woman with abdominal pain and elevated
white count, and renal failure. Status post ileo-right colectomy
and resection of part of the posterior bladder, now on postop
day #10.
COMPARISON: [**2180-4-15**].
TECHNIQUE: Contagious axial images were obtained from the lung
bases to the pubic symphysis. Multiplanar reformatted imaged
were obtained.
CONTRAST: Oral contrast only was administered. No intravenous
contrast administered secondary to poor renal function.
CT ABDOMEN: There is small bilateral pleural effusion at the
lung bases, with adjacent atelectasis.
There is a large amount of ascites. Additionally, in the right
upper quadrant, there is large air fluid level, and air within
the ascites. This region is abutting the right lobe of the
liver, and is centered around the anastomosis between the
transverse colon and the distal ileum. Oral contrast passes
through loops of small and large bowel, and can be seen
extending to the descending colon. There is a tiny focus of
dense material abutting the liver (series 2, image 35), which
cannot definitely be identified within a loop of bowel, and
likely represents a tiny focus of extravasated contrast. The
ascites extends around the spleen, and the descending colon, and
into the deep pelvis.
The bowel is not dilated, there is no evidence of obstruction.
There is limited evaluation of solid organs without intravenous
contrast; however, the liver, spleen, adrenal glands, kidneys,
and pancreas are unremarkable. There is no evidence of
hydronephrosis. No pathologic or retroperitoneum lymphadenopathy
is seen.
Subcutaneous air and post-surgical change can be seen within the
anterior abdominal wall from recent surgery. There is also soft
tissue anasarca.
CT OF THE PELVIS: A foley catheter seen within the bladder.
There is free fluid within the deep pelvis. Tiny foci of air can
be seen within the subcutaneous tissues in the left groin, and
along the left pelvic sidewall, which may be post-surgical, or
related to air in the right upper quadrant.
BONE WINDOWS: There is diffuse osteopenia, which is stable.
There is sclerosis along the anterior and superior aspects of
the sacroiliac joints, consistent with changes from osteitis
condensans ilii, which are stable.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. There is a large amount of ascites, with loculated appearing
air- containing pocket within the right upper quadrant
laterally, abutting the liver, and centered around the
anastomosis between the ileum and transverse colon.
Additionally, there is a small amount of oral contrast outside
of bowel. These findings are concerning for focal anastomotic
leak.
2. There is also a large amount of ascites remote from this
area, and by report, the patient has had bladder surgery. A
second source of ascitic fluid from a urine leak from the
bladder surgery cannot be excluded.
3. Anasarca.
4. Small bilateral pleural effusions.
5. Surgical changes in the anterior abdominal wall from recent
surgery.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] C.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on SAT [**2180-5-6**]
7:26 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 34389**]
Service: Date: [**2180-5-1**]
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(1) 34390**]
PREOPERATIVE DIAGNOSIS: Perforated viscus.
POSTOPERATIVE DIAGNOSES:
1. Perforated viscus.
2. Breakdown of bladder repair.
OPERATION:
1. Repair of perforated colon anastomosis.
2. Repair of bladder injury.
3. Loop ileostomy.
RESIDENT SURGEON: [**First Name8 (NamePattern2) **] [**Doctor Last Name **], INT
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**], RES
ANESTHESIA: General endotracheal.
HISTORY/INDICATIONS: The patient is an 82-year-old female
who underwent a resection of a large right perforated right
cecal tumor which infiltrated the bladder, 12 days ago. She
represented with signs of sepsis and presumed leak on CT
scan. She was taken to the operating room for treatment of
this.
PREPARATION: After the induction of adequate general
endotracheal anesthesia, the patient was identified and a
timeout was performed. The abdomen was prepped with Betadine
and draped sterilely in the usual fashion.
INCISION: The old incision was opened down to the fascia and
it was extended somewhat medially. The fascia was opened by
cutting the previous sutures.
FINDINGS: There was a lot of purulence and some gas in the
abdomen. There was a lot of free fluid, as well. The colonic
anastomosis had a 1 cm defect in the end. The reason why this
broke down was not immediately clear. The bladder had a 1 cm
defect in it, as well. We had instilled indigo [**Male First Name (un) **] and
this was leaking out of the bladder. Indigo [**Male First Name (un) **] into the
Foley catheter and this was leaking into the bladder.
PROCEDURE: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 34391**] retractor was placed. The anatomy was
clearly identified. The first priority was to deal with the
colonic anastomosis. The area where the perforation was, was
cleaned off and this was repaired with interrupted [**Last Name (un) 34392**]
sutures of 3-0 Nurolon with good supply. The omentum was
freed up and tied down over this anastomosis. Attention was
then directed to the bladder which had about 1/2 cm to 1 cm
defect. This was closed with interrupted 2-0 Vicryl full
thickness sutures and then reinforced with 2-0 Vicryl Lembert
sutures. The areas of contamination were widely irrigated and
the decision was to make a diverting ileostomy. This was
freed up such that there would be no excessive tension. This
was brought out through an opening in the abdominal wall on
the left side which had been previously identified. The loop
of the ileum was placed so that the proximal end was
superior. The ileum was attached to the fascia with 3-0
Vicryl sutures. This was then covered with a moist lap and
the abdomen was closed with #2 retention sutures to the
fascia but not through the skin and then the abdomen was
closed with a running #1 Prolene. The wound was packed with
Kerlix and covered. The ileostomy was opened in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 34393**]
fashion with the electrocautery, everted and sutured in place
with interrupted 3-0
Vicryl such that the distal side was flat and the proximal
side was everted. Ileostomy bag was placed over this and
dressings were placed on the wounds and the patient was
awakened, taken back to the intensive care unit intubated in
guarded condition.
ESTIMATED BLOOD LOSS: 200 cc.
COMPLICATIONS: Injury to the bladder from the sepsis and
right down to the ileocolic anastomosis.
SPECIMENS: Microbiology of the peritoneum.
SPONGE INSTRUMENT AND NEEDLE COUNT: Correct.
Brief Hospital Course:
Mrs. [**Last Name (STitle) 34394**] was admitted to the Surgical Intensive Care Unit
under the care of Dr. [**Last Name (STitle) **]. Following an initial CT scan of the
abdomen which demonstrated ascites and a likely leak at the site
of her ileo-colonic anastomosis, she was volume resuscitated and
antibiotic therapy was initiated. She was taken to the
operating room for exploratory laparotomy, and underwent repair
of an anastomosis leak at the site of her ileo-colonic
anastomosis, repair of a bladder perforation, and creation of a
diverting loop ileostomy (see Operative report for details).
She returned to the ICU post-operatively, was weaned from the
ventilator over the next 24 hours, and extubated successfully.
She initially required pressors for blood pressure support, but
these were weaned successfully as well. Her ileostomy began to
function early in her post-operative course, and her diet was
slowly advanced. Nutrition was consulted early on and she was
started on supplements. She was started on Meropenem and
Caspofungin per ID recommendations for gram negative & positive
organisms identified from abdominal wound culture. MRSA & VRE
were negative. The antibiotics will need to continue until [**5-18**].
She was transferred to the regular nursing unit, where she did
quite well. A wound VAC was placed on her abdominal wound. Her
ostomy output remained high and she was started on Loperamide,
her output remained high. The dose was subsequently increased to
10mg qid of Loperamide; this can be adjusted once her output
decreases. She is also on Metamucil wafers tid. Because of her
high output she has been given IV fluids for replacement; her
labs have been followed closely and her electrolytes have been
stable (see pertinent results). Wound ostomy nurse has followed
her closely throughout her hospital.
A wound VAC remains in place, as well as a JP drain. She will
need to follow up with Dr. [**Last Name (STitle) **] in 1 week in Surgery Clinic.
She will also require follow up with Dr. [**Last Name (STitle) **], Urology, in [**2-5**]
weeks because of her bladder perforation; the 22 Fr Foley will
remain in place until that time.
Physical and Occupational therapy were consulted and have
recommended rehab stay; her family would like to take her home
following her rehab stay.
[**Date Range **] Medications:
1. Miconazole Nitrate 2 % Powder [**Date Range **]: One (1) Appl Topical twice
a day: Apply to affected areas.
2. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO BID
(2 times a day): hold fro SBP <110; HR <60.
3. Amlodipine 5 mg Tablet [**Date Range **]: 0.5 Tablet PO DAILY (Daily): hold
for SBP<110.
4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule [**Date Range **]: One
(1) Cap PO DAILY (Daily).
5. Cyanocobalamin 250 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
6. Quinidine Gluconate 324 mg Tablet Sustained Release [**Date Range **]: One
(1) Tablet Sustained Release PO DAILY (Daily).
7. Enoxaparin 60 mg/0.6 mL Syringe [**Date Range **]: 0.5 ML Subcutaneous Q12H
(every 12 hours).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Psyllium 1.7 g Wafer [**Last Name (STitle) **]: One (1) Wafer PO TID (3 times a
day).
10. Loperamide 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO four times a
day.
11. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: Five Hundred (500) mg
Intravenous every eight (8) hours for 7 days.
12. Caspofungin 50 mg Recon Soln [**Last Name (STitle) **]: Fifty (50) mg Intravenous
Q24H @ 1800 for 7 days.
[**Last Name (STitle) **] Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
[**Hospital6 **] Diagnosis:
Colon Cancer s/p colectomy
Anastomosis leak
Bladder perforation
[**Hospital6 **] Condition:
Stable
[**Hospital6 **] Instructions:
Your antibiotics will continue until [**5-18**].
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week in Surgery Clinic, call
[**Telephone/Fax (1) 6439**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **], Urology in [**2-5**] weeks, call [**Telephone/Fax (1) 164**]
for an appointment.
Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab
(Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 133**]).
Completed by:[**2180-5-16**]
|
[
"998.59",
"401.9",
"997.4",
"995.94",
"584.9",
"263.9",
"V10.05",
"997.5",
"276.51",
"038.9",
"V10.43",
"789.5",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.94",
"38.93",
"46.01",
"57.81"
] |
icd9pcs
|
[
[
[]
]
] |
14116, 18086
|
291, 377
|
1227, 2468
|
18109, 18558
|
1137, 1205
|
6932, 6979
|
234, 253
|
7008, 14093
|
405, 700
|
722, 923
|
939, 1121
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Discharge summary
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report
|
Admission Date: [**2117-7-24**] Discharge Date: [**2117-8-10**]
Date of Birth: [**2043-6-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Respiratory distress, hypotension, acute elevation of cardiac
biomarkers
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Cardiac Catheterization
Trach placement
PEG placement
Arterial Line
PICC placement
History of Present Illness:
74 yo man with PMH significant for severe COPD on home O2, HTN
initially presented to [**Hospital1 **] [**Location (un) 620**] on [**2117-7-23**] with
dyspnea/respiratory distress. Patient called his neighbor, who
called EMS. EMS found him in tripod position, talking in [**2-23**]
word sentences, RR 35-40. He reported having dyspnea for [**1-22**]
hours, but COPD flare for past few days. On arrival vitals were
T 96, HR 179, BP 149/85, RR 30-40, O2 sat 94% on 100% NRB. He
had difficulty talking in sentences and was diaphoretic. He
reported running out of his medications at home. He was
immediately intubated and given nebs, solumedrol 125 mg, IVF,
and Levaquin 750 mg. He was transferred to the ICU. While there,
he was given 5-6 L IVF to support his BP. He was continued on
COPD flare treatment. Patient developed elevated cardiac
biomarkers and hypotension on [**7-24**], and transfer to [**Hospital1 18**] CCU was
coordinated. Heparin gtt was started prior to transfer. Femoral
line was placed in ICU prior to transfer.
.
On route by [**Location (un) **] ground transport, patient had SBP 76.
Received 500cc IVF and propofol was decreased from 30 to 10,
however patient woke up and profolol was increased again. He was
started on Levophed 5 mcg/min, and SBP came up to 100. HR was in
90's. He also received albuterol nebs for wheezing, and Fentanyl
250 mcg. He remained on 100% O2, since sat dropped to 92% when
O2 turned down to 70%.
.
Patient denies any chest pain, abd pain now. [**Month (only) 116**] have had chest
pain at home. Rest of ROS deferred b/c intubated.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (?) Dyslipidemia (?),
Hypertension (+)
2. CARDIAC HISTORY: none known
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
COPD
asthma
gastritis
HTN
Social History:
-Tobacco history: long smoking hx, quit 9 mo ago
-ETOH:
-Illicit drugs:
Family History:
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
Physical Exam:
VS: T=97.4 BP=108/62 HR=90 RR=14 O2 sat= 100%
Vent settings: PS 12, FiO2 40%, TV 450, RR 10 (set), PEEP 8, PIP
22
GENERAL: thin, alert and oriented x 3, interactive
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: thin with JVP <10
CARDIAC: Distant heart sounds, no murmurs
LUNGS: CTAB with poor/moderate air movement
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: Pink area beneath coccyx, L elbow has skin breakdown.
Hematoma on uderside of penis, on scrotum; improving. Ecchymoses
on forearms, abdomen from IV lines/SC heparin injections.
PULSES:
Right:DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS ([**2117-7-24**]) 5:00 PM
13.5
22.9>--< 193
41.3
N:94.4 L:2.9 M:2.1 E:0.4 Bas:0.1
.
142 | 112 | 19 / 141 AGap=17
5.2 | 18 | 1.1\
Ca: 8.5 Mg: 2.5 P: 3.4
.
6:30 PM pH 7.26 pCO2 48 pO2 252 HCO3 23 BaseXS -5
Lactate:2.4
.
Max enzymes [**2117-7-24**]: CK: 626 MB: 33 Trop-T: 0.51
enzymes [**2117-7-26**]: CK 11 MB 3.3 trop-T 0.15
[**2117-7-28**]: Trop-T 0.04
.
ALT: 22 AP: 77 Tbili: 0.5 Alb: 3.5
AST: 43 LDH: 344
.
PT: 15.4 PTT: >150 INR: 1.3
Coags on [**2117-8-6**]: PT:13.2 PTT:47.2 INR:1.1
.
Labs:
[**2117-8-9**]:
Hct: 25.8 (up from 21.5 after 1 unit PRBCs on [**2117-8-9**] am)
ABG: 7.41/53/355/35
Chem 7: Na 142, K 3.6, Cl 103, HCO3 37, BUN 19, Cr 0.8 Glucose
145
Reticulocyte ct:1.6
.
EKG ([**2117-7-23**]) sinus tachy at rate 140, w/ PAB's
[**2117-7-24**]: 1st degree AV block, rate 100, rightward axis, low
voltages, Q waves in II, III, aVF (unchanged from prior), new
0.5 mm STe in I, avF, V4 and V5, and TwI in V4-V5, poor R wave
progression.
.
CXR ([**2117-7-23**]): No cardiopulmonary abnormality. ET tube in place.
[**2117-7-24**]: hyperinflated lungs, no e/o pulmonary edema/congestion,
no cardiomegaly
.
CXR on [**2117-8-9**]:
FINDINGS: As compared to the previous radiograph on [**2117-8-8**],
the course of the right-sided PICC line and tracheostomy tube
are in unchanged position. No evidence of changes in the lung
parenchyma. There is unchanged massive overinflation with
bilateral pleural and parenchymal scars. No evidence of
overhydration. No newly occurred focal parenchymal opacity
suggestive of pneumonia.
.
2D-ECHOCARDIOGRAM ([**2117-7-24**]): EF 30-35%, good movement of base
with diffuse hypokinesis of left ventricle from mid-section to
apex. RV with good basal motion, hypokinesis of apex. Mild TR,
no pericardial effusion.
.
Cardiac catheterization ([**2117-7-28**]):
1. Coronary angiography in the right dominant system demonstrate
no
coronary artery disease. The LMCA had no angriographically
apparent
disease. The LAD had no angiographically apparent disease. The
Cx had no
angiographically apparent disiease. The RCA has no
angiograpgically
apparent disease.
2. Resting hemodynamics revealed normal right and left sided
filling
pressures (RA pressure had A wave of 13 mmHg and v wave of 12
mmHg). The
cardiac index was elevated at 6.0. The wedge pressure was 14
mmHg.
Aortic pressure were 116/ 69 mmHg with mean of 91 mmHg.
.
Echocardiogram ([**2117-7-29**]):
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 10-15mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is very mild
regional left ventricular systolic dysfunction with distal
apical hypokinesis. Overall left ventricular systolic function
is normal (LVEF>55%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated
with normal free wall contractility. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
Compared with the prior study (images reviewed) of [**2117-7-24**], the
left ventricular has significantly improved with very minor
residue apical hypokinesis. Severe pulmonary artery systolic
hypertension is now detected.
.
DEFERRED SWALLOWING EVALUATION ([**2117-8-9**]):
He has h/o severe COPD and is still recovering from a recent
ventilator-associated pneumonia. Trach collar was attempted x2
over the weekend with poor tolerance and long recovery period
afterwards. Today pt remains on relatively high vent settings.
He has not tolerated trach collar and per discussion with RT, is
not likely to tolerate cuff deflation for PMV on the vent or for
swallow evaluation. In addition, given pt's severe lung
disease, and recovering PNA, he likely has low tolerance for
even a small
amount of aspiration. As such, swallowing evaluation is
deferred.
.
Brief Hospital Course:
Mr. [**Known lastname **] is a 74 yo M w/ PMHx HTN, COPD presents with
respiratory failure, now transferred from [**Hospital1 **] [**Location (un) 620**] with
respiratory failure s/p intubation, elevated cardiac enzymes,
and hypotension requiring pressors.
.
# Respiratory failure/COPD: Patient has baseline severe COPD on
home O2, with huge hyperinflation on CXR, presenting symptoms
consistent with a COPD flare (tripod position, wheezing) and
reported not taking meds at home. Patient arrived intubated
from outside hospital. There was no evidence of PNA on CXR and
patient was afebrile, though patient still received 5 days of
empiric levofloxacin for COPD flare. Patient started on
albuterol and combivent inhalers, though his lungs were
generally clear to auscultation. Initial ABG showed pH 7.16
pCO2 58 pO2 160 HCO3 22, which improved quickly with pressure
support ventilation. Patient was then stable but was very
uncomfortable and agitated on pressure-support.
Patient's first extubation attempt was [**7-26**], when he was
actively following commands and had a good gag relex. However,
after 1.5 hours he became tachypnic, fatigued, and desaturated
on BiPap with an ABG of pH 7.27 pCO2 54 pO2 428 HCO3 26, with
BPs in the 140s-170s. He was reintubated until [**7-30**], when he
was extubated a second time with his BPs controlled by a nipride
gtt and after a trial of [**5-25**] pressure support. After 80 minutes,
he was reintubated given severely increased work of breathing
and imminent respiratory fatigue. At this point, it was
discussed with him and his family that he would most likely
require prolonged ventilatory support, and both tracheostomy and
PEG-tube placement should be considered. He was initially
reluctant, but agreed [**7-31**]. Due to continued sedation, consent
obtained from brother who was involved in decision-making.
During this period, pt began having low-grade fevers (100's up
to 101.0 F), and increased tan-brownish secretions, and was
requiring more sedation due to increased agitation. Sputum Cx
sent for analysis, and pt started on Cefepime/Vancomycin for
empiric coverage of Ventilator-associated pneumonia. Sputum cx
grew out MSSA, and Abx regimen changed to Cefepime + Nafcillin,
for a total of 8 days of abx. Pt improved rapidly. Pt underwent
procedure for Tracheostomy/PEG tube placement on [**2117-8-6**],
without complications. Pt. tolerated procedure well.
Additionally, pt's Hct has been steadily decreasing since
admission with negative guaiac and no evidence of bleeding. Was
transfused 1 unit PRBCs on [**2117-8-9**] when Hct was at 21.5. Pt
experienced episode of respiratory distress after 15 minutes of
infusion; unclear whether secondary to transfusion-induced
bronchospasm, increased movement of pt (which he tolerates
poorly), or anxiety. Pt given Ativan, increased venilation
support, and albuterol nebs, with good improvement. At this time
patient stable on Pressure support, Fi02=40%, PS=12, PEEP=8,
RR=22. Per discussion with patient he has been changed to DNR/Do
Not Reintubate.
.
# CORONARIES: Patient's initial picture was most consistent
with an NSTEMI. He has no known cardiac history, risk factors
include smoking and HTN. EKG had changes that did not meet
STEMI criteria, and enzymes peaked at CK-MB of 33 and Trop 0.55.
Patient was started on an ACS protocol, w/ ASA 325mg, Plavix
75mg (after load), heparin gtt and simvastatin 80mg. The patient
denied chest pain, but echo showed hypokinesis in all areas
except for the base and an LVEF 30-35%, though not consistent
with territory of EKG changes. After the patient failed
extubation [**7-26**], it was felt that coronary ischemia may be
contributing to his respiratory failure, and the patient went to
catheterization [**7-27**]. Cath showed clean coronaries and normal
filling pressures, and repeat echocardiography [**7-29**] showed
markedly improved heart function, with LVEF >55%. This change
suggests that the initial ECG results were stress/demand, and
not ischemia, mediated.
.
# PUMP: Initial echo showed EF of 30%, though patient appeared
euvolemic on exam and had no pulmonary edema on CXR. After five
days of ventilatory support, repeat echo [**7-29**] showed EF of 55%.
Patient remained euvolemic on exam throughout his stay. Initial
echo result may have been due to poor-quality images, making
assessment difficult, or possibly Takasubo's which has since
resolved.
.
# RHYTHM: Patient initally had sinus tachycardia with 1st degree
heart block. While monitored on tele he had some atrial ectopy
and his heart block improved. He was started on metoprolol 25mg
TID with good control of his tachycardia except when agitated;
Metoprolol was discontinued [**2117-8-7**] due to lack of HTN,
tachycardia.
.
# Hypotension: Patient arrived on Levophed after receiving 5-6L
fluid bolus at outside hospital. Hypotension attributed to
cardiogenic shock and vasodilation by sedative drugs. He had no
obvious cause of sepsis, UA WNL, CXR clear. An arterial line was
placed, sedation was changed from propofol to Versed/Fentanyl
and patient was weaned off Levophed. His pressures were
extremely labile, ranging from SBPs in the 90s while sleeping to
150/160s when agitated. He tolerated addition of Metoprolol
25mg TID and Lisinopril 10mg Daily, though these doses could not
be increased because of relative hypotension while sleeping.
After trach placement, pt's BP and HR stablized, and both
Captopril and Metoprolol were discontinued.
.
#ANXIETY: Pt has h/o anxiety disorder, unclear diagnosis, but
had been on antidepressants for a short time 1 yr ago. He was
quite agitated and had very labile BPs and HR when not heavily
sedated on the ventilator, which improved with Ativan boluses.
He continues to get anxious at mild pertubation of respiratory
status, which likely has contributed to respiratory distress. He
responds very well to 0.5mg IV boluses of Ativan PRN.
.
# Acid-base disturbance: Patient initially presented in
respiratory acidosis which improved rapidly with mechanical
ventilation. He was slightly alkalotic at times, but was kept
slightly acidotic to maximize respiratory drive.
.
# Code Status: Pt was not able to communicate needs initially
during hospital admission due to respiratory
distress/intubation. However, after Trach placement, pt was able
to communicate desires for care. He wishes to be Do Not
Resuscitate/Do Not Reintubate. He does not want to live on a
ventilator for a prolonged period of time, but feels it is
acceptible if he is ultimately able to be weaned from the
ventilator.
.
# Skin care: possible developing ulcer below coccyx, managed
with frequent repositioning and monitoring.
.
FEN: Maintained on tube feeds of fibersource HN full strength,
mostly at night to allow possibility of extubation during the
day.
.
COMM: with brother - [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 83344**] (c) and mother
[**Telephone/Fax (1) 83345**] (H).
Medications on Admission:
Home:
Combivent (Albuterol +Ipratropium) 1 puff QID last filled
[**2117-7-6**]
Advair (Fluticasone + Salmeterol)2 puffs [**Hospital1 **] last filled [**2117-7-8**]
Flovent HFA last filled [**2116-12-2**]
Inactive meds:
Clonazepam 0.5mg PO BID PRN last filled [**6-/2116**]
Mirtazepine 15mg PO q day last filled [**2116-7-10**]
.
On transfer:
heparin gtt at 700 units/hr (started at 3:15pm w/ bolus of 2800
units)
ASA 81 mg x 2
famotidine 20 mg IV q12h
heparin SC TID
metoprolol 12.5 mg q6h
levofloxacin 500mg IV daily
lorazepam 2 mg IV prn
methylprednisolone 125 mg IV q8h
fentanyl boluses
insulin SS
NS at 100cc/hr
Combivent nebs q3h
propofol at 20/hr
Levophed at .09 mcg/hr
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Day/Year **]: [**6-28**]
Puffs Inhalation Q6H (every 6 hours).
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (3) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
6-10 Puffs Inhalation Q2H (every 2 hours) as needed for
wheezing.
4. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day) as needed for constipation.
6. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection [**Hospital1 **] (2 times a day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Prednisone 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily) for 2 days: Last dose 30mg on [**8-12**]. .
10. Prednisone 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily)
for 4 days: Start: [**8-13**]
Stop: [**8-16**].
11. Prednisone 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily)
for 4 days: Start [**8-17**]
Stop [**8-20**].
12. Prednisone 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily)
for 4 days: Start: [**8-21**]
Stop: [**8-24**].
13. Simvastatin 10 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO DAILY
(Daily).
14. Prochlorperazine Maleate 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
15. Bisacodyl 10 mg Suppository [**Month/Day (4) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for for constipation.
16. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Month/Day (4) **]: One (1)
PO DAILY (Daily).
17. Acetaminophen 160 mg/5 mL Solution [**Month/Day (4) **]: Two (2) PO Q6H
(every 6 hours) as needed for Pain.
18. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Month/Day (4) **]:
Four (4) Puff Inhalation [**Hospital1 **] (2 times a day) as needed for
wheeze.
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
20. 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.
21. 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.
22. Ondansetron 2-4 mg IV Q4H:PRN NAUSEA
23. Lorazepam 0.5 mg IV Q4H:PRN agitation
Hold for sedation, RR<12
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: COPD exacerbation
Secondary:
Ventilator Associated Pneumonia
Anxiety
Steroid Induced Hyperglycemia
Anemia
Discharge Condition:
stable. afebrile. Ventilator dependent.
PEG in place. PICC in place.
Patient is now DNR/Do Not Reintubate
Discharge Instructions:
You were admitted to [**Hospital3 **] [**Location (un) 620**] on [**2117-7-23**] with
shortness ob breath and respiratory distress. At [**Hospital1 **] [**Location (un) 620**] you
were intubated and found to have elevated cardiac enzymes (a
marker of cardiac injury). Your were transported to [**Hospital1 **]. Here we performed a cardiac catheterization which
showed no coronary artery disease. We also performed two echos
(ultrasound of the heart). The first showed possible decrease in
heart pump function, however the repeat ECHO showed preserved
cardiac function. With evidence that your heart was functioning
normally we believe this shortness of breath was caused by a
COPD exacerbation. You continued to be intubated and
unfortunatley failed extubation trials. During your hospital
course you also developed a ventilator associated pneumonia
which was treated with antibiotics. Trach and PEG were placed in
preperation for continued respritory/nutritional support during
the ventilator weaning process.
Please follow up with pulmonology on [**9-15**]. Please see the
list of discharge medications for most up to date list of
medications.
Please return to the hospital if you develop chest pain,
increased severe shortness of breath, fever, abdominal pain,
nausea, vomiting, changes in vision, or dizziness.
Followup Instructions:
Pulmonology: Please follow up with Pulmonology. Please arrive at
7:30 for 8:00 am appointment. [**9-15**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2168**].
[**Hospital Ward Name 23**] building [**Location (un) 436**], Medical specialties.
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2117-9-15**]
7:40
PFT,INTERPRET W/LAB NO CHECK-IN PFT INTEPRETATION BILLING
Date/Time:[**2117-9-15**] 8:00
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2117-9-15**] 8:00
PCP: [**Name10 (NameIs) 357**] have patient follow up with PCP after discharge from
extended care facility. Dr. [**Last Name (STitle) **] [**Name (STitle) 59771**] ([**Telephone/Fax (1) 59772**].
Provider:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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27,228
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5988
|
Discharge summary
|
report
|
Admission Date: [**2198-7-18**] Discharge Date: [**2198-7-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Diziness
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation.
Implantation of a Permanent Pace Maker
History of Present Illness:
86 yo female with hx of CAD s/p CABG, DMII, HTN, and tachy/brady
syndrome who presents with bradycardia and diziness. Pt was
recently admitted [**Date range (1) 23590**] for episode of diziness. During that
hospitalization she was started on meclizine for vertigo and
evaluated by EP for tachy/brady syndrome and started on
amiodarone and decreased dose of atenolol. Per notes she was not
feeling well at home with increasing diziness and slow heart
rate. She was seen by her PCP today and found to have sinus
bradycardia in the 40-50 range with nl SBP. She had associated
diziness and diaphoresis, but no chest pain, chest tightness or
palpitations. Her daughter attempted to send her to the [**Name (NI) **] but
she refused. Her PCP decreased her atenolol dose to 50mg with
plan for follow-up with cardiology.
.
In the ED her HR was unclear heart block vs sinus bradycardia
with a faster junctional escape at 30bpm and SBP in the 80's.
She was given 0.5mg atropine started on peripheral dopamine with
only mild improvement in her BP and HR. Attempt was made to
place a central line and the pt exhibited signs of choking with
hypoxia so decision was made for intubation and she was given
succinocholine and etomodate for rapid sequence intubation and
given a dose of 20mg IV lasix due to signs of CHF on repeat CXR.
Due to poor response to atropine, a temporary pacing wire was
placed through a right IJ cordis, but the patient began to mount
an intrinsic escape HR of >60 at that point. Due to continued
difficulty with sedation throughout the procedure she recieved
versed 5mg x2, 2mgx1, fentanyl 100mcgx1 and another undocumented
dose of Versed. BP again remained low after pt appropriately
paced at 80bpm and required 20mc/kg/min of dopamine to maintain
MAP >65.
Past Medical History:
1. Diabetes mellitus
2. Hypertension.
3. Hyperlipidemia.
4. Coronary artery disease s/p 3V CABG ?[**2184**]
5. GERD.
6. Diastolic CHF
7. Frequent UTIs.
8. Chronic renal failure (baseline Cr 1.3-1.7)
9. Cataracts
10. CVA
[**02**]. Vertigo, shaking spells
Social History:
Patient goes to Golden Care Chinese Adult Day Center where
patient goes for 7 hours everyday for 5 days a week. Lives
alone, independent with ADLs, has 4 children who visit every
other day. No smoking, etoh, drugs.
Family History:
non-contributory
Physical Exam:
VS: T 99.0 BP 155/85 HR 80 Vent at AC 550/16 Peep 5 FiO2 50% sat
99%
Gen: elderlh female intubated and sedated.
ENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
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. vented breath sounds
bilat
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission ECG: Probable junctional rhythm, rate 32
Postpacer ECG: Pacemaker rhythm, rate 80. Since previous tracing
the pacemaker rhythm is new
.
Admission Labs:
136 103 35
--------------< 348
5.3 21 2.3
CK: 203 MB: 9 Trop-T: 0.11
Ca: 9.0 Mg: 2.7 P: 4.7
.
12.2
7.0 >----< 195
34
N:70.9 L:21.3 M:5.2 E:2.3 Bas:0.3
.
PT: 10.9 PTT: 30.2 INR: 0.9
.
Trends/Misc:
Discharge CBC: WBC-8.4 RBC-3.16* Hgb-10.3* Hct-30.5* MCV-97
MCH-32.6* MCHC-33.7 RDW-13.1 Plt Ct-144*
Discharge lytes: Glucose-184* UreaN-22* Creat-1.4* Na-141 K-4.5
Cl-111* HCO3-24 AnGap-11
CK: 203-196
MB [**10-5**]
Trop 0.11-0.05
Lactate 1.2
TSH 3.8
.
[**2198-7-17**] Chest x-ray
IMPRESSION: No consolidation.
.
[**2198-7-18**] Chest x-ray 12:30am
IMPRESSION: Findings consistent with worsening failure.
.
[**2198-7-18**] Chest x-ray 11:40am
A permanent pacemaker has been placed with leads overlying
expected location of the right atrium and right ventricle, with
no evidence of pneumothorax. Right-sided temporary pacing lead
has been removed with residual vascular sheath remaining in
place. Minor left basilar atelectasis has developed. No
additional changes are evident compared to the recent chest
radiograph.
.
[**2198-7-18**] 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%). 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. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
Micro: Urine cx enterococcos. [**Last Name (un) 36**] pending
Brief Hospital Course:
Pt is a 86 yo female with history of coronary artery disease s/p
CABG, DMII, HTN, and tachy/brady syndrome who presented with
bradycardia and dizziness. Hospital course by problem:
.
#) Rhythm: Bradycardia likely due to tachy/brady syndrome and
exacerbated by combination of renal insufficiency, atenolol
acumulation and amiodarone use. A temporary pacing wire was
placed on the day of admission. A permanent pacemaker was
placed on the second day of admission. Amiodarone and atenolol
were intially held. After the pacemaker was placed the patient
was started on Toprol XL and amiodarone. The atenolol was not
continued. The patient should followup with EP as instructed.
.
#) CAD: Pt has known history of CAD with mild elevation in
troponin in the setting of ARF and possible new ECG changes of
inf TWI. We continued the patient's aspirin and statin but held
her B-blockade as the patient was likely presenting with
atenolol toxicity. The ACEI was held in the setting of acute
renal failure. It was restarted upon discharge. Per
presentation was thought not to be [**3-2**] ischemia.
.
#) Pump: Pt SOB likely mulifactorial but some component of
cardiogenic shock from bradycardia. An echo revealed fairly
normal pump function with LVEF of >55%. The patient was
intially on dopamine in the setting of hypotension, that was
likely caused by oversedation during intubation. The dopamine
was easily weened on the second day of admission.
.
#) Respiratory failure: The patient was intubated to protect
her airway in the setting of respiratory distress asociated with
placement of the temp wire. The patient has no known intrinsic
lung disease and so was easily extubatable on the second day of
admission.
.
#) Hyperlipidemia: Continued on out patient ezetimibe and
lipitor.
.
#) DM: We held the patient's sulfonylureas and covered her with
glargine 5u qhs and a humalog SS.
Medications on Admission:
1. Aspirin 81 mg qd
2. Glipizide 10mg qam
3. Glipizide 10mg qpm
4. Losartan 50mg qd
5. Quinine Sulfate 324 mg qhs
6. Ezetimibe 10 mg qd
7. Atorvastatin 40 mg qd
8. Atenolol 75 mg qd
9. Meclizine 12.5 mg tid
10. Amiodarone 200 mg qd
12. Omeprazole 40 mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO at
bedtime.
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Atrial Fibrillation complicated by Tachy/Brady syndrome with
symptomatic bradycardia
-respiratory failure [**3-2**] procedure, easily weaned off ventilator
-s/p pacer placement
-acute renal failure, improved
.
Secondary:
Diabetes mellitus
Hypertension
Hyperlipidemia
Coronary artery disease s/p 3V CABG
GERD
Diastolic CHF
Frequent UTIs
Chronic renal failure (baseline Cr 1.3-1.7)
Cataracts
CVA
Vertigo, shaking spells
Discharge Condition:
Ambulating, tolerating POs
Discharge Instructions:
You were admitted with a slow heart rate. You had a pacemaker
placed and your heart rate improved. You were intubated in the
setting of the pacer placement but were easily extubated. Some
of your medications were adjusted.
.
Please take all medications as prescribed. Please attend all
follow up appointments. If you develop palpitations, shortness
of breath, chest pain, or loose consciousness, please contact
your health care providers or return to the emergency
department.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2198-7-26**]
3:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2198-8-7**] 1:30 - This is a nurse practitioner who works
with your PCP.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2198-10-11**]
10:00
|
[
"458.29",
"403.90",
"530.81",
"427.81",
"428.30",
"250.00",
"V45.81",
"972.0",
"272.4",
"518.5",
"585.9",
"584.9",
"E858.3",
"414.01",
"785.51",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"88.72",
"96.71",
"96.04",
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
8512, 8518
|
5519, 5673
|
270, 350
|
9001, 9030
|
3437, 3583
|
9558, 10032
|
2675, 2693
|
7713, 8489
|
8539, 8980
|
7432, 7690
|
9054, 9535
|
2708, 3418
|
222, 232
|
5701, 7406
|
378, 2148
|
3599, 5496
|
2170, 2426
|
2442, 2659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,866
| 108,438
|
26393
|
Discharge summary
|
report
|
Admission Date: [**2115-8-2**] Discharge Date: [**2115-8-10**]
Date of Birth: [**2054-6-13**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
# SOB
Major Surgical or Invasive Procedure:
Hemodialysis x4
History of Present Illness:
61F ESRD s/p L arm HD fistula placement ([**2115-5-29**]), pending
possible HD initiation (not anuric), admitted with increasing
SOB and BLE edema x 3-4d. On the night of admission, pt had
called EMS after noting increasing SOB while lying in bed. Per
report, pt's initial BP=226/94, with SaO2 100/CPAP. Of note, pt
had been recently admitted [**3-25**] with RLL MSSA PNA c/b MSSA
bacteremia.
.
ED course:
# Meds: Nitroglycerin gtt, furosemide 100mg IV x 1, levofloxacin
PO x 1 dose
# Studies: CXR demonstrated edema and ?LLL PNA
# Clinical: Weaned from CPAP to 3L
# Consults: Renal indicated no acute indication for HD.
.
ROS on admission:
(+) As above
(-) Dietary indiscretion, medication non-compliance, UOP decline
.
ROS on floor transfer: Pt stated that she felt "good."
(-) SOB, abdominal pain, chest pain
Past Medical History:
# CV
-CAD s/p cath ([**8-24**]): Mild epicardial disease, collalateral
flow to distal inferior wall, no intervention
-HTN
-Hyperlipidemia
.
# Endo
-DM2
--Neuropathy
--Nephropathy
--Retinopathy
.
# GU
-Chronic kidney disease (stage IV)
.
# Neuro
-Stroke
-Impaired memory s/p MVA
.
# Heme
-Anemia
Social History:
# Alcohol: Never
# Tobacco: Never
# Recreational drugs: Never
Family History:
# F, d70s: Heart disease
# Siblings (two sisters): DM2
Physical Exam:
PE on MICU admission:
.
VS: T 97.1, BP 184/72, HR 85, R 21, SaO2 98/3L
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, no
carotid bruits. 8-10 cm JVD.
CV: Regular, nl s1, s2, no m/r, +s4.
PULM: Crackles bilaterally, no r/w.
ABD: Soft, NT, ND, + BS, no HSM. well healed midline gallston
scar.
EXT: Warm, 2+ DP/radial pulses BL, 1+ B LE edema. L UE fistula
+thrill.
NEURO: Alert & oriented x 3, CN II-XII grossly intact. [**3-23**]
strength symmetric @ triceps, biceps, delts, hip flexion,
dorsoflexion, plantarflexion. Sensation grossly intact.
.
PE on floor transfer:
VS: Tm 97, Tc 97, HR 68-76, BP 139-163/47-74, R 13-21, SpO2
98/RA-100/RA
.
Gen: Sleeping, NAD
HEENT: NCAT, no LAD, no JVD, CN II-XII grossly intact
CV: RRR, S1S2, no m/r/g noted
Chest: CTAB
Abd: Soft, NTND, BS+, large pannus
Ext: No c/c/e
Neuro: Nonfocal
Pertinent Results:
Admission labs of note:
.
[**2115-8-2**] 04:50AM GLUCOSE-351* UREA N-60* CREAT-4.3* SODIUM-134
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-19* ANION GAP-19
[**2115-8-2**] 04:56AM LACTATE-1.0
[**2115-8-2**] 09:11AM CK-MB-5 cTropnT-0.03*
[**2115-8-2**] 09:11AM CK(CPK)-179*
[**2115-8-2**] 11:15AM %HbA1c-8.5*
[**2115-8-2**] 04:50AM WBC-10.0 RBC-4.12* HGB-12.2 HCT-37.4 MCV-91
MCH-29.6 MCHC-32.7 RDW-13.9
.
=========================================
Studies of note:
.
# CHEST (PA & LAT) [**2115-8-2**] 1:31 PM
1. Interval improvement of bilateral pleural effusions, now
moderate to large on left and moderate on right.
2. Interval progression of congestive heart failure.
.
# CHEST (PORTABLE AP) [**2115-8-2**] 4:26 AM
1. Probably large, layering bilateral pleural effusions with
upper zone vascular redistribution suggestive of pulmonary
edema.
2. Dense opacification of the retrocardiac left lower lobe.
While this could represent atelectasis in the context of pleural
effusion, pneumonia cannot be excluded.
.
# ECG Study Date of [**2115-8-2**] 4:38:22 AM
Sinus rhythm. Within normal limits. Compared to the previous
tracing of [**2115-5-27**] no significant diagnostic change.
.
# CHEST (PORTABLE AP) [**2115-8-3**] 3:34 AM
IMPRESSION: Improving interstitial pulmonary edema with
persistent bilateral pleural effusions.
Brief Hospital Course:
61F h/o ESRD [**12-21**] DM2 not yet on HD, presented with increased
SOB, BLE edema, and hypertensive urgency [**12-21**] CHF.
.
# SOB: Pt's SOB was considered likely [**12-21**] either to pulmonary
edema [**12-21**] either ESRD vs PNA per CXR. After receiving one
empirically dose of levofloxacin, pt was diuresed in the ED with
furosemide 100mg IV, leading to UOP 650cc and marked improvement
of SOB. Levofloxacin was stopped and pt was continued on
furosemide 100mg IV PRN for a diuresis goal of 2L in the MICU.
Upon transfer to the floor, pt had SpO2=100/RA and continued to
be monitored for respiratory status. Pt was changed to
furosemide PO. After starting HD, pt was d/c'd without
furosemide and had ambulatory SaO2 = 97%.
.
# HTN: Pt reported baseline SBP=170s, but was found to have
SBP=240s on admit. Pt was therefore placed on a nitroglycerin
gtt, with Toprol XL increased to 300mg daily and amlodipine
increased to 10mg PO daily. As volume overload was considered
the likely primary cause of pt's HTN, pt was diuresed with
furosemide IV with good effect. Pt was also started on
minoxidil 5 mg PO daily for improved SBP control. Upon transfer
to the floor, pt had SBP=139-163, and continued to be monitored
for BP control. After beginning HD, however, pt's BPs
normalized and she was discharged with only Toprol XL 150mg
daily.
.
# ESRD: Pt had ESRD but had not been started on HD. Renal was
consulted and initially determined there was no acute indication
for HD. Pt was therefore continued on her home regimen of
calcitriol and darbepoetin alfa. However, pt was noted to have
persistent nausea and vomiting from uremia, and therefore was
ultimately started on HD. Pt was discharged with sevelamer
800mg TID with meals and nephrocaps 1 cap daily.
.
# DM2: On admission, pt did not know her home insulin regimen,
and HbA1c = 8.5%. The insulin regimen from pt's prior discharge
summary was therefore applied, using insulin 70/30 29 units QAM,
10 units QPM, and HISS. While on this previous fixed dose
regimen, however, pt experienced one episode of hypoglycemia
while on the floor, with BG to 40s. Pt's insulin needs were
therefore calculated after placing her only on humalog sliding
scale, and pt was discharged on NPH 10 units at breakfast and
NPH 6 units at dinner.
.
# CAD: Pt ruled out for MI, with negative CE x3 and EKG
demonstrating no acute changes. Pt was continued on her home
regimen of ASA. Toprol XL was increased from her original home
regimen of 200mg daily to 300mg daily, with improved SBP
control. After beginning HD, pt was discharged on a reduced
dose of Toprol XL 150mg daily.
.
# LFTs: To be screened for outpatient HD placement, laboratories
were drawn to assess LFTs and hepatitis serologies. Pt was
negative for HBV and HCV infection, but ALT and alk phos were
found to be slightly elevated. This could be due to congestive
hepatopathy. Pt was informed that it may be useful to follow up
on these LFTs (if they persist to be abnormal) by liver
ultrasound as an outpatient.
# Full code
Medications on Admission:
# Amlodipine 10mg PO daily
# Calcitriol 0.25mg QOD/ 0.50mg QOD
# Toprol XL 200mg PO daily
# Insulin: Pt did not know regimen
# ASA 325mg po qdaily
# Darbepoetin alfa 25mcg/0.42ml Syringe, 1 injection daily
# Tums
# MVI
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Humalog insulin sliding scale
121-160mg/dL: Breakfast 2 Units; Lunch 2 Units; Dinner 2 Units;
Bedtime 2 Units
161-200mg/dL: Breakfast 4 Units; Lunch 4 Units; Dinner 4
Units; Bedtime 4 Units
201-240mg/dL: Breakfast 6 Units; Lunch 6 Units; Dinner 6 Units;
Bedtime 6 Units
241-280mg/dL: Breakfast 8 Units; Lunch 8 Units; Dinner 8 Units;
Bedtime 8 Units
281-320mg/dL: Breakfast 10 Units; Lunch 10 Units; Dinner 10
Units; Bedtime 10 Units
321-360mg/dL: Breakfast 12 Units; Lunch 12 Units; Dinner 12
Units; Bedtime 12 Units
361-400mg/dL: Breakfast 14 Units; Lunch 14 Units; Dinner 14
Units; Bedtime 14 Units
>400mg/dL: CALL YOUR PRIMARY CARE DOCTOR AND GO TO THE EMERGENCY
[**Apartment Address(1) 65274**]. Outpatient Lab Work
Please check chem 10 on [**Last Name (LF) 2974**], [**8-16**], and fax to Dr. [**Name (NI) 12492**] office at fax [**Telephone/Fax (1) 434**]
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: One (1) bottle Subcutaneous as directed: please inject 10
units at breakfast and 6 units at dinner time. .
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis
# Congestive heart failure [**12-21**] pulmonary hypertension
# Hypertensive, malignant
# Diabetes mellitus type 2, with complications uncontrolled.
# Chronic kidney disease stage 5
# Initiation of hemodialysis
.
Secondary diagnosis
# Hyperlipidemia
# Coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
You came to the hospital because you were short of breath. We
found that you had too much fluid in your body, you had very
high blood sugars and you had a very high blood pressure. We
gave you medications to make you urinate, we gave you blood
pressure medications, and we gave you insulin.
.
We ***CHANGED*** your medications:
.
THIS IS THE NEW INSULIN YOU SHOULD TAKE:
# For your blood sugar:
---Insulin 70/30 10 units when you are eating breakfast
---Insulin 70/30 6 units when you are eating dinner
---WRITE DOWN YOUR SUGARS EVERY FOUR HOURS. BRING THIS TO YOUR
APPOINTMENT WITH DR.[**Doctor Last Name **] OFFICE on MONDAY!
-Please follow the insulin sliding scale attached
.
# For your kidney
---Nephrocaps 1 capsule daily
---Sevelamer 800 mg three times daily with meals
.
For your blood pressure:
-Toprol XL 150mg daily
You should no longer take the amlodipine that you were taking
before you came into the hospital.
Please take the rest of your medications as usual until you see
your primary care doctor.
.
You have several follow-up appointments. See below.
.
If you have fevers, chills, nausea, vomiting, chest pain, or
shortness of breath, call your primary care doctor immediately
and go to the emergency room.
Followup Instructions:
You have the following appointments:
.
YOUR KIDNEY (Nurse [**Last Name (un) **] is part of Dr.[**Name (NI) 9920**] nephrology
team): THIS IS VERY IMPORTANT!
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2115-8-12**] 5:00
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2115-8-15**] 10:00
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2115-10-23**] 11:00
Completed by:[**2115-8-19**]
|
[
"250.60",
"428.0",
"285.21",
"584.9",
"362.01",
"272.4",
"585.5",
"250.80",
"250.40",
"357.2",
"403.01",
"250.50",
"416.8",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8967, 9025
|
3857, 6902
|
283, 301
|
9362, 9371
|
2502, 3834
|
10647, 11274
|
1560, 1616
|
7171, 8944
|
9046, 9341
|
6928, 7148
|
9395, 10624
|
1631, 2483
|
238, 245
|
329, 959
|
973, 1146
|
1168, 1464
|
1480, 1544
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,799
| 138,881
|
30056
|
Discharge summary
|
report
|
Admission Date: [**2151-9-15**] Discharge Date: [**2151-9-23**]
Date of Birth: [**2078-9-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Metastatic HCC, with lesion to T6
Major Surgical or Invasive Procedure:
[**9-15**]:T6 lateral extravaciatry vertebrectomy, T1-10 fusion, ICBG
transfusions
History of Present Illness:
73M with know history of HCC presents for elective vertebrectomy
and fusion after XRT to presumed metastatic lesion to T6.
Past Medical History:
Metastatic HCC(Stge IV), T6 lesion s/p XRT, HTN, Asthma, COPD,
s/p brachy therapy(07)
Social History:
married, retired liquor salesman. quit tobacco, no etoh in 20
years.
Family History:
non-contributory
Physical Exam:
General chronically ill appearing
Mental/Psychological alert
Airway Mallampati [Class III]
Mouth Opening [Marginal (2-3 cm)]
Thyromental Distance [>6 cm]
Mandibular Prognatism [Limited]
Dental Other (upper front bridge)
Head/Neck Range of Motion Limited
Heart rrr
Lungs Moderate wheezing
Other (insp/exp wheezes)
Abdomen soft nt
Extremities no ankle edema
Other neck supple, no cerv lad, no carotid bruits
neuro:motor [**6-1**]
sensation intact LT
On Discharge:
Awake, alert, NAD. Incision clean and dry without erythema,
dishiscence, or collection. Staples in place. MAE with 5/5
strength and good sensation. He has clonus on the left. Pitting
edema at UE's and LE's improved.
Pertinent Results:
Labs:
[**2151-9-15**] 11:12AM GLUCOSE-121* LACTATE-1.3 NA+-131* K+-3.3*
CL--94*
[**2151-9-15**] 11:12AM HGB-11.6* calcHCT-35 O2 SAT-98
[**2151-9-15**] 07:00PM WBC-8.0 RBC-3.15* HGB-10.3* HCT-28.3* MCV-90#
MCH-32.6* MCHC-36.3* RDW-17.2*
[**2151-9-15**] 07:00PM PLT COUNT-235
[**2151-9-15**] 07:00PM PT-13.9* PTT-36.2* INR(PT)-1.2*
--------------
IMAGING:
[**9-15**] Thoracic CT:Multilevel metastatic disease, affecting the
left side of the T6 vertebral body, causing significant left
side neural foraminal narrowing and impinging the thecal sac.
Pathological compression fracture is identified at T7 without
evidence of significant retropulsion. Metastatic lesion is noted
at the transverse process of T9 on the right and bone marrow
infiltration with expansion at the T10 vertebral body on the
right, causing right-sided neural foraminal narrowing.
[**9-15**] CXR: Cardiomediastinal contours are normal. Right IJ
catheter tip is in the right brachiocephalic vein. There is no
evidence of pneumothorax or pleural effusion. Posterior spinal
fusion hardware device is noted. Tube with tip in the distal
esophagus is noted. The lungs are clear.
ECG [**2151-9-16**] 9:13:30 AM
Sinus rhythm. Low limb lead QRS voltage is non-specific. Tracing
is otherwise within normal limits. Compared to the previous
tracing of [**2151-9-13**] the rate is faster, ventricular ectopy is
absent and low limb lead QRS voltage is now seen.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 164 72 366/418 76 33 62
ECG [**2151-9-17**] 7:27:36 AM
Probable multifocal atrial tachycardia at a rate of
approximately 118 with
ventricular premature beats and ventricular couplets. Low
voltage in the
standard leads. Non-specific anteroseptal repolarization
abnormalities.
Compared to the previous tracing of [**2151-9-13**] multifocal atrial
tachycardia is new and the ventricular rate has increased from
approximately 75 to
approximatley 115. Ventricular ectopy persists.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
118 164 80 330/431 70 23 71
ECG [**2151-9-17**] 8:50:02 PM
Probable atrial tachycardia with 1:1 conduction and one
ventricular premature beat seen. Poor R wave progression.
Consider prior anteroseptal myocardial infarction. Low limb lead
voltages. Compared to the previous tracing of [**2151-9-17**] the rhythm
appears to be more consistent with an atrial tachycardia rather
than multfifocal atrial tachycardia. The findings are broadly
similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
133 0 84 306/433 0 -13 96
CXR [**2150-9-17**]:
FINDINGS: In comparison with the study of [**9-15**], the monitoring
and support
devices have been removed. No evidence of acute focal pneumonia
or vascular
congestion.
ECG [**2151-9-18**] 9:45:50 PM
Atrial fibrillation, average ventricular rate 116.
Non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of [**2151-9-17**] the cardiac rhythm is now irregular and consistent
with atrial fibrillation.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
116 0 86 [**Telephone/Fax (2) 71689**]
ECG [**2151-9-18**] 9:50:54 PM
Sinus rhythm. Compared to the previous tracing cardiac rhythm
now sinus
mechanism.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 184 84 380/420 58 -4 16
CXR [**2151-9-18**]
FINDINGS: In comparison with the study of [**9-17**], there is little
overall
change. Cardiac silhouette remains within normal limits and
there is no
evidence of pulmonary vascular congestion or acute focal
pneumonia.
CXR [**2151-9-21**]
FINDINGS: Interpretation of the study is limited due to motion
artifacts.
Slight increase of cardiac left opacity, consistent with
atelectasis. The
cardiomediastinal silhouette and hila are normal. The lungs are
clear without
pleural pathology. Intact and unchanged thoracic spine
instrumentation. IMPRESSION: There is no acute cardiopulmonary
process.
Brief Hospital Course:
Mr. [**Known lastname **] is a 73M with PMH significant for HCC, who
presented on [**9-15**] for an elective procedure to address the
lesion identifed to T6. He underwent a T6 vertebrectomy and
T3-11 fusion with ICBG. In the recovery room, he had some
tachycardia and cardiac enzymes were negative. Metoprolol was
ordered. He received 6U PRBC's and FFP intraoperatively. Post
procedure Hct was stable at 29-30. On [**9-16**] he was transfered to
the regular floor. He was neurologically intact. He had some B
UE edema.He had JP drain that was removed [**9-17**]. On morning of
[**9-17**] he had tachycardia with SBP to 80s, found to have new onset
a fib - cards consult called and pt was transferred to CCU for
closer monitoring
Postoperativelt he was noted to be in afib with rvr refractory
to IV lopressor and diltiazem. His HR was still elevated to
120s-140s.amiodarone therapy initiated, with 150 mg IV bolus and
then 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours. He
converted to NSR at a HR=75 on this regimen and po amiodorone
was started. He was transferred back to stepdown unit [**9-19**] for
tachycardia requiring intermittent lopressor or amiodarone bolus
and IVF
On [**9-20**] he had tachycardia to 150's and cardiology was
reconsulted. They recommended lopressor 400mg [**Hospital1 **] x1wk, then 200
mg daily for 1 wk. His primary care doctore can discontinue this
medicine if necesary. He was started on Aspririn and he was
cleared to start coumadin at 4 weeks post-op per Dr. [**Last Name (STitle) 548**]. On
[**9-21**] he was getting lopressor prn. He had some tachycardia over
night when transfering to commode, this improved on [**9-22**]. He had
some ptiiting edema in all four extremities which improved when
his HCTZ was restarted. He continued to get PT and OT but was
still too weak to stand ind for x-rays. He has no focal motor
deficit. Serial chest X-rays were satisfactory. UO was being
monitored and Foley catheter was left in place for this reason.
He was medically cleared for transfer to rehab and he was
transfered on [**9-23**].
Medications on Admission:
Albuterol MDI, HCTZ, Lisinopril, Spiriva, Ocycodone.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for muscle spasm.
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks.
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily): Please hold for
tachycardia.
15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for back pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Metastatic T6 Lesion(HCC)
Rapid Afib with RVR
Malnutrition
post op anemia of blood loss
Discharge Condition:
Neurologically Stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting for 2 weeks.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for 3 months.
*You may start coumadin in 3 more weeks (4 weeks post-op)
*You may start chemotherapy 2 weeks from the time of surgery.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please have your staples/suture removed at rehab [**2151-9-29**] or if
needed return to the office for removal and a wound check.
Please make this appointment by calling [**Telephone/Fax (1) 2992**].
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**] to be seen in 6 weeks.
??????You will need x-rays prior to your appointment.
Completed by:[**2151-9-23**]
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5,542
| 164,697
|
29806
|
Discharge summary
|
report
|
Admission Date: [**2106-2-27**] Discharge Date: [**2106-3-6**]
Date of Birth: [**2063-3-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17961**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
1. Rigid bronchoscopy with the black [**11-22**] tracheoscope.
2. Flexible bronchoscopy.
3. Electrocautery with cutting and release of the anterior
web-like portion of the complex tracheal stenotic area.
4. [**Location (un) 1661**] balloon dilatation of stenotic region.
History of Present Illness:
42-yo-woman w/ MMP including tracheal stenosis, CAD, CHF, and
asthma presents w/ cough x 2 days. Of note, she was intubated
for nearly 1 month for CHF exacerbation in [**4-16**], which was
complicated by tracheal stenosis. She has had constant stridor
since that time, w/ stridor reportedly increasing in severity
over the past few months.
.
Two days prior to admission, she developed cough productive of
white sputum, and on that day had difficulty breathing after a
coughing episode, prompting eval by her PCP. [**Name10 (NameIs) **] PCP was
concerned about airway compromise and referred her to the [**Hospital1 18**]
ED for evaluation. She denies any recent fever, chest pain,
increasing dyspnea, LE edema, and leg pain. She does complain
of chronic pain in the left lateral chest wall that has been
present for months. ROS reveals nausea and vomiting since
yesterday morning. There is no diarrhea.
.
In the ED, she was normotensive, afebrile, w/ normal O2 sat.
She was treated w/ heliox and had subjective improvement in
dyspnea. CXR did not show any evidence of PNA or CHF. She is
now admitted to the MICU for ongoing heliox therapy.
Past Medical History:
- CAD: h/o MI; s/p cath w/ stents x [**Hospital3 71312**]
- CHF
- DM type 2
- HTN
- hyperlipidemia
- asthma
- tracheal stenosis
Social History:
lives w/ daughter; smoked but quit in [**4-16**]; no alcohol, cocaine,
or IVDU.
Family History:
NC
Physical Exam:
Gen: obese woman sitting up in bed, stridulous, NAD
HEENT: muddy sclerae; EOMI, PERRL; OP clear w/ MMM, no JVD
CV: reg s1/s2, no s3/s4/m/r
Pulm: moderate air movement throughout, scattered wheezes
loudest over back posterior to trachea, no crackles
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP b/l, no edema
Neuro: a/o x 3
Pertinent Results:
Admission Labs:
[**2106-2-27**] 11:17AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2106-2-27**] 07:34AM GLUCOSE-410* UREA N-25* CREAT-0.9 SODIUM-135
POTASSIUM-4.2 CHLORIDE-89* TOTAL CO2-31 ANION GAP-19
[**2106-2-27**] 07:34AM CALCIUM-10.2 PHOSPHATE-5.3* MAGNESIUM-2.1
[**2106-2-27**] 07:34AM ACETONE-NEGATIVE
[**2106-2-27**] 07:34AM WBC-10.9 RBC-5.77* HGB-16.1* HCT-49.2* MCV-85
MCH-27.9 MCHC-32.8 RDW-19.1*
[**2106-2-27**] 07:34AM PT-11.8 PTT-24.0 INR(PT)-1.0
[**2106-2-27**] 07:34AM PLT COUNT-315
[**2106-2-27**] 02:40AM WBC-15.4* RBC-5.50* HGB-14.9 HCT-45.5 MCV-83
MCH-27.2 MCHC-32.8 RDW-19.0*
[**2106-2-27**] 02:40AM NEUTS-95* BANDS-1 LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
Microbiology:
Blood cultures - No growth
Reports:
CT TRACHEA W/O C W/3D REND
IMPRESSION: Right upper tracheal mass measuring 2cm long, up to
7mm wide, arising 3.5cm below the vocal cords, narrowing
tracheal lumen to 3mm across, infiltrating the right
paratracheal soft tissues, possibly the esophagus, innominate
artery, and local mediastinal lymph nodes, most likely squamous
or adenoidcystic carcinoma.
Cardiology Report ECHO Study Date of [**2106-3-3**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 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: *5.9 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%)
Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aorta - Arch: 2.9 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A Ratio: 2.25
Mitral Valve - E Wave Deceleration Time: 176 msec
Pulmonic Valve - Peak Velocity: 0.9 m/sec (nl <= 1.0 m/s)
Conclusions:
The left atrium is mildly dilated. Color-flow imaging of the
interatrial
septum raises the suspicion of a small atrial septal defect, but
this could
not be confirmed on the basis of this study. There was no
right-to-left
shunting with color or saline contrast + maneuvers.. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. There is moderate regional left
ventricular systolic dysfunction with basal to mid infero-septal
and inferior hypokinesis. The distal inferior and lateral wall
are also hypokinetic (including the infero-apex). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. There is mild global right ventricular free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Moderately reduced LVEF with regionality c/w CAD. No
evidence of right to left intra-cardiac (or intra-pulmonary)
however a small ASD with mild left to right shunting cannot be
excluded on the basis of this study. If clinically indicated, a
TEE would be better to exclude a small ASD with left to right
shunting.
PERSANTINE MIBI
Reason: 42 Y/O WITH CAD S/P STENTS TO LAD,LCX,RI,WITH EF 30%
PRESENCE OF ISCHEMIA
INTERPRETATION:
The image quality is good.
Left ventricular cavity size is dilated on stress and rest
images.
Rest and stress perfusion images reveal moderately severe fixed
perfusion
defects involving the mid and distal anterolateral wall as well
as the inferior wall.
Gated images reveal severe hypokinesis.
The calculated left ventricular ejection fraction is 16%.
No comparison studies.
IMPRESSION: There are moderately severe fixed perfusion defects
involving the mid and distal anterolateral wall as well as the
inferior wall. There is left ventricular cavity dilatation on
both stress and rest images with severe global hypokinesis and a
calculated LVEF of 16%.
Stress:
INTERPRETATION: 42 yo woman (h/o ischemic cardiomyopathy; s/p
CABG)
was referred for a CAD evaluation prior to surgery. The patient
was
administered 0.142 mg/kg/min of persantine over 4 minutes. No
chest,
back, neck or arm discomforts were reported by the patient
during the
procedure. No significant ST segment changes were noted from
baseline.
The rhythm was sinus with no ectopy noted. The hemodynamic
response to
the persantine infusion was appropriate. Three min post-MIBI,
the
patient received 125 mg aminophylline IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Nuclear
report sent separately.
CXR: IMPRESSION:
1) Small area of residual stenosis status post balloon
dilatation. No evidence of pneumothorax or pneumomediastinum.
2) Resolution of mild pulmonary edema.
Brief Hospital Course:
Ms. [**Known lastname 8182**] is a 42-yo-woman w/ tracheal stenosis, CAD, CHF,
DM 2, HTN, hyperlipidemia, asthma admitted w/ cough and stridor.
Admitted to the MICU for stridor, airway management and consult
and tx by CT surgery.
.
# Stridor: Ms. [**Known lastname 8182**] was felt to have stridor from tracheal
stenosis/mass seen on CT [**2106-3-2**] as well as extended intubation
in [**Month (only) 359**] for CHF exacerbation. Evaluated by CT surgery and IP.
S/P balloon dilatation. CT surgery wished to schedule for
tracheal reconstruction but was unable to get clearance for
surgery at this time from cardiology. Pt EF is 16%. Her stridor
improved throughout her stay, she was initially maintained on
heliox. She did not require intubation in the MICU and she was
transferred to the floor in no respiratory distress. Of note,
the pt was noted to have a tracheal mass on CT scan and this was
discussed with the patient. She was discharged in stable
respiratory condition. She will see CT surgery as an outpatient
for evaluation for surgery in one week.
.
# Leukocytosis: Thought to be related to ? PNA plus steroids to
treat airway inflammation. Improved off of prednisone. Continued
course of 10 days abx (vanc/zosyn initially, then changed to
levaquin). She was discharged with three remaining days of
Levofloxacin and will follow up with her PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) **] count
was normal at the time of discharge.
.
# CAD: s/p MI and multiple stents. No evidence of active
ischemia. pMIBI ordered for cards clearance for surgery revealed
severely depressed EF and they recommended holding surgery for
now. This was discussed with CT surgery. The patient did not
have any active ischemic episodes while in the MICU. She did not
have any EKG changes noted. She was continued on asa, coreg, and
lipitor. She was instructed to hold the plavix in anticipation
surgery in the future.
.
# CHF: no evidence of decompensated heart failure. EF 16% on
pMIBI. She was maintained successfully on home doses of digoxin,
lasix, aldactone, and metolazone. She will follow up with her
cardiologist for consideration of ICD placement.
.
# DM type 2: controlled w/ lantus 40 units qhs.
.
# HTN: controlled w/ coreg, lasix, metolazone, spironolactone;
will continue.
.
# Full code
Medications on Admission:
- ASA 81 mg daily
- plavix 75 mg daily
- coreg 6.25 mg daily
- lasix 40 mg [**Hospital1 **]
- aldactone 12.5 mg daily
- metolazone 2.5 mg [**Hospital1 **]
- prednisone 40 mg daily
- digoxin 0.125 mg daily
- lipitor 10 mg daily
- lantus insulin 40 units qhs
- xopenex INH q 4 hours prn
- atrovent INH q 6 hours prn
- home O2: 2L/m
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin Glargine 100 unit/mL Cartridge Sig: Forty (40) units
Subcutaneous at bedtime.
9. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: Three (3) ML
Inhalation q4H () as needed for wheeze, sob.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
12. Home supplemental O2 titrate to O2 sat>92%
13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO three times a
day.
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheal stenosis
CAD s/p MI
CHF, systolic EF 16%
Type 2 diabetes mellitus
HTN
Hyperlipidemia
Asthma
Discharge Condition:
Stable. The patient is breathing comfortably on room air and is
hemodynamically stable.
Discharge Instructions:
You were admitted with shortness of breath and cough. As you
know, you have tracheal stenosis which made your breathing more
difficult. You were seen by the pulmonologists who dilated your
trachea to help improve your breathing. You may need surgery in
the future for this problem. [**Name (NI) **] should follow up with the
surgeons within a week of discharge.
Please continue to take all medications as prescribed.
1. You were started on antibiotics to treat a possible
pneumonia. You should complete a 10 day course of Levaquin.
You have three more days of antibiotics.
2. You are no longer taking Plavix, as you should not be taking
it prior to surgery. You will restart this medication following
surgery.
If you have any further shortness of breath, worsening cough, or
any difficulty breathing please call your doctor or come to the
emergency room immediately.
Followup Instructions:
You will need to follow up with CT surgery next week. You may
contact them at the following number ([**Telephone/Fax (1) 1504**] to set up an
appointment. You may contact Dr. [**Last Name (STitle) 11482**] Pe??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
You will also need to follow up with your outpatient
cardiologist for evaluation for an ICD.
You should follow up with your primary doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
1-[**Telephone/Fax (1) 63259**], for an appointment next week.
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|
2047, 2051
|
10064, 11165
|
11215, 11318
|
9708, 10041
|
11454, 12330
|
2066, 2393
|
276, 283
|
630, 1781
|
2428, 7355
|
1803, 1933
|
1949, 2031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,408
| 154,214
|
37912
|
Discharge summary
|
report
|
Admission Date: [**2108-9-17**] Discharge Date: [**2108-10-6**]
Date of Birth: [**2030-8-21**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of Breath, falls
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
78 y.o male with past hx of CABGx2 15 years ago complicated by
left hemothorax, CHF with systolic and diastolic dysfunction,
afib, and hx of melena here with complaint of shortness of
breath and falls and evaluation for potential catherization. He
had a recent admission from [**8-24**] to [**9-1**] at LRGH for GI bleed,
had upper and lower endoscopy with capsule, no source of
bleeding was found. Patient had been on coumadin, this had been
stopped given his long term melena and since then his melena has
stopped (now 3 days without melena).
.
He had been doing well at home until [**9-15**] when he had a fall and
could not get up. He was taken to LRGH again and found to be in
CHF with BNP to ~[**2098**]. He was diuresed there, and then
transferred here for possible right and left heart
catherization.
.
The patient reports that he has been having shortness of breath
for 3 years duration, and 1 month ago began to retain water in
his legs. He also has had recent falls, beginning in the last 6
months. He describes that he has no dizziness or palpitations
prior to falling, but that his legs just feel weak and will
suddenly give out on him. He remains conscious throughout these
episodes, and is usually able to get up on his own with the
exception of his most recent fall. His fall prior to last, he
hit his head and went to the ED, but apparently had a negative
head CT.
.
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,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
afib
past CABG [**13**] y.o complicated by hemothorax
DM type II
hx of AICD placement
aortic stenosis
hx of GI bleed
COPD
Social History:
-Tobacco history: smokes pipe, for many years, long history of
2nd hand smoke from daughter and sister
-ETOH: hx of social etoh, none recently.
-Illicit drugs: none
previous long haul truck driver,, retired at 73.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission exam:
VS: 98.1 bp 142/62 pulse 73 rr 22 sat 92% 4L
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Moderate crackles at
bases
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
2+ DP and radial pulses bilaterally.
Pertinent Results:
[**2108-9-20**] C.Cath- 1. One vessel coronary artery disease.
2. Successful PCI of the RCA.
[**2108-9-23**] Angio: Early active GI bleeding at the splenic flexure
in the colon.
[**2108-10-3**] ECHO: The left atrium is dilated. The right atrium is
moderately dilated. Overall left ventricular systolic function
is moderately depressed (LVEF= 35 %) with global hypokinesis.
The right ventricular cavity is dilated with mild global free
wall hypokinesis. [Intrinsic right ventricular systolic function
is likely more depressed given the severity of tricuspid
regurgitation.] The aortic valve leaflets are moderately
thickened. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. 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.
Brief Hospital Course:
78 y.o male with past hx of CABGx2 15 years ago complicated by
left hemothorax, CHF with systolic and diastolic dysfunction,
afib, and hx of melena here with complaint of shortness of
breath and falls.
.
#CAD - The patient underwent a staged catherization during which
he had angioplasty of his left circumflex and subsequent
placement of a bare metal stent to his RCA. The patient was
started on aspirin and plavix. He also received 18 hours of
integrelin post-stent. Plavix was continued for 2 weeks from the
day of stnet placement. Due to GI bleed and per cardiology, ASA
was held. Several weeks post PCI placement, ASA and plavis were
resumed after stability of hematocrit was assured.
.
#ACUTE EXACERBATION OF CHRONIC HEART FAILURE - The patient was
found to still be in some degree of congestive heart failure
given his elevated JVP and crackles on exam. Given his aortic
stenosis, he was diuresed initially with 20 IV lasix and then
40mg PO lasix [**Hospital1 **]. He was then intubated prior to endoscopy
while in the MICU given his tenous cardiopulmonary status. He
received a total of 14 units pRBCs and was significantly volume
overloaded. Diuresis was hld due to renal failure and
hypotension. Due to significant pulmonary edema contributing to
respiratory failure, Lasix was started.
.
#GI bleed - The patient had one episode of BRBPR just prior to
his first intervention, however his hematocrit was stable. He
had one further episode post catherization and his crit dropped
from ~28 to 25.1 on [**9-21**]. He was transfused one unit of blood,
however, his crit dropped further to 23 the day after and he was
transferred to the unit. The nadir of his Hct was 19. He was
transfused a total of 11 units PRBC, 2 units FFP, 2 bags of
platelets on [**2108-9-22**] (the day of his transfer). He underwent
endoscopy, which was normal. He had a tagged bleeding scan,
which was positive in the splenic flexure. He then underwent
embolization of the [**Female First Name (un) 899**] branches by angio. He had one further
episode of maroon stools, and was transfused one unit
prophylactically. His hematocrit remained stable and he
required no further transfusion.
.
#Thrombocytopenia - It was noted that the patient had an acute
drop in his platelet count from admission of >50%. The patient
had documented exposure to heparin on [**9-15**], and therefore
suspicion for heparin induced thrombocytopenia was high.
Heparin dependent antibodies returned positive, however, f/u
test were negative. Given the timing and resoution of his
thrombocytopenia, integrelin induced thrombocytopenia was
suspected.
.
# Respiratory failure - Pt as determined to be in respiratory
failure due to volume overload [**1-30**] to fluid resucitation. He
was diuresed aggressivly which improved pulmonary status and
improved ventilator requirements. Extubation was attempted
however he developed a collpase of his lung due to mucus
plugging. He underwent bronchoscopy, became hypoxic and was
reintubated. He again underwent agressive diuresis, pt self
extubated became hypoxic and again required extubation.
Finally, he was extubated as ventilator was weaned and he
sustained a SBT for 2 hrs. He again became acutely dyspneic,
most likely due to generalized myopathy. He became distressed
but refused reintuation. He was made comfort measures only,
started on a morphine drip to reduce air hunger, and passed away
several hours later.
.
#Myopathy - Unclear why, but pt appeared to have significant
difficulty with respiratory effort despite prolonged breathing
trials with which he was successful. Consulted neurology who
believed his exam to be non focal and unliklely to be a primary
neurological condition. No further workup was obtained.
Medications on Admission:
lantus 10 units qhs
asa 81mg qd
lasix 40mg [**Hospital1 **]
protonix 40mg qd
lisinopril 40 mg qd
iron 325 po bid
digoxin 0125 mg qd
zoloft 100mg qd
spiriva 1 puff qd
lipitor 10mg po qd
humalog sliding scale
albuerol inhaler prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: GI bleed
Secondary: coronary artery disease, acute exacerbation of
chornic heart failure, upper gastrointestinal bleed,
thrombocytopenia, acute respiratory failure, Myopathy otherwise
unspecified
Discharge Condition:
pt expired
Discharge Instructions:
Patient Expired
Followup Instructions:
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2108-10-15**]
|
[
"414.01",
"996.72",
"518.0",
"250.00",
"518.81",
"285.1",
"V45.02",
"599.0",
"287.5",
"V45.81",
"428.0",
"427.31",
"428.43",
"496",
"584.9",
"578.9",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.56",
"37.22",
"44.44",
"00.45",
"00.40",
"88.42",
"33.24",
"96.04",
"00.66",
"96.6",
"99.20",
"36.06",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8611, 8620
|
4557, 8304
|
310, 333
|
8870, 8882
|
3570, 4534
|
8946, 9115
|
2649, 2764
|
8582, 8588
|
8641, 8849
|
8330, 8559
|
8906, 8923
|
2779, 3551
|
243, 272
|
361, 2254
|
2276, 2399
|
2415, 2633
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,099
| 170,580
|
37048+58122
|
Discharge summary
|
report+addendum
|
Admission Date: [**2168-8-1**] Discharge Date: [**2168-8-9**]
Date of Birth: [**2094-1-5**] Sex: F
Service: SURGERY
Allergies:
Cipro
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted status post colonoscopy and polypectomy with
bright red blood from rectum.
Major Surgical or Invasive Procedure:
Right Colectomy
History of Present Illness:
74F s/p colonoscopy and polypectomy in the cecum and at the
hepatic flexure today by Dr. [**Last Name (STitle) **]; at home noted BRBPR;
intially was seen at [**Hospital3 417**] Hospital. Of note, she had
not discontinued her ASA 325 prior to the procedure. She
reportedly received 4 pRBCs at [**Hospital3 **].
She was had a brief episode of hypotension into the 80s that
responded to IVF. She currently feels, well. She notes some
mild LLQ discomfort, but no nausea/vomiting, fevers/chills.
Past Medical History:
HTN, GERD, UTI, CAD s/p MI, DM
Social History:
Patient lives with son who has mental illness. Daughter lives
nearby.
Family History:
Non-contributory
Physical Exam:
Tc 97.8, HR 71, BP 113/103, RR 22, O2sat 95%2L
Genl: NAD
CV: RRR
Resp: CTA-B
Abd: obese; soft, mildly tender to LLQ, no tap tenderness; no
rebound, no guarding
Extr: no c/c/e
DRE: grossly positive
Pertinent Results:
[**2168-8-1**] 09:15PM WBC-14.8*# RBC-4.23 HGB-12.1 HCT-36.2 MCV-86
MCH-28.7 MCHC-33.5 RDW-15.4
[**2168-8-1**] 09:15PM NEUTS-84.9* LYMPHS-10.7* MONOS-3.7 EOS-0.5
BASOS-0.2
[**2168-8-1**] 09:15PM PLT COUNT-191
[**2168-8-1**] 09:15PM GLUCOSE-184* UREA N-23* CREAT-1.1 SODIUM-140
POTASSIUM-5.3* CHLORIDE-113* TOTAL CO2-17* ANION GAP-15
Brief Hospital Course:
Mrs. [**Known lastname 83534**] was admitted to the hospital and urgently taken
to the Operating Room due to her anemia and hypotension post
colonoscopy and polypectomy. She underwent a right colectomy
and returned to the PACU in stable condition.
Following her post op recovery she was transferred to the
Surgical floor where she continued to make steady progress. Her
pain was controlled with a PCA and her hematocrit was followed
on a daily basis and stable in the 27 range. She had return of
bowel function and her diet was gradually increased from clears
to regular and tolerated well. Her blood sugars were well
controlled post op on her home doses of insulin.
She was seen by the Physical Therapy service for a full
evaluation and required assistance early post op but was
gradually able to ambulate on her own. Her wound was healing
well and her staples were removed on [**2168-8-9**]. After an
uneventful post op course she was discharged on [**2168-8-9**] with VNA
services for wound assessment and physical therapy.
Medications on Admission:
Lipitor 10, Lispro 14, Imdur, Lisinopril 20, Toprol, Prilosec,
ASA 325
Discharge Medications:
1. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Diabetic regimen
humalog 14 units once a day in PM
NPH 14 units once a day in AM
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
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:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Lower gastrointestinal bleed, status post polypectomy.
2. Hypotension.
3. Anemia, post-hemorrhagic
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have 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.
* 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.
Activity:
No heavy lifting of items [**10-6**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower 48 hours after surgery, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks from Discharge.
Please call and schedule your appointment at [**Telephone/Fax (1) 2723**]
Call Dr. [**Last Name (STitle) 83535**] for a follow up appointment in 2 weeks
Completed by:[**2168-8-9**] Name: [**Known lastname 13292**],[**Known firstname 1966**] Unit No: [**Numeric Identifier 13293**]
Admission Date: [**2168-8-1**] Discharge Date: [**2168-8-9**]
Date of Birth: [**2094-1-5**] Sex: F
Service: SURGERY
Allergies:
Cipro
Attending:[**First Name3 (LF) 559**]
Addendum:
Mrs.[**Last Name (un) 13294**] correct dose of insulin is NPH 14 units SC QAM.
She has been taking 14 units of regular insulin pre supper
prior to admission. I advised her to call her endocrinologist
at [**Hospital1 2239**] to discuss this during this periop transition. The VNA
will help to monitor her blood sugars.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**] MD [**MD Number(1) 561**]
Completed by:[**2168-8-9**]
|
[
"414.01",
"530.81",
"211.3",
"288.60",
"250.00",
"998.11",
"E879.8",
"458.29",
"285.1",
"557.0",
"429.83",
"998.59",
"E849.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"88.47",
"45.42",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
6529, 6737
|
1671, 2708
|
353, 371
|
3959, 3968
|
1306, 1648
|
5584, 6506
|
1056, 1074
|
2829, 3735
|
3834, 3938
|
2734, 2806
|
3992, 5191
|
1089, 1287
|
222, 315
|
5203, 5561
|
399, 899
|
921, 953
|
969, 1040
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,639
| 180,167
|
54586
|
Discharge summary
|
report
|
Admission Date: [**2135-2-17**] Discharge Date: [**2135-2-24**]
Service: MEDICINE
Allergies:
Horse Blood Extract
Attending:[**Doctor First Name 1402**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
right groin hematoma evacuation and repair
History of Present Illness:
Mr. [**Known firstname **] [**Last Name (NamePattern1) 7518**] is an 85 y/o male with COPD, HTN, AF on
coumadin admitted to NEBH [**2-8**] with atrial fibrillation s/p CV
developed tachy/brady syndrome s/p AF ablation on [**2-14**]
discharged on CCB, metoprolol and dofetilide now presents with
presyncope and sinus bradycardia. On [**2-14**] patient underwent EP
study which showed several atrial tachycardias and two were
ablated. The plan was for cardioversion following ablation but
patient converted to NSR and remained in NSR with only 2 brief
episodes of AF on telemetry. Since discharge from the hospital
on [**2-15**] the patient has been feeling well. He has not had any
chest pain, lightheadedness or dizziness until this morning.
This AM had minimal appetite at breakfast. Then attempted to
have a bowel movement several times with straining and each time
felt lightheaded and dizzy with associated diaphoresis. He has
been constipated over the past four days. His children were with
him, helped him back to bed and called Dr. [**Last Name (STitle) **] who referred him
to the Emergency Room. The patient did not ever lose
consciousness. He reports that he has been complaint with all of
his medications. He denies any associated chest pain or
shortness of breath. Patient has history of bradycardia in past
when on metoprolol and cardizem (HR ranging from 40-100 bpm).
.
During the patient's last hospitalization he underwent AF
ablation however according to d/c summary only 2 of 4
arrhythmias were ablated. He was in sinus rhythm prior to
discharge and was discharged on lopressor, cardizem and
dofetilide.
.
In the ED, initial vitals were HR: 45-55 BP: 78/39, O2sat 96% on
RA. Exam notable for patient with good mentation. EKG was
initially sinus bradycardia. Patient received 2 g Calcium
gluconate and 1L IVF. Symptoms and EKG changes felt to be
consistent with too much medication.
.
On arrival to the CCU, the patient feels "better". He is
fatigued but overall improved from this afternoon. HR 50s. BP
111/70. He denies chest pain, shortness of breath, palpitations,
cough, abdominal pain, orthopnea, ankle edema and PND. He does
report some persistent groin pain, R>L which has improved over
the past several days.
Past Medical History:
Atrial fibrillation s/p CV [**2126**] on coumadin
hypertension
COPD/Bronchiectasis
congestive heart failure (unknown ef)
gastroesophageal reflux disease,
benign prostatic hypertrophy, ,
anemia,
status post bilateral total knee replacements,
shoulder arthroplasty
.
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension
Social History:
Social history is significant for the absence of current tobacco
use. Former smoker but quit in [**2095**] with 40 pack yr hx. There is
no history of alcohol abuse. No illicit drug use. Widowed. Lives
alone in [**Location (un) 2312**] and completes all his ADLs. Former
fire-fighter but retired 30 years. Has 4 children and 4
grandkids.
Family History:
Significant for heart disease in father (mi [**89**] yo), mother (mi
[**08**] yo), and brother (mi [**67**] yo). No diabetes in the family.
Physical Exam:
VS: HR 56, BP 111/52, 100% on 2L
Gen: Elderly male NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no appreciable JVP.
CV: Bradycardic. s1, s2. No m/r/g. No thrills, lifts. No S3 or
S4. Soft 2/6 systolic ejection murmur at USB.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Resonant to percussion.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Bilateral groin hematomas, right side is firm without ooze,
nontender to palpation, no bruit. Left side is soft, less
ecchymotic. Trace edema bilaterally. No femoral bruits b/l.
.
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:
[**2135-2-17**] 10:10PM GLUCOSE-194* UREA N-22* CREAT-1.0 SODIUM-137
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11
[**2135-2-17**] 10:10PM CK(CPK)-139
[**2135-2-17**] 10:10PM cTropnT-0.09*
[**2135-2-17**] 10:10PM CK-MB-3
[**2135-2-17**] 10:10PM WBC-6.9 RBC-2.77* HGB-8.2* HCT-23.8* MCV-86
MCH-29.4 MCHC-34.3 RDW-15.2
[**2135-2-17**] 10:10PM NEUTS-92* BANDS-0 LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2135-2-17**] 10:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2135-2-17**] 10:10PM PLT SMR-NORMAL PLT COUNT-197
[**2135-2-17**] 10:10PM PT-16.4* PTT-32.0 INR(PT)-1.5*
.
[**2-18**]
Large bilateral groin hematomas demonstrated, without evidence
of
pseudoaneurysm seen.
.
[**2-20**] Femoral U/S:
1. Increase in size of large right groin hematoma extending into
the medial thigh. No evidence for pseudoaneurysm or
arteriovenous fistula.
2. Small left groin hematoma.
Brief Hospital Course:
Patient is an 85 year old male with history of AF s/p CV at OSH
with resultant tachy/brady s/p AF ablation on [**2-14**] started on
dofetilide, CCB and beta blocker now presents with presyncope
and bradycardia likely related to medication. Now off dilt and
metoprolol and on dofetilide and acebutolol with symptomatic
improvement. This hospitalization is complicated by ongoing fall
in HCT with expansion of his bilat groin hematomas R>L now s/p r
hematoma evacuation.
.
## Bilateral groin hematomas: He had bilateral groin hematomas,
and had a hematocrit drop betwee his ablation and this admission
from about 30 --> 24. He had groin ultrasound that showed
bilateral hematomas but no pseudoaneurysm. S/p drainage and
hematoma evacuation by vascular surgery [**2135-2-20**]. Now with one JP
drain in place. Pt denies pain. No transfusions since [**2-21**].
Following vascular recs, he will follow up in 2 weeks with Dr.
[**Last Name (STitle) **]. HCT remained stable at time of discharge.
.
## Rhythm: He does have AF s/p CV c/b bradycardia and
tachycardia recently here for AF ablation on [**2-14**] with 2 of 4
atrial arrhythmias ablated. Discharged on [**2-15**] on Dofetelide,
Cardizem and Metoprolol in normal sinus rhythm. Returns with
near syncopal episodes and sinus bradycardia, likely medication
related. Symptoms are likely exacerbated in setting of anemia.
Cardizem and metoprolol discontinued and he was discahrged on
acebutolol and dofetilide for rate and rhythm control which he
tolerated. HOLD coumadin with lovenox for now pending HCT
stabilization. Should be restarted at follow up with Dr. [**Last Name (STitle) **]
of vascular surgery. He was monitored on telemetry.
.
## Pump: Patient with known history of CHF per chart. Euvolemic
on exam. Monitored I/Os, goal even.
.
## CAD: No known CAD. No ischemic sxs currently.
.
## Cellulitis: Pt had mild erythema R groin near well-healing
incision. had low grade fever with pancultures sent. He was
started on cephalexin to complete 10 day course. His culture
data had no growth at time of discharge and he remained
afebrile>48 hours prior to discharge.
.
## Anemia: Likely related to blood loss in groin based on exam
findings of bilateral hematomas. Baseline approximately 30.
Tranfused total 6 units. Last transfused [**2135-2-21**]. Continue iron
supplementation, B12. Mgmt as above for hematomas.
.
## GERD: Continued ppi
.
## COPD: Continued inhalers
.
##General Care: pneumoboots, ppi, Code status: FULL CODE
confirmed with patient, Communication: [**Name (NI) **] [**Name (NI) **] (son)
[**Telephone/Fax (1) 111656**]. Discharged when cleared by PT.
Medications on Admission:
Dofetilide 500 mcg PO Q12H
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]
Fluticasone 50 mcg/Actuation Spray daily
Pantoprazole 40 mg Tablet PO Q24H
Ferrous Sulfate 325 mg daily
Cyanocobalamin 100 mcg Tablet 5 Tablet PO DAILY
Warfarin 1 mg Tablet PO Once Daily at 4PM
Metoprolol Tartrate 50 mg Tablet PO BID
Cardizem CD 120 mg 1 capsule daily
Lovenox 80 mg/0.8 mL
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
7. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO three times
a day for 8 days.
Disp:*24 Capsule(s)* Refills:*0*
10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H () as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute Blood Loss Anemia
Bilateral groin Hematomas
Chronic Congestive Heart Failure
Atrial Fibrillation s/p Ablation
Hypertension
Discharge Condition:
stable.
Discharge Instructions:
You had bleeding from the right groin site that required surgery
and evacuation of the blood. A drain was placed and will stay in
until you see Dr. [**Last Name (STitle) 3407**] on [**3-8**]. You can walk with this drain
but do not take a shower or bath until after you see Dr. [**Last Name (STitle) 3407**].
Please keep the dressing clean and dry. You were started on an
antibiotic because the right groin site was warm and red, please
take this antibiotic for a total of 10 days. The visiting nurse
will help with the drain.
New medicines:
1. Ceflexin: an antibiotic to treat the local skin infection
near the surgery site.
2. Acebutalol: a beta blocker to take instead of the metoprolol
.
1. Do not take any coumadin or Lovenox until Dr. [**Last Name (STitle) 3407**] or Dr.
[**Last Name (STitle) **] tells you it is OK.
2. Stop taking Cartia XT and metoprolol
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please call Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 3407**] if you have any further
bleeding, increasing swelling, pain or redness, fevers or any
other concerning symptoms.
Followup Instructions:
Vascular Surgery:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2135-3-8**] 10:30
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 7960**] Date/Time:
|
[
"530.81",
"998.12",
"285.1",
"494.0",
"600.00",
"998.59",
"682.2",
"427.31",
"427.89",
"E942.4",
"E878.8",
"428.0",
"V58.61",
"E941.3",
"V43.65",
"401.9",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.0"
] |
icd9pcs
|
[
[
[]
]
] |
9442, 9500
|
5372, 8000
|
244, 289
|
9673, 9683
|
4383, 5349
|
10891, 11165
|
3280, 3421
|
8441, 9419
|
9521, 9652
|
8026, 8418
|
9707, 10868
|
3436, 4364
|
189, 206
|
317, 2554
|
2576, 2909
|
2925, 3264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,231
| 124,045
|
28570+57573
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-8-21**] Discharge Date: [**2120-9-14**]
Date of Birth: [**2076-7-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
TIPS
Blakemoor tube placement
TIPS revision
Paracentesis x2
Dobhoff tube placement x2
Central line placement x3
History of Present Illness:
44 yo male with PMH HCV/etoh cirrhosis with known varices
presented to OSH for hematemesis. Per family, pt was found at
home by neighbor in pool in blood, who called EMS.
.
At OSH, pt was scoped by GI who saw bleeding esophageal vs.
gastric varix which they banded (no report sent over). Pt
re-bled and on re-scope gastric varices were seen but unable to
be reached. Pt was hemodynamically unstable with BP in 70s.
Intubated in setting of hemaodynamic instability and airway
protection. Initial hct at OSH was 29, INR 3. Given 10U PRBC, 5U
FFP, 10L NS. Started on octreotide. Also given thiamine, Vit K
10mg, Versed, Fentanyl, Vecuronium.
.
In our [**Name (NI) **], pt was hypotensive on arrival with SBP 60-70s, tachy
to 140. Intial Hct 30, INR 2, plt 66. Pt was given 4U of FFP and
4U of PRBC. Started on vasopressin gtt. Pt was seen by surgery,
who felt pt was not surgical candidate. Pt was also seen by IR
who feels pt is candidate for TIPS, however, they would prefer
to perform procedure in AM after stabilization. Pt is being
evaluated by Liver service.
.
On arrival to MICU, pt was hypertensive to 150s systolic, so
vasopressin shut off. L EJ was dislodged and removed; per
nursing there is concern that tip looks "jagged" - question of
if piece of tip left in vein. However, there was no difficulty
in pulling line out. ABG on AC 450/22/5/1 was 7.20/43/194 with
lactate 12.3. RR and PEEP increased, FiO2 decreased.
Past Medical History:
ETOH/HCV cirrhosis (varices)
Chronic back pain
Hx of GIB
Depression
Social History:
Heavy drinker. Lives alone in trailer in [**Location (un) **], MA. Is
divorced, with two sons.
Family History:
Unknown at time of admission
Physical Exam:
EXAM on admission:
VS: Tc 94.8, BP 151/75, (60-150/40-70s), 128 (120-140s), rr22,
100% Vent: AC 450/22/5/1
Gen: intubated and sedated
HEENT: PERRL, blood around lips
Neck: unable to palpate anything around EJ site
CVS: tachycardic, no m/g/r
Lungs: diffuse wheezing
Abd: soft, distended, decreased BS, + ascites
Ext: no edema
Pertinent Results:
LABS on admission:
WBC 4.7, Hct 30.3, MCV 92, Plt 64*
PT 20.1, PTT 73.2, INR(PT) 2.0*
Fibrinogen 86.5*
Na 148, K 5.9, Cl 106, HCO3 16, BUN 22, Cr 1.0, Glu 152
ALT 238, AST 1560, AlkPhos 39, Amylase 20, Lipase 36, TBili 4.9*
CK(CPK) 259, CK-MB 6, cTropnT <0.01
Ca 5.2, Phos 4.6, Mg 2.2, Alb 1.9
ABG: 7.20/43/184/18/-10, on AC 450x22, 5 PEEP, 100% FiO2, AADO2
491
by ABG: Glu 144, Lactate 13.3, Na 143, K 6.3, calHCO3 14.3*,
freeCa 0.82*
.
LABS on discharge:
.
MICRO:
[**8-21**] - blood cx no growth
[**8-22**] - sputum cx GRAM STAIN (Final [**2120-8-22**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2120-8-25**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
BETA STREPTOCOCCI, NOT GROUP A. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- 1 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------<=0.03 S
..
[**8-27**] - urine no growth
[**8-27**] - blood cx no growth
[**8-27**] - stool cx neg for C diff
[**8-28**] - stool cx neg for C diff
[**8-28**] - sinus aspirate: gram stain = 2+ PMNs, 2+ GPR, cx sparse
growth OP flora, anaerobic cx neg
[**8-28**] - RRV negative, cx negative
[**8-29**] - stool cx + CDIFF
[**8-29**] - peritoneal fluid cx negative
[**8-29**] - catheter tip no growth
[**9-3**] - peritoneal fluid gram stain 1+ PMNs, no orgs, cx no
growth
[**9-8**] - peritoneal fluid gram stain 1+ PMNs, no orgs, cx pending
.
IMAGING:
[**8-21**] CXR - Cardiomediastinal contour is within normal limits.
Right internal jugular vein catheter tip is projected in the
right brachiocephalic vein. ET tube tip projects 4.8 cm above
the carina. [**Last Name (un) **] tube is slightly deflated. Ill-defined
opacities in the left upper lobe, retrocardiac left lower lobe,
and right lower lobe are unchanged. Given the acute
presentation, these could be due to massive aspiration,
atelectasis or pulmonary hemorrhage. Stable small bilateral
pleural effusions. Right apical opacity is likely due to pleural
effusion, attention to this area should be paid in the following
studies to exclude hematoma.
.
[**8-21**] LIVER U/S - There is a small amount of ascites in all four
quadrants, however, not enough to safely mark for percutaneous
drainage. The most prominent pocket appears in the right upper
quadrant.
.
[**8-21**] PORTABLE KUB - TIPS seen overlying right upper abdomen.
Tubing seen overlying the mid abdomen. Bilateral central venous
line seen overlying the pelvis. No definite evidence of free air
seen on this supine film. Increased haziness seen diffusely over
the abdomen, likely represents ascites.
.
[**8-21**] TIPS -
1. Successful transjugular intrahepatic portosystemic shunt
placement. Pressure gradient was measured at the main portal
vein, which was 49 mmHg. Pressures in the portal vein after the
stent decreased to 43 mmHg, and inside of the stent was measured
as 38 mmHg.
2. Embolization of two separate coronary veins with ethanol and
5-mm coils.
.
[**8-22**] LIVER U/S - This exam is extremely limited secondary to
patient's body habitus and respiratory motion. A TIPS catheter
is present within the right lobe of the liver and only the
proximal and mid portions are visualized on today's study. There
is a proximal TIPS velocity of 115 cm/sec and a mid TIPS
velocity of 64 cm/sec. Wall-to-wall patency cannot be adequately
assessed. Normal flow and waveforms are demonstrated within the
main and left portal vein. A single hepatic vein is visualized
and demonstrates normal flow and waveforms. Normal arterial
waveforms are seen within the main, right and left hepatic
arteries.
.
[**8-22**] ECHO - The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion. Agitated saline contrast study
(at rest x2, patient on ventilator) revealed no intracardiac
shunt.
.
[**8-23**] CT head - No hemorrhage. Opacification of the paranasal
sinuses and left mastoid air cell.
.
[**8-25**] CT head -
1. No evidence of intracranial hemorrhage.
2. No evidence of radiographically visable fracture within the
skull base.
3. Soft tissue swelling around left mastoid consistent with
clinical findings.
.
[**8-25**] LIVER U/S - Study is again limited secondary to patient's
body habitus and respiratory motion. TIPS catheter again seen in
the right lobe of the liver demonstrating a velocity of 94-108
cm/sec at the proximal end of the TIPS, a velocity of 110-130
cm/sec at the distal end of the TIPS. Velocity in the mid
portion measures approximately 210-220 cm/sec. Because the
patient's respiratory motion, Doppler study of the TIPS was not
possible. Hepatopetal flow seen within the main portal vein.
Small amount of free fluid is noted in the abdomen.
.
[**8-26**] CT orbit/sella - No fracture or dislocation is identified.
The patient is intubated with a nasogastric tube in place. There
is opacification of multiple ethmoid air cells, total
opacification of the sphenoid air cells, near total
opacification of both maxillary sinuses, with an air-fluid level
in the right maxillary sinus, and scattered mastoid air cells
opacification bilaterally. The orbits appear unremarkable. The
temporomandibular joints are normal in appearance. The
surrounding soft tissues structures appear unremarkable.
.
[**8-29**] LIVER U/S -
1. Allowing for limitations of the study, likely no significant
change in TIPS velocities. There is persistent acceleration in
the mid portion of the stent from 50 cm per second proximally to
250 cm per second in the mid and distal TIPS. There is
persistent antegrade flow within the left portal vein and the
recannulated paraumbilical vein. The anterior right portal vein
is appropriately reversed towards the TIPS.
2. Gallbladder sludge. No evidence of acute cholecystitis.
Limited assessment of the pancreas was unremarkable. No evidence
of cholangitis.
.
[**9-2**] LIVER U/S - Again seen is persistent acceleration within
the mid portion of the TIPS stent with velocities of
approximately 220 to 280 cm per second within the mid TIPS.
Hepatopedal flow is seen within the main portal vein.There
appears to be reversal flow within the right anterior and left
portal veins. This represent a change from prior study where
persistent antegrade flow was noted within the left portal vein.
Spot marked in the right lower quadrant for paracentesis
.
[**9-4**] CT a/p - No evidence of intraperitoneal or retroperitoneal
hemorrhage. Ascites and anasarca. Small bilateral pleural
effusions.
.
[**9-6**] CXR -
1. Dobbhoff tube coiled in the stomach with the tip in the
region of the gastric fundus. This tube should be advanced if
the desired location is post-pylorus.
2. Persistent multifocal airspace opacities throughout the lung
fields which may represent multifocal pneumonia versus
congestive heart failure.
Brief Hospital Course:
# UGIB/Hypovolemic shock: Presented to hospital with upper GI
variceal bleed. Unsuccessful banding of one of varices.
[**Last Name (un) **] tube was placed. Was stabilized in the MICU after
receiving several units of blood transfusion and subsequently
underwent TIPS procedure. After bleeding came under control,
patient was transferred to the floor. Required a few more units
of blood transfusion due to bleeding from central line site, but
eventually this bleeding was stabilized with fresh frozen
plasma, cryoprecipitate, and Vitamin K administration.
.
# Cirrhosis - Secondary to hepatitis C and alcohol with poor
synthetic function, ascites, esophageal varices, jaundice, and
encephalopathy. Hepatology was consulted. Patient was started
pantoprazole for GI prophylaxis, spironolactone and furosemide
for ascites, nadolol and isosorbide mononitrate for portal
hypertension, lactulose and rifaximin for hepatic
encephalopathy, ursodiol for hyperbilirubinemia, and
levofloxacin 250mg PO daily for spontaneous bacterial
peritonitis prophylaxis. He underwent paracentesis during the
admission to rule out SBP, and ascites fluid did not have any
signs of infection. His hematocrit remained stable after the
central line sites stopped bleeding.
.
# Pancreatitis - Patient experienced pancreatitis that resolved
after being transferred from the MICU.
.
# Sepsis/ARDS - Patient had sepsis while in the MICU and grew
MSSA from his sputum. He was treated with broad-spectrum
antibiotics and subsequently stabilized.
.
# Clostridium difficile colitis - Patient was treated with and
completed a 14-day course of PO vancomycin
.
# FEN: Tolerating regular diet and will require nutritional
supplements with diet.
.
# Access: Patient was maintained with large bore IV access while
bleeding.
.
# PPX: Patient was on pneumoboots for DVT prophylaxis, since he
was too coagulopathic from liver failure for heparin.
.
# Code: Full
.
# Communication: with mother [**Name (NI) **] [**Name (NI) 12067**] who is HCP
.
# DISPO: Will be discharged to [**Hospital1 **] Rehabiliation, [**Last Name (un) 16844**].
Medications on Admission:
Antidepressant (unknown)
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
7. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
12. Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO BID (2
times a day).
13. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16844**] Hospital - [**Location (un) 1157**]
Discharge Diagnosis:
esophageal varices
Upper gastointestinal Bleed
cirrhosis
hepatic encephalopathy
pancreatitis
c. dif enterocolitis
Discharge Condition:
Vital signs stable, tolerating PO diet
Discharge Instructions:
You were evaluated for bleeding from veins in your esophagus
called varices, and cirrhosis.
*
Please seek medical attention immediately if you begin to bleed,
vomit, vomit blood, have dark stool, maroon stool, or blood
streaked stool, if you have a fever, abdominal pain, increasing
distention of your abdomen or ANY OTHER CONCERNING SYMPTOMS.
*
Please continue all medication as prescribed. The medication may
give you diarrhea but this is normal and the medications are
necessary for your health.
*
Please contact your AA sponsor and begin rehabilitation and
sobriety. It is imperative that you do not drink alcohol.
Followup Instructions:
Please continue your care at the rehabilitation facility to
increase your physical strength.
Completed by:[**2120-9-13**] Name: [**Known lastname 11738**],[**Known firstname **] Unit No: [**Numeric Identifier 11739**]
Admission Date: [**2120-8-21**] Discharge Date: [**2120-9-14**]
Date of Birth: [**2076-7-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1775**]
Addendum:
Given the slight trend upward in Mr. [**Known lastname 11740**] white blood cell
count, it was decided to add another week of PO vancomycin for
treatment of C. diff colitis. He was discharged to rehab on
[**9-14**] with a full seven-day course of vancomycin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4955**] Hospital - [**Location (un) 4329**]
[**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**]
Completed by:[**2120-9-14**]
|
[
"995.92",
"571.2",
"785.59",
"577.0",
"276.0",
"486",
"070.71",
"873.0",
"285.9",
"286.7",
"789.5",
"584.9",
"518.5",
"456.20",
"008.45",
"305.00",
"572.3",
"998.11",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"99.29",
"42.33",
"39.49",
"96.72",
"96.6",
"38.93",
"39.1",
"54.91",
"99.07",
"99.05",
"99.15",
"99.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
15371, 15614
|
10360, 12460
|
275, 388
|
13913, 13954
|
2454, 2459
|
14621, 15348
|
2063, 2093
|
12535, 13649
|
13776, 13892
|
12486, 12512
|
13978, 14598
|
2108, 2113
|
232, 237
|
2911, 10337
|
416, 1843
|
2473, 2892
|
1865, 1935
|
1951, 2047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,278
| 147,015
|
4074
|
Discharge summary
|
report
|
Admission Date: [**2200-4-11**] Discharge Date: [**2200-4-25**]
Date of Birth: [**2130-4-17**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
Right hip pain, failure to thrive
Major Surgical or Invasive Procedure:
Right hip hemi-arthroplasty with a tumor prosthesis on [**2200-4-18**]
History of Present Illness:
69 M with history of renal cell ca, with lung mets who underwent
a resection of a giant lytic lesion of the right hip (IM nailing
of impending right proximal femur pathologic fracture on
[**2200-2-5**]). He initially went home after procedure, but had pain
in the hip for months. He had pain and difficulty walking after
discharge, but did not seek follow up care until [**2200-3-17**] when
his R hip was found to be infected; he was admitted for
debridement of wound. He was discharged home on Nafcillin.
He was then re-admitted on [**4-16**] for failure to thrive, N/V
fatigue.
Since his most recent discharge, he had increasing pain while
working with PT and failure to thrive. He was initially
admitted to the oncology service. Following admission and
radiographic evaluation, he was found to have a fracture around
the cephalomedullary femoral nail. He was then admitted to the
orthopaedic service following surgical intervention for this
condition.
Past Medical History:
- right nephrectomy and adrenalectomy in [**3-/2188**]
- renal cell carcinoma found by bx of mediastenal mass in [**2197**].
metastatic to bone and thorax
- left adrenalectomy in [**2-25**]
- pustular psoriasis
- asthma
- HTN
Social History:
He lives with his wife in [**Name (NI) 17927**], [**State 350**]. His
daughter is very much involved in his care. He is a former
smoker, quit about 24 years ago. He smoked roughly 2 packs per
day when he was a smoker. He does not drink alcohol.
Family History:
noncontributory
Physical Exam:
PE: elderly man, nad.
VS: 97.6 78 145/64 16 96%RA
HEENT: eomi. perrl. MMM. op clear.
CV: rrr
PULM: poor air movement, otherwise catb
ABD: obese, soft, nt/nd
EXT: R hip: Incision with staples in place. No erythema.
Incision site benign. Neurovascularly intact distally.
Pertinent Results:
[**2200-4-11**] 03:30PM PT-13.2* PTT-31.6 INR(PT)-1.2*
[**2200-4-11**] 03:30PM PLT COUNT-180
[**2200-4-11**] 03:30PM ANISOCYT-1+ POIKILOCY-1+ MICROCYT-1+
[**2200-4-11**] 03:30PM NEUTS-75.1* LYMPHS-13.8* MONOS-5.7 EOS-4.8*
BASOS-0.6
[**2200-4-11**] 03:30PM WBC-7.4 RBC-3.74* HGB-10.9* HCT-32.2* MCV-86
MCH-29.1 MCHC-33.8 RDW-16.9*
[**2200-4-11**] 03:30PM TSH-2.1
[**2200-4-11**] 03:30PM ALBUMIN-3.5 CALCIUM-10.4* PHOSPHATE-3.7
MAGNESIUM-2.1
[**2200-4-11**] 03:30PM ALT(SGPT)-14 AST(SGOT)-19 ALK PHOS-72 TOT
BILI-0.6
[**2200-4-11**] 03:30PM estGFR-Using this
[**2200-4-11**] 03:30PM GLUCOSE-108* UREA N-21* CREAT-1.4* SODIUM-137
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2200-4-22**] 07:30AM BLOOD WBC-7.0 RBC-3.08* Hgb-9.3* Hct-26.3*
MCV-85 MCH-30.4 MCHC-35.6* RDW-15.8* Plt Ct-107*
XRAY: Right tumor prosthesis hip arthroplasty, intact, reduced,
well aligned. No fractures.
Brief Hospital Course:
He was admitted for the reasons indicated above. He underwent
right hemi hip arthoplasty with a tumor prosthesis for treatment
of his peri-prosthetic fracture. His post-operative course was
remarkable for a prolonged intubation for respiratory failure.
He was extubated on or around post-operative day number one.
The remainder of his hospital course was unremarkable. He worked
with physical therapy, weight bearing as tolerated and was
discharged to rehab in stable condition on post-operative day
number seven.
Medications on Admission:
Fludrocortisone 0.1 mg qday
Atenolol 25 mg qday
Advair Diskus 100-50 mcg [**Hospital1 **]
Albuterol PRN
Prednisone 5 mg Tablet qday
Enoxaparin 30 mg/0.3 mL [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Tablet, Delayed Release (E.C.)(s)
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
5. Insulin Regular Human 100 unit/mL Solution Sig: [**1-21**]
Injection ASDIR (AS DIRECTED).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Fludrocortisone 0.1 mg Tablet Sig: 0.1 Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Enoxaparin 30 mg/0.3 mL Syringe Sig: 30 mg Subcutaneous
Q12H (every 12 hours) for 6 weeks.
14. Hydromorphone 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q2H
(every 2 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Metastatic renal cell carcinoma. Pathologic fracture of the
right femur.
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
During this admission you have been treated for metastatic renal
cell cancer and a pathologic fracture of the right femur.
Please continue to take all medications as prescribed. Seek
immediate medical care if you develop increasing pain, new
shortness of breath or chest pain, change in mental status or
any other concerning symptoms.
Followup Instructions:
Change dressings once a day until staples removed 14 days after
surgery. Keep incision site clean and dry until staples are
removed, then may shower. Do not soak in bathtub for 1 month.
Completed by:[**2200-4-25**]
|
[
"197.0",
"493.90",
"401.9",
"189.0",
"733.14",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.65",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
5262, 5341
|
3203, 3721
|
353, 425
|
5459, 5484
|
2266, 3180
|
5868, 6086
|
1942, 1959
|
3945, 5239
|
5362, 5438
|
3747, 3922
|
5508, 5845
|
1974, 2247
|
280, 315
|
453, 1415
|
1437, 1664
|
1680, 1926
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,829
| 196,691
|
4851
|
Discharge summary
|
report
|
Admission Date: [**2175-6-6**] Discharge Date: [**2175-6-8**]
Date of Birth: [**2105-3-31**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Bee Sting Kit
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Reason for transfer to MICU - hypotension, bleeding s/p IR
procedure
Major Surgical or Invasive Procedure:
R subclavian dailysis line placement
SVC stent placement
Temporary R femoral triple lumen central line placement
History of Present Illness:
70yo F w/ MMP including DM type II, HTN, and ESRD on HD,
presents to IR today for replacement of tunneled HD catheter
line as prior line was obstructed. Ms. [**Known lastname 18995**] had an SVC
obstruction which led to her having to have her R subclavian HD
catheter removed today, and a R IJ tunneled HD line placed. A
stent was placed to the SVC through her R femoral vein, but had
a significant amount of oozing and thus a triple lumen catheter
was placed to help achieve hemostasis. Intraprocedure, she had
been given 3000u heparin. Post-procedure, she was felt to be
oozing from all of her sites of intervention, so protamine was
given and manual compression was attempted. She became
transiently hypotensive after receiving protamine in IR suite,
but her BP responded on its own. On arrival to CC7 she had SBP
of 110 and this decreased to 80's and she had decreased
responsiveness, responding only to pain. Her hct dropped from 36
to 26.5. She has a hematoma on her R neck, circumference has
remained stable, without stridor. Oozing from groin is stable.
When initially evaluated by MICU team, pt minimally responsive,
receiving IVF (total of 1750 L on floor). Taken for emergent CT
scan which demonstrated no RP bleed. While in CT scan, pt became
more awake and responsive, taken to MICU for further
observation, where she was fully responsive. She denies any
chest pain, SOB, confused about recent events.
Past Medical History:
Hypertension
Type II DM
ESRD on HD [**1-26**] DM2 MWF
LGIB s/p cauterization/capping in ([**2-27**])
CAD, s/p NSTEMI
PVD
s/p R fem-[**Doctor Last Name **] bypass ([**2172**]) & s/p R AKA; L bypass ([**2163**]).
Hypothyroid
PAF
Depression
GERD
s/p fistula ligation in the left arm after becasue of
contracture
Social History:
Lives with her husband [**Name (NI) **] and her mother-in-law. Is usually
in a wheelchair, but able to do many ADLs in wheelchair (does
dishes, cleans herself).
Family History:
non-contributory
Physical Exam:
Temp 98.5, BP 104/67, HR 60, RR 18, O2 sat 94% on 3L NC
Gen: elderly woman, now awake, alert, easily reoriented to
recent events, no acute distress
Neck: R sided visible hematoma, pressure dressing in place,
tender to palp
Resp: crackles at bases, good air movement, no stridor
CV: [**Name (NI) 8450**] nl s1, s2, no m/r/g
Abd: soft, ND, NT, guiaic neg
Groin: R side with new femoral line in place, minimal oozing, no
hemotoma, no bruit
Extr: R AKA, L with no distal edema, 2+ distal pulses. L heel
with ulcer wrapped.
Pertinent Results:
[**2175-6-6**] 10:00AM BLOOD WBC-11.8* RBC-3.65* Hgb-11.3* Hct-36.0
MCV-99* MCH-31.1 MCHC-31.5 RDW-17.1* Plt Ct-247
[**2175-6-6**] 09:27PM BLOOD WBC-11.9*# RBC-2.82* Hgb-8.8* Hct-27.8*
MCV-99* MCH-31.4 MCHC-31.8 RDW-17.1* Plt Ct-212#
[**2175-6-6**] 11:18PM BLOOD WBC-9.8 RBC-2.65* Hgb-8.0* Hct-26.5*
MCV-100* MCH-30.1 MCHC-30.1* RDW-17.4* Plt Ct-196
[**2175-6-7**] 02:55AM BLOOD WBC-9.2 RBC-2.43* Hgb-7.6* Hct-24.2*
MCV-99* MCH-31.3 MCHC-31.5 RDW-17.4* Plt Ct-193
[**2175-6-7**] 10:18AM BLOOD Hct-31.5*#
[**2175-6-7**] 02:27PM BLOOD Hct-35.0*
[**2175-6-8**] 05:50AM BLOOD WBC-9.5 RBC-3.22*# Hgb-10.3*# Hct-30.7*
MCV-96 MCH-31.9 MCHC-33.4 RDW-17.0* Plt Ct-170
[**2175-6-6**] 10:00AM BLOOD PT-14.2* INR(PT)-1.3*
[**2175-6-8**] 05:50AM BLOOD PT-12.8 PTT-29.0 INR(PT)-1.1
[**2175-6-6**] 11:18PM BLOOD Glucose-288* UreaN-34* Creat-5.3*# Na-138
K-4.0 Cl-104 HCO3-26 AnGap-12
[**2175-6-8**] 05:50AM BLOOD Glucose-110* UreaN-18 Creat-3.8*# Na-142
K-3.7 Cl-105 HCO3-27 AnGap-14
[**2175-6-6**] 11:18PM BLOOD CK(CPK)-216*
[**2175-6-6**] 11:18PM BLOOD CK-MB-7 cTropnT-0.58*
[**2175-6-6**] 11:18PM BLOOD Calcium-6.5* Phos-4.1 Mg-1.6
[**2175-6-8**] 05:50AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
[**2175-6-7**] 02:55AM BLOOD Vanco-5.7*
.
[**6-6**] IR Procedure summary:
IMPRESSION: Successful placement of a new 14.5 French 23-cm
cuff-tip tunneled right internal jugular vein hemodialysis
catheter with tip in the superior aspect of the right atrium.
The catheter can be used immediately.
The previously placed tunneled right subclavian hemodialysis
catheter was removed.
Post-procedure, there was bleeding from each of the catheter
sites likely secondary to heparin administered for an earlier
performed procedure. The effects of heparin were reduced with
protamine and the bleeding stopped with the aid of manual
compression.
.
[**6-7**] CT torso: IMPRESSION:
1. No evidence of retroperitoneal hematoma. Post-procedure
changes in the right groin as described after line placement.
2. Persistent mediastinal and retroperitoneal prominent lymph
nodes. Please correlate with the patient's history.
3. Bibasilar atelectasis and likely small bilateral pleural
effusions.
Brief Hospital Course:
70 yo F with h/o CAD, DMII, PVD, s/p IR removal of R tunneled
subclavian catheter, placement of R subclavian tunneled
catheter, dilation and stenting of SVC, who was transferred to
MICU s/p procedure because of hypotension and 10 point
hematocrit drop.
.
1. Blood loss/anemia: noted to have 10 point drop in HCT
following extensive bleeding at IR procedure to HCT 24. Bumped
appropriately to 30 after 2 [**Location **], stable next AM at 30.
CT torso with no intraabdominal or retroperitoneal bleeding.
Neck hematoma stable, no active bleeding. Received protamine
after procedure to reverse heparin and DDAVP overnight for
improved platelet function.
Pt has close f/u given that she is scheduled for dialysis
tomorrow.
.
2. H/o afib - not on anticiagulation at home presumably due to
h/o GIB. Cont amiodarone, metoprolol.
.
3. ESRD: On HD, received one session without complication,
scheduled for next session as outpt.
.
4. h/o line infection last admission, rec'd last dose of 14 day
course of vancomycin at dialysis.
.
5. DM - cont outpt regiment of NPH, cover with RISS.
.
6. Hypertension: on metoprolol
.
7. Depression: cont paroxetine.
.
8. GERD: cont lansoprazole
.
9: R heel ulcer: minimal drainage. Per pt is improving. cont
dressing changes with silvadine.
.
10: PPX: pneumoboots, no SQ hep given bleeding, PPI, bowel
regimen
.
11: Code: full
Medications on Admission:
1. Levothyroxine 125 mcg PO DAILY
2. Paroxetine HCl 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Folic Acid 1 mg PO DAILY
5. Amiodarone 200 mg Tablet PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. Zinc Sulfate 220 mg PO DAILY
8. Lansoprazole 30 mg (E.C.) PO DAILY
9. Gabapentin 300 mg PO QHD
10. Calcium Acetate 1334 mg PO TID W/MEALS
11. Ascorbic Acid 500 mg PO BID
12. Acetaminophen 325 mg Tablet 1-2 Tablets PO Q4-6H PRN
13. Epoetin Alfa 6000 units qhd
14. Toprol XL 50 mg PO once a day
15. Docusate Sodium 100 mg PO BID
16. Senna 8.6 mg Tablet PO BID prn
17. Insulin NPH 30 units qAM
18. Codeine-Guaifenesin 10-100 mg/5 mL [**12-26**] tbsp PO QHS
19. Benzonatate 100 mg PO TID
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Epoetin Alfa 10,000 unit/mL Solution Sig: 6000 (6000) Units
Injection ASDIR (AS DIRECTED): QHD.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
17. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
18. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
19. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty
(30) Units Subcutaneous qAM.
20. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Bleeding complication from line insertion
Discharge Condition:
Patient in stable condition, with no bleeding and stable hct
Discharge Instructions:
Please take your medications as prescribed.
.
Please call your doctor ore return to the ER if you have chest
pain, shortness of breath, dizziness, bleeding from your line
site, increasing pain in your groin at the site of your old
line, fevers, or other concerning symptoms.
Followup Instructions:
Follow up with your regular dialysis sessions.
.
Youre previously scheduled appointments:
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Date/Time:[**2175-7-4**] 10:00
Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 10485**], MD Phone:[**Telephone/Fax (1) 2986**]
Date/Time:[**2175-7-4**] 10:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-7-10**] 2:20
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2175-6-8**]
|
[
"585.6",
"427.31",
"E849.7",
"707.15",
"707.14",
"250.40",
"530.81",
"403.91",
"458.29",
"459.2",
"E849.8",
"511.9",
"285.1",
"518.81",
"583.81",
"285.21",
"440.23",
"996.74",
"250.70",
"518.0",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"99.04",
"00.40",
"38.95",
"00.45",
"39.50",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8946, 9005
|
5186, 6542
|
350, 464
|
9090, 9152
|
3010, 5163
|
9475, 10116
|
2437, 2455
|
7269, 8923
|
9026, 9069
|
6568, 7246
|
9176, 9452
|
2470, 2991
|
242, 312
|
492, 1910
|
1932, 2243
|
2259, 2421
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,197
| 186,714
|
21578+57249
|
Discharge summary
|
report+addendum
|
Admission Date: [**2164-9-11**] Discharge Date: [**2164-10-17**]
Date of Birth: [**2120-10-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9223**]
Chief Complaint:
seizure and change in mental status
Major Surgical or Invasive Procedure:
cerebral angigraphy and coiling of anterior communicating artery
aneurysm, cerebral angiography with intrarterial injection of
nicardipine x2, IVC filter placement, PEG tube placement, and
tracheostomy
History of Present Illness:
Mr [**Known lastname 16905**] is a 43 yo male with no significant PMH who was
transfered from [**Hospital **] Hospital for management of subarachnoid
hemorrhage and seizures. He was apparently in his usual state of
good health until this morning. He woke up at 5:30 AM as usual
and then woke his wife. They watched TV in bed for a few minutes
as is their routine when she noted that he suddenly stretched
out
his arms, made a grunting noise, and began to shake "all over".
She immediately called EMS. She thinks this event lasted about 5
minutes or so. Then, he sat up in bed and said he felt fine.
EMS arrived and he was reportedly oriented x3. En route to
[**Hospital **] Hospital, he had another seizure which subsided
spontaneously. On arrival to OH, he was again noted to have
another seizure. He was given 1.5g dilantin. He went for CT
scan which showed large SAH. He was intubated and sedated and
sent via Mediflight to [**Hospital1 **]. In the hellicopter, he had another
prolonged seizure. Was started on phenobarbital drip. On
arrival to [**Hospital1 **] at 9:10AM , HR 80 BP 101/90 and RR15. Vent drain
was placed by neurosurgery in the ER. At 10:35 AM, while on the
CT table- he had another generalized seizure-4 mg Ativan was
given at that time. He was also noted to have questionable
seizure activity on return from CT scan which resolved
spontaneously. Pt was also treated with Pentothal 125mg IV x1 at
10:50AM. CT/CTA showed 4mm aecom aneurysm with large SAH. He
was taken emergently to angio suite for coiling.
Past Medical History:
None
Social History:
Pt lives with his wife and two daughters (age 8 and 13)
Family History:
No hx of aneurysm, stroke or seizure
Mother's side of family with CAD
Physical Exam:
VS: afebrile HR82 BP 121/85 RR 14 O2Sat 100% ICP 14
Gen: Well nourished male in bed, some spontaneous movement of
upper extremities bilaterally.
Neck: Supple
CV: RRR, distant S1/S2 no murmur
Lung: Clear to auscultation anteriorly
Abd: obese, +BS soft, nontender
Neurologic examination:
Mental status: Eyes closed, opens to tactile stimulation.
Intermittantly moves fingers and toes to command, but otherwise
unresponsive.
Cranial Nerves:
No blink to threat. Pupils 2mm trace reactive. Eyes were
midline, conjugate. +doll's. Corneal reflex present
bilaterally, grimaces to nasal tactile stim, No apparent facial
asymmetry, gag diminished.
Motor:
Normal bulk bilaterally. No adventitious movements. Tone
slightly decreased throughout. Some spontaneous arm movement
bilaterally (symmetric). Withdraws to pain purposefully in both
upper extremities. LE do not withdraw to pain, but do move non-
specifically in response to pain elsewhere.
Reflexes:
B T Br Pa Ach
Right 2 2 2 2 (brisk) 2
Left 2 0 2 2 (brisk) 2
Grasp reflex absent
Toes mute bilaterally
(Please see hospital course for phsical exam at discharge.)
Pertinent Results:
[**2164-9-11**] 10:23PM TYPE-ART PO2-127* PCO2-36 PH-7.41 TOTAL
CO2-24 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2164-9-11**] 06:08PM GLUCOSE-123* UREA N-10 CREAT-0.7 SODIUM-144
POTASSIUM-4.4 CHLORIDE-114* TOTAL CO2-17* ANION GAP-17
[**2164-9-11**] 06:08PM CALCIUM-7.6* PHOSPHATE-2.8 MAGNESIUM-1.4*
[**2164-9-11**] 06:08PM WBC-13.4* RBC-3.71* HGB-11.9* HCT-33.5*
MCV-91 MCH-32.2* MCHC-35.5* RDW-13.7
[**2164-9-11**] 06:08PM PT-12.6 PTT-23.5 INR(PT)-1.0
Brief Hospital Course:
On the day of admission, the patient's ruptured aneurysm was
initially managed medically with nimodipine, followed by
placement of a ventriculostomy catheter. The patient then
underwent a cerebral angiogram and a 4x3cm anterior
communicating artery aneurysm was coiled. The patient's seizures
were managed with dilantin and phenobarbital. Patient initially
did well following coiling, was extubated and following commands
intermittently. However, on hospital day 4 he developed
increasing somnolence and tachypnea to 36. HE was emergently re
intubated and a left subclavian central line was placed. On exam
he was noted to be extensor posturing in bilateral upper
extremities. He was taken back for cerebral angiogram where
vasospasm was noted in right PCA, MCA, and ACA territories and
intraarterial nicardipine was administered. Also a lumbar drain
was placed.
On hospital day number five HHH (hemodilution, hypertension,
hypervolemia) therapy was initiated. Blood pressures were kept
above 180 with Levophed and Neo-Synephrine and urine losses were
replaced 1:1 with normal saline. In addition, because of a high
white blood cell count in his CSF and high temperatures,
treatment with levofloxacin was added to previously started
ceftriaxone and vancomycin (later changed to vancomycin and
meropenem). Patient continued to spike fevers over next several
days and continued to have extensor posturing on physical exam.
An EEG on hospital day number 8 showed diffuse encephalopathy.
Third cerebral angiography on hospital day number 8 showed
continued vasospasm which was again treated with intraarterial
nicardipine.
HHH therapy for treatment of cerebral vasospasm, which was
initiated hospital day number 5, was discontinued on day number
20. At this time blood pressure parameters were liberalized to
140-160 and nimodipine was discontinued. His neurologic exam,
however, continued to demonstrate extensor/decerebrate
posturing. At times, nevertheless, he appeared to be withdrawing
to pain in bilateral upper and lower extremities. Despite
previous history of fevers and high WBC count in CSF no organism
was ever isolated from CSF. After numerous blood, urine,
sputum, and CSF cultures, the patient only had one positive
culture with coagulase negative staphylococcus and viridans
streptococcus(several subsequent cultures were negative). He
remained on vancomycin to treat this blood culture for
approximately 14 days. Repeat EEG on hospital day number 26
showed deep midline subcortical dysfunction again consistent
with encephalopathy.
A lumbar puncture on hospital day number 29, following
ventricular drain removal, revealed an opening pressure of 22.
In addition a head CT demonstrated increased hydrocephalus. A
VP shunt was then placed on hospital day number 31. Of
significant note on hospital day number 32 the patient's mental
status improved significantly and he was noted to be following
commands (he moved his tongue, hands, and feet bilaterally to
command). His mental status waxed and waned over the next
several days. CT scans during this time showed no change and a
lumbar puncture performed on hospital day number 35 had an
opening pressure of only 8.
The patient was discharged to the extended care facility in
stable condition with a PEG tube, tracheostomy, IVC filter, and
VP shunt all in place. His vital signs are all stable, and his
neurologic exam continues to fluctuate with occasional following
of commands. In general his pupils are reactive to ambient
light and he moves all four extremities.
Medications on Admission:
none
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
5000 Injection TID (3 times a day).
Disp:*90 5000* Refills:*2*
2. Insulin Regular Human 100 unit/mL Solution Sig: [**12-2**] see
slideing scael Injection ASDIR (AS DIRECTED).
Disp:*qs see sliding scael* Refills:*2*
3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) 1 NEB
Inhalation Q6H (every 6 hours) as needed.
Disp:*QS 1 NEB * Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
ruptured anterior communicating artery aneurysm
Discharge Condition:
fair
Discharge Instructions:
Please call doctor for failure to move any of his extremities,
any change in brain stem reflexes, or any other concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1132**] of neurology in 2 weeks with repeat
head CT
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 9225**]
Name: [**Known lastname 9769**],[**Known firstname **] Unit No: [**Numeric Identifier 10608**]
Admission Date: [**2164-9-11**] Discharge Date: [**2164-10-17**]
Date of Birth: [**2120-10-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10598**]
Chief Complaint:
see previous
Major Surgical or Invasive Procedure:
in addition to previously noted procedures patirnt also had a
lumbar drain, a ventriculostomy, and a VP shunt
History of Present Illness:
see previous
Past Medical History:
see previous
Social History:
see previous
Family History:
see previous
Physical Exam:
see previous
Pertinent Results:
see previous
Brief Hospital Course:
On [**2164-7-16**] the patient's foley stopped functioning and was
replaced. However, the urine abruptly turned bloody and
numerous clots were passed. The urine remained bloody
overnight. Following replacement with 20F foley and copious
irrigaton the urine turned clear. Urology was consulted and was
comfortable with this management. No further work-up was
indicated.
Medications on Admission:
see previous
Discharge Medications:
see previous
Discharge Disposition:
Extended Care
Discharge Diagnosis:
ruptured anterior communicating artery aneurysm
left eye vitreous hemorrhage
cerebral vasospasm
Discharge Condition:
see previous
Discharge Instructions:
Please remove all staples on scalp, behind ear and on abdomen
this Friday and place steri strips on the wound.
Please watch closely for any change in neurologic exam (i.e.
pupils should be reactive to ambient light and patient should
move all four extremities to pain)
Please watch wounds for any sign of infection including redness,
warmth, swelling, or foul smelling drainage.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 365**] of neurology in 2 weeks with repeat
head CT. Please call ([**Telephone/Fax (1) 1702**]
Please follow-up with opthalmology for left eye vitreous
hemorrhage.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 10600**]
Completed by:[**2164-10-17**]
|
[
"780.39",
"379.23",
"430",
"331.3",
"435.8",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"38.7",
"02.2",
"03.31",
"96.04",
"99.04",
"88.41",
"31.1",
"39.72",
"96.72",
"99.29",
"43.11",
"38.91",
"96.6",
"02.34"
] |
icd9pcs
|
[
[
[]
]
] |
10184, 10199
|
9709, 10084
|
9375, 9486
|
10339, 10353
|
9672, 9686
|
10782, 11127
|
9610, 9624
|
10147, 10161
|
10220, 10318
|
10110, 10124
|
10377, 10759
|
9639, 9653
|
9323, 9337
|
9514, 9528
|
2765, 3441
|
2627, 2749
|
2612, 2612
|
9550, 9564
|
9580, 9594
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,590
| 150,126
|
33613+57858
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-5-30**] Discharge Date: [**2112-6-3**]
Date of Birth: [**2031-10-23**] Sex: F
Service: SURGERY
Allergies:
Benzodiazepines / Vancomycin / Oxycontin / Rifampin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
This is a 80 year old female admitted with chronic abdominal
pain.
Major Surgical or Invasive Procedure:
Status Post placement of percutaneous cholecystotomy tube
History of Present Illness:
Had a recent previous admission for 2 days of abdominal pain,
nausea,
and vomiting with fevers as high as 102.1. An U/S was done
revealing cholecystitis.
A [**4-25**] RUQ U/S confirmed cholecystitis and choledocholithiasis
and she underwent percutaneous GB drain placement. 150 mL of
purulent bile was drained from the gallbladder and a pigtail
cathether was left in for further drainage.
Past Medical History:
Hypertension
Cholelithiasis,
T11-L1 osteomyelitis (s. epi, [**Female First Name (un) **]) c/b sepsis,
breast ca,
rotator calf injury R,
Past surgical history: status post Bilateral total hip
replacement THR,
status post L mastectomy,
status post L ankle repair
Social History:
Lives at [**Hospital 14468**] Nursing Home
Family History:
NC
Physical Exam:
Vital Signs: temperature 99, heartrate 100, blood pressure
106/93 respiratory rate 18 97% RA.
Gen: No apparent distress.
Cardiovascular: RRR
Pulmonary: Bilateral breath sounds diminished
Abdomen: abdomen soft with right percutaneous drain
Pertinent Results:
[**2112-5-30**] 12:00PM BLOOD WBC-17.2*# RBC-5.03# Hgb-15.1# Hct-44.2#
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.7 Plt Ct-435#
[**2112-6-3**] 06:05AM BLOOD WBC-9.9# RBC-3.08* Hgb-9.1* Hct-27.2*
MCV-88 MCH-29.6 MCHC-33.6 RDW-14.9 Plt Ct-276
[**2112-5-30**] 09:53PM BLOOD PT-18.6* PTT-44.0* INR(PT)-1.7*
[**2112-6-1**] 04:13PM BLOOD PT-18.8* PTT-38.9* INR(PT)-1.7*
[**2112-5-30**] 12:00PM BLOOD Glucose-68* UreaN-66* Creat-1.9*# Na-126*
K-5.9* Cl-94* HCO3-14* AnGap-24*
[**2112-6-3**] 06:05AM BLOOD Glucose-79 UreaN-6 Creat-0.2* Na-138
K-3.9 Cl-110* HCO3-21* AnGap-11
[**2112-5-30**] 12:00PM BLOOD ALT-18 AST-27 CK(CPK)-24* AlkPhos-284*
Amylase-773* TotBili-0.3
[**2112-6-2**] 07:11AM BLOOD ALT-10 AST-19 CK(CPK)-14* AlkPhos-128*
Amylase-98 TotBili-0.3
[**2112-5-30**] 12:00PM BLOOD Lipase-1340*
[**2112-6-3**] 06:05AM BLOOD Lipase-117*
[**2112-5-30**] 12:00PM BLOOD Albumin-3.4 Calcium-10.2 Phos-8.4*#
Mg-2.4
[**2112-6-3**] 06:05AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.4*
[**2112-5-30**] Ct Scan
IMPRESSION:
1. No evidence of cholecystostomy tube malpositioning or
pericholecystic fluid to suggest leak.
2. Gallstones with no evidence of cholecystitis.
3. Focal head pancreatitis.
4. Duodenal diverticulum.
Brief Hospital Course:
Patient admitted on [**2112-5-30**] with nausea and abdominal pain for
several days. Admitting diagnosis was pancreatitis, urinary
tract infection, and dehydration.
She was given 2 liters of intravenous fluids and started on
Intravenous antibiotics. Urine positive for gram negative rods,
white count 17.2, liver enzymes elevated. Admitted to the
intensive care unit for respiratory decompensation. Monitored
and followed until stable and then transfered to floor on
[**2112-6-1**].
Problems:
1. Pancreatitis - amylase and lipase down to near normal levels.
White count down to 9.9.
2. Urinary tract infection - Foley catheter changed on [**2112-6-3**].
Intravenous antibiotics given.
3. Dehydration - admitting bun and creatinine 66 and 1.9. Bun
and creatinine on [**2112-6-3**] 6 and .2. Would avoid daily lasix,
monitor for chf with daily weights.
4. Chronic Cholecystitis - Cardiology consult obtained on
[**2112-6-3**] in anticipation of a cholecystectomy in approximately 3
weeks.
5. Immobility/osteomyelitis - Patient is virtually immobile and
will need venous thrombus prophylaxis, like heparin SQ 5000
units SQ [**Hospital1 **]. Continue fluconazole po for [**Female First Name (un) **] related to
osteomyelitis. Methadone resumed for pain control on [**2112-6-3**].
6. Hypertension - Patients blood pressure has been well
controlled while in house.
7. Tachycardia - Patient has had bouts of tachycardia probably
related to dehydration. Currently back on her pre hospital
regimen of beta - blocker. While in hospital she required
supplement of intravenous beta - blocker.
Discharge Plans:
Patient will be discharged back to her nursing home today.
She will follow up with Dr. [**Last Name (STitle) **] on [**2112-6-10**]. Depending on
cardiology recommendations we will set up tentative appointment
for a cholecystectomy in approximately 3 weeks.
Medications on Admission:
atenolol 25", fluconazole 200', lexapro 20', protonix, percocet,
methadone 12.5", tylenol, colace, senna, MOM, [**Name (NI) **] 0.25"
Discharge Medications:
1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Methadone 5 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Heparin, Porcine (PF) 5,000 unit/0.5 mL Syringe Sig: One (1)
5000 units Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Admitted with chronic abdominal pain, cholecystitis by
ultrasound, dehydration and urinary tract infection.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have 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.
* 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.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2112-6-10**] 1:30
Completed by:[**2112-6-3**] Name: [**Known lastname 4609**],[**Known firstname 12571**] Unit No: [**Numeric Identifier 12572**]
Admission Date: [**2112-5-30**] Discharge Date: [**2112-6-3**]
Date of Birth: [**2031-10-23**] Sex: F
Service: SURGERY
Allergies:
Benzodiazepines / Vancomycin / Oxycontin / Rifampin
Attending:[**First Name3 (LF) 559**]
Addendum:
Cardiology was consulted and recommended:
1. Echo.
2. Start toprol xl 50 mg daily and stop atenolol.
3. Start lisinopril 5 mg daily.
4. Check a lipid profile and start simvastatin 20 mg daily.
5. Start asa 81 mg daily.
A bedside ECHO was performed before discharge.
A lipid profile will be faxed to Dr. [**Last Name (STitle) **] office.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 12573**] Nursing & Rehabilitation Center - [**Location (un) 4534**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**] MD [**MD Number(1) 561**]
Completed by:[**2112-6-3**]
|
[
"244.9",
"599.0",
"V43.64",
"730.18",
"300.00",
"276.51",
"401.9",
"V10.3",
"577.0",
"574.10",
"112.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7886, 8151
|
2722, 4588
|
378, 438
|
6113, 6122
|
1502, 2699
|
6956, 7863
|
1223, 1227
|
4774, 5827
|
5982, 6092
|
4614, 4751
|
6146, 6933
|
1042, 1146
|
1242, 1483
|
271, 340
|
466, 860
|
883, 1019
|
1162, 1207
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,114
| 188,411
|
21546
|
Discharge summary
|
report
|
Admission Date: [**2141-7-26**] Discharge Date: [**2141-7-31**]
Date of Birth: [**2063-5-18**] Sex: F
Service: MEDICINE
Allergies:
Zomig
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Anasarca
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo woman with a h/o dementia, HTN, AF, CHF (EF 60%), DM2,
recent admit for MRSA bacteremiareferred from neurosurgical
appointment (f/u occipitocervical fusion) for anasarca on [**7-26**],
which, the NH staff reports has gradually progressed over
several weeks The nursing home staff report that she is
intermittently agitated, bed-bound, and generally confused. She
has never complained of recent chest pain, shortness of breath,
N/V, abd pain, fevers, or dysuria. In the ED she was noted to
grade 4 sacral decubitus ulcer and +U/A. Sh recieved vanco and
levo. Head CT negative, CXR c/w CHF. She subsequently dropped
er SBP to the 70s, for whch she was transfused with 1 unit of
pRBCs. She was admitted to the MICU
Past Medical History:
Dementia
A-fib
HTN
OA
hypothyroidism
Asthma
COPD
Restrictive PFTs
OSA, refused BiPAP
CHF EF 60%
NIDDM W/PO antidiabetics.
Hypercapnic respiratory failure in [**11-24**] requiring intubation.
Cervical stenosis s/p cervico-occiptal fusion [**4-25**] --> prolonged
hospital stay at OSH post-op with MRSA bactreremia. On
vanc/rifampin planned until [**7-30**] (only on rifampin at present,
though)
CHF
Social History:
Jehovah's witness. No tobacco or EtOH.
Family History:
N/C
Physical Exam:
99.6 103 120/57 16 100%4L
Obese. NAD. begins speaking when touched
PERRL. MMM
Neck supple.
Heart irreg irreg. Tachycardic. 2/6 SEM at LSB
Lungs CTA ant
Abd +BS. s/NT/ND
4+ pitting edema with weeping fluid in LE.
Large packed 5-6 cm decub ulcer.
Pertinent Results:
[**2141-7-26**] 12:00PM BLOOD WBC-10.8# RBC-3.02* Hgb-9.0* Hct-29.8*
MCV-99* MCH-29.7 MCHC-30.1* RDW-15.7* Plt Ct-363#
[**2141-7-26**] 12:00PM BLOOD Neuts-81.6* Lymphs-13.4* Monos-3.9
Eos-0.9 Baso-0.1
[**2141-7-26**] 12:00PM BLOOD Hypochr-3+ Macrocy-2+
[**2141-7-26**] 12:00PM BLOOD PT-13.5* PTT-35.0 INR(PT)-1.2
[**2141-7-26**] 12:00PM BLOOD Plt Ct-363#
[**2141-7-26**] 12:00PM BLOOD Ret Aut-2.7
[**2141-7-26**] 12:00PM BLOOD Glucose-102 UreaN-15 Creat-1.0 Na-136
K-4.1 Cl-104 HCO3-24 AnGap-12
[**2141-7-26**] 12:00PM BLOOD ALT-10 AST-17 CK(CPK)-51 AlkPhos-113
Amylase-14 TotBili-0.4
[**2141-7-26**] 12:00PM BLOOD Lipase-12
[**2141-7-26**] 12:00PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2141-7-26**] 12:00PM BLOOD Albumin-1.8* Iron-34
[**2141-7-26**] 12:00PM BLOOD calTIBC-131* VitB12-1235* Folate-5.9
Ferritn-252* TRF-101*
[**2141-7-26**] 12:00PM BLOOD TSH-5.7*
[**2141-7-26**] 07:37PM BLOOD Type-ART pO2-94 pCO2-39 pH-7.43
calHCO3-27 Base XS-1 Intubat-NOT INTUBA
[**2141-7-26**] 12:44PM BLOOD Lactate-1.8
[**2141-7-26**] 01:20PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2141-7-26**] 01:20PM URINE Blood-MOD Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2141-7-26**] 01:20PM URINE RBC-[**3-25**]* WBC->50 Bacteri-MANY Yeast-FEW
Epi-0-2
[**2141-7-26**] 01:20PM URINE CastGr-0-2
Brief Hospital Course:
MICU course notable for (1) initial hypotension refractory to
volume/RBC challenge and was transiently on levophed X 1-2 days
(2) new CVL placed [**7-27**] (3) IV vanc for h/o MRSA bacteremia, a
wound Cx from decub grew pseudomonas (2+GPR, 2+GNR), and urine
grew both yeast and pseudomonas (4) TEE showed LVH, EF 70-80%,
dilated Ao and a small effusion, with no evidence for vegetation
(but poor quality study) (5) plastic surgery debrided the decub
(6) recurrent AT with RVR requiring dilt gtt X 1D which was
weaned to PO dilt. Since her hypotension resolved with Abx and
her HR was controlled off dilt gtt, she was transferred to the
floor as she was medically stable.
Pt arrived to floor at 0230 on Kinair bed frequently yelling
out. Portuguese speaking. VS 102/60, 98, 24, 98.6 with 02 sat
96% on 4 liters LS CTA with occ wheezes. Wt 303 lbs (+)
anasarca. On MRSA precautions. NGT in place ?????? (+) placement
via auscultation. Tube feed at 70cc/hr.
Pt was re-positioned at 5:40 am. RN entered room at 5:55am to
find patient cyanotic without respirations or pulse. Code
initiated. Asystolic arrest with transient PEA. Pt pronounced
as expired after approximately 20min of resusitative efforts.
Of note, respiratory noted large amounts of tube feed material
when sxn??????d after intubated.
Medications on Admission:
Meds on transfer to the floor: levofloxacin 250mg iv daily,
fluconazole, vancomycin 1 gram daily, synthroid, diltiazem 30mg
4 times per day, Vitamin B12, Vit C, Zinc, Famotidine, Iron
Sulfate, Docusate, insulin sliding scale, heparin SQ
Discharge Disposition:
Expired
Discharge Diagnosis:
Anasarca
Atrial Fibrillation, Rapid
Cardiac Arrest
Discharge Condition:
Expired
|
[
"428.31",
"273.8",
"427.5",
"707.03",
"038.9",
"250.00",
"427.31",
"041.7",
"496",
"995.92",
"294.8",
"599.0",
"401.9",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"86.22",
"99.04",
"99.60",
"96.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
4793, 4802
|
3195, 4506
|
274, 280
|
4896, 4906
|
1827, 3172
|
1526, 1531
|
4823, 4875
|
4532, 4770
|
1546, 1808
|
226, 236
|
308, 1030
|
1052, 1453
|
1469, 1510
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,825
| 141,379
|
1513
|
Discharge summary
|
report
|
Admission Date: [**2124-3-1**] Discharge Date: [**2124-3-4**]
Date of Birth: [**2058-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Central Venous Line Placement
History of Present Illness:
65 year old with a history of Hypercholesterolemia,
Hyperthyroidism who presents with complaint of nausea and
vomiting x 3 days. Patient reports at least 10 episodes of
vomiting per day. Emesis is non-bloody with no coffee grounds.
He reports +abdominal pain during episodes of emesis but no
emesis in between episodes. He denies diarrhea, melena, BRBPR,
hematochezia, cough, chest pain, SOB, palpitations, radiating
pain, dysuria, urinary frequency or headache. He denies sick
contacts. [**Name (NI) **] recently moved from [**Male First Name (un) 1056**] on [**2124-1-19**]. No
other recent travel.
In the ED:
Patient was noted to have ST depressions in lead V5-6. Plan
initially was for ED Obs and 2 sets with stress test in the
morning. He was given ASA 325mg x 1, Zofran 4mg IV x 1. He was
noted febrile to 102 and became hypotensive with BP 70s/30s. He
received 6L IVF in the ED. RIJ Central Line was placed. He was
still hypotensive and started on Levophed as a pressor. Serum
Lactate was done and was normal. Patient continued with
abdominal pain. RUQ U/S done and was negative. CT
Chest/ABD/Pelvis done and also negative. He was given Levo
750mg IV x 1 and Flagyl 500mg IV x 1. Last vitals in the ED:
107/56, temp 98.4, hr 81, rr 18 100%
Patient was emergently transferred to the Medical ICU for
management of Septic Shock per sepsis protocols.
Past Medical History:
Hypercholesterolemia
Hypothyroidism
Depression
Social History:
Denies EtOH, tobacco or illict drug use. From [**Male First Name (un) 1056**],
recently moved from there on [**2124-1-19**]. Visiting with his wife
in [**Name (NI) 86**].
Family History:
Non-contributory
Physical Exam:
VS: Temp 99.4, BP 113/63, HR 81, RR 18 100% RA
GEN: Elderly man in mild distress, awake, alert
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP dry
and without lesion
NECK: Supple, no JVD, no LAD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
STUDIES:
ECG on arrival: NSR, no T wave changes, < 1mm ST depression
V5-V6.
ECG at 9pm: NSR, no T wave changes, ST depression resolved, no
other ST changes
CT Torso [**2123-2-28**]: (prelim)
No dissection. No filling defects in pulmonary arteries. No
pericardial or pleural effusion. Mild bibasilar atelectasis. No
free fluid or air in the abdomen. +gallstones without wall
thickening or pericholecystic fluid. No bowel obstruction.
CXR [**2123-2-28**]: (prelim)
No acute process
RUQ U/S [**2123-2-28**]: (prelim)
+gallstones. No evidence of cholecystitis
[**2124-3-4**] 06:25AM BLOOD WBC-5.7 RBC-3.48* Hgb-9.9* Hct-27.9*
MCV-80* MCH-28.5 MCHC-35.4* RDW-13.9 Plt Ct-242
[**2124-2-29**] 03:48PM BLOOD WBC-11.7* RBC-4.31* Hgb-12.5* Hct-34.7*
MCV-80* MCH-29.0 MCHC-36.0* RDW-13.8 Plt Ct-296
[**2124-3-1**] 01:30AM BLOOD Neuts-79.7* Lymphs-17.2* Monos-2.7
Eos-0.3 Baso-0.2
[**2124-2-29**] 03:48PM BLOOD Neuts-83.1* Lymphs-13.2* Monos-3.0
Eos-0.3 Baso-0.4
[**2124-3-1**] 03:00AM BLOOD I-HOS-DONE
[**2124-3-3**] 05:15AM BLOOD PT-13.0 PTT-30.3 INR(PT)-1.1
[**2124-3-2**] 03:54AM BLOOD PT-13.9* PTT-33.4 INR(PT)-1.2*
[**2124-3-1**] 01:52PM BLOOD PT-15.9* PTT-35.4* INR(PT)-1.4*
[**2124-3-1**] 01:30AM BLOOD PT-17.0* PTT-94.1* INR(PT)-1.5*
[**2124-2-29**] 03:48PM BLOOD PT-14.9* PTT-30.7 INR(PT)-1.3*
[**2124-3-1**] 03:00AM BLOOD Ret Aut-1.1*
[**2124-3-4**] 06:25AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-144
K-3.3 Cl-106 HCO3-30 AnGap-11
[**2124-3-4**] 06:25AM BLOOD TotProt-6.0* Calcium-8.2* Phos-3.2 Mg-1.8
[**2124-3-2**] 03:54AM BLOOD Calcium-8.0* Phos-1.7* Mg-2.0 Iron-43*
[**2124-3-1**] 01:52PM BLOOD Calcium-7.8* Phos-2.5* Mg-2.5
[**2124-3-1**] 01:30AM BLOOD Calcium-7.4* Phos-3.1 Mg-1.4*
[**2124-2-29**] 03:48PM BLOOD Albumin-4.5 Iron-23*
[**2124-3-2**] 03:54AM BLOOD calTIBC-183* Ferritn-556* TRF-141*
[**2124-3-1**] 04:35AM BLOOD Hapto-77
[**2124-2-29**] 03:48PM BLOOD calTIBC-268 Ferritn-787* TRF-206
[**2124-3-3**] 05:15AM BLOOD TSH-5.8*
[**2124-2-29**] 03:48PM BLOOD TSH-7.2*
[**2124-3-3**] 05:15AM BLOOD T3-48* Free T4-0.53*
[**2124-3-1**] 05:30AM BLOOD T4-3.2*
[**2124-3-1**] 05:30AM BLOOD Cortsol-8.9
[**2124-3-1**] 04:35AM BLOOD Cortsol-5.5
[**2124-3-1**] 04:33AM BLOOD Cortsol-11.2
[**2124-3-4**] 06:25AM BLOOD PEP-NO SPECIFI
[**2124-3-1**] 08:26AM BLOOD Type-MIX
[**2124-3-1**] 01:39AM BLOOD Lactate-0.9
[**2124-2-29**] 08:20PM BLOOD Lactate-1.5
[**2124-3-1**] 08:26AM BLOOD O2 Sat-78
[**2124-3-1**] 01:52PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2124-2-29**] 09:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2124-3-1**] 01:52PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2124-2-29**] 09:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2124-3-1**] 01:52PM URINE RBC-10* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
[**2124-3-1**] 1:52 pm URINE Source: Catheter.
**FINAL REPORT [**2124-3-2**]**
URINE CULTURE (Final [**2124-3-2**]): NO GROWTH.
[**2124-3-1**] 1:00 am Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2124-3-1**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2124-3-1**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2124-3-1**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
[**2124-2-29**] 8:20 pm BLOOD CULTURE
**FINAL REPORT [**2124-3-6**]**
Blood Culture, Routine (Final [**2124-3-6**]): NO GROWTH.
[**2124-2-29**] 8:15 pm BLOOD CULTURE
**FINAL REPORT [**2124-3-6**]**
Blood Culture, Routine (Final [**2124-3-6**]): NO GROWTH.
[**2124-2-29**] 4:30 pm BLOOD CULTURE
**FINAL REPORT [**2124-3-6**]**
Blood Culture, Routine (Final [**2124-3-6**]): NO GROWTH.
Brief Hospital Course:
This 65 yom with hx of HTN, Hyperthyroidism who presents with
complaint of nausea and vomiting x 3 days, also with abdominal
pain who presented in septic shock in the ED admitted to the ICU
for hypotension.
# Septic Shock, Leukocytosis, Fever: Mr. [**Known lastname 8878**] presented to
the Emergency Room with leukocytosis, fevers, abdominal pain,
nausea, vomiting and refractory hypotension. He required
pressor support with levophed for hypotension which was
successfully weaned off in the ICU. No source of infection was
identified despite multiple cultures. CT torso was negative.
LFTs, lipase were also negative. He was covered broadly with
antibiotics with Vancomycin and Zosyn in the ICU, but these were
discontinued on transfer to the floor. He remained afebrile and
normotensive off pressors. Symptoms would be consistent with a
viral syndrome in the setting volume depletion, adrenal
insufficiency, and/or myxedema. He was influenza DFA negative.
Thyroid studies were felt to be consistent with sick euthyroid
syndrome. His cortisol stimulation test was consistent with
adrenal insufficiency and was he started on stress dose
steroids, with improvement in pressures. He was stable off
steroids and antibiotics on discharge.
# ST depressions: Initial ECG with < 1mm ST segment depressions
on ECG which subsequently resolved. These resolved in a few
hours and his cardiac enzymes remained negative.
- He will likely need a stress test as an outpatient for
evalution, although most likely consistent with demand ischemia
in the setting of septic shock.
# Anemia: Patient had an acute hematocrit drop in setting of
IVF resuscitation. Although this was likely dilutional in the
setting IVF resuscitation, he was mildly microcytic with very
poor reticulocyte count. Ferritin was up as well, but this may
be acute phase reactant. He was not grossly iron deficient, but
iron levels were low. His SPEP was normal. His hematocrit was
stable. Would continue to follow and consider outpatient
colonoscopy.
# Hypothyroidism: continued Synthroid, thyroid studies as above
CONTACT: Wife [**Name (NI) **], [**Telephone/Fax (1) 8879**]
Medications on Admission:
(patient was unsure):
Synthroid?
Lisinopril?
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. The remainder of your home medications are unknown. Please
resume according to your previous regimen. Sig: One (1) once
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Nausea/vomiting
Adrenal insufficiency
Hypothyroidism
Discharge Condition:
Hemodynamically stable, afebrile.
Discharge Instructions:
You were admitted to the hospital with fevers, vomiting, and low
blood pressure. You were evaluated for infection and treated
with broad-spectrum antibiotics. Antibiotics were discontinued
after culture data failed to reveal any evidence of infection.
It is possible that this was a viral gastroenteritis.
.
You should return to the hospital if you are experiencing
fevers, sweats, chest pain, shortness of breath, intractable
vomiting, or other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care physician in the next
7-10 days. You should have your thyroid function checked at
this visit. If you do not already have a primary care physician
in [**Name9 (PRE) 86**], please call [**Hospital3 **] at [**Hospital1 18**] to set up
an appointment to establish care with a new physician.
[**Hospital3 **] phone number: [**Telephone/Fax (1) 250**].
.
Please have your Doctor [**First Name (Titles) **] [**Last Name (Titles) 8880**] [**Country **] call [**Hospital1 18**] at
[**Telephone/Fax (1) **] to obtain medical records of your stay.
Completed by:[**2124-3-20**]
|
[
"244.9",
"787.01",
"458.9",
"401.9",
"311",
"255.41",
"272.0",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8915, 8921
|
6440, 8591
|
331, 362
|
9030, 9066
|
2491, 6417
|
9583, 10193
|
2042, 2060
|
8687, 8892
|
8942, 9009
|
8617, 8664
|
9090, 9560
|
2075, 2472
|
275, 293
|
390, 1765
|
1787, 1835
|
1851, 2026
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,712
| 101,245
|
38655
|
Discharge summary
|
report
|
Admission Date: [**2147-2-6**] Discharge Date: [**2147-2-15**]
Date of Birth: [**2098-5-30**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p Self inflicted stab wound to chest/abdomen
Major Surgical or Invasive Procedure:
[**2147-2-6**] Exploratory laparotomy
History of Present Illness:
48 year old man with unknown past medical history with self
inflicted anterior cheststab wounds. Per report, patient's
roommate found him lying in his own
blood with two stab wounds to his anterior chest (slightly left
of
sternum). Per report, patient stated that he "fell on the
kitchen
knife." He was taken to an area hospital where he was intubated
secondary to combativeness and left chest tube placed with < 100
cc of immediate output (200 cc output upon arrival to [**Hospital1 18**]).
Given penetrating abdominal
trauma, he was taken to the OR immediately for exploration and
was found to have a 2 cm left lateral lobe liver laceration.
Also, given concern for possible mediastinal injury and possible
pericardial tamponade, the mediastinum was explored.
Past Medical History:
Unknown
Family History:
Unknown psych family history
Pertinent Results:
[**2147-2-6**] 10:30PM GLUCOSE-365* LACTATE-6.1* NA+-132* K+-4.1
CL--101 TCO2-16*
[**2147-2-6**] 10:20PM WBC-42.6* RBC-3.42* HGB-9.7* HCT-29.8* MCV-87
MCH-28.4 MCHC-32.6 RDW-13.6
[**2147-2-6**] 10:20PM PLT COUNT-464*
[**2147-2-6**] 10:20PM PT-13.0 PTT-26.2 INR(PT)-1.1
Micro/Imaging:
[**2147-2-7**] CXR Subtle decrease of the pre-existing retrocardiac
opacity
[**2147-2-7**] XR Left foot no plain film findings that suggest
osteomyelitis
[**2147-2-7**] wound cx GS - no polys, no orgs; Cx - BETA
STREPTOCOCCUS GROUP B
[**2147-2-7**] elevations
[**2147-2-7**] urine cultur no growth
[**2147-2-7**] sputum culture GS - 1+GPCs pairs; Cx - sparse growth
commensal resp flora
[**2147-2-6**] CXR LLL opacity
[**2147-2-6**] KUB No abnormal radiopaque foreign body identified
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Findings
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Aortic valve not well seen.
MITRAL VALVE: Mild (1+) MR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - bandages,
defibrillator pads or electrodes.
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Grossly preserved biventricular systolic function.
No pericardial effusion.
Brief Hospital Course:
He was admitted to the Trauma Service and taken directly to the
operating room because of hemodynamic instability where he
underwent an exploratory laparotomy and a pericardial window was
created. He was found to have a 2 cm liver laceration. He was
taken to the ICU for hypotension and tachycardia ; he was found
to have a Grade II liver laceration. Post operatively he was
taken to the Trauma ICU where he remained intubated and sedated.
Upon initial admission to the ICU he remained hypotensive and
tachycardia; he received IVF and 6 units of PRBCs (his Hct on
[**2-11**] was 22 and on [**2-13**] 24.8).
Cardiology was also consulted for evaluation and management of
ST elevations. Recommendations included to monitor serial
enzymes and if remained stable no need to continue cycling. Also
follow daily ECG and it was felt that because patient was
without signs of pericarditis that no further treatment was
warranted. If he did develop any signs of pericarditis then
NSAID's would be treatment. An ECHO was also done which showed
grossly preserved biventricular systolic function and no
pericardial effusion. He was noted with increase in his
diastolic blood pressure without any other associated symptoms
such as headache, dizziness or chest pain. Lopressor was started
for this.
On [**2-7**], podiatry was consulted for left foot ulcer. Upon removal
of hyperkeratotic tissue, there was a < 1cm in diameter
ulceration noted to the plantar aspect of the 2nd metatarsal
head tracking dorsally into the 1st and 2nd interspace and 2nd
and 3rd
MPJs. Erythema noted along the medial longitudinal arch as well
as dorsally to the level of the midfoot. Synovial fluid was
drained and sent for culture. The wound probed to skin but not
to bone; left foot xray done and without evidence of
osteomyelitis. Empirical Vancomycin and Zosyn were started. He
was later changed to Levofloxacin 500 mg for a total of 14 days.
His sedation was weaned and eventually he was extubated and was
transferred to the floor on [**2-9**]. He has made significant gains
in terms of his hemodynamic stability and his functional
abilities. He has worked with Physical and Occupational therapy
for ambulation and is independent with his walker. He is on a
regular diet and is tolerating this without any difficulties.
His current vitals signs are T 98.9 BP 122/67 HR 74 (90 w/
activity then back down to 70's) room air sats 95%. His
hematocrit as mentioned previously has run low and has been
followed closely along with other hemodynamic monitoring. There
are no signs of any active bleeding at this time. He failed an
initial voiding trial and the Foley was replaced and he was
started on Flomax. The Foley should remain in place for at least
another several days before another voiding trial is initiated.
For pain control he is receiving Tylenol and prn Dilaudid. His
abdominal staples remain in place, wound edges are well
approximated. The staples will need to be removed in [**10-19**] days
post procedure date.
Medications on Admission:
Unknown
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 13 days.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Self inflicted stab wounds to chest & abdomen
Grade II liver laceration
Left foot ulcer/infection
Acute blood loss anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were hospitalized following self inflicted stab wounds to
your chest & abdominal regions and were taken to the operating
room for exploration of your injuries. You were found to have an
injury to your liver.
You are being treated with an oral antibiotic called
Levofloxacin which will need to continue until [**2147-2-26**].
Followup Instructions:
Follow up next week with Dr. [**Last Name (STitle) **], Trauma Surgery for removal
of your staples. If you are discharged to [**Hospital1 **] 4 the nurse
from that unit may contact the trauma resident pager [**Numeric Identifier 85877**]
during the week of [**2-19**] to have them removed.
Completed by:[**2147-4-19**]
|
[
"864.13",
"041.02",
"E956",
"V62.84",
"420.91",
"276.2",
"276.52",
"311",
"707.15",
"357.2",
"250.80",
"682.7",
"875.0",
"250.60",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.12",
"96.71",
"50.61",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
7033, 7103
|
3061, 6057
|
327, 366
|
7272, 7272
|
1253, 3038
|
7770, 8090
|
1204, 1234
|
6117, 7010
|
7124, 7251
|
6083, 6092
|
7416, 7747
|
241, 289
|
394, 1157
|
7286, 7392
|
1179, 1188
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,339
| 191,031
|
19754
|
Discharge summary
|
report
|
Admission Date: [**2106-10-22**] Discharge Date: [**2106-11-1**]
Date of Birth: [**2027-12-16**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: On [**2106-10-22**], this 78 year old
female had the onset of the worst headache of her life while
shopping. The patient was sent to an outside hospital for
which the CT scan showed a large subarachnoid hemorrhage in
the basal cistern with a right Sylvian fissure clot. While
being transferred en route by ambulance to [**Hospital1 346**], she became apneic and obtunded with
desaturations into the 80s per report of the ambulance crew.
The patient was intubated and paralyzed on arrival, but her
blood pressure is 170/80; pulse is 72; she is intubated and
sedated. Pupils were 2 mm and not reactive. She had
positive doll's eye, negative gag to deep stimulation, not
moving her upper extremities. She withdrew her bilateral
lower extremities triple flexion. Her toes were up; her face
was symmetric.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Paroxysmal atrial fibrillation.
MEDICATIONS:
1. Toprol.
ALLERGIES: None known.
LABORATORY: White blood cell count was 11.7, hematocrit
40.8, platelets 216. PT 12.7, PTT 25, and 1.1 for INR.
Urinalysis was negative.
Sodium 139, potassium 4.7, chloride 101, CO2 23, BUN 13,
creatinine 0.7.
CT scan of the head showed a massive subarachnoid hemorrhage
in the basal cistern, third and fourth ventricles with
increased blood and hydrocephalus between the outside
hospital and arriving here. A CT angiogram showed a 10 mm
right PCom aneurysm.
HOSPITAL COURSE: The patient was brought up to the Intensive
Care Unit where she had a ventriculostomy drain placed
requiring two passes and received a return of bloody
cerebrospinal fluid under high pressure. The patient was
brought to the Angio Suite where she underwent a cerebral
angiogram and a coiling of her right PCom aneurysm. Also
showed sluggish intracranial flow through the right carotid,
right PCom aneurysm and coil of the right PCom aneurysm.
ICPs are stable throughout the procedure. There were no
complications. The patient was brought back to the Intensive
Care Unit where the EVD was kept at 8 and systolic blood
pressure was kept less than 140 and she had a repeat CT scan
in the morning.
Postoperatively in the morning of [**10-23**], her pupils were 2 on
the right and 1.5 on the left, trace, flexor, posturing in
her upper extremities; her toes were upgoing. She was not
withdrawing her lower extremities. Her drain functioned
well.
She had a central line placed. On the 16th, the patient did
open her eyes to stimulation; her pupils were 2.5 to 1.5 more
reactive, localized on the right briskly, attempt to localize
on the left. She was moving her legs to stimulation. Her
blood pressure was kept in the 100s to 140s. She was started
on tube feedings and the patient seemed to be improving.
On the [**4-24**], the patient was opening her eyes
bilaterally and was moving her bilateral arms spontaneously.
It was questionable whether or not she was following
commands. Her CPP was kept between 4 and 6. Her blood
pressure was kept in the 120 to 140 range. On the 17th, the
patient had a CT scan which was stable. She received a unit
of blood for a hematocrit of 24.8.
On the [**4-26**], her temperature rose to 101.6 F.;
cerebrospinal fluid was sent off that showed four plus
leukocytes, no microorganisms. Her ventriculostomy drain
continued to be working well. She was slowly opening her
eyes and moving her right thumb to command, localizing in her
left arm and localizing on her right arm. On the [**4-28**], the patient had a repeat head CT scan which showed
a stable appearance of hemorrhagic areas with no rebleed but
diffuse increased edema with slight increase in mass effect.
There is an interval increase in the left interparenchymal
bleed along the tract of the vent drain with shift; this was
shown on the second CT scan.
The patient's sodium was 130. She was started on 3% saline
at 10 cc an hour to get her sodium up to 135. She had q. two
hour sodium checks. Also on the 21st, it was noted that her
vent drain was not functioning and TPA was given by Dr. [**Last Name (STitle) 1132**]
the vent drain itself which later did start to work again.
Her examination on the morning of the [**4-29**], the
patient's eyes opened spontaneously. Her pupils were 2.5 to
1.5, slight attempt to grasp on the left, localized, and on
her right upper extremity greater than her left upper
extremity, and withdraws bilaterally in her lower
extremities. Did not follow commands.
She continued to have her sodiums checked q. two hours. Her
sodium was 133, in the morning of the 22nd. Her
ventriculostomy drain was at 10. Her systolic blood
pressures kept less than 150.
On [**2106-10-30**], at 10:15 p.m., the vent drain was noted not to
work and Dr. [**Last Name (STitle) 1132**] was called in, where he flushed the drain
with normal saline without improvement. He felt the right
frontal EVD had increased clot and had clotted with new
blood. The head CT scan reports showed no change in
subarachnoid hemorrhage pattern; no suggestion of aneurysmal
rebleed but there is new interventricular hemorrhage
extending along the left frontal hemorrhage. The patient was
noted to have nonreactive pupils with decreased gaze. A
second vent drain was placed and that also clotted off.
Dr. [**Last Name (STitle) 1132**] discussed the poor prognosis with the family and
she was treated with medical management kept neutral with
Lasix and 3% normal saline.
On the morning of the 23rd, the patient's examination showed
nonreactive 5 mm bilateral pupils, no corneal; the patient
was not breathing over the vent. Mannitol was given q. four
hours and we were watching her sodium.
On [**2106-10-31**] at 12:36 p.m., the patient was pronounced brain
dead. The patient later died surrounded by her family and
was pronounced dead on 10:15 p.m. on [**2106-11-1**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2106-11-1**] 23:06
T: [**2106-11-2**] 11:45
JOB#: [**Job Number 53393**]
|
[
"331.4",
"430",
"780.6",
"427.31",
"401.9",
"342.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.41",
"96.72",
"02.2",
"96.6",
"38.91",
"89.62",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
1591, 6236
|
171, 980
|
1002, 1573
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,261
| 113,684
|
52705
|
Discharge summary
|
report
|
Admission Date: [**2193-2-14**] Discharge Date: [**2193-2-16**]
Date of Birth: Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old
male admitted to the MICU with sepsis, hypertension, status
post episode of ventricular tachycardia now on pressors. The
patient was admitted to the Vascular Service between [**12-30**]
and [**2193-1-17**]. He has an extensive history of peripheral
vascular disease and status post left femoral popliteal
bypass with a jump graft and a left second toe amputation and
revision. The patient was found to have a gangrenous wound
with involvement of the left third toe with purulent
discharge and breakdown of the incision site and underwent
further debridement and revision. He was evaluated by his
vascular surgeon Dr. [**Last Name (STitle) **] and thought to be stable for
rehab and that the wound was viable and without need for
further surgical intervention. The patient was at rehab when
he started complaining of difficulty swallowing and coughing
up dried blood on [**2193-2-13**] and neck pain.
Rehab doctor was called to evaluate the patient for same
complaints and blood pressure was noted to be 70/40 with a
heart rate of 92, white count 33.6. Blood cultures from
[**2193-2-12**] had four out of four bottles growing gram positive
cocci while on Vancomycin and Levaquin and the patient was
febrile to 102. The patient was transferred to [**Hospital1 346**], but on route developed ventricular
tachycardia while on Dopamine and was diverted to [**Hospital3 11531**]. Apparently ventricular tachycardia spontaneously
resolved and the patient was stable in their Emergency
Department and he was sent to [**Hospital1 188**] Emergency Department while awaiting MICU bed. In the
Emergency Department here his blood pressure was 60/palp.
The patient was started on neo-synephrine, fluid boluses and
Flagyl was added to his antibiotic regimen.
PAST MEDICAL HISTORY: Coronary artery disease status post
myocardial infarction in [**2169**], status post coronary artery
bypass graft in [**2183**], status post catheterization in [**11-8**]
with patent left internal mammary coronary artery to left
anterior descending coronary artery, patent supraventricular
tachycardia to obtuse marginal two and occluded saphenous
vein graft to right coronary artery. Exercise MIBI on
[**2192-11-22**] showed fixed apical defects, severe fixed distal
anterior wall defect with minimal reversible defect in distal
inferior wall, global left ventricular hypokinesis and apical
akinesis, EF of 22%. Paroxysmal atrial fibrillation, type 2
diabetes, end stage renal disease on hemodialysis since
[**11-8**], hypercholesterolemia, renal cell carcinoma status post
right nephrectomy in [**2182**] with metastasis to bone treated
with radiation therapy in [**10/2192**] with metastasis to
gallbladder status post cholecystectomy and status post
abdominal wall dissection. Hypothyroidism, peripheral
vascular disease status post above surgeries.
MEDICATIONS: Colace, Nephrocaps, Lopressor 12.5 b.i.d.,
Amiodarone 200 q day, Synthroid 100 micrograms q day, Pepcid
20 mg q day, Senna, vitamin C, Levaquin 250 mg po after
hemodialysis. Zocor 40 q.d., NPH 16 units in the a.m. and 3
units in the p.m. Calcitriol, Reglan, zinc, aspirin,
Coumadin 1 mg po q day, Vancomycin dose with hemodialysis.
ALLERGIES: Ativan makes the patient "go crazy."
SOCIAL HISTORY: No tobacco. Rare alcohol.
PHYSICAL EXAMINATION: Vital signs 60/palp increased to 97/36
on neo-synephrine. Pulse 97. Respiratory rate 22. Sating
98% on 2 liters nasal cannula. In general the patient is in
bed in no acute distress. HEENT oropharynx clear. Sclera
anicteric. Neck mildly swollen and full, nontender, no
lymphadenopathy. No JVD. Lungs with decreased breath sounds
at the bases. Cardiovascular irregular irregular rhythm.
Normal S1 and S2. Abdomen was soft, nontender, nondistended
with normoactive bowel sounds. Extremities left lower
extremity with TMA frankly necrotic, but no purulence.
INITIAL DATA: White blood cell count 27.6 with 97%
neutrophils, 3 lymphocytes, 3 monocytes, hematocrit 29.5,
platelets 537, INR 3.1, liver function tests within normal
limits. Chem 7 143, 4.8, 106, 23, 29, 4.2, glucose 73.
Initial CK negative. Rhythm strip with sustained ventricular
tachycardia. Electrocardiogram subsequently showed atrial
fibrillation rate of 97, Q waves in 3 and V1, poor R wave
progression, no ST or T wave changes, unchanged from [**2193-1-30**].
Chest x-ray showed possible right lower lobe infiltrate with
obscured right hemidiaphragm. CT of the neck showed
degenerative changes of the cervical spine, but no pharyngeal
fluid collections.
HOSPITAL COURSE: 1. Vascular surgery evaluated the patient
and they determined when the patient was medically stable
that he would require bilateral below the knee amputations.
In the interim the patient's left TMA wound received bedside
debridement.
2. The patient was also complaining of new onset right sided
blindness. Ophthalmology evaluated the patient in the
Emergency Department. There is no evidence of septic emboli.
The patient's blindness was consistent with AION.
3. The patient was also seen by the Infectious Disease
Service for his staph aureus bacteremia, which is likely
secondary to his gangrenous foot. Other sources of infection
could hve included his dialysis catheter. The patient was
continued on Vancomycin and Ciprofloxacin as well as Flagyl.
4. Cardiovascular, the patient continued to be persistently
hypotensive. He was started on neo-synephrine to which
Levophed was also added. The patient also started to become
dyspneic for which he was intubated. Immediately after his
intubation the patient became increasingly hypotensive and
also had an episode of ventricular tachycardia and also had
several episodes of supraventricular tachycardia. Both of
his arrhythmias resolved spontaneously. The patient also had
a metabolic acidosis, which was being poorly compensated. At
that time a family meeting was held and the gravity of his
situation was explained. On [**2193-2-16**] the patient's family
decided to withdraw care. The patient was extubated and
started on a morphine drip and the patient expired shortly
thereafter. The time of death was 7:30 p.m. on [**2193-2-16**].
CAUSE OF DEATH:
Respiratory failure secondary to sepsis.
No postmortem was performed.
[**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**]
Dictated By:[**Doctor Last Name 10735**]
MEDQUIST36
D: [**2193-7-15**] 14:59
T: [**2193-7-17**] 08:15
JOB#: [**Job Number **]
|
[
"486",
"V10.52",
"530.81",
"038.11",
"785.4",
"427.31",
"427.1",
"518.81",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.95",
"86.28",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4744, 6697
|
3489, 4726
|
157, 1941
|
1964, 3421
|
3438, 3466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,800
| 189,334
|
12486
|
Discharge summary
|
report
|
Admission Date: [**2135-2-15**] Discharge Date: [**2135-2-17**]
Date of Birth: [**2079-7-12**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 16844**] is a 55 year old man
with a history of coronary artery disease, hypertension,
hypercholesterolemia, type 2 diabetes mellitus and ongoing
tobacco use who was admitted to the Coronary Care Unit
left circumflex artery. The patient's coronary history dates
back to [**2128-12-17**] when he presented with unstable
angina. He underwent percutaneous transluminal coronary
angioplasty of the left posterolateral artery at that time.
He developed recurrent symptoms in [**2129-3-18**].
Re-catheterization at that time showed restenosis of the same
region. He therefore underwent stenting of the left
The patient had been feeling well until approximately one and
a half months prior to admission when he developed increasing
dyspnea on exertion with two flights of stairs. He denied
chest pain, palpitations, nausea or vomiting. He has also
denied orthopnea, paroxysmal nocturnal dyspnea, or leg edema.
He was sent for a nuclear stress test and exercised eight
minutes and 15 seconds to a 75% maximum predicted heart rate
with no chest pain or EKG changes. Nuclear images showed
inferoposterior hypokinesis to akinesis with severe
inferoseptal hypokinesis. The patient underwent elective
cardiac catheterization on the day of admission which showed
a left dominant system with 80% proximal left circumflex
lesions followed by a total occlusion.
The patient then underwent a complicated intervention with
stents of the left circumflex artery resulting in a distal
edge dissection and jailing of the obtuse marginal branch.
The jailed segment was corrected with a stent.
Following this, thrombus was noted in the left circumflex
stent which was corrected with heparin and Angioject. A
second stent was placed in the left circumflex artery to
correct the edge dissection. Again thrombus was noted in the
left circumflex artery and the patient underwent a second
Angioject with intracoronary injection of Adenosine,
Diltiazem and Nitroglycerin. At the end of the case, a
distal cut-off was noted involving the distal left circumflex
artery and left PDA. The patient experienced no chest pain
during the case. He received a total of 19,000 units of
heparin, 900 micrograms of Adenosine, 300 micrograms of
Diltiazem, 125 micrograms of Fentanyl, 400 micrograms of
Nitroglycerin, Versed and Integrilin. He also received 851
cc Optiray dye during the catheterization. A left
ventriculogram indicated an ejection fraction of 30% with
inferior akinesis and distal inferior hypokinesis.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post percutaneous
transluminal coronary angioplasty of the left posterolateral
artery in 12/95 and status post stent of the left
posterolateral artery in 03/95 for restenosis.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes mellitus type 2.
5. Status post knee surgery.
6. Tobacco use.
MEDICATIONS ON ADMISSION:
1. Glyburide/Metformin 2.5/500 mg p.o. twice a day.
2. Prilosec 20 mg p.o. q. day.
3. Actos 30 mg p.o. q. day.
4. Lipitor 40 mg p.o. q. day.
5. Diltiazem CD 240 mg p.o. q. day.
6. Aspirin 81 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married with two grown
children. He currently smokes one half pack per day of
tobacco and has smoked as much as two packs per day. He
denies alcohol or illicit drug use.
FAMILY HISTORY: Notable for history of coronary artery
disease in the patient's mother and diabetes mellitus in the
patient's brother.
PHYSICAL EXAMINATION: The patient was afebrile with a heart
rate in the 70s, blood pressure of 100 to 120 over 50 to 60,
respiratory rate of 13, oxygen saturation 98% on two liters
nasal cannula. In general, this is an obese 55 year old man
in no acute distress, lying supine in bed following
catheterization. HEENT examination indicated normocephalic,
atraumatic. Pupils were equal, round and reactive to light.
Extraocular muscles were intact. Oropharynx was clear and
dry. Neck was supple with no bruits and no jugular venous
distention. The chest was clear to auscultation anteriorly.
Cardiovascular examination indicated regular rhythm, normal
S1 and S2. No murmurs, gallops or rubs. The abdomen was
obese, soft, not tender, not distended, with normal bowel
sounds. The patient's right groin was without hematoma,
tenderness or bruit. The patient had good distal pulses and
no peripheral edema.
LABORATORY: Studies were notable for an EKG which indicated
sinus rhythm at 64 with normal axis, normal intervals, left
atrial enlargement, Q waves in leads II, III and AVF and some
T wave flattening in leads I, AVL, and V5 through V6. Chem-7
and CBC were unremarkable with the exception of a hematocrit
of 37.2. CK was 99.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Care Unit for observation following complicated
catheterization and revascularization of the left circumflex
artery and concurrent dye load of 850 cc. The patient
remained hemodynamically stable overnight. He was started on
a heparin drip as well as beta blocker, ACE inhibitors,
Plavix and aspirin.
On hospital day number two, the patient was transferred to
the floor. Serial CKs were flat and his creatinine was
stable at 0.8. He remained without any complaints of chest
pain. Heparin drip was discontinued on the day of discharge.
The patient was to follow-up with his Cardiologist, Dr.
[**Last Name (STitle) 7047**], on [**2-21**], at 11:45 a.m.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post cardiac catheterization with stenting of the
left circumflex artery.
3. Hypertension.
4. Hypercholesterolemia.
5. Type 2 diabetes mellitus.
6. Tobacco abuse.
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg p.o. q. p.m.
2. Lisinopril 2.5 mg p.o. q. a.m.
3. Glyburide/Metformin 2.5/500 mg p.o. twice a day.
4. Prilosec 20 mg p.o. q. day.
5. Actos 30 mg p.o. q. day.
6. Lipitor 40 mg p.o. q. h.s.
7. Enteric coated aspirin 325 mg p.o. q. day.
8. Sublingual Nitroglycerin 0.4 mg p.o. q. five minutes
p.r.n.
9. Plavix 75 mg p.o. q. day times 30 days.
CONDITION AT DISCHARGE: The patient was discharged to home
in good condition.
DISCHARGE INSTRUCTIONS:
1. He was to follow-up with Dr. [**Last Name (STitle) 7047**].
2. It was also strongly suggested that the patient stop
smoking cigarettes and follow up with Dr. [**Last Name (STitle) 7047**] and his
primary care physician in this regard.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2135-2-17**] 17:20
T: [**2135-2-21**] 14:00
JOB#: [**Job Number 38749**]
|
[
"305.1",
"V45.82",
"272.0",
"414.01",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.55",
"36.06",
"88.53",
"36.01",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
3517, 3637
|
5613, 5821
|
5844, 6222
|
3043, 3295
|
4895, 5592
|
6317, 6833
|
3660, 4877
|
6238, 6293
|
147, 2662
|
2684, 3017
|
3312, 3500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,816
| 191,159
|
8473
|
Discharge summary
|
report
|
Admission Date: [**2199-3-18**] Discharge Date: [**2199-3-21**]
Date of Birth: [**2134-2-11**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 65 yo male, DM2, CRI, COPD, h/o CAD s/p CABG x 3 ([**2196**]),
multiple stents (last in [**12-5**] to previously grafted RCA/ last
viz catheterization [**2-5**]), open abdominal wound healing by
secondary intention p/w left sided chest pain since last night.
Presented to OSH with chest pain on left side, shooting down
arm, and hip. Pt says it was a [**11-11**]. Associated with NBNB
vomitting after drinking water. No pain at abd wound site,
states it has been "looking better than ever." No change in
chronic cough, no change in sob. At baseline DOE. No urinary
frequency/urgency/dysuria. Started on hep/int/dopa transferred
here.
*
Pt was transferred to [**Hospital1 **]. EKG in ED: sinus at 88. Nl axis. Nl
intervals. LVH by voltage criteria. ST horizontal depressions 2
mm in lateral leads (V4-V6) Morphine 4 mg x 3, metoprolol 5 mg
x 1 with decrease in BP to sbp 70s. Temp 103, WBC elevated -
Started on sepsis MUST protocol and sent to unit. Seen by cards,
felt EKG changes [**3-6**] demand ischemia, enzymes remained negative,
chest pain abated. Hep/integrillin/dopa off.
MICU course:
1) CV: as listed as above. Was continued on Aspirin. Once HD
stable, restarted on lipitor, lisinopril 20 daily, metoprolol 50
[**Hospital1 **]. BP stable w/ BP 130s-150s/60s-80s P 90s. COmplained of
episode of chest pain similar to prior MI on [**3-19**]. RR 40s O2
100% on NRBM , associated with left hip pain. received 2 SL
nitro w/ improveoment in SOB but no change in chest pain.
Started on nitro gtt @ 6/hrt. Received 40 IV lasix and total 4mg
IV morphine and Chest pain decreased to [**5-12**] and additional
improvement in SOB. EKG, sinus tachy 117, concave ST elevateion
in V2 (old), ST depression V3-V6 w/ TWI V5-6 (all old). Asses to
becardiogenic wheezing/CHF exacerbated by albuterol nebs and
tachycardia with resultant pulmonary edema. CXR w/ RUL
infiltrate (nbew) but no CHF/pulm edema. CE negative. EKG @ 4:30
pm on [**3-19**] no ischemic ahges. @5pm still with 3/10 chest pain on
150 mcg/kg/hr ntg, but VSS (BP 137/75 P 80 O2 96% comfortable).
Likely CP [**3-6**] to PNA or sternal wound
2> leukocytosis: Eivdence of RUL on last CXR explaining
fever/CP. started on levaquin 5-- daily (10 day course). Vanco
and flagyl started initially for empiric coverage for concern of
open rectal flap wound v. pneumonia (CT with new focal ground
glass opacity) v. bladder infection, open abdominal wound as
source. PLastics do not suspect open abd wound as source. on
[**3-20**], assessed RUL as most likely source of leukocytosis
3. Respiratory: Initial concerning of pulm edema. XRAY no signs
of edema on [**3-19**]. Most likley pleurisy from pneumonia +/_
anxiety disorder+/_ sternal arthritis. Pt was continued on
albuterol/atrovent nebs q6 prncautiously
4.> CHF: HIstory of CHF history but no formal TTE. No signs of
CHF on CXR on [**3-19**]. Restarted on lasix 40 daily, continued on
lsiiniopril 20, maintained on 2gm NA diet
5. HTN-stable on lopressor and ACEI
6. DM- stable cont on lantus 65 + SSI
7. chronic DVT: onocumadin for possible DVT (per pt). INR =3.4
at last. Restart coumadin at 2.5 today
8. ARF- Imrpoved with excellent UOP. restarted on lasix.
9. Access: TLC changed to PIV.
Past Medical History:
1. Left circumflex stent in 3/[**2194**].
2. Catheterization in [**10-4**] with three vessel disease.
3. Status post coronary artery bypass graft x 3.
4. s/p catheterization [**12-5**]- with stent to native right
coronary artery with an occluded saphenous vein graft.
5. Insulin dependent diabetes mellitus.
6. CRI with a baseline creatinine of 1.1 to 1.3.
7. Hypothyroidism
8. COPD
9. ? PE in [**2196**]
10. History of ETOH.
11. Pancreatitis.
12. s/p CABG [**11-3**] complicated by osteomyelitis of the sternum.
The
patient had a left hemisternectomy in [**2197-1-1**] due to
infection. Sternal debridement rectus flap and bilateral
pectoralis flaps. Still open wound.
13. History of lens transplant in right eye secondary to
cataract.
Last cath in [**2-/2198**]: LMCA normal. LAD occluded . The LCX was
widely patent and the stented sites were open. At the origin of
the OM3, there was 50% restenosis. The RCA stents were widely
patent. LIMA-LAD patent.
Cath ([**12-5**])
The LAD had a proximal 60% lesion, a mid 80% lesion, and distal
competitive flow from the LIMA-LAD. The LCX stents were widely
patent with normal flow. The RCA had a proximal 60% lesion at a
[**Last Name (un) 29846**] crook, with diffuse mid disease up to a sub-total
occlusion in the mid vessel. The distal vessel supplied a lower
AM/PDA and a RPL branch. 2. Successful stenting of the RCA was
performed with overlapping 2.5 x 28 mm and 3.0 X 13 mm Cypher
(drug-eluting) stents, post-dilated using 2.5 and 3.25 mm NC
balloons respectively. There was <10% residual stenosis, no
angiographically-apparent dissection, and normal flow (see
PTCA Comments).
Social History:
Social History: 2 ppd x 50 years (still smoking). Former EtOH
abuser-vodka. Quit [**8-5**] with relapses per wife. [**Name (NI) **] history of
drug use.
Family History:
F: died at 63 of MI
Physical Exam:
In general,no acute distress with no accessory muscle use.
HEENT:right surgical pupil. NC/AT, OP clear
Chest: Small erythematous patch at right medial and above right
nipple, incisional scar, well healed c/d/i, palpable movable
bone.
Resp: clear to auscultation bilaterally with no rales, wheezes
or rhonchi.
CV: RRR, s1 and s2, no m/r/g
Abd: open wound with minimal sero-sanguinous dressing, mildly
obese, soft, nontender, nondistended with normoactive bowel
sounds. No hepatosplenomegaly palpated.
Ext: no c/c/e
Neuro:cranial nerves II through XII are intact. Strength is 5
out
5 and symmetric. Toes are downgoing.
Skin: clean, dry and intact with no lesions noted.
Pertinent Results:
CT OF THE CHEST WITHOUT CONTRAST:
Marked coronary artery calcifications are seen. Small
mediastinal lymph nodes, not meeting size criteria with
pathologic enlargement are present. Lung windows demonstrate
changes of mild centrilobular emphysema at the apices, as well
as mild paraseptal emphysema, particularly along the right major
fissure. In addition, right lateral dependent change of
atelectasis are seen. A subpleural 2 cm region of ground-glass
opacity within the right upper lobe anteriorly, was not seen on
the prior examination, and could represent an atypical
infectious focus. The patient is status post sternal
debridement, and there is soft tissue density and mild stranding
between the two sides of the sternum.
CT OF THE ABDOMEN WITHOUT CONTRAST: There is a small hiatal
hernia. The upper-pole of the left kidney is quite atrophic in
appearance. Parenchymal calcifications along the pancreas are
consistent with chronic pancreatitis.
CT OF THE PELVIS WITHOUT CONTRAST: Several foci of air are seen
within the bladder, possibly between folds of the thickened
bladder wall. Note that the bladder seems more distended than we
would expect given the fact that the bladder is empty.There is
no pelvic lymphadenopathy or free fluid.
Examination of the osseous structures show no suspicious lytic
or blastic lesions.
IMPRESSION: 1. No definite infectious source is identified.
2. Ground-glass opacity along the anterior subpleural aspect of
the right upper lobe may represent an early or atypical
infectious process, although no definite consolidation is seen.
3. There is soft tissue density in the region of sternal
debridement. Given the lack of IV contrast, it is difficult to
assess for small abscess collections, although no dominant or
obvious fluid collection is seen. Given the history of
sternotomy, ultrasound may be useful for further evaluation of
the soft tissues for fluid collections.
4. The bladder wall also seems quite thickened considering that
it appears not distended with urine on this examination. There
are foci of air, probably trapped between folds of the bladder.
As the patient cannot currently receive IV contrast, GU
ultrasound, with retrograde filling of the bladder through the
Foley catheter may be performed for further characterization of
the bladder wall.
5. Atrophy of the left upper renal pole. Mild to moderate
calcifications of the infrarenal aorta.
6. Hiatal hernia.
.
CXR: Lung volumes are low. The heart size and mediastinal
contours are unremarkable. There are surgical clips overlying
the left upper lobe and within the upper mediastinum
bilaterally. The lungs are clear. There is no pleural effusion
or pneumothorax. The osseous structures are unremarkable.
.
Todays labs:
[**2199-3-21**] 06:11AM BLOOD WBC-14.8* RBC-4.23* Hgb-12.7* Hct-36.9*
MCV-87 MCH-30.0 MCHC-34.4 RDW-14.2 Plt Ct-325
[**2199-3-20**] 06:48AM BLOOD WBC-23.0* RBC-3.76* Hgb-11.2* Hct-33.5*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.4 Plt Ct-289
[**2199-3-21**] 06:11AM BLOOD Plt Ct-325
[**2199-3-21**] 06:11AM BLOOD PT-27.1* PTT-38.8* INR(PT)-4.6
[**2199-3-20**] 06:48AM BLOOD PT-23.1* PTT-35.0 INR(PT)-3.4
[**2199-3-21**] 06:11AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2199-3-20**] 06:48AM BLOOD Glucose-122* UreaN-27* Creat-1.4* Na-141
K-3.5 Cl-106 HCO3-29 AnGap-10
[**2199-3-21**] 06:11AM BLOOD Calcium-PND Phos-PND Mg-PND
Brief Hospital Course:
After he was transferred from the ICU to the floor. He did fine.
*
1. Right upper lobe pneumonia- cough + XRAY findings. Stable O2
on room air
He was continued and discharged with 12 more days of levaquin
2. Chest Pain/coronary artery disease- He has been chest pain
free since transfer. He was continued on aspirin, metoprolol,
lisinopril, statin, lasix. He was discharged on these
medications, except for toprol xl in place of metoprolol.
.
3. Hypertension- This issue was stable. He was continued on
lisinopril, B-blocker and lasix
*
4. Diabetes- He was continued on galrgine 30 units at evening
along with sliding scale insulin,
*
5. Hypercholesterolemia- He was continued on lipitor
*
6. Acute renal failure on [**Name (NI) 26301**] Pt with baseline of 1.1-1.3.1.4
on [**2199-3-20**] Likely secondary to pre-renal state. Monitor
creatinine.
*
7. Hypothyroidism- Continuing synthroid per outpt dose.
*
8. Chronic DVT-INR 3.4 on [**2199-3-20**]. He was asked to hold evening
dose of coumadin and recheck his INR at his primary care
doctor's clinic on [**2199-3-22**] for further instruction regarding
coumadin dosage
*
Medications on Admission:
Medications at Home:
Lantus 65 units qpm
HISS tid 5-10 units
Protonix 40 qday
ASA 81 qday
Celexa 40 [**Hospital1 **]
Neurontin 600 [**Hospital1 **]
Cardura 4 qday
Lasix 40 qday
Toprol XL 100 qday
Lipitor 10 qday
Coumadin 5 qhs
Synthroid 175 mcg qday
Zestril 20 mg qday
Remeron 30 qday
.
Medications on transfer from MICU:
Levofloxacin 500 mg PO Q24H Duration: 8 Days
Acetaminophen 325-650 mg PO Q4-6H:PRN
Lisinopril 20 mg PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Metoprolol 50 mg PO BID
Aspirin EC 325 mg PO DAILY
Mirtazapine 30 mg PO HS
Atorvastatin 10 mg PO Daily
Morphine Sulfate 1-2 mg IV Q4H:PRN
Citalopram Hydrobromide 40 mg PO BID
Nitroglycerin SL 0.4 mg SL
Furosemide 40 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Glargine 30 hs + SSI
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Warfarin 2.5 mg PO HS
Levothyroxine Sodium 175 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
coronary artery disease
diabetes
renal insuffiency
Discharge Condition:
stable
Discharge Instructions:
please take your medications, including your levoquin
(antibiotics) for 12 more days for pneumonia. You should not
take your coumadin for today. Please go to your primary doctor ,
Dr. [**Last Name (STitle) 29847**] to have your followup checkup and have your INR
checked. He will let you know what to do about your coumadin.
Your INR today ([**3-21**] ) is 4.6
Followup Instructions:
please see your primary doctor tomorrow.
|
[
"491.21",
"428.0",
"V45.81",
"038.9",
"785.52",
"995.92",
"584.9",
"486",
"414.01",
"V58.61",
"530.81",
"593.9",
"272.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
11532, 11538
|
9504, 10631
|
280, 286
|
11643, 11651
|
6103, 9481
|
12060, 12104
|
5374, 5395
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11559, 11622
|
10657, 10657
|
11675, 12037
|
10678, 11509
|
5410, 6084
|
230, 242
|
314, 3535
|
3557, 5188
|
5220, 5358
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,343
| 174,549
|
41673
|
Discharge summary
|
report
|
Admission Date: [**2156-9-21**] Discharge Date: [**2156-9-25**]
Date of Birth: [**2071-4-21**] Sex: F
Service: MEDICINE
Allergies:
morphine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hospitalist Admit Note
Patient Name:[**Name (NI) **] [**Name (NI) 4580**] [**Medical Record Number 90591**]
DOB: [**2071-4-21**]
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30878**]
Transferring Facility: [**Hospital3 **]
Transferring Physician:[**Last Name (NamePattern4) **]. [**Last Name (STitle) 69038**] Contact [**Name (NI) **]: [**Telephone/Fax (1) 90592**]
Transferring Floor: N3 3122 Contact [**Name (NI) **]:[**Telephone/Fax (1) 90593**]
.
CC:[**CC Contact Info 90594**]
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
85 yo F with HTN, skin melanoma in [**2153**] and skin squamous cell
cancer in [**2155**] who developed new onset jaundice and nausea. At
OSH, T bili 16 and direct bili 13. AST/ALT: 124/103; AP 303. INR
5.4. CT showed a 7x6x5 cm cystic lesion with calcification at
the head of pancreas. CBD and PD were dilated. She had mild
respiratory distress and CXR showed LLL infiltrate for which she
was started on ampicillin. She was given vitK and 4 unit of FFP
due to coagulopathy, INR improved to 1.3. She underwent ERCP
with Dr. [**Last Name (STitle) 69038**] yesterday under general anesthesia. Cannulation
of CBD was not successful. Only PD was cannulated. Patient with
increasing bili today, needing transfer for repeat ERCP. Per
report, vitals prior to transfer. Tx 101. Tc:99.8 BP:140-170/70
HR:70-80 RR: 15 O2 Sat: 89-93 4L/min O2-per transferring
physician patient with no respiratory symptoms after ERCP
despite O2 requirement.
.
Pt reports that that she developed 1 week of nausea, vomiting,
fever up to 102.7, abdominal distention and 1 day of dark urine
prior to admission to OSH. Reports that symptoms were
intermittent, but worsened on sat prior to admit. Pt reports she
was diagnosed with a UTI on fri and started on cipro. She
reports intermittent chills, weight loss of ~15-20lbs over [**2-26**]
months. In addition, pt reports intermittent diarrhea-non
bloody- over last few months. Pt denies new foods, travel, sick
contacts, abdominal pain, constipation, melena, brbpr, cp, sob,
palpitations, URI/cough, rash, paresthesias, weakness, dysuria,
headache, but does report chronic intermittent dizziness. PT
reports decreased appetite and pO intake x1 week.
Past Medical History:
appendectomy, hysterectomy, tonsillectomy, removal of skin
cancer and melanoma
-formerly had HTN
-formerly HL
-hypothyroidism
Social History:
PT lives at home alone, but multiple family members nearby to
help. Ambulates with a cane occasionally. Former smoker, quit
25yrs ago, former alcoholic quit 27 years ago. Denies drug use
Family History:
mother died at 86-arthritis, "cancer"
dad-alcoholic
Physical Exam:
GEN: lying in bed, jaundiced, NAD
vitals: T 97.2, BP 152/68, HR 75, RR 24, sat 93% on 4L
HEENT: nc/at, EOMI, +icterus, dry MM
neck: supple, +thyromegaly, +JVD to earlobe
chest: +b/l crackles
heart: rrr, m/r/g
abd: +bs, soft, mildly tender, softly distended, no guarding or
rebound,
back: non-tender, no CVA tenderness
ext: no c/c/e 2+pulses
skin: multiple areas of scaring, hypo and hyperpigementation.
L.shin with sutures from recent resection-c/d/i
neuro: AAOx3, CN2-12 intact, motor [**5-27**] x4, sensation intact to
LT, no tremor
psych: calm, cooperative
Pertinent Results:
Labs:
T bili 16 and direct bili 13. AST/ALT: 124/103; AP 303. INR 5.4.
.
Imaging:
CT showed a 7x6x5 cm cystic lesion with calcification at the
head of pancreas.
ERCP-CBD and PD were dilated.
CXR-LLL infiltrate
.
ERCP [**9-20**]-cystic neoplasia of pancreas. Unable to access bile
duct.
.
EKG NSR Q III, TWI III, AVF
.
CT abd/pelvis-[**9-19**]-severe ventilation of the intereim bilary
ducts as well as the main pancreatitic duct. multiloculated
cystic lesion in the head of the pancreas associated with small
punctate calcifications that can be related to a pancreatic
neoplasia like serous cystadenoma of the pancreas. Suboptimal
evaluation due to the lack of IV contrast. ERCP or MRCP is
recommended for further eval. MIld free fluid in pelvis.
Diverticulosis without diverticulitis. b/l cortical renal cysts.
.
RUQ u/s [**9-19**]-marked intrahepatic and extrahepatic biliary ductal
dilatation of ? etiology.
.
CXR [**9-19**]-streaky LLL infiltrate otherwise no significant acute
finding.
.
WBC 13, HCT 29, plt 167. INR 1.3, ap 343, tbili 23.3, direct
13.1, bun 26, ca 9 creat 0.81, gluc 95, lip 33, ast 166, alt
110, TSH 0.654
Brief Hospital Course:
85 yo F with HTN, skin melanoma in [**2153**] and skin squamous cell
cancer in [**2155**] who developed new onset jaundice, nausea with
vomiting and was found to have a cystic pancreatic mass at OSH.
.
# CMO: Patient was made comfort measure after discussion with
family. Palliative care saw patient and it was decided that she
would go home with hospice care. She was comfortable at the time
of discharge. She was sent home on oxycodone, zofran,
promethazine, compazine, & ativan for symptom management.
Patient medications were reviewed and non-palliative medications
were removed from regimen. We called the PCP [**Name Initial (PRE) **] couple of times
during this stay and were only able to reach his answering
machine. We left messages with the new changes in care goals and
with numbers for him to contact us. Family (very involved) has
also said that they will be in touch with her PCP as well. She
will continue to have her foley and oxygen with N as needed at
home, which hospice can provide.
.
#bile duct obstruction with obstructive jaundice/cystic
pancreatic head lesion-Etiology of patients symptoms, abdominal
distention, nausea, jaundice is likely related to obstruction
from pancreatic head mass. DDX includes malignancy vs. cyst. Pt
does have h.o skin cancer, but unlikely to metastasize to
pancreas. Pt may also have stricture or stones. She had an ERCP
with 8cm by 10mm Wallflex fully covered biliary stent which was
successfully placed with large amounts of mucin which drained.
Patient presented with nausea and continued to have nausea
intermittently throughout stay. Have increased regimen as above
to control nausea, able to tolerate PO meds, gingerale, and some
soft foods.
.
#Hypoxia-?LLL infiltrate--Pt thought to have PNA at OSH. CXR
found streaky LLL infiltrate. Pt does have a leukocytosis, but
denies cough. On exam, pt with elevated JVP/crackles more c/w
volume overload. Pt does have suspicion of malignancy, and will
consider if continued hypoxia. Will continue to cover for
suspected pna including atypicals with levofloxacin to end on
[**2156-10-5**]. Able to tolerate PO so will go home with PO regimen.
.
#Transient bacteremia s/p ERCP: will treat with flagyl in
addition to levoflox as above for total of 2 wk course, to end
on [**2156-10-5**]. have been tolerating PO as well.
.
#h.o skin cancer/squamous cell/melanoma--stable, will f/u outpt
if necessary but CMO at this point
.
#Afib: patient found to have atrial fibrillation [**2-25**] to
procedure, which has resolved and has not recurred. No need for
any anticoagulation especially given goals of care.
.
#Hypothyroidism: will continue home levothyroxine as it might
help patient feel better, more energetic.
.
#code-DNR/DNI, CMO, d/w patient in presence of HCP.
Medications on Admission:
levothyroxine 75mcg daily, HCTZ-not on prior to admit, MVI,
prochlorperazine Cipro 250mg [**Hospital1 **]
Inpatient:
She is on Ampicillin 1.5gm Q6hours and prn albuterol.
Allergy: morphine
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for nausea.
Disp:*180 Tablet(s)* Refills:*2*
3. 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.
4. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 11 days: End Date [**10-5**].
Disp:*32 Tablet(s)* Refills:*0*
5. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days: last day = [**2156-10-5**].
Disp:*11 Tablet(s)* Refills:*0*
6. prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
Disp:*60 Suppository(s)* Refills:*2*
7. promethazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for nausea.
Disp:*240 Tablet(s)* Refills:*0*
8. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q 8H (Every 8 Hours) as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
9. oxycodone 20 mg/mL Concentrate Sig: 5-10 mg PO q2h:PRN as
needed for pain and shortness of breath.
Disp:*100 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Central & [**Hospital3 29991**] [**Hospital3 **]
Discharge Diagnosis:
pancreatic head mass
bile duct obstruction/hyperbilirubinemia
hypoxia
pneumonia
.
HTN, benign
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for further work up of a blockage noted in
your bile ducts and a mass that was seen in your pancreas. You
underwent a procedure called an ERCP that showed significant
blockage of your biliary system. There was a stent placed which
relieved the blockage. You were also continued on antibiotics
for a pneumonia and prophylaxis after ERCP which you will
continue until [**10-6**].
.
You had significant nausea during your hospitalization. You will
be sent on on many different medications for your nausea.
.
Medication changes:
Start Oxycodone liquid 20mg/ml 5-10mg PO q4-6h for pain and
shortness of breath SL
Start Ativan 1mg q4-6h as needed for anxiety and shortness of
breath
Continue Flagyl q8h until [**10-5**]
Continue Levofloxacin 250mg every day until [**10-5**]
Continue Prochlorperazine 25mg twice a day as needed for nausea
Continue Promethazine 50mg Tablet every 6 hours as needed for
nausea
Continue Zofran 8mg every day as needed for nausea
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30878**] at
[**Telephone/Fax (1) 30879**] after discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2156-9-26**]
|
[
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"577.9",
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icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
8878, 8964
|
4657, 7418
|
780, 787
|
9102, 9102
|
3502, 4634
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10377, 10729
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2854, 2907
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8985, 9081
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7444, 7635
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2922, 3483
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9830, 10354
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237, 742
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815, 2485
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9117, 9263
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2507, 2634
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2650, 2838
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,371
| 112,392
|
50722
|
Discharge summary
|
report
|
Admission Date: [**2144-1-12**] Discharge Date: [**2144-1-23**]
Date of Birth: [**2096-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
SVC central line placement and removal.
PICC placement and removal.
History of Present Illness:
47yo F with history of DM, HTN and CRI presents with weakness
and dehydration. He was recently discharged on [**2143-12-30**] for DKA.
Patient signed out AMA when glucose better controlled. He was
again admitted on [**2144-1-7**] for DKA at [**Hospital1 2177**].
.
In ED, his VS were T96.7 P103 BP184/64 R24 100% on RA. His BP
went up to as high as 221/88 and he was given Sl nitro. His
glucose was found to be in 800s, insulin gtt started and he
received 2L fluid. He has old STE in V2-V4 and new TWI in V5-6.
He was given aspirin.
.
On ROS, he complains of polyuria and polydipsia today. Patient
claims to be compliant with insulin. The last time he checked
his FS was this AM and it was 140s. He denies chest pain,
shortness of breath, cough, recent URI, abdominal pain, nausea,
diarrhea, urinary complaints, headahce, dizziness, fever,
chills, recent sick contact or recent travel. He claims that he
had been abstinent from alcohol for more than a month and has
not used any drugs recently.
Past Medical History:
# HTN
# Insulin dependent DM
- has had multiple admissions for DKA in setting EtOH use
- last HgbA1C 7.6 ([**2143-10-31**])
- has peripheral neuropathy, retinopathy
# CRI - thought to be due to diabetic and hypertensive
nephropathy
# Sarcoid
- CT [**6-/2129**] = hilar/subcarinal [**Doctor First Name **], nodules in parenchyma
- [**1-/2134**] = L eye proptosis -> CT showed L maxillary mass -> bx
showed non caseating granulomas c/w sarcoid
- decision was made not to begin systemic tx since pt asx
# H/o Chronic RUQ pain
- Present for over 13 yrs (by [**Hospital1 18**] records), evaluated with at
least 12 abdominal/RUQ ultrasounds and multiple abdominal CT's
without evidence of suspicious pathology
# Polysubstance abuse
- Pt drinks regularly 2-3drinks daily; occasionally uses cocaine
(last use many weeks ago)
Social History:
Lives w/ a friend, no children. Works part time as a
tire-changer. Denies tobacco use. Denies recent EtOH or
cocaine use (per report daily EtOH use in past).
Family History:
Mother had diabetes, niece has diabetes. Denies FH of coronary
artery disease, hypertension, cancer, liver disease, or renal
disease.
Physical Exam:
T98.1 P96 BP 169/73 R23 98% on RA
Gen- sleepy but easily arousable
HEENT- left eye injected, right pupil reactive to light, no
sinus tenderness, dry mucus membrane, neck supple, no JVD
CV- regular, no r/m/g
RESP- clear bilaterally, no distress, no accessroy muscle use
ABDOMEN- soft, nontender, nondistended, no hepatosplenomeglay,
normal bowel sounds
EXT- no edema, no lacerations, DP 2+ bilaterally
NEURO- A+O x3, CNII-XII intact, muscle strengh [**6-14**] bilateral
upper and lower extremity, sensation grossly intact
Pertinent Results:
[**2144-1-12**] 09:30PM TYPE-ART PO2-102 PCO2-29* PH-7.25* TOTAL
CO2-13* BASE XS--12
[**2144-1-12**] 09:30PM LACTATE-1.7
[**2144-1-12**] 09:18PM GLUCOSE-515* UREA N-46* CREAT-3.3* SODIUM-136
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-11* ANION GAP-22*
[**2144-1-12**] 09:18PM CALCIUM-7.8* PHOSPHATE-3.1# MAGNESIUM-2.2
[**2144-1-12**] 09:18PM OSMOLAL-331*
[**2144-1-12**] 09:18PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
CXR: [**1-12**] - Satisfactory positioning of this central venous
catheter.
Brief Hospital Course:
AP: 47yo HTN, CRI, sarcoidosis, & poorly controlled DM w/ mult
admissions for DKA who p/w DKA, then hospital course complicated
by fevers thought to be secondary to pneumonia.
.
.
# DKA: In the MICU, he initially had: AG 29, CXR clear, no
intraabdominal complains, afebrile w/ no leukocytosis, EKG show
TWI and troponin of 0.36, but in [**2143-11-28**] clean cath, CK
remained flat and troponin stable. Underlying cause of DKA
thought to be medication non-compliance. No obvious other cause
of DKA--pt does not appear to be infected, no clear ischemic
event (trop elevation [**3-14**] leak in setting of CRI). Patient was
given aggressive hydration and started on insulin gtt in the
ICU. electrolytes checked q2hours initially. His anion gap
closed and he was able to be transitioned to SC insulin. [**Last Name (un) **]
was consulted and assisted in control of sugars during
hospitalization. He was discharged on a simple and effective
regimen of 30U of 75/25 [**Hospital1 **]. He has outpatient follow up with
[**Last Name (un) **].
.
# Trop elevation: Likely leak in setting of CRI. EKG unchange
(non-specific TWI in inferior & lateral precordial leads). Pt
had clean cath [**2143-11-25**]. Trop trending down. Continued on
aspirin, lipitor, Beta-blocker.
.
# HTN: He was continued on all of his home medications
(nifedipine, furosemide, and labetalol) with an increase in
dosage of his labetolol from 400mg TID to 600mg TID.
.
# ARF on CKD: Admission Cr of 3.5, with baseline of [**4-12**].2, was
likely pre-renal in setting of DKA and improved w/ hydration.
CKD is thought to be due to HTN & diabetic nephropathy. Protein
to Cr ratio of 6.0. Improved to 2.8-3.1 during hospitalization.
.
# Anemia: Baseline hct 27-29, during his hospitalization he was
between 24-27. No obvious sources of bleeding. Likely [**3-14**] renal
insufficiency. We continued epogen. Iron studies from [**Month (only) **]
[**2143**] show a mix of iron deficiency anemia (low fe, low fe/tibc
ratio)and anemia of chronic disease (ferritin > 100). Could
consider outpatient iron supplementation to help with epogen.
.
# Cardiomyopathy: EF 40-45%, likely related to
hypertension/alcohol. No active issues during hospitalization.
.
# acute angle glaucoma: Patient was seen by opthamology. We
continued all eyedrops per their recommendations. He will need
outpatient follow up.
.
# Barrett's esophagus: We continued his protonix.
.
# RUE swelling: RUE slightly swollen and uncomfortable at sight
of Right SVC line. Ultrasound was negative for clot. See below.
.
# Pneumonia: Patient had fevers and leukocytosis with right
lower lobe opacity on chest x-ray, oxygen sats around 95% and
right flank pain. The fever and leukocytosis was initially
attributed to ?line infection while central line was in (red
tender at site) and treated temporarily with vancomycin, but the
blood cultures were all negative. He had negative lenis. He
also had a negative RUQ ultrasound. He was discharged on a 7
day course of levofloxacin.
.
# code- full
Medications on Admission:
Aspirin 325 mg DAILY
Atorvastatin 80 mg DAILY
Nifedipine 90 mg DAILY
Labetalol 400 mg PO TID
Albuterol prn
Tobramycin-Dexamethasone 0.3-0.1 % Drops QID
Latanoprost 0.005 % Drops HS
Epoetin Alfa 3,000 Units QMOWEFR
Pantoprazole 40 mg Q12H
Scopolamine HBr 0.25 % Drops [**Hospital1 **]
Dorzolamide-Timolol 2-0.5 % Drops [**Hospital1 **]
Apraclonidine 0.5 % Drops [**Hospital1 **]
Furosemide 40 mg PO DAILY
Insulin Lisp & Lisp Prot (75-25) 25 units QAM and 25 units QPM
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Furosemide 40 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 once a day.
5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): OS.
7. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl
Ophthalmic QID (4 times a day): OS.
8. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 doses: Please take for 7 days. Last day will be
[**2144-1-28**].
Disp:*7 Tablet(s)* Refills:*0*
10. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic TID
(3 times a day): OS.
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): OU .
12. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day): OS.
13. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Insulin
Pen Sig: Thirty (30) Units Subcutaneous QAM.
14. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Insulin
Pen Sig: Thirty (30) Units Subcutaneous 30 minutes after dinner.
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: Sliding
Scale Subcutaneous QACHS: Per sliding scale attached.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Type I diabetes mellitus
Community acquired Pneumonia
Secondary
Hypertension
Glaucoma
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed. In particular please
take your insulin as prescribed, 30U twice a day. This will
help reduce need to be admitted to the hospital and help with
your vision. Please also take the right amount of your blood
pressure medicine labetalol. We increased your dose from 400mg
to 600mg three times daily.
Followup Instructions:
Please follow up in [**Company 191**] with Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-1-29**] 2:00.
.
Please follow up with your PCP [**Name Initial (PRE) 2169**]: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D.
Date/Time:[**2144-2-26**] 9:00.
.
Please follow up with [**Last Name (un) **] ([**Telephone/Fax (1) 2378**]). You have an
appoinment [**2144-1-28**] at 10:10am for vision and another at 11am
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**].
.
Please follow up with opthamology [**2144-1-22**] at 3:45pm in [**Hospital Ward Name 23**]
[**Location (un) 442**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"585.4",
"486",
"403.00",
"584.9",
"250.43",
"250.13",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8850, 8856
|
3710, 6740
|
328, 398
|
9017, 9027
|
3149, 3687
|
9417, 10253
|
2457, 2593
|
7257, 8827
|
8877, 8996
|
6766, 7234
|
9051, 9394
|
2608, 3130
|
275, 290
|
426, 1423
|
1445, 2263
|
2279, 2441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,851
| 142,534
|
8585
|
Discharge summary
|
report
|
Admission Date: [**2126-11-12**] Discharge Date: [**2126-12-5**]
Date of Birth: [**2064-9-20**] Sex: M
Service: MEDICINE
Allergies:
Iodine / ct contrast
Attending:[**First Name3 (LF) 8115**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation, extubation
Incision and drainage of right axillary abscess
Placement of central venous catheter
History of Present Illness:
The patient is a 62 y/o M with a h/o metastatic melanoma with
spine, brain, and adrenal mets who has had left sided weakness
for months and has been developing right sided weakness over the
past week thought to be related to a known C3-4 mass. Presented
to the ED today due to inability to perform ADLs. The patient
was last seen by his oncologist, Dr. [**Last Name (STitle) 724**], on [**2126-11-7**]. At that
time he was started on a TPCH chemotherapy regimen (day [**4-19**]).
Additionally, the patient was recently seen by his PCP for the
left sided weakness and his Dexamethasone regimen was increased
to 10 mg Q6H with minimal improvement. He denies any loss of
bowel/bladder continence. No other neurological Sx. Denies
fever/chills. Has had significant diffulty maintaining
appropriate glucose levels since starting on steroids.
.
Of note the patient has also developed a right axillary abscess
over the past week. Started on Keflex on [**11-11**] by NP at
oncologists office. This has been increasing in size. Began
spontaneuosly draining today when palpated by paramedics.
.
En route to the ED, the patient's FS was noted to be ~500 and he
received Humalog at that time.
.
In the ED, the patient's intial vitals were T 97.4, HR 82, BP
108/60, RR 20, and SpO2 98% RA. Laboratory studies revealed a Na
of 123 and K of 6.2. Given 1amp calcium gluc and an ECG was
performed showing ST without peaked Ts. A CXR showed no acute
intrathoracic process. Received home insulin and became slightly
hypoglycemic. Had a BP of 88 systolic and received 1L IVF with
good response. Got Vanc x1 for his abcess. IV in ED infiltrated
and its unclear how much of the above the patient received.
.
On the floor the patient is mentating well. Somewhat hypotensive
with BP ranging from 80-100 systolic. Otherwise no acute
complaints.
.
ROS: (+) as per HPI. Otherwise denies any CP, palp, SOB, N/V/D,
fever/chills, changes in bowel/bladder habits, weight loss, HA
or vision changes.
Past Medical History:
ONCOLOGIC HISTORY
He [**Month/Day (4) 1834**] biopsy of a 1.84 mm thick primary melanoma without
ulceration from his right mid back in 11/[**2114**]. He [**Year (4 digits) 1834**]
sentinel lymph node biopsy without evidence of melanoma in his
right axillary nodes. He was enrolled in ECOG protocol 1697
randomized to the observation arm. He was well until [**12/2123**]
when CXR revealed multiple new pulmonary nodules with CT
confirmation. He was referred to Interventional Pulmonary, Dr.
[**Last Name (STitle) **], for bronchoscopic biopsy. Brain MRI on [**2124-1-25**] revealed
multiple brain mets and a PET/CT on [**2124-1-25**] revealed widespread
metastatic disease, including a worrisome cervical spine lesion.
On [**2124-1-26**], he [**Date Range 1834**] C-spine MRI confirming intramedullary
metastasis at C3-C4. He was seen urgently by Dr. [**Last Name (STitle) 1352**] of
orthopedics and felt not to be a surgical candidate. He
[**Last Name (STitle) 1834**] bronchoscopy and left adrenal biopsy on [**2124-1-26**] with
the left subcarinal LN showing no malignant cells and the left
adrenal bx c/w metastatic melanoma. He completed a 5 day course
of C-spine radiation at [**Hospital **] [**Hospital **] Hospital on [**2124-2-9**]. He
began ipilimumab on the brain metastasis trial on [**2124-2-23**] and
did very well. He had slow growth in the LLL lung lesion and
[**Date Range 1834**] OR bronchoscopy on [**2126-2-11**] with for bronchoscopy,
biopsy and debridement of tumor. Pathology confirmed metastatic
melanoma. He [**Date Range 1834**] VATS LLL wedge resection by Dr. [**Last Name (STitle) 30119**]
on [**2126-4-1**]. Pathology confirmed melanoma in the lung lesion, but
margins were clear and 4 lymph nodes were negative for tumor.
C-spine MRI was performed in [**2126-5-12**] to evaluate LUE numbness
(noted intermittently since rigid bronchoscopy on [**2126-2-11**])
with slight increase in size of C3-C4 mass, felt r/t
inflammation from ipilimumab. He subsequently developed
progressive left shoulder, arm and neck pain and increased UE
numbness, prompting ER evaluation on [**2126-8-14**]. C-spine MRI
revealed slight increase in the C3-C4 mass and increased edema
and he was started on prednisone. His brain MRI and torso CT
were stable without disease progression. Tumor is BRAF wild
type. He was removed from the ipilimumab brain metastasis
clinical trial due to symptoms and interval increase in the
C3-C4 mass (although ipilimumab related inflammation rather than
true disease progression was felt to be possible). Attempts to
lower steroid dosing were unsuccessful.
- [**8-22**] started on Temodar
Past Medical History:
# Diabetes -- diagnosed in [**2113**]
# Hypertension
# Hypercholesterolemia
# Vasectomy ([**2103**])
Social History:
He is retired from the insurance industry and also taught
computer at a private middle school on [**Location (un) 945**]. 38 pack year
smoker, quit in [**2123-6-13**], 1/2 drinks per month, no drugs.
Family History:
Had an uncle who died of metastatic melanoma. His grandmother
had breast cancer and his brother died of an MI in his sleep at
age 35. His sister also has cardiac problems.
Physical Exam:
ADMISSION PHYSCIAL EXAM:
Vitals- 96.5 100/64 111 13 98%2L
General- Appears well and in NAD, joking in bed
HEENT- PERRLA, EOMI, anicteric, MM Dry, Op clear
CV- RRR, S1 and S2, no m/r/g
Lung- CTAB, no w/r/r
Abdomen- Soft, NT/ND, BSx4
Extremity- Two areas of erythema on the right anterior chest.
Superior lesion is fluctuant and draining. Size is approx 3-4cm.
Neuro- AWake, alert and oriented. Strength 3/5 in LUE and LLE.
[**4-16**] in RUE and RLE. Some numbmness to palpation diffusely over
extremities.
.
DISCHARGE PHYSICAL EXAM:
VS: T 96.6, BP 130/72, HR 62, RR 20, SpO2 100% on RA
General: NAD, A+Ox3
HEENT: Dry MM, OP clear, no oral ulcerations or exudate.
NECK: No JVD.
CV: RRR. No M/R/G.
LUNGS: Clear to auscultation anteriorly. No crackles or wheezes.
ABD: BS+. NT/ND. Soft.
EXT: WWP. Soft pitting edema [**1-13**]+ bilaterally. No clubbing or
cyanosis. Right axillary wound with bandage C/D/I.
NEURO: 4/5 strength in the UE/LE on the right, 3+/5 strength in
the UE/LE on the left.
Pertinent Results:
ADMISSION LABS:
[**2126-11-12**] 04:35PM BLOOD WBC-6.1# RBC-4.80 Hgb-15.7 Hct-44.3
MCV-92 MCH-32.7* MCHC-35.5* RDW-14.0 Plt Ct-81*#
[**2126-11-12**] 04:35PM BLOOD Neuts-66 Bands-22* Lymphs-4* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-2*
[**2126-11-12**] 04:35PM BLOOD PT-12.2 PTT-23.6 INR(PT)-1.0
[**2126-11-13**] 11:07AM BLOOD Fibrino-1147*
[**2126-11-12**] 07:40PM BLOOD Glucose-194* UreaN-89* Creat-2.4*#
Na-123* K-6.2* Cl-88* HCO3-24 AnGap-17
[**2126-11-12**] 07:40PM BLOOD ALT-37 AST-19 AlkPhos-67 TotBili-0.7
[**2126-11-12**] 07:40PM BLOOD ALT-37 AST-19 AlkPhos-67 TotBili-0.7
[**2126-11-13**] 05:28AM BLOOD LD(LDH)-190 CK(CPK)-224
[**2126-11-12**] 07:40PM BLOOD Lipase-12
[**2126-11-12**] 07:40PM BLOOD Albumin-2.9*
[**2126-11-13**] 01:56AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.4
[**2126-11-13**] 12:00PM BLOOD Osmolal-288
[**2126-11-13**] 05:42AM BLOOD Type-MIX pO2-33* pCO2-35 pH-7.42
calTCO2-23 Base XS--1
[**2126-11-12**] 06:37PM BLOOD Glucose-269* Na-120* K-9.4* Cl-88*
calHCO3-19*
[**2126-11-13**] 05:42AM BLOOD Lactate-1.8
.
DISCHARGE LABS:
[**2126-12-5**] 05:12AM BLOOD WBC-15.4* RBC-3.40* Hgb-10.3* Hct-29.6*
MCV-87 MCH-30.4 MCHC-35.0 RDW-14.6 Plt Ct-141*
[**2126-12-5**] 05:12AM BLOOD Neuts-87* Bands-3 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-1*
[**2126-12-5**] 05:12AM BLOOD PT-13.2 PTT-28.5 INR(PT)-1.1
[**2126-12-5**] 05:12AM BLOOD Glucose-275* UreaN-29* Creat-0.8 Na-126*
K-4.6 Cl-94* HCO3-28 AnGap-9
[**2126-12-5**] 05:12AM BLOOD ALT-31 AST-21 LD(LDH)-327* AlkPhos-95
TotBili-0.3
[**2126-12-5**] 05:12AM BLOOD Albumin-2.3* Calcium-7.8* Phos-2.7 Mg-1.7
.
OTHER RELEVANT LABS:
[**2126-12-3**] 05:43AM BLOOD Vanco-16.3
[**2126-11-30**] 06:00AM BLOOD TSH-8.9*
[**2126-12-1**] 05:41AM BLOOD T3-39* Free T4-1.0
.
[**2126-11-30**] 12:11PM URINE Hours-RANDOM Creat-19 Na-112 K-13 Cl-72
[**2126-11-30**] 12:11PM URINE Osmolal-383
.
MICROBIOLOGY:
[**2126-11-22**] 9:13 pm BLOOD CULTURE (Source: Line-left SC)
Blood Culture, Routine (Final [**2126-11-28**]):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
.
[**2126-11-23**] 3:07 am SWAB (Site: RIGHT AXILLA):
GRAM STAIN (Final [**2126-11-23**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
ANAEROBIC CULTURE (Final [**2126-11-27**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
WOUND CULTURE (Final [**2126-11-27**]):
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH.
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ 2 S
.
.
IMAGING / STUDIES:
# CHEST (PA & LAT) ([**2126-11-12**] at 5:30 PM):
FINDINGS: The lungs are clear without consolidation or edema.
The mediastinum is unremarkable. The cardiac silhouette is
within normal limits for size. No effusion or pneumothorax is
noted. Degenerative changes are seen throughout the thoracic
spine.
IMPRESSION: No acute pulmonary process.
.
# MR [**Name13 (STitle) **] ([**2126-11-14**] at 5:51 PM):
FINDINGS: The intramedullary heterogeneously enhancing lesion at
C3/C4 level is stable in size and morphology, currently
measuring 14 (craniocaudal) x 11 (anteroposterior) x 10
(coronal) mm. Likewise, the associated cord edema is unchanged,
notably extending from C2 to C6 level. At the level of the
lesion, the spinal cord is expanded and there is unchanged
severe spinal canal stenosis with loss of CSF signal. Stenosis
at this level is exacerbated by unchanged central disc
protrusion. There is no interval change with regard to
multilevel, multifactorial degenerative changes, most notably
with moderate neural foraminal stenosis on the left at C4/C5
level and multilevel disc bulges at C3/C4, C5/C6, and C6-C7. No
evidence of new metastatic lesions. The visualized paraspinal
soft tissues are unremarkable.
IMPRESSION: Stable appearance of cervical intramedullary
metastatic lesion with extensive cord edema.
.
# CTA ABDOMEN / PELVIS ([**2126-11-15**] at 5:23 PM):
CT ABDOMEN: There is moderate subcutaneous emphysema along the
right anterior chest wall, presumably post-procedural. The lung
bases are clear. There is no pleural effusion. The heart is
normal in size without pericardial effusion. There is
multivessel coronary arterial disease. Intra-abdominal visceral
evaluation is highly limited on current examination due to
significant streak artifacts. However, allowing for such, there
is no focal liver lesion. The gallbladder, spleen, and adrenal
glands are unremarkable. Bilateral kidneys enhance symmetrically
without hydronephrosis or hydroureter. An enteric tube is in
place with tip coiled within the stomach. Small and large bowel
loops are normal in caliber without wall thickening or
obstruction. There is no evidence of active intestinal
hemorrhage on current examination. Extensive colonic
diverticulosis is present without diverticulitis. Hepatic
arterial anatomy is conventional. The celiac trunk, SMA, and
renal arteries are patent. [**Female First Name (un) 899**] is also patent. Moderate
atherosclerotic calcifications are present in the infrarenal
aorta.
CT PELVIS: The bladder is partially collapsed, containing
nondependent air, likely related to Foley catheter placement.
The rectum appears within normal limits. Small bilateral
fat-containing inguinal hernias are present. There is no pelvic
sidewall or inguinal lymphadenopathy by size criteria.
Subcentimeter external iliac and inguinal lymph nodes are
stable. A 3.7 x 2.0 cm mass in the right upper posterior chest
wall soft tissues (3A, 12) is similar as compared to [**2126-8-19**].
BONE WINDOW: No focal concerning lesion.
IMPRESSION:
1. No CT evidence of active lower GI bleed. Colonic
diverticulosis.
2. Likely post-procedural right anterior chest wall subcutaneous
emphysema; correlation with any recent history of
instrumentation is recommended.
3. Stable right upper posterior chest wall soft tissue mass.
4. Unchanged subcentimeter iliac and inguinal lymph nodes.
.
# MR [**Name13 (STitle) **] ([**2126-11-27**] at 6:28 PM):
FINDINGS: Cervical vertebrae are normal in height and alignment.
Craniocervical junction appears normal. As compared to the
previous MRI from [**2126-11-14**] there has been no interval
change in the size and morphology of intramedullary enhancing
lesion at C3-C4 level. Again noted is extensive cord edema
surrounding the lesion extending from C2 to C6 levels.
Multilevel degenerative changes in the cervical spine are
unchanged. No new metastatic lesions are seen. Pre- and
paravertebral soft tissues are unremarkable.
IMPRESSION: No interval change in cervical intramedullary
metastatic lesion with unchanged spinal cord edema.
.
# BILAT LOWER EXT VEINS ([**2126-11-28**] at 3:02 PM):
FINDINGS: The common femoral, superficial femoral, and the
popliteal as well as the deep veins of the calves on both sides
show normal ultrasound appearance, compressibility and Doppler
waveforms.
CONCLUSION: The ultrasound examination was negative for DVT in
either lower extremity.
.
Brief Hospital Course:
# Hypotension/hyperglycemia:
FIRST ICU COURSE upon admission: The initial concern was for
sepsis in the setting of an axillary abscess; patient's blood
pressures responded well to fluids and he stabilized quickly.
In the ED patient's blood glucose was 500 so likely he was
simply volume depleted secondary to osmotic diuresis in his
hyperglycemic state. He also had numerous electrolyte
abnormalities including hyponatremia and hyperkalemia which were
corrected prior to transfer to the floor.
.
SECOND ICU COURSE: Documented under GI bleed (See below).
.
THIRD ICU COURSE: On hospital day 10, patient developed
hypotension and tachycardia in the setting of missing 2 doses of
Unasyn due to loss of IV access. He was intubated for airway
protection, transfered back to the ICU and fluid resuscitated.
His antibiotics were broadened to vanc/zosyn and he responded
well hemodynamically. He was able to be extubated after less
than 24 hours. On his third ICU course, his hypotension was
attributed to sepsis in the setting of Pseudomonas bacteremia,
which was thought to be due to infection of the right axillary
abscess with Pseudomonas (also isolated from culture of the
axillary wound).
.
# Axillary abscess: The patient developed an axillary abscess 1
week prior to admission which started spontaneously draining the
day of admission. The patient had been on Keflex since [**2126-11-11**]
and received 1 dose of Vancomycin in ED. The patient's
presentation was likely related to patient's immunosupression
with chronic steroids and chemo. The patient was covered with
Vancomycin and Zosyn initially. Surgery incised and drained the
abscess. Infectious disease recommended Vancomycin and Unasyn.
After the patient's third admission to the [**Hospital Unit Name 153**], the axillary
abscess was noted to have grown Pseudomonas and Enterococci. He
was initially restarted on Vancomycin and Zosyn; as
susceptibilities returned, the patient was treated with
Vancomycin and Ciprofloxacin.
.
# GI bleeding: On hospital day 3, patient was noted to pass
BRBPR and clots per rectum in setting of platelets of 17. He
was transiently hypotensive to the 70's systolic, but recovered
his pressures to the low 100's, high 90's. He was transferred
to the [**Hospital Unit Name 153**] where NG lavage returned clear gastric contents. He
was transfused 2 units PRBC. The source of the bleeding was
presumed to be from a diverticular bleed. Given his neutropenia,
the patient was not scoped. Patient had a CTA of the abdomen and
pelvis showed no evidence of active lower GI bleed, but the
presence of colonic diverticulosis. He stabilized and improved
with platelet transfusion, ddAVP, IVF, and pRBC while in the
unit. On the floor, the patient had no further episodes of GI
bleeding.
.
# RUE Weakness: Most likely due to the patient's C3-4 vertebral
mass and related nerve impingment. No other signs suggestive of
cord compression. Initially changed dexamethasone to
hydrocortisone due to hypotension and electrolyte abnormalities
but switched back to patient's original steroid dosing once he
was stabilized. Obtained MRI of c-spine and brain which did not
show interval progression of metastatic disease, though the
study was technically limited. The patient right upper and lower
extremity weakness improved through his hospital course while
working with PT and OT.
.
# Acute kidney injury: Prior to hospitalization, patient had a
baseline creatinine of 1.0. On presentation his creatinine was
2.4 and continued to climb to 2.8. Elevated creatinine was
attributed to pre-renal status. The patient's serum creatinine
improved with fluids to 1.1 at the time of transfer to the
oncology floor. His serum creatinine remained stable through the
remainder of his hospitalization.
.
# Melanoma: When the patient initially presented, he had been
started on a new chemotherapy regimen. Per hematology/oncology
recs, TPCH chemotherapy was held because of acute kidney injury.
The patient's chemotherapy was held through the admission. The
patient did undergo an MRI of the brain and cervical spine to
monitor the patient's disease, and it did not show interval
progression of disease.
.
# Diabetes mellitus type 2: Patient's finger stick blood glucose
were checked with meals and prior to bedtime. Initially, the
patient refused to be managed by nurses for insulin and wanted
to take his home medications. He later agreed to follow an
insulin sliding scale, and was started on insulin glargine as
well. His blood sugars were difficult to control during his
stay due to his continued high dose steroids. His evening
Lantus dose was uptitrated several times, but he continued to
have elevated fingersticks. At the time of discharge, his FBGs
were running in the 300s. He will need close followup from
Endocrinology after discharge for further adjustment of his
Insulin regimen.
.
# Hypertension: Given the patient initial presentation of
hypotension, his home Lisionpril was held during his
hospitalization and discontinued at discharge.
.
# Hyperlipidemia: His home Rosouvastatin was continued through
the admission.
.
# Thrombocytopenia: Patient initially presented with
thrombocytopenia thought to be due to chemotherapy. He received
platelets early during his admission to prevent GI bleeding with
transfusion goal to keep platelets greater than 50. The
patient's platelet count recovered later in his hospitalization.
.
# Hypothyroidism: Patient's home dose of synthroid was continued
through much of the hospitalization. A TSH was drawn that
returned elevated, but with a normal free T4. No changes were
made to the patient's synthroid. He will need repeat TFTs 4
weeks from discharge as well as Endocrine followup.
.
# Elevated LDH: His LDH rose since his last admission to the
[**Hospital Unit Name 153**]. His hematocrit remained stable as has his Tbili
suggesting that the elevated LDH was not due to hemolysis. The
patient's AST and ALT were within normal limits (previously were
trending down in the setting of shocked liver secondary to
sepsis) which does not suggest a liver pathology. Given the
patient's Dexamethasone, it was possible that the rise in LDH
may represent a PCP infection, though the patient denies
shortness of breath, and he had been saturating well on room
air. LDH has also been used as a tumor marker for melanoma, so
it is possible that the rise may present the patient's
underlying metastatic disease. Because of the patient's
prolonged dexamethasone course, he was started on PCP
prophylaxis with Bactrim DS.
.
# Hyponatremia: Patient was initially admitted to the [**Hospital Unit Name 153**] with
hyponatremia thought to be due to poor oral intake. Urine lytes
were consistent with SIADH in the setting of his known
metastatic melanoma. Upon the patient's second [**Hospital Unit Name 153**] course, his
sodium improved with stress dose steroids. On the floor, as his
Dexamethasone was being weaned, his serum sodium was noted to be
falling. His Dexamethasone was increased back to 4 mg PO Q6H.
He was briefly treated with Fludrocortisone, but this was
discontinued at discharge. Endocrine consult felt that an
adrenal or thyroid etiology for his hyponatremia was unlikely,
but that he will need a slow taper of his steroids given his
prolonged high dose course. His Na was fairly stable around
125-127 at discharge. He will need to follow up with
Endocrinology soon after discharge for management of his steroid
taper.
.
# Transition of Care:
-- Continue Vancomycin and Ciprofloxacin for total of 4 weeks
after negative blood culture on [**2126-11-24**].
-- Consider Infectious Disease followup for further antibiotic
recommendations.
-- Monitor serum sodium initially every 2-3 days, and then
weekly as sodium levels stabilize.
-- Endocrinology followup within 1-2 weeks of discharge for
hypothyroidism, diabetes management, and steroid taper.
-- Slow steroid taper over several months per Endocrine recs.
-- Repeat TFTs 4 weeks from discharge.
-- Continue to work with PT and OT at rehab
-- Oncology followup as scheduled soon after discharge.
.
Medications on Admission:
DEXAMETHASONE - 6 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours take wtih 4 mg tablet
DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth q 6 hours
take
with 6 mg tablet
HDROXYUREA - - Take 2 tabs every 6 hrs for 2 times and then 3
tabs every 6 hrs for nine times
INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] - (Prescribed
by Other Provider) - 100 unit/mL (75-25) Suspension - up to 50
units with meals
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Cartridge - Cover dose
LEVOTHYROXINE [LEVOTHROID] - 175 mcg Tablet - 1 Tablet(s) by
mouth once a day taken in the morning
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
LORAZEPAM - 1 mg Tablet - [**1-13**] Tablet(s) by mouth at bedtime as
needed for insomnia
LORMUSTINE - - 3 Tabs of 100mg capsules once for a total dose
of 310 mg
NYSTATIN - 100,000 unit/gram Powder - apply topically twice a
day
as needed for groin rash
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth DAILY (Daily)
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth Take 1 tab
for nausea as needed - No Substitution
OXYCODONE - 5 mg Tablet - [**1-13**] Tablet(s) by mouth 4 times daily
as
needed
PROCARBAZINE [MATULANE] - 50 mg Capsule - 3 Capsule(s) by mouth
Take 3 tabs every 6 hrs Take 3 tabs every 6 hrs for 4 times and
4
tabs every 6 hrs for 2 times - No Substitution
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
TESTOSTERONE [TESTIM] - 50 mg/5 gram (1 %) Gel - 50 mg topically
daily
THIOGUANINE [TABLOID] - 40 mg Tablet - 3 Tablet(s) by mouth 3
tabs every 6 hrs Take 3 tabs every 6 hrs for 5 times, then 4
tabs every 6 hrs for 7 times - No Substitution
ASPIRIN - 81 mg Tablet,
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Dose Intravenous Q12H (every 12 hours).
3. vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous
Q 12H (Every 12 Hours).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MONDAY, WEDNESDAY, FRIDAY ().
6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
8. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
10. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for Gas.
11. collagenase clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily): Applied to gluteal wound.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Lantus 100 unit/mL Solution Sig: Forty Six (46) units
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: before meals and at bedtime
according to sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
Primary diagnosis:
Pseudomonas bacteremia and sepsis
Right axillary abscess
Lower gastrointestinal bleeding
Steroid induced hyperglycemia
Hyponatremia
Secondary diagnosis:
Metastatic Melanoma
Diabetes Mellitus Type 2
Hypothyroidism
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 **],
It was a pleasure taking care of your during your
hospitalization at [**Hospital1 69**].
During this hospitalization, you were admitted to the ICU for
concerns of sepsis. You were stabilized and then transferred to
the oncology floor. You then developed bleeding from your GI
tract with low blood pressure and had to be transferred back to
the ICU for stabilization. You had a third course in the ICU
because of a pseudomonas infectious of the right axilla that
spread into your blood. You are currently being treated with
antibiotics for your infection.
Please take all medications as instructed. The following
medication changes have been made:
START: Ciprofloxacin 400 mg IV every 12 hours
START: Vancomycin 1250 mg IV every 12 hours
START: Bactrim DS 1 tab on Monday, Wednesday, Friday
START: Lantus Insulin 46 units at bedtime
START: Humalog Insulin according to sliding scale
CHANGED: Levothyroxine 125 mcg by mouth daily
STOP: Lisinopril 20 mg by mouth daily
You will need close followup with Endocrinology for your
diabetes, hypothyroidism, and steroid tapering. You will also
need Infectious Disease followup for management of the
antibiotics course for your axillary abscess and recent
bacteremia. You also have followup scheduled with your
Oncologist next week. Please keep all appointments as listed
below.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2126-12-10**] at 2:30 PM
With: [**First Name8 (NamePattern2) 20062**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2126-12-10**] at 2:30 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: TUESDAY [**2126-12-24**] at 10:20 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 4908**] MD [**MD Number(2) 8116**]
|
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icd9cm
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[
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[]
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[
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icd9pcs
|
[
[
[]
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25883, 26010
|
14513, 14561
|
291, 425
|
26287, 26287
|
6636, 6636
|
27850, 28821
|
5434, 5608
|
24427, 25860
|
26031, 26031
|
22623, 24404
|
26463, 27827
|
7689, 9334
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5623, 6131
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243, 253
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6156, 6617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,253
| 129,824
|
12543+56377
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-9-2**] Discharge Date: [**2167-9-8**]
Date of Birth: [**2098-3-14**] Sex: M
Service:
This is a 66-year-old male who is status post right carotid
endarterectomy, who had been experiencing exertional
heartburn and becomes tired. He was seen at an outside
hospital which was found to have a low hematocrit and was
found to have an upper GI bleed which was caused by a polyp.
He then after polypectomy was stable.
He had a stress test in [**Month (only) 956**] which was positive and was
transferred here.
His past medical history is significant for paroxysmal atrial
fibrillation, peripheral vascular disease, parotid disease,
history of GI bleed, history of transient ischemic attacks,
and renal calculi.
Past surgical history include polypectomy as well as a TURP.
He has no known drug allergies.
His medications on admission are Lipitor 10 mg po q day,
digoxin 0.25 mg po q day, Protonix 40 mg po q day. He is
taking Coumadin which had been stopped prior to admission.
The patient was brought to [**Hospital1 **] for cardiac
catheterization which found multi-vessel disease. He was
taken to the operating room on [**2167-9-3**] where a coronary
artery bypass graft x4 was performed. He had a LIMA to left
anterior descending artery, saphenous vein graft to OM,
saphenous vein graft to diag, saphenous vein graft to PDA
anastomosis. The patient was transferred postoperatively to
the CSRU, where he did well. He was able to be weaned from
his ventilator and extubated. He was then transferred to the
floor postoperatively.
His chest tubes were removed after arriving on the floor and
he continued to do well. Physical therapy was consulted for
assessment of his ambulation as well as for his stamina and
he was able to clear stairs level five. Under their
recommendations, they felt that he was comfortable to be
discharged home at the end of his medical course. His wires
are removed on postoperative day #4 and question of
restarting on his digoxin and Coumadin was arose. The
primary care physician as well as his cardiologist were
contact[**Name (NI) **] and both felt comfortable not restarting his
Coumadin or digoxin at this time. He had been in sinus
rhythm throughout his hospital course.
On postoperative day #5, his Lopressor was increased to 25 mg
po bid and the patient tolerated it well. He was discharged
home in stable condition.
His discharge medications including Lasix 20 mg po bid,
Lopressor 25 mg po bid, glipizide 2.5 mg po q day, Lipitor 10
mg po q day, [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq po bid, Colace 100 mg po bid,
EC-ASA 325 po q day, Zantac 150 mg po bid, and Percocet 5/325
1-2 tablets po q4 hours prn.
He was instructed to followup with Dr. [**Last Name (STitle) 1537**] in [**3-28**] weeks and
his primary care physician [**Last Name (NamePattern4) **] [**12-24**] weeks. He was also
instructed to followup with his cardiologist in [**1-26**] weeks.
DISCHARGE DIAGNOSES: Paroxysmal atrial fibrillation,
peripheral vascular disease, carotid disease status post
carotid endarterectomy, gastrointestinal bleed, questionable
history of transient ischemic attacks, renal calculi, and now
coronary artery disease status post coronary artery bypass
graft x4.
The patient is discharged home in stable condition.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2167-9-8**] 07:49
T: [**2167-9-8**] 07:57
JOB#: [**Job Number 38854**]
Name: [**Known lastname 7034**], [**Known firstname 33**] J Unit No: [**Numeric Identifier 7035**]
Admission Date: [**2167-9-2**] Discharge Date: [**2167-9-8**]
Date of Birth: [**2098-3-14**] Sex: M
Service:
The patient was discharged on [**2167-9-8**] with no changes in his
medication. His medications include Lasix 20 mg po bid,
Lopressor 25 mg po bid, Glipizide 12.5 mg po q day,
atorvastatin 10 mg po q day, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3112**] 20 mEq po bid, Colace
100 mg po bid, EC-ASA 325 mg po q day, Zantac 150 mg po bid,
Percocet 1-2 tablets po q4 hours prn.
The patient is instructed to followup with his primary care
physician [**Last Name (NamePattern4) **] [**12-24**] weeks, his cardiologist in [**1-26**] weeks, and
with Dr. [**Last Name (STitle) 690**] in [**3-28**] weeks. The patient is discharged in
stable condition.
DISCHARGE DIAGNOSIS: Coronary artery disease status post
coronary artery bypass graft, paroxysmal atrial fibrillation,
peripheral vascular disease, carotid disease status post
carotid endarterectomy, gastrointestinal bleed, status post
polypectomy, transient ischemic attacks, and renal calculi.
The patient is discharged home in stable condition.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**First Name (STitle) 1589**]
MEDQUIST36
D: [**2167-9-8**] 14:40
T: [**2167-9-8**] 14:51
JOB#: [**Job Number **]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
3017, 4543
|
4565, 5164
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,886
| 117,790
|
42517
|
Discharge summary
|
report
|
Admission Date: [**2139-2-15**] Discharge Date: [**2139-3-4**]
Date of Birth: [**2116-9-7**] Sex: M
Service: SURGERY
Allergies:
Ceclor
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Motor vehicle crash - multi-trauma
Major Surgical or Invasive Procedure:
[**2139-2-16**] ORIF posterior pelvic ring bilaterally, ORIF anterior
pelvic ring on right side, I&D elbow open fracture, ulnar nerve
expliration and placment of external fixation [**Doctor Last Name 1005**]
[**2139-2-18**] 1. I AND D RIGHT ELBOW. ORIF RIGHT ELBOW,IVC filter
[**Location (un) **]
[**2139-2-23**] I AND D RIGHT ELBOW WITH BONE GRAFTING
History of Present Illness:
22M was unrestrained driver s/p motor vehicle crash, unknown
rate of speed or mechanism but ejected from vehicle approx
100ft. Cardiac arrest on scene, received CPR in ambulance. Large
volume rescucitation, and bilateral chest tube placement in ED
during code, no blood or air return. FAST neg x2. Pulses
returned w/o epinephrine or shocks.
Past Medical History:
none
PSHx: ureter correction age 8
Social History:
Parents involved in care.
Family History:
Noncontributory
Pertinent Results:
[**2139-2-15**] 11:16PM GLUCOSE-164* UREA N-21* CREAT-1.3* SODIUM-143
POTASSIUM-5.2* CHLORIDE-114* TOTAL CO2-20* ANION GAP-14
[**2139-2-15**] 11:16PM CALCIUM-7.1* PHOSPHATE-4.1 MAGNESIUM-1.9
[**2139-2-15**] 11:16PM WBC-13.8* RBC-4.18* HGB-12.5* HCT-35.4*
MCV-85 MCH-29.8 MCHC-35.3* RDW-14.2
[**2139-2-15**] 11:16PM PLT COUNT-182
[**2139-2-15**] 09:21AM PLT COUNT-188
[**2139-2-15**] 09:21AM PT-12.0 PTT-28.4 INR(PT)-1.1
IMAGING:
[**2-16**] CT head: Stable multicompartmental intracranial hemorrhage
including small globus pallidus and medial temporal lobe
intraparenchymal hemorrhage and minimal hemorrhage in occipital
[**Doctor Last Name 534**] of left lateral ventricle. A tiny focus of hemorrhage may
not be visualized in the occipital [**Doctor Last Name 534**] of the right lateral
ventricle suggestive of redistribution. No new hemorrhage or
shift in midline structures. Right parietal subgaleal hematoma
with associated laceration and staples overlying.
.
[**2-18**] LENIs: no evidence of DVT in b/l LE
.
[**2-19**] CXR: Low lung volumes persist. Bibasilar atelectasis larger
on the left are unchanged. Lines and tubes are in standard
position. There is no pneumothorax or pleural effusion. Left
subcutaneous emphysema has improved.
.
[**2-21**] Abd CT: No evidence of infection in chest, abdomen, and
pelvis, to account for the patient's fever. The study is not
tailored for evaluation of pulmonary embolism; however, within
this limitation, filling defects in left lower lobar and
segmental arteries, is concerning for pulmonary embolus.
Extensive thoracic and abdominal pelvic fractures, with interval
fixation of pelvic fractures in near anatomic alignment. New
mild widening of the right sacroiliac joint. Known right renal
lacerations, with mild interval decrease in the hematoma in the
perinephric space. Stable high-density fluid layering in the
right paracolic gutter and anterior pelvis. No new interval
intra-abdominal or pelvic bleed.
.
[**2-23**] Chest PTA r/o PE: Intraluminal filling defects c/w
pulmonary emboli are visualized in distal left lower lobe
pulmonary artery and extend into anteromedial, lateral and
posterior basal segmental pulmonary arteries. No evidence of
right heart strain.
Brief Hospital Course:
Mr. [**Known lastname 27003**] was noted to have lost pulses in the ambulance on
arrival to the ED. He was intubated in the field. He was
actively coded while bilateral chest tubes were placed, a Cordis
was placed in his right groin and a central line was placed in
his left subclavian. He regained pulses before losing them
approximately 10 minutes later, and was coded for an additional
amount of time prior to regaining his pulses and remaining
stable thereafter with several units of blood and crystalloid
being infused. His FAST was negative and he was noted to have
an open fracture of his right distal humerus as well as pelvic
instability. There was concern for urethral injury and a
catheter was not placed at this time. Given persistent
hemodynamic instability he was sent to the Angio suite with
interventional radiology where they embolized the bilateral
internal iliacs with Gelfoam. They also performed a retrograde
urethrogram at this time which demonstrated an intact urethra
and placed a Foley catheter at this time.
Between the ED and IR, he received 9 units of PRBCs, 4 units of
blood and 4 L of crystalloid. He returned to the Trauma ICU
stable not on pressors, but intubated and sedated. Stable, he
was taken to radiology for further radiologic workup revealing
the following injuries:
Left intraparenchymal hemorrhage basal ganglia
Posterior scalp laceration
Right parietal subgaleal hematoma
Right distal humerus and olecranon fractures
Right renal lacerations with subcapsular hematoma
Right posterior 11th rib fracture
L2-4 transverse process fracture
Right iliac crest fracture
Bilateral superior and inferior pubic rami fractures
Left SI joint diastasis
He was taken to the or on [**2139-2-16**] by the orthopedic team for
ORIF right hip/acetabular fracture as well as I&D and ex-fix of
his right elbow. He returned to the OR on [**2-18**] for another
washout of his elbow with ORIF and concomitantly had an IVC
filter placed.
His hospital course by systems as follows:
Neuro: Neurosurgery was consulted early on due to his brain
injuries - seizure prophylaxis was started, serial exams and
head CT scans were followed as well. His repeat head scans
remained stable. He was kept intubated and sedated through his
initial days in the TSICU. His sedation was weaned for
extubation on [**2-19**] and he was treated with IV Dilaudid for pain
control. He was mildly confused after extubation. Given his
altered mental status his cervical-collar was not able to be
cleared at first. As his mental status improved we were able to
obtain an adequate physical exam and removed the cervical
collar.
At time of discharge he is awake and answers questions and
follows commands. He was started on Trazodone at HS to help
regulate his sleep/wake cycle given his brain injury and this
has seemed to help.
CV: After initial hemodynamic instability, he stabilized and
remained stable throughout his hospital course. His Hcts were
trended and stable. He was initially tachycardic after
extubation and intermittently after transfer out of the ICU
remained tachycardiac. He was stated on beta blockers which has
brought his heart into the 80's-90's range.
Resp: Initially placed chest tubes were removed on [**2-17**] (right
side) and [**2-18**] (left) without complication. He had no pneumo or
hemothorax. He was extubated on [**2-19**]. After transfer to the
floor on [**2-20**] he was transferred back to the ICU on [**2-21**] for
respiratory distress and for a fever. CT Chest/Abdomen/Pelvis
did not reveal an obvious source of fever but he was placed in
the ICU, antibiotics were broadened and he recovered well. On
re-review, radiology could not exclude a pulmonary embolism in
the left lower lobe. This was followed with a CTA on [**2-23**] which
confirmed this finding in the left lower lobe basilar segments
and he was started on a heparin drip. He was transitioned to
Coumadin; his dose was held on [**3-3**] for INR 4.1 after having
received 5mg the night before. We are recommending that he be
given 2.5 mg on [**3-4**] for INR 2.4 repeating INR on [**3-5**].
GI: Initially started on tube feeds via OGT then advanced to a
regular for which he is tolerating much better now with improved
mental status.
GU: His Foley catheter was found to be placed in the urethra
with balloon expansion in the urethra on MRI after Foley
placement in IR. The catheter was advanced. He was also noted
to have a right sided renal laceration and subcapsular hematoma.
Urology was following for both of these issues and recommended
conservative management wit keeping Foley in place for 3-4 weeks
and repeating urethrogram at the end of that time. He will
follow up in [**Hospital 159**] clinic as an outpatient.
ID: He maintained on broad spectrum antibiotic coverage
(Ancef/Levo/Flagyl) for his open fractures and after placement
of orthopedic hardware given high risk of infection. The
antibiotics were eventually stopped. He is afebrile and his WBC
on [**3-3**].
Heme: An IVC filter was placed given his multiple fractures.
Afterwards was deemed okay for heparin (per neurosurgery) and
was started on heparin SQ as prophylaxis which was maintained
throughout the hospitalization. He was started on a heparin
drip on [**2-23**] to treat a pulmonary embolism in the left lower
lobe basal segments. And now on Coumadin as mentioned
previously.
MSK: He has an external fixation on his right arm and is non
weightbearing. He is also non weight bearing on his lower
extremities due to his pelvic fractures. Follow up films of his
pelvis due to complaints of increased pelvic pain were done on
[**3-4**] to assess the hardware and it was noted that there were no
issues. He will follow up as an outpatient in [**Hospital 1957**] clinic.
He was evaluated by Physical and Occupational therapy and is
being recommended for rehab after his acute hospital stay.
Medications on Admission:
Denies
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO three times a day as needed for constipation.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO every evening:
dose daily based on INR goal of 2.0-3.0.
12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO dose daily
based on INR: please adjust dose daily based on maintaining goal
INR range .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Left intraparenchymal hemorrhage basal ganglia
Posterior scalp laceration
Right parietal subgaleal hematoma
Right distal humerus and olecranon fractures
Right renal lacerations with subcapsular hematoma
Right posterior 11th rib fracture
L2-4 transverse process fracture
Right iliac crest fracture
Bilateral superior and inferior pubic rami fractures
Left SI joint diastasis
Pulmonary embolus
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:
You were admitted to the hospital following a motor vehicle
crash where you sustained multiple injuries that required
several operations. You also developed a blood clot in your lung
over the course of your hospital stay requiring treatment with a
blood thinner called wafarin (Coumadin) - you will be on this
medication at least for 6 months and possibly longer.
Due to the extent of your injuires you are being recommended to
go to a rehabilitation facility.
Followup Instructions:
*
Department: ORTHOPEDICS
When: TUESDAY [**2139-3-17**] at 9:25 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2139-3-17**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**], MD
When: MONDAY [**2139-3-23**] at 2:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: THURSDAY [**2139-3-26**] at 1:15 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2139-3-26**] at 2:15 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
We are working on a follow up appointment for you to see one of
our physicians in urology within the next 2-4 weeks. You will be
called at rehab with the appointment information. If you have
questions or have not heard, please call [**Telephone/Fax (1) 92004**] to inquire
about the appointment.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 85521**], MD
Specialty: Internal Medicine
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Completed by:[**2139-3-10**]
|
[
"564.00",
"839.42",
"518.51",
"861.21",
"427.5",
"852.26",
"808.53",
"958.4",
"813.11",
"807.01",
"E937.9",
"458.29",
"955.2",
"868.03",
"812.59",
"866.02",
"873.0",
"878.2",
"415.19",
"853.06",
"852.00",
"E812.0",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"79.52",
"99.60",
"38.7",
"79.32",
"88.42",
"86.59",
"78.43",
"34.04",
"79.19",
"39.79",
"78.12",
"88.47",
"79.31",
"96.6",
"04.6",
"04.49",
"49.21",
"79.62"
] |
icd9pcs
|
[
[
[]
]
] |
10503, 10573
|
3435, 9326
|
302, 656
|
11043, 11043
|
1180, 1633
|
11709, 13882
|
1144, 1161
|
9383, 10480
|
10594, 11022
|
9352, 9360
|
11223, 11686
|
224, 264
|
684, 1027
|
1642, 3412
|
11058, 11199
|
1049, 1085
|
1101, 1128
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,799
| 113,574
|
34566
|
Discharge summary
|
report
|
Admission Date: [**2155-7-12**] Discharge Date: [**2155-7-15**]
Date of Birth: [**2134-8-13**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5272**]
Chief Complaint:
Right Flank pain
Major Surgical or Invasive Procedure:
Right ureteral stent placement on [**2155-7-13**] with Dr. [**Last Name (STitle) 770**].
History of Present Illness:
Unsigned notes are not to be used for clinical decision making.
They are not final.
Date: [**2155-7-13**]
Signed by [**Name6 (MD) **] [**Name8 (MD) **], MD on [**2155-7-13**] at 7:40 am
Affiliation: [**Hospital1 18**]
NEEDS COSIGN
ATTENDING UROLOGIST: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] covering for Dr. [**First Name8 (NamePattern2) 1158**]
[**Last Name (NamePattern1) 770**]
UROLOGY CONSULT: Nausea, vomiting, and flank pain s/p
Extracorporeal Shockwave Lithotripsy (ESWL)
20F H/O bilateral nephrolithiasis presents to ER s/p ESWL 2 days
prior at [**Hospital6 2910**] with persistant N/V and
poor pain control. Denies Fever, chills, dysuria. Last UTI was
[**2-2**] treated with Cipro, diagnosed by lab, asymptomatic. Notes
increased frequencey since procedure but no passage of
fragments.
Denies gross hematuria. Last bowel movement 2 days prior.
PMH: hypothyroidism, nephrolithiasis in contest of >60 pound
weight loss, ADHD
PSH: ESWL x2
MEDS: levoxyl
ALL: NKDA
Physical Exam:
NAD
Soft, NT, ND
No CVAT
Pertinent Results:
[**2155-7-15**] WBC-7.0 Hgb-11.3* Hct-33.3* Plt Ct-248
[**2155-7-14**] Glucose-97 UreaN-6 Creat-1.1 Na-142 K-4.2 Cl-108
HCO3-26
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 825**] Urology service from
the [**Hospital1 18**] ED for overnight observation, pain control, and IV
fluids. A urine culture was obtained and antibiotics (Cipro)
were begun. She became febrile overnight and was taken urgently
to the OR for stent placement. Op Note is dictated separately.
She recieved Ancef pre-operatively in addition to the Cipro she
had been receiving. She became septic post-operatively and was
hypoxic requiring aggressive pulmonary toilet in the [**Hospital Unit Name 153**]
overnight. Her antibiotics were broadened to Ceftriaxone and
gentamycin. A CXR suggested volume overload and she received
Lasix in the PACU. With aggressive pulmonary toilet and diuresis
she improved and was transferred to the floor. Her cultures
returned only Gardnerella, for which she received 2 doses of
Flagyl. She was given fluconazole x1 given the broad coverage
antibiotics she received and issues with vaginal yeast
infections. She was D/C'd in stable condition with 14 days of
Cipro and instructions to follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**].
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) for 7 days: Can decrease frequency or stop if having loose
stools.
Disp:*28 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 20 days.
Disp:*40 Capsule(s)* Refills:*0*
4. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis with obstructing ureteral stone.
Discharge Condition:
Stable
Discharge Instructions:
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequecy over the next month. This is normal with a
stent in place.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain. Max
daily Tylenol dose is 4gm.
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower as normal. No tub baths or submersion until
stone is removed.
-Do not drive or drink alcohol while taking narcotics
-Colace and Senna have been prescribed to avoid post surgical
constipation and constipation related to narcotic pain
medication, discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, unless otherwise noted.
-Call Dr.[**Name (NI) 825**] office for follow-up AND if you have any
questions.
-If you have fevers > 101.5 F, vomiting, severe abdominal pain,
or inability to urinate, call your doctor or go to the nearest
emergency room.
Followup Instructions:
-Call Dr.[**Name (NI) 825**] office for follow-up AND if you have any
questions.
Completed by:[**2155-7-20**]
|
[
"314.01",
"584.9",
"592.1",
"244.9",
"799.02",
"599.0",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
3562, 3568
|
1678, 2830
|
331, 422
|
3655, 3664
|
1526, 1655
|
4772, 4884
|
2853, 3539
|
3589, 3634
|
3688, 4749
|
1481, 1507
|
275, 293
|
450, 1466
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,090
| 172,563
|
53419+59529
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-3-25**] Discharge Date: [**2138-3-30**]
Date of Birth: [**2061-4-8**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Monosodium Glutamate
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
diarrhea, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 76 yoM with an extensive past medical history
including type A aortic dissection in [**2132**] s/p aortic arch
replacement, CABG x 1, re-operation for dilated thoracic aorta
in [**10-11**] with a very complicated post-op course, PAF on
coumadin, PAD, diastolic CHF, HTN and recent C diff presents
with weakness and diarrhea. The patient has had recurrent C
diff. He had C diff initially around [**1-12**], and he had recurrent
diarrhea at the end of [**2-12**]- C diff x 3 were negative at rehab
but he was treated with PO flagyl x 14 days empirically. His
symptoms resolved with flagyl. He was discharged from rehab to
home on [**2138-3-7**] and he stopped flagyl [**3-12**]. After a few days his
diarrhea returned, at first it was just unformed but slowly
progressed to watery diarrhea. His diarrhea acutely worsened
over the past 24 hours- he had 8 large watery BMs over this time
period. He has some mild lower abdominal pain, urinary urgency
and dysuria x 3 days. No nausea or vomiting. No flank pain, no
F/C. He has had a 30 pound weight loss over the past few months.
.
+ cough productive of clear sputum. No CP, SOB or other
symptoms.
.
In the ER initial VS were: T 98.2 HR 60 BP 95/47 O2 sat: 96% RA.
He rec'd 500mg po flagyl x 1 in the ER. He had hypotension to a
systolic 70 while in the ER which improved to systolic 90s after
4 liters of IVF. Prior to transfer VS were: T 98.2 Afib 100-115
BP 103/57 95% on RA.
Past Medical History:
Type A aortic dissection in [**2132**] s/p replacement aortic arch,
resuspension of aortic valve, coronary artery bypass graft x1
s/p coil embolization of his left internal iliac aneurysm [**2136**]
CTA in [**2137-9-3**] showed increase in size of aorta to 6.3cm,
hence [**Year (4 digits) 1834**] planned redo repair in [**2137-10-3**] with
replacement of ascending aorta and arch with graft
- developed seizures post-op, neurology felt this was sign of
anoxic cerebral insult
- found to have E faecalis bacteremia
- LLL PNA with Cx growing serratia and E Coli
- left chest tube placed for pleural effusion
- right IJ thrombosis found during line placement
- hematuria felt to be due to Foley trauma while on coumadin;
required CBI and followed by urology
- had trach and GJ tube [**10/2137**]
- [**Year (4 digits) 1834**] work-up with bronch for possible TBM, which was
negative
- slow neurologic improvement, at time of discharge:
"he was able to follow commands- he was able to open his eyes,
grasp my fingers, and stick out his tongue. He was not moving
his limbs other than moving his toes and fingers and was not
antigravity, he was
areflexic"
- dc'd to rehab [**11-11**] on trach collar with CPAP
Readmitted [**Date range (1) 104398**] with fever and seizures
- coag negative staph bacteremia from PICC line
- found to have Cholecystitis but not felt to be operative
candidate, so had percutaneous choleycystostomy tube
- left subclavian DVT noted [**11-22**]
- dc'd back to rehab with plan for 6 weeks of vancomycin and
return in [**1-4**] months for cholecystectomy
pAFib s/p ablation [**7-/2137**], on coumadin
s/p PPM for tachy-brady syndrome
HTN
Hyperlipidemia
PVD
Anemia, felt to be due to chronic disease
h/o CHF with preserved EF
Diverticulosis
Benign prostatic hyperplasia
Spinal Stenosis
Social History:
Was living at [**Hospital **] rehab- came home and living w/ his wife
since [**2138-3-7**]. [**Name2 (NI) 3003**] smoker, but quit. Married, wife is his HCP.
Family History:
Non-contributory
Physical Exam:
Vitals - T: 99.0 BP: 88/50 HR: 111 RR: 19 02 sat: 98% on RA
GENERAL: NAD, AOX3
HEENT: JVP 7cm while at 15 degrees, MM dry, EOMI, PERRL, sclera
anicteric, conjunctiva pink
CARDIAC: RRR, no m/r/g
LUNG: Rales at L base
ABDOMEN: soft, NT, ND, no masses or organomegaly, BS+
EXT: WWP, no c/c/e
NEURO: AOx3, moving all extremities, resting tremor of L arm
(baseline)
Pertinent Results:
Admission labs:
[**2138-3-25**] 02:00PM WBC-12.1*# RBC-3.85*# HGB-11.8*# HCT-34.9*#
MCV-91 MCH-30.7 MCHC-33.9 RDW-13.9
[**2138-3-25**] 02:00PM NEUTS-85.0* LYMPHS-8.2* MONOS-6.0 EOS-0.3
BASOS-0.4
[**2138-3-25**] 02:00PM PLT COUNT-207
[**2138-3-25**] 02:00PM GLUCOSE-102* UREA N-41* CREAT-1.7* SODIUM-141
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16
[**2138-3-25**] 02:00PM ALT(SGPT)-19 AST(SGOT)-17 LD(LDH)-182
CK(CPK)-45* ALK PHOS-83 TOT BILI-0.4
[**2138-3-25**] 02:00PM cTropnT-0.03*
[**2138-3-25**] 02:00PM ALBUMIN-3.8 CALCIUM-9.1 PHOSPHATE-3.5
MAGNESIUM-1.7
[**2138-3-25**] 04:28PM PT-21.2* PTT-28.3 INR(PT)-2.0*
[**2138-3-25**] 05:23PM LACTATE-1.9
[**2138-3-25**] 05:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2138-3-25**] 05:10PM URINE BLOOD-MOD NITRITE-POS PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM
[**2138-3-25**] 05:10PM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0
Discharge labs:
[**2138-3-30**] 08:35AM BLOOD WBC-8.8 RBC-3.95* Hgb-12.1* Hct-36.6*
MCV-93 MCH-30.6 MCHC-33.1 RDW-13.6 Plt Ct-211
[**2138-3-30**] 08:35AM BLOOD Plt Ct-211
[**2138-3-30**] 08:35AM BLOOD Glucose-87 UreaN-19 Creat-1.2 Na-141
K-3.9 Cl-106 HCO3-23 AnGap-16
[**2138-3-30**] 08:35AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
[**2138-3-30**] 08:35AM BLOOD PT-40.5* PTT-34.4 INR(PT)-4.3*
Micro:
Stool culture:
FECAL CULTURE (Final [**2138-3-27**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2138-3-27**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2138-3-26**]): FECES
POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Blood cx: No growth
MRSA screen: negative
URINE CULTURE (Final [**2138-3-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
KLEBSIELLA PNEUMONIAE. PREDOMINATING ORGANISM.
>100,000 ORGANISMS/ML.. INTERPRET RESULTS WITH
CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ECG: Atrial fibrillation with rapid ventricular response. Right
bundle-branch block. Early beat may be ventricular or
aberration. Since the previous tracing of [**2137-12-4**] the rhythm is
now atrial fibrillation and there is no ventricular pacing
artifact seen.
AP CXR: IMPRESSION: Decrease in size of left pleural effusion
from prior examination. Small residual remaining. Also of note,
not mentioned above, a right upper extremity PICC line has been
removed in the interval. Otherwise, stable exam with no definite
acute pulmonary process.
Abd supine and erect: IMPRESSION: Non-specific bowel gas
pattern. No free intraperitoneal air.
Brief Hospital Course:
The patient is a 76yoM w/ a h/o aortic dissection s/p aortic
arch replacement in [**2132**] and reoperation in [**10-11**], with recent C
diff, stopped flagyl and had recurrent diarrhea.
.
# C diff: In the ED, the patient was hypotensive to an SBP in
the 70s, and remained hypotensive despite receiving 4 liters of
IV fluids, requiring admission to the MICU. He was started on
IV flagyl and PO vanco, another liter of IV fluids, and
stabilized quickly, not requiring pressors. He had a KUB that
showed no signs of obstruction. The next day he was called out
to the general medicine floor, where his diarrhea improved. He
continued to have [**2-5**] loose bowel movements per day. He was
discharged off of Flagyl with a long, 5-week taper of PO
vancomycin. He could be considered for pro-biotics at the end
of that taper. He was seen by physical therapy, who cleared him
to go home with home physical therapy.
.
# Hypertension: The patient was hypotensive on arrival and had
all of his antihypertensives held. He was restarted on
short-acting metoprolol the night of admission because he was
having bursts of asymptomatic afib seen on tele. The next day
he had symptoms of weak stream and urinary retention, so he was
started on tamsulosin 0.4mg daily. The next day he was
restarted on amlodipine 5mg and his home dose of metoprolol. He
was then very hypertensive, up to 180/90. His metoprolol dose
was increased to 150mg a day and his amlodipine to 10mg a day,
with improvement in his BPs to the 150/90s. He was discharged
with close follow-up with Dr. [**Last Name (STitle) 1728**] for a blood pressure checks
and instructions to call his doctor [**First Name (Titles) 151**] [**Last Name (Titles) 57714**] or
lightheadedness.
.
# UTI: The patient had a positive UA and symptoms of dysuria.
He was started on ceftriaxone 1gm Q24hrs. His urine culture
grew multiple bugs, consistent with contamination, but
predominantly cipro-sensitive Klebsiella. He was discharged
with two further days of cipro. He was also having symptoms of
urinary retention despite treatment of his UTI, so he was
started on tamsulosin, which he has taken in the past. His
urinary symptoms improved.
.
# Afib with RVR: previously on dronedarone, now rate-controlled
with metoprolol and anticoagulated. Normal EF as of [**10-11**]. With
improvement of his fluid status and a low dose of metoprolol, he
reverted to sinus rhythm. His was discharged on a higher dose
of metoprolol because of hypertension. His INR was elevated the
day of discharge and he was instructed to hold his coumadin for
two nights and have his INR checked by his visiting nurse.
Medications on Admission:
Aspirin 81 mg po daily
Warfarin 6 mg po daily
Dronedarone 400 mg po bid
Phenytoin 100mg po tid
Keppra 1000mg po bid
Metoprolol Tartrate 50 mg po tid
Simvastatin 10 mg po daily
atrovent / albuterol prn
Bisacodyl 10mg po daily
Docusate Sodium 50 mg/5, 10mL po bid
Senna 8.6 mg po bid
Acetaminophen prn
Ranitidine HCl 150 mg po daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO once a day.
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO Q3days (every 3rd
day).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY PRN
() as needed for GERD.
8. 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*
9. Vancomycin 125 mg Capsule Sig: as directed Capsule PO as
directed: 125 mg orally four times daily for 2 more days-to end
[**3-31**].
125 mg orally twice daily for 7 days-to end [**4-7**].
125 mg orally once for 7 days to end [**4-14**].
125 mg orally every other day for 7 days to end [**4-21**].
125 mg orally every 3 days for 14 days to end [**5-5**].
Disp:*38 Capsule(s)* Refills:*0*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*3 Tablet(s)* Refills:*0*
11. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] senior homecare
Discharge Diagnosis:
Primary diagnosis: Recurrent C.diff
hypotension
BPH-urinary retention
Secondary diagnoses: s/p aortic repair, atrial fibrillation,
hypertension, hyperlipidemia, peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted with recurrent diarrhea and your stool tested
positive for on-going clostridium difficile infection. You were
initially in the intensive care unit because your blood pressure
was low. You were transferred to the floor and your diarrhea
improved. Given that this infection is recurrent, you will be
sent home on a taper of antibiotics as follows:
Oral Vancomycin
125 mg orally four times daily for total of 7 days-until [**3-31**]
125 mg orally twice daily for 7 days-until [**2138-4-7**]
125 mg orally once for 7 days-until [**4-14**]
125 mg orally every other day for 7 days until [**4-21**]
125 mg orally every 3 days for 14 days until [**2138-5-5**].
.
You were also started on flomax/tamulosin 0.4mg at night to help
with urine flow.
.
Your blood pressure was high so your Toprol XL was increased to
150mg daily. Your amlodipine was increased to 10mg daily. If
you are lightheaded or your visiting nurse finds your blood
pressure to be low, please call Dr.[**Name (NI) 14154**] office and let them
know that your blood pressure medications were increased.
.
You were started on an antibiotic called ciprofloxacin for your
urinary infection. You should take one more day of ciprofloxacin
to complete a 7-day course, finishing tomorrow [**3-31**].
.
Your INR, the blood test we use to measure your coumadin levels,
was high this morning. You should not take your coumadin for
two days (today and tomorrow) and have your INR re-checked by
your visiting nurse.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] at [**Telephone/Fax (1) 14148**] to
schedule a follow up appointment within 1 week of discharge. He
should check your INR and blood pressure, and titrate your
coumadin and blood pressure medications as needed.
Completed by:[**2138-4-1**] Name: [**Known lastname **],[**Known firstname 448**] Unit No: [**Numeric Identifier 18034**]
Admission Date: [**2138-3-25**] Discharge Date: [**2138-3-30**]
Date of Birth: [**2061-4-8**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Monosodium Glutamate
Attending:[**First Name3 (LF) 211**]
Addendum:
To be added to hospital course:
#) Acute renal failure: In the setting of diarrhea and
hypotension, the patient's creatinine rose from a baseline of
1.0 to 1.2, up to a maximum of 1.7. This improved quickly with
IV fluids, and was almost definitely of pre-renal origin.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] senior homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2138-5-6**]
|
[
"788.20",
"584.9",
"599.0",
"427.31",
"V45.01",
"008.45",
"600.01",
"458.9",
"285.9",
"345.90",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14961, 15178
|
7432, 10077
|
314, 320
|
12255, 12255
|
4224, 4224
|
13940, 14680
|
3810, 3828
|
10458, 11936
|
12043, 12043
|
10103, 10435
|
14698, 14938
|
12434, 13917
|
5219, 7409
|
3843, 4205
|
12135, 12234
|
253, 276
|
348, 1791
|
4240, 5203
|
12062, 12114
|
12270, 12410
|
1813, 3619
|
3635, 3794
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,963
| 147,935
|
3566
|
Discharge summary
|
report
|
Admission Date: [**2133-12-27**] Discharge Date: [**2134-1-4**]
Date of Birth: [**2058-4-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Right subarachnoid hemorrgae, R intraparenchimal hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 y.o.M with dementia of unclear etiology (?[**Last Name (un) 16280**] body,
?fronotoperietal) with history of multiple falls presented to
[**Hospital1 18**] after falling in NH 5 days prior and minimal responsivness
for 3 days. His unresponsivness was initialy atributed to UTI
and pneumonia. According to the report patient is minimaly
responsive and non-verbal as a baseline. On presentation to ED
patient was non-verbal
Past Medical History:
parkinon's vs. [**Doctor Last Name **] body dementia, min verbal
HTN
depression
recent UTI
recent Pneumonia
s/p turp,
s/p lap chole,
s/p gastric ca resection
Social History:
resides at [**Hospital 100**] rehab
wife lives in the area
Family History:
non-contributory
Physical Exam:
PERLA EOMI, pupils [**1-20**] bilateraly, TM clear bilaterally,
echimosis and sutured lac over R eye
Chest: clear bilateraly, no crepitus
Heart: regular rate and rythm
Abdomen: soft, non-distended
Rectal: reduced tone, guac negative
FAST: negative
Extremities: warm well perfused, no swealing, no echimosis, no
lacs
Back: no step offs
Neuro: GCS 5- withdrawing to pain
can not asses muscle strength or sensation
Pertinent Results:
[**2133-12-27**] 06:47PM CK-MB-6 cTropnT-<0.01
[**2133-12-27**] 03:53PM TYPE-ART TEMP-37.3 PO2-254* PCO2-41 PH-7.42
TOTAL CO2-28 BASE XS-2 INTUBATED-INTUBATED
[**2133-12-27**] 03:33PM GLUCOSE-126* UREA N-25* CREAT-1.0 SODIUM-137
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11
[**2133-12-27**] 03:33PM CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-1.5*
[**2133-12-27**] 03:33PM WBC-9.9 RBC-5.13 HGB-15.0 HCT-43.3 MCV-85
MCH-29.2 MCHC-34.5 RDW-12.5
[**2133-12-27**] 03:33PM PLT COUNT-163
[**2133-12-27**] 10:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2133-12-27**] 10:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2133-12-27**] 09:50AM CK(CPK)-78 AMYLASE-35
CT head:1. Bilateral subarachnoid hemorrhage, predominantly in
the right temporal- parietal and right frontal lobes without
shift of midline structures.
2. Right frontal contusion.
3. Nasal septum fracture.
4. Sinus disease. CT of the facial bones may be performed as
clinically warranted
CXR: The tip of the endotracheal tube is about 4 cm above the
carina. The tip of the feeding tube is in the stomach. There are
bilateral pleural effusions and right lower lobe atelectasis.
Some pulmonary congestion is also seen at the hila.
The study and the report were reviewed by the staff radiologist
Brief Hospital Course:
Patient was intubated in the trauma bay, work up revieled Right
subarachnoid hemmorhage , R intraparenchimal hemorrhage.
Neurosurgical servicce evaluated the patient ahd he was brought
to TICU for further management.
Neuro: patient was kept off allsedation once initial evaluation
finished, his head ct remain unchanged, however he only regained
minimal movement of upper etremities, mostly withdrawing from
pain. This also has not improved once his medications were
started. Discussions were undertaken with patient's family and
neurorugical service and it was agreed that combination of
patient's poor baseline and significant injury, his chance of
miningfull recover would be minimal.
Cardiovascular:patient blood pressure was controlled initially
with nicardapine drip, and once tube feeding was started, with
oral medications. No concerns no issues
Respiratory: after weanning of sedation, patient had good gag,
however remained poor extubation potential due to his deminished
mental status. His chest x-ray showed miniimal evidence of RUL
and LLL iniltrate consistant with old scaring vs pneumonia. Once
discussion with family was undertaken about patient's condition
and he was made CMO he was extubated on HD #7 and was able to
maintain his airway and saturation.
GI/FEN: patient was started on TF and was maintained on his goal
nutriotion until he was made CMO. no concerns no issues. Patient
had intermitant hypokelimia, hypomagnesimia, hypocalcemia with
was corrected in the usuall fasion
Renal: through his admission patient had good urine output and
renal function
Endocrene: minimal insulin dosing for minimaly elevated BS
Ortho: patient had no spine fx on spine films and c-spine ct
scan, his collar was eventually removed, he was taken off
loggroll precausions.
ID: patient was on certriaxone for his pneumonia and UIT in NH.
in [**Hospital1 18**] he was initialy started on Levofloxacin empiricaly, and
Vancomycin was added once hew showed GPC from sputum. Patient
has history of MRSA and VRE colonisation.
Disposition: multuple discussions took place between patient's
family and mutlispecialty team, It was agreed that patient
prognosis was poor, and in accordence with patient's own wishes
as well as his family, he was made CMO on HD#7, and transfered
to the floor. Patient remained stable on the floor x 2[**Hospital 16281**]
transferred to [**Hospital 100**] Rehab.
Medications on Admission:
[**Last Name (un) **] 650 [**Hospital1 **],
EC ASA 325 qd
Oscal w/ Vit D 500 [**Hospital1 **],
Sinemet 25/100 (1 tab @ 10a; 2 tabs tid @ 6a, 2p & 7p)
Celexa 20 [**Hospital1 **]
Vit B12 100 qd
Folic Acid 1qd
Ritalin 2.5 qd
Univasc 7.5 qd
MVI
Ditropan XL 10 qd
Zantac 150 qhs
Senna 2 tabs
STUDIES
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: [**11-22**] Suppositorys Rectal
Q6H (every 6 hours) as needed.
2. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for yeasty rash.
3. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
4. Morphine Sulfate 1-5 mg IV Q1H:PRN respiratory distress
5. Lorazepam 0.5-2 mg IV Q4H:PRN comfort
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
s/p fall
head laceration
R subarachnoid hemorrhage,
R frontal intraparenchimal hemorrhage
R frontal contusion
R occipital subarachnoid hemorrhage
HTN
Parkinon's demnetia
failure to thrive
respiratory failure
hypokalimia
hypomagnesimia
hypocalcemia
Pneumonia
hyponatremia
Discharge Condition:
serious
Discharge Instructions:
patient is CMO
morphine and ativan as needed for comfort
Followup Instructions:
none
|
[
"276.8",
"486",
"851.40",
"311",
"276.1",
"802.0",
"401.9",
"599.0",
"332.0",
"275.41",
"E884.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6133, 6218
|
2957, 5359
|
370, 376
|
6533, 6542
|
1569, 2338
|
6648, 6656
|
1104, 1122
|
5705, 6110
|
6239, 6512
|
5385, 5682
|
6566, 6625
|
1137, 1550
|
273, 332
|
404, 830
|
2346, 2934
|
852, 1012
|
1028, 1088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,125
| 186,729
|
13581
|
Discharge summary
|
report
|
Admission Date: [**2187-7-21**] Discharge Date: [**2187-8-10**]
Date of Birth: [**2136-7-5**] Sex: M
Service: MED
Allergies:
Morphine
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
pneumonia, respiratory failure
Major Surgical or Invasive Procedure:
tracheotomy
ventilation
History of Present Illness:
Mr. [**Known lastname 16977**] is a 50 year old man with complicated past medical
history significant for DM1 s/p renal transplant, multiple CVAs
(last [**5-/2186**]), s/p prolonged recent admit to [**Hospital1 **] (d/c'ed [**2187-7-13**]
to rehab) for PEG placement, complicated by DKA, UTI, and
hypotension followed by ex lap. (During prior admission: he was
also found to have disphagia in a speech swallow eval. This was
thought to have a neurological etiology. Neuro was consulted and
a head MR showed no evidence of new CVA but did reveal
microvascular disease of the midbrain, pons, corona radiata,
thalomi, and internal capsules. It was thought that the
patient's dysphagia was secondary to stroke. It was thought that
the dysphagia was unlikely to improve. In addition, the patient
was not tolerating his feeds, as evidenced by nausea and
vomitting. A PEG tube was placed, and soon after he developed a
surgical abdomen, which was concerning for a hematoma in light
of his aspirin and plavix. Radiology revealed pneumoperitoneum.
He was brought to the OR for adjustment of the PEG tube.)
At rehab, the patient began to experience altered mental status
(disoriented, hallucinating), along with uncontrolled
hyperglycemia, and persistent nausea, vomitting, diarrhea. At
the rehabilitation facility, he was hydrated and a course of
levo/flagyl was begun.
A chest x ray on [**2187-7-22**] showed worsening right midlung
pneumonia with new sites of pneumonia in left lung. At this
facility, his temperature rose to 101.2 with increased O2
requirements and persistent tachypnia (RR 22-26). He also
developed increased gastric residuals and emesis. On the evening
of [**2187-7-22**], Mr. [**Known lastname 16977**] had increasing respiratory distress and
presented to the MICU where he was intubated.
Past Medical History:
DM1 (s/p renal Tx)
multiple CVAs
PVD
Hypothyroidism
HTn
Depression
Social History:
Lives at rehab. Married with 3 children. Currently undergoing a
difficult divorce. Sister very involved in care. No tobacco or
EtOH.
Family History:
NC
Physical Exam:
Vitals: 97.8, BP 102/50, HR 71
Vent settings PSV 10, with PEEP 5 and FiO2 0.35
Gen: alert, appropriate, thin male lying in bed
HEENT: trach in place, MMM, EOMI, PERRLA
CV: RRR, - murmurs
Pulm: CTAB, - wheezes, crackles
Abd: soft, NT, ND, + BS
Ext: hands with bilateral edema. Lower extremities with
pneumoboots in place, no edema, muscles atrophied.
Skin: desquamating. Sacral decubitus ulcer with no evidence of
infection, dressings C/D/I. Heels with accuzyme dressings C/D/I
in place. Right heel with 4 cm eschar, left with 2 cm escar.
Psych: flat affect, mood OK.
Pertinent Results:
[**2187-8-9**] 03:53AM BLOOD WBC-4.5 RBC-3.25* Hgb-10.0* Hct-29.9*
MCV-92 MCH-30.7 MCHC-33.4 RDW-15.4 Plt Ct-322
[**2187-7-20**] 09:45PM URINE RBC-[**10-27**]* WBC-[**5-17**]* Bacteri-FEW
Yeast-FEW Epi-[**2-9**]
[**2187-8-4**] 10:36AM URINE Hours-RANDOM Creat-31 Na-79 K-15 Cl-81
[**2187-8-4**] 10:36AM URINE Osmolal-297
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2187-8-3**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
CRYPTOCOCCAL ANTIGEN (Final [**2187-7-26**]): CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
[**2187-7-21**] 6:20 am BLOOD CULTURE**FINAL REPORT [**2187-7-26**]**AEROBIC
BOTTLE (Final [**2187-7-26**]): [**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **].
URINE CULTURE (Final [**2187-7-24**]): YEAST. 10,000-100,000
ORGANISMS/ML.. 2ND ISOLATE. <10,000 organisms/ml.
RESPIRATORY CULTURE (Final [**2187-7-27**]): OROPHARYNGEAL FLORA
ABSENT.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
YEAST. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Respiratory: Mr. [**Known lastname 16977**] was intubated for respiratory failure.
His aspiration pneumonia likely complicated precipitated the
failure. He was placed on antibiotics and had a tracheotomy
placed approximately 2 weeks into his hospitalization. When he
appeared to improve radiographically and clinically, his
ventilation was weaned. His respiratory status improved to where
he only needed pressure support throughout his last night of
hospitalization.
ID: Mr. [**Known lastname 16977**] grew out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] from his blood. He was
started on caspofungin which he received for 2 weeks. Once his
trach and J tube were placed, he was switched to voriconazole
for another 2 week course which he is to finish at the
rehabilitation facility. He also had a urinary tract infection
with enterococcus and pseudomas and was started on pipericillin/
tazobactam and vancomycin for the UTI and aspiration pneumonia.
He completed a 15 day course.
Endocrine: Mr. [**Known lastname 16977**] is a type I diabetic who was placed on an
insulin drip and titrated to maintain tight control on his blood
sugars. He also developed DKA aroudn the time of the placement
of his J Tube. Once he became afebrile and otherwise stable 2
days prior to discharge, his glargine insulin (20 units) was
restarted. He was covered with sliding scale regular insulin.
His hypothyroidism remained stable and his levothyroxine was
continued.
FEN: Mr. [**Known lastname 16977**] has delayed gastric emptying and severe
gastroparesis secondary to his diabetesThen his PEG was extended
with a J tube to improve his . His tube feeds were restarted
once the trach was placed. He was slowly increased to a goal of
50 which he tolerated with minimal nausea. He reported no
emesis.
Renal: Mr. [**Known lastname 16977**] is s/p living related kidney transplant 13
years ago. He has stable renal function with creatinine around
0.4. His prednisone and azathioprine were continued. When he
grew out [**Female First Name (un) **] from his blood cultures, casponfungin was
started and his cyclosporine was discontinued. Once his blood
cleared and he was afebrile, the neoral was restarted.
Neuro: Mr. [**Known lastname 16977**] is s/p multiple CVAs. His residual deficits
include right lower extremity paralysis and loss of sensation.
His plavix was stopped previous to the tracheotomy and then
restarted the following day. He had no further neurological
events. His aspirin was continued.
Musculoskeletal: Mr. [**Known lastname 16977**] has heel ulcers, 4 cm and 2 cm, one
on each foot. Podiatry was consulted and recommended accuzyme
and also stated that there should be no weight bearing. There
was no evidence of osteomyelitis at the time. Physical therapy
and occupational therapy was started to improve the patient's
deconditioning since he was unable to lift his limbs against
gravity.
Psych: Mr. [**Known lastname 16977**] was admitted on 30 mg of citalopram for
depression. At this time not only is he undergoing a complicated
and difficult hospitalization, but also a stressful divorce. He
had a flat affect but endorsed an "ok" mood. His citalopram was
increased to 40 mg, and he was offered support from a Catholic
priest and the unit social worker.
Medications on Admission:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
6. Baclofen 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
7. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
8. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO QD (once
a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1)
Topical [**Hospital1 **] (2 times a day).
11. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
12. Cyclosporine Modified 100 mg/mL Solution Sig: 100 mg PO Q12H
(every 12 hours).
13. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q6H (every
6 hours).
14. Levothyroxine Sodium 200 mcg Recon Soln Sig: 12.5 mcg Recon
Solns Injection QD (once a day).
15. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain not relieved by tylenol.
16. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
17. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
18. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous
membrane TID (3 times a day).
19. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 12.5-25 mcg
Injection Q4H (every 4 hours) as needed for pain not relieved by
oxycodone & tylenol.
20. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
21. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days.
22. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q8H (every 8 hours) for 4 days.
23. Insulin Glargine 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous once a day.
24. Promethazine
25. lactulose
26. lorazepam
27. prop-apap
28. reglan
27. lansoprazole
28. scopalamine
29. bisacodyl
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
6. Baclofen 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
7. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
8. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO QD
(once a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1)
Topical [**Hospital1 **] (2 times a day).
11. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
12. Cyclosporine Modified 100 mg/mL Solution Sig: 75 mg PO Q12H
(every 12 hours).
13. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q6H (every
6 hours).
14. Levothyroxine Sodium 200 mcg Recon Soln Sig: 12.5 mcg Recon
Solns Injection QD (once a day).
15. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain not relieved by tylenol.
16. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
17. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
18. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous
membrane TID (3 times a day).
19. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 12.5-25 mcg
Injection Q4H (every 4 hours) as needed for pain not relieved by
oxycodone & tylenol.
20. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
21. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days.
22. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q8H (every 8 hours) for 4 days.
23. Insulin Glargine 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous once a day.
24. sliding scale insulin
please see attached sliding scale insulin orders. Use regular
human insulin please
25. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day.
26. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO QOD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
DM type I
multiple CVAs with residual deficits
pneumonia
s/p renal transplant
respiratory failure, ventilation dependent
Discharge Condition:
fair
Discharge Instructions:
Please see med list. Also see attached sliding insulin scale.
Be sure to ask for an appointment for your eye care when you
visit [**Last Name (un) **]. Ask your primary care doctor for a referral to the
podiatrist. You already have an appointment.
Followup Instructions:
Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-8-20**] 2:30
Provider: [**Last Name (LF) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5091**], the office will
contact you for a follow up appointment
Provider: [**Name10 (NameIs) 16337**] [**8-16**] at 11 am with [**First Name9 (NamePattern2) 41006**] [**Last Name (un) 41007**]
at the [**Hospital **] CLINIC [**Telephone/Fax (1) 2378**]. During this appointment, ask
them to arrange an appointment with the ophthalmologist.
Please see Dr. [**First Name (STitle) 3209**] on [**9-3**] at 1 pm with [**Hospital Ward Name 121**] 3
Podiatry. Ask the PCP for [**Name Initial (PRE) **] referral.
|
[
"507.0",
"996.81",
"995.92",
"038.8",
"584.9",
"250.61",
"117.9",
"518.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"97.02",
"31.29",
"38.91",
"96.05",
"96.04",
"99.04",
"38.93",
"88.72",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12643, 12723
|
4743, 8032
|
293, 319
|
12888, 12894
|
3016, 4720
|
13190, 13998
|
2409, 2413
|
10280, 12620
|
12744, 12867
|
8058, 10257
|
12918, 13167
|
2428, 2997
|
223, 255
|
347, 2153
|
2175, 2243
|
2259, 2393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,414
| 162,875
|
561
|
Discharge summary
|
report
|
Admission Date: [**2139-6-3**] Discharge Date: [**2139-6-7**]
Date of Birth: [**2059-2-14**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Quinine / Chloramphenicol
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
urosepsis
Major Surgical or Invasive Procedure:
central line placement and removal
History of Present Illness:
This is an 80 y/o male with a h/o mental retardation, GERD c/b
severe erosive esophagitis, prostate CA s/p TURP without
additional treatment, who presented to the ED with fever to 103,
subjective dyspnea, foul smelling urine and hypotension with
SBPs in the 70s. Pt is not communicative at baseline, but did
report lower abdominal pain, denied any CP, SOB, cough. Pt
otherwise not able to give a more detailed history due to
baseline mental retardation.
.
In [**Name (NI) **], pt was hypotensive, febrile to 103. His lab values were
notable for an elevated WBC at 18.5, elevated transaminases,
elevated lactate at 7.6, and an elevated Cr to 1.9. He was given
5L NS, and after placing a R femoral CVL, started on Levophed
for BP support. He was empirically started on broad spectrum
antibiotics of vancomycin, levofloxacin and flagyl, and admitted
to the ICU for further care.
.
In the ICU, patient transiently required levaphed for pressure
support. Infectious work up included blood cultures which are
NGTD, CXR which was negative, RUQ U/S which was negative, and
urine culture with was positive for e. coli, fluoroquinolone
sensitive. He was maintained on vancomycin, levofloxacin, and
flagyl. On this regimen, the patient stablized, as his BP
returned and levophed was discontinued, his WBC decreased, his
fever resolved. His renal failure also resolved with fluid
rescusitation. His LFTs trended down. His lactate came down.
.
His ICU course was otherwise notable for a transient episode of
atrial fibrillation, which was broken with lopressor 5mg IV x 1,
and the patient was subsequently started on lopressor 12.5mg
[**Hospital1 **].
.
His course thus far was also notable for platelets decreased
from 130 -> 78, and therefore anti-HIT antibodies were sent
(pending) and his SC heparin was discontinued.
.
Currently, he is afebrile X 24hrs and denies any shortness of
breath, fever, chills, chest pain, or abdominal pain.
Past Medical History:
1. Prostate CA, PSA 7, s/p TURP, no hx of treatment for CA
2. GERD c/b erosive esophagitis
3. Mental retardation.
4. Frequent UTIs.
5. G6PD deficiency.
6. S/p ccy.
7. h/o sz d/o as child.
8. h/o guiaic (+) stool, not able to visualize past sigmoid on
scope due to poor prep (no lesion noted to sigmoid), EGD with
esophagitis as above
Social History:
Lives at group home ([**Street Address(1) 4552**], [**Location (un) 3307**], MA), where he
performs some ADLs and walks without assist. Sister, [**Name (NI) 1743**]
[**Name (NI) 4553**] is guardian.
Family History:
unknown
Physical Exam:
VS: T101.8 HR84 BP72/40 RR18 o2sat: 100% on 10L face tent
GEN: Elderly male, grunting, in NAD, in mild discomfort
HEENT: Anicteric sclera
NECK: No elev JVP
CV: Regular, nml s1,s2. No s3 or murmurs
RESP: Coarse BS throughout.
ABD: Soft, mild TTP over suprapubic area. R femoral line in
groin
EXT: No edema bilat. Pulses 2+. No CVAT bilat.
NEURO: Able to answer with 1 word answers. Moves all ext spont.
SKIN: No jaundice.
Pertinent Results:
Labs on admission significant for:
WBC 9.3 with 23% bands, Cr 1.9, lactate 7.6, AST 315, ALT 258,
AP 178
UA: >50 RBC, >50 WBC, many bacteria, neg glu/ketones
.
Imaging: EKG: NSR, 97. Nml axis, nml intervals.
Pseudonormalization of TW V4-V6, no ST changes from previous.
.
CXR [**6-3**]: AP supine portable view. Several thick skin folds limit
the
evaluation of the right hemithorax. Linear opacities at the
right lung base are unchanged, representing atelectasis or
scarring. The remainder of the right lung is grossly clear. The
left lung is clear. Heart size is top normal. There is no
pulmonary edema or pleural effusion.
.
Abdominal US [**2139-6-4**]: Limited study. No evidence of intra- or
extra-hepatic biliary ductal dilatation or focal hepatic mass.
Trace amount of fluid is seen adjacent to the upper pole of the
right kidney of unclear etiology.
.
.
Labs on discharge:
[**2139-6-6**] 07:17AM BLOOD WBC-6.7 RBC-3.81* Hgb-10.5* Hct-31.5*
MCV-83 MCH-27.5 MCHC-33.3 RDW-17.1* Plt Ct-83*
[**2139-6-6**] 07:17AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-141
K-4.1 Cl-110* HCO3-26 AnGap-9 Albumin-2.5* Calcium-8.1*
Phos-2.1* Mg-1.7
[**2139-6-6**] 07:17AM BLOOD ALT-105* AST-43* AlkPhos-133* TotBili-0.3
[**2139-6-5**] 11:48AM BLOOD TSH-1.4
[**2139-6-3**] 11:55AM BLOOD Cortsol-50.3*
[**2139-6-3**] 11:55AM BLOOD CRP-77.0*
[**2139-6-5**] 02:01AM BLOOD Vanco-8.1*
[**2139-6-4**] 02:32AM BLOOD Lactate-2.3*
Brief Hospital Course:
A/P: 80 y/o male with a h/o mental retardation, GERD c/b severe
erosive esophagitis, prostate CA s/p TURP without additional
treatment, who presents with fever to 103, subjective dyspnea,
foul smelling urine and hypotension with SBPs in the 70s.
1. Septic Shock: Pt with sepsis and hypotension, with lactate
7.8 in the ED and bandemia of 23%. Given 5L NS in the ED,
started on levophed to maintain MAP >65. Likely source is urine,
given markedly positive U/A and foul-smelling urine. No
pneumonia on CXR. Patient was admitted to the ICU and was
empirically started on Vanco and Levaquin IV. Urine culture
positive for E. coli, sensitive to levofloxacin, and was
switched to Levo 250mg PO. After aggressive IVF resuscitation,
the patient was weaned off of levophed with SBPs in 90s-100s.
Patient remained afebrile, WBC trended downward, and was
transferred to the medicine floor.
.
While on the medicine floor, he was afebrile with SBP's in the
120's and HR in the 70's, O2 sat was 95% on 2L.
.
2. Respiratory distress: On admission, patient in respiratory
distress, but no clear PNA seen on pulmonary exam. The Levaquin
IV for urosepsis also provided coverage for CAP. Patient was on
a face tent with 40% FiO2 but would not tolerate it very well
and would pull in off his face. O2 sats remained >92%, even on
room air. He was given nebs prn and switched to nasal cannula
with sats>94%.
.
3. ARF: Pt with a normal baseline Cr of 0.7 and admitted with
Cr of 1.9, most likely due to prerenal azotemia given profound
dehydration in the setting of sepsis as above. Cr trended down
after IVF resuscitation and was back to baseline at time of
discharge.
.
4. A-fib: On morning of transfer from ICU to floor, patient went
into a-fib with rates in the 140's-170's. He was given 5mg
lopressor and rate decreased to 80's-120's and returned to
[**Location 213**] sinus rhythm. He was then started on metoprolol 12.5 [**Hospital1 **]
PO with no further episodes of atrial fibrillation on telemetry.
.
5. Mild transaminitis: On admission, he had a mild transaminitis
likely in setting of sepsis. Abdominal US was performed to r/o
biliary/hepatic pathology. US Showed no evidence of intra or
extra hepatic biliary ductal dilitation. The LFTs trended
downward during the course of hospital stay.
.
6. Heparin induced thrombocytopenia: During the hospital stay,
pts platelets fell from 128 to 78 overnight. As he was receiving
SQ heparin for DVT prophylaxis, there was concern for HIT. All
heparin products were stopped, heparin dependent antibodies were
sent and pending at the time of discharge, and the platelet
counts stabilized.
.
7. Mild coagulopathy: On admission, he had a mild coagulopathy
likely in setting of sepsis. A peripheral smear was negative for
any schistocytes. INR was followed and trended downward
appropriately.
.
8. GERD: no active issues during this admission and patient
remained on pantoprazole Q12h.
.
9. Conjunctivitis: He developed some white exudate and injection
in left eye concerning for conjunctivitis. Erythromycin eye
drops were started.
.
10. FEN: Patient given aggressive IVF resusciation with
electrolytes repleted as necessary. Speech and swallow
evaluated patient and recommended pureed diet and thickened
liquid diet. Patient was started on PO prior to transfer, and
tolerated his meals well while on the floor.
.
9. DISPO: DNR/DNI.
.
Comm: HCP [**Name (NI) **] [**Name (NI) 4554**]. [**Telephone/Fax (1) 4555**]
Medications on Admission:
Carbamazepine 200mg qAM, 300mg qhs
Prilosec 20 [**Hospital1 **]
Vit C 500 qD
FeSO4 325
Eucerin cream
Tianctin
Baby Shampoo/[**Name2 (NI) **]
A&D ointment
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
4. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a
day (at bedtime)).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID
(4 times a day) for 2 weeks.
Disp:*qs tubes* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing/SOB for 1
weeks.
9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
urinary tract infection
septic shock
Secondary:
mental retardation
GERD
prostate cancer s/p TURP
Discharge Condition:
good
Discharge Instructions:
You had a urinary tract infection and went into septic shock.
.
Please call 911 or come to the emergency room if you have any
symptoms of fever >101, chills, shortness of breath, chest pain,
or any other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 608**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
[
"995.92",
"038.9",
"V10.46",
"584.9",
"041.4",
"427.31",
"E934.2",
"319",
"599.0",
"530.81",
"372.30",
"276.51",
"287.4",
"271.0",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9382, 9440
|
4789, 8242
|
309, 345
|
9590, 9597
|
3359, 4220
|
9870, 10104
|
2892, 2901
|
8447, 9359
|
9461, 9569
|
8268, 8424
|
9621, 9847
|
2916, 3340
|
260, 271
|
4239, 4766
|
373, 2301
|
2323, 2659
|
2675, 2876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,271
| 139,905
|
33314
|
Discharge summary
|
report
|
Admission Date: [**2112-4-3**] Discharge Date: [**2112-4-22**]
Date of Birth: [**2040-10-16**] Sex: F
Service: MEDICINE
Allergies:
Codeine / OxyContin
Attending:[**Last Name (un) 7835**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
pericardiocentesis [**2112-4-3**]
History of Present Illness:
Ms. [**Known lastname 77320**] is a 71 year old transferred from OSH w/pericardial
effusion found on CT which was associated with early tamponade
physiology and pleural effusions. She presented to [**Hospital 1562**]
hospital this afternoon for increasing dyspnea and nausea x 1
week. Additionally, she noted ankle edema, and continued chest
pain. Ms. [**Known lastname 77320**] had presented for chest pain to [**Hospital1 1562**]
approximately 1 week ago where she ruled out for an MI and was
discharged home with GERD treatment. Upon presentation to the
OSH today, she was found on CT to have a large pericardial
effusion with pleural effusion as well as axillary
lymphadenopathy. Cardiology saw her at the OSH and recommened
transfer for possible pericardial window.
Seen by cards at OSH and sent for poss pericardial window.
h/o breast CA s/p bilat mastectomy, per report adenopathy on CT
scan.
Diagnosis: pericardial effusion
ED Course (labs, imaging, interventions, consults): Upon arrival
in the ED from [**Hospital 1562**] hospital, initially pt was tachy to 150,
RR 23, BP 132/56, 97% on 4L NC (92% on 2L on admission) with a
pulsus of 20mmHg. EKG was obtained which demonstrated sinus
tachycardia. Cardiology and Cardiac Surgery were consulted.
Cardiac surgery recommended window in the morning. Bedside echo
demonstrated RA and RV collapse. Cardiology took Ms. [**Known lastname 77320**] for
an urgent pericardiocentesis.
.
In pericardiocentesis, the RV was initially sampled and
following this Ms. [**Known lastname 77320**] was hypotensive to SBPs in the 50s.
Levophed was initiated, the pericardial effusion was drained for
500cc of a bloody effusion.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers or rigors but
espouses chills. She denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes - , Dyslipidemia - ,
Hypertension -
2. OTHER PAST MEDICAL HISTORY:
Bilateral stage I lobular carcinoma (see below)
goiter, which is being followed
Basal cell cancer ten years ago
.
PSH:
Tonsillectomy at age 14 and a cholecystectomy at age 25, rotator
cuff surgery at 64 and knee surgery at age 55.
.
ONCOLOGIC HISTORY:
1. [**5-/2108**]: Multiple suspicious areas on breast MRI.
Bilateral
breast biopsy demonstrated invasive lobular carcinoma.
2. [**6-/2108**]: Underwent bilateral mastectomy for what appeared
to
be multifocal disease in both breasts and had negative sentinel
lymph node biopsy. The right breast had a lesion staged as T1b
and was grade II, ER positive, PR negative, HER-2 negative,
grade
II. The left breast lesion was T1C M0, ER/PR positive,
HER-2/neu
negative without lymphovascular invasion and grade II. BRCA [**2-15**]
testing negative.
3. [**7-/2108**]: Oncotype DX assay revealed a recurrence score of
21, which was in the intermediate risk group. The patient
declined enrollment in the TAILORx trial because she did not
want
chemotherapy. Started on Arimidex. The last bone mineral
density scan in [**7-/2108**] revealed osteopenia at the left femoral
neck
Social History:
Retired teacher, taking writing courses, married lives with
spouse. [**Name (NI) **] 4 daughters. [**Name (NI) **] smoking or drinking at this time. 20
pack year smoking history.
Family History:
A brother who was diagnosed with breast cancer at age 59,
metastatic disease at age 60. She has a sister who was
diagnosed
with breast cancer at age 49 and died at age 51 from metastatic
disease. She has another sister recently diagnosed with breast
cancer in [**2109**]. Genetic testing for BRCA 1 or 2 mutations was
performed and was negative.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
.
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVD at 3cm above clavicle at 90 degrees
CARDIAC: Hyperdynamic precordium, PMI located in 5th intercostal
space, midclavicular line. tachycardic but regular rhythm,
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. Decreased breath sounds
at bilateral bases, +egophony at bases, LLB > LLB, +[**Last Name (un) **] sign
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: trace LE pitting edema, No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
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:
LABS ON ADMISSION:
.
[**2112-4-3**] 05:10PM BLOOD WBC-11.4* RBC-4.34 Hgb-13.7 Hct-39.2
MCV-90 MCH-31.6 MCHC-35.0 RDW-12.7 Plt Ct-304
[**2112-4-3**] 05:10PM BLOOD Neuts-83.2* Lymphs-11.7* Monos-4.5
Eos-0.1 Baso-0.5
[**2112-4-3**] 05:10PM BLOOD PT-11.0 PTT-22.7* INR(PT)-1.0
[**2112-4-3**] 05:10PM BLOOD Glucose-131* UreaN-26* Creat-1.3* Na-135
K-5.3* Cl-102 HCO3-18* AnGap-20
[**2112-4-3**] 09:20PM BLOOD CK(CPK)-45
[**2112-4-3**] 09:20PM BLOOD CK-MB-3 cTropnT-0.04*
[**2112-4-3**] 09:20PM BLOOD Calcium-8.6 Phos-4.5 Mg-2.4
.
REPORTS
CT TORSO [**2112-4-7**] 11:29 AM
1. Extensive mediastinal, supraclavicular and hilar
lymphadenopathy with mass effect on to the adjacent veins, but
without occlusion.
2. Interval decrease of pericardial effusion, in keeping with
the recent
pericardial drainage.
3. Interval increase of loculated pleural effusions, left
greater than right. New subtotal collapse of the left lower
lobe. Reticulonodular opacities in the lower lobes raise concern
for lymphangitic carcinomatosis.
4. Heterogeneously enhancing right thyroid nodule, concerning
for metastasis.
5. No definite evidence of intra-abdominal or intra-pelvic
metastatic
disease. Likely geographic hepatosteatosis.
PERICARDIAL FLUID Procedure Date of [**2112-4-4**]
POSITIVE FOR MALIGNANT CELLS,
consistent with metastatic adenocarcinoma (see note).
Note: The current specimen shows similar findings to the
prior pericardial fluid specimen (C12-5973S, [**2112-4-3**]), which
was reviewed for comparison.
[**2112-4-4**] Tissue: pericardium. [**2112-4-5**] [**Last Name (LF) **],[**First Name3 (LF) **] C.
Pericardial fluid, cell block:
Positive for Malignant Cells.
Consistent with metastatic poorly differentiated carcinoma.
Note: The tumor cells are immunoreactive for CK7, B72.3, [**Last Name (un) **]-31,
and focally positive for mammoglobin. They are negative for
CK20, CEA, Leu-M1 (background staining of neutrophils and
macrophages), GCDFP, ER, PR, Calretinin, and WT-1. Mucicarmine
staining is negative. These findings support metastasis from
breast origin. See cytology (C12-5973).
CXR AP [**2112-4-11**]
IMPRESSION:
1. Placement of a right Pleurx catheter with interval decrease
in size of a large right pleural effusion. Tiny right basilar
pneumothorax.
2. Unchanged appearance of left retrocardiac opacity, which may
represent
severe atelectasis or consolidation.
3. Unchanged small left pleural effusion
ECHO [**2112-4-4**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. The ascending, transverse
and descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque t.. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a moderate sized pericardial
effusion. The pericardium may be thickened. No right atrial
diastolic collapse is seen.
No pericardial effusion after surgical drainage.
.
Brain MRI [**2112-4-18**]:
Preliminary ReportIMPRESSION:
1. Small left sphenoid [**Doctor First Name 362**] meningioma without evidence of
extension into the optic canal.
2. No additional intra- or extra-axial lesions.
3. Acute-on-chronic sinus disease as detailed above.
Brief Hospital Course:
HOSPITAL SUMMARY:
71 year old female PMHx Breast cancer s/p bilateral mastectomy
who presented w SOB, found to have pericardial effusion with
tamponade, s/p pericardial window, also with L pleural effusion
s/p pleurex placement, both cytology samples returning positive
for adenocarcinoma, course complicated by hypoxia thought to be
secondary to cancer lymphangitic pulmonary burden, now s/p
initiation of taxol.
# Pericardial effusion: On admission, found to have effusion
with tamponade physiology; s/p drainage of pericardial effusion
on [**2112-4-3**] complicated by RV puncture and transient need for
levophed (~3 minutes). Pericardial window performed [**4-4**].
Final cytology report with malignant cells consistent with
breast adenocarcinoma.
# Atrial Fibrillation - First noted following pericardial
window, felt to be secondary to pericardial irritation; no
evidence of PE on CTA chest (although not protocoled for PE).
Initiated on amiodarone and metoprolol, converted to normal
sinus rhythm with occasional episodes of A fib. Pt has been well
controlled on this regimen, although difficult to tolerate due
to pressures, so metoprolol dose was decreased to 6.25mg. She
should continue on this dose, which she tolerates well.
Amiodarone has just been decreased from 200mg tid after 2 weeks
to 200mg [**Hospital1 **], which shold continue for 4 weeks and then 200mg
daily until further recommendations by Cardiology.
# Pleural Effusions - During hospital stay, noted to have
enlarging R pleural effusion, on [**4-8**] underwent tap, with
conversion to pleurex on [**4-11**]. Final cytology report with
malignant cells consistent with breast adenocarcinoma. Patient
underwent daily drainage of pleurex (about 500cc daily) until
[**2112-4-20**]. She had reaccumulating L sided effusion, and had
pleurex placed on that side on [**2112-4-20**], draining 1L of fluid.
She should continue to have effusions drained every other day
(alternating), no more than 1L at a time. Please see attached
directions for details. Pt will f/u with Interventional
Pulmonology team on [**2112-5-2**] for suture removal of L pleurex
cathether.
# RUE DVT: In setting of RUE edema, RUE ultrasound demonstrated
nonocclusive clot around R PICC line; after discussion w primary
oncologist, patient was started on therapeutic lovenox (planned
duration = lifelong given ongoing onc issues)
# Hypoxia: Patient with hypoxia throughout stay, initially
requiring 6LNC and face mask, thought to be multifactorial in
setting of pleural effusions, pulmonary edema, and lymphangitic
spread of tumor to lungs. Of note, patient was never officially
ruled out for pulmonary embolism (had CT chest w contrast that
was not protocoled for PE), but as this would not change
management (already on therapeutic lovenox as above) CT PE was
not obtained. TTE did not demonstrate shunt (PFO). With
diuresis, drainage of R pleural effusion, patient resp status
improved, but not to baseline. Initiated taxol for presumed
tumor burden component. At transfer to floor, patient satting
90-93% on 5L nasal canula, occasionally using humidified air via
shovel mask for comfort. She had increased O2 requirement to
6LNC on [**2112-4-21**] which may have been from small PTX after L
pleruex placement or increased R infiltrate which was possibly
pneumonia, fluid or lymphangitic spread. This most likely
represented a component of lymphangitic spread but since pna
couldn't be ruled out, she will complete a 5 day course of
Levofloxacin.
# Hyponatremia: Sodium ranged from 125-130, initally thought to
be hypovolemic in setting of intravascular depletion (had low
albumin, lots of third-spaced fluids). It did not however,
respond well to hydration. She was then placed on fluid
restriction due to concern for SIADH with normalization of her
sodium. She should continue on a 1200ml fluid restricted diet.
# UTI: Ucx [**4-11**] grew pan-sensitive E. coli for which the patient
was treated w IV ceftriaxone (d1= [**4-11**]) treated for 7-day
course.
# Breast Cancer s/p b/l mastectomy (Her 2 negative, ER/PR
positive) - She was continued on anastrozole, and as discussed
above, started taxol chemotherapy while inpatient. HER 2 status
is pending. She will continue to follow with Dr [**Last Name (STitle) **] and
return for chemo next week.
.
#Hallucinations: Pt developed visual hallucinations during ICU
stay. At that time she had received Ativan, so it was thought
that this was potentially a side effect from ativan. Would
avoid benzos as possible in the future.
Medications on Admission:
anastrozole 1mg daily
Discharge Medications:
1. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
4. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO TID (3
times a day).
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
start [**2112-4-21**] and continue this dose for 4weeks, then change to
once daily.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for gerd.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
13. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12HR ().
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
16. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Metastatic Breast Cancer
Malignant Pericardial Effusion/cardiac tamponade
Malignant Pleural Effusion
Atrial Fibrillation
Deep venous Thrombosis
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 due to SOB and were found to
have fluid around your heart (pericardial effusion) as well as
in your lungs. These were drained, with a procedure "window" to
continue to empty the pericardial effusion done. The fluid in
these was found to be malignant and consistent with metastatic
breast cancer, so you were started on chemotherapy to control
this, which is called Taxol and you will receive this weekly on
3 weeks and then have one week off. While you were in the
hospital you also developed an abnormal heart rhythm (atrial
fibrillation) and have been started on medications for this, as
well as a DVT (clot) in your upper extremity) for which you were
started on a blood thinner and a UTI that was treated for 7 days
with antibiotics.
Followup Instructions:
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2112-5-2**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**Telephone/Fax (1) 7769**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2112-5-27**] at 10:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2112-4-27**] 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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icd9cm
|
[
[
[]
]
] |
[
"37.0",
"99.25",
"34.91",
"37.12",
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] |
icd9pcs
|
[
[
[]
]
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15220, 15286
|
8960, 13507
|
286, 321
|
15473, 15473
|
5510, 5515
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|
3986, 4334
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15307, 15452
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13533, 13556
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|
239, 248
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349, 2522
|
5529, 8937
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15488, 15631
|
2645, 3774
|
3790, 3970
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,082
| 188,685
|
12789
|
Discharge summary
|
report
|
Admission Date: [**2171-4-26**] Discharge Date: [**2171-5-7**]
Date of Birth: [**2093-10-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxycodone / Ofloxacin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2171-4-30**] IABP insertion
[**2171-4-30**] 1. Urgent off-pump coronary artery bypass graft x3: Left
internal mammary artery to left anterior descending artery;
saphenous vein graft to obtuse marginal and distal right
coronary arteries.
History of Present Illness:
77 year old male with history of hypertension, hyperlipidemia,
coronary artery disease, status post angioplasty 20 yo with a
negative pharmacologic stress test last year, presented to
[**Hospital6 3105**] complaining of substernal chest pain
on [**2171-4-22**]. Further cardiac workup revealed multivessel coronary
artery disease. He was transferred to [**Hospital1 18**] for evaluation of
coronary revascularization.
Past Medical History:
-hypertension
-hyperlipidemia
-coronary artery disease, status post angioplasty 20 yo
-BPH
-chronic low back pain
-anxiety
-depression
-OSA on BIPAP
-hypothyroidism
-s/p GI bleed 20 years ago with ibuprofen use
Past Surgical History:
-s/p L TKR
-s/p L shoulder surgery with pin placement
-s/p back surgery
-s/p R cervical neck fusion
Social History:
Race: caucasian
Last Dental Exam: edentulous
Lives with:himself, 3 kids
Contact: Phone #
Occupation:
Cigarettes: Smoked 3-4PPD x 20 yrs. Quit 40yo
ETOH: < 1 drink/week [x] [**1-8**] drinks/week [] >8 drinks/week []
Illicit drug use-denies
Family History:
+Premature coronary artery disease - Brother(+)MI 40s, Mother <
65 [x]
Physical Exam:
Pulse:68 Resp: 18 O2 sat: 97% RA
B/P Right: 110/69 Left:
Height: 64" Weight: 245 lbs
General:
Skin: Dry [x] [**Month/Day (3) 5235**] [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []bilat. wheezes
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x] obese
Extremities: Warm [x], well-perfused [x] Edema [] __no___
Varicosities: None [x]
Neuro: Grossly [**Month/Day (3) 5235**] [x]
Pulses:
Femoral Right: cath site Left: cath site
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2171-4-30**] Carotid U/S: Moderate heterogeneous plaque at the ostia
of both internal carotid arteries. This together with the
findings on the peak systolic and diastolic velocities suggests
a 40-59% stenosis on both sides. However, this is clearly much
closer to 40%. The vertebrals are unremarkable.
.
[**2171-4-30**] Echo: Pre-Procedure: No spontaneous echo contrast is
seen in the left atrial appendage. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic [**Month/Day/Year 5236**]. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. The
IABP is well-positioned in the proximal descending [**Month/Day/Year 5236**].
Post-Procedure: The patient is in SR, on no inotropes. Preserved
biventricular systolic fxn. No AI, trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**].
Brief Hospital Course:
Mr. [**Known lastname 39428**] is 77 year old male with history of hypertension,
hyperlipidemia, coronary artery disease, status post angioplasty
20 yo with a negative pharmacologic stress test last year,
presented to [**Hospital6 3105**] complaining of substernal
chest pain on [**2171-4-22**]. Further cardiac workup revealed
multivessel coronary artery disease (55% prox RCA,MCA-60%
OSTIAL, LAD-80%PROX). He was transferred to BIDMCfor evaluation
of coronary revascularization.
During the pre-operative period he developed chest pain and an
intra-aortic balloon pump was placed and he was subsequently
taken urgently to the operating room where he underwent Urgent
off-pump coronary artery bypass graft x3: Left internal mammary
artery to left anterior descending artery; saphenous vein graft
to obtuse marginal and distal right coronary arteries (see
operative note for details).
Post operatively he was admitted to the ICU intubated and
sedated requiring milrinone and neo for hemodynamic support.
Hemodynamic support was weaned off and Chest tubes and
epicardial pacing wires were removed. He awoke somewhat anxious
and was extubated requiring moderate pulmonary toilet due to
extensive pulmonary history and Bipap support. He was started on
statin, betablocker and ASA therapies. Plavix was started due to
his off pump CABG but was later discontinued when he was started
on coumadin for afib. Post-operative afib was started on
amiodarone and coumadin therapy. He converted to sinus rhythm.
He had baseline CRI and developed post-op ATN. Nephrotoxic drugs
were d/c'd and renal was consulted. His creat peaked at 3.7 and
is down to 2.8 at the time of his discharge today. Low dose po
lasix is ordered to begin on [**2171-5-8**] and his bun/creat and K
should be checked everyother day while on diuretic therapy.
He was evaluated by Physical therapy for strength and
conditioning and rehab was recommended.
Medications on Admission:
Medications at home:
-ASA 325
-Caltrate 1500
-NTG prn
-Flomax 0.4 daily
-Simvastatin 40 daily
-Paroxetine 40 daily
-Metoprolol 25 daily
-Levothyroxine 200(mcg) daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): [**Hospital1 **] for 7 dasy then decrease to daily ongoing .
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Follow BUN/Creat and K every other day. baseline creat
1.3.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation Q6h ().
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
10. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
14. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
15. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
17. Outpatient Lab Work
Draw BUN/Creat/K every other day while on lasix and until creat
returns to baseline of 1.3
18. insulin regular human 100 unit/mL Solution Sig: per rehab
sliding scale units Injection ASDIR (AS DIRECTED): dose based on
qid fingersticks.
19. warfarin 1 mg Tablet Sig: 2.5 mg- dose based on INR mg PO
Once Daily at 4 PM: indication afib
goal INR 2.0-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 3
Past medical history:
-hypertension
-hyperlipidemia
-coronary artery disease, status post angioplasty 20 yo
-BPH
-chronic low back pain
-anxiety
-depression
-OSA on BIPAP
-hypothyroidism
-s/p GI bleed 20 years ago with ibuprofen use
-s/p L TKR
-s/p L shoulder surgery with pin placement
-s/p back surgery
-s/p R cervical neck fusion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait and assist of one for supervision
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema. Small amount serosang
drainage from distal pole.
Leg Right/Left - healing well, no erythema or drainage.
Edema: 1+ LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw wednesday then mon/wed/fri until stable
Results to phone fax: to be followed by rehab medical provider.
[**Name10 (NameIs) 357**] arrange post rehab follow up for coumadin therapy.
paint sternal incision with cloraprep daily and cover with DSD
until drainage stops.
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2171-6-4**] 2:15pm in
the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Please call to schedule appointments with your
Cardiologist: Dr.[**Last Name (STitle) 29070**] in 2 weeks
Primary Care Dr. [**Last Name (STitle) 28745**] in [**3-7**] weeks
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw wednesday then mon/wed/fri until stable
Results to phone fax: to be followed by rehab medical provider.
[**Name10 (NameIs) 357**] arrange post rehab follow up for coumadin therapy.
**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:[**2171-5-7**]
|
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icd9cm
|
[
[
[]
]
] |
[
"36.12",
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icd9pcs
|
[
[
[]
]
] |
7744, 7791
|
3613, 5528
|
297, 538
|
8228, 8532
|
2458, 3590
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9718, 10684
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1636, 1708
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5744, 7721
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7812, 7873
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5554, 5554
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5575, 5721
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247, 259
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566, 985
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,760
| 172,316
|
22010
|
Discharge summary
|
report
|
Admission Date: [**2109-2-4**] Discharge Date: [**2109-2-8**]
Date of Birth: [**2056-10-18**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / Meropenem
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
Fevers, Chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 yo woman with complicated almost continuous hospitalizations
since [**9-15**] with leukocytosis and confusion. She was admitted
initially for abd pain, N/V, anorexia and at OSH found to have
enterococcal UTI and BSI (records unavailable) and treated with
vanco. At [**Hospital1 18**] in [**10-15**], she had elevated LFTs and CT abd with
a nonenhancing liver lesion and ascites. She had a paracentesis
that was negative for SBP. Liver bx showed steatosis and ??????toxic
metabolic disease??????,likely [**2-13**] ETOH. Notes raise question of
EtOH, but husband denies it. [**11-11**] had transient E. faecium (NOT
VRE) and B. fragilis bacteremia. Prior ID team was actually
worried about a microperf and had her on flagyl, etc.
Had EGD [**11-9**] and then colonoscopy [**11-21**] that were neg but c/b
colonic perforation. On [**11-24**], she had ex lap and [**Doctor Last Name **]??????s
pouch, transverse colectomy and liver biopsy. OR confirmed L
colonic perf; perhaps perfed an already sensitive area (i.e.
prior microperf, which perhaps explains her previous bacteremia
[**11-11**], e.g.) On [**12-2**], BCx grew VRE in one set as did R IJ tip.
She was treated with line removal and linezolid for 10 days.
Postop she had LFT bump and a cellulitis (around G tube site)
which appears to be treated with vanco/flagyl. Apparently, she
was confused for entire admission including on d/c to rehab on
[**12-24**]. Was dc'd on vanc/levo with unclear duration planned. She
also had a rash at d/c that was attributed by derm to meropenem
(vs zosyn), though she did not have either of these since [**11-12**]
and [**11-20**]. Note: [**12-23**] XR did not show effusion.
She developed low grade temps and leukocytosis at rehab and was
transferred back to [**Hospital1 **] on [**12-29**]. (some question that she was
also rechallenged with zosyn at rehab) In ED had T101.4, HR 120
and sbp 80 and required pressors and ICU transfer. CXR showed
mod L pleural effusion and ? infiltrate. was put on V/L/F by
team; ID narrowed to levo/clinda [**1-2**], with plan to continue
until [**1-10**]. Rash was treated with topical steroids--felt by
derm to be residual drug rash to prior [**Last Name (un) 2830**]. ? aspiration PNA?
ID team asked for LP: benign [**1-2**]. Neuro thought AMS was
Korsakoff's.
Had persistent LGTs and leukocytosis; thoracentesis done [**1-9**].
exudative, with 325 WBC, 60% L, 9% PMN, 16% other. 1375 RBC. PH
7.6. LDH 146, TP 3.8 (serum alb 2.2). ABx dc'd [**1-9**] to let her
"declare." had LGT since; 100.1 etc. ESR 130 [**1-12**] (no prior).
Called to re-consult [**1-15**] when pleural fluid Cx grew out rare
enterobacter, s to cefepime/imi/[**Last Name (un) 2830**] only. ? was seeded via
either aspiration or a while ago via microperf/perf, then
partially treated with levo, as only rare bacteria grew from Cx,
and was mostly lymphs, etc.
Rec as of [**1-15**]: continue cefepime (had been started [**1-14**]).
Cautious, as [**First Name8 (NamePattern2) **] [**Doctor Last Name **] had bad rash which was ascribed to ceftaz
in past, and derm thought she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2830**] rash. Also concerned
re: inducible B-lactamase from enterobacter-->resistance.
However,if we start [**Last Name (un) 2830**] now and then she gets a rash, won't
know if it is due to [**Last Name (un) 2830**] or cefepime. If she has a rxn to
cefepime or worsened effusion suggestive of failure, will switch
to [**Last Name (un) 2830**], with desensitization.
[**1-16**] no rash, team fine with cefepime plan
[**1-17**] signed off, with plan for 2 weeks cefepime.
dc'd to rehab [**2109-1-22**]; had only LGT, no change in skin. Finished
cefepime [**1-29**]. Started risperdal and neurontin [**1-28**]. WBC were
checked [**1-23**] (14.5, 78% N), then not again until [**2-2**]: were 2.7,
40% N. Also had slightly higher temps. No change in skin. [**2-2**]
BCx at rehab ngtd. risperdal/neurontin stopped [**2-2**]. By [**2-4**],
WBC 1.3 with 1% N, and had high fever (Tm 104.8).
Patient is a 52 yo woman with a complicated PMH, recently d/c'ed
from [**Hospital1 18**] where she was readmitted for F/drug rash and abd pain
(see below), who presents from rehab with sudden onset fevers,
chills x 1 day and found to be neutropenic in ED. Patient is
poor historian, but denies cough, nasal congestion, rhinorrhea,
neck stiffness and headache. + abdominal pain. Per note from
MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], onset of neutropenia 4 days ago, 5 days after
completion of cefepime. Spiked temp in last 24 hours.
Neurontin was D/Ced on 22nd when 1st drop in WBC was noted.
Her PMH is signif for prolonged admission [**Date range (1) 57610**] for GI
workup of abd pain including colonoscopy c/b colonic perforation
requiring abdominal surgery (Left hemicolectomy, [**Doctor Last Name 3379**]
pouch, colostomy, jejunal resection for incidental jejunal mass.
Post-op course complicated by VRE urosepsis, tracheostomy, G-J
tube placement, line infection, cellulitis. Treated with
multiple antibiotics during this hospitalization. Patient was
readmitted [**2108-12-29**] - [**2109-1-22**] for fever, erythematous rash with
desquamation, and abdominal pain. Found to have enterobacter
empyema and started on cefepime which she continued for 2 week
course post-op. Also, dermatology was consulted [**12-29**] and found
that the rash was not a new occurrence, but rather the resolving
drug rash from prior admission. They were not concerned for
[**Doctor Last Name **]-[**Location (un) **] syndrome or TEN.
Past Medical History:
1. Hypothyroidism
2. Endometriosis
3. [**9-15**] Colonoscopy b/c perforation; s/p ex lap with L
hemicolectomy, [**Doctor Last Name 3379**] pouch, colostomy, jejunal resection
4. h/o jejunal mass (heterotopic pancreatic tissue) which was
resected
5. h/o VRE urosepsis
6. h/o enterobacter empyema (resistant to levaquin)
7. diverticulosis
8. iron-defic anemia
9. h/o tracheostomy
10. steatohepatitis (s/p wedge resection liver bx [**10-15**])
11. Portal gastropathy
12. h/o gallstones
13. L adrenal mass
14. L thyroid nodule
Social History:
Lives in W Mass with husband. 10 year h/o smoking. College
educated. Engineer.
Family History:
2 sisters with hypothyroidism. Mother with DM and liver dz
Physical Exam:
PE T 104, BP 121/57, 140 reg, 30, 96% on 2L NC
GEN - shaking chills, alert, oriented x 3, no accessory respir
muscle use, speaks in full sentences
HEENT - PERRL, oral mucosa dry without lesions
NECK - supple, No LAD
HEART - nl S1, S2, tachy, regular, no m/r/g
LUNGS - CTAB
ABD - obese, soft, diffusely tender, 25 cm linear incision site
healing by secondary intention (good granulation tissue with
fibrin deposits at the center), ostomy site clean, G-tube site
slightly erythematous
EXT - non-pitting edema to knee
SKIN - confluent erythematous rash over truck, face and
extremities, area on R breast that is darker purple (striae?)
with 2-3 desquamated areas
on transfer:
PE T , BP 133/67, 103 reg, 30, 97% on RA
GEN - WDWN middle aged W, sitting up in chair,alert, oriented x
3, NAD
HEENT - PERRL, MMM, + oral thrush on tongue and buccal mucosae
NECK - supple, No LAD
HEART - nl S1, S2, tachy, regular, no m/r/g
LUNGS - CTAB
ABD - obese, soft, diffusely tender, 25 cm linear incision site
healing by secondary intention (good granulation tissue with
fibrin deposits at the center), ostomy site clean, pink, G-tube
site slightly erythematous
EXT - non-pitting edema to knee
SKIN - confluent non-papular, non-pruritic erythematous rash
over truck, face and extremities, area on R breast that is
darker purple (striae?) with 2-3 erosions
Pertinent Results:
***Pending at time of discharge: BCX [**2-4**] and [**2-5**] (NGTD)
[**2109-2-4**] 06:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2109-2-4**] 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2109-2-4**] 06:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-OCC
EPI-0-2
[**2109-2-4**] 06:20PM URINE CA OXAL-OCC
[**2109-2-4**] 05:28PM LACTATE-1.5
[**2109-2-4**] 05:20PM GLUCOSE-89 UREA N-21* CREAT-0.9 SODIUM-135
POTASSIUM-6.2* CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
[**2109-2-4**] 05:20PM ALT(SGPT)-29 AST(SGOT)-71* ALK PHOS-220*
AMYLASE-75 TOT BILI-1.1
[**2109-2-4**] 05:20PM WBC-1.7*# RBC-3.27* HGB-10.5* HCT-31.9*
MCV-97 MCH-32.0 MCHC-32.8 RDW-15.7*
[**2109-2-4**] 05:20PM NEUTS-0 BANDS-0 LYMPHS-47* MONOS-52* EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2109-2-4**] 05:20PM PLT COUNT-300
[**2109-2-4**] 05:20PM PT-14.2* PTT-30.3 INR(PT)-1.3
[**2109-2-5**] 02:07AM BLOOD WBC-1.4* RBC-2.79* Hgb-8.9* Hct-27.6*
MCV-99* MCH-31.7 MCHC-32.1 RDW-15.7* Plt Ct-332
[**2109-2-4**] 05:20PM BLOOD Neuts-0 Bands-0 Lymphs-47* Monos-52*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2109-2-5**] 02:07AM BLOOD ESR-103 Gran Ct-520*
[**2109-2-5**] 02:07AM BLOOD Glucose-132* UreaN-23* Creat-0.9 Na-137
K-4.5 Cl-109* HCO3-22 AnGap-11
[**2109-2-5**] 03:13AM BLOOD CK(CPK)-17*
[**2109-2-5**] 02:07AM BLOOD Calcium-9.8 Phos-2.9 Mg-1.4*
[**2109-2-5**] 03:13AM BLOOD TSH-1.9
[**2109-2-5**] 03:13AM BLOOD Cortsol-53.1*
[**2109-2-5**] 02:57AM BLOOD Cortsol-46.8*
[**2109-2-5**] 02:07AM BLOOD Cortsol-25.4*
[**2109-2-5**] 01:54AM BLOOD Type-ART pO2-89 pCO2-36 pH-7.39
calHCO3-23 Base XS--2
[**2109-2-5**] 01:54AM BLOOD Lactate-3.0*
[**2109-2-5**] 01:54AM BLOOD freeCa-1.39*
[**2109-2-4**] 7:40 pm STOOL CONSISTENCY: SOFT
FECAL CULTURE Neg
CAMPYLOBACTER CULTURE Neg
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2109-2-5**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2109-2-4**] 11:41 pm Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2109-2-5**]):
Negative for Influenza A viral antigen.
CULTURE CONFIRMATION PENDING.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2109-2-5**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
CULTURE CONFIRMATION PENDING.
CMV IgG ANTIBODY (Final [**2109-2-5**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2109-2-5**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
[**2109-2-4**] 11:40 pm EBV IgG/IgM/EBNA Antibody Panel
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB Negative:
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB Negative:
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB Negative
[**2109-2-4**] 11:40 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Pending):
BLOOD/AFB CULTURE (Pending):
[**2109-2-4**] 11:40PM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-Neg
CXR: L PICC tip in SVC, RLL band-like atelectasis, no
consolidation
Abd X-ray: no dilated loops of bowel
Abd/Pelvis CT: 1) Decrease in size of the fluid collection in
the left flank, adjacent to area of surgical clips.
2) No definite evidence of free air or contrast extravasation.
3) Stable left adrenal adenoma.
4) Stable low attenuation within the right kidney, incompleteley
characterized on this study. Compare with any prior ultrasounds
or noncontrast CTs.
5) Small aount of fluid in both paracolic gutters.
6) No evidence of bowel obstruction, bowel wall thickening, or
new fluid collections.
Old Lab/Radiology Data ----
HIV AB [**2109-1-15**]: negative
PPD negative [**1-16**]
SPEP/UPEP negative [**2109-1-12**]
Cytology:
1) [**2108-12-4**] Peritoneal fluid - neg malignancy
2) [**2109-1-1**] CSF - neg malignancy
3) [**2109-1-9**] Pleural fluid - neg malignancy
Echocardiogram [**2109-1-8**]: normal with LVEF >60%
EGD [**2108-11-9**]: portal gastropathy, biopsy was normal
Liver biopsy [**2108-11-8**]: marked steatosis, prominent sinusoidal
fibrosis without cirrhosis c/w toxic/metabolic disease.
Abd CT [**12-28**]: no focal fluid collections or bowel pathology,
stable known L adrenal adenoma
RUQ U/S [**12-29**]: neg for gallstones or cholecystitis
Head CT [**1-1**]: no mass effect or hemorrhage. Essentially normal
exam.
WBC study [**2109-1-15**]: negative
CTA [**1-11**]: neg PE, R thyroid nodule
Brief Hospital Course:
A/P: 52 yo woman transferred from MICU where she was admitted
with high fever, chills, erythroderma, and abd pain s/p recent
prolonged admission c/b multiple infections and antibiotic use.
Now hemodynamically stable x24 hours and ready for transfer to
the floor.
1) R/O sepsis - On transfer and in [**Name (NI) **], pt febrile to 104.8,
hypotensive, and neutropenic. Given this presentation, concern
initially for evolving sepsis. A central line was placed, IVF
was aggressively administered, and she was transferred to the
ICU for management. As her BP did not respond to fluids, she
received pressors initially, which were weaned off once she was
able to maintain her pressures and dexamethasone was started
empirically, but d/c'ed when [**Last Name (un) 104**] stim test yielded normal
adrenal functioning. BCx were drawn and remained NGTD at time of
this dictation. Pt improved dramatically over 24 hours, was HD
stable off pressors and afebrile, so was transferred to the
floor. The etiology of her septic picture may be secondary to a
drug reaction (fever, neutropenia, rash, and hypotension all
related to ?risperdal [most likely] vs. neurontin), as
infectious work-up was negative.
Of note, pt does have questionable allergy to meropenem and
zosyn and there was a question as to whether cefepime could be
implicated in current presentation; however, ID adamantly felt
that pt [**Name (NI) **] cefepime without problem and that cefepime
should NOT be considered an allergy.
2) Fever - Pt's fevers resolved after 24 hrs and she remained
afebrile the remainder of her hospital course. Drug reaction was
thought most likely, given acute resolution of her rash, fever,
and neutropenia. Ddx included infection bacterial, viral (EBV,
Parvo, CMV, influenza--all neg), or fungal infection,
malignancy, or connective tissue disease ([**Doctor First Name **] neg). ID was
consulted and recommended empiric broad spectrum ABX: Aztreonam
(for some gram neg coverage that may also get enterobacter if
that is playing a role), linezolid (h/o VRE bacteremia and now
with pus from J tube- also to cover for possible PICC line
infxn), and flagyl (but said if abd CT is ok they did not
necessarily need to cont the flagyl). Given pt's remarkably
rapid improvement, bacterial infection dropped lower on the
differential and linezolid and flagyl were d/c'ed when Cxs were
NGTDx48hr. Aztreonam d/c'ed once BCx NGTD x72 hrs. Pt's PICC and
central line were also d/c'ed at 48 and 72 hrs after admission,
respectively.
3) Neutropenia - ANC 520 on presentation. Etiology remains
unclear, although, most likely [**2-13**] drug reaction from either
neurontin, risperdal (both d/c'ed 2 d PTA), or cefepime (course
complete 5 days PTA). Heme/Onc recommended empiric neupogen. Pt
received x1 dose of 300mcg (for her wt, should have been dosed
at 500mcg) and the following day her WBC rose to 9.6 with 86.4%
neutrophils. This rapid resolution was speculated to be related
to demargination [**2-13**] dexamethasone along with BM stimulation in
response to the neupogen.
4) Erythroderma - Pt's erythrodermic rash was again, most likely
[**2-13**] drug reaction, as Cx data, viral titers, [**Doctor First Name **] were all WNL.
She had marked improvement after her first dose of IV decadron,
also c/w drug reaction. However, dermatology felt that this was
not a drug rash, given it's appearance (not typical morbilliform
pattern); they felt etiology could be viral vs.
medication-related vasodilitation vs. early drug rash. Pt's rash
improved over the course of her stay, interestingly, with
resolution occuring downward from the face first.
5) Liver dz - Pt with known steatosis/cirrhosis at baseline.
AST/ALT/T.bili were WNL; albumin was slightly low (but closer to
normal than it had been in the last several months) and PT was
WNL, suggesting liver synthetic function to be intact. Pt's alk
phos was noted to be slightly elevated, but trended down during
her admission and was the lowest it had been (124) during all of
her past admissions at [**Hospital1 18**] (from [**Date range (1) 57611**]). Given that alk
phos was elevated with normal T Bili and that her calcium levels
have been noted to be high in the past (however, there has been
great fluctuation over the course of her hospitalizations) she
may have a concomitant primary bone process, like Paget's dz, to
explain these findings, in addition to a resolving/resolved
cholestatic process (on last admission, her T.Bili was elevated
to 7.6).
6) Psych - Pt was noted to have a bizarre affect and had a prior
possible dx of Korsakoff's syndrome, which was disputable given
her family's insistence that she was never a heavy drinker. As
pt has been in and out of the hospital and rehab for the past 4
months, it was thought that her reported delusions and
occasional confusion may also have a component of "hospital
psychosis" and perhaps an odd affect at baseline. Her fentanyl
patch was weaned off and all non-essential medications were
d/c'ed. Pt's mental status was noted to improve, her confusion
subsided, and her tangential thought patterns seems to decrease
with these interventions. Because opiates, neuropleptics and
sedatives may be adding to pt's altered mental status, her pain
control regimen should likely consist of tylenol PRN (max dose
2mg as pt w/underlying liver dz) and oxycodone PRN breakthrough
pain. Neuroleptica and sedatives are likely best avoided.
7) Wound dehiscence - Pt's midline incision was noted to have an
approximately 1.5in dehiscence at the upper-most end. Surgery
was consulted and felt that a vac dressing was not necessary,
but that wet to dry dressings with close monitoring and
aggressive wound care to prevent infection were indicated.
8) Hypothyroid - TSH was WNL and synthroid was cont'ed at her
o/p dose.
9) Oral thrush - Clotrimazole troches were prescribed.
10) Dispo - Pt was d/c'ed to rehab where she will undergo
aggressive PT/OT and wound care.
Medications on Admission:
Levoxyl 150 mcg po qd
Thiamine 100 mg po qd
Folate 1 mg po qd
Dilaudid 4 mg q4h po prn
ativan 0.5 tid
metoprolol 25 mg po bid
protonix 40 mg po qd
vitamin b12 500 mcg po qd
dalteparin 5000 units qam
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Oxycodone HCl 5 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed: please give only for breakthrough pain.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed: please give NO MORE than 2g/day .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Fever and neutropenia
hypotension
Secondary:
1. Hypothyroidism
2. Endometriosis
3. [**9-15**] Colonoscopy b/c perforation; s/p ex lap with L
hemicolectomy, [**Doctor Last Name 3379**] pouch, colostomy, jejunal resection
4. h/o jejunal mass (heterotopic pancreatic tissue) which was
resected
5. h/o VRE urosepsis
6. h/o enterobacter empyema (resistant to levaquin)
7. diverticulosis
8. iron-defic anemia
9. h/o tracheostomy
10. steatohepatitis (s/p wedge resection liver bx [**10-15**])
11. Portal gastropathy
12. h/o gallstones
13. L adrenal mass
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor and return to the hospital for any
fevers/chills, rashes, low blood pressure, abnormally low blood
counts, or any other concerning symptoms you may have.
Please note that some of your medications have been changed.
Please review your new medications with your dostor.
Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) 57612**] in [**1-13**] weeks after discharge.
Please call for appointment: [**Telephone/Fax (1) 28724**].
|
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icd9cm
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[
[
[]
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[
"96.6",
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,977
| 158,513
|
38792
|
Discharge summary
|
report
|
Admission Date: [**2144-5-14**] Discharge Date: [**2144-5-25**]
Service: MEDICINE
Allergies:
Penicillins / Fosamax / Codeine / Zestril / Norvasc /
Hydrochlorothiazide
Attending:[**First Name3 (LF) 8928**]
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 year old woman with dementia, COPD, diastolic CHF, HTN,
brought in from nursing home for shortness of breath, productive
cough, wheezing for the past few days. Tmax 99.6. Had portable
CXR which showed possible RLL collapse/pneumonia. Son did not
want her sent in so she was started on levofloxacin, flagyl, and
prednisone. Symptoms worsened today so she was sent to the ED.
.
In the ED initial VS were 97.7, 94, 132/65, 20, 96% on 4L.
Wheezy on exam. Labs notable for normal WBC (but 86%N), Hct 35.5
(at baseline), Cr 1.7 (baseline ~1.5), normal lactate. EKG sinus
at 93, NA/NI, no ischemia. CXR showed small right effusion with
questionable opacity at right lung base. Patient was given
vanc/cefepime for HCAP as well as albuterol and ipratropium
nebs. Desatted to 88% on 5L NC so placed on a NRB. VS prior to
transfer were afebrile, 91, 20, 126/63, 99% on NRB.
.
On arrival to the MICU, patient is resting comfortably in bed
but is non-verbal but intermittently agitated.
Past Medical History:
- Alzheimer's dementia
- parkinsons disease
- COPD
- diastolic CHF
- mitral valve regurgitation
- hypertension
- dyslipidemia
- CKD
- GERD
- ?AVNRT
- h/o vasovagal syncope
- anemia of chronic disease
- anxiety
- depression
- condyloma
- OA of hip
- h/o basal cell carcinoma
- osteopenia
Social History:
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Lives at [**Doctor Last Name **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] Estates [**Hospital3 400**]
([**Telephone/Fax (1) 86120**])
Family History:
Unable to obtain at admission
Physical Exam:
ADMISSION EXAM:
General: Alert but non-verbal, does not answer questions
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, unable to detect elevated JVP
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse end-expiratory wheezes, decreased breath sounds
at right base
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: + foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII grossly intact, unable to perform additional
neuro exam
DISCHARGE EXAM:
VS: not recorded
GENERAL - Elderly female laying supine,responsive to questions,
follows instructions but responses are sometimes
incomprehensible
LUNGS - Patient only able to cooperate with anterior exam,
bronchial BS on left, scattered wheezes on left
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - Overweight NABS, soft/NT/ND
EXTREMITIES - significant brusing on bilateral upper
extremities; hematoma over left hand on dorsum and L leg.
NEURO - Responsive to questions though some answers are
confused/incomprehensible. Follows instructions
Pertinent Results:
ADMISSION LABS:
[**2144-5-14**] 08:42PM BLOOD WBC-8.9 RBC-3.58* Hgb-11.8*# Hct-35.5*#
MCV-99*# MCH-32.9*# MCHC-33.2 RDW-13.8 Plt Ct-235
[**2144-5-14**] 08:42PM BLOOD Neuts-86.4* Lymphs-10.9* Monos-2.2
Eos-0.2 Baso-0.2
[**2144-5-14**] 08:42PM BLOOD Glucose-143* UreaN-35* Creat-1.7* Na-138
K-4.6 Cl-100 HCO3-27 AnGap-17
[**2144-5-14**] 08:42PM BLOOD cTropnT-<0.01 proBNP-153
[**2144-5-14**] 11:02PM BLOOD Lactate-1.2
DISCHARGE LABS:
no blood drawn since [**2144-5-23**] when goals were changed to minimize
invasive testing.
[**2144-5-23**] 06:50AM BLOOD WBC-22.0* RBC-4.26 Hgb-13.4 Hct-42.2
MCV-99* MCH-31.4 MCHC-31.7 RDW-13.7 Plt Ct-284
[**2144-5-23**] 06:50AM BLOOD PT-15.6* PTT-43.0* INR(PT)-1.5*
[**2144-5-23**] 06:50AM BLOOD Glucose-135* UreaN-74* Creat-2.1* Na-146*
K-3.7 Cl-104 HCO3-26 AnGap-20
[**2144-5-23**] 06:50AM BLOOD Calcium-9.6 Phos-5.5* Mg-3.2*
IMAGING:
ECHO [**2144-5-15**]:
Extremely limited image quality. The left atrium is dilated. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function appears grossly normal (LVEF ? 70%). Overall right
ventricular systolic function appears grossly normal. There is a
small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
DVT scan [**2144-5-19**]:
IMPRESSION:
1. Non-occlusive thrombus involving the right superficial
femoral vein.
2. No DVT in left lower extremity.
Brief Hospital Course:
Ms. [**Known lastname 5448**] is an 89 year old woman with a history of COPD,
diastolic CHF, and HTN who presented with SOB, cough, and
wheezing. Her course was complicated by DVT and delirium vs
worsening dementia.
ACTIVE ISSUES:
1. Shortness of breath/cough/wheezing: Upon admission, initial
diferential favored a COPD exacerbation given her diffuse
wheezing and history of COPD. However, also with R lung opacity,
some of which appeared to be potentially due to a chronic shift
of heart to the right (present on prior films), and therefore
could not rule out a RML pneumonia, though no leukocytosis or
fever. Of note respiratory viral antigen panel was negative. No
evidence of pulmonary edema to suggest a distolic CHF
exacerbation and echo with grossly normal LV function. In light
of the likely COPD exacerbation and remote but sufficient
concern for pneumonia, both were treated. Supplemental oxygen,
albuterol/ipratropium nebulizer treatments and a prednisone
burst were begun. Initially she was treated with HCAP
coverage-vancomycin/cefepime/azithromycin, but subsequently her
antibiotic coverage was narrowed to cefpoxodime and
azithromycin. Once she was transferred to the general medicine
floor her oxygen was weaned and a steroid taper was began.
2. DVT
Due to persistent tachycardia and continued oxygen requirements
there was concern for a DVT. A CT of the chest and venous
doppler studies were ordered. The venous doppler studies
demonstrated an occulsion in the the right superficial femoral
vein. Due to agitation, a CT chest could not be performed. She
was started on a heparin drip with a plan to bridge to coumadin.
However, due to increasing agitation the patient refused PO
medications and removed her IV so the heparin was switched to
levonox. After her health care proxy decided to withdraw
aggressive care and focus on comfort measures only the
anticoagulation was held.
3. Delirium vs worsening dementia
Ms. [**Known lastname 5448**] had a known history of dementia at baseline and per
her son, often [**Name2 (NI) 16959**]. Part way through her admission she
was found to be getting increasingly agitated in the afternoons
and overnight. At times she was hostile to staff, attempted to
assault staff, refused medications and imaging studies. She
required bilateral hand restraints and PO, IM or IV sedation
with zyprexa, haldol, and seroquel. Geriatrics was consulted
and they suggested increasing her home risperidone dose, and
adding seroquel every afternoon to her medication regimen, which
seemed to improve her agitation and sundowning. Following these
episodes of agitation discussions about the utility of more
invasive care with Ms. [**Known lastname **] son (the health care proxy)
began. Mr. [**Known lastname 5448**], along with his family, decided to focus on
comfort measures and asked us to withdraw aggressive care.
After a few days of comfort care, mental status improved and she
was discharged to rehabilitation with a consideration for
hospice care afterwards. Rispiridone was increased to 1mg daily
and seroquel 12.5 mg was added in the afternoon.
CHRONIC ISSUES:
# Hypertension: stable during this admission
Metoprolol was continued, until the decision was made to
transition to comfort measures only.
# Hyperlipidemia: Simvastatin was continued, until the decision
was made to transition to comfort measures only.
# Diastolic CHF: An echo performed in the MICU demonstrated
dilated LA and preserved ejection fraction. Furosemide, and
spironolactone were continued through the admission and through
discharge. Daily weights showed no increase in weight.
TRANSITIONAL ISSUES:
Pending labs/imaging: none
Follow up: none
Code status: DNR/DNI,
Medications on Admission:
- acetaminophen 650mg TID + 650mg Q4h prn
- aspirin 81mg daily
- citalopram 40mg daily
- ferrous sulfate 325mg [**Hospital1 **]
- furosemide 60mg daily
- metoprolol succinate 50mg daily
- potassium chloride 20meq daily
- risperidone 0.5mg daily
- senna 8.6mg; 2 tabs QHS
- simvastatin 40mg QHS
- spironolactone 25mg daily
- trazodone 50mg; [**11-18**] tab daily at 5pm and [**11-20**] tab Q6h prn
insomnia
- venlafaxine ER 150mg daily
- clotrimazole-betamethasone 1-0.05% cream [**Hospital1 **] prn
- nystatin powder under breasts prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PR DAILY:PRN Constipation
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Furosemide 60 mg PO DAILY
Hold for sbp<100 or hr<60
6. Lidocaine 5% Patch 1 PTCH TD PRN pain
7. Miconazole Powder 2% 1 Appl TP [**Hospital1 **] fungal infection Duration:
1 Weeks
apply to area underneath breasts
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO DAILY
10. Quetiapine Fumarate 12.5 mg PO QPM:PRN Agitation
11. Risperidone 1 mg PO DAILY
12. Senna 1 TAB PO BID
13. Spironolactone 25 mg PO DAILY
Hold for sbp<100 or hr<60
14. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
Discharge Diagnosis:
Primary: COPD exacerbation, DVT, acute kidney injury, delirium
Secondary: dementia, hypertension, diastolic heart failure
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Ambulatory - requires assistance or aid ([**Last Name (NamePattern1) **]
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
It was a pleasure to participate in your care at [**Hospital1 18**]. You came
to the hospital because of a COPD exacerbation. You were
treated with steroids, antibiotics, nebulizer breathing
treatments and supplemental oxygen. Later in your hospital stay
you were found to have a clot in your leg. We started you on
medication to treat your clot, but after discussions with your
family we decided to focus on comfort measures.
In order to optimize your comfort some of your medications were
stopped and adjusted. Please take all your medications as
prescribed.
Followup Instructions:
Please follow up with your primary care [**Provider Number 76328**] weeks after
discharge from [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8931**]
Completed by:[**2144-5-26**]
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82,154
| 152,484
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43627
|
Discharge summary
|
report
|
Admission Date: [**2156-6-13**] Discharge Date: [**2156-6-26**]
Date of Birth: [**2114-2-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
s/p MVC with acute liver failure and acute renal failure
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
42 y/o woman with history of bipolar disorder, Substance abuse,
Hep C, COPD and DVT on coumadin who initially presented to [**Hospital **] after an MVC. Patient was notably somnolent
during trauma work up and labs were drawn showing an ALT of
11,0000, AST 9000, creatinine 3.0, hct 44, INR>15 and Tylenol
level of 15. Pt was given NAC (inappropriately dosed) and was
transferred to [**Hospital1 **] for further management.
.
On arrival to [**Hospital1 18**], initial VS were: T 97.7 BP 112/72 HR 126 RR
14 Sats 95% on RA. Liver was consulted and recommended CT and
RUQ u/s (no dopplers) which were unrevealing. Pt was given the
NAC with initial bolus and started on continuous gtt. She
remained somnolent but arousable to vigorous stimulation. NG
tube was placed with some coffee grounds returned and pt was
given lactulose 30 mL.
.
On arrival to the MICU, pt was sleepy and not responding to
questions. However, upon arrival of her family, she became more
alert, tearful and was able to answer some questions. She
reported headache, abd pain, mild shortness of breath and denied
any SI or overdose attempt.
.
Review of systems: unable to obtain with exception of above
Past Medical History:
COPD/Asthma/tobacco dependance
LE DVT on Coumadin
Hepatitis C
IVDU and substance abuse
Bipolar disorder
s/p CCY
Chronic Back & Neck pain
Migraines
Social History:
Pt lives with her husband and has substance abuse history but
denies active SI or attempts to hurt herself. Family reports
excessive prescription drug abuse and occaisional alcohol use
without h/o withdrawal. She has an IVDU history and other
illicits.
Family History:
Mother died of respiratory disease
Physical Exam:
BP: 134/84 P: 125 R: 26 O2: 95% on 2L
General: Sleepy, confused, answering some questions
HEENT: sclera injected, anicteric, PERRLA, MMM
Neck: supple, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rhythm, tachy, no murmurs, rubs, gallops
Abdomen: soft, mildly tender diffusely, bowel sounds present, no
rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
Left hand with petechiae
Pertinent Results:
Admission labs:
[**2156-6-13**] 02:30AM BLOOD WBC-10.7 RBC-4.55 Hgb-13.4 Hct-39.0
MCV-86 MCH-29.4 MCHC-34.2 RDW-14.6 Plt Ct-206
[**2156-6-13**] 02:30AM BLOOD Neuts-86.8* Lymphs-10.8* Monos-1.1*
Eos-0.9 Baso-0.4
[**2156-6-13**] 04:25AM BLOOD PT-56.0* PTT-38.1* INR(PT)-6.3*
[**2156-6-13**] 10:11AM BLOOD FDP-80-160*
[**2156-6-13**] 09:10AM BLOOD Fibrino-360
[**2156-6-13**] 02:30AM BLOOD Glucose-94 UreaN-38* Creat-3.8* Na-140
K-3.5 Cl-107 HCO3-17* AnGap-20
[**2156-6-13**] 02:30AM BLOOD ALT-[**Numeric Identifier 93805**]* AST-4924* AlkPhos-170*
TotBili-1.4
[**2156-6-13**] 02:30AM BLOOD Lipase-55
[**2156-6-14**] 02:28AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2156-6-13**] 09:10AM BLOOD Albumin-3.7 Calcium-8.0* Phos-1.4* Mg-2.5
[**2156-6-14**] 11:30AM BLOOD Ammonia-85*
[**2156-6-17**] 04:08AM BLOOD TSH-1.1
.
Discharge labs:
[**2156-6-26**] 06:51AM BLOOD WBC-7.9 RBC-2.89* Hgb-8.3* Hct-25.7*
MCV-89 MCH-28.6 MCHC-32.2 RDW-15.0 Plt Ct-378
[**2156-6-26**] 06:51AM BLOOD PT-16.1* PTT-89.2* INR(PT)-1.4*
[**2156-6-26**] 06:51AM BLOOD Glucose-88 UreaN-18 Creat-2.2* Na-140
K-3.8 Cl-103 HCO3-26 AnGap-15
[**2156-6-26**] 06:51AM BLOOD ALT-43* AST-15 AlkPhos-62 TotBili-0.2
[**2156-6-26**] 06:51AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.2
.
Anemia studies:
[**2156-6-24**] 05:04AM BLOOD calTIBC-265 VitB12-665 Folate-10.3
Ferritn-221* TRF-204
[**2156-6-24**] 05:04AM BLOOD Ret Aut-2.7
.
Toxicology:
[**2156-6-15**] 02:05AM BLOOD Acetmnp-NEG
[**2156-6-13**] 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-15.7
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
.
Microbiology:
.
[**2156-6-13**] Urine culture: no growth
[**2156-6-13**] MRSA screen: negative
[**2156-6-13**] Urine culture: no growth
[**2156-6-16**] VRE swab: negative
[**2156-6-17**] RPR: non-reactive
[**2156-6-19**] Blood cultures x 2: negative
.
[**2156-6-13**] HEPATITIS C - RIBA
Test Result Reference
Range/Units
HCV AB, RIBA Positive A Negative
BAND PATTERN 5-1-1 Reactive A Nonreactive
(p)/cl00 (p)
c33c Nonreactive Nonreactive
c22p Reactive A Nonreactive
NS5 Nonreactive Nonreactive
hSOD Nonreactive Nonreactive
.
EKG [**2156-6-14**]: Sinus tachycardia. Low inferior and precordial lead
T wave amplitude is non-specific and may be within normal
limits. No previous tracing available for comparison.
.
Imaging:
.
RUQ ultrasound [**2156-6-13**]: No biliary obstruction, focal liver
lesion or portal venous thrombosis.
.
CT abdomen/pelvis [**2156-6-13**]:
1. No focal liver lesions or evidence of cirrhosis on this
non-contrast
study.
2. Hepatic hypoattenuation compatible with steatosis or edema.
3. Status post cholecystectomy.
.
RUQ ultrasound with Doppler [**2156-6-13**]:
1. Normal Doppler arterial and venous evaluation of the liver.
2. Normal kidneys, no hydronephrosis.
.
Bilateral lower extremity ultrasound [**2156-6-13**]:
1. Left common femoral and superficial femoral partially
occlusive DVT and
completely occlusive left popliteal venous DVT.
2. No DVT in the right lower extremity.
.
PICC placement [**2156-6-17**]: Uncomplicated ultrasound and
fluoroscopically-guided double-lumen PICC line placement; the
internal length is 35.5 cm with its tip at cavoatrial junction;
the line is ready to use.
.
Endoscopy:
.
Colonoscopy [**2156-6-25**]:
Stool in the colon
Polyp in the sigmoid colon
Polyp at 1cm in the colon
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: Stool in colon. Poor prep. Unable to fully
visualize mucosa. Penduculated and sessile polyp. Pedunculated
polyp could be potential source of bleeding. No polypectomy
performed given patient on coumadin and heparin. Patient will
need repeat full colonoscopy and polypectomy once completed
course of anticoagulation.
.
EGD [**2156-6-25**]:
Erythema in the fundus compatible with mild gastritis
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
42 y/o F with history of bipolar disorder, COPD, substance abuse
and recent MVC transferred with mental status changes and acute
liver and kidney failure in the setting of an overdose.
.
# Acute liver failure: The etiology of the patient liver failure
was likely toxin mediated (given ingestion of >30 grams of
Tylenol). There also may have been a component of ischemic
injury. The patient was treated with NAC and supportive care.
Her transaminases were ALT 11,0000, AST 9000 prior to transfer
and trended downward throughout her hospital course, with ALT 43
and AST 15 at the time of discharge. Tbili was never greater
than 1.5.
.
# Coagulopathy/anticoagulation/DVT: The patient has a left lower
extremity DVT. Her INR was elevated to 15 on presentation. This
was thought to be due to acute liver injury. It was unclear if
there was also a Coumadin overdose. The patient was treated with
vitamin K, with resolution of her coagulopathy. Warfarin was
restarted on [**2156-6-16**], at which time the patient's INR was 1.1. At
the time of discharge, the patient's INR was 1.4. Her goal INR
is 2.0 to 3.0. The patient was discharged on Coumadin 5 mg
daily. She will get her INR checked at her PCP's office on
[**2156-6-28**] and [**2156-6-30**]. The patient will self-administer Lovenox 80
mg daily for 5 days in order to provide a therapeutic bridge.
.
# Acute kidney injury: The patient developed acute kidney
injury, with creatinine peaking at 9.1 on [**2156-6-17**]. The patient
did not require hemodialysis. Her urine output eventually
increased, and her creatinine fell steadily, reaching 2.2 at the
of discharge. The suspected etiology of the patient's acute
kidney injury was acute tubular necrosis due to hypotension and
medication toxicity. The patient will need to get a chem 7
checked (along with other labs) on [**2156-6-30**].
.
# Gastritis/GI bleeding: The patient's nasogastric tube
initially had significant coffee-ground emesis. The patient was
not initially scoped and was treated empirically for gastritis
with sucralfate and pantoprazole. Her hematocrit initially
dropped from 39 on [**2156-6-13**] to 28 on [**2156-6-15**]. Thereafter, the
patient's Hct remained stable, although there was a slow drift
downward for which the patient underwent EGD and colonoscopy on
[**2156-6-25**]. EGD showed mild gastritis. Colonoscopy showed a polyp
as explained below. The patient was discharged on sucralfate and
pantoprazole. She will have a CBC checked (along with other
labs) on [**2156-6-30**].
.
# Colon polyp: The patient underwent colonoscopy on [**2156-6-25**] to
evaluate for a source of a slow Hct drop. A single pedunculated
2.5 cm non-bleeding polyp of benign appearance was found in the
sigmoid colon. A single sessile non-bleeding polyp of benign
appearance was found at 1 cm. No biopsies or excisions were done
due to the patient's anticoagulation. Mucosal visualization was
limited by poor prep. The patient will need to undergo repeat
colonoscopy as an outpatient. She will have a CBC checked (along
with other labs) on [**2156-6-30**].
.
# Dyspnea/Chronic obstructive pulmonary disease: The patient
developed dyspnea, which was felt to be multifactorial, related
to fluid overload, metabolic acidosis (due to renal failure),
and COPD. The patient was treated with Advair, Spiriva, and
albuterol and ipratropium nebs. She never required dialysis. The
patient's dyspnea improved with bronchodilators and recovery of
her kidney function.
.
# Substance abuse/overdose: Patient denied intentional overdose.
The psychiatry service was consulted and did not feel that the
patient was at acute risk for self-harm. Clonidine, [**Date Range 21330**],
[**Date Range 34491**], Topamax, naltrexone, and Cymbalta were stopped.
Seroquel was decreased to 50 mg nightly. Clonzepam was decreased
to 1 mg [**Hospital1 **]. Lidocaine patch was added for pain management. The
patient's primary care doctor [**First Name (Titles) **] [**Name (NI) 653**] to make him aware of
what has occurred. The patient was instructed to follow up with
her psychiatrist.
.
# Hepatitis C: The patient has a history of hepatitis C and IV
drug use. It is unclear if she has a history of cirrhosis.
.
# Communication: Patient, husband & siblings
[**First Name8 (NamePattern2) 1453**] [**Last Name (NamePattern1) 10983**] [**Telephone/Fax (1) 93806**]
[**First Name9 (NamePattern2) **] [**Doctor Last Name 10983**] [**Telephone/Fax (1) 93807**]
Medications on Admission:
Coumadin
[**Name (NI) **] (unclear amounts)
[**Name (NI) 34491**] (approx 80 tabs)
Clonidine 0.3mg TID prn
Naltrexone 50mg daily
Klonopin 1mg TID
Quetiapine 600mg QHS
Cymbalta 120mg daily
Tiotroprium daily
Topamax 100mg daily
Advair daily
Albuterol prn
Discharge Medications:
1. Outpatient Lab Work
INR on [**2156-6-28**]
INR on [**2156-6-30**]
fax results to Dr. [**Last Name (STitle) 18937**], phone [**Telephone/Fax (1) 93808**]
2. Outpatient Lab Work
Chem 7 and CBC, on [**2156-6-30**]
fax result to Dr. [**Last Name (STitle) 18937**], phone [**Telephone/Fax (1) 93808**]
3. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-14**]
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
4 weeks.
Disp:*56 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation once a day.
9. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*1*
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place
on for 12 hours, then remove for 12 hours.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
11. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
your doctor may need to adjust your dose.
Disp:*60 Tablet(s)* Refills:*0*
12. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous once
a day for 5 days.
Disp:*5 syringes* Refills:*1*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain: DO NOT TAKE MORE THAN 2000mg total
per day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute-
Acute liver failure, secondary to tylenol toxicity
Acute renal failure due to acute tubular necrosis
Acute blood loss anemia
Gastritis
Chronic-
DVT/PE
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital due to liver and kidney
failure due to taking too much tylenol and other medications.
Your liver has recovered. Your kidneys are still improving. It
is unclear if you will have any lasting kidney damage. You will
need to have your kindey function checked next week on
Wednesday.
.
You had bleeding from your stomach. Your endoscopy showed
gastritis. You were placed protonix and sucralfate to treat
this. Your blood levels are now stable and starting to improve.
You will need your blood counts checked on Wednesday.
.
Your colonscopy showed a large polyp that should be removed
after you have completed your coumadin treatment.
.
For your history of DVT, you were placed on heparin IV and then
transitioned to coumadin. Your couamdin level (INR) is not high
enough yet, so you were started on lovenox injections. You will
need to use this for the next 5 days, once a day. Please have
your INR checked at your primary care office on Monday ([**6-28**])
and Wednesday ([**6-30**]).
.
Please keep your follow up appointments.
.
The following changes were made to your medications.
-CHANGED coumadin dose
-STARTED on lovenox for 5 days
-STARTED on protonix to protect the stomach
-STARTED on sucralfate to protect the stomach
-STOPPED topamax
-STOPPED naltrexone
-STOPPED clonidine
-STOPPED cymbalta
-STOPPED [**Month/Year (2) 21330**]
-STOPPED fiorcet
-DECRESED tylenol, do not take more than 2000mg per day
-DECREASED seroquel dose
-DECREASED clonazepam to twice a day
-INCREASED advair to twice a day
-STARTED on lidocaine patches
Followup Instructions:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13983**]
Specialty: Primary Care
Phone Number: [**Telephone/Fax (1) 93808**]
Please call on Monday morning for an appointment to see him this
week
.
Please also call your psychiatrist to set up an appoitment to
dicuss your medication changes.
|
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13336, 13336
|
2584, 2584
|
15076, 15391
|
2048, 2084
|
11355, 13092
|
13142, 13315
|
11078, 11332
|
13487, 15053
|
3410, 6597
|
2099, 2565
|
1549, 1591
|
277, 335
|
420, 1530
|
2600, 3394
|
13351, 13463
|
1613, 1762
|
1778, 2032
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,680
| 162,446
|
47366
|
Discharge summary
|
report
|
Admission Date: [**2178-9-18**] Discharge Date: [**2178-10-1**]
Date of Birth: [**2111-4-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation x2
PICC line placement
History of Present Illness:
67y/o M with a PMH of DM type 2, [**Hospital3 9642**] mechanical [**Hospital3 1291**]
([**2168**]), Ascending aorta repair with graft ([**2168**]),CAD, s/p
CABG,hx of VF arrest s/p AICD [**2175**], recurrent high grade CoNS
and VRE BSI s/p removal of leads who presented to [**Hospital1 18**] with
shortness of breath. He was discharged from [**Hospital Unit Name 196**] team on [**9-17**],
and presents again complaining of shortness of breath.
.
His last admission was primarily for pseudomonas urosepsis,
which was complicated by acute pulmonary edema in the setting of
systolic heart failure s/p intubation x3. Exacerbations are
thought to be secondary to hypertension and not acute ischemia.
Overall he was diuresed >12kg during that admission, and
discharged to [**Hospital1 **] on [**9-17**].
.
On [**9-18**], he presented from [**Hospital1 **] to [**Hospital6 12736**]
complaining of suddent onset dyspnea when he woke up this
morning. On arrival to OSH ED, ABG 7.36/47/68. He was placed
on CPAP en route, and received 80mg IV Lasix, with 100cc urine
output.
.
He was started on dopamine at OSH ED at 10/hour, and
transitioned to levophed at OSH ICU. Levophed was 5mcg/min, and
patient had systolic BPs in 90s. He got 500mg Gentamicin x1.
He was transitioned to 50% venti mask, and transferred to [**Hospital1 18**]
at patient's request.
.
Currently, patient continues to feel short of breath. He denies
any chest pain, palpitations, fevers, or chills. He denies any
dysuria or urinary frequency. Last BM yesterday. No diarrhea.
.
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,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
CAD s/p CABGx3 [**2168**]
- h/o VF arrest [**6-30**] s/p ICD placement; required explantation
for MRSA pocket infection with reimplantation [**10-31**], s/p lead
removal [**4-2**]
- mechanical [**Last Name (LF) 1291**], [**First Name3 (LF) **]. [**Male First Name (un) 1525**], [**2168**]
- ascending aorta repair c graft [**4-/2169**]
- CHF (EF 20% per TTE [**2178-8-19**])
- high grade CoNS bacteremia in [**2-2**] c/b high grade CoNS, VRE
bactermia while on vancomycin [**3-2**], s/p 4 weeks daptomycin and
explantation of ICD leads
- pseudomonas UTI [**6-2**] s/p cefepime x 14 days, now pseudomonas
UTI [**8-2**] s/p meropenem x 14 days
- R lateral foot ulcer s/p debridement s/p zosyn x 14 days
- DM2 c/b neuropathy
- Hep C (dx [**4-2**], 2.38 million IU/ml. Seen by Hepatology, [**2178-7-30**]
note emphasizes deferring IFN/ribavirin tx for now given
infections, etc.)
- HTN
- HLP
- PVD s/p L BKA [**7-27**]
- hypothyroidism
- h/o opiate dependence, ?benzo dependence
- acute on chronic SDH, [**8-30**]
- h/o R scapula fx
- h/o MRSA elbow bursitis, [**5-1**]
- h/o closed bimalleolar fx s/p repair, removal of hardware [**6-26**]
Social History:
Lives in [**Location (un) **], though has been in rehab for much of the
past few months. Former cab driver. Social history is
significant
for the current tobacco use of 40 pack years. There is no
history
of alcohol abuse or recreational drug use. Lives with common-law
wife of 35 years who is a home health aid.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=97.7 BP=115/57 on 0.03 of levophed HR= 86 RR=20 O2 sat=
100% on 12L Ventimask
GENERAL: WDWN M clearly short of breath. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. JVP difficult to assess [**1-26**] body habitus, however
appears to be just under the mandible.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs. No S3 or S4.
LUNGS: Labored breathing. Diffuse bilateral rales bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm well perfused. 1+ LE edema bilaterally. 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:
[**2178-9-18**] 2:43p
.
UA:
Leuk Lg Bld Lg Nitr Neg Prot 100 Glu Neg Ket Neg
RBC >1000 WBC >1000 Bact Many Yeast None Epi 0
.
[**2178-9-17**] 05:35a
135 98 28 AGap=11
------------ 110
3.8 30 1.1
Ca: 8.5 Mg: 2.3 P: 3.3
.
7.8
5.2 ------ 213
24.9
.
PT: 20.8 PTT: 85.1 INR: 1.9
OSH EKG [**9-18**]:
NSR @ 61bpm. LBBB. No ST segment changes.
CXR on admission [**9-18**]
FINDINGS: As compared to the previous radiograph, the signs
evocative of
pulmonary edema have slightly decreased. However, today's image
shows a
typical presentation of mild-to-moderate persisting pulmonary
edema with
cardiomegaly, increased vascular markings, increased
reticulations and a
borderline width of the right mediastinum. Minimal blunting of
the left
costophrenic sinus but cannot exclude the presence of a small
pleural
effusion. No focal parenchymal opacities have newly occurred.
Unchanged
alignment of sternal wires after sternotomy. Status post
valvular
replacement. The PICC line projects with its tip over the
superior SVC.
Brief Hospital Course:
67y/o M with a PMH of DM type 2, [**Hospital3 9642**] mechanical [**Hospital3 1291**]
([**2168**]), Ascending aorta repair with graft ([**2168**]),CAD, s/p CABG,
hx of VF arrest s/p AICD [**2175**], recurrent high grade CoNS and VRE
BSI who presents with acute onset shortness of breath and
hypotension, found to be in acute exacerbation of chronic
systolic and diastolic CHF with flash pulmonary edema x2
requiring ventilation.
.
# CHF exacerbation with episodes of flash pulmonary edema:
Patient presented with fluid overload, exacerbation of well
known systolic and diastolic CHF (EF 20%). Med nonadherence
unlikely as pt presented from rehab facility. Patient was
diuresed aggressively with Lasix gtt, and was initially on
nitrates for vasodilation. However, when pt's SBP>100, he had
flash pulmonary edema and needed intubation two times during
this admission. Captopril was initiated (in place of his
Lisinopril, which was initially held for low BP) with the goal
of aggressive afterload reduction, and pt was maintained at
SBP<100. Patient was also initiated on Torsemide and Diuril prn
(received 1 dose so far) after Lasix drip was d/c'ed to keep him
negative 0.5-1L/day to prevent volume overload and flash
pulmonary edema. <<*****He should continue to be diuresed to
his dry weight on Torsemide and Diuril prn.*****>> Patient's
flash pulmonary edema is also suspected to be related to vagal
episodes with straining for bowel movements, and he is on an
aggressive bowel regimen, which should only be decreased if the
patient develops diarrhea. <<*****Please maintain aggressive
bowel regimen.*****>> <<*****Please do NOT hold
anti-hypertensive regimen (Captopril, Metoprolol) for SBP <80.
Patient has flash pulmonary edema with SBP >100.*****>>
.
# Hypotension: BP 80s/50s at OSH, on Levophed initially, then
weaned off. Initially believed to be [**1-26**] acute pulmonary edema
and poor forward flow vs. sepsis (as pt had recent urosepsis and
recently completed a 14 day course of meropenem for pseudomonas
UTI). UCx grew Klebsiella, BCx were negative, patient was
treated with Meropenem. Patient appears to live with SBP in
80's - 90's. In fact, pt had flash pulmonary edema when
SBP>100, and patient's goal SBP was <100 while in-house. See
above for course of medication changes with pt's low BPs.
.
# CAD s/p recent cardiac cath: Patient has known CAD s/p CABG.
Recent cath showed 2VD, patent LIMA to LAD, and diastolic
dysfunction. No interventions were performed at that time.
Pulmonary edema not believed to be [**1-26**] ACS, as negative cath 4
days prior to admission, without acute EKG changes, and
essentially negative CEs. Pt was continued on home Aspirin,
statin. BB and Lisinopril was initially held in the setting of
hypotension initially, then re-started on Metoprolol as SBP
stable in 80's-90's. Lisinopril was changed to Captopril for
afterload reduction, being discharged on 27.5mg tid.
.
# s/p mechanical [**Month/Day (2) 1291**]: Pt was discharged on Heparin GTT just
prior to re-admission, INR initially sub-therapeutic on Coumadin
(and Heparin gtt). INR became supra-therapeutic and Coumadin
was held, then re-started and half dose with goal INR 2.5 - 3.5.
Heparin bridge continued until INR in therapeutic range prior
to discharge.
.
# R leg ulcer - s/p surgical debridement by VSurg [**9-8**]. Wound
VAC placed [**9-9**]. Wound vac removed and leg was wrapped,
vascular was re-consulted prior to discharge and stated pt can
bear weight on the R leg.
.
# DM2 - On SSI with home Glargine 120 u qHS.
.
# ?Vision changes: Ophtho was consulted for c/o ?decreased
vision; pt has cataracts OS>OD, no gross abnormalities, will
need to keep his f/u with ophtho at [**Last Name (un) **].
.
# Hep C - Per Hepatology, deferred tx in-house, may need outpt
reassessment in the future.
.
# h/o VF - Pt does not have working pacer/ICD at this time [**1-26**]
persistent bacteremia that led to lead removal earlier this
year. No indication for pacer/ICD placement in-house, may need
to be re-assessed for one in the future.
.
# h/o Hypothyroidism - Pt not on thyroid replacement as
outpatient. Last TSH wnl.
.
.
*** Please do NOT hold anti-hypertensive regimen for SBP <80.
Patient has flash pulmonary edema with SBP >100.
.
*** Please maintain aggressive bowel regimen.
.
*** Please continue diuresing -1L/day. Attempting to diurese to
dry weight.
Medications on Admission:
Amiodarone 200 mg po daily
Atorvastatin 40 mg po daily
Furosemide 80 mg po bid
Gabapentin 600 mg po tid
Insulin Glargine [Lantus] 120 units qhs
Humalog SSI
Levetiracetam [Keppra] 500 mg po qhs
Lisinopril 2.5 mg po daily
Metoprolol Tartrate 12.5mg po daily
Nitroglycerin 0.4 mg SL PRN CP
Oxycodone-Acetaminophen [Percocet] -1 tab po q4-6h PRN pain
Potassium Chloride 40 mEq po daily
Ranitidine 150 mg po bid
Warfarin 4-6 mg po qhs
Maalox qid PRN indigestion
Aspirin 81 mg po daily
Bisacodyl, Senna
Ativan 0.5-1mg po q6h PRN anxiety
Ferrous sulfate 325mg po daily
heparin gtt (for INR<2.5)
Torsemide 20mg po bid at 8am and 2pm
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO BID (2 times a day): Hold for diarrhea.
4. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): Hold for SBP< 85.
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Outpatient Lab Work
Please check INR daily with Chem-7, CBC every other day
12. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: per weight based protocol units Intravenous
continuous: D/C after INR >2.5 for 48 hours.
13. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety: Please offer every 4 hours and
give if pt seems anxious.
14. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
15. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Titrate per the [**Hospital3 **] instructions.
17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
18. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
22. Meropenem 500 mg Recon Soln Sig: One (1) bag Intravenous
every six (6) hours: last dose.
23. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
25. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): please decrease this medicine first if pt appears dry.
26. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
27. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day: Please check potassium every 3 days with an
electrolyte/chemistry panel, and hold for K >4.0.
28. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
29. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure EF 20%
Coronary Artery Disease
Klebsiella Urinary Tract Infection
Chronic LE wound
Constipation
S/P [**Hospital1 1291**] with [**Hospital3 9642**] Valve
Acute on Chronic Anemia
Hepatitis C
VF s/p ICD placement and removal [**1-26**] infection
Discharge Condition:
stable
Temp Max: 98 Temp current: 97.5 HR:65-69 RR: 20 BP:
83-99/40-50's. O2 Sat: 100% RA
24 hour I= 1485 O= 4000cc
8 hour I= 519 O= 1050
Weight: 109.7 (113.4)
Discharge Instructions:
You had episodes of sudden congestive heart failure that caused
you to be intubated twice. We have adjusted your medicines to
help prevent this from happening again.
Weigh yourself every morning, call provider if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
Medication changes:
1. Captopril was increased to 50 mg TID
2. Torsemide was increased to 40mg [**Hospital1 **]
3. Gabapentin was decreased to 400 mg q 8h
4. Meropenem was added to treat Klebsiella UTI
5. Your bowel regimen was increased to prevent constipation
Followup Instructions:
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2178-10-15**] 3:00
Primary Care:
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-11-12**] 11:20
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2179-1-27**] 1:10
|
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|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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|
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|
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,047
| 195,476
|
24854
|
Discharge summary
|
report
|
Admission Date: [**2136-9-25**] Discharge Date: [**2136-11-9**]
Date of Birth: [**2108-5-30**] Sex: M
Service: MEDICINE
Allergies:
Ambisome
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Nausea, vomiting, diarrhea, dehydration
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
Paracentesis
Bone marrow biopsy
History of Present Illness:
28yo M, history of AML s/p recurrence after 3 allogenic
transplants from unrelated donor, recently discharged from this
service [**2136-9-20**], presents with 1 day history of
nausea/vomiting/diarrhea and dehydration. Has been feeling well
since last discharge, until night prior to discharge when about
45 mins after dinner he vomited up his dinner and pills. [**Known firstname 16376**]
went to bed and was having rib pain R>L of same character as he
had during last admission, for which he has been taking MS
Contin twice a day, and also c/o L shoulder pain, which he
states he was having during an admission earlier this year.
Around 3am, [**Known firstname 16376**] started having stomach cramps and began to
have loose stools. Went to clinic on morning of admission as
was feeling dehydrated. Patient is feeling better now with
IVF's. Magnesium was noted to be low in clinic, was given 2g.
Did not receive ABx in clinic.
.
ROS as above, also significant for fatigue due to deconditioning
since last admission that has been slowly improving, pain in his
ribs R>L and L shoulder, a new onset cough that started day
prior to admission (some phlegm but no purulence). [**Known firstname 16376**] [**Doctor First Name 1638**]
fever, night sweats, weight changes, vision changes, headaches,
other problems with [**Name (NI) 4459**], dysphagia, dyspnea, CP, dysuria, skin
changes, rashes, or any other localizing symptoms. [**Known firstname 16376**] states
he was eating well, sleeping well before this recent episode.
Past Medical History:
PAST ONCOLOGIC HISTORY
- [**10-29**]: Diagnosed with AML (p/w fevers and myalgias, found to
have Influenza A) WBC of 3 with 74% blasts. Started 7+3
consolidation therapy. Had residual disease after completion
requiring HIDAC.
- [**3-2**]: Non-myeloablative allo-transplant from matched sibling.
relapsed shortly thereafter.
- [**2134-4-12**]: Completed a course of clofarabine and ARA-C
- [**2134-5-7**] Full myeloablative allo transplant from the same
matched sibling . Transplant was complicated by prolonged
neutropenia, fevers, high transfusion requirement secondary to
ABO mismatched graft.
- [**2135-11-1**]: p/w progressive fatigue. Found to have 54% blasts in
his peripheral blood without evidence of tumor lysis or DIC.
- Underwent ARA-C (1g/m2) on days [**1-30**] and clofarabine (40 mg/m2)
on days [**3-2**]. He received all 6 days as an outpatient.
- Chronic GVH of the liver, manifesting as liver function test
abnormalities. He had a Liver Bx in [**7-31**]: findings consistent
with GVH, but also increased ferritin consistent with iron
overload. He has received therapeutic phlebotomy for this.
-now s/p ALLO MUD, Day 25 on day of admission
OTHER PAST MEDICAL HISTORY
-HTN - treated prior on metoprolol and more recent on
nifedipine - pt does not immediately recall prior dose - but
states noted pressures have been up and down a bit just recently
- has been off meds since transplant
-Pituitary adenoma: followed by Dr. [**Last Name (STitle) 62546**] at [**Hospital1 2025**]. Recent
MRI did not show any change in adenoma size
-Splenic rupture [**2-27**] MVA in [**2125**], no splenectomy required
-h/o VRE bacteremia in [**4-30**].
Social History:
Previous to this recent admission, [**Known firstname 16376**] worked as an MRI
technician. He has 2 younger brothers, one of whom was his stem
cell donor. He has never smoked and drinks alcohol occasionally.
Family History:
Patient had a cousin who passed away from leukemia at the age of
9. His aunt had polycythemia. His grandfather has DM2, and his
father has multiple kidney stones. He also notes that multiple
relatives on his father's side have had MIs and CAD.
Physical Exam:
T: 99.7 BP: 130/88 HR: 130 RR: 20 SP02: 95%RA
Laying in bed, appears somewhat pale, able to give good history,
appropriate. No cardiopulmonary distress.
PERRLA 3-->2, anicteric. Mouth mucosa appears dry. No lesions
noted in mouth.
No supraclavicular, cervical, or submandibular LAD
Lungs CTAB no w/c/r/r noted
Tachycardic but otherwise reg rhythm, S1 S2 clear, no murmurs
Abdomen soft, NT, ND, BS+. No hepatosplenomegaly appreciated.
Skin--Scars noted in suprclav area from previous lines,
folliculitis widespread on bilateral lower extrems, otherwise no
rashes noted
No edema noted in extremities. 2+ DP's.
Pertinent Results:
[**2136-9-25**] 08:50AM UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-4.3
CHLORIDE-102 TOTAL CO2-25 ANION GAP-13
[**2136-9-25**] 08:50AM ALT(SGPT)-110* AST(SGOT)-114* LD(LDH)-217 ALK
PHOS-840* TOT BILI-2.1*
[**2136-9-25**] 08:50AM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-3.2
MAGNESIUM-1.5*
[**2136-9-25**] 08:50AM CYCLSPRN-72*
[**2136-9-25**] 08:50AM WBC-15.8* RBC-2.86* HGB-9.1* HCT-27.9* MCV-98
MCH-31.9 MCHC-32.6 RDW-21.0*
[**2136-9-25**] 08:50AM NEUTS-76* BANDS-3 LYMPHS-6* MONOS-9 EOS-1
BASOS-1 ATYPS-1* METAS-2* MYELOS-1*
[**2136-9-25**] 08:50AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ STIPPLED-1+
[**2136-9-25**] 08:50AM GRAN CT-[**Numeric Identifier 62548**]*
[**2136-9-24**] 01:40PM UREA N-11 CREAT-1.0 SODIUM-139 POTASSIUM-3.6
CHLORIDE-102 TOTAL CO2-23 ANION GAP-18
[**2136-9-24**] 01:40PM ALT(SGPT)-108* AST(SGOT)-108* LD(LDH)-220 ALK
PHOS-801* TOT BILI-2.1*
[**2136-9-24**] 01:40PM WBC-16.4*# RBC-2.97* HGB-9.5* HCT-28.7*
MCV-97 MCH-31.8 MCHC-32.9 RDW-21.4*
[**2136-9-24**] 01:40PM NEUTS-84* BANDS-2 LYMPHS-7* MONOS-4 EOS-1
BASOS-2 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2136-9-24**] 01:40PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL ENVELOP-2+
[**2136-9-24**] 01:40PM GRAN CT-[**Numeric Identifier 62549**]*
Admission CXR:
As compared to the previous radiograph, the left-sided PICC line
has been removed. The pre-existing right-sided pleural effusion
has markedly decreased but is still visible in the region of the
posterior and the lateral costophrenic sinus. Overall improved
lung ventilation, no newly appeared focal parenchymal opacities
suggesting pneumonia. The pre-existing retrocardiac opacity has
resolved. No newly appeared focal parenchymal opacity suggesting
an infectious episode.
EGD Biopsy [**10-19**]: Positive for adenovirus
Blood culture [**10-29**]: Positive for adenovirus
[**2136-9-27**]
IMPRESSION:
1. Areas of mild thickening of the small bowel wall, most
prominent in the
right lower quadrant. This finding is suggestive of enteritis,
likely
infectious or inflammatory in nature. In the presence of
bilateral effusions and ascites, third-spacing could also call
diffuse bowel wall edema. Unlikely due to ischemia.
2. Mild bowel wall thickening/edema seen in the ascending colon.
Fluid seen throughout the entire colon suggesting diarrhea.
3. Moderate amount of predominantly perihepatic ascites
extending down to the pelvis.
4. Moderately sized bilateral pleural effusions and bibasilar
atelectasis,
unchanged since previous MRI abdomen study of [**2136-9-6**].
CT Abdomen [**11-6**]:
1. Unchanged morphology of left upper lobe nodule and associated
satellite
lesion.
2. Minimally decreasing extent of bilateral pleural effusions,
but slightly increasing extent of right basal peribronchial
consolidation.
3. Minimal increase of bronchial wall thickening and associated
air trapping.
4. Unchanged pericardial effusion, moderate ascites.
5. No other changes.
MRI Abdomen [**10-16**]:
IMPRESSION:
1. No new pathology to explain transaminitis. Specifically, no
imaging
findings to suggest solid organ infection or heptosplenic
candidiasis. Vessels remain patent.
2. Unchanged severe systemic hemosiderosis involving the liver,
spleen,
pancreas, abdominal lymph nodes, and bone marrow. Little change
to bilateral pleural effusions, moderate intra-abdominal
ascites, and diffuse third spacing.
3. Hyperenhancing small bowel mucosa suggests a component of
acute small
bowel graft versus host disease (also recently suggested by
colonic biopsy), though a portion of the bowel wall edema is
also likely secondary to third spacing.
Brief Hospital Course:
This is a 28-year-old gentleman with AML s/p 3 allo transplants
with recurrence, most recently a DLI and SCR, who presents to
[**Month/Year (2) 3242**] with nausea, vomiting, diarrhea, dehydration, and bilateral
rib pain. Upon admission, patient was started on empiric
Levaquin, continued cyclosporine, antifungal prophylaxis, and
acyclovir. He eventually passed away on [**2136-11-9**] from graft
versus host disease of liver and gut, adenoviremia and liver
failure.
(Due to the length and complexity of admission, this hospital
course will go chronologically instead of by problem list).
WEEK 1
Within 24hrs of admission, patient had signs of sepsis with
spiking high fevers and hypotension. Patient was put on
daptomycin and meropenem in addition to Voriconazole and Flagyl.
Patient had 2 negative c.diff cultures but 3rd was positive, so
patient was started on PO Vanc and IV flagyl. CT abdomen with
small bowel wall thickening worse in RLQ c/w enteritis. Started
on levophed. Cyclosporine was started [**2136-9-27**]. TPN also started.
Patient appeared to be going into DIC with increasing PT, PTT,
INR, and increased FDP, however, clinically insignificant and
labs resolved on their own.
Pressors stopped 6:30am [**2136-9-28**]. Still required some IVF boluses.
Was on steroids, tapered from 30 to 15 IV bid, PO Vanc, IV
Meropenem, IV Flagyl, IV Cyclosporine, IV Vori, IV Acyclovir.
IV Dapto d/c'd at that point. By this point, Tbili continuing to
rise, now to about 5.8. Pt still complaining of [**Month/Day/Year 5283**], deep type
pain, imaging with no clear etiology, only showing gross ascites
and small bowel enteritis.
WEEK2
Merrem was stopped and Cipro started. This week, GI was
consulted and they performed a Flex Sig showing severe GVHD, no
pseudomembranes were seen, and the Bx was negative for CMV. He
continued to have significant [**Month/Day/Year 5283**] pain and a [**Month/Day/Year 5283**] u/s was
obtained which was non-diagnostic, only showing ascites and no
etiology of the pain. Cipro was discontinued. Patient continued
to have 2-3L of profuse, watery stool per day, and Tbili
continued to rise. MMF was started at 750 IV q6hrs. Abdominal
pain continued to increase. A CT scan of patient abdomen was
non-diagnostic. He continued to require 12-13mg IV Dilauded per
day. Steroids were increased to 40 IV bid.
WEEK 3
[**Known firstname 16376**] was started on a Fentanyl PCA. A paracentesis was
performed and a significant amount of fluid was removed.
Ascites was negative for infection. At this point, GVHD was
considered to be most likely etiology of abdominal pain.
Steroids were increased to 80mg IV bid (2mg/kg).
At the end of the 3rd week, [**Known firstname 16376**] went into spontaneous atrial
fibrillation with RVR; his systolic BP's were in the 90s and
heart rate in the 140s. Stat bedside echo showed no cardiac
tamponade, only small effusion. [**Known firstname 16376**] was taken to the ICU
where he was started on a Dilt drip, Cefepime, Linezolid, and
restarted on PO Vanco. CE's were negative x2. He converted back
to sinus rhythm quickly 11pm of [**10-13**], and was converted to PO
Dilt 30mg qid. His vitals were stabilized and he was
transferred back to the floor.
WEEK 4
[**Known firstname 16376**] was still having 2-3L of copious diarrhea and LFTs
continued to rise. Enbrel was started 2x/week for GVHD. [**Known firstname 16376**]
began having grossly bloody stool, with some of his BMs being
purely blood. GI was reconsulted, and they decided to urgently
scope him. Results showed cobblestoning consistent with severe
GVHD; CMV cultures negative. The EGD showed areas of erythema,
a heaped up mucosa in the antrum of the stomach, but no gross
bleeding vessels or varices. [**Known firstname 62550**] hematocrit remained fairly
stable through these bleeding episodes, but he intermittently
required transfusions of PRBCs. Moreover, his anasarca was
getting worse, and he was becoming more uncomfortable. [**Known firstname 16376**]
was given lasix on a day-to-day basis with good results.
Week 5
The question of a liver biopsy continued to be entertained.
However, after extensive consultation with patient, family, and
primary team, the decision was made not to perform the
procedure. It would have been difficult to obtain access
through the jugular veins, and a percutaneous biops was much too
risky. [**Known firstname 16376**] did however go for a therapeutic paracentesis;
about 4.5 liters of ascites were removed with profound
symptomatic relief. [**Known firstname 16376**] continued to have large amounts of
stool (~4 liters per day); all stool cultures were negative. He
was started on anti-diarrheal medications with minimal relief.
Lasix was continued for volume overload. Patient also received
Rituxan for treatment of GVHD.
Week 6:
[**Known firstname 16376**] continued to have severe bloody diarrhea. EGD biopsy came
back positive for adenovirus; blood cultures subsequently
returned positive for adenovirus as well. Rituxan and enbrel
were stopped, and focus became on treatment of adenovirus.
[**Known firstname 16376**] was given cidofovir on [**11-1**]--after pre and post hydration
with IVF and probenecid for nephro-protection. He seemed to
tolerate the treatment well. A bone marrow biopsy this week was
negative for leukemic infiltration.
Week 7:
[**Known firstname 62550**] mental status started to decline this week due to
profound hepatic/toxic metabolic encephalopathy. He mood
alternated between delirium, anger, confusion, and somnolence.
The fentanyl was likely adding to mental status changes, and
doses were adjusted. However, [**Known firstname 16376**] continued to be altered,
and a head MRI was performed on [**11-6**]. No acute changes were
seen on MRI. Family meeting was held on [**11-7**], and decision was
made to make [**Known firstname 16376**] DNR/DNI. Throughout the course of this week,
[**Known firstname 16376**] started to became hypothermic (temperatures to 95) and
hypotensive (pressures in the 80s). Sepsis was suspected, and
antimicrobials were broadened (with ID input). Numerous blood,
urine, and stool cultures were negative. Bicarbonate down; BUN,
creatinine, INR, and bilirubin all up. Liver team suggested
starting rifaxamine and increasing ursodiol (however, patient
was too weak to take either). The second dose of Cidofovir,
which was supposed to be administered on [**11-8**], was held in
light of acute renal failure. On the night of [**11-8**], healthcare
team was called to patient's room for seizure-like activity.
Small dose of ativan given and symptoms eventually resolved.
Patient was much more somnolent at this point, and family was
called to bedside. [**Known firstname 16376**] passed away on [**11-9**].
Medications on Admission:
Acyclovir
Cyclosporine
Folic Acid
Ativan
Morphine 15mg
Ondansetron
Pantoprazole
Pentamidine [Nebupent]
Posaconazole [Noxafil]
Prochlorperazine [Compazine]
Ursodiol
Multivitamin
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
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61,800
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15336
|
Discharge summary
|
report
|
Admission Date: [**2136-7-4**] Discharge Date: [**2136-7-6**]
Date of Birth: [**2060-7-24**] Sex: M
Service: MEDICINE
Allergies:
Tape [**12-25**]"X10YD / Zetia / Atorvastatin / Ace Inhibitors /
Beta-Blockers (Beta-Adrenergic Blocking Agts) /
Hydrochlorothiazide
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
75 yo M h/o CAD s/p [**11-3**] DES, HTN, DM2, HLD, diastolic CHF (EF
in [**6-29**] 45-50%) with recent admission for chest pain, s/p
catheterization, p/w recurring chest pain today had received
balloon angioplasty in the AM.
.
Patient noticed chest pain, similar in quality to his previous
angina pain while shaving this morning. The pain was described
as moderate, located at midsternal region, dull in quality, and
responded partially to nitroglycerine X3. Patient came to work
and went to a conference, and his chest pain exacerbated,
despite nitroglycerin use. Upon arrival to the ED, there was no
EKG changs or elevation of troponin. Cardiology was called, and
decision was made to re-cath.
In the cath lab, there was a 60-70% stenosis of the LCX, with
widely patent stents, balloon angioplasty was perfromed from LCX
into L main, and no stents were placed. Patient's chest pain
resolved 30 mins during the procedure, but not temporally
associated with PCTA.
.
Of note, on [**6-26**] patient was admitted for chest pain, and was
taken to cardiac catheterization with DES to RCA ostium given
in-stent restenosis (70-80%). Six days later ([**7-2**]) patient had
similar chest pain, underwent another catheterization with stent
placement in LCx, and resulted in normal flow, with no
dissection or residual stenosis.
.
On arriving the CVICU, patient had VS of T 96.5, HR 80, BP
105/51, O2 Sat 98% on 2L. He is free of chest pain or shortness
breath.
.
No h/o of TIA, stroke, PE, DVT. ROS otherwise negative.
Past Medical History:
1.) CAD - s/p STEMI (36 yrs ago), NSTEMI ([**2094**]), NSTEMI in [**12-31**]
in [**State 15946**], s/p 2 DES to RCA and ?LCX, status post cath [**2133-7-22**]
with 4 DES to RCA, DES to 1st diag. s/p DES to RCA [**2136-6-26**].
(Total of about 12 stents)
2.) CHF: EF >55%([**7-2**]) with diastolic dysfunction
3.) Diabetes mellitus: last A1c 5.5% per his report, a couple of
months ago in AZ.
4.) Gout, on allopurinol, aleve, celebrex
5.) OSA: on CPAP
6.) Spinal stenosis with history of pseudoclaudication that
resolved post laminectomy
7.) History of coronary vasospasm (?etiology of STEMI 36 yrs
ago)
8.) History of hemorrhoids and colonic polyps - last colonoscopy
1 year ago
9.) TURP
10.) Herniorrhapy
11.) Multiple knee and shoulder surgeries
12.) S/p Laminectomy for spinal stenosis
Social History:
Pt is [**Name (NI) **] physician, [**Name10 (NameIs) **] in [**Location (un) 86**] and in [**State 15946**]. He has
authored 26 Emergency Medicine textbooks.
He lives with his wife and is very active, plays golf and
tennis.
-Tobacco history: stopped smoking ~50 years ago
-ETOH: stopped drinking ~4-5 years ago
-Illicit drugs: denies
Family History:
His father died of coronary artery disease in his 60's and one
paternal uncle died relatively young of vascular disease. Mother
died of breast cancer, grandmother died of diabetes.
Physical Exam:
ADMISSION EXAM
VS: T=96.5 BP= 105/51 HR=80 RR=9 O2 sat= 98% on 2L
GENERAL: WDWN men in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, MMM,
NECK: Supple with JVP of 1 cm over clavicle
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Limited exam, because pt could not sit or roll as
post-cath
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: one 1X0.5 CM ulcer over left shin ([**1-25**] trauma per pt)
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
.
DISCHARGE EXAM:
VS: T 97 BP= 110/60 HR 80 RR 12 O2 Sat 98% on RA
GENERAL: NAD
HEENT: NCAT. Sclera anicteric. PERRL, MMM,
NECK: Supple, JVP flat
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: CTAB, no increased WOB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema of the BLEs. No femoral bruits.
SKIN: one 1X0.5 CM ulcer over left shin ([**1-25**] trauma per pt)
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
ADMISSION LAB
[**2136-7-3**] 06:00AM BLOOD WBC-9.7 RBC-4.38* Hgb-12.0* Hct-36.2*
MCV-83 MCH-27.4 MCHC-33.2 RDW-15.2 Plt Ct-277
[**2136-7-4**] 08:25AM BLOOD Neuts-78.9* Lymphs-13.1* Monos-4.1
Eos-3.4 Baso-0.4
[**2136-7-4**] 08:25AM BLOOD PT-11.2 PTT-21.2* INR(PT)-0.9
[**2136-7-3**] 06:00AM BLOOD Glucose-199* UreaN-24* Creat-1.4* Na-140
K-4.5 Cl-102 HCO3-28 AnGap-15
[**2136-7-4**] 08:25AM BLOOD CK(CPK)-71
[**2136-7-3**] 06:00AM BLOOD CK-MB-9
[**2136-7-3**] 06:00AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9
[**2136-7-4**] 08:32AM BLOOD Lactate-2.4*
DISCHARGE LAB
[**2136-7-6**] 05:50 WBC 7.5 RBC 3.73* Hgb 10.3* Hct 31.4* MCV 84
MCH 27.8 MCHC 32.9 RDW 15.5 Plt Ct 303
[**2136-7-6**] 05:50 Glucose 164*1 BUN 26* Cr 1.3* Na 140 K 4.2
Cl 105 HCO3 26 AG 13
PERTINENT STUDIES
PTCA COMMENTS: The left coronary artery was engaged with a XB
3.5
guide catheter providing good support. Initial plan was to cross
the
lesion involving the ostial circumflex by a RADI pressure wire,
but due
to the severe angulation and newly deployed stents in the
proximal LCX,
this was not technically possible. After much difficulty, a
Choice PT
[**Name (NI) 9165**] intermediate wire was delivered across the lesion with
the help
of an Echelon microcatheter. A Pilot 50 wire was positioned in a
large
ramus intermedius branch. At this point patient started
complaining of
chest pain ([**7-1**]) which was unresponsive to IV and IC
nitroglycerin at
high doses. In view of severe chest pain, the ostium of the left
circumflex coronary artery was treated by multiple balloon
inflations to
a maximum of 10 atm with a 2.0 x 12 mm Apex OTW, followed by a
2.5 x 12
OTW balloon. Patient's chest pain improved to about [**3-1**] very
slowly
over the next 15-30 minutes. At this point, we took notice of
very slow
flow in a small caliber first OM branch whose origin had a
90-95%
stenosis and was jailed by the previously deployed proximal LCX
stent.
However, on review of previous angiograms, it was apparent that
the slow
flow in that branch was not a new phenomenon. In view of
uncertainty
about a definitive culprit lesion, patient was admitted to CCU
for
further observation and management. The arterial sheath in the
left
groin was pulled and manual pressure held with excellent
hemostasis.
Final angiograms obtained after PCI showed no dissection,
perforation or
any other mechanical complication.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 53 minutes.
Arterial time = 2 hours 26 minutes.
Fluoro time = 44.70 minutes.
IRP dose = 2759 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 170 ml
, vol 170 ml
Premedications:
Midazolam 2.5 mg IV
Fentanyl 75 mcg IV
Anesthesia:
1% Lidocaine subq.
COMMENTS:
1. Successful POBA to ostial LCX.
2. Patient to remain on aspirin and clopidogrel indefinitely
3. Optimization of anti-anginal therapy.
4. Admit to CCU for further management.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
ETT ([**2136-7-6**]):
This 75 year old man with h/o multiple PCIs most recent PCI to
RCA on [**2136-6-26**] and PTCA to Cx on [**2136-7-4**] was referred to the lab
for evaluation of chest pain. The patient exercised for 4.25
minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol (~ 2.9 METS), representing a
limited exercise tolerance for his age. Test was stopped due to
bilateral hip pain. No chest, neck, back, or arm discomforts
were reported by the patient throughout the study. In the
presence of baseline inferolateral NSSTTW, there was ~0.5-1 mm
of upsloping ST segment depression in these same leads at peak
exercise/recovery (Note: ST segments difficult to interpret at
peak exercise in the setting of artifact). These changes
returned to baseline as recovery continued. The rhythm was sinus
with occasional, isolated apbs throughout the study. Occasional,
single vpbs becoming frequent during exercise/early recovery,
including periods of [**Hospital1 **]/trigeminy. Blunted blood pressure and
heart rate responses to exercise.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 75 yo M with remote hx of coronary
vasospasm, h/o CAD s/p [**11-3**] drug eluting stents in the past
four years, HTN, DM2, Hyperlipidemia, diastolic CHF (EF in [**6-29**]
45-50%) with recent admission a week ago, s/p two cardiac
catheterizations, p/w recurring resting angina today, and was
thought to have printzmetal angina.
ACTIVE ISSUES:
# Angina
Patient presented with resting angina, in the setting of
recurrent symptoms consistent coronary artery ischemia, but no
convincing evidence of EKG changes or cardiac enzyme elevation
in the past week. Three cardiac catheterizations were performed
in the past week, resulting in the placement of drug eluting
stents in the potential flow restricting loci, including the LCX
and the ostium of a prior stent in RCA. However, patient's
angina symptom does not seem to temporally correlate with the
flow of his coronary artey as observed in cath lab. In
addition, the dynamic changes of the coronary artery patency
directly observed during angiogram raised concerns for a
component of vasospasm. Of note, patient has remote history of
NSTEMI 36 years ago that was attributed to vasospasm, and
responded to calcium channel blocker treatment. Patient was
started on nifedipine 30 mg po daily and losartan lowered to
50mg to allow therapy with CCB. There was a transient elevation
of CK-MB on HD#2, with no associated angina symptoms or EKG
changes, which was most likely a result of periprocedure
ischemia. An exercise stress test was done on the third day
that showed non-specific ST-T wave changes. The test was
terminated prematurely [**1-25**] hip pain, and the patient experienced
no anginal symptoms (full report in results). At the time of
discharge, he had 1+ pitting edema to the ankle which is likely
related to nifedipine.
OUTPATIENT ISSUES
- STARTED nifedipine 30 mg daily
- CHANGED losartan 75 mg to 50 mg daily
.
CHRONIC ISSUES
# Asthma
Patient has recent asthma exacerbation requiring oral steroid.
He received the equivalent of his home Advair and albuterol. He
breathes comfortably during this admission, with no wheezes or
O2 requirement to maintain O2 saturation.
.
# Hyperlipidemia
Patient has a documented history of hyperlipidemia. His recent
fasting LDL ([**6-25**]) was 84. We continued to receive
cholestyramine during this admission, and tolerated well.
.
# Hypertension
Patient has a documented history of hypertension and takes
losartan 75 mg daily at home. He received a decreased dose at
50 mg daily considering the addition of nifedipine. His blood
pressure remained stable.
.
# Diabetes
Patient has a history of diabetes, which was controlled by
metformin. We discontinued his metformin and switched him on
sliding scale insulin with qid glucose monitoring.
.
# Chronic kidney disease
Patient has a documented history of chronic kidney disease. His
creatinine was at his baseline during this admission.
.
TRANSITIONAL ISSUES
Patient maintained a full code during this admission. He was
discharged home with Cardiology follow up and a prescription for
Nifedipine.
Medications on Admission:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-25**] puff Inhalation QID prn as needed for shortness of breath or
wheezing.
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. losartan 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Metamucil Powder Sig: One (1) serving PO prn as needed
for constipation.
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
11. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
Disp:*60 Packet(s)* Refills:*2*
12. metformin 850 mg Tablet Sig: One (1) Tablet PO every
morning.
13. metformin 850 mg Tablet Sig: Two (2) Tablet PO at bedtime.
14. Celebrex 50 mg Capsule Sig: One (1) Capsule PO once a day.
15. Aleve 220 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
6. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
7. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
8. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for constipation.
9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. naproxen 250 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for Pain.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-25**] Inhalation four times a day as needed for shortness of
breath or wheezing.
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual Every 5 minutes as needed for chest pain: may repeat
once. If chest pain continues, take third tab and call 911.
14. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Celebrex 50 mg Capsule Sig: One (1) Capsule PO once a day.
16. Aleve 220 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Coronary Vasospasm
SECONDARY
Hypertension
Hyperlipidemia
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. [**Known lastname **],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for angina, for which you had
a cardiac cathetarization that showed single vessle coronary
disease. You underwent successful percutaneous balloon
angioplasty of the L circumflex artery. You also had an
exerceise treadmill test to asses your exercise tolerance that
showed non specific ST-T wave changes of unknown significance.
You were able to exercise to 2.9 METS, but the study had to be
stopped prematurely due to hip pain. The Cardiology team feels
that your angina is most likely due to coronary vasospasm, and
you were started on a calcium channel blocker. It is important
that you continue taking Plavix and Aspirin indefinitely.
During this hospitalization, we made the following changes to
your medications:
DECREASED Losartan to 50mg PO Daily
STARTED Nifedipine CR 30mg PO Daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2136-7-25**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"414.01",
"274.9",
"403.90",
"327.23",
"585.2",
"428.0",
"428.32",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"99.20",
"00.40",
"37.22",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
14815, 14821
|
8663, 9021
|
402, 427
|
14953, 14953
|
4555, 6930
|
16120, 16573
|
3146, 3328
|
13171, 14792
|
14842, 14932
|
11774, 13148
|
7525, 8640
|
15103, 16097
|
3343, 4015
|
4031, 4536
|
6949, 7508
|
352, 364
|
9036, 11748
|
455, 1966
|
14968, 15079
|
1988, 2778
|
2794, 3130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,295
| 153,443
|
3240
|
Discharge summary
|
report
|
Admission Date: [**2168-6-8**] Discharge Date: [**2168-6-16**]
Date of Birth: [**2109-4-12**] Sex: F
Service: Cardiac Surgery
CHIEF COMPLAINT: Bilateral shoulder numbness.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
female with a history of coronary artery disease,
hypertension, hypercholesterolemia, who presented with
bilateral shoulder numbness for a period of two weeks. She
was transferred from an outside hospital Emergency Room for
cardiac catheterization because of her known coronary artery
disease.
PAST MEDICAL HISTORY: 1) Coronary artery disease, status
post stent in [**3-5**] and proximal RCA which had a 95% lesion.
2) Hypertension. 3) Hypercholesterolemia. 4) Craniotomy for
aneurysm 10 years ago. Still has the aneurysm as it was not
accessible for intervention. 5) Status post cholecystectomy
five years ago. 6) Raynaud's. 7) Migraine headaches.
ALLERGIES: None known.
MEDICATIONS: On admission, enteric coated Aspirin 325 mg q
day, Lipitor 10 mg q d, Metoprolol XL 100 mg q d, HCTZ 12.5
mg q d, Multivitamins and Folate, Tylenol #3 for migraine.
FAMILY HISTORY: Father had MI at 60 years of age.
SOCIAL HISTORY: Lives with husband. Smoked one pack per day
for 20 years but quit 10 years ago. No significant alcohol
use.
HOSPITAL COURSE: The patient was admitted to the medical
team for cardiac catheterization. Cardiac catheterization
revealed severe LM stenosis and RCA of 30% with good ejection
fraction. Cardiac surgery was consulted at this point and
the decision to take her to the operating room was made. She
underwent a CABG times three on [**2168-6-10**] with LIMA to LAD, SVG
to DRCA, SVG to OM. She tolerated the procedure well and was
taken to the CSRU postoperatively. Postoperatively she was
noted to have an episode of ventricular tachycardia. She
received a cardiac pump and converted to a normal sinus
rhythm. She was started on Lidocaine infusion. She was
extubated prior to this V tach episode. She remained on
Neo-Synephrine overnight for blood pressure support. She had
an anxiety attack later on in the morning with raised heart
rate and blood pressure. She was started on Amiodarone on
[**2168-6-11**] and the Lidocaine was weaned off. She continued to
have intermittent episodes of anxiety and refused medications
on occasion. On [**2168-6-13**], postoperative day #3, she was
deemed stable for transfer to the regular floor.
Subsequently on the floor she had uneventful course. She
began ambulating with physical therapy. Her pain was under
control with po analgesics. She was cleared by physical
therapy to go home rather than rehab. On postoperative day
#5 she was ready for discharge to home. Just prior to
leaving for home, the patient had a bout of explosive
diarrhea. Subsequently she felt very lightheaded and was
noted to be pale and clammy. She was put back in bed and
vital signs were taken which were within normal limits. The
symptoms resolved in a few minutes but due to this, her
discharge was postponed for the following day. She was then
discharged on postoperative day #5 in stable condition.
DISCHARGE MEDICATIONS: Lasix 20 mg q d times one week, KCL
20 mEq q d times one week, Colace 100 mg [**Hospital1 **], Aspirin,
enteric coated, 325 mg q d, Amiodarone 400 mg q d, Lopressor
25 mg [**Hospital1 **], Lipitor 10 mg po q h.s., Tylenol with Codeine 1-2
tablets q 4-6 hours prn.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
FOLLOW-UP: Primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], in two weeks
and with Dr. [**Last Name (STitle) 70**] in 6 weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2168-6-29**] 14:24
T: [**2168-6-30**] 10:05
JOB#: [**Job Number 15132**]
|
[
"424.0",
"411.1",
"427.1",
"272.0",
"414.01",
"443.0",
"V15.82",
"437.3",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.15",
"36.12",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3479, 3956
|
1130, 1165
|
3156, 3421
|
1311, 3132
|
161, 191
|
220, 545
|
568, 1113
|
1182, 1293
|
3446, 3455
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,662
| 162,747
|
45396
|
Discharge summary
|
report
|
Admission Date: [**2170-10-29**] Discharge Date: [**2170-11-10**]
Date of Birth: [**2091-5-8**] Sex: F
Service: SURGERY
Allergies:
Compazine
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Liver mass segment II, liver mass
segment VIII, poor nutrition.
Major Surgical or Invasive Procedure:
left hepatic/caudate lobectomy, wedge of segment VII and feeding
jejunostomy [**2170-10-29**]
History of Present Illness:
Physical Exam:
At the time of admission revealed a thin woman with normal vital
signs. Examination of the head,
eyes, ears, nose, throat, neck, chest, heart, lungs, abdomen
and extremities was unremarkable except for mild evidence of
dehydration.
Pertinent Results:
[**2170-10-29**] 10:00PM HCT-40.6
[**2170-10-29**] 01:47PM GLUCOSE-158* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-20* ANION GAP-16
[**2170-10-29**] 01:47PM ALT(SGPT)-356* AST(SGOT)-921* ALK PHOS-94
AMYLASE-42 TOT BILI-2.1*
[**2170-10-29**] 01:47PM LIPASE-8
[**2170-10-29**] 01:47PM ALBUMIN-3.1* CALCIUM-8.5 PHOSPHATE-4.7*
MAGNESIUM-1.5*
[**2170-10-29**] 01:47PM WBC-11.1*# RBC-5.37# HGB-16.3* HCT-47.8
MCV-89 MCH-30.4 MCHC-34.2 RDW-16.0*
[**2170-10-29**] 01:47PM PLT COUNT-221
[**2170-10-29**] 01:47PM PT-15.1* PTT-24.7 INR(PT)-1.6
[**2170-10-29**] 01:47PM FIBRINOGE-193
[**2170-10-29**] 12:00PM TYPE-ART TIDAL VOL-390 O2-30 PO2-282*
PCO2-48* PH-7.27* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED
VENT-CONTROLLED COMMENTS-NOT SPECIF
[**2170-10-29**] 12:00PM GLUCOSE-166* LACTATE-2.8* NA+-136 K+-5.2
CL--106
[**2170-10-29**] 12:00PM HGB-15.8 calcHCT-47
Brief Hospital Course:
Pt is a 79F admitted for left hepatic lobectomy and j-tube
placement [**2170-10-29**]. Surgery was uncomplicate as patient was
extubate and fully recovered from anesthesia in PACU. She was
noted to be awake and following commands after extubation. On
post operative day 1 she was noted to be well during 6am
resident rounds but during attending rounds at approximately
9am shwe was found to have slow speech, word finding difficulty
and right side neglect. A code stroke was called at 959 am .
Evaluation by neurology found her to be awake, following
two-step commands, able toread but then perseverated (nonfluent
aphasia). Right palpebral fissure was wider than the left. Drift
right upper and lower extremity. Extinguishing to DSS left side,
right toe was upgoing. CT did not show signs of acute stroke or
hemorrhage. MRI did not show acute stroke or vessel blockage.
She was subsequently found to have lip smacking, and thus stroke
fellow asked an EEG be performed. EEG was done this AM; EEG tech
notified team that she was in nonconvulsive status epilepticus.
In the EEG lab, she was given a total of 2mg IV ativan with good
effect - EEG quieted down. In addition to the non-convulsive
seizures that have been controlled on Keppra, her hospital
course complicated with C. difficile enterocolitis treated with
oral vancomycin, a cut-surface bile leak managed with continued
JP drainage, poor oral intake managed by supplemental tube
feedings via a feeding jejunostomy placed at the time of
surgery, and an E. coli urinary tract infection treated with
levofloxacin. It was decided by tea on [**2170-11-10**] was at at
optimal condition to return home. Discharge plans was discussed
with patient and family which agreed with course of action.
Discharge Medications:
1. Tube Feeding Supplies
IV pole
feeding pump
bags
syringes for flushes
Supply: 1month Refill:2
2. Tube Feed Formula
3/4 strength Promote at 60cc/hour x12 hours qd
Supply: 1month
Refill: 2
3. Erythromycin 5 mg/g Ointment Sig: One (1) application OD
Ophthalmic QID (4 times a day) for 3 days: discontinue use
[**2170-11-12**].
Disp:*1 1* Refills:*0*
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching: for itching.
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO three times a day.
7. Levaquin 250 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: discontinue use [**2170-11-12**].
Disp:*4 Tablet(s)* Refills:*0*
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 2 weeks.
Disp:*20 Tablet(s)* Refills:*0*
13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*50 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
liver mass, necrotizing inflammatory granulomatous dz
s/p whipple [**7-/2161**]
seizure [**2170-10-31**]
hypertension
depression
dyspepsia
Discharge Condition:
stable
Discharge Instructions:
call [**Telephone/Fax (1) 673**] fevers, chills, nausea, vomiting, inability to
take medications, increased abdominal pain, increased diarrhea,
redness/pus/bleeding from incision.labs in 1 week at appointment
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 437**] in neurology in one month.
Please call [**Telephone/Fax (1) 96911**] to schedule an appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2170-11-15**] 11:00
Please have PCP consider decreasing Zoloft dosage to 25 po daily
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2170-11-28**]
|
[
"008.45",
"365.9",
"572.8",
"V10.09",
"345.3",
"570",
"997.09",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"89.14",
"50.3",
"38.93",
"03.31",
"88.74",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
4999, 5058
|
1653, 3404
|
334, 430
|
5241, 5250
|
727, 1630
|
5507, 6057
|
3427, 4976
|
5079, 5220
|
5274, 5484
|
474, 708
|
230, 296
|
459, 459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,330
| 124,852
|
3489
|
Discharge summary
|
report
|
Admission Date: [**2148-5-22**] Discharge Date: [**2148-6-4**]
Date of Birth: [**2085-9-14**] Sex: M
Service:
CHIEF COMPLAINT: Patient is a 62 year-old gentleman with
congestive heart failure with an ejection fraction of 15 to
20 percent, severe dilated cardiopathy with chronic pulmonary
hypertension who presents with class 4 heart failure
symptoms.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
gentleman with a history of severe dilated cardiomyopathy
diagnosed in [**2142**] by catheterization, at which time he was
found to have normal coronaries and elevated PA pressures of
80/45 with a cardiac output of 2.9 and 4+ mitral
regurgitation. Since the summer of [**2147**] patient has been
stable. It has been class 2 heart failure maintained on ACE
inhibitor, Lasix, Digoxin and amiodarone. In [**2148-5-15**], the patient had deterioration in his status with
increased fatigue, weight loss, and abdominal pain. Patient
was found to be H. pylori positive, treated with antibiotics
and on [**4-23**] had an esophagogastroduodenoscopy which showed
chronic inactive gastritis. At the end of [**Month (only) 547**] the patient
noted worsening of dyspnea on exertion as well as orthopnea.
Metricor and Lasix were administered. Patient was admitted
for cardiac catheterization and for inotropic therapy. At a
catheterization on the day of admission the PA pressures were
66/26. Cardiac index was 1.4. His pulmonary capillary wedge
pressure was 24. He had limited angiography but a patent
LAD. Patient was started on milrinone of .5 and his PA
pressures were 64/22 and a cardiac index of 1.9 in the
catheterization laboratory. Patient was transferred to the
Cardiac Care Unit for milrinone therapy and tailored therapy.
On arrival to the Cardiac Care Unit patient denied any chest
pain, shortness of breath, abdominal pain, palpitations,
nausea or vomiting.
PAST MEDICAL HISTORY: 1) Congestive heart failure: severe
dilated cardiomyopathy diagnosed in [**2142**], echocardiogram in
[**2148-4-15**] showed ejection fraction of 15 to 20 percent,
severe global left ventricular hypokinesis, severe global
right ventricular free wall hypokinesis, 1% atrial
regurgitation, 4+ mitral regurgitation, 2+ tricuspid
regurgitation, catheterization in [**2142**] showed normal
coronaries with a cardiac output of 2.9 and an index of 1.4.
2) History of peptic ulcer disease with H. pylori treated.
3) History of hypertension. 4) History of supraventricular
tachycardia on Holter in [**2148-1-16**]. 5) History of left
bundle and intraventricular conduction delay. 6)
Esophagogastroduodenoscopy in [**4-16**] with chronic gastritis.
7) History of positive PPD.
No known drug allergies.
SOCIAL HISTORY: Patient quit tobacco 34 years ago, no
alcohol, lives in [**Location 2268**] wit his wife and children, is a
[**Name (NI) 16042**] witness.
MEDICATIONS ON ADMISSION: Include Lasix 60 q.d., Aldactone
25 q.d., Coreg 25 b.i.d., Captopril 60 t.i.d., digoxin .125
q.o.d., Lipitor 10 q.d., Coumadin 4 q.d., Protonix 40 b.i.d.,
Carafate 1 gram q.i.d.
PHYSICAL EXAMINATION: On admission vital signs - temperature
96.7, heart rate 55 to 58, blood pressure 82/65, respiratory
rate 20, O2 saturation 98 on room air.
General: Patient is a pleasant thin, ill appearing gentleman
lying flat in no acute distress. Head, eyes, ears, nose and
throat examination: extraocular movements intact, oropharynx
dry.
Neck supple with jugular venous distention of 8 cm.
Cardiovascular: Regular rate and rhythm, normal S1 and S3,
loud s3, II/VI systolic murmur at the left upper sternal
border. Left ventricular heave.
Lungs clear to auscultation anteriorly.
Abdomen was soft, nontender, nondistended, positive bowel
sounds with mild tenderness to epigastric region but no
rebound or guarding.
Extremities: No clubbing, cyanosis or edema, 2+ pedal
pulses.
Skin: No rashes.
Neurologic examination was grossly intact.
LABORATORY STUDIES: On admission white count 5.4,
hematocrit 33.8, platelets 218, sodium 136, potassium 4.6,
chloride 100, bicarb 25, BUN 36 and creatinine 2.1, baseline
1.3 to 2.1. PTT 16.6 and INR of 1.9. ALT 25, AST 27, alk
phos 48, total bilirubin 1.0. Normal thyroid function tests.
Arterial blood gases in the catheterization laboratory of
7.43, 32 and 68.
HOSPITAL COURSE: Patient is a 62 year-old gentleman with
class 4 congestive heart failure and a severe dilating
cardiomyopathy admitted for hemodynamic monitoring and
Noridone therapy.
1. Cardiovascular - coronaries: the patient had normal
cardiac catheterization and flat CK's. No evidence of
ischemia.
Heart Failure: Patient was class 4 congestive heart
failure
and severe dilating cardiomyopathy on milrinone therapy which
was started at .4 mcg per minute which was ultimately
titrated down during the hospital course to .3 due to
hypotension. Patient remained on milrinone throughout his
hospital stay. The patient's cardiac output improved to 3.9.
He was continued on his Coreg, Captopril, amiodarone,
aldactone, Lasix, Digoxin. The dosages of these medications
were titrated down during his hospital stay due to
hypotension. He was discharged on the doses as follows.
Amiodarone 200, Lasix 20, Captopril 12.5 t.i.d., Coreg 12.5
t.i.d., Aldactone 12.5 q.d., Digoxin .0125 q.d. and Coumadin
4 q.d. The patient noted that throughout his hospital stay
his symptoms of dyspnea and gnawing abdominal pain resolved
such that he was able to ambulate multiple times daily as
well as climb stairs without experiencing any symptoms. He
had a definite improvement in his symptomatology related to
his class 4 congestive heart failure. He was seen by the EP
consultation service who decided he was not a candidate for
biventricular pacing due to his significant mitral
regurgitation, however, they agreed that a DDD pacer would be
potentially beneficial for increased heart rate to increase
the patient' cardiac output. On [**5-24**] the patient had a DDD
pacemaker placed without any complications and it has been
functioning within normal limits throughout his hospital
stay. That was placed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The Swan-Ganz
catheter was removed after the pacemaker was placed, and
patient was continued on his doses of milranone. His
symptoms and his weight were monitored closely. Patient was
evaluated by a transplant team, including Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **],
from [**Hospital 10908**] regarding the possibilities of a heart transplant in
the future. Because of chronic severe pulmonary hypertension,
transition from He The patient decided along with his family
transition from He ambulatory Heart Mate LVAD to
transplantation was recommendeundergo a heartD to
transplantation was discussed. He decided that he was not
willing to receive blood transfusion, due to his religious
beliefs, which has very high likelihood of being required as
life saving therapy during both procedures. Further discussion
of this will ensue with his family anbd religious advisors.
He was discharged home on intravenous home Milrinone therapy
and will be follow up with Dr. [**Last Name (STitle) **] of the
heart failure service and can readdress the
issues surrounding transplant at that time.
Rhythm: Patient remained in normal sinus rhythm, AV
paced after his DDD was placed on th 10th. He had no events
on telemetry during his hospital stay. He has a history of
atrial fibrillation but remained in normal sinus rhythm. He
had been on heparin prior to the DDD pacer placement, and was
restarted on Coumadin afterward. He was also continued on
his amiodarone but at a lower dose as noted above.
2. Gastrointestinal: The patient has a history of
gastritis and gnawing abdominal pain. He was continued on
his Protonix and Carafate. He was also continued on his two
gram sodium diet with full calorie and 2 liter fluid
restriction. His daily weights were monitored.Abdominal pain
resolved with improvement in hemodynamics and diuresis.
3. Renal: Patient's creatinine improved during his
hospital stay such that his creatinine returned to his
baseline prior to discharge.
4. Access: Patient initially had a Swan-Ganz catheter
placed to the groin. This was removed and he then had
peripheral intravenous access. He had a PICC line placed in
the right arm and will be discharged with the PICC line for
home milrinone therapy. Patient was noted to have an
infiltrative intravenous on the day prior to discharge in his
left forearm with erythema and induration over the area. He
was given a short course of Keflex to treat the superficial
phlebitis.
DISCHARGE DIAGNOSES:
1. NYHA Class 4 heart failure.
2. Severe dilated cardiomyopathy.
3. Hypertension, past history.
4. Chronic renal insufficiency.
5. DDD pacer.
6. Gastritis.
DISCHARGE MEDICATIONS: Amiodarone 200 p.o. q.d., Lasix 20
p.o. q.A.M., Captopril 12.5 p.o. t.i.d., Coreg 12.5 p.o.
t.i.d., Aldactone 12.5 p.o. q.d., Digoxin 0.125 p.o. q.d.,
Protonix 40 p.o. q.d., Coumadin 40 p.o. q.d., Carafate 1 gram
p.o. q.i.d., Milrinone .33 mcg per kg per minute constant
infusion, Keflex 250 p.o. q 8 hours times five days until
[**2148-6-8**].
DISCHARGE INSTRUCTIONS: Patient should have laboratories
draw every Thursday including INR, hematocrit, sodium,
potassium, BUN and creatinine. At some point he should have
a Digoxin level as well. These results should be called to
[**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 3510**] as well as Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient should
also monitor his daily weights and follow up with Dr. [**Last Name (STitle) **]
regarding weight gain or loss. Patient should follow up with
the congestive heart failure clinic in two weeks after
discharge.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2148-6-4**] 14:26
T: [**2148-6-10**] 13:51
JOB#: [**Job Number 16043**]
cc:[**Numeric Identifier 16044**]
|
[
"424.0",
"428.0",
"443.9",
"425.4",
"401.9",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.83",
"88.56",
"37.23",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
8712, 8899
|
8923, 9269
|
2904, 3083
|
4321, 8691
|
9294, 10180
|
3106, 4303
|
144, 370
|
399, 1899
|
1922, 2720
|
2737, 2877
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,307
| 131,262
|
46571
|
Discharge summary
|
report
|
Admission Date: [**2175-10-5**] Discharge Date: [**2175-10-13**]
Date of Birth: [**2100-4-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hypoxemia
Major Surgical or Invasive Procedure:
intubation
Rigid Bronchoscopy on [**10-5**] and [**10-7**]
History of Present Illness:
This is a 75 y/o F h/o anca positive vasculitis (Granulomatosis
with polyangitis) with pulmonary and renal involvement,
complicated by tracheobronchial disease with nodularity and
chronic lung collapse. She has had multiple endoscopic
procedures attempting to open her left main stem a stent placed
from [**2175-1-11**] with endobronchial steroid in the LMS due to
narrowing which was removed on [**2175-6-1**] with some temporary
improvement. She was most recently seen in pulmonary clinic
[**2175-9-26**] with inspiratory wheeze noted in the LLL with CT trachea
showing recurrent narrowing of the LMS. She went to the OR today
from home for rigid bronchoscopy with balloon dilatation,
electrocautery and intralesional steroid injection performed.
She arrived for the procedure on 5L 02 (typically only uses at
night) noted to be tachycardic). At start of procedure, left
main stem was noted to be occluded, some secretions. Had
cryotherapy performed with ablation of airway and biopsy left
mainstem lesion. Were able to open left lower lobe but did not
get good visualization of left upper lobe. 500cc IV fluid was
given during the procedure. Towards the end of the procedure she
became hypoxemic to 85% RA with low tidal volumes and was
intubated with a 7.5french tube with propofol 50mcg/kg/min. Also
received fentanyl 25mcg for autopeeping. A CXR showed completed
left lung collapse. She subsequently became hypotensive with BP
to 69/49 and was started on phenylephrine at 2:30pm with 500cc
IVF fluid bolus x 2 given. She was started on vanc/zosyn for
post obstructive PNA. Unsuccessful foley placement attempt.She
was subsequently transferred to the ICU.
On arrival to the MICU pt intubated and sedated with VS stable.
Noted to have an A line and 2x 22 guage IV.
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, 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:
- Wegener's granulomatosis: Treated with immunosuppression as
well as balloon dilations and s/p stent removal by
interventional pulmonology.
- prior bilateral mainstem balloon dilations and intratracheal
steroid injections
- Hypothyroidism
- Osteoporosis
- History of breast cancer: in [**2151**], s/p mastectomy and chemo
Social History:
Lives in [**Location 1456**] with son [**Name (NI) 122**]. Quit smoking ~50 years ago.
Denies current alcohol use. No illicit substance use.
Family History:
-Brother with [**Name (NI) 98796**] Disease
-Mother passed from sudden cardiac arrest s/p "hand procedure"
at age 75
-Father passed at 89 from "old age" with Parkinson's Disease
-Hypertension in several family members
-[**Name (NI) **] history of cancer, autoimmune diseases
Physical Exam:
Admission exam:
Vitals: T:98.2 BP: 116/62 P:86 R: 18 O2: 99%
General: intubated, sedated, unarousable, does not respond to
noxious stimuli,
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: transmitted upper airway sounds, with inspiratory and
expiratory wheeze on right, diminished breadth sounds on left.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: cool extremities, 2+ pulses, no clubbing, cyanosis or edema
Neuro: does not respond to noxious stimuli
.
Discharge Exam:
VS: 99.1F, 141/72, 86, 22, 96% on 3L
GEN: Lying in bed, NAD
HEENT: NC/AT, sclera anicteric, PERRL, EOMI. MMM, OP clear. Neck
supple, no thyromegaly, JVP not elevated. 2 vesicles on
anterior tongue, tender to palpation
CV: regular rate and rhythm. nl s1 s2.
PULM: transmitted upper airway sounds, mild diffuse ronchi and
diffuse wheezing.
ABD: +BS, NTND
EXT: left upper extremity edema improving
NEURO: A&Ox2, oriented to person and place. CN II-XII intact.
Pertinent Results:
[**2175-10-5**] 03:50PM NEUTS-90.8* LYMPHS-5.6* MONOS-3.2 EOS-0.3
BASOS-0.2
[**2175-10-5**] 03:50PM WBC-18.2* RBC-3.87* HGB-10.6* HCT-34.5*
MCV-89 MCH-27.4 MCHC-30.7* RDW-14.2
[**2175-10-5**] 03:50PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2175-10-5**] 03:50PM CK-MB-2 cTropnT-<0.01
[**2175-10-5**] 03:50PM ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-20* ALK
PHOS-86
[**2175-10-5**] 03:50PM GLUCOSE-158* UREA N-14 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-31 ANION GAP-11
[**2175-10-5**] 04:02PM TYPE-ART PO2-62* PCO2-47* PH-7.41 TOTAL
CO2-31* BASE XS-3
[**2175-10-7**] BLOOD CULTURE Blood Culture, Routine-P
[**2175-10-6**] BLOOD CULTURE Blood Culture, Routine-P
[**2175-10-5**] MRSA SCREEN MRSA SCREEN-P
[**2175-10-5**] URINE URINE CULTURE-FINAL INPATIENT
[**2175-10-5**] BRONCHIAL WASHINGS GRAM STAIN-FINAL;
RESPIRATORY CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S), GRAM
NEGATIVE ROD #2}; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY
[**2175-10-5**]- bronchial biopsy- pending
Discharge and pertinent labs:
[**2175-10-13**] 11:45AM BLOOD WBC-12.6* RBC-3.89* Hgb-10.7* Hct-34.4*
MCV-88 MCH-27.4 MCHC-31.0 RDW-14.4 Plt Ct-728*
[**2175-10-13**] 11:45AM BLOOD Plt Ct-728*
[**2175-10-13**] 07:55AM BLOOD Glucose-72 UreaN-12 Creat-0.6 Na-142
K-3.6 Cl-101 HCO3-34* AnGap-11
[**2175-10-6**] 06:55PM BLOOD CK-MB-3 cTropnT-<0.01
[**2175-10-6**] 12:52AM BLOOD CK-MB-6 cTropnT-<0.01
[**2175-10-5**] 03:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2175-10-13**] 07:55AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
[**2175-10-5**] 11:50 am BRONCHIAL WASHINGS LEFT MAINSTEM.
GRAM STAIN (Final [**2175-10-5**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2175-10-12**]):
Commensal Respiratory Flora Absent.
SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
DR. [**Last Name (STitle) **],J ([**Numeric Identifier 40113**]) REQUESTED FOR THE
Piperacillin/Tazobactam
SUSCEPTIBILITY TEST ON [**2175-10-9**] AT 5:45 PM.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML.. 2ND
STRAIN.
Piperacillin/tazobactam sensitivity testing available
on request.
.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
DR. [**Last Name (STitle) 28089**],J ([**Numeric Identifier 40113**]) REQUESTED FOR THE
Piperacillin/Tazobactam
SUSCEPTIBILITY TEST ON [**2175-10-9**] AT 5:45 PM.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
| SERRATIA MARCESCENS
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- 2 I <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- 1 S <=0.25 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2175-10-6**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2175-10-8**] 4:54 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2175-10-9**]**
C. difficile DNA amplification assay (Final [**2175-10-9**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
URINE CULTURE [**2175-10-5**] no growth
BLOOD CULTURE [**10-6**] and [**10-7**] No growth
CTA CHEST [**2175-10-6**]
1. Small pulmonary emboli are at subsegmental level in right
lower lobe.
2. The patient is known with granulomatosis polyangiitis
(Wegener's). The
disease is mostly affecting the airways with multiple chronic
area of
narrowing. Lingula collapse is new. Small tiny bulla of air
anterior to the
distal main bronchus could be related to microperforation
secondary to recent
bronchoscopy.
3. Multiple areas of consolidation and bronchiolar opacities
are new, mostly
in bilateral lower lobes. This could be a mix of pneumonia,
aspiration and
hemorrhage.
4. Multiple sclerotic foci in the spine have appeared between
[**2173**] and [**2174**],
but is stable since [**2174**]. This patient has prior breast cancer.
The lesions
have already been investigated with MRI and bone scan and were
negative on
bone scan. Considering the fact that they have not evolved,
they could be
related to the vasculitis, although healed metastases are not
excluded.
LOWER EXTREMITIES DOPPLER US [**2175-10-8**]:
IMPRESSION: No evidence of deep vein thrombosis.
UPPER EXTREMITY ULTASOUND: [**2175-10-8**] Partially occlusive thrombus
of the left basilic vein surrounding
the IV line.
CXR [**2175-7-8**]:
1. Multifocal basilar-predominant consolidation and diffuse
ill-defined
nodular opacities, similar to prior study. Findings are
compatible with
multifocal pneumonia possibly coexisting with pulmonary
hemorrhage in this
patient with known vasculitis.
2. Moderate left and small right pleural effusion are similar
to prior.
3. Left midline catheter now terminates at the junction of the
axillary and
subclavian veins.
Brief Hospital Course:
75 y/o F with history of Granulomatosis with polyangitis
complicated by tracheobronchial disease presenting to the ICU
following post procedural intubation with course complicated by
sepsis, serratia post-obstructive pneumonia.
# Hypoxemic and hypercarbic respiratory failure: On imaging she
had left lung collapse with difficulty on initial rigid
bronchoscopy in opening up left mainstem. She became hypoxemic
after initial extubation in the PACU and was thus re-intubated
and sent to the MICU. Given a suspected postobstructive PNA she
was treated initially with vanc/zosyn and subsequently zosyn
alone. In order to guide further intervention of her left
mainstem occlusion, she had a CTA to define the pulmonary and
tracheobronchial architecture. She went back to the OR for
repeat rigid bronchoscopy no stent placed, but had therapeutic
aspiration of secretions and debridement of scar tissue with
recannalisation of left upper and lower lobe segments. Bronchial
washings grew Serritia Marcenscens. Patient was weened off of
ventilator and transfered to the floor on [**10-8**]. She will follow
up with her interventional pulmonologist Dr [**Last Name (STitle) **] as an
outpatient. She will finish a 14d antibiotic course with
levofloxacin and flagyl.
# Hypotension: Pt developed hypotension periprocedurally
initially thought to be secondary to propofol but this persisted
despite switching to fentanyl and versed for sedation. She
required pressor support with neosynephrine and then levophed
initially and she received fluid resuccitation. She had a known
pneumonia, blood and urine cultures were also sent to evaluate
for infection. She received stress dose steroids and her blood
pressures improved with weaning off of pressors.
# Post-Obstrucive Pneumonia Complicated by Septic Shock:
Elevated WBC in MICU with hypotension. CT chest showed multiple
areas of consolidation and bronchiolar opacities. Bronchial
washing with >10,000 Serratia Marcescens. Patient initially
treated with Vancomycin and Zosyn started on [**10-5**], subsequently
Zosyn alone. BP normalized after antibiotics and stress dose
steroids and WBC trended down. On the floor, patient had one
episode of desaturation down to 85%. Resolved after nebs x 2.
Patient's O2 saturation remained stable afterwards and her O2
demanded continued to trend towards baseline. On [**10-11**] patient
started on PO Levofloxacin and Flagyl and will complete 14 day
course on [**10-20**].
# mucus plugging: she had an episode of tachypnea and wheezing
on the floor that responded to nebs and chest PT. She tends to
mucus plug and needs aggressive chest PT, incentive spirometry.
# Granulomatosis with polyangitis: She hs On last evaluation in
pulmonary clinic clinically appeared to be doing well although
with radiographic evidence of narrowing of LMS. Has extensive
pulmonary disease with bronchial and parenchymal involvement
with granulomas and copious secretions. She has had multiple
endoscopic procedures particularly to address occlusion of the
left main stem and had 2 such procedures this admission. She was
continued on her home prednisone 15mg daily, advair,
ipratropium, albuterol and prophylaxis with atovaquone.
# Left Upper Extremity DVT: 2 days after midline placed, her
left arm appeared swollen. Doppler showed thrombis around her
midline in the Brachial vein. Midline removed. Patient was not
anticoagulated.
# Pulmonary Embolism. CTA [**10-6**] showed a small pulmonary emboli
are at subsegmental level in right lower lobe. BLENIs were
negative. A decision was made not to anticoagulate due to the
risk of bleeding secondary to both inflammation in the airways
and mechanical injury secondary to rigid bronchoscopies.
# Orolabial HSV: started acyclovir for suspected HSV infetion
of tounge. will end [**10-17**]. viscous lidocaine used for pain
relief.
# Diarrhea: She developed diarrhea while in the ICU. No
abdominal pain. C diff negative. Likely secondary to
antibiotics. Diarrhea improved during the course of the
hospitalization.
# Bradycardia: she had initial tachycardia when she arrived from
home for her IP procedure. During her MICU stay she became
bradycardic and was found on EKG to have a QTC in the 500s.
Electrolytes were repleted and ultimately this was thought to be
a vagal response to suctioning and airway irritation from
procedure. Cardiac enzymes remained flat and serial ekgs
normalized.
# Anemia: Initial drop in HCT from 41.6 [**9-5**] to 34.5 on
admission (but baseline ~ 38). HCT remained stable subsequently.
#Lower extremity edema: no hx CHF with EF [**2174**] 60-65%, mild
pulmonary artery HTN
Lasix held in MICU and restarted on the floor.
# s/p Breast cancer treated with mastectomy, right
lympadenectomy and chemotherapy in [**2143**]. Currently stable with
no signs of remission.
# Hypothyroidism: continued synthroid.
PENDING TESTS ON DISCHARGE:
-ESR AND CRP
TRANSITIONAL ISSUES:
-followup with rheum to decide further immunosuppression due to
recurrent airway closure from granulation tissue from wegeners
-completion of anitbiotics levaquin and flagyl [**10-20**]
-acyclovir for 5d ending [**10-17**]
-aggressive nebs and incentive spirometry.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Alendronate Sodium 70 mg PO 1X/WEEK ([**Doctor First Name **])
2. Atovaquone Suspension 750 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
5. Furosemide 20 mg PO DAILY
6. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q6h:PRN sob/wheeze/cough
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Lorazepam 0.5 mg PO BID:PRN anxiety
9. Omeprazole 20 mg PO HS
10. PredniSONE 15 mg PO DAILY
11. Vitamin B Complex 1 CAP PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
13. Guaifenesin ER 1200 mg PO Q12H
14. Ocuvite Lutein *NF* (vit C-vit E-lutein-minerals) 1 tab Oral
daily
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Omeprazole 20 mg PO HS
9. PredniSONE 15 mg PO DAILY
10. Vitamin B Complex 1 CAP PO DAILY
11. Acyclovir 400 mg PO Q8H
day 1 = [**10-12**]. last day of 5 day course on [**10-17**].
12. Alendronate Sodium 70 mg PO 1X/WEEK ([**Doctor First Name **])
13. Guaifenesin ER 1200 mg PO Q12H
14. Ocuvite Lutein *NF* (vit C-vit E-lutein-minerals) 1 tab Oral
daily
15. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last day of course [**10-20**].
16. Lidocaine Viscous 2% 20 mL PO TID:PRN mouth pain
17. Levofloxacin 750 mg PO DAILY
day 1 of antibiotic course [**2175-8-4**].
last day of course [**8-19**].
18. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob, wheezing
19. Ipratropium Bromide Neb 1 NEB IH Q4H
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Hypoxemic and hypercapnic respiratory failure
Granulomatosis with polyangitis
Post-obstructive pneumonia complicated by septic shock
small subsegmental pulmonary embolus (NOT on anticoagulation due
to airway bleeding)
orolabial HSV infection
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:
Ms. [**Known lastname 98795**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted after a rigid bronchoscopy procedure for respiratory
and blood pressure support in the ICU. During the course of your
stay you had to have 2 rigid bronchoscopy procedures to open
your airways.
Results from the first bronchoscopy showed you had a pneumonia.
You were transitioned from IV antibiotics to antibiotics by
mouth during the hospital stay. Your breathing, white blood cell
count, and blood pressure all improved after antibiotics.
Please continue your antibiotics.
MEDICATION
STARTED levofloxacin
STARTED metronidazole
Continue to use your nebulizer treatments every 2-4 hours as you
clear the mucus from your airways.
STARTED acyclovir for 5 total days due to mouth infection
Please follow up with your physicans as noted below. Please also
follow up with Dr. [**Last Name (STitle) **] after your are done with rehab.
We wish you a speedy recovery.
Followup Instructions:
Department: RHEUMATOLOGY
When: FRIDAY [**2175-10-20**] at 11:00 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2175-10-24**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: TUESDAY [**2175-11-14**] at 11:20 AM
With: RADIOLOGY [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2010**] when you get out of
rehab.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2175-10-15**]
|
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|
2990, 3133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,790
| 182,635
|
13065
|
Discharge summary
|
report
|
Admission Date: [**2149-12-2**] Discharge Date: [**2149-12-9**]
Date of Birth: [**2072-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
CABGx1(LIMA-LAD) MV repair [**12-4**]
History of Present Illness:
77 yo male with worsening SOB and fatigue. Cath with 1 vessel
disease, echo with 3+ MR.
Past Medical History:
DM, HTN, ^chol, chronic AF, CRI, psoriasis, s/p sigmoid
resection '[**17**], s/p polypectomy, s/p ex lap/LOA '[**95**]
Social History:
retired engineer
denies tobacco
[**3-2**] etoh/day
Family History:
no premature CAD
Physical Exam:
HR 60 RR 16 BP 100/60
Elderly male in NAD
non-healing wound Left shin, very mild cellulitis
teeth in poor repair
Lungs CTAB
Heart RRR, SEM
Abdomen soft, NT, ventral hernia
Extrem 2+ edema
Pulses 2+ t/o
Bilat carotid bruits
Pertinent Results:
[**2149-12-9**] 03:26AM BLOOD WBC-9.2 RBC-3.05* Hgb-9.9* Hct-29.4*
MCV-96 MCH-32.4* MCHC-33.7 RDW-16.6* Plt Ct-182#
[**2149-12-7**] 01:05AM BLOOD WBC-17.0* RBC-2.99* Hgb-9.6* Hct-29.4*
MCV-98 MCH-32.2* MCHC-32.8 RDW-17.0* Plt Ct-105*
[**2149-12-9**] 03:26AM BLOOD Plt Ct-182#
[**2149-12-9**] 03:26AM BLOOD PT-15.3* INR(PT)-1.3*
[**2149-12-9**] 03:26AM BLOOD Glucose-66* UreaN-46* Creat-1.2 Na-146*
K-3.6 Cl-108 HCO3-29 AnGap-13
CHEST (PORTABLE AP) [**2149-12-6**] 3:58 PM
CHEST (PORTABLE AP)
Reason: s/p CT pull
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with
REASON FOR THIS EXAMINATION:
s/p CT pull
UPRIGHT CHEST X-RAY
Comparison to [**2149-12-4**], the Swan-Ganz catheter as well
as the chest tubes are in the left hemithorax, and the
nasogastric tube and endotracheal tube have been withdrawn. The
cardiac silhouette is still slightly enlarged. No pleural
effusion. Retrocardiac atelectasis. No signs of overhydration.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 4174**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 39950**] (Complete) Done
[**2149-12-4**] at 10:09:38 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2072-8-9**]
Age (years): 77 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Atrial fibrillation. Congestive heart
failure. Coronary artery disease. Hypertension. Mitral valve
disease. Palpitations. Shortness of breath.
ICD-9 Codes: 402.90, 427.31, 786.05, 440.0, 424.0
Test Information
Date/Time: [**2149-12-4**] at 10:09 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 12 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Pericardium - Effusion Size: 0.3 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. Cannot exclude LAA
thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. Overall normal LVEF (>55%). [Intrinsic LV systolic
function likely depressed given the severity of valvular
regurgitation.]
RIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Normal
RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Simple
atheroma in ascending aorta. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No valvular AS. The increased transaortic
velocity is related to high cardiac output. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. No MS. Moderate (2+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is moderately dilated. A left atrial
appendage thrombus cannot be excluded. No atrial septal defect
is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.]
3. The right ventricular free wall is hypertrophied. Right
ventricular chamber size is normal. Right ventricular systolic
function is normal.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no valvular aortic
stenosis. The increased transaortic velocity is likely related
to high cardiac output. No aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen. The vena contracta measures
.45 cm. There is both anterior and posterior leaflet retraction
with a dynamic central to posteriorly-directed jet. There is
dilation of the mitral annulus which measures 3.4 cm.
7. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of phenylephrine. Well-seated annuloplasty
ring in the mitral position. No MR. Normal LV systolic
fiunction. LVEF now 60%. Aortic contour normal post
decannulation.
Brief Hospital Course:
He was admitted preoperatively. He was seen by electrophysiology
for bradycardia/atrial fibrillation on admission and his digoxin
and atenolol were discontinued. He was also seen by sleep
medicine after periods of apnea were noted preoperatively, and
he will need outpatient follow up approximately four weeks after
discharge. He was taken to the operating room on [**2149-12-4**] where
he underwent a CABG x 1 and MV Repair. He was transferred to the
ICU in critical but stable condition. He was extubated on POD
#1. He was given 48 hours fo vancomycin as he was in the
hospital preoperatively. He was seen by [**Last Name (un) **] for
hyperglycemia, and was started on Lantus. His chest tubes and
wires were pulled without incident. He remained in the ICU
because there were no beds on the floor. He was ready for
discharge to rehab on POD #5.
Medications on Admission:
coumadin, cozaar 100', atenolol 50', felodipine 10', dig .125',
zocor 10', bumex 3', hytrin 5', tekturn(?)300', proscar 5',
NPH70/30 30a/25p
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Bumetanide 2 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: check INR [**12-10**] and dose accordingly. Goal INR [**2-1**]
for a fib.
11. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous once a day.
12. Insulin Lispro 100 unit/mL Solution Sig: liding scale units
Subcutaneous every six (6) hours.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
CAD, MR s/p CABG/MVR
DM, HTN, ^chol, chronic AF, CRI, psoriasis, s/p sigmoid
resection '[**17**], s/p polypectomy, s/p ex lap/LOA '[**95**]
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 14522**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2149-12-9**]
|
[
"585.9",
"357.2",
"424.0",
"780.57",
"403.90",
"428.0",
"250.60",
"414.01",
"427.89",
"285.21",
"427.31",
"272.0",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"35.33",
"39.63",
"99.04",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9045, 9160
|
6944, 7791
|
340, 380
|
9344, 9352
|
1000, 1517
|
9651, 9763
|
723, 741
|
7982, 9022
|
1554, 1575
|
9181, 9323
|
7817, 7959
|
9376, 9628
|
5268, 6921
|
756, 981
|
281, 302
|
1604, 5219
|
408, 497
|
519, 639
|
655, 707
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,277
| 100,977
|
35322
|
Discharge summary
|
report
|
Admission Date: [**2187-4-18**] Discharge Date: [**2187-5-29**]
Date of Birth: [**2141-8-1**] Sex: M
Service: SURGERY
Allergies:
Azithromycin
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Liver failure
Major Surgical or Invasive Procedure:
[**2187-4-26**] Cadaveric liver transplant with splenectomy
using ABO incompatible liver.
[**2187-4-27**] ex lap, wash out,
plasmapheresis
hemodialysis
[**2187-5-7**] IR drainage of splenic fossa
[**2187-5-11**] transjugular biopsy
[**2187-5-14**] ERCP
[**2187-5-18**] collection drain placed in splenic fossa
[**2187-5-18**] hepatic artery angio
[**2187-5-21**] liver biopsy
ercp
History of Present Illness:
45M with a one month history of jaundice and progressive liver
failure. Pt states that he first starting noticing that he had
low energy last summer. He is the owner of an auto repair and
sales business and noted that he was having to sleep all day on
his days off starig last summer which was unusual for him. The
first week of [**Month (only) 956**], he went to the dentist and was referred
to his PCP because they notes jaundice. His PCP did basic liver
function test and referred him to a hepatologist who
subsequently referred him for liver biopsy that was performed on
[**2187-4-9**]. The patient was not scheduled to follow-up with his
hepatologist until [**4-30**], however, his father suggested that he
see another hepatologist sooner. The patient then was seen at
Brown. He has been followed daily since last Friday and was
transferred to [**Hospital1 18**] today in the setting of worsening renal
failure on top of liver failure.
The patient has a history of heavy drinking. He last drank in
[**Month (only) 956**] when his liver failure was diagnosed. At that point,
he drank [**3-6**] glasses of wine perday. He admits that he used to
drink to excess and that he would consistently drink close to a
6pack of beer a day. He also has a remote history of cocaine
and marijuana use. He smoked 1ppd until this diagnosis. He
denies any foreign travel. He has no sick contacts. [**Name (NI) **] did eat
raw oysters the Sunday before he saw his dentist, though no one
else who dined with him got sick. Pt also used to abuse
percocet and vicodin in combination with alcohol. He states
that he stopped doing this when he learned that this could be
bad for the liver several years ago.
In the ED, vitals 96.9 134/97 83 14 100% RA. The patient's labs
were significant for transaminases in the thousands, Tbili of 50
and a Cr of 3.0. Ammonia level 101. RUQ ultrasound performed.
On arrival to the ICU, vitals 97.2 73 150/93 15 99% RA. Pt
states that he was some abdominal pain, constipation, and
reflux. ROS positive for mild headache, shortness of breath for
the last 2-3 days, orthopnea since Monday, reflux, lower
abdominal pain and distention, constipation, pale stools, [**Location (un) 2452**]
urine, dry, itchy skin and worsening short term memory.
Past Medical History:
Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use
Social History:
Divorced, 3 children. Owns own auto repair and sale business.
Smoked 1 ppd for 20+ years, discontinued with onset of jaundice.
H/o alcohol abuse. Recently drank a couple glasses of wine or
beer with dinner discontinued with onset of jaundice. Remote
history of vicodin and percocet abuse. Remote history of
marijuana and cocaine use. Ate raw oysters the Saunday before
he was found to be jaundiced. Remote history of using
supplements from GNC. No IVDU, risky sexual behavior or
tattoos. No sick contacts. [**Name (NI) **] foreign travel.
Family History:
No liver disease.
Physical Exam:
97.3 75 152/91 18 O2 99%
nad, a&o
scleral icterus
neck supple
lungs clear
cor RRR
abd soft, distended, non-tender, nonrigid, exam positive for
shifting dullness
skin jaundiced
ext no edema
RUQ U/S gallbladder wall thickening likely secondary to
hepatitis with small amount of ascites. no intra or extra
hepatic bile duct dilatation or other son[**Name (NI) 493**] findings to
suggest acute cholecystitis. no hydronephrosis.
Pertinent Results:
[**2187-4-18**] 03:10PM WBC-11.8* RBC-5.13 HGB-16.6 HCT-47.2 MCV-92
MCH-32.4* MCHC-35.3* RDW-20.4* NEUTS-72.2* LYMPHS-20.3 MONOS-6.0
EOS-1.0 BASOS-0.5
[**2187-4-18**] 03:10PM GLUCOSE-120* UREA N-52* CREAT-3.0* SODIUM-138
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-20* ANION GAP-22*
[**2187-4-18**] 03:19PM LACTATE-2.7*
[**2187-4-18**] 03:10PM TOT PROT-4.8* ALBUMIN-3.7 GLOBULIN-1.1*
CALCIUM-9.7 PHOSPHATE-4.8* MAGNESIUM-3.0*
[**2187-4-18**] 03:54PM PT-28.5* PTT-44.0* INR(PT)-2.9*
[**2187-4-18**] 03:10PM ACETMNPHN-NEG
[**2187-4-18**] 03:10PM ETHANOL-NEG
Brief Hospital Course:
45y.o. M with hepatic failure of uncertain etiology and renal
failure transferred to [**Hospital1 18**] MICU for further work-up and
evaluation. Initially liver failure was of unknown etiology.
Autoimmune panels were negative. Biopsy was consistent with
viral hepatitis vs toxin or drug injury. He did consume raw
oysters the Sunday prior to the onset of jaundice. Slit lamp
eval for [**Last Name (un) 80544**]-[**Last Name (un) 23070**] rings was negative. Hepatitis E IgM
came back positive. There was also some thought that Zithromax
may have contributed to acute liver failure as he had taken this
prior to admission. A liver transplant evaluation was done. He
was listed as status 1.
He developed worsening hepatic function with consequent
encephalopathy. Ultimately, on [**4-23**], a right frontal bolt was
placed to monitor ICP pressures. On [**4-24**], the bolt was
repositioned. Hepatorenal syndrome developed. On [**2187-4-26**] an ABO
incompatible liver offer was available. His family consented to
transplant offer. Prior to transplant, he received
plasmapheresis. On [**2187-4-26**], he underwent cadaveric liver
transplant with splenectomy using an ABO incompatible liver.
Surgeons were Drs [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to
operative notes. He received multiple blood products to maintain
hemodynamic stability. On [**4-27**], JP started pouring out blood.
He was taken back to the OR for exploration,washout, control of
hemorrhage and abdominal closure. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
Postop, he returned to the SICU.
Hemodialysis was initiated on [**4-28**] for ATN on HRS and
discontinued as renal function improved. On [**4-29**] the bolt was
removed after receiving platelets and head CT was negative for
bleed. On [**5-2**], he was extubated.
Plasmapheresis continued based on anti-A titers for 5 treatments
postop. Liver u/s on [**5-4**] showed small perihepatic fluid; nl flow
and waveforms. On [**5-12**] liver U/S showed normal vasculature with
trace perihepatic fluid. LFTs started to trend up and a
transjugular biopsy was performed on [**5-11**] showing moderate
cholestasis and no rejection.
A total of 7 doses of ATG (125mg x5 and 75mg x2 due to lower wbc
counts)were given. Steroids were tapered per protocol. Prograf
was started on postop day 1 and titrated per trough levels.
Cellcept 1 gram was given [**Hospital1 **] until around postop day 26/16 when
he complained of nausea. Dose was divided into 500mg qid with
decreased complaints of nausea.
On [**5-4**] neurology was consulted for confusion. CT of head/neck
was wnl. He was following commands, but was disoriented,
confused and weak. He appeared encephalopathic with waxing and
[**Doctor Last Name 688**] mental status likely related to hepatic and renal
insufficiency. Given elevated wbc there was concern for
underlying infection. Weakness was likely from ICU
stay/myopathy. He also developed hyponatremia requiring free
water boluses. Flagyl was added for empiric c.diff. Several
stools were negative for c.diff and flagyl was stopped after 5
days. Speech evaluated at the bedside and recommended npo status
due to signs of aspiration. TPN was initiated then switched to
tube feeds. A post pyloric feeding tube was inserted for feeds
on [**5-2**].
An abd CT on [**5-6**] revealed a LUQ fluid collection in splenic bed.
A # 6 drain was placed into this LUQ collection on [**5-7**]. Vanco
and zosyn were started on [**5-6**] and continued thru [**5-10**]. Repeat Abd
CT on [**5-11**] showed unchanged splenic bed collection, bowel wall
thickening resolution, no obstruction, and b/l pleural effusions
with b/l atelectasis vs pneumonia. On [**5-16**], he was transfered
out of the SICU.
LFTS started to increase with a steady trend up of the alk phos
as high as 1400. Liver duplex was normal. CTA was done on [**5-17**]
which was a suboptimal exam of the distal hepatic artery, but
the proximal to mid hepatic artery was patent. Hepatic Artery
Angio was then done showing a patent hepatic artery anastamosis
with an irregular pattern of donor artery, normal parenchyma
enhancement. A biopsy was then performed on [**5-21**] revealing
moderate to severe cholestasis with foci of associated
hepatocellular necrosis. There was no cellular rejection noted.
On [**5-14**], ERCP was done showing no leak or stricture. There was
concern that cholestasis was due to either bactrim or
fluconazole. Both of these were stopped on [**5-19**]. Ursodiol was
also started. Gradually, LFTs improved with alk phos dropping
into the 600 range. On [**5-25**], a pentamidine treatment (bactrim
replacement) was attempted, but he was unable to complete
treatment due to nausea. He did receive a complete Pentamidine
treatment on [**5-28**].
He experienced several days of nausea with some vomiting. KUB on
[**5-22**] was negatie for ileus or obstruction. It was discovered
that the feeding tube had dislodged and was coiled in his
esophagus. This was removed and remained out. Nausea resolved
and he was able to take in a sufficient kcal count to warrent
cessation of the tube feeds.
On [**5-24**], a repeat abdominal CT was done to evaluate the splenic
bed collection given concern for drain culture that grew coag
neg staph. Drain fluid amylase was 10,840. CT showed splenic bed
collection gone with drain in place. A new infrahepatic
collection measuring 5x7cm was seen near the porta, but was
ammenable to drainage only thru a trans liver approach. Becausea
of this, CT drainage was not done. He was afebrile and WBC was
stable. In fact the wbc decreased.
Mental status improved allowing for medication teaching. He
worked with PT extensively. [**Hospital 38439**] rehab was recommended,
but he became independent with ambulation. He was declared safe
to discharge to home.
He had developed a sacral deep tissue injury while in the SICU
that initially measured 4cm x 1.5cm x .5 cm. This was treated
with commercial cleanser then duoderm gel followed by Mepilex
dressing q 72. Wound bed appeared clean with some fibrin making
the wound non-stageable. Size improved to 3cmx 1cmx 0.5cm. The
pigtail drain in the slenic bed was left in place with an
average output of 10cc. Abdomen was soft, non-distended and
transplant incision was intact without erythema/drainage.
VNA Care NE ([**Telephone/Fax (1) 80193**]was arranged. His parents were very
involved and he was discharged home to stay with them initially.
At time of discharge, vital signs were stable.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
9. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): started [**5-26**].
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): prevents fungal mouth infection.
Disp:*600 ML(s)* Refills:*1*
13. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous three times a day.
Disp:*1 bottle* Refills:*1*
14. syringes
Insulin low dose syringes qid for humalog sliding scale insulin
25 gauge
supply 1 box
Refill 1
15. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous three times a day.
Disp:*1 kit* Refills:*0*
16. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*1*
17. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*1*
18. NovaSource Renal Liquid Sig: Eight (8) ounces PO three
times a day.
Disp:*42 cans* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
acute liver failure
Hepatitis E
ABO incompatible liver transplantsplenectomy
cholestasis, medication related
Abdominal fluid collection near splenic bed
abdominal fluid collection near porta, undrained
malnutrition
sacral decrubitus
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications or
eat, jaundice, abdominal distension, incision/drain site
redness/drainage or any concerns
Empty abdominal drain and record output. Bring record of output
to next appointment in Transplant Office.
Labs every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-6-4**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-6-11**]
9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2187-6-11**]
10:00
Completed by:[**2187-5-31**]
|
[
"263.9",
"276.1",
"359.81",
"707.03",
"576.8",
"707.25",
"287.5",
"584.5",
"570",
"998.11",
"572.2",
"511.9",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.08",
"00.93",
"39.95",
"88.47",
"50.13",
"96.72",
"01.10",
"50.59",
"54.12",
"96.6",
"51.10",
"41.5",
"50.11",
"54.91",
"99.71"
] |
icd9pcs
|
[
[
[]
]
] |
13308, 13371
|
4711, 11332
|
285, 668
|
13647, 13654
|
4119, 4688
|
14073, 14524
|
3636, 3655
|
11387, 13285
|
13392, 13626
|
11358, 11364
|
13678, 14050
|
3670, 4100
|
232, 247
|
696, 2978
|
3000, 3055
|
3071, 3620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,165
| 161,830
|
5209+5210
|
Discharge summary
|
report+report
|
Admission Date: [**2200-4-19**] Discharge Date: [**2200-4-24**]
Date of Birth: [**2143-4-16**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 57-year-old woman
with history of metastatic colon cancer, diabetes mellitus,
end-stage renal disease, and hemodialysis. She was admitted
to the Medical Intensive Care Unit for increasing confusion.
She was found to be in a hypo-osmolar, nonketotic state. The
patient was treated with IV Insulin and carefully monitored
for serum glucose and electrolytes. Over the course of her
Medical Intensive Care Unit stay she was followed by the
[**Last Name (un) **] Staff and her mental status improved slowly with
better control of her blood glucose and decreasing gap.
Given her recent history of falls at home and weakness, head
CT was performed, which was negative. Antihypertensives were
held given low systolic blood pressure. The patient
continued to receive hemodialysis during the course of her
stay in the Medical Intensive Care Unit. She was
subsequently transferred to the [**Hospital1 139**] Firm for further care.
On the floor, the patient's mental status cleared over the
course of time. The patient was unclear regarding time,
course of her symptoms that lead to MICU admission. The
patient does report fluctuating blood glucoses in the past
few months. She reports poor appetite and some nausea. She
denies cough, fevers, chills, or chest pain.
PAST MEDICAL HISTORY:
1. Colon cancer diagnosed in [**2194**] with metastasis to liver,
lymph node, and bone, status post chemotherapy. The patient
has a Port-A-Cath. Status post RFA to liver.
2. End-stage renal disease on hemodialysis on Tuesday,
Thursday, and Saturdays.
3. Diabetes mellitus.
MEDICATIONS ON TRANSFER TO THE FLOOR:
1. NPH insulin.
2. Regular insulin sliding scale.
3. Renagel.
4. Calcium acetate.
5. Sertraline.
6. Docusate.
7. Oxycodone.
8. Phenergan.
9. Reglan.
SOCIAL HISTORY: The patient is on disability, previously a
business manager. The patient lives alone. The patient has
friends who help her out with activities of daily living.
PHYSICAL EXAMINATION: Examination on transfer revealed
temperature of 98; pulse of 68; blood pressure 129/52;
respiratory rate 13; saturation 98% on room air. GENERAL:
The patient was alert and oriented times three. The patient
is tired. HEENT: Pupils were equal and reactive to light.
Extraocular muscles are intact. No lymphadenopathy.
PULMONARY: Bibasilar crackles. CARDIOVASCULAR: S1 and S2,
regular rate and rhythm. ABDOMEN: Soft and nontender,
nondistended, positive bowel sounds. EXTREMITIES: There was
no cyanosis, erythema, edema. NEUROLOGICAL: Cranial nerves
II through XII intact.
LABORATORY DATA: Upon transfer, the white blood cell count
was 7, hematocrit 40, platelet count 219,000, sodium 138,
4.1, chloride 104, bicarbonate 22, BUN 30, creatinine 4.8,
glucose 82.
HOSPITAL COURSE:
#1. ENDOCRINE: The [**Hospital 228**] Medical Intensive Care Unit
course was outlined in the history of present illness portion
of this discharge summary. On the floor, the patient's
mental status remained clear. The patient's blood sugars
were well controlled on her NPH and sliding scale regimen.
The patient will continued to be followed by the [**Last Name (un) **]
Staff. The patient's appetite increased over the course of
her stay in the hospital.
#2. RENAL: The patient continued to receive hemodialysis.
#3. CARDIOVASCULAR: The patient remained normotensive and,
therefore, her antihypertensives were not continued on the
floor.
#4. ONCOLOGY: The patient was seen by the Oncology Staff
and no intervention was recommended at this time.
DISCHARGE DIAGNOSES: Hyperosmolar nonketotic state leading
to mental status changes in the setting of uncontrolled blood
sugars.
DISCHARGE MEDICATIONS:
1. Megace 400 mg p.o.b.i.d.
2. Reglan 5 mg p.o.q.4h. to 6h.p.r.n.
3. Colace 100 mg p.o.b.i.d.
4. Oxycodone 5 mg p.o.q.4h. to 6h.p.r.n.
5. Sertraline 50 mg p.o.q.d.
6. Sevelamer 1600 mg p.o.t.i.d.
7. Prochlorperazine 10 mg p.o.q6h.p.r.n.nausea.
8. Calcium acetate two tablets p.o.t.i.d.
9. Senna one tablet p.o. b.i.d.
10. Regular insulin sliding scale.
11. NPH insulin 5 units subcutaneously at bedtime and 9 units
subcutaneously at breakfast.
CONDITION ON DISCHARGE: Stable. The patient was discharged
to [**Location (un) 2716**] Point Rehabilitation. The patient is to followup
in [**Last Name (un) **] upon discharge from [**Location (un) 2716**] Point Rehabilitation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2200-4-24**] 12:23
T: [**2200-4-24**] 12:42
JOB#: [**Job Number 21305**]
Admission Date: [**2200-4-19**] Discharge Date: [**2200-4-24**]
Date of Birth: [**2143-4-16**] Sex: F
Service: [**Hospital Unit Name 16129**] OF PRESENT ILLNESS: This is a 58 year-old female
with colon cancer with metastases to the liver, bone and
lymph nodes, diabetes mellitus and end stage renal disease
who presented to the Emergency Room, because of an episode of
atrial fibrillation that occurred during hemodialysis. She
chest pain and shortness of breath. She was given 5 mg
intravenous times three of Lopressor, nitroglycerin times
three and morphine times one to relieve the pain. She is
sent to the Emergency Room where she is DC cardioverted with
three shocks 300, 360, 360 and converted into normal sinus
rhythm. Since on the floor she described some chest pain,
which resolved spontaneously with no event on telemetry. She
Emergency Room and it is unclear if this is prior or after
receiving her medications.
PAST MEDICAL HISTORY: Significant for colon cancer with
metastases to liver, bone and lymph nodes. She is status
post chemotherapy with a Port-A-Cath and status post RFA to
the liver. She has diabetes mellitus and has a tendency to
go into hyperosmotic nonketotic coma. She has end stage
renal disease for which she takes hemodialysis three times a
week.
ALLERGIES: She has no known drug allergies.
MEDICATIONS: NPH insulin 14 units in the a.m. and 7 units
subQ in the p.m., regular insulin sliding scale, Renagel,
calcium acetate 100 mg b.i.d., Sertraline 50 mg q day,
Decussate, Oxycodone, Phenergan, Reglan 5 mg q 4 to 6 prn,
Phos-Lo, Megace 400 b.i.d.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She lives at [**Doctor Last Name 21306**]nursing home. She
does not drink alcohol or smoke tobacco. Her oncologist is
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
PHYSICAL EXAMINATION: Temperature 99.5. [**Last Name (NamePattern1) **] pressure
90/40. Pulse 80. Respirations 20. 98% on 2 liters. Her
heart she had a systolic murmur heard best on the right
sternal border. Lungs upper lung fields clear, some
decreased breath sounds at the left lower lobe with some
rhonchi. Abdomen soft, nontender, nondistended. No rash.
Extremities no clubbing, cyanosis or edema.
ASSESSMENT: This patient had new onset atrial fibrillation,
which converted spontaneously. We kept her telemetry to
monitor. A TSH was obtained and an echocardiogram was
obtained.
HOSPITAL COURSE: Her CPKs and troponins were negative ruling
her out. The chest x-ray was clear and the echocardiogram
was clear with an ejection fraction of 60%. Her TSH is still
pending. She did have an episode of slight hyperkalemia at
5.1, however, the OMR provides evidence that this is somewhat
of a chronic problem. [**Name (NI) **] [**Name2 (NI) **] sugar ran high in the high
300 and low 400s at which point her insulin dose was
adjusted.
Social issues included the patient's desire to go to hospice
upon discharge. This was arranged that she would start
hospice the Monday following discharge. Her hemodialysis was
rescheduled for the morning of [**2200-5-17**] after which point she
was discharged.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
Atrial fibrillation converted.
DISCHARGE MEDICATIONS: Same as admission medications.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1730**] 12-607
Dictated By:[**Last Name (NamePattern1) 21307**]
MEDQUIST36
D: [**2200-5-16**] 23:49
T: [**2200-5-19**] 07:29
JOB#: [**Job Number 21308**]
|
[
"198.5",
"518.0",
"197.7",
"276.7",
"153.9",
"585",
"250.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7980, 8016
|
6420, 6438
|
3714, 3823
|
8093, 8369
|
8037, 8069
|
7257, 7958
|
6666, 7239
|
5761, 6403
|
6455, 6643
|
4325, 5738
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,416
| 171,128
|
19971
|
Discharge summary
|
report
|
Admission Date: [**2149-2-16**] Discharge Date: [**2149-2-27**]
Service: MEDICINE
Allergies:
Pravachol / Lipitor
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 40553**] is an 88yoF with h/o Alzeihmer's dementia who p/w SOB
and new onset productive cough that started as a dry cough 3
days prior. She has had this since awakening this AM, worsening
throughout the day. EMS called for rr30's, SaO2 80's, but
afebrile by report. No O2 sat recorded there but 86% on RA per
EMS. Pt denies CP. States never been SOB previously. Per family,
no hx of CHF. Denies increased LE edema. States she felt well
when she went to bed yesterday evening. Never had these symptoms
before.
.
In the ED, initial VS were: 96.4 104 168/84 36 95% 10L
Non-Rebreather. CXR showed lower lobe, BL opacities c/w PNA,
aspiration, or atelectasis. Some vascular prominence concerning
for mild edema. BNP 4300. WBC 13 with neutrophil predominence.
Initial cardiac enzymes show CK-MB 11, MBI 5.4, troponin 0.11.
Discussed with cardiology who thought that MICU would be
appropirate given absence of cardiac history and no evidence of
ischemic changse on EKG. Given ASA, nitro SL, lasix 40mg IV x1,
vanc/ceftriaxone for HCAP.
.
On arrival to the MICU, the patient has advanced dementia and
can not participate in the interview. Talking to her son and
HCP, he says that she has been in her USOH until this AM. She
lives in an Alzheimers community. Her PMH is only significant
for hyperlipidemia and ? silent MI in the past. Her vitals on
admission are 99.9 ax, 94, 95% on CPAP 5/5.
.
Review of systems: (+) Per HPI
The rest is unable to be elicited by the patient
Past Medical History:
Advanced Alzheimers Dementia
Hyperlipidemia
Silent MI in the past (inferior Q-waves)
Critical Aortic Stenosis - valve area 0.6 cm
Social History:
Lives at the [**Last Name (un) 35689**] House in the Alzheimers Unit. Son [**Name (NI) **] is
HCP and his wife, [**Name (NI) **], is also very involved.
- Tobacco: Smoked in the past, but not currently
- Alcohol: none
- Illicits: none
Family History:
NC
Physical Exam:
ADMISSION EXAM
98.2 HR:90-105 130-160-s 143/82 rr24 on cpap CPAP 5cmH2O
General: Agitated, trying to get out of bed, AOx1
HEENT: Sclera anicteric, on BIPAP mask
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, loud ejection
murmur of AS, possible MR, no rubs, gallops
Lungs: Scattered rhonchi at bases, bibasilar crackles, no
wheezes, no increased work of breathing
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: nonfocal
.
On discharge:
Alert, pleasantly demented. Oriented only to self. Lungs with
diffuse rales but mostly clear, unlabored/no wheezing. On room
air. Soft, nontender abdomen. Harsh systolic murmur.
Pertinent Results:
ADMISSION LABS:
[**2149-2-16**] 05:35PM BLOOD WBC-13.2* RBC-4.43 Hgb-12.8 Hct-38.3
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.7 Plt Ct-216
[**2149-2-16**] 05:35PM BLOOD Neuts-89.1* Lymphs-7.6* Monos-2.5 Eos-0.5
Baso-0.3
[**2149-2-16**] 05:35PM BLOOD Glucose-200* UreaN-22* Creat-0.7 Na-134
K-4.2 Cl-99 HCO3-23 AnGap-16
[**2149-2-16**] 05:35PM BLOOD CK(CPK)-202*
[**2149-2-16**] 05:35PM BLOOD CK-MB-11* MB Indx-5.4 proBNP-4350*
[**2149-2-17**] 01:40AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
[**2149-2-16**] 10:22PM BLOOD Type-ART Temp-37.2 Rates-/27 Tidal V-400
PEEP-5 FiO2-100 pO2-85 pCO2-42 pH-7.44 calTCO2-29 Base XS-3
AADO2-603 REQ O2-96 Intubat-NOT INTUBA Vent-SPONTANEOU
Comment-NIV
[**2149-2-16**] 05:42PM BLOOD Lactate-2.2* K-4.0
.
MICRO DATA:
[**2149-2-16**] URINE Legionella Urinary Antigen: negative
[**2149-2-16**] BLOOD CULTURE x 2 (pending)
.
CXR [**2149-2-16**]:
IMPRESSION: Basilar opacities worrisome for pneumonia in the
appropriate
clinical setting although lower airway inflammation, atelectasis
or even
aspiration are other etiologies that could be considered in the
appropriate clinical setting. Although there is perhaps minimal
vascular prominence, since opacities are focal in the lower
lungs, pulmonary edema is doubted as the primary etiology but
could be seen with an atypical pattern.
.
TTE [**2149-2-17**]:
IMPRESSION: Critical aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Pulmonary artery hypertension. Mild aortic
regurgitation. Increased PCWP.
.
CTA [**2149-2-17**]:
IMPRESSION:
1. No evidence for PE.
2. Multifocal pneumonia involving the right upper, middle and
both lower
lobes with bilateral hilar lymphadenopathy.
3. No evidence for a mass.
.
Bladder ultrasound:
IMPRESSION: Foley catheter present within a collapsed bladder.
Superior to
the bladder there is a large cystic structure with no internal
nodules
identified. This may represent a paraovarian or ovarian cyst or
peritoneal
inclusion cyst. MRI pelvis is suggested for further
characterization
.
On discharge:
[**2149-2-27**] 06:50AM BLOOD WBC-10.8 RBC-3.51* Hgb-10.1* Hct-30.7*
MCV-88 MCH-28.7 MCHC-32.9 RDW-13.4 Plt Ct-272
[**2149-2-25**] 05:40AM BLOOD PT-12.1 PTT-31.9 INR(PT)-1.1
[**2149-2-24**] 05:50AM BLOOD Glucose-92 UreaN-22* Creat-0.7 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
Brief Hospital Course:
Hospitalization Summary:
Ms. [**Known lastname 40553**] is an 88y/o lady with advanced Alzheimer's dementia
who presented with sudden-onset SOB, cough, and slight fever.
She was admitted to the MICU, ruled out for PE, and was treated
for multifocal PNA. She completed an 8-day course of
broad-spectrum antibiotics for pneumonia and improved greatly
from a respiratory standpoint - breathing comfortably on room
air upon discharge and afebrile. She developed rectal bleeding
late in her hospital course on [**2-21**], likely diverticular or
hemorrhoidal bleed, but was stable from a hemodynamic and
hematocrit standpt for 5 days. GI recommended against
intervention and her family was in agreement with this plan.
.
ACTIVE ISSUES:
#. Pneumonia: Imaging was concerning for multifocal pneumonia
and the patient presented with a significant oxygen requirement,
was on BiPAP in the ICU. She was treated initially with
vancomycin/levofloxacin, but was broadened to
vancomycin/cefepime on [**2-19**] due to continued high oxygen
requirements. There was concern for aspiration pneumonia,
however, the patient did pass her speech and swallow evaluation
- recommended regular diet and thin liquids. She continued to
improve and an 8-day course of broad-spectrum antibiotics was
completed. The patient was breathing comfortably on room air on
discharge and was afebrile.
.
# Critical Aortic Stenosis: On echo, critical aortic stenosis
was discovered with value area of 0.6 cm2. The patient was
started on a low-dose beta-blocker (Toprol 25 mg qday). On
presentation, she was found to be in mildly decompensated CHF
and was gently diuresed. Discussion was held with her son and
daughter-in-law who did not want aggressive interventions -
valvuloplasty/valve replacement - considered. They agreed with
cardiology outpatient follow-up and this was arranged.
.
#. Troponin leak: Likely in the setting of illness/demand with
critical AS and LVH. The patient never complained of chest pain
and cardiac enzymes trended down (trop peaked at 0.25). She was
started on ASA 81 mg per day and BB.
.
# Rectal bleeding: The patient developed rectal bleeding on
[**2-21**]. She continued to have ~1-2 episodes of bleeding per day.
She remained completely hemodynamically stable. Her Hct was also
stable for 5 days - ~ 30. She did not require any blood
transfusions. The bleeding was discussed with gastroenterology,
who recommended against intervention - they did not want to
perform colonoscopy. They thought the bleeding was likely either
related to hemorrhoids or diverticulum. The bleeding was also
discussed with the patient's family - HCP - [**Name (NI) **] [**Name (NI) 40553**] - who did
not want aggressive interventions. She has been consented for
blood (with son as HCP). Consent is attached with paperwork.
Would only transfuse if Hct drops below 25 (has not required any
transfusions here). Blood count should be checked every 3-4 days
as long as rectal bleeding is ongoing. This was discussed with
Dr. [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) **] at [**Hospital1 599**] of [**Location (un) 55**]. Rectal bleeding
in the absence of acutely worsening anemia or hemodynamic
changes should not warrant rehospitalization - son requested
this be communicated.
.
# Bladder or ovarian cyst: There was initially concern for
urinary retention in this patient after the bladder ultrasound
continued to read high residual bladder volumes. A foley was
placed. Bladder ultrasound revealed a 10.6 x 8.8 x 11.9 cm
cystic structure. Final read: Superior to the bladder there is a
large cystic structure with no internal nodules identified. This
may represent a paraovarian cyst or peritoneal inclusion cyst.
The family did not want further intervention for this problem.
The cyst likely accounts for this patient's urinary urgency.
.
#. Dementia: Advanced Alzheimers.
She lived at [**Last Name (un) 35689**] House [**Hospital3 **]. Per family, this
is her mental status baseline (alert, interactive, not
oriented). She was un-tethered (d/c foley, pneumoboots) and was
kept on her home dose of Seroquel, Namenda, and Donepezil. She
did intermittently and extra doses of prn seroquel. QTc was
normal.
.
# Bilateral hilar LAD: Seen on CXR. No mass was seen on CT scan.
.
# Transitional Issues:
- code status was DNR/DNI
- CONTACT: son [**Name (NI) **] [**Name (NI) 40553**]: [**Telephone/Fax (1) 53843**]
- cardiology follow-up for aortic stenosis
- please read section above on rectal bleeding re: criteria for
rehospitalization
Medications on Admission:
MED LIST FROM [**Last Name (un) **] HOUSE
Seroquel 25mg [**Hospital1 **]
Seroquel 12.5mg daily PRN
Namenda 10mg [**Hospital1 **]
Donepezil 10mg daily
Citalopram 15mg daily
vitamin D 800IU daily
Nystatin cream
Discharge Medications:
1. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for agitation.
3. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. citalopram 10 mg Tablet Sig: 1.5 Tablets PO once a day.
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
Pneumonia
Critical aortic stenosis
Rectal bleeding
NSTEMI
Peritoneal cyst
.
Secondary:
Advanced Alzheimers
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Has been getting
1-person assitance here.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted to the hospital for a severe
pneumonia. We treated you with antibiotics and you improved. We
also discovered that you have a very narrow heart valve - known
as aortic stenosis. You will follow-up with a cardiologist for
this problem. Finally, you developed rectal bleeding later on in
your admission - we think this is from either hemorrhoids or
diverticuli and we will manage this conservatively for now.
.
We made the following changes to your medications:
We STARTED aspirin 81 mg per day
We STARTED Toprol 25 mg per day
.
Your follow-up information is listed below.
Followup Instructions:
Name: [**Last Name (LF) 22673**],[**First Name3 (LF) **] V.
Location: STEWARD GERIATRICS OF [**Location (un) **]
Address: [**Street Address(2) **], [**Apartment Address(1) 32874**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) **]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.**
Department: CARDIAC SERVICES
When: FRIDAY [**2149-3-28**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"788.63",
"294.10",
"V49.86",
"331.0",
"272.4",
"250.00",
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"428.0",
"455.6",
"568.89",
"428.21",
"562.10",
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"293.0",
"518.82",
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"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11126, 11216
|
5364, 6079
|
239, 245
|
11376, 11376
|
2998, 2998
|
12241, 12925
|
2190, 2194
|
10150, 11103
|
11237, 11355
|
9916, 10127
|
11568, 12077
|
2209, 2786
|
5068, 5341
|
12106, 12218
|
1701, 1764
|
188, 201
|
6094, 9629
|
273, 1681
|
3014, 5054
|
11391, 11544
|
9652, 9890
|
1786, 1918
|
1934, 2174
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,590
| 176,886
|
1015
|
Discharge summary
|
report
|
Admission Date: [**2134-2-2**] Discharge Date: [**2134-2-16**]
Date of Birth: [**2055-12-6**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
VATS on [**2-3**], s/p lung biopsy
History of Present Illness:
77 F w/ presumed ILD presented to [**Hospital1 18**] [**Location (un) 620**] on [**2134-1-27**] w/
sob and transferred to [**Hospital1 **] for lung Bx s/p procedure doing well.
Two wks prior to presentation she had the onset of shortness of
breath and cough after just getting over viral gastroenteritis.
She went to her PCP and was treated with levofloxacin x 7 days.
.
Symptoms continued so she presented to [**Hospital1 **] [**Location (un) 620**] [**1-27**] tachypnea
and hypoxia. Imaging suggested pneumonia and she started
empirically on ceftriaxone and azithromycin. Despite treatment
she developed worsening hypoxia. Given concern for IPF
exacerbation she was started on solumedrol 80 mg IV q.6h and
then q8h with minimal response. On [**2134-1-31**] she and episode of
hypoxia with saturations falling to the mid 80s on 5 liters
requiring a nonrebreather but eventually weaned back down to 2
liters facemask. On [**2134-2-2**] she again had an acute episode of
hypoxia this time requiring BIPAP but responded to diuresis with
lasix.
.
As she had never had a lung bx to definitively dx her disease
she was transferred to [**Hospital1 18**] for VATS lung bx. On arrival she
continued to have a 6L by nasal cannula O2 requirement to
maintain saturations >92%. She was continued on levofloxacin and
steroids despite low suspicion for infectious etiology. Pt
underwent VATS RLL wedge biopsy [**2-3**] which she tolerated well.
She underwent further diuresis and CT was removed [**2-5**].
Past Medical History:
ILD (dx [**8-18**]), followed without sx and imaging.
PVD s/p b/l bbypass 7yrs ago
hyperlipidemia
HTN
GERD
Hysterectomy
Social History:
Lives with husband. 6 children and 10 grandchildren. retired
floral designer. quit smoking 40 yrs ago, after 15 pack year hx.
Family History:
Non-contributory
Physical Exam:
98.1 150/60 98-120 20 98 5L
Gen-NAD
HEENT-PERRL, JVP to 10cm, MMdry
Hrt-RRR nS1S2 3/3 SEM at RUSB, 3/6 SEM at apex
Lungs-fine crackles at left base, coarse crackles at rt base
Abd-soft, NT, ND, no HSM
Extrem-2+ rad and dp pulse on left, absent dp on rt, 1+ LE edema
on left
Neuro-CNII-XII intact, [**4-17**] strengh in UE and LE bilat, distal
sensation intact 2+ DTR at patellae bilat
Skin-no lesions, rt CT site dressing CDI
Pertinent Results:
Pertinent labs: on discharge: WBC 14 (range 14-21 on steroids),
HCT stable at 33.1, plt 269, electrolytes within normal limits
with a BUN 21 and Cr 0.7
.
Work up for anemia revealed IRON-96, calTIBC-268, VitB12-984*,
Folate-14.1, Hapto-198, Ferritn-562*, TRF-206
.
legionella antigen negative, mycoplasma pneumonia antibody IgM
negative, pneumonitis hypersensitivity profile negative,
angiotensin 1 converting enzyme test WNL, ANCA negative
.
BCX/UCX all negative
.
U/A negative but had 21-50 RBC with large blood
.
Studies:
Pathology [**2134-2-3**] s/p VATS
DIAGNOSIS
Lung, right lower lobe, wedge resection:
a. Patchy interstitial fibrosis, moderate to severe, with
honey-comb change, fibroblastic foci, and mild chronic
inflammation, see note.
b. Organizing thrombi.
c. Pleural adhesion.
.
Note: The changes are consistent with usual interstitial
pneumonia (UIP)-reviewed by Dr. [**Last Name (STitle) **]. [**Doctor Last Name **]. Clinical correlation
recommended. Special stains for AFB, PCP, [**Name10 (NameIs) **] fungi are
negative.
.
[**2134-2-4**] AP CXR: FINDINGS: There has been interval worsening of
moderate pulmonary edema on top of her chronic pulmonary
interstitial lung disease. There is no pneumothorax. There is
more right pleural effusion. Cardiomediastinal contour is
obscured by the lung abnormality but is not enlarged.
IMPRESSION: Worsening moderate pulmonary edema.
.
[**2134-2-5**] AP CXR: IMPRESSION: Status post removal of chest tube
without pneumothorax. Decreased pulmonary edema. Stable diffuse
interstitial disease.
.
[**2134-2-10**] PA and lat CXR: PA AND LATERAL VIEWS OF THE CHEST:
Compared to recent prior study the appearance of the diffuse
interstitial abnormality has changed slightly raising the
possibility of superimposed fluid overload, although it is
difficult to assess, and there are no pleural effusions.
Cardiomediastinal contour is unchanged.
IMPRESSION: Change in appearance of diffuse interstitial
abnormality raises the possibility of superimposed fluid
overload.
.
[**2134-2-15**] ECHO TTE: LVEF 60% with grade I diastolic dysfunction.
mild AS, 1+MR, moderate pulmonary hypertension with PASP =46.
Brief Hospital Course:
Ms. [**Known lastname 6692**] is a 78 year old female who was transferred to [**Hospital1 18**]
from an OSH for work up for hypoxia with h/o of presumed ILD.
She came to have a VATS for lung biopsy. She spent two days in
the MICU after the procedure until the chest tube was removed.
She was then transferred to the floor. Brief hospital course is
described by problem list below.
.
# Hypoxia: She was treated at the OSH with antibiotics and
initially continued on them in house. These were subsequently
discontinued as she had no signs of pneumonia on CXR or with her
WBC initially. Pathology from lung biopsy shows UIP/IDL and all
cultures from the tissue were negative including fungal
cultures. Although she used no oxygen before her
hospitalization, she now requires baseline oxygen per nasal
cannula at 3-4L to keep oxygen saturation above 92%. The cause
of the exacerbation is unknown; perhaps related to an infection
prior to hospitalization. She still becomes tachypnic and
hypoxia with ambulation for which she will benefit from
pulmonary rehab. Pulmonology was consulted and they have
recommended a month long prednisone taper (she is currently on
50mg daily), nebulizer treatments with albuterol and atrovent
and, mucomyst PO 600mg TID. In addition, based on data from a
clinical trial, they recommended a 2 week course of enoxaparin
given the high ddimer value and the evidence of thrombus on the
pathology tissue. This may help improve her symptoms. She has
PFTs scheduled for the end of [**Month (only) 958**] ([**2134-3-8**]) and an appointment
the same day with her pulmonologist. (please see appointments
section)
.
# fluid overload: She has no history of heart failure, but did
show some fluid overload on CXR. There was concern that her
tachycardia due to hypoxia (and maybe nebulizer treatments) may
contribute to strain on the heart and some failure. She
presented with a BNP in the 1100s at the OSH adn was 1241 on
admission to [**Hospital1 18**]. She has required occassional light diuresis
with furosemide 10mg IV with good outcome. TTE showed LVEF of
60% with grade I diastolic dysfunction, mild AS, 1+MR and
evidence of pulmonary hypertension with an estimated PASP of 46.
.
# diarrhea: She had some episodes of diarrhea and an elevated
WBC, and therefore, was treated empirically with metronidazole
for 7 days. Subsequent cultures showed she was C diff negative
x3.
.
# leukocytosis: Her WBC bounces between 14 and 21 with no signs
of infections including remaining afebrile, no infiltrates on
CXR, clean u/a, no further diarrhea. This is attributed to the
steroid treatment.
.
# hyperglycemia: She has no history of diabetes. This is likely
attributed to the prednisone. She is currently on humalog with
meals and as a sliding scale. The doses with meals is still
being titrated up to better control her blood glucose. The
insulin doses will need to be decreased and even discontinued as
her prednisone taper ends to avoid hypoglycemia.
.
# HTN/tachycardia: She was admitted on norvasc and diovan.
Given her tachycardia and hypertension in house, she is
currrently controlled on amlodipine 5mg, valsartan 160mg [**Hospital1 **],
metoprolol 25mg [**Hospital1 **] with SBP ranging from 110-130's. She has
still been occassionally tachycardic with ranges in heart rate
from 80-110's likely related to medications and perhaps to her
hypoxia.
.
# dyslipidemia: continue lipitor.
.
# anemia: Hct was stable in the mid to low 30's. Iron studies
suggest chronic disease.
.
# PPX: DVT ppx: was on heparin SC but discontinued while on
enoxaparin for the ILD. She will need to be restarted on
heparin subcutaneous 5000 units TID when her course of
enoxaparin is over ([**2134-2-24**]). She was also started on
alendronate 70mg qTuesdays to protect her bones given all the
steroids. Finally, she was started on PCP [**Name9 (PRE) **] with bactrim DS 1
tab qMonday, Wed, Friday given the lung pathology.
.
# Physical therapy: with assistence only and with a walker.
Physical therapy worked with her for improving her strength,
conditioning and breathing.
.
# CODE: FULL
.
# DISPO: to pulmonary rehab
Medications on Admission:
1. Lipitor 20 mg daily.
2. Norvasc 5 mg daily.
3. Prilosec 20 mg a day.
4. Rhinocort [**12-15**] sprays in each nostril.
5. Aspirin 325 mg daily.
6. Multivitamin daily.
7. Diovan 160 mg b.i.d.
8. Ultracet, (acetaminophen-tramadol 325-37.5 mg) q.6h. p.r.n.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
13. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
14. Acetylcysteine 10 % (100 mg/mL) Solution Sig: Six Hundred
(600) mg Miscellaneous TID (3 times a day).
15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days.
16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days.
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
19. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
20. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed) as needed for sore throat.
21. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
22. Insulin Lispro (Human) 100 unit/mL Solution Sig: variable
units Subcutaneous ASDIR (AS DIRECTED): ongoing while on
prednisone. may not need after steroid taper ends.
23. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous [**Hospital1 **] (2 times a day) for 9 days: last dose in PM on
[**2134-2-24**].
24. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
25. oxygen
please use oxygen per nasal cannula to keep oxygen saturation
above 92%. (currently set at 3-4L)
26. lab work
Patient should have CBC, BUN, Cr, sodium, potassium, chloride,
bicarb and glucose checked every Tuesday and Thursday.
27. finger sticks
Finger sticks should be checked qAC and qhs and covered with the
humalog sliding scale. This can be discontinued when the
insulin is discontinued (at the end of the prednisone taper).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Interstitial lung disease/UIP
Congestive heart failure- diastolic
Diarrhea
HTN
tachycardia
hyperglycemia
.
SECONDARY DIAGNOSIS:
PVD s/p b/l bbypass 7yrs ago
Hyperlipidemia
GERD
Hysterectomy
Discharge Condition:
Stable, oxygenation saturation low 90's on 3-4L of oxygen by
nasal cannula, ambulatory with mild SOB.
Discharge Instructions:
You were diagnosed with lung disease which now requires you to
wear oxygen to help you breath better. You have been prescribed
new medications which will help you to breath better as well.
Please take them as instructed.
.
Please take all medications as prescribed.
.
Please use nasal cannula set at 4L oxygen at rest.
.
Call your PCP or return to the emergency department if you
experience worsening shortness of breath, fevers >101, chills,
coughing up blood, chest pain, diarrhea or any other symptoms
which are concerning to you.
Followup Instructions:
Please followup with your PCP [**Name Initial (PRE) 176**] 1 week of discharge for
further medical management: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3393**]
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2134-4-5**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**]
[**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2134-4-5**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 5445**] [**Last Name (NamePattern1) 1843**]/DR. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2134-4-5**] 2:30
|
[
"511.9",
"285.9",
"428.0",
"416.8",
"401.9",
"427.89",
"272.4",
"530.81",
"787.91",
"428.30",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.28",
"33.22",
"34.21"
] |
icd9pcs
|
[
[
[]
]
] |
11901, 11973
|
4797, 8744
|
277, 314
|
12226, 12330
|
2616, 2616
|
12913, 13608
|
2137, 2155
|
9243, 11878
|
11994, 11994
|
8963, 9220
|
12354, 12890
|
2170, 2597
|
8762, 8937
|
2646, 4774
|
230, 239
|
342, 1835
|
12141, 12205
|
12013, 12120
|
2632, 2632
|
1857, 1978
|
1994, 2121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,329
| 155,128
|
30565
|
Discharge summary
|
report
|
Admission Date: [**2134-12-29**] Discharge Date: [**2135-1-7**]
Date of Birth: [**2082-2-4**] Sex: F
Service: NEUROLOGY
Allergies:
Latex
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
Left sided weakness and confusion.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 year old woman hx left temporal hemorrhagic infarct in [**6-26**],
left thalamic infarct in [**2134-5-21**], generalized tonic/clonic
seizures, and complex partial seizure with secondary
generalization seizures, who was found by her son at 10am on
[**2134-12-29**] with confusion and left sided weakness. She was not
following commands and was word finding difficulty. Per EMS her
fingerstick was 138.
.
She arrived in the ED at [**Hospital1 18**] at 1:50pm. Her vitals were tc
98.6, BP 117/53, RR 20, HR 92, and O2 sats 96% on RA. She was
oriented to self only and could follow simple commands. Pt was
moving all four extremities equally and could grasp with both
hands. At 2:50pm she had eye version to the right with increased
rigidity of the right side of her body. She was given Ativan 1
mg
at 2:25pm, 2:40pm, and 2:50pm. She was loaded with Dilantin 1g
iv. Her seizure activity had stopped by 3:10pm. She also got
Keppra 500mg iv.
Past Medical History:
-Hx L hemisphere hemorrhagic infarct in [**6-26**], subsequent GTC,
maintained initially on Dilantin then switched to Keppra. Pt
also had a complex partial seizure with secondary generalization
in setting of getting an abdominal contrast study in [**4-27**].
-[**2134-5-21**]: Left thalamic infarct
Hospitalized at [**Hospital1 18**]
-HTN
-Hx etoh abuse
-ETOH cirrhosis, with elev coags
-Thrombocytopenia, hx bone marrow suppression with etoh
-DM-II
-Hx hospitalizations for pancreatitis in past, related to ETOH
-Hx syphillis 20 yrs ago, s/p tx in [**2131**]
-Was HIV neg in [**2130**]
-Last [**Last Name (un) 3907**] nl in [**2131**]
-Recent pancreatic mass discovered, amidst w/u
Social History:
Lives with one of her sons (has a PCA who comes to home helping
with chores and helping her to take all meds. No longer drinks
etoh (last:prior to stroke in [**2132**]), but formerly had hx ETOH
abuse.
Family History:
No seizures. Both her mother and father abused alcohol.
Physical Exam:
VS: Tc 96.5 BP 102/55 P 83 R 16 0294%
on
2liters
Gen: WD/WN
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: regular rate and rhythm, no murmurs,
Abd: soft, non-distended, non-tender, no mass, positive bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: spider angiomas on chest
Neuro: MS: alert and oriented x1, follows some unilateral
commands, makes several paraphasic mistakes
CN: possible right homonymous hemianopsia, pupils equal, round,
and reactive,extraocular movements intact, intact facial
strength
and symmetry, intact t/u/p
Motor: normal tone and bulk of all four extremities, no tremor
At least anti-gravity strength of all four extremities
proximally
Sensory: intact light touch of all four extremities
Reflex: BR B K A toes
Left 3 3 3 2 mute
Right 3 3 3 2 mute
Coord: deferred
Gait: deferred
Pertinent Results:
[**2134-12-29**] 06:44PM PT-17.4* PTT-34.9 INR(PT)-1.6*
[**2134-12-29**] 06:37PM GLUCOSE-108* UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11
[**2134-12-29**] 06:37PM PHOSPHATE-3.3 MAGNESIUM-1.6
[**2134-12-29**] 06:37PM PHENYTOIN-13.2
[**2134-12-29**] 06:37PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2134-12-29**] 06:37PM WBC-5.4 RBC-4.10* HGB-14.3 HCT-39.9 MCV-97
MCH-34.9* MCHC-35.9* RDW-14.1
[**2134-12-29**] 06:37PM PLT COUNT-57*
[**2134-12-29**] 02:12PM NA+-142
[**2134-12-29**] 02:00PM GLUCOSE-128* UREA N-8 CREAT-0.6 SODIUM-140
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2134-12-29**] 02:00PM estGFR-Using this
[**2134-12-29**] 02:00PM ALT(SGPT)-50* AST(SGOT)-71* CK(CPK)-303* ALK
PHOS-128* AMYLASE-38 TOT BILI-1.9*
[**2134-12-29**] 02:00PM LIPASE-15
[**2134-12-29**] 02:00PM LIPASE-15
[**2134-12-29**] 02:00PM cTropnT-<0.01
[**2134-12-29**] 02:00PM cTropnT-<0.01
[**2134-12-29**] 02:00PM CK-MB-14* MB INDX-4.6
[**2134-12-29**] 02:00PM ALBUMIN-3.9 CALCIUM-10.7* PHOSPHATE-2.9
MAGNESIUM-1.6
[**2134-12-29**] 02:00PM WBC-4.4 RBC-4.29 HGB-14.7 HCT-41.7 MCV-97
MCH-34.3* MCHC-35.3* RDW-14.0
[**2134-12-29**] 02:00PM NEUTS-68.2 LYMPHS-23.7 MONOS-6.2 EOS-1.5
BASOS-0.4
[**2134-12-29**] 02:00PM PLT COUNT-68*
[**2134-12-29**] 02:00PM PT-18.0* PTT-38.1* INR(PT)-1.6*
[**2134-12-28**] 12:33PM %HbA1c-5.4
[**2134-12-28**] 12:33PM WBC-4.4 RBC-4.11* HGB-13.8 HCT-41.2 MCV-100*
MCH-33.7* MCHC-33.6 RDW-13.9
[**2134-12-28**] 12:33PM PLT COUNT-73*
.
[**2134-12-30**] 02:42AM BLOOD Ammonia-62*
[**2134-12-30**] 02:42AM BLOOD Phenyto-12.5
[**2134-12-30**] 02:42AM BLOOD PT-18.2* PTT-40.4* INR(PT)-1.7*
[**2134-12-30**] 02:42AM BLOOD Plt Ct-62*
Non-Contrast Head CT [**2134-12-29**]:
FINDINGS: There has been no interval change in encephalomalacia
of the left temporal lobe with porencephalic change and ex vacuo
dilatation of the left lateral ventricle. No edema, mass
effect, hemorrhage is noted. The right lateral ventricle and
sulci are normal in contour and configuration. The bone windows
do not show any fracture. The paranasal sinuses and mastoid air
cells are clear.
.
IMPRESSION: Overall unchanged appearance of the brain with the
left temporal porencephalic change and ex vacuo dilatation of
the left lateral ventricular components, with no acute
intracranial pathology.
.
CXR [**2134-12-29**]:
PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The cardiomediastinal
silhouette and hilar contours are unchanged. The lungs are
clear with no focal consolidation, pleural effusion or
pneumothorax. The osseous structures of the thorax are
unchanged.
.
IMPRESSION: No acute intrathoracic pathology including no
pneumonia.
EEG DATA/IMPRESSION:
.
[**2134-12-31**]
IMPRESSION: This telemetry captured no pushbutton activations.
Routine
sampling and automated detection algorithms were notable for
persistent
and almost continuous moderate amplitude blunted slow sharp wave
and
sharp and slow wave discharge complexes occurring at a frequency
up to 1
Hz seen broadly over the left hemisphere but with a predominance
in the
left posterior quadrant consistent with periodic lateralized
epileptiform discharges. This suggests a potential focus for
epileptogenesis in the left posterior quadrant. No
electrographic
seizures were noted. There is no obvious clinical correlate. In
addition, throughout the recording period the background was
poorly
organized, typically in the [**4-26**] Hz frequency range, and was
interrupted
by bursts of generalized mixed theta and delta frequency
slowing. This
is consistent with a mild to moderate encephalopathy. This
finding
suggests dysfunction of bilateral subcortical or deeper midline
structures. Medications, metabolic disturbances, and infection
are
among the most common causes of encephalopathy but there are
others.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 1216**] S.
.
................................................................
[**2135-1-1**]
IMPRESSION: This telemetry captured two pushbutton activations.
Both
demonstrated frequent, 2.5-3 Hz moderate amplitude rhythmic slow
sharp
wave and sharp and slow wave discharge complexes broadly over
the left
hemisphere with prominence in the left posterior quadrant and
with
reflection, at times, over to the right hemisphere mainly in the
right
fronto-temporal and fronto-central regions. This is consistent
with
electrographic seizure activity. Clinically, the patient was
noted
during these times to be less responsive, to have eyelid
fluttering, and
facial twitching. Routine sampling and spike and seizure
detection
programs continue to demonstrate a disorganized and slow, [**4-27**] Hz
maximum
posterior dominant rhythm with the background on the left
interrupted by
persistent slow sharp wave and sharp and slow wave discharge
complexes
occurring at a frequency of [**12-23**] Hz at times consistent with
electrographic seizure activity.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 1216**] S.
.
................................................................
[**2135-1-2**]
IMPRESSION: This telemetry captured no pushbutton activations.
Routine
sampling and spike and seizure detection programs continue to
demonstrate persistent, typically 1 Hz slow sharp wave and sharp
and
slow wave discharge complexes broadly over the left hemisphere,
with a
prominence in the left posterior quadrant. At times, however,
these
discharges occurred in brief bursts with a frequency of 1.5-2
Hz.
Compared to prior days' recordings, these periods of more
repetitive
discharges were less frequent. The background continued to be
slow and
disorganized and frequently interrupted by bursts of generalized
mixed
theta and delta frequency slowing consistent with a mild to
moderate
encephalopathy.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 1216**] S.
.
.
................................................................
[**2135-1-3**]
IMPRESSION: This telemetry captured one pushbutton activation.
There
were no associated epileptiform features. Routine sampling and
spike
and seizure detection programs were notable for a slow,
disorganized,
[**4-26**] Hz maximum posterior dominant rhythm admixed with bursts of
moderate
amplitude generalized mixed frequency slowing consistent with a
moderate
encephalopathy. Persistent delta frequency slowing was noted on
the
left in the left fronto-temporal and left fronto-central
regions. This
is consistent with underlying dysfunction of cortical and
subcortical
structures. In addition, the background on the left was
frequently
disrupted by frequent, [**12-23**] Hz, slow sharp wave and sharp and
slow wave
discharge complexes seen broadly over the left hemisphere but
with a
prominence in the left posterior quadrant. Rarely, these
discharges
occurred in brief runs at up to 3 Hz consistent with brief
electrographic seizures. Compared to previous days' recordings,
these
runs of 3 Hz discharges were less frequent.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 1216**] S.
.
.
................................................................
[**2135-1-4**]
IMPRESSION: This telemetry captured no pushbutton activations.
Due to
technical difficulties, only a small number of the time samples
were
available for review. These demonstrated a disorganized, slow
[**4-26**] Hz
frequency posterior dominant rhythm interrupted by bursts of
moderate
amplitude generalized mixed theta and delta frequency slowing
consistent
with a mild to moderate encephalopathy. In addition, the
background on
the left was interrupted by moderate amplitude sharp and sharp
and slow
wave discharges with a left posterior quadrant predominance.
Unlike
prior days' recordings, these discharges were not rhythmic or
periodic
in their appearance. There were no prolonged or sustained runs
of
discharges and no electrographic seizures were noted.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 1216**] S.
Brief Hospital Course:
Given concern for status epilepticus, the patient was admitted
to the neurologic ICU for closer monitoring and evaluation. On
arrival to the unit, the patient was sleepy and confused, likely
a combination of a post-ictal state and sedation from
anti-epileptics received in the ED. However, there was no
obvious focality noted. There were no further seizures
overnight. The following morning, the patient was noted to be
awake, but still confused and disoriented. She continued to
have difficulty following commands and was pleasantly
uninhibited. Her neck was supple. A thorough evaluation
revealed no clear source of infectious, toxic, or metabolic
disturbances to precipitate the seizure, although a relatively
low daily dose of her outpatient keppra was a possibility. Her
baseline hematologic abnormalities remained stable. She was
afebrile. Keppra was increased to 1250 mg [**Hospital1 **]. Blood pressure
medications (for chronic cirhossis) were held given systloic
blood pressures from the 90s to low 100s. However, most of her
other home medications were re-started and her diet was resumed
given her increased alertness. She was placed on EEG telemetry,
which by initial review showed left-sided PLEDs consistent with
her known left temporal lesion, but with no seizure activity
noted. On [**2134-12-31**], the patient was more somnolent during rounds
and had a 30-45 second complex partial seizure with transient
loss of responsiveness to questions and right arm shaking. She
was bolused with an additional 300 mg of dilantin to bring her
level (9's) into therapeutic range.
<br>
An [**Date Range **] consult was called and she was noted to have
additional periods of eye fluttering and agitation, thought to
be possible seizures as well. Pt was noted to have
electrographical seizure activity on [**2135-1-1**]. At the
recommendation of [**Date Range **], keppra was increased to 1500 mg [**Hospital1 **],
an additional 300 mg dilantin was given, as well as 0.5 mg of
ativan for these more frequent episodes. At this point, she was
transferred to the floors for further monitoring and evaluation.
<br>
During patients neurology floor course she was monitored by EEG
through [**2135-1-4**]. Several of these EEG interpretations were
notable for waveforms consistent with mild to moderate
encephalopathy. Patients final AED medications at discharge are
1500mg keppra [**Hospital1 **], dilantin 100mg TID, Zonegran 100mg nightly,
Titrate up to 100mg per week to a max of 300mg total. Once
Zonegran is titrated up pt will follow up in [**Hospital1 **] clinic for
dilantin taper. Dilantin is not the ideal AED as pt has liver
cirrhosis. Pt is scheduled for follow up with Dr. [**First Name (STitle) 437**] and Dr.
[**First Name (STitle) 1557**] on [**2135-2-14**].
<br>
Problem [**Name (NI) **]:
<br>
1. Seizure disorder (see above)
<br>
2. Receptive/Expressive Aphasia: Near baseline per son. [**Name (NI) **]
problems with basic comprehension. Pt to follow up with
behavioral neurology.
<br>
3. ADLs/Cognition/Ambulation: Patient was evaluated by
Occupational therapy and physical therapy while in house. They
recommended that the patient receive 24 hour surveillance, ADL
training, memory training, speech training. They recommend
continued OT and PT.
<br>
4. ETOH cirrhosis: Pts LFTs at discharge were AST 50, ALT 40,
tbili 0.9. When pt was admitted her LFTs were elevated at AST
71, ALT 50, Tbili 1.9. Pt was discharged on home dose of
spironolactone of 50mg daily. Last INR 1.4. Cont lactulose.
<br>
5. GERD: Switch from prilosec to pantoprazole, as prilosec
interacts unfavorably with dilantin.
<br>
6. Hx of pancreatitis and pancreatic mass: no active issues.
Follow with GI.
<br>
7. DM: Pt on ISS while in house. Sent out w/ home dose
glimeripide 1mg [**Hospital1 **].
<br>
8. Depression: Cont mirtazapine and seroquel.
<br>
9. HTN: Sent home on spironolactone 50mg.
<br>
10. Follow up:
<br>
Patient needs to follow up with GI, PCP, [**Name10 (NameIs) **] clinic,
behavioral neurology.
Medications on Admission:
Acetyl L-Carnitine 250mg daily
Ascorbic acid 500mg [**Hospital1 **]
Aspirin EC 81mg daily
Folic acid 1mg daily
Glimepiride 1mg daily
Keppra 750mg [**Hospital1 **]
Lactulose 30mg qid
Lasix 20mg daily
Mirtazapine 22.5mg daily
multivitamin one tablet daily
Prilosec 20mg [**Hospital1 **]
Seroquel 25mg [**Hospital1 **]
Spironolactone 50mg daily
Thiamine 100mg daily
Discharge Medications:
1. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
7. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily): Starting now please take 100mg daily (1 capsule).
-Starting [**2135-1-10**] take 200mg daily (2 capsules)
-Starting [**2135-1-17**] take 3 capsules daily.
Disp:*90 Capsule(s)* Refills:*1*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Acetyl L-Carnitine 250 mg Capsule Sig: One (1) Capsule PO
once a day.
15. 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:*1*
Discharge Disposition:
Home With Service
Facility:
Laboure Center VNS
Discharge Diagnosis:
Primary Diagnosis
Generalized Tonic Clonic Seizure d/o w/ multiple simple partial
(motor sz w/ right arm jerking) and complex partial (right arm
jerking, face jerking)
.
Secondary Diagnosis
Receptive and Expressive Aphasia
Left temporal infarct [**6-26**]
HTN
Hx of ETOH abuse
Thrombocytopenia
ETOH cirrhosis
Hx of Bone Marrow suppresion
Diabetes Melitus 2
Hx of pancreatic mass
Hx of pancreatitis
Hx of syphylis 20 years ago
Discharge Condition:
Stable vitals, No seizures clinically for the past 5 days.
Discharge Instructions:
Mrs. [**Known lastname **] you were admitted to the hospital for mental status
changes and L sided weakness. You were seen in the ED at [**Hospital1 18**]
where they were concerned that you were having seizure activity.
In the ED you received antiepileptic medication.
.
Clinically and electroencephalographically you were found to
have
seizures.
.
We modified your seizure medications to include keppra 1500mg
[**Hospital1 **], Dilantin 100mg TID, and zonegran 100mg daily. Starting
Monday [**1-10**] you should take zonegran 200mg daily, then on [**1-17**]
you should 300mg of zonegran daily.
.
We also started you on Protonix 40mg twice a day in place of
your prilosec for your reflux disease/heart burn. Prilosec
interacts with other medications that you are taking.
.
Physical therapy and 0ccupational therapy assessed you during
your inpatient stay. It was their recommendation that if you
return home that you receive 24 hour supervision, home PT,OT,
speech and language therapy.
.
Please keep all of your appointments as scheduled. Please take
all medications as prescribed.
.
Please return to the emergency department if your seizures
change in quality, if you begin to have them more frequently
than normally, or lasting longer than 5 minutes. Please go to
Emergency department if your condition worsens in any way.
Followup Instructions:
Please follow up with your [**Month/Year (2) **] doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] on
[**2-14**] at 1000am on the [**Location (un) **] of the [**Hospital Ward Name 23**] building [**Hospital Ward Name **].
Please follow up with your nurse practioner visit w/ [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**]
[**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2135-1-18**] 10:00
Please follow up with your [**Month/Day/Year **] exam. Provider: [**Name10 (NameIs) 706**]
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2135-1-28**] 10:45
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2135-1-12**] 10:00.
.
Please follow up with your GI doctor. [**2135-2-18**] 09:30a
[**Last Name (LF) **],[**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX),
[**Location (un) **]
.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
Completed by:[**2135-1-10**]
|
[
"V58.83",
"571.2",
"V58.69",
"401.9",
"530.81",
"348.30",
"345.71",
"250.00",
"438.89",
"438.11",
"577.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17225, 17274
|
11327, 15234
|
301, 307
|
17744, 17805
|
3301, 11304
|
19180, 20456
|
2222, 2280
|
15759, 17202
|
17295, 17723
|
15371, 15736
|
17829, 19157
|
2295, 3282
|
15245, 15345
|
227, 263
|
335, 1276
|
1298, 1985
|
2001, 2206
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,120
| 152,773
|
33319
|
Discharge summary
|
report
|
Admission Date: [**2133-9-8**] Discharge Date: [**2133-9-10**]
Service: MEDICINE
Allergies:
Penicillins / aspirin
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F with h/o lymphoma, GERD, HTN, dCHF presented on [**8-28**] to
[**Hospital3 628**] with shortness of breath and dxd with PNA. Was
previously dxd with PNA and placed on Levo but failed. Placed
on Vanco/Cefepime there. Course complicated by resp failure
requiring BiPAP, no inubation, and hypotension requiring
pressors. Also with dCHF exacerbation. This caused ARF on CKD
and anuria, presumably from ATN, now placed on HD through
femoral HD line. Hypotension now resolved. Course also
complicated by delirium and malnutrition requiring NGT and tube
feeds (haldol and restraints in this setting). Also with
thrombocytopenia to low of 37 over last 3 days, concern for HIT
so stopped heparin and checked HIT ab (pending). Vital signs
have been stable: afebrile, HR 70s, BP 150/52, RR 20, 100% 3L.
WBC 10.9, Cr 2, LFTs normal, Plt 37.
Today HD line clotted and is no longer working. Case discussed
with family, which includes multiple MDs (psych, radiologist, GI
fellow). She is now DNR/DNI and no pressors, but wishes to
continue aggressive medical care otherwise. Thus, they request
transfer for replacement of HD cath and continued HD, as well as
continued treatment of HCAP, delirium, and malnutrition, and
also work up of thrombocytopenia.
Past Medical History:
-Chronic kidney disease stage 4, baseline creatinine around 3.
-GERD
-HTN
-dCHF
-Lung mass, possibly cancer, family denied any further workup or
treatment since [**2129**].
-History of small bowel lymphoma status post surgery.
-Sciatica.
-Osteoarthritis.
-Status post cholecystectomy.
-History of UTI
Social History:
Is currently in respite care at [**Location (un) 582**] of [**Location (un) 620**]. Usually she
lives at home with her son. She has been in the United States
for the last 30 years. No reports of smoking, alcohol or drugs.
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.3 118/52 80 22 98%RA
GENERAL - acutely ill appearing lady, responds to noxious
stimuli by opening eyes wider, but does not withdraw to pain.
Does not follow commands or respond to voice.
HEENT - NC/AT, L pupil post-surgical, R pupil with minimal
reaction to light, does not track to light or voice.
NECK - supple, no JVP appreciated
LUNGS - diffuse crackles throughout b/l lungs anteriorly and
posteriorly, with some transmitted upper respiratory sounds.
Decreased breath sounds at the R base.
HEART - PMI non-displaced, RRR, nl S1-S2, soft holosystolic
murmur loudest at LUSB.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - responds to noxious stimuli by opening eyes wider, but
does not withdraw to pain. Does not follow commands or respond
to voice. pupil post-surgical, R pupil with minimal reaction to
light, does not track to light or voice.
Discharge Physical Exam
No heart sounds present. No peripheral pulses. Pupils fixed and
non-reactive to light. Patient deceased.
Pertinent Results:
ADMISSION LABS
[**2133-9-8**] 09:49PM TYPE-[**Last Name (un) **] PO2-42* PCO2-58* PH-7.26* TOTAL
CO2-27 BASE XS--1 COMMENTS-GREEN TOP
[**2133-9-8**] 09:49PM LACTATE-1.4
[**2133-9-8**] 09:24PM GLUCOSE-77 UREA N-46* CREAT-3.2*# SODIUM-140
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
[**2133-9-8**] 09:24PM estGFR-Using this
[**2133-9-8**] 09:24PM CALCIUM-7.4* PHOSPHATE-2.3*# MAGNESIUM-1.9
[**2133-9-8**] 09:24PM WBC-13.1*# RBC-3.22* HGB-9.7* HCT-29.4*
MCV-91 MCH-30.1 MCHC-33.0 RDW-16.8*
[**2133-9-8**] 09:24PM PLT COUNT-50*#
CXR [**2133-9-6**]:
1. TIP OF THE PICC LINE AT THE LEVEL OF THE SVC.
2. WORSENING IN THE BILATERAL INFILTRATES.
CT head [**2133-9-7**]: NO EVIDENCE OF ACUTE INTRACRANIAL PROCESS.
Renal ultrasound [**2133-9-2**]:
1. DIMINUTIVE KIDNEYS BILATERALLY WITH INCREASED ECHOGENICITY
OF THE CORTEX SUGGESTING MEDICAL RENAL DISEASE.
2. NO HYDRONEPHROSIS.
3. SMALL LEFT SIDED PLEURAL EFFUSION.
4. SMALL AMOUNT OF ASCITES.
CT chest [**2133-8-28**]:
INTERVAL DEVELOPMENT OF WIDESPREAD PATCHY PARENCHYMAL
CONSOLIDATION
MOST CONSISTENT WITH PNEUMONIA IN A PATIENT WITH UNDERLYING
EMPHYSEMA. THERE ARE SMALL PLEURAL EFFUSIONS. PROMINENT
MEDIASTINAL LYMPH NODES WHICH [**Month (only) **] BE REACTIVE. THERE ARE
ENLARGED AXILLARY LYMPH NODES AS WELL.
INCREASE IN SIZE OF LEFT UPPER LOBE MASS CONCERNING FOR
NEOPLASTIC DISEASE.
OSH LABS
White blood cell count 10.9, hemoglobin 10.2, platelets 37 down
from 54. They are starting to drop since [**9-4**]. Sodium
138, potassium 3.6, chloride 106, bicarb 26, BUN 37, creatinine
2.9, again no significant urine to speak of. Glucose 93.
Calcium 7.5, alk phos 175, albumin 2.2, B12 1093. TSH 4.25.
BNP went from 35,000 to 63,000 on [**9-1**]. Her last
transfusion was yesterday x1. She received also another
transfusion of blood packed red blood cells on [**9-6**]. She
received a total of 3 throughout her hospital stay. Her
microbiology preliminary catheter tip grew out [**Female First Name (un) 564**] albicans.
It was from femoral line which was pulled and replaced with a
PICC line. We will start her on fluconazole for that as well.
Brief Hospital Course:
[**Age over 90 **]F with h/o lymphoma, GERD, HTN, dCHF presented on [**8-28**] to
[**Hospital3 628**] with shortness of breath and dxd with PNA,
complicated by resp failure requiring BIPAP, hypotension
requring pressors. Lost HD access but continues to be anuric.
The patient was transfered to [**Hospital1 18**] to replace HD line and
continue dialysis. However, the patient's BP began to drop and
she was tansfered to the ICU with the intention to begin CVVH.
However, her pressure continued to drop and the decision was
made to make her comfort measures only. She passed away shortly
thereafter.
# Goals of Care: The was previously very independent and
functional at baseline, now with AMS in the setting of sepsis
and multiorgan failure (ARF and AMS). At admission, discussions
with the family reveal that they feel the patient is still in an
acute phase of her illness. They do not desire any further
drastic measures such as CPR, intubation, or pressors, but are
ok with the patient getting dialysis including CVVH and other
medical interventions to aggressivly treat her PNA and renal
failure. They were hoping her mental status will improve if she
bounces back from PNA. When the patient's pressures started to
drop to the 90s systolic she was transfered to the unit with the
thought of stating CVVH. However, her pressures continued to
trend down and it became clear that she would no tolerate or
benefit fom CVVH or other invasive care, so the patient was made
comfort measures only and passed soon thereafter.
# Healthcare associated Pneumonia: Course so far had been
complicated by resp failure requiring BIPAP and hypotension
requiring pressors. Treated emperically with Vanc, Cefepime.
# Catheter tip culture grew [**Female First Name (un) 564**] albicans at OSH:
- cont Fluconazole
# CRF requring HD: The patient's current access is clotted and
no longer usable. The patient's family initially desired
dialysis or CVVH, and the patient was tansfered to the ICU with
the intention of getting CVVH, but was unable to maintain her
pressure and was made comfort measures only.
# Delerium: The patient has multiple possible causes of altered
mental status, and is likely encephalopathic. The patient is
septic from b/l pneumonia, and has evidence of end-organ failure
(incl ARF), sepsis was the most likely explanation of AMS. The
patient also had CRF requiring HD, with elevated BUN. Other DDx
inclues non-convulsive status epilepticus, recent CVA, hypoxic
damage, or meningitis. Fs glucose was stable.
# Nutrition: severe malnutrition. NG tube in place. Tube feeds
initiated.
# Thrombocytopenia: Plts 37 on admission, trended down during
prior admission. Heparin SQ DVT PPx was DCed for concern of
HITT. HITT AB negative at OSH. Thrombocytopenia likely [**2-12**]
sepsis
# Anemia: Nadir Hct 22, s/p 3 units PRBC transfusion. Hct 29 at
admission, no signs of active bleeding.
Medications on Admission:
MEDICATIONS AT HOME:
- Lasix 20 mg p.o. daily.
- DuoNeb as needed.
- Levaquin 500 mg p.o. nightly since [**2133-8-18**].
- Alprazolam 0.5 mg p.o. nightly.
- Colace 100 mg p.o. b.i.d.
- Prilosec 20 mg p.o. b.i.d.
- Senna 2 tablets p.o. nightly.
- Levoxyl 50 mcg p.o. daily.
- Lisinopril 30 mg p.o. daily.
- Tums 500 mg p.o. t.i.d.
- Ferrous sulfate 240 mg p.o. daily.
- Vitamin D 1000 units p.o. daily.
- Amlodipine 2.5 mg p.o. daily.
- Metoprolol tartrate 75 mg p.o. b.i.d.
- Trazodone 25 mg p.o. nightly.
- Florastor 1 tablet p.o. b.i.d.
- Mucinex 600 mg p.o. b.i.d.
- Tramadol 50 mg p.o. nightly p.r.n.
- Bowel regimen as directed.
MEDICATIONS ON TRANSFER:
- Cefepime 1 g IV daily.
- Lidocaine patch topical as needed.
- Levothyroxine 25 mcg IV daily.
- Tucks medicated pads b.i.d. to buttocks
- Nystatin 5 cc q.i.d. swish and swallow.
- Haldol 0.5 mg IV q.4 hours p.r.n. agitation.
- Morphine 1 mg q.4 hours p.r.n. IV shortness of breath or pain.
- Magnesium sulfate 1 g IV daily p.r.n. magnesium less than 1.9.
- Dulcolax suppository 110 mg p.r. daily no bowel movement.
- DuoNeb q.4 hours p.r.n. shortness of breath.
- Tylenol 1 g q.6 hours p.r.n. fever.
- Vancomycin dosed by levels. Last level was 15. She got a
dose yesterday 1 g.
- Fluconazole 100 ml IV daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis from pna with multiorgan failure
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"038.9",
"V49.86",
"786.6",
"996.73",
"995.92",
"V66.7",
"428.32",
"585.4",
"287.5",
"486",
"285.9",
"E879.1",
"599.0",
"403.90",
"261",
"785.52",
"V10.79",
"348.31",
"724.3",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9709, 9718
|
5462, 8358
|
235, 241
|
9801, 9811
|
3300, 5439
|
9863, 9998
|
2123, 2127
|
9681, 9686
|
9739, 9780
|
8384, 8384
|
9835, 9840
|
8405, 9019
|
2167, 3281
|
189, 197
|
269, 1541
|
9044, 9658
|
1563, 1865
|
1881, 2107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,718
| 177,142
|
53485
|
Discharge summary
|
report
|
Admission Date: [**2189-10-26**] Discharge Date: [**2189-10-28**]
Date of Birth: [**2150-2-3**] Sex: M
Service: VSU
CHIEF COMPLAINT: Right toe pain.
HISTORY OF PRESENT ILLNESS: This is a 39-year-old man
admitted to the medical service on [**2189-10-26**], and
transferred to the vascular surgical service on [**2189-10-28**].
This is a 39-year-old insulin dependent diabetic male who
presents with right toe infection and DKA. He was in an
outside hospital until [**2189-8-10**], when he noted a
facial rash after applying coconut oil. He was diagnosed with
folliculitis and treated with erythromycin x10 days. His rash
resolved. Then he presented to the ER on [**2189-10-15**],
with return of the rash on his face and questionable open
sore on his toe which he did not mention to the doctor in the
ER and was begun again on erythromycin 500 QID x10 days.
On [**2189-10-22**], his wife noted a large ulceration on his
right great toe. His wife who is a [**Name (NI) **] had intermittently
rubbed cream on his feet for the past few months. On
[**2189-7-27**], his toe became malodorous and swollen. He
had to walk with a cane due to the pain and swelling
progressed. Then on [**10-26**] he noted the toe began to
turn black. While he was still able to walk on his toe, he
was concerned it has gotten 'out of hand' and he presented to
the emergency room. He in the emergency room he was found to
be in DKA. He was placed on insulin drip. He was seen by the
podiatrist in consult with concern for osteomyelitis and
underlying peripheral vascular disease. He was given dose of
gentamycin, Unasyn and vancomycin and transferred to the MICU
for continued care.
ALLERGIES: No known drug allergies.
MEDICATIONS: No medications on admission.
PAST MEDICAL HISTORY:
1. His illnesses include diabetes diagnosed in [**2173**]. He
presented with a glucose of 100 after experiencing a
fall. He is seen at [**Hospital **] clinic intermittently. He was
started on insulin in [**2179**]. His hemoglobin A1C on [**3-18**]
was 15.2. In [**2181**] he discontinued insulin and started
metformin and then glyburide but has been largely
noncompliant with his medical regime.
2. Morbid obesity.
3. Hyperglycemia.
4. Asthma. He has unknown PFTs. He has never been intubated
or on steroids.
5. History of hypertension, poorly controlled.
6. Left 4th and 5th metatarsal fractures.
SOCIAL HISTORY: He is a Muslim. He denies alcohol, drugs, or
tobacco use. He reports marijuana in the past. The patient is
currently not working secondary to his disability related to
his obesity and diabetes. The patient was with his wife and 4
children.
FAMILY HISTORY: Positive on the maternal side for diabetes
and hypertension on the paternal side.
PHYSICAL EXAMINATION: VITAL SIGNS: 99.3, blood pressure
140/70, heart rate 90, respirations 22, oxygen saturation 98%
on room air. GENERAL APPEARANCE: An obese male in no acute
distress. Oriented x3. HEENT exam was unremarkable. Lungs
clear to auscultation bilaterally. Heart has regular rate and
rhythm with a 2/6 systolic ejection murmur at the left lower
sternal border. Abdomen is benign. Extremities: Right great
toe is black, and edematous with discoloration extending to
the tarsal joint with 2+ DP and PT pulses bilaterally. There
is some erythema and edema in the mid calf level. There is
mild TPP over the distal tibia. The patient 2-point
discrimination is diminished on the plantar surface of the
toes bilaterally. Light touch sensation is preserved. Right
toe was nontender with a sterile probe. There is a 1 x 1
darkened spot over the pulp of the third digit of the left
middle finger. Motor is [**3-19**] at plantar, dorsiflexors, GCs,
quads, bilaterally. Gait was not assessed. Toe is malodorous.
ADMISSION LABORATORY DATA: Lactate of 2.0. Electrolytes -
sodium 127, K 5.3, chloride 88, CO2 20, BUN 24, creatinine
1.2, glucose 635, white count 16.6, hematocrit 37.5,
platelets 309, INR 1.2. Foot x-ray, ankle x-rays were
obtained. Chest x-ray was also obtained.
Initial toe culture from the right great toe grew beta
streptococcus group B x2. Staph coag positive, rare, probable
Enterococcus rare. Anaerobic cultures were negative. Blood
cultures with no growth. Urine culture with no growth.
Right foot film showed first toe was subcutaneous emphysema
and possibly lucency in the medial aspect of the first distal
phalanx on AP view only, osteomyelitis could not be excluded.
There was soft tissue edema. There was no evidence of
fracture or malalignment. Degenerative changes were noted.
X-rays of the tib-fib on the right were obtained which were
negative for radiographic evidence of osteomyelitis. [**Last Name (un) **]
service was consulted on [**2189-10-27**] for management of
the patient's diabetes. He remained on insulin drip. When
glucoses were in the 200 ranges, he was begun on 70/30
insulin at that time with continued improvement in his
glycemic control. On [**2189-10-28**], the patient underwent
open toe amputation without complicated and was transferred
to the PACU in stable condition, returning later to the
nursing floor.
The patient was transferred out of the MICU. The remaining
hospital course was unremarkable. The patients glycemic
control improved and he underwent a primary closure of the
amputation sites on [**2189-11-3**]. He tolerated the
procedure well. The patient was converted from Lantus and
Humalog Insulin to 70/30 insulin and a Humalog sliding scale.
The patient will be discharged to home with services. He will
continue his antibiotics for a total of 2 more weeks. He
should follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] at that time.
We will arrange for nursing to make sure the patient is
instructed on insulin administration and glycemic monitoring.
The patient should follow up with Dr. [**Last Name (STitle) **] at [**Last Name (un) **] after
discharge to home. He will be touch-down weightbearing
essential distances only. He will also be seen in follow up.
DISCHARGE DIAGNOSES:
1. Osteomyelitis of the right toe with ischemic changes.
2. Type 2 diabetes, uncontrolled with history of diabetic
ketoacidosis, resolved.
3. History of morbid obesity.
4. History of hyperlipidemia.
5. History of asthma with no history of intubation or
administration of steroids.
6. History of hypertension.
7. History of left 4th, 5th metatarsal fractures.
SURGICAL PROCEDURES: Left toe amputation on [**2189-10-28**], and primary closure of toe amputation on [**11-3**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2189-11-5**] 12:52:00
T: [**2189-11-6**] 14:24:40
Job#: [**Job Number 109967**]
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155, 172
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201, 1766
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2439, 2680
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,409
| 124,337
|
4780
|
Discharge summary
|
report
|
Admission Date: [**2122-7-14**] Discharge Date: [**2122-7-20**]
Date of Birth: [**2045-1-19**] Sex: F
Service: CCU
HISTORY OF THE PRESENT ILLNESS: The patient is a
77-year-old female with a history of hypertension, atrial
fibrillation, coronary artery disease, and congestive heart
failure who presented from an outside hospital on [**2122-7-11**]
complaining of increased shortness of breath much beyond her
baseline. She visited her primary care doctor's office one
week prior who though it might be a pneumonia and gave her
Keflex. Her symptoms did not improve. She presented to the
outside hospital Emergency Room.
In the Emergency Room there she was noted to have ascites,
INR of 9, mild shortness of breath, no chest pain, no nausea
or vomiting. Her hospital course there was notable for
treatment of Lasix with minimal response. By hospital day
number two at the outside hospital the patient was still
dyspneic. Little improvement was noted. The atrial
fibrillation continued with some rate control. She had
moderate ascites on a CT scan but no masses.
On [**2122-7-14**], the patient was noted to have a large
pericardial effusion on echocardiogram with no evidence of
tamponade or right heart collapse. The effusion was found to
be approximately 3 cm.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. History of multiple pneumoniae.
3. Pulmonary hypertension with some parenchymal lung
disease.
ADMISSION MEDICATIONS:
1. Coumadin.
2. Tenormin.
3. Cardia XL.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: In the CCU,
her blood pressure was 121/81, heart rate 112, respirations
31. She was saturating 97% on a nonrebreather. General:
The patient was lying in bed, breathing laboriously, 8 cm of
JVD was appreciated. She had no lymphadenopathy. Chest:
Decreased air entry, crackles at both bases about one-third
of the way up. Cardiac: Notable for an irregular rhythm,
normal S1, S2, and a soft systolic murmur along the left
sternal border. Abdomen: Distended, nontender, bowel sounds
hypoactive. her abdomen was also found to be dull to
percussion. Extremities: Warm. Her DP pulse on the left
was about 2+ and 1+ on the right. She had no edema.
Neurologic: Nonfocal.
LABORATORY/RADIOLOGIC DATA: On admission, sodium 130,
potassium 6.2, BUN 75, creatinine 1.9, INR 2.3.
An EKG was performed and shown to be consistent with atrial
fibrillation.
A chest x-ray showed an enlarged cardiac silhouette
consistent with a pericardial effusion and a large
right-sided pleural effusion on the right.
HOSPITAL COURSE: On hospital day number two, the patient had
a pericardiocentesis and 640 cc of hemorrhagic fluid was
removed. The patient was found to be in severe tamponade
with equalization of pressures that was subsequently relieved
with the pericardiocentesis. After pericardiocentesis, her
cardiac output went from 3.7 to 8.1. Her cardiac index went
from 2.2 to 4.8. Her right atrial pressure went from 21 to
18. Her pulmonary arterial pressure remained unchanged. Her
wedge pressure went from 46 to 37. Her INR was slowly
trending down throughout her hospital admission.
On hospital day number two, the INR had trended down from 2.0
to 1.7. By hospital day number three, her pericardial drain
was removed. Her swan was removed. A lateral decubitus
chest x-ray showed little layering of pleural fluid. She was
given 20 mg of Lasix the previous afternoon and that put out
1.6 liters approximately.
An Infectious Disease consult was brought on board on
hospital day number three as well to investigate the etiology
of her ascites as well as her pleural effusions. Her
pericardial fluid showed no growth of bacterial, AFB or
fungal cultures.
On hospital day number four, a pleural tap was performed to
drain the right-sided pleural effusion; approximately 1 liter
of hemorrhagic fluid was removed and sent for cytology. By
hospital day number six, an echocardiogram was performed that
showed no reaccumulation of the pericardial fluid. Her
atrial fibrillation was being well controlled on Lopressor 50
twice a day and her blood pressure remained stable.
In terms of her pulmonary status, her breathing had improved.
She was discharged in stable condition.
DISCHARGE STATUS: Full code.
DISCHARGE DIAGNOSIS: Pericardial effusion. Cardiac tamponade.
DISCHARGE MEDICATIONS: Atenolol 50 mg twice a day.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] on
[**2122-8-6**] at 2:30.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 3809**]
MEDQUIST36
D: [**2122-8-14**] 02:28
T: [**2122-8-25**] 15:34
JOB#: [**Job Number 20044**]
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icd9cm
|
[
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[]
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] |
[
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icd9pcs
|
[
[
[]
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4408, 4786
|
4342, 4385
|
2628, 4320
|
1460, 1579
|
1594, 2610
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1314, 1437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,435
| 142,171
|
29717
|
Discharge summary
|
report
|
Admission Date: [**2146-6-7**] Discharge Date: [**2146-6-20**]
Date of Birth: [**2077-10-17**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Zometa / Keflex / Tetracycline / erythromycin /
Iodine Containing Agents Classifier / nuts / fish derived /
lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2146-6-10**]-left thoracotomy with placement of epicardial BiV lead
History of Present Illness:
68 yo F w/ Class III systolic HF with EF of [**10-17**]% s/p BiV-ICD
placement, severe asthma and back pain who presents from the
holding area of the cath lab with dyspnea/tachypnea prior to
exchange of LV lead. Pt had recent admission for polymorphine VT
with her ICD discharging 5 times and she was found to have
malpositioned anterior LV lead. After she was stabilized and
breathing had improved she was discharged on [**6-2**] with plan to
come back in for scheduled outpatient LV lead exchange which was
today. Her weight at the time of discharge was 160lbs. Pt
reports she felt fine when leaving on [**6-2**] but quickly started
to all of a sudden feel "worse". Pt reports feeling sick from
then until now. She describes it as feeling fatigued, with
worsened breathing, and nausea. Her weight was decreasing while
at home and she was 156 at home on the day of admission. She
reported worsening breathing, with a coughing fit the day prior.
She denies any fevers or chills or sick contacts. She was
recently treated for a pneumonia on her previous admission. She
denies any dietary indiscretions or problems with the milrinone
pump. Her VNA reported that she heard crackles the day prior to
admission.
Of note at the time of discharge the following changes were made
to her regimen (stopped digoxin, stopped valsartan, stopped
gabapentin, decreased metoprolol from 75mg to 50mg, increased
torsemide prn from 40 to 50mg,decreased sertraline from
200-->100), and the patient reports not problems with physically
making these changes.
In the holding area to the cath lab the patient was noted to be
acute tachypnic to the 40s with crackles in the lungs
posteriorly with JVP elevated to the mandible. She received 80IV
Lasix x1 and placed a foley. Dr. [**First Name (STitle) 437**] evaluated the patient in
the hodling area and felt she required further evaluation and
management with lasix drip and milrinone drip
On arrival to CCU she reports feeling 100% better. She continues
to feel a little nauseus and denies any chest pain or
palpitations. She is feeling overwhelmed with her illness and
her multiple hospitalizations recently. And complaining of back
pain.
On review of systems, she reports improved swelling in her legs
bilaterally, no abdominal pain, last moved her bowels the day
prior to admission, no hematuria or dysuria. She reports her
mood is stable compared to prior to the change in her
medications. She reports she cannot sleep flat because of back
pain and problems getting comfortable.
Past Medical History:
1. Severe nonischemic cardiomyopathy with LVEF of 10% s/p BiVICD
placment
-BiVICD is [**Company 1543**] Model: [**Name6 (MD) 39503**] XT CRT-D,implanted at [**Hospital3 **] Medical Center on [**2141-1-3**]
last interrogated [**2146-5-24**] and set to 1:1AV conduction
2. Severe mitral regurgitation, severe tricuspid regurgitation
and moderate pulmonary hypertension.
3. PAF status post ablation.
4. Severe asthma.
5. Old compression fractions of T8 and T10.
6. Venous stasis disease.
7. Anxiety, depression.
8. Restless legs syndrome.
9. Recent septic bursitis of the right knee.
Social History:
The patient used to work as a jeweler and makes jewelry. She
lives with her husband. Remote smoking history, quit over 40
years ago, occasional ETOH and no illicit drug use
Family History:
Father may have had a heart attack, but died from a blood clot
to the brain. Mother had diabetes and cirrhosis. Son with
[**Name2 (NI) 14595**]-1 antitrypsin deficiency.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8, 107, 79/53, 13, 985 3L NC Wt 155lbs
GENERAL: sitting up in bed, changing positions often, appears
uncomfortable but not in distress
HEENT: PEERLA, sclera anicteric, MMM, no oral lesions
NECK: Supple with JVP of 10 cm.
CARDIAC: Irregular and tachycardic, Systolic murmur at the left
upper sternal border and at the apex, with diffuse PMI at the
6th intercostal 2cm lateral to midclavicular
LUNGS: No chest wall deformities,Pt is kyphotic. Crackles at the
left base but not the right. Moving good air bilaterally, no
wheezes but hollow breath sounds throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Darkned skin bilaterally on the extremities. No
peripheral edema, 2+DP pulses bilaterally. PICC in the LUE
without erythema at hte site.
NEURO: AAOx3, CNII-XII grossly intact, 5/5 strength biceps,
triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
DISCHARGE PHYSICAL EXAM
Tm 98.6 Tc 97.6 HR 77-81 RR 18-20 BP 87-96/50-66 I/O1490/1525
Weight 70.7 O2 96%RA
GEN: AAOx3, fatigued appearing, but affect much improved
HEENT: JVD 1/2 up to mandible. Right scar c/w prior IJ.
HEART: RRR. Dressing left side chest c/d/i
LUNGS: Crackles at left base
ABDOMEN: Soft, NT, NABS
EXT: 1+ edema L>R
NEURO: Nonfocal
SKIN: Right PICC without erythema or exudate
Pertinent Results:
Admission Labs:
[**2146-6-7**] 02:30PM BLOOD WBC-13.7*# RBC-3.66* Hgb-11.7* Hct-34.2*
MCV-93 MCH-31.8 MCHC-34.1 RDW-14.5 Plt Ct-375
[**2146-6-7**] 02:30PM BLOOD Neuts-80.6* Lymphs-11.1* Monos-5.3
Eos-2.6 Baso-0.4
[**2146-6-8**] 05:23AM BLOOD PT-15.4* PTT-32.8 INR(PT)-1.4*
[**2146-6-7**] 02:30PM BLOOD Glucose-116* UreaN-15 Creat-1.3* Na-139
K-3.4 Cl-96 HCO3-29 AnGap-17
[**2146-6-7**] 02:30PM BLOOD ALT-12 AST-20 CK(CPK)-39 AlkPhos-80
TotBili-1.1
[**2146-6-7**] 02:30PM BLOOD CK-MB-2 cTropnT-<0.01
[**2146-6-7**] 02:30PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
Urine:
[**2146-6-7**] 02:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2146-6-7**] 02:25PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2146-6-7**] 02:25PM URINE RBC-4* WBC-3 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
IMAGING:
CT Venography of Coronary Veins [**2146-6-8**]: The only mapped coronary
vein visualized was seen along the inferior septum/inferior wall
aspect of left ventricle, along the posterior descending
coronary artery, most probably a middle cardiac vein. The left
ventricular pacing lead is seen coursing into the coronary sinus
and then into the great cardiac vein. Focal stenosis at the
origin of the celiac artery is causing approximately 40%
narrowing. In addition, there is stenosis in the superior
mesenteric artery just beyond its origin, which is incompletely
imaged.For other findings on the heart and thorax, please refer
to CT dated [**2146-6-1**].
CXR [**2146-6-7**]: 1. Right upper extremity picc unchanged in location
in the lower svc. 2. Interval increase in pulmonary vascular
engorgement and mild interstitial edema. Moderate cardiomegaly
is unchanged.
ECHO [**2146-6-10**]: PRE LEAD PLACEMENT: Perioperative exam performed to
monitor hemodynamics and assess ventricular resynchronization
therapy. Severely depressed LV systolic function with LVEF < 15%
with global HK and severely dilated LV. The left atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The right ventricular cavity is dilated with severe
global free wall hypokinesis. The ascending, transverse and
descending thoracic aorta are normal in diameter with mild
atherosclerotic plaque. 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, but restricted leaflet motion is seen. The
mitral regurgitation vena contracta is >=0.7cm. Severe (4+)
mitral regurgitation is seen. There is no pericardial effusion.
Intact IAS. No clot in LAA. Normal coronary sinus. Severe
diastolic dysfunction with e' = 5 cm/sec.
POST LEAD: Mild improvement in LV systolic function, otherwise
unchanged.
[**2146-6-15**]: The left atrium is moderately dilated. The left atrium
is elongated. The estimated right atrial pressure is at least 15
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 15
%). The estimated cardiac index is depressed (<2.0L/min/m2). The
right ventricular cavity is moderately dilated with severe
global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. The mitral valve
leaflets do not fully coapt. An eccentric jet of Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The tricuspid valve leaflets fail
to fully coapt. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study dated [**2146-6-13**] (images reviewed),
the degree of tricuspid regurgitation is worse. Other findings
are similar.
[**2146-6-13**] TTE: IMPRESSION: Marked biventricular cavity enlargement
with severe global biventricular systolic function c/w diffuse
process (toxin, metabolic, cannot exclude multivessel CAD).
Moderate to severe mitral regurgitation. Pulmonary artery
hypertension.
Compared with the prior study (images reviewed) of [**2146-5-26**],
the left ventricular cavity is more dilated. Right ventricular
function is slightly worse. The estimated PA systolic pressure
is now higher.
Brief Hospital Course:
Ms. [**Known lastname 71175**] is a 68 year old female with history of NYHA
Class III systolic heart failure s/p biventricular pacemaker/ICD
(BiV ICD) placement in [**2141**], who presented for elective lead
revision of her BiV pacer leads. She had placement of an
epicardial lead on the lateral aspect of left ventricle but did
not get improvement in her EF, so she continues on home
milrinone.
#Systolic heart failure- The patient has severe idiopathic
nonischemic dilated cardiomyopathy, followed by Dr. [**First Name (STitle) 437**] in the
[**Hospital **] clinic. She has a BiV ICD and is on betablocker, torsemide,
spironolactone. Pt was previously on digoxin which was d/cd on
her last admission as well as her [**Last Name (un) **] [**2-3**] hypotension. She has
been diuresed with torsemide and on admission her weight was 155
lbs, below her documented dry weight of 160. While in the
holding area for lead revision, she became acutely short of
breath, and likely had a flash pulmonary edema in the setting of
tachycardia with decreased diastolic time. She had increased
pulmonary edema on CXR despite being below her discharge weight.
During this admission she was originally diuresed with a lasix
drip and then on HD#2 was switched back to home PO torsemide.
Her EF was not improved with revision of the BiV pacer (see
below) lead and so she continued on her home heart failure
regimen including milrinone 0.25 mcg/kg/min, metoprolol
succinate 50 mg daily, tosemide 60 mg daily, spironolactone 12.5
mg daily.
#Ventricular dysynchrony: On [**6-10**] Ms. [**First Name (Titles) 71182**] [**Last Name (Titles) 1834**]
placement of epicardial left ventricle pacemaker lead placement
via a left thoracotomy. This procedure was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see the operative note for details. She
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit. She was
extubated and weaned from neosynepherine. On post-operative day
one her chest tube was removed without incident. Her permanent
pacemaker was interrogated by the electrophysiology service and
found to be in good working condition.
After the new lead was placed, however, a repeat
echocardiogram did not show that her dyssynchrony was resolved.
She was taken off her milrinone to see if the new lead would
allow better EF, however her creatinine went up, her blood
pressure dropped and her mental status decreased--all suggesting
decreased perfusion when off the milrinone. Thus, she was
restarted on milrinone and this was set up to continue at home.
She was seen by the palliative care team about her overall
prognosis because she is now milrinone-dependent. They
discussed turning off her ICD when she is ready, and she will
think about this and talk with her family when she goes home.
#Hypotension: Thought to be due to end-stage heart failure.
Patient presented with BP of 79/59. Although she was
asymptomatic, this was below her previous baseline of SBP 90's
to 100's. Following her epicardial lead placement, she continued
to have SBP's of 70's to 80's and complained of fatigue. She was
briefly on phenylephrine infusion in the CVICU following her
procedure, but was weaned off prior to transfer to cardiology
floor on [**6-10**]. Her milrinone was adjusted as above and her blood
pressures remained in the 80-90s, asymptomatic.
# Paroxsymal atrial fibrillation: Was rate controlled with
metoprolol during admission and continued her aspirin 81 mg
daily. She did not like taking warfarin and having INR checks
and her CHADS score is only 2 giving her an overall low risk of
stroke during the rest of her life expectancy from heart
failure, thus her warfarin was discontinued.
# Depression: She did have significant depression during
admission, which worsened when she was taken off the milrinone
and then restarted on it. This was felt to be an appropriate
response due to her worsening overall prognosis and difficulty
adjusting to the fact that she had no other options besides home
milrinone now. She was continued on her sertraline.
TRANSITIONAL ISSUES:
- Monitor for heart failure exacerbation symptoms and adjust her
diuretics as needed
- Return to clinic with Dr. [**First Name (STitle) 437**] and repeat ECHO
Medications on Admission:
1. fluticasone-salmeterol 500-50 mcg/dose Disk [**Hospital1 **]
2. multivitamin qday
3. aspirin 81 mg qdya
4. pantoprazole 40 mg ER qday
5. magnesium oxide 400 mg (hold while inpatient)
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every six (6) hours as needed for SOB.
7. montelukast 10 mg PO HS
8. cholecalciferol (vitamin D3) 800 U qday
9. ropinirole 0.25 mg po qhs (hold while inpatient)
10. Milrinone continuous infusion for weight of 160lbs, at
0.38mcg/kg/min
11. ferrous sulfate 325 mg (65 mg iron) qday
12. sertraline 100 mg po qday.
13. prednisone 10 mg prn for asthma attack (hold while
inpatient)
14. Tums 200 mg calcium 1000mg po qday
15. metoprolol succinate 50 mg ER (switch to 25mg po tartrate
while inpatient)
16. torsemide 50 mg prn if you gain 3 lbs in 1 day: (hold while
inpatient)
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed. (prn while inpatient)
18. Coumadin 2.5mg po qday
19. albuterol sulfate neb
20. loratadine 10 mg qday. (hold while inpatient)
21. spironolactone 12.5mg po qday
22. oxycodone 5 mg Tablet q6h prn pain
23. potassium chloride 20 mEq (hold while inpatient)
Discharge Medications:
1. Milrinone 0.25 mcg/kg/min IV DRIP INFUSION Start: After
completion of bolus dose
RX *milrinone 1 mg/mL continuous Disp #*30 Bag Refills:*2
2. Acetaminophen 1000 mg PO TID
3. Aspirin 325 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY Start: In am
Please hold SBP < 90, HR < 50
5. Fentanyl Patch 12 mcg/hr TP Q72H
RX *fentanyl 12 mcg/hour change every three days Disp #*10
Transdermal Patch Refills:*0
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
7. Magnesium Oxide 400 mg PO BID
8. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg daily Disp #*90 Tablet Refills:*2
9. Spironolactone 12.5 mg PO DAILY
10. Senna 1 TAB PO DAILY
RX *sennosides 8.6 mg daily Disp #*30 Tablet Refills:*2
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezing
12. Montelukast Sodium 10 mg PO DAILY
13. Sertraline 100 mg PO DAILY
14. Ropinirole 0.25 mg PO QPM
15. traZODONE 25 mg PO HS:PRN insomnia/anxiety
[**Month (only) 116**] take 12.5 mg as needed for anxiety
16. 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.
17. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose daily Disp #*30 Unit
Refills:*2
18. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation or rr<10
RX *oxycodone 5 mg every 4 hours Disp #*90 Tablet Refills:*0
19. Pantoprazole 40 mg PO Q24H
20. Loratadine *NF* 10 mg ORAL DAILY
21. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
22. Outpatient Lab Work
Please check Chem-7 with results to Dr. [**First Name (STitle) 437**] at Phone:
[**Telephone/Fax (1) 62**]
Fax: [**Telephone/Fax (1) 9825**]
ICD 9: 428
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
decompensated systolic congestive heart failure--EF 15%
.
Hypertension
Atrila Fibrillation
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 71175**],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**].
You were admitted to the hospital because you were suddenly
short of breath and were briefly in the cardiac intensive care
unit while we got some extra fluid out of your lungs. You
[**Hospital1 1834**] some testing to determine how to fix your pacemaker
lead so that it made your heart squeeze the best. It was decided
that you would require surgery to have this done and tolerated
the procedure well. Unfortunately, this procedure did not help
the pumping function of your heart so you will need to continue
the milrinone at home.
Follow-up needed for:
1. Heart failure- it will be very important to weigh yourself
daily, if you increase in >3 lbs in 1 days or 5 pounds in 3 days
you should take your torsemide and call Dr.[**Name (NI) 3536**] office
2. Surgical Wound: you will see the surgeons at the end of next
week to take off the dressings.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: CARDIAC SURGERY
When: THURSDAY [**2146-6-30**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Address: 131 ORNAC JCB [**Apartment Address(1) **] [**Location (un) 1514**], [**Numeric Identifier 17125**]
Department: Cardiology
When: THURSDAY [**2146-7-21**] at 1:40 PM
Phone: [**Telephone/Fax (1) 62**]
Department: CARDIAC SERVICES
When: TUESDAY [**2146-6-28**] at 10:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2146-6-28**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
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[
[
[]
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|
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|
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|
3658, 3834
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,667
| 133,507
|
47084
|
Discharge summary
|
report
|
Admission Date: [**2181-4-19**] Discharge Date: [**2181-4-28**]
Date of Birth: [**2125-12-21**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 55 year old female from a
group home who presents status post ingestion and mental status
changes. The patient apparently reported taking Roxicet. EMS
found the patient with slurred speech and apparently mental
status deteriorated. She received 2 mg of Narcan intravenously
upon arrival with improvement in her mental status, however,
after several hours, she was disoriented in the Emergency
Department. She was noted to have hypotension with a systolic
BP of 60 and pinpoint pupils. She received more Narcan with some
response.
PAST MEDICAL HISTORY:
1. Polysubstance abuse.
2. Anxiety.
3. Depression.
4. Dysfunctional uterine bleeding, status post hysterectomy.
5. Migraine headaches.
6. Hypertension.
7. PMJ.
8. Gastroesophageal reflux disease.
9. Hepatitis C.
10. Chronic obstructive pulmonary disease.
11. Coronary artery disease, status post PCI in [**11-30**].
ALLERGIES: Erythromycin and Codeine.
MEDICATIONS ON ADMISSION:
1. Dexamethasone.
2. Advair.
3. Combivent.
4. Tamoxifen.
5. Seroquel.
6. Ambien.
7. Zestril.
8. Lopressor.
9. Norvasc.
10. Aspirin.
11. Celexa.
Unclear if these were accurate as this was an old list.
PHYSICAL EXAMINATION: On admission, her blood pressure was
initially 100/74, then 80/50, then 50 palpable and then
110/67. Heart rate was 96, respiratory rate 12, 99% on four
liters nasal cannula. She is a middle age female, lethargic,
rather unarousible. Her pupils are pin point, 2.0 millimeter
bilaterally. Sclera anicteric. Conjunctiva were clear. The
oropharynx was clear. Her chest is clear to auscultation
bilaterally. She had a regular rate and rhythm. Abdomen was
protuberant, soft, positive bowel sounds. She had no edema.
On neurologic examination, she is lethargic and difficult to
assess based on that.
LABORATORY DATA: White blood cell count 9.7, hematocrit
36.8, platelet count 244,000. Sodium 140, potassium 3.2,
chloride 103, bicarbonate 27, blood urea nitrogen 15,
creatinine 1.0, glucose 127. Serum toxicology screen was
negative. Urine toxicology screen was positive for
benzodiazepines and opiates.
Chest x-ray had a questionable density, a small infiltrate.
Electrocardiogram was sinus rhythm at 74 beats per minute,
normal axis, low voltage, no acute ST changes.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit service. Gradually mental status improved.
She complained that she was not attempting suicide but rather
wanted control for her back pain. During hospitalization, her
Medical Intensive Care Unit was complicated by hypotension which
was treated with intravenous fluids. Cortisol stimulation test
was negative for adrenal insufficiency. Her pain was treated
successfully with Ibuprofen and Tylenol. She was therefore
transferred to the floor, placed on [**Last Name (un) **] scale for narcotic
withdrawal to be treated with Clonazepam. All her narcotics were
held. Psychiatry evaluated her. She was placed on a Prednisone
taper and inhalers for improvement in respiratory function and
showed marked improvement. Ionized calcium and PTH were checked
and were normal. The patient's mental status remained somewhat
diminished. She was oriented only to name and time. Her
temperature gradually began to climb and she had minor
electrocardiographic changes. Therefore, a search began for any
electrolyte disturbance or infection as the cause in change in
mental status. However, this workup included head CT without
bleed, lumbar puncture negative, and empiric Vancomycin and
Ceftriaxone begun prior to the results of the lumbar puncture
because of concern for meningitis and she was also started on
Acyclovir while HSV PCR was pending. This was subsequently found
to be negative and all antibiotics were stopped.
Late into the hospitalization, the patient had a seizure for
which she was loaded on Phenytoin. She remained seizure free for
the rest of her hospitalization. She refused
electroencephalogram or magnetic resonance scan at that time. It
was suggested that it be followed up as an outpatient. Psychiatry
followed her and recommended started Celexa but holding Seroquel
or any benzodiazepine or opiate. At that time, she was started
on low dose Celexa. She was seen by physical therapy who
determined that she was safe for discharge home. However, her
[**Hospital3 **] refused her return so she has been screened for
rehabilitation and found and accepted at Star of [**Doctor Last Name **]. She
therefore was transferred to that facility.
MEDICATIONS ON DISCHARGE:
1. Celexa 20 mg p.o. once daily.
2. Ipratropium Bromide two puffs inhaled q4-6hours.
3. Albuterol two puffs inhaled q6hours p.r.n.
4. Potassium Chloride 40 meq p.o. three times a day, hold
for potassium greater than 4.5.
5. Captopril 50 mg p.o. three times a day.
6. Oxycodone/Acetaminophen one tablet p.o. q6hours p.r.n.
7. Phenytoin 100 mg p.o. three times a day.
8. Neutra-Phos one packet p.o. three times a day.
9. Metoprolol 50 mg p.o. twice a day.
10. Aspirin 325 mg p.o. once daily.
11. Acetaminophen 650 mg p.o. q4-6hours p.r.n.
12. Senna one tablet p.o. q.h.s.
13. Docusate Sodium 100 mg p.o. twice a day.
14. Salmeterol two puffs inhaled twice a day.
15. Fluticasone Propionate 110 mcg two puffs inhaled twice a
day.
16. Haldol 0.5 to 2.0 mg p.o. p.r.n. for agitation.
It is recommended that she follow-up with psychiatry.
Dictated By:[**Last Name (NamePattern4) 16198**]
MEDQUIST36
D: [**2181-4-28**] 11:26
T: [**2181-4-28**] 14:10
JOB#: [**Job Number 99820**]
|
[
"780.39",
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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4708, 5704
|
1126, 1336
|
2458, 4682
|
1359, 2440
|
168, 713
|
735, 1100
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,146
| 154,577
|
21620
|
Discharge summary
|
report
|
Admission Date: [**2184-10-4**] Discharge Date: [**2184-10-7**]
Date of Birth: [**2106-7-26**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Unexplained fall yesterday
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 78 year-old left-handed man who was medflighted to
the [**Hospital1 18**] on [**2184-10-4**] after his wife watched him fall and hit
his
head. She got home in the afternoon, and he had been out for a
long walk. She asked him to get some salt out of the garage
since
the walk was icy, and he looked at her as though he did not
understand. She tried to explain, but he did not respond and
kept
wandering around. She told him to come into the house, but he
did
not. Then she watched him "fall backwards," hitting his head on
the [**Doctor Last Name **] of the car and rolling off. He was face forward on the
ground afterwards and was moaning. He did not respond to his
wife
at that time. She did not notice any abnormal limb movements or
incontinence of stool or urine. He had not just eaten, and had
no
recent changes in his medications. Per EMS the patient was
combative and was intubated at the scene. She did not see his
face and does not know if he had abnormal eye movements.
He has a history of two or three previous falls. The first was
nine years ago when he fell out of an armchair at a restaurant.
His blood pressure was found to be high, and he was seen by a
cardiologist at the [**Hospital1 882**]. He was started on some new
medications at that time. He fell asleep or had a syncopal
episode a few weeks later while driving. In addition he had
another episode in the kitchen at home 2-3 years ago, but his
wife is not sure if he passed out or tripped. He was hit by a
car
a couple of years ago, but per report had no head trauma.
His wife started to notice abnormal behavior about a year ago.
He
had trouble remembering things, would put things away in strange
places, and would repeat questions over and over. He recently
saw
the behavioral neurologist Dr. [**Last Name (STitle) 56908**] at the [**Hospital1 112**] ([**Telephone/Fax (1) 56909**])
who
did memory testing. Mr. [**Known lastname **] s brother has Alzheimer s disease,
and apparently he is getting an Alzheimer s work-up. In
addition,
he was diagnosed with sleep apnea about a month ago and is going
to pick up his CPAP mask soon.
Past Medical History:
?Remote history of arrhythmia
HTN (cardiologist Dr. [**First Name (STitle) **] in [**Location (un) 620**])
Syncope
Social History:
Lives with his wife in [**Name (NI) 620**]. Worked with
investments, now retired.
Family History:
Brother with Alzheimer s. No family history of
seizures or sudden cardiac death.
Physical Exam:
Vitals: afebrile, HR 56, BP 146/65, RR 17, O2Sat 96% on 2L
Gen: NAD lying in bed comfortably flat. Awake.
HEENT: PERRL 3-2mm bilaterally, EOMI no nystagmus. Fundus not
visualized.
Right scleral injection. Left lateral orbit ecchymosis, with
dried blood.
Neck: full range of passive motion. No carotid bruits
appreciated, no LAD.
Cor: RRR nl s1/s2, II/VI HSM best at apex.
Chest: Bibasilar crackles of the way up. Occasional
transmitted
upper
airway sonds.
Abd: soft NT/ND. +BS, no HSM
Neuro exam:
Mental Status: Normal affect. A&O times person, place, time,
president, date, history. Able to name [**2-22**] objects at 0 and 1
minute but 0/4 objects at 5 minutes. [**12-24**] objects with prompting.
Able to spell "DLROW" and subtract serial 7's to 93. Able to
name
DOWB. Speech is fluent and coherent, no obvious aphasia but
frequent word-finding difficulties. Naming intact to watch,
thumb, wristband, but not to stethoscope, pen ("pencil"), pen
cap. Able to remember name of wife, and children, but somewhat
unclear as to where his kids live. Can write a sentence. Drew a
clock with no defects.
Cranial Nerves:
I. Not tested
II. Visual acuity not tested. Visual fields intact to
confrontation, pupils normal round 3mm-> 2mm with light.
III, IV, VI: EOMI without nystagmus.
V, VII: Normal facial sensation and musculature.
VIII: Hearing intact to finger rub.
IX, X: Palate rises symmetrically.
[**Doctor First Name 81**]: Trapezius, SCM intact bilaterally.
XII: Tongue midline, good strength bilaterally..
Motor: Increased tone in bilaterally lower extremities. Slight
cogwheelin in wrists with repetitive contralateral arm movement.
No tremors or fasciculations. Pronator drift absent, although pt
unable to lift left shoulder.
Strength: 4-/[**2-22**]+ = mild/moderate/great resistance
[**Doctor First Name **] Tri [**Hospital1 **] WrF WrE FiF [**Last Name (un) **] Ilio Quad
Ham FoF FoE [**Last Name (un) 938**]
Left NT 5 5 5 5 5 5 4 5 5 5 5 5
Right 5 5 5 5 5 5 5 4 5 5 5 5 5
Reflexes:
Biceps Triceps BR Patellar Achilles Plantar
Left 3 2 3 2 1 Down
Right 3 2 3 2 1 Down
Sensory: Romberg not tested given patient in ICU bed attached to
monitor, PIV's. Intact to pinprick, proprioception and
temperature throughout.
Vibration decreased in ankles, toes, but intact and equal at
knees. Coordination: Intact FTN b/l, intact [**Doctor First Name **] b/l, intact heel
to shin b/l.
Gait: not tested. +snout, +jaw jerk.
Pertinent Results:
[**2184-10-4**] 04:00PM BLOOD WBC-4.3 RBC-4.34* Hgb-13.8* Hct-36.7*
MCV-85 MCH-31.8 MCHC-37.6* RDW-12.9 Plt Ct-165
[**2184-10-6**] 05:20AM BLOOD WBC-5.7 RBC-3.93* Hgb-12.2* Hct-33.6*
MCV-86 MCH-31.1 MCHC-36.4* RDW-12.9 Plt Ct-128*
[**2184-10-4**] 04:00PM BLOOD PT-12.6 PTT-22.6 INR(PT)-1.0
[**2184-10-4**] 04:00PM BLOOD Plt Ct-165
[**2184-10-6**] 05:20AM BLOOD PT-12.9 PTT-25.8 INR(PT)-1.0
[**2184-10-6**] 05:20AM BLOOD Plt Ct-128*
[**2184-10-6**] 05:20AM BLOOD Fibrino-358
[**2184-10-4**] 07:19PM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-134
K-3.6 Cl-100 HCO3-26 AnGap-12
[**2184-10-7**] 10:29AM BLOOD Glucose-163* UreaN-8 Creat-0.8 Na-132*
K-4.2 Cl-99 HCO3-26 AnGap-11
[**2184-10-4**] 04:00PM BLOOD CK(CPK)-153 Amylase-90
[**2184-10-5**] 01:19PM BLOOD CK(CPK)-236*
[**2184-10-4**] 04:00PM BLOOD CK-MB-7 cTropnT-<0.01
[**2184-10-5**] 12:53AM BLOOD CK-MB-8 cTropnT-<0.01
[**2184-10-5**] 01:19PM BLOOD CK-MB-6 cTropnT-<0.01
[**2184-10-4**] 07:19PM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
[**2184-10-7**] 10:29AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.2
[**2184-10-5**] 01:19PM BLOOD VitB12-298
[**2184-10-6**] 05:20AM BLOOD Triglyc-65 HDL-70 CHOL/HD-2.8 LDLcalc-114
[**2184-10-5**] 01:19PM BLOOD TSH-0.64
[**2184-10-4**] 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2184-10-4**] 08:36PM BLOOD Type-ART Temp-36.6 pO2-151* pCO2-25*
pH-7.46* calHCO3-18* Base XS--3
[**2184-10-4**] 04:27PM BLOOD Glucose-99 Lactate-4.8* Na-135 K-4.6
Cl-101
[**2184-10-4**] 04:27PM BLOOD Hgb-14.5 calcHCT-44 O2 Sat-89 COHgb-<1.0
MetHgb-<1.0
[**2184-10-4**] 07:34PM BLOOD freeCa-1.09*
Brief Hospital Course:
Mr [**Known lastname **] presented with an acute confusional state after a fall
at home and there was initially question of a trancortical motor
aphasia. Mr. [**Known lastname 56910**] mentation fluctuated throughout the night,
and on evaluation by the primary service the morning after
admission was not thought to have an aphasia, but was still
confused. He was mildly anomic and mildy inattentive with memory
difficulties but there were no neurological deficits other than
this mild confusion, making stroke less likely. MR imaging
revealed chronic microvascular infarcts with no evidence of
acute infarct and there was an incidental lipoma (small) in the
third ventricle. MRA of the head showed no significant stenoses
in the tributaries of the circle of [**Location (un) 431**], and MRA of the neck
was limited by motion artifact but no significant stenosis was
identified. Further trauma work-up revealed likely left humeral
head impaction fracture ([**Doctor Last Name **]-[**Doctor Last Name 3450**]) of undetermined age and
possible mild AC joint malalignment. Orthopedics was consulted
and put the arm in a sling for immobilization, and Mr. [**Known lastname **]
will follow up with Dr. [**Last Name (STitle) 1005**] in 4 weeks. EEG showed
generalized mild sloweing consistent with a mild encephalopathy
along with more focal slowing in the right temperoparietal area.
Mr. [**Known lastname **] improved markedly overnight and examination revealed
only a mild cognitive impairment. He and his family feel that he
is back to baseline. He was stared on Lipitor to keep LDL <100.
Therefore, this man had a mild confusional state after a fall
with head injury, which is now resolving. We suspect that the
confusion is secondary to the fall; however, it remains unclear
why he fell. A mechanical etiology is possible, though
evaluating for cardiac causes is wise. Seizures in the setting
of old small-vessel infarctions remains a likely possibility
though we will not submit this man to medication without clear
evidence of clinical seizure.
Medications on Admission:
Atenolol 50 mg daily
Norvasc 5 mg daily
Iron 325 mg daily
MVI daily
Mg oxide 400 mg daily
Zinc sulfate220 mg daily
Vitamin C 500 mg daily
Vitamin B12 injection once per month
Stool softener 1-2 times per day as needed
Eye drops for ?glaucoma
Discharge Medications:
New medications added to regimen:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute confusional state, secondary to a fall
Discharge Condition:
Improved
Discharge Instructions:
Please return to nearest ER if symptoms return. Take all
medications as prescribed.
Followup Instructions:
Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 5499**]
Date/Time:[**2184-11-4**] 8:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2184-11-4**] 8:40
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2184-11-26**] 2:30
Completed by:[**2184-11-23**]
|
[
"293.0",
"780.2",
"873.42",
"812.09",
"996.78",
"401.9",
"E885.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9611, 9669
|
6910, 8960
|
344, 351
|
9757, 9767
|
5296, 6887
|
9900, 10382
|
2753, 2836
|
9253, 9588
|
9690, 9736
|
8986, 9230
|
9791, 9877
|
2851, 3351
|
277, 306
|
379, 2499
|
3969, 5277
|
3366, 3953
|
2521, 2638
|
2654, 2737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,344
| 132,444
|
45890
|
Discharge summary
|
report
|
Admission Date: [**2130-7-1**] Discharge Date: [**2130-7-4**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
male with a history of hypertension, hypertrophic
cardiomyopathy, prostate cancer, and colon cancer Stage I
status post partial colectomy in [**2112**] presents to the MICU
from the floor for approximately 1600 cc of bright red blood
per rectum. At transfer, his heart rate was 80, blood
pressure 120/60. On admission, his pulse was 63-72, blood
pressure 138/70. He denied lightheadedness, chest pain,
shortness of breath, or any symptoms. He had the bright red
blood per rectum from 12:45 am to 2:30 am, when he had
already drunk 2 liters of GoLYTELY for colonoscopy prep. His
hematocrit on admission was 35.3. At 2:25 pm on the 17th, it
dropped at 33.4. A 1:10 am on the 18th, floor nurse reported
dark maroon blood per rectum.
The patient initially presented to the Emergency Department
on the [**5-1**] with three days of melena. He had routine
colonoscopy on the [**4-22**]. Two polyps were excised, one
in the cecum and one 30 cm in the descending colon. Patient
noted two days of bright red blood on toilet paper following
the procedure. This changed to melena for three days prior
to admission. Patient denies any history of diverticulosis.
Denies chest pain, shortness of breath, abdominal pain. He
denies NSAID or aspirin use greater than 10 days prior to the
colonoscopy.
In the Emergency Department, the patient had a negative upper
GI lavage with 1 liter of normal saline on the floor. He was
being prepped for colonoscopy with GoLYTELY, started on IV
PPI, and his beta blocker was being held. The night-float
intern contact[**Name (NI) **] the GI fellow and ordered a TAG red blood
cell scan prior to his admission to the MICU. The patient
had received 1 unit of packed red blood cells on his transfer
to the MICU.
PAST MEDICAL HISTORY:
1. Colon cancer in [**2112**] status post resection, this is a
partial colectomy. He had a three year follow-up colonoscopy
which was negative. He had a five year follow-up colonoscopy
which was consistent with the two excised polyps.
2. He has a history of HOCM with diastolic dysfunction. He
had an echocardiogram on [**2130-2-15**] with a normal ejection
fraction, 2+ MR, 2+ TR.
3. Hypertension.
4. Prostate cancer status post two TURPs, one in [**Month (only) 205**] and one
in [**2130-1-15**]. His cancer had a [**Doctor Last Name **] score of 3+.
5. Coronary artery disease with clean coronaries and a
catheterization in [**2121**].
6. Hypercholesterolemia.
7. Hypothyroidism.
8. Peptic ulcer disease in the OMR, but the patient denies
this.
OUTPATIENT MEDICINES:
1. Lopressor 50 q am and q hs, 25 in midday for a tid dosing
schedule.
2. Lipitor 10 q day.
3. Synthroid 50 mcg q day.
4. Niacin.
5. Multivitamin.
6. Vitamin E.
7. Aspirin 81 q day.
EXAM ON TRANSFER: Pulse 75, pressure of 140/60, saturating
97% on room air. Not in any acute distress, pleasant, and
lying in bed. Extraocular movements are intact. Pupils are
equal, round, and reactive to light and accommodation.
Anicteric, no jugular venous distention. Chest was clear to
auscultation bilaterally. No wheezes, rales, or rhonchi.
Systolic ejection murmur II/VI, right upper sternal border
radiating to the carotids, large spaced MI, normoactive bowel
sounds, soft, no rebound, nontender, no distention, guaiac
positive. No clubbing, cyanosis, or edema, [**3-19**] dorsalis
pedis pulses. Cranial nerves II through XII intact. Alert
and oriented times three, 5/5 strength in his upper and lower
extremities.
LABORATORY DATA: Admit hematocrit 35.3, white count 7.2,
platelets 167, MCV 94. Sodium 141, potassium which is
hemolyzed at 5.1, repeat was 4.5, BUN of 31, creatinine of
1.1, chloride 104, bicarb 28, INR 1.1, PTT 24.2, AST at 45,
ALT 26, albumin 3.8, alkaline phosphatase 69, total bilirubin
0.9, total protein 6.7, amylase of 151, lipase of 60.
ECG [**1-16**]: Sinus bradycardia, left bundle branch old, normal
axis. Primary A-V conduction delay, PR interval of 252.
SOCIAL HISTORY: No tobacco, no EtOH. Exercises regularly,
swimming, and golf, retired theater manager. Lives with
female friend. [**Name (NI) **] no children.
FAMILY HISTORY: Noncontributory.
This is an 85-year-old male with past medical history of
colon cancer Stage I status post partial colectomy, prostate
cancer, HOCM, hypertension, who presents status post
colonoscopy on the 8th with polypectomy x2 presented to the
Emergency Department with melena and now from the floor with
bright red blood per rectum admitted for workup of the bright
red blood per rectum and observation in the MICU.
1. Bright red blood per rectum: The patient had a TAG red
blood cell scan which showed active bleeding in the cecum.
The patient then went to angiography on the morning of
transfer, and unfortunately, the area of bleeding was not
visualized. Later the same day on the 18th, the patient had
a colonoscopy and the GI team was able to find the bleeding
lesion in the cecum, and cauterized it, and injected.
He was transferred from the floor with a hematocrit of 33.4.
He received 1 unit and his hematocrit was 29.7. On the
morning of the 18th, the patient received another unit,
bumped his hematocrit to 32.1 and it was stable at 31.5 on
the day of discharge. The patient received intravenous
Protonix while he was NPO. His aspirin was held. He also
received no NSAIDs. Beta blocker was initially held until
the day of discharge.
The patient was instructed to followup with his
gastroenterologist, Dr. [**First Name8 (NamePattern2) **] [**Known lastname 349**] approximately one
week following discharge. He was instructed not to take
NSAIDs, aspirin, or vitamin E. The patient is instructed if
he had new melena or bright red blood per rectum, to call his
gastroenterologist and come to the Emergency Department.
2. Hypertension/CAD: Initially, his antihypertensives were
held. On the day of discharge, the patient was hypertensive
and slightly tachycardic. The patient's beta blocker was
instituted with decrease in heart rate and blood pressure.
Patient was monitored to rule out any hypotension. On the
day following the colonoscopy and the bowel prep, the patient
did have blood pressure in the low systolics in the 90s,
responded to IV fluids most likely representing dehydration
in the context of being NPO with a bowel prep and a valvular
lesion that is preload dependent. Following appropriate IV
hydration approximately 3 liters in 24 hours, patient's blood
pressure was stable in the 140s and 150s range.
The patient was instructed to hold his [**Last Name (un) **] until the day
following discharge. The patient was instructed to followup
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] approximately one week following
discharge. The patient was instructed to take easy activity
until following up with Dr. [**Last Name (STitle) **] as per Dr.[**Name (NI) 18056**]
instructions. Patient was continued on his statin.
3. Heme: Patient's coags were monitored and were within
normal limits. Platelet count decreased from 167 to
approximately 108, but remained above 100 throughout his
whole hospital stay.
4. Deep venous thrombosis prophylaxis: The patient was on IV
proton-pump inhibitors and pneumoboots, then converted to a
po proton-pump inhibitors.
Full code. This is discussed with the patient and
reaffirmed. He said he wanted everything done.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed secondary to cecal
polypectomy, status post colonoscopy and
intervention/injection, cauterization of the bleeding lesion.
2. Hypertrophic cardiomyopathy.
3. Hypothyroidism.
4. Hypertension.
5. Hypercholesterolemia.
6. Prostate cancer status post TURP x2.
7. Mitral regurgitation.
8. Tricuspid regurgitation.
9. Diastolic dysfunction.
DISCHARGE CONDITION: Stable/good.
DISCHARGE MEDICATIONS: No changes from his outpatient
regimen except the patient was instructed to not take his
aspirin until instructed by Dr. [**Last Name (STitle) **], and told to take his
metoprolol regimen 50 am and pm and 25 midday. Instructed
not to start his Avapro until the day following discharge.
He can continue on his normal 10 mg of Lipitor 10 q day,
Synthroid 50 mcg q day. Instructed to withhold and not take
his vitamin E, and told to avoid all NSAIDs, ibuprofen.
DISCHARGE FOLLOWUP: Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] in a week
following discharge.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-300
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2130-7-4**] 12:22
T: [**2130-7-8**] 08:05
JOB#: [**Job Number **]
|
[
"V10.46",
"578.9",
"424.0",
"401.9",
"E878.8",
"276.5",
"998.11",
"425.1",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7891, 7905
|
4256, 7481
|
7502, 7869
|
7929, 8391
|
8412, 8726
|
109, 1887
|
1909, 4075
|
4092, 4239
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,880
| 174,942
|
3761
|
Discharge summary
|
report
|
Admission Date: [**2176-2-14**] Discharge Date: [**2176-2-25**]
Date of Birth: [**2114-4-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Levaquin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Esophageal adenocarcinoma, Left lung NSCLC
Major Surgical or Invasive Procedure:
[**2176-2-14**]: 1. Left thoracotomy and left lower lobectomy plus
lingulectomy.
2. Intercostal muscle flap buttress.
3. Laparotomy and partial esophagectomy with
esophagogastric anastomosis in the left chest.
4. Tube jejunostomy.
History of Present Illness:
Ms. [**Known lastname 16919**] is a 61-year-old woman with 1 year history of
recurrent URI-type symptoms. Most recently in the past [**1-24**]
weeks
she has had cough, occasionally productive of yellow sputum. A
chest x-ray ordered by her PCP demonstrated [**Name Initial (PRE) **] suspicious
spiculated LLL lung nodule, and CT scan revealed a 5.2-cm
juxtahilar superior segment spiculated mass and left hilar lymph
node enlargement, as well as esophageal thickening consistent
with primary esophageal neoplasm.
Subsequently, she underwent PET scan which revealed a dominant
FDG-avid left hilar mass, SUVmax 13.6, centered in the superior
segment of the left lower lobe, compatible with bronchogenic
carcinoma, as well as low-level FDG-avid nodules at the base of
the left upper lobe and in the right lower lobe and FDG avidity
in and around the distal esophagus with a thickened wall.
Biopsy obtained on EUS revealed adenocarcinoma, positive
staining
of the tumor cells with CDX2, variable staining of the tumor
cells with cytokeratin 7 and few scattered tumor cells staining
with cytokeratin 20, with tumor cells nonreactive with TTF-1.
These finding support a gastrointestinal origin.
Biopsy obtained on EBUS revealed NSCLC, positive staining of the
tumor cells with cytokeratin 7 and TTF-1, few scattered cells
show positive staining with p63, with tumor cells non-reactive
with CK20 and CDX2. These findings support a pulmonary origin.
Past Medical History:
1) hx bilateral breast CA
- s/p L mastectomy and chemo (CMF) [**2153**] for stage II breast
CA, ER/PR positive
- s/p R mastectomy [**2157**] for stage I breast CA, no adj rx
- s/p bilateral breast reconstruction
2) Squamous cell skin CA excised R thigh [**8-28**], invasive,
well-differentiated, at least 3 mm deep, extended to peripheral
and deep specimen margins. Re-excised [**2174-11-28**] - no residual
squamous cell CA.
3) ?? asthmatic bronchitis, allergic rhinitis
4) Hyperlipidemia:
5) Bilateral [**Hospital1 15309**] neuroma
6) Colonoscopy [**3-26**] - diverticulosis
Social History:
Lives with husband
40 pack-year smoker, quit 2 weeks ago upon
learning diagnosis, using chantix. 2 glasses wine / week.
Family History:
Mother - no cancer or heart disease
Father - MI at 88
Physical Exam:
VS: T: 97.3 HR: 90's SR BP: 118/64 Sats: 97% RA
General: 61 year-old female no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: diminished breath sounds on left otherwise clear
GI: bowel sounds positive.
Extr: warm no edema
Incision: Left thoracotomy clean, dry, intact, abdominal clean,
dry intact
J-tube site clean. no discharge
Neuro: non-focal
Pertinent Results:
[**2176-2-22**] WBC-9.9 RBC-3.14* Hgb-9.7* Hct-29.1* Plt Ct-348
[**2176-2-20**] WBC-8.1 RBC-3.09* Hgb-9.6* Hct-28.6* Plt Ct-304
[**2176-2-17**] WBC-13.6* RBC-3.21* Hgb-10.0* Hct-29.7* Plt Ct-301
[**2176-2-16**] WBC-12.1*# RBC-3.36* Hgb-10.5* Hct-31.1* Plt Ct-269
[**2176-2-14**] WBC-8.5 RBC-3.21*# Hgb-10.5*# Hct-29.7*# Plt Ct-260
[**2176-2-23**] Glucose-121* UreaN-17 Creat-0.7 Na-141 K-4.2 Cl-107
HCO3-25
[**2176-2-22**] Glucose-126* UreaN-18 Creat-0.7 Na-138 K-4.2 Cl-104
HCO3-24
[**2176-2-20**] Glucose-107* UreaN-16 Creat-0.6 Na-144 K-3.6 Cl-109*
HCO3-28
[**2176-2-19**] Glucose-139* UreaN-16 Creat-0.6 Na-148* K-4.2 Cl-114*
HCO3-28
[**2176-2-15**] Glucose-148* UreaN-19 Creat-0.8 Na-139 K-4.9 Cl-111*
HCO3-23 [**2176-2-14**] Glucose-174* UreaN-17 Creat-0.8 Na-138 K-4.7
Cl-110* HCO3-23
[**2176-2-20**] CK(CPK)-285*
[**2176-2-23**] Calcium-8.7 Phos-3.7 Mg-2.2
CXR:
[**2176-2-23**] FINDINGS: In comparison with the study of [**2-19**], the
chest tubes have been removed and there is no evidence of
pneumothorax. The opacification at the left base is somewhat
less prominent than on the previous images. The right lung is
essentially clear.
[**2176-2-19**] There is residual left upper lobe atelectasis and
interval improvement in the right basilar atelectasis.
[**2176-2-18**] Elevation of the left hemidiaphragm reflecting left
lung resection is stable since [**2-15**]. Leftward mediastinal
shift has improved. There is a combination of atelectasis at the
base of the post-operative left lung and the gastric pull-up
which probably is responsible for most of the opacification at
the medial aspect of the left lower lung. Mild atelectasis in
the right lung is new. Upper lungs are clear. No pneumothorax.
Cardiomediastinal silhouette, normal post-operative appearance.
Left jugular line in standard placement. A drainage tube pull up
above the diaphragm. Left pleural tubes still present at the
base and upper midline left hemithorax.
Esophagus: [**2176-2-21**] Status post esophagectomy with gastric
pull-through, without evidence of a leak.
Echo: TEE [**2176-2-14**] Surgeons performed egd prior to TEE to ensure
saftey of probe placement. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses and cavity
size are normal. The right ventricular free wall is mildly
hypertrophied. The right ventricular cavity is mildly dilated
with borderline normal free wall function. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. There is no aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. RV function unchanged after lung
resection. TEE probe removed after lung resection prior to
esophageal surgery. EGD was perfomed after TEE. No complications
or injuries noted
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**2176-2-14**] for Left thoracotomy and
left lower lobectomy plus lingulectomy. Intercostal muscle flap
buttress. Laparotomy and partial esophagectomy with
esophagogastric anastomosis in the left chest. Tube jejunostomy.
She was Extubated in OR. Overnight she did well.
[**2-15**]: AM hypotension not responsive to 1L fluids (crystalloid +
albumin), levophed started. 1 unit PRBC transfused for Hct 27 w/
appropriate response. Weaned off levophed over 20 hours, with
stable Hct.
[**2-17**]: She had rapid atrial fibrillation to the 170's. She
converted to NSR, with a dilt drip converted to po dilt. CTs to
waterseal, trophic TFs started, epidural out
[**2-18**]: rate controlled on PO dilt. NGT D/C'd. Hypernatremic - TFs
changed to 1/2 strength, D5W started. Her hypernatremia
resolved. The tube feeds were converted to full strength. Her
esophagus study on [**2176-2-21**] revealed no leak. She was started
on a clear liquid diet and advanced to full as tolerated. The
anterior apical chest tube was removed on [**2176-2-23**]. Her pain
was well controlled with Roxicet and motrin. She was followed
by physical therapy throughout her hospital course. Nutrition
recommended Replete with fiber goal 60/hr. She continued to do
well and was discharged to home. She will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Chantix, zocor, codiene
Discharge Medications:
1. Replete with Fiber
3/4 Strength: Goal 90cc/hr [**Month (only) 116**] cycle tube feeds
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month (only) **]: [**11-24**]
Drops Ophthalmic PRN (as needed).
3. Sodium Chloride 0.65 % Aerosol, Spray [**Month/Day (2) **]: [**11-24**] Sprays Nasal
QID (4 times a day) as needed.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Day (2) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*400 ML(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
7. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Two (2) mL PO Q8H (every
8 hours).
Disp:*180 mL* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Allcare VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Esophageal Cancer
Lung Cancer
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101, chills, redness or drainage around wound site
-Go directly to the ED if you experience any of the following;
chest pain, acute shortness of breath, intractable
nausea/vomiting, severe pain not relieved by medication, or any
other concerning symptoms.
Take all new medications as prescribed, you may resume all
previous medications unless otherwise directed. Adhere strictly
to the diet as directed. You may cover the chest tube drainage
site with a band-aid.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**3-8**] at 2:30 on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-ray
Completed by:[**2176-2-27**]
|
[
"276.0",
"150.8",
"427.31",
"162.8",
"V10.3",
"458.29",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.52",
"46.39",
"83.82",
"96.6",
"32.49",
"32.39",
"42.41"
] |
icd9pcs
|
[
[
[]
]
] |
8779, 8853
|
6226, 7617
|
317, 558
|
8927, 8936
|
3319, 6203
|
9537, 9814
|
2813, 2869
|
7691, 8756
|
8874, 8906
|
7643, 7668
|
8960, 9514
|
2884, 3300
|
235, 279
|
586, 2034
|
2056, 2658
|
2674, 2797
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,654
| 132,971
|
49423
|
Discharge summary
|
report
|
Admission Date: [**2129-11-7**] Discharge Date: [**2129-11-15**]
Date of Birth: [**2068-7-11**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man
with end stage renal disease on hemodialysis with multiple
comorbidities including hypertension, diabetes mellitus,
hepatitis B infection, who presents to the hospital for a
kidney transplant. On arrival, he denies any recent illness,
fevers, chills, nausea, vomiting or diarrhea.
PAST MEDICAL HISTORY: Diabetes mellitus type 2.
Hypertension.
End stage renal disease, on hemodialysis.
Bilateral renal artery stenosis.
Peripheral vascular disease.
Hepatitis B infection.
Gout.
Anemia.
PAST SURGICAL HISTORY: Appendectomy.
Lower back surgery.
Multiple arterial venous grafts and revisions.
SOCIAL HISTORY: He denies smoking, occasional use of alcohol
with history of heavy alcohol use approximately twenty years
ago, lives with his wife and retired last year, office
supervisor.
FAMILY HISTORY: Positive for diabetes mellitus.
ALLERGIES: Questionable allergy to Oxacillin which gives
shut down of kidneys.
MEDICATIONS ON ADMISSION:
1. Renagel 400 mg three times a day.
2. Aspirin 81 mg daily.
3. Lopressor 100 mg three times a day.
4. Allopurinol 200 mg twice a day.
5. Neurontin 300 mg daily.
6. Zestril 20 mg daily.
7. Multivitamins.
8. Humulin 30 units in the a.m. and 34 units in the p.m.
9. Insulin sliding scale.
PHYSICAL EXAMINATION: Temperature is 98, pulse 78, blood
pressure 166/88, respiratory rate 16, oxygen saturation 96
percent in room air. In general, a middle age to elderly man
with some obesity in the truncal distribution who was in good
spirits. The heart is regular. The lungs are clear
bilaterally. The abdomen is soft, nontender, obese, with
bowel sounds and a right lower quadrant appendectomy scar,
which is well healed. Extremities are warm with palpable
pulses.
LABORATORY DATA: On admission, white blood cell count 8.0,
hematocrit 38.0, platelet count 183,000. Potassium 4.3,
blood urea nitrogen 95, creatinine 9.5. INR 1.1.
HOSPITAL COURSE: The patient presented to the hospital on
[**2129-11-7**], for kidney transplantation. He was taken to the
operating room on [**2129-11-7**], where he received two kidney
transplants intraperitoneal, extra kidney available for the
patient location. Details of the operation can be found on
the operative note. During the transplant, the patient was
noticed to have prolonged clotting time. Approximately 400
cc of blood loss was recorded. Immediately
posttransplantation, he was started on small dose of Neo-
Synephrine which was turned off by the morning. On
postoperative day number one due to elevated potassium level
in the 7.0 range, a decision was made to dialyze the patient
without taking any volume off. He underwent this dialysis
with 1.3 liters without any problems. After this, he was
admitted to the floor for routine postoperative care,
awaiting return of the graft function. The patient's
postoperative care initially was also significant for
increased abdominal distention which was assessed to be
likely postoperative ileus and was followed by KUB
examinations. On postoperative day number two, while being
clinically stable, the patient was noticed to have a rapid
heart rate in the 160s which was confirmed to be atrial
fibrillation by electrocardiogram. He was given extra doses
of Lopressor to control his heart rate and was checked with
enzymes to rule out myocardial infarction. Cardiology
consultation was also called. With help of beta blockers and
electrolyte management, the patient converted to sinus
rhythm. At this time, hepatitis B immunoglobulin and
Lamivudine was also started given the patient's history of
hepatitis B. On the third day, the patient had an
unremarkable course, however, failed to pass any flatus and
maintained his abdominal distention. He also excessively
complained about a sore throat which was evaluated by the ENT
service and found to be irritation from the endotracheal
tube. The patient was continued with some sips, was
encouraged to ambulate and was continued on dialysis. On the
early morning of postoperative day number five on a routine
daily blood check, the patient's hematocrit was found to be
20.2. This was immediately confirmed as real and a stat
abdominal CT scan and ultrasound scan were obtained. The
abdominal CT showed hematoma posterior to the right
transplanted kidney. On ultrasound evaluation, the bowel gas
made it difficult to visualize the right kidney and assess
the Doppler flow to the right kidney. Given this, the
decision was made to take the patient to the operating room
for assessment of the kidney and evacuation of the hematoma.
The patient was taken back to the operating room on
[**2129-11-12**], at 10:00 in the morning for an exploration. He
received right sided hematoma evacuation and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**]
drain placement. Both kidneys were found to be in good
condition and viable. After the operation, the patient did
well and was readmitted to the floor for further
postoperative care. Of note after the exploration, the
patient was found to start making good urine and to start
putting out excessive amounts of serosanguineous fluid in the
one to two liter range from his [**Location (un) 1661**]-[**Location (un) 1662**] drain on the
right side. The [**Location (un) 1661**]-[**Location (un) 1662**] output was checked for
creatinine and was negative for any urine leak. Over the
next two days, the patient continued to make excellent urine
output and it was felt that he would no longer need dialysis.
His abdominal distention, however, continued and he was kept
strict NPO given the appearance of the right colon on
intraoperative examination on [**2129-11-12**]. A small serosal
tear on the right colon was also repaired at this time. On
postoperative day number eight and three, the patient was
seen by the transplant service in the early morning and he
was clinically stable sitting in a chair in good spirits.
Approximately one hour after this, telemetry alarm sounded
for tachycardia and on arrival to the room, the nurses found
the patient lethargic and somewhat difficult to arouse. He
was immediately placed in the bed and the house staff was
called. On initial evaluation, he regained his consciousness
and was alert and oriented, however, his blood pressure was
low with minimal setting in the systolics of 60. He was
given saline for volume and two units of blood immediately.
Stat hematocrit was checked which was 26.0. The hematocrit
jumped to 29.0 after two units of blood and several liters of
saline. Given this acute deterioration, the decision was
taken to move the patient immediately to the Intensive Care
Unit. Upon arrival to the Intensive Care Unit, he continued
to remain stable and started feeling better. Given that the
cause of his instability earlier in the morning may be
hypovolemia or a bleed or a myocardial infarction or a
pulmonary embolus, wide workup was initiated. Volume was
given to correct the hematocrit. A CT scan was obtained
which did not show any major hematomas. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**]
hematocrit was checked which was only 6.0. Enzymes were
cycled which were negative for myocardial infarction. An
arterial blood gas was checked which showed an excellent pO2
of 150 on nasal cannula. Given these negative studies and
clinical improvement, the decision was taken to watch the
patient in the Intensive Care Unit. He continued to do well
and was followed with routine Intensive Care Unit care. At
approximately 10:00 o'clock that night on [**2129-11-15**], the
alarm sounded again and, when the nurse entered the room, the
patient was again unresponsive. A code was immediately
called and as the team rushed into the room, the patient's
rhythm was found to be asystolic. He also at this time
aspirated contrast and was immediately emergently intubated.
Cardiopulmonary resuscitation was initiated according to ACLS
protocol and upon Epinephrine injection the rhythm was
changed to PEA. At multiple times, faint pulse was obtained
and volume resuscitation along with ACLS medications was
continued. Despite prolonged efforts, despite suctioning on
the [**Location (un) 1661**]-[**Location (un) 1662**], despite adequate oxygenation, the patient
could not sustain pulse himself. After forty minutes of
cardiopulmonary resuscitation and no signs of life, the code
resuscitation was stopped and the patient was declared dead
at 2232 on [**2129-11-15**]. The family was informed of the
patient's death.
DISCHARGE DIAGNOSES: Kidney transplantation.
End stage renal disease.
Hypertension.
Diabetes mellitus.
Hepatitis B.
Bilateral renal artery stenosis.
Obesity.
DISPOSITION: The patient died on this admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 22102**]
MEDQUIST36
D: [**2129-11-17**] 23:01:54
T: [**2129-11-18**] 10:27:31
Job#: [**Job Number 103466**]
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19,412
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21699
|
Discharge summary
|
report
|
Admission Date: [**2142-9-3**] Discharge Date: [**2142-10-2**]
Date of Birth: [**2114-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Endocarditis
Major Surgical or Invasive Procedure:
[**2142-9-9**] Redo Bentall procedure ([**Street Address(2) 17009**]. [**Male First Name (un) 923**] mechanical
AV/graft composite)/Hemi Arch aortic replace.(26 mm Gelweave)/
LVOT reconstruction ( pericardial patch)
History of Present Illness:
28 yo male with h/o bicuspid valve with aortic valvuloplasty at
age 15, MSSA endocarditis in [**2137**] (age 24) s/p AVR with a
homograft, and subsequent endocarditis in [**2140**] with AVR with a
mechanical valve, and h/o IVDU; p/w prosthetic valve
enterococcal IE.
The patient was slowly becoming more dyspnic over the past
several weeks. He usually is quite active at baseline, but has
noticed in the past week he has had difficulty walking to class
that has forced him to stop. On Thursday, the patient
experienced acute shortness of breath while sitting at home. He
called 911 and was taken to the emergency room in [**Location (un) **]. On
presentation in the ED, he had profound anemia with a Hct of
11.5. He was found to be in acute pulmonary edema as well. He
had a mild troponin I elevation of 0.37 with a BUN and Creatine
37/1.9 (BUN/Cr baseline 10-18/0.8-1.0). His white count was 8.1.
.
He was electively intubated secondary to respiratory instability
and respiratory acidosis. TEE on [**8-31**] revealed a large
obstructive mass in the ascending aorta, with prosthetic valve
AI, as well as aneurysm and dehiscence in the aorta. After the
TEE, blood cultures were sent, which eventually grew
enterococcus. He was started on Amp/Gent, diuresed and received
10 units of PRBCs. Patient's respiratory status improved and was
extubated [**9-2**]. He was transferred to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] for further
management and evaluation by CT surgery of repeat AVR.
.
Of note, he had a tooth filling in [**Month (only) 404**] and a re-do filling
in [**Month (only) 958**], of which he took antibiotics both times. He states
after [**Month (only) 958**], he started feeling ill. He c/o muscle cramps in his
thighs and increased palpipations. He denied shortness of breath
until the episode last week.
.
Upon arrival to the CCU, vitals were T: 99.5 HR: 73 BP: 95/62
RR: 26 SpO2: 99% on 4L. He denied complaints, notably, denied
CP, SOB, dizziness, and palpitations.
.
On review of symptoms, he complains of left lower extremity
numbness and decreased pulses in DP/PT. He was followed by
vascular surgery in the OSH and no intervention was done.
.
He denies any prior history of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, cough,
black stools or red stools. 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,
pnd, orthopnea, ankle edema, syncope or presyncope.
Past Medical History:
1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure
Social History:
Quit tobacco just prior to admission h/o [**2-9**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR.
Family History:
Patient adopted and does not know family history.
Physical Exam:
72" 90 kg
Blood pressure was 95/62 mm Hg while seated. Pulse was 70
beats/min and regular, respiratory rate was 26 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were appropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. There is a 2x2mm scleral
hemorrage in the L eye. The neck was supple with JVP at
clavicle. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills or
palpable S3 or S4. Mild lift was noted. The heart sounds
revealed a normal S1 and the S2 was normal. There were no rubs
or gallops. Harsh [**5-14**] crescendo/decresendo systolic murmur heard
best at the left sternal border on the clavicle; radiating to
carotids, apex, and back.
.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 1+ PT 1+
Pertinent Results:
Admission Labs:
[**2142-9-3**] 07:32PM PTT-58.3*
[**2142-9-3**] 02:30PM GLUCOSE-103 UREA N-32* CREAT-1.2 SODIUM-139
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11
[**2142-9-3**] 02:30PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2142-9-3**] 02:30PM WBC-8.8 RBC-3.75* HGB-10.3* HCT-29.9* MCV-80*
MCH-27.4 MCHC-34.4 RDW-18.3*
[**2142-9-3**] 02:30PM NEUTS-85.1* LYMPHS-11.6* MONOS-2.0 EOS-1.1
BASOS-0.2
[**2142-9-3**] 02:30PM PT-25.5* PTT-60.3* INR(PT)-2.5*
ECG Study Date of [**2142-9-3**]:
Sinus rhythm. Rightward axis. Deep T wave inversions in leads
V1-V6 raise the possibility of ischemia, metabolic effect or
left ventricular hypertrophy. Compared to the previous tracing
of [**2140-3-19**] anterior and lateral T wave abnormalities are more
pronounced.
ART EXT (REST ONLY) Study Date of [**2142-9-4**]
IMPRESSION:
1. Severe left tibial disease, greater in the dorsalis pedis
than in the
posterior tibial artery.
2. Right ABI of 1.25 and the left ABI of 0.68 at rest.
3. Normal right lower extremity hemodynamics at rest.
MRI Head W/ and W/O Contrast ([**2142-9-4**]):
IMPRESSION:
1. Interval development of small contrast-enhancing and
hemorrhagic lesions along the cerebral hemispheres and left
cerebellum, which may be cortical or leptomeningeal. Given the
clinical setting, they are consistent with septic emboli.
2. Interval increase in chronic infacts and chronic
microhemorrhages, likely due to recurrent emboli in the setting
of AVR.
Chest/Abdomen/Pelvis CT w/ and w/o contrast ([**2142-9-5**]):
IMPRESSION:
1. Post-surgical changes with aortic graft and aortic valve
prosthesis.
2. Dilated ascending aorta measures up to 5.9 cm in diameter.
3. Cardiomegaly.
4. Small left pleural effusion.
5. Left basilar consolidation/atelectasis.
6. Splenomegaly.
7. Small amount of free fluid in the pelvis.
8. No CT evidence for aortoenteric fistula.
9. Air in the non-dependent portion of the urinary bladder may
be related to instrumentation. Please correlate clinically.
MRA Lower extremities ([**2142-9-5**]):
1. Aortoiliac station: The aortoiliac system is widely patent.
2. Left lower extremity: Embolic occlusion of the distal
tibioperoneal trunk, long segment of proximal posterior tibialis
artery, peroneal artery, distal anterior tibialis artery,
plantar arch and proximal dorsalis pedis.
3. Right lower extremity: Abrupt cut off of enhancement of the
distal right posterior tibialis artery, which reconstitutes
retrograde without a gap in enhancement identified on delayed
images is of uncertain significance. The findings would be
unlikely to be a very small focal embolus alternatively
congenital variant. The remainder of the arteries of the right
lower extremity are widely patent.
TEE ([**2142-9-8**]):
No atrial septal defect is seen by 2D or color Doppler. LV
systolic function appears depressed. A mechanical aortic valve
prosthesis is present. A paravalvular aortic valve leak is
present. An aortic annular abscess is seen with turbulent flow
measuring 1.5x3.2cm2 in the anterior portion. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. No
aortomitral continuity disruption is identified. Proximal
pulmonary artery is not well visualized. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
Conclusions
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
severe regional left ventricular systolic dysfunction with
hypokinesia of the anterior wall, anteroseptal wall, septal and
inferoseptal wall . Overall left ventricular systolic function
is severely depressed (LVEF= 25 %). with moderate global RV free
wall hypokinesis. A mechanical aortic valve prosthesis is
present. A paravalvular aortic valve leak is present. The aortic
valve prosthesis cannot be adequately assessed. An aortic
annular abscess is seen. Significant aortic regurgitation is
present, but cannot be quantified. Mild (1+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2142-9-9**] at 945am. Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] present for
the perioperative study and felt the aortic root abscess was
bigger in size compared to yesterday.
Post Bypass
The patient is in sinus rhythm receiving an infusion of
Norepinephrine, milrinone and vasopressin. Biventricular
systolic function is slightly improved. Mechanical valve seen in
the aortic position. Appears well seated and the leaflets move
well. Peak gradient across the arotic valve is 28 mm Hg.
Findings discussed with Dr [**Last Name (STitle) **].
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2142-9-9**] 20:38
Brief Hospital Course:
28 year old with h/o recurrent aortic valve endocarditis, AVR x
2 presenting with enterococcal bacteremia causing dehiscence of
aortic valve replacement ring/right fibrous trigone, and s/p
profound hemolytic anemia secondary to valvular damage.
# Endocarditis: Patient was transferred to our hospital for
enterococcal mechanical valve endocarditis in OSH. He was
continued on ampicillin and changed from gentamycin to
ceftriaxone per ID recommendations, as he has had ototoxicity to
gentamycin in the past. During his workup, he was found to have
embolic phenomena to his left eye ([**Doctor Last Name **] spot),left foot, and
brain (of note, MRA of the head ruled out mycotic aneurysm prior
to surgery). He had new wall motion abnormalities on TTE that
were concerning for emboli to the coronary arteries. He had a
dental filling replacement in [**Month (only) 958**], even though patient took
antibiotics, he started to feel increasingly tired some time
after this procedure. Since patient denies IVDU, it is likely
the dental procedure is the source of his enterococcus
bacteremia.
Approximately 5 days after admission (on [**2142-9-8**]), patient had a
TTE and TEE that showed increased size of his aortic valve
abscess. In addition, his hematocrit dropped signifying
worsening hemolytic anemia and he had worsening signs of heart
failure requiring aggressive diuresis with Lasix. He was
restarted on gentamicin as this is the best treatment for
enterococcal endocarditis, despite the risk of ototoxicity. Per
ID recs and cardiology recs, CT surgery decided to take the
patient for AVR the next morning ([**2142-9-9**]).
# Aortic Valve Replacement: Patient with dehiscent aortic valve
in the right fibrous trigone. Patient was hemodynamicaly stable
in the CCU, but obviously he was clinically worsening and aortic
valve integrity was worsening on echo. Patient on a heparin
drip for anticoagulation prior to the surgery (coumadin stopped
[**2142-9-6**])
# Pump: EF on TTE in [**2141-11-27**] (after AVR) was > 55% with normal
filling pressures PCWP < 12. Patient with symptoms of heart
failure intermittently throughout admission that acutely
worsened with decreased hematocrit and aortic valve destruction.
He was treated with Lasix, which he responded to well with less
shortness of breath and peripheral edema. Afterload reduction
was aggressively pursued in this patient with metoprolol
titrated up during his stay.
# Anemia: Patient anemic throughout admission, most likely due
to anemia. There was some concern for GI bleed, as patient was
guaiac positive, but CT aorta showed no aortoenteric fistula.
Metoprolol was continued to reduce shear stress. He was
transfused 10 units of blood at the outside hospital, and 2
units prior to his surgery here.
# Suspected L foot embolic disease - Patient initially had pain
in left lower extremity with diminished pulses. The feet were
warm and well-perfused. MRA of the lower extremities showed
multiple occlusions but also significant collateral flow.
Clinically, his pain decreased throughout his stay and pulses
became louder on doppler.
# CORONARIES: Cardiac Cath [**3-17**] showed clean coronaries. Patient
did have a troponin leak of 0.37. This is likely secondary to
demand ischemia secondary to profound anemia.
# History of IVDU: Patient states he has not used IV drugs since
prior to his second surgery in [**2139**]. He is Hep C negative. He
is maintained on suboxone as an outpatient. His suboxone was
decreased on admission due to concerns about pain control after
his CT surgery. The addiction team was consulted who managed
his suboxone weaning.
# RHYTHM: Patient remained in normal sinus rhythm throughout his
admission. He was monitored with daily ECG's for signs of new
AV block.
Patient was FULL CODE throughout this admission.
Mr. [**Known lastname 57041**] [**Last Name (Titles) 1834**] a redo sternotomy, redo bental (25mm st.
[**Male First Name (un) **] mechanical aortic valve graft), hemi-arch replacement, and
left ventricular outflow tract reconstruction with pericardial
patch with Dr. [**First Name (STitle) **] on [**9-9**]. He tolerated the procedure well
and was transferred to the CVICU in stable condition on
levophed, milrinone, vasopressin and propofol drips. His
antibiotics were continued per the infectious disease service.
He was weaned from his pressors and extubated. Pain control
quickly became an issue so the acute pain service was consulted.
His chest tubes and epicardial wires were removed. Coumadin
and heparin were started for his mechanical aortic valve. Dr.
[**First Name (STitle) 437**] of the heart failure service followed Mr. [**Known lastname 57047**] course
as he did pre-operatively. He was transferred to the surgical
step down floor on post-operative day four. He was seen in
consultation by infectious disease for vegetation obtained
during OR which was positive for pan sensitive enterococus. He
was treated with ampicillin 2 gms IV q4hrs and gentamycin 90mg
IV q24hrs for enterococcal endocarditis which he will continue
on until [**2142-10-21**]. The pain service was aslo consulted regarding
pain management- he was treated w/ MS contin and Morphine IR
successfully. He was being weaned from his MS contin and has
been on suboxone in the past and will discuss this with his PCP
upon return to home. His current dose of MS contin is 15mg tid
w/ 15 mg of IR morphine for breakthru.
He was doing well until POD#11 when he had vague c/o "not
feeling well". An Echo was done revealing pericardial effusion
with tamponade physiology. Mr. [**Known lastname 57041**] was taken emergently back
to the OR and a moderate amount of clot was evacuated. See
operative note for details. Post operatively he was admitted to
the CVICU intubated and sedated. he was weaned and extubated on
POD#2. he was transferred to the step down unit on POD#3. He
continued to be followed by infectious disease and chronic pain
service. He was restarted on coumadin for mech AVR (goal
2.5-3.5)without heparin bridge d/t risk of bleeding. he was
folowed by daily echo to eval for recurrent pleural effusion-
all echo's were without recurrent effusion.
He was discharged to home on IV ampi and gent thru [**2142-10-21**] with
infectious disease follow up. He will be on 10mg of coumadin to
maintain goal INR 2.5-3.5.
Medications on Admission:
CURRENT MEDICATIONS: HOME
Carvedilol 25 mg [**Hospital1 **]
Lisinopril 10 mg Daily
Aspirin 81 mg Daily
Coumadin 10 mg Daily
Suboxone
.
Medications in OSH:
Ampicillin 2 grams IV q 4 hours
Gentamicin 70 mg IV q 12 hours
Vancomycin 1.25 mg
Ambien
Lasix 40 IV BID
Cefipime: 1 gram IV x 1
Ceftazidime IV 2 grams
Fentanyl
Versed
Morphine
Benedryl
Solumedrol 125 mg IV x 1
Vitamin K 10 mg IV (INR 6.6 on presentation)
.
Discharge Medications:
1. Outpatient [**Hospital1 **] Work
Needs CBC, Panel 7, LFTs, coags, gentamicin level drawn every
Monday and gent level and BUN/Cre every Friday with results sent
to the infectious disease clinic attn: infectious disease nurses
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
4. Outpatient [**Hospital1 **] Work
INR will be drawn on Monday [**2142-10-5**] with results sent to the
coumadin clinic at the office of Dr. [**Last Name (STitle) 57048**] (cardiologist)
phone ([**2142**], fax ([**Telephone/Fax (1) 57049**]. Plan confirmed with [**Doctor First Name **]
on [**2142-9-27**]. INR goal for mechanical AVR is 2.5 to 3.5.
5. Gentamicin 40 mg/mL Solution Sig: Ninety (90) mg Injection
Q24H (every 24 hours): last dose on [**10-21**].
Disp:*19 doses* Refills:*0*
6. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) gms
Injection Q4H (every 4 hours) for 19 days: last dose 9/13.
Disp:*76 doses* Refills:*0*
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*0*
8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
Disp:*42 Tablet Sustained Release(s)* Refills:*0*
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for severe pain.
Disp:*40 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 doses: Take as directed by the office of Dr. [**Last Name (STitle) 57048**].
Disp:*60 Tablet(s)* Refills:*0*
12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
Disp:*4 Patch Weekly(s)* Refills:*2*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Albony VNA
Discharge Diagnosis:
enterococal prosthetic valve endocarditis
CHF, chronic systolic heart failure
s/p redo(X4) Bentall procedure/repl. hemiarch aorta/ LVOT
reconstruct.
prior MSSA endocarditis
prior MRSA endocarditis
prior encephalomalacia ( infarct in past)
[**2137**] septic emboli to spleen, kidney, cerebrum)
prior IVDU
deafness one ear ( gentamicin ototoxicity)
Discharge Condition:
good
Discharge Instructions:
no lotions, creams, ointments, or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
no driving for one month AND off all narcotics
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) ([**Telephone/Fax (1) 57050**] in [**2-9**] weeks.
Please see Dr. [**Last Name (STitle) 57048**] (cardiologist in NY) in [**3-13**] weeks.
Please see Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (cardiologist in MA) in [**3-13**] weeks.
Please see Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] (Cardiac surgeon) in [**3-13**] weeks
[**Telephone/Fax (1) 170**]
Please see Dr. [**Last Name (STitle) **] (Infectious disease) in [**3-13**] weeks.
Needs CBC, Panel 7, LFTs, coags drawn every Monday and a BUN/Cre
every Friday with results sent to the infectious disease clinic
attn: infectious disease nurses
INR will be drawn on Monday [**2142-10-1**] with results sent to the
coumadin clinic at the office of Dr. [**Last Name (STitle) 57048**] (cardiologist)
phone ([**2142**], fax ([**Telephone/Fax (1) 57049**]. Plan confirmed with [**Doctor First Name **]
on [**2142-9-27**]. INR goal for mechanical AVR is 2.5 to 3.5.
If pain continues to be [**Name (NI) 2480**], can follow-up in pain
clinic.
Please obtain a audiology exam within 1-2 weeks.
Please call for all appts.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-10-2**]
|
[
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"427.41",
"995.91",
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"283.19",
"449",
"998.11",
"414.8",
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"E878.1",
"428.23",
"E878.2",
"421.0",
"V12.54",
"038.0",
"423.3",
"444.22",
"996.61",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.45",
"34.03",
"39.61",
"39.59",
"35.22",
"88.41",
"96.71",
"35.39",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19804, 19845
|
10790, 17133
|
286, 504
|
20236, 20243
|
5868, 5868
|
20591, 21920
|
4246, 4297
|
17597, 19781
|
19866, 20215
|
17159, 17159
|
20267, 20568
|
4312, 5849
|
234, 248
|
17180, 17574
|
532, 3093
|
5885, 10767
|
3115, 4026
|
4042, 4230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,777
| 178,607
|
48000
|
Discharge summary
|
report
|
Admission Date: [**2186-7-27**] Discharge Date: [**2186-8-1**]
Date of Birth: [**2141-6-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"nausea and vomtting."
Major Surgical or Invasive Procedure:
Hemodialysis
CVL placement
History of Present Illness:
.
Mr. [**Known lastname **] is a 45 yo M with IDDM c/b nephropathy and ESRD HD
mwf, CABG x 4 and aflutter who presented with nausea and
vomtting. Started to have nausea day PTA. Then, nausea
persisted the following day, which was a dialysis day for him.
He presented to HD with nausea and also fevers and chills x 1
day. At HD, c/o feeling fatigued/chills/unwellness. The
outpatient renal team got blood cultures and the patient was
given IV cefazolin. Still felt abnormal with N/V. They did not
take much fluid off at HD. Went home, got called back for Group
G strep + blood cultures and proteus (pansensitive).
On arrival to the ED, hypotensive received 3 Liters IVF.
Transfered to the MICU was started on Vanc/Zosyn and briefly
required pressor support. Abx's were narrowed to CTX [**2186-7-29**].
TEE was perfromed which did not show vegetations.
Upon transfer from the MICU, his vitals were 98.2,
90-100/50-70s, 60-80, 18, 98% RA. He was comfortable and voiced
only that he was ready to go home. He would like to have abx
dosed with HD so that he does not need an additional line.
.
ROS: Denies fever, chills, night sweats after admission to the
hospital, headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
# Stage V CKD d/t diabetic nephropathy, followed by Dr.
[**Last Name (STitle) 4883**], last seen [**2182-2-6**], on renal replacement for 5
yrs
# Congestive heart failure with an ejection fraction of 60-70%
in [**10-31**], mod LVH, diastolic dysfunction.
# Moderate pulmonary hypertension with significant pulmonic
regurgitation and markedly dilated right atrium on [**10-31**]
# Diabetes mellitus, type 2, insulin dependent, diagnosed [**2171**]
complicated by diabetic neuropathy, retinopathy, nephropathy and
vascular insufficiency, s/p toe amputation.
# Hypertension.
# Obesity.
# Hypercholesterolemia.
# History of sickle trait.
# Acid reflux.
# Secondary hyperparathyroidism
# s/p L vitrectomy
Social History:
The patient lives with wife and two children. He is a chef. No
tobacco or alcohol use. Cat, fish and parrot at home.
Family History:
Mother with diabetes
Physical Exam:
ADMISISON PHYSICAL EXAM:
Vitals: 99.9, 65, 18, 79-90/32-41 99% 2l
General: Alert, oriented, no acute distress, lying comfortably
in bed.
HEENT: Sclera anicteric, MM dry
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, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: rt foot has 2 cm ulcer on the plantar aspect. No erythema,
but blackish area surrounding it. Minimal foul smell
Access:Left bracio-basilic fistula, good bruit
.
DISCHARGE PHYSICAL EXAM:
VS: Tm 97.9, BP 80-110s/60s, HR 70-80, RR 20, O2sat>96% RA
General: Alert, oriented, no acute distress, lying comfortably
in bed.
HEENT: Sclera anicteric, MM dry
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: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: rt foot has 2 cm ulcer on the plantar aspect. No erythema,
but blackish area
Access: Left bracio-basilic fistula, good bruit
Pertinent Results:
ADMISSION LABS:
[**2186-7-27**] 10:00AM BLOOD WBC-4.9 RBC-3.83* Hgb-13.4* Hct-39.9*
MCV-104* MCH-35.0* MCHC-33.6 RDW-16.3* Plt Ct-139*
[**2186-7-27**] 08:08PM BLOOD PT-14.3* PTT-28.8 INR(PT)-1.2*
[**2186-7-27**] 10:00AM BLOOD Glucose-172* UreaN-26* Creat-6.9*#
Na-147* K-4.4 Cl-98 HCO3-36* AnGap-17
[**2186-7-27**] 08:08PM BLOOD ALT-7 AST-23 LD(LDH)-299* CK(CPK)-199
AlkPhos-95 TotBili-0.4
[**2186-7-27**] 08:08PM BLOOD CK-MB-2 cTropnT-0.16*
[**2186-7-28**] 04:40AM BLOOD CK-MB-2 cTropnT-0.14*
[**2186-7-28**] 04:40AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.6
[**2186-7-28**] 09:22AM BLOOD Vanco-7.0*
[**2186-7-27**] 11:27AM BLOOD Lactate-3.0*
.
DISCHARGE LABS:
[**2186-7-31**] 06:27AM BLOOD WBC-4.5 RBC-3.75* Hgb-12.9* Hct-38.7*
MCV-103* MCH-34.3* MCHC-33.3 RDW-16.1* Plt Ct-144*
[**2186-7-31**] 06:27AM BLOOD Glucose-117* UreaN-62* Creat-10.7*#
Na-140 K-4.8 Cl-96 HCO3-30 AnGap-19
[**2186-7-31**] 06:27AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.4
[**2186-7-28**] 05:03AM BLOOD Lactate-1.0
.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP G
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 0.06 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2186-7-27**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2186-7-27**] AT
0710.
GRAM POSITIVE COCCI IN CHAINS.
Aerobic Bottle Gram Stain (Final [**2186-7-27**]):
GRAM POSITIVE COCCI IN CHAINS.
[**7-27**], [**7-28**], [**7-29**] BLOOD CULTURES PENDING, NO GROWTH TO DATE
.
[**7-28**] FOOT XRAY: There is no fracture or dislocation. There is a
curvilinear lucency over the lateral malleolus which likely
represents artifact or overlying structures. There is extensive
disorganization and demineralization of the mid foot, which has
increased from prior study and likely represents worsening
Charcot's arthropathy. There is periostitis at the lateral
portion of the fifth metatarsal, largely unchanged from prior
study. There is significant soft tissue swelling, most prominent
on the plantar surface. There is a small surface irregularity
and radiolucency on the plantar surface inferior to the mid foot
which may represent an ulcer. There is no subcutaneous
emphysema. There are vascular calcifications. There is no
definite radiographic evidence of osteomyelitis.
IMPRESSION:
1. No definite radiographic evidence of osteomyelitis. If
clinically
concerned, consider MRI. Soft tissue irregularity on the plantar
surface
which may correspond to ulcer.
2. Worsening destruction of the mid foot consistent with
progressive
Charcot's arthropathy.
3. Unchanged periostitis in the lateral aspect of the fifth
metatarsal.
.
[**7-28**] UPPER EXTREMITY U/S: Transverse and sagittal images were
obtained of the subcutaneous tissues at the left antecubital
fossa. A large patent hemodialysis fistula is identified on
grayscale and color Doppler imaging. No fluid collection is seen
in this region.
IMPRESSION: No indication of abscess in the left antecubital
fossa. A
palpable mass in the antecubital fossa corresponds to the
hemodialysis
fistula.
.
[**7-29**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is dilated with moderate global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Dilated ascending aorta. No valvular
pathology or pathologic flow identified.
Compared with the prior study (images reviewed) of [**2185-6-2**],
pulmonary artery systolic hypertension is now quantified. Right
ventricular cavity size and free wall motion are similar.
CLINICAL IMPLICATIONS:
Based on [**2181**] 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.
.
[**7-31**] CT ABD/PELVIS: ABDOMEN: Visualized portion of the lung bases
appears unremarkable.
The liver shows no focal lesion or biliary duct dilation. The
gallbladder is decompressed. The spleen is normal in size and
appearance. Pancreas shows no surrounding fluid collection. The
adrenal glands are normal appearing bilaterally.
The kidneys enhance with and excrete contrast symmetrically
without evidence of hydronephrosis or perinephric fluid
collection. In the inferior pole of the right kidney is a
hypodensity that is too small to characterize but likely
represents a simple cyst.
The small and large intestine show no evidence of obstruction or
wall edema. The appendix is visualized and is normal. There is
no free air, free fluid, or lymphadenopathy.
PELVIS: The bladder, prostate, and rectum appear unremarkable.
There is no
free fluid or lymphadenopathy.
BONES: There are no aggressive appearing lytic or sclerotic
lesions.
Moderate degenerative changes are seen throughout the lumbar
spine. Anterior osteophytes are also noted throughout the lumbar
spine. At the L4-L5 level, there is enplate sclerosis, likely
degenerative, however there is ragged or an erosive/destructive
appearance to the adjacent endplates with mild soft tissue
prominence anteriorly.
IMPRESSION:
1. No acute intra-abdominal or intra-pelvic process.
2. Abnormal appearance of L4-L5 level, as described above,
concerning for
discitis/ostemyelitis - correlate with patient's clinical
condition.
Brief Hospital Course:
45 yo gentleman with PMH of diabetes, diabetic neuropathy and
nephropathy, ESRD on HD MWF, presented to the hospital this
morning with fever and chills with GPC in chains in blood
culture.
.
ACTIVE ISSUES BY PROBLEM:
# Spesis: He initially presented with fever and hypotension and
was taken care of in the MICU, requiring fluid and pressors.
His blood cultures grew Group G strep and Proteus. Patient
initially covered with vancomycin and piperacillin/tazobactam.
This was narrowed to ceftriaxone per ID recommendations. Left
Bracio-basilic fistula was imaged and no signs of infection.
Foot ulcer was imaged without any signs of osteomyeltis. He had
a TTE which was negative. The source of the infection was
presumed to be intraabdominal and a CT abdomen was performed.
CT abdomen did not show GI pathology, however, it did show a
ragged edge of the L4/5 disc which might represent discitis.
The patient declined an inpatient MRI to further characterize
this. He preferred to have an outpatient, open MRI with the
knowledge that he might have to be on 8 weeks of antibiotics if
he does not get this MRI since there would have to be treatment
for presumptive discitis. Per ID recommendations he was
discharged on cefazolin and ciprofloxacin dosed with
hemodialysis.
.
# HTN/Vascular: His home medications were held during his
hospitalization due to sepsis-induced hypotension. He was
discharged on a half-dose of home metoprolol given his multiple
risk factors for cardiac disease. He was told to follow-up with
his nephrologist and PCP to increase the dose again.
.
CHRONIC ISSUES BY PROBLEM:
# Foot ulcer: Podiatry evaluated the foot infection and noted
that there are no signs of osteo, but has worsening charcot
neuroarthropathy of midfoot. They changed dressings and
followed along in house. He will continue to follow with them
outpatient.
.
# ESRD/HD: On HD MWF. Continued to get his dialysis and will
have IV antibiotics dosed with dialysis. Will also have
surveillance labs for abx drawn with HD. Fistula not suspicious
for source of infection. He was started on nephrocaps.
.
# Anemia: Baseline anemia due to chronic renal failure.
Continued to monitor. Continued sevalamer and cinacalcet.
.
TRANSITIONAL ISSUES:
- PATIENT WILL NEED OUTPATIENT COLONSOCOPY GIVEN GROUP G STREP
INFECTION. SHOULD HAVE ARRANGMENT THROUGH OUTPATIENT PCP.
[**Name Initial (NameIs) **] PLEASE FOLLOWUP WITH WEEKLY BLOOD TESTING OF CBC, LFTS, AND
CHEM 7 WHILE ON ANTIBIOTICS, these can be drawn with dialysis
- PLEASE CONTINUE ANTIBIOTICS FOR 8 WEEKS TO TREAT PRESUMED
DISCITIS
- PLEASE GET A REPEAT MRI TO DETERMINE WHETHER COURSE OF
ANTIBIOTICS CAN BE ATTENUATED
Medications on Admission:
sensipar 90mg daily
renagel 800mg tid
simvastatin 20mg daily
aspirin 325mg daily
metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: one-half Tablet PO
twice a day.
8. cefazolin 1 gram Recon Soln Sig: 2G MON, 2G WED, 3G FRI GRAMS
Intravenous AS DIRECTED: DOSE AFTER DIALYSIS, FOR 8 WEEKS.
9. Cipro 500 mg Tablet Sig: One (1) Tablet PO MWF, AFTER
DIALYSIS: FOR 8 WEEKS.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Sepsis from Proteus and Group G strep
Chronic Kidney Disease
.
SECONDARY DIAGNOSIS:
Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because you were having fevers
and were found to have a bacteria in your blood stream. We are
not completely sure where this bacteria came from, but it may
have been from the ulcer on your foot or from your abdomen. You
were treated with antibiotics to kill the bacteria.
.
Because there was concern that the bacteria might have landed
somewhere while they were in your blood, a CT of your abdomen
was performed. This showed there might be an infection in the
intervertebral discs of your spine. You should have this
followed up with an MRI as an outpatient in a few weeks, please
call [**Telephone/Fax (1) 327**] to book this.
.
Also, because you will be on antibiotics, you should have blood
work checked every week.
.
The following changes were made to your medications:
- DECREASE your metoprolol to [**11-27**] tab twice a day until
instructed otherwise by Dr. [**Last Name (STitle) 7473**]
- START taking nephrocaps
- START taking cefazolin and ciprofloxacin (antibiotics) for the
next 8 weeks
.
Because you have kidney failure, you should weigh yourself every
morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
.
It is very important that you keep all the follow-up
appointments as listed below.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
You have the following follow up appointments:
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2186-8-14**] at 9:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Name: [**Last Name (LF) 5533**],[**First Name3 (LF) **] M.
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
When: Tuesday, [**8-15**], 4:15PM
.
Name: [**Last Name (LF) 4883**], [**Name8 (MD) **] MD
Location: [**Location (un) **] Dialysis [**Location (un) **]
Phone: [**Telephone/Fax (1) 5972**]
*You will see Dr. [**Last Name (STitle) 4883**] at your reugular dialysis
appointmnets, Monday, Wednesday and Fridays at 3:30PM.
|
[
"713.5",
"707.14",
"250.40",
"416.9",
"278.00",
"V45.81",
"272.0",
"588.81",
"428.32",
"038.49",
"585.6",
"357.2",
"995.92",
"428.0",
"362.01",
"038.0",
"427.32",
"428.30",
"V45.11",
"250.60",
"403.91",
"250.50",
"785.52",
"V58.67",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14542, 14548
|
10845, 13060
|
326, 354
|
14703, 14703
|
3947, 3947
|
16224, 16247
|
2645, 2667
|
13675, 14519
|
14569, 14569
|
13536, 13652
|
14854, 16201
|
4601, 9081
|
2707, 3310
|
9104, 10822
|
13081, 13510
|
264, 288
|
16271, 17156
|
382, 1768
|
14672, 14682
|
3963, 4585
|
14588, 14651
|
14718, 14830
|
1790, 2492
|
2508, 2629
|
3335, 3928
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,018
| 148,182
|
46252+58860
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-5-14**] Discharge Date: [**2149-5-20**]
Date of Birth: [**2082-12-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB and fatigue
Major Surgical or Invasive Procedure:
Mitral valve repair (32 [**Company **] ring);MAZE;Left atrial
appendage ligation [**2149-5-14**]
History of Present Illness:
This is a 66 year old male with known MVP/MR. [**First Name (Titles) 23278**]
[**Last Name (Titles) 98326**] have shown worsening MR. Currently experiencing
CHF symptoms..worsening shortness of breath, dyspnea on
exertion,
increasing fatigue and intermittent lower extremity edema.
Denies
chest pain, orthopnea and PND.
Past Medical History:
Mitral valve prolapse, Paroxysmal atrial fibrillation, HTN,
hypercholesterolemia, OSA, GERD, Asthma, Depression,
Hypothyroid, Prodtatism, Essential Tremor , chronic diastolic
heart failure
Social History:
Lives with wife. [**11-29**] year here and [**11-29**] year in [**State 108**].
Tobacco- 10 pk year. quit 25 yrs ago.
ETOH-rare
Family History:
no history of premature cardiac disease.
Physical Exam:
Physical Exam
Pulse: 76 Resp: 14 O2 sat: 97%RA
B/P Right: Left: 139/88
Height: 72inches Weight: 104kg
General: middle aged male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**1-31**] holosystolic murmur
Abdomen: Soft [x] non-distended [x] non-tender x bowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema - trace
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
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.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). The remaining left ventricular segments contract
normally.
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. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is
moderate/severe mitral valve prolapse. Torn mitral chordae are
present. An eccentric, anteriorly 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 a trivial/physiologic
pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known lastname **]
at 10AM before CPB.
POST-BYPASS:
Normal RV systolic function.
Mild global LV systolic dysfunction (LVEF 45%)
There is no residual MR>
There is a prosthesis in the mitral position, well seated and
functioning well.
The mean mitral gradient is 2 mm of Hg.
Thoracic aorta is intact.
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) **] [**2149-5-14**] 14:16
HISTORY: Postoperative cardiac surgery.
FINDINGS: In comparison with the study of [**5-15**], there has been
some clearing
of the left retrocardiac opacification. Bibasilar atelectasis
with small
bilateral effusions persist in this patient with intact midline
sternal
sutures and a prosthetic valve.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: MON [**2149-5-19**] 4:30 PM
Imaging Lab
?????? [**2142**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr [**Known lastname **] was admitted to [**Hospital1 18**] and taken to the OR on
[**2149-5-14**] for mitral valve repair, MAZE and LAAA ligation. See
operative for details. Post operatively he was taken to the
CVICU intubated, sedated and on amiodarone and propofol drips.
Pt was weaned from the ventilator and extubated on POD#0.
Betablockers and diuresis was started on POD#1. Mr. [**Known lastname **]
was in atrial fibrillation and developed conversion pauses
requiring temporary pacing with epicardial wires. A cardiology
consult was obtained. A permanent pacer was indicated at this
time. Betablockers were held then resumed at low dose on POD#4.
Low dose betablocker was tolerated. He converted to NSR.
Coumadin therapy was initiated. Diuresis was ongoing. Chest
tubes and temporary pacing wires were removed per protocol. Pt
was evaluated by physical therapy and cleared for discharge to
home on POD#6.
Dr. [**Last Name (STitle) 98327**] his PCP will [**Name9 (PRE) 86284**] his coumadin management-
confirmed with [**Doctor First Name **] from Dr.[**Name (NI) 98328**] office.Target INR
2.0-2.5.
Medications on Admission:
Primidone 250mg daily, Piroxicam 10
mg daily, Diltiazem 240 mg daily, Lipitor 40 mg daily,
Omeprazole 20 mg daily, Levoxyl 200 mcg daily, Cozaar 50 mg
daily, Remeron 15 mg daily, Fluoxetine 20 mg daily, Flomax 0.8
mg daily, Ventolin as needed, Aspirin 81 mg daily, Symbicort
twice daily, and Vitamin D and B12.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. 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:*1*
3. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
5. Piroxicam 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*1*
6. Primidone 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*1*
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:*1*
10. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing.
Disp:*1 IH* Refills:*1*
13. Outpatient Lab Work
Next INR draw on [**5-21**] and results called to Dr. [**Last Name (STitle) 20561**]
[**Telephone/Fax (1) 26190**] or fax [**Telephone/Fax (1) 19900**].
INR draws should be at least [**12-31**] week until INR stable.
Goal INR 2.0-2.5 for afib
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
16. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: Take as directed by Dr. [**Last Name (STitle) 20561**] for INR of [**12-30**].5.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral valve prolapse, Paroxysmal atrial fibrillation,
Hypertension, hypercholesterolemia, OSA, GERD, Asthma,
Depression, Hypothyroid, Prodtatism, Essential Tremor
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Have your INR checked on [**2149-5-21**] and resiluts called to Dr. [**Name (NI) 98329**] office [**Telephone/Fax (1) 26190**] or faxed [**Telephone/Fax (1) 19900**]. (confirmed
with [**Doctor First Name **] at Dr.[**Name (NI) 98328**] office)
Your Goal INR is 2.0-2.5 for afib.
Followup Instructions:
please call and schedule the following appointments
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**] in 1 week ([**Telephone/Fax (1) 26190**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] (cardiologist) in [**12-31**] weeks and upon return
to [**State 108**] make appointmemt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**Doctor Last Name **] of Hearts monitor follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**]
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2149-5-20**] Name: [**Known lastname **],[**Known firstname 1937**] Unit No: [**Numeric Identifier 15586**]
Admission Date: [**2149-5-14**] Discharge Date: [**2149-5-20**]
Date of Birth: [**2082-12-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 1543**]
Addendum:
Pt. was discharged on Lasix 40 mg. PO BID for 7 days. He will
also take Potassium Chloride 10 meq PO daily for 7 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2149-5-20**]
|
[
"429.5",
"424.0",
"428.0",
"244.9",
"530.81",
"401.9",
"428.32",
"427.31",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34",
"88.72",
"39.63",
"35.12",
"39.61",
"37.36"
] |
icd9pcs
|
[
[
[]
]
] |
10233, 10446
|
4200, 5308
|
328, 427
|
8128, 8135
|
1933, 4177
|
8955, 10210
|
1150, 1192
|
5670, 7842
|
7941, 8107
|
5334, 5647
|
8159, 8932
|
1207, 1914
|
273, 290
|
455, 777
|
799, 989
|
1005, 1134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,558
| 142,671
|
39491
|
Discharge summary
|
report
|
Admission Date: [**2106-8-26**] Discharge Date: [**2106-8-31**]
Date of Birth: [**2035-11-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hemoptysis/Tracheal bleed, Hypoxia
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with debridement of granulation tissue and
trach size change
History of Present Illness:
70F with DM, asthma, chronic respiratory failure [**1-19**] PNA/asthma
(? vented at night with chronic trach x ? 3 months) CVA, CAD,
s/p recent tracheal bleed and trach change [**2106-7-4**] transferred
from OSH with recurrent tracheal bleed for IP eval and
bronchoscopy. Oxygen saturations 80% on 50% FiO2 in IP suite so
she was admitted to MICU for bronchoscopy and evaluation.
Patient's prior bronch in [**Month (only) 205**] revealed subglottic stenosis,
granulation tissue at stoma, plaque like lesions on main carina
and rigth bronchus intermedius (bx-no malignancy), polypoid
lesions main carina. No evidence of TM and trach replaced with
new cuffless #6 trach tube. There was ? HSV but biopsies were
negative.
.
In IP suite, initial vs were: T97.6 P68 BP121/57 R20 O2 sat92%
on 35%. Patient was transferred to ICU for assessment and plan
for flexible bronch in afternoon and rigid bronchoscopy
tomorrow.
.
On the floor, her only complaint is left arm pain which has been
treated with neurontin. She states this "just started" but
unclear when. reports "a little SOB", but improved now on vent.
Denies further bleeding from trach site, wheezing, chest pain,
cough, abdominal pain, LH, dizziness. States she had fevers and
chills 6 days prior but none since then.
.
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:
IDDM2
Asthma
Chronic resp failure ([**1-19**] asthma and PNA) s/p trach and PEG ? 3
months ago (? on ventilator at night)
s/p bronch [**7-8**], [**7-6**], cuffless trach replacement to cuffed
catheter in ED [**7-4**]
CVA (L weakness)
CAD
HTN
DJD
GERD
h/o AFB in sputum felt to be colonizer
Polypoid lesion trachea
? hypothyroidism
? hyperlipidemia
Social History:
Resident at [**Hospital1 **] Commons. Has 3 sons. [**Name (NI) 87235**] worked as
manager of group home.
- Tobacco: Denies
- Alcohol: rare
- Illicits: None
Family History:
non-contributory
Physical Exam:
General: Alert, intermittently falling asleep during exam,
oriented to city and state, date, not month, no acute distress,
able to communicate by whispering in full sentences
HEENT: Sclera anicteric, MMM with thrush, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds with exp wheezes bilaterally. No
crackles or rhonchi
CV: Regular rate and rhythm, normal S1 + S2 with 2/6 systolic
murmur LUSB, no rubs or gallops
Abdomen: soft, obese, non-tender, multiple ecchymoses,
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. LUE with mild nonpitting edema
Neuro: AAOx2-3 as above. CN 2-12 intact. 5/5 strength RUE and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/L. LUE contracted with inability to uncle[**Name (NI) **] fist.
Pertinent Results:
[**2106-8-26**] 05:40PM BLOOD WBC-13.3* RBC-3.69* Hgb-10.0* Hct-30.4*
MCV-83 MCH-27.1 MCHC-32.8 RDW-16.4* Plt Ct-410
[**2106-8-30**] 03:50AM BLOOD WBC-10.3 RBC-3.29* Hgb-9.0* Hct-28.3*
MCV-86 MCH-27.3 MCHC-31.7 RDW-16.3* Plt Ct-371
[**2106-8-26**] 05:40PM BLOOD Neuts-65 Bands-0 Lymphs-23 Monos-4 Eos-8*
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2106-8-26**] 05:40PM BLOOD PT-12.7 PTT-23.9 INR(PT)-1.1
[**2106-8-26**] 05:40PM BLOOD Glucose-148* UreaN-30* Creat-1.0 Na-138
K-4.8 Cl-95* HCO3-36* AnGap-12
[**2106-8-30**] 03:50AM BLOOD Glucose-92 UreaN-26* Creat-0.9 Na-137
K-5.0 Cl-100 HCO3-27 AnGap-15
[**2106-8-26**] 05:40PM BLOOD Calcium-9.3 Phos-4.6* Mg-2.3
[**2106-8-29**] 04:47AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.2
[**2106-8-29**] 01:35PM URINE Blood-MOD Nitrite-POS Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2106-8-29**] 01:35PM URINE RBC-0 WBC->50 Bacteri-MANY Yeast-NONE
Epi-[**2-19**] TransE-0-2
[**2106-8-27**] 8:36 pm URINE Source: Catheter.
**FINAL REPORT [**2106-8-31**]**
URINE CULTURE (Final [**2106-8-31**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
[**8-26**], [**8-27**] Blood Cx pending, NGTD
[**8-26**] CXR: Low lung volumes. Minimal bilateral atelectasis
[**8-27**] CT Trachea:
1. Extensive abnormal soft tissue thickening in the supraglottic
and
infraglottic regions and surrounding the tracheostomy, likely
reflecting
granulation tissue. Severe stenosis at the level of the cricoid
cartilage. The tracheostomy appears patent.
2. Limited evaluation of the lungs due to respiratory motion. No
large
pulmonary nodules or areas of consolidation.
[**8-30**] CXR: Worsening left mid lung zone opacity concerning for
infection or
worsening atelectasis.
Brief Hospital Course:
Acute Hypoxemic on Chronic Respiratory Failure - This was
thought to be due to granulation tissue seen around the area of
her tracheostomy and subglottic stenosis. She had a rigid
bronchoscopy by IP which showed diffuse granulation tissue
around her stoma and her trach, as well as subglottic stenosis.
This was debrided and a larger size (#7 non-fenestrated) trach
tube was inserted. She tolerated the procedure well without
difficulty. The patient had hemoptysis at an OSH that was
initially thought to be HSV tracheitis, however biopsies were
negative. The hemoptysis was thought to be due to the
granulation tissue. Per IP recs, started omeprazole and
ranitidine. Hct remained stable during admission. WBC trended
down to 10.3. PSV overnight, required peak 10 PEEP 5 overnight
night of [**8-29**]. Trach mask trial successful during day.
UTI: Patient with cloudy, foul smelling urine. U/A showed
evidence of UTI with many bacteria. Started on Cipro. On day 3
of antibiotics, culture results became available, showing
Klebsiella sensitive only to Zosyn, gentamycin, and meropenem.
Patient had a PICC line placed by IR as the PICC team could not
at bedside. She was discharged on meropenem as she had a
previous reaction to zosyn.
Diabetes: On detemir and humalog sliding scale. Hypoglycemic to
60s during afternoon and overnight, so decreased detemir from 25
[**Hospital1 **] to 20 [**Hospital1 **].
Anxiety: Ativan prn.
Yeast infection: Noted white discharge and foul odor. Received
Fluconazole 200mg x1.
Asthma: Continued home albuterol.
Thrush: Nystatin oral suspension.
LUE pain: Pt reports LUE pain with unclear chronicity on
neurontin. [**Month (only) 116**] be secondary to CVA vs DVT, chronic neuropathic
pain. Continued neurontin and used oxycodone prn.
CAD and s/p CVA: Held ASA for procedure. Prior to discharge,
ASA was restarted with agreement from Interventional
Pulmonology.
Hyperlipdemia: Continued statin.
Hypothyroidism: Continued levothyroxine.
Medications on Admission:
Tylenol 650 q4 prn
Dulcolax 10mg Po daily prn
Levothyroxine 0.1 mg PO daily
Lexapro 20mg daily per PEG
ferrous sulfate 320mg PO BID
Neurontin 300mg PO TID
HCTZ 12.5mg PO daily
Novolog sliding scale
Levimere 25mg SC BID
Lactobacillus 1 tab PO TID
Lorazepam 0.5mg PO q6 prn
Milk of magnesia 30ml PEG prn
Oxycodone IR 10 mg PO q4h prn
Pantoprazole 40 mg IV daily
Seroquel 25mg PO BID
Ropinirole 2mg PEG qhs
Zocor 20mg PEG daily
Ambien 5mg PO qhs prn
omeprazole 20mg via PEG [**Hospital1 **]
zantac 30 mg via PEG QHS
Ventolin 2.5 mg INH q 2 hours 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. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain.
5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Oxycodone 5 mg/5 mL Solution Sig: Five (5) ml PO Q4H (every 4
hours) as needed for pain.
Disp:*150 ml* Refills:*0*
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q2H (every 2 hours) as needed for .
15. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
17. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
18. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
19. Levemir 100 unit/mL Solution Sig: 25 units Subcutaneous
twice a day.
Disp:*50 * Refills:*2*
20. Novolog 100 unit/mL Solution Sig: ASDIR Subcutaneous QACHS:
per sliding scale .
21. General Care
Please keep the head of the bed elevated to 60 degrees at all
times.
22. Meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 7 days.
Disp:*21 Recon Soln(s)* Refills:*0*
23. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Commons
Discharge Diagnosis:
hemoptysis, subglottic stenosis, granulation tissue around stoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization.
You were admitted to the hospital for bleeding coming from your
tracheostomy. You underwent a rigid bronchoscopy during which
you had granulation tissue removed and your trach was replaced.
You tolerated this procedure and then had a trial with your
trach mask which you did well with. You were found to have a
urinary tract infection caused by a bacteria called Klebsiella
while in the hospital and we started you on a medication called
meropenem which you will take for 7 days. You had a chest x-ray
that was concerning for pneumonia, however you had no cough or
increasing oxygen requirement that made us concerned for
pneumonia at this time. You should be monitored closely for
fevers and worsening respiratory status that could signal a
pneumonia.
Medication changes:
- Please take nystatin oral suspension 5 ml orally four times a
day as needed for thrush.
- Started meropenem 1000 mg IV every 8 hours for 7 days
- Started ranitidine 300 mg orally in the evening
- Started oxycodone 5mg/5ml Q4H for pain
- Increased omeprazole to 40 mg orally twice a day
- Decreased acetaminophen 650 mg orally every 6 hours for pain
Please make sure the head of your bed is always elevated to 60
degrees.
Note: Attempted to contact family to inform them of Ms. [**Known lastname 87236**]
transfer back to [**Hospital1 **]. Tried calling listed numbers for
HCP [**Name (NI) **] ([**Telephone/Fax (1) 87237**]) and alternate [**Doctor Last Name **] [**Telephone/Fax (1) 87238**]. Both
numbers out of service. Only other number listed in our system
is for [**Hospital1 **]. Pt states that she does not know the new
phone numbers, but has them written down at home. She states
that she does not mind if we do not contact her family, as she
plans to call them when she returns to [**Hospital1 **]. Contact[**Name (NI) **]
[**Name2 (NI) **], and neither the admissions coordinator [**Doctor Last Name 11923**], nor
the staff on her unit were able to locate any other phone
numbers. Checked with case manager [**First Name8 (NamePattern2) 19267**] [**Last Name (NamePattern1) 87239**], who also did
not have any other phone number. Spoke with SW who recommended
contacting PCP. [**Name10 (NameIs) **] listed PCP??????s office; they could not
locate any records for pt.
Followup Instructions:
Please follow up with IP with Dr. [**Last Name (STitle) **] in 2 weeks. - Dr [**Last Name (STitle) **]
([**Telephone/Fax (1) 3020**])
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2106-9-15**] 7:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2106-9-15**]
8:00
Provider: [**Name10 (NameIs) **] ROOM TWO Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2106-9-15**]
8:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.23",
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icd9pcs
|
[
[
[]
]
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11015, 11066
|
6266, 8263
|
308, 389
|
11175, 11175
|
3597, 6243
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,912
| 162,869
|
43548
|
Discharge summary
|
report
|
Admission Date: [**2161-8-28**] Discharge Date: [**2161-9-4**]
Date of Birth: [**2113-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Compazine / Benadryl / Percocet
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
[**2161-8-28**]
1. Minimally invasive esophagectomy with intrathoracic
anastomosis.
2. Buttressing of intrathoracic anastomosis with
pericardial fat pad.
3. Esophagoscopy.
History of Present Illness:
A 47 y.o. male with recent dysphagia
had endoscopy with path + for adenocarcinoma esophagus. EUS
showed lymphadenopathy and perigastric LN had path + for
adenocarcinoma. Pt reports long h/o GERD, occasional heartburn,
indigestion/abd pain, nausea x 1 day only. Wt is stable. He had
one previous upper endoscopy ~15 years ago, and had no lesion at
that time. He was admitted to the hospital for surgery after
undergoing pre op chemo radiation therapy.
Past Medical History:
PAST MEDICAL HISTORY:
GERD
anxiety
PVC's
s/p T+A
s/p odonts
Social History:
Cigarettes: [x ] never [ ] ex-smoker [ ] current
Pack-yrs:____
quit: ______
ETOH: [x ] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [ ] No [ x] Yes/possible [ ] Radiation
[ ] Asbestos [x ] Other: chemicals used in
line of work
Occupation:electrical technician (automotive)
Marital Status: [ x] Married [ ] Single
Lives: [ ] Alone [x ] w/ family [ ] Other:
Other pertinent social history:
Travel history:
Family History:
Father: prostate cancer, mantle cell lymphoma
Physical Exam:
BP: 120/75. Heart Rate: 74. Weight: 216.9. Height: 68. BMI:
33.0.
Temperature: 97.8. Resp. Rate: 16. Pain Score: 4. O2
Saturation%:
99.
ECOG: 2
GENERAL: Alert, oriented, NAD
HEENT: Anicteric, MMM, oropharynx is clear
NECK: No cervical, supraclavicular, or axillary LAD, no
thyromegaly
CV: Regular rate and rhythm, nl S1/S2, no murmurs, rubs or
gallops
PULM: Clear to auscultation bilaterally
ABD: Normoactive bowel sounds, soft, non-tender, non-distended,
no masses or hepatosplenomegaly. J-tube in place. Rectal exam
revealed no external hemorrhoids, no clear evidence of bleeding.
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
Pertinent Results:
[**2161-8-28**] 03:58PM WBC-15.5*# RBC-3.91* HGB-11.1* HCT-32.8*
MCV-84 MCH-28.3 MCHC-33.8 RDW-17.7*
[**2161-8-28**] 03:58PM PLT COUNT-272
[**2161-8-28**] 03:58PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-1.6
[**2161-8-28**] 03:58PM GLUCOSE-160* UREA N-24* CREAT-1.2 SODIUM-141
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
[**2161-9-3**]
Ba swallow :
Appropriate flow of barium through the esophagus into the
stomach. No evidence of stricture, obstruction or leak.
[**2161-9-4**] CXR :
Small right-sided pneumothorax has improved.
Brief Hospital Course:
Mr. [**Known lastname 8421**] as admitted to the hospital and taken to the
Operating Room where he underwent a laparoscopic esophagectomy.
He had an epidural catheter placed for pain control and had
adequate relief. He was transferred to the SICU with stable
hemodynamics.
His J tube feedings were resumed on post day 1 and he remained
stable with good oxygen saturations and stable blood pressure.
His chest tube drained minimally as did his JP drain. He was
able to use his incentive spirometer and cough and deep breath
effectively.
Following transfer to the Surgical floor he remained NPO until
his barium swallow. He was up and walking independently and his
epidural remained effective. His nasogastric tube was removed
prior to his barium swallow on [**2161-9-3**] and the study revealed no
leak. He was then started on a liquid diet and he was delined.
He had a small right pneumothorax on his post pull chest xray
therefore serial films were done which documented improvement.
He was asymptomatic. Following removal of his epidural he was
placed on oral Dilaudid for pain and he swallowed them without
difficulty.
The nutritionist recommended cycling his tube feedings over 12
hours and his Isosource 1.5 ran at 575 cc/hr from 6PM-6AM. He
was comfortable flushing his tube and initiating feedings as he
had them pre op.
After an uncomplicated recovery he was discharged to home on
[**2161-9-4**] and will follow up in the Thoracic Clinic in 2 weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Metoprolol Tartrate 50 mg PO BID
3. Omeprazole 20 mg PO BID
4. Lorazepam 0.5 mg PO Q6H:PRN anxiety
Discharge Medications:
1. Lorazepam 0.5 mg PO Q6H:PRN anxiety
2. Metoprolol Tartrate 50 mg PO BID
3. Omeprazole 20 mg PO BID
4. Docusate Sodium (Liquid) 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**1-19**] tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*1
7. Senna 1 TAB PO BID
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Nutrition
Isosource 1.5 at 75 cc/hr cycled over 12 hours
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting (take anti-nausea medication)
-Increased abdominal pain
-Incision develops drainage
-Remove chest tube and j-tube site bandages Saturday and replace
with a bandaid, changing daily until healed.
Pain
-Dilaudid orally for pain
-Take stool softners with narcoticst avoid constipation
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Tube feeds: Isosource 1.5 Full Strength 75 mL x 12 hrs
Flush J-tube with water every 8 hours with 30 mls of water,
before and after starting tube feeds and giving medications
through tube
Full liquid diet, may increase to soft solids over the next few
days as tolerated.
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Danger signs
Fevers > 101 or chills
Increased shortness of breath, cough or chest pain
Incision develops drainage
Nausea, vomiting (take anti-nausea medication)
Increased abdominal pain
Call if J-tube falls out (save the tube and bring with you to
the hospital to be re-placed) or suture breaks
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2161-9-17**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray
Completed by:[**2161-9-4**]
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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5229, 5235
|
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|
307, 487
|
5298, 5298
|
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,901
| 137,309
|
29167
|
Discharge summary
|
report
|
Admission Date: [**2101-9-1**] Discharge Date: [**2101-9-7**]
Date of Birth: [**2028-11-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
broken esophageal stent
Major Surgical or Invasive Procedure:
attempted stent removal with stent breakage and migration
multiple attempts by ENT to remove stent
Intubation
EGD
History of Present Illness:
72 year-old female with CREST syndrome and Barrett's esophagus
with dysplasia s/p transhiatal esophagectomy, pyloroplasty and
feeding jejunostomy in [**6-9**], with postoperative course
complicated by esophageal leak, s/p esophageal stenting, c/b
stent migration, s/p repositioning who now presents for removal
of the stent. During the removal about 30% of the stent broke
off and was removed from the esophagus. The rest of the stent
stayed in the hypopharynx and also occluded the airway overlying
the epiglottis. A difficult nasal intubation was successfull.
Subsequent attempt to remove the stent were unsuccessful and
only a few small parts were removed. The patient was transferred
to the ICU. ENT was contact[**Name (NI) **].
.
ROS: unable to obtain as patient intubated and sedated.
According to husband negative for cough, SOB, CP, abd pain or
dysuria. Pt just started to take full liquids yesterday,
otherwise has been fed through the PEG-tube.
Past Medical History:
CREST syndrome (GERD/Barrett's Esophagitis/Raynauds/Scleroderma)
Dilated Esophageal Stricture [**2076**]
Right Rotator Cuff Repair
Left shoulder Replacement
Hysterectomy
Social History:
Lives with spouse, retired, no alcohol for 10 weeks, otherwise
social ETOH, no tobacco, or IVDU
Family History:
not obtained
Physical Exam:
VS T 96.0 BP 102/54 HR 86 RR 12 O2Sat 100%
Gen: NAD
HEENT: NC/AT, PERRLA, mmm, small bleed in retropharynx, no stent
visualized
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no r/g, [**3-8**] holosystolic murmur over
apex > radiating into axilla
PULM: CTA b/l, no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, nt, PEG tube in place, scar well
healed except for small midline lesion
Skin: warm extremities, no rash, scattered teleangiectasis
EXT: 2+ DP, no edema/c/c, cool lower extremities, arthritic
deformities of hands b/l with ulnar deviation
Neuro: moving all extremities, following commands, PERRLA,
reflexes 2+ b/l
Pertinent Results:
<b>Admit Labs:</b>
[**2101-9-1**] 09:14PM BLOOD WBC-9.1 RBC-2.96* Hgb-8.7* Hct-25.9*
MCV-87 MCH-29.4 MCHC-33.7 RDW-16.6* Plt Ct-326
[**2101-9-1**] 09:14PM BLOOD Neuts-85.4* Bands-0 Lymphs-10.4*
Monos-3.0 Eos-0.8 Baso-0.4
[**2101-9-1**] 09:14PM BLOOD PT-11.9 PTT-23.9 INR(PT)-1.0
[**2101-9-1**] 09:14PM BLOOD Glucose-78 UreaN-22* Creat-0.4 Na-133
K-4.2 Cl-100 HCO3-20* AnGap-17
[**2101-9-1**] 09:14PM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
[**2101-9-1**] 09:14PM BLOOD Cortsol-13.3
[**2101-9-1**] 09:16PM BLOOD Type-ART Temp-35.6 Rates-12/ Tidal V-450
PEEP-5 FiO2-40 pO2-177* pCO2-42 pH-7.36 calTCO2-25 Base XS--1
-ASSIST/CON Intubat-INTUBATED
<br>
<b>Other Labs:</b>
[**2101-9-1**] 09:14PM BLOOD Cortsol-13.3
[**2101-9-2**] 01:35PM BLOOD Type-ART Temp-36.6 Tidal V-450 FiO2-100
pO2-421* pCO2-33* pH-7.38 calTCO2-20* Base XS--4 AADO2-275 REQ
O2-51 Intubat-INTUBATED Vent-CONTROLLED
[**2101-9-2**] 10:03AM BLOOD Type-ART Rates-[**8-14**] Tidal V-440 FiO2-40
pO2-174* pCO2-36 pH-7.29* calTCO2-18* Base XS--8 -ASSIST/CON
Intubat-INTUBATED
<br>
<b>Imaging Studies:</b>
PORTABLE ABDOMEN [**2101-9-4**] 10:24 AM
FINDINGS:
AP portable supine radiograph is obtained. There is residual
gastrografin within the colon from previous small-bowel follow
through. There is no evidence of obstruction identified.
IMPRESSION:
No evidence of obstruction identified.
<br>
CHEST (PORTABLE AP) [**2101-9-4**] 10:24 AM
FINDINGS:
On the [**2101-8-4**] study, the stent was located in the thoracic area.
The proximal edge resided at the T3 level and the distal aspect
of the stent resided at approximately the T9 level.
On the current study, the stent has migrated proximally. The
distal aspect of the stent now resides at the thoracic inlet at
approximately the T3 level. The proximal aspect of the stent is
not well appreciated on today's study. However, on the [**9-3**] film, the proximal aspect of the stent appears to reside at
the C6-7 level.
The heart is enlarged. Retrocardiac opacity likely represents
the gastric pullthrough. There is also likely a component of
atelectasis. There are two patchy airspace opacities in
bilateral upper lung zones, unchanged. This could represent
aspiration or pneumonia. Postsurgical changes in both shoulders.
IMPRESSION:
1. The stent in question has migrated proximally above the
thoracic inlet since the prior study of [**8-4**]. Please see
discussion above.
2. Unchanged bilateral upper lobe airspace opacities which could
represent aspiration or pneumonia.
<br>
CHEST (PORTABLE AP) [**2101-9-3**] 10:51 AM
FINDINGS:
The endotracheal tube has been removed. An esophageal stent is
present. The tip of the stent terminates just above the
clavicles, stable.
Cardiomediastinal silhouette unchanged. There is a patchy
opacity in the left upper lung zone which could represent
pneumonia or aspiration. There is also a patchy opacity in the
right upper lung zone, and right mid lung zone concerning for
the same. These are new since prior study. There is a
retrocardiac opacity also concerning for same. Again noted is a
total left shoulder prosthesis and postsurgical changes in the
right shoulder.
IMPRESSION:
1. New patchy opacities left upper lung zone, right, mid and
lower lung zones, concerning for aspiration vs. pneumonia.
<br>
BAS/UGI AIR/SBFT [**2101-9-2**] 3:35 PM
There has been interval migration of the esophageal stent which
now is located at the level of upper esophagus and distal
pharynx. The Gastrografin passes freely through the pharynx and
esophagus. There is no retention of the contrast in th e
valecula or piriform sinuses. No aspiration or penetration was
noted. The esophagogram demonstrated normal appearance of the
gastric pull- through with no stricture or leak.
IMPRESSION:
1. Interval migration of esophageal stent to the upper esophagus
- lower pharyngeal area.
2. No leak or stenosis is noted. No aspiration was visualized.
<br>
ESOPHAGUS [**2101-9-1**] 10:04 AM
FINDINGS: Patient was administered Conray orally, no evidence of
extravasation was seen. Subsequently, barium was administered.
The patient is status post esophagectomy with gastric pull-up.
There is no stricture at the anastomosis. A metallic stent is
seen.
IMPRESSION: Status post esophagectomy, gastric pull-up No
evidence of extravasation or strictures at the anastomosis.
<br>
CHEST (PORTABLE AP) [**2101-9-1**] 8:13 PM
FINDINGS:
Compared to [**2101-8-4**], the esophageal stent has migrated
cephalad with its distal most portion now at the thoracic inlet
roughly 10.0 cm cephalad to where it was on the prior study. The
more superior portion may be just below the upper esophageal
sphincter. Endotracheal tube is in expected position roughly 6.0
cm above the carina. There is no gas seen within the stomach in
the mediastinum. Left basilar consolidation persists and there
is high- density material overlying the left lung base which
could represent retained barium if there has been administered
since [**2101-8-4**]. Consolidation in the left mid lung and right
apex are unchanged and may represent slow resolving aspiration
versus scarring. There is likely a small left pleural effusion,
however, the right pleural effusion appears to have resolved. No
new pulmonary opacities. Heart size is unchanged. Total left
shoulder arthroplasty and right chronic rotator cuff
tendinopathy changes and post- surgical suture anchors are
unchanged.
IMPRESSION:
1. Migration of esophageal stent into the cervical esophagus.
2. Persistent pulmonary opacities with new high-density material
overlying the left lung base which could be barium within the
stomach or within the lung.
<br>
<b>Micro Data:</b>
Blood Cx ([**9-6**], [**9-2**]) - no growth x 4
C. Diff Toxin ([**9-5**]) - Negative
<br>
<b>Discharge Labs:</b>
[**2101-9-7**] 10:00AM BLOOD WBC-9.3 RBC-3.26* Hgb-9.6* Hct-28.5*
MCV-87 MCH-29.6 MCHC-33.8 RDW-16.8* Plt Ct-368
[**2101-9-7**] 10:00AM BLOOD Neuts-71.0* Lymphs-19.3 Monos-6.5 Eos-2.8
Baso-0.4
[**2101-9-7**] 10:00AM BLOOD Glucose-100 UreaN-23* Creat-0.4 Na-134
K-4.7 Cl-100 HCO3-27 AnGap-12
[**2101-9-7**] 10:00AM BLOOD ALT-7 AST-12 AlkPhos-67 TotBili-0.2
[**2101-9-7**] 10:00AM BLOOD Albumin-2.9* Calcium-8.1* Phos-2.7 Mg-2.1
[**2101-9-7**] 10:00AM BLOOD Triglyc-74
Brief Hospital Course:
1) Fractured stent
Stent was fractured during removal. Got laryngoscopy and
endoscopy and all but one piece was removed. Final piece is
approximately 9 cm is adhered to anastamosis. Was followed by
thoracic surgery as well. GI feels comfortable leaving remaining
stent in place as esophagus is patent and stent has migrated
distally in past (not proximally). Barium swallow showed no
perforation. Was started on steroids for airway edema. Was
intubated for airway protection but was extubated within a day.
Respiratory status remained stable. She will have follow-up
x-rays done as an outpatient (on [**9-9**] and [**9-12**]) to assess to
location of the stent. These will be reviewed by her
gastroenterologist, Dr. [**Last Name (STitle) **]. She will subsequently follow
up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
<br>
2) Aspiration PNA
Patient was hypotensive and hypothermic in setting of multiple
scopes, patient likely aspirated. CXR is consistent with
aspiration PNA. Patient was subsequently hemodynamically stable.
She was intially treated with Vanco/zosyn, but was switched to
IV flagyl/levo. Ultimately changed to Cefpodox and Flagyl, wich
she will take to complete a full course. Blood cultures were
negative.
<br>
3) CREST
Nifedipine held (not on her med list). She was given viscous
lidocaine to help with her throat pain. Also given Percocet
liquid for pain.
<br>
4) Hypertension
After initially being held, her metoprolol was restarted.
Medications on Admission:
Medications from last discharge summary:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL : 5-10 MLs PO Q4H prn.
2. Metoprolol Tartrate 25mg [**Hospital1 **]
3. tube feed replete at 55 cc/hr continuous
4. Lactulose 10 g/15 mL 30mls'or" prn via feeding tube.
5. Colace 50 mg/5 mL Liquid Sig 10mls prn
6. Polyethylene Glycol 3350 17g 1 packet po daily
7. Lansoprazole 30mg delayed release via j tube
8. Levofloxacin 500 mg Tablet for 7 days
.
Last medication list per husband:
Prevacid
Metoprolol 12.5mg [**Hospital1 **]
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a
day.
Disp:*15 tabs* Refills:*2*
2. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for sore throat.
Disp:*500 ML(s)* Refills:*2*
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
4. Cefpodoxime 100 mg/5 mL Suspension for Reconstitution Sig:
Ten (10) mL PO twice a day for 9 days.
Disp:*180 mL* Refills:*0*
5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 9
days.
Disp:*18 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: [**5-12**] mL
PO every four (4) hours as needed for pain.
Disp:*500 mL* Refills:*0*
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal TID (3 times a day).
Disp:*1 Inhaler* Refills:*2*
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day: via J-tube.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary:
Esophageal Stent Fracture
Likely Aspiration Pneumonia
Secondary:
CREST Syndrome
Barrett's Esophagus (s/p transhiatal resection w/ anastamotic
leak w/ stent placement and stent migration and repositioning)
Dilated Esophageal Stricture
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
Please take all medications as presribed. You will need to
complete the course of antibiotics. The last dose is to be
taken on [**9-16**]. You will need to have neck/upper chest x-rays
taken to evaluate the stent location. This should be done at
[**Hospital1 69**] in [**Location (un) 620**] on [**9-9**] and [**9-12**]
(as arranged). Dr. [**Last Name (STitle) **] will follow up with you regarding
these results.
.
Return to the emergency room or call your primary doctor for:
Shortness of breath
Chest Pain
Nausea/Vomiting/Abdominal Pain
Fever
Followup Instructions:
Dr. [**Last Name (STitle) **] (CT Surgery) - [**Telephone/Fax (1) 4741**] (please follow up next
week as scheduled)
Dr. [**Last Name (STitle) **] (Gastroenterology) - [**Telephone/Fax (1) 17075**] (please follow up
as scheduled or call to confirm)
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70180**] [**Name (STitle) **] [**Telephone/Fax (1) 70181**]. Please call for follow up
appointment.
|
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"427.31",
"V44.4",
"710.1",
"530.85",
"507.0",
"276.1",
"276.2",
"996.59",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.6",
"31.42",
"44.13",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11691, 11754
|
8682, 10181
|
337, 452
|
12042, 12074
|
2462, 3109
|
12673, 13085
|
1761, 1775
|
10744, 11668
|
11775, 12021
|
10207, 10721
|
12098, 12650
|
8186, 8659
|
1790, 2443
|
274, 299
|
480, 1437
|
1459, 1631
|
1647, 1745
|
3120, 3501
|
3517, 8171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,513
| 123,268
|
39079
|
Discharge summary
|
report
|
Admission Date: [**2161-3-18**] Discharge Date: [**2161-3-30**]
Date of Birth: [**2078-5-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aortic stenosis and coronary artery disease
Major Surgical or Invasive Procedure:
Aortic Valve Replacement(21mm St. [**Male First Name (un) **] Epic) &
Coronary Artery Bypass Grafts x2 (LIMA-LAD,SVG-PDA) [**2161-3-20**]
History of Present Illness:
This is an 82 year old female with known aortic stenosis and
w3orsening dyspnea on exertion. An echocardiogram demonstarted
worsening aortic stenosis. Cardiac catheterization revealed [**First Name8 (NamePattern2) **]
[**Location (un) 109**] of 0.7 cm2 and multivessel coronary disease. She was
transferred for surgical intervention.
Past Medical History:
Degenerative joint disease - awaiting Right Total knee
replacement
Atrial Fibrillation
Hypercholesterolemia
s/p Laproscopic cholecystectomy
ERCP for stones
Social History:
Race: Caucasian
Last Dental Exam: <1 month. had extraction pre knee sx.(Dr. [**Last Name (STitle) 86620**]
[**Name (STitle) 31227**] in [**Location (un) **])
Lives with: son
Occupation: retired
Tobacco: never
ETOH: rare
Family History:
father died of colon ca in his 60s, Mother of old age at [**Age over 90 **]yo
Physical Exam:
Admission:
Pulse: Resp:14 O2 sat:
B/P Right:122/56 Left: 124/56
Height:62" Weight:84.4kg
General:WDWN,obese WF in NAD
Skin: Dry [x] intact []eczematous area LT pretibial
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur:GR [**4-14**]/SEM to carotids
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:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:M Left:M
Pertinent Results:
[**2161-3-23**] 02:15AM BLOOD WBC-12.0* RBC-2.64* Hgb-8.1* Hct-23.6*
MCV-89 MCH-30.6 MCHC-34.2 RDW-13.3 Plt Ct-140*
[**2161-3-20**] 03:19PM BLOOD WBC-15.1*# RBC-2.66*# Hgb-8.4*#
Hct-24.4*# MCV-92 MCH-31.4 MCHC-34.3 RDW-13.2 Plt Ct-144*
[**2161-3-23**] 02:15AM BLOOD Glucose-137* UreaN-11 Creat-0.6 Na-139
K-4.0 Cl-104 HCO3-31 AnGap-8
[**2161-3-18**] 07:03PM BLOOD Glucose-95 UreaN-17 Creat-0.6 Na-141
K-4.5 Cl-105 HCO3-27 AnGap-14
[**2161-3-18**] 07:03PM BLOOD ALT-12 AST-18 LD(LDH)-178 AlkPhos-95
TotBili-0.4
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. Left ventricular wall
thicknesses and cavity size are normal. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are simple atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is moderate
thickening of the mitral valve chordae. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
POST CPB;
1. Normal biventricular systolic function (Epinephrine and V
asopressin)
2. Bioprosthesis in m itral and aortic position. Well seated and
stable with leaflet excursion. Trace valvular regurgitation and
minimal gradients.
3. Intact aorta
Brief Hospital Course:
Following admission routine labs, CXR and carotid ultrasound
were performed. Her urinalysis suggested a urinary infection
and oral Cipro was given. Dental clearance was obtained from her
dentist and she was ready for surgery.
On [**3-20**] she was taken to the Operating Room where aortic valve
replacement and coronary revascularization were performed. She
weaned from bypass on Neo Synephrine and Propofol infusions.
She awoke neurologically intact, was weaned from the ventilator
and extubated. Pressors weaned easily and she transferred to
the floor.
Beta blockers were resumed and she was diuresed towards her
preoperative weight. Physical therapy was consulted and worked
with her in her recovery. She developed atrial fibrillation
with moderate hypotension on POD 3 for which transfer back to
the ICU and DC synchronous cardioversion was used, with
restoration of sinus rhythm.
CTs and temporary pacing wires [**Location (un) **] removed according to
protocol. She had recurrent atrial fibrillation after return to
the floor but at a controlled rate which converted with IV
Lopressor. Coumadin was begun for the paroxysmal dysrhythmia and
may be discontinued if sinus rhythm persists later in her
recovery.
The patient developed acute onset aphasia, confusion, right
facial droop, and perioral numbness for approximately 10
minutes. CT did not reveal an acute hemorrhagic event.
Neurology was consulted. The event was likely the result of
small cardioembolic CVA from dysrhythmias. The patient was
maintained on anti-coagulation, rate control and rhythm control.
Symptoms did nearly resolve within 24 hours. She minimal
residual word finding difficulty.
She required a stay at rehab to allow for further recovery prior
to returning home and her diuresis with intravenous Lasix was
continued until she reaches her preoperative weight.
Medications on Admission:
Aspirin 81mg/D
Lopressor 12.5mg/D
Simvastatin 20mgHS
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for high cholesterol.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) as needed for cad.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for gi protection.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x 1 week, then 200mg daily until further
instructed. Tablet(s)
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: dose to change daily for goal INR [**2-11**].
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for diuresis for 2 weeks.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Coronary Artery Disease
Aortic Stenosis
s/p Aortic valve replacement
s/p coronary artery bypass grafts x2
Degenerative joint disease
paroxysmal Atrial Fibrillation
Hypercholesterolemia
Past Surgical History:
s/p Laproscopic cholecystectomy
s/p endoscopic retrograde cholangiopanreatography
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**4-23**] at 1:45pm ([**Telephone/Fax (1) 170**])
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 911**] in [**1-10**] weeks ([**Telephone/Fax (1) 59456**])
Cardiologist: Dr. [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**] in [**1-10**] weeks
Completed by:[**2161-3-30**]
|
[
"433.30",
"424.1",
"401.9",
"285.9",
"414.01",
"V58.61",
"997.02",
"433.10",
"427.31",
"458.29",
"784.3",
"E878.2",
"272.4",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.15",
"36.11",
"99.62",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6450, 6564
|
3622, 5478
|
320, 461
|
6898, 7088
|
2058, 3599
|
7712, 8123
|
1257, 1336
|
5581, 6427
|
6585, 6770
|
5504, 5558
|
7112, 7689
|
6793, 6877
|
1351, 2039
|
237, 282
|
489, 825
|
847, 1004
|
1020, 1241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,679
| 107,828
|
51194+51195
|
Discharge summary
|
report+report
|
Admission Date: [**2148-10-13**] Discharge Date: [**2148-10-15**]
Date of Birth: [**2097-9-27**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Dislodged Dophoff feeding tube
Major Surgical or Invasive Procedure:
Placement of dophoff catheter under fluro
History of Present Illness:
Pt with episode of hiccups, which pt had c/o for many months,
resulting in the dislodging of his dophoff feeding tube
Past Medical History:
anemia
Hepatitis C
CHF
CRI
DVT
portal hypertension
Depression
Social History:
Lives at [**Hospital 106240**] Rehab Centersmoking 15pack year hitoryno
etohremote IVDformer [**Company 2318**] worker
Family History:
noncontributary
Physical Exam:
NAD
AAO times 3
RRR S1+S2
CTA Bilat
Soft NT/ND, incision healing well
Pertinent Results:
US ABD LIMIT, SINGLE ORGAN [**2148-10-14**] 2:33 PM
REPORT: There is a dumb-bell shaped collection in the
gallbladder fossa which contains complex internal echoes. Each
of the limbs of the collection measure approximately 4 cm in
diameter each. The lesion passes close to the stomach
posteriorly but is extragastric.
The liver parenchyma appears normal throughout. No focal hepatic
mass is identified otherwise. No subcapsular lesion is seen.
Status post cholecystectomy. The common bile duct measures 7 mm
in maximum dimensions. The right kidney appears normal in size
shape and echotexture.
Doppler ultrasound. Doppler ultrasound was performed of the
anastomosed vessels. The hepatic veins appear normal. There
appears to be a clip intimately related to the middle hepatic
vein which appears narrowed at this point. Portal vein is patent
with centrifugal flow. The hepatic arteries have not been
examined.
Brief Hospital Course:
Pt admitted on [**10-13**] after dophoff tube was accidentally d/c'd
after a episode of hiccups. A NG tube was placed on admission.
Pt had an episode of nausea and emesis around the tube. A
dophoff was placed on [**10-14**] and the nausea and emesis resolved.
A RUQ US was performed which showed an evolving collection in
the gallbladder fossa but was otherwise unremarkable. Pt
improved and was D/C'd to return to rehab on [**10-15**]
Discharge Medications:
1. CellCept [**Pager number **] mg Capsule Sig: One (1) Capsule PO twice a day.
2. Megestrol Acetate 40 mg/mL Suspension Sig: One (1) PO QID (4
times a day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
4. Methylphenidate HCl 5 mg Tablet Sig: 1.5 Tablets PO QD (once
a day).
5. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
6. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Ribavirin 200 mg Capsule Sig: Two (2) Capsule PO QD (once a
day).
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
12. Interferon alfacon-1 30 mcg/mL Injectable Sig: One (1)
Subcutaneous TIW ().
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
14. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Dislodged Dophoff feeding tube
Discharge Condition:
stable
Discharge Instructions:
Please return for all follow-up appointments
Take all medications as directed, and resume all previous
medications
Return to the ER if any increased pain, nausea and vomitting,
fevers, diarrhea, chest pain, or shortness of breath
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-10-16**] 2:20
Completed by:[**2148-10-15**] Admission Date: [**2148-10-16**] Discharge Date: [**2148-11-18**]
Date of Birth: [**2097-9-27**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Nausea and vomiting, resulting in displacement of dophoff tube
Major Surgical or Invasive Procedure:
[**2148-10-26**] - open feeding jejunostomy
[**2148-11-5**] - exploratory laparotomy, removal of j-tube
History of Present Illness:
51 male with HCV s/p orthotopic liver transplant in [**3-6**]
comlicated by HCV reinfection, was D/c'd from [**Hospital1 18**] [**10-15**] after
placement of dophoff tube. He was feeling well the day of
discharge and had an uneventful evening; on DOA he had an
episode of nausea and bilious/grey vomiting (per transfer note)
which resulted in his tube being displaced. He has [**3-5**] loose
formed BM's per day, which is normal for him. He has some RUQ
pain on palpation. He denies fever/chills, melena, hematemisis,
dysphagia, chest pain, or shortness of breath. He also has some
indigestion which is new for him.
ROS: otherwise negative
Past Medical History:
Anemia
Hepatitis C
-transplant in [**3-6**]
-reactivation of hepatitis C
CHF
-[**3-6**] echo shows 35-40% EF, 2+ MR, inf/post/lat hypokinesis
CRI
DVT
portal hypertension
Depression
Social History:
Lives at [**Hospital6 3355**], smoking 28 year pack hx, etoh
remote, former IVDU (used once), [**Company 2318**] bus driver for 18 yrs
Family History:
noncontributary
Physical Exam:
Temp
BP
Pulse
Resp
O2 sat
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist, no sublingual jaundice
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally with fien insp.
crackles at bases
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nondistended, with normoactive bowel sounds, TTP in
RUQ, neg. [**Doctor Last Name **], RUQ scar from liver transplant; open scar
extening from mid-RUQ to midline under ribcage with pink tissue,
dressed
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-14**] intact,
upper and lower extremity strength 4/5 bilaterally, sensation
grossly intact, negative asterixis
Skin - some jaundice
Pertinent Results:
Labs:
[**2148-10-15**]
WBC-3.9* HGB-10.0* HCT-29.5, PLT COUNT-140*
GLUCOSE-138* UREA N-35* CREAT-1.1 SODIUM-134 POTASSIUM-5.5*
CHLORIDE-110* TOTAL CO2-18* CALCIUM-8.4 PHOSPHATE-3.2
MAGNESIUM-1.3*
ALT(SGPT)-211* AST(SGOT)-166* ALK PHOS-383* TOT BILI-0.6
ALBUMIN-2.6*
PT-13.1 PTT-85.0* INR(PT)-1.1
FK506-16.0
Brief Hospital Course:
A and P/ 51 M with HCV cirrhosis s/p liver transplant in [**3-6**],
CHF, DVT in [**4-4**], who presented with n/v x1 related to dophoff
tube and for further evaluation of a fluid collection in the
gallbladder fossa. The fluid collection was percutaneously
drained, with negative culture and showed resolution on
following CT scans of the abdomen. Since he had very poor PO
intake and had lost enteral access, a feeding jejunostomy was
placed [**2148-10-26**]. Following that he developed a prolonged ileus,
partial obstruction around the J-tube, requiring re-operation.
Postoperative from the inital jejunostomy, his liver function
deteriorated, and he developed klebsiella sepsis. Given the
overall poor prognosis, he was made CMO on POD22 and expired on
POD23.
NEURO: Mr [**Known lastname 71430**] presented with a history of depression,
however, his mental status remained quite good until POD10 at
which time he was intubated for respiratory distress. He was
sedated with propofol initially, however this was discontinued
due to hypotension. He was initially alert and following
commands, but became increasingly encephalopathic with periods
of agitation.
CARDIOVASCULAR: [**Name (NI) **] pt was hemodynamically stable inspite
of a history of CHF with an EF 35-40%. On POD5 from his
jejunostomy, he became oliguric and tachycardic, requiring
multiple fluid boluses. He was transferred to the ICU and a PA
catheter placed. His cardiac index and filling pressures
responded to volume resuciation. He became hypotensive after
his re-exploration and again responded to volume. Lopresser was
restarted and mainted for hypertension and tachycardia after
this.
RESPIRATORY: On POD5 from his j-tube placement, he required
intubation for increasing tachypnea and confusion in the setting
of renal failure and abdominal distention. Chest radiographs
were consistent with CHF and sputum cultures sent after a
temperature spike grew multiresistant klebsiella. His
oxygenation/ventilation remained stable.
Liver transplant: Pt was maintained on prednisone, cellcept, and
tacrolimus adjusted by level. He was continued on bactrim and
valgancyclovir for prophylaxis.
His interferon and ribavirin were also continued until the time
of J tube placement, at which time the interform was stopped.
Just prior to admission his HCV viral load was 21 million
copies, however, postoperatively this increased to greater than
70 million copies. Given his complicated postoperative course,
and debilitated condition, hepatology did not think that he
would tolerate additional interferon therapy. His liver
function deteriorated precipitously postoperaively, with
bilirubin increasing from 1.4 up to 40. He also become
coagulopathic and encephalopathic. An introp liver biopsy
performed on [**2148-11-5**] showed findings consistent with recurrent
Hepatitis C, and bridging fibrosis.
Gallbladder fluid collection: Pt had a fluid collection on
recent U/S. On arrival, he had a repeat U/S that showed a
persistent fluid collection. A CT with IV contrast ordered
showing a fluid collection which was later drained by pigtail
cathater placement. The catheter drained 50 cc of serosanginous
fluid which was sterile (no organisms). Pt was placed on
levofloxacin and flagyl for a total 21 day course. He remained
afebrile without an elevated WBC count. The drain was removed a
week after placement, after confirmation of resolution of
collection via US, without complications.
GI: Pt did not want dophoff tube replaced. On HD 3, an NGT was
placed in presparation for a G tube placmeent, which was later
cancelled due to the fluid collection in the gallbladder and
anterior stomach. The tube was removed, and pt tried to eat on
his own. On calorie counts he ingested less tha 50% of his goals
and had persistent anorexia and nausea. The decision was made to
place an open J tube and he was taken to the operating room on
[**2148-10-26**]. The procedure was uncomplicated and he was stable
initially. Tubefeedings were started on POD1 at 20cc/hour,
however, he was noted the following day to have increasing
hiccups, abdominal distention with small episodes of emesis.
Tubefeeds were stopped and the J-tube was placed to gravity. He
had no flatus or bowel movements during this time. A KUB
showed disteded loops of small bowel and a CT of the abdomen was
performed with contrast given via the J-tube. This showed
findings consistent with a parial small bowel obstruction, and
postoperative changes. He was observed for several days,
however he decompensated on POD4 and required transfer to the
ICU. His abdominal pain was improving, and his abdomen remained
soft. After fluid resucitation, he stabilized and a CT of the
abdomen was performed the following day with oral contrast.
This showed contrast in the colon and collapsed small bowel
loops in the distal ileum. After continued observation, his
urine output improved. NGT output was initially high, then
tapered off however there was no flatus or bowel movements. A
CT of the abdomen was repeated that did not show significant
change, however he had required intubation at this point and
became tachycardic. Decision was made to return to the
operating room for exploration. Please see the operative note
for full details. There was a torsion around the j-tube
insertion site causing obstruction. The j-tube was removed and
a liver biopsy performed. He was returned to the ICU and
subsequently required another round of fluid recusitation. He
continued to have an ileus with minimal bowel movements. On
POD4 from his re-exploration, his hematocrit decreased to 26
inspite of receiving blood transfusions and a CT of the abdomen
showed a RLQ collection consistent with a hematoma. His
platelets were aggresively replaced, and his coagulopathy
corrected with blood products and his hematocrit stabilized.
Renal: Pt had bicarb wasting and potassium retention by the
middle of his hospital stay. Urine studies were sent which was
consistent with a type 4 RTA. Renal involved which suggested
D51/2NS with 1 amp bicar and startign him on bicitra 60 mg [**Hospital1 **]
to help with repletion. He stabilized, however, postop from his
J-tube placement had his creatinine rise to 2.5 with oliguria.
This improved with fluid and he then required lasix for
diuresis.
ID: He was initially placed on levaquin and flagyl emperic
coverage for the gallbladder fossa collection. These cultures
were negative, but antibiotic coverage was continued
postoperatively. His coverage was changed to vancomycin and
zosyn emperically after his transfer to the ICU. On POD 3 from
his re-exploration, he spiked a fever. Multiple blood and
sputum cultures grew klebsiella, sensitive only to meropenem to
which he was changed. Subsequent blood cultures remained
negative. His PICC was removed and triple lumen catheter
changed over wire with a negative tip.
HEME: Initally there was concern for an underlying coagulation
disorder given an elevated PTT on admission. Heme/onc was
consulted by the medical service and thought it to be due to his
underlying liver disease. In the setting of decompensating
liver function, his INR became elevated and he became
thrombocytopenic, requiring daily transfusions of FFP and
platelets. After his coags were relatively corrected, his
intra-abdominal bleeding stabilized and his pRBC transfusion
requirement decreased significantly so the decision was made to
hold on a second re-exploration.
During the above described course, multiple discussions were
carried out with the family who understood the grave prognosis
given the decompensted liver failure as a background for renal
failure, gram negative sepsis and bleeding. The decision was
made to make him CMO [**2148-11-17**] and he expired the following day.
Postmortem examination was declined by the family
Medications on Admission:
cellcept [**Pager number **] mg po bid, megesterol acetate 40 mg/ml po qid,
lansoprazole 30 mg qd, methylpenidate 7.5 mg qd, hydralizine 25
mg po q6 hrs, levothyrozxine 150 mcg qd, mirtazipine 15 mg po
qhs, ribavirin 200 mg two tabs [**Hospital1 **], metoprolol 75 po bid,
valganciclovir 450 mg po bid, bactrim 80-400 po qd, interferon
alpha 30 mcg/ml sc, tacrolimus 1 mg [**Hospital1 **], predinsone 2.5 mg qd,
lispro sliding scale
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Endstage liver failure
Recurrent hepatitis C with portal fibrosis
Chronic renal insufficiency
Acute renal failure
Hepatic encephalopathy
Congestive heart failure
Ventilator associated pneumonia
Respiratory failure
Small bowel obstruction
Intra-abdominal hemmorhage
Blood loss anemia
Klebsiella sepsis
Hypertension
Hypothyroidism
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**0-0-0**]
|
[
"789.5",
"569.69",
"570",
"285.1",
"995.92",
"560.2",
"263.9",
"518.81",
"284.8",
"584.9",
"996.59",
"575.10",
"996.82",
"038.49",
"286.7",
"998.12",
"482.0",
"251.8",
"428.0",
"070.44",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"89.64",
"50.12",
"46.51",
"46.39",
"96.6",
"99.04",
"99.15",
"54.91",
"99.07",
"96.72",
"96.04",
"46.81"
] |
icd9pcs
|
[
[
[]
]
] |
15281, 15360
|
6915, 14770
|
4545, 4650
|
15733, 15743
|
6582, 6892
|
15796, 15827
|
5694, 5712
|
15253, 15258
|
15381, 15712
|
14796, 15230
|
15767, 15773
|
5727, 6563
|
4443, 4507
|
4678, 5321
|
5343, 5526
|
5542, 5678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,372
| 112,764
|
52216
|
Discharge summary
|
report
|
Admission Date: [**2129-12-20**] Discharge Date: [**2129-12-30**]
Date of Birth: [**2055-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2129-12-26**] - Coronary artery bypass x3 with the following grafts:
Left internal thoracic artery to left anterior descending with
reverse saphenous vein graft to obtuse marginal branch and
reverse saphenous vein graft to a right posterior descending
branch.
[**2129-12-20**] - Cardiac Catheterization
History of Present Illness:
74 yo male with history of CAD (3 BMS in [**2119**]) who presented to
PCP office today complaining of exertional/rest/post-prandial
epigastric chest pain/tightness for the past 3 weeks. The pain
has been progressive and now occurs at rest and reminds him of
his chest pain 10 yrs ago. Pt was initialy on aspirin but
stopped it 1 mo when had hematuria. He restarted it 1.5 weeks
ago when recurrent chest pain, orinally intermittent and
associated with exertion describes as exertional. At 5am today
chest pain awoke from sleep.
.
This morning, pt reports chest pain which awoke him from sleep.
It was [**10-1**] and lasted an hour relieved with 325 mg of ASA. He
then reported to PCP office who referred him directly cardiac
cath.
.
In cath lab, pt was found to have mid 80% LAD, 60%OM1, distal
90%RCA, mid RCA stent with some in-stent restenosis, no
interventions occured. Cardiac surgery team will see pt for
likely CABG. Did not receive any plavix. Will place on heparin
gtt, continue aspirin 325, dilt and lipitor.
.
On arrival to the floor, patient had no complaints and reported
tolerating the procedure well.
Past Medical History:
1. CARDIAC RISK FACTORS: -HTN +CHOL -PRIOR CIGS -DM
+FH
2. CARDIAC HISTORY: CAD s/p 3 BMS in [**2119**] (LCX/OM and RCA)
-CABG:None
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2119**] (see above)
3. OTHER PAST MEDICAL HISTORY:
-BPH,
-asthma
-Asbestos exposure (with possible scar tissue)
-hematuria past 3 weeks with newly diagnosed bladder tumor that
is tentatively scheduled for resection on [**2130-1-13**]
Social History:
From NH. Retired Millwright, lives with wife on farm in [**Name (NI) **], no
tobacco, 2 drinks per night. 2 kids, 8 grandkids
Family History:
Father Died of MI at 58. Mother alive in nursing home at age [**Age over 90 **]
with dementia. Paternal uncle died of MI at 60.
Physical Exam:
ADMISSION EXAM
VS: 134/68, 95% on 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 of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Right radial artery
with occlusive band in place, no hematoma.
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:
See below
EKG: [**12-20**] at 3pm: NSR HR 65, PR 150, QRS<120, NA, NI, No ST or
TW changes. No q waves.
.
2D-ECHOCARDIOGRAM:
[**2129-12-21**]: The left atrium is mildly dilated. There is probable
mild regional left ventricular systolic dysfunction with focal
hypokinesis of the basal inferior wall. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The remaining left ventricular segments contract
normally. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Possible basal inferior
wall motion abnormality with preserved left ventricular ejection
fraction. Normal right ventricular systolic function. No
pathologic valvular disease.
.
ETT:
[**2123-12-13**] INTERPRETATION: This 68 year old man with a history of
CAD was referred to the lab for evaluation. The patient
exercised for 6.5
minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and stopped for fatigue. This
represents a
fair physical working capacity for his age. No arm, neck, back
or chest discomfort was reported by the patient throughout the
study. At peak exercise, there was 0.5-1 mm upsloping ST segment
depression in V4-6. These resolved within 1 minute of stopping
the test. The rhythm was sinus with occasional isolated apbs,
vpbs and 1 ventricular couplet. Appropriate hemodynamic response
to exercise. IMPRESSION: Borderline ischemic EKG changes in the
absence of anginal type symptoms. Nuclear report sent
separately.
MIBI IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left
ventricular cavity size and function. LVEF of 53%.
.
CARDIAC CATH:
[**2119**]: 1. Coronary arteriography in this right dominant system
revealed two-vessel coronary artery disease. The LMCA was long
and had mild plaquing. The LAD was a long vessel that wrapped
around the apex with a proximal 30% stenosis after the first
septal perforator and before the first diagonal branch. The left
circumflex artery had a proximal calcified plaque with 70%
stenosis extending into the major OM2 which contained a 90%
stenosis at the origin of the small superior pole. The RCA had a
mid-vessel 80% stenosis just beyond the acute marginal and a 60%
stenosis just before the r-PDA. Overall, there was diffuse
disease along the entire length of the RCA.
2. Resting hemodynamics showed normal filling pressures, with
PCW 8
and LVEDP 11 mm Hg.
3. Left ventriculography showed normal wall motion and a
calculated
LVEF of 60%. No mitral regurgitation was seen.
4. Successful PTCA and stenting of LCx/OM was performed with
<10%
residual stenosis, TIMI 3 flow and no angiographically-apparent
dissection (see PTCA comments).
5. Successful PTCA and stenting of RCA was performed without
residual stenosis, TIMI 2 fast flow into 2 jailed acute marginal
branches, and no angiographically-apparent dissection (see PTCA
comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal left ventricular systolic and diastolic function.
3. Normal right ventricular diastolic function.
4. Successful stenting of LCX/OM and RCA.
.
[**2129-12-20**]:
LMCA- No CAD
LAD- Diffuse prox 50-60%, mid 80%
OM1- 60%
Mid RCA 70-80%
Eccentric instent restenosis, Distal RCA has 90%
[**2129-12-30**] 06:40AM BLOOD WBC-12.3* RBC-2.89* Hgb-8.8* Hct-26.0*
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.4 Plt Ct-220
[**2129-12-26**] 04:19PM BLOOD PT-12.9* PTT-31.6 INR(PT)-1.2*
[**2129-12-30**] 06:40AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-28 AnGap-11
Radiology Report CHEST (PA & LAT) Study Date of [**2129-12-29**] 8:38 AM
[**Hospital 93**] MEDICAL CONDITION:
74 year old man cabg
REASON FOR THIS EXAMINATION:
eval for effusion
CHEST RADIOGRAPH
INDICATION: CABG, evaluation for pleural effusion.
COMPARISON: [**2129-12-27**].
FINDINGS: As compared to the previous radiograph, the venous
introduction
sheath on the right has been removed. The lung volumes are
unchanged. Small
bilateral pleural effusions are present. Subsequent bilateral
areas of basal
atelectasis. Moderate cardiomegaly without evidence of pulmonary
edema.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Brief Hospital Course:
Mr. [**Known lastname 884**] was admitted to the [**Hospital1 18**] on [**2129-12-20**] for further
evaluation of his chest pain. He underwent a cardiac
catheterization which revealed severe three vessel coronary
artery disease. Given the severity of his disease, the cardiac
surgical service was consulted for surgical evaluation. He was
worked up in the usual preoperative manner. A urology consult
was obtained given his known bladder tumor. Although there was
some risk of bleeding associated with the tumor, it was
recommended that he proceed with revascularization. Heparin was
continued for anticoagulation. On [**2129-12-26**], Mr. [**Known lastname 884**] was taken
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. postoperatively he was taken to the intensive care unit
for monitoring. He later awoke neurologically intact and was
extubated. On postoperative day one, he was transferred to the
step down unit for further recovery. He was gently diuresed
towards his preoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. He was noted to have leukocytosis however no fever or
signs of infection were noted. His white blood cell count
trended slowly back towards normal. Mr. [**Known lastname 884**] continued to
make steady progress and was discharged home on postoperative
day 4. He had a CTU of the abdomen and pelvis on the day of
discharge and will need a BUN/creatinine drawn on Mon. [**2130-1-2**].
He will follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 172**] as an
outpatient.
He will also need a referral to a cardiologist from Dr. [**Last Name (STitle) 172**].
Medications on Admission:
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth
once
a day
DILTIAZEM HCL [CARTIA XT] - 240 mg Capsule, Ext Release 24 hr -
one Capsule(s) by mouth once daily
FINASTERIDE - 5 mg Tablet - one Tablet(s) by mouth daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 100 mcg-50 mcg/Dose Disk with Device - one puff(s)
inhale daily at bedtime
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth in
the evening
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth one time a
day
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 vial* Refills:*2*
8. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
12. montelukast 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 90634**]health and home services
Discharge Diagnosis:
CAD with PCI X 4 stents in [**2119**]
dyslipidemia
BPH
asthma
hematuria past 3 weeks with newly diagnosed bladder tumor that
is
tentatively scheduled for Transurethral resection of bladder
tumor on [**2130-1-13**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 172**] [**Telephone/Fax (1) 133**] in [**4-26**] weeks, please call
your PCP for referral to a cardiologist.
Provider: [**Name10 (NameIs) **] CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2130-1-5**]
11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**]
Date/Time:[**2130-1-31**] 2:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2130-2-1**] 1:00
**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:[**2129-12-30**]
|
[
"600.01",
"414.01",
"996.72",
"272.4",
"V45.82",
"599.71",
"188.8",
"V17.41",
"411.1",
"788.20",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
12171, 12251
|
8215, 9975
|
291, 599
|
12509, 12710
|
3417, 6904
|
13599, 14422
|
2353, 2483
|
10661, 12148
|
7643, 7664
|
12272, 12488
|
10001, 10638
|
6921, 7603
|
12734, 13576
|
2498, 3398
|
1861, 1978
|
241, 253
|
7696, 8192
|
627, 1747
|
2009, 2194
|
1769, 1841
|
2210, 2337
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,634
| 174,412
|
45489
|
Discharge summary
|
report
|
Admission Date: [**2128-10-18**] Discharge Date: [**2128-10-22**]
Date of Birth: [**2091-7-7**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain X 3 days with N/V
Major Surgical or Invasive Procedure:
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV, unstable. ETT
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
COMMENTS: 1. Selective coronary angiography revealed a
right-dominant system. The LMCA, LAD, and Lcx all had mild
non-flow
limiting disease. The RCA was totally occluded in the mid-vessel
with
thrombus.
2. Left ventriculography was deferred.
3. Opening hemodyanamics revealed a mildly elevated right and
left-sided filling pressure (RA mean 7mmHg, PA mean 17mmHg, PCWP
mean
8mmHg). The calculated cardiac index was 4.5 l/min/m2.
4. Successful PTCA/stenting of the proximal RCA with a 4.5x13mm
Hepacoat bare metal stent, mid RCA with a 4.0x18mm and 4.0x23mm
postdilated with a 4.5mm balloon
History of Present Illness:
37 year old female with ESRD on Peritoneal dialysis (?lupus
nephritis) and s/p R hip arthoplasty [**9-23**] for coag. neg. staph
infection, h/o HTN, tobacco use, who p/w intermittent CP for 3
days PTA. The CP was sub-sternal and accompanied by nausea and
dry heaves. The patient states that she never had chest pain
prior to this AM. Denies Orthopnea, PND, SOB. EKG showed
Inferior STEMI.
Past Medical History:
1. S/P Subtotal Parathyroidectomy d/t tertiary
Hyperparathyroidism
2. SLE?
3. ESRD thought to be d/t Lupus nephritis
4. S/P Subtotal Parathyroidectomy leaving left lower gland [**2109**]
5. S/P Cadeveric Renal transplant x 1 [**2115**]
6. Peritoneal Dialysis x 1.5 years
7. Right Pathologic Hip Fracture [**2128-1-20**] after bending over to
put on sock, s/p pinning
8. Osteoporosis d/t Renal Osteodystrophy
9. HTN
10. Tumoral calcinosis on left palm, wrist, and right shoulder
over last 6 months, and bilateral buttocks which resolved
11. Hysterectomy x 1
Social History:
Lives with husband and 2 kids. Smokes 1 PPD X >20 yrs. No
ETOH.
Family History:
No significant CAD. No family history of thryoid, parathyroid,
or calcium disease. Mother with ESRD.
Physical Exam:
VS: T=100.1 HR=100 R=60 BP=117/41
Gen: NAD
Neck: 6 cm JVD
Heart: RRR, no m/r/g
Lungs: CTAB with mildly decreased BS in RLL
Abd: S/NT/ND/+BS, PD Cath noted
Extrem: No c/c/e
Neuro/Psy: Alert and oriented X3
Pertinent Results:
[**2128-10-18**] 12:15PM PT-12.7 PTT-26.2 INR(PT)-1.0
[**2128-10-18**] 12:15PM PLT COUNT-411
[**2128-10-18**] 12:15PM HYPOCHROM-3+ ANISOCYT-2+ MACROCYT-1+
MICROCYT-1+
[**2128-10-18**] 12:15PM NEUTS-82.9* LYMPHS-11.0* MONOS-4.3 EOS-1.3
BASOS-0.4
[**2128-10-18**] 12:15PM WBC-7.9 RBC-3.40* HGB-9.3* HCT-30.1*# MCV-89
MCH-27.2 MCHC-30.7* RDW-18.0*
[**2128-10-18**] 12:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-10-18**] 12:15PM CALCIUM-9.8 PHOSPHATE-5.5* MAGNESIUM-2.4
[**2128-10-18**] 12:15PM CK-MB-92* MB INDX-17.0*
[**2128-10-18**] 12:15PM cTropnT-15.92*
[**2128-10-18**] 12:15PM CK(CPK)-542*
[**2128-10-18**] 12:15PM GLUCOSE-82 UREA N-42* CREAT-9.6* SODIUM-138
POTASSIUM-5.5* CHLORIDE-101 TOTAL CO2-23 ANION GAP-20
[**2128-10-18**] 12:34PM LACTATE-1.1
[**2128-10-18**] 09:18PM PT-13.2 PTT-28.3 INR(PT)-1.1
[**2128-10-18**] 09:18PM PLT COUNT-385
[**2128-10-18**] 09:18PM WBC-6.6 RBC-2.62* HGB-7.2* HCT-23.0* MCV-88
MCH-27.5 MCHC-31.3 RDW-18.0*
[**2128-10-18**] 09:18PM VANCO-32.0
[**2128-10-18**] 09:18PM CALCIUM-8.9 PHOSPHATE-6.2* MAGNESIUM-2.1
[**2128-10-18**] 09:18PM CK-MB-95* MB INDX-15.2* cTropnT-24.97*
[**2128-10-18**] 09:18PM CK(CPK)-625*
[**2128-10-18**] 09:18PM GLUCOSE-75 UREA N-42* CREAT-9.3* SODIUM-132*
POTASSIUM-5.9* CHLORIDE-99 TOTAL CO2-22 ANION GAP-17
Brief Hospital Course:
Cardiac: Pt taken to Cath lab where found to have dilated RCA to
5mm and mid-thrombus occlusion. 3 stents placed in RCA.
Admitted to CCU where started on plavix, metoprolol, captopril,
and atorvastatin. BB and ACE-I titrated up to goal HR=70 and
SBP<130. Discharged on Toprol XL 175mg PO QD and lisinopril
20mg PO QD.
Peak TrpT=24.8, persistent Inferior ST elevation on EKG. TTE
was negative for ventricular aneurysm. Patient remained CP free
with the exception of the evening of HD#4 when she did c/o some
atypical CP. Negative cardiac enzymesX2, no EKG changes from
chest-pain free baseline post-MI. Pt to f/u w/ Dr. [**Last Name (STitle) **].
Renal: Patient followed by renal service while inpatient. PD
continued on regular nightly schedule. Upon d/c, setting was
1.5% for 5L X2. Nephrocaps added to meds. Sevelamer increased
to 1600 mg PO TID. Lytes stable.
SLE w/u: Rheumatology consulted re:possible SLE dx. Serologies
pending, pt to F/u as outpt.
Medications on Admission:
Calcitrol 25 mcg
Prednisone 3mg
Vanco dosed to <15
Dilaudid prn
Epogen 4000mg SC qwk
FeSO4 325mg PO QD
fluconazole 250mg PO QD
vitamins
Calcium carbonate 500 mg PO TID
hydromorphone 2mg PO q4-6 hrs PRN
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Inferior STEMI
ESRD on PD
HTN
Discharge Condition:
Afebrile, tolerating oral diet, ambulatory with crutches,
without cardiac chest pain.
Discharge Instructions:
Take nitroglycerin tablet as prescribed for chest pain as
prescribed. Seek immediate treatment if pain does not resolve.
Continue on your prior outpatient medications with the addition
of Toprol XL, Lisinopril, Plavix, Aspirin, and Lipitor for
management of your coronary artery disease. Please note your
Renegel dose has been increased per Dr. [**Last Name (STitle) **] since your
admission. Continue on a low salt, low cholesterol diet. Return
to the ED incase of recurrent chest pain, shortness of breath,
inability to tolerate oral diet, or onset fevers.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 16933**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2128-11-17**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2128-11-22**] 11:30
-Call PCP to schedule hospital follow up appointment within 1
month
-Call your regular kidney doctor within 1 week.
Follow up with cardiologist Dr. [**Last Name (STitle) **] on [**11-18**] at
10:30 on [**Hospital Ward Name 23**] 7 (#[**Telephone/Fax (1) 6197**])
Completed by:[**2128-10-26**]
|
[
"733.00",
"403.91",
"711.05",
"583.81",
"424.0",
"710.0",
"588.0",
"424.1",
"305.1",
"285.9",
"410.71",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.56",
"36.06",
"36.01",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
5135, 5206
|
3914, 4882
|
298, 298
|
5280, 5367
|
2535, 3891
|
5975, 6656
|
2187, 2291
|
5227, 5259
|
4908, 5112
|
412, 1085
|
5391, 5952
|
2306, 2516
|
331, 395
|
230, 260
|
1113, 1507
|
1529, 2087
|
2103, 2170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,148
| 198,760
|
1932
|
Discharge summary
|
report
|
Admission Date: [**2135-5-4**] Discharge Date: [**2135-5-25**]
Date of Birth: [**2060-7-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2135-5-4**] Mitral valve repair (32 mm [**Company **] CG future ring)
History of Present Illness:
74-year-old male with history of nonischemic cardiomyopathy
status post AICD/PPM in [**11/2132**] and known mitral valve
regurgitation followed by serial echocardiograms. He was
admitted to the [**Hospital1 18**] this past [**Month (only) 958**] with congestive heart
failure which was treated with aggressive diuresis. An
[**Month (only) 461**] revealed an ejection fraction of 26%, biatrial
enlargement, 4+ mitral
regurgitation and mild to moderate aortic insufficiency. He
admits to some fatigue and dyspnea with exertion however he does
not claim to be limited in his activities. Given the severity of
his mitral valve disease and his episode of heart failure, he
has been referred for surgical management. He was originally
seen as an inpatient [**2135-2-22**] and returns today for pre-op
cardiac
catheterization. of note, he has a large lipoma on his right
forhead which he is anxious to have removed.
Past Medical History:
1. Dilated cardiomyopathy with previous coronary catheterization
without significant CAD, last EF in [**11/2132**] 23%, s/p
biventricular pacemaker and ICD
2. Hypertension
3. CKD, baseline creatinine around 2
4. Hearing loss
5. History of pulmonary embolism in [**1-/2132**], status post six
months of anticoagulation, now off anticoagulation
6. Prostate Cancer
7. Hypothyroidism
8. Inguinal Hernia, evaluated by surgery
9. Old right occipital infarct, with associated encephalomalacia
and ex vacuo effect (patient denies Hx of stroke).
Social History:
Lives with:wife and daughter lives on the [**Location (un) 453**]. Daughter
helps with medications
Occupation:retired
Tobacco:denies
ETOH:denies
Family History:
brother with an MI at age 75
Father - ca ? type
Mother - HTN, otherwise well
Sibs - sister with ca to bones
brother with an MI at age 75 and another with CAD
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:70 Resp:16 O2 sat:97/RA
B/P Left:111/78 Right:112/72
Height:5'5" Weight:165 lbs
General: NAD appears stated age
Skin: Dry [x] intact [x] large cyst vs. lipoma on right forehead
above eye.
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] Left infraclavicular
pacemaker placement
Heart: RRR [x] Nl S1-S2, [**1-16**] mid-late systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] No edema
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Question left bruit vs transmitted murmur
Pertinent Results:
[**2135-5-4**] Echo: Prebypass: The left atrium is dilated. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No spontaneous echo contrast is seen
in the left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis/dyskinesis of the inferoseptal, inferior, and
inferolateral walls and hypokinesis of the septal, anteroseptal,
anterior, anterolateral, and lateral walls. Overall left
ventricular systolic function is severely depressed (LVEF= 20%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular cavity is dilated with moderate 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. The mitral valve leaflets do not fully coapt. The
mitral regurgitation vena contracta is >=0.7cm. Severe (4+)
mitral regurgitation is seen. There is no pericardial effusion.
Postbypass: The patient is on infusions of milrinone,
vasopressin, and norepinephrine and is AV paced at 80 bpm. There
is an annuloplasty ring in the mitral position which appears
well seated. Mitral regurgitation is now trace. Peak/mean
gradients through the valve are 2/0 mmHg at a cardiac output of
3 L/min and 4/1 mmHg at a cardiac output of 4 5 L/min. Right
ventricular function and left ventricular function are
unchanged. The thoracic aorta is intact post decannulation.
[**2135-5-4**] 12:54PM BLOOD WBC-11.6*# RBC-3.14*# Hgb-9.0*#
Hct-27.6*# MCV-88 MCH-28.7 MCHC-32.7 RDW-15.7* Plt Ct-195
[**2135-5-12**] 03:06AM BLOOD WBC-14.5* RBC-4.19* Hgb-11.7* Hct-36.1*
MCV-86 MCH-28.0 MCHC-32.5 RDW-18.1* Plt Ct-449*
[**2135-5-24**] 06:09AM BLOOD WBC-5.7 RBC-3.90* Hgb-11.3* Hct-34.2*
MCV-88 MCH-29.0 MCHC-33.1 RDW-17.7* Plt Ct-468*
[**2135-5-4**] 12:54PM BLOOD PT-14.9* PTT-28.3 INR(PT)-1.3*
[**2135-5-13**] 03:10AM BLOOD PT-22.6* PTT-64.7* INR(PT)-2.1*
[**2135-5-24**] 06:09AM BLOOD PT-22.0* INR(PT)-2.0*
[**2135-5-4**] 01:50PM BLOOD UreaN-43* Creat-2.1* Na-139 K-4.7 Cl-111*
HCO3-22 AnGap-11
[**2135-5-13**] 03:10AM BLOOD Glucose-167* UreaN-86* Creat-4.1* Na-127*
K-4.4 Cl-90* HCO3-24 AnGap-17
[**2135-5-24**] 06:09AM BLOOD Glucose-103* UreaN-85* Creat-2.8* Na-129*
K-4.4 Cl-90* HCO3-30 AnGap-13
[**2135-5-5**] 08:34PM BLOOD Calcium-8.1* Phos-4.0 Mg-2.8*
[**2135-5-24**] 06:09AM BLOOD Mg-2.8*
[**2135-5-24**] 06:09AM BLOOD WBC-5.7 RBC-3.90* Hgb-11.3* Hct-34.2*
MCV-88 MCH-29.0 MCHC-33.1 RDW-17.7* Plt Ct-468*
[**2135-5-25**] 05:02AM BLOOD PT-21.9* PTT-28.3 INR(PT)-2.0*
[**2135-5-25**] 05:02AM BLOOD Glucose-100 UreaN-79* Creat-3.0* Na-131*
K-4.8 Cl-93* HCO3-27 AnGap-16
Brief Hospital Course:
On [**5-4**] Mr.[**Known lastname 10029**] was admitted taken to the operating room and
underwent mitral valve repair with a size 32 CG Future band,
[**Company 1543**]. Cardiopulmonary Bypass time= 63 minutes, Cross clamp
time= 40 minutes. Please see operative report for further
details. He received Cefazolin for perioperative antibiotics
and transferred to the intensive care unit for post operative
management. He required vasopressin, Levophed, and Milrinone
for hemodynamic support. That evening he was weaned from
sedation, awoke neurologically intact and was extubated without
complications. Electrophysiology was consulted and his permanent
pacemaker was interrogated. On post operative day one he was
started on Captopril and Milrinone weaned off. However on post
operative day two he went into atrial fibrillation, requiring
Amiodarone, and Milrinone was restarted due to decreased cardiac
output. Mr. [**Known lastname 10029**] became progressively oliguric and was
started on Lasix. Levophed was again required due to hypotension
after Captopril. Inotropes and pressors were titrated for
hemodynamics, and Amiodarone for atrial fibrillation.
His renal function continued to worsen requiring increasing
doses of Lasix and Zaroxolyn. On [**5-11**] he was re-intubated for
hypoxia and pulmonary edema requiring a Lasix drip for diuresis
in acute renal failure. He was started on Coumadin and heparin
for anticoagulation due to ongoing atrial fibrillation. On [**5-12**]
he was cardioverted and returned to sinus rhythm. That evening
was able to wean off Levophed and progressively over next 24
hours was weaned off epinephrine. Heparin drip was stopped when
INR was 2.2 and continued on Coumadin for atrial fibrillation.
Amiodarone drip was converted over to oral Amiodarone. On [**5-15**]
he was extubated without complications and continued to remain
stable on milrinone. His Lasix was changed from drip to bolus
dosing. He remained in the intensive care unit for monitoring
and remained stable. He was ultimately weaned off inotropes and
a repeat [**Month/Day (1) 461**] was obtained. His renal function
continued to slowly improve and he was transferred out of the
intensive care unit on post-operative day 17. He was restarted
on his home dose of oral lasix, 80mg daily. Although his labs
have been stable, his sodium, BUN, and creatinine should be
closely monitored at rehab. He was placed on antibiotics for a
urinary tract infection for seven days, to end on [**5-27**]. Physical
Therapy was consulted for evaluation of strength and mobility.
He continued to slowly progress and was cleared for discharge to
[**Hospital 100**] rehab on post-op day 21. All follow up [**Hospital 4314**] were
advised.
Medications on Admission:
1. Outpatient Lab Work
Check Chem 7 on [**2135-5-2**] Please fax to the attention of Dr [**Last Name (STitle) **]
on [**Telephone/Fax (1) 3382**].
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. hydralazine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
7. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13.furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. spironolactone 25 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).
7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
9. hydralazine 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg x 7 days, then 200mg daily until stopped by
cardiologist. Tablet(s)
11. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Goal INR 2-2.5.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for for SOB.
14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for for SOB.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
17. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
hebr
Discharge Diagnosis:
Mitral regurgitation s/p Mitral Valve repair
Dilated cardiomyopathy
Hypertension
Chronic kidney disease
Hearing loss
Pulmonary embolism in [**1-/2132**]
Prostate Cancer
Hypothyroidism
Inguinal Hernia
Old right occipital infarct, with associated encephalomalacia
and ex vacuo effect
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace-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 and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following [**Telephone/Fax (1) 4314**]
Surgeon: Dr [**First Name (STitle) **] on [**6-20**] at 1:45pm
Cardiologist: Dr [**First Name (STitle) 437**] on [**6-27**] at 1:30pm
Please call to schedule [**Month/Year (2) 4314**] with your
Primary Care Dr [**Last Name (STitle) **] in [**Telephone/Fax (1) 250**] 4-5 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2135-5-25**]
|
[
"458.29",
"518.81",
"584.9",
"414.01",
"599.0",
"428.23",
"585.9",
"428.0",
"276.1",
"997.1",
"403.90",
"427.31",
"416.8",
"785.51",
"V10.46",
"244.9",
"425.4",
"V45.02",
"396.3",
"E942.9",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"96.6",
"39.61",
"88.72",
"35.33",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11733, 11764
|
6130, 8873
|
295, 369
|
12089, 12267
|
3128, 6107
|
13190, 13817
|
2046, 2320
|
10138, 11710
|
11785, 12068
|
8899, 10115
|
12291, 13167
|
2335, 3109
|
236, 257
|
397, 1308
|
1330, 1868
|
1884, 2030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,932
| 120,761
|
41201
|
Discharge summary
|
report
|
Admission Date: [**2171-2-9**] Discharge Date: [**2171-2-14**]
Date of Birth: [**2101-1-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 70 year old gentleman with a PMH significant for COPD
on 3L home oxygen therapy, OSA, unknown type of CHF, OSA, cor
pulmonale, who was transferred to [**Hospital1 18**] for further management
of respiratory distress.
Patient was recently discharged from OSH 2 days prior for a COPD
exacerbation returned to OSH the following day with worsening
respiratory symptoms. At OSH, ABG was 7.16, 80, 80. Patient
was transferred here without any intervention or radiographic
tests.
Upon transfer to [**Hospital1 18**] ED, initial vital signs were T: 97, HR:
89, BP: 147/71, RR: 18, O2sat: 88%2L NC. Patient noted to have
poor air movement. Initial ABG was 7.37, 70, 77. Lactate of
0.7. Patient given albuterol and ipratropium nebulizers times
three, SL NTG, and azithromycin 500mg PO X 1. Chest radiograph
demonstrated mild vascular congestion and right lower lobe
opacity. Patient was placed on BIPAP. Two hours later, repeat
ABG was 7.27, 94, 60, and one hour later ABG: 7.24, 100, 103.
Code status was verified to be DNR/DNI with health care proxy
(wife), and as hypercarbia worsened patient became acutely
confused. Due to question of steroid allergy (which later was
denied by health care proxy), the delivery of steroids was
delayed until immediately prior to transfer to the MICU.
.
In the MICU, pt was weaned off BIPAP by the next morning. Pt was
doing well, breathing and satting well on 3L NC (baseline
requirement). Pt was on standing nebs initially, now on Advair
and Spiriva with nebs PRN. Pt was continued on Solumederol, with
plan to transition him to PO Prednisone 60mg daily starting
tomorrow morning. Pt had elev WBC On admission with improved
initially with abx, then bumped up again (likely [**2-27**] steroids).
Blood cx are NTD. Abx initially were broad with
Vanc/Cefepime/Azithro, but then with pt's clinical improvemetn,
have been now narrowed to just Levoquin. Pt has been on Lasix
40mg IV daily with good response. Home Lasix dose is unclear and
needs to clarified. On transfer to the floor, VS were T 98.3 HR
77 BP 169/77 RR 94% (92-95%) on 3L NC and -1.6L net outpt in
last 24hrs.
.
On the floor, pt is comfortable, stated breathing is much
better. Denies CP, fevers. Endorses a chronic mild cough that
occ produces clear sputum.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. ADmits to chronic mild cough, with clear sputum.
Denies chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
- OSA
- cor pulmonale
- COPD with home O2 of 3L, 6L on exertion
- CHF of unclear etiology, will need to verify in AM
- history of gastric malignancy s/p subtotal gastrectomy
- history of DVT
- GERD
- atrial fibrillation
Social History:
Smoked for 30 years prior, stopped years prior. Was an
auto-body worker. Lives with his wife. [**Name (NI) **] alcohol or other
illicit drug use.
Family History:
mother with cancer s/p chemo (not sure what kind), father with
[**Name (NI) 2320**]
Physical Exam:
Admission Exam:
VS: Temp: 97.2, BP: 153/56 HR: 81 RR: 25 O2sat: 100%
GEN: somnolent, bipap mask present
HEENT: PERRL, MMM, difficult to assess JVD secondary to
underlying body habitus
RESP: poor air movement, no audible wheezing
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: obese, soft, NT, ND, no g/r/r.
EXT: no pedal edema
SKIN: hematoma over right hip
NEURO: somnolent, oriented to place
Discharge Exam:
VS: T97.7 BP134/60 P66 RR18 Sat91/3L
GENERAL: well appearing, breathing comfortably without accessory
muscle use, speaking in full sentences without SOB.
PULM: quiet sounds but no wheezing, rhonchi or rales
CARDS: RRR, normal S1 S2 no MRG appreciated
ABDOMEN: obese, soft, nontender, nondistended, positive bowel
sounds
EXT: 1+ pitting edema to the knee bilaterally, at his baseline
per patient.
Pertinent Results:
Admission labs:
[**2171-2-8**] 10:50PM GLUCOSE-146* UREA N-16 CREAT-0.7 SODIUM-145
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-39* ANION GAP-11
[**2171-2-8**] 10:50PM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-2.2
[**2171-2-8**] 10:50PM cTropnT-<0.01
[**2171-2-8**] 10:50PM DIGOXIN-0.9
[**2171-2-8**] 10:50PM WBC-11.5* RBC-4.17* HGB-12.4* HCT-41.6
MCV-100* MCH-29.7 MCHC-29.8* RDW-14.0
[**2171-2-8**] 10:50PM NEUTS-93.9* LYMPHS-4.2* MONOS-1.5* EOS-0.2
BASOS-0.2
[**2171-2-8**] 10:50PM PLT COUNT-429
[**2171-2-8**] 10:50PM PT-23.6* PTT-26.6 INR(PT)-2.2*
[**2171-2-8**] 10:48PM TYPE-[**Last Name (un) **] PO2-77* PCO2-70* PH-7.37 TOTAL
CO2-42* BASE XS-11 COMMENTS-GREEN TOP
[**2171-2-8**] 10:48PM GLUCOSE-144* LACTATE-.7
[**2171-2-9**] 01:12AM TYPE-ART RATES-20/9 O2-50 PO2-103 PCO2-100*
PH-7.24* TOTAL CO2-45* BASE XS-11 INTUBATED-NOT INTUBA
[**2171-2-9**] 01:12AM O2 SAT-96
[**2171-2-9**] 12:11AM TYPE-ART O2-3 PO2-60* PCO2-94* PH-7.27* TOTAL
CO2-45* BASE XS-11 INTUBATED-NOT INTUBA
[**2171-2-9**] 12:11AM O2 SAT-87
[**2171-2-9**] 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2171-2-9**] 02:20AM URINE RBC-0-2 WBC-[**7-5**]* BACTERIA-FEW
YEAST-NONE EPI-1
Discharge Labs:
[**2171-2-14**] 06:50AM BLOOD WBC-12.4* RBC-3.89* Hgb-11.6* Hct-38.0*
MCV-98 MCH-29.7 MCHC-30.4* RDW-14.5 Plt Ct-355
[**2171-2-14**] 06:50AM BLOOD Glucose-99 UreaN-22* Creat-0.8 Na-146*
K-3.6 Cl-99 HCO3-40* AnGap-11
[**2171-2-14**] 06:50AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
MICROBIOLOGY:
[**2171-2-8**] BLOOD CULTURE NEGATIVE
EKG: Normal sinus rhythm with rate of 81, normal axis, no signs
concerning for ischemia.
Chest Radiograph: [**2171-2-8**]
1. Mild cardiomegaly and vascular congestion.
2. Right lower lobe opacity, may represent atelectasis, although
infection cannot be excluded.
TTE [**2171-2-13**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is moderately
dilated with severe global free wall hypokinesis. There is
abnormal septal motion/position. The aortic valve is not well
seen. There is no aortic valve stenosis. The mitral valve
leaflets are not well seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Moderate right ventricular
dilation with severe global hypokinesis. Moderate to severe
pulmonary hypertension. Preserved global left ventricular
systolic function.
LOWER EXTREMITY DOPPLER U/S [**2171-2-13**]:
Limited study as right peroneal veins not visualized. Otherwise,
no evidence of bilateral lower extremity DVT.
CTA CHEST [**2171-2-14**]:
1. No evidence of PE.
2. Mild cardiomegaly.
3. Emphysema.
4. No definite evidence for CHF or pneumonia.
Brief Hospital Course:
70 year old gentleman with a PMH significant for COPD on 3L home
oxygen therapy, OSA, unknown type of CHF, OSA, cor pulmonale,
who was transferred to [**Hospital1 18**] for further management of
hypercarbic respiratory distress.
ACTIVE PROBLEMS:
1. COPD EXACERBATION: he was transferred to [**Hospital1 18**] from OSH for
management of hypercarbic respiratory distress in the setting of
recent and likely ongoing acute exacerbation of COPD. He was
admitted to the MICU after starting BiPAP in the ED and was
subsequently weaned off overnight. He received azithromycin in
the ED and was broadened to levaquin, vancomycin, and cefepime
in the ICU when chest X-Ray showed evidence of possible
pneumonia, though this was narrowed back to levaquin given his
rapid clinical improvement. He was started on solumedrol in
addition to albuterol/ipratropium nebs and advair/spiriva. He
had leukocytosis that was felt to be a steroid effect. Due to
mild pulmonary congestion in the setting of known CHF, he was
diuresed with IV lasix with good effect. He was transferred to
the medicine floor in stable condition where PO steroids were
started. His oxygen saturations remained in the mid-90s on his
home dose supplemental 02 at 3LNC. Diuresis was continued with
oral lasix. He worked with physical therapy, and maintained
saturations in the low 90s on 6LNC (also his home dose). He was
discharged on a 10 day oral steroid taper in addition to advair,
spiriva, and prn albuterol. He will complete a 5 day course of
levaquin as an outpatient.
2. ACUTE ON CHRONIC DIASTOLIC HEART FAILURE: His admission CXR
showed evidence of mild pulmonary congestion. He was diuresed in
the MICU with IV lasix and 2L were removed. As his oxygen
saturations rebounded on the medicine floor, he was placed back
on his oral home-dose lasix. A TTE was obtained to characterize
his heart failure, and demonstrated a preserved EF of 55%. His
right ventricle was dilated and hypokinetic. We obtained lower
extremity ultrasounds, then a CTA to rule out PE given his
recent respiratory distress, tachypnea, hypotension (in the
setting of new ACEI) and dilated RV. These tests were normal.
He was discharged on his home-dose lasix.
3. PAROXYSMAL ATRIAL FIBRILLATION: He remained in sinus rhythm.
He is rate controlled with cardizem and digoxin. He was
continued on coumadin.
4. METABOLIC ALKALOSIS: he had significant alkalosis with
bicarb ranging 35-40 due to his C02 retention and diuresis. He
was continued on diamox with stabilization of his alkalosis.
5. HYPOTENSION: he had asymptomatic hypotension to SBP 80
during the day prior to discharge. He had been started on low
dose lisinopril (2.5mg) as part of CHF optimization therapy
during the previous day. Pressures rebounded when lisinopril
was discontinued when his systolic dysfunction was found to be
preserved.
6. ALTERED MENTAL STATUS: he was somnolent initially in the
ICU which was felt to be due to hypercarbia. His mental status
normalized following BiPAP and improvement of his respiratory
status
INACTIVE PROBLEMS:
7. HYPERTENSION: his cardizem was initially held in the ICU,
though was restarted prior to floor transfer to the floor. He
was normotensive at the time of discharge.
8. OSA: he was continued on BiPAP at night with good effect.
9. GERD: he was continued on nexium
PENDING LABS AT DISCHARGE: none
TRANSITIONAL CARE ISSUES:
- may consider stopping digoxin given his normal sinus rhythm
and diastolic dysfunction
Medications on Admission:
cardizem 240 mg once daily
duonebs 2 puffs PRN
coumadin 10 mg daily
diamox 500 mg daily
iron 650 mg daily
digoxin 0.25 mg daily
lasix 20 mg daily
nexium 40 mg daily
formoterol 20 mcg
pulmicort ? dose
acetminophen
Discharge Medications:
1. Cardizem CD 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
2. warfarin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. acetazolamide 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO Q24H (every 24 hours).
4. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation every
4-6 hours as needed for shortness of breath or wheezing.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. formoterol fumarate 20 mcg/2 mL Solution for Nebulization
Sig: One (1) nebulizer Inhalation twice a day.
11. Pulmicort Flexhaler 180 mcg/Inhalation Aerosol Powdr Breath
Activated Sig: Two (2) puffs Inhalation twice a day.
12. prednisone 10 mg Tablet Sig: 1-5 Tablets PO once a day for
10 days: 5 tablets X2 days, 4 tablets X2d, 3 tablets X2d, 2
tablets X2d, 1 tablet X2d.
Disp:*30 Tablet(s)* Refills:*0*
13. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 disk* Refills:*2*
14. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 disk* Refills:*2*
15. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of central and [**Hospital3 **] [**Hospital3 **]
Discharge Diagnosis:
Primary: COPD exacerbation, diastolic CHF exacerbation
Secondary: Obstructive sleep apnea, GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 89737**],
You were transferred to [**Hospital1 18**] for further management of
respiratory distress that was likely due to an exacerbation of
your COPD. You were briefly in the ICU overnight on a BiPAP
machine, but your symptoms rapidly improved with steroids and
nebulizer treatments, and you were transferred to the medicine
floor. You were also given additional lasix to remove fluid
from your lungs to help with breathing. An echocardiogram
showed that part of your heart, the right ventricle, was
dilated. This could be driven by a blood clot in the lungs
causing strain on the heart. Ultrasounds of your legs and a
scan of your lungs showed this was not the case; you do n ot
have a blood clot in your legs or your lungs. You will complete
oral steroids and antibiotics at home to continue treating your
COPD.
The following changes have been made to your medications
1. CONTINUE LEVAQUIN 750mg daily for 1 more day
2. CONTINUE PREDNISONE as follows:
-50mg for 2 days
-40mg for 2 days
-30mg for 2 days
-20mg for 2 days
-10mg for 2 days
3. START Fluticasone and Tiotropium inhalers
Please take all other medications as prescribed by your other
doctors
It was a pleasure taking care of you, Mr. [**Known lastname 89737**]
Followup Instructions:
You have an appointment with your primary care doctor for
follow-up after this hospitalization:
.
Name: [**Last Name (LF) 23858**],[**First Name3 (LF) **] T.
Address: 37 [**Location (un) **] DR. # 3, N. [**Hospital1 **],[**Numeric Identifier 23859**]
Phone: [**Telephone/Fax (1) 23860**]
When: Tuesday, [**2-19**], 1:15PM
|
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"V10.04",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12875, 12958
|
7407, 10284
|
311, 318
|
13098, 13098
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4376, 4376
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10815, 10905
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10783, 10789
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346, 2619
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4392, 5618
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13113, 13225
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3053, 3275
|
3291, 3442
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,623
| 179,098
|
38811
|
Discharge summary
|
report
|
Admission Date: [**2129-10-10**] Discharge Date: [**2129-10-15**]
Service: MEDICINE
Allergies:
Codeine / Aspirin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o DNR/DNI female with HTN, HLD, mild dementia, who
presented to [**Hospital1 18**] ED today in setting of fall. Per discussion
with patient, she has not been in her usual state of health for
the past 1 week. She denies CP or SOB, but reports diaphoresis
and feeling generally unwell for the past week. Today, she came
in for evaluation of her fall.
.
Per [**Hospital3 **] and daughter, the fall occured 2 days ago
and was unwitnessed and she was found awake on the floor. Per
patient, she felt dizzy, had +LOC, and fell without any
pulmonary or cardiac symptoms prior. She refused to go to
hospital. Over the course of the next day, her breathing became
labored and her mental status had changed and she was confused.
She refused to go to the hospital until today.
.
In the ED, there was concern for head trauma. She also reported
pain in R arm and L hip. CT head and spine without acute
pathology. Also had CT spine showing grade II anterolisthesis of
C3 on C4, likely chronic. Imaging of spine, pelvis, hip, elbow,
and shoulder were all normal, without acute pathology, per
prelim read. CXR without acute pathology.
.
EKG was notable for non-specific ST-T wave changes, no prior for
comparison. Her troponin was 0.66. Cardiology was consulted for
NSTEMI. Aspirin and heparin gtt was initiated, with plan for
admission to [**Hospital1 1516**].
.
However, per ED, patient became "poorly responsive" at 6 pm.
Repeat Head CT performed due to concern for ICH, as patient was
started on heparin. Head CT was negative. A 2nd set of CE's was
drawn and troponin was 1.10. EKG was checked and patient had new
ST elevations in V3-V5, with concern for STEMI. Patient's mental
status was now reported as back to baseline. She denied CP or
SOB and did not have any symptoms. ED spoke with the family and
daughter, and initial plan was for cardiac cath. Dr [**Last Name (STitle) **] was
called in. Cardiology was re-consulted. Bedside echo showed that
her anterior inferior wall was down, but time course was
unclear.
.
Patient was placed on heparin gtt again, and given eptifibatide
(plavix was ordered but pt unable to swallow). Upon discussion
with cardiology, and given overall clinical picture along with
patient's desire to not proceed with cardiac cath, this was
deferred. Plan to admit to CCU due to evolving STEMI with
consideration for cath if patient develops any symptoms.
.
On transfer, vs: afebrile, 68, 151/90, 24, 100 2L (94% RA), no
CP. She is AOx2 and has 1 PIV.
.
In CCU, pts vitals: afebrile, BP 142/84,HR 74, 95% on 3L. Pt
reports some diapharesis in the ED but currently denies any
chest pain, no diapharesis, no nausea, no jaw pain, no SOB.
.
Pt currently denies any chest pain, no shortness of breath, does
report constipation, no headaches, no neurological changes,
remainder of ROS is negtive.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: has had cardiac catheterization in [**State 108**]
in the past, unclear when, without reported intervention
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY (per daughter):
-Hx of supraventricular tachycardia
-mitral valve prolapse
-anemia on iron
-gout
-osteoarthritis vs RA of her bilateral hands and upper
extremities, as well as her neck
-venous stasis ulcers
-Hemmorhoids
-Colon polyps
-"swollen legs" and wears compression stalkings
.
Past Surgical History (per PCP [**Name Initial (PRE) 626**]):
-[**2035**] Tonsils
-[**2052**] Appendix
-[**2066**] Hysterectomy
-[**2068**] and [**2088**] Surgery for "Ulcerated Rectum"
-[**2094**] vaginal hernia
-[**2097**] hernia repair with mesh
Social History:
-Tobacco history: never
-ETOH: denies
-Illicit drugs: denies
Lives in [**Hospital3 **] at Admiral's [**Doctor Last Name **] in [**Location (un) **].
Ambulating with walker last week. HHA 6:30-8:30am, 6:30-8:30pm
(needs assist getting in/out of bed).
.
Family History:
Mother (died age 60) and father (died age 40) both died of MIs .
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Admission
VS: afebrile, BP 142/84,HR 74, 95% on 3L
GENERAL:NAD Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 9 cm.
CARDIAC: RRR, no mrg.
LUNGS: no crackes, rhonchi, rhales
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+
Left: Carotid 2+ Femoral 2+
Pertinent Results:
CBC:
[**2129-10-10**] 11:55AM BLOOD WBC-11.9* RBC-3.90* Hgb-10.8* Hct-32.7*
MCV-84 MCH-27.8 MCHC-33.1 RDW-14.3 Plt Ct-302
[**2129-10-12**] 06:05AM BLOOD WBC-16.1* RBC-3.79* Hgb-10.6* Hct-33.6*
MCV-89 MCH-27.9 MCHC-31.5 RDW-14.8 Plt Ct-245
[**2129-10-15**] 08:00AM BLOOD WBC-11.9* RBC-3.56* Hgb-10.1* Hct-30.4*
MCV-85 MCH-28.4 MCHC-33.3 RDW-15.9* Plt Ct-77*
.
Chem:
[**2129-10-10**] 11:55AM BLOOD Glucose-140* UreaN-39* Creat-1.3* Na-142
K-4.5 Cl-102 HCO3-29 AnGap-16
[**2129-10-11**] 02:19PM BLOOD Glucose-137* UreaN-52* Creat-2.1* Na-143
K-4.8 Cl-108 HCO3-24 AnGap-16
[**2129-10-13**] 04:21AM BLOOD Glucose-102* UreaN-85* Creat-3.9* Na-143
K-5.1 Cl-107 HCO3-21* AnGap-20
[**2129-10-14**] 11:00AM BLOOD Glucose-117* UreaN-105* Creat-4.6* Na-140
K-5.2* Cl-114* HCO3-10* AnGap-21*
[**2129-10-15**] 08:00AM BLOOD Glucose-117* UreaN-120* Creat-5.4* Na-144
K-5.4* Cl-110* HCO3-15* AnGap-24*
.
CEs:
[**2129-10-10**] 11:55AM BLOOD cTropnT-0.66*
[**2129-10-10**] 06:45PM BLOOD cTropnT-1.10*
[**2129-10-11**] 02:40AM BLOOD CK-MB-20* MB Indx-8.4* cTropnT-1.37*
[**2129-10-11**] 02:19PM BLOOD CK-MB-14* MB Indx-6.4* cTropnT-1.54*
[**2129-10-12**] 06:05AM BLOOD CK-MB-14* MB Indx-4.8 cTropnT-1.59*
Brief Hospital Course:
[**Age over 90 **] F with h/o HLD and HTN admitted for fall found to have STEMI
(suspected to be in LAD territory given ST changes in V1-3). Pt
and family declined cardiac cath and wished to proceed with
solely medical management. CK-MB peaked at 20, Trop rose to
1.59. Pt was treated with aggressive medical management for
STEMI with aspirin, bb, integrillin gtt, lisinopril. However,
renal failure persisted, and pt began experiencing respiratory
distress from fluid overload. No intervention was pursued, and
patient was made CMO. Shortly thereafter, pt passed away.
Medications on Admission:
MEDICATIONS, per [**Hospital3 **]:
Paroxetine 15mg daily
Miralax 17g PO QOD
Prednisone 3mg daily
Tramadol ER 200mg QHS
Bisacodyl 10mg PO prn constipation >3d
Lactulose 30mL [**Hospital1 **] prn constipation
Loperamide 2mg QID prn diarrhea
Vit D 1,000 U daily
Tylenol 650mg PO BID
CaCO3 600mg (1500mg) daily
furosemide 20mg PO daily
Lisinopril 2.5mg daily
lutein 6mg PO daily
Toprol XL 75mg daily
Omeprazole 20mg daily
Oxycodone 2.5mg [**Hospital1 **]
Oxycodone 2.5mg Q6h prn pain
Vit B12 1,000 mcg monthly sub q
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"790.7",
"V49.86",
"585.3",
"287.5",
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"410.11",
"403.90",
"584.5",
"272.4",
"294.8",
"424.0",
"428.21",
"274.9",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7441, 7450
|
6268, 6845
|
266, 272
|
7502, 7512
|
5058, 6245
|
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|
222, 228
|
300, 3130
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3152, 3221
|
4000, 4254
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,354
| 147,649
|
46560
|
Discharge summary
|
report
|
Admission Date: [**2124-10-16**] Discharge Date: [**2124-10-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
diarrhea, hypotension
Major Surgical or Invasive Procedure:
intubation
central venous catheter placement
arterial line placement
History of Present Illness:
85 y/o M w/ colon cancer s/p resection [**2120**], with recently
diagnosed metastases to the lung, now receiving chemotherapy,
who was referred to the ED after presenting at onc clinic with
tachycardia, hypotension, poor PO, admitted to MICU for code
sepsis and now tranferred to OMED service for observation.
.
The patient reports that he started having some crampy abdominal
pain in his RLQ and LLQ pain beginning last Wednesday. He had no
other symptoms with this. He went for chemotherapy (3rd dose of
1st cycle) on Friday and following this, developed diarrhea
(about 3 loose nonbloody stools per day) as well as nausea and
some vomiting. He was unable to take anything PO since Saturday
morning, liquid or solid. His pain was fairly constant and
crampy in nature. He denied any dysuria or flank pain. No SOB.
No cough.
.
Patient was 80/palp in the onc clinic and tachycardic to 140,
afib, and received one liter of NS on way to ED. Patient was not
hypotensive in the ED on presentation. He was borderline
neutropenic on labs and received cefepime and flagyl. His
lactate was found to be 6.7 and a code sepsis was called. A RIJ
was placed. Patient has now received a total of [**8-4**] liters of
IVF (NS) along with the antibiotics. He also received some
demerol for rigors. He is currently feeling 100% better. Some
residual diarrhea and abd discomfort. No CP, no SOB.
Past Medical History:
1. Colon cancer [**2120**], stage II, s/p resection
-rising CEA [**8-1**] and solitary lung mass and subcarinal LN found
on PET scan c/w met adenoca on bronch/mediastinoscopy
-now receiving 5FU, leucovorin, and oxaliplatin
-last colonoscopy [**10-31**] normal
2. Afib, recently diagnosed on coumadin
3. HTN
4. Echo w/ nl EF, no other abnormality [**2123**]
Social History:
Lives at home with wife. [**Name (NI) **] tobacco or EtOH. Retired.
Family History:
NC
Physical Exam:
T 96.3 HR 96 BP 140/80 RR 20 95% RA
194.2 lbs
540/450
GEN: aaox3, elderly, WDWN, rigoring slightly
HEENT: PERRL, EOMI, mmm, op clear
Neck: no elevated JVP, no LAD
CV: RRR, nl s1 s2, holsystolic murmur heard best at apex II/VI
LUNGS: CTA b/l no crackles
ABD: soft, midline scar, bs+, slightly tender in LLQ, no HSM,
trace ob+ liquid brown stool
BACK: no CVA tenderness
EXT: no edema, no rashes
Pertinent Results:
CXR: no acute pulmonary process
CT abd: [**2124-10-16**]
IMPRESSION:
1. Circumferential wall thickening involving the rectum.
Abnormal wall thickening involving multiple scattered loops of
small bowel, the etiology of which may include post-radiation
changes, ischemia, and infection.
2. Small amount of free fluid.
3. Right lower lobe lung mass and peripheral nodule again
identified.
Brief Hospital Course:
Mr. [**Known lastname **] was borderline neutropenic on labs in the ED, and
received cefepime and flagyl. His lactate was found to be 6.7
and a code sepsis was called. A RIJ was placed, and he received
aggressive fluid resuscitation. He was admitted to the MICU
where he received antibiotics and IVF. He was transferred to
the [**Hospital Ward Name 516**] on [**10-17**] after stabilization, with improved
abdominal pain and diarrhea, and no nausea, vomiting, or fever.
He was hemodynamically stable and his diarrhea was thought to be
secondary to 5-FU. The diarrhea improved off antibiotics and
with symptomatic treatment only. His Hct was stable throughout
and his stools were guaiac negative. His coumadin was held for
the history of a supratherapeutic INR (7.9) 1 week earlier. His
INR increased from 2.9 on admission to 5.5 today.
.
Pt became hypoxic and agitated at 8pm on [**10-20**]. he was found to
be hypotensive and in A fib with rate in 130s. He became
tachypneic and progressively more obtunded over the next several
minutes. He had a short run of VT and then became bradycardic
to the 30s, with a BP of 60/palp. He was started on peripheral
dopamine, and was given 2 amps of bicarb. He was then
intubated, immediately after which he had a large amount of
coffee ground emesis, with some evident inside the ETT. He was
then transferred to the [**Hospital Unit Name 153**] for ventilation and further
management.
.
Mr. [**Known lastname **] came to the [**Hospital Unit Name 153**] in hypovolemic shock, presumably from
an upper GI bleed. He continued to have coffee-ground material
from his NGT. He received aggressive fluid resuscitation,
vitamin K SC, 5U FFP, 3U PRBC, and 1U platelets. He remained
hypotensive on pressors. He was also given a PPI [**Hospital1 **]. A GI
consult was called for possible EGD to localize and intervene
upon an upper GI source of bleeding. He was suspected to have
aspirated during intubation, so empiric antibiotics were
started. The plan was made to obtain a CT head to rule out
intracranial hemorrhage as a cause for his acute change in
mental status. Also on his differential were CVA,
toxic-metabolic encephalopathy, and seizure. His diarrhea was
suspected to be C. diff colitis vs. 5-FU diarrhea. He was kept
on Flagyl and cefepime for empiric treatment and his stool was
sent for C. diff toxin. Labs showed a severe non-anion gap
acidosis, likely secondary to his diarrhea. He was started on a
sodium bicarbonate drip and his minute ventilation parameters
were increased in an effort to increase respiratory elimination
of carbon dioxide. A femoral TLC and an arterial line were
placed for further monitoring and management. Due to his
persistent hypotension, he was deemed to unstable to travel to
CT. GI consult saw the patient in the morning, but the decision
was made not to scope Mr. [**Known lastname **] per his wife's wishes.
.
On initial discussion with Mrs. [**Known lastname **], his wife and HCP, the
patient was made full code. However, Mrs. [**Known lastname **] decided several
hours later that aggressive treatment would be against her
husband's wishes. He was made comfort measures only and he
expired a few hours later.
Medications on Admission:
1. Cozaar 50
2. Digoxin .[**Telephone/Fax (1) 98860**]
3. Coumadin (held last week when INR was found to be 7.9)
.
Discharge Disposition:
Expired
Discharge Diagnosis:
upper GI bleed
Discharge Condition:
expired
Completed by:[**2124-10-21**]
|
[
"458.9",
"286.9",
"401.9",
"276.5",
"507.0",
"197.0",
"E933.1",
"276.2",
"584.9",
"578.0",
"V10.00",
"518.81",
"288.0",
"427.31",
"558.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.17",
"99.05",
"99.04",
"99.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6477, 6486
|
3093, 6311
|
286, 356
|
6544, 6583
|
2679, 3070
|
2246, 2250
|
6507, 6523
|
6337, 6454
|
2265, 2660
|
225, 248
|
384, 1763
|
1785, 2144
|
2160, 2230
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,939
| 125,516
|
22649
|
Discharge summary
|
report
|
Admission Date: [**2152-6-12**] Discharge Date: [**2152-7-6**]
Date of Birth: [**2110-8-3**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Dicloxacillin
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
s/p motorcycle crash
Major Surgical or Invasive Procedure:
[**2152-6-12**]: right tibial I+D and ex-fix
[**2152-6-14**]: ORIF R acetabulum + R gamma nail
[**2152-6-16**]: ORIF R tibial plateau
[**2152-6-26**]: L5-S1 fusion
[**2152-6-27**]: IVC filter placement
[**2152-7-3**]: revision R gamma nail
History of Present Illness:
Mr [**Known lastname 58702**] is a 41 year old male who was involved in a
motorcycle crash on [**2152-6-12**]
Past Medical History:
none
Social History:
Occasional ETOH, no drugs, no tobacco. Has had unprotected
heterosexual sex with multiple partners. Currently with one
female partner for past one year. No rescent travel out of the
country in the past 2 years. Has only travelled to Europe in
the past. Mother and father are first cousins.
Family History:
Father and brother with hemachromatosis dz gene (awaiting
records). No hx of early cardiac disease in the family.
Physical Exam:
Upon discharge:
AVSS
NAD
A+O
CTA b/l
RRR
S/NT/ND +BS
spine: incisions c/d/i w/ steri strips
[**Date Range **]: incisions c/d/i
VAC working well
+[**Last Name (un) 938**]/FHL/AT
SILT
brisk cap refill
Pertinent Results:
[**2152-6-12**] 07:37PM HCT-24.0*
[**2152-6-12**] 07:10PM TYPE-ART PO2-151* PCO2-43 PH-7.37 TOTAL
CO2-26 BASE XS-0
[**2152-6-12**] 07:10PM GLUCOSE-114* LACTATE-1.7
[**2152-6-12**] 07:10PM freeCa-1.15
[**2152-6-12**] 06:54PM CK(CPK)-1062*
[**2152-6-12**] 06:54PM CK-MB-22* MB INDX-2.1 cTropnT-<0.01
[**2152-6-12**] 12:17PM TYPE-ART PO2-166* PCO2-40 PH-7.34* TOTAL
CO2-23 BASE XS--3
[**2152-6-12**] 12:17PM LACTATE-2.3*
[**2152-6-12**] 11:54AM POTASSIUM-4.5
[**2152-6-12**] 11:54AM CK-MB-29* cTropnT-<0.01
[**2152-6-12**] 11:54AM MAGNESIUM-2.4
[**2152-6-12**] 07:02AM TYPE-ART PO2-169* PCO2-41 PH-7.28* TOTAL
CO2-20* BASE XS--6
[**2152-6-12**] 07:02AM LACTATE-2.8*
[**2152-6-12**] 06:16AM TYPE-ART TEMP-36.5 RATES-12/ TIDAL VOL-700
PEEP-5 O2-60 PO2-231* PCO2-43 PH-7.25* TOTAL CO2-20* BASE XS--8
INTUBATED-INTUBATED VENT-CONTROLLED
[**2152-6-12**] 05:12AM TYPE-ART TEMP-36.1 RATES-12/ PEEP-5 PO2-380*
PCO2-41 PH-7.22* TOTAL CO2-18* BASE XS--10 -ASSIST/CON
INTUBATED-INTUBATED
[**2152-6-12**] 05:03AM O2 SAT-85
[**2152-6-12**] 04:51AM GLUCOSE-190* UREA N-16 CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-17* ANION GAP-17
[**2152-6-12**] 04:51AM CK(CPK)-776*
[**2152-6-12**] 04:51AM CK-MB-23* MB INDX-3.0 cTropnT-<0.01
[**2152-6-12**] 04:51AM CALCIUM-8.2* PHOSPHATE-5.4* MAGNESIUM-1.5*
[**2152-6-12**] 04:51AM WBC-14.4* RBC-3.97* HGB-10.7* HCT-31.9*
MCV-80* MCH-27.0 MCHC-33.5 RDW-15.6*
[**2152-6-12**] 04:51AM PLT COUNT-173
[**2152-6-12**] 04:51AM PT-12.6 PTT-23.0 INR(PT)-1.1
[**2152-6-12**] 04:23AM O2 SAT-76
[**2152-6-12**] 04:20AM TYPE-ART PO2-110* PCO2-37 PH-7.27* TOTAL
CO2-18* BASE XS--8 INTUBATED-INTUBATED VENT-CONTROLLED
[**2152-6-12**] 04:20AM GLUCOSE-210* LACTATE-6.7* NA+-138 K+-3.9
CL--109
[**2152-6-12**] 04:20AM HGB-9.1* calcHCT-27
[**2152-6-12**] 04:20AM freeCa-1.01*
[**2152-6-11**] 11:35PM PH-7.21* COMMENTS-GREEN TOP
[**2152-6-11**] 11:35PM GLUCOSE-152* LACTATE-3.5* NA+-143 K+-5.0
CL--110 TCO2-23
[**2152-6-11**] 11:35PM HGB-10.6* calcHCT-32 O2 SAT-54 CARBOXYHB-1.2
MET HGB-0.7
[**2152-6-11**] 11:35PM freeCa-1.09*
[**2152-6-11**] 11:30PM UREA N-19 CREAT-1.2
[**2152-6-11**] 11:30PM CK(CPK)-342* AMYLASE-39
[**2152-6-11**] 11:30PM CK-MB-15* MB INDX-4.4 cTropnT-<0.01
[**2152-6-11**] 11:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2152-6-11**] 11:30PM URINE HOURS-RANDOM
[**2152-6-11**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2152-6-11**] 11:30PM WBC-24.5*# RBC-3.81*# HGB-9.8*# HCT-29.9*#
MCV-79* MCH-25.8*# MCHC-32.8 RDW-14.9
[**2152-6-11**] 11:30PM PLT COUNT-251
[**2152-6-11**] 11:30PM PT-12.5 PTT-20.0* INR(PT)-1.1
[**2152-6-11**] 11:30PM FIBRINOGE-188
[**2152-6-11**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2152-6-11**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
CT LOW EXT W/O C RIGHT [**2152-6-11**] 11:58
CT LOW EXT W/O C RIGHT
Reason: r/o fx tib plateau
[**Hospital 93**] MEDICAL CONDITION:
41 year old man with motorcycle
REASON FOR THIS EXAMINATION:
r/o fx tib plateau
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Motorcycle accident, rule out tibial plateau fracture.
TECHNIQUE:
Thin section axial images were obtained from the distal femur
through the mid calf and reconstructed using both bone and soft
tissue algorithm. Coronal and sagittal reconstructions were also
generated. The patient's leg is imaged in slight flexion,
resulting in some distortion of the axial images presently
available.
RIGHT LOWER EXTREMITY, WITHOUT CONTRAST:
PRELIMINARY WET [**Location (un) **]:
Please note that a wet [**Location (un) 1131**] was provided by the radiology
resident on the PACS requisition as follows: "extensively
comminuted tibial plateau fracture involving joint surface with
hematoma and deep tissue air. Comminuted proximal fibular
fracture (spiral). Discussed with trauma team (by resident
[**Doctor Last Name **], M,"
FINAL REPORT:
There is a markedly comminuted fracture of the proximal tibia,
extending into the tibial plateau, with considerable axial
dispersion of the fracture fragments. The articular surface
components extend into the lateral plateau, into the tibial
eminence, and into the medial tibial plateau. The distal major
fracture lines exit in the medial and lateral metaphyses, with
comminution. There is dispersion of fragments posteriorly, with
small fragments lying adjacent to the popliteal vessels, though
they do not appear to directly impinge on the vessels (series 2,
images 139-117). The main longitudinal axis of the tibial shaft
is displaced posteriorly with respect to the markedly comminuted
proximal tibia, best appreciated on sagittal views. The tibial
tubercle (insertion site of patellar tendon) is avulsed. There
is also considerable comminution at the expected insertion site
of the posterior cruciate ligament. The ACL is not effectively
evaluated here.
There is a joint effusion, with air within the joint. There is
extensive surrounding soft tissue edema as well as some
subcutaneous emphysema.
There is a comminuted fracture of the proximal diaphysis of the
fibula. The proximal tibiofibular joint remains congruent.
IMPRESSION:
1. Markedly comminuted and impacted fracture of the proximal
tibia, with extensive involvement of the tibial plateau and
posterior displacement of the main shaft of the tibia. Avulsion
of patellar tendon from tibial tubercle. Comminution at expected
site of PCL insertion. Bony fragments abutting the popliteal
vessels.
2. Proximal fibular diaphyseal fracture.
CT C-SPINE W/O CONTRAST [**2152-6-11**] 11:52 PM
CT C-SPINE W/O CONTRAST
Reason: r/o Fx
[**Hospital 93**] MEDICAL CONDITION:
41 year old man with motorcycle
REASON FOR THIS EXAMINATION:
r/o Fx
CONTRAINDICATIONS for IV CONTRAST: None.
ADDENDUM: The findings regarding T4 fracture was communicated to
the covering physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58703**], by telephone at 9:30 p.m. on
[**2152-6-12**]. We tried to reach the ordering physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) **], however, was not successful, and therefore, the
information was also sent to Dr. [**First Name (STitle) **] by e-mail.
INDICATION: 41-year-old male with motorcycle.
C-SPINE CT WITHOUT CONTRAST.
No comparison.
FINDINGS: Note is made of severe scoliosis, however, there is no
gross fracture or dislocation. No prevertebral soft tissue
swelling.
IMPRESSION: Marked scoliosis. No gross fracture or dislocation.
NOTE ADDED AT ATTENDING REVIEW: There is a compression fracture
of T4, with retropulsion of an inferior endplate fragment. CT is
extremely limited for analyzing canal narrowing. There appears
to be only mild osseous encroachment on the canal, but the
possibility of soft tissue abnormality, such as disk protusion
or hematoma, cannot be evaluated. If clinically indicated,
recommend CT of the thoracic and lumbar spine and perhaps an MR
of the spine
Brief Hospital Course:
The patient was admitted to the TSICU s/p his motorcycle crash.
He was emergently taken to the operating room on [**2152-6-12**] for
incision and drainage of his right tibial plateau and spanning
ex-fix. See operative note for details. He returned to the
TSICU post-operatively. He remained intubated secondary to his
poor respiratory status. On [**2152-6-14**] he was taken to the
operating room for ORIF of his right acetabulum and R gamma
nail. See operative note for details. He returned to the TSICU
post-op and remained intubated. On [**2152-6-16**] he was brought to the
operating room for ORIF of his right tibial plateau. He
returned to the TSICU post-op. The patient developed fevers in
the TSICU. This was attributed to pneumonia. He was placed on
vancomycin and ceftazidime as recommended by infectious disease.
On [**2152-6-22**] he was extubated without incident and transferred
later in the day to the floor without incident. On [**2152-6-25**] he
was transferred to the orthopedic service from the trauma
service. On [**2152-6-26**] he was taken to the operating room with
spine service for fixation of his sacral fractures and L4
fracture. See operative note for details. He was extubated and
brought to the recovery room in stable condition. Once stable
in the PACU he was transferred to the floor. On [**2152-6-27**] an IVC
filter was placed by vascular surgery. On the floor he did
well. He worked with physical therapy and progressed well. He
received tranfusions for post-operative anemia and his
electrolytes were repleted. On [**2152-7-3**] he was brought to the
operating room for revision of his right gamma nail and VAC
placement of his [**Date Range **]. He tolerated this well. His labs and
vitals remained stable. His hospital course was otherwise
without incident. He is being discharged today to rehab in
stable condition.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: pain, fever.
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-17**]
Drops Ophthalmic PRN (as needed).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO HS
(at bedtime) as needed.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): hold for SBP<95, HR<55.
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 3 weeks: continue until appointment with orthopedics.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Right acetabulum fracture
Right tibial plateau fracture
Right intertrochanteric fracture
T4 fracture
Right sacral fracture
Pubic rami fracture
L5 transverse process fracture
Pneumonia
Pulmonary contusions
post-operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Please do not bear weight on your right leg. Wear the [**Doctor Last Name 6587**]
brace locked at all times. Please keep incisions clean and dry.
Dry sterile dressing daily as needed. If you notice any
increased redness, swelling, drainage, temperature >101.4, or
room. Take all medications as prescribed. Please follow up as
below. Call with any questions.
Physical Therapy:
Strict NWB [**First Name9 (NamePattern2) **]
[**Doctor Last Name **] to [**Doctor Last Name **] locked in extension
Treatments Frequency:
Dry sterile dressings daily as needed to incisions
VAC on [**Doctor Last Name **] to 125
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1005**] at the [**Hospital1 18**] orthopedic
clinic in 2 weeks. Call [**Telephone/Fax (1) **] for an appointment.
Please follow up with Dr. [**Last Name (STitle) 363**] at the [**Hospital1 18**] ortho spine clinic
in 2 weeks. Call [**Telephone/Fax (1) **] for that appointment as well
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1864**] Call to schedule
appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2152-7-6**]
|
[
"805.6",
"427.89",
"E812.2",
"820.21",
"823.12",
"808.0",
"808.2",
"805.4",
"280.0",
"401.9",
"861.21",
"458.29",
"805.2",
"214.1",
"868.03",
"486",
"425.4",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.53",
"86.3",
"96.6",
"78.47",
"79.39",
"96.72",
"79.66",
"38.7",
"81.62",
"79.36",
"78.17",
"86.22",
"81.08",
"78.57",
"78.67",
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
11879, 11953
|
8521, 10403
|
298, 540
|
12224, 12233
|
1406, 4489
|
12892, 13535
|
1036, 1152
|
10426, 11856
|
7221, 7253
|
11974, 12203
|
12257, 12622
|
1167, 1167
|
12640, 12757
|
12779, 12869
|
238, 260
|
7282, 8498
|
1183, 1387
|
568, 679
|
701, 707
|
723, 1020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,505
| 191,034
|
49334
|
Discharge summary
|
report
|
Admission Date: [**2130-4-24**] Discharge Date: [**2130-4-28**]
Date of Birth: [**2079-2-3**] Sex: M
Service:
CHIEF COMPLAINT: Upper gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old man
with a history of HIV, hepatitis C and cirrhosis who has
noted progressive development of ascites over the two weeks
prior to admission. He has also noted increasing nausea and
vomiting over the two to three months prior to admission.
Approximately one to two weeks prior to admission the patient
noted epigastric discomfort associated with vomitus with
small amount of blood streaking noted. The patient was seen
in the Emergency Department at that time where he was noted
to have mild hepatitis, pancreatitis with coagulopathy. INR
was 2.7 and anemia with a hematocrit of 33.9. He reports
being diagnosed with ascites at that time and asked to follow
up with his primary care physician. [**Name10 (NameIs) **] report his primary
care physician instituted diuretic therapy with Aldactone 50
mg po q.d. at that time and held his heart therapy. On the
morning of admission the patient stated that he felt nauseous
and that he self induced vomiting by "sticking his fingers
down his throat." He reported that the vomitus was somewhat
bloody. He subsequently developed a rapid heart rate with
palpitations and came to the Emergency Department for further
evaluation.
In the Emergency Department he was noted to be tachycardic
with a heart rate of approximately 110 and a blood pressure
of 96/38 and nasogastric tube was placed, which returned
bright red blood. He was lavaged with 1200 cc returning 2700
cc of bloody fluid, which did not clear. The patient was
then resuscitated in the Emergency Department and admitted to
the Medical Intensive Care Unit for further evaluation.
PAST MEDICAL HISTORY: 1. HIV diagnosed in [**2120**] secondary to
intravenous drug use. His last CD4 count was 378 on the
[**1-18**]. His last viral load was 23,700. 2. Chronic
hepatitis C. 3. Lipodystrophy. 4. Hypogonadism.
MEDICATIONS AT HOME: 1. Aldactone 50 mg po q.d. 2.
Vitamin K 10 mg subQ for the two prior days. 3. Mycelex.
4. HAART consisting of Ritonavir, Stavudine, Didanosine and
Kaletra, which was held for this period.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married with two children.
He has a prior history of cocaine and heroine use. He denies
recent ethanol use and has a remote tobacco history.
INITIAL PHYSICAL EXAMINATION: Pulse 110. Blood pressure
116/60. Respiratory rate 14. Oxygen saturation of 100% on
room air. In general, he is a thin ill appearing man in no
acute distress. His HEENT examination was unremarkable with
sclera anicteric, oropharynx with nasogastric tube in place.
Pupils are equal, round and reactive to light. Extraocular
movements intact. He had some temporal wasting. His neck
was supple with full range of motion. His lungs were clear
to auscultation bilaterally. Cardiac examination he was
noted to be tachycardic. Normal S1 and S2. No murmurs, rubs
or gallops were appreciated. His abdomen was distended with
mild epigastric tenderness. No right upper quadrant
tenderness. No rebound or guarding. His rectal examination
had black guaiac positive stool per the Emergency Department.
On extremity examination he had 1+ pitting edema bilaterally
in the lower extremities. Dorsalis pedis pulses were 2+.
INITIAL LABORATORY STUDIES: [**Known lastname 1007**] blood cell 16.6,
hematocrit 22.9, previously 33.9 on [**2130-4-16**]. Platelets of
84, INR 2.7, PTT 57, sodium 135, potassium 4.9, chloride 100,
bicarb 20, BUN 30, creatinine 1.2, glucose 81, ALT 130, AST
201, alkaline phosphatase 172, total bilirubin 2.2, amylase
246, lipase 194, albumin 1.9. His electrocardiogram showed
sinus tachycardia at a rate of 100, intervals of 120, 482,
451, nonspecific ST T wave changes.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit to be stabilized. ON the first
evening he was transfused a total of six units of packed red
blood cells and also one bag of platelets and five units of
fresh frozen platelets to maintain hemodynamic stability. He
also underwent emergent esophagogastroduodenoscopy, which
showed duodenal erosion and a tear consistent with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **] tear leading to his upper gastrointestinal bleed. He
also underwent paracentesis. His ascites showed [**Known lastname **] blood
cell of [**Pager number **] with a differential of 0 polys, 20 lymphocytes,
22 monocytes, 2 mesothelial, 45 macrophages. He also had 245
red blood cells, LDH 55, glucose 72. Gram stain showed 2+
polys, but no microorganisms with evidence of SBP. The
patient was started on prophylaxis with Ciprofloxacin 500 mg
b.i.d. for seven days in the setting of a gastrointestinal
bleed. After being stabilized the patient was transferred to
the floor on [**2130-4-26**]. Repeat esophagogastroduodenoscopy did
not show any evidence of varices. The patient underwent a
therapeutic paracentesis on [**2130-4-27**] with improvement in
symptoms. The patient also had his diuretics increased to
help alleviate further development of ascites and congestion.
On [**2130-4-28**] the patient was discharged to home in stable
condition.
DISCHARGE MEDICATIONS: 1. Protonix 40 mg po b.i.d. for four
weeks. 2. Aldactone 50 mg po b.i.d. 3. Lasix 20 mg po
q.d. 4. Ciprofloxacin 500 mg po b.i.d. for seven days total
and then to be changed to 750 mg po q week for prophylaxis.
4. HAART therapy will be restarted as an outpatient.
The patient has the following appointments scheduled at the
time of discharge, with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6861**] of GI on [**2130-5-30**] at
1:20 p.m. for repeat esophagogastroduodenoscopy to evaluate
for healing. With Dr. [**Last Name (STitle) **] of the Liver Center on [**2130-5-16**]
at 12:20 p.m. for further evaluation of his hepatitis C and
ascites. Dr. [**Last Name (STitle) 9625**] his primary care physician and ID
physician to be scheduled within the next weeks time.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear.
3. Hepatitis C with cirrhosis.
SECONDARY DIAGNOSES:
1. HIV.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10621**], M.D. [**MD Number(1) 10622**]
Dictated By:[**Last Name (NamePattern1) 9348**]
MEDQUIST36
D: [**2130-11-8**] 10:12
T: [**2130-11-13**] 14:51
JOB#: [**Job Number 103351**]
|
[
"532.40",
"V08",
"531.40",
"571.5",
"530.7",
"070.51",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"54.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6230, 6373
|
5409, 6209
|
3939, 5385
|
2083, 2314
|
6394, 6688
|
2520, 3921
|
144, 175
|
204, 1825
|
1848, 2061
|
2331, 2497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,258
| 168,621
|
921
|
Discharge summary
|
report
|
Admission Date: [**2114-10-26**] Discharge Date: [**2114-10-30**]
Date of Birth: [**2041-7-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Metrogel / Desipramine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Ms. [**Known lastname 6164**] is a 73-year-old woman
who had fallen several days ago and who developed shortness
of breath. She was found to have a large hemothorax on chest
CT.
Major Surgical or Invasive Procedure:
right vats evacuation of hematoma
History of Present Illness:
73 y/o woman tripped [**2114-10-23**] and fell onto R. head, R. eye, R.
side and R. knee presents with R hemothorax.
Past Medical History:
CAD s/p MI in 94
PVD (s/p aorto-fem bypass and L femoral endarterectomy)
L Breast CA s/p mastectomy
presumbed diastolic disfunction
colon adenocarcinoma '[**08**] s/p LAR with Chemo and XRT
SBO s/p XLap with LOA in [**3-20**]
asthma
hypothyroidism
hyperlipidemia
osteoporosis
ORIF R tibia
bilateral THR [**2110**]
recurrent UTI
Social History:
no tobacco, alcohol, IVDA
lives with husband
Family History:
NC
Physical Exam:
general: 73 yo female w/ SOB after trip and fall.
HEENT: ecchymosis over right face and orbit.
chest: breath sounds decreased at right base. left clear. +right
rib pain.
Cor: RRR S1, S2
Abd: soft, NT, ND, +BS
extrem: right hip ecchymosis. No limit in ROM. no edema.
neuro: alert and oriented x3.
Pertinent Results:
[**2114-10-26**] 01:15PM GLUCOSE-96 UREA N-23* CREAT-0.9 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14
[**2114-10-26**] 01:15PM WBC-9.1 RBC-2.59*# HGB-8.4*# HCT-23.8*#
MCV-92 MCH-32.4* MCHC-35.3* RDW-15.1
cxr [**2114-10-29**]: FINDINGS: PA and lateral chest radiographs.
Cardiomediastinal silhouette is unchanged. No pneumothoraces are
identified. Right pleural tube has been removed. Right-sided
pleural effusion/atelectasis appears unchanged. Left-sided
streaky atelectasis is also likely. Remainder of the lungs
appears clear.
IMPRESSION: No pneumothorax status post removal of right chest
tube. Stable right-sided pleural effusion/atelectasis.
CT scan: [**2114-10-26**]
IMPRESSION:
1. Large right-sided hemothorax, including an acute hematoma in
the right lower anterior intrapleural space.
2. Associated collapse of the right middle and lower lobes.
3. Prior right-sided rib fractures with callus formation, but
also a nondisplaced right lower anterior seventh rib fracture,
as well as questionable irregularities of the costal portions of
the anterior right tenth and eleventh ribs.
4. Mildly prominent new right hilar lymph node, with multiple,
similar, calcified right hilar lymph nodes, but no evidence of
lung mass.
5. Status post stent graft placement within the infrarenal
aorta, which is occluded, as before. Two aortofemoral bypass
grafts are patent, however.
6. Similar abnormal thickening of the presacral soft tissues, as
well as thickening of the rectosigmoid colon.
7. Small indeterminant hypoattenuating nodule associated with
the distal duodenum or perhaps the uncinate pancreas, with two
year stability already shown by prior CT.
Brief Hospital Course:
Pt reports tripping and falling over electrical cord on [**2114-10-23**]
and presented to Er w/ desaturation and right lower leg
swelling, right knee pain, right head /eye echymosis, and right
rib pain.
Of note, pt on asa and plavix at home.
chest Ct scan showed there was an acute, nondisplaced, fracture
of the right lateral seventh rib, slightly superior to the site
of intrapleural hematoma.
Remainder of Ct scans were unremarkable for acute processes-
including, head, abd, pelvis- see results section.
Pt was taken to the OR [**2114-10-26**] for right VATS evacuation of
hematoma. OR and immed post op courses were unremarkable . Pt
was [**Last Name (un) 1815**] reg diet, pain was well controlled on po percocet. Her
major post op issue was ongoing increased demand for oxygen w/
ambulation. O2 sat at rest was 94% on 2 liters with desaturation
to 85% on 6 liters of oxygen with slight activity. Pt had CTA to
r/o pulmonary embolism- negative.
d/c'd to rehab for ongoing pulmonary hygiene.
Medications on Admission:
ADVAIR DISKUS", AMIODARONE 200', ASA 81', COMBIVENT 2 puffs",
FOLIC ACID 1', FOSAMAX 70 Qwk, FUROSEMIDE 40', IMDUR 30',
LEVOXYL(88mcg five days, 100mcg two days), M-VIT', PERCOCET PRN,
PLAVIX 75MG', POTASSIUM CHLORIDE 20', RANITIDINE 150", SINGULAIR
10', TOPROL XL 25', ZOCOR 20'.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Ranitidine HCl 150 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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Levothyroxine 88 mcg Tablet Sig: as directed Tablet PO DAILY
(Daily): take 88mcgs-5days and 100mcgs-2 days.
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina.
15. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-18**]
Puffs Inhalation Q6H (every 6 hours) as needed.
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
17. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. oxygen
oxygen 2 liters continuous portability pulse dose system
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
right VATS evacuation of clot
CHF, CAD, MIx2, colon ca, afib, hypothyroid, breast ca, OA
Discharge Condition:
desaturates to 85% on 6 liters O2 w/ ambulation- resp
deconditioning. gait unsteady
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
call Dr[**Doctor Last Name **] office [**Telephone/Fax (1) 170**] if you develop fever,
chills, chest pain, shortness, redness or drainage from your
surgical incisions.
You may shower on wednesday. After showering, remove the chest
tube site dressing and cover the site with a clean bandaid daily
until healed.
Take new medications as instructed.
Followup Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a follow up
appointment when you are released from rehab.
Completed by:[**2114-11-5**]
|
[
"E885.9",
"428.32",
"493.90",
"412",
"V10.05",
"V10.3",
"443.9",
"807.01",
"244.9",
"428.0",
"860.2",
"427.31",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
6090, 6163
|
3129, 4127
|
471, 507
|
6296, 6382
|
1419, 3106
|
6877, 7034
|
1084, 1088
|
4458, 6067
|
6184, 6275
|
4153, 4435
|
6406, 6854
|
1103, 1400
|
253, 433
|
535, 653
|
675, 1005
|
1021, 1068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,841
| 111,350
|
34913
|
Discharge summary
|
report
|
Admission Date: [**2105-12-24**] Discharge Date: [**2105-12-31**]
Date of Birth: [**2063-7-4**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy
History of Present Illness:
The patient is a 42 year old male with HIV/AIDS (CD4 74, VL
96K), h/o toxo, anemia, and hep B, who presents to [**Hospital1 18**] ED with
fever, malaise and hemoptysis (per patient's brother). Per
patient, he's been having fevers for 6 months. He denies
abdominal pain, nausea, or diarrhea. He does report vomiting,
but denies hematemesis. He has been having chronic headaches. He
also reports episodes of bright red blood per rectum, though
this is not new. When asked why he came to the ED, he states he
is not sure.
.
Per patient's brother, the patient has communication problems,
particularly stuttering. He also states patient's right side is
not as strong as his left, particuarly after he got diagnosed
with the toxo. The brother also reports the patient has been
weak and coughing up blood for about one month.
.
In the ED, initial VS: 98.8, 108, 112/79, 18, 98%RA. He had a
CXR which showed multifocal patchy opacities, and a CT with
RML/LLL PNA, but too much motion artifact to comment on ground
glass opacity. His oxygenation remained stable. He was given
bactrim, levofloxacin, and prednisone in the ED. He also had
blood on his rectal exam, and an NGL was performed which was
negative. He was given 2L IVF and 1 unit of blood as well as
PPI. Vitals prior to transfer were 82, 101/70, 15, 100%2L NC.
.
The patient was transferred from the ED to the MICU Green
overnight on [**12-24**] for observation. His Hct remained stable and
he required no further transfusions. The bleeding was thought to
be secondary to hemorrhoids (he has a known history of
hemorrhoids). GI was consulted and recommended outpatient scope
as well as stool studies. Given the CT chest findings,
hemoptysis, and HIV status, he underwent BAL for TB, PCP, [**Name10 (NameIs) **]
this showed just blood. These studies are pending. He was
started on empiric levoflox, vanc, bactrim, and prednisone to
cover HCAP and PCP.
.
Currently, the patient is comfortable. He is without any
complaints. He denies pain. He notes only weakness prior to
admission. He does not know of any exposures to TB and has not
lived in a shelter or nursing home and has not been
incarcerated.
Past Medical History:
HIV/AIDS - CD4 74, VL 96K, diagnosed in [**2091**], h/o toxoplasmosis
([**10/2104**]) s/p treatment now on suppresive therapy (with
questionable compliance)
h/o MI, possible PCI placement
Anemia
h/o hematochezia with internal hemorrhoids
h/o Trigeminal Varicella Zoster
B thalassemia trait
Hepatitis B
Unknown speech / language disorder, communicates more by
writing.
Social History:
Cantonese speaking male. He is from [**Country 3992**] and came to the U.S
in [**2087**]. He lives alone in an apartment. Contracted HIV
previously from multiple sexual partners- unknown male, female
or both; denies IVDU.
Family History:
Mother with uterine Ca.
Physical Exam:
Vitals - T: 98.6 BP:96/64 HR:68 RR:16 02 sat:95%RA
GENERAL: Awake, lying in bed, in NAD
HEENT: Sclera anicteric, dry mucus membranes, OP clear
NECK: Supple, no LAD, no JVD
CARDIAC: RRR, normal S1&S2
LUNG: decreased breath sounds at the bases bilaterally, no
crackles or wheezes
ABDOMEN: +BS, soft, non-tender, non-distended, no guarding or
rebound
EXT: Warm, well-perfused, 2+ DP/PT pulses, no LE edema
NEURO: (difficult to assess even with interpreter) EOMI, PERRLA,
tongue protrudes midline, face symmetric, no pronator drift,
mild right sided weakness UE & LE.
Pertinent Results:
[**2105-12-24**] 02:35PM BLOOD WBC-4.3 RBC-3.44*# Hgb-7.7*# Hct-24.2*#
MCV-70* MCH-22.3* MCHC-31.6 RDW-17.8* Plt Ct-138*
[**2105-12-24**] 08:00PM BLOOD WBC-3.9* RBC-2.95* Hgb-6.6* Hct-20.6*
MCV-70* MCH-22.4* MCHC-32.1 RDW-17.5* Plt Ct-100*
[**2105-12-25**] 02:05AM BLOOD Hct-24.5*
[**2105-12-25**] 05:55AM BLOOD WBC-2.9* RBC-3.37* Hgb-7.8* Hct-23.4*
MCV-69* MCH-23.1* MCHC-33.3 RDW-17.3* Plt Ct-104*
[**2105-12-25**] 05:07PM BLOOD Hct-24.5*
[**2105-12-26**] 05:35AM BLOOD WBC-4.3 RBC-3.38* Hgb-8.0* Hct-24.3*
MCV-72* MCH-23.5* MCHC-32.7 RDW-17.9* Plt Ct-133*
[**2105-12-26**] 03:20PM BLOOD WBC-3.4* RBC-3.54* Hgb-8.1* Hct-25.9*
MCV-73* MCH-23.0* MCHC-31.5 RDW-18.3* Plt Ct-137*
[**2105-12-27**] 05:55AM BLOOD WBC-3.1* RBC-3.36* Hgb-7.8* Hct-24.3*
MCV-72* MCH-23.3* MCHC-32.3 RDW-18.0* Plt Ct-111*
[**2105-12-28**] 05:40AM BLOOD WBC-3.6* RBC-2.96* Hgb-6.7* Hct-21.3*
MCV-72* MCH-22.6* MCHC-31.4 RDW-18.1* Plt Ct-120*
[**2105-12-29**] 05:35AM BLOOD WBC-3.6* RBC-4.02*# Hgb-9.1*# Hct-29.0*#
MCV-72* MCH-22.7* MCHC-31.5 RDW-18.0* Plt Ct-116*
[**2105-12-29**] 10:50AM BLOOD WBC-4.1 RBC-3.92* Hgb-9.2* Hct-28.0*
MCV-72* MCH-23.4* MCHC-32.7 RDW-18.0* Plt Ct-104*
[**2105-12-30**] 05:40AM BLOOD WBC-4.0 RBC-3.84* Hgb-9.2* Hct-27.8*
MCV-72* MCH-24.0* MCHC-33.2 RDW-18.1* Plt Ct-128*
[**2105-12-31**] 05:40AM BLOOD WBC-6.8# RBC-3.80* Hgb-9.0* Hct-27.6*
MCV-73* MCH-23.7* MCHC-32.7 RDW-18.4* Plt Ct-120*
[**2105-12-24**] 03:58PM BLOOD PT-13.0 PTT-34.8 INR(PT)-1.1
.
WBC subtypes
[**2105-12-27**] 05:55AM BLOOD WBC-3.1* Lymph-31 Abs [**Last Name (un) **]-961 CD3%-89
Abs CD3-855 CD4%-7 Abs CD4-67* CD8%-80 Abs CD8-766* CD4/CD8-0.1*
.
Chemistries
[**2105-12-24**] 02:35PM BLOOD Glucose-94 UreaN-14 Creat-1.1 Na-132*
K-3.6 Cl-102 HCO3-25 AnGap-9
[**2105-12-31**] 05:40AM BLOOD Glucose-90 UreaN-10 Creat-1.2 Na-134
K-3.7 Cl-107 HCO3-19* AnGap-12
[**2105-12-30**] 05:40AM BLOOD Glucose-108* UreaN-12 Creat-1.5* Na-134
K-3.6 Cl-106 HCO3-17* AnGap-15
[**2105-12-24**] 02:35PM BLOOD ALT-14 AST-29 LD(LDH)-228 AlkPhos-51
TotBili-0.4
[**2105-12-25**] 05:55AM BLOOD Calcium-7.4* Phos-3.5 Mg-1.3*
[**2105-12-24**] 02:35PM BLOOD Iron-15*
[**2105-12-24**] 02:35PM BLOOD calTIBC-153* VitB12-280 Folate-11.2
Hapto-74 Ferritn-825* TRF-118*
[**2105-12-24**] 08:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2105-12-24**] 08:55PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2105-12-24**] 08:55PM URINE RBC-[**10-23**]* WBC-0-2 Bacteri-NONE
Yeast-NONE Epi-0-2
[**2105-12-25**] 01:22PM OTHER BODY FLUID Polys-10* Lymphs-58* Monos-27*
Eos-1* Macro-4*
Microbiology:
Blood Culture [**2105-12-24**]: Negative
Urine Culture [**2105-12-24**]: Negative
Urine Legionella Antigen: Negative
Bronchoalveolar Lavage [**2105-12-25**]:
GRAM STAIN (Final [**2105-12-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2105-12-27**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
POTASSIUM HYDROXIDE PREPARATION (Final [**2105-12-28**]):
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies if
pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2105-12-27**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Bronchial Washing [**2105-12-25**]:
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Respiratory Virus Screen and Culture [**2105-12-25**]:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus.
Sputum Culture [**2105-12-26**]:
[**2105-12-26**] 10:04 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2105-12-27**]): NEGATIVE for Pneumocystis jirovecii
(carinii).
Serum Cryptococcal Antigen [**2105-12-27**]: Negative
Serum RPR [**2105-12-27**]: Negative
Sputum Culture [**2105-12-27**]:
[**2105-12-27**] 8:49 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2105-12-28**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Stool Culture [**2105-12-28**]:
MICROSPORIDIA STAIN (Final [**2105-12-29**]): NO MICROSPORIDIUM SEEN.
CYCLOSPORA STAIN (Final [**2105-12-29**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2105-12-30**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2105-12-30**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2105-12-29**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final [**2105-12-29**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2105-12-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Sputum Culture:
[**2105-12-28**] 3:00 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2105-12-29**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Blood Culture (fungus/mycobacteria):
[**2105-12-29**] 5:35 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Imaging:
Chest X-ray [**2105-12-24**]:
PA and lateral views of the chest show stable cardiac,
mediastinal and hilar contours. Bibasilar ill-defined pulmonary
opacities, left worse than right, are more prominent since [**9-11**] and new from [**9-2**]/09. There is no pleural effusion or
pneumothorax. The spine is notable for an S-shaped scoliotic
curvature as well as an exaggerated kyphosis at the
thoracolumbar junction which is unchanged, related to wedge
compression deformities.
IMPRESSION: Bibasilar ill-defined pulmonary opacities. Given the
provided
history of HIV, pneumonia is favored and atypical organisms
including PCP
should be considered.
CT Chest [**2105-12-24**]:
FINDINGS: Airways are patent to segmental levels bilaterally.
Detail in the
lung bases (both parenchymal and vascular) is obscured secondary
to
respiratory motion. Within that constraint, there may be
bilateral
ground-glass opacity throughout the lower lobes with involvement
also noted in the upper lobes. In the right middle lobe
anteriorly are foci of nodular type opacities with indistinct
margination, suggesting possible inflammatory etiologies. The
right middle lobe is also notable for a more confluent
consolidation. More linear consolidation is present in the left
lower lobe. There is no pleural or pericardial effusion.
The heart and great vessels are notable for a coronary arterial
stent.
Multiple lymph nodes are present throughout the mediastinum and
axilla
bilaterally, these are prominent in their number, though no
single node
appears frankly enlarged.
Imaged portions of the upper abdomen are unremarkable. There is
no suspicious sclerotic or lytic osseous lesion. Note is made of
a mild scoliosis which may be positional.
IMPRESSION:
1. Markedly limited study secondary to patient motion,
nevertheless revealing right middle lobe consolidation and
smaller lingular/lower lobe consolidation.
Despite the presence of HIV/AIDS, diagnostic considerations
still favor
bacterial pneumonia, though atypical infections are not
excluded.
2. Background of bilateral pulmonary ground-glass opacity, these
are likely
related to the extensive motion artifact, however the
possibility of
pneumocystic infection is not excluded.
CT Head [**2105-12-26**]:
NON-CONTRAST HEAD CT: Since the prior head CT from [**2105-8-25**], there
has been increased calcification at the left thalamic lesion, at
the location
of previously biopsied area of toxoplasmosis. There is no
intracranial
hemorrhage, mass effect, or [**Doctor Last Name 352**]-white matter differentiation
abnormality.
Bilateral basal ganglia calcifications are grossly stable. No
definite new
lesions are seen.
POST-CONTRAST HEAD CT: On post-contrast images, there is minimal
to no
enhancement of this lesion. Minimal shift of midline structures
to the left
side and mild dilatation of the lateral ventricles and third
ventricle are
stable. No other focus of abnormal enhancement is seen.
Visualized paranasa sinuses demonstrate mildly increased mucosal
thickening and opacification of the posterior left ethmoid sinus
air cells as well as mucosal thickening in the bilateral
sphenoid sinuses, some of which are aerosolized. There is also
mucosal thickening in the posterior right ethmoid sinus air
cells. Opacification of bilateral mastoid air cells have also
increased since prior exam. Left frontal burr hole is unchanged.
There is no lytic or sclerotic bony lesion to suggest
malignancy.
IMPRESSION:
1. Increase calcification of the left thalamic toxoplasmosis
lesion, with
minimal or no enhancement.
2. Stable mild shift of the midline structures to the left and
dilatation of the lateral and third ventricles.
3. Opacification of the paranasal sinuses and bilateral mastoid
air cells has mildly increased since prior exam. Clinical
correlation is recommended.
Biospies:
BAL washings, cytology [**2105-12-25**]: Negative for malignant cells
Biopsies stomach and duodenum [**2105-12-30**]:
A. Stomach, antrum:
Chronic inactive gastritis. Negative for H. pylori.
B. Duodenum:
Small intestinal mucosa, no diagnostic abnormalities
recognized.
Endoscopy:
EGD:
Erythema and petechiae in the stomach body and antrum (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Colonscopy:
Findings:
Protruding Lesions: Large internal hemorrhoids were noted.
Impression: Internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
42yo M with HIV/AIDS (not on HAART, last CD4 count 74 and VL
96K), h/o toxoplamosis on suppressive therapy, and hemorrhoids
admitted with hemoptysis, anemia (thought [**1-5**] hemorrhoids now
s/p 1 unit prbcs), and RML/LLL PNA now transferred from the MICU
for TB rule out and treatment for pneumonia
.
# Pneumonia: On arrival to the floor, patient was afebrile and
hemodynamically stable. He was kept on negative pressure
repiratory isolation to rule out Mycobacterium tuberculosis.
Infectious disease was consulted. Patient was treated for
suspected community acquired pneumonia with ceftraixone and
azithromycin, and initally treated with therapeutic doses of
bactrim for possible pneumocystis. MTB was ruled out by
bronchoscopy and serial induced sputum. Pneumocystis jiroveci
was ruled out by bronchoscopy and induced sputum. Blood
cultures were negative for MTB and fungi. Urine legionella was
negative. Respiratory viral screen and culture was negative.
Patient completed a five day course of azithromycin and
ceftraixone while in house and was discharge with a two day
course of cefpodoxime.
.
# BRBPR/Anemia: Patient had blood on rectal exam. He has a known
history of internal hemorrhoids and chronic BRBPR. Stool
cultures were negative for C. difficile, giardia,
cryptosporidium, microsporidium, salmonella, shigella,
campylobacter. His hematocrit ranged between 22-26 during this
admission. Iron studies showed low Fe (15), low TIBC (153),
elevated ferritin (825), and a retic of 0.9%. Vit B12, folate,
hapto, LDH, and Tbili were normal. EGD and colonscopy were
performed and demonstrated mild gastritis and internal
hemorrhoids. Follow up was arranged with gastroenterology. It
was thought that his anemia was likely chronic and related to
his HIV disease.
.
# HIV/AIDS: Per out side records, his last CD4 count was 74, and
his HIVviral load was 96,000. Patient reports that he hasn't
been taking his medications for HIV. Through obtaining outside
records, he had been prescribed the following HAART regimen:
Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY, Ritonavir 100
mg PO DAILY, Atazanavir 300 mg PO DAILY and Raltegravir 400 mg
PO BID. It was unclear when he had stopped taking these
medications. He was also prescribed the following regimen for
toxoplasmosis prophylaxis: pryimethamine 25mg PO daily,
sulfadiazine 1g PO q12, & Leucovorin 10mg PO daily. Repeat
absolute CD4 count was 64. A Head CT was performed, that showed
some calcification of prior toxoplasmosis lesions, but no new
lesions. He was restarted on his toxoplasmosis prophylaxis
regimen and keppra for seizure prophylaxis. Once PCP was ruled
out, bactrim was stopped and he was left on his toxoplasmosis
regimen for PCP [**Name Initial (PRE) 1102**]. HAART was held, and re-initiation
of HAART was deferred to his PCP. [**Name10 (NameIs) 269**] was arranged to assist
with medication adherence.
.
# Otitis Externa: Patient was continued on his home
ciprofloxacin ear drops [**Hospital1 **]
.
# h/o Hep B: Liver function tests were followed and remained
within normal limits.
.
# CODE: FULL CODE
.
# CONTACT: Brother [**Name (NI) **] [**Telephone/Fax (1) 79897**]
Medications on Admission:
Daraprim 75 mg daily
Keppra 1000 mg [**Hospital1 **]
Leucovorin 10 mg daily
Sulfadiazine 1500 mg Q6H
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
3. Pyrimethamine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Leucovorin Calcium 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Sulfadiazine 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*120 Tablet(s)* Refills:*2*
6. Ciprofloxacin 0.3 % Drops Sig: Five (5) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural [**Hospital1 269**]
Discharge Diagnosis:
Primary Diagnosis:
Community Acquired Pneumonia
Secondary Diagnosis:
HIV/AIDS
Anemia
Internal Hemorrhoids
Discharge Condition:
Vital signs stable, taking PO well
Mental Status:Clear and coherent
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with fever, malaise, and
cough. You were found to have pneumonia and were treated with
antibiotics. You were also evaluated and ruled out for
tuberculosis and pneumocystis pneumonia. You improved with
antibiotics and no longer had a fever or cough at the time of
discharge.
Additionally, you were found to be anemic and had blood on
rectal exam. You received 1 unit of blood and underwent an
upper endoscopy and colonoscopy for further evaluation. The
colonoscopy revealed large internal hemorrhoids, which were
noted on prior colonoscopy. These are common.
You were also started on medicine to prevent pneumocystis
infection and suppress the toxoplasmosis infection in your
brain. It is extremely important that you take these medications
every day, as instructed.
New Medications:
Levetiracetam (500 mg Tablet): Two(2) Tablets PO BID (2 times a
day).
Cefpodoxime (200 mg Tablet): One(1) Tablet PO twice a day for 2
days.
Pyrimethamine (25 mg Tablet): One(1) Tablet PO DAILY (Daily).
Leucovorin Calcium (5 mg Tablet): Two(2) Tablet PO DAILY
(Daily).
Sulfadiazine (500 mg Tablet): Two (2) Tablet PO Q12H (every 12
hours).
Ciprofloxacin 0.3 % Drops: Five(5) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
Followup Instructions:
Please follow up with your primary care doctor:
[**1-7**] at 9am
Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 6420**]
[**Hospital1 778**] Health [**Telephone/Fax (1) **]
|
[
"786.3",
"070.32",
"458.29",
"455.0",
"285.29",
"486",
"412",
"282.49",
"130.0",
"276.52",
"V15.81",
"380.10",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.16",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
18413, 18477
|
14417, 17588
|
278, 308
|
18628, 18664
|
3759, 7285
|
20039, 20236
|
3134, 3160
|
17739, 18390
|
18498, 18498
|
17614, 17716
|
18764, 20016
|
3175, 3740
|
8632, 9831
|
9864, 12214
|
231, 240
|
336, 2487
|
18568, 18607
|
12638, 14393
|
18517, 18547
|
18678, 18740
|
2509, 2879
|
2895, 3118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,763
| 111,454
|
32947
|
Discharge summary
|
report
|
Admission Date: [**2138-2-1**] Discharge Date: [**2138-2-4**]
Date of Birth: [**2103-5-19**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
pain in rt wrist
Major Surgical or Invasive Procedure:
washout rt open distal radius fx
orif rt distal radius fx
History of Present Illness:
34 yo male trying to escape the authorities jumped out window 3
stories fall
brought to osh and intubatted for agigtation tx to [**Hospital1 **] for
eval of open drf
seen by ortho and scheduled for surgery
Past Medical History:
ivda
Social History:
numerous criminal record
Family History:
n/a
Physical Exam:
heent wnl
chest clear
[**Last Name (un) **] rrr no mrg
abd sft nt nd
ext rt wwrist splinted epl fdp intact sensation intact
neuro non focal
Pertinent Results:
[**2138-2-4**] 04:50AM BLOOD WBC-7.4 RBC-3.90* Hgb-11.1* Hct-32.9*
MCV-84 MCH-28.5 MCHC-33.8 RDW-13.8 Plt Ct-190
[**2138-2-2**] 01:47AM BLOOD WBC-8.0 RBC-4.15* Hgb-11.6* Hct-34.6*
MCV-84 MCH-28.0 MCHC-33.5 RDW-13.9 Plt Ct-185
[**2138-2-1**] 07:55PM BLOOD WBC-13.5* RBC-4.78 Hgb-13.6* Hct-40.1
MCV-84 MCH-28.5 MCHC-34.0 RDW-14.8 Plt Ct-234
[**2138-2-4**] 04:50AM BLOOD Plt Ct-190
[**2138-2-2**] 01:47AM BLOOD Plt Ct-185
[**2138-2-1**] 07:55PM BLOOD Plt Ct-234
[**2138-2-1**] 07:55PM BLOOD PT-13.9* PTT-29.5 INR(PT)-1.2*
[**2138-2-1**] 07:55PM BLOOD Fibrino-300
[**2138-2-4**] 04:50AM BLOOD Glucose-96 UreaN-9 Creat-1.0 Na-138 K-4.6
Cl-102 HCO3-32 AnGap-9
[**2138-2-1**] 07:55PM BLOOD UreaN-15 Creat-1.0
[**2138-2-1**] 07:55PM BLOOD Amylase-92
[**2138-2-1**] 10:30PM BLOOD HBsAg-NEGATIVE
[**2138-2-1**] 10:30PM BLOOD HIV Ab-NEGATIVE
[**2138-2-1**] 07:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2138-2-1**] 10:30PM BLOOD HCV Ab-POSITIVE
[**2138-2-2**] 05:05AM BLOOD Glucose-96
[**2138-2-1**] 08:04PM BLOOD Glucose-89 Lactate-1.6 Na-144 K-3.7
Cl-101 calHCO3-28
[**2138-2-1**] 08:04PM BLOOD Hgb-14.3 calcHCT-43 O2 Sat-94
[**2138-2-1**] 08:04PM BLOOD freeCa-1.12
Brief Hospital Course:
he was taken to the or and had a washout and reduction of the
distal radius fracure. Wsa splinted
and taken to the PACU and then to cc6. He then returned to the
OR and underwent fixation of his fracture. Was then sent to cc6
in custody was placed in a cast. His wounds looked clean and
dry and he was arrained and was tx the custody of authorities.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Extended Care
Facility:
Department of correction, [**Location (un) **] MA
Discharge Diagnosis:
open rt distal radius fx
Discharge Condition:
good to custody of doc ma.
Discharge Instructions:
dc to the custody of doc ma.
take dc meds as ordered
keep cast clean and dry
non weight bearing rt arm
Physical Therapy:
Activity: Activity as tolerated
Right upper extremity: Non weight bearing
Treatments Frequency:
Site: right wrist
Type: Surgical
no dsd till f/u visit
Followup Instructions:
2 weeks with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] np call [**Telephone/Fax (1) 9769**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2138-2-4**]
|
[
"305.90",
"881.10",
"E884.9",
"307.9",
"E849.9",
"813.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"79.62",
"96.04",
"86.28",
"79.02",
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
3372, 3448
|
2118, 2470
|
335, 395
|
3517, 3546
|
898, 2095
|
3876, 4152
|
718, 723
|
2525, 3349
|
3469, 3496
|
2496, 2502
|
3570, 3674
|
738, 879
|
3692, 3770
|
3793, 3853
|
279, 297
|
423, 631
|
653, 660
|
676, 702
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,715
| 132,968
|
41101
|
Discharge summary
|
report
|
Admission Date: [**2124-5-8**] Discharge Date: [**2124-5-15**]
Date of Birth: [**2069-9-7**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
HEADACHE
Major Surgical or Invasive Procedure:
[**2124-5-8**]: Cerebral Angiogram for coiling of the ACOMM aneurysm,
balloon angioplasty of R MCA, and interarterial verapamil
History of Present Illness:
Mr. [**Known lastname 23657**] is a 54 yo RHM with h/o HCV who presents with
headache, R leg and hand weakness. The patient developed a
headache last Wednesday (6 days PTA). The headache was severe
but
waxed and waned, he cannot recall how it started but does not
recall a sudden thunderclap onset. Pain is located behind face
(eyes, forehead) bilaterally, and is pressure-like. It has kept
him awake at nights, and he has slept in few hour increments.
Headache has no positional component. Patient endorses neck
stiffness, denies photophobia. No vision changes or diplopia.
The patient had an episode of leg weakness last night. He was
walking from kitchen to couch when his legs buckled, he felt his
R leg was weaker. There were no other symptoms last night.
This AM, patient went to work and kept dropping his lunchbag
from
the right hand. His legs buckled again. Coworkers made him go to
ED, and he presented to [**Hospital3 **].
At [**Hospital3 **], patient was mildly confused, c/o slurred speech.
NCHCT showed small SAH. He received Zofran, morphine, potassium.
Past Medical History:
HCV- treated x 2 with ribavirin
Social History:
Works for the government as a electronic tech. Smokes, drinks
rare EtOH, no illicits.
Family History:
Negative for intracranial hemorrhage or aneurysm. Uncle had
stroke in his 50s, father had [**Name2 (NI) **].
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 2 [**Doctor Last Name **]: 3
O: T: 97 BP: 155/75/ HR: 78 R 16 O2Sats 96/RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3 to 2.5mm EOMs intact
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Irritable.
Orientation: Oriented to person, place, and date.
Attention: months of year backwards- makes 2 uncorrected errors
Language: Speech fluent with good comprehension and repetition.
Naming intact. Mild dysarthria. No paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-15**] throughout. Trace R upwards
pronator drift.
Sensation: Intact to light touch, propioception, pinprick
bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Gait: normal base and stride
On the day of discharge: [**2124-5-15**]
The patient is alert and oriented to person place and time. The
patient's strength and sensation are full. The patient is
independently ambulatory with steady gait and has been cleared
by physical therapy. There is no facial droop. There is no
pronator drift.
Pertinent Results:
CTA Head [**2124-5-8**]:
ACOMM aneurysm 5x4mm, vasospasm seen especially at R MCA but
appears to still be patent.
[**5-9**] ECHO: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Physiologic mitral regurgitation is seen (within normal limits).
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
[**5-9**] CT head: IMPRESSION:
1. No CT evidence of an acute major vascular infarct. MRI would
be more
sensitive, if indicated.
2. Extensive subarachnoid hemorrhage is again noted in the
interhemispheric fissure and cerebral sulci, grossly stable
allowing for recent iv contrast administration, with stable
extension into the right inferomedial frontal lobe parenchyma
and moderate surrounding parenchymal edema. Stable mild
parafalcine and paratentorial subdural hemorrhage.
CHEST (PA & LAT) Study Date of [**2124-5-12**] 10:32 AM
Final Report
COMPARISON: Radiographs dating back to [**2124-5-9**].
FINDINGS: Right lower lobe density appears new since [**2124-5-9**].
There is no
pleural effusion. The cardiac size is normal. The left internal
jugular
central venous catheter has been removed.
IMPRESSION:
New right lower lobe density could represent either atelectasis
or pneumonia.
The study and the report were reviewed by the staff radiologist.
[**2124-5-8**] 10:07PM GLUCOSE-83 UREA N-11 CREAT-0.7 SODIUM-140
POTASSIUM-3.3 CHLORIDE-111* TOTAL CO2-22 ANION GAP-10
[**2124-5-8**] 10:07PM CALCIUM-7.4* PHOSPHATE-3.5 MAGNESIUM-1.8
[**2124-5-8**] 10:07PM WBC-7.0 RBC-4.10* HGB-14.6 HCT-41.1 MCV-100*
MCH-35.7* MCHC-35.5* RDW-14.3
[**2124-5-8**] 10:07PM PLT COUNT-110*
[**2124-5-8**] 10:07PM PT-18.0* PTT-98.7* INR(PT)-1.6*
[**2124-5-8**] 06:00PM URINE HOURS-RANDOM
[**2124-5-8**] 06:00PM URINE GR HOLD-HOLD
[**2124-5-8**] 04:11PM K+-3.5
[**2124-5-8**] 04:08PM GLUCOSE-88 UREA N-13 CREAT-0.6 SODIUM-137
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
[**2124-5-8**] 04:08PM estGFR-Using this
[**2124-5-8**] 04:08PM ALT(SGPT)-68* AST(SGOT)-84* LD(LDH)-243 ALK
PHOS-100 TOT BILI-2.0*
[**2124-5-8**] 04:08PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-5-8**] 04:08PM WBC-6.2 RBC-4.45* HGB-15.9 HCT-43.7 MCV-98
MCH-35.6* MCHC-36.3* RDW-14.2
[**2124-5-8**] 04:08PM PLT COUNT-101*
[**2124-5-8**] 04:08PM PT-16.6* PTT-29.6 INR(PT)-1.5*
[**2124-5-14**] 09:40AM BLOOD WBC-5.0 RBC-4.00* Hgb-14.9 Hct-40.2
MCV-100* MCH-37.2* MCHC-37.0* RDW-14.1 Plt Ct-122*
[**2124-5-14**] 09:40AM BLOOD Plt Ct-122*
[**2124-5-14**] 09:40AM BLOOD Glucose-138* UreaN-8 Creat-0.7 Na-135
K-3.6 Cl-103 HCO3-24 AnGap-12
[**2124-5-12**] 05:40AM BLOOD ALT-54* AST-85* LD(LDH)-271* AlkPhos-122
TotBili-1.6*
[**2124-5-14**] 09:40AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.7
[**2124-5-12**] 05:40AM BLOOD Phenyto-13.0
Brief Hospital Course:
54M who presented to the ER with headache since [**5-3**], Head CT
showed a SAH and a CTA was performed which showed a ACOMM
aneurysm. He was taken to angiogram and underwent a coiling;
diffused vasospasm was noted and a balloon angioplasty was done
on the R MCA and interarterial verapamil was injected. He was
then admitted to the Neuro ICU. Initially, his SBP was kept at
180-200 with the use of pressors, but after receiving
Nimodipine, his SBP was unable to maintain > 180. Pressors were
increased and multiple ones were added but his SBP remained
labile.
On [**5-8**], Alt/AST68* 84*
On [**5-9**] AM, the pressors were weaned off and he was given a
bolus of dilantin for subtherapeutic level. He was taken to
angio and underwent repeat imaging which revealed no vasospasm.
He was started on aspirin. CXR was consistent with linear
density in the left lower lobe is most likely related to
atelectasis. There was no
evidence of consolidation, effusion or pneumothorax.
On [**5-10**] he remained neurologically stable so he was cleared for
transfer to the stepdown unit.
On [**5-11**], the patient was transferred to the Step Down Unit. The
patient was febrile.
On [**5-12**], CXR consistent with new right lower lobe density could
represent either atelectasis or pneumonia. The patients
neurologic exam continued to be intact.platlet count was 85.
Platlets were trended over next two days. ALT/ AST 54* 85*
On [**5-13**], Dilantin was discontinued secondary to elevated liver
function tests. The subcutaneous Heparin was discontinued.
Platlets 119.
[**5-14**]: Platlet count was 122. Plan for possible discharge was
made for [**5-15**].
[**5-15**]: The electrolytes were repleated for a K of 3.6, MG 1.7, CA
8. The patient was neurologicall intact. He was alert and
oriented to person, place, and time. His strength was full. The
patient had a temperature of 99 and was encouraged to use his
incentive spirometer. The patient was discharged with a
incentive spirometer and asked to use this every 2 hours. The
patient was looking forward to his discharge and asking to leave
the hospital.
Medications on Admission:
None
Discharge Medications:
1. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for insomnia, allergies.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
[**Month/Day (4) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
[**Month/Day (4) **]:*30 Tablet(s)* Refills:*0*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Month/Day (4) **]:*30 Capsule(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain: do not drive while taking, do not take if
lethargic.
[**Month/Day (4) **]:*40 Tablet(s)* Refills:*0*
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day (4) **]:*30 Tablet(s)* Refills:*2*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please discuss with your primary care physician to
continue.
[**Month/Day (4) **]:*10 Tablet(s)* Refills:*0*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please discuss continued use and prscriptions with your primary
care doctor.
[**Last Name (Titles) **]:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
ACOMM Aneurysm
Diffused cerebral vasospasm
Fever
Thrombocytopenia
Elevated liver enzymes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization
Medications:
?????? Take Aspirin 325mg (enteric coated) 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.
Please use your INCENTIVE SPIROMETER every two hours taking care
to take 10 deep breaths every two hours.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 4 weeks with a MRI/MRA
([**Doctor Last Name **] protocol).
[**2124-6-15**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) **] J.
LM [**Hospital Unit Name **], [**Location (un) **]
NEUROSURGERY WEST
[**2124-6-15**] 12:40p XMR WEST GE 3T
CC CLINICAL CENTER, BASEMENT
RADIOLOGY
If you are unable to keep this appointment, please call Ms.
[**Name14 (STitle) 89584**] [**Doctor First Name **] [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2124-5-15**]
|
[
"291.81",
"430",
"780.60",
"305.1",
"435.8",
"305.00",
"V12.09",
"728.87",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.62",
"39.75",
"38.93",
"88.41",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
10649, 10655
|
7127, 9239
|
313, 443
|
10812, 10812
|
3759, 4661
|
12748, 13297
|
1719, 1830
|
9294, 10626
|
10676, 10791
|
9265, 9271
|
10963, 12067
|
12093, 12725
|
1860, 2209
|
265, 275
|
471, 1543
|
2539, 3740
|
4670, 7104
|
10827, 10939
|
1565, 1599
|
1615, 1703
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,015
| 153,830
|
3516
|
Discharge summary
|
report
|
Admission Date: [**2167-8-12**] Discharge Date: [**2167-8-25**]
Service: [**Hospital Unit Name 16129**] OF PRESENT ILLNESS: The patient is an 82 year-old
woman with a history of hypertension, chronic obstructive
pulmonary disease, hypothyroidism, and congestive heart
failure who presented with a two week history worsening
mental status changes. According to the patient's daughter
she had trouble remembering names and her daily routine. The
patient also exhibited increased urination over the week
prior to presentation, with a new onset of incontinence of
urine. The patient also had become increasingly dyspneic
over the two weeks prior to presentation. The patient's
daughter also reported that the patient had been exhibiting
increasing gait instability with two near falls. It should
be noted that the patient also has a history of a fall a year ago
resulting in a left femur fracture above a knee prosthesis,
and a left hip fracture in the setting of pneumonia in
[**2166-12-18**]. The patient was recently hospitalized prior
to this admission and treated for left lower extremity
cellulitis.
REVIEW OF SYSTEMS: The patient denied headache, blurred
vision, chest pain, palpitations, dysuria, cough, abdominal
pain, diarrhea. The patient also denied fevers or chills as
well as recent changes in her medication regimen.
It should be noted at this point, that later in the patient's
hospitalization she developed sinus node dysfunction and
required placement of a pacemaker.
PAST MEDICAL HISTORY: Hypertension, hypothyroidism, gout,
questionable obstructive pulmonary disease. No pulmonary
function
tests available. Reported history of congestive heart
failure. Chronic renal insufficiency. Status post left total
knee replacement, left femur fixation with intramedullary rod,
and left hip repair.
OUTPATIENT MEDICATIONS: Albuterol two puffs q.i.d.,
Allopurinol 100 mg q day, aspirin 81 mg q day, Buspar 5 mg
t.i.d., Hydrochlorothiazide 25 mg q.d., potassium chloride
10 milliequivalents q day, Lasix 20 mg po q day, Levoxyl 75
mcg q day. Multi vitamin, Tums 500 mg b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient prior to presentation lived in
an [**Hospital3 **] facility. The patient has a daughter who
is very involved in her care. The patient has a past tobacco
abuse history, she quit approximately fifteen years ago. The
patient denies past alcohol use.
CODE STATUS: Full code.
PHYSICAL EXAMINATION ON PRESENTATION: As reported by the
admitting team, vital signs temperature 97.7. Heart rate 62.
Blood pressure 125/60. Respiratory rate 22 sating 91% on
room air and 95% on 5 liters. General, the patient was found
to be somnolent and irritable, but in no acute distress.
HEENT moist mucous membranes. Head was normocephalic,
atraumatic. Neck no JVD. Cardiovascular regular rate and
rhythm. Distant S1 and S2. No murmurs. Respiratory, poor
air exchange throughout. No rhonchi, rales or wheezes
bilaterally. Abdomen soft, nontender, mildly distended.
Positive bowel sounds. Positive erythema under abdominal
pannus. Extremities, 1+ pitting edema, which is symmetric
and bilateral. Neurological, strength 5 out of 5 at the
upper extremities. Poor lower extremity effort for strength.
Tongue in midline. Patellar deep tendon reflexes not
obtainable.
LABORATORY DATA ON PRESENTATION: Chem 7 revealed a white
count of 7.4 with a differential of 75% neutrophils, 18%
lymphocytes and 4% monocytes. Hematocrit was 41.4, platelets
164. Chem 7 revealed a sodium of 145, potassium 4.6,
chloride 101, bicarb 36, BUN 44 and creatinine 1.7 and
glucose of 70. Liver function tests were evaluated. ALT was
28, AST 21, LD 199, CK was cycled several times and normal
times six. Alkaline phosphatase 109. Other electrolytes
included calcium, which is 9.2, phosphorus 3.9, magnesium
2.0, albumin was 3.6 on presentation.
Other notable laboratory data during the [**Hospital 228**] hospital
course included TSH, which was normal at 3.8. Iron studies
were sent including TIBC, ferritin, and transferrin. These
were within normal limits. Also haptoglobin was sent and
found to be 183. The patient's vitamin B-12 was in the
low normal range, but folate was normal. Erythrocyte
sedimentation rate was sent and found to be 10, within normal
limits. Of note, the patient was found to be [**Doctor First Name **] positive
with a titer of 1:40.
Electrocardiogram on admission, flipped T waves were evident
throughout the precordium. The patient had a right bundle
branch block pattern. There were no acute ST or T changes.
Chest x-ray on admission, question of a right middle lobe
infiltrate as well as possible left lower lobe infiltrate.
CT of the head without contrast on admission revealed
ventricles and sulci, which were symmetrically enlarged
consistent with age related brain atrophy. There were
regions of low attenuation in the periventricular white
matter most likely due to chronic microvascular infarction.
There was no acute hemorrhage, mass effect or extra axial
collection. Bone windows demonstrated no fractures.
Echocardiogram, [**2167-8-14**], revealed mild left
ventricular hypertrophy, 2+ mitral regurgitation, decreased
right ventricular systolic function, moderate aortic
stenosis, trace aortic regurgitation, severe pulmonary
hypertension.
HOSPITAL COURSE: The patient was admitted on [**2167-8-12**] after a two week history of progressive mental status
changes, which included confusion, poor memory, and
difficulty with daily routines as well as increased frequency
of urination and a one week history of new onset urinary
incontinence. The patient also presented with a two week
history of dyspnea as well as increasing gait instability.
The patient was admitted initially to the ACOVE team. She
was ruled out for myocardial infarction by serial enzymes, as
noted above. A subsequent echocardiogram on [**2167-8-14**] revealed the above noted findings including pulmonary
hypertension.
The patient was treated for a urinary tract infection
initially with Ceftriaxone. However, a rash which
had been present on her neck prior to institution of Ceftriaxone
became dramatically worse, spreading to her face and chest, so
the Ceftriaxone was changed to Cipro ([**8-15**]). The patient
subsequently developed a bulla on
her left lower shin as well as a papular rash on her feet.
On [**8-15**] and 30 the patient was noted to have
asymptomatic pauses in her heart rate with rate running into
the 20s. The patient reportedly responded to atropine. The
patient was also noted at a separate time to have
desaturations to the low 70s on room air. Her arterial blood
gas at that time revealed a pH of 7.26, PCO2 93, PO2 45. On
[**8-17**], she was transferred to the [**Hospital Ward Name **] MICU in hopes
of trying BIPAP, but she was too delirious at the time to
cooperate with the trial. She also had an episode of rapid (170)
atrial fibrillation that day, and developed severe bradycardia
(pause of 8 seconds and HR 20 - 30) when treated with Lopressor.
Because of the patient's sinus node dysfunction she was taken
for dual chamber pacer placement on [**2167-8-18**] and
subsequently transferred to the [**Hospital Unit Name 196**] team.
The remainder of the hospital course will be described by
problem list as follows:
Cardiovascular: 1. Rate and rhythm. On the morning of
[**8-20**] the patient was found to be tachycardic to the
120s. The possible etiologies for this included the fact
that the patient became more delirious again and refused to take
her Lopressor and Amiodarone. Also the
electrophysiology service performed several interrogations of the
pacemaker and adjusted the sensitivities. They were
subsequently satisfied that the pacer was placed correctly
and working well. Through the remainder of the patient's
hospitalization the patient was monitored on telemetry with
occasional premature ventricular contractions being noted.
Otherwise, the patient did not have any difficulty with her
rate or rhythm. The patient is to be placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor on discharge and to follow up with the
Electrophisiology Service as will be noted below.
2. Blood pressure and pump. The patient was felt to be in
heart failure both clinically and by several chest x-rays.
Thus, she was diuresed over the span of several days with
Lasix. She responded to this well such that her sats on
supplemental oxygen and eventually room air improved
significantly.
3. Coronaries. As noted above, the patient was ruled out
for myocardial infarction by serial enzymes.
Pulmonary: 1. Congestive heart failure. As noted above the
patient was felt to have some element of failure. Thus, she
was diuresed with Lasix and subsequently improved
significantly.
2. Pulmonary hypertension. The patient was suspected to
have had some element of sleep apnea. Thus, a sleep study
was suggested. However, because of the patient's overall
condition including her inability to cooperate with the study
and the fact that the patient would not have nursing care on
hand during a sleep study, a sleep study was deferred during
the patient's hospitalization. It should be noted that the
patient was tried on a trial of BI-PAP while she was delirious in
the
MICU and that she did not tolerate this well as she
repeatedly removed the BI-PAP apparatus.
3. Metabolic alkalosis: As noted above the patient did have an
arterial blood gas notable for hypercapnia which improved prior
to discharge. The patient's last arterial blood gas on
[**8-24**] was pH 7.38, PCO2 70 and PO2 of 84. For a time,
the patient's total CO2 was followed by Chem 7 studies and
found to be quite elevated up to 49 (high even prior to
diuresis, but normal during admission in [**2167-6-17**]). Thus at
the
recommendation of the Pulmonary Service, which had been
consulted the patient was placed for a time on Diamox 250 mg [**Hospital1 **].
At this dosage, her total CO2 dropped more quickly than
recommended (i.e., it was > 3 meq drop per day), so the Diamox
was discontinued. It may be necessary to restart it at a later
time, but probably at 125 mg [**Hospital1 **].
Overall the patient's pulmonary status improved with treatment of
CHF during her
hospitalization such that she reported being able to breathe
easier. The patient likewise had an ABG with pO2 of 84 and pCO2
of 70, with normal pH on 1 L/min supplemental oxygen.
Infectious disease: The patient completed a course of
Bactrim (after ceftriaxone, then cipro) for a possible Proteus
urinary tract infection. Subsequently,
urinalysis did not reveal any indications of continuing
infection.
Dermatology: As noted above, the patient exhibited a rash
over her face, neck and chest during the early course of her
hospitalization as well as a subsequent rash over her left
foot and shin as well as a bulla on her left shin. The
Dermatology Service was consulted to evaluate this. They
recommended obtaining laboratories including liver function
tests, erythrocyte sedimentation rate, and creatinine kinase.
In terms of the patient's facial rash, the differential
diagnosis is felt to include dermatomyositis as well as drug
or contact reactions. In terms of the patient's lower
extremity bulla, there was concern that the patient might
have bullous pemphigoid. The patient's above noted
laboratories came back as normal with the exception of [**Doctor First Name **],
which was as noted above positive with a titer of 1:40. The
Dermatology Service requested permission from the patient on
a number of occasions to biopsy her various dermatologic
sites, however, the patient was delirious during this time and
could not be persuaded (even by her daughter) to allow the
procedure.
Renal: The patient has a history of chronic renal
insufficiency. Her creatinine tended to run around 1.7 to
1.8, which is within her historic baseline of 1.6 to 2.0.
Hematologic: Because of the patient's intermittent
rhythm disturbances, the Electrophysiology Service felt that the
patient should be anticoagulated. However, given her other
medical and rehabilitation issues, it was thought to be better to
wait on this until she improved.The ultimate decision of whether
to offer anticoagulation to the patient will be deferred to the
patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 10930**].
CONDITION AT DISCHARGE: The patient was stable, afebrile,
free of chest pain and shortness of breath.
DISCHARGE DIAGNOSES:
1. Bradycardia, sinus node dysfunction.
2. Status post dual chamber pacemaker placement on [**2167-8-18**].
3. Possible pneumonia
4. Possible Urinary tract infection (vs. contaminant)
5. Congestive heart failure, with good left ventricular but
depressed right ventricular function
6. Delirium, multifactorial (hypoxia, hypercarbia, bradycardia,
CHF, possible pneumonia, possible UTI), not yet resolved
7. Hypercarbia and hypoxia, cause undetermined, possibly due to
combination of sleep apnea and CHF
8. Severe pulmonary hypertension, cause undetermined, but
possibly due to central and obstructive sleep apnea.
9. Papular skin rash, cause undetermined
DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg po b.i.d. from
[**2167-8-25**] through [**2167-8-30**] and then the patient
is to take 400 mg q day times seven days. Following the
seven day course, the patient is to thereafter take 200 mg po
q day. 2. Lopressor 25 mg po b.i.d. 3. Lasix 20 mg po q
day. 4. Potassium chloride 10 milliequivalents po q day.
5. Albuterol meter dose inhaler two puffs q.i.d. 6.
Aspirin 325 mg po q day. 7. Flovent 220 mcg two puffs
b.i.d. 8. Levoxyl 0.075 mg po q day. 9. Allopurinol 100
mg po q day. 10. BuSpar 5 mg po t.i.d. 11. Colace 100 mg
po b.i.d. 12. Senna two tabs po q day. 13. Multi vitamin
one po q day. 14. Tums 500 mg po b.i.d.
FOLLOW UP: Mrs. [**Known lastname 23**] will be transferred to the [**Hospital **]
[**Hospital **] Hospital for physical therapy and
further management of delirium. The patient has a follow up
appointment in the
[**Hospital **] Clinic in the Clinical Center on the Fourth Floor
on [**2167-8-26**] at 3:30 p.m. Also, the patient should
follow up with Dr. [**Last Name (STitle) 73**] in approximately three weeks.
Also, the patient should follow up with her primary care
physician within the next week. Issues to discuss would
include whether or not to anticoagulate the patient in light
of her cardiac history as well as in light of her history of
falls and recent gait instability. Also, the patient's
positive [**Doctor First Name **] titer is noteworthy.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1757**], M.D. [**MD Number(1) 1758**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2167-8-25**] 07:57
T: [**2167-8-25**] 08:19
JOB#: [**Job Number 16130**]
|
[
"496",
"593.9",
"398.91",
"426.4",
"427.31",
"244.9",
"396.2",
"599.0",
"782.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
12617, 13279
|
13303, 13974
|
5366, 12502
|
13986, 15021
|
1858, 2149
|
12517, 12596
|
1140, 1504
|
1527, 1833
|
2166, 5348
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,311
| 126,397
|
13745
|
Discharge summary
|
report
|
Admission Date: [**2124-4-1**] Discharge Date: [**2124-4-5**]
Date of Birth: [**2057-1-16**] Sex: M
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
male with a history of coronary artery disease, status post
non-ST-elevation myocardial infarction in [**2124-2-4**], who
presents with chest pain that started at 9 a.m. today.
The patient was sitting in a chair [**Location (un) 1131**] the paper with the
sudden onset of extreme fatigue, "fullness in my throat," and
[**4-14**] rest pain between the scapula (which is his known
anginal equivalent). The patient also had some sharp
shooting pain across his anterior chest wall. He denies
diaphoresis, shortness of breath, palpitations, pressure, or
heaviness. Positive nausea. The patient went back to bed.
bed looking very pale and washed out with persistent nausea.
She gave her husband an aspirin and a nitroglycerin and
called 911. The patient experienced 2/10 chest pain in the
ambulance. He received a nitroglycerin spray with
resolution.
At an outside hospital, he was placed on a heparin drip,
aspirin, morphine, and Pepcid and became pain free again.
His CK/MB was 10.3 with a troponin of less than 0.2, and no
electrocardiogram changes.
The patient was transferred to [**Hospital1 188**] for cardiac catheterization, given rest angina in a
patient with known coronary artery disease; status post
stent.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2116**] with left internal mammary artery to the
left anterior descending artery, saphenous vein graft to the
first diagonal and first obtuse marginal.
2. Status post non-ST-elevation myocardial infarction on
[**2124-3-3**]; status post right coronary artery stent due
to a 99% occluding lesion, a 90% distal posterolateral was
not intervened upon as his grafts were patent. An
echocardiogram in [**2124-3-6**] revealed a left ventricular
ejection fraction of greater than 55%, 2+ mitral
regurgitation, and mild posterior hypokinesis.
3. Hypercholesterolemia.
4. Gastritis/duodenitis (per esophagogastroduodenoscopy
in [**2123**]).
5. Elevated prostate-specific antigen; the patient to have
an outpatient biopsy per primary care doctor.
6. Anxiety with a history of anxiety attacks.
ALLERGIES: Allergy to PLAVIX which causes a rash.
MEDICATIONS ON ADMISSION: Lipitor 40 mg p.o. q.d.,
enteric-coated aspirin 325 mg p.o. q.d., Ticlid 250 mg p.o.
b.i.d., Norvasc 2.5 mg p.o. q.d., Paxil 20 mg p.o. q.d.,
sublingual nitroglycerin as needed for chest pain.
FAMILY HISTORY: Brother died of coronary artery disease at
the age of 60. Sister with diabetes, coronary artery
disease, and ovarian cancer who died one day prior to the
patient's heart attack on [**2124-3-2**].
SOCIAL HISTORY: The patient is married and lives with his
wife in [**Name (NI) 701**]. He has two daughters. [**Name (NI) **] quit tobacco in
[**2090**] and drink occasional alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure in the
right arm was 100/60, in the left arm was 106/60, temperature
was 97.4, heart rate was 52, respiratory rate was 14. General
appearance revealed a pleasant male in no acute distress.
Head, eyes, ears, nose, and throat revealed mucous membranes
were moist. The oropharynx was clear. Pupils were equal,
round, and reactive to light. Extraocular movements were
intact. Neck revealed no jugular venous distention, supple.
No carotid bruits. Heart had a regular rate and rhythm.
Normal first heart sound and second heart sound. Question
fourth heart sound. A 2/6 systolic murmur radiating from the
apex to the axilla. Pulmonary was clear to auscultation
bilaterally. No crackles, wheezes, or rhonchi. The abdomen
was soft, nontender, and nondistended, positive bowel sounds.
Extremities revealed no edema. Distal pulses were 2+.
Neurologically, nonfocal.
RADIOLOGY/IMAGING: Electrocardiogram revealed a normal
sinus rhythm at 55 beats per minute with normal axis and
intervals. Q waves in III with left atrial abnormality. No
ST elevations or depressions. Question pseudonormalization
of T waves versus T wave inversion in [**2124-3-6**]; peri
myocardial infarction that are now resolved. A T wave
inversion noted in lead II.
PERTINENT LABORATORY DATA ON PRESENTATION: Pertinent
laboratory studies on admission revealed a normal complete
blood count, normal Chemistry-7. Creatine kinase was 58.
Calcium was 8.9. Troponin was less than 0.2. Normal liver
function tests.
HOSPITAL COURSE:
1. CARDIOVASCULAR: Given the patient's extensive coronary
disease, he was admitted for rest angina and ruled out by
cardiac enzymes times three. Given nonspecific T wave
changes and electrocardiogram, he was continued on a heparin
drip, aspirin, Ticlid, and Lipitor and was started on a 2B3A
inhibitor upon arrival to [**Hospital1 188**] given his risk of in-stent thrombosis, as he was only
four weeks post stent placement in the right coronary artery.
The patient was unable to tolerate a beta blocker. He has a
long history of symptomatic bradycardia. The patient was not
placed on an ACE inhibitor; as per last admission his blood
pressure dropped too low. However, the patient states that
his back pain had improved on Norvasc which raised the
question of possible vasospasm.
The patient underwent cardiac catheterization on [**2124-4-3**] and was found to have a pulmonary capillary wedge
pressure of 17, right atrial pressure of 10, and pulmonary
artery pressure of 23. His left main coronary artery had an
80% distal occlusion which was unchanged from prior with left
anterior descending artery, diagonal, left circumflex artery
supplied by past grafts which were patent. The right
coronary artery was noted to have a patent stent with diffuse
disease and 90% right posterolateral branch with slow flow;
similar to last cardiac catheterization. This was crossed
with a wire and dilated with balloons; however, a cutting
balloon was unable to be passed. A 40% residual stenosis
with a moderate nonflow-limiting dissection resulted. The
patient became very ill with probable injection of an air
bubble in the right coronary artery necessitating transient
dopamine and pacing. Repeat attempts at recrossing the right
posterolateral branch were not successful, and with normal
flow restored the procedure was aborted.
An echocardiogram in the catheterization laboratory revealed
no significant pericardial effusion. A Foley catheter was
inserted with 700 mL of urine drained. The patient was
subsequently transferred to the Coronary Care Unit for
overnight monitoring; where he remained hemodynamically
stable off pressors and without any difficulties. He was
transferred to the Cardiology floor on [**2124-4-4**].
As the patient had ruled out for a myocardial ischemia, per
cardiac enzymes times three, and had patent grafts and stent
on cardiac catheterization, he was felt to be stable to be
discharged to home with follow up with his outpatient
cardiologist. This cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) in
[**Hospital1 1474**] was [**Name (NI) 653**], and the patient was to follow up with
him at [**Location (un) 41361**]in one week. The patient remained
free of chest pain at the time of discharge.
2. GASTROINTESTINAL: Protonix was continued for gastritis.
3. RENAL: The patient had normal renal function. He was
able to produce urine after Foley catheter was removed.
Creatinine remained stable status post cardiac
catheterization. Urine output was good at the time of
discharge.
4. PSYCHIATRY: The patient was continued on Paxil and
Ativan as needed.
MEDICATIONS ON DISCHARGE:
1. Lipitor 40 mg p.o. q.d.
2. Enteric-coated aspirin 325 mg p.o. q.d.
3. Ticlid 250 mg p.o. b.i.d. (times 30 days).
4. Sublingual nitroglycerin 0.4 mg q.5min. times three as
needed for chest pain.
5. Paxil 20 mg p.o. q.d.
6. Lopressor 12.5 mg p.o. b.i.d. (the patient was reluctant
to take this medication as he has had symptomatic bradycardia
in the past; however, the patient tolerated this dose for the
past 36 hours with a heart rate in the high 40s/low 50s
without symptoms or orthostatic hypotension).
7. Protonix 40 mg p.o. q.d.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was to be discharged to home.
DISCHARGE FOLLOWUP: Follow up with outpatient cardiologist
in one week.
DISCHARGE INSTRUCTIONS: He was to discontinue Lopressor
should he become lightheaded or dizzy; otherwise, continue
beta blocker and follow up with cardiologist in one week.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 10996**]
MEDQUIST36
D: [**2124-8-14**] 19:15
T: [**2124-8-22**] 09:17
JOB#: [**Job Number 41362**]
|
[
"998.2",
"458.2",
"414.01",
"285.9",
"535.50",
"300.00",
"427.89",
"997.1",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"36.01",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
2575, 2773
|
7695, 8249
|
2363, 2557
|
4526, 7669
|
8460, 8846
|
8264, 8360
|
8382, 8435
|
145, 1396
|
1418, 2336
|
2790, 4508
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,266
| 189,623
|
1343
|
Discharge summary
|
report
|
Admission Date: [**2161-7-25**] Discharge Date: [**2161-8-2**]
Service: [**Location (un) **]
CHIEF COMPLAINT: Syncope
HISTORY OF PRESENT ILLNESS: This is an 85-year-old Caucasian
male with a past medical history significant for
hypertension, myocardial infarction in [**2157**], chronic renal
insufficiency, anemia, who presents after falling in the
bathroom earlier on the day of admission. The patient felt
clammy, and was unresponsive for 20 to 30 minutes. The
patient had a sensation of shortness of breath and
lightheadedness around the time of the event. No post-ictal
state was noted. The patient has no history of seizures.
The patient was found to have a urinary tract infection,
consistent with his symptoms of dysuria and increased
frequency of urination. In the Emergency Department, the
patient was found to be febrile, with decreased oxygen
saturation, and tachycardic with ST depression, mostly
rate-related, and most obvious in Leads V4 through V6.
The patient has had a similar experience in [**2157**]. At that
time, he had a pseudomonas/enterococcus urosepsis, that
presumably led to demand ischemia and subsequent myocardial
infarction. His last echocardiogram in [**2157**] showed an
ejection fraction of 35%.
In the Emergency Department, the patient was started on
ceftazidime for pseudomonal coverage, based on his past
episode of urosepsis. The patient was also started on
intravenous normal saline, and his blood pressures hovered at
around 100 systolic. The patient was also given one unit of
packed red blood cells for demand-related ischemia. About
two hours into the patient's transfusion, he had an episode
of tachycardia to 120, an increased respiratory rate up to
40, with a temperature of 100.6. He was found to be very
wheezy and also had distinct rigors. At this point, the
patient was given 80 mg of intravenous lasix, was put on
non-rebreather, and also given Solu-Medrol, Demerol, and
albuterol. The patient was stable, and his oxygen saturation
went up. His chest x-ray showed no evidence of any flash
pulmonary edema.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
in [**2157**]
2. Hypertension
3. Congestive heart failure; echocardiogram in [**2157**] revealed
an ejection fraction of 35%
4. Abdominal aortic aneurysm, measured at 3.6 cm in [**2157**]
5. Chronic renal insufficiency, baseline creatinine is 1.4
to 1.6
6. Anemia, baseline hematocrit is 26 to 30
7. Gastroesophageal reflux disease
8. Benign prostatic hypertrophy
9. Status post appendectomy
10. History of urosepsis
MEDICATIONS:
1. Lasix 40 mg by mouth once daily
2. Lopressor 50 mg by mouth every morning, 25 mg by mouth
daily at bedtime
3. Captopril 12.5 mg by mouth three times a day
4. Aspirin 325 mg by mouth once daily
5. Flomax 0.4 mg by mouth once daily
6. Colace 100 mg by mouth twice a day
7. Iron sulfate 325 mg by mouth three times a day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a 24 hour home health aide.
No significant history of tobacco or alcohol use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vitals: Temperature 99.6, T-max
102.8, pulse 90, respiratory rate 22, blood pressure
98-120/60, oxygen saturation 98% on 2 liters. In general,
the patient is in no apparent distress. Head, eyes, ears,
nose and throat: Pupils equal, round and reactive to light
and accommodation, mucous membranes moist. Neck: No jugular
venous distention, normal carotid upstroke. Lungs: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm, III/VI holosystolic murmur best heard at the apex.
Abdomen: Soft, nontender, nondistended, normal active bowel
sounds bilaterally. A very large scrotal hernia.
Extremities: No cyanosis, clubbing or edema. Neurologic:
Alert and oriented x 3, tangential thoughts.
LABORATORY DATA: White blood cell count 19.8 with a
differential of 92 neutrophils, 1 band, hematocrit 28.9,
platelets 246. Sodium 139, potassium 4.2, chloride 100,
bicarbonate 24, BUN 33, creatinine 1.8, glucose 176. Calcium
9.1, magnesium 2.1, phos 1.9. AST 14, ALT 12, alkaline
phosphatase 111, total bilirubin 0.5, albumin 4.1. PT 13.7,
PTT 34.1, INR 1.3. Amylase 75. CPK number one 76, troponin
less than 0.3. Urinalysis showed leukocyte esterase
moderate, white blood cell count 21-50, no squamous
epithelial cells. Chest x-ray showed no evidence of
consolidation or congestive heart failure. Electrocardiogram
initially was sinus at a rate of 101, [**Street Address(2) 5366**] depressions in
V4 to V6, 2-[**Street Address(2) 2051**] depressions in I, II, III, AVF. A few
hour later, the electrocardiogram showed a rate of 80, with [**Street Address(2) 8206**] depressions in V4 through V6, and 1-2 mm depressions in
I, II, III, AVF.
HOSPITAL COURSE: In short, this is an 85-year-old male with
a past medical history of coronary artery disease status post
myocardial infarction in [**2157**], chronic renal insufficiency,
anemia, who presents with demand ischemia and significant ST
depressions in the lateral leads secondary to developing
urosepsis.
1. Coronary artery disease: The patient initially had a low
CK and troponin. However, with serial CPKs, the patient
began to rule in and had a peak CPK of 1789, with an MB of
130. The MB fraction was 7.3. In addition, the patient had
a troponin of greater than 50. It was concluded that the
patient had a non-Q wave myocardial infarction in the
lateral/inferior leads. It was thought that this myocardial
infarction was secondary to demand ischemia because of the
patient's urosepsis and associated tachycardia.
The patient was continued on his aspirin. His blood pressure
medications were initially held secondary to hypotension.
However, as this was controlled, he was placed back on a low
dose of Lopressor in order to decrease myocardial demand.
The patient was also initially started on weight-based
protocol of heparin with bolus. It was thought that the
patient's myocardial infarction was very unlikely secondary
to a thrombotic event, but this nevertheless could not be
ruled out. Eventually the patient was also restarted on a
low dose of Captopril once his pressures were stabilized.
Given the patient's myocardial infarction, an ACE inhibitor
was certainly indicated.
2. Atrial fibrillation: Two days into the patient's
admission, he developed spontaneous paroxysmal atrial
fibrillation, with rates as high as 140s to 150s. He also
had three separate episodes of [**10-17**] beat ventricular
tachycardia. During the patient's atrial fibrillation and
ventricular tachycardia episodes, he was totally
asymptomatic. No mental status changes were noted. However,
the atrial fibrillation was accompanied by significant
hypotension. The patient's mean arterial pressure went as
low as 50 to 60. At this point, the primary rule was rate
control secondary to the patient's known demand ischemia.
The patient received three consecutive doses of 5 mg of
intravenous Lopressor. This only temporarily decreased the
rate. Given the patient's new onset atrial fibrillation and
hypotension, he was transferred under the care of Coronary
Care Unit. The patient went back and forth between atrial
fibrillation and normal sinus rhythm.
Eventually the patient consented to DC cardioversion. The
patient converted from atrial fibrillation to normal sinus
rhythm with one 200 joule shock. In addition, the patient
was started on amiodarone. He was given a loading dose with
intravenous, and then started on 400 mg by mouth three times
a day. The patient was also continued on his heparin, now
for anticoagulation secondary to atrial fibrillation.
After two days in the Intensive Care Unit, the patient came
back to the general floor. He went back into atrial
fibrillation temporarily, at a rate of 110 to 120. However,
at this time he maintained his systolic blood pressure
greater than 100. Once again the patient was asymptomatic.
Because amiodarone was begun, the patient's liver function
tests were checked. This revealed that his ALT was 829, and
his AST was 273. These values had been normal on admission.
The amiodarone was stopped, recognizing that the half-life of
amiodarone is 90 days and most of it was still in the
patient's system. The following day, the AST and ALT began
to decrease, and continued that trend through the admission.
The patient once again converted back to normal sinus rhythm
spontaneously, and remained so through the rest of his
admission. Heparin was eventually stopped, and Lovenox was
started at 80 mg subcutaneously twice a day. At the same
time, the patient was started on Coumadin 2.5 mg by mouth
once daily.
3. Pump: The patient was initially hypotensive on admission
secondary to his urosepsis. At this point, he received one
unit of packed red blood cells without receiving
pre-medication with lasix. The patient developed acute
episode of wheezing, which may represent a symptom of volume
overload for this patient. The patient also became volume
overloaded during his hypotensive episodes while in atrial
fibrillation. He was given a few boluses of 500 mg of
intravenous normal saline without much change to his blood
pressure. This caused the patient to be noticeably volume
overloaded, and had wet crackles halfway up from the base
bilaterally. The patient was given 40 mg of intravenous
lasix, and restarted on a standing dose of lasix.
In order to quantify the patient's new cardiac status
following his myocardial infarction, an echocardiogram was
obtained. This revealed an ejection fraction of 30 to 35%.
He also had 1+ aortic regurgitation, 3+ mitral regurgitation,
2+ tricuspid regurgitation, and moderate pulmonary artery
hypertension. The patient was also noted to have mild left
ventricular dilatation, anterior, anteroseptal, apical,
inferior hypokinesis and akinesis. This did not represent a
significant change from his echocardiogram in [**2157**], although
the degree of pulmonary artery hypertension had increased.
4. Blood pressure: The patient's pressure was initially low
secondary to his urosepsis. It was also at its trough during
his episode of atrial fibrillation. Once he was back in
normal sinus rhythm, his blood pressure also recovered back
into the 100-110 range. The patient's blood pressure was
well controlled at the end of the admission on his standing
dose of lasix, 12.5 mg by mouth twice a day of Lopressor, and
6.25 mg by mouth three times a day of Captopril.
5. Infectious Disease: The patient was admitted with
urosepsis. Urine culture grew out proteus PCs. The patient
was started initially on ceftazidime, but was then converted
to ceftriaxone 1 gram every 24 hours after sensitivities were
posted. The patient stayed relatively afebrile through his
admission, spiking only to a high of 100.6. Blood cultures
grew only one out of four bottles of proteus species. White
blood cell count initially came down from 19.8, but then
unexplainably went back up to 15.4 about five days into the
admission. It subsequently went down to 12.0. There was no
clear source of infection. The patient had a normal chest
x-ray, C. difficile negative, repeat urine culture negative
other than the presence of sterile pyuria, and blood cultures
otherwise remained negative other than the one out of four
initial proteus growth. For discharge, the patient was
switched to cefpodoxime at a dose of 100 mg by mouth every 12
hours. The patient is to take a total dose of antibiotics
for 14 days.
6. Renal: The patient's baseline creatinine is 1.4 to 1.6.
It went up to a high of 2.5, likely secondary to the
patient's numerous episodes of hypotension. However, the
creatinine recovered, dropping to as low as 1.1, well below
the patient's baseline. This occurred even with standing
dose of lasix.
7. Gastrointestinal: The patient's increase in liver
function tests was most likely secondary to the amiodarone,
which was discontinued. However, a right upper quadrant
ultrasound was obtained, which showed widening of the
inferior vena cava, and echogenic liver changes consistent
with cardiac cirrhosis or fatty changes in the liver. It is
unlikely, however, that these changes could account for the
patient's rise in liver function tests, and then fall after
the amiodarone was discontinued. The patient also initially
had poor oral intake and nausea secondary to amiodarone. By
the end of the admission, the patient had a better appetite
and was taking better oral intake.
8. Hematology: The patient's baseline hematocrit is 26-30.
The patient stayed in that range for the course of his
admission. Because of his demand ischemia, there was an
effort to raise his hematocrit to 30. The patient got a
total of two units of packed red blood cells. The patient
remained guaiac negative.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: The patient is to be discharged to the
[**Hospital3 2558**] for a temporary rehabilitation.
DISCHARGE MEDICATIONS:
1. Furosemide 40 mg by mouth once daily
2. Lovenox 80 mg subcutaneously every 12 hours
3. Cefpodoxime 100 mg by mouth every 12 hours through [**8-7**]
4. Lopressor 12.5 mg by mouth twice a day
5. Captopril 6.25 mg by mouth three times a day
6. Calcium carbonate 500 mg by mouth three times a day
7. Aspirin 81 mg by mouth once daily
8. Coumadin 2.5 mg by mouth daily at bedtime
9. Ambien 5 mg by mouth daily at bedtime as needed for
insomnia
10. Senna one tablet by mouth twice a day as needed
11. Simethicone 40 to 80 mg by mouth four times a day as
needed for indigestion
12. Normal regular insulin sliding scale
13. Flomax 0.4 mg by mouth daily at bedtime
14. Atrovent nebulizers, one nebulizer every four hours as
needed for wheezing
15. Protonix 40 mg by mouth every 24 hours
16. Colace 100 mg by mouth twice a day as needed
FOLLOW UP INSTRUCTIONS: The patient will need to have his
INR checked every other day until it is within therapeutic
range between 2.5 and 3.0. At this point, the Lovenox will
be discontinued. The patient will also need to have liver
function tests checked weekly for at least two weeks in order
to ensure that his liver function tests are declining
secondary to stopping the amiodarone.
DISCHARGE DIAGNOSIS:
1. Urosepsis
2. Non-Q wave myocardial infarction
3. Paroxysmal atrial fibrillation
4. Cardiac heart failure
5. Chronic renal insufficiency
6. Anemia
[**First Name11 (Name Pattern1) 8207**] [**Last Name (NamePattern4) 8208**], M.D.
[**MD Number(1) 8209**]
Dictated By:[**Doctor Last Name 8210**]
MEDQUIST36
D: [**2161-8-2**] 02:00
T: [**2161-8-2**] 02:14
JOB#: [**Job Number 8211**]
|
[
"427.31",
"599.0",
"285.9",
"707.0",
"038.9",
"410.71",
"396.3",
"397.0",
"398.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
3110, 3128
|
13039, 14272
|
14293, 14720
|
4845, 12882
|
3151, 4827
|
12897, 13016
|
123, 132
|
161, 2090
|
2112, 2980
|
2997, 3092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,562
| 138,455
|
53740
|
Discharge summary
|
report
|
Admission Date: [**2142-6-4**] Discharge Date: [**2142-6-26**]
Date of Birth: [**2063-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2142-6-7**] - Urgent Coronary Artery Bypass Graft x 3 (LIMA to LAD,
SVG to OM, SVG to RCA)
[**2142-6-14**] - Exploratory Laparotomy with Lysis of Adhesions
History of Present Illness:
79M h/o known CAD 3VD ([**5-29**] NSTEMI, TropI 4.0, s/p cath: prox
RCA 100%, prox circ 80%, prox LAD 80%) who presented to ED with
episode of chest pain. EKG demonstrated possible worsening ST
depression in leads I/II. Treated accordingly in the ER for MI
and admitted for surgical revascularization. Of note, he was
previously discharged to home awaiting CABG surgery secondary to
recent Plavix administration.
Past Medical History:
(1) IMI ([**2117**])
(2) HTN
(3) Hypercholesterolemia
(4) Type II Diabetes
(5) PVD: aortobi-iliac bypass ([**2128**])
(6) Angina per ETT ([**2122**])
(7) L total knee replacement
(8) R cataract surgery ([**2139**])
(9) R forearm melanoma in situ ([**2140**])
(10) [**2136**] cath: prox RCA 100% (1VD)
Social History:
Pt does not currently smoke, does not abuse alcohol, and has
never used recreational drugs.
Family History:
Mother died at age 82 from complications of Type II diabetes.
Father died at age 58 from stroke, with h/o HTN. Brother died at
age 67 from pancreatic CA, and other brother died at age 74 from
multiple medical problems.
Physical Exam:
VS: BP 134/62, HR 51, RR 18, O2sat 93% RA, pain 0/10
Gen: Obese elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, questionable JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not appreciated
given body habitus. No abdominial bruits.
Ext: +2 BLE edema. No c/c. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2142-6-4**] 02:25PM BLOOD WBC-10.4 RBC-4.68 Hgb-13.3* Hct-37.9*
MCV-81* MCH-28.4 MCHC-35.0 RDW-15.0 Plt Ct-260
[**2142-6-4**] 02:25PM BLOOD PT-11.8 PTT-26.5 INR(PT)-1.0
[**2142-6-4**] 02:25PM BLOOD Glucose-108* UreaN-25* Creat-1.4* Na-140
K-4.8 Cl-108 HCO3-22 AnGap-15
[**2142-6-4**] 02:25PM BLOOD CK-MB-7 cTropnT-0.39*
[**2142-6-4**] 10:45PM BLOOD CK-MB-NotDone cTropnT-0.35*
[**2142-6-5**] 05:59AM BLOOD CK-MB-NotDone cTropnT-0.29* proBNP-2466*
[**2142-6-6**] Echocardiogram: The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with basal inferior and inferolateral hypokinesis.
There is normal systolic function of the remaining segments. The
right ventricular cavity is mildly dilated. Right ventricular
systolic function is normal. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
[**2142-6-13**] Abd CT Scan: Partial small bowel obstruction with
smoothly tapered luminal narrowing at the transition point in
the proximal ileum. Small bilateral pleural effusions left
greater than right. Tiny left renal calculi.2.0 cm left iliac
artery aneurysm.
[**2142-6-18**] Ultrasound: Completely occlusive thrombus of the left
internal jugular vein. No extension into the subclavian vein was
seen.
[**2142-6-19**] Ultrasound: Uncomplicated ultrasound and
fluoroscopically guided double-lumen PICC line placement via the
brachial venous approach. Final internal length is 37 cm, with
the tip positioned in the SVC. The line is ready to use.
[**2142-6-21**] Chest x-ray: Improving left lower lobe atelectasis.
Persistent small bilateral pleural effusions.
[**2142-6-26**] 05:11AM BLOOD WBC-14.3* RBC-2.94* Hgb-8.0* Hct-25.1*
MCV-85 MCH-27.1 MCHC-31.7 RDW-16.2* Plt Ct-524*
[**2142-6-26**] 07:54AM BLOOD PT-31.3* PTT-41.2* INR(PT)-3.3*
[**2142-6-26**] 05:11AM BLOOD Glucose-103 UreaN-25* Creat-1.5* Na-140
K-4.6 Cl-108 HCO3-22 AnGap-15
[**2142-6-24**] 11:43AM BLOOD ALT-33 AST-24 LD(LDH)-189 AlkPhos-116
Amylase-75 TotBili-0.4
Brief Hospital Course:
Mr. [**Known lastname 110315**] was admitted under cardiology with unstable angina.
He ruled in for an acute myocardial infarction and started on
intravenous therapy. His chest pain did improve with medical
therapy. An echocardiogram was obtained prior to surgical
intervention which showed symmetric LVH with mild regional
systolic dysfunction, consistent with coronary artery disease.
He also had a mildly dilated right ventricle with preserved
systolic function. Preoperative course was otherwise uneventful
and he was cleared for surgery. On [**6-7**], Dr. [**Last Name (STitle) **]
performed urgent coronary artery bypass grafting. For surgical
details, please see seperate dictated operative note. Following
the operation, he was brought to the CSRU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated without incident. He developed atrial fibrillation
on postoperative day two which was treated with Amiodarone and
beta blockade. His hemodynamics were labile and intermittently
required pressor support. Over several days, his rhythm and
hemodynamics improved and he eventually transferred to the SDU
on postoperative day four. On postoperative day six, he
experienced worsening nausea and vomiting. A nasogastric tube
was placed and KUB remarkable for dilated loops of bowel with
air fluid levels. He was made NPO and started on intravenous
fluids. Surgery was consulted and an abdominal CT scan was
obtained which confirmed suspicion of partial small bowel
obstruction. On [**6-14**], Dr. [**First Name (STitle) **] performed exploratory
laparotomy with lysis of adhesions. He returned to the CSRU.
Within 24 hours, he was re-extubated. He otherwise maintained
stable hemodynamics and transferred back to the SDU on [**6-16**]. He remained NPO and eventually started on TPN. Due to
persistent episodes of atrial fibrillation, he was eventually
started on Warfarin as Amiodarone and beta blockade were
titrated accordingly. He transiently required Heparin drip for a
subtherapeutic prothrombin time. Over several days, his diet was
gradually advanced and his NGT was removed. By discharge, he has
had several bowel movements with resolution of nausea and
vomiting. Prior to discharge, he experienced uretheral bleeding
immediately following foley removal. Foley was reinserted
without difficulty and without further hematuria. It was
recommended that his foley remains in place until followup with
urology. Postoperative course was also notable for a
leukocytosis. C. Diff cultures were negative. Ciprofloxacin was
started for a urinary tract infection. A swab of his incision
grew e. coli and Keflex was added for coverage. As his INR
became therapeutic, his heparin was discontinued. As he had
increased erythema, the keflex was stopped and intravenous
vancomycin was started.
His UTI was resistant to Cipro and sensitive to Bactrim so his
abx were changed. He also had a sl. wound infection on his
abdominal wound which was debrided and treated with vac. He
will be treated for 1 week with Levoquin for the abd. wound.
He had an elevated INR and his INR on discharge was 3.3. The
coumadin should be held until the INR is less than 3 and then
the goal is 2-2.5. He was discharged to rehab in stable
condition on POD#19 and 12.
Medications on Admission:
Atenolol 100 mg daily
Nifedical XL 60 mg daily
Vytorin 10/40 daily
Prilosec OTC 20 mg daily PRN
Aspirin 81 mg daily
Lisinopril 20 mg daily
Isosorbide mononitrate 30 mg daily
After scheduled CABG on [**6-11**]: Metformin 500 mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Simvastatin 40 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).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Hold
medication tonight, give for INR goal of [**1-5**].5. Tablet(s)
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease - s/p Urgent Coronary Artery Bypass
Graft, Non ST Elevation Myocardial Infarction, Small Bowel
Obstruction - s/p Ex Lap, Postoperative Atrial Fibrillation,
Urethral Bleeding, Thrombus of the Left Internal Jugular Vein,
Postop Leukocytosis
PMH: Hypercholesterolemia, Hypertension, Gastroesophageal Reflux
Disease, Diabetes, Malignant Melenoma (s/p excision of lesions),
h/o Myocardial Infarction [**2117**], s/p AAA repair, Left total knee
replacement, s/p 4th digit flexor sheath
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. Continue foley catheter until follow up
with Urology. Take Warfarin as directed. Warfarin should be
adjusted for goal INR around 2.0. Please call with any further
questions or concerns [**Telephone/Fax (1) 170**].
Followup Instructions:
1)Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
2)Dr [**First Name (STitle) **]([**Telephone/Fax (1) 133**])- call for appt after rehab
3)Dr [**First Name (STitle) **](Transplant Surgery)([**Telephone/Fax (1) 673**]) in 2 weeks,
please call for appt
4)Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2309**] Date/Time:[**2142-7-2**] @ 10:30
5)Dr. [**Last Name (STitle) 120**] [**Telephone/Fax (1) 127**] Date/Time:[**2142-8-1**] @ 10:00
6)[**Hospital 159**] clinic, please call [**Telephone/Fax (1) 164**] for appt in 1 week
7)Dr. [**First Name (STitle) 18575**] [**Telephone/Fax (1) 9347**] Date/Time:[**2142-9-11**] @ 9:15
Completed by:[**2142-6-26**]
|
[
"996.1",
"599.0",
"V43.65",
"427.31",
"560.81",
"998.59",
"278.00",
"414.01",
"041.85",
"250.00",
"996.74",
"682.2",
"401.9",
"599.7",
"E879.8",
"585.9",
"453.8",
"V10.82",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"54.59",
"38.93",
"99.04",
"36.15",
"96.07",
"39.61",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9644, 9716
|
4811, 8094
|
331, 491
|
10263, 10269
|
2483, 4788
|
10930, 11640
|
1383, 1603
|
8388, 9621
|
9737, 10242
|
8120, 8365
|
10293, 10907
|
1618, 2464
|
281, 293
|
519, 934
|
956, 1258
|
1274, 1367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,094
| 199,826
|
32271
|
Discharge summary
|
report
|
Admission Date: [**2113-5-10**] Discharge Date: [**2113-5-15**]
Date of Birth: [**2036-2-21**] Sex: M
Service: MEDICINE
Allergies:
Cephalexin / Bactrim
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77yoM with diabetes mellitus on insulin, melanoma, metastatic
squamous cell carcinoma, complained of dizziness shortly after
leaving [**Hospital 478**] clinic where he had received chemotherapy. He
returned to [**Hospital 478**] clinic within 10 minutes of leaving. He
complained that he was dizzy and on eval there was found to be
hypoxic to 81%RA. O2 supplementation was started with quick
response to 98% on 4L nc. His FSBG was 39 and after eating
crakers and drinking juice he reported to the clinic nurses that
his dizziness was much improved. On arrival to ED fsbg 39, on
arrival to medical floor 87.
He currently denies chest pain, palpitations, sob, orthopnea,
pnd, LE edema, cough. He denies fever, chills, nausea,
vomitting.
In the ER CT head concerning for hypodensity within cerebellum.
CXR showed left pleural effusion, associated atelectasis.
ROS: No dysuria, urgency; No weakness, numbness, headache; ros
otherwise negative except as per HPI.
Past Medical History:
1. Hypertension.
2. Hypercholesterolemia.
3. Type 2 diabetes mellitus, on insulin.
4. Chronic kidney disease.
5. History of squamous cell carcinoma, basal cell cancers, and
melanoma
6. CABG
Social History:
He lives with son. H/o Tobacco, quit 50 years ago. Alcohol, One
drink per week.
Family History:
No family h/o skin cancer
Physical Exam:
T 95.7 HR 57 BP 130/50 RR 22 O2sat 94%2L nc
GEN: NAD
HEENT: PERRL, anicteric, conjunctiva pink, OP clear, moist
mucous membranes
CARDIOVASCULAR: brady and irregular, 2/6 SEM RUSB w/o radiation
LUNGS: marked decreased bs left, no rales, no rhonchi, no
wheeze
ABDOMEN: soft, nontender, nondistended with normal active bowel
sounds. no masses.
EXTREMITIES: no clubbing, cyanosis, or edema
SKIN: Numerous black papules over the left chest and left
shoulder
NEURO: A&Ox2 (states [**2113-3-28**], knowns [**Hospital1 18**]), cranial nerves
II-XII intact, strength 5/5 throughout, finger to nose with
tremors at target, rapid alternating movements slow but
symmetric, heel to shin grossly normal
Pertinent Results:
[**2113-5-10**] 01:07PM WBC-7.4 RBC-3.79* HGB-11.8* HCT-35.1* MCV-93
MCH-31.2 MCHC-33.7 RDW-14.0
[**2113-5-10**] 01:07PM PLT COUNT-195
[**2113-5-10**] 02:20PM ALT(SGPT)-23 AST(SGOT)-25 LD(LDH)-191 ALK
PHOS-68 TOT BILI-0.4
[**2113-5-10**] 02:20PM UREA N-45* CREAT-3.1* SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-26 ANION GAP-12
[**2113-5-10**] 02:20PM GLUCOSE-51*
[**2113-5-10**] 05:59PM CK-MB-NotDone
[**2113-5-10**] 05:59PM CK(CPK)-83
[**2113-5-10**] 07:16PM cTropnT-0.05*
EKG: bradycardic, irregular, atrial fibrillation, no Q waves,
RBBB, normal axis
CXR:PA and lateral views of the chest are obtained. Midline
sternotomy
wires and mediastinal clips are noted compatible with prior
CABG. Curvilinear
calcification is noted projecting over the cardiac silhouette
likely
representing mitral annular calcification. There is a large left
pleural
effusion with likely left lower lobe and lingular collapse. The
right lung is
grossly unremarkable though a small right pleural effusion is
likely present.
Heart size cannot be assessed. Mediastinal contour is grossly
unremarkable.
Atherosclerotic calcification along the aortic knob is noted. No
pneumothorax
is seen. Osseous structures appear intact.
CT head:
Hypodensity within the right cerebellum of questionable etiology
probably
related to fissure.
-----------
[**2113-5-11**] 05:34PM BLOOD WBC-8.9 RBC-3.26* Hgb-10.3* Hct-31.7*
MCV-97 MCH-31.6 MCHC-32.4 RDW-14.2 Plt Ct-167
[**2113-5-12**] 05:04AM BLOOD WBC-7.2 RBC-2.94* Hgb-9.2* Hct-27.8*
MCV-95 MCH-31.3 MCHC-33.1 RDW-14.1 Plt Ct-118*
[**2113-5-13**] 04:30AM BLOOD WBC-8.3 RBC-3.03* Hgb-9.5* Hct-29.0*
MCV-96 MCH-31.4 MCHC-32.8 RDW-14.5 Plt Ct-132*
[**2113-5-14**] 04:19AM BLOOD WBC-7.4 RBC-3.13* Hgb-10.0* Hct-29.4*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.2 Plt Ct-120*
[**2113-5-15**] 04:54AM BLOOD WBC-7.1 RBC-3.51* Hgb-10.9* Hct-32.9*
MCV-94 MCH-31.1 MCHC-33.2 RDW-14.2 Plt Ct-128*
[**2113-5-10**] 05:59PM BLOOD Neuts-80.8* Lymphs-10.5* Monos-5.1
Eos-2.9 Baso-0.7
[**2113-5-11**] 05:34PM BLOOD Neuts-85.1* Lymphs-5.0* Monos-9.5 Eos-0.2
Baso-0.2
[**2113-5-14**] 04:19AM BLOOD PT-13.5* PTT-28.0 INR(PT)-1.2*
[**2113-5-15**] 04:54AM BLOOD PT-13.2 PTT-28.5 INR(PT)-1.1
[**2113-5-10**] 01:07PM BLOOD Gran Ct-5970
[**2113-5-11**] 11:43PM BLOOD Glucose-196* UreaN-57* Creat-3.6* Na-142
K-4.6 Cl-109* HCO3-22 AnGap-16
[**2113-5-12**] 05:33PM BLOOD Glucose-137* UreaN-59* Creat-4.0* Na-143
K-4.9 Cl-108 HCO3-25 AnGap-15
[**2113-5-14**] 04:19AM BLOOD Glucose-134* UreaN-64* Creat-4.5* Na-142
K-4.8 Cl-113* HCO3-21* AnGap-13
[**2113-5-15**] 04:54AM BLOOD Glucose-137* UreaN-69* Creat-4.7* Na-141
K-5.3* Cl-111* HCO3-20* AnGap-15
[**2113-5-10**] 02:20PM BLOOD ALT-23 AST-25 LD(LDH)-191 AlkPhos-68
TotBili-0.4
[**2113-5-11**] 05:34PM BLOOD ALT-103* AST-162* LD(LDH)-269*
CK(CPK)-104 AlkPhos-90 TotBili-0.4
[**2113-5-12**] 05:04AM BLOOD ALT-78* AST-75* LD(LDH)-163 AlkPhos-75
Amylase-46 TotBili-0.4
[**2113-5-12**] 05:04AM BLOOD Lipase-14
[**2113-5-10**] 07:16PM BLOOD cTropnT-0.05*
[**2113-5-11**] 02:40AM BLOOD CK-MB-7 cTropnT-0.05*
[**2113-5-11**] 08:30AM BLOOD CK-MB-6 cTropnT-0.05*
[**2113-5-11**] 05:34PM BLOOD CK-MB-7 cTropnT-0.06*
[**2113-5-11**] 11:43PM BLOOD CK-MB-8 cTropnT-0.07*
[**2113-5-10**] 02:20PM BLOOD Albumin-3.5 Calcium-8.6 Mg-2.3
[**2113-5-11**] 08:30AM BLOOD TotProt-6.3*
[**2113-5-11**] 11:43PM BLOOD Calcium-7.9* Phos-5.3* Mg-2.0
[**2113-5-15**] 04:54AM BLOOD Calcium-8.1* Phos-6.5* Mg-2.1
[**2113-5-12**] 05:04AM BLOOD Osmolal-311*
[**2113-5-15**] 04:54AM BLOOD Valproa-18*
[**2113-5-11**] 01:38PM BLOOD Type-ART pO2-104 pCO2-83* pH-7.00*
calTCO2-22 Base XS--13 -ASSIST/CON Intubat-INTUBATED
[**2113-5-11**] 02:40PM BLOOD Type-ART pO2-325* pCO2-59* pH-7.18*
calTCO2-23 Base XS--6
[**2113-5-11**] 11:24PM BLOOD Type-ART Temp-37.3 Rates-18/2 Tidal V-550
PEEP-5 FiO2-50 pO2-70* pCO2-44 pH-7.34* calTCO2-25 Base XS--2
-ASSIST/CON Intubat-INTUBATED
[**2113-5-12**] 02:46AM BLOOD Type-ART Temp-36.2 Rates-18/0 Tidal V-550
PEEP-5 FiO2-60 pO2-82* pCO2-38 pH-7.39 calTCO2-24 Base XS--1
-ASSIST/CON Intubat-INTUBATED
[**2113-5-12**] 05:25AM BLOOD Type-ART Rates-18/ Tidal V-550 PEEP-5
FiO2-60 pO2-90 pCO2-39 pH-7.39 calTCO2-24 Base XS-0
Intubat-INTUBATED
[**2113-5-13**] 12:11AM BLOOD Type-ART Temp-37.2 Rates-18/ Tidal V-550
PEEP-5 FiO2-60 pO2-86 pCO2-40 pH-7.38 calTCO2-25 Base XS-0
Intubat-INTUBATED Vent-IMV
[**2113-5-14**] 12:21AM BLOOD Type-ART Temp-35.7 Rates-18/ Tidal V-550
PEEP-5 FiO2-60 pO2-82* pCO2-37 pH-7.39 calTCO2-23 Base XS--1
-ASSIST/CON Intubat-INTUBATED
[**2113-5-14**] 08:53PM BLOOD Type-ART pO2-80* pCO2-39 pH-7.34*
calTCO2-22 Base XS--4
[**2113-5-15**] 05:06AM BLOOD Type-ART pO2-83* pCO2-41 pH-7.35
calTCO2-24 Base XS--2
[**2113-5-15**] 05:06AM BLOOD Lactate-1.2
[**2113-5-13**] 12:11AM BLOOD freeCa-1.15
--------------------
TTE: TTE (Complete) Done [**2113-5-11**] at 8:28:04 PM
Conclusions
A small secundum atrial septal defect is present. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with inferolateral, basal inferior and basal lateral
hypokinesis. The remaining segments contract normally (LVEF =
40-45%). The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets are
moderately thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Dilated right ventricle with moderate systolic
dysfunction. Mild regional left ventricular systolic
dysfunction, c/w CAD. Mild pulmonary hypertension.
--------------------
ECG: Atrial fibrillation. Right bundle-branch block.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2113-5-10**] T wave flattening is less pronounced.
TRACING #2
--------------------
CXR: Study Date of [**2113-5-11**] 10:41 AM
IMPRESSION: No loculation of left pleural effusion.
--------------------
CXR: Study Date of [**2113-5-11**] 1:52 PM
FINDINGS: In comparison with study of [**5-10**], obliquity of the
patient makes comparison somewhat difficult. Large left pleural
effusion persists in a patient with intact sternal sutures.
However, there is increasing
opacification involving the lower half of the right hemithorax
with
obscuration of the hemidiaphragm. Although this could represent
atelectatic change and increasing vascular congestion, the
possibility of aspiration must be seriously considered.
Endotracheal tube is now in place with its tip approximately 5
cm above the carina.
--------------------
CT HEAD W/O CONTRAST Study Date of [**2113-5-11**] 8:11 PM
IMPRESSION: No acute intracranial process. Unchanged appearance
of left
posterior fossa hypodensities. As previously described, further
characterization with gadolinium-enhanced MR can be obtained to
exclude
metastases considering patient's known history of melanoma.
These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24692**].
--------------------
MRA BRAIN W/O CONTRAST Study Date of [**2113-5-12**] 5:02 PM
IMPRESSION: Acute right MCA infarct and bilateral cerebellar
infarcts. The
distribution is not typical for hypoxic brain injury but could
be due to
combination of vascular stenosis and hypoperfusion. Mild changes
of small-
vessel disease.
IMPRESSION:
1. High-grade right distal vertebral stenosis greater than 50%.
Non-
visualization of the distal left vertebral artery could be due
to stenosis and slow flow in the neck. Neck MRA can help for
further assessment.
2. Atherosclerotic disease involving both cavernous carotids and
right middle cerebral artery.
CXR: Study Date of [**2113-5-13**] 11:30 AM
IMPRESSION: No significant change.
CXR: Study Date of [**2113-5-15**] 5:18 AM
As compared to the previous radiograph, there is no major
change. The
extensive left-sided pleural effusion distributes in a slightly
different
manner, but its overall extent is unchanged. The same is true
for smaller
right-sided pleural effusion. There is extensive retrocardiac
atelectasis. The overall size of the cardiac silhouette has not
changed. Signs of mild overhydration. The monitoring and support
devices are in unchanged position.
--------------------
CT Head: Study Date of [**2113-5-15**] 1:15 PM
IMPRESSION: Continued evolution of extensive infarction
involving right
cerebral hemisphere in a watershed distribution and bilateral
cerebellum.
Since the prior exams, there is increased leftward shift and
early uncal
herniation.
.
These findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 2 p.m. on
[**2113-5-15**].
--------------------
Brief Hospital Course:
Patient was admitted for evaluation of dizziness and new oxygen
requirement. At 1430 called for cardiac arrest on 11R patient
had been found unresponsive, unclear how long. Per primary team
they had obtained consent for thoracentesis from patient 20
minutes prior to Code Blue. Patient found in PEA and
unresponsive. Received epinephrine and atropine x2. Also
received insulin, bicarb, mag, and calcium in addition to chest
compressions. Patient's pulse returned within 10 minutes of
ACLS. Patient was intubated during this time period, initial
esophageal intubation, significant emesis during chest
compressions although good suction wasperformed throughout code.
Differential for arrest on arrival to ICU was broad an
encompassed PE, pneumothorax, tamponade among other etiologies.
Broad work-up undertaken as per results on previous page showing
no clear evidence of PE, pneumothorax, or tamponade by echo or
exam. Patient was monitored in ICU for further complications.
.
#Neurological Status post-arrest: Given severe nature of imaging
findings, and clinical exam post-arrest it was felt that
patient's overall neurological prognosis was grim. Neurology
was consulted for input who recommended observation for 72
hours, and weaning of sedation to determine underlying mental
status, neurological exam. At 72 hours patient had made no
substantial improvements and so overall prognosis was grim.
Extensive discussions with family and friends were had and
decision to was decided to make the patient comfort measures
only. Patient passed away shortly there after.
Medications on Admission:
amlodopine 10
carvedilol 3.125 [**Hospital1 **]
donepazil 10
insulin lispro
compazine
simvistatin 40
flomax
aspirin 325 MVI
Discharge Medications:
none.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulseless Electrical Activity
Hypoxia
Atrial Fibrillation
Melanoma
Hypoglycemia
Diabetes
Coronary Artery Disease
Squamous Cell Cancer of the Skin
Discharge Condition:
Deceased
Discharge Instructions:
None.
Followup Instructions:
None.
|
[
"585.9",
"511.9",
"434.91",
"348.1",
"427.31",
"250.80",
"V10.83",
"427.5",
"518.0",
"403.90",
"584.9",
"518.81",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13000, 13009
|
11223, 12796
|
291, 297
|
13198, 13208
|
2388, 3610
|
13262, 13270
|
1626, 1653
|
12970, 12977
|
13030, 13177
|
12822, 12947
|
13232, 13239
|
1668, 2369
|
242, 253
|
325, 1293
|
10771, 11200
|
1315, 1511
|
1527, 1610
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,754
| 153,020
|
21272
|
Discharge summary
|
report
|
Admission Date: [**2100-7-27**] Discharge Date: [**2100-7-31**]
Date of Birth: [**2055-7-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
[**Last Name (NamePattern4) **] GI bleeding.
Major Surgical or Invasive Procedure:
Endoscopy, upper; Ileoscopy; Push through upper endoscopy.
History of Present Illness:
45 year old man with UC, status post total proctocolectomy with
ileal pouch anal anastomosis with persistent diarrhea who
presented to [**Hospital 1263**] Hospital with 4 days of loose stools,
fatigue, lightheadedness with stools turning to bloody 2 days
prior to admission ([**2100-7-26**]). On initial evaluation at outside
hospital, he was noted to have "melanotic" stools, that turned
to hematochezia. Admission HCT was 22. Of note, he was taking
Ibuprofen for tendinitis, though only took 10 tablets over a
period of a week. He was transfused 2U on [**7-26**] with unclear
result of on his HCT. On [**7-27**] he had an EGD which showed normal
esophagus, stomach and duodenum and then underwent a
Pouchoscopy/enetorscopy which showed large amount of fresh
bright blood with blold clots, including J pouch and throughout
the entire small bowel examined (~ 70cm). Since the last scope,
he was transufsed another 5U of PRBCs and his HCT remained at
22. He was reported to be hemodynamically "stable", BP 100/50
and HR in 120s. He has 2, 18G IVs at time of transfer.
.
On the floor, he is without of lightheadedness, but has no other
symptoms. He denies recent changes in BM frequency or character
until presentation. No abdominal pain, nausea or vomiting,
cramping or tenesmus. No fevers, chills, malaise or weight
loss. Denies recent CP, but reports shortness of breath for 1
year, which comes and goes, currently reporting mild sx
intensity. No infectious symptoms, no arthralgias or myalgias.
No rashes or skin changes. He has been off all medications for
~ 2 years, as "nothing has worked" for his loose stools.
.
Of note, ~ 1 month ago, had severe constipation and required an
endocsopic treatment to relieve this. Has not had bloody stools
or melanotic stools since that time.
Past Medical History:
Ulcerative colitis
- [**7-/2094**] - Ileoanal pouch w/ ileostomy
- [**10/2094**] - Laparotomy, resection of small bowel including
ileostomy, reanastomosis and dilatation of the anorectal
stricture
- Aortic valve stenosis, mild per outside hospital records, no
documentation at [**Hospital1 18**].
- history of small bowel obstruction: one month prior had a
lower EGD which relieved obstruction.
Social History:
The patient lives with wife and 3 kids who are healthy. He
works as a construction worker.
- Tobacco: quit 10years ago. 30 ppy prior to that.
- Alcohol: 10 drinks on weekends, once per month
- Illicits: denies.
Family History:
- Prostate and stomach cancer - brother
- Breast cancer - sister
- Ulcerative colitis - brother.
- No bleeding diseases
- Brother with coronary artery disease died in 60s
- Uncle died of myocardial infarction at 45
- No h/o sudden cardiac deaths or arryhthmia
Physical Exam:
Vitals: T: 97F BP: 135/57 P:90s R: 22 O2: 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera pale, dMM, oropharynx clear
Neck: supple, flat JVP
Lungs: Clear to auscultation bilaterally
CV: RR, normal S1 + S2, [**3-27**] syst. M loudest at 2nd RICS, strong
PMI.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, dry, 2+ pulses, no edema
NEURO: A/Ox3, DOWb intact, frontal function intact. Full
strength in UEs and LEs, toes down, normal tone.
Pertinent Results:
[**2100-7-27**] 08:16PM LACTATE-1.0
[**2100-7-27**] 07:42PM GLUCOSE-89 UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
[**2100-7-27**] 07:42PM ALT(SGPT)-22 AST(SGOT)-32 LD(LDH)-229 ALK
PHOS-30* TOT BILI-2.9*
[**2100-7-27**] 07:42PM ALBUMIN-3.3* CALCIUM-8.3* PHOSPHATE-2.9
MAGNESIUM-1.8
[**2100-7-27**] 07:42PM CRP-3.1
[**2100-7-27**] 07:42PM WBC-10.9 RBC-3.15*# HGB-9.7* HCT-27.0*#
MCV-86# MCH-30.7# MCHC-35.9*# RDW-15.6*
[**2100-7-27**] 07:42PM NEUTS-74.0* LYMPHS-17.0* MONOS-6.4 EOS-2.1
BASOS-0.5
[**2100-7-27**] 07:42PM PLT COUNT-143*#
[**2100-7-27**] 07:42PM SED RATE-3
.
[**2100-7-27**] : CTA abd/pelvic per IR request. IMPRESSION 1. No CT
evidence of active extravasation of contrast. 2. Most of small
bowel is collapsed, without obstruction. 3. S/p total colectomy
with a ileo-pounch creation. No evidence of surgical
complication at the anastomosis. 4. No free fluid or air.
.
[**2100-7-28**] : Transthoracic Echo: IMPRESSION: hyperdynamic left
ventricle with severe left ventricular outflow tract obstruction
due to systolic anterior motion of the anterior mitral leaflet;
no vegetations seen
.
[**2100-7-29**] : CTA abd/pelvic per IR request IMPRESSION: 1. No
evidence of acute gastrointestinal bleed in this study. 2. Small
amount of simple free fluid in the pelvis is minimally increased
since prior study.
.
[**2100-7-27**] CXR: Nasogastric tube ends in the stomach, with the
most proximal side port just beyond the gastroesophageal
junction. The degree of rightward displacement of the mid and
lower trachea and length of trachea displaced that lies above
the aortic arch is more than I would expect from the aortic arch
alone. This raises the possibility of mass effect from adjacent
goiter or adenopathy, less likely from an esophageal lesion. I
suggest you obtain repeat conventional chest radiographs when
feasible to see if this is a persistent finding. Heart size is
top normal, and the lungs are grossly clear. There is no
appreciable pleural abnormality or indication of pneumothorax.
.
[**2100-7-29**] CXR: Tracheal contour has returned to baseline with no
evidence of mass effect.
Brief Hospital Course:
45 year old man with UC, status post total proctocolectomy with
ileal pouch anal anastomosis with persistent diarrhea who
presented to outside hospital with loose bloody stools, was
found to have hemorrhage in the small bowel with a normal EGD,
status post 7 units pRBCs and with out improvement in HCTs. He
was transferred to [**Hospital1 18**] for further intervention.
.
# Anemia. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-intestinal bleed from small bowel.
Etiology unclear: may be secondary to an arteriovenous
malformation, or to a mechanical injury from previous endoscopy
(although no intermittant bleeding) or from a leaky anastamosis.
Alternatively may be UC flare, but wouldn??????t expect involvement
of the small bowel, although there is a question of underlying
crohns. Patient reports recent NSAID use, however not
significant amount ingested, but a bleeding ulcer was not
completely ruled out. After recieving 7 units without adequate
Hct response at the outside hospital the patient was transfused
2 additional units of pRBCs and 2 units of FFP on arrival to the
MICU. A CT??????A on admission demonstrated no active bleeding. On
HD2 the patient began actively bleeding with several episodes of
[**Last Name (NamePattern1) **] bloody diarrhea ~200 ccs per episode. 2 additional pRBCs
were administered with target Hct above 30. On HD3 after
another episode of [**Last Name (NamePattern1) **] GI bleed, a repeat CT-A demonstrated
again no active bleed - 2 more units of pRBC were transfused
after a Hct drop below 30. An upper and lower endoscopy on HD 2
revealed mild duodenitis, old blood, some mild ulcerations of
small bowel and mild proctitis. No source of bleeding was
identified. A push through enteroscopy was performed on HD 3.
The upper GI tract was visualized to the middle of the ileum and
all appeared normal with no sign of active or prior bleed. It
was felt the site of bleeding was either in the remaining part
of the bowel not visualized or that the site of bleeding had
healed. The patient was scheduled for an outpatient swallow
endoscopy with GI, and observed for 24 more hours for active
bleeding and Hct drops below 30. Pt's Hct remained stable, and
on HD4, pt was discharged home with close GI follow-up for
small-bowel follow-through and capsule endoscopy.
.
# Moderate Resting Left Ventricular Outflow Tract Obstruction:
The patient presented with a systolic murmor thought to be a
high flow murmur. An echo from an outside hosptial in [**12/2099**]
reported a normal LV systolic function with high velocity flow
consistent with mild aortic stenosis or high cardiac output and
mild left ventricular hypertrophy. A transthoracic echo on HD
3--requested to investigate the patient's dyspnea on exertion
and possible endocarditis with emboli to bowel--reported severe
left ventricular outflow tract obstruction due to systolic
anterior motion of the anterior mitral leaflet; no vegetations
seen. Cardiology was consulted and recommended outpatient
followup. Recommendations for future management, given the
patient's symptoms at baseline and the physical nature of his
work, included the addition of a betablocker or verapamil when
stable from a bleeding perspective. The patient will follow up
with Dr. [**Last Name (STitle) 45513**] or in the [**Hospital1 18**] cardiology clinic.
.
# UC. The patient reports his UC has been stable for years. ESR
of 3 and CRP of 3.1 not concerning for active UC flare.
.
# Anxiety. The patient expressed anxiety throughout the
admission. Ativan was given as a sleep aid. Wellbutrin was
held secondary to patient's unstable Hct on hematocrit. Pt can
be re-started on Wellbutrin as outpatient upon follow-up with
PCP.
.
Medications on Admission:
- ibuprofen prn
- advair prn sob/wheezing, does not take regularly
- wellbutrin, stopped 2 mo ago, he feels he did not need it
(anxiety)
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastrointestinal bleed, unknown source; Left
ventricular outflow obstruction.
Secondary: Ulcerative coilitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
No signs of active bleeding, benign abdominal examination.
Cardiac exam notable for III/VI holosystolic murmur loudest at 2
LICS and lightheadedness with ambulation.
Discharge Instructions:
You were admitted to [**Hospital1 18**] from [**Hospital 1263**] Hospital for further
evaluation of your gastrointestinal (GI) bleeding. You
underwent multiple investigations to determine the source of
bleeding, which were negative (upper endoscopy, pouchoscopy,
ileoscopy, pushtrhough endoscopy, CTA abdomen/pelvis). You
received multiple blood transfusions and your blood levels
stabilized but you had significant amounts of blood in your
stool.
Your bleeding from stool has stopped but you are still at a very
high risk of bleeding. It was felt that your bleeding may have
been due to a small injured blood vessel or an ulcer that had
healed (you were on ibuprofen which increases risk of bleeding).
You were discharged home with instructions to return to the
hospital if you have bloody stools again.
You MUST NOT take NSAIDS (aspirin, ibuprofen, naprosy or the
like) drugs as this will increase your risk of bleeding.
In addition, you were found to have a heart murmur and outflow
obstruction from your ventricle. This was felt to be due to an
abnormal valve in your heart. You will need to follow up with
a cardiologist. You can call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45513**] ([**Telephone/Fax (1) 56286**] to
arrange a follow up appointment or alternatively please call the
office of Dr. [**Last Name (STitle) **] at [**Hospital1 18**] to make an appointment, you were
provided with his contact information. [**Name2 (NI) **] will need to be on a
medication for your heart, once your bleeding problem has
resolved.
Should you develop any of the symptoms listed below, please call
your doctor or go to the emergency room.
Please follow up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 25350**] within
one
week of discharge from the hospital.
Please follow up with your Gastroenterologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7493**] at [**Hospital 1263**] Hospital, call ([**Telephone/Fax (1) 56287**] to arrange an
appointment.
You were started on Protonix 40mg twice daily by mouth.
You do not need bacterial endocarditis prophylaxis.
Followup Instructions:
see above
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"556.9",
"578.9",
"429.9",
"300.00",
"424.0",
"V44.2",
"535.60",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10042, 10048
|
5930, 9664
|
366, 427
|
10211, 10211
|
3746, 5907
|
12741, 12890
|
2917, 3178
|
9852, 10019
|
10069, 10190
|
9690, 9829
|
10529, 12718
|
3193, 3727
|
282, 328
|
455, 2253
|
10226, 10505
|
2275, 2671
|
2687, 2901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,018
| 136,493
|
45794
|
Discharge summary
|
report
|
Admission Date: [**2199-8-17**] Discharge Date: [**2199-8-22**]
Service: MED
Allergies:
Penicillins / Zocor / Quinidine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Chest pain for 3 three hours
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. [**Known lastname 2455**] is an 86 y/o male with a h/o CAD (MI x 2, CABG [**2190**]),
PAF s/p ablation and pacer, CRI (Cr baseline is 3), UGIB ([**2155**]
and [**2162**] [**2-4**] PUD), who developed his usual anginal chest pain
while he was at rest, he was taken to an OSH where the pain was
quickly relieved with 3 sublingual NTG. Workup, however,
revealed an UGIB (NG lavage with and guiaic positive) and a Hct
10 points below his baseline (the patient was recently started
on warfarin for his afib). His initial ECG revealed ST
depression in I, avL, and V2-V5 with afib, Tn was .33; afib has
since resolved, ST changes now read as non-specific. He denies
any PUD sx over many years now. He currently denies anginal sx,
sob, abd pain, n/v/d, fever/chills. Says he generally feels
weak all over. He denies any hematemesis, melena, or
hematochezia over the last few months.
Past Medical History:
1. Myocardial Infarction x 2.
2. CABG in [**2190**] (LIMA-LAD, SVG-OM and SVG-RPDA).
2. Cath [**2196**]: Severe Native 3VD, Unsuccessful attempts to cross
the distal RCA.
3. Atrial Fibrillation s/p AVN Ablation.
4. Pacemaker.
5. Peripheral Vascular Disease.
6. Diverticulosis s/p Left Hemicolectomy.
7. Prostate Cancer, s/p XRT - Lupron, c/b radiation proctitis.
8. Malignant Colon Polyp.
9. Gout.
10. Hypercholesterolemia - intolerant of statins.
11. Upper GI Bleed secondary to PUD.
12. COPD.
13. Hypertension.
14. Chronic Renal Insufficiency.
15. Anemia in setting of Chronic Kidney Disease.
16. Secondary Hyperparathyroidism
Social History:
Lives with wife, smokes a pipe, occasional etoh use.
Family History:
Non-contributory
Physical Exam:
Tm 98.2/Tc 96.1, bp 140/47 (117-162/47-67), hr 66 61-74, rr 18
spo2 100% on 2lnc (99% ra)
gen- sleepy but easily rousable a&o male with slow speech in NAD
heent- anicteric sclera, eomi, op clear with mmm
cv- rrr, s1s2, [**3-9**] systol murmur loudest at apex, goes to axilla
pul- good bilat air movement, bibasilar rales, scattered ronchi
abd- soft, nt, nabs
extrm- 2+ pitting edema in right ankle, 2+ radial and dp pulses
neuro- a&ox3, fluent but slow speech, approriate affect, cn
II-XII intact, motor [**5-8**] distal and prox UE, [**4-8**] prox LE, [**5-8**]
distal LE, sensation intact to light touch
Pertinent Results:
[**2199-8-17**] 09:35AM BLOOD WBC-9.5 RBC-2.46*# Hgb-7.5*# Hct-22.3*#
MCV-91 MCH-30.3 MCHC-33.5 RDW-15.1 Plt Ct-236
[**2199-8-18**] 02:45AM BLOOD WBC-9.4 RBC-3.40*# Hgb-10.6*# Hct-29.8*
MCV-88 MCH-31.2 MCHC-35.6* RDW-15.2 Plt Ct-191
[**2199-8-19**] 09:23PM BLOOD Hct-33.2*
[**2199-8-20**] 01:45PM BLOOD WBC-9.1 RBC-3.70* Hgb-11.2* Hct-31.7*
MCV-86 MCH-30.4 MCHC-35.4* RDW-15.9* Plt Ct-195
[**2199-8-21**] 05:43AM BLOOD WBC-8.6 RBC-3.62* Hgb-10.9* Hct-31.1*
MCV-86 MCH-30.2 MCHC-35.2* RDW-16.1* Plt Ct-197
[**2199-8-17**] 09:35AM BLOOD Neuts-89.4* Bands-0 Lymphs-6.1* Monos-3.1
Eos-1.0 Baso-0.3
[**2199-8-21**] 05:43AM BLOOD PT-13.7* PTT-34.1 INR(PT)-1.2
[**2199-8-21**] 05:43AM BLOOD Plt Ct-197
[**2199-8-17**] 09:35AM BLOOD Glucose-178* UreaN-125* Creat-3.3* Na-135
K-4.6 Cl-107 HCO3-16* AnGap-17
[**2199-8-21**] 05:43AM BLOOD Glucose-83 UreaN-77* Creat-2.5* Na-139
K-4.0 Cl-110* HCO3-19* AnGap-14
[**2199-8-17**] 09:35AM BLOOD CK(CPK)-27*
[**2199-8-17**] 03:30PM BLOOD CK(CPK)-50
[**2199-8-17**] 09:35AM BLOOD cTropnT-0.16*
[**2199-8-17**] 03:30PM BLOOD CK(CPK)-50
[**2199-8-17**] 03:30PM BLOOD cTropnT-0.33*
[**2199-8-18**] 02:45AM BLOOD CK(CPK)-30*
[**2199-8-18**] 02:45AM BLOOD CK-MB-NotDone cTropnT-0.72*
[**2199-8-18**] 07:10AM BLOOD CK-MB-NotDone cTropnT-0.81*
[**2199-8-18**] 01:30PM BLOOD CK(CPK)-83
[**2199-8-18**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.87*
[**2199-8-18**] 10:00PM BLOOD CK(CPK)-74
[**2199-8-19**] 03:23AM BLOOD CK(CPK)-64
[**2199-8-20**] 09:10AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Mr [**Known lastname 2455**] presented to the ED, ECG showed afib and ST depression
in V2-V5, initial Tn was 0.18, and he was found to have a Hct of
22, guiaic positive. He was admitted to the MICU where he was
given six units of pRBC's; his chest pain and ST changes
gradually resolved following transfusions, and his Hct increased
to 33.
1.)UGIB -- Given pt's history and lack of blood in stool/emesis,
this was probably secondary to peptic ulcer disease. He had Hct
checked twice daily, and it remained stable at 31-33. He was
treated with pantoprazole, and on the day of discharge, H.
pylori was negative. Would check Hct every other day at rehab.
The plan is for him to follow up with Dr. [**First Name (STitle) 437**] as an outpatient
for an EGD in two weeks.
2.)Chest pain with elevated Tn's and ECG significant for lateral
ischemia -- This pt has a strong cardiac history with most
recent cath in [**2196**] showing severe diffuse disease. The
elevated tn's could have been exaggerated by the pt's CRI, but
the velocity of increase and the level they eventually reached
(0.83) indicate that this probably represented a NSTEMI. By the
time of discharge, Mr. [**Known lastname 2455**] had been asymptomatic for three
days, with resolvution of ECG changes. He was kept on his
metoprolol (dose increased to 100mg twice daily) and isorsobide
mononitrate, with no ASA or heparin due to GI bleed. Plan to
hold all antiplatelet agents until he has an EGD to assess for
GI pathology.
3.)Afib -- Pt has chronic afib with past cardioversions, on
amiodarone. He is rate controlled with metoprolol. It was felt
during the admission that given his enlarged left atrium and the
fact that he had been in afib without anticoagulation for two
days, cardioversion would not be done. Given his large hct drop
GI bleed, anticoagulation will be held until pt is evaluated by
EGD, as risk of thromboembolic disease is felt to be less than
risk of repeat GI bleeding. He remained in afib throughout most
of the admission.
4.)Diastolic dysfunction (E/A 0.89 on [**2199-8-19**]) -- This was found
on his inpatient echocardiogram. The goal was to control rate
with metoprolol to allow for adequate diastolic filling. Plan
for follow-up with his cardiologist.
5.)CRI -- Pt has a history of renal insufficiency, was admitted
and remained at baseline Cr of around 3 throughout admission.
He was seen by his nephrologist who inicated no need for
dialysis, follow-up with Dr. [**Last Name (STitle) 1860**].
Medications on Admission:
ALBUTEROL 90MCG--2 puff twice a day
AMIODARONE HCL 200MG--One every day
EPOETIN ALFA [**2195**] U/ML--As directed
FLOMAX 0.4MG--One at bedtime
FLOVENT 44MCG--2 puff twice a day
FOLIC ACID 1MG--One every day
IMDUR 60MG--Two tabs every day
ISORDIL 10MG--One three times a day
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO QD (once a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Upper GI Bleed.
2. Blood Loss Anemia.
3. NSTEMI - Demand Ischemia.
4. Right Lower Extremity Edema NOS - Negative LENI.
Secondary:
1. Myocardial Infarction x 2.
2. CABG in [**2190**] (LIMA-LAD, SVG-OM and SVG-RPDA).
2. Cath [**2196**]: Severe Native 3VD, Unsuccessful attempts to cross
the distal RCA.
3. Atrial Fibrillation s/p AVN Ablation.
4. Pacemaker.
5. Peripheral Vascular Disease.
6. Diverticulosis s/p Left Hemicolectomy.
7. Prostate Cancer, s/p XRT - Lupron, c/b radiation proctitis.
8. Malignant Colon Polyp.
9. Gout.
10. Hypercholesterolemia - intolerant of statins.
11. Upper GI Bleed secondary to PUD.
12. COPD.
13. Hypertension.
14. Chronic Renal Insufficiency.
15. Anemia in setting of Chronic Kidney Disease.
16. Secondary Hyperparathyroidism
Discharge Condition:
Stable, Hct 31
Discharge Instructions:
Please return to the emergency department for chest pain,
shortness of breath, blood in your stool or vomit or dark-tarry
stools, fainting, fever or chills.
Take medications as prescribed.
Follow-up as below.
Followup Instructions:
Call your cardiologoist Dr [**Last Name (STitle) 120**] at [**Telephone/Fax (1) 127**] for an
appointment in [**3-7**] weeks.
Provider: [**Known firstname **] [**Last Name (NamePattern4) 12427**], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2199-9-3**] 1:00
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:[**2199-8-22**] 3:00
Provider: [**First Name8 (NamePattern2) 8913**] [**Last Name (NamePattern1) 8914**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2199-9-10**] 1:00
|
[
"427.31",
"414.01",
"403.91",
"276.2",
"V10.05",
"531.40",
"285.1",
"410.71",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7792, 7862
|
4201, 6704
|
261, 286
|
8677, 8693
|
2598, 4178
|
8952, 9696
|
1938, 1956
|
7029, 7769
|
7883, 8656
|
6730, 7006
|
8717, 8929
|
1971, 2579
|
193, 223
|
314, 1200
|
1222, 1852
|
1868, 1922
|
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