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16,897
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22998
|
Discharge summary
|
report
|
Admission Date: [**2129-1-19**] Discharge Date: [**2129-2-1**]
Date of Birth: [**2062-5-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
Right colectomy
History of Present Illness:
66 year old male with a past medical history significiant for
CREST, [**Last Name (un) 8061**], HTN and anemia presents with bright red blood
per rectum s/p syncopal episode with a SBP in the 60s.
Transferred from the OSH ([**Hospital 5871**] Hospital) and resuscitated
with 3 units PRBCs. Colonoscopy at OSH was deficient being
unable to get past the hepatic flexure secondary to copious
blood. Tagged RBC scan at OSH shows uptake in the cecum.
Currently reports some abdominal cramping, but much improved.
Denies chest pain, lightheadedness, shortness of breath or any
other changes. Appetite has been good until this AM. Patient
did not take home meds this AM.
Past Medical History:
S/p cecal polypectomy [**1-12**] (Dx=Adenoma)
Aortic stenosis (mod/severe, EF >55%)
CREST syndrome
Sleep apnea
GERD
S/p Cholecystectomy
Hernia
Social History:
No h/o of smoking or EtOH
Married, real estate [**Doctor Last Name 360**],
Physical Exam:
VS: T=96.6, BP=95/52, P=95, R=16
Gen: Lethargic, but arousable and answers questions
appropriately
HEENT: OP-clear, MM-dry, supple, no LAD
CV: RRR III/VI systolic murmur
Pulm: CTA bilaterally
Abd: soft, obese, NT/ND, +BS
Ext: no CCE
Rectal: Guaiac positive, BRBPR
Pertinent Results:
[**2129-1-19**] 11:40PM WBC-14.3* RBC-3.29* HGB-8.5* HCT-25.0*
MCV-76* MCH-25.8* MCHC-34.0 RDW-16.2*
[**2129-1-19**] 11:40PM NEUTS-81.3* BANDS-0 LYMPHS-14.2* MONOS-4.4
EOS-0.1 BASOS-0.1
[**2129-1-19**] 11:40PM PLT SMR-LOW PLT COUNT-138*
[**2129-1-19**] 11:15PM GLUCOSE-151* UREA N-22* CREAT-1.0 SODIUM-147*
POTASSIUM-3.4 CHLORIDE-123* TOTAL CO2-21* ANION GAP-6*
[**2129-1-19**] 11:15PM ALT(SGPT)-13 AST(SGOT)-13 LD(LDH)-99 ALK
PHOS-36* TOT BILI-0.4
[**2129-1-19**] 11:15PM CALCIUM-5.8* PHOSPHATE-3.2 MAGNESIUM-1.3*
[**2129-1-19**] 11:15PM PT-14.6* PTT-29.3 INR(PT)-1.3
[**2129-1-19**] 11:15PM FIBRINOGE-120*
Cardiology Report ECHO Study Date of [**2129-1-21**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are
moderately thickened with restricted motion. There is moderate
to severe aortic valve stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are structurally normal.
Trivial mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CHEST (PRE-OP PA & LAT) [**2129-1-23**] 3:43 PM
Small bilateral pleural effusions and left basilar atelectases.
No evidence for CHF.
PATHOLOGY [**2129-1-24**]: Right Colon
Residual adenoma and changes consistent with prior biopsy.
Separate adenoma (0.8 cm).
Ileal and colonic resection margins; no diagnostic abnormalities
recognized.
Appendix with fibrous obliteration of the lumen.
Fourteen (14) reactive lymph nodes.
[**2129-1-19**] 11:40PM PLT SMR-LOW PLT COUNT-138*
Brief Hospital Course:
The patient was transferred from an outside hospital gi unit
where a polyp was partially removed from th cecum. He was
transfused for some bleedig that stabilized. After preop
evaluation, he was taken for right colectomy on [**1-24**]. On [**1-25**], he
was doing welll. He deveoloped a post op wound cellulitis,
treated with antibiotics. He developed loose stools but the
erythema improved and he was discharged on [**2-1**].
Medications on Admission:
MEDS on transfer:
prednisone 2.5mg PO QD
Pepcid 20mg IV Q12
Hydrocortisone 100mg PO Q8
MEDS at home:
verapamil 240mg PO QD
lisinopril 40mg PO QD
ASA 81mmg PO QD
HCTZ
Prednisone 2.5mg PO QD
zantac 150mg [**Hospital1 **]
calcium
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-28**] Sprays Nasal
TID (3 times a day) as needed.
3. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
Disp:*80 Tablet(s)* Refills:*0*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Verapamil HCl 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right colonic Adenoma
CREST
GERD
Sleep Apnea
Discharge Condition:
Good
Discharge Instructions:
Please keep wound area clean and dry. Take all medications as
prescribed. Seek medical attention if you experience fever,
chills, nausea, vomiting, or increased abdominal pain.
Followup Instructions:
Please call Dr.[**Name (NI) 1863**] office at [**Telephone/Fax (1) 1864**] within the
first few days after discharge to schedule a follow-up
appointment.
|
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80,190
| 199,305
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37923
|
Discharge summary
|
report
|
Admission Date: [**2104-8-26**] Discharge Date: [**2104-8-28**]
Date of Birth: [**2083-5-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Nausea and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
21 year old female with type I DM diagnosed age 14, presented
with nausea and hyperglycemia. She had discontinued her insulin
pump this summer because the pump was disconnecting with
activity. She transitioned herself to basal bolus regimen, but
has been having trouble staying with her schedule since college
began a few weeks ago. She has been having epigastric pressure
the past two weeks, and this morning had nausea, headache, and
fatigue with decreased appetite and increased abd pressure. She
noticed her BS 400's at home and went to the ED. Had nonbloody
emesis en route to ED. She denies fever, cough, sore throat. She
denies chest pain, SOB, or chest pressure. Denies diarrhea.
Denies dysuria, frequency, or urgency. No vaginal dc, LMP two
months ago, no oral contraceptive in past year, irregular menses
since then.
In the ED initial VS were: 98.9 122 112/78 30 97%
Remained afebrile, remained tachycardic, abdomen soft.
Initial K 4.6, AG 32, HCO3 12, BG 444.
ALT 103, AST 99, Alk Ph 200, T Bili 0.2, Alb 4.4, Lipase 28.
UA with glucose 1000, ketones 150, 8WBC, few bact, trace LE, 2
epi UCG -ve
WBC 6.4, H/H 15.3/46.7, MCV 101, platelets 444
RUQ US-> hepatomeg, no gallstone, no acute process
Given 40 IV K, 10U insulin, started on insulin gtt, given 2.5L
NS before transfer and 1gm cefriaxone.
Repeat K Glucose fell to 161 on insulin gtt, D5W started,
insulin gtt stopped.
On arrival to the MICU, she feels like her normal self, except
with some epigastric discomfort. She does not feel short of
breath.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies diarrhea,
constipation, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Type I DM, diagnosed age 14, only prior episode DKA at 18
secondary to EtOH use
Social History:
Social History: College student, not currently sexually active,
no history of STD's, uses protection.
- Tobacco: Never
- Alcohol: 3-4 beers per weekend, no binging
- Illicits: Denies, including denies IVDU
Family History:
Family History:
Cousin and grandfather with [**Name (NI) 17095**], father had gallbladder removed
Physical Exam:
Vitals: T:98.9 BP: 128/109 P: 115 R: 33 O2:97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
round/reactive
Neck: supple, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: No accessory muscle use, good air movement, bibasilar
crackles, no wheezes, rales, ronchi
Abdomen: Soft, some epigastric tenderness to deep palpation,
non-distended, hypoactive bowel sounds, no organomegaly.
Ext: warm, well perfused, 2+ pulses bilaterally, no clubbing,
cyanosis or edema
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation
Pertinent Results:
[**2104-8-26**] 05:27PM BLOOD WBC-6.4 RBC-4.64 Hgb-15.3 Hct-46.7
MCV-101* MCH-33.0* MCHC-32.9 RDW-13.0 Plt Ct-444*
[**2104-8-26**] 05:27PM BLOOD Neuts-51.8 Lymphs-43.3* Monos-3.1 Eos-0.7
Baso-1.0
[**2104-8-26**] 08:22PM BLOOD PT-9.2* PTT-27.3 INR(PT)-0.8*
[**2104-8-26**] 05:27PM BLOOD Glucose-520* UreaN-12 Creat-0.9 Na-135
K-4.6 Cl-91* HCO3-12* AnGap-37*
[**2104-8-26**] 05:27PM BLOOD ALT-103* AST-99* AlkPhos-200* TotBili-0.2
[**2104-8-26**] 05:27PM BLOOD Lipase-28
[**2104-8-26**] 05:27PM BLOOD Albumin-4.4
[**2104-8-26**] 10:43PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-34* pCO2-33*
pH-7.17* calTCO2-13* Base XS--16
[**2104-8-26**] 07:49PM BLOOD Lactate-2.3* K-3.6
[**2104-8-26**] 05:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.020
[**2104-8-26**] 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2104-8-26**] 05:50PM URINE RBC-<1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-2
[**2104-8-26**] 05:50PM URINE UCG-NEGATIVE
Brief Hospital Course:
21 yo F type I DM presenting with DKA.
MICU Course:
# DKA: Secondary to noncompliance. Not pregnant with neg HCG,
CXR clear for PNA, EKG unconcerning for MI, denies drug use. K
not sig elevated, anion gap closed with insulin bolus and gtt.
Sugars dropped swiftly prior to transfer to MICU, 444->141, gtt
was paused, sugars returned to 300's after gtt was restarted,
remained on ICU insulin protocol thereafter, pH 7.17.
Transitioned to SQ insulin with overlap 2hrs on gtt. Maintained
on D5 1/2NS with 40mEq K at 125/hr. [**Last Name (un) **] consulted and
recommended Lantus 27, HISS 5 units breakfast, 4 before lunch, 7
before dinner, correct 1:40 above 120, self reported carb
consumption 40g with breakfast, 30 with lunch, 60 with dinner.
Following transition to diabetic PO diet the patient's anion gap
was noted to remain closed and the patient was without
complaints.
# ?UTI: Patient with 7WBC on initial UA, received dose of
Ceftriaxone. Patient was asymptomatic and urine culture was
negative. No plan for further antibiotics.
Transition Issues:
# Transaminitis: Could be secondary to EtOH or critical illness
in setting of DKA alcohol. Elevated GGT, Fe studies normal, Hep
B Ab positive, Hep B SAg neg, HepC Ab neg, acetaminophen neg.
Transaminases trended down during stay. Would recommend
re-evaluation of liver function tests in [**12-17**] months.
# Macrocytosis: Etiology unclear, not anemic. Considering
possible liver disease in context of transaminitis and DM. Would
recommend re-evaluation in [**12-17**] months.
Transitional Issues:
Follow up with PCP
Medications on Admission:
Lantus 27 units at 6PM
NovaLog SS
Discharge Medications:
Lantus 27 units at 6PM
NovaLog SS
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please continue to take your insulin as perscribed with pre-meal
insulin doses of 5units before breakfast, 4 before lunch and 7
before dinner. Please continue to carefully monitor your blood
glucose level. Call your doctor or return to the hospital if
you have any of the warning signs listed below or any
new/concerning complaints.
Followup Instructions:
[**Last Name (un) **] Diabetes Center, within 1 week
Primary Care Physician, [**Name Initial (NameIs) 176**] 1-2 months
|
[
"289.89",
"V15.81",
"250.13",
"790.4",
"V45.85"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6152, 6158
|
4432, 5969
|
321, 327
|
6225, 6225
|
3401, 4409
|
6734, 6857
|
2656, 2740
|
6094, 6129
|
6179, 6204
|
6036, 6071
|
6376, 6711
|
2755, 3382
|
5990, 6010
|
1892, 2296
|
263, 283
|
355, 1873
|
6240, 6352
|
2318, 2399
|
2431, 2624
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,597
| 154,083
|
19179
|
Discharge summary
|
report
|
Admission Date: [**2159-7-5**] Discharge Date: [**2159-7-14**]
Date of Birth: [**2110-8-4**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: This [**Hospital1 190**] admission for this 49-year-old male was
occasioned by a jump and fall of [**2070**] feet on to his feet and
lower back.
He was seen and evaluated at an outside hospital, and a
computed tomography evaluation demonstrated an L1 burst
fracture with 50% retropulsion. The patient was
neurologically intact at the outside hospital. He was not
started on steroids. He also sustained a right distal radius
fracture and complained minimally of back pain here. Also,
he was on Coumadin on admission.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Mitral valve repair with a mechanical heart valve.
2. Coronary artery disease; status post coronary artery
bypass graft.
3. Hypercholesterolemia.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 15. His blood pressure was
144/79. His temperature was 98. The trachea was midline.
He had anicteric sclerae. He had bilateral breath sounds
that were audible with no chest wall tenderness. His abdomen
was soft. The pelvis was stable. Rectal examination
revealed decreased sphincter tone with heme-positivity. His
right wrist and hand were in a splint. Upper extremity
strength was [**4-16**]. Motor and sensory examinations were
intact. He had weak hip flexors at 3/5 and [**3-17**] knee flexors.
Plantar and dorsal sensation were intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: His hematocrit
was 26.9 on admission.
BRIEF SUMMARY OF HOSPITAL COURSE: He was consulted on by
Spine/Orthopaedics and admitted to the Trauma Surgical
Intensive Care Unit. The L1 burst fracture was noted with
some canal impingement, and he continued to be intubated and
sedated.
He then underwent spinal decompression and right radial
pinning. He was awake and alert on postoperative day four.
He was transfused as well.
On [**7-12**], he was comfortable. An Occupational Therapy
consultation was performed. The patient denied any chest
pressure. He also had some visual hallucinations.
On day one, it was felt he could have his chest tube
withdrawn. On [**7-14**], he had no complaints. A TLSO brace
was awaited by the team. On [**7-14**], he had a line change
over a wire and had an arrest with a decreased blood
pressure. He was found to have pulseless electrical
activity. Cardiopulmonary resuscitation was started
according to ACLS protocol and carried on for 30 minutes.
This was discontinued when he failed to respond.
DISCHARGE STATUS: Deceased.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 12891**]
MEDQUIST36
D: [**2159-11-13**] 13:27
T: [**2159-11-13**] 19:38
JOB#: [**Job Number 52315**]
|
[
"860.0",
"E987.1",
"813.42",
"414.01",
"427.9",
"V45.81",
"806.20",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"96.71",
"81.05",
"34.04",
"77.79",
"81.04",
"03.53",
"79.12",
"96.6",
"77.99"
] |
icd9pcs
|
[
[
[]
]
] |
1731, 3007
|
168, 690
|
713, 1701
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
757
| 149,766
|
52823
|
Discharge summary
|
report
|
Admission Date: [**2182-8-6**] Discharge Date: [**2182-8-10**]
Date of Birth: [**2137-8-13**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillins / Ampicillin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 44 y/o F with PMH significant for
oligoastrocytoma s/p resection chemo and stereotactic
radiosurgery for recurrence, seizure d/o, schizophrenia, DM and
HTN initially presenting with seizures to OSH. Per Mom, pt was
in her usual state of health when she fell asleep while sitting
in a chair. Pt woke up shortly after and was disoriented, but
could recognize her mom. She than became unresponsive, walking
aimlessly through the house, and again fell asleep. According to
Mom, she had no focal movements consistent with a seizure but
had drinking a lot of fluids, consisting of 10cans of diet coke
and 4-16oz bottles of water. Pt usually drinks a great deal of
fluids and had a similar episode of MS changes 6mos prior, when
she was found to be hyponatremic. Mom became concerned and
brought pt to OSH. En route to OSH, she did have bladder
incontinence.
At OSH had episode of emesis. CT of head showed no signs of
bleed, but increased attenuation of frontal lobe c/w prominant
sulci, encephalomalecia of right post temporal lobe. Her FS at
OSH was 270 and Na was 116, she was given ativan 2mg IV,
hydrocortisone 100mg and zofran. She was to have started temodar
her chemo last night. She was then transferred to [**Hospital1 18**] ED.
At [**Hospital1 18**], she was febrile to 102, with leukocytsosis, and
elevated lactate with slightly improved Na to 118. She was
started on 1L of NS for hydration and 1L NS with IV Mg 4gm. LP
was attempted, but unsuccessful, she was started on ceftriaxone
2gm IV, vancomycin 1gm IV, Flagyl 500mg IV and sent to [**Hospital Unit Name 153**] for
monitoring.
[**Hospital Unit Name 153**] Course: Empiric ABx continued; pt given NS & placed on
fluid restriction w/subsequent correction of sodium; LP
successfully re-attempted by Pain Service; EEG done; MR
scheduled; keppra restarted; risperdal restarted; glyburide &
lisinopril held & pt placed on sliding scale.
Past Medical History:
1. Anaplastic oligoastrocytoma in R temporal lobe: s/p resection
in [**2179**]; s/p 12 cycles of Temodar; s/p stereotactic radiosurgery
on [**2181-12-26**] for recurrence
2. Delayed developmentally as a child
3. Autism
4. Hypercholesterolemia
5. NIDDM??????10 yrs, last HBA1c~6
6. HTN
7. Psychosis/schizophrenia?: diagnosed w/schizophrenia
w/childhood schizophrenia by Dr. [**Last Name (STitle) 55381**]; seen by Dr. [**Last Name (STitle) 55381**]
for 20yrs; auditory hallucinations at baseline; last
hospitalized in [**2169**] for suicide attempt
8. Generalized tonic-clonic seizure??????1: per mom prior to tumor
resection; remote seizure hx at 12 y/o
Social History:
Lives with mom, graduated from [**Male First Name (un) 1573**] community college, no
tob/etoh/drugs, patient was knew all her meds and doses and was
self-administering them, doing her finances, and conducting ADLs
until 1.5 weeks ago prior to admission. Walks unaided. Had been
working prior to brain tumor.
Family History:
DM, HTN, Breast cancer, prostate cancer and
brother--schizophrenia
Physical Exam:
VS: Tc 100.4ax/102.0 R in ED BP 127/80 P 125 Sat 96%on 5LNC
GEN awakw, moving all extremities moaning about water
HEENT PERRL, dilated to 5mm bilaterally, clear OP, MMM
CHEST CTAB, poor air mvmt bilaterally
CV RRR, tachycardic, no murmrus
ABD soft, obese, nontender, +BS
EXT trace edema bilaterally, 2+DP pulses bilterally
Neuro: large neck, no neck stiffness, 2+reflexes bilterally,
withdraws to Babinskis', no clonus
.
Pertinent Results:
LABS:
On admission:
[**2182-8-6**] 09:50AM WBC-17.8*# RBC-3.93*# HGB-11.8*# HCT-30.7*#
MCV-78*# MCH-30.0 MCHC-36.8* RDW-13.5
[**2182-8-6**] 09:50AM NEUTS-89.2* BANDS-0 LYMPHS-7.0* MONOS-3.5
EOS-0.2 BASOS-0.1
[**2182-8-6**] 09:50AM PLT SMR-NORMAL PLT COUNT-321
[**2182-8-6**] 07:45AM PT-13.7* PTT-19.1* INR(PT)-1.2
[**2182-8-6**] 07:45AM GLUCOSE-207* UREA N-4* CREAT-0.6 SODIUM-116*
POTASSIUM-4.4 CHLORIDE-79* TOTAL CO2-21* ANION GAP-20
[**2182-8-6**] 08:54AM LACTATE-3.6*
[**2182-8-6**] 09:50AM ALT(SGPT)-50* AST(SGOT)-42* ALK PHOS-90
AMYLASE-47 TOT BILI-0.7
[**2182-8-6**] 09:50AM LIPASE-29
[**2182-8-6**] 01:54PM OSMOLAL-258*
[**2182-8-6**] 01:54PM TSH-0.63
[**2182-8-6**] 01:54PM CORTISOL-18.6
[**2182-8-6**] 09:56PM TYPE-ART PO2-108* PCO2-31* PH-7.42 TOTAL
CO2-21 BASE XS--2 INTUBATED-NOT INTUBA COMMENTS-QNS FOR LA
.
Urine on admission
[**2182-8-6**] 04:25AM URINE OSMOLAL-556
[**2182-8-6**] 04:25AM URINE HOURS-RANDOM CREAT-35 SODIUM-119
POTASSIUM-42 CHLORIDE-105 AMYLASE-88 [**Doctor First Name 674**]/CREAT-3.
.
Labs on discharge:
[**2182-8-10**] 06:05AM BLOOD WBC-10.9 RBC-4.21 Hgb-12.3 Hct-36.4
MCV-87 MCH-29.3 MCHC-33.8 RDW-14.0 Plt Ct-301
[**2182-8-10**] 06:05AM BLOOD Glucose-161* UreaN-10 Creat-0.4 Na-140
K-4.9 Cl-98 HCO3-29 AnGap-18
.
Spinal fluid: NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes, neutrophils and monocytes.
.
EKG: NSR at 96bpm, no st/twave changes, 1mm PR depressions in
II, III
.
CXR: Mild increase in opacity of the right lower lung medially
could represent atelectasis. Aspiration cannot be excluded.
Upper lungs clear. Heart size normal. No pleural abnormality.
.
MRI from [**2182-7-5**]: Status post right temporal lobe brain tumor
resection, with cystic CSF space at the surgical site.
Enlarging mural nodule with
enhancement, measuring 6 mm in diameter, which is worrisome for
progression of previously diagnosed anaplastic astrocytoma.
.
MRI from [**2182-8-9**]:IMPRESSION: Nodules of enhancement along the
posterior margin of the surgical cavity in the right posterior
lobe, slowly increasing in size most notably since the exam of
[**2182-1-19**]. These findings are concerning for recurrence.
EEG:
FINDINGS:
ABNORMALITY #1: There is a continuous mixed delta and theta
frequency
slowing over the left temporal region.
BACKGROUND: Is a low voltage 9 Hz alpha frequency rhythm with
normal
anterior-posterior voltage gradient.
HYPERVENTILATION: Was not performed because of the patient's
clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Was not performed because this
was a
portable study.
SLEEP: Normal transitions of the sleep architecture were not
seen.
CARDIAC MONITOR: Sinus tachycardia with a rate of 102 bpm.
IMPRESSION: This is an abnormal portable EEG obtained in
drowsiness due
to the presence of continuous mixed delta and theta frequency
slowing
over the left temporal region. Anatomical correlation is
recommended.
No epileptiform discharges were seen. A tachycardia was noted.
.
Brief Hospital Course:
[**Hospital Unit Name 153**] Course: In the [**Hospital Unit Name 153**], empiric antibiotics were continued.
Pt's hyponatermia was thought to be secondary to a combination
of dehyration and polydipsia. The patient was given normal
saline and placed on fluid restriction with subsequent
correction of her sodium. Pt's mental status was most likely
secondary to hyponatremia; and it gradually improved with
correction of serum sodium. An infectious work up was negative,
with negative blood, urine, and csf fluid. CSF fluid also
revealed no malignant cells and no growth of bacteria. An EEG
was performed which showed no seizure activity. Pt was initially
given a dilantin load; followed by reinitiation of keppra,
overlapping with dilantin. Risperdal was also restarted.
Glyburide and lisinopril were held and the patient was placed on
an insulin sliding scale. She was transferred to the general
medicine service for further care and treatment.
.
On the floor, Infectious Diseases was consulted and made the
recommendation to stop the patient's empiric antibiotics as her
CSF profile was not suggestive of bacterial meningitis. A chest
X-ray was repeated to investigate other sources of infection and
found to be negative. Her sodium remained within normal limits
and a fluid restriction of 1500cc was imposed. Her mental status
continued to improve.
Pt was restarted on lisinopril and glyburide. A repeat MRI
showed nodules of enhancement along the posterior margin of the
surgical cavity in the right posterior lobe, slowly increasing
in size and concerning for recurrence (pt will have outpt f/u of
this). The patient's dilantin level was below 10 so she was
given an additional dose of dilantin 500mg po. Pt was discharge
home after return to baseline mental status, normalized sodium,
on her home regimen of keppra, dilantin, and decadron with
instructions to f/u with her PCP.
Medications on Admission:
1. Lisinopril 5 mg po QD
2. Keppra 500 mg po BID
3. Glyburide 5 mg po QD
4. Lipitor 20 mg po QHS
5. Risperdal 1 mg po BID
6. Cogentin 1 mg QD
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for seizure d/o.
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Outpatient Lab Work
Dilantin level checked Monday and called to Dr.[**Name (NI) 6767**] office
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Dilantin 30 mg Capsule Sig: One (1) Capsule PO at bedtime:
take in addition to 100mg at bedtime.
Disp:*30 Capsule(s)* Refills:*2*
11. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Psychogenic polydipsia
2. Seizure disorder
3. Psychosis
4. Worsening oligoastrocytoma
5. Hyponatremia
Discharge Condition:
1. Hyponatremia resolved
2. Seizure disorder stable
3. Afebrile with stable vital signs
4. Mental status at baseline
Discharge Instructions:
1. Please go to the Emergency Room if you become short of
breath, dizzy, lightheaded, confused or have chest pain, seizure
activity, fevers/chills, or mental status changes.
2. Please make an appointment to follow up with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] in 1-2weeks.
3. Please avoid drinking caffeine containing beverages or
drinking more than 64 ounces of water a day.
4. You are not being sent home with any new medications. Please
continue taking all of your medications regularly.
Followup Instructions:
1. Please make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (call
[**Telephone/Fax (1) 108918**]) within one to two weeks.
Provider: [**Name10 (NameIs) 706**] MRI Where: [**Hospital6 29**] [**Hospital6 706**]
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-8-30**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6781**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2182-8-30**] 1:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"401.9",
"288.8",
"250.00",
"295.90",
"272.4",
"780.39",
"348.8",
"V10.85",
"276.1",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9890, 9896
|
6812, 8698
|
312, 319
|
10045, 10164
|
3824, 3830
|
10738, 11394
|
3297, 3365
|
8891, 9867
|
9917, 10024
|
8724, 8868
|
10188, 10715
|
3380, 3805
|
264, 274
|
4889, 6789
|
347, 2277
|
3844, 4870
|
2299, 2955
|
2971, 3281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,708
| 193,002
|
52302+52303
|
Discharge summary
|
report+report
|
Admission Date: [**2178-11-19**] Discharge Date: [**2178-11-24**]
Date of Birth: [**2120-6-4**] Sex: M
Service: MICU
CHIEF COMPLAINT: Shortness of breath times two days and
palpitations.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
male with a history of end stage renal disease, usually on
hemodialysis on Tuesdays, Thursdays, Saturdays but was last
dialyzed two days prior to admission secondary to the
holiday.
INCOMPLETE REPORT; DISCONNECTED
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2178-11-30**] 22:18
T: [**2178-11-30**] 22:18
JOB#: [**Job Number **]
Admission Date: [**2178-11-18**] Discharge Date: [**2178-11-24**]
Date of Birth: [**2120-6-4**] Sex: M
CHIEF COMPLAINT: Shortness of breath times two days.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
gentleman with end-stage renal disease, usually on
dialyzed two days prior to admission secondary to the
[**Holiday **] holiday, who has a history of bigeminy, on
amiodarone, history of restrictive lung disease, status post
recent admission in [**Month (only) 205**] and [**Month (only) 359**] for hypercarbia with
shortness of breath; now admitted to the Medical Intensive
Care Unit for congestive heart failure, hyperkalemia, and
status post wide complex tachycardia responsive to DC
The patient was in his usual state of health until two days
prior to admission when he had the insidious onset of
increased shortness of breath. The patient then developed
rapid onset of worsening shortness of breath and palpitations
in the evening on the day of admission. This shortness of
breath progressed, and despite taking an extra half dose of
amiodarone the shortness of breath worsened. The patient
also noted on the day of admission decreased appetite, chest
pressure, and nausea. He called emergency medical
technicians who found him to have vague chest discomfort but
a respiratory rate of 36, a saturation of 90%, and bilateral
crackles three quarters of the way up on examination. The
electrocardiogram by the emergency medical technicians showed
a wide complex tachycardia with a rate of about 180. He was
given 2 mg of Versed, 100 mg intravenous lidocaine, and 2-mg
per minute drip, and DC cardioversion at 100 joules resulting
in a sinus tachycardia with a left bundle.
The patient was brought to [**Hospital1 188**] Emergency Department, still in congestive heart
failure, but in sinus rhythm. His laboratories revealed a
potassium of 6.7. He was given calcium gluconate 2 g, 1 amp
of D-50, 8 units of regular insulin, a nitroglycerin drip,
and started on BiPAP. The patient was then admitted to the
Medical Intensive Care Unit for further management including
hemodialysis.
PAST MEDICAL HISTORY:
1. Acquired immunodeficiency syndrome diagnosed in [**2159**]; no
opportunistic infections, last CD4 was 132 and a viral load
of 15,000 in [**2178-7-25**].
2. Hepatitis B and hepatitis C with cirrhosis.
3. Human immunodeficiency virus cardiomyopathy with an
ejection fraction of 40% on an echocardiogram in [**2178-1-22**].
4. Chronic obstructive pulmonary disease with home oxygen.
5. History of pulmonary embolism and deep venous
thrombosis.
6. History of polysubstance abuse.
7. History of Coombs -positive anemia.
8. End-stage renal disease, on dialysis on Tuesday,
Thursday and Saturday.
9. Benign prostatic hypertrophy.
10. History of pancreatitis. Depression.
12. History of methicillin-resistant Staphylococcus aureus
and vancomycin-resistant enterococcus.
13. Hemorrhoids.
14. Status post left hip fracture and open reduction,
internal fixation in [**2178-9-24**].
15. History of hypercarbic respiratory failure, last in [**Month (only) 205**] and
[**2178-8-24**].
16. Obstructive sleep apnea, refused home BiPAP.
17. Severe tricuspid regurgitation and pulmonary
hypertension.
MEDICATIONS ON ADMISSION: Coumadin 1 mg p.o. q.d.,
aspirin 325 mg p.o. q.d., morphine 30 mg p.o. q.4h. p.r.n.,
oxycodone 10 mg p.o. t.i.d., Duragesic 125 q.72h.,
amiodarone 200 mg p.o. q.d., Protonix 40 mg p.o. q.d.,
Zoloft 50 mg p.o. q.d., lamivudine 20 mg p.o. q.d.,
stavudine 20 mg p.o. q.d., lactulose 30 cc p.o. t.i.d.,
Valium 5 mg p.o. t.i.d., Renagel 4 mg p.o. q.i.d.,
multivitamin, methadone 50 mg p.o. q.d., Colace 100 mg p.o.
b.i.d., Bactrim-DS 1 p.o., Lopressor 12.5 mg p.o. q.d.,
captopril 6.25 mg p.o. t.i.d.
ALLERGIES: THORAZINE leads to anaphylaxis, H2 BLOCKERS lead
to thrombocytopenia; HALDOL, CLINDAMYCIN, CODEINE lead to
rash.
SOCIAL HISTORY: The patient lives with his wife. History of
intravenous drug use, on methadone since [**2162**], history of
ethanol, history of tobacco for 20 years times two packs per
day.
REVIEW OF SYSTEMS: Per the wife, the patient is not
compliant with his diet. He has no current chest pain and
some mild shortness of breath.
PHYSICAL EXAMINATION ON PRESENTATION: On initial admission
to the Medical Intensive Care Unit revealed heart rate
was 98, blood pressure 130/54, respiratory rate 17,
temperature 96.9. In general, the patient was awake,
slightly lethargic, and conversant on BiPAP. Head, ears,
nose, eyes and throat revealed normocephalic and atraumatic.
BiPAP mask was in place. Neck was supple. Cardiovascular
revealed a regular rate and rhythm with a [**1-27**] holosystolic
murmur heard best at the apex. Lungs had bibasilar crackles
one-half of the way up. Abdomen was soft, nontender, and
nondistended, positive bowel sounds. No organomegaly.
Extremities had no clubbing, cyanosis or edema. Radial
pulses 2+, but nonpalpable dorsalis pedis and posterior
tibialis pulses, but lower extremities were warm and well
perfused.
LABORATORY DATA ON PRESENTATION: On admission white blood
cell count of 7.9, hematocrit 43.9, platelets 143. PT 30.4,
INR 6.4, PTT 58.3. Sodium 137, potassium 6.5, chloride 102,
bicarbonate 24, blood urea nitrogen of 41, creatinine 7.3,
glucose of 138. Creatine kinase #1 was 29, troponin of less
than 0.3. Calcium 8.5, magnesium 2.4, phosphate 9.4. Free
calcium of 1.24. Arterial blood gas was 7.05 for pH, PO2 93,
and O2 of 423 on FIO2 of 100%, with positive end-airway
pressure of 5, and tidal volume of 750 on BiPAP.
RADIOLOGY/IMAGING: Chest x-ray revealed mild congestive
heart failure.
Electrocardiogram in the field showed wide complex
tachycardia of 180 with a right bundle branch morphology.
Electrocardiogram in the Emergency Department showed sinus
tachycardia at 109, left axis deviation, questionable left
anterior fascicular block, nonspecific ST-T wave
abnormalities, no peaked T waves. No significant changes
from electrocardiogram of [**2178-9-21**].
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit then transferred to the floor
after he was stable.
1. CARDIOVASCULAR: The patient had an episode of wide
complex tachycardia, unclear if it was ventricular
tachycardia, responded to cardioversion in the field. [**Month (only) 116**]
have been due to the setting of hyperkalemia, but the patient
also has human immunodeficiency virus cardiomyopathy. The
patient also has a history of atrial flutter with aberrancy.
His amiodarone was continued. His hyperkalemia was treated.
Cardiology did not recommend an implanted defibrillator.
They recommended continuing his medications as he was doing.
The patient had emergent dialysis, and his potassium was
followed closely. The patient's volume status was monitored
per the Renal team at dialysis. The patient had no episodes
on telemetry during the remainder of his hospital stay.
(b) CONGESTIVE HEART FAILURE: The patient's volume status
was followed per Renal, and volume was removed during
hemodialysis.
2. PULMONARY: The patient with respiratory acidosis and
hypercarbia with PCO2 in the 90s which was higher than his
baseline. On repeat blood gas on [**11-20**], the patient's
pH was 7.22, and his PCO2 was 65, PO2 was 74 on 21%. The
patient's hypercarbia was thought to likely be secondary to
over narcotic use. The patient's morphine and oxycodone were
discontinued. His Duragesic patch was decreased to 50. He
continued on his methadone. His saturations remained stable.
3. RENAL: The patient was emergency dialyzed when he first
arrived for hyperkalemia. His last dialysis prior to
discharge was on [**2178-11-23**], and he was due for
dialysis on [**11-26**]. He was continued on his medications
as previously, and his other medications were renally dosed.
4. INFECTIOUS DISEASE: The patient was continued on his
antiretroviral and his Bactrim prophylaxis.
5. HEMATOLOGY: The patient had an elevated INR. Coumadin
was held until INR returned to a normal range in the 1.5 to
1.8 range, and the patient was restarted on his Coumadin on
the day of discharge.
6. PSYCHIATRY: The patient was continued on his Zoloft.
7. PAIN MANAGEMENT: The patient's morphine and oxycodone
were discontinued. His dose of Duragesic was decreased. The
patient seemed to be comfortable on this regimen and did not
have any oxycodone for three days prior to discharge. The
patient requested to be restarted on Roxicet on discharge.
This will be deferred to the patient's primary care
physician.
8. SKIN: The patient had a sacral decubitus ulcer. He
continued to complain of continuous pain over the site. He
had an x-ray of that region which showed no evidence of
osteomyelitis. The patient continued to have wound care by
visiting nurse and family as directed.
9. FLUIDS/ELECTROLYTES/NUTRITION: The patient's potassium
improved after dialysis. It remained in the 5 range and was
6 on the day of discharge. He was given Kayexalate 30 for
[**2178-11-24**] and [**2178-11-25**]. He was instructed to
call his primary care physician on [**2178-11-25**] and have
his potassium checked. The patient had an electrocardiogram
prior to discharge that showed no arrhythmias or evidence of
peaked T waves.
MEDICATIONS ON DISCHARGE: (Discharge medications including
the following)
1. Coumadin 1 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Duragesic 50 mg.
4. Amiodarone 200 mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Zoloft 50 mg p.o. q.d.
7. Lamivudine 20 mg p.o. q.d.
8. Stavudine 20 mg p.o. q.d.
9. Lactulose 30 cc p.o. t.i.d.
10. Valium 5 mg p.o. t.i.d. p.r.n.
11. Renagel 4 mg p.o. q.i.d.
12. Multivitamin.
13. Methadone 50 mg p.o. q.d.
14. Colace 100 mg p.o. b.i.d.
15. Bactrim-DS 1 p.o.
16. Lopressor 12.5 mg p.o. q.d.
17. Captopril 6.25 mg p.o. t.i.d.
The patient was also given a prescription for a gel seat for
home. He was also to continue on his home oxygen of 4
liters.
DISCHARGE DIAGNOSES:
1. Hyperkalemia.
2. Wide complex tachycardia.
3. Hypercarbic respiratory failure.
4. Acquired immunodeficiency syndrome.
5. Hepatitis B.
6. Hepatitis C.
7. Human immunodeficiency virus cardiomyopathy.
8. Chronic obstructive pulmonary disease.
DISCHARGE STATUS: The patient was discharged to home. He
was to have home [**Hospital6 **] to check his
potassium on the day following discharge.
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2178-11-24**] 23:17
T: [**2178-12-1**] 08:50
JOB#: [**Job Number 28545**]
|
[
"403.91",
"427.0",
"276.7",
"425.9",
"042",
"276.2",
"707.0",
"428.0",
"E935.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10791, 11460
|
10090, 10770
|
4032, 4655
|
6812, 10064
|
4869, 6794
|
884, 921
|
950, 2871
|
2894, 4005
|
4672, 4848
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,316
| 156,718
|
540
|
Discharge summary
|
report
|
Admission Date: [**2180-2-3**] Discharge Date: [**2180-2-13**]
Date of Birth: [**2101-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
Cabg x4 [**2180-2-7**] (LIMA to prox. LAD, SVG to distal LAD, SVG to
ramus, SVG to OM)
History of Present Illness:
78 yo male with history of internmittent angina for the past
year, relieved by rest. Failed a recent ETT, and referred for
cath which revealed LM 50-60%, 75% LAD, CX 95%, OM 3 70%, RCA
30%, PDA 75%. Referred for CABG.
Past Medical History:
MI
CAD s/p angioplasty [**2165**]
HTN
elev. chol.
PSH: rem. renal calc.
rem. cervical disc [**2154**]
Social History:
Retired: lives alone
50 year history of smoking cigars
Occasional ETOH
Family History:
Non-contributory
Physical Exam:
VS: Wgt: 76.8 kg preop 72.4 HR: 50's SB BP: 104-110/50-60
HEENT unremarkable
Neck supple, full ROM, no carotid bruits appreciated
Resp: decreased breath sounds bilaterally with crackles 1/4 up
on Left
Card: RRR, no murmur
GI: bowel sounds positive, abdomen soft non-tender/non-distened
Extrem: warm, well-perfused, no edema
Neuro grossly intact
Wound: sternal clean,dry, intact, with staples, no erythema
Pulses: 2+ bil. fems/DP/PT/radials
Pertinent Results:
[**2180-2-9**] WBC-15.9* RBC-3.31* Hgb-10.5* Hct-29.8 Plt Ct-156
[**2180-2-9**] Glucose-129* UreaN-12 Creat-0.9 Na-132* K-4.7 Cl-101
HCO3-26
[**2180-2-3**] 04:46PM BLOOD %HbA1c-5.9
[**2180-2-13**] WBC-8.2 RBC-2.68* Hgb-8.3* Hct-24.6 Plt Ct-277
[**2180-2-13**] Glucose-101 UreaN-23* Creat-1.2 Na-141 K-4.4 Cl-105
HCO3-30
[**2180-2-13**] BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1
CHEST (PA & LAT) [**2180-2-13**]
The patient is status post sternotomy, with mediastinal clips
and overlying skin staples. There is prominence of the
cardiomediastinal silhouette. There is no CHF. There is some
residual increased retrocardiac density and some atelectasis in
the left mid zone and right medial base. There is minimal
blunting of both costophrenic angles, consistent with small
bilateral effusions.
Brief Hospital Course:
Admitted for cath on [**2-3**] and started a Plavix washout over the
weekend. Underwent successful CABG x4 with Dr. [**Last Name (STitle) 4453**] on [**1-28**].
Transferred to the CVICU in stable condition on epinephrine,
lidocaine, phenylephrine and propofol drips. Extubated that
evening and started on amiodarone the next morning for atrial
fibrillation. Transferred to the floor on POD #1 to begin
increasing his activity level. He was gently diuresed toward his
preoperative weigh. Chest tubes removed on POD #2, and pacing
wires removed on POD #3. He converted to a sinus rhythm on POD
#4, continued to work with physical therapy. He was started on
Coumadin with an INR goal 2.0-3.0. Given 4 mg of coumadin
[**2180-2-14**] for INR 1.1. He was discharged to rehab on POD #6 and
will follow-up with Dr. [**Last Name (STitle) **] as an outpatient and Dr.
[**Last Name (STitle) 4454**] for coumadin management after discharge from rehab.
Medications on Admission:
lopressor 25 mg [**Hospital1 **]
accupril 20 mg daily
cardizem CD 120 mg daily
vytorin 10/20 mg daily
ASA 325 mg daily
viagra prn
plavix 75 mg daily
Vit. E
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1
doses.
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: then 200 mg daily.
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please dose to maintain INR of 2.0-3.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital @ [**Location (un) 4047**]
Discharge Diagnosis:
CAD s/p cabg x4 and angioplasty [**2165**]
MI
HTN
elev. chol.
PSH: removal kidney stone
rem. cervical disc [**2154**]
Discharge Condition:
good
Discharge Instructions:
SHOWER daily and pat incisions dry
no lotions, creams or powders on any incision
no lifting greater than 10 pounds for 10 weeks
no driving for one month
call for fever greater than 100.5, redness, or drainage
coumadin for Afib INR Goal 2.0-3.0 please dose coumadin
accordingly
Amiodarone 400 mg once daily for 7 days then 200 mg daily
Sternal Staple removal in [**7-22**] days
Followup Instructions:
Dr. [**Last Name (STitle) 4454**] in [**2-16**] weeks call for an appointment after
discharge from rehab for coumadin management
Call Dr. [**Last Name (STitle) 4455**] in [**3-20**] weeks for a follow-up appointment
Call Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2180-2-13**]
|
[
"276.6",
"427.31",
"997.1",
"401.9",
"272.0",
"414.01",
"E878.2",
"412",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4775, 4854
|
2156, 3098
|
279, 370
|
5019, 5026
|
1341, 2133
|
5452, 5774
|
847, 865
|
3304, 4752
|
4875, 4998
|
3124, 3281
|
5050, 5429
|
880, 1322
|
233, 241
|
398, 617
|
639, 743
|
759, 831
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,756
| 106,220
|
54270
|
Discharge summary
|
report
|
Admission Date: [**2181-10-15**] Discharge Date: [**2181-10-21**]
Date of Birth: [**2122-10-7**] Sex: M
Service: MEDICINE
Allergies:
Aldomet / Codeine Phos/Apap/Caff/Butalb / Hydralazine /
Aldactone / Effexor Xr / Lopid / Ciprofloxacin / Tricor /
Percocet / Vicodin
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
nausea and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 111187**] is a 59 yar old man with a PMH significant for ARF x
5, GIB, and cholestatic jaundice during his last admit who was
discharged 9 days prior to admission. He was in his usual state
of health until about 3 days prior to arrival when he developed
the onset of a headache, nausea, dry heaves. This is how he
feels when he has renal failure. He also noted increasing pedal
edema and thirst. He denies hematochezia, fevers, chills,
diarrhea, chest pain, dysuria, or hematuria. He says that his
sugars have been excellent lately. He has not taken lasix since
his last admit. He states that he last took 2 tablets of alieve
2 nights ago.
In the ED, he was found to be in acute renal failure with a
creatinine of 5.2 up from 1.6 six days ago. LENIS were negative
for DVT.
Past Medical History:
DM, COPD, "kidney failure" x 4, heart murmur since infancy,
apnea, veins "stipped" [**3-7**] varicose veins, appendectomy,
"tendency to bleed" since childhood.
Social History:
Lives w/ wife.
EtOH: denies after [**2160**]. Most prior to that would be "5 shots"
on any one night.
Illicits: denies past/present.
Tobacco: denies past/present.
Family History:
Mother died at 36 years old. Had DM, CHF.
Father died at 50 years old; had CAD.
Physical Exam:
95.1 - 62 - 128/36 - 14 - 99%ra
Gen: Morbidly obese body habitus; markedly jaundiced white male
in NAD lying flat on his back. Communicates in full sentences
and breathes comfortably.
HEENT: NC/AT. Sclera markedly icteric bilaterally, PERRL, EOMI.
Nares patent. Oropharynx: no erythema or exudate. Dry MM.
Pulm: cta b.
Back: no cvat.
CV: All heart sounds faint. rrr, S1, S2, II/VI holosystolic
murmur. Unable to assess JVD due to obesity. Pulses: [**3-9**]
bilateral radial.
Abd:+BS. Enormously distended but soft obese abd. No
organomegaly noted though exam limited by obesity. nontender.no
guarding.
Extr: [**3-7**] pitting edema of bilateral LE.
Skin: Violaceous discoloration of anterior tibial region
bilaterally. RLE had 4x2cm area of superficial ulceration that
is non-erythematous and non-draining. 1 dressing on tibial
aspect of right shin clean dry intact.
Pertinent Results:
[**2181-10-15**] 01:00AM WBC-9.3 RBC-3.21* HGB-10.8* HCT-33.3*
MCV-104* MCH-33.7* MCHC-32.5 RDW-17.6*
[**2181-10-15**] 01:00AM NEUTS-86* BANDS-2 LYMPHS-2* MONOS-5 EOS-1
BASOS-0 ATYPS-0 METAS-3* MYELOS-1*
[**2181-10-15**] 01:00AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL TARGET-1+
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL STIPPLED-OCCASIONAL
TEARDROP-OCCASIONAL
[**2181-10-15**] 01:00AM PLT COUNT-222 PLTCLM-1+
[**2181-10-15**] 01:00AM PT-19.2* PTT-61.5* INR(PT)-2.6
[**2181-10-15**] 12:14AM GLUCOSE-150* UREA N-101* CREAT-5.2*#
SODIUM-132* POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-11* ANION
GAP-24*
[**2181-10-15**] 12:14AM ALT(SGPT)-68* AST(SGOT)-65* ALK PHOS-251*
AMYLASE-60 TOT BILI-34.4*
[**2181-10-15**] 12:14AM LIPASE-61*
[**2181-10-15**] 12:14AM proBNP-1472*
[**2181-10-15**] 12:14AM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-7.5*#
MAGNESIUM-2.0
.
CXR: bilateral effusions consistent with pulmonary edema (my
interpretation)
.
LENI negative but limited by habitus
.
U/S [**10-16**]
IMPRESSION:
1. Sludge-filled gallbladder without evidence for cholecystitis.
Common duct dilatation to 2 cm, etiology indeterminate.
2. Normal patency of the hepatic and portal venous vasculature.
3. Fatty liver.
4. Small ascites.
.
ECHO [**10-18**]
Conclusions:
The left atrium is markedly dilated. There is mild symmetric
left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left
ventricular systolic function is normal (LVEF 70 percent). No
masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect.
The aortic root is moderately dilated. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve leaflets are structurally normal. Mitral
regurgitation is
present but cannot be quantified. Tricuspid regurgitation is
present but
cannot be quantified. There is at least moderate pulmonary
artery systolic
hypertension. There is no pericardial effusion.
.
[**10-19**] U/S with dopplers
IMPRESSION:
1. Extremely limited study due to patient body habitus.
2. Distended gallbladder with sludge.
3. Fatty liver. Main and right portal veins are patent.
4. Increased ascites.
Brief Hospital Course:
.
# Oliguric Renal Failure: Initially patient was thought to be
prerenal vs HRS, and FENA was consistent with this. The patient
was hydrated with NaHCO, cautiously, and was started on
hepotorenal medications including octreotide, midodrine, and
albumin. Urine output transiently increased, but unclear if
this was d/t hydration or HRS treatment, as both occurred
simultaneously. Additionally, foley was found to be in urethra
on HD #2 and once this was replaced, urine output increased
transiently. However, the patient continued to have poor urine
output even in the setting of adequate BP. CVVH was started in
setting of uremia. Repeat FENA suggested ATN, but it was
questionable how accurate this was in the setting of CVVH.
There was some concern for right ventricular dysfunction in the
face of pulmonary hypertension, and an ECHO was performed. This
showed mod pulm HTN based on TR gradient of 45, but right
ventricle was not well visualized d/t patient's habitus. CXR
demonstrated a widened mediastinum that was concerning for
congestion. Because the patient's fluid status was not
completely clear and because there was some concern for hepatic
congestion by renal and total body fluid overload, 50cc/hr was
removed with CVVH. Cr intermittently trended down with CVVH but
then trended upwards. Treatment for HRS was continued, but
patient was unable to get midodrine for ~1day as he was
aspirating meds and it was very difficult to pass an NGT.
Patient remained oliguric until death.
.
# Transaminitis: Pt had evidence of non-alcoholic
steatohepatitis and presumed drug injury on previous biopsy and
demonstrated continued worsening of synthetic funtion based upon
INR and bilirubin. No clear etiology of acute liver
decompensation was found. Liver U/S from [**10-17**] showed no
thrombosis of portal or hepatic veins and little ascites, and
this was repeated with no change. There may have been a small
element of hepatic congestion, but this was not the cause of the
acute decompensation as the LFT's would have been more elevated.
Although the patient had already had a full workup for acute
liver disease, repeat workup was performed with CMV, EBV, and
Hep serologies, all of which were negative. No cause for acute
liver decompensation was determined, and the patient became
progressively more encephalopathic. He was treated with
lactulose for encephalopathy, but did not receive this for ~1
day d/t poor PO access. An arterial ammonia level was obtained
and was moderately elevated
.
# Septicemia - The patient did not have fevers or a white count
on presentation or for the majority of his ICU stay. Because
his mental status was deteriorating and white count jumped up,
blood cultures were taken on [**10-19**] which showed GPC in clusters,
which later grew out coagulase negative staph, and broad
spectrum antibiotics were started. However, over the course of
the following day he rapidly became hypotensive, febrile, and
tachycardic. He was found to by hypoxic with PaO2 78 and
adidemic with pH 7.1 and was intubated. His lactate trended
from 1.4 to 11.4 within 16 hours, and his hypotension progressed
to the point or requiring 3 different pressors to maintain MAPs.
A discussion was held with his wife and she made him [**Name (NI) 3225**] in the
face of rapid deterioration, overwhelming sepsis, acute
worsening liver disease of unknown etiology, and renal failure.
Pressors were withdrawn and the patient expired shortly
thereafter from cardiac and respiratory arrest.
.
# Cardiology - Last ECHO on record at [**Hospital1 **] with EF>50% in [**2178**]
with dilated LA and symmetric LVH, right heart not seen, and
cardiac cath in [**2179**] with normal coronary arteries and mild
pulmonary HTN (PCWP 20, PAP 20, RA 13). Repeat ECHO with mod
pulm HTN, LVH, normal EF. After initial resuscitation with
fluids, renal was consulted and started CVVH with goal to remove
50cc/hr in setting of ?right heart failure.
.
#FEN - The patient was found to aspirate liquids and meds, and
an NGT was placed and he was made NPO. A speech and swallolw
was planned but never obtained.
.
# Sleep Apnea: Used CPAP continuously, both at night and during
the day, until intubation.
.
# Type II Diabetes: Continued on outpatient NPH and sliding
scale with fingersticks.
.
# HTN: After fluid resuscitation remained normotensive until day
of death. Home dose of valsartan was held.
.
# Psych: History of anxiety, depression. Former alcoholic but
had not had drink in many years. Was continue lexapro 5 mg QPM.
.
Medications on Admission:
1. Ursodiol 600 mg Capsule QAM
2. Ursodiol 300 mg Capsule QPM
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-4**]
Puffs Inhalation Q6H PRN.
4. Metoprolol Tartrate 12.5 mg PO BID
5. Pantoprazole Sodium 40 mg Q24H
6. Hydroxyzine HCl 25 mg Tablet 1 Q4-6H PRN
7. Morphine 30 mg PRN
8. Diovan 40 mg Tablet Sig: [**2-4**] Tablet PO once a day.
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock
Discharge Condition:
Deceased
Discharge Instructions:
None
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
|
[
"038.9",
"571.8",
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"995.92",
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"278.01",
"275.41",
"780.57",
"428.0",
"250.00",
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
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icd9pcs
|
[
[
[]
]
] |
9872, 9881
|
4894, 9436
|
426, 432
|
9938, 9948
|
2620, 4871
|
1636, 1717
|
9843, 9849
|
9902, 9917
|
9462, 9820
|
9972, 10095
|
1732, 2601
|
356, 388
|
460, 1257
|
1279, 1440
|
1456, 1620
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,327
| 161,696
|
52990
|
Discharge summary
|
report
|
Admission Date: [**2121-1-30**] Discharge Date: [**2121-2-4**]
Date of Birth: [**2066-6-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
upper endoscopy under conscious sedation
History of Present Illness:
54 year old male with h/o GI bleed in [**2117**] secondary to
esophagitis, who was in his usual state of health until he woke
up the morning of admission feeling fatigued. He had a dark
stool this morning. He went to shower, and syncopized in the
shower. He remembers waking up lying in the bath tub. He spent
most of the day resting in bed, but got up in the late afternoon
to take his dog out. While walking outside he syncopized twice
on the sidewalk. The patient hit his face, but did not hit any
other part of his head. He had a final syncopal episode
witnessed by his son while urinating, which caused him to
present to the ED.
Of note, patient was previously on protonix, but ran out one
month prior to admission.
In the ED, initial vitals: T 98.7 HR 90 BP 118/68 RR 16 100% on
RA. He was found to be guaiac negative. However on NG lavage,
there was coffee grounds and bright red clots, that did not
clear with 2L of saline. He received 2L IV fluids, 80mg IV
protonix, and was started on a protonix gtt at 8mg/hour. NG tube
was left in place.
GI was consulted and plan to scope the patient overnight.
Vitals prior to transfer: HR 91 BP 107/61 RR 16 98%on RA.
Past Medical History:
GI bleed in [**2117**] [**3-4**] esophagitis
Hiatal hernia
Grade 3 internal hemorrhoids
HTN
HL
OSA
detached retina in [**2118**]
s/p bilateral cataract surgery
Intermittent back spasms
Depression
Social History:
Lives with his dog, works as a real-estate broker, has 2 kids,
one at Vanderbilt, pre-med. Fairly active, golfs, no
limitations to physical activity. No tobacco, but exposed to
heavy tobacco as a child. Rare etoh.
Family History:
His mother died at the age of 61 of an MI. his father died at
the age of 79 with sepsis. He had colitis at a late age. He has
two sisters, one living at age 47 and one who died at the age of
54 of an MI and he has one living brother at the age of 58 who
has had heart
disease and bipolar disorder.
Physical Exam:
On admission:
Vitals: T: 97.4 BP: 112/66 P:88 R: 18 O2:96% on RA
General: Alert, oriented, no acute distress. NG tube in place.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
HCT 41.7 on admission
Lowest HCT 31.5 on [**2121-1-31**]
HCT 37 on discharge
.
Micro: None
.
Images:
[**2119-11-1**] Colonoscopy
Polyp at 10cm in the rectum (biopsy)
Grade 3 internal hemorrhoids
Otherwise normal colonoscopy to cecum and distal 10 cm of ileum
.
EGD [**2117**]
Medium hiatal hernia
Grade 3 esophagitis in the lower third of the esophagus
Erythema in the antrum
.
EKG: NSR @ 78bpm. Nl axis. No ST segment changes.
.
EGD [**2121-1-30**]: Erythema in the duodenum compatible with
duodenitis
Medium hiatal hernia
Blood clots in the greater curve of the stomach body, not able
to be flushed away
Grade C esophagitis
Salmon colored projections in the distal esophagus compatible
with Esophagitis, ? Barrett's esophagus
Mass in the gastroesophageal junction
Otherwise normal EGD to third part of the duodenum
EGD [**2121-2-3**]
Grade C esophagitis in the gastroesophageal junction
Ulcer noted at the GE junction with visible vessel and overlying
clot. Three clips deployed but unsuccessfully placed. 2cc of
epinephrine injected and BiCAP applied. (thermal therapy)
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
54 yo M with prior GI bleed secondary to esophagitis who
presents with syncope, NG lavage positive for bright red blood.
.
# Upper GI bleed: The pt's initial EGD showed esophagitis with a
large clot at the GE junction. Surgery was consulted but did
not think esophagectomy would be indicated, except as a last
resort in extreme circumstances; additionally, embolization
would not be an option due to the limited blood supply of the
distal esophagus. HCT decreased to 31 from 41, although the pt
remained hemodynamically stable throughout his entire course.
He received a total 4 Liters IVF as well as one unit of PRBC.
After [**2121-1-31**], Hct never dropped below 33, and was 37 on the day
of discharge. Repeat EGD on [**2121-2-3**] showed Grade C esophagitis in
the gastroesophageal junction, Ulcer at the GE junction with
visible vessel and overlying clot. Three clips deployed but
unsuccessfully placed. 2cc of epinephrine injected and BiCAP
applied. (thermal therapy).
Gastrin was checked and was still pending at the time of
discharge (should be followed up as outpatient). H. Pylori
antibodies were negative. He was started on a PPI [**Hospital1 **], and
should remain on protonix 40mg [**Hospital1 **] as an outpatient. Aspirin
(for primary prevention) was held on discharge. He has follow up
with Dr. [**Last Name (STitle) 3315**] in [**Month (only) 956**] and will have repeat EGD in [**Month (only) 958**].
.
# HTN: His home Lisinopril, Norvasc, and HCTZ were held in the
setting of GI bleed. They were not restarted on discharge
because systolic BP's were ranging in 110's to 120 while on the
floors ([**Date range (1) 109233**]). He was given a prescription for home BP
cuff and was instructed to check BP daily, and report any
BP>160/100 to his PCP, [**Name10 (NameIs) 1023**] he will call to make an appointment
next week. His PCP was [**Name (NI) 653**] and instructed of this plan.
.
# HL: Continue Simvastatin per outpatient regimen.
.
# Depression: Continued Celexa.
.
# Communication: Patient. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 109234**] [**Telephone/Fax (1) 109235**].
# Code: Full (discussed with patient)
Medications on Admission:
1. Lisinopril 40 mg p.o. daily.
2. Simvastatin 40 mg p.o. daily.
3. Norvasc 5 mg p.o. daily.
4. Protonix 40 mg p.o. daily.
5. HCTZ 12.5mg po daily.
6. Celexa 60mg po daily.
7. Aspirin 81mg po daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. 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*
4. Blood pressure cuff
Please provide patient with blood pressure cuff.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: 1) upper GI bleed, 2) esophagitis, 3) ulcer
.
Secondary: 1) hypertension
Discharge Condition:
At discharge, the patient was hemodynamically stable, with BP
116/75 and HR 74. His mental status was clear, coherant, alert
and interactive, and was able to ambulate independently as well
as do all his own ADLs.
Discharge Instructions:
You were admitted to [**Hospital3 **] [**Hospital 1225**] Medical Center for
syncope. You had bleeding from the bottom of your esophagus.
You underwent upper endoscopy (the scope of your esophagus,
stomach and duodenum), which showed inflammation of the bottom
of your esophagus and of your duodenum, as well as an ulcer.
You will need to follow up with Dr. [**Last Name (STitle) 3315**] for a repeat
endoscopy in [**9-11**] weeks. You will also need to start taking
protonix twice a day everyday. NEVER miss a dose because you are
at risk for having another episode of bleeding.
Take your blood pressure daily. We spoke with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 311**], about how your medications were stopped on this
admission, and he wants you to follow up with him next week.
Call his office if you are having blood pressures over 160/100
STOP the following medicines:
1. Aspirin
2. Lisinopril
3. Norvasc
4. HCTZ
START
1. Protonix 40mg twice a day
NEVER TAKE ANY ASPIRIN, MOTRIN/IBUPROFEN, OR NSAIDS.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 3315**] ([**Telephone/Fax (1) 12401**] for followup
on [**2121-3-21**] at 8:20 and for endoscopy scheduled for [**2121-4-9**] at
7am in the [**Location (un) 470**] [**Hospital Ward Name 23**] building on the [**Hospital Ward Name **] of
[**Hospital1 18**].
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] [**Telephone/Fax (1) 1713**] next
week. Check your blood pressure daily and report any blood
pressures over 160/100 to him immediately.
|
[
"401.9",
"458.9",
"327.23",
"285.1",
"272.4",
"553.3",
"455.0",
"311",
"785.0",
"E885.9",
"780.2",
"530.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6888, 6894
|
4070, 6237
|
321, 363
|
7020, 7236
|
2919, 4047
|
8325, 8865
|
2032, 2334
|
6492, 6865
|
6915, 6999
|
6263, 6469
|
7260, 8302
|
2349, 2349
|
274, 283
|
391, 1562
|
2363, 2900
|
1584, 1781
|
1797, 2016
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,492
| 106,512
|
677
|
Discharge summary
|
report
|
Admission Date: [**2131-6-17**] Discharge Date: [**2131-6-19**]
Date of Birth: [**2055-3-21**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Norvasc / Zestril / Bactrim Ds
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
inability to swallow
Major Surgical or Invasive Procedure:
EGD and intubation for EGD
History of Present Illness:
76 yo woman with Schatzki's ring s/p dilation in [**2129**] with no
symptoms until 1 mo ago, noticed increased time to pass food
below LES (15 minutes) but night prior to presentation developed
inability to pass food/liquids one hour after eating a meal of
fish and chinese noodles.
In the ED: She was given glucagon, nitro, and zofran. GI was
consulted and requested ICU admission for monitoring, planning
EGD for day of admission.
Past Medical History:
hypertension
schatzki's ring
anemia
s/p hysterectomy
depression
Social History:
remote (quit 30-40 years ago) smoking history, drinks a glass of
wine with dinner, lives with husband, retired.
Family History:
noncontributory
Physical Exam:
Flowsheet Data as of [**2131-6-17**] 06:02 PM
Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since
12 AM
Tmax: 36.6 ??????C (97.8 ??????F)
Tcurrent: 36.6 ??????C (97.8 ??????F)
HR: 100 () bpm
BP: 156/70
RR: 16 ()
SpO2: 97
Heart rhythm: SR (Sinus Rhythm)
Respiratory
O2 Delivery Device: None
Physical Examination
General Appearance: Well nourished, No acute distress, Anxious,
spitting into emesis basin
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Musculoskeletal: No(t) Muscle wasting
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): person, place, and time, Movement:
Purposeful, Tone: Normal
Pertinent Results:
[**2131-6-17**] 11:45AM WBC-7.4 RBC-3.91* HGB-12.9 HCT-38.9 MCV-100*
MCH-33.0* MCHC-33.2 RDW-13.8
[**2131-6-17**] 11:45AM NEUTS-84* BANDS-0 LYMPHS-10* MONOS-3 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2131-6-17**] 11:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2131-6-17**] 11:45AM PLT COUNT-385
[**2131-6-17**] 11:45AM PT-12.8 PTT-22.9 INR(PT)-1.1
[**2131-6-17**] 11:45AM GLUCOSE-118* UREA N-13 CREAT-0.8 SODIUM-141
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
Brief Hospital Course:
76 F w/ Shatzki's ring presents with acute dysphagia s/p
endoscopic disimpaction, now with evidence of new LLL infiltrate
on CXR and slight drop in O2 sat concerning for possible
aspiration pna
.
# Acute dysphagia
s/p endoscopic disimpaction of food proximal to the shatzki's
ring. Continuing liquid diet X 3 days followed by soft
mechanical X 1 wk, plan for dilation procedure next week.
.
# Aspiration pneumonia
New LLL process with mild hypoxia, new leukocytosis and low
grade temperature
concern for aspiration pna, especially in the setting of
intubation for procedure, mediastinitis or micro perf
possibility with small effusion, atelectasis. 7 day course of
antibx for aspiration PNA.
Medications on Admission:
ocuvite daily
xanax 0.125mg qhs
premarin 0.3mg daily
mirtazipine 15mg qhs
cozaar 100mg daily
aspirin 81mg daily
amlodipine, pt unsure of dose
Discharge Medications:
No changes to above, the following added:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Food impaction proximal to Shatzki Ring requiring intubation and
endoscopic disimpaction
.
Aspiration pneumonia
Discharge Condition:
Stable, afebrile, room air saturations normal, culture negative,
tolerating clear liquid diet, ambulatory and voiding without
difficulty.
Discharge Instructions:
Take all medications as prescribed. Resume your home
medications as you were taking them, we have added only two
antibiotics, prescriptions are included.
Take liquid diet only for the next three days, if this goes
well, may advance to a pureed diet.
Return to the Emergency Room at [**Hospital1 18**] for: severe difficult
swallowing, fevers, shortness of breath
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2131-6-26**] 11:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 1641**] (ST-3) GI ROOMS Date/Time:[**2131-6-26**] 11:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-7-10**]
2:20
|
[
"507.0",
"530.3",
"V15.82",
"401.9",
"997.3",
"311",
"935.1",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"98.02",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
4076, 4082
|
2882, 3580
|
334, 362
|
4238, 4378
|
2312, 2859
|
4792, 5178
|
1057, 1074
|
3772, 4053
|
4103, 4217
|
3606, 3749
|
4402, 4769
|
1089, 2293
|
274, 296
|
390, 825
|
847, 912
|
928, 1041
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,225
| 171,381
|
28298
|
Discharge summary
|
report
|
Admission Date: [**2149-5-11**] Discharge Date: [**2149-5-23**]
Date of Birth: [**2068-4-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
-Transesophogeal echocardiogram
-Spirus enteroscopy
History of Present Illness:
81 year old Male with a history of CAD status post CABG, chronic
systolic CHF (EF 15-20), hypertension, hyperlipidemia, and
recent admission [**4-17**] for GIB with negative EGD/colonoscopy
presents from home with dark red bloody diarrhea that developed
overnight and subsequent weakness and lightheadedness.
.
He reports having had a cough for 5-7 days which has been
procductive of [**Last Name (un) 30893**] sputum. He denies fever or chills. He began
feeling weak and lightheaded 2 days ago. At that point he was
having normal color bowel movements which were loose. He had
vomited once non-bloody emesis two days ago. He has had no
change in his CHF symptoms. Orthopnea is stable and no PND,
weight increase or increase in LE edema. He denies sick contacts
or [**Name2 (NI) 56616**], headache, sore throat or other symptoms. Last
night he had "explosive" diarrhea and was unable to make it to
the toilet. His wife reports that the stool was [**Last Name (un) 30212**] and that
there was also a significant amount of bright red blood. There
was also bright red blood on the toilet paper. He felt even more
lightheaded and too weak to get up and EMS was called.
.
Recent medication changes include prescription of cough
suppressants for cough but no antibiotics and increase of
spironolactone from 12.5 to 25 one week ago.
.
On arrival to the ED, he was hypotensive to the 70s. After
receiving 1L NS, his vitals were T 97.2 90 94/49 21 94% RA. An
NG lavage with 500cc returned clear fluid. There was no blood,
coffee grounds or bile. Rectal exam revealed [**Last Name (un) 30212**] stool. He
was transfused 2 units pRBCs. He was also evaluated by surgery
for a question of mesenteric ischemia, which was felt to be
unlikely. Vitals on transfer were 96 124/56 16 99RA.
.
Review of systems: see metavision
.
<h3>[**Hospital1 139**] A PGY1 Daily Progress Note, [**2149-5-12**], 1600</h3>
.
<h3>Accept Note</h3>
.
<b>Brief HPI:</b>
I have received verbal signout from the MICU resident, reviewed
pertinent data and notes, and seen and examined the patient. See
the MICU admission note for details of the H&P.
.
Briefly, this is an 81 yoM admitted to the ICU for maroon stools
and presyncope whose PMH history includes history of chronic
anemia due to erosive gastritis (discharged [**4-/2149**]),
diverticulosis/itis s/p partial colectomy, sCHF (EF 15-20%
[**7-/2148**]), s/p BiV pacemaker, s/p bioprosthetic MVR and tricuspid
annuloplasty ring for iatrogenic endocarditis, DM2, and OSA.
.
Notes never having maroon stools before; endorses black stool,
but takes iron supplement; denies coffee ground emesis.
.
Had an EGD in [**4-/2149**], which showed
* Normal mucosa in the duodenum (biopsy)
* Otherwise normal EGD to third part of the duodenum
.
Had a colonoscopy in [**4-/2149**], which showed
* Diverticulosis of the sigmoid
* Polyp in the terminal ileum (biopsy)
* Otherwise normal colonoscopy to terminal ileum
.
ICU Course:
-Presenting Hct 18
-4 units overnight into AM
-Hct on transfer 30
-1 bottle positive for GPC in clusters
.
Also notes a cough productive of white sputum for a few weeks,
less than a month; no fevers, chills, no sick contacts. Denies
rhinorrhea, no seasonal allergies, no sore throat. Does not
smoke.
.
<b>ROS:</b> No headache, CP, palpitations, SOB, wheeze,
abdominal pain, dysuria, LE swelling, rashes. Endorses
orthopnea; 3 pillow orthopnea stable.
Past Medical History:
History of erosive gastritis
Diverticulosis/itis (13y ago)
Chronic Systolic Congestive Heart Failure (EF 15-20%)
Coronary Artery Disease
CABG complicated by Mitral Valve endocarditis(Eneterococcus)
Bioprosthetic MVR [**2148-2-7**]
Tricuspid annuloplasty
BiV pacemaker
Hypertension
Hyperlipidemia
Type II Diabetes Mellitus (diet-controlled)
Obstructive Sleep Apnea (patient denies having this dx)
Cataracts
Glaucoma bilaterally
Pulmonary nodule left lower lobe
Diverticulitis
Ventral hernia
Social History:
Lives with: wife
Occupation: retired electrical engineer; designed the radio
transmitter that was responsible for communication between the
NASA lunar module and orbiting capsule during the space race of
the [**2097**]
Tobacco: quit 25 years ago; 40-60 PYHx
ETOH: rare occ.
Family History:
son with MI/CABG at 50; brother with MI @ 63
Physical Exam:
Physical Exam: see metavision
DRE: maroon stool and dark red [**Last Name (un) 30212**] blood, abd non tender
.
[**Hospital1 139**] Exam:
Physical Exam: Unchanged Other than**
Gen: Elderly male, not pale in NAD
HEENT: NCAT, PERRL, EOMi, MMMs, OP clear
Neck: Supple, no LAD; no elevated JVP
Pulm: CTAB no wh/rh/ra, no accessory muscles use
CV: RRR nml S1/2 no m/r/g
Ab: +BS soft NTND no tender organomegaly
Ext: 1+ bilateral pitting edema
Neuro: CN2-12 intact FNFi
.
Discharge Exam:
Unchanged other than
Neck: JVP not elevated
Pulm: Scant bibasilar crackles
Ext: trace edema
Pertinent Results:
[**2149-5-11**] 11:20AM
WBC-17.6*# > Hgb-5.4*# / Hct-18.2*# < Plt Ct-469*#
MCV-75*
Neuts-89.8* Lymphs-6.8* Monos-2.8 Eos-0.2 Baso-0.4
PT-15.3* PTT-26.5 INR(PT)-1.3*
Glucose-167* UreaN-68* Creat-1.9* Na-135 K-5.6* Cl-98 HCO3-23
AnGap-20
.
ALT-15 AST-25 AlkPhos-54 TotBili-0.4
ALT-15 AST-25 AlkPhos-54 TotBili-0.4
Lipase-37
cTropnT-0.01
Glucose-164* Lactate-3.9* K-5.3
.
Imaging:
[**5-11**] AP CXR
PORTABLE UPRIGHT FRONTAL CHEST RADIOGRAPH: The heart is mildly
enlarged. A
left-sided pacemaker is seen with leads extending into the right
atrium, right ventricle, and coronary sinus. Multiple sternal
wires are again seen. A previously seen right basilar density
has improved. The central pulmonary vessels remain prominent,
with no evidence of overt edema. There is a retrocardiac left
basilar density, likely reflecting atelectasis, however, an
underlying pneumonia cannot be excluded. Trace blunting of the
left costophrenic angle may be due to a trace effusion. No
pneumothorax seen. The study and the report were reviewed by the
staff radiologist.
.
[**5-12**] PA-L
FINDINGS: As compared to the previous radiograph, there is
increasing
parenchymal opacities at both lung bases, right more than left.
The
pre-existing small left pleural effusion is unchanged. Unchanged
size of the cardiac silhouette. Unchanged course of the
pacemaker leads. At the time of dictation, 8:44 a.m. on [**2149-5-13**], the referring physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was paged for notification.
.
[**5-15**] TEE
IMPRESSION: Mobile echodensity seen associated with the right
atrial pacing wire. Differential diagnosis includes thrombus
versus vegetation. Bioprosthetic mitral valve appears to be
well-seated. Mild mitral regurgitation. Moderately depressed
left ventricular function.
Compared with the report of the prior study of [**2148-2-7**], there
are now pacing wires in the RA/RV and a mobile echodensity is
associated with the right atrial wire.
.
[**5-19**] CT-Chest-Abdomen without contrast
1. No evidence of abscess in the chest, abdomen or pelvis, as
questioned.
2. 7 cm long segment of abnormal bowel wall thickening involving
the midline small bowel, which has a dilated appearance and is
adjacent to several prominent mesenteric lymph nodes. This
appearance of aneurysmal dilation of small bowel is concerning
for small bowel lymphoma.
3. Bilateral pleural effusions.
4. Diastasis of the rectus musculature.
.
[**5-22**] IR guided left sided PICC (also had right sided PICC placed
and removed, then left sided IR guided PICC placed and removed,
and then finally this PICC)
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
4 French
single lumen PICC line placement via the left brachial venous
approach. Final internal length is 46 cm, with the tip
positioned in SVC. The line is ready to use.
.
[**5-22**] Spirus Enteroscopy:
Normal small bowel enteroscopy to mid/distal jejunum with Spirus
device. It is likely that the endoscope did not reach abnormal
area noted on CT scan.
.
Discharge Labs:
.
[**2149-5-22**] 10:05PM BLOOD Hct-25.3*
[**2149-5-22**] 05:20AM BLOOD Glucose-139* UreaN-27* Creat-1.2 Na-138
K-3.3 Cl-102 HCO3-28 AnGap-11
[**2149-5-22**] 05:20AM BLOOD CK(CPK)-29*
[**2149-5-22**] 05:20AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8
Brief Hospital Course:
81 yoM admitted to the ICU for maroon stools and presyncope
whose PMH history includes history of chronic anemia due to
erosive gastritis (discharged [**4-/2149**]), diverticulosis/itis s/p
partial colectomy about 13 years ago, sCHF (EF 15-20% [**7-/2148**]),
s/p BiV pacemaker, s/p bioprosthetic MVR and tricuspid
annuloplasty ring for endocarditis, DM2, and OSA - whose
hospital course has been complicated by CoNS bacteremia, found
to have pacer lead vegetation on TEE, and GNR bacteremia thought
to be related to an abnormally thickened distal jejunal segment
found on CT.
.
# Unresolved leukocytosis: The patient presented with a WBC of
17, which downtrended with blood and was initially attributed to
bone marrow stress response but then attributed to infection
with resolution of the leukocytosis on both GP and GN/Anaerobic
antimicrobial coverage. The day before discharge, he remounted a
leukocytosis, which has been attributed to the enteroscopy
performed that day; he remained afebrile and without any changes
in clinical status. He is discharged on antibiotics and plans to
follow WBC closely in rehab.
.
# Distal jejunal thickening on CT: See CT for full results. The
differential includes a MALT because of the absence of fat
stranding and the presence associated lymph node enlargement. An
attempt was made to biopsy the segment by spirus enteroscopy but
the lesion was too distal. **The patient will follow-up with his
PCP to discuss goals of care and whether further diagnostic
procedures are warranted, including potential consultation with
surgical oncology.**
.
# Lower GI Bleed: Presenting Hct was 18, was transfused 4 units
of blood in the ICU, and transferred to the floor after
reassuring trends were demonstrated in lactate and pre-renal
[**Last Name (un) **]; the floorm Hct remained stable until the end of the
hospitalization, when the patient required an additional unit
for a Hct of 22 with subsequent Hct appropriately increased and
stable on discharge. The etiology of the bleed remained
indeterminate on discharge, but the leading diagnosis was the
distal jejunal thickened segment seen on CT that was unable to
be reached by spirus enteroscopy. Diverticulosis (known history)
was also considered as was colonic ischemia (leukocytosis, but
not abdominal pain). The patient was discharged with follow-up
with the GI department for further management of the bleed.
.
# [**Last Name (un) **], nephrotoxic, pre-renal: On the floor developed mild [**Last Name (un) **]
that showed a trend of stability on discharge. [**Last Name (un) **] was
attributed to nephrotoxicity from a brief interval on
Gentamycin, with urine lytes ruling out pre-renal and the
patient being clinically euvolemic thereby lowering the
possibility of decreased effective circulatory volume. Earlier
in the hospitalization the patient had pre-renal [**Last Name (un) **], which
reversed with the 4 units of pRBCs.
.
# Endocarditis: The patient was found to have an opacity on the
RV pacer lead concerning of endocarditis in the setting of a low
grade leukocytosis (but no fever) and Staph.Epi bacteremia. EP
was consulted and deferred removal of the pacemaker, deciding
instead to treat and reassess at a later time. The patient was
treated with Vancomycin, Gentamycin, and Rifampin before being
transitioned to Daptomycin due to nephrotoxicity of Gentamycin
in the setting of a delicate fluid balance. Discharged on
Daptomycin for a total course of 6 weeks with follow-up with ID
and EP.
.
# GNR, Klebsiella PNA bacteremia: After an interval of sterile
blood cultures, the patient grew out one culture of K.PNA and
was started on Zosyn before being narrowed to Cipro/Flagyl PO.
The etiology of the GNR is indeterminate but thought to be from
the segment of thickened jejunum in the setting of selective
gram positive antimicrobial pressure from Vancomycin. PNA was
considered but thought unlikely in the absence of any suggestive
findings on CT-Chest.
.
# RUE DVT: RUE US was performed because of a superficial
thrombophlebitis that was found; the patient had no symptoms of
edema and the RUE DVT exam was ordered as an adjunct to the
forearm US. Non-occlusive DVT was found within less than 24h of
placing a PICC on the right side with difficulty advancing
reported by the operator. The DVT was deemed non-PICC
associated. Anticoagulation was deferred in absence of good data
on this clinical scenario and clear contraindications - GI
bleed.
.
# Superficial thrombophlebitis R forearm: Resolved with removal
of the line and hot packs.
.
# Transient Hypotension [**5-17**]: Triggered for SBP in the 70s after
being overdiuresed the day prior (had missed the torsemide doses
2 days prior, and received double the dose the day afterwards
due to concern for his tenuous volume status). Sepsis was
considered in the setting of GNR bacteremia, prompting Zosyn, as
was recurrent GI bleed, with rectal showing melenotic stool,
prompting GI re-consult. The patient's pressure rebounded with
small boluses and thereafter remained stable.
CT-Chest/Abdomen/Pelvis showed the jejunal lesion detailed
above, prompting enteroscopy.
.
INACTIVE ISSUES:
.
# Chronic systolic CHF: Remained clinically euvolemic to mildly
hypervolemic throughout the hospitalization. Remained on
diuretic pre-hospitalization diuretic regimen, with Torsemide
intermittently held for BP < 100 and BP medications held in the
acute setting of GI bleed.
.
# Cough: Presented with an long standing cough attributed to
bronchitis; treated with 5 days of Azithromycin without
significant improvemend. Managed thereafter symptomatically. CT
showed no pneumonia, only effusions.
.
# Chronic Anemia: Iron was held in the acute setting of GI bleed
because of its confounding effect on diagosis. It was restarted
on discharge.
.
# CAD: Serial Trops flat x 3. Continued prehospitalization
regimen. Discharged on aspirin. **PCP may consider stopping ASA
if the patient continues to re-present with GI bleeds in the
future if definitive treatment of the jejunal lesion is deferred
by the patient and family.**
.
TRANSITIONAL ISSUES:
As above in **.
Medications on Admission:
torsemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth every day
spironolactone 25 mg Tab 1 (One) Tablet(s) by mouth daily
metoprolol succinate ER 50 mg one-half Tablet(s) by mouth twice
a day Aspirin 81 mg Tab 1 Tablet(s) by mouth one every evening
lisinopril 5 mg Tab 0.5 (One half) Tablet(s) by mouth daily at
night
Simvastatin 40 mg Tab 1 Tablet(s) by mouth at bedtime for
Pantoprazole 40 mg Tab, Delayed Release by mouth once a day
Metamucil 3.3 gram/5.95 gram Oral Powder (dose uncertain)
ascorbic acid 250 mg Tab 1 Tablet(s) by mouth twice a day
ferrous gluconate 325 mg Tab 1 Tablet(s) by mouth twice a day
Take with meals with Vitamin C 250mg
Discharge Medications:
1. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO twice a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
5. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Metamucil Oral
9. ascorbic acid 250 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. ferrous gluconate 325 mg Tablet Sig: One (1) Tablet PO twice
a day: take with meals with vitamin c.
11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: through [**5-30**].
14. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 7 days: through [**5-30**].
15. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 5 weeks: through [**2149-6-13**].
16. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
17. sodium chloride 0.9 % 0.9 % Syringe Sig: One (1) flush
Injection PRN (as needed) as needed for line flush.
18. Outpatient Lab Work
Weekly CBC with diff, BUN/Cr, LFTS, CK, ESR/CRP. Results should
be faxed to Infectious [**Hospital 2228**] Clinic ([**Telephone/Fax (1) 1353**]
19. Outpatient Lab Work
Please check CBC on [**2149-5-26**]. Goal Hematocrit >21, goal WBC<14.
Contact Infectious Diseases office if WBC elevated.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
PRIMARY:
-Abnormal jejunal segment of indeterminate specificity
-Lower gastrointestinal bleed of indeterminate etiology
-Endocarditis of the right ventricular pacemaker
SECONDARY:
-stable chronic systolic congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
.
You were hospitalized for maroon stool, which caused your blood
count to be low. You were given blood in the intensive care
unit, which raised your blood count. Your bleed was likely
caused by an abnormal part of your small intestine found on
cat-scan. You underwent an advanced endoscopy to attempt to
biopsy this abnormal segment of the intestine, but the segment
was too deep into your small intestine for this to be possible.
You have appointments with gastroenterology, surgery, and your
PCP to decide what the next best step is.
.
You were found to have a blood infection, which was treated with
antibiotics. You were seen by the heart doctors [**First Name (Titles) 1023**] [**Last Name (Titles) 68714**]
your pacemaker; they examined your heart with a camera inserted
into your throat and found possible bacteria on your pacemaker
wires. The cause of the infection is unclear. For this infection
you will need to continue antibiotics after discharge.
.
You developed a second blood infection that may have come from
the abnormal segment of your small intestine. You are being
treated with antibiotics for this infection, which you will
continue after discharge.
.
You were found to have a blood clot in the deep veins of your
right arm. You were not treated with blood thinners because of
your recent bleed.
.
Weigh yourself everyday. Call your heart doctor if your weight
increases by more than 3 lbs.
.
No changes were made to your medications other than as detailed
below:
START:
-Daptomycin intravenous antibiotics
-Ciprofloxacin oral antibiotics
-Flagyl oral antibiotics
-Colace to prevent constipation
-Benzonatate for your cough
Have labwork checked as denoted.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2149-5-26**] at 1:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2149-5-30**] at 2:20 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
Department: INFECTIOUS DISEASE
When: MONDAY [**2149-6-2**] at 2:00 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**2149-6-23**] 11:00a [**Last Name (LF) 2483**],[**First Name3 (LF) **] W.
[**Hospital6 29**], [**Location (un) **] [**Hospital 191**] MEDICAL UNIT (SB)
Phone: [**Telephone/Fax (1) 250**]
Department: SURGICAL SPECIALTIES
When: MONDAY [**2149-6-23**] at 9:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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11,003
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5160
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Discharge summary
|
report
|
Admission Date: [**2119-6-13**] Discharge Date: [**2119-6-20**]
Date of Birth: [**2067-9-29**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
confusion/somnolence, low blood pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 51 yo man with HIV (CD4 of 559 and VL
undetectable in [**Month (only) 547**]), ESRD s/p DDRT in [**2114**], DMI, with 3 prior
hospitalizations since [**4-19**] for recurrent RUL/RML pneumonia, who
presents with hypotension and altered mental status. Pt was
found to be lethargic and confused by his partner on [**2119-6-13**]. EMS
was called and his SBP was in the 70s on the field.
.
He was initially admitted from [**4-19**] to [**4-26**] for right middle
lobe PNA treated with ceftriaxone and azithromycin due to a
history of partially treated latent TB. He was discharged and
subsequently readmitted on [**5-17**] for fever to 102, hypotension
(systolic 70), hypoxia (90% with NRB), and neck stiffness. He
was intubated and treated with vancomycin and pressors. He was
extubated on [**5-24**] and was treated and monitored for Hospital
Acquired PNA, C. diff colitis, and troponin leak. He was
discharged on [**6-1**] in good condition. However, pt was readmitted
on [**6-3**] with N/V, and inability to tolerate PO x 1 day. Pt also
noted hyperglycemia in the 400s the morning of presentation. He
took insulin at home and BG was 150 in the emergency room. Pt
was thought to have recurrent aspiration pneumonitis and
discharged two days later.
.
Past Medical History:
DM I
Diabetic retinopathy
Nephropathy, s/p CRT [**2114**], on HIV-transplant protocol
Hyperlipidemia
Neuropathy, c/b ulcers
Charcot foot with R calcaneal injury and collapse/fracture
Necrobiosis lipoidica diabeticorum
Osteoporosis
Depression
Hypertension
Anemia
Syphilis in [**2094**], treated with penicillin
Toxoplasmosis seropositivity
h/o perianal condyloma
h/o c. diff colitis s/p hospitalization in [**2109**]
h/o latent TB, untreated, Quantiferon gold neg.
Social History:
Mr. [**Known lastname **] was born in [**State 350**]. He works for the IRS in
[**Location (un) 2268**]. Lives with long-time partner in monogamous
relationship. No h/o asbestos. Remote h/o tobacco 15yrs x [**12-7**]
ppd. Denies current alcohol use, but has a history of abuse.
Family History:
His mother is deceased, she had breast cancer and CAD. His
father died of a perforated gastric ulcer with peritonitis. He
has one older brother with hepatitis, and a younger brother with
cerebral palsy. No other disorders that he is aware of run in
his family.
Physical Exam:
100.3 95/41 78 95/4L NC
gen: NAD. AAO x 2
chest: bibas crackles
Heart: RRR, no M/R/G
Abd: soft, NT, ND, no HSM, BS +
Extr:
Pertinent Results:
[**2119-6-13**] 08:46PM TYPE-ART TEMP-37.8 RATES-/16 O2 FLOW-2
PO2-83* PCO2-53* PH-7.22* TOTAL CO2-23 BASE XS--6 INTUBATED-NOT
INTUBA VENT-SPONTANEOU COMMENTS-NASAL [**Last Name (un) 154**]
[**2119-6-13**] 08:16PM GLUCOSE-197* UREA N-20 CREAT-1.4* SODIUM-134
POTASSIUM-5.8* CHLORIDE-107 TOTAL CO2-20* ANION GAP-13
[**2119-6-13**] 11:44AM LACTATE-0.7 K+-5.6*
[**2119-6-13**] 11:44AM O2 SAT-71
[**2119-6-13**] 07:35AM AMYLASE-28
[**2119-6-13**] 07:35AM LIPASE-10
[**2119-6-13**] 03:42AM GLUCOSE-119* UREA N-25* CREAT-2.0*#
SODIUM-132* POTASSIUM-6.7* CHLORIDE-104 TOTAL CO2-20* ANION
GAP-15
[**2119-6-13**] 03:42AM WBC-11.9*# RBC-2.48* HGB-9.0* HCT-27.9*
MCV-113*# MCH-36.2* MCHC-32.2 RDW-16.7*
[**2119-6-13**] 03:42AM NEUTS-75* BANDS-6* LYMPHS-11* MONOS-2 EOS-3
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
Brief Hospital Course:
Pulmonary:
Pt was admitted to ICU for hypoxia, acidosis, and altered mental
status. Pulmonary work-up was significant for acidosis on ABG on
admission. Chest CT showed right upper/middle lobe
consolidation/atelectasis that appeared consistant with an
aspiration event. Patient has history over the past three months
of waxing and [**Doctor Last Name 688**] infiltrate consistent with reccurant
aspiration events. Hypersensitivity reaction was in differential
and hypersentitivity panel was pending at the time of discharge.
Patient's rapid resolution of pressor requirement was also in
the setting of known automonic instability likely from his
longstanding diabetes mellitus. Pt was stabilized and transfered
to floor.
.
Pt continued to have coughs which improved with time. Pt was
satting in upper 90s on RA while he was on the floor. It was not
certain whether this was non-infectious aspiration pneumonitis
vs infectious PNA. CT chest showed persistent RML consolidation.
Given the recurrent nature of pt's sx with periods of resolution
in between, it was thought to be likely non-infectious. BCx was
negative. Pt was taken off of all antibiotics and remained
afebrile throughout his hospital stay, with WBC count WNL. Pt
was noted to have a right sided intrapectoralis fluid collection
that was likely due to repeated central line attempts. Pt passed
swallowing study, although silent aspiration during sleep or
during episodes of hypotension could not be excluded. Likely
scenerio is hypotension leading to somnolence, then aspiration
and pulmonary compromise. Also in the differential were
transplant-associated BOOP, hypersensitivity pneumonitis. Labs
for hypersensitivity were pending at the time of discharge. Pt
was given an acapella device for clearing mucus. Pt is to f/u
with pulm as outpatient.
.
Altered Mental Status:
Patient's mental status rapidly improved with resolution of
hyperglycemia and hypotension suggesting it was an issue of
metabolic derangement and poor cerebral perfusion. Patient had a
normal head CT. Given the high CD4 count and rapid improvement
of mentation, infectious disease did not feel a lumbar puncture
was warrented. Patient did have an episode of confusion and
visual hallucination on the night of [**6-15**], his first night after
he was transferred to the floor. He had been given Ativan,
Ambien, Amitriptyline together, as he and his partner requested.
Apparently pt had been taking the three medications at bedtime
for many years, although he hadn't taken them in the ICU. It was
felt that his delirium was due to the medications and possibly
due to his new environment on the floor. Ambien was
discontinued, and Ativan was reduced to 0.25-0.5mg at a time.
Amitriptyline was continued as before. Pt did not have another
episode of delirium.
.
Fever/Leukocytosis: Pt had a fever to 100.4 on admission. In the
setting of HIV and renal transplant, the initial DDx was wide.
Pt has had several episodes of similar presentations over the
past few months, which were deemed to be of pulmonary origin. CT
chest confirmed this dx. He did not have any other evident
source of infection. Blood Cxs and Urine Cxs were negative. The
fevers resolved during the patient's first day of
hospitalization and pt remained afebrile through the rest of his
hospital stay.
.
Hemodynamic instability: Pt was hypotensive to 80s/30s when he
arrived in the MICU. His hypotension was resonsive to fluids and
pressors, which were weaned off during his first evening in the
MICU. His blood pressure remained labile. All of his usual
antihypertensives were discontinued and only metoprolol was
begun and titrated up. Per Dr.[**Name (NI) 5907**] (pt's cardiologist)
recs, the goal was to titrate up to Toprol XL 100 mg daily and
Varsartan 40 mg daily. Pt was discharged on Toprol only and pt
will discuss adding Varsartan when he follows up with Dr.
[**Last Name (STitle) **].
.
Acute Renal Failure: Pt's creatnine bumped to a max of 1.9, with
a baseline below 1. He was found to be pre-renal, as evidenced
by a FeNa of 0.5 and hypotension. His Cr is returned to baseline
quickly.
.
Hyperkalemia: Max K 6.7. EKG did not show any changes since
prior. It was likely due to pt's renal failure and acidosis. It
trended down with fluids, normalization of pH, renal fxn. Pt
refused kayexelate.
.
R upper ext swelling: Pt complained of R>L upper extremity
edema. RUE U/S showed old RIJ clot and new R basilic vein clot.
No anticoagulation was indicated at this time, as the old RIJ
had a low risk of dislodging and the new right basilic vein clot
was superficial. The primary team consulted [**Last Name (un) **] endocrine
fellow, who did state that diabetic retinopathy is not an
absolute contraindication to anticoagulation, although it will
increase the risk of retinal hemorrhage.
.
Neuropathic pain: Pt stated that he was taking Gabapentin 300mg
TID, 600 mg QHS, at home, titrating down if pain is less. As
Gabapentin can have a sedating effect, his dose was decreased
with intructions to f/u with PMD.
.
Diarrhea: Pt has loose stool/diarrhea at baseline at home and
takes Tincture of opium 15 drops [**Hospital1 **]. He complained of worsening
diarrhea while in the hospital (ToO was not started on
admission). Pt has h/o + C.diff however most recent stool
studies on [**2119-6-14**] were negative. Another set of stood studies
were sent, which were negative. Diarrhea was deemed to be due to
diabetic neuropathy, and tincture of opium was started with good
effect.
.
Urinary retention: Pt c/o urinary retention and had to be
straight cathed 2-3 times a day. It was likely due to h/o foley
in the ICU and diabetic neuropathy. There was no documented
history of BPH however pt was on Flomax at home. Pt stated that
Flomax helped greatly at home, however because of pt's labile
BP, Finasteride was started instead. Pt's partner was shown
sterile cath techniques upon discharge and pt was to follow up
with a local urologist for evaluation.
.
DM: Pt had very labile BS, with significant hypoglycemia at
night. Lantus was [**Month (only) **]'d to 20 units, and sliding scale was
adjusted with smaller doses at bedtime. This fluctuation in BS
was likely due to pt's change in diet (ate less than at home).
Pt was to follow up with an endocrinologist for optimization of
insulin regimen.
.
HIV: stable, HAART therapy was continued.
Medications on Admission:
1. Lamivudine-Zidovudine 150-300 mg Tablet Sig: 1-2 Tablets PO
BID (2 times a day).
2. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisolone Acetate 1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic DAILY (Daily).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 2X/WEEK
(TU,SA).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: [**12-7**]
Tablets PO QMOWEFR (Monday -Wednesday-Friday).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. Opium Tincture 10 mg/mL Tincture Sig: Fifteen (15) Drop PO
BID (2 times a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
17. Valsartan 40 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
18. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
19. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
20. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
21. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
22. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
23. AndroGel 1 % (25 mg/2.5 g) Gel in Packet Sig: One (1) packet
Transdermal as directed.
Discharge Medications:
1. Lamivudine-Zidovudine 150-300 mg Tablet Sig: 1-2 Tablets PO
BID (2 times a day).
2. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisolone Acetate 1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic once a day.
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO twice a
week (Tues, Sat).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MON, WED, FRI ().
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. Opium Tincture 10 mg/mL Tincture Sig: Fifteen (15) Drop PO
BID (2 times a day) as needed for diarrhea.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
14. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation TID (3 times a day).
Disp:*1 inhaler* Refills:*2*
16. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
every saturday.
18. AndroGel 1 % (25 mg/2.5 g) Gel in Packet Sig: One (1) packet
Transdermal once a day: one packet to skin daily.
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed.
20. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
21. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous at bedtime.
22. Humalog 100 unit/mL Cartridge Sig: as per scale units
Subcutaneous at meal times.
23. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain: Not to exceed 4g a day.
24. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
25. Lomotil 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO twice a
day as needed for diarrhea.
26. Outpatient Lab Work
Please draw a blood prograf level and fax the result to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Thank you.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Primary:
Autonomic dysfunction secondary to Diabetes, leading to
orthostatic hypotension.
Diabetes Mellitus, Type 1
Neurogenic bladder
Aspiration pneumonitis
Thrombi in right basilic vein and RIJ, not indicated for
anticoagulation.
.
Secondary:
Diabetic retinopathy
Nephropathy, s/p CRT [**2114**], on HIV-transplant protocol
Hyperlipidemia
Neuropathy, c/b ulcers
Charcot foot with R calcaneal injury and collapse/fracture
Necrobiosis lipoidica diabeticorum
Osteoporosis
Depression
Anemia
Syphilis in [**2094**], treated with penicillin
Toxoplasmosis seropositivity
h/o perianal condyloma
latent TB with recent - workup using Quantaferon gold
Transaminitis
left patellar ulcer with questionable osteomyelitis
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital because you were found to be
obtunded and confused with a very low blood pressure. We stopped
all of your blood pressure medications and re-introduced only
one of them (Metoprolol, a beta blocker). We are discharging you
on Toprol XL (a long acting form of the beta blocker) 100mg once
daily. Please monitor your blood pressure at home. Based on the
blood pressure readings, your doctor may want to add other blood
pressure medications when you follow up as outpatient.
.
You were also found to have low iron levels which can contribute
to anemia. We have written you a prescription for iron pills.
Your chronic illnesses may be contributing to the anemia, which
may benefit from a medication called Epogen. Your nephrologist
will be able to determine if you should take this medication.
.
Please catherize your bladder as instructed if your bladder
feels full even after voiding (visiting nurse will have the
supplies). Your urologist will be able to determine if your
prostate is enlarged and is blocking the passage of urine.
.
We also found an old blood clot in the right internal jugular
vein which has a low risk of dislodging. There was a newer clot
in the right basilic vein in the arm, which was superficial.
These are not indications for anticoagulation.
.
Please look over your list of medications carefully, and take
the medications as instructed.
.
Please continue to use the acapella device as well as the
albuterol inhaler to help clear the airways.
.
The use of ativan and ambien may have contributed to the
confusion and delirium that you experienced on the night of
[**2119-6-15**]. Please do not use ambien for sleep. You may use
0.25-0.5mg of ativan for anxiety. Please avoid sedatives and
narcotics as they may cause confusion and depressed mental
state. You may use acetaminophen 1 g twice daily for your knee
pain.
.
We were unable to perform the sleep study due to the episode of
delirium. Your doctor may want to arrange it for you as an
outpatient to assess for obstructive sleep apnea.
.
If you experience fevers/chills, worsening cough, confusion,
light-headedness, or any other worrisome symptoms, please call
your primary care physician or return to the emergency room.
Followup Instructions:
Primary Care: Please call your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 2148**], at [**Telephone/Fax (1) 457**] to arrange a follow-up. You will want
to see him within 2 weeks of discharge.
.
Lungs: Please call Dr. [**First Name4 (NamePattern1) 8513**] [**Last Name (NamePattern1) **], the pulmonologist, at
[**Telephone/Fax (1) 612**] to make an appointment to see her in the next 2
weeks.
.
Urology: Please follow-up with a urologist for your urinary
retention symptoms.
.
Cardiology: Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5003**])
within the next 2 weeks for your blood pressure.
.
Kidneys: Please follow-up with your nephrologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 673**]) within the next 2 weeks. Please visit a
lab in your neighborhood for a check of Prograf level 3-4 days
before your appointment with Dr. [**Last Name (STitle) **]. You can ask them to
fax the result to Dr. [**Last Name (STitle) **].
.
Diabetes: Please follow up with an endocrinologist for
monitoring of diabetes.
Completed by:[**2119-7-7**]
|
[
"785.52",
"038.9",
"250.81",
"719.46",
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"403.90",
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"272.4",
"285.9",
"276.2",
"250.61",
"596.54",
"250.51",
"416.8",
"337.1",
"414.01",
"458.0",
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"494.0",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14416, 14466
|
3685, 5505
|
309, 316
|
15219, 15226
|
2848, 3662
|
17508, 18660
|
2425, 2687
|
12035, 14393
|
14487, 15198
|
10057, 12012
|
15250, 17485
|
2702, 2829
|
229, 271
|
344, 1625
|
5520, 10031
|
1647, 2113
|
2129, 2409
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,294
| 133,251
|
16611
|
Discharge summary
|
report
|
Admission Date: [**2147-4-12**] Discharge Date: [**2147-4-15**]
Date of Birth: [**2127-8-22**] Sex: F
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 19-year-old
Caucasian female with a history of gastroparesis, status post
G tube and gastric pacemaker placement who was in her usual
state of health until the morning prior to admission when she
awoke with headache, nausea, and new onset of fevers,
temperature to 102 degrees Fahrenheit. She noted increasing
nausea as well as dry heaves as well as cramping left lower
quadrant abdominal pain.
On the morning of admission, the patient saw an outside
provider who referred her to the Emergency Room due to
increased abdominal pain and continuation of her symptoms.
She had been on clindamycin for a dental infection and was on
the final day of her week-long course.
In the Emergency Room, she had a temperature to 103.2 with a
heart rate of 119, blood pressure 91/53. She was entered
into the MUSTT trial due to a lactate of 5.6 and was given 2
liters of IV fluids, repeat lactate 2.0. She was given
Levaquin and Flagyl empirically and then a dose of
ceftriaxone. A triple lumen catheter was placed in the right
IJ.
PAST MEDICAL HISTORY:
1. Gastroparesis.
2. Status post gastric pacemaker.
3. Status post G tube placement.
4. Dental infection.
5. Peptic ulcer disease.
6. Osteoporosis.
7. Migraines.
ADMISSION MEDICATIONS:
1. Nexium 40 q.d.
2. Tylenol.
3. Iron.
4. Clindamycin 300 t.i.d.
5. Benadryl.
6. Imitrex p.r.n.
ALLERGIES: NSAID, aspirin, penicillin, erythromycin, and
Reglan.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
on admission 103.0, blood pressure 96/54, heart rate 108,
respiratory rate 16, saturating 100% on room air. General:
The patient was a well appearing Caucasian female lying in
bed in no acute distress. Cardiovascular: Tachy but no
murmurs, rubs, or gallops. Lungs: Clear to auscultation
bilaterally. Abdomen: Mild left lower tenderness, no
masses, no rebound. There was a mass in the right lower
quadrant corresponding to the gastric pacemaker and the G
tube was in place. Extremities: No clubbing, cyanosis or
edema.
LABORATORY/RADIOLOGIC DATA: On admission, white count 6.7
with 81% neutrophils, 14% bands, 39.9 hematocrit, platelets
216,000. Sodium 128, potassium 2.0, chloride 69, bicarbonate
41, BUN 17, creatinine 0.8, lactate 5.8. U/A revealed trace
protein, 15 ketones, occasional bacteria, otherwise negative.
Chest x-ray negative.
EKG revealed tachycardia, normal sinus rhythm.
CT of the abdomen and pelvis revealed no significant
pathology.
HOSPITAL COURSE: 1. FEVER, NAUSEA, ABDOMINAL PAIN: The
patient was admitted to the Medical Intensive Care Unit due
to qualifying for the MUSTT protocol. She was treated with
Levaquin and Flagyl to cover possible GI sources and felt
that the G tube could be a possible portal of entry; however,
the CT of the abdomen and pelvis revealed no evidence of
infection. Blood and urine cultures that were drawn prior to
antibiotics revealed no bacterial growth. The patient
received 48 hours of antibiotics as well as IV fluids with
impressive improvement in her symptoms and no further fevers.
fevers.
On hospital day number two, the patient was transferred to
the medical floor for further care as no source of infection
was discovered, it was felt that the patient's symptoms could
possibly be due to a viral syndrome. The patient's
antibiotics were stopped and the patient was watched for 24
hours for recurrence of fever.
On the following morning, the patient remained well,
afebrile, and, therefore, was discharged home without
antimicrobial therapy.
2. HYPOKALEMIA: The patient was admitted with a potassium
of 2.0. As the patient denied any vomiting or diarrhea, just
dry heaves, it was not clear why she was so hypokalemic.
There was a suspicion of overdrainage of her G tube but this
was never confirmed. The patient was aggressively repleted.
3. PANCYTOPENIA: After intense IV fluid resuscitation, the
patient's blood cells were decreased with a white count of
1.7, hematocrit 25.5, and a platelet count around 100. The
patient's lines had previously been normal, although she does
have an underlying iron-deficiency anemia. Her white count
recovered quickly after 24 hours; however, her platelet count
lingered around 100 for about two days. It was felt that
this could be consistent with a viral syndrome. On the
morning of admission, the patient's platelet count had begun
to rise and no further workup was performed.
The patient was discharged home in good condition, asked to
follow-up with her primary care physician in one week.
DISCHARGE MEDICATIONS:
1. Nexium 40 mg q.d.
2. Iron 325 mg once a day.
3. Tylenol p.r.n.
DISCHARGE DIAGNOSIS:
1. Viral syndrome.
2. History of gastroparesis.
3. Pancytopenia secondary to viral syndrome.
4. Hypokalemia.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2147-4-17**] 08:17
T: [**2147-4-19**] 11:16
JOB#: [**Job Number 47083**]
|
[
"733.00",
"276.5",
"276.8",
"079.99",
"536.3",
"533.90",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4712, 4782
|
4803, 5149
|
2645, 4689
|
1425, 1616
|
1631, 2627
|
1232, 1402
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,265
| 134,004
|
19616+57069
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-9-7**] Discharge Date: [**2128-9-14**]
Date of Birth: [**2077-10-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amitriptyline / Latex
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
requesting eval of ? atrial myxoma seen at OSH
Major Surgical or Invasive Procedure:
s/p Excision LA mass/myxoma, MVrepair (#26 mmCE ring)
History of Present Illness:
50 yoF admitted to [**Hospital6 12112**] for SOB and CP
following argument with her husband. She was treated for
pneumonia complicated by respiratory failure requiring
intubation x48h. Upon further workup a 5x2cm highly mobile mass
in the LA was noted on echo.[**9-7**] she was transferred to [**Hospital1 18**] for
further cardiac workup. Dr.[**Last Name (STitle) **] was consulted for
evaluation of LA mass/?myxoma.
Past Medical History:
anxiety/panic attacks/depression
tachycardia/palpitations
glaucoma
gestational diabetes
h/o stillborn child
s/p (R) shoulder surgery'[**25**]
s/p removal (L)thigh dermofibroma
vertigo
Social History:
smokes 18-20 cigarettes/day; since age 17.On meds to help quit.
married with 16yo daughter at home.
+social ETOH
Family History:
father w/primary lung tumor mets to brain. Also manic/depression
mother w/CHF
Physical Exam:
VSS: 98.7, 96/46, P=105, RR=20, RA O2 SAT=92%
General: A&Ox 3, NAD
CVS: RRR, No m/r/g
Lungs: Bibasilar cracles, decreased insp.effort
ABD: NT/ND, soft, +BS
EXT: trace edema
Wounds: sternal incision C/D/I. No [**Doctor Last Name **]/click
Pertinent Results:
[**2128-9-12**] 07:00AM BLOOD WBC-7.8 RBC-3.13* Hgb-9.5* Hct-28.1*
MCV-90 MCH-30.3 MCHC-33.8 RDW-14.7 Plt Ct-219
[**2128-9-7**] 11:19PM BLOOD WBC-8.5 RBC-3.81* Hgb-11.8* Hct-34.1*
MCV-89 MCH-30.9 MCHC-34.6 RDW-13.8 Plt Ct-333
[**2128-9-13**] 05:50AM BLOOD PT-13.4 INR(PT)-1.2*
[**2128-9-8**] 03:55PM BLOOD PT-13.9* PTT-51.2* INR(PT)-1.2*
[**2128-9-12**] 07:00AM BLOOD Glucose-81 UreaN-6 Creat-0.6 Na-135 K-4.1
Cl-101 HCO3-27 AnGap-11
[**2128-9-7**] 11:19PM BLOOD Glucose-159* UreaN-9 Creat-0.5 Na-141
K-4.0 Cl-107 HCO3-20* AnGap-18
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 53169**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 53170**]
(Complete) Done [**2128-9-10**] at 11:35:03 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2077-10-30**]
Age (years): 50 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Left ventricular function. Mitral valve disease.
Preoperative assessment.
ICD-9 Codes: 424.0, 424.2
Test Information
Date/Time: [**2128-9-10**] at 11:35 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW6-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: 2.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Findings
LEFT ATRIUM: Mass in the body of the LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP.
Eccentric MR jet. Mild to moderate ([**2-4**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**2-4**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
A large (6.9x2.1cm) mobile mass is seen in the body of the left
atrium attached to the interatrial septum and prolapses into the
LV during diastole. No atrial septal defect is seen by 2D or
color Doppler. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic valve
leaflets (3) are mildly thickened. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
mitral valve prolapse of the A2/A3 segment of the anterior
leaflet. An eccentric, posteriorly directed jet of Mild to
moderate ([**2-4**]+) mitral regurgitation is seen.
POSTBYPASS
There is preserved biventricular systolic function. The LA mass
is no longer visualized. The interatrial septum is intact and
there is no evidence of an ASD. There is a ring prosthesis in
the mitral annular position.The anterior MV leaflet no longer
prolapses. There is no MR [**Last Name (Titles) 53171**]. The study is otherwise
unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2128-9-10**] 11:53
[**Known lastname 53169**],[**Known firstname **] [**Medical Record Number 53172**] F 50 [**2077-10-30**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2128-9-10**] 8:49
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CSRU [**2128-9-10**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 53173**]
Reason: Evaluate PA catheter positioning
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with
REASON FOR THIS EXAMINATION:
Evaluate PA catheter positioning
Final Report
HISTORY: For PA catheter position.
FINDINGS: In comparison with the earlier study of this date,
there has
apparently been an attempt to advance the right IJ catheter. It
appears to
extend well into the IVC, before _____ back on itself so that
the tip is in
the pulmonary outflow tract. This information has been
telephoned to Dr.
[**Last Name (STitle) 6479**].
The endotracheal tube and nasogastric tubes have been removed.
Relatively
lower lung volumes with increased opacification at the left base
most likely
reflecting a combination of pleural fluid and atelectatic
change.
The gas-filled stomach has increased in size since the removal
of the
nasogastric tube.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: SAT [**2128-9-11**] 9:16 AM
Brief Hospital Course:
[**2128-9-10**] Mrs.[**Known lastname **] was taken to the OR by Dr.[**Last Name (STitle) **]
where she underwent LA mass/myxoma removal with pericardial
patch repair of atrial septum, and MV repair (#26 mm
annuloplasty ring). Please refer to Dr[**Doctor Last Name 14333**] operative
report for further details. She was transferred to the CVICU
intubated and hemodynamically stable. XCT:138min. CPB:160min.
She was extubated in a timely fashion. POD#1 she was transferred
to the SDU. All lines and drains were discontinued in a timely
fashion. Anticoagulation was started on POD#2 with Coumadin,
which is to continued for 3 months with an INR goal of 2.5 per
DR.[**First Name (STitle) **].Per pt. request, Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office was
contact[**Name (NI) **] and agreed to follow Coumadin dosing and PT/INR draws.
First appointment arranged for Wed.[**9-15**] at 11am. The remainder
of her postoperative course was essentially uneventful and she
progressed well. On POD# (...stopped [**9-13**])
Medications on Admission:
Atenolol 25(2)
Lorazepam 1 qHS
Paroxetine 20(1)
Travoprost gtt (B) eyes
Trazadone 100q HS
Chantix 1(2)
Ambien 10 qHS
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Excision LA mass/myxoma, MVrepair (#26 mmCE ring)
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
-Dr [**Name (NI) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
-Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] [**2128-9-15**] 11am appointment for PT/INR draw and
Coumadin dosing
-Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
-**Daily Coumadin dose [**Name8 (MD) **] MD/ appointment for pt/INR with Dr
[**Last Name (STitle) 410**] as above
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2128-9-14**] Name: [**Known lastname 9881**],[**Known firstname **] Unit No: [**Numeric Identifier 9882**]
Admission Date: [**2128-9-7**] Discharge Date: [**2128-9-14**]
Date of Birth: [**2077-10-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amitriptyline / Latex
Attending:[**First Name3 (LF) 265**]
Addendum:
As discussed with Dr.[**Last Name (STitle) 223**] [**2128-9-14**]:
-verified her following Coumadin dosing with INR/PT draw to be
done at her office. 1st appointment [**2128-9-15**]
-Per her reccommendation for a Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2453**]
([**Telephone/Fax (1) **]). Pt. to call 1-2 weeks for followup.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2128-9-14**]
|
[
"428.0",
"523.40",
"518.81",
"416.8",
"300.01",
"285.9",
"427.31",
"427.1",
"365.9",
"429.71",
"396.8",
"305.1",
"212.7",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"88.72",
"37.33",
"35.61",
"88.53",
"37.23",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10834, 11012
|
7622, 8669
|
334, 390
|
8993, 9000
|
1543, 4567
|
9512, 10811
|
1191, 1270
|
6669, 6692
|
8916, 8972
|
8695, 8814
|
9024, 9489
|
4616, 6629
|
1285, 1524
|
248, 296
|
6724, 7599
|
418, 837
|
859, 1045
|
1061, 1175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,586
| 177,422
|
17599
|
Discharge summary
|
report
|
Admission Date: [**2106-3-1**] Discharge Date: [**2106-3-6**]
Date of Birth: [**2032-12-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2106-3-1**] Aortic Valve Replacement (23mm CE pericardial tissue
valve)
History of Present Illness:
73 y/o female hospitalized in [**11-25**] for congestive heart
failure. Improved with diuresis. Work-up revealed severe aortic
stenosis.
Past Medical History:
Aortic Stenosis, Congestive Heart Failure, Hypertension,
Hypercholesterolemia, Diabetes Mellitus, Obesity,
Osteoarthritis, Left cataract, Hemorrhoids
Social History:
Denies tobacco and ETOH use.
Family History:
Father died of CVA at 55
Brother with CAD
Physical Exam:
VS: 70 12 114/72 62" 169#
General: Obese female in NAD
HEENT: EOMI, PERRLA, NC/AT
Neck: Supple, FROM, -JVD
Lungs: CTAB -w/r/r
Heart: RRR, 4/6 SEM (murmur radiates to carotids)
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
Echo [**3-1**]: PRE-CPB: 1. The left atrium is normal in size. No
spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage. A left-to-right shunt across
the interatrial septum is seen at rest. A small secundum atrial
septal defect is present. 2. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. 3.
Right ventricular chamber size and free wall motion are normal.
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 simple
atheroma in the descending thoracic aorta. 5. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. No masses or vegetations are seen on the
aortic valve. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. 6. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen. 7. There is no pericardial effusion. POST-CPB: The
Bioprosthetic (#23 Perimount) Aortic Valve is well seated
without any paravalvular leak. No Aortic Regurgitation is seen.
The LV systolic function is well preserved. The RV systolic
function is also well preserved. There is no evidence of aortic
dissection.
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undergoing work-up as
an outpatient. On [**3-1**] she was brought to the operating room
where she underwent a aortic valve replacement. Please see
operative report. Following surgery she was transferred to the
CSRU for invasive monitoring in stable condition. Later on op
day she was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one chest tubes were removed and
diuretics and beta blockers were started. She was gently
diuresed towards her pre-op weight. Later this day she was
transferred to the SDU. On post-op day three her epicardial
pacing wires were removed. Physical therapy worked with patient
during hospital course for strength and mobility. She continued
to improve other the next several days with adjustment in her
medications and appeared ready for discharge home on post-op day
****.
Medications on Admission:
Aspirin 325mg qd, Lopressor 25mg qd, Lasix 40mg qd, KCl 20 mEq
qd, Zocor 10mg qd
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Congestive Heart Failure, Hypertension,
Hypercholesterolemia, Diabetes Mellitus, Obesity,
Osteoarthritis, Left cataract, Hemorrhoids
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) **] (cardiologist) in [**1-23**] weeks
Dr. [**Last Name (STitle) **] (PCP) in [**12-22**] weeks
Completed by:[**2106-3-6**]
|
[
"428.0",
"272.0",
"424.1",
"585.9",
"428.32",
"403.90",
"V14.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
3910, 3981
|
2891, 3779
|
297, 373
|
4207, 4213
|
1129, 2868
|
774, 817
|
4002, 4186
|
3805, 3887
|
4237, 4508
|
4559, 4753
|
832, 1110
|
238, 259
|
401, 539
|
561, 712
|
728, 758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,995
| 198,388
|
9105
|
Discharge summary
|
report
|
Admission Date: [**2159-11-12**] Discharge Date: [**2159-11-19**]
Date of Birth: [**2089-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
cabg x4 [**2159-11-15**] (LIMA to LAD, SVG to OM1, SVG to OM2, SVG to
PDA)
History of Present Illness:
70 yo M admitted to OSH with 2 weeks of exertional chest pain.
Past Medical History:
GERD, peptic ulcer disease, prosate cancer, depression, ETOH,
s/p Bilroth (I vs II?), CCY
Social History:
lives alone
daugther lives downstairs
10 years sober
quit tobacco 30 years ago.
Family History:
NC
Physical Exam:
NAD HR 55 BP 144/76
Lungs CTAB
Heart RRR distant heart sounds
Abdomen soft/NT/ND, well healed chole & [**Doctor First Name **] scars
No edema, +pp
no varicosities
no carotid bruits
Pertinent Results:
[**2159-11-19**] 06:35AM BLOOD WBC-6.5 RBC-3.01* Hgb-8.9* Hct-25.8*
MCV-86 MCH-29.6 MCHC-34.5 RDW-14.1 Plt Ct-167
[**2159-11-19**] 06:35AM BLOOD Plt Ct-167
[**2159-11-19**] 06:35AM BLOOD PT-11.7 PTT-23.1 INR(PT)-1.0
[**2159-11-19**] 06:35AM BLOOD Glucose-98 UreaN-24* Creat-0.9 Na-139
K-4.4 Cl-101 HCO3-31 AnGap-11
[**2159-11-19**] 06:35AM BLOOD ALT-22 AST-16 LD(LDH)-211 AlkPhos-58
TotBili-0.5
PA AND LATERAL CHEST ON [**2159-11-18**] AT 11:55
Lines and tubes have been removed and there is no PTX. Some
subsegmental atelectatic changes are seen at the bases
bilaterally. There is evidence of bilateral effusions
posteriorly. Some basilar airspace disease seen on the lateral
view, not well localized, may be corresponding to retrocardiac
densities on the frontal film. Distinction of that finding
between atelectasis and pneumonia cannot be made
radiographically.
IMPRESSION: Findings consistent with expected post-operative
course and no PTX after multiple tube removal. Basilar
atelectatic changes are likely, though pneumonia cannot be
excluded radiographically.
Echo [**11-15**]
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. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is markedly
dilated at the sinus level. The sinuses of Valsalva are dilated.
There is a sinus of Valsalva aneurysm. The ascending aorta is
mildly dilated. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is moderate thickening of the mitral
valve chordae. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
Post CPB:
Preserved [**Hospital1 **]-venytricular systolic function.
No other change
Brief Hospital Course:
Cardiac catheterization showed complex disease and cardiac
surgery was consulted. As Mr. [**Known lastname 4886**] had received plavix, he
awaited plavix washout and was taken to the operating room on
[**11-15**] where he underwent a CABG x 4. He was transferred to the
ICU in critical but stable condition. He was extubated later
that same day. He was transferred to the floor on POD #1. He did
well postoperatively. He did have atrial fibrillation for which
he was given amiodarone and increased lopressor. He converted to
a normal sinus rhythm. He otherwise did well postoperatively and
was ready for discharge home on POD #4.
Medications on Admission:
Protonix 40 mg daily, Lexapro 10 mg daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 6 days, then 400 daily x 1 week. then 200
mg daily until follow up with cardiologist.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p cabg x4
prostate Ca with XRT
PUD/GERD s/p Billroth proc. 30 years ago
depression
sciatica
Discharge Condition:
good
Discharge Instructions:
SHOWER DAILY and pat incisons dry
no lotions, creams, or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**1-23**] weeks
see Dr. [**Last Name (STitle) **] in [**2-24**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2159-11-19**]
|
[
"V12.71",
"276.2",
"V58.63",
"V15.82",
"311",
"V10.46",
"401.9",
"V15.3",
"530.81",
"411.1",
"414.01",
"V58.83",
"427.31",
"414.8",
"724.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"39.61",
"36.13",
"88.53",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5585, 5640
|
3120, 3751
|
345, 424
|
5783, 5790
|
962, 3010
|
6048, 6263
|
742, 746
|
3843, 5562
|
5661, 5762
|
3777, 3820
|
5814, 6025
|
761, 943
|
284, 307
|
452, 516
|
538, 629
|
645, 726
|
3020, 3097
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,038
| 111,329
|
46106
|
Discharge summary
|
report
|
Admission Date: [**2191-9-7**] Discharge Date: [**2191-9-28**]
Date of Birth: [**2138-2-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Prednisone
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right bronchopleural fistula
Major Surgical or Invasive Procedure:
Dr. [**Last Name (STitle) **]:
[**2191-9-7**]
1. Bronchoscopy with aspiration of secretions.
2. Right thoracoplasty with closure of bronchopleural
fistula.
[**2191-9-16**]
Flexible bronchoscopy.
.
Dr. [**First Name (STitle) **]:
[**2191-9-7**]
Combined pectoralis major musculocutaneous flap
containing entire right breast, transferred into the fistula
area and split-thickness skin graft, 200 cm2.
.
Dr. [**Last Name (STitle) **]
[**2191-9-18**]
Flexible bronchoscopy
.
Dr. [**Name (NI) **]
[**2191-9-22**]
Flexible bronchoscopy
History of Present Illness:
Ms. [**Known lastname 4640**] is a 53-year-old former smoker with a prior history
of resected chest wall with invasive carcinoma of the lung
approximately 8 years ago. This was a right upper lobectomy with
en bloc chest wall resection, reconstructed with mesh. She also
had received postoperative radiotherapy. She presented several
months ago with a empyema necessitans draining through the low
right flank. This was traced up to a source arising from the
apical pleural space and mesh. I had previously reopened the
posterior aspect of her thoracotomy, removed the mesh, and
performed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 72968**] window to marsupialize this and place her
on dressing changes. At this time, she was still smoking and
severely malnourished. We placed a percutaneous gastrostomy for
nutritional supplements, and she has gained approximately 4 to 5
pounds. She has been successful in quitting smoking. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of plastic surgery has also placed a tissue expander
under the right breast as she has very little muscular tissue to
help close this flap. It is our hope that a de-epithelialized
flap including the right breast skin and breast tissue along
with the pectoralis, as well as remaining tissue above the
thoracotomy, would be adequate to help close the defect if I
could also collapse the chest using a thoracoplasty. It was our
hope, with this combined technique, that we could close the
bronchopleural fistula and eradicate the space. She understood
the risks involved, including that this would not work and she
would be left with a chronic wound. She agreed to proceed.
Past Medical History:
Squamous cell CA- Right lung
s/p Right lung upper lobectomy and right lower lobe wedge
resection with excision of ribs 5,6, and 7
s/p chemo, radiation
Social History:
Married. Works as waitress. Smokes [**1-7**] cigs/day (20+
pack-years). Recently quit smoking.
Family History:
Noncontributory
Physical Exam:
DISCHARGE PE:
Vitals: 98.4 94 131/57 18 96% room air
Gen: NAD
CVS: RRR
Resp: CTA bilaterally
Abd: soft, ND, NT, NABS
Incisions: clean, dry, intact
Ext: Pulses palpable distally in all extremities
Pertinent Results:
[**2191-9-28**] 04:57AM BLOOD WBC-12.5* RBC-3.24* Hgb-10.5* Hct-32.3*
MCV-100* MCH-32.4* MCHC-32.5 RDW-15.6* Plt Ct-543*
[**2191-9-28**] 04:57AM BLOOD Glucose-102 UreaN-21* Creat-0.4 Na-135
K-5.1 Cl-97 HCO3-34* AnGap-9
[**2191-9-28**] 04:57AM BLOOD Calcium-9.7 Phos-4.3 Mg-1.8
.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 98101**],[**Known firstname **] [**2138-2-2**] 53 Female [**-5/3940**]
[**Numeric Identifier 98102**]
SPECIMEN SUBMITTED: RIGHT NIPPLE, TISSUE EXPANDER RIGHT BREAST,
RIGHT 2ND, 3RD, AND 4TH RIB (5).
Procedure date Tissue received Report Date Diagnosed
by
[**2191-9-7**] [**2191-9-7**] [**2191-9-14**] DR. [**Last Name (STitle) **]. BROWN/vf
Previous biopsies: [**Numeric Identifier 98103**] CHEST WALL PROSTHESIS.
[**Numeric Identifier 98104**] CONSULT SLIDES REFERRED TO DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
DIAGNOSIS:
1. Nipple, right (A):
No evidence of malignancy.
2. Tissue expander, right breast.
Gross exam only.
3. Rib, right fourth (B):
Bone and marrow with no evidence of malignancy.
4. Rib, right third (C):
Bone and marrow with no evidence of malignancy.
5. Rib, right second (D):
Bone and marrow with no evidence of malignancy.
.
CHEST (PA & LAT) [**2191-9-27**] 8:05 AM
REASON FOR THIS EXAMINATION:
eval need for bronch
IMPRESSION: Continued improving aeration in the right mid and
lower lung regions status post right thoracoplasty.
Brief Hospital Course:
The patient is a 53 year-old female admitted to Dr.[**Doctor Last Name 4738**]
[**Name (STitle) 1092**] surgery service at the [**Hospital1 1170**] on [**2191-9-7**] for surgical management of [**Last Name (un) **] chest wall
reconstruction. She underwent a bronchoscopy with aspiration of
secretions, right thoracoplasty with closure of bronchopleural
fistula, and combined pectoralis major musculocutaneous flap
containing entire right breast, transferred into the fistula
area and split-thickness skin graft, 200 cm2 on [**2191-9-7**] by Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **]. For details operation, please refer to
the operative reports. Following the surgery, she was
transferred to the CSRU.
.
On POD 1, she was continued on levofloxacin and ancef. Her pain
was well-controlled with a dilaudid PCA, she was afebrile, had
good oxygenation, and adequate urine output. Her VAC was
functioning, CT was continued to wall suction, and her arm sling
was continued.
.
On POD 2, her pain was well-controlled, however, she was over
sedated from the narcotics and her PCA was discontinued. She
continued to remain afebrile with O2 saturation at 97% on 2L NC.
Her antibiotics were continued. Her VAC remained intact and
her CT was continued on wall suction.
.
On POD 3, she continued to remain afebrile and pain was
controlled with PO dilaudid. The [**Doctor Last Name 406**] drain was placed to bulb
suction. A CXR demonstrated almost complete opacification of
the right lung and a bronch was performed with removal of thick
brown/bloody secretions and mucus plugs from the right mainstem
bronchus, resulting in improved aeration of right lung.
.
On POD 4, her antibiotics was switched to cefepime to
pseudomonas cultured from BAL. She remained afebrile and pain
well-controlled with PO dilaudid. Again the patient required
another bronch following a chest x-ray with progressive
opacification of the right lung. Clear thick secretions were
removed from the right mainstem bronchus. The VAC continued to
be and continued on suction and her [**Doctor Last Name 406**] drain was continued to
bulb suction.
.
On POD 5, she was continued on the cefepime and remained
afebrile. The VAC was continued as well as her [**Doctor Last Name 406**] drain.
Her pain continued to be well controlled with PO dilaudid. No
bronch was required on this day.
.
From POD [**5-13**], the patient continued to remain afebrile in the
ICU, requiring a bronch on POD 7 and POD 9 for removal of thick
secretions. Her VAC was continued on suction and her [**Doctor Last Name 406**] was
continued on bulb suction. Pain continued to be well-controlled
with input from acute pain service.
.
On POD 10, she had a fever of 101.9 with increased WBC to 45.6
and a CT chest demonstrated severe PNA of the right lung. Her
antibiotics were broaden to include vancomycin, tobramycin,
flagyl, and the cefepime was continued. The decision was made
at this point to have daily bronchs for removal of purulent
secretions from the right mainstem bronchus. She also
complained of diarrhea and C.Diff cultures were sent. Her VAC
was continued on suction and her [**Doctor Last Name 406**] was continued on bulb
suction.
.
On POD 11, she continued to have low grade temperatures and her
antibiotics were continued. A CT chest/abdomen/pelvis was
performed showing thickening and pericolonic inflammatory change
of the cecum and ascending colon, consistent with colitis.
Bronch today demonstrated moderate thick prurlent secretions in
the right mainstem bronchus. Her VAC was continued on suction
and her [**Doctor Last Name 406**] was continued on bulb suction.
.
On POD 12, she was found to be C.Diff positive and was continued
on the flagyl, vancomycin, and cefepime. The tobramycin was
discontinued. Her VAC was continued on suction and her [**Doctor Last Name 406**]
was continued on bulb suction. She remained afebrile and
continued to oxygenate well, not requiring a bronch today.
.
On POD 13, she continued to remain afebrile and her diarrhea was
resolving. Her [**Doctor Last Name 406**] drain was discontinued. Bronch
demonstrated moderate secretions in right mainstem bronchus and
she was deemed stable to be tranferred to the floor. She
continued to oxygenate well on 2 liters nasal cannula. The
vancomycinwas discontinued and the flagyl and cefepime were
continued.
.
On POD 14, she was started on a clear liquid diet, which she
tolerated well, and TF were started at 30 cc/hr. She was
continued on the flagyl and cefepime. Her diarrhea continued to
resolve and she remained afebrile. She was advanced to a
regular diet, which she tolerated well.
.
On POD 15, she remained afebrile but continued to have copious
secretions requiring a bronch. Her wound continued to heal
wellwith the [**Doctor Last Name 406**] d/c'd and the VAC d/c'd. She continued to
tolerate her regular diet.
.
On POD 16, she was continued on the flagyl and cefepime without
fevers. Her pain was well-controlled, she was tolerating a
regular diet with increasing PO intake, and starting to ambulate
well. Her wound continued to be clean, dry, intact, and [**Last Name (un) 76914**]
well.
.
On POD 17-19, her TFs were cycled overnight, she remained
afebrile and continued to increase her PO intake. Her chest
x-ray continued to show improvement without a need for further
bronchs. Her antibiotics were continued as well as aggressive
pulmonary toilet and ambulation.
.
On POD 20-21, she continued to improve clinical and remain
afebrile. Her chest x-rays remain unchanged with no indication
for a bronch. She was deemed stable for discharge home. She
will be discharged home with VNA and will continue her cefepime
for 3 weeks and flagyl for 4 weeks. She has been been
instructed to follow-up with Dr. [**Last Name (STitle) **] next week and to
follow-up with Dr. [**First Name (STitle) **] in 1 week.
Medications on Admission:
Neurontin
Percocet
Ultram
Discharge Medications:
1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*30 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
7. Equipment
Peri-Trek-S portable nebulizer.
8. Cefepime 2 g Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 21 days.
Disp:*42 Recon Soln(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 28 days.
Disp:*84 Tablet(s)* Refills:*0*
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous DAILY (Daily): 5 mL (100units/mL) flush to
each lumen Daily.
Disp:*qs qs* Refills:*0*
11. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ML Injection
once a day: 10 mL NS flush to each lumen Daily.
Disp:*qs qs* Refills:*0*
12. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
14. Aquaphor Ointment Sig: One (1) Topical three times a
day as needed for dryness: Apply to skinas needed for dryness.
Disp:*2 2* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Right empyema with chronic bronchopleural fistula.
Discharge Condition:
Stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] / Thoracic Surgery office [**Telephone/Fax (1) 170**]) for:
fever, shortness of breath, chest pain, exscessive foul smelling
drainage from incision sites
.
Please follow-up with as instructed.
.
Continue medications as previous to surgery. Please take new
medications as directed.
.
You may leave incisions/wounds open to air. Apply aquaform
cream twice a day as instructed by plastic surgery. You may
shower, please pat incisions dry.
Followup Instructions:
Scheduled Appointments :
Provider [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**]
Date/Time:[**2191-10-6**] 3:30
.
Appointments to be made:
Please call Dr. [**First Name (STitle) **] / Plastic Surgery at [**Telephone/Fax (1) 1416**] to
schedule a follow-up appointment in 1 week.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,434
| 107,673
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21815
|
Discharge summary
|
report
|
Admission Date: [**2147-2-7**] Discharge Date: [**2147-2-17**]
Date of Birth: [**2093-10-4**] Sex: F
Service: NEUROLOGY
Allergies:
Shellfish / Insulin,Beef / Insulin Zinc,Pork / Compazine /
Droperidol / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
transferred for cerebellar infarct
Major Surgical or Invasive Procedure:
Extraventricular drain placement
Intubation
History of Present Illness:
Pt. is a 53 y/o with a hx of Type II DM, CAD s/p CABG x 3 and
multiple stenting procedures, obesity, hypertension,
hyperlipidemia who is transferred for further management of a L
cerebellar infarct.
Pt. reports that she was in her USOH until Thursday [**2-2**], when
she noticed that her speech was slurred. Then early in the
morning on Friday ([**2-3**]) around 4 AM she got up off the couch and
fell to the floor due to imbalance. She did not notice any
weakness or numbness at that time. She reports she vomited once
and felt very nauseated. She stayed on the floor because she
felt too off balance to stand, and eventually around 6AM her
husband found her and helped her back to bed. She slept for a
few hours, and then tried to get up to go to the bathroom with
the aid of a walker, but fell again. At this point he called
EMS and she was transferred to [**Hospital3 **].
At [**First Name11 (Name Pattern1) 46**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 430**] CT was performed, and was read as 3 cm density
in the L cerebellar hemisphere with surrounding edema, shift of
the 4th ventricle on the R, and partial effacement of hte
paramesencephalic cistern at the level of the pons on the left.
She was admitted for a metastatic work up for brain mass and
started on Decadron 4 mg Q6 given concern for mass effect. A CT
Torso was performed and showed several tiny pulmonary nodules on
the right and an adrenal nodule on the left. CEs were monitored
and were elevated (peaked at 4.33, normal range 0.0-0.04, on [**2-3**]
at 2100, then trended down) and she was seen by Cardiology, who
recommended medical management. She was seen by Neurosurgery
there on [**2-5**], and their exam was significant for intact
strength and normal cranial nerve exam and L sided dysmetria.
They recommended MRI head for further work up. MRI was
performed today (delayed [**1-27**] pt. claustrophobia, required open
MRI at Shields), and was read as a 3 cm area of restricted
diffusion in the L cerebellum with mass effect on the 4th and
medulla, more c/w acute to subacute infarct. Decadron was
d/ced. She was seen by Neurology there this morning, and they
reviewed her MRI.
Their exam was similar to Neurosurgery's exam, and showed intact
strength and cranial nerves and L sided dysmetria. She was
transferred to [**Hospital1 18**] given concern for mass effect on the
brainstem.
Symptomatically she reports that she has continued to feel
nauseated but has not thrown up since Friday. Today, around the
time she was examined by Neurology, she noticed some
intermittent vertical diplopia (although she did not have
diplopia on their exam). She denies any numbness or weakness.
She feels very clumsy on her left side and has been unable to
walk without assistance. She feels that her speech is still
slurred, but denies any problems with word finding or
comprehension. No dysphagia. No change in bowel or bladder
movements. She has had a pounding bitemporal headache on and
off since Friday (has one now) which is similar to her normal
migraine headaches.
Past Medical History:
CAD, s/p CABG x 3, mult caths and stenting procedures, many
angina admissions, EF >=60% on echo from [**2-27**]; most recent
stenting in [**12/2146**]
DM2-insulin dependent with neuropathy
COPD
obesity
hyperlipidemia
HTN
anemia of chronic disease followed by a hematologist
GERD
Diverticulitis
OSA
chronic migraine headaches
chronic pain/arthritis
depression
anxiety
s/p appy, s/p ccy
benign bladder tumor
Social History:
Lives at home with husband. children are grown. No tobacco
currently (10 PY history), no alcohol, no recreational drugs.
Used to work as sales clerk. On disability since CABG in [**2140**].
Family History:
Mother deceased at 69 with diabetes, renal failure, and one MI
in 50s. Father deceased at 57 from alcoholic liver disease, had
1st MI at 52. No family history of stroke or migraines.
Physical Exam:
On admission:
T- 96.4 BP- 149/80 HR- 62 RR- 9 O2Sat- 100% on 3L
Gen: Lying in bed, NAD, obese
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. Mild dysarthria but speech easily
understandable. Registers [**2-25**], recalls [**2-25**] in 5 minutes. No
right left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus. Some
horizontal diplopia at midline, worse with left gaze, better
with right gaze. Sensation intact V1- V3. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. L arm bobs with testing for drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 4+ 4 4+ 5 5- 4+ 5 4+ 4 5 5 5 5 5
Sensation: Intact to light touch and pinprick throughout,
decreased to vibration and proprioception to ankles. No
extinction to DSS
Reflexes:
Trace in patella and achilles bilaterally. 1+ in biceps and
triceps and BR bilaterally. Toes mute bilaterally
Coordination: marked dysmetria on FNF on left, intact on R
Gait: not assessed
On discharge:
Mental status: intact
Cranial nerves: minimal nystagmus on left, right, and upgaze.
Numbness in right face sparing medial cheek, with paresthesias
worst in the right ear.
Motor: strength full bilaterally.
Sensation: intact
Reflexes: as above
Coordination: improved, with mild dysmetria on left
Gait: steady, narrow based, with walker.
Pertinent Results:
OSH labs from [**2-15**]:
WBC 12.7 Hct 39.1 Plt 162 Hgb 12.9 Na 134 K 4.7 Cl 99 HCO3 23
BUN 26 Cr 0.9 Glucose 317
Imaging:
Head CT from OSH:
- new 3 cm area of density within the left cerebellar hemisphere
with surrounding edema with mass effect and shift of the 4th
ventricle to hte R of midline and partial effaceemtn of the
paramesencephalic cisterns at the level of the pons
- 3rd and lateral ventricles symmetric and not enlarged
MRI from OSH (per Neurology consult note):
- 3 cm area of restricted diffusion in the L cerebellum with
mass effect on the 4th and medulla, more c/w acute to subacute
infarct (no report available)
Head CT noncontrast [**2147-2-7**]: A large area of hypodensity
centered in the right cerebellum measuring approximately 47 x 46
mm, with a laterally centered region of higher density measuring
28 x 32 mm is seen, probably representing the known left
cerebellar infarct. This infarct has mass effect on the
midbrain and superior medulla, with compression of the fourth
ventricle rightward. The vermis is displaced rightward,
approximately 7 mm. The cerebellopontine angle cistern and
superior medullary cisterns are effaced.
The lateral ventricles are more prominent than they were in the
[**2145-3-18**] CT scan, concerning for noncommunicating
hydrocephalus. There is no evidence of transependymal edema.
Hypodensities in both corona radiata, especially surrounding the
frontal lobes and in the subinsular white matter on the left
indicate chronic microvascular changes. Imaged sinuses are
clear. No fractures are seen.
IMPRESSION: Left cerebellar edema causing compression and
rightward shift of fourth ventricle and effacement of posterior
fossa cisterns.
MRI/MRA with contrast brain [**2147-2-7**]:
FINDINGS: MR HEAD: Within the left cerebellar hemisphere, there
is a large rounded lesion measuring approximately 3 cm in
greatest diameter, which is heterogeneous in signal on T2 and
slightly hyperintense on T1 weighted images. There is
susceptibility artifact noted on the gradient-echo sequence. On
the post- gadolinium images, there is mild peripheral
enhancement identified. There is T2 hyperintensity surrounding
the lesion extending into the superior aspect of the cerebellum,
consistent with surrounding edema. The lesion is hyperintense on
diffusion-weighted images, which could be due to the blood
products. This lesion could represent a subacute infarct with
hemorrhagic transformation. However, an underlying hemorrhagic
mass cannot be entirely excluded, although the clinical history
includes vascular risk factors predisposing to infarction of the
brain. A follow-up study in several weeks to determine lesion
evolution may be helpful in distinguishing these entities.
There is a ventricular shunt catheter which enters through the
right frontal region and terminates in the region of the right
foramen of [**Last Name (un) 2044**]. There is no evidence of hydrocephalus. There
are scattered areas of T2 hyperintensity within the cerebral
periventricular white matter that were present on the prior
study and are not changed, consistent with chronic small vessel
infarction.
MRA HEAD: There is termination of the right vertebral artery as
a right posterior inferior cerebellar atery. The anterior and
posterior intracranial circulations are otherwise normal. There
is no evidence of aneurysm greater than 3 mm or focal stenosis.
No AV malformations are noted.
MRA NECK: The left vertebral artery is dominant. The right
vertebral artery terminates as a posterior inferior cerebellar
artery . The carotid arterial systems are normal. There is no
evidence of stenosis.
IMPRESSION:
1. Large area of hemorrhage in the left cerebellar hemisphere
2. Unremarkable MR angiogram of the head/neck.
Head CT Noncontrast:
FINDINGS: Since the prior CT examination, there has been
interval placement of a right ventricular shunt catheter with
its tip terminating in the region of the foramen of [**Last Name (un) 2044**] on the
right. The ventricles have decreased in size as compared to the
prior CT scan.
As before, there is a large area of hypodensity within the left
cerebellar
hemisphere with a slightly more dense structure centered within
the area of hypodensity. This lesion could represent an area of
infarction with
hemorrhagic transformation. However, underlying hemorrhagic
lesion cannot be entirely excluded. There is mass effect with
rightward displacement of the cerebellar vermis as well as
compression of the fourth ventricle. There is also effacement
of the cerebellopontine angle cisterns. There is no new
intracranial hemorrhage. There is no shift of the normally
midline
structures.
IMPRESSION:
1. No change from [**2147-2-7**] scan, regarding the left cerebellar
hemisphere lesion which may represent a subacute infarct with
hemorrhagic transformation. However, underlying hemorrhagic mass
cannot be entirely excluded. Nevertheless, given the history of
diabetes, hypertension, and severe cardiac disease, cerebellar
infarction would seem a reasonable diagnostic consideration.
Additionally, a prior MR study from [**2145-2-26**] disclosed two chronic
lacunar infarcts within the inferior aspect of the left
cerebellar hemisphere, suggesting prior vascular disease in some
proximity to the new, much larger lesion.
2. Interval placement of ventricular shunt catheter, with
decompression of the ventricular system.
HCT [**2-15**]:
Since [**2147-2-8**], there has been improvement in the
amount of mass effect within the left cerebellar hemisphere with
less mass effect upon the fourth ventricle.
Status post removal of the right frontal ventriculostomy
catheter with unchanged configuration of the lateral ventricles.
There is still a possibility of mild hydrocephalus as the
frontal horns of the lateral ventricles remain rounded, in
contrast to the [**2-8**] study.
Brief Hospital Course:
Impression: 53 y/o with a long-standing history of CAD s/p CABG
x 3 and multiple stenting procedures (last [**12/2146**]), HTN, DM,
Hyperlipidemia, obesity, who presented with a 3 cm L cerebellar
infarct and concern for mass effect and pressure on the medulla.
Hospital course is reviewed below by system:
NEURO: Ms. [**Known lastname 1662**] was admitted to NeuroICU service. By history
the infarct most likely occurred on early Friday, [**2-3**] (4 days
PTA). Exam was significant for marked L sided dysmetria,
diplopia on L gaze but full EOM and mild L hemiparesis, which
was not seen by Neurology at OSH. Stat head CT was performed
which showed left cerebellar edema causing compression and
rightward shift of fourth ventricle and effacement of posterior
fossa cisterns. Given the new deficits found on neuro exam and
neuroimaging results, the patient was taken emergently to the OR
for placement of an external ventricular drain. She was given
50mg IV mannitol, 10mg IV Decadron and 6 bags of platelets due
to ASA and Plavix inactivation. Cardiology was consulted prior
to procedure for evaluation of risk factors and management of
anti-platelet medications peri-operatively. The EVD was placed
in the OR without complications.
As patient did not tolerated MRI, she was taken post-operatively
while intubated and sedated for MRI of brain and neck which was
suggestive of either a subacute infarct with hemorrhagic
transformation or an underlying hemorrhagic mass. The
ventricular shunt catheter entered through the right frontal
region and terminated in the region of the right foramen of
[**Last Name (un) 2044**]. There was periventricular chronic small vessel
infarction without evidence of hydrocephalus. MRA revealed a
dominant left vertebral artery and right vertebral artery
terminating as a right posterior inferior cerebellar atery.
Carotids were normal. There was no evidence of stenosis,
aneurysm or AV malformation. A follow-up study in several weeks
to determine lesion evolution was recommended.
Sedating medications were held, including Xanax and Ambien.
Topamax and Effexor were continued for migraine prophylaxis.
She was continued on neurontin per home regimen for chronic pain
and arthritis; oxycontin was changed to fentanyl and dilaudid.
Ms. [**Known lastname 1662**] improved clinically through her hospital course. On
[**2-10**], she had sudden onset of headache, followed by R face
numbness (top of head to ear to right face, sparing chin),
followed by moving diagonal lines across her vision. A repeat
head CT was unchanged. The facial numbness was persistent on
discharge and thought to be due to irritation from the EVD
intervention.
The EVD remained in until [**2-14**]; a repeat head CT was performed
after removal and was stable, reviewed by neurosurgery. Mannitol
was discontinued on [**2-13**]. Decadron was tapered and discontinued
just prior to discharge. Aspirin and plavix were restarted on
[**2-15**]. She will follow up with neurosurgery for further
evaluation of the cerebellar lesion (infarct vs mass), as well
as in neurology clinic.
CV: ASA and Plavix were held throughout the hospitalization
while the EVD was in place. Her statin was restarted. BP was
initially allowed to autoregulate to maximize cerebral
perfusion, though Metoprolol and Isordil were continued given
her history of severe CAD. Her BP and HR were optimized with HR
in the 60s and SBP generally <120.
PULM: She has a history of COPD and sleep apnea. She is on home
O2. She was electively intubated for EVD placement on [**2-7**] and
was subsequently extubated on [**2-8**] without complication. She
was stable on 3L NC (her home dose).
ID: Patient was continued on Cefazolin IV until EVD was
discontinued. She was clinically diagnosed with a UTI and was
treated with ciprofloxacin x 3 day course. A urinalysis was
negative.
ENDO: Patient was on insulin drip while in the ICU and was
switched to fixed dose glargine then NPH once transferred out of
the ICU. She was also covered with ISS. As the decadron was
weaned off prior to discharge, she was discharged on her home
insulin regimen.
FEN: Patient was hyponatremic Na 128-130 and received 500cc
hypertonic saline with good correction. Urine Na and Osm were
checked to evaluate for SIADH. Serum osm ranged 300 or less.
She was fluid restricted while hyponatremic with good response;
this was loosened as the mannitol was weaned off and she was
normonatremic at discharge.
Medications on Admission:
Home Meds (from OSH records)
Aspirin 325 mg PO DAILY, Xanax 1 mg [**Hospital1 **] (8A and 12P), Ca
Carbonate, Clopidogrel 75 mg PO DAILY, Venlafaxine 225 mg QD,
Atorvastatin 40 mg PO HS, Zolpidem 10 mg PO HS, Metoprolol
Tartrate 50 QD, Isordil 40 TID, Topiramate 75 mg PO BID,
Pantoprazole 40 mg [**Hospital1 **], Gabapentin 600 [**Hospital1 **] (8A and 12P),
Oxycontin 60 mg TID
Docusate Sodium 100 mg PO BID, Actos 30 mg PO once a day, Lantus
42 units QHS
Diltiazem HCl 120 PO DAILY, Naproxen 500 mg PO BID NTG PRN chest
pain, Miralax 17 g daily PRN, Humalog sliding scale
Meds on Transfer
Aspirin 325 mg PO DAILY, Xanax 1 mg Q6H, Dexamethasone 4 mg PO
Q6H, Ca Carbonate, Clopidogrel 75 mg PO DAILY, Venlafaxine 225
mg QD, Atorvastatin 40 mg PO HS, Zolpidem 10 mg PO HS,
Metoprolol Tartrate 50 QD, Isordil 40 TID
Topiramate 75 mg PO BID, Pantoprazole 40 mg [**Hospital1 **], Gabapentin 600
[**Hospital1 **] (8A and 12P)
Oxycontin 60 mg TID, Docusate Sodium 100 mg PO BID, Actos 30 mg
PO once a day, Lantus 21 units QHS HISS, Diltiazem HCl 120 PO
DAILY, Naproxen 500 mg PO BID
NTG PRN chest pain, Ondansetron 4 mg IV Q4H PRN nausea, Humalog
sliding scale
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Carbonate Oral
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours).
Disp:*240 Capsule(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
16. Humalog Subcutaneous
17. Lantus 100 unit/mL Cartridge Sig: Forty Two (42) units
Subcutaneous at bedtime.
18. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
19. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
20. MRI
MRI head with and without contrast to evaluate cerebellar lesion
seen on MR [**2-7**] (?infarct vs mass)
Please send report to Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 2574**]) and Dr. [**Last Name (STitle) **]
(617-63-BRAIN).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Left cerebellar lesion, likely infarct
Hyponatremia
Coronary artery disease
Hypertension
Diabetes mellitus
Urinary tract infection
Discharge Condition:
Stable. Improving examination with mild left sided dysmetria,
nystagmus, and baseline gait. No chest pain or dyspnea.
Discharge Instructions:
Take all medications as prescribed.
Follow up with Dr. [**Last Name (STitle) 5311**] and Dr. [**First Name (STitle) **] as scheduled. Call
63-BRAIN to make an appointment with Dr. [**Last Name (STitle) **] in 4 weeks.
Please get your MRI performed in 3 weeks. Bring copies of the
MRI to your appointments.
Call your doctor or go to the emergency room if you have any
worsening of your walking, speaking, or hand incoordination, or
if you have any new symptoms, including weakness, numbness, loss
of consciousness, visual problems, chest pain, difficulty
breathing, nausea, vomiting, or any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 5311**] ([**Telephone/Fax (1) 5317**]) to follow up in the next
week.
Get your MRI performed in 3 weeks and bring the results to your
appointments with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **].
Please call Dr.[**Name (NI) 9034**] office (617-63-BRAIN) to make a follow
up appointment for 3-4 weeks from now.
Follow up in the neurology clinic:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2147-3-20**] 3:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"348.5",
"327.23",
"401.9",
"496",
"276.1",
"272.4",
"530.81",
"331.4",
"278.01",
"414.01",
"357.2",
"250.60",
"285.29",
"V45.81",
"431",
"599.0",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
20170, 20231
|
12502, 16972
|
394, 440
|
20406, 20526
|
6633, 12479
|
21193, 21853
|
4199, 4383
|
18180, 20147
|
20252, 20385
|
16998, 18157
|
20550, 21170
|
4398, 4398
|
6278, 6278
|
320, 356
|
468, 3546
|
6316, 6614
|
4412, 4722
|
6293, 6300
|
4746, 4746
|
3568, 3975
|
3991, 4183
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,071
| 149,337
|
34466
|
Discharge summary
|
report
|
Admission Date: [**2122-11-15**] Discharge Date: [**2122-11-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypothermia, bradycardia
Major Surgical or Invasive Procedure:
central venous line [**11-15**]
arterial line [**11-15**]
History of Present Illness:
88 yo female with hx of Multiple Sclerosis, DM p/w hypoglycemia,
hypothermia from nursing home. Per NH worker, patient had low
HR to 40-50 (baseline that am had been 70s) and reported that
she was feeling off-balance. Per EMS had FS 30 and given 1M
glucagon. Ms. [**Name14 (STitle) 79210**] had a recent UTI w/ ATBx at [**Location (un) 745**]
[**Hospital 3678**] Hospital for 7 days. Her baseline mental status is
oriented x 3 with reported fluid conversation about current
political climate.
Patient had 2 admissions in the past 3 weeks for AMS. One week
after [**Holiday 1451**] she developed AMS and was taken to [**Hospital 732**]
Hospital. They thought she had a UTI but her culture was
negative. She had a temperature during that admission of 92.0.
She returned to the [**Hospital3 5277**] and one week later was
admitted to [**Location **] Wellesly with AMS and hypothermia. She was
altered for 3 days and had 2 CTs and an MRI which were
inconclusive. She returned to the institution where on date of
arrival she began having AMS again. Per NH worker, patient's MS
had retunred to baseline.
.
Upon presentation to the ED, vitals were: T 97.1, HR 55, BP
130/60, RR 18, O2Sat 96% RA. In the ED was noted to have
somnolence, though would respond appropriately to questions when
awakened. Was given 1L fluid bolus and then started on D51/2NS
@ 100 mL/hr due to hypoglycemia. Blood cultures were drawn and a
U/A with urine culture was sent in addition to stool cultures
including clostridium dificile. A CXR showed CHF, and b/l L>R
pleural effusions but no consolidation. Patient was empirically
given Vancomycin and Zosyn. Prior to presentation to the floor,
vitals were: T 33.7 rectally, HR irregular 40s-50s, BP 101/35,
RR 13, O2Sat 99% 2L NC. Patient was given another 1L NS bolus
enroute.
.
ROS was unattainable due to patient's altered mental status.
Past Medical History:
1. Multiple sclerosis since [**2092**], followed at [**Hospital1 112**]
2. CAD
3. Hypothyroidism
4. Papillary thyroid cancer
5. Muscle spasma
6. Osteoporosis
7. Insomnia
8. Macular degeneration
9. Deprssion
10. CHF
11. fibromyalgia
12. afib
13. AMI? [**2115**], [**2116**]
14. GERD
15. Gout
16. DM?
17. CRI
Social History:
Denies ETOH or tobacco.
Patient is wheelchair-bound at baseline.
Family History:
Brother deceased of leukemia.
Physical Exam:
BP: 97/39, HR: 55, RR: 17, 99% on NC
GENERAL: Pleasant, ill-appearing, soft spoken woman in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA but small/EOMI. MMM. OP clear.
CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs
or [**Last Name (un) 549**].
LUNGS: crackles anteriorly b/l
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: warm, pitting b/l LE edema R>L
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox1 completely but knows month and can repeat the type
of place she is in. Appropriate.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2122-11-15**] 11:31AM GLUCOSE-130* UREA N-8 CREAT-0.3* SODIUM-139
POTASSIUM-2.5* CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2122-11-15**] 11:31AM ALT(SGPT)-9 AST(SGOT)-16 LD(LDH)-119 ALK
PHOS-79 TOT BILI-0.2
[**2122-11-15**] 11:31AM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.3*
[**2122-11-15**] 11:31AM WBC-5.4 RBC-3.15* HGB-9.3* HCT-28.7* MCV-91
MCH-29.5 MCHC-32.5 RDW-15.9*
[**2122-11-14**] 11:47PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2122-11-14**] 11:47PM URINE RBC-21-50* WBC->50 BACTERIA-RARE
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2122-11-14**] 11:10PM GLUCOSE-114* UREA N-11 CREAT-0.5 SODIUM-137
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11
[**2122-11-14**] 11:10PM WBC-4.0 RBC-3.30* HGB-9.5* HCT-28.9* MCV-88#
MCH-28.8 MCHC-32.8 RDW-16.2*
[**2122-11-14**] 11:10PM NEUTS-40.8* LYMPHS-52.8* MONOS-3.3 EOS-2.3
BASOS-0.8
CT Chest/abdomen/pelvis [**2122-11-16**]:
1. Right ureteral and bladder wall thickening with right-sided
hydronephrosis and hydroureter. The differential includes
ureteritis,
malakoplakia/leukoplakia, urothelial neoplasm. Direct
visualization when
possible is warranted.
2. Large bilateral pleural effusions with atelectasis.
3. Cholelithiasis.
Brief Hospital Course:
This is an 88-year-old woman with multiple sclerosis with recent
admissions for altered mental status and recent urinary
infections, who presents with bradycardia and hypothermia.
#. Septic shock: She was admitted with hypothermia and
hypotension that was thought to be due to overwhelming sepsis
from UTI; however, cultures never yielded an organism. The most
likely source was felt to be the urinary tract, especially given
her recent admissions for UTIs. An infectious work-up including
cultures and CXR were done and the patient was started on
Vanc/Zosyn/Cipro at admission which was changed to
Vanc/Meropenem/Cipro on [**11-15**]. Her PICC line discontinued on
[**11-14**], and Ms. [**Known lastname 79211**] tested negative for C. diff. She
required pressor support through [**11-17**]. Her central venous
pressures were initially low. She responded well to IVF, though
with increased pulmonary edema on x-ray; however, they were
continued due to improved clinical picture and stable O2 sats.
Over the [**Holiday **] holiday, patient took a turn for the worse;
she became less responsive, and temperatures ranged as low as
90.5. She also refused BairHugger or more blankets stating she
"needed air." Most likely representative of overwhelming septic
infection. After long discussions with the family, it was felt
that maximal medical care was not improving patient's
condition/situation, and focus was changed toward optimizing
patient comfort. Family was onboard with all medical decisions
and seemed very satisfied with care. On [**11-21**], patient was made
"CMO" and antibiotics were withdrawn. Patient passed peacefully
overnight on [**11-22**].
#. Pyelonephritis: The most likely source of her infection was
felt to be the urinary source. A CT torso was performed, which
showed bilateral pleural effusions, and right hydroureter and
hydronephrosis. Urology was consulted, and felt that the
hydroureter could be a source of infection, but could be treated
conservatively with antibiotics as long as the patient remained
stable.
#. Dyspnea: Patient had a subjective sense of dyspnea during
admission but maintained a normal blood gas on nasal canula. It
was felt to be due to anxiety, delirium, and exacerbated by
BairHugger. Patient was treated symptomatically with morphine
and ativan.
#. Hypothyroidism: Continued on home levothyroxine dose as FT4
WNL.
#. Multiple sclerosis: During hospital course, baclofen was
started (home medication) for MS.
#. HTN: Home antihyptertensives were held in the setting of
hypotension and shock.
#. PPX: Continued DVT ppx with Lovenox 40 daily
HCP: [**Name (NI) **] [**Name (NI) 79211**] (son) cell [**Telephone/Fax (1) 79212**]; home [**Telephone/Fax (1) 79213**].
Medications on Admission:
Tylenol PM 25mg-500mg/15mL WHS
ASA 81 mg daily
Tiazac 120 mg Cap daily (Diltiazem)
Fosamax 70mg tab weekly
Baclofen 10mg tab TID
Calcium carbonate 500mg tab [**Hospital1 **]
Lovenox 40 mg SC daily
Levothyroxine 50 mcg daily
MVI daily
Zinc sulfate 220 mg daily
senakot 2 QHS
Ascorbic Acid 500 mg tab daily
Bisacodyl 10mg PR every other am
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
|
[
"733.00",
"V10.87",
"340",
"403.90",
"785.52",
"244.9",
"038.9",
"995.92",
"428.0",
"V58.67",
"284.1",
"285.9",
"414.00",
"707.20",
"584.5",
"585.9",
"427.89",
"707.03",
"530.81",
"590.80",
"591",
"427.31",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7820, 7829
|
4652, 7391
|
289, 348
|
7889, 7907
|
3364, 4629
|
7972, 7991
|
2688, 2719
|
7779, 7797
|
7850, 7868
|
7417, 7756
|
7931, 7949
|
2734, 3345
|
225, 251
|
376, 2251
|
2273, 2590
|
2606, 2672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,391
| 192,758
|
26955
|
Discharge summary
|
report
|
Admission Date: [**2103-4-9**] Discharge Date: [**2103-4-11**]
Date of Birth: [**2031-4-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 year old male with CHF (EF 10%), ESRD on HD, who has been
having 3 weeks of malaise, weakness, SOB, and cough. He
presented to [**Hospital1 2177**] ED today with malaise and his K was found to be
6.4. He was given insulin and glucose, and then sent to
outpatient dialysis where his K was 7.0 (? hemolyzed), and it
was thought that he "didn't look right." Outpatient dialysis
reportedly that they did not "feel comfortable dialyzing him",
so he was sent to [**Hospital1 18**] ED. Last dialysis was Friday. He has had
continued diarrhea which he states is close to his baseline. He
also complains of several months of abdominal pain. His stools
have been intermittently guiaic positive. Per pt, pain not
worse when eating.
.
In [**Hospital1 18**] [**Name (NI) **], pt had EKG with was given insulin, D50, bicarb, and
kayexalate. Nephrology was consulted, and he was admitted for
dialysis. He arrived at the dialysis unit, and then refused
dialysis because he says he wasn't feeling up to it. He was
transfered to the general medical floor where a trigger was
immediately called due to hypotension, hypothermia, and hypoxia.
Temp 94.2 axillary, BP 82/50, pulse 65. RR 20, 99% on RA but
intermittently dropping to 60s.
.
He was last admitted to [**Hospital1 2177**] where he gets all of his care on
[**2103-2-18**] for viral gastroenteritis and had a normal abdominal
CT (by report). He says he currently feels OK but has continued
cough, SOB, and abdominal pain. These are the same symptoms he
has been experiencing for the last three weeks. No urinary
symptoms.
Past Medical History:
(Followed at [**Hospital1 2177**])
CHF: EF 10%
ESRD on HD for 6 months via tunneled cath
type 2 DM
1st degree AVB
Anemia of chronic disease
severe PVD
s/p right BKA
s/p amputation of all left toes
s/p 2nd left finger amputation
depression
h/o alcohol abuse
h/o upper GI bleeding
s/p hernia repair
Social History:
Retired meat cutter. He lives with his wife, he smokes 10
cigarettes a day. He has a h/o EtOH abuse but denies EtOh usage
at this time.
Family History:
NC
Physical Exam:
t 96.2, bp 105/61, p 61, r 20 96% RA
Alert and oriented.
Well appearing NAD
PERRL. OP clr.
JVP 7cm
Regular s1,s2. no m/r/g
R basilar coarse crackles
+bs. soft. nt. nd.
No LLE edema. R BKA.
Pertinent Results:
[**2103-4-9**] 05:59PM BLOOD Glucose-53* K-7.0* calHCO3-24
[**2103-4-9**] 06:26PM BLOOD Glucose-103 Na-140 K-5.2 Cl-99*
calHCO3-23
[**2103-4-9**] 10:26PM BLOOD Calcium-9.4 Phos-6.8* Mg-2.4
[**2103-4-9**] 06:20PM BLOOD CK-MB-3 cTropnT-0.07*
[**2103-4-10**] 04:40AM BLOOD CK-MB-4 cTropnT-0.07*
[**2103-4-10**] 04:40AM BLOOD Lipase-11
[**2103-4-9**] 06:20PM BLOOD CK(CPK)-103
[**2103-4-10**] 04:40AM BLOOD ALT-20 AST-15 LD(LDH)-179 CK(CPK)-94
AlkPhos-100 Amylase-47 TotBili-0.4
[**2103-4-9**] 06:20PM BLOOD Glucose-142* UreaN-58* Creat-8.1* Na-136
K-5.6* Cl-93* HCO3-24 AnGap-25*
[**2103-4-10**] 04:40AM BLOOD Glucose-67* UreaN-62* Creat-8.4* Na-144
K-4.8 Cl-96 HCO3-28 AnGap-25*
[**2103-4-10**] 04:40AM BLOOD WBC-4.0 RBC-3.61* Hgb-12.1* Hct-38.0*
MCV-105* MCH-33.5* MCHC-31.8 RDW-16.4* Plt Ct-176
.
CXR: Severe enlargement of the cardiac silhouette is largely
due to cardiomegaly but some pericardial effusion may be
present. Mild interstitial pulmonary abnormality is of uncertain
chronicity and could be edema or chronic change. Pleural
effusion if any is small, and subpulmonic on the right. No
pneumothorax or pathologic widening of the mediastinum is
present. Tips of the dual-channel hemodialysis catheter both
project over the right atrium. No pneumothorax.
.
Echo:
EF 10-20%
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (the basal
inferior/inferolateral wall moves best). No masses or thrombi
are seen in the left ventricle. Tissue Doppler imaging suggests
an increased left ventricular filling pressure(PCWP>18mmHg). The
right ventricular cavity is dilated. There is moderate global
right ventricular free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The
tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. The estimated pulmonary
artery systolic pressure is normal. The pulmonic valve leaflets
are thickened. Significant pulmonic regurgitation is seen. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
.
IMPRESSION: Severe dilated biventricular cardiomyopathy. No
pericardial
effusion. Elevated left sided filling pressures. Severe
tricuspid
regurgitation.
Brief Hospital Course:
Impression: 71 yo m with CHF (EF 10%), ESRD on HD, admitted with
hyperkalemia, transferred to the ICU w/ ? of transient
hypotension and desaturation, with ? PNA.
.
#Hypotension, hypoxia, hypothermia - by report, vital signs
stable on arrival to the ICU without intervention. Remained
stable on the floor; no evidence of sepsis physiology.
.
#PNA - had ?retrocardiac opacity on CXR, symptomatology as
above. However no fevers, chills, sweats or leucocytosis. Anx
not continued on d/c.
.
#ESRD/Hyperkalemia: now resolved after HD.
.
#Lateral tw inversions: now resolved. ? if patient had demand
ischemia in the setting of decompensation. Serial CE checked;
ruled out for MI. No complaints of chest pain.
.
#CHF: pt with EF 10% (unknown etiology). Unclear why patient is
not on ASA.
Continued on carvedilol, ACE. Would consider aggresively
titrating his statin to goal <70 if etiology is ischemic.
.
#? pericaridal effusion- no pulsus on exam and patient
clinically well. TTE obtained; no sig pericardial effusion.
.
#Abd pain: pt reports several months of intermittent abd pain.
Benign exam; LFTs/[**Doctor First Name **]/Lip. Further w/u deferred to outpt as pt
tolerated full POs.
Medications on Admission:
same
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO every other
day.
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
1. Hyperkalemia
2. Chronic Kidney Disease
3. Systolic Congestive Heart Failure
4. Abdominal Pain, NOS
Secondary Diagnoses:
Type 2 DM
1st degree AVB
Anemia of chronic disease
severe PVD
s/p right BKA
s/p amputation of all left toes
s/p 2nd left finger amputation
depression
h/o alcohol abuse
h/o upper GI bleeding
s/p hernia repair
Discharge Condition:
stable
Discharge Instructions:
Please make sure to contact your primary care physician or Dr.
[**Last Name (STitle) 1366**] should you develop any fevers, chills, sweats, nausea,
vomiting, diarrhea, or any other complaints.
Followup Instructions:
Please make sure to follow up with your primary care physician
or Dr. [**Last Name (STitle) 1366**].
|
[
"426.11",
"789.00",
"V49.75",
"250.00",
"276.7",
"285.21",
"585.6",
"V45.1",
"443.9",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7070, 7076
|
5472, 6662
|
327, 334
|
7474, 7483
|
2649, 5449
|
7724, 7828
|
2420, 2424
|
6717, 7047
|
7097, 7222
|
6688, 6694
|
7507, 7701
|
2439, 2630
|
7243, 7453
|
275, 289
|
362, 1928
|
1950, 2249
|
2265, 2404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,586
| 154,342
|
50138
|
Discharge summary
|
report
|
Admission Date: [**2103-9-5**] Discharge Date: [**2103-9-11**]
Date of Birth: [**2051-12-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin / Methotrexate / Ticlid / Bactrim Ds /
Allopurinol / Tetracycline
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
hypotension and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51F with PMH significant for mixed connective tissue disease on
chronic prednisone, CAD, T2DM, and h/o aspiration PNA,
presenting to ED after feeling chills this AM, and finding temp
to be 104F. She had a mild chronic cough and dyspnea at
baseline, but denies any worsening over the past few days. She
does not recall any choking or possible aspiration event. She
denies any abdominal pain or bowel symptoms, other than
constipation with no stools x 5 days. No F/C/NS prior to the
morning of admission.
Past Medical History:
1. CAD, status post AMI in [**2096**], s/p LCx stenting in [**2096**] c/b
instent restenosis --> restented with 2 Cypher stents on
[**2102-4-5**]. Also s/p 2 cypher stents in mid RCA [**2102-4-5**] and
stenting of proximal RCA. LAD diffusely diseased up to 40%, no
intervention. EF 48% on ventriculography.
2. Mixed connective tissue disease manifested by myositis, +
[**Doctor First Name **], GERD, Raynaud's, sclerodactyly, malar rash, telangiectasia.
3. Diabetes mellitus type 2
4. Hypertension
5. Gout
6. Status post CVA without residual deficit
7. GERD with Barrett's esophagus
8. Peripheral neuropathy
9. ? H/O GIB in [**11-14**]. C-scope unrevealing- Grade 1 internal
hemorrhoids. Diverticulum in the sigmoid colon. Bluish
discoloration in the lateral wall of the terminal ileum
compatible with unclear significance.
10. Rt Breast bx lobular carcinoma in situ
Social History:
She lives with her husband. They have no children. She is a
lifelong non-smoker. No EtOH. At baseline, she ambulates with a
walker.
Family History:
Notable for CAD including her mother who died at age 52 of an
MI. Father had CABG in his 50s and later died of an MI. Two
brothers with [**Name (NI) 5290**] in their 50's and one with a CVA.
Physical Exam:
On admission:
PE: T: 101.7F BP 107/55 HR 102 RR 22 SaO2: 98% 2L NC
Gen: Sleepy but interactive, Cushingoid, NAD
HEENT: Sclerae anicteric, conjunctiva clear, very dry MM, OP
clear with no lesions or exudates.
Neck: Supple, no LAD
CV: RRR, no m/r/g, nl S1 and S2
Chest: R basilar rales, L bronchial breath sounds, otherwise
CTAB
Abd: Soft, obese, ND, slightly TTP RLQ, minimal bowel sounds
throughout. No HSM appreciated. Guiaic neg in ED.
Extr: Tr LE edema bilaterally, dopplerable pulses, evidence of
vascular insufficiency with loss of extremity hair and skin
thickening. R great toe bluish and cool, which pt states is
chronic.
Neuro: A&Ox3, no focal deficits
Pertinent Results:
[**2103-9-5**] 09:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2103-9-5**] 09:40AM PT-12.2 PTT-24.5 INR(PT)-1.0
[**2103-9-5**] 09:40AM WBC-13.0*# RBC-3.14* HGB-9.7* HCT-27.4*
MCV-87 MCH-30.8 MCHC-35.3* RDW-14.9
[**2103-9-5**] 09:40AM CK-MB-NotDone cTropnT-0.02*
[**2103-9-5**] 09:40AM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-150
CK(CPK)-40 ALK PHOS-160* TOT BILI-0.2
[**2103-9-5**] 09:40AM GLUCOSE-166* UREA N-45* CREAT-1.3* SODIUM-141
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-15* ANION GAP-20
[**2103-9-5**] 10:27AM TYPE-[**Last Name (un) **] PO2-62* PCO2-30* PH-7.32* TOTAL
CO2-16* BASE XS--9 COMMENTS-NOT SPECIF
[**2103-9-5**] 03:24PM CORTISOL-5.2
[**2103-9-5**] 04:36PM CORTISOL-7.6
[**2103-9-5**] 09:07PM WBC-29.3*# RBC-2.66* HGB-8.4* HCT-24.2*
MCV-91 MCH-31.4 MCHC-34.5 RDW-15.5
[**2103-9-5**] 09:07PM GLUCOSE-156* UREA N-32* CREAT-1.0 SODIUM-143
POTASSIUM-4.6 CHLORIDE-120* TOTAL CO2-11* ANION GAP-17
Brief Hospital Course:
In ED, temp 103.5F, and BP found to be 60/40 with HR 110s-130s,
satting 98% on 2L NC. wbc 13.0 with 90% PMN and no bands, with
venous lactate 2.2. Initial VBG 7.32/30/62CXR revealed mild-mod
RML and RLL PNA. UA was unremarkable. A L IJ was placed, and she
was given 5L NS. She remained hypotensive to 60s/40s, and was
started on Levophed, which was titrated up to 0.50mcg/kg/min.
She was given vancomycin, levofloxacin, and metronidazole, as
well as dexamethasone 10mg, and was sent to the floor for
further management.
In the ICU, pt was started on hydrocort 50 mg IV q6h, abx
changed to vanc and ceftaz, and insulin drip started. Levophed
drip slowly titrated down and turned off in late afternoon on
[**9-6**]. Insulin drip changed to SS insulin on [**9-7**] early morning.
Pt's exam much improved after two days, blood and urine cx's
negative, and she remained AF with large drop in WBC.
Transferred in stable condition to floor at 3pm on [**9-7**].
On arrival to 11R floor, she still had a co2 of 12 and scr of
1.3 on chem 7.
1) Aspiration pna - she improved on abx and at the time of dc,
had excellent o2 sat without requiring any supplemental o2. She
was seen by the speech and swallowing team. She has a long hx of
aspiration but does not always comply with recommendations to
prevent aspiration. These were reviewed and stressed to the pt
to prevent future episodes of aspiration. She will finish 3 days
of Levaquin as an outpt
2) Chronic steroid therapy for her mixed connective tissue
disorder
Her steroids were tapered down to 10mg daily. She is being sent
out on this dose daily until she sees her pcp, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who can
help her titrate down this dose.
3) Renal failure
her scr improved to 0.9 on day of discharge
4) DM
she was treated with sliding scale coverage during her hospital
stay because her metformin was held in setting of renal failure.
Now that her scr is improved, she's to return to taking her
metformin as an outpt.
5) Mobility
was seen by PT who felt her gait was good - no outpt PT
recommended
6) Followup plan
I asked her to call [**Company 191**] to make an appt with either Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
or an episodic provider within one week of discharge.
Medications on Admission:
Aspirin 325mg PO qD
Clopidogrel 75mg PO DAILY
Probenecid 500mg PO QAM, 250mg PO qHS
Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Cholecalciferol (Vitamin D3) 400U PO qD
Furosemide 40mg PO qD
Valsartan 320mg PO qD
Gabapentin 300mg PO HS
Prilosec 80mg PO qD
MVI
Metformin 1000mg PO BID
Acetaminophen 650mg PO Q6H prn
Metoprolol Succinate 100mg XR PO qD
Oxycontin 10mg PO Q12H
Percocet 2.5-325 mg PO every 4-6 hours.
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*0 Capsule(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*2*
4. Probenecid 500 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*0 Tablet(s)* Refills:*2*
5. Probenecid 500 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
Disp:*0 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*0 Tablet(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*6 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
every 4-6 hours.
Disp:*0 * Refills:*2*
9. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*0 Tablet(s)* Refills:*2*
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*0 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
give with food.
Disp:*30 Tablet(s)* Refills:*2* Take this dose daily until you
see your provider in [**Name9 (PRE) 191**] within 1 week of discharge. He/she will
provide you with instructions to taper the dose at that time.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) Sepsis secondary to aspiration pneumonia
2) Renal failure
3) Poorly controlled diabetes mellitus
4) Chronic immunosuppression due to chronic steroid therapy
5) Anemia
Discharge Condition:
STable
Discharge Instructions:
Seek medical attention if you are not feeling well.
Followup Instructions:
Followup with your pcp, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or an episodic provider
within one week of discharge.
|
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icd9pcs
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2,394
| 103,734
|
1732
|
Discharge summary
|
report
|
Admission Date: [**2140-9-21**] Discharge Date: [**2140-10-11**]
Date of Birth: [**2098-4-4**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
central line placement
PICC Line placement ([**10-11**])
History of Present Illness:
(Pt is intubated and sedated on arrival to the [**Last Name (LF) 153**], [**First Name3 (LF) **] the
history is provided by his significant other, [**Name (NI) 401**]). Mr. [**Known lastname **]
is a 42 year-old male with a history of HIV infection and Lyme
disease who presents w/ a diffuse erythematous rash which
started today at 11am. The rash was first noticed last week. He
went to his PCP's office on [**2140-9-15**] when he first noted the
rash. It was described as a generalized, macular papular rash on
his torso and extremities. It was thought to be due to dapsone
(which was being used for PCP [**Name Initial (PRE) 1102**]) and it was
recommended that he d/c dapsone. He had been on dapsone since
mid-[**Month (only) 216**]. For PCP prophylaxis, he was then given inhaled
pentamidine (on [**9-15**]) without any problems. The patient was
advised to use benadryl for symptom relief. The following
weekend ([**Date range (1) 9879**]), the patient continued to have what his
partner described as an erythematous, "spotty" rash all over his
body. It was not itchy, but the patient took benadryl and
claritin RTC to help with the rash, without much improvement. He
also stopped taking Atripla (his previous HAART medication) and
began taking Kaletra and Truvada (the new HAART regimen which
had been prescribed by his PCP [**Last Name (NamePattern4) **] [**2140-9-8**]). He was noted to have
intermittent fevers to 101 and "heart palpitations". His partner
denied any symptoms of night sweats, chills, SOB, chest pain,
cough, URI sx, nausea, vomiting, abdominal pain, diarrhea. He
was noted to be fatigued and his partner states that the patient
"slept for the last 3 days". By Tuesday ([**9-20**]), the patient's
rash had resolved and he went to work without any complaints. He
was noted to have more energy that evening and slept well.
However, upon waking on [**2140-9-21**], he noted to his partner that he
felt poorly but tried to go to work. He also told his partner
that he was beginning a new medication today for pneumonia but
it was unclear what medication this was. The patient then
presented to the ER for further evaluation.
.
In the ER, initial VS were T 98.6, BP 103/51, HR 110, RR 18,
sats of 99% on RA. His initial complaint was of an allergic
reaction at work -he noted that his skin was warm, dry, flushed
and his eyes were red and itchy. He quickly then dropped his BP
to 74/41. He was bolused w/ IVF and started on vancomycin. His
temp started to rise and he was given ibuprofen. IVF were
continually bolused and CTX was given. His SBP remained in the
70s so he was put on dopamine through a peripheral IV while a
central line was placed. He was then switched to levophed. He
then became hypoxic with increasing O2 requirement and was
intubated in the ER using etomidate/succinylcholine. He received
a total of 5.5L of NS and had 80cc UOP (a foley had been
placed). Dermatology was consulted in the ER and had a ddx of
drug hypersensitivity, viral exanthem, or infection. They did
not feel that this was SJS.
.
Per the PCP notes at [**Name9 (PRE) 778**], the patient had stopped Atripla on
[**9-10**] due to a rash and had begun on Kaletra/Truvada on [**9-11**]. The
rash was felt to be self-limited as it resolved with
discontinuation of Atripla. He also noted that he had continued
on the dapsone up until [**2140-9-17**]. He commented on resolution of
the rash, but did note a HA over the weekend that was [**8-26**].
Given pt's intubated status and conflicting story from his
partner, it is unclear what meds the patient was receiving and
when he had discontinued others.
.
Of note, the patient was admitted with a similar chief complaint
in [**3-23**]. He presented with fever, acute renal failure, anemia
and joint pain. He was diagnosed with acute HIV infection (VL
>100,000K, CD4 of 180) and the remainder of the infectious w/u
was negative. ASO titer was positive and complement levels were
negative, but the patient was treated with a full course of
augmentin anyways. Anemia was felt to be due to iron deficiency
and outpatient workup was recommended. He then presented 2 days
after discharge with fever to 103.8, "red eyes", and rash. He
had a lactate of 2.8 at the time. He was initially treated with
CTX, vanco and acyclovir, had an LP (neg for meningitis), head
CT (neg for bleed), and CXR (no infiltrate). His abx were
initially switched to CTX and azithromycin. Lyme antibody was
positive so his antibiotics were switched to doxycycline for a
30 day course. He was discharged on cipro eye drops and
atovaquone for PCP [**Name Initial (PRE) 1102**].
Past Medical History:
1. Anal fissure
2. Adjustment disorder
3. Urethritis NOS [**2133**]
4. Depression/Anxiety
5. Pharyngeal gonococcal infection
6. Anal gonococcal infection
7. New diagnosis of HIV, VL > 100K, CD 4 pending; per his report
had negative HIV test in [**2139-12-18**]
Social History:
Pt is involved with a monogamous partner, with whom he lives
([**Name (NI) 449**]). He works as a social worker for the [**Location (un) **] of
Mass. He reports no recent sexual contact (>6 weeks [**2-19**]
decreased libido). His partner is monogamous per his report.
He drinks [**3-21**] glasses of wine on weekends. He denies tobacco
use. He does not use heroin or cocaine, but does admit to rare
marijuana use.
Family History:
Glaucoma (father, [**Name (NI) 9876**]. Sister and GM with DM.
Physical Exam:
VS - T 101.8, Tmax 102.8, BP 98/62, HR 129, RR 20, sats 96%
AC 500x20, PEEP 10, FiO2 100%
weight - 75kg pre-IVF; 83kg on admit
GEN: WDWN middle aged male intubated and sedated. .
HEENT: Sclera injected but anicteric. PERRL (3->2mm
bilaterally). OP clear around mouth (could not assess posterior
pharynx as pt intubated, OGT in place, pt not opening mouth). No
JVD but prominent visible carotid pulsations.
CV: Hyperdynamic precordium, prominent PMI in mid L clavicular
line. Tachycardic, regular. Normal S1, S2. No m/r/g.
LUNGS: Clear anteriorly at apices. Rhonchorous, vented breath
sounds throughout remainder anterior lung fields.
ABD: Firm, distended. Minimal BS. No rebound or guarding.
EXT: Warm, erythematous, 2+ PT, DP, radial pulses bilaterally. R
IJ. R art line.
GU: Penis w/o any lesions. Rectal exam in ED guaiac negative.
NEURO: Pt intermittently sedated and awake. When awake, follows
commands and answers questions appropriately. Can respond by
shaking head, writing. Using all 4 extremities spontaneously.
Downgoing toes bilaterally.
SKIN: Diffuse, erythematous, fine, maculopapular confluent,
blanching rash that is extensive over his face, neck, torso,
extremities (upper and lower bilaterally) and palms, but spares
his soles. Not pruritic, no excoriations, no skin lesions, no
bullae or vesicles.
Pertinent Results:
CT CHEST/ABDOMEN/PELVIS W/CONTRAST [**2140-10-10**] 10:23 AM
CT CHEST WITH INTRAVENOUS CONTRAST: There is dramatic
improvement in the bilateral effusions with minimal residual
bilateral atelectasis when compared to the previous study. The
central airways are patent to segmental levels bilaterally.
There is a small hyper attenuated lesion in the right middle
lobe of the lung, which is likely a tiny calcified granuloma.
There are small axillary lymph nodes under 1.5 cm as seen in the
previous study. There are no pathologically enlarged mediastinal
lymph nodes. There is no pericardial effusion.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen,
adrenal glands, pancreas, abdominal loops of small bowel are
unremarkable. There is resolved ascites when compared to the
last study. There is minimal gallbladder wall thickening likely
due to third spacing. Tiny paraortic lymph nodes noted, not
significantly enlarged by strict CT criteria.
PELVIS: Mild thickening of the right colonic wall, likely due to
third spacing. A comparison with a prior examination is
difficult due to the lack of contrast filling in the previous
study. Lower left ureter dilation with no evidence of
obstruction as seen in the previous study. No mass is identified
in and around the bladder. No significant lymphadenopathy within
the pelvis.
IMPRESSION:
1. Improvement of effusion and ascites when compared to previous
CT.
2. No abscess or fluid collection seen.
3. Mild right colonic wall thickening, possibly due to third
spacing. A comparison with a previous exam is difficult due to
the lack of opacification from oral contrast in the previous
study.
4. Dilated left lower ureter seen previously, possibly due to
reflux or ureterocele
<br>
CD4 Count ([**10-9**]) - 250.
ESR ([**10-9**])- 58
CRP ([**10-9**])- 20
<br>
<b>Micro Data:</b>
Blood Cx ([**10-1**]) - Coag negative staph x 2 bottles
All other blood/urine cultures negative
Throat strep culture ([**10-8**]) - negative
Toxo Culture ([**10-9**]) - negative
Pending Cultures/serology: blood ([**10-10**], [**10-9**], [**10-7**] x 2), fungal
([**10-6**]), paracoccidio ([**10-10**]), histo ([**10-10**])
<br>
[**2140-10-1**] EEG: "This is an abnormal portable EEG due to the
presence of
frontally predominant generalized delta frequency slowing
suggestive of
deep midline or subcortical dysfunction. No clear epileptiform
features
were seen."
[**2140-9-30**] Head MRI: "Area of encephalomalacia in the right
inferior frontal lobe. No abnormal enhancement, mass effect, or
hydrocephalus. No evidence of slow diffusion to indicate acute
infarct or signs of encephalitis."
[**2140-9-29**] Head CT: "No acute intracranial process. Specifically,
no evidence of hemorrhage, mass, or abnormal enhancement."
[**2140-9-21**] 12:00PM PLT SMR-NORMAL PLT COUNT-335
[**2140-9-21**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
[**2140-9-21**] 12:00PM NEUTS-38* BANDS-39* LYMPHS-17* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2140-9-21**] 12:00PM WBC-1.5* RBC-3.26* HGB-11.0* HCT-32.0* MCV-98
MCH-33.8* MCHC-34.4 RDW-16.0*
[**2140-9-21**] 12:00PM estGFR-Using this
[**2140-9-21**] 12:00PM GLUCOSE-96 UREA N-17 CREAT-1.4* SODIUM-139
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2140-9-21**] 12:37PM LACTATE-2.8* K+-3.9
[**2140-9-21**] 12:37PM COMMENTS-GREEN TOP
[**2140-9-21**] 01:44PM HGB-9.1* calcHCT-27 O2 SAT-78 CARBOXYHB-1 MET
HGB-3*
[**2140-9-21**] 04:30PM URINE HYALINE-0-2
[**2140-9-21**] 04:30PM URINE RBC-0-2 WBC-[**3-21**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2140-9-21**] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2140-9-21**] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2140-9-21**] 04:30PM URINE UHOLD-HOLD
[**2140-9-21**] 04:30PM URINE HOURS-RANDOM
[**2140-9-21**] 08:54PM O2 SAT-94
[**2140-9-21**] 08:54PM LACTATE-2.5*
[**2140-9-21**] 08:54PM TYPE-ART TEMP-38.8 RATES-20/6 TIDAL VOL-500
PEEP-10 O2-90 PO2-315* PCO2-43 PH-7.30* TOTAL CO2-22 BASE XS--4
AADO2-302 REQ O2-55 INTUBATED-INTUBATED
[**2140-9-21**] 09:08PM PLT SMR-NORMAL PLT COUNT-301
[**2140-9-21**] 09:08PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2140-9-21**] 09:08PM NEUTS-87* BANDS-12* LYMPHS-0 MONOS-0 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2140-9-21**] 09:08PM WBC-4.8# RBC-2.73* HGB-9.4* HCT-26.9* MCV-99*
MCH-34.6* MCHC-35.0 RDW-15.4
[**2140-9-21**] 09:08PM CALCIUM-6.2* PHOSPHATE-2.1* MAGNESIUM-1.2*
[**2140-9-21**] 09:08PM ALT(SGPT)-75* AST(SGOT)-77* LD(LDH)-426* ALK
PHOS-54 TOT BILI-0.4
[**2140-9-21**] 09:08PM GLUCOSE-98 UREA N-18 CREAT-1.4* SODIUM-139
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-19* ANION GAP-14
[**2140-9-21**] 09:16PM PT-14.9* PTT-35.8* INR(PT)-1.3*
[**2140-9-21**] 09:16PM PLT COUNT-319
[**2140-9-21**] 09:16PM WBC-6.4 RBC-2.58* HGB-8.8* HCT-25.7* MCV-100*
MCH-33.9* MCHC-34.1 RDW-15.2
[**2140-9-21**] 09:16PM CALCIUM-6.3* PHOSPHATE-2.8 MAGNESIUM-2.4
[**2140-9-21**] 09:16PM ALT(SGPT)-99* AST(SGOT)-106* LD(LDH)-458* ALK
PHOS-46 TOT BILI-0.4
[**2140-9-21**] 09:16PM GLUCOSE-140* UREA N-23* CREAT-1.9* SODIUM-136
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-15* ANION GAP-14
[**2140-9-21**] 09:18PM WBC-6.3 LYMPH-6* ABS LYMPH-378 CD3-69 ABS
CD3-263* CD4-21 ABS CD4-79* CD8-47 ABS CD8-179* CD4/CD8-0.4*
[**2140-9-21**] 09:18PM FIBRINOGE-298 D-DIMER-4843*
[**2140-9-21**] 09:18PM FDP-10-40
[**2140-9-21**] 09:18PM PT-13.1 PTT-28.6 INR(PT)-1.1
[**2140-9-21**] 09:18PM PLT COUNT-363
[**2140-9-21**] 09:18PM WBC-6.3 RBC-2.84* HGB-9.7* HCT-28.6* MCV-101*
MCH-34.3* MCHC-34.0 RDW-15.7*
[**2140-9-21**] 09:18PM CORTISOL-17.0
[**2140-9-21**] 09:18PM CALCIUM-6.7* PHOSPHATE-2.8 MAGNESIUM-1.4*
[**2140-9-21**] 09:18PM ALT(SGPT)-87* AST(SGOT)-90* LD(LDH)-503* ALK
PHOS-62 TOT BILI-0.4
[**2140-9-21**] 09:18PM GLUCOSE-118* UREA N-20 CREAT-1.6* SODIUM-138
POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-20* ANION GAP-15
[**2140-9-21**] 09:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-9-21**] 09:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2140-9-21**] 09:56PM O2 SAT-76
[**2140-9-21**] 09:56PM TYPE-[**Last Name (un) **] TEMP-38.8 RATES-20/8 TIDAL VOL-500
PEEP-10 O2-60 PO2-61* PCO2-64* PH-7.15* TOTAL CO2-24 BASE XS--7
-ASSIST/CON INTUBATED-INTUBATED
[**2140-9-21**] 10:36PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2140-9-21**] 10:36PM URINE OSMOLAL-350
[**2140-9-21**] 10:36PM URINE HOURS-RANDOM UREA N-196 CREAT-117
SODIUM-91
[**2140-9-21**] 10:36PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-9-21**] 10:36PM CORTISOL-16.3
[**2140-9-21**] 10:36PM ALBUMIN-2.6*
[**2140-9-21**] 10:36PM LIPASE-20
[**2140-9-21**] 11:19PM O2 SAT-94
[**2140-9-21**] 11:19PM O2 SAT-94
[**2140-9-21**] 11:19PM LACTATE-1.6
[**2140-9-21**] 11:19PM TYPE-ART TEMP-39.7 RATES-20/6 TIDAL VOL-500
PEEP-10 O2-60 PO2-193* PCO2-54* PH-7.17* TOTAL CO2-21 BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
<br>
<b>Discharge Labs:</b>
[**2140-10-11**]
Chem Panel:
Na-141 Cl-100 BUn-13 Gluc-111 AGap=15
K-3.8 HCO3-30 Cr-1.1
Ca: 9.2 Mg: 1.8 P: 2.6
ALT: 52 AP: 81 Tbili: 0.3 Alb: 4.1
AST: 29
MCV:99
WBC-4.5 Hb-11.3 Plt-260 Hct-33.4
N:60.3 L:32.2 M:3.8 E:3.2 Bas:0.5
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 42-year-old male newly diagnosed with HIV in
[**2140-3-17**] who presented to the [**Hospital1 **] ED on [**2140-9-21**] with fever,
nausea, headache, and a whole body erythematous skin rash that
had started earlier in the day. In the ED, his skin was noted
to be warm, dry, and flushed. His blood pressure, initially
103/51, dropped to 74/41. Fluid boluses failed to improve his
blood pressure and so pressors were started. When he became
hypoxic, he was intubated using etomidate and succinylcholine.
One dose of Ceftriaxone and one dose of Vancomycin were given in
the ED. He was admitted to [**Hospital Unit Name 153**] with a diagnosis of
distributive shock of unknown etiology and started on Zosyn,
Vanco, and Clindamycin.
.
Mr. [**Known lastname **] continued to be hypotensive in the ICU. He
received large amounts of IV fluid and was placed on three
pressors, dopamine, levophed, and epinephrine, and still
remained hypotensive. When [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test showed adrenal
insufficiency, hydrocortisone was added as well. Over the next
few days, pressors were slowly weaned as his blood pressure
recovered. Urine, stool, sputum, throat, eye, and blood
cultures all failed to grow significant pathogens. A nares
Staph aureus swab was negative as well. HIV viral load measured
to be fairly low at 17,000 copies/ml, making acute HIV
superinfection/exacerbation unlikely. A 2D echo on [**9-22**] showed
normal ventricular function. It was felt that the patient had
distributive shock from one of the following three etiologies:
.
1. Dapsone Hypersensitivity Syndrome: Consistent in that the
patient had recent use of dapsone, elevated methemoglobin,
fever, erythematous rash with subsequent exfoliative rash, and
elevated liver enzymes. Inconsistent in that the patient had no
jaundice or eosinophilia. "Sulfa/Sulfone" drugs, including
Lasix, were avoided during the patient's stay to avoid the risk
of re-inciting a hypersensitivity reaction. The patient was
given stress doses of hydrocortisone.
.
2. Toxic Shock Syndrome: Consistent in that patient had fever,
hypotension, intense erythoderma, blanching, conjunctival
injection, and elevated liver enzymes. Inconsistent in that the
patient had no significant renal involvement, thrombocytopenia,
convincing desquamative rash, or known source of bacterial
infection. The patient was examined and cultured extensively
(including throat, eyes, and nose) for Streptococcus or Staph
aureus, but no source was identified. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] Spotty
Fever and Leptospira antibodies were sent as they are in the
differential of TSS. The patient was maintained intially on
broad spectrum antibiotics.
.
3. Bacterial Sepsis: Consistent with the patient's presentation
of 39% bandemia, but inconsistent in that no source of infection
was ever identified. As noted above, extensive culturing
offered no source of bacterial infection. The patient was
maintained initially on broad spectrum antibiotics.
.
Of note, the patient required heavy sedation with fentanyl and
midazolam drips to keep him sedated while intubated. Pressure
support trials were initially unsuccessful as the patient had
prolonged periods of apnea. The trials improved and he was
ultimately extubated on [**9-28**] successfully.
.
Following extubation, the patient initially appeared to be his
normal self. The next day, however, he began to appear agitated
and confused. After being given a dose of Haldol, he displayed
symptoms consistent with antipsychotic-induced dystonia
(lip/tongue smacking, grimacing, etc.). Haldol was discontinued
and Benadryl/Cogentin given. The following morning, while still
agitated and confused, he had a tonic clonic seizure lasting
less than one minute followed by lethargy/confusion interspersed
with 3 or 4 short moments of terror and accompanying screams.
He calmed with 2 mg of IV Ativan.
.
The seizure was felt to be due to benzo withdrawal as the
patient had a long standing history of benzo use and had been on
large doses of midazolam while sedated. While he was being
maintained on 1 mg Ativan [**Hospital1 **] for anxiety prior to the seizure,
this may not have been sufficient. Other etiologies that could
not be ruled out included Levofloxacin reaction, neurological
HIV, and infectious meningitis or encephalitis. The patient
never exhibited autonomic lability, however, as would be
expected with a benzo withdrawal. A head CT with contrast
immediately after the seizure failed to show any acute
pathology.
.
The patient remained agitated, confused, and confrontational.
In order to obtain the appropriate tests for his mental status
change, he was again sedated and intubated on [**9-30**]. A head MRI
showed "encephalomalacia in the right inferior frontal lobe,"
but no acute process. CSF fluid from LP was sent for the
following tests: protein, glucose, cytology, gram stain, HSV,
HIV viral load, [**Male First Name (un) 2326**] virus, cryptococcus, EBV, Lyme disease,
Toxoplasma, Varicella, VDRL, WNV, and cultures. His serum was
tested for toxoplasma, RPR, cryptococcus, B12, folate, and urea.
An EEG was done on [**10-1**].
.
Following the completion of tests on [**10-1**], the patient was
weaned from sedation and extubated. He was placed on standing
doses of Ativan (2mg TID) and Zyprexa for agitation and
prevention of opioid withdrawal. He remained much calmer than
previously and his mental status returned to [**Location 213**]. On [**10-2**],
he was discharged to the floor. No PCP prophylaxis was given
during his [**Hospital Unit Name 153**] stay because he had received Pentamidine
nebulizer treatment on [**2140-9-15**] (dosed every 30 days).
.
On arrival to the floor, the patient was noted to be calm and in
no respiratory distress. He was afebrile and hemodynamically
stable. He was increasingly ambulatory, and was eating and
drinking well. He did not need any prn zyprexa for sedation, so
this was discontinued. He did not require insulin, so this was
discontinued. He was ambulatory on the floor, so subcutaneous
heparin was discontinued. He continued to have low grade fevers
in the 99 degree range, and blood cultures off of his central
line drawn on [**10-1**] showed 2/2 bottles from the line positive for
coagulase-negative, staph. aureus. Peripheral cultures drawn at
the same time showed no growth of bacteria. The catheter tip
culture was negative. Surveillance cultures were drawn. He
continued to look and feel clinically well, and had no
subjective complaints. However, he subsequently had
intermittent fevers. He was restarted on Vancomycin on [**10-6**].
Fevers on [**10-8**] and [**10-9**] were as high as 102.5. On [**10-10**], he had
a fever of 101. On [**10-11**], Tmax was 100.6. All cultures were
ngative except culture from [**10-1**]. Preference was to have
patient monitored until he was consistently without fevers,
however patient reported increased anxiety with staying in
hospital and very strong desire to leave. Given no other clear
souce, pt is being discharged to complete 2-week course of
antibiotics (Vancomycin) for possible line infection.
.
ID team was following him in the hospital, recommended holding
antiretroviral therapy during this hospitalization until
outpatient ID care arranged and acute illness resolved. This
discharge, CD4 count was in 250s, so HAART and prophylaxis not
acutely restarted. Pt can f/u as outpatient for consideration
of these therapies.
.
Psychiatry was also following along and recommended institution
of celexa and taper of benzodiazepines at 25% per day. This was
completed. He was discharged on Celexa 20mg (had briefly been
on 60mg which was home dose, but this was thought to be too high
for him given that he had been off this dose for some time).
.
At the time of discharge, he was culture negative with the
exception of studies off of central line as mentioned above, and
the following studies are outstanding and will need to be
followed up on by his Primary Care Doctor and or his ID
physicians.
.
Pending Studies:
Blood Cultures ([**10-10**], [**10-9**], [**10-7**] x 2)
Fungal Culture ([**10-6**])
Histo Serology ([**10-10**])
Paracoccidio Serology ([**10-10**])
Medications on Admission:
MEDS: (per [**Hospital1 778**] records)
Celexa 60mg PO QHS
Acyclovir (? prolonged course)
Kaletra 200-50 2tabs PO Q12 (lopinavir-ritonavir)
Truvada 200-300mg 1 tab PO QD (emtricitabine-tenofovir)
pentamidine inhaled - first dose on [**2140-9-15**]
.
MEDS that patient had available to him:
Seroquel 50mg PO QHS prn insomnia
Truvada 1 tab PO QD - filled [**2140-9-8**]
Atripla 1 tab PO QD - filled [**2140-9-6**]
SMZ-TMP 400-800mg PO QD (also has DS tabs 2tabs PO BID [**12-21**])
Dapsone 100mg PO QD - filled [**2140-9-2**]
Acyclovir 800mg PO TID x10d - filled [**2140-9-2**]
Celexa 60mg PO QHS
Fluoxetine 20mg PO QD
Kaletra 50-200mg 2tabs PO BID - filled [**2140-9-7**]
Clonazepam 1mg PO QHS - filled [**2140-7-26**]
Fluconazole 100mg PO QD x7d - filled [**2140-9-2**]
Ambien 10mg PO QHS
Triamcin/Orabas 0.1% apply to affected area [**Hospital1 **]
.
MEDS identified by pharmacy as free pills pt had in bag:
Ibuprofen
Acyclovir
Vicodin
Hydrocodone
Percocet
Vicoprofen
Diazepam
Clonazepam
Lorazepam
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
twice a day for 9 days: Last dose on [**10-20**].
Disp:*18 solution bags* Refills:*0*
3. PICC Line Care Sig: As directed as directed: PICC Line
Care per protocol.
Disp:*qs PICC Care* Refills:*0*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*2*
7. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary:
shock, circulatory (sepsis vs. anaphylactic)
dapsone hypersensitivity syndrome
acute renal failure
Coag negative staph infection
Thrush
Secondary:
HIV/AIDS
Discharge Condition:
T-100.6. Vital signs otherwise stable. No complaints.
Discharge Instructions:
Take all medications as prescribed. You will need to take
Vancomycin for 9 more days to complete a 2-week course (last
dose on [**10-20**]). Follow up appointments as indicated below. You
were advised to remain in hospital for further monitoring of
your temperature, however since you insisted on leaving, you are
asked to monitor your temperature at home (ideally every [**4-22**]
hours).
.
Return to the emergency room or call your doctor for:
Temperature of 101 or more
Shortness of breath
Worsening headaches
Followup Instructions:
NEW PCP:
[**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2140-10-13**] 2:00
NEW ID SPECIALIST:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2140-10-17**]
3:30
PSYCHIATRIST:
Triangle Program. [**10-14**] 9AM. [**Street Address(2) 9881**].
[**Location (un) **], MA.
You are also welcome to continue primary care with Dr. [**Last Name (STitle) 2392**]
at the [**Hospital6 **] Center (I have discussed this
with him). Call him to arrange an appointment with him for
within two weeks of leaving the hospital should you elect to
continue your primary care with him.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,210
| 158,010
|
7161+55815
|
Discharge summary
|
report+addendum
|
Admission Date: [**2196-3-15**] Discharge Date:
Date of Birth: [**2135-11-17**] Sex: F
Service: VSU
CHIEF COMPLAINT: Right groin infection with graft
involvement by CT scan.
HISTORY OF PRESENT ILLNESS: This 60-year-old white female
transferred from [**Hospital3 26615**] Hospital with history since
[**Month (only) 956**] of this year, episode flu-like symptoms treated with
Tylenol and then resolved within the next few days. Three
weeks later the patient returned and was hospitalized at [**Hospital3 26616**] for fever and chills for Klebsiella pneumoniae with
sepsis. Patient was discharged home and developed rest angina
and underwent a cardiac catheterization by Dr. [**Last Name (STitle) 26617**] and 3
days afterwards, developed fevers and chills with a T. max of
103 and spontaneous right groin drainage from the right
femoral access site. Patient has also noted right groin pain
and right lower quadrant discomfort and pain on palpation.
Patient was hospitalized at [**Hospital3 26615**] from [**2196-3-14**],
and transferred here for further evaluation on [**2196-3-15**].
Her workup included a TEE which was negative for vegetations.
A CT scan of the abdomen showed a right groin mass with
extension to the right aortobifemoral limb and posteriorly
incompensating the limb of the right AVF graft. Blood
cultures were done which were no growth.
REVIEW OF SYSTEMS: Negative for headache, visual changes,
nausea, vomiting, diarrhea, dyspnea on exertion, shortness of
breath, chest pain, status post cardiac catheterization. No
reoccurrence of symptoms since. No history of stroke. No
history of back or lumbar spine problems.
ALLERGIES: Penicillin allergy.
MEDICATIONS ON TRANSFER: Lantus 15 units at bedtime,
metformin 1000 mg b.i.d., Plavix 75 mg daily, Pletal 100 mg
daily, phenobarbital 60 mg daily, Zocor 40 mg daily,
Lopressor 12.5 mg b.i.d., aspirin 325 mg daily, Percocet
5/325 tablets [**11-17**] q.4 hours p.r.n. for pain, vancomycin 1
gram q.12 hours, Flagyl 500 mg q.8 hours, and Levaquin 750 mg
q.24 hours.
ILLNESSES: Peripheral vascular disease with an
aortobifemoral for claudication in [**2188**], hyperlipidemia on a
statin, type 2 diabetes, insulin controlled; history of
hypertension, history of diverticulitis, status post bowel
resection, history of small bowel obstruction, postbowel
surgery, history of bilateral carotid disease, asymptomatic.
SOCIAL HISTORY: The patient is widowed x7 years. Lives
alone. Denies tobacco or alcohol use. He has a close friend,
[**Name (NI) **] [**Name (NI) **] who assisted with personal needs as requested.
Her contact number is ([**Telephone/Fax (1) 26618**].
PHYSICAL EXAM: Patient is drowsy secondary to IV Dilaudid
administration for pain. Vital signs: Temperature 102.2,
pulse 73, respirations 20, blood pressure 130/84, O2
saturation 100% on room air. HEENT exam: There is no JVD, no
carotid bruits. Lungs are clear to auscultation anteriorly.
Heart is a regular rate and rhythm. Abdomen is obese, soft,
nontender, nondistended. There is some right lower quadrant
discomfort and tenderness on palpation. The bowel sounds are
diminished x4 quadrants. Peripheral vascular exam: The right
groin is with skin necrosis and bleeding of the access site.
Pulse exam shows palpable femorals bilaterally 2+. Popliteals
are absent. The DP and PT are 1+ bilaterally. There are no
femoral bruits. Neurologic exam is nonfocal.
HOSPITAL COURSE: Patient was admitted to the vascular
service. IV antibiotics were instituted. Cultures blood,
urine, and wound were obtained. Patient's initial white count
was 8.2 on admission with gradual rise with a peak white
count on the day after surgery of 19.2 with defervescence of
the white count. The white count on [**2196-3-22**], was 9.5.
Admitting hematocrit was 27.1. Postoperative day 1, her
hematocrit dropped to 21.4. It was rechecked. Patient was
transfused. Posttransfusion hematocrit was 28.4. The patient
drifted again from 24. She was transfused; count was 26.4,
and she required transfusion on [**3-17**] for a hematocrit of
24.4. Hematocrit on [**2196-3-22**], was 28.4.
Admitting urine culture was no growth on final. The swab on
the groin site demonstrated moderate growth of mixed
bacterial flora greater than 3 colony types consistent with
skin flora. She had 3+ gram-positive rods in chains, 2+ gram-
negative rods, and 1+ gram-positive cocci on Gram stain which
identified out at Staph. coag negative x2 species and yeast
rare. Anaerobics were no growth.
A wound culture obtained in the OR grew same organisms. The
tissue cultures grew lactobacillus species, heavy growth of 3
colonies of Staph. coag negative. The anaerobic cultures were
negative. The patient was continued on the vancomycin.
Multiple blood cultures initially on admission which were no
growth. Cultures on [**3-17**] grew [**Female First Name (un) 564**] albicans. The patient
was begun on an antifungal [**Doctor Last Name 360**] at that time. Patient
underwent urgent I and D on the day of admission.
She returned to surgery secondary to ruptured aortobifemoral
limb on [**2196-3-16**], and underwent excision on the right
aortobifemoral limb with right axillopopliteal bypass graft
with PTFE and an intraoperative angiogram. The patient's
operative findings were that there was a leak in the right
limb of the aortobifemoral, but this was contained and the
right foot was pink in the OR with a [**Name (NI) **] PT and no DP
found. Patient was transferred to the PACU in stable
condition.
Postoperative days 2 and 1, she was continued on vancomycin,
Cipro, and Flagyl. Heparin was infused at 800 units per hour.
She remained intubated. Her T. max was 38.7. She remained in
the ICU. Infectious disease was consulted regarding
recommendations of antibiotic therapy and length of therapy.
Recommendations were that the vancomycin should be continued.
The Cipro and Flagyl were discontinued, and she was placed on
meropenem 500 mg IV q.6 hours. Multiple repeat cultures were
obtained. The blood culture on [**3-17**] grew [**Female First Name (un) 564**]. White
count on postoperative days 3 and 2 was 15.7 with a
hematocrit of 22.7. Patient was started on antifungals, and
Flagyl was added to the antibiotic regime.
Over the next 24 hours, the patient continued to have a rise
in her temperature with a T. max of 103.4, became
hypotensive, hypoglycemic. Patient was transferred to the ICU
for continued care. CT scan of the abdomen and pelvis were
obtained. There were no suspicious lytic or sclerotic body
lesions in the bone windows. There was postsurgical change
around the bypass graft running through the right thigh with
minor inflammatory stranding and a few small foci of air.
There was no evidence of hemorrhage. Surgical drain is seen
overlying the soft tissues of the anterior right thigh.
Her hyperglycemia was treated with IV insulin drip, and her
pain was controlled with Dilaudid. She was begun on warfarin
dosing and IV heparinization was continued. Patient continued
to be followed by infectious disease. White count showed
downward trend on [**2196-3-19**], of total white count of 9.3.
Patient's INR became hypercoagulable of 9.3 on [**3-19**], and her
heparin and Coumadinization were held. Her temperature curve
continued to improve, T. max 100.4-98.6. The right groin
dressing and drain remained in place, and the patient had a
[**Month (only) **] DP and a [**Month (only) **] graft signal. Her wound
looked improved. The Coumadin was continued to be held, and
the antibiotics were continued.
Postoperative days 5 and 4, patient's T. max was 99.9.
Hematocrit was 26.6. Total white count was 8.2. INR was 2.4.
Patient remained in the ICU. Continued to be followed by
infectious disease. Caspofungin was added to antibiotic
regimen on [**3-20**] for a 1/2 blood cultures with yeast. The
right IJ was changed over wire and a tip sent for culture
which was no growth.
On postoperative days 6 and 5, the patient was afebrile.
Hemodynamically, she was stable. She remained in the unit.
Patient was transferred later that day to the VICU for
continued monitoring and care. Her hematocrit was 25.3, white
count 7.2. She was afebrile. Antibiotics were continued, and
she was transfused 1 unit of packed cells. Skin care nursing
was consulted for alteration of skin integrity in the right
groin. The right groin showed red granulating tissue.
Presently, they are treating with A and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12536**] and
antimicrobial dressings twice a day. They felt that the
patient would benefit from VAC dressing therapy. The Aquacel
was continued to the lateral right groin wounds.
Postoperative days 7 and 6, the patient continued to do well.
Her glycemic control was improved. Her meropenem and Cipro
were discontinued, and she was placed on fluconazole p.o. She
began ambulating. Was tolerating a regular diet. Patient will
be assessed for a PICC line placement for continued
antibiotics after discharge. Length of therapy will be
discussed with infectious disease prior to discharge. Repeat
cultures were obtained. Recommendations with patient should
have a transesophageal echocardiogram done. This will be
arranged to be done on [**2196-3-23**].
Patient will be discharged to rehab when medically stable.
DISCHARGE MEDICATIONS: Will be dictated at the time of
discharge.
DISCHARGE DIAGNOSES:
1. Right groin infection with graft infection by CT scan.
2. Rupture of right limb graft of the arteriovenous fistula
graft on [**2196-3-16**].
3. Postoperative hypotension secondary to hypovolemia and
sepsis, treated.
4. Postoperative blood loss anemia, transfused.
5. Postoperative blood candidiasis treated.
6. Patient has a history of peripheral vascular disease. She
is status post aortobifemoral for claudication 5 years
ago.
7. History of hyperlipidemia. She is on a statin.
8. She has a history of type 2 diabetes, insulin dependent,
uncontrolled.
9. History of diverticulitis with small bowel resection
complicated by small bowel obstruction.
10. History of bilateral carotid disease, asymptomatic.
11. History of chest pain status post diagnostic cardiac
catheterization on [**2196-2-14**].
DISCHARGE INSTRUCTIONS: Patient may ambulate essential
distances. The INR should be monitored until the patient is
at a steady therapeutic state of 2.0-3.0. She should take all
medications as directed. She should follow up with Dr.
[**Last Name (STitle) 1391**] in 2 weeks from discharge. Should call for an
appointment at ([**Telephone/Fax (1) 4852**]. She should also follow up with
infectious disease clinic.
MAJOR SURGICAL PROCEDURES: Right groin I and D on [**2196-3-15**], excision of right limb on the AVF graft with right
axillofemoral bypass with PTFE and intraoperative angiogram
on [**2196-3-16**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2196-3-22**] 15:19:30
T: [**2196-3-23**] 06:59:44
Job#: [**Job Number 26619**]
Name: [**Known lastname 4595**],[**Known firstname 4193**] Unit No: [**Numeric Identifier 4596**]
Admission Date: [**2196-3-15**] Discharge Date: [**2196-4-4**]
Date of Birth: [**2135-11-17**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2196-3-28**] patient remained in hospital for continued INR and
coumading dosing adjustment and anti biotics. Vac Dressing to
have been applied [**3-24**] was defered secondary to wound excudate.
Vac appliied [**3-28**]. this should be on continous suction at 125mm
and changed q 3 days. Antibiotic length of thearphy 2 weeks
after d/c from hospital.
Routine PICC line care. Followup with Dr. [**Last Name (STitle) **] 1-2 weeks.
[**Date range (1) 4597**] con5tinued with wound care and excisional debridments.
d/c to home stable wound granulating. Will d/c with wet to dry
dressing to rt. groin until VAC dressing arrives [**4-5**].
Continue antibiotics for a total of two more weeks from today
([**4-4**]). Moniter cbc,bun cr and vanco trough weekly while on
antibiotics. INR([**4-4**]) 2.1 BUN/Cr. ([**3-30**]) 9/0.6 WBC ([**3-29**]) 9.0
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care Agency
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2196-4-4**]
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icd9cm
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"88.72",
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icd9pcs
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12322, 12548
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9322, 9366
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3441, 9298
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10251, 12299
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2679, 3423
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139, 197
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226, 1382
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2427, 2663
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,423
| 119,463
|
22694
|
Discharge summary
|
report
|
Admission Date: [**2121-11-10**] Discharge Date: [**2121-12-5**]
Date of Birth: [**2074-2-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Fever, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 y.o. male with multiple medical problems to include [**Name (NI) 11398**] c/b
gastroparesis, retinopathy with legal blindness, nephropathy
with resultant kidney transplant in [**2104**], c/b chronic rejection,
HTN, s/p mitral valve replacement with mechanical valve for
endocarditis in [**2114**], atrial fibrillation, gout and arthritis
who was brought in by his wife for altered mental status for two
days and a tempertaure to 101 orally. He had been complaining to
his wife about a headache, lower back pain, muscle aches/cramps,
and joint pains in his feet for the several days prior to
admission. His wife also noticed that he had been having shaking
chills and sweats. He reported having nausea and vomiting for
the last two months, which has improved recently, but deniesd
diarrhea. His daughter was recently sick with a viral illness,
but otherwise, no sick contacts. ROS otherwise negative.
Past Medical History:
-DM2 c/b diabetic nephropathy, diabetic retinopathy and diabetic
neuropathy.
-prosthetic mitral valve placed for endocarditis [**12-26**] to a dental
procedure
-Hypertension
-hypercholesterolemia
-chronic L ankle pain
Social History:
Married, lives with wife and two stepchildren. Moved to [**Location (un) 86**]
from [**Location (un) 9012**] 3y ago. Unemployed since foot fracture. Denies
tobacco, alcohol, other illicits.
Family History:
Non-contributory.
Physical Exam:
Vitals: T 99.8 HR 83 BP 158/84 RR 15 SAT 98% on RA
General: Sleepy, awakes to verbal stimulation, in no distress
HEENT: Right pupil 2mm, left 1 mm, minimally reactive to light,
EOMI
Neck: No stiffness, no cartoid bruits, no LAD
CHEST: Lungs slear to asculatation and percussion
HEART: 2/6 systolic murmur at upper sternal border, lound S1
ABD: + bowel sounds, non distended, soft, NT
EXT: good perioheral pulses, no edema, no open wounds
Neuro: Oriented to person only, CN II- XII motor function
intact, no neck stiffness, [**3-28**] motor strength equal bilaterally.
Pertinent Results:
[**2121-11-10**] 12:15AM PT-47.0* PTT-40.0* INR(PT)-5.5*
[**2121-11-10**] 12:15AM PLT COUNT-287
[**2121-11-10**] 12:15AM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+
[**2121-11-10**] 12:15AM NEUTS-75.0* LYMPHS-15.8* MONOS-8.2 EOS-0.6
BASOS-0.3
[**2121-11-10**] 12:15AM WBC-8.3 RBC-2.96* HGB-10.2* HCT-28.9* MCV-98
MCH-34.6*# MCHC-35.4* RDW-22.3*
[**2121-11-10**] 12:15AM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-1.7
[**2121-11-10**] 12:15AM CK-MB-NotDone cTropnT-0.01
[**2121-11-10**] 12:15AM ALT(SGPT)-37 AST(SGOT)-25 CK(CPK)-42 ALK
PHOS-149* AMYLASE-23 TOT BILI-0.8
[**2121-11-10**] 12:15AM estGFR-Using this
[**2121-11-10**] 12:15AM GLUCOSE-317* UREA N-44* CREAT-1.9* SODIUM-133
POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-18* ANION GAP-18
[**2121-11-10**] 12:18AM GLUCOSE-278* LACTATE-1.0
[**2121-11-10**] 12:18AM COMMENTS-GREEN TOP
[**2121-11-10**] 12:22AM CYCLSPRN-199
[**2121-11-10**] 01:07AM URINE RBC-0 WBC-[**1-26**] BACTERIA-RARE YEAST-NONE
EPI-0
[**2121-11-10**] 01:07AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2121-11-10**] 01:07AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2121-11-10**] 01:07AM URINE GR HOLD-HOLD
[**2121-11-10**] 01:07AM URINE HOURS-RANDOM
[**2121-11-10**] 01:42AM K+-5.5*
[**2121-11-10**] 01:42AM COMMENTS-GREEN TOP
[**2121-11-10**] 03:48AM GLUCOSE-234*
[**2121-11-10**] 03:48AM GLUCOSE-245* UREA N-43* CREAT-1.8* SODIUM-135
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-19* ANION GAP-15
[**2121-11-10**] 05:49AM GLUCOSE-82
[**2121-11-10**] 05:49AM COMMENTS-GREEN TOP
[**2121-11-10**] 05:49AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2121-11-10**] 05:49AM CK-MB-NotDone cTropnT-0.01
[**2121-11-10**] 05:49AM CK(CPK)-48
[**2121-11-10**] 09:03AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2121-11-10**] 09:03AM URINE HOURS-RANDOM
[**2121-11-10**] 12:32PM TYPE-ART TEMP-37.3 PO2-104 PCO2-42 PH-7.42
TOTAL CO2-28 BASE XS-2 INTUBATED-NOT INTUBA
[**2121-11-10**] 01:06PM PT-50.4* PTT-41.7* INR(PT)-6.0*
[**2121-11-10**] 01:06PM PLT COUNT-333
[**2121-11-10**] 01:06PM WBC-8.0 RBC-2.99* HGB-9.8* HCT-28.1* MCV-94
MCH-32.9* MCHC-34.9 RDW-21.9*
[**2121-11-10**] 01:06PM ACETONE-NEGATIVE
[**2121-11-10**] 01:06PM ALBUMIN-3.6 CALCIUM-8.8 PHOSPHATE-2.3*
MAGNESIUM-1.9
[**2121-11-10**] 01:06PM CK-MB-3 cTropnT-0.01
[**2121-11-10**] 01:06PM ALT(SGPT)-31 AST(SGOT)-19 LD(LDH)-330*
CK(CPK)-39 ALK PHOS-133* TOT BILI-0.7
[**2121-11-10**] 01:06PM GLUCOSE-165* UREA N-36* CREAT-1.6* SODIUM-138
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-13
[**2121-11-10**] 02:25PM URINE RBC-2 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
[**2121-11-10**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2121-11-10**] 02:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2121-11-10**] 02:25PM URINE OSMOLAL-410
[**2121-11-10**] 02:25PM URINE HOURS-RANDOM
[**2121-11-10**] 05:27PM PT-25.4* PTT-32.9 INR(PT)-2.6*
[**2121-11-10**] 05:27PM TSH-1.4
[**2121-11-10**] 05:27PM VIT B12-242 FOLATE-9.7
[**2121-11-10**] 05:27PM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-2.4*
MAGNESIUM-1.7
[**2121-11-10**] 05:27PM LIPASE-24 GGT-137*
[**2121-11-10**] 05:27PM ALT(SGPT)-30 AST(SGOT)-21 LD(LDH)-342*
CK(CPK)-105 ALK PHOS-128* AMYLASE-32 TOT BILI-0.7
[**2121-11-10**] 05:27PM GLUCOSE-109* UREA N-32* CREAT-1.5* SODIUM-139
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2121-11-10**] 05:27PM GLUCOSE-109* UREA N-32* CREAT-1.5* SODIUM-139
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2121-11-10**] 05:56PM LACTATE-2.3*
[**2121-11-10**] 09:51PM LACTATE-0.8
[**2121-11-10**] 09:51PM TYPE-ART PO2-50* PCO2-46* PH-7.38 TOTAL
CO2-28 BASE XS-0
[**2121-11-10**] 11:35PM PT-34.1* PTT-37.4* INR(PT)-3.7*
[**2121-11-10**] 11:35PM PLT COUNT-330
[**2121-11-10**] 11:35PM WBC-8.4 RBC-2.98* HGB-9.7* HCT-29.0* MCV-97
MCH-32.6* MCHC-33.5 RDW-22.2*
[**2121-11-10**] 11:35PM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.8
[**2121-11-10**] 11:35PM GLUCOSE-40* UREA N-27* CREAT-1.3* SODIUM-142
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-24 ANION GAP-14
.
Renal Allograft needle biopsy ([**11-28**]): Chronic allograft
nephropathy.
.
Renal US ([**11-27**]): Mildly elevated resistive indices. No
hydronephrosis.
.
CXR ([**11-21**]): No failure or infiltrates are present.
.
MRA Brain ([**11-19**]):
1. There is no change compared to [**2121-11-11**] and the abnormalities
visible on today's MRI appear to have been present on the CT of
[**10-12**].
2. As noted previously, there is stable cortical and subcortical
T2 hyperintensity involving the occipital poles, perhaps related
to transplantation rejection medication.
3. There may be a small, old superior right frontal cortical
infarct, unchanged.
4. There are ischemic lesions in the cerebral white matter and
probably old white matter infarcts in the centrum semiovale
bilaterally.
.
MR [**Name13 (STitle) 430**] ([**11-19**]):
1. The study is limited by patient motion.
2. There is a superior 3-mm projection of flow from the anterior
communicating artery and a small aneurysm cannot be excluded. A
repeat study is recommended when the patient can be more
cooperative.
3. There is a questionable stenosis at the level of the proximal
right P2 segment, but if real, this does not appear to be
hemodynamically significant, given that there is good, symmetric
distal flow.
.
CT Chest/Abdomen/Pelvis ([**11-14**]):
1. No CT evidence of acute process within the chest, abdomen or
pelvis.
2. Endotracheal tube positioned in the right mainstem bronchus,
tube
should be pulled back for proper positioning.
3. Bilateral pleural effusions with adjacent compressive
atelectasis.
4. Trace ascites and free fluid within the abdomen and pelvis.
.
MR [**Name13 (STitle) **]/L-Spine ([**11-11**]):
1. Essentially unremarkable examination of the entire spine,
with no evidence of vertebral osteomyelitis, discitis or
epidural or paraspinal abscess.
2. T12-L1: Small central protrusion with no evidence of neural
impingement.
Brief Hospital Course:
47 y.o. male with MMP admitted to the [**Hospital Unit Name 153**] for mental status
change. The following issues were investigated during this
hospitalization:
.
# Fever/Altered mental status - Pt. was admitted to the [**Hospital Unit Name 153**]
where an extensive infectious workup yielded negative blood and
urine cultures, an unremarkable LP with cultures negative for
Legionella, negative serologies for Lyme, RPR and Toxoplasma and
nasal aspirates negative for Influenza. He was called out to the
general medicine floor on [**11-20**] to finish an empiric course of
Ceftriaxone 1 mg IV q24 for a CNS infection (questionable, but
being treated as the results of all other workups were
negative). On transfer to the floor, the patient was awake,
alert, oriented x 3 and communicative. However, the following
day he became febrile to 101.2 axillary (pt. was delirious and
thus unable to cooperate with PO temperature)and his coverage
was broadened to Vancomycin to empirically cover MRSA in this
patient with multiple hospitalizations as well as Zosyn to cover
Pseudomonas given his recent intubation in the [**Hospital Unit Name 153**]. Since his
antibiotic coverage at this point was at best, empiric, given
the negative cultures, antibiotics were stopped completely.
Concurrently, the patient was being weaned off of Cyclosporine,
which was thought to perhaps be contributing to encephalopathy.
While off both the antibiotics and Cyclosporine, the patient
remained afebrile and his mental status improved to eventually
no longer requiring restraints or frequent Ativan and being
well-related and polite. The etiology of the fevers and altered
mental status were unclear, but thought to be multifactorial and
shown to resolve with withdrawal of many of his medications.
.
# Renal: Pt. was s/p transplant complicated by chronic rejection
with a baseline creatinine of 2.0. On admission, he was on
Cyclosporine, but after an inconclusive encephalopathy work-up,
this was weaned off out of concern for Cyclosporine-induced
encephalopathy. Simultaneously, the patient was started on
Rapamune. Once Cyclosporine had been completely weaned off,
Rapamune was increased to 3 mg. Coincidentally, the patient's
creatinine was noted to rise at this time, reaching a maximum of
5.3. A kidney transplant biopsy showed chronic rejection, but no
evidence of acute rejection. Urine electrolytes were consistent
with a prerenal etiology and thus, diuretics were discontinued
and the patient was encouraged to take PO. Because of
continuously rising creatinine, Rapamune was discontinued and
eventually stopped completely with gradual resolution of the
acute renal failure. On discharge, the patient's creatinine was
approaching baseline. The patient was discharged with
instruction to follow up in renal clinic for further management
and eventual reinitiation of Rapamune.
.
# DM: The patient was followed by [**Last Name (un) **] diabetes consultants
who made many adjustments to the patient's insulin regimen in
an effort to accommodate for tube feeds initially and a steroid
course, initiated for gout. The patient was discharged on the
most current insulin regimen.
.
# Gout: Pt. developed polyarticular gout in the ICU and was
followed by Rheumatology. A course of steroids were started, but
maintenance agents such as Allopurinol were not started given
the chronic kidney disease. On transfer to the floor, the
patient was finishing a steroid taper and 2 days after the
completion of this taper, experienced another flare of gout,
involving his left hand. He was continued on Morphine and
restarted on Prednisone 20 mg, which had been tapered down to 15
mg at the time of discharge. Additionally, the patient was
started on Colchicine, with good effect.
.
# Atrial Fibrillation/Mechanical Heart Valve: Shortly after
transfer to the medical floor, the patient went into atrial
flutter with RVR, necessitating a transfer to the cardiac
intensive care unit. However, upon arrival to the floor, he
spontaneously converted into sinus rhythm and remained in a
sinus rhythm overnight. The following day, he was transferred to
the medical floor where he remained for the rest of his
hospitalization. He was monitored on telemetry and experienced
episodes of atrial fibrillation, which were rate-controlled with
stable vital signs.
.
The patient was on Coumadin on arrival to the hospital. However,
because of an INR of 6.0 on admission and because of procedures
in the ICU, his Coumadin was held. Eventually, the patient was
started on a Heparin drip with a bridge to Coumadin. Once
Coumadin was restarted, the patient's INR quickly increased to a
maximum of 7.8. This was cautiously reversed with 1 mg of
Vitamin K, resulting in a drop to 2.8. The patient was
discharged with instructions to continue his outpatient dose of
Coumadin, starting the following day.
.
# Anemia: Patient has a history of anemia, thought to be due to
chronic kidney disease. During this hospitalization, he was
maintained on his outpatient dose of Epogen 10,000 units MWF
.
# HTN: Patient's blood pressure was controlled with his
outpatient regimen of Amlodipine, Labetalol and Diltiazem.
Medications on Admission:
Sandimmune 50 mg [**Hospital1 **]
Azothiaprine 50 mg QPM
Prednisone 10 mg QD
Labetolol 400 mg TID
Norvasc 2.5 mg QD
Diltiazem XR 240 mg QPM
Zestril 5 mg QD
Lasix 20 mg PRN
Insulin lantus 20 u QAM and 15 u QPM
Novalog insulin sliding scale
Protonix 40 mg QD
Calcitrate 600D 600 mg QD
Reglan 5 mg [**Hospital1 **]
Androgel 1 pack QD
Ativan 1 mg QHS
Coumadin 5 M/W/F/Sun, 7.5 T/TH/Sat
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*30 doses* Refills:*2*
2. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
3. Cyanocobalamin 500 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
5. Labetalol 200 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
6. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
7. Diltiazem HCl 90 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Colchicine 0.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
15. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Morphine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
17. Prednisone 10 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
18. Outpatient Lab Work
Please have your CBC, electrolytes, BUN, creatinine, PT/PTT/INR
checked on Monday, [**2121-12-8**]
19. Insulin
Continue with 23 units of glargine at bedtime with frequent
fingersticks and sliding scale Novalog as needed
20. Insulin Syringe [**11-25**] mL 28 x [**11-25**] Syringe [**Month/Day (2) **]: ASDIR syringe
Miscellaneous once a day: please use as directed per home
regimen.
Disp:*60 syringes* Refills:*2*
21. Humalog 100 unit/mL Solution [**Month/Day (2) **]: As Directed Units
Subcutaneous four times a day: Please take the required amount
of units, as called for by sliding scale provided. .
Disp:*1 bottle* Refills:*2*
22. Lantus 100 unit/mL Solution [**Month/Day (2) **]: Twenty Three (23) Units
Subcutaneous at bedtime: Take 23 units at bedtime. .
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Primary -
Fever of unknown origin
Encephalopathy, presumed to be secondary to cyclosporine
Acute on chronic renal failure secondary to rapamune
Gouty flare
Secondary -
DM1 c/b gastroparesis
retinopathy with legal blindness
nephropathy with resultant kidney transplant in [**2104**], c/b
chronic rejection
HTN
s/p mitral valve replacement with mechanical valve for
endocarditis in [**2114**]
atrial fibrillation
gout
arthritis
Discharge Condition:
Stable, afebrile, INR<4.0
Discharge Instructions:
-continue to take your medications as prescribed
-do not take Coumadin until you have your PT/PTT/INR checked on
Monday
-please follow-up with Dr. [**Last Name (STitle) **] next Wednesday in clinic and
please have labs drawn prior to the visit and called in to Dr.
[**Last Name (STitle) **]
[**Name (STitle) 19288**] you epxerience any fevers/chills, worsening gout symptoms,
bleeding from any source, or any other concerning symptoms,
please seek medical attention immediately
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 6405**] [**Name (STitle) 6406**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2121-12-24**] 9:30
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2122-1-6**] 3:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2122-5-1**]
9:00
|
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|
1701, 1720
|
14137, 17310
|
17392, 17821
|
13730, 14114
|
17894, 18373
|
1735, 2306
|
229, 259
|
332, 1236
|
1258, 1477
|
1493, 1685
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,338
| 177,136
|
46648
|
Discharge summary
|
report
|
Admission Date: [**2105-6-10**] Discharge Date: [**2105-6-17**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
lower abdominal pain, dysuria
Major Surgical or Invasive Procedure:
[**6-10**] (in IR): Successful placement of 8F percutaneous
nephrostomy tube into the left
kidney and placed to external bag drainage.
History of Present Illness:
This is an 86y/o F with h/o nephrolithiasis requiring
percutaneous nephrostomy placement in [**4-5**] who presented to ED
with 2-3 days of lower abdominal pain with associated dysuria
and decreased PO intake Patient states that she decided to
come to ED because her discomfort had not subsided. She had been
unable to sleep because of the pain. Denies any exacerbating or
alleviating factors to her pain. At its worst it was a [**9-6**]
sharp pain that began in her left flank region and radiated down
to her lower mid abdomen. Otherwise it was dull constant achy
pain in her lower abdomen with [**2105-1-29**] in severity. Denies
fevers, chills, upper abdominal pain, chest pain, SOB, myalgias,
dizziness, nausea, vomiting or diarrhea. The patient does
endorse a chronic dry cough that she states she has had for the
past few months.
In the ED, initial vs were: T 100.4 P 100 BP 148/58 R 20 O2 sat
95. A CTA was completed showing an 8mm L ureteral stone and
hydronephrosis. Patient had a WBC of 26.6 with prominent left
shift as well as a Cr of 1.6 (up from baseline of 0.8-1.1).
Urology was consulted and decision was made for emergent left
nephrostomy placement by IR to decompress hydronephrosis. She
received 2L NS in ED as well as 1g of Cefriaxone.
.
After procedure, the patient was transported to the ICU for
observation given WBC, comorbidities, and possible sepsis. On
admission to ICU, patient was stable and did not have any
complaints. No abdominal pain, flank pain, or dysuria. She was
feeling very hungry. She stated that she felt much better after
the procedure.
.
Past Medical History:
Nephrolithiasis: Cystoscopy, left ureteroscopy, laser
lithotripsy, left ureteral stent placement - [**2104-5-13**] - Dr.
[**First Name (STitle) **] [**Name (STitle) **] and removal [**2104-5-21**]
HTN
Obesity
Osteoarthritis
Anxiety/ depression
Osteopenia
SEVERE Hearing loss/Tinnitus
Hx of breast cancer s/p left mastectomy
Meningiomas
Cataracts
Rosacea
s/p CCY
Depression
Social History:
Lives in [**Location (un) **] in [**Location 1268**]. Husband lives in [**Location **]
x 17 years. No children. Previously used to work in Pathology.
No EtOH, tobacco, or illicits.
Family History:
NC
Physical Exam:
afebrile 200/80 p70 R24 98RA ** pt very agitated
Gen: HOH. Oriented x3. Severely dysarthic, and difficult to
communicate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no
exudates or ulceration.
Neck: JVP not elevated.
CV: Irreg Irreg. Normal rate.
Chest: Resp were unlabored, no accessory muscle use. Occas
wheezes
Abd: Obese, Soft, NTND. +BS.
Ext: No c/c/edema.
Neuro: Severely dysarthric, (pt appears frustrated with
communication. Alert and oriented., 5/5 strength in upper and
lower extremities bilaterally. R sided facial droop.
Pertinent Results:
[**2105-6-10**] 04:45AM BLOOD WBC-26.6*# RBC-4.42 Hgb-13.1 Hct-37.2
MCV-84 MCH-29.6 MCHC-35.1* RDW-13.6 Plt Ct-213
[**2105-6-10**] 04:45AM BLOOD Glucose-132* UreaN-33* Creat-1.6* Na-138
K-3.4 Cl-99 HCO3-26 AnGap-16
[**2105-6-15**] 09:05AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-142
K-3.9 Cl-105 HCO3-32 AnGap-9]
[**2105-6-17**] 04:38AM BLOOD WBC-8.6 RBC-3.82* Hgb-11.2* Hct-33.0*
MCV-86 MCH-29.3 MCHC-33.9 RDW-13.8 Plt Ct-257
[**2105-6-17**] 04:38AM BLOOD Glucose-107* Creat-0.7 Na-141 K-3.7
Cl-104 HCO3-31 AnGap-10
[**2105-6-17**] 04:38AM BLOOD Cholest-118
[**2105-6-13**] 02:17PM BLOOD %HbA1c-5.7 eAG-117
[**2105-6-17**] 04:38AM BLOOD Triglyc-118 HDL-29 CHOL/HD-4.1 LDLcalc-65
LDLmeas-64
[**2105-6-16**] 11:43AM BLOOD TSH-2.8
[**2105-6-15**] 03:58AM BLOOD Vanco-17.4
MIcro:
[**2105-6-10**] 5:30 am BLOOD CULTURE
**FINAL REPORT [**2105-6-16**]**
Blood Culture, Routine (Final [**2105-6-16**]):
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
AEROCOCCUS SPECIES. AEROCOCCUS URINAE, PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
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
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2105-6-11**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12707**] ON [**2105-6-11**] AT 0300.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2105-6-11**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO NICHAN TCHEKMEDYIAN AT 4:00PM ON
[**2105-6-11**].
Echo: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF 70%). 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. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The estimated pulmonary artery
systolic pressure is normal. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: no vegetations seen
.
CT head:
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage,
mass effect,
edema, shift of normally midline structures, or major vascular
territorial
infarct. Previously noted 1 cm parafalcine and right
infratentorial calcified
hemangiomas are unchanged since at least [**2103-9-1**].
Periventricular
white matter hypodensities are redemonstrated, consistent with
known small
vessel ischemic disease. Ventricles and sulci are unchanged in
configuration,
slightly prominent, reflective of mild degree of age-related
involution.
Hyperostosis frontalis is redemonstrated. Osseous structures are
intact.
Paranasal sinuses and mastoid air cells are well aerated.
Vascular
calcifications are noted in the cavernous carotid and vertebral
arteries.
Globes and soft tissues are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Stable calcified hemangiomas.
3. Chronic small vessel ischemic disease.
.
[**6-14**] CXR:
FRONTAL CHEST RADIOGRAPH: Examination is limited by technique.
Right-sided
PICC line is seen with tip residing in the proximal SVC. There
is no
pneumothorax. The cardiomediastinal silhouette is normal. No
focal
consolidation, pneumothorax, or pleural effusion.
IMPRESSION: Right-sided PICC line tip is difficult to visualize
but likely
resides in the proximal SVC.
.
Nephrostogram:
IMPRESSION: 1. Nephrostogram shows mild to moderate left
hydronephrosis and
dilatation of the proximal ureter.
2.Successful placement of 8F percutaneous nephrostomy tube into
the left
kidney and placed to external bag drainage.
[**6-10**] CT abd:
1. Left nephrolithiasis, with an 8-mm obstructing stone in the
proximal-to-mid left ureter associated with periureteral
inflammatory change
and upstream moderate hydroureteronephrosis.
2. Status post cholecystectomy.
3. Unchanged nonspecific thickening of the left adrenal.
4. Colonic diverticulosis.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
86 y/o F with h/o nephrolithiasis s/p L nephrostomy placement
and lithotripsy in [**3-/2104**], here with obstructing 8mm L ureteral
stone requiring emergent percutaneous nephrostomy placement, c/w
urosepsis. Now s/p procedure.
.
# Sepsis: Initially, the patient had an elevated WBC and was
tachycardic. She had a blood culture positive for Proteus
Mirabilis and unsepciated GPC. She was started on Vancomycin and
Cefepime while the blood culture was still speciating. Her fluid
balance and WBC were closely monitored. She was changed to
Vancomycin and Ceftriaxone (discontinued Cefepime) after
speciation finalized. She has been afebrile and WBC is
resolving. Plan for total of 2 weeks of vanco and CTX ending
[**2105-6-28**]. Should monitor vanco trough on [**6-19**] for goal of [**9-11**].
#. S/P Percutaneous Nephrostomy Placement: IR performed the
procedure on [**6-10**]. Her nephrostomy tube output was closely
monitored. Urology and IR recommendations were followed. She
will follow up as outpatient with subspecialty clinic and for
further workup of renal stone. Information regarding care of
this tube is included in the d/c papers. She will follow up with
Dr. [**Last Name (STitle) **] (scheduled [**2105-7-6**]).
#. Acute Renal failure: Thought to be multifactorial - including
post-renal origin from obstruction in ureter. Creatinine has
returned to baseline 0.7. The patient received IV fluids and her
Cr was monitored daily.
.
#. Lacunar infarct: The patient did become agitated while in
the ICU. The etiology of her mental status changes were
orignally unclear however, medications that might contribute to
her delirium, such as anticholinergics, were avoided. She
continued to be agitated on transfer to [**Hospital Ward Name **] to medicine
team. Neurology was consulted. CT head showed lacunar infarct.
Pt refused MRI. Originally with significant dysarthria and R
facial weakness. MS [**First Name (Titles) **] [**Last Name (Titles) 99052**] resolved prior to d/c. Alc
and lipids normal. Started on anticoagulation for stroke in
setting of new afib, see below.
.
#. Hypertension: The patient's home medication HCTZ was held due
to her acute kidney injury. Her pressures were monitored
closely. She was kept at permissive HTN <180 with PRN IV
hydralazine 10mg. After resolution of her symptoms she was
started on low dose ACE inhibitor. continue to titrate as
warrented.
.
# Afib: new onset in setting of urosepsis. Given acute CVA
started anticoagulation. Bridging with enoxaparin. Started on
coumadin. Goal INR [**12-31**]. Will need INR draw on [**6-19**]. By discharge
in PAF.
.
# depression, continued home meds.
.
# Confirmed code DNR/DNI with patient
Medications on Admission:
HYDROCHLOROTHIAZIDE 25 mg po q daily
VENLAFAXINE [EFFEXOR XR] - 150 mg Capsule, Sust. Release 24 hr
po q day
VITAMIN C 500 mg po q day
ASPIRIN 81 mg po q day
CALCIUM CARBONATE-VITAMIN D3 - One Tablet po BID
VITAMIN D3 1,000 unit po q day
COLACE 100 mg po every other night
LORATADINE 10 mg po q day in morning as needed for allergies
MULTIVITAMIN - One Tablet by mouth once a day
SENNOSIDES [SENOKOT] - 8.6 mg po BID prn constipation
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QAM (once a day (in the morning)).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO ONCE (Once) as needed for agitation.
9. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
Disp:*45 Tablet(s)* Refills:*2*
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **]
(2 times a day): Continue Enoxaparin until therapeutic
anticoagulation on Coumadin.
Disp:*60 qs* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. HydrALAzine 10 mg IV Q6H:PRN SBP>180
hold for sbp <100
14. Vancomycin in 0.9% Sodium Cl 1.25 gram/150 mL Solution Sig:
One (1) Intravenous every twenty-four(24) hours for 11 days.
Disp:*qs qs* Refills:*0*
15. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous every
twenty-four(24) hours for 11 days.
Disp:*qs qs* Refills:*0*
16. Calcium Citrate 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
17. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
18. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
19. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Lacunar infarct
New onset atrial fibrillation
Septicemia
Renal stone
Discharge Condition:
Mental Status: Confused - sometimes. - VERY hard of hearing
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a bloodstream infection
secondary to a kidney stone and kidney infection. You were
started on antibiotics and a nephrostomy tube was placed.
You tolerated the procedure well w/o apparent complications and
have been maintained on antibiotis. Hospital course was
complicated by development of a irregular heart ryrhem (atrial
fibrillation) and episode of difficulty speaking though to be
[**12-30**] new stroke (lacunar infarct).
Neurology was consulted and thought your difficulty speaking
from from a stroke. They recommended initiation of blood
thinners. You refused MRI to followup the size of the infarct.
You continued to improve in mental status and your dysarthria
resolved.
.
You conferenced with Pastoral Care services and decided to
establish your code status as DNR/DNI.
.
You must continue Warfarin and Enoxaparin to thin your blood.
You will need frequent checks of your coumadin level. Please
have blood drawn on Friday [**2105-6-19**] to monitor INR (currently
1.4; goal 2.0-3.0).
.
Please continue your antibiotics Vancomycin and Ceftriaxone
until [**2105-6-28**]. Please have your blood drawn Friday [**2105-6-19**] to
check your Vancomycin trough. The level should be between
10.0-15.0.
.
You had a nephrostomy tube placed and instructions for care of
this tube are included in your discharge papers.
.
The following changes were made to your medications:
STARTED Lisinopril 10mg Daily
STARTED Enoxaparin Sodium 90 mg SC BID, cont this medication
until your doctor tells you to stop.
STARTED Ceftriaxone 2g Q24 cont until [**2105-6-28**]
STARTED Vancomycin 1250mg Q24 cont until [**2105-6-28**], vancomycin
trough goal [**9-11**]
STOPPED HCTZ
STOPPED VIT D: please ask your kidney doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**]
this medication
.
Follow up with your doctors at the [**Name5 (PTitle) 32723**] below.
Followup Instructions:
Department: GERONTOLOGY
When: TUESDAY [**2105-11-10**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES (urology)
When: MONDAY [**2105-7-6**] at 1 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"038.9",
"733.90",
"592.1",
"715.90",
"599.0",
"591",
"781.94",
"584.9",
"311",
"427.31",
"V12.41",
"V10.3",
"V13.01",
"995.92",
"434.91",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
13299, 13434
|
8176, 10862
|
251, 389
|
13547, 13547
|
3198, 6210
|
15674, 16286
|
2615, 2619
|
11346, 13276
|
13455, 13526
|
10888, 11323
|
13755, 15651
|
2634, 3179
|
182, 213
|
417, 2004
|
6219, 6232
|
6241, 8153
|
13562, 13731
|
2026, 2400
|
2416, 2599
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,445
| 143,832
|
30008
|
Discharge summary
|
report
|
Admission Date: [**2126-5-2**] Discharge Date: [**2126-5-9**]
Date of Birth: [**2089-3-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Right sided chest pain
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
This is a 37 year-old Polish-speaking man with a history of
Stage 1 papillary RCC s/p right partial nephrectomy who presents
with right-sided chest pain for one day. There was sudden onset
of right-sided chest pain radiating to his right scapula at 4am
which woke him up from sleep. No radiation to his back. This
pain was exacerbated by deep breaths and movement though present
at rest. He has also had nightly fevers to 38C for past [**3-26**]
days. No cough, sore throat, diarrhea, abd pain, loss of
appetite, malaise, or other illnesses. No recent trauma. No h/o
radiation. No lower extremity edema or pain, history of clots,
nor recent long trips. He has never had a similar episodes in
the past. No recent travel outside of country or medication
changes (started Chantix 7 weeks ago), no sick contacts. Denies
dysuria or hematuria, or changes in bowel. Does have some mild
headaches for past week with no vision changes. He has been
taking 1600mg of ibuprofen daily for past 4-5 days for fever and
"anti-inflammatory effect". No skin rashes other than dry skin
at left ankle which was itching and now resolved.
.
In the ED, initial vs were: T 98.8, P 79, BP 149/82, RR 18,
O2sat 98%, pain [**6-30**]. His exam was unremarkable other than for
possible mild tenderness on palpation of chest. Labs with WBC
12.1 with 75.6 neutrophils. LFTs, lipase, lactate, and CE nl...
EKG showed NSR at 73 bpm with LAD. His CXR showed widened
mediastinum and low lung volumes consistent with splinting. As
he was about to be taken down for a CTA torso, he suddenly
developed severe chest pain, became diaphoretic, and appeared
pale. No headaches. His SBP was 180 on the right and 165 on the
left. He was taken urgently to the CT scanner; the study showed
no dissection nor PE. It was notable only for lipomatosis of the
mediastinum and pathologically enlarged hilar LN. However, while
in the CT scanner, he continued to splint with resultant O2
desaturations to the 80s. He was placed on a NRB with
improvement in his O2sat to 100%. He was given morphine 4mg IV,
then dilaudid 4mg IV for pain control. He was reevaluated with
no change in history, but rectal temp was found to be 102, and
he was given Tylenol. He also received vancomycin and zosyn for
broad coverage of an unclear infection; U/A unremarkable. Given
concern that he would trigger on the floor, he was admitted to
the ICU. On transfer, vs were:
.
On the floor, patient reported feeling more comfortable. He
continued to have R sided chest pain and RUQ pain at rest and
worse with inspiration and turning. He also reported dizziness
with sitting up which resolved with lying down, no changes in BP
during episode. Reports that SOB is due to pain.
.
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:
Stage 1 T1b papillary renal cell carcinoma s/p laparoscopic
right partial nephrectomy
Hypertension
Hyperlipidemia
History of atypical chest pain
GERD
Tobacco abuse
Social History:
Originally from [**Month/Year (2) 36978**], in US for 4 years. Works for his
father-in-law in home building. Lives with his wife and his
8-year-old daughter. [**Name (NI) **] also has a 16-year-old daughter in
[**Name (NI) 36978**].
- Tobacco: One drink a day, not recently
- Alcohol: One ppd x 20 years
- Illicits: Denies
Family History:
His father had HTN, HTN, and died of CVA (one at age 63 and 65).
His mother died of kidney cancer at age 68. A maternal aunt had
an unknown cancer. A maternal uncle died of unknown causes. His
paternal grandmother had an unknown cancer. Two sisters have
asthma, and one brother has a [**Last Name **] problem.
Physical Exam:
On Admission:
General: Alert, oriented, no acute distress, mildly diaphoretic
HEENT: EOMI, PERRLA, sclera anicteric, MMM, oropharynx clear
with dental bridge on upper pharynx
Neck: supple, JVP not elevated, no LAD
Lungs: Poor inspiratory effort [**1-23**] pain, no breath sounds in
lower [**12-24**], no rales or wheezes, not in respiratory distress and
not using accessory muscles of respiration; no tenderness on
palpation around anterior chest wall
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Back: no CVA tenderness
Abdomen: obese and distended, soft, mildly tender on palpation
at lower right ribs laterally and RUQ substernally, negative
[**Doctor Last Name 515**] sign, no hepatomegaly or splenomegaly, BS+, healed
laparoscopic scars
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; healing mild folliculitis on L anterior shin with no
other skin rashes
Neuro: CNII-XII intact, 5/5 strength in upper extremities
On Discharge:
General: NAD, resting in bed, has been walking, does not require
oxygen.
HEENT: Sclerae anicteric, MMM, oropharynx clear.
Neck: Supple.
Lungs: Unlabored at rest; deeper respirations today but and
improved breath sounds at right lung base; otherwise clear
CV: S1, S2, no murmurs auscultated
Abdomen: Soft, non-tender, BS+
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Neuro: CNs [**3-2**] intact, motor function grossly intact.
Pertinent Results:
Admission labs:
[**2126-5-2**] 08:00PM BLOOD WBC-12.1*# RBC-3.60* Hgb-12.1* Hct-33.3*
MCV-92 MCH-33.6* MCHC-36.4* RDW-13.2 Plt Ct-277
[**2126-5-2**] 08:00PM BLOOD Neuts-75.6* Lymphs-18.4 Monos-4.5 Eos-1.1
Baso-0.4
[**2126-5-2**] 08:47PM BLOOD PT-11.6 PTT-24.3 INR(PT)-1.0
[**2126-5-2**] 08:00PM BLOOD Glucose-128* UreaN-17 Creat-1.0 Na-141
K-4.4 Cl-105 HCO3-25 AnGap-15
[**2126-5-2**] 08:00PM BLOOD ALT-39 AST-24 LD(LDH)-237 CK(CPK)-212
AlkPhos-75 TotBili-0.4
[**2126-5-2**] 08:00PM BLOOD Calcium-10.1 Phos-4.5 Mg-2.0
[**2126-5-2**] 08:00PM BLOOD TSH-1.8
[**2126-5-2**] 08:00PM BLOOD CRP-100.9*
[**2126-5-2**] 11:03PM BLOOD Lactate-0.7
.
Discharge labs:
[**2126-5-9**] 06:40AM BLOOD WBC-10.1 RBC-4.39* Hgb-14.0 Hct-41.0
MCV-94 MCH-31.8 MCHC-34.0 RDW-12.9 Plt Ct-452*
[**2126-5-9**] 06:40AM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-139
K-5.5* Cl-99 HCO3-27 AnGap-19
[**2126-5-3**] 01:37PM BLOOD HIV Ab-NEGATIVE
[**2126-5-2**] 08:00PM BLOOD TSH-1.8
[**2126-5-3**] 07:27AM BLOOD CK-MB-4 cTropnT-<0.01
[**2126-5-2**] 08:00PM BLOOD cTropnT-<0.01
.
Chest PA/Lateral:
IMPRESSION: A dramatic change in the appearance of the
mediastinum and
cardiac silhouette, likely accentuated by the profoundly low
lung volumes, however, the accompanying pleural effusions and
basilar atelectasis again further complicate the evaluation.
Given the apparent symptoms, cross-sectional imaging is advised.
CT Chest/Abdomen/Pelvis:
IMPRESSION:
1. No pulmonary embolism or aortic pathology identified. Widened
mediastinum on chest x-ray secondary to lipomatosis of the
mediastinum.
2. Pathologically enlarged lymph nodes throughout the
mediastinum and hilum, though fatty hilum of lymph nodes and
normal morphology is maintained. This is suggestive of a
reactive lymphadenopathy.
3. Low lung volumes bilaterally with associated atelectasis and
a small right pleural effusion.
4. No abdominal pathology identified.
5. Expected partial nephrectomy postoperative appearance.
.
CXR ([**2126-5-6**]):
IMPRESSION:
1. Reaccumulation of moderate right pleural effusion.
2. Bibasilar atelectases is unchanged from prior study.
CT chest ([**2126-5-5**]):
IMPRESSION: Right lower lobe pneumonia with small associated
pleural
effusion.
.
CXR ([**2126-5-4**], Preliminary):
No PTX, pleural effusion at right base tracking into the minor
fissure, bilateral atelectasis
.
CT Chest ([**2126-5-4**]):
RLL consolidation c/w PNA, small right pleural effusion,
calcification of the right kidney and adrenal, left renal 2.1 cm
hypodensity c/w cyst
.
[**2126-5-4**]: Peritoneal fluid:
NEGATIVE FOR MALIGNANT CELLS.
.
[**2126-5-4**]: Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
Mr. [**Known lastname 71622**] is a 37 year-old man with HTN, s/p renal cell
carcinoma p/w sudden onset of pleuritic right chest pain.
Patient initially admitted to medical intensive care unit.
.
# Chest / RUQ pain: Pain pleuritic in nature though also occurs
at rest, began acutely though over past week has also had
fevers. No other signs of symptoms of localizing infection.
Etiology is unclear though broadly includes cardiac, pulmonary,
hepatic, or renal. Cardiac etiologies such as pericarditis, ACS
or pericardial effusion though no evidence of this on CT scan or
ECG, negative cardiac enzymes. Pulmonary causes include PE,
pleural effusion, pneumonia, atelectasis, rib fractures, or
infarct. CTA chest did not show any abnormalities, however, and
no recent URI symptoms or evidence of pneumonia. His pain does
extend into the RUQ with some tenderness over the lower lateral
libs. LFTs were normal and no hepatomegaly. There is no evidence
of recurrence of his renal cell ca s/p partial nephrectromy in
[**3-31**] and given his Stage 1 disease with no local recurrence,
suspicion for paraneoplastic disease is low. Does not seem to be
esophageal in nature. Hypoxia is intermittent and occurs in
setting of splinting. Patient does not recall any trauma or
injury to the area though musculoskeletal or costochondritis is
possible. Given high fevers recently with no localizable
infection, viral syndrome is high on differential. Of note,
patient has been taking ibuprofen 1600mg daily for past 4-5 days
for fever, though no transaminitis and would not expect this to
cause such severe hepatic/substernal pain.
Patient was admitted to ICU. He was ruled out for MI and
monitored on telemetry without event. He was treated with
azithromycin and ceftriaxone for possible pneumonia.
.
# Fever: Tmax 102 with no localizing signs of symptoms of
infection. As above, most likely etiology is viral syndrome.
Mild leukocytosis with left shift. Can also consider
immune-mediated causes of fever or systemic inflammatory states.
Treated with ceftriaxone and azithromycin. Cultures showed...
.
# Renal cell carcinoma: diagnosed with Stage 1 papillary renal
cell ca in [**3-31**], s/p R partial nephrectomy with no evidence of
metastases thus far. CT abd/chest did not show any local
recurrence. There were reactive lymph nodes in mediastinum
though radiographically appear to contain fat and likely
suggestive of mediastinal lipomatosis given widened mediastinum.
Patient's LDH was normal.
.
# Widened mediastinum: new since last CT scan in [**2124**].
Radiographically appears to be mediastinal lipomatosis with
fat-containing mediastinal lymph nodes. This is usually seen
with exogenous steroid use or endogenous corticoid excess.
Patient has no history of steroid use though this may be in
setting of simple obesity. Other less likely etiologies include
lymphoma or reactive nodes, though no evidence of pneumonia.
.
# GERD: Continued omeprazole.
.
# HTN: Continued atenolol.
.
On the medicine floor, following his transition from the MICU:
#. Pneumonia with effusion: Pleuritic pain of left chest wall.
No evidence of recurrence of his renal cell cancer s/p partial
nephrectromy in [**2125-3-22**]. Given his Stage 1 disease with no
local recurrence, suspicion for paraneoplastic disease has been
low. Hypoxia has been consistent. Patient received
thoracentesis, and his pleural fluid was consistent with
exudative process. Repeat CT chest read as having a RLL
pneumonia. Thoracic surgery and Interventional Pulmonology both
consulted. Thoracic Surgery recommended that chest tube not
necessary given low level of fluid and no evidence of
complication/loculation. Can consider decortication if lung does
not re-expand when pneumonia clears. IP believes there is not
enough reaccumulation of pleural fluid to be able to remove via
thoracentesis. Pleural fluid cytology negative for malignancy.
Chest physical therapy and acapella valve have helped improve
lung volumes and clear consolidation. The patient's pain
symptoms and breathing improved over the course of his stay. By
the day of discharge, the patient was breathing without oxygen,
was afebrile, and his pain was well controlled. He was
discharged with close follow-up. The patient will complete a
14-day course of antibiotics with azithromcyin and cefpodoxime,
with ongoing improvement in his symptoms. We suspect that he
will require ongoing aggressive pulmonary hygiene given the
denseness of his consolidation.
.
# Hyperkalemia: During the last two days of admission, the
patient's potassium rose above five. He had not started any new
medications. This hyperkalemia was thought to be secondary to
his diet, which included several sports drinks and vitamin water
brought in by his wife as well as multiple yogurts, whose label
showed reasonably high potassium content. The patient was
counseled on keeping his dietary potassium intake low for the
time being, and he was scheduled for lab draws in four days at
his primary care physician's office.
.
#. History of renal cell carcinoma: Diagnosed with Stage 1
papillary renal cell cancer in [**2125-3-22**], s/p partial right
nephrectomy with no evidence of metastases thus far. CT abdomen
during the admission did not show any local recurrence. LDH
normal. Urinalysis negative. Pleural fluid cytology negative for
malignancy.
.
#. GERD: Continued home omeprazole.
.
#. HTN: Continued home atenolol.
.
Transitional issues: We suggest a followup chest xray in [**3-27**]
weeks to ensure resolution of the infiltrate, and further CT as
indicated. The patient may require further pulmonary
consultation as an outpatient if his symptoms associated with
this acute infection do not resolve completely as an outpatient.
Medications on Admission:
Atenolol 50 mg daily
Omeprazole 20 mg [**Hospital1 **]
Fish oil
Discharge Medications:
1. atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. azithromycin 250 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 days.
Disp:*24 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Please obtain blood test to check for potassium.
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia with pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 71622**],
.
It was a pleasure participating in your care at [**Hospital1 771**].
.
You were admitted to the hospital because you were having chest
pain. After several tests and images, it was determined that
your pain was caused by a pneumonia (an infection of the lung).
You were treated with antibiotics for this infection. You will
need to continue to take antibiotics by mouth for 7 days. Even
if you feel better, please take your antibiotics until they are
done. You also have a medication, Dilaudid, to help you if you
have any chest pain. You may take one every four hours if you
are having pain. Please do not take extra of this medication;
please do not operate heavy machinery, such as a car, when
taking this medication.
.
START azithromycin (antibiotics) for seven more days.
START cefpodoxime (antibiotics) for seven more days.
Take Dilaudid as directed for pain.
.
You had some high potassium readings during your last day of
admission. We would like you to go to the [**Hospital **] clinic, where
you see Dr. [**Last Name (STitle) 11616**], on Monday to have this level checked. Also,
limit foods that are high in potassium, such as bananas,
potatoes, and yogurt, for a few days.
.
In four weeks, you will also have to follow up with Dr. [**Last Name (STitle) 11616**]
for another chest X-ray.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
TWO APPOINTMENTS:
1) MONDAY [**2126-5-13**] at 8:30AM--Please arrive at 8:30am for
[**Hospital 11074**] clinic hours of [**9-1**]. There will be a short wait to be
seen by Dr [**Last Name (STitle) 11616**]. Also, please discuss with him if you still
need to come to your previously scheduled Friday appt on [**5-17**].
2)FRIDAY [**2126-5-17**] at 11:30 AM
|
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"272.4",
"482.9",
"272.8",
"276.7",
"511.89",
"V10.52",
"401.9",
"V45.73",
"079.99",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
15010, 15016
|
8530, 13943
|
326, 342
|
15092, 15092
|
5876, 5876
|
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|
370, 3073
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5892, 6514
|
4427, 5393
|
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|
3562, 3727
|
3743, 4071
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,107
| 103,499
|
8167
|
Discharge summary
|
report
|
Admission Date: [**2116-4-29**] Discharge Date: [**2116-5-11**]
Date of Birth: [**2042-5-31**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Synchronous rectal cancer and sigmoid colon cancer
Major Surgical or Invasive Procedure:
Laparoscopic converted to open proctosigmoidectomy with partial
colectomy and end colostomy with takedown of splenic flexure and
prophylactic placement of Surgisis preperitoneal patch to
prevent parastomal hernia
History of Present Illness:
This is a 73 year-old male with locally advanced rectal cancer
with and biopsy-proven liver metastasis who presented electively
on [**2116-4-29**] for a laparoscopic converted to open
proctosigmoidectomy with partial colectomy and end colostomy,
takedown splenic flexure, and prophylactic placement of Surgisis
preperitoneal patch to prevent parastomal hernia.
Past Medical History:
PMH: locally advanced rectal cancer w/ liver mets, viral
cardiomyopathy EF 30%, A.fib on coumadin, multiple episdoes of
V.fib s/p ICD firing
PSH: Early stage urothelial carcinoma of the bladder status post
cystoscopic resection on [**2116-1-30**]
Social History:
Primarily Italian-speaking. He is married and lives at home with
his wife. His son and daughter are local and he is close to
them. He is originally from central [**Country 2559**] and tries to spend
time in [**Country 2559**] yearly. He smoked two packs per day for 40 years,
quitting in the past two years. He drinks two glasses of wine
per day and denies recreational substance use.
Family History:
Father: Died young of unknown causes.
Mother: Lived to 94 and was healthy with no known cancers.
Other: No other known cancer history in his family.
Physical Exam:
VITALS: T 98.2 HR 80 BP 133/64 RR 22 O2sat 99%RA
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally without adventitious
sounds, minimally decreased breath sounds at bases bilaterally.
No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs. Left sided colostomy
stoma is pink-purple, protuberant with mild friability and is
healing well with liquid-brown/green stool output and gas in his
ostomy appliance.
EXTR: 2+ peripheral pulses, without cyanosis, clubbing or edema.
INCISION/WOUND: Midline abdominal incision has mild erythema
extending 1-2 cm from the wound edge without fluctuance,
purulence or induration. [**4-17**] staples have been removed with
granulating tissue and minimally serosanginous drainage
underlying the exposed superficial fascia. The wound appears
clean.
Pertinent Results:
[**2116-5-10**] 06:00AM BLOOD WBC-9.2 RBC-3.58* Hgb-9.7* Hct-31.4*
MCV-88 MCH-27.1 MCHC-30.8* RDW-18.4* Plt Ct-650*#
[**2116-5-9**] 07:55AM BLOOD PT-13.2 PTT-24.7 INR(PT)-1.1
[**2116-5-10**] 06:00AM BLOOD PT-14.6* PTT-25.2 INR(PT)-1.3*
[**2116-5-11**] 03:50AM BLOOD PT-17.1* PTT-27.3 INR(PT)-1.5*
[**2116-5-10**] 06:00AM BLOOD Glucose-97 UreaN-21* Creat-1.2 Na-135
K-3.8 Cl-100 HCO3-27 AnGap-12
CXR ([**2116-5-5**]) - Stable postoperative findings indicative of
CHF. Fluid overload, as suggested in the requisition, may be a
cause of these findings provided other cardiogenic factors are
excluded.
LUE US ([**2116-5-2**]) - No evidence of left upper extremity deep
venous thrombus. Cephalic vein not visualized.
Pathology ([**2116-4-29**]) -
Rectum and sigmoid colon: Two synchronous colonic
adenocarcinomas. Thirty-five lymph nodes; no malignancy
identified.
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on PCA/IV Morphine for
pain medication in the immediate post-operative period and
transitioned to PO narcotic medication with adequate pain
control on POD#[**6-19**]. The patient remained neurologically intact
and without change from baseline. The patient remained alert and
oriented to person, location and place.
CARDIOVASCULAR: The patient experienced a single episode of
what was suspected ventricular tachycardia and his AICD fired a
single time intra-operatively, as previously mentioned. The
event occurred soon after insufflation of the abdomen during
attempted laparoscopy. In light of the rhythm concerns, the
procedure was converted to an open approach. The procedure
progressed without further hemodynamic or arrhythmic issues and
he was transferred to ICU in stable condition, intubated. The
EP/cardiology service was consulted for further management, they
recommended continuing his outpatient anti-arryhthmic [**Doctor Last Name 360**]
(dofetilide) and initiating post-op beta-blockade with IV
metoprolol. Serial EKGs were closely monitored without issue. He
was transitioned to oral Metoprolol, continued his dofetilide,
and started Digoxin with resolve of cardiac issues by POD#4.
Vitals signs were closely monitored via telemetry. Lopressor
increased to provide better appropriate rate control.
RESPIRATORY: The patient was extubated POD# 1 successfully. The
patient had no episodes of desaturation. The patient denied
cough or respiratory symptoms. Pulse oximetry was monitored
closely and the patient maintained adequate oxygenations. serial
CXRs did reveal some evidence of atelectasis versus
consolidation, along with pleural effusions (improved with
diuresis) which was closely monitored. A sputum sample revealed
H. influenzae (non type-B) that was sensitive to Ampicillin.
Given diurnal temperature spikes and the respiratory source of
infection, empiric Vancomycin and Zosyn IV were started on
POD#2. He completed a course of Zosyn and his respiratory
status was stable.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#[**7-21**]. The
patient experienced no nausea or vomiting. His ostomy site began
functioning with liquid stool output and gas in the appliance on
POD# [**5-19**]. His stoma site appeared dusky and friable with some
edema that progressed post-op, but was cloesly monitored and
deemed clinically stable. The patient was transitioned to a
regular diet on POD#9 and IV fluids were discontinued once
adequate PO intake was established.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#6, at which time the
patient was able to successfully void without issue. The
patient's intake and output was closely monitored for > 30 mL
per hour output. The patient's creatinine was stable, his
baseline being above normal.
HEME: The patient remained hemodynamically stable and only
required transfusion of 2 units of packed red blood cells. The
patient's coagulation profile remained normal. The patient had
no evidence of bleeding from their incision.
ID: The patient was febrile immediately post-op and displayed a
nearly diurnal fever curve, the source likely being a sputum
sample which revealed H. influenzae (non type-B) that was
sensitive to Ampicillin. Given diurnal temperature spikes and
the respiratory source of infection, empiric Vancomycin and
Zosyn IV were started on POD#2. Their white count was stable
post-operatively and their incision was closely monitored for
any evidence of infection or erythema. Staples were removed from
the superior aspect of the incision on POD#5 given some
spreading peri-incisional erythema, and green-brown purulence
was expressed and cultured. Dry dressing were changed daily
following the staple removal. There was no induration,
fluctuance. Wound cultures demonstrated pan-sensitive
pseudomonas and he has been on oral ciprofloxacin, which will
continue until [**5-16**].
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op. The patient also had sequential compression
boot devices in place during immobilization to promote
circulation. GI prophylaxis was sustained with
Protonix/Famotidine. The patient was encouraged to utilize
incentive spirometry, ambulate early and was discharged in
stable condition.
Medications on Admission:
1. dofetilide 250 mcg Capsule Sig: Two (2) Capsule PO BID.
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pradaxa 150 mg Tablet Sig: One (1) Tablet, PO BID.
5. furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. metoprolol ER 50mg Tablet Sig: One (1) Tablet PO qday.
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dose
to be adjusted based on INR.
8. colchicine 0.6mg Tablet Sig: One (1) Tablet PO DAILY.
9. simvastatin 40mg Tablet Sig: One (1) Tablet PO DAILY.
10. diovan 80mg Tablet Sig: One (1) Tablet PO DAILY.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. dofetilide 250 mcg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
3. digoxin 125 mcg 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. furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dose
to be adjusted based on INR.
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days: Five more days of antibiotics - course to end on [**2116-5-16**].
9. oxycodone 5 mg Capsule Sig: [**2-16**] Capsules PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Location (un) 55**]
Discharge Diagnosis:
Synchronous sigmoid colon and rectal cancers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a Laparoscopic converted
to open proctosigmoidectomy with partial colectomy and end
colostomy for surgical treatment of your colorectal cancer.
During this procedure a patch was also placed to prevent you
from developing a hernia near your colostomy site. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You
developed pneumonia during your hospitalization and this has
been treated with broad spectrum antibiotics. You will continue
antibiotics by mouth as an outpatient for the wound on your
abdomen. This antibiotic is called Ciprofloxacin which will end
on [**2116-5-16**]. You have tolerated a regular diet, passing gas and
your pain is controlled with pain medications by mouth. You may
be discharge to a rehabiliation facility to finish your
recovery.
Monitor your bowel function closely, if you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonges loose stool, or
constipation. You have a new colostomy. It is important to
monitor the output from this stoma. It is expected that the
stool from this ostomy will be solid to semi-solid and formed
similar to regular stool. You should have [**2-16**] bowel movements
daily. If you notice that you have not had any stool from your
stoma in [**2-16**] days, please call the office. You may take an over
the counter stool softener such as colace if you find that you
are becoming constipated from narcotic pain medications. Please
watch the appearance of the stoma, your stoma has become darker
purple/bluish/slightly yellow which is from some compromised
blood flow after your procedure, occationally this happens with
stomas and we watch the stoma for improvement which yours has
shown. The stoma will likely shed dead tissues which is ok, and
the tissue underneath should be beefy red/pink. This is expected
to happen however it is importnat that this is watched by the
wound/ostomy nurses and surgery team for improvements. The skin
around the ostomy site should be kept clean and intact. Monitor
the skin around the stoma for buldging or signs of infection
listed above. Please care for the ostomy as you have been
instructed by the wound/ostomy nurses. You will be able to make
an appointment with the ostomy nurse in the clinic 5-7 days
after discharge, You will have a visiting nurse at home for the
next few weeks helping to monitor your ostomy until you are
comfortable caring for it on your own.
You have a long vertical incision on your abdomen that is
partially closed with staples. The incision had a small area of
infection , and was opened at the bedside. This dressing must be
cared for by yourself and visiting nurses with wet to dry
dressing changes twice daily. It is important to monitor the
wound for signs of infection listed below. You will take
antibiotics that will help treat infection inthe area and allow
the wound to heal. The staples will stay in place until your
first post-operative visit at which time they can be removed in
the clinic, most likely by the office nurse. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line/ wound and
pat the area dry with a towel, do not rub. Reapply a new
dressing after showering.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excersise Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1120**].
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please see Dr. [**Last Name (STitle) 1120**] in the Colorectal surgery office on
Tuesday, [**2116-5-26**] at 10am. The phone number is
[**Telephone/Fax (1) 160**].
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2116-12-2**]
3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2116-12-2**] 4:00
Please make an appointment with your primary care provider to
update them on your position.
|
[
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"486",
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"197.7",
"276.3",
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"518.0",
"V58.61",
"428.22",
"425.4",
"V45.02",
"427.41",
"427.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"46.13",
"45.75"
] |
icd9pcs
|
[
[
[]
]
] |
9976, 10045
|
3792, 8511
|
354, 569
|
10134, 10134
|
2898, 3769
|
14992, 15513
|
1649, 1800
|
9123, 9953
|
10066, 10113
|
8537, 9100
|
10317, 14969
|
1815, 2879
|
264, 316
|
597, 959
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10149, 10293
|
981, 1231
|
1247, 1633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,578
| 127,454
|
3411
|
Discharge summary
|
report
|
Admission Date: [**2141-2-20**] Discharge Date: [**2141-2-27**]
Date of Birth: [**2060-11-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement
History of Present Illness:
80 yo Russian-speaking only female presenting with SOB with
history of severe diastolic heart failure (EF 55%), untreated
OSA (refuses tx at home), HTN, Afib, pulmonary hypertension,
COPD (baseline 5L nc at home), CRI baseline 2-2.5.
.
In the ED, initial vitals were T 97.6 HR 65 BP 140/76 RR 22
Oxygen Sat 92. She had a chest xray, CT abdomen and was given
zofran and vancomycin and zosyn for a UTI/pyelonephritis.
Received 500cc bolus NS.
.
Currently, patient sommnolent but arousable. Endorses current
SOB, denies CP, no abd pain. Triggered on the floor for hypoxia.
ABG showed 7.22/88/51. CXR with pulmonary edema. Given lasix and
placed on BIPAP. Repeat ABG was 7.25/83/54. Transferred to the
ICU for further monitoring.
Past Medical History:
#HYPERTENSION
#DIASTOLIC CONGESTIVE HEART FAILURE
-estimated dry weight of 94kg
-last TTE [**4-/2140**]; LVEF >55%; 3+ tricuspid regurg
#ATRIAL FIBRILLATION
-s/p cardioversion x 2
-previously on amiodarone, discontinued due to paced rhythm
during hospitalization in [**2140-4-23**]
-not anticoagulated due to history of hemorrhagic CVA
#PULMONARY HYPERTENSION
-RSVP 75 in [**11/2139**]
-thought secondary to longstanding ASD
#COPD
-home O2 (5L NC)
-baseline saturation high 80's-low 90's on 5L O2
#OSA,
-nonadherent to CPAP therapy
Microcytic anemia
#CHRONIC RENAL INSUFFICIENCY
-baseline Cr 2-2.5
#GERD
#ATRIAL SEPTAL DEFECT
- s/p repair [**6-/2133**]
- complicated by sinus arrest
- with PPM placement. #Hypothyroidism
#Hx of hemorrhagic CVA on Coumadin
#Hx of Gallstone pancreatitis s/p ERCP, sphincterotomy
#Frequent hospitalizations
-admitted almost monthly since [**2132**]
#Surgeries
-s/p APPY
-s/p CHOLE ([**2133**])
-s/p TAH/BSO ([**2133**] for fibroids)
Social History:
Lives alone. Daughter-in-law visits frequently and helps out
around house and c groceries. VNA comes once a week to set
medications out in a pill box. No tob, EtOH, IVDU.
Family History:
Non-contributory
Physical Exam:
General: NAD, sommnolent but arousable
HEENT: no OP lesions, mmm EOMI
Neck: supple
Chest/CV: irregularly irregular, no mrg, unable to assess JVP
[**12-19**] body habitus
Lungs: crackles all the way up to top lung fields
Back/CVA,Flank: + CVA tenderness
Abd: obese, +bs, soft, NTND
Ext: chronic venous stasis changes, erythema bilaterally, 1+
distal pulses
Neuro: alert, oriented to person
Skin: chronic venous stasis changes on LE
Pertinent Results:
Admission Labs:
[**2141-2-20**] 08:45PM TYPE-ART PO2-66* PCO2-82* PH-7.26* TOTAL
CO2-39* BASE XS-6
[**2141-2-20**] 06:00PM TYPE-ART PO2-54* PCO2-83* PH-7.25* TOTAL
CO2-38* BASE XS-5 INTUBATED-NOT INTUBA COMMENTS-BIPAP
[**2141-2-20**] 06:00PM LACTATE-0.9
[**2141-2-20**] 04:58PM TYPE-ART PO2-51* PCO2-88* PH-7.22* TOTAL
CO2-38* BASE XS-4
[**2141-2-20**] 12:45PM URINE HOURS-RANDOM
[**2141-2-20**] 12:45PM URINE GR HOLD-HOLD
[**2141-2-20**] 12:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2141-2-20**] 12:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2141-2-20**] 12:45PM URINE RBC-0-2 WBC-[**10-6**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2141-2-20**] 10:16AM COMMENTS-GREEN TOP
[**2141-2-20**] 10:16AM GLUCOSE-133* LACTATE-1.5 NA+-141 K+-4.9
CL--91*
[**2141-2-20**] 10:00AM UREA N-56* CREAT-2.1*
[**2141-2-20**] 10:00AM estGFR-Using this
[**2141-2-20**] 10:00AM ALT(SGPT)-11 AST(SGOT)-25 CK(CPK)-51 ALK
PHOS-137* TOT BILI-0.6 DIR BILI-0.2 INDIR BIL-0.4
[**2141-2-20**] 10:00AM LIPASE-40
[**2141-2-20**] 10:00AM cTropnT-0.02*
[**2141-2-20**] 10:00AM CK-MB-NotDone
[**2141-2-20**] 10:00AM TOT PROT-7.5 CALCIUM-9.0 PHOSPHATE-4.3
MAGNESIUM-2.9*
[**2141-2-20**] 10:00AM DIGOXIN-0.2*
[**2141-2-20**] 10:00AM WBC-10.1# RBC-3.97* HGB-11.2* HCT-34.4*
MCV-87 MCH-28.3 MCHC-32.7 RDW-15.8*
[**2141-2-20**] 10:00AM NEUTS-85.2* LYMPHS-10.0* MONOS-3.6 EOS-0.8
BASOS-0.4
[**2141-2-20**] 10:00AM PLT COUNT-211
[**2141-2-20**] 10:00AM PT-14.3* PTT-28.4 INR(PT)-1.2*
.
Labs at expiration:
[**2141-2-26**] 03:55AM BLOOD WBC-7.9 RBC-3.38* Hgb-9.7* Hct-29.7*
MCV-88 MCH-28.8 MCHC-32.8 RDW-15.9* Plt Ct-183
[**2141-2-27**] 03:58AM BLOOD Glucose-106* UreaN-91* Creat-2.1* Na-143
K-4.8 Cl-101 HCO3-31 AnGap-16
[**2141-2-21**] 08:45PM BLOOD CK-MB-5 cTropnT-0.06*
[**2141-2-26**] 03:55AM BLOOD Calcium-8.7 Phos-4.4 Mg-3.1*
.
Micro data:
URINE Site: NOT SPECIFIED
[**Doctor Last Name **] TOP HOLD # 69086K [**2-20**] 6:03PM.
**FINAL REPORT [**2141-2-22**]**
URINE CULTURE (Final [**2141-2-22**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGING:
CT ABd/Pelvis:
IMPRESSION:
1. Obstructing 5 x 4 x 10 mm stone within the mid to upper right
ureter, with associated hydroureter and hydronephrosis.
2. Unchanged appearance of numerous cystic lesions within
bilaterally
atrophic kidneys.
3. Unchanged appearance of 2.4 x 2.6 cm right adrenal nodule,
most likely an adenoma given stability, despite intermediate
attenuation on current study.
4. Unchanged anterolisthesis of L4 on L5.
Brief Hospital Course:
80 yo F with hypercarbic respiratory failure [**12-19**] fluid overload,
COPD, OSA, acute on chronic dCHF, admitted with respiratory
failure and acute renal failure secondary to an obstructive
renal calculus. Her hospital course is as follows:
.
# Hypercarbic Respiratory Acidosis: Her admission ABG was
7.22/88/51 on 6L nasal cannula which improved to 7.25/83/54
after 30 minutes of BiPAP. Her symptoms were likely related to
her end stage COPD as well as her CHF, OSA, and pulmonary
hypertension with cor pulmonale. Attempted diuresis was
unsuccessful due to her BP and renal failure. She was initially
on vanco/zosyn which was changed to cipro for her UTI. There
was no obvious pulmonary infection. She stabilized with
intermittent BiPAP and 2-6 liters NC. Her mentation fluctuated
as did her oxygenation, ranging low 80s to low 90s. We
continued her bronchodilators. For the rest of her admission
she remained cyanotic. Upon admission she was lucid and
competent to make the decision to be DNR/DNI. Therefore, we did
not intubate her. She finally expired from her hypercarbic and
hypoxic respiratory failure, leading to cardiac arrest, on [**2-27**]
at 12:10 PM.
.
# Acute on chronic diastolic CHF: She appeared fluid overload on
admission with signs of increased pulmonary congestion.
Diuresis was attempted with a lasix gtt with no effect. We
continued her ASA, beta blocker, and statin. However, she may
have been intravscular volume dry, though she did not respond to
gentle IVF boluses. Her repsiratory status eventually
deteriorated die to her co-morbidities. There were no signs of
cardiac ischemia during her admission.
.
# Hypotension: The patient was 94 systolic on admission, which
increase to 120's after 500ml bolus in ED. Her BP stabilized
thereafter. We held her anti-hypertensives in house.
.
# Obstructing Renal Calculus: The patient was found to be in
ARF. CT scan demonstrated an obstructing renal calculus. Urine
studies were also consistent with a UTI. Urology and IR were
consulted. A nephrostomy tube was placed. Her Cr cont to rise
to 3.5 despite gentle fluid boluses. However, the day before
expiration her Cr began to improve to baseline.
.
# UTI: With her renal calculus she was found to have a proteus
UTI. Though she was on vanco/zosyn initially, this was changed
to Cipro to complete a 14 day course before she expired.
.
# Chronic Renal Failure: Baseline 2-2.5. Please see above.
.
# Atrial fibrillation: Was rate controlled during admission. We
continued her digoxin at therapeutic doses, as well as her beta
blocker and ASA.
.
# Hypothyroidism: Continued levothyroxine
.
# FEN: replete lytes prn, NPO for now, no IVf given fluid
overload status, though will intubate if hypotensive and need
boluses
.
# Death: In discussion with the patient, she was made DNR/DNI on
admission. We spoke regularly with her daughter who agreed with
the goals of care and her management plan. On [**2141-2-27**] at noon.
She was brought back to bed after sitting in a chair. Her vital
signs were at her baseline at that time. Shortly thereafter,
she became unresponsive and hypoxemic. She was noted to take 2
gasps. She did not respond to aggressive verbal/painful
stimuli, or cranial nerve reflexes. Her rhythm became atrial
paced. She lost her BP. After 5 minutes no respiratory
function, she was pronounced dead at 12:10 PM on [**2-27**]. Cause of
death: respiratory arrest leading to cardiopulmonary arrest.
Family and PCP were notified.
Medications on Admission:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
[**11-18**] Caps Inhalation DAILY
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H as
needed.
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **]
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-18**] Sprays Nasal
QID as needed.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H as needed.
12. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY
13. Metoprolol Tartrate 12.5 mg PO BID
14. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY
16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
End stage COPD
Respiratory failure
Nephrolithiasis
Cardiopulmonary arrest
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"496",
"276.2",
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"428.0",
"427.31",
"584.9",
"401.9",
"585.9",
"592.1",
"599.0",
"799.02",
"428.33",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10916, 10925
|
6156, 9653
|
336, 377
|
11042, 11051
|
2811, 2811
|
11107, 11117
|
2326, 2344
|
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|
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|
277, 298
|
405, 1133
|
2827, 6133
|
1155, 2121
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,476
| 119,484
|
37231
|
Discharge summary
|
report
|
Admission Date: [**2147-6-15**] Discharge Date: [**2147-7-4**]
Date of Birth: [**2084-2-4**] Sex: M
Service: MEDICINE
Allergies:
Enoxaparin / Gammagard
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Rib Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 year old male with Stage IV small cell lung cancer with
involvement of the liver and a dermatomyositis paraneoplastic
syndrome, h/o PE in the setting of malignancy and IVIG
presenting s/p fall for rib pain. 10 days prior to admission,
he sustained a fall in his yard. He states that even though
there was nothing noticable he tripped over, he did not have any
lightheadedness, dizziness, chest pain, presyncope, memory loss.
The pain was [**2145-6-24**] and is getting progressively worse. He had
pain on his right side which he attributed to broken ribs. The
following day, he presented to an OSH ED, where he was told to
take Ibuprofen for pain control. He had continued pain and
visited his primary oncologist in clinic the day of presentation
([**6-15**]) where he was found to have fractures of the 7th-9th rib
on CXR. He was admitted for pain control. He denies any focal
weakness but notes some increased shakiness with his left hand.
.
Review of Systems:
(+) Per HPI; difficult to take a deep breath secondary to rib
pain.
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, chest
pain or tightness, palpitations. Denies cough, shortness of
breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, melena, hematemesis, hematochezia. Denies dysuria,
stool or urine incontinence. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
[**2144-7-18**]: Presented with rash over forearms and torso.
[**2144-8-18**]: Later developed muscle weakness. Saw dermatologist, Dr
[**Last Name (STitle) 16077**] - biopsy positive for dermatomyositis. Started on
prednisone 60 mg daily with good improvement of his rash and
weakness. He was also referred to a rheumatologist and
neurologist for further evaluation. Dysphagia symptoms also
apparent, evaluated by a speech and swallow therapist at [**Hospital1 18**].
[**2144-10-18**]: Radiographical workup - CT scanning showed a prominent
right hilar node and a lesion in the liver. Liver lesion by MRI
on [**2144-11-9**] at [**Hospital6 1109**] was equivocal.
[**2144-11-23**]: PETCT scan performed at [**Hospital1 **] showed abnormal
uptake in the right paratracheal lymph node, right hilum, liver
nodule in the mid portion of the right lobe, also a region of
the gallbladder.
[**2144-11-17**]: [**2144-11-26**]- an ultrasound guided liver biopsy was
performed at [**Hospital1 **]; lesion consistent with small cell lung
cancer. Staining shows positivity for synaptophysin, TTF-1, with
weak positivity for CK 7 and chromogranin (Pathologist Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 83828**]). Dr [**Last Name (STitle) **] from neurology ordered anti-[**Doctor Last Name **]
and anti-striate muscle antibody which are positive, done on
[**2144-12-7**]. (Anti-[**Doctor Last Name **] positive by immunofluorescence, but was not
positive by Western blot). A head MRI was performed on [**12-16**]
and showed no evidence of intracranial malignancy.
[**2144-12-18**]: Started chemotherapy
[**2145-3-18**]: Complete chemotherapy
[**2145-6-17**]: Dermatomyositis flare; subsequently given course of
steroids, IVIG, methotrexate. Interval CT scans do not show
obvious evidence of cancer progression.
[**2145-10-18**]: Pulmonary Embolism [**2145-11-7**], started on Lovenox
[**2145-11-17**]: hematochezia thought to be inflammatory colitis,
resolved with rectal steroids
[**2145-12-18**]: Dermatomyositis (DM) flare with fevers and ulcerative
lesions; CT on [**2146-1-7**] shows no progression of cancer
[**2146-2-15**]: Fevers, DM continue; lovenox implicated as one of
causes of fevers; fondiparinux substituted for lovenox. Hi dose
IV steroids used to control DM sx.
[**2146-3-18**]: Fevers abated with use of fondiparinux. PETCT suggests
inflammatory changes rather than overt SCLC recurrence.
[**2146-5-18**]: Recurrent disease seen mainly in liver on PETCT
[**2146-6-6**].
TREATMENT HISTORY:
FIRST LINE REGIMEN: carboplatin (5 AUC on day 1) and
etoposide(80mg/m2 on days 1, 2, and 3) every 21 days per cycle.
-Started [**2144-12-21**] and completed 6 cycles. Last chemo given on
[**2145-4-9**].
SECOND LINE REGIMEN: carboplatin (5 AUC on day 1) and etoposide
(80mg/m2 on days 1, 2, and 3) every 21 days per cycle. Repeated
regimen since was >1 year at time of recurrence. Had response.
-Started [**2146-6-14**] C1 D1, and completed 6 cycles without
complication, last chemo on [**2146-10-6**].
[**2146-11-22**] - continues on chemotherapy break after good response on
CT
Social History:
Unmarried, has one daughter- [**Name (NI) 40785**] ; girlfriend - [**Name (NI) 553**].
Computer engineer; unemployed
-Smoking Hx: 45 pkyr hx, has used Chantix.
-Alcohol Use: 2 drinks approximately 3-4 times per week.
-Recreational Drug Use: None
Family History:
Autoimmune disorders. Sister has Grave's disease, mother had
some sort of thyroid disease, 2 nephews have ulcerative colitis.
Physical Exam:
Admission Physical Exam:
Vitals - T 97.8 bp 153/81 HR 90 RR 18 SaO2 96RA
GENERAL: NAD
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent
nares, MMM, good dentition, nontender supple neck, no LAD, no
JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: Tenderness to palpation over right lower ribs
ABDOMEN: nondistended, +BS, nontender no rebound/guarding, no
hepatosplenomegaly, patient holding his right chest secondary to
pain.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: normal perfusion
NEURO: CN II-XII intact, 5/5 strength throughout. Slight
dysmetria on finger to nose exam.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
Vitals - T 97.9 bp 120/80 HR 73 RR 20 SaO2 97% on RA
GENERAL: NAD
HEENT: PERRL, EOMI, anicteric sclera, pink conjunctiva, patent
nares, MMM, no oral lesions, nontender supple neck, no LAD, no
JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nontender, nondistended, normoactive bowel
sounds, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: normal perfusion, 2+ dp pulses
NEURO: CN II-XII intact, 5/5 strength throughout. Slight
dysmetria on finger to nose exam, left hand worse than right.
Slight impairment in rapid alternating movements, left hand
worse than right
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
[**2147-6-16**] 06:20AM BLOOD WBC-6.0 RBC-4.55* Hgb-13.5* Hct-39.9*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.0 Plt Ct-198
[**2147-6-16**] 06:20AM BLOOD Glucose-88 UreaN-21* Creat-0.9 Na-142
K-4.1 Cl-104 HCO3-30 AnGap-12
[**2147-6-17**] 08:15AM BLOOD ALT-15 AST-24 LD(LDH)-261* AlkPhos-63
TotBili-0.8
[**2147-6-17**] 08:15AM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.4 Mg-2.0
[**2147-6-17**] 10:03PM BLOOD Type-ART Temp-37.4 pO2-78* pCO2-41
pH-7.50* calTCO2-33* Base XS-7
[**2147-6-17**] 10:03PM BLOOD Lactate-1.2
DISCHARGE LABS:
[**2147-7-4**] 05:30AM BLOOD Glucose-107* UreaN-22* Creat-0.8 Na-134
K-3.9 Cl-98 HCO3-24 AnGap-16
[**2147-7-4**] 05:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2
[**2147-6-28**] 06:06AM BLOOD WBC-7.7 RBC-4.85 Hgb-14.6 Hct-42.1 MCV-87
MCH-30.2 MCHC-34.8 RDW-14.5 Plt Ct-195
IMAGING:
CXR ([**2147-6-15**]): Seventh, eighth, and ninth rib fractures on the
right laterally.
MRI BRAIN ([**2147-6-16**]): New left cerebellar enhancing mass
measuring 2.7 x 2.3 x 2.3 cm with surrounding vasogenic edema
and effacement of the fourth ventricle concerning for
metastasis.
CT HEAD ([**2147-6-17**]): Left cerebellar mass, as seen on recent MR,
without evidence for hydrocephalus or herniation.
CT HEAS ([**2147-6-22**]): No change from [**2147-6-17**] in left cerebellar
lesion with
surrounding vasogenic edema and mild mass effect on the fourth
ventricle. No hydrocephalus or acute hemorrhage.
CT Head ([**2147-6-28**]): Mass in the left medial cerebellum with
interval decrease in Preliminary Reportposterior fossa mass
effect, associated vasogenic edema, and distortion of the
Preliminary Reportfourth ventricle. No acute hemorrhage or shift
of normally midline
Preliminary Reportstructures. No evidence of hydrocephalus.
Brief Hospital Course:
BRIEF COURSE:
Mr. [**Known lastname 7168**] is a 63 year old male with Stage IV small cell lung
cancer with involvement of the liver and a dermatomyositis
paraneoplastic syndrome, h/o PE in the setting of malignancy and
IVIG initially presented s/p fall for rib pain. Patient
subsequently had an MRI of the brain which showed a large
cerebellar lesion which is presumed to be metastasis from his
SCLC.
ACTIVE ISSUES:
# Cerebellar metastasis: Patient initially admitted to OMED for
rib fractures and pain management. He was noted to have
right-sided weakness so MRI was performed. MRI revealed new
cerebellar mass, likely metastasis from his SCLC. He
subsequently began vomiting. Neurosurgery was consulted and he
was transferred to [**Hospital Ward Name 517**] ICU where follow-up head CT
showed no herniation, worse edema or hydrocephalus. He was
started on dexamethasone 6mg IV q4 hours and his symptoms
(including weakness) resolved, however he remains at high risk
for herniation. Rad-onc and neuro-onc were consulted and his
case was discussed at tumor board on [**6-19**]. On [**6-19**] he began
whole-brain radiation for a total of 10 sessions. He was
transferred back to the OMED service, where he continued to
receive radiation. Repeat CT head on [**6-28**] done to assess for
edema showed some improvement in mass effect and edema so his
dexamethasone was tapered to 4mg q6 hours. He completed his 10
session radiation course and tolerated it well aside from some
nausea. Patient's neurologic exam has remained stable with
slight dysmetria on finger-nose test. He is still a little
unsteady on his feet so he will receive PT at home with close
supervision by family. He is discharged on dexamethasone 4mg TID
with follow up with neuro oncology.
# Falls/Rib Fracture: Likely due to mechanical fall versus
related imbalance from cerebellar lesion (see above). Pt was
started on narcotics for pain control. MRI brain showed
cerebellar met as above. He was continued on oxycontin with
oxycodone for pain control. He worked with PT, and they
recommend discharge on home PT with close observation at home by
family members.
INACTIVE ISSUES:
# Small Cell Lung Cancer: With metastases to liver, lung and now
brain (as above). Managed by Dr. [**Last Name (STitle) **] as an outpatient. To
follow-up with his primary oncologist as an outpatient.
# Dermatomyositis: On Cellcept [**Pager number **] mg [**Hospital1 **]. He was continued on
atovaquone for ppx. Received IVIG in past, but stopped because
possible cause of his PE. Hx of treatment with methotrexate,
hydroxychloroquine. Was on prednisone prior to admission with
plans to decrease as tolerated, however this was stopped while
in hospital because he was started on dexamethasone with taper
as above. He will need to restart his prednisone after his
dexamethasone is discontinued.
# GERD: chronic, stable, continued H2 blocker in house.
# Depression: chronic, stable, cont Zoloft and Ativan PRN.
TRANSITIONAL CARE:
# FULL CODE
# CONTACT: daughter [**Name (NI) 40785**]
# FOllow-up:
1) Dr. [**Last Name (STitle) **]
2) Dr. [**Last Name (STitle) 6570**]
# Medication changes:
- START Dexamethasone 4mg by mouth every 8 hours (You will
continue this dose until you see Dr. [**Last Name (STitle) 6570**] for follow-up)
- START Oxycodone 5mg by mouth every 6 hours as needed for pain
- START Oxycontin 10mg by mouth twice daily for pain
- START Senna 1-2 tablets once to twice daily as needed for
constipation
- START Docusate sodium 100mg twice daily as needed for
constipation
- START Miralax packet daily as needed for constipation
- START Lorazepam 0.5mg tablet every 6 hours as needed for
nausea
- START Ondansetron 8mg tablet every 8 hours as needed for
nausea
- STOP Prednisone for now. You should discuss with your doctors
[**Name5 (PTitle) 9533**] this after your dexamethasone dose is tapered.
# Pending studies: None
Medications on Admission:
AMITRIPTYLINE - 25 mg Tablet - 1 Tablet(s) by mouth as needed
for sleep - no longer taking
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10ml 1(s) by
mouth twice daily
CLOBETASOL - 0.05 % Ointment - Use on rash once a day as needed
for breakouts
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth qhs PRN
insomnia as needed for insomnia do not take before driving or
with alcohol
MYCOPHENOLATE MOFETIL - 500 mg Tablet - 3 Tablet(s) by mouth
twice daily
PREDNISONE - 5 mg Tablet - 3 Tablet(s) by mouth daily for one
month and than taper to 2 tabs daily
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice
daily
SERTRALINE - 50 mg Tablet - 1.5 Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - 500 mg (1,250
mg)-400 unit Tablet, Chewable - 1 Tablet(s) by mouth three times
a day
FLAXSEED
FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - Liquid - 1 can by
mouth twice daily
GREEN TEA LEAF EXTRACT [GREEN TEA]
MULTIVITAMIN - 1 Tablet(s) by mouth daily
VITAMIN E - 1,000 unit Capsule - 1 Capsule(s) by mouth twice a
day
WHITE PETROLATUM [HYDROLATUM]
.
Discharge Medications:
1. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO BID (2
times a day).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea: do NOT take before driving or with
alcohol as this can cause sedation.
Disp:*30 Tablet(s)* Refills:*0*
3. mycophenolate mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. sertraline 50 mg Tablet Sig: 1.5 Tablets PO once a day.
6. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit
Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a
day.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. flaxseed Oral
10. senna 8.6 mg tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. docusate sodium 100 mg capsule Sig: One (1) capsule PO BID
(2 times a day).
Disp:*60 capsule(s)* Refills:*2*
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
Disp:*30 Powder in Packet(s)* Refills:*2*
13. oxycodone 5 mg tablet Sig: One (1) tablet PO every six (6)
hours as needed for pain.
Disp:*30 tablet(s)* Refills:*0*
14. oxycodone 10 mg tablet extended release 12 hr Sig: One (1)
tablet extended release 12 hr PO Q12H (every 12 hours).
Disp:*60 tablet extended release 12 hr(s)* Refills:*0*
15. ondansetron 8 mg tablet,disintegrating Sig: One (1)
tablet,disintegrating PO every eight (8) hours as needed for
nausea.
Disp:*90 tablet,disintegrating(s)* Refills:*0*
16. dexamethasone 4 mg tablet Sig: One (1) tablet PO Q8H (every
8 hours).
Disp:*90 tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. Cerebellar brain metastasis
2. Rib fractures
Secondary:
1. Metastatic small cell lung cancer
2. Dermatomyositis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 7168**],
It was a pleasure taking care of you during this admission. You
were admitted for pain control after your fall. We controlled
your pain with medication. You had a brain MRI that showed a new
mass concerning for spread of the cancer. We discussed this with
your primary oncologist and had the neuro-oncologist come to see
you. They recommended starting whole brain radiation. You
tolerated this well. You will follow-up with your primary
oncologist regarding further treatment for this cancer.
The following medications were changed this admission:
- START Dexamethasone 4mg by mouth every 8 hours (You will
continue this dose until you see Dr. [**Last Name (STitle) 6570**] for follow-up)
- START Oxycodone 5mg by mouth every 6 hours as needed for pain
- START Oxycontin 10mg by mouth twice daily for pain
- START Senna 1-2 tablets once to twice daily as needed for
constipation
- START Docusate sodium 100mg twice daily as needed for
constipation
- START Miralax packet daily as needed for constipation
- START Lorazepam 0.5mg tablet every 6 hours as needed for
nausea
- START Ondansetron 8mg tablet every 8 hours as needed for
nausea
- STOP Prednisone for now. You should discuss with your doctors
[**Name5 (PTitle) 9533**] this after your dexamethasone dose is tapered.
Please continue the other medications you were taking prior to
this hospitalization.
Followup Instructions:
Please follow-up with the following appointments:
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in
the next week. You will be called at home with the appointment.
If you have not heard within 2 business days or have questions,
please call [**0-0-**].
Department: PSYCHIATRY
When: TUESDAY [**2147-7-11**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5750**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: SOCIAL SERVICE HEM/ONC
When: TUESDAY [**2147-7-11**] at 2:00 PM
With: [**First Name8 (NamePattern2) 1112**] [**Last Name (NamePattern1) **], LICSW [**Telephone/Fax (1) 82425**]
Campus: EAST
Name: [**Doctor First Name **] J.ESTRIN, MD
Specialty: Primary Care
When: Monday [**7-17**] at 10am
Location: [**Hospital1 **] INTERNAL MEDICINE
Address: [**Location (un) **], [**Apartment Address(1) 5524**], [**Location (un) **],[**Numeric Identifier 7331**]
Phone: [**Telephone/Fax (1) 7401**]
Department: [**Hospital1 **] MRI (MOBILE)
When: MONDAY [**2147-7-31**] at 9:55 AM
With: MRI [**Telephone/Fax (1) 590**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROLOGY
When: MONDAY [**2147-7-31**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2147-7-4**]
|
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"311",
"197.7",
"V12.55",
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"348.4",
"807.03",
"162.4",
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"710.3",
"348.5",
"E885.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
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8902, 9305
|
290, 296
|
15868, 15868
|
7130, 7130
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|
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|
1855, 4973
|
4989, 5237
|
6255, 7111
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,831
| 102,019
|
54847
|
Discharge summary
|
report
|
Admission Date: [**2134-6-13**] Discharge Date: [**2134-7-3**]
Date of Birth: [**2063-9-23**] Sex: F
Service: MEDICINE
Allergies:
epinephrine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
pneumonia, renal failure
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line placement
PICC line placement
History of Present Illness:
70yo woman with long smoking history, 1ppd for many years,
decreased to [**1-11**] ppd in the last month, none in the last 4 days;
comes in with four days of cough and progressive shortness of
breath. Rigors, chills, sweats 2 days ago.
She presented to the [**Hospital3 **] ED, where initial vitals
were 97.4 90/55 91 26 78% on RA. Cr 7.1, K+ 5.1 (without EKG
changes), lactate 5.3. Creatinine up to 7.1, BUN 120. ABG there
w/ pH 7.33. Sent here.
In the ED, initial VS were: 97.6 85 109/56 26 90% 15L venti. WBC
down to 1.2. Lungs decreased at right base, but no wheezing.
Added levofloxacin for coverage of severe CAP. Long-time smoker.
Vitals prior to transfer 81 16 93% on venti mask at 50% 107/51.
Has two 18G for access.
> 10# decrease in weight in the past month; not trying to lose
weight, has not been hungry. Denies history of previous kidney
problems. [**Name (NI) **] hx of requiring oxygen or nebulizers in the past.
On arrival to the MICU, the patient was on a non-rebreather mask
in no distress or discomfort, but having 1 sentence dyspnea.
She was alert and oriented.
Review of systems:
(+) Per HPI
(-) Denies weight gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies 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.
Social History:
- Tobacco: 1ppd for many years, 1 month ago down to 1/2ppd, none
for last 4 days
- Alcohol:
- Illicits: none
- worked as a nurse for many years in various venues
Family History:
NC
Physical Exam:
ADMISSION
Vitals: T: 97.7 BP: 115/58 P: 86 R: 18 O2: 97% on NR
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, slightly dry mucosa, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, bilateral 18GA IVs in forearms
Lungs: tachypneic, slight suprasternal retractions, no distress,
crackles b/l, R >L, diminished R side with bronchial lung sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
.
DISCHARGE
Pertinent Results:
ADMISSION
[**2134-6-13**] 07:08PM BLOOD WBC-1.2* RBC-4.36 Hgb-13.7 Hct-41.7
MCV-96 MCH-31.3 MCHC-32.8 RDW-14.8 Plt Ct-172
[**2134-6-13**] 07:08PM BLOOD Neuts-46* Bands-14* Lymphs-28 Monos-8
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0
[**2134-6-13**] 07:08PM BLOOD Glucose-83 UreaN-115* Creat-6.8* Na-138
K-4.4 Cl-98 HCO3-13* AnGap-31*
[**2134-6-14**] 01:37AM BLOOD ALT-42* AST-131* LD(LDH)-459* CK(CPK)-87
AlkPhos-60 TotBili-0.3
[**2134-6-14**] 01:37AM BLOOD Albumin-2.7* Calcium-7.5* Phos-7.9*
Mg-1.9
.
PERTINENT
[**6-13**] [**Hospital1 **] BLOOD CULTURE: 1. STREPTOCOCCUS PNEUMONIAE
INTERP M.I.C.
------ ------
LEVOFLOXACIN S
CEFTRIAXONE-(non-meningitis) S 0.012
CEFTRIAXONE(meningitis) S 0.012
PENICILLIN-MIC S 0.016
[**2134-6-14**] 5:57 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2134-6-17**]**
GRAM STAIN (Final [**2134-6-14**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2134-6-17**]):
Commensal Respiratory Flora Absent.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
PENICILLIN G---------- S
[**2134-7-1**] 5:42 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2134-7-1**]**
C. difficile DNA amplification assay (Final [**2134-7-1**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
CXR [**6-13**]
Moderate right pleural effusion with right lung base
consolidation. Smaller opacification likely pneumonia at the
left upper lobe. Repeat imaging to document resolution after
treatment.
.
U/S [**6-14**]
Satisfactory morphologic appearance of both kidneys with no
evidence of
hydronephrosis, renal mass or shadowing calculi.
The bladder is empty containing an indwelling Foley catheter.
.
ECHO [**2134-6-16**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a very small,
predominantly anterior pericardial effusion. There are no
echocardiographic signs of tamponade. No
IMPRESSION: Preserved regional and global biventricular systolic
function. No significant valvular disease. No valvular
vegetations identified.
.
KUB [**2134-6-16**]
IMPRESSION: Paucity of abdominal gas without evidence of toxic
megacolon.
.
U/S [**6-19**]
1. Distended gallbladder containing layering sludge without
definite stones. No gallbladder wall edema. Though no specific
signs of cholecystitis are present, acute acalculous
cholecystitis cannot be excluded.
2. Uniform dilation of the extrahepatic common duct, up to 1.0
cm, to the
level of the pancreatic head, below which the duct is not seen
well. MRCP may be helpful for further evaluation if there is
clinical concern. If not
obtained LFTs should be followed.
3. Small amount of ascites.
.
DOPPLER U/S
IMPRESSION: No evidence of deep vein thrombosis. Cephalic vein
(superficial) thrombosis at the level of the antercubital fossa.
.
CXR [**7-1**]
There is a new tracheostomy tube in standard position. Right IJ
catheter tip is in the mid SVC. NG tube tip is in the stomach.
Cardiomediastinal contours are unchanged. Mild vascular
congestion is increased. Bibasilar opacities are unchanged.
Small bilateral pleural effusions are also stable. There is no
evident pneumothorax. The opacities in the lower lobes may
reflect atelectasis, but superimposed infection cannot be
totally excluded.
.
MRI [**2134-6-30**]
FINDINGS: Diffusion images demonstrate multiple small areas of
restricted
diffusion in both cerebral hemispheres, predominantly in the
subcortical white matter in the periventricular region including
involvement of the left side of the corpus callosum suggestive
of acute infarcts. There are no acute infarcts seen in the
brainstem or cerebellum. Mild brain atrophy is seen. Mild
changes of small vessel disease identified. Small amount of
fluid is seen in the left sphenoid sinus and bilateral mastoid
air cells. There is no evidence of chronic microhemorrhages.
IMPRESSION: Multiple acute subcortical infarction in both
cerebral
hemispheres as described above. No mass effect or
hydrocephalus.
EEG [**6-29**]
This is an abnormal awake and sleep EEG because of
intermittent runs of bifrontocentral rhythmic slowing. In
addition,
there is excess slow activity admixed with background. These
findings
are indicative of a diffuse mild to moderate encephalopathy of
non-
specific etiology. If clinical suspicion for seizure is high, a
24
hour bedside EEG monitoring is recommended. No epileptiform
discharges
or electrographic seizures are present.
EEG [**6-30**]
IMPRESSION: This telemetry captured no pushbutton activations.
The
background was often disorganized and included a fair amount of
drowsiness. There were also brief bursts of slowing seen
multifocally,
especially in the right frontal region, but there were no areas
of
persistent and prominent focal slowing. There were no definitely
epileptiform features. There were no electrographic seizures.
[**7-1**] EEG
IMPRESSION: This telemetry captured no pushbutton activations.
The
recording showed a disorganized background, but one that reached
normal
frequencies. Much of the recording reflected drowsiness or early
sleep.
There was some slowing in several areas, but none was permanent.
There
were no epileptiform features, and there were no seizures.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
70 y/o female without significant past medical history who
presented initially with 4 days of cough, malaise, fever at home
dx with pneumonia via xray, admitted to MICU for increased O2
demand and acute kidney injury. Ultimately intubated for
respiratory distress and found to have Pneumococcal sepsis w/
course c/b MODS.
.
# Hypoxic respiratory failure:
Likely secondary to pneumonia in the setting of underlying COPD,
thus minimal reserve. Patient had progressive increasing work of
breathing ultimately requiring intubation. This was further
complicated by the development of ARDS in the setting of septic
shock, and pulmonary edema from fluid resuscitation. Her
pneumonia was treated with antibiotics (see below) and she
diuresis was started once she was HD stable. Her respiratory
status slowly improved. However, there was concern that due to
critical illness myopathy and resulting poor inspiratory effort,
she would be at high risk of re-intubation. A tracheostomy was
performed on [**6-30**]. Prior to discharge the patient was off the
ventilator with normal saturation on trach mask at FIO2 of 40%.
.
# Pneumosepsis:
Patient presented with leukopenia, bandemia, tachycardia and
tachypnea. Her CXR initially showed RLL infiltrate but evolved
quickly to involve both lungs. She shortly thereafter became
hypotensive and was aggressively fluid repleted and temporarily
required vasopressors. Her blood cultures from OSH prior to
transfer grew Peniccilin sensitive Streptococcus pneumoniae, as
did her sputum cultures here. She completed a 14 day course of
antitiobics on [**2134-6-27**]. She was afebrile and hemodynamically
stable prior to discharge.
.
# Acute renal failure:
Patient presented with BUN/Cr 115/6.8 in the setting of sepsis,
likely secondary to ATN, with evidence of muddy brown casts on
urine analysis. Renal ultrasound revealed no alternative cause
such as hydronephrosis. Her renal function gradually improved as
she became HD stable. Creatinine on discharge was 1.2.
.
# Thrombocytopenia
Patient had significant fall in platelet count during course of
hospitalization. Patter was concerning for [**Last Name (LF) **], [**First Name3 (LF) **] heparin was
discontinued, argatroban was started. [**First Name3 (LF) **] antibody was
eventually negative so argatroaban discontinued and resumed
heparin for DVT prophylaxis. Thrombocytopenia ultimately felt to
be medication related. Famotidine was discontinued. Patient's
platelet count gradually normalized.
.
# Altered/Persistent Depressed mental status:
Patient had significant delay in recovery of mental status,
initially attributed to build up of benzodiazepines used for
sedation (on ventilator) in the setting of [**Last Name (un) **], evidenced by
prolonged presence of benzodiazepines in urine. Slowly improved
but some concern for waxing/[**Doctor Last Name 688**] consciousness. MRI revealed
multiple acute subcortical infarctions in both cerebral
hemispheres. EEG was concerning for brief bursts of slowing seen
multifocally, but especially in the right frontal region
suggestive of possible seizure activity. Her EEG prior to
discharge demonstrated no seizure activity. Her clinical status
continued to improve. Outpatient neurology follow-up was
arranged.
.
# Critical Illness Myopathy/Polyneuropathy:
Patient with significant weakness and difficulty gaining motor
function in setting of sepsis and mechanical ventilation with
use of paralytics. Slowly improved throughout her course. Her
clinical status continued to improve. Outpatient neurology
follow-up was arranged.
.
# Fevers:
Patient intially febrile after completion of ATBx course,
however, repeat blood, urine cultures negative and CDiff toxin
negative and no leukocytosis. Gradually resolved and afebrile
for the 72 hours prior to discharge.
.
# Anemia:
HCT steadily trending down, could be from serial phlebotomies
vs. anemia of chronic disease. Stool guaiac negative.
B12/folate/iron studies unremarkable, hemolysis labs negative;
low ferritin and low retic index indicate hypoproliferative
anemia. Likely anemia of acute disease. Remained stable at 24.3
prior to discharge. She should have her hematocrit trended daily
initially. Our transfusion criteria had been hct < 21.
# Dental issues:
Patient noted to have poor dentition. Evaluation by general
dentistry revealed multiple broken molars which need extraction.
-> Panorex as outpatient given that patient is too weak to
stand/sit on stool independently. Will need outpatient f/u with
oral surgery as well.
# s/p Tachycardia
Patient's course was c/b developement of atrial flutter. She was
initially treated with nodal blocking [**Doctor Last Name 360**] with resulting
hypotension. She eventually responded well to amiodarone.
-> Will likely need taper off this medication given unclear need
and potential for more lung toxicity. Will need to discuss this
with her primaryoutpatient providers upon leaving rehab.
# Transaminitis
LFTs elevated on presentation. Ultimately felt secondary to
hypotension, however in setting of persisten fevers there was
some concern for acalculous cholecystitis. RUQ ultrasound was
initially concerning for tense/enlarged gallbladder, but upon
further review by interventional radiology felt to be within
normal limits and not consistent with alcalculous cholecystitis.
LFTs were downtrending throughout the remainder of her hospital
course.
.
.
TRANSITION OF CARE
- Follow-Up Required--Patient will need repeat CT chest to
evaluate potentitial underlying pulmonary mass
--She will need follow up with Primary Care Physician, [**Name10 (NameIs) **] does
not have an established physician.
[**Name10 (NameIs) 112069**] will need to follow-up with a dental/oral surgery
--She will need neurology follow up
--Tracheostomy: will need removal of sutures around [**2134-7-10**];
keep tracheostomy neck ties in place at all times per
interventional pulmonary recommendations.
--Will be continued on amiodarone and Lasix upon discharge. Will
need outpatient labwork to evaluate renal function,
electrolytes, normalization of LFTs
--Full code
Medications on Admission:
- Quinidine 300mg daily
- ibuprofen 400mg PRN
Discharge Medications:
1. Heparin 5000 UNIT SC TID
2. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN mouth
pain
3. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
4. Albuterol-Ipratropium [**4-16**] PUFF IH Q4H:PRN SOB, Wheezing
5. Amiodarone 200 mg PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
7. Miconazole Powder 2% 1 Appl TP TID:PRN rash
apply to rash
8. Furosemide 40 mg PO BID:PRN volume overload
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
ACUTE ISSUES:
1. Septic shock with multiple organ dysfunction, secondary to
pneumococcal pneumonia
2. Hypoxic respiratory failure
3. Acute tubular necrosis (ATN) causing renal failure
4. Paroxysmal atrial fibrillation
5. Myopathy/polyneuropathy of critical illness
6. Lesions on brain MRI (acute stroke vs. infectious vs.
inflammatory)
7. Thrombocytopenia
8. Normocytic hypoproliferative anemia
CHRONIC ISSUES:
1. Smoking history
2. Chronic obstructive pulmonary disease (COPD)
3. Hypertension
4. Possible history of [**Name (NI) **] (unclear)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the medical ICU
on [**2134-6-13**] with pneumonia causing severe systemic infection and
respiratory failure. You were intubated and treated with
antibiotics. Your course was complicated by kidney failure which
caused your body to become severely fluid overloaded, and by
severe muscle weakness caused by long ICU stay. You were too
weak to be directly extubated so instead you had a tracheostomy
(breathing tube placed in your neck). Your symptoms slowly and
steadily improved with treatment and you are now ready for
discharge to a rehab facility where you will have frequent
physical therapy to help you regain your strength.
.
Please attend the follow-up appointment listed below with
dentistry (for dental x-rays and to possibly have some broken
teeth pulled). Also please attend the neurology appointment
listed below, to follow up on your weakness and the changes on
your brain MRI.
.
We made the following changes to your medications:
1. STOPPED quinidine.
2. STARTED amiodarone 200mg by mouth daily for paroxysmal atrial
fibrillation
3. STARTED heparin 5000 units subcutaneous three times daily
(continue until your mobility improves, rehab doctors [**Name5 (PTitle) **]
decide when you can stop)
4. STARTED colace and senna for constipation
5. STARTED maalox-diphenhydramine-lidocaine 15-30mL by mouth
every 4 hours as needed for mouth/throat pain
6. STARTED miconazole powder three applications per day for rash
Followup Instructions:
[**University/College 46453**] of Dental Medicine View Map
[**Last Name (NamePattern1) 112070**], R407
[**Location (un) 86**], [**Numeric Identifier 13108**]
Phone: [**Telephone/Fax (1) 108313**]
***It is recommended you see an Oral Surgeon as part of your
follow up care from the hospital. The above location may be a
possible resource for follow up.
Department: NEUROLOGY
When: WEDNESDAY [**2134-7-28**] at 4:30 PM
With: DRS. [**Name5 (PTitle) 540**]/[**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You have also been placed on a wait list and will be called at
rehab with an appt if one becomes available.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
|
[
[
[]
]
] |
[
"31.1",
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icd9pcs
|
[
[
[]
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15840, 15906
|
9245, 11758
|
304, 372
|
16495, 16495
|
2806, 9199
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18242, 19142
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2036, 2040
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15418, 15817
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15927, 16323
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15348, 15395
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16673, 17709
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2055, 2787
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17738, 18219
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1512, 1840
|
239, 266
|
401, 1493
|
16510, 16649
|
16339, 16474
|
1856, 2020
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,672
| 110,162
|
48
|
Discharge summary
|
report
|
Admission Date: [**2119-4-6**] Discharge Date: [**2119-4-15**]
Service: MEDICINE
Allergies:
Bactrim Ds / Zyprexa / Lisinopril
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
CT head
MRI/MRA
LP
Larynoscopy
History of Present Illness:
HPI: The patient is an 88 year old female, resident at [**First Name5 (NamePattern1) 553**]
[**Last Name (NamePattern1) 554**] [**Hospital3 **], with medical history pertinent for
Parkinson's disease, Diabetes, and recent cornea transplant who
now presents with altered mental status.
Per last progress note from patient's PCP, [**Name10 (NameIs) **] patient has been
in her usual state of health with exception of management of a
cervical vertebral fracture secondary to fall as well as plans
for a repat penetrating keratoplasty (corneal transplant) s/p
failed prior. The patient was at that time apparently at her
baseline and cleared for surgery. The patient underwent
penetrating keratoplasty on [**2119-3-30**] for indication of failed
graft without complication. The patient was seen by her
ophthalmologist on [**2119-4-4**] with impression that there was
moderate lid edema present suggestive of hypersensitivity but no
discharge to suggest infection. Polysporin was discontinued
(with concern for hypersensitivty per discussion with daughter)
and other meds (Pred 1% TID OS, Timolol 0.5% [**Hospital1 **] OU, Xalatan QHS
OS, Tobradex
[**Doctor Last Name **] OS QHS) continued.
The patient now presents form her [**Hospital3 **] with concern
for altered mental status. Only limited information is available
from available staff at [**Hospital3 400**], with report only that
patient was noted tonight to be acutely confused and "not making
sense". Per discussion with the patient's daughter, the patient
was in her usual state of health as early as yesterday morning,
looking well. Later in the day, the patient was reported to be
walking up and down the hallway, refusing to go to her room. The
patient was noted to be shivering and unsteady on her feet.
Recommendation was made that patient be sent to hospital for
further evaluation. Per discussion with daughter, the patient
has had prior episodes of confusion in setting of underlying
infetion, usually UTI.
.
ED Course: 98.4 -> 102.8 rectal, 186/84, 85, 20, 93% RA. Labs
notable for WBC 8.0, lactate 1.8. Not signed out, but per
nursing report and discussion a central line was attempted given
poor PIV access for which the patient received Haldol. No
documentation of dose is available, [**Name8 (MD) **] RN to RN signout this
was 5mg IV. Central line was not successfully placed and
ultimately a 22 PIV in the hand was obtained.
The patient had a negative UA, CXR without obvious infiltrate
although limited. Ophthalmology was not contact[**Name (NI) **] as [**Name (NI) **]
impression was that eye was not infected. LP was recommended by
ED but patients' daughter declined this. The patient was given
Azithromycin, Vancomycin, and Ceftriaxone empirically and is now
admitted to the medical service for ongoing care.
On arrival to floor patient is lethargic but wakes to voice. She
answers questions although requires repeat questioning at times
to wake her. Patient reports mild neck pain since having collar
removed, denies headache, chest pain, dyspnea, abdominal pain or
other localizing symptoms.
Past Medical History:
Parkinson's Disease
Dementia, mild
Hypertension
Hyperlipidemia
Hypothyroidism
Type II DM, diet controlled
Pernicious anemia
History of breast cancer
Urge incontinence
s/p penetrating keratoplasty [**2119-3-30**]
Cervical vertebral fracture
Social History:
She is widowed. She had a 6-year history of tobacco use but
quit decades ago. Her daughter is in her 50s and is healthy.
She denies alcohol use or abuse. She formerly taught English in
[**Country 532**]; she also worked as an interpreter of [**Doctor First Name 533**], Japanese,
and English.
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals: 98.3, 136/74, 76, 20, 94% RA
General: elderly female. Lethargic but arousable to vocal
stimuli. Only opens eyes after extensive coaching. Can answer
questions but often does not respond the first time.
HEENT: + mild erythema, yellow bruising, and mod edema
periorbital edema surrounding left eye. PERRL
Mouth: Significant tongue swelling and swollen lower lip. Barely
able to visualize uvula when using a tongue depressor. No
erythema of the mouth.
Neck: No LAD
Chest: Difficult to access given pt intermittently snoring
during exam despite repeatedly waking her up. No obvious
crackles.
Cardiac: RRR, III/VI systolic murmur loudest at LLSB
Abdomen: + bs, soft, NTND, no HSM
Ext: erythema bilaterally at ankles with no skin breakdown, DP
pulses and PT pulses +1, radial pulses +[**12-30**]. No c/c/e.
Neuro: oriented to name only. States she is in her apartment. UE
reflexes +2, LE reflexes difficult to access as pt not relaxing
and is pulling away from babinski.
Motor: Due to lethargy pt has poor participation in exam. UE
strength 4-/5 except for grip [**5-2**] bilaterally. LE poor effort.
Sensation: Intact in face, UE and LE to touch
Pertinent Results:
[**2119-4-5**] 08:25PM GLUCOSE-145* UREA N-24* CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
[**2119-4-5**] 08:25PM ALT(SGPT)-16 AST(SGOT)-27 LD(LDH)-261*
CK(CPK)-49 ALK PHOS-129* AMYLASE-35 TOT BILI-0.3
[**2119-4-5**] 08:25PM LIPASE-23
[**2119-4-5**] 08:25PM CK-MB-NotDone cTropnT-<0.01
[**2119-4-5**] 08:25PM ALBUMIN-4.0
[**2119-4-5**] 08:25PM WBC-8.0 RBC-4.42 HGB-13.1 HCT-37.5 MCV-85
MCH-29.7 MCHC-35.0 RDW-15.1
[**2119-4-5**] 08:25PM NEUTS-75.4* LYMPHS-17.2* MONOS-6.0 EOS-1.3
BASOS-0.2
[**2119-4-5**] 08:25PM PLT COUNT-152
[**2119-4-5**] 08:25PM PT-13.6* PTT-24.4 INR(PT)-1.2*
CT head [**4-5**]:
1. No acute intracranial hemorrhage or acute fracture.
2. Diffuse cerebral atrophy with moderate sulcal and ventricular
prominence.
3. Chronic microvascular infarcts, unchanged.
4. Paranasal sinus disease as described, likely acute in the
sphenoid sinus.
CT neck [**4-6**]:
1. Significant swelling/inflammation of the soft tissues at the
base of tongue, oropharynx, with fullness in the vallecula and
the piriform sinuses, overall resulting in moderate to marked
narrowing of the oropharynx. The etiology of this finding is
uncertain from the present study. To correlate with direct ENT
examination.
2. Fullness of the hypopharynx and adjacent portions of
esophagus - no adequately assessed on the present study- further
evaluation recommended.
3. Increased attenuation of the fat in the carotid space, with
soft tissue attenuation opacity, with heterogeneous appearance,
causing indentation on the right internal jugular vein extending
down along the carotid space, into the region of the thoracic
inlet. This may relate to inflammation, phlegmon, and
radiation-related changes if there is history of radiation in
the past and less likely neoplastic. Close followup evaluation,
with ultrasound can be considered to evaluate for any abscess,
given the patient's symptoms of fever.
CT orbits:
1. Increased attenuation of the preseptal soft tissues with some
enhancement, on the left side, likely due to inflamamtion/
post-surgical changes- correlate with clinical examination. No
definite abscess on the present set of images. No intraconal
abnormality. F/u as clinically indicated.
2. Moderate paranasal sinus disease
CT head [**4-9**]:
1. No acute intracranial process.
2. Persistent cerebral atrophy.
3. Chronic microvascular ischemic changes.
4. Paranasal sinus disease.
MRI/MRA brain:
Final Report
HISTORY: Parkinson's, delirium, lethargy, right facial droop and
dysarthria.
Evaluate for signs of intracranial hemorrhage or acute stroke.
Comparison is made to most recent head CT of [**2119-4-9**]
TECHNIQUE: Multiplanar T1- and T2-weighted sequences were
obtained through
the brain without intravenous gadolinium. 3D time-of-flight MR
arteriography
was also performed. Volume-rendering reconstructed images were
evaluated.
MRI OF THE BRAIN AND MRA OF THE BRAIN: There is no evidence of
intracranial
hemorrhage, masses, mass effect, or regions of restricted
diffusion to suggest
acute infarction. A few scattered periventricular T2/FLAIR
hyperintensities
are noted, which are nonspecific but likely suggest chronic
small vessel
ischemia. There are also adjacent prominent Virchow-[**Doctor First Name **]
spaces. While
there is underlying global cerebral atrophy, the degree of
dilatation of the
ventricular system may be somewhat disproportionate to the
amount of central
atrophy. Small amount of fluid is noted in the mastoids
bilateral.
MR arteriography of the circle of [**Location (un) 431**] displays no aneurysmal
dilatation.
Mild atherosclerosis is noted in the right M1 segment. Posterior
circulation
is left dominant.
IMPRESSION:
1. No evidence of acute infarction. Scattered changes likely
related to
chronic small vessel ischemic disease.
2. Question slightly disproportionate degree of ventricular
dilatation in
relation to the amount underlying cerebral atrophy. While this
finding is
nonspecific, in the appropriate clinical scenario it may reflect
underlying
NPH.
Brief Hospital Course:
This pt is a 88yo female w h/o Parkinson's disease, mild
dementia and recent corneal transplant admitted to the hospital
for AMS and to the ICU for airway narrowing.
.
# Airway narrowing: She was noted to have swelling of the tongue
and lower lips on admission. A CT of the Head and Neck with IV
contrast showed no clear evidence of preseptal cellulitis and ?
of soft tissue infection/edema of neck and throat. Over course
of day, noted to have increased audible upper airway sounds with
good O2 sat of 97% on 2L which has been stable. ENT was
consulted and saw extensive edema and soft tissue swelling in
oropharynx with patent airway. Swelling around false cords,
tonsillar edema, but true cords without edema. The team thought
the swelling to be secondary to possible allergic reaction to
medications. She was started on solumedrol 60IV and famotidine
20mg. She was given one dose of zosyn and then switched to
unasyn to cover for possible soft tissue infection. Pt without
leukocytosis, fever (was 102.8 in the ED but afebrile since), or
abcess. ENT and anesthesia recommended transfer to ICU for
further monitoring. She was monitored and continued on Decadron
for three doses. During successive scopes by ENT, oropharyngeal
edema and some secretions were seen, but airway remained patent.
Unclear etiology: possible allergic reaction vs infectious
process vs both given tonsils appear possibly infectious and
lower airway appears more edematous and less infectious.
Lisinopril was stopped, and her laryngoscopic exam visibly
improved by the time she was called out to the floor.
-Pt was treated for 10 days for ?soft tissue infection and
switched to Augmentin for additional 5 days at dc
-ENT follow up appt was set up
# s/p corneal TP: lid edema on exam. Ophtho believes likely
secondary to blockage of drainage and not as likely due to
allergy. Ophtho felt the eye was improving and recommended
decreasing doses of eye drops.
-FU appt with Optho set up
.
#. Altered Mental Status: On admission, she was lethargic,
possibly from the Haldol she received in the ED. By the time she
was called out of the ICU, she was likely at her baseline mental
status, pleasant and easily conversant. Shortely thereafter,
however, she became agitated and combative and received 1.5mg
Haldol and later the same day 5mg of Zyprexa. She remained
agitated for about 36 hours before she became lethargic and
barely arousable. Head CT was unchanged from before. She had not
had any new fevers or new signs of infection. She had a lumbar
puncture that was unremarkable. MRI/MRA was neg except for some
ventriculomegaly in setting of global atrophy which was
difficult to differentiate from NPH. Neurology thought it was
unlikely to be NPH. EEG showed some focal acitivity concerning
for sublinical seizures. Pt was started on keppra, initially
continued to have periods of somnolence along with R sided
facial droop (which was thought be Neurology to represent a
post-ictal state with [**Doctor Last Name 555**] paralysis) but day before discharge
had significant improvement in mental status and was alert and
conversive. Due to hx of dementia and also ongoing hypoactive
delirium, pt was not fully oriented but did have significant
improvement in level of alertness.
-Pt curently is on Keppra 1000mg [**Hospital1 **] for one week and to be
increased to 1500mg [**Hospital1 **] later and kept at that dose.
-Pt should be followed by a neurologist at [**Hospital 100**] Rehab
-Outpt FU w neurology is already set up
.
#. UTI: grew Enterococcus in UCx. She was continued on Unasyn
for 10 days.
.
#. Positive blood cultures: 1/4 bottles growing coag negative
Staph. This was likely a contaminant so vancomycin was stopped.
Repeat blood cultures were negative.
#. Parkinson's Disease: continued Sinemet except when patient
was too lethargic to safely take meds
.
#. Hypertension, benign: Lisinopril was stopped due to concern
of angioedema. Atenolol was continued.
.
#. Hyperlipidemia: continued statin
.
#. Hypothyroidism: TSH normal on [**2119-4-6**] so not a picture of
myxedema and cannot account for MS change. Continued
levothyroxine.
#. Diabetes II, diet controlled without complication:
- insulin sliding scale while inpatient and bs were wnl. Pt can
have [**Hospital1 **] finger checks to Rehab but since not needing insulin,
does not have to be on sliding scale
# Deconditioning: per PT eval, pt was 2 person assist and will
need significant PT therapy to get back to baseline where she
was walking with a walker
Medications on Admission:
Tylenol 1000mg PO twice daliy
Aspirin 81mg daily
Atenolol 25mg daily
Carbidopa/Levodopa 25/100mg three times daily
Enablex 7.5mg SR daily
Fish Oil 1000mg daily
Levothyroxin 125mcg daily
Lisinopril 20mg daily
Simvastatin 10mg daily
Cyanocobalamin 1000mcg daily
Docusate 100mg daily
Pred 1% TID OS
Timolol 0.5% [**Hospital1 **] OU
Xalatan QHS OS
Tobradex OS QHS
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl
Ophthalmic QHS (once a day (at bedtime)).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
7. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): for one week, then increase to 1500mg [**Hospital1 **].
14. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: oropharyngeal swelling, delirium, urinary tract
infection
Secondary: Parkinson's disease, diabetes type 2, hypertension,
hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
You were evaluated for confusion and found to have swelling of
your tongue and throat as well as a urinary tract infection. You
improved with antibiotics. You became delirious in the hospital
but improved with conservative treatment.
If you have fevers, chills, confusion, or any other concerning
symptoms, call your doctor.
Followup Instructions:
1. PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], ph: [**Telephone/Fax (1) 250**], please call and make appt
for fu in [**2-1**] weeks
2. Ophtho, Dr. [**Last Name (STitle) **], ph: [**Telephone/Fax (1) 556**], Appt is on [**2119-4-28**]
at 11:00 AM
3. ENT, Dr. [**Last Name (STitle) **], ph: [**Telephone/Fax (1) 41**], Appt is on [**4-20**],
Thurs, 12:00/noon
4. Neurology, Dr. [**Last Name (STitle) 557**], ph: [**Telephone/Fax (1) 558**], Appt is on [**5-9**],
Tuesday at 9:30 AM
|
[
"250.00",
"V42.5",
"244.9",
"780.39",
"332.0",
"599.0",
"272.4",
"V10.3",
"293.0",
"281.0",
"528.3",
"788.31",
"041.04",
"401.9",
"E947.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.91",
"31.42",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15402, 15487
|
9271, 11246
|
261, 294
|
15676, 15683
|
5202, 9248
|
16057, 16561
|
3985, 4003
|
14195, 15379
|
15508, 15655
|
13810, 14172
|
15707, 16034
|
4018, 4018
|
200, 223
|
322, 3391
|
4032, 5183
|
11261, 13784
|
3413, 3655
|
3671, 3969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,904
| 184,889
|
11752
|
Discharge summary
|
report
|
Admission Date: [**2145-6-17**] Discharge Date: [**2145-7-15**]
Date of Birth: [**2112-2-29**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Compazine / Zantac / Hydromorphone
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Pedestrian struck
Major Surgical or Invasive Procedure:
[**2145-6-17**]: Left femur traction pin placement
[**2145-6-21**]: ORIF Left anterior pelvis and iliac [**Doctor First Name 362**]
[**2145-6-24**]: ORIF Left posterior wall and column
[**2145-6-27**]: Facial sutures removed
[**2145-7-1**]: Left hip I&D with VAC placement
[**2145-7-2**]: VAC changed at bedside
[**2145-7-6**]: VAC removed
[**2145-7-14**]: Anterior staples removed
[**2145-7-14**]: PICC placement in interventional radiology
History of Present Illness:
Ms. [**Known lastname 37173**] is a 33 year old female who was struck from behind
by a motor vehicle while getting into her car. She was
medflighted to [**Hospital1 18**] for further evaluation.
Past Medical History:
1. Crohn's disease with perianal fistuals s/p surgery, disease
in TI and cecum, 14 years of disease
-[**2131**] with ileosigmoid fistual
-s/p colectomy
-admitted in [**2141**] for flare, txt w/ steroids c/b
anxiety/pressured speech with resolved
-25 cm stricture and sessile poly on c-scope at [**Hospital1 1474**]
2. WPW s/p ablation [**48**] years ago at [**Hospital1 336**], Dr [**Last Name (STitle) 7047**]
3. Osteopenia on bone scan
4. Glucose intolerance
Social History:
RN unable to work [**3-19**] to disease
Family History:
1. Father- DM2
2. Breast and ovarian cancer on maternal side
Physical Exam:
BP:134/71 HR:112 RR:13 GCS:15
Awake, alert
CTA b/l
RRR
S/NT/ND
LLE: + ecchymosis in hip area,
NVI distally
superficial abrasions BLE
Pertinent Results:
[**2145-7-12**] 05:10AM BLOOD WBC-7.5 RBC-3.75* Hgb-10.6* Hct-31.5*
MCV-84 MCH-28.3 MCHC-33.7 RDW-15.9* Plt Ct-358
[**2145-7-10**] 01:38PM BLOOD WBC-8.3 RBC-3.77* Hgb-10.7* Hct-31.4*
MCV-83 MCH-28.5 MCHC-34.2 RDW-16.0* Plt Ct-426
[**2145-7-8**] 04:42AM BLOOD WBC-7.5 RBC-3.69* Hgb-10.2* Hct-31.5*
MCV-85 MCH-27.6 MCHC-32.3 RDW-16.2* Plt Ct-511*
[**2145-7-10**] 01:38PM BLOOD Neuts-69.8 Lymphs-17.5* Monos-7.9
Eos-4.3* Baso-0.6
[**2145-7-12**] 05:10AM BLOOD Glucose-114* UreaN-4* Creat-0.6 Na-140
K-3.9 Cl-105 HCO3-30 AnGap-9
[**2145-6-17**] 01:25PM BLOOD ALT-36 AST-57* AlkPhos-49 Amylase-31
TotBili-0.2
[**2145-7-12**] 05:10AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.7
[**2145-7-10**] 01:38PM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
[**2145-6-17**] 01:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Ms. [**Known lastname 37173**] presented to the [**Hospital1 18**] on [**2145-6-17**] via medflighted.
She was evaluated by the trauma service and found to have a left
acetabular fracture. Orthopedics evaluated the patient was
placed a femoral traction pin under conscious sedation in the
emergency room. She was then brought to the TSICU for further
care and monitoring. She was transfused one unit PRBC's and her
tetanus was updated. She was found to have no other injuries
and she was transferred to the floor on the orthopedic service.
On [**2145-6-21**] she was prepped and brought to the operating room for
fixation of her left anterior pelvis and iliac [**Doctor First Name 362**] fractures.
She tolerated the procedure well. On [**2145-6-23**] she was transfused
with 2 units of packed red blood cells due to post operative
anemia. On [**2145-6-23**] the acute pain service was consulted for
recommendations in her pain management. On [**2145-6-24**] she was
again taken to the operating room for the posterior wall and
column ORIF of her left acetabular. She tolerated the procedure
well. An NGT was placed in the operating room and it was
maintained on low wall suction. On [**2145-6-27**] her facial sutures
were removed. On [**2145-6-28**] she underwent an abdominal CT scan.
Her NGT was also removed and her diet was slowly advanced. On
[**2145-7-1**] she returned to the operating room for a left hip
washout of her Merelli lesion. A VAC was placed in the left hip
wound. She was also placed on a KinAir bed for skin protection.
On [**2145-7-2**] the VAC drain was changed at the bedside. On
[**2145-7-6**] the VAC was removed at the bedside. On [**2145-7-8**] her
prozac was restarted at her request. A abdominal CT was done on
[**2145-7-10**] which showed no interval change. On [**2145-7-14**] a PICC line
was placed in interventional radiology for long term
antibiotics. The remainder of her hospital course was otherwise
without incident. She was seen by physical and occupational
therapy to improve her strength and mobility through her
hospital stay. Her labs and vitals remained stable. Her pain
was well controlled. She is being discharged today in stable
condition.
Medications on Admission:
Toprol 100mg daily
Pentaz 6 tabs [**Hospital1 **]
Flagyl
Prilosec
Ambien
Klonopin
Cipro
Discharge Medications:
1. Ancef 1 g Recon Soln Sig: Two (2) gm Injection every eight
(8) hours for 4 weeks.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for muscle spasm.
6. Mesalamine 250 mg Capsule, Sustained Release Sig: Six (6)
Capsule, Sustained Release PO BID (2 times a day) as needed for
Chrons disease.
7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe
Subcutaneous DAILY (Daily) for 4 weeks.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6-8H
(every 6 to 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab hospital
Discharge Diagnosis:
1. Left pelvic/sacral/acetabular fracture
2. Transverse process fractures L2, L3, L4
3. Laceration to forehead (sutured)
4. Post operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Please continue to be touchdown weight bearing on your left leg.
Continue your IV antibiotics for a total of 4 weeks as
instructed.
Keep your incision clean and dry, you may apply a dry sterile
dressing as needed for drainage or comfort
If you notice any increased redness, swelling, drainage,
report to the emergency room.
Please continue your lovenox injections for a total of 4 weeks.
You may resume any normal home medications.
Please follow up as below. Call with any questions.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Left lower extremity: Non weight bearing
Treatment Frequency:
You may apply a dry sterile dressing daily or as needed for
drainage or comfort
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 37174**] at the [**Hospital1 18**] orthopedic
clinic next week. Call [**Telephone/Fax (1) **] to make that appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7167**], RD Phone:[**Telephone/Fax (1) 3681**]
Date/Time:[**2145-7-27**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2145-11-30**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2145-7-15**]
|
[
"805.6",
"728.89",
"E814.7",
"873.42",
"850.5",
"808.8",
"555.9",
"805.4",
"560.9",
"285.9",
"808.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.39",
"38.93",
"93.59",
"79.39",
"86.59",
"97.88",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6623, 6684
|
2635, 4850
|
328, 771
|
6873, 6881
|
1793, 2612
|
7662, 8265
|
1555, 1617
|
4988, 6600
|
6705, 6852
|
4876, 4965
|
6905, 7397
|
1632, 1774
|
7415, 7537
|
271, 290
|
799, 996
|
7558, 7639
|
1018, 1481
|
1497, 1539
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,086
| 154,494
|
45449
|
Discharge summary
|
report
|
Admission Date: [**2196-7-20**] Discharge Date: [**2196-7-27**]
Date of Birth: [**2115-2-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2196-7-20**] Endovascular repair of Thoracic aortic aneurysm with a
TAG modular [**Last Name (LF) 96989**], [**First Name3 (LF) 1092**] aortography and Right femoral
artery repair
History of Present Illness:
Mrs. [**Known lastname 18806**] is an 81 year old female found to have a newly
discovered thoracic aortic aneurysm during preoperative
evaluation for possible D&C for questionable uterine bleeding. A
CT scan in [**2196-3-9**] revealed two areas of fusiform aneurysmal
dilatation of descending thoracic aorta up to 6.6 centimeters.
The CT scan was also notable for an infrarenal abdominal aortic
aneurysm, measuring 6.7 centimeters. Given the above results,
she was referred to the cardiac and vascular services for
endovascular stent grafting. Of note, the etiology of her
bleeding turned out to be hemorrhoids, not uterine.
Past Medical History:
Thoracic and Abdominal Aortic Aneurysms
Hypertension
Diverticulosis
Chronic Back Pain(L1 collapse)
Arthritis
s/p Cataract Surgery
s/p Appendectomy
s/p Cholecystectomy
s/p Mole removals
s/p D&C
Social History:
Active smoker, 50 pack year history. Denies ETOH. She is
widowed, currently lives with her 22 year old granddaughter. She
is retired.
Family History:
Denies history of premature coronary disease.
Physical Exam:
Vitals: BP 127/81, HR 90, RR 14, SAT 98% on room air
General: obese elderly female in no acute distress, smelled of
smoke
HEENT: oropharynx benign, edentulous
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds, pulsatile
mass noted
Ext: warm, trace edema L>R, no varicosities
Pulses: 1+ distally, no femoral or carotid bruits
Neuro: nonfocal
Pertinent Results:
[**2196-7-27**] 06:10AM BLOOD Hct-28.2*
[**2196-7-26**] 05:55AM BLOOD WBC-12.2* RBC-3.46* Hgb-9.9* Hct-28.3*
MCV-82 MCH-28.5 MCHC-34.9 RDW-16.2* Plt Ct-213
[**2196-7-27**] 06:10AM BLOOD Glucose-97 UreaN-35* Creat-1.5* Na-139
K-4.0 Cl-99 HCO3-30 AnGap-14
[**2196-7-26**] Chest CTA ************
Brief Hospital Course:
On the day of admission, Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 1290**] performed
an endovascular repair of her thoracic aortic aneurysm.
Arteriography following stent placement revealed no endo leak at
the proximal attachment site, with a small endo leak seen at the
distal attachment site. The endo leak did not appear to
communicate with the aneurysm sac. The operation was otherwise
uneventful and there were no complications. She was brought to
the CSRU for invasive monitoring. On postoperative day one, she
experienced hypotension. Subsequent CT scan showed a moderate
amount retroperitoneal hemorrhage. Serial hematocrits remained
stable and she transiently required pressors for hemodynamic
support. Over the next 24 hours, her hemodynamics improved and
she successfully weaned from pressors without difficulty. She
was extubated without incident and the lumbar drain was removed
without complication. She made clinical improvements and
transferred to the SDU on postoperative day two. She was
intermittently transfused to maintain hematocrit near 30%. She
maintained stable hemodynamics and tolerated resumption of beta
blockade. She remained in a normal sinus rhythm. She had a
transient decline in renal function with creatinine peaking to
1.8 but by discharge, her renal function improved. Creatinine at
discharge was 1.5. Prior to discharge, a chest CTA was obtained
to re-evaluate the small endo leak at the distal attachement
site. The CTA was reviewed by both the vascular and cardiac
surgery services and it was determined that intervention was not
required at this time. She was discharged in stable condition
to home.
Medications on Admission:
HCTZ 50 qd
Lopressor 25 qd
Ecotrin 81 qd
Crestor 10 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Thoracic Aortic Aneurysm
Postop Anemia with Retroperitoneal Bleed
Abdominal Aortic Aneurysm
HTN
Arthritis
Discharge Condition:
Good.
Discharge Instructions:
Keep incisions clean and dry.
Call with fever, redness or drainage from incisions, or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] & Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 5456**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2196-7-27**]
|
[
"998.11",
"458.29",
"285.1",
"401.9",
"441.7",
"998.2",
"996.1",
"441.4",
"715.90",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.73",
"88.44",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
5271, 5329
|
2397, 4051
|
333, 518
|
5479, 5487
|
2078, 2374
|
1555, 1602
|
4156, 5248
|
5350, 5458
|
4077, 4133
|
5511, 5679
|
5730, 5912
|
1617, 2059
|
281, 295
|
546, 1172
|
1194, 1388
|
1404, 1539
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,909
| 175,576
|
37892
|
Discharge summary
|
report
|
Admission Date: [**2127-10-16**] Discharge Date: [**2127-10-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Urosepsis.
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
Mr. [**Known lastname 18937**] is an 87 year old Spanish speaking male recently
admitted for elective right iliac aneurysm repair on [**2127-10-12**].
Pt had experienced witnessed LOC while ambulating. Of note, had
experienced similar episode syncope 3 weeks prior, found to be
bradychardic by PCP, [**Name10 (NameIs) 151**] atenolol stopped. On this occaision,
he complained of low back pain, came to ED,found on CT R common
iliac artery aneurysm with old contained rupture. Transfered
here to OR emergently for repair. Had aortic stent graft with
extension into R external iliac artery. Stable post op with dc
on [**2127-10-14**]. On [**2127-10-15**] pt developed fever to 104, burning
urination, lower abdominal pain, rigors and went to [**Hospital1 487**]
where he had blood/UCx and got levoquin. He syncopized there in
setting of valsalva (was on commode post valsalva complaining of
dizziness, with BP initially unobtainable but improved on lying
down. Given immediately recently post op from [**Hospital1 **] transferred
here for further care. At [**Hospital1 18**] ED got blood and UCx, CXR and
EKG. Zosyn but not Vanc given, sent to ICU as developed an O2
requirement of 4L and persistently hypotensive despite 3L
IV.Vitals at time of transfer were BP 150/110, HR 90, 94% RA,
afebrile, 20.
.
Blood and urine cultures pending after Abx at both [**Hospital1 487**] and
[**Hospital1 18**].
.
In the ICU, Pt became persistently hypotensive to the 80s.
Received total 5.5 L IVF, with improvement of systolic BPs from
80s systolic to 120's systolic by ICU day 1. Patient did not
require pressors. His uop was low/concentrated with stable cr.
He was febrile to 104.2, defervescing over his ICU course with
tylenol, IVF and ABX. wbc peaked to 12.9 o/n then declined. His
afib was well rate controlled in 70s. He was restarted on his
outpatient coumadin 3mg initially given subtherapeutic INR, then
increased to 5mg given his subtherapeutic INR of 1.5 in setting
of abx. He was eventually weaned from O2 and considered stable
for transfer to the floor.
Past Medical History:
1)Dementia
2)AFib
3)CVA x 3
4)HTN - Baseline BP 140s.
5)CAD
6)scars on abdomen suggest prior surgeries
7)DM- list on problem list from OSH, but pt and family deny
Social History:
Originally from [**Doctor Last Name 84730**] in [**2088**]. Lives with
daugher in [**Hospital1 487**], has 17 children -patriarch of community.
Former tobacco and alcohol, none currently. AOX3 Mild memory
loss-occaissionally forgets namesx2 years. Independent with
ADLs. Walks without a cane, but does have trouble with stairs
and occ getting out of a chair. Gets home VNA several times a
week for meds/blood draws. Quit smoking in [**2107**], used to drink
heavily, none >10 years.
Family History:
Non-contributory.
Physical Exam:
Vitals: T: 98.9 (104.2) BP: 87/52 P: 87 afib R: 11 O2:100% on 4L
General: Sleeping but easily arousable, answers simple questions
in spanish, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Minimal diffuse crackles
CV: irregularlly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Groin: well healed scars bilaterally, small hematoma on right,
no bruits
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes, warm at torso, thighs, cold hand/feet
Pertinent Results:
[**2127-10-16**] 02:46PM GLUCOSE-96 UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-22 ANION GAP-9
[**2127-10-16**] 02:46PM CALCIUM-7.9* PHOSPHATE-3.6# MAGNESIUM-2.5
[**2127-10-16**] 02:46PM WBC-11.9*# RBC-2.91* HGB-8.4* HCT-26.6*
MCV-92 MCH-28.8 MCHC-31.5 RDW-16.0*
[**2127-10-16**] 02:46PM PLT COUNT-153
[**2127-10-16**] 02:46PM PT-17.2* PTT-30.4 INR(PT)-1.5*
[**2127-10-16**] 12:07AM LACTATE-1.2
[**2127-10-16**] 12:00AM NEUTS-88.1* LYMPHS-7.6* MONOS-3.9 EOS-0.2
BASOS-0.2
[**2127-10-16**] 12:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2127-10-16**] 12:00AM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-MOD
[**2127-10-16**] 12:00AM URINE RBC-[**11-21**]* WBC->50 BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2127-10-16**] 12:00AM URINE WBCCLUMP-MOD
Cultures:
[**2127-10-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-10-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-10-18**] STOOL OVA + PARASITES-FINAL INPATIENT
[**2127-10-17**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST-FINAL INPATIENT
[**2127-10-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2127-10-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2127-10-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2127-10-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2127-10-16**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY [**Hospital1 **]
Echo: [**2127-10-16**]:
The left atrium is dilated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending aorta is moderately dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mildly dilated/hypokinetic RV with moderate to
severe tricuspid regurgitation. Normal regional and global LV
systolic function. Mild mitral regurgitation.
CXR: [**2127-10-16**]: No pulmonary edema or pneumonia seen.
2. Right upper lobe pleural thickening and linear opacities, of
uncertain
etiology, possibly atelectasis related to restrictive pleural
thickening or
bronchiectasis. PA and lateral views of the chest are
recommended for further
assessment.
Renal US [**2127-10-20**]: COMPARISON: CTA aorta/bifem of [**2127-10-12**].
FINDINGS: The right kidney measures 10.1 cm. The left kidney
measures 11.3
cm. There is no hydronephrosis, stones, or mass bilaterally. The
bladder is
moderately well distended and appears normal.
IMPRESSION: No hydronephrosis.
Brief Hospital Course:
Mr [**Known lastname 18937**] is an 87 yo M with h/o CAD, HTN, recent iliac artery
repair and readmission for UTI, admitted with hypotension
concerning for sepsis of uro- or surgical source.
# Sepsis: Pt was admitted to the ICU with fever to 104 and
hypotension from baseline 140s to SBP 80s-90s with MAPs in mid
60s. He responded to IVF without requiring pressors. He was
initially started on broad spectrum antibiotics with Levoflox,
Zosyn and Vancomycin. Cultures from [**Hospital 487**] Hospital and [**Hospital1 18**]
revealed ESBL positive E.coli. His antibiotics were narrowed to
zosyn however he spiked a fever on zosyn and was thus switched
to meropenem with clinical improvement. He had a new O2
requirement briefly due to volume overload, but was tapered to
room air by the time he reached the regular floor. His urine
output was good on the floor, his foley was discontinued, with
initial incontinence which subsequently resolved. He should
complete a 14-day course of meropenem to end on [**10-30**].
# Syncope: He experienced Last week episode thought to be due to
bradycardia and BB discontinued. However, symptoms on admission
resembeled orthostatic hypotension post valsalva in the setting
of sepsis. He was monitored on telemetry, was not found to be
orthostatic on exam, did not have any bradychardic or syncopal
episodes here. Plan for outpt holter monitoring to be
orchestrated by PCP by Dr [**Last Name (STitle) 29065**].
# Afib: He had previously been on atenolol as an outpatient
however he had been bradychardic with syncope, and his atenolol
had been discontinued. He was found to be in rapid afib, for
which he was started on low dose metoprolol, with good control
of his heart rate and he remained asymptomatic from his afib. He
was found initially to be subtherapeutic with an INR of 1.5 with
possible interference from antibiotics,
so his coumadin was increased from 3mg to 5 mg, and his INR
remained in the therapeutic range. At time of discharge his
coumadin dose is 4 mg; this dose should be continued until
INR/PTT levels are checked two days after discharge.
# CAD: He had a history of coronary artery disease. His EKG did
not reveal any changes, and his aspirin and simvastatin were
continued. He remained DNR/DNI through the course of his
hospitalization.
Medications on Admission:
Medications at home:
Atenolol 50mg daily held [**2-3**] bradychardia &syncope (dc'[**Initials (NamePattern4) **] [**9-22**])
Coumadin 3mg (decreased during last hospitalization [**Hospital1 487**]?
Aspirin 325mg daily
Aricept 5mg
Simvastatin 10qd
Tylenol prn pain
.
Medications on transfer:
1. Piperacillin-Tazobactam 4.5 g IV Q8H
2. Vancomycin 1000 mg IV Q 12H
3. Warfarin 5 mg PO DAILY16
4. Aspirin 325 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Donepezil 5 mg PO HS
7. Heparin 5000 UNIT SC TID
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Ibuprofen Suspension 600 mg PO Q8H:PRN pain/fever
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
5. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
6. Sodium Chloride 0.9 % Injection
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for line flush.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] Care and Rehab
Discharge Diagnosis:
Primary:
Complicated Urinary Tract Infection.
Secondary:
Iliac artery aneurysm
Atrial Fibrillation
Coronary artery disease
Hypertension
Dementia
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You were admitted to the hospital because you had a urinary
tract infection. You were treated with intravenous antibiotics
and improved a great deal. You will continue to receive
intravenous antibiotics to completely cure your infection.
.
We INCREASED your coumadin from 3 mg daily to 4 mg daily.
We ADDED irtepenem to treat the infection.
We ADDED metoprolol for blood pressure and heart rate control.
.
Please return to the hospital or see your doctor if you have
flank or abdominal pain, chest pain, problems with your
urination, diarrhea, constipation, shortness of breath, nausea,
vomiting, headache, fever, chills, sweats, muscle pain, joint
pain, weight loss, or any other symptoms that are concerning to
you.
Followup Instructions:
-Please schedule follow-up with your primary care physician in
[**Name9 (PRE) 487**] in [**1-3**] weeks. If you do not have a primary care
physician, [**Name10 (NameIs) **] schedule to see a physician at [**Hospital 3038**]: [**Telephone/Fax (1) 250**].
-[**Telephone/Fax (1) **] [**Telephone/Fax (1) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-11-17**] 10:30
-[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-11-17**]
11:10
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45,570
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37974
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Discharge summary
|
report
|
Admission Date: [**2155-9-18**] Discharge Date: [**2155-10-3**]
Date of Birth: [**2094-12-17**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Hypotension at HD, chronic diarrhea
Major Surgical or Invasive Procedure:
PICC line placement
Hemodiaylsis
PEG tube placement
History of Present Illness:
60 yo M w/ hx of CAD, PVD, ESRD on HD who presents with
hypotension at HD and chronic diarrhea of [**Last Name (un) 5487**] etiology.
Patient receives most of his care at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] in
[**Hospital1 789**], RI and has multiple physicians. Patient has been
chronically ill, and has had multiple hospital stays at RW and
rehab centers in RI, most recently for pelvis and femur
fractures, complicated by severe PNA.
Patient reports history of chronic diarrhea for > 1 year and
enormous weight loss (60 lbs in 1 year). Started gradually, had
approximately [**2-6**] BMs daily (green, liquidy, non-bloody). No
associated abdominal pain. Has diarrhea with and without food,
but is exacerbated with meals. Has tried restricting lactose w/o
effect. Family reports no assessment for celiac sprue. Has been
followed by GI physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 84853**], and has reportedly
extensive work-up including endoscopies, and colonoscopies with
biopsies. Per family, no evidence of colonic masses or GI tract
cancers noted. Pt denies dysphagia, but has lost appetite
recently. Reports negative C. difficile and VRE testing in the
past few weeks. Has not tried pancreatic enzymes.
Today, patient was at HD when RN there noticed patient looked
ill, malnourished, and dehydrated. SBPs dropped to 70 systolic
during HD. Patient was sent to [**Hospital1 18**] for evaluation. Patient
admits to chronic cough with worsening sputum production. Denied
dysuria.
In ED VS were 97.8 68 78/41 28 100. Noted to have SBP to 78 in
ED with cool peripheries, received 300 cc NS with improved of
SBPs to 110. Received Vancomycin 1 gram IV x1 and Zosyn 4.75
grams IV x1, Magnesium 2 mg IV x1, and perocet 1 tab x1.
Past Medical History:
ESRD on HD since [**2152**] (unknown baseline Cr)
CAD s/p cardiac stenting x 2 ([**2145**], [**2146**]) due to MI
COPD (on 3 L home O2)
DM2 (no longer requiring insulin [**1-6**] weight loss, controlled on
oral [**Doctor Last Name 360**] only)
PVD s/p stention
?HL
Iron deficiency anemia
?Depression
.
PSH:
L femur/pelvic fx in [**7-13**] (from a fall) c/b severe pna)
L hip fx [**2153**]
s/p amputation of all 5 left toes
s/p back surgeries x 6 (due to injury)
s/p multiple L shoulder surgeries
s/p appendectomy
Social History:
Lives in RI with wife and daughter, both of whom are very
involved in his care. Is retired, used to work as an attendant
in a mental health facility. 1200ppy smoking history, qhit 2
months ago. Denies etoh use or IVDU.
Family History:
FH of DM and CVA in mother. Denies FH of cancer, IBD, or celiac
sprue
Physical Exam:
Physical Exam on Admission:
VS: 97.3 99/62 66 20 100% 3 L NC
GA: cachectic M sitting in bed, AOx3, NAD
HEENT: PERRLA. MM dry. no LAD. elevated JVD. neck supple.
Cards: heart sounds distant. RRR S1/S2 heard. no
murmurs/gallops/rubs.
Pulm: diffuse crackles throughout all lung fields.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. mild
tenderness over suprapubic region.
Extremities: no edema. poor DPs, PTs, limbs cold. +amputated
toes on left foot.
Skin: scattered echymoses and ?ruptured vesicles on extensor
surfaces of elbows and knees covered in crust.
Neuro/Psych: interacting appropriately.
Pertinent Results:
Admission Labs:
[**2155-9-17**] 09:15PM GLUCOSE-83 UREA N-14 CREAT-2.0* SODIUM-139
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
[**2155-9-17**] 09:15PM ALT(SGPT)-22 AST(SGOT)-73* CK(CPK)-59 ALK
PHOS-97 TOT BILI-0.9
[**2155-9-17**] 09:15PM LIPASE-16
[**2155-9-17**] 09:15PM cTropnT-0.15*
[**2155-9-17**] 09:15PM CK-MB-NotDone
[**2155-9-17**] 09:15PM TOT PROT-5.2* ALBUMIN-2.5* GLOBULIN-2.7
CALCIUM-7.8* PHOSPHATE-2.8 MAGNESIUM-1.4*
[**2155-9-17**] 09:15PM IgA-515*
[**2155-9-17**] 09:15PM PT-20.7* PTT-34.9 INR(PT)-1.9*
[**2155-9-18**] 10:20AM %HbA1c-5.1
[**2155-9-18**] 10:20AM TRIGLYCER-110 HDL CHOL-7 CHOL/HDL-7.9
LDL(CALC)-26
[**2155-9-17**] 09:15PM GLUCOSE-83 UREA N-14 CREAT-2.0* SODIUM-139
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
.
CT ABD/PEL - [**9-18**]
1. Findings suggestive of pulmonary edema at the visualized lung
bases.
2. Right basilar bronchovascular opacity (15 mm) which could be
attributed to atelectasis or a lung nodule, although infection
cannot be excluded. Follow-up chest CT within three months is
recommended to evaluate further as a true lung nodule is not
excluded.
3. Pancreatic atrophy and calcifications consistent with chronic
pancreatitis.
4. Moderate gallbladder distention which can be seen in a
fasting state.
However, if there is clinical concern for a source of acute
infection, an
ultrasound could be considered as well as correlation with
pertinent
laboratory data.
5. Extensive vascular calcifications including stents along the
left common and external iliac arteries whose patency cannot be
assessed on this study.
6. Mild dilatation of the proximal small bowel, borderline in
caliber with
lack of distal passage of contrast. However, the appearance is
felt more
likely to reflect a mild ileus than obstruction, noting no sharp
transition. However, if there is continuing clinical concern for
obstruction, follow-up radiographs could be performed.
7. Considerable stool throughout the colon, which is mildly
distended, also suggestive of slow motility. The lower sigmoid
and rectal walls show mild thickening, which is seen in a more
patchy fashion elsewhere as well. This appearance could be seen
with anasarca in the setting of renal disease, although mild
colitis is difficult to exclude. The patient could be considered
at high risk for ischemic colitis given the history of diarrhea
and severe vascular disease, although usually associated CT
findings would be least prominent in the rectum.
8. Small amount of low-density ascites, which is nonspecific
with
splenomegaly.
.
CXR [**9-17**]
1. Findings are most consistent with moderate pulmonary edema,
with moderate cardiomegaly. However, underlying infection is not
excluded, and evaluation for such may be performed after
appropriate diuresis.
2. Dilated loops of bowel are incompletely assessed. Recommend
dedicated
abdominal radiographs for more complete assessment.
.
EKG [**9-17**]
Sinus rhythm. Diffuse T wave flattening makes the Q-T interval
difficult to interpret. No previous tracing available for
comparison.
.
CTA chest [**9-25**]:
FINDINGS:
There is no evidence of pulmonary embolism till the level of
subsegmental
pulmonary arteries bilaterally. The pulmonary arteries are
normal in diameter as well as the aorta. Extensive coronary
calcifications and coronary stents are noted with a coronary
stent being seen in LAD and right coronary artery at least.
Heart size is enlarged. There is no pericardial effusion. Small
left pleural effusion is noted with no evidence of right pleural
effusion.
The imaged portion of the upper abdomen demonstrates the NG tube
tip being in the stomach and otherwise is unremarkable within
the limitations of this study that was not designed for
evaluation of intra-abdominal pathology.
Extensive mediastinal lymphadenopathy involves the entire
mediastinum and
ranges up to 7.5 mm in the right upper paratracheal area, 12 mm
in right lower paratracheal area, 1 cm in the prevascular area,
8.5 mm in aortopulmonic window, 2 cm in subcarinal and
paraesophageal area with bilateral hilar lymph nodes ranging up
to 1.5 cm. This lymphadenopathy might be reactive to the
extensive parenchymal abnormality demonstrated throughout the
lungs and mostly consisting of two types of findings: Bilateral
peribronchovascular opacities
as well as confluent areas of ground-glass in the upper lungs,
3:14, with
focal areas of ground-glass mostly located in the posterior
segment of right upper lobe, 3:14, 15, 16, 18. The lower lobes
are also involved as well as posterior segment of right upper
lung, 3:24, 31, 37. The second
abnormality is bibasal opacities, right significantly more than
left. On the right, there are at least three consolidations in
the right lower lobe with the lowest one mostly posteriorly
located containing eccentric lucency, 3:68, approximately 12 mm
in diameter that might represent a consolidation with a cavity.
There are areas of air trapping, extensive and might be due to
bilateral external bronchial wall thickening and secretions that
are also seen in the main bronchi. Though secretions in
combination with patulous upper esophagus might be due to
aspiration, although infectious origin as part of the extensive
infectious process within the lungs cannot be excluded. The
findings are unlikely to represent pulmonary edema. Some of the
focal opacities might potentially represent hemorrhage in the
appropriate clinical setup.
There are no bone lesions worrisome for malignancy. Extensive
degenerative
changes are noted. No evidence of bone infection was
demonstrated.
[**9-24**] ECHO Conclusions:
The left atrium is elongated. There is symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly 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.
[**10-1**] CXR:
The NG tube tip is in the stomach. Cardiomediastinal silhouette
is unchanged. There is no significant interval change in
bilateral predominantly upper lobe parenchymal opacities as well
as bibasal opacities involving the lung to a lesser extent
compared to upper portion. The right PICC line tip is in the
right atrium and should be pulled back for approximately 4.5 cm
to secure its position at low SVC. Small bilateral pleural
effusion cannot be excluded.
Overall the appearance of the lung has improved compared to
[**9-26**] and 24, [**2154**].
Brief Hospital Course:
60y/o man with multiple medical problems, numerous recent
hospitalizations, ESRD on HD, and chronic diarrhea and 60+ lb
weight loss of unclear etiology who presents with hypotension at
HD and diarrhea.
.
# Diarrhea/weight loss. Unclear etiology. Has had numerous
admissions for nausea/vomiting/diarrhea wouthout clear
diagnosis. Numerous negative C diff tests at OSH, treated
empirically for C diff in past without improvement. Colonoscopy
in [**6-12**] showed cryptitis, crypt abscesses. Possible causes
include medication side effects, autoimmune, amyloidosis,
pancreatic insuffiency, protein losing enteropathy, malignancy,
infectious, bacterial overgrowth. Given likely significant
malabsorption, vitamin deficiency, and weight loss, amyloidosis
and pancreatic insufficiency high on differential. CT abd
showed signs of chronic pancreatitis and stool in colon
suggestive of slowed motility. Amyloidosis could explain
patient's ESRD. Thought to possibly also have a component of
gastroparesis as distended bowel loops and stool in bowels c/w
slowed motility on CT, and patient vomiting what looked like
"stool." Medications possibly compounding problem. Stopped
[**Name2 (NI) 84854**], as diarrhea common side effect, as well as cholesterol
agents. Diarrhea was improved in-hospital, but also difficult
to tell given poor PO's (and patient soon made NPO due to
aspiration risk). Infectious workup negative for C diff, E
coli, Salmonella, Shigella, Campylobacter, Yersenia, Vibrio,
O+P. tTG-IGA negative for celiac. Unable to obtain stool
collection for stool osmolality/lytes and fat content given
cessation of diarrhea in house. SPEP and UPEP pending.
Intended to do colonoscopy and EGD but patient decompensated
from respiratory standpoint and forced to delay.
#. Nausea/vomiting/nutritional status. Likely related to
diarrhea. Patient with very poor nutritional status, albumin of
approx 2, and periodic vomiting. Massive weight loss and
cachexia, poor nutritional status. Developed extremity edema
likely [**1-6**] low albumin, also with elevated PT/INR responsive to
Vitamin K suggestive of extreme malabsorption of fat absorbable
vitamins. Vitamin K level pending. Also with elevated PTH
(despite normal corrected calcium) suggesting Vit D deficiency.
Placed NG tube to improve nutritional status but was frequently
held due to poor tolerance. [**Month (only) 116**] have component of
gastroparesis, given impaired intestinal mobility on CT and
reports of "vomiting stool". Patient had a PEG tube placed on
[**10-2**] for ongoing tube feeds.
.
#. Hypotension. Likely due to overmedication with
antihypertensives in the setting of volume depletion and HD.
History of HTN but has lost 60+lb and reports frequent symptoms
of orthostatis, as well as freuqent low BP's at HD. Decreased
PO intake, with GI losses. Thought to be unlikely sepsis given
normal WBC count on admission, lack of fever, and cool
extremities. D/c'd norvasc and lasix, reduced lopressor from 25
to 12.5bid, held on HD days. BP improved. Still with periodic
hypotension to 90's systolic at HD, 0-2L removed at HD.
.
#. SOB/COPD/pulmonary edema/aspiration/hospital-acquired
pneumonia. Patient on 3L 02 at baseline. Significant congestion
on admission, thought to be c/w COPD as well as pulmonary edema
with resulting inability to maintain intravascular volume. Then
developed increasing dyspnea during hospital stay, spiked fever,
leukocytosis. Concern for pna, possible aspiration, either
before NPO or [**1-6**] secretions. Given poor reserve and poor
nutritional status, decided to treat for hospital-acquired
pneumonia. Patient deteriorated from a respiratory standpoint
with increasing 02 requirement and RR in 40s, unable to clear
secretions [**1-6**] weakness. Transferred to MICU on [**9-22**].
Initially covered pna broadly with vancomycin, cefepime, flagyl,
and azithromycin, then scaled back to vancomycin and cefepime.
Vanc/cefepime continued to complete 8 day course. Flagyl
continued for 14 days for aspiration pneumonia given cavitary
consolidation on chest CT.
.
#. UTI. Patient had dysuria, increased urinary frequency, and
suprapubic tenderness on admission. Found to have UTI on
admission with 750 WBC. Initially treated with cipro and was
covered with antibiotics for hospital acquired pneumonia.
.
#. Delirium. Patient with waxing and [**Doctor Last Name 688**] mental status,
inattention, possible visual hallucinations. Much of this is
after HD session where he can be minimally responsive. Other
contributory factors including infection (UTI, pna),
medications, poor nutrition, and difficulty clearing secretions.
His mental status improved with reduction of contributory
medications (d/c'd percocet and oxycontin, quetiapine, and
doxepin).
.
#. Elevated INR/PT. Thought to be [**1-6**] vitamin K deficiency due
to poor absorption of fat soluble vitamins as well as poor PO's.
INR and PT trended downwards with IV vitamin K. Vitamin K
level normal. Patient had a PEG tube placed on [**10-2**] for
ongoing tube feeds
.
# ESRD on HD MWF. Has been on dialysis since [**2145**], reports
being told ESRD was [**1-6**] DM. Pt continued with HD inhouse. His
SPEP was negative for amyloidosis.
.
#. Sacral ulcer. Unstageable per wound care team. Likely stage
II or III. Position changes q2hour, frequent dressing changes,
pain control with oxycodone.
.
#. Anemia. Normocytic, stable. Known Fe deficiency anemia on
iron supplements. [**Month (only) 116**] have ACD. Fe studies repeatedly ordered
?pending. Likely with low EPO, good candidate for Procrit. Could
also have combination of Fe deficiency anemia (microcytic) and
folate of B12 deficiency (macrocytic), giving a normocytic
picture, as patient known to have Fe deficiency in past, and
given diarrhea and poor nutritional state and possible
malabsorption, may have depletion in stores in either of these.
.
#. DM2. HgbA1c 5.1 on admission, suggesting hypoglycemic
episodes in recent past. Likely [**1-6**] poor PO's and weight loss.
Stopped [**Month/Day (2) 84854**], which is also known to cause diarrhea, placed
on humalog sliding scale. Sugars well controlled.
.
#. CAD/PVD. Pt was continued on ASA and plavix.
.
#. ?HL. On tricor and welchol at home but lipid levels returned
with HDL 7, LDL 26 Total chol 55. His tricor and welchol were
also held due to due to risk of GI upset.
.
#. Psych. Given delirium, pt was continued on sertraline 100
daily but quetiapine and doxepin were discontinued.
.
#. Coping. Family frustrated with patient's course and
difficulties with care in RI, having difficulty coping with
severity of patient's illness, patient at times feeling like he
wants to go home and die. Family meeting from [**10-1**] resulted in
wishes to continue HD, feed through PEG tube, and FULL CODE.
.
#. Chronic back pain: Given his mental status, he was
discontinued from his oxycontin 40 q12h and was treated with
oxycodone prn, tylenol, and lidocaine patch.
Medications on Admission:
Percocet 10/325 mg PO q8H:PRN pain
OxyContin 80 mg PO BID
Alprazolam 0.025 mg TID
Seroquel 300 mg PO QHS
Doxepin 200 mg PO QHS
Tircor 145 mg PO daily
Prantin 0.5 mg PO TIDAC if glucose > 150
Metoprolol 25 mg PO BID
Welchol 625 mg PO QID
Ferrous Sulfate 650 mg PO daily
MVI Norvasc 5 mg PO daily
Sertraline 100 mg PO daily
Plavix 75 mg PO daily
Protonix 40 mg PO daily
Lasix 40 mg PO [**Hospital1 **] daily
Advair INH 150/50 2 PUFFS daily
Albuterol INH as needed
ASA 81 mg PO daily
Renal caps 1 PO daily
Dephenoxyl atropine 2.5 mg TID
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO at bedtime:
FOR TOTAL DOSE OF 15 mg daily.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime: FOR
TOTAL DOSE OF 15 mg daily.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for cough, congestion.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob/wheezing.
9. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): TO the
back.
11. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO BID (2 times a day).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
14. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY
(Daily).
15. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q6H (every
6 hours) as needed for pain: PLS hold for sedation.
16. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
17. Insulin Lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous ASDIR (AS DIRECTED): PLs see insulin sliding scale.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen. .
20. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO twice a day: For
total of 37.5 mg [**Hospital1 **]. PLEASE HOLD ON HD DAYS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 54351**] - [**Location (un) 5503**]
Discharge Diagnosis:
Primary:
[**Hospital **]
Hospital-acquired pneumonia
.
Secondary:
Aspiration
End stage renal disease
Coronary artery disease
Chronic obstructive pulmonary disease
Hypertension
Diabetes Mellitus
Depression
Anxiety
Discharge Condition:
HR 80-100s, SBP 120s-160s, 92-100% on 3L NC. Pt does get
hypotensive during dialysis so please do not give him any
metoprolol on HD days. Pt is also typically minimally
responsive after HD sessions--will not respond to verbal or
tactile stimuli--for the remainder of the day.
HR 80-100s, SBP 120s-160s, 92-100% on 3L NC. Pt does get
hypotensive during dialysis so please do not give him any
metoprolol on HD days. Pt is also typically minimally
responsive after HD sessions--will not respond to verbal or
tactile stimuli--for the remainder of the day.
Discharge Instructions:
You were admitted with diarrhea. Unfortunately, due to your
pneumonia and resulting respiratory distress, you were unable to
have a colonoscopy. All the blood work and stool studies have
NOT shown a cause for you diarrhea. You will need to follow up
with outpatient Gastroenterology.
.
For your pneumonia, you received a course of antibiotics and
your respiratory status has improved. You were noted to have a
cavitary lesion on the CT scan of your chest. You will need to
complete a 14 day course of the antibiotic metronidazole and
have a follow up CT scan in 1 month. Your primary care doctor
will help you arrange this study.
.
In addition, you were noted to have a nodule at the base of your
right lung and need a follow-up CT scan 3 months from your
[**Month (only) 1096**] scan.
Followup Instructions:
As we discussed you were seen to have a cavitary lesion in your
lung and need a follow CT scan in 1 month ([**2155-11-4**]) after
your course of antibiotics. In addition, you were noted to have
a nodule at the base of your right lung and need a follow-up CT
scan 3 months from your [**Month (only) 1096**] scan. Your primary care doctor
will help you arrange this study. Please see your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] within 2 weeks of discharge from rehab.
Please follow up with Gastroenterology regarding your diarrhea.
Please make an appointment with GI in 2 weeks with Attending Dr.
[**Last Name (STitle) 9916**] and Fellow Dr. [**First Name8 (NamePattern2) 1255**] [**Name (STitle) 1256**]. The clinic number is
([**Telephone/Fax (1) 2233**].
|
[
"707.23",
"V45.82",
"507.0",
"263.0",
"518.81",
"577.1",
"458.29",
"428.0",
"536.3",
"496",
"518.89",
"412",
"443.9",
"558.9",
"707.03",
"579.9",
"300.4",
"E942.6",
"285.21",
"112.2",
"268.9",
"349.82",
"250.42",
"276.52",
"585.6",
"272.4",
"724.5",
"286.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"96.6",
"43.11",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
20237, 20312
|
10483, 17462
|
307, 361
|
20569, 21128
|
3693, 3693
|
21968, 22756
|
2959, 3031
|
18047, 20214
|
20333, 20548
|
17488, 18024
|
21152, 21945
|
3046, 3060
|
232, 269
|
389, 2169
|
3709, 10460
|
3074, 3674
|
2191, 2706
|
2722, 2943
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,276
| 153,422
|
4940
|
Discharge summary
|
report
|
Admission Date: [**2185-12-8**] Discharge Date: [**2185-12-19**]
Date of Birth: [**2110-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Elective CABG
Major Surgical or Invasive Procedure:
[**2185-12-13**] Two Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending,
saphenous vein graft to posterior lateral branch
History of Present Illness:
Patient is a 75 y/o man with hx of HTN, hyperlipidemia, CAD (BMS
to RCA in [**2173**] with in-stent occlusion in [**2184**]), recent GI bleed
likely from ulcer in stomach, and atrial fibrillation, who
presented for EGD prior to CABG. The patient was admitted to
[**Hospital1 18**] in [**2185-9-28**] for STEMI in the setting of a GI bleed.
He had a cardiac cath where he was found to have an in-stent
stenosis of his RCA and diffuse 3VD. The patient also had an
EGD performed prior to his admission in [**Month (only) 359**], which
demonstrated a sliding type hiatal hernia, mild gastritis and an
antral ulcer which had a white, healing base with no active
clots or active bleeding. It was decided at the time of
discharge that the patient would have an ECG performed before
elective CABG. The patient states that he has not experienced
any recent chest pain, and he is no longer having melena. He
has been off Plavix and Coumadin since Monday before this
admission date.
.
On ROS, the patient denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis. He denies recent fevers, chills or
rigors. He denies exertional buttock or calf pain. All of the
other review of systems were negative. Cardiac review of
systems is notable for absence of chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
-Coronary Artery Disease/Ischemic Cardiomyopathy
-Prior Thrombectomy/Stenting of RCA [**2173**]
-Prior ICD Placement
-Dyslipidemia
-Hypertension
-COPD
-Atrial fibrillation
-Recent hospitalization for a GI bleed
-Diverticulosis
-Grade I internal hemorrhoids
-Osteoarthritis
-Healing antral ulcer
-Hiatal hernia
Social History:
Mr. [**Known lastname **] is married and lives at home with his wife in [**Name (NI) 2498**],
MA. He considers himself to be an active person for his age. He
is a retired supervisor of [**State 20475**]. He quit smoking
on [**2158**] after a history of 1PPD x 30 years. He denies any
alcohol use and denies any history of illicit drug use.
Family History:
Both parents died of coronary artery disease in their 60s
Physical Exam:
Admission VS - T 98.1, BP 135/87, P 66, R 18, O2 100% on RA
Gen: Elderly man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
Neck: Supple, No JVD appreciated. No LAD
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.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: Right: DP 2+ PT 2+ / Left: DP 2+ PT 2+
At discharge:
Exam mostly same than amission, except:
Chest: Sternal wound healing, clean and dry, -clicks
Ext: Warm, 1+ edema incision healing well
Pertinent Results:
[**2185-12-8**] BLOOD WBC-4.8 RBC-3.71* Hgb-8.8* Hct-27.2* MCV-73*#
MCH-23.7*# MCHC-32.2 RDW-15.9* Plt Ct-246
[**2185-12-8**] BLOOD PT-16.3* PTT-28.7 INR(PT)-1.5*
[**2185-12-8**] BLOOD Glucose-125* UreaN-24* Creat-1.3* Na-137 K-4.4
Cl-104 HCO3-25 AnGap-12
[**2185-12-9**] BLOOD ALT-11 AST-18 LD(LDH)-164 AlkPhos-60 TotBili-0.5
[**2185-12-9**] BLOOD Albumin-3.7 Calcium-8.4 Phos-3.3 Mg-2.1
[**2185-12-9**] BLOOD %HbA1c-6.2*
[**2185-12-9**] ECHO: The left atrium is markedly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. LV systolic function
appears moderately-to-severely depressed (ejection fraction 30
percent) secondary to a large posterobasal aneurysm, severe
hypokinesis of the inferior septum, akinesis of the inferior
free wall, and hypokinesis of the lateral wall. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The left ventricular
inflow pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
[**2185-12-9**] Carotid Ultrasound: Right ICA 1-39% stenosis. Tortuous
left ICA with a low end, 40-59% stenosis. Normal vertebral flow.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital Unit Name 196**] service. Prior to surgical
revascularization and given his history of GI bleed, he
underwent EGD which found 8mm ulcer in the antrum and only mild
gastritis. EGD was otherwise normal. He remained stable on
medical therapy, and was maintained on Lovenox bridge.
Preoperative course was otherwise uneventful and he was cleared
for surgery.
On [**12-13**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting. For surgical details, please see operative note.
Following surgery, he was brought to the CVICU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated. He initially experienced some hypotension but
gradually weaned from Neo-Synephrine over several days. He
remained in atrial fibrillation. His preoperative medications
were resumed and was eventually restarted on Warfarin.
Antibiotics(Amoxicillin and Clarithromycin) were initiated for
positive H. pylori antibodies on serology. On postoperative day
four, he transferred to the SDU. Cardiology service was
consulted given poorly controlled atrial fibrillation.
Recommendations were to increase beta blockade as tolerated as
Verapamil in contraindicated in the setting of Dofetilide. Over
several days medical therapy was optimized. He continued to make
clinical improvements and was eventually cleared for discharge
to rehab on postoperative day six. Warfarin should be dosed for
goal INR between 2.0 - 3.0.
Medications on Admission:
1. Aspirin 325 mg daily
2. Clopidogrel 75 mg daily
3. Warfarin
4. Atorvastatin 80 mg daily
5. Acetaminophen 500 mg as needed
6. Dofetilide 250 mcg twice daily
7. Furosemide 20 mg daily
8. Metoprolol Succinate 100 mg [**Hospital1 **]
9. Lisinopril 5 mg daily
10. Pantoprazole 40 mg twice daily
11. Glucosamine 500 mg daily
12. Chondroitin Sulfate-Vit C-Mn 400-60-2.5 mg daily
13. Multiple Vitamin daily
14. Calcium 600 + D(3) 600 mg(1,500mg) daily
15. Meloxicam 22.5 mg daily
16. Tikosyn 0.5 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
8. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
9. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
10. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours).
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): can reduce to 20mg daily once at pre-op weight or per
cardiologist.
12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours): can reduce to 20mEq daily once at pre-op
weight or per cardiologist. .
13. Warfarin 1 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): goal
INR between 2.0 - 3.0.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Coronary Artery Disease - s/p Coronary Artery Bypass Graft x 2
Ischemic Cardiomyopathy/Chronic Systolic Congestive Heart
Failure
History of Atrial Fibrillation
Hypertension
Dyslipidemia
Chronic Obstructive Pulmonary Disease
Prior ICD Placement
History of GI Bleed
Mild to moderate Carotid Disease
Discharge Condition:
Good
Discharge Instructions:
No driving for 4 weeks.
No lifting more than 10 pounds for 10 weeks.
Shower daily, no baths.
Report any temperature greater than 100.5.
Report any weight gain greater than 2 pounds a day or 5 pounds a
week.
Report any redness of, or drainage from incisions.
No lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**4-2**] weeks, call for appt
Dr. [**Last Name (STitle) 8098**] in [**1-30**] weeks, call for appt
Dr. [**Last Name (STitle) 20478**] in [**1-30**] weeks, call for appt
Completed by:[**2185-12-19**]
|
[
"041.86",
"V45.02",
"458.29",
"496",
"V58.61",
"410.12",
"272.4",
"531.90",
"428.0",
"414.01",
"427.31",
"V45.82",
"428.22",
"455.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.72",
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8667, 8734
|
5346, 6845
|
335, 517
|
9074, 9080
|
3649, 5323
|
9430, 9664
|
2693, 2752
|
7396, 8644
|
8755, 9053
|
6871, 7373
|
9104, 9407
|
2767, 3480
|
3494, 3630
|
282, 297
|
545, 1985
|
2007, 2318
|
2334, 2677
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,498
| 112,133
|
25727
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 64121**]
Admission Date: [**2179-7-14**]
Discharge Date: [**2179-7-29**]
Date of Birth: [**2100-10-28**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) 5586**] [**Known lastname 64122**] was a 78-year-old
man with a past medical history of diabetes,
hypercholesterolemia, hypertension, AAA repair and colon
cancer, who presented with fatigue and chest pain. He
initially presented to [**Hospital6 **], where he was
found to have atrial fibrillation and a non-ST elevation
myocardial infarction with a troponin I of 0.91 and a CK of
84. While at [**Hospital6 **] he developed recurrent
symptoms and was transferred to [**Hospital1 188**] for further care. Upon his arrival he was found to have
cardiogenic shock and was intubated and taken urgently for
cardiac catheterization.
PHYSICAL EXAMINATION: Initial vital signs were temperature
99.4, blood pressure 78/48, heart rate 119, respiratory rate
20. In general he was intubated and sedated. His pupils
were equal, round and reactive to light. He was lying flat
so jugular venous distention could not be evaluated. There
was no apparent goiter. His lungs were clear anteriorly. He
had a regular rhythm and rate with a normal S1 and S2. There
were no murmurs, rubs or gallops. The PMI was lateral. The
abdomen was soft and mildly distended with normal bowel
sounds. There was no guarding. His stool was OB positive.
Extremities were cool with dopplerable pulses. Neurological
exam was limited due to his sedation.
PERTINENT LABORATORY/RADIOLOGY/OTHER FINDINGS: His initial
ECG on [**2179-7-15**], showed sinus tachycardia at a rate of 110,
there was a late transition consistent with possible prior
anterior infarction, there was left axis deviation,
nonspecific ST-T wave changes. Cardiac catheterization was
performed on [**2179-7-14**]. This showed severe 3 vessel disease
with severe systolic and diastolic ventricular dysfunction.
An echocardiogram was performed on [**2179-7-15**]. This showed
severe left ventricular systolic dysfunction on a poor
quality study. A repeat echocardiogram was performed later
that day that confirmed left ventricular systolic dysfunction
and found no significant valvular dysfunction. He again went
for cardiac catheterization on [**2179-7-15**], during which he
had percutaneous intervention of the left main coronary
artery, the left anterior descending, the left circumflex and
a diagonal branch. A chest x-ray was performed on [**2179-7-15**]
which showed pulmonary edema and an intra-aortic balloon
pump. Another echocardiogram was performed on [**2179-7-16**],
which again showed severe systolic dysfunction, with no
significant valvular disease. On [**2179-7-21**] a CT of the
chest, abdomen and pelvis showed a left upper lobe mass
invading the left superior pulmonary vein, left iliac bone
metastasis and liver lesions, likely metastases, and
borderline thickening of the gallbladder.
HOSPITAL COURSE: Mr. [**Name14 (STitle) 64123**] initially presented with
cardiogenic shock in the setting of acute coronary syndrome.
He was intubated and taken to the cardiac catheterization
laboratory. Cardiac catheterization showed severe 3 vessel
disease. Cardiac surgery consultation was obtained, but it
was determined that he was not a good candidate for surgical
revascularization. He, therefore, went back to the cardiac
catheterization lab the next day for high-risk intervention
with placement of an intra-aortic balloon pump. Over the
next several days his cardiogenic shock improved and he was
weaned off the intra-aortic balloon pump and pressors,
however, he remained intubated due to hypoxia and congestive
heart failure. Pulmonary consultation was obtained. A CT of
the chest and abdomen was obtained for further evaluation and
demonstrated metastatic cancer. The decision was made to
treat him medically in consultation with his healthcare
proxy, however, his hypoxia failed to improve. On [**2184-7-26**]
there was a meeting with the family, the healthcare proxy and
the clinical team, and the decision was made to pursue
comfort measures only. He was subsequently extubated and
died on [**2179-7-29**] at 4:08 a.m. Autopsy was declined.
CONDITION ON DISCHARGE: Expired.
DISCHARGE STATUS: Expired.
DISCHARGE INSTRUCTIONS: Not applicable.
DIAGNOSES:
1. Congestive heart failure.
2. Acute myocardial infarction.
3. Metastatic cancer from a probable lung source.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
Dictated By:[**Last Name (NamePattern1) 64124**]
MEDQUIST36
D: [**2184-7-7**] 12:50:33
T: [**2184-7-7**] 13:38:15
Job#: [**Job Number 64125**]
|
[
"276.2",
"276.3",
"427.31",
"535.51",
"507.0",
"707.05",
"198.5",
"785.51",
"197.7",
"518.81",
"789.1",
"414.01",
"038.9",
"501",
"V64.1",
"995.91",
"553.1",
"V10.05",
"211.2",
"285.29",
"250.00",
"280.0",
"537.82",
"401.9",
"456.1",
"410.71",
"428.0",
"162.8",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"99.04",
"36.01",
"37.61",
"96.72",
"88.72",
"38.93",
"37.22",
"88.56",
"45.16",
"89.64",
"96.04",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
2990, 4242
|
4331, 4716
|
867, 2972
|
185, 844
|
4267, 4306
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,339
| 135,338
|
15011+15012
|
Discharge summary
|
report+report
|
Admission Date: [**2116-2-21**] Discharge Date: [**2116-2-28**]
Date of Birth: [**2043-5-20**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43921**] is a 72 year old man
who underwent coronary artery bypass grafting times three as
well as a Maze procedure on the [**3-14**] with an
unremarkable postoperative course. He was discharged to
rehabilitation on [**2-18**] and presented to the emergency
room at [**Hospital **] Hospital on [**2-21**] with
serosanguineous drainage from the lower aspect of his sternal
wound. The drainage began suddenly following an episode of
coughing not associated with any chest pain, increasing
shortness of breath, fever, chills, redness or erythema of
the wound. He was transferred to [**Hospital1 190**] from [**Hospital **] Hospital following initial
evaluation at the emergency room at [**Location (un) **].
PAST MEDICAL HISTORY: Is significant for coronary artery
disease, status post coronary artery bypass grafting,
congestive heart failure, paroxysmal atrial
fibrillation/flutter, status post Maze procedure,
hypercholesterolemia, noninsulin dependent diabetes mellitus,
history of urosepsis, history of colon carcinoma, status post
colonic resection, hypertension, degenerative joint disease,
status post bilateral total knee replacement, abdominal
aortic aneurysm and bilateral cataract surgery.
SOCIAL HISTORY: Patient lives alone. He has a remote
tobacco history, quit over 18 years ago alcohol use limited
to one drink per day.
FAMILY HISTORY: Father died of prostate carcinoma.
ALLERGIES: Patient states no known drug allergies.
MEDICATIONS ON ADMISSION: Include aspirin 81 mg daily, Lasix
20 mg B.I.D., Colace 100 mg B.I.D., potassium chloride 20 mEq
B.I.D., Percocet PRN, Glipizide 2.5 mg daily, amiodarone 400
mg B.I.D., Lipitor 40 mg daily, Lopressor 50 mg B.I.D.,
Coumadin 7.5 mg daily
PHYSICAL EXAMINATION: Temperature 98.9, heart rate 67, blood
pressure 138/62, respiratory rate 24, O2 saturation 94
percent on 3 liters. Neurologic: Alert and oriented times
three, nonfocal examination. Cardiovascular: Regular rhythm
with no murmurs, rubs or gallops, no jugular venous
distension. Respiratory: Coarse breath sounds diminished at
the bases. Sternal wound dehiscence with serosanguineous
drainage, no surrounding erythema, fluctuance or tenderness.
Abdomen is soft, nontender, nondistended with normal active
bowel sounds. Extremities are warm and well perfused with
trace edema and no cyanosis.
HOSPITAL COURSE: Patient was admitted to cardiothoracic
surgery. Chest x-ray showed misaligned sternal wires. His
Coumadin was discontinued and he was scheduled to go to the
operating room upon correction of his INR. On the [**2-23**] the patient was brought to the operating room where
he underwent sternal debridement and reclosure. The patient
tolerated the operation well and was transferred from the
operating room to the cardiothoracic Intensive Care Unit. He
did well in the immediate postoperative area. His anesthesia
was reversed and he weaned from the ventilator and
successfully extubated. The following morning the patient
remained hemodynamically stable. His chest tubes were
removed and he was transferred to 424 for continuous
postoperative management. Over the next several days the
patient had an uneventful postoperative course. His activity
level was increased with the assistance of the nursing staff
as well as the physical therapy staff on [**2-27**]. A PICC
line was placed for administration of long term antibiotics.
At that time the patient's culture data from the operating
room came back as rare coag negative staph as well as sparse
enterococcus from broth culture only resistant to Vancomycin,
sensitive to linezolid. At that time it was decided that the
patient was stable and ready to be transferred to
rehabilitation for continuing postoperative care as well as
antibiotic administration.
The patient's physical examination at the time of discharge:
Temperature 99, heart rate 90, blood pressure 152/75,
respiratory rate 24, O2 saturation 95 percent on room air.
Weight 99.4 kilos. Laboratory data: PT/INR 13.4, INR 1.1.
Physical examination neurologic: Alert and oriented times
three, moves all extremities, follows commands, nonfocal
examination. Pulmonary: Upper airway wheezes, otherwise
clear to auscultation. Cardiac: Irregular rate and rhythm.
Sternum is stable. Incision with staples without erythema or
drainage. Abdomen is soft, nontender, nondistended, normal
active bowel sounds. Extremities are warm with no edema.
Bilateral leg incision open to air with no erythema. PICC
line in the right antecubital space, a 4 French single lumen
catheter.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting times three complicated by sternal
drainage requiring sternal rewiring on [**2-23**].
2. Atrial fibrillation status post Maze.
3. Hypertension.
4. Hypercholesterolemia.
5. Noninsulin dependent diabetes mellitus.
6. Degenerative joint disease, status post bilateral total
knee replacement.
7. Abdominal aortic aneurysm.
8. Colon carcinoma, status post colonic resection.
9. Status post bilateral cataract surgery.
FOLLOW UP: The patient is have follow up in the wound clinic
one week following his discharge from [**Hospital1 190**], that would be on [**5-18**] with one of the mid
level practitioners, and follow up with Dr. [**Last Name (STitle) **] in three
to four weeks.
MEDICATIONS AT TIME OF DISCHARGE: Include metoprolol 75 mg
B.I.D., atorvastatin 40 mg daily, Percocet 5/325 one to two
tablets q 4 to 6 hours PRN, amiodarone 200 mg B.I.D. times
seven days, then daily, lorazepam 0.5 mg to 1 mg q 6 hours
PRN, Combivent 2 puffs q 6 hours, Flovent 2 puffs B.I.D.,
Lasix 40 mg daily, warfarin as directed to maintain a goal
INR of 2 to 2.5. The patient received 5 mg on [**2-26**] as well as
[**2-27**]. His warfarin dose prior to admission was 7.5 mg.
Colace 100 mg B.I.D. and linezolid 600 mg B.I.D. times four
weeks.
It should be noted that the patient will require CBC as well
as liver function tests q week while he is on linezolid. His
staples can be removed on or about [**3-15**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2116-2-27**] 16:25:26
T: [**2116-2-27**] 17:21:18
Job#: [**Job Number 43923**]
Admission Date: [**2116-2-21**] Discharge Date: [**2116-2-28**]
Date of Birth: [**2043-5-20**] Sex: M
Service: CSU
CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43921**] is a
72 year old man who underwent coronary artery bypass grafting
times three as well as Maze procedure on [**2-12**], with an
unremarkable postoperative course. He was discharged to
rehabilitation on [**2-18**] on Amiodarone and Coumadin for
his atrial fibrillation. He presented to the Emergency Room
on [**2-21**], with bloody drainage from the lower aspect of
his sternal wound. The drainage began suddenly on the day of
assessment following a coughing episode. It was not
associated with any chest pain or increasing shortness of
breath. The patient also denies fevers, chills and redness
about the wound. He was transferred from the Emergency Room
at [**Hospital **] Hospital to Far 2 at [**Hospital6 2018**]. A chest x-ray showed misaligned sternal layers in
the inferior sternum with no infiltrates.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, status post coronary artery bypass grafting times
three with left internal mammary artery to the left anterior
descending coronary artery, saphenous vein graft to the
posterior descending coronary artery and saphenous vein graft
to the obtuse marginal, paroxysmal atrial
fibrillation/flutter, status post Maze procedure done during
coronary artery bypass grafting, hypercholesterolemia,
noninsulin dependent diabetes mellitus, history of urosepsis,
history of colon carcinoma, hypertension, degenerative joint
disease, abdominal aortic aneurysm, bilateral cataract
surgery, colon resection and bilateral total knee
replacement.
SOCIAL HISTORY: The patient lives alone, remote tobacco
history, quit 18 years ago and alcohol use is limited to one
drink per day.
FAMILY HISTORY: Father died of prostate cancer, otherwise
insignificant.
ALLERGIES: The patient states no known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 81 once daily, Lasix 20
b.i.d., Colace 100 b.i.d., potassium chloride 20 b.i.d.,
Percocet prn, Glipizide 2.5 once daily, Amiodarone 400
b.i.d., Lipitor 40 once daily, Lopressor 50 b.i.d. and
Coumadin 7.5 once daily.
PHYSICAL EXAMINATION: Temperature 98.9, heart rate 67, blood
pressure 138/62, respiratory rate 24, oxygen saturation 94
percent on 3 liters. Neurologically alert and oriented times
three on focal examination. Cardiovascular, irregular rhythm
with no murmur, rubs or gallops and no jugular venous
distension. Respiratory, coarse breath sounds, decreased at
the bases, sternal wound with serosanguinous drainage, no
surrounding erythema, fluctuance or tenderness. Abdomen is
soft, nontender, nondistended with normoactive bowel sounds.
DICTATION ENDED
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2116-2-27**] 16:01:21
T: [**2116-2-27**] 16:52:27
Job#: [**Job Number 43924**]
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48,463
| 173,608
|
13073
|
Discharge summary
|
report
|
Admission Date: [**2153-11-8**] Discharge Date: [**2153-11-21**]
Date of Birth: [**2081-1-23**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Eye blurriness and Shortness of Breath
Major Surgical or Invasive Procedure:
Right and Left Heart Catheterization
Mitral valve valvuloplasty
History of Present Illness:
72 year old female with h/o CAD s/p CABG in [**2138**], PCI [**2151**], and
left CEA who presented with left eye blurriness one week ago and
was found to have severe carotid restenosis of CEA. She is
being transferred from her outpatient cardiologist's office at
[**Hospital6 33**].
She states that she has had multiple episodes of left eye
blurriness that she describes as "grey veil" that comes down
over her eye. Her most recent episode was 5 days ago and lasted
approximately 1-1.5 hours. She denies any other symptoms such
as dizziness, HA, weakness, dysphagia, slurred speech, or
altered mental status. She does mention that she feels neck
tenderness on the left side that developed about the same time
as her symptoms.
She also mentions chronic progressive dyspnea on exertion that
has worsened substantially since the spring of this year. She
states that she can walk a flight of stairs, but it takes her a
very long time. She gets short of breath going to the bathroom
across the room. She denies orthopnea or peripheral edema. She
occasionally wakes up at night short of breath, but this happens
rarely. She also endorses a chronic cough. She denies any
history of chest pain.
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, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CAD s/p CABG: in [**2138**] following an RCA-dissection complicating
cardiac catheterization (saphenous vein graft to PDA, saphenous
vein graft to OM1, saphenous vein graft to OM2).
-Aortic valve replacement in [**2145**] with Bovine prosthetic valve
-Mild-to-moderate mitral stenosis
PERCUTANEOUS CORONARY INTERVENTIONS: Non-ST elevation myocardial
infarction in [**2151-9-14**], subsequent cath showed the distal RCA
with 80% stenosis, total occlusion of left circ, patent
saphenous vein graft to the RCA, total occlusion of saphenous
vein graft to OM1, 80% stenosis the saphenous vein graft to OM2
had 80% stenosis with thrombus within the graft which was
intervened upon and angioplastied with subsequent placement of
two mini vision stents 2.5 x 18 and 2.5 x 12 mm.
OTHER MEDICAL HISTORY
-Left carotid endarterectomy in [**2139**] and known occluded right
subclavian artery
-Lung cancer status post right upper lobectomy in [**2145**], deemed
currently cured
-Remote history of ruptured intracranial aneurysm in [**2124**],
status post clipping
-COPD
-Obesity
Social History:
Lives with her husband in 3 house complex. Daughters and
grandchildren also live in complex.
-Tobacco history: Prior tobacco use, quit in [**2128**].
-ETOH: Rarely
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 97.6 143/97 91 18 93%RA
GENERAL: Awake, alert, 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 8cm. Slightly tender to palpation on
left.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rate and rhythm with occasional ectopy. III/VI
systolic murmur heard best at LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
Admission Labs:
[**2153-11-8**] 02:08PM WBC-7.6 RBC-4.71 HGB-13.6 HCT-41.4 MCV-88
MCH-29.0 MCHC-32.9 RDW-15.2
[**2153-11-8**] 02:08PM PLT COUNT-295
[**2153-11-8**] 02:08PM GLUCOSE-104 UREA N-31* CREAT-1.4* SODIUM-144
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-32 ANION GAP-15
[**2153-11-8**] 02:08PM %HbA1c-7.0*
[**2153-11-8**] 02:08PM PT-12.2 PTT-23.8 INR(PT)-1.0
[**2153-11-8**] ECG:
Sinus rhythm. Normal tracing. Compared to the previous tracing
there is no
significant change.
[**2153-11-8**] Chest Xray:
Mild cardiomegaly and a small right pleural effusion.
[**2153-11-8**] CTA Head/Neck:
1. High-grade stenosis of the proximal left internal carotid
artery
associated with soft plaque and presence of a "string sign"
extending over an approximately 5-6 mm segment.
2. 40% stenosis of the proximal right internal carotid artery.
3. Moderate atherosclerotic disease at the aortic arch with
40-50% stenosis at the origins of the common carotid arteries,
bilaterally.
4. High-grade stenosis of the proximal right subclavian artery
with what
appears to be complete occlusionl, with reconstitution just
proximal to the origin of the right vertebral artery, raising
the possibility of "subclavian steal" syndrome; this should be
closely correlated clinically.
5. 3-mm left anterolaterally-oriented aneurysm arising from the
anterior
communicating artery, related to aplastic A1 segment of the left
ACA.
6. Post-surgical changes following aneurysm clipping in the
region of the
right carotid terminus.
7. Mediastinal adenopathy and interlobular septal thickening at
the left
apex, which could be further evaluated with a dedicated chest
CT. Reportedly, the patient does have a history of lung cancer,
which
further raises concern of recurrent or metastatic disease given
the superior mediastinal adenopathy; there is possible
lymphangitic carcinomatosis in the left lung apex (these
findings are incompletely imaged).
[**2153-11-9**]: Transthoracic Echo
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The number of aortic valve leaflets cannot be
determined. There is no significant aortic stenosis or
regurgitation. The mitral valve leaflets are severely
thickened/deformed. There is severe thickening of the mitral
valve chordae. There is moderate to severe mitral stenosis (area
1.0 cm2). The tricuspid valve leaflets are mildly thickened. The
tricuspid valve leaflets fail to fully coapt. Severe [4+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate to severe mitral stenosis. Small and
hypertrophied left ventricle with preserved global systolic
function. Dilated and hypertrophied right ventricle with mild
systolic dysfunction and evidence of pressure overload. Severe
tricuspid regurgitation. Severe pulmonary hypertension.
[**2153-11-12**] CT Chest with Contrast:
No comparison is available. Status post right upper lobectomy.
No evidence of local recurrence. Small bilateral pleural
effusions.
Postsurgical scarring without evidence of lung nodules. Findings
consistent with chronic airways disease, including mucus
bronchial plugging. No pathologically lymph node enlargement in
the mediastinum. Status post cholecystectomy. No adrenal
pathology.
[**2153-11-13**] Cardiac catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated a severe three vessel disease with patent SVG to
RCA and
SVG to OM1. The LMCA had a proximal 20% stenosis. The LAD had
mild
disease throughout with 10% stenoses. The LCX was occludded.
The RCA
was known to be occludded.
2. Venous conduit arteriography showed that the SVG/OM1 was
occluded.
The SVG to RCA was widely patent with a long 20-30% stenosis.
The SVG
to OM2 had a widely patent stent and no flow limiting stenoses.
3. Limited resting hemodynamic revealed elevated RVEDP at 19
mmHg. The
mean PA pressure was 46 mmHg (phasic 90/26 mmHg). The PCWP was
29 mmHg.
The cardiac index was mildly depressed at 2 L/min/m2. The mean
systemic
arterial blood pressure was 101 mmHg (phasic 145/72 mmHg).
4. Distal aortography revealed mild diffuse distal disease.
The renal
arteries were patent bilaterally. The CIA, IIA, CFA, PFA and
proximal
SFA were all widely patent bilaterally.
FINAL DIAGNOSIS:
1. Severe two vessel coronary artery disease with patent SVG to
OM2 and
RCA.
2. Occluded SVG to OM1.
3. Severe right ventricular diastolic dysfunction.
4. Severe pulmonary hypertension.
5. Unchanged coronary artery disease.
6. Patent distal vasculature.
[**2153-11-14**] Carotid Series Complete
Right ICA stenosis 70-79%. Retrograde flow right vertebral
artery
with monophasic flow right brachial artery representing a right
subclavian
steel. Left ICA stenosis 80-99%.
[**2153-11-16**] Transthoracic Echo
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve is reported to be a bioprosthesis,
but is not well seen. The measured transvalvular gradients would
be normal for an aortic bioprosthesis. The mitral valve leaflets
are severely thickened/deformed. There is moderate valvular
mitral stenosis (area 1.0-1.5cm2). Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
Severe [4+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Moderate valvular mitral stenosis. Severe tricuspid
regurgitation. Mild symmetric left ventricular hypertrophy with
preserved global and regional systolic function. Dilated and
hypokinetic right ventricle with signs of pressure overload.
Severe pulmonary hypertension.
[**2153-11-19**] Transthoracic Echo
A secundum type atrial septal defect is present. The right
atrial pressure is indeterminate. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. No
aortic regurgitation is seen. The mitral valve leaflets are
severely thickened/deformed. There is moderate valvular mitral
stenosis (area 1.3cm2). No mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2153-11-16**],
the transmitral gradient is lower, the estimated pulmonary
artery systolic pressure is slightly reduced and a secundum type
atrial septal defect is now seen with bidirectional flow. No
significant pericardial effusion is seen on either study.
[**2153-11-19**] Femoral Ultrasound
No evidence of hematoma or pseudoaneurysm.
Brief Hospital Course:
72 year old female with h/o CAD s/p CABG in [**2138**], PCI [**2151**], and
left CEA who presented with shortness of breath on exertion and
transient left-sided visual blurriness.
#. Shortness of Breath/Mitral Stenosis: She has a known
diagnosis of COPD and was found to have moderate-severe mitral
stenosis (mean gradient 15mmHg, MV area 1.0cm2) on transthoracic
echo. She also had severe pulmonary hypertension and evidence
of right-sided pressure overload on admission. She was
aggressively diuresed after admission. She underwent right and
left heart catheterization which showed significantly elevated
right and left-sided filling pressures. Her mitral stenosis
improved to moderate with diuresis but she remained with
significant dyspnea even with ambulating a few steps. She was
also given scheduled nebulizers for wheezing which gave her a
small amount of subjective improvement. She underwent mitral
valvuloplasty without complication and her shortness of breath
substantially improved after the procedure. Repeat echo showed
a lower transmitral gradient, slightly reduced pulmonary artery
systolic pressure, and a secundum type ASD (mean gradient 8mmHg,
MV area 1.3cm2). She was able to ambulate without oxygen on
discharge.
#. Hypotension: After her mitral valvuloplasty, she was admitted
to the CCU overnight for transient hypotension. She required
phenylephrine briefly in PACU but none in the ICU. Cath sites
were intact and she had a negative groin check.
#. Coronary artery disease: She remained without chest pain
throughout her admission. She was continued on aspirin and her
dose of pravastatin was increased to 80mg daily. Her Plavix was
held during most of the hospitalization in preparation for
possible intervention.
#. CEA: She originally presented with transient left eye
blurriness that was concerning for amaurosis fugax. She was
evaluated by neurology and ophthalmology who felt that her
symptoms were not typical of amaurosis fugax but felt that
carotid stenosis was the major concern. CTA head/neck and
carotid duplex showed tight stenosis (80-99%) of the left
internal carotid artery and significant stenosis of the right
internal carotid artery (70-79%). She was evaluated by vascular
surgery who felt that carotid endarterectomy was very high risk
and recommended stenting. This was deferred on this
hospitalization, but she will likely need carotid stenting in
the near future. She was instructed to follow-up with vascular
surgery as an outpatient.
#. Atrial flutter: She had multiple transient episodes of atrial
flutter with rapid ventricular response that converted back to
normal sinus rhythm without intervention. She remained mainly
in normal sinus rhythm and was started on a heparin drip for
anticoagulation with plan to bridge to Coumadin. She was also
started on a beta blocker for rate control.
#. Hypertension: She was continued on her home lisinopril.
Amlodipine was also added for hypertension temporarily which she
tolerated well, but this was discontinued after her mitral
valvuloplasty as her blood pressure returned to [**Location 213**] range
after this procedure.
#. Prophylaxis: She was given SQ heparin for DVT prophylaxis
#. Code Status: She was full code during this admission
Medications on Admission:
Plavix 75mg po daily
Spiriva daily
Pravastatin 40mg po daily
Aspirin 325mg po daily
Furosemide 20mg po daily
Lisinopril 20mg po BID
Tricor 48mg po daily
Albuterol prn
Calcium
Vitamin D
Centrum
Ibuprofen prn for pain
Discharge Medications:
1. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Puff Inhalation once a day.
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
Please start taking this medication on [**2153-11-23**].
5. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
7. Calcium Oral
8. Vitamin D Oral
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day:
Please STOP taking this medication now. Do not restart until
you see your primary care doctor.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Mitral Stenosis
Carotid Stenosis
Secondary Diagnosis:
Coronary Artery Disease
COPD
Discharge Condition:
Good, alert and oriented, ambulating independently. Slightly
orthostatic on discharge.
Discharge Instructions:
You were admitted to the hospital due to shortness of breath.
You were found to have stenosis (narrowing) of the mitral valve
in your heart. You underwent a cardiac catheterization to
measure the pressures in your heart. You then underwent a
mitral valvuloplasty in order to help open up your mitral valve.
You had an ultrasound (echocardiogram) of your heart after the
procedure which showed that your valve is now more open than it
was previously.
You were also found to have significant stenosis (narrowing) of
the carotid arteries in your neck. It was decided to delay any
treatment for this narrowing until your shortness of breath had
resolved. You should follow up with a vascular surgeon
regarding these stenoses.
While you were in the hospital, your heart went into an abnormal
rhythm called atrial flutter. Your heart rate has been very
well-controlled on a new medication called metoprolol. You were
also started on a blood thinner called Coumadin (warfarin). You
will need to have your blood levels of this drug checked very
closely. Please have your primary care doctor check your INR on
Friday, [**11-23**].
On the day of discharge, your blood pressure dropped slightly
when you were standing. Please drink lots of fluids today and
don't take your dose of Lasix tomorrow. Please have your
primary care doctor check your blood pressure while sitting and
standing (orthostatic blood pressure) during your next
appointment.
CHANGES to your medications:
STOP taking Plavix
START taking Coumadin 2mg by mouth daily
START taking metoprolol succinate 25mg by mouth daily
HOLD (do not take) lisinopril 20mg by mouth daily until you see
your primary care doctor
HOLD (do not take) your Lasix tomorrow, then restart Lasix at
20mg by mouth daily
If you experience any of the following, please return to the
hospital:
Worsening shortness of breath
Dizziness
Syncope (passing out) or feeling as though you are going to pass
out
Chest pain
If you experience any of the following, please call your primary
care doctor:
Worsening swelling in your legs
Fever or chills
Nausea
Vomiting
Diarrhea
Followup Instructions:
You have the following appointments scheduled:
Dr. [**First Name (STitle) 39968**], [**Hospital **] Medical Associates
541 Main Steet, [**Apartment Address(1) **],
[**Location (un) 936**], [**Numeric Identifier 2876**]
Phone: [**Telephone/Fax (1) 14967**]
Fax: [**Telephone/Fax (1) 39969**]
Friday, [**2153-11-23**] at 3:00pm
Please also call and make an appointment with your cardiologist,
Dr. [**Last Name (STitle) 2077**] or whoever you choose to follow up with within the
next 2 weeks.
You should also follow up with a vascular surgeon. The
telephone number for the [**Hospital1 18**] vascular surgery clinic is
([**Telephone/Fax (1) 39970**] if you would like to follow up with the vascular
surgeons at our hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
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"V15.82",
"416.8",
"412",
"362.34",
"V58.61",
"493.20",
"V45.76",
"V88.01",
"V45.82",
"V85.31",
"E944.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"35.96",
"88.42",
"37.23",
"88.57",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
16938, 16997
|
12320, 15583
|
308, 373
|
17144, 17234
|
4428, 4428
|
19390, 20248
|
3368, 3483
|
15849, 16915
|
17018, 17018
|
15609, 15826
|
9103, 12297
|
17258, 18708
|
3498, 4409
|
2080, 3148
|
18737, 19367
|
230, 270
|
401, 1950
|
17092, 17123
|
4444, 9086
|
17037, 17071
|
1995, 2060
|
3164, 3352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,536
| 139,765
|
11487
|
Discharge summary
|
report
|
Admission Date: [**2155-11-8**] Discharge Date: [**2155-11-11**]
Service: MEDICINE
Allergies:
Penicillins / Warfarin
Attending:[**First Name3 (LF) 1654**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 y/o lady with CAD s/p CABG, HTN, Afib on coumadin has
experienced generlaized weakness. Patient experienced dark stool
yesterday for the first time. No stools since then. Did not
notice any other bleeding including hematuria. She denies any
fever, chills, cough, cold, chest pain, abdominal pain,
shortness of breath, orhtopnea, PND, lower extremity swelling,
nausea, vomitting, dizzenss, numbness, tingling, dizziness,
change in vision, change in hearing, headache, neckstiffness,
and or backpain. No focal weakness but has generalized weakness.
She was restarted on coumadin on [**2155-10-22**] admission and also
restarted on amiodarone given the presentation with aftrial
fibrillation with rapid ventricular response.
In [**Hospital1 18**] ED her vitals were 97.1 62 192/75 16 95% RA. She
received NS 1 L, Vitamin 10 units IV, and FFP 2 units once. She
was transfered to the MICU for possible scope.
On arrival to MICU her vitals were T 98.1 HR 70 BP 197/55 RR 27
2LNC 100% oxygen saturation. Her blood pressure improved to
154/66. Otherwise she is asymptomatic. She currently refused
upper endoscopy or colonscopy. She is able to walk 1.5 blocks
five times a week without any limiting symtpoms.
Past Medical History:
- H/o Afib priorly treated with coumadin and amiodarone. Stopped
in [**Month (only) 462**] and had been in sinus (in theory) since then.
- AAA 4.5 x 4.7 cm
- Spinal infarct 7 yrs ago. Patient now has partial numbness in
right leg, vagina and perineum.
- Appy, pancreatitis.
- Hyperlipidemia -
- Depression - no meds
- B12 deficiency - on replacement; pt does not know what the
diagnosis was.
- Status post gallstone pancreatitis .
Social History:
She is widowed and lives alone, indepedent in her ADLs. She has
an involved daughter who lives in [**Location **] and a son in [**Name (NI) 4565**].
She's smoked 2-3packs per week for 30-40 yrs, quit 15 yrs ago.
She drinks wine but never heavily, just with meals.
Import Social History
Family History:
Her father died at 77 from bleeding pud, and her mother, who had
a history of HTN, died in her early 90's from old age. She had a
sister who died at 59 of colon cancer,
Physical Exam:
Vitals: T 98.1 HR 70 BP 197/55 RR 27 2LNC 100% oxygen
saturation. Her blood pressure improved to 154/66.
Gen: Alert and awake, no apparent distress, pleasant lady,
following commands
HEENT: MMM, OP clear, JVP not elevated
Heart: S1S2 irregulary irregular, no MRG
Lungs: Bibasilar fine crackles
Abdomen: BS present, midabdominal bruit heard, NTND, no
organomegaly
Ext: WWP, no edema
Neuro: Strength 5/5 in extremities, sensation is intact.
.
Pertinent Results:
[**2155-11-8**] 04:00AM PT-61.8* PTT-42.7* INR(PT)-7.4*
[**2155-11-8**] 04:00AM PLT COUNT-298
[**2155-11-8**] 04:00AM NEUTS-72.6* LYMPHS-21.8 MONOS-4.1 EOS-0.9
BASOS-0.7
[**2155-11-8**] 04:00AM WBC-7.7 RBC-3.71* HGB-10.5*# HCT-29.9*#
MCV-81* MCH-28.3 MCHC-35.1* RDW-15.9*
[**2155-11-8**] 04:00AM CK-MB-NotDone
[**2155-11-8**] 04:00AM cTropnT-<0.01
[**2155-11-8**] 04:00AM CK(CPK)-40
[**2155-11-8**] 04:00AM estGFR-Using this
[**2155-11-8**] 04:00AM GLUCOSE-126* UREA N-46* CREAT-1.1 SODIUM-139
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
[**2155-11-8**] 11:51AM PT-17.4* PTT-31.1 INR(PT)-1.6*
[**2155-11-8**] 11:51AM PLT COUNT-239
[**2155-11-8**] 11:51AM WBC-5.6 RBC-2.83* HGB-8.0* HCT-22.7* MCV-80*
MCH-28.2 MCHC-35.2* RDW-15.8*
[**2155-11-8**] 11:51AM CALCIUM-8.1* PHOSPHATE-2.4* MAGNESIUM-2.0
[**2155-11-8**] 11:51AM ALT(SGPT)-13 AST(SGOT)-16 LD(LDH)-164 TOT
BILI-1.1
[**2155-11-8**] 11:51AM GLUCOSE-92 UREA N-39* CREAT-1.0 SODIUM-141
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
[**2155-11-8**] 01:13PM HCT-23.6*
[**2155-11-8**] 09:20PM HCT-29.3*
[**2155-11-8**] 09:20PM HAPTOGLOB-170
[**2155-11-8**] 09:20PM CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-2.1
[**2155-11-8**] 09:20PM GLUCOSE-98 UREA N-32* CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
.
CT abd [**11-8**]: ABDOMEN: There is minimal dependent atelectasis at
the bilateral bases, with minimal left pleural thickening. The
visualized heart is within normal limits. There is a simple left
renal cyst. Small areas of dense material are noted within the
stomach and proximal small bowel, likely consistent with
ingested material. Duodenal diverticula are noted at the second
and third portions. Mild colonic diverticulosis is noted. There
is a bilobed infrarenal abdominal aortic aneurysm, measuring 5.1
x 4.7 cm in size within the upper portion of the aneurysm and
4.3 x 4.3 cm in size within the lower portion of the aneurysm.
There are degenerative changes and prominent scoliosis of the
lumbar spine.
PELVIS: There is no free pelvic fluid. There is no evidence of
retroperitoneal hematoma, as questioned. Small uterine
calcifications are
noted, likely representing tiny fibroids. The urinary bladder is
somewhat
distended. Mild colonic diverticulosis is noted. A pessary is in
place.
There are atherosclerotic calcifications of the distal abdominal
aorta and
iliac arteries. There are degenerative changes and prominent
scoliosis of the lumbar spine.
IMPRESSION:
1. No evidence of retroperitoneal hematoma, as questioned.
2. Bilobed infrarenal abdominal aortic aneurysm, measuring up to
5.1 cm in
diameter.
3. Mild colonic diverticulosis.
The study and the report were reviewed by the staff radiologist.
.
[**2155-11-11**] 07:15AM BLOOD WBC-7.2 RBC-3.77* Hgb-11.2* Hct-30.5*
MCV-81* MCH-29.6 MCHC-36.6* RDW-15.9* Plt Ct-220
[**2155-11-10**] 07:40AM BLOOD WBC-6.7 RBC-4.07* Hgb-11.6* Hct-33.3*
MCV-82 MCH-28.6 MCHC-35.0 RDW-16.1* Plt Ct-223
[**2155-11-9**] 02:00AM BLOOD WBC-7.1 RBC-3.87*# Hgb-11.2*# Hct-32.1*
MCV-83 MCH-28.9 MCHC-34.8 RDW-15.6* Plt Ct-178
[**2155-11-8**] 11:51AM BLOOD WBC-5.6 RBC-2.83* Hgb-8.0* Hct-22.7*
MCV-80* MCH-28.2 MCHC-35.2* RDW-15.8* Plt Ct-239
[**2155-11-8**] 04:00AM BLOOD WBC-7.7 RBC-3.71* Hgb-10.5*# Hct-29.9*#
MCV-81* MCH-28.3 MCHC-35.1* RDW-15.9* Plt Ct-298
Brief Hospital Course:
Assessment and Plan: 62 y/o lady with CAD, HTN, and atrial
fibrillation presents with gastrointestinal bleed.
.
# Gastrointestinal bleed: Likely lower GIB, but consideration
for sentinel bleed from an aorto-enteric fistula discussed.
Guaic positive dark stool in rectal volt in ED. Hemodynamically
stable. Has refused EGD and colonoscopy throughout her hospital
stay. Was administered vitamin K in ED to reverse INR of 7.4.
Once admitted to ICU, hct dropped to 22.7, transfused 2U PRBC
overnight and hematocrit remained stable. GI followed patient
on initial part of stay. Patient was initiated on PPI [**Hospital1 **] and
discharged on this medication. Patient's diet was initially
clears then advanced without issue. Patient's hct remained
stable; did have a 2pt decline from 33 to 31 on day of
discharge, with recheck in afternoon, which was stable.
Coumadin and aspirin were both discontinued at the time of
discharge due to medication non-compliance and difficulty with
titration of the INR. This issue will need to be readdressed as
an outpatient.
.
# Hypertension: Patient was initally hypertensive in ED, with
resolution. She had no signs or symptoms of infection or
ischemia. Patient was started on amlodopine for BP control,
which helped keep SBPs<160. Patient did communicate that she
has had htn for years and would likely not take any medication
we would give her. Given her AAA, she requires more stringent
control of her BP, which was communicated with her.
.
# Atrial fibrillation: Patient remained rate controlled
throughout her stay and was continued on amiodarone. As above,
her coumadin and aspirin were discontinued. Of note, does have
CHADs score of 2. Anticoagulation to be addressed as outpt.
.
# ARF - Pt's BUN was elevated to 40 with Cr relatively elevated
to 1.1. BUN and cr resolved with fluids to baseline.
.
# CAD: s/p CABG. No active signs of ischemia. As above, will
need to address aspirin issue as outpt.
.
# AAA: Patient was offered a vascular surgery consult while she
was an inpatient, which she adamentaly refused. She will need
outpatient follow-up. Also needs optimal control of SBP as
above.
.
# Hyperlipidemia: continue home simvastatin
.
# B12 deficiency: continue home B12
.
# Contact: Daughter, [**First Name8 (NamePattern2) **] [**Name (NI) 31824**] [**Telephone/Fax (1) 36659**]
# Code: Full Code
Medications on Admission:
Aspirin 81 mg daily
Toprol XL 100 mg daily
Hydrochlorothiazide 12.5 mg daily
Amiodarone 200 mg [**Hospital1 **] for one month (written on [**2155-10-23**])
Cyanocobalamin 500 mcg daily
Simvastatin 10 mg daily
Coumadin 3 mg daily
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Primary
- GI bleed
- Supratherapeutic INR
Secondary
- Hypertension
- Dyslipidemia
- Coronary artery disease
- Atrial fibrillation
- Abdominal Aortic Aneurysm
- B12 deficiency
- Depression
- H/o spinal infarct [**2147**]
- H/o gallstone pancreatitis
- Hard of hearing
Discharge Condition:
Hemodynamically stable, Hct stable at 33.
Discharge Instructions:
You were admitted for gastrointestinal bleed. You were found to
have a very high coumadin level, so your Coumadin and aspirin
were held. We recommended further evaluation with endoscopy and
colonoscopy to find and potentially treat the source of bleed,
but you refused. You received blood transfusions, and although
you continue to have trace amounts of blood in your stool, your
blood count and vital signs remain stable. We still think it's
best for you to have further evaluation by endoscopy and
colonoscopy to prevent a severe and potentially fatal GI bleed
from occurring in the future.
The following changes were made to your medications:
- Pantoprazole 2x daily
- Amlodipine started for additional blood pressure control.
- Do not restart ASA and coumadin until you discuss with your
PCP the risks of further bleeding versus the risks of developing
blood clot.
Please call your doctor or come to the ED if you continue to
have black or bloody stools or develop bleeding from anywhere
else, chest pain, vision changes, one-sided weakness or
numbness, difficulty speaking, severe pain, fever, or any other
concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2155-12-16**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3940**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2155-11-27**] 3:00
|
[
"441.4",
"266.2",
"E934.2",
"311",
"584.9",
"427.31",
"V45.81",
"285.9",
"V15.81",
"V64.2",
"790.92",
"578.1",
"414.00",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9573, 9617
|
6270, 8633
|
243, 250
|
9928, 9972
|
2907, 6247
|
11155, 11461
|
2260, 2430
|
8913, 9550
|
9638, 9907
|
8659, 8890
|
9996, 11132
|
2445, 2888
|
192, 205
|
278, 1483
|
1505, 1940
|
1956, 2244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,695
| 148,810
|
6737
|
Discharge summary
|
report
|
Admission Date: [**2119-12-12**] Discharge Date: [**2119-12-23**]
Date of Birth: [**2036-9-12**] Sex: F
Service: MEDICINE
Allergies:
Lactose Intolerance
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Gastrointestinal bleeding
Major Surgical or Invasive Procedure:
None.
Blood transfusion; 1 unit PRBC
History of Present Illness:
This is a 83 year-old female with IDDM, dementia,
diverticulosis, who presents with hematochezia at her nursing
home. Sent initially to [**Hospital1 487**] Gen, where CT abd showed
thickening in the rectum, and she was transferred to [**Hospital1 18**] ED.
On arrival in the ED here, VS 97.9 110 112/66 18 96% 2L. Copious
maroon stools. Very labile BP--SBP 90s on arrival at OSH and
received only IVF. Here up to SBPs 130s, then briefly down to
80s. Placed fem line, but did not need pressors. Initial Hct 41,
down to 31 after maroon stools and IVF.
Also received insulin 10 units SQ for elevated blood sugar, and
started vanc/cipro for UTI. At the time of transfer, afebrile,
HR 94, BP 164/54, RR 14, 98%RA.
ROS: Nursing home records note that blood sugar has been high
and that pt did not eat last night [**1-8**] nausea; pt is unable to
provide further review of systems.
Past Medical History:
Alzheimers
Diverticulosis
IDDM, c/b diabetic nephropathy and neuropathy w/ some balance
problems
HTN
[**Name2 (NI) **]
s/p TAH/BSO
s/p cholecystectomy
Lt humerus Fx [**2117**]
shoulder tendonitis
s/p breast cyst surgery
osteoarthritis of knees
L eye cataract repair
Social History:
She lives at [**Hospital 599**] rehab currently. Per her son's report, she
doesn't need any inpatient rehab from the nursing home. She
walks on a walker.
She denied any history of smoking, alcohol use, and illegal drug
use.
Family History:
Signficant for Alzheimer dementia : her father, sister. [**Name (NI) **]
mother died of bone cancer.
Physical Exam:
On Presentation:
Vitals: T:98.3 BP:97/58 HR:96 RR:18 O2Sat:99% 2L
GEN: elderly female, mumbling
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mild TTP RLQ, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: oriented to person only, mumbling, moaning at times. not
ambulatory at baseline
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
IMAGING:
CXR:
FINDINGS: As compared to the previous examination, there is a
moderate
elevation of the hemidiaphragms, presumably caused by poor
inspiration. As a consequence, there is a decrease in
transparency over the left lung bases. A pre-existing small
lucency projecting over the left costophrenic sinus that was
documented to correspond to a small conglomerate of cysts on the
CT examination of [**2118-7-2**], is unchanged. To confirm that
the changes at the left lung base are caused by hypoventilation
and to exclude pneumonia, a repeat radiograph, is possible in
standing position, should be performed within the next 12 hours.
Otherwise, the findings are unchanged. The size of the cardiac
silhouette,
known hiatal hernia. No evidence of pleural effusions. Moderate
aortic
tortuosity.
.
EKG:
Sinus rhythm and low amplitude P waves. Tracing is marred by
baseline
artifact. Compared to the previous tracing of [**2118-7-9**] the rate
has increased.
There is diffuse low voltage. Clinical correlation is suggested.
.
Labs:
[**2119-12-12**] 01:50AM BLOOD WBC-10.1# RBC-4.64# Hgb-14.0# Hct-41.7#
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.8 Plt Ct-200
[**2119-12-15**] 08:32AM BLOOD WBC-5.9 RBC-3.23* Hgb-9.7* Hct-28.9*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.4 Plt Ct-109*
[**2119-12-14**] 04:01AM BLOOD PT-13.2 PTT-31.4 INR(PT)-1.1
[**2119-12-12**] 01:50AM BLOOD Glucose-400* UreaN-44* Creat-2.3*# Na-133
K-9.2* Cl-101 HCO3-21* AnGap-20
[**2119-12-15**] 08:32AM BLOOD Glucose-157* UreaN-19 Creat-0.9 Na-147*
K-3.6 Cl-117* HCO3-22 AnGap-12
[**2119-12-15**] 08:32AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.0
<br>
[**12-21**]: STUDY: Bilateral lower extremity veins ultrasound.
INDICATION: Significant baseline dementia with new bilateral
lower extremity
edema.
COMPARISONS: None available.
FINDINGS: [**Doctor Last Name **]-scale, color and pulse Doppler son[**Name (NI) 867**] was
performed on
bilateral common femoral, superficial femoral, and popliteal
veins. Complete
occlusive echogenic thrombus is present within bilateral
superficial femoral
veins. Minimal flow is demonstrated within bilateral popliteal
veins, which
also demonstrate considerable non-compressible echogenic
thrombus within.
Minimal compression is demonstrated within the common femoral
veins which
contain a substantial amount of echogenic clot as well.
IMPRESSION: Extensive bilateral lower extremity DVTs.
Findings relayed by Dr. [**Last Name (STitle) **] to [**First Name8 (NamePattern2) **] [**Doctor Last Name **] immediately
after the study
was performed.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: [**First Name8 (NamePattern2) **] [**2119-12-21**] 4:51 PM
Brief Hospital Course:
83F with IDDM, who presents with hematochezia, dehydration, also
UTI, leukocytosis with bandemia, and hyperglycemia. Pt with
hospitalization as below per problems.
<br>
# DVT - extensive in LE - here with GI bleed - though stable now
- anti-coagulation will be contraindicated has high risk for
bleed which pt would likely have rapid decompensation.
-IVC filter placement by IR done [**12-22**] (late afternoon) - d/w
HCP-[**Name (NI) **] [**Name (NI) **] prior and agreed with plan.
<br>
# Mild mental status aleration - overall at baseline now,
resolved overall. Note had trigger 3 nights prior (just mild
tachycardia) - vanc/zosyn given by night coverage - pt with
noted leukocytosis prior - then loose stools -given flagyl - but
then c. diff noted negative [**12-20**]. d/c flagyl
-overall resolved at baseline now - no infection - noted DVT as
above
<br>
# Fever/leukocytosis - resolved now. unclear etiology prior.
pt initially tx on [**12-19**] night with vanc/zosyn - though noted pt
doing well in am. As above
-off abx
-f/u cultures have been negative to date including c. diff
-d/c PICC today prior to transfer to [**Location (un) 6107**] house
<br>
# GI bleeding/Anemia, acute blood loss: Given age, DM,
tenderness on exam, and rectal inflammation on OSH CT scan, was
likely ischemic colitis, though differential also included
diverticular bleeding, AVM. Serial hcts were done and patient
was transfused 1 unit for an hct drop 30 to 26 early [**2119-12-13**]. She
was treated with flagyl due to concern for ischemic colitis
allowing transolcation of bacteria. Hct were other wise stable
though patient continued to have pink/red stool. GI consult
recommended colonscopy though patient not likely to comply.
Flex sig was considered, but deferred given stabilization of
hct. Patient's HCT remained stable, and did not have recurrance
of florid hematochezia, although did have isolated episodes of
red mucus-like stools. Patient received a total of 4+ days of
flagyl, and 5 days of cipro.
- Flagyl d/c'd
- do not anticipate further transfusion needs
- h/h now established as stable, no further monitoring required
- just for facility to observe stools for frank blood or melena
- otherwise no interventions planned at this time
<br>
# Acute renal failure: Cr 2.3 on admission. Baseline 0.7-0.8 at
her last admission here in [**2117**]. Returned to baseline with
fluids. stable
- avoid nephrotoxins
- encourage po hydration
<br>
# Hypernatremia
pt had developed hypernatremia on [**12-15**] likely d/t poor free water
intake. Resolved now.
<br>
# Urinary tract infection: + UA. Treated initially with empiric
cipro/vanc initially which was narrowed to cipro after
premliminary cultures showed GNR. Cultures later revealed
pan-sensitive Klebsiella.
- Completed 6 days of IV cipro; d/c today (received 3 days
treatment after foley removal)
- foley d/c'd [**12-15**]
- recent ua noted, Ucx neg.
<br>
# DM II, controlled, without complications: Treated with home
NPH 28units QAM and sliding scale (half doses while NPO). BS
mildly elevated prior - increased NPH to 30units [**12-20**] pm - cont
to follow. (1/2 dose given day of IVC filter placement). BS
tend to fluctuate.
-facility to cont Qac,qhs BS checks - titrate NPH as indicated
<br>
# Dementia, Alzheimer's: Severe.
- Continue donepezil, risperdal, depakote.
- Treated with prn olanzipine for procedures with good effect.
<br>
# Code: DNR/DNI per conversation with HCP - her son. [**Name (NI) **] does not
desire escalation of care. Blood transfusions OK. IVC filter
placement discussed with son.
<br>
Contact: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 25623**]
Access: PICC
DISPO: now off abx - IVC filter just placed - transfer to [**First Name4 (NamePattern1) 6107**]
[**Last Name (NamePattern1) **] today. Will have f/u with GI on [**2119-12-26**].
Medications on Admission:
multivitamin
donepezil 10mg daily
prilosec 20mg daily
vitamin d 800 units po daily
calcium 500mg daily
colace, dulcolax
risperdal 0.25mg [**Hospital1 **]
depakote sprinkles 250mg QAM and 500mg QPM
simvastatin 20mg daily
lisinopril 5mg daily
lasix 20mg daily
RISS, NPH 28units QAM
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
7. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO QAM (once a day (in the morning)).
9. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO QPM (once a day (in the evening)).
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
Eight (28) units Subcutaneous q AM.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] Nursing Facility - [**Location (un) 3786**]
Discharge Diagnosis:
# Hematochezia; likely ischemic colitis
# Severe dementia
# Acute renal failure
# Urinary tract infection
# Anemia due to acute blood loss
# Diabetes, type 2 controlled without complications
# Hypertension, benign
Discharge Condition:
stable
Discharge Instructions:
Please seek medical attention if patient develops repeat
gastrointestinal bleeding, fevers, chills, or any other
concerns.
Followup Instructions:
Please follow patient's blood pressure. Patient was previously
taking lisinopril and lasix, however these medications were held
on discharge due to well controlled blood pressures off of these
medications. Please reevaluate blood pressure, and resume
medications if medically indicated.
.
Provider: [**First Name8 (NamePattern2) 3722**] [**Name11 (NameIs) 3723**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2120-1-2**] 2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2119-12-26**]
|
[
"250.60",
"557.0",
"453.42",
"V58.67",
"272.0",
"401.1",
"583.81",
"357.2",
"276.0",
"041.3",
"562.10",
"294.10",
"584.9",
"331.0",
"715.96",
"599.0",
"285.1",
"458.9",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10542, 10682
|
5338, 9189
|
308, 347
|
10940, 10949
|
2525, 5315
|
11120, 11697
|
1802, 1904
|
9520, 10519
|
10703, 10919
|
9215, 9497
|
10973, 11097
|
1919, 2506
|
243, 270
|
375, 1254
|
1276, 1544
|
1560, 1786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,563
| 161,419
|
41596
|
Discharge summary
|
report
|
Admission Date: [**2101-1-19**] Discharge Date: [**2101-4-29**]
Date of Birth: [**2022-1-1**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
[**2101-2-11**]
1. Percutaneous tracheostomy.
2. Percutaneous endoscopic gastrostomy.
History of Present Illness:
[**Known firstname 90434**] [**Known lastname 90435**] is a 79 yo Nepali M who presents from [**Hospital 11373**] with a large brainstem hemorrhage. The patient lives
alone and a neighbor checks on him regularly; Initially it was
not clear how well he speaks English. It was also initially
unclear whether or not he had close family in the US. Later it
turned out that there was a distant niece who checks on him
occasionally.
The patient was last seen well 24 hours ago. He was found down
at 2100, face down and unresponsive, with vomit and feces. EMS
found him with shallow respirations, blood pressures documented
between the 140s to 169, transferred to NVH where he received
one gram of dilantin was intubated (with Versed/etomidate/succ).
CT showed pontine/midbrain hemorrhage with extension into 4th
ventricle. He was placed in hard c-spine collar. He was
transferred to [**Hospital1 18**], on arrival BP 189 /78.
Neurosurgery was first consulted. Their examination revealed
absent corneals, pupils R 1mm and hippus, L pinpoint and NR,
upper extremities no response to noxious, triple flexion in
lower extremities. No intervention was recommended since there
was no hydrocephalus and a poor prognosis.
Past Medical History:
HTN
Social History:
lives alone, per records from [**Country 63412**], w/o family locally
Family History:
Unknown
Physical Exam:
On admission:
VS T afeb HR 109 BP 133/83 RR 20s on PSV
GENERAL
intubated, not sedated.
Traumatic skin tears on L forehead, knee.
Sclera anicteric, in hard C-spine collar.
RRR, no m/r/g
Lungs clear
Ab soft, nondistended, no masses
Ext warm and well perfused. 2 finger amputations on L hand.
NEURO:
CN:
Eyes closed. Pupils 1mm and nonreactive, fixed at midline. No
dolls eyes though head turning limited by collar. Slight corneal
present on R, absent on L. No gag or cough.
MOTOR/[**Last Name (un) **]:
Increased tone throughout.
With stimulation, limbs make slight posturing movements (flexion
of UEs, internal/external rotation of LEs) associated with fine
small amplitude tremor and muscle fasiculations.
Noxious stimulation: UEs slight flexion/internal rotation L>R.
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] flexion with antigravity movement at IP/quad
sustained.
DTR: 2+ and brisk, symmetric bilateral biceps, triceps,
brachioradialis, patellar, 1 Achilles. No clonus. Toes
downgoing.
Pertinent Results:
CXR [**2-16**]: Portable AP chest radiograph was reviewed in
comparison to [**2101-2-3**].
The tracheostomy tube tip is 3.1 cm above the carina. Heart size
is normal. Mediastinum is normal. The lungs are essentially
clear. There is evidence of bilateral nipples projecting over
the lung bases, unchanged. The right PICC line tip is at the
level of cavoatrial junction.
[**2-3**]: US LE's: IMPRESSION: No evidence of deep vein thrombosis in
either leg.
[**1-26**]: C-spine CT: 1. Widening of the intervertebral space at
C4-5 is likely related to a prior anterior wedge compression
fracture of the C5 vertebral body, although recent injury to the
anterior longitudinal ligament could cause a similar appearance.
If there are no contraindications and diagnosis is deemed
clinically relevant, evaluation of the ligamentous structures
with MRI is recommended.
2. Multilevel degenerative changes of the cervical spine as
described above, including mild central canal narrowing at C2-3,
C4-5, C5-6, and C6-7. Narrowing of the central canal
predisposes to spinal cord injury in the setting of trauma. MR
is more sensitive than CT for evaluation of spinal cord injury.
3. Increased size of the pontine hematoma.
4. Increased opacification of the left sphenoid sinus and
increased mucosal thickening of the right sphenoid sinus could
reflect an ongoing inflammatory process.
Brief Hospital Course:
He is a 79 yo M from [**Country 63412**], with reported h/o HTN, found down,
found to have large pontine/midbrain hemorrhage with extension
into 4th ventricle. Most likely etiology is hypertensive
hemorrhage. BP elevated at first arrival but then was
normotensive. Initial neurologic examination was significant
for pinpoint pupils, absent brainstem reflexes, spastic
tetraplegia with posturing. Neurosurgery did not recommend any
intervention, as there was no hydrocephalus at that point. The
course was complicated by absence of relatives/HCP to discuss
goals of care. He was admitted to the neuro ICU for monitoring
and supportive care.
Guardianship papers were filed. However, with the impending
medical need for a tracheostomy and PEG he under went these
procedures and was transferred to the floor. The court granted
a do not escalate care but did not warrant a withdraw of care.
A long court case evolved which was prolonged unnecessarily by
his court appointed lawyer. Despite the fact that his distant
niece came to the hospital and made his wishes very clear,
despite the fact that a religious person made it clear that it
would be against his religion to be kept alive if there was no
meaningful chance for a conscious life or a meaningfull
recovery, the court appointed lawyer insisted that we still did
not know his wishes.
His hospital course has been fairly uneventful exept for an
early bout of gram negative sepsis. He was started on Vanc,
Zosyn, Cipro for coverage of GPCs and GNRs in sputum, GNRs in
anaerobic BCx. CT abd pelvis demonstrated no evidence for
infection or malignancy. Echo did not show any obvious
vegitations. He became afebrile and antibiotics were pared down.
He was placed on a course of DiCLOXacillin. He remained afebrile
and was transferred to the floor.
A court date again around [**4-25**] resulted in an order that
allowed his Guardian to make a decision to withdraw his feeding
tube and to make him comfort measures only.
On [**2101-4-29**], the resident was called to see patient for
prounouncement of death Patient did
not respond to tactile or verbal stimuli, Pupils are fixed and
dilated, carotid pulses absent, no heart sounds, no spontaneous
respirations, extremities warm.
TIME OF DEATH: 15:50 PM. His distant niece was notified and did
not agree to autopsy. Attending and admitting notified.
Medications on Admission:
None
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Pontine Hemorrhage
Discharge Condition:
Mental Status: unable to assess.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 90435**],
You were admitted following a severe bleed in the pons of your
brainstem. You have been unable to communicate since this
event. You were make comfort measures only and passed.
Followup Instructions:
deceased
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2101-4-29**]
|
[
"482.40",
"728.88",
"344.00",
"584.9",
"780.03",
"348.89",
"401.9",
"787.29",
"038.3",
"438.82",
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"V62.5",
"431",
"482.83",
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icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"31.1",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6661, 6670
|
4213, 6577
|
307, 395
|
6732, 6732
|
2820, 4190
|
7112, 7244
|
1763, 1772
|
6632, 6638
|
6691, 6711
|
6603, 6609
|
6871, 7089
|
1787, 1787
|
264, 269
|
423, 1632
|
1801, 2801
|
6747, 6847
|
1654, 1659
|
1675, 1747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,461
| 129,693
|
27440
|
Discharge summary
|
report
|
Admission Date: [**2174-5-1**] Discharge Date: [**2174-8-5**]
Date of Birth: [**2174-5-1**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 67149**], #2, is a 26 and
[**6-12**] week gestational age infant delivered via C-section with
a birth weight of 1105 grams. He was admitted to the NICU
with prematurity and respiratory distress. He was born at
1:02 a.m., product of a twin gestation, to a 31-year-old
gravida 3, para 5 mom, with [**Name (NI) 37516**] [**2174-8-2**].
Previous obstetric history was notable for term [**Doctor Last Name **] and
36 week twins. Prenatal labs including blood type O positive,
antibody negative, RPR nonreactive, rubella immune, hepatitis
B surface antigen negative and GBS negative. This pregnancy
was notable for spontaneous di-di twin gestation complicated
by cervical shortening at approximately 24 weeks. The mother
was admitted at that time for bedrest and monitoring and was
given betamethasone [**4-11**], through [**4-12**]. Ultrasound
showed estimated fetal weights of approximately 60th
percentile with normal amniotic fluid volume and BPPs with
vertex/breech positioning. The mother experienced spontaneous
rupture of membranes on [**4-27**], approximately 84 hours
prior to delivery, and was begun on ampicillin and
erythromycin. This evening she was noted to have progressive
cervical dilatation, was taken for repeat C-section, no fever
or other signs of chorioamnionitis were noted. At delivery,
the baby emerged with moderate tone and weak cry requiring
stimulation and blow by oxygen for resuscitation. Apgar was 6
and 8 at 1 minute and 5 minutes, respectively. The infant was
intubated at approximately 5 minutes of life for respiratory
distress and was brought to the NICU.
PHYSICAL EXAMINATION: Initial physical exam, weight 1105
grams, 75th percentile, head circumference 25 cm, 50th
percentile, length 35 cm, 50th percentile, temperature 96.7,
heart rate 160s, respiratory rate 50s, blood pressure 72/28
with a mean of 39. SIMV 26/5 x rate of 30. FIO2 at 40%,
rapidly weaned to 30%. The baby was a well developed
premature infant responsive to exam, on ventilator.
Fontanelle soft and flat. Ears and nares patent. Palate
intact. Neck supple. Chest with coarse moderate aeration,
appeared comfortable on the ventilator. Heart regular rate
and rhythm, no murmurs. Abdomen soft, no hepatosplenomegaly,
no mass, quiet bowel sounds, 3 vessel cord. Normal GU preterm
male, testes not palpable. Anus patent. Extremities and back
were normal. No lesions. Neurologic exam: Tone and activity
were appropriate for gestational age.
HOSPITAL COURSE: Summary of hospital course by systems:
Respiratory: The baby received Surfactant x2. He was
intubated for less than 48 hours on CPAP through [**5-22**] and
on nasal cannula through [**6-5**]. He has been in room air
since. He has had some bradycardia and apneas as well as some
choking episodes with feeding secondary to reflux.
Cardiovascular: He had a PDA that was treated with Indocin.
He also has transient hypertension which will require follow-
up by the pediatrician with electrolytes.
Nutrition: He was started on feeds on approximately the
second to third day of life and was gradually increased on
calories as well as volume. When he reached full feeds, he began
to have severe reflux resulting in apnea and bradycardia. He was
changed from Enfamil to Enfamil AR to control the reflux. He
experienced some modest improvement but continue to have severe
GERD. He was then switched to plain enfamil thickened with rice
cereal so he could also begin reflux medications. Because he
worstened, a GI consult was obtained. The mentioned concern for
possible milk protein allergy in addition to and aggrivating the
GERD. The recommended changing his formula. He is currently on
Neocate 20 calories/oz with 1 teaspoon of rice cereal/oz
secondary to intractablegastroesophageal reflux disease. He has
been on this feeding regime since [**8-1**]. He has been gaining
weight appropriately. Weight on discharge 4240 grams.
GI: Secondary to intractable gastroesophageal reflux, he was
started on Reglan and zantac. Because his GERD was not properly
controlled, a GI consult was obtained. The recommended beginning
Prilosec. His reflux was finally controlled on Zantac, priolosec
Neocate and rice cereal. During this hospitalization, he was also
brielfy on phototherapy for hyperbilirubinemia with a peak
bilirubin 5.1/0.3 on [**2174-5-3**]. He was noted to have
frequent constipation. He would require glycerin suppositories to
encouarge bowel movements. He began 1 teaspoon of prune juice
daily and then became regular with bowel movements.
Hematology: He is currently on iron. His last hematocrit was
27.8 on [**7-7**]. He is also a carrier of the sickle cell
trait. He was transfused once in the hospital.
Infectious disease: He was on ampicillin antibiotics
initially for rule out sepsis for 1 week. He has had no other
evidence for infection during the hospitalization.
Neurology: He has had normal head ultrasounds, no evidence
for bleeding.
Sensory: Audiology hearing screen was performed and he passed
the hearing screen on [**2174-7-11**].
Ophthalmology: His last eye exam on [**7-11**], showed
bilaterally mature retina. Recommendation is for follow-up
exam at 9 months of age.
He is doing well on discharge. The gastroesophageal reflux is
clinically controlled with his current regimen. He will be
discharged home with his mother. The name of the primary
pediatrician is Dr. [**First Name8 (NamePattern2) 3551**] [**Last Name (NamePattern1) 56424**]. Her phone number is [**Telephone/Fax (1) 67152**]. Fax number [**Telephone/Fax (1) 67153**].
CARE RECOMMENDATIONS:
1. He will be discharged home on Neocate 20 calories/oz since
we cannot rule out milk protein allergy.
2. Medications on discharge include Reglan 0.4 mg q.8 hours,
Prevacid 6.5 mg q.24 hours(he had been on Prilosec during
this hospitalization. We attempted to get him prilosec for
home, but his insurance copy would not cover the medication
At their request, we change him to prevacid), iron,
multivitamins, prune juice.
3. He passed the car seat test.
4. State newborn screen was only significant for sickle cell
trait. They were sent [**5-4**], [**5-15**], [**5-25**],and
[**6-9**].
5. He received his 2 month immunizations which included
Pediarix, HIB and Prevnar on [**7-6**], through [**7-7**]. His
first hepatitis B vaccine was [**6-1**].
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: Born at less than
32 weeks, born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings or 3 with chronic lung disease.
Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
7. Follow-up appointments include an appointment with the
pediatrician which should be scheduled for Monday, [**8-8**]. An appointment also with gastroenterology has been
scheduled for [**2174-10-5**], at 10:30 a.m. with Dr.
[**Last Name (STitle) 19862**], fellow in gastroenterology at [**Hospital1 **].
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress syndrome.
3. Patent ductus arteriosus.
4. Sickle cell trait.
5. Transient hypertension.
6. Intractable gastroesophageal reflux disease.
7. Possible milk protein allergy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Name8 (MD) 67154**]
MEDQUIST36
D: [**2174-8-5**] 09:28:30
T: [**2174-8-5**] 19:01:41
Job#: [**Job Number 67155**]
|
[
"765.23",
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"796.2",
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"282.5",
"769",
"765.14",
"V31.01",
"V05.3",
"774.2",
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icd9cm
|
[
[
[]
]
] |
[
"99.55",
"96.04",
"99.83",
"93.90",
"38.93",
"96.71",
"64.0"
] |
icd9pcs
|
[
[
[]
]
] |
7612, 8091
|
2655, 2666
|
5742, 6537
|
2694, 5720
|
1809, 2563
|
6564, 7591
|
157, 1786
|
2580, 2637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
384
| 122,988
|
13363
|
Discharge summary
|
report
|
Admission Date: [**2163-3-9**] Discharge Date: [**2163-3-16**]
Date of Birth: [**2093-1-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
obtundation
Major Surgical or Invasive Procedure:
hemodialysis
nasogastric intubation
History of Present Illness:
70yo woman with h/o of ESRD on HD, HTN, dementia, and bipolar
disorder with paranoia presents with obtundation and
uncontrolled hypertension in the setting of missing several
sessions of dialysis.
.
Patient was referred to the ED from dialysis, where she had
presented with lethargy and HTN after 10-12 days without
dialysis. Of note, she has a history of paranoia with refusal of
medications and dialysis, per her nephrologist's report (Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 805**]). Her PCP had begun discussions with pt's Health
Care Proxy and her son about moving toward comfort care but son
felt that patient always agreed to care when he is with her, but
refuses when he leaves.
In the ED, initial VS: 98 [**Telephone/Fax (3) 40620**]0 100% NRB. BS 147.
Patient was unresponsive to voice/touch but withdrew from pain.
Labs significant for ABG 7.54/30/159 and PTT 150 with a lactate
of 1.7. Blood cultures were sent and she was given 1 dose of
levaquin 750mg IV. She also received labetalol 20mg IV x 1 and
then was put on labetalol gtt with decrease in BP from peak of
240/120 to 198/112 over 2 hours. She was admitted to the [**Hospital Unit Name 153**]
for emergent hemodialysis and BP mgmt.
Past Medical History:
ESRD on HD [**3-5**] Lithium (Nephrologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**])
HTN
Diabetes insipidus [**3-5**] lithium
Bipolar disorder
Vascular dementia (s/p neurobehavioral testing [**7-9**])
Paranoia
MGUS: +MONOCLONAL IGG KAPPA DETECTED [**7-9**]
Seizure disorder: witnessed during admission to [**Hospital1 18**] [**2161**]
Multiple admissions with refusal to undergo dialysis x weeks
with subsequent mental status change following dialysis
Recent admission [**1-8**] with fevers and hypertension, fevers
resolved without antibiotics
Social History:
Lives at [**Hospital 100**] Rehab. Graduated college, used to work as tech
at [**Location (un) 40552**]. Widowed with two children. Son [**Name (NI) **] lives in
[**State **]. [**Doctor First Name 9496**] is HCP and personal care assistant for last
4 years.
Family History:
N/C
Physical Exam:
On admission - ED vitals as noted.
Upon transfer to medical floor:
Pt lethargic, not responding to command, eventually said "[**Last Name (un) **],
that hurts" to repeated sternal rub.
Pupils small but reactive to light.
NGT in place.
Lungs with coarse breath sounds anteriorly.
RRR S1S2, II/VI SEM
abd soft, ND, NT, NABS
LE no edema, feet warm, 1+ DP pulses
Babinski equivocal b/l, DTR 1+ patellar & brachial.
access: R IJ tunnelled HD catheter, LUE PIV
Pertinent Results:
[**2163-3-9**] 10:44PM POTASSIUM-6.9*
[**2163-3-9**] 09:13PM GLUCOSE-112* UREA N-54* CREAT-7.9* SODIUM-136
POTASSIUM-6.6* CHLORIDE-97 TOTAL CO2-25 ANION GAP-21*
[**2163-3-9**] 09:13PM CALCIUM-10.1 PHOSPHATE-4.6*# MAGNESIUM-2.5
[**2163-3-9**] 09:13PM WBC-8.2 RBC-4.10* HGB-13.6 HCT-42.8 MCV-104*
MCH-33.2* MCHC-31.8 RDW-16.4*
[**2163-3-9**] 10:44PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2163-3-9**] 03:50PM PHENYTOIN-<0.6*
Imaging:
CXR [**3-9**]:
There is a dual-lumen dialysis catheter via right internal
jugular approach whose tip terminates in the right atrium. The
patient is angled and slightly rotated, which limits assessment.
There is increased linear and patchy opacity in the retrocardiac
left lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] represent atelectasis or developing
pneumonia. There is no definite pulmonary vascular congestion.
Lung volumes are low. No definite pleural effusions are noted.
.
CT Head [**3-9**]:
The extracalvarial soft tissues are unremarkable. The calvarium
and skull base are intact without fracture or suspicious osseous
lesion. A calcified plaque is noted in the cavernous and
supraclinoid portions of the internal carotid arteries. The
included paranasal sinuses and mastoid air cells are clear. The
globes are intact with lenses in place.
Intracranially, the ventricles are prominent but midline.
Likewise, the cortical sulci and subarachnoid cisterns are
prominent. These findings reflect an overall generalized brain
parenchymal volume loss which is within normal limits accounting
for the patient's stated age. There has been no significant
progression since the prior examination. A small lacunar infarct
is less conspicuous in the head of the right caudate nucleus,
slightly more conspicuous around low attenuation lesion within
the right basal ganglia, also likely due to lacunar infarction
versus a prominent perivascular space. The [**Doctor Last Name 352**]- white matter
interface is well defined. There is no intracranial
hemorrhage or CT evidence of acute cortical stroke.
Brief Hospital Course:
A/P: 70yo woman who lives at [**Hospital 100**] Rehab with bipolar d/o,
dementia, CKD stage V on HD, HTN, seizure d/o, admitted to [**Hospital Unit Name 153**]
with obtundation after missing several sessions of HD.
.
# Altered mental status in setting of baseline dementia:
Improved dramatically after several hemodialysis sessions. Two
CTs of head where done to eval for evolving stroke and these
were without stroke. She was found to have sub therapuetic
levels of dilantin and so this was re-loaded and maintenance
with keppra and dilantin re-started. Please note speech and
swallow eval of [**2163-3-15**]. She was treated initially with
vancomycin for possible line infection in setting of mild
leukocytosis but blood cx's remained negative and so this was
discontinued.
.
# CKD stage V: Renal following closely, getting daily HD. PTH
within normal and so cinacalcet discontinued. Last HD was
[**2163-3-16**]. .
# low-grade fever on admission: no localizing signs/sx, HD
tunnelled line without evidence of infection. Received empiric
levofloxacin in ED, also vancomycin dosed at HD by level. Follow
blood cultures and redose vanco by trough. If blood cultures
grow, then HD catheter may have to be removed. If blood cx
remain negative, then can discontinue vanco.
.
# Hypertensive Urgency: Stabilized in [**Hospital Unit Name 153**] on labetalol gtt and
after several dialysis sessions, pt required only po lopressor
and intermittent hydralazine. On discharge she should restart
norvasc, lisinopril, and Toprol.
.
# bipolar d/o: Off all neuroleptics & sedatives while mentation
cleared, and did have some early morning agitation. Risperidone
should be restarted. Of note, ativan 0.25mg IV given with
marked sedation.
.
#F/E/N: See speech and swallow eval.
.
# Code: DNR/DNI
Medications on Admission:
Medications (per [**1-8**] discharge summary):
Risperidone 1 mg PO BID
Aspirin 325 mg daily
Acetaminophen 325-650 Q6H prn
Amlodipine 10mg daily
Cinacalcet 30 mg daily
Folic Acid 1 mg daily
Sevelamer 800 mg TID w/ meals
Simvastatin 40 mg daily
Levetiracetam 500 mg PO BID
Phenytoin Sodium Extended 300mg daily
Senna 8.6 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Cholecalciferol (Vitamin D3) 1000 units daily
Metoprolol Succinate 25 mg daily
Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Lisinopril 10 mg daily
Lorazepam 0.5 mg PO Q4H PRN anxiety
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. Tylenol 325 mg Tablet Sig: One (1) Tablet PO once a day.
4. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Phenytoin 100 mg/4 mL Suspension Sig: Three Hundred (300) mg
PO Q24H (every 24 hours).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
10. Colace 100 mg Capsule Sig: Two (2) Capsule PO twice a day as
needed for constipation.
11. Cholecalciferol (Vitamin D3) Miscellaneous
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO three
times a day.
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
delerium
Discharge Condition:
stable
Discharge Instructions:
Please contact Dr.[**Doctor Last Name 4145**] if patient refuses any medication
or if patient in increasingly confused, febrile, or has other
concerning symptoms.
Followup Instructions:
Please follow up with Dr.[**Doctor Last Name 4145**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2163-3-16**]
|
[
"290.40",
"345.90",
"276.7",
"403.01",
"297.1",
"437.2",
"V15.81",
"296.89",
"437.0",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
8505, 8571
|
5062, 6002
|
282, 319
|
8624, 8633
|
2946, 5039
|
8844, 9050
|
2450, 2455
|
7502, 8482
|
8592, 8603
|
6877, 7479
|
8657, 8821
|
2470, 2927
|
231, 244
|
347, 1568
|
6016, 6851
|
1590, 2158
|
2174, 2434
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,143
| 116,069
|
41043
|
Discharge summary
|
report
|
Admission Date: [**2103-4-24**] Discharge Date: [**2103-5-1**]
Date of Birth: [**2059-9-15**] Sex: M
Service: SURGERY
Allergies:
Dicloxacillin
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Liver mass
Major Surgical or Invasive Procedure:
hepatic segment 4b and 5 resection [**2103-4-24**]
History of Present Illness:
43-year-old man with end-stageliver disease due to hepatitis C
who is also coinfected with HIV. He has evidence of mild portal
hypertension including
thrombocytopenia and splenomegaly. He has never had ascites.
Found to have a 1.5 x 1.5 cm hyperenhancing mass in segment IV b
concerning for HCC.
A recent endoscopy demonstrates no esophageal varices,
although he does have a report of an upper GI bleed several
years ago. Risks and benefits of the procedure as well as
alternative procedures including liver transplantation and a
percutaneous ablative therapies were discussed with the
patient and his girlfriend. Appropriate consents were
signed.
Past Medical History:
kidney stones s/p lithptripsy, DM II (on insulin), HTN,
neuropathy, anxiety, [**Doctor Last Name 933**] disease, hypercholesterolemia, HIV,
HCV
Social History:
Single. Supportive partner. Not currently working. Denies
tobacco, etoh or recent substance use. Smoked 1ppd x10 yrs
Family History:
unremarkable for liver disease
Pertinent Results:
[**2103-4-24**] 01:20PM BLOOD WBC-16.5*# RBC-3.84* Hgb-12.7* Hct-36.5*
MCV-95 MCH-33.0* MCHC-34.8 RDW-15.6* Plt Ct-142*#
[**2103-5-1**] 04:43AM BLOOD WBC-5.2 RBC-3.14* Hgb-10.2* Hct-30.3*
MCV-96 MCH-32.3* MCHC-33.5 RDW-16.0* Plt Ct-90*
[**2103-4-27**] 03:00AM BLOOD PT-16.2* PTT-26.1 INR(PT)-1.4*
[**2103-5-1**] 04:43AM BLOOD Glucose-143* UreaN-15 Creat-1.0 Na-137
K-4.2 Cl-105 HCO3-28 AnGap-8
[**2103-4-24**] 01:20PM BLOOD ALT-77* AST-190* AlkPhos-121 TotBili-2.5*
[**2103-5-1**] 04:43AM BLOOD ALT-90* AST-164* AlkPhos-167* TotBili-0.7
[**2103-5-1**] 04:43AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.7
Brief Hospital Course:
On [**2103-4-24**], he underwent exploratory laparotomy, intraoperative
ultrasound, cholecystectomy, and segment 4b/5 resection. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the bare area
behind the right lobe as well as in the resection bed. Please
refer to operative note for details. Postop, BP was low
requiring a neo drip, and iv albumin was given. BP responded to
these treatments. Neo drip was stopped and BP stabilized.
He complained of a lot of abdominal pain and was medicated with
IV Dilaudid and methadone then a Ketamine drip. A Dilaudid PCA
was also started. He was transferred to the CSICU for
management. The pain service was consulted for difficult pain
control management.
Pain control improved. Ketamine was weaned off. Neurontin was
increased. Mental status was notable for sleepiness.
Blood sugars were elevated and an insulin drip was used with
improvement. Diet was advanced. Hepatology was consulted.
Recommendations included starting Lactulose and Rifaximin.
[**Last Name (un) **] was consulted and assisted with insulin management.
Insulin drip was switched to Lantus and Humalog sliding scale.
Of note, Levoxyl was started. Recommendations included checking
TSH, T4 and T3.
Hepatology was consulted and recommended increasing Rifaximin
dose titration of Lactulose per BMs. Home dose of Methadone was
resumed. Diet was advanced. Abdomen was distended. He did have
multiple stools likely from Lactulose. JP drain outputs
(ascites)increased to ~ 1100-1000 ml/day. Abdomen became more
distended concerning for ascites. Diet was changed to 2gm sodium
and Lasix 20mg qd was started on [**5-1**] for 3 days.
PT evaluated him and declared him safe for discharge to home. He
was discharged and scheduled to f/u with Drs [**Last Name (STitle) **] and [**Name5 (PTitle) 497**]
on [**5-4**].
Medications on Admission:
albuterol, Xanax, Reyataz, Truvada, Nizoral, levothyroxine,
lisinopril, methadone, omeprazole, oxycodone, Isentress, Norvir,
Androderm, and NPH insulin
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
2. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
5. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): decrease to 15ml 3x/day when Rifaximin available.
you should have2-3 stools/day. if greater than 4 stools,
decrease to 15ml 3x/day.
Disp:*1000 ml* Refills:*2*
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. levothyroxine 150 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: f/u with Dr. [**Last Name (STitle) **] [**5-4**] for further dosing.
Disp:*10 Tablet(s)* Refills:*0*
12. NPH insulin human recomb 100 unit/mL Suspension Sig:
Seventeen (17) units Subcutaneous once a day.
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous at bedtime.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1)
Transdermal once a day.
16. methadone 10 mg Tablet Sig: Four (4) Tablet PO three times a
day: for pain.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] VNA
Discharge Diagnosis:
HCC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you have:
fever (101 or greater), chills, nausea, vomiting, jaundice,
increased abdominal pain, increased abdominal distension,
incision redness or bleeding.
You will take Lasix 20mg daily for the next 3 days.
Weigh yourself EVERY DAY. Write weight down on paper. Bring
record of weights to next appointment with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if your weight increases
by 2 pounds in a day.
check your blood sugar prior to meals and write down results.
follow up with your PCP
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2103-5-4**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2103-5-4**] 10:40
Completed by:[**2103-5-3**]
|
[
"242.00",
"571.5",
"572.3",
"V58.67",
"300.00",
"287.5",
"272.0",
"070.54",
"458.29",
"250.00",
"356.9",
"307.9",
"V08",
"401.9",
"155.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.22"
] |
icd9pcs
|
[
[
[]
]
] |
5882, 5937
|
2006, 3944
|
283, 337
|
5985, 5985
|
1386, 1983
|
6790, 7125
|
1335, 1367
|
4146, 5859
|
5958, 5964
|
3970, 4123
|
6136, 6767
|
233, 245
|
365, 1018
|
6000, 6112
|
1040, 1185
|
1201, 1319
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,415
| 158,269
|
40285+40286
|
Discharge summary
|
report+report
|
Admission Date: [**2122-8-1**] Discharge Date: [**2122-8-13**]
Date of Birth: [**2060-12-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 19859**]
Chief Complaint:
Multiple colon polyps not amenable to colonoscopic resection
Major Surgical or Invasive Procedure:
[**2122-7-31**]:
1. Laparoscopic assisted total abdominal colectomy ileorectal
anastomosis.
2. Umbilical hernia repair.
3. Rigid sigmoidoscopy.
4. Bilateral ureteric stents (placed by urology team).
[**2122-8-2**]:
1. Exploratory laparotomy.
2. Resection of ileorectal anastomosis.
3. Redo ileorectal anastomosis.
4. Flexible sigmoidoscopy.
History of Present Illness:
The patient is a 61-year-old gentleman who underwent a
colonoscopy which demonstrated 20 large adenomatous polyps
within the colon. These polyps were
so large that they were not amenable to colonoscopic resection.
He expressed his desire to proceed with surgical intervention to
address these colonic polyps.
Past Medical History:
Anemia, iron deficiency
Inguinal hernia, s/p repair with mesh [**2122-7-3**]
Colonic adenoma
Obesity, morbid
Thyroiditis - chronic lymphocytic
Atrial fibrillation - on chronic coumadin
Hypertension
COPD
Hyperlipidemia
Sleep Apnea
Social History:
Lives alone, smoked 1 ppd x 30 years, hx of alcoholism 20 years
ago, no IVDU
Family History:
Family History Of Ulcerative Colitis
Physical Exam:
Upon Discharge:
Vitals - 98.6 97.9 69 124/54 20 96%RA
Gen - AAOx3, in no apparent distress
CV - RRR +S1/S2
Resp - CTAB
Abd - soft, mildly tender to deep palpation per-incisionally,
nondistended, +BS, no rebound/rigidity/guarding, no palpable
masses, VAC in place
Inc - VAC in place to good suction @125 mmHG, no leaks,
draininge serosanguinous output
Ext - varicosities noted, no edema/cyanosis/clubbing
Pertinent Results:
OPERATIVE PATHOLOGY ([**2122-7-31**]):
1. Omentum (A-C) - Mature adipose tissue.
2. Total abdominal colon, colectomy (D-BH) - Twenty-seven
adenomas, ranging from 0.3 - 4.7 cm, two with focal high-grade
dysplasia; no invasive adenoma identified. One serrated sessile
adenoma. Unremarkable terminal ileum and vermiform appendix.
Five unremarkable lymph nodes.
3. Hernia sac ([**Hospital1 **]) - Fibroadipose tissue consistent with hernia
sac.
CT ABDOMEN/PELVIS AND CHEST([**2122-8-2**]):
1. Exam is severely limited due to patient body habitus. Foci
of air and
hyperattenuation traveling away from the axis of the bowel at
the level of the ileorectal anastamosis is highly suspicious for
a leak. There is inferior extension of the extravasated contrast
and gas containing material into the right inguinal canal.
2. Marked gastric distention. Multiple dilated proximal small
bowel loops with change in caliber distally, although an abrupt
transition point is not identified. Findings could be related to
ileus, however a partial small bowel obstruction cannot be
excluded.
3. Limited evaluation of the distal pulmonary arterial
branches, however, no central or segmental pulmonary
thromboembolic disease. No pulmonary arterial hypertension or
right ventricular strain.
5. Bilateral basilar airspace disease may represent
atelectasis, however
infectious consolidation is difficult to exclude.
OPERATIVE PATHOLOGY ([**2122-8-2**]):
Ileorectal anastomosis, excision (A-B) - Viable intestinal
tissue with acute serositis.
CHEST X-RAY ([**2122-8-3**]):
Lung volumes remain quite low with most severe atelectasis at
the base in both lower lungs, slightly worse today on the left
than it was yesterday. There has been some improvement in mild
pulmonary vascular congestion, but there is no pulmonary edema.
Heart size is top normal. Pleural effusions are small if any.
No pneumothorax. Upper alimentary tube can be traced only as
far as the gastroesophageal junction, but the tip is not
visible.
Pro-BNP ([**8-4**]): [**2132**]
CT ABDOMEN/PELVIS ([**8-5**]):
1. Exam is severely limited due to patient's body habitus.
Within these
limitations, no evidence of leak of rectal contrast.
2. Rim-enhancing fluid collection with air in the anterior
abdominal wall
soft tissues extending from the right rectus to the right
scrotal sac without clear connection to bowel. This is
unchanged since [**2122-8-2**].
3. Small left pleural effusion with overlying atelectasis.
4. Gallbladder sludge.
DISCHARGE LABS:
[**2122-8-12**] 06:06AM BLOOD WBC-13.5* RBC-3.66* Hgb-9.5* Hct-30.1*
MCV-82 MCH-25.8* MCHC-31.4 RDW-17.8* Plt Ct-490*
[**2122-8-13**] 04:18AM BLOOD PT-24.6* INR(PT)-2.4*
[**2122-8-12**] 06:06AM BLOOD Glucose-106* UreaN-8 Creat-1.1 Na-137
K-4.3 Cl-102 HCO3-28 AnGap-11
[**2122-8-12**] 06:06AM BLOOD Calcium-8.1* Phos-4.3 Mg-1.9
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2122-7-31**], the patient underwent the
following procedure:
1. Laparoscopic assisted total abdominal colectomy ileorectal
anastomosis.
2. Umbilical hernia repair.
3. Rigid sigmoidoscopy.
4. Bilateral ureteric stents (placed by urology team).
The reader is referred to the Operative Note for details). After
a brief, uneventful stay in the PACU, the patient arrived on the
floor NPO, on IV fluids, with a foley catheter, JP drain, and
intermittent IV dilaudid for pain control. He was placed on
telemetry for a history of atrial fibrillation. The patient was
hemodynamically stable.
On POD#1 ([**8-1**]): His Foley catheter, JP drain, and telemetry
were maintained. He was given a clear liquid diet. Pain control
was continued with IV medications. On this day, he experienced
an episode of atrial fibrillation with rapid ventricular
response, sustained HR to 140s, which broke and resolved with 10
mg of IV lopressor. He was restarted on his home medications.
His Foley, JP drain were maintained.
On POD#2 ([**8-2**]): The patient experienced sudden-onset dyspnea,
RR 34, tachycardia to HR 130s, sever abdominal pain, and an
increase in WBC. He was transferred to the ICU for further care.
A CT scan was performed (reader referred to 'Pertinent Results'
section for full details) which raised concern for peritonitis
due to a leak from the blind end of the ileum. The patient was
emergently taken to the OR for the following procedure:
1. Exploratory laparotomy.
2. Resection of ileorectal anastomosis.
3. Redo ileorectal anastomosis.
4. Flexible sigmoidoscopy.
After a brief stay in the recovery room, he returned to the ICU.
He was NPO, on IV fluids, on a diltiazem drip for atrial
fibrillation, with a Foley catheter, JP drain, and NG tube in
place. He was placed on IV zosyn for antibiotic coverage. A PICC
line was also placed on this day. A dilaudid PCA was provided
for effective pain control.
On POD#[**2-5**] ([**8-3**]): The patient was weaned off the diltiazem drip
on this day, and transitioned successfully to IV metoprolol
q6hours. Pain was well controlled with his PCA. NGT, foley, and
JP drains were maintained. In the evening, the patient was
transferred out of the ICU and onto the general surgical floor.
On POD#[**3-9**] ([**8-4**]): The patient experienced an episode of atrial
fibrillation with rapid ventricular response, HR sustained in
140s, SBP 110-120s. This resolved with 10mg of IV lopressor. His
standing dose was increased to IV lopressor 10mg q4H thereafter.
His pain remained well-controlled with a PCA. NGT, JP drain, and
Foley catheter were maintained. PT and OT were consulted and
began following the patient.
On POD#[**4-9**] ([**8-5**]): The NGT was removed on this day, and the
patient was transitioned to clear liquids for diet, which he
tolerated well. He was placed on home PO meds (both for home
medications) but a PCA was maintained for pain control. On this
day, a CT abdomen/pelvis was obtained (reader referred to
'Pertient Results' section for details).
On POD#[**5-11**] ([**8-6**]): The patient was permitted to advance diet as
tolerated to regular diet. He had good pain control with a PCA.
On POD#[**6-11**] ([**8-7**]): The patient was given Ensure supplementation
with his diet, and encouraged to eat. He was seen by Physical
Therapy. He was given his home medications as usual, and had
pain control with a PCA.
On POD#[**7-13**] ([**8-8**]): On this day, he was strongly encouraged to
ambulate and eat a regular diet with Ensure supplementation. He
was weaned off oxygen. He was given all oral home medications.
He was transitioned to oral medications for pain control. He
tolerated this change well. His dressings were changed
regularly. At this time, his JP drain continued to be
maintained, but was noted to have decreasing amounts of output
with each passing day. Erythromycin and reglan were discontinued
on this day due to increased bowel movements.
On POD#[**8-14**] ([**8-9**]): On this day, he was continued on regular diet
with Ensure supplementation, and metamucil wafers were added to
his regimen. He ambulated with nursing assistance. His JP drain
was removed, all staples removed from his incision, and a wound
VAC was placed. He continued to have good pain control with oral
medications, and continued his home medications as usual.
On POD#[**9-14**] and POD#[**10-16**] ([**8-10**] and [**8-11**]): He was continued on
regular diet with Ensure, metamucil wafers. Imodium was started,
and reduced the frequency of his frequent bowel movements. His
VAC was maintained. He was continued on his usual home
medications.
On POD#[**11-16**] AND POD#13/11 ([**8-12**] and [**8-13**]) the patient was started
on opium and lomotil in addition to the prior agents to slow his
bowel movements, with success. He was continued on a regular
diet with Ensure supplementation. He ambulated to the bathroom
with assistance. His VAC was changed on [**8-12**] and maintained on
[**8-13**]. He was continued on his home medications as usual.
Throughout his hospital stay, vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
Electrolytes were routinely followed, and repleted when
necessary. The patient's white blood count and fever curves were
closely watched for signs of infection. Wound care was performed
regularly and thoroughly. The patient's blood sugar was
monitored throughout his stay; insulin dosing was adjusted
accordingly. The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Combivent 18 mcg-103 mcg/actuation Aerosol Inhaler 2 puffs(s)
Ecotrin Low Strength 81 mg daily
Endocet 7.5 mg-325 mg tablet [**12-8**] tab q 4h PRN
Pulmicort Flexhaler 180 mcg 1 puff [**Hospital1 **]
diltiazem SR 240 mg Cap
folic acid 3 mg daily
furosemide 80 mg Tab daily (was d/c'd recently for hypotension)
levothyroxine 25 mcg
metoprolol succinate ER 200 mg [**Hospital1 **]
ranitidine 150 mg QHS
warfarin 5 mg daily
ASA 81mg qd
valsartan 160 mg qd
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever/pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
3. Albuterol-Ipratropium [**12-8**] PUFF IH Q6H:PRN sob
4. Aspirin 81 mg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
Hold for SBP<100, P<60.
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Loperamide 2 mg PO QID
8. Metoprolol Succinate XL 200 mg PO BID
Hold for SBP<100, P<60.
9. Psyllium Wafer [**12-8**] WAF PO TID
10. Opium Tincture 5 DROP PO BID
11. Miconazole Powder 2% 1 Appl TP TID:PRN groin/pannus
irritation
12. OxycoDONE (Immediate Release) 5-10 mg PO Q4H pain
Please hold for oversedation or RR < 12.
13. Ranitidine 150 mg PO DAILY
14. Warfarin 2 mg PO DAILY16
15. Domeboro 1 PKT TP [**Hospital1 **]
Please apply domeboro soaks to buttox
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Multiple colon polyps not amenable to colonoscopic resection.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for surgical
evaluation and treatment of your multiple colon polyps not
amenable to colonoscopic resection. You have done well in the
post operative period and are now safe to complete your recovery
at an extended care rehabilitation facility with the following
instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-16**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Wound VAC care:
*Please maintain the wound VAC with regular (every 2 day)
changes
*Please use a standard VAC black sponge in the wound
*The VAC should always be placed to good suction at 125 mmHg,
with no leaks
*Please check the VAC regularly for any leaks or defects
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or output from the VAC.
*You may shower, gently pat the area dry.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2122-9-30**] 2:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING
Date/Time:[**2122-9-30**] 2:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) 611**]
Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2122-9-30**] 3:50
Please call to schedule a follow up appointment with Dr. [**Last Name (STitle) **]
by calling one of the following phone number:
[**Hospital1 **]
[**Street Address(2) 34126**]
[**Location 1268**], [**Numeric Identifier 26374**]
Phone: [**Telephone/Fax (1) 88393**]
--- OR ---
[**Hospital1 **]
[**Location (un) 4363**]
[**Location (un) 86**], [**Numeric Identifier 4364**]
Phone: [**Telephone/Fax (1) 2284**]
Completed by:[**2122-8-13**] Admission Date: [**2122-8-19**] Discharge Date: [**2122-8-27**]
Date of Birth: [**2060-12-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Feculent abdominal wound drainage
Major Surgical or Invasive Procedure:
[**8-20**]: PICC line placement
History of Present Illness:
Pt is 61 y/o morbidly obese M who is s/p total abdominal
colectomy with ileo-rectal anastomosis for colon polyps 3 weeks
ago complicated by anastomotic leak requiring take back to OR
for
re-do of anastomosis who now presents with concern for
enterocutaneous fistula after he was noted to have feculent
drainage from his abdominal wound which was being managed with a
VAC dressing at his rehab facility yesterday. He denies fevers,
chills, or abdominal pain. He states that he has continued to
have a poor appetite and did have occasional episodes of nausea
and bloating with small volume emesis. Pt did feel that his
loose bowel movements were improving in terms of quantity and
consistency.
Past Medical History:
PMH:
Atrial fibrillation, COPD, HTN, morbid obesity, HLD, OSA, Iron
deficiency anemia, colon polyps, chronic lymphocytic thyroiditis
PSH:
[**6-/2822**] RIH repair with mesh
[**2122-7-31**] Lap assisted total abdominal colectomy, umbilical hernia
repair, rigid sigmoidoscopy
[**2122-8-2**] Exploratory laparotomy, resection of ileorectal
anastamosis, redo ileorectal anastamosis, flexible sigmoidoscopy
Social History:
Lives alone (was at rehab prior to this admission), smoked 1 ppd
x 30 years, h/o alcoholism 20 years ago, no IVDU
Family History:
Family History Of Ulcerative Colitis
Physical Exam:
ADMISSION EXAM
T 97.9 P 97 BP 104/53 R 29 SaO2 97% RA
Gen: no acute distress
Heent: no scleral icterus
Lungs: clear
Heart: irregular rate and rhythm
Abd: soft, nontender, nondistended, no guarding or rigidity,
abdominal wound with feculent drainage, no large defects in
fascia
Extrem: no edema
DISCHARGE EXAM
Gen: no acute distress
Heent: no scleral icterus
Lungs: clear
Heart: irregular rate and rhythm
Abd: soft, nontender, nondistended, wound VAC in place, has some
skin breakdown in pannus crease- c/d/i
Back: skin excoriations in lower back
Pertinent Results:
ADMISSION LABS
[**2122-8-19**] 05:00PM PT-22.0* PTT-44.5* INR(PT)-2.1*
[**2122-8-19**] 05:00PM PLT COUNT-401
[**2122-8-19**] 05:00PM NEUTS-77.7* LYMPHS-13.4* MONOS-7.0 EOS-1.7
BASOS-0.4
[**2122-8-19**] 05:00PM WBC-8.5 RBC-3.76* HGB-9.7* HCT-30.5* MCV-81*
MCH-25.9* MCHC-32.0 RDW-17.3*
[**2122-8-19**] 05:00PM ALBUMIN-2.4*
[**2122-8-19**] 05:00PM proBNP-1864*
[**2122-8-19**] 05:00PM LIPASE-35
[**2122-8-19**] 05:00PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-78 TOT
BILI-0.6
[**2122-8-19**] 05:00PM GLUCOSE-117* UREA N-20 CREAT-1.0 SODIUM-130*
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-28 ANION GAP-10
[**2122-8-19**] 05:09PM LACTATE-1.5
CT Abdomen/Pelvis [**2122-8-19**]
IMPRESSION:
1. Probable enterocutaneous fistula extending from the lower
aspect of the anterior abdominal wound through thickened
anterior abdominal wall fascia, probably connecting at the site
of the ileocolic anastomosis with disrupted appearance of the
suture material in this area. No drainable collection with
phlegmonous change in the left lower quadrant anteriorly.
2. Air and fluid traversing the right lower anterior abdominal
wall into the right inguinal canal and scrotum is slightly
improved from the previous study, though superinfection would be
difficult to exclude.
3. The anterior bladder is tented towards the right lower
quadrant with air collecting anteriorly. This is likely just
post-surgical change with air from recent Foley catheterization,
but correlation with history of instrumentation is recommended.
DISCHARGE LABS
[**2122-8-27**] 06:00AM BLOOD WBC-6.3 RBC-3.35* Hgb-8.6* Hct-27.9*
MCV-83 MCH-25.6* MCHC-30.8* RDW-18.5* Plt Ct-276
[**2122-8-27**] 06:00AM BLOOD PT-15.8* PTT-36.7* INR(PT)-1.5*
[**2122-8-27**] 06:00AM BLOOD Glucose-134* UreaN-16 Creat-0.5 Na-135
K-4.0 Cl-103 HCO3-26 AnGap-10
Brief Hospital Course:
61 year old morbidly obese male who is s/p total abdominal
colectomy with ileo-rectal anastomosis for colon polyps
complicated by anastomotic leak requiring take back to OR for
re-do of anastomosis presented with an enterocutaneous fistula.
Upon admission, VAC was placed over the patient's abdominal
wound and a PICC was placed for TPN. He was started on zosyn and
octreotide to decrease wound output. A Foley catheter was placed
upon admission, and was continued upon discharge.
On hospital day 2, patient's home aspirin and Coumadin were
restarted. His INR was checked throughout his hospitalization,
and Coumadin titrated accordingly. He was also continued on his
home anti-hypertensives and COPD and thyroid medications.
Wound care followed the patient throughout his hospitalization
for management of excoriations on his back and perirectally.
Physical and occupational therapy were consulted to work with
patient to prevent deconditioning.
Patient's wound VAC was changed every three days and output was
continually monitored. Output was seen to be decreasing.
Throughout the stay, patient remained afebrile, and did not have
leukocytosis. Zosyn was subsequently discontinued on hospital
day 7. At the time of discharge to [**Hospital 100**] Rehab, patient was
afebrile, feeling well, had decreased drainage from abdominal
wound. He had a Foley in place, and was able to ambulate with
minimal assistance.
Medications on Admission:
1. Warfarin 2 mg PO DAILY16
2. Aspirin 81 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
6. Albuterol-Ipratropium [**12-8**] PUFF IH Q6H:PRN sob
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Loperamide 2 mg PO QID
9. Psyllium Wafer [**12-8**] WAF PO TID
10. Opium Tincture 5 DROP PO BID
11. Miconazole Powder 2% 1 Appl TP TID:PRN groin/pannus
irritation
12. OxycoDONE (Immediate Release) 5-10 mg PO Q4H pain
13. Ranitidine 150 mg PO DAILY
14. Domeboro soaks 1 PKT TP [**Hospital1 **] to buttox
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Albuterol-Ipratropium [**12-8**] PUFF IH Q6H:PRN wheezing
4. Aspirin 81 mg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
Please hold for SBP<110, HR<60
6. Domeboro 1 PKT TP [**Hospital1 **]
please appy domeboro soaks to buttocks
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Loperamide 2 mg PO QID
10. Metoprolol Succinate XL 150 mg PO BID
Please hold for SBP<110, HR<60
11. Miconazole Powder 2% 1 Appl TP TID:PRN pannus/groin
irritation
12. Octreotide Acetate 200 mcg SC Q8H
13. Opium Tincture 5 DROP PO BID
14. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
15. Psyllium Wafer [**12-8**] WAF PO TID
[**Month (only) 116**] not refuse
16. Ranitidine 150 mg PO DAILY
17. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Feculent abdominal wound discharge
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Dear Mr [**Known lastname 1356**],
You were admitted to the hospital for management of discharge
from your abdominal wound. You have recovered well and are now
ready to continue your recovery at an extended care
rehabilitation facility.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-16**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Wound VAC care:
*Please maintain the wound VAC with regular (every 3 day)
changes
*Please use a standard VAC black sponge in the wound
*The VAC should always be placed to good suction at 125 mmHg,
with no leaks
*Please check the VAC regularly for any leaks or defects
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or output from the VAC.
*You may shower, gently pat the area dry.
Foley Care
You are being discharged with a Foley urinary catheter in place.
*Please empty the bag often, and keep a record of the output
*Please discuss with your primary care doctor when you can have
the catheter removed
Thank you for allowing us to participate in your care.
Followup Instructions:
Please call to schedule a follow up appointment with Dr. [**Last Name (STitle) **]
by calling one of the following phone numbers:
[**Hospital1 **]
[**Street Address(2) 34126**]
[**Location 1268**], [**Numeric Identifier 26374**]
Phone: [**Telephone/Fax (1) 88393**]
--- OR ---
[**Hospital1 **]
[**Location (un) 4363**]
[**Location (un) 86**], [**Numeric Identifier 4364**]
Phone: [**Telephone/Fax (1) 2284**]
Completed by:[**2122-8-27**]
|
[
"E878.6",
"998.6",
"567.29",
"427.31",
"V85.44",
"245.2",
"V15.82",
"428.32",
"997.49",
"278.01",
"428.0",
"244.9",
"272.4",
"V45.72",
"401.9",
"E878.2",
"496",
"553.1",
"211.3",
"327.23",
"280.9",
"V58.61",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"93.56",
"48.23",
"45.62",
"46.94",
"45.93",
"38.91",
"45.24",
"99.15",
"53.43",
"45.81",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
22771, 22837
|
19821, 21237
|
16026, 16059
|
22916, 22916
|
17985, 19798
|
24633, 25075
|
17360, 17399
|
21886, 22748
|
22858, 22895
|
21263, 21863
|
23074, 24610
|
4413, 4741
|
17414, 17966
|
15953, 15988
|
1484, 1879
|
16087, 16784
|
22931, 23050
|
16806, 17212
|
17228, 17344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,981
| 142,138
|
36044
|
Discharge summary
|
report
|
Admission Date: [**2182-2-12**] Discharge Date: [**2182-2-15**]
Date of Birth: [**2134-9-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Augmentin
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
asiration pneumonia
Major Surgical or Invasive Procedure:
Removal of esophageal stent
Attempted broncheal stent placement
History of Present Illness:
47F with non-small cell lung cancer
(NSCLC) stage IIIA s/p chemotherapy, XRT complicated by
development of transesophageal fistula. Patient is s/p
esophageal
stent and PEG tube placement in 11/[**2181**]. Patient had multiple
admission for aspiration pneumonia with prior culture growing
pseudomonas. Patient was on a course of Levofloxacin and flagyl.
Patient was admitted most recently to OSH with increasing SOB,
fever during antibiotic course. CXR on admission showed
bilateral pleural effusion and consolidation at right lung base.
Patient was started on broad spectrum antibiotics for presumed
aspiration pneumonia then switch to Ceftazidime and flagyl when
sputum grew out pseudomonas resistant to Levofloxacin. Due to
suspicion of stent leak causing pneumonia, a barium swallow was
ordered. The swallow study showed tracheoesophageal fistula
with
leakage of barium into left bronchus. CT chest showed
pericardial
effusion, collapsed right lower lobe, consolidation right lower
lobe, and bilateral pleural effusions. Empyema was suspected and
IR placed a pigtail and drained pleural fluid which was negative
for organisms and malignant cells. Pigtail was removed prior to
transfer to [**Hospital1 18**]. Bronchoscopy was performed due to concern of
reoccurance and found mass in bilateral main bronchus. After
discussion with oncology and gastroenterology a bronchial stent
placement was recommended to prevent further aspiration and
patient was transferred to [**Hospital1 18**] for placement of stent.
Past Medical History:
NSCLC, s/p chemo, xrt, h/o
tracheoesophageal fistula, h/o aspiration pneumonia, migraine,
COPD, s/p septoplasty for chronic sinusitis [**2169**], sternal fx in
childhood, s/p excision of left mandibular gland for recurrent
sialodenitis [**2178**], h/o heavy mentrual bleeding with iron
deficiency anemia
Social History:
Ex-smoker, D/C'd on [**12-1**], 30pack year
Occupation: food [**Last Name (un) 12003**] industry
Married, Lives With family
No ETOH:
No Exposure: Asbestos
Family History:
Mother - Breast cancer
Father - died from cardiac issues
Siblings - sister: hepatitis C
Physical Exam:
97.2 108 104/69 17 100%
NAD, AOX3
BRONCHI B/L
RRR
ABD SOFT, NT/ND
EXT WNL
Pertinent Results:
[**2182-2-12**] 10:08PM BLOOD WBC-11.8* RBC-3.39* Hgb-8.7* Hct-27.2*
MCV-80* MCH-25.5* MCHC-31.8 RDW-18.2* Plt Ct-613*
[**2182-2-12**] 10:08PM BLOOD PT-16.1* PTT-29.1 INR(PT)-1.4*
[**2182-2-12**] 10:08PM BLOOD Glucose-89 UreaN-5* Creat-0.4 Na-137
K-5.1 Cl-99 HCO3-30 AnGap-13
[**2182-2-12**] 10:08PM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0
[**2182-2-15**] 04:24AM BLOOD WBC-20.6* RBC-2.99* Hgb-7.6* Hct-23.8*
MCV-80* MCH-25.4* MCHC-31.9 RDW-17.8* Plt Ct-718*
[**2182-2-15**] 04:24AM BLOOD Glucose-127* UreaN-7 Creat-0.4 Na-135
K-4.6 Cl-100 HCO3-30 AnGap-10
[**2182-2-15**] 04:24AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.9
[**2182-2-15**] 04:45AM BLOOD Type-ART pO2-149* pCO2-48* pH-7.42
calTCO2-32* Base XS-6
[**2182-2-15**] 12:13AM BLOOD Type-ART Temp-37.0 Rates-/20 PEEP-5
FiO2-40 pO2-94 pCO2-49* pH-7.41 calTCO2-32* Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2182-2-15**] 04:45AM BLOOD Lactate-0.8
[**2182-2-15**] 04:45AM BLOOD freeCa-1.21
Brief Hospital Course:
47F lung ca c/b transesophageal s/p esophageal stent w/
persistent leak and aspiration pneumonia was admitted on [**2-12**].
She was placed on antibiotics, made NPO and taken to the OR for
Rigid bronchoscopy was performe on [**2-13**] and found complete
destruction of bronchus intermedius. On [**2-14**] patient was sent
for EGD to remove the esophageal stent. The esophageal stent
was removed without complications. Then an attempt was made to
place a bronchial stent. The tracheoesophageal fistula was found
to involve right main stem and bronchus intermedius and was
deeemed unable to stent or repair. At that point the procedure
was aborted and patient was sent to PACU. She was extubated
successfully in PACU then sent to SICU for further recovery.
Family and patient was approached and told the prognosis of the
patient's condition. After discussion with family and patient
hospice care was decided Patient was made DNR/DNI. Patient
will be transferred to [**State 531**] for further care.
Medications on Admission:
Albuterol 2puff q2h, Advair 250/50 1puff", flonase
1sp", zofran 4""PRN, tylenol 650"", loratadine 10',
amitriptyline
25", triamcinolone 0.1%"', sucralfate 1g""PRN, fentanyl 25mcg
q3d, motrin 600"""PRN, nexium', oxycodone 500""
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily ().
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
TID (3 times a day).
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) as needed for abdominal pain.
7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Ibuprofen 100 mg/5 mL Suspension Sig: Six Hundred (600) mg PO
Q6H (every 6 hours) as needed for pain.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 2.5-10 mg PO
q15mins as needed for pain.
Disp:*qsuff qsuff* Refills:*0*
13. Ativan 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for agitation.
Disp:*20 Tablet(s)* Refills:*0*
14. Home Oxygen Therapy
Titrate to O2sat > 90%
Discharge Disposition:
Extended Care
Discharge Diagnosis:
NSCLC, s/p chemo, xrt, h/o tracheoesophageal fistula, h/o
aspiration pneumonia, migraine, COPD, s/p septoplasty for
chronic sinusitis [**2169**], sternal fx in childhood, s/p excision of
left mandibular gland for recurrent sialodenitis [**2178**], h/o heavy
mentrual bleeding with iron
deficiency anemia
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if experience:
-Fever> 101 or chills, increased cough, shortness of breath,
sputum production, chest pain
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] as directed [**Telephone/Fax (1) 7769**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2182-2-15**]
|
[
"530.84",
"162.8",
"482.1",
"507.0",
"496",
"423.9",
"V44.1",
"478.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"98.02",
"33.22",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6256, 6271
|
3597, 4603
|
308, 374
|
6619, 6628
|
2639, 3574
|
6847, 7076
|
2438, 2530
|
4881, 6233
|
6292, 6598
|
4629, 4858
|
6652, 6824
|
2545, 2620
|
249, 270
|
402, 1920
|
1942, 2248
|
2264, 2422
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,654
| 180,810
|
45984
|
Discharge summary
|
report
|
Admission Date: [**2118-12-28**] Discharge Date: [**2119-1-3**]
Date of Birth: [**2063-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Type A dissection
Major Surgical or Invasive Procedure:
[**2118-12-29**] Bentall procedure with a St. [**Male First Name (un) 923**] 21-mm composite
valve
graft with coronary button reimplantation. Valve data is the
following: Reference #[**Serial Number 97893**] #[**Serial Number 97894**].
Replacement of ascending aorta and hemiarch with a 24-mm
Vascutek Dacron tube graft using deep hypothermic circulatory
arrest rest. Graft data is the following: Catalog #[**Numeric Identifier 97895**],
lot #[**Serial Number 97896**], serial #[**Serial Number 97897**]
History of Present Illness:
This 55 year old white male developed chest pressure while
walking his dog. He summoned EMS who noted a 20 point
difference between left and right arm pressures. In the ED he
was stable and pain free and a CT showed a Type A dissection.
Past Medical History:
hypertension
hyperlipidemia
s/p cholecystectomy
s/p Achilles tendon repair
Social History:
Lives with:girlfriend-[**Name (NI) **] ([**Telephone/Fax (1) 97898**]
[**Name2 (NI) **]t: daughter [**Name (NI) 97899**] Phone #([**Telephone/Fax (1) 97900**]
Occupation:locksmith
Family History:
Father had a Type A dissection
Physical Exam:
Pulse:60 SR Resp: 15 O2 sat:96% on RA
B/P Right:110/50 Left:SBP90
General:
Skin: Dry [x] intact [x]
HEENT: R pupil 3-4mm L pupil 2-3mm EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] distant heart sounds unable to assess murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: cool, hands dusky bilat L>R, radial pulses 1+L 2+R
Edema none Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:1+
DP Right:1+ Left:2+
PT [**Name (NI) 167**]:Tr-1+ Left:1+
Radial Right:[**2-6**]+ Left:Tr-1+
Carotid Bruit none
Pertinent Results:
[**2118-12-28**] 08:40PM BLOOD WBC-9.4 RBC-5.51 Hgb-16.0 Hct-46.7 MCV-85
MCH-29.0 MCHC-34.2 RDW-13.0 Plt Ct-216
[**2119-1-1**] 03:09AM BLOOD PT-15.9* PTT-29.1 INR(PT)-1.4*
[**2118-12-31**] 12:14AM BLOOD PT-15.9* PTT-28.1 INR(PT)-1.4*
[**2118-12-30**] 01:37AM BLOOD PT-14.1* PTT-28.3 INR(PT)-1.2*
[**2118-12-29**] 04:46AM BLOOD PT-15.4* PTT-36.6* INR(PT)-1.3*
[**2118-12-29**] 03:30AM BLOOD PT-16.3* PTT-38.5* INR(PT)-1.4*
[**2118-12-28**] 08:40PM BLOOD Glucose-98 UreaN-31* Creat-1.5* Na-144
K-3.9 Cl-102 HCO3-29 AnGap-17
[**2118-12-29**] 09:27AM BLOOD %HbA1c-5.5 eAG-111
[**2119-1-2**] 12:40PM BLOOD WBC-10.2 RBC-3.63* Hgb-10.6* Hct-32.9*
MCV-91 MCH-29.3 MCHC-32.4 RDW-13.7 Plt Ct-261
[**2119-1-3**] 07:15AM BLOOD PT-24.0* INR(PT)-2.3*
[**2119-1-3**] 07:15AM BLOOD Glucose-101* UreaN-36* Creat-1.1 Na-141
K-4.0 Cl-106 HCO3-27 AnGap-12
[**2118-12-29**] 04:47AM BLOOD ALT-28 AST-83* LD(LDH)-425* CK(CPK)-301
AlkPhos-48 Amylase-56 TotBili-1.3
[**2118-12-29**] 04:47AM BLOOD Lipase-66*
[**2119-1-3**] 07:15AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.3
[**2118-12-29**] 09:27AM BLOOD %HbA1c-5.5 eAG-111
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.4 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: *0.24 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: *4.7 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated ascending aorta Mildly dilated
descending aorta. Ascending aortic intimal flap/dissection..
Aortic arch intimal flap/dissection. Descending aorta intimal
flap/aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). Mechanical
aortic valve prosthesis (AVR). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: No pericardial effusion.
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. The descending
thoracic aorta is mildly dilated. A mobile density is seen in
the ascending aorta consistent with an intimal flap/aortic
dissection. A mobile density is seen in the aortic arch
consistent with an intimal flap/aortic dissection. The
dissection flap extends through the arch to descending aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. Trace
central aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
POST-CPB:
There is a bileaflet mechanical valve in the aortic position.
The valve is well-seated with normal leaflet motion. There are
the normal washing jets. There are no apparent paravalvular
leaks. The peak gradient across the aortic valve is 24mmHg, the
mean gradient is 10mmHg with a cardiac output of 9L/min. There
is echogenic material in the root and ascending aorta,
consistent with tube graft.
The LV systolic function is preserved, estimated EF>55%. The RV
systolic function remains normal.
The dissection flap seen in the distal arch and descending aorta
appear grossly unchanged from pre-op.
Sinus rhythm. Borderline left ventricular hypertrophy.
Intraventricular
conduction delay with T wave inversions in leads II and aVF.
Compared to
the previous tracing QRS duration has increased and T wave
changes in
leads III and aVF are new.
TRACING #3
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 152 108 380/429 24 -13 -26
Brief Hospital Course:
Following diagnosis he was taken emergently to the Operating
Room where a Bental procedure (21mm St. [**Male First Name (un) 923**] valved conduit) and
grafting of the hemi arch (24mm Gelweave) were performed under
deep hypothermic circulatory arrest (25minutes).
He weaned from bypass on Neo Synephrine and remained stable. He
awoke, weaned from the ventilator and was extubated. He had
some postoperative confusion which cleared and was started on
Lopressor and diuresed towards his preoperative weight. CTs and
temporary pacing wires were removed per protocols. He was
anticoagulated for his mechanical valve. He was seen by Physical
Therapy for mobility and strength. he deeloped atrial
fibrillation for a brief time after tyransfer to the floor and
converted to sinus rhythm without intervention. Amiodarone was
begun orally.
Dr. [**First Name (STitle) 679**], his primary care physician, [**Name10 (NameIs) 18142**] to manage his
anticoagulation. Followup appointments were given and discharge
medications, restriction and precautions discussed with the
patient prior to discharge on [**1-3**].
Medications on Admission:
toprol XL
lisinopril
simvastatin
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
3. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): Two tablets(400mg) twice a day until [**1-9**] then
decrease to two tablets once a day, until [**1-16**] then decrease to
one tablet once a day.
Disp:*80 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. warfarin 5 mg Tablet Sig: goal INR 2.5-3 Tablets PO once a
day: goal INR 2.5-3 - dose to vary based on results - Dr [**First Name (STitle) 679**] to
dose .
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): 75 mg three times a day .
Disp:*270 Tablet(s)* Refills:*2*
8. lisinopril 5 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:
Type A aortic dissection
s/p repair of Type A dissection
post operative atrial fibrillation
Hyperlipidemia
Bell's Palsy
s/p cholecytectomy
s/p knee surgery
hypertension
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) 914**]([**Telephone/Fax (1) 170**]) on [**2119-2-13**] at 1:15pm
Primary Care: Dr [**First Name (STitle) 679**]([**Telephone/Fax (1) 682**]on [**1-25**]/at 10:45am - he will
refer you to a cardiologist
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: mechanical aortic valve
Goal INR 2.5-3.0
First draw [**1-4**]
Results to:Dr. [**First Name (STitle) 679**]
phone:[**Telephone/Fax (1) 682**] fax:[**Telephone/Fax (1) 25380**]
Completed by:[**2119-1-3**]
|
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12,951
| 180,137
|
6205
|
Discharge summary
|
report
|
Admission Date: [**2141-2-19**] Discharge Date: [**2141-2-25**]
Date of Birth: [**2092-12-14**] Sex: M
Service:
CHIEF COMPLAINT: Shortness of breath and right sided
weakness.
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old
male with a history of hepatitis B, Child's A cirrhosis and
hepatocellular carcinoma who had been followed and treated by
Dr. [**First Name (STitle) **] in [**Hospital **] Clinic. He presented with right arm
and right leg weakness, dyspnea, hemoptysis and several hours
of pleuritic chest pain. In route to the Emergency
Department, he had witnessed tonoclonic seizures and was
stabilized at [**Hospital3 **] and transferred to [**Hospital1 346**]. The patient was loaded on Dilantin
in the Emergency Department and transferred to the Medical
Intensive Care Unit. There he was found to have a pulmonary
embolus and some hemorrhage around new brain metastases. An
IVC filter was placed to protect against new pulmonary emboli
but no deep vein thromboses were found in the lower
extremities. The patient also received Decadron for brain
metastases and was transferred to the [**Hospital Ward Name 516**] for
radiation treatment. Currently, the patient felt that his
shortness of breath and chest pain are improving. The
weakness on his right side is subjectively worse. Otherwise,
the patient had been diagnosed with hepatitis and liver
cancer in [**2139**], after routine screening. He has no ethanol
history. He has a mother with hepatitis B.
On review of systems, the patient has no hemoptysis or bright
red blood per rectum. No nausea or vomiting. He does
complain of sleep disturbance and confusion over the past
week prior to admission.
PAST MEDICAL HISTORY:
1. Hepatitis B and Child's A cirrhosis.
2. Portal hypertension.
3. Hepatocellular carcinoma with known lung metastases.
MEDICATIONS ON ADMISSION:
1. Celebrex 200 mg p.o. once daily.
2. Cholestyramine once daily.
3. Epivir 100 mg p.o. once daily.
4. Propranolol 20 mg p.o. twice a day.
ALLERGIES: Tylenol and Aspirin which both lead to a rash.
FAMILY HISTORY: The patient's mother has hepatitis B as well
as his maternal uncle who also died of liver cancer.
SOCIAL HISTORY: The patient is married and lives in [**Hospital1 392**]
with his family. He denies any alcohol use. He moved to the
United States in the [**2117**].
PHYSICAL EXAMINATION: On admission, in general, the patient
is well appearing pleasant male in no apparent distress.
Head, eyes, ears, nose and throat examination - positive
scleral icterus, moist mucous membranes. Extraocular
movements are intact. Cardiac - regular rate and rhythm, no
murmurs, rubs or gallops. Pulmonary - Bilaterally clear to
auscultation, decreased breath sounds at the bases. The
abdomen revealed positive bowel sounds, soft, nontender,
nondistended, no hepatosplenomegaly, no ascites, a scar in
the abdomen from previous liver surgery. Extremities - no
cyanosis, clubbing or edema, good pulses. Neurologically,
cranial nerves III through XII are intact. Mild asterixis.
Right are the weakest muscles on the patient's neurologic
examination which are 3 and otherwise his triceps are 4-,
biceps 4+, and the remainder of the examination is [**4-10**] except
for the right quadriceps muscles which are also [**3-11**].
LABORATORY DATA: On admission, white blood cell count 9.4,
hemoglobin 13.5, hematocrit 37.1 down from 41.7 and platelet
count 83,000. Prothrombin time was 14.2, INR 1.3. Chem7
showed sodium 138, potassium 3.9, chloride 105, bicarbonate
23, blood urea nitrogen 12, creatinine 0.9, and glucose 189.
Magnetic resonance scan of the head showed left parietal
occipital hemorrhagic metastatic lesions and a left
frontoparietal enhancing metastatic focus with mild blood
products and surrounding edema in the left frontotemporal
region. There was mild mass effect in the left lateral
ventricle without midline shift. There were no other
metastatic foci seen. CTA of the chest had also been
performed on admission which showed multiple segmental and
subsegmental left sided pulmonary emboli. There were nodular
lung parenchymal and mediastinal masses consistent with the
patient's known metastatic disease. There was occlusion of
the left lower lobe bronchus with associated atelectasis and
superimposed infectious process could not be excluded.
Given the above, the patient was managed on the [**Hospital Ward Name 516**].
He was seen by Dr. [**First Name (STitle) **] and by the radiation oncology
service for treatment of his brain metastases. During his
stay, hematology/oncology wise, for his pulmonary emboli, the
patient was managed supportively. He remained approximately
99% oxygen saturation in room air. He was not anticoagulated
given his propensity for coagulopathy with his liver disease.
Otherwise in terms of his brain metastases, the patient
received radiation treatment daily during his stay. He was
also seen by physical therapy and occupational therapy to
improve his function given his right sided deficits. In
terms of his gastrointestinal issues, the patient had mild
encephalopathy and was treated with Lactulose which was
titrated to approximately three bowel movements per day. For
question of esophageal varices, the patient was treated with
Propranolol. He was continued on Protonix. He was also
given a low protein diet to minimize any further exacerbation
of his encephalopathy. He was also given Vitamin K to
improve his coagulopathy and he was discharged on [**2141-2-26**],
in stable condition.
DISCHARGE DIAGNOSES:
1. Hepatitis B cirrhosis.
2. Hepatocellular carcinoma.
3. Pulmonary emboli.
4. Metastatic hemorrhagic brain lesions.
He was instructed to follow-up with Dr. [**First Name (STitle) **] in one to two
weeks. He was also instructed to follow-up for radiation
treatment on Monday, [**2141-2-27**], at 11:00 a.m. in the [**Hospital Ward Name 12573**]
basement of [**Hospital Ward Name 516**] where further appointments would be
set.
MEDICATIONS ON DISCHARGE:
1. Epivir 100 mg p.o. once daily.
2. Vitamin K 5 mg p.o. once daily.
3. Dilantin 100 mg p.o. three times a day.
4. Protonix 40 mg p.o. once daily.
5. Ambien 5 mg p.o. q.h.s.
6. Colace 100 mg p.o. twice a day.
7. Thorazine 25 mg p.o. three times a day.
8. Lactulose 30 ml p.o. three times a day.
9. Decadron 6 mg p.o. q6hours.
10. Propranolol 20 mg p.o. twice a day.
[**First Name11 (Name Pattern1) 396**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9758**]
Dictated By:[**Name8 (MD) 10249**]
MEDQUIST36
D: [**2141-2-26**] 11:36
T: [**2141-2-26**] 13:11
JOB#: [**Job Number 24191**]
|
[
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
[]
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] |
2104, 2203
|
5578, 6012
|
6038, 6710
|
1883, 2087
|
2395, 5557
|
150, 197
|
226, 1711
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1733, 1857
|
2220, 2372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,072
| 179,375
|
45083
|
Discharge summary
|
report
|
Admission Date: [**2171-5-12**] Discharge Date: [**2171-5-15**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Influenza Virus Vaccine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Blue foot
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, Ms. [**Known lastname 284**] is an 87 year old woman with history of
dementia and recent admission for pneumonia who presents with a
blue foot. She had recently been discharged after a
hospitalization for pneumonia. She was discovered to have a
bilateral occlusive DVT presenting as ischemia (phlegmasia
cerulea dolens) as well as a UTI, hypernatremia, and elevated
white count. CTA of the abdomen showed a non-occlusive SMA
thrombus She was started on enoxaparin but was not considered a
surgical candidate given her poor functional status. On the day
prior to transfer, palliative care was consulted regarding end
of life options for the patient, and in a meeting between Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**] of palliative care, the HCP for the patient
(information below), and a close friend of the patient, she was
made [**Name (NI) 3225**] (comfort measures only).
Past Medical History:
1. Alzheimer's dementia
2. hypertension
3. hyperlipidemia
Social History:
No tobacco, alcohol or illicits. Lives at [**Location 582**] in long term
care.
Family History:
unknown, estranged son. [**Name (NI) **] [**Name (NI) **] [**Name (NI) 2795**] is health care proxy
and very involved in her care.
Physical Exam:
VS: 96.3 ax, 128/60, 98, 18, 95% RA,
Gen: elderly, minimal speech, screams with movement, but NAD at
rest
HEENT: poor dentition, MM extremely dry, sclera anicteric, op
clear, neck supple
Heart: regular
Lungs: diminished at R base, exam limited by pt cooperation
Abd: soft, diffusely tender, no rebound/guarding, +BS, + stool
guaic
Ext: cyanotic, cool R forefoot, +edema. DP trace palp. L DP 1+.
b/l posterior calf tenderness
Skin -- sacral erythema
Pertinent Results:
[**2171-5-12**] 12:50PM PT-12.7 PTT-19.9* INR(PT)-1.1
[**2171-5-12**] 12:50PM PLT COUNT-299
[**2171-5-12**] 12:50PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
TEARDROP-OCCASIONAL
[**2171-5-12**] 12:50PM NEUTS-89.6* BANDS-0 LYMPHS-7.5* MONOS-2.4
EOS-0.2 BASOS-0.3
[**2171-5-12**] 12:50PM WBC-20.1* RBC-3.83* HGB-11.4* HCT-36.1 MCV-94
MCH-29.8 MCHC-31.6 RDW-14.0
[**2171-5-12**] 02:50PM estGFR-Using this
[**2171-5-12**] 02:50PM GLUCOSE-117* UREA N-64* CREAT-1.8*
SODIUM-157* POTASSIUM-8.3* CHLORIDE-123* TOTAL CO2-24 ANION
GAP-18
[**2171-5-12**] 03:06PM LACTATE-3.3*
[**2171-5-12**] 04:15PM URINE RBC-[**3-20**]* WBC-[**12-5**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2171-5-12**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2171-5-12**] 04:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2171-5-12**] 04:30PM LIPASE-44
[**2171-5-12**] 04:30PM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-97 TOT
BILI-0.2
[**2171-5-12**] 04:30PM GLUCOSE-110* UREA N-62* CREAT-1.7*
SODIUM-159* POTASSIUM-3.9 CHLORIDE-125* TOTAL CO2-22 ANION
GAP-16
[**2171-5-12**] 04:39PM K+-4.2
[**2171-5-12**] 09:31PM LACTATE-2.2*
.
[**2171-5-12**]: Occlusive right common femoral, superficial femoral,
and popliteal DVT. Occlusive-to-partially occlusive left greater
saphenous, common femoral, and superficial femoral DVT. Left
popliteal vein unable to be evaluated due to patient
incooperation. Of note, the concurrent CT excludes more central
venous thrombosis in the illiac vessels and IVC, through the
level of the right atrium.
.
CXR: 1. Interval development of moderate right pleural effusion.
The right middle and lower lobe consolidative changes have
improved. 2. No pneumoperitoneum is visualized.
.
AXR [**2171-5-12**]: 1. No supine evidence of free intraperitoneal air.
2. Non-obstructive bowel gas pattern is noted.
3. Possible rectal fecal impaction.
.
CT Abd/Pelv: 1. Non-occlusive non-calcified proximal SMA
atheroma resulting in less than 50% narrowing of the lumen. No
other findings to suggest acute mesenteric ischemia; however,
even with a normal CT this cannot be completely excluded.
Clinical correlation is advised. 2. Right common femoral DVT.
This can be further evaluated for extent with dedicated right
lower extremity ultrasound. 3. Right lower lobe pneumonia with
mild right lower lobe compression atelectasis and moderate to
simple right pleural effusion. 4. Multiple bilateral renal cysts
of which display a partial septal calcification on the right.
This is likely of no clinical significance given patient's age.
5. Ill-defined hypoattenuating peripheral right hepatic lesion
may represent a irregular area of parenchymal fibrosis,
persistent perfusion abnormality ([**Male First Name (un) **]) related to underlying
FNH or, less likely, atypical hemangioma.
Brief Hospital Course:
Ms. [**Known lastname 284**] is a 87yF with dementia, recent pneumonia, now
with phlegmasia cerulea dolens, abdominal pain. Prognosis
extremely poor, with ischemia/imminent infarction of right foot
+/- bowel (given abdominal exam and known non-occlusive SMA
thrombus). After a family meeting between the health care proxy
and the palliative care team, it was decided to pursue [**Known lastname 3225**]
status. The patient was transferred to an inpatient hospice
facility.
- HCP [**Name (NI) **] [**Last Name (NamePattern1) **] cell [**Telephone/Fax (1) 96363**] home [**Telephone/Fax (1) 96364**] work
[**Telephone/Fax (1) 96365**].
Medications on Admission:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Acetaminophen 325 - 650 mg PO Q6H PRN
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**]
Discharge Diagnosis:
Primary:
Phlegmasia cerulea dolens
Non-occlusive SMA thrombus
Secondary:
Alzheimer's dementia
Discharge Condition:
Stable, pain free
Discharge Instructions:
If you develop any pain, nausea, vomiting, or shortness of
breath, or any other concerning symptoms, please seek help from
your hospice provider.
Followup Instructions:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"511.9",
"451.19",
"294.10",
"276.0",
"792.1",
"276.2",
"331.0",
"401.9",
"272.0",
"584.9",
"486",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5861, 5955
|
5038, 5675
|
277, 284
|
6094, 6114
|
2045, 5015
|
6338, 6431
|
1426, 1559
|
5833, 5838
|
5976, 6073
|
5701, 5810
|
6138, 6285
|
1574, 2026
|
228, 239
|
312, 1229
|
1251, 1311
|
1327, 1410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,829
| 129,684
|
44151+58688
|
Discharge summary
|
report+addendum
|
Admission Date: [**2199-10-9**] Discharge Date: [**2199-10-22**]
Service: NEUROSURGERY
Allergies:
Captopril / Erythromycin Base / Ampicillin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
RUE weakness
Major Surgical or Invasive Procedure:
[**10-9**]: C2-C7 POSTERIOR LAMINECTOMY FUSION; C5-6 FORAMINOTOMY
History of Present Illness:
84-year-old woman had previously undergone an anterior cervical
diskectomy with carbon fiber cage at C4- C5. She initially did
well but then went onto fall and
developed subsidence of significant kyphosis. She also had
disability of the left upper extremity.
Past Medical History:
HTN
Diastolic CHF
Gout
Barrets
Polymyositis
Bell's Palsy (Rt)
Massive PE s/p Trendy procedure, IVC filter placement
TAH
Appendectomy
T4, T8 vertebroplasty [**2196-10-11**]
C4-C5 disectomy and hardware placement
3.9 cm infrarenal AAA
Recent BM biopsy from iliac crest
Social History:
40 pack year hx of tobacco, quit over 20 years ago, no
etoh/illict drug use; was living independently until recently;
now in [**Hospital 100**] Rehab after recent surgery; does not have much
family - is close with friends; good friend [**Name (NI) 2184**] [**Name (NI) 951**] is her
HCP
Family History:
mom with osteoporosis and heart disease, died at age 79; no
other history of heart disease
Physical Exam:
Discharge examination:
AOx3, continually improving motor strength of the RUE(5- on day
of dischage).
Pertinent Results:
Labs on Admission:
[**2199-10-9**] 03:19PM BLOOD WBC-8.7 RBC-3.86* Hgb-11.4* Hct-34.5*
MCV-89 MCH-29.6 MCHC-33.1 RDW-16.1* Plt Ct-326
[**2199-10-9**] 11:22PM BLOOD Glucose-145* UreaN-31* Creat-1.4* Na-143
K-5.3* Cl-104 HCO3-31 AnGap-13
[**2199-10-9**] 11:22PM BLOOD Calcium-8.8 Phos-5.0*# Mg-1.8
Labs on Discharge:
XXXXXXXXXXXXXXXXX
Imaging:
Standing AP/Lateral C-spine images obtained prior to discharge;
pending formal interpretation at the writing of this note
Brief Hospital Course:
Patient was electively admitted on [**10-9**] for a posterior C2-C7
fusion. Operative course was uneventful. She was transferred to
the neurosurgery floor on POD#0. She was seen by physical
therapy on POD#1, and thought to be an appropriate candidate for
rehab placement. On POD#2, her wound drain was removed and
approximated with steri-strips. She was then discharged to rehab
facility on [**10-12**].
Medications on Admission:
Acetaminophen (Tylenol)
(prn)
ASA (Aspirin)
(325 mg daily)
Calcium carbonate (oyster shell)
(650 mg [**Hospital1 **])
Colace (Docusate sodium)
(250 mg [**Hospital1 **])
Coumadin [Warfarin] (1.5-2 mg daily)
Folic acid (Folvite)
(1mg po daily)
Fosamax
(70 mg weekly)
Furosemide [Lasix] (40mg po daily)
Lidocaine topical (Xylocaine)
(patch between shoulders)
Losartan (Cozaar)
(75mg po daily)
Metoprolol tartrate [Toprol, Lorpessor] (50
mg TID)
Multi Vitamin
(daily)
Omeprazole [Prilosec] (20 mg po daily)
Other 3 (B 12 injection every 2 months)
Other 4 (vitamin D2)
Oxycodone Hydrochloride (Roxicodone,
Oxycontin) (5 mg every 6 hours)
Prednisone (20 mg every other day)
Prozac (Fluoxetine)
(10 mg daily)
Simvastatin [Zocor] (10 mg daily)
Other (pyridoxine 50mg po qday)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Losartan 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
15. Oxycodone 5 mg/5 mL Solution Sig: [**12-19**] PO Q3H (every 3
hours) as needed for pain.
16. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Diastolic Heart Failure
Cervical Stenosis
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound clean and dry / No tub baths or pool swimming
until seen in follow up/begin daily showers [**10-13**]
?????? 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 your incision checked daily for signs of infection.
?????? You are required to wear cervical collar.
?????? You may shower briefly without the collar.
?????? 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 restart your coumadin therapy after 10 days post-op
?????? 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 return to the office in 10 days for removal of your
staples or have them removed at rehab by [**10-18**].
??????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:[**2199-10-11**] Name: [**Known lastname 14976**],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Unit No: [**Numeric Identifier 14977**]
Admission Date: [**2199-10-9**] Discharge Date: [**2199-10-22**]
Date of Birth: [**2115-8-5**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Erythromycin Base / Ampicillin
Attending:[**First Name3 (LF) 211**]
Addendum:
[**Hospital **] Hospital Course:
The patient was NOT discharged on [**10-12**]. That was the plan but
then the following events occurred.
.
On [**10-11**] patient desated to the 50s and was transferred over to
the MICU where she was on non-rebreather mask. CTA was
performed to determine whether a PE had occurred. No PE was
identified on CTA and patient maintained saturations in the 90s
and was transferred to the floor. On [**10-14**] patient had oxygen
saturations in 80s. Medicine was consulted to evaluate the
cause of desaturation. CXR was negative for PNA. However pt
continued to require 3-6L O2 on [**10-15**]. Pt had video swallowing
by S&S which stated that pt has a baseline dysphagia and chronic
aspiration, however with her recent surgery could have
exacerbated it. Recommendations per S&S was followed. Pt has
been on Prednisone and had a temp of 99.7, WBC of 12 from 9 and
RLL infitrate on CXR from [**10-15**]. Therefore pt was treated for
aspiration PNA and transferred to the Medicine service.
.
On the evening of [**2199-10-15**], the patient was transferred to the
Medicine service for further evaluation of her continued
hypoxia. At approximately 8:30pm, the patient was taking po
oxycodone. The administering nurse left the room for 5 minutes
and when she returned, she found Ms. [**Known lastname **] [**Last Name (Titles) 14978**]. A Code
Blue was called and she was intubated for respiratory failure.
A L femoral CVL was placed during the code. She was then
transferred to the MICU for further management and evaluation
for her acute respiratory failure. Per the transferring team,
there was concern that she may have aspirated her medications or
other food products during the day.
.
In the MICU, her respiratory status improved and she was
extubatd on [**2199-10-16**]. She was emperically treated with
Vancomycin and Ceftriaxone for possible aspiration pneunomnia.
She was re-evaluated by speech and swallow who stated that she
continued to aspirate and was made NPO until she could safely
clear secretions, as the was felt to be secondary to thick
secretions from intubation. She was hemodynamically stable and
oxygen saturation was 96% on 3L. She was transferred back to
the floor on [**2199-10-17**]. Her blood cultures grew GPCs in [**12-21**]
bottles which was possibly a contaminate. She had a PICC line
placed and arterial and central IJ lines were removed. She had
bilteral ultrasounds done of the lower extremities which showed
recanalization of veins and possible acute vs. chronic clots.
She was put on heparin gtt for hx of PE.
Chief Complaint:
Neck pain - admitted for elective neurosurgical procedure
Major Surgical or Invasive Procedure:
C2-C7 Posterior Laminectomy Fusion
C5-6 Foraminotomy
Intubation
Right subclavian central line
PICC line
History of Present Illness:
84 y/o F with history of PE s/p IVC filter --> admitted for
elective neurosurg procedure. Following this had episode of
hypoxia with O2 sat to 50% RA --> transferred to MICU with CTA
negative for PE with improvement in hypoxia and transferred back
to Neurosurg service. While there, pt continued to have moderate
O2 requirement, and was dx w/possible aspiration PNA. Pt was
transferred to medicine service on [**10-15**] then acutely
decompensated from a respiratory standpoint, became unresponsive
very shortly after being given liquid oxycodone, and was
intubated for resp failure. Resp failure possibly related to
aspiration event vs. mucous plug, and ABx broadened despite no
significant change on CXR and no fever/leukocytosis. Pt now s/p
extubation and ready for transfer out of MICU. Of note, CTA
negative this admission, but LENIs show acute vs. chronic L leg
DVT. Pt had been off A/C in anticipation of elective neurosurg
procedure, but now on Heparin gtt.
.
[**2199-10-15**] - Episode of unresponsiveness/unconsciousness after
being given liquid oxycodone. ? Aspiration given abnormal S&S
eval. Pt was started on Levo/Flagyl/Meropenem --> Vanc/CTX on
[**10-16**]. CXR did not show any evidence of clear infiltrate, but
due to concern for possible Asp PNA, though no leukocytosis.
Intubated during this episode. Extubated [**10-16**]. Head CT
negative. TTE: unchanged from prior exam in [**8-26**] (mild AS,
dilated RV, EF 60-65%, diastolic dysfunction).
Currently 96% on 3L, CE small Trop leak to 0.2, but EKG's
unchanged.
.
Leni L leg: Acute vs. Chronic partially recannulated L common
vein, SFA, L popliteal.
Past Medical History:
HTN
Diastolic CHF
Gout
Barrets
Polymyositis
Bell's Palsy (Rt)
Massive PE s/p Trendy procedure, IVC filter placement
TAH
Appendectomy
T4, T8 vertebroplasty [**2196-10-11**]
C4-C5 disectomy and hardware placement
3.9 cm infrarenal AAA
Recent BM biopsy from iliac crest
Social History:
40 pack year hx of tobacco, quit over 20 years ago, no
etoh/illict drug use; was living independently until recently;
now in [**Hospital **] Rehab after recent surgery; does not have much
family - is close with friends; good friend [**Name (NI) **] [**Name (NI) **] is her
HCP
Family History:
mom with osteoporosis and heart disease, died at age 79; no
other history of heart disease
Physical Exam:
DISCHARGE PHYSICAL:
T:98.6 BP:124/52 HR:83 RR:16 O2 Sat:94% on3 L nc
GEN: NAD, pleasant
Neck: supple, surgical wound with no erythema, no exudate, no
TTP
CV: rrr no mrg
PULM: Rhonchorous throughout
ABD: +BS, soft, NTND
Ext: 1+ pitting edema to mid calf
Neuro: a/o x3, has 7th nerve palsy (at baseline)
Pscyh: Appropriate
Pertinent Results:
IMAGING:
CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST [**2199-10-12**]:
Non-enhanced images display no evidence of intramural hematoma.
Contrast-enhanced images display no evidence of aortic
dissection or pulmonary embolism to the segmental level. Some of
the subsegmental branches are not well visualized due to
atelectasis and respiratory motion. The previously described
pulmonary nodules are unchanged with no new lesions identified.
Enhancing atelectasis is noted within the lower lobes
bilaterally and the regional scarring is present within the
right middle lobe. There is no pleural or pericardial effusion.
The airways are patent to the segmental level. Aerosolized
debris is noted within the trachea. Underlying emphysema of
centrilobular nature is unchanged.
.
Atherosclerotic disease within the heart, and coronary
circulation is stable as is dilatation of the main pulmonary
artery and right pulmonary artery which measures greater than 3
cm suggestive of underlying pulmonary hypertension.
.
Please note this exam was not tailored for subdiaphragmatic
evaluation.
Included portions of the abdomen display unchanged bilateral
hypodense renal lesions, most likely cysts, and cholelithiasis
with no secondary findings to suggest acute cholecystitis.
.
BONE WINDOWS: No malignant-appearing osseous lesions identified.
Extensive
degenerative changes and extenuated kyphosis is stable as is
post-operative appearance of prior vertebroplasties.
.
IMPRESSION:
1. Slightly limited examination with no evidence of aortic
dissection or
pulmonary embolism to the segmental level.
.
2. Bibasilar atelectasis and small right effusion. No focal new
regions of
consolidation suspicious for pneumonia.
.
3. Unchanged emphysema.
.
4. Stable appearance to extensive vascular disease and
dilatation of the
pulmonary arteries consistent with pulmonary hypertension.
.
5. Aerosolized secretions within the upper trachea.
.
.
PLAIN FILM BILAT HIPS: [**2199-10-20**]
Frontal view of the pelvis and upper femurs and two views of the
left hip show no fracture or dislocation. There is appreciably
more severe narrowing and sclerosis of the right hip joint than
the left. Region of demineralization on the left at the junction
of the acetabulum with the ischium is probably artifactual given
the symmetric appearance on the frontal view. Clips denote prior
surgery in the mid and lower abdomen.
.
.
CARDIAC ECHO:
The left atrium is elongated. 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. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
.
CT HEAD:
FINDINGS: There is no evidence of gross acute intracranial
hemorrhage, large areas of edema, or mass effect. Streak
artifacts from the right globe metallic object limit evaluation
for abnormalities in this area.
.
Mild prominence of the ventricles and sulci are most likely due
to age-
appropriate parenchymal atrophy. Hypodensities located within
the
periventricular white matter are most likely due to chronic
small vessel
ischemic changes. Visualized portions of the paranasal sinuses
and mastoid air cells are unremarkable. Partial obliteration of
the nasopharyngeal airway relates to intubation and thickening
of tissues.
.
IMPRESSION:
No evidence of acute intracranial hemorrhage or mass effect, but
cannot
exclude acute infarct. Streak artifact from metallic object in
right globe
precludes evaluation of abnormalities in the surrounding area.
.
.
VIDEO OROPHARYNGEAL SWALLOW:
.
INDICATION: 84-year-old woman with chronic dysphagia. More
difficulty
swallowing after C2-6 posterior laminectomy, question
aspiration.
.
TECHNIQUE: Videooropharyngeal swallow study was performed in
conjunction with the speech therapist. Barium of various
consistencies was given to the patient under video fluoroscopic
guidance.
.
ORAL PHASE: Bolus formation and bolus control are mildly
impaired, with
premature spillover. AP tongue movement was decreased. Oral
transit times were slightly increased.
.
PHARYNGEAL PHASE: The pharyngeal swallow was initiated promptly
with normal palatal elevation. Laryngeal elevation was reduced
with absent epiglottic deflection. There was a large amount of
residue in the valleculae and piriform sinuses, after the
swallow, worse with [**Location (un) **] cracker than with pudding. Upper
esophageal sphincter relaxation was moderately decreased.
.
ASPIRATION/PENETRATION: There was aspiration of thin liquids,
nectar and
cracker ,which was sensate. Reclining to almost 45 degrees was
somewhat
helpful in preventing aspiration, particularly with solids and
puree.
.
IMPRESSION: Moderate to severe pharyngeal dysphagia and
aspiration with
multiple consistencies, which improved somewhat with reclined
position. For further details, please see the speech pathologist
report from the same date.
.
.
DISCHARGE LABS:
CBC: 13.2/ 9.2/28.2/511
CHEM 7: 139/4.2/98/36/16/1.1/79
Brief Hospital Course:
84 yo F admitted for elective C2-C7 fusion with neurosurgery who
post-operatively upon transfer to the floor desated to 50% on RA
and a code blue was called. This was thought to be [**1-19**] an
aspiration event vs. mucous plugging from thickened secretions.
She was intubated, sedated and transfered to the ICU. She was
started on broad spectrum abx over concern for aspiration. Blood
cultures were also drawn at this time and showed gram positive
[**Last Name (un) **]-bacili which speciated to peptostreptococcus. In the ICU
she was weaned off the ventilator and sucessfully extubated and
was 95% on 2L by nc. Her central line was pulled before
transfer to the floor for continued management of her hypoxia.
She was treated with chest PT, and incentive spirometry. Her
vancomycin was discontinued in as speciate=ion indicated a
likely contaminate.
.
See Neurosurgery discharge summary for surgical course.
.
# Hypoxia:
On [**10-11**] patient desated to the 50s and was transferred over to
the MICU and intubated. CTA was performed to determine whether
a PE had occurred. No PE was identified on CTA and patient
maintained saturations in the 90s
and was transferred to the floor. On [**10-14**] patient had oxygen
saturations in 80s. Medicine was consulted to evaluate the
cause of desaturation. CXR was negative for PNA. However pt
continued to require 3-6L O2 on [**10-15**]. Pt had video swallowing
by S&S which stated that pt has a baseline dysphagia and chronic
aspiration, however with her recent surgery could have
exacerbated it. Recommendations per S&S was followed. Pt has
been on Prednisone and had a temp of 99.7, WBC of 12 from 9 and
RLL infitrate on CXR from [**10-15**]. Therefore pt was treated for
aspiration PNA and transferred to the Medicine service.
.
On the evening of [**2199-10-15**], the patient was transferred to the
Medicine service for further evaluation of her continued
hypoxia. At approximately 8:30pm, the patient was taking po
oxycodone. The administering nurse left the room for 5 minutes
and when she returned, she found Ms. [**Known lastname **] [**Last Name (Titles) 14978**]. A Code
Blue was called and she was intubated for respiratory failure.
A L femoral CVL was placed during the code. She was intubated
and then transferred to the MICU for further management and
evaluation for her acute respiratory failure. Per the
transferring team, there was concern that she may have aspirated
her medications or other food products during the day.
.
In the MICU, her respiratory status improved and she was
extubatd on [**2199-10-16**]. She was emperically treated with
Vancomycin and Ceftriaxone for possible aspiration pneunomnia.
She was re-evaluated by speech and swallow who stated that she
continued to aspirate and was made NPO until she could safely
clear secretions, as the was felt to be secondary to thick
secretions from intubation. She was hemodynamically stable and
oxygen saturation was 96% on 3L. She was transferred back to
the floor on [**2199-10-17**]. Her blood cultures grew GPCs in [**12-21**]
bottles which was likely a contaminate (see below). She had a
PICC line placed and arterial and central IJ lines were removed.
She had bilteral ultrasounds done of the lower extremities
which showed recanalization of veins and possible acute vs.
chronic clots. She was put on heparin gtt for hx of PE. LENIs
were performed that showed a DVT.
.
On transfer to the floor patient was sating well on 2L and
afebrile. She had intermittant episodes of asymptomatic hypoxia
to the high 80's. Her respiratory status improved and she was
discharged on 3L by nasal cannula sating at 95%, onnebulizer
treatments and tessalon perles.
.
# Positive Blood Cultures:
Likely represented a contaminate as patient was afebrile and has
no leukocytosis. Cultures showed peptostreptococcus. Received 6
days of iv vancomycin before cultures returned.
.
# Fluid Overload:
Was aggressively treated with fluids in setting of respiratory
decompensation. Diuresed well with IV lasix. Restarted on po
lasix and discharged on her home dose of Lasix 40mg po qd.
.
# DVT with History of PE:
Patient with known history of post-surgical PE and IVC filter.
DVT found on LENI obtained in setting of respiratory
decompensation. Unclear if acute of chronic. patient bridged
with heparin gtt in the post-operative period and in in the
process of fully transitioning to coumadin. Patient will
received appropriate INR monitoring at rehab facility. Heparin
to be d/c'ed when INR [**1-20**]. PICC line to be pulled upon
discontinuation of heparin gtt.
.
# S/p C2-C7 Fusion:
Surgical staples removed, wound with minimal erythema, no
exudate, no TTP, wound edges well approximated. Patient has
follow up with Neurosurgeru - Dr. [**Last Name (STitle) 752**] [**2199-11-22**] at 10:45am.
.
# Acute Renal Failure:
Baseline Cr 1.0, rose to 1.8 and returned to baseline of 1.1
after fluids. Lasix and [**Last Name (un) **] were held in setting of ARF and
restarted before discharge.
.
# Dysphagia:
Patient with known history of dysphagia. Patient was made NPO
after respiratory decompensation given question of aspiration.
As chest x-ray showed no evidence of aspiration, speech and
swallow evaluated patient and discussed risks of restarting diet
with patient. Patient was able to express risks of restarting
diet and was started on thin liquid and pureed solids per S/S
recommendations. Speech and swallow also discussed possible PEG
tube with patient who is considering it.
.
# Leukocytosis:
13.6 on discharge. Likely small aspiration event on day prior
to discharge, nothing seen on CXR. Patient afebrile, VSS.
.
# History of Diastolic Heart Failure:
Patient treated with home BB and [**Last Name (un) **] which were held in setting
of respiratory failure and restarted as above without
complication.
.
# Anemia:
Likely anemia of chronic disease. Stable on discharge.
.
# Hypertension:
Patient treated with home medications of BB and [**Last Name (un) **], held as
above. BP's stable on discharge.
.
# History of Polymyositis:
Patient continued on home medication of prednisone 20mg every
other day.
.
# Osteoporosis:
Treated with home medication.
.
# Anxiety:
Treated with home medication.
.
# Hyperlipidemia:
Treated with home medication.
.
# Code Status: FULL CODE per patient at HCP.
.
# Health Care Proxy: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 14979**](h)
[**Telephone/Fax (1) 14980**](c)
Medications on Admission:
Acetaminophen
ASA 325 mg daily
Calcium carbonate 650 mg [**Hospital1 **]
Colace 250 mg [**Hospital1 **]
Coumadin 1.5-2 mg daily
Folic acid 1mg po daily
Fosamax 70 mg weekly
Furosemide 40mg po daily
Lidocaine topical
Losartan 75mg po daily
Metoprolol tartrate 50 mg TID
Multi Vitamin
Omeprazole 20 mg po daily
B 12 injection every 2 months
vitamin D2
Oxycodone Hydrochloride 5 mg every 6 hours
Prednisone 20 mg every other day
Prozac 10 mg daily
Simvastatin 10 mg daily
pyridoxine 50mg po qday
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Losartan 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
12. Oxycodone 5 mg/5 mL Solution Sig: [**12-19**] PO Q3H (every 3
hours) as needed for pain.
13. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
14. Cortisone 1 % Cream Sig: One (1) Appl Topical TID (3 times a
day) as needed for itching.
15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours).
17. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): hold for diarrhea.
18. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to area of pain. 12 hours on 12 hours off.
20. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-19**]
Drops Ophthalmic Q8H (every 8 hours) as needed.
21. 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.
22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
23. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
24. Heparin, Porcine (PF) 10,000 unit/5 mL Solution Sig: Eight
Hundred (800) units Intravenous gtt: drip at 800units/hour with
q6 PTT checks with the following parameters:
-PTT <40: [**2190**] units Bolus then Increase infusion rate by 200
units/hr
-PTT 40 - 59: 700 units Bolus then Increase infusion rate by 150
units/hr
-PTT 60 - 80*: no change
-PTT 81 - 100: Reduce infusion rate by 150 units/hr
-PTT >100: Hold 60 mins then Reduce infusion rate by 200
units/hr
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
Discharge Diagnosis:
Cervical Stenosis
Hypoxia
Bacteremia
.
Hypertension
Diastolic Heart Failure
Gout
Barrett's Esophagus
Polymyositis
Bell's Palsy (Right side)
Massive PE s/p Trendy procedure, IVC filter placement
S/p TAH
Appendectomy
T4, T8 vertebroplasty [**2196-10-11**]
C4-C5 disectomy and hardware placement
3.9 cm infrarenal AAA
Recent BM biopsy from iliac crest
Discharge Condition:
Fair
Discharge Instructions:
You were admitted for a neursurigcal procedure - C2-C7 spinal
fusion which was completed without complication. When you were
transferred from the ICU to the general floor, you had an
episode of decreased oxygen in your blood (hypoxia) this was
thought to be due to a mucous plug in your lung, though there
was concern that you aspirated food in to your lungs. You were
intubated for a brief period of time for support and then
extubated. You have been breathing well on oxygen given to you
through your nose and will contine to received this at the rehab
facility.
.
You were also found to have a bacteria growing in your blood
though you were asymptomatic. This was likely from a bacteria
that grown in your mouth and the infection occurred when you
were intubated. You were treated with antibiotics for one week
for this infection.
.
Your DCT is being treated with a heparin drip until you are
therapeutic on your coumadin.
.
The following medication changes have been made:
ADDED:
-Fluticasone neb treatments for breathing twice a day
-Oxycodone solution for pain [**Last Name (un) **] 4 hours as needed for pain
-Hydrocortisone cream 1% for skin itching three times a day as
needd for itching
-Lidocaine 5% patch apply to area of pain, 12 hours on 12 hours
off
-Artifical Tears as needed for dry eyes
-Albuterol nebulizer treatments every 4 hours as needed for
wheezing
-Senna 1 tablet twice a day as needed for constipation
-Benzonate 100mg three times a day
-Vancomycin 1g Iv for one dose to get on [**2199-10-22**]
-Pantoprazole 40mg tablet once a day
-Heparin drip
STOPPED:
-Omeprazole
.
If you have chest pain, shortness of breath, severe abdominal
pain, pain or swelling at your surgical site or any other
concerning symptom, please seek medical care immediately.
.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 752**] on Friday, [**2199-11-22**] at
10:45am on the [**Location (un) 457**] of the [**Hospital Ward Name **] Building at [**Hospital1 8**] [**Hospital Ward Name 7284**].
.
Follow up with your primary care physician as needed after you
are discharged from rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2199-10-22**]
|
[
"723.0",
"428.0",
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"492.8",
"507.0",
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"710.4",
"518.81",
"285.21",
"585.9",
"733.00",
"737.19",
"V58.61",
"584.9",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"81.03",
"96.04",
"99.60",
"38.93",
"81.63",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
27555, 27621
|
17989, 24479
|
9666, 9772
|
28014, 28021
|
12479, 15661
|
29913, 30389
|
12025, 12118
|
25023, 27532
|
27642, 27993
|
24505, 25000
|
6998, 9552
|
28045, 29890
|
17906, 17966
|
12133, 12460
|
9569, 9628
|
1784, 1935
|
9800, 11423
|
15670, 17890
|
1487, 1765
|
11445, 11714
|
11730, 12009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,387
| 146,360
|
37445
|
Discharge summary
|
report
|
Admission Date: [**2135-2-17**] Discharge Date: [**2135-2-20**]
Date of Birth: [**2082-4-12**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Transfer from [**Hospital1 **] [**Location (un) 620**] with severe acute blood loss anemia due
to bleeding duodenal polyp
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 year old male with a recent history of CAD s/p MI and PCI
with placement of 3 drug eluting stents in the LAD 1 month prior
to admission presenting to OSH with syncopal episode 3 days
prior to transfer to [**Hospital1 18**]. Patient was at his third cardiac
rehab session, and had felt fine after running on the treadmill.
He sat down and was talking with a nurse when he syncopized. Per
report, episode lasted for less than one minute. He had no
prodromal symtpoms, no chest pain, no SOB, no blurry vision, no
HA, no unilateral weakness, no localizing symptoms. He was not
post-ictal when he regained consciousness.
His work up at the OSH was notable for Hct drop from 39 on [**2-14**]
to 26 on [**2-16**] with melena. An EGD 1 day prior to transfer showed
a 2cm duodenal polyp with ulcer on the medial side wall. This
was not able to be bicapped or injected with epi due to its
mobility. 2 clips were successfully placed and patient was
transferred to the ICU for monitoring out of concern that he may
re-bleed as his plavix and aspirin could not be stopped. He is
transferred here for observation and possible repeat endoscopy.
He had received a total of 3 units pRBC, 2 the day prior to
transfer and one the morning of transfer.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, cough, shortness of breath,
chest pain, chest pressure, abdominal pain.
Past Medical History:
- Hemochromatosis
- s/p MI with PCI DES x3 [**1-/2135**]
- h/o nephrolithiasis
- Multinodular thyroid followed since [**2132**]
- h/o basal cell carcinoma nasal skin resection
Social History:
Patient is married x 28 years with 4 children. He is currently
unemployed, although has worked previously as an investment
manager. He denies smoking, drinks 3 times a year, and denies
other drug abuse.
Family History:
No family history of premature HA. Family history of HTN and
elevated lipids. Mother died of AAA at 73 and father healthy and
alive now at 88. Brother with prostate cancer and melanoma.
Physical Exam:
VSS AF Stable
GEN: NAD
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT, - rebound, - guarding, Stool GAUIAC (-)
on discharge
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
Labs on Admission:
[**2135-2-17**] 08:04PM BLOOD WBC-9.7 RBC-3.79* Hgb-11.2* Hct-31.5*
MCV-83 MCH-29.6 MCHC-35.6* RDW-16.1* Plt Ct-232
[**2135-2-17**] 08:04PM BLOOD PT-14.0* PTT-24.2 INR(PT)-1.2*
[**2135-2-17**] 08:04PM BLOOD Glucose-84 UreaN-14 Creat-1.0 Na-142
K-4.2 Cl-106 HCO3-23 AnGap-17
[**2135-2-17**] 08:04PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
Labs on Discharge:
[**2135-2-20**] 07:55AM BLOOD WBC-10.2 RBC-3.99* Hgb-11.4* Hct-34.0*
MCV-85 MCH-28.7 MCHC-33.6 RDW-16.4* Plt Ct-271
[**2135-2-19**] 08:35AM BLOOD PT-13.4 PTT-26.3 INR(PT)-1.1
[**2135-2-20**] 07:55AM BLOOD Glucose-103* UreaN-10 Creat-1.1 Na-143
K-4.0 Cl-106 HCO3-27 AnGap-14
[**2135-2-20**] 07:55AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.2
Brief Hospital Course:
52 yo M hx of CAD s/p MI and PCI with placement of 3 DES in LAD
1 month ago presenting to OSH with syncopal episode 3 days ago
and found to have bleeding duodenal polyp s/p clipping x2.
1. Acute blood loss anemia due to GI Bleeding due to Duodenal
polyp:
Acute blood loss is the etiology of patient's syncopal episode
upon presentation. The patient was transfused a total 2 units
pRBCs on presentation. IV PPI was started, PIVx2 and active
type and screen were maintained. The patient underwent EGD with
polyp clipping x2 at OSH. Following the procedure, the patient
was admitted to ICU and monitored closely for signs of re-bleed
if polyp becomes necrotic given the continuation of patient's
aspirin/plavix. Hct was monitored closely and remained stable,
requiring no further transfusions. The patient remained free of
symptoms. Diet was advanced as tolerated to regular.
Antihypertensives and heparin SC were transiently held on
admission in the setting of potentional GI Bleed and re-started
upon discharge. Plavix/ASA were continued throughout given
recent placement of DES. IV PPI has been switched to PO PPI [**Hospital1 **]
prior to discharge. The patient will follow-up with his PCP and
[**Name9 (PRE) 84146**] within 1 week of discharge.
2. Syncope.
GI Bleeding causing anemia is likely etiology of patient's
initial syncope. Patient was ruled out for MI at OSH. He was
monitored on telemetry throughout this admission and had no
further syncopal episodes.
3. CAD Native Vessle, Recent MI s/p PCI Drug Eluting Stents x3.
Anticoagulation needed to maintain patency of recently placed
stents per extensive discussion with OSH cardiologist. With
strong cardiology recommendation to continue aspirin/plavix, we
continued the patient's anticoagulation and monitored him
closely throughout this admission.
4. Hemochromatosis.
Per OSH records, most recent ferritin is 106 from [**Month (only) **]
[**2134**]. He is homozygous for the 863D gene.
Medications on Admission:
- Tylenol 650mg PO q4hr prn
- Aspirin 325mg PO Daily
- Plavix 75mg PO Daily
- Fish oil 2000mg PO Daily
- Lisinopril 10mg PO Daily
- Toprol XL 50mg PO Daily
- Nitroglycerin SL prn
- Simvastatin 40mg PO Daily
Discharge Medications:
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. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for chest pain.
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastrointestinal bleeding from a bleeding duodenal
ulcer
Secondary: Coronary Artery Disease
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 because you collapsed. You
were found to have a low red blood cell count and given 3 units
of red blood cells. Endoscopy was performed. Because you were
on Aspirin and Plavix, you were transferred to [**Hospital1 18**] Intensive
Care Unit for close monitoring. Your red blood cell counts have
remained stable and you remained free of symptoms. You are
being discharged home.
You may continue to eat normal heart healthy diet.
We prescribed you omeprazole 40mg twice a day. Please makes
sure to take this medication carefully.
You should continue to take all your other medications as
prescribed.
You need to follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
doctor (see below).
It is critical that you call your GI doctor immediately or
present to the Emergency Department right away if you develop
any of the signs or symptoms of GI bleed: dizziness,
lightheadedness, changes in vision, red, black/tarry stools, or
any other symptoms that concern you.
Followup Instructions:
You need to follow-up with your Primary Care Doctor Dr. [**Last Name (STitle) 73250**]
(phone number [**Telephone/Fax (1) 54195**]) and your Gastroenterologist Dr.
[**Last Name (STitle) **] Phone number ([**Telephone/Fax (1) 23364**]. Please call right away
to make appointments with both of them within 1 week of
discharge.
Completed by:[**2135-3-14**]
|
[
"285.1",
"780.2",
"532.40",
"V45.82",
"241.1",
"414.01",
"275.0",
"410.92"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6352, 6358
|
3391, 5348
|
391, 398
|
6504, 6504
|
2663, 2668
|
7714, 8072
|
2238, 2425
|
5605, 6329
|
6379, 6483
|
5374, 5582
|
6649, 7691
|
2440, 2644
|
1682, 1803
|
230, 353
|
3035, 3368
|
426, 1663
|
2682, 3015
|
6518, 6625
|
1825, 2002
|
2018, 2222
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,956
| 192,859
|
14891
|
Discharge summary
|
report
|
Admission Date: [**2106-12-21**] Discharge Date: [**2107-1-3**]
Date of Birth: [**2030-10-4**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo M with hx of CAD (s/p CABG), Dementia, CHF, MRSA UTI
presents from OSH with fever, lethargy, increased WBC and
hypotension. He was febrile at NH to 102.9, diagnosed with a UTI
and pneumonia. It appears he was started on ceftriaxone,
ceftazidime and levaquin. Pt recently admitted to OSH on
[**11-6**] for similar sx which resolved with IVF and abx (CTX,
Vanc, Flagyl). Pt then decompensated today with either
aspiration event or UTI and had increased HR and hypotension, O2
sat stable. Found to have R renal mass on CT with necrosis and
bleeding at OSH. This was initially found at recent admission to
[**Hospital1 **] where he had hematuria. It appears embolization was
considered but deferred given the hematuria and felt he would
not tolerate procedure. In the ED his vitals were T 98.9, HR 99,
BP 80's/40's, 100%2L. WBC 17, HCT 23 (bl 25-27), Na 150, Creat
1.7, lact 1.8, u/a >50 WBC. He was given fluid boluses (up to
4L) and BP did not improve. He was also given diltiazem 10 IVx2
for HR 120s with no response, vancomycin and zosyn and flagyl.
.
His BP dropped to SBP 60s and was started on levophed via his
PICC. He was transfused one unit of PRBC. He is DNR/DNI and
family did not want aggressive measures including CVL placement.
They do want pressors.
.
On arrival to [**Hospital Unit Name 153**] he was in a. flutter to 150, BP 103/61 on
levophed. He converted to SR within a few minutes, BP stable
100/58.
Past Medical History:
CAD (s/p CABG)
Dementia
CHF
MRSA UTI
Chronic indwelling foley, for one month
R lower pole renal mass dx in [**3-/2106**], 5.1x4cm exophitic
necrotic, not biopsied
h/o urinary retention
UTI
PEG [**11/2106**]
Laser procedure to shrink prostate
.
Social History:
lives in [**Location **]. Has supportive family including wife, daughter,
son. Daughter [**First Name4 (NamePattern1) 17728**] [**Last Name (NamePattern1) **] is primary spokesperson for
family.
Family History:
Noncontributory
Physical Exam:
96.2, 103/61, 150->101, 24, 100% 2L
GENL: chronically ill appearing, noncommunative, mild tremors in
L arm
HEENT: JVP at about 8 cm, OP dry, PERL
CV: RRR no MRG
Lungs: decreased BS at R base, no crackles
Abd: soft, ?tenderness, no masses, +PEG
Back: 2cm x 2cm stage 2-3 sacral ulcer
Ext: no edema
Pertinent Results:
urine: +[**Last Name (NamePattern1) **]
sacral debub wound: +[**Last Name (NamePattern1) **]
.
CT OF ABDOMEN WITH AND WITHOUT IV CONTRAST:
There are bilateral moderate pleural effusions and associated
dependent atelectasis of lung bases.
There is a 7 x 7 cm mass arising from the lower pole of the
right kidney that has a necrotic mass within it. This mass is
enhancing peripherally and is associated with few
retroperitoneal collaterals. There are multiple large necrotic
lymph nodes in the retroperitoneum near right renal vain
measuring up to 23 x23 mm. There is one right renal artery for
each kidney. Right renal vein has heterogenous appearance and
cannot be well assesed due to phase of the study. The left
kidney, left adrenal gland, right adrenal gland, liver,
pancreas, the loops of small and large bowel are unremarkable.
The gall bladder is enlarged. No free air or f luid is seen
within the abdomen.
.
CT OF PELVIS WITH IV CONTRAST:
The rectum, sigmoid colon, urinary bladder, distal ureters are
unremarkable. The prostate gland has areas of calcification
within it and looks enlarged.
No free air or free fluid is seen within the pelvic cavity.
No pathologically enlarged inguinal or pelvic lymph node is
detected.
.
BONE WINDOWS: No concerning lytic or sclerotic lesion is seen.
Again noted is severe degenerative changes of thoracic and
lumbar spine.
.
TTE: IMPRESSION: Mild regional left ventricular systolic
dysfunction, consistent with CAD. Severe mitral regurgitation.
Mild aortic regurgitation. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
Brief Hospital Course:
76 yo M with h/o CAD s/p CABG, dememtia, CHF who presents with
sepsis. Patient has been made CMO (please see below).
.
# Sepsis/Infection: Likely due to pneumonia and a UTI. He
initially required pressors for support and was covered
empirically with broad spectrum antibiotics. He was also
started on stress dosed steroids for a poor response to cortrysn
stimulation. He was switched to zosyn and then to ceftaz/flagyl
when he needed a lower sodium load. He received more than 7
days antibiotics. For his urinary tract infection (vancomycin
resistant enterococcus), his chronic indwelling foley (present x
approximately one month prior to admission; he is s/p curative
laser treatment for his history of obstructive BPH) was
discontinued and he was treated with linezolid. He is urinating
well, independently of his foley with a stable creatinine.
Bladder scans were non [**Last Name (NamePattern1) 65**] residuals. The patient does have a
flailed urethra making him urinate all over and he will need
frequent cleanings to keep the skin dry and intact. The patient
continued to have an elevated WBC of unclear etiology. His
sacral decub wound grew [**Last Name (LF) **], [**First Name3 (LF) **] he will finish 4 more days
linezolid for 14 days total. He was c diff negative for
multiple samples. After discussion with the family, further
investigation was discontinued with goals changed to comfort
(see below).
.
# CHF: ECHO showed EF 45% with severe MR resulting in moderate
pulmonary hypertension. Patient was started on an ACEI and seen
by cardiology who said to titrate this up as tolerated.
.
# Anemia: Labs suggest anemia of chronic disease but given
guaic positive stools and history of hematuria, also concerned
for possible acute blood loss. Folate/B12 were normal. Patient
received 1 more unit PRBCs after transfer to the floor. At this
time family would not want further blood draws. On day of
discharge patient had another large BM, darker, with heme +
stool. Should be monitored.
.
# Dementia: Per his daughter, he was at his baseline mental
status upon discharge from the [**Hospital Unit Name 153**]. He has advanced dementia
and was continued on aricept and namenda.
.
# CAD: His ASA was held given guaic positive stool and history
of hematuria. He was not on a statin on admission and his lipid
profile is normal. His beta blocker was added back once his BPs
stabilized.
.
# Hypernatremia: Sodium elevated to low 150s following 7+L NS
fluid resuscitation. He received D5W and free water boluses via
G-tube and eventually the Na returned to [**Location 213**] ranges.
.
# ARF: Creatinine on admission was elevated to 1.7 in the
setting of dehydration and poor perfusion in setting of sepsis.
Creatinine improved with treatment of sepsis and IVFs.
.
# Afib w/ RVR: Pt. was in and out of a. fib and a. flutter
during his stay. He did drop his BP to 70s systolics during one
episode of a. flutter w/ rates of 150s while in the ICU, but
otherwise remained HD stable. His lopressor was restarted.
Despite his age and h/o CHF, he is a poor candidate for
anticoagulation and has had bleeding from right sided necrotic
renal mass.
.
# Sacral decubitus ulcer: Stage 3. Wound care RN was consulted
and recommended allevyn dressing. He remained on a kinair bed
and was rotated q3 hours.
.
# Renal mass: Seen on imaging at OSH with ?renal cell. He had
hct drop at OSH without clear source so there was some question
as to whether he had bled into this necrotic mass. Repeat scan
here again revealed enlarged necrotic mass on R side with
necrotic lymph nodes. Patient also continued to have
intermittent hematuria with some clots, believed to be from
kidney mass. Reviewed with family who are aware of the
suspicion or renal cell CA and do not want further work up (ie
surgery).
.
# FEN: Has PEG and tube feeds were continued. Free water
flushes were started in the setting of his free water deficit
and hypernatremia and should be continued.
.
# Code: Patient's daughter [**Name (NI) 17728**] was met with daily for
updates, along with other family members. [**Name (NI) **] remained very sick
and minimally responsive through hospital stay. He also had
episodes lower blood pressure. After prolonged hospital stay,
h/o dementia and now likely renal cell carcinoma, family (wife,
son, daughter) have made the goals of his care to be comfort.
They wish for him to be returned to his [**Hospital1 1501**] under hospice care.
No more blood draws. No more IVs. At this time they wish to
continue tube feeds and meds through G-tube. They understand
that some time in the future they may decide to discontinue
this. Can discuss with doctors [**First Name (Titles) **] [**Last Name (Titles) 1501**]. Will finish 4 more days
linezolid, but will need to discuss in future whether to give
any further antibiotics. Patient also DNR/DNI. Family
expressed wish not to have him return to the hospital again but
to be cared for at his [**Hospital1 1501**] if he becomes unstable with goals
there being comfort as well. This can be reviewed on his
return.
Medications on Admission:
ceftriaxone 1g IV daily
ceftazidime 2 g IV Q12
levaquin 250 mg daily
protonix 40 mg daily
lopressor 12.5 [**Hospital1 **]
Lovenox 30 mg SQ daily
lasix 40 mg daily
RISS
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed.
2. Donepezil 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime).
3. Memantine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily () as
needed for dementia.
4. Ascorbic Acid 500 mg Wafer [**Hospital1 **]: One (1) PO BID (2 times a
day) for 14 days.
5. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily) for 14 days.
6. Linezolid 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
9. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: One (1) 13 Units
Subcutaneous at bedtime.
11. Scopolamine Base 1.5 mg Patch 72HR [**Last Name (STitle) **]: One (1) Patch 72HR
Transdermal PRN (as needed).
12. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
13. Morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 0.5-1 PO Q4-6H (every 4
to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 1110**]
Discharge Diagnosis:
Sepsis
[**Location (un) **] urinary tract infection
Aspiration pneumonia
GIB
anemia secondary to blood loss
hematuria
renal cell carcinoma (likely) with necrotic mass and necrotizing
lymph nodes
Discharge Condition:
Poor
Discharge Instructions:
Goal of care for patient is comfort measures only. He is not to
have further blood draws or IVs started. Please see discharge
summary for details.
All medications should be given through NG tube, not by mouth.
Followup Instructions:
Patient to be seen by doctors at his [**Name5 (PTitle) 1501**] with transition of
goals of care to comfort. Should be seen this week.
|
[
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"189.0",
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"599.0",
"285.1",
"276.0",
"584.9",
"424.0",
"428.22",
"785.52",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10832, 10919
|
4204, 9294
|
288, 294
|
11158, 11165
|
2596, 4181
|
11425, 11563
|
2246, 2263
|
9513, 10809
|
10940, 11137
|
9320, 9490
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11189, 11402
|
2278, 2577
|
242, 250
|
322, 1747
|
1769, 2015
|
2031, 2230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,754
| 130,458
|
50392
|
Discharge summary
|
report
|
Admission Date: [**2145-12-26**] Discharge Date: [**2146-1-4**]
Date of Birth: [**2073-6-24**] 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:
Cardiac cath [**2144-12-25**]
Off pump coronary artery bypass graft x1(LIMA-LAD) [**2144-12-28**]
History of Present Illness:
71 year old male with h/o CAD s/p DES complicated by ISR with
subsequent stent placed [**11-28**], ESRD on HD, hyperlipidemia, HTN,
DM2 who presents with chest pain. had PMIBI with multiple fixed
defects but no reversible defects; presents with dypsnea with
exertion and orthopnea; unable to lay flat. Had 2 episodes of
CP, improved with nitro. CP resolved with oxygen, Received
aspirin 325mg in ED.
Currently CP free but has ongoing SOB which he describes as a
worsening of his recent SOB from his last admission. .
Past Medical History:
CAD, s/p stent to the LAD on [**2142**] then overlapping DES to the
LAD on [**2144-8-26**] and ISR of LAD with taxus stent placed [**11-28**]
Hypertension
CHF- EF 33% as of [**11-29**]
Diabetes
Hyperlipidemia
Heart block s/p pacemaker [**2-/2142**]
Chronic renal failure on HD q MON, and Friday (plan for a
transplant in the future)
S/P right arm AV fistula [**3-/2143**]
Cellulitis [**6-/2141**]
Bilateral adrenal adenomas
Diverticulosis
Antral polyps
Cholelithiasis by CT on [**2143-7-16**]
S/P right CFA pseudoaneurysm repair [**2143-7-16**] for wound cellulitis
CARDIAC HISTORY:
C.CATH: [**8-29**]: The LMCA had no angiographically apparent flow
limiting lesions. The LAD had a 70% stenosis LCX had a 30%
proximal with diffuse disease in the L PDA. The RCA was not
engaged as it was known to be a small non dominant vessel s/p
PTCA and stenting of the proximal and mid LAD with 2 DES.
C.CATH [**11-28**]: In stent restenosis of LAD stent s/p placement of
taxus stent and severe diffuse dz LCX
.
Pacemaker/ICD: Complete heart block s/p PPM [**2-/2142**]
.
Social History:
Mr. [**Known lastname 105012**] works as a restauranteur. He lives with his wife.
[**Name (NI) **] does not drink alcohol or use tobacco. He quit smoking in
[**2117**] (40 pk-yr history). No illicit drug use.
Family History:
Family history is negative for coronary artery disease. Mother:
died of multiple myeloma at age 84. Father: Died at age 30 as a
casualty of war.
Physical Exam:
Admission
VS: 97.5 129/62 71 24 95% on 4L
GENERAL: Obese elderly male, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP difficult to assess [**1-24**] body habitus
CARDIAC: Distant heart sounds. RR, normal S1, S2. [**1-28**]
holosystolic murmur LUNGS: Rales at bases bilaterally with
prolong expiration and wheezes
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema of the LE bilaterally
PULSES: Right: Radial 2+ DP 2+ PT 2+ Left: Radia 2+ DP 2+ PT
2+
.
Discharge
VS T 97.8 HR 73 SR BP 121/84 RR 20 O2sat 95%-RA
Gen NAD
Neuro A&Ox3, MAE, nonfocal exam
CV RRR, no M/R/G. Sternum stable-incision CDI
Pulm scattered rhonchi, diminished @ bases L>R
Abdm soft, NT/+BS
Ext warm 2+ pedal edema bilat.
Pertinent Results:
[**2145-12-26**] 01:19PM CK(CPK)-215*
[**2145-12-26**] 01:19PM CK-MB-7 cTropnT-0.26*
[**2145-12-26**] 10:32AM %HbA1c-7.3*
[**2145-12-26**] 12:55AM GLUCOSE-196* UREA N-38* CREAT-6.1* SODIUM-139
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-30 ANION GAP-14
[**2145-12-26**] 12:55AM CK-MB-6 proBNP-[**Numeric Identifier 105016**]*
[**2145-12-26**] 12:55AM TRIGLYCER-320* HDL CHOL-31 CHOL/HDL-4.3
LDL(CALC)-37 LDL([**Last Name (un) **])-<50
[**2145-12-26**] 12:55AM WBC-9.0 RBC-3.37* HGB-10.3* HCT-29.8* MCV-88
MCH-30.6 MCHC-34.7 RDW-15.1
[**2145-12-26**] 12:55AM PLT COUNT-262
[**2145-12-26**] 12:55AM PT-12.5 PTT-27.2 INR(PT)-1.1
[**2146-1-4**] 08:45AM BLOOD WBC-11.7* RBC-3.05* Hgb-9.2* Hct-27.7*
MCV-91 MCH-30.2 MCHC-33.3 RDW-15.0 Plt Ct-339#
[**2146-1-4**] 08:45AM BLOOD Plt Ct-339#
[**2146-1-1**] 12:10PM BLOOD PT-13.5* PTT-30.8 INR(PT)-1.2*
[**2146-1-4**] 08:45AM BLOOD Glucose-122* UreaN-44* Creat-6.8* Na-136
K-5.1 Cl-97 HCO3-28 AnGap-16
[**2145-12-28**] 09:10AM BLOOD ALT-12 AST-19 CK(CPK)-118 AlkPhos-80
TotBili-0.6
=
=
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=
================================================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 105017**] M 72 [**2073-6-24**]
Radiology Report CHEST (PA & LAT) Study Date of [**2146-1-3**] 1:19 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2146-1-3**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 105018**]
Reason: f/u effusions
Final Report
INDICATION: Patient is a 72-year-old male status post coronary
artery bypass grafting. Please evaluate for effusions.
EXAMINATION: PA and lateral chest radiographs.
COMPARISONS: Comparison to chest radiographs from [**2145-12-31**].
FINDINGS: There is interval removal of a right internal jugular
introducer
catheter. Patient is status post median sternotomy with CABG. A
pacemaker is noted with leads appropriately placed within the
right atrium and right
ventricle. There are low lung volumes. There is a left pleural
effusion that is largely unchanged in size and appearance. There
is bibasilar atelectasis most prominent at the left base. No
pneumothorax is seen. The cardiac and mediastinal contours are
stable in configuration. The visualized osseous structures are
unremarkable.
IMPRESSION: Stable left pleural effusion and bibasilar
atelectasis, more
prominent at the left base.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] LI
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: MON [**2146-1-3**] 7:14 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105019**] (Complete)
Done [**2145-12-29**] at 1:42:40 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2073-6-24**]
Age (years): 72 M Hgt (in): 68
BP (mm Hg): 140/60 Wgt (lb): 236
HR (bpm): 60 BSA (m2): 2.19 m2
Indication: coronary artery bypass grafting
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2145-12-29**] at 13:42 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 16 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 4 mm Hg
Aortic Valve - Valve Area: *1.8 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderate regional LV systolic dysfunction. Moderately depressed
LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS (AoVA 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
MVP. Moderate mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be A-V paced. Results were personally reviewed with the MD
caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-OPCAB:
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. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction with focalities
in apical anterior, anteroseptal and inferoseptal walls. Overall
left ventricular systolic function is moderately depressed
(LVEF= 40 %). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results on Mr.[**Known lastname 105012**] at 11AM before the procedure start.
Post-OPCAB:
Intact thoracic aorta.
LVEF 40%.
Normal RVEF.
Mild AS, AR and Mild MR.
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) **] [**2145-12-29**] 13:49
[**Known lastname **],[**Known firstname **] [**Medical Record Number 105017**] M 72 [**2073-6-24**]
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2145-12-28**]
2:39 PM
[**Last Name (LF) **],[**First Name3 (LF) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 53630**] [**2145-12-28**] SCHED
CAROTID SERIES COMPLETE Clip # [**Clip Number (Radiology) 105020**]
Reason: PREOP CABG
Final Report
STUDY: Carotid series complete.
REASON: Preop CABG.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries.
There is mild plaque seen in the proximal ICA bilaterally.
On the right, peak velocities are 76, 59, and 75 cm/sec in the
ICA, CCA, and ECA respectively. This is consistent with less
than 40% stenosis.
On the left, peak velocities are 76, 67, and 71 cm/sec in the
ICA, CCA, and ECA respectively. This is consistent with less
than 40% stenosis.
There is antegrade vertebral flow bilaterally.
IMPRESSION: Bilateral less than 40% carotid stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2146-1-3**] 2:16 PM
=
=
=
=
=
=
=
================================================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 105017**] M 72 [**2073-6-24**]
Cardiology Report C.CATH Study Date of [**2145-12-27**]
BRIEF HISTORY: Patient is a 72 year old male with diabetes as
well as
ESRD on dialysis for 2.5 years. He has had multiple
interventions to
his LAD with Cypher stent to LAD in [**6-27**]. He then had a Cypher
placed
proximally in [**8-29**] followed by a Taxus for ISR in [**11-28**]. He now
presents angina and is referred for relook.
INDICATIONS FOR CATHETERIZATION:
angina, prior CAD
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
left femoral artery, using a 5 French right [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour23 minutes.
Arterial time = 0 hour20 minutes.
Fluoro time = 2.5 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 60 ml,
Indications - Renal
Premedications:
ASA 324 mg P.O.
Versed .25 and fentanyl 12.5
Nitroglycerin 100mcg ic
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 0 units IV
Cardiac Cath Supplies Used:
6FR ACCESS CLOSURE, MYNX VASCULAR CLOSURE DEVICE
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
5FR [**Company **], MULTIPACK
COMMENTS: 1. Selective coronary angiography in this left
dominant
patietn revealed single vessel CAD. The LMCA had mild disease.
The LAD
had 90% in stent restenosis with possible fracture of the stent.
There
was moderate diffuse distal disease beyond the stent but the
remainder
of the LAD was a good sized vessel suitable for LIMA touchdown.
The LCX
had diffuse distal disease in the left PDA. The RCA was not
engaged as
known to be small, non-dominant vessel.
2. Limited hemodynamics with BP 129/61 with HR 75 paced.
3. Referral for surgery for LIMA-LAD given that stented area
has had
ISR twice and failed both Cypher and Taxus stents.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Referral for CABG.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) 38290**],[**First Name3 (LF) **] M.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Brief Hospital Course:
MEDICINE - CARDIOLOGY HOSPITAL COURSE [**2145-12-26**] to [**2145-12-29**]:
71 year old diabetic male with h/o CAD s/p DES x2 to
mid/proximal LAD, HTN, hyperlipidemia who presented with chest
pain and SOB. Recent MIBI concerning for worsened anterior wall
motion abnormalities. Cath this admission which showed proximal
LAD disease. Pt was referred for CABG
CT SURGERY HOSPITAL COURSE-
Patient to operating room on [**2145-12-29**] at which time he had an off
pump coronary artery bypass graft times one with left internal
mammary artery to left anterior descending artery. Please see
operating room report for details. He tolerated the operation
well and was transferred from the operating room to thecardiac
surgery ICU in stable condition. He was hemodynamically stable
in the immediate post-operative period but remained intubated on
the day of surgery due to relative hypoxia. On POD1 he was
hemodialyzed and then extubated after dialysis. On POD2 he was
transferred from the ICU to the step down floor. Once on the
floor he had an uneventful course, he was hemodialyzed every
other day but he progressed very slowly from an activity
standpoint. On POD6 it was decided he was stable and ready for
discharge to rehabilitation at the [**Location (un) 86**] Center. His dialysis
will continue at [**Hospital6 **] in [**Location (un) **] on a M-W-F
[**Location (un) **]
Medications on Admission:
Nifedipine 60mg [**Hospital1 **]
Aspirin 325mg daily
Plavix 75mg daily
Lipitor 20mg daily
Calcium acetate 1334 TID
Lasix 80mg qpm (M,F after dialysis)
Lasix 160mg qam and 80mg qpm non-HD days
Valsartan 160mg [**Hospital1 **]
Toprol 100 [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for off pump for 3 months.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
12. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection Q AC&HS.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Heparin
Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
s/p Off pump coronary artery bypass graft x1 with Left internal
mammary artery to left anterior descending artery [**12-29**]
PMH: HTN, Syst HF, CHB s/p PPM, DM, ^chol, ESRD-HD, rt arm AV
fistula, Bilat adrenal adenomas, Diverticulosis, Antral polyps,
cholelithiasis, Rt CFA pseudoaneurysm repair
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Continue Hemodialysis at the [**Hospital6 **] in [**Location (un) **]
on a M-W-F [**Location (un) **]
Followup Instructions:
Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3357**] ([**Telephone/Fax (1) 4606**]) 2-3 weeks after discharge from rehab
Dr [**Last Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 1504**]) in 4 weeks
Patient to call for all appointments
Completed by:[**2146-1-4**]
|
[
"996.72",
"403.91",
"414.01",
"413.9",
"428.22",
"443.9",
"428.0",
"V45.01",
"426.0",
"E878.8",
"585.6",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.72",
"37.22",
"36.15",
"39.95",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
17712, 17795
|
14326, 15699
|
332, 432
|
18136, 18145
|
3351, 8810
|
18449, 18746
|
2308, 2455
|
16003, 17689
|
17816, 18115
|
15725, 15980
|
13907, 14303
|
18169, 18426
|
8853, 12047
|
2470, 3332
|
12600, 13890
|
12080, 12581
|
282, 294
|
460, 980
|
1002, 2065
|
2081, 2292
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,723
| 184,243
|
6122
|
Discharge summary
|
report
|
Admission Date: [**2132-9-12**] Discharge Date: [**2132-9-24**]
Date of Birth: [**2055-8-7**] Sex: F
Service: SURGERY
Allergies:
Tylenol / Zithromax / Clindamycin / Amoxicillin
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal distention (Cecal vascule).
Major Surgical or Invasive Procedure:
1. Rigid sigmoidoscopy.
2. Exploratory laparotomy.
3. Lysis of adhesions.
4. Right colectomy with primary ileotransverse colostomy.
History of Present Illness:
77-year-old female who was admitted to the hospital
approximately 36 hours prior to her operative intervention. She
had previously undergone a right hip replacement approximately 1
week ago at an outside referring institution. She presented with
a distended abdomen. At first, her clinical picture was
consistent with [**First Name8 (NamePattern2) **] [**Last Name (un) **]-type syndrome, however after failure
of conservative management along with neostigmine, the x-rays
more resembled the possibility of a cutaneous cecal vascule. She
was taken to the operating room for exploratory laparotomy.
Past Medical History:
Fibromyalgia
Nephrolithiasis
s/p Appendectomy
s/p Bilat mastecomies
Social History:
Married
Lives with husband
Family History:
Noncontributory
Pertinent Results:
[**2132-9-21**] 01:25PM BLOOD WBC-15.3*# RBC-3.38* Hgb-10.6* Hct-30.1*
MCV-89 MCH-31.3 MCHC-35.1* RDW-15.6* Plt Ct-587*
[**2132-9-18**] 09:00PM BLOOD WBC-9.5 RBC-3.27* Hgb-9.6* Hct-28.7*
MCV-88 MCH-29.4 MCHC-33.5 RDW-15.5 Plt Ct-624*
[**2132-9-18**] 09:28AM BLOOD WBC-10.1 RBC-3.15* Hgb-9.6* Hct-27.7*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.7* Plt Ct-611*
[**2132-9-16**] 12:27AM BLOOD Neuts-86.5* Lymphs-8.4* Monos-3.7 Eos-1.3
Baso-0
[**2132-9-16**] 12:27AM BLOOD Poiklo-1+
[**2132-9-21**] 01:25PM BLOOD Plt Ct-587*
[**2132-9-21**] 01:25PM BLOOD Glucose-93 UreaN-9 Creat-0.3* Na-138
K-3.8 Cl-101 HCO3-23 AnGap-18
[**2132-9-21**] 08:35AM BLOOD K-3.5
[**2132-9-20**] 06:26AM BLOOD Glucose-78 UreaN-8 Creat-0.3* Na-137
K-4.7 Cl-101 HCO3-24 AnGap-17
[**2132-9-22**] 06:33AM BLOOD CK(CPK)-57
[**2132-9-22**] 10:24AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0
[**2132-9-12**] 02:17AM BLOOD Lactate-2.6*
.
[**2132-9-12**] 2:01 am BLOOD CULTURE
**FINAL REPORT [**2132-9-18**]**
AEROBIC BOTTLE (Final [**2132-9-18**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2132-9-18**]): NO GROWTH.
.
[**2132-9-21**] Cardiology ECG [**2132-9-23**]: Atrial fibrillation with
rapid ventricular response; Lead(s) unsuitable for analysis: V2
Left axis deviation; Left bundle branch block; Possible inferior
infarct - age undetermined; Since previous tracing of [**2132-9-18**],
rhythm is atrial fibrillation and left bundle branch block
present
.
[**2132-9-19**] Cardiology ECHO [**2132-9-19**]: 1. The left atrium is
mildly dilated. 2. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional
left ventricular wall motion is normal. 3. The aortic root is
mildly dilated. The ascending aorta is mildly dilated. 4. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. 5. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. 6. There is
mild pulmonary artery systolic hypertension.
.
[**2132-9-17**] Cardiology ECG [**2132-9-19**]: Sinus rhythm; Left axis
deviation; Left bundle branch block; Lateral infarct - age
undetermined; Possible inferior infarct - age undetermined;
Since previous tracing of [**2132-9-16**], inferior Q waves and left
bundle branch block are new
.
[**2132-9-17**] Radiology ABDOMEN (SUPINE & ERECT): Multiple air-fluid
levels and dilated small bowel loops are identified likely
representing postoperative ileus, although obstruction cannot be
ruled out with this study.
.
[**2132-9-16**] Cardiology ECG [**2132-9-18**]: Sinus rhythm; Left axis
deviation; Intraventricular conduction delay; Left ventricular
hypertrophy; Minor nonspecific ST-T wave abnormalities; Since
previous tracing of [**2132-9-16**], no significant change.
.
[**2132-9-16**] Cardiology ECG [**2132-9-17**]: Sinus rhythm; Left axis
deviation; Intraventricular conduction delay; Left ventricular
hypertrophy; Minor nonspecific ST-T wave abnormalities; Since
previous tracing of [**2132-9-16**], no significant change
.
[**2132-9-15**] Cardiology ECG [**2132-9-17**]: Sinus rhythm; Left axis
deviation; IV conduction defect; Possible left ventricular
hypertrophy; Lateral T wave changes are probably due to
ventricular hypertrophy; Since previous tracing of [**2132-9-12**],
anterior T wave abnormalities less marked.
.
[**2132-9-13**] Radiology PORTABLE ABDOMEN: There is a markedly dilated
portion of the colon with additional dilated loops of small
bowel. An NG tube is present, sideport and tip over proximal
stomach. No free air is identified. However, portions of the
abdomen including the lower pelvis are excluded from this supine
view. Compared with [**2132-9-12**], the colonic distension is similar,
possibly slightly less. However, the small bowel distension may
be slightly greater. The pattern, as noted on prior films,
suggest possible cecal volvulus of bascule type.
.
[**2132-9-12**] Cardiology ECG [**2132-9-17**]: Sinus rhythm with PVCs;
Possible left anterior fascicular block; Left ventricular
hypertrophy; Ant/septal and lateral ST-T changes are probably
due to ventricular hypertrophy.
.
[**2132-9-12**] Radiology PORTABLE ABDOMEN: Stable severe distention of
the cecum/ascending colon. The configuration of bowel loop
together with the dilated small bowel loopsbut paucity of air in
the descending and rectum and transverse colon are concerning
for possible cecal volvulus of bascule type.
.
[**2132-9-12**] Radiology ABDOMEN (SUPINE & ERECT): No significant
interval change in severe gaseous distention of the right colon
and small bowel concerning for large bowel obstruction.
.
[**2132-9-12**] Radiology ABDOMEN (SUPINE & ERECT: Findings concerning
for large bowel obstruction beyond transverse colon. Cecal
volvulus is considered less likely given the presence of gas
throughout the transverse colon.
.
Brief Hospital Course:
Patient admitted to surgical service. She was taken to the
operating room on [**9-13**] for rigid sigmoidoscopy, exploratory
laparotomy, lysis of adhesions and right colectomy with
ileotransverse colostomy. On postoperative day #4 she did have
an ileus which did eventually resolve with decompression. Her
oral intake was initially very poor; she was started on Boost
tid. She will require continued Nutrition consult and calorie
counts once discharged to rehab.
Cardiology was consulted for runs of ventricular tachycardia
which patient experienced intermittently; she was asymptomatic
with these events. She underwent cardiac ECHO (see pertinent
results) and serial ECG's; and remained on telemetry throughout
her hospital stay. It was recommended that she be started on
Amiodarone and Lopressor (see medications). Her primary
cardiologist Dr. [**Last Name (STitle) **] was contact[**Name (NI) **]; known history of LBBB, no
known CAD or history of arrhythmias. She will need to follow up
with him after discharge from rehab.
She is currently being treated for a urinary tract infection
with Cipro; course will be completed in 2 days.
Physical and Occupational therapy were consulted and have
recommended short rehab stay.
Discharge Medications:
1. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to affected areas.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): hold for loose stools.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days.
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Begin on [**2132-9-27**].
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR <60 and/or SBP <110.
9. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day as needed for
constipation.
10. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
12. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Cecal vascule
Discharge Condition:
Good
Discharge Instructions:
You were recently started on 2 new medications to help regulate
your heart rate. Be sure to follow up with your primary doctor
and your cardiologist after discharge from rehab.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Surgery Clinic, in 2 weeks. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Completed by:[**2132-9-24**]
|
[
"552.8",
"599.0",
"729.1",
"427.31",
"V10.3",
"560.2",
"V43.64",
"560.1",
"V13.01",
"V58.61",
"789.5",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.08",
"99.04",
"45.73",
"53.9",
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
8655, 8800
|
6191, 7420
|
344, 482
|
8858, 8865
|
1297, 6168
|
9090, 9249
|
1261, 1278
|
7443, 8632
|
8821, 8837
|
8889, 9067
|
267, 306
|
510, 1110
|
1132, 1201
|
1217, 1245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,986
| 139,545
|
20295
|
Discharge summary
|
report
|
Admission Date: [**2129-4-1**] Discharge Date: [**2129-4-5**]
Date of Birth: [**2057-11-16**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
bleeding sphincterotomy site
Major Surgical or Invasive Procedure:
mesenteric angiogram [**2129-4-1**]
History of Present Illness:
71 yo woman who is a poor historian and has a ten-month history
of "feeling sick to my stomach" associated with progressive (20
pound) weight loss. Patient unable to further characterize this
sensation. She may have nausea but has not had emesis; she may
sometimes have dry heaves. She has had progressive anorexia.
She denies fevers, although she has occasional chills. She also
reports sweats that sometimes soak through her bed clothes.
There is no abdominal pain, diarrhea, constipation, odynophagia,
or dysphagia. All of her symptoms got worse two months ago and
then got worse again five days ago. There is some question as
to whether or not all of her symptoms are due to chronic
narcotic (OxyContin) use for DJD pain. Although there is no
other information available, presumably no etiology of her
symptoms has been identified.
For evaluation of her acute-on-chronic discomfort, LFTs were
ordered earlier this week and were mildly elevated. An abdominal
CT scan was therefore performed that showed L intrahepatic
ductal dilatation (mild-to-moderate) and a low-density area in
the head of pancreas (separate from the duodenum). Given concern
for a neoplasm of the pancreas, ampulla, or CBD, or porta
hepatis nodes causing intermittent biliary obstruction, she was
admitted to an OSH [**3-31**] for further w/u. ERCP was therefore done
[**3-31**]. During this study, sphincterotomy and stenting (of the
CBD?) were performed. There was a small sphincterotomy bleed
that stopped spontaneously (3cc), as well as a difficult
cannulation and possible submucosal injection.
On [**4-1**], the patient had a falling Hct and BRBPR. Repeat EGD
with a side-viewing scope showed a sphincterotomy bleed.
Multiple injections with epinephrine were done with temporary
control of bleed, but a nearby site subsequently started to
bleed rapidly. In addition, the stent was no longer seen.
She was given two units of FFP and two units of pRBC and was
transferred to the [**Hospital1 18**] MICU for further evaluation.
...
Pt transfer to [**Hospital1 18**] on evening of [**4-1**] at which time she
received 2 more units of pRBCs and 2 units of FFP. IR attempted
to located source of bleed for embolectomy - but unable to
identify source at time of intervention, so prophylactically
embolized gastroduodenal artery. Pts hct has been stable since
that time and she was trasnfered to the floor . She states that
although stool still dark, the amount of BRBPR has decreased.
STent dislodged and moving down through GI tract.
Past Medical History:
1. PVD
2. bilateral CEA
3. PUD s/p NSAID-induced UGI bleed [**2128**]
4. GERD
5. chronic DJD (on low-dose narcotics)
6. small AAA
7. 2V-CAD s/p LAD stent [**2127-12-25**]
8. dyslipidemia
9. paroxysmal AFib s/p DCCV ~10 years ago
10. anxiety
11. remote EtOH abuse
12. migraine headaches
Social History:
Active smoker with ~50 pack-year smoking history. Currently
smokes [**11-3**] cigarettes daily. No current alcohol use. Denies
illicit drug use.
Family History:
Sister and father had rectal cancer. One cousin had another
unknown malignancy. Extensive cardiac disease on both sides of
the family.
Physical Exam:
Temp 98.1, BP 140/62, HR 76, RR 16, SpO2 98% RA
Gen: Pleasant woman, appears stated age, non-toxic
HEENT: No sinus tenderness, PERRL, OP clear, MM slightly dry
Neck: Soft, supple, no carotid bruits, no cervical adenopathy
CV: RRR with ectopy, normal S1 and S2, II/VI HSM throughout
precordium
Pulm: Bibasilar crackles, coarse breath sounds, scattered
rhonchi, no wheezes
Abd: Soft, NTND, active BS, no HSM
Back: No CVA or spinal tenderness
Ext: No edema, 2+ DP pulses
Skin: Multiple seborrheic keratoses
Pertinent Results:
WBC-9.3 (N-81.3 L-14.0 M-4.5) HCT-28.0 MCV-83 Plt-173
PT-13.4 PTT-27.4 PT-1.1
Na-130 K-3.0 Cl-93 Bicarb-30 BUN-13 Cr-0.9 Glu-90
Ca-8.0 Mg-1.2 Phos-2.8
ALT-78 AST-48 Alk Phos-139 TBili-0.8 [**Doctor First Name **]-267 Lip-390
OSH Labs ([**4-1**] at 1508):
WBC-21.0 (N-91 band-1 L-4 M-4) Hct-34.1 MCV-86 Plt-221
PT 11.7, aPTT 27.4
Na-123 K-3.8 Cl-88 Bicarb-24 BUN-14 Cr-1.1 Glu-382 Ca-7.4
[**3-31**] at 0700:
ALT-57 AST-23 Alk Phos-159 TBili-0.5 Alb-4.0
[**3-28**] at 1500:
ALT-120 AST-121 Alk Phos-215 TBili-0.5 Alb-3.7
OSH EKG ([**2129-3-31**]): NSR at 55 bpm, normal axis, normal intervals,
mildly delayed R wave progression, no ischemic ST segment or T
wave changes.
Brief Hospital Course:
1. Bleeding Sphincterotomy Site: Sphincterotomy at OSH has been
complicated by post-procedural bleeding. The [**Hospital1 18**] GI fellow
discussed the case at length with GI attending at OSH earlier
today. Given the difficulties achieving hemostasis while using
the side-viewing scope earlier today, there appears to be no
role for repeat EGD with a side-viewing scope at this time.
Also, there was initially concern of the possibility that there
may have been migration of the stent upwards into the biliary
tree. The bleeding is also clearly worsened by her recent
clopidogrel use.
As above, on evening of [**4-1**] pt underwent coil embolization of
gastroduodenal artery by IR. Following intervention, her hct was
checked q6hrs in ICU and remained stable around 32-34. She
continued to have melanotic stools [**2-16**] residual blood in tract.
KUB was done to localize stent on admission (to determine
location: in place in biliary tree vs. in intestinal tract vs.
migrated upwards into biliary tree), which was seen initially in
lower right quadrant on admission(ie moving down through GI
tract) and no longer visible on repeat KUB [**4-3**], therefore
assuming that stent was passed with stool. Hct remained stable
throughout remainder of hospitalization at [**Hospital1 18**] without further
transfusions.
2. Nausea and Weight Loss: Etiology unclear, although weight
loss with drenching sweats raises concern for a primary
malignancy. Her recent CT reportedly showed a mass near the
pancreatic head. There is no ERCP report available, so it is
not clear if a mass at the head of the pancreas was seen. Other
possibilities include a primary pulmonary malignancy (maybe
non-small cell with associated SIADH given her hyponatremia) or
a GI malignancy (esophageal? gastric cancer?) given her
difficulty with nausea and trouble swallowing. There is no
palpable cervical adenopathy, although lymphoma is also on the
differential. Presumably she is up-to-date on her colon cancer
screening given her extensive family history, although this
should be verified. Narcotics may also be playing a role here.
Per Dr.[**Name (NI) 54478**] request she will be transfered back to
[**Hospital3 36606**] on [**4-4**] for further w/[**Location 54479**] seen on CT.
3. Hyponatremia: Suspect hypovolemic hyponatremia due to
bleeding and poor po intake recently. HCTZ may also be
contributing. She was given NS with improvement of serum
sodium(130 on admission to 137 on d/c). HCTZ continued to be
held during admission and on transfer.
4. Hyperlipasemia/amylasemia: Likely related to mild, post-ERCP
pancreatitis. Asymptomatic. Pt was already NPO for ? need for
further intervention. Amylase/lipase and LFTs all normalized by
[**4-3**]. Morning of [**4-3**] pt said that she had appetite for the
first time in months, and diet was advanced. While she tolerated
diet without n/v, her appetite was still not impressive when
food came and only nibbled at meals. IVFs at maintance levels
were continued.
5. Leukocytosis: Noted at OSH but now resolved. Etiology
unclear; may simply be a stress response to this acute episode.
There are no reports that the patient has been febrile at the
OSH, although no notes are available. There reportedly was no
concern for cholangitis on admission to the OSH. Also possible
is post-ERCP pancreatitis given the mildly elevated amylase and
lipase. Pt remained afebrile without increase in WBC throughout
admission.
6. CAD: Stable. Given concern for bleeding, clopidogrel (which
she has been taking for stents placed [**12-17**]) was held; unclear
if she still needs this medication. WIll leave up to PCP on
discharge. Clopidegrel continued to be held at time of transfer.
No ASA given h/o UGI bleed. Continued atenolol and atorvastatin
at outpt doses during admit and on transfer.
7. HTN: Not hypertensive on admission. Continued atenolol.
Nifedipine was initally held but restarted without complications
on [**4-2**]. HCTZ continued to be held at time of transfer.
8. GERD: Pantoprazole 40 mg orally twice daily.
9. DJD: Pain control with methadone, gabapentin as per baseline.
10. F/E/N: IV fluids, NPO initially and advanced diet when hct
stable and amylase/lipast normalized on [**4-4**], pt continued to
have poor intake and IVS continued at maintanence. repleted K
and Mg as necessary.
11. Proph: PPI as above, pneumoboots
12. Code: Full
13. Dispo: will transfer back to St [**Hospital1 107**] for further w/[**Location 54480**] seen on CT
Medications on Admission:
1. methadone 20 mg orally twice daily
2. metoclopramide 10 mg orally twice daily
3. gabapentin 300 mg orally three times daily
4. nifedipine 60 mg orally once daily
5. atenolol 100 mg in the morning, 50 mg at night
6. clopidogrel 75 mg orally once daily
7. HCTZ 25 mg orally once daily
8. alprazolam 0.5 mg as needed for anxiety
9. pantoprazole 40 mg twice daily
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
4. Methadone HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
8. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 1495**] [**Hospital 107**] Hospital, [**Hospital1 189**]
Discharge Diagnosis:
Primary
1. Upper [**Hospital1 **] bleed secondary to sphincterotomy w/ significant
blood loss
2. Embolization of gastroduodenal artery
3. Pancreatic Mass (from report from CT scan from OSH)
Secondary
1. Chronic nausea/anorexia/weight loss
2. Peptic ulcer disease
3. Coronary artery disease
4. Severe degenerative joint disease
Primary
1. Upper [**Hospital1 **] bleed secondary to sphincterotomy w/ significant
blood loss
2. Embolization of gastroduodenal artery
Secondary
1. Chronic nausea/anorexia/weight loss
2. Peptic ulcer disease
3. Coronary artery disease
4. Severe degenerative joint disease
Discharge Condition:
Stable w/ hematocrit 30-34 for the past 3 days
Discharge Instructions:
Pt being transfered back to [**Hospital3 36606**] for further work up
and evaluation of mass seen near pancreatic head on CT.
Hct stable 30-33 s/p coil embolization of gastroduodenol artery
by IR on [**4-1**]. Please continue to monitor hct closely.
Followup Instructions:
Continue work-up for abdominal problems and chronic nausea and
weight loss at Saints-[**Hospital1 107**] with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 52855**]
([**Telephone/Fax (1) 54481**]) and gastroenterologist Dr. [**Last Name (STitle) **].
|
[
"414.00",
"V45.01",
"530.81",
"401.9",
"276.1",
"280.0",
"V45.82",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
10407, 10510
|
4744, 9239
|
296, 333
|
11156, 11204
|
4044, 4721
|
11502, 11769
|
3369, 3505
|
9652, 10384
|
10531, 11135
|
9265, 9629
|
11228, 11479
|
3520, 4025
|
228, 258
|
361, 2881
|
2903, 3190
|
3206, 3353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,567
| 154,592
|
3870
|
Discharge summary
|
report
|
Admission Date: [**2204-12-24**] Discharge Date: [**2205-1-3**]
Date of Birth: [**2143-6-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea, wheezing
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
61 y/o female with severe COPD and frequent flares who presents
with dyspnea, admitted to MICU for respiratory distress. She is
on 2L oxygen by nasal cannula at baseline and has required
intubation 2 times for COPD exacerbations. She reports three
days of dyspnea despite using her home nebulizer machine. She
also notes productive cough with greenish sputum. No fever or
chills. No coryza, congestion, sinus pain, headache. No sick
contacts. [**Name (NI) **] chest pain, palpitations.
ROS: occ heartburn. occ constipation, requiring stool
softeners. no BRBPR or melena. reports 'bone pain' with
coughing.
In the ED vitals were: 98.8 168/98 124 32 95% 5L. Lung
exam with diffuse expiratory wheezes and crackles. Given
albuterol nebulizer treatment continuously. Also given
solumedrol 125 IV, mag 2 g IV x 1. Ceftriaxone 1 gram and
levofloxacin 750 mg given. She received an ASA 325 mg and
morphine IV 2 mg. EKG with sinus tachycardia and no acute
changes. She was admitted to the [**Hospital Unit Name 153**] given need for frequent
nebs.
Past Medical History:
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
1. COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66%
(61% and 40% predicted respectively); intubated twice. on 2L
home O2.
2. IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**].
3. CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI
in [**2197**] (chest pain with left arm discomfort). Cath in [**2197**]
with
PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA
and LCx.
4. Hypertension
5. Hyperlipidemia
6. Gastritis, on PPI
7. Osteoporosis, with history of multiple compression and rib
fractures from coughing
8. History of thrush/[**Female First Name (un) **] esophagitis [**12-29**] steroid therapy
9. Depression
10. Tremor
Allergies:
Tetracycline, Bactrim--GI upset
Social History:
She lives with her daughter, [**Name (NI) 6177**], son-in-law and 3
grand-children. She is a widow. She is an ex-smoker, with
about a 30-pack-year smoking history, quit in [**2200**]. No EtOH.
Uses a cane and walker to ambulate.
Family History:
Mother with DM, father with pancreatic cancer.
Physical Exam:
VS: 98.8 143/64 111 25 95% 4L 49kg
GENERAL: thin female, sitting up in bed tremulous, in mild
respiratory distress. Not using accessory muscles, able to speak
in several word phrases.
HEENT: MMM, OP clear, no exudates. non elevated JVP.
HEART: tachycardic, regular rhythm. No murmur.
CHEST/BACK: Kyphosis; ?pes excavatum
LUNGS: Moving air reasonably well with increased expiratory
phase. Decreased breath sounds bilaterally. Bilaterally
expiratory wheeze. +rhonchi.
ABDOMEN: Non-tender. + Distended. + BS.
EXTREMETIES: Muscle wasting to LE, no edema.
NEURO: 4+/5 strength in LE b/l
SKIN: Warm, well perfused.
Pertinent Results:
Labs:
[**2204-12-24**] 02:10PM BLOOD WBC-14.5* RBC-5.19# Hgb-15.2# Hct-47.0#
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.1 Plt Ct-371
[**2204-12-25**] 04:25AM BLOOD WBC-8.2 RBC-4.43 Hgb-12.9 Hct-41.5 MCV-94
MCH-29.2 MCHC-31.2 RDW-13.4 Plt Ct-336
[**2204-12-25**] 04:25AM BLOOD Neuts-93.4* Lymphs-4.4* Monos-1.9*
Eos-0.1 Baso-0.2
[**2204-12-24**] 02:10PM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-141
K-3.8 Cl-97 HCO3-33* AnGap-15
[**2204-12-25**] 04:25AM BLOOD Glucose-159* UreaN-14 Creat-0.8 Na-140
K-5.5* Cl-102 HCO3-33* AnGap-11
[**2204-12-24**] 02:10PM BLOOD CK(CPK)-29
[**2204-12-24**] 02:10PM BLOOD cTropnT-0.02*
VBG [**12-24**]: pH 7.36 / pCO2 66 / pO2 22
EKG [**12-24**]: sinus tach @ 129, nl axis/intervals. no ST-T wave
changes, inferior Q waves (old)
CXR [**12-24**]: Portable upright AP chest radiograph is obtained.
There is a
stable appearance of bibasilar linear opacities, which likely
reflect
atelectasis. There is no evidence of pneumonia or CHF. No
definite pleural effusions are appreciated. Heart size is
grossly unchanged. Mediastinal contour is stable. There is no
pneumothorax. Upper lobe lucency and splaying of
bronchovasculature likely reflects underlying emphysema.
Extensive ribcage deformity and thoracic kyphosis are again
noted.
IMPRESSION:
No significant change. No evidence of pneumothorax.
.
EKG: [**2205-1-2**]:
Sinus rhythm. Q-T interval prolongation. Compared to the
previous tracing
of [**2204-12-25**] the rate has slowed. Otherwise, no diagnostic interim
change.
.
CXR: [**2205-1-2**]:
Lateral aspect of the left lower chest is excluded from the
examination. While there is some obscuration by overlying chest
cage there may be new right perihilar consolidation. Lateral
aspect of the left lower chest is excluded from the examination.
Multiple healed rib fractures are seen on both sides of the
chest. The heart is borderline enlarged. There is no abnormality
of the imaged pleural surfaces. Thoracic aorta is tortuous but
not focally dilated. No pneumothorax.
Brief Hospital Course:
61 y/o female with severe COPD and frequent flares who presents
with dyspnea, admitted to MICU for respiratory distress.
.
The patient was given levalbuterol nebs and solumedrol IV to
treat her COPD. She was intubated for hypoxia. In addition, she
was given azithromycin and ceftriaxone to treat a suspected
pulmonary infection, which might have triggered her COPD flare.
She then had ceftriaxone discontinued, and was extubated two
days later. She did well with decreasing need for nebulizers.
In the morning, she was 100% on 4L NC; she is on 2L NC at home.
She was gradually weaned down on her oxygen. Patient was
initially given solumedrol 125 mg IV every 8 hours, and was
tapered down to prednisone 10 mg daily, which is her home dose.
She was given Atrovent nebulizers. Her sputum cultures were
negative. She then developed altered mental status and agitation
requiring quetiapine and haloperidol, which was attributed to
steroid psychosis and which improved with tapering of her
steroid dose. Her QT was prolonged to 490, which remained stable
with her antipsychotics. She was monitored on telemetry. She was
in restraints at times for her psychosis, but did not require
them in the 24 hours prior to discharge.
.
She was initially ruled out for an MI in the setting of her
shortness of breath, with three negative sets of enzymes and a
CXR which did not suggest heart failure. Her EKG was unchanged.
She was continued on her aspirin and Plavix and her other
cardioprotective medications. She was tachycardic and
hypertensive while in respiratory distress, but this improved
with improvement in her breathing.
.
Her creatinine was slightly elevated on admission to 0.9, which
improved with hydration.
.
She was continued on calcium and vitamin D for her osteoporosis
and her pain was controlled with a fentanyl patch, lidocaine,
nortryptilline and percocet. The nortriptylline was discontinued
in the setting of mental status changes.
.
She remained full code. She was given heparin SC and a PPI for
prophylaxis. Communication was with her daughters.
Medications on Admission:
-Albuterol nebs/INH prn
-Ipratropium Q4H prn
-Simvastatin 20mg po qam
-Clopidogrel 75 mg po daily
-Omeprazole 20 mg po daily
-Fentanyl 25 mcg/hr Patch 72HR
-Oxycodone-Acetaminophen 5-325 mg 1-2 Tabs po Q4-6H prn
-Nortriptyline 25 mg po qhs
-Fluticasone-Salmeterol 500-50 mcg [**Hospital1 **]
-Calcium 500 mg po daily
-Docusate Sodium 100 mg po bid prn
-Prednisone 10 mg daily
-Singulair 10 mg QDay
-MVI
-KCl 20 mEq QDay
-paroxetine 10 mg QDay
-fluticasone nasal 2 sprays QDay
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q2h ().
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
20. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous ASDIR (AS DIRECTED): Per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - at [**Hospital 1263**] hospital
Discharge Diagnosis:
1. COPD exacerbation
2. Steroid psychosis
3. Respiratory failure
4. Bronchitis
5. Acute renal failure
6. Hypertension
6. Pain control for low back pain
Discharge Condition:
Stable
Discharge Instructions:
If you develop worsening trouble breathing, fevers, chills,
nausea or vomiting, please call your primary care doctor or go
to the emergency room.
Followup Instructions:
Please follow up with your primary care doctor in [**11-28**] weeks.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2205-1-15**] 11:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2205-1-15**] 12:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2205-1-15**] 12:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"493.22",
"491.21",
"724.2",
"292.9",
"272.4",
"518.81",
"401.9",
"311",
"733.00",
"333.1",
"584.9",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9636, 9716
|
5233, 7292
|
299, 311
|
9912, 9921
|
3214, 5210
|
10115, 10771
|
2522, 2570
|
7818, 9613
|
9737, 9891
|
7318, 7795
|
9945, 10092
|
2585, 3195
|
242, 261
|
339, 1406
|
1428, 2256
|
2272, 2506
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,954
| 163,143
|
31836+57767
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-9-21**] Discharge Date: [**2177-9-23**]
Date of Birth: [**2158-3-6**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p motorcycle collision
Major Surgical or Invasive Procedure:
ICP monitor
CVL placement
chest tube placement
History of Present Illness:
Pt is a 19F who arrived to [**Hospital1 18**] ED via medlight from the scene
of a motorcycle vs automobile. She was the helmeted passenger
of the motorcycle. The driver the motorcycle was pronounced
dead at the scene. [**Known firstname 44924**] GCS was 3 at the scene. She was
intubated at the scene. Her left breathsounds were decreased
and a L dart was placed for decompression at the scene.
Past Medical History:
none
Social History:
[**University/College 74683**] in [**Location (un) 620**], MA.
Family History:
.
Physical Exam:
upon arrival:
98.8 135 120/p 16 96%intubated
GCS 2T
L pupil 6mm & fixed. R eye swollen and unable to be opened
L oribtal contusion
multiple facial trauma
+breath sounds B/L, L dart present from the field
FAST NEG
pelvis stable
no rectal tone, neg for occult blood
Pertinent Results:
[**2177-9-21**] 07:20PM FIBRINOGE-117*
[**2177-9-21**] 07:20PM PT-17.2* PTT-72.0* INR(PT)-1.6*
[**2177-9-21**] 07:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2177-9-21**] 07:20PM AMYLASE-166*
[**2177-9-21**] 07:20PM UREA N-13 CREAT-0.8
[**2177-9-21**] 07:29PM HGB-11.1* calcHCT-33 O2 SAT-96 CARBOXYHB-2
MET HGB-0
[**2177-9-21**] 07:29PM GLUCOSE-217* LACTATE-2.6* NA+-139 K+-4.0
CL--113* TCO2-19*
Brief Hospital Course:
In the trauma bay the patient was hemodynamically stable with a
GCS of 2T with a +gag reflex. She had evidence of severe facial
trauma. CT scan revealed diffuse cerebral edema resulting in
mass effect on the lateral ventricles, with uncal and downward
transtentorial herniation and effacement of the suprasellar and
basilar cisterns. Neurosurgery was present for immediate
evaluation. A bolt was placed for ICP monitoring, mannitol was
started as well as hypertonic saline. She was brought to the
TSICU. The family was contact[**Name (NI) **] via neurosurgery and told of
[**Known firstname 44924**] extremely poor prognosis. They made immediate plans to
travel from [**State 4565**].
The patient was also evaluated by ortho spine, ortho trauma, &
OMFS. However, given her extremely poor prognosis, treatment was
delayed. NEOB was notified upon arrival to the TSICU.
During the rest of her hospital course the patient was
intermittently hemodynamically unstable with a falling
hematocrit. She was treated with massive volumes of fluid,
blood transfusions, and pressors. On the evening of HD 1 the
patient briefly went into V Tach which resolved before
cardioversion could be performed. Measures were continued to
attempt to decrease her ICP.
The family arrived the morning of hospital day 2 from
[**State 4565**]. Per the patient's and families wishes, NEOB began
discussion of organ donation. On [**2177-9-22**] approximately 9pm the
patient's condition changed significantly with drop in BP
requiring pressors, pupils fixed and dilated, no longer
breathing above the vent. Pt was evaluated by the TSICU fellow
and attending. ICP rose to 100 with CPP = 0. The family was
notified of the change in status and returned to their
daughter's bedside.
On the morning of [**2177-9-22**] the TSICU team performed the brain
death testing and she met all criteria. She was pronounced dead
at 10:25am. The family was again notified. The medical
examiner was notified who accepted the case with the
understanding that her organs would be donated. The NEOB
continued the process of placing her organs with the appropriate
recipients.
Her known injuries include:
1. Diffuse cerebral edema resulting in mass effect on the
lateral ventricles, with uncal and downward transtentorial
herniation and effacement of the suprasellar and basilar
cisterns.
2. Obliteration of the IVth ventricle and tonsillar herniation.
3. Small left-sided subdural hematoma and subdural hematoma
layering over the
tentorium.
4. Small right-sided subarachnoid hemorrhage.
5. Comminuted "burst" fracture of the T2 vertebral body with
small retropulsed fragment occupying the right central canal and
proximal neural foramen without canal stenosis.
6. Associated fracture of the tip of the right superior
articulating facet of the T3 vertebral body, without evident
facetal subluxation.
7. Non-displaced spiral fracture of the left first rib.
8. Extensive contusions involving both lung apices, with tiny
right apical pneumothorax.
9. Small-to-moderate sized medial basal left-sided
pneumothorax.
10. Extensive hemorrhage and edema in the deep dorsal soft
tissues and muscles of the right lower neck, shoulder and upper
back, with noted subcutaneous emphysema.
11. Numerous facial, sinus, maxillary, skull base and mandibular
fractures with involvement of the right carotid canal and left
orbital apex.
12. Tiny right apical pneumothorax.
13. Bilateral diffuse lung opacities representing aspiration or
contusion.
14. Findings consistent with hypoperfusion syndrome/"shock
bowel."
15. Minimally displaced oblique fracture through the right
middle clavicle.
16. Right trapezius, levator scapulae and longissimus
intramuscular hematoma.
Medications on Admission:
birth control patch
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
brain herniation, poly-trauma
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Name: [**Known lastname 12313**], [**Known firstname **] Unit No: [**Numeric Identifier 12314**]
Admission Date: [**2177-9-21**] Discharge Date: [**2177-9-23**]
Date of Birth: Sex: F
Service: Trauma Surgery
This is an addendum to the discharge summary previously
dictated for this patient by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. I was the
surgical attending of record at the time of the patient's
admission to the hospital. In the prior discharge summary
under the entry "History of the Present Illness," it is
stated that the patient was transported from the scene of the
accident which was described as "a motorcycle versus
automobile." I note that no reliable information was
available to any of the treating physicians concerning the
exact circumstances of the incident. We have no knowledge of
whether this was a single vehicle collision with an inanimate
object or with another moving vehicle. Such details are more
reliably obtained from the police reports or from the records
of the transporting entities.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 9968**]
Dictated By:[**Last Name (NamePattern4) 9969**]
MEDQUIST36
D: [**2177-12-30**] 16:29:51
T: [**2177-12-31**] 10:28:56
Job#: [**Job Number 12315**]
|
[
"805.2",
"E812.3",
"810.02",
"807.01",
"860.0",
"958.7",
"802.8",
"348.5",
"868.09",
"427.1",
"900.03",
"801.25",
"861.21",
"802.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5523, 5532
|
1694, 5425
|
319, 368
|
5606, 5616
|
1222, 1671
|
5668, 7169
|
920, 923
|
5495, 5500
|
5553, 5585
|
5451, 5472
|
5640, 5645
|
938, 1203
|
255, 281
|
396, 796
|
818, 824
|
840, 904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,870
| 171,113
|
54007
|
Discharge summary
|
report
|
Admission Date: [**2128-8-3**] Discharge Date: [**2128-8-6**]
Date of Birth: [**2064-6-8**] Sex: M
Service: MEDICINE
Allergies:
Nsaids / Ambien
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
Pill endoscopy
History of Present Illness:
64yo male with history of chronic back pain, Aflutter on
coumadin presenting with complaints of melena x 2 episodes
(Saturday and yesterday), associated with lightheadedness and
shortness of breath which worsened today. Patietn also
complains of nausea but denies vomiting, abdominal pain, or
bright red blood per rectum. He presented to his PCP today with
complaints of general malaise, found to be guaic + and sent to
the ED for further evaluation. He reports taking more ibuprofen
800mg twice daily for a couple of weeks for his chronic back
pain, though reports having stopped the NSAIDs about 2-3 weeks
ago in the setting of abdominal discomfort.
.
In the ED, initial vitals were as follows: 100.2 64 105/66 18
100%. Denied symptoms of orthostasis. 500ccs NS placed on NG
lavage, but only 100cc on return, clear in appearance. Rectal
vault was empty and guaiac negative. His hematocrit was noted
to be 25 (last Hct in OMR was 41 in [**2127**]). Pt was transfused 1u
pRBCs, 1 bag FFP, and started on pantoprazole gtt.
.
On the floor, patient feels overall well. Denies
lightheadedness currently. No abdominal pain, shortness of
breath. States that his stools frequently change in color or
consistency after gastric bypass surgery several years ago.
Past Medical History:
Asymptomatic atrial flutter status post ablation, on warfarin
Right bundle-branch block
Hypertension
Nephrolithiasis
Osteoarthritis
s/p Gastric Bypass (Roux-en-y) surgery about 8 yrs ago
s/p spinal surgery
s/p Right inguinal hernia repair
s/p cataract surgery
- complicated by retinal detachment and blindness of right
eye
- at which time they sent sample of vitrious fluid,
concerning for B cell lymphoma, so he has been followed for this
and had two LPs in last few years, no signs of B cell lymphoma
so far
s/p tonsillectomy
Social History:
Lives with wife. Daughter and son-in-law live nearby.
Tobacco: quit in [**2087**], smoked for about 10 yrs x2ppd.
ETOH: Drinks socially, usually 2 drinks at a time but
infrequently.
Illicits: none
Works as a software engineer, programmer.
.
Family History:
No CAD
Physical Exam:
ADMISSION:
Vitals: T: 98.3 BP: 109/90 P: 64 R: 17 O2: 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mildly dry mucous membranes, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild suprapubic tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
DISCHARGE:
Pertinent Results:
Admission Labs:
[**2128-8-3**] 04:30PM BLOOD WBC-6.3 RBC-2.72*# Hgb-8.3*# Hct-24.7*#
MCV-91 MCH-30.6 MCHC-33.7 RDW-16.5* Plt Ct-262
[**2128-8-3**] 04:30PM BLOOD Neuts-65.3 Lymphs-28.7 Monos-4.4 Eos-1.2
Baso-0.5
[**2128-8-3**] 04:30PM BLOOD PT-23.5* PTT-31.3 INR(PT)-2.2*
[**2128-8-3**] 04:30PM BLOOD Glucose-106* UreaN-22* Creat-0.9 Na-141
K-4.1 Cl-105 HCO3-30 AnGap-10
[**2128-8-3**] 05:05PM BLOOD Lactate-1.4
Discharge Labs:
[**2128-8-6**] 10:55AM BLOOD WBC-7.4 RBC-3.59* Hgb-11.3* Hct-32.0*
MCV-89 MCH-31.5 MCHC-35.3* RDW-15.3 Plt Ct-206
[**2128-8-6**] 10:55AM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-145
K-3.7 Cl-109* HCO3-26 AnGap-14
[**2128-8-6**] 10:55AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0
[**2128-8-5**] 05:10AM BLOOD PT-15.3* INR(PT)-1.3*
Hct Trends:
[**2128-8-3**] 04:30PM BLOOD WBC-6.3 RBC-2.72*# Hgb-8.3*# Hct-24.7*#
MCV-91 MCH-30.6 MCHC-33.7 RDW-16.5* Plt Ct-262
[**2128-8-4**] 02:00AM BLOOD WBC-5.9 RBC-2.87* Hgb-9.0* Hct-24.9*
MCV-87 MCH-31.3 MCHC-36.0* RDW-16.0* Plt Ct-191
[**2128-8-4**] 10:30AM BLOOD WBC-5.5 RBC-3.27* Hgb-10.4* Hct-28.5*
MCV-87 MCH-31.8 MCHC-36.5* RDW-15.6* Plt Ct-186
[**2128-8-4**] 04:15PM BLOOD WBC-5.7 RBC-3.24* Hgb-10.3* Hct-28.9*
MCV-89 MCH-31.9 MCHC-35.6* RDW-15.6* Plt Ct-219
[**2128-8-5**] 02:31AM BLOOD Hct-29.8*
[**2128-8-5**] 05:10AM BLOOD WBC-6.2 RBC-3.25* Hgb-10.3* Hct-29.1*
MCV-90 MCH-31.6 MCHC-35.3* RDW-15.6* Plt Ct-207
[**2128-8-5**] 02:00PM BLOOD Hct-32.0*
[**2128-8-5**] 09:35PM BLOOD Hct-31.3*
[**2128-8-6**] 10:55AM BLOOD WBC-7.4 RBC-3.59* Hgb-11.3* Hct-32.0*
MCV-89 MCH-31.5 MCHC-35.3* RDW-15.3 Plt Ct-206
[**2128-8-3**] 04:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019
[**2128-8-3**] 04:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2128-8-3**] 4:30 pm BLOOD CULTURE - Pending, No growth to date.
EGD [**2128-8-4**]:
-Normal mucosa in the esophagus
-Prior gastric bypass surgery noted, with small erosions in the
pouch but --no ulcerations noted
-Normal mucosa in the roux-n-y limb
Brief Hospital Course:
Assessment and Plan:
64M with hx of hypertension, gastric bypass, presented with
melena and lightheadedness.
.
# GI Bleed
Likely upper GI bleed, potentially secondary to NSAID use.
Patient reported lightheadedness for a few days, concerning for
brisk GI bleed, though he has not had any further melena since
yesterday and reports no BRBPR. He received 2u pRBCs since
presentation with an appropriate rise in his HCT and denies
lightheadedness or orthostatic symptoms currently. INR was
initially 2.2 at presentation patient was treated with 10 mg
Vitamin K as well as one unit FFP with an improvement in INR.
An EGD was preformed by GI which showed normal mucosa through
out the esophogus and roux-en-Y with mild erosions, but no
ulcerations in the remnant pouch. Patient was seen by Surgery
who felt the likely etiology to be related to elevated INR and
NSAIDS. He was placed on a PPI drip, misoprostil and clear
liquid diet. HCT was stable with no signs of bleeding prior to
transfer from the MICU. Hematocrit remained stable with no
further bleeding on the medical floor. He was discharged with
plans for outpt f/u. He was continued on misoprostol and
pantoprazole at the time of discharge.
.
# Aflutter s/p ablation on warfarin: Anticoagulation was
reversed as above. Coumadin was held at discharge, should be
restarted as an outpatient.
.
# Hypertension: Initially held antihypertensives [**2-11**] GIB.
However, they were restarted when there were no further episodes
of bleeding.
.
# Back Pain: Encouraged patient to avoid NSAIDS. Continued home
vicodin.
TRANSITIONAL ISSUES:
- Coumadin and aspirin were held at discharge. Should be
restarted as an outpatient.
Medications on Admission:
BUPROPION HCL - 150 mg Tablet Extended Release 24 hr daily
CLINDAMYCIN PHOSPHATE - 1 % Solution - [**Hospital1 **] PRN to folliculitis
DOXAZOSIN - 2 mg Tablet daily
HYDROCODONE-ACETAMINOPHEN - 10 mg-500 mg Tablet - [**1-11**] Tablet(s)
by mouth q 6 hrs prn
LISINOPRIL - 40 mg Tablet daily
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr daily
MUPIROCIN - 2 % Ointment - apply [**Hospital1 **] to affected area for 7-14
days as needed then stop topical antibiotic
POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Extended
Release
- 2 Tablet(s) by mouth once a day
POTASSIUM CITRATE - (Prescribed by Other Provider) - 10 mEq
(1,080 mg) Tablet Extended Release - [**Hospital1 **]
TRIAMTERENE-HYDROCHLOROTHIAZID - 37.5 mg-25 mg Capsule - daily
WARFARIN - 1 mg Tablet - [**1-14**] Tablet(s) by mouth qd as directed
by
physician
[**Name Initial (PRE) **] - 4 mg Tablet - 1 Tablet(s) by mouth qd as directed by
physician
[**Name Initial (PRE) **] - 5 mg Tablet - 1 Tablet(s) by mouth qd as directed by
physician
.
Medications - OTC
ASPIRIN [ADULT ASPIRIN EC LOW STRENGTH] - 81 mg Tablet daily
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider; OTC) - 1,000 mcg Tablet - 1 Tablet(s) by mouth
weekly
GLUCOSAMINE-CHONDROITIN - (Prescribed by Other Provider) - 750
mg-600 mg Tablet - 2 Tablet(s) by mouth twice a day
IRON-VITAMIN C - (Prescribed by Other Provider; OTC) - Dosage
uncertain
MULTIVITAMIN WITH IRON-MINERAL - (Prescribed by Other Provider;
OTC) - Tablet - 1 Tablet(s) by mouth twice daily
PHENYLEPHRINE HCL [HEMORRHOIDAL SUPPOSITORY] - (Prescribed by
Other Provider) - 0.25 % Suppository - 1 Suppository(s) rectally
[**1-11**] daily as needed
Discharge Medications:
1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
2. clindamycin phosphate 1 % Solution Sig: One (1) Topical
twice a day as needed for folliculitis.
3. doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. hydrocodone-acetaminophen 10-500 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours as needed for Pain.
5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
7. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO once a day.
8. potassium citrate 10 mEq Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
9. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Capsule PO once a day.
10. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a week.
11. glucosamine-chondroitin 750-600 mg Tablet Sig: Two (2)
Tablet PO twice a day.
12. iron-vitamin C Oral
13. multivitamin with iron-mineral Oral
14. phenylephrine HCl Rectal
15. misoprostol 100 mcg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*0*
16. pantoprazole 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:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Upper GI Bleed
Secondary Diagnosis:
Atrial Flutter s/p Ablation
Hypertension
Obesity s/p Gastric Bypass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with lightheadedness and blood in
your stools. You were admitted to the ICU and underwent an
endoscopy. This showed some ulceration in your stomach, which
was likely related to the large amount of pain medications that
you had been taking. You did not have any further episodes of
bleeding.
CHANGES TO YOUR MEDICATIONS:
- STOP coumadin and aspirin. You should discuss with your doctor
about when you should restart these medications.
- START Misoprostol 100 mcg every 6 hours
- START Pantoprazole 40 mg twice a day
- Continue all of your other medications as you had been taking
them previously.
It was a pleasure taking part in your medical care.
Followup Instructions:
Department: [**State **]When: THURSDAY [**2128-8-12**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
**It is recommended that you have a Colonscopy within the next 2
weeks. Please discuss with your PCP the best time to have this
done.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2128-9-8**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"V58.61",
"401.9",
"427.32",
"491.8",
"578.0",
"280.9",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9944, 9950
|
5095, 6664
|
280, 300
|
10118, 10118
|
3036, 3036
|
10973, 11776
|
2428, 2436
|
8504, 9921
|
9971, 9971
|
6797, 8481
|
10269, 10591
|
3464, 5072
|
2451, 3017
|
6685, 6771
|
10620, 10950
|
234, 242
|
328, 1592
|
10027, 10097
|
3052, 3448
|
9990, 10006
|
10133, 10245
|
1614, 2152
|
2168, 2412
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,244
| 121,416
|
48496+59096
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-10-12**] Discharge Date: [**2137-10-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
[**Age over 90 **] year old male with a past medical history of atrial
fibrillation and diabetes mellitus admitted with a one day
history of dysphagia.
.
Patient states that the night prior to admission he was eating
dinner and felt as if food was stuck in his chest. He continued
with his dinner and stopped when he noticed that the sensation
would not abate. Described it as chest pressure, no chest
pain. After dinner he had a glass of water and had an episode
of emesis. He states food or water could not go down. He awoke
in the morning and had similar symptoms of emesis with dysphagia
and decided to go to the ED. He denies odynophagia, sore
throat, fevers, chills, cough. Patient also reports
intermittent episodes of food getting stuck in his chest in the
past 4 months. Patient also with weight loss of 15lbs since
[**7-31**], s/p his right hip surgery, assoicated with decreased
appetite. Patient complains of persistent right lower extremity
pain s/p right hip repair. He denies chest pain, shortness of
breath, abdominal pain, diarrhea, change in stools, melena,
numbness, tingling.
.
In the ED:
V/S T 97.6 HR 71 BP 185/75 RR 16 O2sat 99%
Patient was transferred to the MICU for endoscopy.
.
MICU course:
Patient underwent endoscopy, which found a large food bolus
within the esophagus. The procedure lasted 3 hours [**2-1**]
difficulty in extracting large food bolus. GE junction noted to
be extremely narrowed. Patient tolerated procedure well and was
transferred to the medical floor on [**2137-10-13**] in stable
condition.
Past Medical History:
Atrial Fibrillation
Diabetes Mellitus
Hypertension
Hypothyroidism
Hypercholesterolemia
Coronary Artery Disease s/p CABG - EF 40%
Congestive Heart Failure
s/p TURP
s/p Hip Fracture and recent stay at rehab
Parotid tumor s/p XRT
s/p GI bleed
Glaucoma
Social History:
Home: Lives in [**Location **] with wife who has [**Name (NI) 2481**] Disease;
lives with 24 hour assistance for wife; originally from
[**Country 1931**], lived in [**Country **], and then immigrated to US in [**2090**].
No EtOH use, 40 pack year smoking history, quit 25 years ago,
no IVDA,
Family History:
Mom with Diabetes Mellitus
Physical Exam:
V/S T 99.6 HR 70 BP 100/64 RR 16 O2sat 98% RA
Gen: NAD, lying comfortably in bed, conversing pleasantly
HEENT: EOMI, PERRLA, AT, NC, MMM, oropharynx clear, nares
clear,dry skin on face
NECK: Supple, nl thyroid, nl JVP
CV: +S1, +S2, no M/R/G, RRR
LUNGS: CTAB
ABD: soft, NT/ND, no HSM
EXT: +1 pedal pulses, no peripheral edema
SKIN: dry skin, no rashes
NEURO: AAOx3, CN 2-12 intact
Pertinent Results:
Labwork on admission:
[**2137-10-12**] 05:20PM BLOOD WBC-12.2* RBC-3.49* Hgb-11.6* Hct-34.0*
MCV-98 MCH-33.4* MCHC-34.2 RDW-17.7* Plt Ct-223
[**2137-10-12**] 05:20PM BLOOD Neuts-75.8* Lymphs-15.6* Monos-5.1
Eos-3.2 Baso-0.4
[**2137-10-12**] 05:20PM BLOOD PT-15.1* PTT-25.8 INR(PT)-1.4*
[**2137-10-12**] 05:20PM BLOOD Glucose-63* UreaN-20 Creat-1.6* Na-142
K-3.6 Cl-104 HCO3-25 AnGap-17
[**2137-10-13**] 04:29AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3
[**2137-10-13**] 04:29AM BLOOD WBC-15.7* RBC-3.39* Hgb-11.1* Hct-33.0*
MCV-98 MCH-32.9* MCHC-33.7 RDW-17.9* Plt Ct-208
[**2137-10-13**] 04:29AM BLOOD PT-15.6* PTT-25.6 INR(PT)-1.4*
[**2137-10-13**] 04:29AM BLOOD Glucose-89 UreaN-19 Creat-1.6* Na-145
K-3.3 Cl-107 HCO3-23 AnGap-18
.
STUDIES:
[**2137-10-12**] CXR:
FINDINGS: PA and lateral views of the chest are obtained. A
dual-lead pacer is again noted with lead tips positioned in the
approximate location of the right atrium and right ventricle.
Midline sternotomy wires are noted. There is minimal elevation
of the left hemidiaphragm, with probable left lower lobe
subsegmental atelectasis. No large pleural effusions are seen.
There is no overt CHF. The cardiomediastinal silhouette is
unchanged. There is tortuosity of the thoracic aorta, with
calcification noted along the aortic knob. There is pleural
thickening noted at the apices bilaterally. Scoliosis is noted
in the thoracic spine.
IMPRESSION:
Left lower lobe atelectasis, stable. No acute intrathoracic
process.
.
[**2137-10-13**] CXR:
Single portable radiograph of the chest excludes the left
costophrenic angle. Visualized cardiomediastinal contours are
unchanged compared with [**2137-10-12**]. No consolidation is evident.
There is left basilar atelectasis. No pneumothorax. Trachea is
midline. Patient is status post median sternotomy.
IMPRESSION:
Persistent left basilar atelectasis
.
[**2137-10-14**] Barium swallow:
FINDINGS: The upper portion of the esophagus was patulous with
loss of normal peristaltic wave. Tertiary contractions were seen
in the lower two thirds of the esophagus. The gastroesophageal
junction is widely patent with no evidence of stricture or
intraluminal mass. Mildly prominent folds are seen in the lower
esophagus.
IMPRESSION: No evidence of stricture or esophageal mass. Mildly
patulous upper esophagus with moderate dysmotility.
D/W dr [**First Name (STitle) 679**]
.
PROCEDURES:
[**2137-10-12**] EGD:
ESOPHAGUS:
Contents: A large amount of food was found in the esophagus.
Retrieval of the food bolus was extremely difficult due to the
size of the bolus and the extremely narrowed GE junction.
Decision was made to intubate the patient for airway protection
part way through the procedure. Subsequent food bolus removal
took approximately 3 hours- during which the GE junction was
effectively dilated by an EGD scope, which was initially
difficult to pass, followed by a larger bore therapeutic scope.
The GE junction appeared extremely narrowed, but could be
traversed with gentle pressure by the endoscope and then would
remain open for a period of time. This was felt to be possibly
consistent with achalasia. No mass was seen.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Impression: Food in the esophagus (foreign body removal)
Recommendations: Barium swallow should be next step in
evaluation for achalasia, vs pseuodachalasia vs stricture etc
.
Labwork on discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2137-10-16**] 06:25AM 11.4* 3.17* 10.6* 30.9* 98 33.4* 34.3
17.6* 209
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2137-10-16**] 06:25AM 135* 16 1.5* 140 3.0* 102 28 13
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2137-10-16**] 06:25AM 209
[**2137-10-16**] 06:25AM 13.9* 27.5 1.2*
Brief Hospital Course:
[**Age over 90 **] year old male with past medical history significant for
diabetes mellitus, hypertension, and atrial fibrillation
admitted with dysphagia and found to have food impaction with
decreased esophageal diameter at the GE junction.
.
1) Dysphagia: Patient presenting with acute episode of dysphagia
and food impaction. EGD [**2137-10-12**] showed food impaction and
narrowing of the esophagus at the GE junction which was
traversed and dilated by the EGD scope; no grossly evident
esophageal masses were observed. Barium swallow [**2137-10-14**] showed
no stricture, no narrowing of the GE junction, no esophageal
masses, however, esophageal dysmotility was noted. The patient
was advised to take small bites, chew thoroughly, and eat with
plenty of liquids to aid in esophageal transport of food
boluses. The patient is cleared for a regular diet. The patient
is advised to follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]. Differential
includes peptic stricture, achalasia, esophageal compression,
esophageal ring or neoplasm, all less likely given above
imaging.
.
2) Atrial fibrillation: The patient has been in sinus with
outpatient amiodarone. Patient also on metoprolol. Coumadin
was held for above procedure but was restarted on [**2137-10-16**] with
an INR of 1.2. INR to be followed with adjustment in Coumadin
as needed. Goal INR is 2-2.5.
.
3) Congestive heart failure: History of CHF with EF of 40%.
Euvolemic on exam throughout admission. The patient was
continued on metoprolol 50mg [**Hospital1 **], furosemide 40mg PM daily and
120mg AM, valsartan 80mg daily, isosorbide mononitrate 90mg.
.
4) Right hip fracture status post repair: The patient will be
discharged to a rehabilitation center to continue physical
therapy.
.
5) Macrocytic anemia: The patient's hematocrit during his
hospital stay has ranged from 30-32, with no signs or symptoms
of bleeding. MCV has been 98-103. B12/folate studies showed
normal levels. The patient is advised to follow-up with PCP for
potential myelodysplastic syndrome.
.
6) Hematuria: The patient was noted to have 21-50 RBC in his
urine. A foley catheter had been placed earlier in his course.
The patient is advised to follow-up with primary care doctor
regarding this hematuria.
.
7) Hypothyroidism: Currently stable. The patient was continued
on levothyroxine.
.
8) Glaucoma: Stable. Patient continued on Timolol Drops ou gtt,
Dorzolamide 2% drops tid, and Brimonidine 0.15% ou gtt q8h per
outpatient regimen
.
9)Diabetes Mellitus: Stable with BS 139-135 for the past two
days with PO food intake. Patient to continue on diabetic diet
with humalog insulin sliding scale.
.
10) Chronic kidney disease: Baseline creatinine 1.2 to 1.6.
Medications were renally dosed.
.
11) Depression: The patient was continued on effexor.
.
Code: Full
.
Disposition: [**Hospital3 2558**]
Medications on Admission:
Docusate 100mg PO bid
Amiodarone 200mg PO daily
Levothyroxine 75 mcg PO daily
Atorvastatin 20mg PO daily
Furosemide 120mg PO qAM / 40 mg PO qPM
Valsartan 80mg PO daily
Metoprolol Tartrate 50mg PO bid
Timolol Drops ou gtt
Brimonidine .15% ou gtt q8h
Effexor 75mg PO bid
Dorzolamide 2% drops tid
Imdur 90mg PO daily
ASA 81mg PO daily
Calcium Carbonate 500mg PO qid
Pantoprazole 40mg PO daily
Oxycodone 5mg PO q4h prn
Senna 2 tab PO bid
Bisacodyl 2 tab PO daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Acute Esophageal Food Impaction
Esophageal Dysmotility
Discharge Condition:
Stable, patient is eating well.
Discharge Instructions:
You were admitted into the [**Hospital1 69**]
for treatment of your trouble swallowing food. You had a large
amount of food stuck inside of your esophagus. This was removed
via endoscopy. A Barium Swallow Xray showed that your esophagus
has trouble pushing the food down into your stomach. This is
known as esophageal dysmotility.
You have been instructed to chew small amounts of food during
meals. You are to use fluids when swallowing and you are to
increase your fluid intake during meals to help prevent future
episodes of getting food stuck in your esophagus.
You have been restarted on your Coumadin at 5mg daily. Your INR
should be followed at the rehab facility and your Coumadin
should be adjusted as needed.
You are to continue with your regular home medications as
instructed.
If you experience trouble swallowing, inability to eat or drink,
choking, vomiting, chest pain, shortness of breath, cough,
fevers, nausea, vomiting, diarrhea or any other concerning
symptoms then please call your doctor or report to the nearest
emergency room.
Please attend all follow ups as listed below.
Followup Instructions:
Please follow up with your Primary Care Doctor, Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] on
Monday [**10-28**] at 230pm. [**Telephone/Fax (1) 682**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2138-1-14**] 10:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Name: [**Known lastname 16471**],[**Known firstname 16472**] Unit No: [**Numeric Identifier 16473**]
Admission Date: [**2137-10-12**] Discharge Date: [**2137-10-16**]
Date of Birth: [**2044-4-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4091**]
Addendum:
Problem 3 of the Hospital Course should read, "Chronic systolic
heart failure."
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**First Name8 (NamePattern2) 1558**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2301**]
Completed by:[**2137-11-4**]
|
[
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"414.00",
"530.3",
"E915",
"E849.0",
"593.9",
"935.1",
"272.0",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"42.92",
"98.02",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12492, 12719
|
6737, 9659
|
276, 288
|
10337, 10371
|
2941, 2949
|
11528, 12469
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2483, 2512
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10259, 10316
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9685, 10145
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10395, 11505
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2528, 2922
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6319, 6714
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225, 238
|
316, 1884
|
2963, 6305
|
1906, 2156
|
2172, 2467
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,278
| 191,716
|
34769+57946
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-9-23**] Discharge Date: [**2191-10-11**]
Date of Birth: [**2130-2-1**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Eructation
Major Surgical or Invasive Procedure:
PICC
Abscess Aspiration
History of Present Illness:
Patient is a 61-year-old male, recently discharged on
[**2191-8-18**] from excision of a gastrinoma, who presents with an
difficulty tolerating oral intake due to persistent eructation.
The patient noticed increasing burping approximately 3 days
prior
to presentation. The patient reports persistent, intermittent
episodes of burping which is worsened by food and drink. The
burping occurs approximately 15 minutes after oral consumption
and is worsened while in the seated position. Due to the
eructation, the patient reports decreasing consumption of water
and foods. The patient has also had intermittent episodes of
hiccupping over the same time period. The patient denies
experiencing nausea and has had no episodes of emesis. He
reports decreased amounts of flatus. He reports one bowel
movement since discharge which was described as decreased in
volume without color or consistency changes. He denies
heartburn, difficulty or pain with swallowing, fevers, chills,
or
sweats. There is mild right-upper quadrant pain which can be
exacerbated by palpation. The patient reports some yellowish
discharge the day prior to admission of the left lateral aspect
of the subcostal wound. He denies redness, swelling,
tenderness,
or warmth of this area.
Past Medical History:
Zollinger-Ellsion Syndrome, hypertension,
hypercholesterolemia, gastroesophageal reflux, coronary artery
disease s/p angioplasty, atrioventricular re-entrant
tachycardia.
.
Past Surgical History: Excision of gastrinoma including
antrectomy with Billroth-II repair, open cholecystectomy,
duodenectomy, and regional lymphadenectomy of the portal
lymphatics performed on [**2191-9-8**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.,
at [**Hospital1 **] Hospital.
Social History:
Retired from [**Country 11150**]. Brother and son are part of support network.
Physical Exam:
General: Alert and oriented to all spheres.
Comfortable-appearing gentleman lying in a bed in no acute
distress.
Vital Signs: T 96.6 F (oral); HR 60; BP 100/72; RR 16, 98% RA.
HEENT: Mucous membranes are moist. No jugular venous
distention
noted.
Lungs: Clear to auscultation bilaterally without evidence of
wheezing, rhonchi, or rales.
CV: Regular rate with a regular rhythm. No evidence of
murmurs,
gallops, or rubs.
Abdomen: Clean, dry, and intact subcostal surgical incision is
noted without overt drainage. There are dry dressings over
incision in the right periumbilical area. Abdomen is soft with
mild tenderness of the right upper quadrant. Subcostal incision
site is nontender with no evidence of erythema, edema, or
warmth.
There is no evidence of distention. Bowel sounds are globally
decreased across all four quadrants.
Extremities: Capillary refill is approximately 1-2 seconds.
Bilateral lower extremities are nontender, warm, well-perfused,
and without evidence of pitting edema.
Neurologic: Globally intact, nonfocal.
Pertinent Results:
[**2191-9-23**] 10:40AM BLOOD WBC-10.0 RBC-3.72* Hgb-11.6* Hct-34.0*
MCV-91 MCH-31.2 MCHC-34.2 RDW-14.8 Plt Ct-391#
[**2191-9-26**] 05:21AM BLOOD Glucose-134* UreaN-31* Creat-1.4* Na-138
K-4.2 Cl-108 HCO3-19* AnGap-15
[**2191-9-23**] 10:40AM BLOOD ALT-30 AST-31 AlkPhos-98 Amylase-64
TotBili-0.8
[**2191-9-23**] 10:40AM BLOOD Lipase-102*
[**2191-9-26**] 05:21AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2
[**2191-9-27**] 04:44AM BLOOD Glucose-135* UreaN-29* Creat-1.4* Na-138
K-4.1 Cl-111* HCO3-19* AnGap-12
[**2191-9-25**] 05:10AM BLOOD Triglyc-84
.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2191-9-23**]
12:23 PM
IMPRESSION:
1. Slight thickening of the afferent/efferent limbs at the
gastrojejunostomy junction. Contrast is seen entering both
limbs. Mild gastric distension in addition to these findings
suggests an element of impedance of emptying.
2. Unchanged appearance of bilateral renal hypodensities.
3. Fluid seen within the lesser sac and mesentry as described
above.
.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2191-9-24**] 1:37 PM
IMPRESSION:
1. Left PICC terminates in SVC.
2. No active disease in the chest.
.
Cardiology Report ECG Study Date of [**2191-9-28**] 8:06:32 AM
Probable supraventricular tachycardia at rate 170 with right
bundle-branch
block and non-specific inferolateral repolarization change.
Compared to
the previous tracing of [**2191-9-18**] normal sinus rhythm with
borderline first
degree A-V block has given way to supraventricular
tachy-arrhythmia and the rate has increased from 63 to 170.
Right bundle-branch block persists.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
170 0 126 286/478 0 68 -31
.
[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 147**] FA9A [**2191-9-28**] SCHED
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # [**Clip Number (Radiology) 79648**]
Reason: Assess for fluid collection, infectious process. PO and
IV c
IMPRESSION:
1. Intra-abdominal fluid collections are not significantly
changed, however CT cannot exclude superinfection of these
collections.
2. Although there is no evidence of abnormal dilatation of the
afferent or
efferent limbs of the gastrojejunostomy, the majority of the
oral contrast was still in the stomach at the time of the study.
There is some edema along the jejunostomy.
3. Slight increase in edema in the hepatic flexure.
4. Mild fat stranding in the mesentery and omentum is again
noted, consistent
with recent surgery.
5. Bilateral renal hypodensities are unchanged.
.
Radiology Report PUNC ASP ABS HEM BUL CYST Study Date of
[**2191-9-30**] 8:27 AM
IMPRESSION: Successful CT-guided needle aspirations of right
upper quadrant fluid collection with recovery of a total of 40
cc of pus.
.
EGD [**2191-10-7**]
Normal esophagus.
Stomach:
Lumen: Evidence of a previous Billroth II was seen in the
stomach body. Minimal edema at the anastomotic site which is not
stenotic. Normal-appearing afferent and efferent loops
Duodenum: Normal duodenum.
Impression: Previous Billroth II of the stomach body
Otherwise normal EGD to Afferent and efferent loop
.
[**2191-10-4**] 06:35AM BLOOD WBC-9.4 RBC-3.81* Hgb-11.0* Hct-34.2*
MCV-90 MCH-29.0 MCHC-32.3 RDW-15.3 Plt Ct-259
[**2191-10-6**] 04:31AM BLOOD Glucose-172* UreaN-21* Creat-1.2 Na-137
K-4.1 Cl-106 HCO3-24 AnGap-11
[**2191-10-6**] 04:31AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.1
Brief Hospital Course:
This is a 61 year old male s/p
1. Exploratory laparotomy.
2. Duodenotomy with excision of two lesions for gastrinoma.
3. Antrectomy with Billroth II gastroenterostomy.
4. Open cholecystectomy.
5. Regional lymphadenectomy of the portal lymphatic system.
6. Intraoperative ultrasound.
He returns after being discharged on [**2191-9-18**] with burping and not
able to tolerate POs. A CT showed Slight thickening of the
afferent/efferent limbs at the gastrojejunostomy junction.
Contrast is seen entering both limbs. Mild gastric distension in
addition to these findings suggests an element of impedance of
emptying.
He was NPO with IVF. His abdominal exam was benign. He was not
complaining of pain. He reported +flatus and +BM.
A PICC and TPN was started. Over the next couple days, his TPN
was ramped up to goal and then cycled over night. He still had
much burping and was only taking in small amounts of PO's.
On HD 6, he triggered for acute atrial tachycardia to 180's with
hypotension.
He received carotid massage, Adenosine, Lopressor, IV fluid
Bolus. A cardiology consult was obtained and he was transferred
to the ICU.
He rate was better controlled with beta blocker and his dose was
titrated up.
It was possible that he had an infectious process going on that
was stimulating his tachycardia. He did have fevers to 101.6.
He was pan-cultured and ultimately blood cultures from [**9-28**] grew
out ESCHERICHIA COLI. He was started on ABX. His PICC was D/C'd.
Repeat CT scan demonstrated small intra-abdominal fluid
collections. He went for CT guided aspiration on [**9-30**] of right
upper quadrant
fluid collection with recovery of a total of 40 cc of pus. The
aspirate ultimately grew out pan-sensitive E.Coli. He continued
on Cipro.
He did have several more episodes of self limiting bursts of
rapid atrial tachycardia and had occasional fevers. He required
IVF bolus for hypotension on several occasions. He defervesced
over the next few days and was stable from a cardiac standpoint
and was transferred out to the floor. His Lopressor continued at
37.5mg tid, as well as aspirin and simvastatin.
A new PICC was placed on [**10-3**] and he was restarted on TPN. TPN
was ramped up.
GI: An EGD was performed on [**10-7**] and showed open and patent
limbs with mild residual edema. There were no ulcerations. His
PO diet was then advanced along and calorie counts revealed
adequate nutrition. He did not require TPN for home.
HIT: His platelets dropped and he was found to be HIT positive.
He was switched to Fondaparinux Sodium and discharged home on
Coumadin.
Medications on Admission:
amlodipine 2.5', isosorbide 60', lisinopril 5', metoprolol 25',
omeprazole, simvastatin 40', oxycodone [**5-21**] q6hr, docusate
100''.
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Have
your PCP monitor INR and adjust Coumadin dose accordingly.
Disp:*30 Tablet(s)* Refills:*2*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Check INR 2x/week and call PCP: [**Name10 (NameIs) 79649**],[**Name11 (NameIs) **] at Phone:
[**Telephone/Fax (1) 79650**] with results.
11. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily) for 1 weeks.
Disp:*7 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Failure to Thrive
Delayed Gastric Emptying
Eructation
Abdominal Abscess
Bacteremia
NSVT - Atrial tachycardia
HIT positive
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**10-26**] lbs) for 6 weeks.
* You may shower and wash. No tub baths or swimming.
* Monitor your incision for signs of infections
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 5656**], on Thursday or
Friday. Call [**Telephone/Fax (1) 79650**] to schedule an appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D., Cardiology, on Tuesday [**10-25**]
at 1:00pm. [**Hospital Ward Name 23**] [**Location (un) 436**]. Phone:[**Telephone/Fax (1) 62**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2191-11-4**] 9:00
Completed by:[**2191-10-11**] Name: [**Known lastname **],[**Known firstname 12801**] Unit No: [**Numeric Identifier 12802**]
Admission Date: [**2191-9-23**] Discharge Date: [**2191-10-11**]
Date of Birth: [**2130-2-1**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2083**]
Addendum:
I spoke with PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 12803**] ([**Telephone/Fax (1) 12804**]) and he believes that
Coumadin is not indicated for Mr. [**Known lastname **] based on his HIT +
status. He stated that he would not follow that patient if he
was discharged on Coumadin. He sited various recent articles and
strongly recommended against anticoagulation.
Therefore, based on the PCP's recommendation and the patient's
stable status, he will not be discharged on Coumadin.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2191-10-11**]
|
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icd9cm
|
[
[
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[
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13962, 14126
|
6802, 9382
|
284, 310
|
10987, 10994
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3300, 6779
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1820, 2119
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2231, 3281
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234, 246
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338, 1601
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1623, 1796
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2135, 2216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,975
| 185,270
|
29643
|
Discharge summary
|
report
|
Admission Date: [**2180-1-1**] Discharge Date: [**2180-1-4**]
Date of Birth: [**2107-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
CC:[**CC Contact Info 71061**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72yo man with h/o schizophrenia presented with one day of
coffee-ground emesis. He initially presented to [**Hospital 1263**] hospital
with coffee ground emesis x two hours on day of admission. He
was found by EMS in "pool of black tarry stool". There, he was
given volume and 1units PRBC.
In our ED, initial vitals were 97.1, 104, 99/72, 16, 100% RA. He
was NG lavaged with persistent return of coffee-grounds. He also
had melenotic heme positive stool in the ED. He had two lg bore
peripheral IV's initiated. His hemodynamics were concerning for
HR in the 100s and SBP around 100. He remained stable otherwise.
He received 2L IVF and one unit of PRBC. Hct was 31 at OSH, and
29 on admit to [**Hospital1 18**] ED. He received IV protonix.
Otherwise, he has no history of chronic ETOH abuse, cirrhosis,
known liver disease, or previous known varices. GI was made
aware of his situation. He was transferred to the MICU.
.
Past Medical History:
1. schizophrenia
.
Social History:
Lives at [**Location **] Rest Home.
.
Family History:
none
Physical Exam:
.
vs: 97.1, 102, 25, 102/72, 100% 4lnc
.
gen a/o, no acute distress
neck supple; no JVD
heent dry mucous membranes, dried blood on oral mucosa
cv tachycardic, regular, no m/r/g
resp cta bilat
abd soft, mild epigastric pain
rectal guiaiac pos melenotic stool
extr no c/c/e
neuro no deficits
Pertinent Results:
.
admit EKG:
.
Sinus tachycardia at 100bpm, Nl axis, intervals; Twave
flattening in V2. No acute changes compared to EKG from earlier
same day at [**Hospital 1263**] Hosp.
EGD [**2180-1-1**]:Multiple large non-contiguous linear ulcers
encompassing the entire circumference of the esophagus were seen
at the GE junction. These findings are consistent with severe
erosive esophagitis.
Medium-sized hiatal hernia with evidence of [**Location (un) 25056**] lesions
Erosion and erythema in the cardia compatible with gastritis
Diverticulum in the second part of the duodenum
Suggestion of a Zenker's diverticulum was noted in the proximal
esophagus near the UES.
.
[**2180-1-1**] 08:24PM HCT-24.6*
[**2180-1-1**] 05:49PM HCT-24.6*
[**2180-1-1**] 09:10AM GLUCOSE-91 UREA N-49* CREAT-0.7 SODIUM-140
POTASSIUM-3.5 CHLORIDE-111* TOTAL CO2-21* ANION GAP-12
[**2180-1-1**] 09:10AM ALT(SGPT)-20 AST(SGOT)-23 LD(LDH)-189 ALK
PHOS-82 AMYLASE-21 TOT BILI-0.7
[**2180-1-1**] 09:10AM LIPASE-17
[**2180-1-1**] 09:10AM ALBUMIN-3.3* CALCIUM-7.3* PHOSPHATE-1.1*
MAGNESIUM-2.2
[**2180-1-1**] 09:10AM WBC-10.6 RBC-3.31* HGB-10.1* HCT-28.6* MCV-87
MCH-30.5 MCHC-35.2* RDW-13.4
[**2180-1-1**] 09:10AM PLT COUNT-222
[**2180-1-1**] 09:10AM PT-12.6 PTT-29.9 INR(PT)-1.1
[**2180-1-1**] 06:20AM ALT(SGPT)-27 AST(SGOT)-52* LD(LDH)-540* ALK
PHOS-87 AMYLASE-21 TOT BILI-0.5
[**2180-1-1**] 06:20AM LIPASE-24
[**2180-1-1**] 06:20AM ALBUMIN-3.4
[**2180-1-1**] 06:20AM WBC-12.7* RBC-3.29* HGB-10.2* HCT-29.0*
MCV-88 MCH-30.9 MCHC-35.1* RDW-14.0
[**2180-1-1**] 06:20AM NEUTS-86.2* BANDS-0 LYMPHS-11.1* MONOS-2.6
EOS-0.1 BASOS-0.1
[**2180-1-1**] 06:20AM PLT SMR-NORMAL PLT COUNT-243
[**2180-1-1**] 06:20AM PT-11.7 PTT-25.5 INR(PT)-1.0
Brief Hospital Course:
72yo man with schizophrenia presented with coffee ground emesis
and failed to clear with NG lavage.
.
# Upper GI bleed. The patient presented with hemodynamically
significant coffee-ground emesis and melena. He was mildly
tachycardic and mildly hypotensive (90's/50's) on presentation.
The patient was admitted to the MICU. Emergent EGD revealed
erosive ulcerations in the esophagus and erosive gastritis.
Likely this is secondary to chronic NSAID use. The patient was
placed on a PPI twice daily and all NSAID's were held. He was
initially NPO, though his diet was advanced without problem. The
patient was maintained with an active T&S and 2 large bore
peripheral IV's, though he had no more hemodynamically
significant bleeding. The patient's Hct stabilized around 26-29
and he was transferred to the medicine floor. Of note, the
patient was H. Pylori serology antibody negative. The patient
was given a prescription for repeat Hct check to be completed 5
days after discharge. Iron studies were pending at the time of
discharge.
.
# Zencker's Diverticulum. The patient's EGD revealed a question
of a Zencker's Diverticulum. The patient was sent for a barium
swallow for further evaluation. The patient became extremely
withdrawn and refused the study for unclear reason, though by
his account because the study was unexpected. The patient's
primary care physician was [**Name (NI) 653**] regarding need for
outpatient barium swallow as follow-up on this issue.
.
# Schizophrenia. The patient had an odd affect and
intermittently would become withdrawn and sometimes combative.
He was continued on his home haloperidol, benztropine and
lorazepam with good control. The patient returned to his rest
home upon discharge.
Medications on Admission:
Haldol 5mg [**Hospital1 **]
Cogentin
Ativan 0.5 HS
Motrin 1 tab po prn
Flomax 0.4mg
MVI
Discharge Medications:
1. Outpatient Lab Work
Blood draw: CBC. To be completed 5 days after discharge.
2. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
6. Pantoprazole 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*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Upper GI bleeding
.
Schizophrenia
Discharge Condition:
Stable. Hct stable for several days without signs of active
bleeding.
Discharge Instructions:
You were admitted due to bleeding ulcers in your esophagus and
inflammation of the stomach. The reason for this is likely the
chronic use of non-steroidal anti-inflammatory medications, such
as motrin, which can be very abrasive to the stomach. Please
avoid motrin and other non-steroidal anti-inflammatory
medications. Please take pantoprazole 40mg twice daily 30
minutes prior to breakfast and dinner to prevent recurrence of
this problem. [**Name (NI) **] must have your blood counts measured 5 days
after discharge to insure that you are no longer bleeding.
.
Take all medications as prescribed. The only new medication is
pantoprazole.
.
You will be cared for at your rest home. Follow-up with your
primary care physician.
.
Call your doctor or return to the hosptial for any new or
worsening black or bloody stools, nausea, vomiting, black or
bloody vomit, dizziness or lightheadedness.
Followup Instructions:
You must have your blood counts measured 5 days after discharge
to insure that you are no longer bleeding.
.
You will be cared for at your rest home. Follow-up with your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 36712**] ([**Telephone/Fax (1) **]).
|
[
"E935.9",
"276.8",
"276.51",
"553.3",
"530.19",
"530.6",
"530.21",
"V58.64",
"285.1",
"295.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6051, 6066
|
3511, 5234
|
343, 349
|
6144, 6216
|
1754, 3488
|
7157, 7446
|
1421, 1427
|
5373, 6028
|
6087, 6123
|
5260, 5350
|
6240, 7134
|
1442, 1735
|
273, 305
|
377, 1304
|
1326, 1348
|
1364, 1405
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,838
| 117,120
|
3443
|
Discharge summary
|
report
|
Admission Date: [**2170-1-6**] Discharge Date: [**2170-1-17**]
Date of Birth: [**2095-6-11**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old
male with a history of coronary artery disease, congestive
heart failure, history of deep venous thrombosis and PEs who
presents with complaints of worsening shortness of breath.
The patient was recently admitted to [**Hospital1 190**] from [**12-18**] to the 4th for an asthma
exacerbation. He was treated with Albuterol and Atrovent
nebulizers and placed on Flovent and started on a rapid
steroid taper. The patient showed some mild to moderate
improvement in his shortness of breath. He was noted at that
time to have a known vocal cord polyp, which was believed to
be stable on laryngoscopy down in the Emergency Department.
Since that time the patient was seen by Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**] of pulmonary in clinic on [**2169-12-28**]. Pulmonary
function tests at that time revealed mild restrictive lung
disease and flow volume loop revealed extra thoracic
obstruction.
The patient was diagnosed with vocal cord polyps in [**2169-6-16**] by ENT and it was felt by Dr. [**Last Name (STitle) 217**] that this
was the etiology of the patient's worsening shortness of
breath. Although the patient's symptoms seem to improve with
inhalers and steroids after discharge he noted a one week
worsening shortness of breath upon exertion, worsening
hoarseness and orthopnea. Concurrently the patient's Lasix
dose was changed to 20 mg po q.d. to 40 mg po q.d. on account
that there was a question of whether the patient's congestive
heart failure was exacerbating. The patient denies any
fever, productive cough, change in peripheral edema, pleurisy
or chest pain. The patient denies any dysphagia with food or
liquids, no weight change or night sweats. The patient had a
25 pack year smoking history, but has quit times several
years. No prior history of chewing tobacco. No hemoptysis.
The patient presented to the Emergency Department on [**1-6**]
with increase of inspiratory [**Last Name (un) 15883**]. Chest x-ray was found
to be negative. The patient was satting over 98% on room
air. Given the patient's previous history of pulmonary
emboli a CTA was performed, which showed no PEs. The patient
was also seen by ENT in the Emergency Department secondary to
significant inspiratory and expiratory [**Last Name (un) 15883**] on
examination. The patient was evaluated at that time with
laryngoscopy and it was noted that there was significant
edema and erythema of the false cords and folds bilaterally.
The left true vocal cord was not able to be visualized and
the right vocal cord was immobile. The bilateral arytenoid
was mobile during phonation and inspiration, but without much
mobility at the glottic level. Given the question of a
supraglottitis versus laryngeal mass CT of the neck was
performed simultaneously with the CT angiogram and showed
fullness and thickening of the vocal cords bilaterally with
narrowing of the airway. There was no discreet mass or
abnormal lymphadenopathy noted at that time. Given the
significant narrowing of the airway the patient was started
on Decadron and Ceftriaxone and transferred to the Intensive
Care Unit for monitoring of airway.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft in [**2163**].
2. Congestive heart failure last echocardiogram from [**2166**]
shows biventricular enlargement, systolic dysfunction with an
EF of 25%, moderate mitral regurgitation and pulmonary artery
hypertension.
3. History of atrial fibrillation status post duel chamber
pacemaker and AICD in [**2166**]
4. History of lower extremity deep venous thrombosis status
post IVC filter secondary to PEs bilaterally in [**2168-6-16**].
5. History of retroperitoneal bleed.
6. Hypertension.
7. Gastroesophageal reflux disease.
8. Restrictive lung disease.
9. Hypercholesterolemia.
ALLERGIES: Codeine equals gastrointestinal upset. OxyContin
equals mental status change.
MEDICATIONS:
1. Flovent 220 micrograms four puffs b.i.d.
2. Combivent inhaler four puffs b.i.d.
3. Coumadin 2.5 mg po q.h.s.
4. Lasix 20 mg po q.d. increased recently to 40 mg po q.d.
5. Digoxin .125 mg po q.d.
6. Spironolactone 25 mg po q.d.
7. Zantac 150 mg po b.i.d.
8. Nexium 40 mg po q.d.
SOCIAL HISTORY: No alcohol, 25 pack year smoking history,
quit 40 years ago. Lives with wife. [**Name (NI) **] history of chewing
tobacco. The patient is a singer.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 98.2. Heart rate 50.
Blood pressure 144/85. Respiratory rate 26, 98% on 2 lites.
General, obese male moderately uncomfortable using accessory
muscles to breath. HEENT mucous membranes are moist.
Oropharynx is clear. Neck audible inspiratory and expiratory
[**Last Name (un) 15883**]. No visible abnormalities. Chest diffusely
transmitted inspiratory and expiratory wheeze and [**Last Name (un) 15883**]
bilaterally, decreased breath sounds at the right base.
Cardiac irregularly irregular rhythm, normal S1 and S2.
Abdomen soft, obese, nontender, nondistended, positive bowel
sounds. Extremities left greater then right, 1+ lower
extremity edema, tender to palpation in the bilateral calf.
No clubbing, cyanosis or edema. Neurological alert and
oriented times three, moving all extremities, no focal
abnormalities.
LABORATORY: White blood cell count 19.3, hematocrit 49.4,
platelets 227. Diff 87% neutrophils, 10% lymphocytes.
Chemistry 136, 4.8, 94, 29, 35, 1.0 and glucose 221. Digoxin
level .9, calcium 9.7, phos 3.8, mag 2.0, PT 16.9, PTT 25.8
and INR 1.9. Chest x-ray showed no pneumonia or congestive
heart failure. Neck and CTA showed no PE and fullness and
thickening of the bilateral vocal cords with narrowing of
airway as described above, no discreet mass or
lymphadenopathy. Electrocardiogram showed atrial
fibrillation with frequent premature ventricular
contractions. Significant bigeminy with normal axis, QRS
prolongation, old significance of S wave or R wave in lead
V1, old T wave inversion in lead 1. This was compared with
electrocardiogram from [**2169-12-18**].
HOSPITAL COURSE: The patient was transferred to the MICU for
observation overnight while placed on humidfied air, 10 mg of
Decadron and Ceftriaxone. The plan was in place so that the
patient's status decompensated. He would be started on
Heliox and likely intubated. If intubation were required
fiberoptic assistance would be likely needed. The patient
was started on CPAP at night in order to prevent soft tissue
collapse and was placed on cool nebs throughout the day.
Repeat fiberoptic examination on [**1-7**] revealed mild
epiglottic edema, bilateral false vocal cord edema, limited
PVC motion and limited visualization of the left posterior
vocal cord. Slightly improved laryngeal edema. The follow
up plan was for endoscopy in the Operating Room for
performance of biopsy of the left laryngeal lesion. For
preparation of the procedure the patient's Coumadin was held
and he was started on a heparin drip. The patient was also
evaluated by cardiology and with echocardiogram to rule out
any valvular abnormalities or significant atrial thrombus
secondary to atrial fibrillation.
Repeat echocardiogram showed an EF less then 20% with severe
left ventricular dilatation. The plan was for the patient to
continue Carvedilol at 6.25 mg b.i.d., Aldactone, Lasix and
Digoxin. Of note the patient also had significant atrial
fibrillation with tachybrady events. He was rate controlled
with beta blockade and Digoxin. At times he dropped his rate
down into the 40s, but with over symptomatic or dropped his
blood pressure. When evaluated by EP to assess his pacemaker
EP noted that the patient's pulse was only palpable every
other beat secondary ventricular bigeminy and that his pacer
was functioning perfectly well. Ultimately on [**2170-1-10**] the
procedure was performed after the patient's INR was
satisfactory. Biopsy of the left vocal cord lesion and right
vocal cord lesion were done by Dr. [**First Name (STitle) **]. Following the
procedure the patient was given 12 mg of intraoperative
Decadron and an endotracheal tube was placed secondary to
narrow airway. The patient was returned to the MICU
following the procedure. Pathology quickly returned, which
showed a squamous cell carcinoma of the larynx. The left
true vocal cord and commissure lesion showed an invasive and
in situ squamous cell carcinoma moderately differentiated.
On the right vocal cord lesion there was an invasive squamous
cell carcinoma also moderately differentiated.
In addition to biopsy there was small amount of debulking,
which was done at the time of the procedure. Following the
procedure the Ceftriaxone which discontinued as it was used
as a prophylactic medication for any possible laryngeal
infection. Following the biopsy it was known that the edema
was more consistent with tumor and therefore the Ceftriaxone
was discontinued. Dexamethasone was continued as was
Albuterol and Atrovent and the patient's intubation. A
repeat laryngoscope was performed on [**1-11**] through the ET
tube. Trachea was found to be clear with slight secretions.
The nose, tongue base and epiglottis were all found to be
stable. The larynx showed some edema, but decreased
erythema. The patient was extubated on [**2170-1-12**] in the
presence of anesthesia. The possibility for tracheostomy
following the extubation or any time in the future was
discussed with the patient and the family, but was not felt
to be necessary during this hospital stay.
On [**1-13**] the patient was transferred from the MICU out to the
medical [**Hospital1 **]. The patient showed no further evidence of
[**Last Name (un) 15883**] status post extubation. The Dexamethasone was
tapered. In regard to the patient's vocal cord lesion and
new diagnosis of squamous cell carcinoma he was followed by
his ENT Dr. [**First Name (STitle) **] while in house. The plan is for the patient
to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3311**] at [**Hospital3 328**] Cancer
Institute. The patient was given the phone number
[**Telephone/Fax (1) 15884**] to contact Dr. [**First Name (STitle) 3311**] since Dr. [**First Name (STitle) **] was unable
to arrange an inpatient consult. Given the patient's airway
has remained stable for several days he was evaluated by
physical therapy and felt to be an excellent rehab candidate.
The plan is for the patient to follow up with Dr. [**First Name (STitle) 3311**] for
a possible chemotherapy versus radiation next week. It is
possible still that the patient may require tracheostomy
during his cancer treatment.
Of note, the patient also experienced left upper extremity
edema in the last few days during his hospital stay. An
ultrasound revealed a deep venous thrombosis in the left
axillary vein extending to the brachial veins. No deep
venous thrombosis was evident in the jugular or subclavians.
The patient was restarted on heparin and his Coumadin dose
was increased to 5 mg po q.h.s. secondary to his previous INR
goal for atrial fibrillation. The patient denies any new
shortness of breath and reported that his [**Last Name (un) 15883**] symptoms
had significantly improved. The patient was persistently
hoarse and noted more psychosocial damage secondary to the
fact that he would never be able to sing again. The patient
completed his Decadron taper on [**2170-1-15**] and is
presently being evaluated for rehab placement.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Squamous cell carcinoma of the bilateral vocal cords.
2. Left upper extremity deep venous thrombosis.
3. Atrial fibrillation.
4. Congestive heart failure.
5. Coronary artery disease.
6. Asthma.
7. History of PEs status post IVC filter placement.
8. Status post pacemaker and AICD placement.
DISCHARGE MEDICATIONS:
1. Digoxin .125 mg po q.d.
2. Captopril 12.5 mg po t.i.d.
3. Carvedilol 6.25 mg po b.i.d.
4. Albuterol MDI four puffs q 6 hours prn wheezing.
5. Lansoprazole 30 mg po q.d.
6. Lasix 40 mg po q.d.
7. Ativan .5 to 1 mg po q 4 to 6 hours.
8. Atrovent MDI two puffs q.i.d.
9. Flovent 110 micrograms four puffs b.i.d.
10. Colace 100 mg po b.i.d.
11. Senna 8.6 mg tab po b.i.d. prn.
12. Albuterol nebulizes q 6 hours prn.
13. Coumadin 5 mg po q.h.s.
14. Regular insulin sliding scale as described and page one.
FOLLOW UP PLANS: The patient is being transferred to a
rehabilitation facility where he will receive physical
therapy. The plan is for the patient to follow up next week
with Dr. [**First Name (STitle) 3311**] at [**Hospital3 328**] Institute for possible
treatment of his squamous cell carcinoma. The patient will
also follow up with his primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 1270**]. The patient's INR should be followed given his
recent change in Coumadin dose and recent antibiotic
Ceftriaxone. Additionally, the patient's finger sticks
should be done on a q.i.d. basis until they have normalized
and sliding scale insulin should be administered prn. Most
likely the patient's glucose should resolve to normal in the
immediate future given that his Decadron has since been
discontinued. The patient is to follow up in the Device
Clinic in three months to have his pacemaker checked. The
patient's sodium should also be followed. It was slightly
low during his hospital stay on the [**1-16**] it was 132.
This is believed to be secondary to the patient's Lasix. No
intervention is required at this time, but follow up so it
does not continue to decrease should be continued. The
patient should be continued on a cardiac diet.
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2362**]
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2170-1-17**] 09:59
T: [**2170-1-17**] 10:08
JOB#: [**Job Number 15886**]
|
[
"424.0",
"428.0",
"V45.81",
"161.0",
"530.81",
"427.31",
"272.0",
"707.0",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"31.43"
] |
icd9pcs
|
[
[
[]
]
] |
4603, 4621
|
11717, 12020
|
12043, 14108
|
6276, 11662
|
4644, 6258
|
169, 3344
|
3366, 4417
|
4434, 4586
|
11687, 11696
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,704
| 198,498
|
49663
|
Discharge summary
|
report
|
Admission Date: [**2178-2-10**] Discharge Date: [**2178-2-11**]
Date of Birth: [**2133-10-18**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 103861**]
Chief Complaint:
difficult to extubate
Major Surgical or Invasive Procedure:
left knee arthroscopy
History of Present Illness:
44 y/o male with PMH asthma, hypertension, GERD s/p L knee
arthroscopy today for meniscal tear who now presents to [**Hospital Unit Name 153**]
after difficulty extubating. [**Name (NI) 101830**], pt was initially
given LMA but was converted to ETT intraoperatively secondary to
?"floppy epiglottis". Pt could not be extubated successfully in
the post-op period so pt was admitted to MICU overnight for
continued ventilation overnight with plan to extubate in
morning.
Intraoperatively, pt was given 3200ccLR, transferred to [**Hospital Unit Name 153**] on
propofol and versed, HD stable, on SIMV ventilation
TV750/rate10/FIO250%/PEEP 5. ABG on that setting 7.33/51/98,
lactate 3.8. CXR with R middle and lower lobe haziness with
obscuring of R hemidiaphragm.
Past Medical History:
1. Asthma
2. HTN
3. GERD
4. exploratory laparotomy following stab wound to abdomen
Social History:
pt is firefighter. denies IVDA, tob use. Occ EtOH.
Physical Exam:
T 96.4 BP 114/66 P75 R12 Sat 96-97%
Vent SIMV 750/10/100%/5
Gen: sedated, intubated
HEENT: pupils pinpoint
Neck: supple, JVD diff to assess given thick neck
CV: RRR, no m/r/g
Pulm: CTA anteriorly, no wheezing
Abd: s/nt/nd hypoactive BS
Ext: no edema, +2 DP pulses bilat, L knee with ice pack and foam
immobilizer in place, mild serosanguinous drainage on gauze
covering wound
Pertinent Results:
[**2178-2-10**]
11:42p
140 102 18 / AGap=15
------------- 150
4.3 27 0.9 \
Ca: 9.2 Mg: 2.0 P: 4.5
87
8.2 \ 13.8 / 273
/ 39.1 \
N:89.1 L:9.9 M:0.8 E:0 Bas:0.2
PT: 13.0 PTT: 25.4 INR: 1.1
[**2178-2-10**]
11:33p
pH7.36 pCO244 pO296 HCO326 BaseXS0 Type:ArtLactate:3.2
CXR IMPRESSION:
1. Satisfactory positioning of endotracheal tube.
2. Right basilar opacity, which could reflect infiltrate versus
aspiration.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] W.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on WED [**2178-2-11**] 7:31 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 103862**]
Service: ORT Date: [**2178-2-10**]
Date of Birth: [**2133-10-18**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) 1692**] [**Last Name (NamePattern4) 103863**], [**MD Number(1) 103864**]
PREOPERATIVE DIAGNOSIS:
1. Torn lateral meniscus left knee.
2. Neuropathy with atrophy of the left quads and left calf.
PRIMARY CARE PHYSICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
[**Known firstname **] presented with a magnetic resonance imaging scan dated
[**2177-12-30**]. I reviewed that image. He has a thick tear of
the lateral meniscus. He has a positive [**Doctor Last Name 103865**]. The
risks and benefits of arthroscopic for torn lateral meniscus
were discussed and understood. He is a firefighter from
[**Location (un) **].
[**Known firstname **] was brought to the outpatient Operating Room and
induced under general anesthesia, prepped and draped in the
usual manner. The left lower extremity was outlined per his
topographical landmarks. A 4 mm stab wound was placed in the
anterior lateral Hardy-[**Doctor Last Name **] triangle. A 4 mm [**Doctor Last Name 79**]
arthroscope, 30 degree lens, was inserted. The knee was
distended with saline. High outflow cannula was placed
superior and medial to the patella. With transillumination a
working portal was established in the anterior medial.
There was marked synovitis within the knee and a very
metaplastic fat pad that, with the ligamentum mucosum encased
the entire ACL. At this point the articular cartilage of the
patella showed grade 3 changes particularly of the medial
facet. The trochlea just appeared age appropriate. We
performed a synovectomy along the medial gutter up under the
inferior pole of the patella and down to the ligamentum
mucosum. This was lysed and then we resected the interior 60
percent of the inflamed infrapatellar fat pad ([**Last Name (un) 75398**]
lipoiditis) and continued the synovectomy up the lateral
gutter which was impacted with synovium metaplasia. Once the
major synovectomy was completed, we were able to visualize
the medial compartment. The articular cartilage looked fine.
The medial meniscus was lax and had loss of hoop tension,
however, it was serially visualized on the inferior and
superior surfaces and was intact.
The anterior cruciate ligament was intact.
In the modified figure-of-four position we found a radial
tear right at the mid point of the lateral meniscus as well
as a tear of the anterior [**Doctor Last Name 534**]. The meniscus was discolored
and there was mucoid degeneration in the horizontal cleavage
portion of the meniscal tear. With a series of hand meniscal
punches, we trimmed it back to a stable rim. We then used
the Mitek thermal radiofrequency wand for part of the more
degenerate parts of the lateral meniscus. This will give us
more stability. The knee was then copiously lavaged,
vacuumed, reinspected, and no further mechanical derangement
was noted.
[**Known firstname **] tolerated the procedure well. He had some asthmatic
symptoms at the end and was taken to the Recovery Room
intubated and on pulse oximeter and we will order an x-ray at
the recommendations of the anesthesiologist.
[**First Name11 (Name Pattern1) 1692**] [**Last Name (NamePattern4) 103863**], [**MD Number(1) 103864**]
Dictated By:[**Last Name (NamePattern4) 103866**]
Brief Hospital Course:
1. s/p left knee arthroscopy - procedure went well. Will need to
f/u with Ortho (Dr. [**Last Name (STitle) 13355**] as outpatient, scheduled already
[**2-13**]. Ortho resident = [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18732**] [**Telephone/Fax (1) 103867**], pager [**Numeric Identifier 56149**]
2. Hypoxia/difficulty extubating - The patient had a difficult
intraoperative course from respiratory standpoint and required
conversion from LMA to ETT for "floppy airway" and was difficult
endotracheal intubation. Unclear if pt may have aspirated during
surgery or post-operatively given CXR findings, elevated
lactate, and aspiration PNA vs pneumonitis may be contributing
to difficulty weaning from vent. He had stable ABG's overnight
and RSBI of 24 and was extubated without difficuty the next
morning with anaesthesia present.
3. Elevated lactate - elevated, ranging between 3.2 to 3.9. Not
acidotic and anion gap is 12. Unlikely sepsis/aspiration
pneumonia as patient is clinically stable and afebrile without
evidence of hypoperfusion.
4. Asthma - No wheezes on exam. Given albuterol MDIs Q4H
through ventilator overnight but given normal PIP and plateau
pressures unlikely asthmatic.
5. GERD - PPI IV was continued.
6. HTN - HCTZ was held
Medications on Admission:
HCTZ
protonix
albuterol prn
ibuprofen prn
Discharge Medications:
HCTZ
protonix
albuterol prn
Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 30
days.
Disp:*30 Tablet(s)* Refills:*0*
Darvocet-N 100 100-650 mg Tablet Sig: 1-2 Tablets PO every [**3-4**]
hours for 2 days: no more than 6 pills total per day.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left knee arthroscopy
aspiration pneumonitis
Discharge Condition:
patient was frustrated that he had been intubated. He was
eating, walking, drinking, and sats were good on room air.
Discharge Instructions:
Weight bearing on your legs as tolerated.
Change knee dressing in 2 days and put band-aids over the
incisions.
You may shower in 5 days.
Resume your home medications - protonix and HCTZ, plus take 1
aspirin daily for the next 30 days.
Return or call your doctor if you have fevers, chills, increased
pain or other concerns.
Followup Instructions:
With Dr. [**Last Name (STitle) 13355**] on [**2178-2-13**] as scheduled:
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ORTHOPEDIC PRACTICE Where: [**Doctor Last Name **]
ORTHOPEDIC PRACTICE Date/Time:[**2178-2-13**] 10:30
|
[
"518.81",
"530.81",
"E928.9",
"997.3",
"355.8",
"836.1",
"493.90",
"507.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.76",
"80.6",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7567, 7573
|
5891, 7166
|
344, 367
|
7662, 7780
|
1743, 5868
|
8156, 8434
|
7258, 7544
|
7594, 7641
|
7192, 7235
|
7804, 8133
|
1346, 1724
|
283, 306
|
395, 1157
|
1179, 1263
|
1279, 1331
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,065
| 143,576
|
41556
|
Discharge summary
|
report
|
Admission Date: [**2197-3-5**] Discharge Date: [**2197-3-12**]
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Bleeding after L partial nephrectomy
Major Surgical or Invasive Procedure:
Angiogram
History of Present Illness:
88yo F with recent partial nephrectomy for renal cell carcinoma
on [**2-20**], afib on coumadin, AS s/p [**Month/Year (2) 1291**] (CoreValve - porcine
valve) now presenting with bleeding from surgical site after
restarting her coumadin after her surgery. Patient had pain in L
side for 1 day prompting her to present to the OSH ED. At OSH
found to have extravasation from her nephrectomy site on CT and
found to have hct of 24 (27 on [**2-26**]). She received 3 units ffp,
2units prbcs, and PO vit k for reversal prior to transfer.
Admitted to TSICU for monitoring and frequent hct checks.
Past Medical History:
1. Hypertension
2. DM type II, mild (A1c 7% in [**5-/2196**])
3. Dyslipidemia
4. Pacemaker implanted on [**2186**] ([**Company 1543**] St. [**Male First Name (un) 923**]), device
changed in [**2193**] ([**Company 1543**] NWR20022LH, SESR01) for sick sinus
syndrome. Note acute onset of anterograde memory deficit
coinciding with the [**2186**] procedure (see above).
5. Atrial fibrillation (was on coumadin, discontinued prior to
surgery on Monday, currently only on aspirin 81mg)
6. Aortic valve repair (percutaneous) [**5-/2196**], previously on
ASA+Plavix.
7. Dementia since [**98**] year ago, after the pacemaker surgery per
family, steady since.
8. Hyperthyroid s/p radioactive iodine
9. CHF, on Lasix; improved (less [**Location (un) **] and less pulm edema per
dtr)
since [**Name (NI) 1291**] last year. Still sleeps last few hours of night
sitting
up in recliner some mornings.
10. PUD
11. h/o hysterectomy, s/p cholecystectomy
Social History:
Lives with husband.
-Tobacco history: 7 pack year history, quit 70 years ago
-ETOH: Denies
-Illicit drugs: Denies
Family History:
She and family deny any Family history Neurologic disease. No Hx
of early MI, arrhythmia, cardiomyopathies, or sudden cardiac
death.
Physical Exam:
NAD
Chest clear to auscultation
Abdomen soft, NT, ND
Incisions c/d/i, steris
Right femoral access site c/d/i
L chest tube insertion site c/d/i
Brief Hospital Course:
Patient was admitted to the ICU after receiving 3 units FFP, 2
units pRBC, and vitamin K at OSH. She underwent an angiogram
that revealed no evidence
for active extravasation, pseudoaneurysm or early draining vein.
She had evidence of L pleural effusion for which a pigtail
catheter was placed. That was removed after one day. She had
some renal failure after receiving dye load which resolved with
gentle hydration and restarting her home diuretic regimen. She
had a chest x-ray prior to discharge which revealed stable
atelectasis and pleural effusion. She will have follow up with
Nephrology and restart her Coumadin on Thursday [**2197-3-16**] per
advice of her Cardiologist, Dr. [**Last Name (STitle) **].
Medications on Admission:
Coumadin 2.5 mg daily
aspirin 81 mg daily
pravastatin 20 mg PO HS
rivastigmine 3 mg [**Hospital1 **]
memantine 10 mg PO BID
furosemide 40 mg every other day: alternating with 80mg dose
levothyroxine 125 mcg PO DAILY
tiotropium bromide INH
losartan 25 mg DAILY
docusate sodium 100 mg PO BID
latanoprost QPM
glipizide ER 2.5mg daily
Discharge Medications:
1. rivastigmine 3 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
4. furosemide 40 mg Tablet Sig: Two (2) Tablet PO MWF
(Monday-Wednesday-Friday).
5. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/fever.
7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
11. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Start on Thursday [**2197-3-16**].
Discharge Disposition:
Home With Service
Facility:
VNA South Eastern [**State 2748**]
Discharge Diagnosis:
Bleeding after partial nephrectomy
Discharge Condition:
Stable
Alert and Oriented x 3
Ambulatory with assistance
Discharge Instructions:
-Tylenol should be your first line pain medication
-You may shower but do not bathe, swim or immerse your incision.
-Do not eat constipating foods for 2-4 weeks
Followup Instructions:
-Call Dr.[**Name (NI) 11306**] office ([**Telephone/Fax (1) 8791**] ‎for follow-up
AND if you have any questions (page Dr. [**Last Name (STitle) 3748**] at [**Telephone/Fax (1) 2756**]).
[**Hospital **] [**Hospital 10701**] clinic Phone:
([**Telephone/Fax (1) 10135**] for follow up appointment
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,972
| 103,761
|
18938
|
Discharge summary
|
report
|
Admission Date: [**2138-9-17**] Discharge Date: [**2138-10-28**]
Date of Birth: [**2068-3-23**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Bright Red Blood per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70 yo female with myelodysplastic syndrome, chronic renal
insufficiency secondary to cyclosporine, extensive GI bleeding
over the past several years, presenting with multiple episodes
of BRBPR starting on the morning of admission. Pt was initially
admitted to the OMED service with a hct drop of 4 points and was
transfused 2U PRBC and 3U pf HLA matched platelets for a
platelet count of 14. She was also given DDAVP for presumed
dysfunctional platelets. She was hemodynamically stable. Last
night she was also found to be febrile and was started on
Cefepime and Flagyl and then changed over to Zosyn as she
complained of severe nausea on Flagyl.
This am the patient developed worsening BRBPR and again had one
bloody stool with associated abdominal pain as well as
hypotension with a systolic BP of 90 and tachycardia. She was
transfused another 3U PRBC and her BP and HR normalized again.
The patient then went to nuclear medicine and subsequently was
transferred to the ICU for closer monitoring.
.
ROS: negative for lightheadedness, chest pain, palpitations,
SOB, dysuria or altered mental status. She reports fatigue, mild
cramping abdominal pain, and increased number of echymoses
across her abdomen, arms, and legs.
Past Medical History:
1) Aplastic anemia/Hypocellular myelodysplastic syndrome with
trisomy 8 and 21. s/p high dose prednisone and gamma globulin,
s/p Anti-thymocyte globulin therapy [**2126**], on cyclosporine since
with renal insufficiency; started IVIG q3 weeks [**2138-7-10**]
2) s/p terminal ileum resection [**3-26**] for multiple bleeding
ulcers
3) h/o candidemia with [**Female First Name (un) 564**] parapsilosis
4) Renal insufficiency (recent baseline Cr 1.2 - 1.6)
5) Hypertension
6) h/o hypercholesterolemia
Past Surgical History:
- TAH/BSO [**2-21**] fibroids
- Appendectomy
- Venous stripping LLE
Social History:
Married, 5 children. Does not smoke, drink alcohol or coffee
Family History:
Mother died of scleroderma, father died of CAD
Physical Exam:
Vital signs: T:100.4, HR 80, RR 20, Sats 94% ra
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI, no scleral icterus noted, MMM, white
patches on oropharynx consistent with thrush.
Neck: supple, no JVD no lymphadenopathy
Pulmonary: Lungs CTA bilaterally, no crackles or wheezes. equal
aeration bilaterally.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. purpura across her abdomen
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: purpura and echymoses across arms, legs and abdomen.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: Plantar response was flexor bilaterally.
Pertinent Results:
[**2138-9-17**] 09:31PM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.018
[**2138-9-17**] 09:31PM URINE BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2138-9-17**] 09:31PM URINE RBC-2 WBC-6* BACTERIA-MOD YEAST-NONE
EPI-3
[**2138-9-17**] 07:31PM WBC-2.1* RBC-2.68* HGB-9.5* HCT-26.9*
MCV-101* MCH-35.3* MCHC-35.1* RDW-21.0*
[**2138-9-17**] 07:31PM PLT COUNT-19*
[**2138-9-17**] 02:05PM PLT COUNT-36*#
[**2138-9-17**] 11:50AM GLUCOSE-129* UREA N-42* CREAT-1.7*
SODIUM-131* POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-21* ANION
GAP-13
[**2138-9-17**] 11:50AM ALT(SGPT)-81* AST(SGOT)-39 LD(LDH)-265* ALK
PHOS-38* TOT BILI-1.0 DIR BILI-0.5* INDIR BIL-0.5
[**2138-9-17**] 11:50AM ALBUMIN-3.1* CALCIUM-8.0* PHOSPHATE-2.2*
MAGNESIUM-1.5*
[**2138-9-17**] 11:50AM WBC-2.5*# RBC-2.35* HGB-8.4* HCT-24.8*
MCV-105* MCH-35.7* MCHC-33.9 RDW-20.3*
[**2138-9-17**] 11:50AM NEUTS-93* BANDS-0 LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2138-9-17**] 11:50AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2138-9-17**] 11:50AM PLT SMR-RARE PLT COUNT-14*#
[**2138-9-17**] 11:50AM PT-11.6 PTT-20.6* INR(PT)-1.0
[**2138-9-17**] 11:50AM GRAN CT-2325
.
Imaging:
CXR: Single AP view of the chest reveals the tip of a port line
in the SVC in satisfactory position. The mediastinum is
midline. There is peribronchial thickening and increased
markings in both lung bases without gross consolidation however
early pneumonitis in the left lower lobe cannot be excluded.
.
Nuclear bleeding scan: negative per oral report
CHEST (PORTABLE AP)
Reason: progression of opacities, likely PCP [**Name Initial (PRE) 1064**]
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with myelodysplastic syndrome, with fever and
neutropenia, with decreased o2 sats and SOB.
REASON FOR THIS EXAMINATION:
progression of opacities, likely PCP pneumonia
HISTORY: Fever. Shortness of breath.
Single portable radiograph of the chest demonstrates similar
cardiomediastinal contour to that seen on [**2138-10-15**]. Right-sided
Port-A-Cath remains unchanged. Increased opacity involving the
bilateral lungs remains similar in appearance. There is very
mild blunting of the bilateral costophrenic angles. Trachea is
midline.
IMPRESSION:
No interval change.
CT CHEST W/O CONTRAST [**2138-9-28**] 3:47 PM
CT CHEST W/O CONTRAST
Reason: please evaluate for infiltrates
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with MDS fevers, acute hypoxia
REASON FOR THIS EXAMINATION:
please evaluate for infiltrates
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT of the chest without contrast.
INDICATION: 70-year-old female with history of myelodysplastic
syndrome presenting with fevers, acute hypoxia. Assess for
infiltrates.
COMPARISONS: [**2138-9-24**].
TECHNIQUE: MDCT axial images of the lungs are acquired. Coronal
and sagittal reformatted images were then obtained.
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There are several,
subcentimeter mediastinal lymph nodes. No pathologically
enlarged axillary or hilar lymph nodes are present. A small
pericardial effusion is relatively unchanged in size compared to
the examination four days prior. A moderate- to large-sized
hiatal hernia is also again noted.
Lung windows demonstrate dramatic interval change with diffuse,
ground-glass opacities present throughout both lungs, mostly new
compared to the previous examination. A few pulmonary nodules
within the right lung are again noted and unchanged compared to
the previous examination. Incidental note is also made of
bibasilar atelectasis.
No lytic or blastic lesions within the osseous structures are
noted. Limited views of the upper abdomen are unremarkable.
IMPRESSION: Multifocal air-space process throughout both lungs
dramatically new compared to examination from four days prior.
Given the non-pathologic but prominent mediastinal
lymphadenopathy, infectious etiologies including atypical
infections if the patient is immunocompromised should be
considered. ARDS given the timing of these findings is also a
diagnostic consideration. Clinical correlation is advised. No
pleural effusion.
Findings were discussed with Dr. [**Last Name (STitle) **] at 4:55 pm by Dr.
[**First Name (STitle) 7747**] over the telephone on [**2138-9-28**].
[**2138-10-28**]
HCT 28.8
platelet 67
wbc 3.5
Na 130
creat 1.9
BUN 25
K 4.5
Brief Hospital Course:
A/P: 70 y.o. woman with myelodysplastic syndrome and resultant
pancytopenia and recurrent GIB associated with ulcerations in
her small intestine.
.
# GI Bleeding: Likely due from previously discovered small
intestinal ulcerations, with increased propensity for bleeding
given thrombocytopenia. No evidence of UGIB. Baseline hct 32,
was 22 on admission. On the second day of hospitalization the
patient had further bleeding per rectum, became hypotensive, and
had sinus tachycardia to 140. She was soon transferred to the
MICU. While in the ICU, Angiography did not show active bleed,
although unable to catheterize the [**Female First Name (un) 899**]. Tagged RBC study also
did not show site of bleed. At present, there are no surgical
or endoscopic options, so will continue with supportive care.
NG lavage was negative. The patient received numerous PRBC
transfusions. Platelets remain above 50 after many platelent
transufsions. After stabilization, the patient was transferred
to the floor where she remained hemodynamically stable for the
remainder of her hospitalization. She did have occasional
BRBPR, and always remained guaiac positive. She continued to
receive prbc's nearly every other day to maintain a stable
hematocrit, and she received HLA matched platelets on nearly a
daily basis to maintain her platelet count over 50.
.
# Neutropenic fever: The patient finished her 5th day of
decitabine for MDS treatment on [**9-12**]. Previous to decitabine
therapy the patient had adequate cell counts, and after
decitabine the patient became progressively neutropenic. On
return to the floor form the MICU the patient proceeded to spike
daily fevers as high as 103.0, with associated rigors. The
source of fever was not identified. Daily blood cultures were
negative. stool was C.Diff negative. The patient placed on
several antibiotics, including vancomycin, Zosyn, Flagyl, and
fluconazole, and continued to spike. CT chest/Abdomen/Pelvis on
[**9-24**] did not reveal a source of fevers. CT Pelvis
revealed fat stranding and questionable external iliac [**Last Name (un) **]
thrombus, followup MRI showed fat stranding but no thrombus.
Antibiotics eventually switched to Vanc/Cefepime/Flagyl
(cefepime was discontinued secondary to drug rash), to
Vanc/Aztreonam/Caspofungin. The patient desaturated on [**9-28**] to
78%, and CT chest showed extensive infiltrates. Clinical
suspicion for PCP was high, and after consulting ID, the patient
was maintained on Vanc/Caspo/Meropenem, and the patient was
begun on Bactrim and steroids empirically, unable to perform
bronchoscopy with the high likelihood of being unable to
extubate her. Soon after Bactrim administration her fevers
stopped. She was continued with a full 14 day course of IV
Bactrim. After completing this course she was transitioned to
Bactrim DS 3 times weekly.
.
#O2 desaturation-Patient began to desat on [**9-26**]. Thought
initially to be due to fluid overload in setting of increased
platelet and prbc transfusions, and CT on [**9-24**] showing bibasilar
atelectasis. Oxygen improved with lasix on [**9-26**] and [**9-27**], and
patient was saturating at 94% on room air on [**9-27**]. Patient
desaturated to 78% on [**9-28**]. CT chest showed extensive
infiltrates. ID reccomended broad antibiotic coverage, and
biggest concern was for PCP in the setting of an
immunocompromised patient. She was subsequently begun on
Bactrim and steroids. Soon after bactrim administration the
patient stopped spiking fevers, however she persisted with low
oxygen saturation and required 6L O2 by nasal cannula. The
patient's O2 saturation ranged from 89-94%, and appeared to
improve with lasix administration. She occasionally required
masked ventilation to maintain O2 saturation over 90%. After
six days of bactrim therapy, her bactrim was discontinued out of
concern that it was contributing to the patient's neutropenia.
Primaquine and clindamycin were begun instead. Her neutrophil
count slowly increased over a period of four days from 40 to
170, she remained afebrile, but her oxygenation did not improve.
On [**10-12**] the patient was transferred back to the ICU after
having another acute oxygen desaturation of 78% on 6LNC. Patient
was stabilized and transeferred back to the floor on NRB 100%,
she continued on IV antibiotic regimen of meropenem and Bactrim.
She remained afebrile and was continued on Bactrim and
voriconazole. She was able to be weaned to 99% on 3L nasal
cannula prior to discharge. Her prednisone dose was tapered, she
was discharge on Prednisone 30mg AM, 10mg PM per Dr. [**First Name (STitle) 1557**] who
will follow her at the rehabilitation facility. Given her risk
of GIB it was very important to taper her steroid dose.
# MDS: The patient is s/p decitabine treatment from [**9-12**], and
gradually became neutropenic. While in the hospital her
cyclosporine was discontinued. She was administered neupogen
and her counts eventually recovered slowly. Her last ANC on the
day of discharge was 3100. Further treatment for underlying
disease at Dr.[**Name (NI) 6168**] discretion.
# Hyponatremia: Urine electrolytes consistent with SIADH, likely
from the pulmonary process. She was fluid restricted to 1L, it
was diffucult to mantain this restriction given the IV
medications. Once she was taken off the IV meds her sodium level
rose, 130 upon dishcharge. She was continued on salt tabs.
#Sundowning: Her mental status would wax and wane at nighttime,
multifactorial etiology of undrlying infection, hypoxia,
hyponatremia and medications. Her medication list was reviewed
and with treatment of her underlying disease her mental status
improved. She was alert and oriented at discharge.
Medications on Admission:
Home Medications:
1. Cyclosporine 50 mg twice daily
2. IVIG finished 9 week therapy 3 weeks ago.
3. Prednisone 20 mg daily, 15mg qam, 5mg qpm
4. Decitabine c1 [**Date range (3) 51772**]
5. Metoprolol 50mg twice daily
6. Aranesp PRN
7. Vitamin B6
8. Folic Acid
9. Danazol 200g Daily
10. Protonix 40mg Daily
11. Potassium 20mEq twice daily
12. Mg supplements.
.
Medications on transfer:
Meperidine 25-50 mg IV Q6H:PRN
Acetaminophen 325-650 mg PO Q6H:PRN
Nystatin Oral Suspension 5 ml PO QID:PRN
CycloSPORINE (Sandimmune) 50 mg PO Q12H
Pantoprazole 40 mg PO Q12H
Danazol 200 mg PO QD
DiphenhydrAMINE 25 mg PO Q6H:PRN
FoLIC Acid 1 mg PO DAILY
HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN pain
Zolpidem Tartrate 10 mg PO HS:PRN
Hydrocortisone Na Succ. 100 mg IV Q8H
Lorazepam 0.5 mg PO Q8H:PRN
Zosyn 2.25mg Q6h
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed for wheezing.
3. Danazol 200 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
14. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-21**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for dry nose.
16. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO BID (2
times a day) as needed for hyponatremia.
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
19. Prednisone 20 mg Tablet Sig: 0.5 Tablet PO QPM for 5 days.
20. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO QAM for 5 days.
Discharge Disposition:
Extended Care
Facility:
NE [**Hospital1 41724**]
Discharge Diagnosis:
Primary:Aplastic anemia/Hypocellular myelodysplastic syndrome
with trisomy 8 and 21. s/p high dose prednisone and gamma
globulin, s/p Anti-thymocyte globulin therapy [**2126**], on
cyclosporine since with renal insufficiency; started IVIG q3
weeks [**2138-7-10**]
Empiric tx for PCP [**Name Initial (PRE) 1064**]
s/p terminal ileum resection [**3-26**] for multiple bleeding
ulcers
h/o candidemia with [**Female First Name (un) 564**] parapsilosis
Renal insufficiency (recent baseline Cr 1.2 - 1.6)
Hypertension
h/o hypercholesterolemia
Past Surgical History:
- TAH/BSO [**2-21**] fibroids
- Appendectomy
- Venous stripping LLE
Discharge Condition:
Stable, ambulating with assistance, alert and oriented
Discharge Instructions:
You were admitted with GI bleeding, you were in the ICU and
transfused. Your hospital course was further complicated by
hypoxia which was treated as PCP [**Name Initial (PRE) 1064**]. This led to 2
transfers to the ICU for problems [**Name (NI) 51773**] your oxygen status.
You completed treatment for PCP pneumonia and your oxygen was
weaned to 3 liter by nasal canula. You have an appointment with
Dr. [**First Name (STitle) 1557**] on [**2138-10-31**] at 11 am for follow up. Take all of your
medications as prescribed.
Followup Instructions:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2138-11-28**] 12:30
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2138-10-31**] 11:00
|
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icd9cm
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icd9pcs
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[
[
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]
] |
16296, 16347
|
7865, 13581
|
296, 302
|
17026, 17083
|
3385, 5128
|
17654, 17992
|
2263, 2311
|
14436, 16273
|
5901, 5950
|
16368, 16912
|
13607, 13607
|
17107, 17631
|
3107, 3366
|
16935, 17005
|
2326, 3011
|
13625, 13967
|
229, 258
|
5979, 7842
|
330, 1555
|
3026, 3090
|
13992, 14413
|
1577, 2076
|
2184, 2247
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,206
| 149,114
|
11254
|
Discharge summary
|
report
|
Admission Date: [**2116-9-22**] Discharge Date: [**2116-9-29**]
Date of Birth: [**2041-4-17**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
female with mild dyspnea on exertion and chest pressure with
exertion for several years. Over the past couple of months
her shortness of breath worsened and her ejection fraction
was 60%. Cardiac catheterization showed a left main
occlusion of 30% LAD, distal occlusion of 70%, mid occlusion
of 90%, left circumflex 60% occlusion and RCA about 95%
occlusion. The patient had exercise tolerance test on [**2116-6-19**] that was positive.
PAST MEDICAL HISTORY: Included sciatica, diverticulitis,
arthritis.
PAST SURGICAL HISTORY: Included hysterectomy, colon surgery.
MEDICATIONS: Include Aspirin 325 mg, Atenolol 50 mg po q d,
Zantac 150 mg po bid, Isordil 20 mg po tid, Protonix 40 mg po
q d, Hydrochlorothiazide 25 mg po q d.
HOSPITAL COURSE: The patient was taken by Dr. [**Last Name (STitle) 70**] to
the operating room on [**2116-9-24**] for CABG times three, LIMA to
LAD, SVG to OM and SVG to RCA and PD. Post-operatively the
patient did well and was extubated and drips were weaned off.
Chest x-ray tube was discontinued. The pericardial wires
were discontinued without incident. The patient was
transferred to the floor and recovered very well. Upon
discharge patient was ambulating at level V. Upon discharge
her heart rate was 62, normal sinus and blood pressure
119/60.
DISCHARGE MEDICATIONS: Included Lopressor 12.5 mg po bid,
Lasix 20 mg po bid times five days, then KCL 20 mEq po bid
times five days, Aspirin 81 mg po q d, Zantac 150 mg po bid,
Iron Sulfate 325 mg po tid and Percocet 1-2 tablets po q 4-6
hours prn.
CONDITION ON DISCHARGE: Stable. Chest was clear. Heart was
regular rate and rhythm, normal sinus. Incision was clean,
dry and intact, no pus, no drainage. Sternum stable.
DISCHARGE STATUS: The patient was discharged home and told
to follow-up with Dr. [**Last Name (STitle) 70**] in [**2-23**] weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2116-9-29**] 08:24
T: [**2116-9-29**] 08:45
JOB#: [**Job Number 36150**]
|
[
"414.01",
"272.0",
"V12.79",
"724.3",
"401.9",
"285.9",
"530.81",
"413.9",
"716.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.15",
"39.61",
"88.72",
"42.23",
"88.56",
"88.53",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
1534, 1762
|
968, 1510
|
748, 950
|
184, 654
|
677, 724
|
1787, 2360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,011
| 162,714
|
52897
|
Discharge summary
|
report
|
Admission Date: [**2116-9-13**] Discharge Date: [**2116-9-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization via left radial artery
Right PICC line placed and discontinued prior to discharge
History of Present Illness:
Mr. [**Known lastname 12163**] is an 86 yo man with extensive hx of CAD as well as
severe AS, who presented to [**Hospital3 **] this morning after
having chest pain overnight. PMH signficant for diabetes,
dyslipidemia, hypertension, with CABG in [**2104**], RCA stent X2 in
[**2105**] and OM stent in [**2110**] with most recent cath in [**2116-5-5**].
Mr. [**Known lastname 12163**] has chest pain at least once weekly, which usually
resolves with one Nitro. Last night developed CP while in bed,
took Nitro x3, pain resolved each time but when pain came back
the fourth time he became concerned and drove with wife to
[**Name (NI) 620**] [**Name (NI) **]. The CP was the same in character to his usual CP,
with some radiation to jaw, no radiation to back. No SOB, no
diaphoresis.
.
At baseline, patient lives with wife, can walk around and climb
stairs without chest pain.
.
Arrived in [**Location (un) 620**] ED with chest pain and EKG at 330 showed
sinus rhythm with rate of 130, left axis deviation, LAFB with
RBBB, ST depressions in V3-V5. No ST elevations were noted.
Vitals were HR 98 BP 176/110 and Sat 99% RA. Patient was given
bolus of heparin with heparin gtt start; started on Nitro gtt
and Integrilin gtt. Patient became CP free and EKG showed
improvement in ST depressions in V4-V5 with continue depression
V3. First set of enzymes at OSH were negative. On arrival to
[**Hospital1 18**] CCU patient was pain free.
Past Medical History:
CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: CABG in [**2104**] (LIMA-LAD, SVG-OM)
-PERCUTANEOUS CORONARY INTERVENTIONS: RCA stent x2 in [**2105**],
SVG-OM (3.5 x 18mm cypher) stent placed in [**2110**]
Type II DM
Right Kidney removed years ago
Prostatectomy
Tonsillectomy
Appendectomy
Hernia x2
Social History:
Retired, lives with wife. Was [**Name2 (NI) **] fire chief of [**Location (un) **],
where he worked for 40+ yrs.
-Tobacco history: 100-150 PY smoking history, quit 10 years
ago.
-ETOH: occasionally
-Illicit drugs: Denies
Family History:
Father died of CAD at the age of 57. Mother died in her 80's.
One brother died of pancreatic cancer in his 70's, the other of
unknown cancer, also in his 70's.
Physical Exam:
GENERAL: Elderly gentleman in NAD. Oriented x3.
HEENT: NCAT. Mucous membranes slightly dry.
CARDIAC: Distant heart sounds, RRR
LUNGS: Good air movement and CTAB.
ABDOMEN: Soft, NTND.
EXTREMITIES: No LE edema, + pedal pulses.
Pertinent Results:
Admission Labs:
[**2116-9-13**] 11:48PM SODIUM-138 POTASSIUM-4.2 CHLORIDE-104
[**2116-9-13**] 11:48PM CK(CPK)-531*
[**2116-9-13**] 11:48PM CK-MB-45* MB INDX-8.5*
[**2116-9-13**] 11:48PM MAGNESIUM-1.9
[**2116-9-13**] 08:56PM PTT-63.4*
[**2116-9-13**] 05:20PM CK(CPK)-566*
[**2116-9-13**] 05:20PM CK-MB-64* MB INDX-11.3*
[**2116-9-13**] 02:55PM PTT-58.7*
[**2116-9-13**] 11:44AM CK(CPK)-381*
[**2116-9-13**] 11:44AM CK-MB-44* MB INDX-11.5*
[**2116-9-13**] 06:13AM GLUCOSE-213* UREA N-29* CREAT-0.9 SODIUM-140
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2116-9-13**] 06:13AM estGFR-Using this
[**2116-9-13**] 06:13AM CK(CPK)-128
[**2116-9-13**] 06:13AM CK-MB-13* MB INDX-10.2* cTropnT-0.09*
[**2116-9-13**] 06:13AM CALCIUM-9.2 PHOSPHATE-2.8 MAGNESIUM-2.5
[**2116-9-13**] 06:13AM WBC-10.3# RBC-4.05* HGB-12.6* HCT-36.3*
MCV-90 MCH-31.2 MCHC-34.8 RDW-13.1
[**2116-9-13**] 06:13AM PLT COUNT-250
[**2116-9-13**] 06:13AM PT-13.1 PTT-99.3* INR(PT)-1.1
EKG [**2116-9-13**]: Sinus rhythm. Left atrial abnormality. Left axis
deviation with left anterior fascicular block. Right
bundle-branch block. Compared to the previous tracing of [**2116-5-22**]
there is no significant diagnostic change.
Echocardiogram [**2116-9-14**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is severe
regional left ventricular systolic dysfunction with only the
lateral wall having relatively normal function. There is an
anteroapical left ventricular aneurysm. A left ventricular
mass/thrombus cannot be excluded. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal.
Compared with the prior study (images reviewed) of [**2114-7-19**],
there are more extensive wall motion abnormalities (suggestive
of interim LAD ischemia/infarction). The velocities across the
aortic valve are similar. The degree of aortic stenosis may be
underestimated on the current study (low output - low gradient
aortic stenosis).
Cardiac Catherization [**2116-9-15**]:
Coronary angiography in this right dominant system demonstrated
three
vessel disease. The LMCA was diffusely diseased with 80-95%
stenosis.
The LAD was occluded proximally. The distal LAD filled via the
LIMA and
was a small, 1.5mm vessel with diffuse disease and a 60-70%
apical
stenosis that was unchanged from the catheterization of 6/[**2115**].
The LCx
was diffusely diseased. OM1 and OM2 were very small vessels with
serial
60-80% stenoses. The RCA had mild luminal irregularities with
serial
calcific 30-40% stenoses. There was a diffusely diseased PDA
branch
with 80% stenosis unchanged from prior.
Arterial conduit arteriography demonstrated a widely patent
LIMA-LAD.
The SVG-OM was known to be occluded and was not engaged.
Limited resting hemodynamics revealed significantly elevated
left-sided filling pressures with LVEDP 32mmHg. The systemic
arterial
blood pressure was normal with SBP 107mmHg and DBP 52mmHg.
There was minimal gradient across aortic valve (peak to peak 20
mm Hg).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease, essentially unchanged
from [**5-14**].
2. Markedly elevated left-sided filling pressures
CXR [**2116-9-19**]
A right subclavian PICC line is present. The tip is not
optimally visualized, but likely overlies the distal SVC near
the RA junction. Possible minimal change in position compared
with the film from [**2116-9-16**]. No pneumothorax is detected.
Background COPD is noted. There are bibasilar opacities, similar
to [**2116-9-16**], though the degree of opacity in the left
cardiophrenic region is greater on today's exam. Small bilateral
pleural effusions are present. No CHF. Otherwise, no new
infiltrate. No pneumothorax detected.
Discharge Labs:
138 104 29
--------------< 127
4.2 27 1.1
Ca: 8.6 Mg: 1.9 P: 3.2
5.6 > 11.8/33.7 < 193
PT: 22.8 PTT: 72.3 INR: 2.2
Brief Hospital Course:
Mr. [**Known lastname 12163**] is an 86yo male with HTN, DM, HLD and extensive
history of CAD s/p CABG as well as severe AS, who was admitted
to the CCU with the diagnosis of
NSTEMI: No EKG changes suggestive of ST-elevation on admission;
CK peaked at 566 and CKMB peaked at 64. He was medically managed
for his NSTEMI with a heparin drip, metoprolol, lisinopril,
crestor, plavix, and full dose ASA. On [**2116-9-14**] an
echocardiogram showed an interval decrease in his EF from [**2113**]
of 50% to 25-30%. The echocardiogram also demonstrated a new
left ventricular aneurysm. In the setting of the new
hypokinesis, the patient also intermittently complained of
chest/jaw pain and anginal symptoms responsive to SL nitro with
reversible new ischemic changes in the lateral leads. This
prompted investigation of whether the LIMA to LAD graft from his
bypass was still patent as it was in 6/[**2115**]. The catherization
was performed through his left brachial artery and showed no
change from 6/[**2115**]. The patient's jaw/chest pain was
subsequently deemed to be the result of demand ischemia in the
setting of bigeminy; BB was uptitrated and he was started on
long acting nitro. The patient was then evaluated by CT surgery
for potential re-do bypass and AVR. He was considered to be a
surgical candidate, however the patient declined surgical
intervention knowing the risks and benefits at this time. The
patient will be evaluated as an outpatient for the possibility
of aortic angioplasty or further intervention. He is discharged
on maximal medical management for NSTEMI as well as isosorbide
nitrite, amiodarone 200 mg [**Hospital1 **] for 1 month with plans to taper
to 200 mg daily, and warfarin for anticoagulation in the setting
of apical hypokinesis.
.
WIDE COMPLEX TACHYCARDIA: As noted above, on [**2116-9-15**] the
patient complained of chest pain and was noted to have a wide
complex tachycardia with heart rate in the 140s that resolved
with IV lopressor. The patient was evaluated by EP who thought
the rhythm was more likely to be a supraventricular tachycardia
then ventricular tachycardia. He was started on 200 mg
amiodarone [**Hospital1 **]. The patient did not have another episode during
his hospital stay.
.
ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: Reduction in EF from 50
to 25-30% and new left ventricular aneurysm on TTE. The patient
was bridged on warfarin therapy with goal INR of [**1-8**] due to new
LV aneurysm and the inability to exclude a clot. The warfarin
dose was titrated up to reach the INR goal. His INR at discharge
was 2.2.
.
VASCULAR ACCESS: a left side hematoma developed after
infiltration of the IV in which heparin was being administered
on [**9-14**]. The patient's right PIV then infiltrated the following
day. A PICC line was placed on the right on [**2116-9-16**]. It was
removed prior to discharge.
.
LEFT UPPER EXTREMITY HEMATOMA. On [**2116-9-17**] the patient was noted
to have a hematocrit of 27 from 34. He was transfused 1 unit of
blood and responded appropriately and his hematocrit remained
stable for the remainder of his hospital course. His hematoma
on his left upper extremity remained stable throughout his
hospital course.
.
DIABETES: Last A1C was 7.0 in [**7-/2116**] The patient's home PO
diabetic medications where held on admission to the hospital and
an insulin sliding scale was started. The patient's blood
glucose was well controlled with the sliding scale. Home
medications were restarted on discharge.
.
HYPERLIPIDEMIA: The patient was started on simvastatin on
admission which was changed to crestor secondary to starting
amiodarone. LFTs were checked after this change and were within
normal limits.
.
Medications on Admission:
CLOPIDOGREL [PLAVIX] 75 mg QD
GLYBURIDE 10 mg Tablet [**Hospital1 **]
LISINOPRIL 40 mg Tablet QD (stopped one week ago by PCP)
METFORMIN 1,000 mg Tablet [**Hospital1 **]
METOPROLOL SUCCINATE 50 mg QD
NITROGLYCERIN 0.3 mg Tablet sublingually as needed for chest
pain
SIMVASTATIN - 80 mg Tablet QD
ISOSORBIDE- 30mg tablet daily
ASPIRIN 81 mg Tablet daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for jaw/chest
pain: Can take 3 times, five minutes apart; call 911.
5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day:
Daily, in AM.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Daily
in PM.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
13. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1411**] VNA/[**Company 1519**] Phone
Discharge Diagnosis:
Myocardial Infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to take care of you at the [**Hospital1 18**]. You were
admitted to the hospital because you had a small heart attack.
We did various studies of your heart and did not think that
there were new areas of blockage to your coronary arteries. We
think your heart attack was likely due to areas of narrowing
that you already had in your heart. Here we controlled your
chest pain and initiated optimal medical management of your
disease. We discussed your case with cardiac surgery for
treatment of your coronary artery disease and aortic stenosis,
but you have decided not to pursue surgery at this time.
.
Please make the following changes to your medications:
# STOP Lisinopril from 40 mg daily
# START Lisinopril 2.5 mg daily
# START Ranitidine 150 mg twice daily
# START Amiodarone 200 mg TWICE daily
You will continue this Amiodarone dosing for 1 month, and
thereafter you will decrease the dosing to Amiodarone 200 mg
ONCE daily as prescribed your cardiologist. Please be sure to
follow-up with your cardiologist about when to decrease your
Amiodarone dosing.
# STOP Metoprolol Succinate 50 mg once daily
# START Metoprolol Succinate 100 mg once daily, in the AM
# START Metoprolol Succinate 50 mg once daily, in the PM (Total
Metoprolol dose = 150 mg daily)
# START Coumadin 2mg daily
# STOP Simvastatin 80 mg daily
# START Rosuvastatin Calcium 20 mg PO DAILY
(Of note, Discharge Plan signed [**2116-9-20**] erroneously documents
no change in Simvastatin 80 mg; the patient was called to notify
him of the change to Rosuvastatin 20 mg daily and the Rx was
called in to his pharmacy.)
.
Please be sure to attend all of the appointments listed below;
unfortunately, since it is the weekend, we have not been able to
make these appointments for your. Please schedule all of the
appointments for the week of [**2116-9-21**].
.
Followup Instructions:
[**Hospital 197**] Clinic, [**Location (un) 620**]. Phone: [**Telephone/Fax (1) 10413**]. Please call to
schedule an appointment for the week of [**2116-9-21**] to have your
INR checked to ensure that your Coumadin dose is correct. Please
make the appointment for no later than Wednesday [**2116-9-23**].
[**Last Name (un) **],PERMINDER. Phone: [**Telephone/Fax (1) 29110**]. Please Call Dr. [**Last Name (STitle) 11302**],
your cardiologist, to schedule an appointment for the week of
[**2116-9-21**]. Dr.[**Name (NI) 30616**] office will be expecting your call.
|
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"414.01",
"998.12",
"410.71",
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"428.23",
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"V45.82",
"272.4",
"428.0",
"276.7",
"496",
"427.89",
"250.00",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
12811, 12895
|
7268, 10964
|
273, 380
|
12960, 12960
|
2890, 2890
|
15017, 15585
|
2467, 2630
|
11372, 12788
|
12916, 12939
|
10990, 11349
|
6419, 7102
|
13143, 13789
|
7118, 7245
|
2645, 2871
|
1949, 2209
|
13818, 14994
|
223, 235
|
408, 1839
|
2906, 6402
|
12975, 13119
|
1861, 1929
|
2225, 2451
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,040
| 133,638
|
15494
|
Discharge summary
|
report
|
Admission Date: [**2154-1-7**] Discharge Date: [**2154-1-11**]
Date of Birth: [**2100-4-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2154-1-8**]: CABG x 3 (LIMA->LAD, SVG->PDA, SVG->OM)
History of Present Illness:
53 yo male with history of acute STEMI and VF arrest in [**Month (only) **]. He
had a DES to OM1 in the setting of 3VD.In [**Month (only) **],, a repeat cath
showed a 70% LAD lesion and an occluded OM stent that was
re-angioplastied. RCA is also known occluded from prior cath.
Referred for surgery.
On [**2154-1-7**], he was admitted pre-operatively for heparin IV
after stopping coumadin and plavix.
Past Medical History:
Past Medical History:
coronary artery disease
inferior myocardial infarction and V Fib ([**9-3**])
obesity
hypertension
pre-diabetes mellitus
dyslipidemia
L upper extremity DVT (prior failed L radial access for cath)
anxiety
GERD
cervical DJD - which placed him on disability
Past Surgical History:
s/p skin graft to R hand ( from R abd)
s/p bilateral cataract surgery
vasectomy
Past Cardiac Procedures
- s/p DES to OM1 [**2153-8-23**]
- s/p POBA of OM1, [**2153-11-22**]
Social History:
Race:Caucasian
Last Dental Exam:last year
Lives with:girlfriend
Contact: [**Name (NI) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 44913**]
Occupation:disabled
Cigarettes: Smoked no [] yes [x] last cigarette today_____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [] [**1-29**] drinks/week [] >8 drinks/week
[]none
Illicit drug use-smoked MJ, last yr most recent
Family History:
Family History:Premature coronary artery disease
Father MI < 55 [] Mother < 65 []had MIs ( not
premature)
Physical Exam:
Pulse:68 Resp:16 O2 sat: 98%
B/P Right:none ( has DVT) Left: 139/76
Height: 67" Weight: 180#
Five Meter Walk Test #1_______ #2 _________ #3_________
General:NAD, anxious
Skin: Dry [x] intact [x], several small scattered healed lac.
scars
HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable
Neck: Supple [] Full ROM []no JVD; neck pain
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur -none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema [] __none___
Varicosities: None [x]
Neuro: Grossly intact;MAE [**4-27**] strengths; nonfocal exam; R post
calf tender to palpation, minimally larger girth than L calf, no
palpable cord
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2153-10-30**] Cardiac Echocardiogram: LVEF 61%. Moderate TR. Trivial
MR. [**Name13 (STitle) **] evidence of AI or AS. RV normal size and function. RVSP
30-35mmHg.
[**2154-1-10**] 04:49AM BLOOD WBC-11.9* RBC-2.90* Hgb-9.0* Hct-26.2*
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.8 Plt Ct-158
[**2154-1-9**] 02:10AM BLOOD WBC-12.7* RBC-3.43* Hgb-10.4* Hct-30.6*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.5 Plt Ct-194
[**2154-1-8**] 08:43PM BLOOD Hct-32.5*
[**2154-1-10**] 04:49AM BLOOD PT-13.6* PTT-32.2 INR(PT)-1.3*
[**2154-1-8**] 04:00PM BLOOD PT-13.1* PTT-32.9 INR(PT)-1.2*
[**2154-1-8**] 02:35PM BLOOD PT-17.4* PTT-35.3 INR(PT)-1.6*
[**2154-1-10**] 04:49AM BLOOD Glucose-140* UreaN-17 Creat-0.8 Na-140
K-4.2 Cl-106 HCO3-27 AnGap-11
[**2154-1-9**] 02:10AM BLOOD Glucose-128* UreaN-12 Creat-0.7 Na-137
K-4.6 Cl-105 HCO3-26 AnGap-11
[**2154-1-8**] 08:43PM BLOOD Na-136 K-4.8 Cl-105
[**2154-1-8**] TTE
PRE-CPB:
No thrombus is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. There appears to
be mild hypokinesis of the mid-inferoseptal segment. 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. There are simple atheroma
in the descending thoracic aorta. No thoracic aortic dissection
is seen.
The aortic valve leaflets (3) are mildly thickened with focal
calcification of the non-coronary cusp, but aortic stenosis is
not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POST-CPB:
The patient is on a low-dose phenylephrine infusion. The left
ventricular function remains unchanged, estimated EF>55%. Right
ventricular function is preserved.
There is no evidence of aortic dissection.
Brief Hospital Course:
On [**2154-1-7**], the patient was admitted to the cardiac surgery
service pre-operatively for intravenous heparin. On [**2154-1-8**],
he underwent an elective coronary artery bypass grafting times
three (LIMA->LAD, SVG->PDA, SVG->OM) and was transferred
post-operatively to thesurgical intensive care unit. Please see
the operative note for details. By the following day he was
extubated. Lopressor was started. Coumadin was resumed for a
deep vein thrombosis in his left upper extremity. Plavix was not
resumed as his stent had been bypassed during his surgery. Pain
control was initially difficult as he has chronic cervical back
pain, but it was managed successfully with oxycodone. His chest
tubes were removed. He was transferred to the surgical step down
floor and his epicardial wires were removed. He complained of
right calf pain and so he underwent an ultrasound which revealed
no deep vein thrombosis. By post-operative day three he was
ready for discharge to home. Dr. [**Last Name (STitle) 5017**], his cardiologist,
will follow his INR. All follow-up appointments were advised.
Medications on Admission:
** COUMADIN 5 mg daily, alternating with 2.5mg LD [**2154-1-3**]
** Plavix 75 mg daily LD [**2154-1-1**]
xanax 0.5 mg [**Hospital1 **]
calcium carbonate 500 mg [**Hospital1 **] prn
lisinopril 10 mg daily
metoprolol 50 mg [**Hospital1 **]
simvastatin 80 mg daily
ASA 81 mg daily
vicodin 5 /500 mg prn TID
omeprazole DR 20 mg daily
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication history of DVT
Goal INR 2.0-3.0
First draw Monday [**1-14**]
Results to phone fax ([**Telephone/Fax (1) 44914**]
To Dr. [**Last Name (STitle) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Last Name (un) 39144**], STE#404, [**Hospital1 **],[**Numeric Identifier 39146**]
Phone: [**Telephone/Fax (1) 5424**]
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 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. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: take 2.5mg daily alternating with 5mg daily for INR
goal of [**1-25**].
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease s/p CABG
inferior myocardial infarction and V Fib ([**9-3**])
hypertension
glucose intolerance
dyslipidemia
L upper extremity DVT ( Prior failed L radial access for cath)
anxiety
GERD
cervical DJD - which placed him on disability
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] on [**2-13**] at 1:00pm
Cardiologist:Dr. [**Last Name (STitle) 5017**] on [**2-6**] at 10:15am
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] in [**3-28**] weeks [**Telephone/Fax (1) 44915**]
**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 history of DVT
Goal INR 2.0-3.0
First draw Monday [**1-14**]
Results to phone fax ([**Telephone/Fax (1) 44914**]
To Dr. [**Last Name (STitle) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Last Name (un) 39144**], STE#404, [**Hospital1 **],[**Numeric Identifier 39146**]
Phone: [**Telephone/Fax (1) 5424**]
Plan confirmed with [**Doctor First Name **] of Dr.[**Name (NI) 44916**] office on [**1-11**]
Completed by:[**2154-1-11**]
|
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icd9cm
|
[
[
[]
]
] |
[
"36.12",
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icd9pcs
|
[
[
[]
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7537, 7586
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7884, 8108
|
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8132, 8925
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1125, 1299
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1839, 2805
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270, 278
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401, 804
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848, 1102
|
1315, 1692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,745
| 103,746
|
47600
|
Discharge summary
|
report
|
Admission Date: [**2159-2-8**] Discharge Date: [**2159-2-10**]
Date of Birth: [**2075-5-3**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
Bladder tumor
Major Surgical or Invasive Procedure:
Cystoscopy, TURBT [**2159-2-8**] - Dr. [**Last Name (STitle) 9125**]
History of Present Illness:
83yoM hx htn, dm, chf, presented for anesthesia assisted,
urological transurethreal resection of presumed bladder cancer,
admitted to [**Hospital Unit Name 153**] for post-procedure monitoring given significant
[**Hospital Unit Name 1106**] disease.
Over previous 2 months, pt has had hematuria, in addition to
multiple UTIs, without resolution with abx. Dr. [**Last Name (STitle) 9125**] from
urology performed outpt cystoscopy, showing bladder tumors, c/w
bladder CA; was scheduled for transurethral bx and removal of
tumors with anesthesia assitance, given past hx of [**Last Name (STitle) 1106**] cva.
On day of admit to [**Hospital1 18**], pt underwent transurethral resection
of tumour, 45min procedure, stable hemodynamics throughout
procedure. SBP prior to procedure 180, kept on peripheral
phenylephrine throughout procedure to maintain MAPs (unclear if
BPs dropped throughout procedure). Patient was transferred to
PACU with pressor off and stable hemodynamics then transferred
to [**Hospital Unit Name 153**] in stable condition.
Past Medical History:
PMH:
CRI, baseline 2.5-3.5
NIDDM
[**11/2139**] AMI
PVD: s/p RLE bypass [**7-/2143**], [**5-/2148**] left Fem [**Doctor Last Name **] bypass, [**2-4**]
angioplasty of left Fem-AT bypass stenosis
Hyperlipidemia
Gallstones s/p [**2156-1-2**] ERCP w/ CBD [**Month/Day/Year **] placement needs
[**Month/Day/Year 100581**]
AAA (3cm stable sine [**2145**])
Elevated Alk Phos
[**9-/2147**] embolic CVA, seven CVA's since most recently in [**10-8**].
Afib/flutter s/p Ablation [**11-6**], EPS [**11-8**]
Syncope
HTN
renal arteries no stenosis by cath [**2154-5-17**]
[**5-9**] s/p TTE w/ EF to be newly depressed at 30-35% with left
ventricular hypertrophy and [**12-8**]+MR. [**Name14 (STitle) **] w/ reversible defect
PSH:
[**2142**] R Fem [**Doctor Last Name **] in situ
[**2147**] L Fem [**Doctor Last Name **] in situ
[**2150**] vein angioplasty L Fem artery
Social History:
Married for 53 years with three sons. They have assistance with
cleaning and cooking at home through elderly affairs assistance.
His son manages all their bills and mail and lives upstairs.
Wife is legally blind and is a care taker for Mr. [**Known lastname 100582**]. The
patient walks unassisted now. He is very hard of hearing. +80
ppy history, quit [**2145**]. No EtOH or illicits.
Family History:
NC
Physical Exam:
97.1, 57, 142/51, 13, 100%RA
PHYSICAL EXAM
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=flat
LUNGS: mild exp wheezes
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
PSYCH: Listens and responds to questions appropriately, pleasant
Brief Hospital Course:
83yoM hx htn, dm, chf, presented for anesthesia assisted,
urological transurethreal resection of presumed bladder cancer,
admitted to [**Hospital Unit Name 153**] for post-procedure monitoring given significant
[**Hospital Unit Name 1106**] disease. In [**Hospital Unit Name 153**], he was found to possibly have OSA,
monitored on continous O2 and telemetry, no events. He was
transferred out of ICU POD1. Urine clear off CBI POD2 and foley
removed. He passed voiding trial and discharged home in stable
condition. He will follow-up with Dr. [**Last Name (STitle) **] of sleep clinic
for OSA work-up, per ICU team and respiratory.
Medications on Admission:
Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Discharge Medications:
1. Pyridium 100 mg Tablet Sig: One (1) Tablet PO twice a day for
3 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bladder tumor
Discharge Condition:
Stable
Discharge Instructions:
--Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
--The operation you have experienced is a "scraping" operation;
that is to say, the bladder tumor or biopsy sample was "scraped"
off the bladder wall. Bleeding was controlled with
electrocautery which will produce a "scab" in the inside bladder
wall. About 1-2 weeks after the operation, pieces of the scab
will fall off and come out with the urine. As this occurs,
bleeding may be noted which is normal. You should not worry
about this. Simply lie down and increase your fluid intake for a
few hours. In most cases, the urine will clear. Because of this
tendency for bleeding, aspirin (or Advil) must be avoided for 2
weeks following your operation (Tylenol is okay). If bleeding
occurs or persists for more than 12 hours or if clots appear
impairing your stream, call your urologist.
If you develop a fever over 101??????, or have chills, call your
urologist. Although not common, this may indicate infection that
has developed beyond the control of the antibiotics that you
have taken.
It will take 6 weeks from the date of surgery to fully recover
from your operation. This can be divided into two parts -- the
first 2 weeks and the last 4 weeks. During the first 2 weeks
from the date of your surgery, it is important to be "a person
of leisure". You should avoid lifting and straining, which also
means that you should avoid constipation. This can be done by
any of 3 ways: 1) modify your diet, 2) use stool softeners which
have been prescribed for you, and 3) use gentle laxatives such
as Milk of Magnesia which can be purchased at your local drug
store. It is important for you to avoid prolonged sitting. You
should avoid sexual activity during this time. Also, avoid
driving. The danger is not so much the driving, but it may delay
you from urinating if you have the urge; and, "holding" urine
may cause bleeding. If you return to work before 2 weeks, you
may feel fatigued and require a decreased work load.
During the second 4 week period of your recovery, you may begin
regular activity, but only on a graduated basis. For example,
you may feel well enough to return to work, but you may find it
easier to begin on a half-day basis. It is common to become
quite tired in the afternoon, and if such occurs, it is best to
take a nap! Also, you may begin to drive as well as lift objects
such as a briefcase, etc. If you are a golfer, you may begin to
swing a golf club at this time. Sexual activity may be resumed
during this time, but only on a limited basis. In general, your
overall activity may be escalated to normal as you progress
through this second time period, such that by 6-8 weeks
following the date of surgery, you should be back to normal
activity. If you take aspirin as a regular medication, it may be
resumed at this time.
Finally, call your urologist in one week after your surgery for
the results of your biopsy and your next appointment
Followup Instructions:
Please call Dr. [**Last Name (STitle) 9125**] for a f/u appointment.
Call [**Telephone/Fax (1) 55570**] Sleep Medicine for work-up of sleep apnea, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
|
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"414.01"
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icd9cm
|
[
[
[]
]
] |
[
"57.49"
] |
icd9pcs
|
[
[
[]
]
] |
5389, 5395
|
3459, 4091
|
337, 408
|
5453, 5462
|
8486, 8707
|
2781, 2785
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284, 299
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30,707
| 172,274
|
31325
|
Discharge summary
|
report
|
Admission Date: [**2150-10-12**] Discharge Date: [**2150-10-21**]
Date of Birth: [**2104-4-7**] Sex: M
Service: MEDICINE
Allergies:
Sevoflurane / [**Location (un) **] Juice / Reglan
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
R internal jugular central line placement
Hemodialysis
History of Present Illness:
46 M w/ pmh of anoxic brain injury, diabetes, GERD, and end
stage renal disease on hemodialysis, recently admitted with a
non-ST elevation myocardial infarction and new onset seizure
disorder p/w chest pain and coffee ground emesis. UGI bleed with
vomiting of jelly like substance, abd pain, called in by VNA who
called ambulance for transit to [**Hospital1 18**]. Patient also has had the
hiccups for the last 4 days, has not slept at all and is
miserable. He feels like the hiccups prevent him from breathing
well. He has had hiccups in the past thought to be secondary to
gastroparesis, and treated with thorazine or baclofen.
.
In the ED, vital signs were: 98.9, 167/93, 75, 16, 100% on 1L
NC. NG lavage---coffee ground; hct 25; guaiac neg; BP to 192/92,
had CP that resolved w/ NTG and morphine. EKG and enzymes at
baseline. L EJ is his access. Given protonix 40 mg IV X 1,
zofram 4 mg IV X 1, Morphine 4 mg IV X 2. Admitted for R/O MI
and upper GI bleed but went to dialysis prior to arriving to the
floor where he received 2 U PRBC.
.
On arrival to the floor, the patient is feeling bad. He is very
uncomfortable with his NG tube in place, so it was removed. He
has a sore throat from the tube. He continues to have severe
hiccups. His chest pain is now minimal. He no longer feels
nauseated. He has not vomitted since this morning with the jelly
like substance.
Past Medical History:
- Diabetes mellitus, type I , c/b retinopathy (legally blind
on left), neuropathy and nephropathy , gastroparesis
- Chronic kidney disease stage V, on HD Tues/Thurs/Sat; s/p AVG
placement
- Chronic systolic heart failure, EF 40-45% ([**2149-9-6**])
- NTEMI [**2150-8-10**]
- Hypertension
- Pulmonary hypertension
- Glaucoma
- s/p surgical debridement of left arm fistula ([**5-25**]) and
ruptured aneurysm repair ([**6-25**])
- History of PEA arrest ([**6-25**])during AV fistula repair
- History of positive PPD, s/p one year of treatment
- CAD, NSEMI [**8-26**].
- Seizure d/o on dilantin while hospitalized in [**7-27**]
- Hiccups.
Social History:
Originally from [**Male First Name (un) 1056**]. Separated, with five healthy
children. Not currently working, but has worked for a security
guard in the past. He just moved from [**Location (un) 7349**] to permanently stay in
[**Location (un) 86**] with his brother. [**Name (NI) **] [**Name (NI) **] current tobacco use (quit
several years ago). He [**Name (NI) **] EtOH or illicit drug use. History
of homelessness, but currently lives in [**Location 2326**] (a house). Has HD in
[**Location (un) **].
Family History:
Multiple siblings with hypertension and diabetes. Two sisters
with a "[**Last Name **] problem." No known early coronary disease or
kidney disease.
Physical Exam:
PE on admission:
Vitals - T 99.6, BP 189/97 (max 209/103), P 82, R 22, 100% on
2L, pain is [**7-29**], recent FS was 66
Gen - sitting up in bed, appears visibly uncomfortable,
hiccuping quickly, maybe about 40x/minute
HEENT - ATNC, PERRLA, moist mucous membranes, supple neck, no
JVD, no bruits, no LAD
CV - RRR, no m,r,g (difficult to hear because hiccups)
Lungs - CTA bilaterally, no wheezes/rhonchi/rales
Abd - +BS, soft NTND abdomen, no HSM, no masses, no guarding
Ext - No LE edema, 2+ DP pulses bilaterally, fistula w/ thrill
LUE
Pertinent Results:
Imaging:
CXR [**10-12**]
FINDINGS: There is vascular engorgement consistent with mild
pulmonary edema. There is no evidence of pneumonia. Moderate
degree of cardiomegaly is stable. Mediastinal contours are
unremarkable. There is no pneumothorax. There are small
bilateral pleural effusions. Osseous structures appear intact.
No free air is seen beneath the diaphragms.
IMPRESSION: Stable cardiomegaly. Bilateral small pleural
effusions with mild fluid overload.
[**2150-10-18**] 05:30AM BLOOD WBC-6.3 RBC-3.94* Hgb-12.3* Hct-36.4*
MCV-92 MCH-31.2 MCHC-33.8 RDW-15.8* Plt Ct-200
[**2150-10-15**] 04:00AM BLOOD Neuts-79.5* Lymphs-9.6* Monos-5.4
Eos-4.8* Baso-0.9
[**2150-10-18**] 05:30AM BLOOD Glucose-119* UreaN-26* Creat-7.5*# Na-137
K-3.7 Cl-99 HCO3-28 AnGap-14
[**2150-10-16**] 04:03AM BLOOD ALT-21 AST-19 LD(LDH)-264* AlkPhos-265*
Amylase-37 TotBili-0.3
[**2150-10-16**] 04:03AM BLOOD Lipase-16
[**2150-10-14**] 08:33PM BLOOD CK-MB-5 cTropnT-0.24*
[**2150-10-14**] 02:49PM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2150-10-14**] 07:38AM BLOOD CK-MB-NotDone cTropnT-0.25*
[**2150-10-14**] 02:49PM BLOOD TSH-3.3
[**2150-10-16**] 04:03AM BLOOD Phenyto-6.6*
[**2150-10-15**] 09:00PM BLOOD Phenyto-9.0*
[**10-14**] CT head
FINDINGS: There is no acute intracranial hemorrhage, mass
effect, edema, or
shift of normally midline structures. There is no evidence of an
acute major
vascular territorial infarction. A small chronic lacunar
infarction is again
seen in the right parietal subcortical white matter. The
ventricles are
stable in size.
The imaged bones appear unremarkable. Calcifications are again
noted in the
lens of the left globe. Thickening and calcification are again
noted in the
sclera of the left globe.
IMPRESSION: No evidence of acute intracranial abnormalities.
MRI brain [**10-15**]
IMPRESSION: Somewhat limited study, both by patient-motion and
lack of
intravenous contrast, with:
1. No acute intracranial abnormality.
2. Stable small focal FLAIR-signal abnormality centered on a
small vascular
structure in the left frontal corona radiata, with imaging
characteristics
most suggestive of an underlying developmental venous anomaly
(as suggested
previously); there is no associated cavernous angioma or other
vascular
abnormality, or hemorrhage.
3. Mild cortical atrophy, as before.
4. Unremarkable cranial MRA, with no flow-limiting stenosis or
aneurysm
larger than 3 mm in diameter.
5. Extensive chronic abnormalities involving the left globe and
its contents
with evidence of past retinal detachment and subretinal
hemorrhage, as well as
evidence of apparently known glaucoma (N.B. according to the
history provided
for one of the prior examinations, the patient is "blind in this
eye"); there
is no evidence of abnormality involving the contralateral orbit
or globe.
Brief Hospital Course:
45 M with ESRD, DM I, HTN, p/w chest pain, hematemesis x1 day
and four days of unremitting hiccups.
.
# CP - many possible etiologies of chest pain. Most likely is
severe esophagitis as seen on prior EGD. Treated with viscous
lidocaine for now and morphine to see if it improves. Troponins
negativeCould be cardiac pain, trending troponins (slightly
high, although CKs are going down). EKGs did not show ST
elevations. Think ischemia is not likely contributing and
increasing troponins are likely from demand stress from HTN.
Patient remained chest pain free during hospitalization.
# Hematemesis - has known esophagitis on last EGD, found to have
upper GI bleed in ER. Not actively bleeding during hospital
stay, with stable HCT. GI was consulted and defered EGD given
risk of intubation, and recent EGD showing esophagitis. They
will follow up with him as an outpatient and consider EGD as an
outpatient. Continue [**Hospital1 **] PPI.
# Hiccups - Initially treated with baclofen, but this was
discontinued once patient was in the ICU. Neurology considered
that the baclofen may lower his seizure threshold. Without
hiccups for one week prior to discharge.
.
# DM I - Sugars well controlled with lantus and sliding scale
insulin.
# ESRD - on HD, due for dialysis tomorrow and is on Mon Wed Fri.
# HTN - patient severely hypertensive on admission with SBPs in
200s. BPs well controlled on Losartan 10mg po qd and Metoprolol
50mg po tid.
.
# Chronic systolic heart failure, EF 40-45% ([**2149-9-6**]) -
increasing losartan, switching to PO beta blocker; appears
euvolemic on exam, has fluid status monitored at HD.
.
# Hx of seizure disorder - Patient had EEG which showed no
epileptiform activity. Had episode of unresponsiveness and
hypoventilation. Was transferred to ICU. Neurology recommended
dilantin; baclofen and reglan thought to lower seizure
threshold. He is to continue dilantin until he follows up with
Neurology in [**Month (only) 404**].
.....
MICU course:
The patient was transferred to the MICU for unresponsiveness
associated with apnea, hypoxia (88% on 2L NC), and acidemia.
# Altered mental status: Unclear etiology, though much improved
after starting dialysis (though 2nd dialysis session since his
code). Serum tox was negative, LP neg, no evidence of infection
(no fever, elevated WBC, or localizing source), MRI unchanged
from prior. [**Month (only) 116**] have been secondary to seizure or to some
toxic/metabolic process or [**Month (only) 4085**] related. Patient??????s
[**Month (only) 4085**] regimen has been greatly simplified. He did have
some periods of [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations with occasional
desats, but recovered spontaneously on his own. Altered
respirations likely related to a central process and has
improved with patient??????s improved mental status.
- f/u neurology recs
- continue Dilantin 100 mg QAM, 100 mg Qnoon, and 200 mg QHS.
.
# Hypertension: BPs elevated to 200s/100s on arrival to the ICU.
BPs improved to goal range of 160-180 with metoprolol 10 mg IV
Q8H. With improved mental status he was switched to a PO
regimen of metoprolol 50 mg TID and losartan 50 mg daily the
afternoon of [**10-16**].
.
# Positive blood culture: Patient with one positive blood
culture, gram positive cocci in clusters, from [**10-12**] (prior to
CVL placement). Received one dose of vancomycin but was not
redosed post dialysis on [**10-14**]. Likely a contaminate as no
other BCx have come back positive and the patient is afebrile.
Vanco stopped [**10-15**].
.
Once he was transferred back to the medical floor, he remained
clinically stable. His mental status returned to baseline and he
had a nonfocal neuro exam. He was discharged home once his
sister returned from [**Male First Name (un) 1056**].
.
Medications on Admission:
-Amitriptyline 25 mg QD
-B Complex-Vitamin C-Folic Acid [Dialyvite] 1 mg Tablet QD
-Insulin Glargine [Lantus] 6u QAM
-Losartan [Cozaar] 50 mg Tablet QD
-Metoclopramide 10 mg QID
-Metoprolol Tartrate 25 mg TID
-Pantoprazole 40 mg [**Hospital1 **]
-Phenytoin Sodium Extended 100 mg QAM, 100mg QNoon, 200mg QHS
-Sevelamer HCl 800 mg TID w/ meals Tablet
-Simvastatin 80 mg QD
-Sucralfate 1 gram Tablet four times a day Take two hours after
pantoprazole
-Aspirin 325 mg QD
-Senna, Docusate prn.
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching/dry skin.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO QNOON ().
Disp:*120 Capsule(s)* Refills:*2*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QHS (once a day (at bedtime)).
6. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 tabs* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
9. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for throat pain.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO QAM (once a day (in the morning)).
13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed units Subcutaneous qachs: Please follow sliding scale.
Disp:*2 pens* Refills:*2*
14. Insulin Glargine 100 unit/mL Solution Sig: Three (3) units
Subcutaneous qAM.
Disp:*1 pen* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] health systems
Discharge Diagnosis:
Primary diagnosis:
Upper GI bleed
encephalopathy of mutifactorial etiology, resolved
Chronic kidney disease stage V
Type 1 diabetes mellitus
Hypertension
history of seizures
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with chest pain, and upper GI bleed. You did
not have a heart attack, and didn't have any further bleeding
while in the hospital. You became unresponsive and were not able
to breathe on your own, so you were transferred to the intensive
care unit. They did a CT scan of your head that was normal.
Neurology evaluated you and started you on Dilantin. You will
need to take this [**Hospital 4085**] and follow up with them.
Gastroenterology evaluated you. They would like to follow up
with you in clinic to consider an EGD procedure, where they use
a scope to look for bleeding in your stomach. Nephrology
followed you, and you received dialysis three times a week.
Please call your primary doctor or go to the emergency room if
you have chest pain, vomiting blood, blood in your stools, black
stools, seizures, falls, fevers, or any other symptoms that
concern you.
Followup Instructions:
You have an appointment for an ultra sound on [**10-21**] at
8:30am. The number for the office is [**Telephone/Fax (1) 6713**]
You have an appointment with Dr. [**First Name (STitle) **] on [**10-26**] at 1pm.
The clinic number is [**Telephone/Fax (1) 40554**].
You have an appointment in liver transplant clinic on [**10-28**] at 9am.
Someone will call you to set up an appointment with your primary
care doctor.
You have an appointment on [**10-29**] at 2:30pm in
ophthalmology with Dr. [**Last Name (STitle) **]. The clinic is on the [**Location (un) 442**] of
the [**Hospital Ward Name 23**] building at [**Hospital3 **]. The clinic number is [**Telephone/Fax (1) 73860**].
You have an appointment with Dr. [**Last Name (STitle) 2340**] in neurology on
[**11-24**] at 2pm. The clinic phone number is [**Telephone/Fax (1) 73861**].
You have an appointment with Dr. [**Last Name (STitle) **] in Gastroenterology on
[**11-30**] at 2pm. The clinic number is [**Telephone/Fax (1) 2233**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2150-10-21**]
|
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"416.8",
"585.6",
"530.10",
"250.43",
"V45.11",
"280.0",
"293.0",
"345.90",
"786.03",
"536.3",
"357.2",
"403.91",
"428.22",
"V12.04",
"530.82",
"530.81",
"786.59",
"786.8",
"428.0",
"250.63",
"412",
"365.9",
"369.4",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"03.31",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12529, 12590
|
6512, 8625
|
322, 378
|
12808, 12817
|
3696, 6489
|
13749, 14893
|
2975, 3124
|
10850, 12506
|
12611, 12611
|
10335, 10827
|
12841, 13726
|
3139, 3142
|
271, 284
|
406, 1778
|
12630, 12787
|
3156, 3677
|
8640, 10309
|
1800, 2437
|
2453, 2959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,999
| 172,694
|
26690
|
Discharge summary
|
report
|
Admission Date: [**2199-10-14**] Discharge Date: [**2199-10-17**]
Date of Birth: [**2134-4-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 y/o F with likely idiopathic pulmonary fibrosis p/w 3 weeks
of worsening dyspnea.
Her pulmonary symptoms started last [**Month (only) 1096**] with progressive
shortness of breath impacting activities of daily living. Due
to severe dyspnea, she had to stop working in [**Month (only) 205**].
Approximately 3 months ago, she was placed on oxygen 4LNC which
she initially wore intermittently although for the last several
weeks she has needed to wear her oxygen continuously. The tempo
of her symptoms has progressed sgnificantly within the past 2
weeks to significant dyspnea even at rest. Over the past 24
hrs, she has been unable to take significant POs due to her
constant symptoms. She notes a cough productive of thick- white
sputum of a glue-like consistency, unchanged from prior
accompanied by significant abdominal/ chest pain caused by
coughing. She denies any associated fevers, sick contacts,
recent travel, medication noncompliance or other symptoms.
She is followed by Dr. [**Last Name (STitle) 2168**] in pulmonary, and unfortunately,
her symptoms have progressed too rapidly to allow pulmonary
biopsy. She is undergoing empiric treatment with steriods (on
bactrim for PCP [**Name Initial (PRE) **]) with the addition of cellcept without
significant improvement. Her last course of antibiotics was
avelox at the end of [**Month (only) **].
When she called EMS, initial O2 sats were 50% and she was placed
on 100% NRB. In the ED, VS were T98.6 HR 127 RR 35 and 100% on
NRB. Labs notable for WBC of 15.7, lactate of 2.5 and BNP of
1719. CXR was reportedly unchanged from prior with extensive
biilateral infiltrates. She was placed empirically on
levofloxacin, given 125mg solumedrol and started on continuous
nebulizers with slight improvement in subjetcive dspnea. Given
tenuous respiratory status, she was admitted to MICU for further
management.
Past Medical History:
- pulmonary fibrosis
- seasonal allergies
- s/p c-section
- s/p breast reduction
Social History:
lives at home with husband, previously worked as banking clerk
but unable to work since decline in functional status.
Family History:
N/C
Physical Exam:
VS: Temp: afebrile BP: 117/53 HR: 81 RR: 31 O2sat: 93% on 100%
NRB
GEN: moderately obese, pleasant woman, speaking in short
sentances due to SOB
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
RESP: poor air entry bilaterally with minimal chest wall
excursion
CV: tachycardia, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: CN II-XII intact, moves all extremities
Pertinent Results:
Initial Labs:
[**2199-10-14**] 02:05PM WBC-15.7* RBC-4.80 HGB-15.5 HCT-45.6 MCV-95
MCH-32.4* MCHC-34.1 RDW-15.8*
[**2199-10-14**] 02:05PM NEUTS-95.7* LYMPHS-3.2* MONOS-0.5* EOS-0.2
BASOS-0.3
[**2199-10-14**] 02:05PM PLT COUNT-377
[**2199-10-14**] 02:05PM PT-12.1 PTT-25.7 INR(PT)-1.0
[**2199-10-14**] 02:05PM cTropnT-<0.01
[**2199-10-14**] 02:05PM LD(LDH)-664*
[**2199-10-14**] 02:05PM GLUCOSE-214* UREA N-13 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
[**2199-10-14**] 02:26PM LACTATE-2.5*
[**2199-10-14**] 07:37PM TYPE-ART TEMP-38.2 PO2-144* PCO2-44 PH-7.42
TOTAL CO2-30 BASE XS-4 INTUBATED-NOT INTUBA
[**2199-10-14**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2199-10-14**] 05:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-250 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-10-14**] 05:15PM URINE RBC-[**11-9**]* WBC-[**2-22**] BACTERIA-FEW
YEAST-MOD EPI-[**2-22**]
[**2199-10-14**] 05:15PM URINE WBCCAST-[**2-22**]*
Imaging:
CXR: [**2199-10-14**]
Probable progression of interstitial lung disease; although
superimposed pneumonia or edema is not excluded.
Echo: [**2199-10-15**]
The left atrium is elongated. A patent foramen ovale is likely
present. The estimated right atrial pressure is 0-10mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). 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) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2199-5-10**],
the detected pulmonary artery systolic pressure is lower. A PFO
is probably present.
Microbiology:
blood cx: [**10-14**] NTD
urine cx: [**10-14**]: no growth
Brief Hospital Course:
65 yo/f with likely pulmonary fibrosis presenting with
progressively worsening dyspnea with high A-a gradient requiring
100% NRB to maintain oxygen saturations in the low 90s%. CXR on
admission with worsening bilateral infiltrates, which was most
consistent with acute worsening of likely pulmonary fibrosis. A
superimposed process such as infection, fluid overload, right to
left cardiac shunt or PE was also possible.
To treat likely progressive pulmonary fibrosis started on pulse
dose steriods with 1gm solumedrol daily. Also maintained on
broad spectrum antibiotics with vanc, cefepime and azithromycin
given possibility of superimposed infection in setting chronic
immunosuppression. As patient was too unstable for CT scan or
brochoscopy, she was also initiated on empiric therapy for PCP
PNA with IV bactrim. Given limited data that acute
decompensated pulmonary fibrosis may be improved with
anticoagulation, patient was started on heparin gtt. A echo
with bubble study did reveal a PFO, suggesting that right to
left shunting could be exacerbating hypoxemia, further treatment
of this was not pursued.
Despite maximal therapy, patient continued t6o suffer from
respiratory distress. A trial of NIPPV was attempted but poorly
tolerated by patient. Given dismal prognosis, patient decided
to shift goals of care first towards DNR/ DNI and then to
comfort measures only. She was initiated on morphine SR to
decrease work of breathing and symptoms improved slightly.
Unfortunately, patient's respiratory distress continued and she
began to complain of respiratory fatigue. On [**10-16**], patient
became more lethargic and obtunded. After discussion with
health care proxy, medical regimen was narrowed to morphine gtt.
The patient expired from respiratory failure on [**10-17**] at 13:45.
As per family wishes a post-mortem exam will be pursued.
Medications on Admission:
methylprednisilone 64mg daily
cellcept 500mg [**Hospital1 **]
bactrim DS three times weekly
atenolol 50mg daily
advil 200mg prn
albuterol prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Arrest secondary to likely progression pulmonary
fibrosis
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"V66.7",
"V58.65",
"799.1",
"427.89",
"276.51",
"515",
"288.60",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7432, 7441
|
5344, 7211
|
326, 332
|
7554, 7563
|
3003, 5321
|
7615, 7621
|
2495, 2500
|
7404, 7409
|
7462, 7533
|
7237, 7381
|
7587, 7592
|
2515, 2984
|
279, 288
|
360, 2239
|
2261, 2344
|
2360, 2479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,539
| 177,675
|
24538
|
Discharge summary
|
report
|
Admission Date: [**2198-5-22**] Discharge Date: [**2198-6-13**]
Date of Birth: [**2135-9-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Codeine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Group B Strep Endocarditis with OD Endophthalmitis
Major Surgical or Invasive Procedure:
TEE
PICC line placement
EGD
History of Present Illness:
This is a 62yo female with history of autoimmune hepatitis on
chronic immunosuppression, liver cirrhosis, diabetes, COPD,
chronic leg swelling from previous fracture, on imuran and
prednisone, transferred from OSH with Strep B bacteremia and
endopthalmitis. The patient was initially admitted to OSH on
[**2198-5-17**] for diarreha, nausea, and vomiting, with fever of 102 on
the day of admission. She was initially felt to have an acute
gastroenteritis, mild CHF, and LLE cellulitis. On admission she
was started on IV Vanc for presumed LLE cellulitis, and her
other meds (including imuran and prednisone) were held. She
developed acute loss of vision in her R eye on the night of
admission, and MRI/MRA was obtained. MRI showed multiple
punctate bilateral embolism c/w septic emboli. She was started
on heparin. Neurology recommended echo and MRA of the aortic
arch, concluding her symptoms were c/w embolic stroke. Her
gastroenterologist, Dr. [**Last Name (STitle) 62005**], recommended continuing the
pts Imuran and prednisone. She was also started on stress dose
solu-cortef for unclear reasons (not clear if pt was
hypotensive). On [**5-19**] she was started on IV Gent in addition to
her IV Vanc. Prior to transfer she was seen by opthamology who
felt her sxs were consistent with endopthalmitis and needs
urgent eval for vitreous tap and possible vitrectomy. Of note,
the pt is growing 4/4 bottles from [**5-17**] with strep agalactiae
group B. CXR on [**5-17**] was c/w mild CHF. ESR on [**5-18**] was 75. Urine
cx on [**5-17**] is growing strep agalactiea. Echo on [**5-21**] was
suspicious for mitral valve vegetation.
.
Past Medical History:
A-utoimmune hepatitis with liver cirrhosis and splenomegaly--on
imuran and prednisone
-Grade I esophageal varices
-anemia in setting of imuran
-COPD
-depression
-osteopenia
-chronic sinusitus
-endometrial metaplasia
-L ankle arthritis
Social History:
Employed as conservation [**Doctor Last Name 360**]. Husband. Two children. Non
smoker
Family History:
Non contributory
Physical Exam:
PE: 96.9, 130/62, 71, 18, 94%RA
Gen: ill appearing female laying in bed with eyes closed.
HEENT: Right eye with cloudy purulence coating [**Doctor First Name 2281**], pupil.
Scleral injection. No proptosis. Able to visualize light through
right eye, no movement. No papilledema left eye. Vision intact
on left. JVP to ear lobe.
CV: III/VI SEM LUSB radiating to carotids. Holosystolic murmur
to apex.
LUNGS: Sparse crackles at bases bilaterally
AB: Distended, non tender, + BS. Liver not palpable.
EXTREM: 2+ edema on right, 3+ on left. Erythema over posterior
aspect of calf, anteriorly to knee. Non tender to palpation.
Chronic venous stasis changes. 2+ DP right, 1+left given edema
difficult to palpate.
NEURO: Alert and oriented x 3. EOMI. Cranial nerves not
Skin- no lesions on palms or soles, echymoses throughout body.
Pertinent Results:
[**2198-5-22**] 09:21PM GLUCOSE-175* UREA N-28* CREAT-1.0 SODIUM-138
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2198-5-22**] 09:21PM estGFR-Using this
[**2198-5-22**] 09:21PM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-79 TOT
BILI-3.7*
[**2198-5-22**] 09:21PM CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-2.3
[**2198-5-22**] 09:21PM WBC-15.9*# RBC-3.41* HGB-12.5 HCT-36.3
MCV-106* MCH-36.8* MCHC-34.5 RDW-16.5*
[**2198-5-22**] 09:21PM NEUTS-86.9* LYMPHS-5.9* MONOS-6.0 EOS-0.1
BASOS-1.1
[**2198-5-22**] 09:21PM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+
[**2198-5-22**] 09:21PM PLT COUNT-130*#
[**2198-5-22**] 09:21PM PT-18.9* PTT-35.4* INR(PT)-1.8*
BLOOD WORK [**2198-6-2**]
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-6-2**] 07:00AM 13.8* 2.58* 9.6* 28.0* 109* 37.4* 34.5
21.7* 59*
Source: Line-PICC
INR 1.5
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-6-2**] 07:00AM 139* 34* 0.7 128* 4.2 94* 31 7*
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili [**2198-6-2**] 07:00AM 34 41* 79
6.5*
.
[**5-24**] CT HEAD
IMPRESSION: No evidence of acute intracranial hemorrhage.
Multiple hypodensities could be consistent with history of
septic emboli. However, for specific evaluation, a
contrast-enhanced CT of the brain or MRI is recommended.
.
[**2198-5-25**] ECHO
Conclusions:
No thrombus is seen in the left atrial appendage. The
interatrial septum is aneurysmal, but no atrial septal defect or
patent foramen ovale is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular systolic function is normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. The aortic valve leaflets
(3) are mildly thickened. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. There is a
large (1.6 x 1.5 cm) vegetation on the posterior mitral leaflet,
with leaflet perforation. An associated jet of severe (4+)
mitral regurgitation is seen. The anterior mitral leaflet is
normal in appearance, and there is no associated mitral annular
abscess. No vegetation/mass is seen on the pulmonic valve and
tricuspid valve.
IMPRESSION: Mitral valve endocarditis with posterior leaflet
perforation. Severe mitral regurgitation.
.
[**2198-5-28**] PELVIS ULTRASOUND
This is a technically difficult examination. The transabdominal
study is very limited due to the patient's body habitus.
Endovaginal examination was also technically difficult. The
uterus measures 4 cm in transverse x 4.7 cm in AP x 6.5 cm in
sagittal dimensions. The endometrial stripe measures 5 mm in
maximum dimension. Multiple heterogenous areas are identified
within the uterus in the mid body which may represent fibroids.
The largest of these measures less than 2 cm. The ovaries are
not visualized.
IMPRESSION: Technically difficult abdominal and transvaginal
examinations in patient with normal endometrial stripe thickness
and heterogenous appearance of uterus which may represent
fibroids. Ovaries not imaged.
.
[**2198-5-28**] DOPPLER LIVER
COLOR & PULSED DOPPLER SON[**Name (NI) **] LIVER: Normal flow and
waveforms are demonstrated within the hepatic arteries. No
portal venous flow is identified within the main portal vein and
the main portal vein is not well delineated.
IMPRESSION: 1) Heterogeneous echotexture of the liver consistent
with cirrhosis. No focal mass lesion identified.
2) The portal vein is not well delineated on this study. No
color flow or Doppler pulse is present within the expected
region of the portal vein. Chronic portal vein thrombus cannot
be excluded.
3) Cholelithiasis without evidence of cholecystitis.
.
REPEAT ECHO [**2198-6-7**]
No significant changes from prior.
.
Brief Hospital Course:
This is a 62 yo pt with autoimmune hepatitis on chronic
immunosuppression transferred from OSH, with Group B strep
bacteremia, septic brain emboli, endopthalmitis, endocarditis
with large mitral valve vegetation and small perforation.
# Endocarditis/bacteremia: The patient was initially on
vancomycin and gentamycin when transferred, and placed on the
sepsis protocol. AS per ID, gentamycin was discontinued and then
was switched to penicillin 3 million units q 4 hours IV after
desensitization in the MICU without adverse reaction. Pt was
afebrile while in house, with no growth from blood cultures in
house. Vitreous fluid grew group B strep sensitive to vancomycin
and Penicillin. ID followed the patient and she must remain on
antibiotics for a minimum of six weeks. On ID follow up on the
[**6-19**], they will determine the total treatment length. A PICC
line was placed on [**2198-6-1**].
.
# Mitral valve damage: Given bacteremia and probable septic
emboli, as well as likely mitral vegetation on outside hospital
TTE, TEE was performed [**5-25**]. This revealed large mitral valve
vegetation with perforation and severe mitral regurgitation.
Cardiac surgery was immediately consulted. They followed the
patient and determined she was not a surgery candidate given her
multiple risk factors, including her Childs B/C classification.
The patient was started on lasix 20 mg PO daily, and a low dose
of lisinopril. Her beta blocker was increased, and she tolerated
these changes well until an episode of low BP(see below). Prior
to discharge, her nadolol was again reduced to 10 mg [**Hospital1 **] and
tapered off due to decreased low pressure in the setting of
steroid taper.
She developed hypotension 70s/doppler on [**6-6**], which did not
respond appropriately to 1.5 L fluid bolus plus one unit PRBCs.
She was put back on stress dose steroids, all BP meds were d/c
and new blood cultures were sent, with no growth. The next day,
a new echo was ordered out of concern for cardiogenic shock. The
results were similar to the previous one. She never became
febrile or tachycardic. On [**6-7**], BP was 100s/doppler and the
patient continued to be asymptomatic. She compalined of
intermittent atypical chest pain, and several EKG revealed no
ischemic changes.
She needs to be on afterload reduction ideally, consisting of
BB, ACE-I and lasix, however due to her blood pressure running
in the 100's systolic without any symptoms, these medications
were stopped and should slowly be added back as blood pressure
tolerates. Patient is clinically hypervolemic with LE edema and
JVD, however no evidence of pulmonary fluid overload on exam.
.
# Embolic stroke: MRI/MRA outside hospital with evidence of
punctate lesions likely septic emboli. Pt was on Heparin at
outside hospital, but given risk of hemorrhagic bleed into
emboli, it was discontinued upon presentation to the [**Hospital1 18**].
Neurology followed the patient in house. She was disoriented at
times but this was more consistent with hepatic encephalopathy
and depression. She did not develop any neuro deficits. CT head
repeated with no evidence of acute bleed.
.
#Endophtalmitis: the patient presented with hypopyon and
complete vision loss. She underwent tap and aspiration, but not
vitrectomy, liquid growing Strep B, and had antibiotics injected
directly into the chamber: vancomycin and cefepime. Ophto
followed closely and they deem the R eye not salvageable.
Evisceration versus enucleation was planned, however the patient
wished to wait. In the meantime, she was continued on eye drops
recommended by ophto (see medication list). She must protect her
remaining eye at all times. She has been arranged for follow up
with ophto.
.
#Hyperkalemia and hyponatremia- No evidence of adrenal failure.
With hyponatremia and hyperkalemia, there was concern for
adrenal insufficiency, though patient was on stress dose
steroids, which were subsequently tapered to 10 mg daily IV,
then started PO on 80 mg, tapered down to 20 mg PO daily, final
goal 5 mg every other day. Pharmacy was consulted about
penicillin with ~30 MEQ daily potassium, but they did not feel
that this could cause persistent hyperkalemia. The patient was
previously on K sparing diuretic Spironolactone which was held.
The patient required [**Hospital1 **] lyte checks for a few days and several
doses of kayexelate. The hyperkalemia resolved 8 days prior to
discharge, also in the setting of increased insulin.
Hyponatremia persists, and is consistent with ADH derangements
with concentrated urine osmolality. The patient was placed on
free water restriction 1.5 liter daily.
.
#Thrombocytopenia- Platelets decreased during admission, but
remained above 50 except for a value in the 40s on [**6-12**]. Low
platelets are in the setting of cirrhosis with compromised
synthetic function (albumin 1.5). She received vitamin K SQ x 3
doses. HIT was positive, but Serotonin Release Antibody was
negative, therefore the patient was continued on SQ heparin with
no evidence of decreased platelet count or thrombosis. Small
amount of vaginal bleeding during admission, which resolved.
.
#Cirrhosis: EGD demonstarted grade I varices. The hepatology
service followed the patient. Imuran was held. Nadolol was
re-started at 10 [**Hospital1 **], then increased to 20 [**Hospital1 **]. The BB was
subsequently decreased again to 10 mg in the setting of low
blood pressures. Aldactone was held with the development of
hyperkalemia. The patient developed hepatic encephalopathy with
asterixis and lactulose was begun and titrated to 3 BM daily,
with the patient's mental status improving. The patient
developed worsening unconjugated bilirubinemia with some
evidence of hemolysis. Bilirubin then trended down (although it
remains elevated). Transaminases remained normal with a mild
elevation the last few days. Hepatology started rifaximin on
[**6-7**]. Per hepatology, Imuran can be restarted if LFTs double.
Taper of prednisone can continue while watching her LFTs. She
should continue on 20 mg prednisone daily for [**6-13**] and [**6-14**] and
then be decreased to 10 mg daily to be continued indefinitely.
.
#Hemodynamics: The patient blood pressure became low on [**6-5**] and
[**6-6**]. On [**6-6**], she triggered for BP 78/doppler. She was clammy on
exam but not lightheaded or diaphoretic. That same day, her
HCT<25 with no significant bleeding (she had persistent
hematuria throughout admission, insufficient to explain her Hct
drop). She was treated with 1500 cc NS and transfused one unit,
without adequate response. She was started on stress dose
hydrocortisone. After transfusion, the HCT was appropriately 2
points higher. Blood cultures were sent, which were negative.
The next day, an echo showed no changes from prior. BP was
100s/doppler and an EKG was obtained as described above, with no
ischemic changes. The patient's blood pressure stabilized and
she was again placed on steroid taper 2 days later. Discharge BP
was 100/50, which is consistent with patient's baseline BP.
.
#Hyperglycemia: Initially the patient's sugars were 200-300s.
Lantus dose was increased to 32 units, then 34 and 36, and
humalog as well as sliding scale was successively tightened. At
discharge, the finger sticks were significantly improved, and
the lantus dose is again decreased in setting of steroid taper.
.
#Depression: initially, all psychotropic medications were held
due to the patient's poor mentation in the setting of bacteremia
and possibly hepatic encephalopathy. The patient's sensorium
cleared significantly with treatment, however her mood became
increasingly depressed. The patient endorsed feelings of
hopelesness, helplessness, and deep depression. Celexa was
restarted on [**6-11**].
.
#Vaginal bleeding: The patient developed mild vaginal bleeding
with stable crit. She had had a normal Gyn exam and Pap 4 months
prior to admission. Gyn was consulted and examination revealed
dark blood at the cervical os. They recommend that the patient
have an endometrial biopsy as an outpatient.
.
#Funguria: Two successive urine cultures revealed yeast. A
decision was made to institute a short course of fluconazole
(last day [**2198-6-6**]) given the patient's immunosppression. An
attempt was made to d/c Foley, but the patient became unable to
void, and the Foley was reinstituted. A spontaneous voiding
trial on 5/ 5/ 07 again resulted in the patient being unable to
void, therefore the Foley remains in place at discharge. The
patient had at all times a normal neuro exam and specifically,
she did not have saddle anesthesia.
.
#ADL: PT and OT evaluated the patient and the consensus is that
she is significantly below baseline and has excellent rehab
potential. The patient is severely deconditioned and has
difficulty ambulating at discharge.
.
#FEN: diabetic, cardiac diet
.
#PPX: SSI while on steroids, PPI, heparin SQ.
.
#Code: full
.
#[**Name (NI) **] husband at [**Telephone/Fax (1) 62006**]
.
#Dispo- to rehab.
Medications on Admission:
-imuran 75 mg daily
-aldactone 100 mg daily
-lasix 40 mg daily
-prednisone 20 mg daily
-solu-cortef 100 mg IV bid
-Vanc 1 g IV bid
-Garamycin 80 mg IV q 8hr since [**5-19**]
-heparin gtt
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
2. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q3H
(every 3 hours): Right eye.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Right eye.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Penicillin G Potassium 5,000,000 unit Recon Soln Sig: One
(1) Recon Soln Injection Q4H (every 4 hours).
12. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q3H (every 3 hours): Right eye.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed.
14. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day): Right eye.
15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO TID (3
times a day).
18. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
19. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days: Please continue for [**6-13**] and [**2198-6-14**]. .
20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on [**2198-6-15**] and continue indefinitely. .
21. Insulin
Please continue glargine and humalog per sliding scale insulin
sheet attached to discharge paperwork.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Endocarditis with mitral valve rupture
Endophtalmitis with irreversible loss of vision OD
Septic Emboli brain
Autoimmune hepatitis with cirrhosis and bilirubinemia
Secondary:
Diabetes Mellitus
Anemia
Thrombocytopenia
Funguria
Vaginal bleeding
Urinary retention
Hepatic encephalopathy
Discharge Condition:
Fair to good.
Discharge Instructions:
You were admitted with an infection in your heart
(endocarditis), which has damaged one of your heart valves, the
mitral valve. In addition, your right eye was severely infected
with endophtalmitis and you also had some septic emboli to your
brain. Other problems with which you presented were uncontrolled
blood sugars, anemia (low blood), and yeast infection to your
urine.
You were desensitized to penicillin and have been receiving
penicillin intravenously. This antibiotic needs to be continued
for at least 6 weeks, and can be administered through the PICC
line that was placed in your right arm. You need to follow the
recommendations of your Infectious Disease doctor (with whom you
have an appointment) as to the exact number of days you must
take antibiotics. Please continue the antibiotics until you see
the ID physician.
[**Name10 (NameIs) 62007**] medical consults were ordered while you were in the
hospital:
- The liver service recommended you stop taking imuran. Your
steroid dose was also slowly reduced to 20 mg daily, which is
your current dose and will be further tapered to 10 mg daily.
- The eye doctors recommend surgery on your right eye, and you
need to follow up with them. YOU MUST PROTECT YOUR LEFT EYE AT
ALL TIMES.
- You were also seen by a gynecologist for vaginal bleeding, and
you need to arrange for an endometrial biopsy as an outpatient.
- The GI doctors examined your [**Name5 (PTitle) 62008**], stomach and duodenum
and found enlarged veins.
You were started on a medication to control your fluid status,
lasix, once a day. You were also started on a new blood pressure
medication, lisinopril. Your nadolol dose was increased to help
your heart. However due to lower blood pressures, these
medications were stopped and can be restarted slowly.
Followup Instructions:
DR [**Last Name (STitle) **] (Eye, [**Last Name (un) **] Center) [**2198-6-22**], 2:30 pm
With your gynecologist as soon as feasible.
With provider (Infectious Disease): [**First Name8 (NamePattern2) 7618**] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2198-6-19**] 9:00
With provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2198-9-6**] 10:45
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
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8,731
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30828
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Discharge summary
|
report
|
Admission Date: [**2136-5-14**] Discharge Date: [**2136-5-18**]
Date of Birth: [**2077-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 YOM found at work altered and confused walking around. EMS
was called and finger stick 70mg/dl, [**11-25**] amp D50 given and BS
improved to 338mg/dl.
.
In the ED, initial vs were: T P 90 BP R O2 sat. Imaging of chest
and head were obtained and within normal limits. Urine and serum
tox were negative. UA was clear. Patient then complained of
abdominal pain and a CT ab/pelvis was obtained. Upon return for
CT scan, he become more agitated and pulled out an IV and he
received 5mg IV Haldol and 2mg IV Ativan. A toxicology consult
was called and felt this was most consistent with ETOH
withdrawal. Patient was given 5mg of Diazepam. 1L of Banana bag,
1L of D5NS. Blood and urine cultures were sent. Because he
remained tachycardic and required 4 point restraints, he was
admitted to the MICU for ETOH withdrawal. At the time of
transfer, VS HR 114 BP 159/85 POx99 on 2 L.
.
On arrival to the floor, he was in 4 point leather restraints.
He was saying "help me, help me". Remainder of information
obtained from prior records.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied 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:
Past Medical History:
- Diabetes type 2 on insulin
- Alcohol abuse
- Asthma
- Hypertension
- Chronic Pancreatitis
Social History:
Social History:40-pack-year smoking. Continues to smoke. Alcohol
- drinks 1 to 2 quarts of beer about 3 to 4x a week. No IV drug
use. Has a history of cocaine abuse, quit in [**2127-12-25**]. He
works in sterile processing at the VA.
Family History:
Family History: Father has coronary artery disease. Brother with
drug addiction. Mother alive and healthy.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T:100.1 BP:179/94 P:114 R: 18 O2: 97%on 2L NC
General: Drowsy, intermittently answering questions, saying
expliatives intermittently, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy, regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, + hyperactive bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII without focal deficit, pupils 2mm and reactive,
moving all for extremities, exam limited by cooperation and
leather restraints
Pertinent Results:
ADMISSION LABS:
[**2136-5-14**] 08:18PM LACTATE-2.6*
[**2136-5-14**] 08:00PM GLUCOSE-113* UREA N-13 CREAT-1.3* SODIUM-136
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-18* ANION GAP-17
[**2136-5-14**] 08:00PM estGFR-Using this
[**2136-5-14**] 08:00PM ALT(SGPT)-30 AST(SGOT)-21 CK(CPK)-71 ALK
PHOS-157* TOT BILI-0.4
[**2136-5-14**] 08:00PM LIPASE-13
[**2136-5-14**] 08:00PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-2.8
MAGNESIUM-1.9
[**2136-5-14**] 08:00PM WBC-9.1 RBC-3.96* HGB-12.7* HCT-35.0* MCV-88
MCH-32.0 MCHC-36.3* RDW-13.5
[**2136-5-14**] 08:00PM PT-12.4 PTT-22.9 INR(PT)-1.0
[**2136-5-14**] 08:00PM PLT COUNT-308
TOX SCREENS:
[**2136-5-14**] 08:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-5-14**] 09:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
URINE STUDIES:
[**2136-5-14**] 09:30PM URINE HOURS-RANDOM
[**2136-5-14**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2136-5-14**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
IMAGING:
CXR [**2136-5-14**] - FINDINGS: The cardiomediastinal silhouette is
unremarkable. There is no focal pulmonary consolidation or
pleural effusion. There is thoracic kyphosis with multilevel
degenerative changes in the spine.
CONCLUSION: No acute cardiopulmonary process.
.
Head CT [**2136-5-14**] - FINDINGS: The scan is somewhat compromised due
to artifact from motion, within these limitations the midline
structures are central. There is no mass effect or edema. There
is no acute intracranial hemorrhage. The visualized paranasal
sinuses are clear. CONCLUSION: No acute intracranial process.
.
Abd CT [**2136-5-14**] - CONCLUSION: 1. 3-mm nodule at the right lung
base should be followed up with a chest CT in one year to ensure
resolution/stability.
2. 6.5 mm dilated pancreatic duct with multiple punctate
pancreatic
calcifications. These findings are most consistent with sequelae
of
pancreatitis; however IPMN cannot be excluded. Further
evaluation with MRCP should be performed as clinically
indicated. 3. Bilateral pars defects at L5.
.
MICROBIOLOGY:
[**2136-5-15**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2136-5-15**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
INPATIENT
[**2136-5-15**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2136-5-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2136-5-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2136-5-14**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
Brief Hospital Course:
ALTERED MENTAL STATUS: This is a 59 yo M who presents with
altered mental status and concern for ETOH withdrawal based on
prior h/o ETOH per report. Tox screen was negative on admission
and patient was started on CIWA and given MVI/folate/thiamine.
Patient continued to be aggitated and was given diazepam and
haldol with good effect. His mental status improved throughout
his ICU stay and patient was responsive and cooperative prior to
transfer to the general wards. Upon transfer to wards, patient
was delerious and agitated, requiring additional haldol. Based
on prior admissions, psychiatry assessed mental status change
most likely due to benzodiazepene toxicity. Vitals remained
stable and there was no evidence of ETOH withdrawal. Valium was
held and mental status changes resolved.
DIABETES: Pt is a known diabetic and his blood glucose was
stable during ICU stay. Upon transfer to floors, his blood
sugar was difficult to control, ranging between 63 and >500. It
was eventually controlled with a reduced glargine dose and
sliding scale insulin. Patient is being discharged on 15 units
glargine QAM.
CHRONIC PANCREATITIS: Patient intermittently complained of
nonspecific abdominal pain. He tolerated PO with no nausea or
vomiting and abdominal exam was unremarkable. Upon discharge,
patient states pain is minimal.
INCIDENTAL PULMONARY NODULE: A pulmonary nodule was found on
imaging in the ED and should be re-imaged by CT in 1 year.
HYPERTENSION: Blood pressure well-controlled with home meds of
lisinopril 40mg PO Qdaily and Norvasc 10mg PO Qdaily.
ISSUES FOR FOLLOW-UP:
1. 3-mm nodule at the right lung base should be followed up with
a chest CT in one year to ensure resolution/stability.
2. 6.5 mm dilated pancreatic duct with multiple punctate
pancreatic calcifications. These findings are most consistent
with sequelae of pancreatitis; however IPMN cannot be excluded.
Further evaluation with MRCP should be performed as clinically
indicated.
3. [**Name (NI) 20472**] Pt was adjusting his insulin dose dramatically
without consulting a physician. [**Name10 (NameIs) **] was told to take 15 units
glargine QAM and sugars should be closely monitored.
Medications on Admission:
1. Albuterol inhaler
2. Atrovent inhaler
3. Lantus 18 units SQ QHS
4. Norvasc 10mg PO Qdaily
5. Lisinopril 40mg PO Qdaily
6. Multivitamin Qdaily
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed for prn wheezing.
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous QAM.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-25**] Inhalation every 4-6 hours as needed for
shortness of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Hypoglycemia
2. Benzodiazepine Toxicity
3. Chronic pancreatitis
4. History of Alcohol Abuse
5. Hypertension
6. Asthma
Discharge Condition:
Stable, Alert and Oriented x 3
Discharge Instructions:
You were admitted to the hospital because you were confused and
your blood sugar was low.
.
You had pictures of your head and chest taken. The pictures of
your head were normal. The pictures of your chest were normal
except for a small lump in one of your lungs. You need another
picture of your chest in one year to make sure the lump goes
away and does not get bigger.
.
You had pictures of your pancreas taken. These pictures showed
that one of the tubes connecting your pancreas is too wide. You
need to have more tests done to look at your pancreas.
.
While you were in the hospital, you had problems with your blood
sugar. We changed your insulin doses to help keep your sugars
more stable.
Followup Instructions:
1. 3-mm nodule at the right lung base should be followed up with
a chest CT in one year to ensure resolution/stability.
2. 6.5 mm dilated pancreatic duct with multiple punctate
pancreatic
calcifications. These findings are most consistent with sequelae
of
pancreatitis; however IPMN cannot be excluded. Further
evaluation with MRCP should be performed as clinically
indicated.
3. You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48975**] ([**Telephone/Fax (1) 72966**]
at the [**Hospital **] Clinic on [**2136-5-24**] at 10:30 am.
|
[
"305.1",
"303.90",
"E939.4",
"V58.67",
"250.80",
"276.2",
"493.90",
"284.1",
"518.89",
"577.1",
"292.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8891, 8897
|
5756, 5764
|
335, 341
|
9079, 9111
|
3085, 3085
|
9858, 10440
|
2218, 2310
|
8132, 8868
|
8918, 9058
|
7963, 8109
|
9135, 9835
|
2325, 2339
|
1419, 1798
|
274, 297
|
369, 1400
|
3101, 5733
|
2353, 3066
|
5779, 7937
|
1842, 1935
|
1966, 2186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,909
| 184,636
|
16172
|
Discharge summary
|
report
|
Admission Date: [**2108-12-16**] Discharge Date: [**2108-12-25**]
Date of Birth: [**2038-5-8**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Ruptured aneursym.
HISTORY OF PRESENT ILLNESS: This 70 year-old male who
underwent a right nephrectomy for a benign lesion who noted
one month prior to admission vague abdominal pain. On [**12-16**]
noted sudden onset of sharp abdominal pain 10 out of 10
nonradiating without hematuria, leg numbness or melena. He
called 911. He was taken to an outside hospital. A CT scan
showed ruptured aneurysm. The patient was transferred here
for emergent surgery.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Prostate carcinoma.
3. Status post brachytherapy on [**2108-5-21**].
4. Right nephrectomy, remote secondary to benign lesion.
5. Chronic renal insufficiency, baseline creatinine of 2.2.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Hydrochlorothiazide 25 mg q.d.,
Diltiazem 240 mg po q day, Lisinopril 10 mg po q day.
HOSPITAL COURSE: The patient was admitted from the Emergency
Room and went directly to surgery and underwent an urgent
abdominal aortic repair. He was transfused 500 cc of
CellSaver and 4 units of packed red blood cells
intraoperatively. He was transferred to the CICU
postoperatively for continued monitoring. Immediately
postoperatively, his physical examination, he was intubated
and sedated. Heart regular rate and rhythm. Abdominal
examination dressings were dry. He had a palpable femorals
bilaterally with dopplerable dorsalis pedis pulses and
posterior tibial pulses bilaterally. His postoperative
hematocrit was 40. His BUN 41, creatinine 2.1, K 5.7. Blood
gas was 7.31, 33, 87 and 17, -2. He is continued on a
Propofol drip and intubated with intravenous fluid
resuscitation and he remained in the CICU. On postoperative
day two overnight events were persistent systolic
hypertension requiring intravenous fluid boluses. His
morphine was converted to Dilaudid with stabilization of his
blood pressure. Temperature max was 38.2. Hematocrit was
32.9, BUN 44, creatinine 2.6, K 4.8. He required
intermittent doses of Lopressor to for systolic hypertension
and tachycardia rate control. He was extubated without
difficulty. He remained NPO. His hematocrit remained
stable. His physical examination remained unchanged.
Cultures, blood, urine and sputum were obtained, because of
his temperature max. The patient's cultures finalized at no
growth. The patient was screened for MRSA, which was
negative. The patient was transferred to the VICU on
postoperative day two for continued monitoring and care.
Postoperative day three there were no overnight events. He
defervesced. Hematocrit was 25.9, white blood cell count
7.7, BUN 41, creatinine 2.4, K 4.1. He required Lasix and a
unit of packed red blood cells for his hematocrit.
Postoperative day four his post transfusion hematocrit was
29.2, BUN 54, creatinine 2.5. The patient's abdomen was soft
with bowel sounds present. Pulse examination remained
unchanged. His Swan was converted to a peripheral heplock
and his A line was discontinued. Ambulation was begun.
Postoperative day six his creatinine peaked at 2.7. Renal
consult was requested. Recommendations were urine
electrolytes, urinalysis and renal ultrasounds. Ultrasound
was negative. Renal electrolytes were unremarkable and
repeat urinalysis was unremarkable. Adjustments were made in
his ace inhibitor and Lasix.
Over the next 48 hours his creatinine continued to
defervesce. At the time of discharge his creatinine was 2.4.
The patient should follow up with his primary care physician,
[**Name10 (NameIs) **] and should have electrolytes drawn over the next
week. The patient is having continued improvement in his
renal function. He should follow up with Dr. [**Last Name (STitle) 1391**] in two
weeks time.
DISCHARGE MEDICATIONS: Diltiazem extended release 120 mg q
day, Percocet tablets one to two q 4 to 6 hours prn,
Metoprolol 25 mg b.i.d. Ace inhibitor and Lasix have been
held. He will follow up with his primary care physician,
[**Name10 (NameIs) **] to have renal functions monitored over the next
week and his antihypertensives adjusted accordingly.
DISCHARGE DIAGNOSES:
1. Ruptured abdominal aortic aneurysm status post repair.
2. Renal failure secondary to ATN, improving.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2108-12-25**] 08:11
T: [**2108-12-25**] 08:25
JOB#: [**Job Number 46196**]
|
[
"441.3",
"V45.73",
"401.9",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
4254, 4640
|
3902, 4233
|
921, 1008
|
1026, 3878
|
160, 180
|
209, 622
|
644, 894
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,985
| 109,123
|
42670
|
Discharge summary
|
report
|
Admission Date: [**2127-1-8**] Discharge Date: [**2127-1-14**]
Date of Birth: [**2102-9-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
tylenol and paxil overdose
Major Surgical or Invasive Procedure:
Right IJ Placement
History of Present Illness:
HPI: 24 previously healthy female presents as direct admission
to Transplant Surgery ICU for tylenol overdose. Patient reports
having a recent break-up with her fiance and between yesterday
afternoon to this morning ingested ~ 80-100 tablets of tylenol
PM
along with ten tabs (30 mg) of Paxil. After telling her mother
what she had done, she was [**Last Name (un) 4662**] to the [**Hospital 792**]Hospital
ED
this morning (~ 9AM). She reports no abdominal pain, but has
mid-chest pain and throat pain/burnig. She reports feeling
unsteady and slightly forgetful. She also reports vomiting some
pill fragments. Per records, at OSH Ed she was bolused with
loading dose of NAC (8200 mg IV, 150 mg/kg) and recieved 1 L of
NS. She was transferred to [**Hospital1 18**] for further treatment. She
denies recent EtOH use. She reports smoking marijuana ~ 2 days
ago after work but denies any other drug use. She reports
having
sweats but denies fevers, chills, diarrhea or constipation.
Past Medical History:
PMH: panic attacks/anxiety
PSH: c-section
Social History:
Lived with her fiance and their 3 year old daughter. She is
employed as a cook. Her family lives nearby. Her fiance's
family lives in [**Male First Name (un) 1056**]. She denies suicide attempts or
ever
attempting overdose in the past. She reports rare EtOH use.
Occasional marijuana. [**1-20**] PPD smoker x ~4 years.
Family History:
Non contributory
Physical Exam:
On Admission:
VS: 97.8 110 152/85 20 96% RA
Gen: NAD, AOx3 with occasional innappropriate responses and
attention loss, but easily re-oriented
CVS: sinus tachycardia
Pulm: CTA-B, no respiratory distress
Abd: S/NT/ND no rebound, no guarding
Ext: no LLE, no track marks on arms
.
GENERAL: Well appearing 24yo M/F who appears stated age.
Comfortable, appropriate.
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: S1 S2 clear. No MRG noted. Difficult to appreciate for
S3 or S4 given tachycardia.
LUNGS: Nonlabored with no accessory muscle use, moving air well
and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Thin, with small amount of redundant skin. NABS. Soft,
nontender and nodistended. No HSM noted.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
NEURO: AAOx3. CNII-XII grossly intact. Strength 5/5 throughout.
No gross sensory loss. Cerebellar fxn intact to FTN.
Pertinent Results:
Labs on Admission:
[**2127-1-8**] 08:19PM BLOOD WBC-9.4 RBC-4.09* Hgb-13.0 Hct-36.3
MCV-89 MCH-31.8 MCHC-35.8* RDW-13.0 Plt Ct-175
[**2127-1-8**] 08:19PM BLOOD PT-35.3* PTT-33.0 INR(PT)-3.4*
[**2127-1-8**] 08:19PM BLOOD Glucose-59* UreaN-9 Creat-0.5 Na-142
K-2.8* Cl-111* HCO3-20* AnGap-14
[**2127-1-8**] 08:19PM BLOOD ALT-1139* AST-918* LD(LDH)-666*
AlkPhos-84 Amylase-38 TotBili-6.1*
.
Labs on Discharge:
[**2127-1-13**] 06:20AM BLOOD WBC-6.1 RBC-4.16* Hgb-13.1 Hct-36.6
MCV-88 MCH-31.4 MCHC-35.7* RDW-13.3 Plt Ct-191
[**2127-1-13**] 06:20AM BLOOD PT-13.1* PTT-42.1* INR(PT)-1.2*
[**2127-1-13**] 06:20AM BLOOD Glucose-89 UreaN-17 Creat-0.6 Na-139
K-4.3 Cl-105 HCO3-29 AnGap-9
[**2127-1-14**] 01:05PM BLOOD ALT-1582* AST-86* AlkPhos-96 TotBili-1.2
[**2127-1-13**] 06:20AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.0
.
[**2127-1-8**] 08:19PM BLOOD calTIBC-270 Ferritn-558* TRF-208
[**2127-1-13**] 06:20AM BLOOD TSH-<0.02*
[**2127-1-13**] 06:20AM BLOOD T4-11.8 T3-126
[**2127-1-8**] 08:19PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-1-8**] 08:19PM BLOOD HCG-<5
[**2127-1-8**] 08:19PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2127-1-8**] 08:19PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2127-1-8**] 08:19PM BLOOD CEA-<1.0 AFP-1.2
[**2127-1-8**] 08:19PM BLOOD IgG-1049 IgA-179 IgM-80
[**2127-1-8**] 08:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-119*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-1-11**] 06:02AM BLOOD Lactate-0.9
.
[**2127-1-8**] Right Upper Quadrant:
IMPRESSION:
1. Normal liver echotexture without discrete lesions.
2. Gallbladder wall edema, most likely related to acute
hepatitis.
3. An incompletely imaged left renal cystic lesion with internal
focus of
increased echogenicity, may represent calcification within a
calyceal
diverticulum. Follow up dedicated renal ultrasound exam when the
patient's
condition stabilizes is recommended for further evaluation.
.
[**2127-1-8**] CXR: FINDINGS: Normal size of the cardiac silhouette.
Normal hilar and mediastinal contours. No pleural effusions. No
pneumothorax, no pneumonia, no pulmonary edema. Unremarkable
morphology in the upper abdomen
.
[**2127-1-9**] Echo: Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 24 year old female with history of
depression/anxiety who presented with acute liver failure after
suicide attempt by tylenol/paxil ingestion.
.
#. Acute Liver Failure: Patient was initially cared for in the
surgical intensive care unit given concern that liver failure
would progress and she would need transplant. Transplant
evaulation was initiated with psych, social work and hepatology
consultation. N-Acetylcysteine was continued per fulminant liver
failure pathway. Initially INR climbed and peaked at 6.2 prior
to trending down. Bilirubin trended up to 6.1 prior to returning
to normal range. The patient developed no renal dysfunction.
Patient did develop mild encephelopathy which promptly resolved
with improvement in her liver function. Her liver function
continued to improve during hospitalization.
.
#. Depression/Anxiety: Now with suicide attempt. Psychiatry was
consulted and recommended section 12 and 1:1 sitter. Patient was
followed by psychiatry and transfered to an inpatient facility.
Per psychiatry recommendations patient's paxil was held.
.
#. Tachycardia: EKG revealed sinus tachycardia. TSH was checked
and <0.02. T3 and T4 were within normal range. Endocrinology was
consulted and recommended T3 uptake scan which will be completed
during the psychiatric admission. Endocrinology will continue to
follow the patient. Propanolol was started with improvement in
the patient's heart rate.
.
#. Urinary Tract Infection: Complicated in setting of foley
catheter placement. Patient to complete 7 day course of
Ciprofloxacin for treatment.
.
FOLLOW UP/TRANSITIONAL ISSUES:
1. Ciprofloxacin should be continued for 4 more days to complete
7 day course for complicated UTI
2. Patient should have Thyroid uptake scan on [**2128-1-15**].
Endocrinology is follow patient and will make further
recommendations.
3. Appreciate endocrinology recommendations.
Medications on Admission:
paxil 30 mg daily
Discharge Medications:
1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
3. propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Depression/Anxiety
Hyperthyroidism
Tachycardia
Liver Failure secondary to tylenol toxicity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure caring for you while you were admitted to
[**Hospital1 18**]. During your admission you were monitored very closely in
the intensive care unit given concern for liver failure
secondary to tylenol overdose. With N-Acetylcysteine (a
medication which protects the liver against tylenol) your liver
function improved.
During your stay you were also found to have a fast heart rate
and your thyroid hormone was found to be elevated meaning you
may have hyperthyroidism.
.
You were evaluated by the psychiatric team during your stay and
they recommended inpatient psychiatric evaluation given your
suicide attempt.
The following changes were made to your medications:
-- STOP Paxil
-- START Ciprofloxacin 500mg Twice Daily for 4 more days (for
UTI)
-- START Propanolol 10mg TID for fast heart rate
-- START Nicotine Patch
Please follow up with your primary care physician after
discharge from the psychiatric unit.
Followup Instructions:
After discharge from the psychiatric facility you should follow
up with your primary care physician.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
|
[
"251.2",
"286.9",
"296.20",
"599.0",
"724.2",
"346.90",
"242.90",
"V62.84",
"300.00",
"969.09",
"E950.0",
"305.1",
"965.4",
"570",
"305.20",
"E950.3",
"572.2",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7966, 7981
|
5720, 7325
|
332, 353
|
8125, 8125
|
2819, 2824
|
9257, 9454
|
1797, 1815
|
7693, 7943
|
8002, 8104
|
7650, 7670
|
8276, 9234
|
1830, 1830
|
7346, 7624
|
265, 294
|
3226, 5697
|
381, 1372
|
2838, 3207
|
8140, 8252
|
1394, 1439
|
1455, 1781
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,973
| 160,118
|
4030
|
Discharge summary
|
report
|
Admission Date: [**2182-1-18**] Discharge Date: [**2182-2-26**]
Date of Birth: [**2120-10-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide
Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Pt initially presented for blood transfusion and HD. She became
acutely tachypneic requiring transfer to the ICU. In the ICU,
she was hypotensive and treated for urosepsis with 7 days of
Meropenem. On the floor, she was stable, and finished pre-op
evaluation for MVR/CABG
Major Surgical or Invasive Procedure:
[**2182-1-29**] MV repair ( 28mm [**Company 1543**] CG Future Ring)/CABG x5 (LIMA
to LAD, SVG to PDA, SVG to OM2 sequenced to SVG to OM 1,
sequenced to SVG to DIAG)/ closure ASD
History of Present Illness:
61 yo F with kidney and pancreas transplant presented to the ED
after missing her dialysis appointment today. She was found to
be anemic to Hct 20, but asymptomatic. She was transfused 2
units of blood with plan to dialyze tomorrow, but this could not
be obtained as an outpatient. During the transfusion, the
patient became tachypnic and febrile, but TRALI was ruled out.
The patient was transfered to the ICU for monitoring, where she
was found to have a UTI and hypotension concerning for a septic
picture. The patient was treated with a 7 day course of
Meropenem. While in the hospital, the patient was evaluated for
MVR and CABG. She is due for surgery on [**2182-1-29**].
Past Medical History:
# CHF, chronic systolic and diastolic EF 35-45%
# 4+ MR
# moderate pulmonary artery systolic hypertension
# CAD: s/p DES to mid-LAD in [**9-/2181**]
# End-stage renal disease (ESRD) HD: s/p renal transplant x2,
on HD MWF. tacrolimus, sirolimus, and prednisone.
# Atrial fibrillation: Amiodarone. Coumadin
# Anemia: on Epo.
# Type 1 diabetes mellitus: s/p pancreatic transplant.
# autonomic neuropathy
# sleep-disordered breathing on CPAP
# osteoporosis
# hypothyroidism
# cataracts
# glaucoma
# h/o Reucrrent MDR E.coli pyelonephritis
# s/p left [**Year (4 digits) 6024**] ([**8-/2179**])
Social History:
retired psychiatrist, currently lives at a rehab facility
Family History:
Father with MI at 57 year old; denies family history of
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
Physical Exam:
Pulse:70 Resp:16 O2 sat:99/RA
B/P 110/60
Height:67" Weight:56.1 kgs
General: awake, alert, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR, Nl S1-S2, II/VI Systolic murmur best heard at apex.
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x], peritoneal dialysis catheter in place
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: (L) [**Year (4 digits) 6024**]. Vein appears suitable but unable to
stand.
Right appears suitable but small/absent at ankle.
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: s/p [**Name (NI) 6024**]
PT [**Name (NI) 167**]: palp Left: s/p [**Name (NI) 6024**]
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
ADMISSION LABS
[**2182-1-18**] 09:13PM BLOOD WBC-4.1# RBC-3.52* Hgb-10.4* Hct-31.9*
MCV-91 MCH-29.5 MCHC-32.6 RDW-17.5* Plt Ct-162
[**2182-1-18**] 02:43PM BLOOD PT-19.1* PTT-35.5 INR(PT)-1.8*
[**2182-1-18**] 01:50PM BLOOD Glucose-82 UreaN-81* Creat-4.7*# Na-140
K-3.7 Cl-99 HCO3-32 AnGap-13
[**2182-1-18**] 01:50PM BLOOD ALT-6 AST-22 LD(LDH)-169 AlkPhos-64
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2182-1-18**] 01:50PM BLOOD Calcium-8.6 Phos-4.9*# Mg-1.9
INDICATIONS FOR CONSULT:
Investigation of transfusion reaction
CLINICAL/LAB DATA: Ms. [**Known lastname 17759**] is a 61 year old female with
history of
failed renal transplant and chronic heart failure who was
admitted due
to missed dialysis. Due to low hematocrit, she received two
units of red
blood cells with the first unit beginning at 1700 on [**2182-1-18**].
Transfusion of the second unit began at 1820 with
pre-transfusion
vitals of T=97.8, HR=70, RR=20, BP=95/57. Transfusion was
stopped at
2100 after 275cc of the second unit had been transfused, and her
temperature went up to 100.3F degrees with concurrent dyspnea.
No other
symptoms were noted. She remained febrile overnight with Tmax of
102.0
at 0815 on [**2182-1-19**]. As she was also found to have increased
white blood
cells in the urine, she was empirically treated for presumed
urinary
tract infection. A chest Xray on [**2182-1-18**] revealed moderate
pulmonary
edema. She was therefore placed on ultrafiltration overnight
with 1.5L
of urine output and improvement of her respiration. A routine
clerical
check revealed no clerical errors.
Laboratory date:
Patient ABO/Rh: Group AB, Rh positive (both
pre-/post-transfusion
samples)
Red blood cell product (#04x[**Pager number 17780**] - second unit):Group A, Rh
positive
Post-transfusion plasma: Yellow, DAT negative
Transfusion history:
Previous non-reactive red cell transfusions: 19
Previous non-reactive plasma transfusions: 8
Transfusion restrictions: Leukoreduced, irradiated
Transfusion reactions met: Yes
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname 17759**]
experienced a
temperature increase of 2.5 degrees F with concurrent shortness
of
breath toward the end of her second unit of a leukoreduced
compatible
red cell transfusion. Laboratory data revealed no evidence of
hemolysis. Given the short duration of the patient's fevers, a
febrile
non-hemolytic transfusion is a potential explanation. Although
her
fevers may also be attributed to a urinary tract infection. Her
respiratory distress is likely related to volume overload from
transfusion of two units of red cells over a relatively short
period of
time. The patient was at risk for circulatory overload with
chronic
heart failure and the delay in hemodialysis. The resolution of
her
respiratory distress after good urine output is also supportive
of
volume overload. No change in transfusion practice is
recommended at
this time for this patient
TEE [**2182-1-29**]:
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage.
No spontaneous echo contrast is seen in the body of the right
atrium.
A patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is moderately depressed (LVEF= 30 %). The LV
is globally hypokinetic with the anteriolateral wall more
hypokinetic than the remaining segments. The estimated cardiac
index is depressed (<2.0L/[**Month/Day/Year **]/m2). No masses or thrombi are seen
in the left ventricle.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened and
retracted. There is moderate thickening of the mitral valve
chordae. The mitral regurgitation vena contracta is >=0.7cm.
Severe (4+) mitral regurgitation is seen. There is flow reversal
in the two pulmonary veins interrogated.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen.
The pulmonic valve leaflets are thickened.
There is no pericardial effusion. There is a left sided pleural
effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
POSTBYPASS:
The patient is A paced on milrinone, epinephrine and
norepinephrine infusions. There is a well seated annuloplasty
ring in the mitral position. There is residual mild MR. [**Name13 (STitle) **] and
mean gradients across the valve are 4mmHg & 1mmHg, respectively
with a cardiac output of 4.1L/m by thermodilution. RV function
is improved. LV function is mildly improved with much
improvement of the anterolateral segment. EF now 40% while on
inotropic support. The remaining valves are unchanged. The aorta
remains intact. There is no flow seen across the interatrial
septum.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2182-1-29**] 16:05
[**2182-2-26**] 06:27AM BLOOD WBC-7.0 RBC-2.95* Hgb-9.1* Hct-27.8*
MCV-94 MCH-31.0 MCHC-32.9 RDW-16.5* Plt Ct-397
[**2182-2-25**] 05:15AM BLOOD WBC-6.5 RBC-2.89* Hgb-8.8* Hct-26.8*
MCV-93 MCH-30.5 MCHC-33.0 RDW-15.8* Plt Ct-314
[**2182-2-26**] 09:00AM BLOOD PT-32.1* INR(PT)-3.1*
[**2182-2-25**] 05:15AM BLOOD PT-28.6* INR(PT)-2.8*
[**2182-2-24**] 05:03AM BLOOD PT-24.2* INR(PT)-2.3*
[**2182-2-23**] 11:11AM BLOOD PT-26.2* INR(PT)-2.5*
[**2182-2-22**] 01:00PM BLOOD PT-32.7* PTT-42.2* INR(PT)-3.2*
[**2182-2-21**] 12:19AM BLOOD PT-18.4* PTT-35.4 INR(PT)-1.7*
[**2182-2-20**] 03:08AM BLOOD PT-15.0* INR(PT)-1.4*
[**2182-2-26**] 06:27AM BLOOD Glucose-95 UreaN-56* Creat-4.6* Na-135
K-3.8 Cl-94* HCO3-29 AnGap-16
[**2182-2-25**] 05:15AM BLOOD Glucose-76 UreaN-54* Creat-4.6* Na-136
K-3.8 Cl-94* HCO3-31 AnGap-15
[**2182-2-24**] 05:03AM BLOOD Glucose-109* UreaN-53* Creat-4.3* Na-137
K-3.7 Cl-95* HCO3-30 AnGap-16
Brief Hospital Course:
MEDICAL COURSE:
Ms. [**Known lastname 17759**] is a 61y/o lady with DM1 s/p renal and pancreas
transplant, admitted for PRBC transfusion and dialysis, with
course complicated by hypoxic respiratory distress, sepsis from
a urinary source, and worsening MR to be taken to OR for
MVR/CABG
.
ACTIVE ISSUES
.
1. Sepsis from a urinary source: The patient had pansensitive E
coli grow in her urine and she had hypotension with somnolence
while in the ICU concerning for sepsis. She was treated with a 7
day course of Meropenem, as she has allergies to multiple other
antibiotics.
.
2. Hypoxic Respiratory Distress: Patient became hypoxic and
tachypnic during her second unit of PRBCs. Blood bank was aware
and they did not believe that this was TRALI. More likely to be
fluid overload secondary to CHF with MR. The patient's
respiratory status improved with urgent dialysis. The patient
also developed a few episodes of scant hemoptysis. She was ruled
out x three for pulmonary TB.
.
3. Anemia - Initial HCT was 20 from a baseline of 32. Stool was
guaiac negative. Hemolysis labs wnl. B12 normal. Hematology was
consulted and they believed that this was most likely due to
chronic disease and renal failure. They recommended giving a B12
injection and sending an EPO level, which returned elevated. The
patient continues her Epo supplements qweek.
4. Pancreas transplant - The patient continued her tacro,
rapamycin, and prednisone. She received her Pentamadine ppx on
[**2182-1-23**].
SURGICAL COURSE:
Underwent surgery on [**1-29**] with Dr. [**First Name (STitle) **] and transferred to the
CVICU in stable condition on titrated milrinone, levophed, and
propofol drips. Extubated on POD #1. She remained in the unit
for several days for renal issues, daily HD, pressor
requirement, aggressive respiratory therapy, and altered mental
status. Chest tubes and pacing wires removed per protocol.
Amiodarone and anti-coagulation started for recurrent Atrial
Fib. Transferred to the floor on POD #7 to begin increasing her
activity level. PD cath clotted and treated with tPA.
She developed a right lower extremity cellulitis and was started
on Vancomycin. Cellulitis resolved and Vancomycin stopped. She
developed a Klebsiella UTI and was started on Meropenem, which
will continue through [**2182-2-27**].
The patient became somnolent and hypercarbic and was transferred
to CVICU on [**2182-2-10**]. She was re-intubated for respiratory
failure. Bilateral pleural pigtail drains were placed for small
effusions. Initial yield was approximately 1300cc bilaterally.
She remained hypotensive on pressors for several days. She was
started on Midodrine, Florineff, and stress dose steroids to
wean from Neosynephrine. Tube feeding was initiated along with
calorie counts for poor oral intake. The patient was started on
salt tabs for hyponatremia. She was extubated and pressors
weaned.
She continued to slowly progress and was transferred to the
telemetry floor. Physical therapy evaluated the patient and
worked with her on strength and mobility. She continued on
peritoneal dialysis. Tunneled line was placed for HD, and this
should remain in place on transfer to rehab given the tenuous
state of her PD catheter.
The patient remained stable and was transferred to [**Hospital1 **],
[**Hospital1 8**] on POD #28. All follow up appointments were advised.
Medications on Admission:
Acyclovir 200mg q12h
Atorvastatin 80mg daily
Famotidine 20mg daily
Folic acid 1mg daily
Prednisone 5mg daily
Albuterol PRN wheezing
Amiodarone 200mg daily
Docusate
Sirolimus 1mg daily (was reduced due to fluconazole use)
Clopidogrel 75mg daily
Aspirin 325mg daily
Midodrine 5mg [**Hospital1 **]
Cyclosporine drops daily
Latanoprost drops daily
Creon 12 TID with meals
Simethicone PRN gas
Tacrolimus 2mg q12h (was reduced due to fluconazole use)
Oxycodone 5mg q4h pain
Levothyroxine 112mcg MWFSa, 100mcg TTSu
Gabapentin 300mg q48hr
Sevalamer TID w/meals
Methazolamide 50mg TID
Brimonidine drops
Dorzolamide-timolol drops
Fluconazole (for 2 weeks)
Nephrocaps
Warfarin 2mg daily
Discharge Medications:
1. Outpatient Lab Work
check Tacrolimus level on [**2182-2-27**], results to [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD
Phone:[**Telephone/Fax (1) 673**]
2. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): MD
to dose daily for goal INR [**1-25**], dx: AFib.
3. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day) as needed for hemorrhoidal
itching/pain.
4. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
8. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
13. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
([**Doctor First Name **],TU,TH).
14. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,WE,FR,SA).
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
17. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
18. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
19. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
20. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
21. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
25. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
26. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
27. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
28. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
29. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
30. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
31. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
32. 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.
33. Meropenem 500 mg IV Q24H Duration: 5 Days
end date [**2182-2-27**] per ID recs
34. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per attached sliding scale.
35. PD
PD orders
Solution: 1.5 % alt with 2.5 %
Volume: 1.75 ltrs
Dwell time: 4 hours
Total cycle in 24 hours: 5
36. warfarin 1 mg Tablet Sig: 0.5 Tablet PO ONCE (Once) for 1
doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for continuing medical care [**Hospital1 **]
Discharge Diagnosis:
mitral regurgitation/coronary artery disease s/p MV repair/CABG
x5/closure atrial septal defect
Diabetes mellitus type I
- complicated by neuropathy, retinopathy, dysautonomia
Diastolic CHF
Autonomic neuropathy
Sleep disordered breathing- Unable to tolerate CPAP; uses oxygen
2L NC at night
Osteoporosis
Hypothyroidism
Pernicious anemia
Cataracts
Glaucoma
Anemia of CKD, on Aranesp
Right foot fracture c/b RLE DVT
Chronic LLE edema
Recurrent E. coli pyelonephritis
Past Surgical History:
s/p pancreas transplant
- with allograft pancreatectomy ([**5-/2174**])
- redo pancreas transplant ([**6-/2175**])
s/p renal transplant ([**2157**]) complicated by chronic rejection
- second renal transplant ([**2160**])
s/p left [**Year (4 digits) 6024**] ([**8-/2179**])
s/p anal polypectomy ([**5-/2176**])
s/p bilateral trigger finger surgery ([**8-/2178**])
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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 [**Telephone/Fax (1) **], avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] [**2182-3-5**] at 2:30p, [**Hospital Ward Name **] 2A
Cardiologist: Dr. [**Last Name (STitle) 171**] [**2182-3-18**] at 10:20a, [**Hospital Ward Name 23**] 7
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2182-3-19**]
2:00
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2182-3-29**] 10:50
Please call to schedule appointments with your:
Primary Care Dr.[**Last Name (STitle) **] in [**3-28**] weeks, [**Telephone/Fax (1) 250**]
**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:[**2182-2-26**]
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5,783
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1110
|
Discharge summary
|
report
|
Admission Date: [**2171-2-24**] Discharge Date: [**2171-3-1**]
Date of Birth: [**2100-2-3**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
blurred vision and R weakness/tingling
Major Surgical or Invasive Procedure:
catheterization, L ICA stenting
History of Present Illness:
71 yr old male who is s/p CABG at [**Hospital1 18**] on [**2170-9-18**] with other
pmh of bilateral renal artery stenting [**9-3**], cabg in 94, htn,
lipids, R CEA in [**2166**] and known left carotid stenosis, presented
to OSH on [**2-22**] with TIA symptoms, including tingling and
numbness in right arm + transient vision loss (like walking into
a shower with eyes open), which resolved after a brief time. No
associated CP, SOB. No dizziness, lightheadedness, no syncope.
No fevers, no chills.
.
[**Month/Year (2) 4338**] done at MW shows 81-99% [**Doctor First Name 3098**] stenosis. There is no evidence
of stroke on DWI. Neuro symptoms have all resolved. Pt was
scheduled for carotid angio/intervention with Dr. [**First Name (STitle) **] [**Name (STitle) 766**]
[**2-25**].
Past Medical History:
PVD
RAS (s/p stenting by [**Doctor Last Name 1870**] in '[**69**])
Carotid disease
s/p RCEA [**2166**]
known L Carotid stenosis
CAD, s/p CABG in [**2158**]
choley,
L hernia repair
chronic mild idiopathic thrombocytopenia (baseline 76K-100K),
had a non-dx bone marrow bx 20yrs ago.
Social History:
SH: no tob, etoh, drugs ever. married, no kids. 4 bunnies for
pets
Family History:
FHX: mom died of stroke at age [**Age over 90 **], dad died of leukemia at 79.
Physical Exam:
Vitals: 97.0; 147/93; HR 80; RR 16; 98%ra
General: elderly male, NAD.
HEENT: NO JVP. R sided neck scar. bilateral neck bruits
ausculatated
RESP: CTAB. no wheezes, rales, rhonchi
CV: regular S1, S2.
ABD: soft, NT, ND, +BS, no HSM
EXT: no edema, WWP, decr hair growth on legs, intact peripheral
pulses.
NEURO: A&O x 3. No focal neurologic deficits (please see neuro
note for complete neurological exam). decreased vibratory
sensation.
Pertinent Results:
Cath [**2171-2-26**] (L carotid stenting):
1. Access was obtained via the right CFA in a retrograde
fashion.
2. Resting hemodynamics showed severe central aortic
hypertension.
3. Renal arteries: Bilateral single with prior stents widely
patent.
4. Carotid arteries: The left CCA was normal. The ICA had a 70%
stenosis and supplied the ipsilateral ACA and MCA and
cross-filled the
contralateral ACA.
5. Successful stenting of the left ICA with a 8-6x40 mm Xact
stent.
6. The right CFA arteriotomy was closed with a 6 French
Angioseal.
.
[**Month/Day/Year 4338**]/MRA Head:
1. Multiple punctate foci of restricted diffusion in bilateral
cerebral and right cerebellar hemispheres, consistent with acute
embolic ischemia.
2. Lack of visualization of signal in the region of the left
internal carotid stent, which may well to be due to
susceptibility effects. Gadolinium administration offered no
improvement in imaging.
3. Questionable diminished flow at the bifurcation of bilateral
supraclinoid internal carotid arteries.
4. Apparent mid-cervical stenosis of the left vertebral artery.
.
CTA Head/Neck:
1. Findings consistent with [**Month/Day/Year 4338**]/MRA performed [**2171-2-27**].
Left internal carotid artery appears patent. While it is
possible that there may be significant narrowing of the lumen,
it is impossible to quantify any amount of stenosis secondary to
artifact from the carotid stent.
2. Occlusion of the left vertebral body at the C2-3 level with
reconstitution of the vessel above the C2 level.
Brief Hospital Course:
71 M with severe PVD, RCEA for 70%, L ICA 81-99%, CABGx2,
presents with TIA-like symptoms of R weakness/tingling and
blurry vision.
.
# Cardiac:
Pt was referred to Dr. [**First Name (STitle) **] for intervention and possible
stenting of his L carotid artery. Pt was found to have 81-99% L
internal carotid a stenosis by OSH MRA. [**First Name (STitle) 4338**] DWI images from OSH
showed no evidence for acute stroke. During admission, pt had
normal neuro exams throughout.
.
In the cath lab, pt had LOC twice, each time in response to the
balloon angioplasty and occlusion of his L carotid flow. When
the balloon was deflated both times, the pt rapidly regained
consciousness and was asymptomatic. Pt had his L carotid a
stented with a Xact stent. Neuro consult was called to assess
for neuro signs, decreased vibratory sense, peripheral
neuropathy, and Neuro assessed pt was not having an acute
stroke. Pt was admitted to the CCU for observation post-cath.
.
# Hypotension:
In the CCU, the pt was hypotensive, with MAP 60-70s and SBP
58-120. His BP elevated upon lying down, and decreased upon
standing and ambulating, but pt was encouraged to ambulate and
get in his chair. Pt was mildly dizzy upon standing or sitting
up when SBP was 60s. On [**2-27**], pt's SBP was 67, and pt became
dizzy and aphasic upon attempting to ambulate. Pt had [**Month/Day (4) 4338**]/MRA
head to look for acute ischemic stroke (possibly residual from L
carotid manipulation), as well as hemorrhagic stroke. Pt's BP
was maintained at measurable SBP 100, which was an actual BP of
around 130.
.
Pt's EF is 50-55% by TTE. He was maintained on ASA, plavix, but
antihypertensives were held. He showed hypotension on tele.
.
# HTN, hyperlipidemia:
Pt was maintained on ASA, plavix, vytorin (his own meds).
.
#CRI:
Pt's baseline Cr is 1.3-1.5, though in [**7-3**] Cr was 1.0. Pt's
Cr was stable during admission, and remained well hydrated with
several liters of fluid to help increase his BP.
.
FEN: cardiac diet, no sq heparin [**1-31**] thrombocytopenia.
FULL CODE
Medications on Admission:
Toprol 25,
asa 325mg
lisinopril 5mg
pronoix 40mg
vytorin
colace [**Hospital1 **].
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please d/w Dr. [**First Name (STitle) **] regarding duration.
Disp:*90 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Vytorin [**10-18**] 10-20 mg Tablet Sig: One (1) Tablet PO Qday ().
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) **] VNA
Discharge Diagnosis:
Left internal carotid stenosis s/p stent
PVD
RAS s/p stent [**2169**]
right carotid CEA
CAD s/p CABG [**2158**]
s/p chole
s/p left hernia repair
thrombocytopenia
Discharge Condition:
afebrile, hemodynamically stable, ambulating without difficulty
Discharge Instructions:
Please take all medications as prescribed. Please be aware that
you should not take your blood pressure medications until
directed by Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) 1295**].
Please return to the Emergency Department if you have chest
pain, weakness, numbness, dizziness, visual changes, slurred
speech, headache or any other worrisome symptoms.
Followup Instructions:
Please keep the following appointments:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-4-30**]
2:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-4-30**]
2:30
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-4-30**] 3:15
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6256**], [**2171-5-7**], 11:00 AM
Completed by:[**2171-3-24**]
|
[
"V45.81",
"414.00",
"458.29",
"585.9",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.45",
"88.41",
"00.61",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
6494, 6550
|
3654, 5715
|
305, 338
|
6757, 6823
|
2107, 3631
|
7247, 7770
|
1558, 1638
|
5852, 6471
|
6571, 6736
|
5741, 5829
|
6847, 7224
|
1653, 2088
|
227, 267
|
366, 1152
|
1174, 1457
|
1473, 1542
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,956
| 162,848
|
40533
|
Discharge summary
|
report
|
Admission Date: [**2118-5-5**] Discharge Date: [**2118-5-7**]
Service: MEDICINE
Allergies:
Bactrim / lisinopril
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Hypersensitivity Reaction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 y.o. male with a past medical history of bioprosthetic AVR,
hypertension, hyperlipidemia, diastolic heart failure who
initially presented to [**Hospital1 **] [**Location (un) 620**] last night with sudden onset
facial/ lip/ tongue swelling, fever, and rash. Patient states
that he just recently started lisinopril 2-3 weeks ago and just
finished a course of bactrim completed 2 days prior. The rash
was pruitic in nature and was located on chest, arms, and face.
He also noticed ulcers/sores in his mouth.
.
On arrival to [**Hospital1 **] [**Location (un) 620**], rash appeared bullous and no ulcers
were apparent on oral mucosa. He was initially sating 95% on
Non-rebreather. He was scoped by ENT at [**Location (un) 620**], which showed
no threatning largyngeal edema or encroachment of airway. Got
decadron, racemic epi neb, benadryl, zofran, famotidine and his
symptoms starting to improve. He was transferred here fo urgent
dermatology evaluation.
.
In the ED, initial vs were: 100.8 80 151/65 24 98% 4L
Non-Rebreather . He had significant swelling of the mouth and
tongue with no visible bullous lesion in mouth, and a
Maculopapular rash on chest, arms, and abdomen. Dermatology
evaluated the patient and concluded that he likely had a
hypersensitivity reaction to lisinopril or bactrim. VS prior to
transfer 99, 74, 125/50, 18, 99 100% NRB.
.
On the floor, patient comfortable, sating in the mid 90s on 4 L
NC.
.
<h3>[**Hospital1 139**] A PGY1 Daily Progress Note, [**2118-5-6**], [**2106**]</h3>
.
<h3>Accept Note:</h3>
.
<b>Brief HPI:</b>
.
I have received verbal signout from the ICU resident, reviewed
pertinent notes and data, and seen and examined the patient;
please see MICU admission note for details of the history.
.
Briefly, this is an 89 year-old male with a past medical history
of bioprosthetic AVR, hypertension, hyperlipidemia, diastolic
heart failure who presented with a hypersensitivity drug
reaction to Bactrim, whose airway was never compromised, was
observed in the ICU overnight and then called out for further
management of [**Last Name (un) **].
.
He presented 1 day prior to transfer to [**Hospital1 **] [**Location (un) 620**] with sudden
onset facial/lip/ tongue swelling, fever, and rash. The rash was
pruritic located on chest, arms, and face. He also noticed
ulcers/sores in his mouth.
.
In [**Location (un) 620**], was cleared by ENT, received decadron, was
transferred to [**Hospital1 18**] for dermatology evaluation; was
subsequently cleared by dermatology and called out of ICU.
.
Past Medical History:
- Bioprosthetic Aortic valve replacement 6 years ago
- hypertension
- hyperlipidemia
- Diastolic heart failure
Social History:
- Tobacco: Prior smoker, quit many years ago
- Alcohol: Denies
- Illicits: Denies
Family History:
NC
Physical Exam:
Vitals: 98.5 74 123/49 17 95% 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, Erythematous maculopaaular rash on
face, throat erythema, + tongue swelling
Neck: No JVD
Lungs: Insipratory crackles at bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest Wall: Erythematous mayculopapular rash on trunk/back
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Erythematous maculopapular rash
.
Discharge Exam:
97.6 AF 124/56 62 18 93 RA
Gen: Elderly man WDWN in NAD
HEENT: NCAT PERRL MMMS OP clear; edematous lips, poor dentition
Neck: No elevated JVP supple
Pulm: CTAB no wh/rh/ra
CV: RRR SEM radiating to clavicles no r/g
Ab: +BS NTND soft
Ext: No edema
Neuro: CN2-12 intact no rhomberg
Skin: Diffused macular rashes over trunk and proximal
extremities
Pertinent Results:
ADMISSION LABS:
.
[**2118-5-5**] 01:25PM BLOOD WBC-17.9* RBC-4.28* Hgb-12.3* Hct-37.5*
MCV-88 MCH-28.7 MCHC-32.8 RDW-14.6 Plt Ct-220
[**2118-5-5**] 01:25PM BLOOD Neuts-88* Bands-1 Lymphs-4* Monos-4 Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2118-5-5**] 01:25PM BLOOD PT-16.2* PTT-31.8 INR(PT)-1.4*
[**2118-5-5**] 01:25PM BLOOD Glucose-112* UreaN-38* Creat-1.6* Na-135
K-4.8 Cl-101 HCO3-24 AnGap-15
[**2118-5-6**] 04:05AM BLOOD Calcium-9.2 Phos-5.5* Mg-2.4
Imaging:
Discharge Labs:
[**2118-5-7**] 07:25AM BLOOD WBC-15.7* RBC-4.41* Hgb-12.6* Hct-40.2
MCV-91 MCH-28.5 MCHC-31.2 RDW-14.8 Plt Ct-215
[**2118-5-7**] 07:25AM BLOOD Plt Ct-215
[**2118-5-7**] 04:06PM BLOOD Glucose-109* UreaN-63* Creat-1.9* Na-137
K-5.0 Cl-102 HCO3-24 AnGap-16
[**2118-5-7**] 07:25AM BLOOD Glucose-81 UreaN-63* Creat-2.1* Na-137
K-5.5* Cl-102 HCO3-25 AnGap-16
[**2118-5-7**] 04:06PM BLOOD Calcium-8.6 Phos-4.4 Mg-2.4
Brief Hospital Course:
89 year-old male with a past medical history of bioprosthetic
AVR, hypertension, hyperlipidemia, diastolic heart failure who
presented with a hypersensitivity drug reaction to Bactrim,
whose airway was never compromised, was observed in the ICU
overnight and then called out for further management of [**Last Name (un) **].
.
ACTIVE ISSUES
.
#. Hypersensitivity reaction: The working diagnosis at the time
of discharge was that the patient's reaction was to Bactrim.
Lisinopril was considered, but the cutaneous skin manifestations
were inconsistent with angioedema. Lasix was also considered,
but the patient had been stable on this regimen for weeks prior.
He received decadron at the OSH and on presentation to [**Hospital1 18**] ICU
showed no evidence of airway compromise with EGD showing no
laryngeal edema. The patient was observed overnight in the ICU
and transferred to the floor. Discharged with an Epi-Pen Rx and
received training on how to use it by MD.
.
# RASH: There were never signs of TEN or SJS. Dermatology
recommended clobetasol 0.05% ointment [**Hospital1 **] to affected areas of
body for up to 3 weeks, avoiding face, axillae, groin,
intertriginous folds, hydrocortisone 2.5% ointment [**Hospital1 **] to
affected areas of face, axillae, groin, intertriginous folds for
up to 3 weeks, atarax 25mg po q6hr prn pruritus. Discharged on
this regimen.
.
# Chronic diastolic heart failure: In light of its rare cross
reactivity with Bactrim, Lasix was held; the patient was given
ethacrynic acid in the ICU to which he had marked urine output
and thereafter further diuresis was held. Discharged on Lasix
with instructions not to take the medication until he was in the
presence of his PCP with an [**Name9 (PRE) 88759**] in hand.
.
# Pre-Renal Acute Kidney Injury, Chronic Renal Insufficiency:
Baseline Cr was presumed 1.3-1.6. The patient presented to the
floor with a Cr above this baseline due to overdiuresis as
above; Cr showed a trend toward normalization off diuretics.
.
INACTIVE ISSUES:
.
#. Hypertension, HL: Continued aspirin, statin, beta blocker.
Lisinopril was held, with plans for the PCP to restart this
medication at her discretion.
.
TRANSITIONAL ISSUES:
# Lasix to be restarted by PCP at her discretion.
# Lisinopril to be restarted by PCP at her discretion.
Medications on Admission:
Metoprolol 50 [**Hospital1 **]
Aspirin 81 mg
Lisinopril 5 mg
Lasix 40 mg once a day
Crestor unknown dose
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. hydrocortisone 2.5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 tube* Refills:*2*
4. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
5. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritis.
Disp:*30 Tablet(s)* Refills:*0*
6. Crestor Oral
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Injection
Intramuscular As needed as needed for allergy symptoms.
Disp:*2 pens* Refills:*0*
9. Outpatient Lab Work
[**2118-5-9**] please check Cr and restart Lasix or other alternative
non-sulfa diuretic medication.
10. TEMPORARILY STOP LASIX
Do not take LASIX until you see your primary care physician, [**Name10 (NameIs) 1023**]
can administer an Epi-Pen if you have a severe allergic
reaction, although there is less than a 10% chance of this
happening.
11. YOU ARE ALLERGIC TO TMP-SULFA (BACTRIM)
Never take TMP-SULFA (BACTRIM) because you are allergic to it.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis:
Hypersensitivity Reaction
Acute on chronic renal failure
Secondary Diagnosis:
None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
.
You were admitted for observation after an allergic reaction.
You were treated with several medications to help calm the
reaction and you did well. You improved and never had any
concerning changes to your vital signs.
.
Your reaction was most likely due to TMP-SULFA (BACTRIM); there
is a possibility that it was due to Lisinopril, but it seems
unlikely since you were taking this medication weeks before the
reaction. **Do not take TMP-SULFA** because you are allergic to
this medication. You should also not take Lisinopril until you
have seen your primary care physician and she has instructed you
to start it again.
.
We have temporarily stopped your Lasix, which has less than a
10% change of causing a similar allergic reaction to the
TMP-SULFA; we have not permanently stopped it because you were
taking this medication weeks prior to the reaction. Since there
is a risk, we would like you to not take this medication until
you have filled the prescription for an anti-allergy shot called
an Epi-Pen. Take the Lasix when you see your primary care
physician, [**Name10 (NameIs) 1023**] can administer the Epi-Pen if you have an
allergic reaction that causes you to not be able to breath.
.
You are being discharged with symptomatic therapies for your
itching. Your rash will resolve on its own over time (up to
three weeks).
.
Your medications have been changed.
-You have been started on Hydrocortisone and Clobetasol
ointments (Hydrocortisone for face and skin folds and Clobetasol
for the rest of your body)
-You have been given a prescription for a non-sedation
antihistamine to help with itching
-You have been given a prescription for an Epi-Pen. Only use
this medication if you are having difficulty breathing. If you
develop a rash, go to the ED but don't use the Epi-Pen.
.
STOP:
-Lisinopril; do not take this until you see your primary care
physician
[**Name10 (NameIs) 46090**] until you see your primary care physician
.
NEVER TAKE TMP-SULFA (BACTRIM).
Followup Instructions:
Please call your primary care physician [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7341**] at
[**Telephone/Fax (1) 25814**] to schedule an appointment in the next week to have
your kidney function checked and restart Lasix.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**2118**], [**Hospital1 **],[**Numeric Identifier 53049**]
Phone: [**Telephone/Fax (1) 25814**]
Appointment: Monday [**5-16**] at 11:30AM
**Please contact your insurance and provide them with the
correct name for your Primare Care Provider. [**Name10 (NameIs) 20282**] have a
different Dr [**Last Name (STitle) 88760**].**
|
[
"584.9",
"403.90",
"585.9",
"428.0",
"414.01",
"784.2",
"V13.02",
"V49.86",
"288.60",
"E931.0",
"693.0",
"428.32",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8604, 8675
|
4909, 6906
|
253, 259
|
8822, 8822
|
3992, 3992
|
11039, 11788
|
3079, 3083
|
7363, 8581
|
8696, 8696
|
7233, 7340
|
8973, 11016
|
4475, 4886
|
3098, 3610
|
3626, 3973
|
7100, 7207
|
187, 215
|
287, 2826
|
8794, 8801
|
6923, 7079
|
4008, 4458
|
8715, 8773
|
8837, 8949
|
2848, 2961
|
2977, 3063
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,180
| 135,448
|
38085
|
Discharge summary
|
report
|
Admission Date: [**2114-12-27**] Discharge Date: [**2115-1-1**]
Date of Birth: [**2030-10-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex / Bactrim
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2114-12-27**]
PROCEDURES:
1. Redo sternotomy and tricuspid valve replacement.
2. Placement of epicardial biventricular and atrial pacing leads
as well as insertion of biventricular pacemaker.
History of Present Illness:
The patient is an 84-year-old
gentleman referred to me by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] for tricuspid
valve replacement. The patient developed tricuspid
regurgitation shortly after having an infected pacemaker lead
removed. His existing pacemaker was working was working fine
but he developed severe tricuspid regurgitation and then
severe left-sided heart failure. The patient
was therefore referred to me for a tricuspid valve
replacement, as well as removal of existing transvenous
pacemaker lead and pacemaker and placement of a new
epicardial pacemaker system.
Past Medical History:
Iatrogenic tricuspid regurgitation.
chronic diastolic Congestive heart failure
s/p TVR, biventricular pacer
PMH:
afib s/p pacer, hyperlidemia, hypertension,
mild pulmonary hypertension, severe TR, Renal insufficiency,
[**Location (un) **] cell tumor, chronic lower extremity leg ulcers, PVD, LUE
DVT [**11-21**]- developed hematoma -anticoag stopped- see d/c summary
from [**Month (only) **] in OMR.
Past Surgical History:
s/p pacer-? type/model unknown
Patient denies CABG but records from OSH state CABG [**2110**]-pateint
states pericardial effusion/tamponade- unknown where. Primary
team contacting PCP for op note.
PVD s/p right fem-[**Doctor Last Name **] bypass in [**Month (only) **]
right total hip replacement
Social History:
quit smoking 50 years ago, had smoked less than a year. social
EtOH. lives with wife, walks with cane.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:67 irreg O2 sat: 98RA
B/P Right: Left:161/83
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs - diminished bilaterally
Heart: RRR [] Irregular [x] Murmur III/VI left sternal border
Abdomen: Soft [x] softly-distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:[X]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+1
PT [**Name (NI) 167**]: +2 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:? soft vs radiation
Pertinent Results:
[**2114-12-30**] 08:45AM BLOOD WBC-16.4* RBC-3.27* Hgb-10.2* Hct-29.7*
MCV-91 MCH-31.3 MCHC-34.5 RDW-19.8* Plt Ct-184
[**2114-12-29**] 04:24AM BLOOD WBC-17.1* RBC-3.23* Hgb-10.0* Hct-29.5*
MCV-91 MCH-31.0 MCHC-33.9 RDW-20.4* Plt Ct-193
[**2114-12-30**] 08:45AM BLOOD Glucose-103* UreaN-30* Creat-0.9 Na-135
K-4.1 Cl-98 HCO3-28 AnGap-13
[**2114-12-29**] 04:24AM BLOOD Glucose-92 UreaN-23* Creat-0.8 Na-134
K-4.2 Cl-99 HCO3-26 AnGap-13
Brief Hospital Course:
The patient was brought to the operating room on [**2114-12-27**] where
the patient underwent redo sternotomy, TVR, (33mm St. [**Male First Name (un) 923**]
porcine), removal and replacement of pacer with placement of
epicardial pacing leads. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. He
was on milrinone and phenylephrine at the time of transfer.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Pacer was interrogated by the EP service.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient has a history of
sacral/coccyx ulcer and the wound care service consulted and
made recommendations. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. The patient was maintained on vancomycin
and ciprofloxacin until OR cultures were finalized to complete a
7 day course. Cultures showed no growth, but were still
preliminary at the time of discharge. By the time of discharge
on POD 4 the patient was ambulating, yet deconditioned, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to Langdon Place Rehab, [**Location (un) **], NH in
good condition with appropriate follow up instructions.
Medications on Admission:
lipitor 20mg daily, ASA 81mg, lasix 20mg daily, sotalol 120mg
[**Hospital1 **], plavix 75mg daily, lisinopril 5mg daily, isosorbide 30mg
daily, nexium 40mg daily, MVI, diclofen 50mg daily, HCTZ 25
daily, norvasc 5mg daily, fluticasone daily.
Plavix - last dose: [**2114-12-15**]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
9. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Langdon Place of [**Location (un) **], NH
Discharge Diagnosis:
Iatrogenic tricuspid regurgitation.
chronic diastolic Congestive heart failure
s/p TVR, biventricular pacer
PMH:
afib s/p pacer, hyperlidemia, hypertension,
mild pulmonary hypertension, severe TR, Renal insufficiency,
[**Location (un) **] cell tumor, chronic lower extremity leg ulcers, PVD, LUE
DVT [**11-21**]- developed hematoma -anticoag stopped- see d/c summary
from [**Month (only) **] in OMR.
Past Surgical History:
s/p pacer-? type/model unknown
Patient denies CABG but records from OSH state CABG [**2110**]-pateint
states pericardial effusion/tamponade- unknown where. Primary
team contacting PCP for op note.
PVD s/p right fem-[**Doctor Last Name **] bypass in [**Month (only) **]
right total hip replacement
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time:[**2115-1-22**] 2:15
Cardiologist Dr. [**First Name (STitle) 437**] on [**1-14**] at 1pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 251**] A. [**Telephone/Fax (1) 85023**] in [**4-16**] weeks
Completed by:[**2114-12-31**]
|
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"428.32",
"427.31",
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icd9cm
|
[
[
[]
]
] |
[
"37.74",
"35.27",
"37.87",
"37.76",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6631, 6699
|
3281, 4926
|
303, 500
|
7465, 7611
|
2823, 3258
|
8399, 8812
|
2028, 2143
|
5257, 6608
|
6720, 7122
|
4952, 5234
|
7635, 8376
|
7145, 7444
|
2158, 2804
|
243, 265
|
528, 1144
|
1166, 1567
|
1905, 2012
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,611
| 146,598
|
32854
|
Discharge summary
|
report
|
Admission Date: [**2138-8-8**] Discharge Date: [**2138-8-18**]
Date of Birth: [**2068-6-16**] Sex: F
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:
[**2138-8-13**] Coronary Artery Bypass Graft x 4 (left internal mammary
artery to left anterior descending artery, saphenous vein graft
to diagonal, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending artery)
History of Present Illness:
This 70-year-old female smoker 1 [**11-22**] PPD x 50yrs presented about
three weeks ago with a two-week history of intermittent chest
pain. On the date of admission to [**Hospital1 **] on [**2138-7-11**],
she presented with unrelenting chest pain and diagnosis of acute
anterolateral MI was made in the emergency room at [**Hospital1 **].
She was immediately taken to the cardiac catheterization
laboratory where her OM branch of her circumflex was noted to be
completely occluded with clot. Bare-metal stent was placed at
that time. Further catheterization revealed the presence of
three-vessel coronary artery disease. She was started on Plavix
now daily for a new bare-metal stent with eye towards coronary
artery bypass grafting about four to six weeks after placement
of this stent so that Plavix could be stopped one week before
bypass. Mrs. [**Known lastname 76483**] however continues to smoke daily and
developed recurrent chest pain radiating to her jaw with
ambulation. She was admitted to MWMC and then transferred to
[**Hospital1 18**] for evaluation of cardiac surgery.
Past Medical History:
Coronary Artery Disease s/p ST-elevation Myocardial Infarction
with a bare-metal stent
to the circumflex in [**2138-6-21**]
Osteoporosis
Tobacco abuse
Renal calculi in the past
Peripheral vascular disease with an RFA stenosis
Social History:
Race: Iranian
Last Dental Exam: januray
Lives alone with supportive sons nearby
Occupation: retired dress maker
Tobacco: current [**1-22**] cigarettes per day plus 1 [**11-22**] ppd x50 years
ETOH: one drink per day
Family History:
Significant that her sister had MI and coronary artery bypass
grafting in her 60s.
Physical Exam:
Height: 5' 3" Weight: 63kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused x[] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left:+2
Carotid Bruit none Right: +2 Left:+2
Pertinent Results:
[**2138-8-13**] Echo: PRE-BYPASS: The left atrium is normal in size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**11-22**]+) mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**Known lastname 76483**] before CPB. Post_Bypass:
Preserved biventricular systolic function. LVEF 55% Mild Mitral
regurgitation. Intact thoracic aorta
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 76483**] was admitted for
recurrent chest pain and appropriately worked-up. She was ruled
out for myocardial infarction and was medically managed until
Plavix wash-out. On [**8-13**] she was brought to the operating room
where she underwent a coronary artery bypass graft x 4. Please
see operative report for surgical details. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours she weaned from sedation, awoke
neurologically intact and extubated. Transferred to the floor on
POD #1 to begin increasing her activity level. Beta blockade and
lisinopril were titrated and she was gently diuresed toward her
preop weight. She was evaluated by physical therapy and cleared
for discharge to home on POD# 5 with VNA services.
Medications on Admission:
Lisinopril 10 mg daily, Aspirin 325 mg daily, Plavix 75 mg
daily, Lipitor 80 mg daily, and Lopressor 50 mg three times a
day
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*2*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Past medical history:
s/p ST-elevation Myocardial Infarction with a bare-metal stent
to the circumflex in [**2138-6-21**]
Osteoporosis
Tobacco abuse
Renal calculi in the past
Peripheral vascular disease with an RFA stenosis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] at [**Hospital1 **] in 4 weeks [**Telephone/Fax (1) 6256**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**11-22**] weeks
Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 1295**] in [**12-24**] weeks
please call for all appts.
Completed by:[**2138-8-18**]
|
[
"733.00",
"530.81",
"305.1",
"414.01",
"410.02",
"411.1",
"V17.3",
"V45.82",
"790.29",
"599.0",
"305.01",
"440.20",
"V13.01",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6116, 6175
|
3904, 4732
|
331, 575
|
6503, 6509
|
2868, 3881
|
7307, 7644
|
2191, 2275
|
4907, 6093
|
6196, 6257
|
4758, 4884
|
6533, 7284
|
2290, 2849
|
281, 293
|
603, 1693
|
6279, 6482
|
1958, 2175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,259
| 161,407
|
261
|
Discharge summary
|
report
|
Admission Date: [**2104-3-24**] Discharge Date: [**2104-4-4**]
Date of Birth: [**2021-6-12**] Sex: F
Service: EMERGENCY
Allergies:
Levofloxacin / Penicillins / IV Dye, Iodine Containing /
Statins-Hmg-Coa Reductase Inhibitors / simvastatin
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
red urine
Major Surgical or Invasive Procedure:
Urinary Foley catherization
Central line insertion
Mechanical Intubation
History of Present Illness:
Mrs. [**Known firstname 2554**] F. [**Known lastname 2555**] is a 82 year-old spanish and italian
speaking woman with DM2, asthma, AFib who presents with weakness
for the past week. She has been unable to stand or get out of
bed and has had generalized weakness.
.
In the ED, initial vitals were 99, 103, 181/84, 16, 96%. Her
labs were significant for CK elevation to [**Numeric Identifier 2566**] without renal
failure. Her EKG was unchanged from prior. Neurology was
consulted given her weakness and felt this was likely related to
rhabdo. Patient received approximately 1 liter of NS in the ER
given CXR with concern for volume overload. Head CT showed small
(<4.5mm) L frontal area that was possibly SDH vs calcium. She
was admitted to medicine with vitals on transfer of 94, 155/66,
16, 98% RA.
.
On the floor, her son translates for her and says she feels ok.
She denies any pain, SOB, CP, palpitations. She is asking for
water.
.
ROS: Per son, patient frequently complains of having to urinate.
Denies headache, vision changes, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation.
Past Medical History:
- Diastolic CHF
- Hypertension
- Diabetes
- Paroxysmal AFib on coumadin
- Asthma
- GERD
Social History:
She is originally from [**Country 2559**] and then moved to [**Country 2560**], where
she lived most of her life. She has been in the US since [**2085**].
She denies any current or past history of smoking. Drinks
alcohol socially and has never used illicit drugs. She lives
with her husband, who is her primary care taker. She uses a
walker at baseline and requires a lot of help with her ADLs.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission
PHYSICAL EXAM:
VS: 97.7, 145/86, 125, 18, 98% RA
GENERAL: Elderly female in NAD, comfortable, appropriate.
HEENT: NC/AT, EOMI, sclerae anicteric, MM dry, OP clear.
NECK: Supple, no JVD
HEART: Tachycardic, no MRG, nl S1-S2.
LUNGS: CTA bilat anteriorly (pt unwilling to sit forward), no
r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
LYMPH: No cervical LAD.
NEURO: Awake, CNs II-XII grossly intact, muscle strength 4/5 in
bilateral feet (would not participate with rest of exam)
.
[**4-3**]
PHYSICAL EXAM:
VS: 95.9, 162/51, 78, 18, 99% RA
GENERAL: Elderly female in NAD, comfortable, appropriate,
oriented X 0.
HEENT: NC/AT, EOMI, sclerae anicteric, MM dry, OP clear.
NECK: Supple, elevated JVD to mandible
HEART:irregular rhythym, no MRG, nl S1-S2.
LUNGS: Bilaterl lower lung insp. crackles and decreased breath
sounds toward the bases.no wheezes, good air movement, resp
unlabored.
ABDOMEN: Soft/NT to palp/ND,positive bowel sounds, no masses or
HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. No CVA
tenderness
LYMPH: No cervical LAD.
NEURO: Awake, CNs II-XII grossly intact, muscle strength 4/5 in
bilateral feet on plantarflexion (would not participate with
rest of exam)
Pertinent Results:
Admission Labs
[**2104-3-24**] 08:45PM SODIUM-138 POTASSIUM-3.8 CHLORIDE-99
[**2104-3-24**] 08:45PM ALT(SGPT)-507* AST(SGOT)-880* CK(CPK)-[**Numeric Identifier 2567**]*
ALK PHOS-71 TOT BILI-0.5
[**2104-3-24**] 06:30PM URINE COLOR-AMBER APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2104-3-24**] 06:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-3-24**] 06:30PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2104-3-24**] 06:30PM URINE AMORPH-OCC
[**2104-3-24**] 06:30PM URINE MUCOUS-OCC
[**2104-3-24**] 05:51PM PT-34.5* PTT-26.5 INR(PT)-3.4*
[**2104-3-24**] 05:25PM SODIUM-134 POTASSIUM-6.4* CHLORIDE-95*
[**2104-3-24**] 05:25PM GLUCOSE-474* UREA N-26* CREAT-0.9 SODIUM-133
POTASSIUM-7.4* CHLORIDE-96 TOTAL CO2-28 ANION GAP-16
[**2104-3-24**] 05:25PM estGFR-Using this
[**2104-3-24**] 05:25PM CK(CPK)-[**Numeric Identifier 2566**]*
[**2104-3-24**] 05:25PM cTropnT-0.07*
[**2104-3-24**] 05:25PM proBNP-1537*
[**2104-3-24**] 05:25PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2104-3-24**] 05:25PM WBC-11.0# RBC-4.66# HGB-14.1 HCT-42.6 MCV-91
MCH-30.2 MCHC-33.1 RDW-13.6
[**2104-3-24**] 05:25PM NEUTS-76.1* LYMPHS-18.3 MONOS-4.2 EOS-0.7
BASOS-0.7
[**2104-3-24**] 05:25PM PLT COUNT-251
.
Discharge Labs
[**2104-4-4**] 07:03AM BLOOD WBC-35.9* RBC-1.82*# Hgb-5.5*# Hct-18.4*#
MCV-101* MCH-30.3 MCHC-30.0* RDW-16.2* Plt Ct-150
[**2104-4-4**] 05:22AM BLOOD WBC-42.8* RBC-2.93* Hgb-9.0* Hct-28.3*
MCV-96 MCH-30.7 MCHC-31.9 RDW-15.7* Plt Ct-260
[**2104-4-3**] 09:24PM BLOOD WBC-32.9*# RBC-3.14* Hgb-9.4* Hct-30.1*
MCV-96 MCH-29.8 MCHC-31.1 RDW-15.5 Plt Ct-274
[**2104-4-3**] 06:38AM BLOOD WBC-20.7* RBC-3.65* Hgb-11.3* Hct-34.5*
MCV-95 MCH-31.1 MCHC-32.8 RDW-15.0 Plt Ct-259
[**2104-4-2**] 02:40AM BLOOD WBC-15.7* RBC-3.70* Hgb-11.3* Hct-35.2*
MCV-95 MCH-30.5 MCHC-32.1 RDW-15.2 Plt Ct-231
[**2104-4-1**] 03:19AM BLOOD WBC-14.8* RBC-3.77* Hgb-11.3* Hct-35.6*
MCV-95 MCH-29.9 MCHC-31.6 RDW-15.2 Plt Ct-232
[**2104-3-31**] 06:29PM BLOOD WBC-15.8* RBC-3.78* Hgb-11.6* Hct-35.6*
MCV-94 MCH-30.6 MCHC-32.5 RDW-15.3 Plt Ct-227
[**2104-4-4**] 07:03AM BLOOD Neuts-77* Bands-4 Lymphs-10* Monos-4
Eos-0 Baso-0 Atyps-1* Metas-4* Myelos-0 NRBC-1*
[**2104-4-3**] 09:24PM BLOOD Neuts-81* Bands-3 Lymphs-7* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2104-4-3**] 06:38AM BLOOD Neuts-75* Bands-2 Lymphs-4* Monos-11
Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-5*
[**2104-4-1**] 03:19AM BLOOD Neuts-77* Bands-2 Lymphs-12* Monos-4
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-2*
[**2104-4-4**] 07:03AM BLOOD Plt Smr-NORMAL Plt Ct-150
[**2104-4-4**] 07:03AM BLOOD PT-63.6* PTT-150* INR(PT)-7.04*
[**2104-4-4**] 05:22AM BLOOD Plt Ct-260
[**2104-4-4**] 05:22AM BLOOD PT-49.4* PTT-69.0* INR(PT)-5.2*
[**2104-4-3**] 09:24PM BLOOD PT-35.3* PTT-150* INR(PT)-3.5*
[**2104-4-3**] 05:00PM BLOOD PT-28.7* PTT-39.4* INR(PT)-2.8*
[**2104-4-2**] 02:40AM BLOOD PT-32.3* PTT-30.0 INR(PT)-3.2*
[**2104-3-28**] 04:20AM BLOOD PT-73.6* PTT-36.9* INR(PT)-8.3*
[**2104-3-26**] 07:15AM BLOOD PT-29.3* PTT-27.1 INR(PT)-2.8*
[**2104-4-4**] 07:03AM BLOOD Glucose-286* UreaN-33* Creat-1.0 Na-141
K-5.4* Cl-103 HCO3-22 AnGap-21*
[**2104-4-4**] 05:22AM BLOOD Glucose-187* UreaN-32* Creat-0.7 Na-139
K-5.1 Cl-102 HCO3-24 AnGap-18
[**2104-4-3**] 09:24PM BLOOD Glucose-268* UreaN-26* Creat-0.7 Na-138
K-4.7 Cl-103 HCO3-26 AnGap-14
[**2104-4-3**] 05:00PM BLOOD Glucose-205* UreaN-24* Creat-0.5 Na-140
K-4.4 Cl-105 HCO3-28 AnGap-11
[**2104-4-4**] 05:22AM BLOOD ALT-443* AST-508* LD(LDH)-1116*
AlkPhos-86 TotBili-0.8
[**2104-4-3**] 09:24PM BLOOD ALT-298* AST-144* LD(LDH)-545*
CK(CPK)-535* AlkPhos-84 TotBili-0.4
[**2104-4-3**] 09:24PM BLOOD CK-MB-17* MB Indx-3.2 cTropnT-1.18*
[**2104-4-3**] 05:00PM BLOOD CK-MB-17* MB Indx-2.9 cTropnT-1.19*
[**2104-4-3**] 11:01AM BLOOD CK-MB-18* MB Indx-3.2 cTropnT-1.36*
[**2104-4-4**] 07:03AM BLOOD Calcium-10.9* Phos-7.7*# Mg-2.3
[**2104-4-4**] 05:22AM BLOOD Albumin-2.1* Calcium-7.2* Phos-4.5 Mg-2.2
[**2104-4-3**] 09:24PM BLOOD Albumin-2.0* Calcium-7.1* Phos-3.1 Mg-1.7
[**2104-4-3**] 05:00PM BLOOD Calcium-7.2* Phos-2.3* Mg-1.7
[**2104-3-27**] 04:01AM BLOOD Osmolal-313*
[**2104-3-31**] 03:46AM BLOOD TSH-0.87
[**2104-3-27**] 08:13AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2104-4-3**] 06:38AM BLOOD Digoxin-2.0
[**2104-3-24**] 05:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2104-4-4**] 07:17AM BLOOD Type-CENTRAL VE pO2-95 pCO2-68* pH-7.10*
calTCO2-22 Base XS--9 Comment-GREEN TOP
[**2104-4-4**] 05:45AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2104-3-30**] 01:06PM BLOOD Type-ART pH-7.36
[**2104-4-4**] 07:17AM BLOOD Lactate-15.3*
[**2104-4-4**] 06:43AM BLOOD Glucose-104 Lactate-14.8* Na-144 K-7.1*
Cl-99*
[**2104-4-4**] 05:45AM BLOOD Lactate-7.5*
[**2104-4-3**] 09:28PM BLOOD Lactate-4.2*
[**2104-3-28**] 11:10PM BLOOD Lactate-3.4*
[**2104-3-28**] 03:02PM BLOOD Lactate-3.8*
[**2104-4-4**] 07:17AM BLOOD freeCa-1.53*
[**2104-4-4**] 06:43AM BLOOD freeCa-0.77*
[**2104-3-31**] 04:00AM BLOOD freeCa-1.07*
[**2104-3-30**] 01:06PM BLOOD freeCa-0.98*
Brief Hospital Course:
[**Hospital1 **] Floor course
Mrs. [**Known lastname 2555**] was a very nice 82 year-old spanish and italian
speaking woman with DM2, asthma, chronic systolic heart failure
(EF 55%), HTN, paroxysmal Atiral Fibrilliation who initially
presented with rhabdo. which was complicated by altered mental
status, leukocytosis, and acute renal failure, she recieved
intavenous Bicarbonate and was placed on Amiodarone in the ICU
and was transferred back to the general wards ( on [**4-2**]) from
the ICU after her acute renal failure and atrial fibrilliation
was rate controlled.
.
#Positive Troponins/NSTEMI- On morning of [**4-3**] the patient
complained of vague abdominal pain and EKG was carried out with
cardiac enxymes. Troponin was found to be positive at 1.2 with
CK index of 2.4. The patient's pain resolved with no
intervention and she was asymptomatic on morning rounds with the
only complaint of weakness. Her EKG was hard to assess for ST
changes given chronic left bundle branch block.Her vitals
remained stable and her troponin remained between 1.2-1.35.
Heparin drip was started on the morning of [**4-3**] with full dose
aspirin with cardiology consult. On the morning of [**4-3**] the
patient was in rate controlled atrial fibrilliation on standing
metoprolol and amiodarone which was continued. During the
afternoon on [**4-3**] the patient went into atrial fibrilliation
with RVR to 140's and responded to 2 pushes of 5mg metoprolol
and 10mg diltiazam to rate controlled idioventricular rhythym in
the 60's with BP 150/80's and 100% oxygenation on RA. The
patient was noted to be unresponsive a few hours later for few
minutes , blood sugars were normal, neurological exam was
nonfocal,abdominal exam benign with no distension, only insp
crackles diffusley was observed, vitals were stable (including
systolic BP above 150, afebrile, without tachycardia), the
patient became more responsive but still delirious after 5
minutues. ABG at the time showed no carbon dioxide retention or
hypoxemia but was remarkable for lactate of 4. The MICU was
notified of the patient however the patient did not meet
transfer criteria vitals wise at the time. The patient was found
to be pulseless on the floor [**4-4**] AM code blue was called and
she was transferred to MICU. In the MICU patient initally had a
pulse but quickly had another cardiac arrest. Resuscitation
efforts were continued for another 20 minutes but ultimately the
patient did not have return of circulation and she was pronouced
dead on [**4-4**] at 744am.
.
# Atrial fibrillation: Patient was s/p cardioversion here twice
during this admission which failed to keep her in sinus rhythym.
Her INR continued to be elevated off coumadin for unclear
reasons, perhaps acute liver failure. Her LFT's and CK were
trending down significantly while on the floor and she had
normal liver ultrasound with patent vasculature. Continued
Amiodarone and Metoprolol per above.
.
# Acute on Chronic systolic heart failure : Her recent EF was
approximately 40% last month.However a echocrdiogram on [**3-28**]
showed a EF of 20% with global hypokinesis and no coronary
distribution. Possible causes for the lowered EF could have been
volume overload, atrial fibrilliation or tachycardia induced
cardiomyopathy though this was lower on the differential. She
was volume overloaded with elevated JVD, pulmonary edema and
lower extremity edema. Was monitored clinically and admin IV
lasix per above for net goal of negative 500cc-1000cc/day. Given
40mg and 80mg lasix bolus's on [**4-3**], negative 400cc as of [**4-3**]
6PM.
.
# Rhabdomyolysis: Her rhabdo was likely related to statin
myopathy as she was supposed to stop this medication after
recent admit to [**Hospital3 2568**] in [**1-25**] but she continued to take it
secondary to confusion with med rec. Successfully treated with
IV fluids, and creatinine normalized with good urine output on
transfer to the floor [**4-3**]. Etiology remained unclear, though
statin was discontinued on admission, on the differenital
remained viral myositis (studies EBV, CMy negative), autoimmune
disease. CK and LFT's had significantly trended down as of the
morning of [**4-3**]. Neurology recommended myositis panel, and
EMG(not done) and autoimmune panel including Mi2 pending.TSh was
normal.
.
#Transaminitis- no signs of hepatic disease on ultrasound of the
liver with patent vasculature. Experienced a significant
trasnaminits which was associated with a significant elevated
INR of 8.0. Was hypotensive by report after cardioversion and
could have been due to ischemic hepatitis with antibiotics/poor
nutrition contributing though remians unclear.
.
#. Asthma: She used albuterol inhaler PRN at home with history
of asthma and COPD per records. Continued PRN nebs while inpt.
.
#. GERD: Continued home PPI.
.
# Hyperdense brain lesion: Her CT head in the ER showed a small
<4.5 mm hyperdense focus in the L frontal area which could be
small SDH or calcium deposition. This was a film limited by
motion so repeat may be helpful to further characterize this
small area.Not signifiant given no neurological signs or
deficits, plan was to reimage when clinically stable
.
#. Diabetes Mellitus Type 2: continued insulin ss
*******************
MICU course through [**2104-4-2**]:
Patient admitted to the ICU for altered mental status and
respiratory distress. Initially, this was presumed due to flash
pulmonary edema as she was hypertensive and CXR appeared to be
consistent. Therefore, she was initially diuresed. However, in
the morning her urine output was minimal, her hematocrit/CBC
appeared very hemoconcentrated, her lactate was rising and her
02 sats were >94% on RA. Renal was consulted who agreed that
the patient was volume deplete and she was given 5L LR
throughout the day as well as 150ml/hr of d51/3amps of bicarb to
alkalinize the urine. Even with this amount of fluid, her 02
sat on room air was >90%. It was hypothesized that the patient
aspirated on the floor rather than flashed though this is
unclear.
.
The patient's creatinine increased from 1.0 to 1.4 in the first
day in the ICU. Her urine was spun and was consistent with ATN.
The renal consultants felt this was due to pre-renal azotemia
on the floor as well as rhabdomyolysis. Her CK trended down
from 50,000 to 30,000 over the first day in the ICU. Her
creatinine peaked at 2.4 and then started to trend down and her
urine output increased. She also had evidence of hypotensive
liver injury (with some contribution from rhabdomyolysis). Her
AST/ALT peaked in the low [**2092**] and trended down rapidly. There
was no abnormalities in her liver synthetic function.
.
The patient' hematocrit also decreased from 47 to 34 after the
5L IVF and bicarb. She was guaiac negative. This was felt to
be dilutional. However, her INR was supratherapeutic at 4.5 so
she was monitored closely for bleeding. She did not have flank
echymosis. Repeat HCTs were 32-37 and she had no further signs
of bleeding.
.
The patient's WBC was 22 on arrival to the ICU (up from 11 on
admission) and she had fever to 100.8. She had copious diarrhea
so C.Diff was sent and PO Vanco and IV flagyl were started
empirically. C. Diff came back negative x1, but the suspician
was still high so Vanco and Flagyl were continued and Cipro was
added (patient listed allergy to levofloxacin was GI upset).
She had a CT abdomen (with PO contrast only given acute renal
failure), this showed no acute process and no signs of colitis,
and 2 more C. Diff were negative so cipro, flagyl and PO vanco
were stopped. She also had blood and urine cultures sent that
were negative. The patient's WBC plateued and she was started
on Vanc/aztreonam for RLL infiltrate.
.
The patient's mental status was initially lethargic but after
IVF resuscitation, improved to close to her baseline per family.
However, given the acute onset of the AMS and the patient's
supratherapeutic INR head CT was performed and showed no acute
process. Neuro was consulted for myopathy and started a workup.
The patient continued to have delirium in the ICU with
sundowning and was started on standing seroquel and night which
helped.
.
Although the patient reportedly came to the hospital in NSR, she
was tachycardic into the 140s consistently. It was difficult to
control her rate with IV dilt, IV metoprolol because her
pressures became low. She was trialed on esmolol drip and this
improved her rate into the 120s but this, too, was limited by
hypotension. She was cardioverted on MICU day 3 and stayed in
sinus for about 24 hours before she reverted to tachycardia.
She then had marginal blood pressures and esmolol was tried but
stopped. Cardiology again tried cardioversion and after
discussing with liver, bolused and loaded with amiodarone. She
became hypotensive after the cardioversion and a central line
was placed and the patient started on neo with good response.
She again reverted to tachycardia 12 hours later and received 1
more bolus of amio and reverted to sinus. She reverted yet again
on [**3-31**] to afib/flutter to 130s despite being started on amio
load. She was seen by cards who recommended diuresis and EP
consult. EP recommended digoxin loaded which improved her rates
into low 100s.
Patient was discharged from the ICU to the [**Hospital1 **] where she was
noted to have a mildy elevated troponin and a decision was made
to initiate heparin. She continued to have intermittent a.
fibrillation. On the evening before she died, she had another
episode of atrial fibrillation. The team rate controlled the
atrial fibrillation but approximately 8-12 hours later she
suffered a sudden cardiac arrest and was transported back to the
ICU. I arrived in the ICU that morning while CPR was in
progress and had been for a prolonged period of time. Despite
standard ACLS, the patient did not have ROSC and she was
pronounced dead. Though the patient had not been under my care
for the days preceding the death, I spent time discussing the
possible reasons for her death.
Medications on Admission:
Tolterodine 2 mg [**Hospital1 **]
Levothyroxine 125 mcg daily
Calcium 600 600 mg (1,500 mg) daily
Colace 100 mg daily
Lasix 20 mg daily
Losartan 100 mg daily
Multivitamin daily
Nitroglycerin 0.4 mg SL PRN
Nortriptyline 10 mg qHS
Lorazepam 0.5 mg [**Hospital1 **] PRN
Insulin glargine 20 units daily
Insulin aspart sliding scale
Senna 8.6 mg two tabs qHS
Albuterol sulfate 90 mcg/Actuation HFA q4 PRN
Bisacodyl Oral
Diltiazem CD 180 mg qday
Metoprolol succinate 200 mg qday
Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM.
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2104-4-6**]
|
[
"348.89",
"995.92",
"584.5",
"V58.61",
"250.00",
"410.71",
"428.23",
"570",
"728.88",
"038.9",
"428.0",
"401.9",
"530.81",
"493.90",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.62",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
19419, 19428
|
8761, 18790
|
378, 452
|
19487, 19504
|
3641, 8738
|
19568, 19613
|
2169, 2284
|
19379, 19396
|
19449, 19466
|
18816, 19356
|
19528, 19545
|
2921, 3622
|
329, 340
|
480, 1628
|
1650, 1740
|
1756, 2153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,695
| 108,090
|
52015
|
Discharge summary
|
report
|
Admission Date: [**2135-6-30**] Discharge Date: [**2135-7-7**]
Date of Birth: [**2056-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is a 79 y/o M with h/o of HTN, DM, recent CVA [**Month (only) **],
chronic respiratory failure on vent, trached, ESRD on HD who was
sent from rehab facility fro wrosening mental status.
.
Per refferal notes, he went to hemodyalisis today in the
morning. 1 L was removed. At about 2:30 pm, he was found to have
worsening mental status. In that setting he was hypotensive down
to the 92/45, and was given 1 L NS. Fs was also checked 179. At
that time, it seems that he had been on T peace since 4 am
today. At 2:30 he was also found with sats in the 90%. ABG done
7.1, 89/72- he was placed on AC 600/0.4 and 6 PEEP- sats up to
94%.
Given persistent lethargy, patient was sent to Falkener ED.
.
Of note, after interview with HCP, at around [**5-17**], patient
started having episodes of dizziness, and had unstable gait.
he was taken to [**Last Name (un) 33526**] ICU until [**6-3**] when he was
discharged to [**Hospital **] Rehab. he had a peg tube and tracheostomy
prior to d/c. He had been chronicallyl vent dependent. His
companion states that they have been trying to wean him down at
rehab. his basline mental staus apparently responds with his
head shaking, and also try to write sentences.
.
In the ED: VS T 103 rectal BP90/44 HR: 84 RR 16 Sats: 98
+ guiac stool. He received tylenol, levofloxacin 500 mg IV,
Flagyl 500mg and Vancomycin and I L NS.
.
ROS: difficult to obtain 2x2 to patient mental status baselin
Past Medical History:
CVA [**Month (only) **]/[**2134**]
HTN
DM
CRI on HD since [**Month (only) **] (Tu, Thurs, Sat)
Neuropathy right leg
s/p cCY
Social History:
Uset to be truck driver. Retired 15 years ago. He has 1 son,
two grandson. smoking (-), alcohol -
Family History:
brother died cerebral aneurysm
Brother [**Name (NI) **] cancer
brother prostate cancer
father [**Name (NI) 107681**]
Physical Exam:
Physical Exam:
Vitals: T: 99 P:84 BP: 145/62
AC: 600, x12/0.5/5 SaO2: 100%
General: Awake, alert, responding to voice.
HEENT: PEERLA, no JVD. + tracheostomy
Pulmonary: clear anteriorly. decrease breath sounds bases.
Cardiac: RRR, nl. S1S2, soft holosytolic murmur apex
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. + g tube
Extremities: Left arm AVF
1+ trace edemalymphadenopathy noted.
Skin: no rashes, small decubit in the back.
Neurologic: alert, awake, partially interacting and responding
to comands.
decreased reflexes Lower extremities. bilaterally. spastic right
upper extremity.
Pertinent Results:
141 103 53 167 AGap=14
------------->
5.7 30 3.6
CK: 29 MB: Notdone Trop-*T*: 0.44
Comments: Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2135-6-30**] 6:50p
Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 8.6 Mg: 2.4 P: 5.0
Other Blood Chemistry:
proBNP: [**Numeric Identifier 107682**]
WBC 15.2 Plat 395
HCT: 28.4
N:89.8 Band:0 L:5.8 M:4.1 E:0.3 Bas:0.1
PT: 12.1 PTT: 37.5 INR: 1.0
[**2135-6-30**]
5:04p
Green Top
K:5.5 Lactate:1.3
.
Brief Hospital Course:
Assessment and Plan:
This is a 79y/o M with h/o HTN, DM, recent CVA, chronic
ventilatory failure, CRI on HD who presents with change in MS
and febrile in the ED, admitted to MICU.
.
# Altered mental status: Ct scan with no evidence of new
intracraneal bleeding. Patient febrile in the ED. High WBC. It
was thought that it could have been a combination of
hypotension, hypercapnia and infection. He was initially started
on broad spectrum antibiotics. Despite having a profund
limitation communicating given his neurological status, his
mental changes seemed to improved initially. However later on
during his course, his mental status deteriorated, being even
less responsive.
.
#ID:
Patient febrile and with a high WBC on admission. After starting
broad spectrum antibiotics-cefepime-vancomycin and flagyl(for
initial concern of aspiration pneumonia), he responded
clinically. Urine cx from Rehab showed gram negative rods >100K
enterobacter cloacae. Urine Cx in house grew Citrobacter Freundi
and his sputum grew Acinetobacter Baummani. Since there was no
more evidence of gram positive infections, vancomycin was
discontinued and cefepime was kept.
.
# Fevers: in the ED, high WBC, possible pneumonia. Also possible
source sinus infections given findings on intial CT (see summary
in significant studies). He did not spike any fevers after being
transfer to the MICU from the ED.
.
# Resp: Patient was intermitentely switched from AC to Pressure
support trials.
However, after
Patient did well. Then trach mask trials were done. He
tolerated this well, although he required PS overnight.
.
# ESRD on hemodyalisis: Renal service was consulted and HD was
continued.
.
# CV:
Rhythm: NSR, not tachycardic.
.
Pump: With trace of lower extremity edema. X ray suggested some
pulmonary edema on admission. Despite this findings, he was
supported with 40% FIO2 most of the time.
.
CAD: On admission Ck low normal, MB not done. Troponin 0.44. It
was more likely due to CRI. Second set 12 hours apart, showed no
changes.
.
s/p stroke: continue aspirin, statin, plavix
.
# Hypotension: per referral form. Intially concern for sepsis in
the setting of fevers and high blood count. His BP medications
were held on admission. Patient di dnot require pressors. His
blood pressure remained stable and BP meds were restarted.
.
#FEN:
Tube feedings were started thorugh peg tube. On [**2135-7-3**], patient
pulled out peg tube. Temporary foley was placed and on [**2135-7-6**],
On [**2135-7-7**] after deterioration of his mental status and also of
his blood pressure, goals of care were discussed with his HCP.
It was decided to direct goals of care towards confort care.
Patient passed away accompanied by his significant other.
Medications on Admission:
Novolin 16 U q 12h
Aranesp 40 mcg sc
Prozac liquid 20 mg qam
Heparin 3000 U tu, thursday saturday
Norvasc 10 mg daily GT
Tylenol PRN
Reglan 5 mg q6h,
fergon 300 mg [**Hospital1 **]
Plavix 75 mg GT
nephrocaps 1 daily
novolin Sliding scale
heparin sc 5000 q8h
Protonix 40 mg daily GT
Combivent 2 puff qid inh
zocor 10 mg Tab /day GT
aspirin 325 mg tab
Ferrlecit Sodium ferric gluconate Mo-We Fr IV
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Change in Mental status
2. Urinary tract Infection
3. Chronic respiratory failure
.
Secondary:
1. Hypertension
2. Diabetes Mellitus
3. End stage renal disease on HD
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2135-9-6**]
|
[
"585.6",
"276.7",
"507.0",
"V44.0",
"041.85",
"428.0",
"599.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6566, 6581
|
3371, 3563
|
345, 351
|
6793, 6802
|
2868, 3348
|
6854, 7023
|
2090, 2209
|
6537, 6543
|
6602, 6772
|
6116, 6514
|
6826, 6831
|
2239, 2849
|
282, 307
|
379, 1810
|
3578, 6090
|
1832, 1958
|
1975, 2074
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,094
| 148,837
|
51699
|
Discharge summary
|
report
|
Admission Date: [**2179-3-13**] Discharge Date: [**2179-4-1**]
Date of Birth: [**2124-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Trouble swallowing
Major Surgical or Invasive Procedure:
Evacuation of cervical hematoma by ENT
Penrose drain placement and removal
PICC line placement and removal
History of Present Illness:
This is a 55 y/o M with history of recent DVT s/p IVC filter,
s/p ACD (anterior cervical discectomy) on [**2179-3-7**], who was
admitted with prevertebral hematoma that was evacuated by ENT on
[**2179-3-13**], hospital course complicated by pneumonia.
The patient intially was planned to have ACD for cervical
stenosis. He was diagnosed with a DVT pre-op, and had an IVC
filter placed on [**2179-3-6**], then had the ACD on [**2179-3-7**]. He
tolerated this procedure well, and was discharged to rehab on
[**2179-3-9**] on heparin gtt for his DVT with no clear long term plan
for anticoagulation. At rehab, he developed right sided neck
swelling and difficulty breathing. He was brought back to the ER
on [**2179-3-13**] and was diagnosed with a prevertebral hematoma. He
had a evacuation of hematoma done by ENT that day. He did fine
postop and was extubated, but then on [**3-14**] he became hypoxic,
had increased size of the wound and cough. ENT inserted penrose
drain at bedside and evacuated 30cc of blood as well as a venous
clot and he was transferred to the SICU (from [**Date range (1) 84712**]). He was
febrile to 102. He was started on Ancefx1 day in the setting of
the penrose placed at bedside. He continued to require 4L NC to
maintain sat >94%. On [**2179-3-16**] he had a chest CT to r/o PE, see
below. He was scoped by ENT that day that showed no obvious
upper airway cause of hypoxia. The CT scan was notable for
several nonocclusive acute/subacute subsegmental emboli and also
showed multifocal pneumonia. He was started on vanc/levaquin on
[**2179-3-17**] in the AM. He was changed to vanc/zosyn for coverage of
hospital acquired pneumonia on [**2179-3-18**], and is on standing
nebulizers. On [**2179-3-19**], he began to complain of L. sided chest
pain which lasted 20 minutes. There was evidence of an ECG with
RBBB which was present on EKG of his last admit, but absent
before. He denies current chest pain.
An ABG on [**2179-3-19**] showed pH 7.48 pCO2 46 pO2 44 HCO3 35 off of
oxygen. He has no history of known lung disease, has never
smoked, and has had no respiratory problems before.
[**Name2 (NI) **] had a presyncopal episode on [**2179-3-23**], with hypotension
to 80/40s and drop in O2Sats to high 70s, one hour after walking
to restroom. Patient had a similar episode on the floor the
night before. Patient placed on non-rebreather and O2Sat
returned to 96% on Non-Rebreather. Trigger called, and patient
ABG showed evidence of hypoxia: pH 7.48 pCO2 46 pO2 43 HCO3 35.
CXR normal. Patient transferred to ICU for closer monitoring of
O2 Sat and non-rebreather oxygenation.
In MICU, patient had CT of chest and abdomen which showed
improvement in his multifocal pna as well as extension of DVT to
IVC filter. Additionally, Neurosurgery was reconsulted in
regards to his ongoing weakness. They believed this was
consistent with contusion from his prior cord compression. No
neurosurgery indicated. Symptoms may not improve with time. As
oxygenation improved to 92-96% 2L nasal cannula, patient was
transferred back to the floor for further evaluation.
Patient reports that he has been feeling short of breath since
the hematoma developed on his neck. His recent episode of
dyspnea began 5 days prior to initial admission to medicine. He
reports mild dyspnea at rest, and worsening shortness of breath
with any type of exertion, including standing to shave.
Of note, patient has experienced significant R. sided weakeness
since [**2178-11-29**]. Weakness was noted after H1N1 infection,
[**First Name9 (NamePattern2) 7816**] [**Location (un) **] work up was negative at OSH. Now he associates
his symptoms temporally with a work injury in which he was
reaching and felt pain in his cervical spine. While on the
medicine floor, patient began to have more progressive weakness
and numbness of the anterior thigh.
Past Medical History:
Chronic LBP with prior surgeries including instrumented fusion
Multiple neck surgeries in the distant past
Hypertension
IVC filter placed [**2179-3-6**] for DVT
Discectomy x2 for herniated disc with cord compression
Social History:
Denies smoking or drinking. Works in plumming. Lives in [**Location **],
is widowed and has daughter. [**Name (NI) **] a significant other. Pt would
like cousin, [**Name (NI) **] [**Name (NI) 107098**], to speak for him with regards to
medical decisions if he cannot speak for himself.
Family History:
Father died of MI at age 70.
Physical Exam:
GENERAL: Middle aged male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. well healed scar at
R. neck
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: crackles at right middle lobe, less audible after cough.
left side CTA
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: 2+ pitting edema of right leg, patchy
erythema,non-tender and normal temperature. No cords palpated.
2+ dorsalis pedis/ posterior tibial pulses. 1+ pitting edema of
the R. leg
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Decreased
sensation bilaterally R>L - to mid-calves. 5/5 strength on Left
and 4/5 strength on right. 1+ reflexes bilaterally. abnormal
coordination with Right hand. Gait assessment deferred,
significant extensor weakness of right wrist and fingers
PSYCH: Listens and responds to questions appropriately
Pertinent Results:
[**2179-3-18**] 05:05AM BLOOD WBC-12.1* RBC-3.39* Hgb-11.0* Hct-31.5*
MCV-93 MCH-32.5* MCHC-34.9 RDW-13.5 Plt Ct-160
[**2179-3-13**] 09:50AM BLOOD Neuts-91.1* Lymphs-5.4* Monos-2.5 Eos-1.0
Baso-0
[**2179-3-18**] 05:05AM BLOOD Plt Ct-160
[**2179-3-18**] 05:05AM BLOOD Glucose-127* UreaN-9 Creat-0.8 Na-137
K-3.6 Cl-95* HCO3-32 AnGap-14
[**2179-3-18**] 05:05AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2
[**2179-3-16**] 06:39PM BLOOD Type-ART pO2-59* pCO2-42 pH-7.49*
calTCO2-33* Base XS-7
[**2179-3-13**] 09:50AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-138
K-3.7 Cl-99 HCO3-29 AnGap-14
[**2179-3-28**] 07:30PM BLOOD Glucose-141* UreaN-7 Creat-1.4* Na-141
K-4.0 Cl-104 HCO3-30 AnGap-11
[**2179-3-31**] 03:10AM BLOOD Glucose-101* UreaN-6 Creat-1.2 Na-143
K-3.9 Cl-105 HCO3-29 AnGap-13
[**2179-3-13**] 03:55PM BLOOD CK(CPK)-112
[**2179-3-21**] 06:45AM BLOOD TotBili-0.5
[**2179-3-23**] 04:30AM BLOOD CK(CPK)-29*
[**2179-3-13**] 03:55PM BLOOD CK-MB-2 cTropnT-<0.01
[**2179-3-13**] 03:55PM BLOOD Calcium-8.8 Phos-4.1 Mg-2.3
[**2179-3-30**] 03:37AM BLOOD Albumin-2.8* Calcium-8.0* Phos-4.2 Mg-2.0
[**2179-3-21**] 06:45AM BLOOD calTIBC-228* Hapto-269* Ferritn-289
TRF-175*
[**2179-3-16**] 12:49PM BLOOD Type-ART Temp-37 pO2-59* pCO2-47* pH-7.45
calTCO2-34* Base XS-7 Intubat-NOT INTUBA
[**2179-3-24**] 05:45AM BLOOD Type-ART pO2-86 pCO2-57* pH-7.41
calTCO2-37* Base XS-8
MICROBIOLOGY:
[**2179-3-14**] 7:15 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2179-3-20**]** Blood Culture, Routine (Final
[**2179-3-20**]): NO GROWTH.
[**2179-3-17**] 5:26 am SWAB Source: neck wound. **FINAL REPORT
[**2179-3-19**]**
GRAM STAIN (Final [**2179-3-17**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2179-3-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2179-3-17**]):
TEST CANCELLED, PATIENT CREDITED.
[**2179-3-17**] 5:03 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2179-3-23**]** Blood Culture, Routine (Final
[**2179-3-23**]): NO GROWTH.
[**2179-3-17**] 5:03 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2179-3-23**]** Blood Culture, Routine (Final
[**2179-3-23**]): NO GROWTH.
[**2179-3-17**] 5:50 pm URINE Source: Catheter. **FINAL REPORT
[**2179-3-18**]**
URINE CULTURE (Final [**2179-3-18**]): NO GROWTH.
[**2179-3-19**] 5:15 pm BLOOD CULTURE **FINAL REPORT [**2179-3-26**]** Blood
Culture, Routine (Final [**2179-3-26**]): NO GROWTH.
[**2179-3-19**] 4:20 pm BLOOD CULTURE **FINAL REPORT [**2179-3-25**]** Blood
Culture, Routine (Final [**2179-3-25**]): NO GROWTH.
[**2179-3-23**] 11:28 pm MRSA SCREEN Source: Nasal swab. **FINAL
REPORT [**2179-3-26**]** MRSA SCREEN (Final [**2179-3-26**]): No MRSA
isolated.
STUDIES:
[**2179-3-13**] Portable AP CXR: IMPRESSION: Minimal leftward deviation
of the trachea at the level of the cervical fixation hardware
with fullness of the right sided soft tissues of the neck,
likely due to the patient's known hematoma. Lungs are clear.
[**2179-3-14**] Lower extremity US: IMPRESSION: DVT of the right
popliteal vein and the posterior tibial and peroneal veins
within the right calf.
[**2179-3-15**] Portable CXR: FINDINGS: In comparison with study of
[**3-13**], there is some ill-defined opacification in the
retrocardiac region suggesting some atelectatic changes at the
left base. However, no evidence of acute pneumonia, [**Month/Year (2) 1106**]
congestion, or pleural effusion.
[**2179-3-16**]: CT chest with and without contrast: IMPRESSION:
1. Three areas of equivocal subsegmental pulmonary artery
filling defects are not definitive for acute pulmonary embolus.
The only definitive finding for that diagnosis is a tiny
non-occlusive filling defect in a subsegmental artery in the
right lower lobe. Worsening hypoxia could be explained by
multifocal pneumonia and atelectasis with extensive bronchial
inflammation in both lungs, right worse than left, which
probably explains mild diffuse central lymph node enlargement. I
have requested 1mm thick,axial reconstructions of this imaging
(compared to the current, 2.5mm wide axial images) in hopes of
lending greater diagnostic certainty to evaluation of the
attenuated but not occluded arterial branches. If review yields
more information, an addendum will be dictated.
2. Multifocal pneumonia and probable bronchial infection.
[**2179-3-17**] portable CXR: There is new right lower lobe
consolidation with air bronchogram highly worrisome for interval
development of pneumonia (relatively rapid) or aspiration
pneumonia. There is a smaller opacity in the left perihilar area
that potentially may represent similar process. On the chest CT
from [**2179-3-16**], the right basilar opacity has been
present, but the impression is that it has been a progression
since then that might explain the patient's symptoms of fever
and leukocytosis. There is no pneumothorax or pleural effusion.
[**2179-3-18**] PA/LAT CXR: IMPRESSION: Improved multiple parenchymal
opacities with residual right lower lobe opacity compared to
[**2179-3-17**],
[**2179-3-20**] ECG: Baseline artifact is present. Sinus rhythm. Right
bundle-branch block. Compared to the previous tracing there is
no significant change. Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 144 134 384/433 49 -7 26
[**2179-3-20**] CXR: IMPRESSION: No active pulmonary disease.
[**2179-3-22**] Video oropharyngeal swallow: IMPRESSION: Moderate
pharyngeal dysphagia with aspiration of thin liquids.
[**2179-3-23**] MR C/T/L-spine without contrast:IMPRESSION: 1. No cord
signal abnormality within the thoracic spine. 2. Post-surgical
changes in the lumbar spine as above. Severe bilateral neural
foraminal stenosis at L3-L4. 3. Incompletely evaluated left
kidney, T2 hyperintense lesion.
[**2179-3-23**] CT chest/abd/pelvis without contrast: IMPRESSION: 1. No
evidence of retroperitoneal hematoma. 2. Interval improvement in
multifocal pulmonary consolidation with residual opacity in the
right base greater than left. Follow up to complete resolution
recommended. 3. Infrarenal IVC filter with hyperdense material
indicating clot within the filter which extends down the IVC. 4.
Air in the nondependent portion of the bladder. Clinical
correlation recommended for recent instrumentation or Foley
catheterization.
[**2179-3-24**] Echocardiogram: The left atrium is mildly dilated. The
right atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with low normal free wall contractility (no overt
RV strain seen). The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2179-3-24**] Portable AP CXR: FINDINGS: As compared to the previous
radiograph, there is no relevant change. Borderline size of the
cardiac silhouette. No evidence of focal parenchymal opacities.
No pleural effusions. No pulmonary edema. Normal hilar and
mediastinal contours. Mild tortuosity of the thoracic aorta.
[**2179-3-26**] Bilateral LE U/S: CONCLUSION: 1. Bilateral patent common
femoral veins with symmetric waveforms demonstrating respiratory
variability, consistent with patent iliac venous drainage. 2.
Acute and highly occlusive venous thrombosis involving the
femoral through popliteal veins on the right side probably also
involving the peroneal veins. 3. Patent left venous system up to
the popliteal vein, but no flow in the peroneal veins on the
left consistent with occlusive thrombus.
Brief Hospital Course:
Mr [**Name13 (STitle) 107099**] was admitted to the Neurosurgery service after being
at rehab. He developed a cervical hematoma while on Heparin at
his rehab facility. He was taken emergently to the OR by ENT (Dr
[**First Name (STitle) **] on [**3-13**] who evacuated 50ml clot. Post operatively he was
monitored in the ICU, he was ruled out for an MI. Follow up
LENIs showed DVT of the right popliteal vein and the posterior
tibial and peroneal veins within the right calf. On [**3-14**] his
wound was found to be [**Hospital1 2824**] and he had periods of desaturations
to 86%, ENT expressed a large amount clot and placed a penrose
drain which was subsequently removed. His ICU course was
complicated by continued desaturations and fevers. Eventual
fever work up revealed a multifocal pneumonia and atelectasis
with extensive bronchial inflammation in both lungs, right worse
than left; there was evidence of a PE though given recurrent
bleeding into surgical wound with airway compromose,
anticoagulation was not initiated. He was started on
Vancomycin/levaquin for the pneumonia. On [**3-16**] he was scoped by
ENT and found to have no obstruction, his penrose drain was dc'd
and was transferred to the floor.
The patient continued to require oxygen. A follow up chest XRay
on [**3-18**] showed no change. On [**3-18**] patient continued to
desaturate to 88% on venturi mask, medicine consult was called
and hypoxia was presumed to be caused by pneumonia. Antibiotics
were changed to vancomycin/zosyn for 10 days. On [**3-19**], patient
continued to decline and complained of chest pain. EKG showed a
bundle branch block which had been seen intermitently on prior
EKG, cardiac enzymes were ordered to rule out MI. ENT was
contact[**Name (NI) **] to determine when heparin can be restarted due to
concern for clots forming above the IVC filter site. It was
determined that heparin can be restarted the morning of [**3-20**] by
Dr. [**Last Name (STitle) **]. There is significant concern for re-acumulation of
hematoma. The patient's steri strips and dressing were changed
and wound continues to drain. Sutures can be removed on [**3-21**] by
ENT and they would like to follow up with the patient on [**3-24**].
He was transferred to the medical service for further management
of his hypoxia. He was continued on vanc/zosyn. On the morning
of [**3-23**], patient had what appeared to be a micturitional vagal
episode though was hypoxic to the 80s at the time. After
consulting again with ENT and given high suspicion for pulmonary
emboli, heparin gtt was initiated. Later that day, he again
became hypoxic with an arterial blood gas concerning for severe
hypoxia (7.48/46/43 on room air). Given patient required a
non-rebreather, he was transferred to the MICU for further
management. There, he had a CT without contrast demonstrating
extension of clot up to IVC filter. Subsequent LENIs
demonstrated that there were areas of patent vasculature, though
clot burden was extensive. Given stable hypoxia requiring [**3-4**]
L of O2, he was transferred back to the medical service.
Vascuilar was consulted and did not feel that any intervention
was needed for his large lower extremity clot (just
anticoagulation for at least 6 months). He was started on
coumadin and was therapeutic for >48 hours with overlap of his
heparin gtt which was discontinued on the day of discharge. INR
should be monitored carefully with a goal of [**3-3**]. INR montoring
should be arranged with outpatient PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11907**] on
discharge from rehabilitation.
# Prevertebral hematoma per above.
# Hospital acquired pneumonia per above. Treated with
vancomycin and zosyn from [**3-18**] x 10 days and albuterol and
ipratropium nebulizers with clinical and radiographic
resolution. He has not required nebulizer treatment for several
days.
# Pulmonary embolism: He required nonrebreather to maintain
adequate O2 Sat for the first 12 hours. Heparin drip was
continued. Transthoracic echo was obtained to evaluate R heart
disfunction, showing moderate PA hypertension without R heart
strain. CT chest without contrast to evaluate for change in
parenchymal lung disease compared to prior CT that could be
contributing to hypoxia showed only improving HAP and clot on
the IVC filter and in the IVC itself. His oxygen requirement
remained 2-3L at discharge. He remained afebrile with improving
residual cough.
#. Cord compression: On transfer to the ICU, there was concern
for cord compression given RLE weakness. Emergent MRI showed no
new cord compression but severe bilateral neural foraminal
stenosis at L3-L4. Neurosurgery felt that cervical lesions were
consistent with contusion from prior cord compression and
surgical intervention. These may take time to improve. His
neurologic exam remained stable until discharge.
# R sided thigh numbness: Noncontrast CT abdomen ruled out RP
hematoma as the cause. This is likely meralgia paresthesica.
# Deep venous thromboses: Previous US indicated DVT of the right
popliteal vein and the posterior tibial and peroneal veins
within the right calf on US [**3-14**], consistent with clotted IVC
filter seen on CT. Repeat LENI revealed patent femoral veins
bilaterally highly occlusive clot on the right with peroneal
clot on the left. He is therapeutic on coumadin
# RBBB: Has had in the recent past since this admission but was
not present on prior ECG. No chest pain. Ruled out for MI with
3x negative enzymes. Likely due to PE as Echo demonstrated
moderate pulmonary arterial systolic htn.
# HTN: History of chronic HTN, he was normotensive and
antihypertensives were held (in the setting of bleeding). This
can be reevaluated over time as these medications may need to be
resumed.
# Back pain: The patient has chronic LBP, takes large amount of
NSAIDs at home along with percocet. Oxycodone was used prn in
the hospital to good effect.
# Bradycardia: Overnight [**Date range (1) 107100**] the patient had [**1-31**] second
episodes of bradycardia to the high 30s, in the setting of
removed oxygen cannula; patient was asymptomatic and O2
saturations remained in the 90s. Cardiology was consulted and
not concerned as determined to be asymptomatic sinus bradycardia
with occasional junctional beats. No intervention indicated.
# Anxiety: Diazepam was used as needed to good effect.
# Dysphagia: Patient reported significant discomfort and
difficulty swallowing. He was evaluated by speech and swallow
and video study demonstrated pharynx edema with mild aspiration.
He was reevaluated several times over the course of his stay
and his diet was progressed from thin liquids, puree to full
diet by the time of discharge with improvement in pharyngeal
edema.
# Acute kidney injury: Patient developed elevated creatinine to
a peak of 1.4 likely in the setting of medications (vanc/zosyn)
and decreased PO intake. Creatinine returned to [**Location 213**] of 1.1
with discontinuation of antibiotics and IVF as well as increased
PO intake.
Medications on Admission:
From rehabilitation records/medication list:
Heparin drip
Lisinopril 10 mg daily
Nifedipine 60 mg daily
Percocet 5 mg [**Hospital1 **]
Benadryl
Valium
Ambien
Protonix
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please follow INR closely (goal [**3-3**]).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipatiion.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 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. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for sob/wheeze.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
# Prevertebral Hematoma
# Deep vein thrombosis with IVC filter placement [**2179-3-6**]
# Pulmonary embolism
# Hospital acquired pneumonia
# Cervical contusion secondary to prolonged cord compression
# Weakness
# Chronic back pain
# Acute renal failure
# Hypertension
# Anterior cervical discectomy [**2179-3-7**]
# Normocytic anemia [**3-2**] acute blood loss
Discharge Condition:
Alert and oriented x 3. Ambulating with assistance.
Discharge Instructions:
You were originally admitted with increased difficulty
swallowing and a right sided blood collection in your neck.
This was in the setting of recent neck spine surgery and being
on a heparin drip for blood clots in your legs (deep venous
thrombosis). You were diagnosed with a blood collection in your
neck (hematoma). You were treated with stoppage of the heparin
and surgical evacuation of the blood. Following surgery you
were in the intensive care unit, and had fevers. You were
treated with antibiotics and had low blood oxygenation
(hypoxia). A CT scan revealed blood clots in your lungs
(pulmonary emboli) and infection in your lungs (pneumonia). You
were treated with antibiotics and heparin and improved and
subsequently transferred out of intensive care. Your blood
clots in your legs and lungs have since been treated with
warfarin and your heparin discontinued after both levels were
therapeutic for a sufficient period.
You were also found to have difficulty swallowing (dysphagia)
which was evaluated using video swallow study. This
subsequently improved and you were taught appropriate chewing
and swallowing technique.
Please:
?????? 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.
?????? 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. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
We have stopped your blood pressure medications (Nifedipine,
Lisinopril) while you were here due to low blood pressures.
These may need to be restarted as an outpatient. This can be
determined by your primary care doctor.
Please make sure to contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11907**] when you are
released from the rehabilitation facility so that he can follow
your coumadin levels regularly.
Followup Instructions:
Appointment #1
Specialty: Radiology
Provider: [**Name10 (NameIs) **] SCAN
Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2179-4-20**] 1:30
Appointment #2
Specialty: Neurosurgery
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD
Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2179-4-20**] 1:45
Appointment #3
Specialty: [**Month/Day/Year **]
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2179-6-2**] 10:00
|
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icd9cm
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,541
| 160,651
|
54706
|
Discharge summary
|
report
|
Admission Date: [**2192-6-16**] Discharge Date: [**2192-6-23**]
Date of Birth: [**2128-1-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Vocal cord injection
History of Present Illness:
This is a 64 year old man on aspirin and Plavix for a cardiac
stent who was initially admitted to this hospital following a
motorcycle crash on [**2192-6-9**] and was discharged on [**2192-6-14**]. He
presents from rehab with worsening headache and Head Ct
consistent with left sided temporal IPH.
At the time of his initial injury he was admitted to the ACS
service as he had multiple traumatic injuries, some of which
include: comminuted left distal clavicle fx,comminuted displaced
left scapular fx,small left pneumothorax,small left pleural
effusion,Left 1st rib fracture, Left temporal bone fracture,
facial nerve injury, left chest tube [**6-9**]
Past Medical History:
CAD s/p stenting, HLD, HTN, recently passed kidney stone
Past Surgical History:
cardiac cath, otherwise unknown
Social History:
Denies tobacco, alcohol, and illicit durg use. previously
Independent with ADLs but now in rehab since accident.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T:98.6 BP:164 / 94 HR:92 R:20 O2Sats:97% 2 liters
Gen: comfortable, NAD.
HEENT: Pupils: 4-3mm EOMs: intact
Neck: Supple.
Extrem: eccymotic left shoulder and chest
Neuro:
Mental status: lethargic cooperative with exam
Orientation: Oriented to person, place, and date.
Recall: too lethargic to recall
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial plasy on left- since discharge [**6-14**]
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full except LEFT delt 0/5, biceps/triceps
4+/5.
No pronator drift
Sensation: Intact to light touch, proprioception, bilaterally.
Toes downgoing bilaterally
PHYSICAL EXAM UPON DISCHARGE: ***
Pertinent Results:
[**6-16**] CT Head: IMPRESSION:
1. Increased hyperdensity and slight thickening along the
posterior falx and tentorium may be calfication, however
possible subdural hematoma cannot be excluded.
2. Extraaxial hematoma, likely epidural, in the left middle
cranial fossa with mild mass effect on the temporal lobe. This
is increased in size compared to the [**2192-6-9**].
3. Fracuture of the overlying left temporal bone which extends
to the middle ear and tympanic cavity with involvement of the
glenoid and base of the zygomatic process with 2 mm depression
of the squamous temporal bone.
4. Fracture through the right portion of the sphenoid sinus
extending to the right carotid canal. Hyperdense material in
sphenoid sinus likely blood. CTA of the head is recommended to
rule out right carotid artery injury.
5. There is layering blood within the ventricles bilaterally
(series 2, image 14), which is new since the most recent prior
examination.
[**6-16**] CXR: FINDINGS: Two images were obtained to show the course
of the NG tube which is with the tip either in the distal
stomach or proximal duodenum. There is increased left pleural
effusion, a component of which is loculated laterally. Multiple
left-sided rib fractures are visualized. There is left-sided
subcutaneous emphysema similar in amount compared to prior.
There is left lower lobe volume loss. The heart is mildly
enlarged, and there is pulmonary vascular redistribution
suggesting an element of fluid overload.
[**6-17**] CT Head: IMPRESSION: Minimally changed left temporal
hematoma subjacent to a transverse left temporal bone fracture.
Unchanged trace blood within the occipital horns of the lateral
ventricles. Fractures of the left temporal bone and blood
products within the sphenoid sinuses are unchanged, described in
detail on prior studies. No new hemorrhage or mass effect is
seen.
[**6-17**] CTA Head/Neck: IMPRESSION: 1. No evidence of carotid
dissection or injury identified. The vertebral arteries are
patent. No intracranial vascular abnormalities are seen.
2. Fractures of sphenoid and the left temporal bone described
previously. The rib fractures are also seen and also described
previously. Please also see torso CT report for further
evaluation of the chest abnormalities.
[**6-17**] EEG: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of continuous focal slowing and
attenuation of faster frequencies in the left temporal region.
These findings are indicative of focal cortical and subcortical
dysfunction in the left temporal region, likely
secondary to the known intracerebral hemorrhage. In addition,
there is
a slow alpha rhythm and mild diffuse background slowing,
indicative of
more diffuse cerebral dysfunction, which is etiologically
non-specific.
There are no epileptiform discharges or electrographic seizures.
[**6-19**] MR HEAD W/O CONTRAST:IMPRESSION: Limited study by motion.
There is no evidence of mass effect or midline shift seen.
Evaluation for diffuse axonal injury somewhat limited in absence
of diffusion or susceptibility images, but no obvious foci of
signal abnormality are seen on the FLAIR images in the expected
positions at the [**Doctor Last Name 352**]-white matter junction or in the corpus
callosum. Left temporal hematoma with mild surrounding edema
seen and soft tissue changes are seen in the left temporal bone
and sphenoid sinus.
[**6-21**] VIDEO OROPHARYNGEAL SWALLOW: FINDINGS/IMPRESSION:
Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple
consistencies of barium were administered. There is no
oropharyngeal obstruction with free passage of barium into the
proximal esophagus. There is persistent left
pharyngeal weakness. Note is made of significant oropharyngeal
residual with aspiration of thin and nectar-thick liquids.
There was improvement with left-sided head turns during
swallowing with small amount of persistent residue. For full
details, please see the speech and swallow division note in the
OMR.
[**2192-6-16**] 07:20PM BLOOD WBC-9.8 RBC-3.28* Hgb-9.8* Hct-29.2*
MCV-89 MCH-29.8 MCHC-33.5 RDW-15.7* Plt Ct-198
[**2192-6-16**] 07:20PM BLOOD PT-12.3 PTT-26.5 INR(PT)-1.1
[**2192-6-16**] 07:20PM BLOOD Glucose-105* UreaN-16 Creat-0.6 Na-137
K-3.6 Cl-102 HCO3-25 AnGap-14
[**2192-6-17**] 03:00AM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.1 Mg-2.2
[**2192-6-17**] 03:00AM BLOOD Phenyto-7.3*
[**2192-6-18**] 02:17AM BLOOD Phenyto-9.9*
[**2192-6-22**] 05:38AM BLOOD WBC-10.1 RBC-3.53* Hgb-10.7* Hct-32.6*
MCV-92 MCH-30.3 MCHC-32.8 RDW-16.8* Plt Ct-261
[**2192-6-19**] 03:20AM BLOOD Glucose-93 UreaN-18 Creat-0.7 Na-137
K-3.6 Cl-103 HCO3-22 AnGap-16
[**2192-6-19**] 03:20AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.2
Brief Hospital Course:
Pt was admitted to the ICU on [**6-16**] for neurological monitoring.
His asa/plavix were held and he was started on an EEG (noted to
be negative on HD 2). u/a was negative. He remained
neurologically stable but continued to be lethargic. CT on [**6-17**]
was stable. Radiology recommended a CTA to rule out dissection
due to the sphenoid [**Doctor First Name 362**] fracture, and it was negative for
vascular abnormality. Dilantin level corrected to 9.4 so he was
given a 500mg bolus. The family was concerned about the
patient's dysphagia which required an NG Tube placement at
rehab. The ACS team that followed the patient during his initial
hospitalization was re-consulted and a speech/swallow eval was
ordered.
On [**2192-6-18**] he failed a speech & swallow eval with video swallow
noting decreased left vocal cord function. He was kept NPO.
ENT evaluated and recommended an audiology exam which was
performed on [**2192-6-19**] showing moderate sloping primarily
sensorineural hearing loss in the right ear and a moderate to
profound hearing loss on the left side with bilateral conductive
loss in both ears. They also recommended prednisone x 14 days
with a 5 day taper (total of 19 days), started on [**2192-6-18**]. If
the 7th nerve palsy did not improve they would assess via an ENG
on [**2192-6-26**] to assess for potential decompression.
On [**2192-6-20**] ENT performed an injection of the vocal cords with
Radiesse Voice Gel with improved augmentation, glottic closure,
and voice. Neurosurgery advsied 3 months of dilantin for
seizure prophylaxis.
On [**2192-6-21**] he underwent another speech & swallow eval with video
swallow which he passed and he was cleared for nectar-thick
liquids, ground solids, and thin liquids only between meals (see
report in pertinent results for details). His NG tube was then
removed and his diet was advanced.
On [**6-22**] the patient had an episode of emesis, which we believed
was from taking all of his PO medications all at once. He had
no further episdoes of emesis or nausea, and a KUB was performed
and was not obstructive. He felt better immediately after
vomiting.
On [**6-23**] the patient was discharged feeling well.
Medications on Admission:
1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: Four (4) drops Otic
twice a day for 9 days: to left ear.
Disp:*1 bottle* Refills:*0*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Medications:
1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
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. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. fluoxetine 20 mg/5 mL Solution Sig: Ten (10) MG PO DAILY
(Daily).
6. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. oxycodone 5 mg/5 mL Solution Sig: 1-2 tablets PO Q4H (every 4
hours) as needed for pain.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. levetiracetam 100 mg/mL Solution Sig: Five Hundred (500) MG
PO BID (2 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-20**]
hours as needed for pain.
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for dryness:
LEFT EYE .
17. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic Q 8H (Every 8 Hours).
18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
19. ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic [**Hospital1 **]
(2 times a day) for 4 days: left ear.
20. prednisone 20 mg Tablet Sig: Three (3) Tablet PO Daily ()
for 9 days: Stop after last dose on [**6-30**]. Begin tapering doses
on [**7-1**].
21. prednisone 20 mg Tablet Sig: 2.5 Tablets PO Daily () for 1
days: give on [**7-1**] only - continue taper.
22. prednisone 20 mg Tablet Sig: Two (2) Tablet PO Daily () for
1 days: give on [**7-2**] only - continue taper.
23. prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily ()
for 1 days: give on [**7-3**] only - continue taper.
24. prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for
1 days: give on [**7-4**] only - continue taper.
25. prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
1 days: give on [**7-5**] only and discontinue taper after this dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Intraparenchymal hemorrhage
Sphenoid [**Doctor First Name 362**] fracture
Vocal cord paralysis
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 for further evaluation of your
brain hemorrhage and for vocal cord paralysis. You were evlauted
by the Neruosurgery and Otolaryngology teams. Your brain
hemorrhage did not rewuire any operations. For your vcal cord
paralysis you were given steroids which are being tapered and
you also underwent a procedure where your vocal cords were
injected. As your symptoms improved you underwent a swallowing
evaluation to determine if you would be able to eat solids. In
the meantime an nasogastric tube was placed and tube feedings
were started in order to provide adequate nutritional support
for you as you heal.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this.
??????
?????? **You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Followup Instructions:
Department: ORTHOPEDICS
When: FRIDAY [**2192-7-6**] at 12:25 PM
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: FRIDAY [**2192-7-6**] at 12:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: MONDAY [**2192-7-9**] at 2:15 PM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2192-7-12**] at 1 PM
With: ACUTE CARE CLINIC with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
Department: RADIOLOGY (10am arrival time)
When: TUESDAY [**2192-7-24**] at 10:15 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2192-7-24**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2192-6-23**]
|
[
"401.9",
"810.02",
"414.01",
"807.18",
"272.4",
"E813.2",
"811.09",
"787.20",
"951.4",
"V13.01",
"951.5",
"478.31",
"348.5",
"801.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.6",
"99.29",
"31.0"
] |
icd9pcs
|
[
[
[]
]
] |
13155, 13202
|
7331, 9524
|
313, 336
|
13341, 13341
|
2536, 2547
|
14928, 17013
|
1305, 1309
|
10658, 13132
|
13223, 13320
|
9550, 10635
|
13492, 14905
|
1124, 1158
|
1339, 1527
|
265, 275
|
2512, 2517
|
364, 1021
|
1788, 2482
|
4043, 7308
|
13356, 13468
|
1043, 1101
|
1174, 1289
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,228
| 131,652
|
51785
|
Discharge summary
|
report
|
Admission Date: [**2128-2-15**] Discharge Date: [**2128-2-26**]
Date of Birth: [**2083-9-24**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfonamides / Morphine / Shellfish
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
44y/o F w/ h/o MSSA bacteremia, Burkholderia bacteremia, crohns
disease s/p colectomy with ileo rectal anastomosis [**6-25**], on
weekly remicaide infusions, GERD, Raynauds, Crohns arthopathy,
iron def anemia, was noted today by husband to [**Name2 (NI) 79059**].
Husband went to wake patient up at noon today to get ready for
church. Was unable to arouse patient, was alarmed and went to
seek help. Contact[**Name (NI) **] [**Name2 (NI) 9259**] to help, called covering pcp and
was told to come to ED. EMS was called and pt was taken to ED
at [**Hospital1 18**]. Here patient was febrile to 102, tachycardic to 123,
hypotensive to SBP 92. She was given total of 7L of NS, one dose
of vancomycin 1gm, zosyn 3.375gm, flagyl 500mg. She was also
given 10mg decadron, 2 units of PRBCS and transferred to ICU for
further management.
.
ROS: DOE for past 6 months, worse over last 4 months, very
dyspneic/LH and dizzy with flight of stairs. Has chronic
diarrhea and abd pain (For which she is seen in pain clinic here
at [**Hospital1 18**]). Intermittent fevers/chills.
Past Medical History:
1) Crohn's disease (dx [**2122**], on MTX/Remicaide, baseline [**11-7**]
BM's per day), s/p colectomy [**1-25**], reanastamosis (ileo-rectal)
[**6-25**], h/o collagenous colitis
2) Crohn's arthropathy (seronegative)
3) GERD
4) Raynaud's
5) Depression/Anxiety
6) Migraine HA's
7) Iron Def Anemia
8) MSSA line infxn [**8-27**]
9) Burkholderia bacteremia [**9-27**] and [**10-27**]
10) Chronic Hickman Catheter for IVF
11) SVC syndrome, Left IJ and Left Subclavian stenosis s/p
angioplasty in
[**4-28**]
12) hx of left exudative pleural effusion of unclear etiology
h/o VATS~[**2123**] - for left exudative pleural effusion around time
of #7
13) hx of left pneumothorax due to porta-cath placement
14)left knee arthroscopy
15)Schatzki's ring-noted on EGD
16) h/o post menopausal vaginal bleeding
17) oral hsv
Social History:
The pt lives in [**Location 246**] with her husband and two children, She
does not work, She smokes 0.5-1ppd x 20 yrs, She drinks [**1-26**]
beers/day.
Family History:
Father has polycythemia, mother has melanoma.
Physical Exam:
VS: T: 99.7 P: 104, BP: 130/89, R: 14, Sats: 96%, 4L NC.
GEN: NAD, pleasant female, appears sick, appears pale
HEENT: NC/AT, facial plethora, EOMI, PERRL, mm dry, o/p clear,
NECK: no LAD, unable to appreciate JVD, no bruits,
CV: distant, tachy, RR, no m/r/g; left ant chest wall with line
c/d/i, no erythema present.
PULM: CTA b/l, no w/r/r
ABD: distended, round, BS+, no gaurding, no rebound, surgical
scars appreciated in RLQ and mid lower abd. Diffuse tenderness
to palpation.
EXT: trace edema in lower ext, no c/c
Vasc: DP/PT 2+ b/l
Neuro: CN II-XII grossly intact, sensation grossly intact,
strength 4/5 flex/ext in upper and lower ext. moves all ext.
Pertinent Results:
Upon d/c:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2128-2-26**] 05:24AM 7.8 3.65* 9.1* 29.6* 81* 25.0* 30.8*
21.5* 467*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2128-2-21**] 06:00AM 70 0 21 3 5* 0 0 0 1*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2128-2-26**] 10:00AM 16.6*1 >150*2 1.5*
.
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2128-2-26**] 05:24AM 87 4* 0.9 139 4.1 103 301 10
1 NOTE UPDATED REFERENCE RANGE AS OF [**2127-7-25**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2128-2-15**] 03:15PM 12 30 170 93 39 0.2
OTHER ENZYMES & BILIRUBINS Lipase
[**2128-2-15**] 03:15PM 23
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2128-2-26**] 05:24AM 8.4 3.9 2.0
HEMATOLOGIC Hapto
[**2128-2-15**] 03:15PM 97
OTHER ENDOCRINE Cortsol
[**2128-2-18**] 04:41AM 18.41
ALB TP ADDED [**2-17**] @ 16:13
.
Bcx [**2-15**]: No growth
Ucx [**2-15**]: no growth
c.diff toxin [**2-19**]: no growth
.
Chest/abd CT [**2-15**]:
IMPRESSION:
1. Acute pulmonary emboli, within segmental and subsegmental
branches of the right intralobar pulmonary artery.
2. Bilateral consolidative opacities.
3. Extensive intralobular septal thickening throughout both
lungs, which may be related to pulmonary venous hypertension or
fluid overload.
4. Mediastinal lymphadenopathy, and stranding within the
mediastinum.
5. Extensive inflammatory and/or edematous changes in the
mesentery and retroperitoneum, including pericholecystic fluid,
fluid and stranding around the duodenum, as well as fluid within
the mesentery and stranding. This appearance is atypical of a
Crohn's flare, and is non-specific, although peritonitis is a
possibility.
6. Marked thickening of the bowel wall in ileum, most severe in
a segment in the upper pelvis of about 10 cm in length, with no
evidence of obstruction. This degree is thickening is somewhat
more than expected in Crohn's and may be related to non-specific
wall edema.
7. Periportal edema.
8. Cystic lesion in the right adnexa, for which follow-up
evaluation by ultrasound would be recommended to ensure
resolution after six weeks. An adnexal cystic lesion is felt
much more likely than an abscess.
.
CXR [**2-15**]:New multifocal patchy opacities in the right and left
lungs concerning for infectious process. No free air under the
diaphragm.
.
Echo [**2128-2-15**]
Conclusions:
1.The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction. Overall left ventricular
systolic function is mildly depressed.
3.Right ventricular chamber size and free wall motion are
normal.
4.There is no pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
.
EKG:Sinus tachycardia
Borderline low QRS voltage - is nonspecific but clinical
correlation is
suggested
Since previous tracing of [**2127-11-13**], probably no significant
change
.
Abd ultrasound [**2-16**]:
FINDINGS: A limited abdominal ultrasound shows a trivial amount
of fluid within the right lower quadrant of the abdomen in a
quantity insufficient for safe paracentesis. A paracentesis was
not performed due to limited quantity of fluid. These findings
were discussed with Dr. [**Last Name (STitle) 6812**] at the time of interpretation.
.
Echo [**2-16**]:
Conclusions:
1.The left atrium is mildly dilated.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion.
5.The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen.
6.The estimated pulmonary artery systolic pressure is normal.
7. There is an anterior space which most likely represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded. There are no echocardiographic signs of tamponade.
.
CT head [**2-18**]:IMPRESSION: No acute intracranial hemorrhage or
findings to suggest acute major vascular territorial infarction.
.
CXR [**2-19**]:IMPRESSION: More widespread appearance of previously
seen multifocal patchy opacities, concerning for infectious
process.
.
CT abd/ches [**2-20**]: No definite evidence of prevailing pulmonary
emboli.
2. Resolution of bilateral consolidative opacities.
3. Increase in extent of patchy ground glass opacities mostly in
the upper lobes. This may represent changes due to fluid
overload. An infectious process cannot be excluded but seems
less likely.
4. Increase in bilateral pleural effusions.
5. Minimal improvement in the mediastinal lymphadenopathy.
6. Almost complete resolution of inflammatory and/or edematous
changes in the mesentery and retroperitoneum, including
resolution of pericholecystic fluid and stranding around the
duodenum, if that was fluid within the mesentery and stranding.
7. No evidence on today's study for bowel wall thickening in the
ilium.
8. Decrease in size of the right adnexal cystic structure.
.
[**2-20**] MRI/MRA:
1. No signal abnormalities in the brain to indicate acute brain
ischemia.
2. MR angiography of the circle of [**Location (un) 431**] as well as the
extracranial carotid and vertebral arteries is limited by
patient motion. However, continuous flow signal is seen in these
major vessels.
.
FINDINGS: PA and lateral chest examination performed with
patient in upright position is analyzed in direct comparison
with a preceding similar chest examination of [**2128-2-23**].
The heart size is unchanged. The previously remaining mild
degree of increased interstitial pattern has further improved
and no reoccurrence is noted concerning the previously described
diffuse patchy pulmonary infiltrates. The already on the
previous examination identified infrahilar density on the left
side, obliterating the contour of the descending aorta, remains
and in comparison may even have increased slightly. It is in
slightly higher position than on lateral view detectable local
thickening of the pleura along the posterior wall. These
densities may communicate and represent loculated collection of
pleural effusion. Considering patient's treatment with
anticoagulation following pulmonary embolism, the possibility of
a wall hematoma in the descending portion of the aorta cannot be
completely ruled out. Review of the chest CT of [**2-20**] again
does not disclose this unexplained density which consequently
must have developed during the following days. Further followup
is recommended.
Brief Hospital Course:
1. Sepsis - On admission to the hospital patient was febrile to
102, tachycardic w/ HR 123, hypotensive w/ SBP 92. Labs were
significant for elevated WBC 19.3 P94.3, L4.4, M2.2 and Hct
23.9. Imaging relieved patchy consolidations on CXR, acute PE's
in subsegmental, segmental and anterior lobar artery on CTA,
and mediastinal LAD w/ a prominent lymph node (22X18mm)and
non-specific marked ileal wall thickening, pericholecystic
fluid, mesenteric fat stranding, and cystic lesion in right
adnexa. Patient was admitted to the MICU where she received 7L
NS, 1 dose of 1gm Vancomycin,3.375gm Zosyn, 500mg Flagyl, 10mg
Decadron and 2U PRBCs. Patient's vital signs stabilized
overnight and she was transferred to the Medical Service.
.
Blood, and urine cultures were negative. GI and Pulmonary were
consulted regarding the lung and abdominal findings however no
clear etiology for patient's symptoms were found. The initial
fluid collection was deemed to be insignificant to be tapped
therefore a diagnostic paracentesis/thoracentesis was not
performed. GI and Pulm recommended repeat CT and MR-Abdomen to
evaluate for abnormalities in the mesenteric vasculature, repeat
imaging revealed resolution of ileal wall thickening,
pericholecystic fluid and mesenteric fat stranding. The
mediastinal LAD was also noted to have decreased in size.
Initial radiologic findings were therefore attributed to be [**2-26**]
volume overload from aggressive fluid resuscitation.
.
An induced sputum and BAL was negative for PCP and RSV, AFB and
fungal cultures are still pending.
.
Cosyntropin test was also ordered to r/o adrenal insufficiency,
revealed adequate cortisol response and Decadron was
discontinued on hospital day 3.
.
As noted in patient's HPI, onset of symptoms occurred a week
after the Remicade infusion, therefore this presentation may be
[**2-26**] serum sickness reaction to the Remicade. Concern was also
raised about possible immunosuppression from the MTX/Remicade
regimen which was held during the entire hospital course.
Patient will f/u with Dr. [**Last Name (STitle) 79**] her gasteroenterologist, who may
place her on new Crohn's regimen.
Patient was advised to start the MTX on completion of her
antibiotic course.
.
Patient was afebrile and vitals remained stable throughout her
hospital stay, w/ SBPs>100 and normal Temp. She completed 10 day
course of Vanco/Flagyl/Zosyn. Despite unclear etiology for
sepsis WBC trended down to from 19.3 on admission to 7.8 on
discharge and was diagnosed w/ SIRS and BOOP based on radiologic
lung findings with a proload dependance state due to PE.
.
2. Acute PE - On admission to the hospital patient was diagnosed
w/ acute PE's in right subsegmental, segmental and anterior
lobar artery. She was initially placed on 4mg Warfarin and
Heparin SS, and gradually increased warfarin dose to 10mg. INR
at time of discharge was 1.5 and she received Lovenox bridge for
added anticoagulation. Patient will be followed closely on d/c
by the [**Hospital 197**] clinic and PCP. [**Name10 (NameIs) 907**] CT on [**2-20**] showed marked
improvement in emboli load.
.
Of note patient developed intermittent and scant vaginal
bleeding for 4 days, which seemed to occur in association w/
Heparin administration. Patient has not had menses for the past
8m and prior w/u for premature menopause/amenorrhea was
negative. Gyn consult advised further w/u as an outpatient.
Patient's Hct gradually dropped w/ the bleeding to a low of 23.9
but improved w/ resolution of the bleeding. Patient was
resistant to repeat blood transfusion. Repeated stool guaiac
tests and U/A were negative. Patient was maintained on Fe
supplements for iron deficiency anemia. Hct was followed closely
and at time of discharge was 29.6 (baseline =30-32).
.
The hypercoaguability was thought to be [**2-26**] to systemic
inflammatory state due to active Crohn's disease, however
patient reports episodes of excessive bleeding s/p surgery and
the birth of her children. She may therefore benefit from
further hematologic w/u for Factor V Leiden or other causes of
thrombophilia. An appointment w/ [**Hospital **] Clinic was arranged for 1m
post-discharge.
.
3. Mediastinal LAD - Repeat chest CT revealed improvement in
mediastinal LAD, largest node was now 12X10mm therefore it was
concluded that the LAD was [**2-26**] to aggressive fluid resuscitation
and improved w/ adequate diuresis.
.
4.Crohn's disease - Due to concerns about immunosuppression and
infection MTX/Remicade was held. Patient was maintained on
Dilaudid/Methadone regimen for chronic abdominal pain w/ good
effect. Patient was initially maintained on a fluid diet and
gradually advanced to regular diet. Her bowel movements remained
unchanged from baseline ([**11-7**] watery BMs/day). Per Dr. [**Last Name (STitle) 79**]
regimen will be switched to Humuran/MTX as outpatient. Due to
concerns about acute infection, SBFT/ileoscopy was deferred to
outpatient to evaluate the progression of her disease.
.
5.Mental Status - On admission patient was brought in by husband
because she had been unresponsive and [**Last Name (STitle) 79059**]. The following
day patient was more awake but her response to questions was
very slow but appropriate. On hospital day 4 patient noted being
very forgetful, she was unable to remember her husband's
cellphone no. Due to concerns about acute ICH, a head CT and MRA
were ordered. Both were negative for acute bleed/stroke.
Patient's symptoms resolved and serial neuro exams were negative
for focal neurological/cognitive deficits.
.
6. Depression/Anxiety - Patient was understandably frustrated
and anxious about the unclear diagnosis of her illness and
etiology for the PE. She was maintained on her outpatient
regimen of clonazepam and amytriptyline.
.
7. COPD - Patient has 20pkyr smoking history, currently smokes
0.5-1 ppd. Patient did not develop a COPD exacerbation during
the hospital stay. Was maintained on Advair.
.
8. Oral HSV - Patient developed erythematous vesicular rash on
lower left lip on hospital day 9. Was treated w/ Acyclovir 400mg
tid. Rash remained stable and patient was discharged on
Acyclovir and Valtrex.
.
Full code
.
Dispo - patient is to follow up with Dr. [**Last Name (STitle) 79**], OB/GYN, PCP.
Medications on Admission:
CURRENT MEDICATIONS:
1. Flovent MDI 44 mcg two puffs b.i.d.
2. Advair MDI one puff b.i.d.
3. Albuterol p.r.n.
4. Pentasa 1000 mg t.i.d.
5. Clonazepam 1 mg q.i.d.
6. Protonix 40 mg b.i.d.
7. Amitriptyline 25 mg q.h.s.
8. Methadone 30 mg q.i.d.
9. Dilaudid 16 mg q.4h. p.r.n. for breakthrough pain.
10. DTO p.r.n. with meals.
11. Weekly methotrexate.
12. Remicade infusions.
13. Folate supplements.
14. Iron supplements.
15. Plavix 75 mg a day.
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO TID (3 times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Gluconate 300 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 Q12H (every 12 hours).
7. Hydromorphone 4 mg Tablet Sig: Four (4) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*10 Tablet(s)* Refills:*0*
11. Methadone 10 mg Tablet Sig: Three (3) Tablet PO QID (4 times
a day).
12. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO ONCE (once) for 1 doses.
13. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
once a day for 1 weeks.
Disp:*7 7* Refills:*0*
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
15. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
16. Valtrex 1 g Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
18. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Pulmonary emboli
2. SIRS
3. Interstitial lung disease
.
Secondary diagnosis:
1. Crohn's disease
2. Raynauds
3. SVC syndrome
4. Migraine HA's.
5. GERD
Discharge Condition:
Stable. Oxygenating well on RA.
Discharge Instructions:
Please call your PCP if you develop fevers, chills, nausea,
vomiting, increased abdominal pain, chest pain, or increased
shortness of breath.
Followup Instructions:
1. Please follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19779**], MD [**First Name (Titles) 2593**] [**Last Name (Titles) 766**], [**3-1**] [**2128**] at 10:30AM. Phone:[**Telephone/Fax (1) 250**]
.
2.Please follow up with [**Doctor Last Name 8155**],NON-FLUORO(A) PAIN
MANAGEMENT CENTER on [**Doctor Last Name 766**] 02, [**2128-2-25**] at 11:20AM.
.
3.Please follow up with [**Name6 (MD) **] [**Name8 (MD) **], MD [**First Name (Titles) **] [**2128-3-23**], at
8:40AM Phone:[**Telephone/Fax (1) 1954**]
.
4. Hematology @ [**Hospital1 18**] [**Telephone/Fax (1) 39833**]. Provider: [**Name10 (NameIs) **]
[**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2128-3-15**] 12:00.
.
5. OB/GYN @ [**Hospital1 18**] ([**Telephone/Fax (1) 22754**] [**2128-3-17**] @ 1 pm, Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] -
[**Hospital Ward Name 23**] [**Location (un) **].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
Completed by:[**2128-3-15**]
|
[
"038.9",
"785.52",
"623.8",
"713.1",
"995.92",
"459.2",
"054.2",
"286.9",
"428.0",
"V45.3",
"555.9",
"496",
"415.19",
"V58.69",
"285.1",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
18679, 18685
|
10121, 16359
|
315, 322
|
18901, 18935
|
3172, 10098
|
19125, 20173
|
2432, 2479
|
16852, 18656
|
18706, 18706
|
16385, 16385
|
18959, 19102
|
2494, 3153
|
267, 277
|
16406, 16829
|
350, 1416
|
18805, 18880
|
18725, 18784
|
1438, 2246
|
2262, 2416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,464
| 107,128
|
29204
|
Discharge summary
|
report
|
Admission Date: [**2120-12-13**] Discharge Date: [**2121-1-4**]
Service: MEDICINE
Allergies:
Benzodiazepines / Heparin Agents
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
respiratory distress, hypotension
Major Surgical or Invasive Procedure:
Endotracheal intubation
Swan-ganz catheter placement
Blood component transfusions
History of Present Illness:
Pt is an 88 yo male h/o CAD, MI, AAA (s/p repair, no leak)
recent AICD for syncopal episode NOS ([**11-11**]), severe
cardiomyopathy EF 10%, who originally presented to OSH with
epigastric pain found to be hypotensive there to 60s systolic.
He was then intubated for hypoxic respiratory failure with ABG
7.26/52/41 (was DNR/DNI). He was transferred to the [**Hospital1 **] CCU. A
CTA was done to rule out AAA and did not show any leak but
aneurysm of 6.5 cm and stable.
.
Pt was treated for his shock which was of unclear etiology. He
was started on Zosyn and Vancomycin on [**2120-12-13**] and vancomycin
was d/cd as sputum from [**2120-12-14**] grew GNR not further speciated.
There was not found to be any other source of infection. In the
CCU, pressors were weaned off [**2120-12-17**]. Pt was started on
steroids on [**2120-12-14**] for inappropriate cortisol stimulation test
though it appears not drawn correctly.
.
Called by floor team today as pt with "[**10-15**]" abdominal pain
that was sharp and radiated to his back x 10 minutes. Their exam
revealed pain out of proportion to it and concern was for
mesenteric ischemia. Lactate on a VBG was noted to be up to 2.4
but repeat with ABG is 1.7. Pt says that he vomited x 1 today,
did not notice the color. +mild sob. +dry cough that started
today. +abdominal pain [**9-15**] when I saw pt.
Past Medical History:
CAD s/p CABG
PAF
AAA (s/p repair)
severe cardiomyopathy-EF 10%
s/p AICD for sick sinus syndrome([**11-11**])
s/p biV pacer
HTN
GERD
hypercholesterolemia
PVD s/p iliac stent placement bilaterally
h/o DVT/PE in past
Social History:
wife in [**Name (NI) **], former smoker
Family History:
non-contributory
Physical Exam:
T: 97 (r); BP: 106/70; HR: 88; RR: 22; O2 98 2L
Gen: Sitting up in bed tachypnic speaking in full sentences
HEENT: EOMI; sclera anicteric; OP clear
Neck: No LAD. JVD not appreciated at 80 degrees
CV: Irregularly irregular, S1S2. I-II/VI systolic murmur at LUSB
and apex
Lungs: Good air flow. Crackles at left base. No change to
percussion
Abd: NABS. Soft, ND. Mild tenderness to deep palpation in
epigastric area. No rebound or guarding
Back: No spinal, paraspinal, CVA tenderness
Ext: No edema. DP 2+
Neuro: CN II-XII tested and intact. "[**12-19**]" "[**2110**]". Knew
he was at a hospital, though not which one.
Pertinent Results:
CTA [**2120-12-13**]-IMPRESSION:
1. No evidence for aortic dissection or pulmonary embolus.
2. 6.5-cm infrarenal abdominal aortic aneurysm with evidence of
graft repair distally. No evidence of aneurysm rupture or leak.
3. Pulmonary vascular congestion, intra-abdominal ascites,
periportal edema, and anasarca suggest congestive heart failure
versus volume overload or both.
4. Cardiomegaly.
5. Bibasilar subsegmental atelectasis with small bilateral
pleural effusions.
.
Echo [**2120-12-13**]-The left atrium is elongated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis, EF 10-15%. No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated.
There is mild global right ventricular free wall hypokinesis.
The ascending aorta is mildly dilated. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-8**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CXR AP (not official read)- enlarged heart s/p sternotomy wires.
There are b/l pleural effusions. ? left retrocardiac opacity.
.
CTA wet read from radiology: SMA is patent. [**Female First Name (un) 899**] cant see [**2-8**]
graft. No post-ischemic changes. Free fluid in abdomen and
anasarca, all unchanged. No change from prior.
Brief Hospital Course:
In Brief, the patient is an 88 year old man with severe ischemic
cardiomyopathy s/p BiV-ICD placement, atrial flutter, CAD,
chronic kidney disease who presented with hypoxic respiratory
failure and shock which was stablized. His course was further
complicated by acute abdomial pain, psoas muscle hematoma, upper
GI bleed, acute on chronic renal failure, heparin induced
thrombocytopenia with upper extremity DVT, intermittent hypoxia,
and urinary retention.
.
1) Shock - Patient intially presented in shock requiring
vasopressors. Cardiac index was normal with decreased SVR which
were not consistent with cardiogenic shock. The likely cause of
was distributive/septic shock of unclear source of infection.
He completed a full course of empiric antibiotics. He completed
7 days of hydrocortisone/fludrocort for sub-optimal response to
ACTH. BP stablized by time of discharge.
.
2) Respiratory Failure: The patient initially presented in
hypoxic respiratory failure likely secondary to CHF,
hypoventilation and decreased mental status. He was intubated
prior to transfer to [**Hospital1 18**]. He was weaned from the ventilator
successfully. He did have intermittent hypoxia largely
secondary to pulmonary edema from inadequate diuresis. He was
stabilized on standing twice daily lasix. He was started on
BiPaP at night for hypoventilation.
.
3) Abdominal pain - During the hospital stay he developed acute
severe epigastric pain. He was transfered to the MICU for
concern for mesenteric ischemia. An abominal CTA was negative
for this. A surgery consult was obtained and recommended no
surgical intervention. The pain resolved without specific
intervention. He was subsequently found to have an psoas muscle
hematoma and required several blood transfusions with
appropriate response in his hematocrit.
4) Cardiovascular:
a. CAD- history of MI s/p CABG. will continue ASA, simvastatin,
beta-blocker.
.
b. Pump- Severe ischemic cardiomyopathy with EF 10-15% s/p
BiV-ICD placement. No evidence of cardiogenic shock upon initial
presenation as C.I. was normal. Medically managed CHF with
ACEi, beta-blocker, digoxin, spironolactone, furosemide.
.
c. rhythm- [**Hospital1 **]-V paced with underlying rhythm is atrial
flutter/fibrillation. Started on amiodarone for maintenance of
sinus rhythm to maximize likelihood of atrial kick. Also,
amiodarone to decrease in-appropriate shocks from ICD.
5) Upper GI bleed - The patient did develop guaiac positive
stools in the setting of anticoagulation for the atrial
fibrillation. The hematocrit drop was largely due to the psoas
hematoma as above. The patient refused EGD. If the patient
develops recurrent melenotic stools he could be referred to GI
for endoscopy. He will continue on a PPI.
.
6)Acute on Chronic Renal failure - Initial creatinine down from
admission to peak 2.5 this was likely from pre-renal secondary
to shock state; no evidence of ATN. By time of discharge, the
creatinine had resolved to baseline.
.
7) Anemia- In addition the the acute blood loss anemia as
described above. The patient has a chronic microcytic anemia.
Iron studies were consistent with anemia of chronic disease
(labs drawn before blood transfusions were given). Also with
regard to the significant microcytosis and his Italian
extraction, hemoglobin electrophoresis was performed to evaluate
for thallasemia. These results were pending at time of
discharge.
.
8) Thrombocytopenia - HIT type II. PF4 positive on [**2120-12-27**],
Platelets stable at around 70K with subsequent recovery to
greater than 150K. He did have a left upper extremity venous
clot although the developement of this was after his platelets
had stabilized. Started argatroban on [**2120-12-27**] with transition
to coumadin. He continued on argatroban until his INR on
combined anti-coagulation was >4. At which time he was
maintained on coumadin alone.
.
9) Urinary retention: - The patient has no prior history of
urinary retention, nocturia, frequency or related BPH symptoms.
During one attempt at removing the foley catheter he had
decreased urine output with a large volume detected on bladder
scan. The foley was replaced. He was started on finasteride,
not wanting to use an alpha-blocker that would likely cause
hypotension when added to his extensive cardiac regimen. The
catheter was left in at discharge. This should be removed in
[**2-9**] days followed by confirmation that the patient can urinate.
.
10) Code Status: DNR/DNI confirmed with patient and HCP.
.
11) Dispo: the patient was discharged to rehab
Medications on Admission:
Hydrocortisone Na 50 mg IV q6
RISS
Ipratropium MDI prn
Tylenol prn
Albuterol prn
Lactulose 30 mg po q8 prn
Pantoprazole 40 mg po q24 hr
Amiodarone 200 mg po qday
ASA 81 mg po qday
Colace 100 mg [**Hospital1 **]
Senna [**Hospital1 **]
Fludrocortisone 0.05 mg po qday
Simvastatin 40 mg po qday
Heparin gtt
Zosyn 2.25 mg IV q6
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed: to maintain at least 1BM per day.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for sbp <95.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for wheezing, dyspnea.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime:
titrate to INR goal [**2-9**].
16. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Compazine 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
18. Outpatient Lab Work
Please draw PT/INR daily for 3 days and thereafter per protocol
for INR goal [**2-9**]
19. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
20. BiPaP
BiPAP with mask at night 10cmH2O PS, 5 cmH2O PEEP. Titrate FIO2
to keep O2sat >95%
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Septic Shock
Hypoxic respiratory failure
Secondary:
Heparin induced thrombocytopenia
Acute blood loss anemia from Psoas muscle hematoma
Urinary retention
Upper extremity venous clot
Ischemic cardiomyopathy
Atrial fibrillation/ Atrial flutter
Congestive heart failure - systolic, compensated
Microcytic Anemia
Discharge Condition:
good. stable vital signs. tolerating oral medications and
nutrition. ambulating with minimal assist.
Discharge Instructions:
You have been evaluated for respiratory distress, and very low
blood blood pressure. These resolved with time, antibiotics,
and close management of your chronic heart disease. Your course
was complicated by a bleed into a hip muscle, a reaction to a
medication called heparin, and difficulty urinating. These were
all stablized over the course of the hospital stay.
Please take the medications as prescribed.
Please make and attend your recommended follow-up appointments.
If you develop any concerning symptom particularly chest pain,
shortness of breath, bloody or tarry stools please seek medical
attention.
Followup Instructions:
Please contact your primary doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58623**] at
[**Telephone/Fax (1) 58624**] to be seen within the next 1-2 weeks.
In the meantime you will be evaluated by the physicians at the
rehab facility.
|
[
"285.1",
"584.9",
"038.9",
"785.52",
"788.20",
"453.8",
"728.89",
"287.4",
"428.23",
"V53.32",
"V58.61",
"414.8",
"427.32",
"E934.2",
"V45.81",
"518.81",
"578.1",
"789.06",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"93.90",
"00.17",
"89.64",
"99.04",
"38.93",
"99.07",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11153, 11225
|
4434, 8988
|
273, 357
|
11588, 11691
|
2718, 4411
|
12356, 12620
|
2048, 2066
|
9363, 11130
|
11246, 11567
|
9014, 9340
|
11715, 12333
|
2082, 2699
|
200, 235
|
385, 1737
|
1759, 1975
|
1991, 2032
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,529
| 104,779
|
7584
|
Discharge summary
|
report
|
Admission Date: [**2135-11-7**] Discharge Date: [**2135-11-11**]
Date of Birth: [**2057-1-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old man
with a history of coronary artery disease, who is referred
for cardiac catheterization due to exertional chest pain and
an abnormal ETT. He is a patient of Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **].
Patient has a history of coronary artery disease with a MI
and CABG at [**Hospital6 1129**] in [**2111**] with
reverse SVG to LAD and circ. He reports that since [**Month (only) **] he
has noticed exertional chest tightness. This occurred after
walking 20 minutes on a flat surface at a fast pace, and
resolved with result. He also notices more fatigue at the
end of the day. The patient also has a history of atrial
flutter, status post successful cardioversion in [**2134-7-5**]
and [**2135-8-5**].
The patient underwent an echocardiogram on [**2135-9-1**], which
showed an ejection fraction of greater than 50%, 1+ AI, 2+
MR, 2+ TR. The patient underwent an ETT on [**2135-10-11**]. He
was able to complete 8.25 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol,
reaching 75 maximum PHR. He had positive diffuse ischemic
EKG changes inferior and anterolaterally, these resolved by
10 minutes into recovery. Imaging revealed a mild reversible
lateral defect. EF was noted to be 59%. The patient denies
claudication, orthopnea, edema, PND, or lightheadedness.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post MI in [**2115**].
2. Peptic ulcer disease.
3. Hypertension.
4. Hyperlipidemia.
5. Bladder cancer status post chemotherapy. In remission
since [**2126**].
6. Herpes zoster.
7. Degenerative joint disease.
PAST SURGICAL HISTORY:
1. Bilateral hernia repair.
2. Rotator cuff repair.
3. CABG.
MEDICATIONS:
1. Atenolol 12.5 mg p.o. q.d.
2. Zocor 40 mg q.h.s.
3. Coumadin 2 mg q.d. alternating with 3 mg q.d.
4. Aspirin 81 mg q.h.s.
ADMISSION LABORATORIES: Unremarkable. Patient's INR was
3.2.
PHYSICAL EXAM: Heart rate 70, blood pressure 104/53.
General: Alert, oriented, and in no apparent distress.
HEENT: Oropharynx clear. Moist mucous membranes. Lungs are
clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm, no murmurs, rubs, or gallops. No jugular
venous distention. Abdomen was soft, nontender, and
nondistended. Lower extremities: No clubbing, cyanosis, or
edema. Neurologic: Grossly intact.
HOSPITAL COURSE: The patient was referred for elective
catheterization on [**2136-11-7**]. This revealed two vessel
native disease. The LAD was diffusely diseased and mildly
calcified. The vessel had a long 80% mid vessel stenosis and
a 70% distal stenosis of the site of prior anastomosis. The
left circ gave off a totally occluded OM-1 branch, with
left-to-left collaterals and antegrade flow through a
stenotic SVG graft. RCA had mild diffuse disease. There was
extensive graft disease. SVG to LAD had a stump occlusion.
The SVG to OM-1 had an 80% complex stenosis in the proximal
part and a 60% stenosis in the mid graft.
On [**2135-11-7**], the patient had two stents placed to his mid
LAD. The plans were made to bring him back to laboratory on
[**2135-11-8**] for graft stenting. The patient thus returned to
the Cardiac Catheterization Laboratory on [**2136-11-8**] and
underwent successful stenting of his 80% SVG lesion.
However, during the post procedure period, the patient was
noted to be hypotensive and had a right atrial pressure of 8.
Fluid resuscitation was unsuccessful and the patient required
dopamine and Neo-Synephrine to bring his pressure up. He was
transferred to the CCU for further care.
The patient was transfused with 2 units of packed red blood
cells. He improved over the following days and was quickly
weaned off of Neo-Synephrine and dopamine. He underwent a CT
scan, which was negative for a retroperitoneal bleed. The
patient appeared euvolemic status post blood transfusions and
IV hydration. He remained in normal sinus rhythm. He was
transferred to the floor with telemetry.
He was seen by Physical Therapy, who felt that he was stable
for discharge home. The patient was thus discharged home.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Last Name (NamePattern1) 9725**]
MEDQUIST36
D: [**2136-4-6**] 18:47
T: [**2136-4-10**] 10:28
JOB#: [**Job Number 27674**]
|
[
"998.12",
"414.01",
"411.1",
"427.32",
"272.0",
"401.9",
"414.02",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"37.22",
"99.20",
"36.01",
"88.53",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
2541, 4547
|
1814, 2079
|
2095, 2523
|
157, 1524
|
1546, 1791
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,600
| 102,808
|
6944
|
Discharge summary
|
report
|
Admission Date: [**2157-7-9**] Discharge Date: [**2157-7-15**]
Date of Birth: [**2099-5-3**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
"I throw up blood"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a Vietnamese-speaking 58 y.o. man with a PMH of a
positive PPD, depression, PTSD, POW during [**Country 3992**] war, hernia
with repair, and chronic back pain. He was admitted to the ICU
[**2157-7-9**] with complaints of dizziness, HA, fatigue, dyspnea, and
a 13 lb wt loss over the last one month. Pt also c/o spitting up
BRB since one day prior to admission with reports of 400cc
hemoptysis in the ED. He also c/o nausea and vomiting. He
denies CP/Palpitations/fevers chills/sick contacts. [**Name (NI) **] has a
history of a positive PPD with 6 months INH treatment. He
endores abdominal pain which he has had since his bilateral
hernia repairs. He also endorses urinary hesitancy but denies
dysuria. Recent colonoscopy showed adenoma, no bleeding.
While in the ICU there were no witnessed episodes of hemoptysis
or bloody emesis. The patient's Hct continued to fluctuate,
dropping from 39 to 27 and then returning to 33. Bronchoscopy
did not show any evidence of acute bleed, and showed normal lung
findings. The patient was guiac negative, and studies for
hemolysis were also negative. CXR and CT were negative for
pathology. NG lavage was negative.
On the day of transfer, the patient reported he was still
spitting up blood. Given his previous psych history of
depression, PTSD, and possible psychosis, he was transferred to
the floor for further psychiatric evaluation.
Past Medical History:
1. Posttraumatic stress disorder.
2. Status post bilateral inguinal hernia repair.
4. h/oPPD pos, tx with INH x 6 mo.
5. chronic LBP
6. migraines
7. h/o R shoulder [**Doctor First Name **].
8. urinary retention
Social History:
Social history: Came from [**Country 3992**] 6 yrs ago and lives with wife.
Smokes 3 [**Name2 (NI) 26105**] per day, denies EtOH and drugs
Family History:
noncontributory
Physical Exam:
Vitals: T 97.2 HR 76 RR 20 BP 130/70 95%RA
Gen: Vietnamese speaking, unable to communicate, NAD
HEENT: PERRL, anicteric, OP clear w/o blood, nares w/o blood,
MMM, neck supple w/o LAD
CV: RRR, no m/r/g, nl s1s2
Resp: CTAB
Abd: +BS, soft, tender BLQ to palpation, no peritoneal signs,
no masses
Ext: no edema, nontender, 2+ DP pulses B
Pertinent Results:
[**2157-7-9**] 11:56AM HGB-12.6* calcHCT-38
[**2157-7-9**] 11:30AM GLUCOSE-95 UREA N-12 CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12
[**2157-7-9**] 11:30AM WBC-4.0 RBC-4.09* HGB-12.7* HCT-39.1* MCV-95
MCH-31.0 MCHC-32.5 RDW-12.8
[**2157-7-9**] 11:30AM PT-12.6 PTT-29.8 INR(PT)-1.0
[**2157-7-9**] 11:30AM PLT COUNT-206
[**2157-7-9**] 11:30AM cTropnT-<0.01
[**2157-7-9**] 11:30AM LIPASE-20
[**2157-7-9**] 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2157-7-13**] WBC 6.0 Hgb 12.1 Hct 33.1 repeat Hct 32.0 pltl
173
[**2157-7-13**] Na 141 K 3.3 Cl 105 HCO3 31 BUN 9 Cr 0.7
Glu 86
Ca 7.6 Mg 1.9 Phos 2.5
[**2157-7-12**] Hapto 113
Brief Hospital Course:
58 y.o. Vietmanese man with h/o +PPD, with 2-3 wks increasing
fatigue, wt loss, and spitting up blood x 1 day. The patient
presented to the ED hemodynamically stable. In ED, coughed up
400 cc of BRB. CXR clear, NG lavage neg. SBP decreased into the
80's (baseline 100-110), HR up to 70's (baseline 40-50's). HCT
decreased from 39 to 35.8, then to 36.9 after 8 L NS. Torso CT
neg. SBP further dropped into the 70's after IVF, but patient
was mentating well, with good urine output. RIJ central line
placed. Rec'd 4 mg IV dex given hypotension and 7.6% eos on
peripheral smear. No blood products rec'din ED. CT, CXR
negative.
Mr. [**Known lastname **] was transferred to the ICU in a negative pressure room,
given his h/o +PPD and new hemoptysis with constitutional
findings, to r/o TB (although neg CXR/CT, afebrile). Other
possible etiologies included upper GI bleed (although NG lavage
neg, Guaiac neg) or nasopharyngeal dx (no h/o trauma, no active
nasal or OP bleeding). Other respiratory etiologies were also
considered including resp AVM or resp-renal d/o (nml cr).
IV Fluids with NS were continued and the patient maintained good
BP's, without the need for pressor support. HCT decreased from
30.3-->28.9-->27.7. No active bleeding per mouth or nose
appreciated. No hemoptysis or hematemesis. He was transfused
with 1U PRBC's and HCT increased to 30. It remained stable at 30
overnight. Bronchoscopy was performed in the ICU, and
demonstrated normal airways with no bleeding. AFB per BAL was
negative, and sputum AFB also negative.
The patient was discussed with both GI and [**Known lastname **], who felt given
his clinical stability and stable HCT, endoscopy/fiberoptic
scope were not indicated at this time. Mr. [**Known lastname **] was set for
discharge home from the ICU given his improvement over the last
two days, however on [**7-13**] he again complained of spitting up BRB
overnight. However, no bleeding was seen overnight either by the
nursing staff or by the housestaff. There was no blood seen per
mouth/nose or blood on the pillows/sheets. In addition, the
patient reported spitting up over a liter of blood, which would
not have gone un-noticed with continual care in the ICU setting.
Therefore, we did not feel comfortable sending him home with the
thought that he might be confused or delusional. He does have a
psych history w/ PTSD for which he recieves medications. In
addition he appeared to have a flat affect and per his family
seemed anxious/depressed about his current situation. Psychiatry
evaluated the patient and found him stable for discharge. He was
also encouraged to follow-up with his home PCP and Psychiatrist.
Physical therapy also evaluated the patient and recommend
continued PT care. Hct remained stable 33-34 while on the floor,
and he was discharge to home
Medications on Admission:
meds:
BUTALBITAL/APAP/CAFFEINE [**Medical Record Number 3668**]--Twice a day
COMBIVENT 103-18MCG--2 pffs [**Hospital1 **]-qid
DEPAKOTE 250MG--Three times a day
FLUOXETINE HCL 20MG--Twice a day
LORATADINE 10MG--One by mouth every day
NAPROSYN 500MG--Twice a day as needed
PROTONIX 40MG--By mouth every day as needed
TRILEPTAL 600MG--Three times a day
Venlafaxine
tramadol 600MG--Three times a day
Discharge Medications:
1. Venlafaxine HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**12-31**]
Tablets PO BID (2 times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
1. Hemoptysis
2. Delirium
Secondary Diagnoses:
1. PTSD
2. +PPD
3. Chronic bilateral abdominal pain
Discharge Condition:
good
Discharge Instructions:
1. Please follow up with primary care physician [**Last Name (NamePattern4) **] [**12-31**] weeks
Please recheck calcium, phosphorus at the office and screen for
hyperparathyroidism
2. Please take medications as directed
3. Please have your PCP check your Valproic acid level
4. Please have your PCP recheck your blood counts (Hematocrit)
5. Call your PCP or return to the ED if you have fevers, chills,
blood coming from your nose, mouth, vomit, or stool.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2157-8-9**] 9:30
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] INTERNAL MEDICINE Where: OFF CAMPUS
[**Hospital1 7975**] INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2157-9-13**]
9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7976**]. [**Last Name (LF) 766**], [**8-8**]. 2:25.
Provider: [**Name Initial (NameIs) **] (Ears, Nose, Throat Surgery). Please call ([**Telephone/Fax (1) 26106**]
to schedule an appointment
|
[
"789.00",
"458.9",
"786.3",
"296.20",
"795.5",
"780.09",
"285.9",
"309.81",
"275.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.04",
"38.93",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
7312, 7387
|
3374, 6187
|
327, 333
|
7550, 7556
|
2582, 3351
|
8062, 8791
|
2187, 2204
|
6634, 7289
|
7408, 7454
|
6213, 6611
|
7580, 8039
|
2219, 2563
|
7475, 7529
|
269, 289
|
361, 1779
|
1801, 2014
|
2046, 2171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,901
| 116,700
|
9583
|
Discharge summary
|
report
|
Admission Date: [**2145-7-22**] Discharge Date: [**2145-7-29**]
Date of Birth: [**2077-8-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Avandia
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
6lb weight gain
Major Surgical or Invasive Procedure:
Swan Ganz Catherization
History of Present Illness:
67yo Arabic-apeaking man with h/o severe biventricular failure,
dilated ischemic CM, EF<=20%, s/p BiV ICD, severe pulm HTN, who
was transferred to CCU today from OSH for CHF management. Pt was
recently discharged from [**Hospital Unit Name 196**] ([**Date range (1) 32502**]), where he was
treated for decompensated, [**Last Name (un) 11840**]. R sided, heart failure. He
was discharged to home on [**7-17**] and has been doing well until a
couple of days ago, when he noticed 6lb weight gain, mild
dyspnea and profound weakness. Yesterday, he was having
difficulty urinating, called clinic, was instructed to increase
his aldactone to 25mg po qd. However, he was unable to urinate
the entire day, and finally presented to [**Hospital 7188**] Hospital, RI at
4am this morning. Pt denies palpitations, CP, N/V, abd pain,
fever, chills, dysuria, orthopnea, PND, LE swelling. He c/o some
lightheadedness. No reports of ICD firing. Compliant with all
medications and dietary modifications. At the OSH, got CTA
chest/abd that showed no dissection/AAA, mod. ascites
abd/pelvis, increased density within omental and mesenteric fat.
He was afebrile, HR 70, initial BP 70/45, 96% 2L NC; got 300cc
NS bolus, then NS @ 100cc/hr. At [**Hospital1 18**], c/o "wheezing" in chest,
mild dyspnea, profound fatigue.
Past Medical History:
1. CAD, s/p MI [**2119**]; exercise mibi ([**2145-7-7**])- reversible
ant/apical perf. defect, fixed inf/lat defects
2. CHF: dilated ischemic cardiomyopathy w/VT (h/o ablation
[**2137**]), s/p [**Hospital1 **]-V ICD placement ([**2137**]); TTE- EF<=20%, severe
global hypokinesis, 3+MR, 2+TR, severe pulm HTN
3. s/p BiV pacemaker
4. HTN
5. Type II diabetes mellitus
6. Gout
7. Ascites [**2-24**] R heart failure
8. Hypothyroidism s/p thyroidectomy
9. Chronic renal insufficiency, baseline Cr 2.0
10. Anemia of chronic disease
11. Guaiac+ stools, negative EGD and colonoscopy
11. h/o +PPD, treated with INH/PZA/RIF in [**Country 1684**]
Social History:
originally from [**Country 1684**], moved to US in [**2125**], prior distant
tobacco hx, denies EtOH use
Family History:
F- MI @59yo, B- MI in 40s
Physical Exam:
Vit: 78 92/55 18 100% 2L NC
Gen: appears fatigued
HEENT: WNL
Neck: JVD to ear
CV: PMI displaced, RRR, nl s1 and s2, [**3-28**] TR and 2-3/6 MR
Pulm: CTAB, no w/c/r
Abd: distended, + ascites, + fluid wave, + palpable liver edge
Ext: trace - 1+ edema, 1+ DP and PT pulses
Pertinent Results:
Admission Labs:
[**2145-7-22**] 02:38PM BLOOD WBC-12.8* RBC-3.42* Hgb-9.7* Hct-29.3*
MCV-86 MCH-28.3 MCHC-33.1 RDW-17.5* Plt Ct-182
[**2145-7-22**] 02:38PM BLOOD Glucose-40* UreaN-84* Creat-2.5* Na-127*
K-3.9 Cl-90* HCO3-25 AnGap-16
[**2145-7-22**] 02:38PM BLOOD ALT-21 AST-24 LD(LDH)-140 CK(CPK)-51
AlkPhos-91 TotBili-0.6
.
[**2145-7-25**] 04:20PM BLOOD Digoxin-1.0
[**2145-7-29**] 07:30AM BLOOD Glucose-144* UreaN-72* Creat-1.8* Na-127*
K-4.7 Cl-91* HCO3-25 AnGap-16
.
Urine Cytology - NEGATIVE FOR MALIGNANT CELLS.
.
[**2145-7-22**] - CXR:
The heart is enlarged. There are no focal infiltrates. The
defibrillator with RA, RV, and coronary sinus leads is again
noted. There is pulmonary vascular engorgement. The post-CABG
changes are evident.
IMPRESSION: Congestive failure.
.
[**2145-7-22**] - LIMITED ABDOMEN ULTRASOUND:
The liver is normal in echotexture and without intrahepatic
biliary ductal dilatation. A large pocket of ascites fluid is
identified within the right lower quadrant and a smaller amount
is identified within the left upper quadrant. There is a left
pleural effusion.
IMPRESSION: Intraabdominal ascites.
.
EKG:
A-V sequential pacing. Compared to the previous tracing of
[**2145-7-7**] no
significant diagnostic change.
Brief Hospital Course:
# CHF - Patient was admitted with CHF exacerbation felt to be
secondary to confusion regarding medication regimen. A PA
catheter was placed and showed CVP=22, RA=25, RV=70/26,
PA=70/32, PCWP=32. He was diuresed with improvement in
pulmonary edema and was started on lasix, hydralazine,
isosorbide dinitrate, and digoxin. His lisinopril and aldactone
were discontinued due to increasing potassium and history of
hyperkalemia.
.
# CAD - He was continued on ASA, atorvastatin, digoxin and
started on hydralazine and isosorbide dinitrate for afterload
reduction in place of his lisinopril. He was hemodynamically
stable on this regimen.
.
# h/o VT, h/o AFib, [**Hospital1 **]-V ICD in place - Patient was continued on
amiodarone and did not have any episodes of VT or Afib during
this admission.
.
# Hematuria - Patient was noted to have gross blood on admission
with report of traumatic foley insertion at the OSH and a hx of
non-cancerous bladder lesions treated in [**Country 1684**] 3 years ago.
U/A and culture ruled out UTI. Continuous bladder irrigation
was performed until urine cleared. He was seen by urology who
recommended urine cytology which was negative for malignant
cells, and follow up as outpatient for further workup including
cystoscopy and CT urogram (cr 1.9), MR-urogram or U/S.
.
# DM - Patient was hypoglycemic to 49 on admission. Oral
hypoglycemics were held. He was seen by [**Last Name (un) **] and started on
lantus with an insulin sliding scale. He will have VNA services
for further diabetes teaching and will call [**Hospital **] clinic at
[**Telephone/Fax (1) 2384**] for diabetes follow up appt as oupatient.
.
# ARF/CRF - Patient was admitted in prerenal ARF with inital Cr
of 2.3, with diuresis and afterload reduction his Cr had
improved to 1.8 (baseline) at discharge.
.
# Anemia of chronic disease - Patient had a slight decrease in
hct and given his cardiac risk factors, the patient received one
unit of blood during this admission without complications. He
was continued on Procrit and iron supplements.
Medications on Admission:
Digoxin 62.5mcg qd
ASA 325mg qd
Atorvastatin 10mg qd
Hydralazine 10mg q6h
Furosemide 120mg [**Hospital1 **]
Amiodarone 100mg qd
Lisinopril 2.5mg qd
Spironolactone 25mg qd
Glyburide 10mg qam, 5mg qpm
Avandia 4mg qd
Lantus (per home regimen)
Procrit 4,000U MWF
Levothyroxine 250mg qd
Allopurinol 100mg qd
Pantoprazole EC 40mg q12h
Flomax SR 0.4mg qd
MVI qd
Folic acid 1mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Epoetin Alfa 4,000 unit/mL Solution Sig: [**Numeric Identifier 890**] ([**Numeric Identifier 890**]) units
Injection once a week.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Levothyroxine Sodium 125 mcg Tablet Sig: Two (2) Tablet PO
once a day.
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*30 Capsule(s)* Refills:*2*
12. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
16. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
Disp:*1 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 7188**] [**Doctor Last Name **]
Discharge Diagnosis:
Congestion Heart Failure exacerbation
Hyperglycemia
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 L
Please note the changes in your medications.
Followup Instructions:
Please follow up with your PCP within one week.[**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3330**], M.D. Where: OFF CAMPUS Phone:[**Telephone/Fax (1) 3331**]
Date/Time:[**2145-8-2**] 11:30
Please follow up with [**Doctor Last Name **] on [**8-18**], call the office
for specific time at ([**Telephone/Fax (1) 9530**].
Please follow up with Urology ([**Telephone/Fax (1) 32503**] for an appt and
scheduling of studies.
Please call [**Hospital **] clinic at [**Telephone/Fax (1) 2384**] for diabetes follow up
appt as soon as possible.
Completed by:[**2146-2-13**]
|
[
"428.0",
"414.01",
"789.5",
"414.8",
"V45.02",
"599.7",
"276.1",
"416.8",
"584.9",
"285.9",
"250.80",
"867.0",
"585",
"E879.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
8085, 8171
|
4053, 6104
|
298, 324
|
8267, 8274
|
2785, 2785
|
8491, 9078
|
2449, 2476
|
6527, 8062
|
8192, 8246
|
6130, 6504
|
8298, 8468
|
2491, 2766
|
243, 260
|
352, 1651
|
2801, 4030
|
1673, 2311
|
2327, 2433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,080
| 191,183
|
10843
|
Discharge summary
|
report
|
Admission Date: [**2181-4-4**] Discharge Date: [**2181-4-5**]
Service: ICU MED
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
female who is a resident of [**Hospital3 **], who
presented to the Emergency Department with increasing
shortness of breath. At [**Hospital3 **], O2
saturations were recorded to be at 62% with a temperature
maximum of 99.7 F., rectally. The patient had been having
increasing shortness of breath with desaturations throughout
the day at [**Hospital3 **] on the day prior to
admission and was treated there with Lasix and nebulizer
treatments. In the Emergency Room, the patient was treated
with Levofloxacin, Vancomycin and Flagyl for a pneumonia on
chest x-ray. O2 saturations were stable in the low 90s on
100% non-rebreather.
REVIEW OF SYSTEMS: Negative for fever or chills, negative
for cough, negative for headache, negative for visual changes
or diarrhea. Per family, the patient is slightly confused
which is not unusual in the setting of acute infection.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Degenerative joint disease.
3. Questionable dementia.
4. Third degree AV block status post pacemaker placement.
5. Constipation.
MEDICATIONS: On admission.
1. Atenolol 100 mg p.o. q. day.
2. Diltiazem 360 mg p.o. q. day.
3. Lisinopril 20 mg p.o. q. day.
4. Imdur 90 mg p.o. q. day.
5. Calcium.
SOCIAL HISTORY: The patient is a resident of [**Hospital3 1761**]. She has a history of 50 pack years tobacco.
The patient is "DO NOT RESUSCITATE", "DO NOT INTUBATE".
PHYSICAL EXAMINATION: On physical examination, temperature
98.4 F.; blood pressure 135/52; heart rate 54; respiratory
rate 20; O2 saturation 100% on non-rebreather. In general,
the patient is sitting up comfortably and talking profusely.
The patient is Russian speaking only. Oropharynx clear.
Right eye closed. Neck was supple. No jugular venous
distention, no lymphadenopathy. Lungs: Fair air movement,
crackles bilaterally. Egophony at right base.
Cardiovascular: Regular, no audible murmur. Abdomen soft,
nontender, nondistended. Positive bowel sounds. Extremities
warm and well perfused, no edema. Good pulses bilaterally.
Neurologic: Right eye closed. Left eye with reactive
pupils. Five out of five strength throughout all
extremities.
LABORATORY DATA: Significant for a creatinine of 2.0 from a
baseline of 1.5. White blood cell count of 9.5, 81%
neutrophils, hematocrit of 33, PT and PTT, INR within normal
limits.
Urinalysis was negative.
Chest x-ray with left lower lobe infiltrate and right middle
lobe infiltrate.
EKG paced at 60.
HOSPITAL COURSE:
1. The patient is a [**Age over 90 **] year old female with shortness of
breath and hypoxia with infiltrates on chest x-ray, who
presents with likely pneumonia. The patient was continued on
Levofloxacin and Flagyl for a full seven day course. Blood
cultures were sent which were negative. The patient was also
gently diuresed.
The patient seemed to rapidly improve from her admission and
was thought that it might have been secondary to diuresis. A
chest CT scan was proposed but was not done at this time,
considering that the patient did not want any invasive
procedures if anything were to be found on chest CT scan.
The patient's hypoxia improved and she was saturating 93 to
97% on five liters nasal cannula.
2. In terms of the patient's hypertension, the patient was
continued on her beta blocker, ACE inhibitor, aspirin, Imdur
and her blood pressure remained stable.
The patient's renal functioning showed worsening creatinine
to 2.0 baseline, however, the day after admission, it
improved to 1.8 despite diuresis. FEna was 6.8. P.o.'s were
encouraged and the patient's creatinine was continued to be
monitored. No interventions were taken.
3. Possible dementia/psychosis: The patient appeared
confused on admission, however, improved with Haldol p.r.n.
The patient's mental status also improved with treatment of
her infection.
4. Fluids, Electrolytes and Nutrition: The patient was
maintained on a regular diet and had Protonix prophylaxis
while in the Intensive Care Unit.
DISCHARGE DIAGNOSES:
1. Multifocal pneumonia of unclear etiology.
2. Possible congestive heart failure component.
3. Hypoxia.
4. Mental status changes.
DISCHARGE MEDICATIONS:
1. Atenolol 100 mg p.o. q. day.
2. Diltiazem 250 mg p.o. q. day.
3. Lisinopril 20 mg p.o. q. day.
4. Imdur 90 mg p.o. q. day.
5. Calcium.
6. Lasix 20 mg p.o. q. day; this dose will be changed at
[**Hospital3 **] as needed.
7. Levofloxacin 250 mg p.o. q. day.
8. Flagyl 500 mg q. eight hours p.o.
CONDITION AT DISCHARGE: The patient was discharged back to
[**Hospital3 **] on hospital day number two.
DISCHARGE INSTRUCTIONS:
1. The patient's O2 saturations will continue to be
monitored.
2. The patient will complete her course of Levofloxacin and
Flagyl.
3. The patient will follow-up with her physician at [**Hospital3 1761**] as needed.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2181-5-20**] 15:31
T: [**2181-5-22**] 08:48
JOB#: [**Job Number 22179**]
|
[
"V45.01",
"429.3",
"428.0",
"593.9",
"486",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4202, 4338
|
4361, 4676
|
2678, 4181
|
4797, 5302
|
1617, 2661
|
4692, 4773
|
858, 1075
|
107, 129
|
158, 837
|
1097, 1424
|
1441, 1594
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,443
| 102,296
|
34421
|
Discharge summary
|
report
|
Admission Date: [**2172-9-28**] Discharge Date: [**2172-9-30**]
Service: MEDICINE
Allergies:
Quinolones
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
acute blood loss
Major Surgical or Invasive Procedure:
RBC transfusion
History of Present Illness:
Ms. [**Known lastname **] is an 86yo woman with h/o recent stroke who was
transferred from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] after being found to have a low
hematocrit. There was no reported bleeding and she was without
complaint. Per review of notes in the chart, there was no
preceeding diarrhea or vomiting. She does not have any
endoscopies or colonoscopies in the [**Hospital1 **] record. Pt denies abd
pain but hx limited by her aphasia/non-verbal status. Per PCP
and family, [**Name9 (PRE) 79134**] invasive treatment/work-up is preferred as
long as there is no significant GI bleed.
.
She was taken to [**Hospital1 18**] ED where her VS were stable, Hct 17.4,
and she was noted to have guaiac +, formed, brown stool. Coags
wnl at 1.2. Also had sodium 151, which has since resolved w/
D5W IF. Pt was given 2uRBCs, including that given in MICU. She
spent 1 day in MICU where her Hct bumped back to 17.4->27.7 o/n.
She was seen by GI who recommended conservative rx w/ PPI and
prn transfusions.
Past Medical History:
Alzheimer's Dementia
h/o L MCA stroke [**9-/2172**] with persistent hemiparesis and aphasia
HTN
B12 deficiency
Anemia with baseline Hct 25-27
h/o UTIs
Cataracts
Glaucoma
Social History:
Lives in [**Hospital3 **] facility ([**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **])
Does not smoke/ ETOH/ take illicit drugs.
Family History:
not available at present
Physical Exam:
VS: 98.1 102 134/95 19 100% RA
Awake, responsive and orients well to examiner. Unable to
produce coherent speech. +Cachectic.
EOMI. Right pupil is round and reactive but left is difficult to
appreciate if it is reacting. Will not open mouth or follow
commands but has a symmetric face.
Neck is supple
Heart is tachycardic and regular with a systolic murmur heard
best at apex, though not holosystolic.
No increased work of breathing, no accessory muscle use. Lungs
clear though does not breathe deeply.
Abd is soft and not tender.
LE are non-edematous b/l.
She is able to squeeze her left hand and slow the rate of fall
of her left leg. Right arm is kept in flexion and is resistant
to movement. 0/5 strength on right side.
Pertinent Results:
CBC: WBC-6.5# RBC-1.92*# Hgb-5.3*# Hct-17.4*# MCV-90# Plt Ct-271
Coags: PT-13.4 PTT-27.0 INR(PT)-1.2*
Chemistries:
153 117 42
-------------< 161
4.2 27 1.1
Hemolysis labs: calTIBC-334 Hapto-287* Ferritn-27 TRF-257
EKG: Sinus tachycardia. Borderline leftward axis. Possible prior
inferior
myocardial infarction. Compared to the previous tracing of
[**2172-9-8**] the findings are similar.
CXR: IMPRESSION: No evidence of pulmonary edema.
Brief Hospital Course:
This is an 86yo woman with dementia and h/o recent left MCA
stroke complicated by persistent aphasia and hemiparesis
admitted with acute hematocrit drop and guaiac positive stool.
.
# Anemia: Pt has chronic anemia w/ baseline Hct 25-27.
Hemolysis work-up was negative. Acute drop in Hct was thought
to be from GI source. Pt's Hct bumped appropriately with 2u RBC
transfusions, and she was monitored for 1 day in MICU, where she
remained hemodynamically stable. GI was consulted, and given
her family's desire for minimal intervention, she was managed
conservatively with PPI, Hct checks, and PRN transfusions. She
was also taken off ASA ppx for stroke, in setting of GIB.
Although labs do not show iron deficiency, she was supplemented
as she may continue to have GIB. Her Hct remained stable at ~25
on day of discharge. She should have her hematocrit checked on
the day after discharge. Her hematocrit should be regularly
monitored afterwards according to her attending doctor's
discretion, but we would advise that another Hematocrit be
checked this [**Last Name (LF) 2974**], [**10-2**], and that she be transfused
as needed to keep her Hct at baseline ~ 25
.
# Hypernatremia: Pt arrived with sodium of 153, which was
thought to be due to free water deficit from poor access to
water. She was gently hydrated with D5W and her hypernatremia
resolved and has remained within normal range.
.
# Elevated troponin: Patient unable to verbalize chest pain.
EKG does not show changes from prior tracing 3 weeks ago. Her
troponin remained stable at 0.03 after 3 sets of enzymes. She
was continued on home simvastatin.
.
# s/p Left MCA stroke: Continues to have significant aphasia and
right sided weakness. Keppra was continued. ASA was held in
setting of active bleed.
.
# HTN: Remained HD stable throughout hospitalization with good
BP control. Norvasc was held b/c of GI bleed, but discharge
instructions were to re-start her anti-hypertensive medications
at her long term care facility if she remained hemodynamically
stsable.
.
# h/o cataracts and glaucoma: Pt was continued on levobunolol.
She was given xalatan eye drops instead of travatan due to
formulary issues.
.
# Heel ulcer: Stage 1 pressure ulcer was identified this
admission. The pt's legs were kept in waffle boots to minimize
pressure to this area.
.
# Code: DNR/DNI
Medications on Admission:
ASA 325mg daily
Keppra 500mg [**Hospital1 **]
Simvastatin 20mg QHS
Norvasc 2.5mg QHS
Risperdal 0.25mg QHS--recently stopped [**Name8 (MD) **] MD
Lasix 20mg PO daily
Calcium + Vit D 500mg/200IU [**Hospital1 **]
Colace
Senna
Dulcolax
Travatan eye gtt OU QHS
Levobunolol 0.5% eye gtt OU QHS
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed.
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
This was held during the hospitalization, but should be
re-started if the patient's SBP remains stable >100.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: This
was held during the hospitalization, but should be re-started
and added back to her regimen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
-Acute-on-chronic anemia with guaiac + stools and no further GI
work-up secondary to family's desire for minimal intervention
-Hypernatremia secondary to inability to take adequate water,
resolved with IV fluids
Secondary:
-s/p left MCA stroke with persistent hemiparesis and aphasia
-Left heel ulcer
-Alzheimer's dementia
-Hypertension
-History of glaucoma & cataracts
Discharge Condition:
Improved hematocrit, hemodynamically stable
Discharge Instructions:
You were admitted for an acute drop in your blood count. Your
blood count stabilized after 2 units of blood transfusion. It
was thought that you are bleeding from your GI tract. Because
your family desires minimal interventions, we plan to
conservatively treat your bleeding by monitoring your blood
count and giving transfusions on an as needed basis.
Please continue to have your blood count monitored at your
living facility.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2172-10-5**] 1:30pm
Completed by:[**2172-10-1**]
|
[
"294.10",
"331.0",
"401.9",
"365.9",
"438.11",
"707.07",
"276.0",
"366.9",
"438.20",
"266.2",
"578.9",
"V58.66",
"285.1",
"E935.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6631, 6704
|
2953, 5301
|
234, 251
|
7126, 7172
|
2483, 2930
|
7652, 7868
|
1698, 1724
|
5639, 6608
|
6725, 7105
|
5327, 5616
|
7196, 7629
|
1739, 2464
|
178, 196
|
279, 1321
|
1343, 1515
|
1531, 1682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,272
| 137,014
|
23788
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 60728**]
Admission Date: [**2118-4-18**]
Discharge Date: [**2118-4-25**]
Date of Birth: [**2066-7-21**]
Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 51-year-old female had an
aortic valvuloplasty performed via a sternotomy in [**2093**] at
[**Hospital3 1810**] with a known diagnostic of bicuspid
aortic valve and complaints of increasing fatigue and
decreasing exercise tolerance over the past year. She had
been followed by cardiologists, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**] and Dr. [**Last Name (STitle) 60729**]
[**Name (STitle) 60730**] at [**Hospital3 1810**]. Recently, echocardiogram and
cath were performed which revealed severe aortic stenosis.
Preoperatively, a cardiac cath was performed at [**Hospital **]
Hospital. It showed normal coronaries and aortic valve area
of 0.6 cm to 0.8 cm2, and a gradient of 60 mmHg. Cardiac echo
performed on [**2118-3-24**] showed a bicuspid aortic valve
with a gradient of 103 mmHg, normal LV function, normal
sinus, normal aortic root, and no aortic regurgitation. Her
ascending aorta was 3.9 cm.
PAST MEDICAL HISTORY:
1. Aortic valvuloplasty in [**2093**].
2. Prior surgical history also includes inguinal
herniorrhaphy on the right in [**2109**].
3. Tonsillectomy and adenoidectomy as a child.
4. Laparotomy in [**2104**].
MEDICATIONS PRIOR TO ADMISSION:
1. Calcium and Vitamin D daily.
2. Multivitamin 1 daily.
3. Antibiotics p.r.n. for dental procedures.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She lives with her husband and works as a
housewife. She had a dental exam in [**2118-1-25**]. She has no
tobacco history. Consumed 1 glass of wine periodically. She
had no history of other recreational drugs.
PREOP LAB WORK: White count 7.5, hematocrit 41.8, platelet
count 330,000, PT 12.1, PTT 27.7, INR 1.0. Urinalysis
negative. Sodium 142, K 3.8, chloride 101, bicarb 31, BUN 14,
creatinine 0.8, blood sugar 79, HPA1C of 5.2%. ALT 17, AST
20, alkaline phosphatase 73, total bilirubin 0.5, total
protein 7.1, albumin 4.8, globulin 2.3. Preop chest x-ray
showed prior median sternotomy with a tortuous aorta. Lungs
were clear. Prior EKG preoperatively showed sinus rhythm at
60 with a poor R wave progression.
EXAM: She was in sinus rate at a rate of 80, respiratory
rate 16, blood pressure 118/78 on the left, height 5 feet 1
inch tall, weight 118 pounds. She appeared her stated age and
was in no apparent distress. She had no obvious skin lesions
and was unremarkable. Her EOMs were intact. Her pupils were
round and reactive to light and accommodation. Her neck was
supple. She had full range of motion with no lymphadenopathy
or thyromegaly noted. Her lungs were clear bilaterally
without any rales or rhonchi. She had a well-healed sternal
incision from her aortic valvuloplasty. Heart was regular
rate and rhythm with a grade IV/VI systolic ejection murmur
that radiated throughout her chest. Her abdomen was soft,
nontender, nondistended with positive bowel sounds.
Extremities were warm and well-perfused with no peripheral
edema. She had no obvious large varicosities. She was grossly
intact neurologically with cranial nerves II through XII
grossly intact with a nonfocal exam, was alert and oriented
x3. She had bilateral 2+ femoral, DP and PT pulses. She had
no carotid bruit noted.
Sh[**Last Name (STitle) **]admitted on [**2118-4-18**] and underwent redo
sternotomy and aortic valve replacement with a 21 mm CE Magna
ThermaFix pericardial valve and a 22 mm Gelweave thoracic
outlet ascending aorta graft by Dr. [**Last Name (Prefixes) **] and [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]-[**Doctor Last Name 634**] of [**Hospital3 1810**]. She was transferred to
the cardiothoracic ICU in a stable condition in sinus rhythm
on an epinephrine drip at 0.02 mcg/kg/min, a Levophed drip of
0.03 mcg/kg/min, and a propofol drip of 50 mcg/kg/min. Of
note, the patient did have 2 separate cardiopulmonary bypass
runs. Please refer to the operative dictated report.
On postoperative day 1, the patient was weaning slowly, was
agitated on CPAP, with a cardiac index of 3.34, a stable
blood pressure of 93/62, and T-max of 100.6. She was in sinus
rhythm at 86 with a postoperative white count of 8.4,
hematocrit 27.9, and creatinine of 0.7. She was in no
apparent distress and was alert. Her heart was regular rate
and rhythm, and her chest was stable. Her lungs were clear
bilaterally. She had 2+ peripheral edema in her extremities.
She was on a nitroglycerin drip at 1.0 and an epinephrine
drip at 0.02, as well as an insulin drip at 3 units/h, and
was started on her low-dose aspirin. She also began Lasix
diuresis.
She was seen postoperatively also by Dr. [**Name (NI) **], her
surgeon from [**Hospital1 **], as well as the cardiology fellow
from [**Hospital3 1810**]. She was also seen and evaluated by
case management.
On postoperative day 2, she was off her epinephrine drip and
began gentle beta blockade with Lopressor 12.5 p.o. b.i.d.
She was in sinus rhythm with a pressure of 92/46. She also
had decreased breath sounds at her bases. Chest tubes
remained in place, and the patient had been extubated the day
prior.
On postoperative day 2, the patient was also transferred out
to the floor and was encouraged to increase her pulmonary
toilet with incentive spirometry, was started on a low dosed
statin, and was given Toradol IV q. 6 for several doses and
then switched over to Ultram. Mediastinal chest tubes and
pacing wires were removed. Lasix was switched over to p.o.
dosing 20 mg b.i.d. The patient was encouraged to increase
her activity level. She remained in sinus rhythm with a
stable creatinine of 0.6, and a stable hematocrit at 26.2.
Her sternal incision was clean, dry and intact and was
stable. The patient had some flatus that morning, but no
bowel movement at the time, and was again encouraged to
increase her activity level and fluid intake.
Of note, on postoperative day 3, the patient had a blood
pressure of 90-100/50 with a little bit of elevated JVP. She
was also seen and evaluated by her [**Hospital1 **] cardiology
attending, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her Lopressor was held for her
blood pressure at that time. The patient remained pleasant
and cooperative and well-oriented. She received 1 unit of
packed cells on the 26th with a blood pressure of 83/42 prior
to transfusion. She continued to work with nurses and
physical therapist. Her mediastinal chest tube and her pacing
wires had been removed that morning also. Her beta blockade
was discontinued. Pleural tubes remained in place. Her Foley
was on gravity drainage with a plan to discontinue the Foley
later in the afternoon.
On postoperative day 5, the patient had no events overnight,
remained off her beta blockade. A chest x-ray was ordered.
She was encouraged to continue ambulating, and discharge
planning was begun. She had a moderate amount of drainage
from her left pleural chest tube site. Her central venous
line had already been removed, and pacing wires had already
also been removed. She was alert and oriented and nonfocal.
Her heart was regular rate and rhythm, and sternal incision
was clean, dry and intact. She remained afebrile.
On[**Last Name (STitle) 14810**]perative day 6, the patient continue on diuresis with
Lasix 20 mg b.i.d. Hematocrit remained stable at 29.2, and
her exam was otherwise unremarkable. Her peripheral edema
remained only trace at that time, and she continued to make
excellent progress. Her left pleural tube was also removed on
postoperative day 6, and she was discharged to home in stable
condition with VNA services on [**2118-4-25**] with the
following recommendations for follow-up: She was instructed
to follow-up with Dr. [**Last Name (STitle) 60731**] in [**12-30**] weeks postdischarge, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], her primary care, in [**11-28**] weeks postdischarge,
to see her cardiologist, Dr. [**Last Name (STitle) 1924**], postoperatively, and to
follow-up with Dr. [**Last Name (Prefixes) **] in the office at 4 weeks for
postop surgical visit.
DISCHARGE DIAGNOSES:
1. Status post redo sternotomy with aortic valve replacement
and replacement of ascending aorta.
2. Status post aortic valvuloplasty in [**2093**].
3. Status post right inguinal herniorrhaphy, tonsillectomy
and adenoidectomy.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d. for 30 days.
2. Enteric-coated aspirin 81 mg p.o. once daily.
3. Tramadol 50 mg p.o. q. [**3-2**] h. as needed.
4. Potassium chloride 20 mEq p.o. b.i.d. for 7 days.
5. Lasix 20 mg p.o. b.i.d. for 7 days.
6. Zantac 150 mg p.o. b.i.d.
The patient was discharged to home in stable condition on [**2118-4-25**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2118-6-10**] 11:09:48
T: [**2118-6-10**] 11:49:54
Job#: [**Job Number 60732**]
|
[
"V15.1",
"458.29",
"424.1",
"441.2",
"746.4",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.45",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
1554, 1572
|
8243, 8477
|
8500, 9094
|
1395, 1537
|
190, 1130
|
1152, 1363
|
1589, 8222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,163
| 184,213
|
18009
|
Discharge summary
|
report
|
Admission Date: [**2134-3-7**] Discharge Date: [**2134-3-11**]
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Name13 (STitle) 9995**] is an 80 year old,
white male, with a history of atrial fibrillation and aortic
insufficiency. He presents as a transfer from the [**Hospital6 18075**] for a semi-urgent endoscopic retrograde
cholangiopancreatography. Mr. [**Name13 (STitle) 9995**] was originally
admitted to [**Hospital6 2561**] for evaluation after haven
fallen at home. During his evaluation, he was noticed to be
jaundiced with a bilirubin of 11.0 with an amylase of 4,000
and lipase of 1,000. On careful history, it appears that the
patient had been feeling mildly febrile and fatigued for
approximately two to three days prior to falling.
Additionally, he noted dark urine and light colored stools
during this time. His daughter has also noticed that he was
jaundiced for the past one to two days.
Mr. [**Name13 (STitle) 9995**] was started on Levaquin and Flagyl at [**Hospital6 18075**] and watched clinically. At the time, a right
upper quadrant ultrasound was performed which showed a two cm
common bile duct as well as multiple stones in the
gallbladder. They were unable to exclude an obstructing
common bile duct stone.
The patient was watched clinically over the weekend but then
was transferred to [**Hospital1 69**] for
semi-urgent endoscopic retrograde cholangiopancreatography
when he began to have symptoms of fever and respiratory
distress. Upon arrival to the endoscopic retrograde
cholangiopancreatography suite, the patient was felt to be in
mild respiratory distress. Conscious sedation was attempted
but the patient was uncooperative with the examination and
was subsequently intubated for general anesthesia.
The endoscopic retrograde cholangiopancreatography was
significant for the finding of approximately one liter of
dark coffee ground as well as hemorrhagic gastritis in the
superficial pyloric ulcer. The patient's duodenum, however,
was so edematous that the ampulla could not be engaged and
the endoscopic retrograde cholangiopancreatography was unable
to be completed.
An ultrasound at that time did reveal a 1.1 cm stone in the
distal common bile duct. Notice was made of the patient's
dropping platelet count from 300 at the outside hospital to
63 upon transfer. The patient is subsequently transferred to
the Intensive Care Unit for monitoring and care after the
endoscopic retrograde cholangiopancreatography and requisite
intubation.
PAST MEDICAL HISTORY: Atrial fibrillation, chronic. The
patient has never been anticoagulated due to history of
severe gastrointestinal bleed. Aortic insufficiency, also
long standing per patient's primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 49844**]. The patient most recently had an echocardiogram
ten days prior to transfer which showed moderate to severe
aortic insufficiency and mild to moderate mitral
regurgitation with a normal ejection fraction of 55%. Recent
pneumonia. The patient had recently bee4n admitted and
treated at the [**Hospital6 2561**] for pneumonia with
Levaquin in early [**Month (only) 956**]. History of diverticulitis.
History of a colectomy secondary to a severe gastrointestinal
bleed. History of degenerative joint disease. Benign
prostatic hypertrophy.
ALLERGIES: On admission, the patient was noted to be
allergic to Penicillin.
MEDICATIONS AS AN OUTPATIENT:
Aspirin 181 mg p.o. q. day.
Propanolol 10 mg p.o. twice a day.
Nifedipine XL 30 mg p.o. q. day.
MEDICATIONS ON TRANSFER:
In addition to the above, he was on Levaquin 500 mg p.o. q.
day and Flagyl 500 mg p.o. three times a day.
Colace.
SOCIAL HISTORY: The patient denies any significant history
of smoking or significant alcohol abuse. He currently lives
with his family. He denies any significant family medical
history.
PHYSICAL EXAMINATION: On admission, temperature was 99.1;
blood pressure 92/56; heart rate 105; respiratory rate 12;
oxygen saturation 99%. The patient was intubated and
sedated. In general, the patient was sedated and largely
unresponsive but wincing to noxious stimuli. Pupils are
equal, round, and reactive to light and accommodation. Neck:
There was no noticeable jugular venous distention or
lymphadenopathy. Heart was irregularly irregular with a [**2-11**]
holosystolic murmur, best heard at the apex in the left lower
sternal border. Lungs were clear to auscultation
bilaterally. Abdomen was soft, nontender, non distended. The
liver was non palpable. Otherwise, there was also no
splenomegaly. Extremities showed no evidence of clubbing,
cyanosis or edema. There were 2+ pedal pulses bilaterally.
Skin was jaundiced throughout the body. There were otherwise
no stigmata of chronic liver disease.
On neurologic examination, the patient was sedated,
responsive to noxious stimuli and moving all extremities.
On admission to [**Hospital1 69**]
hospital, the patient's laboratory studies revealed a white
count of 17.4; hemoglobin of 10.4; hematocrit of 30.9;
platelet count on admission was 30 with an INR of 1.6, PTT of
33.3 and PT of 15.9. Fibrinogen was 435. FDP was 160 to
320. D-Dymer was 1,000 to 200.
Original chemistry 7 showed a sodium of 136; potassium of
3.9; chloride of 109; bicarbonate of 23; BUN of 56;
creatinine of 1.2. Glucose of 99. Amylase was 877. Total
bilirubin was 11.9. Alkaline phosphatase was 231. ALT was
124; AST 220. Lipase of 975. Treponin went from 3.3 to 3.8
to 1.6.
Last electrocardiogram and CK MB's were negative.
HOSPITAL COURSE: The patient was transferred to the
Intensive Care Unit directly after endoscopic retrograde
cholangiopancreatography and intubation. The patient was
immediately evaluated by the interventional radiology service
for a percutaneous biliary drain. He immediately went for
this procedure shortly after arrival to the Intensive Care
Unit. At that time, he successfully underwent placement of a
percutaneous drain into the hepatic duct as well as a drain
placed from the common bile duct into the duodenum so that he
could drain dually.
Over the next three hours, the patient's sedatives and
pressors were weaned and he was successfully extubated
shortly afterwards. He remained stable from a respiratory
standpoint for the remainder of the evening and had an
uneventful night. He was started immediately upon arrival on
Levaquin, Flagyl and Vancomycin for empiric coverage of
possible cholangitis.
Hematocrit was followed throughout the remainder of his
hospitalization, given his potential recent gastrointestinal
bleed. Hematocrit did subsequently remain stable and did not
require any transfusions. He was continued on Proton pump
inhibitor for prophylaxis throughout his hospitalization.
On admission, the patient's platelet counts were dramatically
lower than his recent admission. His initial laboratory
studies were consistent with an element of DIC. However, the
severity of the thrombocytopenia raised the possibility of a
second process, such as medication. To that extent, a heparin
induced antibody was sent and the patient was not started on
any heparin or H2 blockers.
The patient's electrocardiogram showed no evidence of any
acute changes, as compared to his other hospital. His
troponin leak continued to trend downwards and was more
suggestive of a distant event. He continued to be in atrial
fibrillation but was never heparinized given his recent
gastrointestinal bleed and obvious coagulopathy and
thrombocytopenia.
The next day, the patient continued to drain copious amounts
of dark bile from his percutaneous drain. His bilirubin,
lipase, amylase and transaminase all trended downwards. His
initial blood cultures which were drawn on admission
subsequently grew Enterococcus which was then revealed as
Vancomycin resistant. He was switched to Nasalilid on the
fifth of [**Month (only) 958**] to cover this [**Doctor Last Name 360**]. The enterococcus also
grew from the viral cultures as well.
The heart was investigated with echo which revealed an
ejection fraction of 45%, moderate to severe aortic
regurgitation, moderate to severe mitral regurgitation and
moderate to severe tricuspid regurgitation. He continued to
be mildly tachycardiac but was started on his baseline
betablocker on hospital day number three. He was
additionally felt to possibly benefit from an ace inhibitor
in a low dose. Captopril was started on hospital day number
three as well. Aspirin was held throughout the
hospitalization given his thrombocytopenia.
On [**3-8**], Mr. [**Name13 (STitle) 9995**] went back to the interventional
radiology suite for potential percutaneous stone removal;
however, given the size of the stone, this procedure was
unable to be performed. Instead, the ampulla and common bile
duct were both dilated with contrast around the stone
demonstrated in the suite under fluoroscopy.
The patient was then transferred back to the floor and has
remained stable since that time. He is planned currently to
have the drains remain in place for the next three to four
weeks. They are currently capped and the patient appears to
be draining internally through his common bile duct and
through his duodenum. IN approximately three to four weeks,
the patient is tentatively planned to return back to [**Hospital1 1444**] to have a second endoscopic
retrograde cholangiopancreatography attempted with the
presence of IR for possible stone extraction as well as a
sphincterotomy. It is felt that the patient will most likely
need a cholecystectomy in the future; however, given his
obvious bacteremia and cholangitis, it is felt that he should
most likely wait until these issues become more stabilized.
He is ready, at this time, to be transferred back to [**Hospital6 18075**] to resume care with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 49845**].
DISPOSITION: [**Hospital6 2561**].
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
Nasalilid 600 mg intravenous q. 12 hours for 11 days.
Captopril 6.25 mg p.o. three times a day.
Metoprolol 25 mg p.o. twice a day.
Protonic 40 mg p.o. q. 12 hours times two more days and then
40 mg p.o. q. day.
DISCHARGE PLAN: The patient is to have the percutaneous
drain remain in place with cap, to allow internal drainage.
He will return to [**Hospital1 69**] in
three to four weeks for an attempt at a repeat endoscopic
retrograde cholangiopancreatography. He will also be
evaluated by the surgery team at [**Hospital6 2561**] for
potential cholecystectomy in the future. He additionally
will be evaluated by the cardiology service at the [**Hospital6 18075**] for maximization of his cardiac regimen prior
to a potential open operative procedure.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Name8 (MD) 22406**]
MEDQUIST36
D: [**2134-3-11**] 11:15
T: [**2134-3-11**] 05:20
JOB#: [**Job Number 49846**]
|
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|
[
[
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,883
| 155,494
|
52653
|
Discharge summary
|
report
|
Admission Date: [**2171-7-8**] Discharge Date: [**2171-7-24**]
Date of Birth: [**2086-10-27**] Sex: M
Service: MEDICINE
Allergies:
Coumadin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Variceal Bleed, BRBPR
Major Surgical or Invasive Procedure:
TIPS
[**Last Name (un) 10045**] balloon
History of Present Illness:
84 y.o male with pmhx of cryptogenic cirrhosis presenting with
gastric/esophageal variceal bleeding from [**Hospital1 18**] [**Location (un) 620**]. His
admission Hct was 25.5, he was noted to have bright red blood
per rectum (admitted today [**7-8**]) and was initially
hemodynamically stable. His hemodynamics worsened and he had
increased BRBPR. Hct nadir was 22, and he got 3 units of PRBC, 1
units FFP, 1 unit of Plt at [**Hospital1 18**] and in [**Location (un) **]. EGD at
[**Location (un) 620**] revealed AVM's, esophageal/gastric varices with
esophageal varices being injected with epinephrine. Copious
amounts of blood was noted in the esophagus and stomach. The
patient was started on levophed.He is on home pradaxa for hx of
a fib with last dose per family given around 20 hours ago. He
was also given 1 unit of factor 9, 4 liters of fluid.
.
He was noted to have noted to have a wbc ct of 27.2 at [**Location (un) **],
he was started on vanco/zosyn and a paracentesis was performed
showing: 557 wbcs, 16% polys. 53% monos, 22% other, [**2138**] rbcs.
He was intubated at [**Location (un) 620**] prior to transfer. He was also noted
to have aspirated during intubation.
On arrival to the MICU, the patient is intubated, unresponsive
with stable hemodyanmics. [**Last Name (un) **] was placed with the GE
junction baloon inflated but not the esophageal baloon itself.
Review of systems:
Cannot be obtained given intubated status
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Hypertension.
2. Sick sinus syndrome with atrial fibrillation status post
permanent
pacemaker, and off Coumadin for gastrointestinal bleed, now on
Pradaxa.
3. Complications of pacemaker insertion in the past history.
4. Fatty liver disease.
5. Cryptogenic cirrhosis with portal hypertension and varices.
6. Upper gastrointestinal bleed from AV malformations in the
duodenum in [**2169**]. Most recently noted a duodenum AVM which is
likely source of the current gastrointestinal bleed.
7. Chronic anemia, bone marrow suppression, baseline hematocrit
is low.Previously Darbepoetin dependent.
8. Prostate cancer [**2166**] status post radiation therapy.
9. Colon cancer [**2167**] status post colectomy incompletely, this is
now
treated.
10. Neuroendocrine tumor of the liver diagnosed in [**2166**] per Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) 1726**] at [**Hospital3 2358**].
11. Orthostatic hypotension.
12. Benign prostatic hypertrophy.
13. Hypothyroidism.
14. Cataracts.
15. Rotator cuff repair.
16. Status post inguinal hernia.
17. Diverticulosis.
18. Asthma.
Social History:
Lives independently with his wife here in assisted-living
facility. He is an [**University/College **] professor. He stopped smoking 40 years
ago. Has a 30 pack year history of smoking. Takes 2 ounces of
alcohol a week. He uses a cane to ambulate.
Family History:
[**Name (NI) **] father had a stroke at age 63, mother died of unknown
causes at 83.
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.0 BP: 90/40 P:65 R:12 18 O2:99% Intubated CMV fiO2
100%
General: Alert, intubated, unresponsive
HEENT: Sclera anicteric,
Neck: supple, JVP not elevated, no LAD , 2 central lines in
rihgt IJ
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: no wheezes, rales, insp and exp ronchi diffusely
Abdomen: soft, distended, bowel sounds hypoactive diffusley, has
large LLQ soft 4cmX5cm mass could be hernia . Surgical scar
midline.
GU: foley yellow urine
Ext: warm, well perfused, 1+ pulses b/l, no clubbing, no
cyanosis or 2+ pitting edema in left LLE up to knee, nonpitting
edema on RLE.
Neuro: pupils 3mm b/l sluggish reactivity to light
DISCHARGE EXAM:
T-98.4 BP-110/53 HR-67 RR-20 O2-96%RA
General: Oriented x3. Conversive and responds to questions.
Joking about politics
HEENT: Sclera anicteric. MMM
Neck: supple, No JVP
CV: RRR. NS1&S2. [**2-12**] holosystolic murmur at apex
Lungs: CTAB. Good air flow.
Abdomen: Non-tender. soft, mildly distended, BS+4, has large LLQ
soft 4cmX5cm mass could be hernia. Surgical scar midline, well
healed.
Ext: RUE asymmetrical edematous compared to LUE. warm, well
perfused, 1+ pulses b/l, no clubbing, no cyanosis. 1+ pitting
edema of all extremities. 20G IV in right hand.
Neuro: pupils 3mm b/l reactive to light, confused. Baseline
ptosis of L eyel
Skin: Multiple echymotic lesions of torso, and extremities
Pertinent Results:
ADMISSION LABS:
[**2171-7-8**] 05:30PM BLOOD WBC-31.6*# RBC-3.36* Hgb-10.7* Hct-32.4*
MCV-96 MCH-31.8 MCHC-33.0 RDW-20.5* Plt Ct-127*
[**2171-7-8**] 05:30PM BLOOD Neuts-70 Bands-9* Lymphs-3* Monos-18*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-7-8**] 05:30PM BLOOD PT-13.2* PTT-29.2 INR(PT)-1.2*
[**2171-7-8**] 05:30PM BLOOD Glucose-150* UreaN-36* Creat-1.0 Na-141
K-4.4 Cl-110* HCO3-22 AnGap-13
[**2171-7-8**] 05:30PM BLOOD ALT-29 AST-45* LD(LDH)-253* AlkPhos-96
TotBili-1.6*
[**2171-7-8**] 05:30PM BLOOD Albumin-3.0* Calcium-7.6* Phos-4.8*
Mg-1.9
[**2171-7-8**] 06:11PM BLOOD Lactate-1.2
[**2171-7-8**] 06:11PM BLOOD freeCa-1.03*
Discharge Labs:
[**2171-7-24**] 06:25AM BLOOD WBC-9.0 RBC-3.02* Hgb-9.6* Hct-30.3*
MCV-100* MCH-31.8 MCHC-31.6 RDW-19.6* Plt Ct-165
[**2171-7-16**] 05:15AM BLOOD Neuts-67 Bands-1 Lymphs-5* Monos-20*
Eos-0 Baso-0 Atyps-0 Metas-7* Myelos-0 NRBC-1*
[**2171-7-24**] 06:25AM BLOOD PT-13.2* PTT-42.0* INR(PT)-1.2*
[**2171-7-24**] 06:25AM BLOOD Glucose-97 UreaN-17 Creat-1.0 Na-139
K-4.1 Cl-107 HCO3-26 AnGap-10
[**2171-7-24**] 06:25AM BLOOD ALT-58* AST-76* AlkPhos-208* TotBili-0.8
[**2171-7-24**] 06:25AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8
OTHER LABS:
[**2171-7-19**] 06:31AM BLOOD VitB12-1744* Folate-14.2
[**2171-7-19**] 07:30PM BLOOD TSH-7.6*
[**2171-7-15**] 03:53AM BLOOD TSH-0.91
[**2171-7-19**] 07:30PM BLOOD Free T4-1.1
[**2171-7-10**] 03:06AM BLOOD Fibrino-200
[**2171-7-14**] 04:35AM BLOOD Fibrino-183
[**2171-7-12**] 04:31AM BLOOD %HbA1c-5.4 eAG-108
[**2171-7-12**] 12:07AM BLOOD Lactate-1.3 calHCO3-25
[**2171-7-9**] 05:44PM BLOOD freeCa-1.11*
[**2171-7-19**] 10:35 am URINE Site: CATHETER Source:
Catheter.
**FINAL REPORT [**2171-7-21**]**
URINE CULTURE (Final [**2171-7-21**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
IMAGING:
CXR [**7-8**]:
The [**Last Name (un) **] device is in place. The tip of the device is not
visualized. There is an endotracheal tube with its tip
projecting
approximately 7 cm above the carina. A right internal jugular
venous
introduction sheath and right internal jugular [**Last Name (un) 5703**] catheter is
in situ.
Moderate parenchymal opacity in the left perihilar lung areas.
Mild
atelectasis at the left lung base. Minimal atelectasis at the
right lung
base, otherwise unremarkable right lung. Borderline size of the
cardiac
silhouette. Left pectoral pacemaker with correct position of
the wires.
ABD u/s DOPP [**7-9**]:
1. Multiple right and left lobe hepatic masses consistent with
metastatic
disease.
2. Extensive non-occlusive portal thrombosis in the right, left
and main
portal veins extending to the SMV.
CXR [**7-9**]:
The fundic balloon, previously inflated in standard position,
has now been
deflated. The tube has not migrated in position.
ET tube, right internal jugular line and introducer are in
standard
placements. Transvenous right atrial pacer lead in standard
placement.
Ventricular lead has a relatively short ventricular excursion
and may not be
accurate.
Right basal edema has improved. Considerable left perihilar
consolidation,
presumably aspiration pneumonia, is unchanged. No pneumothorax
or appreciable
pleural effusion is present. Heart size is normal.
DOPPLER LE: No evidence of deep [**Month/Day (4) 5703**] thrombosis. The deep
peroneal veins are
not visualized.
CXR [**7-11**]: Since the prior study there has been slight interval
improvement in pulmonary edema which is still present associated
with bilateral large pleural effusions and bibasal atelectasis.
NG tube tip is in the stomach. ET tube tip is in unchanged
appropriate position. Apices were not included in the field of
view.
ECHO [**7-15**]: Suboptimal image quality. Normal biventricular cavity
sizes with preserved global biventricular systolic function.
Moderate tricuspid regurgitation. Pulmonary artery hypertension.
Mild mitral regurgitation
Abd Doppler [**2171-7-16**]: Patent TIPS shunt. Nonocclusive thrombus is
seen within the main portal [**Month/Day/Year 5703**] and in the left portal [**Month/Day/Year 5703**].
Multiple hepatic masses are again seen throughout the liver
consistent with metastatic disease as was seen on prior imaging.
Scant trace of ascites seen in the right upper quadrant. The
study and the report were reviewed by the staff radiologist
RUE Venous U/S [**2171-7-17**]: Nonocclusive thrombus in the right
internal jugular [**Month/Day/Year 5703**]. Nonocclusive thrombus in the right
cephalic [**Month/Day/Year 5703**].
CT Head [**2171-7-20**]: No acute intracranial process.
Brief Hospital Course:
84 yo M with PMH cyptogenic cirrhosis and afib who presented
with variceal bleeding, hypotension, and leukocytosis. Intubated
and sedated upon arrival from OSH. Bleed stabilized in ICU with
[**Last Name (un) 10045**] and TIPS. Transferred from ICU to floor. Noted to have
multiple UE clots, and started on lovenox. EGD positive for
bleeding AVM x5, s/p ablation. Course c/b by AMS thought to be
[**1-10**] ICU delirium
.
Active Issues:
# Variceal Bleed: hct drop down to 22 at [**Hospital1 **] [**Location (un) 620**]. Received 1
unit PRBCs after transfer to [**Hospital1 18**]. [**Last Name (un) **] balloon placed to
stabilize bleed in MICU. Pt underwent TIPS on [**2171-7-9**] and portal
[**Date Range 5703**] thrombectomy also done for non-occlusive clot present. Hct
stabilized after TIPS and [**Last Name (un) **] removed the next day. Pt had
large BM with blood of varying shades mixed in on [**7-11**]. His Hct
did not drop but he was given 1 unit PRBC to be safe. Hct
remained stable with no further bleeding noted in house. Treated
with CTX 1g daily for 7 days for prophylaxis. Transferred to
floor after hct stable. EGD several days after initial bleed
significant for grade 2 non-bleeding esophageal varices and
several oozing gastric AVM's. Ablated 5 AVM on repeat EGD. Pt
had already undergone TIPS, so nadolol not given. Discharged
with stable hct.
.
# aspiration PNA: pt noted to have aspirated during intubation
at OSH. treated with clindamycin and CTX x7 days for presumed
aspiration PNA and infection ppx as above. Resolved by the time
he wsa on the floor, and pt had no additional cough, purulent
sputum or fever
.
# Multiple thrombi and h/o PE: On pradaxa which was stopped due
to GIB. Obtained LLE doppler to r/o DVT and it was negative. Pt
developed asymmetrical edema of LUE while on the floor. U/S
demonstrated non-occlusive thrombi of RIJ and cephalic [**Month/Day (2) 5703**].
Although pt had recent h/o GIB, decision made to place on
chronic anticoagulation as chance of stroke or other
embolic/thrombotic event very high. Pt is allergic to coumadin
and pradaxa irreversible, so started on lovenox 90mg [**Hospital1 **].
Monitored for worsening of GIB for several days prior to
discharge and hct remained stable.
.
#Leukocytosis: Elevated between 20-40 throughout ICU stay
despite treatment of PNA, SBP ppx, and resolution of GIB. Had
diagnostic para at OSH which had high WBC count but not enough
PMN to satisfy criteria for SBP. C. diff neg during admission.
Contact[**Name (NI) **] [**Name2 (NI) 3782**] oncologist who reproted a baseline WBC of 4 in
this pt. Heme/onc was consulted and believed that given the
acuity in onset, this represented leukemoid reaction rather than
malignancy/dyscrasia. WBC monitored throughout stay, and
gradually trended down. WBC of 9 on discharge.
.
# Hypoxia: intubated at OSH. extubated on [**2171-7-12**]. several liters
up at that time [**1-10**] aggressive volume resuscitation and was also
being treated for PNA, which were the likely causes of his
hypoxia. Also had bilateral pleural effusions. diuresed with
lasix and resp status improved. abx as above. Obtained echo to
eval cardiac function in setting of effusions and it showed
"Normal biventricular cavity sizes with preserved global
biventricular systolic function. Moderate tricuspid
regurgitation. Pulmonary artery hypertension. Mild mitral
regurgitation." he was satting in high 90s on face tent at time
of transfer out of MICU. Hypoxia resolved on the floor after
lasix administration
.
#VRE Bacteruria: Pt grew VRE from urine several times, however,
symptom free and UA not suspicious for infection. Treated this
as contaminant after consulting ID and confirming this does not
need treatment.
.
Chronic Issues:
#Cryptogenic cirrhosis: s/p TIPS as above. Started lactulose and
rifaximin for ppx against hepatic encephalopathy. Mental status
waxing and [**Doctor Last Name 688**] after extubation but he was oriented for the
most part with some mild confusion. Per wife pt had been
confused a lot at home prior to procedure. At time of calloout
pt AA&Ox3. Shortly after hitting the floor he became very
agitated/confused and oriented x0. Would attempt to pull out IV
lines and drains. Temporarily placed in restraints, for several
hours at a time. Full encephalopathic workup was negative.
Likely component of hepatic encephalopathy in setting of new
TIPS. Delirium resolved after 3-4 days of hitting the floor.
Thought to have component of ICU delirium.
.
# Afib: off diltiazem on admission due to bleeding. Went into
afib with RVR to 140s on [**7-11**] and became hypotensive to SBP 80s
while in RVR. At same time was more agitated, hypoxemic to mid
80's on PSV. converted spontaneously back to NSR once restarted
on home diltiazem dosing. pressures normalized at that time as
well. This happened again on [**7-14**] (RVR to 150s + hypotension to
SBP 80s). He was asymptomatic at that time. Interrogated pacer
and it was normal. TSH WNL. Went into one additional episode of
Afib w/RVR on the floor with hypotension, however, reverted to
NSR after 5mg metoprolol IV x3. Was in NSR at time of discharge.
.
#CHF: History of ?diastolic CHF. Volume overloaded in the ICU
and started on IV lasix on floor. Became euvolemic and continued
on home dose of lasix. ECHO on [**7-15**] demonstrated EF >60%
.
# BPH
Finasteride held in setting of bleeding and hypotension. No
urinary retention throughout inpatient course. Should be
re-evaluated upon discharge.
.
Transitional Issues:
#Be aware of VRE colonization
#Needs [**Hospital1 **]-weekly monitoring of electrolytes and HCT to ensure
stability
#Continue lovenox.
#Follow up with gastroenterology/hepatology
Medications on Admission:
Lasix 20 mg [**Hospital1 **]
levothyroxine 150mg daily
vit D 2000mg daily
nadolol 20mg daily
lipitor 5mg daily
prilosec 20mg [**Hospital1 **]
metamucil 1 teaspoom daily
zantac 300mg daily
finasteride 5mg daily
iron
ASA 81mg daily
pradaxa 150mg daily
calcium citrate
advair 2/500 daily
diltiazem 240mg daily
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC Q12H
2. Diltiazem 60 mg PO Q6H
hold for SBP<100
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 20 mg PO BID
5. Lactulose 30 mL PO Q8H
Notify MD [**First Name (Titles) **] [**Last Name (Titles) **] < 0 after 6 hours. If improvement, ask MD to
change to TID dosing. If not, discuss converting to enemas q2hrs
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Rifaximin 550 mg PO BID
9. Pantoprazole 40 mg PO Q12H
10. Atorvastatin 5 mg PO DAILY
11. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Bleeding gastric arteriovenous malformations
cryptogenic cirrhosis
atrial fibrillation w/ rapid ventricular response
congestive heart failure
internal jugular venous thrombus
thrombophilia
altered mental status
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted to
the intensive care unit from an outside hospital. You had
extensive bleeding from your stomach and esophagus. You were
transfused several units of blood and a balloon was temporarily
placed in your esophagus to prevent further bleeding. To take
some of the pressure of your esophageal veins, a shunt was made
that connects your portal [**Hospital1 5703**] to your jugular [**Last Name (LF) 5703**], [**First Name3 (LF) **] that
blood doesn't pool behind your cirrhotic liver. After you
stopped bleeding you were sent to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service where
you were monitored for several days
We took a small camera to look at your esophagus and stomach. We
gound several sites of bleeding in your stomach. These were
destroyed with a laser. You may have more sites of bleeding i
your colon or bowel that we could not find with the camera we
used. We also found several nodules on your esophagus. This
should be followed up by the liver doctor. You have an
appointment scheduled for this.
Several clots were detected in your veins. This can be
life-threatening because the clots could move to your heart or
brain. We started you on lovenox to stop these clots from
worsening. You will need to take this twice a day.
You had several episodes of atrial fibrillation that resulted in
temporary lowering of your blood pressure. This was treated with
IV medication. Your home diltiazem was continued in-house and
should be continued when you leave.
MEDICATION CHANGES
Stop Nadolol
Stop Omeprazole
Stop Dabigatran
Stop Finasteride
Start Pantoprazole (to prevent intestinal bleeding)
Start Rifaximin (to prevent encephalopathy)
Start Lactulose (to prevent encephalopathy)
Start Enoxaparin ( to treat blood clot)
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Hospital3 **],[**Apartment Address(1) 108661**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 108662**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: Wednesday [**8-21**] at 1:45pm
Address: [**Hospital3 **] [**Apartment Address(1) 66579**], [**Hospital1 **],[**Numeric Identifier 53049**]
Phone: [**Telephone/Fax (1) 66580**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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icd9cm
|
[
[
[]
]
] |
[
"39.1",
"39.79",
"45.13",
"44.43",
"88.64",
"96.71",
"38.97",
"96.6",
"96.06",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
16802, 16868
|
10119, 10540
|
291, 332
|
17142, 17142
|
5164, 5164
|
19140, 19889
|
3640, 3726
|
16158, 16779
|
16889, 16889
|
15827, 16135
|
17293, 19117
|
5816, 6335
|
3741, 4431
|
4447, 5145
|
15621, 15801
|
1760, 2249
|
230, 253
|
10555, 13845
|
360, 1741
|
5180, 5800
|
16908, 17121
|
17157, 17269
|
13861, 15600
|
2271, 3359
|
3375, 3624
|
6347, 10096
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,111
| 147,012
|
14987
|
Discharge summary
|
report
|
Admission Date: [**2148-4-8**] Discharge Date: [**2148-4-23**]
Date of Birth: [**2092-8-16**] Sex: M
Service: MICU
CHIEF COMPLAINT/REASON FOR TRANSFER: Hypotension.
Hypoxic respiratory failure.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old male with
history of coronary artery disease, congestive heart failure,
with an ejection fraction of less than 20 percent, syndrome
of inappropriate antidiuretic hormone, adrenal insufficiency,
diabetes mellitus type 2, history of left ventricular
thrombus in [**4-/2147**] on Coumadin, chronic ulcer status post
vacuum-assisted closure device and ostea, returns from rehab
on [**2148-4-8**] with increased swelling on a cyst in the left
thigh with increased redness and tenderness.
In the Emergency Room patient was hypotensive at 80/40.
Given intravenous fluids with improvement and admitted to the
Surgical Intensive Care Unit and intubated for hypoxia with a
gas of 7.28, 35, and 54 and broadly treated with vancomycin,
Levofloxacin, and Flagyl, and taken for incision and drainage
with 20 cc of pus removed. Antibiotics were changed to
meropenem for Methicillin-sensitive Staphylococcus aureus,
posterior pharynges. Also, briefly on Vasopressin for
question septic shock. Had a Swan with likely cardiogenic
picture on [**2148-4-11**] with a CVP of 16, a wedge pressure of
41/21, cardiac index of 1.8, and SVR of [**2168**] and started on
Natrecor and Dobutamine drip. Extubated [**2148-4-12**]. Post
arterial blood gas was 7.24, 40, 91, and given bicarbonate,
Xigris, and diuresed with Lasix on transfer to the congestive
heart failure team.
Patient also with positive abdominal distention relieved with
nasogastric tube and then elevated total bilirubin seen by
the liver team possibly due to congestive heart failure
versus antibiotics versus total parenteral nutrition versus
infection. Hepatic serologies were sent and pending at the
time and was started on Ursodiol, Lactulose for hepatic
encephalopathy.
On [**2148-4-19**] the patient was out three liters and on
[**2148-4-20**] out four liters then had episodes of desaturations
to 87 percent oxygen on 3 liter nasal cannula. Chest x-ray
with left lower lobe infiltrate, right pleural effusion.
Natrecor and Lasix drip were discontinued for decreasing SBP
and thought overdiuresis. An ABG at the time was 7.38, 49,
and 108, and patient was intubated for respiratory distress.
PAST MEDICAL HISTORY: Coronary artery disease status post
right coronary artery and left anterior descending stent in
04/[**2147**].
Peripheral vascular disease status post left femoral to
popliteal bypass graft.
Status post right femoral to tibial graft status post
metatarsal phalangeal amputation.
Diabetes mellitus type 2.
History of adrenal insufficiency and question syndrome of
inappropriate antidiuretic hormone.
Hypertension.
Congestive heart failure with an ejection fraction less than
20 percent.
Cardiomyopathy.
Acute ischemia.
2 plus mitral regurgitation, 2 plus tricuspid regurgitation
left ventricular thrombus [**4-/2147**] cardiac catheterization on
chronic Coumadin.
Chronic left heel ulcer, probing no bone, status post vacuum-
assisted device for closure.
PHYSICAL EXAMINATION: At the time of transfer to the unit on
[**2148-4-23**] temperature 100.6, respiratory rate 96, blood
pressure 154/116 to 109/40, respiratory rate 22, satting 95
percent FIO2 of 1.0 on AC, 640 x 22. Intubated, sedated.
Icteric sclerae. Mucous membranes dry. Bronchial breath
sounds bilaterally. Regular rate and rhythm. Normal S1, S2
without murmurs, rubs, or gallops on cardiac exam. Abdomen:
Soft, mildly distended with tympany; decreased bowel sounds
with enlarged and palpable liver. Extremities: 2 to 3 plus
dependent edema bilaterally lower extremities with vacuum-
assist device. Left shin with 5 x 4 cm elliptical
granulating ulcer. Left heel with erythematous ulcer probing
to bone. Neuro sedated with pinpoint pupils.
PERTINENT LABORATORY DATA: EKG: Normal sinus rhythm, 100,
right axis deviation, T-wave inversions to aVF and V6, [**Street Address(2) 28585**] elevations V1 to V3 with low voltage.
ALT 9, AST 37, LDH 259, total bilirubin 13.5, amylase 40,
albumin 2.4, lipase 43, white count 6.2. Differential: 9.5
percent eosinophils, 67 percent polys, 16 percent lymphs,
hematocrit is 29.6, creatinine 1.3, potassium 5.1.
HOSPITAL COURSE: Respiratory failure: Patient presented to
the Intensive Care Unit with left white-out with ipsilateral
shift, left lower lobe infiltrate, bilateral pleural effusion
status post bronchoscopy with secretions and reinflation,
likely obstructive atelectasis and hypoxia,
Given worsening pleural effusion and infiltrate the patient
had a chest CT to be considered.
Shock: Patient presented with likely hypovolemia from
overdiuresis. He initially was maintained on Levophed and
Dobutamine with consider to wean down, possible sepsis from
multiple sources including the osteo ulcer and pneumonia.
The goal CVP was 12 to 14 with the goal to try to wean off
pressors and bolus p.r.n. After further discussion with a
grim prognosis of this patient, patient was made Do Not
Resuscitate/Do Not Intubate, and after further family meeting
with the wife, the patient was started on comfort measures
only on [**2148-4-23**] given the overall course. At
approximately 3:15 in the afternoon physician was called to
see the patient for PA arrest. Patient was nonresponsive.
No breath sounds were noted. No heartbeat was noted. The
patient was warm to touch. No pulse was palpated in four
extremities. The patient was declared dead at 3:27 p.m. on
[**2148-4-23**]. Family was notified and declined postmortem
examination.
Adrenal insufficiency: Patient had a random cortisol of 10
empirically treated with dexamethasone, Fludrocortisone, and
Hydrocort.
Abscess: Patient was initially treated with astrianam.
Pneumonia: The patient had a bronchoscopy which revealed
collapse due to mucus plugging. Patient was treated with
vancomycin and dosed by levels of anemia. Patient was
transfused a hematocrit less than 30, CHF EF less than 20,
goal CVP was 10 to 12, data QCHF on transfer, and patient was
well commutated. Patient was maintained on Dobutamine to
improve cardiac output.
Hepatitis: Patient had elevated transaminases likely
infectious versus hepatic congestion. Hepatic bout
cholangitis. We needed to follow up with serologies.
Heel ulcer: Patient had wet-to-dry dressing changes and was
seen by Podiatry.
Left ventricular thrombus: Discussed with [**Doctor Last Name **] regarding
reversing of flow, who recommended reevaluation versus
organized thrombus since it had been one year since he had
the thrombus in the left ventricle.
Decreased bowel sounds due to IV narcotic effect. KUB was
unremarkable.
Access: The patient was maintained with a right IJ, right A-
line.
FEN: The patient was NPO, awaiting total parenteral
nutrition.
DISPOSITION: As described above the patient expired on
[**2148-4-23**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 6327**]
Dictated By:[**Last Name (NamePattern1) 12481**]
MEDQUIST36
D: [**2148-7-8**] 18:13:08
T: [**2148-7-9**] 12:42:05
Job#: [**Job Number 43875**]
|
[
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icd9cm
|
[
[
[]
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[
"89.64",
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] |
icd9pcs
|
[
[
[]
]
] |
4401, 7283
|
3230, 4383
|
247, 2419
|
2442, 3207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,207
| 158,159
|
23035
|
Discharge summary
|
report
|
Admission Date: [**2153-6-1**] Discharge Date: [**2153-6-5**]
Date of Birth: [**2095-9-18**] Sex: M
Service: MEDICINE
Allergies:
Asparagus
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
57 M w/ NSCLCA Stage IIIB s/p 6 cycles [**Doctor Last Name **]/taxol (no chest
XRT), h/o malignant pericaradial effusions last drained [**1-3**]
(600 cc clear initially, then 200 cc bloody)in cath lab
well until [**4-3**] d ago, incr dyspnea limiting even sl movement.He
cannot walk more than 25-50 ft without dyspnea. He also has
neuropathy in LE from the ankle down to the foot.
Labs in clinic on [**5-31**] were significant for Hct 30 (decreased
from baseline of mid 30's), stable renal funciton.
Outpatient echo at OSH large pericardial effusion w/ RV
compromise noted. Pt tx'd here for futher definitive care.
On arrival, tachy 120s regular, BP 110 (baseline 140-150s), no
tachypnea (sat 95% RA), neck veins 14-15 cm, muffled heart
sounds
pulsus [**10-10**] in ED.
Urgent echo at [**Hospital1 **]: 3 cm anterior loculated effusion, RV
collapse, no evidence LV collapse, no resp variation.
IN ER, got 1.5 L fluid resuscitation. Thoracics consulted and
felt pt high risk for thoracic surgery, preferred drain then ?
window later.
Cards consulted for pericardiocentesis, ? balloon
pericardectomy.
Past Medical History:
PMH:
1. Nonsmall cell lung cancer, stage IIIB
-presented in [**1-3**] with pericardial tamponade requiring
intubation, 850 cc fluid was removed; right upper lobe mass with
mediastinal and hilar LAD
-chemo course: [**Doctor Last Name **]/taxol 6 cycles, on chemo holiday
-CEA 220, decreased from prior, peak 297 in [**2153-3-30**]
2. GERD
3. Hypercholesterolemia
4. Dx with astham years ago but not treated
.
Social History:
He is married for ten years. He has two kids
that are 5 and 7 years of age. He is a CPA who works at home. He
had smoked cigarettes for about 30 years, but quit at the age of
42. He smoked at least two packs per day and many times more.
He was previously an alcoholic, but quit drinking alcohol about
15 years ago. He lives in [**Location **], [**State 350**].
Family History:
hx of TB, father w/ [**Name2 (NI) 499**] cancer and had radiation txt
Physical Exam:
Day of DC:
99.5 130/81 (122-130/81-86) 109 (98-112) 18 95%3L 900/475
Lying in bed in NAD
MMM and clear
ctab
PP6; jvd @6cm; nl s1/s2; pericardial drain site with tiny fluid
leak
soft, nt, nd, nabs
R groin cath site w/o hematoma, thrill or bruit
Bil DP intact; no skin changes LEs
A&O X 3
Pertinent Results:
[**2153-6-4**] 07:32AM BLOOD WBC-3.9* RBC-2.98* Hgb-10.2* Hct-31.0*
MCV-104* MCH-34.2* MCHC-32.8 RDW-16.4* Plt Ct-277
[**2153-6-3**] 05:00AM BLOOD WBC-3.7* RBC-2.76* Hgb-9.4* Hct-28.3*
MCV-103* MCH-33.9* MCHC-33.1 RDW-16.6* Plt Ct-247
[**2153-6-2**] 04:04AM BLOOD WBC-4.1 RBC-2.65* Hgb-8.8* Hct-27.3*
MCV-103* MCH-33.3* MCHC-32.3 RDW-17.1* Plt Ct-231
[**2153-6-1**] 10:06PM BLOOD Hct-28.2*
[**2153-6-1**] 12:35PM BLOOD WBC-4.4 RBC-2.98* Hgb-10.3* Hct-30.8*
MCV-104* MCH-34.6* MCHC-33.5 RDW-17.3* Plt Ct-264
[**2153-5-31**] 09:40AM BLOOD WBC-4.0# RBC-2.83* Hgb-9.8* Hct-30.1*
MCV-106* MCH-34.8* MCHC-32.7 RDW-17.6* Plt Ct-195
[**2153-6-1**] 12:35PM BLOOD Neuts-73.4* Lymphs-17.1* Monos-8.2
Eos-0.8 Baso-0.4
[**2153-6-1**] 12:35PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-3+
[**2153-6-4**] 12:30PM BLOOD PT-12.2 PTT-23.7 INR(PT)-1.0
[**2153-6-4**] 07:32AM BLOOD Plt Ct-277
[**2153-6-3**] 05:00AM BLOOD Plt Ct-247
[**2153-6-2**] 04:04AM BLOOD Plt Ct-231
[**2153-6-2**] 04:04AM BLOOD PT-13.0 PTT-21.6* INR(PT)-1.1
[**2153-6-1**] 12:35PM BLOOD Plt Ct-264
[**2153-6-1**] 12:35PM BLOOD PT-12.7 PTT-21.8* INR(PT)-1.1
[**2153-5-31**] 09:40AM BLOOD Plt Ct-195
[**2153-6-1**] 12:35PM BLOOD D-Dimer-3683*
[**2153-6-4**] 07:32AM BLOOD Glucose-104 UreaN-11 Creat-0.7 Na-143
K-4.2 Cl-107 HCO3-25 AnGap-15
[**2153-6-2**] 04:03PM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-142
K-3.6 Cl-107 HCO3-23 AnGap-16
[**2153-6-2**] 04:04AM BLOOD Glucose-111* UreaN-14 Creat-0.7 Na-143
K-3.3 Cl-108 HCO3-22 AnGap-16
[**2153-5-31**] 09:40AM BLOOD Glucose-105 UreaN-16 Creat-0.8 Na-144
K-3.6 Cl-107 HCO3-28 AnGap-13
[**2153-6-1**] 12:35PM BLOOD CK(CPK)-61
[**2153-6-1**] 12:50PM BLOOD cTropnT-<0.01
[**2153-6-4**] 07:32AM BLOOD Mg-1.3*
[**2153-6-2**] 04:03PM BLOOD Mg-2.2
[**2153-6-2**] 06:10AM BLOOD Mg-1.1*
[**2153-6-2**] 04:04AM BLOOD Mg-1.1*
[**2153-5-31**] 09:40AM BLOOD CEA-220*
[**2153-6-1**] 06:31PM BLOOD Type-ART O2 Flow-2 pO2-71* pCO2-30*
pH-7.50* calHCO3-24 Base XS-0 Intubat-NOT INTUBA Comment-NP
[**2153-6-1**] 05:35PM BLOOD Type-ART pO2-62* pCO2-34* pH-7.43
calHCO3-23 Base XS-0 Intubat-NOT INTUBA
[**2153-6-1**] 06:31PM BLOOD Hgb-10.8* calcHCT-32 O2 Sat-94
[**2153-6-1**] 05:35PM BLOOD O2 Sat-90
...
[**6-2**] Echo:
Limited study.
1. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
2. Right ventricular chamber size and free wall motion are
normal.
3. The previously seen echodense pericardial effusion is no
longer seen. Suspect the anterior loculated effusion has
resolved but the views are too limited to be completely sure.
.
[**6-4**] Echo:
1. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
2. The aortic valve leaflets are mildly thickened.
3. The mitral valve leaflets are mildly thickened.
4. There is a small, loculated pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
5. Compared with the findings of the prior study of [**2153-6-1**], the
size of the pericardial effusion has decreased and tamponade is
gone.
.
Torso CT:
IMPRESSION:
1. Interval appearance of pericardial fluid, which appears to
loculated, and
concentrated mostly on the right side of the heart.
2. There is interval appearance of a small (5 mm) filling defect
in proximal
portion of right iliac vein (near bifurcation in inguinal
region). This may
represent an intraluminal thrombus. If clinically indicated, a
right lower
extremity ultrasound may be performed. 3. Moderate right pleural
effusion,
with smaller left pleural effusion. Associated compressive
atelectasis.
4. Increase in size of right upper lobe mass, with
stable/slightly worsened
nodular pericardial thickening and mixed interval appearance of
lymphadenopathy in the mediastinal and hilar lymphadenopathy.
5. Stable appearance of liver lesions. Stable appearance of left
kidney
lesion.
.
INDICATIONS: 57-year-old man with lung cancer and question of
filling defect
in right common iliac vein seen on recent CT.
TECHNIQUE: Right lower extremity venous ultrasound and Doppler
examination.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the right common
femoral,
superficial femoral, and popliteal veins demonstrate normal
compressibility
and augmentation and Doppler flow and waveforms. No intraluminal
thrombus is
identified. In particular, there is no evidence of thrombus seen
at the site
noted on recent CT. A small right inguinal lymph node measures
1.7 cm in
length.
IMPRESSION: No evidence of deep vein thrombosis at the site
noted on recent
CT or elsewhere in the right lower extremity.
Brief Hospital Course:
This 57 man w/nsclc and recurrent malignant pericardial efussion
was felt to be at high surgical risk. He was therefor taken to
the cardiac catheterization laboratory where balloon
pericardotomy and pericardial drain placement were performed
succesfully and without complications. Pericardial drain was
removed on the fourth hospital day. Pulsus was measured at
least [**Hospital1 **] and was never elevated; the patient remained
asymptomatic through his hospital stay. On the fourth hospital
day, the drain was removed. On the morning of the fifth
hospital day, the bandage covering the drain site was soaked
with clear fluid. TTE was performed to rule out re-accumulation
and was negative.
.
As a courtesy to the patient and his oncologist, torso CT was
performed for staging. On review of the radiology report, it
was noted that remaining pericardial fluid appeared loculated
and that there was a 5mm filling defect in the proximal R iliac
vein. Therefor, the patient's discharge was delayed overnight
to allow for careful monitoring and LENI of the R leg, which was
negative for thrombosis, notably including the site of
visualization on CT.
.
For the patient's GERD, his PPI was continued. He was full code
throughout his hospital stay.
Medications on Admission:
lipitor
ambien
protonix
MVI
B6 200 mcg
vit C
Discharge Medications:
1. Pyridoxine HCl 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
9. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Pericardial effusion s/p pericardial balloon
NSCLC Stage IIIB
Discharge Condition:
Ambulating.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Take all your medications as prescribed.
Call your doctor or go to the emergency room if you have fevers,
chills, shortness of breath, pain, or any other concerns.
Followup Instructions:
1) Follow up with Dr. [**Last Name (STitle) **], cardiologist, on Tuesday [**6-19**]
at 10 am. Call his office at ([**Telephone/Fax (1) 5909**] if you have any
questions.
2) Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2153-6-7**] 10:00
3) Provider: [**Name10 (NameIs) 8848**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Where: [**Hospital 4054**] [**Hospital **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2153-6-7**] 10:00
4. Followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; his seceratary will call you
to make the appointment.
5. You need a followup echocardiogram; please call [**Telephone/Fax (1) 62**]
for a followup appointment.
|
[
"E933.1",
"530.81",
"423.8",
"357.6",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
9611, 9660
|
7410, 8662
|
279, 299
|
9765, 9778
|
2660, 7387
|
10092, 10962
|
2261, 2332
|
8757, 9588
|
9681, 9744
|
8688, 8734
|
9802, 10069
|
2347, 2641
|
229, 241
|
327, 1431
|
1453, 1863
|
1879, 2245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,073
| 144,770
|
21180
|
Discharge summary
|
report
|
Admission Date: [**2108-5-23**] Discharge Date: [**2108-5-30**]
Date of Birth: [**2047-3-27**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 61 year old white male has
a history of lung cancer and is status post pneumonectomy.
He presented with worsening exertional shortness of breath
over a seven week period and also complained of substernal
chest pain/pressure, lightheadedness and bilateral leg
swelling. An echocardiogram in [**2108-4-5**], revealed regional
hypokinesis of the distal septum and apex and an ejection
fraction of 40 percent with one plus mitral regurgitation and
two plus tricuspid regurgitation. A cardiac catheterization
on [**2108-5-9**], showed an ejection fraction of 53 percent with
apical hypokinesis. No mitral regurgitation. A 50-60
percent left main lesion, a 70-80 percent left anterior
descending coronary artery lesion, a 50-60 percent mid left
anterior descending coronary artery lesion and a 50-60
percent left circumflex lesion and an 80 percent obtuse
marginal lesion. He is now admitted for elective coronary
artery bypass graft.
PAST MEDICAL HISTORY: History of squamous cell carcinoma of
the left main bronchus which was treated with chemotherapy,
radiation and a left pneumonectomy in [**2101**].
History of obstructive sleep apnea. He uses CPAP at night.
History of anemia and myelodysplastic syndrome.
History of congestive heart failure.
History of emphysema of the right lung.
Status post neck surgery ten years ago and rodding of the
left femur in [**2082**].
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION:
1. Advair one puff twice a day.
2. Combivent two puffs five times a day.
3. Prozac 20 mg p.o. once daily.
4. Mirapex 0.50 mg p.o. twice a day.
5. Ibuprofen p.r.n.
6. Aspirin 325 mg p.o. once daily.
7. Erythropoietin 40,000 units subcutaneously q.week.
8. Lasix 20 mg p.o. once daily.
9. IMDUR 30 mg p.o. twice a day.
10. Sublingual Nitroglycerin p.r.n.
11. Vitamin C and garlic.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: He lives with his wife and has a couple
drinks per week. He has an 80 pack year smoking history and
quit five months ago.
REVIEW OF SYMPTOMS: As above.
PHYSICAL EXAMINATION: On physical examination, he is a well-
developed, well-nourished white male in no apparent distress.
Vital signs are stable and afebrile. Head, eyes, ears, nose
and throat examination is normocephalic and atraumatic,
extraocular movements intact. The oropharynx is benign. The
neck is supple with full range of motion. No lymphadenopathy
or thyromegaly. Carotids are two plus and equal bilaterally
without bruits. The lungs are clear to auscultation and
percussion. No breath sounds on the left. The abdomen was
soft, nontender, with positive bowel sounds, no masses or
hepatosplenomegaly. Extremities are without cyanosis,
clubbing or edema. Neurologic examination was nonfocal.
Pulses were two plus and equal bilaterally throughout.
HOSPITAL COURSE: On [**2108-5-23**], the patient underwent a
coronary artery bypass graft times one and a pericardiectomy,
cross pump time was 22 minutes and total bypass time 53
minutes. He was transferred to the CSRU on Propofol and
Levophed. He had a stable postoperative night. He was
extubated. He was on Levophed and Pitressin. He remained on
that. He had his chest tubes discontinued on postoperative
day number two. His Levophed was weaned off but he remained
on the Pitressin. He continued to slowly progress and was
eventually weaned off the Pitressin on postoperative day
number five and transferred to the floor in stable condition.
He continued a stable postoperative course and discharged to
home on postoperative day number seven in stable condition.
MEDICATIONS ON DISCHARGE:
1. Atenolol 25 mg p.o. once daily.
2. Lasix 20 mg p.o. twice a day for seven days.
3. Potassium 20 mEq p.o. twice a day for seven days.
4. Colace 100 mg p.o. twice a day.
5. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
6. Advair one puff twice a day.
7. Combivent two puffs five times a day.
8. Mirapex 0.5 mg p.o. twice a day.
9. Prozac 20 mg p.o. once daily.
10. Ecotrin 325 mg p.o. once daily.
Laboratories on discharge showed a white blood cell count
7.5, hematocrit 30.8, platelet count 110,000. Sodium 144,
potassium 4.0, chloride 104, CO2 32, blood urea nitrogen 27,
creatinine 0.8, blood sugar 125.
DISCHARGE DIAGNOSES: Coronary artery disease.
Lung cancer, status post pneumonectomy.
Obstructive sleep apnea.
Anemia with myelodysplastic syndrome.
Emphysema.
Congestive heart failure.
FO[**Last Name (STitle) 996**]P: The patient will follow-up with Dr. [**Last Name (STitle) **] in one
to two weeks, Dr. [**Last Name (STitle) 34798**] in two to three weeks as he may
need a stent for further revascularization in six weeks. He
will also follow-up with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2108-5-30**] 17:05:31
T: [**2108-5-30**] 18:27:16
Job#: [**Job Number 56137**]
|
[
"238.7",
"780.57",
"423.2",
"285.9",
"428.0",
"492.8",
"414.01",
"V10.11",
"519.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"89.61",
"89.68",
"37.31",
"36.11",
"38.91",
"96.71",
"39.61",
"99.04",
"89.64",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2025, 2040
|
4432, 5181
|
3784, 4410
|
1617, 2008
|
3000, 3758
|
2236, 2982
|
165, 1105
|
1128, 1591
|
2057, 2213
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,246
| 190,644
|
34135
|
Discharge summary
|
report
|
Admission Date: [**2142-8-12**] Discharge Date: [**2142-8-21**]
Service: NEUROSURGERY
Allergies:
Morphine / Ceftriaxone
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
transferred from rehab facility for after having seizures.
?Abscess in right frontal area
Major Surgical or Invasive Procedure:
s/p drainage of right frontal abscess
History of Present Illness:
Patient is an 86 year-old right-handed woman with a past
medical history of mild dementia, coronary artery disease status
post CABG [**2104**], hepatitis C, left frontal meningioma, and newly
diagnosed metastatic lung cancer. She was recently admitted to
the neurosurgery service and underwent 3rd ventriculostomy and
extensive evaluation for her new brain masses. Work-up
concluded
with a plan for whole brain radiation and oncology evaluation
from Dr. [**Last Name (STitle) 78695**]. It was determined during her previous
inpatient stay that surgical resection of the associated lesions
was not indicated given the location of the lesions and surgical
risk on the patient with regard to her age, and other comorbid
conditions.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG [**2104**]
2. Early Alzheimer's disease
3. Hepatitis C
4. Left frontal meningioma
5. s/p 3rd ventriculostomy
Social History:
SOCIAL HISTORY: Widowed. Lives with son. [**Name (NI) **] six kids.
Smoked
in past, quit in [**2104**]. No alcohol or drug use.
Family History:
FAMILY HISTORY: Non-contributory
Physical Exam:
Exam upon admission:
T: 98.0(101.4) BP:92/54(145/80) HR: 100 RR:14 O2Sats:98% NC
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Pupils: PERRL EOMs: intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam,slightly
depressed affect
Orientation: Oriented to person, year(with prompting).
Language: Speech fluent with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: patient able to follow commands with right upper
extemity(offers thumbs up, 4/5 strength) and right lower
extremity. Patient is unable to
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes upgoing bilaterally
Pertinent Results:
Head CT [**8-17**]: Final Report
FINDINGS: The right frontal postoperative hematoma has evolved,
decreasing in size and is isointense to the brain parenchyma. A
single locule of air
remains. There is residual vasogenic edema within the right
frontal lobe. No new foci of hemorrhage are seen. There is no
significant midline shift or change in ventricular size or
configuration.
The calcified left frontal mass as well as hyperdense cerebellar
lesions are unchanged with continued mass effect on the fourth
ventricle. The paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
1. Evolving hematoma in the right frontal lobe, markedly
decreased in size.
2. Stable size of hyperdense/calcified left frontal and
cerebellar masses.
MRI Brain with and without contrast [**8-13**]:
Final Report
FINDINGS: Again seen is an air and fluid collection within the
right frontal lobe measuring 43 x 29 mm with a thin rim of
peripheral enhancement. On DWI, there is slow diffusion. The
findings are most consistent with abscess along the prior
ventriculostomy site. The dominant left cerebellar lesion with a
heterogeneous pattern and minimal capsular enhancement has
mildly increased measuring 43 x 33 mm (previously 35 x 29 mm).
The lesion now extends to the cerebellar vermis and causes
increased mass effect on the fourth ventricle and cerebellar
pontine angle. The 15-mm right cerebellar lesion has not
appreciably increased in size. The enhancing left parietal
lesion is not appreciably changed in size. Post-surgical changes
are noted within the right frontal region.
The normal vascular flow voids are preserved. There is no
appreciable change in the ventricular configuration.
IMPRESSION:
1. Mild increase in size of right frontal fluid and air
collection with
signal characteristics most consistent with an abscess.
2. Slight interval growth in heterogeneous left cerebellar mass.
This is
concerning for metastatic disease.
Brief Hospital Course:
The patient was admitted after having a seizure and mental
status changes from rehab. She had previously had a 3rd
ventriculostomy from which her sutures were supposed to have
been removed between [**7-22**] and [**2142-7-27**]. A CT scan of the brain
revealed a right frontal abscess. She went to the OR for
drainage of the abscess on [**2142-8-13**] and as soon as the sutures
were removed a large amount of purulent drainage came out.
Post-operatively she went to the ICU and POD#1 her exam was much
better. She was talking a following commands. Her left side was
still plegic. On [**8-15**] she was transferred out of the ICU to the
floor.
ID was consulted for the abscess and the patient received
vancomycin per their recommendations. She also received
aztreonam but had a rash from it so it was stopped on [**8-16**]. On
[**8-19**] they recommended a complete course of 14 days for the vanco
and bactrium DS.
The patient's left arm strength slightly improved. She remained
oriented to herself and was following commands with full
strength on the right. Her incision was clean, dry, and intact.
Physical therapy and occupational therapy evaluated her and
recommended rehab. She was discharged on [**2142-8-21**].
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Estradiol 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pravastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Medroxyprogesterone 2.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days: The last dose should
be on Friday [**2142-8-24**].
7. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 days.
8. Hydromorphone (PF) 1 mg/mL Syringe Sig: One (1) Injection
Q6H (every 6 hours) as needed for pain.
9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) as needed for brain abscess
for 5 days: Please d/c after dose on Sun [**8-26**].
11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 doses.
12. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 3 doses: Please start on [**8-22**].
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 doses: Please start on [**8-23**].
14. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 doses: Please start on [**8-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
right frontal brain abscess
Discharge Condition:
neurologically improving
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
-You should have your dilantin level checked upon arrival to
rehab and it should be checked weekly. It should be between 10
and 20.
-Please draw weekly CBC, LFT, BMP while on vancomycin (end date
0779. Thank you.
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
You need you sutures removed on [**2142-8-23**]. This must be done
at your rehab hospital. If there are any questions please call
Dr.[**Name (NI) 12757**] office at [**Telephone/Fax (1) 1669**].
Follow up in Brain [**Hospital 341**] Clinic on [**Hospital Ward Name 23**] 8 on the [**Hospital Ward Name 516**]
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2142-9-3**] 10:30 am.
Completed by:[**2142-8-21**]
|
[
"E878.8",
"E930.8",
"198.3",
"331.0",
"V45.81",
"294.10",
"693.0",
"225.2",
"780.39",
"998.59",
"V45.89",
"324.0",
"070.54",
"414.00",
"162.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
8339, 8418
|
4792, 6014
|
325, 364
|
8489, 8515
|
2825, 4769
|
10101, 10587
|
1513, 1532
|
6799, 8316
|
8439, 8468
|
6040, 6776
|
8539, 10078
|
1547, 1554
|
195, 287
|
392, 1126
|
2021, 2806
|
1568, 1769
|
1784, 2005
|
1170, 1330
|
1363, 1480
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,646
| 150,534
|
41616
|
Discharge summary
|
report
|
Admission Date: [**2127-11-24**] Discharge Date: [**2127-12-2**]
Date of Birth: [**2072-11-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior fusion L3-S1
Anterior fusion T11-L3
Posterior fusioin T3-S1
History of Present Illness:
Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She is electing to proceed with surgical intervention.
Past Medical History:
Scoliosis, Liver disease, history of ulcer, mumps, measles,
chicken pox as child, hepatitis A,
PSH: R inguinal hernia repair at age 8, laparoscopic tubal
ligation, R knee arthroscopy, R foot surgery, L 3rd digit cyst
removal, tonsillectomy
Social History:
Denies tobacco, occassional EtOH; denies illicit drug use
Family History:
N/A
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2127-11-30**] 08:11AM BLOOD WBC-6.6 RBC-3.70*# Hgb-11.2*# Hct-32.5*#
MCV-88 MCH-30.1 MCHC-34.3 RDW-14.5 Plt Ct-189
[**2127-11-29**] 05:24AM BLOOD WBC-6.0 RBC-2.83* Hgb-8.7* Hct-24.7*
MCV-87 MCH-30.7 MCHC-35.1* RDW-14.8 Plt Ct-150#
[**2127-11-28**] 02:32AM BLOOD WBC-5.5 RBC-3.52*# Hgb-10.9*# Hct-30.2*
MCV-86 MCH-31.1 MCHC-36.1* RDW-15.3 Plt Ct-98*
[**2127-11-27**] 02:55PM BLOOD WBC-7.4 RBC-2.43* Hgb-7.5* Hct-21.5*
MCV-89 MCH-30.8 MCHC-34.7 RDW-15.2 Plt Ct-91*
[**2127-11-27**] 11:24AM BLOOD WBC-7.7 RBC-3.13* Hgb-9.4* Hct-27.9*
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.8 Plt Ct-111*
[**2127-11-27**] 01:17AM BLOOD WBC-6.8 RBC-3.54* Hgb-11.3* Hct-31.9*
MCV-90 MCH-31.9 MCHC-35.4* RDW-14.0 Plt Ct-117*
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2127-11-24**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T11-L3 anterior fusion through a thoracotomy as part
of a staged 3-part procedure. A chest tube was placed at the
time of this surgery. Please refer to the dictated operative
note for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was low and she was
transfused PRBCs with good effect. A bupivicaine epidural pain
catheter placed at the time of the posterior surgery.
she was transfered to the T/SICU for hemodynamic monitoring.
She was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#2
from the third procedure. She was fitted with a TLSO brace for
ambulation. Physical therapy was consulted for mobilization OOB
to ambulate. Hospital course was otherwise unremarkable. On the
day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
tramadol
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Scoliosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatment Frequency:
Please continue to change the dressing daily.
Followup Instructions:
Wtih Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2127-12-1**]
|
[
"327.23",
"E870.0",
"733.00",
"V12.09",
"511.9",
"458.29",
"286.9",
"721.3",
"737.30",
"285.1",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"81.62",
"84.52",
"84.51",
"81.06",
"77.79",
"80.51",
"38.93",
"81.04",
"03.90",
"81.05",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
4365, 4462
|
2166, 3802
|
319, 389
|
4547, 4553
|
1444, 2143
|
6692, 6771
|
904, 909
|
3861, 4342
|
4483, 4526
|
3828, 3838
|
4577, 4683
|
924, 1425
|
6533, 6601
|
4719, 4912
|
270, 281
|
4948, 5403
|
5415, 6515
|
417, 549
|
6622, 6669
|
571, 813
|
829, 888
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,290
| 177,431
|
32028
|
Discharge summary
|
report
|
Admission Date: [**2200-3-4**] Discharge Date: [**2200-4-1**]
Date of Birth: [**2143-8-4**] Sex: M
Service: MEDICINE
Allergies:
Aldactone
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
EGD
Attempt at capsule endoscopy x 2
PICC placement [**2200-3-14**]
History of Present Illness:
56 y/o M with PMH congenital heart disease s/p VSD repair, PVR
and MVR, CHF, DM, afib on coumadin and mult. GIB who presents
from [**Hospital1 1501**] with 2 days of black stools. Of note the patient was
recently discharged from [**Hospital1 18**] on [**2-14**] after an admisison for
GIB. He underwent EGD with small bowel enteroscopy as well as
colonoscopy. EGD showed mild gastritis and no active bleeding.
Capsule endoscopy was also performed on [**2-13**] that showed a few
mild erosions in the duodenum and proximal small bowel as well
as a few nonbleeding redspots in the mid and distal small bowel.
Since discharge from [**Hospital1 18**] the patient reports that he has had
dark stools but has not had any BRBPR. On sunday night the
patient developed a tightness in his abdomen which he describes
as a knot. He also had some nausea, however denied abdominal
pain, SOB, CP, or LH. Labs at his [**Hospital1 1501**] this morning showed Hct
20.1 (down from 27 on [**2-27**]) and he was sent to [**Hospital1 18**] for further
workup.
.
In ED VS were T 97 HR 85 BP 96/53 86% TM. Rectal exam showed
guaiac pos. black stool, no blood. He was given a total of 4L NS
as well as 2 units RBCs. He also received protonix 40mg IV. On
arrival to the ICU the patient reported feeling much better. he
cont. to deny abdominal pain, SOB, CP. He had an additional
black, guaiac pos. stool on arrival to the ICU.
Past Medical History:
#congenital heart disease
-s/p pulmonic valvulotomy in [**2160**]
-s/p VSD repair [**2185**]
-[**2199-12-24**]: redo sternotomy, PVR (porcine), MVR (porcine), VSD
closure, PFO closure
#CHF
#s/p trach, open J-tube in [**1-10**]
#DM
#anxiety
#depression
#A fib
#RBBB
#RLE varicosities
#s/p R hernia repair
#s/p appy
Social History:
disabled
never used tobacco
occasional ETOH
Family History:
father had MI at age 55
Physical Exam:
VS: Temp 98.0 98.0 113/51 97% trach.
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist, trach in place
Neck - no JVD, no cervical lymphadenopathy
Chest - [**Month (only) **]. BS at bases, otherwise clear to auscultation
bilaterally
CV - Irregular, III/VI SEM loudest at RUSB
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No clubbing, cyanosis, 2+ pitting edema b/l LE with
chronic venous stasis changes
Neuro - Alert and oriented x 3, cranial nerves [**1-14**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rashes
Rectal: guaiac positive stool
Pertinent Results:
[**2200-3-4**] 11:15AM BLOOD WBC-9.0# RBC-2.39* Hgb-6.9* Hct-21.9*
MCV-91 MCH-28.9 MCHC-31.6 RDW-14.1 Plt Ct-323#
[**2200-3-9**] 06:30AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.0* Hct-30.6*
MCV-92 MCH-30.0 MCHC-32.7 RDW-15.2 Plt Ct-284
[**2200-3-4**] 11:15AM BLOOD PT-11.9 PTT-29.9 INR(PT)-1.0
[**2200-3-4**] 11:15AM BLOOD Glucose-118* UreaN-73* Creat-2.0*# Na-139
K-4.1 Cl-93* HCO3-37* AnGap-13
[**2200-3-9**] 06:30AM BLOOD Glucose-141* UreaN-9 Creat-0.7 Na-151*
K-4.2 Cl-111* HCO3-33* AnGap-11
[**2200-3-4**] 11:15AM BLOOD ALT-17 AST-34 CK(CPK)-135 AlkPhos-140*
TotBili-0.1
[**2200-3-4**] 11:15AM BLOOD cTropnT-0.04*
[**2200-3-4**] 11:15AM BLOOD Calcium-8.9 Phos-4.4 Mg-3.2*
[**2200-3-7**] 05:30AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.8
[**2200-3-6**] 06:35AM BLOOD VitB12-851 Folate-GREATER TH Hapto-197
[**2200-3-4**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2200-3-4**] 12:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2200-3-4**] 12:00PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2200-3-9**] 06:54AM URINE Hours-RANDOM UreaN-855 Creat-119 Na-45
[**2200-3-9**] 06:54AM URINE Osmolal-572
.
CT ABD W&W/O C [**2200-3-6**] 2:23 PM
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: source of GI bleeding.Please administer PO and IV
contrast.C
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with congenital heart dz, s/p VSD repair, GI
bleeding.
REASON FOR THIS EXAMINATION:
source of GI bleeding.Please administer PO and IV
contrast.Concer for small bowel source, CT enterography please.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: GI bleeding, query source, concern for small bowel
source, CT enterography please.
COMPARISON: [**2200-1-23**].
TECHNIQUE: Multiple MDCT images were obtained through the
abdomen and pelvis after the administration of 150 cc of Optiray
intravenously. There are technical limitations to this study
since it appears that the patient was not administered the
VoLumen and this limits the accuracy of this study. Multiplanar
reformations were derived.
FINDINGS:
CT ABDOMEN WITH IV CONTRAST AND WITH LIMITED ORAL CONTRAST:
Again there is evidence of median sternotomy and four-chamber
cardiac dilatation consistent with a history of conigential
cardiac disease. There are essentially unchanged bilateral
pleural effusions and associated compressive atelectasis. The
IVC and hepatic veins appear dilated but otherwise the liver,
gallbladder, pancreas, spleen, adrenal glands and kidneys appear
unremarkable. Within the limitations of the study there is no
evidence of a gross mass within the bowel or for extravasation
of intravenous contrast into the bowel lumen. A ventral defect
previously seen has resolved with residual soft tissue being
demonstrated. There is no free fluid or free air within the
abdomen or pelvic lymphadenopathy. There is left gynecomastia. A
J-tube is again seen.
CT OF THE PELVIS WITH IV CONTRAST AND WITH LIMITED ORAL
CONTRAST: No intravenous contrast is seen within the lumen of
the pelvic loops of bowel though enteric contrast is seen in the
rectosigmoid area. There is no significant free fluid or free
air or pelvic lymphadenopathy and the bladder and distal ureters
appear normal. There is an unchanged small fluid collection
measuring 3.9 x 2.6 cm overlying the left common femoral (2,
111).
MUSCULOSKELETAL: Persistent severe thoracolumbar scoliosis but
no suspicious lytic or blastic lesion.
IMPRESSION:
1. Technically limited study without sufficient oral contrast;
within these limitations no GI bleed is unambiguously defined
and no gross mass is identified. Enteric contrast is seen in the
sigmoid rectum of unknown origin. For further clarification
consider a tagged red blood cell nuclear medicine study with
delayed views if bleed is intermittent.
2. Essentially unchanged bilateral pleural effusions with
associated compressive atelectasis.
3. Unchanged massive cardiomegaly with associated mege-pulmonary
artery and a seroma overlying the left common femoral artery.
.
G/GJ/GI TUBE CHECK PORT [**2200-3-8**] 1:07 PM
G/GJ/GI TUBE CHECK PORT
Reason: eval for correct placement of J-tube
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with J-tube that fell out today, was replaced at
the bedside. please eval for proper replacement, and that the
tube is in correct position to resume tube feeds. thanks
REASON FOR THIS EXAMINATION:
eval for correct placement of J-tube
EXAMINATION: Injection of J-tube.
Injection of a J-tube was performed without a radiologist
present and shows contrast in several loops of non-distended
small bowel.
Brief Hospital Course:
56 y/o M with PMH congenital heart disease s/p VSD repair, PVR
and MVR, CHF, DM, afib on coumadin and mult. GIB who presents
from skilled nursing facility with 2 days of black stools.
.
# Anemia/black stools: Has had extensive workup this month
without discovering active bleeding source, including EGD, small
bowel enteroscopy, capsule endoscopy and colonoscopy. He did
have some erosions in duodenum and small bowel which may be
source of chronic slow bleed. He received 3 units of PRBCs upon
admission and an additional 7 spread out through his course. He
never had a notable large bleed but hematocrit continuously
drifted down slowly. His bleeding is complicated by the need to
keep him anticoagulated due to Afib and large atrial size. GI
followed him while here. At one point there was consideration
of transfer to [**Hospital6 **] for double balloon
enteroscopy, as repeat EGD was thought to be low yield as most
of the erosions were not within reach. However, he had some
respiratory distress requiring placement on the ventilator and
the GI team at [**Hospital1 2177**] recommended deferring the procedure at this
time. Repeat capsule endoscopy was attempted this admission but
he could not swallow enough in order to tolerate capsule
placement (with or without endoscopy). He is considered
transfusion dependent at this time. We recommend checking
hematocrits weekly and transfusing for Hct < 25.
.
# Acute on chronic resp. failure: Trached during admission in
[**Month (only) 404**] for heart surgery due to difficulty weaning. No longer
on vent at rehab per patient. His trach mask was continued.
Inhalers and nebulizers were continued. He was transferred to
the MICU twice for respiratory distress requiring mechanical
ventilation. His first transfer was in the the setting of
volume overload and mucous plugging which improved with
treatment of the MRSA/stenotrophomonas in his sputum. The
second incident of respiratory failure was in the setting of
getting high doses of IV ativan leading to likely respiratory
depression. He completed a 5 day course of Bactrim for
Stenotrophomonas and completed a 7 day course of vanco.
.
# Acute renal failure: He was diuresed given volume overload
affecting respiratory status. After being diuresed for 3 days,
he developed oliguria with urine microscopy consistent with ATN.
Diuresis has been held and can be restarted when needed for
volume overload and creatinine allows. His creatinine has
currently plateaued at 2.1. Good urine output currently, and as
his creatinine remained at approximately 2, his lasix was
restarted at 20mg po bid. His creatinine should be checked one
week after discharge and adjusted accordingly.
.
# Paroxysmal Atrial Fibrillation:Patient was previously on
coumadin. Given his large atrial size (>8 cm), anticoagulation
with coumadin was restarted (INR will need to be monitored at
rehab and coumadin adjusted prn). Cardiology was consulted.
Rate control was acheived with a beta blocker. In light of his
chronic lower GI bleed, it was decided by the ICU team that his
anticoagulation would be discontinued. His PCP was notified via
voice mail.
.
# Congenital heart disease: s/p recent surgery. No CAD on cath
in [**12-10**]. Cardiology was consulted for periop risk assessment
given his history - feel no increased risk since no CAD on cath.
LVEF 45-50% on TTE [**1-10**]. Continued on outpatient regimen of
lipitor, metoprolol, ASA.
.
# Anxiety/depression: increased fluoxetine to 30. Held benzos
given resp depression as above.
.
# DM: Cont. outpatient glargine and RISS
Medications on Admission:
1. Atorvastatin 20 mg Daily
2. Ascorbic Acid 500 mg [**Hospital1 **]
3. Fluoxetine 20 mg DAILY
4. Docusate Sodium 50 mg/5 mL [**Hospital1 **]
5. Miconazole Nitrate 2 % Powder QID
6. Albuterol Sulfate 2.5 mg/3 mL Inhalation Q6H PRN
7. Ipratropium Bromide 0.02 % Solution Q6 PRN
8. Clonazepam 0.5 mg Tablet PO BID PRN
9. Lansoprazole 30 mg Tablet Daily
10. Aspirin 81 mg TabletDaily
11. Ferrous Sulfate 300 mg/5 mL Daily
12. Metoprolol Tartrate 25 mg Tablet PO twice a day.
13. Insulin Glargine Twenty (20) UNITS Subcutaneous at bedtime.
14. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: Sliding Scale
Coverage Subcutaneous four times a day.
15. Nutrition Tube Feeds Glucerna Tube Feeds 90cc/hour
16. lasix 20mg PGT [**Hospital1 **]
17. ? coumadin at rehab, INR here normal
Discharge Medications:
1. 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.
2. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
3. Fluoxetine 10 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day): please hold for SBP < 95 or HR < 55.
5. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. insulin
see attached sliding scale
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day) as needed for anxiety.
13. Clotrimazole 10 mg Troche [**Last Name (STitle) **]: One (1) Troche Mucous
membrane QID (4 times a day) as needed for thrush.
14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath or wheezing.
15. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: Five (5) mL PO once
a day.
16. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
17. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Topical four
times a day.
18. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
19. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Twenty (20)
units Subcutaneous at bedtime.
20. Insulin Lispro 100 unit/mL Cartridge [**Last Name (STitle) **]: as per sliding
scale units Subcutaneous qachs.
21. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
22. Outpatient Lab Work
please draw chem 7 to monitor creatinine on lasix
23. Ciprofloxacin in D5W 400 mg/200 mL Piggyback [**Last Name (STitle) **]: Four
Hundred (400) mg Intravenous Q12H (every 12 hours) for 7 days.
24. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime).
25. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary
GI Bleed
Respiratory failure-hypercarbia
enterococcus bacteremia
.
Secondary
Mitral and Pulmonic tissue valve replacement
Congenital heart Disease
Acute renal failure [**1-4**] ATN
MRSA/Stenotrophomonas HAP
Discharge Condition:
Stable, afebrile, ambulatory with assistance
Discharge Instructions:
.
You were admitted to the hospital after you were found to have
dark black stool. You have had extensive workup for GI bleeding
in the past and again this admission. You were administered
several units of blood for low hematocrit, and we feel that you
may need to continue transfusions chronically. In addition you
developed problems with your breathing that were related to a
class of medications called benzodiazepines, as well as a likely
pneumonia. You required mechanical ventilation at night. You
also had an infection of your bloodstream that was treated with
ciprofloxacin that you will have to take for a total of 14 days.
You will not be taking coumadin for your atrial fibrillation for
now as you have had bleeding.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed.
.
Please return to the hospital if you have bloody vomit, large
amounts of blood in your stool, large drop in hematocrit at
rehab, dizziness, low blood pressure, poor urine output, or any
new symptoms that you are concerned about.
Followup Instructions:
Please followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24305**], at
[**Telephone/Fax (1) 24306**] within 1 week of leaving rehab.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2200-4-22**]
|
[
"041.89",
"300.00",
"311",
"293.0",
"483.8",
"428.0",
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"V44.0",
"276.0",
"790.7",
"578.9",
"250.02",
"518.83",
"427.31",
"574.20",
"933.1",
"428.22",
"518.81",
"280.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"96.6",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
14800, 14874
|
7608, 11190
|
274, 344
|
15133, 15180
|
2931, 4287
|
16316, 16653
|
2191, 2216
|
12022, 14777
|
7166, 7350
|
14895, 15112
|
11216, 11999
|
15204, 16293
|
2231, 2912
|
228, 236
|
7379, 7585
|
372, 1775
|
1797, 2113
|
2129, 2175
|
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