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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2,625
| 117,659
|
14355
|
Discharge summary
|
report
|
Admission Date: [**2114-3-17**] Discharge Date: [**2114-3-20**]
Date of Birth: [**2059-5-3**] Sex: F
Service: MEDICINE
Allergies:
Amiodarone / Quinidine
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
54 y/o with hx. MI age 35, EF 20-30%, [**First Name3 (LF) **] ICD, PAF, VT, s/p
trials of amiodorone, dofetilide, quinidine, recently admitted
([**Date range (1) 42566**]) for MVR d/t 4+ MR presents with palpitations found
to be in AFib with HR in the 120s and SBP 70's-80's (when
discharged yesterday was in NSR), admitted to the CCU for
further management.
Past Medical History:
1. Mitral valvuloplasty for MR ([**Last Name (un) 3843**]-[**Doctor Last Name **] Physio
ring)[**2-21**]
2. MI vs viral myocarditis at age 35
3. EF less than 20% s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 19961**] ICD [**2108**]
4. Spleenectomy [**2106**] d/t ITP
5. Paroxysmal atrial fibrillation, intolerant of amiodarone,
dofetilide and quinine therapy
6. Hypertension
7. Hyperlipidemia
8. noninsulin dependent DM
9. Chronic Kidney Disease
Social History:
She is single and lives alone. She works as office manager for
construction company. Does not smoke, social drinker.
Family History:
Father died of MI in his 70s and mother died of CRI in her 70s.
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 99/58 mm Hg while supine. Pulse was 126
beats/min and irregular, respiratory rate was 14 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 7 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2114-3-16**] 07:50AM PT-20.9* PTT-27.2 INR(PT)-2.0*
[**2114-3-16**] 07:50AM PLT COUNT-913*
[**2114-3-16**] 07:50AM WBC-22.1* RBC-3.28* HGB-8.7* HCT-28.7* MCV-88
MCH-26.6* MCHC-30.4* RDW-16.0*
[**2114-3-16**] 07:50AM GLUCOSE-92 UREA N-18 CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-27 ANION GAP-16
[**2114-3-17**] 03:35PM PT-21.4* PTT-26.0 INR(PT)-2.1*
[**2114-3-17**] 03:35PM PLT COUNT-1089*
[**2114-3-17**] 03:35PM cTropnT-0.16*
[**2114-3-17**] 03:35PM CK-MB-NotDone proBNP-[**Numeric Identifier 42567**]*
.
IMAGING/
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2114-3-17**] for further
management of her atrial fibrillation. Esmolol was used with
good rate control and eventual conversion back into normal sinus
rhythm. Amiodarone was also started to maintain her in a normal
sinus rhythm. Coumadin was continued for anticoagulation. The
electrophysiology service followed Ms. [**Known lastname **] given her
pacemaker in situ and new atrial fibrillation. She remained in
normal sinus rhythm and was discharged home on [**2114-3-20**]. She will
follow-up with Dr. [**Last Name (STitle) **] of the electrophysiology service,
Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as
an outpatient.
Medications on Admission:
ASA 81
Pravastatin 20
Percocet prn
Calcium Carbonate 500 qid
Captopril 6.25 [**Hospital1 **]
Metoprolol tartrate 50 [**Hospital1 **]
Lasix 40 [**Hospital1 **]
Warfarin 1 mg TTSS, 2 mg MWF
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
osteoporosis.
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Insulin
Please resume your pre-hospitalization insulin regimen.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
10. Outpatient [**Name (NI) **] Work
PT/PTT/INR on Wednesday [**2114-3-21**] and Friday [**2114-3-23**]. Please fax
results to Dr.[**Name (NI) 21128**] office - Fax: [**Telephone/Fax (1) 18684**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
1. atrial fibrillation with rapid ventricular response
2. s/p MV annuloplasty
.
Secondary:
1. Mitral valvuloplasty for MR ([**Last Name (un) 3843**]-[**Doctor Last Name **] Physio
ring)[**2-21**]
2. MI vs viral myocarditis at age 35
3. EF less than 20% s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 19961**] ICD [**2108**]
4. Spleenectomy [**2106**] d/t ITP
5. Occasional palpitations with documented non-sustained VT
6. Hypertension
7. Hyperlipidemia
8. noninsulin dependent DM
9. Chronic Kidney Disease
Discharge Condition:
Stable. Afebrile. Tolerating PO. Ambulates without assistance.
Discharge Instructions:
You were admitted to the hospital for atrial fibrillation with a
rapid heart rate. You should return to the ER or call your
doctor if you experience any of the following symptoms: fever >
101.4, palpitations, chest pain, shortness of breath,
weakness/dizziness, nausea, vomiting or any other concerning
symptoms.
.
Please take all medications as prescribed.
.
Please follow up with all appointments as scheduled. VNA will be
visiting your home on Wednesday and Friday to check your blood
work. Your coumadin dosing should be adjusted accordingly by Dr.
[**Last Name (STitle) **].
Followup Instructions:
1. PT/PTT/INR check on Wednesday and Friday (will be done by VNA
services). Results to be sent to Dr. [**Last Name (STitle) **] (Phone:
[**Telephone/Fax (1) 3183**]).
2. An appointment has been made for you with Dr. [**Last Name (STitle) **] (Phone:
[**Telephone/Fax (1) 3183**]) on Thursday, [**3-29**] at 3:15P.
3. Return to [**Hospital Ward Name 121**] 2 on Tuesday, [**3-27**] for your post-op
check and staple removal with Cardiothoracic surgery.
4. Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-21**] weeks.
.
You have the following appointments scheduled:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2114-4-13**] 2:20
Completed by:[**2114-3-22**]
|
[
"403.90",
"585.9",
"250.00",
"427.31",
"412",
"424.0",
"V45.02",
"427.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5569, 5624
|
3611, 4343
|
294, 302
|
6219, 6284
|
3037, 3588
|
6912, 7684
|
1347, 1493
|
4581, 5546
|
5645, 6198
|
4369, 4558
|
6308, 6889
|
1508, 3018
|
242, 256
|
330, 690
|
712, 1196
|
1212, 1331
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,513
| 163,500
|
33935
|
Discharge summary
|
report
|
Admission Date: [**2114-5-13**] Discharge Date: [**2114-5-29**]
Date of Birth: [**2092-9-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Central line placement
History of Present Illness:
HPI: 21 previously healthy male presents dyspnea. He developed a
mild frontal headache and mild nonproductive cough at noon on
the day prior to admission. At about 9 pm he developed worsening
HA and severe, "hacking" nonproductive cough. The cough
continued today, and he found he was too short of breath to walk
to his dorm after work. He felt "terrible" overall, so presented
to the ED for evaluation.
.
No recent travel, +sick contact: roommate recently ill with
"bronchitis" x ~2-3 weeks, did take antibiotics. No HIV risk
factors (see SH, below)
ROS: +anorexia/poor PO intake x 1 day. No n/v/d. No stiff
neck/meningeal signs. no rash.
.
ED course:
Initial vitals: T101.6, HR 120s, BP 130/70s Satting 88% RA, then
94% 6L, and 99% NRB. WBC 19.7; CXR with b/l reticular opacities
as well as focal consolidation in the lingula and left upper
lobe. Given ceftriaxone, azithromycin, 1L IVF.
Past Medical History:
None
Social History:
lives with: roommate. Student at [**University/College 23925**] College (biomedical
electrical engineering); employed at [**University/College **] [**Location (un) **].
tobacco: none
etoh: [**3-20**] drinks/ 1 night per week
drugs: denies IVDU ever, no illicits
2 prior sexual partners, both female, used condoms.
Family History:
Father: alive and well
Mother: obesity
Physical Exam:
VS 98.3 100/72 110 18 97% RA
GEN: comfortable, NAD, resting in bed
HEENT: NC, AT, MMM
PULM; CTAB, air movement significantly improved
CV: tachy, rrr, no m/r/g
ABD: +bs, soft, nt/nd
EXT: no c/c/e
Pertinent Results:
Admission labs:
[**2114-5-13**] 01:50PM WBC-19.7* RBC-5.75 HGB-17.6 HCT-49.4 MCV-86
MCH-30.7 MCHC-35.7* RDW-12.9
[**2114-5-13**] 01:50PM NEUTS-92.2* BANDS-0 LYMPHS-2.7* MONOS-3.0
EOS-1.7 BASOS-0.3
[**2114-5-13**] 01:50PM PLT COUNT-224
[**2114-5-13**] 01:50PM GLUCOSE-121* UREA N-15 CREAT-1.3* SODIUM-141
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
[**2114-5-13**] 02:28PM LACTATE-1.5
.
Studies:
CHEST (PA & LAT) [**2114-5-13**]
IMPRESSION:
Diffusely increased reticular opacities bilaterally with more
focal region of consolidation noted within the lingula and
peripheral left upper lobe. Findings may relate to a bacterial
or atypical pneumonia (ie. mycoplasma or viral, including CMV or
even varicella); etiologies such as Pneumocystis jiroveci should
be considered, if patient is immunocompromised.
.
TTE (Complete) Done [**2114-5-19**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
.
Had 18 chest x-rays in total, put on disk for outpatient
pulmonolgist.
Last CXR - [**2114-5-27**] - Near resolution of left lower lobe opacity.
Improving small pleural effusions.
Brief Hospital Course:
21M presents with SOB, found to have ARDS likely secondary to
acute eosinophilic pneumonia.
.
# Respiratory distress/ARDS/Acute eosinophila pneumonia: Pt met
criteria for ARDS and was initially intubated for concern of
respiratory fatigue. This was initially thought to be [**2-17**]
community acquired pneumonia, and he was started on
azithro/vanc/zosyn for 7 day course. Given the results of the
BAL (negative culture and 25% eosinophils), pt was felt to have
acute eosinophilic pneumonia and was started on steroids. He
had an extensive ID workup inc. influenza (neg), resp. viral
antigen panel (neg), legionella (neg), Chlamydia ab (neg),
mycoplasma (pending), HIV AB (neg), HIV VL (neg), BAL for PCP
(neg), galactomannan (neg), histo ab (neg), B-glucan (neg),
blasto ab (neg), Coccidio ab (neg), and hantavirus ab (neg). He
was also initially worked up for DAH: [**Doctor First Name **] (neg), ANCA (neg),
anti-GBM (neg). He was maintained on ARDS net protocol in
regards to ventilation. During ventilation, pt had acute
episodes of agitation 2-3x/day, requiring high doses of
sedation. After his BAL results came back with 25% eosinophils,
he was started on solumedrol. After one week of intubation his
oxygen requirements decreased and radiographic improvement was
seen on his CXR. His ventilation setting were decreased to
pressure support and after a breathing trial was successful he
was extubated without event. He remained on steroids, and was
tapered to 40mg prednisone q daily at time of discharge with no
supplemental oxygen requirement.
.
#. Septic shock [**2-17**] ?community acquired pneumonia: It is
unclear if pt was actually septic. He became hypotensive after
intubation and receiving propofol and was hypotensive in the
setting of high PEEP, requiring levophed for 24 hrs. CVP had
been slightly low, and pt was likely intravascularly volume
depleted, requiring IVF boluses. Overall, he had good urine
output and then became hypertensive off pressors.
.
# Pancreatitis-While receiving intitial high dose steroids he
had abdominal pain, LFTs as well as amylase and lipase were
checked. His amylase and lipase were elevated, and his
pancreatitis was felt to be secondary to steroids. His tube
feeds were held and his symptoms as well as his amylase and
lipase improved.
.
# Elevated LFTs-After extubation, his abdominal pain prompted
evaluation of his LFTs, which were found to be elevated. A RUQ
u/s was done to evaluate for acalculous cholecystitis, which was
negative for stones or evidence of infection. His LFTs were
monitored and trended down without intervention.
.
# Hallucinosis- The patient developed hallucinations after
extubation, a few days after receiving steroids. Also, this was
in the context of cessation of large dose midazolam, which he
had been receiving while intubated. The etiology was felt to be
steroid induced vs benzodiazepine withdrawal. However, over the
next few days his symptoms seemed to be more consistent with
steroid induced hallucinosis and his symptoms were controlled
with haldol prn. He did not require more than 2 doses of
haldol. His symptoms had completely resolved prior to discharge
.
# Tachycardia/Atrial fibrillation with RVR: Pt went into rapid
a. fib in the evening of [**5-18**]; he was otherwise hemodynamically
stable. EKG had no evidence of ischemia. This was likely
secondary to pulmonary disease or increased cathecholamines. He
was started on a diltiazem gtt with good response and converted
to sinus in AM of [**5-19**]. ECHO was obtained and was normal. Pt
was noted to be tachyacrdia throughout his hospitalization. His
intitial presentation with tachycardia was likely due to his
infection. With the exception of the episode of afib, the
patient was in sinus rhythym. His symptoms were triggered by
exertion. He was completely asymptomatic denying shortness of
breath or palpitations. At time of discharge, his resting heart
rate was in the 80s but would increase with physicial exertion.
Given his negative ECHO and prolonged hospital course with
intubation and mechanical ventilation it is believed that there
is an element of deconditionning to his tachycardia.
.
#. Acute Renal Failure: Slightly elevated creatinine on
admission was likely prerenal as pt had poor PO intake x 1 day
and insensible losses with fever. FeNA of 0.6%. Improved with
IVFs.
.
#. Hyperglyemia-Pt with FS in 200s likely [**2-17**] steroids, was
covered with strict Insuling SLiding Scale.
.
#. Code: FULL
Medications on Admission:
None
Discharge Medications:
1. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Respiratory Distress Syndrome
Acute Eosinophilic Pneumonia
Tachycardia
Acute Pancreatitis, likely steroid-induced
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for pneumonia and subsequently
developed acute respiratory distress syndrome requiring you to
be intubated. Your pneumonia was treated with antibiotics and
steroids. You will need to continue to take these steroids as
directed until you see your pulmonologist in follow up who will
prescribed a slow taper of this medication. You were also
started on a medication called Bactrim that you will need to
take while you take the steroids to prevent an additional
infection. You have also been precribed a medication,
omeprazole, that will help with acid reflux and indigestion
while you are on the steroid as well. Please take all
medications as prescribed and please follow up with your
pulmonologist in [**Location (un) 9095**] as scheduled below.
.
Should you experience any increased shortness of breath, heart
palpitations, worsening cough or any other symptoms that are new
or of concern to you, please contact your primary care physician
immediately or return to the Emergency Department.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Pulmonology at
[**Location (un) 60883**]Hospital on Thursday, [**2114-6-14**] at 9:20 am.
Please take your CD with your chest x-rays with you to this
appointment. If there is a problem with this appointment, please
contact their office at ([**Telephone/Fax (1) 78387**]. You should also receive
information regarding this appointment in the mail.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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"785.0",
"577.0",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8753, 8759
|
3815, 8315
|
333, 395
|
8923, 8934
|
1962, 1962
|
10013, 10588
|
1690, 1731
|
8370, 8730
|
8780, 8902
|
8341, 8347
|
8958, 9990
|
1746, 1943
|
274, 295
|
423, 1314
|
1978, 3792
|
1336, 1342
|
1358, 1674
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,737
| 102,016
|
25715
|
Discharge summary
|
report
|
Admission Date: [**2163-7-20**] Discharge Date: [**2163-8-8**]
Date of Birth: [**2113-11-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p motorcycle accident
Major Surgical or Invasive Procedure:
1. external fixation open L distal radius/ulna fx
2. operative washout L open distal radius/unla fx
3. ORIF L metatarsal fx
History of Present Illness:
49 yo man status post motorcycle collision vs car. + helmet, ?
LOC. Patient was combative and agitated at the scene with a
GCS=10. Patient was brought by ambulance to [**Hospital1 1474**] ED, found
to have a GCS=14 on arrival. By report from [**Hospital1 1474**], patient
was found to have a closed book pelvic fracture, open L radial
fracture. He was electively intubated prior to [**Hospital 7622**]
transfer to [**Hospital1 **]. By report, a crack pipe was found with the
patient at the scene.
Past Medical History:
Hx Colon Ca (~[**2159**]), s/p [**Month (only) **], chemo, radiation
Hx multiple traumatic bony injuries
Hx substance abuse
Social History:
Homeless since [**2145**], rides motorcycle around country. +tobacco,
occ. EtoH, + substance abuse.
Family History:
Noncontributory
Physical Exam:
VITALS: 167/94 88 22 97% (intubated)
Exam on arrival:
GEN: sedated, intubated
HEENT: pupils equal + sluggish bilaterally. Face with large
amounts of dried blood, no obvious bony deformity or facial
laxity. Blood in L external auditory canal.
CHEST - equal BS bilaterally
CV - RRR
ABD - soft, nontender, nondistended, s/p colostomy
RECTAL - no anus, ostomy heme negative
GU - foley in place
EXTR - open L forearm deformity, L 5th metacarpal deformity
BACK - no abrasions, 1-2cm puncture wound R flank
NEURO - MAE x 4
Exam on discharge:
GEN: awake and alert
HEENT: PERRL, EOEMI
CHEST - equal BS bilaterally
CV - RRR
ABD - soft, nontender, nondistended, s/p colostomy
EXTR - extremity splints C/D/I
BACK - well-healed wound, sutures removed, no erythema/pus
NEURO - MAE x 4
Pertinent Results:
[**2163-7-20**] 05:20PM URINE RBC-[**2-12**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2163-7-20**] 05:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2163-7-20**] 05:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2163-7-20**] 05:20PM FIBRINOGE-222
[**2163-7-20**] 05:20PM PT-14.0* PTT-27.5 INR(PT)-1.3
[**2163-7-20**] 05:20PM PLT COUNT-201
[**2163-7-20**] 05:20PM WBC-18.5* RBC-4.06* HGB-12.8* HCT-36.3*
MCV-90 MCH-31.5 MCHC-35.2* RDW-13.0
[**2163-7-20**] 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2163-7-20**] 05:20PM URINE GR HOLD-HOLD
[**2163-7-20**] 05:20PM URINE HOURS-RANDOM
[**2163-7-20**] 05:20PM URINE HOURS-RANDOM
[**2163-7-20**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2163-7-20**] 05:20PM AMYLASE-75
[**2163-7-20**] 05:20PM UREA N-12 CREAT-0.9
[**2163-7-20**] 05:34PM freeCa-1.02*
[**2163-7-20**] 05:34PM HGB-13.6* calcHCT-41 O2 SAT-95 CARBOXYHB-4
MET HGB-1
[**2163-7-20**] 05:34PM GLUCOSE-115* LACTATE-1.9 NA+-145 K+-3.8
CL--112 TCO2-23
[**2163-7-20**] 05:34PM TYPE-ART PH-7.35 COMMENTS-GREEN TOP
RADIOLOGIC STUDIES (SUMMARY):
CXR: R mainstem intubation, bilateral clavicular fxs
Pelvis plain film: R superior/inferior pubic rami fxs (new?),
old sacral pinning
CT head: negative
C spine: negative
CT Chest/Abdomen/Pelvis: no fx's, no solid organ injury, s/p
ostomy
L arm: open, displaced distal radial/ulnar fxs
L ankle: no fx
Brief Hospital Course:
The patient was admitted to the TSICU from the ED. He was
evaluated via physical exam and review of the images that were
taken in the ED and found to have the following injuries:
open L ulnar fracture/dislocation, and distal radial fracture
L elbow dislocation
old R pubic fractures
new nondisplaced L inferior pubic ramus fracture
bilateral old clavicle fractures
R 8th rib fracture
R pulmonary contusions and small effusion
small R pneumothorax
face and R flank lacerations
He was taken to the OR on [**2163-7-21**] for irrigation and
debridement of the both fracture in the left arm, placement of
an external fixator across the wrist and examination of the left
elbow under anesthesia with confirmation of reduction. For
additional details regarding this procedure please see Dr. [**Name (NI) 64103**] operative note. He returned to the OR on [**7-23**] for
irrigation and debridement of his left open distal ulnar and
radius fractures. For additional details regarding this
procedure please see Dr.[**Name (NI) 21863**] operative note.
He was released from the unit to the floor. Here he was seen by
PT and social work. He was encouraged to stop smoking to
promote wound healing and was given a nicotine patch to aid in
this process. However he insisted on smoking and would take
himself downstairs in his wheelchair to do so.
On [**7-28**] L foot 2,3,4 metatarsal fractures with angulation of 4
were found on XRay. He was scheduled for surgery to fix his
metatarsal fractures on [**8-1**] but refused to adhere to his NPO
status so his surgery had to be postponed. On the evening of
[**8-2**] he ate a tray of homemade ziti and developed severe belly
pain. He stopped putting out stool into his ostomy and by the
morning of [**8-3**] CT revealed dilated loops of bowel, a tranistion
point in the mid abdomen, no passage of contrast beyond this
point, and compressed bowel in his pelvis with a transition.
These images along with his physical exam were consistent with
SBO and he was taken to the OR on [**8-3**] for lysis of adhesions,
closure of an internal space adjacent to the colostomy and
repair of a lateral internal hernia. For additional details
regarding this procedure please see Dr.[**Name (NI) 1863**] operative
note.
On [**8-6**] he returned to the OR for open reduction and internal
fixation 4th L metatarsal by podiatry concurrent with open
reduction and internal fixation of
his right distal radius fracture, volar by ortho. For
additional details regarding these procedures please see Dr. [**Name (NI) 64104**] and Dr.[**Name (NI) 4213**] operative notes.
He returned to the floor to await PT work and diet advancement
but again refused to adhere to his NPO status and requested to
be sent home with his girlfriend. After restarting his diet
against medical advice, he remained without abdominal pain or
vomiting for over 24 hours and began to pass gas into his
ostomy. He was discharged with a wheelchair and follow-up plans
in place with all participating services.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p motorcycle crash
open left ulnar fracture and dislocation
left distal radius fracture
nondisplaced left inferior pubic ramus fracture
right 8th rib fracture
right pulmonary contusion with small effusion
small right pneumothorax
lacerations on right flank and faceleft
left 2nd-4th metatarsal fractures
small bowel obstruction
internal hernia
Discharge Condition:
Fair to good
Discharge Instructions:
You should call a physician or come to ER if you have worsening
pains, fevers, chills, abdominal pain, nausea, vomiting,
shortness of breath, chest pain, redness or drainage about the
wounds, or if you have any questions or concerns.
It is important you take medications as directed. You may
continue to take your pre-admission medicaitons unless otherwise
directed, but you should not take motrin or for at least a week
after surgery. You should not drive or operate heavy machinery
while on any narcotic pain medication such as percocet as it can
be sedating. You may take colace to soften the stool as needed
for constipation, which can be cause by narcotic pain
medication.
You should keep your splints intact and dry until seen at
follow-up visit.
You may remove the bandage on your neck tomorrow.
Followup Instructions:
Call for a follow-up appointment at the Trauma Clinic
([**Telephone/Fax (1) 2359**]) in 1 week.
Left arm: Call for a follow-up appointment with Dr. [**Last Name (STitle) 1005**]
(Orthopedic Surgery; [**Telephone/Fax (1) 4845**]) in 2 weeks.
Right arm: Call for an appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 4845**])
in 1 week.
Foot: Call for an appointment with Dr. [**First Name (STitle) 3209**] ([**Telephone/Fax (1) 543**]).
Call for an appointment at the [**Hospital **] Clinic ([**Telephone/Fax (1) 2384**]);
your blood glucose levels in the hospital were suggestive of
mild diabetes.
|
[
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"305.1",
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icd9cm
|
[
[
[]
]
] |
[
"79.72",
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] |
icd9pcs
|
[
[
[]
]
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7036, 7042
|
3699, 6707
|
337, 462
|
7431, 7445
|
2098, 3508
|
8300, 8922
|
1268, 1285
|
6730, 7013
|
7063, 7410
|
7469, 8277
|
1300, 1823
|
274, 299
|
490, 988
|
1842, 2079
|
3517, 3676
|
1010, 1135
|
1151, 1252
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,524
| 129,446
|
2283+55366
|
Discharge summary
|
report+addendum
|
Admission Date: [**2166-11-14**] Discharge Date: [**2166-12-25**]
Date of Birth: [**2090-9-9**] Sex: F
Service: Blue Surgery
HISTORY OF PRESENT ILLNESS: Patient was admitted on [**2166-11-14**] with a chief complaint of recurrent right pleural
effusions. Patient is a 76-year-old female with polycystic
liver disease status post two prior cyst excisions and one
aspiration, who presented on [**10-25**] with a large right pleural
effusion, plus herniation to the liver, and superior cyst
into the right hemithorax with whiteout of the right chest
and mediastinal shift. An ultrasound guided pigtail catheter
was inserted on [**10-26**] and effectively drained the effusion.
She was discharged home in good condition on [**11-1**].
The day prior to admission she was seen in followup by Dr.
[**Last Name (STitle) **] and repeat chest x-ray was found to have
reaccumulation of her pleural effusion. She presented on the
date of admission for workup management per her primary care
physician.
PAST MEDICAL HISTORY:
1. Polycystic liver disease.
2. Hypertension.
3. Diabetes mellitus, diet controlled.
4. Diverticulosis.
PAST SURGICAL HISTORY:
1. Status post liver cyst excision about 26 years ago.
2. Status post exploratory lap.
3. Status post cholecystectomy.
4. Status post oophorectomy.
SOCIAL HISTORY: Remarkable for no tobacco use and no alcohol
use. Lives alone.
FAMILY HISTORY: No polycystic disease.
ALLERGIES: Sulfa causing nausea and vomiting and codeine.
MEDICATIONS ON ADMISSION:
1. Lisinopril 5 q.d.
2. Aspirin.
3. Colace 100 mg p.o. b.i.d.
REVIEW OF SYSTEMS: Showed mild worsening of the exertional
dyspnea, most prominently some increased dyspnea when she
lies down, but denies orthopnea, paroxysmal nocturnal
dyspnea. No fever or chills. No changes in abdominal girth
and no changes in bowel habits.
PHYSICAL EXAMINATION: She was afebrile at 96.9 with a heart
rate of 100, pressure of 189/84, respirations 15, and satting
96% on room air. In general, she was a pleasant female in no
acute distress breathing comfortably. Her HEENT examination
showed no scleral icterus. Trachea was midline without
stridor. Chest: Decreased breath sounds on the right with
dullness to percussion throughout. Positive egophony and
chest was clear to auscultation on the left. Heart was
regular rate and rhythm without murmurs, rubs, or gallops.
Abdomen with a firm mass, nontender over the right upper
quadrant just under the right subcostal region. Extremities
showed no clubbing, cyanosis, or edema. Palpable DP and PT
pulses were felt.
LABORATORIES: On admission her laboratory values were a
white count of 6, hematocrit of 43.9, and platelets of 184
with chemistries of sodium 143, potassium 3.4, chloride 101,
bicarb 33, BUN 11, creatinine of 0.6, and a glucose of 187
with an AST of 81, ALT of 88, alkaline phosphatase of 410,
and T bilirubin of 1.4.
A chest x-ray showed a right chest whiteout with positive
shift.
Abdominal MRI on [**11-12**] showed 17 x 16 x 13 cm liver cyst in
the right lobe, right chest, bilateral kidney cysts largest 4
cm.
Patient was immediately followed up by Hepatology for massive
cyst in the liver. MRI in [**2166-2-8**] showed innumerable
hepatic cysts with preponderance in the left lobe. There is
a large right hepatic lobe cyst which measured 13 x 15 x 17.5
cm. The distal common bile duct was normal in contour and
caliber, mild dilatation of the central hepatic ducts. Some
of the liver cysts demonstrated proteinaceous hemorrhagic
debris. There was normal hepatofugal flow in the main portal
vein. No arterial enhancing lesions were identified within
the liver.
Patient had thoracentesis and fluid sent for culture
cytology. Chest tube placement at that time was also done at
that time. Chest x-ray still showed elevation of right
hemidiaphragm secondary to compression from the liver. The
best option was felt to be surgical decompression of the
large cyst in the posterior portion of the right liver lobe
as per recommendations of Hepatobiliary house staff.
Patient was preoped for right thoracoscopy by Thoracics on
[**2166-11-16**], and was taken to the operating room on [**2166-11-17**]
for a diagnosis of polycystic liver disease and for
fenestration of giant liver cyst with repair of the diaphragm
and chest tube placement, pleural biopsy. Surgeons are Dr.
[**Last Name (STitle) **], Dr. [**Last Name (STitle) 7820**], and Dr. [**Last Name (STitle) 175**]. Under general anesthesia,
the patient was given 4500 units of crystalloid with 600
units of urine output with an estimated blood loss of 200 cc.
Patient was stable postoperatively and was admitted to the
Trauma SICU.
Upon admission to Trauma SICU, the patient was noted to be in
AFib with a heart rate of 103, pressures were 80s/50s, CVP 3,
respiratory rate of 19, and 100% on nasal cannula on 4
liters. Hematocrit was 36 with a preoperative of 40. PT was
14.7, PTT was 26, and INR was 1.4. Albumin 2.1. Sodium was
140, potassium 4.4, chloride 109, bicarb 25, BUN 9,
creatinine 0.4, glucose 179 with a calcium of 7.9, magnesium
1.4, and phosphorus 3.7, ALT of 186, AST of 253, alkaline
phosphatase 302, T bilirubin 2.6.
Chest x-ray at that time showed elevated right hemidiaphragm.
Right chest tube was in place without effusion. Heart was
rotated to the left without pneumothorax. Central line was
in good position and nasogastric tube terminated in the
stomach.
Patient continued to require significant volume to maintain
blood pressures and urine output around 8 liters on [**11-18**], developing a significant metabolic acidosis with a base
access deficit of -8. Albumin was started at that time in
order to increase intervascular volume load. Aggressive
resuscitation remained throughout postoperative days two and
three.
Patient was transfused on postoperative day two with volume
resuscitation and was extubated. By postoperative day three,
the patient was stable and prn Morphine for medications.
Neurologically wise and cardiovascular wise, the patient was
stable. Respiratory wise, the patient was aggressively
treated with pulmonary toilet and incentive spirometry.
GI: Patient was on clears. GU: Patient was given albumin
to increase urine output. Heme: Patient's hematocrit was
stable at 32.9. Was given vitamin K, and patient was
continued on Unasyn.
Patient's Swan-Ganz catheter was D/C'd on postoperative day
four. The patient was without complaints, and once again,
aggressive hydration was instilled for decreased urine
output. Replacement of chest tube losses with IV fluids and
albumin was continued on postoperative day #5. Small dosed
Lasix was begun, and patient was encouraged p.o. intake of
regular soft diet with continued pulmonary toilet.
Albumin q.i.d. was started on postoperative day #6. Patient
was seen by Physical Therapy throughout. Right subclavian
was changed over wire on [**11-26**]. Patient had mild
thrombophlebitis from IV infiltrate on [**11-28**]. Was started on
Kefzol 1 gram IV q.8. Chest tubes were placed to water-seal
on postoperative day #11. Chest x-ray was obtained, however,
greater than 500 a day of fluid was still being drained from
the chest tube. Patient was begun on TPN at that time.
Chest tube was continued to water-seal, and patient was
started on Levaquin on [**2166-12-10**]. Tap pleurodesis was done
on [**2166-12-17**], postoperative day 30. Patient remained
stable throughout, however, high output continued throughout
the chest tube, and patient began to develop 2+ peripheral
edema on postoperative day 34.
The patient had second tap pleurodesis on [**2166-12-22**].
Chest x-ray showed increased aeration in the right upper
lobe, however, still fluid buildup in the right lobe. Chest
tubes were D/C'd on [**2166-12-24**]. After chest tube
output decreased from 300 cc/24 hours to 25 cc/24 hours, and
the patient was discharged on [**2166-12-25**] in good
condition to a rehabilitation facility.
DIAGNOSES:
1. Massive liver cyst.
2. Hypertension.
3. Type 2 diabetes mellitus.
3. Polycystic liver disease.
4. Right diaphragmatic dysfunction status post secondary
drainage surgery.
5. History of shortness of breath.
6. Status post oophorectomy and cholecystectomy.
7. Anxiety.
8. Diverticulosis.
Summary of patient's culture data showed blood cultures from
[**2166-12-10**] with no growth as were 2/2 bottles, pleural fluid
sent showed no growth and no PMNs. On [**2166-12-7**] catheter
tip was sent for culture. It showed Enterococcus greater
than 15 colonies. Sensitive to ampicillin, levo, penicillin,
Vancomycin. Hence, the patient was started on levofloxacin.
Blood cultures on [**2166-12-7**] showed Enterococcus fecalis
sensitive to ampicillin, levo, penicillin, and Vancomycin.
Urine culture was contaminated on [**2166-12-7**]: No growth on
blood cultures. On [**2166-11-25**] 2/2 bottles. Catheter tip on
[**2166-11-25**] showed no growth. MRSA screen on [**2166-11-19**]
showed no Staphylococcus aureus isolated. Fluid sent on
[**2166-11-17**] from liver abscess showed no PMNs, no growth. No
microbacteria, no acid-fast bacilli, no growth on anaerobic
culture, no growth on tissue culture, and Gram stain was
negative for tissue sent from operating room. Pleural fluid
from operating room also was negative.
Pathology showed diagnosis of cauterized dense fibrovascular
tissue, not iron deficiency, no iron stain, or trichrome
stain showing fibrous tissue. Cyst draw with multiple cysts
lined on single layer of cuboidal epithelial cells and
focally calcified fibrous wall consistent with polycystic
liver disease. Focal mild chronic also present in the wall.
No liver parenchyma was seen.
CONDITION ON DISCHARGE: The patient was discharged home in
good condition.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Polysaccharide iron complex 150 mg p.o. q.d.
2. Lasix 40 mg p.o. b.i.d.
3. Promethazine 25 mg p.o. q.6h. prn.
4. Protonix 40 mg p.o. q.d.
5. Cepacol prn.
6. Percocet 1-2 tablets p.o. q.4-6h. prn.
7. Ibuprofen 400 mg p.o. q.8h. prn.
8. Acetaminophen 325-650 mg p.o. q.4-6h. prn.
9. Zinc sulfate 220 mg p.o. q.d.
10. Aluminum magnesium hydroxide 15/30 mL p.o. q.i.d. prn.
11. Senna one tablet p.o. b.i.d.
12. Psyllium wafer one wafer p.o. q.d.
13. Colace 100 mg p.o. b.i.d.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Name8 (MD) 11998**]
MEDQUIST36
D: [**2166-12-24**] 21:57
T: [**2166-12-25**] 05:40
JOB#: [**Job Number 11999**]
Name: [**Known lastname 1714**], [**Known firstname 1715**] Unit No: [**Numeric Identifier 1716**]
Admission Date: [**2166-11-14**] Discharge Date: [**2167-1-3**]
Date of Birth: [**2090-9-9**] Sex: F
Service:
THIS IS AN ADDENDUM:
HISTORY OF PRESENT ILLNESS: Please see prior discharge
summary dated [**2166-12-25**], for prior events. Briefly the
patient is a 76 year old female with polycystic liver disease
status post prior liver cyst excisions and one aspiration, a
large right pleural effusion status post pigtail catheter
drainage, status post right thoracoscopy on [**2166-11-16**],
with subsequent demonstration of a giant liver cyst with
repair of diaphragm and chest tube placement and pleural
biopsy on the following day, and one cyst aspiration.
Since the time of the last discharge summary on [**2166-12-25**], the patient was slated to go to rehabilitation
facility, however on [**12-26**], the patient developed
respiratory chest with chest pain and oxygen desaturation. A
cardiology consult was obtained which suggested no acute
coronary syndrome.
On [**2166-12-29**], the patient was transferred to the
Surgical Intensive Care Unit for presumed fluid overload as a
cause of her shortness of breath. In the surgical Intensive
Care Unit the patient was placed on a Lasix strip. A left
sided subclavian line was placed. A left subclavian central
line for Swan-Ganz catheterization was placed. A small left
pneumothorax developed. The patient was placed on
levofloxacin empirically for question of pneumonia causing
her shortness of breath. She was continued to be given
intermittent Lasix with albumin.
On approximately [**12-31**], the patient had an episode of
hypoxia. A CT angiogram was obtained to rule out pulmonary
embolism which was negative. The patient developed oliguria
not responsive to Lasix and Zaroxolyn. It was thought that
the patient likely had ATN. He was transferred to the floor
on [**2167-1-2**]. The next day the patient appeared to
have respiratory distress with increased edema.
The patient was transferred to the medical Intensive Care
Unit on [**2167-1-3**].
A family meeting with the patient's son, and daughter and
daughter in law were held. At this family meeting the family
agreed that the patient would not want aggressive level of
care as would require for hemodialysis. They said their
mother expressed wishes to spend her last days at home.
Arrangements were made for home hospice and treatment of her
dyspnea for comfort. The patient was transferred later than
day to home with hospice care.
DISCHARGE MEDICATIONS:
1. Roxanol
2. Colace.
3. Senna
4. Ativan
5. Heparin flushes for PICC line
6. Tylenol.
DISCHARGE DISPOSITION: To home with hospice.
DR.[**Last Name (STitle) 72**],[**First Name3 (LF) 73**] 12-761
Dictated By:[**Name8 (MD) 1721**]
MEDQUIST36
D: [**2167-2-4**] 14:21
T: [**2167-2-4**] 20:39
JOB#: [**Job Number 1722**]
|
[
"286.9",
"751.62",
"518.81",
"427.31",
"512.1",
"999.2",
"428.0",
"584.5",
"511.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"34.09",
"99.15",
"33.22",
"54.59",
"89.64",
"34.92",
"99.04",
"53.81",
"34.24",
"50.29"
] |
icd9pcs
|
[
[
[]
]
] |
13301, 13546
|
1415, 1499
|
13184, 13277
|
1525, 1588
|
1167, 1316
|
1877, 9698
|
1608, 1854
|
10864, 13161
|
1039, 1144
|
1333, 1398
|
9723, 9823
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,298
| 183,445
|
10966
|
Discharge summary
|
report
|
Admission Date: [**2134-6-29**] Discharge Date: [**2134-7-5**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 87 -year-old
female with a history of myocardial infarction who presented
on [**2134-6-15**] to [**Location (un) **] for rule out myocardial infarction,
represented on [**2134-6-29**] with post myocardial infarction
infarct angina, also a rule out myocardial infarction. The
patient was transferred to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **]
[**Last Name (Titles) **] for catheterization and the catheterization showed
three vessel disease.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Chronic obstructive pulmonary disease.
3. Paget's disease.
4. History of arthritis.
5. History of non-Q-wave myocardial infarction on [**2134-6-15**].
6. Anxiety.
PAST SURGICAL HISTORY: The patient is status post bilateral
hip replacement.
ADMITTING MEDICATIONS: Included aspirin 325 mg po q day,
Imdur 30 mg q day, Atenolol 25 mg q day, Lisinopril 5.0 mg q
day, nitroglycerin one inch q six hours, calcium 500 mg q
day, Calcitonin nasal spray one spray q day, Klonopin 0.5 mg
[**Hospital1 **].
ALLERGIES: Include codeine, ciprofloxacin, Demerol, sulfa,
amoxicillin, and penicillin.
SOCIAL HISTORY: The patient lives alone in an [**Hospital3 5673**] unit. She has three daughters nearby and can be
described as independent.
PHYSICAL EXAMINATION: Pulse 76, blood pressure 159/75.
Neck: carotids +2 with no bruits. Heart was regular rate and
rhythm, S1, S2, with a positive septal murmur. Lungs were
positive crackles which were few and bibasilar. Extremities
included negative edema, +2 femoral pulses, +1 dorsalis pedis
pulses, and +1 posterior tibial pulses bilaterally.
LABORATORY DATA: Initial electrocardiogram showed normal
sinus rhythm with slight ST-T-wave decreases laterally. Labs
included a white blood cell count of 7.7, hematocrit of 36.5,
platelets 305,000. Sodium 132, potassium 3.9, chloride of
37, CO2 of 27, BUN of 9.0, creatinine of 0.6, and glucose of
99.
The coronary angiogram showed heavy calcified coronaries,
right dominant left anterior descending was 99% proximal, 85%
mid, small diffuse disease in first diagonal, subtotally
occluded proximal second diagonal, left circumflex 90% mid
and 30% after second obtuse marginal artery, first obtuse
marginal artery was small, not observed, second obtuse
marginal artery was 50%, osteal taper of third obtuse
marginal artery was large, non-observed. Right coronary
artery was subtotal mid filled by R-R and L-R collaterals
with a final assessment of severe three vessel and branch
coronary artery disease with preserved left ventricular
ejection fraction.
HOSPITAL COURSE: The patient was brought to the Operating
Room on [**2134-6-30**] for a coronary artery bypass graft times
three with an left internal mammary artery to the left
anterior descending, and vein grafts to the first obtuse
marginal artery and second obtuse marginal artery. The
patient tolerated the procedure well and was transferred to
the Cardiothoracic Intensive Care Unit.
On postoperative day one, the patient was extubated and doing
well and was transferred to the Cardiac Floor. On
postoperative day two, the patient was doing well, on
increased ambulation and physical therapy. On postoperative
day two, also the mediastinal chest tubes were removed and on
postoperative day three the pleural chest tube was removed.
The patient continued to do well with slow progression on
physical therapy, resulting in a rehabilitation screening.
The patient's discharge physical examination included a
maximum temperature of 99.8 F, pulse of 96, blood pressure
133/46, respiratory rate 20, 96% on one liter, -3.1 kg weight
change from preoperative. In general, was alert and
oriented, in no acute distress. Cardiovascular was regular
rate and rhythm, negative murmurs, positive sternal stability
with negative click. Respiratory rate was clear to
auscultation bilaterally. Abdomen was soft, nontender,
positive bowel sounds. Extremities showed negative pitting
edema with mild swelling. Incision was intact, clean, and
dry.
COMPLICATIONS: None.
DISCHARGE MEDICATIONS: Include Lopressor 50 mg [**Hospital1 **], Lasix 20
mg po bid times seven days, KCL 120 mg po bid times seven
days with the Lasix, Klonopin 0.5 mg po bid, Plavix 75 mg po
q day, ranitidine 150 mg po bid, aspirin 81 mg po q day,
Percocet one to two tablets po q three to four hours, Serax
50 mg po q HS prn, and Tucks prn.
DISPOSITION: The patient was discharged to rehabilitation in
good and stable condition.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1537**] in three
to four weeks.
PRIMARY DIAGNOSIS:
Status post coronary artery bypass graft times three.
SECONDARY DIAGNOSES:
1. Coronary artery disease.
2. Hypertension.
3. Chronic obstructive pulmonary disease.
4. Paget's disease.
5. History of arthritis.
6. Status post bilateral hip surgeries.
DISCHARGE STATUS: The patient will be going to Life Care
Centers of America. She will be going to Life Care Centers
of [**Location 15289**], phone number [**Telephone/Fax (1) 35574**], fax number
[**Telephone/Fax (1) 35575**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 33068**]
MEDQUIST36
D: [**2134-7-5**] 07:26
T: [**2134-7-5**] 09:05
JOB#: [**Job Number 35576**]
|
[
"300.00",
"496",
"401.9",
"414.01",
"272.0",
"411.1",
"410.72",
"731.0",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.53",
"88.56",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4193, 4708
|
2718, 4169
|
842, 1244
|
4803, 5492
|
1411, 2700
|
112, 595
|
4727, 4782
|
617, 818
|
1261, 1388
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,562
| 196,533
|
30503
|
Discharge summary
|
report
|
Admission Date: [**2112-3-7**] Discharge Date: [**2112-3-15**]
Date of Birth: [**2065-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain, +ETT
Major Surgical or Invasive Procedure:
Cardiac catheterization [**3-7**]
CABG [**3-11**]
History of Present Illness:
46yoM w/1 year history of exertional chest pain, had +ETT
referred for cardiac catheterization.
Past Medical History:
HTN
^chol
GERD
Social History:
Married, works in sports store.
Remote tobacco-quit 5 years ago, Occaisional ETOH
Family History:
sister had PCI at age 50 years
Physical Exam:
Admission
VS T HR 70 BP 127/81 RR 20 Ht 6'2" Wt
Gen NAD
Neuro A&Ox3
Neck supple, no bruits
Pulm CTA bilat
CV RRR no murmurs
Abdm soft, NT/ND/NABS
Ext no edema or varicosities. Pulses 2+ throughout
Discharge
VS T 98.7 HR 100ST BP 112/62 RR 18 O2sat 94%RA Wt 92.5kg
Gen NAD
Neuro nonfocal exam
Pulm CTA bilat
CV RRR S1-S2, no MRG. Sternum stable, incision CDI
Abdm soft NT/NABS
Ext warm, well perfused. 1+Pedal edema bilat. Rt SVH site
w/steri CDI
Pertinent Results:
[**2112-3-7**] 07:45PM GLUCOSE-84 UREA N-12 CREAT-0.9 SODIUM-140
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-11
[**2112-3-7**] 07:45PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-59
AMYLASE-30 TOT BILI-0.8
[**2112-3-7**] 07:45PM ALBUMIN-3.9 CHOLEST-256*
[**2112-3-7**] 07:45PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE
[**2112-3-7**] 07:45PM TRIGLYCER-296* HDL CHOL-36 CHOL/HDL-7.1
LDL(CALC)-161*
[**2112-3-7**] 07:45PM WBC-8.8 RBC-4.57* HGB-13.9* HCT-40.6 MCV-89
MCH-30.4 MCHC-34.2 RDW-13.1
[**2112-3-7**] 07:45PM PLT COUNT-218
[**2112-3-7**] 07:45PM PT-11.8 INR(PT)-1.0
[**2112-3-15**] 07:20AM BLOOD WBC-6.5 RBC-3.02* Hgb-9.5* Hct-26.9*
MCV-89 MCH-31.3 MCHC-35.1* RDW-14.4 Plt Ct-225#
[**2112-3-15**] 07:20AM BLOOD PT-12.3 PTT-24.5 INR(PT)-1.1
[**2112-3-15**] 07:20AM BLOOD Glucose-88 UreaN-15 Creat-0.9 Na-138
K-4.3 Cl-102 HCO3-29 AnGap-11
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2112-3-15**] 8:48 AM
CHEST (PA & LAT)
Reason: pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
46 year old man s/p CABG
REASON FOR THIS EXAMINATION:
pleural effusion
INDICATION: Status post CABG, evaluate for effusion.
COMPARISON: [**2112-3-13**].
FRONTAL AND LATERAL CHEST RADIOGRAPHS
Median sternotomy wires and clips overlying chest again seen.
Cardiac and mediastinal contours appear stable. There has been
interval removal of the right-sided central venous line. No
sizable pneumothorax is identified. Pulmonary vascularity
appears within normal limits. No focal consolidations are seen
within the lungs. Small bilateral pleural effusions noted.
Improving left basilar atelectasis is also seen.
IMPRESSION: Small bilateral pleural effusions. Improving basilar
atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Cardiology Report ECHO Study Date of [**2112-3-11**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: cabg
Status: Inpatient
Date/Time: [**2112-3-11**] at 09:28
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW01-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.4 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 2.2 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal inferior
- normal; mid inferior - normal; basal inferolateral - normal;
mid inferolateral - normal; basal anterolateral - normal; mid
anterolateral - normal; anterior apex - normal; septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Trivial MR.
TRICUSPID VALVE: No TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
Pre-CPB: Normal LV systolic fxn. No spontaneous echo contrast is
seen in the left atrial appendage. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
Post-Bypass: Preserved biventricular systolic fxn. No AI, no MR.
Aorta intact.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Pt admitted to cardiology service after +ETT for scheduled
cardiac cath that revealed 3VD with preserved EF of 65%.
After catheterization he was referred to cardiac surgery for
bypass grafting. On [**3-11**] he was brought to the operating
room for coronary artery bypass grafting. Please see OR report
for details, in summary had CABGx4 with LIMA-LAD,Free RIMA-OM,
SVG-Diag,and SVG-RCA, his bypass time was 98 min with crossclamp
of 82 min. He tolerated operation well and was transferred from
OR to Cardiac surgery ICU. He did well in the immediate post-op
period , anesthesia was reversed he was weaned from ventilator
and extubated. On POD1 he was weaned from vasoactive intravenous
medications and started on oral medications. On POD2 his chest
tubes were removed and he was transferred to the step down
floors. On POD3 his epicardial wires were removed and activity
advanced. By POD4 it was determined the patient was stable and
ready for discharge home with Visiting nurses.
Medications on Admission:
Omeprazole 30'
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Isosorbide Mononitrate 30 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*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
Disp:*90 Tablet(s)* Refills:*2*
9. Omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO once a day: resume preop
dose and schedule.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p CABGx4(LIM-LAD, Free RIMA-OM, SVG-Diag, SVG-RCA)
HTN
^chol
GERD
Discharge Condition:
good
Discharge Instructions:
keep wounds clan and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
wound clinic in 2 weeks
Dr [**Last Name (STitle) 7047**] in [**3-27**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2112-3-15**]
|
[
"411.1",
"429.9",
"414.01",
"427.31",
"272.0",
"401.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"99.04",
"36.15",
"37.22",
"39.61",
"88.53",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8240, 8295
|
5944, 6927
|
338, 390
|
8411, 8418
|
1194, 2158
|
8619, 8767
|
668, 700
|
6992, 8217
|
2195, 2220
|
8316, 8390
|
6953, 6969
|
8442, 8596
|
3211, 5884
|
715, 1175
|
282, 300
|
2249, 3185
|
418, 515
|
5921, 5921
|
537, 553
|
569, 652
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,984
| 172,578
|
47896
|
Discharge summary
|
report
|
Admission Date: [**2170-12-21**] Discharge Date: [**2170-12-26**]
Date of Birth: [**2108-4-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
EtOH Withdrawal, s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 5636**] is a 62 year old man with h/o EtOH abuse, prior
withdrawal, no seizures or DTs, HIV (last CD4 245 in [**6-20**]), who
presented s/p fall, BIBEMS for likely EtOH withdrawal.
Patient was found down in the bathroom today by his assistant.
Patient does not remember falling, but noted pain in his neck.
He drinks 2-3 cups of alcohol every night, last drink evening of
[**2170-12-20**]. He has had prior hospitalizations for EtOH withdrawal,
but denied prior seizures, DTs, or visual hallucinations.
In the ED, initial vs were: 98.7 131 143/85 20 94%. Tox screen
was negative. EKG showed sinus tachycardia. CT head and Cspine
unremarkable. Patient was given 3L IVF, MVI/thiamine/folate, and
Ativan 26mg over the course of 3 hours. Vitals prior to
transfer: 109, 140/93, 26, 97% 4L
On the floor, the patient is currently lethargic, but arousable.
He is comfortable and has no complaints. No trouble breathing,
nausea, chest pain, abdominal pain.
Past Medical History:
- ETOH abuse
- HIV, last CD4 245 in [**6-20**]
- HTN
- HLD
- GERD
- fall [**4-/2170**] c/b bifrontal SAH; L occipital bone/ L occipital
condyle fxs
- s/p proximal tibia ORIF
Social History:
Retired city planner. He lives at home alone with his 2 cats.
Tobacco: none
ETOH: Drinks 2-3 cups of white wine or brandy/night. hx of prior
hospitalizations for withdrawal
Drugs: none
Family History:
Father - [**Name (NI) 2481**]
Mother - CVA
Brother - CA
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.2 BP: 141/87 P: 97 R: 24 O2: 96% 2LNC
General: lethargic, orientedx2, no acute distress
HEENT: Sclera anicteric, dried blood on lip
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, reducible
umbilical hernia
GU: foley
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema
Neuro: A&Ox2, moving all extremities, tremulous
DISCHARGE EXAM:
Patient was A&O x 3. No evidence of tremor or neurlogic
compromise. Overall he is weak and needs help with ambulation
but much improved.
Pertinent Results:
ADMISSION LABS:
[**2170-12-21**] 07:00PM BLOOD WBC-11.0# RBC-4.82# Hgb-15.0# Hct-44.7#
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.4 Plt Ct-309
[**2170-12-21**] 07:00PM BLOOD Neuts-87.3* Lymphs-9.5* Monos-2.8 Eos-0.1
Baso-0.4
[**2170-12-21**] 07:00PM BLOOD PT-13.5* PTT-30.1 INR(PT)-1.2*
[**2170-12-21**] 07:00PM BLOOD Glucose-148* UreaN-7 Creat-0.7 Na-136
K-4.4 Cl-97 HCO3-20* AnGap-23*
[**2170-12-21**] 07:00PM BLOOD ALT-50* AST-81* LD(LDH)-277* CK(CPK)-96
AlkPhos-128 TotBili-0.8
[**2170-12-22**] 05:02AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6
[**2170-12-21**] 07:00PM BLOOD Albumin-4.0
[**2170-12-21**] 07:00PM BLOOD Osmolal-293
[**2170-12-21**] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE:
[**2170-12-21**] 08:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2170-12-21**] 08:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2170-12-21**] 08:20PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
[**2170-12-21**] 08:20PM URINE CastHy-33*
[**2170-12-21**] 08:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
STUDIES:
[**2170-12-21**] CT head:
No evidence of acute intracranial process.
[**2170-12-21**] CT Cspine:
No acute fracture or malalignment.
[**2170-12-22**] EEG: No evidence of seizure on preliminary read, final
read pending.
.
Abdominal ultrasound:
INDICATION: 62-year-old male alcohol withdrawal and abdominal
distention.
Question liver disease or ascites.
COMPARISON: None available.
FINDINGS: Liver demonstrates increased echogenicity, compatible
with
hepatosteatosis. There is no focal lesion. There is no biliary
dilatation. The common duct is 5 mm. Gallbladder demonstrates
no stone, pericholecystic fluid, or significant wall thickening.
Spleen measures 11 cm. The portal vein demonstrates normal
hepatopedal flow. Bilateral kidneys are normal in size and
morphology without hydronephrosis or stone. There is no
abdominal ascites. Partially visualized pancreas, IVC, and aorta
are within normal limits.
IMPRESSION:
1. Echogenic liver consistent with hepatosteatosis. No focal
liver lesion. Other forms of advanced liver disease such as
cirrhosis or fibrosis cannot be excluded purely by imaging
appearance.
2. No ascites.
.
DISCHARGE LABS:
***
Brief Hospital Course:
#. s/p Fall: concerning for ? seizure vs EtOH withdrawal. CT
head and Cspine were negative for acute process. Neuro was
consulted and cleared the patient. EEG was unconcerning. His
mental status and CIWA requirements improved over several days
and he did not trigger over the last 72 hours of his stay. He
had no evidence of other etiology for syncope or fall.
#. EtOH abuse: Monitored on CIWA for withdrawal. Given
MVI/thiamine/folate daily. LFTs consistent with EtOH use. No h/o
cirrhosis, but given abdominal fullness on exam, had abdominal
u/s that was unrevealing. SW was consulted and recommended
follow up with [**Hospital1 **] outpatient attending services.
#. Tachycardia: Likely [**3-14**] to EtOH withdrawal, improved with IVF
and benzos. Less likely underlying infectious process. His
tachycardia resolved upon discharge.
#. HIV: Last CD4 245, viral load 57,200 in [**6-20**]. Not on HAART
per medication list. Prior d/c summaries note poor adherence
with medication and HAART held at that time earlier this year.
After discussion with patient he elected to restart HAART.
#. GERD: continued Omeprazole
Medications on Admission:
Thiamine 100mg PO daily
Folate 1mg PO daily
MVI 1tab PO daily
Omeprazole 20mg PO daily
Tylenol 650mg PO q6h prn
Oxycodone 5mg PO q6h prn
Lovenox 40mg SC daily - til [**2170-7-14**]
Calcium/Vitamin D
Bactrim SS PO daily
Diphenoxylate-atropine 2.5-0.025mg PO q8h prn diarrhea
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection
Injection twice a day.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
9. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
10. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
ETOH abuse
s/p fall
HIV
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 with fall after drinking. You
should stop drinking alcohol. Please continue your medications
at rehab and call [**Hospital1 778**] to set up a new primary care physician
upon discharge from rehab.
Followup Instructions:
Location: [**Hospital **] HEALTH CENTER
Address: [**First Name8 (NamePattern2) 5243**] [**Location (un) **], [**Numeric Identifier 6425**]
Phone: ([**Telephone/Fax (1) 10757**]
**Please discuss with the staff at the facility the need for a
follow up appointment with a new PCP when you are ready for
discharge.**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2170-12-26**]
|
[
"348.89",
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"V15.51",
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"303.91",
"291.81",
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icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7319, 7389
|
4931, 6053
|
332, 338
|
7457, 7457
|
2587, 2587
|
7897, 8338
|
1756, 1813
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6377, 7296
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7410, 7436
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6079, 6354
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7640, 7874
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4903, 4908
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1828, 2412
|
2428, 2568
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267, 294
|
366, 1341
|
3780, 4887
|
2603, 3771
|
7472, 7616
|
1363, 1538
|
1554, 1740
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,774
| 103,984
|
10321
|
Discharge summary
|
report
|
Admission Date: [**2153-6-11**] Discharge Date: [**2153-6-12**]
Date of Birth: [**2094-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
elective cardiac cath
Major Surgical or Invasive Procedure:
left and right heart cath
History of Present Illness:
58 y/o male with hx borderline hyperlipidemia, remote smoking,
who presents for scheduled PCI after postitive stress test.
Taken to cath lab and found to have 90% p-LAD, 80% m-LAD
involving D1 takeoff. Normal filling pressures. LVgram 63%. Pt
had 2 overlapping stents with transient jail of D1. Pt
developed hypotension in the cath lab requiring dop gtt to 18,
now in the CCU for weaning of dopamine. Etiology of hypotension
presumably [**3-14**] medication affect.
Past Medical History:
hyperlipidemia
htn
Social History:
remote smoking
Family History:
non-contrib
Physical Exam:
AF 120's/70's 70's 15
Gen: NAD, A&O X 3
Heent: Diffuse rash over face and trunk (chronic)
Neck: No JVD
Heart: RRR no mrg
Lungs: CTAB
Abd: Soft, nt/nd. NABS
Ext: No c/c/e
Pertinent Results:
[**2153-6-12**] 04:15AM BLOOD WBC-9.1 RBC-4.34* Hgb-12.9* Hct-36.6*
MCV-84 MCH-29.6 MCHC-35.2* RDW-13.1 Plt Ct-204
[**2153-6-11**] 12:44PM BLOOD Neuts-83.2* Bands-0 Lymphs-11.5*
Monos-3.1 Eos-1.8 Baso-0.4
[**2153-6-11**] 12:44PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2153-6-12**] 04:15AM BLOOD PT-12.0 PTT-26.6 INR(PT)-0.9
[**2153-6-12**] 04:15AM BLOOD Glucose-87 UreaN-23* Creat-1.0 Na-140
K-4.0 Cl-106 HCO3-29 AnGap-9
[**2153-6-12**] 04:15AM BLOOD CK(CPK)-91
[**2153-6-12**] 04:15AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
Prox and mid LAD stented (90% and 80% resp).
Brief Hospital Course:
1. Hypotension: Liklely [**3-14**] drug effect in setting of
hypovolemia (low PCWP). Preserved CO and normal SVR, so
unlikely cardiogenic or distributive shockDop easily weaned.
Restarted BB.
2. CAD: S/P overlapping LAD stents to 90% and 80% prox and mid
LAD lesions. Cont asa/plavix/statin. Hold ACE for now. Outpt
stress in future.
3. Pump: Preserved EF and CO. Normal valves. Hypo-euvolemic.
3. Rhythm: Cont tele.
4. Rash: Pt has hx skin cancer. He has been seeing
dermatology who has prescribed him topical lotions with to help
heal the sun-damaged areas. This is a chronic problem.
5. Polyuria: Pt has a long history of polyuria. He has been
followed by urology and this problem is being worked on as an
outpt. He is c/o severe pain [**3-14**] catheter insertion, which he
has been started on pyridium for.
Medications on Admission:
lipitor
asa
atenolol
plavix
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*3*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Elective heart cath
Discharge Condition:
good
Discharge Instructions:
If you have these symptoms, call your doctor:
- fevers/chills
- chest pain
- shortness of breath
- dizziness
- visual changes
Followup Instructions:
f/u with your PCP [**Last Name (NamePattern4) **] 2 weeks
Completed by:[**2153-6-12**]
|
[
"401.9",
"272.4",
"458.29",
"782.1",
"V10.83",
"414.01",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"88.56",
"88.53",
"37.23",
"36.07",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
3329, 3335
|
1818, 2656
|
319, 346
|
3399, 3405
|
1169, 1795
|
3580, 3669
|
935, 948
|
2734, 3306
|
3356, 3378
|
2682, 2711
|
3429, 3557
|
963, 1150
|
258, 281
|
374, 845
|
867, 887
|
903, 919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,222
| 172,286
|
46069
|
Discharge summary
|
report
|
Admission Date: [**2133-4-27**] Discharge Date: [**2133-5-7**]
Date of Birth: [**2050-7-3**] Sex: M
Service: SURGERY
Allergies:
Calcium Channel Blocking Agents-Benzothiazepines / Horse/Equine
Product Derivatives
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Left chest pain
Major Surgical or Invasive Procedure:
[**2133-4-27**] Left chest thoracostomy
[**2133-5-1**] Evacuation of hematoma/Left VATS
History of Present Illness:
82M ESRD, coumadin for afib, s/p fall, no LOC
Past Medical History:
- Coronary artery disease (EF = 60%)
- R kidney stone s/p Lithotripsy ([**6-23**], complicated by Klebsiella
UTI)
- s/p stroke (cerebellar)
- Chronic renal failure: h/o HD in past (thought to be due to
obstructive uropathy, kidney stones, BPH)
- Hypertension
- Anemia
- Benign prostatic hypertrophy
- Cluster headaches
- History of paroxysmal SVT (on Flecanide in past, now
Amiodarone)
- History of mesenteric ischemia s/p 90% bowel resection
- ventral hernia
- s/p open cholecystectomy [**2130-4-21**]
- s/p small bowel resection (80-90%) for mesenteric ischemia
- s/p umbilical hernia repair
- s/p cystocele repair
- s/p laminectomy
Social History:
Lives with wife in [**Name (NI) 8**]. Children are grown. Former chief
of psychiatry at the [**State 43840**]. Tob-quit 16
years ago but smoked up to 3ppd for 40 years. EtOH- [**11-19**] glasses
per week.
Family History:
Noncontributory
Pertinent Results:
[**2133-4-27**] 07:00PM WBC-9.1 RBC-2.21* HGB-7.4*# HCT-23.3*
MCV-105* MCH-33.7* MCHC-32.0 RDW-15.6*
[**2133-4-27**] 07:00PM PLT COUNT-248
[**2133-4-27**] 06:29PM PT-18.9* PTT-33.4 INR(PT)-1.7*
[**2133-4-27**] 11:10AM WBC-12.2*# RBC-2.93* HGB-10.4* HCT-30.8*
MCV-105* MCH-35.6* MCHC-33.8 RDW-15.5
[**2133-4-27**] 11:10AM CK(CPK)-77
[**2133-4-27**] 11:10AM CK-MB-NotDone cTropnT-0.12*
CT HEAD W/O CONTRAST Study Date of [**2133-4-27**] 12:01 PM
HEAD CT WITHOUT IV CONTRAST: There is no hemorrhage, edema, mass
effect, or
shift of normally midline structures. Prominence of the
ventricles and sulci
is related to age-appropriate parenchymal atrophy.
Periventricular
hypodensities consistent with chronic small vessel ischemic
disease. Vascular
cacifications of the carotid arteries are identifed. The
visualized paranasal
sinuses and mastoid air cells are clear. No fracture is
identified.
IMPRESSION: No fracture or hemorrhage.
[**2133-5-5**] SCHED
CHEST (PORTABLE AP)
INDICATION: Left-sided chest tube removal, evaluate for
pneumothorax.
FINDINGS: AP single view of the chest obtained with patient in
sitting
semi-upright position is analyzed in direct comparison with a
preceding
similar study obtained approximately six hours earlier during
the same date.
During the interval, the left-sided basal pleural chest tube has
been removed.
No pneumothorax has developed. Lung findings are unchanged and
without
evidence of new infiltrates.
IMPRESSION: No evidence of pneumothorax after left-sided chest
tube removal.
CT CHEST W/CONTRAST Study Date of [**2133-4-27**] 1:09 PM
CT CHEST: A 15.5 x 10.6 x 5.3 cm extrapleural ovoid hematoma is
noted
indenting the posterolateral aspect of the left lung (2:47).
There is
hematoma also noted in the adjacent left posterolateral left
chest wall
(please see below for full description of left posterior rib
fractures). There
is no pooling of contrast on delayed images to suggest active
bleeding. There
is a moderate to large left pleural effusion which is of
intermediate density
and somewhat loculated which likely reflects hemothorax. There
is left sided
compressive atelectasis.
The right lung demonstrates minimal subsegmental atelectasis.
The aorta
contains atherosclerotic calcifications. There are also
extensive coronary
artery calcifications. The heart and mediastinal structures are
mildly
shifted to the right. There is no mediastinal hematoma ot
evidence of great
vessel injury. A left brachiocephalic vein stent is again noted.
There is no evidence of splenic laceration or other solid organ
injury. The
kidneys are atrophic bilaterally. The left kidney contains
several calculi
measuring up to 9- mm. Additional punctate right renal calculi
are noted.
There is extensive bilateral renal arterial atherosclerotic
calcification. No
intra- abdominal free fluid is identified. There is no evidence
of
diaphragmatic rupture. Please note, there is chronic elevation
of the left
hemidiaphragm.
OSSEOUS STRUCTURES: There are multiple rib fractures involving
the left fourth
through ninth ribs posteriorly. The fourth rib is fractured at
the
costovertebral junction (2:23). Segmental fractures of the 5th,
6th, and 7th
ribs are noted with fractures at the costovertebral margin and
along the
posterior arch. The eighth and ninth posterior ribs are
fractured along the
posterior arch only (2:39 and 2:46). There is displacement of
the posterior
arch fractures at 7 through 9, with elements of comminution. The
clavicles and
scapulae appear are intact. The thoracic and upper lumbar
vertebrae maintain
normal alignment and appear intact. Degenerative changes are
noted in the
spine.
IMPRESSION:
1. Large extrapleural hematoma along the left lateral lung and
left chest
wall hematoma. No evidence of active bleeding. Multiple left
posterior rib
fractures described in detail above involving the left 4th
through 9th ribs.
2. Large left hemothorax with a compressive atelectasis. Mild
mediastinal
shift to the right.
3. No evidence of splenic injury or diaphragmatic rupture.
Elevation of left
hemidiaphragm is a chronic finding as seen on multiple prior
chest radiographs
dating back to [**2130-5-9**].
Brief Hospital Course:
He was admitted to the Trauma service. A left thoracostomy was
performed and he was given 2 units fresh frozen plasma in the
emergency room. Once stabilized he was then transferred to the
Trauma ICU. The Acute Pain service was consulted given his
multiple rib fractures; he was placed on Morphine PCA initially
and was later changed to MS Contin. The MS Contin was stopped
and he was placed on Oxycodone prn which is offering him
adequate relief at this point.
Nephrology was also consulted early on because of his ESRD and
history of receiving hemodialysis three times per week. He did
receive his hemodialysis throughout his stay here.
Thoracics was also consulted for the extrapleural hematoma. he
was taken to the operating room on [**5-2**] for evacuation of this
and a VATS procedure. His chest tubes were removed several days
later.
Physical and Occupational therapy were consulted early during
his stay and have recommended rehab after acute hospital stay.
Medications on Admission:
Amiodarone 100', [**Last Name (un) **]#3, Oxycodone, Nephrocap, B12, Ca acetate,
Finasteride 5', Ativan 0.5 q4h, Lotemax eye gtt, Coumadin 2 x 5
days, 4 x 2 days, Provigil, Protonix
Discharge Medications:
1. Chair Lift
This note is to inform the recipient that a chair lift / stair
assistance device is medically indicated for [**Known firstname 333**] [**Known lastname **].
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO qAM ().
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Lotemax 0.5 % Drops, Suspension Sig: 1-2 Drops Ophthalmic
qhs ().
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p Fall
Injuries:
Left 4-9th rib fx
Left hemothorax (pre-existing pleural effusion)
Left extrapleural hematoma
Left flank hematoma
Discharge Condition:
Good
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in Surgery CLinic next week, call
[**Telephone/Fax (1) 600**] for an appointment.
Follow up in [**Hospital 16814**] clinic next week with Dr. [**Last Name (STitle) **], call
[**Telephone/Fax (1) 170**] for an appointment.
The following appointment were made for you prior to your
hospitalization:
Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2133-6-4**] 3:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2133-6-18**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2133-6-25**] 3:40
Completed by:[**2133-5-7**]
|
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"396.3",
"V12.59",
"285.9",
"E849.0",
"496",
"511.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"34.06",
"34.04",
"99.07",
"99.04",
"99.05",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8238, 8317
|
5671, 6640
|
357, 448
|
8493, 8500
|
1461, 5648
|
8523, 9380
|
1425, 1442
|
6872, 8215
|
8338, 8472
|
6666, 6849
|
302, 319
|
476, 523
|
545, 1182
|
1198, 1409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,605
| 190,647
|
29187
|
Discharge summary
|
report
|
Admission Date: [**2128-12-8**] Discharge Date: [**2128-12-12**]
Date of Birth: [**2128-12-8**] Sex: F
Service: Neonatology
HISTORY: Baby girl [**Known lastname **] was born to a 28-year-old G1/P0 (now
1) mother with prenatal screens blood type B+, DAT negative,
HBsAg positive, RPR nonreactive, rubella immune, GBS
negative.
ANTENATAL HISTORY: This infant was born on [**12-8**] at 40 weeks'
gestation. This pregnancy was complicated by hepatitis
B antigen positive maternal status and an echogenic cardiac focus
prenatally. There was spontaneous onset of labor leading to
spontaneous vaginal delivery under epidural anesthesia. The
mother was febrile on admission with a peak temperature
intrapartum of greater than 103 degrees in association with
sustained fetal tachycardia. Rupture of membranes occurred 10
hours prior to delivery and yielded clear amniotic fluid.
Intrapartum antibiotic therapy was administered 4 hours prior to
delivery. During delivery it was noted that the infant
received free-flow oxygen and tactile stimulation. Apgar's
were 7 and 9 and one and five minutes. The NICU team was
called due to the continued need for oxygen, and the infant was
taken to the NICU for further assessment; and admitted mainly for
rule out sepsis.
PHYSICAL EXAMINATION ON ADMISSION: Showed a birth weight of
3250 grams, which is 50th percentile; head circumference of
35 cm, which is 75th percentile; length of 50 cm, which is
50th to 75th percentile. HEENT: Anterior fontanelle soft and
flat, nondysmorphic, intact palate. Neck and mouth normal.
Small left occipital parietal caput. No nasal flaring. Red
reflexes deferred. CHEST: No retractions, good breath sounds
bilaterally. CV: Well perfused, normal rate and rhythm,
femoral pulses normal, normal S1/S2 without a murmur.
ABDOMEN: Soft, nondistended, no organomegaly, no masses,
bowel sounds active, patent anus, 3-vessel umbilical cord.
GU: Normal female genitalia. CNS: Mildly lethargic with
responsiveness to moderate stimuli. Tone mildly-to-moderately
reduced in symmetrical distribution. Normal suck, root and
gag. Facial symmetry observed. SKIN: Mongolian spot on
buttocks. MUSCULOSKELETAL: Normal spine, shallow spinal
dimple with a well visualized face. Limbs, and hips and
clavicles intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: The infant came to the NICU and required
nasal cannula on admission. The infant remained on nasal
cannula until day of life #1 when it weaned to room air.
The infant did have episodes of apnea after crying. The
most recent episode of apnea after crying was on [**12-10**], [**2128**]. Other than that, the infant's respiratory rate
has been stable; and there have been no further
desaturations.
2. CARDIOVASCULAR: The infant has maintained a normal
cardiovascular status. There have been no murmurs
audible. Normal heart rate and blood pressure.
3. FLUIDS, ELECTROLYTES, NUTRITION: The infant was started
on ad lib p.o. feeds of Similac 20 with iron, and the
most recent weight is 3510 grams. No electrolytes have been
measured on this infant. Most recent HC=35.5cm, L=51cm.
4. GI: Bilirubin level was drawn on [**2128-12-11**]; and
the bilirubin level was 7.6/0.3. The infant has not
required any phototherapy thus far.
5. HEMATOLOGY: Hematocrit at birth was 53, platelet count
was 254. At day #2 of life, the hematocrit was 46 and the
platelet count was 192. No further hematocrits or
platelets have been measured.
6. INFECTIOUS DISEASE: CBC and blood culture were screened
on admission to the NICU. An LP was done prior to
starting antibiotics. There was minimal CSF available
during that LP, so the LP was sent for culture only; and
antibiotics were started at that time. The infant was
started on ampicillin and gentamicin. The CBC was not
left shifted, and there was a normal white blood cell
count; but due to the maternal temperature of 103 in the
mother and the infant was admitted with a temperature of
103.6, the infant was planned for a 7-day course of
ampicillin and gentamicin. On day of life #[**12-5**], [**2128**] - a repeat LP was done to assess cell count. The
WBCs were 22, RBCs 9400, 50 poly's and 20 lymphocytes.
All cultures have remained negative so far. A chest x-ray
was done which did not show any focal areas and was
normal. The infant received a 7-day course of
ampicillin and gentamicin.
7. NEUROLOGY: The infant has maintained a normal neurologic
exam for a term infant.
8. SENSORY:
1. AUDIOLOGY: A hearing screen passed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: This infant will be followed
at [**Hospital3 **]; telephone number ([**Telephone/Fax (1) 70213**].
CARE RECOMMENDATIONS:
1. Ad lib p.o. feeds of Similac 20 with iron.
2. No medications.
3. State newborn screen was sent on day of life #3, results
are pending.
4. passed car seat test
IMMUNIZATIONS RECOMMENDED: The infant has received a
hepatitis B vaccine on [**2128-12-8**]. Infant also received
Hepatitis Immuneglobulin due to maternal hepatitis B positive
status.
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: (1) born at less than 32
weeks gestation; (2) born between 32 and 35 weeks gestation
with 2 of the following: Either 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.
DISCHARGE INSTRUCTIONS: Follow-up appointment is recommended
with [**Hospital3 **] after discharge from
the hospital.
DISCHARGE DIAGNOSES: Presumed sepsis; respiratory distress,
resolved; meningitis ruled out.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31759**], MD [**MD Number(1) 43886**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2128-12-12**] 03:37:27
T: [**2128-12-12**] 18:05:59
Job#: [**Job Number 70214**]
|
[
"779.89",
"780.6",
"V29.0",
"V30.00",
"V05.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.55"
] |
icd9pcs
|
[
[
[]
]
] |
4693, 4831
|
6082, 6451
|
4853, 5023
|
5965, 6060
|
2324, 4637
|
5238, 5940
|
1313, 2297
|
4662, 4669
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,914
| 108,846
|
3383
|
Discharge summary
|
report
|
Admission Date: [**2193-8-14**] Discharge Date: [**2193-8-23**]
Date of Birth: [**2114-5-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
Cough, decreased responsiveness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 79 yo [**Location 7972**] male with a hx of DM2, HTN,
HL who presents with cough for several days, as well as
decreased responsiveness. The patient was recently admitted to
[**Hospital1 18**] from [**Date range (1) 12542**] and again [**8-7**]/-[**8-12**] for pneumonia. On the
first admission, was treated with five day course of
levofloxacin, on the most recent was treated with vanc/cefepime
-> narrowed to azithro/cefpodoxime, which he should still be
taking. He is now brought to the ED by ambulance from home with
cough, decreased responsiveness. Per the patient's daughter, he
was intermittently weak and confused during the last
hospitalization, but seemed to be fine and talkative until about
noon today. This morning she gave him breakfast - he ate well
and was communicative, and did not appear to be choking. Around
noon she tried to give him lunch and he refused to open his
mouth, was sleepy and weak appearing. He was not complain of any
nausea or pain.
In the ED, initial VS were 98.6 106 122/60 36 98% 10L. He was
found to have an anion gap of 15, K 5.7, glucose 373. U/A was
notable for 1000 glucose but no ketones, no cells. ABG showed
7.49/28/93/22. CXR was consistent with LLL/retrocardiac opacity
that was also seen on prior xrays last week. He was given
vanco/cefepime, Ca and started on an insulin gtt. Prior to
transfer, repeat chem 7 was drawn and gap had closed to 10. He
was admitted to the micu for further management.
On arrival to the MICU, patient difficult to understand with
soft voice. Not able to speak though phone interpreter because
patient unable to enunciate vs unable to understand vs too
somnolent.
Review of systems: Unable to obtain
Past Medical History:
- type two diabetes (last hemoglobin a1c ~ 10 in [**5-9**])
- hypertension
- hyperlipidemia
- incontinence to urine over past month, cause unknown
- wheelchair bound since last [**Month (only) 216**], cause unknown, reports "i
have a problem with my legs and grab onto my wheelchair"
- question of peripheral neuropathy
- dementia
Social History:
Distant 50 pack year smoking history, distant alcohol history,
lives in [**Location 686**] with one of his daughters, [**Name (NI) **]. [**Name2 (NI) **] has
many sons and daughters. [**Name (NI) **] has been married twice, his new wife
lives in [**Country 3587**].
Family History:
Negative for cardiac disease.
Physical Exam:
On admission:
Vitals: T: 98.3 BP: 117/56 P: 80 R: 23 O2: 96% on 4L
General: ill-appearing, thin elderly male
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
On discharge:
Vitals: T97.6, HR 152-172/78-94, HR 86, RR 18, POx 95%RA
General: thin elderly male, sitting in bed watching television.
Exam somewhat difficult [**2-28**] difficulty communicating
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Keeps it bent to the left, no meningisimal signs this AM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Initial rattle clears with forceful cough; then clear to
auscultation bilaterally, no wheezes, rales, ronchi
Abdomen: soft, nontender, soft distension, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no pedal edema
Neuro: EOMI. strength unable to assess [**2-28**] pt deferred, grossly
normal sensation, 2+ reflexes bilaterally, gait deferred
Pertinent Results:
On admission:
[**2193-8-14**] 02:00PM BLOOD WBC-9.7# RBC-5.38 Hgb-15.1 Hct-46.1
MCV-86 MCH-28.0 MCHC-32.7 RDW-12.8 Plt Ct-230
[**2193-8-14**] 02:00PM BLOOD Neuts-83.8* Lymphs-9.5* Monos-4.7 Eos-1.7
Baso-0.3
[**2193-8-14**] 02:00PM BLOOD PT-15.9* PTT-25.8 INR(PT)-1.5*
[**2193-8-14**] 02:00PM BLOOD Glucose-373* UreaN-18 Creat-1.2 Na-136
K-5.7* Cl-100 HCO3-21* AnGap-21*
[**2193-8-14**] 02:00PM BLOOD ALT-105* AST-71* AlkPhos-73 TotBili-0.7
[**2193-8-14**] 02:00PM BLOOD Albumin-4.2
[**2193-8-14**] 08:08PM BLOOD Calcium-9.5 Phos-3.5 Mg-1.7
ABG [**2193-8-14**] 02:06PM BLOOD pO2-93 pCO2-28* pH-7.49* calTCO2-22
Base XS-0 Comment-GREEN TOP
On discharge:
[**2193-8-21**] 06:20AM BLOOD WBC-4.9 RBC-4.34* Hgb-12.2* Hct-37.5*
MCV-87 MCH-28.1 MCHC-32.5 RDW-12.8 Plt Ct-245
[**2193-8-21**] 06:20AM BLOOD Plt Ct-245
[**2193-8-21**] 06:20AM BLOOD Glucose-141* UreaN-14 Creat-1.3* Na-144
K-3.4 Cl-109* HCO3-24 AnGap-14
[**2193-8-22**] 10:10AM BLOOD Creat-1.2
[**2193-8-21**] 06:20AM BLOOD ALT-93* AST-69* AlkPhos-45
[**2193-8-21**] 06:20AM BLOOD Phos-3.0 Mg-1.7
[**2193-8-20**] 07:30PM BLOOD Vanco-17.5
Radiology:
[**8-15**] CXR
IMPRESSION: Increased left lower lobe opacity, likely
combination of effusion and atelectasis.
[**8-16**] CXR
There is no significant change since the previous exam. There
are bibasilar mild atelectases. Stable left retrocardiac
opacities can be atelectasis, but superimposed infection or
aspiration cannot be excluded in the appropriate clinical
setting.
[**8-15**] CT Head w/o contrast:
No evidence of acute disease. Mild atrophy.
Microbiology:
[**8-14**], [**8-15**], [**8-16**], [**8-17**]: negative except one bottle of
coag-negative staph aureus (likely skin contamination).
====================
VIDEO SPEECH AND SWALLOW EVALUATION [**2193-8-21**]
Mr. [**Known lastname 15655**] presented with a slight improvement in his oral and
pharyngeal swallow with reduced aspiration compared to his
previous study, but he is continuing to intermittently aspirate
both thin and nectar thick liquids. His aspiration remains
silent, or without spontaneous coughing and he could not cough
on
command to try to clear aspirate material. Compensatory
techniques were attempted, but pt could not follow commands to
implement these on the study.
At this time, there continues to be no diet that is free from
risk of aspiration an the safest recommendation is to remain
NPO.
Pt was admitted with lethargy and altered mental status which
are
resolving, and his current swallow function may be baseline
given
his history of PNAs. Agree with discussions with pt and his
family which team is pursuing to determine goals of care. If his
family wishes to accept the risks of aspiration and allow the pt
to eat, suggest a PO diet of thin liquids and moist, ground
solids (no pieces larger than ground beef). Thickening his
liquids did not significantly reduce the risk of aspiration on
today's study. We are happy to follow up and participate in any
family meetings if helpful to relay the above results.
FOIS rating of 1
RECOMMENDATIONS:
1. There are no consistencies that are free from risk of
aspiration at this time
2. Continue discussions regarding goals of care and nutritional
plan (POs accepting the risk of aspiration vs PEG tube)
3. If pt and his family agree to accept the risks of aspiration,
suggest a PO diet of thin liquids and moist, ground solids, as
thickened liquids did not significantly reduce the risk of
aspiration.
4. Regular oral care with mouthwash as able- Q4 during admission
5. Meds crushed with purees
6. We are happy to participate in family meetings if helpful
Brief Hospital Course:
Mr. [**Known lastname 15655**] is a 79y/o gentleman with underlying dementia and
diabetes who was admitted due to lethargy and cough. In the
MICU, he was diagnosed with an aspiration pneumonia for which he
was treated with antibiotics. During his stay, he was evaluated
by Speech and Swallow, and he was shown to silently aspirate.
Based on goals of care, the decision was made to allow him to
eat a modified diet, accepting the risks of aspiration, and he
was discharged home.
#. Lethargy/somnolence: aspiration pneumonia.
He was treated with a full course of antibiotics for aspiration
pneumonia with Vanc ([**Date range (1) 15659**]) and Zosyn ([**Date range (1) 15660**]). His WBC
count decreased (~5 on discharge) and he remained afebrile.
Unfortunately, infection is likely from aspiration and it is
expected that he will develop subsequent aspiration pneumonias.
This was discussed with his daughter (please see "Goals of care"
below).
#. Aspiration: still persists.
He has known pharyngocele but it is unclear if this is
contributing. He might have an esophageal cause for his
aspiration. He was assessed by Speech and Swallow, and indeed,
aspiration was noted. He was initially made NPO and his
coughing resolved, and with food he was noted to cough again.
Repeat video oropharyngeal exam revealed that his swallow
function was improved but that he was still aspirating. He is
being discharged on a [**Hospital1 **] PPI to attempt to prevent aspiration
pneumonia.
#. Goals of care: no invasive measures, goal of being home.
Family meetings was held. Given that he has significant
dementia with poor nutritional status, his overall prognosis is
poor (likely has a life expectancy <6mo or a year). In light of
this, daughter [**Name (NI) **] would not want any aggressive measures with
regards to his aspiration, i.e. would not pursue a GJ-tube. She
believes that he would not want any interventional measures if
he were to decompensate and the decision was made to change his
code status to DNR/DNI. Goals of care also include going home
(she would not want him to be placed in a Nursing home).
Consideration was made to going to acute rehab but per Physical
Therapy evaluation, his functional mobility is unlikely to
improve so he would not be likely to benefit. He should,
however, have a home PT evaluation. In addition to having
visiting Nurse services for diet teaching, med teaching, and
evaluation for other services, he should have a Social Work
referral to initiate discussions about possible "Do not
hospitalize" status in the future, as well as bridge to hospice.
#. Dementia: likely [**Last Name (un) 309**] body dementia.
MRI head from [**2193-5-27**] significant only for chronic small vessel
ischemic disease, but this could be contributing to gait
difficulties. Gerontology was consulted and concluded that pt
most likely suffers from [**Last Name (un) 309**] Body Dementia as pt has a h/o
hallucinations, and recommended nonpharmacologic interventions
to prevent delirium.
***He should not receive antipsychotics such as Haldol and
Seroquel as he likely has [**Last Name (un) 309**] Body dementia.***
#. DM2: stable.
He had stable blood sugars but in light of his decreased oral
intake of food he is being discharged on a lower dose of
Glargine. Will continue on Metformin. Has follow-up planned
with his PCP. [**Name10 (NameIs) **] he develops blood sugars <70 or >300 he should
contact his PCP.
Transitional issues:
-Antipsychotics are discouraged in pt with [**Last Name (un) 309**] Body Dementia.
-Needs home PT evaluation.
-Visiting Nurse services for diet teaching, med teaching, and
evaluation for other services.
-Should have a Social Work referral to initiate discussions
about possible "Do not hospitalize" status in the future, as
well as bridge to hospice.
-Note that if family decides to pursue further workup regarding
his aspiration, could consider an Upper GI series to evaluate
esophageal causes of dysphagia (per GI consult) as well as
possible follow-up of his known pharyngocele with ENT.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 325 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. Lisinopril 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Glargine 30 Units Bedtime
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Azithromycin 250 mg PO Q24H
10. Cefpodoxime Proxetil 200 mg PO Q12H
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Glargine 20 Units Bedtime
3. Lisinopril 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Gabapentin 100 mg PO TID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice a day Disp #*60 Capsule
Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 17 grams by mouth daily
Disp #*510 Gram Refills:*0
11. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg [**1-28**] tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*0
12. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
13. Acetaminophen 1000 mg PO TID:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*100 Tablet Refills:*0
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY
aspiration
aspiration pneumonia
SECONDARY
dementia
diabetes
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 Mr. [**Known lastname 15655**],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
for being less responsive to your family members, and having a
worsening cough at the same time. You were initially admitted to
the ICU, where you were stable the entire time. You received
antibiotics to treat you for pneumonia (a lung infection) that
you developed from coughing and choking on your food. You were
then transferred to the medical floor.
We held extensive discussions with your family (including your
daughter [**Name (NI) **] who is your healthcare proxy) about your overall
prognosis. The exact cause of your aspiration is unclear, but
your poor nutrition, incontinence, and cognitive issues are due
to your dementia. Your family agreed that your goals of care
include eating by mouth (accepting the risk of aspiration), not
treating you with aggressive measures if your health suddenly
declines or your breathing fails (code status changed to "Do not
resuscitate, Do not intubate." Your goals of care also included
being sent back home to live with your daughter, which we were
able to arrange. You will go home with visiting nurse services.
We made the following changes to your medications:
-START Tylenol and Oxycodone as needed for pain
-START Colace, Senna, and Miralax as needed for constipation
-START Omeprazole because of reflux
-DECREASE Lantus insulin to 20 units at bedtime, since you are
eating less
Please take all other medications as previously prescribed.
Dear Mr. [**Known lastname 15655**],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
for being less responsive to your family members, and having a
worsening cough at the same time. You were initially admitted to
the ICU, where you were stable the entire time. You received
antibiotics to treat you for pneumonia (a lung infection) that
you developed from coughing and choking on your food. You were
then transferred to the medical floor.
We held extensive discussions with your family (including your
daughter [**Name (NI) **] who is your healthcare proxy) about your overall
prognosis. The exact cause of your aspiration is unclear, but
your poor nutrition, incontinence, and cognitive issues are due
to your dementia. Your family agreed that your goals of care
include eating by mouth (accepting the risk of aspiration), not
treating you with aggressive measures if your health suddenly
declines or your breathing fails (code status changed to "Do not
resuscitate, Do not intubate." Your goals of care also included
being sent back home to live with your daughter, which we were
able to arrange. You will go home with visiting nurse services.
We made the following changes to your medications:
-START Tylenol and Oxycodone as needed for pain
-START Colace, Senna, and Miralax as needed for constipation
-START Omeprazole because of reflux
-DECREASE Lantus insulin to 20 units at bedtime, since you are
eating less
Please take all other medications as previously prescribed.
Followup Instructions:
Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2193-9-6**] at 2:00 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2193-9-6**] at 2:00 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2193-9-20**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
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"276.2",
"276.7",
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"401.9",
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icd9cm
|
[
[
[]
]
] |
[
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
13405, 13476
|
7840, 11286
|
336, 342
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13589, 13589
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370, 2031
|
4227, 4852
|
13604, 13743
|
2091, 2423
|
2439, 2706
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,362
| 136,142
|
7188
|
Discharge summary
|
report
|
Admission Date: [**2124-12-5**] Discharge Date: [**2124-12-22**]
Date of Birth: [**2046-12-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Increasing fatigue
Major Surgical or Invasive Procedure:
[**2124-12-8**] Coronary Artery Bypass Graft x one (SVG to OM) and
Aortic valve replacement with a [**Company 1543**] Mosaic tissue valve
History of Present Illness:
Ms. [**Known lastname 3175**] is a 77 year old female who recently [**Known lastname 1834**] a
cardiac catheterization and echocardiogram secondary to
increasing fatigue. These studies revealed severe aortic
stenosis and two vessel coronary artery disease. Therefore she
was referred to [**Hospital1 69**] for
surgical evaluation.
Past Medical History:
MI in [**2108**]
CAD
Hypertension
Diabetes
hypothyroidism
positive PPD 1 month ago (35 mm), seen by chest clinic at
[**Location (un) 1157**] and on rifampin
COPD
lung cancer [**2111**]
s/p AAA repair 99 by Dr. [**Last Name (STitle) 1391**]
bilateral fem bypass
right lobectomy [**2111**]
bilateral cataract surgery
right hipprosthesis [**2111**]
Social History:
Patient currently lives alone in elderly apartments. 50 pack
year history of smoking, quit [**2111**] after lung cancer diagnosed.
Rare alcohol use. She has been widowed since [**2098**]. Her pet dog
who she's had for 18 years died today.
Family History:
no family h/o cancer. Mother had "heart problems"in 80's. Father
had a stroke.
Physical Exam:
Upon physical exam today, Ms. [**Known lastname 3175**] is awake, alert, and
oriented times three. Auscultation of her chest reveals
scattered rhonchi and a heart of regular rate and rhythm. No
sternal incision drainage or erythema is noted. Staples are
intact along the mediastinal incision. Her abdomen is soft,
non-tender, and non-distended. Her extremities are warm with 2+
edema. her left lower extremity endovascular site is exhibits a
small amount of serous drainage. Her PICC line was intact.
Pertinent Results:
[**2124-12-22**] 07:10AM BLOOD Hct-29.7*
[**2124-12-22**] 07:10AM BLOOD PT-19.2* INR(PT)-1.8*
[**2124-12-22**] 07:10AM BLOOD Glucose-122* UreaN-42* Creat-0.9 Na-135
K-5.4* Cl-96 HCO3-30 AnGap-14
[**2124-12-14**] 04:49AM BLOOD Glucose-57* K-4.0
Brief Hospital Course:
Ms. [**Known lastname 3175**] [**Last Name (Titles) 1834**] a coronary artery bypass graft times one
(SVG to OM) and aortic valve replacement with a 19 mm [**Company 1543**]
Mosaic tissue valve. The patient tolerated this procedure well
and was transferred in stable condition to the surgical
intensive care unit.
In the surgical intensive care unit she was seen in consultation
by the cardiology service for atrial fibrillation and
hypotension. She was slowly weaned from her pressors as
tolerated. Her chest tubes and wires were removed. Her
coumadin was restarted secondary to her atrial fibrillation. By
post operative day 7 she was ready for transfer to the step down
floor.
On the step down floor Ms. [**Known lastname 3175**] was diuresed and encouraged to
ambulate. She was seen in consultation by physical therapy.
Her rhythm converted to sinus spontaneously. By post-operative
day 14 she was ready for discharge to a rehabilitation facility.
Medications on Admission:
toprol XL 75 in the am and 25, lipitor 40, folic acid 800,
glucotrol 10, glucophage, levoxyl 75, lasix 30", advair 500/50",
spiriva 10, aspirin 325, flonase
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
11. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: 1-2 MLs
Inhalation Q6hr ().
Disp:*30 ML(s)* Refills:*0*
12. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*0*
15. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO ONCE (Once): please
titrate dose for goal INR of [**1-5**].5.
Disp:*30 Tablet(s)* Refills:*0*
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-5**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
[**12-5**] Caps Inhalation DAILY (Daily).
Disp:*60 Cap(s)* Refills:*0*
18. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*30 * Refills:*0*
19. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
increasing fatigue
Discharge Condition:
good
Discharge Instructions:
Continue coumadin for paroxysmal atrial fibrillation with a goal
INR of [**1-5**].5.
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see your PCP [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 26674**] in [**12-5**]
weeks.
Please see your cardiologist [**Last Name (un) **] [**Doctor Last Name 1911**] in [**12-5**] weeks.
Please see your surgeon [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 26675**] in [**3-9**] weeks.
Completed by:[**2124-12-22**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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|
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|
342, 482
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6043, 6050
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2109, 2354
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3364, 3522
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6074, 6440
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|
284, 304
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510, 844
|
866, 1214
|
1230, 1470
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,718
| 183,975
|
44501
|
Discharge summary
|
report
|
Admission Date: [**2203-4-4**] Discharge Date: [**2203-6-6**]
Date of Birth: [**2162-8-15**] Sex: M
Service: MEDICINE
Allergies:
Betadine / Iodine; Iodine Containing / Compazine / Heparin
Agents
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 40 year old man well known to [**Hospital1 18**] with history of C6
quadraplegia, autonomic dysreflexia, renal transplant, multiple
sacral decubitus ulcers, chronic pain, suspected HIT and
recurrent UTI with indwelling suprapubic catheter sent in to ED
from [**Hospital3 672**] with 2 days of increasing dyspnea. Patient
is on oxygen 3 liters nasal cannula at home for COPD, generally
running sats around 94-95% on this, 88% on RA. One week ago, his
mother came to visit and she was sick with a cold, "pneumonia"
per the patient. Then 2 days ago, the patient developed a cough
productive of yellow-brown sputum, which is new for him. No
fever, chills. No chest pain, palpitations or other pain. Since
that time, he has become more hypoxic, with sats in high-80s on
3 liters, now up to mid-90s with 5 liters. Sent in from [**Hospital1 1099**] Hospital for further evaluation.
.
He states that his breathing has been actually gradually
worsening over the past several months. He was initally on no
oxygen / 1L NC after being discharged in [**Month (only) 404**], and his oxygen
requirement has steadily increased, with an acute on subacute
worsening this week. He was placed on 3L oxygen by NC and BIPAP
at 12/8 as tolerated
.
In ED, patient found to be afebrile, with no leukocytosis or
left shift, lactate 2.0. Anemia with hct 31.1, above baseline
26-30. Gluc 179, above his baseline. CXR with stable
retrocardiac opacity and left-sided effusion. LENI attempted but
refused because pt could not lay flat for test, d-dimer high at
1302 (has had checked 6 times prior at [**Hospital1 18**], all 400-600 range
except [**2195-2-4**] when he had a clotted portacath). Blood cx drawn,
started on Levaquin and Vancomycin for possible pneumonia. CTA
deferred given contrast dye allergy. VQ and noncontrast CT
considered, but deferred as patient says he cannot lay flat,
wants to try again later. Discussed with patient that the
alternative is to treat with Argatroban, which he wants.
.
Of note, in [**7-16**] had CT chest without contrast that showed a
small, right-sided pleural effusion with minimal reactive
atelectasis; opacities at the lung apices, right greater than
left which likely represents scarring; scattered ground glass
opacities seen throughout the lungs; scattered blebs; cervical
fusion hardware; a portacath approaching from left subclavian
vein; surgical sutures in the left lower lobe. No mention of
retrocardiac opacity at that time.
.
Pt started to complain about right lower quandrant abdominal
pain, radiating to right flank. The suprapubic catheter was
changed. CT did not show any hepatic fluid collection, hernia,
stone or free air/fluid. UTI was suspected and pt was started on
IV ceftriaxone and IV tobramycin. Blood culture was [**Male First Name (un) 2083**] ordered
and grew G- rods susceptible to tobramycin but resistant to
ceftriaxone. Hence it was discontinued.
Past Medical History:
1. Status post motor vehicle accident resulting in C6
quadraplegia and autonomic dysreflexia. His course is also
complicated by sacral decubiti.
2. Status post renal transplant
3. Obesity (260lbs)
4. Depression
5. Anemia
6. Chronic pain
7. Recurrent UTI with indwelling suprapubic catheter
8. History of HIT thrombosing port-a-cath
9. History of anyphylaxis with iodine refractory to pretreatment
with steroids
10. History of cocaine-induced MI '[**88**]
11. Chronic osteomyelitis
12. Status post right BKA
13. Status post diverting colostomy
14. History of adrenal insufficiency
15. Status post splenectomy
16. Asthma
Social History:
He lives at [**Hospital3 672**] rehab, He is a former smoker and
denies alcohol or illicits since cocaine in '[**88**].
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.0, BP 132/80, RR 18, Sat 96% 5LNC
Gen: cushingoid, obese, chronically ill-appearing man, with HOB
up, coughing occassionally productive of brown sputum, drinking
water frequently
HEENT: EOMI, sclerae anicteric, MMM
Neck: thick neck, supple, no JVP elevation
CV: tachycardic, nl s1/s2, L SCV port-a-cath in place,
non-tender with mild erythema
Resp: difficult exam [**1-13**] constant coughing, bronchial throughout
Abd: protruberant, nontender, suprapubic catheter in place,
ostomy in place
Extrem: right BKA, no erythema or induration; 2+ pitting edema
in LLE.
Pertinent Results:
LABS/MICROBIOLOGY:
ON ADMISSION:
[**2203-4-4**] 04:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2203-4-4**] 04:59PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2203-4-4**] 04:59PM URINE RBC-[**10-31**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0
[**2203-4-4**] 01:10AM LACTATE-2.0
[**2203-4-4**] 12:05AM proBNP-220*
[**2203-4-4**] 12:05AM GLUCOSE-179* UREA N-15 CREAT-0.4* SODIUM-143
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-33* ANION GAP-12
[**2203-4-4**] 12:05AM WBC-6.2 RBC-3.52* HGB-9.5* HCT-31.1* MCV-89
MCH-27.0 MCHC-30.6* RDW-16.9*
[**2203-4-4**] 12:05AM NEUTS-77.3* LYMPHS-12.1* MONOS-7.5 EOS-2.6
BASOS-0.4
[**2203-4-4**] 12:05AM D-DIMER-1302*
Urine culture ([**2203-4-14**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
2ND ISOLATE. <10,000 organisms/ml.
IMAGING([**2203-4-6**]):
LENI No right or left lower limb deep venous thrombosis
demonstrated.
ECHO ([**2203-4-5**]): Suboptimal image quality.The left atrium is
mildly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
systolic function is normal. The ascending aorta is mildly
dilated. There is no aortic valve stenosis. No aortic
regurgitation is seen. There is an anterior space which most
likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
CXR 1. Persistent retrocardiac opacity, which could represent
infection in the appropriate clinical context. Associated small
chronic left pleural effusion vs pleural thickening.
2. Probable early/mild congestive heart failure.
US ABD LIMIT, SINGLE ORGAN ([**2203-4-26**])
CONCLUSION:
1. Coarse echogenic liver consistent with fatty infiltration.
The possibility of underlying significant liver disease such as
cirrhosis or fibrosis is not excluded.
2. Rim of perihepatic hypoechoic tissue of uncertain etiology
but raising the question of a gel-phase clot. Further evaluation
with abdominal CT is recommended.
ABDOMEN U.S. (COMPLETE STUDY) PORT ([**2203-5-1**])
1. Fatty liver for which more significant liver disease such as
cirrhosis/fibrosis cannot be excluded.
2. Unchanged perihepatic hypoechoic tissue/fluid of unclear
etiology but may still represent a chronic clot. Abdominal CT
may provide further information.
CT abdomen and pelvis with contrast([**2203-6-2**])
There are dependent atelectatic changes and blebs at the lung
bases. Please note that portions of the right abdomen are
obscured by artifact. The liver, gallbladder, spleen, and
adrenal glands are within normal limits. The pancreas is fatty
replaced. The native kidneys are atrophic. The stomach is mildly
distended. The small bowel is unremarkable. There are no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes. There is no free air or free fluid within the abdomen.
The transplanted kidney is seen in the right lower quadrant and
there is no surrounding perinephric stranding or free fluid.
There is no evidence of appendicitis. A colostomy is again seen
within the left anterior abdominal wall. Contrast is seen within
a blind ending rectum. A suprapubic catheter is seen within the
bladder. There are bilateral decubitus ulcers with associated
heterotopic ossification. The right sided decubitus ulcer
appears enlarged. Degenerative changes are seen in the spine.
Post-surgical changes are seen in the right hip with resection
of the proximal femur or dislocation of the hip and heterotopic
ossification are again seen.
IMPRESSION:
1. No findings to explain the patient's right-sided pain.
2. Bilateral decubitus ulcers. Mild increase in size of the
right sided decubitus ulcer.
[**2203-6-3**] 2:50 pm BLOOD CULTURE
AEROBIC BOTTLE (Preliminary):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 95360**] [**Last Name (NamePattern1) **] CC7A [**2203-6-4**] 405PM.
GRAM NEGATIVE ROD(S). FURTHER IDENTIFICATION TO FOLLOW.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- R
LEVOFLOXACIN---------- R
TOBRAMYCIN------------ S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC BOTTLE (Preliminary):
ON [**2203-6-4**]. GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
BEING ISOLATED FOR FURTHER IDENTIFICATION.
Brief Hospital Course:
Briefly, 40 year old man with a history of COPD, OSA, obesity
presenting with a 2 day history of productive cough and
increasing dyspnea.
#. Dyspnea: He had a subacute course of dyspnea and increasing
oxygen requirement. His d-dimer was positive. He could not get
a CTA because of anaphylactic reaction to contrast dye. He was
refusing a V/Q scan. He also appeared to have significant body
edema with a low albumin. He had low suspicion for PE (negative
LENI), and had an echo that showed relatively well preserved
cardiac function. ABG showed that he most likely had a chronic
hypercarbic respiratory failure. He was felt to be slightly
fluid overloaded on exam, so he was started on prn Lasix.
However, BNP was not elevated. Pulmonary was consulted and
agreed patient with increased weight as a cause of obesity /
hypoventilaltion with or without an acute bronchitis. He also
likely has sleep apnea. His nebs were continued q6 prn. Urine
culture grew proteus and sputum culture overgrown with multiple
bacteria however patient remained afebrile during hospital
course without symptoms of cystitis and stable O2 nasal cannula.
No leukocytosis. Aspiration also low suspicion given no
complaints of choking and tolerating taking PO medications. He
was treated conservatively with modest improvement in dyspnea
and oxygen requirement. A sleep study was performed in MICU
night of [**4-27**] which showed a dramatic decrease in tidal volume
with REM sleep. It is unclear whether this was secondary to
obstruction v diaphragmatic dysfunction. Also, the study was
limited by short duration of sleep (~2hrs). Venous blood gas
following BiPAP showed some improvement in patient's respiratory
acidosis. Given increased sputum production, CXR was checked on
[**4-28**] which showed mild vascular congestion. Initially his fluid
goal was negative at least 500cc. Presently he is autodiuresing.
His HCO3 has been elevated but stable in the high thirties to
low forties. Rechecked VBG's were stable at pH 7.34-7.36. At
time of discharge from ICU to floor, patient was at baseline 3L
NS O2 requirement and was continued on this throughout stay. He
was continued on mask bipap at 12/8, which he intermittently
tolerates. Patient, at most, tolerates being on machine for [**12-13**]
hrs a night, however this should be encouraged as much as
possible. A repeat sleep study should be considered in the
future if his respiratory status or hypercarbia worsens.
#. Right Lower Quandrant Abdominal pain: On exam the patient has
been intermittently tender to palpation. He reports a history of
an abscess requiring drainage in the past. An abdominal
ultrasound showed perihepatic gel-phase collection of unclear
etiology. AST/ALT, amylase/lipase were all wihtin normal limits.
He had a slightly elevated alkaline phosphatase, which was
stable. Repeat abdominal ultrasound was unchanged. One week
prior to discharge, patient had a "flare" of chronic abdominal
pain. Normal bowel movements, however his WBC increased and he
had low grade tempearature. A repeat abdominal CT scan with
contrast was done [**2203-6-2**] to evaluate this change in his
abdominal pain. The CT scan did not show any acute
intraabdominal pathology, specifically no urolithiasis, hernia,
bowel obstruction or inflammation or fluid collection. Given his
history of recurrent urinary tract infection and tenderness over
suprapubic area, the abdominal pain was concerning for urinary
tract infection. UA and culture were sent and patient was
started on ceftriaxone. His urinalysis suggested infection,
however his urine culture appeated contaminated, growing out
multiple organsims with no clear source. He continued to have
low grade fevers < 100.5 while on ceftriaxone, therefore
coverage was broadened to tobramycin to cover resistant
organisms he had grown in past. Repeat UA and culture again
unrevealing. However, 1 bottle of blood culture grew gram
negative rod sensitive only to tobramycin. It was felt that
patient did indeed have UTI with likely transient bacteremia. He
should be continued on a 14 day course of tobramycin for this.
#. Recurrent urinary tract infection, with bacteremia: The
patient has a suprapubic catheter that requires flushing every
shift. The patient complained of urinary symptoms on [**5-13**]. A
urine culture revealed Proteus, which was treated with a ten day
course of ceftriaxone. Pt complained of RLQ abdominal pain and
was suspected to have UTI again. The suprapubic catheter was
changed on [**2203-6-4**] due to the second UTI. Pt was started on IV
ceftriaxone and IV Tobramycin. Blood cultures sent at this time
grew gram negative rods resistant to ceftriaxone, sensitive to
tobramycin. Additionally, the anaerobic bottle grew gram
positive cocci in pairs and clusters which was not yet
identified on discharge, but felt to be a contaminant.
Therefore, patient was continued on tobramycin alone for 14 day
course of treatment. The tobramycin will need to be monitored
closely. Mr. [**Known lastname 11679**] is on a q day regimen with goal trough < 1.
Of note, per Dr.[**Name (NI) 825**] most recent note, Mr. [**Known lastname 11679**] should
have this catheter changed every 3 months (would be due
[**2203-9-4**]). Repeat blood cultures were sent which were no growth
to date on day of discharge. The results of the blood cultures
will need to be followed up on on discharge.
#. LLE edema: The edema is of unclear etiology though it
remained stable throughout the admission. A bilateral LENI was
performed on [**4-5**] which was negative. The patient refused all
other repeat LENIs as well as pneumoboots for prophylaxis.
#. h/o HIT: No heparin products were given. No documentation of
a positive HIT or SRA could be found. If we had decided to treat
for a PE, we would have been willing to challenge with heparin
while in hospital setting. However, this issue did not arise and
should receive further discussion on future hospitalizations.
#. Skin lesions: Dermatology was consulted and diagnosed
seborrheic dermatiits on the patient's face, recommending
topical ketoconazole. They also diagnosed seborrheic keratosis
bilaterally on his thighs with no further intervention
recommended.
#. Tooth Pain: Developed pain in tooth on Friday [**2203-4-8**], which
resolved. It resumed on [**2203-5-29**]. There has been no evidence of
abscess. No inpatient dental consult is available. He was
written for lidocaine swish as needed. He should have outpatient
dental evaluation at nursing home.
#. Anemia: The patient has a history of iron deficiency
documented. His hematocrit was stable. He is to be continued on
his out-patient feosol.
#. Sacral decubiti/chronic osteomyelitis: The patient was
continued on Zinc, MVI, and wound care throughout the admission.
The wound remained slightly improved during the course of the
hospital stay.
#. Status post renal transplant: The patient was continued on
his immunosuppressive meds (Azathioprine and Prednisone). There
was no evidence of acute rejection on repeat abdominal CT.
#. Chronic pain: The patient was continued on his standing
methadone, with dilaudid prn for breakthrough pain.
#. Spasticity: The patient was continued on his out-patient
baclofen and lamotrigine.
#. Depression: The patient was continued on his home paxil
during the admission. His outpatient psychiatrist was contact[**Name (NI) **]
and reported that the patient occasionally starts gnawing on
fingers which usually resolves within a few days to a one week.
The patient did have occasional episodes of this. He refused
mittens for this. However, he is agreeable to wound care and
daily dry bandages, covered with either tegaderm or dry tape.
#. FEN: The patient was maintained on a cardiac healthy diet
throughout the admission.
#. Prophylaxis: The patient was maintained on a PPI, [**Last Name (un) 12376**]
regimen, fall and contact precautions throughout the admission.
The patient refused pneumoboots during the admission. Heparin
could not be used given a question of HIT.
#. CODE: full
Medications on Admission:
Medications on Admission:
Prednisone 5mg daily
Atrovent
Paxil 30mg [**Hospital1 **]
Dulcolax 10mg [**Hospital1 **]
Zinc 220mg qd
Senekot 2 tid
Phenergan 12.5mg q6:prn
Protonix 40mg qd
Nicorette q1h:prn
MVI
Methadone 5mg tid
Lamictal 25mg qd
Humalog sliding scale
Dilaudid 3mg q4h:prn
FA 1mg qd
Feosol 325mg [**Hospital1 **]
Vit D 400u qd
Colace 200mg [**Hospital1 **]
Benadryl 25mg q6:prn
Tums 2500mg tid
Lioresal 20mg tid
Imuran 75mg qd
Tylenol
Simethicone 80 [**Hospital1 **]
Albuterol prn
Lactulose 20mg/30ml TID
Reglan 5mg ACHS
MgOx 800mg q12h
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: not to exceed 4g/day.
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Nicotine 2 mg Gum Sig: Two (2) mg Buccal Q1H (every hour) as
needed for nicotine withdrawal.
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
14. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
15. Azathioprine 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
17. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Hold for loose stools.
18. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO ACHS ().
19. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
20. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours) as needed for itching: Do not give if giving
IV.
21. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for tooth pain.
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
23. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): Apply to nasolabial folds and affected areas on
face.
24. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-13**] Sprays Nasal
TID (3 times a day) as needed for nasal congestion.
25. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
26. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
27. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
28. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
29. Phenergan 25 mg/mL Solution Sig: 0.5-1 ml Injection every
six (6) hours as needed for nausea.
30. Hydromorphone 1 mg/mL Solution Sig: 4-6 mg Injection every
4-6 hours as needed for pain.
31. Benadryl 50 mg/mL Solution Sig: 0.5-1 ml Injection every six
(6) hours as needed for itching: Do not give if giving oral
benadryl. Use one or the other.
32. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
33. Tobramycin Sulfate 40 mg/mL Solution Sig: One [**Age over 90 11578**]y
(180) mg Injection Q24H (every 24 hours) for 10 days: Please
check trough 1-2 hours prior to dosing. Do not dose if trough
>1.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
PRIMARY:
Hypercarbic respiratory failure
Obesity
Urinary tract infection with bacteremia
SECONDARY:
Iron deficiency anemia
Sacral decubiti/chronic osteomyelitis
Status post renal transplant
Tooth pain
Chronic pain/spasticity
Depression
Quadriplegia
Discharge Condition:
Good, afebrile, stable respiratory status
Discharge Instructions:
Please take all medications as prescribed. Please continue using
the BiPAP machine overnight as directed.
Please keep all follow up appointments as scheduled.
If you experience any chest pain, worsening shortness of breath,
fever, passing out, or any other concerning symptom, please call
for evaluation.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 95361**]
[**Name (STitle) 21578**] within one week of discharge. Phone: [**Telephone/Fax (1) 76422**]
Doctor on call at the nursing home should call [**Hospital1 18**] labarotory
at 617 667 LABS for results of blood cultures still pending on
discharge. One bottle with gram positive cocci in pairs and
clusters was thought to be contaminated.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2203-6-6**]
|
[
"789.03",
"522.4",
"428.30",
"496",
"327.23",
"V42.0",
"344.00",
"599.0",
"041.6",
"707.14",
"276.4",
"428.0",
"790.7",
"V58.65",
"337.3",
"518.83",
"278.01",
"707.03",
"041.85",
"780.39",
"280.9",
"305.51",
"707.8",
"996.65",
"311",
"V63.2",
"V55.3",
"730.18",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"59.94"
] |
icd9pcs
|
[
[
[]
]
] |
21240, 21295
|
9387, 17412
|
343, 350
|
21589, 21633
|
4710, 4729
|
21987, 22595
|
4079, 4097
|
18011, 21217
|
21316, 21568
|
17464, 17988
|
21657, 21964
|
4112, 4691
|
284, 305
|
378, 3281
|
4743, 9364
|
3303, 3924
|
3940, 4063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,395
| 167,582
|
34883
|
Discharge summary
|
report
|
Admission Date: [**2154-9-8**] Discharge Date: [**2154-9-21**]
Date of Birth: [**2106-3-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Biliary sepsis
Major Surgical or Invasive Procedure:
ERCP with plastic stent placement
PICC line placement
ERCP with 8 mm x 80 mm Biliary Wallflex stent placement into the
hilum and left intrahepatic system
History of Present Illness:
48 yo W w PMH of HTN, DM who underwent CT-guided biopsy of newly
diagnosed liver mass on [**2154-9-6**]. Pt presented to OSH ED on
[**9-8**] with chills, sweats and reported temp at home of 92 F. In
the [**Hospital3 **] ED, VS notable for rectal temp of 94, HR 52, BP
87/58, 99%RA. KUB was within normal limits. Labs were notable
for WBC count of 17 with 9% bands, BUN/CR of 78/2.8, T Bili 40,
Direct 17, glucose of 43. Pt received 2L NS, 1 amp D50, Unasyn x
1 dose and underwent CT abdomen prior to transfer to the ICU.
There she also received Vanco x 1 dose and 3rd liter of IVFs.
On arrival to the [**Hospital Unit Name 153**], patient was stable but with BPs in the
low 90's. Otherwise, without complaints. ROS unrevealing. Denies
history of hepatitis or recent travel.
Past Medical History:
HTN
Hyperlipidemia
Type II DM
GERD
PSH:
Appy
Social History:
Pt quit tobacco 13 years ago; total 15 pk year history. Married
without children. No hx of ETOH abuse
Family History:
No hx of pancreatic hx
Physical Exam:
VS: T 97 BP 91/50, HR 61, 99% RA
GEN: Obese female in NAD, jaundiced
HEENT: EOMI, PERRL, anicteric
NECK: Supple
CHEST: CTABL, no w/r/r
CV: RRR, S1S2, no m/r/g
ABD: Obese, Soft/ND, + BS, TTP in RUQ
EXT: no cyanosis, edema
SKIN: Jaundiced, no rashes
NEURO: CN ii-xii intact; Strength/sensation grossly intact; AAO
x 3; toes downgoing bilaterally
Pertinent Results:
[**2154-9-8**] 07:49PM NEUTS-87* BANDS-1 LYMPHS-4* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2154-9-8**] 07:49PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-4.7*
MAGNESIUM-2.7*
[**2154-9-8**] 07:49PM WBC-13.7* RBC-5.32 HGB-15.3 HCT-44.1 MCV-83
MCH-28.7 MCHC-34.6 RDW-19.0*
[**2154-9-8**] 07:49PM ALT(SGPT)-31 AST(SGOT)-47* LD(LDH)-229 ALK
PHOS-242* AMYLASE-42 TOT BILI-32.8*
[**2154-9-8**] 07:49PM LIPASE-55
[**2154-9-8**] 07:49PM PLT SMR-NORMAL PLT COUNT-388
[**2154-9-20**] 05:48AM BLOOD WBC-16.4* RBC-4.09* Hgb-11.7* Hct-35.6*
MCV-87 MCH-28.7 MCHC-33.0 RDW-20.5* Plt Ct-315
[**2154-9-20**] 05:48AM BLOOD PT-15.4* PTT-25.2 INR(PT)-1.4*
[**2154-9-20**] 05:48AM BLOOD Glucose-140* UreaN-11 Creat-0.8 Na-139
K-3.9 Cl-107 HCO3-21* AnGap-15
[**2154-9-20**] 05:48AM BLOOD ALT-18 AST-33 LD(LDH)-226 AlkPhos-117
TotBili-11.1*
[**2154-9-18**] 03:53AM BLOOD CA [**64**]-9 -502 H
CT Chest:
IMPRESSION:
1. No good evidence for intrathoracic malignancy. A 4 mm left
upper lobe
nodule is the only candidate for metastasis. Small right and
tiny left
pleural effusions are probably due to volume overload or
migration of ascites.
2. Subpleural cyst or old abscess or infarct, right lung, do not
warrant
followup, unless patient is symptomatic.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: TUE [**2154-9-17**] 10:39 AM
CT ABD/PELVIS
IMPRESSION:
1. Infiltrative hepatic mass which surrounds the IVC and appears
to
obliterate the right and middle hepatic veins as well as the
right posterior
portal vein. In addition, innumerable masses are also seen
satellite to this
lesion at the liver dome, and throughout the right lobe. There
is relative
preservation of the left lobe of the liver from this mass,
although portions
of the dominant mass extends contiguously into the left lobe.
2. Marked intrahepatic biliary ductal dilatation.
3. Moderate ascites.
4. Moderate right-sided pleural effusion and atelectasis; trace
left-sided
pleural effusion and atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2154-9-14**] 11:00 PM
Cytology Report PERITONEAL FLUID Procedure Date of [**2154-9-16**]
Peritoneal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, histiocytes and lymphocytes.
Cytology Report COMMON BILE DUCT BRUSHINGS Procedure Date of
[**2154-9-10**]
Bile duct stricture:
SUSPICIOUS.
Scattered clusters of highly atypical cells with
increased nuclear:cytoplasmic ratios and irregular
nuclear contours, suspicious for adenocarcinoma.
Brief Hospital Course:
48 year old female with DM, HTN, and recently found liver mass,
transferred from OSH with hypotension, bandemia, hypoglycemia,
ARF likely secondary to sepsis after recent liver biopsy.
#. Hyperbilirubinemia/hepatic failure/liver mass: Patient
presented with painless jaundice, significant hyperbilirubinemia
and was also known to have a liver mass. She had had a liver
biopsy done at [**Hospital3 10377**] hospital prior to
admission with results reportedly demonstrating fibrosis only.
On admission, with above presentation, concern for carcinoma,
hepatocellular versus cholangiocarcinoma.
On presentation, she underwent ERCP with plastic stent placed
initially, and brushings done which were sent to cytology and
returned "highly suspicious for malignancy". She also underwent
a triple phase CT scan of abdomen/pelvis that demonstrated tumor
throughout right lobe, extending into left lobe of the liver, as
well as infiltrating the vena cava, and some enlarged lymph
nodes.
.
Hepatobiliary surgery and oncology teams were consulted, and
evaluation was made to determine if the patient was a surgical
candidate. Evaluation included large volume paracenteses with
ascitic fluid sent for cytology which returned negative.
However, upon evaluation of extent of liver metastasis, it was
determined that the patient was not a surgical candidate for her
cancer. Social work was consulted for assistance with coping
with her new diagnosis of cancer, and the fact that she was not
a candidate for surgery. Prior to discharge, she underwent
repeat ERCP with metal stent (more permanent stent) placement
and repeat brushings sent to cytology. The results of this are
pending at the time of discharge. The patient will follow up
with Dr. [**Last Name (STitle) **] on [**10-1**] for the results of this and discussion re:
chemotherapy.
--> Plans for discharge with oncology follow up. They will also
follow up on cytology of ERCP brushings and if inconclusive will
schedule an outpatient liver biopsy.
#. Sepsis, now resolved: On presentation, patient had elevated
WBC count with bandemia, and was hypotensive, consistent with
sepsis. Infectious source thought to be hepatobiliary given
severe jaundice and recent instrumentation of liver biopsy prior
to presentation. Also concern for MRSA with recent
hospitalization and right lower lobe infiltrate versus effusion
seen on chest x-ray. She was started on Zosyn and vancomycin and
completed 9 day course. She initially required IVF boluses to
maintain adequate blood pressure. Blood pressure and symptoms
stabilized and patient was transferred to the floor, and she
remained well throughout remainder of hospital course. Her
antihypertensive medications were held for the duration of her
hospitalization and Dr. [**Last Name (STitle) **] personally advised her to
continue to NOT take these medications (HCTZ and ACE-inhibitor)
until further directed by a physician. [**Name10 (NameIs) **] her WBC was still
elevated at discharge, she was discharged on a seven day course
of levofloxacin, as recommended by Dr. [**Last Name (STitle) 79848**] from ERCP.
# Hypoglycemia/diabetes: Patient was initially hypoglycemic
during her hospital course, off of her home insulin regimen.
Concern for hepatic failure initially, but then resolved, and
therefore was likely to sepsis and oral agents in the setting of
acute renal failure. She was otherwise maintained on insulin
sliding scale throughout remainder of hospital course. On the
day of discharge, she was given 15 units of glargine which is
half of her usual dose. She was instructed to continue this (15
units each morning) and take her FS 4 x daily. She will call
her endocrinologist on Monday to discuss further therapy. She
declined to continue her metformin given her hepatic process
which seems reasonable.
# UTI: UA on admission with pyuria. OSH urine culture with no
growth. Urine culture no growth. Any potential UTI was likely
covered by Zosyn.
# Acute renal failure: FeNa of 1.9 initially suggested ATN
consistent with hypotension. Renal function improved with IVF
and was much improved (0.8) at time of discharge.
# HTN: Anti hypertensives held during hospital course
# GERD: maintained on PPI
Medications on Admission:
Protonix
Flonase
(Following recently discontinued)
HCTZ
Benicar
Tricor
Amaryl
Lantus 30 U
Metformin
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: 15 Units 15 Units
Subcutaneous once a day: Take 15 units of glargine every
morning. If you are unable to eat, call your doctor and do not
take this medication.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**11-28**]
sprays Nasal [**Hospital1 **] PRN as needed for Postnasal drip.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cholangiocarcinoma
Obstructive jaundice s/p metallic stent placement
Secondary:
HTN
Diabetes type 2 uncontrolled
Discharge Condition:
Good. Patient without pain, tolerating PO, ambulating without
difficulty.
Discharge Instructions:
You were admitted to the hospital with jaundice and liver
masses, as well as sepsis (severe infection with low blood
pressure). Your infection was treated and your jaundice and
liver masses were worked up and determined to be
cholangiocarcinoma. You are discharged with follow up with
oncology services.
Please follow up with appointments as directed.
.
Please contact physician if develop abdominal pain,
fevers/chills, nausea/vomiting, increase in jaundice, any other
questions or concerns.
.
Call your endocrinologist on Monday to discuss your insulin
regimen. You are being discharged on half your usual dose of
lantus/glargine. This is because you have lost weight and you
are not eating the same amount as before admission. You may
ultimately need more long-acting insulin. Please continue to
take your fingersticks 4 times per day. Call Dr. [**Last Name (STitle) 34488**] ([**Telephone/Fax (1) 29561**] if your fingersticks are higher than 200 or below 80.
As we discussed, you have not been on your metformin since
admisson and we agreed for you not to take this medication until
further directed. You can discuss this with Dr. [**Last Name (STitle) 34488**] if you
wish.
.
Do not take your hydrochlorothiazide, your benicar, tricor,
amaryl or metformin until directed otherwise by a physician.
.
The ERCP team recommended that you start levofloxacin (an
antibiotic) on discharge. You are being discharged on a one
week course of this medication. You should take it once per day
for seven days.
Followup Instructions:
Please follow up with the [**Hospital **] clinic, Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 22**] on Tuesday [**10-1**] at 3pm. This is
located on the [**Location (un) **] of the [**Hospital 23**] clinic building at [**Hospital 61**] Hospital. (This building is on the corner [**Location (un) 79849**] and [**Hospital1 1426**].)
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on
Tuesday [**2154-9-24**] at 11AM.
|
[
"789.59",
"155.1",
"530.81",
"584.5",
"995.92",
"272.4",
"197.7",
"038.9",
"401.9",
"250.82",
"576.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91",
"51.87",
"99.07",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
9740, 9746
|
4674, 8892
|
327, 482
|
9913, 9990
|
1897, 4651
|
11551, 12075
|
1492, 1517
|
9042, 9717
|
9767, 9892
|
8918, 9019
|
10014, 11528
|
1532, 1878
|
273, 289
|
510, 1287
|
1309, 1356
|
1372, 1476
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,475
| 152,133
|
47269
|
Discharge summary
|
report
|
Admission Date: [**2146-2-7**] [**Month/Day/Year **] Date: [**2146-2-12**]
Service: MEDICINE
Allergies:
Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85F h/o sCHF (EF 45%), CAD s/p NSTEMI, PVD s/p left BKA, DM,
HD-dependent ESRD, stage IV decub ulcer who presents to the ER
with hypotension. Last hospitalization was [**1-11**]/-[**2146-1-22**] for
hypotension thought to be due to UTI staphyloccocus and
streptococcus, speciation pending at time of [**Month/Day/Year **],
completed a 10 day course vancomycin, but cultures eventually
grew MSSA and VRE. She has had multiple recent hospitalizations
over the past month for lower GI bleed requiring transfusions
refusing colonoscopy on most recent admission, CHF complicated
by bilateral pleural effusions that responded to HD.
.
Lives at [**Location **]. Had been doing relatively well although was more
somnolent recently that family thought due to overmedication
with oxycodone and lorazepam that was being dosed standing for
decub dressing changes and anxiety. Has chronically required
supplemental O2 for the past month, but no recent change and no
new productive cough. Chronic unchanged diarrhea. Today for
scheduled HD session and noted to have SBPs 80s pre-HD, but
still dialyzed and completed session. Post-HD, SBPs dropped to
60-70s although patient mentating well and otherwise without
complaints. Sent to ED for evaluation.
.
In the [**Name (NI) **], pt was noted to have a SBP of 60s and therefore given
2 liters normal saline without improvement. Other vitals 97.5,
72, 22, 99% NRB. Right femoral CVL placed. Norepinephrine gtt
started with improvement to BP 105/30. WBC 12.3k without left
shift, lactate 1.5, CK 107, TnT at baseline 0.21, U/A grossly
positive and foley with purulent urine. Stool trace guaiac
positive. Blood cultures sent and given Vancomycin and Zosyn.
Admit ICU for urosepsis.
.
ROS: Per HPI, otherwise the patient denies any fevers, chills,
nausea, vomiting, abdominal pain, constipation, chest pain,
shortness of breath, cough, dysuria, lightheadedness, focal
weakness, vision, headache, rash.
Past Medical History:
1. CAD s/p NSTEMI in [**4-27**]. Medically managed, felt not to be
candidate for catheterization. Plavix had to be stopped due to
rectus sheath hematoma. Post-MI echocardiogram demonstrated
regional LV systolic dysfunction with inferolateral/basal
inferior wall hypokinesis with EF of 50-55%, elevated LV filling
pressure and 1+ MR.
2. PVD s/p left BKA with Dr. [**Last Name (STitle) **]
3. Insulin dependent diabetes mellitus
4. Hypertension
5. Hyperlipidemia
6. ESRD on HD M/W/F
7. Positive PPD -- hospitalized at [**Hospital1 2025**], had 3 negative sputum
8. Lower GI Bleed--unable to tolerate colonoscopy prep as
inpatient, plan for outpatient procedure
9. Stage IV Decubitus ulcer, 2 ischial ulcers and heel ulcer.
10. Depression
11. Colon cancer s/p resection
12. h.o. VRE
13. h.o. MRSA
14. Spontaneous rectus sheath hematoma ([**4-27**])
Social History:
Widowed. Currently at rehab, but lived alone with son in
apartment below. No tobacco, alcohol or drugs.
Family History:
Parents lived until 95. Cause of death is unknown, but patient
denies a family history of CAD/MI or early cardiac death.
Physical Exam:
Admission Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
[**Month/Year (2) **]/Death Exam:
Patient unresponsive, pulseless. Pupils dilated and fixed. No
heart or lung sounds.
Pertinent Results:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2146-2-8**]):
REPORTED BY PHONE TO SHEEHAM [**2146-2-8**] 3:00PM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Admission labs:
[**2146-2-7**] 02:50PM BLOOD WBC-12.3* RBC-3.40* Hgb-8.5* Hct-28.9*
MCV-85 MCH-25.1* MCHC-29.6* RDW-17.5* Plt Ct-174
[**2146-2-7**] 02:50PM BLOOD PT-15.6* PTT-33.0 INR(PT)-1.4*
[**2146-2-7**] 02:50PM BLOOD Glucose-127* UreaN-19 Creat-2.4* Na-143
K-3.3 Cl-101 HCO3-33* AnGap-12
[**2146-2-7**] 02:50PM BLOOD CK(CPK)-107
[**2146-2-7**] 02:50PM BLOOD TotProt-5.0* Albumin-2.0* Globuln-3.0
Calcium-7.0* Phos-3.4 Mg-1.6
[**Month/Day/Year **] Labs:
[**2146-2-11**] 01:08AM BLOOD WBC-17.6* RBC-3.59* Hgb-9.1* Hct-30.8*
MCV-86 MCH-25.4* MCHC-29.6* RDW-17.6* Plt Ct-255
[**2146-2-11**] 01:08AM BLOOD PT-20.1* PTT-43.9* INR(PT)-1.9*
[**2146-2-11**] 04:43PM BLOOD Glucose-92 UreaN-26* Creat-2.9* Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
[**2146-2-11**] 04:43PM BLOOD Calcium-7.5* Phos-4.1 Mg-1.8
[**2146-2-11**] 04:55PM BLOOD Type-ART Temp-36.1 Rates-/19 pO2-72*
pCO2-64* pH-7.15* calTCO2-24 Base XS--7 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2146-2-11**] 04:55PM BLOOD freeCa-1.04*
Imaging:
CXR [**2-11**]: IMPRESSION: Interval left PICC with tip within right
atrium that can be withdrawn by approximately 3 cm for more
optimal positioning within the low SVC. Stable large bilateral
pleural effusions with associated bilateral atelectasis, and
mild congestive heart failure.
Renal U/S [**2-7**]:
Atrophic kidneys bilaterally with prominent cortical thinning,
consistent with chronic medical renal disease. No perinephric
fluid
collections are identified.
Brief Hospital Course:
An 85 year old lady admitted for hypotension due to sepsis. She
was found to have C.diff colitis and osteomyelitis. During this
admission a decision was made to focus on comfort measures after
medical therapy provided no clear improvement and she passed
away peacefully on [**2146-2-12**].
1. Hypotension: The patient was admitted with hypotension
consistent with sepsis given increasing WBC count, C. diff
positivity, and sacral ulcer probing to bone. She was treated
with Flagyl IV and Vancomycin PO only given no evidence of
bacteremia or culture from her wounds. She was maintained on
levophed as needed for blood pressure maintenance.
2. Hypercarbic Respiratory Distress: The patient developed
mixed respiratory and metabolic acidosis with mental status
changes. This resolved on its own with arousal. CVVH was
briefly initiated to clear fluid overload and correct acidosis,
but stopped by the family when made CMO.
3. Acute on Chronic renal failure: The patient was briefly on
CVVH but stopped by the family when made CMO. Renal followed
closely.
4. Stage IV Decubitus Ulcer: Wound Care & Plastic Surgery were
consulted and followed. They made care recommendations but no
operative interventions.
5. Depression: The patient was continued on remeron and celexa.
Medications on Admission:
1. Citalopram 20 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Mirtazapine 7.5 mg PO HS
4. Oxycodone 5 mg PO Q6H as needed.
5. Metoprolol Tartrate 25 mg PO TID
6. Albuterol Sulfate Nebulization Q6H as needed.
7. Lorazepam 0.5 mg PO BID as needed.
8. Omeprazole 20 mg PO DAILY
9. Sevelamer HCl 800 mg PO TID W/MEALS
10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY.
11. Docusate Sodium 100 mg PO BID.
12. Bisacodyl 10 mg PO DAILY as needed for constipation.
13. Senna 8.6 mg PO BID as needed.
14. Heparin 5,000 unit/mL TID.
15. Lisinopril 5 mg PO DAILY
16. Glargine 10 units qhs and humalog insulin per scale
subcutaneous four times a day.
[**Year (4 digits) **] Medications:
N/A
[**Year (4 digits) **] Disposition:
Expired
[**Year (4 digits) **] Diagnosis:
C. Diff colitis Sepsis
[**Year (4 digits) **] Condition:
Expired
[**Year (4 digits) **] Instructions:
N/A
Followup Instructions:
N/A
|
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"584.9",
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icd9cm
|
[
[
[]
]
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[
"38.91",
"38.93",
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"86.28"
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icd9pcs
|
[
[
[]
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5910, 7192
|
264, 270
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4222, 4428
|
8109, 8115
|
3237, 3359
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7218, 8086
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3374, 4203
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213, 226
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298, 2230
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4444, 5887
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2252, 3100
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3116, 3221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,529
| 148,697
|
32638
|
Discharge summary
|
report
|
Admission Date: [**2140-10-23**] Discharge Date: [**2140-11-3**]
Date of Birth: [**2072-6-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
sepsis, multisystem organ failure
Major Surgical or Invasive Procedure:
Right Colectomy- [**Last Name (un) 1724**]
Ex-lap, abd washout, closure-[**Last Name (un) 1724**]
Ex-lap, abd washout of necrotic hematoma, placement [**Location (un) **]
bag-[**Hospital1 18**]
History of Present Illness:
68 yo M s/p R colectomy for presumed R colon CA/mass at [**Last Name (un) 1724**].
[**First Name8 (NamePattern2) **] [**Last Name (un) 1724**] physciians pt had Hct drop requiring 7+PRBC transfusion,
with increased bladder pressures. Pt was taken back to OR at [**Last Name (un) 1724**]
on POD 3 for Ex-lap which showed hematoma, mild geeralized
peritoneal oozing , but no active bleed. Pts abdomen was closed.
Pt shorly became septic an dwent into multisystem organ failure
including cardiac, respiratory, hepatic, and renal. Pt was
transfered to [**Hospital1 **] for optimization of ICU care and to undergo
CVVHD which was not available at [**Last Name (un) 1724**]
Past Medical History:
CAD, Hepatic Dsyfunction, CRI, h/o MI
CABG x 4
CABG x 4
Cardiac stent
Physical Exam:
pt had expired
Pertinent Results:
[**2140-10-23**] 01:06AM LACTATE-1.9
[**2140-10-23**] 01:06AM TYPE-ART PO2-53* PCO2-45 PH-7.23* TOTAL
CO2-20* BASE XS--8
[**2140-10-23**] 01:09AM PT-17.0* PTT-55.8* INR(PT)-1.6*
[**2140-10-23**] 01:09AM WBC-10.4 RBC-3.35* HGB-10.5* HCT-30.3* MCV-91
MCH-31.4 MCHC-34.6 RDW-14.8
[**2140-10-23**] 01:09AM ALBUMIN-2.9* CALCIUM-8.1* PHOSPHATE-6.7*
MAGNESIUM-2.5
[**2140-10-23**] 01:09AM CK-MB-69* MB INDX-1.3 cTropnT-9.54*
[**2140-10-23**] 01:09AM LIPASE-168*
[**2140-10-23**] 01:09AM ALT(SGPT)-971* AST(SGOT)-1368* CK(CPK)-5246*
ALK PHOS-60 AMYLASE-209* TOT BILI-11.1* DIR BILI-9.1* INDIR
BIL-2.0
[**2140-10-23**] 01:09AM GLUCOSE-87 UREA N-46* CREAT-4.9* SODIUM-142
POTASSIUM-5.3* CHLORIDE-107 TOTAL CO2-20* ANION GAP-20
[**2140-10-23**] 09:35AM CK(CPK)-5057*
[**2140-10-23**] 11:19AM PT-19.1* PTT-103.0* INR(PT)-1.8*
[**2140-10-23**] 11:54AM TYPE-ART PO2-91 PCO2-41 PH-7.26* TOTAL
CO2-19* BASE XS--8
[**2140-10-23**] 05:05PM CK-MB-55* MB INDX-1.2 cTropnT-10.38*
[**2140-10-23**] 05:05PM GLUCOSE-117* UREA N-37* CREAT-3.4* SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-19* ANION GAP-21
[**2140-10-23**] 10:14PM LACTATE-2.0
[**2140-10-23**] 10:14PM TYPE-ART TEMP-36.6 RATES-32/ TIDAL VOL-300
PEEP-18 O2-60 PO2-114* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--3
-ASSIST/CON INTUBATED-INTUBATED
[**2140-11-3**] 05:10PM 12.6*1 3.34* 10.4* 30.8* 92 31.2 33.9
16.1* 50*2
Source: Line-aline
[**2140-11-3**] 05:10PM 161* 31* 1.21 145 4.5 104 29 17
[**2140-11-3**] 05:10PM 23 41* 268* 32* 52 41 18.1*
Source: Line-aline / ICTERIC SAMPLE
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2140-11-4**] 09:12AM 9.2*1
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent Comment
[**2140-11-4**] 09:12AM ART 43*1 99*1 6.89*1 21 -18
INCORRECT 2
RADIOLOGY Final Report
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2140-10-28**] 3:39 PM
LIVER OR GALLBLADDER US (SINGL
Reason: acalculous cholecystitis,
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with R colectomy, sepsis, MI, arf, liver
failure, improving, with continuly rising bilirubin.
REASON FOR THIS EXAMINATION:
acalculous cholecystitis,
INDICATION: Rising bilirubin.
COMPARISON: [**2140-10-23**].
FINDINGS: Examination limited to the right upper abdomen. The
gallbladder is normal without distension, gallstones, mural
thickening or pericholecystic fluid. The patient is sedated and
intubated, and therefore son[**Name (NI) 493**] [**Name (NI) **] sign could not be
assessed. There is no intra- or extra- hepatic biliary ductal
dilatation and the common duct measures 2 mm in the porta
hepatis.
IMPRESSION: No son[**Name (NI) 493**] evidence of acute cholecystitis or
biliary ductal dilatation.
RADIOLOGY Final Report
CT GUIDANCE DRAINAGE [**2140-10-29**] 9:49 AM
CT GUIDANCE DRAINAGE; CT GUIDED NEEDLE PLACTMENT
Reason: Please drain and send contents for full gram stain and
cultu
[**Hospital 93**] MEDICAL CONDITION:
68 year old man on s/p R colectomy c/b ARDS, sepsis, multiorgan
failure, s/p abd compartment syndrome, now on CVVH, w/ large
complex gas-containing collection in the right abdomen and
pelvis measuring 20 x 7 cm in the coronal plane
REASON FOR THIS EXAMINATION:
Please drain and send contents for full gram stain and culture
CONTRAINDICATIONS for IV CONTRAST: Elevated Cr
REASON FOR EXAMINATION: CT-guided drainage of intra-abdominal
collection.
COMPARISON: CT abdomen from [**2140-10-28**].
PROCEDURE: After explaining potential risks, benefits and
alternatives of the procedure to the patient proxy, a written
informed consent was obtained. All questions were answered. A
qualified IV nurse was present to administer 50 mcg of fentanyl.
Patient identity was confirmed by name and date of birth, and
medical record number. A CT abdomen from the lung bases to the
pelvis was obtained without injecting of IV contrast material
for localization purposes. No oral contrast was given.
Images confirm the presence of heterogeneous mass in the right
mid and lower abdomen about 9.2 x 6.5 cm in size continuing
towards the lower abdomen and entering the pelvis. No
significant change compared to the CT abdomen obtained at day
before was demonstrated. Large amount of nonhemorrhagic
peritoneal fluid was again demonstrated with no significant
change compared to the previous study.
Right anterolateral approach was chosen for drainage of the
intra-abdominal collection. The overlying skin was marked,
prepared and draped in the usual sterile fashion. 1% lidocaine
was injected into the overlying skin and subcutaneous tissues
for local anesthesia. Thereafter, using CT guidance, a TLA
sheath was introduced into the collection and approximately 5 cc
of red, yellow fluid was aspirated and sent for the Gram stain
and culture. Over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] wire, the tract was dilated with 7
and 8 fr dilators. A 8fr [**Last Name (un) 2823**] catheter was then placed over
the guidewire. After each exchange, catheter or wire poisiton
was confirmed with CT fluoro.
About 150 cc of content of the intra- abdominal abscess were
aspirated. The patient tolerated the procedure and there were no
immediate complications. Dr. [**Last Name (STitle) **] participated in the entire
procedure.
Impression:
1. Aspiration of a right mid abdomen heterogenous collection
with aspirated fluid most suggestive of infected hematoma.
2. Drainage of the right mid abdomen collection, with 8 fr
Navare catheter.
3. No change in large ascites, bibasilar atelectasis and
bilateral pleural effusion and small right pneumothorax compared
to CT ob
[**Known lastname 31804**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76070**]Portable TTE
(Complete) Done [**2140-10-24**] at 10:11:28 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
Conclusions
1. There is moderate to severe regional left ventricular
systolic dysfunction of the inferior, septal and anterior walls
extending from the base to the apical regions. The septal wall
is dyskinetic.. There is severe global left ventricular
hypokinesis (LVEF = 15-20 %).
2. The right ventricular cavity is mildly dilated. Right
ventricular systolic function is borderline normal.
3. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation
is seen.
4. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
5. The tricuspid valve leaflets are mildly thickened
IMPRESSION: Mild global hypokinesis and moderate hypokinesis of
the entire septum
[**Known lastname 31804**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76071**]
(Complete) Done [**2140-11-3**] at 4:22:34 PM FINAL
proceedures:
[**Last Name (LF) **],[**First Name3 (LF) **] M.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on WED [**2140-11-9**] 6:48 AM
Name: [**Known lastname 31804**], [**Known firstname **] Unit No: [**Numeric Identifier **]
Service: TRAUMA [**Last Name (un) **] Date: [**2140-11-2**]
Date of Birth: [**2072-6-28**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 67121**]
PREOPERATIVE DIAGNOSIS: Respiratory failure, septic shock.
POSTOPERATIVE DIAGNOSIS: Respiratory failure, septic shock.
PROCEDURE: Flexible bronchoscopy, percutaneous tracheostomy.
[**Last Name (LF) **],[**First Name3 (LF) **] M.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on WED [**2140-11-9**] 6:14
PM
Name: [**Known lastname 31804**], [**Known firstname **] Unit No: [**Numeric Identifier **]
Service: Date: [**2140-11-3**]
Date of Birth: [**2072-6-28**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 52594**]
ASSISTANT: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 122**].
ANESTHESIA: General endotracheal.
PREOPERATIVE DIAGNOSIS:
1. Septic shock.
2. Intra-abdominal infected hematoma.
POSTOPERATIVE DIAGNOSIS:
1. Septic shock.
2. Intra-abdominal infected hematoma.
3. Intra-abdominal abscess.
NAME OF PROCEDURES:
1. Exploratory laparotomy.
2. Drainage of intra-abdominal abscess and infected
hematoma.
3. Temporary [**Location (un) 5701**] bag closure of the abdominal wall.
Brief Hospital Course:
To to the multiple medical issues while in the SICU the patient
hospital course will be broken down by in a systems based
approach.
Neuro: pt arrived sedated and intubated . Initially pt was on
cisatricuium and fentanyl for sedation and paralyzation. Pt was
never able to be completely off sedation due to intubation. Pt
was eventually taken off paralytic. Pt did move all extremities,
but true neurologic cognitive fuction could not be assessed
throughout his course. Pt did grimace to pain.
CV: Pt initailly presented to [**Hospital1 18**] on multiple pressors. Early,
during his course these pressors were rapidly weened. However,
throughout his course the pt needed continual low dose pressor
in order to maintain adequate MAP. It had been reported
Troponin levels as high 100 at [**Last Name (un) 1724**], upon arrival at [**Hospital1 18**]
troponin levels were aprox 9, which were elevated to as high as
14 at one point. Cardilogy was consulted. Echo showed some
hypokinesia. It was determined that the pt had a fair amount of
cardicac insult and based upon initial Swan Ganz cath numbers
showed cadiac insufficiency which improved overtime. However,
the patient eventually went into overwhelming sepsis, worsening
echo results, and eventual cardiac failure. Near the end of the
pts course he was on multiple pressors and rquired cpr which was
unsucessful
Resp: pt arrived at [**Hospital1 18**] with severe respiratory failure that
required Nitric Oxide and well as paralyzation with
cisatricurium and maximal Fio2 and ventilatory settings. Pt was
eventually weened off meds, and decreased vent setting. however,
due to continued resp failure the pt underwent percutaneous
trachestomy on [**11-2**]
GI: Pt had know hepatic dysfunction Craigler-Nijar with know
elevated direct bilirubin. However pt was in shock liver upon
arrival to [**Hospital1 18**] with elevated trasaminases in the 1000's. Pt
underwent RUQ u/s which showed no abnormalities other than
ascites. Pt underwent CT scan whcih showed a large likely
necrotic hematoma which was initially sucessfully drained by IR.
Near the end of the patients hospital course , the pt became
rapidly septic and it was noted that the drin had decreased
output. The decision was made that the likely septic source was
the hematoma nd teh decision was made to reoperate, at which
time frank pus was found ( please see op note for further
details)
GU: A primary reason the pt was transfered to [**Hospital1 18**] was due to
unresolving renal failure, acidosis requiring CVVHD. Upon
arrival a renal dialysis cath was palced and CVVHD was begun.
The patients acidosis, BUN, creatinine, and electrolytes
improved over the subsequent days. And the patient did make a
fair amount of urine. Near the end of the pts hospital course
with ensuing sepsis and increased pressor requirements the urine
outpu dropped off
Heme: Pt Hct was essentially stabe throughout the hospital
course. Initially the pt had a mild coagulopathy that was
corrected with FFP.
ID:Initally the pt was on broad coved antibiotics though no true
source could be found. on [**10-29**] E Coli bacteremia was noted in
blood cultures and appropriate antibiotics were adjusted for
coverage.The worsening sepsis was attributed to the frank
peritoneal abscess found at the time of exploration
FEN: The patients electrolytes were intially irregualr due to
ARF, however, they were quicklky corrected with CVVHD.
Additionally, TPN was begun after initail sepsis had improved as
well as slow tube feeds for enterocyte viability
Medications on Admission:
neuro: fentanyl, cisatricurium
resp: nebulizing treatmens Albuterol
CV: levophed, vasoprerssin
GI: Protonix
ID: vanc, meropenum
Heme: Heparin subcutaneously
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis, multisystem organ failure, death
Discharge Condition:
death
Completed by:[**2140-11-13**]
|
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icd9pcs
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[
[
[]
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13772, 13781
|
9994, 13535
|
348, 544
|
13865, 13902
|
1385, 3418
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13743, 13749
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13802, 13844
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1350, 1366
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275, 310
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4676, 9971
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572, 1242
|
1264, 1335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,873
| 103,496
|
8098
|
Discharge summary
|
report
|
Admission Date: [**2161-6-17**] Discharge Date: [**2161-6-21**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
dyspnea, hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 year old Female with history of severe COPD on 2L Home
Oxygen, pulmonary hypertension, renal insufficiency and carotid
insufficiency was referred to the ED for hyponatremia and
dyspnea. Mrs. [**Known lastname **] was brought to the ED by EMS with dyspnea
x 2 days, recieving multiple nebulizer treatments in route to
the ED. Dyspnea started 2 days prior to admission, accompanied
with bilateral leg swelling. Denies any chest pain. No
palpitations. Says her urine output seems unchanged.
Symptoms started "when the weather got hot." She reports having
a poor apetite over the last few days and drinks very little. Of
note, Mrs. [**Known lastname **] was recently started on Lasix ([**6-3**]) for
symptom control of her cor pulmonale. Her sodium was noted to
decline gradually on subsequent with nadir of 122 on the morning
of referral to the emergency room. She has continued to take her
daily lasix, despite her PCP notifying her of her low sodium and
encouraging her to stop taking that med. Additionally, Mrs.
[**Known lastname **] was recently started on home O2, 2L, and is supposed to
wear it at all times, previously just at night. Her
granddaughter notes she often takes her oxygen off, particularly
while at her day program.
In the ED, initial vs were: T=98.1, HR=81, BP=121/76, RR=16
98%4LNC. Patient was given lasix, nitro gtt and BiPap, ASA 325,
for a presumed CHF exacerbation. Her CXR came back clear. She
was additionally treated for a COPD exacerbation with albuterol
and ipatropium nebs, azithromycin and solumedrol.
Past Medical History:
Pulmonary hypertension
COPD on 2L Home
carotid stenosis
Stage III CKD
Social History:
lives with family with good support, widowed, has VNA sevice.
past smoker, quit 50 yrs ago, smoked for about 20 years. Lost 2
children.
Family History:
Non-Contributory
Physical Exam:
Vitals: T: 95.1 BP: 129/57 P: 78 R: 18 O2: 97% on 4L by NC
General: Alert, oriented, appears tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear, pale
conjunctiva, dry mouth,d ry mucosa
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally, few expiratory wheezes.
CV: Regular rate and rhythm, systolic murmur at left sternal
border non radiating, no murmurs, rubs, gallops
Abdomen: soft, nt, nd, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: Foley in place to gravity
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. mild
pitting edema
Pertinent Results:
[**2161-6-21**] 06:30AM BLOOD WBC-10.8 RBC-4.76 Hgb-13.1 Hct-40.3
MCV-85 MCH-27.6 MCHC-32.6 RDW-13.6 Plt Ct-508*
[**2161-6-18**] 04:40AM BLOOD WBC-12.1* RBC-4.27 Hgb-11.6* Hct-34.8*
MCV-82 MCH-27.2 MCHC-33.4 RDW-13.6 Plt Ct-401
[**2161-6-16**] 10:30PM BLOOD WBC-11.1* RBC-4.92 Hgb-13.3 Hct-40.6
MCV-83 MCH-27.0 MCHC-32.7 RDW-14.0 Plt Ct-524*
[**2161-6-18**] 04:40AM BLOOD Neuts-86.6* Lymphs-7.8* Monos-5.4 Eos-0.1
Baso-0.1
[**2161-6-16**] 10:30PM BLOOD PT-11.5 PTT-25.6 INR(PT)-1.0
[**2161-6-21**] 06:30AM BLOOD Glucose-77 UreaN-18 Creat-1.2* Na-138
K-4.3 Cl-97 HCO3-35* AnGap-10
[**2161-6-18**] 01:33PM BLOOD Glucose-117* UreaN-27* Creat-1.3* Na-132*
K-5.5* Cl-97 HCO3-28 AnGap-13
[**2161-6-17**] 07:27PM BLOOD Glucose-121* UreaN-30* Creat-1.4* Na-122*
K-5.7* Cl-89* HCO3-26 AnGap-13
[**2161-6-17**] 05:54AM BLOOD Glucose-161* UreaN-35* Creat-1.7* Na-116*
K-5.6* Cl-83* HCO3-24 AnGap-15
[**2161-6-16**] 10:20AM BLOOD UreaN-33* Na-122* K-5.2* Cl-86* HCO3-24
AnGap-17
[**2161-6-17**] 05:54AM BLOOD CK(CPK)-140
[**2161-6-17**] 05:54AM BLOOD CK-MB-8 cTropnT-0.03*
[**2161-6-16**] 10:30PM BLOOD cTropnT-0.02*
[**2161-6-16**] 10:30PM BLOOD proBNP-2439*
[**2161-6-21**] 06:30AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.1
[**2161-6-17**] 02:28PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1
[**2161-6-16**] 10:30PM BLOOD Calcium-9.8 Phos-4.1 Mg-2.4
[**2161-6-17**] 07:27PM BLOOD Osmolal-266*
[**2161-6-17**] 05:54AM BLOOD Osmolal-257*
[**2161-6-17**] 05:54AM BLOOD TSH-0.70
[**2161-6-17**] 09:40AM BLOOD Cortsol-95.6*
[**2161-6-16**] 10:30PM BLOOD Cortsol-39.0*
[**2161-6-17**] 01:24AM BLOOD Type-ART FiO2-100 O2 Flow-4 pO2-90
pCO2-43 pH-7.33* calTCO2-24 Base XS--3 AADO2-582 REQ O2-95
Intubat-NOT INTUBA
[**2161-6-16**] 10:43PM BLOOD Glucose-168* Lactate-1.8 Na-123* K-4.9
[**2161-6-18**] 01:33PM URINE Hours-RANDOM UreaN-207 Creat-17 Na-49
K-12 Cl-47 TotProt-<6
[**2161-6-18**] 08:13AM URINE Hours-RANDOM Creat-14 Na-46 K-8 Cl-39
[**2161-6-17**] 09:38PM URINE Hours-RANDOM Creat-30 Na-26 K-20 Cl-25
[**2161-6-17**] 05:54AM URINE Hours-RANDOM Creat-22 Na-59 K-25 Cl-73
[**2161-6-18**] 01:33PM URINE Osmolal-199
[**2161-6-18**] 08:13AM URINE Osmolal-172
[**2161-6-17**] 05:54AM URINE Osmolal-237
[**2161-6-17**] 4:05 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2161-6-19**]**
MRSA SCREEN (Final [**2161-6-19**]): No MRSA isolated.
Brief Hospital Course:
1. COPD with Acute Exacerbation:
- Pts dyspnea, hypoxemia, but normal CO2, was thought to be
secondary to Pulmonary HTN exacerbation in setting of low
intravascular volume. Patient had poor PO intake several days
prior to admission and continued her daily lasix which likely
volume depleted her. She had an echocardiogram which showed
severe pulmonary HTN but no sigificant changes from her [**2157**]
echo. She was given nasal canula O2 and weaned down to her home
dose of 2L. She was then given a steroid taper with prednisone
from [**6-17**] through [**6-21**] at the direction of the pulmonary
consultation team in concert with her primary pulmonologist Dr.
[**Last Name (STitle) 2168**].
2. Hyponatremia:
Found to have hypo-osmolar hyponatremia. Likely secondary to low
volume state after several days of poor PO intake and persistent
lasix with free water repletion. She was given lasix in ED as
patient was thought to initially present with CHF exacerbation.
Fluids were then repleted and Na levels normalized from
116-->138 over the admission. She was not restarted on
diuretics.
3. Pulmonary Hypertension:
- Unclear etiology as patient was known in OMR to have severe
pulmonary HTN but mild obstructive pattern on PFTs. Echo
revealed peristent severe pulmonary HTN with no signs of left or
right heart failure. Patient should meet with pulmonologist
outpatient to follow up.
4. Acute Renal Failure on Stage III CKD:
- Patient was pre-renal with low volume status. Cr peaked at 1.8
and baseline is 1.6. Gave IVF and Cr trended down to 1.3.
5. Hyperkalemia:
- Pt had hyperkalemia on admission. Cortisol level was 39 making
adrenal insuficiency unlikely. Losartan likely contributed to
hyperkalemia and was discontinued.
6. Benign Hypertension:
Her hypertension mends were all held while in the ICU. And her
beta-blocker and calcium channel blocker were restarted prior to
discharge on the floor.
DISPO: She was sent for short term rehabilitation for mobility
and strengthing, along with stability training while carrrying
her oxygen.
Medications on Admission:
Atneolol 50 mg [**Hospital1 **]
Cilostazol 100 mg qday
Advair 100/50 1 puff daily
Lasix 20 mg qday (stopped)
Nifedipine ER 60 mg qday
Ranitidine 150 mg [**Hospital1 **]
Spiriva 18 mcg daily
Valsartan 160 mg qday
Calcium
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing, SOB.
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
COPD With Acute Exacerbation
Hyponatremia
CKD Stage 4
Hyperkalemia
Pulmonary Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It is very important that you continue to wear your oxygen,
particularly when out and about, such as at your day program.
While at rehab, you should use your oxygen contininously
particularly when exercising. You should practice moving around
with your oxygen with the physical therapist.
We have made some changes to your medications as you had a very
low sodium, and we have stopped your furosemide (lasix). Dr.
[**Last Name (STitle) **] and [**Doctor Last Name 2168**] will address this after you return home.
Followup Instructions:
Please make an appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 133**]
when you are leaving the rehab.
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2161-8-5**] at 8:00 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.7",
"491.21",
"416.0",
"403.90",
"584.9",
"276.1",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8474, 8559
|
5115, 7164
|
237, 243
|
8692, 8692
|
2735, 5092
|
9412, 9869
|
2075, 2093
|
7434, 8451
|
8580, 8671
|
7190, 7411
|
8874, 9389
|
2108, 2716
|
176, 199
|
271, 1811
|
8707, 8850
|
1833, 1905
|
1921, 2059
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,274
| 199,278
|
53061
|
Discharge summary
|
report
|
Admission Date: [**2166-4-9**] Discharge Date: [**2166-4-17**]
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
Black stools.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD), [**2166-4-10**].
History of Present Illness:
This is an 84 year old male with CHF (EF 20%), CAD s/p CABG,
Afib on coumadin, HTN, h/o prostate CA, presents with dark
colored stools. Per the patient, he has been noting black stool
on the toilet paper intermittently for a few weeks. Also with
loose stools and occasional incontinence of stool. Has been
feeling more fatigued over the past month with mild exertion and
notes that he has been falling asleep easily while at social
occasions or watching a movie. He went to see his PCP today for
[**Name Initial (PRE) **] regularly scheduled follow-up visit. PCP checked hct which was
20 (from 30.4 in [**7-26**]). BP was reportedly 80/50 in PCP's office.
He was sent to the ED for further evaluation. The patient denies
fevers, chills, dizziness, lightheadedness, abdominal pain,
nausea, vomiting, or hematemesis. No chest pain or SOB. He does
mention that he had an EGD 2-3 years ago in [**State 108**] as part of a
dysphagia work-up and as far as he knows this was negative.
Colonoscopy here in [**8-/2165**] was only notable for polyps. He has
no known history of GI bleeding. Denies use of NSAIDS or
significant EtOH.
In the [**Hospital1 18**] ED, vitals T 97.3, BP 97/42, HR 71, RR 18, SaO2
100%.
SBP ranged from 85-89 to low 90s (baseline is 90s to low 100s,
per PCP). On exam, looked dry, JVD flat, lungs clear. Abdomen
non-tender. Rectal exam revealed dark brown, guaiac positive
stool. Hct was 20.7, INR 3.7. He was also noted to have an
elevated creatinine of 2.5 (baseline 1.6). EKG reportedly
unremarkable (though not in chart). Received 1u RBC and 10 IV
vitamin K. Admitted to the MICU for close monitoring overnight.
Past Medical History:
-Diabetes Type II, diet-controlled
-CAD s/p 3 stents to the RCA [**2154**], stent to prox RCA, rPL in
[**2160**]
-2V CABG [**12-23**] with mitral valve repair (at OSH in [**State 108**])
-Pacemaker placement [**2160**] for complete heart block; Pacemaker
upgrade to biventricular ICD [**2162**] (in [**State 108**]); s/p cardiac
arrest [**8-26**] [**1-20**] pacer/ICD malfunction
-Afib on coumadin
-Hyperlipidemia
-Hypertension (HTN)
-CKD, baseline Cr 1.6
-Prostate cancer s/p prostatectomy '[**44**] with complication
requring colostomy, reversed 3 months later
- History of c. diff in [**8-/2164**]
Social History:
Married, 3 children, lives in [**Location **], MA with wife and oldest
daughter. [**Name (NI) 3106**] veteran. Remote tobacco use, quit in [**2116**] or
[**2126**], previously 2 pks/wk x 30 yrs. Social EtOH, no IVDA.
Family History:
Father who died of pancreatic CA at age 60. Mother with heart
dz, passed away at 76. Brother with CAD, s/p PTCA in his 70s.
Physical Exam:
On admission:
BP 111/62, HR 80 (V-paced), RR 14, SaO2 100% on 2L--> 100% on RA
General: Alert, frail-appearing, thin elderly male, no
respiratory distress.
HEENT: PERRL, EOMI, dry MM.
Neck: flat JVP, supple, no cervical or supraclavicular LAD.
Heart: RRR, no murmur appreciated.
Lungs: CTAB.
Abdomen: multiple surgical scars, +BS, soft, nontender,
nondistended, no hepatosplenomegaly.
Extrem/Skin: Warm. 2+ radial pulses, 1+ DP pulses, no LE edema
Neuro: A+O x 3, grossly intact
Pertinent Results:
Labs on admission:
[**2166-4-9**] 12:55PM BLOOD WBC-7.3 RBC-2.46*# Hgb-6.9*# Hct-20.7*#
MCV-84 MCH-28.2 MCHC-33.6 RDW-17.9* Plt Ct-329#
[**2166-4-9**] 12:55PM BLOOD Neuts-70.0 Lymphs-18.9 Monos-7.9 Eos-2.9
Baso-0.3
[**2166-4-9**] 01:28PM BLOOD PT-34.7* PTT-55.9* INR(PT)-3.7*
[**2166-4-9**] 12:55PM BLOOD Glucose-107* UreaN-139* Creat-2.5* Na-136
K-4.6 Cl-103 HCO3-19* AnGap-19
[**2166-4-10**] 03:15AM BLOOD Calcium-9.0 Phos-5.3*# Mg-2.6
Chest x-ray [**2166-4-9**]: Possible trace pleural effusions and
otherwise no acute cardiopulmonary process.
Brief Hospital Course:
This is an 84 year old male with history of CAD, CHF, Afib on
coumadin, who presented with fatigue, hematocrit drop, and
guaiac positive black stools.
# Hematocrit drop: This was felt to likely be secondary to upper
GI bleed in the setting of mildly supratherapeutic INR. Two
peripheral IV's, an active type and screen, and IV protonix were
initiated and maintained. The patient received a total of 5
units of PRBCs during hospitalization with serial HCTs revealing
stability at HCT of ~34. On the morning of [**2166-4-11**], his HCT was
32.3 and the patient was hemodynamically stable overnight. INR
then was down to 1.5. EGD on [**4-10**] revealed only mild gastritis,
which is unlikely to have caused a bleed this brisk and severe.
The patient was prepped for colonscopy on [**4-11**] during which GI
was unable to advance the scope beyond the sigmoid due to the
fixed loop formation likley secondary to previous abdominal
surgery. The procedure was an otherwise normal colonoscopy to
sigmoid colon. The patient underwent a CT colonography which
showed no evidence of masses or polyps in the colon. The
patient underwent a capsule study which was still pending on
discharge. As the patient was hemodynamically stable and Hct
remained stable in the 30s, the patient was restarted on aspirin
on [**2166-4-14**]. Coumadin was not restarting during his stay given
the risk of bleeding.
# Acute on CKD: At admission, the patient's Cr was up to 2.5
from baseline of 1.8. Etiology was likely pre-renal in the
setting of GI bleed. Following resuscitation, Cr has improved to
1.6 on [**4-14**]. BUN also trended down to 57 on [**4-14**], and was likely
elevated in setting of GI bleed.
# CAD: The patient has a history of multiple stents and CABG but
no chest pain. In the setting of GI bleed and hypotension,
aspirin, lisinopril, and nadolol were held on admission.
Eventually lisinopril, metoprolol and aspirin were restarted.
The patient was continued on zetia.
# Chronic Congestive heart failure (CHF): The last Echo in our
system is from [**2163**] with EF 20%. The patient appeared euvolemic
on admission. On admission, Lisinopril, Nadolol, Spironolactone,
and Lasix were held in the setting of GI bleed and borderline
BP. Lisinopril and spironolactone were restarted, however had
to be held on numerous occassions because of borderline blood
pressures. Eventually the patient was restarted on metoprolol,
but spironolactone was held. The patient was discharged on
lisinopril, metoprolol and aspirin only with instructions to
check weights daily and report to VNA.
# Hypotension with history of hypertension (HTN): The patient on
admission was borderline hypotensive, however baseline SBP is
~90s to low 100s. On admission, Lisinopril, Nadolol, and Lasix
were held. The patient remained with borderline blood pressures
during hospital stay. Lisinopril and spironolactone were
restarted, however nadolol and lasix continued to be held.
# Afib: INR was supratherapeutic on admission. Coumadin was held
and INR reveresed with 10mg vitamin K in the setting of GI
bleed. Coumadin was restarted prior to discharge.
Medications on Admission:
Aspirin 81mg PO daily
Nadolol 20mg PO daily
Lisinopril 2.5mg PO daily
Lasix 80mg PO daily
Spironolactone 25mg PO daily
Warfarin 2.5mg PO daily
Levothyroxine 50 mcg PO daily
Zetia 10mg PO daily
Sublingual Nitroglycerin (SLN) PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis: GI bleed
Secondary Diagnoses: Diabetes Type II, diet-controlled
Coronary artery disease
Atrial fibrillation
Hyperlipidemia
Hypertension
Chronic kidney disease
Prostate cancer
History of c diff
Discharge Condition:
Good, breathing comfortably on room air, tolerating oral intake.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of blood in your bowel
movements. Many tests were done, however the source of the
bleeding was not found. Most likely the bleeding was related to
your blood thinner, coumadin. This medication was stopped
during your hospital stay, you should not restart this
medication without discussing it with your primary care
provider. [**Name10 (NameIs) **] had a capsule endoscopy study, for which the
results are still pending.
Medication Changes:
STOP Lasix, Nadolol, Spironolactone, Coumadin - DO NOT Take
these medications on discharge
START Metoprolol 12.5mg twice a day
START Pantoprazole 40mg daily
Continue Lisinopril at decreased rate of 2.5mg once a day
You should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs.
Adhere to 2 gm sodium diet and Fluid Restriction: 2L You will
have a visiting nurse to monitor your blood pressures and daily
weights.
If you develop sudden chest pain, shortness of breath, fever,
chills, or any other concerning symptoms please call your
primary care doctor or return to the emergency room.
Followup Instructions:
Please call [**0-0-**] to make an appointment to see your
primary care doctor within the next 2 weeks.
Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**]
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2166-5-8**]
8:30
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2166-5-8**] 9:00
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
Completed by:[**2166-4-17**]
|
[
"578.9",
"272.4",
"V58.61",
"427.31",
"250.00",
"V45.01",
"403.90",
"414.00",
"585.9",
"428.0",
"428.22",
"584.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
8129, 8178
|
4029, 7154
|
227, 279
|
8435, 8502
|
3456, 3461
|
9660, 10458
|
2816, 2941
|
7432, 8106
|
8199, 8199
|
7180, 7409
|
8526, 9006
|
2956, 2956
|
8249, 8414
|
9026, 9637
|
174, 189
|
307, 1942
|
8218, 8228
|
3475, 4006
|
1964, 2566
|
2582, 2800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,213
| 180,694
|
19598
|
Discharge summary
|
report
|
Admission Date: [**2101-12-18**] Discharge Date: [**2102-1-6**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 547**] is an 82 year old male
with a history of atrial fibrillation, chronic obstructive
pulmonary disease and abdominal aortic aneurysm, who
presented with stuttering chest pain for two weeks and was
awoken from sleep the night prior to admission, with crushing
substernal chest pain. He went to All [**Doctor Last Name 15594**] [**Hospital 107**]
Hospital where he was found to have [**Street Address(2) 2051**] elevations
anteriorly and received thrombolytics. At 5:30 a.m. on the
day of admission, he was administered these thrombolytics and
only had minimal improvement in his ST elevations and in his
chest pain. He was given aspirin, Plavix and placed on a
heparin drip. He was transferred to [**Hospital1 190**] for rescue angioplasty.
In the cardiac catheterization laboratory, he was found to
have elevated filling pressures with an RA pressure of 18, RV
EDP of 21; PA pressure of 46/26; cardiac output of 5.2 and
cardiac index of 2.6. He had a 40% proximal left main
occlusion, 99% left anterior descending occlusion and had
percutaneous transluminal coronary angioplasty and stenting
of his left anterior descending lesion with resultant
TIMI-II flow. He also had a left circumflex distal
occlusion and mild right coronary artery disease.
While in the catheterization laboratory, he became
hypotensive and developed complete heart block and a
temporary pacing wire was placed. He also developed systolic
blood pressure to the 50's and an intra-aortic balloon pump
was placed and was started.
PAST MEDICAL HISTORY: 1.) Paroxysmal Atrial fibrillation. 2.)
Chronic obstructive pulmonary disease on chronic steroids and on
no home oxygen. 3.) Abdominal aortic aneurysm. 4.) History of
colonic resection for unknown etiology.
SOCIAL HISTORY: Mr. [**Known lastname 547**] lives at home with his wife. [**Name (NI) **]
denies any tobacco or alcohol use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Albuterol MDI.
2. Azmacort.
3. Atrovent MDI.
4. Amiodarone 100 mg q. day.
5. Prednisone 5 mg q. day.
6. Digoxin .125 mg p.o. q. day.
7. Zantac.
PHYSICAL EXAMINATION: On admission, vital signs revealed a
blood pressure of 91/48; heart rate of 87; respirations of
12; 91% on two liters nasal cannula. He was afebrile with a
temperature of 96.1. In general, he was confused, however,
in no acute distress. HEAD, EYES, EARS, NOSE AND THROAT:
Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements intact. He had moist
mucous membranes. His jugular venous distention was noted to
be approximately 12 cm. His lungs were clear to auscultation
bilaterally anteriorly. Heart was regular with a normal S1
and S2; there was an appreciable S3. He had distant heart
sounds. No murmurs were appreciated. His abdomen was obese,
nontender, nondistended. He had normoactive bowel sounds.
Extremities were warm and without clubbing, cyanosis or
edema. He had a 2+ dorsalis pedis pulse on the right and a
1+ dorsalis pedis pulse on the left. He had 2+ posterior
tibial pulses bilaterally. He had a right groin with a Swan
and A line without any evidence of oozing.
LABORATORY DATA: CBC revealed a white count of 15.6 with
hematocrit of 38.3. Chemistries revealed sodium of 140;
potassium of 4.3; chloride of 112; bicarbonate of 22; BUN of
20; creatinine of 1.4 and glucose of 133.
Cardiac catheterization revealed filling pressures reported
in the history of present illness. He also had vessel
disease as described in the history of present illness. He
underwent stenting to his left anterior descending with
resultant TIMI-II flow.
A preprocedure electrocardiogram showed evidence of a right
bundle branch block with 2 to [**Street Address(2) 2051**] elevations in leads V1
through V4. Post procedure electrocardiogram revealed an
irregular rhythm with a rate of 75. There was evidence of
atrial fibrillation. There was also evidence of right bundle
branch block. He had Q waves in V1 through V4 and T wave
inversions in V1 through V3. He had persistent ST elevations
anteriorly and evidence of a left anterior fascicular block.
HOSPITAL COURSE: 1.) Cardiovascular: In regards to
ischemia, as mentioned above, Mr. [**Known lastname 547**] suffered a large
anterior ST elevation myocardial infarction and underwent
stenting to his left anterior descending, with subsequent
poor reperfusion flow. He was started on aspirin, statin,
and Plavix at 75 mg q. day after being loaded in the
catheterization laboratory. He was initially not started on
Captopril and a betablocker in the setting of cardiogenic
shock. He was eventually restarted on his ace inhibitor and
betablocker and will be discharged to rehabilitation on ace
inhibitor, betablocker, statin, aspirin and Plavix.
In regards to pump function, as mentioned before in the
catheterization laboratory, Mr. [**Known lastname 547**] became hypotensive,
requiring intra-aortic balloon pump and Dopamine. He had an
echo the day after admission which revealed a dilated left
ventricular cavity. There was severe global left ventricular
hypokinesis to akinesis with some preservation of basal wall
motion. The overall left ventricular systolic dysfunction
was severely depressed. He had an ejection fraction of less
than 25%. He had a trivial valvular disease. He was able to
eventually be weaned off his intra-aortic balloon pump and
pressors. His balloon pump was weaned off as his ace
inhibitor was titrated. He was also diuresed prn. He will be
discharged home on a betablocker and ace inhibitor as well as
standing p.o. Lasix.
In regards to his rhythm, there was evidence of complete
heart block in the catheterization laboratory, requiring a
temporary pacing wire. He had this ventricular pacing wire
for several days, which was subsequently augmented with a
coronary sinus pacer for AV synchrony, to help with cardiac
output. He underwent AICD and pacer placement on [**2101-12-29**]
without complications. After the AICD and pacer placement,
he was noted to intermittently be V-paced versus both A and V
paced. He was also noted to be in atrial fibrillation early
in his CCU course and was anticoagulated for this. He was
also cardioverted after one day of being in atrial
fibrillation and then was loaded on Amiodarone which was
subsequently titrated down to his home dose of 100 mg q. day.
He developed a pericardial effusion several days into his CCU
course and his anticoagulation for atrial fibrillation was
discontinued. It was thought that this effusion was most
likely secondary to removal or the initial ventricular pacing
wire.
The pericardial effusion was watched for several days with
serial echocardiograms; however, his effusion continued to
grow and he ultimately had a pericardial drain placed on
[**2101-12-29**] which was removed after several days. It was decided
by the team not to restart him on anticoagulation due to his
high risk for bleeding.
2.) Pulmonary: Mr. [**Known lastname 547**] has a history of chronic
obstructive pulmonary disease on steroids with a dose of
Prednisone 5 q. day at home. He was initially started on
stress dose steroids which were tapered throughout his
course. He will be discharged home on 5 mg of Prednisone
p.o. q. day. He was continued on his MDI's and nebs prn. He
had a persistent oxygen requirement throughout admission,
felt to most likely be due to congestive heart failure.
There was no evidence of an active chronic obstructive
pulmonary disease flare. His heart failure was managed, as
mentioned above, with prn Lasix and he will be discharged
home on Lasix 40 mg q. day.
3.) Gastrointestinal: After being transferred from the CCU
to the floor, on [**2102-1-1**], Mr. [**Known lastname 547**] had several episodes of
melena with a 3% drop in his hematocrit. He was asymptomatic
at this time. Nasogastric lavage was negative. He
transiently required fluids and Dopamine while on the floor
and was transferred back to the CCU. Gastrointestinal was
consulted and esophagogastroduodenoscopy was done on [**2102-1-1**],
revealing erythema and congestion in the antrum, compatible
with gastritis; two small erosions in the second part of the
duodenum which were cauterized; and a possibility of the
erosions in the second part of the duodenum may have been due
to scope trauma. His hematocrit was subsequently followed
and he required several units of packed red cells. He was
continued on aspirin and Plavix in this setting, due to his
large myocardial infarction and recent stent placement. He
underwent a tagged red cell scan the following day, which
revealed no evidence of bleeding. His hematocrit subsequently
stabilized; however, he underwent push enteroscopy on [**2102-1-4**]
which revealed angiectasia in the second part of the duodenum
which were cauterized, again ulcers in the duodenum but an
otherwise normal enteroscopy. He then subsequently underwent
colonoscopy on [**2102-1-5**], which revealed a polyp at four cm in
the rectum; erythema in the sigmoid colon and diverticulosis
of the entire colon. It was recommended to repeat his
colonoscopy in a year due to poor prep and a rectal polyp.
There was no evidence of bleeding at this time and it was
recommended to continue to watch him and proceed with a
tagged red cell scan or repeat esophagogastroduodenoscopy if
he bled again. He will be discharged home on Protonic with a
follow-up colonoscopy in one year.
4.) Endocrine: As mentioned above, Mr. [**Known lastname 547**] is on home
steroids for chronic obstructive pulmonary disease and was
initially given stress dose steroids with Hydrocortisone.
This was tapered over several days and he will be discharged
on his home dose of Prednisone 5 mg q. day.
5.) Musculoskeletal. Mr. [**Known lastname 547**] was seen by physical therapy
while admitted and it was recommended that he be discharged
to rehabilitation for strengthening.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post anterior ST elevation
myocardial infarction. Status post left anterior
descending stent placement.
2. Atrial fibrillation, status post cardioversion.
3. Complete heart block, status post AICD and pacemaker
placement.
4. Chronic obstructive pulmonary disease.
5. Upper gastrointestinal bleed.
6. Congestive heart failure.
7. Cardiogenic shock.
8. Pericardial effusion.
DISCHARGE STATUS: At the time of discharge, Mr. [**Known lastname 547**] was
without complaints. He denied chest pain or shortness of
breath. His only complaint was that he felt weak. He was
requiring two liters of oxygen by nasal cannula.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg q. day.
2. Aldactone 12.5 mg q. day.
3. Toprol XL 25 mg q. day.
4. Lasix 40 mg q. day.
5. Prednisone 5 mg q. day.
6. Lisinopril 2.5 mg q. day.
7. Amiodarone 100 mg q. day.
8. Albuterol MDI.
9. Atrovent MDI.
10. Azmacort.
11. Lipitor 10 mg q. day.
12. Aspirin 325 mg q. day.
13. Plavix 75 mg q. day.
FOLLOW-UP: Mr. [**Known lastname 547**] will be discharged to rehabilitation.
He will be scheduled for follow-up with his primary care
physician and with [**Name Initial (PRE) **] cardiologist at [**Hospital1 190**] as well as by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**]. He will
need a follow-up colonoscopy in one year. He also will need
follow-up by his primary care physician for [**Name9 (PRE) 53127**]'s, LFT's and
PFT's while on Amiodarone. The exact dates and times of his
follow-up appointments will be dictated in a later addendum.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. 12.[**Doctor First Name **]
Dictated By:[**Last Name (NamePattern1) 53128**]
MEDQUIST36
D: [**2102-1-5**] 10:56
T: [**2102-1-6**] 05:04
JOB#: [**Job Number 53129**]
|
[
"426.0",
"578.9",
"410.11",
"427.31",
"428.0",
"785.51",
"441.4",
"496",
"423.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04",
"37.22",
"36.06",
"37.94",
"37.61",
"36.01",
"45.13",
"88.52",
"37.0",
"88.55",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
2063, 2287
|
10117, 10790
|
10813, 12001
|
4332, 10096
|
2310, 4314
|
152, 1684
|
1707, 1918
|
1935, 2046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,141
| 125,096
|
5015
|
Discharge summary
|
report
|
Admission Date: [**2161-9-15**] Discharge Date: [**2161-9-23**]
Date of Birth: [**2118-7-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Dilaudid / Ciprofloxacin
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mr. [**Known lastname **] is a 43 y/o man with ESRD on HD s/p recent removal of
transplant nephrectomy in [**8-7**], HTN, and hepatitis C who
presents with ongoing abdominal pain, hematuria, and difficulty
breathing. The patient notes ongoing right lower quadrant
abdominal pain at site of nephrectomy (done in [**8-7**]) since
surgery. No real change in pattern or quality of pain. Pain
located directly over site of surgical incision. No diarrhea or
vomiting but nauseated. No increase in pain today. Has also had
hematuria since his nephrectomy last month without change.
Hematoma was visualized at nephrectomy site on CT done [**2161-8-21**].
Also complaining of dysuria with subjective fevers at home with
unclear timeline (states that subjective fevers have occurred
since his prior hospitalization).
.
In addition, patient notes recent orthopnea and increasing
dyspnea at rest. He did not go to dialysis today (usual
T,Th,Sat). Has not missed any doses of medication per his
report. He denies increased salt intake. He endorses chest pain
while "fatigued" but does not further characterize. Reports no
chest pain at rest. No palpitations. Has chronic right lower
extremity edema per his report. No chest pain currently.
.
On arrival to our ED, the patient's initial vitals were T 98.2,
HR 80, BP 152/106, RR 16, 100% on RA. BP in the ED ranged from
160s-170s systolic. He desaturated to 90 and then in to the 80s
with sleeping and was placed on a NRB mask with improvement in
sats to 100%. He received 2 mg IV morphine X 1 for abdominal
pain. CXR demonstrated volume overload; renal was contact[**Name (NI) **] for
possible dialysis tonight. Transplant surgery was also consulted
given his recent nephrectomy.
.
ROS: + subjective fevers at home. No weight changes. No chills.
Denies headache, sore throat, difficulty swallowing, pain with
swallowing. Endorses chest pain while "fatigued" but does not
further characterize. No CP at rest. Dyspnea as above. No
palpitations. Nausea without vomiting. No hematemesis. No
diarrhea or blood in stools. Pain in RLQ at site of prior
nephrectomy. + hematuria as above. Chronic RLE swelling. No
joint pain or rash.
.
Patient was admitted to the MICU. He had dialysis and his
dyspnea improved some. Called out of the MICU when he was
satting 100% on RA after dialysis and fluid removal. Patient
was started on cefpedoxime for trace + UTI.
.
Overnight, his O2 Sat dropped to the high 80's on [**12-31**] L NC. ABG
was done which showed PO2 at 74. Increased O2 to 4L NC and O2
sat improved to 95% on RA. At the same time the patient was
complaining of chest pain. He said this pain was present at
rest and constant. He said it was worse with inspiration,
relieved somewhat by nitroglycerin. CE's sent and were at
baseline. CXR done, showed continued fluid overload.
.
This AM, the patient continued to feel chest pain with
inspiration. He continues to feel short of breath. He reports
diaphoresis, but consistent with his subjective fevers. He said
the pain never really went away overnight even though he was
given nitroglycerin. Repeated EKG this AM, no change. Cycling
enzymes. Patient going to HD early this AM.
Past Medical History:
* ESRD secondary to FSGS s/p cadaveric transplant in [**2156**],
failed in [**2160**] now s/p nephrectomy of transplanted kidney in
[**8-7**]
* hepatitis C virus
* congenital single kidney
* hypertension
* depression
* status post MVA in [**2157-6-30**] with a right facial fracture
and orbital zygomatic fracture
* REM behavior disorder
Social History:
Lives with his wife, 2 step-sons, and 2 grandchildren. No pets.
No current alcohol, tobacoo, or drug use. Previously worked as a
janitor.
Family History:
Reports brother had end-stage renal disease.
Physical Exam:
vs: T 97.9, BP 164/106, P 87, RR 16, 100% on NRB
gen: alert, oriented, appropriately responsive
heent: PERRL bilaterally, EOMI, sclerae anicteric, MMM, OP
clear, neck supple with prominent external jugular veins
chest: left tunnelled IJ HD catheter in place, site nontender
lungs: crackles up 1/2 posterior lung fields with dullness to
percussion at bases, decreased breath sounds at bases, no
wheezing or rhonchi
CV: RRR, 3/6 systolic murmur at LUSB
abd: normoactive bowel sounds, nontender without guarding or
rebound throughout, incision at nephrectomy site well-healed
with one area of point tenderness overlying apparent retained
suture, no erythema or oozing from site
ext: right AV fistula with clean incision
skin: no rash
neuro: alert, oriented, CN II-XII intact, moving all extremities
without difficulty, sensation intact to light touch in all four
extremities, toes downgoing bilaterally
Pertinent Results:
CXR: [**2161-9-15**]: Worsening pulmonary edema and slight interval
increase in size of small bilateral pleural effusions, left
greater than right.
.
Echo: [**2161-9-16**]: The left atrium is mildly dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is
0-10mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is
moderate global left ventricular hypokinesis (LVEF = 30-35 %).,
most prominent in the septum and anterior walls. No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**12-31**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2161-7-24**],
the LVEF has signficantly declined
.
CXR: [**2161-9-16**]: The double-lumen dialysis catheter tip is in the
right atrium. The cardiomediastinal silhouette is stable.
Interval increase in bilateral perihilar opacities consistent
with volume overload and current pulmonary edema. Bilateral
pleural effusions are present as well as bibasal atelectasis.
.
Abd US: [**2161-9-16**]: 1. 4.7 x 2.2 x 2.9 cm thick-walled fluid
collection in right lower quadrant has decreased in size from
previous examination from [**2161-8-21**]. 2. Bilateral pleural
effusions.
3. Gallbladder polyps.
.
CXR: [**2161-9-17**]: Persistent but improved mild pulmonary edema.
.
US of AV Fistula: Patent radiocephalic AV fistula on the right.
There are no focal velocity elevations to suggest stenosis in
the outflow vein. The elevated anastomotic velocities with
turbulence is characteristic and is difficult to correlate with
any level of stenosis. Suggest repeat exam with volumetric flow
analysis to judge suitability of the fistula for dialysis.
.
Cardiac MRI: Impression:
1. No significant obstructive coronary artery disease.
2. Severely dilated left ventricle with mild global hypokinesis
and no
regional wall motion abnormalities. The LVEF was mildly
decreased at 42%. The effective forward LVEF was moderately
decreased at 31%.
3. Moderately dilated right ventricular cavity size with mild
free wall
hypokinesis. The RVEF was mildly depressed at 37%.
4. Moderate mitral regurgitation. Mild tricuspid regurgitation.
Trace aortic regurgitation.
5. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was mildly dilated.
6. Moderate biatrial enlargement.
7. Small bilateral pleural effusions.
.
Lab Results:
[**2161-9-14**] 04:50PM BLOOD WBC-4.7 RBC-3.67* Hgb-9.9* Hct-31.6*
MCV-86 MCH-27.0 MCHC-31.4 RDW-20.3* Plt Ct-334
[**2161-9-15**] 05:00PM BLOOD WBC-5.1 RBC-3.53* Hgb-9.5* Hct-31.2*
MCV-89 MCH-26.8* MCHC-30.3* RDW-19.5* Plt Ct-345
[**2161-9-16**] 01:07AM BLOOD WBC-6.5 RBC-3.72* Hgb-10.1* Hct-33.0*
MCV-89 MCH-27.3 MCHC-30.7* RDW-19.4* Plt Ct-393
[**2161-9-16**] 09:22AM BLOOD WBC-5.4 RBC-3.78* Hgb-10.0* Hct-33.3*
MCV-88 MCH-26.6* MCHC-30.2* RDW-19.3* Plt Ct-352
[**2161-9-17**] 04:00AM BLOOD WBC-5.4 RBC-3.51* Hgb-9.7* Hct-30.9*
MCV-88 MCH-27.6 MCHC-31.3 RDW-19.1* Plt Ct-316
[**2161-9-18**] 04:40AM BLOOD WBC-6.0 RBC-3.56* Hgb-9.8* Hct-31.4*
MCV-88 MCH-27.5 MCHC-31.3 RDW-18.7* Plt Ct-279
[**2161-9-19**] 06:25AM BLOOD WBC-4.8 RBC-3.24* Hgb-8.9* Hct-28.3*
MCV-87 MCH-27.4 MCHC-31.4 RDW-18.3* Plt Ct-268
[**2161-9-20**] 06:35AM BLOOD WBC-4.1 RBC-3.22* Hgb-8.9* Hct-28.5*
MCV-89 MCH-27.6 MCHC-31.1 RDW-18.2* Plt Ct-296
[**2161-9-21**] 05:12AM BLOOD WBC-4.9 RBC-3.15* Hgb-8.7* Hct-27.1*
MCV-86 MCH-27.8 MCHC-32.3 RDW-17.8* Plt Ct-321
[**2161-9-22**] 04:50AM BLOOD WBC-4.4 RBC-3.03* Hgb-8.2* Hct-26.1*
MCV-86 MCH-27.3 MCHC-31.6 RDW-17.7* Plt Ct-262
[**2161-9-23**] 07:30AM BLOOD WBC-3.6* RBC-3.09* Hgb-8.6* Hct-26.4*
MCV-85 MCH-28.0 MCHC-32.8 RDW-17.5* Plt Ct-285
[**2161-9-23**] 07:30AM BLOOD WBC-3.6* RBC-3.09* Hgb-8.6* Hct-26.4*
MCV-85 MCH-28.0 MCHC-32.8 RDW-17.5* Plt Ct-285
.
[**2161-9-15**] 05:00PM BLOOD PT-15.1* PTT-29.3 INR(PT)-1.3*
[**2161-9-16**] 01:07AM BLOOD PT-15.3* PTT-35.6* INR(PT)-1.4*
[**2161-9-16**] 09:22AM BLOOD PT-15.3* PTT-34.0 INR(PT)-1.3*
.
[**2161-9-14**] 04:50PM BLOOD Glucose-103 UreaN-38* Creat-10.8*# Na-140
K-4.9 Cl-98 HCO3-31 AnGap-16
[**2161-9-15**] 05:00PM BLOOD Glucose-131* UreaN-55* Creat-13.5*#
Na-139 K-7.9* Cl-97 HCO3-28 AnGap-22*
[**2161-9-16**] 01:07AM BLOOD Glucose-94 UreaN-59* Creat-13.8* Na-139
K-6.4* Cl-96 HCO3-26 AnGap-23*
[**2161-9-16**] 09:22AM BLOOD Glucose-93 UreaN-62* Creat-15.0*# Na-140
K-6.8* Cl-98 HCO3-24 AnGap-25*
[**2161-9-17**] 04:00AM BLOOD Glucose-90 UreaN-39* Creat-10.4*# Na-137
K-5.1 Cl-96 HCO3-24 AnGap-22*
[**2161-9-18**] 04:40AM BLOOD Glucose-96 UreaN-32* Creat-8.6*# Na-137
K-4.7 Cl-98 HCO3-28 AnGap-16
[**2161-9-19**] 06:25AM BLOOD Glucose-90 UreaN-51* Creat-10.8*# Na-135
K-5.4* Cl-93* HCO3-26 AnGap-21*
[**2161-9-20**] 06:35AM BLOOD Glucose-77 UreaN-37* Creat-7.7*# Na-134
K-4.8 Cl-94* HCO3-25 AnGap-20
[**2161-9-21**] 05:12AM BLOOD Glucose-89 UreaN-52* Creat-10.3*# Na-133
K-5.3* Cl-93* HCO3-25 AnGap-20
[**2161-9-22**] 04:50AM BLOOD Glucose-101 UreaN-69* Creat-12.6*#
Na-129* K-5.7* Cl-91* HCO3-23 AnGap-21*
[**2161-9-23**] 07:30AM BLOOD Glucose-83 UreaN-42* Creat-8.6*# Na-135
K-5.3* Cl-94* HCO3-25 AnGap-21*
.
[**2161-9-15**] 05:00PM BLOOD ALT-25 AST-105* CK(CPK)-124 AlkPhos-68
[**2161-9-16**] 01:07AM BLOOD ALT-20 AST-24 LD(LDH)-297* CK(CPK)-66
AlkPhos-86 Amylase-77 TotBili-0.8
[**2161-9-18**] 04:40AM BLOOD ALT-21 AST-19 LD(LDH)-217 AlkPhos-73
TotBili-0.7
.
[**2161-9-16**] 09:22AM BLOOD CK(CPK)-55
[**2161-9-17**] 04:00AM BLOOD CK(CPK)-49
[**2161-9-17**] 12:50PM BLOOD CK(CPK)-56
[**2161-9-17**] 09:15PM BLOOD CK(CPK)-43
[**2161-9-18**] 01:20PM BLOOD CK(CPK)-37*
[**2161-9-21**] 02:04AM BLOOD CK(CPK)-33*
.
[**2161-9-15**] 05:00PM BLOOD cTropnT-0.10*
[**2161-9-16**] 01:07AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2161-9-16**] 09:22AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2161-9-17**] 04:00AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2161-9-17**] 12:50PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2161-9-17**] 09:15PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2161-9-18**] 01:20PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2161-9-21**] 02:04AM BLOOD CK-MB-NotDone cTropnT-0.08*
.
[**2161-9-16**] 01:07AM BLOOD TotProt-7.2 Albumin-4.6 Globuln-2.6
Calcium-10.3* Phos-5.7* Mg-2.5
.
[**2161-9-16**] 09:22AM BLOOD Calcium-9.9 Phos-6.3* Mg-2.5
[**2161-9-17**] 04:00AM BLOOD Calcium-9.7 Phos-6.2* Mg-2.0 Cholest-110
[**2161-9-18**] 04:40AM BLOOD Calcium-9.5 Phos-6.1* Mg-2.0 Iron-16*
[**2161-9-19**] 06:25AM BLOOD Calcium-9.3 Phos-7.4* Mg-2.3
[**2161-9-20**] 06:35AM BLOOD Calcium-9.3 Phos-6.6* Mg-2.0
[**2161-9-21**] 05:12AM BLOOD Calcium-9.6 Phos-6.3* Mg-2.2
[**2161-9-22**] 04:50AM BLOOD Calcium-9.2 Phos-5.2* Mg-2.3
[**2161-9-23**] 07:30AM BLOOD Calcium-9.6 Phos-5.9* Mg-2.1
.
[**2161-9-18**] 04:40AM BLOOD calTIBC-237* Ferritn-332 TRF-182*
[**2161-9-22**] 04:50AM BLOOD Hapto-147
.
[**2161-9-17**] 04:00AM BLOOD Triglyc-99 HDL-41 CHOL/HD-2.7 LDLcalc-49
.
[**2161-9-16**] 09:22AM BLOOD TSH-2.8
.
[**2161-9-16**] 01:07AM BLOOD Cortsol-16.4
.
[**2161-9-23**] 07:30AM BLOOD Vanco-26.6*
.
[**2161-9-17**] 06:42AM BLOOD Type-ART FiO2-94 O2 Flow-4 pO2-74*
pCO2-35 pH-7.49* calTCO2-27 Base XS-3 AADO2-565 REQ O2-93
Brief Hospital Course:
43 y/o man with PMH of ESRD s/p failed transplant and subsequent
nephrectomy admitted with worsening dyspnea and ongoing
abdominal pain and hematuria.
.
# Dyspnea/Hypoxia: Patient reported increased respiratory
distress with hypoxia to the high 80s on room air. Pt on HD, and
missed HD on day prior to admission. CXR showed effusion, L > R
initially. Effusions have been present on x-rays and CT scans
for past several weeks at least. Size of effusion difficult to
judge, but as has been chronic and is not massive, seems
unlikely that accounts for current worsening dyspnea and
hypoxia. By ultrasound, effusion could be tapped, but was not
sufficiently large to explain dyspnea. Renal consulted had
ultrafiltration the night of admission for volume removal (4
kg). He then had another HD on [**9-16**]. Initally improved after
dialysis on admission, then worsened. Likely secodary to fluid
overload and new onset decrease in systolic heart function, see
below. Able to wean off of new 02 requirement prior to
discharge.
.
# Chest pain: Patient developed chest pain after being
transfered out of the MICU. Most likely secondary to new onset
systolic heart faiure and component of pericarditis from uremia.
Etiologies of new onset heart failure included bacteremia (see
below), viral myocarditis, or high output failure from AV
fistula, as patient does not have evidence of severe CAD and
echo does not show sign of focal wall motion abnormality.
Although recent MIBI showed moderate to severe LV cavity
dilation and mild septal hypokinesis so likely has some degree
of CAD. Patient also reports feeling subjective fevers for some
time since his recent admission. [**Month (only) 116**] support viral etiology.
HIV and Lyme antibodies negative. Thyroid functin tests normal.
Most likely not amyloid as acute onset and does not show signs
of diastolic dysfunction. [**Month (only) 116**] be related to high output failure
from AV fistula. Patient had a drop in his EF in the past when
an AV fistula was placed in [**2157**]. Checked central venous 02 sat
from HD line, consistent with high output failure. There was
discussion to do an echo with compression of AV fistula to
determine if function improved, however the decision was made
not to perform this due to potential compromise of the fistula
with compresion. Doppler of fistula showed normal flow, no sign
of stenosis. Increased metoprolol to 37.5, started on [**2161-9-18**]
for increased ectopy, and discontinuing amlodipine, increased
lisinopril dose to 20mg, eventually up to 40mg on [**2161-9-23**]. MRI
showed systolic heart failure increased function from previous
echo, EF at 42%. Started ibuprofen for pain control. Patient
will follow up with Dr. [**Last Name (STitle) **] for repeat echo and management.
Will continue ace, beta blocker and ibuprofen for management on
discharge.
.
# Gram positive bacteremia: Most likely from HD line. Started
Vancomycin on [**2161-9-18**]. Dosed by HD. Other blood cultures
negative. Planned on getting TEE if more blood cultures became
positive. Daily surveillance cultures, all negative. Will
continue vancomycin for 2 week course.
.
# Hematuria/UTI: Has been ongoing since nephrectomy in [**Month (only) 216**].
Recently seen by Dr. [**Last Name (STitle) 3748**] in Urology with plans for
cystoscopy. Urology seen while inpatient and recommended
outpatient evaluation after antibiotic therapy with cefpodoxime
for corynebacterium species in urine. Will likely need
cystoscopy and possible cystogram to evaluate the ureteral
stump. Procedure in acute setting made risky by possible UTI.
.
# Abdominal pain: Pain seems localized over prior nephrectomy
site without any guarding or rebound on exam. RLQ ultrasound
showed 4.7 x 2.2 x 2.9 cm thick-walled fluid collection in right
lower quadrant has decreased in size from previous examination
from [**2161-8-21**]. His symptoms resolved prior to discharge.
.
# ESRD on HD: Seen by Renal team on arrival to the MICU.
Patient received HD while inpatient with fluid removal by
ultrafiltration for volume removal. Continued sevelamer,
nephrocaps, and calcium carbonate, adjusted doses per renal. AV
Fistula US showed no sign of stenosis. Patient will follow up
with transplant surgery regarding when fistula will be ready for
use. Plan on patient getting HD on thursday after discharge.
.
# Hypertension: Increased metoprolol to 37.5 in an attempt to
decrease ectopy. Discontinued amlodipine as not indicated in
high output CHF Increased lisinopril to 20mg initially, then up
to 40mg prior to discharge. All in an attempt to get better BP
control as patient has decrease in systolic function. Discharged
on new regimen.
.
# Anemia: likely anemia of chronic disease from ESRD. Stable.
Recently noted to be iron-deficient, patient started on iron.
Trended Hct while inpatient.
.
# Depression/sleep difficulty: continued home imipramine,
citalopram, and clonazepam
.
# Hepatitis C: No active issues.
.
# FEN: maintained on regular diet, electrolyte management per HD
.
# Ppx: heparin SC tid, PPI per home regimen, bowel meds prn
.
# CODE: full, confirmed with patient.
Medications on Admission:
amlodipine 10 mg daily
atorvastatin 10 mg daily
celexa 20 mg daily
clonazepam 1 mg QHS
colace 100 mg [**Hospital1 **]
imipramine 25 mg QHS
lisinopril 10 mg daily
lopressor 25 mg [**Hospital1 **]
nephrocaps daily
omeprazole 20 mg daily
percocet 5/325 mg four times daily
prednisone 1 mg daily (on taper, last week)
renagel 800 mg TID
senna 8.6 mg [**Hospital1 **]
tums 1000 mg TID
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for insomnia.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Imipramine HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Congestive Heart Failure
.
Secondary Diagnoses:
ESRD
HTN
Anemia
hepatitis C virus
depression
REM behavior disorder
Discharge Condition:
stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for abdominal pain and shortness of
breath. The abdominal pain was found to be a result of your
recent surgery. The surgeons were notified and determined that
there was no intervention needed.
.
The shortness of breath was found to be a result of congestive
heart failure. It was thought that the heart failure was due to
your fistula that was placed in [**Month (only) 116**]. You will need to take your
medications that have been changed, see below, and follow up
with the cardiologist, Dr. [**Last Name (STitle) **], regarding repeating the
echocardiogram and your medications.
.
These medications were changed during your hospitalization, you
should continue to take them as they are prescribed:
Metoprolol 25mg twice per day
Lisinopril 40mg once per day
Pantoprazole 40mg once per day
Sevelamer 1600mg TID with meals
Ferrous Sulfate 325mg once per day
Nitroglycerin 0.3mg as needed for chest pain
Ibuprofen 400mg every 6 hours as needed for chest pain (use this
first)
.
If you experience worsening chest pain, shortness of breath,
abdominal pain, fever, chills or any other worrisome symptoms
please seek medical attention.
Followup Instructions:
Please report to your dialysis clinic on Thursday for your next
dose of hemodialysis
.
Please follow up with your transplant [**Last Name (LF) 5059**], [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**],
MD Phone:[**Telephone/Fax (1) 673**], on Friday [**2161-9-25**] at 2:20pm
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2161-9-25**]
3:00
.
Please follow up with Dr. [**Last Name (STitle) **], your cardiologist, on Monday
[**2161-9-28**] at 4:20pm.
.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 13983**], phone number ([**Telephone/Fax (1) 20749**] in the next few weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2161-9-27**]
|
[
"311",
"428.21",
"585.6",
"285.21",
"403.91",
"041.85",
"428.0",
"790.7",
"518.81",
"996.62",
"070.54",
"599.0",
"V45.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
20146, 20152
|
12756, 17910
|
303, 318
|
20330, 20340
|
5038, 12733
|
21562, 22493
|
4056, 4102
|
18341, 20123
|
20173, 20173
|
17936, 18318
|
20364, 21539
|
4117, 5019
|
20240, 20309
|
256, 265
|
346, 3523
|
20192, 20219
|
3545, 3885
|
3901, 4040
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,083
| 104,791
|
33686
|
Discharge summary
|
report
|
Admission Date: [**2178-3-12**] Discharge Date: [**2178-4-2**]
Date of Birth: [**2118-10-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
s/p unwitnessed vfib arrest
Major Surgical or Invasive Procedure:
Intubation
ICD placement [**3-23**]
History of Present Illness:
59yo delivery man with unknown PMH ([**Last Name (un) 15025**] answering at home
number), was found down in basement after owner of house heard
"thump". 911 called, with police arriving within 3 minutes per
report, and pt. found to be pulseless and CPR initiated. EMS
arrived within a few minutes (13:52) and pt. found to be in Vfib
arrest, shocked X 1 into eventual VT, after which he received
atropine and epi X 2 with return of perfusing atrial
fibrillation. GCS of 3 initially. Per EMS notes first measured
BP at 14:05. Pt. was intubated in the field and brought to to
[**Location (un) **] ED, where he had EKG initially in afib with TWI and <1mm
depressions in inferior and lateral leads. Initial vitals
showed temp 97, HR 128, BP 152/84, RR 16, 100% intubated. He
was given asa 325, lopressor, and started on heparin gtt, and
given 2.1 L NS. Transferred to [**Hospital1 18**] for catheterization and
further management.
.
Per ED note, pt. initiated on plavix 600mg and aggrastat by
[**Location (un) **] and started on cooling protocol. In ED, initial
vitals HR 95, BP 154/79. EKG notable for sinus rhythm and
similar TWI and depressions as at [**Location (un) **]. Head CT and C-spine
negative, CXR with pulmonary edema. Given vecuronium X 1 and
continued cooling and transferrred to ICU.
.
Unable to obtain review of symptoms, as pt. intubated.
Past Medical History:
unknown
Social History:
Pt lives at home
Family History:
unknown (patient unablet to respond)
Physical Exam:
VS: T 94.6 on artic sun, BP 140/80, HR 70, RR 16, O2 100% on
vent AC 100%/500/16/5
Gen: intubated sedated, cooled
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: neck in cervical spine collar, JVP not above collar
CV: RRR, nls1s2, no MRGs
Chest: No chest wall deformities, scoliosis or kyphosis. No
crackles, wheezes anteriorly
Abd: soft, NTND, No HSM, No abdominial bruits.
Ext: No c/c/e. No femoral bruits, cool and clammy
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+; Femoral 2+ without bruit; 1+ DP
Neuro: fundi wnl, initially pupils minimally reactive
3mm-->2.5mm, without corneal responses. EOM not tested [**1-10**] neck
brace. no gag. not withdrawing at any extremities with absent
reflexes. flaccid tone.
.
On recheck [**12-10**] [**Last Name (un) **] later as vecuronium wearing off, pt. with
brisk reflexes in UEs, but not LEs, down going toes bilaterally
however. shivering in all 4 ext., though not withdrawing from
painful stimuli. PERRL 5mm->2mm, + corneal blink bilaterally, +
gag.
Pertinent Results:
[**2178-3-15**] 04:57AM BLOOD WBC-8.4 RBC-3.94* Hgb-12.1* Hct-35.8*
MCV-91 MCH-30.7 MCHC-33.8 RDW-13.0 Plt Ct-236
[**2178-3-12**] 04:25PM BLOOD Neuts-82.4* Bands-0 Lymphs-14.1*
Monos-3.0 Eos-0.4 Baso-0.2
[**2178-3-15**] 04:57AM BLOOD Plt Ct-236
[**2178-3-15**] 04:57AM BLOOD Glucose-110* UreaN-20 Creat-0.9 Na-146*
K-3.6 Cl-115* HCO3-23 AnGap-12
[**2178-3-14**] 05:02AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-143
K-4.6 Cl-111* HCO3-24 AnGap-13
[**2178-3-13**] 09:41AM BLOOD CK(CPK)-2290*
[**2178-3-13**] 01:24AM BLOOD CK(CPK)-2719*
[**2178-3-12**] 04:25PM BLOOD ALT-86* AST-97* CK(CPK)-207* AlkPhos-65
Amylase-82 TotBili-0.2
[**2178-3-13**] 09:41AM BLOOD CK-MB-67* MB Indx-2.9
[**2178-3-13**] 01:24AM BLOOD CK-MB-66* MB Indx-2.4 cTropnT-0.15*
[**2178-3-12**] 04:25PM BLOOD CK-MB-10 MB Indx-4.8 cTropnT-0.05*
[**2178-3-15**] 04:57AM BLOOD Calcium-8.2* Phos-1.9*# Mg-1.9 Iron-29*
[**2178-3-15**] 04:57AM BLOOD calTIBC-225* Ferritn-266 TRF-173*
[**2178-3-13**] 01:24AM BLOOD Triglyc-29 HDL-75 CHOL/HD-2.6 LDLcalc-114
[**2178-3-15**] 05:13AM BLOOD Glucose-108* Lactate-0.7
[**2178-3-15**] 05:13AM BLOOD freeCa-1.20
[**2178-3-15**] 06:17PM BLOOD O2 Sat-97
[**2178-3-27**] 07:15AM BLOOD WBC-7.4 RBC-4.28* Hgb-13.3* Hct-39.0*
MCV-91 MCH-31.0 MCHC-34.0 RDW-13.3 Plt Ct-310
[**2178-3-25**] 07:20AM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.2*
[**2178-3-27**] 07:15AM BLOOD Glucose-99 UreaN-19 Creat-0.9 Na-139
K-4.5 Cl-105 HCO3-26 AnGap-13
[**2178-3-30**] 07:30AM BLOOD UreaN-18 Creat-0.9 K-4.9
[**2178-3-27**] 07:15AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.3
[**2178-3-15**] 04:57AM BLOOD Calcium-8.2* Phos-1.9*# Mg-1.9 Iron-29*
[**2178-3-26**] 07:30AM BLOOD Calcium-9.6 Phos-3.3 Mg-2.2 Cholest-166
[**2178-3-15**] 04:57AM BLOOD calTIBC-225* Ferritn-266 TRF-173*
[**2178-3-26**] 07:30AM BLOOD Triglyc-148 HDL-38 CHOL/HD-4.4 LDLcalc-98
[**2178-3-14**] 05:02AM BLOOD Cortsol-28.1*
[**2178-3-13**] 01:24AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2178-3-13**] 01:24AM URINE RBC-[**10-29**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2178-3-14**] 12:01PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2178-3-14**] 12:01PM URINE RBC-69* WBC-8* Bacteri-FEW Yeast-NONE
Epi-0
[**2178-3-15**] 11:42PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-150 Bilirub-SM Urobiln-1 pH-5.0 Leuks-TR
[**2178-3-15**] 11:42PM URINE RBC->50 WBC-[**2-11**] Bacteri-FEW Yeast-FEW
Epi-0
.
Micro:
Blood Culture, Routine (Final [**2178-3-22**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
OF THREE COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET
ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2178-3-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 17441**] [**Last Name (NamePattern1) 394**] AT 1810 ON [**3-16**]..
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
Three negative BCx since above.
.
UCx negative x 2.
.
GRAM STAIN (Final [**2178-3-15**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2178-3-16**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
.
Reports:
.
Rhythm strips:
- initial EMS rhythm strip: with Vfib, asystole for secs after
shock followed by polymorphic VT
- 2nd rhythm strip with monomorphic WCT interrupted by 2nd
morphology VT vs. atrial tachycardia with aberrancy.
- 3rd strip with afib with RVR
- 4th strip with afib with RVR
.
EKG demonstrated NSR at 82, with LVH and 1mm ST depressions and
TWIs in I, inferior leads and v3-v6. no olds for comparison.
.
LABORATORY DATA: no labs provided from OSH. CK 152 with MB 6.3,
trop 0.07, Cr 1.3, AST 97 ALT74
.
CXR:
IMPRESSION:
1. Low-lying endotracheal tube. Recommend withdrawing 3 cm for
optimal positioning.
2. Moderate pulmonary edema.
.
CT C-spine:
FINDINGS: The patient is intubated and a nasogastric tube is
present within the esophagus limiting evaluation of the
prevertebral soft tissues. No acute fracture or malalignment is
detected. Normal spinal alignment is preserved.
The lateral masses of C1 are well apposed on C2. The dens is
intact. The thyroid gland is normal in appearance.
IMPRESSION: No acute fracture or malalignment.
.
CT Head:
FINDINGS: No acute hemorrhage, mass lesion, shift of normally
midline
structures, hydrocephalus or evidence of major territorial
infarct is
apparent. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
The major intracranial cisterns are preserved. There is a 3-mm
focal calcification in the left periventricular white matter.
The extra-calvarial soft tissues are within normal limits. No
acute fracture is identified. There is mild mucosal thickening
of the ethmoid sinuses. The remainder of the paranasal sinuses
and mastoid air cells are clear.
IMPRESSION: No acute hemorrhage or mass effect.
.
Echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. No dissection flap is seen/suggested
(does not exclude). The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mildly dilated ascending aorta.
.
Cardiac Catheterization:
1- Selective coronary angiography of this right-dominant system
demonstrated no angiographically-apparent coronary artery
disease. The
LMCA, LAD, LCX and RCA had normal flow pattern.
2- The RCA had a high takeoff and required an AL1 catheter for
selective
engagement.
3- Limited resting hemodynamic assesment revealed normal
sustemic
arterial pressure (108/57 mmHg) and mildly elevated left-sided
filling
pressures (LVEDP 15 mmHg post LV-gram).
4- Left ventriculography revealed normal systolic function (LVEF
60%)
and no mitral regurgitation. Marked apical hypertrophy with
cavity
obliteration was noted suggestive of apical hypertrophic
cardiomyopathy.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function.
3. APical hypertrophic cardiomyopathy.
.
CHEST (PA & LAT) [**2178-3-24**] 8:34 AM
FINDINGS: In comparison with study of [**3-17**], there has been
placement of a ICD with its tip in the general area of the apex
of the right ventricle. No evidence of pneumothorax. No acute
pneumonia.
Of incidental note is again seen the old healed fracture of the
right clavicle.
IMPRESSION: ICD placement with no pneumothorax.
.
ECG Study Date of [**2178-3-12**] 4:11:46 PM
Sinus rhythm. Deep T wave inversions in leads I, II, III and
aVF. ST segment depressions and T wave inversions in leads
V3-V6. Left atrial abnormality. No previous tracing available
for comparison.
TRACING #1
.
ECG Study Date of [**2178-3-13**] 8:04:36 AM
Sinus bradycardia. Compared to the previous tracing bradycardia
has appeared. Left atrial abnormality is evident. The Q-T
interval is slightly prolonged.
TRACING #2
.
ECG Study Date of [**2178-3-14**] 10:08:04 AM
Sinus rhythm. Non-specific low amplitude T waves in leads I and
V4.
Non-specific ST segment depressions and low amplitude T waves in
leads II, III and V4-V6. Extensive ST-T wave abnormalities. ST
segment
depressions might represent ischemia. Consider clinical
correlation. Compared to the previous tracing of [**2178-3-15**] T wave
inversions in leads I, II, aVL, V2-V6 are either no longer
present or are of much lower amplitude.
.
ECG Study Date of [**2178-3-15**] 8:36:14 AM
Normal sinus rhythm. T wave inversions in leads I, aVL and V2-V6
suggest the possibility of anterior and lateral ischemia.
Compared to the previous tracing of [**2178-3-13**] no diagnostic
interval change.
.
ECG Study Date of [**2178-3-20**] 7:49:58 AM
Normal sinus rhythm with occasional premature atrial
contractions. Left
atrial abnormality. Probable left ventricular hypertrophy with
secondary
ST-T wave abnormalities. Compared to the previous tracing of
[**2178-3-15**] no
diagnostic interval change.
.
ECG Study Date of [**2178-3-26**] 11:02:52 AM
Sinus bradycardia
Left ventricular hypertrophy
Diffuse ST-T wave abnormalities - may be in part left
ventricular hypertrophy and possible ischemia
Clinical correlation is suggested
Since previous tracing of [**2178-3-20**], atrial ectopy absent and
further ST-T wave changes seen
Brief Hospital Course:
# Vfib Arrest: The patient had a Vfib arrest of unknown origin.
He was initially cooled x 24 hours for neural protection and
paralyzed with cisatracuronium. he presented with elevated CKs
with a mild troponin leak suggestive of possible NSTEMI. He was
started on on tirofiban, heparin and aspirin, and plavix
initally. However, as this occurred in the context of chest
compressions and shock, and the patients had negative MBs,
tirofiban and heparin were discontinued. He had serial EKGs
while hypothermic which revealed resolution of initial t-wave
inversions and normalization of his EKG. After his initial
episode the patient was extubated, stabilized, and remained in
sinus rhythm. he underwent cardiac catheterization to
investigate the etiology of his arrythmia. Cardiac cath did not
reveal significant coronary artery disease. It did, however,
reveal an apical hypertrophic cardiomyopathy, known as the
[**Last Name (un) **] abnormality. After extubation, the patient developed a
pneumonia, for which he was treated with bactrim. After
resolution of his pneumonia he had an ICD placed by EP. He was
started on a beta blocker and lisinopril. The lisinopril was
limited by blood pressure. He is being sent out on 2.5mg of
lisinopril daily and should be titrated as tolerated.
.
# respiratory status: Patient was initially intubated during
resuscitation for his Vfib arrest. After extubation, he
developed a pneumonia with coagulase positive staph aureus in
his sputum, sensitive to bactrim. He was treated with bactrim
for this, and remained afebrile once treatment began.
.
# Mental status: Initially, the patient had poor mental status
and neurological exam after extubation. There was a concern the
the patient has suffered anoxic brain injury. The neurology team
was consulted. The recommended holding all sedatives. head CT
did not reveal any acute intracranial process. Throughout his
hospital stay, the patient't mental status gradually improved.
At discharge, he was still experiencing memory lapses and
confusion. He would occasionally also experience episodes of
delirium, during which he did not know where he was, and
experiencing visual hallucinations. He will need 24 hour
supervision at home for the time being. Because of his memory
problems, we are concerned about things like leaving the stove
on or other related oversights that could cause harm, but are
completely related to the state of his memory. We hope that
this will continue to improve, especially with outpatient
neurological rehab. If his caregiver leaves the house, she
either needs to find someone to watch him while she is gone, or
have him go with her. It is common to experience depression
after a big event like this. He may benefit from contacting a
psychiatrist or therapist.
.
#Hyperkalemia: K trending up since admission. [**Month (only) 116**] be in setting
of lisinopril. Bactrim may also cause hyperkalemia, and patient
completed course of bactirm for pneumonia. His potassium
improved after discontinuing bactrim.
.
# Fever: S.Aureus pneumonia, completed course of bactrim,
afebrile since treatment.
Medications on Admission:
unknown
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Primary:
Ventricular Fibrillation
[**Last Name (un) 51827**] abnormality (cardiac apical hypertrophy)
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital after being found down and
unresponsive, secondary to an arrythmia called ventricular
fibrillation. You were resuscitated. During hospitalization, you
were found to have a cardiomyopathy which may have precipitated
this arrythmia. You received an ICD, which will hopefully
prevent this rhythm from causing future loss of consciousness.
.
Please take your medications as prescribed.
.
You will need 24 hour supervision at home for the time being.
Because of your memory problems, we are concerned about things
like leaving the stove on, getting lost on a walk, or other
related oversights that could cause harm and that are related to
the state of your memory. We hope that this will continue to
improve, especially with outpatient neurological rehab.
.
If your caregiver leaves the house, she either needs to find
someone to watch you while she is gone, or have you go with her.
.
If any unsafe situation arises, please call Dr. [**Last Name (STitle) 77975**] or
return to the emergency department.
.
It is common to experience depression after a big event like
this. You may benefit from contacting a psychiatrist or
therapist.
.
Please follow-up as below.
.
Please call Dr. [**Last Name (STitle) **] below (your new primary care
provider) or return to the hospital if you experience chest
pain, shortness of breath, or other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2178-5-1**]
10:00
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-5-6**] 2:30
.
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2178-5-25**] 11:30
.
Please call if you need to reschedule.
|
[
"790.7",
"599.0",
"428.0",
"276.7",
"425.4",
"518.81",
"482.41",
"427.41",
"999.9",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.55",
"37.22",
"96.71",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
15926, 15991
|
12361, 13951
|
343, 381
|
16147, 16154
|
3088, 7918
|
17586, 18043
|
1855, 1893
|
15535, 15903
|
16012, 16126
|
15503, 15512
|
10024, 12338
|
16178, 17563
|
1908, 3069
|
276, 305
|
409, 1774
|
7927, 10007
|
13966, 15477
|
1796, 1805
|
1821, 1839
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,930
| 160,124
|
32697+57819+57820
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2132-12-16**] Discharge Date: [**2132-12-23**]
Date of Birth: [**2068-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Presented to ER c/o nausea and vomiting associated
w/intermittent diarrhea. In ER had episode of chest pain with
EKG changes.
Major Surgical or Invasive Procedure:
CABG x4 (LIMA-LAD, SVG-OM2, SVG-OM3, SVG-Diag)[**12-18**]
emergent cardiac catheterization [**12-18**]
History of Present Illness:
64yoM s/p fem-[**Doctor Last Name **] bypass in [**10-10**] that had had persistent UTI's
and malaise post-op. Presented to OSH-ER c/p nausea and
vomiting, then develped chest pain with EKG changes which
resolved w/NTG. Cardiac cath revealed 3VD and patient was
referred for CABG.
Past Medical History:
PVD s/p right fem-[**Doctor Last Name **] BPG [**10-10**]
right knee repair patellar fx
HTN
elev. lipids
MI( date unknown)
s/p cerv. vert. fx
s/p abd. [**Doctor First Name **] ( unknown per pt.)
s/p cystoscopy last week
cholelithiasis
Social History:
lives alone
retired
smokes less than [**2-5**] ppd
couple of beers daily
Family History:
non-contributory
Physical Exam:
alert and oriented , but poor recall of poor memory of previous
events
RRR, no murmur
CTAB, no wheezes or rales
hypoactive BS, softly distended, obese, large abd ( baseline)
well-healed old midline scar
RLQ tender to palp., no RUQ tenderness
bladder tender to palp.
NGT in place at time of exam, draining light pink with occ.
clots, irrigated to clear
extrems warm, equal temp
2+ right fem/[**Doctor Last Name **]/DP/radial; 1+ PT
2+ left fem/radial; 1+ [**Doctor Last Name **]/DP/PT
no carotid bruits
no varicosities
Pertinent Results:
[**2132-12-22**] 06:15AM BLOOD WBC-8.0 RBC-3.39* Hgb-10.3* Hct-29.9*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.7 Plt Ct-206#
[**2132-12-17**] 02:58AM BLOOD WBC-5.6 RBC-3.03* Hgb-8.9* Hct-26.6*
MCV-88 MCH-29.2 MCHC-33.3 RDW-15.2 Plt Ct-244
[**2132-12-22**] 06:15AM BLOOD Plt Ct-206#
[**2132-12-22**] 06:15AM BLOOD PT-13.3 PTT-28.0 INR(PT)-1.1
[**2132-12-17**] 02:58AM BLOOD Plt Ct-244
[**2132-12-17**] 02:58AM BLOOD PT-13.2 PTT-23.2 INR(PT)-1.1
[**2132-12-22**] 06:15AM BLOOD Glucose-97 UreaN-13 Creat-1.4* Na-136
K-4.2 Cl-98 HCO3-29 AnGap-13
[**2132-12-17**] 02:58AM BLOOD Glucose-99 UreaN-18 Creat-1.4* Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
[**2132-12-19**] 01:24AM BLOOD ALT-12 AST-44* AlkPhos-59 Amylase-72
TotBili-0.5
[**2132-12-17**] 02:58AM BLOOD ALT-11 AST-14 LD(LDH)-118 AlkPhos-77
Amylase-77 TotBili-0.3
[**2132-12-19**] 01:24AM BLOOD Lipase-31
[**2132-12-17**] 02:58AM BLOOD Lipase-17
[**2132-12-17**] 02:58AM BLOOD CK-MB-3 cTropnT-0.01
[**2132-12-22**] 06:15AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9
[**2132-12-17**] 02:58AM BLOOD Albumin-3.5 Mg-1.5* UricAcd-6.4
[**2132-12-17**] 02:58AM BLOOD %HbA1c-6.2*
[**2132-12-17**] 02:58AM BLOOD TSH-3.2
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76189**], [**Known firstname 1730**] [**Hospital1 18**] [**Numeric Identifier 76190**]Portable TTE
(Complete) Done [**2132-12-22**] at 3:05:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2068-7-30**]
Age (years): 64 M Hgt (in): 69
BP (mm Hg): 102/60 Wgt (lb): 168
HR (bpm): 80 BSA (m2): 1.92 m2
Indication: Left ventricular function. S/p CABG. VT/VF.
ICD-9 Codes: 785.2, 786.05, 424.0
Test Information
Date/Time: [**2132-12-22**] at 15:05 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Suboptimal
Tape #: 2007W036-0:44 Machine: Vivid [**8-10**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 15
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 0.88
Mitral Valve - E Wave deceleration time: *335 ms 140-250 ms
TR Gradient (+ RA = PASP): *31 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Mild regional LV systolic dysfunction.
No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter.
AORTIC VALVE: Normal aortic valve leaflets. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild
mitral annular calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal inferior wall. Overall
systolic function is good. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular hypokinesis with good
global systolic function. No valvular pathology identified. Mild
pulmonary artery systolic hypertension.
CLINICAL IMPLICATIONS:
Based on [**2132**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2132-12-22**] 16:08
Cardiology Report ECG Study Date of [**2132-12-18**] 2:40:04 PM
Sinus rhythm. Atrial ectopy. Left axis deviation. Right
bundle-branch block
with left anterior fascicular block. There are Q waves in the
inferior leads
consistent with prior myocardial infarction. No previous tracing
available for
comparison.
TRACING #1
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
91 128 118 374/428 35 -66 13
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2132-12-21**] 1:03 PM
CHEST (PORTABLE AP)
Reason: s/p removal of Chest tubes, chk for PTX
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with
REASON FOR THIS EXAMINATION:
s/p removal of Chest tubes, chk for PTX
PORTABLE CHEST
CLINICAL INDICATION: Status post removal of the chest tube.
Assess for pneumothorax.
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2132-12-18**]. The left-sided
chest tube has been removed in the interim. No pneumothorax is
seen. The Swan-Ganz catheter has been removed, as has the
endotracheal tube. There is a right IJ line terminating within
the expected region of the distal SVC. There is a right basilar
hazy opacity likely reflects a small effusion. Minimal left
basilar atelectatic changes are again seen. The cardiac
silhouette remains mildly enlarged.
DR. [**First Name (STitle) 2353**] [**Doctor Last Name **]
Approved: MON [**2132-12-22**] 7:35 AM
Brief Hospital Course:
Transferred from OSH for cardiac surgery evaluation. He
underwent preoperative workup including urology consult for
persistent UTI and Vascualar surgery for abdominal pain. Foley
catheter was placed and he was treated with antibiotics, with
urine culture [**12-18**] with no growth. Workup by vascular surgery
revealed duodentitis with recommendation of EGD in the future.
He was cleared for surgery and went to the operating [****]
under going a coronary artery bypass graft. Please see
operative report for further details. He was transferred to the
CVICU and awoke neurologically intact and was extubated. He
received Vancomycin perioperative since he was inpatient
preoperatively. That evening he had ventricular tachycardia and
arrested requiring defibrillation and medications. He was
intubated and returned to the operating to evaluate coronaries.
All grafts were patent and he was started on amiodarone with EP
consulted. He was weaned from vasoactive medications and
extubated on post operative day 1. He continued to improve and
no further ventricular tachycardia. He was transferred to the
floor on post operative day 3. Physical followed patient during
entire post-op course for strength and mobility. He continued to
make steady process without any further post-op complications
and was discharged home with VNA services on post-op day 5 with
[**Doctor Last Name **] of hearts for monitoring during amiodarone load being
followed by Dr [**Last Name (STitle) **].
Medications on Admission:
ASA
Lipitor
Toprol XL
Levofloxacin
Oxytrol
Ambien
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: for 7 days until [**12-30**],then 200 mg - 1 tablet daily
ongoing.
Disp:*40 Tablet(s)* Refills:*0*
8. 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*
9. Oxybutynin Chloride 10 mg Tab,Sust Rel Osmotic Push 24hr Sig:
One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 5450**] VNA
Discharge Diagnosis:
CAD s/p CABG
Ventricular tachycardia
PMH: s/p Rt fem-[**Doctor Last Name **] bypass, s/p Rt knee [**Doctor First Name **], s/p cervical
vertebrae fx, CAD s/p MI, HTN, PVD, ^chol, s/p Abdominal [**Doctor First Name **],
s/p cystoscopy
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:
wound clinic in 2 weeks on [**Hospital Ward Name 121**] 6
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] appointment scheduled for Thrusday [**1-1**] at
1pm - [**Telephone/Fax (1) 68559**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] - [**Location (un) 511**] heart institute [**Telephone/Fax (2) **]
appointment scheduled for [**1-21**] at 3pm
Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
[**Doctor Last Name **] of Hearts monitor - please follow instructions from holter
lab
Completed by:[**2132-12-23**] Name: [**Known lastname 12461**],[**Known firstname **] P Unit No: [**Numeric Identifier 12462**]
Admission Date: [**2132-12-16**] Discharge Date: [**2132-12-23**]
Date of Birth: [**2068-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Follow change
Cancelled appt with NEHI
To follow up with Dr [**Last Name (STitle) 12463**] with [**Location (un) 5299**] Cardiology
in 1 month [**Telephone/Fax (1) 12464**]
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 4898**] VNA
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2132-12-23**] Name: [**Known lastname 12461**],[**Known firstname **] P Unit No: [**Numeric Identifier 12462**]
Admission Date: [**2132-12-16**] Discharge Date: [**2132-12-23**]
Date of Birth: [**2068-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Made appointment with cardiologist Dr. [**Last Name (STitle) 12465**] for [**1-7**]
at 3:20. Called and told Mr. [**Known lastname **] ([**Telephone/Fax (1) 12466**].
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 4898**] VNA
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2132-12-24**]
|
[
"443.9",
"414.01",
"535.60",
"E878.2",
"272.4",
"788.20",
"427.5",
"411.1",
"997.1",
"427.41",
"305.1",
"599.0",
"600.01",
"427.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.60",
"88.52",
"37.22",
"36.13",
"39.61",
"96.71",
"34.03",
"36.15",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
14709, 14936
|
8905, 10394
|
448, 553
|
12199, 12206
|
1800, 5958
|
12718, 13874
|
1227, 1245
|
10495, 11831
|
8050, 8071
|
11942, 12178
|
10420, 10472
|
12230, 12695
|
6007, 6968
|
1260, 1781
|
6991, 8013
|
283, 410
|
8100, 8882
|
581, 863
|
885, 1121
|
1137, 1211
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,204
| 109,763
|
10865+56188+56189
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2126-8-26**] Discharge Date: [**2126-8-31**]
Service: Medicine
IDENTIFICATION/CHIEF COMPLAINT: The patient is an 80 year
old female who was admitted for a lower gastrointestinal
bleed from [**Hospital1 5042**].
PAST MEDICAL HISTORY: 1. Coronary artery disease; patient
has had coronary artery bypass grafting times two with
saphenous vein grafts to the posterior descending artery and
left anterior descending artery as well as aortic valve
replacement for critical aortic stenosis and tricuspid valve
repair in [**2126-5-14**] at [**Hospital6 1129**];
postoperative course complicated by a stroke, renal failure,
tracheotomy, percutaneous endoscopic gastrostomy tube
insertion and tracheal stenosis. 2. Hypertension. 3.
Chronic renal failure. 4. Chronic obstructive pulmonary
disease. 5. Hyperthyroidism. 6. Clostridium difficile.
7. Methicillin resistant Staphylococcus aureus/Klebsiella
pneumoniae. 8. Tracheal stenosis.
ALLERGIES: Codeine.
MEDICATIONS ON ADMISSION: Atenolol, Epogen, Flagyl, Pepcid,
albuterol, Combivent, l-thyroxin, metoclopramide, NPH
insulin, sliding scale insulin, vitamin C, Nepro, Flovent,
trazodone, iron sulfate, renal multivitamins, heparin
subcutaneously.
HISTORY OF PRESENT ILLNESS: The patient was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for lower
gastrointestinal bleeding at [**Hospital1 5042**]. The patient was noted
to pass large blood clots from her rectum and was
subsequently hypotensive at [**Hospital1 5042**]. The patient was
transferred here for stabilization. She underwent a
colonoscopy which demonstrated a proctosigmoiditis. The
patient was treated with Rowasa and hydrocortisone enemas as
recommended by the gastroenterology service. During her
stay, the patient also was followed by the nephrology service
for dialysis treatments. The patient was maintained on her
medications as she had been on at [**Hospital1 5042**].
PHYSICAL EXAMINATION: The patient, when transferred out of
the Intensive Care Unit to the medical service, was in no
acute distress. She had stable vital signs and she was
afebrile. On neurological examination, the patient was
responsive to voice and seemed to communicate with facial
expressions. She obeyed commands in all of her extremity
except for her right arm, which was related to her previous
stroke. On cardiovascular examination, the patient had
normal heart sounds and no murmurs appreciated. The
respiratory examination demonstrated coarse breath sounds
bilaterally. On abdominal examination, the patient had a
percutaneous endoscopic gastrostomy tube and a slightly
distended abdomen, bowel sounds were present, she was soft
and nontender. On musculoskeletal examination, the patient
did not have any edema.
HOSPITAL COURSE: The [**Hospital 228**] hospital course proceeded as
stated in the history of present illness. She also underwent
a procedure on [**2126-8-30**] in the Operating Room for a
T-tube change and rigid bronchoscopy. She was transferred to
the Post Anesthesia Care Unit and subsequently to the floor
in stable condition. In initial attempt at capping the
T-tube was made and the patient was not able to tolerate it
immediately postoperatively.
The gastroenterology division recommended that the patient
was likely to have some ongoing bleeding from her
proctosigmoiditis and, thus, will need continued monitoring
of her hematocrit. She was also recommended to continue with
both her Rowasa and hydrocortisone enemas. The
hydrocortisone enemas were to be discontinued on [**2126-9-5**]. Her Rowasa enemas were to continue once a day for a
month and then change to an as needed basis. It was also
recommended that the patient should follow up with an
affiliated gastroenterology with [**Hospital1 5042**].
DISPOSITION: The patient was discharged to [**Hospital1 5042**] in
satisfactory condition on [**2126-8-31**].
DISCHARGE MEDICATIONS:
Protonix 40 mg per PEG-tube q.d.
Flagyl 250 mg per PEG-tube t.i.d.
Levofloxacin 250 mg per PEG-tube q.o.d.
Rowasa enema p.r.q.p.m. times one month then p.r.n.
Hydrocortisone enema p.r.q.a.m. until [**2126-9-5**].
Metoclopramide 5 mg per PEG-tube q.6h.
L-thyroxine 0.15 mg per PEG-tube q.d.
Ritalin 5 mg per PEG-tube b.i.d.
Nepro tube feeds 10 cc/hour per PEG-tube, advance q.4h. until
goal is reached and held for residuals greater than 150 cc.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 26201**]
MEDQUIST36
D: [**2126-8-30**] 17:56
T: [**2126-8-30**] 19:35
JOB#: [**Job Number 35391**]
Name: [**Known lastname **], [**Known firstname 634**] Unit No: [**Numeric Identifier 6302**]
Admission Date: [**2126-8-26**] Discharge Date:
Date of Birth: [**2046-8-7**] Sex: F
Service:
ADDENDUM TO DISCHARGE MEDICATIONS:
Vancomycin dosed with hemodialysis for level of less than 15.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 6303**]
MEDQUIST36
D: [**2126-8-31**] 07:18
T: [**2126-8-31**] 09:33
JOB#: [**Job Number 6304**]
Name: [**Known lastname **], [**Known firstname 634**] Unit No: [**Numeric Identifier 6302**]
Admission Date: [**2126-9-2**] Discharge Date: [**2126-9-9**]
Date of Birth: [**2046-8-7**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient was re-transferred
to the MICU on [**2126-9-2**] after being found by her nurse
having severe respiratory distress. She was suctioned and
found to have no pulse. A code was called. The patient was
found on monitor to be in V-tach in the 180's to 190's. She
was shocked times three, Lidocaine 100 mg bolus, given
calcium, insulin, D50 and mag. Subsequently pacer captured,
pulse was palpated. The patient was started on the Lidocaine
drip and transferred to the MICU service. The patient was
responding to yes or no questions by the time of arrival to
the Intensive Care Unit.
HOSPITAL COURSE:
1. Pulmonary: The patient was started on pressure support
ventilation upon admission to the Intensive Care Unit. She
was slowly weaned over her week in the ICU. By the time of
discharge she was tolerating a trach mask with only
occasional episodes of tachypnea benefiting from periods of
rest on pressure support. Further bronchoscopic evaluation
of her subglottic stenosis was deferred until patient was
stable and could follow-up as an outpatient. Tight stress
dose steroids were started for her subglottic stenosis and
weaned over the week in the ICU.
2. Cardiovascular: The patient had negative CKs upon
cycling of enzymes after arriving in the unit. Pacer was
capturing by the time the patient arrived. Lidocaine drip
was discontinued after a period of stability in the unit.
The patient was started back on Lopressor with titration up
to 50 po bid to control blood pressures which were ranging in
the 150's to 170's.
3. GI: The patient had no further evidence of GI bleeding
after admission to the unit. Hydrocortisone enemas were
discontinued during her stay. Rowasa enemas were continued
with the plan for stopping them approximately one month after
discharge. With plan to follow-up with the [**Hospital **] clinic.
Hematocrit remained stable through her stay and her Epogen
was continued.
4. ID: The patient was negative for C. diff toxin times
three and no further antibiotics were instituted after the
completion of her previous antibiotic courses from earlier on
the day of admission.
CONDITION ON DISCHARGE: Patient was discharged to [**Hospital 6305**]
Rehabilitation in improved and stable condition.
DISCHARGE MEDICATIONS: L-Thyroxine 150 mcg per PEG q d,
Ritalin 5 mg per PEG [**Hospital1 **], Rowasa enemas, one enema q p.m.,
sliding scale insulin, Lansoprazole 30 mg per PEG q day,
Vitamin C 250 mg [**Hospital1 **] per PEG, Zinc Sulfate 220 mg per PEG q
d, Nystatin powder to affected areas [**Hospital1 **], Epogen 12,000 units
IV three times per week at hemodialysis, Lopressor 50 mg po
PG [**Hospital1 **], Ativan 1-5 mg IV prn q 4-6 hours, Morphine 1-5 mg IV
prn q 6 hours.
DISCHARGE INSTRUCTIONS: The patient was instructed to
follow-up with Dr. [**Last Name (STitle) **] in approximately one months time to
reassess her subglottic stenosis. The patient was instructed
to follow-up with GI in [**1-15**] months.
DISCHARGE DIAGNOSIS:
1. Lower GI bleed.
2. Sigmoiditis.
3. Subglottic stenosis.
4. Respiratory failure, resolved.
[**First Name11 (Name Pattern1) 77**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 639**], M.D. [**MD Number(1) 640**]
Dictated By:[**Name8 (MD) 6306**]
MEDQUIST36
D: [**2126-9-8**] 18:17
T: [**2126-9-8**] 20:34
JOB#: [**Job Number 6307**]
cc:[**Hospital1 6308**]
|
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|
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127, 244
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,977
| 198,367
|
54129
|
Discharge summary
|
report
|
Admission Date: [**2146-11-25**] Discharge Date: [**2146-12-9**]
Date of Birth: [**2098-10-13**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Compazine / Reglan / Betadine Surgi-Prep / Tape /
Iodine; Iodine Containing / Vancomycin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 1557**] is a 48 year old woman with medical history
significant for [**Location (un) **] syndrome (s/p colectomy on chronic
TPN) and recent admission for embolic CVA (paradoxical embolus)
c/b hemorrhagic conversion (fondaparinaux) presents from rehab
with new dyspnea on exertion x 2 weeks and tachycardia. The
patient was recovering at rehab after her CVA and was able to
walk with a walker with 1 assist and was improving greatly. She
began having dyspnea on exertion x 2 weeks, no SOB at rest, no
pleuritic chest pain, no cough / hemoptysis. She states she also
had pedal edema x 1 week. She had no abdominal pain, no
increased ostomy output, no blood in her ostomy, no n/v, no
change in appetite.
.
She has a significant clotting history with multiple episodes of
line associated thrombosis and paradoxical embolism due to PFO.
She had been treated with coumadin, but was stopped due to
difficult to control INR from concomitant antibiotic therapy.
She had also been treated with lovenox but this was stopped due
to skin welts. She was then treated with fondaparinaux but then
developed an ICH. Since late [**2146-9-25**] she has not been
anticoagulated given the intracranial hemorrhage.
Past Medical History:
++ [**Location (un) **] syndrome
- diagnosed age 23
- total colectomy, end ileostomy [**2121**]
- small bowel resection (multiple) secondary to recurrent
polyposis
- subsequent short gut syndrome
- on TPN since [**2123**], [**9-/2131**]
++ Benign cystadenoma
- partial hepatectomy, [**2131**]
++ Line-associated blood stream infections
- Her CVL in her L leg has been in place for at least 5 years,
when she has had infections the line has been changed over a
wire as pt has limited remaining access (L groin vessels and
hepatic vessels are only usable vessels).
- MSSA, [**2127**]
- [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] [**12/2139**]
- C. parapsilosis + coag neg Staph, [**2-/2140**]
- [**Female First Name (un) 564**] non-albicans, [**3-/2141**]
- C.parapsilosis, [**9-/2142**]
- K. pneumoniae, [**9-/2145**]
--> Resistant to cipro, cefuroxime, TMP/SMX
--> Treated with meropenem [**Date range (1) 110935**]/08
- Line change due to positive blood cultures (?) [**10/2145**]
--> Had an echocardiogram that was abnormal as noted below
Coag neg Staph [**1-/2146**]
--> Line changed over wire
--> Linezolid [**Date range (1) 110936**]
--> Coag Neg Staph [**6-2**], no line change, on Dapto till [**2146-6-28**]
- Admitted to [**Hospital1 18**] [**2145-9-27**] with history of + urine for VRE
isolated on [**2145-9-8**] at Healthcare [**Hospital 4470**] hospital.
++ Venous thrombosis/occlusion
- Failed access in R IJ, R brachiocephalic
- Reconstructed IVC w/ kissing stent extensions into high IVC
- Stenting to R femoral, external iliac
++ GI bleed
++ HSV-1
++ Fibromyalgia
++ Osteoporosis
++ Scoliosis; h/o surgical repair
++ Right hip fracture; ORIF [**2129**]
++ Meniscal tears of knee; 4 prior surgeries, [**2133**]
++ Total abdominal hysterectomy; bilateral salpingo-oophorectomy
++ Dermoid cyst removal (small bowel, ovaries)
++ Hepatic cyst adenoma; resected
++ Cholecystectomy, [**2131**]
++ Intracranial Hemmorhage on fondaparinux
.
PREVIOUS MICROBIOLOGY(selected positive results):
[**2146-6-17**] UCx: klebsiella and pseudomonas (? contaminated)
[**2146-6-10**] UCx: Klebsiella
[**2146-6-1**]: BCX: MALASSEZIA SPECIES.
[**2146-2-24**] BCx: [**Female First Name (un) **] albicans
Social History:
The patient lives in [**Hospital3 7665**] Center after recent
discharge. Mother helps her with her medical needs. Pt also has
PCAs who she has hired to help with care. Denies alcohol or
tobacco. Sister, [**Name (NI) 3235**], is very involved in her care and likes
to be updated frequently.
Family History:
Father and 6 of 8 siblings with [**Location (un) **] syndrome. Mother and
relatives with HTN and resulting CVA. Sister with breast cancer.
Her father's parents died of cancer.
Physical Exam:
Vitals: 97.9 96/78 105 n 16 99/ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: RRR, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left femoral hickman line in place.
Neuro: CN II-XII intact, stregnth [**3-29**] grip bilaterally, wrist
flex/extend, biceps 4+/5 on R, [**3-29**] on left, tricep [**3-29**], deltoid
[**2-27**] on R, [**3-29**] on L. LE 4+/5 quad and hams on R, [**3-29**] on L,
dorsiflex, plantarflex, abd/adduct all [**3-29**] bilaterally.
sensation to light touch normal, bilaterally symmetric. reflexes
diminished patellar bilaterally, bicep R 2+, L 1+,
brachioradialis diminished bilaterally. not assessed. Left
visual field defect.
Pertinent Results:
Admission Labs:
[**2146-11-24**] 08:15PM BLOOD WBC-4.2 RBC-3.78* Hgb-10.8* Hct-33.3*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.1* Plt Ct-239
[**2146-11-24**] 08:15PM BLOOD Neuts-64.6 Lymphs-28.7 Monos-3.1 Eos-3.1
Baso-0.4
[**2146-11-24**] 08:15PM BLOOD PT-11.4 PTT-25.2 INR(PT)-0.9
[**2146-12-3**] 04:07AM BLOOD PT-26.9* PTT-150* INR(PT)-2.6*
[**2146-11-24**] 08:15PM BLOOD Glucose-103 UreaN-15 Creat-0.6 Na-140
K-4.0 Cl-103 HCO3-30 AnGap-11
[**2146-11-26**] 03:20AM BLOOD cTropnT-0.03* proBNP-44
[**2146-11-26**] 03:20AM BLOOD Calcium-8.6 Phos-5.0*# Mg-1.9
Discharge Labs:
[**2146-12-9**] 05:40AM BLOOD WBC-2.7* RBC-3.24* Hgb-9.3* Hct-27.6*
MCV-85 MCH-28.7 MCHC-33.7 RDW-15.6* Plt Ct-389
[**2146-12-9**] 05:40AM BLOOD PT-21.2* INR(PT)-2.0*
[**2146-12-9**] 05:40AM BLOOD Glucose-118* UreaN-25* Creat-0.7 Na-143
K-4.1 Cl-109* HCO3-26 AnGap-12
ECG [**2146-11-24**]:
Sinus tachycardia. Incomplete right bundle-branch block.
Prominent P waves.
Tracing is consistent with atrial septal defect. Since the
previous tracing
of [**2146-9-16**] there are no significant changes.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name 640**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
102 146 92 342/415 56 5 31
CT Head [**2146-11-25**]:
FINDINGS: There is no new acute intracranial hemorrhage or
infarction.
Hyperdensity in the right parieto-occipital lobe with
surrounding edema is
again seen and demonstrates evolution of the known
intraparenchymal
hemorrhage. However, given the four-week interval and remaining
hyperdense
attenuation centrally, interval subacute re-bleed is not
excluded. Overall,
the blood products and edema measure 6.5 x 3.7 cm compared to
9.0 x 5.4 cm
previously. There is decreased shift of the normally midline
structures
leftward, currently 6 mm compared to 15 mm previously. There is
mild mass
effect on the left posterior [**Doctor Last Name 534**]. Effacement of the right
basilar cistern has
largely resolved. Hypodensities in the bifrontal lobes adjacent
to the
frontal horns is not significantly changed from prior.
There is polypoid mucosal thickening in the right maxillary
sinus. The
remainder of the visualized paranasal sinuses and mastoid air
cells are well
aerated. No osseous abnormality is identified.
IMPRESSION:
1. No evidence of new hemorrhage.
2. Evolution of known right parieto-occipital intraparenchymal
hemorrhage
with overall decreased size and mass effect.
[**2146-11-25**] 8:00 pm (after heparin drip started)
FINDINGS: A non-contrast CT of the head was obtained. The
[**Doctor Last Name 352**]-white matter
differentiation is preserved. Again noted is a large right
parietooccipital
lobe hemorrhage with a clear acute component and surrounding
edema measuring
3.5 x 5.8 cm. There is mild mass effect on the posterior [**Doctor Last Name 534**] of
the right
lateral ventricle and stable 6 mm of right-to-left midline
shift. The basilar
cisterns are patent. No new foci of hemorrhage are identified.
Again noted
are stable hypodensities within the frontal lobes bilaterally
adjacent to the
frontal horns. The extra-axial spaces are unremarkable. Again
noted is an
area of polypoid mucosal thickening in the right maxillary
sinus.
IMPRESSION:
Stable size and appearance of known right parietooccipital
intraparenchymal
hemorrhage with mild mass effect on the posterior [**Doctor Last Name 534**] of the
right lateral
ventricle and stable 6 mm of right-to-left midline shift. No new
foci of
hemorrhage are identified.
The study and the report were reviewed by the staff radiologist
[**2146-11-26**]:
FINDINGS: Again is noted a right parieto-occipital
intraparenchymal
hemorrhage measuring 3.7 x 1.8 cm compared to prior 3.7 and 1.9
cm. There is
associated peri-hemorrhagic edema, unchanged since the prior
study. There is
minimal leftward mass effect without subfalcine herniation.
There is mild
mass effect on the posterior [**Doctor Last Name 534**] of the right lateral ventricle
causing
anterior displacement of the posterior [**Doctor Last Name 534**] without significant
ventricular
compression. There is mild encephalomalacia in the territory of
the right
parieto-occipital prior infarct which is also partly accounting
for the
rightward deviation of the occipital [**Doctor Last Name 534**] of the lateral
ventricle.
A focus of high attenuation at the apex of the lateral cerebral
fissure is
unchanged since the most remote comparison of [**2145-3-23**] and
is likely a
parenchymal calcification. There are no other foci of intra- or
extra-axial
hemorrhage.
CXR: [**2146-11-28**]:
IMPRESSION: AP chest compared to [**10-13**] and [**10-31**].
Right hemidiaphragm is chronically elevated. Heart is shifted to
the left of
midline as a result, probably normal size. Atelectasis at the
base of the
left lung is mild. More substantial atelectasis at the right
lung base is
slightly more pronounced today. Vascular stent traverses the
superior vena
cava. Upper lungs clear. No pneumothorax. Small left pleural
effusion may
be present, but there is none on the right. Nodule at the left
lung base has
been evaluated by CT scanning as atelectasis.
TTE [**2146-11-29**]:
The left atrium is normal in 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) are [**Month/Day/Year 3841**]
[**Month/Day/Year 39707**] but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved biventricular
systolic function. No pulmonary hypertension detected.
Compared with the prior study (images reviewed) of [**2146-9-19**],
heart rate is faster. The severity of tricuspid regurgitation is
reduced. Estimated pulmonary artery pressures are lower. The
patent foramen ovale is not appreciated on this study.
CT Head [**2146-12-5**]:
FINDINGS: A non-contrast CT of the head was obtained. Again
noted is a right
parietooccipital intraparenchymal hemorrhage, currently
measuring 3.7 x 1.7 cm
with evidence of evolution of blood products as evidenced by the
diminishing
size of the hyperdense central focus. Also noted is associated
perihemorrhagic edema and mild leftward mass effect, not
significantly changed
from the prior study. There is stable mass effect on the
occipital [**Doctor Last Name 534**] of
the right lateral ventricle in addition to encephalomalacia
within the
territory of the right parietooccipital prior infarct. No new
foci of
hemorrhage are identified. Ventricular size is stable. There are
stable
areas of encephalomalacia within the periventricular white
matter, which are
unchanged. No extra-axial collections are identified. No new
loss of
[**Doctor Last Name 352**]-white matter differentiation is noted. The basilar cisterns
are
preserved, without evidence of transtentorial or uncal
herniation. The
calvarium is intact. The soft tissues are unremarkable.
IMPRESSION:
Evolution of right parietooccipital intraparenchymal hemorrhage
and
surrounding edema and mass effect on the posterior [**Doctor Last Name 534**] of the
right lateral
ventricle. No new foci of hemorrhage identified.
Brief Hospital Course:
48 year old woman with extensive past medical history, most
significant for paradoxical thromboembolism, recent embolic CVA
c/b hemorrhagic conversion presents with bilateral DVT and new
PE.
.
# PE/anti-coagulation: Patient was initially admitted to the ICU
and monitored on telemetry. She had mild tachycardia, but no
chest pain, and she maintained good oxygen saturation on 2L NC.
Neurosurgery was consulted, and agreed with full
anticoagulation. A heparin drip was started, and repeat head CT
showed no progression of ICH. Patient was transferred to the
floor in stable condition. Heparin drip was difficult to
titrate due to inconsistent PTT values, and patient was switched
to lovenox 70mg SC daily. Coumadin PO was started and dose was
titrated to an INR of [**12-28**]. Lovenox was stopped, once therapeutic
on coumadin for two days. On discharge she was taking coumadin
2mg PO daily, and had been at this does for four days prior to
discharge. Follow up was arranged with neurology, hematology and
neurosurgery, witha repeat head CT in 8 weeks.
.
#. ASD, paradoxical emboli: Consideration for percutaneous ASD
closure could be considered as an outpatient, pending clinical
improvement.
.
#. SHORT GUT SYNDROME: Patient was continued on TPN per
nutrition recommendations. She also had a regular diet. She
was discharged home with TPN managed by NutriShare.
.
#. H/O Line sepsis: Her hickman was flushed with daily ethanol
flushes of both lumens while in house. Before discharge,
extensive teaching was held with her family regarding the
importance of line care, and how to perform ethanol and heparin
flushes.
.
#. Headache: Patient was continued on her prior treatment of
fentanyl patch and PO morhine prn. On [**2146-12-5**], patient
complained of a bilateral frontal headache, similar to that when
she had her intracranial hemmorhage. A repeat head CT showed
evolution of the prior ICH, but no increase in size or new
hemmorhage. The headache reolved later that day with PO
morphine and she had no other HA during her stay.
.
# GOALS OF CARE: A family meeting was held [**2146-11-30**], and the
patient elected to be DNR/DNI. She expressed that what is most
important to her is to be able to think and communicate with her
family, and that she would not want life sustaining therapy if
this were compromised.
Medications on Admission:
Metoprolol 12.5mg [**Hospital1 **]
Amitriptyline 50mg PO QHS
Pantoprazole 40mg
Fentanyl patch 75mcg (Due [**2146-11-25**])
Lorazepam 1mg HS:PRN
Dexamethasone (D/C'd after taper on [**11-21**])
Lidocaine patch to L Knee
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Ethanol (Ethyl Alcohol) 98 % Solution Sig: Two (2) ML
Injection DAILY (Daily).
3. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
4. Line Care
Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
Not for IV use. To be instilled into central catheter port for
local dwell. (please instill post TPN, both lumens)
5. Line Care
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
6. Morphine 10 mg/5 mL Solution Sig: [**4-3**] ml PO every six (6)
hours as needed for pain.
7. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for anxiety.
8. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours.
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA and hospice
Discharge Diagnosis:
Pulmonary Embolism
Deep Venous Thrombosis
Discharge Condition:
Stable, alert and oriented to person, place and time. Can
transfer to chair with assistance.
Discharge Instructions:
You were admitted for high heart rate and were found to have a
pulmonary embolism, a blood clot in your lungs. You were
treated with anticoagulants, initially heparin, follwed by
lovenox (enoxaparin) and coumadin (warfarin). Neurosurgery was
consulted given your prior intracranial hemmorhage, and agreed
with this course of anticoagulation. Otherwise, you were
continued on your home medications.
The following changes were made in your medications:
Please START warfarin 2mg by mouth daily
Please continue all other medications as you were before.
Please review all medication changes with your primary care
physician.
Followup Instructions:
Please follow up with the following appointments:
MD: Dr. [**First Name8 (NamePattern2) 3608**] [**Last Name (NamePattern1) 22917**]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: [**Name Initial (PRE) 16337**], [**12-13**] at 1:00pm
They will check your INR at this visit and advise you regarding
your coumadin dose.
Location: FAMILY MEDICAL & MATERNITY CARE, [**Location (un) 90864**],
[**Location (un) **],[**Numeric Identifier 89510**]
Phone number: [**Telephone/Fax (1) 75498**]
Special instructions for patient:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6944**]
Specialty: Hematology
Date/ Time: Wednesday, [**12-21**] at 11:00am
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 106847**]
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Neurology
Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2146-12-13**] 2:00
CAT SCAN
Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2147-1-31**] at 11:30am
[**Hospital1 18**] [**Hospital Ward Name 517**] Clinical Center - [**Location (un) 470**] (Radiology)
[**Last Name (Titles) **]. [**Location (un) 86**], MA
Dr. [**Last Name (STitle) **]
Neurosurgery
Date/time: [**2147-1-31**] at 1:00pm.
Please proceed to Dr.[**Name (NI) 9034**] office immediately after your CAT
scan. His office will try to fit you in sooner.
[**Hospital **] Medical Office Building, [**Location (un) 470**], [**Last Name (NamePattern1) **].
[**Location (un) 86**], MA
|
[
"431",
"263.9",
"453.40",
"348.5",
"745.5",
"579.3",
"V44.2",
"285.9",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
16529, 16587
|
12761, 15094
|
381, 388
|
16673, 16768
|
5315, 5315
|
17442, 18968
|
4204, 4381
|
15363, 16506
|
16608, 16652
|
15120, 15340
|
16792, 17419
|
5881, 12738
|
4396, 5296
|
322, 343
|
416, 1631
|
5331, 5865
|
1653, 3880
|
3896, 4188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,542
| 199,171
|
26916
|
Discharge summary
|
report
|
Admission Date: [**2132-3-27**] Discharge Date: [**2132-4-1**]
Date of Birth: [**2051-12-15**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Heparin Agents / Linezolid
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography (ERCP) with
replacement stent
History of Present Illness:
80yoM with h/o biliary obstruction due to cholangiocarcinoma,
s/p stent placement with h/o prior VRE and Proteus septicemia,
presenting from rehab with fevers, lethargy. Patient was
admitted to [**Hospital1 18**] [**Date range (1) 66202**]/07. At that time he was diagnosed
with Proteus and VRE bacteremia and a liver abscess as well as
SBP with peritoneal tap growing sacchromyces cervesiae. A
pigtail catheter was placed to drain the liver abscess. He was
discharged to rehab on Flagyl, Cipro, and Daptomycin. Of note,
during that hospitalization family meetings were held with
patient and his [**Date range (1) 802**]. It was determined that he did not want
to pursue further aggressive care or invasive procedures, and
that after rehab he would prefer hospice level care.
.
At rehab he spiked a temperature to 101.4 and exhibited
increasing lethargy, prompting transfer back to [**Hospital1 18**]. In the
ED T 98.2 HR 65 BP initially 89/58, improved to 101/72 after
1.5LNS, RR 16, 96%RA. He had a CT abdomen performed which
showed persistance of catheter, decrease in size of old abscess
and question of new liver abscess. He was treated with Zosyn
and Linezolid prior to transfer to the floor.
.
On presentation now he c/o minimal pain over drain site in RUQ.
He denies nausea, vomiting, or change in bowel movements.
Past Medical History:
1. TB as child, spent 7.5 yrs in sanitroium
2. h/o IA
3. h/o detached retina
4. hypercholesterolemia
5. history of biliary obstruction s/p plastic stent [**3-4**] at Good
[**Hospital **] Hospital - brushings concerning for adenocarcinoma, CA
19-9 normal (10) in [**3-4**], CEA elevated (11) in [**3-4**], CT
revealed portohepatic and gallbladder masses in [**3-4**]; patient
previously followed by Dr. [**Last Name (STitle) 66200**] of gastroenterology at
[**Hospital1 1474**].
6. Liver abscess as above, s/p IR-guided drainage
Social History:
former machinist, no ETOH for a few years, retired, lives alone,
multiple pets. HCP is [**Name2 (NI) 802**] [**Name (NI) 717**] [**Name (NI) **] [**Telephone/Fax (1) 66201**]
Family History:
1. brother-lung cancer
2. brother-CAD
3. sister- cancer, one with breast cancer
Physical Exam:
T 97.1 HR 83 BP 130/70 RR 18 95%RA
GEN: comfortable, speaking full sentences, rolls in bed with
assist
HEENT: PERRL, sclera mildly icteric, conjunctiva pink, OP
clear, dryMM
Neck: supple, no LAD
CV: RRR, no mrg
Resp: trace RUL crackles, o/w CTA
Abd: RUQ biliary drain, +BS, soft, thin, ttp RUQ without
rebounding or guarding, no fluid wave
Ext: no edema, 1+ DPs
Neuro: A&Ox2 (person, place, not time), answers questions
appropriately, CN II-XII intact with decreased hearing left ear,
MAEW, sensation intact grossly to touch
Pertinent Results:
[**2132-3-26**] CT ABD/PELVIS: 1. Significant interval decrease in the
size of the right hepatic lobe collection drained by the pigtail
catheter.
2. Significant interval increase in inferior right hepatic
abscess which is not drained by the indwelling catheter. A
second percutaneous catheter placement may be needed to drain
this collection.
3. Unchanged hypodense lesion within the left lobe of the liver,
which may represent a metastasis or a focus of infection.
4. Probably mild interval increase in intrahepatic biliary
ductal dilatation compared to [**2-12**], though comparison
is difficult given differences in technique. There is a small
amount of pneumobilia centrally within the liver, suggesting at
least partial patency of the common bile duct stent.
5. Large amount of stool throughout the colon.
.
[**2132-3-26**] CXR: 1. No evidence of pneumonia. Air within the
inferior right lobe of the liver is located within an abscess,
as seen on CT.
2. Bilateral pleural effusions, moderate.
.
[**2132-3-27**] ERCP: Previous placed stent had completed obstructed.
This was removed.
Biliary stricture compatible with malignant biliary stricture in
the middle third of the common bile duct and at the bifurcation.
A 60 mm X 10 mm covered wall stent was placed.
.
[**2132-3-30**] CXR: Worsening bilateral pleural effusions with likely
developing fluid overload/failure.
.
[**2132-3-31**] ECHO: The left ventricular cavity size is normal. There
is severe regional left ventricular systolic dysfunction with
mid to distal anterior/anteroseptal akinesis and apical
akinesis/dyskinesis (EF 25-35%). LV systolic function appears
depressed. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade. Suboptimal image
quality - patient unable to cooperate.
.
[**2132-4-1**] CXR: Uncomplicated placement of PICC line with
appropriate termination point.
Brief Hospital Course:
# Septicemia in setting of biliary stent occlusion and liver
abscess: CT showed new liver abscess and worsening intrahepatic
biliary dilation. Patient underwent ERCP for stent replacement
as well as placement of a percutaneous abscess drain done by
radiology. LFTs steadily improved s/p ERCP. He was maintained
on daptomycin and meropenem in house but will complete his
course on vancomycin and meropenem, given enterococcus is
sensitive to vancomycin. Please check vancomycin trough on
[**2132-4-4**]. Plan for at least 4 weeks of antibiotics. Patient is
scheduled for follow-up with Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] of infectious
diseases to follow-up an interval CT and for possible
discontinuation of his drain based on the CT. A PICC is in
place for antibiotics. He has been hemodynamically stable and
afebrile with these treatment interventions.
.
# Liver abscess: Abd CT showed decreased size of prior right
lobe abscess (pigtail in place), but new inferiorly located
right liver abscess (~ 6 cm). Discussed with patient and his
HCP; he would not want surgery but was agreeable to IR drainage.
Aspirin was held and procedure done. His other drain was
discontinued. Biliary stent also replaced this admission, which
may have been a contributing factor.
.
# Systolic CHF: Patient noted to have EF 25-35% on ECHO done to
rule out an overt vegetation. He also complained of worsening
shortness of breath and had a chest xray which suggested
worsening CHF. Patient was diuresed and creatinine remained
stable. He remains stable on room air. He has been started on
an ACEI and will need qd weight and dietary restriction for
continued management.
.
# Altered mental status: Improved. Still agitated at night.
Remeron restarted. Likely infection is contributing. TSH and
B12 in normal range.
.
# Cholangiocarcinoma: Presumed based on imaging, not
biopsy-proven. Evidence of liver mets. Pt does not desire
chemo/surgery.
.
# Iron deficiency anemia: Hematocrit stable at 33. Labs from
[**2-6**] suggest iron deficiency. Patient started on po supplement.
# DNR/DNI: confirmed with pt and HCP. During prior admit, there
was discussion of possible hospice placement. The patient/HCP
clearly state that they want minimally invasive procedures
(ERCP, abscess drainage) but are declining surgery. Palliative
care was consulted and assisted in discussions with patient.
.
7) HCP: [**Name (NI) **], [**Name (NI) 717**] [**Name (NI) **] [**Telephone/Fax (1) 66201**]
Medications on Admission:
Remeron 15mg QHS
ASA 81mg daily
MVI daily
Senna 2tabs QHS
Protonix 40mg daily
Colace 100mg TID
Percocet 1-2tabs Q4hr prn
Zofran 4mg Q6hr prn
RISS
Discharge Medications:
1. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: hold for oversedation.
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
9. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q8H (every 8 hours) for 4 weeks.
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp < 100.
12. Outpatient Lab Work
Please check weekly CBC with diff, BUN, creatinine, ALT, AST
starting [**2132-4-4**] and fax results to Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 1419**])
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
every twelve (12) hours for 4 weeks.
14. Outpatient Lab Work
Please check vancomycin trough (30 minutes prior to AM dose) on
[**2132-4-4**] and fax result to Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 1419**]
Discharge Disposition:
Extended Care
Facility:
Braemoor
Discharge Diagnosis:
liver abscess
citrobacter and enterococcus septicemia
cholangiocarcinoma
systolic congestive heart failure
iron deficiency anemia
Discharge Condition:
fair
Discharge Instructions:
Please monitor for temperature > 100.5, drop in blood pressure,
decreased mental status, or other concerning symptoms.
Please transport patient to all follow-up appointments.
Please follow qd weight and give lasix 10 mg po if weight
increases > 3 lbs, following creatinine closely.
Followup Instructions:
1. You have a follow-up appointment scheduled with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] (PCP) on [**2132-4-15**] at 9:00. [**Telephone/Fax (1) 3183**]
2. You have a follow-up appointment scheduled with Dr.
[**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] (ID) in the [**Hospital Ward Name **] Bldg on [**2132-4-25**] at 9:30. ([**Telephone/Fax (1) 10**]
3. Please follow-up for your abdominal CT scan on [**2132-4-23**] at
12:00 PM. Location: [**Hospital1 18**], [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) **]. Phone: [**Telephone/Fax (1) 327**]
* YOU ARE NOT TO EAT FOR 3 HOURS PRIOR TO THIS EXAM
* YOU CAN TAKE ALL OF YOUR REGULAR MEDICATIONS THE DAY OF YOUR
EXAM
|
[
"995.91",
"428.21",
"576.2",
"197.7",
"155.1",
"572.0",
"280.9",
"038.49",
"428.0",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"97.05",
"50.91"
] |
icd9pcs
|
[
[
[]
]
] |
9704, 9739
|
5443, 7160
|
303, 382
|
9913, 9920
|
3152, 5420
|
10252, 11020
|
2507, 2589
|
8160, 9681
|
9760, 9892
|
7990, 8137
|
9944, 10229
|
2604, 3133
|
258, 265
|
410, 1743
|
7175, 7964
|
1765, 2297
|
2313, 2491
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,790
| 113,032
|
13081
|
Discharge summary
|
report
|
Admission Date: [**2151-9-23**] Discharge Date: [**2151-9-29**]
Date of Birth: [**2072-8-9**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Cough, Nausea, Vomiting, Respiratory Failure
Major Surgical or Invasive Procedure:
Endotracheal Intbuation
Central Line
Arterial Line
History of Present Illness:
79 yom with hx of SDH and dementia, CAD s/p CABG, who presents
with fever to 104, cough and hypoxia. He had a prolonged
hospital course [**4-8**] during which patient underwent craniotomy
for subdural hematoma. Patient also developed Klebsiella PNA s/p
trach and PEG. He has been in rehab since and now wheelchair
bound wit poor functional status on/off tubefeeds. According to
family, he received a feeding early Sunday morning and was found
approx one hour later flat in bed with tubefeed material in his
mouth. Since that time he had a cough and gargling breathing. He
had overall fatigue and was essentially confined to bed, talking
less and eating very little. On the evening prior to admission
he spiked a fever to 103.8 and was noted to be hypoxic and in
more respiratory distress. In the ED he received 2L IVFs,
Vanco/CTX/Azithro as well as 5mg IV metoprolol for a SBP 220 and
HR Afib in 130s. He desatted <90% on 6L and required NRB and was
transferred to the ICU.
Past Medical History:
Diabetes Mellitus
History of CAD
History of Mitral regurgitation
S/P CABG with LIMA graft in [**2148**], MV repair.
Hypertension
Hypercholesterolemia
Chronic Kidney Disease 2
Sigmoid resection/polypectomies
Social History:
Retired engineer
Denies tobacco
[**3-3**] etoh/day
Family History:
non-contributory
Physical Exam:
At Admission:
VS: HR 111 BP 141/75 RR 34 O2 95% on NRB
Gen: Awake but drowsy, apparent respiratory distress w/ shallow
breaths and abdominal breathing. Able to follow some commands,
squeezes hand
HEENT: MM dry
Neck: Supple, no JVD, no LAD
Heart: Irregular, tachycardic, no murmurs
Lungs: Rhonchi throughout, poor air movement
Abd: Slightly distended, soft, NT, normoactive BS
Extrem: No edema
Neuro: Pt is sleepy, answers questions appropriately
Pertinent Results:
At Admission
[**2151-9-22**] 11:57PM BLOOD WBC-12.5* RBC-4.45*# Hgb-14.5# Hct-41.9#
MCV-94 MCH-32.5* MCHC-34.5 RDW-14.5 Plt Ct-167
[**2151-9-22**] 11:57PM BLOOD Neuts-93.6* Lymphs-3.6* Monos-2.4 Eos-0.2
Baso-0.2
[**2151-9-22**] 11:57PM BLOOD PT-11.3 PTT-22.9 INR(PT)-0.9
[**2151-9-22**] 11:57PM BLOOD Plt Ct-167
[**2151-9-22**] 11:57PM BLOOD Glucose-155* UreaN-17 Creat-1.0 Na-139
K-3.0* Cl-103 HCO3-25 AnGap-14
[**2151-9-23**] 07:44AM BLOOD Calcium-6.9* Phos-3.0 Mg-1.5*
[**2151-9-23**] 04:13AM BLOOD Type-ART pO2-138* pCO2-48* pH-7.26*
calTCO2-23 Base XS--5
[**2151-9-22**] 11:50PM BLOOD Lactate-3.2*
[**2151-9-23**] 12:38PM BLOOD freeCa-1.14
At Discharge
[**2151-9-29**] 02:20AM BLOOD WBC-7.7 RBC-2.92* Hgb-9.5* Hct-28.1*
MCV-96 MCH-32.6* MCHC-34.0 RDW-14.8 Plt Ct-230
[**2151-9-29**] 02:20AM BLOOD PT-12.5 PTT-30.2 INR(PT)-1.1
[**2151-9-29**] 02:20AM BLOOD Plt Ct-230
[**2151-9-29**] 02:20AM BLOOD Glucose-200* UreaN-22* Creat-0.9 Na-145
K-3.5 Cl-110* HCO3-27 AnGap-12
[**2151-9-29**] 02:20AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.8
Brief Hospital Course:
A/P: 79 year old man with CAD, DMII, past h/o SDH s/p craniotomy
and Klebsiella VAP [**4-7**] who presents with cough, fever, altered
mental status, vomiting, found to have a likely pneumonia on
CXR.
# Respiratory failure: Patient intially presented as hypoxic and
hypercarbic, with tachypnea and shallow breaths. ABG at initial
presentation was 7.26/48/138 on 100% NRB. He had a highly
suspected aspiration event 4 days PTA with retrocardiac opacity
on CXR that was otherwise clear making aspiration pneumonia most
likely etiology of respiratory failure. Patient was thus
intubated for hypoxic respiratory failure and was started on
Vancomycin and Meropenum for broad spectrum coverage of
underlying pnuemonia. Antibiotics were continued for a 7 day
course. Patient initially had poor mental status, evaluated
with head CT which was negative. His mental status gradually
improved after sedation was turned off. Patient was gradually
weaned off ventilator and extubated on [**9-28**].
# Septic shock: Patient was initially hypotensive after 5 liters
of crystalloid in the setting of dropping urinary output and
worsening mental status. Patient was also febrile to 104 with
aspriation pneumonia as likely underlying source. Central venous
access was obtained and leveophed was started to support MAP
goals > 65. A-line was also placed for BP monitoring with a
goal CVP > 10. Broad spectrum antibiotics were also started as
discussed above.
# Pneumonia: Patient was covered broadly with history strongly
suggestive of aspiration but also known risks for hospital
acquired pneumonia. He also had a known history of MRSA + swabs.
A KUB was performed to rule out obstruction in the setting of
possible aspiration from G-tube feeds which was negative.
Legionella urine antigen was negative and BAL was possitive for
moderate yeast growth and minimal growth of GNR. Patient was
treated with 7 days of antibiotics and sputum was sent prior to
discharge with a negative gram stain.
# Oliguria: patient had a reduced urine output in the setting of
sepsis concerning for poor forward flow vs. impending renal
failure. He was initially given fluid boluses with some effect.
The ICU team felt there was a large component of respiratory
failure do to fluid overload and the patient was started on
Lasix boluses to which he responded with excellent urine output.
He was substantially diuresed with improved pulmonary function
prior to extubation.
# Diabetes mellitus: patient was started on a sliding scale with
modest management of sugars in the setting of sepsis. He may
require home dose of insulin at rehab.
Medications on Admission:
tylenol 650 prn
vit D 1000U
iron sulfate 325 [**Hospital1 **]
insulin 70/30 [**Hospital1 **]
RISS
metoprolol tartrate 25 mg daily
prilosec 20 daily
senna
visine opthalmic 1 drop [**Hospital1 **] to left eye
nasal saline 1 spray daily to both nostrils
valsartan 320 once daily
mag hydroxide prn constipation
sorbitol prn constipation
miconazole
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) syringe
Injection TID (3 times a day). syringe
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day): Please hold for BP < 110.
5. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: 40 mg Injection DAILY
(Daily).
6. Insulin
Continue Humalog sliding scale - see attached
7. Colace 50 mg/5 mL Liquid [**Last Name (STitle) **]: 100 mg PO twice a day.
Additional medications from his home list may be started at the
discretion of the rehab facility.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for a pneumonia (lung
infection). During the hospitalization, a machine helped you
breath and you were given antibiotics. We also felt that part of
your respiratory failure resulted from being fluid overloaded
and we gave you some medicines which helped with this fluid
balance.
Please call your doctor or return to the emergeny department for
any of the following
- documented fevers, shaking chills
- nausea with vomiting
- chestpain, increasing shortness of breath
- any other new symptoms which concern you
Followup Instructions:
Please follow up with your primary care doctor in [**1-1**] weeks for
further evaluation and a physical exam.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"272.0",
"V12.72",
"V44.1",
"V58.67",
"995.92",
"V12.04",
"414.01",
"518.0",
"V45.3",
"507.0",
"799.02",
"038.9",
"427.31",
"403.90",
"250.40",
"584.9",
"585.2",
"V43.3",
"V14.8",
"438.20",
"518.5",
"V45.81",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"38.93",
"96.6",
"99.17",
"33.24",
"99.29",
"99.21",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7128, 7194
|
3255, 5864
|
320, 373
|
7248, 7255
|
2195, 3232
|
7851, 8100
|
1693, 1711
|
6258, 7105
|
7215, 7227
|
5890, 6235
|
7279, 7828
|
1726, 2176
|
236, 282
|
401, 1377
|
1399, 1608
|
1624, 1677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,616
| 193,383
|
50373
|
Discharge summary
|
report
|
Admission Date: Discharge Date: [**2113-8-22**]
Date of Birth: [**2060-2-5**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Shortness of breath and fatigue
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53-year-old
gentleman with a history of rheumatic heart disease, who has
been followed over the years by serial echocardiograms. His
most recent echocardiogram in [**2113-3-3**] revealed a
severely dilated left ventricle with mild hypertrophy of the
septum. Ejection fraction was 55%. His aortic valve had
moderate to severe aortic insufficiency and mild to moderate
restriction. Peak gradient was 55 mm Hg, with an estimated
aortic valve area of 1.9 cm sq. Aortic root was moderately
dilated, and the mitral valve had probable moderate mitral
regurgitation. Mr. [**Known lastname **] has noticed some shortness of
breath and fatigue with heavy exertion. He occasionally
feels palpitations, but denies chest pain. He now presents
to [**Hospital1 69**] for aortic valve
surgery by Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY:
1. Rheumatic heart disease/valve disease
2. Mild chronic obstructive pulmonary disease
3. Hyperlipidemia
4. Tonsillectomy
5. Hernia repair
6. Splenectomy for traumatic accident
SOCIAL HISTORY: The patient has smoked two to three
cigarettes a day for 30 years.
MEDICATIONS: Lipitor, Lotrel which the patient recently
stopped on his own.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is afebrile, vital signs
are stable. Normocephalic, atraumatic. His neck is supple,
with no palpable masses. His lungs are clear to auscultation
bilaterally. His heart is regular rate and rhythm, with a
III/VI murmur. The abdomen is soft, nontender, nondistended,
with normal active bowel sounds. The extremities are without
cyanosis, clubbing or edema.
HOSPITAL COURSE: Mr. [**Known lastname **] was taken to the operating room
on [**2113-8-16**] for aortic valve replacement and aortic graft.
The aortic valve was a 29 mm SJ mechanical valve. The aortic
graft for his aortic dilatation was a 30 mm Hemashield graft.
The procedure was performed without complication, and Mr.
[**Known lastname **] was subsequently transferred to the Cardiac Surgery
Intensive Care Unit. In the Unit, he was extubated and
weaned off drips. He was fluid resuscitated. Coumadin
therapy was started for his valve replacement.
Mr. [**Known lastname 104989**] stay in the Intensive Care Unit was uneventful,
and he was then transferred to the floor on the evening of
postoperative day one. On the floor, Mr. [**Known lastname **] did have one
episode of atrial fibrillation with exertion. This episode
lasted approximately one minute, and he converted to sinus
rhythm without intervention. Also during his stay on the
floor, Mr. [**Known lastname **] developed some right eye vision changes. The
patient stated that he had had similar problems prior to the
surgery. He was evaluated by Ophthalmology, who observed a
possible peripheral retinal artery embolus. Mr. [**Known lastname **] will be
followed and evaluated in [**Hospital 8183**] Clinic. Visual field
testing will be performed at this time.
Otherwise Mr. [**Known lastname **] continued to improve daily. He was
tolerating an oral diet, and his pain was controlled with as
needed oral medications. He ambulated well with Physical
Therapy and, on [**2113-8-22**], he was felt stable to be discharged
home. His INR upon discharge was 3.7.
Physical examination at discharge: Temperature 97.5, heart
rate 72, blood pressure 122/64, respirations 18, oxygen
saturation 95% on room air. His heart is regular rate and
rhythm. The lungs are clear to auscultation bilaterally.
The abdomen is soft, nontender, nondistended, with normal
active bowel sounds. His incision is clean, dry and intact.
The extremities are without cyanosis, clubbing or edema.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg by mouth twice a day
2. Amiodarone 400 mg by mouth once daily
3. Enteric-coated aspirin 325 mg by mouth once daily
4. Colace 100 mg by mouth twice a day
5. Ibuprofen 600 mg by mouth every six hours as needed
6. Percocet one to two tablets every four to six hours as
needed
7. Coumadin 4 mg tonight, then as directed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
FOLLOW UP: Mr. [**Known lastname **] should follow up with Dr. [**Last Name (STitle) **] in one
month. He should follow up with the RTC in two weeks for
wound care. He should follow up with the Eye Clinic in one
week, and also Dr. [**Last Name (STitle) **] for monitoring of his Coumadin doses
and INR and as needed in clinic.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Mr. [**Known lastname **] is to be discharged home.
DISCHARGE DIAGNOSIS:
1. Status post aortic valve replacement and ascending aorta
graft
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Doctor First Name 24423**]
MEDQUIST36
D: [**2113-8-22**] 21:43
T: [**2113-8-23**] 00:31
JOB#: [**Job Number 104990**]
|
[
"997.1",
"396.2",
"496",
"428.0",
"E878.1",
"362.30",
"427.31",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
4714, 4794
|
3945, 4361
|
4815, 5157
|
1893, 3533
|
4373, 4692
|
1502, 1875
|
3548, 3922
|
159, 192
|
221, 1072
|
1094, 1278
|
1295, 1479
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,857
| 188,691
|
28747
|
Discharge summary
|
report
|
Admission Date: [**2102-10-11**] Discharge Date: [**2102-10-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Angiographic coil embolization of left colic artery branch
History of Present Illness:
[**Age over 90 **]M with h/o diverticulosis and colonic polyps (on c'scopy
[**2099**]), pacemaker, TIAs on [**Year (4 digits) 4532**] and ASA who presented with
BRBPR. Patient reported urge to move bowels, had BM after
dinner with BRP, went to [**Location (un) 620**] and had continued bright red
blood. HCT checked at [**Location (un) 620**] was 41.3, given 2 units blood and
sent to [**Hospital1 **] because no angio at [**Location (un) 620**]. Also in [**Location (un) 620**],
creatinine 1.8, troponin <0.01.
.
In the ED, initial vs were: T: 98.3 P: 86 BP: 166/81 R:18.
Patient was hypoxic on presentation. Labs notable for HCT 40.0
(s/p 2units at OSH) and creatinine of 1.5 (was 1.1 in [**2100**]). NG
lavage negative. CXR showed volume overload and the patient was
given lasix 20 IV and his 02 improved to 96% on RA. Patient then
had a CTA abdomen which showed focal active bleeding in the
descending colon. GI and sugery were consulted and patient was
sent to angio. In the angio suite [**Female First Name (un) 899**] arteriogram with extrav
in branch of left colic, had that coiled x 2 with no residual
extravasation. On transfer now 96% on 2L02 (lying flat in
angio). SBP 126 and HR 80s.
.
On the floor, the patient denies abdominal pain, nausea, or
further bowel movement.
.
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:
Melanoma ([**2078**]) s/p resection on ledt neck.
Mitral Valve Prolapse ([**2078**])--ECHO 200 with moderately severe MR
[**Last Name (Titles) **] ([**2089**])
CAD
Sesoneural hearing loss
Cataract, Macular degeneration, pseudophakia
Pacemaker
Colonic Polyps, adenoma ([**2099**])
h/o Diverticulosis
Chronic kidney disease, baseline creatinine 1.5
Social History:
Was married, 3 children, worked as a chemist at Polaroid from
[**2051**]-[**2076**].
- Tobacco: never
- Alcohol: occ
- Illicits: denies
Family History:
no colon cancer
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, 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:
[**2102-10-17**] 06:10AM BLOOD WBC-9.6 RBC-3.05* Hgb-9.4* Hct-27.6*
MCV-90 MCH-30.7 MCHC-34.0 RDW-16.2* Plt Ct-178
[**2102-10-11**] 09:20PM BLOOD WBC-10.2 RBC-4.41* Hgb-13.4* Hct-40.0
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.0 Plt Ct-199
[**2102-10-13**] 02:11PM BLOOD Neuts-72.1* Lymphs-21.5 Monos-4.3 Eos-1.6
Baso-0.5
[**2102-10-11**] 09:20PM BLOOD Neuts-78.9* Lymphs-16.0* Monos-4.3
Eos-0.6 Baso-0.2
[**2102-10-14**] 03:20AM BLOOD PT-13.3 PTT-24.7 INR(PT)-1.1
[**2102-10-11**] 09:20PM BLOOD PT-13.0 PTT-29.6 INR(PT)-1.1
[**2102-10-17**] 06:10AM BLOOD Glucose-97 UreaN-19 Creat-1.0 Na-142
K-4.1 Cl-110* HCO3-27 AnGap-9
[**2102-10-11**] 09:20PM BLOOD Glucose-95 UreaN-35* Creat-1.5* Na-140
K-6.7* Cl-112* HCO3-21* AnGap-14
[**2102-10-14**] 03:20AM BLOOD CK(CPK)-47
[**2102-10-13**] 04:50AM BLOOD CK(CPK)-55
[**2102-10-12**] 02:26AM BLOOD CK(CPK)-60
[**2102-10-11**] 09:20PM BLOOD CK(CPK)-90
[**2102-10-14**] 03:20AM BLOOD CK-MB-4 cTropnT-0.04*
[**2102-10-13**] 08:00PM BLOOD cTropnT-0.06*
[**2102-10-13**] 02:11PM BLOOD CK-MB-3 cTropnT-<0.01
[**2102-10-13**] 04:50AM BLOOD CK-MB-3 cTropnT-0.02*
[**2102-10-12**] 02:26AM BLOOD CK-MB-4 cTropnT-0.04*
[**2102-10-11**] 09:20PM BLOOD cTropnT-<0.01
[**2102-10-17**] 06:10AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1
[**2102-10-12**] 02:26AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.8
[**2102-10-12**] 02:19AM BLOOD Lact/ate-0.9/
[**2102-10-11**] 09:31PM BLOOD Hgb-13.7* calcHCT-41
[**2102-10-14**] 12:47AM BLOOD freeCa-1.08*
.
CXR [**2102-10-11**] Heart failure. Repeat radiography after appropriate
diuresis is recommended to assess for underlying infection.
.
CTA ABD/PELVIS [**2102-10-11**] 1. Active intraluminal contrast
extravasation within the distal descending colon. 2.
Diverticulosis without diverticulitis.
.
Transcatheter Embolization [**2102-10-11**] Successful coiling of area
of active extravasation in a branch of the left colic artery.
Final arteriogram demonstrates no active extravasation.
.
CXR [**2102-10-12**] As compared to the previous radiograph, there is a
clear
improvement. Increased lung volumes, the pre-existing bilateral
parenchymal opacities have now completely resolved, except for
small atelectasis in the retrocardiac lung areas. No pleural
effusions. No pneumothorax. Unchanged course of the pacemaker
leads.
.
Echo [**2102-10-13**] e left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Mild to moderate ([**2-11**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is moderate/severe posterior leaflet mitral
valve prolapse. An eccentric, anteriorly directed jet of severe
(4+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CTA Abd [**2102-10-13**] Active extravasation from the right femoral
artery with extensive retroperitoneal hematoma.
.
Guide for Pseudoaneurysm Injection [**2102-10-13**] Extensive hematoma
surrounding the right common femoral artery with a 1-cm
pseudoaneurysm. Following the procedure, no flow was documented
within the pseudoaneurysm indicating satisfactory thrombin
injection with thrombosis of the pseudoaneurysm. There were no
immediate complications
.
CTA [**2102-10-14**] 1. No findings of active bleeding within the bowel
or adjacent to the previous pseudoaneurysm site with no residual
filling of the pseudoaneurysm identified. 2. Significant
interval decrease in size to the right-sided retroperitoneal
hematoma with no new sites of bleeding.
3. Slightly increased size to small right pleural effusion and
adjacent
compressive atelectasis. 4. Unchanged infrarenal ectasia without
aneurysmal dilatation.
Brief Hospital Course:
[**Age over 90 **] y/o male with PMHx ?CAD, [**Age over 90 **] on aspirin and [**Age over 90 4532**],
diverticulosis who presents from OSH with BRBPR.
.
# Acute blood loss anemia [**3-14**] lower GI bleeding: Patient
received 2 units PRBC at [**Location (un) 620**], and HCT 41 to 40. He was
transferred to [**Hospital1 18**] as they do not have angio services at
[**Location (un) 620**]. The patient's vitals were stable on presentation to
the ED. He had a CTA of his abdomen/pelvis which showed
extravasation of blood into his descending colon. He went to IR
where they were able to successfully coil a branch of his left
colic artery and his repeat HCT was 32. His [**Location (un) 4532**] and aspirin
were held (indication was TIAs). After discussion with his
primary care physician, [**Name10 (NameIs) 4532**] was not restarted given [**Name10 (NameIs) **]
greater than 10 years ago and GI bleed and frequent nose bleeds
of greater concern. Aspirin will be re-started on the Friday
after discharged after discussion with IR.
.
# Femoral Artery pseudoaneurysm rupture: On ICU day 2, the
patient became acutely hypotensive and complained of right hip
pain. His hematocrit was rechecked and found to be 23, he was
given 2 units of PRBCS and sent for stat CT which showed a
bleeding pseudoaneurysm which IR injected with thrombin. Serial
HCTs remained stable, and DP pulses and abdominal exam also
remained reassuring. The RLQ pain resolved. On transfer to the
floor on HD4, repeat HCT demonstrated significant drop to ~22.
Mr. [**Known lastname 1356**] was asymptomatic, vital signes were stable, femoral
wound was tender but clean and dry without evidence of evolving
hematoma. He was transferred 2 units of pRBCs. Repeat CTA in
the morning revealed no active bleeding and interval decrease in
the size of the RP hematoma. Serial hematocrits were stable and
Mr. [**Known lastname 1356**] was discharged back to independant living.
.
# Dyspnea: On arrival to the [**Hospital1 18**], the patient required 4L02
(did not require any 02 at [**Location (un) 620**]. His CXR showed ? volume
overload thought [**3-14**] to his blood transfusions. He received
lasix 20mg IV with resolution of his symptoms. He was weaned
slowly from 02 and had an ECHO which showed EF 60-65%, severe MR
(known from history), mild AS and mild/mod AR. He no longer
needed oxygen supplementation prior to discharge.
.
# Elevated Creatinine: On admission, Mr. [**Known lastname 30613**] creatinine was
elevated to 1.5. Baseline creatinine unknown. Elevation may
have been in setting of acute volume depletion from blood loss.
Given 3 CTAs in several days, he was given Mucamyst [**Hospital1 **] and
gentle IVF before his third CTA for renal protection. His
creatinine was 1.0 at dicharge.
.
# Physical Therapy: Physical therapy was consulted to evaluate
Mr. [**Known lastname 1356**] in setting of hospital stay. He was given a walker
prior to discharge.
.
# BPH: He was continued home finasteride.
.
#Insomnia: He was continued home prn lorazepam QHS
Medications on Admission:
[**Known lastname **] 75 mg day
Aspirin 81mg/day
Finasteride 5mg/day
Metamucil
Multivitamin
Calcium with vit D
Preservision oral
lorazepam 0.5 qhs insomnia
Discharge Medications:
1. Metamucil 0.52 g Capsule Sig: One (1) Capsule PO once a day
as needed for constipation.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
5. Calcium 500 + D Oral
6. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1. Lower GI Bleed
2. Pseudo-aneurysm at right femoral cath site
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 for treatment of a lower GI bleed. An imaging
study of your abdomen was able to localize the bleed in your
intestine such that our interventional radiologists could access
the bleed via a vessel in your groin area to stop it. Your
blood counts and blood pressures were monitored carefully in the
ICU. You were subsequently found have developed bleeding from a
pseudoaneurysm at the site where the interventional radiologists
accessed your arteries. They were able to again stop this area
of bleeding. One more imaging study was performed several days
after the procedure to make completely sure that you were not
bleeding. Your blood counts and blood pressures have remained
stable since.
Please continue to take your regular medications as directed.
Your [**Company **] and aspirin increased your risk of bleeding. We
discussed this with your primary care physician who agreed that
you no longer need to your [**Company **] as your [**Company **] was over ten years
ago; please discontinue this medication. We are holding your
aspirin for now, but you can restart your aspirin this Friday
unless otherwise directed by your primary care physician.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 69482**]
Date: [**2102-10-20**]
Time: 8:10AM
Phone: [**Telephone/Fax (1) 69483**]
|
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"E849.8",
"414.01",
"V45.01",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"99.29",
"39.79",
"88.77"
] |
icd9pcs
|
[
[
[]
]
] |
11214, 11263
|
7513, 10299
|
270, 330
|
11371, 11371
|
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1666, 2114
|
225, 232
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358, 1647
|
11386, 11530
|
2136, 2484
|
2501, 2641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,671
| 175,582
|
11052
|
Discharge summary
|
report
|
Admission Date: [**2194-12-6**] Discharge Date: [**2194-12-26**]
Date of Birth: [**2139-7-9**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: The patient is status post left
upper wedge resection and chest wall resection for Pancoast
tumor and status post chemotherapy and radiation therapy.
the patient had intermittent left shoulder pain and weight
loss preoperatively. Postoperatively, the patient did not
keep multiple appointments. On [**12-3**], he presented to an
outside hospital with cough, disorientation. A workup
revealed a pneumonia empyema. The patient was then
transferred to the [**Hospital1 **] Hospital after being
started on antibiotics and obtaining cultures at the outside
hospital, which were negative for any growth.
PAST MEDICAL HISTORY: Migraine headaches, hyperthyroidism,
vitamin B-12 deficiency, anemia, Pancoast tumor.
PAST SURGICAL HISTORY: Spine surgery, cholecystectomy.
MEDICATIONS: Oxycontin, Percocet, iron, [**Name (NI) 8863**], PTU.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 98.7. Heart rate 68.
Blood pressure 106/63. Respiratory rate 20. O2 sat 95% 4
liters. Chest decreased breath sounds left side. Right side
with coarse breath sounds. Cor regular rate and rhythm.
Abdomen soft, nontender, nondistended. Extremities no edema.
LABORATORY ON ADMISSION: White blood cell count 6.9,
hematocrit 31.3, platelet 316, sodium 138, potassium 3.6,
chloride 98, bicarbonate 33, BUN 13, creatinine .3, glucose
82. A chest CT done on [**12-6**] revealed a 10.3 by 8.5 cm
loculated fluid collection at the left apex and a moderate
size left pleural effusion at the left lung base with
evidence of gas bubbles.
The patient was admitted to the hospital and had a
thoracocentesis performed, which revealed some cloudy
purulent fluid. The patient was admitted and started on
Ceftriaxone and Clindamycin. On [**12-8**] he had pigtail
drainage by interventional radiology of the left upper and
left lower lobe fluid collections. It was decided on [**12-9**] to take the patient to the Operating Room and a total
pulmonary decortication was done. Postoperatively with two
chest tubes and two Malecot tubes were placed. The patient
was transferred to the Intensive Care Unit intubated. The
patient was in the Intensive Care Unit for essentially
aggressive pulmonary toilet. On [**12-11**] the patient self
extubated, however, he tolerated it well and was not
reintubated. On [**12-14**], tube feeds were started for
approximately three days, however, the patient removed the
tubes on several occasions and further attempts were aborted.
On [**12-15**], Levaquin was started and Ceftriaxone and
Clindamycin were discontinued.
The patient was stable on transfer to the floor on [**12-16**]. Multiple chest x-rays were reviewed on the floor over
the next several days, which revealed left apical
pneumothorax and left basilar hydropneumothorax, which was
stable. On [**12-21**] a chest CT was performed, which
revealed significant improvement of the left apical
pneumothorax and also significant improvement of the left
basilar hydropneumothorax. The patient had interventional
radiology drain the left basilar pneumothorax. Several 100
cc of fluid were obtained. The Malecot tubes were
discontinued on [**12-23**]. On [**12-24**] a pain consult was
obtained and his pain medications were optimized. On [**12-26**] chest tubes were removed after obtaining a chest x-ray,
which revealed significant improvement of his disease.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS: Levaquin 500 mg q.d. for 28 days, iron sulfate
325 mg t.i.d., MS Contin 60 mg b.i.d., Ritalin 2.5 mg b.i.d.
at 6:00 a.m. and 12:00 p.m., sodium chloride 1 gram po
b.i.d., MSIR 10 to 20 mg q 2 hours prn, [**Month (only) 8863**] XL 100 mg q
day, multi vitamin, Colace 100 b.i.d., Boost one can t.i.d.
with meals, Zantac 150 mg b.i.d., PTU 100 mg po t.i.d.,
Celexa 200 mg q.h.s., heparin 5000 units b.i.d.
DISCHARGE STATUS: Rehabilitation facility. The patient will
follow up with Dr. [**Last Name (STitle) 175**] in two weeks and primary care
physician in two weeks.
DISCHARGE DIAGNOSIS:
Empyema status post open lung decortication.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2194-12-26**] 09:22
T: [**2194-12-26**] 10:54
JOB#: [**Job Number 35732**]
|
[
"510.0",
"998.59",
"511.8",
"512.1",
"486",
"261"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.51",
"34.04",
"34.03",
"33.22",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
4179, 4495
|
909, 1049
|
1072, 1358
|
172, 775
|
1373, 3541
|
798, 885
|
3566, 4158
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,427
| 113,595
|
13260
|
Discharge summary
|
report
|
Admission Date: [**2142-9-27**] Discharge Date: [**2142-10-4**]
Date of Birth: [**2063-3-27**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79F with h/o multiple UTIs c/b urosepsis p/w acute mental status
changes associated with cloudy urine with foul odor. Also noted
to have involuntary muscle twitches. She recently recovered from
an admission to [**Hospital1 **] [**Location (un) 620**] in late [**Month (only) 216**]
where she was diagnosed with a UTI with urine culture showing
VRE/E.Coli/Proteus and treated with linezolid and ertapenem.
In ED: T99.3 134/54 18 94%RA
U/A floridly +; given cefepime
<br>
Patient's family members currently not at bedside, but per
nursing report, her mental status appears to be at baseline
<br>
She currently denies any fevers, chills, cough, shortness of
breath, chest pain, palpiations, abdominal pain, change in
appetite. She does complain of feeling hot all of the time.
Past Medical History:
1. Chronic UTIs: Mulpiple prior admissions with urosepsis
2. Coronary artery disease: MI [**2135**] s/p stent placement
3. Peripheral vascular disease
4. Diabetes mellitus
5. Hypertension
6. Hyperlipidemia
7. Hypothyroidism
8. Anemia
9. Right renal staghorn calculus.
10. Polymyalgia Rheumatica
11. Dyspnea secondary to morbid obesity
12. Rheumatoid arthritis
13. Morbid obesity
14. Bladder diverticulum.
15. History of syncope secondary to poor glycemic control
16. History of C. difficile
17. Cholecystitis s/p cholecystostomy [**7-1**]
18. Status post sigmoidectomy with ileostomy
19. Groin abscess [**2141**] with non-healing wound
Social History:
Pt lives at [**Hospital **] Nursing Home. She is wheelchair-bound
secondary to lower back and lower extremity joint pain. She has
3 children who live locally and are active in her healthcare.
She has never smoked cigarettes.
Family History:
Non-contributory. Sister with [**Name (NI) 10322**] and colon cancer.
Physical Exam:
Physical Exam:
vitals - T 99.1, BP 112/80, HR 73, 95% on 2L.
gen - Obese female, lying flat in bed. Is sleeping but
arousable. A&Ox2; responding appropriately to questions,
speaking comfortably in full sentences
heent - Large neck. Could not assess JVP.
cv - RRR. No murmurs heard but heard sounds were distant.
pulm - Assessed anteriorly and clear.
abd - Soft and very obese. Non-tender. Non-healing wound in
right groin
ext - Warm; no edema; erythema without skin breakdown at site of
previous ulcer
Pertinent Results:
[**2142-9-26**] 10:00PM GLUCOSE-134* UREA N-33* CREAT-1.3* SODIUM-138
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12
<br>
[**2142-9-26**] 10:00PM WBC-13.3* RBC-3.93* HGB-12.0 HCT-35.2* MCV-90
MCH-30.5 MCHC-34.0 RDW-16.6*
[**2142-9-26**] 10:00PM NEUTS-80.7* LYMPHS-11.9* MONOS-2.8 EOS-4.5*
BASOS-0.2
<br>
[**2142-9-26**] 10:53PM LACTATE-1.1
<br>
[**2142-9-26**] 10:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2142-9-26**] 10:20PM URINE BLOOD-MOD NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2142-9-26**] 10:20PM URINE RBC-0-2 WBC-[**11-15**]* BACTERIA-MANY
YEAST-NONE EPI-0-2 TRANS EPI-[**2-28**]
Brief Hospital Course:
79 F with known staghorn caliculi, h/o urosepsis, and multidrug
resistant UTIs, presenting from her nursing home with muscle
twitching and ?change in mental status.
.
Staghorn calculus: Pt has a h/o R staghorn calculus. She had a
recent UTI with urine culture showing VRE and she was placed on
linezolid and ertapenem to treat E. coli and proteus and VRE.
She was noted to have cloudy urine x 1 day at her nursing home,
and mental status slightly off baseline. She received a dose of
cefepime in the ED and then the following day was started on
meropenem based on prior urine culture results and
sensitivities. By the morning after admission, the pt felt she
was back to her baseline mental status. A renal ultrasound
showed a continued R staghorn calculus, but no L staghorn
calculus, no hydronephrosis, and no perinephric abscess.
Urology was consulted as the patient had been seen by Dr. [**Last Name (STitle) 3748**]
as an outpatient and he had been planning to treat the staghorn
calculus as an outpatient in [**11-3**], but elected to perform the
procedure while she is hospitalized.
Patient underwent lithotripsy on [**2142-10-1**]. Transferred to [**Hospital Unit Name 153**]
for further management and particularly due to post-procedure
risk of sepsis/DIC. Did extremely well in ICU - hemodynamically
stable with no evidence of active bleeding. Antibiotic coverage
with meropenem. WBC elevated, though febrile and with no
symptoms indicating active infection. Per urology recs on
[**2142-10-2**], removed Foley and started Flomax 0.4mg QHS to help pass
stones.
# Pannus Wound: Pt had ulcerations under left side of pannus.
This wound was recently examined by her [**Last Name (LF) 5059**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**], who
per report saw her several weeks ago at which time he thought
the wound looked alright, and was unlikely to ever heal. At that
time she had a fistula gram which did not clearly demonstrate a
track, rather the contrast terminated in the subcutaneous tissue
adjacent to the abdominal wall
Medications on Admission:
levothyroxine 150mg
ASA 81mg
prednisone 5mg
MVI
Colace
Loratadine
Prilosec
Cymbalta 20mg
Hydroxychloroquine 400mg
gabapentin 600mg tid
artifical tears
Morphine Sulfate 30mg CR
oxycodone 5mg tabs prn
metoprolol 25 mg
Senna
lidoderm patches 5%
lorazepam .5mg prn
albuterol/ipratropium
Humulin 48U qam/12Uqhs
nitro prn
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Urinary Tract Infection with sepsis
Acute Renal Failure
Right staghorn calculi
Non-healing left groin fistula
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a urinary tract infection. You were
treated with antibiotics for this. You also had acute kidney
failure, but this resolved with IV fluids.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-10-18**] 10:15
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2142-10-25**] 10:30
Provider: [**Name10 (NameIs) **] RM 1 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2142-10-25**]
11:30
|
[
"599.0",
"038.9",
"250.00",
"725",
"278.01",
"276.51",
"569.81",
"995.92",
"V45.82",
"592.0",
"584.9",
"244.9",
"414.01",
"707.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"56.0",
"59.8",
"87.74",
"56.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5758, 5863
|
3329, 5392
|
275, 281
|
6017, 6026
|
2612, 3306
|
6238, 6622
|
2004, 2075
|
5884, 5996
|
5418, 5735
|
6050, 6215
|
2105, 2593
|
232, 237
|
309, 1085
|
1107, 1745
|
1761, 1988
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,365
| 159,198
|
52192
|
Discharge summary
|
report
|
Admission Date: [**2103-1-7**] Discharge Date: [**2103-1-16**]
Date of Birth: [**2023-7-29**] Sex: M
Service: MEDICINE
Allergies:
Quinolones / Simvastatin / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
intubation
central line placement and removal
History of Present Illness:
79M w/ Parkinson's disease, CHF, HTN, and AS who presents today
from his nursing home with hypoxia. Per report, he was in his
USOH until today when he had a mild nonproductive cough and
rhinorrhea. At this time, he was not febrile and had no CP,
SOB, abdominal pain, N/V, diarrhea, rash, weakness, or dysuria.
Around 9:30pm he was check on in bed and found to have vomited.
His oxygen saturations were checked and he was hypoxic to 73% on
RA. He did not come back to normal with supplemental oxygen and
eventually was placed on a non-rebreather with his oxygen levels
rising to 86%. He continued to deny fever, chest pain,
abdominal pain, or other symptoms and had no further episodes of
emesis. At baseline the wife reports that he is able to
recognize people but cannot follow a TV show plot, identify the
date, or engage in higher level thinking. He was sent to [**Hospital1 18**]
for further management.
.
In our ED he was found to be hypoxic and his labs were
significant for only mild renal insufficiency. His CXR showed a
? RML infiltrate vs CHF and he was given zosyn, CTX, and
clindamycin for a presumed aspiration event. He was initially
DNR/DNI but his code status was changed to DNR/OK to intubate
after discussion with the patient and his wife. [**Name (NI) **] was placed
on BiPAP and tolerated this well with an improved ABG and was
admitted to the ICU for further evaluation and management.
.
On the floor, he was tachypneic and sleepy but arousable and was
unable to be interviewed secondary to his mask. He denied pain,
nausea, or SOB.
Past Medical History:
1. Parkinson's Disease x 24yrs (s/p pallidotomy in [**2090**])
2. Hypertension
3. Dyslipidemia
4. CHF (EF reportedly 40%)
5. Aortic stenosis
6. History of DVT
7. BPH
8. Diverticulosis
9. R inguinal hernia repair
10. MRSA positive
11. GERD
12. Chronic renal insufficiency (Cr 1.2 in [**11-10**])
Social History:
Married with a son and daughter. Lives at [**Hospital1 100**] Senior Life.
Uses a wheelchair. Mildly demented at baseline. Denies
tobacco, alcohol, or ilicit drug use. Former film teacher.
Family History:
NC
Physical Exam:
98.1, 92/53, 85, 30, 95% CPAP ([**9-14**], 80%, 600)
Gen: CPAP mask in place, sleepy but arousable to voice, responds
to questions but voice difficult to understand w/ CPAP mask in
place
HEENT: MM appear slightly dry, EOMI
CV: RRR, 2/6 SEM at the USB
Lungs: Bibasilar decreased breath sounds and crackles,
inspiratory wheezes anteriorly
Abd: S/NT/ND, +BS, -HSM
Ext: Trace edema of the LE bilaterally, warm/well perfused
Neuro: Rhythmic motions of the R hand
Pertinent Results:
[**2103-1-6**] 11:15PM WBC-9.3 RBC-4.57* HGB-14.3 HCT-41.8 MCV-91
MCH-31.3 MCHC-34.2 RDW-13.1
[**2103-1-6**] 11:15PM NEUTS-61 BANDS-10* LYMPHS-18 MONOS-9 EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2103-1-6**] 11:15PM PLT COUNT-344
[**2103-1-6**] 11:15PM GLUCOSE-245* UREA N-42* CREAT-1.5* SODIUM-139
POTASSIUM-7.2* CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
[**2103-1-6**] 11:23PM LACTATE-2.5*
[**2103-1-7**] 01:03AM K+-3.8
[**2103-1-7**] 01:27AM TYPE-ART TEMP-37.1 O2 FLOW-100 PO2-194*
PCO2-44 PH-7.35 TOTAL CO2-25 BASE XS--1 -ASSIST/CON
.
IMPRESSION:
1. Bibasilar atelectasis with superimposed consolidation likely
aspiration or pneumonia.
2. Probable tracheomalacia; for confirmation a dedicated CT
examination of the trachea would be recommended if clinically
warranted.
3. Incidental right adrenal gland lesion which is partially
enhancing and should be further evaluated by another examination
such as a dedicated adrenal MRI study or CT examination.
Brief Hospital Course:
#Respiratory failure - Patient was initially admitted to the
hospital and required intubation in the setting of respiratory
failure. The patient had an aspiration pneumonia. The patient
was noted to be positive for influenza and it was likely in this
setting that he vomited and aspirated causing the hypoxia noted
at his nursing home. He had a difficult course of extubation
because of copious secretions. A broncoscopy was performed
which showed some significant tracheitis. There was a concern
for HSV infections. He completed a course of steroids and
acyclovir for this tracheitis. He also completed a course of
tamiflu and Vanc/Zosyn for his aspiration pneumonia. All of
these were completed by the time of discharge. He was extubated
and called out to the medicine floor on 3L NC. His respiratory
status continued to improve and his oxygen requirement decrease.
His oxygen will continue to be weaned at this long term care
facility.
.
#Cardiovascular - Patient was briefly hypotensive in unit,
requiring pressors in the setting of intubation. His pressures
stablized and at the time of call out, he was restarted on his
midodrine. His lasix was also resumed. He does not appear
volume overloaded.
.
#Parkinsons's Disease - Continued home dosing of meds
.
#Nutrition - Patient had some difficulty swallowing after his
extubation. A NG tube was placed and he recieved tube feeds.
Speech and swallow saw the patient and cleared the patient for a
regular diet, now straws with 1:1 supervision and assistance as
needed. He can also take whole pills in some puree. His
nutritional status should be closely monitored at his long term
care facility to ensure he is taking enough nutrition.
.
#Incidental Findings on CT: Patient noted to have a right
adrenal lesion. The radiologists recommended a dedicated
adrenal MRI or CT scan for further evaluation. Probably
tracheomalacia was also noted. If needed, this could be further
evaluated in the future with a dedicated CT of the trachea.
These findings should be addressed and monitored by his primary
care physician.
.
#GERD - continued PPI
.
Code Status - DNR but ok to intubate
Medications on Admission:
Calcium/Vitamin D
Celexa 20mg daily
Colace/Senna
Finasteride 5mg daily
Lasix 20mg daily
Midodrine 5mg tid
Prilosec 20mg daily
Rivastigmine 3mg [**Hospital1 **]
Ropinirole 0.5mg [**Hospital1 **]
Sinemet 25/100mg (1tab q 8a/10a/noon; 2tab q 2p/4p/6p/8p/10p/2a)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Aspiration Pneumonia
Parkinson's Disease
Discharge Condition:
Stable, on oxygen but with decreased requirement. Improved
respiratory status
Discharge Instructions:
You were seen in the hospital for treatment of an aspiration
pneumonia. You needed to be intubated to help you breath. You
completed a course of IV abx.
.
Two incidental findings on CT scan were noted during admission.
They should be followed by your primary care physician. [**Name10 (NameIs) **]
details are included in the discharge summary.
.
Either return to the emergency room or call your primary care
physician if you have chest pain, shortness of breath, fevers,
or other symptoms of concern to you.
Followup Instructions:
Please call your primary care physician and schedule [**Name Initial (PRE) **] follow up
appointment in [**12-6**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2103-1-16**]
|
[
"995.92",
"585.9",
"518.81",
"518.0",
"458.9",
"428.22",
"507.0",
"424.1",
"038.9",
"054.79",
"464.10",
"403.90",
"332.0",
"584.9",
"428.0",
"348.30",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"33.23",
"96.07",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6456, 6522
|
3996, 6146
|
320, 368
|
6607, 6688
|
3005, 3973
|
7248, 7493
|
2507, 2511
|
6543, 6586
|
6172, 6433
|
6712, 7225
|
2526, 2986
|
273, 282
|
396, 1962
|
1984, 2281
|
2297, 2491
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,166
| 140,858
|
13107
|
Discharge summary
|
report
|
Admission Date: [**2174-9-21**] Discharge Date: [**2174-9-23**]
Date of Birth: [**2102-4-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
gentleman admitted status post right carotid artery stenting.
History of bilateral carotid stenosis. Patient found to have
70% to 80% stenosis by ultrasound at an outside hospital.
PAST MEDICAL HISTORY: Hypertension. CAD. Aortic valve
disease. Pneumonia. Right cataract. Noninsulin dependent
diabetes mellitus.
PAST SURGICAL HISTORY: Hernia repair bilaterally. CABG
times three in [**2154**]. AVR in [**2163**] on Coumadin. Right
cataract surgery in [**2173**].
MEDICATIONS ON ADMISSION: Digoxin 0.125 p.o. q.day, Lescol
XL 80 mg q.day, Lasix 40 mg q.day, metformin 500 mg q.day,
Coumadin 5 mg alternating with 7.5 mg q.day.
ALLERGIES: Penicillin.
PHYSICAL EXAMINATION: Temperature was 96.3, heart rate 45,
blood pressure 146/57, respiratory rate 18, sat 100% on 6
liters. He was awake. Pupils were equal, round and reactive
to light. Chest was clear to auscultation. Cardiac regular
rate and rhythm with a murmur. Abdomen soft, nondistended,
nontender. Extremities warm times four. Right groin was
clean, dry and intact.
LABORATORY DATA: PTT on admission was 150, PT 16, INR 1.8.
Hematocrit 30.8.
HOSPITAL COURSE: The patient was admitted to the intensive
care unit status post stenting of right carotid artery. Post
procedure day one vital signs were stable. He was afebrile.
He was awake, alert and oriented times three with no drift.
Positive pedal pulses. Groin site was clean, dry and intact.
Neurologically intact. Was transferred to the regular floor.
Was out of bed ambulating, voiding spontaneously and
tolerating a regular diet. He was discharged to home on post
procedure day two with Plavix 75 mg p.o. q.day, aspirin 325
p.o. q.day. Follow up with Dr. [**Last Name (STitle) 1132**] in one month.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2174-9-23**] 09:25
T: [**2174-9-23**] 09:27
JOB#: [**Job Number 40040**]
|
[
"250.00",
"414.01",
"401.9",
"433.30",
"V45.81",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.90",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
692, 855
|
1334, 1935
|
533, 665
|
878, 1316
|
160, 372
|
395, 509
|
1960, 2227
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,481
| 170,318
|
53669
|
Discharge summary
|
report
|
Admission Date: [**2187-4-1**] Discharge Date: [**2187-4-4**]
Date of Birth: [**2139-7-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
melena/BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
Capsule endoscopy
History of Present Illness:
47 year old male with history of AVR w/ St. Jude's valve (in
[**2173**]) on coumadin, CHF, HLD, OSA on BiPAP, asthma, recent
admission for Asthma flare and low hemoglobin at [**Hospital 27217**]
Hospital, presents with four episodes of bright red bloody
stools.
.
Patient reports an episode of melena at 8am today. He had a
subsequent large volume liquid bowel movement that was bright
red two hours later, and two further episodes. He complains of
nausea earlier with the bowel movements as well as LUQ abdominal
cramps. He denies shortness of breath, lightheadedness, chest
pain, nausea, vomiting, and hematemesis. He presented initially
to [**Hospital3 26615**]. His labs were notable for INR: 3.8, Hct 31
(down from prior 41, one week ago). He received 10 vit K, 40 MG
protonix, and 2 units of FFP. He was transferred to [**Hospital1 18**] for
further management.
.
At [**Hospital1 18**] ED, his initial VS were: T 99.7, HR 78, BP 136/71, RR
18, O2 98%. On exam he was guaiac +. His labs were notable
for: Hct 27.5 (MCV 74), WBC 8.5, Plt 330, INR 2.4, Na 141, K
3.8, Cl 104, HCO3 29, BUN 20, Cr 0.9. He was started on a
protonix gtt, tylenol x1 for h/a, 1L NS, and was written for
2units pRBC which he has not received yet. His VS remained
stable HR 70-80s, SBP 120s-130s. GI and cardiology were
consulted in the ED. Plan was to admit to MICU for further work
up of GI bleed, likely colonoscopy in the AM, and to start
heparin gtt when INR<2. On transfer, he has 2 18g pivs and 1
20g piv. He is full code.
.
Of note, patient states that he recently had an asthma flare,
requiring frequent albuterol rescue inhalers as well as steroid
taper. He went to [**Hospital 27217**] Hospital for this and was found to
have a hemoglobin of 6. He was transfused a total of 4units of
pRBC. He had a CT head/abd/pelvis that were negative. He had a
colonoscopy that showed AVMs, not felt to be the source of
bleeding. He had an EGD that was normal, and was discharged
with a plan for capsule endoscopy as an outpatient. Of note, he
recently cracked a tooth and had an extraction. He had been
taking 800mg ibuprofen tid for 14 days.
.
Currently, patient c/o anxiety and headache.
Past Medical History:
Microcytic anemia
CAD s/p St. [**Male First Name (un) 923**] mechanical AVR in [**2173**] (on coumadin) and 1v
CABG (LIMA to LAD) in [**2175**] on coumadin
CHF- had recent echo at [**Hospital 27217**] hospital; had recent stress
test and cardiac catheterization w/in past 6months that was
negative
Asthma- s/p recent flare on steroids, admitted to [**Hospital 27217**]
hospital 2 weeks ago, has never been intubated
OSA on BiPap
DM, controlled with diet
HTN
HLD
Recent dental extraction
Anxiety, depression
Social History:
Works as a manager for [**Company **]
- Tobacco: quit 3 yrs ago, used to smoke <1ppd for 20 years
- Alcohol: social, weekends only
- Illicits: none
Family History:
Mother: had chron's disease passed away of lymphoma
Father: passed away, had dementia
Sister: bicuspid aortic valve
Grandmother with Crohns and brother with unspecified IBD
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Opening click, normal S1 + S2, regular
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, mildly-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 EXAM
Vitals: T: m98.6, c97.8, BP: 132/88 P: 63 R: 18 O2: 95%RA
General: sleeping with BiPap on, drowsy, but arousable and A&Ox3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: short neck with significant adipose tissue, supple, JVP
could not be evaluated, no LAD
CV: RRR, Opening click loudest at LLSB, normal S1 + S2, III/VI
systolic murmur best over RUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: obese, soft, non-tender, nondistended, 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 normal
Pertinent Results:
Admission Labs:
[**2187-4-1**] 09:12PM BLOOD WBC-8.5 RBC-3.74* Hgb-8.2* Hct-27.5*
MCV-74* MCH-22.1* MCHC-29.9* RDW-22.8* Plt Ct-330
[**2187-4-1**] 09:12PM BLOOD Neuts-69.1 Bands-0 Lymphs-21.5 Monos-6.4
Eos-2.2 Baso-0.9
[**2187-4-1**] 09:12PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL
[**2187-4-1**] 09:12PM BLOOD PT-24.9* PTT-41.5* INR(PT)-2.4*
[**2187-4-1**] 09:12PM BLOOD Glucose-137* UreaN-20 Creat-0.9 Na-141
K-3.8 Cl-104 HCO3-29 AnGap-12
[**2187-4-1**] 09:12PM BLOOD ALT-55* AST-36 LD(LDH)-406* AlkPhos-96
TotBili-0.2
[**2187-4-2**] 04:42AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.0
[**2187-4-2**] 04:42AM BLOOD Hapto-18*
CBC trend:
[**2187-4-1**] 09:12PM BLOOD WBC-8.5 RBC-3.74* Hgb-8.2* Hct-27.5*
MCV-74* MCH-22.1* MCHC-29.9* RDW-22.8* Plt Ct-330
[**2187-4-2**] 04:42AM BLOOD WBC-7.6 RBC-4.02* Hgb-9.3* Hct-30.2*
MCV-75* MCH-23.1* MCHC-30.7* RDW-22.3* Plt Ct-282
[**2187-4-2**] 10:16AM BLOOD Hct-29.6*
[**2187-4-2**] 07:29PM BLOOD WBC-9.9 RBC-4.10* Hgb-9.4* Hct-31.5*
MCV-77* MCH-22.9* MCHC-29.7* RDW-22.7* Plt Ct-329
[**2187-4-3**] 12:01AM BLOOD Hgb-9.8* Hct-32.8*
[**2187-4-3**] 05:35AM BLOOD WBC-7.9 RBC-4.00* Hgb-9.3* Hct-30.9*
MCV-77* MCH-23.2* MCHC-30.0* RDW-22.8* Plt Ct-333
[**2187-4-3**] 12:45PM BLOOD Hgb-9.5* Hct-32.5*
[**2187-4-3**] 09:18PM BLOOD Hgb-9.1* Hct-30.1*
[**2187-4-4**] 05:40AM BLOOD WBC-8.0 RBC-3.98* Hgb-9.4* Hct-31.1*
MCV-78* MCH-23.5* MCHC-30.0* RDW-22.9* Plt Ct-377
INR Trend:
[**2187-4-1**] 09:12PM BLOOD PT-24.9* PTT-41.5* INR(PT)-2.4*
[**2187-4-2**] 04:42AM BLOOD PT-29.3* PTT-91.7* INR(PT)-2.8*
[**2187-4-2**] 10:16AM BLOOD PT-25.8* PTT-37.6* INR(PT)-2.5*
[**2187-4-3**] 05:35AM BLOOD PT-20.3* INR(PT)-1.9*
[**2187-4-3**] 12:45PM BLOOD PT-18.8* INR(PT)-1.8*
[**2187-4-4**] 05:40AM BLOOD PT-17.1* PTT-33.1 INR(PT)-1.6*
TTg:
[**2187-4-3**] 12:01AM BLOOD tTG-IgA-3
Discharge labs:
[**2187-4-4**] 05:40AM BLOOD WBC-8.0 RBC-3.98* Hgb-9.4* Hct-31.1*
MCV-78* MCH-23.5* MCHC-30.0* RDW-22.9* Plt Ct-377
[**2187-4-4**] 05:40AM BLOOD PT-17.1* PTT-33.1 INR(PT)-1.6*
[**2187-4-4**] 05:40AM BLOOD Glucose-124* UreaN-8 Creat-0.8 Na-139
K-4.3 Cl-102 HCO3-30 AnGap-11
[**2187-4-4**] 05:40AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2
[**2187-4-1**] ECG:Normal sinus rhythm. Left bundle-branch block.
Non-specific ST-T wave No previous tracing available for
comparison. Read by: [**Last Name (LF) **], [**First Name3 (LF) **] P.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 156 154 420/446 63 97 -48
[**2187-4-2**]: Colonoscopy
Impression: Polyp in the sigmoid colon
Angioectasias in the cecum and sigmoid colon
Otherwise normal colonoscopy to cecum
[**2187-4-3**] Capsule Endoscopy - pending on discharge. Prelim report
showed AVM and angioectasias without blood in lumen
Brief Hospital Course:
47 year old male with history of AVR w/ St. Jude's valve (in
[**2173**]) on coumadin, CHF, HLD, OSA on BiPAP, asthma, recent
admission for asthma flare and low hemoglobin (suspected GIB) at
[**Hospital 27217**] Hospital, presents with melena followed by bright red
bloody stool.
# Gastrointestinal bleed: Given FFP and vitamin K at OSH, prior
to transfer. Patient was stablized with 2 units of pRBCs at
[**Hospital1 18**], and remained hemodynamically stable throughout the
admission. Colonoscopy showed 1 polyp and several angioectasias
throughout the colon. Capsule endoscopy final report was pending
at discharge, however preliminary report showed an AVM,
angioectasias and no evidence of blood in the small bowel. Acute
GI bleed was felt to be due to bleeding from AVM in the setting
of an elevated INR.
.
# Microcytic Anemia: MCV 75. This was felt to be due to chronic
gastrointestinal bleeding, likely from anticoagulation and
multiple AVMs, worsened acutely by significant GI bleed. Patient
had evidence of minimal intravascular hemolysis with an elevated
LDH and low haptoglobin, which was felt to be a result of being
given PRBCs. The patient received 2units of pRBCs on admission.
He was restarted on his home iron supplementation once work up
for GI bleed was complete. He will have a follow up CBC in
several days to ensure that his blood count is stable.
.
# Colonic Polyp: Single sessile 6 mm polyp of benign appearance
seen on colonoscopy, not intervened upon given high INR. Plan is
for patient for have a repeat colonoscopy in the next 6-12months
off warfarin and bridged with lovenox. Patient has GI followup
later this month.
.
# Aortic Valve Replacement: S/p [**Hospital3 **] prosthetic valve, on
Coumadin at home, and supratherapeutic INR on presentation to
OSH (which often fluctuates, per patient). Goal INR ideally
[**2-16**]. Cardiology was consulted and felt that given valve location
(aortic) and type (bileaflet), it was appropriate not bridge
with heparin and permit INR to drift down in setting of a GI
bleed, with the thought that once the INR was <1.7, we could
start a heparin drip if still concerned for bleeding. Given the
patient was stable x2days without further signs of bleeding, he
was restarted on his home dose of warfarin on HD#2. He was
discharged with a Levonox bridge given subtherapeutic INR of
1.6. Dr. [**Last Name (STitle) **] will resume warfarin management and the patient
was instructed to have his INR checked 2 and 5 days
post-discharge.
.
# CHF: Echo at [**Location (un) 12918**] earlier this month showed EF 40-45% and
impaired LV relaxation. On admission, patient was hypovolemic
and showed no signs of volume overload after 2units of PRBCs. He
showed no signs of CHF during his hospitalization, thus his
Lasix was held. His lasix was not restarted on discharge, as he
did not appear to be requiring it.
# Asthma: Recent exacerbation, s/p prednisone taper. We
continued his home inhalers and he remained asymptomatic in the
hospital.
TRANSITIONS OF CARE ISSUES:
1. We discontinued the Lasix given clinical stability and no
signs of volume overload
2. Capsule endoscopy final report pending at discharge
3. Patient will need continued outpatient management of his INR
and warfarin dosing, as well as a follow up CBC which will be
drawn on [**2187-4-9**] and faxed to his PCP.
4. His PCP's office will call him with an appointment in the
next couple days. He knows to call Dr.[**Name (NI) 110211**] office if they do
not contact him in the next day.
Medications on Admission:
Coumadin 5mg daily
Nexium 40mg daily
Crestor 40mg daily
Lasix 40mg daily
Vesicare 10mg 4 tablets daily
Celexa 40mg daily
Dulera 100mcg-5mcg daily
Albuterol 90 mcg q4-6hours
Iron
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for shortness of breath or wheezing.
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Dulera 200-5 mcg/actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation Inhalation [**Hospital1 **] (2 times a day).
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Outpatient Lab Work
Please check CBC and INR on [**2187-4-6**] and [**2187-4-9**] and fax
results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (Phone: [**Telephone/Fax (1) 10508**]; Fax:
[**Telephone/Fax (1) 110212**])
8. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg (1
syringe) Subcutaneous Q12H (every 12 hours).
Disp:*14 syringes* Refills:*0*
9. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as
needed for anxiety: Do not drive or operate heavy machinery when
taking this medication.
Disp:*5 Tablet(s)* Refills:*0*
10. Vesicare 10 mg Tablet Sig: Four (4) Tablet PO once a day.
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower Gastrointestinal bleed
Angioectasias in Colon
Anemia, Iron deficiency
Mechanical Aortic Valve
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your stay at [**Hospital 61**] Hospital. You were admitted for anemia and blood in your
stool. You underwent a colonoscopy and a capsule endoscopy to
identify the source of the bleeding. No active bleeding was seen
however, a polyp and some vascular malformations were seen which
could be the cause of your bleeding. The bleeding stopped on its
own and your blood counts remained stable.
Please have your INR checked on Friday, [**4-6**] and [**4-9**] and send the results to Dr. [**Last Name (STitle) **], who will resume
management of your warfarin dosing and INR levels.
The following changes were made to your medications
1. We STOPPED your lasix as you did not need it. Please follow
up with your primary care doctor.
2. You were given 5 tablets of ativan for anxiety. Please take 1
tablet no more than every 6 hours as needed for anxiety. Do not
drive or operate heavy machinery when taking this medication.
3. START lovenox injections twice daily until your primary care
provider instructs you to stop.
Followup Instructions:
If you would like to receive you primary care at [**Hospital1 **], call #[**Telephone/Fax (1) 2010**]. This is the scheduling number for
[**Hospital6 733**] ([**Company 191**]). Let them know you are a new
patient and would like to establish care within the [**Hospital1 **] system.
*** Dr. [**Last Name (STitle) **] is working on an appointment for you. His office
staff will contact you at home to schedule an appointment. If by
tomorrow afternoon, you have not heard from Dr.[**Name (NI) 110211**] office
concerning an appointment date and time, please call them and
have them schedule you for an appointment within the next
week.***
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: THE MEDICAL GROUP
Address: [**Last Name (un) 15488**] [**Apartment Address(1) 31103**], [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 10508**]
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2187-4-25**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22337**], 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
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,186
| 183,829
|
20329
|
Discharge summary
|
report
|
Admission Date: [**2199-11-18**] Discharge Date: [**2200-1-20**]
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Change in Mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Patient is an 85 year-old male with history of Atrial
Fibrillation (on Coumadin), multiple falls, who was initially
admitted to the Neurosurgery service in late [**Month (only) **] s/p fall
and change in MS with a right-sided SDH, where he received a
burr hole and subdural drain placement. He was discharged to
rehab and returned to [**Hospital1 18**] one week later from rehab with AMS,
slurred speech and left-sided upper and lower extremity
weakness; head CT on [**2199-11-18**] showed acute on chronic right
parietal SDH. Patient began seizing in the ER, was intubated,
sedated; he was also noted to have fever to 102F and received
Vancomycin, Levaquin, Flagyl, and Ceftriaxone. Patient remained
only on levofloxacin until [**11-23**] for ?UTI (though with neg Ucx)
and then was started on vancomycin on [**11-23**] for MRSA found in
sputum cx. All other cultures (including blood, CSF, Urine) have
been neg to date. Patient was extubated the following day.
Patient has a history of afib but was initially sinus rhythm on
presentation who converted to afib with RVR to 140's. EP was
consulted, diltiazem was started and Lopressor was added for
rate control; plan was for possible ablation if rate was not
well controlled. On the morning of [**11-25**], patient was noted to
have increased respiratory demand with occ 30 seconds of apnea
and tachypnea as well as fever of 101.6. CXR showed interval
worsening of moderate CHF and development of a left and possibly
right pleural effusion, no EKG changes. Patient was given lasix
20mg iv x1, restarted on ceftriaxone. ABG showed 7.48/35/66% on
3L NC. Pt denied having diarrhea. Has baseline non- productive
cough in the past month per family.
.
Of note, prior admission was s/p fall and change in MS, went to
[**Hospital **] Hosp, INR 5.1, seen to have subdural hematoma on CT,
given Dexamethasone, Dilantin, Mannitol. He was intubated, sent
to [**Hospital1 18**], where repeat CT showed Acute on Chronic SDH,
effacement and some midline shift-went to OR for Burr hole and
Subdural drain placement.
Past Medical History:
1. CAD
- admission in [**Month (only) **] for STEMI -- Catherization at that time
showed 100% proximal LAD stent restenosis, diffuse RCA disease,
and a patent LCx stent. A PTCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was successfully placed
in LAD. The catherization was complicated by the development of
wide complex tachycardia and hypotension (SBP 80s). As a result,
the patient was defibrillated once, given IV lopressor, IV
Amiodarone, Dopamine pressor, an Intraaortic Balloon Pump, and
intubated to protect airway. He was treated in the CCU,
stabilized, and discharged to [**Hospital **] Rehab
-s/p PCI to L circ and LAD in [**2-12**]
-s/p MI [**04**] years ago
-[**9-12**]: pMIBI showed a small fixed inferior defect with slight
apical redistribution suggestive of ischemia.
2. CHF (EF 30-35%)
3. AFib
4. Pacemaker(Cardioverter/Defibrillator) for sick sinus syndrome
5. s/p bilateral total knee replacement
6. s/p umbilical hernia repair
Social History:
Denies tobacco, ETOH, Italian speaking. Patient apparently is
essentially self-sufficient and is able to garden on a daily
basis. Has been at rehab facilty since last admission for
subdural hematoma evacuation. Prior to fall, patient was
essentially self-sufficient and was able to garden on a daily
basis.
Family History:
No history of CAD
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 102 HR 91 BP 139/93 RR 25 Sat 100 Vent
PE: intubated/sedated, well-nourished
CV: Reg s m/g/r
LUNGS: CTAB
ABD: soft/nt/nd
Neuro
MS: GCS 4T, intubated and sedated
CN: I--not tested; II,III-PERRL 3-2mm, III,IV,VI- Doll's Eyes
intact/VOR w/o nystagmus, no ptosis/facial droop; V-corneal
reflex present; VII-intact gag
Motor: normal bulk and tone
Strength: Could not assess appropriately, but patient did MAE to
pain; [**4-13**] minimal.
Coord: Could not assess
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2 | 2 | 2 | 0 | 2 | up |
R | 2 | 2 | 2 | 0 | 2 | up |
[**Last Name (un) **]: Could not assess
.
PHYSICAL EXAMINATION ON MEDICAL FLOOR (after transfer from MICU)
Vitals: Tm: 98.9 Tc: 98.9 BP: 100/43 P: 62 RR: 17 O2 sat: 98% on
3L (his baseline), I/O 1[**Telephone/Fax (5) 54535**].
GEN: Italian speaking male in NAD, comfortable, appears sleepy
HEENT: JVD to jaw line. MM dry. Anicteric. OP clear, no lesions.
CV: Irregularly irregular rhythm. S1 S2. II/VI systolic murmur
best heard at apex.
LUNGS: Bibasilar crackles heard anteriorly. Pt would not sit up
to listen posteriorly.
ABD: Soft, NT/ND. + BS. No masses felt.
EXT: Trace edema to mid-calf. DPs symmetric, 1+ bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2199-11-18**] 01:20PM WBC-12.1* RBC-4.15* HGB-12.5* HCT-38.7*
MCV-93 MCH-30.2 MCHC-32.4 RDW-17.5*
[**2199-11-18**] 01:20PM NEUTS-76.9* LYMPHS-18.1 MONOS-4.1 EOS-0.7
BASOS-0.3
[**2199-11-18**] 01:20PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-1+
[**2199-11-18**] 01:20PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-1+
[**2199-11-18**] 01:20PM PT-13.2 PTT-25.0 INR(PT)-1.2
DISCHARGE LABS:
[**2200-1-20**] 06:15AM BLOOD WBC-6.9 RBC-3.55* Hgb-10.2* Hct-32.0*
MCV-90 MCH-28.7 MCHC-31.8 RDW-18.7* Plt Ct-303
[**2200-1-20**] 06:15AM BLOOD Glucose-104 UreaN-22* Creat-1.1 Na-138
K-4.7 Cl-100 HCO3-27 AnGap-16
[**2200-1-20**] 06:15AM BLOOD Plt Ct-303
.
CSF from LUMBAR PUNCTURE [**2199-11-18**]:
[**2199-11-18**] 09:28PM WBC-12 RBC-196* Polys-74 Lymphs-9 Monos-17
[**2199-11-18**] 09:28PM WBC-167 RBC-6722* Polys-70 Lymphs-7 Monos-23
[**2199-11-18**] 09:28PM TotProt-106* Glucose-59
.
UA [**2199-11-18**]:
[**2199-11-18**] 02:47PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2199-11-18**] 02:47PM URINE RBC-[**4-13**]* WBC-[**12-29**]* Bacteri-FEW
Yeast-NONE Epi-0
[**2199-11-18**] 02:47PM URINE CastHy-0-2
.
MICROBIOLOGY:
[**2199-11-18**]: blood cultures X4 negative
[**2199-11-18**]: urine neg
[**2199-11-18**]: CSF Neg gram stain, neg culture
[**2199-11-19**]: Sputum: GRAM STAIN (Final [**2199-11-20**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2199-11-21**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**8-/2500**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2199-11-25**]: urine negative
[**2199-11-25**]: blood negative X 2
[**2199-11-29**]: blood negative X 6
[**2199-11-30**]: blood negative X 2
[**2199-11-30**]: blood AFB neg fungus neg
[**2199-12-3**]: blood neg X 4
[**2199-12-4**]: blood AFB neg fungus neg
[**2199-12-4**]: blood neg X 2
[**2199-12-4**]: urine neg
[**2199-12-5**]: blood neg
[**2199-12-6**]: blood negative X2
[**2199-12-28**]: blood neg X 4
[**2200-1-5**]: blood neg X 2
[**2200-1-5**]: urine yeast 10-100K
[**2200-1-5**]: sputum
[**2200-1-5**] 9:53 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2200-1-5**]**
GRAM STAIN (Final [**2200-1-5**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
[**2200-1-13**]: MRSA screen positive
.
ECHOCARDIOGRAM, most recent this admission ([**2200-1-8**]):
Conclusions: EF 25%. The left atrium is moderately dilated. The
right atrium is markedly dilated. A mass/thrombus (1.0 x 0.5 cm)
associated with a catheter/pacing wire is seen in the right
atrium. There is second mobile echodensity seen in the RA atrium
that likely represent a Chiari network but cannot exclude a
second vegetation/mass. There is mild (non-obstructive) focal
hypertrophy of the basal septum. The left ventricular cavity
size is top normal/borderline dilated. There is severe global
left ventricular hypokinesis. No masses or thrombi are seen in
the left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. The aortic
valve leaflets are moderately thickened. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**2-10**]+)
mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary
artery systolic [**Month/Day (2) **]. There is a small pericardial
effusion.
.
ECHOCARDIOGRAM, initial [**2199-11-29**]
Conclusions:
The left atrium is moderately dilated. The right atrium is
markedly dilated. A vegetation/thrombus associated with a pacing
wire is seen in the right atrium; this measures approximately
1.7 by 0.5 cm and is mobile/pedunculated, attached to the
pacemaker by a thin stalk. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (ejection fraction 20 percent). The right ventricular
cavity is dilated. Right ventricular systolic function appears
depressed. The ascending aorta is mildly dilated. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
to severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery
systolic [**Month/Day/Year **]. There is no pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2199-1-30**], the mitral regurgitation is increased; the
left ventricular ejection fraction is significantly decreased. A
moderate-sized vegetation/thrombus is now seen attached to the
pacemaker wire in the right atrium.
.
HEAD CT's
.
[**2199-11-18**]
COMPARISON: Head CT from [**2199-11-10**].
NONCONTRAST HEAD CT: The large subdural collection over the
right cerebral hemisphere is again identified, and demonstrates
heterogeneous attenuation with focal areas of more dense blood
products anteriorly. Since the prior study, there has been an
interval decrease in the attenuation values in the majority of
the collection. The collection along the lateral aspect of the
right temporal lobe and inferior parietal lobe may be slightly
more wide than on the previous study, but the frontal area
appears slightly thinner, and this could be due to shifting of
blood products, but an interval rebleed cannot be completely
excluded. There is slight worsening of sulcal effacement over
the right cerebral hemisphere and stable mild leftward
subfalcine herniation. No new extraaxial collections over the
left cerebral hemisphere or evidence of subarachnoid hemorrhage.
Widening of the extraaxial space anterior to the left temporal
tip, which could reflect a small arachnoid cyst, is also
unchanged. There are changes from prior right frontal
craniotomy. There is mucosal thickening in the ethmoid air
cells. Aerosolized mucus is present within the sphenoid sinus.
Evaluation of the skull base is limited due to motion artifact.
IMPRESSION:
1) Persistent right subdural hematoma. Slight change in
configuration likely reflects dependent changes and
reorganization over time.
2) Slight questionable worsening of sulcal effacement over the
right cerebral hemisphere, raising suspicion for increased
intracranial pressure.
.
HEAD CT [**2199-11-25**]
HEAD CT WITHOUT IV CONTRAST:
IMPRESSION:
1. No significant interval change in the size of the right
subdural hematoma. There is no significant subfalcine
herniation. The previously seen sulcal effacement over the right
cerebral hemisphere appears less pronounced on the current
examination.
2. No new intracranial hemorrhage or mass effect identified.
.
[**2199-12-3**]
NON-CONTRAST HEAD CT: Portions of the study are limited by
patient motion. There is no change in the intermediate
attenuation, moderately large right extra-axial fluid
collection. A moderate-sized arachnoid cyst anterior to the left
temporal tip is also unchanged. There is no evidence of acute
hemorrhage, worsening ventricular dilatation, or other change
from [**11-25**].
IMPRESSION: No change in chronic right subdural hematoma. No
evidence of new acute intracranial hemorrhage.
.
[**2199-12-26**]
TECHNIQUE: Non-contrast head CT. Comparison with previous study
from [**2199-12-6**].
IMPRESSION: Improvement in the right subdural hematoma. No
evidence of an acute hemorrhage.
.
[**2200-1-10**]
TECHNIQUE: Non-contrast head CT.
FINDINGS: There has been slight improvement in the small
subacute subdural hematoma along the right hemispheric
convexity. There is no evidence of acute hemorrhage within the
intra- or extra-axial space. There is no evidence of mass effect
or shift of normally midline structures. The right sphenoid air
cell has an air-fluid level as well as aerosolized mucus. No
other changes are identified since the prior study of [**12-28**].
IMPRESSION: Slight decrease in size of the small subacute right
subdural hematoma. No evidence of acute intra- or extra-axial
hemorrhage.
.
RECENT CXR: [**2200-1-5**]
Film is somewhat underpenetrated.
The heart remains enlarged. Bilateral interstitial alveolar
opacities are again seen.
.
EKG [**2200-1-5**]
L-R arm lead reversed. Atrial fibrillation
Borderline low QRS voltage Left anterior fascicular block
Poor R wave progression with late precordial QRS transition -
may be due in part to left axis deviation/ left anterior
fascicular block but consider also prior anterior myocardial
infarction
Since previous tracing of [**2200-1-2**], ventricular ectopy absent
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 0 102 408/454.57 0 -127 92
Brief Hospital Course:
Impression: 85 year-old Italian-speaking male with multiple
medical problems including Afib, chronic SDH, CHF, and dementia,
admitted with AMS, left sided weakness, found on admission to
have acute on chronic SDH by head CT, began seizing in the ED
and transferred to the MICU on admission. LP was negative,
urine and blood cultures were negative to date. CXR on admission
negative. Infectious workup negative. Pt stabilized, extubated,
and transferred to medical floor. His post-MICU admission course
was complicated by several issues, which will be reviewed by
problem.
.
1. Apnea: Throughout this admission, the pt appeared to have
[**Last Name (un) 6055**] [**Doctor Last Name **] Respirations, thought most likely secondary to his
congestive heart failure with an ejection fraction of 25%. The
patient demonstrated evidence of failure on exam with elevated
JVP (decreased from jawline to mid-neck by discharge),
peripheral and sacral edema, and bibasilar rales. His chest
X-rays were consistent with volume overload and he was diuresed
with both IV and po lasix. Initially, it was difficult to
diurese the patient, given his agitation with foley catheters,
condom catheters being placed. The pt would consistently pull
the catheters out in setting of waxing and [**Doctor Last Name 688**] mental status.
He spent 24 hours in the MICU ~3 weeks prior to discharge for
an episode of desaturation in the setting of apnea/[**Last Name (un) 6055**] [**Doctor Last Name **]
respirations, volume overload. He was transferred out to the
medical floor within 24 hours, with stabilization of O2 sats,
s/p diuresis with IV lasix in MICU, and afterload reduction with
valsartan. In the MICU, a foley catheter was successfully
placed, and the patient was diuresed with improvement in neck
veins, bibasilar rales, and his peripheral edema decreased to
trace to 1+. We continued with his CHF management with diuresis
with standing po lasix [**Hospital1 **] on the medical floor, with additional
IV lasix as dictated by I/O to allow for the goal diuresis to be
-500cc to -1L per day. This was tailored to his diet/oral
intake/volume status. His other CHF management was outlined as
below.
.
2. Altered Mental Status, improving slowly: Throughout the
course of this admission, the patient demonstrated waxing and
[**Doctor Last Name 688**] agitation, delerium, and confusion. The reasons for
agitation included his chronic SDH (which was found to be
smaller on repeat head CTs, but still present, his sz
prophylaxis w/phenytoin), ?infection, the unfamiliar
environment, restraints, the Italian language barrier, and
intermittent apnea with [**Last Name (un) 6055**]-[**Doctor Last Name 6056**] respirations. He was
noted to improve markedly with his family present. Of note, he
also experienced day-night dissociation by staying up all night,
then sleeping throughout the daytime. During this admission,
the pt required intermittent wrist restraints, a 1:1 sitter, and
required infrequent prn haldol IV. He was titrated off Seroquel
[**Hospital1 **] to seroquel only in the evening, 25mg po. His AM Seroquel
was weaned off, and he was much more awake during the day time.
At discharge, he was still w/ intermittent agitation, pulling at
his nasal cannula, PICC line (which he eventually pulled out),
and striking RNs during episodes of agitation (infrequent, but
did occur on a few occasions). At discharge, he was much
improved from a mental status point of view. He was awake
during most of the day, singing and talking in Italian, taking
his medicines orally (he passed a bedside-swallow evaluation for
soft solids) without aspiration, and walking with assistance and
physical therapy.
.
3. Oxygen requirement/hypoxia: He continued to have an oxygen
requirement, stabilized on 3L nasal cannula during his stay on
the medical [**Hospital1 **]. This was thought secondary to pulmonary edema
and CHF, possibly worsening in setting of his intermittent bouts
of RVR. Also with sedation intermittently, COPD with mild
restrictive pattern FEV1 2.16 in [**3-16**], when his amio was
discontinued (although pulm fibrosis not suspected). He was
diuresed as above (see apnea), and his CHF and Afib were managed
as above, and below, respectively.
.
4. Atrial fibrillation with RVR: Pt was noted this admission to
be in Atrial fibrillation, new onset. An echo on [**11-29**] revealed
the mass/vegetation on lead wire in right atrium. The pt was
noted to have occasional bursts of RVR, and his rate control
regimen was tailored and modified throughout his stay to achieve
optimal control. At discharge, he will be continued on
diltiazem po qid and metoprolol tid po. This regimen allows for
his HR to be maintained in the 80s-90s with only infrequent HR
to 120s-130s when agitated, up and walking around. His digoxin
was continued. Part of the difficulty in getting his rate
initially under control was related to missed doses of meds
secondary to somnolence and inability to take po with his waxing
and [**Doctor Last Name 688**] mental status. This had improved by discharge, and
his meds could be crushed in applesauce or ice cream. His ICD
was in place, did not fire this admission. After lenghthy
discussion with Neurosurgery and the primary medicine team, it
was decided not to anticoagulate this patient given his fall
risk, and the continued presence of his subdural hematoma
(smaller but still present).
.
5. Fever with Mass/Vegetation on Pacer/ICD Lead Wire: On
[**2199-11-29**], the pt was found to have vegetation on pacer lead wire
seen on echocardiogram in the setting of a fever (with other cx
negative, neg CXR). IV Vancomycin and Ceftriaxone were
initiated and continued for approximately 7 weeks, with repeat
echocardiogram [**2200-1-8**] showing the same prior vegetation/mass,
now smaller in size, but with another vegetation/mass on the
lead wire. Of note, all blood cultures spanning 2 months have
been negative. Although the mass may be a vegetation, it could
also be a thrombus, given the pt's Atrial fibrillation.
However, it could not be ruled out that the mass was not
infectious. The pt had a positive MRSA screen.
Electrophysiology was originally consulted and felt that removal
of the hardware posed risks that would outweigh benefits.
Infectious Disease was also consulted, and it was felt that the
best course of action would be to treat through it with IV
antibiotic therapy. After completing ~7 weeks of IV
antibiotics, with the new echo finding [**1-8**] of persistent
mass/vegetation seen on prior study plus new mass/vegetation, it
was decided between both the medicine and infectious disease
teams to continue IV antibiotics (CTX/VANCO) and then transition
the pt to po linezolid prior to discharge. Pt will be
discharged on po linezolid, with q weekly CBC checks on the
linezolid to monitor for marrow suppression, a possible side
effect of the medication. His PCP was informed that the results
will be faxed to him by VNA, who will draw the pt's labs. He
has a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with Infectious
Disease department, as well.
.
6. Congestive Heart Failure/Coronary Artery Disease: He had an
echo in [**11-13**] that showed an EF of 20% and moderate to severe
MR. Additional echocardiograms, with the most recent being
[**2200-1-8**] demonstrated severe global left ventricular
hypokinesis, mild (1+) aortic regurgitation, mild to moderate
([**2-10**]+) mitral regurgitation, moderate [2+] tricuspid
regurgitation with severe pulmonary artery systolic
[**Month/Day (2) **]. For his heart failure, the patient was continued
on a beta [**Month/Day (2) 7005**], po and IV lasix (see apnea above) and a
statin. He was tried on an ACEI but it was discontinued for
cough, and initial trial of [**First Name8 (NamePattern2) **] [**Last Name (un) **] resulted in hypotension. He
was intermittently gently diuresed in an effort to improve his
volume and respiratory status without creating hypotension. His
[**Last Name (un) **] was eventually re-initiated in MICU stay (3 weeks prior to
discharge) with success, so valsartan was continued for
afterload reduction. For his coronary artery disease, he is to
be maintained on a beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], statin, [**Last Name (un) **].
.
7. Subdural Hematoma: Chronic right subdural hematoma with no
significant subfalcine herniation, improving on CTs done during
his stay. His most recent Head CT prior to discharge was
[**2200-1-10**], showing slight improvement in the small subacute
subdural hematoma along the right hemispheric convexity, with no
evidence of acute hemorrhage within the intra- or extra-axial
space. Overall, a slight decrease in the SDH since [**Month (only) **] the
19th, when a prior Head CT was done. Because the patient
initially presented with tonic clonic seizures in the emergency
deparment thought secondary to his SDH, Neurosurgery and the
primary medicine teams decided on indefinite seizure prophylaxis
with dilantin. Anticoagulation for his atrial fibrillation was
also discussed at length with NSGY, and ultimately, the risk
most likely outweighs the benefits given this pt's waxing and
[**Doctor Last Name 688**] mental status and fall risk. His dilantin levels will
need to be monitored as an outpatient with his primary care
physician. [**Last Name (NamePattern4) **]. [**Last Name (STitle) 23813**] with NSGY should see the patient in
outpatient follow up for interval head CT to follow improvement
in his SDH.
.
8. GERD: Stable and continued on famotidine.
.
9. PPx: SC Heparin, PPI.
.
10. FEN:
The pt underwent a speech and swallow study and was found to
tolerate a soft mechanical diet. He will tolerate his
medications well if they are crushed and blended in applesauce
or ice cream.
.
9. Code status: FULL CODE, discussed with HCP and family
Medications on Admission:
Meds on initial transfer to [**Hospital1 18**] [**11-18**]:
1. Haloperidol 2 mg IV Q1H:PRN
2. Heparin 5000 UNIT SC BID
3. Insulin SC (per Insulin Flowsheet)
4. Ipratropium Bromide Neb 1 NEB IH Q6H
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
6. Metoprolol 75 mg PO TID
7. Atorvastatin 80 mg
8. Metoprolol 5-20 mg IV Q4H:PRN HR>100
9. Ceftriaxone 1 gm IV Q24H for empiric pulmonary pathogen
10. Phenytoin 200 mg PO BID
11. Digoxin 0.125 mg NG DAILY
12. Quetiapine Fumarate 25 mg PO TID
13. Diltiazem 60 mg PO QID
14. Famotidine 20 mg PO Q12H
15. Vancomycin HCl 1000 mg IV Q 12H
16. Furosemide 20 mg PO BID
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID (3 times a day).
Disp:*360 Tablet, Chewable(s)* Refills:*2*
5. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): You will need to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or your
PCP, [**Name10 (NameIs) 1023**] can refill this medicine. You will need to have
labwork done on this medication. .
Disp:*60 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: for constipation.
Disp:*100 Tablet(s)* Refills:*2*
9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)): if needed for insomnia, sleep, agitation at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 tab* Refills:*2*
14. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for agitation: only give if patient is
acutely agitated, combative.
Disp:*40 Tablet(s)* Refills:*0*
15. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for wheezing.
Disp:*1 MDI* Refills:*2*
16. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for wheezing.
Disp:*1 MDI* Refills:*2*
17. Outpatient Lab Work
Please draw CBC, chem 10 (electrolytes plus magnesium, calcium,
and phosphate) qweek and fax results to Dr.[**Name (NI) 54536**] office
at [**Telephone/Fax (1) 54537**]. Thank you.
18. home oxygen
Please administer continuous home oxygen. Thank you.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
1. Acute on Chronic Subdural Hematoma
2. [**Last Name (un) 6055**] [**Doctor Last Name **] Respirations secondary to Congestive Heart
Failure
3. Atrial fibrillation
4. Endocarditis/Vegetation on Lead Wire
5. Congestive Heart Failure
6. Coronary Artery Disease
7. Gastroesophageal Reflux Disease
Discharge Condition:
Stable
Discharge Instructions:
Return to ER if you have a fever in excess of 101 degrees,
experience increasingly frequent/severe headaches, nausea or
vomiting. Please return if you start to experience any acute
neurological changes (weakness, numbness, paralysis, facial
droop, gait instability). Please return if you have chest pain,
shortness of breath, sweating.
Please take all of your medications as prescribed. Please
follow up with your doctors.
Followup Instructions:
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], INFECTIOUS DISEASE
SPECIALIST, for Friday, [**2200-2-7**], 10:00am. Please arrive
at [**Hospital1 **] [**Last Name (Titles) 517**] [**Hospital Unit Name **], located at
[**Last Name (NamePattern1) 54538**].
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40066**], your Primary
Care Physician. [**Name10 (NameIs) **] office number is: [**Telephone/Fax (1) 40067**]. Your
appointment is for this Friday, [**2200-1-24**] at 2:45pm.
.
Please follow up with Dr. [**Last Name (STitle) 739**] in 6 weeks with head CT
prior to visit. Please call [**Telephone/Fax (1) 3571**] to schedule an
appointment.
.
You will have your bloodwork done every week by the VNA. She
will fax results to Dr. [**Last Name (STitle) 40066**] at [**Telephone/Fax (1) 54537**], who will be
monitoring your blood levels to make sure the linezolid is not
causing anemia, low platelets, etc.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2200-2-5**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,210
| 107,932
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27985
|
Discharge summary
|
report
|
Admission Date: [**2168-9-6**] Discharge Date: [**2168-9-28**]
Date of Birth: [**2142-10-11**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Oxycodone / Demerol / MS Contin / Penicillins /
Fentanyl / Bactrim / Tamiflu / Keflex
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Left chest Port-A-Cath removal
Insertion and subsequent removal of right-sided PICC
History of Present Illness:
Ms. [**Known lastname **] is a 25F with IDDM1 c/b chronic pancreatitis and
gastroparesis with chronic g-j tube, depression, and borderline
personality disorder who p/w with abdominal pain since the
evening PTA. She reports abdominal pain [**9-16**] in intensity and
similar to previous pancreatitis pain, radiating to the back "a
little," in association with T to 101, chills/sweats,
nausea/vomiting, and loose stools. She denies hematemesis or
melena/BRBPR. She also endorses chest pain and shortness of
breath, but denies joint pains, rashes, or dysuria. She
indicates that she has been compliant with her insulin regimen
at home. Of note, she has had repeated admissions for similar
symptoms, most recently in [**7-19**], when she was found to have DKA.
In the ED, she was found to be in DKA with glucose of 595, AG of
27 with uncorrected Na of 132, and UA with 40 ketones and 1000
glucose. She received 2L IVNS and was started on an insulin gtt
at 7u/hour. On exam, her lungs were clear, and UA was otherwise
negative for infection. VS on transfer were: 98.0, 107, 122/78,
18, 100% RA. Of note, she has a h/o multiple ED visits for
chronic abdominal pain and remains on a strict narcotics
contract, including 6mg PO Dilaudid q3h prn pain. On arrival to
the MICU, VS were as follows: 98.5, 99, 108/62, 14, 97% RA. She
was crying and requesting medication for abdominal pain.
Past Medical History:
IDDM1 c/b gastroparesis with chronic g-j tube (though most
recent gastric emptying study in [**4-17**] was normal)
Chronic abdominal pain presumed to be chronic pancreatitis
(narcotics contract with [**Hospital1 **] PCP; reportedly receives weekly
prescription on Tuesdays, though she reports she is no longer
seeing her [**Hospital1 **] PCP)
- pancreatic divisum (fibrosis and calcification in the pancreas
as well as 2 completely separate pancreatic ducts on ERCP)
- ampullary stenosis s/p stenting
Depression and borderline personality disorder with h/o cutting
behavior and suicide attempts
Asthma
H/o urinary retention
PUD due to H. pylori
Gastritis
Iron deficiency anemia
R adnexal cyst
S/p Cholecystectomy
Social History:
She was born in the [**Country 13622**] Republic and moved to the United
States as a child. She has a sister, who is married with a
child/children. She has a strained relationship with other
relatives, most notably her father, against whom she has a
restraining order. She lives with her husband in a multi-bedroom
apartment in [**Location (un) 686**], where she feels unsafe due to the
presence of weapons in her landlord's room, as well as a prior
attempt by her landlord to harm/threaten her by slashing her
Port. She reportedly works at an electronics store in [**Location (un) 14307**] as a technician. Endorses intermittent cigarette smoking.
Denies EtOH or illicit/IVDU.
Family History:
Mother, grandmother, and uncle with DM. Uncles with chronic
pancreatitis. No family h/o diabetic gastroparesis.
Physical Exam:
On admission:
VS: 98.5, 108/62, 99, 14, 97% RA
General: Alert, oriented, crying, but with very flat affect and
voice
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, TTP over RUQ, only mild TTP with deep palpation
over epigastrium and elsewhere, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
At discharge:
Afebrile/AVSS.
General: Lying comfortably in bed
CV: RRR, no m/r/g
Lungs: CTAB
Chest: Mild TTP at former L chest Port site with stable
keloiding and stable palpable fluid collection with minimal
erythema and no drainage
Abdomen: NTTP, no guarding/rebound
GU: No foley
Ext: Warm, well perfused, 2+ pulses, R PICC with stable
ecchymosis
Neuro: AOx3, appropriately interactive, CNs [**4-18**] intact, moving
all 4 extremities
Head: No focal contusion/stepoff
Pertinent Results:
Admission labs:
CBC: 13.1/47/367
Lytes: 132/4.7/94/19/0.6/595 AG 24
LFTs: 30/19/223/0.6
Lipase 13
Discharge labs:
CBC: 5.8/30.8/244
Lytes: 135/4.3/104/27/18/0.5/177
[**9-8**]: HBsAg negative, HIV Ab negative, HCV Ab negative
-
BCx ([**9-10**]) in [**5-11**] bottles:
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 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----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Port-A-Cath wound Cx swab ([**9-11**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
Port-A-Cath wound Cx swab ([**9-15**]): STAPHYLOCOCCUS, COAGULASE
NEGATIVE. SPARSE GROWTH.
Port-A-Cath wound Cx foreign body at removal ([**9-16**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Port-A-Cath wound Cx swab at removal ([**9-16**]): STAPHYLOCOCCUS,
COAGULASE NEGATIVE. SPARSE GROWTH.
-
Portable CXR ([**9-6**]): Left Port-A-Cath terminating within the
right atrium. No focal consolidation, pneumothorax, or effusion.
Portable CXR ([**9-10**]): There are low inspiratory volumes. Allowing
for this, no significant change is detected compared with [**9-6**], [**2168**]. No CHF, focal infiltrate, effusion, or pneumothorax is
detected. A left-sided
indwelling catheter tip overlying the SVC/RA junction or upper
RA is
unchanged.
Portable KUB ([**9-10**]): Non-obstructive bowel gas pattern. No free
air identified. Stool present in the colon.
LUE US ([**9-14**]): No e/o LUE DVT.
Chest wall US ([**9-14**]): No e/o fluid collection or abscess near L
port site.
Portable CXR ([**9-20**]): In comparison with study of [**9-10**], there are
continued low lung volumes. No evidence of acute pneumonia or
vascular congestion. Tip of the PICC line is in the lower
portion of the SVC.
L chest soft tissue US ([**9-22**]): 3 cm left chest wall fluid
collection, most consistent with hematoma.
Noncontrast head CT ([**9-22**]): No acute intracranial hemorrhage or
fractures.
Brief Hospital Course:
Ms. [**Known lastname **] is a 25F with IDDM1 c/b chronic pancreatitis and
gastroparesis with chronic g-j tube, depression, and borderline
personality disorder who p/w abdominal pain since the evening
PTA and was found to have DKA, since resolved, and later
developed Klebsiella bacteremia and coagulase negative Staph
Port-A-Cath pocket infection, now s/p Port removal and treatment
with vancomycin/ciprofloxacin.
#IDDM1 c/b DKA: DKA was attributed to medical noncompliance,
though patient reported adherence to insulin regimen as
prescribed. She was started on IVF and insulin gtt and
transitioned to home insulin after AG closed. CXR, UA, and
lipase were normal on admission. She subsequently revealed that
she had been injecting insulin into the deltoid and was
counseled on proper administration, though it was not clear that
she planned on changing her behavior. Home [**Known lastname 8472**] was uptitrated
incrementally from 40 to 80u qhs and later qpm due to
hyperglycemia intermittently to the 400s without AG in the
setting of infection, surreptitious consumption, and insulin
resistance, with simultaneous increase in Humalog insulin SS and
subsequent addition of NPH. Due to her profound insulin
requirement, she was ultimately discharged on insulin U500
regular 70u at breakfast, lunch, and dinner, with close PCP
[**Name9 (PRE) 702**] arranged.
#Klebsiella bacteremia/coagulase negative Staph Port-A-Cath
pocket infection: On HD5, patient developed T to 103 with HR to
140s attributed to ciprofloxacin-sensitive Klebsiella bacteremia
presumed secondary to her L chest Port-A-Cath, which she
reportedly had been chewing, with a 2-week course of IV
ciprofloxacin ([**Date range (1) 68146**]) initiated at that time. CXR, KUB, and
UCx were negative. When the Port was found to be draining
purulent material, wound Cx demonstrated coagulase negative
Staph, prompting Port removal and R-sided PICC placement, given
difficult peripheral access, under general anesthesia. Wound Cx
from the time of removal confirmed the presence of
vancomycin-sensitive coagulase negative Staph, prompting a
19-day course of IV vancomycin ([**Date range (1) 68147**]). She remained largely
afebrile with intermittent low-grade temperatures in the setting
of self-disconnecting IV antibiotics and HD stable without
leukocytosis on vancomycin/ciprofloxacin without recurrent
bacteremia on surveillance BCx. US of her L chest pre- and
post-Port removal were negative for soft tissue abscess. Patient
declined Port replacement, and R-sided PICC was removed prior to
discharge.
#Behavioral complications: Patient with known depression,
borderline personality disorder, and h/o aggressive behavior
became uncooperative, and threatened care team (MDs and RNs) and
posed challenges to her own care by self-disconnecting IV
antibiotics and reportedly chewing on/manipulating her
Port-A-Cath and other lines and consuming carbohydrate-[**Doctor First Name **]
foods surreptitiously outside of her restricted diabetic diet,
prompting involvement by psychiatric nurse specialists, to whom
she is well-known, and ultimately security on multiple
occasions, followed by transient physical/chemical restraints
with permission of her legal [**Doctor First Name 18297**] and subsequent seclusion
under 1:1 security sitter surveillance for the duration of her
admission.
#Chest pain: Patient reported chest pain pre- and post-removal
of her L chest Port-A-Cath, with L chest US negative for soft
tissue abscess both pre- and post-removal, though the latter US
was notable for a small hematoma. EKGs demonstrated no acute
ischemic changes, and the appearance of her L chest remained
stable with minimal erythema and no purulent drainage
post-procedurally. Although pain control became a flash point in
the setting of her strict narcotics contract, her pain was
ultimately well-controlled on regularly administered PO Dilaudid
6mg q3h.
#Soft blood pressures: Patient demonstrated intermittently soft
blood pressures, SBP to 90s, unassociated with fevers or
localizing symptoms in the setting of regular Dilaudid use and
likely intravascular volume depletion due to limited fluid
intake and hyperglycemia, with universal fluid responsiveness
and return to baseline SBP of 100s-120s.
#Abdominal pain: Patient with known h/o chronic abdominal pain
presumed [**3-10**] pancreatitis p/w epigastric pain c/w baseline.
Lipase was normal on admission. IV pain medications were
initiated per previously documented care plan, with transition
to PO pain medications once tolerating POs, also as per care
plan. Patient became uncooperative and threatening to care team
(MDs and RNs) on transition to PO medications, prompting
involvement of security and psychiatric nurse specialists, with
subsequent deescalation. In this setting, she removed her g-j
tube; reinsertion was deferred, given ability to tolerate POs,
in consultation with her PCP.
#Fall: Patient fell and struck her head on the front desk while
playing around when not confined to her room. Noncontrast head
CT was negative, and she displayed no LOC or focal neurologic
deficits throughout admission.
#Depression and borderline personality disorder: She received IV
Ativan and Benadryl initially as per documented care plan, with
transition to PO psychiatric medications once tolerating POs.
Patient declined psychiatric involvement, with the exception of
psychiatric nurse specialists, on this admission.
#Asthma: Home albuterol, ipratropium, and Advair were continued.
#PUD: She received IV pantoprazole initially, with transition to
home omeprazole once tolerating POs.
#Transitional issues:
-IDDM1: Patient was started on a new insulin regimen consisting
of tid insulin U500 regular at discharge due to profound insulin
resistance and will need close follow-up in the outpatient
setting.
-Access: On admission, patient had L chest Port-A-Cath, given
difficult peripheral access and frequent admissions for DKA.
Port was removed in the setting of bacteremia and pocket
infection and not replaced prior to discharge due to patient
preference. Need for new Port may be addressed at a later time
if indicated.
-Pain control: Patient remained on a strict narcotics at the
time of discharge, and pain control likely will remain an
ongoing concern in the outpatient setting.
-Soft blood pressures: Intermittently soft blood pressures in
the setting of frequent Dilaudid use may be reassessed on PCP
[**Last Name (NamePattern4) 702**].
-Depression and borderline personality disorder: Patient
declined psychiatric involvement, with the exception of
psychiatric nurse specialists, on this admission, but likely
would benefit from psychiatric follow-up if ever amenable in the
future.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Acetaminophen (Liquid) 325 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Diazepam 10 mg PO Q8H:PRN insomnia, anxiety
5. DiphenhydrAMINE 100 mg PO HS:PRN insomnia
6. Docusate Sodium (Liquid) 50 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
8. Gabapentin 500 mg PO HS
9. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN pain
10. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
11. Glargine 70 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Lactulose 45 mL PO Q8H:PRN constipation
13. Mirtazapine 30 mg PO HS
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Simvastatin 20 mg PO DAILY
17. traZODONE 100 mg PO HS:PRN insomnia
18. Zolpidem Tartrate 10 mg PO HS
19. HydrOXYzine 25 mg PO Q6H:PRN itch
20. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
21. Prochlorperazine 10 mg PO Q6H:PRN nausea
22. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Acetaminophen (Liquid) 325 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Diazepam 10 mg PO Q8H:PRN insomnia, anxiety
RX *diazepam [Valium] 10 mg 10 mg by mouth every 8 hours Disp
#*3 Tablet Refills:*0
4. DiphenhydrAMINE 100 mg PO HS:PRN insomnia
5. Docusate Sodium (Liquid) 50 mg PO BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
inhalation . twice a day Disp #*1 Unit Refills:*0
7. Gabapentin 500 mg PO HS
RX *gabapentin 250 mg/5 mL 500 mg by mouth at night Disp #*30
Each Refills:*0
8. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 3 tablet(s) by mouth Q3H Disp
#*21 Tablet Refills:*0
9. HydrOXYzine 25 mg PO Q6H:PRN itch
10. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
11. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 1 puff .
every 6 hours Disp #*1 Unit Refills:*0
12. Mirtazapine 30 mg PO HS
RX *mirtazapine 30 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
13. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
17. traZODONE 100 mg PO HS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
18. Zolpidem Tartrate 10 mg PO HS
RX *zolpidem 10 mg 1 tablet(s) by mouth at bedtime Disp #*1
Tablet Refills:*0
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
RX *albuterol 2 puffs every 4 hours Disp #*1 Unit Refills:*0
20. Lactulose 45 mL PO Q8H:PRN constipation
21. Regular U 500 70 Units Breakfast
Regular U 500 70 Units Lunch
Regular U 500 70 Units Dinner
22. Diabetes supplies
Please provide glucometer. Also, please provide alcohol swabs,
lancets, test strips, and insulin syringes needed for one (1)
month supply. Two (2) refills.
23. Insulin U500
Regular U 500 70 Units at Breakfast
Regular U 500 70 Units at Lunch
Regular U 500 70 Units at Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
klebsiella septicemia
sepsis
complicated central line/port site blood stream infection
poorly controlled type 1 diabetes with complications
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you. You were admitted for
abdominal pain and found to have diabetic ketoacidosis. You were
treated with pain medications and insulin, and your abdominal
pain and diabetic ketoacidosis have now resolved.
It is very important that you take your medications as
prescribed, especially your insulin.
Followup Instructions:
You have an appointment with you PCP: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD
Telephone: [**Telephone/Fax (1) 7976**]
Time: Thursday, [**10-6**], at 1:00pm
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
You should also follow-up with the [**Last Name (un) **] center. Please call
([**Telephone/Fax (1) 4847**] to make an appointment.
|
[
"536.3",
"999.33",
"999.31",
"311",
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"301.83",
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"041.86",
"250.13",
"305.1",
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"V49.87",
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icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
16977, 16983
|
7070, 12678
|
370, 455
|
17189, 17189
|
4597, 4597
|
17726, 18194
|
3313, 3427
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14799, 16954
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17004, 17168
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13811, 14776
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17340, 17703
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3442, 3442
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12699, 13785
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316, 332
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483, 1864
|
4613, 4696
|
3456, 4106
|
17204, 17316
|
1886, 2601
|
2617, 3297
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,355
| 141,230
|
42892
|
Discharge summary
|
report
|
Admission Date: [**2126-3-12**] Discharge Date: [**2126-3-27**]
Date of Birth: [**2088-5-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p attempted hanging
Major Surgical or Invasive Procedure:
[**3-12**] - intubation, therapeutic hypothermia
History of Present Illness:
38M w/ hx depression transferred from OSH following attempted
hanging and PEA arrest. Pt was found hanging by girlfriend and
cut down. EMT reported the pt to be in PEA arrest w/ subsequent
return of spontaneous circulation following 10 minutes of
resuscitation (CPR, epinephrine x1). He was intubated in the
process, requiring 3 attempts. GCS was reported as 3T. Pt was
initially taken to an OSH where mannitol was administered before
[**Hospital 7622**] transfer to [**Hospital1 18**].
Upon arrival to the [**Hospital1 18**] ED the pt was hemodynamically stable
with some left upper extremity movement reported. Pt had
intermittent desaturations noted, w/ initial ABG 7.06, 87, 188,
26, -8. Preliminary imaging revealed no c-spine fracture, no
obvious vascular disturbance on CTA, and no acute ICH; however,
cerebral edema was evident. The pt was admitted to the TSICU for
further care.
Past Medical History:
PMH: Depression, Lyme disease
PSH: Unknown
Social History:
N/C
Family History:
N/C
Physical Exam:
expired
Pertinent Results:
EEG [**3-20**]: This is an abnormal continuous ICU monitoring study
because
of very frequent generalized bursts of spike and polyspike
activity.
These findings are consistent with myoclonic status epilepticus
which
has started during the rewarming phase of hypothermia after
cardiac
arrest in this patient. Compared to the prior day's recording,
there is
worsening with higher voltage and increased frequency of spikes
and
polyspikes which occur continuously throughout the recording.
Brief Hospital Course:
Mr [**Known lastname 27953**] was brought to the [**Hospital1 18**] ED after a suicide attempt
via hanging. He suffered a cardiac arrest at the scene, and had
an extended period of no/low flow prior to return of
circulation. After a 15[**Hospital 15386**] hospital stay, he was prepared for
organ procurement in accordance with his expressed wishes for
organ donation, and was terminally extubated at 15:51. He
suffered cardiopulmonary arrest at 16:47, and was brought to the
operating room and prepared for organ procurement. At 16:52,
after 5 minutes of cardiac arrest, he was declared dead.
Neuro: He was noted to have movements of his left arm in the
trauma bay, consistent with myoclonus. He was paralyzed for the
hypothermia protocol, and monitored by EEG. His EEG was
abnormal during hypothermia, and failed to improve after
warming. The abnormal left arm movements persisted after
paralysis was weaned, and neurology was consulted. They felt
these movements represented myoclonic seizures, which are a very
poor prognostic sign in a patient with anoxic brain injury. His
brainstem reflexes were intact, but he never regained higher
cortical functions. His seizures were suppressed with multiple
anti-epileptic drugs.
CV: He was found in PEA arrest at the scene, and required CPR
and epinephrine prior to regaining circulation. Once admitted
to the hospital, his blood pressure and heart rate were
routinely monitored and remained stable.
Resp: He arrived at the hospital intubated and remained so
throughout his stay. He developed a MRSA pneumonia while
admitted, which was treated with appropriate antibiotics.
GI/GU: He was kept NPO with IV fluids, and had a foley catheter
placed.
Heme: His hematocrit was monitored routinely and remained
stable.
ID: He developed a ventilator-associated pneumonia due to MRSA,
and was treated with appropriate antibiotics.
Medications on Admission:
ativan, celexa, oxycontin
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
death after anoxic brain injury due to suicide attempt by
hanging
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2126-3-27**]
|
[
"333.2",
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"997.31",
"E953.0",
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"288.60",
"348.1",
"311",
"401.9",
"348.5",
"994.7",
"511.9",
"276.2",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.24",
"96.72",
"33.23",
"96.6",
"38.93",
"89.19",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
3949, 3958
|
1954, 3841
|
324, 374
|
4067, 4076
|
1444, 1931
|
4132, 4170
|
1396, 1401
|
3917, 3926
|
3979, 4046
|
3867, 3894
|
4100, 4109
|
1416, 1425
|
263, 286
|
402, 1292
|
1314, 1359
|
1375, 1380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,816
| 186,333
|
16334
|
Discharge summary
|
report
|
Admission Date: [**2207-12-13**] Discharge Date: [**2208-1-7**]
Date of Birth: [**2143-12-24**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Doctor First Name 3290**]
Chief Complaint:
multiple falls, acute on chronic SDH
Major Surgical or Invasive Procedure:
[**12-15**] Right Craniotomy for SDH
[**12-21**] IVC filter
[**2207-12-31**] PEG
[**2208-1-4**] MRI spine with sedation
History of Present Illness:
This is a 63 year old Male who was switched from Cymbalta a few
months prior to Prozac and noted some dizziness and
lightheadedness episodes. The patient notes over the past 2.5
weeks he has experienced 2 falls without LOC, associated with
intermittent 6/10 intensity headaches, with gait instability,
but he did not seek medical care. His daughter lives with him.
She finally noticed he had multiple ecchymoses and chronic falls
and decided to bring him to [**Hospital1 18**] [**Location (un) **]. A CT head [**2207-12-13**]
showed a grossly stable acute on chronic Right hemispheric
subdural hematoma and scattered Right SAH; R cerebral sulcal
effacement and roughly 6 mm R-to-L MLS (was 5mm) with no
evidence of
herniation. No recent trauma or injury for at least 2 weeks. He
has a history of chronic anticoagulation for history of PE with
Coumadin (INR 17.5 on admission). Patient received oral/IV
vitamin K prior to transfer.
.
He notes chronic peripheral neuropathy with no sensation,
temperature or pain felt below the knees bilaterally, but
ongoing.
Past Medical History:
-Gout: diagnosed when patient was in his 20's. Experiences
flares regularly and is on chronic meds.
-Status post clamshell repair of PFO: presented with massive
bilateral pulmonary emboli and emboli in spleen
-Hypertension
-Hyperhomocysteinemia
-Alcohol abuse
-Cervical stenosis
-Neuropathy
-ETOH abuse
Social History:
Works as a personal consultant. Lives with 27 year old daughter
and her son. [**Name (NI) **] used to smoke, but stopped 7 years ago.
Denies current alcohol abuse, but endorses previous alcohol
abuse.
Family History:
Father died from complication of abdominal surgery at 93. Mother
with brain tumor.
Physical Exam:
PHYSICAL EXAM: On Admission
O: T 97.2 BP 120/84 P 108 R 16 O2sat 94%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-2 mm bilateral pupils equally reactive to
light.
EOMs intact bilaterally.
Neck: Supple. No point tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, tender, BS+ Notable ecchymosis over LUQ/LLQ
diffusely.
Extrem: Warm and well-perfused. Right 4th digit tender to
palpation with ecchymosis.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-4**] throughout bilateral LE, but
full strength 5/5 UE. No pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally in upper extremities; below the knee, no
vibration, temperature sensation bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ -- 1+ --
Left 2+ -- 1+ --
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
DISCHARGE PHYSICAL EXAM
VS: Tm99. Tc96.1, BP 90s-120s/50s-80s, 80s-110s, 18, 94/RA
I/O: Y: 2.6/800 + (inc); MN: 1L/incontinent
GEN: responds intermittently (verbal today), appears
comfortable. Acknowleges questions but answers dysarthric.
Shaved right head after craniotomy with scar
Neck: JVP at 7 cm with possibly HJR
Cardiac: irregular, no murmurs appreciable
Pulm: lungs with some crackles in anterior lung fields
bilaterally
Abd: soft and nontender
Ext: 1+ edema in upper and lower extremities. LUE elbow with
erythema, effusion noted, and TTP in elbow as well as to passive
flexion/extension (improved from yesterday), decreased erythema.
Neuro: Pupils equal but sluggish in reaction, EOMI, visual
tracking intact intermittently. Withdraws to pain in upper
extremities but non localizing. This am moves both arms, but not
legs.
Skin: Pt noted to have erythema and skin breakdown by PEG tube.
On back side, violaceous macular skin changes on left gluteal
region along medial area area with no mass underneath, no fluid
collections in left gluteal region.
Pertinent Results:
CT HEAD W/O CONTRAST [**2207-12-13**]: Grossly stable acute on chronic R
hemispheric SDH and scattered R SAH; R cerebral sulcal
effacement and ~6mm R-to-L MLS (was 5mm) with no herniation
noted, final read pending, film reviewed with Neurorads.
.
CT head [**2207-12-14**]
Interval enlargement of previously visualized right subdural
hematoma with more of an acute component, more mass effect, and
a greater shift of the normally midline structures.
.
CT head [**2207-12-15**]
Interval decrease in thickness of the right convexity subdural
hematoma, which may, in part, reflect redistribution and stable
small left frontal subdural hematoma, with decreased leftward
shift of normally midline structures.
.
CT head [**2207-12-16**]
Stable overall appearance of bilateral subdural hematomas, with
stable leftward shift of the normally-midline structures.
.
GB US [**2207-12-16**]
1. Focused examination demonstrates an abnormal, sludge-filled,
distended
gallbladder with wall edema, concerning for acalculous
cholecystitis. A
hepatobiliary nuclear medicine scan with CCK may be of use if
further
assessment is desired.
2. Echogenic liver compatible with fatty infiltration. Other
forms of liver disease such as cirrhosis or fibrosis cannot be
excluded by imaging.
Evaluation for portal hypertension can be achieved with Doppler
ultrasound if desired.
.
EEG [**2207-12-16**]
This is an abnormal video EEG telemetry due to the presence of a
slow background which reached a maximum of 4 Hz frequency. This
is representative of a moderate to severe encephalopathy such as
can be seen in diffuse ischemia, infection, toxic/metabolic, or
other diffuse etiologies. Of note, there was significant
electrical artifact from 17:23 onward in the right hemisphere
leads. There were no clear epileptiform discharges or
electrographic seizures noted.
.
EEG [**2207-12-17**]
Showed an irregularly irregular rhythm.
IMPRESSION: This is an abnormal video EEG telemetry due to the
presence
of bursts of up to one minute each of periodic lateralized
epileptiform
discharges (PLEDs) over the right central region. PLEDs are
commonly
seen in the setting of acute structural brain lesions and can
indicate
epileptogenic cortex, although no frank electrographic seizures
were
seen. The slow background also indicates a moderate to severe
encephalopathy such as seen in toxic/metabolic, ischemic, or
infectious
etiologies.
.
CT head [**2207-12-17**]
No significant change in the size of the right-sided subdural
hemorrhage
with mild mass effect on the cerebral hemisphere, cerebral edema
and shift of the midline structures to the left side along with
mass effect on the right lateral ventricles; along with a few
foci of hemorrhage in the right frontal lobe at the vertex. Mild
improvement in the post-surgical changes noted before. No new
hemorrhage noted. Continued close followup as clinically
indicated.
.
EEG [**2207-12-18**]
This video EEG telemetry was abnormal due to the presence of a
slow, disorganized background that was usually in the delta
frequency range with superimposed bursts of generalized delta
slowing, often with a bifrontal predominance. These findings
suggest the presence of a severe encephalopathy which can be due
to diffuse ischemia, toxic/metabolic changes, infections,
medication effects, or other etiologies. No epileptiform
features or electrographic seizures were seen.
.
ECHO [**2207-12-18**]
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 80%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is markedly
dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No mitral regurgitation is seen. The main
pulmonary artery is dilated. The branch pulmonary arteries are
dilated. There is no pericardial effusion. Compared with the
findings of the prior study (images reviewed) of [**2204-4-16**],
the right ventricle is now dilated and hypocontractile, and the
left ventricle is now hyperdynamic
.
EEG [**2207-12-19**]
This video EEG telemetry is abnormal due to the presence of a
slow, disorganized background, mostly in the delta frequency
range, with bursts of generalized slowing. These findings
suggest the presence of a severe encephalopathy such as can be
seen from diffuse ischemia, toxic/metabolic changes, medication
effects, infections, and other such etiologies. Bursts of more
prominent slowing were often seen in the right fronto-central
region, sometimes with sharp features, suggesting the presence
of more focal subcortical dysfunction in that area, but no frank
epileptiform discharges or electrographic seizures were seen.
.
EEG [**2207-12-20**]
This EEG gives evidence still for intermittent PLEDs-like
discharges in the right central temporal region. On occasion,
these become more organized and appear to have electrographic
seizure occurrence. There is no obvious clinical accompaniment.
Over time, these seem, if anything, to be increasing in
frequency of occurrence and in duration. There is also a severe
diffuse encephalopathy with some structural asymmetric features
suggesting more right hemisphere involvement.
.
CT head [**2207-12-20**]
1. Overall stable appearance of bilateral subdural hematoma with
stable
leftward shift of normal midline structure.
2. Stable appearance of right parenchymal hemorrhage with
slightly increased zone of surrounding vasogenic edema.
3. Stable appearance of small foci of subarachnoid hemorrhage
within the
right hemisphere.
.
UE US
Nonocclusive thrombosis of the left cephalic vein. No evidence
of deep venous thrombosis.
.
CT head [**2207-12-27**]
1. Stable size of right-sided subdural hematoma and small
left-sided subdural hematoma. Stable leftward shift of midline
structures of 5 mm.
2. Resolving right frontal intraparenchymal hemorrhage with
stable amount of surrounding edema. No new acute hemorrhage.
NOTE ON ATTENDING REVIEW:
There is 2.9x1.6cm mass lesion in the nasopharynx, similar the
prior MR of
[**2198-4-15**] with obstruction to the lumen; this was felt to
represent a
lipoma/cyst with dense contents, more likely the latter given
the density on CT. There is likely obstruction of the eustachian
tubes. There is diffuse mucosal thickening and fluid in the
mastoid air cells on both sides. Rec. ENT consult as suggested
earlier in [**2204**].
.
CTA chest [**2207-12-27**]
1. Breathing motion gives suboptimal evaluation of the vessels
at
subsegmental level. No pulmonary embolus in the main pulmonary
artery, right and left pulmonary artery and segmental branches.
2. Bilateral moderate pleural effusions with adjacent
atelectasis.
3. Emphysema.
4. Tip of left central line terminates at the left
brachiocephalic vein.
5. Right heart enlargement.
.
Abd X-ray [**2207-12-27**]
In comparison with the study of [**12-29**], the tip of the
nasogastric
tube is in the region of the esophagogastric junction with the
side hole in the lower esophagus. It should be pushed forward
approximately 20 cm. IVC filter is in place.
.
Chest X-ray [**2207-12-29**]
In comparison with earlier studies of this date, the side port
of
the nasogastric tube again lies above the diaphragm. Much of the
proximal
portion of the tube is coiled in the hypopharynx.
.
CT head [**2207-12-30**]
IMPRESSION: Incomplete study with substantial artifact limiting
evaluation
for interval change. Apparent residual right subdural collection
with
leftward shift of normally midline structures.
COMMENT: Patient could return for completion of the study, with
appropriate pre-medication, when feasible.
.
CT HEAD [**2208-1-3**]
IMPRESSION: Limited study, demonstrating interval evolution of
right subdural
hematoma, without increase in size. There is no midline shift,
and mass
effect upon the right lateral ventricle is unchanged
Venous Duplex [**2208-1-4**]
IMPRESSION: No evidence of DVT of the left upper extremity.
MRI C/T/L SPINE [**2208-1-4**]
1. Compared with the prior study of the cervical spine performed
[**10-14**], [**2204**], the anterolisthesis of C4 on C5 unchanged. There is
new 2-3mm grade
1 retrolisthesis of C3 on C4 whcihc results in mild-to-moderate
spinal canal
narrowing without signal abnormality of the cervical cord. No
signal
abnormality is identified on the STIR sequences to suggest edema
suggesting
this retrolisthesis is of a degenerative etiology.
2. Incompletely imaged within the left gluteus maximus muscle,
there is a T1
hyperintense oval-shaped mass. Clinical correlation and
ultrasound are
recommended.
3. Mild cervical and lumbar spondylosis without severe spinal
canal or neural
foraminal narrowing.
4. Aneurysmal dilation of the infrarenal abdominal aorta- tr-
5cm,
incompletely assessed and likely increased from prior of [**2200**].
Consider
dedicated imaging with ultrasound/MR
ADMISSION LABS:
[**2207-12-13**] 05:00PM BLOOD WBC-6.1 RBC-3.93* Hgb-13.5* Hct-37.0*
MCV-94 MCH-34.3*# MCHC-36.4* RDW-14.8 Plt Ct-102*
[**2207-12-13**] 05:00PM BLOOD Neuts-77.3* Lymphs-14.7* Monos-6.3
Eos-0.4 Baso-1.3
[**2207-12-13**] 05:00PM BLOOD PT-133.2* PTT-60.0* INR(PT)-17.5*
[**2207-12-13**] 05:00PM BLOOD Glucose-126* UreaN-24* Creat-1.4* Na-134
K-2.4* Cl-85* HCO3-35* AnGap-16
[**2207-12-13**] 05:00PM BLOOD Lipase-26
[**2207-12-13**] 05:00PM BLOOD cTropnT-<0.01
[**2207-12-13**] 11:08PM BLOOD Calcium-7.8* Phos-1.9*# Mg-1.3*
[**2207-12-13**] 11:08PM BLOOD Phenyto-LESS THAN
[**2207-12-13**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2207-12-13**] 05:21PM BLOOD Glucose-120* Lactate-3.2* Na-135 K-2.4*
Cl-80* calHCO3-39*
[**2207-12-13**] 05:21PM BLOOD Hgb-14.0 calcHCT-42
PERTINENT LABS
[**2207-12-15**] 04:50PM BLOOD Fibrino-342
[**2207-12-16**] 05:08PM BLOOD Fibrino-390
[**2207-12-18**] 01:30AM BLOOD proBNP-[**Numeric Identifier 46533**]*
[**2207-12-28**] 09:08AM BLOOD CK-MB-2 cTropnT-<0.01
[**2207-12-28**] 04:26PM BLOOD cTropnT-0.02*
[**2207-12-16**] 02:51AM BLOOD VitB12-509 Folate-6.7
[**2207-12-31**] 07:00AM BLOOD Free T4-1.1
[**2207-12-31**] 07:00AM BLOOD TSH-2.4
[**2208-1-1**] 07:20AM BLOOD Digoxin-0.4*
[**2208-1-3**] 05:55AM BLOOD Digoxin-0.6*
DISCHARGE LABS
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2208-1-6**] 07:45 97 27* 0.8 145 3.6 109* 27 13
Hct: 27.3
Brief Hospital Course:
# Subdural Hematoma / SAH -
Pt was admitted to the ICU and monitored closely. He remained
neurologically intact but repeat CT of head [**12-14**] showed
expanding SDH. He demonstrated a significant coagulopathy on
admission with an INR of 17.5 and a PTT of 133.2 which was
reversed with oral/IV vitamin K and 2U FFP in the ER at [**Hospital1 18**].
Repeat INR/PTT revealed improvement, but he required another 2U
FPP. On [**12-14**] the patient experienced a LUE seizure and received
6 mg of Ativan which resulted in cessation of seizure activity.
Patient's mental status was declining along with neurologic exam
and repeat imaging documented progression of his right sided
SDH. He was taken to the OR on [**2207-12-15**] for right craniotomy and
subdural hematoma evacuation. Intra-operatively, the patient
received 2 more units of FFP and 1 pack of platelets. His INR
was 1.8 pre-op and platelets 81 pre-op. He tolerated the
procedure well. Repeat imaging 4 hours post-op showed
improvement of his right SDH with post-surgical changes and no
complications. He remained intubated post-op given his inability
to awaken, but he was breathing spontaneoulsy. On [**12-16**], his
neurologic exam demonstrated continued difficulty with arousal
and the patient followed minimal commands with slight response
to noxious stimuli. The patient was started on phenytoin, and
then was transitioned to Keppra, to be continued on discharge.
His Keppra will be readdressed by NSGY at f/u.
.
The patient was able to be transferred out of the ICU to the
step down unit on [**12-24**]. His neuro exam was followed by the
neurosurgery service, and NSG continued to follow the patient
after the pt was transferred to the Medical service for
management of his tachypnea and atrial fibrillation (see below).
.
# Respiratory Status/tachypnea/hypoxia: Directly after the
surgery, the pt was transferred to the ICU intubated. He was
able to weaned and extubated, however was reintubated on [**12-17**].
After he was weaned from the vent, he was extubated on [**2207-12-23**].
The medicine consult service was consulted for persistent
tachypnea and hypoxia. Chest x-rays demonstrated pulmonary
edema, and the patient was aggressively diuresed. An ECHO was
also done which showed an EF of 80% and right heart strain. Out
of concern for PE causing the tachypnea, a CTA was performed,
which ruled out PE. Prior to the CTA, an IVC filter was placed
(as suspicion was high and a CTA could not be done at the time
[**3-3**] high Cr). Also, the patient had a Cx that was positive for
Moraxella, and so was treated with abx (broad spectrum, then
narrowed to cefepime for 8 days). Upon transfer to the medical
floor, he was satting well on RA, but over time, required O2 and
further diuresis in the setting of volume overload. daily
weights and strict Is/Os were done and he was diuresed with a
goal of negative 1.5-2L per day. Also complicating the issue
was a-fib which developed in the setting of diuresis, then
contributing to volume backup into the lungs. (See below for
management of A-fib)
.
# Atrial Fibrillation - The patient is not an anticoagulation
candidate given SDH. For that reason, cardioversion wasn't an
option. The medicine consult service saw the patient while he
was on the NSG service, and the patient was titrated up on
metoprolol. After transfer to the medicine service, metoprolol
was further titrated up to 50 mg PO/NG QID, however could not be
continued given low BPs. The patient was subsequently dig
loaded and was ultimately maintained on 0.250 mg of dig PO/NG
daily. Out of concern for underlying reasons for the Afib/RVR,
the patient was treated for pain with
fentanyl/dilaudid/lidocaine patch, and labs were sent to r/o
other causes (pt has a normal TSH/Free T4). Also, the pt had
fevers upon transfer, however this subsided after the pt's
subclavian line was pulled, and so fevers/infx were no longer
thought to be the reason for his Afib-RVR. As the pt was volume
overloaded, it was thought that perhaps diuresis would help his
heart rate. Also, to ensure all causes of the tachycardia were
r/o, we consulted the Cardiology service, which agreed with our
work up, and recommended adding verapamil. This was done and
the patient's heart rate was controlled to the 80s-100s range.
EKGs were done over the course of his hospitalization which
verified Afib with RVR. The pt has pAF, as he also was noted to
be in sinus rhythm at times. When his PCP was [**Name (NI) 653**], it
seems he has been in pAF for 7 years now.
.
Of note, anticoagulation is definitely indicated in this
gentleman. Unfortunately, we are unable to do so currently
given the recent NSG intervention. It will be important that
this issue is followed up by Neurosurgery as well as his PCP so
that he can hopefully be restarted on coumadin after NSG deems
it safe to do so.
.
# LE weakness: The patient's LEs were noted to be markedly
weak, which was not consistent with the SDH. For that reason,
the pt underwent an MRI of the C, T, and L spine. There was
concern for hematoma or other compressive physiology on the
spinal cord. The MRI revealed no acute pathology or cord
compression to account for the weakness. A Neurology c/s was
called who felt that this was c/w neuropathy of critical
illness. Other recommendations were to send B12, folate, RPR,
TSH, which were done prior to his discharge. However, this will
need to be followed up as an outpatient/at rehab.
.
# Hypernatremia: Secondary to the patient's inability to take in
water from thirst given AMS. For that reason, free water
flushes were increased with tube feeds, and D5W was administered
prn hypernatremia. Care was taken to evaluate his Chem7 to
ensure correction was both effective, and not too rapid. Upon
discharge, his Na was 149, and per discussion with Nutrition,
would recommend increasing Free water flushes to 350 cc Q4h.
Recommends increasing further if hypernatremia persists. Also,
can give D5W slowly (500cc at 75cc/hr) if necessary.
.
# Fevers - The patient developed a fever during his
hospitalization. He had already been treated with 8 days of
cefepime for possible HAP. It may also be due to the SDH, and
also the pt was noted to have a CVL (left subclavian) at the
time. The subclavian was pulled on the floor, and the fevers
resolved. The pt was pan-cx'ed after the fever, and all cxs
were negative. He was given tylenol prn for symptomatic
treatment. Of note, the pt did have an indwelling foley,
however the UCx was negative. We continued to monitor with VS.
He had been afebrile for >1 week at the time of discharge. Of
note, the pt did have a short course of dicloxacillin as well
for possible cellulitis, however this was d/c'ed after we
concluded it was more likely gouty elbow vs bursitis instead of
cellulitis.
.
# Report of bloody stools/Anemia: The pt was guaiac'ed and was
negative, however was noted to have some blood on other
instances. This is most likely [**3-3**] hemorrhoidal bleeding given
that it is not intermixed with the stool but rather overlying
it. Prior to this, the pt had an active type and screen, and
his Hct was monitored daily to [**Hospital1 **]. Of note, earlier in the
hospitalization, the pt did receive transfusions for low Hct.
At time of d/c, his Hct was stable between 27 and 30.
.
# Hypertension - The pt's BP was normotensive to hypotensive
with the titration of nodal agents for his a-fib. We stopped
the pt's atenolol that he was on as an outpatient as his BP is
normotensive on the new regimen for A-fib.
.
# [**Name (NI) 20973**] The pt had an NG-tube after the procedure for tube
feeds and PO medications. He was actually advanced to a soft
diet with NSG, however with further altered mental status, he
was made NPO and all nutrition was done via NG tube. The pt
self-d/c'ed his NGT, and after an unsuccessful attempt to
replace it, he underwent a PEG placement after a family meeting
was called and it was deemed in line with his healthcare goals.
The general surgery service assisted us in the placement of his
PEG tube. His tube feeds were restarted after 24 hours without
incidence. (See below for management of erythema at site of PEG
tube per Surgery team)
.
# Gout vs Bursitis: L elbow eryhema and MTP erythema and
swelling felt to be most consistent with gout. In addition,
supportive evidence was the fact that this occurred in the
setting of diuresis. Patient initially placed on dicloxacillin,
but discontinued when felt to be less likely cellulitis. Patient
improved with indomethicin treatment, with plan to continue Rx
for 2 more days. If necessary, can use prednisone after
indomethacin if clinical improvement slows (eg 20 mg daily).
.
# Erythema and skin breakdown at PEG site: Evaluated by surgery,
feels no need to loosen stitches. Recommends dry dressings,
changes daily, clean regularly, keep dry.
.
# Hyperlipidemia - On statin
.
# HIT history - Avoided heparin products, not anticoagulation
candidate. To maintain pneumoboots and compression stockings for
prevention of DVT.
.
# Incidental findings on MRI: Patient noted to have infrarenal
abdominal aneurysm on routine imaging. Size warrants follow-up
with ultrasound or MRI per PCP. [**Name Initial (NameIs) **] T1 hyperintense image in
left gluteal muscle. On clinical exam no fluid filled area,
slight erythema along midline without inflammatory signs. Would
recommend to continue to monitor, no indication to US at this
time.
.
# Communication: With [**Name (NI) **], [**First Name3 (LF) **] ([**Telephone/Fax (1) 46534**])
.
# On discharge, please continue PT, OT, PEG tube feeds, wound
care, and please consider repeat speech and swallow evaluation.
F/U with NSGY and neurology.
Medications on Admission:
Medications prior to admission: Coumadin 2.5 mg PO daily, Folic
Acid, Colchicine, Allopurinol, Lisinopril, Plavix, Estrilyrica,
Prozac
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day): can hold if diarrhea.
2. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: please crush to administer via G-tube.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb treatment Inhalation Q6H (every 6 hours) as needed
for shortness of breath or wheezing.
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
6. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold if sbp<100 or hr<55.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to
right shoulder.
10. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. indomethacin 25 mg/5 mL Suspension Sig: Ten (10) mls PO TID
(3 times a day).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold if sbp<100.
14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours): hold if sbp<100 or hr<55.
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
18. Ondansetron 4 mg IV Q8H:PRN nausea
19. HYDROmorphone (Dilaudid) 0.125 mg IV Q4H:PRN pain
hold for sedation, RR < 10
20. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
21. ipratropium bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed for wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care-[**Hospital1 8**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Subdural Hematoma
SECONDARY DIAGNOSES
- Subarachnoid hemorrhage
- Intraparenchyma hemorrhage
- Atrial Fibrillation
- Hospital Acquired Pneumonia
- Polyneuropathy of Critical illness
- Gout arthropathy vs. Bursitis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization. You were admitted to [**Hospital1 18**] with a Subdural
Hematoma (bleed around the brain), and you were on the
Neurosurgery service after your surgical procedure to relieve
the blood/pressure in the skull. Afterward, you developed a
pneumonia which was treated with antibiotics, and you also had a
fast heart rate from "Atrial Fibrillation" which was treated
with medications to slow your heart down. You also weren't
moving your legs too much after the procedure, and so an MRI was
done which showed nothing that could account for your weakness.
We asked our Neurology colleagues who felt you had weakness
because of your critical illness. Also, you had a sore left
elbow which we feel is gout or bursitis, which we are treating
with medications (Indomethacin).
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
1) START taking KEPPRA 1000 mg G-tube twice daily
2) START taking VERAPAMIL 40 mg G-tube every 8 hours
3) START taking METOPROLOL 50 mg G tube every 6 hours
4) START taking INDOMETHACIN 50 mg G-tube three times a day for
2 more days
5) START using IPROTROPIUM NEBS every 6 hours as needed for
shortness of breath or wheezing
6) START using ALBUTEROL NEBS every 6 hours as needed for
shortness of breath or wheezing
7) CONTINUE taking THIAMINE 100 mg G-tube daily
8) CONTINUE taking FOLATE 1 mg G-tube daily
9) START taking DILAUDID 0.125 mg IV every 4 hrs as needed for
pain
10) START taking SENNA 1 tab G-tube twice daily as needed for
constipation
11) START taking DOCUSATE 100 mg G-tube twice daily (hold if
diarrhea)
12) CONTINUE taking LASIX 40 mg G-tube daily
13) CONTINUE taking MULTIVITAMIN 1 tab G-tube daily
14) START taking ZOFRAN 4 mg IV every 8 hours as needed for
nausea
15) START taking BISACODYL 10 mg daily as needed for
constipation
16) START using FENTANYL patch 12 mcg/hr every 72 hours
17) START using LIDODERM PATCH 5% daily to right shoulder (12
hrs on, 12 hrs off)
18) START using MICONAZOLE POWDER as needed for fungal rash
19) INCREASE the dose of DIGOXIN to 250 mcg G-tube daily
20) START taking POTASSIUM 20 Meq daily
DO NOT USE HEPARIN as you have a history of HIT. Please wear
compression stocking and/or pneumoboots to prevent blood clots.
STOP taking the following medications:
COUMADIN
COLCHICINE
ALLOPURINOL
LISINOPRIL
PLAVIX
ESTRILYRICA
PROZAC
ATENOLOL
PYRIDOXINE
General Instructions from the Neurosurgery Service:
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
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, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Department: NEUROSURGERY
When: THURSDAY [**2208-1-28**] at 10:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: THURSDAY [**2208-4-28**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2208-1-7**]
|
[
"263.9",
"293.0",
"401.9",
"V12.51",
"799.02",
"482.83",
"V58.61",
"342.00",
"357.5",
"357.82",
"432.1",
"788.20",
"276.3",
"455.6",
"272.4",
"274.01",
"575.11",
"V15.82",
"349.82",
"453.81",
"276.0",
"852.21",
"428.43",
"441.4",
"285.9",
"428.0",
"707.8",
"303.90",
"852.01",
"427.31",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"01.31",
"96.04",
"38.7",
"43.11",
"38.93",
"33.24",
"89.19",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
27647, 27744
|
15727, 25447
|
314, 435
|
28022, 28022
|
4966, 14229
|
31385, 32012
|
2084, 2168
|
25633, 27624
|
27765, 28001
|
25473, 25473
|
28157, 31362
|
2198, 2611
|
25505, 25610
|
238, 276
|
463, 1522
|
2903, 4947
|
14245, 15704
|
28037, 28133
|
1544, 1848
|
1864, 2068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,636
| 118,835
|
1991
|
Discharge summary
|
report
|
Admission Date: [**2106-9-28**] Discharge Date: [**2106-10-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
noninvasive ventilation
History of Present Illness:
86yo Chinese-speaking man with h/o dCHF admitted on [**9-28**] with 3d
L-sided hip pain and fever. Mild O2 requirement, 93% on 3L NC,
WBC 16.5, and CXR with old L base opacity, started on
ceftriaxone and azithromycin for empiric treatment of CAP. He
had a witnessed aspiration event with liquids at ~0230 on [**9-30**].
RR 28, desatted to 84-88% RA, 90-91% 4L NC. Noted to have
bibasilar crackles on exam. He was given 1 ipratropium neb
treatment with little response. He was also given 40mg IV Lasix,
to which he put out approximately 400cc of urine. Repeat CXR
showed possible new RML opacity. On conversation with son, the
patient denies chest pain and shortness of breath. He was
transferred to the MICU for worsening hypoxia and possible CO2
retention.
In ICU found to have aspiration pneumonia and treated with BiPAP
and antibiotics with some improvement. Sent to floor on [**10-7**]
Past Medical History:
1. CHF- last TTE in [**11-29**] with EF 50-55%, mild LVH, severely
dilated LV with intrinsically depressed systolic function [**1-28**]
valvular disease
2. Aortic Regurgitation- 3+ on last TTE
3. Mitral Regurgitation- [**12-28**]+ on last TTE
4. Hypertension
5. Gout- not on any meds
Social History:
Lives with wife and son (very involved in care). Able to perform
some ADLs; however, is functionally limited [**1-28**] to CHF. No
tobacco (quit 20 yrs ago). Denies EtOH and drug use.
Family History:
CAD, HTN
Physical Exam:
(in ICU)
Vitals- T 100.8, HR 96, BP 142/72, RR 28, 90-94% 50% FM, 84% RA
General- elderly, Chinese-speaking man, face mask pulled off,
mildly tachypneic
HEENT- sclerae anicteric, PERRL, dry MM,
Neck- no JVD
Pulm- + crackles 1/3 up b/l R>L, dullness to percussion on
CV- RRR, nl S1/S2, [**3-1**] HSM at apex--> axilla, [**2-1**] diastolic
murmur
Abd- + BS, distended but soft, nontender, no organomegaly
Extrem- no LE edema; L hip TTP, not cooperative with ROM exam
Neuro- lethargic but arousable, now oriented to person,
"hospital", and "[**2106-9-26**]"
Pertinent Results:
[**2106-9-28**] 02:00PM WBC-16.5*# RBC-4.91 HGB-15.3 HCT-44.7 MCV-91
MCH-31.2 MCHC-34.3 RDW-14.6
[**2106-9-28**] 02:00PM NEUTS-83.6* LYMPHS-7.1* MONOS-8.2 EOS-0.5
BASOS-0.5
[**2106-9-28**] 02:00PM PLT COUNT-285
[**2106-9-28**] 02:00PM PT-14.7* PTT-34.8 INR(PT)-1.3*
[**2106-9-28**] 02:00PM SED RATE-62*
[**2106-9-28**] 02:00PM GLUCOSE-128* UREA N-56* CREAT-1.6*
SODIUM-128* POTASSIUM-7.6* CHLORIDE-92* TOTAL CO2-26 ANION
GAP-18
[**2106-9-28**] 04:25PM CRP-214.4*
[**2106-9-28**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
.
MICROBIOLOGY
C DIFF NEGATIVE X 3
BLOOD CX [**10-8**]: pending, 10/4,5,6: no growth
URINE LEGIONELLA ANTIGEN: negative
SPUTUM CX: OP FLORA
.
EKG
Sinus rhythm. A-V conduction delay. Left atrial enlargement.
Left ventricular hypertrophy. Compared to the previous tracing
of [**2102-6-30**] the rate has slowed and ST-T wave abnormalities
previously recorded in leads I and aVL are less prominent.
Otherwise, no diagnostic interim change.
.
STUDY: CT scan of the pelvis without intravenous contrast.
[**2106-9-28**].
1. Degenerative changes of both hip joints without signs for
acute bony injury. No fractures or dislocations identified.
2. Degenerative changes seen of the lower lumbar spine.
.
L-spine
IMPRESSION:
1. No fracture or listhesis.
2. Multilevel spondylosis.
3. Transitional vertebral body.
.
LEFT LOWER EXTREMITY ULTRASOUND:
1. No evidence of left lower extremity DVT.
2. Small left suprapatellar knee effusion.
.
LEFT HIP ULTRASOUND: No evidence of fluid collection adjacent to
the left femoral head and neck.
.
VIDEO SWALLOW EVAL:
FINDINGS: Video oropharyngeal swallow study was performed in
conjunction with the speech and swallow service. Varying
consistencies of barium liquids and barium-coated solids were
administered under fluoroscopic guidance. The patient
demonstrated premature spillover and poor valve closure. There
was marked penetration of barium liquids. There was also a
single episode of witnessed aspiration of thin barium liquids
which was not recognized by the patient. A relatively weak cued
cough was then observed. There was also significant retention of
liquids in the valleculae. There findings demonstrated minimal
improvement with [**Known lastname **] tuck maneuver and clearing maneuvers.
IMPRESSION: Significant penetration of barium liquids with
episode of silent aspiration.
.
ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated. Overall
left ventricular systolic function is normal (LVEF 60%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated. The ascending aorta is moderately dilated. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened. The study is inadequate to
exclude significant aortic valve stenosis. Moderate to severe
(3+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are moderately thickened. The mitral valve
shows characteristic rheumatic deformity. There is no mitral
valve prolapse. A mass or vegetation on the mitral valve cannot
be excluded. Mild to moderate ([**12-28**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
supporting structures of the tricuspid valve are
thickened/fibrotic. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
# Aspiration pneumonia:
Patient presented with left hip pain but was found to have a 3
liter oxygen requirement on admission. On hospital day #1,
patient had a witnessed aspiration with desaturation. He was
confused and pulling off his mask. He required transfer to ICU
for continued care. He had been started on
ceftriaxone/azithromycin on admission for community acquired
pneumonia. This was changed to ceftriaxone/flagyl for
aspiration pneumonia in the unit and he has completed a 10 day
course for treatment. He did not require intubation. Bedside
evaluation showed overt aspiration and video evaluation reveals
silent aspiration so patient is now on aspiration precautions
and modified diet. Currently he is [**Age over 90 **]% on 2 L supplemental
oxygen
.
# Persistent hypoxia:
Likely due to aspiration vs end stage CHF. O2 sats are
improving without anticoagulation, thus low suspicion for PE.
.
# Atrial fibrillation with rapid ventricular response:
Onset in unit. Back in sinus. Patient is currently on a beta
blocker for rate control. Consider starting coumadin as an
outpatient for stroke prevention if recurs.
.
# Left hip pain:
Pain in left hip on admission with negative work-up (CT and
ultrasound). Ortho was consulted. Pain resolved without
intervention.
.
# Possible neuromuscular vs CNS disorder:
Given aspiration, low NIF, and ptosis, neuro was consulted for
possible neuromuscular disease. Recommendation for MRI and if
normal, EMG. However, given patient's steady improvement in
house and complicated course requiring readmission to the ICU,
the family wishes to defer this work-up at this time and to get
the patient to rehab. PCP involved and had discussion with
family re: goals of care given severe AI. Of note,
acetylcholine receptor antibody high normal. Neuro recommended
avoiding aminoglycosides and quinolones. Family is not currently
interested in hospice services.
.
# CHF:
Patient has end stage heart failure and is followed by Dr.
[**Last Name (STitle) 120**]. During his admission, he had an episode of aspiration
vs possibly flash pulmonary edema. He was diuresed in the unit
and is back on an ACEI. His CCB was changed to a BB which he
continues on currently. He received lasix for diuresis but is
now back on his home diuretic regimen (metolazone 3x per week).
.
# Confusion: Most likely [**1-28**] CO2 retention. Resolved.
.
# Code status: FULL CODE, confirmed with sons
.
# Communication: son, [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 10937**], 2 other sons also
involved in care- [**Name (NI) **] ([**Telephone/Fax (1) 10938**], Ray ([**Telephone/Fax (1) 10939**]
.
# Dispo: patient discharged to [**Hospital **] Health Center
Medications on Admission:
Nifedipine 30mg PO daily
Lisinopril 40mg PO daily
Metolazone 2.5mg PO 3x/week
ASA 81mg PO
Discharge Medications:
1. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO qMon, Wed,
Fri.
2. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
7. Ipratropium Bromide 0.02 % Solution Sig: Two (2) neb
Inhalation every six (6) hours.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: max = 2 grams per day.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
injection Injection four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
aspiration pneumonia
congestive heart failure
acute renal failure
left hip pain
transient atrial fibrillation with rapid ventricular response
history of aortic regurgitation
Discharge Condition:
good: stable on 2 L oxygen, afebrile
Discharge Instructions:
Please monitor for temperature > 101, diarrhea, increasing O2
requirement, or other concerning symptoms.
Please monitor weight qd and call Dr. [**Last Name (STitle) 724**] for additional
diuretic prescription if weight increases > 3 pounds.
Followup Instructions:
Please call to schedule follow-up with Dr. [**Last Name (STitle) **] within 1
week. Phone: [**Telephone/Fax (1) 608**].
Please follow-up with Dr. [**Last Name (STitle) 4229**] of urology, as previously
scheduled.
Please follow-up with Dr. [**Last Name (STitle) 120**] on [**2106-10-27**] at 3:30
PM. Your son MUST accompany you to this appointment for
interpretation as an interpreter could not be arranged for such
a timely appointment. Phone: ([**Telephone/Fax (1) 10085**]
|
[
"288.60",
"719.45",
"293.0",
"401.9",
"427.31",
"428.0",
"428.30",
"274.9",
"518.84",
"507.0",
"424.1",
"584.9",
"458.8",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10088, 10158
|
6210, 8916
|
277, 303
|
10377, 10416
|
2351, 6187
|
10706, 11189
|
1749, 1759
|
9056, 10065
|
10179, 10356
|
8942, 9033
|
10440, 10683
|
1774, 2332
|
224, 239
|
331, 1225
|
1247, 1532
|
1548, 1733
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,336
| 147,125
|
31781
|
Discharge summary
|
report
|
Admission Date: [**2149-1-3**] Discharge Date: [**2149-1-9**]
Date of Birth: [**2071-7-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Dilaudid
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
T2 pathological collapse
Major Surgical or Invasive Procedure:
C7 to T4 posterior spinal fusion and thoracoscopic biopsy of the
lung lesion
History of Present Illness:
He has known T2
pathologic fracture just picked up on CT. He also has lesions
in
his sternum as well as his lung. He has had radical neck
dissection on the right side. This patient has been discussed
with [**Doctor First Name **] [**Location (un) **] as well as Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] in person.
He has multiple medical issues including a defibrillator. He
has
a low ejection fraction. He is on multiple medications
including
aspirin 325 mg. His history as well as his medications were
reviewed.
In terms of his physical examination, he is alert and oriented.
Affect is within normal limits. His gait is within normal
limits. There is no evidence of myelopathy or hyperreflexia or
balance disturbance. He has minimal to no tenderness to
palpation, but does feel a difference in palpating his upper
thoracic spine versus his lumbar, lower thoracic spine. He
definitely has referred shoulder pain either from this sternal
lesions or the lung lesions.
Imaging: A CT was performed today, which shows a pathologic
fracture through the T2 vertebral body. This involves the
posterior wall.
At this point, given the nature of his fracture and a lytic
lesion, I would recommend stabilization. This involves a
minimum
of C7-T4 posterior spinal fusion with perhaps some isolated
decompression at T2. This can be combined in talking with Dr.
[**Last Name (STitle) 11482**] [**Name (STitle) **] with his biopsy of his lung. We try to get
this done on the same day.
In terms of his anticoagulation, we spoke with his cardiologist
so that he can be off his anticoagulation for seven days. This
will come off five days preoperatively and two days
postoperatively. He will be in the hospital for approximately
four days. His wife was present with him today. We will
schedule him hopefully on [**1-3**].
He understands the risks of surgical intervention and not
operating. There is both the risk of paralysis with leaving him
alone as well as operative procedure. The risks are significant
given his medical history. However, this will allow him to move
forward with his care. An e-mail was also sent to his
physicians
outlining the plan.
Past Medical History:
Stage III melanoma, right neck, s/p excision with sentinal LN
biopsy (positive [**12-2**]) [**2145-12-7**], Right modified neck dissection
[**2145-12-16**].
CAD
ICD [**2142**]-EF 35-40% (per patient on most recent echo last week)
Myocardial infarctions- [**2106**]'s and [**2128**].
Ischemic Cardiomyopathy
Dyslipidemia
Hypertension
R knee surgery
R rotator cuff repair [**5-/2137**]
R Ulnar nerve release [**6-/2138**]
R cataract [**6-/2143**] L [**5-/2144**]
Percutaneous coronary intervention at [**Hospital3 **] Hospital, in [**7-7**]
anatomy as follows: Coronary arteriography revealed an occluded
circumflex artery but no other significant obstructive coronary
artery disease. Patient had an MI in [**2126**] treated with lytics.
ICD implantation [**7-/2143**] for primary prevention. (St. [**Male First Name (un) 923**] model
7001 active fixation ICD electrode and a St. [**Male First Name (un) 923**] V 193 single
chamber ICD pulse generator.
ICD lead revision [**2144-7-6**] repetitive ICD firing and probable
insulation breech on ICD
ICD lead revision [**8-/2144**]: inappropriate ICD firing suggestive
of
lead dislodgement. On [**2144-8-7**] the passive fixation lead was
removed and a new active fixation lead placed.
Infected ICD lead extraction and explantation [**8-/2144**]
Social History:
Lives in [**Hospital3 635**] with his wife. Retired. Nonsmoker, drinks 2
EtOH daily.
Family History:
He has a half-brother who has melanoma in situ and a father who
had some form of skin cancer. He has a brother who had basal
cell cancer on his nose. There are no other cancers in the
family. There is no family history of sudden
death. His father had an MI while in his 50s. He is retired
from the phone company and has about 2 drinks per night.
Physical Exam:
see HPi
Pertinent Results:
[**2149-1-6**] 05:50AM BLOOD Hct-33.8*
[**2149-1-5**] 04:50AM BLOOD WBC-11.3* RBC-3.56* Hgb-11.7* Hct-34.3*
MCV-97 MCH-32.9* MCHC-34.1 RDW-14.0 Plt Ct-151
[**2149-1-3**] 02:50PM BLOOD WBC-6.5 RBC-3.32* Hgb-10.9* Hct-32.3*
MCV-97 MCH-32.9* MCHC-33.8 RDW-14.1 Plt Ct-178
[**2149-1-5**] 04:50AM BLOOD Plt Ct-151
[**2149-1-6**] 05:50AM BLOOD Glucose-120* UreaN-19 Creat-1.0 Na-138
K-4.4 Cl-103 HCO3-29 AnGap-10
[**2149-1-5**] 04:50AM BLOOD Glucose-117* UreaN-17 Creat-1.0 Na-135
K-4.4 Cl-99 HCO3-27 AnGap-13
[**2149-1-4**] 02:13AM BLOOD Glucose-102* UreaN-19 Creat-1.2 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2149-1-3**] 02:50PM BLOOD Glucose-113* UreaN-23* Creat-1.3* Na-141
K-4.3 Cl-106 HCO3-22 AnGap-17
[**2149-1-5**] 04:50AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.6
[**2149-1-4**] 02:13AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.6
[**2149-1-3**] 02:58PM BLOOD Type-ART pO2-128* pCO2-42 pH-7.35
calTCO2-24 Base XS--2
[**2149-1-3**] 12:06PM BLOOD Type-ART Rates-/10 Tidal V-600 PEEP-3
FiO2-39 pO2-182* pCO2-34* pH-7.41 calTCO2-22 Base XS--1
Intubat-INTUBATED Vent-CONTROLLED
[**2149-1-3**] 11:18AM BLOOD Type-ART pO2-142* pCO2-35 pH-7.38
calTCO2-22 Base XS--3 Intubat-INTUBATED
[**2149-1-3**] 02:58PM BLOOD Glucose-105 Lactate-1.0 Na-138 K-4.1
Cl-106
[**2149-1-3**] 12:06PM BLOOD Glucose-126* Lactate-1.3 Na-137 K-4.2
Cl-105
[**2149-1-3**] 11:18AM BLOOD Glucose-145* Lactate-1.5 Na-138 K-4.2
Cl-104
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. 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
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Physical therapy was consulted for
mobilization OOB to ambulate.
[**2149-1-3**]
Pt transferred to TICU for post op observation. and extubated
after 24 hours
[**2149-1-4**]
Chest tube discontinued by Thoracic service with normal post
removal CXR
[**2149-1-5**]
HVAC Drain and Foley d/c
[**2149-1-7**] Patient had two episodes of vomiting with abdominal
distention. KUB showed few dilated bowel loops suggestive of
paralytic ileus
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:
Omez, 40', Benazepril 40', Exetimibe 10', Fenofibrate 54',
Metformin 500'', Niacin 1000'', Tamsulosin 0.4', Aspirin 325',
Carvedilol 12.5''
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at
bedtime)).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. lactobacillus acidophilus 100 million cell Capsule Sig: One
(1) Capsule PO TID (3 times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. niacin 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. benazepril 10 mg Tablet Sig: Four (4) Tablet PO once a day
().
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
15. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO
once a day ().
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **]
Discharge Diagnosis:
Metastatic melanoma T2 collapse and Lung lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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:
o 2-3 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.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Physical Therapy:
see discharge instructions
Treatments Frequency:
see discharge instructions
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3736**]
Date/Time:[**2149-1-17**] 1:40
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2149-1-14**] 9:00
|
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icd9cm
|
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[
[]
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[
"77.49",
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,702
| 171,625
|
49780
|
Discharge summary
|
report
|
Admission Date: [**2154-8-23**] Discharge Date: [**2154-9-1**]
Date of Birth: [**2079-7-7**] Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
Fever, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 75 year old male with a history of pancreatic
cancer s/p ressection in [**3-19**] with splenectomy, MDS, CHF and
hypertension who presents with one week of lethargy and one day
of shortness of breath and fever. The patient has had a number
of recent admissions for pneumonia. He was most recently
admitted to [**Hospital1 18**] [**Location (un) 620**] from [**2154-7-12**] to [**2154-7-16**] when he
presented with fevers, bilateral infiltrates and hypoxemia. At
that time it was thought that he most like had a pneumonia
related to his MDS but he was also thought to have an element of
congestive heart failure and his hypoxemia resolved quickly with
diuresis. Upon discharge his final diagnosis continued to be
unclear.
.
He was discharged and was feeling significantly better. He and
his wife took a trip to [**Name (NI) **] this week. His wife reports that
approximately ten days ago she developed a viral URI with cough
and congestsion and that her husband caught this virus as well.
Their acute symptoms resolved but the patient continued to have
cough. Starting a week prior to this admission he reports
starting to feel more lethargic although even as late as one day
prior to admission he was able to walk [**4-18**] of a mile without
getting short of breath (although he was fatigued). He did not
sleep well the night prior to admission but was not SOB. On the
day of admission he woke up and did not feel particularly
poorly. At 10 AM he began to feel nauseus and vomited x 1. At
11 AM he began to feel somewhat short of breath and his wife
noticed that he felt warm. He also noted that his cough was
more productive than previously of clear sputum. He took his
temperature and found that it was 102 degrees. He called his
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who advised him to come here.
.
In the ER his vitals were T 100.8, BP 180/64, HR 86, RR 17, O2
85% on RA -> 99% NRB. Lab values were remarkable for a WBC of
54K with 12% bands. BNP was 17K (prior 8K-25K), Hct 23(BL
26-30). CXR and CTA show RLL PNA and mild pulmonary edema.
Guaiac negative. He received 1 gram of ceftriaxone and 500 mg of
azithromycin as well as 40 mg of IV Lasix. He was admitted to
the MICU.
.
On arrival to the MICU the patient was found to be breathing
comfortably on NRB without respiratory distress or accessory
muscle use. He was continued on ceftriaxone and azithromycin
and received one dose of vancomycin. He received albuterol and
atrovent nebs. His metoprolol was decreased and his lisinopril
was held given slight elevation in his serum creatinine at 1.1
from baseline 0.6 to 1.0. His hematocrit was noted to fall from
23.1 to 20.4 and he received one unit PRBCs. His oxygen slowly
weaned to nasal cannula and he was transferred to the floor.
.
On review of sytems he now denies headache, neck stiffness,
nausea, vomiting, chest pain, says his SOB is much improved,
abdominal pain, diarrhea, constipation, dysuria, hematuria,
melena, hematochezia, hematemasis, easy bruising, calf pain or
swelling. He has had worsening lower extremity edema over the
past month but this is actually improved at this time. He
denies any changes in his diet.
.
Past Medical History:
PMHx:
Incisional Hernia
CHF
Pancreatic cancer - Adenocarcinoma, grade I, T3, [**3-12**] LN. s/p
subtotal pancreatectomy [**2-19**], Xeloda, Cyberknife, XRT in [**6-19**].
Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years
ago, ringed sideroblastic anemia diagnosed via BM biopsy.
Multiple GI bleeds [**2-15**] angioectasias from XRT.
Anemia
Squamous cell carcinoma in-situ
T2DM
BPH
Gout
Scarlet fever as a child
Diverticulosis
PSH: Lami '[**27**], TURP, knee '[**99**], Distal Panc/Splenectomy
Social History:
The patient was married, had three children and quit tobacco in
[**2122**]. Prior to that, he had a 30 pack year history. He used
alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived
in [**Location (un) 745**].
Family History:
His sister died of congestive heart failure.
Physical Exam:
Admission Physical Exam:
PE: T: 98.1 BP: 120/70 HR: 66 RR: 18 O2 94% 6L NC
Gen: Pleasant, comfortable, speaking in full sentences
HEENT: No conjunctival pallor. PERRL, EOMI, MMM. OP clear.
NECK: Supple, No LAD, JVP ~ 12 cm H2O.
CV: RRR. nl S1, S2. II/VI holosys murmur heard best at apex
LUNGS: course breath sounds throughout. crackles [**1-16**] way up
bilaterally, no wheezes or ronchi
ABD: NABS. Soft, NT, ND
EXT: WWP, Trace LE edema. 2+ DP pulses BL
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all
extremities
Pertinent Results:
Admission Laboratories [**2154-8-23**]:
Chemistries:
[**2154-8-23**] 03:35PM BLOOD Glucose-92 UreaN-28* Creat-1.1 Na-140
K-4.6 Cl-102 HCO3-24 AnGap-19
[**2154-8-23**] 03:35PM BLOOD ALT-72* AST-90* LD(LDH)-[**2117**]* CK(CPK)-86
AlkPhos-556* Amylase-17 TotBili-1.7*
[**2154-8-23**] 03:35PM BLOOD Albumin-4.3 Calcium-9.5 Phos-2.7 Mg-1.9
[**2154-8-23**] 03:50PM BLOOD Lactate-2.5*
[**2154-8-23**] 03:35PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
.
Hematology:
[**2154-8-23**] 05:05PM BLOOD WBC-54.3*# RBC-2.13* Hgb-7.6* Hct-23.1*
MCV-109* MCH-35.8* MCHC-33.0 RDW-31.1* Plt Ct-814*
[**2154-8-23**] 05:05PM BLOOD Neuts-66 Bands-12* Lymphs-4* Monos-0
Eos-5* Baso-0 Atyps-0 Metas-11* Myelos-2*
[**2154-8-23**] 03:35PM BLOOD PT-16.1* PTT-34.3 INR(PT)-1.5*
[**2154-8-24**] 12:42AM BLOOD Type-ART pO2-88 pCO2-41 pH-7.46*
calTCO2-30 Base XS-4
.
Urinalysis [**2154-8-23**]: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-[**3-18**]* WBC-0-2
Bacteri-FEW Yeast-NONE Epi-0-2
.
Urine electrolytes: UreaN-337 Creat-27 Na-89
.
Discharge Laboratories [**2154-9-1**]:
Hematology:
CBC: WBC-39.9* RBC-2.59* Hgb-8.9* Hct-26.7* MCV-103* MCH-34.4*
MCHC-33.4 RDW-28.1* Plt Ct-686*
Differential: Neuts-68 Bands-6 Lymphs-14 Monos-0 Eos-3 Baso-0
Atyps-0 Metas-6* Myelos-3 NRBC-84*
Coags: PT-14.4* PTT-33.5 INR(PT)-1.3*
.
Chemistries:
Glucose-129* UreaN-24* Creat-0.9 Na-138 K-5.4* Cl-98 HCO3-31
AnGap-14
Calcium-8.5 Phos-2.4* Mg-2.5
.
Other Laboratories:
[**2154-8-28**] 06:30AM BLOOD VitB12-[**2105**]* Folate-8.6
[**2154-8-28**] 06:30AM BLOOD TSH-6.6*
[**2154-9-1**] 07:45AM BLOOD Free T4-1.1
.
Microbiology
[**2154-8-27**]: urine culture negative
[**2154-8-24**]: urine culture with ~1000 gram positive bacteria
[**2154-8-23**] and [**2154-8-26**] - blood cultures negative
[**2155-8-25**]: legionalla antigen negative
.
Imaging
CXR PA and Lateral [**2154-8-30**]: MPRESSION: Improving congestive
heart failure and right basilar pneumonia.
.
Portable CXR [**2155-8-25**]:
Consolidation in the right lower lobe has progressed since
[**8-23**] consistent with worsening pneumonia. Mild pulmonary
edema and mild
cardiomegaly stable. No appreciable pleural effusion. No
pneumothorax.
.
PA and Lateral CXR [**2154-8-23**]:
1. New airspace process in the left lower lobe, posteriorly; in
this clinical setting, early pneumonic consolidation is a
consideration.
2. Significant improvement in findings of CHF since the [**2-20**]
study, with residual interstitial edema and no significant
effusion.
.
CTA [**2154-8-23**]:
1. right lower lobe pneumonia
2. mild pulmonary edema
3. pathologic mediastinal adenopathy, unchanged
.
EKG [**2154-8-23**]: NSR @ 75. LAD. LAFB. LVH. Early RW progression.
Nonspecific ST-TW changes. Unchanged from prior.
Brief Hospital Course:
A/P: 75M w/hx of pancreatic CA s/p resection and splenectomy,
MDS, CHF, and htn presents with fever, productive cough and SOB.
Physical exam significant for decr breath sounds on R, crackles
(R>L), and dullness at right base. CT/CXR showed evidence of
RLL consolidation. In this clinical setting, most likely
diagnosis is a community-acquired pneumonia.
.
# Community-acquired pneumonia: The patient presented with
fevers, cough and shortness of breath. In the emergency room he
was found to be desaturating to the mid 80s on room air and 93%
on 5L nasal cannula. He was found to have a RLL pneumonia seen
in CXR and Chest CT scan. The patient has chronically elevated
WBC secondary to MDS with acute rise on this admission to 56k
which is consistent with acute infection although it is
difficult to assess given his chronic MDS. On exam the patient
was noted to have significant crackles in his lung fields
bilaterally, an elevate JVP and mild lower extremity edema and
it was thought that congestive heart failure was likely
contributing to his oxygen requirement. He was originally
admitted to the MICU for management of his hypoxia but at no
time did he require mechanical ventillation. He was started on
ceftriaxone and azitromycin received one dose of vancomycin
while in the MICU. He was transferred to the floor on hospital
day two. On the floor he was continued on azithromycin and
ceftriaxone with slow improvement in his symptoms. He was
slowly weaned off of his oxygen. He was also aggressively
diuresed with IV lasix with good effect. The patient's symptoms
of cough and SOB gradually resolved over hospital course with O2
sat of 93% on 5L improving to 95 %RA at rest and with
ambulation. He underwent repeat CXR on [**8-30**] which was notable
for an improved right basilar pneumonia. He completed a 7 day
course of azithromycin. He received 8 days of ceftriaxone and
was discharged with plans for two days of cefpodoxime to
complete a ten day course. He will follow up with his primary
care physician in one week.
.
# Congestive Heart Failure: The patient has a history of
diastolic heart failure with preserved biventricular function
from last echo in [**Month (only) 956**]. He also has a history of elevated
BNPs from 8000-[**Numeric Identifier 16351**]. On admission his BNP was [**Numeric Identifier 6085**]. He has
only trace edema on CT and CXR but during his last
hospitalization he presented very similarly and responded well
to diuresis. Exam notable throughout hospitalization for b/l
inspiratory crackles, midly elevated JVP and trace pedal edema.
He was diuresed aggressively with IV lasix and he responded
well. Over course, patient's symptom of SOB improved as did
his respiratory exam. Repeat CXR on [**8-30**] showed decreased
pulmonary edema. He was continued on his home dose of
metoprolol. His lisinopril was increased from 30 mg to 40 mg
daily. He was discharged on lasix 40 mg [**Hospital1 **] with plans to follow
up with his cardioogist in three days post discharge. His
weight on discharge was noted to be 155.6 lbs.
.
# Fever: On admission the patient was noted to be febrile to 102
degrees. Given the finding of infiltrate on CT and CXR this was
thought to be the most likely source. He had two sets of
negative blood cultures in the emergency room. Urine culture
grew ~1000 gram positive organisms but repeat culture later in
this hospitalization was negative. Patient did have a
significant leukocytosis but this is consistent with his past
values in the setting of his myelodysplastic syndrome. Upon
discharge he had been afebrile for greater than 72 hours.
.
# Hypertension: Patient was noted to have elevated blood
pressures to the 150s to 180s on the floor. He was continued on
his home dose of metoproll and his lisinopril was increased from
30 mg to 40 mg daily with a decrease in his systolic blood
pressures to the 140s. He will follow up with his primary
cardiologist soon after discharge to readdress this issue.
.
# Myelodysplastic Syndrome: The patient was diagnosed 15 yrs
ago. According to report received from PCP to [**Name9 (PRE) **], patient has
recently been transfusion dependent. His baseline hematocrit is
26-30. On admission his hematocrit was noted to be 23. He was
guaiac negative in the ER. He was transfused 3 units of PRBCs
over the course of this hospitalization. On discharge his
hematocrit was 26.7. The patient has a chronically elevated
WBC. This has been noted in the past by the patien's primary
oncologists. Per his outpatient PCP the patient has no evidence
of AML conversion at this time. He was continued on his home
dose of hydroxyurea during this hospitalization and will follow
up with his primary care physician.
.
# Anemia: The patient has a chronically low hematocrit which
ranges from 26-30. As described above he received three units
of PRBCs during this hospitalization. B12, folate were checked
during this admission and were normal. He will continue weekly
aranesp injections as an outpatient. On discharge his
hematocrit was 26.7.
.
# pancreatic cancer: The patient is s/p subtotal pancreatectomy,
Xeloda, XRT, and Cyberknife. This issue was stable throughout
this hospitalization.
.
# Type II diabetes: As an outpatient the patient reports that he
takes levemir 9 units QHS with glipizide 10 mg [**Hospital1 **] and metformin
500 mg [**Hospital1 **]. His metformin was held on admission given the need
for CT imaging. On a regimen of lantus 9 units QHS and
glipizide 10 mg [**Hospital1 **] the patient was noted to have significant AM
hypoglycemia with AM blood sugars on chemistries in the 30s and
40s. His glipizide was decreased to 10 mg in the AM and 5 mg in
the PM. On discharge he was restarted on his levemir and
metformin. The patient will check his AM blood sugars for the
week after this hospitalization and bring these numbers with him
when he follows up with his primary care physician.
.
# Subclinical Hypothyroidism: During this admission the patinet
was noted to have an elevated TSH at 6.6 and a normal T4 at 1.1.
He was asymptomatic. He should have repeat TFTs as an
outpatient once he has recovered from his acute illness.
.
# Hyperkalemia: On the day of discharge the patient was noted to
have a potassium of 5.4. During this admission his potassium
was noted to be on the upper end of normal throughout. He was
advised to follow a low potassium diet and was given literature
regarding this. He should have a repeat potassium check as an
outpatient when he follows up with his primary care physician.
.
# CODE: FULL
.
Medications on Admission:
Levemir 9 units qhs
metoprolol 125 mg TID
lisinopril 30 mg Qday
Allopurinol 300 mg Qday
Protonix 40 mg [**Hospital1 **]
lasix 20 mg Qday
sucralfate 1 gram QID
hydroxyurea 500 mg Qday
glipizide 10 mg [**Hospital1 **]
pyridoxine 100 mg TID
Procrit Qwk
Ambien qhs
Discharge Medications:
1. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
5. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO QAM: Take one
in the morning.
10. Glipizide 10 mg Tablet Sig: 0.5 Tablet PO QPM: Take one half
tablet at night.
11. Levemir 100 unit/mL Solution Sig: Nine (9) units
Subcutaneous at bedtime.
12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Codeine-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**5-23**] mL PO
every six (6) hours as needed for cough.
Disp:*200 mL * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia
Congestive Heart Failure
.
Secondary:
Hypertension
Diabetes
Myleodysplastic Syndrome
Pancreatic Cancer
Discharge Condition:
Stable
Discharge Instructions:
You were seen and evaluated for your difficulty breathing. You
were found to have a pneumonia and evidence of congestive heart
failure. You were treated with antibiotics and diuretics.
.
Please take all your medications as prescribed. The following
changes were made to your medication regimen:
1. You will need to take cefpodoxime 200 mg two times a day for
two more days
2. Your glipizide was decreased from 10 mg twice a day to 10 mg
in the morning and 5 mg in the evening
3. Your lisinopril was increased from 30 mg daily to 40 mg daily
4. Your lasix was increased from 20 mg once a day to 40 mg twice
a day
5. You can take cough syrup with codeine every six hours as
needed for your cough
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Your potassium was noted to be elevated during this admission.
We have provided you with a list of high potassium containing
foods. Please try to limit your potassium intake as much as
possible.
.
Your blood sugars were noted to be low in the morning. Please
check your blood sugars every morning this week and let your
primary care physician know these numbers when you follow up
with him.
.
Please follow up with your primary care physician within one
week of discharge.
.
Please follow up with your cardiologist Dr. [**Last Name (STitle) **] within three
days.
.
If you experience any fevers, chest pain, worsening shortness of
breath, lightheadedness, dizziness, inability to eat, numbness
or weakness, very high or very low blood sugars, or any other
concerning symptoms please seek immediate medical attention.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 2539**] within one week of discharge. His office phone number is
[**Telephone/Fax (1) 49151**].
.
Please follow up with your cardiologist Dr. [**Last Name (STitle) **] within three
days of discharge. His office phone numbers are [**Telephone/Fax (1) 127**] in
[**Location (un) 86**] and [**Telephone/Fax (1) 4105**] in [**Location (un) 620**].
|
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"285.22",
"428.33",
"428.0",
"250.00",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
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15945, 15951
|
7794, 14392
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276, 282
|
16117, 16126
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4932, 7771
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17795, 18289
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226, 238
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310, 3520
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3542, 4049
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4065, 4305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
439
| 137,678
|
8079
|
Discharge summary
|
report
|
Admission Date: [**2104-10-23**] Discharge Date: [**2104-11-7**]
Service: Medicine
CHIEF COMPLAINT: Status post fall.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female, nursing home resident status post a fall on [**10-23**]
with left hip and left knee pain. The patient has had a left
hip replacement and revision in the past, is now here with a
left acetabular shell loosening.
PAST MEDICAL HISTORY: Coronary artery disease, status post
CABG in [**2097**], status post aortic valve replacement in [**2097**],
status post TAH BSO, history of DVT, history of increased INR
on Coumadin with a history of a left leg hematoma, history of
lymph node cancer in the abdomen, diverticulitis, falls,
possible hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS: Upon presentation to hospital, Coumadin,
Lopressor, Lasix, Zestril, Aleve.
SOCIAL HISTORY: The patient supposedly lives at home with
home health aide and uses a motorized wheelchair. The
patient has a 10 pack year smoking history and quit 40 years
ago.
PHYSICAL EXAMINATION: Upon presentation to the hospital,
patient's temperature was 97.9, blood pressure 108/96, pulse
64, respirations 16, 98% on room air. Patient with no
apparent distress. Pupils were equal, round and reactive to
light. Neck was supple. Lungs clear to auscultation
bilaterally. Tenderness over left knee, not thigh. Hip,
range of motion was limited, lower left extremity with
shortening, sternally rotated. Patient's dorsalis pedis and
posterior tibial pulses were not palpable. Needed to be
evaluated by doppler. X-ray upon presentation showed a loose
acetabular shell with a question of a loose femoral head.
The patient was on anticoagulation due to her aortic valve
replacement, thus was waiting for her coagulation factors to
be more optimal for operative management of her hip. During
the waiting period for this, patient suddenly started
complaining of right lower quadrant abdominal pain with
slight nausea but no vomiting. The patient also began to
have some guaiac positive diarrhea. On exam the patient had
newly noted right lower quadrant mass 6 by 6 cm. The patient
was also diaphoretic and cool. Patient's temperature dropped
to 94, Lactate was 17.5, hematocrit 20 which dropped earlier
in the day on [**10-27**] from 29.3. The patient was transferred
to the MICU for evaluation for decreased hematocrit,
decreased blood pressure. The patient at that point in time
also had an NG tube that elicited approximately 200 cc of
coffee ground emesis that cleared with 200 cc of saline. It
was found upon further evaluation that patient was having a
brisk lumbar artery bleed secondary to her fall. She is
currently status post an embolization by interventional
radiology for the fall. Patient remained in the MICU from
[**10-27**] to [**2104-11-1**] and then was transferred to the medicine
floor.
LABORATORY DATA: Upon presentation to the hospital, white
count was 13, hematocrit 29, INR 4.3, PTT 150, ESR 77, CRP
2.1. Urinalysis was negative for nitrites, [**5-11**] white blood
cells per high power field. Chem 7, sodium 136, potassium
4.9, chloride 100, CO2 24, creatinine 2.0, glucose 230.
HOSPITAL COURSE:
1. Ortho: The patient is status post fall on [**2104-10-23**] with
an acetabular shell slippage and a question of a fem
loosening. This fall was complicated by a retroperitoneal
bleed from lumbar artery bleed. She is currently status post
embolization, interventional radiology. The patient's
orthopedic issues have not been fully treated due to
patient's more acute issues during [**Date Range 12876**]. Upon
discharge from hospital patient's orthopedic issues still
were not treated due to patient's need for continued
rehabilitation secondary to hypovolemic shock. For questions
concerning orthopedic follow-up, please call Dr. [**First Name (STitle) 4135**] at
[**Telephone/Fax (1) 11262**].
2. Cardiovascular: 1) Hypovolemic shock - patient was found
to have a lumbar artery bleed, was found to be hypotensive,
diaphoretic. Patient's hematocrit fell from 29 to 23.4 on
[**10-25**] to 16. The patient was resuscitated with crystalloid,
5 units of packed red blood cells, 4 units of FFP. The
patient was started on Dopamine 4 mcg/kg/minute while patient
was fluid resuscitated. While patient was fluid
resuscitated, the patient required less pressors and
ultimately was weaned off pressors completely. The patient
has remained hemodynamically stable after pressors were taken
off and patient was adequately fluid resuscitated. The
patient's blood pressures during the last week of
[**Month/Year (2) 12876**] were in the 140's to 160's/80's to 90's, not
requiring fluid resuscitation, not requiring pressors for
majority of [**Hospital 228**] hospital stay. 2) Aortic valve
replacement - patient was on Coumadin with a questionable
dose of 4 mg upon presentation to the hospital. The patient
has been on an IV Heparin drip since her presentation to the
hospital. The patient's Heparin orders were weight based
upon 55 kg with an ideal PTT between 60 and 100. On [**11-7**] the
patient was switched from Heparin drip to Lovenox 30 mg subcu
[**Hospital1 **]. This should continue for one week and then patient
should be reevaluated to whether patient can be started back
on Coumadin with a question of 4 mg dose. With questions of
Coumadin dose, please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 608**] which was
patient's nurse practitioner [**First Name (Titles) 5001**] [**Last Name (Titles) 12876**].
3. Respiratory: Patient went into respiratory failure after
patient went into hypovolemic shock secondary to lumbar
artery bleed. The patient was intubated and then weaned
appropriately and extubated on [**2104-10-31**]. The patient's
respiratory status remained stable after extubation. The
patient's respiratory rate remained anywhere between 22 and
28 after patient's extubation. The patient's oxygen
requirements were decreased from 50% face tent to 35% face
tent. The patient's oxygen status was always greater than
92% on 30% face tent. On [**11-7**] it was found that patient's
oxygen status was greater than 92% without face tent, thus
oxygen was weaned appropriately.
4. GI: The patient had guaiac positive stool with her right
lower quadrant pain and her hypovolemic shock due to lumbar
artery bleed. The patient had an acute increase in LFTs
during her hypovolemic shock. The patient's ALT, AST went
from [**9-15**] respectively to 448 and 524. Patient's LDH went
up to 1806. Patient's amylase went from 58 to 123. This
acute increase in liver function tests were most likely
secondary to shock liver due to hypoperfusion. After patient
became hemodynamically stable, adequately fluid resuscitated,
patient's liver function tests improved dramatically. The
patient's liver function tests decreased slowly during
[**Hospital 228**] hospital course and on day of discharge patient's
ALT was 53, AST 27, alkaline phosphatase 105, bilirubin 1.7.
The patient was complaining of some right upper quadrant pain
the last week of her [**Hospital 12876**]. A right upper quadrant
ultrasound was done which showed cholelithiasis and no
evidence of cholecystitis.
5. Renal: Acute renal failure. Patient's base creatinine
was 2.0. Patient went into acute renal failure secondary to
hypoperfusion due to hypovolemic shock. The patient's
creatinine crept up to 3.5. Patient's Zestril was held at
that point in time. After hypovolemic shock patient did have
inadequate urine output secondary to decreased blood
pressure. As patient lives adequately fluid resuscitated and
improved during the hospital stay, patient's urine output
became adequate and patient's creatinine began to creep
downward slowly and on hospital day #16, [**11-7**], patient's
creatinine reached a nadir of 1.6. Patient was started on
Captopril on [**11-1**], a low dose of 6.25, po tid which was
increased slowly to 25 mg po tid to help patient's renal
function. The patient was discharged to home on Captopril 25
mg po tid.
6. ID: The patient has remained afebrile during [**Hospital 228**]
hospital course. The patient actually was hypothermic during
patient's hypovolemic shock with a temperature nadir of 94
degrees. The patient was empirically started on Ceftriaxone,
Flagyl and Vancomycin on [**10-30**] for a question of bowel sepsis
vs pneumonia seen as an infiltrate on chest x-ray. The
patient's Flagyl and Vancomycin were discontinued on [**11-2**] at
first respectively. Patient was continued on a 14 day course
of Ceftriaxone for a question of pneumonia. The patient did
have an increase in white cell count during [**Month/Day (2) 12876**]
with a max of 28.9 with an unclear source of why the white
cell count went up. There is question of acute phase vs
pneumonia. Right upper quadrant ultrasound showed no
evidence of cholecystitis. There is a question of sinusitis
with NG tube placement and tube feeds. Sinus films were not
done. Patient's white cell count did start to go down on day
of discharge, [**11-7**]. It went down gradually to 23.1. Patient
remained afebrile. A C. diff culture for stool was sent
which was negative. The patient's central line tip was sent
for culture which is still pending upon discharge. Patient's
white cell count most likely due to pneumonia.
7. Neuro: The patient had a slow return to consciousness
after hypovolemic shock, probably secondary to sedation in
MICU stay, hypotension, metabolic derangement. There was a
question of a stroke but a head CT was negative for evidence
of stroke. Patient continued to improve and improved
dramatically from [**11-1**] until discharge, going from being
mildly sedated to being able to answer questions
intelligently, being alert and oriented times three and able
to follow commands. During patient's MICU stay it was
thought that an MRI and EEG would be needed but with
patient's improvement an MRI and EEG were not done.
Neurology felt that those did not need to be done as well.
The patient will continue to improve as outpatient most
likely.
8. Fluids, Electrolytes & Nutrition: Upon patient's
hypovolemic shock patient was made npo. An NG tube was
placed. Tube feeds were started on [**2104-10-30**]. The patient
was started on tube feeds with a goal of 40 cc per hour and
held for residuals of greater than 100 cc per hour.
Nutrition continued to follow patient's course and patient's
tube feeds were changed to Ultracal 4% to a goal of 55 cc per
hour as tolerated. Due to patient's hypovolemic shock and
metabolic derangement and slow return to base function, there
was a question of whether patient was an aspiration risk.
Speech therapy began to see patient on [**11-4**] and on [**11-4**] and
[**11-5**] patient was felt to be an aspiration risk and the NG
tube and tube feeds were continued. Patient improved on [**11-6**]
and a video swallowing study was scheduled. Video swallowing
study was done on [**11-7**] which showed that the patient still
had risk of aspiration, thus speech pathology recommended
that patient continue on tube feeds with NG tube for one week
and then retry with an other video swallow to see whether
patient is less of an aspiration risk. The patient became
hypernatremic during hospital stay with sodium in the max of
150. At that point in time the patient was started on free
water boluses. Ultimately 200 cc boluses done q 4 through NG
tube was done and patient's sodium normalized.
9. Access: A right subclavian central line was placed. A
Foley catheter was placed. An NG tube was placed upon MICU
admission. All of these things have been removed except
patient's Foley catheter. An NG tube needs to be placed upon
patient's admission to rehab for tube feeds to continue.
Patient's right subclavian line was pulled and two peripheral
IV's are now present for access.
10. Code Status: On [**10-31**] it was discussed with patient's
daughter. [**Name (NI) **] at that point in time was DNR, not DNI.
On [**11-5**] after patient became lucid and was able to answer
questions for herself, the patient wanted to be full code so
thus patient is full code at this point in time.
DISCHARGE DIAGNOSIS:
1. Status post fall with acetabular head dislocation,
complicated by lumbar artery bleed, status post embolization
for hypovolemic shock.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: Patient is to be discharged to [**Hospital **]
Rehabilitation. Dr. [**Last Name (STitle) 1266**] will not follow patient while
patient is in [**Hospital1 **]. Patient should continue on tube
feeds, the Ultracal at 55 cc per hour to be held for
residuals of greater than 100 cc. Patient should continue on
medications on page 1 and should be evaluated for Coumadin
use, change from Lovenox in approximately one week. For
questions concerning patient's Coumadin, please call [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 608**]. For questions regarding patient's
orthopedic issues, call Dr. [**First Name (STitle) 4135**] at [**Telephone/Fax (1) 11262**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (NamePattern1) 6763**]
MEDQUIST36
D: [**2104-11-7**] 14:59
T: [**2104-11-7**] 15:12
JOB#: [**Job Number 28848**]
|
[
"570",
"821.01",
"276.0",
"285.1",
"958.4",
"E885.9",
"996.4",
"902.0",
"584.9"
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icd9cm
|
[
[
[]
]
] |
[
"99.29",
"96.04",
"96.6",
"96.34",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12429, 13429
|
12267, 12407
|
3221, 12246
|
1081, 3204
|
113, 132
|
161, 412
|
435, 877
|
894, 1058
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,054
| 106,500
|
13400
|
Discharge summary
|
report
|
Admission Date: [**2192-10-3**] Discharge Date: [**2192-10-8**]
Date of Birth: [**2134-8-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
known coronary artery disease, who had been offered coronary
artery bypass graft in the past but had refused, who had had
angioplasty and stenting in [**Month (only) 547**], followed by brachytherapy,
who now presented with chest pain and congestive heart
failure, presented to an outside hospital and was taken to
the cardiac catheterization laboratory, which showed
progression of his disease. The patient was transferred to
[**Hospital1 69**] for evaluation and
coronary artery bypass graft.
Several weeks prior to admission, the patient had developed
chest pain and dyspnea on exertion. The patient now is
willing to have the coronary artery bypass graft, and was
transferred here for that. Cardiac catheterization at the
time revealed a 90% left anterior descending stenosis, 80%
diagonal stenosis, an ejection fraction of 65%.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Significant for coronary artery
disease status post angioplasty and stent, status post
brachytherapy, high cholesterol, borderline diabetes.
MEDICATIONS ON ADMISSION: Lipitor 40 mg by mouth once daily,
Plavix 75 mg by mouth once daily, atenolol 25 mg by mouth
once daily, enteric-coated aspirin 325 mg by mouth once
daily.
His electrocardiogram was sinus bradycardia at 50 beats per
minute, with some lateral ST/T wave changes which were
stable.
SOCIAL HISTORY: Significant for significant alcohol abuse,
six to seven drinks per day, and tobacco one to one and a
half packs per day for many years.
LABORATORY DATA: On admission, white count was 5.6,
hematocrit 40.4, platelets 494. PT 12.8, PTT 27.6, INR 1.1.
Sodium 137, potassium 4.2, chloride 104, bicarbonate 23, BUN
27, creatinine 1.0, glucose 110. ALT 27, AST 16, alkaline
phosphatase 83, total bilirubin 0.4.
PHYSICAL EXAMINATION: He was afebrile, vital signs stable.
He was in no apparent distress. His pupils were equally
round and reactive to light. His extraocular muscles were
intact. He had no lymphadenopathy. His neck was supple,
with no bruits. His lungs were clear to auscultation
bilaterally. His heart had distant heart sounds, regular
rate and rhythm, with no murmurs, gallops or rubs. His
abdomen was soft, obese, nontender, nondistended. His bowel
sounds were present. He had no hepatosplenomegaly. His
extremities were warm and well perfused, with no edema, and
2+ dorsalis pedis pulses bilaterally.
HOSPITAL COURSE: The patient was admitted to the hospital
and we planned for coronary artery bypass graft at that time.
The patient consented to the coronary artery bypass graft,
and chest x-ray and preoperative laboratories were done.
The patient was taken to the operating room on [**2192-10-5**], where
a coronary artery bypass graft x 2 was performed. The
patient did well postoperatively, and was slowly weaned from
his ventilator and was extubated. He continued to do well.
He was kept on an alcohol drip for prevention of delirium
tremens. He was started on beta blockers and lasix, and he
was transferred to the floor.
On the floor, his chest tubes were removed. His Foley was
removed, and his wires were also removed. Physical Therapy
was consulted for ambulation and endurance. He did quite
well, and it was felt that he could quickly achieve Level V
and be discharged home. The patient, when transferred to the
floor, was also given as needed alcohol at his request, in
order to request delirium tremens. He was continued on his
Plavix postoperatively for an off-pump coronary artery bypass
graft. All of his lines were removed, as stated previously,
and he continued to improve.
On postoperative day number three, he achieved Level V of
physical therapy, and was discharged home in stable
condition.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg by mouth once daily
2. Percocet one to two tablets by mouth every four hours as
needed
3. Enteric-coated aspirin 325 mg by mouth once daily
4. Zantac 150 mg by mouth twice a day
5. Potassium chloride 20 mEq by mouth twice a day
6. Colace 100 mg by mouth twice a day
7. Lasix 20 mg by mouth twice a day
8. Lopressor 25 mg by mouth twice a day
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass graft, status post angioplasty, status post stenting,
status post brachytherapy
2. High cholesterol
3. Borderline diabetes; blood sugars in-hospital were within
the normal range, without requiring treatment
The patient is discharged in stable condition, and instructed
to follow up with Dr. [**Last Name (STitle) 70**] in four weeks, and with his
primary care physician in one to two weeks. The patient is
discharged home in stable condition.
Please see addendum for any changes in medications or change
in discharge date.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 10459**]
MEDQUIST36
D: [**2192-10-7**] 22:14
T: [**2192-10-8**] 00:15
JOB#: [**Job Number 40683**]
|
[
"250.00",
"272.0",
"414.01",
"303.90",
"V45.82",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3934, 4301
|
4322, 5219
|
1259, 1540
|
2603, 3911
|
1989, 2585
|
159, 1067
|
1090, 1232
|
1557, 1966
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,866
| 180,313
|
25908
|
Discharge summary
|
report
|
Admission Date: [**2120-8-14**] [**Month/Day/Year **] Date: [**2120-8-22**]
Date of Birth: [**2054-6-13**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
anemia work-up
Major Surgical or Invasive Procedure:
Endotracheal intubation
Left IJ CVC placement
Right arm PICC line placement
History of Present Illness:
66 yo F with PMH of multiple CVAs, CAD, Htn, Hld, ESRD on HD
m/w/f, h/o UGIB, gastritis, duodenitis, with recent admission
[**Date range (1) 64433**] for HCAP c/b new left parietal stroke, seizure and
hypertensive urgency, now admitted from [**Hospital **] Rehab for
work-up of anemia, with development of septic shock in the ED.
Per report from ED, patient had persistent anemia at [**Hospital **]
Rehab, and was undergoing work-up there. She was transfused with
4 units PRBCs over the several days prior to admission, with
subsequent H/H 6.6/19.8 prior to admission (from 9.3/29.5 at the
time of prior [**Hospital **]). At [**Hospital1 **], she did not have any
reported melena, hematochezia or hematemesis; she was Guaiac
negative. Anemia work-up was pursued with CT/Abd pelvis which
was negative for RP bleed ([**8-13**]), RUQ scan showed subcutaneous
edema but not fluid collections. GI team consulted at [**Hospital1 **] on
[**8-12**] did not believe that patient had GI bleed; their GI lavage
was negative. Of note, she was dialyzed with 2L taken off on
[**8-13**] prior to transfer to [**Hospital1 18**] ED. Doctors [**First Name (Titles) **] [**Last Name (Titles) **] requested
Neuro and Heme/Onc consults at [**Hospital1 18**] for anemia work-up, as it
was thought that recently initiated Dilantin may be
contributing. Baseline Neuro status at [**Hospital1 **] includes arousal
to noxious stimuli.
In the [**Hospital1 18**] ED, initial VS were: T 98.0 HR 80 BP 146/60 RR 14
SaO2 98% 2L NC. She was Guaiac negative, with no noted melena,
BRBPR or hematochezia. Was noted to be non-verbal with
occasional eye-opening and moaning to noxious stimuli. Labs were
notable for WBC 17.5 with N 93%, H/H 7.2/22.2, proBNP 1872, Na
130, Cl 93, BUN 23, Cr 3.1, glucose 231, ALT 91, AST 124, ALK
328, lipase 138, phenytoin 9.7, and initial lactate 1.8. UA
showed large LE, neg nitrites, 100 pr, 2 RBCs, 92 WBCs, few
bacteria, no epis. CXR was rotated, and showed no focal
consolidation/effusion with possibly enlarged cardiac
silhouette.
At 22:00, developed hypotension with decrease in BP from 158/61
to 90/39, along with apneic breathing at 7 breaths per minute.
At that time, HR remained in the 80s with RR 14-16 and SaO2 96%
on 2L NC. A left IJ triple lumen CVL was placed for
resuscitation. Patient was intubated with etomidate/rocuronium.
Initial ABG was 7.48 / 34 / 223/ 26 with lactate 3.9. CXR
confirmed placement of ETT 4 cm above carina and CVL in lower
SVC.
In the ED, she was given etomidate 20 mg IV x1 and rocuronium 80
mg IV x1 for intubation, and maintained on fentanyl/midazolam
for sedation. She was started on norepinephrine drip for pressor
support initially at 0.03 mcg/kg/min and uptitrated to 0.05
mcg/kg/min. She was also given vancomycin 1 g IV x1 and cefepime
2 g IV x1. She was given 1 unit of blood and 1L NS fluid bolus.
VS prior to transfer were: T 98.7 BP 137/72 HR 93 RR 30 SaO2
100% on vent settings 450 tidal vol / 16rr /5peep 50%. Most
recent ABG at 23:57 was 7.48 / 34 / 223 / 26 with iCal 1.11 and
lactate 3.1.
On arrival to the MICU, patient was intubated and sedated.
Second unit of blood ordered from ED was continued.
Review of systems: unable
Past Medical History:
1. Coronary artery disease
- s/p cath ([**8-24**]): Mild epicardial disease, collalateral flow
to distal inferior wall, no intervention
2. Hypertension
3. Hyperlipidemia
4. Diabetes: complicated by retinopathy, neuropathy, and
nephropahy
5. ESRD on HD MWF
6. Stroke: left frontal MCA and occipital PCA stroke
7. Impaired memory s/p MVA
8. Anemia
9. History of MSSA PNA, [**3-25**]
10. Treated for presumptive endocarditis, [**12-27**]
11. H/o Upper GI bleed NOS, gastritis, duodenitis
Social History:
Born in [**Country **]. Denies tobacco, EtOH. Now at [**Hospital **] Rehab
since last hospitalization.
Family History:
-Father died in his 70's with heart disease
-Siblings (two sisters) with diabetes mellitus (type II).
Physical Exam:
Admission exam:
Vitals: T: 97.2 BP: 153/66 P: 90 R: 20
SaO2: 100% on CMV assist TV 400 x 14 RR with PEEP 5, FiO2 40%
CVP: [**3-24**]
General: intubated/sedated, appears comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, +anisocoria with
left pupil constricted to 1 mm responsive to light; left pupil 2
mm and unresponsive to light.
Neck: left IJ central line with edema, unable to assess JVP
secondary to habitus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor air movement with coarse upper respiratory sounds
tramsitted throughout.
Abdomen: NABS, soft, non-tender, non-distended
GU: +foley
Ext: warm, well perfused, 2+ distal pulses, 3+ nonpitting edema
in right hand, 2+ nonpitting edema in left hand, 2+ nonpitting
edema of upper extremities
Neuro: intubated/sedated, anisocoria as above, no response to
voice, touch, sternal rub or nailbed pressure. Toes are
downgoing bilaterally, with wincing and leg movement in response
to Babinski reflex exam.
[**Month/Day (3) **] exam:
Vitals: 98.5 160/74 R16 84 98%RA
GEN: Awakens to verbal stimuli. In no apparent distress. Appears
comfortable
HEENT/NECK: left IJ s/p removal
LUNGS: Coarse breath sounds anteriorly. No wheezes
CV: S1, S2. Systolic ejection murmur, No gallops/rubs
aprpeciated. Pulses 2+ throughout. No JVD appreciated.
EXTREMITIES: 2+ pitting edema B/L LEs, nonpitting edema of UEs
but RUE >L . + bruits left arm with overlying dressing at renal
fistua site
NEURO: Grips right hand and tracks.
Pertinent Results:
I. Microbiology
[**2120-8-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2120-8-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2120-8-16**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2120-8-16**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2120-8-16**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2120-8-15**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2120-8-15**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2120-8-14**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2120-8-14**] URINE URINE CULTURE-FINAL {LACTOBACILLUS
SPECIES} EMERGENCY [**Hospital1 **]
[**2120-8-14**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
II. Labs
A. Admission
[**2120-8-14**] 06:08PM BLOOD WBC-17.5*# RBC-2.26* Hgb-7.2* Hct-22.2*
MCV-98 MCH-31.9 MCHC-32.5 RDW-16.5* Plt Ct-404
[**2120-8-14**] 06:08PM BLOOD Neuts-93* Lymphs-2* Monos-3 Eos-2 Baso-0
[**2120-8-14**] 06:08PM BLOOD PT-10.8 PTT-29.3 INR(PT)-1.0
[**2120-8-14**] 06:08PM BLOOD Fibrino-301
[**2120-8-20**] 07:00AM BLOOD Ret Aut-3.5*
[**2120-8-14**] 06:08PM BLOOD Glucose-231* UreaN-23* Creat-3.1*#
Na-130* K-4.2 Cl-93* HCO3-28 AnGap-13
[**2120-8-14**] 06:08PM BLOOD ALT-91* AST-124* AlkPhos-328* TotBili-0.5
[**2120-8-14**] 06:08PM BLOOD proBNP-1872*
[**2120-8-15**] 01:31AM BLOOD CK-MB-2 cTropnT-0.07*
[**2120-8-15**] 08:33AM BLOOD CK-MB-3 cTropnT-0.08*
[**2120-8-15**] 04:15PM BLOOD CK-MB-3 cTropnT-0.06*
[**2120-8-14**] 06:08PM BLOOD Albumin-3.5 Calcium-9.0 Phos-3.1# Mg-2.1
[**2120-8-14**] 06:08PM BLOOD Hapto-128
[**2120-8-16**] 03:00PM BLOOD Vanco-9.3*
[**2120-8-14**] 06:08PM BLOOD Phenyto-9.7*
[**2120-8-14**] 09:49PM BLOOD Type-ART pO2-110* pCO2-35 pH-7.49*
calTCO2-27 Base XS-3 Intubat-NOT INTUBA
[**2120-8-14**] 06:35PM BLOOD Lactate-1.8
[**2120-8-14**] 11:57PM BLOOD O2 Sat-97
[**2120-8-14**] 11:57PM BLOOD freeCa-1.11*
B. [**Month/Day/Year **]
[**2120-8-22**] 07:00AM BLOOD WBC-9.6 RBC-2.78* Hgb-8.8* Hct-27.2*
MCV-98 MCH-31.6 MCHC-32.3 RDW-17.9* Plt Ct-519*
[**2120-8-22**] 07:00AM BLOOD PT-19.1* PTT-45.2* INR(PT)-1.8*
[**2120-8-22**] 07:00AM BLOOD Glucose-126* UreaN-21* Creat-3.8*# Na-136
K-4.2 Cl-98 HCO3-25 AnGap-17
[**2120-8-22**] 07:00AM BLOOD ALT-3 AST-34 AlkPhos-386* TotBili-0.3
[**2120-8-15**] 04:15PM BLOOD CK-MB-3 cTropnT-0.06*
[**2120-8-22**] 07:00AM BLOOD Albumin-3.2* Calcium-9.0 Phos-2.9 Mg-2.1
III. Radiology
A. [**2120-8-21**] Radiology UNILAT UP EXT VEINS US
IMPRESSION: No acute deep vein thrombosis seen in the right
arm. The
cephalic vein is very small and appears to contain old thrombus.
B. [**2120-8-20**] Radiology PICC LINE PLACMENT SCH
IMPRESSION: Uncomplicated fluoroscopically-guided double-lumen
PICC placement
Preliminary Reportvia the right basilic venous approach, the
final internal length is 41 cm,
Preliminary Reportwith the tip positioned in the distal SVC. The
line is ready to use.
C. [**2120-8-19**] Radiology CHEST PORT. LINE PLACEM
CONCLUSION:
New right-sided PICC line has some redundancy in its course and
ends in
proximal subclavian vein.
ICU team has been verbally contact[**Name (NI) **] with the results.
D. [**2120-8-17**] Cardiovascular ECHO
The left atrium is mildly dilated and elongated. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is borderline pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2120-7-17**],
findings are similar. There is no evidence of valvular
vegetations (better excluded by TEE).
E. [**2120-8-15**] Radiology UNILAT UP EXT VEINS US
IMPRESSION: No evidence of deep vein thrombosis in the right
arm. Note is made that the right cephalic vein could not be
visualized. Edematous
superficial tissues noted.
F. [**2120-8-15**] Radiology CT HEAD W/O CONTRAST
CONCLUSION: No evidence of acute hemorrhage or infarction.
G. [**2120-8-15**] Cardiovascular ECG
Sinus rhythm. Within normal limits. Compared to tracing #2 no
diagnostic
interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 154 92 [**Telephone/Fax (2) 64434**] 72
H. [**2120-8-13**] Radiology CT ABD & PELVIS W/O CON
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Calcified fibroids.
3. Sub-4-mm right lower lobe pulmonary nodule for which no
additional
followup is required as it is stable since [**2119-4-19**].
I. [**2120-8-13**] Radiology CT UP EXT W/C RIGHT
IMPRESSION:
1. Diffuse subcutaneous edema.
2. Mild degenerative changes.
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
66 F with complicated PMH including multiple CVAs, CAD, ESRD on
HD (MWF), and seizure disorder admitted to MICU for respiratory
failure requiring intubation and MSSA septic shock and
bacteremia thought to be secondary to a PICC line.
ACUTE DIAGNOSES:
# RESPIRATORY FAILURE: Pt was intubated in the ED for apnea in
context of sepsis and acidosis. No evidence for active
pulmonary disease or pneumonia. Extubated on [**8-17**] after
confirmation of her baseline mental status. Breathed and
saturated well on room air thereafter.
# REFRACTORY SEPTIC SHOCK: Pt was admitted with vasopressor
dependent septick shock and subsequently found to have MSSA
bacteremia which was felt to be secondary to a PICC line. The
PICC was removed in the ICU. Her graft site for dialysis access
did not clinically appear infected making the midline catheter
more suspected site.
Given staph aureus bacteremia, ID was consulted and felt that no
further work up was indicated given her poor health at baseline.
Culture data was obtained from the outside hospital and the
patient was started on cefazolin based on the sensitivities.
She is being treated with cefazolin on HD protocol with 2 grams
after Monday and Wednesday HD and 3 grams after [**Month/Year (2) 2974**] HD
session. Her course will run from [**2120-8-16**] to [**2120-8-30**]. Patient
remained afebrile and without SIRS criteria throughout the rest
of her stay.
# UPPER EXTREMITY SWELLING: Patient developed left upper arm
swelling after left CVC placement. She also developed right
upper arm swelling after right PICC line placement. Upper
extremity dopplers were negative for DVT (see radiology
section). Her left central line was discontinued on [**2120-8-22**].
Her arm swelling sites should be monitored carefully with
consideration for repeat dopplers to assess for DVT if
indicated. Her left arm fistula was functioning properly on
[**Date Range **].
# NORMOCYTIC ANEMIA: The patient was initially referred to the
ED for the evaluation of her anemia, however, she decompensated
in the ED and found to have septic shock. Patient has Hct
stable at ~ 27-28 and similar to prior admission. She did need
transfusions at an OSH for unclear reasons likely from ESRD and
poor RBC production given her reticulocyte index. She had no
signs/symptoms of active bleeding. She should continue on her
EPO medication in setting of ESRD.
#Nutrition: There is a concern that she will not be able to eat
enough to maintain caloric intake. There is thoughts of a PEG
discussion, but goals of care should be discussed with family as
PEG has not been [**Last Name (un) 22315**] to prolong life, improve comfort, or
reduce aspiration events in this type of patient. A discussion
was held with her daughters, and they want to continue to see
how she progresses after this hospitalization.
Her diet is as follows:
1. PO diet: thin liquids, pureed solids.
2. Meds crushed with applesauce.
3. 1:1 supervision with POs.
4. Feed only when awake and participatory.
5. Nutrition consult as needed for oral supplements based on
overall PO intake.
6. TID oral care.
# Chronic encephalopathy: As per family, patient is currently at
baseline. She is AAOx0, arousable to verbal stimuli and touch,
and will say one word expressions to family members but not to
the medical team.
# History of seizures:
Neurology saw the patient in the ER and thought she was
stabilized on Keppra and Phenytoin regimen. Her phenytoin level
imiproved although not within lab range of [**9-7**] (likely closer
to [**6-27**] based on ablumin). It was felt that there is not likely a
need to chagne phenytoin dosing unless the patient has a repeat
seizure (last was in [**7-/2120**] during last hospitalization at
[**Hospital1 18**] during HD).
# ESRD on HD: Patient continued on M/W/F schedule.
She received her keppra and cefazolin post HD per protocol.
# Hypertension: Upon resolution of septic shock, the patient was
restarted on her home anti-hypertensives.
# CAD: She continues on aspirin and beta-blockade
# Elevated ALP - Most likely related to secondary
hyperparathyroidism in setting of CKD. Phenytoin can also
increase ALP. As patient has transaminitis, checking GGT to
ensure this is indeed bone source and not [**12-21**] cholestasis
although pending at time of [**Month/Day (2) **].
# Transamnitis (WNL in [**6-30**]), likely elevated in setting of
sepsis/severe illness. LFTs normalized after acute illness
# Hyperlipidemia: She continues on pravastatin
# Diabetes complicated by retinopathy, neuropathy, and
nephropahy
She continued on HISS insulin.
# Left frontal MCA and occipital PCA stroke: She continues on
ASA/plavix
# H/o Upper GI bleed NOS, gastritis, duodenitis - Her PPI was
changed to a dissolving version given her mental status.
# Prophylaxis: pneumoboots, heparin SC
# Access: right antecubital PICC placed on [**2120-8-20**] by IR and
confirmed under fluroscopy.
# Communication:
Primary: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **]
Other daughter: [**Name (NI) **] [**Name (NI) 64426**] [**Telephone/Fax (1) **]
# Code: Full (confirmed with daughter [**Name (NI) **])
# Transitional issues
- continue treatment for MSSA bacteremia
- continue to monitor nutritional intake
- continue to monitor upper extremity swelling
- continue goals of care discussion
- follow-up with PCP, [**Name10 (NameIs) **] after rehab [**Name10 (NameIs) **]
Medications on Admission:
amlopidine 10 mg PO daily
biacodyl 10 mg PR daily prn constipation
clopidogrel 75 mg PO daily
darbepoetin alpha 40 mcg subcut q7 days (last dose [**2120-8-14**])
diazepam 10 mg PR gel daily prn seizure
docusate sodium 200 mg PO q12 hours
hydralazine 75 mg PO q8 hours
insulin sliding scale: FSBS < 180 no insulin; FSBS 181-250 1
unit; FSBS 251-300 2 units; FSBS > 301 3 units; qACHS
lacutlose 30 mL q12hours prn constipation
levetiracetam 1000 mg PO qHS
levetiracteam 500 mg PO 3x per week on M/W/F at 12pm
lisinopril 40 mg PO daily
metoprolol tartrate 50 mg PO q8hours
nephrocapes 1 cap PO daily
pantoprazole 40 mg IV q12hours
phenytoin 150 mg PO q8 hours
polyethylene glycol 17 g PO daily
pravastatin 40 mg PO qHS
senna 2 tabs PO q24 hours
sevelamer carbonate 800 mg powder w/meals
[**Month/Day/Year **] Medications:
1. Amlodipine 10 mg PO DAILY
hold for SBP < 100
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Clopidogrel 75 mg PO DAILY
4. darbepoetin alfa in polysorbat *NF* 40 mcg/mL Injection
weekly
last dose [**2120-8-14**]
5. diazepam *NF* 10 mg Other prn seizure
diazepam 10 mg PR gel daily prn seizure
6. Docusate Sodium (Liquid) 100 mg PO BID
7. HydrALAzine 75 mg PO Q8H
hold for SBP < 100
8. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
9. Lactulose 30 mL PO Q8H:PRN constipation
10. LeVETiracetam Oral Solution 500 mg PO POST HD
11. LeVETiracetam Oral Solution 500 mg PO BID
12. Lisinopril 40 mg PO DAILY
hold for SBP < 100
13. Metoprolol Tartrate 50 mg PO TID
hold for SBP<100, HR<60
14. Nephrocaps 1 CAP PO DAILY
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
16. Phenytoin Infatab 150 mg PO TID
17. Heparin 5000 UNIT SC TID
18. Senna 1 TAB PO BID:PRN Constipation
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
20. sevelamer CARBONATE 800 mg PO TID W/MEALS
21. Aspirin 81 mg PO DAILY
22. CefazoLIN 2 g IV POST HD
Monday and Wednesday only
Course: [**Date range (1) 64435**]
23. CefazoLIN 3 g IV POST HD
Only Fridays
Course: [**Date range (1) 64435**]
[**Date range (1) **] Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
[**Location (un) **] Diagnosis:
Primary: Methicillin sensitive Staphylcoccus aureus bacteremia,
upper extremity swelling
Secondary: end-stage renal disease, seizure disorder
[**Location (un) **] Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
[**Location (un) **] Instructions:
You were admitted to the hospital with a bacteria infection in
your blood from an IV. You will continue treatment with
antibiotics to cure the infection.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] (PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 45347**])
Follow-up with your kidney doctor [**First Name (Titles) **] [**Last Name (Titles) **]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 10135**]
Completed by:[**2120-8-25**]
|
[
"414.01",
"785.52",
"790.4",
"250.50",
"250.40",
"345.90",
"438.89",
"V45.11",
"357.2",
"348.39",
"585.6",
"272.4",
"995.92",
"403.91",
"583.81",
"999.31",
"518.81",
"362.01",
"038.11",
"250.60",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.97",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11074, 16550
|
305, 382
|
5884, 11051
|
19436, 19865
|
4240, 4344
|
16576, 18813
|
4359, 5865
|
3586, 3595
|
18845, 18989
|
251, 267
|
19021, 19021
|
19168, 19413
|
410, 3567
|
19036, 19133
|
3617, 4104
|
4120, 4224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,007
| 148,575
|
23637
|
Discharge summary
|
report
|
Admission Date: [**2163-4-21**] Discharge Date: [**2163-5-3**]
Date of Birth: [**2094-8-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
altered mental status
RLE pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68-year-old female with h/o DM2, HTN, CAD, CHF and PVD s/p left
AKA, angioplasty to R tibial artery in [**3-19**], chronic venous
stasis ulcers s/p debridement one week PTA, also with death of
son 10d PTA, who presents with several days of RLE pain and
confusion. Patient unable to give history, spoke with her
grandson at [**Telephone/Fax (1) 60469**] to gain some sense of story, though per
his report his aunt will be calling in to provide more detail.
From the grandson, the patient has had increasing RLE pain times
several days, and from the limited info provided by the patient
she ran out of the 60 tabs of Percocet also several days ago. It
is unclear if the patient has been taking more of her MS Contin
in the absence of Percocet. Per the grandson, the pt has been
"in and out of reality" for these past few days, unable to sleep
at night, poorly interactive during the day. The VNA saw the
patient on the DOA and felt that she was somnolent, called 911.
In the ED, the patient was confused and somnolent but in obvious
pain, wailing out but unable to give a history. She repeated
"cut it off" while holding her RLE. She received 2mg MSIR IV,
then 2 Percocets. On the floor she was still in pain, received
1mg IV dilaudid.
Past Medical History:
DM2,
hypertension,
coronary artery disease (h/o angina in past currently stable),
history of congestive heart failure,
severe PVD
h/o GIB
Left above-knee amputation,
left common iliac stenting,
IVC filter placement,
hysterectomy,
lumpectomy
Social History:
Pt lives at home with second son, first son recently deceased 3d
PTA from unclear etiology, possibly liver disease vs. HIV per
pt. Followed by VNA daily. wheelchair bound. She is a current
smoker,
~half pack per day. Denies EtOH/IVDU.
Family History:
NC
Physical Exam:
Vitals:
Gen - lying in bed, breathing comfortably, NAD except upon
manipulation of RLE wounds
Heent - PERRL, EOMI, OP wnl, MMM
Neck - supple, thick, JVP 8cm
CV - RRR, nl s1/s2, [**2-20**] holosyst murmur loudest at apex
Pulm - rhonchi throughout, likely transmitted from upper airway;
scant bibasilar rales, L>R
Abd - obese, soft, NT, NABS
Ext - left AKA; R foot with non-pitting edema, venous stasis
changes,
4 ulcerations s/p recent debridement appearing clean with no
significant granulation yet, no evidence of cellulitis or
superimposed infection
Pulses - Rt: 1+fem/no [**Doctor Last Name **]/no DP or PT; Lt: 1+fem
Neuro - A&Ox3, slighy ptosis on right, CNs otherwise intact,
answers all questions appropriately, UE stregth intact, LE
strength 3/5 in flexors/extensors
Pertinent Results:
Chemistries
[**2163-4-21**] 11:40AM GLUCOSE-161* UREA N-15 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14
LFTs
[**2163-4-21**] 11:40AM ALT(SGPT)-6 AST(SGOT)-12 LD(LDH)-155 ALK
PHOS-77 AMYLASE-70 TOT BILI-0.2
[**2163-4-21**] 11:40AM LIPASE-42
[**2163-4-21**] 11:40AM AMMONIA-14
CBC
[**2163-4-21**] 11:40AM WBC-9.2 RBC-3.53* HGB-9.9* HCT-30.0* MCV-85
MCH-28.1 MCHC-33.0 RDW-17.1*
[**2163-4-21**] 11:40AM NEUTS-68.4 LYMPHS-24.7 MONOS-3.2 EOS-3.4
BASOS-0.4
[**2163-4-21**] 11:40AM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+
[**2163-4-21**] 11:40AM PLT COUNT-339
Coags
[**2163-4-21**] 11:40AM PT-12.9 PTT-25.8 INR(PT)-1.1
U/A
[**2163-4-21**] 11:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2163-4-21**] 11:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Reports:
[**2163-4-21**] AP AND LATERAL VIEWS OF THE CHEST: Unchanged
cardiomegaly. The hilar and mediastinal contours are unchanged.
There are increased pulmonary [**Month/Day/Year 1106**] markings. The patient is
rotated but there is probable small linear atelectasis at the
left lung base. No effusions are seen. Soft tissue and osseous
structures remain unchanged.
IMPRESSION: Mild cardiac failure.
[**2163-4-21**] CT HEAD W/O CONTRAST
FINDINGS: There is no sign for the presence of an intracranial
hemorrhage. There are cluster of small (less than 1 cm)
hypodense areas near the atrium of the left lateral ventricle.
While nonspecific in etiology, the findings are most commonly
secondary to chronic small vessel infarction. Probable
additional chronic small vessel infarction is seen in the right
corona radiata. There is no sign for hydrocephalus or shift of
normally midline structures. It is to be noted that a number of
the sections are degraded by patient motion. The surrounding
osseous and soft tissue structures show no overt pathology.
CONCLUSION: No evidence for intracranial hemorrhage. Probable
multiple small chronic infarcts, as noted above.
EGD
Findings:
Esophagus: Normal esophagus.
Stomach:
Contents: Clotted blood was seen in the fundus.
Protruding Lesions: Three polypoid structures ranging in size
from 5mm to 7mm were found in the stomach body. One of them had
stigmata had recent bleeding. Three 1 cc.Epinephrine 1/[**Numeric Identifier 961**]
injections were applied for hemostasis at the base of the polyp
with stigmata of recent bleeding. [**Hospital1 **]-CAP Electrocautery was
applied for hemostasis successfully.
Excavated Lesions A single superficial non-bleeding 5mm ulcer
was found in the stomach body.
Duodenum: Normal duodenum.
Brief Hospital Course:
Impression: 68 yo w/ MMP now with recent GIB from likely
polypoid lesions s/p MICU stay, and severe PVD likely needing
[**Hospital1 1106**] surgery intervention.
Upper GI bleed
The patient has a history of GI bleeding and had a normal EGD in
the past several months per report. She was on aspirin and
plavix for her common iliac stent. During her hospitalization,
she had an episode of large volume hematemesis, requiring PRBC
support (x6 units) and a MICU transfer. There she underwent two
EGDs which demonstrated normal esophagus and normal duodenum,
but showed three polypoid lesions in the stomach, one of which
had stigmata of bleeding; she underwent epinephrine injection
and cauterization to this area. She also had a 5mm non bleeding
gastric ulcer. She was started on a [**Hospital1 **] ppi. Her HCT was
stable after this, and she had no further episodes of
hematemesis. GI recommended a repeat EGD in [**3-20**] months, and a
colonoscopy for age appropriate screening. These things were
conveyed in the discharge information to the patient and her
primary provider. [**Name10 (NameIs) **] aspirin and plavix were not reinitiated
on discharge and she will follow up with her [**Name10 (NameIs) 1106**] surgeon as
below. Given that she will likely have a surgical procedure
within the next two weeks, consideration of restarting her
plavix alone after surgery was recommended.
Chronic Pain
The patient presented with difficult to control lower extremity
pain and a change in mental status on admission. A head CT was
negative. Acute and chronic pain service consults were
obtained, and her mental status cleared on modification of her
pain regimen. A regimen of a fentanyl patch (25mcg q3 days),
MSSR (60 [**Hospital1 **]), amitryptiline (10 qhs), gabapentin (900 tid), and
4-8mg oral dilaudid q6h prn for breakthrough was finally arrived
at. She will follow up with her primary care physician
regarding pain management.
Peripheral [**Hospital1 1106**] disease and ulcerations
The patient was on [**Hospital1 **] and plavix after a common iliac stent and
angioplasty on right tibial artery. These two medications were
held given the GI bleed, and the patient was instructed to
follow up with Dr. [**Last Name (STitle) 60470**] regarding when to reinitiate
these medications. Dr. [**Last Name (STitle) 60470**] is planning for a STSG of
her RLE ulcerations in two to three weeks after discharge. She
was briefly on vancomycin given her history of MRSA colonization
of her RLE lesions, but this was discontinued prior to discharge
as there was no sign of infection.
CAD
The patient was continued on a beta blocker, losartan, and a
statin; her [**Last Name (STitle) **] was held in the setting of her GI bleed. She
was started on a small dose of lisinopril given her diabetes,
though she did not have proteinuria on this admission. She was
continued on lasix per her outpatient dose.
DM2
The patient was started on glargine insulin, and she was
discharged with 10 units qAM. The VNA will check fingerstick
values to ensure adequate control.
FEN:
The patient was kept on a diabetic, cardiac diet.
Ppx
The patient was discharged with a [**Hospital1 **] ppi, an aggressive bowel
regimen given her narcotics, and vitamin C, iron, phoslo, Zn.
ACCESS: right subclavian CVL, removed prior to discharge
Medications on Admission:
Lasix 20 mg [**Hospital1 **]
Protonix 40 mg daily
Colace 100 mg b.i.d.
Plavix 75 daily
Aspirin 325 mg
Losartan 100 mg daily
Toprol XL 150 mg daily
MS Contin 60mg [**Hospital1 **]
Oxycodone/Acetaminophen (5/325) [**1-16**] tab q4h prn
Nortriptyline 10 mg qhs
Gabapentin 300mg tid
Lipitor 10mg qd
Combivent
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): HOLD UNTIL TOLD TO RESTART BY [**Month/Day (2) **] SURGEON.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): HOLD UNTIL TOLD
TO RESTART BY [**Month/Day (2) **] SURGEON.
3. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Nortriptyline HCl 10 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-16**]
Puffs Inhalation Q6H (every 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Morphine Sulfate 30 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q12H (every 12 hours).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
Disp:*270 Capsule(s)* Refills:*2*
13. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): apply after showers.
Disp:*1 month supply* Refills:*2*
14. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 month supply* Refills:*2*
15. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
16. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
19. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
20. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous once a day: at breakfast.
21. Pantoprazole Sodium 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*
22. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
23. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
24. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
25. Lactulose 10 g Packet Sig: One (1) PO once a day as needed
for constipation.
Disp:*1 month supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses
- Upper GI bleed s/p EGD
- Right LE ulcerations
Secondary Diagnoses
- Type II Diabetes
- CAD
- HTN
- Severe peripheral [**Location (un) 1106**] disease s/p left AKA, right iliac
stenting and right tibial angioplasty
- Chronic pain
Discharge Condition:
Stable, HCT stable, tolerating an oral diet, per PT at baseline
function, pain adequately controlled, follow up in place.
Discharge Instructions:
We are discharging you today, though we strongly feel that it
would be more appropriate to fully change your pain medications
over to oral forms prior to your leaving the hospital. You
should discuss your pain regimen with your primary care provider
[**Name Initial (PRE) 3011**].
Hold off on taking your aspirin and plavix until you talk with
Dr. [**Last Name (STitle) **] tomorrow. Take your other medications as
prescribed. The VNA nurses should go over the changes with you
if you are confused about them.
It is very important for you to get a repeat "EGD" within [**3-20**]
months to re-evaluate your GI tract. Please coordinate this
with your primary care physician.
Followup Instructions:
Please see your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
([**Telephone/Fax (1) 60471**]) as scheduled today. Talk with him about your pain
management, getting a repeat "EGD" within 3-6 months, and
getting a routine screening colonoscopy. You should ask about
seeing a GI specialist at [**Hospital1 2177**] so your care is all coordinated,
or you can follow up at the [**Hospital 18**] [**Hospital **] clinic. You can call
[**Telephone/Fax (1) 1983**] to arrange this.
Keep the following appointment:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2163-5-4**] 10:00. Ask him about when to restart
the aspirin and plavix. The [**Month/Day/Year 1106**] surgeons plan to do your
surgery in ~2 weeks time.
|
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"211.1",
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icd9cm
|
[
[
[]
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[
"86.22",
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"45.13",
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icd9pcs
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[
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12261, 12318
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5652, 8982
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344, 350
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12612, 12735
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2966, 5629
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9337, 12238
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12339, 12591
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9008, 9314
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12759, 13438
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2168, 2947
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274, 306
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378, 1614
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1636, 1879
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1895, 2133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,399
| 118,793
|
33209
|
Discharge summary
|
report
|
Admission Date: [**2203-5-20**] Discharge Date: [**2203-5-30**]
Date of Birth: [**2151-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
CC:[**CC Contact Info 77154**]
Major Surgical or Invasive Procedure:
EGD. Push enteroscopy. Endotracheal intubation.
History of Present Illness:
51yoM with h/o heavy Etoh use and [**2199**] craniotomy for left
subdural due to fall +/- seizure in the setting of drunkeness,
transfered from [**Location (un) **] for GIB and anemia. History is pieced
together from records, pt not good historian. He was reportedly
found down today at home (unwitnessed, unclear how long down).
Brought to [**Location (un) **] with Hct 13.8, ETOH 460, INR of 2.2, ammonia
of 100. He may have had guiaic positive yellow/brown stool there
per the ED dash. CT head with 3mm hyperdensity L
fontal/parietal, ? new blood vs changes from old SDH at same
site. Placed 20G IV there. BPs were stable en route to [**Hospital1 **] with
SBP 100, HR 90.
.
Upon arrival, SBPs 80-90. Cordis placed in right IJ. Patient
states that he had been in a fight earlier in the week -- his
daughter's boyfriend may have punched him in the eye, unclear.
[**Name2 (NI) **] was noted to be jaundiced with severe anasarca. He was guiaic
negative with no stool in the vault on signout.
.
In ED, initial VS 97.4, 103, 98/44, 16, 100/2L.
Labs in ED showed:
WBC 13.2, N 79.9, Hct 14.2, Platelets 168. INR 1.7, PTT 39.5.
UA with few bact, 5 WBC, elevated glucose, protein, ketone.
Trop 0.01, creatinine 0.9.
ALT 40, AP 226, TB 8.6, DB 6.7, Alb 2.3, Lipase 88.
.
Multiple images showed chronic fractures per ED. CT chest with
contrast with sternal mid body fracture without hematoma new
since [**2198**], right 11th posterior rib deformity likely subacute
with more chronic rib deformities in right 8.9 ribs, trace b/l
pleural effusions vs subpleural fat, anasarca, ascites. CT
C-spine without acute fracture. CT head with b/l subdural
hematomas measuring 3mm in max diameter without shift. CT abd
and pelvis with small b/l pleural effusions and adjacent
atelectasis, free fluid without hemoperitoneum, mild anasarca,
subacute Right post 11th rib fracture. CXR with chronic sternal
fracture and rib fractures.
.
Peritoneal fluid with 12 WBC, 246 RBC, 12 poly, protein 0.9, Glu
171. Cultures were sent of the peritoneal fluid.
.
Most concerning, was a L parietal/temporal hemorrhage which is
not apparently new. Seen by neurosurgery but nothing to do. GI
wants NG lavage but ED team feels hesitant doing it down in ED.
.
He received Octreotide 0.6mg, Zofran, Vitamin K 10mg IV X 1,
Morphine 4mg, Lactulose 45 mg PO x1, Neomycin 3gm PO x1, 1g IV
Ceftriaxone. On Octreotide and Protonix gtts now. He was
transfused 4u PRBC's, 2u FFP, 2u platelets, and 2.5 L NS.
.
VS on tranfer were, 85, 98/44 -> 106/85, 16, on NC. He was
getting either his third or fourth U of PRBC. Twin brother will
be in on Saturday.
.
ROS: He states he's had 6 months of BRBPR (last episode a long
time ago) and melena (last episode 1 mo ago) and no other blood
loss otherwise. Increased abdominal distention for the past [**1-6**]
months. Endorses PND and orthopnea, SOB. Negative for f/c/ns,
CP, abd pain, dizziness/LH. He has been drinking everyday, pints
of vodka. States last episode of hematemesis was 8 months ago at
which point he was "operated on" and [**Location (un) **] and had to have his
stomach pumped -- again poor history.
Past Medical History:
- History of heavy etoh use (1 quart vodka daily)
- S/p craniotomy in [**2199**] for L SDH with shift, at that time
noted chronic bilateral subdurals as well
- GERD
- depression
Social History:
Smoked from 8 yrs old until [**5-13**] yrs ago; heavy ETOH use - 1
quart vodka/daily, lives with wife [**Telephone/Fax (1) 77153**] ([**Doctor Last Name 1356**]). Has 22
yo daughter, no IVDU or drug use now.
Family History:
M - EtOH
F - deceased at 87yo
Physical Exam:
97 p94 - 105 108/50 (105-124) 15 94% 4LNC
Very large and obviously jaundiced and distended M in no
distress, smells of EtOH. Conversant but slow speech, not
slurred.
Bilateral eyes with purulent crust in eyes, scleral edema, and
scleral icterus
Mouth dry but no obvious lesions, did not open mouth very wide,
unable to assess OP
CTAB anteriorly without w/c/r/r
Low grade tachycardia but regular, no m/g
Abd grossly distended and slightly tight, +caput medusae
Gross anasarca along abdominal wall, BUE's and BLE's
CN 2-12 grossly intact, no focal neuro deficit noted
Pertinent Results:
OSH labs: WBC 16.5, Hct 13.8, Plts 176
Ammonia 102, BUN/Cr 18/0.8, Tbili 9.1, AST 151, ALT 36, Lipase
79, AlkP 218, CK 278, MB 4.3, INR 2.2, Tylenol negative, EtOH
468
.
EKG: NSR at 101, normal QRS axis, normal P waves, sub 1-mm STD's
in V4-6, diffusely smaller complexes in comparison to prior EKG.
CT Abd/Pelvis: [**2203-5-19**]
IMPRESSION:
1. Bilateral trace pleural effusions versus pleural fat with
adjacent
compressive atelectasis.
2. Simple free fluid (ascites) noted within the abdomen with no
hemoperitoneum.
CT Head [**5-19**]:
IMPRESSION:
1. Bilateral subacute to chronic subdural hematomas.
2. Enlarged right parotid gland; correlate with clinical
examination and
history. There is suggestion on prior exams, this may be
chronic.
CT C-spine [**5-19**]:
IMPRESSION:
1. No acute fracture identified.
2. There appears to be obliteration of much of the [**Last Name (un) **] and
oropharynx upto
the level of the epiglottis which may reflect external
compression versus
material within the pharynx (3;11). Beyond the epiglottis the
airway is
patent.
Recommend clinical correlation and examination. Findings
discussed with Dr.
[**Last Name (STitle) **] at 3;40am on [**2203-5-19**] via telephone.
CT Chest [**5-19**]:
IMPRESSION:
1. Eleventh posterior right rib deformity consistent with
subacute fracture.
Additional more chronic-appearing fractures are noted along the
right eighth
and ninth ribs.
2. Lucency through the sternal body with no significant
surrounding hematoma
may represent a sternal fracture of indeterminate chronicity,
correlate
clinically.
3. Bilateral trace pleural effusions versus pleural fat with
adjacent
compressive atelectasis.
RUQ/Abdominal US [**5-20**]:
IMPRESSION: Moderate amount of ascites seen within the abdomen.
Very
echogenic liver consistent with fatty infiltration. The degree
of
echogenicity severely limits the ability to visualize the liver.
Patent left
portal vein. The remainder of the exam is virtually
nondiagnostic as
ultrasound is unable to visualize the patient's anatomy due to
the body
habitus.
TTE [**5-26**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF 65%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is mild posterior leaflet mitral valve
prolapse. An eccentric, anteriorly directed jet of Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
RUQ US ([**5-28**]):
IMPRESSION:
1. Cirrhosis of the liver. Hepatofugal flow in the main and left
portal vein
(through periumbilical vein) suggests portal hypertension.
Stable mild
splenomegaly.
2. Mildly distended gallbladder, without evidence of
cholelithiasis or
son[**Name (NI) 493**] signs specific for cholecystitis.
3. Moderate amount of ascites. The above findings were discussed
with Dr.
[**Last Name (STitle) 3419**] at 12:50 p.m. on [**2203-5-28**].
CT chest/abdomen/pelvis [**5-28**]
IMPRESSION:
1. Left upper lobe consolidation. While the imaging appearance
is most
consistent with atelectasis, the location is somewhat unusual,
and the airways
appear patent. Thus, it is difficult to definitively exclude
pneumonia.
Lungs are otherwise clear with no further evidence of infectious
process in
the chest.
2. Enlargement of the pulmonary artery measuring up to 4 cm,
suggesting
underlying pulmonary hypertension.
3. Engorgement of the upper lobe pulmonary vessels without frank
pulmonary
edema.
4. Hepatosteatosis. No focal liver lesions.
5. Cholelithiasis without CT evidence of cholecystitis.
6. Mild splenomegaly.
7. Small-moderate simple ascites. No loculated collection to
suggest abscess
formation. No other evidence of intraabdominal infection.
8. Multiple thoracic vertebral bodies segmentation anomalies, as
previously
detailed on chest CT [**2203-5-19**].
[**2203-5-20**] 08:56PM WBC-13.3* RBC-2.45* HGB-7.4* HCT-22.2* MCV-91
MCH-30.1 MCHC-33.2 RDW-20.3*
[**2203-5-20**] 08:56PM PLT COUNT-179
[**2203-5-20**] 08:56PM PT-16.8* PTT-36.2* INR(PT)-1.5*
[**2203-5-20**] 08:56PM FIBRINOGE-264
[**2203-5-20**] 04:47PM WBC-15.5* RBC-2.77* HGB-8.0* HCT-25.1* MCV-91
MCH-28.9 MCHC-31.9 RDW-20.2*
[**2203-5-20**] 04:47PM PLT COUNT-192
[**2203-5-20**] 04:47PM PT-16.6* PTT-36.1* INR(PT)-1.5*
[**2203-5-20**] 04:47PM FIBRINOGE-320
[**2203-5-20**] 04:34PM ASCITES TOT PROT-0.9 GLUCOSE-180 CREAT-1.0
LD(LDH)-69 ALBUMIN-<1
[**2203-5-20**] 04:34PM ASCITES WBC-75* RBC-1800* POLYS-7* LYMPHS-1*
MONOS-0 MESOTHELI-8* MACROPHAG-84*
[**2203-5-20**] 01:23PM TYPE-CENTRAL VE PO2-63* PCO2-49* PH-7.28*
TOTAL CO2-24 BASE XS--3
[**2203-5-20**] 01:23PM LACTATE-1.5
[**2203-5-20**] 01:23PM freeCa-1.07*
[**2203-5-20**] 01:16PM WBC-17.3* RBC-2.60* HGB-7.4* HCT-23.5* MCV-91
MCH-28.6 MCHC-31.6 RDW-20.5*
[**2203-5-20**] 01:16PM PLT COUNT-230
[**2203-5-20**] 01:16PM PT-16.6* PTT-36.1* INR(PT)-1.5*
[**2203-5-20**] 01:16PM FIBRINOGE-317
[**2203-5-20**] 01:12PM GLUCOSE-163* UREA N-21* CREAT-1.0 SODIUM-138
POTASSIUM-5.2* CHLORIDE-107 TOTAL CO2-22 ANION GAP-14
[**2203-5-20**] 01:12PM CALCIUM-7.7* PHOSPHATE-4.8* MAGNESIUM-2.2
[**2203-5-20**] 08:22AM LACTATE-1.7
[**2203-5-20**] 08:13AM GLUCOSE-165* UREA N-21* CREAT-1.1 SODIUM-137
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-14
[**2203-5-20**] 08:13AM ALT(SGPT)-43* AST(SGOT)-191* LD(LDH)-313*
CK(CPK)-155 ALK PHOS-213* TOT BILI-10.6*
[**2203-5-20**] 08:13AM CK-MB-5 cTropnT-<0.01
[**2203-5-20**] 08:13AM WBC-15.1* RBC-2.27* HGB-6.5* HCT-20.6* MCV-91
MCH-28.8 MCHC-31.6 RDW-21.0*
[**2203-5-20**] 08:13AM PLT COUNT-206
[**2203-5-20**] 08:13AM PT-16.8* PTT-36.8* INR(PT)-1.5*
[**2203-5-20**] 08:13AM FIBRINOGE-296
[**2203-5-20**] 08:13AM WBC-15.1* RBC-2.27* HGB-6.5* HCT-20.6* MCV-91
MCH-28.8 MCHC-31.6 RDW-21.0*
[**2203-5-20**] 08:13AM PLT COUNT-206
[**2203-5-20**] 08:13AM PT-16.8* PTT-36.8* INR(PT)-1.5*
[**2203-5-20**] 08:13AM FIBRINOGE-296
[**2203-5-20**] 02:53AM GLUCOSE-153* UREA N-19 CREAT-1.0 SODIUM-136
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-19* ANION GAP-17
[**2203-5-20**] 02:53AM ALT(SGPT)-41* AST(SGOT)-198* LD(LDH)-346* ALK
PHOS-233* TOT BILI-9.7*
[**2203-5-20**] 02:53AM CALCIUM-7.7* PHOSPHATE-4.5 MAGNESIUM-2.2
[**2203-5-20**] 02:53AM WBC-14.6* RBC-2.44*# HGB-7.0*# HCT-22.1*#
MCV-91 MCH-28.8 MCHC-31.7 RDW-20.9*
[**2203-5-20**] 02:53AM PLT COUNT-216
[**2203-5-20**] 02:53AM PT-17.5* PTT-37.6* INR(PT)-1.6*
[**2203-5-19**] 10:15PM ASCITES TOT PROT-0.9 GLUCOSE-171 ALBUMIN-0.5
[**2203-5-19**] 10:15PM ASCITES WBC-12* RBC-246* POLYS-12* LYMPHS-4*
MONOS-0 MESOTHELI-20* MACROPHAG-64*
[**2203-5-19**] 10:00PM GLUCOSE-125* UREA N-18 CREAT-0.9 SODIUM-136
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
[**2203-5-19**] 10:00PM estGFR-Using this
[**2203-5-19**] 10:00PM ALT(SGPT)-40 AST(SGOT)-163* CK(CPK)-219 ALK
PHOS-226* TOT BILI-8.6* DIR BILI-6.7* INDIR BIL-1.9
[**2203-5-19**] 10:00PM LIPASE-88*
[**2203-5-19**] 10:00PM cTropnT-<0.01
[**2203-5-19**] 10:00PM ALBUMIN-2.3* CALCIUM-7.6* PHOSPHATE-3.2
MAGNESIUM-2.2 IRON-21*
[**2203-5-19**] 10:00PM calTIBC-213* FERRITIN-43 TRF-164*
[**2203-5-19**] 10:00PM ACETMNPHN-NEG
[**2203-5-19**] 10:00PM WBC-13.2* RBC-1.51*# HGB-4.1*# HCT-14.2*#
MCV-94 MCH-27.2# MCHC-29.0*# RDW-23.5*
[**2203-5-19**] 10:00PM NEUTS-79.9* LYMPHS-14.1* MONOS-4.9 EOS-0.5
BASOS-0.7
[**2203-5-19**] 10:00PM PLT COUNT-168#
[**2203-5-19**] 10:00PM URINE COLOR-DkAmb APPEAR-SlHazy SP [**Last Name (un) 155**]-1.015
[**2203-5-19**] 10:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-15 BILIRUBIN-LG UROBILNGN-4* PH-5.0 LEUK-NEG
[**2203-5-19**] 10:00PM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-6
[**2203-5-19**] 10:00PM URINE HYALINE-42*
[**2203-5-19**] 10:00PM URINE MUCOUS-OCC
[**2203-5-19**] 09:03PM PT-18.5* PTT-39.5* INR(PT)-1.7*
Brief Hospital Course:
The patient had presented with a GI bleed on [**2203-5-20**]. He had
two EGDs and a small bowel enteroscopy performed during this
hospitalization which showed varices which were not actively
bleeding and were too small to intervene upon. His source of GI
bleed was believed to be secondary to portal hypertensive
gastropathy as well as abnormal mucosa in the duodenum with
evidence of active diffuse oozing which was not intervenable. A
raised lesion was also noted in the stomach body which did not
show evidence of active bleed, but 2 endoclips were placed on
[**5-29**] at the time of the enteroscopy. A family meeting was held
at which time it was decided that further escalation of care
would be medically futile, and the patient was made DNR/DNI,
with no further escalation of care. It was decided not to check
daily labs, not to transfuse further blood products, and not to
increase pressor doses. The patient had continued to have
active rectal bleeding with dark red blood in his stool until
the time of death. The patient became hypotensive for 2 hours
prior to time of death with progressively decreasing blood
pressures, likely secondary to his GI bleed which was due to his
end stage liver disease. He then became progressively
bradycardic until his rhythm became asystolic, and the time of
death was pronounced as 20:55 on [**2203-5-30**], with chief cause of
death recorded as gastrointestinal bleed, immediate cause of
death cardiac arrest, and antecedent cause of death hypotension.
His family, including his daughter, [**Name (NI) 53239**] [**Name (NI) 14840**], who was
his health care proxy, his twin brother [**Name (NI) **] [**Name (NI) 14840**], and
his sister [**Name (NI) **] were notified of his death. The family refused
an autopsy. The primary care physician, [**Name10 (NameIs) 17029**], [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] was attempted to be contact[**Name (NI) **] but his covering physician
did not return the page to inform him of the patient??????s death.
The MICU team will attempt to contact his PCP again in the
morning.
Medications on Admission:
none. States was previously on Paxil, Wellbutrin, denies ever
being on Spironolactone, Lasix, Nadolol, other liver meds.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
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|
3745, 3954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,807
| 189,602
|
45115
|
Discharge summary
|
report
|
Admission Date: [**2187-10-24**] Discharge Date: [**2187-10-30**]
Date of Birth: [**2104-1-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ditropan XL / Norvasc
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
83 yo female with history of HTN, HLD, CAD, stage IV CKD, COPD,
dCHF (EF >55%) with multiple recent admissions for CHF last
discharged [**2187-10-23**] who developed palpitations while being
dialyzed and was found to be in rapid afib. Patient does not
have a prior history of afib. At dialysis, EKG revealed afib to
140. She was given Cardizem bolus then gtt and her pressure
"tanked" to SBP 80-100. She had an episode of hypotension
followed by nausea and vomiting, but denied CP, SOB, F or C.
She reported posterior neck pain but noted this was chronic and
related to positioning. A left femoral central line was placed
in the field and she was started on neo. Two peripherals, 24
and 20 were placed in her feet.
.
In the ED, vitals upon admission were 97.9 120 121/72 22 100%
2L. She arrived from OSH off neo in rapid afib to 140 with
systolic bp over 100. Cardiology consult was obtained and
recommended CCU admission with cardioversion. V/S prior to
transfer: 100/61 148 97% on 3L.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
CAD- per pt. No records of this at [**Hospital1 18**]
dCHF
Stage 4-5 CKD c/b anemia and secondary hyperparathyroidism
R carotid stenosis
Depression
Asthma
Osteoporosis
Osteoarthritis
R hip fx s/p ORIF
Thyroid disease- h/o both hypo and hyperthyroidism
Vitamin D deficiency - 25 OH 19 [**2-15**]
Benign adnexal cyst followed [**8-18**] and planned again for imaging
[**8-19**]
Chronic Aspiration- based on video swallow eval [**8-18**]
Chronic labyrinthitis
h/o L pneumothorax
Social History:
SOCIAL HISTORY: Widowed, no smoking, etoh, illicits. Has been
living at home with her son and his fiance with [**Name (NI) 269**] assistance
and private home care services.
.
Family History:
Son with heart surgery for unknown reason on fall [**2185**].
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission PE:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Dilated L pupil (for years per
PT), EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
NECK: Supple
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur best heard at the
RUSB.
No thrills, lifts. No S3 or S4.
LUNGS: Bibasilar crackles, no wheezing
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ edema b/l.
Discharge PE:
Vitals - Tm/Tc:98.0/97.5 HR: 60-69 BP:103-115/50 RR:16-20 02
sat:100% RA
.
GENERAL: 83 yo F in no acute distress, lying in bed
HEENT: mucous membs dry, no lymphadenopathy, JVP non elevated
CHEST: Crackles left base, no wheezes, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR, 2/6 systolic
murmur best heard at the RUSB.
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: wwp, no edema. DPs, PTs 1+.
NEURO: A/O x3, HOH. MAE.
SKIN: stage 2 pressure sore on coccyx. Pt developed this at
home. No drainage, redness.
Pertinent Results:
Admission labs:
[**2187-10-23**] 06:40AM BLOOD WBC-6.3 RBC-2.65* Hgb-8.9* Hct-25.6*
MCV-97 MCH-33.6* MCHC-34.7 RDW-14.5 Plt Ct-210
[**2187-10-24**] 07:05PM BLOOD WBC-8.2 RBC-2.54* Hgb-8.5* Hct-24.5*
MCV-97 MCH-33.5* MCHC-34.8 RDW-15.6* Plt Ct-202
[**2187-10-23**] 06:40AM BLOOD Plt Ct-210
[**2187-10-24**] 07:05PM BLOOD PT-12.2 PTT-27.3 INR(PT)-1.0
[**2187-10-23**] 06:40AM BLOOD Glucose-88 UreaN-20 Creat-3.2*# Na-136
K-4.9 Cl-101 HCO3-28 AnGap-12
[**2187-10-24**] 07:05PM BLOOD Glucose-115* UreaN-11 Creat-2.0*# Na-143
K-3.5 Cl-101 HCO3-32 AnGap-14
[**2187-10-24**] 07:05PM BLOOD CK(CPK)-47
[**2187-10-24**] 07:05PM BLOOD CK-MB-8 proBNP-[**Numeric Identifier 27607**]*
[**2187-10-25**] 02:51AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
Discharge labs:
[**2187-10-30**] 06:55AM BLOOD WBC-6.9 RBC-3.20* Hgb-10.5* Hct-30.5*
MCV-95 MCH-32.7* MCHC-34.2 RDW-19.0* Plt Ct-284
[**2187-10-30**] 06:55AM BLOOD PT-24.2* INR(PT)-2.3*
[**2187-10-30**] 06:55AM BLOOD Glucose-93 UreaN-36* Creat-4.6*# Na-139
K-4.6 Cl-99 HCO3-31 AnGap-14
[**2187-10-30**] 06:55AM BLOOD Calcium-9.4 Phos-2.1* Mg-2.3
[**2187-10-26**] 12:42PM BLOOD VitB12-1498* Folate-GREATER TH
[**2187-10-26**] 12:42PM BLOOD TSH-2.0
Vitamin D pending.
Brief Hospital Course:
83 yo female with history of HTN, HLD, CAD, stage IV CKD, COPD,
dCHF (EF >55%) with multiple recent admissions for CHF last
discharged [**2187-10-23**] who developed palpitations while being
dialyzed and was found to be in rapid afib.
.
# AFib w/RVR. Had hypotension (SBPs 80-100) after diltiazem
given in field. Unclear etiology of new onset Afib. Most likely
cause is worsening CHF with atrial distension. Spontaneously
converted to NSR and started on admiodarone with approx 5 gram
load (400 mg [**Hospital1 **] for 1 week). Metoprolol was also increased to
100 mg daily. Will need to follow HR and decrease metoprolol as
needed as amiodarone load cont. CHADS score 3 so started on
warfarin at 5mg x 2 doses, [**Month (only) **] to 4mg on [**10-30**] and will
discharge on 3mg [**10-31**] and thereafter. Please follow INR closely
as amiodarone will cause higher INR on lower dose. Holding
albuterol to prevent tachycardia but may restart if pt becomes
wheezy now that she is rate controlled.
.
#Hypotension: Related to rate especially in setting of dCHF.
continued to be an issue during dialysis but treatment today was
tolerated well. Diltiazem caused briefly depressed BPs.
Transiently required pressor support. Now with SBP 93-115 on
metoprolol. Home dose of Lisinopril 5mg was not continued [**1-10**]
low blood pressure but should be considered in the setting of
CHF.
.
# Acute on chronic Diastolic Congestive heart failure: Recent
admission (DC [**10-23**]) for dCHF in setting of elevated BP and
flash pulm edema. DC at 53 KG though dry weight was 51KG she had
hypotension during dialysis so her dry weight was not achieved.
She is 49.0 KG at discharge and this should be considered her
new dry weight. Fluid management per dialysis. She is on long
acting beta blocker but no ACE inhibitor as noted above, this
should be considered.
.
#ESRD: on HD. Sevelamer d/c'ed as phosphorus low. Cont on
nephrocaps and calcitriol. Receives epogen in HD. Noted Vitamin
D deficiency in PMH but did not have supplement on her home
medicaton list. Vitamin D 25 Hydroxy is pending at discharge but
would suggest vitamin D as per nephrology.
.
#Hyperlipidemia: Cont atorvastatin
.
#Depression: Cont Venlafaxine
..
Transitional Issues:
#1 Pt will be discharged with [**Doctor Last Name **] of Hearts event monitor and
will need to send transmissions to the [**Hospital1 18**] Holter Lab as
directed
#2 consider Vitamin D supplementation as per nephrology
#3 Follow heart rate and decrease metoprolol for low HR or BP
#4 check INR with labs on [**11-1**] and adjust warfarin dose,
continue frequent monitoring as amiodarone interaction can occur
late
#5 Please make primary care appt at discharge from
rehabilitation
Medications on Admission:
1. acetaminophen 325 mg Tablet PO Q6H as needed for pain.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Inhalation Q6H as needed for wheezing/SOB.
3. B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
4. calcitriol 0.25 mcg PO DAILY
5. docusate sodium 100 mg Capsule PO BID
6. ipratropium bromide 0.02 % Solution Inhalation Q6H
7. polyethylene glycol 3350 17 gram/dose PO DAILY
8. senna 8.6 mg Tablet PO BID as needed for constipation.
9. sevelamer carbonate 800 mg Tablet PO TID W/MEALS
10. venlafaxine 150 mg Capsule, Ext Release 24 hr PO QHS
11. bisacodyl 5 mg Tablet, Delayed Release Two PO DAILY as
needed for
constipation.
12. metoprolol tartrate 37.5 mg Tablet PO BID
13. atorvastatin 80 mg Tablet PO DAILY
Discharge Medications:
1. Colace 100 mg Capsule Sig: Two (2) Capsule PO twice a day.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for wheezing/shortness
of breath.
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
9. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 3 days: last day [**2187-11-1**], then decrease to 200 mg
daily therafter.
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**2187-11-2**].
13. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Outpatient Lab Work
Please check CBC, Chem 7 and INR on Thursday [**11-1**].
15. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for continuing medical care
Discharge Diagnosis:
New onset atrial fibrillation with rapid ventricular response
End stage renal disease
Chronic diastolic congestive heart failure
Anemia of chronic disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 96427**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you had
heart palpitations, and we found that your heart was beating
fast and it was in an irregular rhythm called atrial
fibrillation. YOu were started on a medicine called amiodarone
and your heart rhythm converted back to a normal rhythm. Atrial
fibrillation makes you much more likely to have a stroke so you
were started on a medicine called warfarin, a blood thinner, to
prevent a stroke. You will need to get your blood level of
warfarin checked regularly to make sure your warfarin level is
not too high or too low. The goal warfarin level is 2.0-3.0. You
also received a unit of blood because your blood count was low,
it is still low but much closer to what it normally is now.
.
We made the following changes to your medicines:
1. START taking amiodarone to lower your heart rate and keep you
in a normal rhythm
2. START taking warfarin (coumadin) to prevent a stroke with the
atrial fibrillation
3. INCREASE tylenol to three times a day to prevent any pain and
help you with physical therapy
4. INCREASE colace to prevent constipation
5. Decrease atorvastatin to 40 mg daily to lower your
cholesterol
6. STOP taking Albuterol as this could cause a fast heart rate.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2187-11-14**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **], [**Hospital 18**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2187-10-30**]
|
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"285.21",
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] |
icd9cm
|
[
[
[]
]
] |
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,578
| 179,661
|
14566
|
Discharge summary
|
report
|
Admission Date: [**2182-2-23**] Discharge Date: [**2182-2-26**]
Date of Birth: [**2138-9-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Erythromycin Base / Levofloxacin
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Dyspnea, hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
REASON FOR MICU TRANSFER: pneumonia; trach-dependent chronic
respiratory failure
.
HISTORY OF PRESENT ILLNESS: 43 year old man with Duchenne
muscular dystrophy with chronic respiratory failure s/p
tracheostomy who is ventilator dependent (for chest
expansion/volume, not oxygen). He has been having increasing SOB
and rust-colored sputum from his trach, and has not been as
comfortable with his normal titer volume on his vent (700). He
has had two recent pneumonias, both of which were treated with
ciprofloxacin, the last one approximately 2 weeks ago. These
were managed at home by his pulmonologist. Today, given the
increasing oxygen requirement he went to the [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **] where he
was noted to have a leukocytosis (WBC 19.9 with 87%PMNs) and
lactate 2.6. CXR showed right-sided pneumonia. He was given
vancomycin 1.5g and was transferred to [**Hospital1 18**] given lack of ICU
beds at [**Location (un) 5871**].
.
In the [**Hospital1 18**] ED initial VS were: 98.8, 68, 100/64, 16, 100%.
Labs notable for WBC 19.2 (90% PMN) with normal lactate. Initial
ABG was 6.9/113/101/24 on 100% FiO2. He was difficult to
ventilate which was thought to be secondary to the placement of
the trach. He was given vecuronium, his trach was readjusted,
and Dr. [**Last Name (STitle) **] [**Name (STitle) 42972**] him in the ED and suctioned mucus from
the right lung and BAL was sent. His subsequent ABG were
7.26/34/275/16 on 100% FiO2, and then 7.18/47/128/18. A repeat
CXR confirmed likely right-sided pneumonia. He was given
levofloxacin 750mg IV but developed a rash around the IV, so the
antibiotic was stopped. He was febrile to 101.2 and most recent
VS prior to transfer are: 98, 117/83, 98% on Fi02 100%, PEEP 5,
RR 20, TV 350. He is currently on versed/fentanyl.
.
On arrival to the MICU, the patient is ventilated by the trach.
He is sedated and paralyzed.
.
Past Medical History:
PAST MEDICAL HISTORY:
- Duchenne muscular dystrophy
- Chronic respiratory failure s/p trach [**2170**], vent-dependent
- Bronchiectasis
- S/p cardiac arrest in [**2163**] in setting of viral pnumonia, s/p
ICD
- Left ventricular ejection fraction of 37% by cardiac MRI in
[**2173**] at [**Hospital3 1810**]
- H/o ventricular tachycardia [**8-/2180**] (thought most likely due to
an atrial flutter conducting 1:1 across the AV node in the
setting of his baseline abnormal QRS complex)
- Long QT interval
- Right bundle branch block
- Scoliosis
- Cholelithiasis
- S/p open gastrectomy and PEG tube placement
Social History:
He lives with his [**Last Name (LF) **], [**First Name3 (LF) 4559**] and Pirina. He has nursing
care 5 days a week. He is a nonsmoker and denies alcohol use.
Family History:
Mother has arrhythmia for which she takes metoprolol; father had
CABG for CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 96/58, 65, 24, 100% on FiO2 100%
General: Trached, sedated, paralyzed
HEENT: Sclera anicteric, PEERL
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds bilaterally, L>R
Abdomen: Obese, soft, non-tender, bowel sounds present
GU: + foley
Ext: Feet contracted and cool to touch, rest of body WWP, no
peripheral edema
Neuro: Unable to assess
Access: Right femoral triple lumen, 22-gauge in left hand
.
DISCHARGE PHYSICAL EXAM:
Tmax: 37.3 ??????C (99.1 ??????F) Tc: 36.7 ??????C (98.1 ??????F) HR: 60 (60 - 85)
bpm BP: 81/42(54) {79/42(54) - 146/91(107)} mmHg RR: 14 (14 -
16) insp/min SpO2: 99%
General: Trached, interactive
HEENT: Sclera anicteric, PEERL
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds bilaterally, otherwise clear to
auscultation bilaterally
Abdomen: Obese, soft, non-tender, bowel sounds present
GU: + foley
Ext: Feet contracted and cool to touch, rest of body WWP, no
peripheral edema
Neuro: Alert and oriented, CN grossly intact, otherwise unable
to asses
Pertinent Results:
[**2182-2-23**] 11:42PM VANCO-26.4*
[**2182-2-23**] 05:42PM TYPE-ART TEMP-36.6 PO2-203* PCO2-28* PH-7.40
TOTAL CO2-18* BASE XS--5 INTUBATED-INTUBATED
[**2182-2-23**] 05:42PM LACTATE-0.6
[**2182-2-23**] 05:42PM freeCa-1.14
[**2182-2-23**] 02:15PM GLUCOSE-71 UREA N-8 CREAT-0.0* SODIUM-134
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-17* ANION GAP-11
[**2182-2-23**] 02:15PM CK(CPK)-74
[**2182-2-23**] 02:15PM CK-MB-5 cTropnT-<0.01
[**2182-2-23**] 02:15PM WBC-7.0 RBC-3.99* HGB-11.4* HCT-35.8* MCV-90
MCH-28.5 MCHC-31.9 RDW-16.4*
[**2182-2-23**] 02:15PM PLT COUNT-200
[**2182-2-23**] 11:45AM TYPE-ART TEMP-36.5 RATES-20/ TIDAL VOL-450
PEEP-10 O2-50 PO2-234* PCO2-25* PH-7.45 TOTAL CO2-18* BASE XS--4
-ASSIST/CON INTUBATED-INTUBATED
[**2182-2-23**] 11:45AM LACTATE-1.0
[**2182-2-23**] 09:56AM TYPE-ART TEMP-37.0 RATES-20/ TIDAL VOL-450
PEEP-10 O2-50 PO2-240* PCO2-27* PH-7.42 TOTAL CO2-18* BASE XS--4
-ASSIST/CON INTUBATED-INTUBATED
[**2182-2-23**] 09:56AM GLUCOSE-92 LACTATE-1.0 NA+-135 K+-2.9*
[**2182-2-23**] 09:56AM freeCa-1.06*
[**2182-2-23**] 09:45AM GLUCOSE-97 UREA N-11 CREAT-0.0* SODIUM-137
POTASSIUM-3.2* CHLORIDE-111* TOTAL CO2-18* ANION GAP-11
[**2182-2-23**] 09:45AM CALCIUM-7.5* PHOSPHATE-2.0*# MAGNESIUM-1.9
[**2182-2-23**] 09:45AM OSMOLAL-281
[**2182-2-23**] 09:45AM WBC-9.4# RBC-4.05* HGB-11.6*# HCT-36.3*#
MCV-90 MCH-28.6 MCHC-31.9 RDW-16.1*
[**2182-2-23**] 09:45AM NEUTS-82.2* LYMPHS-11.9* MONOS-5.5 EOS-0.2
BASOS-0.2
[**2182-2-23**] 09:45AM PLT COUNT-191
[**2182-2-23**] 09:45AM PT-17.5* PTT-36.4 INR(PT)-1.6*
[**2182-2-23**] 08:01AM TYPE-ART TEMP-37.0 RATES-24/24 TIDAL VOL-490
PEEP-10 O2-100 PO2-458* PCO2-22* PH-7.47* TOTAL CO2-16* BASE
XS--4 AADO2-236 REQ O2-47 INTUBATED-INTUBATED VENT-CONTROLLED
[**2182-2-23**] 08:01AM LACTATE-0.7
[**2182-2-23**] 08:01AM freeCa-1.09*
[**2182-2-23**] 04:14AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2182-2-23**] 04:14AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2182-2-23**] 04:14AM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
[**2182-2-23**] 03:47AM estGFR-Using this
[**2182-2-23**] 03:47AM estGFR-Using this
[**2182-2-23**] 03:47AM CK(CPK)-94
[**2182-2-23**] 03:38AM TYPE-ART O2-100 PO2-275* PCO2-34* PH-7.26*
TOTAL CO2-16* BASE XS--10 AADO2-407 REQ O2-71
[**2182-2-23**] 03:38AM LACTATE-2.0
[**2182-2-23**] 02:39AM TYPE-ART O2-100 PO2-101 PCO2-113* PH-6.90*
TOTAL CO2-24 BASE XS--14
[**2182-2-24**] 01:43AM BLOOD WBC-6.7 RBC-3.92* Hgb-11.0* Hct-35.5*
MCV-90 MCH-28.1 MCHC-31.1 RDW-16.6* Plt Ct-189
[**2182-2-25**] 06:22AM BLOOD WBC-6.4 RBC-3.97* Hgb-11.2* Hct-35.4*
MCV-89 MCH-28.3 MCHC-31.7 RDW-16.7* Plt Ct-227
[**2182-2-26**] 04:08AM BLOOD WBC-6.0 RBC-3.91* Hgb-11.1* Hct-34.8*
MCV-89 MCH-28.3 MCHC-31.8 RDW-16.9* Plt Ct-192
[**2182-2-23**] 02:15PM BLOOD Plt Ct-200
[**2182-2-25**] 06:22AM BLOOD Plt Ct-227
[**2182-2-26**] 04:08AM BLOOD Plt Ct-192
[**2182-2-24**] 01:43AM BLOOD Glucose-60* UreaN-9 Creat-0.0* Na-136
K-4.0 Cl-108 HCO3-17* AnGap-15
[**2182-2-24**] 12:20PM BLOOD Glucose-76 UreaN-12 Creat-0.2* Na-137
K-3.9 Cl-107 HCO3-11* AnGap-23*
[**2182-2-24**] 06:45PM BLOOD Glucose-91 UreaN-11 Creat-0.1* Na-135
K-3.5 Cl-107 HCO3-12* AnGap-20
[**2182-2-26**] 04:08AM BLOOD Glucose-87 UreaN-8 Creat-0.0* Na-136
K-3.7 Cl-108 HCO3-17* AnGap-15
[**2182-2-23**] 03:47AM BLOOD CK(CPK)-94
[**2182-2-23**] 02:15PM BLOOD CK(CPK)-74
[**2182-2-24**] 01:43AM BLOOD Calcium-8.6 Phos-2.1* Mg-1.9
[**2182-2-24**] 12:20PM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
[**2182-2-24**] 06:45PM BLOOD Calcium-8.4 Phos-1.9* Mg-1.8
[**2182-2-25**] 06:22AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.3
[**2182-2-26**] 04:08AM BLOOD Calcium-8.3* Phos-1.6* Mg-2.0
[**2182-2-23**] 11:42PM BLOOD Vanco-26.4*
[**2182-2-24**] 11:06AM BLOOD Vanco-22.4*
[**2182-2-24**] 06:45PM BLOOD Vanco-16.2
[**2182-2-24**] 05:43AM BLOOD Type-[**Last Name (un) **] Temp-36.8 pH-7.39
[**2182-2-24**] 12:01PM BLOOD Type-ART Temp-36.7 Tidal V-600 PEEP-10
FiO2-40 pO2-174* pCO2-26* pH-7.23* calTCO2-11* Base XS--15
Intubat-INTUBATED
[**2182-2-24**] 12:45PM BLOOD Type-ART Temp-36.7 Tidal V-600 FiO2-40
pO2-179* pCO2-29* pH-7.22* calTCO2-12* Base XS--14
Intubat-INTUBATED
[**2182-2-24**] 05:53PM BLOOD Type-ART Temp-37.2 FiO2-40 pO2-213*
pCO2-21* pH-7.36 calTCO2-12* Base XS--11 Intubat-INTUBATED
[**2182-2-24**] 05:43AM BLOOD freeCa-1.22
[**2182-2-24**] 12:01PM BLOOD freeCa-1.19
[**2182-2-23**] 2:30 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2182-2-23**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
Commensal Respiratory Flora Absent.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Time Taken Not Noted Log-In Date/Time: [**2182-2-23**] 2:40 pm
URINE SPECIMEN TAKEN FROM 133D.
**FINAL REPORT [**2182-2-24**]**
Legionella Urinary Antigen (Final [**2182-2-24**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2182-2-23**] 9:45 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2182-2-25**]**
MRSA SCREEN (Final [**2182-2-25**]): No MRSA isolated.
[**2182-2-23**] 4:14 am URINE
**FINAL REPORT [**2182-2-24**]**
URINE CULTURE (Final [**2182-2-24**]): NO GROWTH.
[**2182-2-23**] 3:45 am Rapid Respiratory Viral Screen & Culture
**FINAL REPORT [**2182-2-25**]**
Respiratory Viral Culture (Final [**2182-2-25**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2182-2-23**]):
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing Interpret all negative results from this specimen
with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by DR [**Last Name (STitle) **].MUEHLBAUER [**2182-2-23**]
1025AM.
[**2182-2-23**] 3:45 am BRONCHIAL WASHINGS
**FINAL REPORT [**2182-2-25**]**
GRAM STAIN (Final [**2182-2-23**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
SINGLY IN PAIRS.
RESPIRATORY CULTURE (Final [**2182-2-25**]):
~3000/ML Commensal Respiratory Flora.
[**Month/Day/Year 42973**] AERUGINOSA. ~3000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml. SENSITIVITIES PERFORMED ON REQUEST..
[**2182-2-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is moderate regional left ventricular systolic
dysfunction with akinesis of the basal half of the inferior and
inferolateral wall and hypokinesis of the distal half of the
septum and anterior wall and apex The remaining segments
contract normally (LVEF = 30 %). Right ventricular chamber size
is normal with focal hypokinesis of the apical free wall. The
aortic valve leaflets (?#) appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Physiologic mitral regurgitation is seen (within
normal limits). The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
dilation with regional systolic dysfunction c/w multivessel CAD
or other diffuse process.
Compared with the prior study (images reviewed) of [**2180-8-24**],
the current study is of superior image quality, but remains
suboptimal and suggests multivessel CAD or other diffuse
process.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
CHEST (PORTABLE AP) Study Date of [**2182-2-23**] 2:23 AM
IMPRESSION: Bibasilar consolidations, likely atelectasis and
pleural
effusions but cannot exclude infectious process.
Moderate-to-severe
background pulmonary edema.
The study and the report were reviewed by the staff radiologist.
CHEST (PORTABLE AP) Study Date of [**2182-2-24**] 1:54 AM
FINDINGS: In comparison with study of [**2-23**], there is continued
enlargement of the cardiac silhouette with pulmonary vascular
congestion and bilateral
pleural effusions with compressive atelectasis, more prominent
on the right. In the appropriate clinical setting, supervening
pneumonia would have to be considered.
CHEST (PORTABLE AP) Study Date of [**2182-2-24**] 11:42 AM
FINDINGS: In comparison with the earlier study of this date,
there is little overall change. On this apparent upright view,
there is some movement of the bilateral pleural effusions, again
more prominent on the right. There is some shift of the
mediastinum to the right, which has been present on all
examinations since at least [**2180-11-2**].
CHEST PORT. LINE PLACEMENT Study Date of [**2182-2-25**] 8:54 AM
IMPRESSION: Right PICC terminates in the right atrium and should
be withdrawn 4-5 cm for better positioning.
CHEST (PORTABLE AP) Study Date of [**2182-2-26**] 2:15 AM
Tracheostomy tube is seen in standard position. Right PICC tip
is in the
upper SVC. Transvenous pacemaker leads are in unchanged
positions in the
right atrium and likely in the right ventricle. The
cardiomediastinum is
shifted towards the right as before. Right pleural effusion with
adjacent
consolidation has increased. Left lower lobe opacities are
unchanged. It
could be due to atelectasis, but superimposed infection cannot
be excluded. No other interval change.
Transitional issues:
f/u blood culture from [**2182-2-23**]
ECHO results: pt is already on a beta blocker, can consider
increasing.
Brief Hospital Course:
Mr. [**Known lastname 42970**] was admitted to the medical ICU for concerns of
dyspnea and hemoptysis. in brief, his a 43M with Duchenne
muscular dystrophy with chronic respiratory failure s/p trach
with multiple recent pneumonias who presents with SOB and
hemoptysis, with concerns of pneumonia.
.
# Dyspnea: Initially there was concern for ventilator acquired
pneumonia. The patient received a dose of vancomycin in the
[**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **] but had a drug rash during infusion of the
levofloxacin at [**Hospital1 18**]. His last bronchial cultures were cipro
and meropenem-resistant. As such, the patient was maintained on
vancomycin and aztreonam and he was suctioned and bronchial
washing and sputum cultures were sent.A PICC line was placed for
IV access but this was removed on day of discharge. His cultures
grew only low levels of [**Hospital1 **]. The patient's respiratory
status improved greatly in the ICU and he felt back to his
baseline by HOD 3. ID was consulted and felt his cultures showed
pseudomonal colonization and not true infection. They
recommended stopping all antibioitcs. The patient recevied 3
days of antibioitcs total. The patient remained afebrile in the
MICU. On day of discharge he was on his home ventilator
settings.
.
# Chronic Respiratory failure: Most recent ABG is
7.18/47/128/18, consistent with a mixed AG metabolic acidosis +
respiratory acidosis. Delta-delta is 0.5, so there is also a
non-AG metabolic acidosis. The etiology of the AG acidosis is
unclear. [**Name2 (NI) **] does have mildly elevated lactate, but no evidence
of ketoacidosis or renal failure and no ingestions. His ABG
normalized during HOD 2. The patient's respiratory status
improved throughout his hospitalization stay and on day of
discharge he was on his home ventilator settings.
.
# H/o cardiac arrest s/p ICD/pacemaker: Currently AV paced at
60bpm. Patient was monitored on telemetry throughout his
hospital stay. He had a brief episode of likely atrial
tachycardia which resolved on its own [**2182-2-24**]. During his
hospitalization he also had a cardiac ECHO performed, which
showed left ventricular cavity dilation with regional systolic
dysfunction c/w multivessel CAD or other diffuse process. These
findings were similar to his last ECHO in [**2179**]. His EF was 30%.
The patient also did receive several liters of fluid during his
stay and required a dose of IV lasix for diuresis. The patient
was hemodynamically stable in the MICU. On day of discharge his
vital signs were also stable.
.
Transitional issues:
f/u blood culture from [**2182-2-23**]
ECHO results: pt is already on a beta blocker, can consider
increasing.
Medications on Admission:
- Chlorpheniramine 4mg [**Hospital1 **]
- Trazodone 50mg QHS
- Lisinopril 5mg [**Hospital1 **]
- Enulose 40mg via G tube daily
- Diocto liquid 10cc via G tube daily
- Lotrimin 1% cream [**Hospital1 **]
- Nexium 40mg daily
- Kenalog 0.1% cream prn to G tube
- Albuterol/Atrovent 3ml via neb [**Hospital1 **]
- Colace 100mg [**Hospital1 **]
- Multivitamin with minerals daily
- Water bolus 360ml 5x day
- Cough assist TID via trach
- Glycerin suppository prn
- Fleets enema prn
- Desinex powder to toes [**Hospital1 **] prn
- Simethicone 125mg daily
- Tylenol 650mg Q4-6h prn
- Fexofenadine 60mg [**Hospital1 **]
- Amiodarone 200mg daily
- Bactrim 400mg daily
- Lopressor 25mg [**Hospital1 **]
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**3-8**]
Puffs Inhalation Q4H (every 4 hours).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
5. chlorpheniramine maleate 4 mg Tablet Sig: One (1) Tablet PO
twice a day.
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Enulose 10 gram/15 mL Solution Sig: Forty (40) mg PO once a
day.
8. Diocto 50 mg/5 mL Liquid Sig: Ten (10) ml PO once a day.
9. Lotrimin AF 1 % Cream Sig: One (1) thin amount Topical twice
a day.
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Kenalog 0.147 mg/gram Aerosol Sig: One (1) thin amount
thin amount Topical once a day as needed for skin redness.
12. Multi-Vitamin HP/Minerals Capsule Sig: One (1) Capsule
PO once a day.
13. glycerin (adult) Suppository Sig: One (1) suppository
Rectal once a day as needed for constipation.
14. Enema Enema Sig: One (1) enema Rectal once a day as
needed for constipation.
15. Desenex Aerosol Powder Sig: One (1) small amount Topical
twice a day as needed for itching.
16. simethicone 125 mg Capsule Sig: One (1) Capsule PO once a
day.
17. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for fever or pain.
18. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a
day.
19. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
Respiratory distress
Acute on Chronic respiratory failure
Acute on chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Patient chronically wheelchair/bed bound.
Discharge Instructions:
Dear Mr. [**Known lastname 42970**],
You were admitted to [**Hospital1 69**] for
concerns for a lung infection. You were admitted to the ICU
given your tracheostomy. We gave you strong antibiotics for 3
days and also sent cultures of your sputum. Your sputum grew low
levels of [**Hospital1 **] (a type of bacteria). We talked to the
infectious disease doctors and the [**Name5 (PTitle) **] levels look like
colonization (meaning the bacteria are not causing active
infection but are just always there). Because of this we stopped
your antibiotics. Your breathing status improved during your
stay and you were discharged home.
During your hospital stay you were found to have a rash from an
antibiotic called levofloxacin. We do not think this is an
allergy but as this is an antibiotic you may need in the future,
you should follow up with our allergy doctors [**First Name (Titles) 4120**] [**Name5 (PTitle) 42974**] to this antibiotic. An appointment has been made
for you and is listed below.
You also had an ECHO of your heart performed which showed that
your heart pumping function is mildly decreased. You can discuss
this with your primary care doctor. You are already on a beta
blocker (lopressor) which is often used for this.
You may resume your ventilator setting at their previous
settings.
Changes to your medications:
NONE
Followup Instructions:
Allergy and Immunology appointment.
[**2182-3-5**] at 9:30.
[**Location (un) 42975**], [**Location (un) 895**], [**Apartment Address(1) 20447**], [**Location (un) **], [**Numeric Identifier 1415**].
You need to update your registration/insurance information.
Call: [**Telephone/Fax (1) 10676**] prior to your appointment to update this.
Please also make an appointment with your primary care physician
within the next couple days regarding your hospital stay.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2182-2-27**]
|
[
"494.0",
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"276.2",
"934.9",
"428.0",
"359.1",
"V02.59",
"V44.1",
"V45.02",
"E930.8",
"V44.0",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
20668, 20716
|
15568, 18137
|
344, 351
|
20858, 20858
|
4391, 9110
|
22444, 23028
|
3118, 3198
|
19013, 20645
|
20737, 20837
|
18296, 18990
|
21076, 22385
|
3238, 3718
|
13470, 15412
|
9151, 13447
|
18158, 18270
|
22414, 22421
|
285, 306
|
490, 2298
|
20873, 21052
|
2342, 2926
|
2942, 3102
|
3743, 4372
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,179
| 193,291
|
47782
|
Discharge summary
|
report
|
[** **] Date: [**2128-4-15**] Discharge Date: [**2128-4-20**]
Date of Birth: [**2056-3-12**] Sex: F
Service: MEDICINE
Allergies:
Sotalol
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Lethargy, sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 100868**] is a 72F w/ history of non-ischemic dilated CMP w/ EF
20%, complete heart block s/p PPM/ICD, and primary effusion
lymphoma s/p chemotherapy [**2128-4-9**] who presents with lethargy and
weakness for a few days. No fever, chills, CP, SOB, nausea or
vomiting. Initial evalutation in the ED found that she is HD
stable, afebrile. Her uric acid was notable to be 16. She
received sodium bicarb IVF for urine alkalization. Concerning
for tumor lysis syndrome, she was admitted to medicine for
further management.
On the floor, she feels better with less fatigue. Denies CP,
SOB, lightheadness, dizziness, muscle pain, numbness or
tingling.
ROS: Denies fever, chills, night sweats, headache, vision
changes, mucosal lesions, sore throat, cough, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
The ten point review of systems is otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: Cath in [**2108**] @ [**Hospital1 2025**] with
clean coronaries per report
- PACING/ICD: Dual Chamber [**Company 1543**] Virtuoso DR [**Last Name (STitle) **] in
[**5-/2124**] as replacement of [**Company **] gem for imminent pocket
erosion. PPM placed originally in [**2112**], then repaired in [**2114**]
and [**2115**].
- Nonischemic Dilated Cardiomyopathy, sCHF (LVEF 20% [**2-/2128**])
- Complete heart block s/p PPM
- Severe tricuspid regurgitation
- Pulmonary artery systolic hypertension (TTE [**2-/2128**])
- Atrial fibrillation on warfarin and amiodarone.
- Pericardial effusion [**10/2127**], drained 650cc, atypical cells on
cytology
3. OTHER PAST MEDICAL HISTORY:
- Osteoporosis
- GERD
- E. Coli cystitis [**11/2127**] treated with 7 days of cipro
- C. diff with PO metronidazole ([**11/2127**]) x14 days
- Chronic kidney disease
.
Oncologic history: Primary Effusion Lymphoma
- admitted several times in [**2126**] for heart failure
- [**2127-10-21**]: echocardiogram showed large pericardial effusion
with
evidence of tamponade physiology
- [**2127-10-22**]: pericardial effusion drained, fluid was grossly
bloody with atypical cells. The cells co-expressed CD138 and
CD38. They did not express CD20, CD3, CD5 and did not express
BCL6, BCL2, or BCL1. The proliferation index was over 95% by
MIB-1 staining. EBV was negative and HHV-8 staining was
positive. Pathology was consistent with primary effusion
lymphoma.
- [**2127-11-21**]: started on Velcade 1.2 mg on days 1, 4, 8, 11 with
plans to start valganciclovir after [**2127-12-7**] when her insurance
will pay for it.
- [**Date range (3) 100872**]: Admitted for CHF exacerbation
- [**2127-12-8**]: re-presented to [**Hospital1 18**] for symptoms of leg swelling,
admitted
- [**Date range (1) 100873**]: Admitted for CHF
- [**2127-12-26**]: Resumed cycle 2 Velcade at 0.5 mg/m2 with
Valgancyclovir 450 mg given twice a week in clinic.
- cycle 2 days 4, 8 and 11 held due to fluid retention and
peripheral edema
- [**2128-1-23**]: cycle 3 Velcade at 0.5 mg days 1, 4, 8, 11
- [**Date range (3) 100874**]: admitted for hypercalcemia, treated with IVF
Social History:
She is originally from Sicily, [**Country 2559**], and
immigrated in [**2084**], Italian speaking, can speak some English.
She lives with her son, [**Name (NI) 100875**]. She previously worked as a
factory worker.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
Her mother and 1 sibling were killed during World War II in a
bombing. She denies any family history of leukemia or lymphoma.
She reports that her father had heart disease. Overall, she had
4 brothers and 4 sisters, none of
which had any malignancy.
Physical Exam:
[**Name (NI) **] exam:
VS: 97.9, 92-97/60, 70, 18, 96% RA
GENERAL: Elderly, thin, chronically ill lady in NAD
HEENT: NC/AT, sclerae anicteric, MM dry, OP clear.
NECK: Supple, no JVD noted.
HEART: irregularly irregular, [**2-10**] holosystolic murmur best heard
at the L sternal border, nl S1-S2, no rubs.
LUNGS: Bibasalar crackles, good air movement, resp unlabored.
+kyphosis
ABDOMEN: Soft/NT, moderate distention, no masses or HSM, no
rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. No carpal
spasm. No tetany.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3. Intact sensation to touch. 5/5 strength in
UE and LE.
DISCHARGE EXAM
Vitals - T: 98.6 BP: 90-110/48-70 HR: 69-73 RR: 16-18 02 sat:
>94% RA I/O: 950/550 + BM
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, no thrush on tongue, good dentition, nontender
supple neck, no LAD, JVD to angle of jaw
CARDIAC: RRR, S1/S2, systolic murmer. No rub.
LUNG: crackles at left base > right base, good respiratory
effort, no use of accessory muscles, good air movement
throughout
ABDOMEN: slightly distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, 4+/5 strength throughout, no deficits,
finger to nose intact.
DISCHARGE WEIGHT 91.4KG ON [**4-19**]
Pertinent Results:
[**Month/Year (2) **] LABS
[**2128-4-15**] 01:55AM BLOOD WBC-6.6 RBC-3.99* Hgb-12.9 Hct-40.2
MCV-101* MCH-32.2* MCHC-32.0 RDW-16.9* Plt Ct-191
[**2128-4-15**] 01:55AM BLOOD Neuts-88.2* Lymphs-8.1* Monos-3.0 Eos-0.5
Baso-0.2
[**2128-4-15**] 02:02AM BLOOD PT-20.0* PTT-29.9 INR(PT)-1.9*
[**2128-4-15**] 01:55AM BLOOD Glucose-101* UreaN-72* Creat-2.1* Na-123*
K-4.7 Cl-83* HCO3-29 AnGap-16
[**2128-4-15**] 01:55AM BLOOD LD(LDH)-300* CK(CPK)-35
[**2128-4-15**] 06:40AM BLOOD ALT-31 AST-49* LD(LDH)-285* CK(CPK)-36
AlkPhos-289* TotBili-1.4
[**2128-4-15**] 01:55AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.3 UricAcd-16.5*
PERTINENT LABS AND STUDIES
[**2128-4-17**] 03:22AM BLOOD QG6PD-14.5*
[**2128-4-17**] 03:22AM BLOOD Ret Aut-2.6
[**2128-4-20**] 06:10AM BLOOD ALT-198* AST-173* LD(LDH)-387*
AlkPhos-273* TotBili-1.3
[**2128-4-15**] 01:55AM BLOOD cTropnT-0.13*
[**2128-4-15**] 06:40AM BLOOD CK-MB-2 cTropnT-0.10*
[**2128-4-15**] 01:00PM BLOOD CK-MB-3 cTropnT-0.09*
[**2128-4-16**] 03:22PM BLOOD Albumin-3.1* Calcium-10.0 Phos-6.4*
Mg-2.5
[**2128-4-15**] 01:00PM BLOOD TSH-0.95
[**2128-4-16**] 07:05AM BLOOD Cortsol-68.1*
[**2128-4-17**] 08:00AM BLOOD Vanco-16.5
[**2128-4-17**] 11:29AM BLOOD Type-[**Last Name (un) **] Temp-36.3 FiO2-20 pO2-43*
pCO2-41 pH-7.52* calTCO2-35* Base XS-9 Intubat-NOT INTUBA
[**2128-4-16**] 03:55PM BLOOD Lactate-15.4*
[**2128-4-19**] 06:54AM BLOOD Lactate-1.3
[**2128-4-15**] 01:55AM URINE RBC-0 WBC-8* Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2128-4-17**] 08:02AM URINE RBC-59* WBC-6* Bacteri-FEW Yeast-NONE
Epi-1
[**2128-4-15**] 01:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-TR
[**2128-4-17**] 08:02AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2128-4-15**] URINE CULTURE NEGATIVE
[**2128-4-16**] BLOOD CULTURE PENDING
EKG: [**2128-4-15**] Sinus rhythm with atrial sensing and ventricular
paced rhythm with capture as compared with previous tracing of
[**2128-4-15**], which recorded A-V sequential pacing.
CXR [**2128-4-17**] AP AND LAT Compared with [**2128-4-16**] at 23:54 p.m.,
there is negligible interval change in the appearance of the AP
film. Small left effusion is again seen. There is associated
atelectasis. No focal consolidation.
RUQ US [**2128-4-17**]
1. Gallbladder wall edema and pulsatile portal venous flow,
compatible with changes of right heart failure, as seen
previously.
2. Small amount of lower abdominal ascites.
3. No evidence for biliary ductal dilation.
CXR [**2128-4-16**]
1. Interstitial markings in both lungs, likely reflecting CHF.
2. Left effusion with left base atelectasis. An early
infiltrate in this area cannot be excluded.
ECHO [**2128-4-16**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is severe global left ventricular hypokinesis
(LVEF = 20%). The right ventricular cavity is moderately dilated
with mild global free wall hypokinesis. The diameters of aorta
at the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild to moderate ([**12-8**]+) aortic regurgitation is
seen. Moderate (2+) mitral regurgitation is seen. Severe [4+]
tricuspid regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Dilated right ventricle with mild global systolic
dysfunction and severe functional tricuspid regurgitation.
Dilated left ventricle with severe global systolic dysfunction.
Mild to moderate aortic regurgitation. Moderate mitral
regurgitation
Brief Hospital Course:
Ms. [**Known lastname 100868**] is a 72F with history of non-ischemic dilated
cardiomyopathy (EF=20%), primary effusion lymphoma s/p chemo on
[**4-9**] who presents with lethargy found to have elevated uric acid
level, and on the floor she became increasing lethargic and was
found to have a lactic level of 15. She was transferred to the
[**Hospital Unit Name 153**] on hospital day 2 for close monitoring and further
management.
# Elevated uric acid: The etiology of her elevated uric acid
could be due to overdiuresis or tumor lysis syndrome from recent
chemotherapy. Renal was consulted. She received IVF w/ 3 amp
bicarb, rasburicase x 1 dose. Her uric acid level is 0.0 - 0.1
on hospital day 2 which stayed <1 until transfer to the OMED
service.
# Electrolytes abnormalities: Her phosphate was initially within
but subsequently trended up. Her potassium was initially low
(3.1) and received 60 meq, but subsequently trended to [**4-11**] on
hospital day 2. The etiology was likely tumor lysis syndrome vs
poor renal function. Her electrolytes were monitored closely.
# Lactic acidosis: On hospital day 2, patient's lactate level
was 15 with an increased anion gap. Unclear etiology of
acidosis. Patient did not appear to be in septic shock (despite
increasing WBC and left shift) given lack of change in blood
pressure from baseline, though cardiogenic shock was possible.
Rare causes such as Type B lactic acidosis from her primary
effusion lymphoma, in addition to rasburicase were on the
differential diagnosis. Concerning for sepsis, she received
vancomycin and cefepine. Blood cultures were sent. She was
transferred to [**Hospital Unit Name 153**] for further management. Lactate was
subsequently down from 15 to 6 on the same night, with narrowing
anion gap. The etiology of her lactic acidosis is unclear,
however it rapidly improved with fluids. She was started on
vanc/cefepime briefly bcause of concern for sepsis as an
etiology for her lactic acidosis, however these were stopped
after 48h when culture data was negative. She was transferred
from the [**Hospital Unit Name 153**] to the OMED service after 1 day in the ICU.
# Elevated LFTs: Her LFTs were trended up in hospital day 2
which was thought to be secondary to rasburicase. It is a known
adverse effect happening suddenly after medication
administration. Abdominal ultrasound was obtained to rule out
obstruction which showed no biliary dilation.
# Chronic systolic heart failure from dilated cardiomyopathy
(EF=20%): Initially her home diuretics were held given she
looked dry on exam. On hospital day #2, patient complained of
SOB with labored breathing. Lung exam was notable for bibasilar
crackles. Her extremities were cold. Her symptoms likely related
to her heart failure. We restarted her home torsemide at half
dose (30 mg PO daily), in addition to continuing fluid
restriction and low salt diet. Prior to [**Hospital Unit Name 153**] transfer, she was
satting at 95% on RA.
# Acute on chronic renal failure: Her Cr was initially at
baseline at 1.8 and IVF was held after the uric acid level were
normalized. On hospital day #2 her Cr subsequently trended up.
It was likely related to hypovolemia from poor forward flow.
Renal was consulted. We continued to trend her renal function
and her medication was renally dose.
# Primary effusion lymphoma: S/p chemo with Doxil on [**4-9**] (cycle
2 day 7). Pt c/o nausea and received Zofran. The hemo-onc team
has been following during her hospitalization here.
# Hyponatremia: Likely related to hypovolemia from poor forward
flow with history of chronic hyponatremia in low 130s. Urine
lytes and osm was obtained to determine the etiology.
# Elevated troponin: Initially with elevated troponin
(0.13->0.10->0.09) at presentation likely secondary to renal
failure. Pt denied CP, or palpitation.
# Atrial fibrillation: Rated control w/ metoprolol and
amiodarione. Warfarin were dosed based on INR. No active issues.
# CODE: full
# CONTACT: son [**Name (NI) 100875**] ([**Telephone/Fax (1) 100871**])
# ISSUES TO ADDRESS AT FOLLOW UP:
- please recheck INR and LFTs in follow up and dose Warfarin
accordingly
- please consider starting allopurinol.
Medications on [**Telephone/Fax (1) **]:
AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
LACTULOSE - 10 gram/15 mL Solution - 15-30 ml(s) by mouth three
times a day as needed for constipation
LORAZEPAM - 0.5 mg Tablet - one Tablet(s) by mouth up to twice a
day as needed for anxiety/ insomina
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - half Tablet(s) by mouth once a
day
POTASSIUM CHLORIDE - (Prescribed by Other Provider; ON HOLD) -
20 mEq Tablet, ER Particles/Crystals - 1 Tablet(s) by mouth
every other day as directed
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
three times a day as needed for nausea
QUETIAPINE - 25 mg Tablet - 0.5-1.0 Tablet(s) by mouth at
bedtime as needed for insomnia
SPIRONOLACTONE - 25 mg Tablet - one Tablet(s) by mouth DAILY
TORSEMIDE - 20 mg Tablet - three Tablet(s) by mouth once a day
(decreased from 4 tabs) as directed based on daily weight
VALGANCICLOVIR [VALCYTE] - (On Hold from [**2128-2-11**] to unknown
for not currently needed, will resume when clinically indicated)
- 450 mg Tablet - 1 Tablet(s) by mouth every other day
WARFARIN - 2 mg Tablet - 1 Tablet(s) by mouth qd or as directed
ACETAMINOPHEN - (OTC) - 325 mg Tablet - [**12-8**] Tablet(s) by mouth
every 6-8 hours as needed for pain
DOCUSATE SODIUM - (OTC) - 100 mg Capsule - [**12-8**] Capsule(s) by
mouth twice a day
FERROUS SULFATE [FERROUSUL] - (OTC) - 325 mg (65 mg iron) Tablet
- 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. lactulose 10 gram/15 mL (15 mL) Solution Sig: 15-30 mL PO
three times a day as needed for constipation.
3. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
three times a day as needed for nausea.
4. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
7. docusate sodium 100 mg Capsule Sig: [**12-8**] Capsules PO BID (2
times a day).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. multivitamin Oral
10. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
12. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary diagnosis:
primary effusion lymphoma
non-ischemic cardiomyopathy
atrial fibrillation
secondary diagnosis
severe tricuspid regurgitation
complete heart block
pulmonary hypertension
chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 100868**],
You were admitted and found to have abnormal labs. Your labs
returned to your baseline and you felt better.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please note the following changes to your medications:
- STOP Quetiapine
- STOP Ativan
- START Trazodone as needed for insomnia
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2128-4-23**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2128-4-23**] at 10:30 AM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2128-4-30**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2128-4-30**] at 9:30 AM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: FRIDAY [**2128-4-30**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 437**], [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] MD
Location: [**Hospital1 18**] DIVISION OF CARDIOLOGY
Address: [**Location (un) **], W/[**Hospital1 **] - 319, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
***The office is working on an appt for you in the next week and
will call you at home with the appt. IF you dont hear from them
by Thursday, please call the office directly to book.
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: FRIDAY [**2128-4-30**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,278
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7339
|
Discharge summary
|
report
|
Admission Date: [**2152-10-19**] Discharge Date: [**2152-10-20**]
Date of Birth: [**2101-4-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
knee injury s/p fall
Major Surgical or Invasive Procedure:
ORIF L tib plateau
History of Present Illness:
51 y/o w/ DM2, alcohol abuse, charcot's foot s/p neuropathy,
presented with tibial plateau fracture. Pt had ankle fusion
about one month ago for charcot's foot. He was treated at rehab
for ~ 10days, and discharged ~10 days ago. Pt fell yesterday
evening down 8 stairs. He reportedly drank some alcohol
yesterday at lunch. He had 8 beers and 3 hard liquor 4 days
ago. Pt came to ED this morning, had negative X-ray and was
found to have subtle tibial fracture on CT. Pt was seen by
orthopedics, initially had knee aspiration for effusion, which
showed ~8000 WBC, 200,000 RBC, with no crystals. Pre-op got
versed, underwent general anesthesia with a total of 2 mg
midazolam, 200 mg propofol, and nerve block for procedure. He
had tibial fracture repair with metal plate placement, and ankle
screw tightening. In [**Name (NI) 13042**], pt was found to have CIWA 24, HTN to
SBP 200, tachycardia to 140-150s, tremulous, headache. No
hallucinations. Got 10 mg diazepam with some improvement HR
120s, HTN 150-160s.
Pt is aware of his alcohol problem, said he "could drink a lot",
>10 beers at party. He denies withdrawal seizure or DT.
Most recent set of vitals prior to transfer to MICU: afebrile,
100% 3L 12 HR 115 BP 145/69. Access is right PIV.
Past Medical History:
DM2 x17 yrs (on glyburide/metformin)
Venous insufficiency (on daily lasix 20 mg tid)
Boarderline HTN (not actively treated)
Gout (off colchicine)
HLD (on simvastatin)
Social History:
Cig: Prior 1 ppd x20 yrs hisotry; Quit 15 years ago.
ETOH: Occasional
Illicits: Denies
Worked as a Machinist for aerospace products. Has not worked
since [**Month (only) 958**].
Family History:
Father passed away of pancreatic cancer at age 50s and mother is
alive, healthy. Siblings all healthy.
Physical Exam:
ADMSSION EXAM
General: Alert, oriented X2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 grossly intact, muscle strenth intact in UE and
right LE, LLE not tested.
DISCHARGE EXAM
VS: Temp 100.8, HR 94, BP 158/78, RR 22, O2 sat 98% on RA
GEN: AOX3, nontremulous
Otherwise exam not changed from admission
Pertinent Results:
[**2152-10-20**] 04:45AM BLOOD WBC-7.0 RBC-2.75* Hgb-8.2* Hct-24.3*
MCV-88 MCH-30.0 MCHC-34.0 RDW-14.6 Plt Ct-178
[**2152-10-20**] 04:45AM BLOOD PT-14.8* PTT-24.8 INR(PT)-1.3*
[**2152-10-20**] 04:45AM BLOOD Glucose-115* UreaN-19 Creat-1.8* Na-141
K-4.1 Cl-104 HCO3-28 AnGap-13
[**2152-10-19**] 05:45PM BLOOD ALT-9 AST-18 LD(LDH)-187 AlkPhos-139*
TotBili-0.4
[**2152-10-20**] 04:45AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.8
[**2152-10-19**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2152-10-20**] 12:33AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
PERTINENT IMAGING
[**10-19**] ANKLE X-ray:
1. Lateral tibial plateau fracture with dense joint effusion.
This could be confirmed with a CT as discussed with the ED
staff.
2. Neuropathic changes of the ankle with unchanged hardware.
[**10-19**] Knee X-ray
1. Lateral tibial plateau fracture with dense joint effusion.
This could be confirmed with a CT as discussed with the ED
staff.
2. Neuropathic changes of the ankle with unchanged hardware.
[**10-19**] CT LE
1. Schatzker type 2 fracture of the lateral tibial plateau, with
small
lipohemarthrosis.
2. Intact quadriceps tendon.
3. Diffuse mild periostitis. Correlate clinically for
hypertrophic
osteoarthropathy or venous stasis.
Brief Hospital Course:
51 yo M w/ ho DM2, alcohol abuse, presented with knee pain after
fall, found to have tibial plateau fracture, s/p surgical
reductiona and repair, with recovery complicated by concerns for
alcohol withdrawal.
#) Tibial plateau fracture
Mr. [**Known lastname 27081**] was admitted to the Orthopedic service on [**2152-10-19**] for
left tibial plateau fracture after being evaluated in the
emergency room. He underwent open reduction internal fixation
of the left tibial plateau fracture without complication on
[**2152-10-19**]. He was extubated without difficulty and transferred to
the recovery room in stable condition. He had adequate pain
management and worked with physical therapy while in the
hospital.
OUTPATIENT ISSUES
- STARTED Levonox 40 mg sc qd while on case.
- STARTED calcium carbonate 500 mg qd, vitamin 800 mg qd
- Please consider starting alendronate 70 mg qweek
Per ortho recommendation: Clinical trial data supports that two
weeks following fracture is a safe time to initiate
bisphosphonates and it should not interfere with bone healing.
Patients who have been treated with bisphosphonates starting at
two weeks following fracture have been shown to have decreased
incidence of recurrent fracture and decreased overall mortality.
While bisphosphonates are indicated and safe for most patients
with osteoporosis related fractures, there are exceptions.
Contraindications to bisphosphonates include renal failure with
creatinine clearance less than 35 ml/minute, esophageal
dysmotility including strictures or achalasia, active
esophagitis or gastritis, esophageal or gastric ulcers,
hypocalcemia, or inability to comply with dosing instructions.
Please note that controlled GERD is NOT a contraindication to
bisphosphonates. While we have ordered this medication on
discharge, it is up to your discretion to discontinue it if you
feel that it is contraindicated for your patient. For the
majority of patients at average risk of suffering an
osteoporosis related fracture, the current data supports
treatment with bisphosphonates for a total of five years.
.
#) Fever
Pt developed fever to 101.7. Blood, Urine culture no growth.
CXR shows no evidence of pneumonia. Pt is otherwise
asymptomatic. Given the recent operation with instrumentation,
inflammatory response secondary to trauma is the most likely
eetiology. Infection needs to be monitored, but still early to
attribute fever to surgery induced infection now.
.
#)Charcot's foot
Pt had recent operation for charcot's foot. He has been closely
followed by podiatry at [**Hospital1 18**]. There was a new ulcer on the
left big toe, and was evaluated by podiatry in the ED.
OUTPATIENT ISSUES:
- Pt need to complete a 10 day's course of augmentin
- Pt need daily wet-to-day dressing change for left big toe
until evaluated by his podiatrist.
.
#) Alcohol withdrawal
Pt was found to be confused, tremulous, with HR of 135 and
elevated BP to 200/109, with improvement after 10 mg of valium.
The timing of presentation is most consistent with
post-anesthesia effect. However, given his alcohol history,
alcohol withdrawal cannot be ruled out. Pt denied hx of
withdrawal seizure and DT in the past. Pt received iv thiamine.
He was placed on CIWA protocol post-op, had a total of 10 mg
Valium X3 overnight, and remained low CIWA score > 16 hours
before discharge.
.
#) Anemia
It was found that pt has profound normocytic anemia with Hct of
24.9, baseline 34.8 since admission in [**Month (only) **], that has never been
addressed per our records. Given the normal RDW, it is hard to
attribute that completely to alcohol use. Would need to
initiate workup for anemia in an outpatient setting. Given the
high ALP and progressing renal insufficiency, would need to rule
out multiple myeloma as well.
OUTPATIENT ISSUES:
- Please consider anemia workup
- Please consider colonoscopy if pt has not had one
.
#) Acute on chronic renal insufficiency
Pt presented with Cr 1.8 on this admission. Pt had recent ATN
in [**Month (only) 216**], with Cr on discharge of 1.2. Pt did not respond to
fluid overnight. Given the protein on UA, it is unclear whether
this is new baseline secondary to his diabetes. Of note, his
A1c in [**Month (only) **] was 6.2. We held his lasix since admission. Pt will
need work-up ideally from a nephrologist.
OUTPATIENT ISSUES
- HELD lasix
- Pt need nephrology workup
.
#) Type 2 Diabetes
Per record, pt has 17 yr type 2 diabetes, with complication of
charcot's foot. Pt takes glyburide-metformin 5-500 [**Hospital1 **] at home.
We discontinued his oral anti-glycermic medication, and started
him on sliding scale insulin.
OUTPATIENT ISSUES:
- HELD oral anti-glycemic medication
- STARTED sliding scale insulin
- Please CONSIDER STARTING ACEI in the setting.
.
CHRONIC ISSUES
#) Venous insufficiency
Pt has documented venous insufficiency and presumatively takes
lasix 20 mg tid at home. We held his lasix given concerns for
renal insufficiency.
.
#) Gout
Documented hx of gout. Joint fluid analysis does not support
acute flare. Pt not currently on treatment.
.
#) Hyperlipidemia
Not active issue, continued home dose simvastatin 10 mg qd
.
TRANSITIONAL ISSUES
Pt declares a full code. He will need to set up an orthopedics
appointment for post-op followup.
Medications on Admission:
lasix 60mg daily
glyburide-metformin 5-500 [**Hospital1 **]
percocet 5-325 1 tab q6hr prn
simvastatin 10mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours) for 14 days.
Disp:*14 * Refills:*0*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain: please hold for sedation or RR < 8.
Disp:*30 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
10. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q2H PRN () as
needed for CIWA >10.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 1475**]
Discharge Diagnosis:
L tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance.
Discharge Instructions:
Dear Mr. [**Known lastname 27081**],
You came to our hospital for knee pain after a fall from the
stairs. In the ED, we found that you had a tibial plateau
fracture. You were seen by orthopedics and underwent tibial
plateau repair with a metal plate. While you were in the OR,
you ankle screw from the previous operation was also adjusted.
You tolerated the procedure well. You had an elevated blood
pressure and heart rate after the surgery, likely due to pain
and the anesthesia medications, so you were observed in the ICU
overnight. Your blood pressure and heart rate improved.
We felt that you can continue your recovery at a rehabilitation
facility. While you were in the hospital, we found that your
kidney function was worse than expected for your age, and your
blood count was low. We will notify your primary care doctor.
But you should discuss them with both your PCP and doctors at
the rehab.
MEDICATION CHANGES:
- Please stop taking lasix until further workup for your kidney
function.
- Please STOP taking oral diabetes medication,
glyburide/metformin, until further workup for your kidney
function.
- In the meantime, please make sure that your blood sugar is
being checked at rehab, and treated according with sliding scale
insulin.
- Please make sure that the rehab doctors aware [**Name5 (PTitle) **] [**Name5 (PTitle) **]
experience alcohol withdrawal, and will be treated accordingly.
- You will take a medication called enoxaparin to help prevent
blood clots while you recover from surgery.
- Please take a multivitamin, thiamine, and folic acid
- Please take augmentin to complete a 10 day course to treat the
lesion on your toe
- You may take oxycodone as needed for pain
- While you are on pain medication, you should take medications
such as colace and senna to soften your stools and prevent
constipation
INSTRUCTIONS FOR WOUND CARE:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Keep pin sites clean and dry.
-Sutures/staples will be removed at your first post-operative
visit.
-Please call [**Telephone/Fax (1) 1228**] and schedule an appointment with
[**Doctor Last Name **], the NP in 2 weeks.
It has been a pleasure taking care of you at [**Hospital1 18**]. It is our
recommendation that you should consider stop drinking alcohol
given the repeated injuries you had and impact on your overall
health. We wish you a speedy recovery.
Activity:
-Continue to be non weight bearing on your left leg.
-You should not lift anything greater than 5 pounds.
-Elevate left leg to reduce swelling and pain.
-Do not remove splint/brace. Keep splint/brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications unless otherwise directed. Take
all medications as instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so 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 narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
In order to decrease your risk of fracture you have been started
on calcium and vitamin d. In addition, we have also recommended
that you start taking Fosamax (alendronate sodium) 70 mg once a
week to further decrease your risk of having a fracture. You
should take the first dose of this medication starting two weeks
after you are discharged from the hospital. It is very important
that Fosamax (alendronate sodium) is taken with a full glass of
water first thing in the morning, on an empty stomach, with no
lying down or eating for at least 30 minutes following
administration. Following discharge, please be sure to talk with
your primary care doctor and inform them that you have been
started on this medication
Followup Instructions:
Please call [**Telephone/Fax (1) 1228**] and schedule an appointment with
[**Doctor Last Name **], the NP in 2 weeks.
Please call your podiatrist and schedule an appointment within
10 days. The phone number is ([**Telephone/Fax (1) 4335**].
Please follow-up with your PCP on discharge from rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"823.00",
"291.81",
"285.9",
"250.60",
"E878.1",
"713.5",
"E849.8",
"305.00",
"E880.9",
"585.9",
"272.4",
"274.9",
"996.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"81.91",
"78.59"
] |
icd9pcs
|
[
[
[]
]
] |
10894, 10965
|
4217, 9494
|
334, 355
|
11035, 11035
|
2863, 4194
|
15714, 16151
|
2047, 2153
|
9658, 10871
|
10986, 11014
|
9520, 9635
|
11190, 12105
|
2168, 2844
|
12125, 13048
|
274, 296
|
13060, 15691
|
383, 1643
|
11050, 11166
|
1665, 1834
|
1850, 2031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,589
| 110,972
|
45114
|
Discharge summary
|
report
|
Admission Date: [**2189-7-22**] Discharge Date: [**2189-8-10**]
Date of Birth: [**2111-4-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vitamin E / Hydrocortisone / Penicillins / Bacitracin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Mental status changes and fever
Major Surgical or Invasive Procedure:
[**2189-7-29**] 1. Left thoracotomy, placement of epicardial left atrial
and left ventricular bipolar pacing leads and insertion
of abdominal pocket dual-chamber pacemaker.
2. Multilevel left-sided intercostal nerve block.
[**2189-7-29**] Removal of previously implanted
transvenous DDD pacing system.
[**2189-8-5**] Delayed primary closure of old pacemaker pocket.
History of Present Illness:
78 year old male with history of MSSA endocarditis mitral valve
and suspected pacer lead infection discharged from [**Hospital3 635**]
hospital for 3 days to nursing home. Presented back to [**Hospital3 635**]
hospital mental status changes,
confusion and agitation - diagnosed with metabolic
encephalopathy. Additionally he has been complaining of right
knee pain but worsening just prior to admission at [**Hospital3 635**]
hospital. He is now being transferred for surgical evaluation.
Prior admission to [**Hospital3 635**] hospital with dc to rehab for
Staphyloccus bacteremia treated with oxacillin completed 6 week
course on [**2189-7-1**] - Antibiotics were resumed this admission at
[**Hospital3 635**] hospital with oxacillin and vancomycin and ceftriaxone
until sensitives were available due to + [**Hospital3 **] culture and
sepsis.
Also noted for tick bite and was tested at [**Hospital3 635**] hospital
which the lyme, anaplasma and babesia were negative He was
discharged to rehab on oxacillin and rifampin for 6 week course.
Past Medical History:
Mitral valve endocarditis
Septic emboli
AV block
Atrial Fibrillation
Degenerative joint disease
Peripheral vascular disease
Anemia
s/p Aortic valve replacement(23 Mosaic porcine)
s/p permanent pacemaker
Abdominal surgery after stabbing incident
Social History:
retired [**Last Name (un) 33982**]
lives alone
Tobacco:10 pack year history off and on - quit in [**4-18**]
ETOH occasional 1 shot brandy in coffee 2-3 days/week
beer with dinner
Family History:
non-contributory
Physical Exam:
Pulse: 72 Resp: 20 O2 sat: 100 on RA temp 98.0
B/P 151/68
General: No acute distress, cachetic
Skin: Dry [x] intact [] stage 1 decub on coccyx, non healing
stage 2 ulcer front of left calf, multiple areas of eccyhmosis
in
particular right flank, bilateral forearms
Midline sternal incision healing no erythema/drainage
Midline abdominal surgical scar
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur systolic [**2-13**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Cool, Edema no edema, bilateral knees with
tenderness with ROM - PICC line left arm no erythema at site
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right and Left: murmur vs bruit
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 96424**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 96425**]Portable TTE
(Complete) Done [**2189-7-22**] at 4:29:11 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: [**2111-4-12**]
Age (years): 78 M Hgt (in): 71
BP (mm Hg): 151/68 Wgt (lb): 155
HR (bpm): 72 BSA (m2): 1.89 m2
Indication: H/O cardiac surgery. Endocarditis.
ICD-9 Codes: 424.90, V43.3, 424.0, 424.2
Test Information
Date/Time: [**2189-7-22**] at 16:29 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2009W053-: Machine: Vivid [**6-15**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.6 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Right Ventricle - Diastolic Diameter: *2.7 cm <= 2.1 cm
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 20 mm Hg
Mitral Valve - Pressure Half Time: 95 ms
Mitral Valve - MVA (P [**12-12**] T): 2.3 cm2
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.7 m/sec
Mitral Valve - E/A ratio: 0.76
Mitral Valve - E Wave deceleration time: *315 ms 140-250 ms
TR Gradient (+ RA = PASP): *42 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.9 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
Normal IVC diameter (<2.1cm) with >55% decrease during
respiration (estimated RA pressure (0-5mmHg).
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with conduction
abnormality/ventricular pacing.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. Minimally increased gradient consistent with
trivial MS. Mild to moderate ([**12-12**]+) MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Significant PR.
pericardial effusion.
Conclusions
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. There is moderate symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. A bioprosthetic aortic valve prosthesis
is present. The aortic valve prosthesis appears well seated,
with normal disc motion and transvalvular gradients. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are severely
thickened/deformed but without rheumatic deformity. An
underlying vegetation cannot be excluded, but is not seen. There
is a minimally increased gradient consistent with trivial mitral
stenosis. Mild to moderate ([**12-12**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Normal functioning aortic bioprosthesis. Markedly
thickened/deformed mitral leaflets and annulus with minimal
mitral stenosis and at least mild-moderate mitral regurgitation.
Pulmonary artery systolic hypertension.
If clinically indicated, a TEE would be better able to define
the mitral valve morphology and severity of mitral
regurgitation.
CLINICAL IMPLICATIONS:
Based on [**2186**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2189-7-22**] 17:36
Brief Hospital Course:
Mr. [**Known lastname **] is a 78 year-old male who completed his course of
antibiotics for MSSA mitral valve endocarditis and possible
pacer lead infection . He was admitted for lead removal. Once
cleared by infectious disease, he was taken to the operating
room for pacer insertion and removal of old pacer system. See
operative report for further details. This was complicated by a
hematoma at old pacer site pocket which was opened and packed.
On [**2189-8-5**] he underwent delayed closure of the old pacer pocket
which he tolerated.
ID: He was seen by infectious disease who recommended continuing
nafcillin and rifampin until culture date final. He developed a
reaction to nafcillin and was changed to gentamycin for 5 days
and cefazolin. PICC line was removed and the tip was cultured
with no growth. His cultures remained negative since admission.
He was placed on cefazolin for treatement with completion plan
for [**2189-9-8**].
Cardiology: he was followed by EP throughout his hospital
course. The [**Company 1543**] DDR was interrogated with normal
function.
Respiratory: with aggressive pulmonary toilet and nebs he weaned
to room air with oxygen saturations in the high 90's.
Renal; he was gently diuresed. His renal function remained
normal. His lytes were repleted appropriately.
GI: His bowel function remained normal.
Wound: Upon admission he was found to have coccygeal stage I
pressure ulcer, and LLE old traumatic ulcer. See wound care
notes.
Nutrition: He was followed by nutrition throughout his hospital
course. His diet improved with PO supplementals.
PICC: Placed [**2189-7-31**] in interventional radiology. Successful
placement of a
5-French double-lumen, 41 cm, a left PICC with tip in the distal
SVC.
Disposition: He was followed by physical therapy throughout his
stay. He continued to make steady progress and was discharged
to rehab.
Medications on Admission:
Apirin 81'
Coumadin
Dulcolax 1'
Flomax 0.4'
KCL 20'
lopressor 25"
Magnesium Oxide 400'
Oxycontin IR 5/prn
Oxycontin CR 30"
Prednisone 5'
Prilosec 20'
Oxacillin 2 q4hr
Rifampin 300'''
Senekot 2 tabs'
MVI
Miralax-prn
Discharge Medications:
1. Cefazolin 1 gram Recon Soln Sig: Two (2) gm Injection every
eight (8) hours: through [**2189-9-8**].
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
6. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet
PO once a day as needed for constipation.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast: groin .
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Oxycodone 15 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO twice a day.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**]
Discharge Diagnosis:
Lead infection s/p removal of implanted pacemaker
S/p Pacemaker placement
Mitral valve endocarditis
Discharge Condition:
Good
Discharge Instructions:
Keep wounds clean and dry.
Please shower daily, no bathing or swimming.
Take all medications as prescribed.
Call for any fever 100.5, redness or drainage from wounds.
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Suture removal from pacer site at follow up with Dr [**Last Name (STitle) 914**]
[**2189-8-18**]- [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] (ID) clinic appt on [**9-7**], at 9:30am. [**Telephone/Fax (1) **]
Dr [**Last Name (STitle) 914**] [**2189-8-18**] plase call for appointment [**Telephone/Fax (1) **]
Dr [**Last Name (STitle) 96426**] [**Hospital **] clinic in 2 weeks
Dr [**Last Name (STitle) **]. Eten in [**1-13**] weeks
Completed by:[**2189-8-10**]
|
[
"998.12",
"V42.2",
"443.9",
"E878.1",
"707.03",
"707.12",
"427.31",
"285.9",
"715.90",
"263.9",
"996.61",
"707.22",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.79",
"37.89",
"86.04",
"00.50",
"37.77"
] |
icd9pcs
|
[
[
[]
]
] |
12492, 12591
|
8787, 10681
|
351, 727
|
12735, 12742
|
3262, 8327
|
13154, 13504
|
2284, 2302
|
10946, 12469
|
12612, 12714
|
10707, 10923
|
12766, 13131
|
2317, 3243
|
8350, 8764
|
280, 313
|
755, 1802
|
1824, 2070
|
2086, 2268
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,495
| 196,563
|
45395
|
Discharge summary
|
report
|
Admission Date: [**2197-3-31**] Discharge Date: [**2197-4-2**]
Date of Birth: [**2139-10-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Pt is a 57 yo lady w/ HCV, presumed cirrhosis, grade I-II
esophageal varices, recently treated with IFN/ribavirin
complicated by FUO [**2-3**] with discontinuance of therapy at 6
months, who was admitted to MICU with hematemesis on [**2197-3-31**].
She reported feeling nauseated followed by few episodes of
emesis with "blood clots in the bowl" with associated dizziness.
She was hemodynamically stable in the ER but then had another
episode of large volume emesis w/ blood clots after NG tube
placement attempts for which she was admitted to the MICU. The
patient has no prior history of GI bleeds (never had variceal
bleed). She denies any episodes of BRBPR ormelena. The patient
was seen by the liver service in the MICU with recommendation
that she be started on octreotide overnight. An EGD was
performed which showed an ulcer in fundus of stomach with clot
covering it but no active bleeding. The patient has had serial
Hcts with nadir of 24.6 ([**3-31**] 5 am) from 30 on [**3-30**], coags stable
at INR 1.3. The patient received vitamin K on admission and she
received only one unit of PRBCs since admission. The patient has
had no repeat episodes of hematemsis and is now ready for
transfer to the floor.
.
Currently, patient denies any discomfort or bleeding. She denies
any further episodes of emesis and reports no abdominal pain.
She denies dizziness, lightheadedness, chest pain, or dyspnea.
Past Medical History:
# HCV genotype I w/presumed cirrhosis, followed by [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
--s/p Peg IFN/ribavirin x 6 mos, stopped for FUO-- last VL
undetectable [**2197-3-21**]
# admits for FUO [**2-3**], [**3-6**] w/ extensive, unrevealing workup,
treated for pneumonia
-eval for FUO included bone marrow biopsy, CT torso, extensive
ID work up, [**3-27**] gallium scan (No abnormal areas of increased
tracer uptake concerning for inflammation). Still ?lymphoma w/
enlarged left inguinal lymph node.
# pleural/pericardial effusion
# Grade I-II esophageal varices, no h/o bleeds
# presumed cirrhosis
# S/p TAH
# Hepatitis A in [**2161**]'s
# ECHO [**2-3**]: nl EF, 1+ MR, no wall motion abnl or veggies
# Anemia of chronic inflammation
Social History:
Per report, the patient was never a heavy alcohol drinker. She
now drinks approximately one glass of wine or one vodka and
tonic a week. She is a nonsmoker. She works in Customer Service
for U.S. Airways. She also runs her own business, designing
notepaper. She currently lives alone. She is currently divorced
and has a son living in [**Name (NI) **] and a daughter in [**Name (NI) 531**].
Denies IVDU.
Family History:
sister w/ CABG age 61, father passed away of MI age 64, mother
passed away w/ complications of biliary surgery.
Physical Exam:
PE: T 99.1 BP 142/80 R 80 R 18 99%RA
Gen: sleeping, easily arousable, conversant
HEENT: MM moist, OP clear
CHEST: CTA
CV: RRR w/ [**2-3**] early systolic murmur at LUSB
ABD: non tender, no HSM, nabs, no ascites.
SKIN: warm, well perfused
EXTRM: no edema, no rashes, strong peripheral radial and DP
pulses
NEURO: totally intact, conversant, oriented x 3, normal extrm
exam; full exam not completed at this time
Pertinent Results:
Admission Labs:
.
[**2197-3-30**] 08:25PM PT-14.4* PTT-27.5 INR(PT)-1.3*
[**2197-3-30**] 08:25PM PLT COUNT-120*
[**2197-3-30**] 08:25PM ANISOCYT-1+ MACROCYT-1+
[**2197-3-30**] 08:25PM NEUTS-65.2 LYMPHS-25.5 MONOS-4.5 EOS-3.7
BASOS-1.0
[**2197-3-30**] 08:25PM WBC-7.2 RBC-3.34* HGB-10.2* HCT-30.6* MCV-91
MCH-30.5 MCHC-33.3 RDW-16.7*
[**2197-3-30**] 08:25PM LIPASE-58
[**2197-3-30**] 08:25PM ALT(SGPT)-23 AST(SGOT)-32 ALK PHOS-71
AMYLASE-132* TOT BILI-0.4
[**2197-3-30**] 08:25PM GLUCOSE-114* UREA N-25* CREAT-0.6 SODIUM-140
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2197-3-31**] 01:25AM PT-14.5* PTT-28.7 INR(PT)-1.3*
[**2197-3-31**] 01:25AM PLT COUNT-81*
[**2197-3-31**] 01:25AM WBC-5.3 RBC-2.82* HGB-8.6* HCT-25.6* MCV-91
MCH-30.5 MCHC-33.5 RDW-16.7*
[**2197-3-31**] 01:25AM CALCIUM-7.5* PHOSPHATE-3.0 MAGNESIUM-1.7
[**2197-3-31**] 01:25AM LIPASE-41
[**2197-3-31**] 01:25AM AMYLASE-104*
[**2197-3-31**] 01:25AM GLUCOSE-124* UREA N-25* CREAT-0.5 SODIUM-139
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-22 ANION GAP-11
[**2197-3-31**] 05:39AM PT-14.2* PTT-30.5 INR(PT)-1.3*
[**2197-3-31**] 05:39AM PLT COUNT-85*
[**2197-3-31**] 05:39AM WBC-4.8 RBC-2.70* HGB-8.2* HCT-24.6* MCV-91
MCH-30.4 MCHC-33.3 RDW-16.6*
[**2197-3-31**] 05:39AM ALBUMIN-3.0* CALCIUM-7.2* PHOSPHATE-2.9
MAGNESIUM-2.5
[**2197-3-31**] 05:39AM AMYLASE-86
[**2197-3-31**] 05:39AM GLUCOSE-111* UREA N-23* CREAT-0.5 SODIUM-141
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-24 ANION GAP-10
[**2197-3-31**] 11:10AM PLT COUNT-83*
[**2197-3-31**] 11:10AM WBC-5.6 RBC-2.68* HGB-8.1* HCT-24.4* MCV-91
MCH-30.1 MCHC-33.0 RDW-16.9*
[**2197-3-31**] 07:04PM PLT COUNT-91*
[**2197-3-31**] 07:04PM WBC-6.7 RBC-2.99* HGB-9.1* HCT-26.7* MCV-89
MCH-30.2 MCHC-33.9 RDW-16.9*
Pertinent Labs/Studies:
.
Hct: 25.6 ->> 24.4 ->> 29.6 (s/p 1U PRBCs) ->> 28.0 on discharge
.
.
[**2197-3-31**] EGD:
Esophagus:
Protruding Lesions: 3 cords of grade I-II varices were seen in
the lower third of the esophagus and gastroesophageal junction.
The varices were not bleeding.
Stomach: A large clot was seen in the fundus. Attempts to
dislodge it by lavage and changing position of patient were
unsuccessful. There was no active bleeding seen. There were no
gastric varices or portal gastropathy
Duodenum: Melena was seen in the second part of the duodenum but
no bright blood was present. There were no obvios ulcers or
bleeding lesions seen.
.
Impression: Blood in the second part of the duodenum
Blood in the fundus
Varices at the lower third of the esophagus and gastroesophageal
junction
Otherwise normal egd to second part of the duodenum
.
.
Microbiology:
[**2197-3-31**] - HELICOBACTER PYLORI ANTIBODY TEST - NEGATIVE BY EIA.
.
.
Imaging: None
Discharge Labs:
.
[**2197-4-2**] 07:18AM BLOOD WBC-4.1 RBC-3.11* Hgb-9.6* Hct-28.0*
MCV-90 MCH-31.0 MCHC-34.4 RDW-17.0* Plt Ct-97*
[**2197-4-2**] 07:18AM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
[**2197-4-2**] 07:18AM BLOOD Mg-1.8
Brief Hospital Course:
A/P: Patient is a 57 year old female w/Hepatitis C (last VL
undetectable), presumed cirrhosis, history of FUO who presents
to the ICU with episodes of hematemesis.
.
#. UGI bleed: As per admission note the patient was admitted to
the MICU directly from the E.D. given repeat episodes of
hematemesis although the patient remained hemodynamically
stable. The patient was treated with IVF, IV protonix, given
Vitamin K, started on an Octreotide gtt and transfused 1U PRBCs.
EGD was performed which revealed grade I-II varices without
evidence of recent bleed but did demonstrate a large clot in the
fundus of the stomach without active bleeding, likely
representing the source of bleeding. After EGD demonstrated no
active bleed octreotide was discontinued and the patient was
observed overnight. As the patient remained stable without any
repeat episodes of bleeding the patient was transferred to the
floor. The patient had serial Hcts after transfer to the floor
that remained stable. IV protonix was changed to PO and the
patient's diet was advanced from clears to regular without
difficulty. The patient remained stable the day after transfer
but was kept in house for an additional 24 hours given the
increased risk of repeat bleed within the first 48 hours
following a bleeding event. H. Pylori antibodies were negative.
The patient was discharged to home with appropriate follow up
and plans for repeat endoscopy in 2 to 4 weeks as an outpatient.
.
#. Hep C: On admission the patient was known to be Hepatitis C
positive s/p 6 months of IFN/ribavirin, which has since been
discontinued secondary to FUO. Patient last had a VL performed a
few weeks prior to admission that was at that time undetectable.
The patient is followed closely by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and has
evidence of cirrhosis on imaging including CT although she has
no evidence for end-stage liver disease on exam. The patient has
no documented liver biopsy results to detail stage and
chronicity of her cirrhosis. Given lack of gastric varices it is
not clear that the patient's bleeding event is secondary to her
cirrhosis. However, given grade I-II esophageal varices the
patient was started on Nadolol 20mg po qd by the liver service
on this admission for prophylaxis of UGI bleed. Her Hepatitis C
was otherwise not active or addressed this admission.
.
#. FUO: The patient has a history of FUO with previous extensive
work up on last two admissions. The patient remained afebrile
throughout her course with the exception of one low grade
temperature < 100.3 for which cultures or additional imaging
were not performed. The patient is followed by Dr. [**Last Name (STitle) 2504**] in
ID with recent note documenting in detail workup to date.
.
#. HRT: The patient was continued on her outpatient regimen of
Premarin.
.
#. FEN: Patient tolerated transition from clears to regular diet
Medications on Admission:
Pantoprazole 40 mg IV
Acetaminophen 325-650 mg PO Q6H:PRN
Estrogens Conjugated 0.9 mg PO DAILY
Discharge Medications:
1. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 8 weeks.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hematemesis
Cirrhosis
Discharge Condition:
Good. Patient is hemodynamically stable with stable Hct. No
repeat episodes of hematemesis, still with some melanatic stool
which may persist for a few days.
Discharge Instructions:
1. PLease take all medications as prescribed
.
2. Please keep all outpatient appointments
.
3. Please return for repeat hematemesis, dizziness, loss of
consciousness, blood in stool, persistent black tarry stool, or
any other concerning symptoms.
Followup Instructions:
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2197-4-17**] at
09:30. Please call her office at [**Telephone/Fax (1) 2422**] with any questions
or scheduling needs.
.
You should take one week from work to ensure proper recovery
.
You will require a repeat endoscopy and possible colonocopy in 2
to 4 weeks. Please ask Dr. [**Last Name (STitle) **] about scheduling this
appointment when you see her on [**4-17**].
|
[
"531.40",
"070.54",
"571.5",
"456.21",
"E935.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9987, 9993
|
6571, 9474
|
327, 333
|
10068, 10228
|
3551, 3551
|
10523, 10998
|
2992, 3105
|
9619, 9964
|
10014, 10047
|
9500, 9596
|
10252, 10500
|
6300, 6548
|
3120, 3532
|
276, 289
|
361, 1769
|
3567, 6284
|
1791, 2555
|
2571, 2976
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,063
| 144,794
|
27733
|
Discharge summary
|
report
|
Admission Date: [**2201-9-20**] Discharge Date: [**2201-9-30**]
Date of Birth: [**2129-9-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Bioprosthetic aortic stenosis
Major Surgical or Invasive Procedure:
[**2201-9-21**] - Redo Sternotomy, Aortic valve replacement (23mm St.
[**Male First Name (un) 923**] Regent Mechanical)
History of Present Illness:
This 71 year old gentleman has a history of an AVR(#23 mm
[**Last Name (un) 3843**] [**Known firstname **] bovine pericardial valve/radiofrequency Maze
ablation of pulmonary veins)done [**5-4**]. Recently, he has been
experiencing progressive stenosis of his aortic valve
prosthesis. His most recent echo done on [**2201-7-8**] demonstrated a
peak gradient of 175mmHg and a mean gradient of 100mmHg.
Symptomatically he has mild dyspnea with exertion for the past 2
months, but no chest pain or lightheadedness.He denies PND,
orthopnea, lightheadedness, edema or claudication. Cardiac cath
did not show significant coronary disease. His surgery has been
delayed due to need for ongoing diuresis as an out patient. He
is admitted today for CXR and posssible further diuresis and
surgery tomorrow.
Past Medical History:
s/p bovine AVR/MAZE procedure [**5-4**]
atrial fibrillation
obstructive sleep apnea on CPAP
gout
gastroesophageal reflux
noninsulin dependent diabetes mellitus
cholelithiasis
left lower lobe nodule
s/p left knee surgery [**2195**]
s/p exploratory laparotomy and removal of foreign body
s/p bilateral hernia repair
s/p Basal cell skin cancer removal
Social History:
smoked 1-1.5 ppd x 18 years, quit 30 years ago
occ. glass of wine
retired and lives with companion
last dental visit in [**Month (only) 958**]
Family History:
2 daughters with aortic valve problems
Physical Exam:
Pulse:69 Resp:18 O2 sat: 96%
B/P 120/62
Ht: 5 feet 10 inches
Wt: 225 lbs
General:NAD
Skin: Dry [x] [**Month (only) 5235**] [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM []no JVD appreciated
Chest: Lungs clear bilaterally [x]; healed large keloid
sternotomy scar
Heart: RRR [x] Irregular [] Murmur [x] grade __III/VI radiates
to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]; no HSM; well-healed RUQ scar
Extremities: Warm [x], well-perfused [x] Edema [] _none____
nodule B dorsum of feet
Varicosities: None [x]
Neuro: Grossly [**Month (only) 5235**] [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: NP Left:NP
Radial Right: 2+ Left:2+
Carotid Bruit :murmur radiates to B carotids
Pertinent Results:
[**2201-9-20**] WBC-6.9 RBC-3.85* Hgb-11.4* Hct-35.9* RDW-13.9 Plt
Ct-173
[**2201-9-20**] PT-14.3* PTT-22.9 INR(PT)-1.2*
[**2201-9-20**] Glucose-103* UreaN-21* Creat-1.0 Na-141 K-4.9 Cl-103
HCO3-24
[**2201-9-20**] Albumin-4.5
[**2201-9-20**] %HbA1c-5.8 eAG-120
.
[**2201-9-21**] TEE, PREBYPASS:
No atrial septal defect is seen by 2D or color Doppler. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the distal heart segments and apex. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending [**Month/Day/Year 5236**] is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. The prosthetic
aortic valve leaflets are thickened. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**11-30**]+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve leaflets are mildly thickened. Mild
to moderate ([**11-30**]+) mitral regurgitation is seen.
.
[**2201-9-27**] Chest X-ray:
There continues to be a small left-sided pleural effusion and
retrocardiac opacity that could be due to volume
loss/effusion/infiltrate. There is a small right effusion.
Compared to the prior study there is no new infiltrate.
.
[**2201-9-30**] WBC-8 RBC-3.05* Hgb-9.1* Hct-28.3* Plt Ct-271
[**2201-9-29**] WBC-12.4* Plt Ct-228
[**2201-9-28**] WBC-11.5* Hgb-9.6* Hct-29.3* Plt Ct-215
[**2201-9-27**] WBC-10.6 RBC-2.89* Hgb-8.9* Hct-26.6* Plt Ct-204
[**2201-9-30**] PT-21.4* PTT-91.5* INR(PT)-2.0*
[**2201-9-29**] PT-18.6* PTT-71.2* INR(PT)-1.7*
[**2201-9-28**] PT-17.3* PTT-92.8* INR(PT)-1.5*
[**2201-9-27**] PT-17.3* PTT-54.1* INR(PT)-1.5*
[**2201-9-26**] PT-17.6* PTT-49.6* INR(PT)-1.6*
[**2201-9-30**] UreaN-23* Creat-0.7 Na-142 K-4.0 Cl-103 HCO3-31
AnGap-12
[**2201-9-28**] UreaN-29* Creat-0.8 Na-140 K-4.1 Cl-102 HCO3-29
AnGap-13
[**2201-9-27**] UreaN-34* Creat-0.7 Na-138 K-3.7 Cl-101 HCO3-30
AnGap-11
[**2201-9-26**] UreaN-42* Creat-0.8 Na-138 K-3.6 Cl-103 HCO3-29
AnGap-10
[**2201-9-30**] 06:50AM BLOOD Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2201-9-20**] for surgical
management of his bioprosthetic aortic valve disease. The
following day, he was taken to the operating Room where he
underwent redo sternotomy and replacement of his aortic valve
using a 23mm St. [**Male First Name (un) 923**] Regent mechanical valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. Over the next 24 hours, he
awoke neurologically [**Male First Name (un) 5235**] and was extubated without incident.
He was transferred to the floor on POD #1 to begin increasing
his activity level. Low dose beta blockade was resumed and
Coumadin started for his mechanical valve. Amiodarone was also
started for postoperative atrial fibrillation. Chest tubes and
pacing wires were removed per protocol without complication.
Warfarin was dosed daily and titrated for a goal INR between 2.5
to 3.0. Due to a subtherapeutic INR, he temporarily required
Heparin bridge. Over several days, he continued to make clinical
improvments with diuresis. Once his INR reached 2.0, he was
cleared for discharge to rehab. Prior to discharge, arrangements
were made with Dr. [**Last Name (STitle) **] to monitor PT/INR following
discharge from rehab. He was discharged to [**Location (un) 246**] Nursing and
Rehab Facility on postoperative day nine. At discharge, he
remained in a rate controlled atrial fibrillation.
Medications on Admission:
AMIODARONE 200 mg daily
EZETIMIBE-SIMVASTATIN 10 mg-80 mg Tablet - 1 Tablet(s) by mouth
daily
GEMFIBROZIL 600 mg twice a day
GLIPIZIDE 5 mg daily
LEVOTHYROXINE 50 mcg daily
LISINOPRIL 10 mg daily
METFORMIN 500 mg twice a day
METOPROLOL TARTRATE 25 mg twice a day
ASPIRIN 81 mg daily
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit Capsule - 1 Capsule(s)
by mouth daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for HR < 60 and/or SBP < 95.
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO daily
().
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
INR between 2.5 to 3.0.
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: Please take with KCL.
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days: Please
take with Lasix.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 246**] Nursing Center - [**Location (un) 246**]
Discharge Diagnosis:
Bioprosthetic aortic valve stenosis - s/p redo AVR
Prior bovine aortic valve replacement/MAZE procedure [**2196-4-28**]
Atrial fibrillation
Hypothyroidism
Obstructive sleep apnea on CPAP
Noninsulin dependent diabetes mellitus
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
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
.
Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve
and atrial fibrillation. Goal INR: 2.5 - 3.0.
First PT/INR draw: [**2201-10-1**]
Results to: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
** Please arrange appopriate coumadin followup with Dr.
[**Last Name (STitle) **] prior to discharge from rehab. **
.
**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 [**2201-10-28**] at 1:30pm
Cardiologist: Dr [**Last Name (STitle) 5686**] on [**2201-10-6**] at 9:30am
Wound check on [**10-8**] at 10:30am in [**Hospital Unit Name **] [**Last Name (NamePattern1) **]
[**Hospital Unit Name **]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 23874**]in [**3-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
.
Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve
and atrial fibrillation. Goal INR: 2.5 - 3.0.
First PT/INR draw: [**2201-10-1**]
Results to: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
** Please arrange appopriate coumadin followup with Dr.
[**Last Name (STitle) **] prior to discharge from rehab. **
Completed by:[**2201-9-30**]
|
[
"V58.83",
"327.23",
"793.11",
"427.31",
"997.1",
"V58.61",
"250.00",
"996.02",
"530.81",
"244.9",
"E878.2",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7661, 7752
|
4784, 6247
|
307, 429
|
8023, 8187
|
2714, 4761
|
9426, 10426
|
1803, 1843
|
6660, 7638
|
7773, 8002
|
6273, 6637
|
8211, 9403
|
1858, 2695
|
238, 269
|
457, 1254
|
1276, 1626
|
1642, 1787
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,985
| 118,400
|
38976
|
Discharge summary
|
report
|
Admission Date: [**2191-2-19**] Discharge Date: [**2191-2-23**]
Date of Birth: [**2106-8-11**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
[**2191-2-19**] ERCP and stent placement
History of Present Illness:
84 y.o male with h.o CAD s/p CABG and stenting, pacemaker
placement, seizure who presented to OSH with weakness, fatigue,
epigastric tenderness, jaundice, and febrile to 101. Pt was
given vanco and levaquin, U/S apparently showing CBD dilatation.
[**Doctor First Name **] called and wanted to admit to [**Doctor First Name **] ICU on the east, with
plans of ERCP in the am.
Pt states his fatigue/chills started 1 wk ago and progressed to
where he could not get out of bed today or move. Pt reports
waxing/[**Doctor Last Name 688**] symptoms over the week. He also reports chills,
difficulty in taking a deep breath, occasional "knot" in
epigastric area, and severely decreased appetite. He also
reports the sensation of falling when trying to sit upright. Pt
denies fever, headache, dizziness, ST/URI/blurred
vision/cough/cp/palp/abd
pain/n/v/d/c/melena/brbpr/dysuria/hematuria/joint pain/skin rash
paresthesias. He reportedly had and US at OSH without clear
evidence of gallstones or CBD dilation. He then had a CT scan
that suggested choledocholithiasis with mild dilation of the CBD
but no significant intrahepatic duct dilation.
.
Currently, pt reports that his pain is gone.
.
In the ED, vital signs were initially:
Time Pain Temp HR BP RR Pox
-21:00 7 98.6 92 152/118 18 98
102.7T, 97, 157/58, 18, 97% on 3L
He was given flagyl and morphine.
-pt refusing tylenol in the ED stating it will make him bleed.
Pt underwent RUQ u/s and surgery was consulted.
Past Medical History:
-cabg [**2175**] after ?blood clot in heart, ?silent MI. Stenting a
few years later
-pacemaker, 2 yrs ago after fainting spells
-seizure, started after neck injury
-neck fracture
-l.hip fx.
-kidney stones
-gout.
Social History:
Lives by himself. Quit smoking 40 years ago.
Denies ETOH.
Family History:
NC
Physical Exam:
VS:T. 98.2, HR 84, BP 109/55, RR 20 sat 93% on 2L
GEN:The patient is in no distress and appears comfortable,
jaundiced.
SKIN:No rashes or skin changes noted
HEENT:EOMI, unable to assess JVD, neck supple, No
lymphadenopathy in cervical, posterior, or supraclavicular
chains noted.
CHEST:b/a ae, +faint crackles at bases.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. distant
heart sounds. +midline sternal scar, well healed.
ABDOMEN: +bs, soft, Nt, ND, no guarding or rebound.
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-18**], and BLE [**5-18**] both proximally and distally.
Pertinent Results:
ULTRASOUND:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and mnore severe liver disease including
significant hepatic
cirrhosis/fibrosis is not excluded.
2. No intra- or extra-hepatic biliary dilatation.
3. Distended gallbladder with mild wall thickening and edema,
which could be secondary to third spacing, though in the
appropriate clinical setting
cholecystitis is not excluded.
ERCP:
-A single periampullary diverticulum with large opening was
found at the major papilla.
-The diverticulum distorted the position of the major papilla
making cannulation difficult.
-Cannulation of the biliary duct was attempted with a
sphincterotome as well as a 5-4-3 tapered cannula with a
guidewire, and ultimately cannulation was successfully performed
with a sphincterotome after a guidewire was placed. Contrast
medium was injected resulting in complete opacification.
-A moderate dilation was seen at the main duct with the CBD
measuring 10-11 mm. Two 10 mm round stones that were causing
partial obstruction were seen at the lower third of the common
bile duct. A 7cm by 10FR plastic biliary stent was placed
successfully.
-After the stent was placed, pus and sludge were seen exiting
from the stent and the ampulla.
-A sphincterotomy was not performed due to the increased risk of
bleeding on aspirin and Plavix.
[**2191-2-18**] 09:10PM BLOOD WBC-11.0 RBC-5.07 Hgb-14.9 Hct-45.9
MCV-90 MCH-29.3 MCHC-32.4 RDW-14.5 Plt Ct-242
[**2191-2-19**] 04:16AM BLOOD WBC-12.9* RBC-4.18* Hgb-12.7* Hct-38.0*
MCV-91 MCH-30.4 MCHC-33.5 RDW-14.4 Plt Ct-223
[**2191-2-20**] 03:38AM BLOOD WBC-8.4 RBC-4.32* Hgb-13.0* Hct-40.8
MCV-95 MCH-30.2 MCHC-31.9 RDW-14.7 Plt Ct-212
[**2191-2-21**] 06:54AM BLOOD WBC-8.3 RBC-4.24* Hgb-12.8* Hct-39.8*
MCV-94 MCH-30.1 MCHC-32.1 RDW-14.7 Plt Ct-278
[**2191-2-18**] 09:10PM BLOOD PT-12.5 PTT-20.6* INR(PT)-1.1
[**2191-2-19**] 04:16AM BLOOD PT-14.4* PTT-22.4 INR(PT)-1.2*
[**2191-2-20**] 09:38AM BLOOD PT-14.1* PTT-23.2 INR(PT)-1.2*
[**2191-2-18**] 09:10PM BLOOD Glucose-124* UreaN-34* Creat-1.7* Na-135
K-3.6 Cl-98 HCO3-24 AnGap-17
[**2191-2-19**] 04:16AM BLOOD Glucose-153* UreaN-33* Creat-1.6* Na-136
K-3.1* Cl-104 HCO3-19* AnGap-16
[**2191-2-19**] 03:15PM BLOOD Glucose-87 UreaN-31* Creat-1.3* Na-139
K-3.8 Cl-109* HCO3-20* AnGap-14
[**2191-2-20**] 03:38AM BLOOD Glucose-82 UreaN-26* Creat-1.1 Na-139
K-3.7 Cl-110* HCO3-19* AnGap-14
[**2191-2-21**] 06:54AM BLOOD Glucose-119* UreaN-19 Creat-1.1 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2191-2-18**] 09:10PM BLOOD ALT-277* AST-246* AlkPhos-339*
TotBili-8.6* DirBili-6.8* IndBili-1.8
[**2191-2-19**] 04:16AM BLOOD ALT-211* AST-190* LD(LDH)-221
AlkPhos-269* TotBili-8.0*
[**2191-2-20**] 03:38AM BLOOD ALT-197* AST-161* LD(LDH)-184
AlkPhos-243* Amylase-18 TotBili-7.7*
[**2191-2-21**] 06:54AM BLOOD ALT-164* AST-117* AlkPhos-275*
TotBili-7.3*
[**2191-2-18**] 09:10PM BLOOD Lipase-152*
[**2191-2-19**] 04:16AM BLOOD Lipase-54
[**2191-2-20**] 03:38AM BLOOD Lipase-59
[**2191-2-18**] 09:10PM BLOOD Albumin-3.6
[**2191-2-19**] 04:16AM BLOOD Albumin-2.7* Calcium-7.7* Phos-3.5 Mg-2.0
[**2191-2-19**] 03:15PM BLOOD Calcium-7.8* Phos-3.5 Mg-2.1
[**2191-2-20**] 03:38AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.1
[**2191-2-21**] 06:54AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
[**2191-2-18**] 09:30PM BLOOD Lactate-1.9
[**2191-2-19**] 03:15PM URINE Color-[**Location (un) **] Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2191-2-19**] 03:15PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-4* pH-5.5 Leuks-TR
[**2191-2-19**] 03:15PM URINE RBC-368* WBC-15* Bacteri-FEW Yeast-NONE
Epi-<1
[**2191-2-19**] 03:15PM URINE CastHy-2*
[**2191-2-19**] 03:15PM URINE Eos-POSITIVE
[**2191-2-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2191-2-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2191-2-19**] URINE URINE CULTURE-FINAL INPATIENT
[**2191-2-18**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{GRAM NEGATIVE ROD(S)}; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY [**Hospital1 **]
[**2191-2-18**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{GRAM NEGATIVE ROD(S)}; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
MICU Course:
Mr. [**Known lastname 86463**] was admitted with fever jaundice and RUQ pain. Labs
and imaging consistent with cholangitis. He went for ERCP and a
drain was placed. Sphincterotomy was not performed as he was on
aspirin and Plavix. He was noted to have a wide-complex
tachycardia with pacing spikes. Electrophysiology was consulted
and this was determined to be an atrial tracking rhythm
resulting from the settings on his pace-maker. Routine
cardiology follow-up is recommended. He was on Cipro/Flagyl.
After ERCP he was hypotensive, he responded very well to
aggressive fluids resuscitation. IV Vancomycin was added to
antibiotic regiment for empiric cover of Enterococcus.
After procedure home dose of aspirin and Plavix was started.
On PPD 1 we restarted regular diet, he tolerated very well and
did not have any abdominal pain. Liver function tests,
bilirubin, amylase and lipase were followed every day with
marked improve in values.
Blood cultures from ED were positive for BACTEROIDES FRAGILIS
GROUP. BETA LACTAMASE POSITIVE. Further surveillance blood
cultures were negatives, as well as urinary cultures. IV
vancomycin was discontinued.
Patient was transferred from MICU to the floor on the evening of
[**2191-2-20**].
Physical therapy started working with him. They recommended the
patient to go to the Rehab facility on discharge.
On evening of [**2191-2-21**] patient had SOB, EKG showed no acute
changed, cardiac enzymes times 3 showed no elevation, We started
him on Pulmonary toilet and Albuterol Nebs which worked very
well and patient had relieve from symptoms.
Morning od [**2191-2-22**] patient has asymptomatic hypertensive episode
with SBP 190, he was given IV Hydralazine 10mg blood pressure
decreased properly. His blood pressure was stable the rest of
his hospitalization.
On [**2-23**]/ 10 : patient feeling fine, vital signs stable and no
abdominal pain.
Medications on Admission:
Isosorbide Dinitrate 30 mg Tab Oral daily
Allopurinol 100 mg Tab Oral daily
Avapro 150 mg Tab Oral [**Hospital1 **]
coreg 6.25 [**Hospital1 **]
Protonix 40 mg Tab Oral [**Hospital1 **]
Zocor 20 mg Tab Oral daily
Levetiracetam 500 mg Tab Oral [**Hospital1 **]
Plavix 75 mg Tab Oral daily
Niacin 800 mg PO BID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO HS
(at bedtime) as needed for insomnia.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
10. Carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. Avapro 150 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Niacin Oral
16. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 10 days.
17. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for
10 days.
Discharge Disposition:
Extended Care
Facility:
Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**]
Discharge Diagnosis:
Primary: Cholangitis, choledocholithiasis
Secondary: coronary artery disease, acute renal insufficiency
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname 86463**],
It was a pleasure caring for you. You were admitted for
cholangitis, which is an infection in your biliary tract. You
had a procedure called an ERCP. There were stones obstructing
but they were not removed because of the risk of bleeding from
your plavix and aspirin. A drain was placed to remove the
infection and bile. You are on antibiotics for the infection
which also spread to your blood. You had an abnormal heart
rhythm that was not dangerous and resulted from the settings of
your pace maker. It is called atrial tracking. You should
discuss this with your cardiologist.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain 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.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-23**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
ERCP:
Please call Dr.[**Name (NI) 2798**] office to schedule an appointment in
4 weeks. ([**Telephone/Fax (1) 86464**]
Dr. [**Last Name (STitle) **]
([**Telephone/Fax (1) 9011**]
Please schedule an appointment with Dr. [**Last Name (STitle) **] after your
appointment with ERCP. Dr [**Last Name (STitle) **] will discuss
Cholecystectomy surgery options (Remove of gallbladder) to
prevent further episodes of gallstones complications.
Completed by:[**2191-2-23**]
|
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28,721
| 193,916
|
48484
|
Discharge summary
|
report
|
Admission Date: [**2161-7-17**] Discharge Date: [**2161-8-1**]
Date of Birth: [**2096-6-9**] Sex: F
Service: MEDICINE
Allergies:
Latex / Oxaliplatin / Iodine; Iodine Containing / Fluconazole /
Ace Inhibitors
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
port occlusion and iatrogenic right atrial perforation
Major Surgical or Invasive Procedure:
angiography and Hickman catheter manipulation
right heart catheterization
swan ganz catheter placement
History of Present Illness:
Ms. [**Known lastname 69629**] is a 65 yo F w/ metastatic colon cancer to the
anterior abdominal wall and peripancreatic region on previously
on 5FU/leucovorin and [**Known lastname **], admitted following iatrogenic
right atrial perforation during IR procedure to recannulate her
port.
.
The patient's port had been malfunctioning from presumed SCV
thrombus. During her procedure there were multiple attempts to
strip the catheter; then it was suspected that the right atrium
may have been perforated; dye was introduced and extravasated
into the pericardium. Stat echo showed trivial pericardial
effusion without evidence of tamponade. She then had R heart
catheterization and swan ganz catheter placement for closer
monitoring. She remained hemodynamically stable. Following the
procedure she denied chest pain, shortness of breath, or
dizziness. There was a prior history of intermittent facial
swelling that was of unclear etiology.
Past Medical History:
PAST ONCOLOGIC HISTORY: Metastatic colon cancer (mets to
anterior abdominal wall and peripancreatic region)
[**2158-2-12**]: Oxaliplatin/xeloda discontinued after 1 dose because of
allergic reaction to oxaliplatin
[**2158-3-15**] to [**2158-11-22**]: Irinotecan/Xeloda for 9 cycles. Discontinued
because of rising CEA
[**2158-12-27**]: Erbitux/Irinotecan weekly started, baseline CEA 45.
She received a total of 7 combined Erbitux/irinotecan
treatments. CEA fell to 7 ([**2159-3-14**])
[**2159-4-11**]: Begin single [**Doctor Last Name 360**] Erbitux, baseline CEA 22
[**2159-6-6**] to [**2159-10-3**]: Erbitux/irinotecan discontinued because of
allergic reaction to Erbitux
[**2159-10-24**]: Begin [**Month/Day/Year 49565**]/irinotecan, CEA rose to 43
[**2159-12-25**]: Begin 5-FU/LCV/[**First Name9 (NamePattern2) 49565**]
[**2160-1-13**]: Cyberknife treatment (radiation therapy)
[**2160-11-4**]: Began [**Month/Day/Year 102068**], developed angioedema (unclear if
culprit [**Name (NI) 102068**] or Fluconazole), transiently discontinued, then
resumed with Medrol and Benadryl
[**2161-3-12**]- [**2161-5-12**] 5-FU/Leucovorin/[**First Name9 (NamePattern2) 49565**]
[**2161-6-12**] Cyberknife
*
PAST MEDICAL HISTORY:
1. Metastatic colon cancer as above
2. Hypertension
3. Gastroesophageal reflux disease on Prevacid
4. Anxiety on Ativan as needed
5. Allergic rhinitis
6. Iron deficiency anemia, tolerated oral iron poorly
Social History:
She lives at home with her husband. They have 3 grown sons. She
is initially from [**Country 5976**], moved to the US 33 years ago.
Family History:
1 child with asthma and allergic rhinitis.
Physical Exam:
VS: T 98.7, BP 128/77, HR 106, RR 25, 91% RA
CVP 14, PA 35/24, pulsus 4
Gen: Awake, alert, Oriented x3. Mood, affect appropriate.
Pleasant. Lying flat, breathing comfortably.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP flat
CV: Tachy, regular, no m/r/g nl S1 S2
Chest: Lungs clear to auscultation anteriorly, No crackles,
wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: 2+ DP
Left: 2+ DP
Pertinent Results:
Admission Labs:
[**2161-7-17**] 04:00PM GLUCOSE-158* UREA N-6 CREAT-0.7 SODIUM-140
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
[**2161-7-17**] 04:00PM estGFR-Using this
[**2161-7-17**] 04:00PM MAGNESIUM-1.8
[**2161-7-17**] 04:00PM WBC-6.8 RBC-3.32* HGB-9.1* HCT-28.4* MCV-86
MCH-27.5 MCHC-32.2 RDW-20.5*
[**2161-7-17**] 04:00PM PLT COUNT-316
[**2161-7-17**] 04:00PM PT-12.6 PTT-26.7 INR(PT)-1.1
.
IMAGING:
[**2161-7-17**] C. Cath:
COMMENTS:
1. Resting hemodynamics slightly elevated right sided filling
pressures
with RVEDP of 13 mm Hg. Pulmonary capillary wedge pressure was
slightly
elevated (20/23/20).
2. No evidence of cardiac tamponade.
3. Evidence of contrast extravasation into pericardial space.
FINAL DIAGNOSIS:
1. No evidence of cardiac tamponade.
2. Contrast extravastion into pericardial space.
3. PA catheter left in place for ongoing hemodynamic monitoring.
4. Observe overnight in CCU.
.
ECHO [**2161-7-17**]:
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. There
is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a fat pad.
Brief Hospital Course:
In summary, Ms. [**Known lastname 69629**] is a 65 yo F w/ metastatic colon cancer
with iatrogenic RA perforation during attempt to recannulate
malfucntioning port. previously stable, newly found SVC
thrombus, bilateral PE who developed and increasing pericardial
effusion on anticoagulation. Anticoagulation was stopped and
patient transferred to the CCU for closer observation on
[**2161-7-21**]. Patient had no further signs of tamponade with
resuming therapeutic Lovenox.
.
# Pericardial Effusion/RA Perforation. Iatrogenic perforation of
the RA initially without significant effusion, no sign of
tamponade. She was monitored in the CCU without event. On
[**2161-7-19**], she was noted to have upper extremity and facial
swelling concerning for SVC thrombus. MRV was performed which
showed nearly complete occlusive SVC thrombus, and saddle PE in
the right/left pulmonary arteries. The patient was therefore
started on heparin gtt after discussion with the cardiology
consult service. The patient initially did well, with TTE on
[**7-20**], early [**7-21**] with minimal pericardial effusions. However, TTE
repeated later on [**7-21**] demonstrated increased pericardial
effusion with evagination (but not collapse) of the RA. At that
time the patient was HD stable, stable oxygenation, though with
episodes of breakthrough sinus tachycardia to 120s-140s. The
heparin gtt was stopped for concern of bleeding into the
pericardium from the previous RA perforation. She was again
transferred to the CCU for monitoring. Cardiothoracic surgery
was also consulted and advised against any surgical
intervention. She continued to be hemodynamically stable with
mild sinus tachycardia. She was started on Lovenox without
further incident. Serial echocardiograms were performed and
were stable. She will have followup echocardiogram as an
outpatient.
.
# SVC thrombus: She had onset of dramatic upper extremity and
facial swelling within two days of the procedure. This was
concerning for SVC syndrome due to thrombus around her occluded
port (still in place). This finding was confirmed by MRV. She
was anticoagulated with heparin with the events above.
Following monitoring in the CCU, Lovenox was started with
continued stability of the pericardial effusion. She had
gradual reduction in her upper extremity swelling. She had a
repeat MRV after 1-2 weeks which showed little change in the
thrombus. Interventional radiology was consulted for possible
intervention and presented the patient with options. She plans
to continue with anticoagulation and further consider IR or
surgical intervention if her swelling does not resolve. She
remains with mild upper extremity and intermittent facial edema.
.
# Pulmonary embolism: MRV performed for SVC syndrome as above
also revealed pulmonary embolus straddling the right and left
main pulmonary arteries. She remained hemodynamically stable
without oxygen requirement. She was anticoagulated with heparin
gtt with the events above. She will be discharged on Lovenox as
above.
.
# Tachycardia: She became intermittently tachycardic with sinus
rhythm at various points during her admission. She becomes
tachycardic to the 120's with mild exertion. The etiology of
this could be due to pulmonary embolism, poor preload from SVC
clot, or due to irritation from blood within the pericardium.
Her tachycardia should improve as her pericardial effusion
clears and as her endurance increases with physical therapy.
Her diltiazem was adjusted as needed and she will be discharged
on her home dose 360 mg daily.
.
# HTN: She was on Cartia 360mg daily as outpatient and will be
discharged on this dose.
.
# Metastatic Colon Ca. She is followed by Dr. [**Last Name (STitle) **] as an
outpatient. No treatments for her colon cancer occured during
this hospitalization. Her CEA was checked and was 83 (trending
downward).
.
# Anxiety: Anxiety is stable. She was treated with PRN ativan.
.
Full code
Medications on Admission:
Cartia XT 360 daily
Protonix 40 daily
Lorazepam 0.5 mg (two tabs) twice a day
Oxycodone prn
Potassium
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for anxiety.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): please take 80 mg (0.8 mL)
every 12 hours by subcutaneous injection.
5. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
7. Cardizem LA 360 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day: please hold
for SBP less than 100 or HR less than 60.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Right atrial perforation
Pericardial effusion
SVC syndrome
Pulmonary embolism
Malfunctioning port
Discharge Condition:
stable
Discharge Instructions:
You were admitted because your port was clogged. You have some
complications while in the hospital, including more clotting
around your catheter and some blood in the sac around the heart.
We treated your clotting with blood thinners, and you will
remain on these for several months. The blood around your heart
appears to be slowly resolving and will take time to slowly
resolve.
.
Please call your primary care physician or call 911 if you
experience chest pain, shortness of breath, abdominal or back
pain, fevers, increased swelling, or other concerning symptoms.
.
Please continue your home medications as previously prescribed.
Additionally you will be getting Lovenox injections twice daily
as was occuring in the hospital.
Followup Instructions:
Please schedule an appointment to see Dr. [**Last Name (STitle) **] within [**1-13**]
weeks. At this time you can also discuss further management of
your SVC syndrome. Please call ([**Telephone/Fax (1) 102069**] on Monday to
schedule this appointment.
.
You also have a followup appointment with cardiology (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 171**]). This appointment is on [**2161-8-19**] at 1 pm. You will also
have an echocardiogram at this time. Please call the office at
[**Telephone/Fax (1) 1989**] if you have any questions.
.
Please schedule an outpatient appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2427**] at [**Telephone/Fax (1) 250**], within 1-2 weeks.
|
[
"E870.8",
"197.6",
"280.9",
"415.19",
"530.81",
"998.2",
"453.2",
"423.9",
"153.8",
"996.74",
"198.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"89.64",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
9949, 10026
|
5006, 8961
|
392, 497
|
10168, 10177
|
3781, 3781
|
10959, 11721
|
3083, 3127
|
9114, 9926
|
10047, 10147
|
8987, 9091
|
4528, 4983
|
10201, 10936
|
3142, 3762
|
298, 354
|
525, 1470
|
3797, 4511
|
2711, 2917
|
2933, 3067
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,100
| 145,681
|
53797
|
Discharge summary
|
report
|
Admission Date: [**2120-12-8**] Discharge Date: [**2120-12-17**]
Date of Birth: [**2066-10-13**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
" total body swelling" and BRBPR
.
Time of encounter: [**2120-12-12**] at 7:30PM
Major Surgical or Invasive Procedure:
Intubation. S/p Extubation [**12-10**]
History of Present Illness:
53 yo primarily Spanish speaking female with obesity
hypoventilation on home CPAP with multiple hospital admissions
for hypercarbic respiratory failure, OSA, panhypopituitarism,
pulmonary HTN, diastolic CHF, brought in by EMS to ED on [**12-8**] as
requested by daughter. The main complaints being total body
swelling with concern for fluid over load and BRBPR unclear
amount frequency and duration. Pt her self is poor historian and
can not give report with regard to ROS.
.
She was found to be in hypercarbic resp failure and was
intubated for that. In the ICU, she was also diuresed with IV
lasix. She was started on high dose prednisone. She was
eventually transitioned to CPAP.
Past Medical History:
1)Obstructive Sleep Apnea on home CPAP, 16cm H20
2)Obesity Hypoventilation
- Multiple admissions for hypercarbic respiratory failure; PFT's
consistent with a restrictive defect
- PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO reduced
3)ASD with right-left shunt (12% shunt fraction documented in
nuclear study from [**2116-3-30**])
4)Pulmonary artery hypertension: Echo in [**10/2118**] demonstrated a
TR gradient of 33mmHg ?????? followed by [**Location (un) 4507**]
5)Hypertension
6)Pan-hypopituitarism with partially empty sella on
desmopressin, levothyroxine, prednisone ?????? followed by Dr.
[**Last Name (STitle) **]
7)Diastolic CHF with dilated RA/LA on previous echo
8)Angioedema (unclear history, possibly related to ACE-I)
Social History:
Lives with daughter and 3 grandchildren [**Location (un) 6409**].
Originally from [**Male First Name (un) 1056**]. Goes to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Program
History of tobacco use, no h/o ETOH or IVDU
Family History:
Non-contributory
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, + Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia, + [**Last Name (un) **]
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
.
VS - 98.8, 90/62, 62, 16, 97%/2L
GENERAL - short, obese woman, sitting in bed in no obviouse
discomfort
HEENT - PERRL, EOMI. Strabismus
LUNGS - good air entry, CTAB
HEART - RRR, 3/6 SEM heard across the precordium
ABDOMEN - soft, NT, obese, BS+
EXTREMITIES - slightly warm with trace erythema but no evidence
of open lesions; 1+ pedal edema bilaterally
Pertinent Results:
[**2120-12-7**] 10:25PM BLOOD WBC-6.9# RBC-3.04* Hgb-8.0* Hct-28.2*
MCV-93 MCH-26.4* MCHC-28.4* RDW-16.0* Plt Ct-101*
[**2120-12-12**] 04:48AM BLOOD WBC-11.6* RBC-3.04* Hgb-8.2* Hct-27.4*
MCV-90 MCH-27.0 MCHC-29.9* RDW-17.5* Plt Ct-173
[**2120-12-7**] 10:25PM BLOOD PT-15.0* PTT-32.0 INR(PT)-1.3*
[**2120-12-7**] 10:25PM BLOOD Glucose-121* UreaN-26* Creat-1.4* Na-141
K-4.4 Cl-99 HCO3-37* AnGap-9
[**2120-12-12**] 05:37PM BLOOD Glucose-101 UreaN-8 Creat-1.9* Na-147*
K-3.5 Cl-100 HCO3-39* AnGap-12
[**2120-12-8**] 03:46AM BLOOD CK(CPK)-42
[**2120-12-7**] 10:25PM BLOOD CK(CPK)-44
[**2120-12-7**] 10:25PM BLOOD cTropnT-0.02*
[**2120-12-8**] 03:46AM BLOOD CK-MB-3 cTropnT-0.01
[**2120-12-7**] 11:39PM BLOOD Type-ART pO2-145* pCO2-91* pH-7.23*
calTCO2-40* Base XS-6
[**2120-12-12**] 05:42AM BLOOD Type-ART pO2-75* pCO2-71* pH-7.40
calTCO2-46* Base XS-14
[**2120-12-7**] 11:39PM BLOOD Lactate-0.7
.
CXR [**2120-12-7**]
Massive cardiomegaly with improving pulmonary edema
.
CXR [**2120-12-9**]
Little change in the congestive failure and bilateral pleural
effusions, more prominent on the left.
Brief Hospital Course:
Patient is a 54 year old woman with history of morbid obesity,
obesity hypoventilation, OSA, panhypopituitarism, diastolic
congestive heart failure who presented with hypercarbic
respiratory failure was intubated and in the intensive care unit
and transferred to the medical service on [**12-12**].
.
#Hypercarbic respiratory failure: Resolved; patient is
chronically hypercarbic in the 60-70s due to chronic obstructive
sleep apnea/obesity hypoventilation syndome. In the past no
clear percipitant was found and most likely a combination of
CHF, poor underlying lung function and perhaps non compliance
with home CPAP; however, pt states that she is compliant at
home.
.
#Obesity Hypoventilation/Obstructive Sleep Apnea: Chronic,
causing hypercarbia. Once extubated was placed on CPAP nightly
and 3L 02 via NC . Did not keep last appointment with outpatient
sleep lab. Now set up for close follow up for
sleep and weight management. Patient needs to faithfully use her
CPAP at home and close f/u with sleep physicians.
.
#Acute on chronic blood loss anemia: in the past had acute blood
loss Anemia from gastritis and guaiac positive emesis in the
past thought to be likely Likely [**3-2**] high dose steroids given.
Patient was transfused 1 unit of PRBC on [**2120-12-7**] (prior to
admission), and did not require further transfusion. Pt was
treated with [**Hospital1 **] ppi, and bleeding appeared to resolve, and H/H
remained stable.
.
# Acute renal failure:
Patient's CR maxed at 2.3, renal failure was possibly secondary
to overdiuresis and bactrim use. This improved with loosening
of fluid restriction and holding of her lasix and valsartan.
Creatinine on discharge was 1.8. The patient was instructed to
restart her lasix and valsartan on [**12-19**].
.
# Acute on Chronic Diastolic Heart Failure: Improved. Patient
needs to use CPAP nightly to help prevent exacerbations.
# Hypernatremia: Resolved with loosening of fluid restriction
and discontinuation of lasix.
.
# Wheezing, mild) Albuterol
.
# Benign Hypertension: Continued lopressor, clonidine. Restart
valsartan on [**12-19**].
.
# Panhypopituitarism: Thought to be secondary to "empty sella".
Prednisone 5mg, Levoxyl, and Desmopressin.
.
# UTI: was on bactrim, changed to Cipro and course finished.
.
# FEN: cardiac diet, low sodium, repleate lytes po
# code full
Medications on Admission:
1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Apply to inner thighs.
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
12. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing. neb
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
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 shortness of breath or wheezing.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day:
RESTART ON [**12-19**], DO NOT TAKE FOR 2 DAYS after discharge.
12. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM: HOLD FOR
2 DAYS AFTER DISCHARGE, RESTART on [**12-19**].
13. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM: RESTART
ON [**12-19**], DO NOT ATKE FOR 2 DAYS AFTER DISCHARGE.
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
# obesity hypoventilation syndrome
# Obstructive sleep apnea
# Acute on chronic blood loss anemia
# Acute renal failure
# Acute on chronic diastolic heart failure
# Hypernatremia
# Hypertension; benign
# Panhypopituitarism
# Urinary tract infection
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc/day
Followup Instructions:
Patient to schedule f/u with her PCP: [**First Name8 (NamePattern2) 3296**] [**Last Name (NamePattern1) 3297**],[**Name12 (NameIs) 3295**] I.
[**Telephone/Fax (1) 608**] in [**1-31**] weeks.
|
[
"584.9",
"416.0",
"253.2",
"280.0",
"V46.2",
"428.0",
"518.84",
"287.5",
"428.33",
"327.23",
"285.1",
"276.0",
"578.1",
"745.5",
"278.00",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9358, 9410
|
4246, 6589
|
371, 411
|
9703, 9712
|
3131, 4223
|
9891, 10084
|
2198, 2216
|
8056, 9335
|
9431, 9682
|
6615, 8033
|
9736, 9868
|
2231, 3112
|
251, 333
|
439, 1124
|
1146, 1889
|
1905, 2182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,228
| 167,826
|
25447
|
Discharge summary
|
report
|
Admission Date: [**2193-6-19**] Discharge Date: [**2193-6-27**]
Date of Birth: [**2147-1-13**] Sex: M
Service: LIVER TRANSPLANT SURGERY SERVICE
HISTORY OF PRESENT ILLNESS: Mr. [**Name14 (STitle) 63574**] was a 46 year-old
gentleman with a long history of end stage liver disease
secondary to alcohol, diabetes that was transferred from
[**State 1558**], [**Hospital1 189**], on [**2193-6-19**] to the
[**Hospital1 69**] for evaluation of
possible liver transplant. His premorbid condition remained
somewhat unclear at the time of his transfer but by patient
report, records, and family information he had had a long
history of bacteremia and hypotension who presented to
[**State 1558**] on [**2193-5-28**] with fever and
change in mental status. In the [**State 1558**]
emergency department he was found to be febrile with a
hematocrit of 23% and worsening hypotension. He received
multiple bolluses of Crystalloid and ultimately was
stabilized on pressors. Blood cultures drawn at the time of
admission to the emergency department showed 4 out of 4
positive for streptococcus salivarius. The patient was
started on Levaquin, Flagyl and Tobramycin, although
Tobramycin was also ultimately discontinued and Vancomycin
was started. On hospital day 3 patient began to show signs of
worsening hepatic failure including change in mental status
and hypotension. He developed a gastrointestinal bleed and
was ultimately intubated for airway protection on [**2193-6-9**]. Bronchoscopy performed soon thereafter showed positive
cultures for [**Female First Name (un) 564**]. Shortly thereafter patient's renal
function ultimately deteriorated and he was started on CVVHD.
On [**2193-6-18**] after consultation with [**Hospital1 346**] transplant service. It was agreed
that the patient would be transferred to the [**Hospital1 346**] for evaluation for possible liver
and/or kidney-liver transplant.
PRIOR MEDICAL HISTORY:
1. End stage liver disease secondary to alcohol.
2. Diabetes mellitus type 2.
3. Right femoral neck fracture, status post open reduction,
internal fixation on [**2190-9-7**], procedure complicated
by MRSA infection.
4. Osteomyelitis, status post multiple surgical debridements
of his back.
5. Multiple episodes of bacteremia including most recently
MRSA bacteremia in [**2191-6-7**], pseudomonas bacteremia in
[**2191-8-8**] and strep viridans bacteremia in [**Month (only) **]
[**2191**].
6. Osteoporosis with multiple compression fractures of T3,
T7, T12, L1, L3, L5.
7. Peptic ulcer disease.
8. Grade 2 esophageal varices.
9. Depression.
10. Anemia.
11. Gravius esophagus.
MEDICATIONS ON TRANSFER: Protonix 40 mg IV b.i.d.,
hydrocortisone 100 mg t.i.d., sliding scale insulin,
Ceftriaxone, octreotide drip approximately 15 mg q 1 hours,
Tylenol p.r.n., Bactrim, Fentanyl drip, total parenteral
nutrition, intermittent CVVHD.
LABORATORY RESULTS ON ADMISSION: Sodium 139, potassium 4.1,
chloride 104, CO2 24, BUN 110, creatinine 6.7, glucose 75,
hematocrit 23, platelets 63, calcium 8.6, magnesium 1.5,
phosphorus 2.1.
PHYSICAL EXAMINATION: Upon presentation to the [**Hospital1 346**] surgical intensive care unit the
patient was intubated and sedated. He was noted to be
generally icteric appearing. He showed some response in
localization to pain. Skin color consistent with jaundice.
Sclerae noted to be markedly icteric. Pupils are equal and
reactive to light. Cardiovascular examination is regular rate
and rhythm. Pulmonary examination: Coarse breath sounds
bilaterally. Abdomen is extremely obese without any obvious
hepatomegaly or any obvious spider angiomatas. Extremities
showed 2 to 3+ edema.
BRIEF HOSPITAL COURSE: Shortly after arrival in the
intensive care unit the patient's right internal jugular
catheter was immediately exchanged for a catheter capable of
accepting a Swan. The Swan was floated successfully showing
mild cardiogenic shock and dehydration. Preparations were
made at that time for additional inotropic support as well as
CVVHD. Initial evaluation at that time by the transplant team
concluded that the patient's presentation was most consistent
with resolving sepsis, acute renal failure and possibly adult
respiratory distress syndrome. It was felt given that the
family still was quite interested in possible transplant
candidacy it was felt that additional work up was necessary.
Effort during the next several days thus surrounded
transplant work up as well as stabilization of his multiple
medical problems. Infectious disease consultation felt that
the patient had multiple possible sources for sepsis and
final antibiotic course regimen including Vancomycin,
meropenum, caspofungin was selected. At that time HIV testing
was necessary to assess patient's candidacy for transplant.
Ethics consult was requested and per recommendations of that
consult HIV testing was performed. At that time neurologic
function was questionable at best. Patient responded to some
basic commands, however, was never oriented to person, place
or time. Ammonia level check shortly after arrival in the
Intensive Care Unit showed ammonia to be 69. Hospital days 2
through 4 patient's pressor requirements continued to
increasing including Neo-Synephrine drip which at that time
was 1.25. A delicate balance had to be maintained for
diuresis and dialysis needs which were maintained using CVVHD
and Neo-Synephrine for blood pressure maintenance. Despite
expansion of the antibiotic regimen patient's white count
continued to increase peaking at 24.6 on hospital day 4.
Repeated culturing and imaging failed to reveal any
undiagnosed sources for this infection. By hospital day 8 or
[**2193-6-25**], patient's condition had continued to
deteriorate. His blood pressure was refractory to additional
pressors. Over the course of several family discussions
including the chief resident and Dr. [**Last Name (STitle) **] [**Name (STitle) 228**] family
began to inquire about changing the patient's status to Do
Not Resuscitate, Do No Intubate. Given the patient's
increasing coagulopathy, sepsis and circulatory collapse he
was not longer being considered a good candidate for liver
recipient and the family's request was thought to not be
unreasonable. On [**2193-6-27**] or hospital day 10, with
patient's white blood cell count at 36.1, pressor support
maxed out, patient's family including his mother, the
designated health care proxy, requested that he be made Do
Not Resuscitate, Do Not Intubate and life support be
gradually withdrawn. In accordance with their request
pressors were withdrawn and ventilator settings were changed
to room air. Patient expired shortly thereafter. Per the
patient's family's request patient was submitted for autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2193-7-4**] 14:30:54
T: [**2193-7-4**] 15:36:05
Job#: [**Job Number 63575**]
|
[
"570",
"995.92",
"789.5",
"311",
"709.8",
"584.9",
"572.4",
"V66.7",
"348.39",
"530.85",
"250.40",
"571.2",
"458.9",
"518.81",
"456.0",
"038.9",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"99.05",
"99.07",
"54.98",
"96.72",
"96.07",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3708, 7024
|
3118, 3684
|
194, 2647
|
2935, 3095
|
2673, 2920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,427
| 175,448
|
33564
|
Discharge summary
|
report
|
Admission Date: [**2150-11-3**] Discharge Date: [**2151-2-17**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Surgical Wound Debridement
History of Present Illness:
Mr. [**Known lastname 77792**] is a 75 with chronic respiratory failure s/p
tracheostomy, type II diabetes, peripheral vascular disease s/p
right BKA, CAD, atrial fibrillation, and ESRD on dialysis who
presented on [**2150-11-3**] from his chronic rehab facility with
hypotension to the 70s systolic with associated cough and sputum
production. Since [**2150-11-3**] he has had multiple ICU transfers for
hypotension and somnolence.
.
On DOA on [**2150-11-3**], he presented with BP of 50/33 and it was
presumed to be sepsis from large known sacral decubitus ulcer
which was felt to be infected. He was admitted to the [**Hospital Unit Name 153**] for
concern for sepsis. He was in the [**Hospital Unit Name 153**] from [**2150-11-3**] to
[**2150-11-26**]. In [**Hospital Unit Name 153**] he had a broad infectious workup. Multiple
blood cultures were negative. Both sputum and urine cultures
were positive for acinetobacter. He was treated with a
prolonged course of daptomycin, meropenem and PO vancomycin.
Antibiotics were discontinued on [**2150-11-26**] prior to transfer to
the floor. While in the ICU his blood pressures were
persistently in the 70s to 80s systolic but he was afebrile and
was noted to be mentating appropriately. His blood pressures
were noted to be particularly sensitive to narcotic pain
medications. He was followed closely by the renal, infectious
disease and plastic surgery services. He initially required
CVVH given his labile blood pressures but was ultimately
transitioned back to intermittent hemodialysis. His back wound
was debrided on multiple occassions by plastic surgery. His
back wound was noted to be consistently contaminated by fecal
material despite flexiseal use. Diverting colostomy was
recommended but was declined by the patient. He was transferred
to the floor on [**2150-11-26**] for further management.
.
On [**2150-11-29**] he was transferred back to the MICU for hypotension.
He was not febrile, new cultures failed to reveal a source. He
was started back on daptomycin, meropenem and PO vancomycin. He
also received stress dose steroids. His hypotension resolved
with this regimen. He was transferred back to the floor with
blood pressures in the 90s to 110s systolic. The patient did
well on the floor until [**12-8**] when 2 hours after receiving 10 mg
oxycodone to control sacral decub pain in setting of dressing
change he became unresponsive.
Narcan did imporve his alertness but the medical staff was
unable to obtain reliable vital measurements and in setting of
worsening productive sputum and worsening leukocytosis, patient
was transferred to ICU were he was monitored for 2 days. The
patient returned to the medicine floor on [**12-10**]. However, on
[**12-12**] he again became hypotensive and returned to the ICU, again
likely multifactorial. Midodrine was restarted and uptitrated to
15mg tid. He received one unit of PRBCs with hemodialysis for
colloid volume resuscitation. He was transferred back to the
floor on [**12-14**].
.
On review of systems he does not note any pain/discomfort
anywhere. He denies chest pain, shortness of breath, nausea,
vomiting, abdominal pain, dysuria, leg pain.
Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and Vent Dependent [**1-18**] PNA in [**12-24**]
hypercarbic/hypoxic respiratory failure, bronchoscopy on [**9-10**].
He diffuse airway edema consistent with volume overload. There
were no significant secretions and a full survey of the airways
reveals all airways were patent without any endobronchial
lesions. His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.
# PNA [**4-23**] (Stenotrophomonas - Bactrim sensitive)
and Acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# MRSA PNA
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Coccyx Ulcers
# MGUS
Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].
Family History:
Non-Contributory
Physical Exam:
Review of systems:
ROS is is negative except for what is mentioned in the HPI
.
EXAM
Vitals: 971., 115/40, 69, 16, 96%/40% FM
GEN: NAD, lying in bed, +trach, obese, awake, alert,
HEENT:PERRLA, EOMI, anicteric, MMM
neck: +trach in place, c/d/I, supple, unable to assess for JVP.
Chest/Pulmonary:b/l +poor respiratory effort, CTAB anteriorly.
R.sided HD catheter
Heart: s1s2 distant heart sounds, unable to appreciate m/r/g.
Abdomen: +bs, obese, soft, NT, ND
Ext: s/p R.BKA, wound at stub. L.leg dusky, dark in color, dry
skin, faint pulses. R.midline c/d/i. 3+body edema.
Back: +stage 4 sacral decub, with multiple surrounding decubs of
various stages. +evidence of zoster infection/dermatomal
vesicular rash.
Neuro: AOx3
Pertinent Results:
[**2150-12-14**] 03:04AM BLOOD WBC-21.3* RBC-2.72* Hgb-8.3* Hct-25.7*
MCV-95 MCH-30.4 MCHC-32.1 RDW-22.5* Plt Ct-232
[**2150-11-3**] 07:40PM BLOOD WBC-13.2*# RBC-3.27* Hgb-9.1* Hct-29.7*
MCV-91 MCH-27.8 MCHC-30.6* RDW-17.7* Plt Ct-415#
[**2150-12-14**] 03:04AM BLOOD PT-24.6* PTT-64.0* [**Month/Day/Year 263**](PT)-2.4*
[**2150-12-14**] 03:04AM BLOOD Glucose-74 UreaN-22* Creat-1.9*# Na-146*
K-3.3 Cl-110* HCO3-24 AnGap-15
[**2150-12-14**] 03:04AM BLOOD Calcium-8.8 Phos-2.1*# Mg-1.9
[**2150-12-13**] 08:28AM BLOOD Tobra-3.1*
.
CXR [**11-3**]
IMPRESSION: Cardiomegaly with bilateral small pleural effusions,
left greater than right. Retrocardiac opacity may represent a
combination of atelectasis and pleural effusions. Cannot rule
out pneumonia. Followup is recommended.
.
FOOT 2 VIEWS LEFT PORT Study Date of [**2150-11-4**] 10:04 AM
FINDINGS: No previous images. There has been resection of the
phalanges of
the fourth and fifth digits as well as a substantial portion of
the fifth
metatarsal in a patient with vascular calcification consistent
with diabetes. Specifically, no evidence of erosion of the
calcaneus, though there is evidence of an adjacent ulcer. Small
posterior calcaneal spur.
.
TTE (Complete) Done [**2150-11-9**]
The left atrial volume is increased. The left atrium is dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Left ventricular systolic function is hyperdynamic (EF>75%).
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. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2150-4-4**],
mild symmetric LVH is present, left ventricular cavity size is
smaller and overall left ventricular systolic function has
improved. The degree of mitral regurgitation has increased
slightly. Moderate pulmonary artery systolic hypertension can be
seen on the current study.
.
[**2150-11-4**] 11:33 am SWAB Source: Stool.
**FINAL REPORT [**2150-11-8**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2150-11-8**]):
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
.
[**2150-11-10**] 4:51 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2150-11-13**]**
MRSA SCREEN (Final [**2150-11-13**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2150-11-20**] 6:10 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-11-20**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
.
[**2150-11-29**] 7:49 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2150-12-3**]**
GRAM STAIN (Final [**2150-11-29**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2150-12-3**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- =>64 R 32 R
CEFTAZIDIME----------- =>64 R 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R 4 S
IMIPENEM-------------- 8 I
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- 32 S
TOBRAMYCIN------------ 8 I <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2150-12-12**] 11:48 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-12-12**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
COLISITIN AND TIGECYCLINE REQUESTED BY DR.[**Last Name (STitle) **].
[**Doctor Last Name **],[**2150-12-17**].
COLISTIN AND Tigecycline REQUEST SENT TO [**Hospital1 4534**]
[**2150-12-21**].
ACINETOBACTER BAUMANNII COMPLEX. HEAVY GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
TO ADD TIGECYCLINE ,DURAPENEM AND COLISTIN PER DR.
[**First Name (STitle) **] PAGER
[**Numeric Identifier 36772**] [**2150-12-14**].
DURAPENEM RESISTANT AT >32 MCG/ML Sensitivity testing
performed
by Etest.
TIGECYCLINE AND COLISTIN SENT TO [**Hospital1 4534**] LABORATORIES FOR
SENSITIVITY.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. SECOND
MORPHOLOGY.
COLISTIN AND TIGECYCLINE REQUESTED BY DR. [**Last Name (STitle) **].
[**Doctor Last Name **],[**2150-12-17**].
COLISTIN AND Tigecycline REQUEST SENT TO [**Hospital1 4534**]
[**2150-12-21**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ACINETOBACTER BAUMANNII
COMPLEX
| | PSEUDOMONAS
AERUGINOSA
| | |
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- 32 R =>64 R 8 S
CEFTAZIDIME----------- 32 R 4 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ 4 S 2 S 4 S
IMIPENEM-------------- =>16 R
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- 32 S <=4 S
PIPERACILLIN/TAZO----- 64 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- 2 S
LEGIONELLA CULTURE (Final [**2150-12-19**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
.
[**2150-12-18**] 3:16 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-12-21**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Preliminary):
.
Brief Hospital Course:
Mr [**Known lastname 77792**] is a 76 year old man with a chronic trach, s/p multiple
admissions, End-stage renal disease, coronary artery disease,
atrial fibrillation, type two diabetes and a plasma cell
dyscrasia admitted originally with hypotension and sepsis from
an infected sacral decub with prolonged hospitalization course
involving multiple transfers back and forth between the ICU and
floor for hypercapneic respiratory failure secondary to narcotic
pain medication.
.
# Stage IV Decubitus Ulcer: Overall, the patient has a very
severe stage 4 sacral decubitus ulcer and multi-drug resistant
organisms. He completed a 6 week course of Meropenem on [**2151-1-11**]
for empiric coverage. A diverting colostomy was performed on
[**2151-1-6**] to prevent fecal contamination of the wound and to
facilitate any possible wound healing. For pain control during
wound dressing was managed with various regimens transitioned to
IV morphine eventually.
# Hypotension: Pt was noted to have a baseline of sBP in the 70s
to 80s. On his original day of admission it was thought that it
may be a component of sepsis however his BP has persisted even
with resolution of sepsis. Pt has been asymptomatic and
mentating well with his above noted systolic pressures. His
baseline low BP is most likely due to autonomic dysfunction
given his negative work up and lack of clinical findings.
[**Name (NI) **] pt did require intermittent low dose Levophed
as pt's BP was decreased to the mid 60s most likely secondary to
hypovolemia. Pt was started and continued on midodrine 15 mg po
tid. Throughout [**Month (only) 956**], BP's ranged from 60's/20's- 100's/40's
thought likley to be [**1-18**] chronic sepsis and autonomic
dysfuntion.
#Pseudomonal Pneumonia: The patient was diagnosed with a
possible drug-resistant pseudomonal pneumonia which was treated
with a 14 day course of tobramycin finishing [**12-22**]. Following
treatment pt showed a negative sputum culture on [**12-26**], pt has
not shown any positive blood cultures since admission.
# ESRD: Pt was briefly on CVVH for fluid removal for several
days in early [**Month (only) 956**]. Otherwise, he was maintained on MWF HD.
By the last week of [**Month (only) 956**], his pressures were unable to
tolerate fluid removal during HD.
# Presumed C.Diff: Pt was started empirically on PO Vancomycin
given his course on antibiotics, however they were discontinued
given lack of diarrhea and C. diff negative toxin assays.
# Chronic Respiratory Failure: He has experienced several
transfers between floor status and the ICU for hypercapneic
respiratory failure. Pt is very sensitive to pain medication,
particularly Oxycodone. For his decub ulcer pain pt was trialed
on Oxycodone of 10mg and became somnelent. Pt has been
transitioned to Fentanyl patch 100mcg for baseline pain control
plus morphine for dressing changes. During [**Month (only) 956**], his
respiratory failure worstened and he was put on ventilator for
support.
# Coronary Artery Disease: Last echocardiogram with preserved
ejection fraction. Had troponin leak on admission which peaked
at 0.53. Pt was continued on simvastatin, his beta blockers were
held given his low pressures.
# Atrial Fibrillation: Pt's A. fib during hospitalization has
been rate controlled. Due to his [**Country **] score 2 pt was continued
on Coumadin in house, given his supratherapeutic [**Country 263**] pt's
Coumadin was held. In early [**Month (only) 956**], coumadin was discontinued
all together due to his comorbid conditions and risk of bleeding
from multiple ulcers on feet and sacrum.
# Type II Diabetes: Pt has diabetes and has been noted to have
lower blood sugars following his surgery. His Lantus originally
at 28 was transitioned down to 15. Given his recent surgery it
was thought he most likely had some malabsorption from bowel
edema. Lantus was changed to 15units daily without any further
hypogycemia.
# Peripheral Vascular Disease: s/p BKA on right with left heel
ulcer on leg. Also left second toe ulcer. Was followed by
vascular surgery. Left amputation was considered given chronic
cyanosis but pt was too unstable for this.
# Plasma Cell Dyscrasia: Known IgA kappa on electrophoresis,
bone marrow with 5-10% plasma cells. Also with known
retroperitoneal mass s/p non-diagnostic FNA and needle core
biopsy indicating lymphoid tissue with quiescent germinal
centers.
# Pain Control: Patient with significant pain from sacral
ulcer. Unfortunately blood pressures and respiratory failure
occur with his narcotic use. Pain consult was obtained however
recommendations were not favourable given their side effects.
He is maintained on the fentanyl patch and trying out morphine
concentrate prn before dressing changes.
# Upper gastrointestinal bleeding: Patient with guaiac positive
NG aspirates on [**11-24**]. He has had no subsequent gross bleeding
as well as no bleeding out of the ostomy. Following surgery pt's
Hct was noted to be 19 and he received 1u PRBC. He increased his
Hct appropriately and his subsequent Hcts were noted to be in
the mid 20s which is his baseline. Pt was continued on PPI
threrapy.
# Goals of care: [**2151-2-2**] a family meeting was held with ICU team
at which the family was informed that there were no further
medical or surgical options for treatment. Code status was
changed to DNR/DNI and it was made clear to the family that
CVVH, pressors or any escalation in care were not indicated. No
further cultures, radiologic studies were ordered. Pt continued
to get MWF blood draws prior to dialysis but pt quickly became
unable to tolerate fluid removal due to low BPs during dialysis.
Pain was controlled PRN and narcotics were not held in setting
of hypotension. On [**2151-2-16**] another conversation with the family
and the ICU team took place, at which time the family was
informed that Mr [**Known lastname 77795**] blood pressure would not tolerate
additional dialysis. The family decided that the pt would be
CMO, and a morphine drip was initiated. On [**2151-2-17**] at 11:45 pt
passed away from cardiac arrest.
Medications on Admission:
epoetin alfa 20,000 units with HD
famiotidine 20mg daily
recent course with fluconazole/levoflox
metoprolol 12.5mg [**Hospital1 **]
zofran 4mg IV q6h prn nausea
percocet 5/325 mg 1-2 tabs, q4h prn pain
senna
sevelamer 800mg TID
simvastatin 10mg daily
vanco 1g with HD at [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
End stage renal failure
Sepsis
Stage 4 Decubitus Ulcer
Upper GI Bleeding
Pneumonia
Hypoxemia
Hypotension
Altered Mental Status
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2151-2-18**]
|
[
"584.9",
"V46.11",
"707.14",
"730.28",
"707.03",
"250.40",
"707.09",
"276.4",
"707.15",
"V49.75",
"507.0",
"482.1",
"250.70",
"008.45",
"038.9",
"273.9",
"285.21",
"707.05",
"578.9",
"V09.81",
"414.8",
"276.7",
"599.0",
"403.91",
"V44.0",
"518.84",
"276.0",
"427.31",
"585.6",
"443.81",
"278.01",
"707.24",
"995.92",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.6",
"39.95",
"77.69",
"97.02",
"46.03",
"38.93",
"86.28",
"00.14",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
20025, 20104
|
13567, 19657
|
313, 341
|
20275, 20285
|
5243, 9243
|
20338, 20510
|
4468, 4486
|
19996, 20002
|
20125, 20254
|
19683, 19973
|
20309, 20315
|
4501, 4501
|
13231, 13505
|
13541, 13544
|
4520, 5224
|
262, 275
|
369, 3549
|
3571, 4373
|
4389, 4452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,995
| 164,810
|
5938+55713
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-8-15**] Discharge Date: [**2194-8-25**]
Date of Birth: [**2143-1-30**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Darvon / Gabapentin / Mucinex / Robitussin /
Lyrica / Lipitor / Oxycontin / Codeine
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
[**2194-8-16**]: Left IJ placement
[**2194-8-17**]: Abdominal CTA
History of Present Illness:
51 yo F s/p cadaveric renal transplant on [**2194-6-5**] now with
multiple admissions for abdominal pain, nausea, and vomiting now
returns with nausea/vomiting. The patient states that she has
had 3 episodes nausea/vomiting.
She has had multiple recent admissions, the most recent of which
was on [**7-18**] at which time the patient had similar symptoms. She
had a KUB that showed mild distension but no evidence of
obstruction and a renal U/S that showed simple fluid around the
lower pole of her graft.
She was scheduled for EGD and colonoscopy as an outpatient, but
this was cancelled as the patients symptoms completely resolved.
Past Medical History:
ESRD due to chronic GN s/p living related kidney tx [**2194-6-5**],
Hypercholesterolemia, s/p R AVG [**2194-6-4**], failed living related
kidney transplant [**2187-1-30**], RUE AV fistula with multiple
revisions for aneurysm s/p removal and wound revision, PD
catheter placement
stool + c.diff [**2194-8-17**]
Social History:
Lives at home with husband and children; has smoked
[**12-7**] PPD for the last 30 years but despite plans to quit after
her transplant she has not; denies past or current alcohol or
illicit/recreational drug use
Family History:
Mother had [**Name (NI) 2320**], brother had brain aneurysm
Physical Exam:
PE: 97.7 102 104/74 18 99RA
NAD, A&Ox3
RRR
CTAB
Abdomen: Minimal tenderness throughout, no guarding/rebound
Pertinent Results:
On Admission: [**2194-8-14**]
WBC-6.3# RBC-2.76* Hgb-8.7* Hct-26.1* MCV-95 MCH-31.6 MCHC-33.4
RDW-20.9* Plt Ct-292
PT-14.7* PTT-24.9 INR(PT)-1.3*
Glucose-112* UreaN-24* Creat-1.0 Na-135 K-3.8 Cl-102 HCO3-18*
AnGap-19
ALT-5 AST-10 AlkPhos-106* TotBili-0.2 Lipase-9 GGT-13
Albumin-3.1* Calcium-9.0 Phos-2.2* Mg-1.3* Triglyc-89
Lactate-1.2
[**2194-8-16**] PTH-43
[**2194-8-16**] BLOOD BK VIRUS BY PCR: No DNA Detected
[**2194-8-15**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 URINE
Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-150
Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG, URINE RBC-[**2-7**]* WBC-0
Bacteri-FEW Yeast-NONE Epi-<1
[**2194-8-16**]: Urine culture: NO GROWTH.
[**2194-8-16**]: CMV Viral Load: CMV DNA not detected.
[**2194-8-17**]: CLOSTRIDIUM DIFFICILE: FECES POSITIVE FOR C. DIFFICILE
TOXIN [**2194-8-19**]: MICROSPORIDIA STAIN (Final [**2194-8-20**]): NO
MICROSPORIDIUM SEEN.
FECAL CULTURE (Final [**2194-8-21**]): NO ENTERIC GRAM
NEGATIVE RODS
FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2194-8-21**]): NO
CAMPYLOBACTER FOUND.
OVA + PARASITES (Final [**2194-8-20**]): NO OVA AND PARASITES
SEEN.
FECAL CULTURE - (Final [**2194-8-21**]): NO YERSINIA FOUND.
FECAL CULTURE - (Final [**2194-8-21**]): NO E.COLI 0157:H7
FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2194-8-20**]): NO
CRYPTOSPORIDIUM OR GIARDIA SEEN.
VIRAL CULTURE (Preliminary):
[**2194-8-25**] 06:15AM BLOOD WBC-2.7* RBC-3.10* Hgb-9.8* Hct-29.0*
MCV-94 MCH-31.6 MCHC-33.7 RDW-20.6* Plt Ct-175
[**2194-8-25**] 06:15AM BLOOD Glucose-86 UreaN-17 Creat-0.7 Na-134
K-5.3* Cl-103 HCO3-27 AnGap-9
[**2194-8-18**] 05:43AM BLOOD ALT-4 AST-8 AlkPhos-71 Amylase-16
TotBili-0.3
[**2194-8-25**] 06:15AM BLOOD Calcium-9.5 Phos-2.3* Mg-1.8
[**2194-8-19**] 04:44AM BLOOD Triglyc-89
[**2194-8-22**] 04:52AM BLOOD TSH-6.1*
[**2194-8-25**] 06:15AM BLOOD tacroFK-10.2
Brief Hospital Course:
51 y/o female admitted with recurrent abdominal pain, and 5 kg
weight loss since time of transplant in [**Month (only) 205**]. Transplant kidney
ultrasound was performed that showed no hydronephrosis or other
abnormality involving the left pelvic transplant kidney. There
was interval decrease in size of simple fluid collection along
the lower pole and there was normal vascular evaluation of the
transplant kidney. KUB on admission demonstrated
normal-appearing bowel gas pattern without evidence of small
bowel obstruction. There was no free air. Incidental note was
made of splenic artery and abdominal aortic calcifications. No
pneumoperitoneum. Hematocrit was low requiring transfusion. On
[**8-16**], a CVL was placed and Vanco, Flagyl and Ceftazadime were
started initially.
Blood and urine cultures were negative. Stool cultures were
sent, and C diff was isolated from the [**8-17**] specimen. Ceftaz and
IV Vanco were stopped, Flagyl was continued and oral Vancomycin
was started on [**8-18**]. ID recommended a 2 week course. Flagyl was
discontinued on [**8-20**]. GI had been consulted and an
EGD/colonoscopy were initially set up, but these were cancelled
given findings of c.diff. Follow up colonoscopy was recommended
after a 2 week course of po vancomycin.
Abdominal CT on [**8-17**] demonstrated the following: mo pneumatosis,
portal venous gas, or other evidence of bowel ischemia.
Gallbladder was moderately distended. There was a small
perihepatic fluid collection as well as small liver cysts. There
was question of occlusion of the origin of the [**Female First Name (un) 899**]. However,
branches of the [**Female First Name (un) 899**] were opacified. She continued to receive IV
morphine for abdominal pain. Narcotics were weaned down and
eventually switched to Ultram.
Valcyte was held for 2 days due to neutropenia (WBC 1.9) and was
then restarted at 450 mg daily. The CMV viral load that was sent
on admission was negative. Imuran was decreased from 75mg to
50mg. Prograf was adjusted per trough levels.
Oral intake was suboptimal, however she initially refused a
feeding tube. Due to persistence of abdominal pain and poor po
intake, TPN was given to meet her caloric needs. A post pyloric
feeding tube was placed on [**8-22**]. Full strength Isosource 1.5 was
started and advanced to goal rate of 55ml/hr. This was
tolerated. Serum potassium was noted to be 5.2 on [**8-25**].
Nutrition recommended switching to Novasource renal if serum
potassium increased to 5.5 or greater. Please see
recommendation.
Psychiatry was consulted for low energy and motivation.
Recommendations were made that included decreasing Klonopin and
starting Ritalin. Klonopin was decreased to 0.25mg daily.
Ritalin 5mg was started twice daily. Her energy level increased.
TSH on [**8-22**] was 6.1. Levoxyl was increased to 50mcg daily on
[**8-25**]. A TSH should be checked in 6 weeks.
PT evaluated and worked with her recommending rehab. A bed was
available at [**Hospital1 **] in [**Location (un) 701**]. She will transfer there
today. CVL was removed on the day of discharge.
Medications on Admission:
Azathioprine 75', Beclamethasone IH prn, Klonopin 0.5-1hsprn,
Famotidine 20', Combivent 18/103 2puffs prn, synthroid 25',
Flagyl 500''', Savella 50', Oxazepam 15-30qhsprn, Protonix 40',
Prochlorperazine 5', Bactrim ss, Tacro 3mg'', Valcyte 450',
Cetirizine 10'.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze, sob.
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob, wheeze.
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): 14 day course started on [**8-18**]. complete through [**8-31**].
8. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp <110 or HR < 60.
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours): trough levels every Monday and Thursday with results
fax'd to [**Hospital1 18**] Transplant office.
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): check tsh in 6 weeks.
16. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): 1st dose at 8am and 2nd dose prior to 3pm .
17. Neutraphos
2 packets tid x 3 doses for low phosphorus
18. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
at HS.
19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
20. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection ASDIR (AS DIRECTED): see printed scale.
21. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
22. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
h/o renal transplant [**2194-6-5**]
c.diff colitis
hypothyroidism
anemia
malnutrition
Failure to thrive/adjustment disorder with depressed mood
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
See PT notes
Discharge Instructions:
You will be transferred to [**Hospital **] Rehab in [**Location (un) 701**] today
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the listed
Tube feeds will continue
You will also have labs drawn every Monday and Thursday
Oral vancomycin will continue indefinately
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**]
Date/Time:[**2194-9-8**] 3:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2194-9-4**]
10:00
Completed by:[**2194-8-25**] Name: [**Known lastname 3997**],[**Known firstname **] S. Unit No: [**Numeric Identifier 3998**]
Admission Date: [**2194-8-15**] Discharge Date: [**2194-8-25**]
Date of Birth: [**2143-1-30**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Darvon / Gabapentin / Mucinex / Robitussin /
Lyrica / Lipitor / Oxycontin / Codeine
Attending:[**First Name3 (LF) 3999**]
Addendum:
Ureteral stent was removed on [**2194-8-19**] by Urology.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4000**] MD [**MD Number(2) 4001**]
Completed by:[**2194-8-27**]
|
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icd9cm
|
[
[
[]
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[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,317
| 114,994
|
12933
|
Discharge summary
|
report
|
Admission Date: [**2137-5-6**] Discharge Date: [**2137-6-7**]
Date of Birth: [**2059-1-24**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Left Lower Extremity Ischemia
Major Surgical or Invasive Procedure:
[**2137-5-6**] PROCEDURE: 1. Left groin exploration with left common
femoral
artery arteriotomy and thrombectomy of left superficial
femoral artery and profunda femoris artery with bovine
pericardial patch angioplasty. 2. Left lower extremity four
compartment fasciotomy
History of Present Illness:
The patient is a 78 year old male with PMH significant for CAD
s/p CABG x 4/MV repair in [**1-/2133**], 7 cm infrarenal AAA, s/p EVAR
in [**2129**], c/b migration of his Endograft with a large type 1
proximal endo leak found incidentally on CTA at the time of
CABG. While awaiting a scheduled repair of the endoleak, in
[**2-/2133**], patient developed rupture of the aneurysm and emergent
endovascular repair using a uni-iliac graft with occlusion of
the contralateral left iliac artery and subsequent right to left
fem-fem bypass graft with 8mm ringed PTFE. In [**2133-6-7**], the
aneurysm sac measured 6.9 cm in maximum diameter which has
decreased in size since the last study several months ago. He
was transferred from [**Hospital3 24768**] for an evaluation of
painful left lower extremity concerning for ischemia. The LLE
became incredibly painful at around noon time
on the day of admission. The leg from just above the knee was
cool and mottled.
There is no dopplerable PT and DP signal or popliteal signal on
that side. Patient has decreased sensation to touch on below the
knee on the left side. Patient reports significant amount of
nausea and persistant severe pain. He received heparin bolus and
was on heparin gtt for about 3 hours without any
improvement.
Past Medical History:
PMH:
- Coronary Artery Disease s/p CABG x4 ([**2132**])
- Mitral Regurgitation s/p MV repair ([**2132**])
- Heart Failure (systolic)
- Paroxysmal Atrial Fibrillation
- Renal Insufficiency
- Peripheral Vascular disease
- Hypertension
- Chronic Anemia
- AAA s/p Endovascular stent [**2129**], developed Type I endoleak,
s/p
rupture and emergent endovascular repair in [**2132**]
- Myocardial Infarction [**2109**]
- Gout
- Osteoathritis
- Venous ligation
- GI bleeding
- bladder cancer
- chronic renal failure
PSH:
[**2130-4-7**] (Dr. [**Last Name (STitle) **]
1.Endovascular stent graft repair of infrarenal abdominal
aortic aneurysm.
2.Femoral artery exposure bilaterally.
3.Two catheters in aorta via both femoral arteries.
4.Modular bifurcated endograft.
5.Left common iliac artery extender cuff.
6.Aortogram in pelvis.
7.Radiologic S&I for endograft.
8.Radiologic S&I for extender piece.
[**2133-2-4**]
Coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery and a
radial artery sequential grafting to obtuse marginal 1 and 2,
and saphenous vein graft to posterior descending artery and
mitral valve repair with size 26 [**Company 1543**] Future Ring.
[**2133-3-4**] (Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **]
Emergent endovascular repair of ruptured abdominal aortic
aneurysm using aorta uni-iliac graft (Zenith 32 x125) with
occlusion of the contralateral left iliac artery( 18 mm [**Doctor Last Name 4726**]
Excluder) and subsequent right to left fem-fem bypass graft with
8mm ringed PTFE. Extension right CIA with 18X 54 Zenith limb
Social History:
retired, worked in plastics factory,
Married lives with spouse
[**Name (NI) 1139**] - quit 25 years ago, 80 pack year history
Denies ETOH
Family History:
Brother and mother deceased from [**Last Name **] problem
Physical Exam:
Admission PE:
VS: 98 83 190/82 21 96% RA
CV: RRR
pulm: CTA b/l
abdomen: obese, + BS, ND/NT
extremities: R - normal capillary refil, warm to touch
L - mottled to above the knee, painful to touch, decreased
sensation in the LLE below the knee
pulses:
fem-fem fem [**Doctor Last Name **] PT DP
R dop palp dop dop dop
L dop palp - - -
Exam on transfer:
AVSS
CV: RRR
pulm: CTA b/l
abdomen: obese, + BS, ND/NT
extremities: R - normal capillary refil, warm to touch
L - warm to knee, incision CDI,
pulses:
fem-fem fem [**Doctor Last Name **] PT DP
R dop palp dop dop dop
L dop palp - dop dop
Exam on discharge:
GEN: Resting in bed in NAD, arouses easily to voice.
HEENT: NCAT, EOMI.
COR: +S1S2, no m/g/r. Irregularly irregular heartbeat.
PULM: CTAB, with slight crackles in bases. Improves with cough.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND. No peritoneal signs.
EXT: Left lower extremity incisions healing well, no erythema or
discharge. Lower extremities warm. PT, DP with weak doppler
signals
NEURO: Awake & alert, MAEE.
Pertinent Results:
[**2137-5-6**] 04:15PM BLOOD WBC-19.1*# RBC-4.45* Hgb-13.7*# Hct-40.0#
MCV-90 MCH-30.8# MCHC-34.3 RDW-14.2 Plt Ct-256
[**2137-5-18**] 03:16AM BLOOD WBC-20.9* RBC-2.58* Hgb-7.7* Hct-24.6*
MCV-95 MCH-29.9 MCHC-31.3 RDW-14.2 Plt Ct-518*
[**2137-5-27**] 03:00AM BLOOD WBC-14.7* RBC-3.41* Hgb-10.5* Hct-31.0*
MCV-91 MCH-30.9 MCHC-33.9 RDW-15.5 Plt Ct-398
[**2137-5-29**] 05:03AM BLOOD WBC-10.7 RBC-3.06* Hgb-9.1* Hct-27.4*
MCV-90 MCH-29.9 MCHC-33.4 RDW-15.2 Plt Ct-267
[**2137-5-7**] 05:32AM BLOOD PT-13.3 PTT-46.1* INR(PT)-1.1
[**2137-5-9**] 01:27AM BLOOD PT-15.9* PTT-58.5* INR(PT)-1.4*
[**2137-5-17**] 12:59AM BLOOD PT-23.4* PTT-102.2* INR(PT)-2.2*
[**2137-5-22**] 02:55AM BLOOD PT-30.0* PTT-28.9 INR(PT)-2.9*
[**2137-5-23**] 03:15AM BLOOD PT-33.5* PTT-30.2 INR(PT)-3.3*
[**2137-5-27**] 06:09AM BLOOD PT-34.5* INR(PT)-3.4*
[**2137-5-28**] 04:56AM BLOOD PT-31.7* PTT-30.1 INR(PT)-3.1*
[**2137-5-29**] 05:03AM BLOOD PT-27.5* PTT-28.7 INR(PT)-2.6*
[**2137-5-6**] 04:15PM BLOOD Glucose-181* UreaN-72* Creat-4.1*# Na-140
K-4.2 Cl-104 HCO3-16* AnGap-24*
[**2137-5-7**] 02:56AM BLOOD Glucose-128* UreaN-63* Creat-3.8* Na-139
K-5.5* Cl-107 HCO3-30 AnGap-8
[**2137-5-9**] 01:27AM BLOOD UreaN-62* Creat-5.3*# Na-140 K-4.4 Cl-105
HCO3-22 AnGap-17
[**2137-5-11**] 12:13AM BLOOD Glucose-147* UreaN-102* Creat-6.5* Na-143
K-5.2* Cl-102 HCO3-30 AnGap-16
[**2137-5-22**] 02:07PM BLOOD Glucose-116* UreaN-36* Creat-2.6* Na-139
K-4.3 Cl-103 HCO3-23 AnGap-17
[**2137-5-27**] 05:06PM BLOOD Glucose-95 UreaN-45* Creat-3.5*# Na-140
K-3.5 Cl-102 HCO3-23 AnGap-19
[**2137-5-29**] 05:03AM BLOOD Glucose-111* UreaN-67* Creat-5.7* Na-142
K-3.7 Cl-103 HCO3-27 AnGap-16
Disharge Labs:
[**2137-6-7**] 06:55AM BLOOD WBC-11.0 RBC-2.96* Hgb-9.3* Hct-27.6*
MCV-93 MCH-31.3 MCHC-33.7 RDW-14.7 Plt Ct-253
[**2137-6-7**] 06:55AM BLOOD WBC-11.0 RBC-2.96* Hgb-9.3* Hct-27.6*
MCV-93 MCH-31.3 MCHC-33.7 RDW-14.7 Plt Ct-253
[**2137-6-7**] 06:55AM BLOOD PT-28.4* PTT-30.1 INR(PT)-2.7*
[**2137-6-7**] 06:55AM BLOOD Plt Ct-253
[**2137-6-7**] 06:55AM BLOOD Glucose-99 UreaN-22* Creat-6.1*# Na-134
K-4.1 Cl-94* HCO3-28 AnGap-16
[**2137-6-7**] 06:55AM BLOOD Calcium-9.7 Phos-5.3* Mg-1.9
Brief Hospital Course:
The patient was admitted to the Vascular surgery service on
[**2137-5-6**] and had a Left groin exploration with left common
femoral artery arteriotomy and thrombectomy of left superficial
femoral artery and profunda femoris artery with bovine
pericardial patch angioplasty; Left lower extremity four
compartment fasciotomy. He had a dopplerable DP/PT pulse post op
and throughout his hospital stay. His fasciotomy sites were
primarily closed with nylon sutures once his lower extremity was
no longer threatened by compartment syndrome. Those sutures were
removed on POD 21.
The patient had a complicated hospital course and spent 17 days
in the ICU before being transferred to the floor. He was
ultimately transferred to the medical service for placement of a
tunneled line and initiation of long term dialysis.
Neuro: Post-operatively, the patient received fentanyl and
propofol until he was extubated on POD before POD 10. When
tolerating oral intake, the patient was transitioned to oral
pain medications. The patient was A&O x1-2 post extubation. He
would become agitated during his ICU stay and was treated w
zyprexa and olanzapine. His mentation improved slowly throughout
his hospitalization.
CV: The patient was anticoagulated postoperatively with a
heparin ggt, with a goal PTT of 60-80 until POD 5. During this
time coumadin was started and the heparin ggt stopped once the
patient was therapeutic on his coumadin. The coumadin was
continued throughout his hospitalization to prevent LE
thrombosis and to prevent complications from the patient's
paroxismal afib.
Pulmonary: The patient was thought to have undergone an
aspiration event in the OR and vanc/zosyn were started
immediately postoperatively. He ended up growing E coli from his
sputum and ultimately completed a course of cefepime. His
respiratory status improved and his vent settings were weaned
until the patient was ultimately extubated. He required
supplemental oxygen throughout the rest of his hospitalization
and was maintained on an aggresive pulmonary toilet. He was
weaned to room air in the VICU which he tolerated well.
GI/GU: Post-operatively, the patient was given IV fluids and
started on TF on POD2. Due to persistent confusion TF were
continued through POD 15. Once extubated the patient's diet was
slowly advanced to a renal diet, which he tolerated well. He was
also supplemented with Ensure boosts as his nutritional status
postop was poor. Immediately postoperatively the bicarbonate was
continued, a renal consult was obtained because the patient's Cr
was elevated to 4.0. The renal team felt that the elevation was
due to [**Last Name (un) **] superimposed on chronic renal insufficiency and
recommended backing off of the IVF the patient was making good
urine. ON POD 2 his urine output dropped off and the patient was
given 80mg of lasix with minimal effect. The patient's lasix was
titrated to a goal urine output of 1-2L negative daily.
Unfortunately his Cr remained elevated and he became oliguric;
he was started on HD after placement of a dialysis catheter on
POD 14. Dialysis was continued throughout the rest of his
hospitalization and ultimately a tunneled line was placed by IR
so the patient could continue dialysis as an outpatient.
ID: Post-operatively, the patient was started on IV V/Z for a
possible aspiration PNA. Pt grew out Ecoli and was switched to a
full course og cefepime. The patient had persistent leukocytosis
and loose stools during this hospitalization and blood, urine,
and stool cultures were checked, all of which were negative. He
was briefly given an empiric course of flagyl and his diarrhea
ultimately resolved. A C diff PCR was checked and was negative
and the flagyl was discontinued. Clinically the patient improved
on antibiotics. The patient's temperature was closely watched
for signs of infection.
Prophylaxis: The patient received a heparin ggt and then was
anticoagulated with coumadin during this stay, he had
dopplerable DP/PT pulses postoperatively and his foot while cool
was not threatened.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, and tolerating a renal diet.
He will be discharged on dialysis to a rehabilitation center for
further care.
Medications on Admission:
- aspirin 325 mg daily
- diovan 320 mg dialy
- furosemide 40 mg daily
- citracal
- felodipine ER (? 5 or 10 mg)
- allopurinol 100 mg daily
- folvent
- centrum
- colcrys 0.6 mg 1-2 times a week
- combivent
- omeprazole 20 mg daily
- zolpidem 5 mg PRN
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for yeast .
4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO 1-2 TIMES PER
WEEK ().
5. warfarin 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Flovent HFA 44 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
puffs Inhalation four times a day.
8. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO QHS.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 39721**] Health Rehab
Discharge Diagnosis:
Ischemic Left lower extremity
Renal failure
Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Mr. [**Known lastname 39719**], it was a pleasure to help take care of you while
you were in the hospital. You came to the hospital because
there was an artery in your leg that was blocked. You underwent
an operation to remove the obstruction. While you were here,
you developed renal failure which required that you start renal
replacement therapy (dialysis). You had a catheter placed to
allow you to have dialysis when you leave the hospital. You
also developed a pneumonia while you were on the ventilator that
was treated with with antibiotics.
Please follow the instructions below and follow up with your
surgeon Dr [**Last Name (STitle) **] within 2 weeks of discharge.
MEDICATION CHANGES:
- Medications ADDED:
Nephrocaps 1 cap daily
warfarin 0.5 mg daily
miconazole powder for rash
- Medications STOPPED: You no longer need to take valsartan,
lasix, allopurinol, felodipine
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 10693**]) within 2 weeks
after discharge to make an appointment.
|
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icd9cm
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|
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|
297, 570
|
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11311, 11563
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228, 259
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598, 1873
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4433, 4857
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1895, 3500
|
3516, 3656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,696
| 188,176
|
11473
|
Discharge summary
|
report
|
Admission Date: [**2170-9-27**] Discharge Date: [**2170-11-12**]
Date of Birth: [**2118-2-1**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Latex
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
-Formalin instillation into bladder on [**2170-10-19**]
-Cystoscopy, irrigation of organized clot, fulgaration of
bladder [**2170-9-28**]
-Right IJ central line placed [**9-29**] and removed [**10-1**]
-PICC line placement [**2170-10-1**]
-RIJ Multi Lumen - [**2170-10-15**], removed [**2170-10-22**]
-PICC Line - [**2170-10-15**]
-Arterial Line - [**2170-10-15**]
History of Present Illness:
52M with history of metastatic [**Doctor Last Name **] 8 prostate cancer
diagnosed in [**2163**] s/p neo-adjuvant Rx and RRP [**2164**], most recent
PSA [**2170-7-19**] >5000 presents to ER after 2 admissions for
hematuria. Pt was discharged yesterday and began to bleed
shortly after discharge. Pt was on SQH at rehab. No f/c/n/v.
No weakness. Labs in ED show HCT 32 and plts 81.
.
Mr. [**Known lastname **] [**Known lastname **] is a 52 year old male w/ metastatic prostate
cancer s/p neo-adjuvant Rx and RRP admitted for recurrent
hematuria s/p Cystoscopy, fulguration of bladder, clot
evacuation.
.
Pt recently discharged from oncology service day prior to
admission. Two days at his rehab facility pt noticed clots in
his urine again. Day of admission pt stated he noticed a lot of
blood clots in his urine and decreased urine flow. He was
admitted to Urology and underwent cystoscopic evaluation
yesterday for his hematuria, notable for radiation cystitis,
with bladder neck bleeding s/p vessel fulguration. He has
continued to have gross hematuria causing a drop in his Hct
30.2->26.9->20.9.
.
Pt has had bruising over his abdomen and arms since his last
admission when his platelets were low. Pt has also had scleral
icterus and jaundice for the past few weeks.
.
ROS was otherwise essentially negative. The pt denied recent
unintended weight loss, fevers, chills, headaches, dizziness,
hematemesis, coffee-ground emesis, nausea, vomiting, diarrhea,
constipation, melena, hematochezia, cough, hemoptysis, wheezing,
shortness of breath, chest pain, palpitations.
Past Medical History:
Oncologic history:
diagnosed with prostate cancer in [**2163**]. with a [**Doctor Last Name **] score of
8, PSA of 38. He was treated with neoadjuvant clinical trial
prior to his surgery. He has also had multiple treatments
including radiation Taxotere, mitoxantrone, 12 cycles of
Taxotere, carboplatin. His hormonal therapies have been
ketoconazole, hydrocortisone, DES. He has also been on androgen
ablation with Lupron this time. He was recently treated with
samarium on [**2170-5-23**], for diffuse bony pain and he was
hospitalized in the interim for pain control and altered mental
status, thought to be secondary to narcotics. He also has
extensive history of DVT for which he is on Lovenox and PE.
.
# metastatic prostate cancer to bone refractory to hormone
therapy
# B LE DVTs c/b B PE s/p IVC filter [**4-/2168**]
- s/p IVC venogram and mechanical thrombolysis with local TPA on
[**2170-5-7**] for worsening clot burden
- lovenox dose increased from 80 mg [**Hospital1 **] to 120 mg [**Hospital1 **] with
therapeutic factor Xa on that dose
# Psoriasis
# Hypercholesterolemia
# h/o fundus angioectasia s/p thermal therapy
# duodenal bezoar
# depression
# Seasonal allergies
# Obstructive sleep apnea on CPAP
Social History:
He lives at home with his wife and his 12 year-old son. [**Name (NI) **] does
not smoke. He denies tobacco, alcohol or illicit drug use. He
formerly worked as heavy machine operator at [**Location (un) 86**] Water and
Sewage.
Family History:
noncontributory
Physical Exam:
Admission PE:
Vitals: T:98.6 BP:94-122/60-64 P:76-130 R:18 SaO2:96-98% RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative,
slightly jaundiced.
HEENT: NCAT, PERRL, EOMI, b/l scleral icterus noted (present for
weeks), MMM.
Neck: Supple, Rt IJ in place.
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: Pupuric lesions noted diffusely on pt's abdomen (present
since last admission per pt and pt's wife).
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.
Discharge PE:
Vitals: T:98.6 BP:94-122/60-64 P:76-130 R:18 SaO2:96-98% RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative,
slightly jaundiced.
HEENT: NCAT, PERRL, EOMI, b/l scleral icterus noted (present for
weeks), MMM.
Neck: Supple, Rt IJ in place.
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: Pupuric lesions noted diffusely on pt's abdomen (present
since last admission per pt and pt's wife).
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.
Pertinent Results:
==========
Labs
==========
[**2170-10-7**] 05:18AM BLOOD WBC-2.3* RBC-2.84* Hgb-8.6* Hct-25.4*
MCV-90 MCH-30.4 MCHC-33.9 RDW-19.1* Plt Ct-48*
[**2170-10-6**] 05:35AM BLOOD WBC-2.8* RBC-2.89* Hgb-8.8* Hct-25.7*
MCV-89 MCH-30.4 MCHC-34.1 RDW-18.7* Plt Ct-57*
[**2170-10-5**] 05:20AM BLOOD WBC-2.4* RBC-3.09* Hgb-9.3* Hct-27.4*
MCV-89 MCH-30.2 MCHC-34.1 RDW-18.8* Plt Ct-47*
[**2170-10-4**] 04:37AM BLOOD WBC-2.6* RBC-3.09* Hgb-9.4* Hct-27.2*
MCV-88 MCH-30.3 MCHC-34.4 RDW-19.0* Plt Ct-62*
[**2170-10-3**] 05:53AM BLOOD WBC-2.5* RBC-3.16* Hgb-9.5* Hct-27.7*
MCV-88 MCH-30.0 MCHC-34.2 RDW-18.5* Plt Ct-72*
[**2170-10-2**] 05:27AM BLOOD WBC-3.2* RBC-3.15* Hgb-9.5* Hct-27.0*
MCV-86 MCH-30.2 MCHC-35.1* RDW-18.7* Plt Ct-50*
[**2170-10-1**] 06:41PM BLOOD WBC-4.1 RBC-3.46* Hgb-10.5* Hct-29.7*
MCV-86 MCH-30.4 MCHC-35.5* RDW-18.8* Plt Ct-69*
[**2170-10-1**] 05:51AM BLOOD WBC-3.0* RBC-3.15* Hgb-9.5* Hct-27.0*
MCV-86 MCH-30.2 MCHC-35.2* RDW-18.6* Plt Ct-64*
[**2170-9-30**] 08:20PM BLOOD WBC-3.1* RBC-3.18* Hgb-9.7* Hct-27.1*
MCV-85 MCH-30.6 MCHC-35.9* RDW-18.4* Plt Ct-69*
[**2170-9-30**] 04:55AM BLOOD WBC-3.0* RBC-2.68* Hgb-8.2* Hct-23.3*
MCV-87 MCH-30.4 MCHC-35.0 RDW-19.7* Plt Ct-49*
[**2170-9-29**] 06:50AM BLOOD WBC-3.1* RBC-2.31* Hgb-6.9* Hct-20.9*
MCV-91 MCH-29.8 MCHC-33.0 RDW-21.1* Plt Ct-79*
[**2170-9-28**] 06:20AM BLOOD WBC-4.9 RBC-2.98* Hgb-8.9* Hct-26.9*
MCV-90 MCH-29.9 MCHC-33.2 RDW-20.7* Plt Ct-68*
[**2170-9-27**] 02:55PM BLOOD WBC-5.6# RBC-3.36* Hgb-10.3* Hct-30.2*
MCV-90 MCH-30.6 MCHC-34.1 RDW-21.1* Plt Ct-80*
[**2170-9-26**] 07:00AM BLOOD WBC-3.5* RBC-3.52* Hgb-10.4* Hct-31.7*
MCV-90 MCH-29.6 MCHC-32.8 RDW-20.0* Plt Ct-54*
[**2170-10-7**] 05:18AM BLOOD ALT-331* AST-273* AlkPhos-1419*
TotBili-4.1*
[**2170-10-6**] 05:35AM BLOOD ALT-355* AST-306* AlkPhos-1388*
TotBili-4.0*
[**2170-10-5**] 05:20AM BLOOD ALT-344* AST-326* AlkPhos-1473*
TotBili-4.3*
[**2170-10-4**] 04:37AM BLOOD ALT-313* AST-307* LD(LDH)-446*
AlkPhos-1317* TotBili-3.8*
[**2170-10-3**] 05:53AM BLOOD ALT-301* AST-329* AlkPhos-1120*
TotBili-3.9*
[**2170-10-2**] 05:27AM BLOOD ALT-348* AST-457* LD(LDH)-535*
AlkPhos-1172* TotBili-5.8* DirBili-4.1* IndBili-1.7
[**2170-9-29**] 06:50AM BLOOD LD(LDH)-545* TotBili-3.5* DirBili-2.4*
IndBili-1.1
==========
Radiology
==========
RUQ U/S - [**10-3**] - IMPRESSION: 1. Innumerable hypoechoic hepatic
lesions, consistent with diffuse hepatic metastatic disease. 2.
Somewhat contracted gallbladder, limiting evaluation. 3. No
intra- or extra-hepatic biliary ductal dilatation. 4. Images of
the kidneys demonstrate no hydronephrosis.
.
U/S guided PICC placement [**10-1**] - Uncomplicated ultrasound and
fluoroscopically guided 5 French double-lumen PICC line
placement via the right basilic venous approach. Final internal
length is 49 cm, with the tip positioned in SVC. The line is
ready to use.
.
[**2170-10-15**] RUQ U/s: No evidence of cholecystitis. Metastases
throughout the liver.
[**2170-10-16**] CT Abd/Pelvis:
1. No acute retroperitoneal hemorrhage.
2. further decrease in size of gluteal hematoma.
3. Unchanged metastatic disease.
.
[**2170-10-18**] CXR: Increasing vascular congestion.
[**2170-10-30**]: Lung volumes are appreciably lower today than
previously, which may account for some of the increase in
opacification of both lungs, particular the right, but there is
clearly new perihilar consolidation in the left lung and
probably interstitial abnormality on the right. Differential
diagnosis is either a very asymmetric pulmonary edema or large
left upper lobe pneumonia and mild edema elsewhere. Pleural
effusion, if any, is minimal. Heart size is partially obscured
by elevated diaphragm, but does not appear grossly enlarged.
Azygos vein, on the other hand, may be distended.
Brief Hospital Course:
Mr. [**Known lastname **] is a 52 year old man with metastatic prostate cancer,
who had been recently admitted with hematuria; also with history
of DVT and PE now off Lovenox since recent admission, presented
again with hematuria and bladder discomfort.
.
## Hematuria: Pt's has gross hematuria from radiation cystitis.
Bleeding improved since Urology performed cystoscopy,
fulguration of bladder, and clot evacuation on [**9-28**]. Still with
mild hematuria ([**Location (un) 2452**] to pink) with occasional passing of
clots, but not hemodynamically significant. CBI was continued
for patient comfort. OF NOTE, he was previously on enoxaparin
for PE/DVT but this was held throughout the hospital stay
because it was thought to worsen patient's hematuria. In
conjunction with the patient's outpatient oncologist Dr. [**Last Name (STitle) **],
the decision was made *not* to restart lovenox because it was
thought that risks outweigh benefits at this point, so he should
not continue any anticoagulation. Pt was continued on CBI and
he continued to have hematuria requiring multiple blood and
platelet transfusions. He was taken by urology for a formalin
procedure on [**2170-10-19**] and his Hct remained stable at first
post-procedure. His hematuria did slow but his Hct did continue
to slowly trend down to maintain Hct>25. CBI was able to be
discontinued but soft foley was maintained. Urology would have
liked to d/c foley with q3hour timed voiding with vagal
sensation and gravity but patient is too weak to stand.
.
## Anemia/Thrombocytopenia: Pt has a long history of
thrombocytopenia, work up in the past was negative. Likely
secondary to underlying malignancy and bony involvement. Anemia
likely secondary to blood loss anemia (hematuria and blood in
stool) and AOCD given iron study results. Indirect bilirubin not
elevated and haptoglobin not elevated, so patient is unlikely to
be hemolyzing. Patient received 6 bags of platelets and 5 units
of pRBC on this admssion and subsequently required transfusion
for Hct<25 and Plts<50. In the ICU the patient continued to have
a drop in his hct secondary to blood loss. He was transfused
multiple units of pRBC. He did not bump appropriately to
platelet transfusions which supported the fact that his
platelets were not functioning appropriately.
.
## Transaminitis: Likely secondary to hepatic involvement of
prostate cancer. Baseline ALT/AST in the hundreds and baseline
alkphos 200-800. Elevated GGT indicates high alkaline
phosphatase is at least partly due to a hepatic source, if not
entirely, and not just secondary to bony involvement of his
prostate cancer. Pt remains jaundiced with elevated direct
bilirubin to 10 and positive asterixis. RUQ U/s negative for
stentable lesions but positive for metastatic disease. In ICU
transaminitis worsened. Lactulose was started although
subsequently stopped after prolonged period of constipation and
high residuals.
.
## Oral candidiasis: Thrush noted for first time on exam [**10-7**].
Likely secondary to overall immunocompromised state [**2-10**]
malignancy. Was given Nystatin S and S. Resolved.
.
##[**Hospital Unit Name 153**] stay: He was transferred to ICU on [**2170-10-15**] for
hypotension, tachycardia, worsening anemia and acute renal
failure (creatinine 1-->1.8). Patient was found to be
hypotensive at 10/6 at 4 am with systolic blood pressure in the
mid 80s and HR 120s. He was given a total of 1500 cc of fluid
and bp improved to high 80s systolic. While, in the ICU, he
required platelet transfusions at first and daily blood
transfusion. Patient's temperature was 99.3 but he was on
steroids for bony mets and pain control. Patient thought to
possibly be septic and coverage broadened from ceftriaxone to
vanc and zosyn. No recent procedures except for multiple bladder
manipulations by urology for clotted catheters. Pt has CBI with
hematuria in foley. The hypotension was likely due to
hypovolemia from blood loss. Infection unlikely ?????? afebrile, no
positive cultures. Urine, blood cultures with no growth to this
point ?????? antibiotics d/c??????d on [**10-17**]. The team did not think he was
hemolyzing. A urinary hematocrit was obtained and it was high.
Urology had been following and took him to the OR for a
procedure to inject formalin into his bladder. Immediately
following the procedure, his Hct and platelets had been stable.
His mentation improved and he had good urine output.
Transferred again to ICU on [**10-26**] due to hypotension in
context of 1 out of 4 positive blood cultures with coag negative
staph. Initally treated with vancomycin and Zosyn and stress
dose steroids. Also given 2U pRBCs due to low hematocrit.
Arterial line placed for close BP monitoring. Given that
pressure remained stable and that positive blood culture was
likely a contaminant, antibiotics were stopped. Steroid dose was
tapered. Patient continued to maintain BP well. All subsequent
cultures have been negative.Prior to return to medical floor
palliative care was contact[**Name (NI) **] for assistance in helping to make
patient as comfortable as possible - while still continuing to
treat his medical issues.
#MICU Stay [**Date range (1) 36630**]/08 : Admitted to the MICU s/p R
nephrostomy tube placement by IR. Difficulty with extubation
post-operatively, thus re-intubated. Developed hypotension and
tachycardia, treated with IV fluids, PRBCs, and started on
pressors. Upon arrival to ICU, pt was in likely hypovolemic
shock. He was continued on pressors, IVFs, and PRBCs. Hct was
stable and bumped appropriately with PRBC transfusions. He grew
Klebsiella out of his blood and sputum and enterococcus out of
his blood. He was subsequently placed on ceftriaxone and
daptomycin. The pressors were weaned with relative success.
After numerous conversations with the family, the family changed
his status to DNR/DNI with the intention of no escalation of
care. The pressors were weaned and he was then extubated.
After a few days without improvement, the family made him CMO.
He died peacefully a day later.
Medications on Admission:
Citalopram 40 mg daily
Enbrel twice weekly
Dexamethasone 4 mg TID
dilaudid 8mg q2hours prn
Methadone 20mg [**Hospital1 **]-TID
Neurontin 200mg [**Hospital1 **]
Ativan 1 mg TID
Ritalin 5mg [**Hospital1 **]
lovenox 120 mg sq [**Hospital1 **]
Protonix 40 mg daily
compazine prn
sucralfate 1 gm QID
B12 1000 mcg daily
colace
senna
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
None, pt. expired.
Followup Instructions:
None, pt. expired.
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62,909
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49988
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Discharge summary
|
report
|
Admission Date: [**2180-12-3**] Discharge Date: [**2180-12-7**]
Date of Birth: [**2138-4-16**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Morphine / Demerol / Tape / Vicodin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
On [**2180-12-5**], she underwent pericardiocentesis with removal of
150cc and placement of a pericardial drain. Cytology sent. Right
8Fr FV removed in cath lab + compression with no issues.
History of Present Illness:
History per [**Hospital1 1516**] B noted dated [**2180-12-4**]. [**Known firstname **] [**Known lastname 12041**] is a
42F with a history of low grade follicular lymphoma being
followed off therapy, with a remote history of Hodgkin's disease
s/p splenectomy, chemotherapy (MOPP) and mantle irradiation who
presented to [**Hospital1 18**] on [**2180-12-4**] with chest pain and dyspnea with
exertion. Of note, she had a recent admission at [**Hospital1 18**] from
[**2180-11-15**] - [**2180-11-16**] for pleuritic chest pain and a fever to 102.
CTA during that admission did not show a pericardial effusion.
No source of her fever was identified and she was discharged to
complete a 7 day course of augmentin given her asplenia. She was
seen in follow up on [**2180-12-1**] at the [**Hospital 1944**] clinic,
during which time she reported that she felt well and that her
chest pain and shortness of breath had improved. However, she
was having ongoing fevers to 101.4 so plan was to repeat CT
torso this week for eval of lymphoma. At that visit, she was
found to have bacturia (no symptoms) and started on bactrim. On
the evening of [**2180-12-3**] she developed shortness of breath with
exertion and possible wheezing. She is [**Name8 (MD) **] NP and she listened to
her lungs and thought she heard a rub. On Sunday, at work she
had [**Name8 (MD) **] MD also listen and he also felt there was a rub. She
noted DOE that morning and was unable to walk short distance to
car. Normally, she can walk up 3 flights of stairs before
getting SOB.
.
In ED initial VS are 99.2 125 144/69 24 95% ra. She was not
given any medications in the ED, but she did receive 1L of NS.
Exam notable for rub. CXR with new bilateral effusions. TTE with
mild early tamponade physiology per Cardiology fellow. Pulsus
was 12-14 per fellow. VS prior to transfer, afebrile, HR down to
107 139/66 20 93% RA. Overnight the VS remained stable, however
while on the floor has developed SOB at rest requiring O2
supplementation and pulsus has widened to 16 mmHg.
Past Medical History:
CARDIAC RISK FACTORS: + Dyslipidemia
CARDIAC HISTORY:
#Radiation-induced aortic and tricuspid regurgitation.
OTHER PAST MEDICAL HISTORY:
# Hodgkin disease Stage IIb diagnosed [**2150**], s/p staging
laparotomy with splenectomy, mantle radiation with persistent
mediastinal adenopathy, followed by MOPP chemotherapy for six
cycles.
# Indolent follicular lymphoma, diagnosed 8 years ago
# Hypothyroidism
# GERD
# LE parasthesia
# Overactive bladder - due to ependymoma.
PSHx: T+A, ExLap/Splenectomy (staging), Excision of T8-T10
ependymoma, Bx L-groin, right clavicular fx s/p pinning
Social History:
Occupation: nurse [**First Name (Titles) 3639**]
[**Last Name (Titles) **]: none
Tobacco: previous
Alcohol: none
Family History:
PGF with sudden cardiac death at age 56.
FH positive for bladder cancer, diabetes and hypertension.
No family history of early MI, arrhythmia, or cardiomyopathies.
Physical Exam:
On Admission To CCU:
VS: T: 98.8 BP: 120/66 HR: 111 regular RR: 18 O2: 92%RA
Pulsus: 6 (126 --> 120)
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm, no carotid bruits
CARDIAC: S1, S2 increased rate, friction rub, pericardial drain
to gravity with minimal output
LUNGS: auscultated anteriorly, CTA bilaterally, unlabored
respirations
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: warm, distal pulses intact, right groin on
hematoma, no bruit, dressing C/D/I.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On Discharge:
General: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: PERRL. Conjunctiva were pink, no pallor or cyanosis of
the oral mucosa.
Neck: Supple with JVP of 8 cm, unable to visualize above the
clavicles when sitting upwards
Cardiac: S1, S2 increased rate, no friction rub appreciated,
middle thorax incision with dressing ?????? c/d/i
Lungs: CTA bilaterally, decreased breath sounds in Left base
Abdomen: Soft, NTND. No HSM or tenderness.
Extremities: warm, distal pulses intact, right groin no hematoma
or ecchymosis.
Pertinent Results:
CBC: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2180-12-7**] 06:10 5.5 3.11* 9.8* 28.9* 93 31.5 33.9 14.8
580*
[**2180-12-6**] 05:00 7.4 3.34* 10.7* 31.5* 94 32.0 34.0 14.9
556*
[**2180-12-5**] 05:30 7.6 3.20* 9.9* 30.2* 94 30.8 32.7 14.6
532*
[**2180-12-4**] 16:44 7.8 3.29* 10.3* 30.7* 93 31.2 33.4 14.9
529*
[**2180-12-3**] 18:50 9.6 3.21* 10.1* 29.9* 93 31.5 33.9 14.7
510*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps
Metas
[**2180-12-5**] 05:30 67.8 21.6 5.8 4.0 0.8
[**2180-12-4**] 16:44 70.0 18.4 7.5 3.2 0.9
[**2180-12-3**] 18:50 76.7* 14.8* 5.5 2.4 0.6
BASIC COAGULATION PT PTT INR(PT) Plt Ct
[**2180-12-7**] 06:10 580*
[**2180-12-7**] 06:10 12.1 25.6 1.0
[**2180-12-6**] 05:00 556*
[**2180-12-6**] 05:00 12.7 25.7 1.1
[**2180-12-5**] 05:30 532*
[**2180-12-5**] 05:30 13.2 29.2 1.1
[**2180-12-4**] 16:44 529*
[**2180-12-4**] 16:44 13.2 26.4 1.1
[**2180-12-3**] 18:50 510*
[**2180-12-3**] 18:50 12.5 26.2 1.1
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2180-12-7**] 06:10 89 12 0.7 138 4.6 105 28
10
[**2180-12-6**] 05:00 81 12 0.7 141 4.4 103 30
12
[**2180-12-5**] 05:30 99 13 0.6 140 4.3 105 29
10
[**2180-12-4**] 16:44 104 9 0.6 138 4.3 104 26
12
[**2180-12-3**] 18:50 84 15 0.8 132* 4.7 98 26
13
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili
[**2180-12-3**] 18:50 38 33 205 117* 0.2
CPK ISOENZYMES proBNP
[**2180-12-3**] 18:50 337*
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg Uric Acid
[**2180-12-7**] 06:10
[**2180-12-6**] 05:00 9.1 4.1 2.3
[**2180-12-5**] 05:30 8.4 3.9 2.4
[**2180-12-4**] 16:44 8.8 3.4 2.1
[**2180-12-3**] 18:50 3.8 8.9 3.8 2.0 2.9
PERITOCARDIAL FLUID Analysis WBC RBC Polys Lymphs Monos
[**2180-12-4**] 09:45 [**2170**]* [**Numeric Identifier 5863**]* 27* 39* 34*
PERITOCARDIAL FLUID STAINS & FLOW CYTOMETRY CD23 CD45 HLA-DR
[**Last Name (STitle) 7736**]7 Kappa CD2 CD7 CD10 CD19 CD20 Lamba CD5: All completed, no
evidence of lymphoma per hematology/oncology
PERITOCARDIAL FLUID FOR IMMUNOPHENOTYPING T SUBSETS & CD34 CD3
[**2180-12-4**] 14:17 DONE
PERICARDIAL FLUID FOR IMMUNOPHENOTYPING FLOW CYTOMETRY IPT
[**2180-12-4**] 14:17 DONE1
PERITOCARDIAL FLUID CHEMISTRY TotProt Glucose LD(LDH) Amylase
Albumin
[**2180-12-4**] 09:45 4.7 83 557 19
2.9
Pathology report pericardial fluid: NEGATIVE FOR CARCINOMA.
Echo [**2180-12-3**] on admission: LVEF>55%. There is a small to
moderate sized pericardial effusion most prominent anterior to
the right atrium (1.5cm) and right ventricle (1.0cm with
prominent anterior fat pad. No right atrial or right ventricular
diastolic collapse is seen.
CXR AP/Lateral [**2180-12-3**]: Interval development of bilateral
effusions, with associated left basilar opacity, possibly
representing effusion and atelectasis, though associated
airspace consolidation is difficult to exclude radiographically.
Echo [**2180-12-4**]: LVEF>55. The right ventricular cavity is
unusually small. There is a small to moderate sized pericardial
effusion. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology. Compared
with the prior study (images reviewed) of [**2180-12-3**], the
effusion is slightly larger with impaired right ventricular
filling and smaller cavity. Tamponade physiology is now
suggested.
Cardiac Catherization [**2180-12-4**]:
Pericardiocentesis was performed under ultrasound guidance.
Right
heart catheterization revealed elevation of right and left heart
filling
pressures with equalization of diastolic pressures consistent
with
tamponade physiology. After drainiage of 140cc of fluid her left
and
right heart filling pressures remained elevated consistent with
effuso-constrictive physiology. Subxyphoid pericardial drain
sutured into position with drainage to gravity.
Post Cardiac Catherization Echo [**2180-12-4**]: LVEF>55%. RV cavity is
small. Initially, there is a small-moderate size pericardial
effusion, primarily anterior to the right atrium and right
ventricle. With injection of agitated saline, contrast is seen
in the pericardial space. After removal of 140ml of fluid, there
is minimal residual anterior pericardial fluid with expansion of
the right ventricular cavity. Biventricular systolic function
appears good/grossly normal.
Post Drain removal Echo:
LVEF>55%. Right ventricular chamber size and free wall motion
are normal. There is abnormal septal motion/position. There is a
very small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade.
CXR [**2180-12-5**]: Interval increase in bilateral pleural effusions,
moderate on the left with associated atelectasis, and small on
the right.
CXR AP/Lateral [**2180-12-6**]: Large pleural effusions are again seen
bilaterally, more prominent on the left, where there is
substantial decrease in volume of the lower lobe. Mild
prominence of interstitial marking suggests some elevation of
pulmonary venous pressure.
Brief Hospital Course:
42 year old woman with a h/o low grade follicular lymphoma and
remote history of Hodgkin's disease s/p splenectomy,
chemotherapy (MOPP) and mantle irradiation who presented to
[**Hospital1 18**] on [**2180-12-3**] with dyspnea.
1. Pericardial Effusion with tamponade physiology by
Echocardiogram: The patient presented with a pericardial
effusion and was found to have constrictive and tamponade
physiology by echocardiogram on Day 2 of hospital stay. The
patient was taken to cardiac catherization and 140 cc of
pericardial fluid was drained and a pericardial drain was left
in place. A repeat echocardiogram showed minimal pericardial
effusion and no longer demonstrated tamponade physiology. The
patient was transferred to the CCU for monitoring. The
pericardial drain had little output over 24 hours and was
removed on [**2180-12-5**]. A repeat echocardiogram continued to show
minimal pericardial effusion and no longer demonstrated
tamponade physiology. The fluid was sent for cytology, flow
cytometry and culture. There is no evidence of lymphoma or
bacterial infection.
2. Bilateral Pleural Effusion: The patient presented with
dyspnea and decreased breath soudns at the bases. The patient
was found to have bilateral pleural effusions by chest x-ray.
The effusions increased in size from [**12-3**] - [**12-5**], but remained
stable after [**12-5**]. The patient originally required oxygen on
admission to the CCU, but no longer required it by discharge.
The patient maintained O2 saturation while ambulating on room
air. The effusions were thought to be secondary to a viral
pleuritis, and there was no clinical evidence for infection.
The hem/onc was not concerned for lymphoma.
3. Urinary Tract Infection: Patient was started on Bactrim DS as
an outpatient for an antibiotic course. This was continued
during the hospital admission has been completed.
4. Follicular Lymphoma: Hematology/Oncology was consulted during
admission. No evidence of active lymphoma causing symptoms
during admission. Patient will follow up as an outpatient. CT
of torso scheduled as an outpatient [**2180-12-8**].
Hematology/Oncology has requested only a CT of abdomen and
pelvis to evaluate for lymphadenopathy.
5. Hypothyroidism: The patient's home medication of
levothyroxine was continued during admission.
6. Bladder Instability: The patient's home medication of
oxybutynin was continued during admission.
Medications on Admission:
HOME MEDICATIONS:
- Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
- Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
- Omeprazole 20 mg Capsule, PO BID
- Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY
- Oxybutynin Chloride 10 mg Tablet Extended One Tablet PO once a
day.
- Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H as needed
for pain.
- Bactrim DS 1 tab PO BID x 7 days started [**2180-12-1**].
TRANSFER MEDICATIONS:
-tylenol 500-1000mg PO Q6hr PRN
-colase 100mg PO BID PRN
-senna 1 tab PO BID PRN
-bactrim DS 1 tab PO BID (duration 5 days)
-oxybutynin 10mg PO daily
-omeprazole 20mg PO BID
-levothyroxine 100mcg PO daily
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) 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. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis
Pericardial Effusion
Pleural Effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for receiving your care at [**Hospital3 **]. You were
diagnosed with pericarditis, pericardial effusion, and bilateral
pleural effusions secondary to pleuritis. You had a pericardial
drain placed to remove pericardial fluid because you had signs
of cardiac tampanode by cardiac echo. The fluid drained from
the heart was not infected, and did not contain any malignant
cells. You will need an outpatient CT scan of your abdomen and
plevis to look for lymphadenopathy. You will also need to go
the following appointments listed below.
The following medications were changed to your regiment:
ADDED: None
STOPPED: Valacylovir, Bactrim, Ibuprofen
CHANGED: None
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **], 8:30 am [**2180-12-13**]. [**Hospital Ward Name 23**] [**Location (un) **]. Central
Suite.
Cardiology: Dr. [**Last Name (STitle) 171**] 1:00 pm on [**2180-12-20**]. [**Location (un) 8661**] [**Location (un) **].
|
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"424.1",
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icd9cm
|
[
[
[]
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] |
[
"37.0",
"37.21",
"88.55"
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icd9pcs
|
[
[
[]
]
] |
13927, 13933
|
10328, 12747
|
315, 507
|
14029, 14029
|
4810, 7647
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14879, 15163
|
3351, 3517
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13455, 13904
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13954, 14008
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12773, 12773
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3532, 4241
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4255, 4791
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268, 277
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13226, 13432
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535, 2568
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7661, 10305
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14044, 14156
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2733, 3204
|
3220, 3335
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,468
| 160,344
|
1584
|
Discharge summary
|
report
|
Admission Date: [**2111-9-19**] Discharge Date: [**2111-10-21**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female who had a colonoscopy and polypectomy three days prior
to presentation. The patient went home and had two days of
bright red blood per rectum. She also developed right lower
quadrant pain which seemed to be getting worse. She spiked a
fever up to 103 degrees Fahrenheit with worsening of pain and
distention, at which point she presented to the Emergency
Department.
PAST MEDICAL HISTORY:
1. Status post right hip hemiarthroplasty in [**2108-8-11**], complicated by hematoma and protracted drainage.
2. Chronic obstructive pulmonary disease.
3. Coronary artery disease.
4. Congestive heart failure (with an ejection fraction of
25%).
5. Atrial fibrillation.
6. Polymyalgia rheumatica.
7. Asthma.
8. Hypercholesterolemia.
9. Hypertension.
10. Chronic renal insufficiency.
11. Osteopenia.
12. Hypothyroidism.
13. Depression.
14. History of lower gastrointestinal bleed in [**2106**], at which
time colonoscopy revealed diffuse polyposis with pan-colonic
bleeding from multiple polyps.
MEDICATIONS ON ADMISSION:
1. Albuterol.
2. Atrovent.
3. Verapamil.
4. Prednisone 3 mg by mouth once per day.
5. Lasix 20 mg by mouth once per day.
6. Lipitor.
7. Protonix.
8. Detrol.
9. Levoxyl.
10. Buspirone.
11. Multivitamin.
12. Digoxin.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a pleasant and cooperative female in mild distress.
Temperature was 102 degrees Fahrenheit, her heart rate was
80, her blood pressure was 123/42. Cardiovascular
examination revealed irregularly irregular. The lungs were
clear to auscultation bilaterally. The abdomen was
distended and tympanitic. Very tender to palpation; worse in
the right lower quadrant with rebound. Rectal examination
revealed decreased tone and occult-blood positive. During
examination by Dr [**Last Name (STitle) 519**], the patient had a large frankly melenic
stool.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed her white blood cell count 16.8, her hematocrit was
26.5 (decreased from 36.9 four months prior), and her
platelets were 262. Her INR was 1.1. Sodium was 140,
potassium was 4.1, chloride was 109, bicarbonate was 21,
blood urea nitrogen was 29, and her creatinine was 1.6.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was within normal
limits.
Electrocardiogram revealed a left bundle-branch block. No
changes from prior electrocardiogram.
A computed tomography scan was interpreted to show acute
appendicitis.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was taken to
the operating room on [**2111-9-19**] and underwent a subtotal
colectomy, ileoproctostomy, and splenectomy. Please see the
Operative Note for details. Due to the patient's guarded
status, she was kept in the Postanesthesia Care Unit and then
transferred to the Intensive Care Unit.
On postoperative day one, she was successfully extubated.
However, over the next two days she started spiking fevers up
to 102 degrees Fahrenheit and went into respiratory distress
with difficulty breathing and decreased PCO2 and had to be
reintubated. Her sputum culture grew gram-negative rods.
The patient was started on ceftriaxone and ciprofloxacin.
One day later she grew gram-negative rods in [**2-14**] bottles, at
which point vancomycin and Flagyl were added. She was also
started on tube feeds for nutritional support. The
Infectious Disease Service was consulted for continuous fever
spikes and antibiotics and agreed with management.
On postoperative day seven, the patient's ceftriaxone and
Flagyl were discontinued. The patient remained intubated and
in respiratory distress. The patient went into atrial
fibrillation.
The patient was again extubated on postoperative day eleven;
however, again she went into respiratory distress and was
emergently reintubated. The patient's atrial fibrillation
was becoming more difficult to rate control with increasing
of Lopressor. The patient had a couple of episodes of
bradycardia. The Electrophysiology Service was consulted who
recommended switching the patient to amiodarone. They also
started anticoagulation with heparin. Digoxin was
discontinued. The patient had an echocardiogram which showed
an ejection fraction of 45%. The patient also started
growing methicillin-resistant Staphylococcus aureus out of
her sputum cultures. The patient's antibiotics were adjusted
to Zosyn and Flagyl.
On postoperative day seventeen, the patient's liver function
tests were noted to increase. On postoperative day eighteen,
the patient underwent a computed tomography scan which showed
a distended gallbladder and dilated common bile duct. Unable
to wean off of ventilator.
The Gastrointestinal Service was consulted, and the patient
underwent an endoscopic retrograde cholangiopancreatography
on [**2111-9-30**] which showed a stone in the middle of the
common bile duct. A stent was placed. A sphincterotomy was
not performed due to the patient's coagulation status.
Due to the patient's prolonged/extended distended
gallbladder, a percutaneous cholecystostomy tube was placed.
The patient had a few more episodes of poorly controlled
atrial fibrillation and was started on amiodarone. A chest
x-ray showed increased pleural effusion, and an
ultrasound-guided thoracentesis was performed which drained
100 cc of yellow fluid.
The patient continued to have respiratory distress with large
amounts of thick secretions with suctioning of the lungs
almost around the clock. Otherwise, she remained stable and
afebrile.
A long discussion was held with the family who wished to
extubate the patient and change her status to do not
resuscitate/do not intubate which was done on [**2111-10-19**]. The patient remained stable, however, guarded. She
continued to have ectopy. Her status was changed to comfort
measures only on [**10-21**]. The patient continued to have
ectopy which was increasing in frequency and severity. The
patient's respiratory status was also slowly decreasing until
she finally desaturated and ceased to have a blood pressure
and heart rate and was pronounced dead.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Status post colectomy.
3. Status post splenectomy.
4. Appendicitis.
5. Chronic obstructive pulmonary disease.
6. Respiratory distress and prolonged intubation.
7. Failure to thrive.
8. Prolonged tube feeds and total parenteral nutrition.
9. Status post right hemiarthroplasty.
10. Atrial fibrillation.
11. Polymyalgia rheumatica.
12. Asthma.
13. Hypertension.
14. Hypercholesterolemia.
15. Chronic renal insufficiency.
16. Hypothyroidism.
17. Osteopenia.
18. Depression.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Dictator Info 9213**]
MEDQUIST36
D: [**2111-11-12**] 07:46
T: [**2111-11-12**] 08:24
JOB#: [**Job Number 9214**]
|
[
"540.1",
"599.0",
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"285.1",
"038.11",
"428.0",
"574.50",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.79",
"41.5",
"99.62",
"51.87",
"38.93",
"96.72",
"99.15",
"34.91",
"45.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6273, 7078
|
1189, 2649
|
2678, 6251
|
114, 522
|
545, 1162
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,772
| 187,110
|
49692
|
Discharge summary
|
report
|
Admission Date: [**2168-10-28**] Discharge Date: [**2168-11-26**]
Date of Birth: [**2106-1-30**] Sex: F
Service: MEDICINE
Allergies:
Zestril / Omeprazole
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Abdominal subcutaneous hematoma
Major Surgical or Invasive Procedure:
Blood transfusion
Multiple Abd CT scans
upper and lower extremity Ultrasounds
History of Present Illness:
Ms. [**Known lastname **] is a 62 y/o F with h/o IDDM, h/o multiple PE's, on
chronic anticoag, recently bridged on lovenox (150 [**Hospital1 **]) for
colonoscopy. Lovenox was initiated on [**10-22**] for colonoscopy
performed on [**10-26**]. She presents to the ED with large >15x40cm
SQ abdominal hematoma at site of Lovenox injections. Patient
also noted to have drop Hct by 7 point (37.6 -> 30.8). Patient
had colonoscopy two days prior to admission for evaluation of
rectal bleeding episodes which had occurred 4-5x over the past
few weeks. Following the colonoscopy, she restarted coumadin
([**10-26**]) with ongoing Lovenox for bridge to goal INR. Patient
noted over several days expanding bruise, then hard swelling on
LLQ at injection sites. She was told by VNA to stop using that
site, but reports continued expansion. Pt held lovenox on
evening of [**10-27**] given continued expansion.
.
Per patient, she was reported to have only hemorrhoids. She
denies any subsequent episodes of BRBPR, hematochezia. She
denies shortness of breath or chest pain.
.
Patient had CT abdomen in ED which showed hematoma but no RP
bleed. Patient being admitted for serial Hct checks.
Past Medical History:
1. Post-op pulmonary emboli ([**2160**]) status post IVC filter
secondary to retroperitoneal bleed on coumadin; Sadddle embolus
([**1-/2168**]), on coumadin for life
2. Thoracic osteomyelitis status post 6 week treatment with
vancomycin. Also concern for underlying tumor that is being
worked up.
3. Insulin dependent diabtes complicated by neuropathy and
retinopathy.
4. Congestive heart failure diagnosed per patient.
Echocardiagram [**1-29**] shows LVEF 70%
5. Chronic lower extremity edema
6. Obesity
7. Right foot ulcers
8. Fibromyalgia
9. Osteoarthritis, left knee status post "injection" and prior
knee surgery
[**72**]. multiple surgeries: appendectomy, cholecystectomy (ex lap),
partial hysterectomy
11. Obstructive sleep apnea on BIPAP at night
13. L4-5 herniated disc, status post steroid injections
14. Depression
Social History:
She quit smoking 23 years ago - she started at age 13 with 1
pack per day and then increased to 2-3 packs per day until she
quit. She denies alcohol. She lives at home with a [**Doctor Last Name **] son
who is 20 years old and two biological sons. She has cleaning
lady. She previously walked independently.
Family History:
Her brother had a stroke at age 65. There is a family history
of diabetes, hypertension, and multiple sclerosis.
Physical Exam:
(on admission)
PE: T 99.1 HR 84 BP 170/86 RR 16 O2Sat 97% RA
Gen: obese WF, appears comfortable reclining in bed
CV: distant heart sounds, regular rhythm
Resp: CTA B/L
Abd: very large 15x40 cm hematoma in LLQ, extending to left
flank, tender to palpation; large area of periumbilical
firmness; candidal infection in crease below pannus
Extrem: 2+ dp pulses in RLE, 1+ dp pulses in LLe; 2+ pitting
edema, blue bruise on medial aspect of left ankle; s/p
amputation of 3rd digit of right foot, well-healed
Pertinent Results:
CT abdomen [**2168-10-28**]: Large subcutaneous hematoma involving mid to
left lower anterior tissues. No intraperitoneal or
retroperitoneal component.
LAB DATA:
CBC:
---On admission:
[**2168-10-28**] 05:15AM WBC-8.8 RBC-3.66* HGB-10.6* HCT-30.8* MCV-84
MCH-29.0 MCHC-34.5 RDW-17.0*
[**2168-10-28**] 05:15AM NEUTS-71.5* LYMPHS-22.2 MONOS-3.7 EOS-2.3
BASOS-0.2
[**2168-10-28**] 05:15AM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+
[**2168-10-28**] 05:15AM PLT COUNT-197
[**2168-11-13**] 06:00AM BLOOD WBC-9.7 RBC-3.48* Hgb-10.4* Hct-30.5*
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.7* Plt Ct-312
[**2168-11-15**] 06:20AM WBC 10.4 3.46* 10.3* HCT 30.8* 89 29.8
33.5 16.0* PLT 408
[**2168-11-14**] 10:45PM HCT 28.8*
[**2168-11-14**] 06:20AM WBC 10.1 3.61* 10.4* HCT 32.3* 89 28.9
32.4 15.8* PLT 361
[**2168-11-13**] 06:00AM WBC 9.7 3.48* 10.4* HCT 30.5* 88 29.8
34.0 15.7* PLT 312
[**2168-11-25**] 05:58AM WBC 7.4 3.21* HGB 9.7* HCT 28.1* 88 30.1
34.4 16.9* PLT 246
---Acute Change:
[**2168-11-7**] 06:40AM Hct-28.3* MCV-86 MCH-28.5 MCHC-33.3 RDW-16.6*
[**2168-11-7**] 12:38PM Hct-21.3* MCV-87 MCH-28.0 MCHC-32.3 RDW-16.9*
[**2168-11-7**] 06:34PM Hct-23.5*
[**2168-11-8**] 03:44AM Hct-25.0* MCV-86 MCH-30.6 MCHC-35.7*#
RDW-15.7*
COAGS:
[**2168-10-28**] 05:15AM PT-13.4 PTT-30.3 INR(PT)-1.2*
[**2168-11-7**] 06:40AM BLOOD PTT-99.3 Plt Ct-265
[**2168-11-7**] 06:34PM PT 16.1 PTT 26.0 INR 1.5*
[**2168-11-7**] 12:38PM PTT >150
[**2168-11-7**] 06:34PM PT 16.1* PTT 26.0 INR 1.5*
[**2168-11-10**] 04:13AM PT 13.4* PTT 27.4 INR 1.2*
[**2168-11-11**] 03:17AM PT 12.7 PTT 26.3 INR 1.1
[**2168-11-15**] 06:20AM PT 13.1 PTT 23.6 INR 1.1
---
[**Year (4 digits) **]:
INHIBITORS & ANTICOAGULANTS
[**2168-11-15**] 06:20AM ACA IgG 5.8 ACA IgM 10.4
[**2168-11-15**] 06:20AM Prot C 127* Prot S 61
[**2168-11-15**] 06:20AM Lupus anticoag NEG
[**2168-10-29**] 05:20AM LMWH 0.21
[**2168-11-8**] 03:44AM Haptoglobin 198
CHEMISTRIES:
[**2168-10-28**] 05:15AM GLUCOSE-233* UREA N-36* CREAT-1.2* SODIUM-140
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
[**2168-11-3**] 11:09AM Glu 76 BUN 17 Cr 0.7 Na 138 K 4.7 Cl 103
HCO3 27 AG 13
[**2168-11-16**] 09:00PM Glu 116 BUN 31 Cr 1.2 Na 135 K 5.6 Cl 99
HCO3 30 AG 12
[**2168-11-20**] 06:55AM Glu 91 BUN 18 Cr 0.7 Na 140 K 4.8 Cl 104
HCO3 28 AG 13
[**2168-11-19**] 06:15AM Glu 124 BUN 20 Cr 0.8 Na 140 K 4.6 Cl 103
HCO3 30 AG 12
[**2168-11-18**] 11:25AM Glu 99 BUN 25 Cr 0.9 Na 137 K 4.8 Cl 101
HCO3 30 AG 11
[**2168-11-17**] 06:05AM Glu 82 BUN 29 Cr 1.0 Na 136 K 5.1 Cl 100
HCO3 29 AG 12
[**2168-11-25**] 05:58AM Glu 80 BUN 25 Cr 0.9 Na 140 K 4.0 Cl 101
HCO3 30 AG 13
LFTS:
[**2168-10-28**] 05:15AM ALT(SGPT)-21 AST(SGOT)-18 LD(LDH)-211 ALK
PHOS-104 AMYLASE-24 TOT BILI-0.3
[**2168-10-28**] 05:15AM LIPASE-15
[**2168-10-28**] 05:15AM ALBUMIN-3.6
URINE:
[**2168-10-28**] 08:25AM URINE RBC-0 WBC-21-50* BACTERIA-MOD YEAST-FEW
EPI-0-2
[**2168-10-28**] 08:25AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2168-10-28**] 08:25AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
CT ABD ([**2168-10-28**]):
Large subcutaneous hematoma involving mid to left lower anterior
abdomen. No intraperitoneal or retroperitoneal component.
CT ABD ([**2168-10-30**]):
1. Large subcutaneous hematoma, similar in size to perhaps
slightly decreased, with similar fluid-fluid levels.
2. Increased nonspecific stranding along the left flank which
may relate to edema and/or redistribution of hemorrhagic
products.
CXR ([**2168-11-5**]):
The lung volumes are relatively low, likely accentuating the
cardiac silhouette and bronchovascular structures. This limits
assessment of the cardiovascular status of the patient. No
confluent areas of consolidation are evident in either lung.
However, considering the concern for pneumonia, dedicated PA and
lateral radiographs may be helpful to more fully evaluate the
lungs if clinical suspicion for infection persists.
CT ABD ([**2168-11-7**]):
1. Limited study secondary to beam hardening artifact. Large
left femoral sheath hematoma extending from the liver tip on the
contralateral side, into the pelvis. Fluid, fluid levels seen
with within this large hematoma. Estimated that 50% of hematoma
is free flowing.
2. Largely resolved subcutaneous hematoma when compared to the
previous study.
CT ABD ([**2168-11-8**]):
1. Stable large left hematoma and smaller subcutaneous
hematomas.
2. IVC filter without evidence of IVC thrombus.
LOWER EXT US ([**2168-11-10**]):
No DVT in either lower extremity.
CT ABD ([**2168-11-15**]):
1. Stable appearance of large left lateral abdominal wall
hematoma and smaller subcutaneous hematomas. No new sites of
hematoma in this non-contrast scan.
2. Small left pleural effusion. Minimal bibasilar atelectasis.
3. IVC filter, unchanged.
Upper Ext US ([**2168-11-17**]):
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the right and left
internal jugular, subclavian, axillary, basilic, and cephalic
veins were performed. These demonstrate normal compressibility,
waveforms, augmentation, and flow. No intraluminal thrombus is
identified.
IMPRESSION: No evidence of upper extremity DVT.
Brief Hospital Course:
This is a 62 year-old female with history of congestive heart
failure, diabetes [**Name (NI) **], multiple pulmonay emboli on chronic
anticoag who was recently bridged on lovenox for colonoscopy and
presented with an abdominal hematoma.
.
1) Hematoma: Patient had been on chronic anticoagulation with
warfarin and an IVC filter given history of pulmonary emboli.
She developed a large subcutaneous abdominal hematoma likely
secondary to high dosage Lovenox SC injections. CT showed
collection in subcutaneous tissue with increased stranding
posteriorly (? dependant movement of hematoma). Restarted
warfarin on [**11-4**], however, subsequently developed hematocrit
drop from 29 to 21 as a result of over-anticoagulation with
heparin during warfarin bridging. She was found to be guaiac
negative but abdominal CT showed a new, large rectus sheath
hematoma. Her anticoagulation was discontinued, she was
transfused 2 units of blood and then transferred to MICU for
protamine reversal.
.
MICU course included multiple transfusions of red blood cells as
well as FFP. A central venous catheter was placed and removed
just prior to her discharge to the floor. Hct improved to 28.7
by [**11-10**].
.
Pt was transferred out of MICU on [**2168-11-13**] once her HCT had
stabilized. She remained stable with pain in the site of the
hematoma and had PT and OT coming to see her. She was able to
slowly begin ambulating more and further each day with aid. On
[**11-14**] pt seemed to have acutely worse pain and an abd CT was
obtained which showed no change in the hematoma even though the
HCT went from 32.3 to 28.8 but returned to baseline the next
morning to 30.8. Other than increasing ambulation and getting
the pt's pain under control with oxycodone SR 30mg Q12h and
oxycodone 20mg q4hr as well as 1-2mg IV morphine q3-4hr prn for
breakthrough pain. Pt was started on a lidoderm patch to try to
help control pain at site of hematoma. Pt was also maintained
on her gabapentin which was increased to 300, 300, 400mg a day
to help with her neuropathic pain from DM.
.
Vascular and [**Month/Year (2) 1978**] were following the pt while she was
hospitalized. Vascular assessed that the hematoma did not need
to be drained surgically and that her IVC filter was still in
good position and should not be replaced. [**Month/Year (2) **] (Dr.
[**Last Name (STitle) **] ordered clotting studies on pt but none were determined
to be abnormal. [**Last Name (STitle) **], vascular surgery, and ophthomalogy
all assessed pt and her history and gave opinions about whether
pt should restart anticoagulation at any point.
.
Ophthomalogy remarked that her hemorrhages in her eyes were due
to the anticoagulation as well as her DM and that she should
still be anticoagulated even if it meant bleeding in her eyes if
it kept her from having a fatal PE.
.
Vascular surgery (Dr. [**Last Name (STitle) **] felt that her risks of
bleeding outweighed her risks of having a PE and that her IVC
would help prevent a PE while another bleed might be fatal.
They remarked that if she was restarted on anticoagulation that
it should be coumadin and not heparin or lovenox as she seemed
to have more bleeding problems from those anticoagulants than
coumadin and that no anticoagulation should be started until her
hematoma has resolved.
.
[**Last Name (STitle) **] had suggested restarting coumadin without a heparin
bridge and starting and adjusting the dose very gingerly with
tight INR monitoring and control as they did not think she had a
bleed while on coumadin. They wanted to better assess the pt's
bleeding and anticoagulation that she was on when she had the
bleeding and it seemed that the pt bled when supratherapeutic on
lovenox and heparin but not coumadin. However, neither
[**Last Name (STitle) 1978**] or the pt's PCP wanted to start back any
anticoagulation for at least 2weeks after discharge from the
hospital.
.
The pt will be following up with [**Last Name (STitle) 1978**] in 2 weeks after
discharge, with ophthomology 2.5 weeks after discharge and with
Dr. [**Last Name (STitle) 5263**] in 2weeks after discharge.
.
2) Cough/Wheezing: Possible secondary to reactive airway
disease, due to patient's extensive smoking history. However,
per patient, past spirometry studies showed only restrictive
disease secondary to obesity and now obstructive or reversible
process. Her oxygen saturations remained stable during the
hospitalization and her chest x-ray was unremarkable for
infiltrative process. She was placed on standing nebulized
treatments and this alleviated the symptoms to some extent.
Chest x-rays showed no pleural effusion or pneumothorax. On the
medical floor, SaO2, BP, and RR were stable; patient had no
chest pain or pressure to indicate pulmonary embolus. She was
maintained well on her nebulizers and bi-pap at night for her
OSA.
.
3) Visual changes. Patient reported decrease in vision on
presentation to ED, especially with straining, movement. One
month PTA, she had experienced hemorrhage into left eye per
patient report. Ophtho consultation diagnosed bilateral vitreous
hemorrhage and noted that the patient was legally blind, though
it was not confirmed that this was due to recent antigoagulation
because the patient has significant diabetes. No intervention
was planned, and outpatient follow-up at [**Last Name (un) **] was recommended.
It was unclear whether bleeding continued through the hospital
course. Patient does have services at home prior to
hospitalization but may require additional services after
discharge. She will have a follow up appointment in [**Last Name (un) **]
ophthalmology [**Last Name (un) **] on discharge in 2.5 weeks with possible
ultrasound to assess for retinal bleeding at that appointment.
She was also given stool softeners and cough suppressants to
decrease strain. Her [**Last Name (un) **] ophthalmologist is as follows.
(Monvi [**Telephone/Fax (1) 103922**]) Since she was diagnosed as legally blind
she spoke with SW in regards to finding appropriate housing and
services after she is done with rehab.
.
3) Diabetes [**Telephone/Fax (1) **]: Patient was maintained on her home regimen
of 42 units glargine at night plus sliding scale insulin
coverage. Coverage was good, and sugars were in the low 100s on
the medical floor. Her sugars went up a bit when pt regained
her appetite and became lax in regards to her diet, but by
dishcarge were very well controlled on her home regimen,
especially after [**Last Name (un) **] came to see her and adjusted her evening
scale slightly. A nutrition consult also was ordered to help
remind/educate the pt on what foods to avoid.
.
4) ARF: Elevated creatinine on admission 1.2 (baseline 0.8)
likely of pre-renal etiology, secondary to volume loss from
hematoma. Following volume repletion, Cr returned back to
baseline. On [**11-15**] the pt's creatitine starting to rise slowly
and reached as high as 1.2 which was again likely caused by
prerenal causes secondary to pt being off IVF and not taking in
enough fluids to counteract her being on her diovan and lasix
home doses. The diovan was stopped and the lasox was held for 3
days and restarted back at 40mg for two days before agains being
on 80mg dialy home dose again.
.
5) Complicated urinary tract infection, with urine culture that
initially grew Klebsiella, pan-sensitive. Completed 7-day course
of Ciprofloxacin on [**11-4**]. Culture [**11-9**] later grew
cipro-resistant but TMP/SMX-sensitive E. coli. Bactrim was begun
x7 days. New UA and culture show E. coli UTI, resistant to
bactrim and foley was removed and pt was started on ceftriaxone
for 10 days and follow up UA was negative for UTI and the
culture is pending. Pt is asymptomatic. Pt was restarted on
her home dose of urecholine for urinary retention on [**11-26**].
.
6) Hypercholesterolemia: continued simvastatin
.
7) Depression: continued Celexa
.
8) OSA: Bipap at home settings of 11 I, 8 E.
.
9) FEN: Diabetic diet.
.
10) Prophylaxis: Pneumoboots. Prior to ICU admission, patient
was maintained on an IV heparin drip with a plan to start
coumadin when PTT reached 60-80. Hct was noted to be as low as
27, and blood transfusions were given PRN. Coumadin was
re-introduced [**11-4**]. With fall in Hct and ICU admission,
pharmacologic anticoagulation was DC'ed entirely. She will be
kept on pneumoboots for rehab. Pt was maintained on a bowel
regimen to keep her BMs regular and to decrease straining to
help maintain
.
11) Full code.
Medications on Admission:
Lovenox 150 mg SC BID
Coumadin
Diovan 80mg daily
Gabapentin 400mg [**Hospital1 **]
Lantus 42U qhs
Lasix 80mg daily
Mirapex 0.5mg qhs and 0.25mg afternoon
Omeprazole 20mg [**Hospital1 **]
Oxycodone prn
Simvastatin 10mg qhs
Spectravite 18mg daily
Ultram 100mg qid
urecholine 25mg qid
Celexa 40mg qhs
Discharge Medications:
1. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO qhs ().
Tablet(s)
2. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO afternoon;
1pm ().
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
10. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
17. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
18. Oxycodone 5 mg Tablet Sig: Four (4) Tablet PO Q4H (every 4
hours) as needed.
19. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for pain.
22. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
23. Insulin Glargine 100 unit/mL Solution Sig: Forty Two (42)
units Subcutaneous at bedtime.
24. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale units Subcutaneous four times a day: Please follow sliding
scale.
25. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for irritation.
26. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
27. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
28. Morphine Sulfate 1-2 mg IV Q3-4H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Abdominal Hematoma
2. Anemia
3. Hypercoagulable state, unspecified
4. Diabetes [**Hospital1 **], insulin-dependent
5. Obstructive sleep apnea
6. Lower extremity edema
6. Depression
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for an abdominal hematoma. While in the
hospital you received blood transfusions and supportive care.
.
Please schedule follow-up appointments with 1. Dr [**Last Name (STitle) **] at
the [**Hospital **] [**Hospital 8183**] [**Hospital **] within the next two and a half
weeks, 2. Dr [**Last Name (STitle) **] at [**Hospital **] [**Hospital **] and 3. Dr [**Last Name (STitle) 5263**]
your PCP within the next two and a half weeks.
.
While in the extended care facility, you should wear pneumoboots
to prevent developing a DVT. You should not receive any
anticoagulation for the next two weeks.
Followup Instructions:
You have the following appointments already scheduled:
1. [**Location (un) **] GATES, [**Location (un) 280**] MSN Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2168-11-29**]
10:15
2. [**Location (un) **],GASTRIC GASTRIC BYPASS NON BILLING Date/Time:[**2168-12-8**]
11:00
3. [**Name6 (MD) 4739**] [**Last Name (NamePattern4) 4740**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2168-12-14**]
1:30
Please schedule the following appointments:
1. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 15928**], MD Ophthalmology at [**Hospital **] [**Hospital 982**]
[**Hospital **] for a retinal ultrasound within 2 1/2 weeks. Phone:
[**Telephone/Fax (1) 25524**].
2. [**Name6 (MD) **] [**Name8 (MD) 13145**],[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. Phone:[**Telephone/Fax (1) 22**] or
[**Telephone/Fax (1) 103923**]
3. [**First Name8 (NamePattern2) **] [**Location (un) **], Primary Care within 2 1/2 weeks.
Phone:[**Telephone/Fax (1) 250**].
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,609
| 117,224
|
29076
|
Discharge summary
|
report
|
Admission Date: [**2153-11-6**] Discharge Date: [**2153-11-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Transferred for subdural hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 y/o man who lives alone, on warfarin for afib, fell 2 weeks
ago and then 4 days ago (3 d pta) at home, hit head, presented
to OSH c/o HA, N, V found to have Rt. SDH without midline shift.
Of note, pt. had self - d/c'd his warfarin 6 days pta d/t
hemoptysis. He also related that he had a "head cold" for the
week pta. Transferred here for further evaluation. On arrival
here, CT head revealed acute on chronic SDH (multiple densities
of blood) 7 mm in greatest dimension, no midline shift. He was
given Vitamin K in the ED for INR 1.3. He was evaluated by NSx.
and admitted to the SICU for q 1 hour neuro exams. His repeat CT
head 12 h later demonstrated stability of the SDH. Repeat head
CT x 2 also did not show any interval change. Incidentally, he
had a CXR which showed a large Rt ML vs. RLL mass. CT of the
chest showed this to be a large RLL mass with necrotic
components, mediastianal LAD, pleural thickening with plaques
(asbestosis), and ? other hepatic and renal cysts and ? adrenal
nodule. He had CT torso with and without contrast (pre hydration
and mucomyst ordered by NS) for staging. He also spiked a fever
to 101 at 11 pm on the evening of admission, and urine and blood
cultures were obtained (UA neg). Due to fever, change in mental
status suggestive of delirium, and the lack of ongoing
neurosurgical issues, he was transferred to the medicine service
for further management.
Past Medical History:
HTN
Afib
hyperlipidemia
CAD
Social History:
Pt lives at home alone. Has one son. Previous smoking history
including cigars. no ETOH or drugs.
Family History:
NC
Physical Exam:
T 98.2 P 81 (afib) BP 123/39 R 25 O2 sat 100% RA
Somnolent but arrousable, difficulty maintaining
attention/alertness
Oriented to person, but not place or date, lying in bed, appears
comfortable, foley in place, pneumoboots on bt. LE's
Face symmetric, difficulty keeping eyes open, but PERRL
No JVD
[**Last Name (un) **] [**Last Name (un) **], [**2-5**] hsm
Clear anteriorly
hyperactive bs, soft, nt, nd
No peripheral edema, moving all 4 extremities
neuro- CN 2-12, strength could not be assessed
Pertinent Results:
Initial labs:
[**2153-11-6**] 11:53PM GLUCOSE-126* UREA N-13 CREAT-1.2 SODIUM-135
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17
[**2153-11-6**] 11:53PM ALT(SGPT)-18 AST(SGOT)-27 ALK PHOS-109 TOT
BILI-1.0
[**2153-11-6**] 11:53PM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-1.2*
MAGNESIUM-1.8 IRON-17*
[**2153-11-6**] 11:53PM calTIBC-244* VIT B12-769 FOLATE-17.7
FERRITIN-456* TRF-188*
[**2153-11-6**] 11:53PM PHENYTOIN-9.6*
[**2153-11-6**] 11:53PM WBC-15.4* RBC-3.86* HGB-11.9* HCT-34.2*
MCV-88 MCH-30.9 MCHC-34.9 RDW-13.8
[**2153-11-6**] 11:53PM NEUTS-86.7* LYMPHS-9.1* MONOS-3.2 EOS-0.7
BASOS-0.4
[**2153-11-6**] 11:53PM PT-14.2* PTT-34.6 INR(PT)-1.3*
[**2153-11-6**] 11:53PM PLT COUNT-434
[**2153-11-6**] 11:18PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2153-11-6**] 11:18PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2153-11-6**] 11:18PM URINE RBC-[**2-4**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2153-11-6**] 10:48AM HCT-30.2*
[**2153-11-6**] 10:48AM PT-15.2* PTT-35.4* INR(PT)-1.4*
[**2153-11-6**] 10:42AM GLUCOSE-119* UREA N-16 CREAT-1.1 SODIUM-136
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-13
[**2153-11-6**] 10:42AM CALCIUM-7.8* PHOSPHATE-2.0* MAGNESIUM-1.8
[**2153-11-6**] 05:00AM GLUCOSE-114* UREA N-17 CREAT-1.3* SODIUM-135
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-21* ANION GAP-16
[**2153-11-6**] 05:00AM estGFR-Using this
[**2153-11-6**] 05:00AM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-2.1
[**2153-11-6**] 05:00AM WBC-12.6* RBC-3.92* HGB-11.8* HCT-35.1*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.1
[**2153-11-6**] 05:00AM NEUTS-75.3* LYMPHS-17.9* MONOS-4.7 EOS-1.3
BASOS-0.7
[**2153-11-6**] 05:00AM PLT COUNT-444*
[**2153-11-6**] 05:00AM PT-14.5* PTT-34.5 INR(PT)-1.3*
Discharge labs:
wbc 13.9 hgb 11.2 hct 33.4 plt 386
133 104 17
-----------< 102
4.1 21 1.1
Ca 7.7 Mg 1.8 P 2.2
phenytoin 7.5
FDP 0-10, fibrinogen 539, ddimer 1874
Pt 15.3, PTT 36.1, INR 1.4
Notable imaging:
CT head [**11-6**]:
1. 7-cm right lower lobe mass, highly suspicious for malignancy
(possibly Large Cell Carcinoma) with adjacent pleural thickening
but no evidence of chest wall invasion. Enlarged right hilar and
mediastinal lymph nodeas suggest involvement. PET/CT is
recommended for staging. Indeterminate adrenal lesions can also
be assessed at that time.
2. Interlobular and bronchovascular thickening with ground glass
change may represent CHF or chronic diffuse interstitial
disease, but lymphangitic spread of tumor is not excluded.
3. Asbestos related pleural plaques.
4. Low attenuation lesion near the base of the liver and in the
right kidney are not completely characterized on this study but
may represent simple cysts.
head CT [**11-6**] : Stable appearance of the head compared to the
exam of 12 hours prior.
[**11-7**] head ct: Stable interval appearance of this head CT scan.
CXR: 9- x 8.5- x 8.1-cm mass-like density within the right lower
lobe. A chest CT is recommended for further evaluation.
CT torso:
IMPRESSION: CT of the torso demonstrating:
1. Large necrotic right lower lobe mass. This is combined with
bilateral adrenal lesions strongly suggestive of primary lung
carcinoma in particular squamous cell carcinoma. There is
associated mediastinal adenopathy as described above.
2. Other incidental findings such as hepatic and renal simple
cysts bladder wall thickening.
Brief Hospital Course:
#. SDH - Patient experience fall while on coumadin and presented
to OSH with headache, nausea and vomiting. Transferred here to
SICU for management of SDH. Since admission, patient has had two
stable head CTs with no midline shift or interval changes. When
transferred to floor, pt was very somnolent and lethargic, but
today he is alert and awake. Still not oriented to place and
date. Patient started on dilantin for seizure prophylaxis and
will need to be on this medication until his neurosurgery
follow-up which will have to be coordinated when he leaves [**Hospital **]. We held all coumadin and aspirin given bleed and
have been giving vitamin k to bring down his INR. Goal SBP
should be below 150. He was on IV antihypertensives because he
was too lethargic to take po, but was switched to oral
metoprolol and hydralazine today since he is awake and taking
food by mouth. He passed speech and swallow eval, but needs
supervision while eating.
.
#. RLL mass - CT torso for staging done and there is large
necrotic mass in RLL along with b/l adrenal lesions suggesting
primary lung CA. Also see assoc mediastinal adenopathy and
hepatic and renal simple cysts. Patient had pulmonary consult
and they reccommended CT guided biopsy which he should get for
tissue dx. This will be done at [**Hospital6 2752**]. We
didn't consult heme-onc since we didn't have tissue dx.
.
#. Fever - unclear etiology, but likely pneumonia ? bacterial v.
aspiration. Patient empirically started on vancomycin, levaquin
and flagyl on [**2153-11-6**]. He has defervesced and his white count
has gone down. Pt could potentially have post obstructive PNA.
No evidence of diarrhea for c. dif. UA negative. No wound
infections. ? atalectasis. No evidence of DVT. Urine cx negative
and all bld cx ngtd.
.
#.Afib - currently in afib. Risk of anticoagulation is
unacceptable. Hold all anticoagulation given ICH. Rate control
with metoprolol.
.
#.HTN- we did not have outpt BP med dosages, PCP was [**Name (NI) 653**],
but did not hear back at time of discharge. We converted IV to
po metoprolol and hydralazine today. Keep sbp < 150.
.
#. HDL- can restart statin.
.
#. FEN - passed swallow study, thin liquids, full solids, with
supervision. Replete lytes prn. Cardiac diet.
.
#. Access - PIV, Foley (d/c as soon as pt. more alert and
oriented).
#. Code - presumed full.
Medications on Admission:
Atenolol
Lipitor
Enalapril
Warfarin
Isosorbide
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*10 Tablet(s)* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 10 days.
Disp:*qs qs* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: as directed
by sliding scale units Injection ASDIR (AS DIRECTED).
Disp:*qs qs* Refills:*2*
9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*120 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: [**12-4**] Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day): patient needs this until
neurosurgery follow-up.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary
1. Acute on chronic subdural hematoma
2. Lung neoplasm
Secondary
1. Atrial fibrillation (off anticoagulation)
2. Hypertension
3. Coronary [**Last Name (un) **] disease
4. Hyperlipidemia
Discharge Condition:
HD stable. He was transferred to [**Hospital3 **] due to his
insurance needs.
Discharge Instructions:
You were admitted with subdural hematoma which has been stable.
While in the hospital, a chest xray showed a concerning mass of
the lung that needs to be biopsied to rule out cancer.
Take all medications as directed.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] when you leave the hospital.
|
[
"786.6",
"486",
"414.01",
"276.52",
"V58.61",
"285.8",
"852.21",
"293.0",
"401.9",
"458.8",
"427.31",
"272.4",
"E888.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9866, 9881
|
5909, 8257
|
296, 303
|
10120, 10201
|
2451, 4264
|
10467, 10552
|
1914, 1918
|
8355, 9843
|
9902, 10099
|
8283, 8332
|
10225, 10444
|
4281, 5318
|
1933, 2432
|
223, 258
|
331, 1732
|
5327, 5886
|
1754, 1783
|
1799, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,072
| 151,600
|
43021
|
Discharge summary
|
report
|
Admission Date: [**2184-9-16**] Discharge Date: [**2184-9-27**]
Date of Birth: [**2143-11-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endotracheal intubation
PICC line placement
History of Present Illness:
40 y/o female with MMP including morbid obesity, HTN, CHF EF
40%, atrial fibrillation on AC, COPD s/p multiple
intubations/prior trach, and ethanol abuse who presented to the
ED with SOB. The patient was found to be in acute respiratory
failure and she was emergently intubated in the ED. She was also
found to be in atrial fibrillation with RVR and started on an
esmolol gtt. There was also a concern for acute CHF and she was
started on a nitro gtt. She was not accompanied by any family.
Recent documentation in OMR regarding conversations with her PCP
indicate that she had felt more SOB of late and has not been
compliant with her medications. There was also concern expressed
about her living situation.
.
In the ED, vitals upon presentation were: T 101.2, HR 146, BP
112/68, RR 40, and 94-100% (no documentation of oxygen
requirement).
.
ED course: Patient was noted to c/o CP and SOB x 1 week. She has
been unable to sleep and was tearful and anxious. She was given
nebulizer treatment, solumedrol, and zofran. She was started on
CPAP. Given worsening respiratory status, she was emergently
intubated with anesthesia. She was started on a versed and
fentanyl gtt. She was started on a nitro gtt and esmolol gtt.
She was also given Lasix 80 mg IV x 1. She was also given
levaquin 750 mg IV x 1, vancomycin 1 gram IV x 1, and flagyl 500
mg IV x 1. She was transferred to the MICU intubated, sedated,
and on the above mentioned gtts.
.
ROS: Deferred given sedation
Past Medical History:
Hypertension
CHF (diastolic) diagnosed [**3-3**], last EF > 55%
Afib diagnosed [**3-3**], on AC since that time
History of hypercarbic respiratory failure
Morbid Obesity
Influenza [**3-3**]
Mild pulm HTN (per recent TTE)
2+ TR
PFTs with a mild restrictive defect
h/o hyperglycemia
h/o ETOH abuse
OSA on BIBAP at home
Obesity hypoventilation syndrome, on home oxygen
h/o severe burns at age 5 s/p multiple sking grafts
h/o thyroglossal duct cyst
s/p B/L breast reduction
s/p C-section x 3
Depression
Cocaine abuse (no use in 10 years per records)
Social History:
Single mother of two children (aged 19 and 12). History of
tobacco but not currently. Has been in alcohol rehabilitation
last year but no current drinking. Last drink 2 months ago per
records. She lives with her children and her mother. Used
cocaine ten years ago. Denies any IVDU. Lives in [**Location 686**],
worked as a cashier at [**Last Name (un) 59330**].
Family History:
OA
Physical Exam:
Vitals:
T 99 HR 98 BP 135/85 RR 12
100% AC TV 550 FiO2 1.00 PEEP 5
General: 40 y/o F, morbidly obese, intubated and sedated.
HEENT: NC/AT. Pupils pinpoint [**2-27**] to fentanyl gtt, reactive.
MMM. ET tube in place.
Neck: Diffucult to assess JVP 2/2 to neck girth.
CV: Irregularly irregular rhythm, no m/r/g.
Pulm: Decreased BS at bases. No wheezes or crackles.
Abd: Soft, obese, NT/ND with normoactive BS.
Ext: 1+ pitting edema B/L, L > R.
Neuro: Intubated and sedated.
Skin: No rash. Evidence of prior B/L breast reduction scars on
chest. Evidence of prior burns on chest and B/L legs, evidence
of prior skin grafts.
Pertinent Results:
CXR [**2184-9-16**]
Cardiomegaly. Findings consistent with interval development of
pulmonary edema with bilateral pleural effusions.
.
U/A negative.
.
UCx negative.
.
BCx NGTD.
.
[**2184-9-17**] U/S B/L.
No DVT
.
[**2184-9-17**] TTE
The left atrium is normal in size. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated. There is severe global right
ventricular free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Dilated right ventricle with severe RV systolic
dysfunction.
Preserved global left ventricular systolic function. Moderate
tricuspid
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2184-6-15**],
right
ventricular function has probably deteriorated, but RV was not
as well seen on the prior study. Tricuspid regurgitation is more
severe. Compared with the study from [**2184-2-28**], where RV was
better seen, right ventricular function is now worse.
Brief Hospital Course:
40 y/o female with MMP including morbid obesity, HTN, dCHF EF >
55%, atrial fibrillation on AC, COPD s/p multiple
intubations/prior trach, and ethanol abuse who presented to the
ED with SOB. She was intubated emergently in the ED and admitted
to the MICU for respiratory failure.
.
# Respiratory failure
The patient was found to be in respiratory failure and was
emergently intubated in the ED. The reason for her respiratory
failure was multifactorial in etiology. She was found to have a
MRSA PNA. She received vanc, flagyl, and levofloxacin in the ED.
Levo and vanc were continued and once a sputum culture grew
MRSA, she was continued on a 10 day total course of vancomycin
and the levofloxacin was D/C. She has a h/o OSA and obesity
hypoventilation syndrome. She was also volume overloaded and she
was diuresed throughout this admission. On [**2184-9-23**], she
self-extubated herself and was reintubated. She was then
electively extubated on [**2184-9-24**] and was stable since then. She
was extremely difficult to wean from the ventilator [**2-27**] to
hypercarbic respiratory failure in the setting of severe OSA and
obesity hypoventilation syndrome. She is s/p trach in [**3-5**],
removed after discharge at rehab. There was concern that if she
was not able to be extubated that she would need another trach.
However, it became easier to wean her from the vent which
resulted in a successful extubation. She did receive one dose of
IV steroids in ED. She underwent bronchoscopy which revealed
bronchospastic airways and bronchomalacia. She was continue on
INH/nebs and finished a course of steroids. She requires BIPAP
at night, [**12-29**] without any supplemental oxygen.
.
# Atrial fibrillation
She was initially admitted and found to be in atrial
fibrillation with a RVR. She was started on an esmolol gtt in
the ED which was not continued in the MICU. She was given
antihypertensives IV which controlled her HR. Her PO meds were
gradually restarted. She was maintained on a heparin gtt given
possibility of a trach. Once she was extubated, she was started
back on her home dose of Coumadin.
.
# Cardiac
She was found to have evidence of severe right sided heart
disease on TTE and cardiology was consulted. Her right-sided
failure and severe RV disease was felt to be secondary to her
severe pulmonary disease. Her medications were optimized.
.
# Hallucinations
When the pt was extubated, she had some hallucinations. She has
a h/o depression with psychotic features. She was started on
Wellbutrin and her agitation responded well to PRN Haldol.
Medications on Admission:
Aspirin 81 mg PO daily
Warfarin 2.5 mg PO QHS
Furosemide 40 mg PO daily
Quetiapine 37.5 mg PO QAM and QPM
Quetiapine 50 mg PO QHS
Lisinopril 5 mg PO daily
Metoprolol Tartrate 200 mg PO daily
Prilosec OTC 20 mg PO daily
Celexa 10 mg PO daily
Albuterol INH
Advair Diskus 100-50 mcg INH [**Hospital1 **]
Colace
Folic Acid
Thiamine
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
MRSA pnemonia
Obesity-hypoventilation syndrome
OSA
CHF exacerbation
pulm HTN
.
Secondary:
Atrial fibrillation
Depression
Hypertension
History of hypercarbic respiratory failure
Morbid Obesity
Influenza [**3-3**]
2+ TR
PFTs with a mild restrictive defect
h/o hyperglycemia
h/o ETOH abuse
h/o severe burns at age 5 s/p multiple sking grafts
h/o thyroglossal duct cyst
s/p B/L breast reduction
s/p C-section x 3
Cocaine abuse (no use in 10 years per records)
Discharge Condition:
Fair
***Pt is leaving against medical advice***
Discharge Instructions:
You were admitted for SOB and thought to have MRSA pneumonia,
obesity-hypoventilation syndrome as well as CHF exacerbation.
.
You have decided to leave against medical advice, despite the
risks associated with such a decision and you have been informed
of all the possible consequences of this decision including
death.
.
Please return to the hospital if you change your mind at any
time, or if you have chest pain, shortness of breath, fever
.38.5C or if you at any time become concerned about your medical
condition.
.
Regarding your CHF;
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please take your medication as prescibed. the following changes
have been made to your medications during your hospital stay:
- The following medications have been discontinued: celexa,
remeron and lisinopril. Please do not take these medications any
more.
- The following medications have been started: bupropion.
Please take this medication as directed
- We also made a change in the dose of your warfarin from 2.5 mg
daily to 5 mg daily.
Followup Instructions:
Please schedule an appt with your PCP to be seen within [**1-27**]
weeks
.
Previously sched appts:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 7976**]
Date/Time:[**2184-10-1**] 10:30
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-11-17**] 10:30
|
[
"416.0",
"482.41",
"401.9",
"491.21",
"278.01",
"327.26",
"327.23",
"518.81",
"427.31",
"V09.0",
"428.0",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"33.24",
"38.91",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7748, 7754
|
4807, 7369
|
302, 347
|
8263, 8313
|
3470, 4784
|
9446, 9892
|
2811, 2815
|
7775, 8242
|
7395, 7725
|
8337, 9423
|
2830, 3451
|
243, 264
|
375, 1846
|
1868, 2416
|
2432, 2795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,564
| 193,285
|
45385
|
Discharge summary
|
report
|
Admission Date: [**2110-1-3**] Discharge Date: [**2110-1-8**]
Date of Birth: [**2057-1-30**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
HA, R sided weakness and numbness, double vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52y RH woman with background of migraines and
hypercholesterolaemia transferred with L thalamic hemorrhage
from [**Hospital3 **] today.
.
Patient awoke about 6.30am and went to the bathroom then back to
bed normally. Awoke about 0800h with headache and R sided
weakness with visual difficulites and some dizzyness. Has some
difficulty describing the visual problem. [**Name (NI) **] some double
vision. At the OSh her systolic BP was over 200 and CT scan
showed L thalamic hemorrhage. She was treated with nitro to
reduced BP and was down to about 140 here, and also loaded with
1000mg phenytoin. She was transferred here and repeat Ct scan
shows L thalamic bleed is stable.
.
She denies other illness including fever, respiratory symptoms,
abdominal symptoms.
Past Medical History:
Migraine headaches
Hypercholesterolaemia
Social History:
Lives alone, no children. Lifetime non-smoker, admits "moderate"
drinker (x2 beers/d) , denies other drugs.
Family History:
Father 72y and mother 74y, 2 sisters, 1 [**Name2 (NI) 96896**], all in good
health. No HTN noted.
Physical Exam:
T-99.4 BP-128/83 HR-59 RR-15 O2Sat97%RA
Gen: Lying in bed, squinting with one eye closed
HEENT: NC/AT, moist oral mucosa
Neck: 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, well perfused
.
Neurologic examination:
Mental status: Eyes closed, open to voice, cooperative with
exam. Oriented to person, hospital-says [**Hospital1 **], then recall at
new hospital, and month, year (initially Says DOWF, backwards
Sun...Wed-Sat-Tues..Mon. Speech is fluent with normal
repetition; naming intact. No dysarthria. Registers [**3-8**]. No
right left confusion. No apraxia , has R tactile neglect.
.
Cranial Nerves:
Pupils equally round and reactive to light, 2 to 1.5 mm
bilaterally. Nystagmus at rest in midline. Visual fields appear
full to confrontation. Some difficulty initially with counting
fingers in lower field R eye, then sees finger movements
accurately. Counts fingers correctly in both eyes superior and
inferior fields otherwise. Extraocular movements intact
horizontally, nystagmus in all directions. Sensation intact L
V1-V3, not felt on R face to LT. R facial droop. Hearing
intact to finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
.
Motor:
Normal bulk bilaterally. Tone decr RUE. No observed myoclonus or
tremor
No pronator drift on L
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF FAbd IP Hext H Q DF PF
R 3 4- 4+ 4 4- 3 4+ 3 4- 5- 5- 4+ 4+ 5-
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
.
Sensation: Intact to light. touch R neglect.
.
Reflexes:
+2 and symmetric throughout. Toes downgoing L, equivocal R.
.
Coordination: initially poor localisation of my finger then
improved on L , not tested R.
.
Gait/ Romberg: deferred
Pertinent Results:
Admission Labs:
[**2110-1-3**] 06:29PM CK(CPK)-169* CK-MB-2 cTropnT-<0.01
[**2110-1-3**] 10:25AM GLUCOSE-156* UREA N-14 CREAT-1.0 SODIUM-138
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
[**2110-1-3**] 03:48PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2110-1-3**] 10:25AM CK(CPK)-178* CK-MB-2 cTropnT-<0.01
[**2110-1-3**] 10:25AM CALCIUM-9.4 PHOSPHATE-2.0* MAGNESIUM-2.2
[**2110-1-3**] 10:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2110-1-3**] 10:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2110-1-3**] 10:25AM WBC-4.6 RBC-5.22 HGB-12.7 HCT-39.6 MCV-76*
MCH-24.3* MCHC-32.1 RDW-14.0
[**2110-1-3**] 10:25AM NEUTS-63.9 LYMPHS-30.4 MONOS-3.3 EOS-1.6
BASOS-0.7
[**2110-1-3**] 10:25AM PT-11.9 PTT-26.7 INR(PT)-1.0
[**2110-1-3**] 10:25AM PLT COUNT-274
[**2110-1-3**] 10:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2110-1-3**] 10:25AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
.
CTA Head [**2110-1-3**]:
FINDINGS: On non-contrast imaging, a left thalamic hemorrhage
is again seen measuring 16 x 10 mm in diameter (previously 19 x
11). There is stable minimal mass effect on the third
ventricle. No additional intra- or extra- axial hemorrhage is
seen. Density values of the remaining brain parenchyma are
within normal limits. There are no foci of abnormal
enhancement. The [**Doctor Last Name 352**]-white matter differentiation is
preserved.
.
CT ANGIOGRAM CIRCLE OF [**Location (un) **]: Major tributaries of the circle
of [**Location (un) 431**] are widely patent. There is no area of significant
stenosis or aneurysmal
dilatation. Within the limits of coverage of the study, no sign
of
arteriovenous malformation is apparent.
.
IMPRESSION: Stable interval appearance of left thalamic
hemorrhage with slight mass effect on the third ventricle. The
location suggests a hypertensive etiology. In the absence of
hypertension, an arteriovenous malformation may be possible.
While no AV malformation is detected on today's study,
malformations may be missed on CTA, the most sensitive study
would be catheter angiography when mass effect subsides.
.
CT Head [**1-4**]:
FINDINGS: There is no short interval change in appearance,
size, and extent of a left thalamic hemorrhage measuring 16 x 10
mm. There is stable mass effect on the third ventricle. No new
areas of hemorrhage are identified. [**Doctor Last Name **]-white matter
differentiation is preserved. Ventricles and sulci are normal
in caliber and configuration. The basal cisterns are not
effaced. The visualized paranasal and mastoid air cells are
well aerated. Regional soft tissues are unremarkable.
.
IMPRESSION: Stable interval appearance of left thalamic
hemorrhage with
slight mass effect on the third ventricle. No new areas of
hemorrhage are
identified.
.
Brief Hospital Course:
Pt. was initially admitted to the Neuro-ICU for close
monitoring. On HOD #2 she developed some vomiting and had a new
vertical gaze palsy and convergence nystagmus c/w Perinaud's
syndrome, which would be c/w the location of her hemorrhage.
Repeat Head CT at that time showed no extension of hemorrhage.
Over her admission her strength improved, and on day of
discharge she had 4/5 strength in her R arm and leg in UMN
pattern, as well as a lack of sensation in her R face, arm, and
leg, c/w the location of her hemorrhage. She was transferred to
the floor on HOD #3. Her diet was advanced to a full diet with
supervision with no evidence of aspiration. She was started on
Lipitor 10 mg QD for secondary stroke prevention. She was
initially covered with IV Labetalol and Hydralazine for BP
control with a goal MAP < 130 given hemorrhage, and transitioned
to Metoprolol 12.5 mg PO Q8 with good BP control for several
days prior to discharge. This can be titrated as needed to
maintain MAP < 130. She was given Percocet and Tylenol as
needed for HA and Anzemet as needed for nausea (which was much
improved after HOD #2) She was started on Zoloft for some
depressive symptoms.
Medications on Admission:
Zomig 20mg po qd
Lipitor 10mg po qd
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q8 ().
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 DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for severe headache.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain/fever.
9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
11. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left thalamic intracerebral hemorrhage
Discharge Condition:
Stable, R arm and leg weakness ([**4-10**] in UMN pattern) and loss of
sensation in R face, arm, and leg, impaired upgaze and diplopia,
mental status intact
Discharge Instructions:
Please call your doctor or go to the ER if you develop any
severe headache, nausea, vomiting, confusion or excessive
fatigue, worsening of your double vision, worsening weakness or
numbness, or any other symptoms that concern you.
Please take all medications and attend all follow up
appointments.
Please avoid the use of triptans (drugs like zomig). It is
likely that your brain hemorrhage resulted from high blood
pressure caused by excessive use of zomig.
Followup Instructions:
Neurology: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], [**Telephone/Fax (1) 657**], [**Hospital1 18**] [**Hospital Ward Name 516**],
[**Hospital Ward Name 23**] 8. Date/Time:[**2110-1-21**] 3:30
Primary Care: Please call Dr.[**Doctor Last Name 14539**] at [**Telephone/Fax (1) 41973**] to set up
a follow up appointment for 1-2 weeks after you are discharged
from Rehab
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2110-1-8**]
|
[
"796.2",
"E947.8",
"431",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8633, 8730
|
6386, 7569
|
363, 370
|
8813, 8972
|
3375, 3375
|
9482, 10017
|
1367, 1466
|
7656, 8610
|
8751, 8792
|
7595, 7633
|
8996, 9459
|
1481, 1768
|
275, 325
|
398, 1161
|
2186, 3356
|
3392, 6363
|
1807, 2170
|
1792, 1792
|
1183, 1225
|
1241, 1351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,707
| 142,132
|
31317
|
Discharge summary
|
report
|
Admission Date: [**2149-9-20**] Discharge Date: [**2149-9-26**]
Date of Birth: [**2104-4-7**] Sex: M
Service: MEDICINE
Allergies:
Sevoflurane
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
back pain, hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 73843**] [**Known lastname **] is a 45 man with with a history of diabetes
and ESRD on HD, who presents with back pain and a missed
dialysis session.
.
Two recent admission ([**8-25**] - [**8-28**] and [**9-5**] - [**9-12**]). The
former admission was for nausea/vomiting and resulted in a
diagnosis of gastroparesis. The latter admission was for edema
and weight gain which was felt to be secondary to dietary
indiscretion resulting in fluid overload as well right heart
failure secondary to left heart failure. A thorough work-up
included normal albumin, TSH and cholesterol. Diagnostic para
showing macrophages, though otherwise unrevealing. The patient's
ascites improved considerably with hemodialysis and
ultrafiltration. Also noted to have a pericardial effusion and
pulmonary hypertention by echo.
.
Four days prior to admission, patient felt dizzy prior dialysis
and fell onto the ground and onto his back. Since then, he has
been experiencing worsenimg back pain, exacerbated with walking
up and down stairs and lying on his back. Pain is described as
both sharp and dull. He has taken Motrin and Tylenol with some
relief. Did not go to dialysis today given his pain.
.
In the ED, was afebrile with an initial BP of 161/83. BP
increased to 212/82 and was started on nitro gtt (titrated up to
50mcg/min). O2 sat fell to 80s and the patient was started on a
NRB. Noted to be somewhat lethargic but oriented x3. Treated for
hyperkalemia with calcium gluconate 1gram, 10 units of insulin,
amp of D50, amp of bicarb and kayexalate. For FS of 63, given
additionaly amp of D50 with latest FS of 123.
Past Medical History:
1. Diabetes mellitus, type I
- c/b retinopathy (legally blind in left eye), neuropathy and
nephropathy
2. End Stage Renal Disease, HD TThS
- AVG creation on [**8-6**], not being used yet
3. Congestive heart failure, EF 40-45% ([**2149-9-6**])
4. Hypertension
5. Pulmonary hypertension
6. Glaucoma
7. s/p surgical debridement of left arm fistula ([**5-24**]) and
ruptured aneurysm repair ([**6-24**])
8. History of PEA arrest in [**6-24**]
9. History of positive PPD, s/p one year of treatment
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**] and is homeless. He denies current tobacco use (quit
several years ago). He denies EtOH or illicit drug use
Family History:
Multiple siblings with HTN and diabetes. Two sisters with a
"[**Last Name **] problem." No known early coronary disease or kidney
disease.
Physical Exam:
On Admission
---------
vitals - T 97.0, BP 155/90, HR 72, RR 20, 100% on NRB, 95% on
room air.
gen - Breathing comfortably and in no distress.
heent - JVP hard to assess. Glaucoma in left eye.
cv - Regular with no murmurs. +S4.
pulm - Bibasilar crackles. Expiratory wheeze.
abd - Soft and non-tender.
ext - Warm. No edema.
back - Mild tenderness at L-spine.
neuro - Alert, oriented x3. Strength 5/5 throughout. Sensation
grossly intact though patient was 0/2 when asked to identify
which toe was being touched and has decreased proprioception.
Pertinent Results:
Admit Labs:
----------
136 93 83
------------- 130
7.0 27 10.0 (repeat K: 5.7)
.
CK: 89
.
WBC: 5.0
PLT: 143
HCT: 34.8
N:65.4 L:23.8 M:6.6 E:4.0 Bas:0.3
.
UA: 1.019 / 7.0 Bld Tr Nitr Neg Prot 500 Glu 100
RBC 0 WBC 0-2
.
Serum Tricyc Pos
Serum ASA, EtOH, Acetmnphn, Benzo, Barb Negative
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
.
EKG: Sinus tachycardia. 1st degree AV block. Left axis. LAA.
Peaked T-waves.
.
CXR ([**2149-9-20**]): Cardiomegaly with some fullness of right
pulmonary vasculature.
.
CT HEAD ([**2149-9-20**]):
There is no intra- or extra-axial hemorrhage. There is no mass
effect or shift of normally midline structures. The ventricles,
cisterns, and sulci maintain a normal configuration and the
[**Doctor Last Name 352**]-white matter differentiation is preserved. The visualized
paranasal sinuses are clear, the mastoid air cells are clear,
and no fractures are identified. The patient is edentulous.
.
CT L-SPINE ([**2149-9-20**]):
There is loss of the normal lumbar lordosis. Vertebral body
alignment is anatomic. Vertebral body height is preserved. No
fractures are
identified. Very mild posterior disc bulges are present at L3-L4
and L4-L5, there is no evidence for spinal canal narrowing. The
neural foramina are normal at all levels.
.
Alternate read: Nondisplaced fractures through left L1, L2
transverse processes.
Brief Hospital Course:
Mr. [**Known lastname 73843**] [**Known lastname **] is a 45 man with with a history of diabetes
and ESRD on HD who was admitted on [**9-20**] with back pain and
hypertensive urgency after missing an HD treatment. Initially in
the ED, he was afebrile with a BP of 161/83. BP increased to
212/82 and was started on nitro gtt (titrated up to 50mcg/min).
O2 sat fell to 80s and the patient was started on a NRB. Noted
to be somewhat lethargic but oriented x3. Treated for
hyperkalemia (k 7.0)and admitted to the ICU for hypertensive
urgency. Of note, in setting of fall, had head CT which was
negative, and L spine CT with nondisplaced L2-L3 fracture. The
patient was seen by the orthopedics team with a recommendation
that no acute intervention or bracing was necessary.
In ICU, the plan was initially for HD, however after initiating
HD patient moved his arm and the AV fistula infiltrated, so
dialysis could not be continued at that time. The patient was
managed with kayexalate and IV calcium, insulin. HD was resumed
the next day without complications. The patient's electrolytes
have remained stable. He was placed back on his home regimen of
anti-hypertensives with adequate control of his BP. Of note,
there was initial difficulty accessing the AV fistula with the
above mentioned infiltration. To evaluate the patency a
fistulogram was obtained on [**9-25**] which showed no evidence of
clot and patent flow. The area where the intial infiltration
occurred continues to improve. The patient will be discharged
with HD follow up tomorrow at his outpatient center. At
discharge the patient's potassium is 4.9. He will resume his
Tu,Th,Sat HD tomorrow.
In regards to the patient's back pain, he has sustained the
above mentioned non-displaced fractures that do not require
surgical intervention at this time. He will be discharged on
oxycodone for pain relief as well as a bowel regimen while
receiving narcotics. The patient has been instructed to follow
up with his PCP if he develops any new neurological symptoms,
worsening back pain or weakness.
Medications on Admission:
1. Aspirin 81 mg daily
2. Furosemide 80 mg daily
3. Metoprolol Tartrate 50 mg TID
4. Amlodipine 7.5 daily
5. Losartan 100 mg daily
6. Isosorbide Mononitrate 30 mg SR
7. Hydralazine 10 mg q8h
8. Insulin slinding scale Lantus 4 U bed time
9. Calcium Acetate 1664 TID with meals
10. Prilosec OTC 20 mg daily
11. Docusate Sodium 100 mg [**Hospital1 **]
12. Amitriptyline 25 mg qhs
13. Lanthanum 500 mg TID with meals
14. B Complex-Vitamin C-Folic Acid 1 mg / daily
15. Reglan 5 mg TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
4. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr 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.
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 2048**]-[**Doctor Last Name **] House
Discharge Diagnosis:
ESRD
hypertensive urgency
non-displaced L1,L2 fracture of Left transverse process
Discharge Condition:
stable, tolerating po intake, pain free
Discharge Instructions:
You were admitted with back pain and found to have hypertensive
urgency after missing one of your scheduled HDs. You were found
to have a non-displaced L1-L2 fracture of your left transverse
process that requires no surgical intervention. You will need
to follow up with your PCP in one week of discharge and attend
each scheduled HD session in the future.
Followup Instructions:
You should return to your outpatient HD center tomorrow [**2149-9-25**]
for HD and labs.
Please call Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] for an appointment
in [**11-19**] weeks.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 18975**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2149-10-16**] 2:30
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2149-12-4**]
8:00
|
[
"805.4",
"250.41",
"996.74",
"365.9",
"357.2",
"428.22",
"416.8",
"E888.9",
"585.6",
"403.01",
"250.51",
"250.61",
"276.7",
"536.3",
"362.01",
"583.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
8915, 8999
|
4972, 7039
|
295, 302
|
9125, 9167
|
3586, 4949
|
9574, 10108
|
2865, 3006
|
7571, 8892
|
9020, 9104
|
7065, 7548
|
9191, 9551
|
3021, 3567
|
232, 257
|
330, 1957
|
1979, 2474
|
2490, 2849
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,616
| 122,604
|
40711
|
Discharge summary
|
report
|
Admission Date: [**2160-5-5**] Discharge Date: [**2160-5-6**]
Date of Birth: [**2102-9-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
RCA dissection
Major Surgical or Invasive Procedure:
-Cardiac catheterization with 2 closed stents placed on either
side of RCA stent (placed at OSH) for proximal and distal
dissections
- Intraaortic balloon pump
History of Present Illness:
57F CAD (LAD diffuse irregularity, LCx dissuse irregularity, RCA
70-80% stenosis) HTN, AAA, HL, COPD that presenting from from
[**Hospital6 3105**] (LGH) with RCA dissection and IABP.
.
The pt was seen by her PCP [**Last Name (NamePattern4) **] [**2160-4-29**] in the setting of
increased blood pressure. At that time, per PCP records, she
"had an unusual sensation in her head and her chest and she just
does not feel right". Of note during the visit her PCP noted [**Name Initial (PRE) **]
LUE BP of 150/79 and RUE BP of 124/70. Wt 167.8kg. During the
visit her Atenolol was increased to 50mg Daily and HCTZ was
added at 12.5mg. She was also started on Citalopram 10mg Daily.
.
The pt was admitted to LGH on [**5-3**] with abdominal/epigastric
pain - stated she had never had the pain before - associated
with nausea/vomiting. Abd pain was relieved by GI cocktail. CEs
negative, EKG without signs of ischemia. The pt underwent
cardiac cath today after a + nuclear stress test that revealed
an 80% RCA stenosis. The pt was enrolled in Mass comm. for which
she was randomized to LGH-RCA stented with PROMUS 2.75 x 18mm
proximal RCA c/b RCA dissection (proximal and distal to the
stent). A balloon pump was placed (augmenting 15mm greater than
systolic, good wave form). She was transferred to [**Hospital1 18**] via
[**Location (un) **].
.
In the cath lab, LMCA, LAD, and LCX showed no flow-limiting
lesions. There was dissection visible proximal to the stent and
spasm/dissection distal to the stent. A stent was placed to
cover the proximal dissection and a second stent to cover the
distal dissection. Final angiography revealed normal flow, no
dissection, and 0% residual stenosis. Post-procedure Echo showed
'nearly' normal inferior wall and RV function, no effusion.
.
On arrival to the CCU the patient was alert and oriented x 3. VS
97.6 57 130/63 16 96% 2L nc w/ IABP at 1:1. She was quickly
weaned off the balloon pump, which was subsequently pulled 5:20
PM. A-line was placed in right radial. She reported no CP or
abdominal pain. EKG showed NSR, Nl axis and intervals without ST
changes. Her only complaint is of recent fatigue - worse
recently.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None prior to [**2160-5-5**]
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# Cystic Breast Disease
# s/p hysterectomy (BSO followed by Dr. [**Last Name (STitle) 20764**]
# s/p bladder suspension
# Kidney Laceration
# Basal Cell Skin Cancer Removal
# Throat popls followed by [**Location (un) 7658**] Ear, Nose and Throat
# s/p CCY
# Colonoscopy [**2154**] with polyps (Dr. [**Last Name (STitle) **] in NH)
# EGD [**2154**]
# s/p AAA (4cm) followed by Dr. [**Last Name (STitle) 26438**]
# Adrenal Adenoma and Hepatic Cyst followed by Dr. [**Last Name (STitle) 20672**]
# COPD
# Depression
# Tobacco Abuse
# Bone spurs in feet and right shoulders
Social History:
(Per PCP [**Name9 (PRE) **] and reconfirmed with pt)
Married, from [**Location (un) 12595**] MA. Homemaker. Previously 1.5ppd smoker,
now down to 3 cigarettes per day. Denies ETOH.
Family History:
(Per PCP [**Name9 (PRE) **] and reconfirmed with pt)
Father: deceased COPD early 50s, hx of renal disease. Mother:
deceased 56yrs. Breast Cancer in her early 50s. Killed in car
accident. Sister: Rheumatoid Arthritis, CHF (age 74), MRSA,
Renal Disease. Son and Daughter healthy. Questionable hx of CHF
and CAD in rest of family.
Physical Exam:
On admission:
VS: 97.6 57 130/63 16 96% 2L nc w/ IABP at 1:1; BP 122/68
after IABP pulled
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Xanthalesma
present.
NECK: Supple with JVP not elevated
CARDIAC: RR, distant S1, S2. No m/r/g
LUNGS: CTA anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: No c/c/e. 2+ dp/pt pulses bilaterally
GU: foley in place
Neuro: moves all extremities normally, a&ox3
Access: balloon pump in R groin, L radial sheath in place, PIVs
Pertinent Results:
Labs:
[**2160-5-5**] 06:57PM BLOOD WBC-10.1 RBC-4.21 Hgb-13.6 Hct-38.6
MCV-92 MCH-32.3* MCHC-35.3* RDW-13.6 Plt Ct-163
[**2160-5-5**] 06:57PM BLOOD Glucose-127* UreaN-8 Creat-0.5 Na-138
K-3.5 Cl-104 HCO3-25 AnGap-13
[**2160-5-5**] 06:57PM BLOOD CK-MB-5
.
OSH LABS/STUDIES
Labs:
WBC 7.2, RBC 5.0, HB 15.8, HCT 47.9
Plt: 188 na 136, k 4.0, cl 102, bun 8, creat 0.5, gluc 99
INR 0.9
.
PCP [**Name Initial (PRE) 89024**]:
Chol 175, Trig 75,HDL 56,LDL (Calc) 104
[**5-3**] Lipids: Chol 128 HDL 49 TG 71 LDL 65
.
OSH CXR REPORT: No acute process
.
OSH EMG OF LEs: [**2160-3-17**]
Reason for Study: Tingleing sensation in both feet for 8 mon
duration.
Findings: Normal Study. No electrophysiologic evidence of focal
or diffuse neuropathy or evidence or lumbosacral radiculopathy
on either right or left.
.
CT Abdomen and Pelvis: [**2160-2-25**]
1) Stable bilateral adrenal adenomatous hyperplasia
2) Enlarging fusiform intrarenal AAA 4.0 cm axially
3) No hydronephrosis, stones or masses in either kidney
.
EKG: NSR, Nl axis and intervals, no ST segment changes
..
[**Hospital3 **] CARDIAC CATH:
LMCA: Normal
LAD: Diffuse irregularity
LCx: Diffuse irregularity
RCA: Focal Stenosis and diffuse irregularity. 70-80% proximal
stenosis
LVEF: 55%
.
[**Hospital1 18**]:
.
EKG: sinus brady rate = 48, Nl axis, Nl intervals, No ST-
changes
.
Cath:
LMCA, LAD, and LCX showed no flow-limiting lesions. There was
dissection visible proximal to the stent and spasm/dissection
distal to the stent. 2 stents placed, to each dissection site.
TTE ([**2160-5-6**])
Normal global and regional biventricular systolic function.
Trivial pericardial effusion.
Brief Hospital Course:
57F with HTN, HL and AAA that presented to OSH with epigastric
pain, underwent RCA stenting complicated by RCA dissection
transferred to [**Hospital1 18**] for repair now with IABP; now s/p stent x 2
to dissection proximal and distal to newly placed stent.
# RCA Dissection: Cath at [**Hospital6 3105**] for presumed
unstable angina and positive stress test showed 80% proximal RCA
lesion. A DES was placed, however the procedure was complicated
by dissections proximal and distal to this stent. An IABP was
placed and the patient was transferred to [**Hospital1 18**] via [**Location (un) **].
In the cath lab, closed stents x 2 were placed to cover both
dissections. IABP was quickly weaned after arrival to ICU from
cath lab. She was started on Plavix 75 mg per day x 12 months,
ASA 325 mg per day, and continued on simvastatin 10 mg per day.
TTE showed normal structure and function.
# IABP: Quickly removed after arrival to cath lab - patient had
no compromise in distal pulses
# PUMP: TTE showed normal structure and function
# Rhythm: No abnormal rhythm noted on telemetry
# HTN: Normotensive currently. Atenolol discontinued and
metorprolol succinate 50 mg po qdaily.
# Anxiety/Depression: Continued celexa 10 mg per day
# AAA: 4cm. Outpatient f/u.
# COPD: Pt not compliant with Advair/combivent. Outpt f/u
# Vitamin D Deficiency: Cont. VitD 1000U qday
Code status was confirmed full code. Communication was with
[**First Name5 (NamePattern1) **] [**Known lastname 89025**] [**Telephone/Fax (1) 89026**]
Medications on Admission:
HOME MEDICATIONS PER PCP [**Name Initial (PRE) **]:
ASA 81mg Daily
Simvastatin 10mg Daily
Atenolol 50mg Daily (Increased from 25mg on [**4-29**])
HCTZ 12.5mg Daily (Started [**4-29**])
.
Citalopram 10mg Daily (Started [**4-29**])
Lunesta 3mg QHS
[**Doctor First Name **]-D 180-240mg PRN
Vitamin D 1000 units
.
MEDICATIONS ON TRANSFER FROM OSH:
Fentanyl: 150mcg
Versed: 6 mg
Morphine 8mg for chest pain
Heparin bolus 3800 at 746 am during diagnostic cath
Heparin 1000 bolus during RCA intervention at 817
Protamine 936 am 1.5mg given--- MOST RECENT ACT 150 at 1025 am
NTG 150mcg IC
ASA 325mg this am at 8am
Prasugrel 60mg this am at 759
Simvastatin 10mg
Atenolol given
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Lunesta 3 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. [**Doctor First Name **]-D 24 Hour 180-240 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day as
needed for allergy symptoms.
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. DES to RCA complicated by proximal RCA perforation and
dissection
2. DES to fix RCA dissection/perforation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 89025**],
It was a pleasure participating in your care. You were
transferred to [**Hospital1 18**] after having a complication during your
percutaneous intervention. A cardiac stent was placed to fix
this complication. Because you now have this stent, you will
need to take a new medication, Plavix, for no less than one year
in order to ensure that this stent does not become clotted.
Please call or return to the hospital if you develop chest
pain, shortness of breath, or any other symptoms that concern
you.
--------------------
Please START the following medication:
- Plavix 75 mg by mouth daily
- Metoprolol succinate 50 mg by mouth daily
Please STOP the following medications:
- Atenolol 50 mg by mouth daily
- Hydrochlorothiazide 12.5 mg by mouth daily
The following medication has CHANGED:
- Aspiring should be taken 325mg daily
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**]
Address: [**Location (un) 10767**]., [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 10768**]
Phone: [**Telephone/Fax (1) 77368**]
**Please call your primary care physician and book [**Name Initial (PRE) **] follow up
appointment within the next 1-3 days.
Department: CARDIAC SERVICES
When: THURSDAY [**2160-6-5**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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79,117
| 197,456
|
12136
|
Discharge summary
|
report
|
Admission Date: [**2147-5-8**] Discharge Date: [**2147-5-14**]
Date of Birth: [**2062-5-25**] Sex: M
Service: MEDICINE
Allergies:
Bee Sting Kit / Lisinopril
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
Delerium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo M with h/o COPD, GERD, bullous pemphigoid, prostate CA,
CVA, who is a long term resident at NewBridge on the [**Doctor Last Name **].
Presents today after a work-up of increasing confusion on
morning of [**2147-5-8**] prompted labwork, which revealed an
elevated creatinine and a leukocytosis. This was in setting of
patient being on an elevated dose of prednisone to 30 mg [**Hospital1 **]
since [**2147-5-2**]. Patient's recent past medical history
significant for hypertension with SBPs to 230 associated with
chest pain on [**2147-5-5**]. Beta blocker was increased at that
time. Patient's oxycodone was increased day prior to admission
due to increased complaints of non-focal pain.
.
In the ED, initial VS were: T 98.1, HR 72, BP 128/42, RR 26,
O2Sat 95% 2L. CT scan showed large amount of urine in the
bladder. RUL lung nodule reportedly suspicious for infection per
CT chest. Was given 1g of Vanc and 1 g Cefepime in setting of a
leukocytosis of 24.9. Abdomen CT showing bladdder wall
thickening and distended bladder. Foley was replaced, and he
drained 650 mL urine. Abdominal discomfort improved with this
measure. Was on [**2-21**] L supplemental oxygen throughout ED course.
Reportedly remained confused throughout ED course. Prior to
transfer to the ICU, VS were: T 99, HR 60, BP 120/80, RR 18,
O2Sat 95% 5L FM.
.
Upon arrival to the floor the patient reports that his breathing
is comfortable. He has some left leg pain, that is chronic. He
denies any fever or chills. Notes that his cough is at its 6
year baseline.
.
Review of systems:
(+) mild abdominal pain, left leg pain, cough, constipation,
rash, skin tears
(-) fever, chills, night sweats, recent weight loss or gain,
headache, shortness of breath, wheezing, chest pain, chest
pressure, palpitations, weakness, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria, frequency, urgency,
arthralgias, myalgias
.
Past Medical History:
1) COPD with intermittent 2L supplemental oxygen
2) Presumptive bronchoaveolar carcinoma (Followed by Dr. [**Last Name (STitle) **]
and [**Doctor Last Name **] in pulm)
3) Coronary artery disease s/p NSTEMI in [**1-17**]
4) Hypertension
5) s/p MCA CVA with residual left-sided hemiplegia, wheelchair
bound
6) Pulmonary embolism in [**2129**]
7) Bullous pemphigoid
8) Bilateral hernia repair
9) Appendectomy
10) Prostate Cancer
Social History:
Widower, retired salesman, living at NewBridge on the [**Doctor Last Name **].
He is wheelchair bound. Smoked [**11-19**] PPD x 60 years, he quit over
ten years ago. He denies the use of alcohol or illicit
substances.
Has 2 daughters: [**Name (NI) **] [**Name (NI) 31759**] [**Telephone/Fax (1) 38029**]
The patient has had a longstanding DNR/DNI.
Family History:
*per recent oncology note*:
His mother died of lung cancer.
His father died of heart disease.
He is one of seven children, five of which have died due to old
age and heart disease.
Physical Exam:
Vitals ([**5-14**]):
Tc: 97.8 / Tm 98.7 / BP 168/66 (141-216/61-84) / HR 59 (48-74) /
RR 20 (18-20) / Sats: 98% on 2L NC (96-100% on 2-4L)
.
Exam ([**5-14**])
Gen: A&O, crying (but not sad), conversational, comfortable
Lungs: very shallow breathing, could not appreciate any
crackles, no wheezing currently
Cardiac: mild Bradycardiac, sinus rhythm, no m/r/g
Abd: soft, NT, ND, BS+
Ext: warm, well perfused, L foot in protective boots
Skin: no change in skin from previous days - wounds not examined
on this exam
Pertinent Results:
Admission Labs:
[**2147-5-8**] 05:10PM BLOOD WBC-24.9*# RBC-3.68* Hgb-11.5* Hct-33.2*
MCV-90 MCH-31.1 MCHC-34.5 RDW-13.2 Plt Ct-308
[**2147-5-8**] 05:10PM BLOOD Neuts-91.7* Lymphs-3.2* Monos-4.7 Eos-0.3
Baso-0.1
[**2147-5-8**] 05:10PM BLOOD PT-59.3* PTT-47.5* INR(PT)-6.7*
[**2147-5-8**] 05:10PM BLOOD Glucose-156* UreaN-84* Creat-6.7*#
Na-129* K-5.3* Cl-89* HCO3-24 AnGap-21*
[**2147-5-8**] 05:10PM BLOOD ALT-16 AST-19 AlkPhos-87 TotBili-0.3
[**2147-5-8**] 05:10PM BLOOD Albumin-3.0* Calcium-8.7 Phos-6.6*#
Mg-2.1
[**2147-5-9**] 05:50AM BLOOD PSA-33.6*
[**2147-5-8**] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2147-5-8**] 05:10PM BLOOD Lactate-1.1
Other Results:
[**2147-5-13**] 08:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2147-5-13**] 08:40AM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2147-5-13**] 08:40AM URINE RBC-[**4-27**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2147-5-13**] 8:40 am URINE Source: Catheter.
**FINAL REPORT [**2147-5-14**]**
URINE CULTURE (Final [**2147-5-14**]): NO GROWTH.
[**2147-5-13**] 1:30 pm BLOOD CULTURE -> Blood Culture, Routine
(Pending):
Radiology:
**CXR ([**5-12**]): IMPRESSION:
1. Ground-glass opacities at the right mid lung concerning for
infectious
process, or aspiration.
2. Minimal bibasilar atelectasis, with stable minimal blunting
of the
costophrenic angles.
3. Stable mild cardiomegaly.
**CT of chest/abdomen/pelvis ([**5-8**]):
IMPRESSION:
1. Slight enlargement of right upper lobe ground-glass nodule,
with
development of adjacent opacities that could represent either
infection/inflammation, or progression of indolent malignancy
such as
bronchoalveolar cell carcinoma.
2. Marked bladder distension and new hydronephrosis, without
evidence of
obstructing stones. Mild questionable left sided bladder wall
thickening.
Nonemergent evaluation with contrast-enhanced CT, MR (as renal
function
allows) or ultrasound is recommended. Urologic consultation
should be
considered.
Dr. [**Last Name (STitle) **] was notified of these findings on [**2147-5-8**] at 7:15 p.m.
Per resident
report, patient had incorrect Foley placement, and revision
yielded a large
amount of fluid with associated pain relief.
3. Stable infrarenal abdominal aortic ectasia.
**TTE ([**5-12**]):
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
calcific aortic stenosis. Mild pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2142-9-3**], aortic sclerosis has progressed to
mild stenosis and pulmonary pressures are higher. The other
findings appear similar.
Discharge Labs ([**5-14**]):
CBC: WBC 17.9 (down from 19.9) / Hgb 11.4 / Hct 35.3 / plts 411
PT 30.5 / INR 3.0
Chem: Na 138 / K 4.8 / Cl 98 / HCO3 34 / BUN 27 / Cr 0.8 /
glucose 231
Ca 9.2 / Mg 1.5 / P 3.0
Urine Cx and Blood Cx Pending
Brief Hospital Course:
1. [**Last Name (un) **] due to obstructive uropathy:
Mr. [**Known lastname 38030**] was admitted to MICU for increasing confusion,
elevated Cr to 6.7 (baseline <1), fever, leukocytosis. CT had
demonstrated large volume of urine in bladder, and foley was
placed, draining urine (roughly 650ml). UA was wnl, BCx was
sent. The foley catheter was left in place and patient continued
to make good urine output. Pt PSA was found to be 33.6 (from
34.5 in [**1-/2147**], 7.8 in [**10/2146**]), raising concern of obstructive
uropathy [**12-20**] prostate ca enlargement. On [**5-10**] patient Cr had
normalized to 1.1. A few days after ICU discharge pt was given a
voiding trial which he failed with >1L in the bladder on bladder
scan. A foley was replaced and immediately voided over 1L of
urine. Urology was contact[**Name (NI) **] and they indicated that patient
should be discharged with a foley and will be seen by Dr.
[**Last Name (STitle) 770**] in follow-up within the week to address what to do with
the foley.
.
2. Atrial Fibrilation with Rapid Ventricular Response:
Upon arrival in MICU Pt was noted to have rate of 130, found to
be be in Afib w RVR, started on a dilt gtt and converted back to
SR. He was transitioned to PO but missed some of his PO doses
[**12-20**] to bradycardia. Once patient was more stable he was
transfered out of the icu. On the general [**Hospital1 **] he again was
intermittently in afib with RVR and multiple diltiazem IV pushes
were needed to control his rate. A cardiology consult was
obtained and they recommended using metoprolol for the main rate
control [**Doctor Last Name 360**]. Pt was switched to metoprolol 75mg PO BID with
PRN IV pushes. On this new regimen pt no longer suffered from
RVR. Each night for the next couple evenings pt has asymptomatic
bradycardia in the 30-50s. As a result the evening dose of his
metoprolol was changed to 50mg PO. His rate continued to be
adequately controlled and he continued to have normal rate
during the day and mild, asymptomatic bradycardia while sleeping
on this regimen.
.
3. Aspiration Pneumonia:
A chest CT in the past had indicated RUL nodule, and CXR on
admission showed right lung opacity possibly consistent with
infectious process. pt received cefepime and vanco in ED, and
was continued on cefepime on arrival to MICU. When his WBC
quickly came back to normal after foley placement and bladder
drainage, the ICU service decided that the elevated WBC wsa more
likely due to stress from the bladder obstruction. Later in the
hospitalization the pt's WBC starting to rise although he was
afebrile. CXR was obtained that showed some ground glass
opacifications in the RML which would be consistent with an
infectious process. He were started on metronidazole and
levofloxacin to treat suspected aspiration pneumonia with plans
to complete an 8 day course if responsive. When patient's WBC
dropped after starting therapy and pt showed greater energy the
day after therapy initiated, it was deemed acceptable to
discharge him with 6 days of medication left to take as an
outpatient. His warfarin dose was reduced to 1mg PO daily while
on the antibiotics due to pharmacy recommendations. Once he
finishes the antibiotics he can increase the dose back to 2mg
per day.
.
4. Bullous Pemphagoid:
Pt seen by derm consult regarding pt's hx of bullous pemphigoid;
recommendedations: 1. doxycycline 100mg TID 2.nicotinamide
(niacin) 500mg PO TID 3. d/c hydrocortisone 4. start
clobetasol 5. continue prednisone 20mg [**Hospital1 **]. Taper to be
determined by clinical course on follow up. 6. Continue calcium
and vitamin D and PPI 7. Consider starting PCP prophylaxis
with bactrim or atovaquone (as patient has been taking
prednisone daily since [**12-28**]). PCP prophylaxis was started and
pt was instructed to follow up with the dermatology clinic upon
discharge.
.
5. Hypertension:
Pt was intermittently hypertensive after ICU discharge with a
couple isolated pressures >200 systolic for which IV hydralazine
was given. Because Mr. [**Known lastname 38030**] continued to run elevated blood
pressures throughout much of the admission, an addtional
anti-hypertensive (Losartan) was started to help with blood
pressure control.
.
New Medications:
1. Metoprolol Tartrate with twice each day dosing as follows:
-> 75mg taken orally in the evening
-> 50mg taken orally in the evening
2. Losartan 50mg PO daily
3. Levofloxacin 750mg PO daily for total of eight days (six
additional days after discharge)
4. Metronidazole 500mg PO three times a day for a total of eight
days (six additional days after discharge)
Medications on Admission:
1) Terazosin 5 mg PO HS
2) Isosorbide Mononitrate 15 mg PO DAILY
3) Metoprolol Succinate 50 mg PO/NG [**Hospital1 **]
4) Fluticasone Propionate 220 mcg 2 PUFF IH [**Hospital1 **]
5) Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
6) Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing, dyspnea
7) Senna 2 TAB PO/NG HS
8) PredniSONE 20 mg PO/NG [**Hospital1 **]
9) Simvastatin 20 mg PO/NG DAILY
10) OxycoDONE (Immediate Release) 5 mg PO/NG [**Hospital1 **]
11) Omeprazole 20 mg PO DAILY
12) Finasteride 5 mg PO DAILY
13) Vitamin D 50,000 UNIT PO/NG 1X/WEEK (WE)
14) Diltiazem 30 mg PO/NG TID
15) Calcium Acetate 667 mg PO/NG TID W/MEALS
16) Albuterol-Ipratropium 2 PUFF IH [**Hospital1 **]
17) Acetaminophen 650 mg PO/NG [**Hospital1 **]
18) Calcium carbonate 650 mg [**Hospital1 **]
19) Lactobacillus Bulgaricus 1 tab [**Hospital1 **]
20) Warfarin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO twice a
day.
2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: 2
Tablet(s) by mouth twice a day for
one week, then 3 tablets once daily for 1 week, then 2 tablets
once daily for 1 week, then 1 tablet once daily for 1 week, then
stop.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing, dyspnea.
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day): Rinse mouth after each use.
13. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day.
Disp:*60 Capsule(s)* Refills:*0*
15. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
16. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*90 Tablet(s)* Refills:*0*
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Do not restart 2mg/day dose until finish all antibiotics
(metronidazole and levofloxacin).
18. Niacin 250 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*60 Capsule, Sustained Release(s)* Refills:*0*
19. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
QAM (once a day (in the morning)).
Disp:*90 Tablet(s)* Refills:*0*
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
Disp:*30 Tablet(s)* Refills:*0*
21. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Every day at 4pm
for 7 days for 7 days: Once finish 7 days at this dose, may
return back to old dose of 2mg every day.
Disp:*7 Tablet(s)* Refills:*0*
22. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: Please only give 1mg of warfarin each day until
finish this antibiotic.
Disp:*6 Tablet(s)* Refills:*0*
23. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 6 days: Please do not give 2mg of warfarin each
day until patient finishes this antibiotic.
Disp:*18 Tablet(s)* Refills:*0*
24. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day:
Please check potassium level after 5-7 days of use.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
1) Acute Kidney Failure due to Obstruction
2) Atrial Fibrillation with Rapid Ventricular Response
3. Aspiration pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 38030**], it was a pleasure taking care of you during your
stay.
You were admitted to the hospital with kidney failure due to
obstruction of your bladder, most likely by your prostate. When
we put a new urine catheter in your bladder, you were able to
make a large amount of urine immediately and your kidney failure
quickly resolved. A few days later we removed the catheter and
allowed you to attempt to urinate on your own. When after 8
hours you were unable to do so and your bladder contained a
large amount of urine, we replaced a urine catheter.
While you were here you had intermittent rapid heart rate due to
your atrial fibrillation. We had to give you multiple doses of
medications called metoprolol and diltiazem in order to control
your heart rate. You were briefly on a continuous infusion of
diltiazem. We had a cardiology service see you to help us
control your heart rate. Your heart rate was finally controlled
with larger amounts of metoprolol. An ultra sound of your heart
was obtained which showed no serious abnormalities. Your heart
ran somewhat slow in the high 30s-50s while you were asleep once
you started your metroprolol. However, you should continue
taking this medication at the perscribed doses as you have no
symptoms with the slower heart rate while asleep.
Finally, you developed an elevated white blood cell count during
your hospitalization and a chest xray showed a possible
pneumonia in your right lung. You were started on two
anti-biotics called metronidazole and levofloxacin to treat you
pneumonia - you will take these for a total of 8 days. Your
warfarin dose will also be reduced to 1mg by mouth each day
while you are taking your antibiotics. Once you finish the
antibiotics you can increase the dose back to your usual 2mg per
day.
Your blood pressure was also high so we started an additional
blood pressure medication called losartan.
New Medications:
1. Metoprolol Tartrate with twice each day dosing as follows:
-> 75mg taken orally in the evening
-> 50mg taken orally in the evening
2. Losartan 50mg PO daily
3. Levofloxacin 750mg PO daily for total of eight days (six
additional days after discharge)
4. Metronidazole 500mg PO three times a day for a total of eight
days (six additional days after discharge)
The dermatology clinic would like to see you after discharge to
help treat your bullous pemphagoid. Please call [**Telephone/Fax (1) 1971**] to
schedule an appointment with the dermatology clinic.
Urology would also like to see you in clinic within the week to
address what to do with your foley catheter. Please call
[**Telephone/Fax (1) 5727**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 770**].
Followup Instructions:
1) Consider f/u CT of chest in [**12-21**] weeks in order to evaluate
resolution of infiltrate seen on CXR
2) Speech Eval for swallowing ability and aspiration risk
3) CBC in 7 days to evaluate WBC
4) K and Cr in [**3-24**] days to evaluate renal funct w/ Losartan
5) INR in [**1-20**] days with goal range 2.0-3.0
6) Follow up with Dermatology in their clinic for treatment of
the Bullous Pemphagoid. Call [**Telephone/Fax (1) 1971**] to schedule the
appointment.
7)Urology would also like to see you in clinic within the week
to address what to do with your foley catheter. Please call
[**Telephone/Fax (1) 5727**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 770**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
|
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[
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|
2701, 3052
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Discharge summary
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report
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Admission Date: [**2149-8-22**] Discharge Date: [**2149-10-27**]
Date of Birth: [**2075-6-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Iodine-Iodine
Containing / Tetanus / Codeine / Zyvox / Plaquenil / Vibramycin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Chief Complaint: Altered mental status, fevers
Reason for ICU admission: Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 74 year old female with PMH of DM2, asthma, PVD,
rheumatoid arthritis, ulcerative colitis, multiple non-healing
ulcers and sacral decubitus ulcers presenting for further
evaluation of altered mental status and fevers noted by the
patient's home VNA service. The patient has been admitted 4
times this year for multiple issues including cellulitis and
[**Last Name (un) **]. Each time, the patient refuses to go to a rehab facility
and instead opts for going home with VNA services. The VNA
observed the patient talking to and asking for family members
who have already passed.
.
In the ED, initial vs were: 97.5 95 111/58 16 95%. She was
sleepy but arousable and oriented to person and intermittently
to time. Stage II sacral decubitus ulcers with erythematous
bases were noted with small ~ 2x2 cm areas with purulent
discharge. Chronic bilateral lower extremity ulcers for which
she completed a course of Vancomycin for on previous admissions
were erythematous with clean bases. Per the ED, her UA was
positive and she was treated with ciprofloxacin 400 mg IV for
possible UTI. She was also given 1 liter of IVF for [**Last Name (un) **]. She is
incontinent of stool and wheelchair bound with chronic Foley for
urinary incontinence. Transfer vitals were 96.9 94 117/49 16 99%
1L.
.
On the floor, the patient is aroused with wound care, but is
otherwise somnolent and will not provide a history
.
Review of sytems: Unable to obtain secondary to mental status
Past Medical History:
1. Diabetes mellitus type 2 for 24 years.
2. Asthma.
3. Peripheral vascular disease.
4. Osteoporosis.
5. Hypertension.
6. Rheumatoid arthritis.
7. Iron-deficiency anemia.
8. Hypothyroidism.
9. Ulcerative colitis.
10. Hyperlipidemia.
11. Gastroesophageal reflux disease.
12. Allergic rhinitis.
13. Fibromyalgia.
14. Urinary incontinence with chronic foley
15. Depression.
16. Anxiety.
17. History of recurrent left lower extremity cellulitis.
18. History of MRSA infections of the left heel.
19. Peripheral neuropathy.
20. Left rotator cuff injury in 09/[**2141**].
21. Vitiligo.
22. Chronic diabteic foot ulcer.
23. Pancytopenia of unknown etiology, however, improved off MTX
24. H/o MRSA pelvic osteomyelitis
25. s/p bilateral great toe amputations
26. Right clavicular fx.
Social History:
Lives alone in [**Hospital1 3494**]. She has a homemaker come to help with
cleaning. She has VNA for wound care MWF. She denies EtOH,
tobacco. Wheelchair bound x ~5 years. She has no family except
for a nephew who she hasn't heard from in a while.
.
Over the course of the pt's stay, a legally appointed guardian
was established. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95429**] [**Telephone/Fax (1) 95430**]
Family History:
Mother with MI at 29, Father with lung/oral cancer, 3 sisters
and 1
brother all who passed away (alcohol, DM, CAD)
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 103.4 BP: 130s/70s P: 130s R: 16 O2: 97% 2L
General: awake, alert answering questions appropriately although
screaming out in pain and frustration intermittently
HEENT: Sclera anicteric, dry MM, oropharynx clear, PERRL
Neck: supple
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: tachycardic and regular with 3/6 systolic murmur across
precordium
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Skin: Multiple deep ulcers on buttocks with green purulent
discharge
Neuro: moving all extremities, otherwise uncooperative
Ext: multiple LE wounds, erythematous without any prurulent
drainage
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tc: 98.7 BP: 132/76 (130-168/64-76) P: 88 (88-99) R: 20
O2: 98-100%
General: NAD, resting
HEENT: Sclera anicteric, MMM
Neck: supple
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: mild tachycardic and regular with 3/6 systolic murmur across
precordium unchanged from prior exams
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Skin: limited exam showed clean dry dressing no apparent
drainage; PICC site on Left arm looks okay, no apparent
extention of erythema
Neuro: moving all extremities
Ext: multiple LE wounds, erythematous without any prurulent
drainage, dressings dry clean and intact
Pertinent Results:
ADMISSION LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.1 3.08* 8.3* 26.7* 87 26.9* 31.0 16.7* 355
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos NRBC Plasma
68.6 0 17.5 6.0 7.3 .6
Glucose UreaN Creat Na K Cl HCO3 AnGap
147*1 28* 1.4* 132* 5.8*8 97 24 17
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
93 304 369*1 712 122* 18 0.3
albumin 2.4, low of 1.7
Calcium Phos Mg
7.7* 3.1 1.5*
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.6 2.96* 9.1* 28.3* 96 30.9 32.2 19.0* 187
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos NRBC Plasma
77.3* 12.7* 8.0 1.4 0.6
Glucose UreaN Creat Na K Cl HCO3 AnGap
77 18 0.4 135 4.4 104 28 7*
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
31 26 266* 0.3
Calcium Phos Mg
8.2* 4.2 1.7
.
STUDIES:
CXR [**2149-8-22**]:
SINGLE VIEW CHEST RADIOGRAPH: There is borderline cardiomegaly.
Both lungs appear grossly clear with no focal consolidation,
pleural effusion or pneumothorax. Minimal scarring opacification
at the right upper lung is stable in appearance since multiple
priors.
IMPRESSION: Borderline cardiomegaly. No acute cardiopulmonary
process.
.
KUB [**2149-8-23**]:
There is no evidence of toxic megacolon. There is a
nonobstructing bowel gas pattern with few air-filled
nondistended small bowel loops in the pelvis and air-filled
transverse colon measuring up to 6.2 cm. Coarse calcification in
the left pelvis is unchanged from [**2140**]. Hardware in the left
proximal femur is partially visualized.
.
TTE [**2149-8-25**]:
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. 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 diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). 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.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2142-11-23**] , mild aortic stenosis is new. No
vegetation is seen. However, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
MICROBIOLOGY:
BCX [**2149-8-22**] - pending
BCX [**2149-8-23**] - pending
.
[**2149-8-22**] 7:30 pm URINE Site: CATHETER
**FINAL REPORT [**2149-8-23**]**
URINE CULTURE (Final [**2149-8-23**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
[**2149-8-23**] 2:53 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2149-8-24**]**
MRSA SCREEN (Final [**2149-8-24**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
.
[**2149-8-23**] 2:45 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2149-8-25**]**
FECAL CULTURE (Final [**2149-8-25**]):
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final [**2149-8-25**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2149-8-24**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2149-8-23**] 2:45 pm URINE Source: Catheter.
**FINAL REPORT [**2149-8-25**]**
URINE CULTURE (Final [**2149-8-25**]): NO GROWTH.
.
C. diff PCR - negative
.
MRI PELVIS W/O CONTRAST Study Date of [**2149-8-27**] 8:01 PM
FINDINGS:
There is a Foley catheter in the bladder and a rectal tube in
place. Limited visualization of pelvic structures with in- and
out-of-phase T1-weighted images and axial T2-weighted images do
not demonstrate any gross pelvic abscess or obvious fistulous
tract. This study is suboptimal without gadolinium injection and
cystographic images.
IMPRESSION:
Incomplete study shows no gross evidence of fistula or abscess.
.
Brief Hospital Course:
74 yo F with DM2, asthma, PVD, rheumatoid arthritis, ulcerative
colitis, multiple non-healing ulcers and sacral decubitus ulcers
presenting with fever and hypotension concerning for sepsis.
.
# Hypotension, fevers: Originally thought to be multifactorial
from hypovolemia (from diarrhea and decreased PO intake) as well
as possible sepsis from various possible sources including
urine, sacral ulcers, heel ulcers, and possible C. diff. She
received IVF hydration with good response and did not require
pressors. Stress dose corticosteroids were started given her
medication list of taking methylprednisolone daily. A KUB showed
no evidence of megacolon. She was continued on abx therapy with
vancomycin IV and PO, flagyl, cefepime, and daptomycin after
consulting with ID as well as stress dose steroids with
hydrocortisone. Blood and urine cultures were sent and
negative. Her leflunomide was held as well out of concern for
sepsis. Her Daptomycin, flagyl, and cefepime were discontinued
on [**2149-8-25**], given that she continued to be afebrile with
negative cultures. She was continued on po vancomycin, as she
continued to have watery stools, while C. diff PCR was pending.
The C. diff PCR returned as negative on [**2149-8-27**], and the
vancomycin was discontinued. Her steroids were tapered as her
blood pressures stabilized.
.
However, the patient continued to have SBPs in the 90s-low 100s
with low urine output given her GI losses and poor po intake.
She also frequently lost IV access. The IV team was unsuccessful
in placing a PICC line. On [**2149-9-9**], the patient's SBP dropped to
the 80s. Her IV line inflitrated when attempting to give an IV
bolus. IV was unsucessful in placing a new line. Pt refused an
EJ line. Despite attempting to encourage po intake, pt's SBP
dropped to the 70s and she was transferred back to the MICU
where a subclavian line was placed.
.
IN THE MICU: It was felt that her low blood pressure was a
result of adrenal insufficiency and volume depletion, or
possible sepsis from UTI. She was started on hydrocortisone. Her
blood pressure remained stable after she was bolused with
fluids. She was initially started on Meropenem and Vanco for
coverage of her possible UTI. Her urine culture eventually grew
E.coli that was pan-sensitive. She was started on ceftriaxone.
Her dose of hydrocortisone was lowered prior to transfer to the
floor. Her statin was held (since she refused po's) and her
levothyroxine was changed to IV.
.
IV steroids were initially continued upon transfer back to
medical floor. However, given stable BPs and no appreciable
improvement in stool output, steroids were tapered to her old
home dose. She continued to refuse po the majority of the time
with little to no po nitrition. Albumin was 1.7 at the lowest;
INR became elevated and fibrinogen was quite low, which were
thought to be [**1-7**] her poor nutritioal status. She was started on
TPN with subesquent normalization in her INR and moderated
improvement in albumin to 2.3-2.4. As her condition improved she
was able to be restarted on verapimil 80 q8hr (she could not
take the long acting for b/c pt refused to swallow pill but
would take crushed meds in applesauce).
.
On the day of discharge she was hemodynamically stable and
remained afebrile.
.
# Sacral wounds: The patient has multiple deep ulcers on her
buttocks with green
purulent drainage. She was treated with abx as above, and had a
wound care consult. She received morphine for pain control.
Wound care evaluated the wounds and make dressing
recommendations. General surgery was consulted for evaluation of
possible debridement. They recommended debridement, but the
patient refused bedside debridement on multiple occasions.
Flexiseal was placed to avoid wound contamination by fecal
matter.
.
# Diarrhea: Originally thought to be infectious in origin;
however, as above, C. diff was negative. She continued to have
profuse watery diarrhea, with negative stool cultures. She was
initially treated with loperamide, which was then changed to
Lomotil. The diarrhea worsened when her steroids were being
tapered. GI was consulted and felt that given the negative
infectious workshop, this was likely a flare of her UC. The
patient refused colonoscopy, CT scan, as well as empiric
steroids. As noted above, steroids were restarted in the MICU
during her second stay there for hypostension, but were tapered
back down to prior home dose when pressures were stable and
stool output was not noticably decreased. Initially CMV viral
laod had been equivocal, but repeat viral load [**2149-9-16**] was
1,590 copies/mL. She was started on IV gancyclovir. One week
into her course, viral load had dreased to 834 copies/mL. She
was completed a 2 week course of gancyclovir. However, she
continues to have loose, dark brown, guaic + flexiseal output.
On [**2149-9-24**], Hct dropped to 21.3 and she was started on IN
pantoprazole and transfused 2 units pRBCs. He condition
improved. After completion of the gancyclovir course, lomotil
was restarted as GI and pt flet that this improved symptoms.
.
#. Agitation, hallucinations: She originally presented to the
MICU with concern from the VNA for altered mental status. She
was agitated and screaming on admission to the ICU. However, on
transfer to the medicine floors she began to improve. Her
Alprazolam and Trazodone continued to be held. On [**2149-8-28**] she
began to have visual hallucinations and was much more agitated.
Geriatrics and psychiatry were both involved in her care. In
addition to modifying her pain regimen, the patient was started
on haloperidol, ultimately 1mg in the morning and 2mg at HS. In
the MICU, olanizpine was found to be effective. Upon retrn to
the medical floor, olanzipine was kept as a PRN, but was very
rarely needed; haldol was d/c'ed. While she remained less
aggitated, the patient was still at times confused. Given the
waxing and [**Doctor Last Name 688**] of the pt's mental status and incapacity to
make her own decisions, social work was consulted to help
establish guardianship. Family was [**Name (NI) 653**], but no one was
willing to be her guardian. After a meeting between the
patient's PCP, [**Name10 (NameIs) **] primary team, and social work, the decision
was made to persue a court-issued gaurdian. After several weeks,
a court appointed guardian was established ([**Name (NI) **] [**Name (NI) 95429**]
[**Telephone/Fax (1) 95430**]) who will help to make key care decisions.
.
#. [**Last Name (un) **]: Patient was admitted with creatinine of 1.4 thought to
be pre-renal secondary to dehydration, that improved with fluid
resuscitation. Nephrotoxins were avoided. On discharge, her
creatinine was back to baseline.
.
# Anemia: Her hematocrit was at baseline. Normocytic, with iron
studies suggestive of anemia of chronic inflammation. She had
guaiac positive stools, and her Aspirin was held. Anemia was
stable throughout most of the admission. As noted above, she
required transfusion of 2 units on [**2149-9-24**] for an Hct of 21.3
but required no further transfusions.
.
# Diabetes: She was initially continued on her home NPH with a
diabetic diet. However, because of low po intake, the patient
had episodes of hypoglycemia, so the decisions as made to hold
her NPH and cover with Humalog sliding scale. Patient began to
refuse SQ insulin, so it was decided to include insulin in her
TPN to be adjusted on a daily basis along with heparin.
.
# Hypertension: Her blood pressure [**Date Range 4982**] were originally
held given hypotension. When pressures were stable, her
verapamil was re-started, but patient took it only
intermittently. As her condition improved she was able to be
restarted on verapimil 80 q8hr (she could not take the long
acting for b/c pt refused to swallow pill but would take crushed
meds in applesauce).
.
Pt was discharged to [**Location **] rehabiliation facility for continued
care.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95429**] [**Telephone/Fax (1) 95430**] is the pt's legally appointed
guardian.
[**Telephone/Fax (1) **] on Admission:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for asthma.
5. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Take with 8oz of water. Do not eat/lie down for 30 min.
7. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
8. Conjugated Estrogens 0.625 mg/g Cream Sig: One (1) Vaginal
once a day: Apply daily to vulva.
9. Cyanocobalamin (Vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection once a month.
10. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day: 1 spray per nostril.
12. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Inhalation every four (4) hours as needed for
wheezing.
13. Ketoconazole 2 % Cream Sig: One (1) Appl Topical Q24H (every
24 hours).
14. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Methylprednisolone 4 mg Tablet Sig: One (1) Tablet PO once a
day.
16. Mupirocin 2 % Ointment Sig: One (1) Topical twice a day:
apply to wounds.
17. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
QHS (once a day (at bedtime)) as needed for pain.
19. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
20. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
21. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day) as needed for rash.
22. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO twice a day.
23. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO HS (at bedtime).
24. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
25. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
26. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-7**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
27. Leflunomide 20 mg Tablet Sig: One (1) Tablet PO once a day.
28. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous QAM.
29. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Three
(3) Units Subcutaneous at bedtime.
Discharge [**Month/Day (2) **]:
1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
2. venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing, SOB.
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for redness.
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
8. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchiness.
10. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-7**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
11. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
12. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO HS
(at bedtime) as needed for itching.
15. verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
16. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for lip soreness.
18. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for pain.
19. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hosp for [**Hospital **] Medical Care - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
1. Fevers
2. Hypotension
3. Heel ulcer
4. Sacral ulcer
.
Secondary Diagnoses:
1. Diabetes
2. Hypertension
3. Depression
4. Rheumatoid arthritis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Bedbound; if tolerated by pt, can be moved out
of bed to chair or wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 95432**],
.
It was a pleasure taking care of you during this admission. You
were admitted with high fevers. You were initially treated in
the ICU for low blood pressure. You were given antibiotics and
fluids. Your fevers improved and you were transferred to the
medicine floors. Your blood pressure improved. You were seen by
the infectious disease service who recommended stopping your
antibiotics as your fevers stopped. You had an MRI of your
abdomen, which showed no infection.
.
You continued to have a substantial amount of diarrhea, and you
were not eating well. You were transferred back to the MICU
temporarily for low blood pressures. We began to give you
nutrition through your IV. Your condition imoroved.
.
Because you declined aggressive treatment for your ulcerative
colitis and other medical treatment, we worked to optimize your
care while trying to keep you comfortable. A court appointed
guardian was [**Name2 (NI) 95671**] to help with difficult medical
decisions.
.
As your condition improved, it was felt that you would be best
served by transferring you to a longterm care facility where you
could be comfortable while having your health issues managed.
.
The following [**Name2 (NI) 4982**] were changed during this admission:
-STOP Alprazolam** This [**Name2 (NI) 4982**] was stopped due to
confusion. Please follow-up with your primary care doctor
regarding when it is safe to start these [**Name2 (NI) 4982**].
-STOP Leflunomide***This medication was stopped because you had
high fevers and there was concern for infection. Please check
with your doctor when it is safe to start this medication.
-STOP Losartan **This medication was stopped due to low blood
pressure and kidney problems. Please follow-up with your doctor
regarding when it is safe to restart this medication.
-Please also stop taking Atorvastatin
-Please also stop taking Fluticasone
-Please also stop taking Alendronate
-Please also stop taking Conjugated Estrogens
-Please also stop taking Cyanocobalamin
-Please also stop taking Ketoconazole 2 % Cream
-Please also stop taking Methylprednisolone
-Please also stop taking Pregabalin
-Please also stop taking Aspirin
-Verapamil 180 mg Tablet Sustained Release was changed to short
acting verapamil 80mg q8h so that the pill could be crushed in
apple sauce to make it easiear for you to take.
-Long acting venlfaxine 150mg daily was changed to short acting
venlafaxine 75 mg [**Hospital1 **].
-Please continue taking prednisone 5mg daily
-Please take pantoprazole instead of Omeprazole
-Please start taking olanzapine 5 mg twice a day as needed for
agitation
-Low dose benadryl (12.5mg QHS) was written for itching
-Fexofenadine 60 mg PO twice daily as needed for itching
-Sarna lotion was also written for itching
-Benzocaine 20 % ointment was written for your lip lesion
The need for stopping or restarting these [**Hospital1 4982**] should be
discussed with your doctors. [**First Name (Titles) **] [**Last Name (Titles) 4982**] have been stopped
because you consistently voiced a desire not to take many of
your [**Last Name (Titles) 4982**].
.
Please continue all other [**Last Name (Titles) 4982**] you were on prior to this
admission. Please discuss medication changes with your doctor.
.
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your PCP
and other healthcare providers.
.
It was a pleasure taking care of you and we wish you a speedy
recovery
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP
and other healthcare providers.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2149-12-3**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
22014, 22114
|
9255, 17326
|
470, 477
|
22320, 22367
|
4794, 4794
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|
1930, 1976
|
505, 1912
|
4810, 5207
|
17340, 21991
|
22382, 22500
|
1998, 2776
|
2792, 3226
|
4098, 4775
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,700
| 108,045
|
23711
|
Discharge summary
|
report
|
Admission Date: [**2123-6-25**] Discharge Date: [**2123-7-2**]
Date of Birth: [**2043-12-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Central venous line placement
Esophagogastroduodenoscopy (EGD)
History of Present Illness:
79-year-old woman who is being admitted for abdominal pain and
hypotension. She was noted in the ED to have temperature to 104.
Cultures were taken, pressures dropped to SBP 80s. Femoral line
was placed and patient was started on norepinephrine. CXR was
reportedly clear (?retrocardiac opacity). UA was negative. Labs
remarkable for white count of 13.3 and creatinine of 1.5, up
from baseline 1.0. Patient was given 1g vancomycin (?hand
cellulitis) and meropenem. Vitals at time of transfer were T
99.8, HR 102, BP 140/54, 99% on 4L, RR 18.
Of note, patient was recently admitted to the general medicine
service ([**Date range (1) 21715**]) for neck pain. She was treated
conservatively with ibuprofen and tylenol prn, with negative
head CT and negative CT c-spine. She was also treated for
urinary tract infection during that admission with a Levaquin. A
foley catheter was left in place due to concern of urinary
retention.
Past Medical History:
- Churg-[**Doctor Last Name 3532**] vasculitis, Positive p-ANCA
- Vascular dementia
- Chronic leg edema
- Osteoporosis
- Asthma
- History of GI bleed
- Right hip replacement due to AVN ([**2121-7-13**])
- Hypertension
- Chronic renal insufficiency (baseline Cr 1.0-1.5)
- Recent hospitalization for multiple left-side rib fractures
- Cholelithiasis s/p CCY
- GERD
- CAD (unclear details)
- Anemia (Hct in [**6-20**] 33.7)
- G3P3, all vaginal deliveries
- Recent ?zoster infection in left lateral chest wall
- Per patient, h/o heart murmur
Social History:
She currently lives at [**Location (un) 5481**] for short term rehab. She's
a widow. She was prior living independently at [**Hospital1 **] Village a
few weeks ago. She has good family support [**First Name8 (NamePattern2) **] [**Hospital1 **] dc
summary. Has 3 sons and 7 grandchildren (only 1 grandchild is a
girl). No tobacco, alcohol, or illicit drug use. Denies smoking,
occasional alcohol, none recently.
Family History:
Had niece with some type of cancer ("maybe lung cancer but also
in stomach" per son). Unclear how parents died.
Physical Exam:
Admission Exam
General: sleeping but rousable.
HEENT: non-icteric sclera, pupils equal and reactive
Heart: RRR, normal s1/s2
[**Last Name (un) **]: soft, non-distended, mild diffuse tenderness without
rebound or guarding
Extremities: warm and well-perfused
Pertinent Results:
On admission:
[**2123-6-24**] 07:20PM BLOOD WBC-13.3* RBC-3.69* Hgb-10.2* Hct-30.9*
MCV-84 MCH-27.5 MCHC-32.9 RDW-16.9* Plt Ct-232
[**2123-6-24**] 07:20PM BLOOD Neuts-80* Bands-0 Lymphs-16* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2123-6-24**] 07:20PM BLOOD Plt Smr-NORMAL Plt Ct-232
[**2123-6-24**] 07:20PM BLOOD Glucose-108* UreaN-13 Creat-1.5* Na-141
K-3.9 Cl-102 HCO3-26 AnGap-17
[**2123-6-24**] 07:20PM BLOOD ALT-13 AST-23 AlkPhos-76 TotBili-0.9
[**2123-6-24**] 07:20PM BLOOD Albumin-3.3*
[**2123-6-25**] 05:49AM BLOOD Albumin-2.9* Calcium-7.4* Phos-3.1
Mg-0.9*
[**2123-6-25**] 05:49AM BLOOD TSH-3.1
[**2123-6-25**] 05:49AM BLOOD Cortsol-6.1
[**2123-6-26**] 05:38PM BLOOD ANCA-NEGATIVE B
[**2123-6-26**] 05:38PM BLOOD CRP-168.9*
.
On discharge:
[**2123-7-1**] 07:50AM BLOOD WBC-10.2 RBC-4.15* Hgb-11.2* Hct-35.3*
MCV-85 MCH-27.0 MCHC-31.8 RDW-16.7* Plt Ct-378
[**2123-7-1**] 07:50AM BLOOD Plt Ct-378
[**2123-7-1**] 07:50AM BLOOD PT-12.5 PTT-22.4 INR(PT)-1.1
[**2123-7-1**] 07:50AM BLOOD Glucose-97 UreaN-5* Creat-0.8 Na-141
K-3.6 Cl-101 HCO3-32 AnGap-12
[**2123-6-26**] 03:59AM BLOOD ALT-12 AST-20 LD(LDH)-184 CK(CPK)-49
AlkPhos-72 TotBili-0.4
[**2123-6-26**] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2123-6-26**] 03:59AM BLOOD Lipase-51
[**2123-7-1**] 07:50AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.6
.
LUE ultrasound:
IMPRESSION: No DVT in the left upper extremity.
Brief Hospital Course:
Ms. [**Known lastname **] is a very pleasant 79 yo woman who presented to the
[**Hospital1 18**] ED with initial symptom of abdominal pain, and was
admitted to the ICU with fevers and hypotension without obvious
source. She was called out to the general medicine service on
[**2123-6-27**], and was discharged from the hospital on [**2123-7-1**] in good
condition, ambulatory, with stable vital signs. Her brief
hospital course was notable for:
.
# Fever/Hypotension: At the time of admission septic shock was
the largest concern. There was no obvious infection despite
broad infectious work-up. Only clear source of infection was
left hand cellulitis which rapidly improved on Vancomycin. TSH
and cortisol both normal, ruling out endocrine sources of
hypotension. During admission she did have evidence of melena
with a GI hemorrhage, but had minimal drop in Hct. She was
treated with Vancomycin for 7-day course for possible hand
cellulitis (Day 1 = [**6-24**]). Was also treated with Flagyl
empirically for C. Diff. This was stopped with culture came
back negative. By the time the Pt was called out to the floor
fevers and hypotension resolved and the Pt remained afebrile and
normotensive or hypertensive while on the floor. The Pt
completed a 7 day course of vancomycin for presumed L hand
cellulitis. The exact cause of the patient's fever and
hypotension remains unclear. She has had recent admissions to
outside hospitals for fevers which have reportedly been
unrevealing. This will require further outpatient workup, but at
the time of discharge the Pt did not have active medical issues
to prohibit her discharge.
.
# Melena: Hematocrit downtrended slowly. Received one unit
PRBCs on [**6-27**]. H.pylori serology negative. GI was consulted and
recommended EGD. EGD was performed on [**2123-6-29**] which demonstrated
gastritis and esophagitis, but no active bleeding. Two biopsies
were obtained. Pt was started on sucralfate 1 mg QID and given
prescription to continue this as outpatient. Pt's dose of
pantoprozole was increased from 40 mg qD to 40 mg [**Hospital1 **]. Diet
recommendations were made including avoiding caffeine, onions,
alcohol, chocolate, and peppermint. Pt's aspirin 81 mg daily was
stopped. Pt did not have any further episodes of melena or Hct
drop while in the hospital.
.
# Vasculitis. Initially started on IV steroids given concern
for possible adrenal insufficiency as source of hypotension.
Cortisol was normal. She was then rapidly tapered to on day to
Prednisone 5 mg [**Hospital1 **]. Home prednisone dosing was confirmed and
she was transitioned to 5 mg prednisone daily. At the time of
discharge she was maintained on her admission dose of 2.5 mg qD
and 5 mg qHS.
.
# Hypoxic episodes: Patient intermittently with oxygen
saturation below 90%. This was in the setting of Ativan and
associated somnolence. Also appeared to have a positional, OSA
component. At the time of discharge the Pt had been maintaining
O2 sats over 90% on RA for over 24 hours. Should have
outpatient sleep evaluation.
.
# Dementia: Patient was continued on Namenda.
.
# GERD: Patient was continued on Protonix. This was increased
to [**Hospital1 **] once she developed guaiac positive stools.
.
# Neck pain: Contined on lidocaine patch.
.
# Depression: Continued on Citalopram.
.
# Hypertension: Pt was noted to be hypertensive to 180s systolic
on the day prior to discharge. Her Metoprolol dose was increased
on the day of discharge from 12.5 mg [**Hospital1 **] to 25 mg [**Hospital1 **].
Optimization of her outpatient medication should be done as an
outpatient, including addition of a thiazide diuretic and/or ACE
inhibitor.
.
# Left hand swelling: Pt had left hand swelling and was treated
with a 7 day course of Vancomycin for cellulitis. After the
treatment, on two different days the Pt experienced left hand
swelling, without pain, erythema, warmth vascular compromise, or
limitation in range of motion, which resolved spontaneously. The
etiology of this swelling is unclear. The Pt had negative
ultrasound studies of the upper extremity to rule out DVT.
.
All other chronic medical issues for this patient were stable.
She was discharged to rehab in good condition, ambulatory, with
stable vital signs, and appropriate outpatient follow-up
arranged. No further changes were made to her outpatient
medication regimen other than those described above.
Medications on Admission:
(per most recent discharge summary [**6-6**])
- aspirin 81 mg daily- multivitamin
- namenda 10 mg daily
- prednisone 2.5 mg daily, 5 mg qhs
- simvastatin 20 mg daily
- protonix 40 mg daily
- calcium carbonate 500 mg tid
- cholecalciferol 800 u daily
- citalopram 20 mg daily
- senna
- docusate 100 mg [**Hospital1 **]
- lidocaine patch
- magnesium hydroxide 400 q8h
- acetaminophen
- metoprolol 12.5 mg daily
- ibuprofen 400 mg q8h
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Memantine 5 mg Tablet Sig: One (1) Tablet PO bid ().
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Place
on for 12 hours then off for 12 hours daily.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: One (1) dose
PO three times a day.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary: cellulitis, sepsis
Secondary: Chrug-[**Doctor Last Name 3532**] vasculitis, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 69**] on
[**2123-6-26**] after you experienced fevers and hypotension. You
were initially treated and monitored in the medical intensive
care unit. Your condition improved and you were treated and
monitored on a general inpatient medicine floor. Your condition
has improved and you are now being discharged to a
rehabilitation facility in good condition, with stable vital
signs.
.
We have made the following changes to your outpatient medication
regimen:
- CHANGED Metoprolol tartrate 12.5 mg [**Hospital1 **] to Metoprolol tartrate
25 mg [**Hospital1 **]
- CHANGED Pantoprozole 40 mg PO qD to Pantoprozole 40 mg PO BID
- STARTED: Sucralfate 1mg QID (four times daily) for esophagitis
and gastritis
- STOPPED: Aspirin 81 mg qD
.
Please continue to take all other outpatient medications as you
had been prior to this hospitalization.
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2123-7-27**] at 1 PM
With: EMG LABORATORY [**Telephone/Fax (1) 2846**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: THURSDAY [**2123-9-2**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
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"995.92",
"V43.64",
"535.50",
"290.40",
"733.00",
"437.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
10447, 10541
|
4122, 8515
|
286, 351
|
10683, 10683
|
2720, 2720
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|
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|
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|
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|
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|
232, 248
|
379, 1307
|
2734, 3465
|
10698, 10810
|
1329, 1869
|
1885, 2297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,613
| 136,663
|
29639
|
Discharge summary
|
report
|
Admission Date: [**2110-2-23**] Discharge Date: [**2110-3-7**]
Date of Birth: [**2049-3-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Dyspnea, cough, wound dehiscence
Major Surgical or Invasive Procedure:
Esophagoscopy
History of Present Illness:
60yo M s/p transhiatal esophagectomy, J-tube placement, w/
pyloroplasty on [**2110-2-11**] p/w dyspnea, cough and wound dehiscence
on [**2110-2-23**]. Symptoms of dyspnea began in AM and lasted ~20min
each episode. He also has the top portion of L neck incision
open with pain around the site with yellowish-green discharge.
He denied any fever/chills/N/V, has been passing flatus and
normal BMs.
Past Medical History:
GERD, hypertension, and orally controlled diabetes
Social History:
He works as an electrician and has a remote 20-pack-year smoking
history. He
quit drinking one year ago, but drank a 6-pack of beer per week
prior to that.
Family History:
Noncontributory
Physical Exam:
T: 98.8/98.8 HR: 90 BP: 154/92 RR: 20 O2: 99%RA
Gen: NAD
Neck: L neck incision open, clean, with persistent but markedly
decreased discharge, no erythema, no fluctuance, no edema, no
crepitus
Heart: RRR
Lungs: CTAB
Abd: J-tube intact, soft, NT
Extr: no peripheral edema, NT
Pertinent Results:
[**2110-2-23**] WBC-13.9* RBC-3.69* Hgb-11.0* Hct-32.3* Plt Ct-638*#
[**2110-2-25**] WBC-9.1 RBC-3.25* Hgb-9.4* Hct-28.9* Plt Ct-586*
[**2110-3-5**] WBC-7.2 RBC-3.61* Hgb-10.4* Hct-31.4* Plt Ct-532*
[**2110-2-23**] Neuts-92.3* Bands-0 Lymphs-5.2* Monos-1.6* Eos-0.6
Baso-0.3
[**2110-2-23**] Plt Smr-HIGH Plt Ct-638*#
[**2110-3-5**] Plt Ct-532*
[**2110-2-23**] Glucose-203* UreaN-18 Creat-0.8 Na-135 K-5.1 Cl-100
HCO3-26 [**2110-3-5**] Glucose-162* UreaN-14 Creat-0.8 Na-136 K-4.3
Cl-104 HCO3-26 [**2110-3-5**] Calcium-8.8 Phos-3.1 Mg-2.4
[**2110-2-23**] Lactate-2.4*
[**2110-2-23**] URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018
[**2110-2-23**] URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG
Ketone-NEG Bilirub-SM Urobiln-1 pH-7.0 Leuks-NEG
[**2110-2-23**] URINE RBC-0-2 WBC-[**2-3**] Bacteri-FEW Yeast-NONE Epi-0
.
[**2110-2-23**] 5:01 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2110-2-25**]**
URINE CULTURE (Final [**2110-2-25**]): <10,000 organisms/ml.
[**2110-2-23**] 4:55 pm BLOOD CULTURE #2.
**FINAL REPORT [**2110-3-1**]**
AEROBIC BOTTLE (Final [**2110-3-1**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2110-3-1**]): NO GROWTH.
.
RADIOLOGY Final Report
[**2110-2-23**] 10:27 PM CHEST (PORTABLE AP)
Reason: R/O ptx
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p s/p esophagectomy, [**Last Name (un) 1236**]. leak, s/p bedside
debridement.
REASON FOR THIS EXAMINATION:
R/O ptx
REASON FOR EXAM: Rule out pneumothorax, patient post
esophagectomy, anastomosis leak s/p bedside debridement.
Comparison is made with prior study performed 5 hours before.
Cardiomediastinal contour is unchanged with mild possibility
mediastinal widening. There is a small lower lobe atelectasis.
Small bilateral pleural effusion have increased in the left
side, given horizontal straight contour in the left CP angle,
this is suggestive of a small air fluid level consistent with
small pneumothorax. There has been interval decrease in
subcutaneous emphysema in the left side of the neck.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: MON [**2110-2-24**] 10:32 AM
.
CT PELVIS W/CONTRAST [**2110-2-23**] 6:08 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: PLEASE EVAL. FROM MANDIBULAR ANGLE DOWN. Eval.
esophageal an
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with esophageal ca s/p transhiatal
esophagectomy, now with wound dehiscence
REASON FOR THIS EXAMINATION:
PLEASE EVAL. FROM MANDIBULAR ANGLE DOWN. Eval. esophageal
anastomosis.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 60-year-old man with esophageal carcinoma status
post transhiatal esophagectomy with gastroesophageal
anastomosis. Presenting with wound dehiscence.
COMPARISON: Preoperative CT torso of [**2110-1-30**].
TECHNIQUE: MDCT axial images of the chest, abdomen, and pelvis
were obtained following administration of 130 cc of Optiray
intravenously. Coronal and sagittal reformatted images were
obtained.
CT CHEST WITH INTRAVENOUS CONTRAST: There is extensive air and
soft tissue stranding within the soft tissues of the neck. At
the area of anastomosis, at the level of T1-2 there is a fluid
collection with gas bubbles, consistent with anastomotic leak.
There is a simple fluid collection at the level of hiatus,
without enhancing wall, measuring approximately 5 x 4.8 x 3.7
cm. This could represent a postoperative fluid collection or
sequelae of perforation tracking down the mediastinum. There are
trace bilateral pleural effusions, right greater than left, with
adjacent compressive atelectasis bilateral, lungs are otherwise
clear. There are coronary artery calcifications.
There are multiple small subcentimeter lymphatic nodes noted in
the mediastinum.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder,
adrenal glands, pancreas are unremarkable. Gallbladder is
without stones. There is no intra- or extra-hepatic biliary
ductal dilatation. There is an extensive stranding and marked
edema of omentum and transverse mesocolon, that could still be
consistent with postoperative state. The J-tube is in place.
There are aortic vascular calcifications. Kidneys enhance
equally and excrete contrast normally.
There is no pathologically enlarged retroperitoneal or
mesenteric lymphatic nodes.
CT PELVIS WITH CONTRAST: The urinary bladder, distal ureters,
seminal vesicles, prostate, rectum are unremarkable. There is
extensive diverticulosis of the sigmoid colon, without evidence
of acute diverticulitis.
BONE WINDOWS: Demonstrate no lytic or sclerotic lesions.
IMPRESSION:
1. Upper mediastinal air and fluid collection, consistent with
anastomotic leak at the level of the esophagogastric anastomosis
at the level of T1-T2.
2. Larger fluid collection with thin wall at the level of the
hiatus along the posterior gastric wall. No definite signs that
this is infected though infection cannot be excluded.
3. Extensive subcutaneous emphysema and soft tissue fat
stranding, consistent with wound dehiscence.
4. Interval development of bilateral small pleural effusions,
right greater than left.
5. Extensive atherosclerosis of the abdominal aorta, extending
into the iliac arteries bilaterally.
6. Diverticulosis without evidence of acute diverticulitis.
Findings were discussed with Dr. [**Last Name (STitle) 71050**] at 7:00 p.m. on [**2-23**], [**2109**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2110-2-24**] 10:15 PM
.
Brief Hospital Course:
Mr. [**Known lastname 71037**] who was s/p transhiatal esophagectomy POD#12 was
re-admitted to the thoracic surgery service on [**2110-2-23**] with
dyspnea, cough and dehiscence of esophagogastric anastomosis
seen on CT scan. He was admitted to the CSRU and was febrile to
102.9F and was started on Vancomycin, cipro, flagyl and
fluconazole. He was strictly NPO and a Foley catheter was
placed for close monitoring of renal function. His neck wound
was debrided at bedside using sterile scissors and forceps,
yielding moderate amount of yellow fluid along w/ serosanguinous
discharge and was then packed with sterile kerlix. His
temperature curve began to decline and he was transferred to the
floor in stable condition on [**2110-2-24**]. Frequent dressing changes
(~every 2-3 hours) with sterile packing the neck wound were
performed (initially w/ sterile gauze and then w/ iodoform gauze
as wound size decreased).
With the nutrition service following, his tube feeds were
started on [**2110-2-26**] w/ replete w/ fiber and was advanced slowly
to a goal of 75cc/hr via J-tube. A PICC line was placed on
[**2110-2-26**] by IR for continued antiobiotic administration. His WBC
continued to trend down and was within normal limits after
[**2110-2-24**] and he remained afebrile throughout the remainder of his
hospital stay. Given these data, along with negative blood and
urine cultures, his antibiotics were discontinued on [**2110-3-2**].
His PICC line was eventually removed prior to discharge.
An EGD was performed on [**2110-3-4**] (POD#21), which demonstrated a
15-20% circumferential dehiscence/leak at esophagogastric
anastamosis at 22cm. It was decided that no stent would be
placed at this time. Throughout the hospital course, he was
ambulatory and in no distress. He and his wife were taught how
to perform the dressing/packing changes and was eventually
discharged home on POD#24 with continued tube feeds, NPO w/
medications via J-tube and w/ VNA services.
Medications on Admission:
1. Replete/Fiber Liquid Sig: Eight (8) cans PO once a day:
75 cc/hour continuous.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. regular insulin
6. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for dysuria for 3 days.
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Discharge Medications:
1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day:
Crush VERY FINELY and dissolve in 50cc of warm water then
instill via feeding tube then flush with 50cc of water.
Disp:*60 Tablet(s)* Refills:*2*
2. Ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q6H (every 6 hours) as needed for pain.
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day: give via feeding tube.
Disp:*30 doses* Refills:*2*
4. regular insulin
check your finger stick every 6 hours and dose yuor insulin per
the sliding scale provided.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**] [**Hospital1 487**]
Discharge Diagnosis:
Esophageal anastomotic leak after esophagectomy
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you have increased or
foul smellling drainage from your neck incision, fever, chills,
chest pain, shortness of breath.
Do eat anything by mouth
Crush your lopressor(metorolol) VERY FINELY and dissolve
completely in warm water then administer via feeding tube. Flush
with 50cc of water immediately after instilling any medication.
If your feeding tube sutures become loose, call the office
[**Telephone/Fax (1) 170**]. If your feeding tube falls out, save the tube,
call the office immediately and we will direct you to your
nearest emergency room or come to the office and have the tube
replaced.
Please change your neck dressing every 4-6 hours with the
iodoform packing and sterile gauze.
Followup Instructions:
Please call Dr.[**Doctor Last Name 4738**] office at for [**Telephone/Fax (1) 170**] for a follow
up appointment.
|
[
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"998.59",
"401.9",
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"998.81",
"530.81",
"V10.03",
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"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"86.22",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10465, 10535
|
7252, 9237
|
353, 369
|
10627, 10634
|
1392, 2720
|
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|
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4062, 7229
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397, 797
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819, 871
|
887, 1046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,270
| 146,196
|
47899
|
Discharge summary
|
report
|
Admission Date: [**2171-11-3**] Discharge Date: [**2171-11-9**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
pedal edema
Major Surgical or Invasive Procedure:
1. Colonoscopy - [**2171-11-7**]
2. EGD - [**2171-11-8**]
History of Present Illness:
Ms. [**Known lastname 83312**] is an 82 yo female with MMP including DM with
triopathy, ESRD on HD since [**2167**], CAD s/p MI X2, RCA stent, HTN,
Rectal cancer, noted on excisional biopsy of a polyp in [**2163**],
h/o CVA [**8-7**] while on asa/plavix, now on coumadin; h/o PVD s/p
b/l fem [**Doctor Last Name **] and L fem-tib bypass, CHF(EF of 40%) who presents
with 2 day h/o increasing LE swelling. Ms. [**Known lastname 83312**] notes that
she had dialysis on Fri [**11-1**] which was terminated 30 minutes
early due to L arm pain (? dialysis needle hit ulnar nerve per
daughter). ALthough h/o b/l pedal edema (R chronically>L), she
notes inc swelling after eating can of sardines yesterday. She
reports h/o difficult fluid balance, with recent admit to ICU
with flash pulmonary edema requiring emergency dialysis which
also p/w similar symptoms. She is compliant with 29cc fluid
restriction/day. Dry weight~80 kg and she notes 3.5 lb weight
gain over past 3 days. c/o pain in R hand which started during
dialysis friday.- very sensitive and swollen. No R
distal/proximal arm pain. She currently denies SOB/CP/leg
pain?abd pain. no n/v/diarrhea/constipation. no dark/tarry
stools or change in stool diameter. She does report occ. BRB on
toilet paper [**2-4**] hemorrhoids. + chronic lightheadedness,
especially after dialysis without recent change. +fatigue -
chronic problem.
In [**Name2 (NI) **], hct down from 38 ([**10-8**])to 28.6, and 29 on repeat. Guiaic
positive with dark brown stool. NGlavage negative.
Hemodynamically stable. No recent falls/trips. EKG without
changes and CXR actually with improvement of CHF). Sating 100%RA
in ED.
Last colonscopy in [**2167**] - 1 polyp removed and 3 others bx -
benign per patient. No recent colonoscopy.
Morning of transfer to floor, Ms. [**Known lastname 83312**] had a sudden episode
of resp distress with sats dropping down to 40%, so a code was
called. During the code, she had a pulse and blood pressure;
however she was unresponsive and hypoxic with an ABG of
7.08/91/146.
*
In addition, during the code there was a question of poor RUE
movement. Neurology was called and a CT of the head was
obtained once the pt was stable which was negative. Once
transferred to the MICU, the patient was moving all extremities
equally. Neurology felt that the patient's short duration
episode
*
In the ICU the patient remained intubated. A CXR was notable
for new patchy opacity at the right base, so was started on
levo/flagyl. She also underwent HD on [**11-3**], at which time 2
liters were removed and 2 units of RBCs were transfused. On
[**11-4**], UF by dialysis team of 2.0 L. After approximately 24
hours, at 10:10 on [**11-4**], the patient was extubated without
complications and sent back to the floor.
*
Reapeat CXR was done on morning of [**11-5**]. Currently, the patient
reports feeling relatively well. She reports that her breathing
is now improved from the time of admission. She denies CP/SOB,
palpitations, abdominal pain, diarrhea, or constipation. She
notes decreased swelling of LE bilat(R chronically more swollen
than left) and also decrease swelling of LUE, although still
with parasthesias.
Past Medical History:
1. End-stage renal disease, on hemodialysis since [**2167**].
2. Coronary artery disease, status post right coronary artery
stent in [**8-6**] with thrombus, in-stent restenosis in [**10-6**] elevation MI.
3. Congestive heart failure with an ejection fraction of 40%, +1
mitral regurgitation.
4. Hypertension.
5. Type 2 diabetes complicated by nephropathy, neuropathy and
retinopathy status post laser photocoagulation.
6. Depression.
7. Hyperlipidemia.
8. History of transient ischemic attack 15 years ago with
slurred speech and unsteady gait per the patient.
9. Glaucoma.
10. Cataracts.
11. Peripheral vascular disease, status post bilateral
femoral-popliteal and left femoral-tibial bypass.
12. Cervical spondylosis with myelopathy status post anterior
cervical diskectomies infusion C3-6 complicated by postoperative
dysphagia.
13. H/o rectal CA in [**2163**] s/p poly removal.Last colonoscopy in
[**2167**] with 1 polyp removal, 3 others bx
Social History:
Nonsmoker, occasional alcohol use(wine with dinner). She lives
with her husband, who unfortunately was just brought to ED 2
days ago. Daughters very involved in her care.
Family History:
nc
Physical Exam:
On transfer to floor on [**11-5**]:
T: 98 BP: 100/48 P: 81 RR: 20 O2: 94%RA
BG: 127
GEN: Well appearing eldery female, sitting up in chair, speaking
in fluent sentences, no dysarthria, NAD.
HEENT: PERRL OD, surgical pupil OS, EOMI bilaterally, OP clear,
MMM
NECK: supple, no cervical LAD, no JVD
CV: RRR, + systolic murmur loudest @ RUSB/LUSB, no R/G
RESP: breathing comfortably, no inc WOB, CTA bilat with decrease
breath sounds at b/l bases
ABD: NABS, soft, NT, ND, no masses, no organomegaly
EXT: b/l LE edema to the knees(R>L), improved since admission.
Baseline per pt.
Improved swelling of RUE, + parasthesia; LUE - no swelling, nml
sensation
NEURO: A&OX3, responding appropriately, remembers episodes
leading to acute disress, following commands, CN II-XII intact
bilaterally, 5/5 strength throughout, sensation to light touch
intact - with +parasthesia on R distal UE.
Pertinent Results:
[**2171-11-3**] 10:48PM CK(CPK)-216*
[**2171-11-3**] 10:48PM CK-MB-11* MB INDX-5.1 cTropnT-0.40*
[**2171-11-3**] 10:42PM HCT-31.5*
[**2171-11-3**] 08:16PM TYPE-ART TEMP-36.6 RATES-14/19 TIDAL VOL-600
PEEP-5 O2-100 PO2-499* PCO2-33* PH-7.53* TOTAL CO2-28 BASE XS-5
AADO2-196 REQ O2-41 INTUBATED-INTUBATED VENT-CONTROLLED
[**2171-11-3**] 08:16PM LACTATE-1.0
[**2171-11-3**] 08:16PM LACTATE-1.0
[**2171-11-3**] 08:16PM O2 SAT-97
[**2171-11-3**] 04:30PM GLUCOSE-119* UREA N-97* CREAT-7.3* SODIUM-141
POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-25 ANION GAP-25*
[**2171-11-3**] 04:30PM CK(CPK)-204*
[**2171-11-3**] 04:30PM CK-MB-11* MB INDX-5.4 cTropnT-0.30*
[**2171-11-3**] 04:30PM CALCIUM-10.2 PHOSPHATE-5.5* MAGNESIUM-2.6
[**2171-11-3**] 04:30PM PLT COUNT-308
[**2171-11-3**] 04:30PM PT-19.1* PTT-29.0 INR(PT)-2.3
[**2171-11-3**] 01:23PM freeCa-1.38*
[**2171-11-3**] 11:23AM HCT-26.4*
[**2171-11-3**] 05:20AM GLUCOSE-98 UREA N-88* CREAT-6.4* SODIUM-140
POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-25 ANION GAP-25*
[**2171-11-3**] 05:20AM PT-20.0* PTT-33.3 INR(PT)-2.5
[**2171-11-3**] 02:57AM HCT-29.3*
[**2171-11-2**] 11:24PM GLUCOSE-189* UREA N-83* CREAT-6.2* SODIUM-142
POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-26 ANION GAP-24*
[**2171-11-2**] 11:24PM CK(CPK)-59
[**2171-11-2**] 11:24PM cTropnT-0.23*
[**2171-11-2**] 11:24PM CALCIUM-11.1* PHOSPHATE-5.1* MAGNESIUM-2.6
[**2171-11-2**] 11:24PM WBC-6.6 RBC-2.85* HGB-9.0*# HCT-28.6*#
MCV-101* MCH-31.7 MCHC-31.5 RDW-16.1*
[**2171-11-2**] 11:24PM NEUTS-60.3 LYMPHS-27.7 MONOS-7.5 EOS-3.8
BASOS-0.7
[**2171-11-2**] 11:24PM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-2+
[**2171-11-2**] 11:24PM PLT COUNT-331#
[**2171-11-2**] 11:24PM PT-18.6* PTT-29.8 INR(PT)-2.2
Brief Hospital Course:
A/P:
82 yo W w/ h/o CVA, ESRD, DMII, CHF, rectal ca admitted w/
increased pedal edema, G+ stool, sent to the MICU after
admission w/ respiratory arrest and is now s/p intubation. She
is now extubated, doing well, and be sent back to the floor.
*
1) Respiratory failure - On admission, Mrs. [**Known lastname 83312**] was
breathing comfortably with no complaints of SOB. On morning of
admission (as per HPI) she experienced acute SOB-->respiratory
distress. This was thought to be [**2-4**] to flash pulmonary edema
vs. mucus plug vs. PNA. Given h/o noncompliant diet(s/p
sardines) and incomplete dialysis 2 days prior to admit, flash
pulm edema seems most likely diagnosis. 2 L fluid taken off at
emergent HD upon transfer to MICU with symptomatic improvement.
Also started patient on levo/flagyl [**11-3**] for ? PNA - however,
f/u CXR showed improvement and was thought to be more consistent
with atelectasis. After extubation, patient was stable from
respiratory standpoint, with no further SOB or need for
supplemental oxygen.
*
2) ESRD - [**2-4**] DMII; aneuric; admitted with volume overload
secondary to dietary noncompliance(ate can of sardines [**11-2**]).
s/p emergent dialysis on [**11-3**](with 2 units of RBCs). She was
then continued on her outpatient M/W/F dialysis schedule and
followed by renal team without further complications.
*
3) CAD - demand ischemia w/ trop elevated during this admission
(to 0.4); likely high in the setting of renal failure. BB or
ace-I were held while she was in the ICU and initially on
tranfser to floor because low BP; however, BP normalized and
medications were restarted at outpatient doses. Aspirin and
plavix were continued throughout hospitalization and on
discharge. She is to follow up with Dr. [**Last Name (STitle) **] on discharge for
further evaluation/treatment of cardiac disease.
*
4) NEURO - On admission, Mrs [**Known lastname 83312**] did not demonstrate any
residual defects from her previous strokes. However, at onset of
respiratory distress there was concern for ? stroke as patient
did not appear to be moving L side of body. Head CT negative and
after intubation, she was alert and able to move all 4
extremities. Neuro evaluated patient and felt that the episode
was likely due to her tenuous cardiorespiratory/fluid status and
not CVA.
*
5) GIB - G+ stool on admission. Patient was anticoagulated on
admission (coumadin started 8 weeks ago after pt had stroke on
asa/plavix). INR 2.5 on admission). Hct had dropped 10 points
since earlier in the month. Case discussed with GI team who
planned to get EGD/colnoscopy when Mrs. [**Known lastname 83312**] was stabalized
on floor. Of note, she has a hx of rectal cancer, noted on
excisional biopsy. She received to units of blood during
emergency dialysis after episode of respiratory distress, which
increased hct from 28.5 ->33.2. Hct was stable throughout the
rest of admission with no further transfusions required.
Coumadin was held during admission for GI procedures and there
was discussion with PCP as to whether to continue coumadin on
d/c given acute drop in HCT. However, given risk of repeat CVA,
her coumadin was restarted on d/c at 2.5mg each evening. PPI was
continued during admission and on d/c. Colonoscopy was performed
on [**11-7**] with polypectomy (adenoma per path report) diverticulae,
but no other gross abnormalities. Bx of antrum of stomach on
EGD on [**11-8**] revealed chronic inactive gastritis. No evidence of
active bleeding per GI studies. Hematocrit was stabalized and
patient was discharged with close f/u with Dr. [**Last Name (STitle) 665**] to trend
cbc.
*
6) L arm swelling: Per patient, there was some difficulty with
palcement of dialysis needle on Fri [**11-1**] with ? nerve damage.
She c/o continued swelling, numbness, tingling, and inability to
use L hand. She had discussed with outpt nephrologist last
friday - who told her it was likely nerve damage. Seen by OT
who recommended wrist splint which pt refused to wear. U/S on
[**11-4**] without evidence of DVT [**11-4**]. Her fistula remained patent
with no needle placement issues during admission. Likely [**2-4**] to
nerve damage, but considered sympathetic nerve dystrophy
syndrome. Symptomatic improvement during admission and she is to
f/u with nephrologist and report and new/worsening symptoms.
*
7) OPHTHALMOLOGIC ISSUES: The patient with a history of glaucoma
and cataracts. The patient was continued on her glaucoma
eyedrops (per her home regimen).
*
8) Full code
*
10) Communication - daughters(very involved in patient care),
granddaughter
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
2. Vitamin E 400 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Sertraline HCl 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO QHD
(each hemodialysis): Please take only on dialysis days and prior
to dialysis.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop
Ophthalmic Q8H (every 8 hours).
11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] ().
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
15. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*200 Tablet(s)* Refills:*2*
16. insulin
Please continue to take your 12 units of NPH in the morning and
continue your outpatient sliding scale.
17. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis:
1. Fluid overload resulting in flash pulmonary edema,
respiratory distress, and intubation
2. Acute blood loss
Secondary Diagnosis:
1. End-stage renal disease, on hemodialysis since [**2167**].
2. Coronary artery disease, status post right coronary artery
stent in [**8-6**] with thrombus, in-stent restenosis in [**10-6**] elevation MI.
3. Congestive heart failure with an ejection fraction of 40%, +1
mitral regurgitation.
4. Hypertension.
5. Type 2 diabetes complicated by nephropathy, neuropathy and
retinopathy status post laser photocoagulation.
6. Depression.
7. Hyperlipidemia.
8. History of transient ischemic attack 15 years ago with
slurred speech and unsteady gait per the patient.
9. Glaucoma.
10. Cataracts.
11. Peripheral vascular disease, status post bilateral
femoral-popliteal and left femoral-tibial bypass.
12. Cervical spondylosis with myelopathy status post anterior
cervical diskectomies infusion C3-6 complicated by postoperative
dysphagia.
13. H/o rectal CA in [**2163**] s/p poly removal.Last colonoscopy in
[**2167**] with 1 polyp removal, 3 others bx
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 28 ounces
Please call your PCP or return to the ED IMMEDIATELY if you
develop shortness of breath, chest pain, increase lower
extremity swelling, or other worrisome symptom.
Please take all medications as prescribed.
Please continue with your Monday, Wednesday, Friday dialysis
schedule.
Please do not restart warfarin.
**You have been scheduled for a cardiac stress test on [**11-13**] at 9:50 AM. No food/drink after midnight prior to test.
Please bring list of all medications with you. Plan to be there
for 3 hours. You can reach the lab at [**Telephone/Fax (1) 101075**].
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 23305**] [**Name (STitle) **] Where: CC-2 PODIATRY UNIT
Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2171-12-9**] 2:50
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2172-3-31**]
11:20
Please call Dr.[**Name (NI) 666**] office to schedule follow up
appointment within the next 1-2 weeks.
Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] office to schedule a follow up
cardiology appointment within the next 1-2 weeks.
|
[
"V45.82",
"428.0",
"V10.06",
"V12.59",
"362.01",
"357.2",
"250.60",
"250.50",
"211.3",
"518.81",
"285.1",
"414.01",
"437.9",
"403.91",
"V58.61",
"V45.1",
"365.9",
"535.11",
"518.0",
"424.0",
"311",
"272.4",
"440.20",
"412",
"V15.81",
"250.40",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"00.17",
"99.04",
"39.95",
"45.42",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13966, 14037
|
7392, 11979
|
269, 329
|
15180, 15188
|
5634, 7369
|
15932, 16579
|
4714, 4718
|
12002, 13943
|
14058, 14058
|
15212, 15909
|
4733, 5615
|
218, 231
|
357, 3538
|
14209, 15159
|
14077, 14188
|
3560, 4510
|
4526, 4698
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,722
| 118,311
|
10618
|
Discharge summary
|
report
|
Admission Date: [**2180-11-27**] Discharge Date: [**2180-11-30**]
Date of Birth: [**2114-5-16**] Sex: F
Service: EMERGENCY
Allergies:
Penicillins / Sulfa (Sulfonamides) / Levaquin / Erythromycin
Base / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
PICC placement
Femoral Line Placement
History of Present Illness:
66 yo F with multiple medical problems including CAD, CHF,
cirrhosis (and prior encephalopathy), hx DVT's, aspiration,
chronic lower extremity ulcers w/cellulitis on abx presented
from home with altered mental status. Per husband, her MS had
been worsening gradually over the past 3 days. She was having
cough with some sputum production. She was responsive on the
morning of admission but very lethargic and also had
incontinence. A FSG showed recording of 34 but was corrected to
~150 with administration of juice. However her MS did not
improve with improvement in her FSG.
.
ED: Her BP was around 80's/40's, after 1L -> SBP was >100
(baseline SBP in 90-100). She was DNR/DNI but family was okay
with lines in the ED. A L Fem line was placed as no other access
could be obtained. CXR - ?LLL PNA, left sided effusion. Vascular
[**Doctor First Name **] consulted who did not think that the leg was likley source
of sepsis. Head CT showed sinusitis. She got vanc/[**Last Name (un) 2830**].
.
[**Hospital Unit Name 153**]: upon arrival to ICU, I had extensive discussion with the
husband who is her HCP. [**Name (NI) **] note, patient's functional status
had been gradually declining over the last 7 months. The patient
and family were frustrated with the fact that the patient had
been at home for only 2 weeks of the last 7 months and she had a
poor quality of life. The husband did not want any aggressive
measures which included no NG tube, no pressors and the goal was
to make her comfortable and to try only IV medications if
required.
.
Past Medical History:
1.Type I Diabetes Mellitus--+nephropathy, no A1C available
2.Coronary Artery Disease
3.Congestive Heart Failure--EF 30%, 2+ TR, mod PA HTN per echo
in [**2180-7-19**]
4.CKD stage III with baseline Cr 1.3-1.9
5.Hyperlipidemia
6.Gastritis
7.Venous Stasis
8.Allergic Rhinitis
9.Osteomyelitis
10.RLE wound--after trauma, s/p graft
11.Cirrhosis--thought to be due to NASH; on lactulose, ursodiol
and rifamixin in the past
12.hepatic encephalopathy and ?seizures on keppra .
Social History:
Lives with husband, who is primary caregiver. [**Name (NI) **] lives next
door and he and wife wife help with her care. Has VNA services.
Needs help with ADLs. Quit smoking in [**2154**]. h/o alcohol abuse.
Can walk up four steps with assistance.
Family History:
non-contributory
Physical Exam:
ICU admission vitals: 96.7, 87, 103/46, 100/4L
Gen: extremly lethargic, open eyes to commands but no
verbalization
HEENT: PEERL, EOMI, anicteric sclera, dry MM
Chest: clear anteriorly, crackles bilaterally at the bases
CV: distant heart sound, RRR, nl S1, S2, II/VI SEM
Abd: Distended nontedner, no rebound or guarding, edematous.
Unable to appreciate h/s.
Neuro: extremely lethargic, opens eyes to commands
Skin: diffuse bilateral erythema, more pronounced in lower ext,
has many areas of torn skin and weeping lesions with ulcerations
Pertinent Results:
[**2180-11-27**] WBC-12.0*# RBC-4.90 Hgb-12.4 Hct-40.1 MCV-82 MCH-25.2*
MCHC-30.8* RDW-19.9* Plt Ct-115* Neuts-81* Bands-9* Lymphs-5*
Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
PT-36.7* PTT-54.0* INR(PT)-3.9*
Glucose-129* UreaN-102* Creat-2.7* Na-133 K-3.5 Cl-86* HCO3-30
AnGap-21*
ALT-24 AST-43* CK(CPK)-42 AlkPhos-343* Amylase-44 TotBili-1.8*
Lipase-13
cTropnT-0.05* Albumin-2.9* Calcium-9.4 Phos-6.3*# Mg-2.4
Cortsol-40.7*
CRP-52.7*
[**2180-11-29**] 08:14AM Vanco-26.3*
[**2180-11-27**] 03:27PM Type-ART pO2-467* pCO2-47* pH-7.45 calTCO2-34*
Base XS-8 Intubat-NOT INTUBA
[**2180-11-27**] Lactate-3.8*
[**2180-11-27**] 03:27PM O2 Sat-100
CT HEAD W/O CONTRAST [**2180-11-27**] 2:12 PM
CT HEAD W/O CONTRAST
Reason: Please evaluate for intracranial hemorrhage in this
patient
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with multiple medical problems presenting with
altered mental status.
REASON FOR THIS EXAMINATION:
Please evaluate for intracranial hemorrhage in this patient on
coumadin or any other explanation for her altered mental status.
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 66-year-old female with multiple medical problems
presenting with altered mental status.
COMPARISON: CT head of [**2180-8-8**].
TECHNIQUE: Contiguous axial images through the brain were
acquired without IV contrast administration.
FINDINGS: No evidence of acute hemorrhage, edema, mass, mass
effect, or large vascular territory infarction is present.
Ventricular configuration is not changed. Vascular
calcifications are noted in the intracranial vertebral arteries
and the internal carotid arteries. The patient is status post
left cataract surgery. Compared to [**2180-8-8**], there is new
opacification of some ethmoid air cells and mucosal thickening
in the left maxillary sinus. The remainder of the visualized
paranasal sinuses and the mastoid air cells are well aerated. No
fracture is present.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Left maxillary and ethmoid sinus disease.
CHEST (PORTABLE AP) [**2180-11-27**] 10:53 AM
CHEST (PORTABLE AP)
Reason: cardiopulmonary process
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with rhonchi
REASON FOR THIS EXAMINATION:
cardiopulmonary process
HISTORY: 66-year-old female with rhonchi.
COMPARISON: A series of chest radiographs from [**2180-10-19**] through
[**2180-11-4**].
PORTABLE SUPINE CHEST RADIOGRAPH: Since [**2180-11-4**], there has been
interval removal of a right PICC and Dobbhoff tube. There is
likely some increase in the moderate-to-large left pleural
effusion compared to the study performed nearly a month prior.
The left retrocardiac opacity persists, likely representing
pleural effusion, associated atelectasis, although underlying
pneumonia cannot be excluded. The cardiac silhouette is obscured
on the left by the pleural effusion and atelectasis; however,
there is likely stable cardiomegaly. Prominence of the pulmonary
vessels is consistent with pulmonary venous congestion and
indistinctness of the pulmonary vessels likely represents
interstitial edema. No focal airspace opacities are seen in the
right lung or left upper lung. The bony thorax appears intact.
IMPRESSION:
Vascular congestion with interstitial edema, overall unchanged
from [**2180-11-4**]. There may be some increase in the left pleural
effusion which is now likely moderate to large in size, with
associated atelectasis.
CHEST (PORTABLE AP) [**2180-11-29**] 11:29 AM
CHEST (PORTABLE AP)
Reason: interval change, worsening effusion, chf and/or pna
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with pna, inc SOB this am s/p volume
resuscitation last night
REASON FOR THIS EXAMINATION:
interval change, worsening effusion, chf and/or pna
HISTORY: Shortness of breath.
FINDINGS: In comparison with the study of [**11-27**], the degree of
vascular congestion has substantially decreased, though there is
still evidence of elevated pulmonary venous pressure and a large
left effusion. Right subclavian catheter extends to the lower
portion of the SVC.
Brief Hospital Course:
66 F with NASH cirrhosis, seizure dz on keppra, DVT on coumadin,
chronic LE ulceration now with altered mental status in setting
of multiple medical problems including new pneumonia and sepsis.
# Sepsis [**1-21**] wound infections vs. PNA: Transiently hypotensive
responded to 1L NS in ED; elevated white count with bandemia.
Hypotensive on night of admissionwith worsening UOP to <10cc/hr
which trailed off to anuria. Treated with antibiotics and gentle
fluid hydration without improvement in sepsis. Family did not
want any life sustaining measures including the use of pressor
agents.
.
# Acute oliguric on chronic renal failure: baseline 1.8 until
[**10-19**], then increased to 2.3-2.5. Increased further to 2.7 after
IVF boluses. FENA suggested prerenal failure initially, then
urine found to have muddy brown casts suggesting ATN. Dialysis
was not in accordance with the wishes of the family or patient.
.
# ALtered Mental Status/Delirium: Differential included hepatic
encephalopathy, SBP, sepsis, seizures, keppra (in setting of
ARF), cardiogenic shock. HCP did not want any measures including
NGT, invasive procedures etc. In this context, home regimen of
keppra, lactulose, and rifaximin was continued as patient
tolerated po.
.
# Right Lower Extremity Ulceration: Started on Vanc/Meropenem
per vascular during last admission and legs improved rapidly.
Vascular did not think that the leg was the likely source of
sepsis with no open ulcers there in the ED on this admission.
Conservative management with wound care continued during this
admission.
.
# Acute on chronic systolic heart failure: Pt with worsening wet
cough and rales on exam after 6L positive on [**11-28**] to maintain
SBP and UOP and with cold extremities concerning for cardiogenic
shock picture. Family was offerred trial of dobutamine which was
not accepted.
.
# Diabetes: Long-standing, covered with insulin sliding scale.
.
# Anticoagulation: on coumadin for DVT, held on admission in
setting of supratherapeutic INR. INR reversed for PICC placement
[**11-29**].
.
# Access: Right Femoral line placed in ED. In discussion with
family, PICC was obtained for cleaner access.
.
# PPX: supratherapeutic INR
.
# Code Status: DNR/DNI with goal of aggressive measures but no
NG tube on admission, changed to CMO on [**11-29**] in the setting of
new pneumonia, sepsis and acute renal failure. Patient remained
hypotensive on the evening of [**11-29**] and became bradycardic and
expired on [**2180-11-30**] at 3:45PM. Family, PCP, [**Name10 (NameIs) **] admitting
notified.
Medications on Admission:
1. Carvedilol 3.125 mg Tablet QD
2. White Petrolatum-Mineral Oil QHS
3. Camphor-Menthol 0.5-0.5 % Lotion TID
4. Travoprost 0.004 % Drops Sig: hs
5. B Complex-Vitamin C-Folic Acid 1 mg QD
6. Acetaminophen 325 mg Tablet 2 PO Q6H
7. Levetiracetam 500 mg PO BID
8. Rifaximin 400 mg TID
9. Bumetanide 6 mg [**Hospital1 **]
10. Miconazole Nitrate 2 % Powder [**Hospital1 **]
11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
12. Mupirocin Calcium 2 % Cream (1) Appl Topical TID
13. Lactulose 30 ml [**Hospital1 **]
14. Nystatin 100,000 unit/g Cream
15. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment [**Hospital1 **]
16. Lantus 3units QHS
17. Insulin SS
18. Warfarin 1 mg Tablet QHS
19. Prilosec 20 mg QD
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Pneumonia
Acute Renal Failure
Diabetes mellitus
Venous statis ulcers
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
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icd9cm
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[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,676
| 182,641
|
52110
|
Discharge summary
|
report
|
Admission Date: [**2138-5-26**] Discharge Date: [**2138-6-1**]
Service: MEDICINE
Allergies:
Penicillins / Aspirin / A.C.E Inhibitors
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
fall, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History obtained from chart and daughter. Ms. [**Known lastname **] is a [**Age over 90 **] yo
F with CKD, diabetes, HTN, atrial thrombus on coumadin who
presented on [**5-26**] with altered mental status since [**5-25**].
According to the daughter, she noticed that the patient was
acting stangely, mumbling words and referencing things that were
not there. She supposedly had a bad dream, fell, and hit her
head on the bed post. She had been more weak recently, requiring
more help with her ADLs. She is not normal at baseline. At that
time, she denied chest pain, SOB, HA, dizziness, abdominal pain,
but had mild pain in her shoulders. She was recently diagnosed
with spinal stenosis and had been undergoing PT/OT. Per the
daughter, patient recently started tramadol on [**5-19**].
.
In the ED, BP 174/134, HR 77, Rr 22, 98%RA. CT head and C spine
without bleed or fx. CXR unremarkable. She was admitted to the
floor for further work up.
.
On the floor, she became agitated and tried to get out of bed
mult times. She was given zyprexa 5mg x1. During the course of
the day she became increasingly more somnolent, not arousable to
stimuli. Her exam was otherwise non-focal. AVSS with pt 97%RA.
ABG 7.28/79/101/39. Pt was placed on BiPAP with little clinical
improvement. Repeat ABG 7.37/66/59. Pt was transferred to the
MICU for further care.
Past Medical History:
-Chronic renal insuffiency baseline cr 1.4.
-Diabetes with neuropathy
-Left atrial thrombus on warfarin dx [**2136**], not seen on repeat
ECHO in [**2137**]
-Dyslipidemia
-Polymotor sensory deficit
-Spinal stenosis
-Hypertension
-Cardiomyopathy (Echo: [**9-/2137**], EF55%, Mild mitral regurgitation,
-Minimal aortic stenosis, Moderate pulmonary hypertension)
-Peptic ulcer disease
-GERD
-Hypothyroidism/goiter
-Chronic constipation due to puborectalis dysfunction
-Arthritis
-Glaucoma
-Legally blind in both eyes
-Bilateral cataracts s/p surgery
-s/p TAH
-s/p cholecystectomy
-peripheral [**Year (4 digits) 1106**] disease history:
-[**7-20**]: non-healing left great toe ulcer
-[**2135-6-28**]: right great toe ulcer excision, bone biopsy
-[**2135-6-22**]: right above-knee popliteal to DP bypass with NRSVG & R
[**Doctor Last Name **] aneurysm ligation for a critically ischemic right foot
-[**2136-5-8**]: right proximal SFA to DP bypass with L NRSVG c/b
dehiscence of RLE incision on POD7, requiring re-suturing
Social History:
In rehab now for physical therapy/occupational therapy for
deconditioning secondary to spinal stenosis. Originally from
[**Location (un) 4708**]. She has 5 children. She denies smoking, alcohol or
drug use.
Family History:
No known history of stroke, mother with diabetes, and nearly all
with hypertension.
Physical Exam:
T98.5, HR74, BP 163/73, RR 23, 92% BiPAP 14/5
General: eyes closed, awakens and mumbles, NAD
HEENT: R eye ecchymoses with opacification of eye, L eye
enucleated
Neck: supple, no LAD
Lungs: Uncooperative, decreased BS, no obvious focal changes
CV: RRR no m/r/g
Abdomen: obese, soft, NT/ND + BS no rebound or guarding
Ext: warm, well perfused, no pitting edema
Neuro: awakens and mumbles, moving all extremities with
preserved strength in all muscle groups. Uncooperative with
Pertinent Results:
Lab studies:
On admission:
[**2138-5-26**] 01:35PM BLOOD WBC-7.4 RBC-4.48 Hgb-12.6 Hct-39.5 MCV-88
MCH-28.0 MCHC-31.8 RDW-14.9 Plt Ct-275
[**2138-5-26**] 01:35PM BLOOD PT-41.2* PTT-39.4* INR(PT)-4.5*
[**2138-5-26**] 01:35PM BLOOD Plt Ct-275
[**2138-5-26**] 01:35PM BLOOD Glucose-137* UreaN-20 Creat-1.4* Na-135
K-3.8 Cl-96 HCO3-33* AnGap-10
[**2138-5-26**] 01:35PM BLOOD CK(CPK)-200*
[**2138-5-26**] 01:35PM BLOOD CK-MB-4
[**2138-5-26**] 01:35PM BLOOD Calcium-8.5 Phos-3.6 Mg-1.7
[**2138-5-26**] 01:56PM BLOOD Glucose-129* K-3.9
.
INR trend:
[**2138-5-28**] 03:30AM BLOOD PT-26.7* PTT-31.1 INR(PT)-2.7*
[**2138-5-30**] 11:00AM BLOOD PT-18.0* INR(PT)-1.6*
[**2138-5-30**] 12:25PM BLOOD PT-16.2* INR(PT)-1.5*
[**2138-5-31**] 05:55AM BLOOD PT-15.1* PTT-26.6 INR(PT)-1.3*
.
[**2138-5-28**] 03:30AM BLOOD ALT-14 AST-21 LD(LDH)-253* AlkPhos-110
TotBili-0.3
[**2138-5-26**] 01:35PM BLOOD Cortsol-11.4
[**2138-5-28**] 03:30AM BLOOD TSH-1.2
[**2138-5-26**] 01:35PM BLOOD TSH-2.9
[**2138-5-26**] 01:35PM BLOOD Free T4-1.3
[**2138-5-28**] 03:30AM BLOOD VitB12-885 Folate-GREATER TH
.
ABG trend:
[**2138-5-27**] 01:52PM Type-ART Temp-36.7 O2 Flow-3 pO2-101 pCO2-79*
pH-7.28*
[**2138-5-27**] 03:28PM Type-ART pO2-59* pCO2-66* pH-7.37 calTCO2-40*
Base XS-9
[**2138-5-28**] 12:51AM Type-ART pO2-36* pCO2-92* pH-7.23* calTCO2-41*
Base XS-6
[**2138-5-28**] 12:58AM Type-ART pO2-148* pCO2-79* pH-7.29* calTCO2-40*
Base XS-8
[**2138-5-28**] 11:59AM Type-ART pO2-117* pCO2-75* pH-7.33* calTCO2-41*
Base XS-10
[**2138-5-28**] 01:57PM Type-ART Temp-37.4 Rates-/14 PEEP-5 pO2-62*
pCO2-59* pH-7.38 calTCO2-36* Base XS-7
.
Micro Data:
[**2138-5-27**] 8:21 pm URINE Source: Catheter.
**FINAL REPORT [**2138-5-28**]**
URINE CULTURE (Final [**2138-5-28**]): NO GROWTH.
.
[**2138-5-28**] 12:00 pm MRSA SCREEN NASAL SWAB.
**FINAL REPORT [**2138-5-30**]**
MRSA SCREEN (Final [**2138-5-30**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
.
Radiographic studies:
CT cspine (wet read): No fracture or malalignment. no
prevertebral soft tissue swelling. Multilevel degeneratvie
change with posterior osteophytes causing mild central canal
stenosis.
.
CT head: diffuse parenchymal atrophy and small [**Last Name (un) 12599**] ischemic
disease, unchanged. no acute intracranial process. soft tissue
swelling seen over the right superior orbit. deformity of the
left globe appears chronic, but correlation history of trauma
recommended.
.
Repeat CT head: No new intracranial hemorrhage or fracture.
.
CXR: No acute processes
.
CT Chest: IMPRESSION: Limited interpretation due to near
expiratory state and motion artifact. No evidence of acute
pulmonary or mediastinal disease. Bilateral dorsal areas of
atelectasis, accompanied by volume loss. No acute infection or
edema.
.
EKG: NSR, LAD, IVCD, non-specific STT changes
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] YO F with h/o atrial thrombus on coumadin,
HTN, CKD, admitted with altered mental status after a fall with
acute decompensation on the floor, transferred to the MICU.
.
Altered Mental Status: Likely multifactorial to unclude
medications (Tramadol recently started) in addition to sedating
medications in a patient with baseline hypercarbia and dementia.
There was no evidence on CT scan to suggest ICH and no exam
findings to suggest stroke. There was no evidence of infection.
Sedating medications were held including tramadol and
gabapentin. She was treated on BIPAP given hypercarbic
respiratory failure. With this treatment her CO2 improved and
her mental status gradually returned to baseline. Geriatrics
consult was called for recommendations regarding polypharmacy as
well as treatment of agitation. Geriatrics was consulted and
had the following specific recommendations which we followed:
- avoid anti-psychotics/sedating meds given hypercarbia
associated with single dose of Zyprexa
- if severely agitated, would recommend 1:1 sitter instead of
meds
- would avoid tramadol and other narcotics if possible
- would increase bowel regimen to ensure BMs daily
- would consider lidoderm patch for back pain
.
In addition, the geriatric team had the following general
recommendations for non-pharmacologic delirium prevention which
we think would be helpful for Ms [**Known lastname **] in her ongoing care:
1) Remove all lines and catheters as soon as possible, esp Foley
2) Avoid sedatives, especially antihistamines and
benzodiazepines
3) Encourage family to be at bedside, with familiar home objects
4) Explore and encourage baseline religious/spiritual coping
mechanisms for illness.
5) Preserve sleep wake cycle by minimizing overnight
interruptions and allowing for stimulation and activity during
the day ie cancelling midnight vitals unless medically indicated
6) OOB for meals if/when eating TID
7) Reorient frequently
8) Increase Bowel regimen to ensure BM at least once every other
day
9) Providing hearing aids and dentures as needed
.
#)Hypercarbic respiratory failure: Appears to be chronic
retainer given elevated bicarbonate with baseline PCO2 likely in
the mid 50's. During acute altered mental status and somnolence
CO2 was elevated into the 90's. This resolved with BIPAP and
holding sedating medication.
.
#) Atrial Thrombus: Seen initially on echocardiogram in [**2136**] for
which anticoagulatin was started. Repeat echo in [**2137**]
demonstrated resolution of thrombus. Given patient refusal of
lab draws and high risk for falls her coumadin was initially
discontinued. However, once her mental status improved and she
was agreeing to lab draws and taking oral medicines, the team
communicated with her Cardiologist Dr [**Last Name (STitle) 171**] was contact[**Name (NI) **] and
he recommended continuing her coumadin unless she has repeated
falls that put her at too high of a risk to continue
anticoagulaion. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was notified of these changes.
INR was elevated to 4.5 on admission and initially held. It
was restarted and was 1.4 on the day of discharge. Her INR
level needs to be monitored and coumadin dose adjusted
appropriately.
.
#) CKD: Baseline 1.4-1.6. Stable during admission.
.
#) Cardiomyopathy: Cont ACE-I, BB, and lasix
.
#) HTN: Elevated bps during admission - increased losartan from
75 to 100mg. Metoprolol and nifedipine were continued.
.
#) Diabetes: Held glipizide while patient in ICU. Re-started on
floor.
.
#) Spinal Stenosis: No obvious neuro deficits
- Tylenol standing, lidoderm patch
.
#) Lipids: Cont statin
.
#) Hypothyoridism: TSH, free T4 wnl.
- Cont levoxyl at current dose
.
#) Glaucoma: Cont drops - when patient admitted, Atropine had
been changed from OS to OU - should only be getting in L eye so
changed prescription back.
.
#) Arthritis: Hold tramadol. Cont Tylenol standing
.
#) FEN: S&S recommendations:
1. Continue baseline diet of thin liquids and ground solids.
2. Pills may be taken whole with thin liquid or puree as
tolerated.
3. 1:1 supervision with all PO.
4. Patient seated upright 90 degrees for all meals.
.
#) Access: PIV
.
#) Ppx: PPI, warfarin, bowel regimen
.
#) Code: DNR/DNI - discussed with family during this admission
as per the ICU team.
Medications on Admission:
1. Omeprazole 20 mg PO DAILY
2. Vitamin D 800 UNIT PO DAILY
3. Losartan Potassium 75 mg PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Senna 1 TAB PO BID:PRN
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Tartrate 100 mg PO BID
8. Gabapentin 300 mg PO TID
9. Acetaminophen 500 mg PO Q6H:PRN
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q 12H
11. Atropine Sulfate Ophth 1% 1 DROP BOTH EYES Q 12H
12. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]
13. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
14. Furosemide 40 mg PO DAILY
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
16. Calcitonin Salmon 200 UNIT NAS DAILY
17. Levothyroxine Sodium 25 mcg PO DAILY
18. NIFEdipine CR 90 mg PO DAILY
19. TraMADOL (Ultram) 50 mg PO TID
20. GlipiZIDE XL 10 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic Q 12H (Every
12 Hours): 1 drop to L eye only [**Hospital1 **].
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily): please alternate nostrils.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
12. Insulin Lispro Subcutaneous
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
15. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): please hold for diarrhea.
19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD (): 12 h/12h off.
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
22. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
altered mental status
Discharge Condition:
good. AAOx3, tolerating POs, vital signs stable. INR 1.4
Discharge Instructions:
You were admitted to the hospital for some confusion following
an incident where you hit your head on the bedpost at your rehab
facility. While you were in the hospital you had worsening
confusion and had to be transported to the ICU for a short stay
because you were not breathing well during these episodes. We
checked labs, had cat scans of your head and chest performed,
and had our neurolgy and gerentology colleagues involved in your
care to help us figure out why you were confused. It seems that
your confusion was likely due to two medications that you were
taking for pain - Gabapentin (Neurontin) and tramadol (Ultram).
Please stop taking these medications. We have recommended
instead that you take tylenol and use lidoderm patches to help
with your neck and back pain.
.
We held your coumadin intially because your level was high, but
we have re-started it now after communicating with your
outpatient cardiologist. Please continue to take this medicine.
Please have your INR rechecked as it is currently
subtherapeutic.
.
Please return to the ED if you develop any of the following
problems: high fever, chills, worsening confusion,
nausea/vomiting and inability to tolerate food or take your
medicines, headache, chest pain, shortness of breath, or any
other symptoms that are concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2138-7-9**] 10:40
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2138-9-15**] 2:10
|
[
"357.2",
"429.89",
"V58.61",
"721.0",
"585.9",
"518.83",
"425.4",
"530.81",
"E936.3",
"995.29",
"349.82",
"250.60",
"403.90",
"E935.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13598, 13669
|
6433, 6660
|
274, 281
|
13735, 13795
|
3535, 3548
|
15154, 15494
|
2939, 3024
|
11648, 13575
|
13690, 13714
|
10826, 11625
|
13819, 15131
|
3039, 3516
|
207, 236
|
309, 1656
|
6042, 6410
|
3562, 5741
|
6675, 10800
|
1678, 2699
|
2715, 2923
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,360
| 194,699
|
52160
|
Discharge summary
|
report
|
Admission Date: [**2153-1-22**] Discharge Date: [**2153-2-3**]
Date of Birth: [**2076-3-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Prozac
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2153-1-22**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM,
SVG to Diag)
History of Present Illness:
76 y/o male with exertional chest pain. Had abnormal ETT and was
then referred for cardiac cath. Cath revealed severe 3 vessel
disease with a 70% left main lesion.
Past Medical History:
Hyperlipidemia, Hypertension, Gastroesophageal Reflux Disease,
Cervical and Lumbar Disc Disease, Pleural thickening d/t
Asbestos exposrure, Benign Prostatic Hypertrophy, Depression,
Sleep Apnea, h/o TIA, s/p AAA repair [**2147**], s/p Appendectomy, s/p
Tonsillectomy, s/p Laminectomy, s/p Bilat. Rotator cuff repairs,
s/p Bilat. knee surgery, s/p Left breast lumpectomy, s/p TURP,
s/p Penile Implant with replacement [**2147**], s/p Bilat. hernia
repair, s/p ankle pin placement
Social History:
Quit in [**2114**]. Social ETOH.
Family History:
Mother with CAD at unkown age
Physical Exam:
VS: 59 22 143/68 5'9" 93kg
General: NAD
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, -Carotid Bruits
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft NT/ND, +BS, healed AAA scar
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2153-1-22**] Echo: PRE-BYPASS: The interatrial septum is aneurysmal.
No atrial septal defect is seen by 2D, color Doppler, or bubble
study. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated with simple
atheroma. The descending thoracic aorta is mildly dilated with
complex (>4mm) atheroma. There are three aortic valve leaflets.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
to at worst mild to moderate (2+) mitral regurgitation is seen.
Pulmonarty vein flow is normal. The mitral annulus is not
dilated. There is a mild partial prolapse of P2. POST-BYPASS:
Pt is [**Name (NI) 107919**], on phenylepherine drip. Preserved biventricular
function. LVEF >55%. Mitral regurtigation is now trace to mild
(1+). Aortic contours are intact. Remaining exam is unchanged.
All findings discussed with surgeons at the time of the exam.
[**1-23**] Echo: Emergency TEE in CSRU for hypotension. No atrial
septal defect is seen by 2D or color Doppler. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is systolic anterior motion ([**Male First Name (un) **]) of the
mitral valve leaflets. This [**Male First Name (un) **] is extremely dynamic. An LVOT
gradient of 50 mm Hg was measured. With vasopressors, this
gradient was seen to improve to near 20 mmHg. There is moderate
(2+)mitral regurgitation associated with this [**Male First Name (un) **]. It is dynamic
as well. The mitral regurgitation jet is eccentric. The
tricuspid valve leaflets are mildly thickened.
[**1-31**] Head CT: 1. No acute intracranial hemorrhage. No fracture.
2. Scattered mastoid air cell opacification on the right.
[**2-1**] CXR: Grossly stable bibasilar atelectasis and small pleural
effusions.
[**2153-1-22**] 01:42PM BLOOD WBC-17.4*# RBC-2.67*# Hgb-9.1*#
Hct-25.6*# MCV-96 MCH-34.0* MCHC-35.4* RDW-14.2 Plt Ct-150
[**2153-1-26**] 02:42AM BLOOD WBC-11.8* RBC-3.17* Hgb-10.5* Hct-29.3*
MCV-92 MCH-33.2* MCHC-36.0* RDW-15.6* Plt Ct-89*
[**2153-1-31**] 07:30AM BLOOD WBC-8.5 RBC-2.92* Hgb-9.2* Hct-27.3*
MCV-94 MCH-31.4 MCHC-33.6 RDW-15.6* Plt Ct-209
[**2153-2-1**] 07:11AM BLOOD Hct-26.6* Plt Ct-256
[**2153-1-22**] 01:42PM BLOOD PT-16.0* PTT-33.6 INR(PT)-1.5*
[**2153-1-28**] 08:59PM BLOOD PT-13.4* PTT-38.1* INR(PT)-1.2*
[**2153-2-2**] 06:25AM BLOOD PT-17.6* PTT-71.4* INR(PT)-1.6*
[**2153-1-23**] 04:14AM BLOOD Glucose-180* UreaN-15 Creat-0.9 Na-135
K-4.4 Cl-108 HCO3-20* AnGap-11
[**2153-1-31**] 07:30AM BLOOD Glucose-106* UreaN-22* Creat-0.7 Na-138
K-4.1 Cl-101 HCO3-31 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 107917**] was admitted to the [**Hospital1 18**] on [**2153-1-22**]. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to three vessels. Please see operative
report for surgical details. Following surgery he was
transferred to the CSRU for invasive monitoring in stable
condition. During initial post-op course he became hypotensive
requiring multiple pressors. Echocardiogram was preformed to r/o
tamponade, but instead found systolic anterior motion ([**Male First Name (un) **]) of
the mitral valve leaflets. His hemodynamics abruptly stabilized
and a repeat Echocardiogram which showed that he had a baseline
chordal [**Male First Name (un) **] and the outflow obstruction becomes obstructive with
mild to moderate eccentric mitral regurgitation and an LVOT
gradient of about 20 mm Hg. As he was somewhat acidotic and
hypoxic, a bronchoscopy was performed which removed a moderate
amount of thick right sided secretions. Tube feeds were started
to maintain his nutrition. After his inotropes were weaned off,
aspirin, beta blockade and a statin were resumed. He developed
atrial fibrillation for which amiodarone was given. Heparin was
started as a bridge to coumadin for his atrial fibrillation. On
postoperative day five, Mr, [**Known lastname 107917**] was extubated. The
cardiology service was consulted who arranged for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
hearts monitor to monitor his QT interval and incidence of
arrythmia. As there was a concern for aspiration with oral
intake, a swallow study was performed. No overt signs of
aspiration were noted and his diet was advanced to regular. On
[**2153-1-30**], Mr. [**Known lastname 107917**] was transferred to the step down unit for
further recovery. He continued to be gently diuresed towards his
preoperative weight. The physical therapy service worked with
him daily to help increase his postoperative strength and
mobility. As his atrial fibrillation was tachycardic alternating
with rate control, the electrophysiology service was consulted.
Amiodarone, beta blockade and coumadin were continued and he
returned to a normal sinus rhythm. Over the next several days,
his INR became therapeutic and heparin was discontinued. Keflex
for 2 weeks was started for mild mid sternotomy erythema. He
continued to make steady progress and was discharged home on
postoperative day twelve. He will follow-up with Dr. [**Last Name (STitle) 1290**],
his cardiologist and his primary care physician as an
outpatient. Dr. [**Last Name (STitle) 107920**] will follow his coumadin dosing for an
INR of 2.0-2.5 for atrial fibrillation.
Medications on Admission:
Simvastatin 40mg qd, Toprol XL 25mg qd, Nexium 40mg qd, Detrol
4mg qd, Lisinopril 10mg qd, Quinine 260mg qd, Aspirin 325mg qd,
Plavix 75mg qd, Ambien prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 400mg [**Hospital1 **] until [**2-6**] and then decrease 400mg
once daily for 7 days. then decrease to 200 mg daily until
follow up with cardiologist .
Disp:*60 Tablet(s)* Refills:*0*
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 2
days: please take 4mg [**2-3**] and [**2-4**] and have INR checked [**2-5**]
with results to Dr [**Last Name (STitle) 8682**] .
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Outpatient [**Name (NI) **] Work
PT/INR as needed
Results to Dr [**Last Name (STitle) 8682**] at [**Telephone/Fax (1) 445**]
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 14 days.
Disp:*42 Capsule(s)* Refills:*0*
14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Post-operative Atrial Fibrillation
PMH: Hyperlipidemia, Hypertension, Gastroesophageal Reflux
Disease, Cervical and Lumbar Disc Disease, Pleural thickening
d/t Asbestos exposrure, Benign Prostatic Hypertrophy,
Depression, Sleep Apnea, h/o TIA, s/p AAA repair [**2147**], s/p
Appendectomy, s/p Tonsillectomy, s/p Laminectomy, s/p Bilat.
Rotator cuff repairs, s/p Bilat. knee surgery, s/p Left breast
lumpectomy, s/p TURP, s/p Penile Implant with replacement [**2147**],
s/p Bilat. hernia repair, s/p ankle pin placement
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 [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in [**1-20**] weeks
Dr. [**Last Name (STitle) 8682**] in [**12-19**] weeks
Coumadin will be followed by Dr. [**Last Name (STitle) 8682**] Phone ([**Telephone/Fax (1) 17909**]
Fax ([**Telephone/Fax (1) 107921**]
Completed by:[**2153-2-9**]
|
[
"272.4",
"401.9",
"424.0",
"530.81",
"722.83",
"695.9",
"414.01",
"511.9",
"413.9",
"458.29",
"426.82",
"E912",
"518.5",
"501",
"V58.61",
"427.31",
"327.23",
"276.2",
"934.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.15",
"99.04",
"96.72",
"34.04",
"88.72",
"39.61",
"96.6",
"36.12",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
9492, 9526
|
4605, 7287
|
283, 371
|
10150, 10156
|
1462, 3595
|
1132, 1163
|
7491, 9469
|
9547, 10129
|
7313, 7468
|
10180, 10451
|
10502, 10843
|
1178, 1443
|
233, 245
|
399, 564
|
3604, 4582
|
586, 1066
|
1082, 1116
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,098
| 116,867
|
24661
|
Discharge summary
|
report
|
Admission Date: [**2168-11-16**] Discharge Date: [**2168-11-23**]
Date of Birth: [**2097-9-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
CC: SOB, cough
.
HPI: 71 yo M with recent diagnosis of metastatic nonsmall cell
lung cancer (unresectable stage IV) s/p first treatment of
taxol, carboplatin, and zometa on [**2168-11-15**] presents with
worsening SOB, cough, and fever. Pt underwent his first round
of chemotherapy yesterday. Per report he had intermittent
desaturations to 89-92% during chemo. This am he awoke with
fever to 100.6 and worsening productive cough. He took tessalon
pearls and Robitussin with codeine without relief.
.
In the ED his temp was 102, HR 100-120's, BP 160-180's, RR
26-34, satting 95% on NRB. He was given
Levo/Flagyl/Vanco/Azithro. A Chest CT revealed a large left
pleural effusion and LLL/lingular/portions of LUL collapse
(worsened significantly compared to [**2168-10-22**]). He was
transferred to the [**Hospital Unit Name 153**] for further management.
.
Upon arrival to the [**Hospital Unit Name 153**] he was noted to have a RR of 40 with a
gas of 7.47/32/68. He was intubated. His BP's dropped to the
80's with sedation/intubation and he was started on levophed.
An A-line and central line were placed.
.
Past Medical History:
- metastatic nonsmall cell lung cancer (unresectable stage IV)
s/p Taxol, Carboplatin, and Zometa on [**2168-11-15**]
- gout
Social History:
quit smoking 53 years ago, smoked 20 pack years.
asbestos exposure while in military
lives with wife, is retired
employed previously as electrician
Daughter [**Name8 (MD) **] RN @ [**Hospital1 18**]
Family History:
father died 83years lung cancer
mother died of liver cancer, ? age
sister CAD, s/p CABG
Physical Exam:
Tm 102 Tc 101.4 BP 80/45 HR 95 RR 14 Sat 100%
AC Vt 550/RR 14/PEEP 12/FiO2 100%
Gen: intubated, sedated
HENNT: MMM, anicteric
Neck: no LAD, no JVD
CV: tachy, regular, nl S1S2, No M/R/G
Lungs: coarse breath sounds, bibasilar crackles, no wheezes
Abd: soft, NT/ND, +BS, No HSM
Ext: no edema, strong DP/PT pulses bilaterally
Neuro: moving all extremeties
Pertinent Results:
[**2168-11-16**] 10:51PM TYPE-[**Last Name (un) **] TEMP-38.4 RATES-16/ PO2-155* PCO2-42
PH-7.37 TOTAL CO2-25 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED
[**2168-11-16**] 09:47PM PLEURAL TOT PROT-4.3 GLUCOSE-185 LD(LDH)-273
[**2168-11-16**] 09:47PM PLEURAL HCT-2.5*
[**2168-11-16**] 09:47PM PLEURAL WBC-2922* RBC-[**Numeric Identifier 62249**]* POLYS-17*
LYMPHS-37* MONOS-18* EOS-2* ATYPS-7* MESOTHELI-2* MACROPHAG-2*
OTHER-15*
.
Studies:
- CT chest [**2168-11-16**]:
1. No evidence of pulmonary embolism.
2. large left pleural effusion and collapse of left lower lobe,
lingula and portions of the left upper lobe have worsened
significantly compared to [**2168-10-22**]. Occlusion of the left
lower lobe and lingular bronchi
3. Bulky mediastinal and bilateral hilar adenopathy.
4. New pathological fracture of the left seventh rib. Lytic foci
within the T1 vertebral body and right fifth rib are unchanged.
6. Patchy opacity within the right lower lobe, likely reflecting
an
infectious or inflammatory process.
.
- CXR [**2168-11-16**]: Interval increased left pleural effusion, and
increasing parenchymal opacities in left lower lobe and lingula.
Given the known lesions in the left hila, this is concerning for
postobstructive pneumonia/atelectasis. Mediastinal and hilar
lymphadenopathy. Left rib met.
.
- MRI head [**2168-11-5**]: Mild-to-moderate brain atrophy. No
enhancing lesions are seen. No evidence of mass effect or
hydrocephalus.
.
- PET CT scan:
1. Intense FDG avidity in the partially collapsed left lower
lobe extending to the hilum. The intensity of this uptake is
greater than expected for postobstructive inflammatory change
alone and is consistent with the given history of non-small cell
lung cancer.
2. FDG-avid bilateral hilar adenopathy and widespread bilateral
mediastinal adenopathy.
3. Multiple foci of FDG-avid lytic metastases involving the left
scapula, the left lamina of T1, the right 5th rib (with
pathologic fracture), the left 7th rib, the right sacrum and
right acetabulum. Asymmetric activity associated with the right
L5 pars defect may
be degenerative.
.
- Chest CT [**2168-10-22**]: bulky, bilateral mediastinal
lymphadenopathy as well as bilateral hilar adenopathy, the
largest lymph nodes include a subcarinal node or mass measuring
approximately 2.5 cm x 3.5 cm in diameter. There are also
bilateral calcified pleural plaques present. The lower lobe is
partially collapsed, and within the area of enhancing
atelectatic lung, there is a low-density rounded area measuring
2.0 cm x 1.8 cm in diameter. The lungs also demonstrate
emphysematous changes, also was found to have a
small-to-moderate pleural effusion and a small pericardial
effusion. Additional central peri-bronchovascular thickening in
the left lower lobe was found which could be related to
lymphatic obstruction or localized lymphangitic spread of tumor.
Brief Hospital Course:
A/P: 71 yo M with recently diagnosed metastatic non small cell
lung cancer (unresectable stage IV) s/p first treatment of
Taxol, Carboplatin, and Zometa on [**2168-11-15**] presents with
worsening cough and fever.
.
Patient's shortness of breath, cough and fever were likely
secondary to a post-obstructive pneumonia in setting of a known
malignancy. Patient was started on empiric broad spectrum
coverage with vancomycin/levofloxacin/metronidazole. CT chest
revealed a large left pleural effusion and collapse of left
lower lobe, lingula and portions of the left upper lobe. Shortly
after transfer to the ICU patient became hypoxic and required
intubation. Tap of left pleural effusion on [**11-16**] was positive
for non-small cell carcinoma. A left sided chest tube was
placed. Bronchial washings, subcarinal mass, and paratracheal
lymph node obtained on [**11-19**] were again consistent with
malignancy. Repeated blood, sputum, and urine cultures did not
identify etiology of infection; viral screen also negative.
Course was further complicated by developing neutropenia (s/p
chemotherapy). Aztreonam and AmBisome were both added for
broader coverage. The oncology service was following along
throughout his ICU course. Patient received Neupogen 300 mcg SC
daily for neutropenia. Despite the placement of a second chest
tube, patient continued to have hypoxic respiratory failure,
secondary to large malignant pleural effusion and left lung
collapse. Patient became hypotensive, likely secondary to
sepsis, and required pressors and fluid boluses to maintain his
CVP and urine output. The patient's primary oncologist Dr.
[**Last Name (STitle) 3274**] had a discussion with the patient's family regarding
goals of care and the patient's prognosis and a decision was
made to make him CMO. The patient passed away at 1:55 am on
[**2169-11-23**].
Medications on Admission:
1. Allopurinol 300 mg PO DAILY
2. Tessalon Perles 200 mg t.i.d.
3. Robitussin With Codeine cough syrup
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired on [**2169-11-23**].
Discharge Condition:
Discharge Instructions:
Followup Instructions:
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"486",
"196.1",
"518.84",
"288.0",
"995.92",
"733.19",
"198.5",
"162.8",
"V15.84",
"038.9",
"197.2",
"790.29",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"96.04",
"33.22",
"96.6",
"34.04",
"34.09",
"34.91",
"38.91",
"96.72",
"38.93",
"33.24",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
7256, 7265
|
5221, 7074
|
307, 321
|
7347, 7347
|
2326, 5198
|
7427, 7510
|
1850, 1939
|
7227, 7233
|
7286, 7324
|
7100, 7204
|
7373, 7373
|
1954, 2307
|
248, 269
|
349, 1469
|
1491, 1617
|
1633, 1834
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,837
| 148,986
|
12382+12452+56359
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2130-3-16**] Discharge Date: [**2130-6-1**]
Date of Birth: Sex: F
Service: NEUROSURGERY
The patient is to be discharged to the [**Hospital6 19682**] on the morning of [**2130-6-1**].
HISTORY OF PRESENT ILLNESS: This is the first [**Hospital1 346**] admission for this 54 year old white
disease who was transferred from an outside hospital in [**Location (un) 38033**], [**State 350**] for further workup of a reported stroke.
The patient lives at home with her mother and was last seen
in her usual state of good health approximately 1:00 a.m. on
the morning of admission. She had been complaining of a mild
headache for approximately one week with flu like symptoms
day of admission.
She was subsequently found unresponsive lying on her bed with
her head hanging off the edge of her bed at approximately
8:00 a.m. on the day of admission. The patient was taken to
the [**Doctor Last Name 38554**] Hospital in [**Location (un) 14663**], [**State 350**] and
was reported at that time to be moving all extremities but no
speech, no eye deviation. The patient was intubated for
airway protection and paralyzed and sedated and subsequently
transferred to the [**Hospital1 69**].
PAST MEDICAL HISTORY: As noted positive for bipolar disorder
and depression as well as a past surgical history of a
tonsillectomy and appendectomy and a reported closed head
injury one year prior to admission at which time the patient
was hit by falling scaffolding.
MEDICATIONS ON ADMISSION:
1. Prozac.
2. Neurontin.
3. Ativan.
ALLERGIES: Allergy history was unknown.
SOCIAL HISTORY: She is a two pack per day smoker with a
negative alcohol and negative recreational drug use history.
PHYSICAL EXAMINATION: On physical examination at the time of
admission, the vital signs revealed temperature 102, blood
pressure 102/55, heart rate 96 and normal sinus rhythm,
respiratory rate 15, with oxygen saturation of 99% but the
patient was intubated. In general, she was a middle age
appearing white female in no acute distress but was intubated
and sedated at the time. There was no evidence of external
trauma. The cardiovascular examination was unremarkable. The
heart was regular rate and rhythm without murmurs, rubs or
gallops. Pulmonary examination was clear to percussion and
auscultation. Abdominal examination was unremarkable with
bowel sounds present in all four quadrants. The abdomen was
nontender, nondistended. Neurologic examination - The
patient was intubated, sedated and unresponsive. The pupils
were 3.0 millimeter bilaterally and minimally reactive.
There were negative doll's eyes and a positive gag reflex was
present. The patient withdrew all extremities to painful
stimuli and intermittently followed commands to move her
toes. Reflexes were brisk in the upper extremities and
symmetric.
LABORATORY DATA: A CT scan which was initially done at the
outside hospital revealed the question of a right middle
cerebral artery infarct with minimal mass effect and magnetic
resonance scan showed a right parietal mass with minimal mass
effect and question of obstructive hydrocephalus. Chest
x-ray was normal. Electrocardiogram showed normal sinus
rhythm.
Sodium 140, potassium 2.4, chloride 99, bicarbonate 27, blood
urea nitrogen 19, creatinine 0.4, blood sugar 181. White
blood cell count 18.2, hematocrit 36.6, platelet count
375,000. Prothrombin time 14.4, partial thromboplastin time
29.4, INR 1.4.
HOSPITAL COURSE: Due to clinical findings, the patient was
seen urgently in the Emergency Department by the neurosurgery
service. She was given a bolus of 20 mg intravenous Decadron
and was to begin on 10 mg intravenous Decadron q6hours
thereafter. Ventricular drain was placed for the obstructive
hydrocephalus with an opening pressure felt to be slightly
elevated and the drain was maintained at 15 centimeters above
the level of the tragus. She was given a Dilantin one gram
load and a magnetic resonance scan and view
scope study was done urgently.
On the morning following admission, the patient remaining
intubated and sedated with the ventriculostomy drain in
place. The patient was taken to the operating room where
under general endotracheal anesthetic, the patient underwent
a right parietal craniotomy with evacuation and drainage of
an abscess. The patient tolerated the procedure well, was
returned to the Intensive Care Unit and the abscess initial
gram stain findings showed a gram positive organism and she
was initially started on Oxacillin but then switched to
Vancomycin, Ceftriaxone and Flagyl for broad spectrum
coverage. Subsequent cultures grew out Streptococcus milleri
and she was therefore seen and followed throughout the next
several weeks by the infectious disease service.
Cardiac echocardiogram was obtained which essentially was
felt to be a suboptimal study but was felt to show no
evidence of vegetation on the cardiac valves. The patient
was kept in the Intensive Care Unit and remained intubated
and sedated for the next several days. On [**2130-3-20**], she
began to respond to voice commands as well as showing facial
grimacing and opening her eyes and she was therefore
extubated at that time.
Due to the confirmation of Streptococcus milleri, the
Vancomycin was discontinued on [**2130-3-21**]. The patient then
became afebrile for several days. The vent drain was clamped
on [**2130-3-24**], but this was poorly tolerated with the patient
developing mild somnolence. Therefore, the vent drain was
reopened. The vent drain was again clamped on [**2130-3-27**], for
a trial. The patient tolerated this well.
Therefore, on [**2120-3-27**], the vent drain was discontinued as
well as central line was discontinued and a PICC line was
placed for antibiotic coverage for four to six weeks of
Ceftriaxone for treatment of the brain abscess. The patient
was also transferred to the floor on [**2130-3-28**].
However, the patient developed persistent fever on [**2130-3-29**],
and neurologic status at that time showed the patient to be
confused, but moving all extremities. She was at times
combative and agitated and was not following commands. Her
speech was confabulatory with apparent delirium. A lumbar
puncture was performed on [**2130-3-31**], which showed gram
positive bacteria and Vancomycin was restarted. The patient
removed her PICC line on [**2130-4-2**]. This was replaced on
[**2130-4-3**], in order to continue the antibiotic coverage for a
full six week course for the brain abscess.
The patient had episodic seizures throughout this time and
developed a rash while on Dilantin so that Dilantin was
discontinued and Depakote was started. The patient
defervesced over the next several days. However, on
[**2130-4-16**], the patient again developed fever and decreased
mental status. Lumbar puncture was done again which showed
gam positive bacteria and Vancomycin was continued and Zosyn
was started and later a culture and sensitivity of the
cerebrospinal fluid showed coagulase negative Staphylococcus
in the cerebrospinal fluid. The lumbar puncture that was
done on [**2130-3-19**], included drainage of approximately 20 ccs
of pink cerebrospinal fluid at which time the patient became
slightly more awake, alert and returned to her previous state
of alertness with persistence of her previous delirium and
confusion.
On [**2130-4-18**], the Vancomycin dose was increased to 1.2 grams
b.i.d. and Rifampin was added. The patient was transferred
to the Intensive Care Unit due to right lower lobe collapse
and respiratory distress. She was reintubated, resedated due
to the respiratory distress. The patient tolerated the
reintubation well. She also had a ventriculostomy placed
again on [**2130-4-18**], for access to cerebrospinal fluid for
routine cultures and surveillance. She did well and on
[**2130-4-22**], was extubated and the vent drain was discontinued
and a percutaneous gastrostomy tube was placed for
nutritional needs.
The patient did well until [**2130-5-1**], when all cultures were
now considered negative. Antibiotics were discontinued. On
[**2129-5-3**], the patient developed a deep venous thrombosis in
the left subclavian, axillary, basilic and brachiocephalic
veins which was felt to be related to the presence of the
PICC line and the PICC line was then discontinued.
The patient did well for the next several days and was
transferred back to the hospital floor on [**2130-5-10**]. Due to
the mental status of the patient a long period of
consideration of having the patient undergo placement of an
indwelling ventriculoperitoneal shunt was entertained.
However, her mental status gradually improved and she showed
increased alertness with occasional brief episodes of
lucidity and oriented to her self and to the hospital and
following some simple commands. Her speech was clear albeit
occasionally nonsensical and the delirium remained present.
However, due to this mental status, it was determined to
defer placement of a ventriculoperitoneal shunt at that time.
The patient remained in stable condition on the hospital
floor throughout the remainder of her hospitalization while
arrangements were made for the patient to be evaluated and
subsequently placed in a rehabilitation center. The patient
was accepted for rehabilitation transfer on [**2130-5-31**], with
plans to be transferred to [**Hospital6 85**]
on [**2130-6-1**], for cognitive behavioral therapy as well as
physical therapy and occupational therapy.
MEDICATIONS ON DISCHARGE:
1. Lovenox 60 mg subcutaneous q12hours for treatment of her
history of deep vein thrombosis.
2. Miconazole Powder 2% with one application to the affected
areas t.i.d. p.r.n.
3. Folic Acid 1 mg p.o. q.d.
4. Ferrous Sulfate 325 mg p.o. t.i.d.
5. Zantac 150 mg p.o. b.i.d.
6. Lopressor 25 mg p.o. t.i.d. with additional instructions
to hold the Lopressor for blood pressure systolic of less
than 110 or a heart rate less than 60,
7. Seroquil 25 mg p.o. b.i.d.
8. Depakene or Depakote one gram (1000 mg) p.o. t.i.d.
9. Tube feedings throughout the remainder of her hospital
stay consisted of Promote with Fiber at 65 ccs/hour and there
was consideration of cycling the tube feedings to 85 ccs/hour
times eighteen hours per day with the tube feedings
discontinued for six hours during the night time.
CONDITION ON DISCHARGE: Stable and improved from her initial
admission status. Anticipated goals are activities of daily
living, rehabilitation potential is indeterminate to good.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2130-5-31**] 19:31
T: [**2130-5-31**] 20:35
JOB#: [**Job Number 38555**]
Admission Date: [**2104-4-7**] Discharge Date: [**2130-9-14**]
Date of Birth: Sex: F
Service:
Discharge summary originally dictated on [**2130-6-1**].
Addendum: The patient's discharge was delayed secondary to
financial concerns, as well as appointment of a legal
guardian for patient who is unable to make medical legal
summary on [**2130-7-8**], the patient did have an incident where a
can of Ensure dropped on her toe causing a fracture of her
toenail on her second toe of her right foot requiring a
podiatry consult who removed the toenail and did dressing
changes. There was increased blood loss secondary to
being on Lovenox for a blood clot in her left upper
extremity. The toe is healing
There was no abscesses or any kind of further treatment
needed, just Peridex rinses to her mouth and improved oral
care. She also did develop a urinary tract infection, was
fully treated. Urinary tract infection was on [**2130-8-7**]. She
received full treatment and has had no further episodes,
fever, or any type of infection. Her neurologic status
slowly improved. She still continues to be very apraxic and
requires redirection, but she is awake, alert, oriented x1,
has difficulty following commands and is independent
ambulating. She does have a G-tube in place and is receiving
cycled tube feedings and requires encouragement for meals.
She will need follow up with Dr. [**First Name (STitle) **] in one month and she is
stable at the time of discharge with stable vital signs.
DR.[**First Name (STitle) **],[**First Name3 (LF) 125**] 14-118
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2130-9-14**] 09:22
T: [**2130-9-14**] 10:16
JOB#: [**Job Number 38683**]
Name: [**Known lastname **]-[**Known lastname 6974**], [**Known firstname **] Unit No: [**Numeric Identifier 6975**]
Admission Date: [**2130-3-16**] Discharge Date: [**2130-7-8**]
Date of Birth: [**2075-7-17**] Sex: F
Service: Neuro [**Doctor First Name **]
Discharge date is pending awaiting rehabilitation bed.
DISCHARGE SUMMARY ADDENDUM: This is an addendum to the
discharge summary dictated previously after [**2130-6-1**].
HOSPITAL COURSE: The patient stayed in house at [**Hospital1 960**] and discharged to a rehabilitation
bed was deferred due to family issues. Her subsequent stay in
the hospital has been uneventful. She has gradually improved
in her mental status. She did a change of her G tube during
this month because of a leak in the G tube. She currently has
a working G tube and is being tube fed via that.
Neurologically she is currently alert, awake and talkative
with aphasia and word finding difficulty. She complains of
some discomfort related to tube feeds and occasionally shouts
about herself.
Cardiovascularly she is bradycardic at baseline with a blood
pressure of 98/50 baseline.
Respiratory wise she is saturating 100% on room air.
Gastrointestinal - the patient has poor po intake and needs
much encouragement. She continues on tube feeds which are
currently Promote with fiber at 100 cc an hour cycled on
between six P.M. until ten A.M.
Activity level - she does ambulate with supervision and has a
steady gait.
DISCHARGE STATUS: She will be discharged to rehabilitation
as soon as social issues are resolved and she has a bed.
DISCHARGE MEDICATIONS:
1. Ferrous Sulfate 325 mg tid.
2. Folic Acid 1 mg po q day.
3. Divalproex Sodium 1,000 mg tid.
4. Lovenox 60 mg subcutaneous 12 hours.
5. Miconazole 2% cream one application topical [**Hospital1 **] prn.
6. .................... 10 mg po qid ACHS.
7. Colace 100 mg po bid.
8. Tube feeding resume currently is Promote with fiber full
strength at a rate of 100 cc per hour which is the goal rate
to start at six P.M. and end at ten A.M. Check residue q
four hours and hold for residue greater than 100 cc. Flush
with 30 cc of water before and after each feed.
[**First Name11 (Name Pattern1) 919**] [**Last Name (NamePattern4) 920**], M.D.
Dictated By:[**Last Name (NamePattern1) 5028**]
MEDQUIST36
D: [**2130-7-8**] 11:28
T: [**2130-7-10**] 09:13
JOB#: [**Job Number 6976**]
|
[
"263.9",
"453.8",
"518.0",
"599.0",
"780.39",
"518.81",
"324.0",
"E936.1",
"693.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.71",
"01.24",
"96.04",
"38.93",
"03.31",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
14203, 15022
|
9546, 10352
|
1527, 1609
|
13056, 14180
|
1751, 3477
|
263, 1233
|
1255, 1501
|
1626, 1728
|
10377, 13039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,988
| 130,982
|
4064
|
Discharge summary
|
report
|
Admission Date: [**2128-6-22**] Discharge Date: [**2128-7-5**]
Date of Birth: [**2072-9-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Fever, fatigue, hypotension
Major Surgical or Invasive Procedure:
Hemodialysis catheter exchange
History of Present Illness:
This is a 55 year-old female with a history of ESRD secondary to
hypertensive nephropathy, on HD and PD, who presents with 2
weeks of fatigue, uncontrolled hypertension, and new gram
negative bacteremia. She was found to have discharge from
tunneled HD catheter exit site on [**6-21**] and blood cultures and
swab were sent. Blood cultures returned 2/2 bottles gram
negative rods, and patient was referred by outpatient
nephrologist to [**Hospital1 18**] ED for further evaluation, where she was
found to have blood pressure markedly elevated from baseline.
She reports she has not taken her blood pressure medications for
past 4 days because she ran out and was waiting for refills. She
denies any chest discomfort other than her chronic breast pain
that is related to swelling and erythema. She has had occasional
headache, but no vision disturbance. She also reports that she
has been doing fewer cycles of her peritoneal dialysis over the
past few days.
.
The patient reports subjective fevers, with temperature at home
in high 99s. She also reports decreased appetite over past 2
weeks. She denies any nausea, vomitting, or abdominal pain. She
denies cloudy peritoneal dialysate. She was given a dose of
Vancomycin at dialysis empirically to cover for line infection,
after initial cultures were drawn.
.
In the ED, vitals were T:101.1 HR:78 BP:190/101 RR:24 O2Sat:96%
on RA. Repeat blood cultures were drawn and she was given
additional dose of vancomycin and gentamicin. She was
transferred to MICU for management of uncontrolled hypertension.
Past Medical History:
-ESRD on HD: proliferative glomerulonephritis. ? hx of lupus
On steroids several years ago. Diagnosed in [**2122-10-25**] ([**Doctor First Name **]
1:160)
-Bilateral total knee replacement in [**2125-1-23**]
-CAD
-Rheumatic fever
-HTN
-Left shoulder OA
-Left rotator cuff tear
-Hyperparathyroidism
-Iron deficiency anemia
-Hypercholesterolemia
.
PSHx:
Multiple catheter placements for HD, most recently today with
right subclavian catheter.
-Hysterectomy; fibroids
-Bilateral knee replacements [**1-28**]
-Herpes Zoster prior history with resulting post-herpetic
neuralgia right side
Social History:
Lives with housemates in [**Location (un) 669**]. Works as social worker for
DSS, currently not working. One-half pack tobacco per day x32
years- quit 3months ago. Former cocaine user.
Family History:
Father myocardial infarction in his 40s. Uncle with a
myocardial infarction in his 40s. Brother with a myocardial
infarction in his 40s. There is no family history of connective
tissue disease.
Physical Exam:
Tmax: 38.2 ??????C (100.8 ??????F)
Tcurrent: 38.2 ??????C (100.8 ??????F)
HR: 73 (73 - 83) bpm
BP: 159/110(122) {155/92(108) - 174/110(122)} mmHg
RR: 26 (15 - 26) insp/min
SpO2: 99%
Height: 65 Inch
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : ), Tunneled dialysis
catheter without erythema or drainage
Abdominal: Soft, Non-tender, Bowel sounds present, Obese,
Peritoneal dialysis catheter without drainage or inflammation
Extremities: no c/c/e
Skin: Warm
Neurologic: Attentive, Follows simple commands, Oriented (to):
person, place and time
Pertinent Results:
=====ADMISSION LABS=====
[**2128-6-22**] 09:22AM WBC-9.8# RBC-3.65* HGB-11.2* HCT-35.4* MCV-97
MCH-30.8 MCHC-31.7 RDW-14.5
[**2128-6-22**] 09:22AM NEUTS-89 BANDS-0 LYMPHS-5 MONOS-3 EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2128-6-22**] 09:22AM GLUCOSE-69* UREA N-39* CREAT-9.4*# SODIUM-136
POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-22 ANION GAP-22*
[**2128-6-22**] 09:50AM PT-24.4* PTT-38.5* INR(PT)-2.4*
[**2128-6-22**] 09:22AM ALT(SGPT)-6 AST(SGOT)-18 LD(LDH)-459* ALK
PHOS-99 TOT BILI-0.4
[**2128-6-22**] 09:22AM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.5#
MAGNESIUM-2.1
[**2128-6-22**] 09:22AM PLT COUNT-329
.
C diff- negative
.
Blood Culture, Routine Drawn [**2128-6-21**] and [**2128-6-22**]: ENTEROBACTER
CLOACAE.
.
All other bloox cx- negative
.
Peritoneal fluid analysisL [**2128-6-25**]
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN. Cx-negative
.
Peritoneal fluid analysis: [**2128-6-26**]
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES, Cx
negative
CXR [**2128-6-22**]
IMPRESSION: Vague nodular density at the left lung base. This
may be due to overlapping structures, although if there is
persistent clinical concern, consider formal PA and lateral
views. Right perihilar atelectasis.
.
U/S UE Veins [**2128-6-22**]
IMPRESSION:
1. Occlusive thrombus within the right internal jugular vein.
Note that
there was right IJ thrombus on Duplex study of [**2127-4-1**].
There have been no interval studies. Therefore, the chronicity
of this thrombus cannot be determined.
.
2. The central extent of the internal jugular thrombus is
indeterminate. Some central occlusion is possible given the
dampened waveforms of the more peripheral veins.
.
Unilateral Breast U/S [**2128-6-22**]
IMPRESSION: Subcutaneous edema, without focal drainable fluid
collection
identified.
If the swelling persists, consider repeat ultrasound and
mammographic
correlation for further evaluation.
.
MRA chest with and without contrast: [**2128-6-29**]
IMPRESSION:
1. Thrombus in the right subclavian and bilateral
brachiocephalic veins and
supra-azygos superior vena cava. The SVC is patent more
inferiorly near its
junction with the right atrium.
2. Chronic thrombosis of the bilateral internal jugular veins
and left
brachiocephalic vein.
3. Patent left subclavian vein which, however, demonstrates
narrowing
proximally.
.
KUB of abdomen for catheter tip placement [**2128-6-30**]:
IMPRESSION: Peritoneal dialysis catheter tip overlying the
pelvic inlet.
Brief Hospital Course:
Pt is a 55 y/o F with hx ESRD, on HD and PD, admitted for
uncontrolled hypertension and gram negative bacteremia.
# Gram negative bacteremia- The patient was found to have GNR
bacteremia which was enterobacter. She was originally started
on gentamicin and ciprofloxacin which was later changed to
ceftazidime when it was found to be pan-sensitive. Her HD
catheter was changed over a wire as there was pus at the
catheter site and she was previously febrile. She needs to be
treated with ceftazidime for a total of 3 weeks with a start
date of [**2128-6-28**] (date of catheter change). The peritoneal fluid
cultures had no growth x2 but the patient was empirically
treated. The PD dialysis fluid on [**6-24**] showed 4+PMNs with a
subsequent sample only having 2+ polys. The pt was started on
vancomycin prior to the PD cx returning as the peritoneal fluid
looked cloudy. Breast ultrasound showed no evidence of abscess
on ultrasound and is less likely to be source of infection given
chronicity. Pt has negative chest imaging and shows no signs of
pulmonary infection clinically. Patient will receive
ceftazidime at hemodialysis treatments.
.
#RIJ Thrombosis/SVC syndrome: The pt has a history of RIJ
thromboses. She was on home Coumadin, which was held initially
and vitamin K was given so she could have her HD line changed
over a wire. While in the hospital the patient was on a heparin
drip. She also had swelling of the R breast at admission. Later
in her hospitalization she developed swelling of the left arm,
neck, face, left breast, and around her eyes. A MRV with and
without contrast was done which showed thrombus in the right
subclavian, bilateral brachiocephalic veins, supra-azygos
superior vena cava, and bilateral internal jugular veins.
[**Month/Day (4) **] surgery was consulted and felt there would be no
benefit from intervention. Patient was discharged with 5mg dose
of coumadin. Her INR will be followed at her [**Hospital **] clinic and
adjusted as necessary.
.
#Breast pain: Breast tenderness is chronic and is likely related
to venous clots. Pt has had no evidence of abscess on
ultrasound, and is unlikely to be the source of infection given
chronicity. Pt was seen by Breast Surgery for further
recommendations, and it was determined that she likely has edema
secondary to a clot in the region of her right subclavian, given
her history of possible trauma to the site 5 months prior during
HD catheter placement. Pt is recommended to have dedicated
breast ultrasound and mammogram as an outpatient as these
studies are not convered by insurance as an inpatient. Also,
patient will follow up with Dr. [**Name (STitle) 17486**] [**Doctor Last Name 11635**] as an
outpatient.
.
#Chest pain: Pt has had several episodes of chest pain,
described as a mix of substernal pressure and heartburn. Repeat
EKGs and cardiac enzymes have been negative. Pain improved
mildly with NG. Also increases with inspiration, which is more
consistent with a pleuritic etiology. Chest pain also improves
after Maalox. Pt was started on a daily PPI.
.
# Hypertension ?????? Per pt, baseline at home is 120/80. She missed
4 days of low-dose atenolol prior to admission. Her BP early in
her admission was elevated in the 170s with a BP max of 200s.
She had another episode of increased BP when she became febrile.
With HD and her home doses of Atenolol and Captopril her blood
pressure was fairly well controlled throughout the rest of her
admission.
.
# ESRD ?????? Pt is on a regular HD schedule of Mon/Fri and also does
regular peritoneal dialysis at home. She received HD 7/30 per
renal as she has been having issues with regular PD, due to
fibrin clotting in her line. She received TPA per her PD tube by
Renal [**6-24**], with improved flow of effluent. The pt is
transitioning from HD to PD due to issues of poor venous access.
In addition her HD catheter had to be changed over a wire
during her admission due to pus at the HD site, blood cx + for
enterobacter, and fevers. While in the hospital she increased
the frequency and volume of her PD dialysis. The ultimate goal
is for her the patient to only need PD so the HD line can be
discontinued. She was continued on her home lanthanum,
sevelamer, Iron, vitamin D, cinacalcet. She will continue with
HD as an outpatient per Dr.[**Name (NI) 17897**] recommendations. Will
also continue PD at home. The goal is to ultimately be on PD
with home nursing.
.
# Psych: The patient has a history of depression on citalopram.
During her hospitalization she had difficulty in adjusting to
the stress of all her medical problems. The patient received
low dose Ativan once a day to help her with her anxiety and was
seen by social work. She denied any suicidal ideation or
intent to harm herself. She needs close follow up with her PCP.
.
#Sleep apnea: While the patient was sleeping her oxyen
saturation was 72% and a pulmonary consult was called. It was
decided the patient should be put on CPAP and continuous oxygen
monitoring. She will get a CPAP machine delivered to her home
and she will follow up with Sleep Health Centers for a sleep
study.
Medications on Admission:
Atenolol 25 mg Tablet [**11-26**] tab Tablet(s) by mouth once a day
Cinacalcet [Sensipar] 60 mg Tablet 1 Tablet(s) by mouth once a
day Citalopram 10 mg Tablet [**11-26**] Tablet(s) by mouth qam
Epoetin Alfa [Epogen] 4,000 unit/mL Solution q hd q hd
Gabapentin 300 mg Capsule 1 Capsule(s) by mouth once a day
Iron Sucrose [Venofer] 100 mg/5 mL Solution 50 mg q wk at HD
Lanthanum [FOSRENOL] 1,000 mg Tablet, Chewable 1 Tablet(s) by
mouth three times a day
Lorazepam 0.5 mg Tablet 1 Tablet(s) by mouth once a day as
needed for stress
Paricalcitol [Zemplar] 5 mcg/mL Solution 6.5 mcg at HD TIW
Sevelamer HCl [Renagel] 800 mg Tablet 3 Tablet(s) by mouth three
times a day Warfarin [Coumadin] 5 mg Tablet 1 Tablet(s) by
mouth once a day
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
10. Paricalcitol
Paricalcitol 6.5 mcg IV QHD
11. Ferric gluconate
Ferric Gluconate 125 mg IV QWEEK AT HD
12. ceftazidime
CeftazIDIME 1 g IV 3X/WEEK (MO,WE,FR) Duration: 3 Weeks with
start date [**2128-6-28**]
13. Outpatient Lab Work
Please check INR at next HD session
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
16. Ferric Gluconate 125 mg IV QWEEK AT HD
17. CPAP
CPAP with 2L O2
Auto CPAP range 4-20
Diagnosis: OSA
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] of [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
1. Septic infection (due to HD line)
2. SVC
3. Venous clots
4. ESRD on HD and PD
5. Depression
6. HTN
.
Secondary Diagnosis
1. CAD
2. Left rotator cuff tear
3. Hyperparathyroidism
4. Left shoulder OA
5. Hypercholesterolemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital due to a bacterial infection
due to your HD catheter which has pus at its site. You were
also admitted with hypertension because you had recently missed
doses of your medication. While you were at the hospital you
were found to have enterobacter bacteria in your blood stream.
You were treated with antibiotics. Your HD catheter was changed
over a wire. You also developed a clot in your right internal
jugular vein early on in your hospitalization and were treated
with a heparin drip. You also developed clots in:
1. the right subclavian vein
2. bilateral brachiocephalic veins
3. supra-azygos superior vena cava
4. bilateral internal jugular veins
.
The clots lead to swelling of your head, neck, and around your
eyes. You were transitioned from heparin to coumadin prior to
discharge to prevent further development of clots.
.
Please follow up with your regular hemodialysis doctor, Dr.
[**First Name (STitle) 805**], for your renal disease management, dosing of your
antibiotics, and management of your coumadin by checking your
INR blood test.
.
Also, you were started on CPAP machine at night for your
suspected sleep apnea. You will be getting a CPAP machine
delivered to your home in the next few days. You will have to
get a formal sleep study at Sleep Health Centers located in
[**Location (un) 583**]. You will have to give the prescription for the CPAP
and the information of the sleep center to the CPAP delivery
company.
.
If you develop shortness of breath, chest pain, further swelling
of your face/neck/upper extremities, redness or pus of your
catheter site, fevers, suicidal ideation, or any other worrisome
symptonm please seek medical attention.
Followup Instructions:
Please follow up with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) 507**]
[**Doctor First Name 508**] [**Telephone/Fax (1) 133**] in the next week. Please address difficulty
coping with your medical problems at this visit.
.
Please have INR checked and antibiotic dosing at next HD with
Dr. [**First Name (STitle) 805**]
.
Please follow up in the renal clinic in one week.
.
Please obtain outpatient mammogram and outpatient ultrasound
which will be set up by your PCP.
.
Please make an appointment to see Dr. [**Name (STitle) 17486**] [**Doctor Last Name 11635**]
regarding your breast swelling. Her clinic phone number is
[**Telephone/Fax (1) 17898**]
.
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2128-10-4**] 1:00
.
Sleep study to be scheduled at Sleep Health Centers, [**Location (un) 17899**] [**Location (un) 583**], [**Numeric Identifier 994**] ([**Telephone/Fax (1) 17900**]
Completed by:[**2128-7-6**]
|
[
"252.01",
"V45.1",
"585.6",
"327.23",
"996.62",
"403.91",
"453.8",
"285.21",
"459.2",
"272.0",
"414.01",
"E879.1",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"54.98",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13742, 13817
|
6371, 11498
|
340, 372
|
14105, 14115
|
3852, 6348
|
15873, 16912
|
2784, 2981
|
12287, 13719
|
13838, 13838
|
11524, 12264
|
14139, 15850
|
2996, 3833
|
273, 302
|
400, 1954
|
13857, 14084
|
1976, 2563
|
2579, 2768
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,553
| 138,869
|
28126
|
Discharge summary
|
report
|
Admission Date: [**2191-9-28**] Discharge Date: [**2191-10-6**]
Date of Birth: [**2137-12-3**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Obstructive jaundice
Pancreatic Head Mass
Major Surgical or Invasive Procedure:
Diagnostic Laparoscopy with Liver Biopsy
Open Cholecystectomy
Pylorus Preserving Whipple resection
Portal Vein Repair
Portal Vein Resection with Patch Reconstruction
IOUS
History of Present Illness:
This is a 53 year old female with a history of painless jaundice
who was ultimately worked up with an ERCP on [**2191-9-20**] by Dr.
[**Last Name (STitle) **] showing previous attemot at bile cannulation and
inability ti cannulate CBD. She subsequently had a CT on
[**2191-9-21**] and then a PTC with Successful drainage via an
internal-external catheter. A CT showed a 1.5cm pancratic head
lesion abuting the SMV but not involving the SMA. She now
presents for a staging laparoscopy and possible Whipple
procedure.
Past Medical History:
PTC drain [**2191-9-21**]
ERCP [**2191-9-20**]
Gallstone pancreatitis ('[**89**])
Depression
Irritable bowel syndrome
Kidney disease (child)
TAH/BSO for fibroids
Social History:
20 pack year tobacco
social EtOH
self-employed cleaner
Family History:
n/a
Physical Exam:
NAD, AAOx3
HEENT: scleral icterus, much improved s/p PTC drainage on
[**2191-9-22**]
CV: RRR
PULM: CTA B/L
ABD: soft, NT, ND
EXT: no edema, jaundiced
Pertinent Results:
[**2191-10-2**] 11:43AM BLOOD WBC-10.8 RBC-3.19* Hgb-10.7* Hct-30.2*
MCV-95 MCH-33.5* MCHC-35.4* RDW-15.0 Plt Ct-399#
[**2191-10-4**] 06:40AM BLOOD Glucose-162* UreaN-9 Creat-0.4 Na-140
K-3.4 Cl-105 HCO3-24 AnGap-14
[**2191-10-4**] 06:40AM BLOOD ALT-69* AST-33 AlkPhos-214* TotBili-2.4*
[**2191-10-4**] 06:40AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
US INTR-OP 60 MINS [**2191-9-28**] 4:43 PM
IMPRESSION: Hemodynamically significant narrowing in SMV at
level of venous patch, just below portosplenic confluence. The
findings were related to Dr. [**Last Name (STitle) **] in detail, as the exam was
performed.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 68379**],[**Known firstname 247**] [**2137-12-3**] 53 Female [**-4/4343**]
[**Numeric Identifier 68380**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], DR. [**Last Name (STitle) **]. SAMEDI/mtd
SPECIMEN SUBMITTED: RIGHT LOBE LIVER LESION (2), WHIPPLE
SPECIMEN, GALLBLADDER, DUODENAL CUFF & JEJUNUM.
Procedure date Tissue received Report Date Diagnosed
by
[**2191-9-28**] [**2191-9-28**] [**2191-10-4**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma??????
DIAGNOSIS:
I. Right lobe liver lesion (A):
1. Fragments of peritoneum and adipose tissue.
2. No tumor.
II. Right lobe liver lesion, additional (B):
1. Fragment of liver with cholestasis.
2. No tumor.
III. Gallbladder (C-E):
1. Mild fibrosis.
2. No tumor.
IV. Jejunum (F-H):
1. Segment of small intestine, within normal limits.
2. No tumor.
V. Portal vein margin (I):
Fibroadipose tissue, with no tumor.
VI. Pancreaticoduodenectomy (J-Z, AC):
1. Adenocarcinoma of the pancreas, see synoptic report.
2. Chronic inactive pancreatitis.
3. Segment of common bile duct with mild inflammation; no
tumor.
4. Segment of duodenum, within normal limits.
VII. Duodenal cuff (AA-AB):
Segment of proximal duodenum, without tumor.
<
Pancreas (Exocrine): Resection Synopsis
MACROSCOPIC
Specimen Type: Pylorus sparing pancreaticoduodenectomy, partial
pancreatectomy.
Tumor Site: Pancreatic head.
Tumor Size
Greatest dimension: 1.8 cm. Additional dimensions: 1.7
cm.
MICROSCOPIC
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G1: Well-differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 15.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 5 mm. Specified margin:
Pancreatic neck.
Margin(s) involved by invasive carcinoma:
Uncinate process margin (non-peritonealized surface of
the uncinate process).
Venous/Lymphatic vessel invasion: Absent.
Perineural invasion: Present.
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL
Eval for portal vein thrombosis
ABDOMINAL ULTRASOUND
INDICATION: 53-year-old woman with jaundice, pancreatic mass,
postop.
COMPARISON: [**2191-9-28**].
FINDINGS: The liver is homogeneous in echotexture. A biliary
stent is visualized. There is no intrahepatic biliary
dilatation. The main portal vein is patent with normal Doppler
waveforms. The distal aspect of the portal vein and SMV cannot
be evaluated due to the presence of gas. Small amount of
right-sided pleural effusion is noted.
IMPRESSION:
1. Main portal vein is patent with antegrade flow and normal
color and pulsed wave Doppler.
2. Small right-sided pleural effusion.
BILIARY CATH CHECK [**2191-10-4**] 12:39 PM
REASON FOR THIS EXAMINATION:
d/c PTC
IMPRESSION: Status post discontinuation of right-sided 8 French
percutaneous biliary drainage catheter and Gelfoam torpedo
embolization of the transhepatic tract.
Brief Hospital Course:
She was admitted on [**2191-9-28**] for a Whipple Procedure. This was
complicated by a Portal Vein Injury. She remained intubated
overnight in the SICU and was extubated the next morning. Her
HCT remained stable at 30. She received 6L of crystalloid and 4
Units PRBC's, 250 cc cell [**Doctor Last Name 10105**], and 750 cc 5% Albumin. An US
was performed the next day and showed Main portal vein is patent
with antegrade flow and normal color and pulsed wave Doppler.
CV: HR was stable between 70-110. She was on IV Lopressor. POD 3
she was tachy to HR 130 with ambulation. Once tolerating PO's,
she was put on PO Lopressor.
Pain: Pain was controlled with an epidural and then started on a
PCA. She was eventually switched to PO meds.
Abd/GI: Her abdomen was soft, tender and nondistended. She had a
NGT draining brownish fluid. The midline dressing was dry and
intact. A JP drain was in the RLQ.
Her diet was slowly advanced once the NGT was removed. She was
tolerating a regular diet at time of discharge.
She had a PTC drain in place from the previous admission. This
was capped and she had no pain or elevation in her LFT's. The
PTC drain was removed on POD 6. Her JP amylase was 4 on POD 7.
This was removed. The staples were D/C'd prior to discharge.
Steri strips were in place and the incision was clean, dry, and
intact. There were no signs of infection.
Pathology: Pathology was discussed with her on [**2191-10-5**]. She will
need to follow-up with Oncology as an outpatient.
Activity: She was ambulating the halls and safe to go home.
Anxiety: She was started back on her home medications on POD 3
and anxiety was better.
Medications on Admission:
Prozac, Wellbutrin, Klonopin, Calcium
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
7. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Head Mass
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
Please resume all of your regular medications and take any new
medications as ordered.
Continue to ambulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Completed by:[**2191-10-6**]
|
[
"998.2",
"577.1",
"575.8",
"E870.0",
"157.8",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.12",
"51.22",
"52.7",
"38.47"
] |
icd9pcs
|
[
[
[]
]
] |
8375, 8381
|
5569, 7209
|
312, 485
|
8446, 8453
|
1495, 5343
|
8793, 8952
|
1304, 1309
|
7297, 8352
|
8402, 8425
|
7235, 7274
|
8477, 8770
|
1324, 1476
|
231, 274
|
5372, 5546
|
513, 1030
|
1052, 1215
|
1231, 1288
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,289
| 186,303
|
28123
|
Discharge summary
|
report
|
Admission Date: [**2144-11-30**] Discharge Date: [**2144-12-16**]
Date of Birth: [**2070-4-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sudafed / Amoxicillin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
I&D of peri rectal abscess
[**2144-12-11**] PICC line placement
[**2144-12-9**] CT guided drainage of R pleural effusion and
thoracostomy tube placement
History of Present Illness:
74M s/p TAA repair [**9-26**] w/ stage 4 decub ulcer presenting from
rehab with fever and hypotension. Postop complications
paraplegia, trach, PEG, pneumonia, chylothorax.
Past Medical History:
Hypertension
Benign Prostatic Hypertrophy
Hernia Repair
s/p Appy
Gastric Esophageal reflux disease
Left shoulder bursitis
ETOH
s/p AAA repair c/b chylothorax s/p L thoracotomy and drainage
[**10-15**] and trach/PEG [**10-27**],
Social History:
Lives with spouse
ETOH 1 drink/day
Tobacco: quit over 10 years ago
Family History:
NC
Physical Exam:
No Corneal reflex.
No Breaths after 2 minutes of observation
no audible heart sounds
no peripheral pulses
Brief Hospital Course:
The pt was admitted to the ICU for resusitation. He was
stabalized. Sharp debridment was used to remove all devitalized
tissue. A wound vac was placed. The pt was found to have a
pleural effusion. A pigtail drain was placed and chyle was
drained from the chest. The pt was hemodynamically unstable for
the majority of his hospital course. The patient was offered a
thorocotomy and thorasic duct ligation as treatment for his
chylothorax. The patient refused surgery. A meeting was held
with the patient and his family where he decided that he did
not wish to have any further treatment. he felt that his his
quality of life would be very poor. After a discussion with the
patient and the patients family it was decided that the patient
would be made CMO. A morphine gtt was started on the afternoon
of [**2144-12-15**] and the patient expired at 435 on [**2144-12-16**].
Medications on Admission:
doxycycline, ASA, colace, insulin SS, lantus 12 hs,
lansoprazole, Hep sc, amiodarone 200', lopressor 75", lasix 20",
vit C, FeSO4, citalopram 20'
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2145-1-18**]
|
[
"401.9",
"600.00",
"293.0",
"566",
"V44.1",
"707.03",
"707.02",
"427.31",
"276.4",
"599.0",
"530.81",
"682.2",
"V44.0",
"511.9",
"038.9",
"486",
"518.83",
"250.00",
"995.92",
"344.1",
"457.8",
"372.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"96.6",
"86.28",
"93.59",
"34.91",
"86.22",
"38.91",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2259, 2268
|
1152, 2035
|
296, 450
|
2319, 2328
|
2380, 2414
|
1003, 1007
|
2231, 2236
|
2289, 2298
|
2061, 2208
|
2352, 2357
|
1022, 1129
|
250, 258
|
478, 651
|
673, 902
|
918, 987
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,097
| 119,100
|
9565
|
Discharge summary
|
report
|
Admission Date: [**2145-6-14**] Discharge Date: [**2145-6-23**]
Date of Birth: [**2077-12-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2145-6-14**] Aortic Valve Replacment utilizing a 21 millimeter CE
Perimount Tissue Valve
History of Present Illness:
This is a 67 year old male with known bicuspid aortic valve and
aortic valve stenosis. Serial echocardiograms have revealed
worsening aortic stenosis. His only complaint is dyspnea on
exertion. He denies chest pain, PND, orthopnea, syncope and
pedal edema. His most recent echocardiogram is from [**2145-5-10**]
which confirmed severe AS([**Location (un) 109**] 0.6cm2, peak 98, mean 63), and
mild aortic insufficiency. There was only trivial MR and his
LVEF was estimated at 60%. Cardiac catheterization back in
[**2144-9-10**] showed normal coronary arteries. Based on the
above results, he was referred for cardiac surgical
intervention. Of note, Mr. [**Known lastname 1968**] has known carotid disease. A
recent carotid ultrasound in [**2145-6-10**] revealed bilateral
carotid artery plaques, left worse than right, associated with
luminal narrowings stable since [**2144-2-11**] (diameter
reduction less than 40% on the right and between 60 and 69% on
the left).
Past Medical History:
Aortic Valve Stenosis/Bicuspid Aortic Valve, Hypertension,
Hypercholesterolemia, Carotid Disease, Glaucoma, Cataracts,
History of Sinusitis and deviated septum, Degenerative Joint
Disease, s/p L eye surgery, s/p R elbow surgery, s/p
Tonsillectomy, s/p Dental extractions
Social History:
Quit tobacco in [**2110**]. Admits to social ETOH, no history of ETOH
abuse. He currently lives alone. He is a warehouse worker.
Family History:
No premature history of CAD
Physical Exam:
Vitals: BP 157/86, HR 60, RR 14, SAT 98% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign, edentulous
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 3/6 SEM which radiates to
carotids
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities, small left inguinal hernia
Pulses: 1+ distally
Neuro: alert and oriented, nonfocal
Pertinent Results:
[**2145-6-23**] 07:30AM BLOOD Hct-34.9*
[**2145-6-21**] 09:20AM BLOOD WBC-10.2 RBC-4.11* Hgb-12.6* Hct-37.4*
MCV-91 MCH-30.7 MCHC-33.7 RDW-12.9 Plt Ct-385#
[**2145-6-21**] 09:20AM BLOOD Plt Ct-385#
[**2145-6-23**] 07:30AM BLOOD UreaN-20 Creat-1.1 K-4.9
[**2145-6-21**] CXR
Unchanged small right apical pneumothorax and small bilateral
pleural effusions.
[**2145-6-14**] ECHO
Prebypass
1. No spontaneous echo contrast or thrombus is seen in the body
of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
2.There is severe 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%).
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
5.The aortic valve is bicuspid. The aortic valve leaflets are
severely
thickened/deformed. There is severe aortic valve stenosis. Trace
aortic
regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen. There is no pericardial effusion.
Post Bypass
1. Biventricular systolic function is preserved.
2. Bioprosthetic valve seen in the aortic position. Valve is
well seated and the leaflets move well. Trace Aortic
insufficiency that resolved with
protamine.
3. Trace to mild mitral regurgitation present.
4. Mild to moderate tricuspid regurgitation present. (unchanged
from
prebypass)
5. Aorta intact post decannulation
Brief Hospital Course:
On the day of admission, Dr. [**Last Name (STitle) 1290**] performed an aortic valve
replacement utilizing a tissue valve. The operation was
uneventful and he was brought to the CSRU for invasive
monitoring. For additional surgical details, please see separate
dictated operative note. Within 24 hours, he awoke
neurologically intact and was extubated. He maintained good
hemodynamics as he weaned from pressor support without
difficulty. After all invasive lines and chest tubes were
removed, he was transferred to the SDU on postoperative day one.
Beta blockers and diuretics were started and he was gently
diuresed to his pre-op weight. Routine chest x-ray revealed a
sizeable right sided pneumothorax. Epicardial pacing were wires
removed on post-op day three. He remained stable over the next
several days and the pneumothorax was followed very closely by
serial chest x-rays. On post-op day seven he became hypotensive
with walking. Beta blockers and diuretics were held and he was
bolused with fluid with an adequate response. He appeared to be
doing well with stable labs and physical exam on post-op day
eight. He was discharged to rehabilitation on postoperative day
nine with the appropriate follow-up appointments. He will return
monday for a chest x-ray to again evaluate his small right
apical pneumothorax.
Medications on Admission:
Lipitor 40 qd, Atenolol 12.5 qd, Cosopt eye gtts, Aspirin 81 qd,
Multivitamin
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours): one month supply.
Disp:*2 MDI* Refills:*2*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day): one month supply.
Disp:*2 MDI* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5344**] Knoll Nursing & Rehabilitation - [**Location (un) 5344**]
Discharge Diagnosis:
Aortic Valve Stenosis/Bicuspid Aortic Valve s/p Aortic Valve
Replacement
Postoperative Pneumothorax
PMH: Hypertension, Hypercholesterolemia, Carotid Disease,
Glaucoma, Cataracts, History of Sinusitis and deviated septum,
Degenerative Joint Disease, s/p L eye surgery, s/p R elbow
surgery, s/p Tonsillectomy, s/p Dental extractions
Discharge Condition:
Good
Discharge Instructions:
1) Patient may shower, no bathing or swimming until wound has
healed.
2) No creams, lotions or ointments to incisions.
3) No driving for one month.
4) No lifting more than 10 lbs for at least 10 weeks from the
date of surgery.
5) Monitor wounds for signs of infection. These include redness,
drainage or increased pain\
6) Report any fever greater then 100.5.
7) Please return to the [**Hospital1 18**] [**Location (un) 470**] clinical building Monday
[**2145-6-28**] for a chest xray. Bring yellow requisition slip with
you.
8) Please call with any concerns or questions.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**] (surgeon) in 4 weeks ([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) 32467**] (primary care provider) in [**1-11**] weeks ([**Telephone/Fax (1) 32468**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiologist) in [**1-11**] weeks.
Please call all providers for appointments
Need to have chest x-ray [**2145-6-28**].(Report to radiology on [**Location (un) **] clinical center between 8:00AM-4:00PM)
Completed by:[**2145-6-23**]
|
[
"401.9",
"424.1",
"512.1",
"272.0",
"433.10",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6546, 6655
|
4049, 5372
|
312, 405
|
7029, 7035
|
2351, 4026
|
7656, 8196
|
1859, 1888
|
5500, 6523
|
6676, 7008
|
5398, 5477
|
7059, 7633
|
1903, 2332
|
253, 274
|
433, 1403
|
1425, 1697
|
1713, 1843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,271
| 181,224
|
43896+58695
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-3-29**] Discharge Date: [**2194-4-13**]
Date of Birth: [**2138-11-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Aspirin / Augmentin / Trazodone Hcl / Ibuprofen /
Atrovent / Reglan / Ampicillin / Lipitor
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is 53F with multiple medical problems including [**Name (NI) 2320**],
CAD, HTN, and CHF (EF 55%) who presented w/ hyperglycemia.
Patient was seen in orthopedics clinic yesterday, and had a
cortisone injection to her right knee. That evening, patient
noted an elevation of her FSBG to the 400s. The following
morning, the patient had a >600 value on her morning FS. She
doubled up her usual SS, but continued to have a >600 value.
She endorses symptoms of increased thirst, head ache, blurred
vision, palpitations, and notable confusion. Patient called
into the [**Hospital 191**] clinic, and was told to come to the ED by the
triage nurse.
In the ED, the patients vs were HR 73, BP 180/77 O2 95% on RA.
Patient had FS of 632. She was given 16U sc regular insulin,
with continued critically high FS. The patient was started on
an insulin gtt. Upon arrival to the ICU, her FS was 250. Her
symptomatic complaints had resolved.
Past Medical History:
CAD cath [**7-3**] with non-flow limiting proximal LAD 40% stenosis:
CHF - diastolic (last echo [**1-/2193**], EF > 55%, diastolic
dysfunction)
PE: bilateral acute PE [**11-4**] at [**Hospital1 18**]
DM
CRI
Asthma
BiPolar
HTN
GERD
Obesity
Uterine Fibroids
Migraines
Fibromyalgia
Anemia
Renal failure
Social History:
Denies any tobacco, alcohol or drug use. Baby sits her
granddaughters, unemployed.
Family History:
Mother had HTN, CAD, died at the age of 34 of an MI. DM on
mother??????s side of family. Grandfather died of colon CA in his
70??????s. Three sisters, one age 51 with Lupus. One brother with
Asthma.
Physical Exam:
GEN: obese AAF with cushingoid features
HEENT: dry mucous membranes, due to body habitus unable to
assess JVP, no LAD
HEART: reg rate, S1S2, III/VI SEM loudest LUSB
LUNGS: CTA b/l
ABD: obese, non-tender, non-distended, hypoactive bowel sounds
EXT: no cce, 1+DP, warm, no LE edema
Pertinent Results:
[**2194-4-13**] 08:00AM BLOOD WBC-18.6*
[**2194-4-9**] 06:40AM BLOOD WBC-25.0* RBC-3.82* Hgb-10.4* Hct-33.7*
MCV-88 MCH-27.3 MCHC-30.9* RDW-16.7* Plt Ct-232
[**2194-3-29**] 01:25PM BLOOD WBC-11.5* RBC-3.96* Hgb-10.9* Hct-34.4*
MCV-87 MCH-27.6 MCHC-31.7 RDW-15.3 Plt Ct-210
[**2194-4-10**] 06:30AM BLOOD Neuts-87.8* Lymphs-10.4* Monos-1.6* Eos-0
Baso-0.1
[**2194-4-13**] 08:00AM BLOOD PT-25.5* INR(PT)-2.5*
[**2194-4-12**] 07:20AM BLOOD PT-29.9* INR(PT)-3.1*
[**2194-4-11**] 07:05AM BLOOD PT-26.0* INR(PT)-2.6*
[**2194-4-11**] 07:05AM BLOOD UreaN-37* Creat-1.1 Na-139 K-4.8 Cl-104
HCO3-28 AnGap-12
[**2194-4-10**] 06:30AM BLOOD UreaN-35* Creat-1.1 Na-137 K-5.2* Cl-102
HCO3-27 AnGap-13
[**2194-4-7**] 06:50AM BLOOD LD(LDH)-311*
[**2194-4-7**] 06:50AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.6
[**2194-3-30**] 04:11AM BLOOD %HbA1c-10.7*
[**2194-3-29**] 01:25PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2194-3-29**] 01:25PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2194-3-29**] 01:25PM URINE RBC-<1 WBC-0 Bacteri-RARE Yeast-NONE
Epi-[**4-2**]
TWO VIEWS OF THE CHEST DATED [**2194-3-29**]
HISTORY: 55-year-old woman with hyperglycemia; evaluate for
pneumonia.
FINDINGS: Two views are compared with studies dated [**2194-2-4**] and
[**2193-11-18**]; the overall appearance is unchanged. Vague opacity at
the lateral aspect of left lung base, unchanged, likely
corresponds to the prominent paracardiac fat pad, well-seen on
the lateral view. Lung volumes are slightly improved and the
lungs are clear. The cardiomediastinal silhouette and pulmonary
vessels are unchanged and there is no pleural effusion.
Incidentally noted are cholecystectomy clips and DISH involving
the thoracic spine.
Cardiology Report ECG Study Date of [**2194-3-31**] 11:32:30 PM
Sinus rhythm with second degree A-V block (Wenckebach). Left
atrial
abnormality. Right bundle-branch block. Consider prior inferior
myocardial
infarction. Delayed R wave progression with late precordial QRS
transition is
non-specific. QTc interval appears prolonged but it is difficult
to measure.
Since the previous tracing of [**2194-3-29**] second degree A-V block is
now present.
STUDY: PA and lateral chest, [**2194-4-5**].
HISTORY: 55-year-old woman with asthma and increasing cough.
FINDINGS: Comparison is made to previous study from [**2194-3-29**].
Cardiac silhouette is upper limits of normal. There is some
streaky densities at the left base which may be due to
atelectasis or early infiltrate. This is more apparent than on
the prior study. No pulmonary edema or pleural effusions are
seen. There are severe degenerative changes seen of the right AC
joint.
PA and lateral upright chest radiograph compared to [**2194-4-5**].
The heart size is mildly enlarged but stable. Mediastinal
contours are unremarkable. The lungs are essentially clear with
no new focal infiltrate demonstrated. The pleural surfaces are
smooth and there is no pleural effusion or pneumothorax.
IMPRESSION: No evidence of acute cardiopulmonary process on the
current radiographs. Cardiomegaly.
Brief Hospital Course:
The patient presented with hyperglycemic non ketotic state
related to uncontrolled diabetes. Last Hbg A1C of 9.3. Current
hyperglycemia is possibly in the setting of steroid injection in
ortho clinic. Pt developed BG > 600 and was symptomatic. Sugars
significantly improved on insulin gtt and she was sent to the
floor. [**Last Name (un) **] team followed with daily adjustment of NPH and
sliding scale, particularly after initiation of steroids for
asthma exacerbation. She was switched over from regular to
humalog (lispro) sliding scale. Sugars were fairly controlled
but since patient is on steroids (as noted below), will need
closer [**Last Name (un) 7941**] outpatient.
In the hospital, the patient developed an asthma exacerbation.
This was initially treated with nebulizers with not much
improvement and so I steroids followed by po steroids started.
CR revealed question of lung infiltrate and so levofloxacin was
started to complete a 7 day course.
Initially, INR was supra therapeutic and so warfarin was held.
Eventually restarted in the hospital. Since she is on
levofloxacin that can interact with warfarin, the dose of latter
was decreased to 4 mg daily and she was asked to follow up for
INR checks with PCP [**Last Name (NamePattern4) **] [**3-2**] days after discharge. INR on day of
discharge was 2.5.
Medications for CAD, HTN, Chronic diastolic HF, depression were
continued.
Dose of gabapentin was reduced to match with renal function.
Medications on Admission:
ADVAIR DISKUS 250-50MCG--One puff twice a day
ALBUTEROL SO4 0.083 %--As directed with home nebulizer
ALBUTEROL SULFATE 17GM--2 puffs four times a day as needed for
wheeze
CALCITRIOL 0.25 mcg--1 (one) capsule(s) by mouth monday,
wednesday, friday
CLONAZEPAM 1 mg--1 tablet(s) by mouth before sleep
COLACE 100MG--One twice a day
EFFEXOR XR 150 mg--1 capsule(s) by mouth every morning
FIORICET 325 mg-40 mg-50 mg--one tablet(s) by mouth three times
a day as needed for prn ha do not take more than 3 per day or 5
per week
GLUCAGON EMERGENCY KIT 1MG--As directed for severe hypoglycemia
HUMULIN N 100 unit/mL--60 units in am 44 units at pm twice a day
INSULIN REGULAR HUMAN REC 100 U/ML--Sliding scale as directed
LANCETS,THIN --Use four times a day
LASIX 40 mg--1 and one half tab tablet(s) by mouth qam
LISINOPRIL 5 mg--1 (one) tablet(s) by mouth once a day
MIRALAX 100 %--one tablespoon by mouth once a day as needed for
constipation
NEURONTIN 300 mg--[**1-29**] capsule(s) by mouth three times a day
NITROGLYCERIN 0.4MG--One tablet under the tongue at onset of for
chest pain can repeat every 5 minutes x 3 if no relief call 911\
PERCOCET 5 mg-325 mg--1 to 2 tablet(s) by mouth every 4-6 hrs as
needed for pain
PRILOSEC OTC 20 mg--one tablet(s) by mouth once a day
RANITIDINE HCL 150 mg--take two tablet(s) by mouth at bedtime
RENAGEL 800 mg--one tablet(s) by mouth three times a day
SEROQUEL 200 mg--One to one and a half tablet(s) by mouth before
sleep
SEROQUEL 25 mg--1 tablet(s) by mouth once-twice a day as needed
for irritability
SIMVASTATIN 10 mg--1 tablet(s) by mouth once a day
SINGULAIR 10MG--One every day
TOPAMAX 25 mg--1 tablet(s) by mouth at bedtime
VERAPAMIL 360 mg--one cap(s) by mouth once a day
WARFARIN 2 mg--as directed up to 5 tablet(s) by mouth daily as
directed by coumadin clinic
WELLBUTRIN SR 100 mg--1 tablet(s) by mouth every morning
scooter --as directed once a day
Discharge Medications:
1. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMWF ().
3. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Topiramate 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
13. Verapamil 180 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q24H (every 24 hours).
14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
16. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
17. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
twice a day as needed for shortness of breath or wheezing.
18. Warfarin 4 mg Tablet Sig: One (1) Tablet PO daily at 1600
hours: follow up with Primary doctor [**First Name (Titles) **] [**Last Name (Titles) 7941**].
19. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 4 days: Take 3 tablets on [**2194-4-14**] and 3
tablets on [**2194-4-16**] and then stop.
[**Date Range **]:*6 Tablet(s)* Refills:*0*
20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take as directed. take 3 tablets for 3 days, then 2.5
tablets for 3 days, then 2 tablets for 3 days, then 1.5 tablets
for 3 days, then 1 tablet for 3 days and the half tablet for 3
days and then stop. Discuss further with your doctor.
[**Last Name (Titles) **]:*90 Tablet(s)* Refills:*0*
21. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
22. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
23. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
24. Fioricet Oral
25. Miralax Oral
26. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain.
27. Percocet Oral
28. Insulin
Take insulin NPH as follows:
90 units subcutaneously before breakfast;
60 Units subcutaneously at bedtime
29. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose as
directed by sliding scale. Subcutaneous at breakfast, lunch,
dinner and bedtime.
[**Last Name (Titles) **]:*3 vials* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Diabetes mellitus type 2, uncontrolled with complications /
hyperglycemic hyperosmolar nonketotic state
2. Acute asthma exacerbation
3. Possible pneumonia
4. History of pulmonary embolism
5. History of hypertension, chronic diastolic heart failure,
chronic kidney disease stage 3, depression, bipolar disorder
Discharge Condition:
stable. PEFR 200-240.
Discharge Instructions:
You were hospitalized with high blood sugar and had an asthma
exacerbation. Continue to take the prednisone as instructed. If
asthma gets worse with prednisone taper, call your doctor
immediately.
Take your insulin as prescribed. Return to the emergency
department if you have fever greater than 101, increasing
shortness of breath, chest pain, or any other concerns.
Your INR is 2.5 today ([**2194-4-13**]). the dose of warfarin was
adjusted to 5 mg daily. Since you are on the antibiotic, it is
important taht you continue to closely follow up with your
[**Hospital3 **], or Dr [**Last Name (STitle) **] to adjust the warfarin
dosing. INR check should be done in the next 2-3 days.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2194-4-14**] 11:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2194-4-25**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2194-5-8**] 1:50
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 11596**],[**Name Initial (NameIs) **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2194-4-14**]
10:00
Name: [**Known lastname 796**],[**Known firstname 15001**] Unit No: [**Numeric Identifier 15002**]
Admission Date: [**2194-3-29**] Discharge Date: [**2194-4-13**]
Date of Birth: [**2138-11-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Aspirin / Augmentin / Trazodone Hcl / Ibuprofen /
Atrovent / Reglan / Ampicillin / Lipitor
Attending:[**First Name3 (LF) 653**]
Addendum:
Pt discharged on warfarin 4 mg daily.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**]
Completed by:[**2194-4-14**]
|
[
"250.22",
"493.92",
"427.1",
"428.32",
"E932.0",
"V12.51",
"403.90",
"296.50",
"585.3",
"428.0",
"426.13",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14151, 14363
|
5459, 6925
|
376, 383
|
12253, 12277
|
2312, 5436
|
13012, 14128
|
1797, 1997
|
8871, 11816
|
11917, 12232
|
6951, 8848
|
12301, 12989
|
2012, 2293
|
323, 338
|
416, 1357
|
1379, 1681
|
1697, 1781
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,141
| 178,080
|
12811
|
Discharge summary
|
report
|
Admission Date: [**2113-10-11**] Discharge Date: [**2113-10-19**]
Date of Birth: [**2030-4-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
asymptomatic RLL mass
Major Surgical or Invasive Procedure:
[**2113-10-11**]
Redo right thoracotomy, lysis of adhesions, right lower
lobectomy, mediastinal lymph node dissection, bronchoscopy with
bronchoalveolar lavage, and pericardial fat pad buttress to the
bronchial stump.
[**2113-10-13**]
Bronchoscopy
[**2113-10-16**]
Flexible bronchoscopy with therapeutic aspiration.
History of Present Illness:
Ms [**Known lastname 37080**] is an 83F with FDG avid RLL mass with
positive bronchial washings for NSCLC. Although the biopsies
were
negative, the positive PET scan and positive washings make this
lesion highly suspicious for lung cancer. She currently denies
cough, SOB, DOE, sweats, chest pain, wt loss, HA or bony pain.
Past Medical History:
PMH:
syncope/TIA/left facial droop [**2113-5-28**]
hypothyroidism
cavernous angioma dx'd [**2094**]
osteopenia
thyroid cancer, s/p thyroidectomy [**2094**]
RUL lung cancer, s/p RUL lobectomy [**2094**]
BCC
hyperlipidemia
HTN
PSH:
RUL lobectomy [**2094**]
Thyroidectomy [**2094**]
Social History:
Cigarettes: [x ] never [ ] ex-smoker [ ] current
Pack-yrs:____
quit: ______
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:
Marital Status: [ ] Married [x] Single
Lives: [x] Alone [ ] w/ family [ ] Other:
Other pertinent social history:
Travel history: NONE
Family History:
Mother - [**Year (4 digits) 499**] Ca
Father
Siblings - Sister with [**Name2 (NI) 499**] Ca, brother with lung Ca
Offspring
Other
Physical Exam:
BP: 168/81. Heart Rate: 74. Weight: 139.6. Height: 60.5. BMI:
26.8. Temperature: 96.8. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 97.
Gen: NAD
Neck: no [**Doctor First Name **]
Chest: clear ausc
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
[**2113-10-13**] 4:24 pm Mini-BAL R MAINSTEM.
GRAM STAIN (Final [**2113-10-13**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). ~1000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml. WORK-UP PER DR. [**Last Name (STitle) 39463**],[**First Name3 (LF) 39464**] PAGER [**Numeric Identifier 39465**]
[**2113-10-16**].
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2113-10-16**] 7:25 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2113-10-18**]**
GRAM STAIN (Final [**2113-10-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2113-10-18**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
[**2113-10-16**] 4:55 am URINE Source: Catheter.
**FINAL REPORT [**2113-10-18**]**
URINE CULTURE (Final [**2113-10-18**]):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2113-10-11**] 08:02PM WBC-21.1*# RBC-3.88*# HGB-11.4*# HCT-33.8*#
MCV-87 MCH-29.4 MCHC-33.8 RDW-13.4
[**2113-10-11**] 08:02PM PLT COUNT-303
[**2113-10-11**] 03:33PM GLUCOSE-149* LACTATE-1.6 NA+-139 K+-3.5
CL--108
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2113-10-19**] 06:45 20.1* 3.17* 9.2* 29.0* 91 28.9 31.6 14.2
481*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2113-10-19**] 06:45 77* 0 11* 9 2 1 0 0
0
[**2113-10-18**] CXR :
In comparison with the study of [**10-17**], this upright view shows at
least two air-fluid levels in the right hemithorax. Presumably,
these are
related to the recent surgery and at least one of these
represents a loculated collection in or adjacent to the
mediastinum. Extensive post-surgical changes are again seen in
the right hemithorax. The left lung is clear and hyperexpanded
with blunting of the costophrenic angle.
Brief Hospital Course:
Mrs. [**Known lastname 37080**] was admitted to the hospital and taken to the
Operating Room where she underwent a redo right thoracotomy with
right lower lobectomy. She tolerated the procedure well and
returned to the PACU in stable condition. She had some sinus
bradycardia intraop therefore had cardiac enzymes cycled post
op. Her troponin were normal x 3 and she had no EKG changes.
Following transfer to the Surgical floor her chest tubes
remained in place until the drainage decreased and she was
attempting to use her incentive spirometer. She desaturated on
post op day #2 and was transferred to the ICU for more pulmonary
toilet as her remaining right lung was collapsed. A
bronchoscopy was done on [**2113-10-13**] to evaluate her airway and
thick tenacious secretions were found in the bronchus
intermedius and removed. She improved from a respiratory
standpoint thereafter.
She was seen by the Geriatric service as she had some confusion
and dizziness prior to transfer. They felt that her neuro exam
was that of MCI (mild cognitive impairment) as opposed to
Alzheimer's as she had no functional impairment and was not
dependent. The Aricept can cause orthostasis and would not be
effective with MCI therefore was stopped. She gradually
improved and had no more confusion or dizziness.
Her chest xrays were followed daily and she underwent another
bronchoscopy on [**2113-10-16**] and had secretions in both the right and
left main stem which were aspirated. Her nebulizer treatments
were increased and she remained afebrile.
From an ID standpoint she had some dysuria after the Foley
catheter was removed and was started on Cipro. Her culture grew
>100K Citrobacter. She also had BAL's sent with each
bronchoscopy and the antibiotic was changed to Levaquin for more
gram positive coverage. Her WBC has been as high as 27K and as
low as 15K post op, currently 20K without any bands in her
differential. Her lungs are clearer and her wound is healing
well. She has no evidence of phlebitis or any skin problems and
the elevated WBC is unclear as she clinically looks well. She
will complete a 7 day course of antibiotics which will end on
[**2113-10-23**]. She's tolerating a regular diet and working with
physical therapy so that she may return home.
She was discharged to rehab on [**2113-10-19**] and will follow up in the
Thoracic Clinic in 2 weeks or sooner if needed.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Alendronate Sodium 70 mg PO QFRI
2. Donepezil 5 mg PO HS
3. Enalapril Maleate 20 mg PO BID
4. Levothyroxine Sodium 175 mcg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. NiCARdipine 20 mg PO DAILY Start: noon
give at noon
7. NiCARdipine 40 mg PO BID
8. Pravastatin 80 mg PO DAILY
9. Calcium Carbonate 1000 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Alendronate Sodium 70 mg PO QFRI
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 80 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Albuterol 0.083% Neb Soln [**1-30**] NEB IH Q6H:PRN wheeze
8. Docusate Sodium 100 mg PO BID
9. Guaifenesin ER 600 mg PO Q12H mucus plug
10. Heparin 5000 UNIT SC TID
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
13. Levofloxacin 750 mg PO DAILY
thru [**2113-10-23**]
14. Milk of Magnesia 30 mL PO HS:PRN constipation
15. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
16. Senna 1 TAB PO BID
17. TraMADOL (Ultram) 25-50 mg PO Q6H:PRN pain
18. Calcium Carbonate 1000 mg PO DAILY
19. NiCARdipine 20 mg PO DAILY
give at noon
20. NiCARdipine 40 mg PO BID
Hold for SBP < 100
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
Lung cancer
Collapse of the right lung with mucus plugging
Right lung atelectesis
Urinary tract infection (Citrobacter)
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 for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2113-10-31**] at 2:30 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray
Completed by:[**2113-10-19**]
|
[
"997.1",
"599.0",
"427.89",
"934.1",
"331.83",
"438.83",
"244.0",
"V10.83",
"272.4",
"V10.87",
"041.85",
"458.0",
"401.9",
"733.90",
"162.5",
"518.0",
"V16.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.78",
"33.24",
"40.3",
"32.49",
"34.99",
"03.90",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10133, 10223
|
6334, 8741
|
298, 618
|
10387, 10387
|
2120, 2410
|
12031, 12521
|
1721, 1853
|
9251, 10110
|
10244, 10366
|
8767, 9228
|
10570, 12008
|
1868, 2101
|
2451, 6311
|
237, 260
|
646, 973
|
10402, 10546
|
995, 1278
|
1682, 1705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,386
| 120,925
|
44097
|
Discharge summary
|
report
|
Admission Date: [**2113-6-30**] Discharge Date: [**2113-7-2**]
Date of Birth: [**2036-9-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10552**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
GI bleed with intermittent hypotension
History of Present Illness: 76 year old male with history of
moderate calcific aortic stenosis, HTN/HL, DM2, now presenting
with weakness and fatigue for 2-3 days, preceded by black stools
several hours prior. She reports episodes of diaphoresis,
tachycardia, epigastric discomfort with belching. [**Name6 (MD) **] Cardiology
NP referral, the patient has never had a colonoscopy or upper
endoscopy. He reports taking a "charcoal pill" for his
epigastric discomfort today and that this has turned his stools
dark before. However, he had not been taking them prior to when
his stool first appeared dark. He has never had any episodes
like this before and denies any diarrhea, saying the stools are
dark but formed. He does not drink or smoke and does not
endorse any NSAID use. He has been taking ASA for the past few
years for his heart disease. He denies fevers/chills,
nausea/vomiting, or headaches. EKG prior to transfer to ED from
cardiology clinic showed sinus rhythm at 98/min, RBBB with LAFB,
and likely LVH. No diagnostic interim change from prior tracing
(per read from Cardiology clinic).
Of note, during his last visit to Dr. [**Last Name (STitle) 171**] on [**6-21**], he
continued to
have occasional mild chest tightness with exertion, which goes
away with rest. The pattern of discomfort has not changed in >2
years. His aortic valve disease remains stable, monitored with
serial TTEs. He is continuing to try to lose weight and has had
mild success so far.
In the ED, initial VS were: 97.1 70 126/58 16 97%. Exam was
notable for grossly melanotic stools, occult positive per
rectal. He was started on IV pantoprazole gtt, peripheral IVs
(18g) were placed, and type and cross obtained. He has had
pressure dips to SBP of 98 to low 100s. Given his prior history
of aortic stenosis with presumed upper GI bleed, the decision
was made to monitor him in the ICU. Admission vitals: 109, RR:
16, BP: 107/65, O2Sat: 100, O2Flow: RA.
On arrival to the MICU, he is conversant, comfortable, and in
good spirits. He appears quite well.
Past Medical History:
- Moderate calcific AS ([**Location (un) 109**] (1-1.2 cm2, from TTE in [**2112-8-5**])
---normal LVEF of last TTE
---last ETT-MIBI ([**2112**]) - 6.5 METS, no ischemia (probable CAD
based on prior stress testing with inferior ischemia)
- Hypertension
- Dyslipidemia
- Bifascicular block (LAFB, RBBB)
- DM2
- mild CKD
- senile cataract s/p surgery
- status post right shoulder arthroscopic rotator cuff repair
with biceps tenotomy.
Social History:
Retired architect and is now a professional inventor with over
15 patents. Married. No current smoking or drinking.
Family History:
Noncontributory
Physical Exam:
Admission Physical:
.
Vitals: T: 98.4 BP: 117/60 P: 104 RR: 27, O2 sat:97 on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, conjunctivae nl, MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1, blunted S2 with III/VI
holosystolic, machine-like murmur heard best over 2nd right ICS,
no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace edema, no clubbing,
cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge Physical
Pertinent Results:
Admission Labs:
.
[**2113-6-30**] 04:20PM BLOOD WBC-13.4*# RBC-3.19* Hgb-9.9* Hct-30.4*
MCV-96 MCH-31.1 MCHC-32.6 RDW-14.1 Plt Ct-209
[**2113-6-30**] 04:20PM BLOOD Neuts-80.3* Lymphs-15.0* Monos-4.2
Eos-0.4 Baso-0.3
[**2113-6-30**] 04:20PM BLOOD PT-12.1 PTT-30.7 INR(PT)-1.1
[**2113-6-30**] 04:20PM BLOOD Plt Ct-209
[**2113-6-30**] 04:20PM BLOOD Glucose-310* UreaN-58* Creat-1.1 Na-136
K-4.8 Cl-102 HCO3-20* AnGap-19
[**2113-6-30**] 04:20PM BLOOD Calcium-9.6 Phos-2.8 Mg-1.9
.
Imaging:
.
CHEST RADIOGRAPH PERFORMED ON [**2113-6-30**].
COMPARISON: None.
CLINICAL HISTORY: Weakness, assess for pneumonia or CHF.
FINDINGS: PA and lateral views of the chest were obtained.
Lung volumes are low with bronchovascular crowding in the lower
lungs. No definite sign of pneumonia or CHF. No large effusion
or pneumothorax. Heart size cannot be assessed on the frontal
view though appears within normal limits on the lateral view.
Mediastinal contour is normal. Bony structures appear intact.
Mild degenerative changes in the upper thoracic spine noted.
IMPRESSION: Limited, negative.
Brief Hospital Course:
Assessment and Plan: 76 year old male with history of moderate
aortic stenosis and likely CAD, DM2, HTN/HL, now presenting with
melenotic stools in the setting of weakness and fatigue, likely
secondary to blood loss anemia from upper GI bleed.
# Gastrointestinal bleeding form duodenal ulcer: Presented with
two days of melena. He was admitted to the MICU because his
blood pressure was slightly low and his moderate aortic stenosis
would complicate fluid resucitation. He was transfused two units
of PRBCs without complication. He underwent EGD which showed
multiple small duodenal ulcers with evidence of recent bleeding.
He was treated with IV PPI and was then transitioned to PO
pantoprazole. His h. pylori serologies were positive and he was
started on two weeks of amoxicillin and clarithromycin and 6
weeks of oral PPI. He will need a test of cure in 6 weeks by a
stool H. Pylori antigen test or a urease breath test. His
aspirin was restarted on discharge. Because of an interaction
between simvastatin and clarithromycin, he was instructed not to
take his simvastatin for the two weeks that he will be taking
clarithromycin.
#Hypertension: He normally takes verapamil, imdur, lisinopril,
and triamterne/hydrochlorothiazide. However he was slightly
hypotensive on admission likely from reduced preload in the
setting of his aortic stenosis so his antihypertensives were
held. His blood pressure slowly came back up but his blood
pressure was 120/80 on discharge without any medications so he
was told not to restart his medication until instructed by his
VNA or primary doctor.
.
# Aortic stenosis: Moderate, per most recent TTE, with [**Location (un) 109**] of
1.0-1.2cm2. His low blood pressure may have been related but
there were otherwise no complications during this admission.
.
# Diabetes mellitus: His medications were held while he was NPO
but restarted metformin and januvia when he resumed his diet.
TRANSITIONAL ISSUES
-Restarting his BP meds as appropriate. A home VNA will visit
daily to ensure normal vitals.
-Test of cure after completion of H. Pylori treatment
Medications on Admission:
ASA 81 mg daily
triamterene-HCTZ 37.5-25 mg daily
ImDur 30 mg daily
lisinopril 40 mg daily
metformin 500 mg [**Hospital1 **]
Januvia 25mg daily
glimepiride
simvastatin 40 mg daily
verapamil SR 240mg daily
MVI
Discharge Medications:
1. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Januvia 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 6 weeks.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start until after finishing antibiotic [**2113-7-16**].
5. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: On
hold until instructed to restart.
7. Imdur 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet
Extended Release 24 hr PO once a day: On hold until instructed
to restart.
8. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Capsule PO once a day: On hold until instructed to restart.
9. Prevpac 500-500-30 mg Combo Pack Sig: One (1) PO once a day.
10. amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
11. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis
Duodenal ulcer
Helicobacter pylori infection
Secondary Diagnoses:
Moderate aortic stenosis
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 4640**],
Thank you for coming to the [**Hospital1 1170**]. You were admitted to the hospital because you were
having bleeding from ulcers in your GI tract. This developed
because you have a bacteria in your stomach. You will need to
take antibiotics for two weeks. We also started you on a
medication to decrease the acid in your stomach. Your blood
pressure was low in the hospital so we stopped several of your
blood pressure medicines. Please follow up with your primary
doctor and cardiologist as directed.
Medication Recommendations
-Please START amoxicillin 1000 mg twice daily for two weeks
(last day [**2113-7-16**])
-Please START clarithromycin 500 mg twice daily for two weeks
(last day [**2113-7-16**])
-Please START pantoprazole 40 mg twice for six weeks
-Please STOP simvastatin because this can interact with one of
the antibiotics. you should restart this after you finish
antibiotics ([**2113-7-17**])
-Please STOP Lisinopril, Imdur, verapamil,
triamterene/hydrochlorothiazide until instructed to restart
them.
Followup Instructions:
Please call your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
within 3 days of discharge.
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) 35593**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 35276**]
Fax: [**Telephone/Fax (1) 35649**]
Please call your cardiologist to [**Telephone/Fax (1) **] a follow up
appointment with your cardiologist in the next two-three weeks.
Name: [**Last Name (LF) 171**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: CARDIOVASCULAR DIVISION, E/RW-453
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Fax: [**Telephone/Fax (1) 19842**]
|
[
"530.10",
"532.40",
"530.81",
"585.9",
"250.40",
"401.9",
"041.86",
"458.9",
"285.1",
"414.01",
"424.1",
"426.52",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8572, 8629
|
4998, 7090
|
311, 316
|
8805, 8805
|
3891, 3891
|
10036, 10843
|
3043, 3060
|
7349, 8549
|
8650, 8714
|
7116, 7326
|
8956, 10013
|
3075, 3872
|
8735, 8784
|
265, 273
|
412, 2439
|
3907, 4975
|
8820, 8932
|
2461, 2894
|
2910, 3027
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,439
| 153,669
|
38474
|
Discharge summary
|
report
|
Admission Date: [**2120-5-8**] Discharge Date: [**2120-5-17**]
Date of Birth: [**2052-9-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
cough, carcinoid
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
This is a 67 year-old male, primarily Lebanese speaking, with a
past medical history of carcinoid tumor of right lung with past
episodes of hemoptysis, chronic obstructive pulmonary disease,
coronary artery disease s/p stent placement, pneumonia (atypical
vs. post-obstructive), diabetes mellitus, GERD, and positive PPD
who was treated for TB with negative sputum cultures who was
transferred from [**Hospital 1474**] Hospital after admission for pneumonia
now for rigid bronchoscopy for evaluation and laser therapy of
his carcinoid tumor.
Patient initially presented to [**Hospital 1474**] Hospital on [**2120-5-3**] with
fever and cough of one day duration. Fever up to 100 F. Cough
productive of yellow-green sputum, pink-tinged, but no frank
blood. He was also complaining of shortness of breath and home
O2 sats were measured in the high 80s. At [**Hospital1 1474**], he was
treated for post-obstructive pneumonia with IV avelox and
vancomycin. Sputum cultures returned "few mixed bacteria
consistent with normal respiratory flora including gram negative
rods." During that hospitalization he also complained that his
urine was warm. Urine cultures have shown no growth to date.
Antibiotics were discontinued.
Patient was diagnosed with carcinoid tumor of right lung in
[**Month (only) **]/[**2119-12-5**] and has been followed with observation by
Dr. [**Last Name (STitle) 31573**] at [**Hospital1 1474**]. He has had tumor involvement of his right
middle lobe bronchus (initially presenting with hemoptysis) and
has undergone debulking of the tumor. He has had an Octreotid
scan indicating involvment in the right hilum and masses and
consolidation in the right middle and right lower lobe
consistent with metastatic disease. Bilobectomy was recommended
in the past, but patient has declined. He has been seen by Dr.
[**First Name (STitle) **] in Oncology. Current chest CT indicates disease progression
with a larger hilar mass, new mediastinal node disease, and
tumor almost filling the right mainstem bronchus, however, CT
and CXR document aeration of right lung indicating that tumor is
not completely obstructing. Patient was seen by Dr. [**First Name (STitle) **] of
Radiation therapy who felt that radiation along with
chemotherapy could be an option if patient is not a surgical
candidate. Dr. [**Last Name (STitle) 31573**] spoke with Dr. [**Last Name (STitle) 8099**] [**Name (STitle) **] ([**Hospital1 18**]),
interventional pulmonary division, to request rigid bronchoscopy
and laser therapy and patient was transferred.
Patient is currently stable and afebrile. He complains of
shortness of breath and cough. Cough is productive of yellow
sputum, pink-tinged, but no frank blood. He has also had a few
episodes of post-tussive emesis.
Past Medical History:
Carcinoid diagnosed [**2119**] as above
Coronary artery disease s/p stenting [**2110**] (in [**Country 1684**])
Chronic obstructive pulmonary disease
Pneumonia (atypical vs. post-obstructive)
Diabetes mellitus
GERD
Positive PPD (was treated for 3 months, cultures returned
negative)
PSH:
Cardiac stent placed in [**Country 1684**] after + stress test [**2111**]
Bronchoscopy for hemoptysis [**2107**]
Flexible fiberoptic bronchoscopy with bronchial biopsies at
[**Hospital 1474**] Hospital by Dr. [**Last Name (STitle) 31573**] [**2119-10-9**]
Flexible/rigid bronchoscopy and removal of tumor from bronchus
intermedius at [**Hospital 1474**] Hospital by Dr. [**Last Name (STitle) 85621**] [**2119-11-29**]
Social History:
Patient is from [**Country 1684**] originally, although he spent much of
his life in [**First Name8 (NamePattern2) 466**] [**Country 467**] and other parts of [**Country 480**]. He moved to
the United States seven years ago with his wife to live with his
son. [**Name (NI) **] and his wife live in a two family house with his son's
family (son, wife, 2 children) in [**Location (un) 5110**]. Patient works with
his son as a maintenance worker. He used to work as a contractor
in [**Country 480**]. He and his wife have 4 living sons and 1 daughter who
died in a car accident. The other sons live in [**Name (NI) 1684**] or
[**Name (NI) 480**].
- Tobacco: smoked 3 ppd for 53 years, but quit smoking 2 years
ago
- EtOH: very rare, special occasions only
- Illicits: denies
- Exercise: no dedicated exercise, but active in job doing
maintenance
Family History:
Denies family history of diabetes, cancer, and heart disease.
Physical Exam:
Vitals: 96.6 134/78 89 20 96% on 3L
General: Thin elderly man in mild respiratory distress. He is
alert, oriented, cooperative, and appropriate.
HEENT: Head: normocephalic, atraumatic; Eyes: PERRLA, EOMI, lids
and conjunctiva normal; Ears: hearing grossly intact; Oropharynx
non-erythematous, no exudate, no lesions
Lungs: mild respiratory distress with use of accessory muscles,
diffuse expiratory wheezes, but good air movement to bases
bilaterally
CV: RRR, no murmurs, rubs, or gallops
Abdomen: soft, non-distended, non-tender, BS+
Rectum: deferred
GU: deferred
Extremities: warm, well-perfused, no edema, 2+ PT and DP pulses
bilaterally
Skin: no rashes or lesions
Neuro: A+Ox3, grossly intact
Pertinent Results:
[**2120-5-4**] Culture, Respiratory ([**Hospital1 1474**]): few mixed bacteria with
normal respiratory flora including gram negative rods
[**2120-5-4**] Gram Stain, Respiratory ([**Hospital1 1474**]): no epithelial
cells/LPF, [**10-28**] WBC/LPF, [**1-13**] mixed bacteria consistent with
normal respiratory flora
[**2120-5-4**] Culture, Urine ([**Hospital1 1474**]): no growth
[**2120-5-5**] Chem ([**Hospital1 1474**]): Na 139 K4.2 Cl 105 CO2 26 Ca 8.5, Mg
2.0, Gluc 100, BUN 20, Cr 1.1, Phos 3.2
[**2120-5-5**] CBC/diff ([**Hospital1 1474**]): WBC 9.1 RBC 4.64 HGB 12.4 HCT 38.0
MCV 81.0 PLT 252 NEUT 72.3 LYMPHS 16.5 MONO 8.7 EOS 2.3 BASO 0.2
[**2120-5-3**] CXR PA/LAT ([**Hospital1 1474**]): Study is read in conjunction with
recent CT scan from previous day. Chest radiograph again shows a
somewhat ovoid tubular opacity within the right middle lobe
extending to the right hilum which on CT scan appears to
correspond to a fluid and/or debris filled distal mainstem and
right middle lobe bronchi likely representing superimposed
infectious process and/or mucoid impactin in associated
bronchiectatic right middle lobe bronchi. The left lung is
clear. There is no acute congestive failure. An underlying
endobronchial leion with distal obstruction could not be
completely excluded. Clinical correlation and if indicated
bronchoscopic examination is suggested.
[**2120-5-2**] Chest CT ([**Hospital1 1474**]): 3.9 x 4.5 x 3 cm right parahilar
mass increased slightly in size since prior study. New
pretracheal adenopathy. New 5 mm left lower lobe nodular
density. Persistent tubular opacities in right middle lobe which
may represent fluid filled bronchi.
[**2120-5-8**] 04:00PM WBC-14.4* RBC-4.61 HGB-12.5* HCT-36.9*
MCV-80* MCH-27.0 MCHC-33.8 RDW-14.1
[**2120-5-8**] 04:00PM NEUTS-90.1* LYMPHS-6.4* MONOS-2.5 EOS-0.7
BASOS-0.3
[**2120-5-8**] 04:00PM PLT COUNT-339
Brief Hospital Course:
Mr. [**Known lastname 11929**] is a 67 yo M with h/o right endobronchial carcinoid
tumor s/p resection complicated by bleed necessitating left main
stem intubation who was transferred to the MICU for further
monitoring.
.
# Hypoxic Respiratory Failure: Secondary to pts bleeding
mainstem bronchus tumor following bronch procedure on top of
baseline COPD with sats on RA at home ranging only 88-92.
Throughout pts course in the ICU he had persistent white out of
the right lung. The patient was unable to wean the vent while
ventilating only the left lung, most likely [**2-6**] underlying
severe COPD. The patient also developed left lung infiltrates,
thought to be secondary to spillage from the right lung. Two
repeat bronchoscopies were attempted, both times clot and
secretions overflowed from the right when the ET tube was pulled
back and it was thought to be unsafe to attempt washout or
aspiration for fear of causing significant cross contamination
of the good lung. Ultimately the patient became persistently
hypoxic despite high PEEP, high tidal volume ventilation.
.
# Sepsis: Thought secondary to patient post-obstructive
pneumonia that developed behind the right-sided endobronchial
carcinoid tumor. The pt was persistently febrile for the first
several days of admission and covered with broad spectrum
antibiotics. Pts blood pressures remained low and pt
intermittently required pressors, complicated by intermittent AF
with RVR.
.
#AFib with RVR- Contributed to patients hypotension. Eventually
converted to sinus with amiodarone gtt.
.
# Atypical Carcinoid Tumor: With new lad concerning for spread.
Oncology and radiation oncology services were consulted and
emphasized pts overall poor prognosis. Palliative chemo and
radiation were offered as options only if patient was able to
wean off the vent.
.
On [**5-18**], the patient developed worsening refractory hypoxia
despite maximal ventilator settings as well as hypotension on
maximal single pressors. In discussion with the family, given
the patients poor overall prognosis, the decision was made to
make withold further escalation of care. The patient expired at
7:38 pm with his wife and son at the bedside.
Medications on Admission:
Metformin 500 mg daily
Glyburide 5 mg daily
Simvastatin 10 mg daily
Lisinopril 2.5 mg daily
Omeprazole 20 mg daily
Spiriva 18 mcg
Proair
Discharge Medications:
-
Discharge Disposition:
Expired
Discharge Diagnosis:
-
Discharge Condition:
Death
Discharge Instructions:
-
Followup Instructions:
-
|
[
"V45.82",
"250.00",
"997.39",
"414.01",
"038.9",
"530.81",
"795.5",
"786.3",
"V66.7",
"E879.8",
"518.5",
"486",
"209.21",
"995.92",
"785.52",
"496",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.72",
"32.01",
"96.04",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
9840, 9849
|
7434, 9627
|
330, 344
|
9894, 9901
|
5534, 7411
|
9951, 9955
|
4739, 4802
|
9814, 9817
|
9870, 9873
|
9653, 9791
|
9925, 9928
|
4817, 5515
|
274, 292
|
372, 3133
|
3155, 3863
|
3879, 4723
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,667
| 146,220
|
27134
|
Discharge summary
|
report
|
Admission Date: [**2160-10-11**] Discharge Date: [**2160-10-21**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
a-line
femoral triple lumen line
History of Present Illness:
[**Age over 90 **] year old male with warm hemolytic anemia on chronic
prednisone 10mg, GI Bleeds, AF with [**Age over 90 5509**], CHF with EF 45%,
listeria endocarditis, mechanical AVR on coumadin, CKD stage
III, presenting from nursing facility with complaints of
tachycardia, fever, abdominal pain. The onset was 3 days prior;
due to the patient's poor baseline mental status and intubation,
limited history was obtained from the patient.
.
It was noted per EMS notes that the patient was found in [**Hospital 100**]
Rehab with evidence of SVT in 160s, sBP in 120s, got 6 of
adenosine responded with 10 sec pulse (90-100 BP) intermittent
hypotension, otherwise no localizing symptoms despite the
patient's subjective complaints of abdominal pain. On arrival
to the ED, he was noted to be febrile to 105, on a
non-rebreather. CT of torsal showed BIL infiltrates, consistent
with aspiration PNA. EKG: SVT, 160, no appreciable ischemic
changes. He was intubation with etomidate and succinylcholine,
first pass with bougie, 7.5 tube that is at 22 at the lips.
Phenylephrine used in the peri-intubation for goal systolic
blood pressure greater than 120, given fentanyl, versed. Abx
were targetting HCAP: Cefepime, Vancomycin, Levofloxacin.
Recieved 2L of IVF. Has a 20-gauge peripheral, right-sided PICC
central access - R groin. After these intervention, pt's HR
down to 90 (regular, sinus) and SBP approx 100-120. Admitted to
MICU for sepsis/PNA complicated by SVT that has currently
resolved. Of note, MICU was asked to need to pull PICC and
culture tip as a potential additional source of infection. ED
was unable to pass the Foley despite 3 attempts. Urology
consult as an inpatient was recommanded by the ED.
.
On review of transfer notes, PICC line was last changed on
[**2160-10-10**] (changed weekly), zinc oxide to butt, lotrisone to
foot. He was last transfused on [**2160-10-7**] with PRBC hct of 24.6
on [**2160-10-6**]. He has been complaining of abdominal pain for the
past week treated with maalox and simethicone. He had VS: Temp
of 102 Axillary; HR 164; BP 115/81; RR 26; 86% RA 92% 2L.
.
Past Medical History:
# Anemia, multifactorial as below, baseline HCT 28
# Autoimmune hemolytic anemia (Coomb's +, warm autoantibody),
on prednisone 10mg Po daily
# Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped
due to hemolytic anemia
# Aortic mechanical valve, recently Coumadin resistant so
intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **]
# hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon
with melanotic stool in terminal ileum
# GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on
the wall opposite the ampulla. Small hiatal hernia. Otherwise
normal EGD to third part of the duodenum.
# H/o presyncope
# CKD Cr 1.6-2.0 Stage III
# CAD s/p NSTEMI [**7-10**]
# Chronic CHF, likely diastolic, ([**9-9**] EF=50%)
# Hyperlipidemia
# Hypertension
# Depression vs adjustment disorder after death of brother
# Prostate cancer- s/p radiation
# Bladder/bowel incontinence
# Right lateral malleolus stage 1 pressure ulcer
# Dementia
# Hypothyroidism
Social History:
Never smoked, no EtOH or other drugs. Currently living at [**Hospital 100**]
Rehab. Uses wheelchair typically. Requires assistance in all his
ADLs and IADLs. Has 2 sons and 4 grandchildren
Family History:
No bleeding diatheses or heart disease. Father had stomach
cancer. No other cancers including colon.
Physical Exam:
Vitals: T:98.5 BP:93/47 P:76 R: 18 O2: 98% vent
General: intubated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: CTAB, no w/r/c anteriorly.
CV: Regular rate and rhythm, normal S1, pronounced S2, no
murmurs, rubs, gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
GU: no foley, blood around the scrotum.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
At admission:
[**2160-10-11**] 10:19PM URINE HOURS-RANDOM UREA N-329 CREAT-97
SODIUM-20 POTASSIUM-43 CHLORIDE-17
[**2160-10-11**] 10:19PM URINE OSMOLAL-378
[**2160-10-11**] 10:19PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-<1.005
[**2160-10-11**] 10:19PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-0.2 PH-5.0 LEUK-NEG
[**2160-10-11**] 10:19PM URINE RBC->182* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-0
[**2160-10-11**] 10:19PM URINE EOS-NEGATIVE
[**2160-10-11**] 09:15PM GLUCOSE-121* UREA N-35* CREAT-1.8* SODIUM-136
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-21* ANION GAP-16
[**2160-10-11**] 09:15PM ALT(SGPT)-41* AST(SGOT)-50* ALK PHOS-79 TOT
BILI-0.5
[**2160-10-11**] 09:15PM ALBUMIN-2.9* CALCIUM-7.6* PHOSPHATE-2.6*
MAGNESIUM-2.2
[**2160-10-11**] 09:15PM WBC-15.3* RBC-3.75* HGB-12.0* HCT-35.0*
MCV-93 MCH-32.0 MCHC-34.3 RDW-20.8*
[**2160-10-11**] 09:15PM PLT COUNT-106*
[**2160-10-11**] 09:15PM PT-24.2* PTT-41.5* INR(PT)-2.3*
[**2160-10-11**] 09:14PM TYPE-[**Last Name (un) **] PO2-34* PCO2-47* PH-7.31* TOTAL
CO2-25 BASE XS--2
[**2160-10-11**] 09:14PM LACTATE-2.9*
[**2160-10-11**] 05:55PM TYPE-[**Last Name (un) **] PO2-40* PCO2-43 PH-7.39 TOTAL CO2-27
BASE XS-0
[**2160-10-11**] 05:55PM LACTATE-1.8
[**2160-10-11**] 05:30PM GLUCOSE-112* UREA N-34* CREAT-1.5* SODIUM-138
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-12
[**2160-10-11**] 05:30PM ALT(SGPT)-40 AST(SGOT)-41* CK(CPK)-61 ALK
PHOS-75 TOT BILI-0.4
[**2160-10-11**] 05:30PM CK-MB-6 cTropnT-0.21*
[**2160-10-11**] 05:30PM ALBUMIN-2.9* CALCIUM-7.4* PHOSPHATE-2.2*
MAGNESIUM-2.2
[**2160-10-11**] 05:30PM WBC-15.2* RBC-3.70* HGB-12.0* HCT-34.4*
MCV-93 MCH-32.4* MCHC-34.8 RDW-19.9*
[**2160-10-11**] 05:30PM NEUTS-78* BANDS-1 LYMPHS-10* MONOS-7 EOS-1
BASOS-0 ATYPS-1* METAS-2* MYELOS-0
[**2160-10-11**] 05:30PM HYPOCHROM-NORMAL ANISOCYT-2+
POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2160-10-11**] 05:30PM PLT SMR-LOW PLT COUNT-119*
[**2160-10-11**] 05:30PM PT-24.8* PTT-37.9* INR(PT)-2.3*
[**2160-10-11**] 03:15PM TYPE-ART RATES-16/ TIDAL VOL-500 O2-100
PO2-353* PCO2-36 PH-7.43 TOTAL CO2-25 BASE XS-0 AADO2-323 REQ
O2-59 -ASSIST/CON INTUBATED-INTUBATED
[**2160-10-11**] 12:16PM LACTATE-1.7
[**2160-10-11**] 12:00PM GLUCOSE-106* UREA N-32* CREAT-1.4* SODIUM-137
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11
[**2160-10-11**] 12:00PM estGFR-Using this
[**2160-10-11**] 12:00PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-69 TOT
BILI-0.6
[**2160-10-11**] 12:00PM cTropnT-0.07*
[**2160-10-11**] 12:00PM CALCIUM-7.5* PHOSPHATE-2.1* MAGNESIUM-2.3
[**2160-10-11**] 12:00PM WBC-11.7*# RBC-3.74* HGB-12.1* HCT-34.6*
MCV-93 MCH-32.4* MCHC-35.0 RDW-20.8*
[**2160-10-11**] 12:00PM NEUTS-82* BANDS-0 LYMPHS-5* MONOS-12* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2160-10-11**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-2+
POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL STIPPLED-OCCASIONAL
[**2160-10-11**] 12:00PM PLT SMR-LOW PLT COUNT-89*
[**2160-10-11**] 12:00PM PT-28.0* PTT-34.6 INR(PT)-2.7*
Micro:
[**2160-10-15**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2160-10-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2160-10-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2160-10-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2160-10-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2160-10-11**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2160-10-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2160-10-11**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2160-10-11**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {ENTEROCOCCUS FAECALIS}; Anaerobic Bottle
Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2160-10-11**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {ENTEROCOCCUS FAECALIS, ENTEROCOCCUS
FAECALIS}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle
Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2160-10-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECALIS}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL EMERGENCY
[**2160-10-11**] 12:20 pm BLOOD CULTURE RIGHT PICC #2.
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
SENSITIVE TO Daptomycin MIC = 1.0 MCG/ML, Sensitivity
testing
performed by Etest.
ENTEROCOCCUS FAECALIS. SECOND MORPHOLOGY.
SENSITIVE TO Daptomycin @ 0.5 MCG/ML, Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S S
LINEZOLID------------- 1 S
PENICILLIN G---------- 1 S
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2160-10-11**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2053**] @ 1030PM [**2160-10-11**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final [**2160-10-12**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
TTE [**10-13**]
The GE junction was not crossed. Propofol sedation.
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Depressed RAA ejection velocity
(<0.2m/s). No ASD by 2D or color Doppler.
AORTA: Simple atheroma in aortic arch. Simple atheroma in
descending aorta.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). No
masses or vegetations on aortic valve. No aortic valve abscess.
Trace AR. [The amount of AR is normal for this AVR.]
MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or
vegetation on mitral valve. Moderate to severe (3+) MR.
TRICUSPID VALVE: No mass or vegetation on tricuspid valve.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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 monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
Information section). No glycopyrrolate was administered. No TEE
related complications. The rhythm appears to be atrial
fibrillation. Results were personally reviewed with the MD
caring for the patient.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The right atrial appendage
ejection velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. Simple atheroma are seen
in the aortic arch and descending thoracic aorta to 35 cm. A
well-seated mechanical aortic valve prosthesis is present.Trace
aortic regurgitation is seen (normal for this prosthesis). No
masses, vegetations or abscess are seen on the aortic valve. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Moderate to severe (3+)
mitral regurgitation is seen.
IMPRESSION: Well-seated mechanical aortic valve prosthesis trace
aortic regurgitation and no discrete vegetation or abscess. No
evidence for valvular mass or vegetations. Moderate to severe
mitral regurgitation.
LE ultrasound
TECHNIQUE AND FINDINGS: There is a diminutive right internal
jugular vein
which does demonstrate some flow on spectral imaging. The right
subclavian
vein is patent along its course. There is thrombosis of the
right axillary
vein with a distended hypoechoic lumen, which does not compress.
The right
brachial vein is also filled with hypoechoic thrombus, but some
flow is seen
through this. The right basilic and cephalic veins are normal
without
evidence of thrombus.
Normal flow is seen in the left subclavian vein.
IMPRESSION: Occlusive thrombus in the right axillary vein, with
non-occlusive
thrombus in the right brachial vein.
The finding of right upper extremity DVT was discussed with Dr.
[**Last Name (STitle) **] by phone
at 10 a.m.
CTA chest, abd, pelvis
FINDINGS:
CHEST CTA:
Opacification of the pulmonary vasculature demonstrates no
filling defects to
suggest a pulmonary embolus. The aorta is without evidence of
dissection.
Atherosclerotic calcifications are visualized throughout the
aortic arch.
Otherwise, the aorta is within normal limits. Great vessels are
within normal
limits. Coronary artery calcifications along with mitral and
aortic annulus
calcifications are noted.
There are bibasilar opacities, greater on the left than the
right, suggestive
of aspiration. Otherwise, the airways are patent to the
subsegmental levels
and the lungs are without evidence of other consolidations,
effusions, or
pneumothorax. No hilar, mediastinal, or axillary lymphadenopathy
by CT size
criteria.
CT OF THE ABDOMEN WITH IV CONTRAST: Hypodensities are visualized
throughout
the spleen and may be representative of contusions or
infarctions. Otherwise,
the liver, stomach, visualized loops of small and large bowel,
pancreas, and
bilateral adrenal glands are within normal limits. The kidneys
appear
atrophic with surrounding stranding suggestive of medical renal
disease. No
free fluid or free air throughout the abdomen. Atherosclerotic
calcifications
are visualized throughout the abdominal aorta, but the aorta is
of normal
caliber and contour.
CT OF THE PELVIS WITH IV CONTRAST: Large amount of stool is
visualized in the
sigmoid colon and rectum. Otherwise, the visualized loops of
sigmoid colon
are within normal limits. The bladder is normal. Brachytherapy
seeds are
again visualized within the prostate. There is no pelvic or
inguinal
lymphadenopathy. No free fluid or free air throughout the
pelvis. Surgical
clips are visualized along bilateral external iliac arteries.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic osseous
lesions.
Degenerative changes are visualized throughout the thoracolumbar
spine. Old
compression deformities are again visualized involving L1 and
L4. There are
compression fracture involving L3 and L5, which are new in
comparison to prior
study from [**2160-1-24**], but likely not acute.
Additionally, there is a
left 10th posterior rib fracture which is also new from [**1-23**], [**2159**]
but of unknown chronicity.
IMPRESSION:
1. No evidence of pulmonary embolism or dissection.
2. Hypodensities are visualized throughout the spleen and may be
representative of contusions or infarctions. No evidence of free
fluid or air
in the abdomen.
3. There is a left 10th posterior rib fracture, adjacent to the
spleen, which
is also new from [**2160-1-24**] but of unknown chronicity.
4. Old compression deformities are again visualized involving L1
and L4.
There are compression fracture involving L3 and L5, which are
new in
comparison to prior study from [**2160-1-24**].
5. Bibasilar lung opacities, raising the possibility of
aspiration pneumonia.
[**10-11**] EKG
Sinus rhythm. Slight left axis deviation. Right bundle-branch
block.
Non-specific ST-T wave abnormalities. Compared to the previous
tracing right bundle-branch block is once again present. The
other findings are similar.
TRACING #1
CXR
Final Report
INDICATION: Sepsis, evaluate tube placement.
COMPARISON: [**2160-8-11**].
FINDINGS: A single portable supine view of the chest was
obtained. Low lung
volumes result in bronchovascular crowding. The endotracheal
tube ends 4.0 cm
above the carina. An orogastric tube follows the expected
course, although
the tip is not seen. A right PICC ends in the lower SVC. There
is no focal
consolidation, pleural effusion, or pneumothorax. Cardiac and
mediastinal
silhouettes are stable with aortic knob calcifications.
IMPRESSION: Endotracheal tube ends 4 cm above the carina.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2160-10-11**] 3:49 PM
Final Report
INDICATION: [**Age over 90 **]-year-old man with worsening renal function.
Please assess for
obstruction or vascular disease.
TECHNIQUE:
Grayscale and color Doppler ultrasound images of both kidneys
were obtained.
COMPARISON: CT of the torso from [**2160-10-11**].
FINDINGS: The right kidney measures 11.8 cm, the left kidney
measures 11.1 cm
without evidence of hydronephrosis, obstructing stones or
masses.
The resistive indices of the right kidney range from 0.73 to
0.84 and the left
kidney from 0.72 to 0.80. No parvus tardus .
The main renal artery and main renal vein are patent.
IMPRESSION:
1. No hydronephrosis.
2. Patent vasculature without signs of renal artery stenosis.
The study and the report were reviewed by the staff radiologist.
INDICATION: [**Age over 90 **]-year-old man with warm hemolytic anemia on
chronic prednisone
with GI bleed, atrial fibrillation with [**Age over 90 5509**], status post
traumatic Foley
placement with stool coming out of the Foley catheter.
TECHNIQUE: MDCT images were acquired through the pelvis without
IV contrast.
After an initial non-contrast examination, 300 cc of iodinated
contrast was
injected into the Foley catheter.
The partially imaged abdomen shows an unremarkable lower pole of
both kidneys
and unremarkable small and large bowel loops. No abdominal free
fluid or free
air is present.
CT OF THE PELVIS WITH IV CONTRAST:
Contrast fills the bladder completely as well as numerous mural
trabeculations
consistent with a "[**Holiday **] Tree" appearance related to a
neurogenic bladder.
Air within the bladder is likely related to Foley insertion.
Small amount of
extraluminal contrast is noted in the prostatic urethra with
increased
contrast also noted inferiorly at the anal verge. No evidence of
a frank leak
is noted, although evaluation of the rectal lumen is limited due
to a large
amount of stool within it. No pelvic or inguinal lymphadenopathy
or pelvic
free fluid is present. The sigmoid colon is unremarkable.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or
blastic lesions or
fractures, although compression fractures of the L5 and L4
vertebral bodies
are unchanged compared to the previous examination. Also noted
is mildly
increased sclerosis of the femoral heads of uncertain
significance.
IMPRESSION:
Extraluminal contrast surrounds the prostatic urethra suggesting
a leak at
that location.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: [**Doctor First Name **] [**2160-10-16**] 11:58 PM
CT head noncontrast [**10-16**]
FINDINGS: Exam is severely limited by motion artifact. However,
no gross
evidence of intracerebral hemorrhage is seen. The ventricles are
slightly
dilated out of proportion to the sulci which may suggest normal
pressure
hydrocephalus or could be compatible with central aprenchymal
volume loss and
more conspicuous from prior. No edema or shift of normally
midline structures
is noted. No suspicious osseous lesions are noted. The mastoid
air cells are
normal. There is mild mucosal thickening within the maxillary,
ethmoidal and
sphenoidal sinuses. This may relate to recent endotracheal
intubation.
IMPRESSION: The examination is limited by motion; however, no
gross
intracerebral hemorrhage is seen. Prominence of the ventricles
could
represent normal pressure hydrocephalus or central parenchymal
volume loss.
Correlate clinically and followup.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
[**Age over 90 **] year old male with warm hemolytic anemia on chronic
prednisone 10mg, GI Bleeds, AF with [**Age over 90 5509**], CHF with EF 45%,
listeria endocarditis, mechanical AVR on coumadin, CKD stage
III, presenting from nursing facility with complaints of
tachycardia, fever, abdominal pain found to have aspiration PNA
c/b SVT. He was treated for enterococcal bacteremia and
pneumonia, but eventually died on [**2160-10-21**] from shock of unclear
etiology. See below for details of his hospitalization:
# Pulmonary: Patient was initially intubated as below, then
reintubated on [**10-17**] for difficult to manage secretions.
Conversation was had with son on [**10-19**] and decision was made that
patient would likely want to proceed to tracheostomy/PEG tube.
IP was consulted though he destabilized prior to evaluation and
intervention.
# Septic Shock: He was initially intubated and required
vasopressors for septic shock and atrial fibrillation. On
intake, he was found to have aspiration pneumonia and gram
positive bacteremia which speciated to enteroccocus. He was
initially placed on Linezolid/Cefepime, this was switched to
Daptomycin for a planned 6 weeks course from [**10-13**] through [**11-24**].
He completed a course of Levaquin [**10-17**] for pneumonia. He had a
TEE which did not show endocarditis. PICC line was placed on
[**10-16**]. His urine output began to decrease during the early
morning of [**2160-10-21**], though he remained normotensive until
mid-morning, when he developed hypotension followed by profound
bradycardia culminating in asystole/PEA. He was subsequently
coded and developed a VT which was defibrillation responsive.
Suspecting an acidosis or hyperkalemic-induced wide-complex
tachycardia, she was given aggressive bicarbonate and calcium
boluses. His pulse returned. Laboratories revealed profound
lactic acidosis. The difficult prognosis was discussed with his
son, who elected to not further escalate care and changed code
status to DNR. The patient was sustained on pressors and
bicarbonate gtt until another son arrived from [**Name (NI) 5256**].
He later passed away with his family at the bedside. The cause
of his decompensation remains unclear, but may be related to
worsening septic shock or possible cardiogenic shock from sudden
MI.
# Atrial fibrillation: Initially in the ICU went into afib with
[**Name (NI) 5509**] to the rate of 170s, given adenosine 6mg, then given amio
load, then amio gtt, on levophed and vasopressin for hypotension
which were quickly weaned to off. An NG tube was placed on [**10-14**]
and his beta-blocker was restarted
# DVT: axillary/brachial vein DVT on the right was found, likely
due to prior PICC which had been initially pulled. He was
maintained on Heparin/Coumadin as below.
# Uretheral perforation: Due foley placement in ED. Urology was
consulted and recommended to have a voiding trial in 10 days
from [**10-11**] (on [**10-21**]) and if does not void, to call urology back.
Regarding urethro-rectal fistula cystogram as outpatient with
possible colorectal surgery outpt f/u.
# Chronic Anemia: required frequent outpatient transfusions. He
was transfused 1U on [**10-13**] and bumped appropriately. He was
transfused 1U on [**10-19**].
# Mechanical AVR - Goal INR 1.8 to 2.2. He was supratherapeutic
on admission and coumadin was initially held. He was restarted
on coumadin when INR was 1.8 on [**10-15**] at 3mg daily. Heparin gtt
was also started at that time then turned off once INR
therapeutic.
# Hypothyroidism - Continued levothyroxine.
# Chronic systolic CHF - EF of 45%. He was diuresed with lasix
40mg at a time.
# Warm hemolytic anemia - Continued prednisone (decreased dose
to 10mg during admission) per Dr. [**Last Name (STitle) **] with bactrim
prophylaxis.
# Hyperlipidemia - Stopped pravastatin given possibility of
interaction with daptomycin. This should be restarted at the
conclusion of daptomycin course.
# Altered mental status: After extubation, patient sleepy but
arousable and could not carry conversation. This was thought to
be secondary to sedation which was slowly clearing. If does not
improve, further work-up should be dont as an outpatient and
nutritional goals will need to be addressed.
Medications on Admission:
- levothyroxine 75 mcg PO DAILY
- omeprazole 40 mg Capsule PO BID
- pravastatin 20 mg Tablet PO DAILY
- sulfamethoxazole-trimethoprim 400-80 mg Tablet PO DAILY
- zinc oxide 40 % Ointment One app Topical [**Hospital1 **]
- senna 8.6 mg Tablet Two tab PO HS
- Lotrisone cream 1 app [**Hospital1 **]
- Maalox/MagOH/simeth 30ml PO Q4H PRN
- oxycodone 5 mg Tablet 0.5 PO Q8H PRN pain.
- Smithethicone 80 mg PO BID prn
- Smithethicone 160 mg PO TID
- prednisone 20 mg Tablet PO DAILY
- Calcium carbonate 650 mg PO TID PRN
- warfarin 3 mg Tablet PO SunTuWeThFrSa at 1800.
- acetaminophen 1000mg [**Hospital1 **]
- acetaminophen 650mg Q4 PRN
- carvedilol 3.125 mg PO daily
- cyanocobalamin [**2149**] mcg Tablet PO DAILY
- folic acid 4 mg Tablet PO DAILY
- sucralfate 1 gram PO QID
- bisacodyl 10 mg PO DAILY PRN constipation.
- docusate sodium 100 mg PO BID
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
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32,377
| 178,842
|
34271
|
Discharge summary
|
report
|
Admission Date: [**2139-3-11**] Discharge Date: [**2139-3-31**]
Date of Birth: [**2089-7-20**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
hemothorax
Major Surgical or Invasive Procedure:
Liver Biopsy.
Intubation.
Chest Tube placement.
PICC placement.
History of Present Illness:
49 M c/ PMH HCV and alcoholic cirrhosis, presented on [**3-10**] for
biopsy and fiducial placement into liver by interventional
radiology for 2 liver nodules that are being followed. The
patient has had shortness of [**Last Name (un) 6250**] and some evolving chest pain
in the setting of dizziness. Evaluation
at an outside hospital revealed a HCT of 24, down from a HCT in
the 40's in [**Month (only) 1096**]. The patient was given 2 units of blood and
imaging at an outside hospital revealed a large hemothorax in
the
R lung. HE was subsequently transferred here for further care
and
management. He now complains of dull lower R lateral chest pain.
No sharp pain, no radiation. not position dependent. No
alleviating or exacerbating symptoms other than cough and
pressure feom the outside. Notably patient had a fall several
weeks ago where he reports he was found at an outside hospital
to
have a lung contusion and possible history of broken ribs.
.
Pt has a long history of alcoholism and had his last drink 3
days
ago prior to presenting to the hospital for his biopsy.
.
The patient denies fevers, chills, nausea, vomiting.
.
Patient's hemothorax was evacuated through his chest tube, on
day of transfer he had drained approximately 120 cc over 12
hours. He received a total of 2 additional units of pRBCs during
his SICU stay and 1 unit of FFP. He required multiple boluses of
midazolam and high doses of propofol gtt to maintain sedation.
He spiked temperatures as high as 103.3- these were attributed
to administration of blood products and cultures and antibiotics
were not sent. He developed seizure-like activity on [**3-12**] at
7pm. Neurology was consulted who recommended uptitration of
versed and diazapam boluses as needed and continuous EEG
monitoring. Seizures were felt to be secondary to delirium
tremens. Patient continued to spike, suffered from decreased
urine output. Attempts were made to wean patient off propofol by
adding fentanyl, decrease midazolam. Patient was felt to be
stable from a thoracics standpoint and was transferred to the
MICU for further management.
.
On evaluation, patient was intubated, sedated, unresponsive and
actively seizing.
.
Review of systems: Unable to obtain ROS given patient's mental
status.
Past Medical History:
HCV
Alcoholism
HTN
Esophageal varices
s/p hernia repair
Social History:
Lives on [**Location (un) **] with his wife, has 2 children. Smokes [**2-1**] ppd,
drinks ~3 nips of Whiskey a few times per week. Reports he has
been in rehab for ETOH before and has experienced symptoms of
ETOH withdrawal. Reports remote history of marijuana use. Denies
IVDU.
Family History:
DM, stroke, cardiac disease.
Physical Exam:
Vitals: T: 97.8 BP: 148/84 P: 101 R: 17 O2: 100%
General: intubated, sedated, unresponsive; total body tremor
HEENT: Icteric sclerae; pupils 2mm, but b/l reactive to light;
dry MM; OG and endotracheal tube in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, distended, bowel sounds present, no rebound
tenderness or guarding; + ascites; unable to assess tenderness
given mental status
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: jaundiced
Discharge Physical Exam:
General: NAD
HEENT: Anicteric sclerae
Lungs: CTA-bilateraly
CV: Normal S1, and S2 no S3 or S4, no murmurs, rubs, or gallops
Abd: Soft, Non-tender, non-distended, non-tympanic. No
ascities.
Pertinent Results:
ADMISSION LABS
[**2139-3-11**] 06:15PM BLOOD WBC-8.3# RBC-3.01* Hgb-10.0* Hct-27.8*#
MCV-92# MCH-33.1* MCHC-35.8*# RDW-19.4* Plt Ct-44*
[**2139-3-10**] 09:30AM BLOOD PT-14.7* INR(PT)-1.3*
[**2139-3-11**] 06:15PM BLOOD Glucose-102* UreaN-10 Creat-0.7 Na-134
K-3.4 Cl-98 HCO3-25 AnGap-14
[**2139-3-11**] 06:15PM BLOOD ALT-53* AST-249* AlkPhos-104 TotBili-3.1*
[**2139-3-11**] 06:15PM BLOOD Lipase-33
[**2139-3-11**] 06:15PM BLOOD Albumin-3.0*
[**2139-3-12**] 12:57AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.2*
[**2139-3-11**] 06:30PM BLOOD Glucose-98 Lactate-3.2* Na-136 K-3.5
Cl-97* calHCO3-26
[**2139-3-11**] 11:00PM URINE Type-RANDOM Color-Amber Appear-Clear Sp
[**Last Name (un) **]->1.035
[**2139-3-11**] 11:00PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-12* pH-6.5 Leuks-NEG
[**2139-3-11**] 11:00PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2139-3-11**] 11:00PM URINE CastHy-0-2
.
PERTINENT LABS
[**2139-3-15**] 03:33PM ASCITES TotPro-1.7 Glucose-142 LD(LDH)-67
Albumin-LESS THAN
[**2139-3-15**] 03:33PM ASCITES WBC-200* RBC-[**Numeric Identifier **]* Polys-43*
Lymphs-10* Monos-0 Mesothe-1* Macroph-46*
.
MICROBIOLOGY:
Blood Cultures 2/10, [**3-13**], [**3-15**], [**3-19**]: No Growth
.
URINE CULTURE (Final [**2139-3-15**]): STAPHYLOCOCCUS, COAGULASE
NEGATIVE. 10,000-100,000 ORGANISMS/ML.
.
Urine Cultures 2/13, [**3-19**]: No Growth
.
[**2139-3-12**] 8:16 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2139-3-15**]**
GRAM STAIN (Final [**2139-3-13**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2139-3-15**]):
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
HAEMOPHILUS SPECIES NOT INFLUENZAE. MODERATE GROWTH.
.
[**2139-3-15**] 3:33 pm PERITONEAL FLUID
**FINAL REPORT [**2139-3-21**]**
GRAM STAIN (Final [**2139-3-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2139-3-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2139-3-21**]): NO GROWTH.
.
PATHOLOGY:
[**2139-3-10**] LIVER CORE BX (1 JAR)
1. Established cirrhosis (Stage IV). Trichrome stain evaluated
and also shows focal sinusoidal fibrosis.
2. Moderate predominantly macrovesicular steatosis. Rare cells
with balloon degeneration are seen.
3. Mild chronic inflammation of portal areas/fibrous tracts
with bile ductular proliferation.
3. Iron stain is negative.
4. No carcinoma seen. Additional levels and reticulum stain
examined.
Note: The findings are consistent with cirrhosis with focal
features consistent with a component of metabolic injury. The
patient also has a clinical history of hepatitis C.
.
CYTOLOGY
[**2139-3-15**] Peritoneal Fluid: NEGATIVE FOR MALIGNANT CELLS.
.
IMAGING
[**2139-3-11**] CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST:
CT CHEST: There is a large right hemothorax with collapse of the
right lowerand middle lobes. Only a portion of the right upper
lobe remains aerated. Layering hyperdense blood products is
noted posteriorly within this hemothorax. While there is no
evidence of active extravasation on this study, the cause of
this bleeding is likely due to bleeding from an intercostal
vessel or from the diaphragm as there is a fiducial seed noted
immediately adjacent to or through the diaphragm at the dome of
the liver. No definite diaphragmatic defect. There is no
pneumothorax. The left lung is clear with minimal dependent
atelectasis. The heart size is normal.
CT ABDOMEN: The liver is nodular in contour consistent with
known cirrhosis. Three fiducial seeds are present at the dome of
the liver with the most superior seed abutting the diaphragm.
Hypodensities are again noted in the liver, unchanged since the
prior study. The portal, hepatic, splenic, and superior
mesenteric veins remain patent. Extensive varices including
paraesophageal and recannulated umbilical vein and vein of
Sappey are present. The spleen, pancreas, stomach, adrenal
glands, and kidneys are within normal limits. Small amount of
ascites is again noted surrounding the liver. This fluid remains
low density and volume is stable since the prior studies, likely
simple ascites. There is no evidence of hemoperitoneum. The
gallbladder is normal. There is no free air.
CT PELVIS: The appendix is somewhat prominent but is unchanged
in appearance over multiple prior studies. The rectum, prostate,
and bladder are within normal limits. A small amount of fluid is
noted within the pelvis, unchanged.There is no inguinal or
pelvic lymphadenopathy. Intrapelvic loops of bowel are within
normal limits.
BONE WINDOWS: Multiple old rib fractures are noted in the right
hemithorax.
No concerning osseous lesions are identified. Wedge compression
fraction of
vertebral body T6 is unchanged since [**2138-3-5**].
IMPRESSION:
1. Interval development of large right hemothorax with right
lower and middle lobe collapse. The right upper lobe remains
mostly aerated. While there is no evidence of active
extravasation on this study, the source of this bleeding could
be from an intercostal vessel or from injury to the diaphragm
from the recent procedure.
2. Cirrhotic liver with multiple varices, as seen and
characterized on
multiple prior studies.
3. Small amount of abdominal ascites, unchanged in volume with
no evidence of hemoperitoneum.
.
[**2139-3-11**] CHEST (PORTABLE AP)
Interval insertion of right-sided chest tube with re-expansion
of
the right mid and lower lobe and evacuation of large right
hemothorax.
Minimal right lower lung atelectasis persists.
.
[**2139-3-13**] EEG
This prolonged EEG recording captured three pushbutton
activations. One showed shaking activity that appeared to be
shivering
or a behavioral change and not epileptic, and the EEG at the
time showed
just the movement artifact with the same frequency as the
movements.
There was plentiful movement and muscle artifact throughout the
rest of
the recording, but the background showed a low voltage record,
often
with some generalized slowing. This suggested a widespread
encephalopathy, and the faster activity raised the possibility
that some
of this was due to medications. There were no clear seizures.
.
[**2139-3-15**] Chest (Portable AP)
The endotracheal tube is 4 cm above the carina. The NG tube tip
is
off the film, at least in the stomach. There is a right lower
lobe infiltrate that is increased in the interval. There is also
increased opacity in the left lower lung which is predominantly
due to volume loss but underlying infectious infiltrate cannot
be excluded. There is pulmonary vascular redistribution. There
is a small right effusion.
IMPRESSION: Worsening appearance of the lungs, particularly on
the right.
.
[**2139-3-16**] Abdomen (Supine Only)
here is a nonspecific bowel gas pattern with no evidence of
overt
obstruction or pneumatosis. There is graying of the abdomen
suggestive of
ascites. An NG tube is visualized with the tip in the stomach.
Visualized
osseous structures are grossly unremarkable.
IMPRESSION: Nonspecific bowel gas pattern with no evidence of
obstruction.
.
[**2139-3-18**] RUQ U/S:
The liver is nodular in contour and heterogeneous in
echotexture, in keeping with known history of cirrhosis. A cyst
with peripheral calcification measuring 1.5 cm is seen
anteriorly in the left lobe, unchanged from prior study. The
liver dome is not well visualized.
There is no intra- or extra-hepatic biliary ductal dilation.
Common bile duct is normal in caliber, measuring 5 mm. The
gallbladder is not distended, and there are no stones within,
though a small amount of sludge is present. The gallbladder is
thick-walled and edematous, though given the lack of gallbladder
distention, this likely reflects third spacing and
underlyingliver disease. Moderate ascites and right pleural
fluid is noted. The spleen measures 9.9 cm.
IMPRESSION:
1. No evidence of acalculous cholecystitis. In the setting of a
non-distended gallbladder, gallbladder wall thickening likely
reflects third spacing and underlying liver disease
2. Nodular coarsened liver, compatible with known history of
cirrhosis. A
cyst is seen anteriorly in the left lobe, as on prior CT. The
liver dome is
not well evaluated on this study.
3. Ascites and right pleural fluid.
Brief Hospital Course:
The patient is a 49 yo M with Hep C and EtOH Cirrhosis who
presented after liver biopsy with hemothorax now who was
transferred to the hepatorenal service following a prolonged
MICU course complicated by delirium tremens and pneumonia.
.
#. Ventilator Associated Pneumonia: On admission to the ICU the
patient was noted to have sputum culture growing H.Influenzae.
He had been intubated for hemodynamic instability (tachycardia,
HTN, in the presence of high grade fevers). He was treated with
ceftriaxone and azithromycin. Later in his MICU course he was
started on vancomycin and cefepime for a question of ventilator
associated pneumonia, as extubation was proving to be difficult.
He was eventually successfully extubated and called out to the
hepatorenal service. By day 2 of his antibiotics he was
breathing well on room air. His antibiotics were stopped in
sequence as he remained breathing well on room air, afebrile,
and with a decreasing white count. He received three days of
vancomycin and four days of cefepime.
.
#. Delirium Tremens / Hepatic Encepholopathy / ICU Delirium: The
patient was disoriented upon transfer to the hepatorenal
service, but showed no evidence of agitation. He was treated
with lactulose and rifaximin and quickly returned to his
baseline mental status. At the time of discharge he was not
confused or encephalopathic. He was alert and oriented x 3 at
the time of discharge.
.
#. Acute Renal Failure - The patient's creatinine increased to
1.3 from baseline of 0.6, likely due to pre-renal causes. His
lasix and aldactone were held. He was discharged home on his
home dose of aldactone. His Cr was 1.1 and will require follow
up as an outpatient.
.
#. EtOH Cirrhosis complicated by ascites, varices: The patient
was maintained on a low salt diet. He continued on lactulose
and rifaximin. Diuretics were held in the setting of acute
renal failure (see above). He did not have an EGD prior to
discharge. His last EGD was [**2136**].
.
#. Liver Lesions: The IR guided biopsy showed no evidence of
malignancy. The patient will need surveillance MRI in 3 months
time.
.
#. Hyperglycemia: The patient developed hyperglycemia while on
TPN. He was started on an insulin sliding scale which was
discontinued once he was off TPN and tolerating po's without
evidence of hyperglycemia. His TPN was discontinued prior to
discharge.
.
#. Code - Full Code.
.
# Contact: Mother: [**Name (NI) **] [**Name (NI) **] HCP: [**Telephone/Fax (1) 78895**]
.
# Possible Issues for Readmission: 1) The patient continues to
drink despite counseling. He was advised to start PT at home
with outpatient detoxification.
Medications on Admission:
chlordiazepoxide 10-20 mg q4-6H PRN shakes
magnesium oxide 400 [**Hospital1 **]
gabapentin 300 TID
spironolactone 25 daily
MVI daily
Discharge Medications:
1. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please take until you have [**4-3**] bowel movements per
day.
Disp:*2700 ML(s)* Refills:*2*
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Physical Therapy
Please do excercises to increase gain stability.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hemothorax
Ventilator associated pneumonia
Delirium secondarily to hepatic encephalopathy and ICU stay
Delirium tremens and alcohol withdrawal with possible seizures
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 78893**]
You were admitted to [**Hospital1 69**] for a
blood in your thorax, alcohol withdrawl, penumonia and and
changes in your ability to think. You were evaluated by
physical therapy and occupational therapy who think you are safe
to return home. You will need to refrain from drinking alcohol.
The following meidcation chnages were made:
ADDED:
Lactulose, which will cause diarrhea. You must have ~3 bowel
movements a day.
Rifaximin, which will also prevent you from getting confused.
STOPPED:
Gabapentin: given your confusion.
Chlordiazepoxide
Magnesium
Followup Instructions:
Department: TRANSPLANT
When: FRIDAY [**2139-4-3**] at 10:00 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2139-4-1**]
|
[
"780.39",
"998.11",
"E849.8",
"291.81",
"997.31",
"789.59",
"041.19",
"511.89",
"293.0",
"518.81",
"571.2",
"599.0",
"518.0",
"041.5",
"E879.8",
"070.71",
"584.9",
"572.3",
"E849.7",
"303.91",
"790.29",
"456.21",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"99.15",
"34.04",
"96.72",
"38.93",
"94.62",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
16148, 16154
|
12696, 15346
|
280, 346
|
16383, 16383
|
3940, 12673
|
17182, 17481
|
3021, 3051
|
15529, 16125
|
16175, 16175
|
15372, 15506
|
16566, 17159
|
3066, 3704
|
2576, 2629
|
230, 242
|
374, 2557
|
16194, 16362
|
16398, 16542
|
2651, 2708
|
2724, 3005
|
3729, 3921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,803
| 166,290
|
19604
|
Discharge summary
|
report
|
Admission Date: [**2139-11-13**] Discharge Date: [**2139-11-24**]
Date of Birth: [**2072-5-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 31**] is a 67 year-old female with history of atrial
fibrillation, schizophrenia, who was recently discharged two
days prior to admission on for altered mental status and slurred
speech. She re-presents for the same problem. During recent
admission from [**Date range (1) 7291**], an etiology for patient's altered
mental status was not determined. There was no evidence of
infection, positive tox screen, or acute intracranial process on
head CT. She was re-started on her haloperidol and quetiapine,
as her symptoms seemed more typical of schizophrenia than of
delirium. According the notes, the patient was fully oriented
and back to her baseline on [**2139-11-12**]. On [**11-13**], patient was
reportedly found on the ground outside of her housing facility,
awake but unresponsive. She was not following commands and was
not able to speak. She was not tracking with her gaze.
.
A code stroke was called in the ED and was negative and a serum
and urine tox screen was negative. There were no obvious signs
of infection. She was observed in the MICU and remained
unresponsive, awake consistent with catatonia.
.
On the floor, she was awake and alert and uncommunicative. She
was staring off into space and did not respond to questions. She
was moving all fours and did not appear to be in any acute
distress.
.
Past Medical History:
-Atrial Fibrillation - recently started on digoxin and
metoprolol, stopped coumadin, diltiazem, lisinopril, atenolol
-DM2
-Microcytic Anemia - extensive recent GI wkup at [**Hospital1 112**] unrevealing
-Schizophrenia - diagnosed age 23
-Eczema
Social History:
Lives alone in an apartment. Independent of ADLs. Smokes 1
cigarrette occasionally, ETOH only 1 drink/3months, no IVDA.
Family History:
Mother with ETOH abuse, no FH of heart disease, HTN, DM or
malignancy.
Physical Exam:
Admission exam
Vitals: T: 98.9 BP: 148/92 P: 103 R: 20 O2: 97%RA
General: Eyes open does not track, not responding to any
commands
HEENT: Conjunctiva injected, MMM, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregular, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, mild pedal edema
Neuro: PERRL, unable to assess remaining cranial nerves, mild
cogwheeling in RUE, some finger and toe movement b/l, downgoing
toes b/l
.
Discharge physical exam:
Vitals: Tc97.4, HR 83 (80-90s), BP 134/76 (97-134/50-70s), RR
18, 100% on RA, 0/10 pains
Gen: pleasant, cooperative middle aged AA female sitting talking
to self at nurse's station
HEENT: NCAT, EOMI, OP clear, MMM
CV: irregularly irregular, S1/S2, no m/r/g
Pulm: CTAB
Abd: soft, NT, ND
Extrem: no c/c/e
Skin: warm, dry
Psych: oriented to person, time (knows date, but year [**2129**]),
Thinks is at a school. Tangential but pleasant. Talking about
her need for a regular doctor and history as a "mental patient."
Pertinent Results:
ADMISSION LABS
[**2139-11-12**] 05:53AM BLOOD WBC-10.3 RBC-3.73* Hgb-8.9* Hct-27.5*
MCV-74* MCH-23.9* MCHC-32.4 RDW-17.8* Plt Ct-421
[**2139-11-14**] 05:30AM BLOOD Neuts-85.1* Lymphs-11.7* Monos-3.0
Eos-0.2 Baso-0.1
[**2139-11-13**] 06:45PM BLOOD PT-13.7* PTT-30.3 INR(PT)-1.2*
[**2139-11-14**] 05:30AM BLOOD Glucose-140* UreaN-8 Creat-0.6 Na-140
K-4.6 Cl-106 HCO3-24 AnGap-15
[**2139-11-13**] 06:45PM BLOOD Calcium-10.0 Phos-4.0 Mg-2.0
[**2139-11-12**] 05:53AM BLOOD Digoxin-1.0
[**2139-11-13**] 07:09PM BLOOD Glucose-171* Lactate-1.8 Na-140 K-4.7
Cl-102 calHCO3-27
.
DISCHARGE LABS:
[**2139-11-22**] 06:30AM BLOOD WBC-7.5 RBC-3.66* Hgb-8.9* Hct-29.0*
MCV-79* MCH-24.3* MCHC-30.5* RDW-19.2* Plt Ct-446*
[**2139-11-19**] 05:34AM BLOOD Glucose-117* UreaN-12 Creat-0.6 Na-141
K-4.0 Cl-103 HCO3-29 AnGap-13
[**2139-11-20**] 06:37AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.0
.
MICROBIOLOGY:
Urine Culture [**11-14**] No growth
Blood Culture [**11-13**] No growth
.
PERTINENT STUDIES
CXR [**11-14**]
Mild cardiomegaly is stable. Hilar lymphadenopathy is better
seen in prior
study. There is no pneumothorax or pleural effusion. Aside from
minimal
opacities in the left lower lobe that are likely atelectasis,
the lungs are clear. Moderate degenerative changes are in the
thoracic spine.
.
EEG [**11-14**]
EEG: Limited study because of frequent bursts of EMG activity
from jaw clenching. Brief interpretable segments between EMG
show diffuse background slowing and attenuation, no alpha
rhythm, but no focal slowing or epileptiform discharges.
Indicative of diffuse cerebral dysfunction, etiologically
nonspecific. If clinically indicated, repeat EEG with sedation
may be helpful.
.
CT spine [**11-13**]
IMPRESSION:
No fracture or subluxation within the cervical spine. Mild
degenerative
changes.
.
CT head [**11-13**]
IMPRESSION:
No acute intracranial findings.
.
CXR [**2139-11-18**]:
FINDINGS: Frontal view of the chest. Moderate cardiomegaly is
unchanged.
Pulmonary vascular congestion has improved and is now mild. No
overt
pulmonary edema. New retrocardiac opacity likely represents
atelectasis.
Small bilateral pleural effusions are new. No pneumothorax.
IMPRESSION:
1. New retrocardiac atelectasis with small bilateral pleural
effusions.
2. Improved pulmonary vascular congestion, now mild, without
pulmonary edema.
.
Brief Hospital Course:
Ms. [**Known lastname 31**] is a 67 year-old female with history of
schizophrenia, with recent admission for altered mental status
and slurred speech, who re-presents with altered mental status.
.
#. Altered mental status: No clear medical etiology. CT showed
no acute intracranial process. Seizure was initially felt to be
a possibility given rhythmic movements of facial muscles;
however, no focal slowing or epileptiform discharges were seen
on EEG. She had no electrolye abnormalities and a negative tox
screen, making ingestion unlikely. Infection was considered
given initial leukocytosis, but urine and blood cultures were
negative and leukocytosis resolved on its own by [**2139-11-19**].
Psychiatry was consulted and felt that the patient's decreased
responsiveness represented a catatonic form of schizophrenia.
The patient's psychiatric medications were adjusted, including
addition of lorazepam 1 mg TID. The patient's mental status
gradually improved and she became more interactive (although
remained disoriented and tangential). On the day of discharge,
lorazepam was decreased to 1 mg [**Hospital1 **]; psychiatry suggested a
taper of this medication over the next 3-5 days.
.
#. Atrial fibrillation: During this admission, the patient had
episodes of rapid ventricular rate with an ECG showing strain on
[**2139-11-18**]. Labs showed a small troponin leak and cardiology was
consulted; they felt the elevated troponin represented strain
secondary to increased rate. On their advice, digoxin was
discontinued, and metoprolol and diltiazem titrated up and
changed to long-acting formulations. The patient's rate
improved with these changes, and on discharge her HR ranged from
80-110s. She was continued on an aspirin only for stroke
prevention.
.
# FEN: Speech and swallow recommended supervision, thin liquids,
ground solids.
.
# Anemia: Hematocrit at recent baseline. She was continued on
folic acid 1 mg daily and ferrous sulfate 300 mg [**Hospital1 **].
.
# DM: The patient was continued on her home metformin.
Medications on Admission:
1. senna 8.6 mg PO BID as needed for constipation.
2. docusate sodium 100 mg PO BID
3. polyethylene glycol 3350 PO DAILY
4. aspirin 81 mg PO DAILY (Daily)
5. folic acid 1 mg One Tablet PO DAILY
6. metformin 500 mg Two Tablet PO BID
7. haloperidol 1 mg Two Tablet PO HS
8. ferrous sulfate 300 mg PO DAILY
9. quetiapine 300 mg One Tablet PO daily as needed for agitation
10. digoxin 125 mcg One Tablet PO DAILY
11. metoprolol tartrate 50 mg Two Tablet PO BID
12. quetiapine 200 mg Two Tablet PO QHS
13. ascorbic acid 500 mg PO BID
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
11. quetiapine 100 mg Tablet Sig: One (1) Tablet PO twice a day.
12. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day:
Please taper this medication over then next 3-5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2561**] - [**Hospital1 8**]
Discharge Diagnosis:
Altered mental status, likely secondary to decompensated
schizophrenia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 31**],
It was a pleasure participating in your care at [**Hospital1 771**].
You were admitted because you were found at home confused and
unable to take care of yourself. Imaging was obtained to make
sure you did not have any damage to your brain, which you did
not. Instead, it was thought that your schizophrenia had
worsened or was not responding to your usual medications.
In addition, your irregular heart rate was not well controlled.
We adjusted your medications to keep your heart beating at an
apporpriate rate.
We made the following medication changes:
STOP Digoxin
START Diltiazem XR 360 mg daily
INCREASE Metoprolol to long acting 300 mg daily at night
INCREASE Aspirin to 325 mg daily
START Lorazepam 1 mg three times a day
DECREASE Quetiapine to 100 mg twice daily
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2139-12-2**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"784.51",
"427.31",
"280.9",
"348.30",
"295.24",
"250.00",
"692.9",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9472, 9539
|
5710, 5919
|
328, 334
|
9654, 9654
|
3373, 3942
|
10636, 11057
|
2123, 2195
|
8329, 9449
|
9560, 9633
|
7775, 8306
|
9807, 10376
|
3958, 5687
|
2210, 2812
|
10396, 10613
|
267, 290
|
362, 1699
|
9669, 9783
|
1721, 1969
|
1985, 2107
|
2837, 3354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,973
| 124,313
|
6879
|
Discharge summary
|
report
|
Admission Date: [**2143-2-13**] Discharge Date: [**2143-2-20**]
Date of Birth: [**2084-5-2**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Bactrim Ds / Lisinopril
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
AMS, PNA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 58 year old male with progressive end stage multiple
sclerosis with chronic pain, central sleep apnea, recurrent
UTIs, history of seizures in the setting of hyponatremia,
admitted for AMS.
.
Pt with multiple recent admissions to [**Hospital1 18**] ICUs, including last
week for aspiration pneumonia. He was discharged home on feeding
restriction and was doing well until 1 day prior to admission
when he was noted to be less responsive and have bleeding from
his tongue. Although there was no witnessed tonic clonic
movement, this was concerning for [**Hospital1 862**] activity which he
generally has in setting of hyponateremia or infection. Pt was
reportedly more confused and lethargic than baseline, grunting
in bed rather than interactive.
.
[**Name (NI) 1094**] wife called his neurologist, who asked to cont meds (except
hold seroquel) and have labs checked to rule out infection
sparked [**Name (NI) 862**]. He was then brought to [**Location (un) **] ED, where CXR
showed RLL PNA, and also UTI (bac and WBC in urine--chronic
suprapubic foley though). On exam he was SOB, had secretions and
harsh upper airway sounds, with productive cough. He was given
unasyn, solumedrol, albuterol, 1L NS and was transferred to
[**Hospital1 18**] ED.
.
On arrival here, pt with temp of 96.2, HR 88, BP 215/123--to
150-160 w/out intervention, RR 20-30, initialy on RA 95%, then
suddenly desat'd to low 80's on RA, got suctionned, 50%
ventimask. He recieved nebs, vanc/cefepime for worsened RLL
infiltrate and possible Left base opacity. CT head--WNL
Past Medical History:
- Multiple sclerosis, diagnosed in [**2119**] c/b neurogenic bladder
requiring suprapubic catheter
- h/o UTIs including: Enterobacter, Proteus, P.aeruginosa,
K.pneumo, Enterococcus (pan-[**Last Name (un) 36**]), yeast/[**Female First Name (un) 564**] parapsilosis
- Automonic dysreflexia
- Quadraplegia
- Autonomic dysreflexia
- Quadraplegia
- Hypertension
- Carotid stenosis
- GIB [**12-24**] esophageal ulcer disease
- GERD
- Glaucoma, legally blind
- Sleep Apnea
- deafferentation-type sensory illusion syndrome
- ? colonoization of Pseudomonas in the urine
Social History:
He is married 32 years and lives with his wife at home. He has
three children and three grandchildren. He was a professor [**First Name (Titles) **] [**Last Name (Titles) 25931**] engineering at [**University/College 25932**], but
retired on disability after the [**2128**] spring semester due to his
MS. [**Name13 (STitle) **] is wheelchair-bound. He denies tobacco, alcohol, and
recreational drug use. Has personal care assistant.
Family History:
Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother
has diabetes.
Physical Exam:
Vitals: HR 113, BP 142/51, 91% on BiPAP
GEN: Caucasian male, appearing older than stated age, sleeping
but arousable
HEENT: PERRL, sclera anicteric, MMM, large neck, unable to see
JVP
CAR: tachycardic but regular, no M/G/R, normal S1 S2
PULM: CTA
ABD: Soft, obese, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Sleepy, unable to assess
Pertinent Results:
[**2143-2-13**] 05:45PM GLUCOSE-108* UREA N-12 CREAT-0.7 SODIUM-137
POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
[**2143-2-13**] 05:45PM estGFR-Using this
[**2143-2-13**] 05:45PM WBC-13.3* RBC-3.80* HGB-11.3* HCT-34.4*
MCV-91 MCH-29.6 MCHC-32.8 RDW-15.3
[**2143-2-13**] 05:45PM NEUTS-92.3* LYMPHS-7.0* MONOS-0.3* EOS-0.3
BASOS-0
[**2143-2-13**] 05:45PM PLT COUNT-389
Brief Hospital Course:
This is a 58 year-old Male with end stage [**Hospital **] transferred from
[**Location (un) **] for LLL PNA, UTI, admitted to ICU for large O2
requirement.
## AMS: due to infection, most likely. Improved with abx.
therapy (see below). Neurology consulted for ? [**Location (un) 862**]. AEDs
titrated up (see below). No overt evidence of [**Location (un) 862**] seen.
## UTI: UA at [**Location (un) **] with large leuk esterase, poisitve
nitrites, mod bacteria, 1 epi. No leukocytosis. Urine culture
here grew a small amount (~8000/mL) of GNRs. Unclear if this
represents true infection given indwelling (suprapubic)
catheter, and more likely source of infection is aspiration
pneumonia; antibiotics given for pneumonia would likely treat
urine GNR at any rate.
## End Stage Multiple Sclerosis: had a two hour family meeting
with pt., wife, son, son-in-law, neurology fellow, palliative
care team, social work, and myself to discuss goals of care and
plan moving forward to minimize recurrent hospitalizations. PEG
tube discussed and decided against this (pt. does not want).
Palliative care to come to pt.s home to discuss palliative
approach and care further. Cont. diet modifications as rec. by
speech therapist. See OMR note by [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] detailing this
meeting further.
This was verbally relayed to his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. She agrees. I
also mentioned the following possibilities to her for
consideration: home antibiotics to take if high clinical
suspicion for aspiration pna and or cystitis; levsin q hs to
reduce secretions, however, in my opinion, this may cause more
harm than good through decreasing gut motility and increasing
the risk of reflux aspiration.
Medication list greatly simplified. All non essential
medications removed due to aspiration risk (to minimize number
and frequency of med administration and to have as many be
liquid or crushable as possible).
Medications on Admission:
ALBUTEROL neb q4h prn
ALPHAGAN 5ml drop [**Hospital1 **] into left eye
ASPIRIN 81mg daily
BACLOFEN 2,000 mcg/mL Kit -pump
CALCIUM 500mg TID
CARVEDILOL - 25 mg Tablet [**Hospital1 **]
CENTRUM daily
CLONIDINE - 0.2 mg Tablet [**Hospital1 **]
COMBIVENT 2puffs QID
CRANBERRY 475mg [**Hospital1 **]
ENULOSE 10g/1.5ml 2teaspoons prn
FENTANYL - 12 mcg/hour Patch 72 hr
FISH OIL 1200mg [**Hospital1 **]
FUROSEMIDE - 40 mg Tablet qd
GLYCERIN and MAGIC BULLET suppositories QOD
IPRATROPIUM q6 prn
KEPPRA 750mg [**Hospital1 **] liquid
LAMOTRIGINE 1000mg [**Hospital1 **]
LACTULOSE prn
OMEPRAZOLE 20 [**Hospital1 **]
OXYBUTYNIN CHLORIDE 15 mg qhs
SENNA [**Hospital1 **]
SIMVASTATIN 20mg qhs
TRAVATAN drop L eye once a day
ACETAMINOPHEN prn
ASCORBIC ACID 500 [**Hospital1 **]
VITAMIN B12 500mg daily
ERGOCALCIFEROL (VITAMIN D2)400 [**Hospital1 **]
SEROQUEL 25mg at night pern agitation
Discharge Medications:
1. CloniDINE 0.3 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. 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:*0*
3. Glycerin (Adult) Suppository [**Last Name (STitle) **]: One (1) Suppository
Rectal PRN (as needed).
Disp:*30 Suppository(s)* Refills:*0*
4. Clotrimazole 1 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 2 weeks.
Disp:*1 tube* Refills:*0*
5. Lamotrigine 25 mg Tablet, Dispersible [**Hospital1 **]: Five (5) Tablet,
Dispersible PO BID (2 times a day).
Disp:*300 Tablet, Dispersible(s)* Refills:*0*
6. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day): only use if pt. complaining of bladder spasm/pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
Disp:*1 bottle* Refills:*0*
8. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*0*
9. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 bottle* Refills:*0*
10. Carvedilol 12.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Fifteen (15) ML PO DAILY
(Daily) as needed.
Disp:*60 ML(s)* Refills:*0*
12. Fentanyl 12 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
13. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
15. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
16. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: 7.5 mL PO BID (2 times
a day).
Disp:*500 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Aspiration pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Follow up with your home care providers and home palliative care
services as we discussed. Call your primary care doctor for:
fevers, lethargy, malaise, shortness of breath and or cough
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2143-2-26**] 2:30
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2143-3-5**] 4:30
Provider: [**Name10 (NameIs) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2143-3-28**] 3:30
|
[
"996.64",
"365.9",
"V46.3",
"507.0",
"345.90",
"344.00",
"599.0",
"340",
"E879.6",
"369.4",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9010, 9073
|
3839, 5847
|
303, 309
|
9138, 9147
|
3430, 3816
|
9382, 9851
|
2945, 3033
|
6771, 8987
|
9094, 9117
|
5873, 6748
|
9171, 9359
|
3048, 3411
|
255, 265
|
337, 1893
|
1915, 2478
|
2494, 2929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,570
| 154,982
|
15299
|
Discharge summary
|
report
|
Admission Date: [**2140-6-23**] Discharge Date: [**2140-6-30**]
Date of Birth: [**2093-10-1**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Paracentesis x 2
IV portacath
EGD with banding of esophogeal varices
History of Present Illness:
The patient is a 47-year-old female with a history of pancreatic
cancer status-post Whipple in [**2137**] followed by chemotherapy and
radiation. She had done well for a few years after the Whipple,
and in [**2140-3-26**] she started to notice an increase in abdominal
girth. MRCP showed no evidence of metastatic
disease or pancreatic disease. In early [**Month (only) 205**], she was admitted
for work-up of her ascites. During that hospitalization, she
underwent EGD, which disclosed grade I esophageal varices
(non-bleeding) and gastritis. She was last hospitalized at
[**Hospital1 18**] from [**6-2**] to [**6-4**] for additional work-up of new onset of
ascites. She underwent a liver biopsy to further evaluate the
etiology of the ascites. The biopsy showed minimal portal mixed
inflammation with focal bile duct proliferation, and mild
increase in portal fibrosis seen on trichrome stain. There was
no liver cirrhosis. Two weeks ago, she underwent a therapeutic
paracentesis with removal of 8 liters of fluid. She was found to
have triglyceride of about 600 in the fluid. The diagnosis of
chylous ascites was made. She notes some recurrence of the
fluid since that time.
Three days ago, the patient began to feel dizzy and
fatigued. On Wednesday, the patient had an episode of coffee
ground emesis. On Thursday afternoon, she had another episode
of coffee ground emesis and 1 dark stool. She presented to the
ED at [**Hospital6 8283**], where she was found to have BP
113/55 and HR 114, and a HCT of 21. She was given 2 U PRBCs and
was transferred to [**Hospital1 18**] for further work-up. On presentation
to the [**Hospital1 18**] ED, the patient was hemodynamically stable and had
a HCT of 29.8. In ED, she was given 3 L NS, 4 mg IV morphine, 40
mg IV Protonix, and 30 gm PO Kayexylate for K=6. She refused NG
lavage. She was admitted to the medical floor. Around 3 AM,
the patient had another episode of hematemesis, and vomited 300
cc of bright red blood mixed with clots. Thirty minutes later,
she vomited an additional 200 cc of bright red blood. A repeat
HCT was found to be 27.8.
She denies any fever, chills, nausea, or abdominal pain.
She denies
diarrhea or bright red blood per rectum. She has no jaundice or
pruritus. She does complain of back pain, which is a chronic
complaint.
Past Medical History:
Pancreatic Cancer, diagnosed [**6-27**] after she was found to have a
pancreatic mass following an episode of acute pancreatitis.
In [**7-28**], she underwent a Whipple procedure by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]
at the [**Hospital1 69**]. She had [**12-13**] lymph
nodes positive, no perineural vascular invasion noted. She
received adjuvant chemotherapy with 5-FU and gemcitabine as well
as radiation therapy.
Grade I esophageal varices, noted on EGD [**5-27**].
Depression
Chronic Renal insufficiency
Anemia
s/p Cesarean section in [**2129**]
s/p tubal ligation in [**2131**]
Ascites, noted in [**4-29**]. The patient is followed by Dr. [**Last Name (STitle) **].
She underwent an MRCP in [**4-29**]. MRCP disclosed 1) a new large
amount of ascites, 2) no evidence of a pancreatic duct stone or
biliary/pancreatic duct dilatation, and 3) the mid-portal vein
was suboptimally visualized. Repeat taps have demonstrated
chylous ascites. Liver biopsy in [**5-29**] was negative for
cirrhosis.
Chronic renal insufficiency, thought to be secondary to diuretic
use.
Social History:
She smoked a pack of cigarettes a day for thirty years, and
currently smokes 4 cigarettes per day. She drank alcohol in the
past, suspect heavy use. She denies alcohol use since [**2-28**].
She is married and has a 9 year old son.
Family History:
Her father died at 71 of lung cancer and liver cancer. Her
mother is healthy at age 80.
Physical Exam:
General: Pale, chronically ill appearing female lying in bed in
NAD.
VS: 96 110/70 93 18 98% RA
HEENT: NC/AT. PERRL. EOMI. MMM. Oropharyx has some dried blood.
Neck: Supple. No cervical lymphadenopathy.
Heart: RRR. S1, S2. No m/r/g.
Lungs: CTAB. No rales, wheezes, or crackles.
Abd: Distended, NT, +BS. No rebound or guarding. No shifting
dullness.
Ext: No c/c/e. Warm. Good distal pulses.
Skin: Palmar erythema. No rashes.
Rectal: Guiac + per ED.
Neuro: AxOx3. CN II-XII grossly intact. Strength 5/5 in all
extremities. Motor function intact. Sensation intact.
Pertinent Results:
[**2140-6-23**] 09:25PM WBC-9.9# RBC-3.44* HGB-10.5* HCT-29.8* MCV-87
MCH-30.4 MCHC-35.2* RDW-14.4
[**2140-6-23**] 09:25PM PLT COUNT-231
[**2140-6-23**] 09:25PM PT-12.4 PTT-23.8 INR(PT)-1.0
HCT at 3:22 AM: 27.8
[**2140-6-23**] 09:25PM GLUCOSE-139* UREA N-52* CREAT-1.3*
SODIUM-128* POTASSIUM-6.0* CHLORIDE-94* TOTAL CO2-24
Anion gap = 10
[**2140-6-23**] 09:25PM ALT(SGPT)-44* AST(SGOT)-46* ALK PHOS-190*
AMYLASE-23 TOT BILI-0.7
[**2140-6-23**] 09:25PM LIPASE-11
EKG: (OSH)
K=5.3
Sinus tachycardia 118. Normal intervals. Normal axis. No ST/TW
changes. No peaked T waves.
Brief Hospital Course:
A/P: 46 year old female with PMH of pancreatic cancer
status-post Whipple procedure in [**2137**] followed by chemotherapy
and radiation, with recently diagnosed Grade I esophageal
varices and chylous ascites. The patient is being transferred
to the MICU for management of hematemesis.
Hematemesis - Upon admission, pt underwent an EGD that showed
active variceal in one spot, which was banded with prompt
resolution of GI bleed. Subsequently, the patient was started
on octreotide, pantoprazole IV, and nadolol. The patient did
well with good hemodynamic stability. Four days prior to
discharge, the patient had three maroon colored, guiaic positive
stools. A stat hematocrit was sent off, twice daily hematocrits
were ordered, and the GI team who was following the patient in
conjunction with the medicine team was alerted. Her stat
hematocrit showed no acute change, and the following hematocrits
were all consistent with this. Per GI's recommendation,
octreotide was stopped after five days of therapy. On the day
prior to admission, Mrs. [**Known lastname 44490**] was transitioned to oral
pantoprazole and was continued no nadolol (although occasional
doses were held because of sbp's in the low 90's -- these bp's
are near pt's baseline).
Chylous ascites - A recent paracentesis disclosed triglyceride
level of 600 in ascites, and a liver biopsy was negative for
cirrhosis. Presence of chylous ascites raised concern for
recurrent malignancy. The pt's Ca [**54**]-9 was sent off and came
back 248. Two in-house paracenteses were performed, the first
yielding over three liters of fluid and the second just under
three hundred milliliters. At the time of discharge the first
specimen's cytology was negative for malignant cells and the
second's was pending; both had serum-acites albumin gaps of
greater than 1.1. However, the patients CT scan was very
concerning for recurrence of malignancy, as was the ascites
itself. The patient was counseled on the fact that a recurrence
was likely, and she decided to proceed with her discharge and
follow up with her PCP and oncologist.
Electrolyte abnormalities - Patient had hyponatremia and
hyperkalemia. This was felt to be primarily due to her
aldactone, however, once stopped, these abnormalities persisted.
Given bicarbonate abnormalities, there may be an RTA component
as well, but her urine electrolytes were still pending at time
of discharge.
Anxiety/depression - Pt was continued on BuSpar and Celexa.
Medications on Admission:
Celexa 40 mg qd
Spironolactone 50 mg qd
Lasix 40 mg qd
MVI 1 tab qd
Buspar 15 mg [**Hospital1 **]
Propanolol 20 mg [**Hospital1 **]
Pancrease 2 tabs p every meal
Discharge Medications:
1. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*60 Cap(s)* Refills:*2*
3. Buspirone HCl 5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*2*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Pantoprazole Sodium 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:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary:
1. Variceal Bleed.
2. Chylous Ascites.
Secondary:
1. Pancreatic Cancer s/p whipple, Chemo, XRT.
2. CRI.
3. Liver bx: low grade periportal inflammation.
4. Anemia.
5. Depression.
Discharge Condition:
Stable
Discharge Instructions:
Return to ED as needed.
Follow up with your PCP and oncologist
Followup Instructions:
Please contact your PCP and oncologist for appointments.
|
[
"276.1",
"285.1",
"457.8",
"276.7",
"456.0",
"V10.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.91",
"45.13",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
9067, 9135
|
5442, 7923
|
320, 390
|
9366, 9374
|
4830, 5419
|
9486, 9546
|
4138, 4228
|
8135, 9044
|
9156, 9345
|
7949, 8112
|
9398, 9463
|
4243, 4811
|
269, 282
|
418, 2747
|
2769, 3872
|
3888, 4122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,711
| 143,442
|
169
|
Discharge summary
|
report
|
Admission Date: [**2175-5-3**] Discharge Date: [**2175-5-23**]
Service: MEDICAL ICU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1764**] is an 80 year-old
female with a past medical history significant for dementia
presents as a transfer from HCRA with fevers and hypotension.
Per available information the patient was in her usual state
of health until 9:30 in the morning of [**2175-5-3**] when she
spiked a temperature to 104. She was seen by [**Name6 (MD) 1765**] cover MD
and found to be bradycardic. A few hours later the patient
was found to be hypotensive with a systolic blood pressure in
the 50s. She was unresponsive. She was bolused 500 cc of
normal saline without a change in blood pressure and was
transferred to the [**Hospital1 69**]
Emergency Department at that point.
Initial vital signs in the Emergency Room were temperature
100.8. Blood pressure 54/27 with a pulse of 88.
Respirations 28 with an O2 saturation of 91% on room air
increasing to 99% on 10 liters. She received 4 liters of
intravenous fluids, antibiotics were started Ampicillin,
Gentamycin and Flagyl and a left subclavian triple lumen
catheter was placed. Physical examination was
noncontributory initially. Initial laboratories were notable
for a white blood cell count of 10.9 with a bandemia.
Urinalysis was very concentrated and multiple white blood
cells. Despite intravenous fluids systolic blood pressure
remained low and she was started on a dopamine drip titrated
to 15 mcs per minute and systolic blood pressure was
maintained in the low 100s. At that point the patient was
transferred to the MICU for further evaluation.
PAST MEDICAL HISTORY: 1. Dementia. 2. Hypertension. 3.
Glaucoma. 4. Coronary artery disease. 5. Ischemic
cardiomyopathy with EF of 40%. 6. PEG tube. 7. Paroxysmal
atrial fibrillation on Amiodarone. 8. Type 2 diabetes.
MEDICATIONS ON TRANSFER: Sorbitol 30 mg po q day, Amiodarone
200 mg po q day, vitamin C 500 units po q day, aspirin 81 mg
po q day, multivitamin q day, Axid 150 mg po q day, Risperdal
10 mg po b.i.d. and zinc 220 mg po q day.
PHYSICAL EXAMINATION: Afebrile 97.9. Heart rate 99. Blood
pressure 84/43. O2 sat 99% on nonrebreather. Generally, was
unresponsive to oral stimuli or to sternal rub. Of note,the
patient is Russian speaking only. HEENT pupils are equal,
round and reactive to light and accommodation. Extraocular
movements intact. Neck was supple without lymphadenopathy.
Neck veins were flat. Chest was clear to auscultation
bilaterally. Heart was tachycardic with distant heart
sounds, 2/6 systolic murmur at the left lower sternal border.
Abdomen soft, nontender, nondistended. Normoactive bowel
sounds. Extremities mild pedal edema.
LABORATORY: White blood cell count 10.9, hematocrit 34.4,
platelet count of 214, INR 2.0, sodium 147, creatinine 2.0,
anion gap of 14. Her differential showed 62 polys and 20
bands. Urinalysis was cloudy, specific gravity of 1.015, pH
of 8.5, large blood, positive nitrite, greater then 300
protein, large leukocyte esterase, greater then 50 white
blood cells and red blood cells with many bacteria. Chest
x-ray showed diffuse left sided infiltrates.
Electrocardiogram was sinus at 100 with normal axis and
intervals, ___________________ voltage with nonspecific T
diffuse T wave inversions and 1 to [**Street Address(2) 1766**] depressions, T
wave inversions in V2 to V5. Blood and urine cultures were
sent at that point.
HOSPITAL COURSE: The patient was presumed to have urosepsis
initially managed on Dopamine and Levophed drips. She had
intermittent runs of rapid atrial fibrillation on Amiodarone
requiring at one point Diltiazem drip. She was successfully
weaned from her Dopamine and Levophed drips on hospital day
four. She was presumed to have aspiration pneumonitis versus
pneumonia and acute lung injury. During intubation and was
initially managed with Levofloxacin, Vancomycin and
Ceftazidime. Her antibiotics regimen were switched around
several times when she would intermittently spike
temperatures with no obvious source. She was extremely slow
to wean from the vent despite the aggressive pulmonary
toilet, chest physical therapy and broad spectrum
antibiotics. Of note, the patient's urine initially grew
Providencia stuartii E and proteus mirabilis and she grew
proteus mirabilis as well in her blood. On [**2175-5-3**] also had
coag negative staph in her blood, which was the rational for
the Ceptaz and Vancomycin and Levofloxacin initially.
Subsequent blood cultures were negative on [**5-5**] and [**5-6**].
She completed a course for her urinary tract infection.
Ceftazidime was subsequently stopped. However, she was
febrile on [**5-10**]. Sputum showed Pseudomonas aeruginosa again.
The patient was subsequently restarted on Ceftazidime, which
was later switched to Piperacillin and Tazobactam.
At the time of discharge the patient had completed nineteen
days of Levofloxacin and was on day eight of her third round
of her Vancomycin and Zosyn. Her central lines were changed
on multiple occasions. She had a PICC line placed on [**5-19**].
Given her slow wean off of pressors and intermittent
hypotensive episodes the patient had [**Last Name (un) 104**] stem test on [**5-20**],
which was performed according to regular protocol and it
showed an inappropriate Cortisol response to ACTH infusion.
Her baseline Cortisol was 18 and a one hour Cortisol level
was measured at 18. She was therefore started on Prednisone
5 mg po q day as replacement therapy. She may at some point
require mineral corticoid supplementation. However, elected
not to add Florinef at this time.
The patient was very slow to wean from the vent given her
continued diffuse pulmonary infiltrates and adult respiratory
distress syndrome type picture. She was trached on [**5-18**]
without complications. She was maintained on assist control
ventilation, however, her PEEP was successfully weaned from
15 to 5 and her FIO2 was weaned from 0.6 to 0.4. The patient
tolerated that with O2 saturations in the high 90s. The
patient did continue to spike low grade temperatures. Her
line sites looked clean and had a PICC line placed on [**5-19**].
She did have twelve hours of increased stool output while on
broad spectrum antibiotics, therefore C-diff was sent. The
first C-diff was pending at the time of discharge. Her
active issues upon discharge include:
1. Pulmonary, the patient continues to have diffuse
bilateral infiltrates presumed noncardiogenic pulmonary edema
and resolving acute lung injury/pneumonia. She will be
discharged on Vancomycin day eight of fourteen, Piperacillin
and Tazobactam day eight of fourteen and Levofloxacin day
nineteen. She will require aggressive pulmonary toilet and
is currently being suctioned more overnight, but generally
every two to three hours. She currently is on assist control
450 by 20 breathing at 26 with a PEEP of 5 and an FIO2 of 0.4
maintaining O2 sats in the high 90s. She continues to
auto diurese and generally is more awake and interactive.
She will most likely be a very slow wean and may not be
possible to decannulate her trach
2. Infectious disease: The patient continues to hve
intermittent low grade temperature spikes with no obvious
source. Her cultures remain negative at this point. She
should receive two more C-diff toxins upon reaching the rehab
facility and po Flagyl should be added to her nasogastric
tube should she come back positive. At this point her stool
output has decreased and she has been afebrile for greater
then 24 hours at the time of discharge. She should complete
a fourteen day course of Vancomycin and Piperacillin and
Tazobactam. Dosages are listed at the end of this dictation.
I would continue the Levofloxacin for the remaining six days
and stop all antibiotics at that point. Should she spike she
should be recultured for sources, although I feel that her
intermittent temperature spike was likely related to her
pulmonary disease.
3. Cardiovascular/atrial fibrillation: The patient has
intermittent atrial fibrillation currently in normal sinus
rhythm. She responds very well to Diltiazem should she have
recurrent atrial fibrillation. There is no plan to
anticoagulate the patient at this time despite her risk of
stroke given her multiple comorbidities.
4. FEN: Our goal ins and outs at this point are even to
slightly negative. The patient continues to auto diurese and
generally line status is euvolemic to slightly positive.
Continue to follow her electrolytes and replete. She is
currently on tube feeds and at goal with minimal residuals.
She has a PICC line, which was placed on [**5-19**], which is
functioning well and the site looks clean.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Acquired Immunodeficiency Syndrome.
3. Urinary tract infection.
4. Atrial fibrillation with rapid ventricular response.
5. Dementia.
6. Respiratory failure requiring tracheostomy placement.
DISPOSITION: [**Hospital3 1767**].
DISCHARGE MEDICATIONS: Vancomycin 750 mg intravenous q 18
hours day eight of fourteen, stop on [**2175-5-29**], Piperacillin
Tazobactam of 2.25 grams intravenous q 6 hours day eight of
fourteen stop [**2175-5-29**]. Levofloxacin 500 mg po q day eighteen
of twenty four stop [**2175-5-29**]. Reglan 10 mg intravenous q.i.d.,
Prevacid 50 mg po q day, Amiodarone 200 mg po q day, aspirin
325 mg po q day, ProMod with fiber tube feeds 55 cc per hour,
check residuals q 4 hours. Regular insulin sliding scale,
specific listed on page one. Neutrophos one tab po b.i.d.
times one day stop [**2175-5-24**]. SubQ heparin 5000 units subQ
b.i.d., Prednisone 5 mg po q day, Ativan 0.5 mg per G tube q
4 to 6 hours prn. Morphine sulfate 1 to 2 mg intravenous q 2
to 3 hours prn.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 1768**]
MEDQUIST36
D: [**2175-5-23**] 08:40
T: [**2175-5-23**] 08:54
JOB#: [**Job Number 1769**]
|
[
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"507.0",
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"599.0",
"427.31",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.15",
"31.1",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8766, 9017
|
9041, 10083
|
3490, 8745
|
2133, 3472
|
125, 1648
|
1908, 2110
|
1671, 1882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,195
| 197,483
|
29000
|
Discharge summary
|
report
|
Admission Date: [**2112-8-11**] Discharge Date: [**2112-8-17**]
Date of Birth: [**2058-4-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Unable to obtain as on ventilator
Obtained history from nursing home records. Called both
HCP/guardians but unable to reach. Patient unable to provide
history as has developmental disabilities with good receptive
language skills but non-verbal due to presence of tracheostomy
placed on [**2111-1-13**].
54F MR, tracheomalacia s/p tracheostomy in [**2107**], PVD, multiple
aspiration pneumonias, DM2 among other conditions who had low
oxygen saturations at her nursing facility. She was noted to
have thick yellow secretions from her trach tube on [**2112-8-9**].
She was started on zithromax. It was noted that today her pulse
ox was low in 70s-80s on supplemental oxygen with no improvement
with suction today. She was tremulous and bluish. She was
transferred to the ER for further care.
Of note, the patient has tracheomalacia. She was hospitalized at
[**Hospital1 18**] for evaluation of severe PVD in Feburary [**2110**] at which
time she went into respiratory distress from pulmonary edema.
Adequate intubation was not possible due to tracheomalacia, and
she underwent open tracheostomy. She stabilized but remained
ventilator dependent for severe week but eventually weaned at
pulmonary rehab. Because of tracheomalacia and subsequent trauma
from tracheostomy (Portex #7), she will likely remain
teacheostomy dependent and not a candidate for decannulation.
Per the IP team, she is not a candidate for a PM valve.
At baseline, she receives continuous humidifcation via trach
mask and large volume nebulizer. The FiO2 settings is from 21-40
% to keep O2 sat > 90 %.
The patient also has a history of bipolar disorder with a long
history of mood swings including agitation, assault, and
depression.
In the ED, initial VS were: Triage 19:51 0 99 112 127/49 18 97%
10 l humidified
Labs were performed
- WBC 19.1 Hgb 10.8 (Baseline [**7-22**]) Plt 175 Diff N 81 L 7.5
- Coags within normal limits
- Na 129 K 4.2 Cl 88 HCO3 34 BUN 23 Cr 1 (baseline 0.8-1) Glc
163
- Lactate 3.4
- UA SpG 1.008 pH 8.5 LE LG Nit neg WBC 12 Bacteria Few Epi < 1
CXR showed limited lung volumes with no acute intrathoracic
process detected although ? pneumonia.
She was given vancomycin, zosyn, and levaquin.
Access was difficult with 20G peripheral IV in shoulder and
failed attempt of right femoral line.
Patient was placed on a ventilator due to continued respiratory
distress and tachycardia. Vent settings were 350x20, PEEP 5,
FIO2 40 %. She was suctioned x 2.
VS on transfer: 00:08 100.3 113 101/64 20 98%
On arrival to the MICU, patient was resting comfortably on the
vent.
Review of systems: unable to obtain as on ventilator
Past Medical History:
Past Medical History:
Mental retardation
tracheomalacia s/p tracheostomy
h/o aspiration pneumonia
E.Coli bacteremia [**10-23**]
diabetes mellitus
h/o C. difficile infection
glaucoma
hypertension
HLD
osteoarthritis
depression/anxiety,
constipation
psychosis
PAST SURGICAL HISTORY:
Tracheostomy and PEG [**2107**],
R total knee replacement
R hip replacement
Right common iliac artery stent placement and right external
iliac recanalization with stent placement x2. [**1-/2111**]
Social History:
lives at nursing home
Father and Brother are [**Name2 (NI) **]-guardians
Family History:
unable to obtain
Physical Exam:
Admission Exam:
VS 100.3 113 101/64 20 98%
General: would state shake head "yes or no" to questions,
follows commands, unable to speak due to ventilator and trach
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, poor dentition
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops although exam limited due to coarse breath sounds
Lungs: diffuse coarse breath sounds, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. PEG tube located in LUQ
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact although disconjugate gaze especially
with right eye
Skin: ? stage I pressure ulcer on sacrum
Pertinent Results:
[**2112-8-10**] 10:42PM BLOOD WBC-19.1*# RBC-3.52* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.7 MCHC-34.2 RDW-16.3* Plt Ct-175
[**2112-8-10**] 10:42PM BLOOD Neuts-81.0* Lymphs-7.5* Monos-11.0
Eos-0.2 Baso-0.2
[**2112-8-15**] 03:59AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2112-8-10**] 10:42PM BLOOD PT-10.0 PTT-26.4 INR(PT)-0.9
[**2112-8-10**] 10:42PM BLOOD Glucose-163* UreaN-23* Creat-1.0 Na-129*
K-4.2 Cl-88* HCO3-34* AnGap-11
[**2112-8-11**] 04:00AM BLOOD Calcium-8.6 Phos-1.7* Mg-2.0
[**2112-8-10**] 10:59PM BLOOD Type-ART pO2-101 pCO2-50* pH-7.47*
calTCO2-37* Base XS-10 Intubat-NOT INTUBA
[**2112-8-10**] 10:59PM BLOOD Lactate-3.4*
Blood Culture, Routine (Final [**2112-8-13**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
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----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
URINE CULTURE (Final [**2112-8-12**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
RESPIRATORY CULTURE (Final [**2112-8-15**]):
HEAVY GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
CIPROFLOXACIN sensitivity testing performed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SECOND
MORPHOLOGY.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S 2 S
CEFTAZIDIME----------- 4 S 4 S
CIPROFLOXACIN--------- S 0.5 S
GENTAMICIN------------ 2 S 4 S
MEROPENEM------------- 1 S 1 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
[**2112-8-17**] 04:00AM BLOOD WBC-7.5 RBC-3.36* Hgb-10.1* Hct-31.4*
MCV-94 MCH-30.1 MCHC-32.2 RDW-15.2 Plt Ct-154
[**2112-8-17**] 04:00AM BLOOD Glucose-72 UreaN-14 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-33* AnGap-6*
[**2112-8-17**] 11:32AM BLOOD Type-CENTRAL VE pO2-37* pCO2-61* pH-7.35
calTCO2-35* Base XS-5
=
=
=
=
=
=
=
=
=
=
================================================================
Imaging:
[**2112-8-10**]
FRONTAL CHEST RADIOGRAPH: A tracheostomy tube is appropriately
positioned. Low lung volumes result in bronchovascular
crowding. The central pulmonary vessels are engorged, however,
no overt edema is seen. There is no definite consolidation,
pneumothorax, or pleural effusion.
[**2112-8-15**]
Renal U/s
FINDINGS: The study is markedly limited due to patient body
habitus, edema and portable technique. The right kidney is 8.6
cm and the left kidney is 10.1 cm. There is no obvious
hydronephrosis. We cannot evaluate for stones or masses. The
bladder is not seen.
[**2112-8-15**]
Chest CT
FINDINGS: There are no pulmonary arterial filling defects to
suggest the
presence of pulmonary embolism. There is no aortic dissection.
There are
small bilateral non-hemorrhagic pleural effusions as well as
large areas of atelectasis bilaterally. On the left, most of
the posterior basal segment is collapsed. There are also
multiple areas of airspace consolidation consistent with
multifocal pneumonia.
There are multiple enlarged lymph nodes within the
mediastinum. The largest are a 19 x 12 mm right paratracheal
lymph node (3:19) and a 20 x 11 mm paraesophageal lymph node
further inferiorly (3:34). Severe tracheomalacia is again
identified beginning just distal to the endotracheal tube and
continuing through the carina (3:10). This is similar in extent
and severity to the prior examination from [**2112-4-13**]. No
focal osseous lesions are identified. There is extensive
atherosclerotic calcification within the thoracic aorta and
coronary arteries. A small pericardial effusion is present,
without evidence
of tamponade as well as a probable edematous lymph node in the
epicardial fat pad (4:112).
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Multifocal pneumonia and segmental atelectasis, with small
bilateral
non-hemorrhagic pleural effusions.
3. Severe tracheomalacia.
4. Mediastinal lymphadenopathy, likely reactive hypertrophy in
the setting of pneumonia.
Brief Hospital Course:
53F history of mental retardation, tracheomalacia s/p
tracheostomy with multiple aspiration pneumonias, DM2 among
other conditions who presented with tachypnea, increased oxygen
requirement, and thick secretions from tracheostomy concerning
for sepsis from a pulmonary source. Was found to have sputum
positive for pseudomonas and blood culture positive for E. Coli.
Both organisms were sensitive to ciprofloxacin.
# Sepsis from a pulmonary and/or urinary source, initially
treated with broad coverage with vancomycin and cefepime.
Received fluid resuscitation. Initial lactate was 3.4, which
cleared with resuscitation. Pt. had episode of hypotension to
SBPs of 70s requiring placement of femoral CVC, and brief use of
NE for less than 24 hours. CVC was then pulled and a PICC line
was placed.
Blood Cx showed E. Coli, and suputum culture showed pseudomonas,
both of which were sensitive to ciprofloxacin. When this data
was obtained, antibiotic coverage was narrowed to just
ciprofloxacin. As patient was also on large doses of seroquel,
EKG was obtained, which showed normal QTc.
She is to continue a 15 day course of antibiotic coverage for
pseudomonas VAP/E. Coli bacteremia with ciprofloxacin. End date
for cipro is [**2112-8-25**].
# Respiratory failure
Patient may have respiratory failure secondary to pulmonic
process such as pneumonia or tracheobronchitis with some
component of mucous plugging per reports in ER. Pt. was able to
be weaned off the vent, saturating well with trach mask. The
evening before discharge she was placed on pressure support
ventilation to see if this would improve her tachycardia. She
was able to come off of vent on day of discharge. Would likely
benefit from CPAP at night and albuterol nebulizer.
# Anemia: Likely multifactorial ACD, acute blood loss, and
dilutional. Admitted at baseline Hgb ~ 10. Crit dropped after
placement of fem line with bleeding noted at fem site, concern
for retroperitoneal bleed at that time but responded
appropriately to 4 units with no evolving signs of bleeding.
Remained stable, then dropped two days later in context of 2L
fluid bolus, bumped appropriately to 2 units PRBC. Hematocrit
stable at discharge.
# Altered mental status: Patient waxed and waned. Initially
attributed to sepsis and respiratory distress, the patient was
eventually decreased on Seroquel from 250mg TID to 125mg TID.
She became alert and oriented at discharge.
# Tachycardia: Etiology unclear, developed tachycardia to 120's
after sepsis resolved. Responded to CPAP at night, IVF, and
resumption home metoprolol.
# Rash: Likely drug reaction to cefepime-erythematous blanching
over abd and torso, nonpruritic, no swelling, no pustules,
evolved two days after cefepime started and one day after vanc
DC'd. Rash resolved with narrowing to ciprofloxacin. The patient
had some relief with hydrocortisone cream.
# Hyponatremia: Hypovolemic hyponatremia, admitted Na 130, rose
to 141 with IVF.
Chronic Issues:
# Peripheral Vascular Disease: Lower extremity pulses are
evidence by doppler on admission. Continued ASA 325 mg PO qD,
held fenofibrate, restarted at discharge.
# Bipolar disorder
She had no active signs or symptoms of psychiatric
decompensation. Continued seroquel 250 mg PO TID initially, then
decreased to 125mg TID in the setting of altered mental status.
Continued valproic acid syrup 500 mg PO qAM and 750 mg PO qPM.
# DM2: Blood sugars were stable, Lantus decreased from 48 to 35
units at bed time.
# Hypothyroidism: Continued home levothyroxine
# Hypertension: After sepsis resolved, pressures stabilized.
# Glaucoma: Continued latanoprost drops qAM
# Osteoporosis: Continued calcium and vitamin D after sepsis
stabilized
Transitional Issues
MEDICATION CHANGES
STOPPED Metoprolol for hemodynamic instability, resume at
outpatient facility
STARTED Ciprofloxacin IV 500mg [**Hospital1 **], last day [**8-25**] for total of
15 days coverage
STARTED Hydrocortisone Cream 0.5% 1 Appl TP [**Hospital1 **]:PRN pruritis
STARTED Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheeze
CHANGED Seroquel 250mg TID to 125mg TID
-ventilator support as needed, may trial CPAP at night
-IV ciprofloxacin administration until [**2112-8-25**]
-wound care for buttocks and inner thighs
-Seroquel dose was downtitrated from home dose of 250mg TID to
50mg TID while in hospital. Patient did well on this dose and
on discharge was not agitated. If agitated, may uptitrate dose
of seroquel as needed if there is no QTc prolongation
-Monitor hemodynamics: if tachycardic and blood pressure
tolerates, please restart metoprolol and uptitrate as needed
(this had been held in the hospital due to hypotension and
concern for sepsis; her home dose prior to hospitalization was
150mg [**Hospital1 **])
-Speech & swallow evaluation:
1. Pt is not safe to wear the PMV at this time
2. Discuss safety of trach cuff deflation trials to allow
intermittent periods where pt can try to speak
3. Remain NPO with tube feeds
4. Q4 oral care as pt allows
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from nursing
home records.
1. Aspirin 325 mg PO DAILY
2. Calcium Carbonate Suspension 1250 mg PO DAILY
5 mL (1 tsp) = 1250 mg Calcium Carbonate = 500 mg of Elemental
Calcium
3. fenofibrate *NF* 54 mg Oral daily
4. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Tartrate 150 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Quetiapine Fumarate 250 mg PO TID
10. Valproic Acid 500 mg PO QAM
11. Valproic Acid 750 mg PO QHS
12. Lorazepam 1 mg PO Q6H:PRN agitation
13. Vitamin D 400 UNIT PO DAILY
14. Azithromycin 250 mg PO Q24H
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QAM
16. lactobacillus acidophilus *NF* Oral [**Hospital1 **]
17. Amoxicillin [**2099**] mg PO PREOP
prior to dental exams
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QAM
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lorazepam 1 mg PO Q6H:PRN agitation
5. Quetiapine Fumarate 50 mg PO TID
adjusted for MS
6. Valproic Acid 500 mg PO QAM
Liquid form
7. Valproic Acid 750 mg PO QHS
Liquid form
8. Amoxicillin [**2099**] mg PO PREOP
prior to dental exams
9. fenofibrate *NF* 54 mg Oral daily
10. lactobacillus acidophilus *NF* 0 capsule ORAL [**Hospital1 **]
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Miconazole Powder 2% 1 Appl TP QID:PRN fungal infection
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
16. Hydrocortisone Cream 0.5% 1 Appl TP [**Hospital1 **]:PRN pruritis
17. Ciprofloxacin 400 mg IV Q12H
Started Gram-negative bacteremia coverage on [**8-11**] days
ending [**8-25**]
18. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheeze
19. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
20. Calcium Carbonate Suspension 1250 mg PO DAILY
5 mL (1 tsp) = 1250 mg Calcium Carbonate = 500 mg of Elemental
Calcium
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Sepsis with gram negative bacteria
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with a blood infection and placed on antibiotics for
this. This infection was likely from a urinary source, and will
require ciprofloxacin IV 5000mg twice daily up to and including
[**2112-8-25**].
In addition, you lost some blood after placement of a line in
your groin through which to administer fluid. You received a
blood transfusion to bring your blood levels back up.
Followup Instructions:
Follow up with physicians at your rehabilitation facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
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|
3482, 3557
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,761
| 138,092
|
51911
|
Discharge summary
|
report
|
Admission Date: [**2149-8-26**] Discharge Date: [**2149-9-2**]
Date of Birth: [**2089-11-18**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Sulfonamides / Macrodantin / Levofloxacin / Penicillins
/ Clindamycin / Protonix / Cephalosporins / Erythromycin Base /
Biaxin / Ciprofloxacin / Tetracycline / Flagyl / Triple
Antibiotic / Betadine / Ivp Dye, Iodine Containing / Atropine /
Latex / Morphine / Codeine / Percocet / Imodium A-D / Demerol /
Tape / Linezolid
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Diarrhea and right upper quadrant pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a pleasant 59 year old woman with a history of
immune deficiency, recurrent cellulitis, multiple medication
intolerances and hyperfibrinolysis syndrome who presented with
five days of cellulitis and gastrointestinal intolerance of the
minocycline therapy she had received. Per the patient, she
began to notice some redness and tenderness of the tip of her
nose five days prior to admission. She presented to the office
of her PCP, [**Name10 (NameIs) 1023**] started minocycline therapy for her cellulitis
as she had tolerated this antibiotic in the past. Her
cellulitis initially seemed to improve but then stopped
improving and may have worsened a bit in the days immediately
preceding admission. About three days prior to admission she
developed diarrhea and RUQ/R flank pain, which she has had
before in reaction to medications. During this previous use,
however, she had been an inpatient and her reaction was
attributed to confounding factors due to the hospitalization.
The patient had been dealing with these pains and symptoms over
the last few days, but continued to be concerned that she was
not absorbing enough food and that her nose appeared to be
worsening again. When asked to better describe her pain, she
described the RUQ pain as constant in nature without radiation.
She had decreased PO intake over the last three days prior to
admission due to GI distress and abdominal pain. She denied
nausea, vomiting, fevers, or chills. She also denied dysuria or
hematuria. After reporting this GI distress to her PCP she was
told to come to the hospital. Regarding the state of her
cellulitis on admission she reported it was improved from when
it had started but had worsened a bit from the first few days of
treatment.
In the ED, T:95.9 HR65 BP143/70 RR16 SaO2:97(RA). The patient
received a RUQ u/s, labs, and blood cultures. She was sent to
the floor for further management.
On arrival to the floor the patient was comfortable, awake,
alert, and reclining in bed.
<b><u>REVIEW OF SYSTEMS</B></U>
Patient denied fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, dysuria, and
hematuria.
Past Medical History:
-IgG and IgA deficiency with resultant MSSA folliculitis and
cellulitis
-Herpes simplex virus type 1
-Irritable bowel syndrome
-non ulcerative dyspepsia
-chronic fatigue syndrome - stable now
-depression
-status post appendectomy
-recurrent proctitis
-local anal squamous cell carcinoma s/p 3 resections ([**2133**],
[**2135**], [**2137**]), surveillance bx c-scope [**2140**] negative for
recurrence, no XRT or chemo
-history of uterine cancer s/p TAH ([**2124**])
-DCIS s/p recent wide resection in [**11/2147**], ER and PR positive
and HER2/neu negative by IHC and FISH
Social History:
Retired nurse. No longer works because of chronic fatigue. No
alcohol, smoking, illegal drug use.
Family History:
Negative for any immune deficiency disorders.
Physical Exam:
Vitals - T: 97.2 BP: 118/62 HR:60 RR:18 02 sat:98% on RA
GENERAL: Thin, pale, chronically ill appearing female with
erythematous nose
HEENT: Sclerae anicteric, PEERL, bandage on head over popped
sebaceous cyst w/o blood or drainage, oropharynx benign
CARDIAC: RRR, no m/r/g, nl s1 and s2
LUNG: CTAB, no W/R/R
ABDOMEN: Soft, NT, ND, BS+
EXT: W&WP, no C/C/E
NEURO: A&O* 3, strength 5/5 in all extremities, no abnormal
movements, CNII-XII grossly intact
SKIN: WNL except nose (described above)
On Discharge T 98.7, HR 70, BP 112/66, RR 18, O2 Sat 100% on
room air. Patient continues to be chronically ill appearing
woman in NAD. HEENT reveals less erythema and in smaller area
on nose. Otherwise exam not significantly changed from
admission except interim development of mildly tender abdomen on
exam.
Pertinent Results:
<b><u>LABORATORY RESULTS</B></U>
On Admission:
WBC-4.8 RBC-4.08* Hgb-12.8 Hct-37.3 MCV-92 Plt Ct-146*
---Neuts-51.3 Lymphs-42.7* Monos-4.2 Eos-1.6 Baso-0.3
PT-13.7* PTT-30.4 INR(PT)-1.2*
Glucose-95 UreaN-21* Creat-1.3* Na-143 K-3.5 Cl-105 HCO3-26
ALT-24 AST-28 AlkPhos-83 TotBili-0.6
Albumin-4.5
Lactate-1.6
On Discharge:
WBC-3.9* RBC-3.65* Hgb-11.4* Hct-33.4* MCV-91 Plt Ct-152
Glucose-87 UreaN-5* Creat-1.0 Na-145 K-3.4 Cl-106 HCO3-29
Albumin-4.1 Calcium-8.9 Phos-3.8 Mg-2.1
<b><u>RADIOLOGY</B></U>
Liver and GB Ultrasound:
IMPRESSION: No evidence of cholelithiasis or cholecystitis.
Brief Hospital Course:
59 yr old female with hx of IgA deficiency and multiple
antibiotic allergies/intolerances admitted with worsening nasal
cellulitis and GI intolerance of her antibiotic regimen.
1) Cellulitis: The patient has an extensive history of MSSA skin
infections. She presented with cellulitis on the tip of her
nose for which she had been given minocycline as an oupatient.
Unfortunately, the patient had been having worsening of the
appearance of her nose as well as increasing GI intolerance
while on minocycline therapy. Therefore, she was admitted. She
was initially treated with vancomycin, but the primary team
hoped to find a simpler regimen the patient could take at home.
Given her history of multiple infections and multiple antibiotic
intolerances the infectious disease service was consulted and
recommended nafcillin desensitization in the ICU with transition
to dicloxacillin for discharge. Her respiratory desensitization
was accomplished without any respiratory symptoms or major
complications and after switch to nafcillin the patient almost
immediately began to have decreased erythema and discomfort at
the tip of her nose. She was transitioned to dicloxacillin and
discharged with plan to complete a 14 day course of therapy.
The patient never had fever or elevated white count during this
hospitalization.
2) Right Upper Quadrant Pain: The patient had a normal right
upper quadrant ultrasound and presentation and normal
transaminases and bilirubin so this was presumed to simply be
part of her GI intolerance syndrome to minocycline. This
resolved after the minocycline was discontinued.
3) Diarrhea/GI sensitivity: The patient presented complaining of
loose stools and abdominal pain, which was presumed secondary to
her gastrointestinal intolerance of minocycline. Given her
history of C difficile colitis, however, a toxin assay was
checked and was negative. The patient's gastrointestinal
symptoms improved during her first and second day in the
hospital off minocycline but then began to worsen again,
presumably secondary to nafcillin therapy. The patient reported
soft stools and abdominal discomfort and bloating. This was
alleviated somewhat simethicone but other symptomatic therapies
were not possible as the patient has a history of intolerances
to almost all anti-emetics and anti-diarrheals including
ondansetron, lomotil, and immodium. Eventually, she was put on
lorazepam with some improvement of her nausea. The patient had
been on IV fluids but eventually these were discontinued and the
patient, despite complaints of considerable diarrhea, did not
appear dehydrated and in fact had improved creatinine from
presentation. She was eating and drinking despite abdominal
complaints. Given there was no further indication for
hospitalization as she was tolerating a PO diet and there was no
suspicion of a dangerous etiology of her GI symptoms she was
discharged with encouragement to keep up good PO intake and use
probiotics for GI symptoms.
4) Thrombocytopenia: The patient has a chronic thrombocytopenia,
which was stable throughout this hospitalization.
5) Hypotension: The patient had one episode of hypotension with
SBP's down to the 70's on the morning after admission. This
resolved with IV fluids and required no further management.
The patient was maintained on a full diet with restrictions made
for her numerous food allergies. She was not put on SC heparin
as she has a history of easy bleeding but did ambulate TID as
she was asked by the primary team. She was full code.
Medications on Admission:
ALENDRONATE [FOSAMAX] - (Not Taking as Prescribed: bleeding) -
70 mg Tablet - 1 Tablet(s) by mouth weekly
CLONAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth at bedtime
MINOCYCLINE - 50 mg Capsule - take 1 Capsule(s) by mouth twice a
day for 10 days
RETAPAMULIN [ALTABAX] - (Prescribed by Other Provider) - 1 %
Ointment -
TRAZODONE - 50 mg Tablet - 0.5 Tablet(s) by mouth at bedtime
CALCIUM-MAGNESIUM-ZINC - (Prescribed by Other Provider) -
Dosage
uncertain
DIPHENHYDRAMINE HCL [BENADRYL] - (other provider) - 25 mg
Capsule - 1 Capsule(s) by mouth once a day as needed for to be
taken with imodium
TOLNAFTATE [TINACTIN] - (Prescribed by Other Provider) - 1 %
Powder - apply to feet daily
Discharge Medications:
1. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 9 days.
Disp:*36 Capsule(s)* Refills:*0*
2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for indigestion.
Tablet, Chewable(s)
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea: Do not drive while using this
medication.
Disp:*45 Tablet(s)* Refills:*0*
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep.
5. Tinactin 1 % Cream Sig: One (1) application Topical three
times a day as needed for fungus.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
------------------
Cellulitis
Multiple Medication Intolerances
.
Secondary Diagnoses:
--------------------
IgG subclass deficiency
Increased fibrinolysis syndrome
Chronic fatigue syndrome
Depression
History of ductal carcinoma in situ
History of anal carcinoma in situ
Discharge Condition:
Good, afebrile, resolving cellulitis, no respiratory compromise
Discharge Instructions:
You were admitted because you had cellulitis that was not
responding to the antibiotic you were initially prescribed.
Because of your medication intolerances we switched you to
another antibiotic under close monitoring in the ICU. You never
had respiratory issues with this transition. Your cellulitis
was improving and you had no fevers or signs of spreading
infection so you were discharged home to complete your recovery.
Your medications have been changed. You have been started on
DICLOXACILLIN, an antibiotic, to treat your cellulitis. You
will complete another nine days of therapy after discharge. You
have also been started on LORAZEPAM (ATIVAN) as an anti-nausea
medication. You should not drive or operate heavy machinery
after using this medication as it can sedate you.
Please call your doctor or come to the hospital if you have
fever>101 F, chest pain, shortness of breath, inability to stay
hydrated, or any other concerning changes in your health.
Followup Instructions:
You have a follow up scheduled with [**First Name11 (Name Pattern1) 31804**] [**Last Name (NamePattern1) 31805**], MD on
[**2149-9-24**] at 2:00 pm. His office can be reached at [**Telephone/Fax (1) 250**].
You have an appointment with [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2149-9-29**] at
3:15 pm. You can reach Dr[**Name (NI) 105845**] office at [**Telephone/Fax (1) 6733**].
Prior to this appointment you have an appointment in radiology
at 2:00 pm. The readiology suite can be reached at
[**Telephone/Fax (1) 327**].
You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2150-3-12**] at
4:00 pm. Dr[**Doctor Last Name **] office can be reached at [**Telephone/Fax (1) 22**].
|
[
"311",
"780.71",
"286.6",
"682.0",
"287.5",
"789.01",
"458.9",
"279.03",
"787.91",
"V14.1",
"E930.9",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10146, 10152
|
5206, 8746
|
629, 636
|
10484, 10550
|
4594, 4627
|
11572, 12384
|
3703, 3751
|
9520, 10123
|
10173, 10173
|
8772, 9497
|
10574, 11549
|
3766, 4575
|
10278, 10463
|
4917, 5183
|
550, 591
|
664, 2972
|
10192, 10257
|
4641, 4903
|
2994, 3569
|
3585, 3687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,173
| 110,037
|
36267
|
Discharge summary
|
report
|
Admission Date: [**2169-4-2**] Discharge Date: [**2169-4-8**]
Date of Birth: [**2091-3-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Iodine / Shellfish Derived
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p unwittnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 year old woman who takes Plavix and Aspirin daily and fell
[**4-2**] at her daughter's home. The patient is intubated and non
communicative at the time of initial exam. Her daughter and
health care proxy is able to relay the events from the time of
the patients fall at 430 pm [**4-2**]. Her daughter reports that she
was in another room when her mother fell. The daughter heard
her mother fall and went immediately to her side. The patient
tripped on the last stair of her home. There was no observed
loss of consciousness and the patient stated at the time of the
fall that she lost her footing on the steps. At baseline, the
patient has difficulty with her knees that caused her
unsteadiness. The patient had a left eyebrow laceration from
the fall, but was completely neurologically intact per the
daughter. The daughter took the patient to [**Name (NI) 620**] [**Name (NI) **] . At 7pm
the pt became aphasic and lethargic and had a Head CT which
showed a large left intraparenchymal bleed. The patient was
electively intubated and transferred to [**Hospital1 18**] ED for definitive
care.
Past Medical History:
diabetes, HTN, CABG X 2 vessels-[**2160**], CVA following CABG
[**2160**], cataract surgery [**2167**].
Social History:
husband has advanced [**Name (NI) 2481**] and 2 daughters are the
designated Health Care Proxy for the patient. One of the
daughters lives in [**Name (NI) 26692**]
Family History:
non-contributory
Physical Exam:
On Admission:
Gen: intubated no eye opening to voice or stimulus.
HEENT: left eyebrow laceration, ecchymosis around left eye
Pupils: 3 to 2.5 mm EOM pt not cooperative
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS-6
Orientation: not oriented
Recall:
Language: intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
mm 2.5 bilaterally.
III, IV, VI,V, VII,VIII,IX, X,[**Doctor First Name 81**],XII: face appears symmetric-pt
unable to perform cranial nerve exam due to poor mental status
Motor: purposeful Left upper extremity, lifting off bed reaching
for ET tube, flexes and withdraws bilateral lower extremities to
painful stimulation, minimal movement of right upper extremity
to
noxious stimuli. No abnormal movements/tremors. Pronator
drift-pt
unable to perform
Pertinent Results:
Labs on Admission:
[**2169-4-2**] 09:45PM BLOOD WBC-13.4* RBC-4.38 Hgb-12.3 Hct-37.9
MCV-87 MCH-28.2 MCHC-32.6 RDW-12.8 Plt Ct-312
[**2169-4-2**] 09:45PM BLOOD Neuts-85.7* Lymphs-9.3* Monos-4.4 Eos-0.3
Baso-0.3
[**2169-4-2**] 09:45PM BLOOD PT-13.3 PTT-25.6 INR(PT)-1.1
[**2169-4-2**] 09:45PM BLOOD Glucose-158* UreaN-21* Creat-0.8 Na-141
K-4.1 Cl-107 HCO3-22 AnGap-16
[**2169-4-2**] 09:45PM BLOOD CK-MB-11*
[**2169-4-2**] 09:45PM BLOOD cTropnT-<0.01
[**2169-4-3**] 02:19AM BLOOD Phenyto-13.8
Imaging:
Head CT [**4-2**]:
NON-CONTRAST HEAD CT: Compared to two hours prior, there has
been slight
interval increase in the large left frontal intraparenchymal
hemorrhage, which now measures 7.5 x 3.8 cm in greatest
dimension, previously 6.7 x 3.8 cm. The hemorrhage has now
dissected into the left lateral ventricle with a small amount of
blood also layering within the right lateral ventricle. There is
mass effect on the ventricles, however no evidence of
hydrocephalus. 7 mm of rightward midline shift and subfalcine
herniation are unchanged. Moderately extensive right
parietotemporal subarachnoid hemorrhage is stable. The basal
cisterns are preserved with no evidence of uncal herniation. The
left lens is absent. There is no soft tissue hematoma or skull
fracture.
IMPRESSION:
1. Slight interval increase in extent of large left frontal
intraparenchymal hemorrhage, now with extension into the left
lateral ventricle. No evidence of hydrocephalus.
2. Unchanged 7-mm of rightward midline shift.
3. Stable moderate right parietotemporal subarachnoid
hemorrhage.
Head CT [**4-3**]:
IMPRESSION: No significant change compared to eight hours prior
except for
slight redistribution of intraventricular blood products.
Unchanged large
left frontal intraparenchymal hemorrhage and moderate right
subarachnoid
hemorrhage.
Head CT [**4-4**]:
NON-CONTRAST HEAD CT: There has been no significant interval
change in
multiple intracranial hemorrhages. The left frontal
intraparenchymal
hemorrhage measures 7.6 x 4.4 cm, grossly unchanged when
accounting for head position. The moderate right parietotemporal
subarachnoid hemorrhage is also unchanged. Small amount of blood
layering within the ventricles is unchanged. There is no new
hydrocephalus. Subfalcine herniation and 5 mm of rightward
midline shift are stable. Left lens is absent. The calvarium and
soft tissues are normal.
IMPRESSION: No significant interval change in large left frontal
IPH and
moderate right parietotemporal subarachnoid hemorrhage. No
change in mass
effect or intraventricular extension of blood. No hydrocephalus.
EKG [**4-3**]:
Sinus rhythm with borderline resting sinus tachycardia. Left
ventricular
hypertrophy by voltage. Inferolateral ST-T wave changes with ST
segment
depressions may be due to ischemia, etc. Compared to the
previous tracing
of [**2169-4-2**] precordial voltage is more prominent. ST-T wave
changes are
more apparent. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 134 82 [**Telephone/Fax (2) 82209**] 162
EKG [**4-5**]:
There is arm lead reversal. Sinus rhythm. Left atrial
abnormality. Probable left ventricular hypertrophy with
secondary repolarization abnormalities. Compared to the previous
tracing of [**2169-4-3**] no diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 112 84 344/415 110 123 -51
CXR [**4-5**]:
FINDINGS: As compared to the previous examination, the
pre-existing left
lower lung opacity has slightly increased in density and evolves
towards a
retrocardiac consolidation. The pre-existing left lower lobe
opacity is of
similar density but slightly more extensive, the changes could
be consistent with bilateral evolving aspiration pneumonia. The
size of the cardiac silhouette is slightly increased. There is
no evidence of fluid overload. The monitoring and support
devices are unchanged. No evidence of larger pleural effusions.
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] after transfer from OSH with
significantly sized intracranial hemorrhage while on
anticoagulation therapy from previous cardiac surgery. Upon
admission; she was administered platelets and admitted to the
intensive care unit for continuous monitoring. On [**4-3**], repeat
head CT was performed and determined to be stable, and not
indicitative of ongoing hemorrhage. She was subsequently
extubated. On [**4-4**], she was observed to have difficulty managing
her secretions, and an arterial blood gas was performed and
revealed a PaO2 in the 50s, and was reintubated. Head CT was
again performed to evaluate whether the ICH had evolved to
attribute to the poor respiratory effort, but was stable. On
[**4-5**], a bedside mini bronchoscopy was done to evaluate if she
had aspirated any secretions during her period of poor
respiratory effort. A lung consolidation was identified, and
antibiotics were started. On [**4-5**] her exam was stable and social
work was consulted for family regarding the possibility for
trach/peg & DNR/I status. On [**4-6**] her sodium was 153, mannitol
was stopped, free H2O was increased to 150cc QID, and her exam
was stable. On [**4-7**] she had a troponin leak 1.19 and a family
meeting w/ palliative care where the conclusion was to make her
CMO and she was eventually extubated and started on morphine for
comfort. On [**4-8**] she passed away.
Medications on Admission:
janumet 50mg/500mg, Plavix 75 mg, diltiazem 300 mg, cilostazol
50 mg, Cymbalta 30 mg, aspirin 81 mg, Zetia 10 mg, simvastatin
80 mg, cilostazol 50 mg
Discharge Disposition:
Expired
Discharge Diagnosis:
Left intraparenchymal hemorrhage, intraventricular hemorrhage,
and right subarachnoid hemorrhage.
Aspiration Pneumonia
NSTEMI(+troponin 1.19)
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"V45.81",
"853.01",
"250.00",
"V66.7",
"518.81",
"V58.61",
"401.9",
"E880.9",
"276.0",
"410.71",
"V12.54",
"E944.4",
"414.00",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"38.91",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8208, 8217
|
6581, 8007
|
311, 318
|
8403, 8413
|
2650, 2655
|
8470, 8481
|
1776, 1794
|
8238, 8382
|
8033, 8185
|
8437, 8447
|
1809, 1809
|
250, 273
|
346, 1450
|
2110, 2631
|
4509, 6558
|
2669, 3184
|
2033, 2094
|
1472, 1577
|
1593, 1760
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,108
| 128,788
|
19979
|
Discharge summary
|
report
|
Admission Date: [**2137-2-13**] Discharge Date: [**2137-2-19**]
Date of Birth: [**2068-7-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**Doctor First Name 1402**]
Chief Complaint:
increased frequency of ICD firing
Major Surgical or Invasive Procedure:
AV ablation, ICD generator change
History of Present Illness:
67 M w/ CAD s/p MI [**56**] yrs ago, ischemic CM, EF 10-15%, VT s/p
ICD placement in '[**26**], s/p upgrade in '[**31**], had stem cell therapy
in [**Country **] in [**6-23**], PVD, resented [**8-25**] with recurrent firing of
his ICD. Received VT ablation and ICD reprograming. He was
continued on amiodarone. He presents now after ICD fired
earlier this am. Here for possible ICD generator change +/- AV
nodal ablation
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post MI [**56**] years ago.
2. Congestive heart failure with an EF of 15%.
3. Peripheral vascular disease.
4. Ventricular tachycardia status post implantable
cardioverter-defibrillator placement s/p VT ablation and BiV ICD
upgrade.
PAST SURGICAL HISTORY: He has had a cardiac aneurysm
resected. On last visit, total of 7 shocks, not consistently
associated with any activity. First 3 were not associated with
any sx, had interrogation at OSH. Over past week 4 more shocks,
3 with LOC, unknown duration of syncope likely seconds. Syncope
clearly preceded shock. Final shock he felt palpations in his
lower chest immediately prior to ICD firing.
Social History:
Retired businessman. He lives in [**Location 311**]. He does not smoke and
does not drink alcohol.
Family History:
Non-contributory.
Physical Exam:
T=98
BP=104-118/69-72
P=68-81
R=20
O2Sat=96-98%RA
Gen: lying in bed, nad
HEENT: no elevated JVP, no carotid bruits
PULMO: CTAB
CV: rrr, nl s1/s2, 1/6 sem rusb
ABD: bs+, nt, nd
EXT: warm, 2+ DP/PT, no c/c/e
Pertinent Results:
[**2137-2-13**] ECG: A-V paced rhythm, no significant change since
previous tracing of [**2136-9-14**]
.
[**2137-2-15**] CT ABD: Right-sided rectus sheath hemorrhage extending
along the oblique muscles as well. There is no
retroperitoneal/intraperitoneal extent of hemorrhage.
.
[**2137-2-15**] ECG: A-V sequentially paced rhythm with capture.
Compared to the previous tracing of [**2137-2-13**] the paced interval
has decreased.
.
[**2137-2-16**] ECG: The rhythm is likely atrial fibrillation with
ventricular pacing. Compared to the previous tracing of [**2137-2-15**]
atrial paicng is not evident.
.
[**2137-2-17**] ECG: Atrial fibrillation and ventricular paced rhythm
with capture. Compared to the previous tracing of [**2137-2-16**] no
diagnostic interim change.
.
[**2137-2-18**] CT CHEST: 1) No findings to indicate amiodarone lung
toxicity.
2) Left circumflex artery stent and calcification of the distal
anterior and septal left ventricular walls. 3) Emphysema
.
[**2137-2-13**] 04:50PM BLOOD WBC-9.0 RBC-4.51*# Hgb-10.6* Hct-34.0*
MCV-76*# MCH-23.6*# MCHC-31.2 RDW-15.9* Plt Ct-208#
[**2137-2-19**] 06:15AM BLOOD WBC-7.1 RBC-3.90* Hgb-10.0* Hct-31.4*
MCV-81* MCH-25.7* MCHC-31.9 RDW-18.6* Plt Ct-154
[**2137-2-13**] 04:50PM BLOOD PT-17.2* PTT-30.9 INR(PT)-1.9
[**2137-2-19**] 06:15AM BLOOD PT-13.9* PTT-28.3 INR(PT)-1.2
[**2137-2-13**] 04:50PM BLOOD Glucose-128* UreaN-55* Creat-2.3* Na-138
K-3.4 Cl-101 HCO3-25 AnGap-15
[**2137-2-19**] 06:15AM BLOOD Glucose-99 UreaN-44* Creat-1.7* Na-140
K-4.1 Cl-107 HCO3-24 AnGap-13
[**2137-2-13**] 04:50PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.3
[**2137-2-13**] 04:50PM BLOOD Digoxin-0.7*
[**2137-2-16**] 06:34AM BLOOD Digoxin-0.9
[**2137-2-17**] 02:36AM BLOOD Digoxin-1.0
[**2137-2-15**] 06:59PM BLOOD AMIODARONE AND DESETHYLAMIODARONE-
1.2/1.0
Brief Hospital Course:
.
EP: In the EP lab [**2-14**] the Pt had [**4-26**] different VTs, two of
which were ablated, one of which was not well tolerated. The Pt
was on dopamine and neosynephrine during the case secondary to
hypotension. During the case he also had Afib which was
cardioverted. He was placed in the CCU overnight and dopamine
was weaned off. He returned to the EP lab [**2-15**] for an ICD
generator ([**Company 1543**]) replacement w/o complication. Rhythm post
procedure was AF.
.
PAF: Pt was placed on heparin IV for anticoagulation
pre-procedure and continued on carvedilol for rate control. Pt
was in Afib post generator change and cardioverted. digoxin and
amiodarone levels were checked and meds dosed accordingly. CT
chest performed, and did not show any findings suggestive of
amiodarone toxicity. Pt had asymtomatic runs of VT noted on
telemetry throughout the hospitalization. His final ECG showed
atrial fibrillation and ventricular paced rhythm with capture
[**2-17**].
.
HEMATOMA: Pt developed a right-sided rectus sheath hemorrhage
extending along the oblique muscles post [**2-15**] procedure. Pt was
transferred to the CCU, heparin and coumadin held, received
PRBCs with stabilization of Hct. Coumadin was restarted after
Hct stabilization. Pt was seen by rehabilitation before
discharge
.
CAD: no angina. Continued on atorvastatin, isosorbide
mononitrate (Extended Release), and aspirin at time of
discharge.
.
CHF: euvolemic throughout stay. Continued on furosemide,
spironolactone, carvedilol, digoxin at time of discharge.
.
GOUT: Pt with gouty flare noted on [**2-13**], started on colchicine,
discharged on allopurinol once gout resolves.
.
Medications on Admission:
Spironolactone (Aldactone)25 mg QD
Furosemide (Lasix) 40 mg QD
Metolazone (Zaroxoyln) 5 mg once or twice a wk
Isosorbide mononitrate (Imdur) 30 mg QAM
Digoxin (Lanoxin) 0.0625 QD
Carvedilol (Coreg) 9.375 mg [**Hospital1 **]
Atorvastatin (Lipitor) 10 mg QD
Amiodarone 200 mg [**Hospital1 **]
Calcium 10 mg QD
Aspirin 81 mg QD
Zithromax 250 mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Amiodarone HCl 200 mg Tablet Sig: [**12-23**] (see below) Tablets PO
three times a day: Take:400 mg (2tabs) in am and pm and 200 mg
midday (1 tab) x 1 week until [**2-25**] (total 1gm/day).Then,take 200
mg 3x/day for total 600mg/day.
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
5. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
13. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days: Cont for 5 days or until your left ankle swelling
resolves.
Disp:*10 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Ventricular tachycardia s/p ICD generator change
2. CHF
3. Chronic renal insufficiency
4. Gout
5. s/p rectus sheath hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed. YOu will continue to
take Amiodarone 1 gram per day (400 mg qam, 200 mg midday,400 mg
at night) for the rest of this week, but then decrease to 600 mg
total per day on Monday [**2-25**] (200 mg TID). You will also need to
have your INR checked tomorrow at Dr.[**Name (NI) 7914**] office and he
will adjust your INR accordingly.
Please return to the ED or call your PCP if you experience any
worsening chest pains or palpitations, shortness of breath,
abdominal pain, dizziness/lightheadedness or any other
concerning symptoms.
Return to the ED if you experience any worsening chest pain,
palpitations, loss of consciousness, dizziness/lightheadedness,
nausea or vomiting, sweats, or any other concerning symptoms.
Followup Instructions:
You should see Dr. [**Last Name (STitle) **] in his office at 12:30 pm tomorrow
[**2-20**] and he will have your INR checked and coumadin dose adjusted
accordingly (phone number [**Pager number **])
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2137-2-26**] 11:30
|
[
"443.9",
"427.1",
"998.12",
"996.04",
"285.1",
"428.0",
"414.01",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.98",
"37.26",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
7533, 7539
|
3770, 5449
|
327, 363
|
7713, 7722
|
1950, 3747
|
8531, 8886
|
1685, 1704
|
5844, 7510
|
7560, 7692
|
5475, 5821
|
7746, 8508
|
1157, 1551
|
1719, 1931
|
254, 289
|
391, 818
|
862, 1133
|
1567, 1669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,342
| 171,372
|
40703
|
Discharge summary
|
report
|
Admission Date: [**2199-11-3**] Discharge Date: [**2199-12-18**]
Date of Birth: [**2149-3-13**] Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Previous admission: Transplant; [**2199-10-17**]: Exploratory
laparotomy, orthotopic liver transplant, renal transplant.
[**2199-10-18**]: Abdominal washout and closure
Admission Starting [**2199-11-3**];
[**2199-11-3**]: Exploratory laparotomy with abdominal washout, biliary
diversion, small bowel resection and liver biopsy
[**2199-11-10**]: Exploratory laparotomy, Resection distal common bile
duct, Resection debridement segments 4 and 5, Jejunal tube.
[**2199-11-25**]: IR drainage of hepatic abscess
History of Present Illness:
50 yo M s/p liver and kidney transplant. ESLD secondary to
hepatitis C and ESRD likely secondary to HTN, DM and hepatorenal
syndrome who was on dialysis for short time prior to transplant.
On [**2199-10-17**] he underwent OLT and cadaveric renal transplant
abdomen packed and left open given intraoperative oozing and
second look on POD# 1 for packing removal, hepaticojejunostomy
for bile leak and abdominal closure. He was discharged three
days prior to his current admission and initially did well at
home,tolerating a diet, ambulating with regular non-bloody bowel
movements. He returned 2 days ago with increasing right upper
quadrant and peri-umbilical abdominal pain.
Past Medical History:
hepatitis C ([**2184**]) c/b cirrhosis, salmonella gastroenteritis
with acute renal failure, chronic kidney disease with renal
stones s/p lithotripsy ([**2192**]), DM (dx [**2188**], off medications,
diet-controlled), HTN ([**2196**], well-controlled, off medications),
ITP s/p splenectomy ([**2173**]), asthma
PSH: splenectomy [**2173**], lithotripsy [**2192**], Combined liver/kidney
transplant [**2199-10-17**]
Social History:
SH: Lives with sister, has two children. Prior heroin user,
sober for two years, on methadone program.
Family History:
FH: His family history is significant for an aunt and uncle with
diabetes.
Physical Exam:
Vitals: 98.0 158 129/95 24 99 RA
GEN: A&O, non-toxic appearing
HEENT: No scleral icterus, mucus membranes dry
CV: sinus tachycardic, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender to palpation in RUQ and
peri-umbilical region, no rebound or guarding. Operative
incisions well-healed, staples in place. No discharge or
erythema.
DRE: normal tone, no gross or occult blood
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
On Admission: [**2199-11-3**]
WBC-25.4* RBC-4.81 Hgb-14.7 Hct-45.5 MCV-95 MCH-30.6 MCHC-32.3
RDW-14.9 Plt Ct-355#
PT-15.3* PTT-21.6* INR(PT)-1.3*
Glucose-233* UreaN-32* Creat-1.3* Na-137 K-5.1 Cl-101 HCO3-23
AnGap-18
ALT-76* AST-85* LD(LDH)-530* AlkPhos-176* TotBili-2.0*
Lipase-10
Albumin-2.7* Calcium-8.5 Phos-2.8 Mg-1.3*
[**2199-11-3**] FACTOR V LEIDEN-Not Detected
.
[**2199-12-9**] TSH-3.3
.
At Discharge:
[**2199-12-16**] WBC-10.5 RBC-2.81* Hgb-8.7* Hct-26.8* MCV-96 MCH-30.8
MCHC-32.2 RDW-18.4* Plt Ct-482*
PT-15.6* PTT-29.3 INR(PT)-1.5*
Glucose-68* UreaN-34* Creat-0.8 Na-133 K-5.0 Cl-104 HCO3-23
AnGap-11
ALT-43* AST-41* CK(CPK)-22* AlkPhos-560* TotBili-0.7
Calcium-8.4 Phos-3.9 Mg-1.4*
tacroFK-8.9
.
Culture Data:
[**2199-11-10**] 8:35 am FLUID,OTHER
HEMATOMA (BEHIND THE LIVER AREA BLOOD CLOT).
GRAM STAIN (Final [**2199-11-10**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
ENTEROCOCCUS SP.. MODERATE GROWTH.
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
YEAST, PRESUMPTIVELY NOT C. ALBICANS. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 32 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
[**2199-11-25**] 6:05 am BLOOD CULTURE
**FINAL REPORT [**2199-11-28**]**
Blood Culture, Routine (Final [**2199-11-28**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
[**2199-11-27**] - [**2199-12-10**]: Blood Cultures: No growth
Brief Hospital Course:
The patient is a 50-year-old man who is 17 days out from a
deceased donor liver and kidney transplant who has had a
complication of hepatic artery thrombosis, based upon physical
findings of tachycardia and he eventually developed peritoneal
signs. A CT was done on admission showing free air and fluid
near the hepaticojejunostomy. Dr [**Last Name (STitle) **] took him to the OR on
day of admission due to concern for disruption of the
anastomosis. He underwent Exploratory laparotomy with abdominal
washout,
biliary diversion, small bowel resection and liver biopsy for
Hepatic artery thrombosis and peritonitis with bile leak. The
bile duct at this time was in discontinuity, with a drain to the
outside.
Following the initial surgery with Dr [**Last Name (STitle) **], the patient spent
4 days in the ICU. Blood cultures and the peritoneal fluid
sample taken in the OR both grew Bacteroides fragilis. He had
been started on Vanco and Zosyn. After the brief ICU stay, he
was transferred out to the regular surgical transplant floor.
LFTs and Bilirubin were improving.
On [**11-10**], the patient was taken back to the OR again,
this time because of the bile duct discontinuity. He was not
eligible for additional MELD points or Status 1 due to the time
frame of the original surgery. He underwent exploratory
laparotomy with resection of the distal common bile duct,
resection debridement of liver segments 4 and 5, and also had a
Jejunal feeding tube placed.
He was again placed in the ICU. At the time of surgery a
hematoma was evacuated from behind the liver. This was sent for
culture, and was found to be growing VRE, Klebsiella and yeast.
He had been started on Micafungin and meropenem immediately
after the surgery on the 13th, however once the culture data was
finalized, the [**Last Name (un) 2830**] was stopped and cefepime was started, which
he received for 3 weeks.
AST and ALT have normalized since the time of the surgery on the
13th. Bilirubin has remained stable around 0.6, however the Alk
Phos has slowly risen over the course of his hospital stay.
On [**11-18**], the patient had a Roux tube cholangiogram, findings
include that the contrast rapidly opacifies the jejunal Roux
limb. Trace biliary reflux is inadequate to evaluate the biliary
tree. No evidence of anastomotic leak is evident. The Roux drain
was left uncapped with minimal output until the day it was
capped on [**12-2**].
The remaining JP drains in the surgical bed have decreased to
around 10 cc daily, however, they absolutely will not be taken
out until the patient receives a new transplant liver.
Since the time of the first positive blood cultures, the patient
was having daily blood cultures drawn. These were persistently
positive with VRE. Daptomycin was started on the [**12-18**]. This has continued since that time and will remain
indefinitely as will the Micafungin.
CT of abdomen was done on [**11-20**], with findings consistent
with necrosis and locules of air seen, concerning for
superinfection. An attempt was made to drain this area, however,
it was not liquid enough until [**11-25**] when a pigtail drain was
able to be successfully placed. Drainage is approximately
100-300 cc daily. Since the time of the successful drainage
however, the ensuing surveillance blood cultures have all been
negative.
A PICC line was placed on [**12-6**] for known long term antibiotic
needs.
Immunosuppression has been followed by level, and Prograf dosed
accordingly. Cellcept was reduced to 500 mg [**Hospital1 **] [**11-28**], and
prednisone taper was accelerated due to patients continued
infection.
Patient has been receiving tube feeds via the J tube with no
problems of nausea or diarrhea. He may eat as tolerated.
Kidney function throughout has been excellent. Creatinine
remains around 0.8 with 1-2 liters urine daily. Of note the
Ureteral stent was removed [**11-20**]
On [**11-22**] TEE done, no vegetations seen, and he received
pentamadine administered
[**12-1**] staples removed.
The patient has received 32 MELD exception points and is
re-activated on the liver transplant list.
Medications on Admission:
tacrolimus 2'',
Cellcept [**Pager number **]'', prednisone 20' (until [**11-5**]), valganciclovir
900', fluconazole 400', famotidine 20', Kayexalate 4 tsp prn,
percocet prn pain, colace 100'', methadone 35', effexor 37.5',
pentamadine inhaled monthly, NPH insulin 20 units with
breakfast,
humalog sliding scale, dilaudid 2 mg q 6 prn pain
Discharge Medications:
1. diphenhydramine HCl 25 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
2. metoprolol tartrate 25 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO BID (2
times a day): Hold for sbp less than 110 or HR less than 60.
3. valganciclovir 450 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO Q24H
(every 24 hours).
4. trazodone 50 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at
bedtime).
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
6. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain: Max 2 grams per day.
7. mycophenolate mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day).
8. methadone 40 mg Tablet, Soluble [**Last Name (STitle) **]: One (1) Tablet, Soluble
PO DAILY (Daily): Please hold for over sedation.
9. hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
11. micafungin 100 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): End date to be determined by
transplant clinic.
12. daptomycin 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): End date to be determined by
transplant clinic.
13. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Fourteen (14)
units Subcutaneous at bedtime.
14. insulin lispro 100 unit/mL Solution [**Last Name (STitle) **]: per sliding scale
Subcutaneous four times a day: Please see insulin scale.
15. tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO Q12H
(every 12 hours) for 2 doses.
16. heparin, porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
17. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
Discharge Diagnosis:
Hepatic artery thrombosis s/p liver transplant
Bile duct necrosis
Hepatic abscesses
Bacteremia; Enterococcus faecium, bacteroides fragilis
Peritonitis
Malnutrition
Adjustment disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You will be transferring to [**Hospital3 **] in [**Hospital1 8**].
Please note it is EXTREMELY important that all drains are not
allowed to hang freely at any time. Dressings should be well
taped and stat locks well adhered to skin. Pin drains to
garment, do not have drains tied to bedframes. If drains appears
to be loosened or sutures come out, please call the transplant
clinic right away. It is imperative that the drains do not
dislodge.
.
Please send labwork every Monday and Thursday: CBC, Chem 10,
AST, ALT, Alk Phos, T Bili, Trough Prograf. Fax results to
[**Telephone/Fax (1) 697**]
.
Continue Tube feeds (cycled) via J tube
.
Patient should not lift greater than 10 pounds
.
Drain and record drain outputs twice daily and as needed. Send
copy of report with patient to clinic visits. Dressings changed
daily with good reinforcement of drains
.
Please do not adjust medications without first discussing with
the transplant clinic
.
Right arm PICC line care per facility protocol
Followup Instructions:
Labs q Monday and Thursday (add CPK q Monday while on Dapto)
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2199-12-26**] 2:00, [**Last Name (NamePattern1) **] ([**Hospital **] Medical Building)
[**Location (un) **], [**Location (un) 86**], Ma
Completed by:[**2199-12-18**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"46.39",
"50.11",
"99.15",
"51.37",
"50.29",
"51.51",
"54.91",
"45.62",
"51.69",
"00.14",
"87.54",
"88.72",
"97.62",
"38.97",
"54.25"
] |
icd9pcs
|
[
[
[]
]
] |
12107, 12158
|
5547, 9641
|
283, 793
|
12386, 12386
|
2639, 2639
|
13551, 13913
|
2074, 2151
|
10031, 12084
|
12179, 12365
|
9667, 10008
|
12537, 13528
|
2166, 2620
|
3051, 5524
|
229, 245
|
821, 1497
|
2653, 3037
|
12401, 12513
|
1519, 1936
|
1952, 2058
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,698
| 190,004
|
23245
|
Discharge summary
|
report
|
Admission Date: [**2142-2-23**] Discharge Date: [**2142-3-9**]
Date of Birth: [**2072-4-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Bilateral PE, recent SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 1794**] is a 69 year old with past medical history significant
for multiple prior Deep Vein Thrombosis, Pulmonary Emboli, L.
hip replacement and recent CVA, presenting from OSH ([**Hospital 6451**] Hospital) with bilateral pulmonary emboli. He was
recently discharged from the NSG service on [**2142-2-19**] s/p SDH
evacuation to Rehab.
Regarding the pt's [**2-13**] - [**2-19**] admission: he was admitted to NSG
at [**Hospital1 18**] after he had complained of a headache for several days
and had multiple episodes of vomiting. His head CT revealed a
large left SDH. He was taken to the OR on [**2142-2-13**] for a Left
craniotomy for SDH evacuation. He became febrile to 101.8 early
am on [**2142-2-15**], sputum cultures were positive for Gram + cocci in
pairs, and LENIS showed a Left superficial femoral DVT that was
determined to be a new partially occlusive DVT (with the pt's
last documented DVT having occured in [**2139**], after which he was
begun on Coumadin 6mg daily). No anticoagulation was safe to be
administered in the immediate post-operative setting of
SDH/surgery. SQ heparin on HD2 and levofloxacin 4d course was
started in the setting of low grade fever and sputum with gram +
cocci. Pt was discharged to rehab [**2142-2-19**] on Heparin 5,000
unit/mL TID, and instructed to hold coumadin until [**2142-2-26**].
While at rehab, he had sudden onset SOB at PT on [**2142-2-23**]. He was
taken to an OSH and had a CTA that demonstrated large PEs in
both main pulmonary arteries and segmental branches with RV
dilitation. The patient was started on a Hep gtt at the OSH,
with a large bolus (8700 units) and was continued on Heparin
gtt. He was trasfered to [**Hospital1 18**] for further management.
.
Patient was transferred to [**Hospital1 18**] with initial VS 99, 135/94, 97,
24, 97% on [**10-16**] 100% FiO2 on BiPap.
Past Medical History:
HTN
hyperlipidemia
h/o Pulmonary Embolism
-- previously on warfarin
-- s/p IVC filter placement
L4-5, L5-S1 stenosis
hip replacement
Left subdural hematoma
Left Superficial Femeral Deep Vein Thrombosis
Left PCA infarct
Social History:
warehouse worker forced to quit 1 [**1-13**] yrs ago due to L hip pain.
no tobacco, no ETOH
Family History:
No family history of early CAD or sudden cardiac death.
Physical Exam:
GENERAL: Agitated.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: JVP 7cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI mid systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: CTA anterolaterally, no crackles, wheezes or rhonchi.
ABDOMEN: Tympanitic, NT. Distended. Hypoactive BS.
EXTREMITIES: No c/c. 1+ LLE edema.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
[**2142-2-23**] 06:05AM BLOOD WBC-15.3*# RBC-4.48* Hgb-13.2* Hct-39.8*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.9 Plt Ct-191
[**2142-2-23**] 06:05AM BLOOD Neuts-89.2* Lymphs-8.3* Monos-1.5*
Eos-0.3 Baso-0.7
[**2142-2-23**] 06:05AM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1
[**2142-2-23**] 06:05AM BLOOD Glucose-277* UreaN-30* Creat-1.1 Na-133
K-8.4* Cl-103 HCO3-21* AnGap-17
[**2142-2-23**] 06:05AM BLOOD ALT-62* AST-123* CK(CPK)-247 AlkPhos-61
TotBili-0.6
[**2142-2-23**] 06:05AM BLOOD CK-MB-6 proBNP-1778*
[**2142-2-23**] 06:05AM BLOOD cTropnT-0.18*
[**2142-2-23**] 02:24PM BLOOD Calcium-7.8* Phos-3.3 Mg-2.5
[**2142-3-2**] 02:41AM BLOOD CRP-256.3*
[**2142-2-23**] TTE: IMPRESSIONS: Compared with the prior study (images
reviewed) of [**2142-2-19**], the right ventricle is now mildly dilated
with moderate free wall hypokinesis and there is mild pulmonary
artery systolic hypertension. Mild-moderate mitral regurgitaiton
is also now seen.
[**2142-2-23**] CCATH: FINAL DIAGNOSIS:1. Successful insertion of
retrievable Optease IVC filter via RCFV approach 2. Continue
Heparin gtt and maintain therapeutic aPTT 3. Careful
neurological assessment and follow up brain CT scan given
history of SDH.
[**2142-2-23**] EKG: Sinus tachycardia. Left atrial abnormality. Right
bundle-branch block. Left anterior fascicular block. Compared to
the previous tracing of [**2142-2-21**] the rate has increased. There is
inferolateral upsloping ST segment depression.
[**2142-2-23**] CT HEAD: 1. Unchanged or slightly smaller multifocal
extra-axial hemorrhage as described above. Other areas of
hemorrhage as described above. Follwo up as clinically
indicated. 2. Hypoattenuation in the left parietal lobe, likely
represents evolving subacute infarct.
[**2142-2-23**] LENIs: Bilateral common femoral and right deep femoral
venous thrombosis.
[**2142-3-1**] CTA torso: IMPRESSION: 1. New multifocal areas of
ground-glass opacity within bilateral lung parenchyma most
compatible with infectious etiology. 2. Mildly decreased extent
of bilateral pulmonary embolism within the right and left
pulmonary arteries extending into the segmental and subsegmental
branches. 3. Fluid collection and enlargement of the left hip
abductor muscles may represent hematoma, abscess, or infarction.
This is also at the location of previous interventions in the
left groin for IVC filter placement. Clinical correlation is
recommended. In case of clinical concern for abscess formation,
an MRI can be obtained for further evaluation. 4. Renal cysts,
liver cysts and enlarged prostate.
Echo [**2142-3-2**]:
Suboptimal image quality. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The RV is now well seen but appears normal in size (function
cannot be adequately assessed on this study). The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. Trivial mitral
regurgitation is seen. Tricuspid regurgitation is present but
cannot be quantified. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2142-2-21**], RV
apppears smaller however images are of poor quality.
[**2142-3-2**] Femoral vascular ultrasound:
IMPRESSION:
1. Hematoma at the left groin.
2. No evidence of pseudoaneurysm arising from the left common
femoral artery.
The study and the report were reviewed by the staff radiologist.
[**2142-3-2**] Hip 2 view:
HISTORY: Hip prosthesis and fluid collection, evaluate for
abscess or bone
destruction. Four views. Comparison with [**2138-1-17**]. A left hip
prosthesis remains in place. Cortical margins are otherwise
intact. Bony mineralization appears normal. Surgical clips are
present in overlying soft tissues. Incidental note is made of
degenerative changes in the spine.
IMPRESSION: Status post THR. No definite interval change.
[**2142-3-3**] CXR:
HISTORY: Pulmonary embolism. Hypoxia.
One portable upright view. Comparison with the previous study
done [**2142-3-1**]. There is streaky density at the left lung base
consistent with subsegmental atelectasis and/or parenchymal
consolidation as before. The right lung remains clear. The heart
and mediastinal structures are unchanged.
IMPRESSION: No significant change.
[**2142-3-4**] portable abdomen:
ONE PORTABLE SUPINE VIEW: The upper abdomen and lateral
abdominal walls are not included. Comparison is made with the
previous study done [**2142-2-19**].
Dilated air-filled loops of colon are again demonstrated down to
the level of the sigmoid colon. Some gas is noted in the region
of the lower sigmoid colon and rectum. Degenerative changes are
again demonstrated in the spine and the left hip prosthesis
remains in place.
IMPRESSION:
Nonspecific bowel gas pattern, which may represent colonic
ileus.
[**2142-3-6**] MRI pelvis:
IMPRESSION:
1. 11.6 x 5.0 cm rim-enhancing fluid collection involving the
adductor
musculature of the left groin. While the presence of peripheral
high T1
signal raises the possibility of a hemorrhagic component, the
presence of
infection cannot be excluded and diagnostic aspiration is
suggested.
2. Similar but separate 2.5-cm collection near the left common
femoral vein access site.
[**2142-3-6**] Chest PA/lat:
Lordotic positioning makes it hard to assess the lower lungs.
There could be a substantial new right basal atelectasis. The
upper lobes are largely clear. Heart size top normal, unchanged.
Mediastinal fullness in the paratracheal region, is stable since
[**3-1**], when a chest CT showed this was due to a
combination of tortuous vessels, mediastinal fat and atelectasis
or consolidation in the right upper lobe anterior segments.
Findings of massive pulmonary emboli are not apparent on this
conventional chest radiograph.
[**2142-3-7**] CT guided aspiration:
INDICATION: 69-year-old man with status post IVC filter, now
with
rim-enhancing fluid collection in left groin and known left hip
hardware.
Please perform aspiration of this lesion.
After risk, benefits, alternatives and procedure were explained
to the
patient, written informed consent was obtained. A pre-procedure
timeout was performed using three patient identifiers. Initial
CT imaging showed subtle hypodense fluid collection not well
demarcated on this non-contrast study within the internal
muscles of the left hip.
Site was marked, prepped and draped in usual sterile fashion.
Local
anesthesia was achieved with lidocaine 1% buffered solution.
Moderate
sedation was provided by administering divided doses of Versed
and fentanyl throughout the total intra-service time of 20
minutes during which the patient's hemodynamic parameters were
continuously monitored.
18-gauge [**Last Name (un) 4300**] needle was used to aspirate the contents of the
collection. Small amount of bloody fluid was aspirated and sent
to lab as requested. A Bentson guidewire was also inserted into
the collection and taken out.
The patient tolerated the procedure well. No immediate
post-procedure
complications were noted.
The attending radiologist, Dr. [**Last Name (STitle) **], was present and
supervised the whole
procedure.
IMPRESSION: Successful CT-guided aspiration of the left hip
muscle fluid
collection.
Brief Hospital Course:
Mr. [**Known lastname 1794**] is a 69 Year old man with history of multiple DVT and
PE, recent subdural hematoma s/p evacuation, presenting with
massive bilateral PE.
# Bilateral Pulmonary Emboli:
Patient was found to have massive bilateral pulmonary emboli and
extensive lower extremity DVTs at an outside hospital. Patient
was transferred from outside hospital for possible thrombectomy
via catheterization. Thrombolysis was not done in setting of
recent large subdural hematoma. On arrival to [**Hospital1 18**], an IVC
filter was placed by Interventional Cardiology. Patient was
continued on heparin drip (with narrow goal PTT as close to
55-65 as possible) from the outside hospital and bridged to
coumadin once CT scan confirmed no recurrence of subdural
hematoma ([**2142-2-25**]). Frequent neurological checks were done, and
Neurosurgery followed with the patient to monitor for signs of
intracranial bleeding. Patient required 5L oxygen by NC on
presentation with fluctuating O2 requirement throughout
hospitalization. O2 requirement peaked at 6L two days after
presentation at which time he also spiked a fever to 101.3; he
had some scant hemoptysis the following day which resolved. He
also continued to have bursts of sinus tachycardia to the 140s
with ambulation and BMs. He was not on his home dose of
metoprolol and verapamil at the time. He became supratheraputic
on his coumadin after starting antibiotics for pneumonia (see
below) and his coumadin was held. He was discharged on coumadin
2 mg a day with an INR of 2.1. He should remain on this dose
until [**2142-3-11**] while the flagyl (which can potentiate the effects
of coumadin and which was stopped on [**2142-3-9**]) washes out of his
system. On [**2142-3-12**] he should resume his home dose of
coumadin 5 mg a day. He should continue to have daily INR
checks at the rehab facility and make adjustments as needed
until his INR becomes stable and theraputic. The pt requires no
further follow up for his IVC filter was was left in place given
the concern for future DVTs.
# Subdural Hematoma:
Patient had recent hospitalization on Neurosurgery service for
subdural hematoma, which was evacuated. Neurosurgical team
followed patient. Head CT showed no recurrence of his subdural
hematoma after heparin drip was therapeutic, and neurologic
examination was stable throughout hospitalization. He will need
to go to his follow up appointment with the neurosurgeon in one
month and get a head CT. He has an appointment for [**3-29**].
He should call [**Telephone/Fax (1) 1669**] if he needs to change this
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
# Hospital acquired pneumonia: The patient spiked fevers
throughout his CCU stay, and on [**2142-3-1**] had an acute
desaturation to 74% on RA. He was placed on Non rebreather with
return of his SaO2. His temperature was found to be 105. He
became hypotensive and required NS bolus. On [**2142-3-1**] a CXR
showed new retrocardiac and left lower lobe opacity likely
representing left lower lobe aspiration. A CTA was done to
evaluate PNA and progression of PEs, which showed bilat filling
defects right and left pulm arteries + segmental branches left
and right side, minimally decreased in size with no evidence of
pna. A fluid collection was also incidentally seen in left hip
abductor area (same side as IVC filter placed), representing a
hematoma vs. abscess (see below). The patient was started on an
8 day course of vanc/cefepime/flagyl as well as nebulizers. He
continued to have low grade fevers for a few days. His oxygen
was weaned over time and he became afebrile without cough. He
was satting 95% on 3 L oxygen the day of discharge. His last
day of antibiotics was [**2142-3-9**]. Of note, his flagyl likely wsa
responsible for elevating his INR. Therefore his warfarin dose
was temporarily decreased and his INR should be followed until
he is theraputic and stable.
# Groin hematoma: A CTA was obtained on [**2142-3-1**] to evaluate for
pneumonia and a fluid collection was also incidentally seen in
left hip abductor area (same side as IVC filter placed),
representing a hematoma vs. abscess. The next day on [**2142-3-2**], pt
developed worsening left hip/thigh pain. Ortho was consulted due
to concern for septic prosthetic joint as the patient had been
having low grade fevers. Ortho initially felt exam was
concerning for septic hip, and rec'd aspiration by IR (however
IR felt this was not possible while anticoagulated). Hip X-rays
were obtained and showed no bony destruction or evidence of
osteomyelitis around L. prosthetic joint. Ultrasound of the
fluid collection was obtained and was consistent with hematoma.
An MRI was obtained which showed 11.6 x 5.0 cm rim-enhancing
fluid collection involving the adductor musculature of the left
groin. On [**2142-3-7**] IR performed a CT guided aspiration of the
fluid and obtain 1 cc of fluid. No organisms or PMNs were seen
on gram stain and it was thought that it was simply a hematoma
that was a complication of the IVC filter which should resolve
over time.
# Abdominal Ileus:
Patient was noted to have hypoactive bowel sounds and distended
abdomen on presentation. Patient denied any symptoms of nausea,
and there was no evidence of obstruction on CT abdomen/pelvis.
The CT showed rectosigmoid colon opacification which is of
unclear significance. Patient was initially kept NPO, then
advanced to a clear liquid diet which he tolerated well. He was
given a bowel regimen and had multiple bowel movements.
# Urinary retention: In the CCU a foley catheter was placed.
Upon removal of the catheter, the patient was unable to void
more than small droplets at a time. He was bladder scanned and
it was found that he had over 900 ccs of urine in his bladder so
the foley was replaced. It was difficult to replace the foley
and a coude catheter was used successfully to replace it. The
patient was started on tamsulosin 0.4 mg Q HS. Given the
difficulty inserting the foley and likelyhood that the patient
will retain again, he should keep the foley in place at rehab
and wait a few days before attempting to undergo another voiding
trial. He should then follow up with a urologist as an
outpatient.
# Hypertension:
Home antihypertensives were held on admission in the setting of
low normal blood pressures. Patient was started on low dose
Lisinopril 5mg daily. His verapamil and metoprolol were also
held. He should resume all of his home BP meds upon discharge.
# Hyperlipidemia:
Patient was continued on simvastatin.
# Code Status:
Patient is DNR/DNI
Medications on Admission:
MEDICATIONS AT HOME:
1. Acetaminophen 325 mg Tablet PO Q6H (every 6 hours)
2. Simvastatin 10 mg Tablet PO DAILY
3. Verapamil 120 mg Tablet Sig: 0.5 Tablet PO Q8H
4. Levetiracetam 750 mg Tablet PO BID
5. Heparin (Porcine) 5,000 unit/mL TID
6. Insulin Lispro 100 unit/mL Solution
7. Aspirin 325 mg Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 12.5 mg PO Q6H
9. Hydrocortisone Acetate 1 % Ointment
10. Bisacodyl 5 mg Tablet PO BID
11. Lactulose 10 gram/15 mL (30) ML PO Q6H
12. Magnesium Hydroxide 400 mg/5 mL Thirty (30) ML PO Q6H (every
6 hours) as needed for Constipation.
13. Senna 8.6 mg Tablet PO BID
14. Docusate Sodium 50 mg/5 mL
15. Polyethylene Glycol
16. Famotidine 20 mg Tablet
17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days. Tablet(s)
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
19. Ondansetron 4 mg IV Q8H:PRN nausea
20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Verapamil 120 mg Tablet Sig: 0.5 Tablet PO three times a day:
please hold for HR < 60 or BP < 100.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO every six
(6) hours: please hold if BP < 100 or HR < 60.
5. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Rectal once
a day.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. Lactulose 10 gram Packet Sig: One (1) PO every six (6)
hours.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ml PO every six (6) hours as needed for constipation: for
constipation.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO once a
day as needed for constipation.
13. Polyethylene Glycol 3350 Oral
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 2 days.
17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: To
start [**3-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Bilateral Pulmonary Embolus
Left groin hematoma
Hospital acquired pneumonia
Secondary diagnosis:
Subdural hematoma
hyperlipidemia
hypertension
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You came to the hospital because you were having trouble
breathing. You were found to have blood clots in your lungs and
legs. You had an IVC filter placed to prevent any more clot
from going to your lungs. You were also found to have a blood
collection in your groin which was likely a complication from
this procedure. The interventional radiologists took the fluid
out and saw that it was not infected. It should get better on
its own with time.
You were also found to have pneumonia and you were treated for
this with antibiotics and have completed your course. You have
not had any fevers for several days and we think your infection
has cleared.
You also developed difficulty urinating. A foley catheter was
placed because of this. You should leave the catheter in for a
few more days and then have it removed to see if you can urinate
on your own. If you can't you may need to have a foley placed
again. We started you on a medication for this which you should
continue. You should have your primary care doctor set you up
with an appointment with a urologist when you get home from
rehab.
In addition, you were found to have low levels of potassium.
This is probably because of your diarrhea and nausea. You will
need to take potassium suplements and have your levels monitored
at the rehab facility.
The following changes have been made to your medications:
Please start tamsulosin for your urinary retention
Please decrease your dose of warfarin to 2 mg once a day until
Monday ([**3-12**]) when you should resume your home dose of 5 mg a
day.
Please follow up with your primary care docotr after you are
discharged from rehab as well as with the neurologists.
Followup Instructions:
Primary care:
[**Last Name (LF) **],[**First Name3 (LF) **] H. Phone: [**Telephone/Fax (1) 14331**] Please make an appt to see Dr.
[**Last Name (STitle) 1057**] after you get out of rehabilitation. You should ask him to
refer you to a urologist for the urinary retention you have been
having.
Please also make a neurology appointment for a follow up
appointment in one month. Please call [**Telephone/Fax (1) 1669**] to make this
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You will also need to schedule
a repeat head CT and can ask them about scheduling this at that
time.
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18,172
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Discharge summary
|
report+addendum
|
Admission Date: [**2127-4-13**] Discharge Date: [**2127-4-30**]
Date of Birth: [**2098-12-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Pedestrian struck by car.
Major Surgical or Invasive Procedure:
s/p IM nail L tibia
History of Present Illness:
Ms [**Known lastname 26438**] is a 28 y/o woman who was a pedestrian struck by an
automobile. She was seen at [**Hospital 1474**] Hospital, stabalized, and
transferred to [**Hospital1 18**]. On presentation at [**Hospital1 1474**], she was c/o
left leg pain. Per report the car was travelling at 30 mph and
clipped her in the leg. ? LOC. She apparently admitted to the
use of crack cocaine prior to the accident. She was intubated at
[**Hospital 1474**] Hospital for agitation and failure to follow commands.
Past Medical History:
1) s/p pituitary adenoma resection w/ resulting
panhypopituitarism, on hydrocortisone, levothyroxin and DDAVP at
home.
2) s/p colon resection as a child
3) hx of crack cocaine abuse
Social History:
+ crack cocaine, + tobacco, + EtOH.
Family History:
N/C.
Physical Exam:
On admission in the ED:
Afebrile, HR 150, BP 122/63, RR 22, SPO2 97% RA.
GCS 12, in c-collar.
Cor reg
Chest CTA, equal BS.
Abd soft, NT, vertical surgical scar, well healed.
Foley in place.
Ext warm, palp DP/PT bil. L leg splint.
LLE: SILT @ DP/SP, warm toes, + [**Last Name (un) 938**]/FHL.
Spine non-tender, no abrasions, no step-offs
Pertinent Results:
[**2127-4-13**] 04:30AM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2127-4-13**] 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2127-4-13**] 04:30AM PT-12.3 PTT-20.2* INR(PT)-1.1
[**2127-4-13**] 04:30AM WBC-13.7* RBC-4.69 HGB-13.4 HCT-39.2 MCV-84
MCH-28.5 MCHC-34.1 RDW-14.1
[**2127-4-13**] 04:30AM PLT COUNT-409
[**2127-4-13**] 04:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2127-4-13**] 04:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-4-13**] 04:30AM GLUCOSE-92 UREA N-3* CREAT-1.0 SODIUM-156*
POTASSIUM-3.5 CHLORIDE-120* TOTAL CO2-22 ANION GAP-18
[**2127-4-13**] 04:43AM GLUCOSE-100 LACTATE-2.5* NA+-159* K+-3.6
CL--118* TCO2-22
[**2127-4-13**] 09:56AM OSMOLAL-352*
[**2127-4-13**] 09:56AM SODIUM-172* CHLORIDE-139*
[**2127-4-13**] 04:08PM SODIUM-177* CHLORIDE-146*
*** Last several sodium checks, all on DDAVP 0.2/0.1/0.2 mg: ***
[**4-28**]: 136
[**4-29**]: 138
[**4-30**]: 137
Brief Hospital Course:
The pt was admitted and resuscitated in the Trauma ICU. Her most
immediate complication was her DI. Her sodium levels quickly
rose, and it was unclear how long the pt had gone without DDAVP
(per mother the pt had been away from home and using drugs
consistently for a few days prior to the accident). The
endocrine service was consulted, and her sodium levels were
carefully followed as she was given free water and DDAVP,
correcting her sodium slowly enough to avoid CPM. On HD 3 she
was stable enough to go to the OR for an IM nail of her left
tibia. She tolerated this well, without complication. Please see
the dictated operative note for details. She was extubated and
transferred to the floor [**2127-4-17**] without event.
The [**Hospital **] hospital course was further complicated by delirium:
the pt took several days to return to her baseline mental
status, probably due to her waxing and [**Doctor Last Name 688**] sodium. The pt
became quite agitated on HD 11, which was possibly related to
friends [**Name (NI) 66175**] attempting to bring narcotics into the
patient's room. Urgent psychiatric and neurologic evaluations
were obtained. She was started on haldol on the recommendation
of psychiatry, and an MRI was obtained on the recommendation of
neurology. The pt remained calm with haldol, which was slowly
weaned and finally switched to PO, then stopped prior to
discharge. The brain MRI was only remarkable for post-operative
changes, c/w her hx of pituitary adenoma resection. The pt
slowly returned to her baseline mental status as her sodium
level was [**Last Name (un) 4662**] under control by adjusting her DDAVP dose. She
was cleared by the speech and swallow team for restarting a PO
diet, which she tolerated well. Her cervical collar was cleared
once she was lucid.
The pt was evaluated by social work, and she was interested in
drug rehabilitation. However, as the the PT service recommended
physical rehabilitation for the patients left leg, a suitable
facility was found that could provide both. She was discharged
on the dose of DDAVP that kept her Na level the most stable
(0.2/0.1/0.2 mg), and she was tolerating a regular diet with her
pain controlled. She was A+O x 3 for the last several days of
her hospitalization, remaining off sitter supervision for
several days before discharge. Please see the results section
for her last few sodium levels.
Medications on Admission:
Cortef 15mg AM/5mg PM, levoxyl 150 mcg', DDAVP 0.2tid.
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 3 weeks.
Disp:*42 syringe* Refills:*0*
2. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
4. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Desmopressin 0.1 mg Tablet Sig: 1-2 Tablets PO three times a
day: Take 0.2 mg AM, 0.1 mg midday, and 0.2 mg PM.
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
1) Proximal left tibia/fibula fracture, closed.
2) s/p pituitary adenoma resection w/ panhypopituitarism
Discharge Condition:
Good.
Discharge Instructions:
1) Call or return to the ED if you have any of the following
symptoms:
** fevers > 101.4 degrees
** increasing headaches, dizziness or blurred vision
** increasing drainage or redness around your incision
2) Keep the knee brace on when walking or standing on your left
leg or when using crutches.
3) Take all medications as prescribed.
Followup Instructions:
1) 2 weeks in trauma clinic-- call [**Telephone/Fax (1) 6439**] to schedule an
appointment.
2) 4 weeks in orthopaedic clinic-- call [**Telephone/Fax (1) 1228**] to schedule
an appointment. Tell the secretary you will also need x-rays
taken just before your appointment.
3) Call you PCP to schedule an appointment in [**2-17**] weeks.
Completed by:[**2127-4-30**] Name: [**Known lastname 11561**],[**Known firstname 11562**] J Unit No: [**Numeric Identifier 11563**]
Admission Date: [**2127-4-13**] Discharge Date: [**2127-4-30**]
Date of Birth: [**2098-12-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3524**]
Addendum:
Urinalysis obtained [**4-29**] because of compalints of urinary
frequency by patient; came back postive for nitrites and WBC's;
culture pending at time of dictation. She will be started on
Cipro 500 mg po BID for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2127-4-30**]
|
[
"253.6",
"599.0",
"300.00",
"253.7",
"V15.81",
"823.02",
"244.8",
"307.9",
"041.85",
"253.5",
"780.09",
"E814.7",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.57",
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7742, 7972
|
2650, 5038
|
340, 362
|
6352, 6360
|
1553, 2627
|
6744, 7719
|
1174, 1180
|
5143, 6107
|
6224, 6331
|
5064, 5120
|
6384, 6721
|
1195, 1534
|
275, 302
|
390, 900
|
922, 1105
|
1121, 1158
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,801
| 127,484
|
36863
|
Discharge summary
|
report
|
Admission Date: [**2116-12-18**] Discharge Date: [**2116-12-23**]
Date of Birth: [**2067-5-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Keppra
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Recurrent Glioblastoma
Major Surgical or Invasive Procedure:
[**2116-12-18**]: s/p Left Craniotomy for tumor resection with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
History of Present Illness:
49 year old woman admitted on [**2116-12-18**] with recent diagnosis of
phyllodes tumor of the left breast in [**2116-5-15**], who has a newly
diagnosed glioblastoma
multiforme. She had resection of a left frontal lobe mass that
showed glioblastoma multiforme on [**2116-8-31**] and is s/p
involved-field cranial irradiation with daily temozolomide from
[**2116-10-1**] to [**2116-11-12**]. She was admitted with emotional lability,
sharp pain in L forehead, and found to have recurrance.
Past Medical History:
Glioblastoma, s/p crani for resection [**8-23**]
s/p excision of fibroid cyst L breast ([**6-/2116**]), s/p
appendectomy (childhood)
Social History:
lives at home with mother and siblings
Family History:
no notable family history
Physical Exam:
Prior to Admission her neuro exam was nonfocal.
Upon discharge:
AOx3, RUE 0/5, but able to move right thumb. RLE: toes moved to
light stim, withdrawl to noxious stim. Speech: Word finding
difficulty; if given choices to questions, she will answer
correctly. Head incision C/D/I, Dissolveable sutures.
Pertinent Results:
MRI Brain [**2116-12-18**]:
IMPRESSION: Stable left frontal lobe mass
CT Head [**2116-12-18**]:
IMPRESSION: Postoperative changes are identified since the
previous MRI of
[**2116-12-18**] with expected post-surgical changes and a small
amount of blood
products and pneumocephalus. No midline shift seen or
hydrocephalus
identified.
MRI Brain [**2116-12-18**] (post-op)
IMPRESSION:
1. New area of restricted diffusion in the left anterior
cerebral artery
territory, consistent with acute infarct.
2. Residual area of enhancement at the medial aspect of the
resection margin. Expected postoperative changes.
Head CT [**2116-12-23**]:
Stable scan.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 19371**] is a 49 yo female with a known history of
glioblastoma s/p left frontal craniotomy on [**2116-8-31**]. She
underwent radiation treatment and Temodar. Recurrence was noted
after she complained of sharp pain at L forehead. On [**2116-12-18**]
she underwent a left craniotomy for tumor resection.
Post-operatively, she had non-fluent aphasia and right
hemiparesis. MRI revealed a small, non-territorial infarct in
the left anterior communicating artery territory involving the
supplemental motor area. on [**12-20**] she was transferred to the
floor. [**12-21**] she remained stable and was noted to begin to show
improvement with speech. Speech therapy was consulted and found
that she had 80% accuracy with naming. [**12-22**] further improvement
was seen with her speech as well as movements. Rehab screening
was initiated and was transferred to [**Hospital3 **] on
[**2116-12-23**].
Medications on Admission:
Decadron
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
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) as needed for constipation.
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Glioblastoma
Discharge Condition:
Neurologically Stable. Word finding difficulty improving. Right
sided hemiparesis also improving slowly.
Discharge Instructions:
General Instructions/Information
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair 10 days after surgery. Your sutures are
dissolveable.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
??????If you are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home.
Followup Instructions:
You will need to follow up with Dr. [**First Name (STitle) **] in the Brain [**Hospital 341**]
Clinic.
4 weeks post-operatively. Please call [**Telephone/Fax (1) 1844**] to make this
appointment. You will need a Brain MRI with and without contrast
3 months after surgery.
Completed by:[**2116-12-23**]
|
[
"V87.41",
"434.91",
"E878.8",
"784.3",
"V15.3",
"191.1",
"997.02",
"342.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
4075, 4145
|
2219, 3155
|
295, 430
|
4202, 4309
|
1545, 2196
|
5858, 6162
|
1180, 1208
|
3214, 4052
|
4166, 4181
|
3181, 3191
|
4333, 5835
|
1223, 1272
|
233, 257
|
1288, 1526
|
458, 950
|
972, 1107
|
1123, 1164
|
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