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Discharge summary
|
report
|
Admission Date: [**2173-10-17**] Discharge Date: [**2173-11-2**]
Date of Birth: [**2114-12-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
1. Mechanical ventilation
2. Arterial line placement
History of Present Illness:
This is a 58 year-old male with a history of Hodgkin's Disease,
s/p surgery, radiation, splenectomy in [**2141**], CAD s/p PCI [**2165**],
HTN, HL, hypothyroidism, babesiosis w/ severe parasitemia [**4-5**]
presents with hemoptysis. The has been having SOB over the last
week. He went to see his PCP on [**Name9 (PRE) 2974**] and was started on
Flovent. Last night the patient had worsening SOB and a "small
amount" of blood while coughing. Today the SOB worsened and had
several more episodes of hemoptysis with a "cup full" this
afternoon that prompted him to go to the [**Location (un) 620**] ED.
.
In the ED at [**Location (un) 620**] 99.0 118 158/127 32 83% RA. He was noted
to have blood in his OP and worsenign hemoptysis. Labs were
significant for leukocytosis of 20.8, Hct 45.4, plts 457, INR:
1.1, CE negative x1. He was given Cefepime/Vancomycin. He was
intubated for airway protect and respiratory distress. He was
given succinylcholine/etomidate and started on a propofol gtt.
Post-intubation CXR showed LUL consolidation and ETT tube in
proper position. He had a CTA chest that showed L-sided
consolidation vs blood. No evidence of PE. He was was paralyzed
for transport with vecuronium and 2mg of versed.
.
On arrive the patient was on Vt 450, FiO2: 100%, RR: 14, PEEP:
5. He was noted to have blood in his ET tube and NG lavage was
performed that showed BRB that continued to be pink colored
after 1L. His vent setting were changed to Vt 580, RR:18, FiO2:
100%, PEEP: 8 on arrival and ABG was 7.24/55/78/25 and rate was
increased to 20. His foley catheter also showed blood. The
prelim CT read showed LUL consolidation that is likely blood.
There was also an area of constriction in the LLL that was
concerning for mass. He also had a left pleural lesion and
small left effusion.
.
ROS: Unable to obtain
Past Medical History:
- Babesia requiring hospitalization from [**Date range (1) 85522**] with
severe parasitemia due requiring exchange transfusion. Recently
stopped azithro/atovaquone on [**9-20**].
-Hodgkin's Disease, s/p surgery, radiation, splenectomy in [**2141**]
-Hypothyroidism
-Essential hypertension
-Hyperlipidemia
-Esophageal stricture: s/p dilatation in [**2164**]
-Basal cell carcinoma
-CAD s/p PCI [**2165**]: 90% prox to mid LAD lesion with cypher sent,
nl left main and LCx
Social History:
Resides in [**Location (un) **] MA with wife, three children, dog and 2 cats.
Owns his own consulting company. Patient reports 14 pack year
history (quit [**2150**]), consumes ~6 drinks per week. Reports
occasional marijuana
use in college and denies elicit drug use.
Family History:
Father deceased (48 [**Name2 (NI) 1686**]) from emphysema and mother deceased from
'old age.' No family history of malignancy
Physical Exam:
ADMISSION PHYSICAL:
GEN: intubated and sedated, blood in his ET tube, no acute
distress
HEENT:pupils reactive to light, sclera anicteric, blood in his
ET and dried blood in his mouth
NECK: No JVD, carotid pulses brisk, no LAD
COR: RRR, no M/G/R, normal S1 S2
PULM: diminished BS on the left side, coarse rhonchi, also
rhonchi in the right upper lobe
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: sedated, CN II ?????? XII grossly intact. Moves all 4
extremities. Strength 5/5 in upper and lower extremities.
Patellar DTR +1. Plantar reflex downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
DISCHARGE PHYSICAL:
Gen: Alert, Oriented, NAD
HEENT: EOMI, sclera anicteric, MMM
COR: RRR, normal S1 S2, soft systolic murmur, ne edema
PULM: diminished BS in LUL, bronchial breath sounds, good
aeration b/l
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
Neuro: intact, no focal deficits
Skin: trunk and extremity red, pruritic urtical rash improving;
persistent rash on back:
Pertinent Results:
MICRO:
**FINAL REPORT [**2173-11-3**]**
URINE CULTURE (Final [**2173-11-3**]): <10,000 organisms/ml
.
Source: Stool.
**FINAL REPORT [**2173-11-1**]**
OVA + PARASITES (Final [**2173-11-1**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
CMV IgG ANTIBODY (Final [**2173-10-29**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
127 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2173-10-29**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
If current infection is suspected, submit follow-up serum
in [**12-30**]
weeks.
Greatly elevated serum protein with IgG levels >[**2162**] mg/dl
may cause
interference with CMV IgM results.
.
FECAL CULTURE (Final [**2173-10-29**]):
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final [**2173-10-29**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2173-10-28**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2173-10-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2173-10-18**] 2:15 pm TISSUE EBUS TBNA LEVEL 7 LYMPH NODE.
GRAM STAIN (Final [**2173-10-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2173-10-21**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2173-10-24**]): NO GROWTH.
ACID FAST SMEAR (Final [**2173-10-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2173-11-1**]): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2173-10-19**]):
NO FUNGAL ELEMENTS SEEN.
.
[**2173-10-18**] 2:24 pm BRONCHOALVEOLAR LAVAGE LEFT UPPER LOBE.
GRAM STAIN (Final [**2173-10-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2173-10-20**]):
~[**2162**]/ML Commensal Respiratory Flora.
ACID FAST SMEAR (Final [**2173-10-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2173-11-1**]): NO FUNGUS ISOLATED
.
[**2173-10-18**] 8:08 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2173-10-20**]**
GRAM STAIN (Final [**2173-10-18**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2173-10-20**]): NO GROWTH.
.
IMAGING: patient provided with CD, hard copies to be faxed
TTE [**10-18**]:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears grossly normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. There is no evidence of
pericardial constriction.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No valvular pathology identified. No evidence for
pericardial disease.
.
CXR [**10-18**]:
IMPRESSION:
1. Improved left and upper lobe consolidation, likely reflective
of
aspiration and atelectasis.
2. Mild pulmonary edema.
.
CXR [**10-20**]:
Over the past 24 hours, consolidation in the left upper lobe and
previous
moderate left pleural effusion have improved substantially.
Region of right lower lobe consolidation has worsened slightly
since [**10-18**]. Heart size is normal. Mediastinal widening in
the region of the aortic arch is attributable to adenopathy.
ET tube at the upper margin of the clavicles is at least 5 cm
from the carina. Right internal jugular line is just above the
estimated location of the superior cavoatrial junction.
Nasogastric tube passes below the diaphragm and out of view.
Small right pleural effusion remains.
.
CXR [**10-22**]:
IMPRESSION:
Slightly increased moderate left pleural effusion.
.
CXR [**10-23**]:
The patient was extubated in the meantime interval. The NG tube
was removed as well. There is currently unchanged appearance of
the widened left mediastinum. Left retrocardiac consolidation
and left pleural effusion are unchanged. The perihilar opacity
has slightly increased in the interim and might potentially
represent area of atelectasis, although hemorrhage as well as
aspiration cannot be entirely excluded. Correlation with
multiple prior radiographs demonstrates slight improvement of
the right basal aeration.
.
FNA FLOW CYTOMETRY [**10-18**]:
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin lymphoma
are not seen in specimen. However, there are clusters of highly
atypical cells on the cytospin preparation, which are highly
suspicious for involvement by a non-hematologic malignant
neoplasm. Refer to concurrent surgical pathology report
(S10-[**Numeric Identifier **]) for final diagnosis. Correlation with clinical
findings is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas as due to topography, sampling or
artifacts of sample preparation.
.
Level 7 lymph node, EBUS-TBNA, cell block
Metastatic non-small cell lung carcinoma.
Immunohistochemical stains show that tumor cells stain positive
for cytokeratin cocktail (AE1/3 and CAM 5.2), cytokeratin 7 and
TTF-1. Cells are negative for cytokeratin 20, chromogranin,
synaptophysin, neuron-specific enolase, CD56 (NCAM) and HMB45.
LCA (CD45) highlights background inflammatory cells. The
cytomorphologic and immunophenotypic findings are consistent
with metastatic non-small cell lung carcinoma; the tumor cannot
be further classified in this sample.
ADMISSION LABS:
[**2173-10-17**] 10:17PM TYPE-ART TEMP-37.3 RATES-22/0 PEEP-8 PO2-269*
PCO2-36 PH-7.40 TOTAL CO2-23 BASE XS--1 -ASSIST/CON
INTUBATED-INTUBATED
[**2173-10-17**] 10:10PM CK(CPK)-158
[**2173-10-17**] 10:10PM CK-MB-5 cTropnT-0.26*
[**2173-10-17**] 10:10PM HAPTOGLOB-120
[**2173-10-17**] 10:10PM HAPTOGLOB-120
[**2173-10-17**] 10:10PM ANCA-NEGATIVE B
[**2173-10-17**] 10:10PM WBC-18.0* RBC-4.37* HGB-12.7* HCT-37.0*
MCV-85 MCH-29.1 MCHC-34.3 RDW-16.3*
[**2173-10-17**] 10:10PM PLT COUNT-419
[**2173-10-17**] 10:10PM PT-13.8* PTT-21.1* INR(PT)-1.2*
[**2173-10-17**] 10:10PM FIBRINOGE-211
[**2173-10-17**] 10:10PM PARST SMR-NEGATIVE
[**2173-10-17**] 05:02PM TYPE-ART PO2-78* PCO2-55* PH-7.24* TOTAL
CO2-25 BASE XS--4
[**2173-10-17**] 05:02PM LACTATE-1.1
[**2173-10-17**] 04:40PM URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.032
[**2173-10-17**] 04:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2173-10-17**] 04:40PM URINE RBC->50 WBC-[**5-6**]* BACTERIA-FEW
YEAST-NONE EPI-0
[**2173-10-17**] 04:35PM GLUCOSE-167* UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2173-10-17**] 04:35PM estGFR-Using this
[**2173-10-17**] 04:35PM ALT(SGPT)-23 AST(SGOT)-27 LD(LDH)-318*
CK(CPK)-187 ALK PHOS-71 TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2
[**2173-10-17**] 04:35PM CK-MB-3 cTropnT-0.06*
[**2173-10-17**] 04:35PM ALBUMIN-4.6 CALCIUM-8.6 PHOSPHATE-5.5*#
MAGNESIUM-1.9
[**2173-10-17**] 04:35PM HAPTOGLOB-189
[**2173-10-17**] 04:35PM WBC-26.4*# RBC-5.05 HGB-15.1 HCT-44.3 MCV-88
MCH-29.9 MCHC-34.1 RDW-16.1*
[**2173-10-17**] 04:35PM NEUTS-71.8* LYMPHS-22.2 MONOS-3.6 EOS-1.6
BASOS-0.8
[**2173-10-17**] 04:35PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-3+ MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-2+ TEARDROP-OCCASIONAL
ELLIPTOCY-OCCASIONAL
[**2173-10-17**] 04:35PM PLT COUNT-470*
[**2173-10-17**] 04:35PM PT-13.6* PTT-20.2* INR(PT)-1.2*
[**2173-10-17**] 04:35PM FIBRINOGE-250#
ADMISSION LABS:
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
13.8* 3.45* 9.9* 30.5* 89 28.7 32.4 16.2* 1034*1
Glucose UreaN Creat Na K Cl HCO3 AnGap
101 10 0.8 135 4.1 101 24 14
PLEURAL
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro
[**2173-11-1**] 14:48 9000* [**Numeric Identifier 3301**]* 0 67* 0 1* 10* 22*
Brief Hospital Course:
This is a 58 year-old male with a history of Hodgkin's Disease,
s/p surgery, radiation, splenectomy in [**2141**], CAD s/p PCI [**2165**],
HTN, HL, hypothyroidism, babesiosis w/ severe parasitemia [**4-5**],
who presented with hemoptysis found to have non-small cell lung
cancer.
.
#. Hemoptysis/Metastatic non-small cell lung carcinoma.
Regarding cancer risk patient with 14 pack year history of
tobacco as well as h/o of Hodgkins disease s/p Mantle radiation
in the [**2132**]. The patient was diagnosed with Hodgkin's lymphoma
in [**2141**] and treated with splenectomy and thoracic mantle
radiotherapy by Dr. [**Last Name (STitle) **] at [**Hospital1 2025**]. He has since had no
evidence of disease, and flow cytometry on [**2173-9-28**] revealed no
evidence of lymphoma. Repeat chest x-rays have shown stable
bilateral paramediastinal fibrosis.
Regarding immediate history prior to this presentation patient
developed shortness of breath in mid-[**Month (only) **], was started on
Flovent by his primary care physician. [**Last Name (NamePattern4) **] [**2173-10-16**], he coughed
up sputum with streaks of blood, and the following day had an
episode of hemoptysis measuring one cup. He presented to [**Hospital1 **]
[**Location (un) 620**], where oxygen saturation was 83%, and he was intubated.
CTA of the chest showed no pulmonary embolism, but revealed a
large density involving the majority of the left upper lobe,
likely representing pulmonary hemorrhage. It also showed a left
lower lobe consolidation and an adjacent paramediastinal area of
heterogeneous attenuation with adjacent focal narrowing of the
left pulmonary artery apical segmental branch to the lower lobe.
There was also a 2-cm subcarinal node and a 0.9-cm node adjacent
to the left mainstem bronchus. Hematocrit at that time was 45.5,
with a WBC count of 20.8, and the patient was started on
cefepime and vancomycin. He was transferred to [**Hospital1 18**] for further
evaluation and management, where his hemoptysis continued.
Initial bronchoscopy reportedly revealed a protruding lesion
with intraluminal and
extraluminal component in the left lower lobe, but there is no
offical report of this, and no biopsies were taken. Rigid
bronchoscopy on [**2173-10-18**] showed slow oozing of bright red blood
from the apical posterior segment of the left upper lobe and an
enlarged subcarinal lymph node. Biopsy of the left upper lobe
revealed scant strips of benign respiratory epithelium and
fibrinous exudate and clot with acute and chronic inflammation.
Flow cytometry revealed no lymphoma, but showed clusters of
highly atypical cells on the cytospin, suspicious for a
non-hematologic malignancy. Biopsy results of the enlarged
subcarinal lymph node + non-small cell lung cancer
(Immunohistochemical stains show that tumor cells stain positive
for cytokeratin cocktail (AE1/3 and CAM 5.2), cytokeratin 7 and
TTF-1. Cells are negative for cytokeratin 20, chromogranin,
synaptophysin, neuron-specific enolase, CD56 (NCAM) and HMB45.
LCA (CD45) highlights background inflammatory cells. The
cytomorphologic and immunophenotypic findings are consistent
with metastatic non-small cell lung carcinoma; the tumor cannot
be further classified in this sample).
The patient underwent IR embolization of right bronchial artery
branches on
[**2173-10-18**], and IR embolization of left bronchial, intercostal,
and internal mammary branches on [**2173-10-19**]. He was seen by the
thoracic surgery team on [**2173-10-19**] for consideration of lobectomy
which due to involvement/encasement of pulmonary arteries did
not appear to be an option. Rad Onc and Med Onc [**Date Range 4221**].
Further staging was performed including CT chest, abd, pelvis,
MRI head and brain - which were negative for metastasis. US
guided thoracentisis performed on day prior to discharge to
determine presence of malignany effusion as well as further
delinate adenocarcinoma vs squamous cell carcinoma. Cell block
obtained; results pending at time of discharge - initial
results below:
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro
[**2173-11-1**] 14:48 9000* [**Numeric Identifier 3301**]* 0 67 0 1* 10* 22*
Home regimen of ASA/plavix discontinued. Hematocrit monitored
closely and stable at 30 at time of discharge.
.
# Pulmonary embolism, DVT s/p IVC filterplacement. On patient
with complaint of area of induration on posterior right leg on
[**10-29**]. LENI's + popliteal DVT. CT with non-occlusive thrombis
within the right pulmonary artery. Decision made to place
permanent filter due to inability to anti-coagulate. Patient did
demonstrate intermittent sinus tachycardia to 130s with exertion
though likely manifestation of pulmonary embolism. No document
hypoxia on the floor. Ambulatory sat 93-94% on RA.
.
# GI Bleed. GI [**Month/Day (4) 4221**] due to several episodes of dark tarry
stool as well as bright red blood per rectum. During
hospitalization, shortly after extubation, patient with several
episodes of small volume loose black, sticky foul smelling
stool. Additionally, on [**2173-10-25**], he began having loose stools
with bright red blood surrounding his stool, last BRB bowel
movement this AM. He has some anal discomfort but no abdominal
pain. Denies nausea, vomitting, or persistent reflux.
Last episode of hemoptysis was [**2173-10-24**] and patient remembers
swallowing a large amount of blood at that point. He denies a
history of hematochezia, melena, hemaetemesis prior to
admission. He has been on Plavix and aspirin for his CAD up
until admission on [**2173-10-17**]. He has never had a colonscopy due
to the fact that he has been on Plavix. Prior to admission
bowel movements were regular (occuring once daily), no change in
caliber, brown and formed, no abdominal pain with bowel
movements. Patient underwent EGD which was negative - dark
stools thought secondary to aspirated blood, Colonscopy
demonstrated 2 small poylps in the rectum s/p polypectomy.
Circumferential area in rectum of ulceration, erythema and
friability of unknown significance. Biopsies demonstrated
Colonic mucosal samples: Sigmoid polyp (polypectomy): fragments
of adenoma. Rectum (biopsy): Fragments of colonic/rectal mucosa
with focal, sharply demarcated ulceration, fibrinopurulent
exudate and adjacent crypt regeneration; No diagnostic features
of chronic colitis, granulomata or viral inclusions are
identified. The differential includes infection, a drug effect
(e.g. NSAID's) or, less likely, ischemic injury, among other
etiologies. Patient started on canasa suppositories with
improvement in rectal irritation. Will follow-up with GI as
outpatient if needed.
.
#. Babesiosis: Pt with severe prior infection and PCR from [**9-28**]
was negative. His azithro and atovoquone were stopped per ID
roughly one month prior. No evidence that babesiosis is related
to his hemoptysis. Admission thick and thin smears negative.
Resent Babesia PCR per ID's request. They will follow-up results
.
#. Urinary retention. Patient noted to have hematuria in MICU
which was deemed traumatic bleeding in the setting of foley
placement. Coags wnl. No further episodes of hematuria in house
however initial concern for metastatic disease to spine in
setting of new retention. MRI spine without any spinal lesions.
Patient passed voiding trial on day prior to admission. Did
endorse some urinary discomfort, no overt dysuria. UA without
sign of infection. [**Month (only) 116**] benefit from urology follow-up as
outpatient if symptoms do not improve.
.
#. ECG changes: On admission to MICU ECG demonstrates less then
1mm ST elevations diffusely. CE at [**Location (un) 620**] were negative.
Troponins in house elevated likely (peak to .26, downtrended
last check 0.09) illustrating a cardiac events however in
setting of hemoptysis patient not candidate for heparin gtt.
Patient without anginal complaints in house.
.
# Rash. Patient started on levofloxacin due to concern for
pneumonia in asplenic patient. On day 5 patient developed
pruritic urtical rash on back. Levofloxacin was transitioned to
ceftriaxone with improvement of rash. Patient completed course
of antibiotics with 5 additional days ceftriaxone. On [**10-27**],
final day of ceftrixone, patient developed pruritic, urticaral
rash on trunk and upper and lower bilateral extremities. Patient
was treated with anti-histamines and short pulses of low dose
prednisone, 20mg daily. Rash improved and day of discharge.
#. HL: continued home statin
.
#. HTN: Held all anti-hypertensives in house. At time of
discharge medications were not restarted.
.
#. Hypotension: Patient presenting blood pressures labile and
required periperal neo for the bronch. This was likely due to
sedation, but concern for sepsis prompted ICU team to
empirically cover with vanco/cefepime to cover encapsulated
organisms due to patient asplenic status. Patient weaned off neo
as sedatives wore off and hematocrit stabilized. Home atenolol
held in house and throughout remainder of stay on the floor
patient normotensive without anti-hypertensives.
PENDING STUDIES:
Babesia PCR
Pleural fluid analysis and cytology
Medications on Admission:
azithro/atovaquone stopped on [**9-20**]
Lorazepam 0.5mg [**Hospital1 **]:prn
Atenolol 25mg daily
Protonix 40mg [**Hospital1 **]
Plavix 75mg daily
Lipitor 10mg daily
ASA
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for esophageal stricture/spasm.
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
6. menthol-cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for cough/sore throat.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*2 inhalers* Refills:*2*
8. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Metastatic Non-small Cell Lung cancer
Pulmonary embolism s/p IVC filter placement
.
Secondary:
Hypertension.
Coronary Artery Disease.
Hyperlipidemia
Discharge Condition:
Mental status: clear and coherent
Ambulates without assistance.
Discharge Instructions:
Mr [**Known lastname 23050**] it was a pleasure taking care of you.
.
You were admitted to [**Hospital1 18**] after episode of coughing up blood.
You were initially admitted to the Intensive Care Unit for close
monitoring and intubated for protection of your airway. Our team
of interventional pulmonologists examined your airways and
identified the bleeding source. They cauterized the area and
stopped the bleeding. Unfortunately imaging demonstrated a large
mass in the left upper lobe of your lung. Biopsy of an adjacent
lymph node was performed which was positive for non-small cell
lung cancer. Due to the fact that the lymph node is located
outside of your lung your lung cancer is characterized as
metastatic, which indicates spread (the pathology slide will be
mailed to [**Company 2860**]). Additional imaging of your belly, spine and
brain where negative for metastasis. To complete staging, a
sample of fluid was removed from your pleural space, the pleura
is a sac that surrounds your lungs. This fluid will be
analysized by the lab. The results will be used to help tailor
your chemotherapeutic regimen. These were pending at the time of
discharge and will be followed by your oncologist.
.
During your hospitalization you noted both dark stools as well
as episodes of bright blood in the toilet. Our team of GI
doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**] and [**Name5 (PTitle) **] underwent both an upper endoscopy
which visualized the upper part of your GI tract as well as a
colonoscopy which visualized your lower GI tract. The EGD was
negative and the colonoscopy illustrated rectal ulcerations.
Biopsies were obtained which were consistent with rectal
irritation/inflammation. Overall the team of GI doctors were not
[**Name5 (PTitle) 85523**] concerned. You can discontinue the enemas and follow-up
with them if you have any additional questions or occurences of
blood in stool.
.
You also broke out in a rash twice while hospitalized, both
which were attributed to a drug rash (first levofloxacin,
second: ceftriaxone) To treat your rash you were started on
anti-histamines as well as oral steriods. At time of discharge
your rash was overall improving but still present.
.
Also the Infectious Disease Doctors [**Name5 (PTitle) 79634**] in on the monitoring
of the Babesia. A lab test was sent off to monitor for any signs
of Babesia in the blood. This result was pending at the time of
discharge but will be followed up by your team of infectious
disease doctors.
.
Regarding ongoing transfer of care, you were discharged with
media copy of all imaging studies. A hard copy of results
including discharge summary will be faxed to [**Company 2860**]. The pathology
results/slide will be mailed from our pathology department to
[**Hospital1 112**].
.
CHANGES TO YOUR MEDICATIONS:
To treat your rash:
CONTINUE taking PREDNISONE 20mg. Take one 20mg tablet through
[**11-5**] - at that time you will have completed a 7 day course.
For sympotamatic relief of your rash you make take/apply the
following as needed:
- RANTIDINE 150mg tablets. Take one pill twice daily as needed
until rash resolves.
- BENADRYL 25mg tablets. Take one pill every six hours as needed
for itch.
.
To help in your breathing you may use:
- ALBUTEROL INHALER: 1-2 puffs every 4-6hrs as needed for SOB.
- GUAIFENESEN: 5-10ml PO every four hours for cough suppression.
.
STOP taking PLAVIX and ASPIRIN to minimize your risk of
bleeding.
STOP taking ATENOLOL.
.
Take all other prescription medications as prescribed.
.
Again, it was a honor taking care of you. We wish you and your
family as the best. Take care.
Followup Instructions:
Regarding your ongoing treatment at the [**Company 2860**] - you will plan to
follow-up with both Dr. [**Last Name (STitle) 17474**] and [**First Name8 (NamePattern2) **] [**Last Name (un) 10595**] this Friday.
Below is the number for the [**Hospital **] Clinic. Please feel
free to contact if you have further questions or concerns.
[**Telephone/Fax (1) 463**] [**Hospital **] Clinic.
Completed by:[**2173-11-3**]
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icd9cm
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24183, 24189
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13414, 13414
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24406, 24457
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2270, 2741
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2757, 3026
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,315
| 145,532
|
26701+57511
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-11-25**] Discharge Date: [**2169-12-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
S/P Fall in Nursing Home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 82-year-old male who is
status post a witnessed fall at his nursing home. The
patient had loss of consciousness and vital signs were stable
at the time of the episode. Was being seen at [**Hospital **]
center for 2 weeks history of failure to thrive, decreased po
intake, abd. distention and incontinence being treated for UTI.
He normally ambulates
with a cane and is non verbal at baseline. Needs assist with
most ADL's.
Past Medical History:
Includes a history of CVA,
hypertension, dementia, hypernatremia, history of UTI.
Social History:
Lives in Nursing Home, has family involved in care
No reported use of alcohol or tobacco
Physical Exam:
Reveals vital signs with a temperature
of 100.2, heart rate of 108 and blood pressure 162/51.
Saturation 98% with a respiratory rate of 21 on room air. The
patient is awake and alert and responsive to voices but is
otherwise a poor historian. The patient's head and neck exam
reveals intact vision and cranial nerves intact. Chest exam
reveals some slight crackles at the lung bases but otherwise
clear. Heart is regular rate and rhythm. Abdominal exam is
soft, nontender, nondistended,
Neuro:Neuro: Pts eyes closed, not opening to voice or stim,
Pupils
reactive slightly 2.5mm b/l, roving eye movements, localizes to
sternal rub briskly (L>R), no posturing, withdraws lower
extremeties R>L, toes downgoing bilaterally, no
clonus/spasticity.
HEENT: No Obvious CSF rhinorrhea/otorrhea (+cerument impactions
bilaterally), No battle/raccoons sign
Pertinent Results:
[**2169-11-25**] 10:07PM LACTATE-3.8*
[**2169-11-25**] 10:00PM UREA N-19 CREAT-1.0 SODIUM-143 POTASSIUM-4.4
CHLORIDE-110* TOTAL CO2-19* ANION GAP-18
[**2169-11-25**] 10:00PM CK(CPK)-314*
[**2169-11-25**] 10:00PM cTropnT-0.05*
[**2169-11-25**] 10:00PM CK-MB-4
[**2169-11-25**] 10:00PM CALCIUM-7.5* PHOSPHATE-2.1* MAGNESIUM-1.6
[**2169-11-25**] 10:00PM WBC-23.3*# RBC-3.07* HGB-9.7* HCT-27.8*
MCV-91 MCH-31.4 MCHC-34.7 RDW-12.8
[**2169-11-25**] 10:00PM PLT SMR-NORMAL PLT COUNT-352
[**2169-11-25**] 10:00PM PT-13.0 PTT-26.6 INR(PT)-1.1
[**2169-11-25**] 08:35PM PT-13.2 PTT-29.5 INR(PT)-1.2
[**2169-11-25**] 05:14PM LACTATE-2.5*
[**2169-11-25**] 04:55PM URINE RBC->1000 WBC-[**12-3**]* BACTERIA-FEW
YEAST-NONE EPI-0
[**2169-11-25**] 04:55PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2169-12-12**] 04:20AM BLOOD WBC-6.3 RBC-2.56* Hgb-7.9* Hct-23.6*
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.5 Plt Ct-530*
[**2169-12-13**] 04:33AM BLOOD WBC-5.5 RBC-2.90* Hgb-8.9* Hct-25.8*
MCV-89 MCH-30.7 MCHC-34.6 RDW-14.7 Plt Ct-559*
[**2169-12-14**] 05:30AM BLOOD WBC-5.0 RBC-2.86* Hgb-8.9* Hct-25.5*
MCV-89 MCH-31.0 MCHC-34.8 RDW-14.7 Plt Ct-591*
[**2169-12-13**] 04:33AM BLOOD Glucose-93 UreaN-11 Creat-1.0 Na-135
K-4.4 Cl-103 HCO3-24 AnGap-12
[**2169-12-13**] 11:23PM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-136
K-4.1 Cl-104 HCO3-22 AnGap-14
[**2169-12-14**] 05:30AM BLOOD Glucose-86 UreaN-10 Creat-0.9 Na-136
K-4.3 Cl-104 HCO3-23 AnGap-13
[**2169-12-12**] 04:20AM BLOOD ALT-19 AST-34 LD(LDH)-321* AlkPhos-101
Amylase-104* TotBili-0.5
[**2169-12-13**] 04:33AM BLOOD ALT-19 AST-39 LD(LDH)-329* AlkPhos-124*
Amylase-78 TotBili-0.5
[**2169-12-13**] 04:33AM BLOOD Lipase-49
[**2169-12-14**] 05:30AM BLOOD Lipase-34
[**2169-11-25**] 10:00PM BLOOD cTropnT-0.05*
[**2169-11-26**] 09:18AM BLOOD CK-MB-7 cTropnT-0.10*
[**2169-11-26**] 12:57PM BLOOD CK-MB-8 cTropnT-0.07*
[**2169-11-27**] 03:19AM BLOOD CK-MB-5 cTropnT-0.11*
[**2169-11-27**] 12:20PM BLOOD CK-MB-6 cTropnT-0.13*
[**2169-11-28**] 03:01AM BLOOD CK-MB-4 cTropnT-0.10*
[**2169-12-6**] 04:15AM BLOOD CK-MB-3 cTropnT-0.09*
[**2169-11-25**] 10:00PM BLOOD CK-MB-4
[**2169-11-26**] 04:20AM BLOOD CK-MB-6
[**2169-12-13**] 04:33AM BLOOD Albumin-2.2* Calcium-7.7* Phos-2.4*
Mg-2.1
[**2169-12-13**] 11:23PM BLOOD Calcium-7.5* Phos-2.2* Mg-2.1
[**2169-12-14**] 05:30AM BLOOD Calcium-7.6* Phos-2.4* Mg-2.1
[**2169-12-7**] 09:00AM BLOOD Cortsol-20.7*
[**2169-12-8**] 04:45AM BLOOD Cortsol-15.2
[**2169-12-10**] 04:05PM BLOOD Hapto-164
[**2169-12-8**] 09:35PM BLOOD Lactate-1.4
[**2169-12-9**] 12:21AM BLOOD Lactate-1.1
[**2169-12-14**] 11:23AM BLOOD Lactate-0.9
.
[**2169-11-25**] CT Head (w/o contrast): 1. Acute left subdural hematoma
with subarachnoid hemorrhage involving the left frontal and
parietal sulci, in addition to the sylvian fissure and basal
cisterns. There is no shift of normally midline structures at
this time.
2. A small hemorrhagic contusion at the superior right frontal
lobe as
described.
3. More chronic right extraaxial fluid collection.
4. The findings were related to the ED dashboard immediately on
interpretation. In addition, the findings were called to Dr.
[**Last Name (STitle) **].
.
[**2169-11-25**] CXR: No evidence of pneumonia.
.
[**2169-11-25**] CT C-spine: No evidence of cervical spine fracture or
malalignment. There is calcification of the posterior
longitudinal ligament at the C3/4 level that encroaches on the
central spinal canal.
.
[**2169-11-25**] CT Head (w contrast): 1. 3 mm focal widening of the
left internal carotid artery at the level of the posterior
communicating artery.
2. Fusiform dilatation of the basilar artery just distal to its
formation.
3. New hyperdense focus at the anterior most aspect of right
temporal lobe
consistent with contusion.
4. Stable appearance of right superior frontal contusion, left
subdural
hematoma, and primarily left subarachnoid hemorrhage since prior
exam.
5. Multiple areas of arterial narrowing and irregularity, which
may represent arteriosclerosis, arterial spasm or both.
6. Left parotid tumor.
.
[**2169-11-26**] CT Head: 1. Minimal increase in size of the left
subdural hematoma which now extends more inferiorly and
posteriorly than on the prior exam, however, no significant
shift of midline structures is demonstrated.
2. Relatively stable appearance of right frontal
intraparenchymal hemorrhagic contusion and subarachnoid blood.
3. Stable appearance of the ventricles.
NOTE ADDED AT ATTENDING REVIEW: I believe there has been an
increase in the volume of the ventricles since the prior
examination.
.
[**2169-11-26**] CT Abd/Pelvis:
1. Patent mesenteric vasculature without evidence of ischemic
bowel. The
bowel appears nondistended and unremarkable.
2. Moderate amount of ascites and periportal edema.
3. Small bilateral pleural effusions with bibasilar compressive
atelectasis.
4. Mildly distended gallbladder with gallbladder wall edema and
cholelithiasis. No intrahepatic or extrahepatic biliary duct
dilatation is
noted. Clinical correlation is recommended. HIDA scan could be
performed if there is concern for acute cholecystitis
5. Subcentimeter low attenuation lesions within both kidneys,
which may
represent simple cysts but are too small to fully characterize.
6. Sigmoid diverticulosis without evidence of diverticulitis.
7. Heterogeneous-appearing and enlarged prostate most likely
representing
benign prostatic hypertrophy.
.
[**2169-11-29**] CT Head: No interval change in the appearance of
intracranial hemorrhage and the brain.
.
[**2169-11-30**] CXR: Moderate-to-large pleural effusions, right greater
than left, increased since [**11-26**]. Progressive
consolidation in left lower lobe could be atelectasis or
pneumonia. Minimal, if any, interstitial pulmonary edema
present. Heart size top normal. Right internal jugular line tip
projects over the SVC. Feeding tube with a wire stylet in place
passes below the diaphragm and out of view. Thoracic aorta is
tortuous, but not focally dilated.
.
[**2169-12-2**] KUB: A portable supine view of the abdomen show gas
filled nondilated large and small bowel loops without evidence
of intestinal obstruction. There are bilateral pleural
effusions. Note is made of an NG-tube with the tip in stomach.
.
[**2169-12-4**] CXR: A feeding tube remains in place within the
stomach. Cardiac and mediastinal contours are stable. Again
demonstrated are bilateral pleural effusions, moderate on the
right and small on the left. The left effusion appears slightly
smaller in the interval, but positional differences of the
patient may account for this difference. There remains increased
opacity in the lung bases adjacent to the effusions, most likely
due to atelectasis. No new or progressive abnormalities are
evident.
.
CT OF THE SINUSES WITHOUT CONTRAST [**2169-12-4**]: negative
.
[**2169-12-5**] CXR: 1. Interval placement of a left subclavian central
line with the tip in the mid SVC. No evidence of pneumothorax.
2. Stable bilateral pleural effusions and left retrocardiac
opacity.
.
[**2169-12-6**] CT CAP: 1. Large bilateral pleural effusions with
bibasilar compressive atelectasis. Significant increased in size
of these effusions when compared to prior exam ([**2169-11-26**]).
2. 8-mm stone within the distal CBD. Not significantly changed
from prior exam. The common bile duct is upper limits of normal
in size, measuring 7 mm. Given the patient's recent negative
HIDA scan, there likely is no functional obstruction. However,
if clinically indicated, further evaluation can be performed
with an MRCP.
3. Diffuse ascites and anasarca.
4. No evidence for intraabdominal abscess.
.
[**2169-12-7**] CT head:Continued evolution of bilateral subdural and
subarachnoid hemorrhage with possible slight interval increase
in degree of mass effect of the right subdural hemorrhage.
.
[**2169-12-8**] CXR (post-tap): Portable semi-erect AP radiograph of
the chest is reviewed, and compared with previous study of
[**2169-12-5**]. The left subclavian IV catheter terminates
in the left innominate vein. A feeding tube terminates in the
gastric body. The previously identified bilateral lower lobe
opacity has been mproving. There is continued left lower lobe
consolidation indicating atelectasis versus pneumonia. There is
small bilateral pleural effusion. The heart and mediastinum are
within normal limits. The lungs are clear otherwise. There is no
evidence of pneumothorax.
.
[**2169-12-8**] CXR PM (prelim): Increasing moderate L pleural
effusion, small loculated R pleural effusion, bibasilar
atalectasis, no pneumothorax.
.
[**2169-12-8**] ECHO: 1. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
2. The aortic root is moderately dilated.
3. The aortic valve leaflets (3) are mildly thickened. Moderate
(2+) aortic regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
5. There is a small pericardial effusion.
.
[**2169-12-10**] EEG: Abnormal awake EEG due to diffuse delta slowing as
well as background slowing with decreased voltages over the left
temporal
region, more so than the left convexity. This tracing gives
evidence
for a cortical and subcortical encephalopathic process with
voltage
asymmetry consistent with the patient's known subdural hematoma.
No
epileptiform activity was seen and there was no suggestion of
subclinical status epilepticus on this tracing.
.
[**2169-12-11**] CXR: There is a small persistent left pleural effusion
but progressive leftward mediastinal shift indicates left lower
lobe collapse. Small right pleural effusion is present. Heart is
top normal size. Left subclavian catheter tip projects over the
SVC and a feeding tube ends in the stomach.
.
[**2169-12-12**] CXR: 1. Dobbhoff tube is seen, with the tip in the mid
esophagus.
2. Interval complete opacification of the left hemithorax, which
likely represents a combination of an increase in the left
pleural effusion with associated left lung atelectasis.
.
[**2169-12-14**] CXR: Improving aeration in the right upper lobe.
Persistent collapse of left lower lobe with likely accompanying
large effusion.
.
[**2169-12-16**] CXR: : Accounting for positioning differences, no
significant interval change without definite evidence for
developing pneumonia.
.
MICRO:
[**2169-12-16**] BLOOD CULTURE: NGTD
[**2169-12-16**] URINE CULTURE: negative
[**2169-12-14**] Cath tip: no growth
[**2169-12-11**] SPUTUM CULTURE: contaminated, culture not done
[**2169-12-11**] URINE CULTURE: negative, fungal negative
[**2169-12-11**] BLOOD CULTURE: negative
[**2169-12-10**] URINE CULTURE: negative
[**2169-12-10**] BLOOD CULTURE: negative
[**2169-12-9**] SPUTUM CULTURE: contaminated, culture not done
[**2169-12-8**] URINE CULTURE: negative
[**2169-12-8**] BLOOD CULTURE: negative
[**2169-12-7**] C DIFF: negative
11/23/2205 C DIFF: negative
[**2169-12-6**] RPR: non-reactive
[**2169-12-6**] BLOOD CULTURE: negative
[**2169-12-5**] URINE CULTURE: negative
[**2169-12-5**] BLOOD CULTURE: negative
[**2169-12-5**] C DIFF: negative
[**2169-12-4**] BLOOD CULTURE: negative
[**2169-12-2**] SPUTUM: contaminated, culture not done
[**2169-12-2**] URINE CULTURE: negative (X 2)
[**2169-12-2**] CATH TIP: negative
[**2169-12-2**] BLOOD CULTURE: negative
[**2169-12-1**] BLOOD CULTURE: negative
[**2169-12-1**] URINE: negative
[**2169-11-27**] MRSA SCREEN: negative
[**2169-11-27**] RECTAL SWAB: positive for VRE
[**2169-11-27**] MRSA SCREEN: negative
[**2169-11-26**] SPUTUM: 2+ GNR, 1+ GPR, 1+ GPC in pairs
[**2169-11-26**] URINE: negative
[**2169-11-26**] BLOOD CULTURE: negative
[**2169-11-26**] BLOOD CULTURE: negative
[**2169-11-25**] BLOOD CULTURE: negative
[**2169-11-25**] BLOOD CULTURE: negative
[**2169-11-25**] URINE: negative
[**2169-11-25**] UA: >1000 RBC, [**12-3**] WBC, few bacteria, neg leuk, neg
nitrite
.
[**2169-12-8**] Cytology of pleural fluid: NEGATIVE FOR MALIGNANT CELLS
Brief Hospital Course:
Neurosurgery Course:
.
Pt was admitted to Neurosurgery [**2169-11-25**] after falling at the
rehabilitation hospital he had been discharged to one day
earlier after an admission at [**Hospital 4415**] for a
UTI. he was found to have a sub-arachnoid sub-dural hemorrhages,
and was admitted to the SICU as he required intubation and
pressors (for desaturation, tachycardia, and hypotension) to
maintain his hemodynamic status. He was evaluated by
Neurosurgery and Trauma who did not feel surgery was required at
that time. He was loaded with dilantin for seizure control, and
his neuro exam slowly improved throughout his SICU stay with
increasing spontaneous movment and awakening. He was weaned off
pressors and extubated [**2169-11-28**]. Repeat imaging of his head
revealed that his bleeds were stable.
.
During the first 3 days of his admission he was noted to have
elevated cardiac enzymes, and some EKG changes. His peak
troponin was 0.13 and his peak CK was 508 with an MB of 8.
Cardiology was consulted, and felt that this mild increase in
the setting of his intracranial hemorrohage likely represented
demand ischemia. Per their recommendations, his lopressor dose
was adjusted to 25 [**Hospital1 **], and they signed off.
.
Also on admission he was noted to have an elevated temperature,
and he was started on levofloxacin and vancomycin. His fevers
continued despite antibiotic treatment, and he was transferred
to the medicine service for further evaluation and management on
[**2169-12-1**], and Neurosurgery signed off that day.
.
Medicine Course:
.
# Fevers: Mr [**Known lastname 10940**] was febrile on admission, and had just been
transferred to a rehab facility after inpatient treatment at [**Hospital **] for a UTI, where he received
ciprofloxacin. He was initially treated with vancomycin and
levofloxacin for a total of 5 days for a presumed UTI and
possible MRSA exposure in OSH or rehab. The vancomycin was then
stopped, and flagyl started. The vanco was restarted after being
off for 2 days. Throughout this time the patient continued to
spike to 103 daily, and was pan-cultured multiple times, with no
growth of any culture including urine. Although his chest Xray
suggested a possible pneumonia at one point, follow up studies
did not support this diagnosis. An ECHO did not show
endocarditis. A diagnostic tap of his pleural effusions revealed
no malignant cells, and grew nothing on culture.
.
The only potential source of infection was that the patient was
seen to have gall stones and a stone in the common bile duct
with mildly elevated LFTs, raising concern for cholangitis. A
HIDA scan was negative for cholecystitis, and Surgery did not
feel he needed a procedure at that time. Finally, after
extensive work up, ID was consulted. Per their recommendations
the patient was taken off levofloxacin and flagyl and started on
zosyn to complete a 14 day course to cover possible cholangitis.
MRCP was attempted but the patient did not tolerate lying flat
for the procedure. His fever curve slowly trended down, and
after negative cutures of all line tips, the patient was taken
of vancomycin as well, having received 14 days of that
antibiotic. ERCP was considered, but given the patient's
improvement, and the risks of the procedure, which would have to
be done under general anesthesia, it was decided not to pursue
this further at this time.
.
After he was afebrile for 48 hours he received a PICC line
[**2169-12-13**], and PEG [**2169-12-14**]. He has had one febrile spike since
that time, on [**2169-12-16**], with negative cultures. At time of
discharge he has been afebrile since 1AM [**2169-12-16**]. He has
completed a 14 day course of zosyn on [**2169-12-18**]. Of note, it may
be that the patient will intermittantly spike temperatures due
to aspiration of his oral secretions, as he has failed two
speech and swallow evaluations (see below). Another
consideration would be his phenytoin, and he could be
transitioned to an alternative medication for seizure
prophylaxis if fevers continue, since there has been no strong
evidence for continuing infectious source of fevers.
.
# Respiratory: Mr. [**Known lastname 10940**] had thick secretions throughout his stay,
requiring frequent suctioning, and resulting in mucous plugging
with episodes of desaturation. THese routinely resolved with
deep suctioning and nebulizer treatments. At the time of
discharge he has had no desaturations in four days.
Additionally, he had bilateral pleural effusions on transfer to
medicine. The right side was tapped for diagnostic and
therapeutic purposes, and has remained resolved. The left
pleural effusion resulted in significant left-sided atalectasis,
both of which have been resolving with diuresis. As his
effusions have resolved his respiratory status has improved. He
is still requiring frequent suctioning and close monitoring for
mucous plugging at time of discharge. As his status further
improves he will be able to transition to a lower level of
nursing care.
.
In addition to the above respiratory issues, Mr. [**Known lastname 10940**] began
[**Last Name (un) 6055**] [**Doctor Last Name **] breathing several days after transfer to the
Medicine service with apneic episodes lasting 10-20 seconds and
spontaneously resolving. He was placed on an apenea monitor and
Pulmonary Critical Care was consulted. They felt this breathing
pattern was part of the natural course of his intracranial
bleed. The apneic episodes never required intervention for
resolution, and have completely resolved - he has had no apneic
episodes for 4-5 days at discharge.
.
# Anemia: Mr [**Known lastname 10940**] was anemic on admission, likely related to his
age, chronic medical conditions, and his poor nutritional
status. However, his hematocrit then dropped over two days
(11/27-28/05): 31 -> 26.7 -> 25.8 -> 22.7 -> 24.8; with
haptoglobin normal, reticulocyte count 1.0, and total bilirubin
0.7; so no clear sign of hemolysis. He was repeatedly Guaiac
negative, with no sign bleeding elsewhere. This did occur
shortly after thoracentesis, so we considered that he could be
slowly bleeding there as well. His pleural effusions have been
continuing to improve with diuresis however, and there was no
sign of new areas on repeat chest Xrays. His hematocrit then
dropped to 23.4 a couple days later, and he finally received one
unit of packed RBCs, with a good response in his hematocrit. On
discharge he has stabilized for more than 3 days.
.
# SAH/SDH after fall: Per the Neurosurgery team, Mr. [**Known lastname 10940**] was
stable on transfer to the Medicine service, and does not require
surgery. They suggested a bloob pressure goal of systolic less
than 160 per a verbal statement of the Neurosurgery PA. On
[**2169-12-7**] a repeat head CT was done for a change in Mr. [**Known lastname 65798**]
breathing (see above), and showed no new hemorrhage, but slight
increase in mass effect and R to L shift. We contact[**Name (NI) **]
Neurosurgery, and they felt no intervention was needed at that
time. They would intervene if >1cm midline shift and his was
less. They also suggested keeping his INR < 1.3 and approved SC
heparin for DVT prophylaxis. He received a total of 5mg Vitamin
K subcutaneously for an INR of 1.6, and his INR has been normal
since. His INR should continue to be kept below 1.3. His
dilantin levels were monitored closely, and were therapeutic. He
required one reloading of 300mg, but has been stable for more
than a week on his current dose. Neurology advised us on his
replading dose. Additionally there was some qustion of whether
he had some facial twitching that might represent seizures. His
dilantin was reloaded as descirbed, and an EEG was done 11/27/5,
which showed diffuse slowing and activity consistent with his
intracranial bleed, and no sign of seizure activity. Of note his
measured phenytoin levels were adjusted for his albumin level.
.
# Possible heart Failure: On transfer to the medicine service
Mr. [**Known lastname 10940**] had anasarca and bilateral pleural effusions. Although
he ahd no previous diagnosis of congestive heart failure, there
was concern for new onset failure versus poor nutritional status
and acute illness with fluid resucitation. An ECHO showed 2+ AR
and an EF > 55%. It is possible his AR in combination with his
poor nutritional status underlies his fluid accumulation. His
lopressor was continued with frequent EKGs as he has had PVCs
throughout his stay. The plan was to stop beta-blocker treatment
if his QTc interval increased to > 450, and then start
lisinopril instead for afterload reduction. However his QTc
interval has remained below 450, and beta-blocker therapy is in
place on discharge. Of note, his electrolytes are stable, and
there is no current therapy required for his PVCs. Mr. [**Known lastname 65798**]
edema has almost completely resolved at time of discharge,
following daily diuresis.
.
# Hematuria/incontinence: Mr. [**Known lastname 10940**] had accidental foley removal
associated with his fall while at his prior rehabilation
facility, with resulting traumatic injury to his urethra/penis,
and bleeding. He was seen by urology, who advised keeping the
foley in to tampanade bleeding, and further suggested that he
should be discharged with foley in place to follow up in urology
clinic at a later date. He is scheduled for a follow up
appointment.
.
# Hypertension: Mr. [**Known lastname 10940**] was normotensive throughout his time on
the medical service on his current regimen of lopressor. Per
Neurosurgery we were keeping his SBP < 160 in the setting of his
intracranial hemorrhage. In addition to his lopressor, he was
written for prn hydralazine, but did not require this as his SBP
was did not go above 145. As he recovers further, his
beta-blocker dosing could be further adjusted to maintain normal
BP. He should continue to be maintained with a SBP < 160.
.
# FEN: Mr. [**Known lastname 10940**] failed two swallowing evaluations, and therefore
received enteral feedings through an NGT. These were
intermittantly stopped to accomodate procedures and/or acute
decompensations in his condition. He was able to reach his goal
feeding of Probalance full strength at 55cc/hr. Prior to
discharge a PEG tube was placed to provide access for long-term
enteral nutrition. He should continue to receive tubefeeds, and
his albumin should be monitored for improvement. His
electrolytes should continue to be monitored and repleted as
needed. They have been stable throughout his stay, requiring
little to no repletion. Of note, his calcium levels have been
normal when adjusted for his albumin level. Mr. [**Known lastname 10940**] received
small fluid boluses at times throughout his stay for low UOP.
Largely however, he did not receive many supplemental IV fluids,
as he was quite fluid overloaded, receiving a significant volume
of IV medications, and we were required to diurese him to
improve his edema a respiratory status.
.
# Prophylaxis: Mr [**Known lastname 10940**] was on protonix for ulcer prophylaxis, and
SC heparin for DVT prophylaxis after cleared by Neurosurgery.
.
# Disposition: Mr. [**Known lastname 10940**] was discharged for further [**Hospital 65799**]
nursing care and physical therapy as he continues to recover
from his fall, intracranial hemorrhage, and sepsis. He may
finally require chronic care in a lower level nursing facility,
depending on the level of his recovery from this acute injury.
.
# Code: Full Code: Multiple family meetings were held with the
medical team, Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) **], and Mr. [**Known lastname 65798**] wife and
children to discuss his current medical status and prognosis. It
was explained many times that DNR/DNI does notmean withdrawing
care, but rather sets limits on the extent of care pursued in
case of acute decompensation. Mr. [**Known lastname 65798**] full family met and
finally decided they want to keep him full code and pursue all
treatment options at this time.
Medications on Admission:
Norvasc 10mg po daily
Aspirin 325mg po daily
Pravachol 10mg po daily
Ciprofloxacin
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q3-4H (Every 3 to 4 Hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q3H (every 3 hours) as needed.
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for fever or pain.
4. Papain Powder Sig: 5-10 MLs Miscell. PRN (as needed) as
needed for indigestion.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for yeast infection.
7. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
9. Phenytoin 100 mg/4 mL Suspension Sig: One [**Age over 90 1230**]y (150)
mg PO Q8H (every 8 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for heart rate less than 60 or systolic blood
pressure less than 100.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
via PEG tube.
12. Hydralazine 20 mg/mL Solution Sig: Twenty (20) mg Injection
Q6H (every 6 hours) as needed for hypertension for 5 days:
please give for systolic blood pressure greater than 160 only,
hold for systolic blood pressure less than 140.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
primary:
subdural hemorrhage, subarachnoid hemorrhage, sepsis
secondary:
dementia
hypertension
acute coronary syndrome
fluid overload
poor nutritional status
Discharge Condition:
Stable: afebrile, decreased supplemental oxygen requirement,
tolerating enteral feeding, seizure-free, with no signs of
further intracranial hemorrhage.
Discharge Instructions:
Please inform your doctor if you have worsening breathing,
temperatures greater than 101 Farenheit, nausea & vomiting,
diarrhea, seizures, or any other health concern.
Followup Instructions:
Please follow with the primary doctor at your skilled nursing
facility.
.
Provider: [**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. UROLOGY, Phone:[**Telephone/Fax (1) 10941**]
Date/Time:[**2170-1-10**] 8:30
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 742**] NEUROSURGERY WEST
Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2170-1-17**] 9:00
Completed by:[**2169-12-18**] Name: [**Known lastname 11539**],[**Known firstname 11540**] JING Unit No: [**Numeric Identifier 11541**]
Admission Date: [**2169-11-25**] Discharge Date: [**2169-12-18**]
Date of Birth: [**2087-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11542**]
Addendum:
Discharge Physical Exam:
.
Tm/Tc 99.8/99.2 (ax) BP 113/59 P: 98 R: 22 O2: 99% 35% FM
I/O: 24: [**2129**]/2450; 12: 695/940
Gen: asleep in bed, awakens to voice and movement, NAD
HEENT: NCAT, PERRL, anicteric, MMM & intact
Neck: visible carotid pulse, JVP flat
Cor: RRR, [**2-19**] diastolic murmer
Lungs: CTAB, no wheezes or apneic episodes noted today,
breathing much improved overall, still mildly decreased BS at L
base, sounds somewhat wet in upper airway
Abd: soft, NT/ND, +BS, no masses, PEG in place, no erythema,
dressing CDI
GU: scrotal and penile edema - much improved; foley in place
Ext: trace edema B hands and feet, much improved; R PICC line in
place, dressing CDI
Neuro: responds to painful stimuli, moves all extremities
spontaneously
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] - [**Location (un) 42**]
SAN YOU [**Name8 (MD) **] MD [**MD Number(1) 11543**]
Completed by:[**2169-12-18**]
|
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"933.1",
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icd9cm
|
[
[
[]
]
] |
[
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"38.93",
"96.04",
"96.72",
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icd9pcs
|
[
[
[]
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] |
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|
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|
289, 295
|
27727, 27882
|
1858, 5979
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26055, 27430
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225, 251
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323, 766
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788, 872
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888, 978
|
28954, 29690
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,362
| 186,833
|
24182
|
Discharge summary
|
report
|
Admission Date: [**2165-2-25**] Discharge Date: [**2165-3-7**]
Date of Birth: [**2107-2-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T3,2,1, decompression, instrumentation C5-t4
History of Present Illness:
The patient is a 58 year old female with a history of 2 ppd x 20
year smoking history and now metastatic lung cancer (initial
presentation in [**2151**]) to bone who originally presented to the
orthopedic service on [**2165-2-25**] with back pain secondary to known
spine metastases. She underwent a T3,2,1 decompression &
instrumentation C5-t4 on [**2-26**]. She had received 3 units of blood
intra-operatively. Her post-operative course was complicated by
a painless lower GI bleed with bright red blood per rectum and
maroon stools on [**2165-3-2**]. The patient's hematocrit dropped from
37 to 25 and she was transferred back to the SICU where she
received an additional 3 units of blood and 4 units of FFP. The
patient remained hemodynamically stable.
GI was consulted and she underwent a tagged RBC scan on [**2165-3-2**]
which showed no active bleeding. The patient is undergoing a
colonoscopy on [**2165-3-5**] with concern for a possible diverticular
bleed or disease related to her metastatic lung cancer.
Meanwhile, the patient denies any abdominal pain, nausea, or
vomiting. She herself had not noted any blood and the nurses
report no bloody stools for 24 hours. Her Hct has remained
stable at 29-32 over 24 hours. She has never had a colonoscopy
and never had GI bleeding before. She denies any epigastric
burning associated with meals.
ROS:
Denies any chest pain, shortness of breath, cough. Denies
current weight loss, fevers or chills.
Past Medical History:
*Metastatic lung cancer with history of RUL pancoast tumor s/p
chemo, radiation, and RUL lobectomy in [**2151**] which was
complicated by a bronchopleural fistula, mets to spine. PET in
[**1-20**] showed an intensely FDG avid large left apical lung mass
with destruction of the left T2 through T4 ribs and T2 through
T4 vertebral bodies and/or posterior elements with extension of
the mass into the spinal canal at the T3 level without definite
evidence for spinal cord compression. Negative Head MRI in [**1-20**]
for metastatic disease.
* S/p right shoulder fracture s/p fall
* LUL lung cancer recurrence in [**2162**]
Social History:
The patient lives with her husband and 2 daughters. She formerly
smoked 2 ppd x 20 years. Denies EtOH.
Family History:
Mother died from ovarian cancer.
Father alive with HTN.
Has 6 children.
Physical Exam:
Tc -98.8 P=101 BP=180/79 (A-line in left upper extremity) BP
range from 93-180 RR=22 99% O2 on 3 liters O2
Gen - NAD, AOX3, appears much older than stated age
HEENT - NG tube in place, MMM, no JVD
Heart - Increased rate, regular rhythm, Grade II/VI holosystolic
murmur at LUSB
Lungs - CTAB anteriorly
Back - Staples in place cervical, thoracic spine
Abdomen - Soft, NT, ND, no HS, + BS
Ext - No C/C/E, SCD bilaterally, +2 d. pedis bilaterally
Pertinent Results:
CT ABD W&W/O C [**2165-3-3**] 2:59 PM
1. No evidence of free intraperitoneal air or fluid.
2. Multiple hepatic cysts.
3. Bilateral small to moderate pleural effusion.
4. A widespread soft tissue edema.
GI BLEEDING STUDY [**2165-3-2**]
IMPRESSION: No evidence of active bleeding.
C-SPINE NON-TRAUMA [**1-18**] VIEWS [**2165-3-1**] 2:05 PM
AP AND LATERAL RADIOGRAPHS OF THE CERVICAL AND THORACIC SPINE:
Comparison is made to [**2165-2-28**]. Appearance of paraspinal hardware
construct is unchanged.
CT T-SPINE W/O CONTRAST [**2165-2-25**] 4:43 PM
IMPRESSION: Large left apical mass and paraspinal mass producing
marked destructive changes of the first three thoracic vertebra
with invasion of the spinal canal.
CT C-SPINE W/O CONTRAST [**2165-2-25**] 4:42 PM
IMPRESSION: Large left apical calcified mass is again
demonstrated and paraspinal mass with extensive destructive
change of the upper thoracic spine with material present within
the spinal canal that appears to surround the cord.
[**2165-3-2**] CXR :
A single portable AP view is compared to a previous examination
of [**2165-1-7**]. There is a new right IJ line with the tip
in right atrium proximally. There is no evidence of
pneumothorax. The right upper ribs have been resected with signs
of thoracoplasty. There is a left Pancoast tumor with
post-radiation changes in left paramediastinal region. The
remainder of the lungs are clear without evidence of
consolidation.
Colonoscopy [**2165-3-6**]:
Diverticulosis of the sigmoid and descending colon
Internal hemorrhoids
Bleeding likely secondary to diverticulosis.
Brief Hospital Course:
The patient is a 58 year old female with a history of metastatic
lung cancer to bone who initially presented for spinal
decompression secondary to mets and subsequently developed what
appears to be a lower GI bleed transferred from the SICU to the
medical service
#.Lower GI bleed
- Switched to PO PPI.
- Colonoscopy on [**3-6**] showed no active bleeding with
diverticulosis and internal hemorrhoids, recommended high fiber
diet.
- The patient received a total of 6 units of blood during this
hospitalization and her hematocrit has remained stable with no
more significant bleeding with her last Hct being 28.
- She tolerated a regular diet with boost post colonoscopy
without difficulty.
- Goal Hct >28.
- She has had no additional bloody stools for >48 hours.
.
#. Metastatic lung cancer with bony mets
- Her pain is well-controlled on oxycontin 30 mg PO Q12 and
vicodin prn.
- Continue good bowel regimen.
.
#. Hypoxia
- The patient had an O2 requirement of [**1-18**] liters in the ICU
which was likely secondary to bilateral effusions after multiple
blood products in ICU and malignancy as well. Her continuous IVF
was discontinued.
- No echo on record. However, the patient has an S3 on exam.
- The patient on the day of discharge was sat'ing 95% on RA.
.
# Right scapular wound
- Plastics consulted on [**3-6**]. She had formerly seen Dr. [**First Name (STitle) **]
at [**Location (un) 620**] for this. Plastics here felt that this was most
likely a pressure ulcer and recommended wet to dry dressings
[**Hospital1 **]. They feel that the patient is not a surgical candidate for
a closure/flap given her current condition.
.
# Hyponatremia
- Urine lytes confirmed that the etiology of her hyponatremia is
SIADH. Her urine sodium was high at 157 and urine osmolality
187.
- Fluid restrict to 2 liters.
#. FEN - Regular diet with boost TID, monitor electrolytes
.
# Code status - Presumed full
.
Medications on Admission:
Medications on Admission:
Vicodin
Oxycontin
.
Meds on Transfer to floor:
Anzemet prn
PPI IV Q12
SSI
Oxycodone 10 mg PO Q12
Dilaudid 1-2 mg IV Q3-4 prn
Megace 30 mg PO QD
Golytely as directed
Discharge Medications:
1. Megestrol 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Lower GI bleed secondary to diverticulosis
Metastatic lung cancer to bone with spinal compression
Blood loss anemia
Discharge Condition:
Stable. Tolerating POs.
Discharge Instructions:
Please keep incisions clean and dry. Dry sterile dressing daily
as needed.
Please call your primary care physician or return to the ER if
you experience any fevers, chills, bleeding from your rectum,
lightheadedness or dizziness.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **], your orthopedic
surgeon, on Thursday, [**3-14**] at 2:40 pm on the [**Location (un) 1773**]
of the [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**]. Please call [**Telephone/Fax (1) 1228**]
should you have any questions.
Please call ([**Telephone/Fax (1) 51002**] to schedule an appointment with Dr. [**Name (NI) 29874**] at his [**Location (un) 620**] office next week. He is aware of your
hospitalization and asked that you call for an appointment next
week.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,615
| 115,152
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46651+58936
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-7-3**] Discharge Date: [**2103-7-12**]
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
hypotension, LLE pain
Major Surgical or Invasive Procedure:
Right groin line placement
Right radial artery line placement
History of Present Illness:
Pt is a legally blind [**Age over 90 **] y/o F with PMH significant for CHF,
infra-renal AAA s/p endovascular repair with chronic leak, and
peripheral vascular disease with chronic bilateral LE skin
tears, presented to the [**Hospital1 18**] on [**7-3**] with hypotension and a
3-day hx of worsening LLE pain. She was seen by her VNA (helps
manage her chronic skin tears) who found patient hypotensive.
Patient also reports LE pain was throbbing and sharp diffuse
throughout her entire leg. On presentation, she denies any chest
pain/SOB/palpitations, fevers/chills (although frequently cold),
nausea/vomiting. She reported chronic diarrhea, decreased
appetite and chronic skin tears worse in the lower extremities
bilaterally.
.
Per patient's nephew (very involved in her care): Pt. has been
hypotensive over the last week accompanied with weakness and
confusion. Also, pt's PCP discontinued her [**Name9 (PRE) **] 80 mg on
[**2103-6-27**] for these episodes of hypotension and weakness, but
increased her furosemide to 40 mg [**Hospital1 **]. Her nephew voiced concern
about pt's very poor PO intable, ability to take medications on
her own and perform ADLs.
.
In the ED, initial vs were: T 97.4 P 61 BP 91/48 R 20 O2 sat.
SBPs were in the 90-100s range. On exam she is a frail, elderly
woman and LLE warm, erythematous w/ appearance of cellulitis.
Cannot palpate pulses, but easy to doppler. Patient was given
vanc/zosyn/clinda. Access 20G in R antecub. Got 1500cc of fluid
total. Reported guiac positive stool in the ED. Vitals prior to
transfer 96.7 56 101/83 13 96% on 4L NC.
.
On arrival in the MICU, her VS were T:94.8 (rectal) BP: 95/42
P:64 R: 18 O2: 94% on 3L NC and she complained of pain in her LE
extremities worse in her left, chills, oriented to self, place
and date but had somewhat of tangential speech. She was bolused
500cc twice with unresponsive MAPs and with difficult central
access via SC or IJ, an A-line was placed and phenylepherine
(stopped at 6AM on [**7-5**]) given for 24 hours and was gradually
weaned off. She was found to grow 4000 GNR on urine cultures
resistant to b-lactams on speciation. There were no other
impressive sources of infection although a CT abd and
gallbladder U/S had evidence of chronic cholecystitis. LE films
was neg for gas or fluid collections. She was worked up with a
CT abd, hand was gradually weaned of pressors with 250cc
boluses. Her labs were neg for bands.
Past Medical History:
1. CHF (EF 45%, though likely an overestimate given severe MR)
2. CAD (last cath in [**2096**] with complete occlusion of ramus
intermedius, moderate disease elsewhere)
3. Decreased vision R eye, now legally blind
4. PVD - s/p arthrectomy and B/L superficial femoral artery PTCA
5. Severe mitral regurgitation
6. Depression
7. Hysterectomy
8. Endoscopic aortic aneurysm repair [**11-28**]
9. Chronic kidney disease (baseline Cr 1.4)
Social History:
Born in [**Location (un) 669**] MA but currently lives in [**Location **] Corner alone.
She has a home VNA and someone to help clean her house. Her
nephew who lives in [**State 2748**] visits weekly to check on her
and brings her groceries. Has no family in [**Location (un) 86**] (twin sister
and two older siblings passed away). Retired from advertising
and currently spends her days listening to the television.
Ambulates with a scooter but nephew has expressed concern about
patient's inability to ambulate well around her home in addition
to inconsistently taking her medication.
- Tobacco: remote history, discontinued over 35 years ago
- Alcohol: 6oz of Vermouth every evening (per patient's nephew).
Patient states drinks occassionally).
.
Family History:
Twin sister-died from liver cancer at age 43
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:94.8 (rectal) BP: 95/42 P:64 R: 18 O2: 94% on 3L NC
General: Alert, oriented, no acute distress
HEENT: Sclara are cloudy, reactive pupils 3-->2 mm. Dry mucuos
membranes. Oropharynx clear without lesions or ulcers.
Neck: supple, JVP to level of mandible at 30 degrees
Lungs: Poor inspiratory effort without rales.
CV: Regular rate with occassional PVC's, 2/6 systolic murmur. No
rubs, gallops
Abdomen: protuberant abdomen with linear midline scar. Soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Tympanic to percussion
GU: foley with clear urine
Ext: B/L lower extremity erythema with erosions and ulcerations.
TTP. Dopplerable pulses.
Neuro: AOX3 but tangeintal speech. Sluggish but MAE. Can move
toes and hands
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tc:97.2, BP:138/69(90-130/50-60) HR:74(60-80), R:20
O2:95% on 2L. I/O: 8h (100/200, 24h (2380/1300)
General: Elderly female lying comfortable in bed, oriented to
self and place not date, no acute distress
HEENT: Sclera translucent, mucous membranes dry, poor dentition
with many missing dention, oropharynx clear
Neck: supple, JVP not assessed, no LAD
Lungs: Clear to auscultation bilaterally, decreased breath
sounds on the right base and mild crackles in the left base
CV: Regular rate with extra heart sounds, 2/6 systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, midline abd scar, dependent
edema and skin breaks in the lower abdomen/inguinal area (better
than yesterday).
Ext: Warm, well perfused, 2+ edema with several ulcerations of
different depths. pulses not palpated
Pertinent Results:
Admision Labs
=================
[**2103-7-3**] 06:31PM LACTATE-2.3*
[**2103-7-3**] 02:09PM URINE HOURS-RANDOM
[**2103-7-3**] 02:09PM URINE GR HOLD-HOLD
[**2103-7-3**] 02:09PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2103-7-3**] 02:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-LG
[**2103-7-3**] 02:09PM URINE RBC-<1 WBC-20* BACTERIA-MOD YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2103-7-3**] 02:09PM URINE MUCOUS-RARE
[**2103-7-3**] 01:32PM LACTATE-2.6*
[**2103-7-3**] 01:20PM UREA N-45* CREAT-1.5* SODIUM-126*
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-22 ANION GAP-17
[**2103-7-3**] 01:20PM ALT(SGPT)-16 AST(SGOT)-29 LD(LDH)-203
CK(CPK)-63 ALK PHOS-151* TOT BILI-1.9* DIR BILI-1.5* INDIR
BIL-0.4
[**2103-7-3**] 01:20PM LIPASE-15
[**2103-7-3**] 01:20PM CK-MB-11* MB INDX-17.5* cTropnT-0.02*
[**2103-7-3**] 01:20PM ALBUMIN-3.5
[**2103-7-3**] 01:20PM WBC-8.3 RBC-3.51* HGB-11.9* HCT-35.4*
MCV-101* MCH-33.9* MCHC-33.6 RDW-18.2*
[**2103-7-3**] 01:20PM NEUTS-75* BANDS-8* LYMPHS-9* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-3* MYELOS-0
[**2103-7-3**] 01:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-1+
[**2103-7-3**] 01:20PM PLT SMR-NORMAL PLT COUNT-151
[**2103-7-3**] 01:20PM PT-19.2* PTT-36.7* INR(PT)-1.7*
[**2103-7-6**] 06:15AM BLOOD WBC-6.2 RBC-3.49* Hgb-11.3* Hct-36.3
MCV-104* MCH-32.4* MCHC-31.1 RDW-19.0* Plt Ct-118*
[**2103-7-7**] 07:00AM BLOOD WBC-6.3 RBC-3.96* Hgb-12.6 Hct-41.3
MCV-104* MCH-31.8 MCHC-30.5* RDW-18.9* Plt Ct-134*
[**2103-7-8**] 06:30AM BLOOD WBC-6.8 RBC-3.45* Hgb-11.6* Hct-37.3
MCV-108* MCH-33.8* MCHC-31.2 RDW-18.6* Plt Ct-125*
[**2103-7-9**] 06:35AM BLOOD WBC-6.8 RBC-3.63* Hgb-11.8* Hct-37.7
MCV-104* MCH-32.4* MCHC-31.3 RDW-18.5* Plt Ct-126*
[**2103-7-10**] 07:17AM BLOOD WBC-6.8 RBC-3.61* Hgb-11.7* Hct-37.3
MCV-103* MCH-32.3* MCHC-31.3 RDW-18.4* Plt Ct-123*
[**2103-7-11**] 05:21AM BLOOD WBC-7.4 RBC-3.33* Hgb-11.2* Hct-34.8*
MCV-105* MCH-33.8* MCHC-32.3 RDW-18.2* Plt Ct-168
[**2103-7-12**] 05:30AM BLOOD WBC-7.6 RBC-3.24* Hgb-10.9* Hct-34.0*
MCV-105* MCH-33.5* MCHC-32.0 RDW-18.3* Plt Ct-201
[**2103-7-6**] 06:15AM BLOOD Neuts-79.8* Lymphs-15.6* Monos-2.4
Eos-1.9 Baso-0.3
[**2103-7-7**] 07:00AM BLOOD Neuts-76.0* Lymphs-17.5* Monos-4.1
Eos-2.1 Baso-0.3
[**2103-7-8**] 06:30AM BLOOD Neuts-72.1* Lymphs-20.8 Monos-4.1 Eos-2.5
Baso-0.4
[**2103-7-10**] 07:17AM BLOOD Neuts-74.5* Lymphs-21.9 Monos-2.6 Eos-0.8
Baso-0.2
[**2103-7-6**] 06:15AM BLOOD Plt Ct-118*
[**2103-7-7**] 07:00AM BLOOD Plt Ct-134*
[**2103-7-8**] 06:30AM BLOOD Plt Ct-125*
[**2103-7-9**] 06:35AM BLOOD Plt Ct-126*
[**2103-7-10**] 07:17AM BLOOD Plt Ct-123*
[**2103-7-11**] 05:21AM BLOOD Plt Ct-168
[**2103-7-12**] 05:30AM BLOOD Plt Ct-201
[**2103-7-8**] 03:33PM BLOOD Glucose-114* UreaN-22* Creat-1.1 Na-142
K-4.4 Cl-113* HCO3-18* AnGap-15
[**2103-7-9**] 06:35AM BLOOD Glucose-105* UreaN-20 Creat-1.0 Na-144
K-4.0 Cl-112* HCO3-19* AnGap-17
[**2103-7-10**] 03:45PM BLOOD Na-140 K-4.3 Cl-109*
[**2103-7-11**] 05:27PM BLOOD Na-140 K-4.2 Cl-108
[**2103-7-12**] 05:30AM BLOOD Glucose-96 UreaN-22* Creat-0.9 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
[**2103-7-7**] 07:00AM BLOOD ALT-15 AST-22 AlkPhos-154* TotBili-1.1
[**2103-7-8**] 06:30AM BLOOD ALT-13 AST-25 AlkPhos-137* TotBili-1.1
[**2103-7-10**] 07:17AM BLOOD ALT-14 AST-23 LD(LDH)-258* AlkPhos-134*
TotBili-1.4
[**2103-7-9**] 06:35AM BLOOD Albumin-2.8* Calcium-8.5 Phos-2.8 Mg-2.0
[**2103-7-10**] 03:45PM BLOOD Mg-1.9
[**2103-7-11**] 05:21AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.6
[**2103-7-12**] 05:30AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.1
[**2103-7-4**] 12:55AM BLOOD Lactate-3.2*
[**2103-7-4**] 10:37AM BLOOD Lactate-1.9
[**2103-7-7**] 08:18PM BLOOD Lactate-1.8
Brief Hospital Course:
.
#Septic Shock: Patient presented with hypotension, as well as
bandemia and hypothermia to 35C. She was admitted to the ICU.
Her blood pressure was refractory to IV fluids and she was
started on vasopressors to maintain a MAP> 60 through a left
femoral line. Her blood pressure medications (isosorbide
mononitrate, metoprolol, lasix ) were held due to hypotension.
She was started on broad spectrum antibiotics that included
Vanc/Cefepime/Flagyl. Her blood culture from admission grew
Acinetobacter Baumannii. Her antibiotics were changed to
meropenem on [**2103-7-5**]. She was weaned of vasopressors by ICU
day three and was transferred out to the medicine floor where
she remained hemodynamically stable with systolic blood
pressures ranging from 90s to 120s.
#Acinetobacter bacteremia: Her blood culture from admission grew
Acinetobacter Baumannii. The infectious disease service was
consulted. The source was likely urinary as urine culture on
admission was dirty (although culture not obtained until after
antibiotics initiated). A skin source was also considered given
multiple skin tears in her lower extremities. She was started on
meropenem on [**2103-7-5**] with plan to complete a fourteen day
course (finishing [**2103-7-18**]). She will need blood cultures drawn
after completion of antibiotics to verify eradication of
infection.
.
#Acute on chronic systolic heart failue: An echocardiogram
showed an ejection fraction of 30-35% with a 2+ mitral
regurgitation, new as compared to a study in [**11/2102**] which
showed an ejection fraction of 45%. She developed a new oxygen
requirement. Exam and chest imaging were consistent with volume
overload (2-3L nasal cannula). This likely occurred due to
aggressive IVF resuscitation in the ICU. She was started on
lasix 10-20IV boluses for goal diuresis of 500cc daily. She has
achieved that goal with a regimen of 20IV lasix twice daily.
This at times has been limited by borderline blood pressures
with systolics in the 90s. At discharge she is satting 95% on
2L nasal cannula breathing comfortably at 16 resps per minute.
She still appears volume overloaded with crackles at bases and
significant lower extremity edema at her upper thighs. Would
recommend further diuresis with lasix 20IV [**Hospital1 **] with goal
negative of 500cc daily. She was given a dose of 20IV this
morning at 11AM. Would check electrolytes twice daily and
replete as has had brief runs (up to 8 beats) of SVT with LBBB
conduction noted on telemetry. Her home metoprolol succinate
(100mg daily) was changed to 6.25mg TID during the
hospitalization, which her blood pressure tolerates well.
Isosorbide has been held during diuresis. She has a foley
catheter for urine monitoring and also has lower extremity
breakdown that could potentially be a nidus for infection.
.
#Lower extremity Skin tears: This is a chronic problem although
per her nephew her legs looked significantly worse of late.
Ultra-sound of the legs were negative for deep venous
thrombosis. Wound care was consulted and recommended: 1.
Pressure Redistribution - Atmos Air 2. Cleanse bilateral groins
and perineum with Aloe Vesta foam cleanser daily. Pat dry 3.
Apply Critic aid clear to bilateral groins daily. Place Kerlix
in between skin fold to separate skin and wick moisture. [**Month (only) 116**]
re-apply skin barrier ointment after each 3rd cleansing. 4.
Apply Crit aid clear antifungal to perineum daily. 5. Reposition
q2 hours. 6. OOB to chair on chair cushion for 2 hr at a time.
7. Waffle to bilateral feet. Float heels. 8. Apply Aloe Vesta
ointment to intact dry skin daily. 9. Continue with wound care
to BLE's traumatic skin tears
for planning. 10. Patient is not safe at home alone, MSW and
Case Management
for planning. Her wounds were improved at discharge.
.
#Coagulopathy: Her PTT/PT were elevated on admission (INR of
1.9) thought to be due to malnutrition or possibly chronic liver
disease. She was given vitamin K 10mg PO for three days and her
INR trended down to 1.4 at discharge.
.
#Gallstones: She was found to have gallstones but no evidence of
acute cholecystitis on abdominal imaging (CT and ultrasound).
.
#Chronic Kidney Disease: Her creatinine on admission ranged from
1.5-1.1 and on discharge it was 0.9. All nephrotoxins were
avoided and her medications were renally dosed.
.
#Diarrhea: She reports loose stools at home and etiology is
unclear especially since CT of the abdomen showed well formed
stools but there was no evidence of inflammation or enteritis. C
diff toxin was negative. There was some concern for overflow
encoparesis and stool impaction. She was put on a bowel regimen
and this stabilized over the hospital stay.
.
#Aneursym: CTA showed her aneursym was stable w/ type 3 endoleak
with unchanged aneurysmal sac diameter and no evidence of any
free fluid suggestive of blood.
.
#CAD: No symptoms of active ischemia. Her isosorbide was held in
the setting of hypotension from sepsis and then active diuresis.
was stable and she was continued on her pravastatin and aspirin.
.
#Code status: per patient and her nephew she would want to be
DNR but ok to intubate.
Medications on Admission:
Furosemide 40mg [**Hospital1 **]
Metoprolol Succinate 100mg daily
ASA 81mg daily
Pravastatin 10mg daily
Sertraline 50mg daily
Omeprazole 20mg daily
Ferrous sulfate 325mg daily
Vit D3 1000 daily
Multivitamin daily
Imiquimod 5% cream
Isorbide mononitrate 30mg daily
Discharge Medications:
1. meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
twelve (12) hours for 6 days: last day to complete 14 day course
will be [**2103-7-18**].
Disp:*12 * Refills:*0*
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily) as needed for apply to leg ulcers.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for Pain/Fever.
11. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO TID (3
times a day).
Disp:*10 Tablet(s)* Refills:*2*
12. Meropenem 500 mg IV Q12H
Day 1 = [**2103-7-5**]
13. Outpatient Lab Work
check Chem-7 twice daily while diuresing with IV lasix
14. lasix 20IV twice daily; hold for SBP<90
15. telemetry
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Primary Diagnosis:
-Septic Shock
-Pulmonary Edema
.
2. Secondary Diagnosis:
-CHF (EF 45%, though likely an overestimate given severe MR)
-CAD (last cath in [**2096**] with complete occlusion of ramus
intermedius, moderate disease elsewhere)
-Decreased vision R eye, now legally blind
-PVD - s/p arthrectomy and B/L superficial femoral artery PTCA
-Severe mitral regurgitation
-Depression
-Hysterectomy
-Endoscopic aortic aneurysm repair [**11-28**]
-Chronic kidney disease (baseline Cr 1.4)
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 **],
It was a pleasure taking care of you at the [**Hospital1 18**] when you were
recently admitted for low blood pressures and found to have
bacteria growing in your blood. You were first stabilized in
the intensive care unit and then you were transferred to the
medicine floor where your blood pressures continued to be
stable. You were treated with antibiotics for you infection. You
will need to contine to take antibiotics while at rehab until
[**7-18**].
.
Over your hospital stay, you required oxygen to maintain your
oxygen saturation at normal levels. The decline in your
pulmonary function was thought to be from a combination of fluid
in your lungs and decreased lung volumes. You were give some
lasix to reduce the fluid in your lungs and that is something
you will have to continue at rehab.
.
We changed the dressings on your leg ulcers daily and they were
improved your hospital stay.
.
Followup Instructions:
You should follow-up with the scheduled appointments below:
Department: VASCULAR SURGERY
When: THURSDAY [**2103-9-6**] at 2:45 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2103-9-20**] at 12:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Name: [**Known lastname 15852**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 15853**]
Admission Date: [**2103-7-3**] Discharge Date: [**2103-7-12**]
Date of Birth: [**2006-8-2**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 196**]
Addendum:
The patient is legally blind. She requires assistance with
feeding. She eats very slowly. She requires assistance with
feeding and should be fed very slowly as she can aspirate if fed
quickly. Diet was Low sodium / Heart healthy Consistency: Soft
dysphagia); Thin liquids please sit patient up and monitor for
aspiration, medications in crushed in applesauce, nectar thick
liquids per nurse [**First Name (Titles) 15854**] [**Last Name (Titles) **] speech and swallow
Brief Hospital Course:
The patient is legally blind. She requires assistance with
feeding. She eats very slowly. She requires assistance with
feeding and should be fed very slowly as she can aspirate if fed
quickly. Diet was Low sodium / Heart healthy Consistency: Soft
(dysphagia); Thin liquids please sit patient up and monitor for
aspiration, medications in crushed in applesauce, nectar thick
liquids per nurse [**First Name (Titles) 15854**] [**Last Name (Titles) **] speech and swallow
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 199**]
Completed by:[**2103-7-12**]
|
[
"682.6",
"038.9",
"403.90",
"443.9",
"E878.2",
"428.0",
"496",
"787.91",
"424.0",
"414.01",
"585.3",
"369.4",
"276.1",
"995.92",
"785.52",
"V49.86",
"311",
"286.9",
"263.9",
"599.0",
"996.1",
"428.23",
"695.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20115, 20331
|
19621, 20092
|
241, 304
|
16874, 16874
|
5767, 9541
|
18005, 19598
|
3996, 4042
|
15003, 16247
|
16357, 16360
|
14714, 14980
|
17050, 17982
|
4082, 4870
|
179, 203
|
332, 2757
|
16436, 16853
|
16379, 16415
|
16889, 17026
|
2779, 3214
|
3230, 3980
|
4895, 5748
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,286
| 105,199
|
33002
|
Discharge summary
|
report
|
Admission Date: [**2172-11-6**] Discharge Date: [**2172-11-16**]
Date of Birth: [**2114-6-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
AVASTIN
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
s/p RUL lobectomy
Major Surgical or Invasive Procedure:
[**2172-11-6**]
1. Right thoracotomy.
2. Right upper lobectomy.
3. Hand sewn closure of right upper lobe bronchial stump.
4. Buttressing of bronchial closure with intercostal muscle
flap.
[**2172-11-8**], [**2172-11-9**], [**2172-11-10**] Bronchoscopy
History of Present Illness:
58yo M with a stage III non-small-cell lung cancer diagnosed
over a year
ago. He was treated with chemoradiation therapy and was
documented to have persistent nodal disease in the mediastinum.
He therefore was treated to a definitive dose of radiation
therapy. However, he had persistent FDG avid disease in the lung
and after lengthy discussion, he was brought to the operating
room today for attempted pulmonary resection. Before the
operation, we met on several occasions and discussed both the
conduct and risks of the operation. He was well aware of the
risks including respiratory failure, pneumonia, inability to
completely resect the tumor, bronchopleural fistula and
death.
Past Medical History:
CAD, MI, HTN, HLD, COPD (FEV1 69% [**2171**]), CVA
PSHx: hip repair, elbow fracture repair
Social History:
Polish speaking. Former 40 year pack history. No etoh, no drugs.
Currently unemployed but former factory worker in Poland.
Family History:
sister with CAD. No family history of cancers
Physical Exam:
BP: 151/76. Heart Rate: 92. Weight: 170.4. Height: 70.75. BMI:
23.9. Temperature: 97.5. Resp. Rate: 18. O2 Saturation%: 100.
Gen: AAOx3, NAD
HEENT: no cervical or supraclavicular LAD, mucous membranes
moist, no icterus
Neuro: CN 2-12 grossly intact
CV: RRR, nml s1/s2
Resp: CTAB
Abd: soft, nt/nd, no masses
Ext: no c/c/e
Pertinent Results:
[**2172-11-6**] 03:26PM BLOOD WBC-12.0*# RBC-2.93* Hgb-9.2* Hct-27.9*
MCV-95 MCH-31.3 MCHC-32.9 RDW-16.3* Plt Ct-308
[**2172-11-8**] 01:42AM BLOOD WBC-11.3*# RBC-3.01* Hgb-9.1* Hct-27.6*
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.9* Plt Ct-284
[**2172-11-14**] 05:40AM BLOOD WBC-9.2 RBC-2.80* Hgb-8.5* Hct-25.2*
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.6 Plt Ct-418
[**2172-11-6**] 03:26PM BLOOD Glucose-179* UreaN-24* Creat-1.2 Na-139
K-5.1 Cl-110* HCO3-21* AnGap-13
[**2172-11-10**] 02:21AM BLOOD Glucose-132* UreaN-16 Creat-1.0 Na-136
K-4.1 Cl-104 HCO3-25 AnGap-11
[**2172-11-15**] 04:47AM BLOOD Glucose-111* UreaN-17 Creat-1.5* Na-140
K-4.0 Cl-100 HCO3-30 AnGap-14
[**2172-11-6**] 03:26PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.2*
[**2172-11-15**] 04:47AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.6
Imaging:
[**2172-11-9**] CT Chest:
IMPRESSION:
1. Peristent postoperative right middle lobe atelectasis. No
evidence of
right middle lobe torsion. The middle lobe bronchus is occluded,
but the
right middle lobe pulmonary artery and draining vein are intact.
The findings
thus most likely reflect mucus impaction.
2. Postoperative changes in the right hemithorax, including
nonhemorrhagic
layering pleural fluid, additional fluid interposed between the
superior
segments of the right lower lobe and the mediastinum, and a
small right apical
pneumothorax. The upper lobe bronchial stump is unremarkable.
Two chest
tubes, one anterior and one posterior, are in expected position.
3. Moderate emphysema.
[**2172-11-10**] CXR
There are two chest tubes seen on the right side with each one
ending near the right lung apex. The right mid lung opacity
representing an
unresolved collapsed right middle lobe is unchanged. There are
no new
opacities which are of concern. Endotracheal tube terminates
approximately
4.7 cm above the carina and is adequately placed. Gastric tube
is seen to
course through the diaphragm into the stomach and is appropriate
in position.
Small right apical pneumothorax is unchanged. Overall, no
interval relevant
changes.
[**2172-11-15**] CXR :
Overall appearance of the chest is stable with minimal residual
subcutaneous emphysema in the right lateral soft tissues. A tiny
amount of residual air within the surgical bed at the right apex
in this patient status post right upper lobectomy. No focal
airspace consolidation is seen to suggest pneumonia. No
pulmonary edema or pleural effusions. Slight nodularity of the
right lateral pleura particularly at the base is likely
postoperative in etiology.
Brief Hospital Course:
The patient was admitted to the thoracic surgery service on
[**2172-11-6**] after he underwent a thoracotomy and RUL lobectomy.
Neuro: Post-operatively, the patient had an epidural with good
effect but with some hypotension and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: The patient was initially hypotensive to the SBPs 80s
immediately post-op and he was placed on neo up to 0.5mcg. He
was monitored in the PACU overnight and was stable to be
transferred to the floor on POD1. On the floor, his BPs have
remained stable off neo but he was placed again on the neo when
he was intubated and sedated in the SICU. Once transferred to
the floor again, he remained off all pressors. Vital signs were
routinely monitored.
Pulmonary: The patient was initially stable from a pulmonary
point of view post-op. His post-op CXR showed RML collapse but
aerated RLL. However, on POD 2 on the floor, the patient began
to desat to mid 80s on room air. A CXR was obtained and showed
RML as well as RLL collapse. He was transferred to the SICU on
[**2172-11-8**] to undergo a bronchoscopy with BAL, which was sent for
studies. For the bronch, he was intubated and sedated. He had a
repeat bronch on [**2172-11-9**] and [**2172-11-10**] AM and suctioned out more
mucous from his RLL and RML. He was stable from a pulmonary
standpoint thereafter and extubated on [**2172-11-10**] after CXR showed
good stable RLL. His CT was placed to waterseal on [**11-10**] and
removed on [**11-11**]. Post-pull CXR was stable. He was transferred to
the floor on [**11-12**] and his pulmonary status remained stable,
although with desat to the mid 80s on ambulation. He has not
been anle to wean off of oxygen but his requirements are
decreasing daily. For that reason he will be sent home with
oxygen at 1-2 liters per minute and can gradually wean off over
time.
GI/GU: Post-operatively, the patient was given IV fluids. His
diet was advanced when appropriate once extubated in the SICU,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on [**11-12**]. Intake
and output were closely monitored. His Cr was elevated to 1.6,
FeNa was 0.7%, showing a likely pre-renal etiology. He was
bolus'd w/ 500cc NS two times on [**11-13**] and [**11-15**].
ID: Post-operatively, the patient was not placed on any
antibiotics. However, upon transfer to the SICU, he was started
on vanc, zosyn, and tobra for empiric coverage of HAP. He was
switched to PO augmentin once tolerating PO and due to a rising
Cr.
Cultures only showed respiratory flora but a 10d course of
antibiotics was planned.
The patient's temperature was closely watched for signs of
infection. He had a temperature of 101.3 on [**11-14**] and fever
workup was sent but have so far been negative.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on [**2172-11-16**] , he was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. His incision was healing well.
Medications on Admission:
ALBUTEROL SULFATE""PRN, AMLODIPINE 10',ATENOLOL 100',
ATORVASTATIN 80', ADVAIR 500-50', LISINOPRIL 40' NITROGLYCERIN
0.4prn, PROCHLORPERAZINE MALEATE 10"'prn nausea, TIOTROPIUM
BROMIDE 18', WARFARIN 5'
Discharge Medications:
1. Home oxygen
O2 1-2 liters continuous Dx COPD
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*7 Disk with Device(s)* Refills:*2*
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-12**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for angina.
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 caps* Refills:*2*
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 MDI* Refills:*2*
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold for SBP < 100, HR < 60.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours): thru 11//[**9-20**].
Disp:*6 Tablet(s)* Refills:*0*
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Stage III A non-small-cell lung cancer.
Post op atelectesis
Acute blood loss anemia
Stage III A non-small-cell lung cancer.
Post op atelectesis
Acute blood loss anemia
Stage III A non-small-cell lung cancer.
Post op atelectesis
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough (it is normal to cough up
blood tinge sputum for a few days) or chest pain
-Incision develops drainage
-Continue to use your incentive spirometer 10 times an hour
while awake
Pain
-Acetaminophen 650 every 6 hours as needed for pain
-Dilaudid 2 mg every 3-4 hours as needed for pain
-No driving while taking narcotics
-Take stool softners with narcotics
Activity
-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
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
-Oxygen via nasal cannula at 1-2 liters per minute. The VNA
will monitor your saturations and help you wean off.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2172-12-1**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes earlier to the Radiology Department on
the [**Location (un) **] in the [**Hospital Ward Name 23**] Clinical Center for a chest Xray.
Completed by:[**2172-11-16**]
|
[
"518.81",
"427.89",
"285.1",
"272.4",
"414.01",
"518.0",
"E878.6",
"162.3",
"997.39",
"496",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.29",
"38.91",
"33.22",
"32.49",
"33.24",
"83.82",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
9359, 9416
|
4468, 7691
|
293, 552
|
9718, 9718
|
1946, 4445
|
10809, 11309
|
1541, 1588
|
7943, 9336
|
9437, 9697
|
7717, 7920
|
9869, 10786
|
1603, 1927
|
236, 255
|
580, 1268
|
9733, 9845
|
1290, 1384
|
1400, 1525
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,746
| 156,849
|
55142
|
Discharge summary
|
report
|
Admission Date: [**2125-8-31**] Discharge Date: [**2125-9-4**]
Date of Birth: [**2075-6-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
L arm numbness
Major Surgical or Invasive Procedure:
[**2125-8-31**] CABG X3 LIMA>LAD, SVG>OM, SVG>PDA
History of Present Illness:
Mr. [**Known lastname 11519**] is a 50 year old man who has a history of coronary
artery disease (PCI to LAD in [**2115**]), hypertension,
hyperlipidemia, and infrequent smoking. He
complains of increasing left arm numbness and heaviness. A
cardiac cath today at [**Hospital6 3105**] revealed
significant coronary artery disease and he therefore was
transferred to [**Hospital1 18**] for evaluation for an urgent bypass.
Past Medical History:
Coronary Artery Disease s/p interior wall MI, s/p 2 LAD stents
[**Hospital1 2025**]
s/p CABG [**2125-8-31**]
Hypertension
Hyperlipidemia
Smoking, has been trying to quit since [**2125-8-17**]
Social History:
Race:caucasian
Contact: [**Name (NI) 553**](sister)Phone #cell([**Telephone/Fax (1) 112492**] home([**Telephone/Fax (1) 112493**]
Occupation:exterminator
Cigarettes: Smoked no [] yes [x] last cigarette current Hx:
Other Tobacco use:
ETOH: < 1 drink/week [x] [**1-23**] drinks/week [] >8 drinks/week []
No llicit drug use
Family History:
Father MI deceased of MI age 75
Mother deceased of [**Name (NI) 5895**] age 73
Physical Exam:
Pulse: 100 Resp: 16 O2 sat:
B/P 134/84
Height: 69 inches Weight: 179 pounds
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:1+ Left:1+
Right radial cath site
Carotid Bruit Right: - Left: -
Pertinent Results:
Echo [**2125-8-31**]
Pre-Bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thicknesses and cavity size are normal.
There is mild global left ventricular hypokinesis (LVEF = 45-50
%). with borderline normal free wall function.
The diameters of aorta at the sinus, ascending and arch levels
are normal. There are simple atheroma in the ascending aorta,
aortic arch, and descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post-Bypass:
The patient is on a epinephrine and phenylephrine infusion s/p
CABG.
Left Ventricular function is preserved with an estimated EF-
50-55%. There are no apparent wall motion abnormalities.
Mitral regurgitation remains trace.
There is no echocariographic evidence of dissection
post-decannulation.
The remainder of the exam is unchanged.
.
[**2125-9-2**] 05:45AM BLOOD WBC-9.0 RBC-2.74* Hgb-9.9* Hct-28.9*
MCV-106* MCH-36.3* MCHC-34.3 RDW-12.7 Plt Ct-101*
[**2125-9-1**] 02:09AM BLOOD WBC-14.9* RBC-3.48* Hgb-12.3* Hct-37.3*
MCV-107* MCH-35.4* MCHC-33.1 RDW-12.4 Plt Ct-112*
[**2125-9-3**] 06:30AM BLOOD Glucose-106* UreaN-8 Creat-0.6 Na-139
K-3.5 Cl-104 HCO3-32 AnGap-7*
[**2125-9-4**] 06:15AM BLOOD UreaN-8 Creat-0.6 Na-138 K-3.9 Cl-103
Brief Hospital Course:
The patient was brought to the Operating Room on [**2125-8-31**] where
the patient underwent CABG X3 LIMA>LAD, SVG>OM, SVG>PDA.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He required neo
for low BP only and weand and extubated wihtout difficulty. POD
1 found him alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable,
weaned from vasopressor support. Beta blocker was initiated and
the patient was gently diuresed toward the preoperative weight.
The patient was transferred to the telemetry floor for further
recovery on POD#1. While on the floor he continued to have
episodes of mild hypotension and lasix and lopressor were
adjusted. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with VNA in good
condition with appropriate follow up instructions.
Medications on Admission:
MVI
Folic Acid 1mg daily
ASA 81mg daily
Lisinopril 10mg daily
HCTZ 12.5mg daily
Toprol 50mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Oxycodone-Acetaminophen (5mg-325mg) [**12-18**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg [**12-18**] tablet(s)
by mouth every four (4) hours Disp #*60 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p interior wall MI, s/p 2 LAD stents
[**Hospital1 2025**]
s/p CABG [**2125-8-31**]
Hypertension
Hyperlipidemia
Smoking, has been trying to quit since [**2125-8-17**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
SVH site small amount serosang drainage
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2125-9-13**]
10:15
Surgeon Dr. [**Last Name (STitle) **], [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2125-10-4**] 2:30
Cardiologist Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] [**Telephone/Fax (1) 83705**], [**2125-10-2**] at
2:30p
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 70170**] [**Name (STitle) 6352**] [**Telephone/Fax (1) 70172**] in [**3-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2125-9-4**]
|
[
"305.1",
"V45.82",
"401.9",
"272.4",
"412",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5706, 5781
|
3697, 4920
|
293, 345
|
6017, 6225
|
2131, 3674
|
7013, 7836
|
1370, 1451
|
5069, 5683
|
5802, 5996
|
4946, 5046
|
6249, 6990
|
1466, 2112
|
238, 255
|
373, 798
|
820, 1014
|
1030, 1354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,832
| 114,878
|
18502+18503
|
Discharge summary
|
report+report
|
Admission Date: [**2167-10-13**] Discharge Date: [**2167-11-21**]
Date of Birth: [**2097-2-20**] Sex: F
Service: SURGERY/BLUE
REASON FOR ADMISSION: The patient is a 70-year-old female,
with COPD, 100-pack year tobacco use and currently still
smoking 1-pack per day, coronary artery disease status post
MI, and PTCA with stent in [**2162**], hypercholesterolemia,
hypothyroidism, who fell down two steps on the [**10-8**]
suffering multiple ribs fractures on the left. The patient
presented to an outside hospital, [**Hospital 1562**] Hospital,
Emergency Department and became hypotensive, and a needle
thoracostomy was performed for decompression followed by a
tube thoracostomy. The patient was intubated and taken to
the ICU there. She remained intubated over the weekend and
continued to have worsening subcu emphysema, and persistent
air leaks from the chest tube. She was extubated the day
prior to transfer and then sent to the thoracic surgery
service at [**Hospital1 18**] for further work-up and treatment.
PAST MEDICAL HISTORY: As above.
MEDS AT HOME:
1. Atenolol 50 qd.
2. Losartan 50 [**Hospital1 **].
3. Lasix 20 qd.
4. Aspirin 325 qd.
5. Zantac 150 [**Hospital1 **].
6. Prilosec 20 qd.
7. Norvasc 10 qd.
8. Zocor 10 qd.
9. Synthroid 0.1 qd.
10.Atarax prn.
11.Motrin prn.
12.Colace 100 [**Hospital1 **].
13.Atrovent MDI prn.
14.Albuterol MDI prn.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Smoking as above and occasional alcohol.
PHYSICAL EXAM ON ADMISSION: Vitals - 97.4, 85, 162/94, 18,
94% on 2 liters. General - The patient was an elderly,
pleasant female in no acute distress. Pupils equally round
and reactive to light. There was extensive subcu emphysema
of the left eye and face, as well as the neck and chest. The
trachea was midline. Chest exam was limited by crepitus.
There was no hyperresonance to percussion. There was
ecchymosis of the left chest wall, and a 24 French chest
tube. The site was without erythema. Heart was regular rate
and rhythm. Abdomen was soft, nontender. There was slight
increased firmness to the left midabdominal and subcostal
area. No discrete masses. No organomegaly. Back showed
ecchymosis to the left flank. Extremities - a right femoral
central line was in place. There was no clubbing, cyanosis
or edema, and there were palpable femoral, popliteal,
dorsalis pedis and posterior tibial pulses bilaterally.
Rectal showed no mass and was guaiac negative.
PERTINENT LABS: The patient's white count was 14.5, crit
39.1, platelets 305, sodium 131, potassium 3.9, chloride 94,
CO2 29, BUN 11, creatinine 0.5, glucose 114. [**Name (NI) 2591**] - PT
12.9, PTT 22.9, INR 1.1. ABG was 7.47, 41, 68, 31 and 5, 93%
on 2 liters. Chest x-ray showed extensive subcu emphysema,
chest tube in place, and no residual pneumothorax, rib
fractures.
IMPRESSION: The patient is a 70-year-old female with severe,
underlying lung disease, status post left chest blunt trauma
with rib fractures and pulmonary parenchymal injury leading
to pneumothorax and persistent air leak.
HOSPITAL COURSE: The patient was admitted and had a chest
x-ray which showed a small pneumomediastinum, chest tube, and
posterior rib fractures 6 through 9 which were displaced, and
extensive subcu air.
SUMMARY OF PATIENT'S PROCEDURES THIS ADMISSION: On [**10-14**], the patient went to the OR for a left video-assisted
thoracoscopic surgery with debridement of the broken rib
spicules, as well as wedge resection of the damaged lung
parenchyma. On [**10-16**], the patient was taken to the OR
for an acute abdomen and was found to have a gangrenous right
colon. She underwent a right colectomy, end-ileostomy, and
transverse colon mucous fistula. The small bowel was found
to have patchy areas of ischemia. On [**10-19**], the patient was
taken back to the OR for a second-look laparotomy, and
underwent small bowel resection and end-ileostomy. On [**10-23**],
the patient was taken back for a third-look laparotomy and
was found to have a bowel perforation x 2. She had further
bowel resection with end-jejunostomy, resulting in a total
bowel length of approximately 3'. On [**11-9**], the patient
underwent percutaneous tracheostomy, and on [**11-17**], the
patient underwent left ultrasound-guided thoracentesis.
Additionally, the patient had multiple monitoring lines
placed this admission.
HOSPITAL COURSE BY SYSTEM - 1) CENTRAL NERVOUS SYSTEM: The
patient had no mental status changes during this admission.
Earlier in her acute hospital course, she required a morphine
drip for pain control and intermittent ativan for sedation,
as well as a propofol drip early-on. Most recently, her pain
has been managed with dilaudid prn, as well as a dilaudid
PCA.
2) CARDIOVASCULAR: The patient had a septic physiology
through her initial three laparotomies requiring Swan-Ganz
catheter placement and monitoring with pressor management
including Levophed and vasopressin. The patient underwent an
echo after the initial laparotomy to look for an embolic
source; however, no clot was identified on the limited study,
and her ejection fraction was 55%. On serial cardiac
enzymes, the patient was found not to have any evidence of
myocardial ischemia. At this time, the patient is
hemodynamically stable and is receiving metoprolol for beta
blockade at a dose of 25 mg [**Hospital1 **]. She is in sinus rhythm, and
her blood pressure is 143/59.
3) RESPIRATORY: Due to the patient's persistent air leak,
she was taken by the thoracic service on the 10 for a VATS
procedure. The broken ends of the ribs were debrided which
had punctured and damaged the lung parenchyma, resulting in a
persistent air leak. This section was lung was resected. On
postop day #1 from that, the patient was stable and was
transferred to the floor, and her chest tube was DC'd.
However, the patient developed respiratory distress and was
reintubated on the [**10-15**], with an ABG showing a
PCO2 of greater than 100, and a pH of 7.0. A new left chest
tube was placed with a moderate egress of air. Additionally,
a left subclavian Cordis was placed, a Swan-Ganz catheter,
and a right femoral A-line was placed. Resulting chest x-ray
showed no pneumothorax.
The patient then had an acute abdomen and was transferred to
the general surgery service. Her chest tube was kept in
place to suction and was finally put to water-seal and then
DC'd on the [**10-29**].
The patient had multiple attempts at vent weaning, however
failed spontaneous breathing trials, and this was felt to be
multifactorial due to her underlying lung disease, as well as
malnutrition, volume loss in her left thorax, and a residual
pleural effusion on the left, as well as a pneumonia. The
patient underwent percutaneous tracheostomy on the [**11-9**] to facilitate pulmonary toilet, as well as weaning,
and an ultrasound-guided left thoracentesis for 250 cc on the
[**11-17**]. This showed no organisms on Gram stains, and
no neutrophils, and grew nothing on culture. On [**11-5**], the
patient had a sputum positive for Klebsiella pneumoniae for
which she was treated with a course of aztreonam and
gentamycin double-antibiotic coverage. Despite this, the
patient has been persistently unable to tolerate weaning
trials and is currently vent dependent on pressure support of
10 and PEEP of 5, with a RSBI of 55, and a PCO2 of 55.
4) ABDOMEN: After the patient's reintubation on the 11, the
patient was found to be persistently hypotensive and acidotic
requiring pressors, and a new abdominal finding of distention
and tenderness was noted. A general surgery consult was
obtained on the [**10-16**]. At this point, the patient
had a white count of 19.7 and a lactate of 1.6, and she was
on a Neo drip for blood pressure support. The patient was
placed on broad-spectrum antibiotic coverage of vancomycin,
Levofloxacin and Flagyl.
A rigid sigmoidoscopy was done at the bedside which showed
viable sigmoid mucosa. A KUB showed a dilated colon. The
patient was taken later that day on the [**10-16**] to
the OR for an exploratory laparotomy where a gangrenous right
colon was resected. There were several patchy areas of small
bowel ischemia which were left alone initially, and the
patient was given an end-ileostomy, a transverse colon mucous
fistula, and was sent back to the ICU for further
resuscitation with a planned second-look laparotomy. At this
time, the patient was on Levophed for blood pressure support
and was continued on broad-spectrum antibiotics.
On the [**10-19**], the patient was taken to the OR for a
second-look where frankly necrotic small bowel was resected,
and the end-ileostomy was refashioned. The transverse mucous
fistula was left in place. At this time, the patient was
also evaluated for sources of possible embolic phenomenon
with an echo which did not show any mural thrombus. A
vascular consult was also obtained, and the patient's
ischemic bowel was felt likely due to a low-flow state.
On the [**10-20**], the patient was started on TPN, and
then on the 18 the patient had a desaturation episode. A CTA
was negative for a PE and did show a left upper lobe
infiltrate. She was requiring more fluid, had a persistent
acidosis, and was on increasing Levophed and pressor
requirements. Fluconazole was added to the vanc, levo and
Flagyl. The levo was then DC'd and imipenem was started.
The patient's white count was now 31.7, and on the [**10-23**] the patient was taken to the OR again and found to
have two small bowel perforations which were resected, and
the patient was given an end-jejunostomy with a resultant
approximate 3' of small bowel remaining. The patient was
persistently hypotensive and vasopressin was added to her
pressor management.
On the [**10-29**], due to refractory leukocytosis, an ID
consult was obtained, and recommendation was made to increase
her fluconazole dose. Tube feeds were also instituted at a
trophic rate of 10 cc/h of half strength alimental tube
feeds.
Following the third laparotomy, the patient gradually
stabilized over the remainder of her hospital course, and her
tube feeds were gradually advanced. Her ostomies remained
viable, and her abdominal exam improved. The lower portion
of her lower wound separated and has been managed by [**Hospital1 **]
wet-to-dry packings. Most recently, it has required some
debridement if some fibrinous exudate at the base of the
wound.
Today, the patient's abdomen is soft. Her ostomies, that is
her jejunostomy and mucous fistula, are pink and viable. Her
lower wound separation is granulating laterally with a
fibrinous exudate at the base with visible fascial sutures at
the base of the wound. This will be managed with [**Hospital1 **]
wet-to-dry dressing changes.
5) GU AND RENAL: The patient's renal function remained
stable throughout all of her septic complications. She had a
Foley in place throughout this hospitalization and maintained
good urine output. Following her final laparotomy, the
patient did require diuresis to facilitate weaning of her
ventilator. However, this has not helped with the vent
weaning. The patient is currently on lasix 40 per NG tube
[**Hospital1 **].
6) INFECTIOUS DISEASE: The patient has had multiple
infectious complications during this complicated admission.
Her swab from the laparotomy on the 15 grew out yeast and
Klebsiella. Additionally, she had Klebsiella grown out of
her sputum on the 13, and yeast of the sputum on the 16, as
well as MRSA. On the 18, an additional sputum culture grew
out Klebsiella, and her urine from the 18 grew out yeast.
Wound culture from the 19 and 23 grew out yeast. These were
all sensitive to fluconazole. Currently, the patient is on
aztreonam day 11 and gentamicin day 12 of a 14-day course for
a Pseudomonas and Klebsiella culture that was grown out from
her sputum on the [**11-5**]. Additionally, she is on a
fluconazole course also to be completed for a 14-day course.
The patient has remained afebrile over the last week, and
currently her refractory leukocytosis is at 17.1.
7) HEMATOLOGY: The patient has had rare transfusion
requirements after her laparotomies. Additionally, after her
initial laparotomy she required a platelet transfusion for a
thrombocytopenia, and her heparin was also held at that
point, and a HIT antibody was sent which ultimately came back
negative, and she was restarted on heparin for DVT
prophylaxis. Currently, her crit is 31.2 and her platelets
249. Her INR is 1.1, and PTT is 27.2.
8) FEN: The patient has become TPN dependent essentially.
She is also receiving tube feeds at a rate of 60 an hour
using Impact with fiber 3/4 strength, and this is felt not to
be adequately absorbed with her short-gut syndrome. So, she
is also on essentially goal TPN calories. She also has
hyponatremia of 129. Her K is 4.6, chloride 94, mag 1.8,
phos 2.7, calcium 8.4. The hyponatremia is being treated
with decreasing her free-water intake.
9) ENDOCRINE: The patient has been managed with a regular
Insulin sliding scale.
10) PROPHYLAXIS: The patient has received GI prophylaxis
using a proton pump inhibitor. Currently, she is on
lansoprazole 30 per NG tube qd. Additionally, she is
receiving heparin in her TPN, and has Pneumoboots in place
for DVT prophylaxis.
TUBES, LINES AND DRAINS: Currently, the patient has a Foley,
a transpyloric feeding tube, a tracheostomy tube, a PICC
line, and A-line.
DISCHARGE DIAGNOSES:
1. Multiple left rib fractures.
2. Left pneumothorax.
3. Status post left video-assisted thoracic surgery (VATS)
with debridement of rib fragments and wide-resection of
injured lung segment.
4. Infarcted small bowel and right colon.
5. Status post laparotomy with right colectomy,
end-ileostomy, and transverse colon mucous fistula.
6. Second-look laparotomy with small bowel resection and redo
end-ileostomy.
7. Third-look laparotomy for small bowel perforation x 2,
status post further small bowel resection, end-jejunostomy.
8. Short-gut syndrome with total parenteral nutrition
dependence.
9. Klebsiella and Pseudomonas pneumoniae.
10.Peritoneal fluid yeast positive culture.
11.Ventilator dependence, status post tracheostomy.
12.Coronary artery disease, status post myocardial infarction
with percutaneous transluminal coronary angioplasty and stent
in [**2162**].
13.Chronic obstructive pulmonary disease.
14.Hypercholesterolemia.
15.Hypothyroidism.
16.Hyponatremia.
17.Leukocytosis.
18.Midline laparotomy wound infection, status post wet-to-dry
dressing changes [**Hospital1 **].
DISCHARGE MEDICATIONS:
1. Tincture of opium per NG tube qid.
2. Sodium chloride 1 tablet tid.
3. Lansoprazole 30 per NG tube qd.
4. Dilaudid prn.
5. Lasix 40 per NG tube [**Hospital1 **].
6. Levothyroxine 100 per NG tube qd.
7. Metoprolol 25 per NG tube [**Hospital1 **].
8. Fluconazole 400 per NG tube qd.
9. Albuterol and Atrovent nebs per tracheostomy prn.
10.Gentamicin 400 mg IV qd, day 12 of 14.
11.Aztreonam 1 gm IV q 8, day 11 of 14.
12.Regular Insulin sliding scale.
DISCHARGE PLAN: Discharge to [**Hospital3 **] pending bed
availability, and further addendums will be dictated in a
separate report.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (STitle) 50865**]
MEDQUIST36
D: [**2167-11-20**] 12:14
T: [**2167-11-20**] 12:27
JOB#: [**Job Number 50866**]
Admission Date: [**2167-10-13**] Discharge Date: [**2167-11-25**]
Date of Birth: [**2097-2-20**] Sex: F
Service:
ADDENDUM: The patient was to be discharged on [**11-25**] to
[**Hospital3 **].
DISCHARGE DIAGNOSES: As per previous dictation.
HOSPITAL COURSE (CONTINUED): The patient was kept in the
Intensive Care Unit pending bed availability at the
rehabilitation facility.
Events on [**11-20**] included the discontinuation of the
patient's antibiotics. On the evening of [**11-20**], the
patient had an episode of respiratory distress following a
period of being sat up in a chair after he had been put back
in bed. He was treated with suctioning and bagging briefly.
However, the patient was attempting to pull out some of her
tubes and drains. A chemistry panel was checked which showed
a hyponatremia. Her sodium which had been 131 earlier that
day was now 121. The patient was started on 3% hypertonic
saline at 10 cc per hour with close followup of her sodium.
The sodium was repleted back to 131 for a period of five to
six hours. Following this, the patient's mental status
appeared to clear.
The patient had no other acute events throughout the
remainder of her hospital stay. She remained afebrile. Her
white blood cell count trended down.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable. Her temperature maximum for the last 24 hours
was 99.2 degrees Fahrenheit, her heart rate was 94 (in
sinus), her blood pressure was 116/50, and her respiratory
rate was 14, and her oxygen saturation was 97%. Her current
ventilator settings were continuous positive airway pressure
with a pressure support of 15 and positive end-expiratory
pressure of 5 on 40% FIO2. She is receiving total parenteral
nutrition at a rate of 47 cc per hour. This is in 1150 cc
with 60 grams for dL of amino acids 170 dextrose and 23 of
lipids. Electrolyte additives include 250 mEq of sodium
chloride, 10 of sodium phosphate, 30 of potassium chloride,
10 of potassium phosphate, 10 magnesium sulfate, 10 calcium
gluconate, 6000 units of heparin, insulin 10 units, 10 mg of
zinc, 1 mg of folate. She receives vitamin K additive every
Monday, multivitamins once per day, and trace elements once
per day. The patient also getting Impact with fiber at a
rate of 60 per hour full strength. Her goal on that formula
would be 65 cc per hour which she can be advanced to. The
goal calories for this patient, however, due to her short
gut syndrome, the patient likely not receiving much calories,
so supplemental total parenteral nutrition is warranted.
PERTINENT LABORATORY VALUES ON DISCHARGE: The patient's
laboratories on the day of discharge revealed her white blood
cell count was 11.2, her hematocrit was 29.8, and her
platelets were 369. Her sodium was 139, potassium was 4.1,
chloride was 105, bicarbonate was 30, blood urea nitrogen was
31, creatinine was 0.8, and blood glucose was 123.
PHYSICAL EXAMINATION ON DISCHARGE: On physical examination,
the patient was alert and following commands. Heart was
regular in rate and rhythm. The lungs were clear to
auscultation bilaterally. The abdomen was soft, nontender,
and nondistended. Bowel sounds were present. Her end
jejunostomy was viable and functioning, and her transverse
mucous fistula was also viable. Her lower midline wound
separation was granulating and had some exudate at the base.
This has been treated with three times per day wet-to-dry
dressing changes using 4 X 4 soaked in quarter strength
Dakin's solution. It has been showing good progression of
granulation tissue.
MEDICATIONS ON DISCHARGE:
1. Impact with fiber tube feeds 60 cc per hour; add 15
drops of tincture of opium with each 2 liter of tube feed.
2. Methadone 5 mg twice per day.
3. Sodium chloride two tablets per nasogastric tube three
times per day.
4. Metoprolol 25 mg per nasogastric tube twice per day.
5. Haldol 1 mg to 5 mg intramuscularly q.4h. as needed.
6. Dakin's quarter strength for wound changes three times
per day.
7. Lansoprazole 30 mg per nasogastric tube once per day.
8. Furosemide 40 mg per nasogastric tube twice per day.
9. Levothyroxine 100 mcg per nasogastric tube once per day.
10. Albuterol and Atrovent breathing treatments 8 to 12
puffs inhaled through the tracheostomy tube q.4h. as needed.
11. Clobetasol 0.5% cream twice per day as needed.
12. Sarna lotion as needed (for rash).
13. Benadryl 25 mg intravenously q.6h. as needed.
14. Regular insulin sliding-scale; regular insulin use 2
units subcutaneously for 121 to 160; for 161 to 200 use 6
units subcutaneously; for 201 to 240 use 8 units
subcutaneously; for 241 to 280 use 8 units subcutaneously;
for 281 to 320 use 10 units subcutaneously; 321 to 360 use 12
units subcutaneously; for 361 to 400 use 14 units
subcutaneously; for greater than 400 use 16 units
subcutaneously. The patient should receive fingerstick blood
sugar check q.6h.
15. Miconazole 2% cream twice per day as needed.
16. Ativan 0.5 mg to 2 mg q.4h. as needed.
17. Potassium as needed.
18. Magnesium as needed.
19. Calcium as needed.
DISCHARGE DISPOSITION: The patient was to be sent to
[**Hospital3 **] today ([**2167-11-25**]).
DISCHARGE INSTRUCTIONS/FOLLOWUP: Followup can be arranged by
calling Dr. [**First Name (STitle) **] [**Name (STitle) **] clinic through the [**Hospital1 346**] operator and should arrange followup
approximately one to two weeks following rehabilitation
discharge.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Name8 (MD) 50867**]
MEDQUIST36
D: [**2167-11-25**] 09:43
T: [**2167-11-25**] 10:04
JOB#: [**Job Number 50868**]
|
[
"557.0",
"518.5",
"860.0",
"861.22",
"807.09",
"569.83",
"567.2",
"482.0",
"518.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.81",
"33.43",
"46.23",
"45.79",
"34.21",
"04.81",
"45.62",
"31.1",
"32.29",
"54.11",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
20533, 20607
|
15627, 16688
|
14556, 15010
|
19021, 20508
|
3081, 13423
|
20641, 21111
|
16703, 18017
|
18372, 18994
|
1503, 2458
|
2475, 3063
|
15027, 15605
|
1066, 1415
|
1432, 1488
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,486
| 183,308
|
22141
|
Discharge summary
|
report
|
Admission Date: [**2128-7-12**] Discharge Date: [**2128-7-24**]
Service: CSU
HISTORY OF PRESENT ILLNESS: This is an 82-year-old male who
was transferred in from [**Hospital3 35813**] Center in [**Location (un) **],
[**Doctor Last Name 792**]after experiencing chest pain while coming to
the hospital for preadmission testing for his carotid
endarterectomy surgery.
The patient had similar pain intermittently for the last few
weeks. His pain was exacerbated by exertion and relieved
with rest. He complained of midsternal and retrosternal
heaviness in [**Doctor Last Name **]. He was hemodynamically stable
with a systolic blood pressure of approximately 190. His
chest pressure lasted 5 to 10 minutes. Electrocardiogram
showed ST depressions in his anterior and lateral leads.
The patient state he had experienced similar pain prior to
going to that hospital that day. It was also accompanied -
when he was doing yard work - with shortness of breath and
increased lower extremity edema over a period of
approximately three months. He said the chest pain has been
increasing in frequency for three months also.
The patient was referred in after he was medically stabilized
and taken to the Catheterization Laboratory. Catheterization
results were as follows. Ejection fraction was 46 percent,
with a distal left main stenosis, an ostial circumflex lesion
of 95 percent, and a proximal right coronary artery lesion of
70 percent. The patient was referred to the [**Hospital1 346**] for a coronary artery bypass
grafting. Upon arrival to the hospital, the patient was pain
free.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diet controlled non-insulin-dependent diabetes mellitus.
3. Glaucoma.
4. Status post appendectomy.
5. Status post hernia repair.
6. Status post cataract surgery in [**2126**].
7. Right carotid disease.
ALLERGIES: He has no known drug allergies.
MEDICATIONS AT HOME:
1. Plavix 75 mg by mouth once per day.
2. Avandia 4 mg by mouth once per day.
3. Lasix 20 mg by mouth once per day.
SOCIAL HISTORY: He had a positive tobacco history, but he
quit 40 years ago. No alcohol use at this time.
PHYSICAL EXAMINATION ON ADMISSION: His examination was
unremarkable. He had no jaundice. He appeared to be well
hydrated. He had no bruits. He had no murmur, rub or
gallop. There were normal heart sounds. The abdomen was
soft, nontender, and nondistended. He was oriented
appropriately.
REVIEW OF SYSTEMS: Negative for chronic obstructive
pulmonary disease, gastrointestinal bleed, transient ischemic
attack, syncope, or cerebrovascular accident. At this time,
he was preoperative for carotid surgery.
LABORATORY DATA ON ADMISSION: Preoperative laboratories
revealed sodium was 143, potassium was 3.2, chloride was 113,
bicarbonate was 21, blood urea nitrogen was 20, creatinine
was 0.8, and blood glucose was 131. His creatine kinase was
31. Calcium was 7.9. His magnesium was 1.9. White blood
cell count was 6.7, hematocrit was 32.8, and his platelet
count was 191,000. Prothrombin time was 13.2, partial
thromboplastin time was 129, and INR was 1.1. His urinalysis
was negative.
RADIOLOGY: His chest x-ray on [**7-12**] showed a question of
a right lower lobe nodule with a known history of asbestos
exposure.
A computed tomography of the chest for the right lower lobe
nodule on [**7-12**] showed bilateral extensive calcified
pleural plaque consistent with a prior history of asbestos
exposure. There was a large right lower lobe pleural nodule
and a second smaller node which was in the right lower lobe.
It also showed extensive coronary calcifications. Please
refer to the final CT report dated [**7-12**].
SUMMARY OF HOSPITAL COURSE: On [**7-13**], the patient
underwent coronary artery bypass grafting times three with a
left internal mammary artery to the left anterior descending,
a vein graft to the obtuse marginal, and a vein graft to the
right coronary artery by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
The patient was transferred to the Cardiothoracic Intensive
Care Unit on an amiodarone drip at 1 mg per minute, an
insulin drip at 3 units per hour, a titrated propofol drip,
and a phenylephrine drip at 0.3 mg/kilogram per minute.
On postoperative day one, the patient was in a sinus rhythm
with a heart rate of 82 and a cardiac index of 2.9. His
blood pressure was 130/50. His laboratories were as follows.
Sodium was 138, potassium was 4.7, chloride was 107,
bicarbonate was 28, blood urea nitrogen was 10, creatinine
was 0.7, and blood glucose was 125. His heart was regular in
rate and rhythm. He had decreased breath sounds bilaterally.
His abdominal examination was benign. His sternum was
stable. His white blood cell count was 9.3. His platelet
count was 156,000. He was on an amiodarone drip at 0.5 mg
per minute. The patient was extubated without incident later
in the afternoon on the day of his operation.
A Thoracic Surgery consultation had also been obtained on
[**7-13**] for evaluation of the incidental finding of a
pulmonary nodules on his computed tomography scan
preoperatively.
Early in the morning on [**7-14**], on postoperative day one,
the patient was alert and oriented, but he was a little more
lethargic in the evening prior. His grasping strength was
strong and equal. He was in a normal sinus rhythm without
ectopy on the amiodarone drip at 0.5 mg per minute. He was
on and off nitroglycerin to keep his systolic blood pressure
in the 120 to 140 range. He had a cardiac index of greater
than 2.8. His right femoral arterial sheath was removed in
the early morning hours.
The patient was transferred to the floor late in the evening
on [**7-14**]. Pacing wires were in place. He was a little
bit forgetful but was alert and oriented times three. He was
encouraged to cough and deep breathe. He was also seen by
Thoracic Surgery again.
On [**7-15**], the patient had his vital signs taken early in
the morning. He was on incentive spirometry. He tried to
climb out of bed. He was disoriented. He was reoriented.
His oxygen saturations and vital signs were the same as has
been previously taken. He complained of some incisional pain
and was given some Percocet, and the bed alarm was put back
on for safety. The patient was checked frequently. He did
not attempt to get out of bed the rest of the night.
At 4:30 a.m., he had vital signs checked and had done
incentive spirometry at about 5:00 a.m. The incisional pain
was better at that time. At about 5:20 a.m., he was noted to
be pacing on telemetry which he had not done prior during the
night despite his AV wires. His pacer box had been set at
60. It was noted in telemetry that he went into ventricular
tachycardia and the VF on telemetry. The patient turn blue
in the room. Pads were on, and automatic external
defibrillator was indicated. The patient was shocked for VF
with 200 joules delivered, and the patient went into atrial
fibrillation rhythm with random pacing at 75. The code team
was alerted.
The patient was intubated and returned to the Cardiothoracic
Surgery Recovery Unit immediately at 6:00 a.m. A new
internal jugular triple lumen was inserted on the Unit. The
patient had been re-intubated by Anesthesia. A chest x-ray
showed the line was at the brachiocephalic and superior vena
cava junction with no pneumothorax. The patient remained in
the Cardiothoracic Intensive Care Unit. He was seen by the
Electrophysiology Service who thought he had an acute
anterolateral ST elevation myocardial infarction and were
worried about the left internal mammary artery to left
anterior descending occlusion, noted his atrial fibrillation
with a rapid ventricular response, and he was immediately
taken to the Cardiac Catheterization Laboratory to rule out
any problems in his grafts.
In the Catheterization Laboratory, his grafts were all
patent. He had no more ectopy since the Catheterization
Laboratory. He was continued on an amiodarone drip at 1 mg
per minute. Physical Therapy was re-consulted. They were
willing to evaluate him again when he got out to the floor.
On postoperative day three, he was extubated on the Unit. He
was in a sinus rhythm at 60 with a good urine output. He was
saturating 97 percent on 4 liters nasal cannula. His
hematocrit was 24.4. He had a temperature maximum of 99.3.
His potassium was 4, his blood urea nitrogen was 13, and his
creatinine was 0.9. His heart was regular in rate and
rhythm. His lungs were clear. His abdominal examination was
benign. His extremities had 1 plus edema. The plan was to
continue him on the amiodarone drip. On [**7-16**], the
patient was also transfused with 1 unit of packed red blood
cells for a hematocrit of 20 percent. He had occasional
premature ventricular contractions and ectopy. He was
reevaluated by Physical Therapy for his unsteady gait and a
little bit of lethargy.
He was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the stroke attending
neurologist on [**7-16**] for his facial droop and to rule out
a stroke, and her recommendations were noted.
The patient was unable to get a magnetic resonance imaging at
that time, as the patient had staples on his chest and pacing
wires in place. Therefore, the patient was prepared for a
computed tomography scan. The computed tomography scan of
his head was negative for cerebrovascular accident or bleed.
His neurologic examination was approximately at his baseline,
per Dr. [**Last Name (STitle) **], he was hemodynamically stable and in a normal
sinus rhythm.
On [**7-17**], on postoperative day four, his potassium was
4.1, his blood urea nitrogen was 13, and his creatinine was
0.3. His hematocrit came up to 24.7. He continued with
Lopressor. His nitroglycerin was being weaned. He received
magnesium repletion. He was followed again by
Electrophysiology who recommended maximizing his beta
blockade. They also recommended that his amiodarone be
discontinued and would consider an Electrophysiology study on
the week following discharge.
On postoperative day five, the patient was in a normal sinus
rhythm. His white blood cell count was 7.3. His hematocrit
was 31.9. His platelet count was 200,000. His examination
was unremarkable. He continued to improve. His blood
pressure was 110/61. He was in a sinus rhythm at 72. There
was no ectopy on his amiodarone.
On postoperative day six, he had no events overnight. His
laboratories were stable. His hematocrit was 33. His
sternum was stable. He had good breath sounds bilaterally,
and his heart was regular in rate and rhythm. His blood
pressure was 120/41. He did have some complications of
lightheadedness and nausea which started on [**7-19**] and a
decreased appetite. He was given doses of Zofran with some
affect, and his nausea improved.
On [**7-18**], the patient was transferred to the floor. He
was encouraged to use the incentive spirometry frequently and
to cough and deep breathe. He had good bowel sounds but a
very poor appetite. He had a productive cough. He was in a
sinus rhythm. He had no ectopy on the by mouth amiodarone.
An echocardiogram. He was continued on oral amiodarone as
well as beta blockade with metoprolol at 12.5 mg twice per
day.
On postoperative day six, he had no ectopy. His heart was
regular in rate and rhythm. There were no murmurs. He had
bilateral rhonchi in both upper zones of his lungs. His
lungs were clear at the bases. He had hypoactive bowel
sounds. His sternum was stable. All incisions were clean,
dry, and intact; including the saphenectomy sites on the
right leg. His blood pressure was 180/78 in the morning
prior to his beta blocker dose. He was saturating 95 percent
on 3 liters. His blood sugar was 158; for which the patient
did receive some sliding scale insulin. His hematocrit
stabilized in the middle 30s with a white blood cell count of
9.1. His chest x-ray from [**7-20**] showed a mild-to-
moderate left pleural density on the left without any lung
compromise. It also showed the bilateral plaque that were
consistent with asbestosis as on previous scan. He had no
pneumothorax, infiltrates, or significant congestive heart
failure. His echocardiogram from [**7-20**] showed moderate
left atrial enlargement and moderate right atrial enlargement
with an ejection fraction of greater than 55 percent. No
aortic insufficiency, and 1 plus mitral regurgitation,
moderate mitral anular calcification, and trivial tricuspid
regurgitation. He continued to have some nausea with no
appetite. He was encouraged though. He had not vomited in
24 hours. He was also instructed to elevate his legs for his
peripheral pedal edema and was covered with sliding scale
insulin. He was followed by the neurology consultation team.
He was seen again by Dr. [**Last Name (STitle) **]. He also continued to have
unsteadiness and was requiring two person support with
Physical Therapy and nursing to ambulate for his unsteady
gait. Electrophysiology recommended discontinuing his
amiodarone, but Dr. [**Last Name (STitle) **] requested that it be continued for
one month and decreased to just 400 mg by mouth once per day.
On postoperative days eight and nine, the patient remained in
a sinus rhythm with no events overnight. His examination was
unremarkable. His amiodarone was decreased to 400 mg by
mouth once per day times one month. A sputum culture was
sent for his productive cough, and he was encouraged to
continue coughing and deep breathing and using the incentive
spirometry as frequently as possible. Case Management was
consulted and arranged for potential discharge back to [**Hospital3 57833**] Center.
On postoperative day nine, the patient noted improvement in
his nausea. He did have a bowel movement. His incisions
were clean, dry, and intact. His cardiovascular examination
was otherwise benign. He continued to have some ataxia but
was improving. His Lasix was discontinued as he was below
his preoperative weight. He did receive a single dose for an
increase of 1 kilogram from the prior day. Discharge
planning was begun. He remained afebrile and in stable
condition.
On postoperative day ten, he was saturating 94 percent on
room air with a good blood pressure of 130/60. He was in a
sinus rhythm at 66. His beta blocker remained in place at
12.5 mg twice per day. He had decreased breath sounds at his
left base with occasional rhonchi at both bases. He had
positive bowel sounds. The incisions were clean, dry, and
intact. His sternum was stable. The Gram stain on the
culture showed gram-positive cocci consistent with
oropharyngeal flora. Final sputum culture was still pending.
This will be checked prior to discharge. The patient needs
tighter glucose control. The patient was still encouraged to
have aggressive pulmonary toilet. We anticipate a bed for
the patient on [**7-24**] in the morning to the facility [**Location (un) 57834**] [**State 792**]near his home.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times three.
2. Hypertension.
3. Non-insulin-dependent diabetes.
4. Glaucoma.
5. Status post appendectomy.
6. Status post hernia repair.
7. Status post cataract surgery.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg by mouth twice per day.
2. Enteric coated aspirin 325 mg by mouth once per day.
3. Lipitor 10 mg by mouth once per day.
4. Bisacodyl 5-mg tablets enteric coated two tablets by mouth
every day as needed.
5. Brimonidine tartrate 0.2 percent drops 1 drop both eyes
twice per day.
6. Dorzolamide/Timolol 2/0.5 percent drops 1 drop both eyes
twice per day.
7. Avandia 4 mg by mouth once per day.
8. Tylenol 325-mg tablets two tablets by mouth q.4h. as
needed (for pain).
9. Metformin 500 mg by mouth twice per day.
10. Protonix 40 mg by mouth once per day (enteric
coated).
11. Plavix 75 mg by mouth once per day.
12. Latanoprost 0.005 percent drops 1 drop both eyes at
hour of sleep.
13. Captopril 6.25 mg by mouth three times per day.
14. Trazodone hydrochloride 100 mg by mouth at hour of
sleep as needed.
15. Metoclopramide 10 mg by mouth four times per day (at
meals and at bedtime).
16. Amiodarone 400 mg by mouth once per day.
17. Metoprolol 12.5 mg by mouth twice per day.
18. Regular insulin per sliding scale at the
rehabilitation facility.
DISCHARGE DISPOSITION: Discharge is anticipated on Saturday
morning, [**7-24**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2128-7-23**] 11:38:10
T: [**2128-7-23**] 12:48:48
Job#: [**Job Number 57835**]
|
[
"401.9",
"410.01",
"272.0",
"250.00",
"414.01",
"433.10",
"501",
"427.41",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"36.15",
"36.12",
"88.56",
"96.71",
"99.62",
"96.04",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
16448, 16774
|
15041, 15260
|
15286, 16424
|
1917, 2035
|
3713, 15020
|
2460, 2674
|
118, 1605
|
2689, 3684
|
1627, 1896
|
2052, 2165
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,015
| 150,549
|
48781
|
Discharge summary
|
report
|
Admission Date: [**2154-3-18**] Discharge Date: [**2154-3-22**]
Date of Birth: [**2079-1-1**] Sex: F
Service: MEDICINE
Allergies:
Latex / Amoxicillin / Percocet / Propoxyphene
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
mechanical ventilation
Intubation and extubation
History of Present Illness:
75 y/o female with COPD, OSA, T2DM, HTN, CHF EF 40%, frequent
UTIs, CAD, and CKD who presented from her nursing home ([**First Name4 (NamePattern1) 2299**]
[**Last Name (NamePattern1) **]) with respiratory distress. Patient was initially admitted
through the ED when she developed increasing congestion,
shortness of breath, and somnolence. Patient visited by HCP on
[**Name (NI) 2974**], and was noted to have increased work of breathing. She
did not have cough, fevers, chills, chest pain, leg swelling, or
increased sputum at the time, and did not note nausea, vomiting,
or diarrhea. Per HCP, patient had a CXR done which was normal.
Patietn was seen again by her HCP the next day and was noted to
have worsening respiratory distress, and was given nebulizers by
nursing home staff. At the time patient was noted to be confused
as well, and was not alert to place, but did recognize her HCP.
[**Name (NI) **] HCP states that this is about her baseline. Patient recently
had Lasix and lisinopril discontinued by her PCP. [**Name10 (NameIs) **] also
with a recent UTI and was being treated with IV antibiotics.
Patient has stable orthopnea, lower extremity swelling. She is
not ambulatory at baseline. Her blood sugars have been stable.
In the ED, patient's initial VS: 99.9 BP 172/113 HR 110 O2sat
93%. She received lasix 40 mg IV x1 and put out 600 cc urine,
and was originally on CPAP satting 99-100%. She was also started
on a heparin gtt for ACS based on elevated troponins, no EKG
changes. It is unclear why the patient was intubated, but
presumably for mental status changes. She was started on a nitro
gtt for blood pressure control and had a right subclavian line
placed for access.
Past Medical History:
COPD
T2DM on insulin
HTN
CHF (EF 40%)
CAD
CKD (baseline creatinine 1.8-2.1)
OSA
OA
Depression
Gout
Hyperlipidemia
GERD
[**2154-1-5**]: I&D/VAC L leg, Ex Fix LLE, splint R leg
[**2154-1-8**]: I&D, closure, ex-fix adjustment LLE; ORIF R distal
tibia
Difficult to wean vent after above recent surgeries
Social History:
Lives in nursing home. Denies smoking or alcohol. No illicit
drug use. Patient is Spanish speaking only, from [**Name (NI) 5976**], husband
passed away after their move to the United States.
Family History:
Non-contributory.
Physical Exam:
Vitals: 100.7 HR 87 BP 142/76 RR 20 O2sat 100% on FiO2 80% PEEP
5 TV 400 RR 20
General: well appearing, obese female, intubated, comfortable.
HEENT: Dried blood over buccal mucosa. MMM.
Neck: Thick. Unable to assess JVD.
CV: RRR. Distant heart sounds.
Pulm: Diffuse expiratory wheezing. Rhonchi diffusely anteriorly.
Abd: Obese. Soft, nontender. Normoactive bowel sounds.
Ext: WWP. Left tibia externally fixated. 2+pulses.
Skin: +Candidal intertrigo.
Neuro: PERRL. Grimaces to sternal rub. Toes downgoing
bilaterally. Reflexes symmetric bilaterally.
Pertinent Results:
[**2154-3-18**] 08:45AM WBC-8.5 RBC-4.03*# HGB-12.3# HCT-38.6#
MCV-96# MCH-30.6 MCHC-31.9 RDW-17.3*
[**2154-3-18**] 08:45AM PLT COUNT-103*#
[**2154-3-18**] 08:45AM NEUTS-90.4* BANDS-0 LYMPHS-6.3* MONOS-1.7*
EOS-1.2 BASOS-0.4
[**2154-3-18**] 08:45AM CALCIUM-10.5* PHOSPHATE-4.6* MAGNESIUM-1.6
[**2154-3-18**] 08:06PM GLUCOSE-114* UREA N-62* CREAT-2.4*
SODIUM-146* POTASSIUM-5.3* CHLORIDE-116* TOTAL CO2-19* ANION
GAP-16
[**2154-3-18**] 08:45AM CK(CPK)-77
[**2154-3-18**] 08:45AM CK-MB-NotDone cTropnT-0.14* proBNP-[**Numeric Identifier **]*
[**2154-3-18**] 08:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2154-3-18**] 08:35AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2154-3-18**] 08:35AM URINE RBC-0-2 WBC-[**4-17**] BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2154-3-18**] 07:53AM GLUCOSE-34* LACTATE-1.7 NA+-143 K+-GREATER TH
CL--117* TCO2-15*
[**2154-3-18**] 11:45AM TYPE-ART O2-100 PO2-71* PCO2-35 PH-7.32*
TOTAL CO2-19* BASE XS--7 AADO2-617 REQ O2-99 INTUBATED-NOT
INTUBA COMMENTS-CPAP
.
EKG 2/4/8: NSR. No acute ST-T changes.
.
Micro
[**2154-3-18**] 8:35 am URINE Site: CATHETER
**FINAL REPORT [**2154-3-22**]**
URINE CULTURE (Final [**2154-3-22**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
2ND MORPHOLOGY.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- =>32 R 16 I
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- R R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- R R
CEFUROXIME------------ =>64 R 32 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I 4 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R 128 R
PIPERACILLIN/TAZO----- 8 S 8 S
TOBRAMYCIN------------ 8 I 2 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
Imaging
[**3-18**] CXR
With repositioning of the ET tube in standard position, the left
upper lobe consolidation has entirely cleared indicating that
this was atelectasis not pneumonia. There are, however,
substantial areas of consolidation in the left lower lobe and in
the right upper lobe marginating the major fissure in the
posterior segment that are quite likely pneumonia. Severe
cardiomegaly is stable. There is no pulmonary edema. The small
left pleural effusion is probably unchanged. Right central
venous line ends in the region of the superior cavoatrial
junction and a nasogastric tube passes into the low stomach and
out of view. No pneumothorax.
.
[**3-18**] CT head
IMPRESSION: No acute intracranial abnormalities.
.
Brief Hospital Course:
The patient was intubated and admitted to the ICU for
respiratory failure. Was thought to be a combination of
pneumonia, acute on chronic systolic heart failure, superimposed
on COPD exacerbation Was treated with empiric levofloxacin and
vancomycin, which was subsequently tailured to levofloxacin and
completed course. She also received a prednisone pulse with
taper, as well as aggresive inhaler therapy. She was
subsequently extubated and transferred to the floor without
further incident.
She was noted to be have acute renal failure, so aggressive
diuresis was not pursued. Her serum creatinine gradually
improved without intervention.
Initially, the patient was noted to hypertensive urgency, but
aggressive control of her blood pressure was accomplished
despite holding her ACE inhibitor in the setting of ARF. It was
not necessary to resume her ACE inhibitor on discharge to
control her blood pressure, but is recommended once her ARF
resolves.
Her urine culture was intially treated with the levofloxacin,
when identification and sensitivities returned, she was started
on Zosyn (piperacillin/tazobactam), dose for her kidney
function, for a total of 14 days. Her Foley catheter was also
exchanged. A PICC catheter was placed for the antibiotics.
Thrombocytopenia was stable during her hospitalization but
should be monitored.
Her chronic kidney disease related anemia may need institution
of erthrypoiesis stimulating agents. This decision was deferred
to the outpatient physician.
Medications on Admission:
Lantus 50u qam, 45u qpm
Novolin SS
Bactrim DS 1 tab [**Hospital1 **] start [**2153-3-10**] for 7 days
Robitussin cough syrup
Calcitriol 0.25 mg qd
Allopurinol 100 mg qd
ASA 81 mg qd
Celexa 20 mg qd
Ferrous sulfate 325 mg qd
Folic acid 1 mg qd
Furosemide 10 mg qd (on hold x 4 days)
Lisinopril 10 mg qd
Oxybutynin 5 mg 1 patch semiweekly
Prilosec 20 mg qd
Simvastatin 40 mg qd
Risperdal 0.5 mg qd
Colace 100 mg [**Hospital1 **]
Flovent 2 puffs [**Hospital1 **]
Gabapentin 200 mg [**Hospital1 **]
Megestrol 5 ml [**Hospital1 **]
Metoprolol 100 mg tid
Calcium carbonate 1 tab tid
Heparin SC
Tramadol 25 mg q6h
Tylenol 650 mg qid
SPS 60mg qid
Senna 2 tabs qhs
Trazadone 50 mg qhs
Bisacodyl prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Prednisone 10 mg Tablet Sig: UD Tablet PO once a day: 40 mg
daily for 2 days, then 20 mg daily for 3 days, then 10 mg daily
for 5 days, then discontinue.
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
[**2-13**] neb Inhalation Q6H (every 6 hours) as needed for wheezing or
dyspnea.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
16. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
17. Docusate Sodium 50 mg/5 mL Liquid Sig: Twenty (20) mL PO BID
(2 times a day).
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by
1ml of 100 units/ml heparin (100 units heparin) each lumen of
PICC daily and PRN. Inspect site every shift.
19. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
20. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
21. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 2 weeks.
22. Lantus 100 unit/mL Solution Sig: UD Subcutaneous twice a
day: 50 units SQ qAM, and 45 units SQ qPM.
23. Humalog 100 unit/mL Solution Sig: UD Subcutaneous four
times a day: Check fingerstick glucose before each meal and at
bedtime. Glucose <70, give juice and crackers and notify MD,
71-150 observe, 151-200 2 units lispro SQ, 201-250 4 units,
251-300 6 units, 301-350 8 units, 351-400 10 units, >400 12
units and notify MD.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
1. Acute on chronic systolic congestive heart failure
2. Chronic obstructive pulmonary disease exacerbation
3. Pneumonia
4. Klebsiella urinary tract infection
5. Type 2 diabetes mellitus
6. Hypertension
7. Coronary artery disease
8. Acute renal failure with chronic kidney disease, stage 4
9. Obstructive sleep apnea
10. Osteoarthritis
11. Depression
12. Gout
13. Hyperlipidemia
14. Gastroesophageal reflux disease
15. Left open tibial-fibula fracture
16. Right tibial fracture s/p ORIF
17. Obesity
Discharge Condition:
Fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please contact your primary care physician or [**Name9 (PRE) 71410**] physician
if you develop fevers, sweats, chills, shortness of breath,
wheezing, chest pain, or pain when you urinate.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-4-11**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-4-11**] 10:20
|
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"585.4",
"491.21",
"518.81",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11837, 11933
|
6915, 8413
|
309, 360
|
12475, 12481
|
3237, 6892
|
12818, 13087
|
2632, 2651
|
9154, 11814
|
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|
8439, 9131
|
12505, 12795
|
2666, 3218
|
266, 271
|
388, 2084
|
2106, 2407
|
2423, 2616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,715
| 113,440
|
15961
|
Discharge summary
|
report
|
Admission Date: [**2193-2-4**] Discharge Date: [**2193-2-19**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 79-year-old female
with a past medical history significant for increased
cholesterol who presented to our hospital who presented for
several days of malaise, nausea, vomiting, weakness, and
dizziness. The patient was OB+. She had a Hartmann in her
40's and was found to be hypotensive. She denies any chest
pain or shortness of breath. Electrocardiogram showed [**Street Address(2) 11741**] depression in V2 and V4 and ST elevations in 2, 3, and AvF
as well as complete heart block. The patient was started on
IV heparin and then became apneic and hypotensive in the
emergency room. This required intubation and administration
of dopamine. She was transferred to the [**Hospital1 18**] for cardiac
catheterization, but has now become hypotensive on admission
and still in complete heart block. She had a left heart
catheterization which revealed 95% of left anterior
descending stenosis and 100% occluded left circumflex which
was stented. She was also found to have a small RC not
supplying a large part of myocardium. After this cardiac
catheterization, the patient has hypotension with an episode
of supraventricular tachycardia. All of these stopped with
the initiation of intra-aortic balloon pump. In addition on
doing cardiac catheterization, the saturations in the left
and right side of the heart suggested presence of
atrioventricular septal defect.
PAST MEDICAL HISTORY: Unremarkable.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: She is widowed and lives alone. No smoking
or alcohol.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature is 98.7, heart rate of
105, blood pressure was 126/50. Respiratory rate is 20,
oxygen saturation is 98. The patient is intubated and was
generally nonreactive to stimuli. Head, ears, eyes, nose and
throat: Pupils are small, but equal and reactive to light.
Mucus membranes are dry. Neck: Difficult to appreciate
jugular venous distention. No lymphadenopathy is palpable.
Cardiovascular: Tachycardic, obscured heart sounds. Chest:
Good breath sounds bilaterally. Abdomen: Soft and nontender
and normal active bowel sounds. Extremities: No edema. Good
bilateral pulses.
LABORATORY DATA: Significant for CK of 159, MB of 15, index
of 10 and troponin of 1.9.
HOSPITAL COURSE:
1. Cardiovascular: The patient was admitted to the Coronary
Care Unit for close observation monitoring. Immediately upon
admission, she had a TU which revealed anteroseptal defect.
The initial impression was to try to close this with a clam
shell procedure which is going to offer her best chances of
stabilizing a hemodynamics given that she became to be very
hypotensive.
However, discussion with the family, they decided that they
did not want any procedures done. The patient's blood
pressure remained extremely labile requiring a few pressors
in the beginning with fair satisfactory result. Initial
subsequent echocardiogram revealed that she had global left
ventricular hypokinesis. She was started on aspirin, Plavix
and maintained on IV heparin. She was also started on
Lipitor. Initially, we could not start a beta-blocker given
her complete heart block and hypotension. However, this
subsequently improved. This was added to her regimen. To
further improve her hemodynamics upon arrival to the CCU she
received large amounts of fluid and became about 15 liters
positive. However, this increased preload and had
significant improvement in her hemodynamics and initially was
tolerated. After while she became volume overloaded without
evidence of compromising her oxygenation. This volume
overload was gradually improved with gentle diuresis and
sometimes with autodiuresis. Once the condition improved,
she was started on Captopril which she tolerated a small
dose. The balloon pump was stopped and had no significant
effect on her hemodynamics.
On hospital day #4 and #5, it became apparent that the
patient was aseptic which is the cause of her continued
hypotension. She required pressors for about 10 consecutive
days, but eventually was able to be weaned off completely and
maintained good blood pressure. In terms of rhythm, the
patient remained most of the time in first degree AV block
and notable in complete heart block with tachycardia in the
unit. However, she did have one episode of atrial
fibrillation in the context of ventilatory weaning. Because
of this, she was started on amiodarone 400 mg p.o. q. day.
She had no further episodes of atrial fibrillation. She is
also being anticoagulated for atrial fibrillation and for low
ejection fraction with akinetic ventricle.
2. Infectious disease: There were multiple consults
involving infectious disease. The patient was probably
aspirated during episodes of nausea and vomiting in the
outside hospital and particularly given the findings on
x-ray. Sputum showed multiple organisms including gram
positive cocci and gram negative rods, but none of these were
grown. She received a 14 day course of levofloxacin and
Flagyl with marked improvement in her symptoms.
Additionally, the patient had 2 out of 4 blood cultures
positive for staph. Both local lines were stopped and she
received a 14 day course of IV vancomycin. Upon discharge,
all of her infectious disease issues has been resolved and
she has no evidence of being infected at this point.
3. Renal: Upon admission, the patient may be in very mild
acidosis which could have an myocardial infarction. This
improved. She was being diuresed while in the hospital
course. She had a mild increase of creatinine and this is
probably normal and to be expected.
4. Endocrine: The patient initially had very labile blood
sugars in the 300 to 500 range. She required initiation of
IV insulin drip and this was continued for at least 4 days.
This patient was getting better and was changed to a standing
NPH insulin. It is quite likely that she has unrecognized
underlying diabetes mellitus that has not been treated. She
will probably require further follow up for this condition.
5. Pulmonary: The patient was initially intubated for
protection. She had a very prolonged and complicated course
including inability to wean over a week, pneumonia and fluid
overload. On hospital day #10, the final attempts to
extubate the patient was successful and she remained very
stable from respiratory standpoint and positioned to room air
shortly thereafter. She has no acquired pneumonia and was
able to breathe comfortably on room air at this point.
6. Gastrointestinal: The patient had some episodes of
bleeding from the oropharyngeal tract, but this is believed
more to be due to injury from the TE and intubation rather
than any gastrointestinal bleed. Consultation of ENT was
obtained. There is no continued gastrointestinal bleeding
from the gastrointestinal tract.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE MEDICATIONS:
1. Plavix 75 p.o. q. day indefinitely.
2. Aspirin 325 p.o. indefinitely.
3. Amiodarone 400 mg p.o. q. day to be switched to 200 mg
p.o. q. day in about 3 to 4 weeks.
4. Lisinopril 5 mg p.o. q. day.
5. Lipitor 10 mg p.o. q. day, this may need to be readjusted
for proper INR.
6. NPH 60 units in the morning, 10 units at night.
7. Lopressor 12.5 b.i.d.
DISCHARGE DIAGNOSIS:
1. Acute myocardial infarction.
2. Status post catheterization.
3. Diabetes mellitus.
4. Atrial fibrillation.
5. Sepsis.
6. Aspiration pneumonia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-191
Dictated By:[**Name8 (MD) 5094**]
MEDQUIST36
D: [**2193-2-18**] 10:59
T: [**2193-2-19**] 05:54
JOB#: [**Job Number 45730**]
|
[
"428.0",
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"507.0",
"410.21",
"427.89",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"37.21",
"96.72",
"36.02",
"88.56",
"99.20",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
6955, 7003
|
1663, 1681
|
7026, 7378
|
7399, 7765
|
2401, 6933
|
1704, 2384
|
112, 1494
|
1517, 1572
|
1589, 1646
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,354
| 171,893
|
51817
|
Discharge summary
|
report
|
Admission Date: [**2181-7-20**] Discharge Date: [**2181-7-25**]
Date of Birth: [**2130-6-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Fever, chills, lethargy
Major Surgical or Invasive Procedure:
[**2181-7-24**] PICC line placement
History of Present Illness:
Mr. [**Known lastname 80287**] is a 51 year old man with history of multiple
sclerosis necessitating self bladder catheterization complicated
by recurrent UTI's with resistant organisms, who was brought by
EMS to the ED after being found lethargic at home. He stated
that he was in his usual state of health until the morning of
[**7-19**] when he awoke feeling thirsty and unwell. He went back to
bed and when he woke up in the afternoon he couldn't move and
was having chills. He called to his tenant, who found him to be
very lethargic and called EMS. There was no dysuria, frequency
or urgency. Of note, he does not remember self cathing on the
day of admission but did so yesterday.
In the ED, initial vitals were: T 107.4 (temporal), P 120, BP
157/84, RR 26, SaO2 95% RA. He was found to have lactate of
7.2, WBC 2.3 with 10% bands and a U/A with 11-20 WBCs. A CXR was
normal. He was given 5L NS and started on vancomycin and zosyn.
His lethargy greatly improved and his repeat lactate was 2.7.
On the floor, the patient felt much improved but weaker than his
baseline.
Past Medical History:
1. MS- clinically definite since [**2167**]- secondary progressive
type
2. Status post ADCF C5-C7 ([**2171-9-25**])
3. History of depression [**2164**] to [**2166**] and currently.
4. History of alcoholism in the past (last drank 10 years ago)
6. Recurrent UTIs with multi-drug resistance urinary pathogens
7. Hyperlipidemia
Social History:
Single, lives alone, has a VNA. Works for [**Company 107279**] during tax
season; Smokes: [**12-9**] ppd, 20 pk/yr history. Smokes marijuana once
every 2 months. Rents a three family house.
Family History:
No family history of MS.
Father: [**Name (NI) 2320**]
Mother: Melanoma
Physical Exam:
Vitals: T: 98.5 BP: 114/70 P: 61 RR: 17 O2: 97% RA
General: Thin, AO3, NAD
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. Baclofen
pump is felt on the LLQ.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: 3 x 3 cm non-painful, L hip ulcer with 2 cm area of
surrounding erythema and central eschar
Neuro: CNII-XII intact, strength and sensation intact distal UE
and LE. Lower extremity tone very high.
Pertinent Results:
IMAGES:
[**2181-7-19**] Hip Film:
1. No radiographic evidence for osteomyelitis. If there is
continued clinical concern for a bone infection, recommend
further evaluation with MRI.
2. Severe osteoarthritis of the left hip and mild osteoarthritis
of the right hip.
LABS:
[**2181-7-19**] CXR: IMPRESSION: No acute cardiopulmonary process.
[**2181-7-25**] 06:15AM BLOOD WBC-7.6 RBC-4.15* Hgb-12.4* Hct-36.8*
MCV-89 MCH-29.8 MCHC-33.7 RDW-12.4 Plt Ct-291
[**2181-7-19**] 08:45PM BLOOD WBC-2.3*# RBC-4.75 Hgb-14.3 Hct-43.4
MCV-91 MCH-30.1 MCHC-32.9 RDW-13.0 Plt Ct-206
[**2181-7-19**] 08:45PM BLOOD Neuts-60 Bands-10* Lymphs-24 Monos-2
Eos-0 Baso-4* Atyps-0 Metas-0 Myelos-0
[**2181-7-25**] 06:15AM BLOOD Glucose-93 UreaN-17 Creat-0.9 Na-140
K-4.3 Cl-106 HCO3-28 AnGap-10
[**2181-7-19**] 08:45PM BLOOD Glucose-117* UreaN-15 Creat-1.3* Na-138
K-4.8 Cl-99 HCO3-21* AnGap-23*
[**2181-7-25**] 06:15AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.2
[**2181-7-19**] 08:54PM BLOOD Glucose-113* Lactate-7.2* K-4.2
MICRO:
[**2181-7-19**] Blood Culture, Routine (Final [**2181-7-23**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2181-7-19**] URINE CULTURE (Final [**2181-7-22**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2181-7-20**] MRSA Screen: Negative
Brief Hospital Course:
This is a 51 year old man with MS, on self-catheterization
regimen at home with hx of recurrent UTIs, who presented to the
ED on [**7-19**] with lethargy, high fevers, tachycardia, elevated
lactate, and gram negative rods growing out of urine and blood
cultures (later speciated as ESBL E. Coli). He was resuscitated
in ICU while receiving zosyn, with marked improvement.
# Urosepsis: Patient presented with fever >104, WBC <2,000, RR
26, HR 120, (+)UA, MS changes and lactate of 7 meeting criteria
for severe sepsis. After fluid resucitation and initial
antibiotic the patient's condition greatly improved as his MS
returned to baseline, his HR and RR decreased to WNL, his
lactate returned to [**Location 213**] levels and his temperature decreased
to WNL. His urine speciated ESBL E. Coli sensitive to Zosyn.
He received additional hydration in the ICU, but did not require
pressors. He was stable on arrival to the floor and was
maintained on IV zosyn. Surveillance cultures drawn [**7-21**], [**7-22**],
[**7-23**] were negative. A PICC line was placed on [**2181-7-24**], and he
was discharged to a rehab facility where he can complete the
course of IV zosyn. We recommended he stop his prophylactic
regimen of Methenamine Hippurate until completion of his zosyn
course, at which point he can resume it. Regarding prophylaxis,
this patient needs more extensive services at home to prevent
recurrent UTIs.
# Acute renal failure: Patient presented with Cr 1.3 from a
baseline of 0.8. This likely represents pre-renal azotemia in
the setting of sepsis and hypovolemia. On [**2181-7-21**] his Cr. was
0.7.
# Left hip wound: Patient states it is due to a fall 1 month
ago. It is unhealed despite VNA care. It was deemed an unlikely
source of infection given history of UTIs and (+) UA. Plain
radiographs did not show any evidence of osteomyelitis. On the
floor, wound team continued to consult. They recommended Q72H
cleaning with sterile normal saline followed by duoderm and
mepalex dressings.
# Multiple sclerosis. The patient endorsed stiffness and
spasticity consistent with his recent baseline. He was
continued on his home medications. His baclofen pump does not
need maintenance until late [**Month (only) **]. PT saw him while on the
floor and recommended further therapy at the rehabilitation
center.
# Hyperlipidemia: This issue was stable. He was continued on
his home medications.
# Depression: This issue was stable. He was continued on his
home medications.
Medications on Admission:
1. Aspirin 325 mg Daily
2. Oxybutynin Chloride 5 mg [**Hospital1 **]
3. Ascorbic Acid 1000 mg [**Hospital1 **]
4. Baclofen intraabdominal pump
5. Fluoxetine 20 mg Daily
6. Ezetimibe 10 mg Daily
7. Methenamine Hippurate 1 g [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily). Capsule(s)
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 grams Intravenous Q8H (every 8 hours) for 5 days: Take as
instructed until [**2181-7-30**].
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed) as needed for Self-catheterization.
9. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous every eight (8) hours as needed for line
flush: PICC, non-heparin dependent: Flush with 10 mL Normal
Saline daily and PRN per lumen. .
11. Methenamine Hippurate 1 gram Tablet Sig: One (1) Tablet PO
twice a day: To be restarted on [**7-30**] after course of antibiotics
complete.
12. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary: Extended-spectrum beta-lactamase E. Coli urinary tract
infection, Extended-spectrum beta-lactamase E. Coli bacteremia,
Acute Kidney Injury, Left hip wound
Secondary: Multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were brought to the hospital on [**2181-7-19**] after waking up with
fevers, chills, and lethargy. On arrival to the emergency room
you were found to have evidence of active infection including
high fevers, a rapid pulse, and fast respiratory rate. Labs
showed infection in your bladder and in your blood, along with
evidence of some kidney injury. You were given a significant
amount of fluid through your IV along with antibiotics. Within
24 hours, your symptoms were largely resolved and your kidney
function had normalized. As your blood infection requires
additional intravenous antibiotics, we placed a PICC
(peripherally inserted central catheter). As you will need
assistance to administer these medications, we have arranged
transfer to a rehab facility. Staff at the rehab facility will
continue to care for your left hip wound as well.
Please note the following changes to your regular medications:
- Please continue to take the zosyn (piperacillin/tazobactam)
through [**2181-7-30**] to complete a 10 day course.
- Please continue to take docusate sodium twice daily as you
have had some constipation. Bisacodyl and senna are also
included in your discharge medications; you can request these as
required for constipation.
- Please stop taking the Methenamine Hippurate until you have
completed your course of zosyn; you can resume it at that point.
- Please take the rest of your medications as you did prior to
your admission.
- Please follow up with your PCP [**Name9 (PRE) 7476**],[**Name9 (PRE) **] [**Telephone/Fax (1) 7477**] on
Monday [**2181-7-30**] at 1030AM.
Followup Instructions:
- Please follow up with your PCP [**Name9 (PRE) 7476**],[**Name9 (PRE) **] [**Telephone/Fax (1) 7477**] on
Monday [**2181-7-30**] at 1030AM.
|
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"599.0",
"340"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10111, 10194
|
6001, 8502
|
338, 376
|
10432, 10432
|
2888, 5978
|
12228, 12372
|
2060, 2132
|
8792, 10088
|
10215, 10411
|
8528, 8769
|
10608, 12205
|
2147, 2869
|
275, 300
|
404, 1488
|
10447, 10584
|
1510, 1836
|
1852, 2044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,652
| 134,427
|
36944
|
Discharge summary
|
report
|
Admission Date: [**2169-10-2**] Discharge Date: [**2169-10-8**]
Date of Birth: [**2119-9-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin / Etoposide
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Stage III-a squamous cell carcinoma left lower lobe.
Major Surgical or Invasive Procedure:
[**2169-10-2**] Left thoracotomy, left pneumonectomy,
mediastinal lymph node sampling and therapeutic bronchoscopic
aspiration of secretions.
History of Present Illness:
This is a 50-year-old woman with biopsy-proven squamous cell
carcinoma of the left lower lobe. She underwent induction of
neoadjuvant chemoradiation therapy
completed on [**2169-8-31**]. She had previously undergone a
mediastinal and left VATS lymph node sampling of pleural fluid
biopsy that demonstrated a positive AP window node for
metastatic carcinoma. All other nodal stations sampled and the
pleural fluid were negative for malignancy. She now presents for
definitive resection.
Past Medical History:
hyperlipidemia
Stage III NSCL squamous lung cell cancer
Social History:
lives alone, works for a flooring company.
Smoked 1 ppd for 30 years, quit 3-4 years ago. Drink wine
occasionally. Arrives today with her sister.
Family History:
notable for breast cancer in four aunts, mostly
premenopausal. Also notable for gastric cancer in her
grandmother, and throat cancer in her father, who was also a
heavy smoker.
Physical Exam:
98.5 93 126/76 20 96% RA
Gen: Alert and oriented x 3, NAD
Cardiac: RRR no murmers, rubs, gallops
Pulm: R lung CTA
Abdomen: soft, nontender, no masses +BS, nondistended
Ext: no edema + pulses
Pertinent Results:
[**2169-10-7**] 04:28PM BLOOD Hct-31.1*
[**2169-10-7**] 04:23AM BLOOD WBC-5.0 RBC-3.00* Hgb-8.9* Hct-26.3*
MCV-88 MCH-29.8 MCHC-34.0 RDW-17.3* Plt Ct-282
[**2169-10-7**] 04:23AM BLOOD Glucose-96 UreaN-20 Creat-0.8 Na-138
K-4.0 Cl-101 HCO3-31 AnGap-10
[**2169-10-7**] 04:23AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
Brief Hospital Course:
Ms. [**Known lastname 36653**] was admitted on [**2169-10-2**] for Left Pneumonectomy. She
was extubated in the operating room and transferred to the SICU
for further management.
Respiratory: left chest removed POD1. Chest X-ray revealed right
pleural effusion which lasix was given.
Cardiac: she responded to fluid challenges to maintain MAPs >
60. She remained in sinus rhythm. Low dose beta-blocker was
started prophylaxis for atrial fibrillation. She occasinally had
sinus tachycardia which responded to fluid and betablockade.
GI: bowel function returned. Prophlyaxtic PPI was started.
Nutrition: She was seen by Speech and Swallow for bedside
swallow evaluation. They felt she was safe for a diet of
regular consistency solids and thin liquid. She was started on a
clear liquid diet advanced as tolerated.
Renal: normal renal function. Initially low urine output which
responded to fluids.
Heme: developed post-op anemia and had 1 Unit of blood which
brought her hct up to 31.
Pain: Epidural was removed POD1. PO pain medication and toradol
was initated with good pain control.
Wound: Left thoracotomy site clean intact, no erythema or
discharge
Neuro: no deficiits
Medications on Admission:
FAMOTIDINE 20 mg [**Hospital1 **], HYDROCODONE-HOMATROPINE [HYDROMET]QID PRN
Cough, HYDROCORTISONE cream, LORAZEPAM 0.5-1 mg QID PRN, Maalox
PRN, ONDANSETRON HCL 8 Q8h PRN, ROXICET PRN PAIN, PROTONIX 40 mg
[**Hospital1 **], SUCRALFATE - 1 gram/10 mL PRN Dysphagia, Colace 100 [**Hospital1 **]
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Squamous Cell CA post-induction chemo/XRT
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath,cough or sputum production
-Chest pain
-Incision develops drainage or increased redness
-You may shower. No tub bathing or swimming for 6 weeks
-No driving until seen in follow-up
-No lifting more than 10 pounds
Followup Instructions:
Follow-up with Dr.[**Name8 (MD) 4738**] NP [**10-24**] at 11:30 am in the Chest
Disease Center, [**Hospital Ward Name 121**] Building [**Hospital1 **] I
Chest X-Ray 45 minutes before your appointment in the [**Hospital Ward Name 12837**] Clinical Center [**Location (un) **] Radiology
|
[
"V15.3",
"285.9",
"196.1",
"458.29",
"511.9",
"V15.82",
"162.5",
"V87.41",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.73",
"33.24",
"32.59",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
3916, 3974
|
2019, 3208
|
359, 503
|
4060, 4069
|
1686, 1996
|
4472, 4760
|
1279, 1459
|
3551, 3893
|
3995, 4039
|
3234, 3528
|
4093, 4449
|
1474, 1667
|
266, 321
|
531, 1018
|
1040, 1097
|
1113, 1263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,702
| 132,822
|
7757+7758+55873
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2176-12-9**] Discharge Date:[**2176-12-16**]
Date of Birth: [**2100-11-19**] Sex: F
Service: MEDICINE
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: Ms. [**Name13 (STitle) 469**] is a 76-year-old
woman with a history of end stage multiple sclerosis and
quadriplegia with dysphasia, decubitus ulcers, bilateral
pleural effusions and ascites, and a recent admission on
[**12-2**] for sepsis, who presented to the [**Hospital3 **] with
hypoxia requiring intubation and hypotension requiring
dopamine. She had recently been admitted on [**12-2**]
through [**12-8**] with sepsis secondary to Prevotella and
Peptostreptococcus requiring a one day Medical Intensive Care
Unit stay. She was discharged on [**12-8**] to [**Hospital3 6373**] on a regimen of vancomycin, Ceftriaxone and
Flagyl for a planned five week course. At that time, the
patient was noted to have ascites and bilateral pleural
effusions which were not tapped.
On [**12-9**], while at [**Hospital1 **], her husband noticed the
patient reportedly to have aspirated secretions. Her oxygen
saturations acutely dropping to 47%, which bumped to 96% on
100% nonrebreather. She was transferred to the Emergency
Room where her vital signs were blood pressure 133/85, heart
rate 122, saturating at 98% on 100% nonrebreather. The
patient was noted to rapidly deteriorate. Her respiratory
rate rose into the 40s with significant hypoventilation
prompting her to be intubated. With this, her blood pressure
dropped to 40/20. She responded transiently to boluses of
normal saline intravenous fluids, but needed a dopamine drip
to be started in the Emergency Room.
A right IJ central line was placed and resulted in a
right-sided pneumothorax. A right side chest tube was placed
draining 800 cc of clear yellow pleural fluid.
Subsequent to this, she was admitted to the Medical Intensive
Care Unit.
PAST MEDICAL HISTORY:
1. End stage multiple sclerosis times 17 years, aphonia,
dysphasia, quadriplegia.
2. Decubitus ulcers, Stage 4., thoracic and sacral.
3. Multifocal atrial tachycardia.
4. Incontinence.
5. Fibroids.
6. Ascites.
7. Hyponatremia.
8. History of sepsis.
9. Bilateral pleural effusions.
10. History of atrial fibrillation.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Insulin sliding scale.
2. Bowel regimen.
3. Ambien 5 mg po q.h.s.
4. Heparin subcutaneously.
5. Vitamin C.
6. Zinc.
7. Multivitamins.
8. Ceftriaxone 1 gram q. 24 intravenously.
9. Flagyl 500 mg po t.i.d.
10. Vancomycin 1 gram intravenously q.d.
11. Morphine sulfate 2-4 mg q. 4 hours prn for pain.
SOCIAL HISTORY: No history of tobacco, no alcohol, [**Hospital1 595**]
speaking only, presently nonverbal, prior to her most recent
hospitalization, she had been living with her husband.
PHYSICAL EXAM ON ADMISSION: Her temperature was 98.6. Her
blood pressure when examined on dopamine was 122/99. Her
heart rate 115. Respiratory rate of 15, intubated,
saturating at 97% on vent settings of assist control
500/12/5/1.0. At this point her dopamine was at 10
mcg/kg/minute. In general, flaccid, extremely cachectic
female, ill-appearing, significant blanching, mottling in a
reticular pattern over her anterior torso, bilateral upper
extremities, intubated and sedated at this time. Pupils
equal, round and reactive to light. She was edentulous. An
ET tube was in place and secured. She had a right IJ central
line in place. Her lungs had right basilar rales, decreased
breath sounds at the left base. Her heart rate and rhythm
were regular, but tachycardic and with distant heart sounds.
Her abdomen was soft, nontender, nondistended. She had no
hepatosplenomegaly. Bowel sounds were present. She had
flaccid muscle tone. Her extremities had 2+ pitting edema,
bilateral upper and lower extremities. A left PICC line was
in place with more edema on the left upper extremity than the
right. Her left calf had a bandage which was clean, dry and
intact. She had a Stage 4 decubitus ulcer, 2 cm thoracic, 4
cm sacral. Neurologically, she was completely flaccid with
no muscle tone. Her left arm had a deformity and was
contracted.
LABORATORY VALUES ON ADMISSION: White blood cell count 9.2,
hematocrit 30.2, platelet count 514,000. Sodium 133,
potassium 3.9, BUN 19, creatinine 0.4 up from a baseline of
0.1, chloride 99, bicarbonate 30, calcium 7.4, magnesium 1.7,
phosphorus 2.7. Urinalysis was clean. An arterial blood gas
showed 7.44/43/330 on assist control 500/12/5/1.0. Her
lactate was 2.3.
IMAGING ON ADMISSION: Chest x-ray showed a moderate sized
right-sided pneumothorax. An ET tube was in place. PICC
line and right IJ lines were in place. She had bilateral
pleural effusions. A chest x-ray from two hours earlier,
prior to the line placement, showed no pneumothorax. An
electrocardiogram showed atrial tachycardia in the 130s with
T wave inversions in II, III, V4 through V6, T wave
flattening in III, V3, no ST changes, no Qs, normal axis,
normal intervals, no evidence of right heart strain.
BRIEF HOSPITAL COURSE: While in the Intensive Care Unit, she
was rapidly weaned off pressors and extubated on the 29th.
She was continued on broad spectrum antibiotics, Flagyl,
Ceftriaxone and vancomycin as per her prior infectious
course. This was a presumed aspiration event and these
antibiotics were presumed to be sufficient to cover any
superimposed bacterial infection.
Subsequent to extubation, she was called out to the floor
where she initially did well, however, on the 31st, she had
an episode of decompensation with hypoxia to the mid 80s,
placed on a nonrebreather face mask. A chest x-ray showed
that she had an almost complete white out of her left lung
consistent with either new consolidation or large pleural
effusion. She was maintained on oxygen overnight. The
following morning, thoracentesis was performed. A liter and
a half of serous fluid was removed with resolution of much of
her shortness of breath and hypoxia. Follow-up chest x-ray
showed almost complete resolution of the white out of her
lung. However, she has continued to have bilateral pleural
effusions.
Her decubitus ulcers were continued with their existing
management. Plastic Surgery was consulted for evaluation of
these wounds and proper dressing. They continued with
wet-to-dry packing and no changes were made to her management.
At the time of this dictation, she has a continued sacral
decubitus, a thoracic decubitus, both unchanged from her
prior admission, as well as small wound in her left axillary
line where a chest tube was placed. This is healing well.
Her neurological status has been stable with severe neurologic
compromise. She does have end stage multiple sclerosis and is
immobile and bedbound. Despite her inevitable decline, her
family has expressed strongly their desire to have all
interventions performed including intubation, and
cardiopulmonary resuscitation should she require it. This
issue will need to be discussed further with them as there is
likely little utility in performing CPR.
In terms of nutrition, she has been maintained on tube feeds
through an nasogastric tube. Of note, the Gastrointestinal
Service has been spoken with on several occasions about the
possible placement of a percutaneous feeding tube, either in the
stomach, or the jejunum. The feeling of multiple attendings and
the Gastroenterology Service has been that this is not indicated
and that the risks of having a percutaneous endoscopic
gastrostomy tube in a patient with ascites far outweigh the
benefits. At this time, the plan is to continue tube feedings
via the nasogastric tube.
At the time of this dictation, the plan is for her to be
discharged to a long-term care facility, most likely [**Hospital **]
Hospital to receive continued care.
DISCHARGE DIAGNOSES:
1. End stage multiple sclerosis.
2. Aspiration pneumonia.
3. Respiratory failure.
4. Hypotension.
5. Malnutrition.
6. Pleural effusions.
7. Stage 4 decubital ulcers.
DISCHARGE CONDITION: Stable.
DISCHARGE DISPOSITION: Pending.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneously q. 8 hours.
2. Ascorbic acid 500 mg po b.i.d.
3. Lansoprazole oral suspension 30 mg per nasogastric tube
q.d.
4. Insulin sliding scale.
5. Flagyl 500 mg intravenous q. 8 hours.
6. Vancomycin 1 gram intravenously q. 24 hours.
7. Ceftriaxone 1 gram intravenously q. 24 hours.
8. Multivitamins 1 capsule po per nasogastric tube q.d.
9. Zinc sulfate 220 mg per nasogastric tube q.d.
10. Docusate sodium 100 mg per nasogastric tube b.i.d.
11. Senna 1 tablet per nasogastric tube b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD [**MD Number(2) 11775**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D:
T: [**2176-12-15**] 13:25
JOB#:
Admission Date: [**2176-12-9**] Discharge Date: [**2176-12-17**]
Date of Birth: [**2100-11-19**] Sex: F
Service: [**Location (un) 259**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old
white female with a past medical history significant for
end-stage multiple sclerosis, decubitus ulcers, atrial
tachycardia, who presents with hypoxia from [**Hospital3 6373**] Center. The patient was recently admitted for
sepsis secondary to decubitus ulcers. She was discharged on
[**2176-12-7**] with an extended course of broad spectrum
antibiotics.
She presents the day after discharge with an episode of
hypoxia at her rehabilitation facility. The patient was
noticed to have an aspiration event by the husband who was at
the bedside. Following this, she had some coughing and was
found to be hypoxic with 02 saturation at 47% on room air by
the medical staff. The patient was placed on a
nonrebreathing with improved saturations to 96%. However,
the patient remained tachypneic and was transferred to [**Hospital6 1760**] for further workup and
management.
Upon arriving in the Emergency Department, the patient was
initially on a 100% nonrebreather with good oxygenation at
98%. However, she then developed significant tachypnea with
respiratory rate into the 40s. She maintained her
respiratory rate for some time; however, then began to have
decreased rate, eventually dropping to less than ten. She
was finally noticed to be apneic and was intubated.
Approximately 30 minutes after the intubation, the patient
became severely hypotensive with systolic blood pressure at
40. The patient responded to 1 liter of normal saline and a
dopamine drip at 10 micrograms. Central venous access was
obtained. A subsequent chest x-ray showed a small to
moderate right-sided pneumothorax. A chest tube was placed
at this time with withdrawal of 800 cc of clear yellow
pleural fluid.
On mechanical ventilation, the patient initially had
oxygenation and was hemodynamically stable.
ADMISSION MEDICATIONS:
1. Ceftriaxone 1 gram q. 24 hours.
2. Flagyl 500 mg t.i.d.
3. Vancomycin 1 gram q.d.
4. Regular insulin sliding scale.
5. Ambien 5 mg q.h.s.
6. Subcutaneous heparin.
7. Multivitamins.
8. Senna.
9. Colace.
10. Vitamin C.
11. Morphine sulfate 2-4 mg q. four hours p.r.n.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: No history of tobacco or alcohol use. The
patient is a [**Hospital6 595**]-speaking female, although she has been
nonverbal secondary to her multiple sclerosis. She had been
living with her husband until her recent admission and
transfer to the [**Hospital3 **] Facility.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.6, blood pressure 122/99, pulse 118, respiratory rate 15,
02 saturation 97% on assist control ventilation with tidal
volume of 500 cc, respiratory rate of 12, positive
end-expiratory pressure of 5, FI02 of 100%. General: The
patient was flaccid and extremely cachectic and ill
appearing. The patient had a significant blanching rash in a
reticular pattern over the anterior torso and bilateral upper
extremities. HEENT: The patient was normocephalic,
atraumatic. Her pupils were equally round, and reactive to
light. Lungs: The patient had right basilar rales with
decreased breath sounds at the left base, otherwise clear.
Cardiovascular: Tachycardiac with a regular rate, distant
heart sounds. Abdomen: Soft, nontender, nondistended,
normoactive bowel sounds, no hepatosplenomegaly.
Extremities: The patient had 2+ pitting edema of the
bilateral upper and lower extremities. There is a left PICC
line in place. Skin: The patient has stage IV decubitus
ulcers at the sacrum and at the thoracic spine. Neurologic:
the patient is completely flaccid with no muscle tone.
LABORATORY/RADIOLOGIC DATA: CBC revealed a white blood cell
count of 9.2, hematocrit 30.2, platelets 514,000.
Chemistries of significance were a chloride of 99,
bicarbonate 30, BUN 19, creatinine 0.4, calcium 7.4,
phosphate 1.7.
Microbiology studies: The patient had positive blood
cultures from a previous admission on [**2176-12-1**]. She
had one out of two bottles positive for Prevotella and one
out of two bottles positive for pepto streptococcus. Her
urine cultures from previous admission were negative. Repeat
blood culture on [**2176-12-3**] was also negative.
Chest x-ray: The patient had a moderate right-sided
pneumothorax, as previously mentioned. There were moderate
bilateral pleural effusions.
EKG showed tachycardia with rate in the 130s with T wave
inversions in II, III, V4 through V6 and no ST changes.
HOSPITAL COURSE: 1. HYPOXIC RESPIRATORY FAILURE:
Initially, the patient was intubated due to her respiratory
failure. She did well initially on mechanical ventilation
and was able to be weaned off without difficulty. The patient
was extubated on hospital day number two and subsequently had
good respiratory function and oxygenation. She was continued
on her previous broad spectrum antibiotics for a history of
sepsis as well as for a possible new aspiration pneumonia.
2. HYPOTENSION: The patient was hypotensive after her
intubation. This was likely secondary to initiation of
positive pressure ventilation, perhaps in combination with
medications that she received prior to the intubation. She
was quickly weaned off the dopamine and maintained good blood
pressure off the pressors. She had no further hemodynamic
instability.
3. PNEUMOTHORAX: The patient had a small right pneumothorax
likely secondary to placement of her central venous line.
Chest tube was placed and discontinued after two days. The
pleural fluid that was drained and analyzed during the
placement of the chest tube showed that the effusion was
transudative.
Once the patient was transferred from the ICU to the floor,
she had an episode of hypoxia which was likely secondary to
reaccumulation of the pleural fluid. She had a repeat
thoracentesis done for drainage of the fluid and subsequently
had good respiratory function.
4. DECUBITUS ULCERS: The patient was found to have
decubitus ulcers on her previous admission. She continued to
have wet-to-dry dressing changes b.i.d. The Plastics team
was consulted and recommended continuing the dressing
changes. The patient was also continued on her antibiotics
with ceftriaxone, vancomycin, and Flagyl for a total of a six
week planned course.
On this admission, there were no clinical signs or symptoms
of bacteremia or sepsis secondary to her decubitus ulcers.
5. MULTIPLE SCLEROSIS: The patient has end-stage multiple
sclerosis and was given supportive care.
6. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
placed on aspiration precautions and tube feeds were advanced
as tolerated.
7. CODE STATUS: The patient was full code on admission and
at discharge.
DISCHARGE STATUS: The patient is to be discharged back to
[**Hospital3 **] Center.
CONDITION ON DISCHARGE: The patient is in good condition,
afebrile, hemodynamically stable, tolerating tube feeds.
DISCHARGE DIAGNOSIS:
1. Hypoxic respiratory failure secondary to aspiration.
2. Decubitus ulcers.
3. End-stage multiple sclerosis.
4. Pneumothorax: Right-sided pneumothorax resolved.
DISCHARGE MEDICATIONS:
1. Ceftriaxone 1 gram q. 24 hours.
2. Vancomycin 1 gram q. 24 hours.
3. Metronidazole 500 mg t.i.d.
4. Vitamin C.
5. Colace.
6. Senna.
7. Subcutaneous heparin.
8. Regular insulin sliding scale.
9. Multivitamins.
10. Magnesium sulfate.
DISCHARGE INSTRUCTIONS: The patient will be discharged to
[**Hospital3 **] Center where she will continue her
broad spectrum antibiotics for a total of six weeks. She
should also continue q.d. to b.i.d. wet-to-dry dressing
changes for her decubitus ulcers. The patient should be
placed on aspiration precautions and tube feeds should be
continued.
FOLLOW-UP: The patient should follow-up with her primary care
provider.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD [**MD Number(2) 11775**]
Dictated By:[**Name8 (MD) 5709**]
MEDQUIST36
D: [**2176-12-16**] 11:22
T: [**2176-12-16**] 11:36
JOB#: [**Job Number 28128**]
Name: [**Known lastname **], [**Known firstname 4899**] Unit No: [**Numeric Identifier 4900**]
Admission Date: [**2176-12-9**] Discharge Date: [**2176-12-28**]
Date of Birth: [**2100-11-19**] Sex: F
Service: [**Location (un) **]
ADDENDUM: This is a Discharge Summary Addendum.
CONCISE SUMMARY OF HOSPITAL COURSE (CONTINUED): As per the
previous Discharge Summary, the patient was planned to be
discharged to a [**Hospital 2754**] rehabilitation care facility.
However, on the planned day of discharge the patient
developed hypoxic respiratory failure requiring intubation
and transfer to the Medical Intensive Care Unit.
The respiratory failure was thought to be due to an
aspiration event or mucous plugging. The patient was also
started on pressors briefly for mild hypotension at that
time. The patient's antibiotic coverage was changed to
linezolid, cefepime, and ciprofloxacin for double coverage of
possible Pseudomonas pneumonia. The patient had improvement
the day following transfer to the Medical Intensive Care
Unit, and the linezolid was discontinued after two days. The
cefepime and ciprofloxacin were continued.
The patient was then transferred from the Medical Intensive
Care Unit back to the regular floor. On the same day after
her transfer, the patient once again developed hypoxic
respiratory failure; again thought to be due to an aspiration
event. This time the patient was not initially intubated but
was first placed on [**Hospital1 **]-level positive airway pressure. The
patient did not require intubation during this Medical
Intensive Care Unit stay. The patient had rapid recovery to
her previous baseline and was weaned off the [**Hospital1 **]-level
positive airway pressure. The acute hypoxic event was
thought to be due to mucous plugging. The patient was
continued on her previous antibiotics of cefepime and
ciprofloxacin. The patient was placed on a regimen of
q.2-3h. suctioning to prevent repeat mucous plugging and
aspiration.
As the patient was at a high risk for aspiration, she was
kept nothing by mouth and started on tube feeds via a
nasogastric tube. The patient tolerated this well.
She was then transferred from the Medical Intensive Care Unit
back to the floor. Initially on the floor, she was
oxygenating well on room air and was stable.
After one to two days on the floor, the patient had increased
oxygen requirements on room air and was placed on a face
mask. It was unclear if this was due to a recurrent
aspiration event; although, the patient was witnessed to be
coughing prior to this decrease in her oxygen saturations.
She did remain stable and was oxygenating well on the face
mask.
With regard to her feedings, Gastroenterology was consulted.
A percutaneous endoscopic gastrostomy tube was placed, and
tube feeds were restarted through this percutaneous
endoscopic gastrostomy tube.
While in the Intensive Care Unit, the patient was also noted
to have a gradually decreasing hematocrit; however, there was
no evidence of bleeding. Her hematocrit eventually
stabilized without any further intervention.
The patient was also hyponatremic with sodium levels in the
mid 120s. A workup showed that the urine was inappropriately
concentrated, suggesting possible syndrome of inappropriate
secretion of antidiuretic hormone as the etiology of her
hyponatremia. The patient was placed on a fluid restriction
of 1.5 liters per day. On this, her sodium was stable at
approximately 128.
DISCHARGE STATUS: The patient was to be discharged to an
extended care rehabilitation facility.
CONDITION AT DISCHARGE: The patient was in good condition.
She was afebrile, hemodynamically stable, and requiring
oxygen by face mask. She was tolerating tube feeds well.
Her mental status was that of baseline.
DISCHARGE DIAGNOSES:
1. End-stage multiple sclerosis.
2. Aspiration pneumonia.
MEDICATIONS ON DISCHARGE:
1. Ciprofloxacin 500 mg by mouth q.12h. (to be continued for
a total of 14 days).
2. Cefepime 1 gram intravenously q.12h. (to be continued for
a total of 14 days).
3. Prevacid 30 mg once per day.
4. Vitamin C 500 mg twice per day.
5. Multivitamin one tablet once per day.
6. .................... 220 mg once per day.
7. Colace.
8. Senna.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient will require supportive care for decubitus
ulcers on the back and the extremities. She will require
daily dressing changes as had been done in the hospital.
2. The patient will also require aggressive pulmonary toilet
with frequent suctioning to prevent recurrent aspiration and
mucous plugging.
3. The patient was instructed to follow up with her primary
care provider.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3538**], MD [**MD Number(2) 3539**]
Dictated By:[**Name8 (MD) 1404**]
MEDQUIST36
D: [**2176-12-27**] 11:18
T: [**2176-12-28**] 05:43
JOB#: [**Job Number 4901**]
|
[
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"340",
"518.81",
"512.1",
"507.0"
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"86.27",
"43.11",
"00.14",
"34.04",
"96.6",
"34.91",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8097, 8107
|
5102, 7847
|
8064, 8073
|
20938, 20999
|
16161, 16406
|
15970, 16138
|
21025, 21373
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2330, 2641
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13542, 15832
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16431, 20712
|
10914, 11247
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21406, 22060
|
20727, 20917
|
155, 177
|
206, 1917
|
11575, 13524
|
1939, 2304
|
11264, 11560
|
15857, 15949
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,822
| 156,286
|
36308
|
Discharge summary
|
report
|
Admission Date: [**2199-6-26**] Discharge Date: [**2199-7-5**]
Date of Birth: [**2123-1-16**] Sex: F
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
hematoma s/p pulmonary vein isolation
Major Surgical or Invasive Procedure:
EP study
Right femoral arterial line
History of Present Illness:
76yo F w/ hx of CAD, s/p prior MI and PCI, PVD, s/p CEA and left
leg PTA and paroxysmal Afib dating back to [**2191**] presenting today
s/p PVI for afib c/b groin bleed admitted to the CCU overnight
for monitering. More recently her AF has been persistent with
ventricular rates up to 150 bpm. She had previously been treated
with Sotalol 40mg b.i.d. Her dosing had been limited by a
history of chronic renal insufficiency. She has undergone two
prior DC cardioversions, the last in [**2199-4-17**].
Unfortunately, she maintained sinus rhythm for only 48 hours
following her cardioversion. Her Sotalol was discontinued and
additional treatment options for her AF were discussed. The
decision was made to proceed with pulmonary vein isolation. She
was currently on 150mg of Toprol QD for rate control. With
regard to symptoms, the patient reports dyspnea with walking
approximately 50 feet. This has been present for several months.
She denies palpitations, PND, orthopnea, LE edema.
.
Pt underwent the procedure today with an INR of 3.0, and because
of liable blood pressures required a 5F femoral arterial line.
The procedure itself went well. Post-procedure she developed a R
groin arterial bleed, and pressure needed to be held for 1-1.5h.
Her hematocrit dropped from 50 one week ago to 44.8. Vascular
surgery was consulted and 2units FFP were given. Her hematoma is
currently soft ball sized and not expanding. In the PACU her BP
remained stable. Pt also got a CT w/o contrast of the pelvis and
thigh prior to coming up to the CCU.
.
Currently, pt is having severe burning pain at the R thigh
hematoma site, feels anxious. She denies any current CP, or SOB.
Denies recent palpitations or syncope.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias
Past Medical History:
1. Cardiac risk factors: +HL, +HTN, +prior MI, +Age >65, +FH,
unknown LDL.
2. Caridac hx: CAD
- [**2180**] s/p MI and angioplasty, s/p thrombolytics and RCA
PCI.
- [**2191**] NSTEMI, s/p bare metal stenting of the LAD
- [**2195**] Repeat cath: RCA T.O., LAD stent patent.
3. Other medical hx:
- Atrial fibrillation, s/p DC cardioversions, the last in [**4-25**]
- PVD s/p left leg stenting with subsequent thrombotic occlusion
requiring ? thrombectomy/PTA
- s/p Right carotid endarterectomy in [**2195**]
- Hx of retinal vein occlusion involving right eye
- Dyslipidemia
- Hypertension
- CRI ?baseline 1.3
- [**2196**]- Admission for GIB while on plavix- no details
- Interment symptoms of GERD
- Occasional coughing and wheezing- pt. reports recently being
evaluated by a pulmonologist-workup unremarkable
- Anxiety
- Left knee meniscus tear, s/p surgical repair
- Lower back pain
- Hysterectomy
- Neuropathy of both feet
- Glaucoma involving the left eye requiring enucleation
- Macular degeneration involving the right eye
- obesity
- hx of benign thyroid mass s/p excision
- Diverticulosis/diverticulitis
Social History:
Patient is divorced and lives alone.
Contact upon discharge: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (daughter): [**Telephone/Fax (1) 82261**]
ETOH: rare occasion
Tobacco: quit 20 years ago
Home care Services: none
Family History:
Father had MI at age 50
Physical Exam:
Admission:
Vitals: 97.3, 72, 193/109, 72, 16, 99%RA
General: pleasant, in pain
HEENT: NC/AT, anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB anteriorly, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: +BS NT/ND, soft
Ext: no c/c/e, pulses: +dopplers at PT and DP pulses
bilaterally; R groin hematoma about 2 in. wider from darcation
post-procedure. Firm and tender to touch. Main area of firm
hematoma at R thigh near softball sized.
Neuro: AOx3, sensation intact at LE and [**5-21**] motor at LE
Pertinent Results:
Admission:
[**2199-6-26**] 08:26PM BLOOD WBC-9.5 RBC-4.84 Hgb-15.4 Hct-44.8 MCV-93
MCH-31.8 MCHC-34.3 RDW-13.7 Plt Ct-211
[**2199-6-26**] 07:50AM BLOOD PT-29.1* PTT-32.9 INR(PT)-3.0*
[**2199-6-27**] 01:51AM BLOOD Glucose-203* UreaN-36* Creat-1.4* Na-143
K-3.5 Cl-104 HCO3-26 AnGap-17
[**2199-6-27**] 01:51AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.4*
ECG [**6-26**]
Atrial fibrillation with a mean ventricular rate of 109.
Inferior myocardial infarction. Diffuse non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of [**2199-6-20**] no major change.
ECG [**6-27**]
Sinus rhythm with atrial premature depolarizations. Compared to
the previous tracing cardiac rhythm is now sinus mechanism.
CT [**6-26**]
Extensive right groin hematoma with multiple collections
spanning a region
measuring roughly 10 cm cc x 9 x 3 cm. Extensive stranding of
subcutaneous
tissues of medial right thigh. In the pelvis, sigmoid
diverticulosis without diverticulitis. Atherosclerotic vascular
calcifications.
CXR [**6-26**]
IMPRESSION: Moderate cardiomegaly including left atrial
enlargement. No
evidence of acute pulmonary vascular congestion. Observed that
circulatory
fluid overload cannot be identified on chest examination unless
criteria for CHF or venous congestion is present. The latter is
not the case in this patient.
Lower ext U/S [**6-27**]
IMPRESSION: Large hematoma in the right groin, with suggestion
of a small
vessel AV fistula, involving the greater saphenous vein and a
small branch
artery in the groin, without involvement of the common femoral
artery.
Brief Hospital Course:
76yo F w/ hx of CAD, s/p prior MI and PCI, PVD, s/p CEA and left
leg PTA and paroxysmal Afib dating back to [**2191**] presenting today
s/p PVI for afib c/b R inguinal and thigh hematoma
# Hematoma, R groin/thigh- Pt underwent the procedure [**6-26**] with
an INR of 3.0, and because of liable blood pressures required a
5F femoral arterial line. The procedure itself went well.
Post-procedure she developed a R groin arterial bleed, and
pressure needed to be held for 1-1.5h. Her hematocrit dropped
from 50 one week ago to 44.8. Vascular surgery was consulted and
2units FFP were given. Her repeat Hct dropped to 27.9. She was
given another 3U FFP and transfused 3U pRBC. Her hematoma
remained stable and Hct increased 34.9. She was hemodynamically
stable. Vascualr U/S of the groin showed large hematoma and
concern for AV fistula with plan to repeat U/S in AM. However,
overnight the patient became agitated and and repeat Hct that
evening dropped to 29.6 (erroneous Hct of 13.9). She received an
additional 2U pRBC. Additionally, her hematoma enlarged and
groin became more tense and expanding. She was evaluated by
vascular surgery and taken to the OR for evacuation and repair
of a pseudoaneurysm was performed. The procedure was initially
under MAC, but due to blood loss and hypotension the patient was
intubated and required neo. Her pressors were eventually weaned
off the following day. A drain was left in place to drain the
area. She remained stable and was extubated on [**6-30**]. Vascular
surgery continued to follow the patient. The patient received a
total of 7U pRBC (last transfusion on [**6-29**]) and 7U FFP. Her Hct
remained stable.
.
# Rhythm- h/o atrial fibrillation, s/p DC cardioversions, the
last in [**4-25**]. The patient underwent EP procedure on [**6-26**]. She
was in NSR s/p PVI. On [**6-29**] around 9am pt developed narrow
complex tachycardia, got DCCV became asystolic for and required
a couple seconds of CPR and 1mg atropine, and was in NSR for
1-2hrs. Then around 11am pt was in HR 180s-190s with EKG c/w
AVNRT. Amiodiorone was loaded Adenosine 6mg x1 given and pt went
into 130s with EKG then c/w Afib. Pt was then given a second
DCCV and was in NSR. Then around 5pm pt went back into 190s,
recieved third DCCV remained NSR 70-90s. However, on [**6-30**] the
patient reverted back into a-fib with rates between 80-120's.
She was loaded with 0.5mg of digoxin x2 and continued on 0.25mg
daily. Additioanlly, her metoprolol was titrated up for better
rate control. On discharge her metoprolol was 75mg TID
(previously toprol 150 qday). She was started on coumadin on
[**7-3**].
# Coronaries- known CAD w/ multiple MI and prior hx of
angioplasty and stenting. Currently pt denies CP, and EKG was
unchanged prior/post procedure. Do not suspect ACS or demand.
.
# Pump- LVEF 60%. no significant valve disease. Euvolemic.
.
# HTN- hypertensive urgency likely from pain and anxiety. Pt's
SBP improved from 200s to 160 with 1 of morphine and 1 of
ativan. She was continued on metoprolol as above.
.
#Pneumonia: On [**6-29**] the patient had a fever and CXR showed a new
bibasilar opacitiies, new L sided effusion, fluid overload. She
was started levoflox 250 mg daily (renally dosed) for empiric tx
of aspiration pna with a planed 7 day course.
.
#. UTI: Pt with pan-sensitive E. Coli growing in her urine from
[**6-30**]. She was already being covered with levofloxacin for
aspiration pneumonia as above and no additional coverage was
needed.
# Anxiety/Delerium- Patient had recurrent episodes of acute
delirium during her hospitalization. He was treated with haldol
with little effect and zyprexa and ativan. She underwent a head
CT that was negative for acute process. Currently oriented x3,
remembers hospital course, with mostly intact short term memory.
However has hallucinations about surroundings, thinks her room
is a beauty parlor. She has good insight into her condition and
is encouraged that delerium is [**2-18**] hospitalization and illness
and will likely clear. No infectious source apparant at present.
Has low grade bacteria in urine in setting of Foley, on Levo for
presumed PNA and currently afebrile. Having regular stools. No
meds that would exacerbate. Was on Xanax at home, currently has
Lorazepam prn.
.
# DVT: U/S performed on [**7-1**] showed DVT in right posterior
tibial vein. She was not started on heparin gtt given her
hematoma. She was inititated coumadin as above given her a-fib.
No evidence of decreased circulation with warm feet and no SOB.
-pt should have a follow up ultrasound in [**4-22**] months to
re-evaluate
.
# Left wrist Phlebitis: s/p IV site. Pt had some tracking
initially with IV use, IV has been pulled and there is still
mild swelling at the site, slowly improving. This should resolve
please use warm packs and elevation.
# R medial foot erythema/ Joint pain- pt devleoped minor joint
pain on day of discharge. This may be gout, pt has no previous
history. Uric acid was not drawn as not diagnostic. Pt was
treated discharged on one week of Ibuprofen. Pt should take
protonix for one week for GI protection, and follow up as outpt
for this joint pain and procede with joint tap for diagnosis of
Gout if this reoccurs.
Medications on Admission:
Alprazolam 0.5 mg Tablet
1 Tablet(s) by mouth at bedtime
Ezetimibe-Simvastatin [Vytorin 10-40] 10 mg-40 mg Tablet
1 Tablet(s) by mouth qpm
Hydrochlorothiazide 25 mg Tablet
1 Tablet(s) by mouth qam
Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
1.5 Tablet(s) by mouth once a day
Valsartan [Diovan] 80 mg Tablet
1 Tablet(s) by mouth qam
Warfarin 4 mg Tablet
1 Tablet(s) by mouth on Thursday/Saturday, half a tablet all
other days
* OTCs *
Aspirin 81 mg Tablet
2 Tablet(s) by mouth qam
Multivitamin Capsule 1 Capsule(s) by mouth qam
Omega-3 Fatty Acids-Vitamin E [Omega-3 Fish Oil]
1,000 mg-5 unit Capsule 2 Capsule(s) by mouth every afternoon
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Goal
INR [**2-19**]. Please resume home regimen of 2 mg daily 5x/week and 4
mg daily 2x/week when INR is therapeutic.
7. Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale
units Subcutaneous ASDIR (AS DIRECTED): Please d/c if BS
consistantly <150.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO Q8 ().
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: use while pt
on NSAIDS.
14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day for 1 weeks: for gout, please d/c if symptoms resolve.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Arial Fibrillation
Hypertension
Coronary Artery disease
Chronic Kidney Disease
Peripheral Vascular Disease
Legally Blind with Macular Degeneration right eye and left eye
prosthesis
Anxiety
Delerium
Peripheral Vascular Disease
Discharge Condition:
stable
Discharge Instructions:
You had a pulmonary vein isolation to treat your atrial
fibrillation. Unfortunately, the atrial fibrillation returned
and you were restarted on Metoprolol to control your rate. You
also have been restarted on coumadin to prevent strokes. You
have a blood clot in your lower right leg and the coumadin
should prevent further clots. You should have an ultrasound in 6
months of your lower right leg to see if the blood clot is gone.
AFter the procedure, a catheter was removed from your right
groin and a large blood collection formed at the site requiring
surgery to treat. The blood was removed from the site but there
will be some bruising and discomfort that should improve slowly.
The drain will be removed by Dr. [**Last Name (STitle) 1391**].
New medicines:
1. Warfarin was increased to 5 mg daily until your INR is
therapeutic, please then decrease to previous home dose of 2 mg
daily 5 times per week and 4 mg daily 2 times per week.
2. Levofloxacin: to treat pneumonia and UTI
3. Digoxin: to control your heart rate
4. Ibuprofen: to treat your gout
5. Pantoprazole: to protect your stomach from the Ibuprofen
6. Metoprolol: your dose was increased to 75mg three times a day
to have better heart rate control
Stop taking:
1. Diovan and hydrochlorothiazide
.
You have an appt with Dr. [**Last Name (STitle) 5051**] in [**Month (only) 205**] and with Dr. [**Last Name (STitle) 1391**]
in [**Month (only) **] to remove the drain and staples.
Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) 6989**] [**Last Name (NamePattern1) 5051**] Phone: [**Telephone/Fax (1) 6256**] Date/Time: [**8-6**] at
1:00pm.
.
Vascular Surgery:
Dr. [**Last Name (STitle) 1391**] Phone: ([**Telephone/Fax (1) 4852**] [**Hospital **] Medical Office Building
Suite 5C. [**Last Name (NamePattern1) 439**] [**Location (un) 86**]. Wednesday [**7-10**] at
10:45am.
Primary Care:
CHIRASEVINUPRAPHAN,PRAMODHYA D. Phone: [**Telephone/Fax (1) 20261**] Please make
an appt to see him after you get out of rehabilitation.
Completed by:[**2199-7-5**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,755
| 114,083
|
2107
|
Discharge summary
|
report
|
Admission Date: [**2130-8-18**] Discharge Date: [**2130-8-22**]
Date of Birth: [**2078-7-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Vicodin / Sustiva / Abacavir Sulfate / Bactrim DS / Augmentin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
increased size of meningioma
Major Surgical or Invasive Procedure:
[**2130-8-18**]: Right craniotomy and resection of parasaggital
meningioma
History of Present Illness:
52yo woman with history of HIV/AIDS who was hospitalized in [**2124**]
for ARF and PNA. At that time a CT and MRI were performed of her
brain revealing 2 meningiomas. These have been treated
conservatively and monitored with surveillance scans since this
time. Recently it was noted that there was significant increase
in size of the right parasaggital meningioma. It was recommended
that this be surgically removed and she electively presents now
for this procedure.
Past Medical History:
- HIV/AIDS (on HAART since [**2108**])
- meningiomas
- A1 cerebral aneurysm s/p coiling
- hx CMV retinitis in right eye
- cervical dysplasia
- rectal cancer in [**2121**] had XRT, chemo, and surgery.
- s/p TAH/BSO
- history of oral HSV
Social History:
She smokes one pack per day; she doesn't drink alcohol; she has
a distant history of cocaine use
Family History:
Maternal grandparents died of cancer (unknown type) in their 60s
or 70s. Her parents are alive in their 70s. No other known
cancer in the family. Paternal grandmother diet of cirrhosis.
Pertinent Results:
Pathology Report Tissue: tumor, FS TUMOR. Procedure Date of
[**2130-8-18**]
*********Report not finalized*****************
MR HEAD W/ CONTRAST Study Date of [**2130-8-18**] 5:24 AM
IMPRESSION:
1. Multiple dural-based lesions, likely meningiomas again noted
with increase in size of the right parasagittal and right
paratentorial lesions compared to the prior exam and no change
in size of the left occipital, right sphenoid [**Doctor First Name 362**] and planum
sphenoidale lesions.
2. Right maxillary sinus thickening.
CT HEAD W/O CONTRAST Study Date of [**2130-8-18**] 1:56 PM
CONCLUSION:
1. Status post resection of right parasagittal meningioma with
evidence of pneumocephalus, blood, and edema in the operative
bed, consistent with
appropriate post-operative changes. There is also evidence of
pneumocephalus tracking anteriorly to the right frontal lobe.
No other evidence of hemorrhage, mass effect, or acute
infarction.
2. Stable meningioma in the left occipital lobe as noted
previously on MRI.
MR HEAD W & W/O CONTRAS [**2130-8-20**]*****************
Brief Hospital Course:
The patient electively presented and underwent a craniotomy and
resection of mass. Post operatively and she was extubated and
transferred to the ICU for close neurological observation. Post
op head CT revealed expected post operative change. On post
operative exam, the patient left lower extremity showed poor
motor function and was given Dexamethasone 15mg. Dexamethasone
6mg every 6 hours was initiated. Intravenous fluid was
increased and the Systolic Blood Pressure goal was liberalized
to 160. The neurological exam began slowly improving and some
left lower extremity lateral movement was noted.
On [**8-20**], The patient motor exam continued to improve slowly.
Transfer orders were written for the patient to transfer to the
floor and the patient was awaiting an available bed. A Decadrom
wean was initiated and the patient was mobilized out of bed to
the chair. A physical therapy consult was placed.The foley
catheter was discontinued. Subcutaneous heparin was initiated
for deep vein thrombosis prophylaxis.
On [**8-21**] she was neurologically stable. PT and OT were requested
for discharge planning. They recommended discharge....
Medications on Admission:
emtricitabine-tenofovir [Truvada]
etravirine
famciclovir
gabapentin
imiquimod
levetiracetam
prochlorperazine maleate
raltegravir
cromolyn
loratadine
multivitamin
naproxen
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q12H
3. Dexamethasone 3 mg po q8hrs Duration: 2 Days
then discontinue
RX *dexamethasone 1.5 mg 2 tablet(s) by mouth every 8 hours Disp
#*12 Tablet Refills:*0
4. Dexamethasone 2 mg PO Q8HRS Duration: 2 Days
then discontinue
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
5. Dexamethasone 1 mg PO Q8HRS Duration: 2 Days
then discontinue
Tapered dose - DOWN
RX *dexamethasone 1 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
6. Dexamethasone 1 mg PO Q12HRS Duration: 2 Days
then discontinue
Tapered dose - DOWN
RX *dexamethasone 1 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*4 Tablet Refills:*0
7. Dexamethasone 1 mg PO Q24HRS Duration: 2 Days
then discontinue
RX *dexamethasone 1 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. Etravirine 200 mg PO BID
11. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
12. Gabapentin 100 mg PO HS
13. imiquimod *NF* 1 Appl TP 3X/WEEK ([**Doctor First Name **],WE) Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
Apply to molluscum 3 times a week
14. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*28 Tablet Refills:*0
15. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg [**11-21**] tablet(s) by mouth every 4-6 hours Disp
#*30 Tablet Refills:*0
16. Raltegravir 400 mg PO BID
17. Heparin 5000 UNIT SC TID
RX *heparin (porcine) 5,000 unit/mL please inject subcutaneously
into abdomen three times a day Disp #*60 Cartridge Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right parasaggital meningioma
Discharge Condition:
stable
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? **Your wound was closed with staples so you must wait until
after they are removed to wash your hair. You may shower before
this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? **You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? 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, unless you have been instructed not to.
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:
Follow-Up Appointment Instructions
?????? Your staples need to be removed 10-14 days from your date of
surgery. This can be done at your rehab facility. If they have
questions or if you are discharged prior to this, please call
[**Telephone/Fax (1) 1669**] to make an appt. If you live quite a distance from
our office, please make arrangements for the same, with your
PCP.
?????? You have an appointment in the Brain [**Hospital 341**] Clinic on [**2130-9-4**]
at 2pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2130-8-22**]
|
[
"305.1",
"V10.06",
"722.6",
"V15.3",
"V87.41",
"225.2",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
5932, 6029
|
2619, 3772
|
353, 430
|
6102, 6110
|
1525, 2596
|
7706, 8521
|
1316, 1506
|
4006, 5909
|
6050, 6081
|
3799, 3983
|
6134, 7683
|
285, 315
|
458, 927
|
949, 1186
|
1202, 1300
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,711
| 114,378
|
6457
|
Discharge summary
|
report
|
Admission Date: [**2154-9-9**] Discharge Date: [**2154-9-14**]
Date of Birth: [**2085-7-20**] Sex: M
Service: SURGERY
Allergies:
Ceftriaxone / Cartia Xt / Hydroxyzine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Left infected Charcot foot
Major Surgical or Invasive Procedure:
[**2154-9-10**] Left Below the knee amputation
History of Present Illness:
This 69-year-old gentleman with dialysis dependent renal
failure, longstanding diabetes mellitus, and peripheral
neuropathy, has bilateral Charcot foot deformity. He has had a
Charcot foot reconstruction on the left. This became unstable
again, chronically infected from osteomyelitis and he now has a
flail ankle which is non- salvageable. He was advised to have a
below-the-knee amputation.
Past Medical History:
1. DM2 complicated by retinopathy, nephropathy, neuropathy
2. ESRD (recent baseline Cr 7-7.5). HD M/W/F.
3. HTN
4. Hyperlipidemia
5. Paralyzed right hemidiaphragm s/p MVA [**2135**]
6. OSA on CPAP 11, secondary to #5 per pt
7. h/o syncope, has implanted event recorder x2yrs.
8. Glaucoma
Social History:
Lives at home with wife on [**Hospital3 **]. Owns a construction
company. Denies EtOH/TOB/IVDU.
Family History:
Mom died from DM complications. Has 1 sister and 3 children -
healthy.
Physical Exam:
Afebrile/VSS
Gen: no distress, alert and oriented x 3
HEENT: PERLA, EOMI, anicteric
Neck: no bruits heard
Chest: RRR, lungs clear
Abdomen: soft, nontender, nondistended
Ext: rigth foot warm well perfused, left BKA stump incision
clean and dry, no erythema, there is minimal ecchymoses, minimal
edema
.
Pulses: palpable femorals bilaterally, doppler signals in right
foot
Pertinent Results:
[**2154-9-13**] 08:15AM BLOOD WBC-11.2* RBC-3.99* Hgb-10.2* Hct-32.8*
MCV-82 MCH-25.6* MCHC-31.2 RDW-16.4* Plt Ct-332
[**2154-9-12**] 06:25AM BLOOD WBC-9.6 RBC-4.01* Hgb-10.4* Hct-33.5*
MCV-84 MCH-26.0* MCHC-31.1 RDW-16.4* Plt Ct-311
[**2154-9-9**] 05:30PM BLOOD Neuts-82.0* Lymphs-9.3* Monos-5.8 Eos-2.6
Baso-0.3
[**2154-9-13**] 08:15AM BLOOD Plt Ct-332
[**2154-9-13**] 08:15AM BLOOD Glucose-143* UreaN-51* Creat-7.1*# Na-136
K-4.2 Cl-93* HCO3-33* AnGap-14
[**2154-9-11**] 10:00AM BLOOD CK(CPK)-63
[**2154-9-11**] 03:15AM BLOOD ALT-52* AST-60* AlkPhos-192* TotBili-0.6
[**2154-9-13**] 08:15AM BLOOD Calcium-8.1* Phos-5.6* Mg-2.3
[**2154-9-13**] 08:15AM BLOOD Vanco-21.7*
[**2154-9-11**] 10:10AM BLOOD Type-ART pO2-100 pCO2-57* pH-7.33*
calTCO2-31* Base XS-1 Intubat-NOT INTUBA
[**2154-9-11**] 06:39AM BLOOD O2 Sat-98
[**2154-9-11**] 01:35AM BLOOD freeCa-1.04*
CXR [**2154-9-10**] 6:33 PM
IMPRESSION: Mild dependent pulmonary edema changed in
distribution but not in overall severity since [**9-9**].
Greater opacification in the left lower lobe could be
atelectasis, with likely persistence of at least a small left
pleural effusion. Heart size normal. Mediastinal contours are
unremarkable. ET tube ends at the thoracic inlet. The caliber of
the endotracheal tube may be small, since the diameter, 12 mm,
is less than a half the coronal diameter of the trachea, 26 mm.
Clinical assessment is indicated.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**9-9**] after his normal dialysis
session for preoperative preparation for a left BKA. He
underwent a successful Left BKA on [**2154-9-10**]. While still in the
OR during emergence from anesthesia, he developed profound
bradycardia and lost his blood pressure. Chest compressions
were initiated. After a minute of compressions and a dose of
atropine, his blood pressure returned to 120 systolic.
Postoperatively the patient was kept intubated and transferred
to the cardiovascular intensive care unit where he required
Neosynephrine to maintain his blood pressure. He was quickly
weaned off the Neo and extubated on POD1. His cardiac arrest
was attributed to hypercarbia. The rest of the work up was
normal. He underwent HD on POD1 and tolerated it well. He was
then transferred to the VICU. On the floor, he remained
hemodynamically stable with his pain controlled. He progressed
with physical therapy to improve his strength and mobility. He
continues to make steady progress without any incidents. He was
discharged to a rehabilitation facility in stable condition.
Medications on Admission:
novolog SSI, nephrocap daily, asa 81mg daily, crestor 5mg daily,
norvasc 2.5mg on non-HD days, lasix 80mg Fri/Sat/Sun, cosop 1
gtt ou [**Hospital1 **], alphagan 1 gtt os [**Hospital1 **], renvela 3200mg tid w/ meals,
zoloft 100mg daily
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. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
([**Doctor First Name **],FR,SA).
6. Sevelamer Carbonate 800 mg Tablet Sig: Four (4) Tablet PO
EACH MEAL ().
7. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
14. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
15. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): take while not ambulatory and
decreased mobility.
17. Ondansetron 4 mg IV Q8H:PRN nausea
18. Lantus 100 unit/mL Cartridge Sig: Five (5) units
Subcutaneous once a day.
19. Insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-55 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
56-70 mg/dL 0 Units 0 Units 0 Units 0 Units
71-100 mg/dL 7 Units 5 Units 8 Units 0 Units
101-150 mg/dL 8 Units 6 Units 9 Units 0 Units
151-200 mg/dL 9 Units 7 Units 10 Units 0 Units
201-250 mg/dL 10 Units 8 Units 11 Units 0 Units
251-300 mg/dL 11 Units 9 Units 12 Units 2 Units
301-350 mg/dL 12 Units 10 Units 13 Units 4 Units
351-400 mg/dL 13 Units 11 Units 14 Units 5 Units
>401 mg/dL 14 Units 12 Units 15 Units 6 Units
20. Amoxicillin/Clavulanate Sig: One (1) 500mg twice a day
for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
Rehab.hosp. of [**Location (un) **] & Islands-[**Location (un) 6251**]
Discharge Diagnosis:
Left non-healing charcole foot
DM2
ESRD
Hypertension
Hyperlipidemia
Glaucoma
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
Continue taking the antibiotic Augmentin for 1 week.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2154-10-14**] 1:20
|
[
"250.60",
"786.09",
"V45.11",
"997.1",
"272.4",
"365.9",
"E878.6",
"427.5",
"403.91",
"730.18",
"250.40",
"585.6",
"250.50",
"362.01",
"718.87",
"707.14",
"440.23",
"713.5",
"V58.67",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.71",
"99.60",
"84.15"
] |
icd9pcs
|
[
[
[]
]
] |
6997, 7094
|
3149, 4277
|
323, 372
|
7215, 7224
|
1714, 3126
|
12662, 12822
|
1236, 1308
|
4563, 6974
|
7115, 7194
|
4303, 4540
|
7248, 8986
|
1323, 1695
|
257, 285
|
8998, 11963
|
11986, 12639
|
400, 795
|
817, 1106
|
1122, 1220
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,578
| 121,815
|
16006
|
Discharge summary
|
report
|
Admission Date: [**2177-6-11**] Discharge Date: [**2177-6-15**]
Date of Birth: [**2111-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Exertional symptoms increasing over past month.
Major Surgical or Invasive Procedure:
1. CABG x3 (LIMA-LAD, SVG-OM, SVG-diag)
History of Present Illness:
65M c h/o CAD, presenting with increasing exertional symptoms
over the past month. S/p PTCA/stent in LAD [**10-10**], re-stent [**2-10**],
re-stent [**2-11**]. This episode, cardiac cath at [**Hospital3 **] showed severe LAD restenosis and LCx 40%, EF 55%.
Transferred to [**Hospital1 18**], referred for CABG.
Past Medical History:
1. CAD
2. DM
3. hypertension
4. hypercholesterolemia
Social History:
unremarkable
Family History:
Father: MI, age 66
Physical Exam:
NAD, alert
Afebrile, VSS
Neck: no bruits, no JVD
Heart: RRR, no murmurs
Lungs: CTAB
Abd: soft, NT, ND
Ext: no edema
Brief Hospital Course:
65M c h/o CAD, presenting with increasing exertional symptoms
over the past month. S/p PTCA/stent in LAD [**10-10**], re-stent [**2-10**],
re-stent [**2-11**]. This episode, cardiac cath at [**Hospital3 **] showed severe LAD restenosis and LCx 40%, EF 55%.
Transferred to [**Hospital1 18**], referred for CABG.
To OR [**2177-6-11**], CABG x3 (LIMA-LAD, SVG-OM, SVG-diag). Post-op,
transferred to CSRU where he was extubated on POD0, chest tubes
and swan ganz removed on POD1, transferred to floor on POD1.
Did well on the floor with exception of sinus tach, ? Afib on
POD2-3 which resolved spontaneously. Pericardial wires removed
on POD3. Cleared PT. D/C to home on POD4.
Medications on Admission:
1. Lipitor 10'
2. Glyburide 5"
3. Lisinopril 20'
4. Toprol XL 50'
5. Plavix 75'
6. ASA 325'
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. 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*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: 2.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. CAD
2. hypercholesterolemia
3. DM
4. hypertension
Discharge Condition:
Good
Discharge Instructions:
1. Medications as directed.
2. Follow up as directed.
3. Call office or go to ER if fever/chills, drainage from
sternum, chest pain, shortness of breath.
Followup Instructions:
Dr. [**Last Name (STitle) **], 4 weeks.
Cardiologist, 2 weeks.
PCP, 2 weeks.
|
[
"722.10",
"272.0",
"401.9",
"414.01",
"996.72",
"413.9",
"250.00",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"89.60",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
3214, 3272
|
1050, 1731
|
369, 411
|
3369, 3375
|
3577, 3659
|
875, 895
|
1873, 3191
|
3293, 3348
|
1757, 1850
|
3399, 3554
|
910, 1027
|
282, 331
|
439, 753
|
775, 829
|
845, 859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,550
| 170,988
|
2059
|
Discharge summary
|
report
|
Admission Date: [**2155-10-26**] Discharge Date: [**2155-11-1**]
Service: [**Hospital 11212**] [**Hospital6 733**] Firm
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
Italian gentleman with a history of coronary artery disease
and 3-vessel disease by cardiac catheterization, and
congestive heart failure with systolic and diastolic
dysfunction (last ejection fraction 20% in [**2155-6-8**]) who
had a recent Coronary Care Unit admission from [**9-15**]
through [**2155-9-24**] for a congestive heart failure
exacerbation requiring intubation. This hospital stay was
complicated by methicillin-resistant Staphylococcus aureus
pneumonia and bacteremia, and the patient was discharged to
rehabilitation with six weeks of vancomycin treatment.
The patient presents today with diaphoresis and weakness with
shortness of breath. He denies chest pain, nausea, vomiting,
or palpitations. He was brought to the Emergency Department
from his rehabilitation facility.
As mentioned above, on his last admission the patient had
flash pulmonary edema requiring intubation and pressors with
a difficult extubation secondary to aspiration. The patient
was found to have methicillin-resistant Staphylococcus aureus
in his sputum and blood and was treated with vancomycin for a
6-week course.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post 3-vessel disease by
cardiac catheterization in [**2155-9-8**].
2. Congestive heart failure (with an ejection fraction of
20% by transthoracic echocardiogram in [**2155-6-8**]).
3. Peripheral vascular disease; status post right
ileofemoral bypass in [**2152-10-8**] and status post left
iliac angioplasty in [**2154-7-8**].
4. Status post automatic internal
cardioverter-defibrillator for ventricular tachycardia
arrest.
5. Status post dual-mode, dual-pacing, dual-sensing
pacemaker for sick sinus syndrome.
6. Chronic obstructive pulmonary disease.
7. Chronic renal insufficiency (with a baseline creatinine
of 2 to 3.6).
8. Hypertension.
9. Dyslipidemia.
10. History of gallstone pancreatitis.
MEDICATIONS ON ADMISSION:
1. Aspirin by mouth once per day.
2. Amiodarone 200 mg by mouth once per day.
3. Plavix 75 mg by mouth once per day.
4. Isordil 10 mg by mouth three times per day.
5. Lipitor 10 mg by mouth once per day.
6. Seroquel 25 mg by mouth twice per day.
7. Hydralazine 25 mg by mouth four times per day.
8. Toprol-XL 25 mg by mouth once per day.
9. Vancomycin 750 mg intravenously q.48h. (the patient is on
week five out of six for six weeks of treatment).
ALLERGIES: ACE INHIBITORS.
SOCIAL HISTORY: The patient lives in [**Location 1268**] with his
wife; however, he has been in rehabilitation over the past
five weeks at the [**Hospital3 537**]. Occasional alcohol. He
quit smoking 10 years ago. No intravenous drug use. The
patient is from [**Country 2559**].
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 98.4 degrees
Fahrenheit, his blood pressure was 121/39, his heart rate was
64, his respiratory rate was 20, and his oxygen saturation
was 100% on a nonrebreather. His weight was 87 kilograms.
In general, the patient was an elderly gentleman in moderate
respiratory distress. Neck examination revealed jugular
venous pressure at 8 cm while the patient was at 90 degrees.
Chest examination revealed rhonchorous breath sounds
bilaterally with rales one quarter of the way up from the
bases bilaterally. Cardiovascular examination revealed
normal first heart sounds and second heart sounds. A regular
rate. No murmurs, rubs, or gallops. The abdominal
examination revealed normal active bowel sounds. The abdomen
was soft, nontender, and nondistended. Extremity examination
revealed 1+ edema bilaterally to the tibias. The extremities
were warm. Neurologic examination revealed the patient was
alert, awake, and oriented times three.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
upon admission revealed the patient's white blood cell count
was 19.8, his hematocrit was 35.9, and his platelets were
1056. His potassium was 5.1, his blood urea nitrogen was 36,
his creatinine was 2.8, and his glucose was 209.
Coagulations were normal.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed
cardiomegaly that was stable from the last study, moderate
interstitial edema, and mild pleural effusions, with
worsening congestive heart failure.
Electrocardiogram revealed a sinus rhythm, right axis
deviation, left bundle-branch block, atrioventricularly
paced.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was initially admitted to the [**Hospital Ward Name 332**] Intensive Care
Unit Service for careful management of this congestive heart
failure exacerbation with unclear precipitant. He remained
in the [**Hospital Ward Name 332**] Intensive Care Unit for two days and was
transferred to the [**Hospital6 733**] Medicine Service on
[**10-28**] in stable condition. Below, please find a summary
of the hospital course divided by issues/systems.
1. CONGESTIVE HEART FAILURE ISSUES: The patient was
diuresed with intravenous Lasix and metolazone with a good
response.
The patient was placed on intravenous nitroglycerin for the
initial 24 hours of his admission, and afterload was reduced
with hydralazine. The patient was placed on [**Hospital1 **]-level
positive airway pressure initially for respiratory management
but was quickly weaned to nasal cannula.
An echocardiogram was performed on [**10-28**] which showed no
dramatic change from last echocardiogram done in [**Month (only) **]. The
left atrium was moderately dilated as well as the right
atrium. The left ventricular cavity was borderline dilated.
The overall systolic function was unchanged at 25% to 30%.
There were several wall motion abnormalities seen.
The patient diuresed very nicely and was stabilized on a by
mouth regimen that was continued on the regular medicine
floor of Lasix 40 mg by mouth every day, spironolactone 25 mg
by mouth once per day, isosorbide dinitrate 10 mg by mouth
three times per day, Toprol-XL 25 mg by mouth once per day,
and hydralazine 25 mg by mouth four times per day.
The patient remained with crackles during this admission and
did not develop any lower extremity edema. He was weaned to
room air with ease and was maintained off of oxygen during
his Medicine Service course.
2. CORONARY ARTERY DISEASE ISSUES: The patient with
3-vessel coronary artery disease. The patient was continued
on the above regimen with the addition of aspirin by mouth
once per day, and atorvastatin, as well as his Plavix 75 mg
by mouth once per day. The patient was ruled out for a
myocardial infarction as a precipitating factor.
3. RHYTHM ISSUES: The patient is atrioventricularly paced.
Amiodarone was continued.
4. INFECTIOUS DISEASE ISSUES: The patient's cultures on
[**10-27**] were positive for coagulase-negative
Staphylococcus. An Infectious Disease consultation was
obtained, and this was deemed to be a peripherally inserted
central catheter line contaminant. The patient was
recommended to finish his complete 6-week course of
vancomycin for methicillin-resistant Staphylococcus aureus
bacteremia and pneumonia that was started prior to this
admission. The patient had surveillance cultures during this
admission which were negative. Urine cultures were also
negative during this admission. A midline intravenous line
was placed for antibiotic infusion upon discharge. The
patient was to have five more days of vancomycin treatment
upon discharge.
5. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient remained
at baseline with good urine output during this admission.
Spironolactone was held near discharge due to a creatinine of
2.8. This should likely be restarted in the future.
6. ANEMIA ISSUES: The patient's hematocrit trended downward
during his admission. The patient was found to be iron
deficient on laboratories, and oral by mouth supplementation
was started. In addition, on [**10-27**], intravenous an iron
treatment was infused. The patient has not had a workup of
this anemia and will need an outpatient colonoscopy. He was
guaiac-negative during this admission. He received one unit
or packed red blood cells with a good response during this
admission. The source of anemia also likely due to chronic
renal insufficiency.
7. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: Nebulizer
treatments were continued. The patient was stable and on room
air.
8. THROMBOCYTOSIS ISSUES: Likely acute phase reactant
secondary to iron deficiency or recent bacteremia and
pneumonia. The patient's platelet count improved during this
admission and was in the 700s upon discharge.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: The patient was to go to a subacute
rehabilitation facility as recommended by Physical Therapy.
DISCHARGE DIAGNOSES:
1. Congestive heart failure exacerbation.
2. Coronary artery disease.
3. Resolving methicillin-resistant Staphylococcus aureus
bacteremia and pneumonia.
4. Coagulase-negative Staphylococcus bacteremia.
5. Hypertension.
6. Dyslipidemia.
7. Iron deficiency anemia.
8. Sick sinus syndrome with pacemaker.
9. History of ventricular tachycardia with automatic
internal cardioverter-defibrillator.
10. Chronic obstructive pulmonary disease.
11. Chronic renal insufficiency.
12. Thrombocytosis.
MEDICATIONS ON DISCHARGE:
1. Hydralazine 25 mg by mouth four times per day.
2. Toprol-XL 25 mg by mouth once per day.
3. Isosorbide dinitrate 10 mg by mouth three times per day.
4. Salmeterol inhaler.
5. Iron sulfate 325 mg by mouth twice per day.
6. Lasix 40 mg by mouth once per day.
7. Senna.
8. Colace.
9. Vancomycin 750 mg intravenously q.48h. (until [**11-5**]).
10. Seroquel 25 mg by mouth twice per day.
11. Atorvastatin 10 mg by mouth once per day.
12. Plavix 75 mg by mouth once per day.
13. Amiodarone 200 mg by mouth once per day.
14. Aspirin 325 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to be seen
at the Cardiology Service at [**Hospital1 188**] on [**12-5**] at 2 o'clock in the afternoon with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **] for followup of his congestive heart failure.
DISCHARGE DISPOSITION: The patient was to be discharged to
a rehabilitation facility; most likely the [**Hospital3 537**]
where he was admitted from.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Name8 (MD) 11213**]
MEDQUIST36
D: [**2155-10-30**] 15:27
T: [**2155-10-30**] 15:40
JOB#: [**Job Number 11214**]
|
[
"996.62",
"414.01",
"482.41",
"790.7",
"496",
"428.0",
"V09.0",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10362, 10698
|
8954, 9463
|
9490, 10072
|
2110, 2598
|
10106, 10337
|
4610, 8751
|
8766, 8932
|
161, 1307
|
1330, 2084
|
2615, 4576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,603
| 192,499
|
53142
|
Discharge summary
|
report
|
Admission Date: [**2107-2-28**] Discharge Date: [**2107-3-10**]
Date of Birth: [**2053-3-13**] Sex: M
Service: Liver Transplant Surgery Service
This is a 53-year-old patient who was admitted to the
transplant service on [**2107-2-28**]. He was admitted
under Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **].
CHIEF COMPLAINT: Endstage liver disease. Here for DCD liver
transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
male with a history of hepatitis C virus cirrhosis, endstage
liver disease, first diagnosed approximately 2 years prior to
admission. He also has a history of alcohol abuse. Recently
the patient was admitted to [**Hospital1 18**] approximately 2 weeks prior
to admission with right upper quadrant pain and headache and
was found to have a distended gallbladder with stones. He
underwent an ERCP with sphincterotomy at that time and was
discharged home on [**2107-2-22**] with a 7-day course of
Flagyl and Levaquin. He has felt well over the past week
prior to his admission.
REVIEW OF SYMPTOMS: He denied any fevers, chills, rigors,
upper respiratory infection symptoms, GI symptoms including
diarrhea, melena, hematochezia, UTI symptoms or recent
changes in headache or hematemesis.
PAST MEDICAL HISTORY: Significant for endstage liver
disease, hepatitis C virus cirrhosis, post traumatic stress
disorder, depression, history of long QT, hypertension, grade
1 esophageal varices, endocarditis and poly substance abuse.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Percocet, not seeking now.
2. Protonix 40 mg PO once daily.
3. Citalopram 20 mg PO once daily.
4. Folic acid 1 mg PO once daily.
5. Thiamine 100 mg PO once daily.
6. Lasix 40 mg PO once daily.
7. Rifaximin 200 mg PO t.i.d.
8. Nadolol 20 mg PO once daily.
9. Lisinopril 10 mg PO once daily.
10. Lactulose 15 ml t.i.d.
11. Spironolactone 50 mg PO once daily.
12. Levofloxacin 500 mg 1 a day with 1 day left to complete 7-
day treatment.
13. Flagyl 500 mg t.i.d. The patient complaining last day of
treatment.
14. Multivitamin 1 tab PO once daily.
15. Methadone 5 mg PO once daily.
SOCIAL HISTORY: Posttraumatic stress disorder, polysubstance
abuse, IV drug abuse in the past and was using heroin,
cocaine and alcohol; now on methadone. The patient is married
with 4 children, worked as a truck driver x25 years on
disability currently.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 98, heart rate 48, BP
102/62, respiratory rate 16, 95% on room air. Weight was
107.6 kg. He is in no acute distress. He is comfortable.
Regular rate and rhythm. Lungs are clear bilaterally. Abdomen
appeared soft and nontender, and appeared distended. Positive
ascites. Normal rectal tone, guaiac negative. No gross heme.
EXTREMITIES: No clubbing, cyanosis. 1+ pedal edema with
sitting. NEUROLOGIC: Alert and oriented x3. Cranial nerves II
through XII grossly intact. Cranial nerve X not tested. 5 out
of 5 strength throughout. 2+ lower extremity reflexes at
knees.
The patient was preop'd. An EKG was done as well as a chest x-
ray. Chest x-ray demonstrated no acute cardiopulmonary
abnormality. Urinalysis was sent off. Urine was negative. The
patient was started on preoperative heparin and Unasyn. Of
note an echo on [**2106-12-30**] demonstrated an EF of
greater that 55% with a patent foramen ovale. A
catheterization on [**2106-9-14**] demonstrated mild
pulmonary hypertension. PST's on [**2106-7-23**] demonstrated
decreased diffusion capacity (isolated), ? perfusion
limitation.
The patient was taken to the OR on [**3-1**] for orthotopic
DCD liver transplant. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],
assisted by Dr. [**First Name (STitle) **] [**Name (STitle) **], and assisted by resident Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative report for further details.
No complications occurred. EBL was 2 liters. He received 6
liters of Plasmalyte, 2 units of fresh frozen plasma, 5 units
of packed red blood cells, 3 units of platelets, and 1500 cc
of cell [**Doctor Last Name 10105**]. Urine output was 3370 cc. He also received 1
unit of cryoglobulin. Assessment of the liver was sent to
pathology. Two JP drains were placed. He was stable. He was
intubated and transferred to the surgical intensive care unit
where he remained for a total of 5 days during which time his
liver function tests initially increased. AST was 2471 up
from 115. ALT was 1161, up from 55. Alkaline phosphatase 164,
up from 135 and total bilirubin 13.9 up from 2.9. His
hematocrit was relatively stable at 32.3.
On postoperative day 1, he did receive 2 units of packed red
blood cells and one bag of platelets. His hematocrit dropped
down to 22 as well as platelet count decreased into 40s. He
received 4 units of packed red blood cells as well as 3 bags
of platelets and repeat hematocrit was 30 and platelet count
of 86. He was extubated on postoperative day 1. Pressures
were off as of day 1. He was maintained on an insulin drop
for hyperglycemia with blood sugars ranging to 143. A liver
duplex was done. This demonstrated normal arterial, venous,
and portal venous wave forms. A tiny amount of ascites was
noted on [**2107-3-1**]. Repeat chest x-ray was done that
demonstrated satisfactory positioning of all lines and tubes
without any pneumothorax and bibasilar atelectasis was noted
with the left side greater than the right side.
On [**3-1**] he had pathology assessment of the native
liver that demonstrated well differentiated hepatocellular
carcinoma 1 cm present in the right lobe. No vascular
invasion was seen. A nodule of small cell dysplasia measuring
0.6 cm in diameter was present in the left lobe. Serosa with
grade 2 inflammation was noted. Multiple bile duct
hamartomas were noted. Iron stain demonstrated moderate iron
deposition in hepatic sites and bile ducts. It was
recommended that the patient be evaluated to rule out iron
overload disease. The gallbladder appeared with mild
autolytic changes and there was negative vascular and biliary
margin. Trichome and reticulin stains were evaluated. A
biopsy of the liver donor demonstrated predominantly
macrovascular steatosis involving 20% of the liver
parenchyma. Bile duct hamartoma was noted with no significant
inflammation. Liver function tests trended down daily. By
postoperative day 5 his AST was 62, ALT 188, alkaline
phosphatase 176 with a bilirubin of 3.1. Creatinine
diminished to 1.0 and ranged between 1.1 to 1.3. His
hematocrit remained stable throughout the remainder of the
hospital course. His medial JP was removed on postoperative
day 5 and the lateral JP was removed on postoperative day 8.
His incision appeared clean, dry and intact.
He received pamidronate 30 mg IV x1 on postoperative 5. For
immunosuppression he remained on CellCept 1 gram PO b.i.d..
Solu-Medrol was tapered per protocol over the course of the
hospital stay down to 20 mg PO once daily and he was
discharged home on 20 mg of prednisone PO once daily.
Prograf was initiated on postoperative day 1 at 1 mg PO
b.i.d. This was up titrated to 5 mg over the course of 4
days. Prograf level was achieved of 15.4. The Prograf dosing
was decreased to 3 mg b.i.d. and repeat Prograf level
demonstrated a level of 15.4. He was decreased to 3 mg PO
b.i.d of Prograf. Hepatology followed throughout his hospital
course concurring with the plan. Given the low platelet
count, the HIT antibody was checked; this was subsequently
found to be negative. Platelets increased to 112 by the day
of discharge.
In the surgical intensive care unit he received IV diuresis
using Diamox. A chest x-ray demonstrated no overt evidence of
CHF. A repeat chest x-ray on [**2107-3-3**] demonstrated
bilateral pleural effusions and associated bibasilar
atelectasis as well as discoid atelectasis in the right
apical region.
Of note on [**2107-3-1**] the patient received intraop
cardiac echo for evaluation of ASD/patent foramen ovale.
Ejection fraction was 50 to 60%. Conclusion demonstrated tiny
atrial septal defect seen by color Doppler with minimal left
to right flow. They were unable to obtain adequate
transgastric views. The left ventricle was not well seen from
the transgastric. It was noted that the left ventricle was
grossly normal in function without significant wall motion
abnormalities. The right ventricle appeared normal. Aortic
leaflet appeared structurally normal with leaflet excursion
and no aortic regurgitation. The mitral valve leaflets
appeared structurally normal. There was mild 1+ mitral
regurgitation seen as well as 2+ moderate tricuspid
regurgitation.
[**Last Name (un) **] was consulted for management of hyperglycemia. He was
placed on 70/30 insulin q a.m. and pre supper as well as the
Humalog sliding scale. Blood sugars were decreased. Nutrition
consult was obtained. Diet was progressed. By the time of
discharge he was tolerating a regular diet without problems.
He was started on 10 mg of methadone and was maintained on
this. Towards the end of hospital stay it was discovered that
the patient had actually been weaned off his methadone
maintenance program on [**2-15**], and had been restarted on
methadone on admission to the hospital. After consultation
with the methadone clinic it was decided to taper and wean
the patient from methadone. He dose was decreased and he was
sent him with 2.5 mg of methadone one a day for 2 days and
then off; the methadone was to be stopped. He tolerated this
taper well without incident. He also took oral pain
medication in the form of Percocet for discomfort.
Psychiatry was called to discuss management of his history of
depression and PTSD. Recommendations included resuming
Risperdal and Celexa. This was restarted on hospital day 5.
He appeared clear. He did comment that his mood was somewhat
depressed but he was given reassurance that the prednisone
taper would help to alleviate some of this depressed mood.
Physical therapy followed the patient and discharged him home
without home PT.
He continued to receive IV Lasix 20 mg b.i.d. for generalized
edema. His preoperative weight was 107.6; this had increased
to 122.9 kg on postoperative day 2. This continued diuresis.
His weight decreased to 115.4 on postoperative day 8.
He was sent home on Lasix 20 mg PO once daily. He was
discharged home on postoperative day 9 in stable condition.
He was alert and oriented. His lungs were clear. Heart rate
was regular. His abdomen appeared rounded. He had positive
bowel sounds and was passing flatus. He was tolerating a
regular diet, voiding independently without any problems. His
incision was open to air with staples.
LABORATORY DATA ON DISCHARGE: White blood cell count 10.2,
hematocrit 31.5, platelet count 111. His creatinine was 1.3,
and his BUN 29. AST was 41, ALT 99, alkaline phosphatase 208
and total bilirubin was 2.4. He and his wife received
instructions on administration of insulin. The visiting nurse
services were set up. VNA was set up.
DISCHARGE MEDICATIONS:
1. Prednisone 20 mg PO once daily.
2. Protonix 40 mg PO once daily.
3. Percocet 1 to 2 tablets PO p.r.n. q 4 to 6 hours.
4. Fluconazole 400 mg PO once daily.
5. CellCept 1 gram PO b.i.d.
6. Lisinopril 10 mg PO once daily.
7. Celexa 20 mg PO once daily.
8. Multivitamin 1 tablet PO once daily.
9. Bactrim single strength 1 tab PO once daily.
10. Methadone 2.5 mg PO once daily x2 days and then stop.
11. Risperdal 1 mg PO qhs.
12. Prograf 3 mg PO b.i.d.
13. Valcyte 900 mg PO once daily.
14. Lasix 20 m PO once daily.
15. Insulin 70/30. Insulin 10 units s.c. q a.m. and 3 units
of s.c pre supper.
16. Insulin Humalog sliding scale.
The patient was scheduled to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **] on [**2107-3-16**] at 10:30 a.m.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2107-3-11**] 16:34:39
T: [**2107-3-12**] 06:11:57
Job#: [**Job Number 109453**]
|
[
"070.70",
"309.81",
"304.71",
"401.9",
"572.3",
"759.6",
"790.29",
"155.2",
"311",
"456.1",
"571.5",
"305.00",
"745.5",
"571.2",
"568.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"54.59",
"00.93",
"38.93",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
2466, 2484
|
11143, 11968
|
2507, 10798
|
10813, 11120
|
402, 458
|
487, 1303
|
1326, 2192
|
2209, 2449
|
11993, 12264
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,628
| 115,667
|
51864
|
Discharge summary
|
report
|
Admission Date: [**2124-4-27**] Discharge Date: [**2124-4-29**]
Date of Birth: [**2049-2-1**] Sex: M
Service: MEDICINE
Allergies:
Ambien / Avodart
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
nasal packing by ENT
History of Present Illness:
75 yo M with a history of mechanical AVR and MVR, afib on
coumadin who complains of epistaxis. The patient was cleaning
his nose this morning, and his nose started bleeding. He has
never had issues with nose bleeds or GI bleeds before. Notably,
the patient saw his PCP [**Last Name (NamePattern4) **] [**2124-4-18**]. Routine labs showed BUN of
112 and Cr of 2.3. It was thought that his lasix dose of 80mg po
bid was too much. He was told to hold the lasix and repeat his
labs. Repeat labs from [**4-26**] showed BUN 130 and Cr of 2.1.
.
In the ED, Labs notable for INR 3.9, Hct 27 down from bl(32),
but found to have ARF w K 6.2. Trop 0.05. ED course complicated
by hypotension to SBP 50s, fluid responsive, now SBP 100s w 3L
fluid, found to have UTI, ? urosepsis, with 18gauge IVx2. EKG:
paced @60, no ST/Twave changes, no peaked Ts. ENT did Silver
nitrate + affrin, found bleeding to be intermittent, requiring
packing. Given D50, insulin, ca gluconate repeat 4.2->5.6 CXR no
acute process. UA c/w UTI, Blood and urine culture and was
started on zosyn. FS<70, likely [**1-12**] to poor clearance of insulin
in setting of renal failure, continue D50 prn. 98.3 65 94/45 18
100% on RA.
.
In the ICU, patient without complaints. Denies CP, SOB, cough,
fever, chills, N/V/D. His epistaxis stopped once being packed in
ED. Denied dysuria. Reports being fatigued since coming in. He
c/o itching throughout body.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies cough, shortness of breath, or
wheezes. Denies diarrhea. No recent change in bowel or bladder
habits. Denies rashes or skin breakdown. No numbness/tingling in
extremities. No feelings of depression or anxiety. All other
systems reviewed in detail with no significant findings.
Past Medical History:
# Mechanical MVR/AVR ([**2098**]) [**1-12**] rheumatic fever
# Atrial fibrillation s/p AV node ablation, biventricular pacer
([**2115**]) on anticoagulation
# s/pw ith a history of a rectosigmoid polyp
resection and subsequent rectal bleeding with multiple
sigmoidoscopies c/b perforation requiring a Hartmann procedure
[**2123-10-25**]
# Biventricular pacer
# Dyslipidemia
# HTN
# COPD
# Asthma
# GERD
# Osteoarthritis
# Bilateral total knee replacements [**1-12**] OA
# Gout
# Hypothyroidism [**1-12**] amiodarone
# Chronic Kidney Disease Stage II, baseline cr 1.6
# anemia
# Melanoma
# obesity
# ETOH use
# insomnia
# hemorrhoids
# h/o cellulitis
# h/o MRSA PNA
# osteopenia
# # s/p Cholecystectomy
# s/p Appendectomy
Social History:
Lives with wife.
# Professional: Retired construction worker.
# Tobacco: 1ppd x 15y, quit [**2083**].
# Alcohol: Former binge alcohol abuse x30y (hard liquor), quit
mid [**2102**]. last drank 3 mo ago- 3 drinks at that time
# Recreational drugs: Experimental mescaline in youth.
Family History:
# Mother d 85: Asthma
# Father d 99 [**10-21**]: PAD, HTN
# Siblings (5B, 2S): HTN, unknown, rheumatic fever
Physical Exam:
VS: 96.5 84 134/44 18 100%RA
GEN: AOx3, NAD
[**Month/Year (2) 4459**]: PERRLA. MMM. no LAD. JVP to 8cm. neck supple.
Cards: RRR, mechanical S1/S2. 1-2/6 holosytolic murmur best
heard at LLSB, no gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign. Colostomy in place in LLQ.
Extremities: wwp,trace edema. DPs, PTs 2+.
Skin: erythema in b/l LE, no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
Pertinent Results:
1. Admission labs:
[**2124-4-26**] 11:25AM BLOOD WBC-7.0 RBC-3.36* Hgb-9.7* Hct-28.9*
MCV-86 MCH-28.9 MCHC-33.6 RDW-18.4* Plt Ct-188
[**2124-4-26**] 11:25AM BLOOD Neuts-62.4 Lymphs-21.9 Monos-7.0 Eos-8.1*
Baso-0.5
[**2124-4-26**] 11:25AM BLOOD PT-35.6* INR(PT)-3.6*
[**2124-4-26**] 11:25AM BLOOD UreaN-130* Creat-2.1* Na-140 K-5.6*
Cl-110* HCO3-18* AnGap-18
[**2124-4-27**] 07:00PM BLOOD ALT-19 AST-22 AlkPhos-102 TotBili-0.7
[**2124-4-27**] 04:35PM BLOOD cTropnT-0.03*
[**2124-4-27**] 09:30AM BLOOD cTropnT-0.04*
[**2124-4-27**] 07:00PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.7
[**2124-4-26**] 11:25AM BLOOD %HbA1c-5.6 eAG-114
.
2. Discharge labs:
[**2124-4-29**] 06:20AM BLOOD WBC-6.4 RBC-2.94* Hgb-8.3* Hct-25.6*
MCV-87 MCH-28.3 MCHC-32.4 RDW-19.0* Plt Ct-160
[**2124-4-29**] 06:20AM BLOOD PT-24.9* PTT-31.3 INR(PT)-2.4*
[**2124-4-29**] 06:20AM BLOOD Glucose-89 UreaN-40* Creat-1.0 Na-139
K-5.2* Cl-111* HCO3-20* AnGap-13
.
Imaging:
- CXR ([**2124-4-27**]): No acute pulmonary process. Resolved pleural
effusion.
Otherwise, stable exam with no acute process.
.
- Renal ultrasound ([**2124-4-28**]): *** Preliminary read *** No
hydronephrosis. Multiple simple renal cysts.
.
Brief Hospital Course:
75 yo M with a history of mechanical AVR and MVR, afib on
Coumadin, who presents with epistaxis also found to have
hypotension, hyperkalemia, and ARF.
.
#Hypotension: The patient had hypotension to the 50s in the
emergency department, which was transient and fluid responsive.
The etiology was thought to be hypovolemia. Lasix was held, and
the patient was admitted to the MICU for hemodynamic monitoring.
He had no further hypotension.
.
#Epistaxis: The patient presented with epistaxis, which was
treated with Afrin, silver nitrate, and packing in the emergency
department.
.
#Acute kidney injury: Differential diagnosis included pre-renal
and obstructive etiology. A foley catheter was placed. Lasix was
held. Renal ultrasound showed no hydronephrosis but some benign
cysts which should be followed by primary care doctor. Renal
function completely recovered. He will follow-up with outpatient
urologist after discharge.
.
#Hyperkalemia: The patient presented with potassium 6.1 in the
setting of acute renal failure. He was given calcium, insulin,
and glucose in the emergency department. In the MICU, he
received Kayexalate. Enalapril was held. Potassium level
normalized prior to discharge. He never developed EKG changes.
.
#Urinary tract infection: Treated initially with ceftriaxone and
switched to nitrofurantoin prior to discharge based on urine
culture sensitivities to complete a 7-day course.
.
# Rash/peripheral eosinophilia: Rash on both arms started prior
to admission. Suspected to be a drug reaction and offending
[**Doctor Last Name 360**] (Avodart) was stopped. Patient treated symptomatically.
.
# Atrial fibrillation: Coumadin initially held given
supratherapeutic INR. Re-started prior to discharge and patient
instructed to follow-up closely with [**Hospital 197**] clinic.
.
#BPH: Held tamsulosin given foley. Foley removed and restarted
tamsulosin prior to discharge.
Medications on Admission:
-allopurinol 300 mg po daily
-colchicine-probenecid 0.5-500mg po daily --> held
-ipratropium-albuterol inh q6h PRN SOB
-Combivent inh [**Hospital1 **] --> held
-enalapril 20 mg po bid --> held
-levothyroxine 88 mcg po daily
-metoprolol succinate 50 mg po daily
-pantoprazole 40 mg po q12h --> stopped
-tamsulosin 0.4 mg po qhs --> held
-tizanidine 4 mg po qhs --> held
-warfarin 7.5 mg po daily --> held
-ferrous sulfate 300 mg (60 mg Iron) po daily --> 325 mg pill
- fluticasone-salmeterol 250-50 mcg/dose Disk inh [**Hospital1 **]
-furosemide 80 mg po bid on home --> held
-fluticasone 50 mcg nasal daily
-Ciclopirox- 0.77 % Gel - apply to abdomen folds twice a day
-Clobetasol - 0.05 % Cream
-Hydroxyzine 25mg po qhs PRN
-Nystatin- 100,000 unit/gram Powder - as directed daily
-Omeprazole 40mg po daily
-Trazodone 25-50mg po qhs PRN
-Docusate 100mg po daily
Discharge Medications:
1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
2. Combivent 18-103 mcg/Actuation Aerosol Sig: [**12-12**] puff
Inhalation four times a day.
3. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) ampule Inhalation four times a day
as needed for shortness of breath or wheezing: 1 ampule in
nebulizer up to qid as needed for lung disease flare .
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
7. tizanidine 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK ([**Doctor First Name **],
TU, WE, TH, SA).
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR).
10. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
11. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
whiff Inhalation twice a day.
12. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for itching.
14. ciclopirox 0.77 % Gel Sig: One (1) application Topical twice
a day: Apply to abdomen folds.
15. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
16. docusate sodium 100 mg Tablet Sig: One (1) Capsule PO BID (2
times a day).
17. trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime)
as needed for insomnia.
18. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
19. nitrofurantoin macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO four times a day for 5 days: Please take from [**4-28**] -
[**2124-5-4**].
Disp:*20 Capsule(s)* Refills:*0*
20. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Epistaxis
Atrial fibrillation
Acute renal failure
Hyperkalemia
Hypotension
Urinary tract infection
Skin rash
.
SECONDARY DIAGNOSES:
COPD
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **], you were admitted to the [**Hospital1 1170**] because you were having a nosebleed. We also found that
your kidneys were not working well and the level of potassium in
your blood was very high. We put in a catheter to help drain the
urine in your bladder and your kidney function improved. We did
an ultrasound of your kidneys were showed that they were not
swollen. You had an urinary tract infection and we gave you
antibiotics to treat that which you should continue after your
leave the hospital.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
We found some small kidney cysts on ultrasound. Please ask your
primary care doctor to follow-up on them.
.
MEDICATIONS:
ADDED:
- Nitrofurantoin 100 mg by mouth four times a day from [**2124-4-28**] -
[**2124-5-4**]
- Sarna cream as needed for rash
CHANGED: none
HELD (please speak to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**]
them):
- Colchicine-probenecid 0.5-500 mg by mouth per day
- Enalapril 20 mg by mouth twice a day
- Furosemide 80 mg by mouth twice a day
REMOVED:
- pantoprazole 40 mg by mouth twice a day
Followup Instructions:
Please make an appointment and follow-up with your primary care
doctor within the next week.
.
Please also make an appointment and follow-up with your
urologist Dr. [**Last Name (STitle) 770**] within the next week.
.
Please make sure to go to [**Hospital 197**] clinic on [**2124-5-1**] to have
your Coumadin level checked and dose adjusted accordingly.
.
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2124-5-3**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 9316**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2124-5-22**] at 9:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2124-5-22**] at 10:00 AM
With: [**Year (4 digits) **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2124-4-29**]
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29,035
| 139,813
|
17990
|
Discharge summary
|
report
|
Admission Date: [**2154-3-14**] Discharge Date: [**2154-3-28**]
Date of Birth: [**2089-12-13**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatic artery stenosis, status post liver transplant.
Major Surgical or Invasive Procedure:
[**2154-3-14**]: Saphenous vein interposition graft repair of hepatic
artery; harvesting of left saphenous vein graft
History of Present Illness:
Per Dr.[**Initials (NamePattern4) 1369**] [**Last Name (NamePattern4) **] note: 64-year-
old female who underwent a combined liver and kidney
transplant and splenectomy on [**2153-7-22**] for end-stage
liver disease secondary to nonalcoholic steatohepatitis and
end-stage renal disease. She has recently been found to have
a stenosis of the hepatic artery distal to the anastomosis
just near the bifurcation of the right and left hepatic
arteries. She underwent attempted angioplasty and stenting
that was unsuccessful on 2 occasions. Therefore, she has
provided informed consent for operative exploration and
repair of the hepatic artery stenosis with a saphenous vein
interposition graft.
Past Medical History:
NASH, esophageal varices, ascites, aenmia, thrombocytopenia,
ESRD, T2DM, CDiff, seizures, meningioma, HTN, GERD, OSA, ?RLS,
nekc DJD, dermoid cyst, R adrenal mass, AFib, splenic vein
thrombosis
s/p combined liver/kidney transplant [**7-17**]
s/p VATS decortication [**11-16**]
pacemaker placement
hepatic artery stenosis
[**2154-3-14**] Saphenous vein interposition graft
repair of hepatic artery; harvesting of left saphenous vein
graft
Social History:
Widowed, lives in [**Hospital3 **] in [**Hospital1 6930**] MA. Has 4
children, several in MA.
Smoking: None; EtOH: Never; Illicits: None
Family History:
NC
Physical Exam:
98.9, 141/52, 66, 18, 90%.
General: Pale, frail in appearance
Card: Pacemaker in place, RRR, no M/R/G
Lungs: CTA bilaterally, diminished right base
Abdomen: Obese, non-distended, tender at incision and c/o pain
over kidney graft site
Extr: [**2-9**]+ pitting edema
Pertinent Results:
On Admission: [**2154-3-14**]
WBC-16.8*# RBC-3.17* Hgb-9.6* Hct-29.7* MCV-94 MCH-30.2
MCHC-32.2 RDW-19.0* Plt Ct-351
PT-27.6* PTT-32.2 INR(PT)-2.7*
Glucose-145* UreaN-24* Creat-1.1 Na-142 K-5.4* Cl-108 HCO3-24
AnGap-15
ALT-552* AST-646* AlkPhos-299* TotBili-1.0
Albumin-3.3* Calcium-8.2* Phos-6.0* Mg-1.6
At Discharge: [**2154-3-28**]
WBC-16.7* RBC-3.25* Hgb-9.8* Hct-30.9* MCV-95 MCH-30.2 MCHC-31.8
RDW-17.4* Plt Ct-932*
PT-31.6* INR(PT)-3.2*
Glucose-56* UreaN-32* Creat-0.8 Na-141 K-4.4 Cl-99 HCO3-34*
AnGap-12
ALT-36 AST-27 AlkPhos-365* TotBili-0.4
Calcium-8.9 Phos-4.2 Mg-1.8
tacroFK-8.3
Brief Hospital Course:
On [**2154-3-14**], she underwent saphenous vein interposition graft
repair of hepatic artery; harvesting of left saphenous vein
graft for hepatic artery stenosis, status
post liver transplant. Surgeon was [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please
refer to operative note for complete details.
Postop, she did well. LFTs increased initially. On [**3-15**], a duplex
to assess the hepatic artery demonstrated more normal
intrahepatic left and right arterial flow. However, there was
persistent high velocities seen within the extrahepatic artery
where it made a tight loop. Subsequent LFTs trended down.
Hematocrit drifted down to 23.6 on postop day 3. She was
transfused with 2 units of PRBC. Repeat duplex on [**3-18**] noted
persistent elevated velocity in the extrahepatic main hepatic
artery. LFTs continued to trend down with the exception of the
alk phos which remained in the 360-390 range. Prograf levels
were therapeutic. Dose was adjusted.
Heparin was held postop as she was coagulopathic with INR as
high as 3.8. Coumadin was started on [**3-16**]. INR was therapeutic.
Hct trended down again to 24 and another 2 units of PRBC were
transfused with hct increase to 30. Subsequent hcts were stable.
Vital signs were stable. She received lasix daily for
generalized edema. Renal function was stable.
Psychiatry was consulted on [**3-22**] for suicidal ideation.
Recommendations included stopping Remeron which caused the
patient to have visual hallucinations. A 1:1 sitter was used. On
[**3-25**], psychiatry felt that the 1:1 sitter was no longer needed
and that the patient would be safe for discharge to home with
outpatient followup with her psychiatrist as well as attendence
at a Day Psychiatry Program. Social Work was involved and
assisted to make arrangements.
Of note, she complained of right lower quadrant pain. On [**3-20**],
an abdominal CT noted patent hepatic artery, hepatic and portal
veins. New areas of hypodensities along the anterior margin of
liver and within the medial left lobe. There was a subcentimeter
hypodensity along the inferior liver margin is too small to
characterize. A large hematoma was seen along the inferior
margin of liver with adjacent fascial thickening and fat
stranding. Unchanged splenic vein thrombosis. Interval increased
anasarca and unchanged omental infarct.
She also experienced significant sacral pain. The area appeared
wnl. L-S spine films showed generalized demineralization, but no
evidence of compression fracture. There was minimal hypertrophic
spurring with the vertebrae and intervertebral disc spaces well
maintained. A pelvic CT was done revealing no intrapelvic
collection, right lower quadrant renal transplant with
surrounding inflammatory stranding and air within the collecting
system, extensive body wall edema, predominantly along the right
lower quadrant, superficial to the right lower quadrant renal
transplant, and no suspicious osseous abnormalities.
PT worked with her declaring her safe to return to her [**Hospital 4382**] facility using a walker.
Medications on Admission:
Mycophenolate 500mg [**Hospital1 **]
Prednisone 5mg daily
Atrovastatin 10mg daily
Carvedilol 25mg [**Hospital1 **]
Bactrim 1 tab daily
Omeprazole 40mg daily
Celexa 60mg daily
Keppra 500mg [**Hospital1 **]
Trazodone 50mg qHS
Remeron 7.5mg qHS
Vit D 50,000u q week
Thiamine 100mg daily
Folic Acid 1mg daily
MVI
Iron 325mg daily
ISS
Amlodipine 5mg daily
Furosemide 40mg [**Hospital1 **]
Ursodiol 300mg [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (MO).
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for incision pain: No more than 4
grams of tylenol daily. Maximum combined tylenol #3 and tylenol
is 12 tablets daily.
17. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
20. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
Two (22) units Subcutaneous once a day: AM dose.
21. Novolin R 100 unit/mL Solution Sig: per sliding scale
Injection four times a day.
22. Sodium Polystyrene Sulfonate Powder Sig: Four (4)
teaspoons PO As directed as needed for hyperkalemia: Take as
directed by transplant clinic for high potassium. Mix 4 tsp with
water.
23. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
24. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
25. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime.
26. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day as needed for abdominal pain.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Hepatic artery stenosis, status post liver transplant
Depression
Splenic vein thrombus
Pacemaker [**1-16**]
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
take or keep down food, fluids or medications
Weigh yourself daily and call the transplant clinic if you have
gained or lost more than 3 pounds in a single day
Take all meds as directed
Monitor the incision for redness, drainage or bleeding
No heavy lifting
No driving if taking narcotic pain medications
You may shower, no tub baths or swimming
Continue your outpatient psychiatry visits and counseling
sessions
Labs once a week at Quest labs as you were doing prior to this
hospitalization to include CBC, Chem 10, PT/INR, AST, ALT, T
bili, Alk Phos, Trough Prograf and Urinalysis
Followup Instructions:
You have an appointment with your outpatient psychiatrist, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on Monday [**2154-4-1**] at 1:40pm.
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2154-4-3**]
10:40
.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],[**MD Number(3) 13795**]:[**Telephone/Fax (1) 37766**] Date/Time:[**2154-4-5**]
8:00
.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-5-2**]
10:40
.
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2154-7-24**] 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2154-4-2**]
|
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"428.0",
"327.23",
"296.24",
"276.2",
"250.40",
"V42.7",
"447.1",
"530.81",
"583.81",
"V62.84",
"997.79",
"443.29",
"250.50",
"996.81",
"416.8",
"518.81",
"584.9",
"362.01",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.46",
"96.71",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
8858, 8961
|
2765, 5875
|
367, 487
|
9113, 9113
|
2149, 2149
|
10004, 10871
|
1842, 1848
|
6342, 8835
|
8982, 9092
|
5901, 6319
|
9258, 9981
|
1864, 2130
|
2468, 2742
|
272, 329
|
515, 1209
|
2163, 2454
|
9127, 9234
|
1231, 1671
|
1687, 1826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,129
| 187,381
|
40294
|
Discharge summary
|
report
|
Admission Date: [**2165-1-20**] Discharge Date: [**2165-1-27**]
Date of Birth: [**2078-3-19**] Sex: F
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / lisinopril /
Zinc / bacitracin
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 year-old female with h/o PE on coumadin, COPD/asthma, HTN,
who was found down at her home. The patient is unable to
remember the event. According to family, the patient was found
next to her bed in her own excrement. Pt was concious at that
point, and unable to get up, however, she doesnt remember the
episode. Pt has been in good health recently reporting no
fevers, urinary symptoms, SOB, CP, abdominal pain, change in
bowel habits, antibiotic use or weight change. Has a cough at
baselines which was unchaged recently. Patient reports a
reduction in appetite but no associated weight change. She does
not use home o2 and does not have a hx of OSA. She reports no
previous hx of fainting, irregular heartbeat, orthostatic sx,
seizures, unresponsiveness, angina etc.
.
Pt usually ambulates independently (went to mohegan sun
yesterday).
.
In the ED, initial VS were 102 116 161/76 20 98% RA. Patient was
sleepy, but easily arousable on exam. Labs were remarkable for
WBC 24 (22% bands), INR 3.1, lactate 3.3, CK 480 (hemolysed),
Cre 1.3 (.98 baseline). UA showed no evidence of infection. CT
Head, C-spine, and pelvic x-ray were negative for fracture.
Patient was given ceftriaxone and azithromycin for ?left sided
PNA on CXR.
On arrival to the ICU, 102.3 118 157/96 26 97 RA. Patient was
having some rigors but was AOX3.
Past Medical History:
Pulmonary Embolism
Uncontrolled DM Type II w/ renal impairment (Hba1c 8.2, Cr 1.0)
COPD w/ multiple admissions for exacerbation
Thickened endometrium
Kidney mass
Asthma
Diverticulosis
Hypertension
Hypercholesterolemia
Social History:
lives with her son [**Name (NI) 4468**]. Does her own shopping. Ambulates
independantly.
Smoking: Former Smoker
Smokeless Tobacco: Never Used
Alcohol: Yes
.
Family History:
Sister Breast [**Name (NI) 3730**] (recently died)
Physical Exam:
Admission Physical Exam:
Vitals: T: 102.3 BP: 102/61 P: 115 R: 22 O2: 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral wheezes
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
Discharge Physical Exam:
Patient's vital signs were normal, and she appeared very well.
Her lungs were had scattered mild wheezes, and cardiac exam was
regular.
Her abdominal exam was soft, and no edema on her legs.
She was aox3, but did not have good recall of parts of her past
medical history.
She was often surrounded by her family.
Pertinent Results:
Admission Labs:
WBC-24.0*# RBC-3.70* HGB-11.1* HCT-31.8* MCV-86 MCH-30.1
MCHC-35.0 RDW-15.3
LACTATE-3.3*
PT-32.3* PTT-43.9* INR(PT)-3.1*
ALT(SGPT)-16 AST(SGOT)-55* CK(CPK)-480* ALK PHOS-64 TOT BILI-0.5
cTropnT-<0.01
Discharge labs:
[**2165-1-26**] 06:16AM BLOOD WBC-12.6* RBC-3.22* Hgb-9.4* Hct-27.6*
MCV-86 MCH-29.1 MCHC-33.9 RDW-15.6* Plt Ct-348
[**2165-1-26**] 06:16AM BLOOD PT-31.9* INR(PT)-3.1*
[**2165-1-26**] 06:16AM BLOOD Glucose-122* UreaN-12 Creat-1.0 Na-142
K-3.7 Cl-105 HCO3-26 AnGap-15
[**2165-1-25**] 07:30AM BLOOD CK(CPK)-988*
IMAGING:
# CT Head w/o contrast- no intracranial process
# CT C-spine w/o contrast-
1. No fracture or malalignment.
2. Moderate to severe degenerative changes, espec. C4/5& C5/6
# Pelvis AP x-ray- no fracture
# Chest x-ray- Left upper lobe/perihilar opacity might represent
pneumonia. Healed left rib fractures. The cardiomediastinal
silhouette and hila are normal. There is no pleural effusion
and no pneumothorax.
IMPRESSION: Left upper lobe opacity might represent pneumonia.
CHEST CT IMPRESSION:
1. Multifocal pneumonia.
2. Partially visualized 3-cm partially exophytic left interpolar
renal mass
warrants further workup with MRI.
3. Prominent thyroid gland extending into the superior
mediastinum with
heterogeneous parenchyma likely represents substernal goiter;
however, further
workup with ultrasound should be considered.
4. Hilar and mediastinal lymphadenopathy might be reactive.
However given the
large size, followup with chest CT is recommended to rule out
neoplastic
involvement (metastasis) after workup of the left kidney and
thyroid mass
5. Small-to-moderate left and small right pleural effusion with
mild
associated bibasilar atelectasis.
BRAIN MRI:
IMPRESSION: Scattered foci of high signal intensity in the
subcortical and
periventricular white matter, likely reflecting chronic
microvascular ischemic
disease. Mild mucosal thickening identified at the maxillary
sinuses
bilaterally, more significant on the right and also mild mucosal
thickening at
the ethmoidal air cells.
Brief Hospital Course:
86 year-old female with h/o PE on coumadin, COPD/asthma,
HTN/DM2, found down on floor, noted to have fever, leukocytosis
w/bandemia and elevated lactate.
#. Sepsis/community acquired PNA/fever- On admission, patient
met SIRS criteria for temperature, white count and heart rate.
She was found to have a pneumonia on both cxr and CT scan. She
was initially treated with broad spectrum antibiotics, but she
improved dramatically, so she was switched to oral levaquin,
which she tolerated well.
# Hilar lymphadenopathy: Found to have enlarged perihilar lymph
nodes on CT scan of the chest. These are likely reactive to the
pneumonia, but radiologists advise to also r/o any possible
primary malignancy. She has known renal mass which is being
followed by [**Hospital1 112**] urologist Dr [**First Name (STitle) 2643**] and also has irregular
thyroid seen on CT scan. I was in contact with PCP regarding
this, and advised f/u renal MRI to see if renal mass is
enlarging or consideration of renal biopsy to definitively r/o
that the peri-hilar [**Doctor First Name **] does not represent metastatic disease
from renal cell carcinoma. I also advised outpatient thyroid
ultrasound.
.
#. ?Syncope/found down: Patient was found down at home w/
evidence of defecation. I suspect that she became hypotensive
on account of her pneumonia and had some kind of vasovagal
event. There were no arrhythmias seen on telemetry, and Brain
MRI did not show any lesion or CVA. She ambulated well with PT
in the hospital.
.
#. Acute renal failure: Resolved in the hospital. Instructed
to resume cozaar on returning home.
.
# History of PE: INR therapeutic at time of discharge.
#Ear pain-Patient complained of severe intermittent pain near
left ear. No pain over mastoid or parotid. Has long standing
hearing loss and tinnitus. Exam of ear revealed cerumenosis and
perforated Left TM (old). She was seen by ENT who felt that she
had TMJ syndrome and advised NSAIDS. Her pain was very well
treated with NSAIDS. Given that she will be using them at home
on a prn basis, she was also started on omeprazole
#. DM2: She was advised to resume home meds on discharge.
However, the quinolone antibiotics may precipitate hypoglycemia,
so she was advised to take half the dose of glyburide for three
days, during which she would be taking quinolone abx.
.
#. COPD/asthma: Continued on home meds.
.
#. HTN: Well controlled after she recovered from her SIRS
presentation.
.
Medications on Admission:
Cozaar 100 mg daily
Verapamil 300 mg daily
metformin 500 mg po bid
glyburide 5 mg po bid
Warfarin
Advair
Albuterol prn
combivent prn
Discharge Medications:
1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-19**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
2. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*4 Tablet(s)* Refills:*0*
3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours: Please give as needed for ear pain.
4. Cozaar 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. verapamil 300 mg Capsule, 24hr ER Pellet CT Sig: One (1)
Capsule, 24hr ER Pellet CT PO once a day.
6. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day:
Take one tablet twice a day for three days, then continue two
tablets twice a day (your usual dose).
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
START THIS ON [**2165-1-28**]. YOU WILL GET YOUR INR CHECKED ON
[**2165-1-30**], AND THEY WILL ADJUST THE DOSE AS NEEDED. .
Disp:*30 Tablet(s)* Refills:*2*
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Take this medicine
to protect your stomach as long as you are on ibuprofen. .
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation four times a day: Use as needed for
shortness of breath.
12. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day: use as needed for shortness of
breath.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Pneumonia
2. Rhabdomyolysis (muscle breakdown)
3. Temporomandibular Joint pain (TMJ)
4. History of pulmonary embolism
5. Hypertension
6. Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after being found on the ground in your home.
You were found to have a pneumonia, and you improved with
antibiotics. You also had some evidence of muscle breakdown
(because you were down on the ground for a while), but this
cleared with IV fluids.
The CAT scan of your chest shows not only the pneumonia, but
also a known kidney mass and an irregularity of your thyroid
gland. In addition, there are enlarged lymph nodes in your
chest. These lymph nodes likely increased in size because of
the pneumonia. However, Dr [**Last Name (STitle) 86505**] should make sure that they
decrease in size by repeating a CAT scan of your chest in [**2-19**]
months. In addition, you need an MRI of your kidneys. If the
mass in your kidney is growing, you should have a biopsy of your
kidney. You also need an ultrasound of your thyroid gland.
You had ear pain, and had an MRI of your head. It did not
reveal a cause of your ear pain. You were seen by an ear
specialist, who feels that your pain is from your
temporo-mandibular joint, otherwise known as TMJ. Please take
ibuprofen with food when you have discomfort there. Please
discuss this with Dr [**Last Name (STitle) 86505**] if this discomfort persists.
You should continue your medicines for diabetes, hypertension
and your coumadin. In addition, you have been given a
prescription for the antibiotic levaquin, and you should take
this for an additional 3 days. You have also been started on a
medicine called omeprazole; this will protect your stomach from
ulcers as you are now taking ibuprofen and a blood thinner
(coumadin).
MEDICINE CHANGES
1. TAKE LEVAQUIN (ANTIBIOTIC) FOR THREE DAYS STARTING ON
MONDAY, [**1-28**].
2. TAKE YOUR BLOOD PRESSURE MEDICINES (COZAAR AND VERAPAMIL)
STARTING TOMORROW, [**1-28**].
3. TAKE YOUR COUMADIN STARTING TOMORROW, [**1-28**] - BUT ONLY TAKE
2.5 MG. YOU NEED TO HAVE YOR INR CHECKED ON [**1-30**] AT [**Location (un) 2274**].
4. START YOUR DIABETES MEDICINES TOMORROW - [**1-28**]. TAKE
GLYBURIDE 2.5 MG (1 TABLET) TWICE A DAY FOR THE NEXT THREE DAYS,
AS YOUR ANTIBIOTIC CAN INTERFERE WITH THIS MEDICINE. AFTER YOU
HAVE FINISHED YOUR ANTIBIOTIC, YOU CAN TAKE YOUR NORMAL DOSE OF
GLYBURIDE.
5. TAKE IBUPROFEN AS NEEDED FOR YOUR EAR PAIN.
6. TAKE OMEPRAZOLE EVERY DAY AS LONG AS YOU TAKE IBUPPROFEN (TO
PROTECT YOUR STOMACH)
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 85758**] [**Name (STitle) 86505**]
[**Telephone/Fax (1) 3530**], for an appointment later this week.
|
[
"276.2",
"038.9",
"275.2",
"785.6",
"V12.51",
"401.9",
"V58.61",
"524.60",
"493.20",
"486",
"275.3",
"285.9",
"250.00",
"593.9",
"584.9",
"995.91",
"728.88",
"276.51",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9403, 9460
|
5154, 7624
|
352, 358
|
9668, 9668
|
3078, 3078
|
12193, 12393
|
2149, 2202
|
7807, 9380
|
9481, 9647
|
7650, 7784
|
9819, 12170
|
3311, 5131
|
2242, 2721
|
301, 314
|
386, 1716
|
3094, 3295
|
9683, 9795
|
1738, 1958
|
1974, 2133
|
2746, 3059
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,743
| 158,939
|
53598
|
Discharge summary
|
report
|
Admission Date: [**2129-10-13**] Discharge Date: [**2129-10-27**]
Date of Birth: [**2083-3-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
46M s/p AVR (23mm St. [**Male First Name (un) 923**])/MVR(33mm St. [**Male First Name (un) 923**])/MAZE [**10-17**] EF 55%
PMH: HTN, ^ lipids, afib, GERD, retinal art occlusion, GERD,
renal transplant x 2 (s/p glomerulnephritis strep throat as
child) in [**2102**], [**2121**].
Major Surgical or Invasive Procedure:
Aortic and Mitral Valve replacement.
History of Present Illness:
HPI / Subjective Complaint: 46 y/o male initially presented to
ED
with memory loss and new onset AFib on [**7-20**]. TEE showed mitral
and aortic stensis, and mitral regurgitation with L atrial
rhombus. Now adm [**10-13**] for cardiac sx preop. Underwent AVR/MVR
and MAZE on [**10-17**]
Past Medical History:
PMH / PSH: HTN, hyperlipids, renal txplnt x2 after
glomerularnephritis ('[**02**]/'[**21**]), AFib, GERD, retinal occlussion
Social History:
Social / Occupational History: (support system, education, work,
role, cultural / religious beliefs) Recently stopped working due
to retinal visual loss
Living Environment: (housing, barriers) Lives alone in
[**Location (un) 12017**], NH; 1 flight to bathroom
NC
Family History:
NSocial / Occupational History: (support system, education,
work,
role, cultural / religious beliefs) Recently stopped working due
to retinal visual loss
Living Environment: (housing, barriers) Lives alone in
[**Location (un) 12017**], NH; 1 flight to bathroom
Physical Exam:
Axo
NAD NC AT
ireg HRm SEM
S-NT/ND
No cellulitis of extremities
Pertinent Results:
[**2129-10-13**] 07:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2129-10-13**] 05:05PM GLUCOSE-121* UREA N-26* CREAT-1.6* SODIUM-140
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2129-10-13**] 05:05PM ALT(SGPT)-31 AST(SGOT)-28 LD(LDH)-232 ALK
PHOS-92 AMYLASE-69 TOT BILI-0.5
[**2129-10-13**] 05:05PM ALBUMIN-4.3 CALCIUM-10.2 PHOSPHATE-2.7
MAGNESIUM-2.0
[**2129-10-13**] 05:05PM %HbA1c-5.4
[**2129-10-13**] 05:05PM WBC-10.1 RBC-4.55* HGB-14.2 HCT-40.9 MCV-90
MCH-31.1 MCHC-34.6 RDW-13.7
[**2129-10-13**] 05:05PM NEUTS-77.6* LYMPHS-16.3* MONOS-5.4 EOS-0.4
BASOS-0.3
[**2129-10-13**] 05:05PM PLT COUNT-227
[**2129-10-13**] 05:05PM PT-14.8* PTT-28.6 INR(PT)-1.4
Brief Hospital Course:
Admitted underwne t MVR/AVR PROCEDURE: Aortic valve replacement
with [**Street Address(2) 11688**]. [**Male First Name (un) 923**].
Mitral valve placement with [**Street Address(2) 12523**]. [**Male First Name (un) 923**], and atrial Maze
procedure.
FINDINGS: The aorta was normal sized with no disease
palpable on bidigital palpation as well as on the
transesophageal echo. The heart had moderate cardiomegaly.
The aortic valve was heavily calcified especially on the
noncoronary and the left coronary cusps. The tricuspid valve
was severely stenotic. The mitral valve was very calcified
especially along the posterior leaflet with the calcification
extending onto the atrial and ventricular walls and along the
annulus in the location of most of the posterior leaflet
annulus. There was some calcification anteriorly as well.
The valve was very heavily calcified and narrow. Given
decalcification there was an area in the beginning of P1 on
the annulus which had an abscess cavity with greenish cheesy
material inside it. The gram stain came back as negative for
bacterial or pus cells. This area might have been atrial
abscess in the past.
Pt tolerated porocedure weel andwas D/C in stable condition
after pocedure on [**10-17**], he spent a brief ICU stay and was D/C to
the floor and rehab evaluation occurred and he was cleared all
tubes and lines were removed in timely fashion and PT was D/C in
stable condition- I unfortunately did not participate in the
care of this patient but my contact has consisted of this D/C
summary from the reviewed chart
Medications on Admission:
Medications before [**2129-5-25**]:
AMOXICILLIN 500 MG--Take four by mouth one hour prior to dental
procedure
ASPIRIN 81 MG--Take one by mouth every day
CARDIZEM CD 240 MG--Take one by mouth every day
CELLCEPT [**Pager number **] MG--Take two by mouth twice a day
FOLIC ACID 1 MG--Take four by mouth every day
FOSAMAX 70 MG--Take one by mouth every week
LIPITOR 20 MG--Take one by mouth every day
NEORAL 25 MG--Take three by mouth every morning and two by mouth
every evening
PLAVIX 75 MG--Take one by mouth every day
PREDNISONE 2.5 MG--Take four by mouth every other day
PRILOSEC 20 MG--Take one by mouth every day
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*90 Tablet(s)* Refills:*4*
2. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*4*
Discharge Disposition:
Home
Discharge Diagnosis:
Valvular disease.
Afib.
Kidney Transplant
Discharge Condition:
Good.
Discharge Instructions:
No heavy lifting or strenous activity for 6 weeks.
[**Month (only) 116**] shower.
No tub bathing or hot tub for 2 weeks.
Followup Instructions:
Follow up with your PCP and Cardiologist in [**12-17**] weeks.
Follow up with Dr. [**Last Name (STitle) **] in 4 weeks.
Completed by:[**2129-10-27**]
|
[
"V42.0",
"427.31",
"530.81",
"396.0",
"272.0",
"782.3",
"401.9",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"37.33",
"35.24",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5253, 5259
|
2550, 4110
|
603, 642
|
5345, 5352
|
1771, 2527
|
5522, 5674
|
1407, 1672
|
4779, 5230
|
5280, 5324
|
4136, 4756
|
5376, 5499
|
1687, 1752
|
284, 565
|
670, 959
|
981, 1108
|
1124, 1391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,300
| 107,033
|
54599
|
Discharge summary
|
report
|
Admission Date: [**2168-3-13**] Discharge Date: [**2168-3-19**]
Date of Birth: [**2096-6-10**] Sex: M
Service: TRAUMA/SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 71 year old
male, status post motor vehicle crash driver, high speed
crash approximately 70 mph, no loss of consciousness,
however, ETOH involved, whose chest impacted the steering
wheel. The patient presented to the Trauma Bay, was found on
examination to be hemodynamically stable.
Trauma workup revealed a grade III liver laceration of a
complex nature, close to but not involving the hilum and
portal venous structures. The patient's workup also revealed
some elevated liver enzymes consistent with this injury and
some T wave inversions on his electrocardiogram in leads I,
II and V6.
HOSPITAL COURSE: For this, he was admitted to the Surgical
Intensive Care Unit where he underwent volume resuscitation
and he was ruled out for myocardial infarction. Over the
next couple days, the patient's hematocrit was serially
followed and he was found to have a slowly decreasing
hematocrit although the changes were slowing and the patient
remained hemodynamically stable. The patient's hematocrit
continued to be serially followed and were found to level out
at approximately 29.0.
After several days, the patient was transferred to the floor
where he remained afebrile with stable vital signs. However,
he developed a significant ileus requiring placement of a
nasogastric tube. Nasogastric decompression for three days
resulted in resolution of the patient's nausea and vomiting.
He began passing stool and flatus. Nasogastric tube was
removed and diet was slowly advanced. On the day of
discharge, he was tolerating regular diet, passing stool and
flatus, and will be discharged home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 25 mg p.o. b.i.d. which the patient was on
prior to admission.
2. Captopril 100 mg p.o. t.i.d., however, he did not require
this during this admission and has been instructed not to
continue this as a home medication and he should follow-up
with his primary care physician regarding this.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2168-3-18**] 21:36
T: [**2168-3-22**] 20:34
JOB#: [**Job Number **]
|
[
"443.9",
"560.1",
"E815.0",
"412",
"496",
"864.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
1876, 2454
|
801, 1787
|
172, 783
|
1812, 1850
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,201
| 155,244
|
47500
|
Discharge summary
|
report
|
Admission Date: [**2183-10-3**] Discharge Date: [**2183-10-9**]
Service: MEDICINE
Allergies:
Shellfish / Zolpidem
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 y/o M from [**First Name3 (LF) **] Reb with h/o CAD s/p CABG, CHF (unknown EF),
A.fib, PPM, h/o GI bleed, anemia, CRI, DM, urinary retension,
prostate CA p/w decreased urine output, hypotension and fever to
104. Had 3x loose stool prior to admission, noted low UOP from
Foley, BP 80/40s at rehab, also vomited x 1. Patient noted to be
at baseline mental status, A+O x3. Given Levofloxacin at NH.
.
In the ED VS T 102.8 BP 70/30-->90-100s HR 65 O2 Sat 94% 4L,
Started periperal fluids, given Ceftriaxone x 1, Vanco x 1 for
?MRSA otitis externa. Labs notable for WBC of 27, Hct 21, Guiac
neg in ED. Received one unit of blood in the ED.
Past Medical History:
- urinary retention
- prostate CA
- CAD s/p CABG
- CHF ?EF
- PPM
- A.fib on coumadin
- HOH with hearing aid
- MRSA otitis externa
- squamous cell CA
- COPD
- CRF
- PVD
- DM
- recurrent UTIs
- HTN
Social History:
Lives at [**Name (NI) **] Reb, girlfriend [**Name (NI) 2894**] is HCP, has one son.
Family History:
NC
Physical Exam:
VS: 100.0 HR 65 BP 82/35 RR 14 100% 2L
Gen: elderly man, NAD, labored breathing
Skin: many echymosses, thin skin
Heent: Op clear, dry, pale, anicteric, PERRL, EOMI
Neck: unable to asses JVD, supple
CVS: nl S1 S2, irregular, RRR, no m/r/g
Abd: obese, soft, ventral hernia easily reducible, active BS, NT
Ext: warm, trace edema
Neuro: Awake, confused, HOH, follows commands
Pertinent Results:
[**2183-10-6**] 06:25AM BLOOD calTIBC-135* VitB12-785 Folate-9.9
Ferritn-1126* TRF-104*
[**2183-10-3**] 10:10AM BLOOD Glucose-148* UreaN-105* Creat-3.6*
Na-130* K-4.8 Cl-93* HCO3-23 AnGap-19
[**2183-10-9**] 05:19AM BLOOD Glucose-126* UreaN-46* Creat-1.2 Na-144
K-3.8 Cl-107 HCO3-29 AnGap-12
[**2183-10-9**] 05:19AM BLOOD PT-22.2* PTT-30.4 INR(PT)-2.2*
[**2183-10-3**] 10:10AM BLOOD Neuts-96.0* Bands-0 Lymphs-1.9*
Monos-1.2* Eos-0.8 Baso-0.1
[**2183-10-3**] 10:10AM BLOOD WBC-27.4* RBC-2.37* Hgb-7.4* Hct-21.7*
MCV-92 MCH-31.0 MCHC-33.9 RDW-18.5* Plt Ct-230
[**2183-10-9**] 05:19AM BLOOD WBC-15.7* RBC-2.59* Hgb-7.7* Hct-23.8*
MCV-92 MCH-30.0 MCHC-32.5 RDW-18.8* Plt Ct-267
.
Blood Cultures:
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S 16 I
CEFAZOLIN------------- 32 R 8 S
CEFEPIME-------------- R <=1 S
CEFTAZIDIME----------- R <=1 S
CEFTRIAXONE----------- R <=1 S
CEFUROXIME------------ R 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 4 S
.
CXR [**10-7**]
Moderate cardiomegaly is unchanged. Small bilateral pleural
effusions, probably stable. Pulmonary vascular congestion is
unchanged. Transvenous right atrial and right ventricular pacer
leads in standard placements, unchanged. No pneumothorax.
Brief Hospital Course:
Hospital course, by problem:
.
#UROSEPSIS: Patient started on vanco and zosyn in ICU. BP
responded to fluids. Per HCP and family pt was DNR/DNI and did
not want any CVL. BLood cultures grew out GNR eventually
speciated as klebsiella and E coli, which were both sensitive to
Zosyn; UA markedly positive. Pt defervesced and WBC improved.
BB and ACE-I initially held d/t hypotension but then restarted.
Will complete a total of a 14 day course of IV abx.
.
#? Otitis externa: No significant otitis noted on exam but pt
had h/o MRSA otitis. As there was no evidence of ongoing
infection, vanco d/c'd.
.
#ELEV INR: INR up on admission. coumadin held and vit k given.
INR trended down and coumadin restarted at 5mg. He was
transfused for HCt in low 20s but Hct remained in 20s. No
evidence of bleeding and iron studies show ACD.
.
#ARF: Cr over 3 on admission. With hydration and treatment of
sepsis trended down steadily to 1.2 upon d/c
.
#Anemia: HCT noted to be low on admission (21.7); the patient
was given 2U PRBC with elevation to 24.9; HCT remained stable
during rest of admission. Labs consistent with Anemia of
Chronic disease. Epogen should be started as an outpt along
with iron.
.
#CHF: the patient developed volume overload in the setting of
volume resuscitation. Once BP stabilized, Lopressor and
Captopril readded, along with PO lasix. He can be further
diuresed at rehab. Lopressor and Captopril should be titrated
as BP/HR allow.
.
#Speech/Swallow: pt had ?aspiration event while in house.
Speech swallow consult obtained; recommended obtaining a video
swallow. This showed mild-moderate oropharyngeal dysphagia
characterized by reduced base of tongue retraction, hyolaryngeal
excursion, and laryngeal valve closure resulting in
moderate-severe vallecular residue which builds up over time.
This residue is more significant with solids than liquids
andputs the pt at increased risk for penetration and aspiration.
As such, s/s team recommended: diet be restricted to pureed
solids
and thin liquids with PO meds crushed in purees. Strict
aspiration precautions and swallowing strategies should be
followed. Pt would benefit from follow up by speech/swallowing
therapy at rehab to determine appropriateness for a repeat video
swallow study for possible diet upgrade.
.
RECOMMENDATIONS:
1. Pureed solids and thin liquids.
.
2. PO meds crushed in puree, wash down with sip of liquid.
.
3. Strict aspiration precautions including:
a) Swallow twice for every bite.
b) Alternate between sips and bites.
Medications on Admission:
- senna
- tylenol
- warfarin 5 mg daily
- simvastatin 10 mg daily
- trazadone 150
- lexapro 10 mg daily
- pantoprazole 20 mg daily
- iron
- combivent
- amoxicillin [**2176**] mg prn
- colace
- lasix 60 mg po daily
- loperamide
- lisinopril 10 mg daily
- toprol 50 mg daily
- phenazopyridine 100 mg tid
- levofloxacin 250 mg po daily
- Ceftriaxone 1 gram IV x 1
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed.
Disp:*qs Tablet, Rapid Dissolve(s)* Refills:*0*
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
3. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): please titrate as BP allows.
Disp:*90 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Lexapro 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 gm
Intravenous Q8H (every 8 hours): to continue through [**10-18**].
Disp:*qs gm* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) U
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs U* Refills:*2*
12. Trazodone 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
13. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection ASDIR (AS DIRECTED).
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Urosepsis secondary to E. Coli/Klebsiella bacteremia
2. Anemia of Chronic Disease
3. Congestive Heart Failure
4. Acute Renal Failure, resolved
5. Atrial Fibrillation
Secondary Diagnoses:
h/o Urinary retention
h/o prostate CA
CAD s/p CABG
PPM
HOH with hearing aid
h/o MRSA otitis externa
h/o squamous cell CA
COPD
CRF (unclear baseline)
PVD
Type 2 DM
h/o recurrent UTIs
Hypertension
Dyslipidemia
Discharge Condition:
stable, normal O2 sats on RA
Discharge Instructions:
Please contact your primary care provider should you have any
fevers, chills, night sweats, shortness of breath, chest pain,
or any other complaints.
Followup Instructions:
Please fllow up with your primary care doctor within one week.
|
[
"427.31",
"788.20",
"785.52",
"995.92",
"250.00",
"496",
"V10.46",
"996.64",
"403.90",
"V58.61",
"428.0",
"038.42",
"584.9",
"599.0",
"V45.81",
"V45.01",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7980, 8046
|
3396, 5939
|
238, 245
|
8494, 8525
|
1661, 3373
|
8723, 8789
|
1248, 1252
|
6351, 7957
|
8067, 8242
|
5965, 6328
|
8549, 8700
|
1267, 1642
|
8263, 8473
|
189, 200
|
273, 912
|
934, 1131
|
1147, 1232
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,927
| 132,694
|
46039+58880+58881
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2168-2-25**] Discharge Date: [**2168-3-18**]
Date of Birth: [**2102-5-18**] Sex: F
Service: O-MED
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with
a history of metastatic rectal cancer to her spine and liver
status post chemotherapy, most recently with FOLFOX last
received six weeks ago, status post colostomy in [**2167-11-23**] who presents with increasing right greater than left
lower extremity weakness over the period of two weeks.
The patient slumped to the ground on the day of admission and
was unable to get up even with the assistance of her husband
and daughter. Therefore, she came to the Emergency
Department.
She denies any fall or back pain worse that her baseline
pain. No urinary incontinence. No fevers or chills. She
does report intermittent and variable pain in her legs with
movement that changes location as well as intensity.
Additionally, she does report some electrical tingling in her
bilateral insteps with head flexion.
PAST MEDICAL HISTORY:
1. Metastatic rectal adenocarcinoma diagnosed in [**2167-11-23**].
(a) She is status post 5-fluorouracil and oxaliplatin;
completed in [**2167-12-24**].
(b) She is also status post laparoscopic colostomy in
[**2167-9-23**] as well as Port-A-Cath placement in [**2167-9-23**].
(c) Her disease is metastatic to the liver and throughout
her spine.
(d) Additionally, she has pleural effusions.
2. Status post colostomy. She has had occasional recurrent
bleeding from the ostomy site.
3. Anemia.
ALLERGIES: PENICILLIN (which causes a rash).
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg by mouth once per day.
2. Coumadin 1 mg by mouth once per day.
3. OxyContin 10 mg by mouth every day.
4. Oxycodone as needed.
5. Colace and Senna as needed.
6. Iron 325 mg by mouth once per day.
7. Vitamin C.
8. Calcium.
9. Peridex as needed.
10. Zometa every month.
SOCIAL HISTORY: The patient is married. She lives with her
husband. She has [**Hospital6 407**], home physical
therapy, and home health aide. She denies alcohol or tobacco
use. She uses a walker for ambulating.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature maximum
was 100.7 degrees Fahrenheit, temperature current was 98.6,
her blood pressure was 104/60, her heart rate was 82, her
respiratory rate was 16, and her oxygen saturation was 96% on
room air. In general, this was a partially bald, pleasant,
elderly woman in no acute distress. Head, neck, chest,
cardiovascular, and extremity examinations were within normal
limits. Abdominal examination was notable for an ostomy with
mild bleeding, although not perfuse. Otherwise, the
abdominal examination was unremarkable. Neurologic
examination was notable for 4/5 strength in the bilateral
deltoids, biceps, and triceps. Distal upper extremity
strength was [**4-27**]. Iliopsoas was [**1-28**] to [**2-26**] bilaterally.
Knee flexion and extension was [**3-28**]. Plantar and dorsiflexion
was 4+/5. Toe extension was [**4-27**]. The deep tendon reflexes
were 2+ in the upper extremities bilaterally and 0 to 1+
patellar and ankle reflexes. The toes were downgoing.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 16.3 (with 86% polys and 4% bands), her
hematocrit was 30.4, and her platelet count was 167.
Chemistry-7 was notable for a sodium of 132, her bicarbonate
was 17, and her creatinine was 1.1. Her lactate was 1.6.
PERTINENT RADIOLOGY/IMAGING: A magnetic resonance imaging of
the spine essentially showed diffuse but unchanged metastatic
disease to the spine as well as severe spinal stenosis at
L4-L5 that was compressing nerve roots. No cord compression.
A chest x-ray showed no infiltrate or effusions and a
Port-A-Cath in place.
ASSESSMENT: This is a 65-year-old woman with metastatic
rectal cancer to the spine and liver, status post
chemotherapy six weeks ago, with two weeks of progressive
lower extremity weakness.
Physical examination showed proximal muscle weakness.
Magnetic resonance imaging showed diffuse metastases, L4-L5
spinal stenosis squeezing on the nerve roots, but no change
since the [**2167-10-24**] magnetic resonance imaging.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. LOWER EXTREMITY WEAKNESS ISSUES: The etiology of this
remains unclear. Possibilities include myopathy
(perineoplastic versus steroid-induced) versus additive
effects of spinal stenosis and metastases versus
leptomeningeal spread.
Both Neurology Service and Radiology/Oncology Service were
consulted. Given the absence of cord compression, it was
felt that radiation therapy would unlikely be effective.
An electromyogram was done that showed only very mild
myopathy; not enough to explain symptoms. A lumbar puncture
was done by Interventional Radiology on [**2-29**] that showed
no infection, and the cytology was negative for malignant
cells, making leptomeningeal spread less likely despite the
increased CEA.
It was doubtful that this was a steroid-induced myopathy.
Nevertheless, all steroids were held since admission. Her
muscular pain was treated with OxyContin and oxycodone
titrated to control her pain.
After this evaluation, it was felt that the weakness was
likely related to her cancer or some sort of perineoplastic
syndrome. Therefore, chemotherapy was started on [**3-10**] to
hopefully improve her weakness.
2. METASTATIC RECTAL CANCER ISSUES: CEA had nearly doubled
in the last month, so there was an increasing concern that
the weakness was secondary to perineoplastic syndrome or to
central nervous system and meningeal involvement.
A repeat abdominal pelvis computed tomography was unrevealing
and showed unchanged disease. She was started on a low-dose
continuous 5-fluorouracil infusion on [**3-10**].
3. INFECTIOUS DISEASE ISSUES: Initially, the patient had
only low-grade fevers and an elevated white count on
admission. However, several days into her hospital course,
blood cultures drawn on [**2-29**] showed 4/4 bottles positive
for Escherichia coli, and ceftriaxone was begun on [**3-1**].
However, on the night of [**3-2**], the patient spiked a
temperature to 104.9. She had mental status changes, was
tachycardic, and tachypneic; and gentamicin was started. The
fever resolved, but she started to have a decrease in her
blood pressure. She received a total of 4 liters of normal
saline, and her systolic blood pressure was still in the 70s
by the next morning, so she was transferred to the Intensive
Care Unit where she stabilized after receiving a total of 5
liters.
Her antibiotics were changed to levofloxacin, Flagyl,
gentamicin, and vancomycin. Infectious Disease Service was
consulted. It was felt that the Escherichia coli was likely
secondary to gut translocation from the site of her rectal
cancer. An abdominal and pelvic computed tomography did not
show any abscess.
She stabilized and was transferred back from the Unit to the
floor. However, several days later, she began spiking fevers
again to 102. This was felt to either be likely from
continued gut macroperforation from her cancer or possibly
due to a noninfectious etiology. Her temperature came down
with the continued antibiotic therapy, and chemotherapy was
started on [**3-10**] in an effort to decrease her tumor and
therefore decrease the likelihood of macroperforation. Blood
cultures since the 4/4 bottles positive for Escherichia coli
on [**Month (only) 958**] have been negative to date.
4. ANEMIA ISSUES: On the day after admission, after
receiving intravenous fluids, the patient's hematocrit
decreased to approximately 23. Her anemia is felt to likely
be secondary to chronic disease, although she also has had
some intermittent bleeding for her ostomy site. She received
a total of 4 units of packed red blood cells, and her
hematocrit was now roughly stable. She showed no evidence of
acute disseminated intravascular coagulation when she had
sepsis. Due to the small oozing and bleeding from her ostomy
site, her low-dose Coumadin has been held and she received 10
mg of vitamin K subcutaneously times one dose.
5. ACUTE RENAL FAILURE ISSUES: Acute renal failure resolved
after receiving intravenous fluids.
6. LONG-TERM CARE PLANS: The patient is currently
considering what she wishes as far as long-term care plans
go. She is rethinking her code status. Additionally, she is
obtaining more information about hospice care. However,
currently, we are continuing to treat her infection with
antibiotics and continuing chemotherapy in the hopes that it
will improve her lower extremity weakness.
NOTE: The remainder of the [**Hospital 228**] hospital course will be
dictated by the physician taking over her care.
[**First Name11 (Name Pattern1) 396**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9758**]
Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36
D: [**2168-3-14**] 11:27
T: [**2168-3-15**] 07:37
JOB#: [**Job Number 97992**]
Name: [**Known lastname **], [**Known firstname **] K Unit No: [**Numeric Identifier 15651**]
Admission Date: [**2168-2-25**] Discharge Date: [**2168-3-17**]
Date of Birth: [**2102-5-18**] Sex: F
Service:
Of note, since the last discharge summary, her MS contin has
been titrated up for better pain control and with better
success of pain control. Also she was continued for her 5FU
and also started on new chemo regimen yesterday which she
tolerated well. Plan is for her to be discharged off the
chemotherapy and discharge to rehabilitation center from the
hospital here. Other discharge information as discussed in
the previous discharge summary except her MS Contin which is
going to be a higher amount and see page 1 for that.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15098**]
Dictated By:[**Name8 (MD) 5105**]
MEDQUIST36
D: [**2168-3-16**] 15:59
T: [**2168-3-16**] 16:03
JOB#: [**Job Number 15652**]
Name: [**Known lastname **], [**Known firstname **] K Unit No: [**Numeric Identifier 15651**]
Admission Date: [**2168-2-25**] Discharge Date: [**2168-3-23**]
Date of Birth: [**2102-5-18**] Sex: F
Service: .
ADDENDUM TO DISCHARGE SUMMARY:
The patient was discharged in stable condition to an extended
care facility. Discharge instructions as noted in Page one.
DISCHARGE DIAGNOSES:
1. Metastatic rectal carcinoma.
FOLLOW-UP INSTRUCTIONS:
1. Recommended follow-up with primary care physician
[**Name Initial (PRE) 15653**].
2. To follow-up with oncologist regularly.
There were no major surgical invasive procedures.
CONDITION AT DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Pantoprazole.
2. Docusate 100 twice a day.
3. Ferrous sulfate 325 q. day.
4. Calcium carbonate 500 q. day.
5. Cholecalciferol 400 units q. day.
6. Lorazepam 0.5 mg p.o. q. four to six hours p.r.n.
7. Tylenol p.r.n.
8. Senna p.r.n.
9. Ascorbic acid one tablet p.o. twice a day.
10. Camphor menthol lotion four times a day p.r.n.
11. Clotrimazole 10 mg four times a day.
12. Ibuprofen p.r.n.
13. Oxycodone 5 mg, two to three tablets p.o. q. four hours.
14. Benadryl p.r.n.
15. Miconazole twice a day powder.
16. Chlorpromazine 10 mg p.o. q. six hours as needed.
17. Heparin subcutaneously 5000 units twice a day.
18. Oxycodone 60 mg tablets sustained release twice a day.
19. Multivitamin q. day.
20. Zinc sulfate.
21. Morphine 2 mg intravenously q. four to six p.r.n.
Follow-up and the rest of the discharge as indicated above.
See also main Discharge Summary as previously indicated by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15098**]
Dictated By:[**Name8 (MD) 1902**]
MEDQUIST36
D: [**2168-3-23**] 13:06
T: [**2168-3-23**] 13:45
JOB#: [**Job Number 15654**]
|
[
"584.9",
"154.1",
"276.1",
"197.7",
"285.9",
"198.5",
"359.9",
"038.42",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.31",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
2140, 4229
|
10545, 10579
|
10841, 12103
|
1602, 1906
|
4263, 10524
|
10811, 10818
|
163, 1006
|
10603, 10795
|
1028, 1575
|
1923, 2123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,031
| 172,929
|
2026
|
Discharge summary
|
report
|
Admission Date: [**2195-11-16**] Discharge Date: [**2195-11-26**]
Date of Birth: [**2162-1-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetanus,Diphtheria Toxoid / Lisinopril
Attending:[**First Name3 (LF) 3967**]
Chief Complaint:
CC: dark urine/ n/v, hyperglycemia
Reason for MICU Admission: acute hemolytic anemia
Major Surgical or Invasive Procedure:
Splenectomy
History of Present Illness:
This is a 33 year-old male with a history of ITP, autoimmune
hemolytic anemia, DM type I, and splenomegaly scheduled for
splenectomy in [**Month (only) 1096**] who presents with 3 days of progressive
weakness, lightheadedness with exertion and 1 day of jaundice.
He was in his USOH until approximately [**2195-10-27**] when he
contracted cold-like symptoms with rhinorhea, cough, and
malaise. He then ([**2195-11-9**]) presented to his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
with left lower quadrant pain, which he started noticing when he
awoke on [**11-6**] and a CT Abd/Pelv showed stable, marked
splenomegaly. He was given pain meds and scheduled for
splenectomy. Also, of note he was given Pnemoccoal,
Meningiococcal, and HIB vaccinations on [**2195-11-10**].
.
On Sat [**2195-11-14**] he began noticing fatigue and lightheadedness
with exertion which progressively worsened to the point of
nearly passing out each time he got up. His blood sugars were
difficult to control, requiring nearly double the dose of
insulin. Urine was brown. He also endorses N/V and is able to
hear his heart in his ears.
.
In the ED, vitals were 98.9, hr 144, bp 116/73, rr 30, SaO2 98%
RA. He got 2L IVF with 12 U insulin. Insulin gtt was started
as patient noted to have AG of 15 and sugars in 400s. Admitted
to ICU for DKA and hemolytic anemia
.
ROS: The patient denies any fevers, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, focal weakness,
headache, or rash.
.
Past Medical History:
Hemolytic anemia - last in [**2190**] requiring steriods and IVIG
(never transfused PRBCs)
ITP - last episode [**2192**] tx with rituxan
Diabetes type I - since age 6, last A1C 7.8 [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs
HTN
Hyperlipidemia
Hypothyroidism
.
Social History:
He is married, without children. Lives in [**Location 11103**], works for Lucent Technology. He does not smoke, use
alcohol or drugs.
Family History:
He has a sister with antiphospholipid antibody
syndrome and "clotting or thick blood problems." Mother and
father and various minor medical problems, "such as
hypertension,
but no blood dyscrasias."
Physical Exam:
On Presentation:
Vitals: T: 100.8 BP: 121/60 HR: 131 RR: 19 O2Sat: 100% RA
GEN: Well-appearing, no acute distress, mildly anxious, obese
HEENT: EOMI, PERRL, sclera grossly icteric, no epistaxis or
rhinorrhea, MM dry, OP Clear
NECK: Unable to assess JVD, carotid pulses brisk, trachea
midline
COR: Tachycardic, reg rhythm, no M/G/R, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, TTP at LUQ and LLQ, obese, +BS, no masses palpated
EXT: No C/C/ trace edema
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.
SKIN: Obvious jaundice. No cyanosis, or gross dermatitis. No
ecchymoses.
Pertinent Results:
Admission Labs:
[**2195-11-16**] 01:50PM WBC-12.7*# RBC-1.84*# HGB-5.8*# HCT-17.6*#
MCV-96 MCH-31.6 MCHC-32.9 RDW-14.3
[**2195-11-16**] 01:50PM NEUTS-78* BANDS-2 LYMPHS-9* MONOS-4 EOS-3
BASOS-2 ATYPS-0 METAS-2* MYELOS-0
[**2195-11-16**] 01:50PM PLT SMR-HIGH PLT COUNT-611*#
.
[**2195-11-16**] 01:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
.
[**2195-11-16**] 01:50PM RET AUT-4.7*
[**2195-11-16**] 01:50PM calTIBC-247* HAPTOGLOB-<20* FERRITIN-GREATER
TH TRF-190*
.
[**2195-11-16**] 01:50PM GLUCOSE-416* UREA N-30* CREAT-0.6 SODIUM-134
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-21* ANION GAP-20
[**2195-11-16**] 01:50PM ALT(SGPT)-32 AST(SGOT)-47* LD(LDH)-983* ALK
PHOS-90 TOT BILI-11.2* DIR BILI-1.1* INDIR BIL-10.1
[**2195-11-16**] 01:50PM ALBUMIN-3.3* CALCIUM-8.3* PHOSPHATE-2.9
MAGNESIUM-1.8 IRON-224*
.
TREND OF CBC:
[**2195-11-18**] 01:26AM BLOOD WBC-20.4* RBC-2.20* Hgb-7.2* Hct-20.1*
MCV-91 MCH-32.9* MCHC-36.0* RDW-16.2* Plt Ct-619*
[**2195-11-19**] 07:49AM BLOOD WBC-20.5* RBC-1.86* Hgb-6.0* Hct-16.6*
MCV-90 MCH-32.3* MCHC-36.0* RDW-15.3 Plt Ct-429
Post Splenectomy:
[**2195-11-19**] 04:44PM BLOOD WBC-38.2*# RBC-3.12*# Hgb-9.8*#
Hct-27.1*# MCV-87 MCH-31.4 MCHC-36.1* RDW-14.9 Plt Ct-283
[**2195-11-20**] 05:01AM BLOOD WBC-31.9* RBC-2.78* Hgb-8.7* Hct-24.5*
MCV-88 MCH-31.2 MCHC-35.4* RDW-16.7* Plt Ct-221
[**2195-11-20**] 10:11AM BLOOD Hct-24.2*
[**2195-11-20**] 04:31PM BLOOD Hct-26.0*
[**2195-11-21**] 04:55AM BLOOD Hct-20.9*
[**2195-11-21**] 02:29PM BLOOD Hct-25.5*
[**2195-11-21**] 10:06PM BLOOD Hct-23.7*
[**2195-11-22**] 04:18AM BLOOD WBC-21.4* RBC-2.50* Hgb-8.0* Hct-22.3*
MCV-89 MCH-31.9 MCHC-35.8* RDW-19.5* Plt Ct-272
.
[**2195-11-16**] CXR: IMPRESSION: No acute intrathoracic process
.
[**2195-11-19**] Portable ABDOMEN: IMPRESSION: No obstruction or free
air identified on this limited study.
.
[**2195-11-22**] RUE U/S: IMPRESSION: Incompletely occlusive thrombus
along the upper (more proximal) portion of the right basilic
vein. Right basilic PICC in place.
.
RUQ ultrasound [**2195-11-24**]: 1. Limited exam given poor acoustic
windows. The liver shows mild increased echogenicity consistent
with fatty infiltration. More severe forms of liver disease
including significant hepatic fibrosis/cirrhosis is not excluded
on this study. No focal hepatic lesion is identified. 2.
Sludge-filled gallbladder. No evidence of cholecystitis or
intra/extra-hepatic biliary dilatation.
.
RUE Ultrasound [**2195-11-25**]: Occlusive thrombosis of right basilic
vein, slightly more extensive than that seen on [**2195-11-22**].
Thrombosis also demonstrated in distal right cephalic vein.
Brief Hospital Course:
This is a 33 year-old male with a history of ITP, autoimmune
hemolytic anemia, and splenomegaly scheduled for splenectomy in
[**Month (only) 1096**] who presents with DKA and hemolytic anemia.
.
ICU Course:
# Hemolytic anemia: Most likely [**1-31**] to recent immunizations
tipping off autoimmune hemolysis. He has had episodes of
hemolytic anemia in the past, controlled with steroids. He had
never had a transfusion of PRBCs but has Warm autoantibodies,
making crossmatching very difficult. He was antigen matched by
blood bank and his Hematologist, Dr. [**Last Name (STitle) 6944**]. He recieved
several transfusions while in the ICU and by day 3, the decision
was made for splenectomy. He tolerated the procedure well and
was transfused 3 U intra-op, with post-op Hct of 28. He
continued to required transfusions post-op. Total # of units
was 10 U during ICU stay.
.
# DKA: Patient with generally good control [**First Name8 (NamePattern2) **] [**Last Name (un) **] records
(A1C of 7.8), but sugars very difficult to control in the 400s
prior to admit. He was place on insulin gtt and his gap closed,
but remained on this for control during the peri-operative
period. Post-op day 3 he was transitioned off insulin gtt to
sub-Q insulin and was transfered to floor.
.
# Fever/elevated WBC: White count of 13 with 74 neutrophils and
2 bands. Monospot negative on [**2195-11-10**]. Suspicion for infection
was very low on presentation, so antibiotic were not started.
His cultures remained without growth.
.
# HTN: Held antihypertensives initially, but added them back as
needed.
.
# Hyperlipidemia: Hold statin for now given marginal LFTs
.
# Hypothyroidism: Continued levothyroxine.
.
Hospital Course from when patient transferred from ICU to
surgical floor:
.
Post-operatively the patient did well after being transferred to
the floor. His JP was draining serosanginous fluid. Analysis
of this fluid for amylase and lipase was not significant.
Therefore his JP was discontinued. He tolerated a regular diet
and was passing gas. He was ambulating well without problems.
His pain was controlled on PO pain meds.
.
His hematocrit did fall to 21-22 from 24-26 in the ICU, for
which he recieved one unit of blood. Because his overall
bilirubin was still elevated along with a mild increase in
alkaline phosphatase, heme/onc recommended that he get a RUQ U/S
to evalulate for biliary etiology. His RUQ U/S although a
limited study, revealed gallbladder sludge but no evidence of
cholecystitis or dilated ducts. He became febrile, likely from
the transfusion however was started empirically on levaquin.
Since the transfusion he is afebrile for 24 hours. His hct has
been stable at 21-22 without futher transfusions for at least 24
hours.
.
Hospital course when patient transferred from surgical to Heme
Onc floor ([**Date range (1) 11104**]):
.
Patient received Rituxan [**2195-11-25**]. Right upper arm continued to
be swollen and RUQ U/S demonstrated occlusive thrombosis of
right basilic vein. Patient was discharged on Lovenox for
anti-coagulation. Patient had significant lower extremity edema
and consequently was diuresed with IV Lasix. Morning hematocrit
was 18 and received 1 unit of blood. Patient scheduled for
followup lab checks on [**2195-1-27**] 12:00, [**2195-11-30**] 10:00 and
followup with Dr. [**Last Name (STitle) 6944**] [**2195-12-2**] 11:00.
- Patient discharged on Levofloxacin for infection prophylaxis
however insurance does not cover. Informed pharmacy to fill a
prescription for Augmentin 875 mg 30 day supply. Patient should
discuss with outpatient hematologist regarding necessity and
continuation of antiobiotics.
- Patient's statins were on hold during admission and should be
restarted when appropriate
- Patient was started on Metoprolol Tartate 25 mg [**Hospital1 **] and
continued on outpatient Valsartan 160 mg. Blood pressure should
be followed by primary care physician.
[**Name Initial (NameIs) **] Additional new discharge medications include: Lovenox, Folic
Acid, Trazodone, Lasix, Oxycodone for pain control.
Medications on Admission:
Insulin Pump
Diovan 160mg daily
Simvastatin 40mg daily
Levothyroxine 175 mcg daily
fexofenadine 150 daily
Benadryl PRN for sleep
He stopped taking phentermine about a week ago.
.
Discharge Medications:
1. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day: 1 syringe for total 120 mg dose twice
a day. .
Disp:*60 syringes* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Continue until directed by your oncologist.
Disp:*90 Tablet(s)* Refills:*0*
9. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours): Continue until directed by your oncologist. .
Disp:*60 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Insulin
Use insulin pump as directed by [**Last Name (un) **].
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed: Medication will make you drowsy. Do not drive
while taking. .
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Warm autoimmune hemolytic anemia
ITP
Acute hemolysis
Spleenectomy
.
Secondary:
Warm Autoimmune Hemolytic Anemia diagnosed in [**2190**] (treated with
steroids), ITP diagnosed in [**2192**] (treated with Rituxan and
IVIG), Diabetes type I, HTN, hyperlipidemia, hypothyroidism
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
You were admitted for hemolytic anemia and had a spleenectomy.
You were found to have a blood clot in your upper extremity and
we started you on anti-coagulation (Lovenox). It is important to
come in for your count checks and follow-up with Dr. [**Last Name (STitle) 6944**] -
your appointments are listed below. Please review your
medications closely on discharge as you have been started on new
medications. Call your oncologist if you experience fever,
chills, nausea, dark urine, lightheadness, chest pain, shortness
of breath or any concerning symptoms.
.
You have been started on the following new medications:
1) Lovenox for upper arm clot
2) Folic Acid
3) Trazodone to help you sleep
4) Lasix
5) Prednisone 60 mg - please discuss the duration of this
medication with Dr. [**Last Name (STitle) **]
6) Levofloxacin - please discuss the duration of this medication
with Dr. [**Last Name (STitle) **]
7) Metoprolol for your blood pressure - see your primary care
doctor regarding your high blood pressure
8) Oxycodone for pain control. DO NOT DRIVE WHILE TAKING.
.
The following instructions have been provided by your Surgeon:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
- Your staples will be removed at your follow-up appointment
with Dr. [**Last Name (STitle) 1924**]. Steri strips will be applied.
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Have your blood counts checked on 7 [**Hospital Ward Name 1826**]:
BED 3-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2195-11-28**] 12:00
BED 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2195-11-30**] 10:00
.
Follow up with oncologist:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2195-12-2**]
11:00 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC
.
3. Please make a follow-up appointment with Dr. [**Last Name (STitle) 1924**]
[**Telephone/Fax (1) 7508**] in [**12-31**] weeks.
4. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] in 1
week and as needed.
[**Name6 (MD) **] [**Last Name (NamePattern4) 3974**] MD, [**MD Number(3) 3975**]
Completed by:[**2195-11-29**]
|
[
"244.9",
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"287.32",
"401.9",
"V45.85",
"701.9",
"789.2",
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"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"38.93",
"99.28",
"99.14",
"86.3"
] |
icd9pcs
|
[
[
[]
]
] |
11740, 11746
|
6097, 10164
|
403, 416
|
12074, 12152
|
3411, 3411
|
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2484, 2684
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|
276, 365
|
444, 2014
|
3427, 6074
|
2036, 2316
|
2332, 2468
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
127
| 141,647
|
3774
|
Discharge summary
|
report
|
Admission Date: [**2183-8-20**] Discharge Date: [**2183-8-24**]
Date of Birth: [**2135-2-1**] Sex: F
Service: .
CHIEF COMPLAINT: Worsening shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old
female with a history of metastatic breast cancer status post
lumpectomy and radiation with a history of two recent
admissions in [**Month (only) 116**] and [**2183-7-10**], for bilateral malignant
pleural effusions and bilateral pleurodesis requiring home O2
and Bi-PAP, now presenting with one week of progressive
worsening shortness of breath. The patient noted, starting
approximately one week ago, progressively worsening shortness
of breath at rest with increasing home O2 requirements. Two
days prior to admission, the patient presented to the
Emergency Department complaining of shortness of breath,
increased heart rate, decreased O2 saturations in the low
90s. The patient was evaluated for pulmonary embolism by CT
angiogram which was negative with only slight increase in the
right pleural effusion and atelectatic changes. The patient
was discharged home with home O2 to follow-up with her
Pulmonologist, Dr. [**Name (NI) **].
On the morning of admission, the patient saw Dr.
[**Name (NI) **], reporting worsening shortness of breath,
increased O2 requirements from 1.5 to 4 liters, decreased O2
saturations from the mid-90s to the low 90s and increased
heart rate above 100. An echocardiogram of the lungs was
done showing no change in pleural effusions and the patient
was referred to the [**Hospital1 69**] for
transthoracic echocardiogram.
The echocardiogram revealed a moderate to large sized
pericardial effusion with a right atrial collapse and a right
ventricular diastolic collapse, consistent with impaired
filling and tamponade.
PAST MEDICAL HISTORY:
1. Metastatic breast cancer diagnosed in [**2177**]: Infiltrating
ductal carcinoma status post lumpectomy and radiation with
axillary node dissection, recurrence [**2182-8-10**];
admission [**4-/2183**] and [**7-/2183**] for bilateral pleural
effusions, bilateral pleurodesis requiring home O2.
2. Cerebrovascular accident in [**2178**]: Small hemorrhagic
cerebrovascular accident from a cavernous hemangioma.
3. Seasonal allergies.
4. Right low anterior rib fracture.
MEDICATIONS ON ADMISSION:
1. Xeloda 150 mg p.o. twice a day.
2. Claritin q. day.
3. Protonix 40 mg p.o. q. day.
4. Ativan 0.4 to 1 mg p.o. q. six p.r.n.
5. Motrin p.r.n. for rib pain.
6. Home O2.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has been an Intensive Care Unit
nurse here at the [**Hospital1 69**] for 28
years. Drinks alcohol socially. She has a 20 pack year
history of tobacco and quit in [**2174**].
FAMILY HISTORY: The patient has an aunt and great-aunt with
breast cancer. Her mother died of mixed connective tissue
disorder. Her father died of hairy cell leukemia.
PHYSICAL EXAMINATION: Vital signs upon admission,
temperature maximum of 97.7 F.; heart rate of 104 to 109;
blood pressure of 121/89, nap of 102; respiratory rate of 30;
pulses 16, 128/112. The patient's O2 saturation is 92 to 97
on four liters. Generally, the patient is a thin female,
notably short of breath while speaking. HEENT examination:
No scleral icterus. Extraocular muscles are intact. Pupils
are equal, round, and reactive to light and accommodation.
Mucous membranes were moist. Neck examination: At 30
degrees with jugular venous distention approximately 10
centimeters. No carotid bruits noted. Lung examination with
decreased breath sounds bilaterally at the bases, right
greater than left, crackles half way up the right side and a
third of the way up the left side. Dullness to percussion
bilaterally, right greater than left; no wheezes.
Cardiovascular examination with increased heart rate; normal
S1, split S2. No murmurs, rubs or gallops. Pulsus paradoxus
with radial pulse decreasing with inspiration. Pulses at 16.
Her abdominal examination with normoactive bowel sounds.
Abdomen was nondistended, nontender. Spleen tip was
palpable. Extremities were warm with normal dorsalis pedis
pulses bilaterally. No peripheral edema, clubbing or
cyanosis. Neurologic examination: The patient is awake,
alert and oriented times three with no gross lesions.
LABORATORY DATA: On [**8-18**], white blood cell count 6.9,
hematocrit of 39.2, platelets of 353. Sodium 136, potassium
3.9, chloride 99, carbon dioxide 25, BUN 15, creatinine 0.4,
glucose 104, calcium 9.1. Alkaline phosphatase 91, AST 24,
ALT 14, albumin 3.4, FSH 91.
Blood cultures negative. CA antigen [**585-7-13**] and
[**900-8-7**].
CT angiogram in the Emergency [****], showed no evidence
of pulmonary embolus, slight interval increase in right
pleural effusion with left loculated atelectatic changes. A
[**8-20**] lung ultrasound showing no change in pleural
effusion.
Transthoracic echocardiogram showing left ventricular
systolic function, mildly decreased septal hypokinesis,
moderate to large pericardial effusion, right atrial
collapse, right ventricular diastolic collapse consistent
with impaired filling or tamponade.
On [**8-20**], white blood cell count 5.7, hematocrit 37.5,
platelets 329, potasium 4.1.
HOSPITAL COURSE: In brief, the patient is a 48 year old
female with a history of metastatic breast cancer status post
two recent admissions for bilateral malignant pleural
effusions, bilateral pleurodesis requiring home O2 and
bi-PAP, now presenting with progressively worsening shortness
of breath times one week and transthoracic echocardiogram
consistent with pericardial effusion.
1. Cardiovascular: The patient with an echocardiogram
consistent with pericardial effusion. The patient was taken
to the Catheterization Laboratory on [**8-21**], where the
effusion was tapped and drained for 250 cc. of serosanguinous
fluid. Right ventricular pressure of 33/15, P- a pressure of
35/17, wedge of 21. Cardiac output 5.3, cardiac index 3.2.
The drain was subsequently pulled on [**8-23**]. Miss [**Known lastname 16968**] had
an EKG upon admission which showed no evidence of electrical
alternans and EKG upon discharge which also showed no
evidence of electrical alternans.
The house officer was called to see the patient in the
evening of [**8-21**], for chest pain with inspiration. A
pericardial rub was heard. An EKG showed some elevation in
PR interval in AVR.
Throughout her hospital course, the patient remained
tachycardic, in the low 100s to 110. A follow-up
echocardiogram was done revealing normal ejection fraction 45
to 50% and no evidence of pericardial effusion.
2. Pulmonary: The patient has a history of malignant
pleural effusions likely contributing to her symptoms of
shortness of breath. Dr. [**Name (NI) **] was made aware and
recommended no further intervention at this point. The
patient was saturating well in the low 90s to 95 range on
four liters of nasal cannula which was decreased to two
liters prior to discharge. The patient reported subjectively
that her shortness of breath had improved somewhat following
the tap. She will return home on home O2 and Bi-PAP.
3. Hematology/Oncology: The patient has a history of
metastatic breast cancer and malignant bilateral pleural
effusions, now with a new pericardial effusion which is
exudative. Cytology has been sent to evaluate if this is, in
fact, a malignant pericardial effusion. Dr. [**Last Name (STitle) **] was made
aware that the patient was hospitalized and involved in her
care during her inpatient stay. She is scheduled to
follow-up with him on Tuesday, [**8-26**]. She will continue on
Xeloda and pain control with morphine, Percocet, Toradol and
Motrin p.r.n.
The patient was discharged home on [**8-24**], with the following
medications, discharge diagnoses and instructions.
DISCHARGE DIAGNOSES:
1. New pericardial effusion, cytology pending.
2. Metastatic breast carcinoma with a history of malignant
pleural effusions.
3. Cerebrovascular accident in [**2178**].
4. Seasonal allergies.
5. History of rib fracture.
MEDICATIONS UPON DISCHARGE:
1. Xeloda 1650 mg twice a day.
2. Protonix 40 mg p.o. q. day.
3. [**Doctor First Name **] 60 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. An appointment has been made for Miss [**Known lastname 16968**] to follow-up
with Dr. [**Last Name (STitle) **] in Hematology/Oncology on Tuesday, [**8-26**], at 02:30 p.m.
2. It is recommended that the patient have a follow-up
echocardiogram to evaluate any further re-accumulation of
pericardial fluid.
3. The patient is to call if she has worsening symptoms or
shortness of breath, palpitations, chest pain.
4. The patient is to resume all prior medications. No new
medications have been added upon this admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 16969**]
MEDQUIST36
D: [**2183-8-24**] 14:56
T: [**2183-8-24**] 15:13
JOB#: [**Job Number 16970**]
cc:[**Last Name (NamePattern4) 16971**]
|
[
"V10.3",
"197.2",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
2768, 2923
|
7868, 8105
|
2327, 2543
|
5268, 7847
|
8258, 9105
|
2947, 4213
|
152, 184
|
8121, 8234
|
214, 1804
|
4238, 5249
|
1826, 2301
|
2561, 2750
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,840
| 154,711
|
5614
|
Discharge summary
|
report
|
Admission Date: [**2119-11-26**] Discharge Date: [**2119-12-3**]
Date of Birth: [**2042-4-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6029**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
ORIF of left femur
Intubation
Swan Ganz catheter placement
Extubation
History of Present Illness:
77 yo M w/ CAD, HTN, AFIB on coumadin presents after fall x 2.
He reports generalized weakness for the last few days. 1 day
prior to admission, he got up to walk to bathroom and he fell.
No head trauma/LOC or pain. On the day of admission, he again
tried to get off the couch, after a few steps his "legs gave
out" and fell to the floor. He could not get up 2/2 pain in his
left leg. He was on the floor for 4 hours kicking his door with
his right leg and screaming. Around 4 am, he was found and EMS
was called. He denies CP, Lightheadedness, SOB, palpitations. He
denies changes in vision. He denies fecal/urinary incontinence.
He denies f/c/sweats/cough.
.
In the ED, he was mildly hypoxic - 89%RA. A CXR was done with
question of pneumonia. He was given a dose of levofloxacin. The
final read of the CXR was of concern of [**Location (un) 22533**] Hump so a CTA
was done which was negative for PE and still with question of
PNA or atelectasis. He was also given aspirin and had 2 sets of
CEs checked for question of MI causing weakness. Prior to
leaving the ED, his BP dropped to 90/45 from 105/63. He was
given an additional bolus of 1L NS.
Past Medical History:
1. Hypertension.
2. Peptic ulcer disease.
3. Gastroesophageal reflux disease.
4. Atrial fibrillation.
5. Coronary artery disease status post MI in [**2113-1-31**]
with severely decreased left ventricular ejection fraction - 20%
in 3/00,.
6. Hypercholesterolemia.
7. History of liver abscess.
8. Status post Meckel diverticulum in [**2069**].
9. Status post Nissen fundoplication in [**2112-2-1**].
10. Status post left inguinal hernia repair in [**2112-12-31**].
11. Status post small bowel hernia/resection in [**Month (only) 956**] of
[**2112**].
12. Type 2 DM.
13. Dementia.
14. Right Inguinal Hernia
Social History:
He lives in [**Hospital3 22534**]. He never smoked.
He drinks on M, W, Fs a few beers/wine. His last drink was
Friday. He walks up and down 1 flight of stairs from his
apartment to the dining room every day without shortness of
breath. He rarely walks outside.
Family History:
Non-contributory
Physical Exam:
VS: Temperature 100.3, HR 73, BP 90/50, RR 20 O2 Sat 94%2L,
respirations 20, Wt 163lb
GENL: NAD, No increased work of breathing
HEENT: EOMI, PERRLA, sclera anicteric, sl dry MM, No OP lesions
NECK: JVP - 7cm, supple
PULM: clear ant/lat
CV: RRR, Nl S1, S2, No Murmurs, Rubs, or Gallops.
ABD: soft, nontender, and nondistended, positive bowel sounds.
Well healed midline scar, large right inguinal hernia
EXT:
--LLE: Shortened and externally rotated, pain with all range of
motion. pain to palpation left hip/femur. no hematoma noted.
--RLE: no clubbing, cyanosis or edema.
Distal pulses 2+ bilaterally,
NEURO: AandOx3, CN 2-12 intact, M [**5-5**] UE bl,RLE, sensation
intact.
Pertinent Results:
#CXR - Right mid lung base opacity may represent atelectasis
versus pneumonia. An underlying lesion cannot be excluded.
.
#CTA:
1. Airspace opacity in the right upper lobe, consolidative in
nature, representing either atelectasis or pneumonia.
2. Old rib fracture and fusion anomaly of two left
posterolateral ribs, but no acute rib fracture.
3. No pulmonary embolism.
.
#CT head: PRELIM: atrophy; prior stroke in right frontal lobe;
no evidence of intrancranial hemorrhage or acute injury
.
#CT C-SPINE: PRELIM: spondylosis; no evidence of fx or
dislocation
.
Foot Xray: Two views. There is a comminuted fracture of the
distal shaft of the fifth metatarsal. There is moderate medial
angulation at the fracture site. Degenerative arthritic changes
are present, most pronounced at the first metatarsophalangeal
joint. There is a large plantar calcaneal spur. There is no
evidence of dislocation. Scattered atherosclerotic calcification
is present.
.
Hip Xray: AP PELVIS AND TWO VIEWS LEFT HIP: There is a
comminuted left intertrochanteric fracture with proximal
displacement and varus angulation. The femoral head approximates
well within the acetabulum. The right hip, bilateral sacroiliac
joints, and pubic symphysis are unremarkable. No additional
fractures are seen.
IMPRESSION: Comminuted left intertrocahnteric fracture as
described above.
.
#ECG NSR 80, [**Last Name (LF) 22535**], [**First Name3 (LF) **] elev V3-V6-old
.
[**2119-11-26**] 11:37PM LACTATE-1.7
[**2119-11-26**] 11:36PM WBC-12.0* RBC-3.29* HGB-11.5* HCT-30.8*
MCV-94 MCH-35.0* MCHC-37.4* RDW-13.4
[**2119-11-26**] 11:36PM PLT COUNT-196
[**2119-11-26**] 07:11PM CK(CPK)-1667*
[**2119-11-26**] 07:11PM cTropnT-0.07*
[**2119-11-26**] 07:11PM CK-MB-15* MB INDX-0.9
[**2119-11-26**] 12:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2119-11-26**] 12:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2119-11-26**] 12:15PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2119-11-26**] 10:48AM GLUCOSE-98 LACTATE-3.4* NA+-136 K+-4.9
CL--100
[**2119-11-26**] 10:30AM GLUCOSE-103 UREA N-36* CREAT-1.6* SODIUM-134
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18
[**2119-11-26**] 10:30AM CK(CPK)-[**2045**]*
[**2119-11-26**] 10:30AM CK-MB-21* MB INDX-1.1
[**2119-11-26**] 10:30AM cTropnT-0.08*
[**2119-11-26**] 10:30AM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.2
[**2119-11-26**] 10:30AM WBC-15.4* RBC-4.21* HGB-14.0 HCT-39.1*
MCV-93# MCH-33.1*# MCHC-35.7* RDW-13.1
[**2119-11-26**] 10:30AM NEUTS-88.9* LYMPHS-4.8* MONOS-6.1 EOS-0.1
BASOS-0.1
[**2119-11-26**] 10:30AM PLT COUNT-254
[**2119-11-26**] 10:30AM PT-18.3* PTT-30.6 INR(PT)-1.7*
Brief Hospital Course:
Mr. [**Known lastname **] is a 77 year old male who presented after fracture of
the left femur after feeling weak for 2-3 days at home.
.
Mr. [**Known lastname **] presented on [**11-26**] with a fracture of the left femur
after falling while in the bathroom at home. Imaging revealed a
femur fracture, no intracranial hemorrhage, no vertebral
fractures. He had been taking coumadin for atrial fibrillation
and had an INR of 1.7 on admission, repeat was 2.2. It was
noted that his hematocrit on admission was 39 and a follow up
hematocrit was 30.8. There was concern that Mr. [**Known lastname **] was
bleeding from an unknown source and orthopedic surgery was held
until the patient was medically cleared. A CXR done on
admission showed a possible PNA in the right upper lobe and the
patient was started on levaquin. CT chest in the ED ruled out
PE and also raised suspicion for PNA. CT head showed no bleed,
no acute process.
.
On [**11-27**] subsequent hematocrits were stable and it was felt that
the initial value was likely concentrated due to dehydration.
He was cleared for the OR on [**11-28**]. Of note, the night prior to
going to the OR, he triggered for a SBP of 89 and temperature to
101.9. He was given a fluid bolus and his blood pressure
responded appropriately. His antibiotics were not changed at
that time; he remained on levofloxacin.
.
He underwent ORIF of his L femur on [**2119-11-28**], receiving 2 units
of FFP and 2 units of PRBC and following extubation he was
brought to the PACU unresponsive. He arrived in the PACU in
afib with rates in the 130s-140s. The pt appeared to be having
difficulty with respiration and his ABG was 7.12/89/114 (unclear
how much FiO2). He was given Lasix 20 mg IV and after pt was
noted to have repiratory distress; he was reintubated with
etomidate 14 mg and succinylcholine 120mcg. Propofol was given
and pt was given Lopressor 3 mg IV. His SBP decreased to the
80s, and he was given a 500 cc bolus with his SBP rising to the
low 100s. A L IJ cordis was placed with 4 mg IV morphine given
prior. He also received Flagyl 500 mg IVx1 (in addition to the
Levaquin he was taking for PNA). EKG revealed [**Street Address(2) 4793**]
elevations in V1-V4 (increased from prior) and stat bedside echo
in the PACU revealed old septal akinesis/hypokinesis. CXR
revealed persistent RML infiltrate without evidence of volume
overload. On SIMV 600x12 wtih PEEP 5, PS 5, Rate 12, FiO2 50%
pts ABG was 7.33/44/184. The pt was weaned on his propofol to
off and he was weaned on his vent to PS at 5/5 with TV of
500-800cc. On arrival to the MICU from the PACU, the pt was
found hypotensive with a SBP in the 60s. The following is his
subsequent course:
.
#Sepsis/SIRS: Pts SBP was in the 60s on arrival to the ICU with
temp of 103 F. The pt was started on levophed gtt and bolused 1
L IVF. [**Last Name (un) **] stim test revealed a normal baseline cortisol
level. A swans-ganz catheter was floated through the L IJ
cordis and revealed a SVR of 700, CVP 14, wedge of 18, SV of 69,
and CO 4.5-6.5. Thus, the main cause of the pts hypotension was
felt to be sepsis rather than cardiogenic shock. Over the first
night in the ICU, the pts levophed was weaned off, and he
received a total of 4 L NS and 1 unit PRBC (for hct of 27 and
mixed venous O2 sat of 61%). The pts SBP rose to the low 100s.
The only source for sepsis was the pts RML PNA. Blood cx,
sputum cx, and urine cx were negative. He was called out to the
floor on [**11-30**]. While on the floor, he remained hemodynamically
stable, afebrile. He will continue a 10 day course of levaquin
and flagyl for possible aspiration pneumonia.
.
#Respiratory Failure: Ms. [**Known lastname **] initial ABG was c/w hypercarbic
resp. distress. He was unresponsive on arrival to the MICU, so
his hypercarbia was likely due to mental status changes. His
mental status had greatly improved on the morning after transfer
to the ICU. In the PACU the pt had already been weaned to PS
[**5-5**] with 50% FiO2, and he was taking in Tv in the 500s with sats
of 93-97%. He was extubated on the morning after transfer to the
ICU without complication. He was weaned to 2L on [**12-1**] however
O2 sat decreased to 88%. At that time he was noted to have
crackles at the bases on exam. As his blood pressure had
improved, he was restarted on lasix for duiresis. He remains on
2L, satting well at discharge.
.
#CAD/demand ischemia: Immediately following surgery, Mr. [**Known lastname **]
had increased ST elevations in the anterior leads on the EKG
with rapid afib. These elevations resolved after the HR
decreased. Per cards, this elevation was likely due to anterior
wall akinesis in the setting of tachycardia. Stress in [**2112**] had
shown fixed lesions of the apical/septal walls and
akinesis/hypokinesis of these regions. Stat TTE revealed EF
still severly depressed. Metoprolol and ACE were held in the
setting of hypotension. The pts troponin trended up to 0.12
which was likely due to demand ischemia. Pt was given PR ASA
while intubated and then po ASA and lipitor were restarted after
extubation. Metoprolol and ACE were held in the setting of
hypotension. Once hypotension resolved, his beta blocker was
restarted on [**11-30**] and increased to TID on [**12-2**]. A small dose
of an ace inhibitor was restarted on [**12-1**]. He tolerated both
medications well with stable BP.
.
#Altered Mental Status: Pts altered MS seemed to be related to
oversedation as he was mentating better hours later. DDX
included toxic metabolic, infection, stroke, nonconvulsive
seizure. In addition, the pt was febrile to 103 with PNA, which
could certainly account for altered mental state. His UA from
[**11-26**] was clear. He was moving all extremities and following
commands, so stroke and seizure were unlikely. On discharge, he
was mentating well. He was able to correctly state person,
place and time.
.
#Afib: Pt was in RVR post-op, likely secondary to fluid shifts
and peri-op complication. Pt spontaneously cardioverted to NSR
after 3 mg lopressor. He was restarted on coumadin after surgery
at a dose of 5mg qhs. This was changed to 2.5mg. On the day of
discharge his INR was 2.7 and his discharge coumadin dose is
2.0.
.
#Left Femur Fracture/ 5th metatarsal fracture: Detailed hospital
course above. After ORIF and MICU course the patient was
transferred to the floor. Ortho continued to follow and the
patient was able to weight bear on the left leg. On [**12-2**]
ecchymosis was noted on the left lateral malleolus, heel and
plantar aspect of foot. A foot xray showed a fracture of the
5th metatarsal, likely incurred from the fall. He remained pain
free and was comfortable on the day of discharge. He was
anticoagulated with lovenox, until coumadin level reached >2.0.
Lovenox was d/c'd on [**12-2**]. He will follow up with Dr. [**Last Name (STitle) **]
on [**12-21**].
.
#Systolic Dysfunction: Pt has EF 20-25%. He was given IV fluids
as needed and lasix was initially held due to low blood
pressures. Lasix was restarted on [**12-2**] for increased O2
requirement and crackles on exam. This improved his oxygen
saturation and a standing dose was reinitiated on [**12-2**].
.
#DM II: Pt was maintained on SSI while in the hospital. He will
be discharged on glucophage.
.
#Dementia: Aricept was held while pt was intubated and was
restarted after extubation. His mental status while not sedated
was appropriate. He was awake, alert and oriented x3.
.
#GERD: Mr. [**Known lastname **] was given protonix to prevent reflux.
.
#FEN: After extubation and on return to the floor, the patient
was seen by speech and swallow who felt that he could be
advanced to thin liquids and ground solids.
Medications on Admission:
Coumadin 2.5/3
Aricept 10 daily
Lipitor 10 daily
Glucophage 500 mg [**Hospital1 **]
Atenolol 25 mg daily,
Lasix 40 mg daily,
Lisinopril 20 mg daily
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: Last day [**12-6**].
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days: Last dose on [**12-7**].
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Left femur fracture
Aspiration pneumonia
Sepsis
Anemia
Secondary:
Hypertension
Atrial fibrillation
CAD
hypercholesterolemia
diabetes mellitus
dementia
Discharge Condition:
Stable. The patient is breathing comfortably and satting well
on 2L O2. He is mentating appropriately and oriented to person,
place and time.
Discharge Instructions:
You were admitted to the hospital after a fall during which you
fractured your left thigh and the small toe on your left foot.
You had surgery to help repair the fracture of your leg.
Immediately after surgery your blood pressure was very low,
likely because of pneumonia. This is why you went to the ICU.
You are currently on antibiotics to treat the pneumonia. You
need to take antibiotics for a 10 day course.
Please take all medications as prescribed.
You are taking coumadin 2mg daily. It is important that you
have your INR checked regularly.
If you begin to have fevers, chills, lightheadedness, dizziness,
increased pain of your leg or foot or any other concerning
Followup Instructions:
You have the following appointments:
1. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2119-12-21**]
8:00
2. ORHTO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2119-12-21**] 7:40
You should follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 608**] early next
week.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]
|
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"518.5",
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"995.92",
"414.8",
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icd9cm
|
[
[
[]
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[
"89.64",
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] |
icd9pcs
|
[
[
[]
]
] |
14815, 14886
|
5977, 11402
|
325, 397
|
15091, 15237
|
3224, 3596
|
15963, 16432
|
2495, 2513
|
13921, 14792
|
14907, 15070
|
13749, 13898
|
15261, 15940
|
2528, 3205
|
277, 287
|
425, 1573
|
3605, 5954
|
11417, 13723
|
1595, 2201
|
2217, 2479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,070
| 129,434
|
3832
|
Discharge summary
|
report
|
Admission Date: [**2186-6-8**] Discharge Date: [**2186-6-13**]
Date of Birth: [**2122-4-20**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 64-year-old female
with a history of follicular low-grade non-Hodgkin lymphoma
diagnosed in [**2175**] with cervical lymphadenopathy, status post
auto-BMT in [**2179**] and mini allo-BMT in [**2185**] with recent
diagnosis of posttransplant lymphoproliferative disorder in
[**2186-4-6**] involving the left carotid sinus. Now, the
patient is status post 10 rounds of XRT. MRI revealed stable
disease on [**2186-6-5**]. The patient's last dose of radiation
was on a [**2186-6-2**]. She is now being admitted with 2 days
of severe substernal chest pressure associated with left
visual floaters and headache although the patient reports her
headache has been a chronic issue. The patient states that
her pain is relieved by sitting forward. There were no recent
febrile illnesses and no history of cardiac disease or
shortness of breath. In the emergency department, the patient
was hypotensive intermittently with a systolic blood
pressures in the 90s. She was also tachycardic. However, she
stabilized with 2 liters of IV fluid. Her EKG did not reveal
any evidence of alternans. A CTA was performed which did not
reveal a pulmonary embolus. Her cardiac enzymes were
negative.
PAST MEDICAL HISTORY:
1. NHL, status post CHOP x8, rituximab, HDC.
2. PTLD, status post rituximab, XRT, presented with syncope.
3. Hypothyroidism.
4. Asthma.
5. Fibromyalgia.
6. Chronic headaches.
7. Status post cholecystectomy.
8. Status post TAH-BSO.
SOCIAL HISTORY: The patient is married with 1 son. [**Name (NI) **]
tobacco or alcohol use.
FAMILY HISTORY: Positive for renal cell carcinoma in her
mother. [**Name (NI) **] father had an MI in his 50s.
ALLERGIES: ASPIRIN, OXYCODONE AND CODEINE--ALL OF WHICH
CAUSE NAUSEA AND VOMITING.
MEDICATIONS ON ADMISSION: Folate 1 mg daily, Levoxyl 50 mcg
daily, gabapentin 300 mg t.i.d., Tylenol No. 3 p.r.n.,
midodrine 5 mg t.i.d., Decadron 0.5 mg b.i.d., Diflucan 100
mg daily, Protonix 40 mg daily.
PHYSICAL EXAMINATION FROM ADMISSION: Vital signs: T-max
99.4, blood pressure 115/63, heart rate 99, 16 was
respiratory rate, 97% on room air. Physical exam generally,
the patient is in no apparent distress. Alert and oriented.
HEENT: Oropharynx is clear. No JVD. Cardiac exam: Regular
rate, S1 and S2, no rubs appreciated. Lung exam: Clear to
auscultation bilaterally. Chest: There are no areas of
tenderness upon palpation. Abdominal exam: Soft, nontender
and nondistended. Active bowel sounds. Neurologically grossly
intact. Extremities: No edema.
LABORATORY DATA FROM ADMISSION: White blood cell count 11.1,
hematocrit 39.3, platelets 228, INR 0.8, PTT 20.3, D-dimer
343, CK 77, troponin less than 0.01, chemistry profile within
normal limits.
EKG normal sinus rhythm, poor R wave progression, no ST-T
wave changes. No evidence of alternans.
CT angiogram of the chest revealed no evidence of pulmonary
embolus or dissection. On [**6-5**], an MRI revealed a left
parapharyngeal infiltrating mass similar to prior study,
retention cyst in maxillary sinus, decreased size of left
neck mass and fluid collection, abnormal tissue in the left
mastoid tip left base of skull near left jugular foramen
longus [**Last Name (un) **] muscle. No intracranial extension.
HOSPITAL COURSE: Chest pain. The patient presented with
chest pain and was thought to have evidence of pericarditis
either related to a malignant process versus a viral process.
The patient was afebrile upon presentation and did not have
any prodrome of a URI leading up to this diagnosis. Given the
fact that her pain was so severe and there was no evidence of
myocardial damage, we initiated NSAID treatment as well as
prednisone to assist in management of her pain. The patient
also received morphine on an as-needed basis. However, on the
afternoon of her admission, the patient's respiratory rate
increased as well as her blood pressure decreased. A stat
echocardiogram was performed which showed early evidence of
tamponade-like physiology with a collection of pericardial
fluid which appeared to be fibrinous. The patient was
emergently taken to the cardiac intensive care unit where a
pericardial window was placed. In the CCU, the patient was
normotensive. However, she was tachycardiac to about 130.
Echocardiogram initially showed right atrial diastolic
collapse with a pericardial effusion. The patient developed a
fever in this setting to 102. A Swan-Ganz catheter was placed
to monitor the patient hemodynamically. Her RA pressure was
12, RV was 40/15. pulmonary artery pressure was 35/14 with a
square rate sign, wedge was 15, cardiac output was 5 with an
index of 2.78, SVR 1100. The patient's symptoms improved
dramatically after pericardial window was placed. The fluid
was sent for analysis. On initial evaluation, it did not
appear to be consistent with a malignant effusion.
1. Fevers, likely secondary to viral and post-XRT
pericarditis. The patient was afebrile for 48 hours prior
to discharge. The patient was initially started on
levofloxacin empirically which was also discontinued.
However, the third blood cultures grew 1 out of 4 bottles
positive for gram-positive cocci. The patient was started
on vancomycin empirically. One speciation was obtained
that was thought to be related to a likely contaminant
and all antibiotics were discontinued at the time of
discharge.
2. Hypothyroidism. The patient was maintained on Levoxyl.
3. Asthma. There were no active issues during this
hospitalization.
4. GI. The patient was continued on Protonix and mouth care.
5. Fibromyalgia. The patient was maintained on Demerol and
Decadron. Prednisone was discontinued.
DISCHARGE DIAGNOSES:
1. Pericarditis.
2. Pericardial effusion with tamponade-like physiology,
status post pericardial window placement.
3. Posttransplant lymphoproliferative disorder, status post
radiotherapy treatment.
CONDITION ON DISCHARGE: The patient was stable without any
further chest discomfort and breathing comfortably.
DISCHARGE STATUS: The patient will be discharged to home.
DISCHARGE MEDICATIONS: The same as what she was admitted
with. There were no new medications upon discharge.
[**Last Name (LF) **],[**First Name3 (LF) **] J. 12-749
Dictated By:[**Last Name (NamePattern1) 12866**]
MEDQUIST36
D: [**2187-9-12**] 14:34:47
T: [**2187-9-13**] 09:04:54
Job#: [**Job Number 17217**]
|
[
"238.7",
"780.6",
"420.90",
"202.00",
"V42.81",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"34.04",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
1718, 1899
|
5832, 6043
|
6240, 6557
|
1926, 3376
|
3394, 5811
|
159, 1345
|
1367, 1607
|
1624, 1701
|
6068, 6216
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,233
| 159,326
|
25382
|
Discharge summary
|
report
|
Admission Date: [**2116-4-27**] Discharge Date: [**2116-5-4**]
Date of Birth: [**2065-9-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
50 year old white male with history of a heart murmur and
increasing SOB and fatigue.
Major Surgical or Invasive Procedure:
Aortic Valve replacement with a 27mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **] valve [**2116-4-27**]
History of Present Illness:
This 50 year old white male has had a heart murmur for 10 years
and had an echo in [**11-5**] which showed severe aortic stenosis.
He has had increasing SOB and faitgue for the past 2 years and
an echo on [**2116-3-19**] revealed: LA enlargement, mod. LVH, mild
pulmonary HTN, aortic root enlargement, and severe AS with [**First Name8 (NamePattern2) **]
[**Location (un) 109**] of 0.8 cm2 and a peak gradient of 76mmHg. His EF was 65%
and he had a bicuspid AV and mild MR. [**Name13 (STitle) **] underwent cardiac cath
on [**3-26**] which showed clean coronaries.
Past Medical History:
Heart murmur
Aortic stenosis
HTN
^chol.
s/p R achilles repair
Social History:
Married, lives with wife. [**Name (NI) 1403**] as landscape developer.
Cigs: 50 pk. yr., quit 6 yrs. ago
ETOH: 1 drink/month
Family History:
CAD, father had CABG at age 63
Physical Exam:
Gen: WDWN [**Male First Name (un) 4746**] in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign.
Neck: Supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR, II/VI SEM @ R sternal border
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext: without C/C/E, pulses 2+= bilat. throughout
Neuro: nonfocal
Pertinent Results:
[**2116-5-2**] 05:17AM BLOOD WBC-6.4 RBC-3.35* Hgb-10.1* Hct-28.5*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.1 Plt Ct-203
[**2116-5-4**] 06:05AM BLOOD PT-36.4* PTT-35.6* INR(PT)-4.0*
[**2116-5-4**] 06:05AM BLOOD Glucose-105 UreaN-21* Creat-1.1 Na-137
K-4.7 Cl-102 HCO3-26 AnGap-14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2116-5-1**] 5:24 PM
CHEST (PA & LAT)
Reason: assess atelectasis
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p AVR with h/o Left atelectasis
REASON FOR THIS EXAMINATION:
assess atelectasis
INDICATION: 50-year-old status post AVR with left-sided
atelectasis, please reassess.
PA AND LATERAL CHEST: Compared to AP upright chest of [**2116-4-29**].
Median sternotomy wire status post valve replacement. Prosthetic
AVR again identified. Mild linear right basilar atelectasis. The
atelectatic opacity at the left lung base has improved and
somewhat cleared compared to the prior study. The heart remains
moderately enlarged but there is no evidence of congestive heart
failure. The mid and upper lung zones are clear. The visualized
osseous structures are unremarkable.
IMPRESSION: Bibasilar atelectasis, with improved aeration at the
left base.
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) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: FRI [**2116-5-1**] 10:05 PM
Cardiology Report ECHO Study Date of [**2116-4-27**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Mitral valve disease.
Shortness of breath. Valvular heart disease.
Status: Inpatient
Date/Time: [**2116-4-27**] at 12:50
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW598-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.7 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Ejection Fraction: 50% to 60% (nl >=55%)
Aorta - Valve Level: 2.3 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Arch: *3.3 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: *3.0 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: *4.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 48 mm Hg
Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2)
Pericardium - Effusion Size: 0.2 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the
LA. No spontaneous echo contrast or thrombus in the body of the
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No
LA mass/thrombus (best excluded by TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA. A catheter or pacing wire is seen in the RA and
extending into
the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Severe symmetric LVH. No asymmetric LVH. Normal
LV cavity
size. No LV aneurysm. Normal regional LV systolic function.
Overall normal
LVEF (>55%). No resting LVOT gradient. No LV mass/thrombus.
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.
Normal RV wall
thickness. Normal RV systolic function.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque. Mildly dilated aortic root. Normal
ascending aorta
diameter. Focal calcifications in ascending aorta. Normal aortic
arch
diameter. Simple atheroma in aortic arch. Focal calcifications
in aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending
aorta. Focal
calcifications in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve
leaflets. No masses or vegetations on aortic valve. Severe AS.
Mild (1+) AR.
Eccentric AR jet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure. The patient
appears to be in sinus rhythm.
Conclusions:
PRE-CPB: The left atrium is normal in size. No spontaneous echo
contrast is
seen in the body of the left atrium. No spontaneous echo
contrast or thrombus
is seen in the body of the left atrium or left atrial appendage.
No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography).
No atrial septal defect is seen by 2D or color Doppler. There is
severe
symmetric left ventricular hypertrophy. There is no asymmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. No left
ventricular aneurysm is seen. Regional left ventricular wall
motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and
free wall motion are normal. Right ventricular systolic function
is normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter
and free of atherosclerotic plaque. The aortic root is mildly
dilated. There
are simple atheroma in the aortic arch. There are focal
calcifications in the
aortic arch. The descending thoracic aorta is mildly dilated.
There are simple
atheroma in the descending thoracic aorta. The aortic valve is
bicuspid. The
aortic valve leaflets are severely thickened/deformed. No masses
or
vegetations are seen on the aortic valve. There is severe aortic
valve
stenosis. Mild (1+) aortic regurgitation is seen. The aortic
regurgitation jet
is eccentric. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
PRE-CPB: Well-seated mechanical valve in the aortic position
with small
paravalvular leak at the side of the intraatrial septum (NCC
location).
Residual gradient is 8 mmHg peak and 5 mean. Trivial AI. LV
systolic finction
is preserved.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2116-4-27**] 14:36.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 63460**])
Brief Hospital Course:
The pt. was admitted on [**2116-4-27**] and underwent AVR with 27mm St.
[**Male First Name (un) 923**] mechanical valve. He tolerated the procedure well and was
transferred to the CSRU in stable condition on Neo and Propofol.
The cross clamp time was 57 mins., and the total bypass time
was 75 mins. He was extubated on the post op night and
continued to progress. He was on Neo and had his chest tubes
d/c'd on POD#1. He was transferred to the floor on POD#2.
POD#3 his epicardial pacing wires were d/c'd and he was
anticoagulated with heparin and coumadin. His INR went to 6 on
POD#5 and then drifted down to 4 on POD#7 and he was discharged
to home in stable condition.
Medications on Admission:
Lisinopril 40 mg PO daily
ASA 325 mg PO daily
MVI 1 PO daily
Lipitor 20 mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Dosage will vary according to INR.
Disp:*90 Tablet(s)* Refills:*2*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
Disp:*90 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]
Discharge Diagnosis:
AS
hypercholesteremia
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever >101, redness or drainage from incision, or
weight gain more than 2 pounds in one day or five pounds in one
week.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in four weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 25270**] in two weeks
Dr. [**Last Name (STitle) 5543**] in two weeks
Completed by:[**2116-5-5**]
|
[
"V58.61",
"530.81",
"401.9",
"724.2",
"272.0",
"424.1",
"746.4",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.22",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10682, 10729
|
8985, 9665
|
405, 539
|
10795, 10802
|
1825, 2211
|
11172, 11373
|
1380, 1412
|
9799, 10659
|
2248, 2298
|
10750, 10774
|
9691, 9776
|
10826, 11149
|
3399, 8886
|
1427, 1806
|
280, 367
|
2327, 3373
|
567, 1136
|
8920, 8962
|
1158, 1221
|
1237, 1364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,637
| 193,377
|
32469
|
Discharge summary
|
report
|
Admission Date: [**2131-9-21**] Discharge Date: [**2131-9-26**]
Date of Birth: [**2086-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy with brush cytology, biopsy and lavage
History of Present Illness:
45 yo gentleman with EtOH use, smoking history, family hx of
[**Hospital 2754**] transferred from [**Location (un) **] s/p 2 episodes of hemoptysis with
associated lightheadeness, dizziness. Patient initially went to
[**Hospital3 7569**] and required ICU admission for hypertensive
urgency, requiring labetolol and then nipride gtts. Initial CXR
showed a consolidation in the posterior segment of the LUL and
subsequent CT Scan revealed a segmental infiltrate in the
posterior segment of the LUL. Bronchoscopy revealed BRB and
there was a lesion in the posterior segment in the LUL. This was
not biopsied and cytology showed mixed cells. Bronchoscopy was
repeated on day of transfer and there was active bleeding in the
posterior segment of the LUL, controlled with epi. Washings were
collected and biopsies were not done. Patient was started on
Unasyn and Solumedrol.
.
Patient also underwent EGD showed that Barrett's and possible
Grade I varices.
.
On ROS, patient endorses nonradiating [**4-5**] squeezing chest pain
on exertion that has remained stable, tinnitus, epistaxis weekly
for 2 years, night sweats intermittently for 2 years, and an
unintentional weight loss of 30 lbs two years ago but none
during the past year. Patient denies any change in appetite. He
has also been having intermittent diarrhea, with up to 5 bowel
movements a day of loose stools.
.
Patient denies changes in vision, dysphagia, odynophagia,
previous hemoptysis, hematemeis, oral ulcerations, abdominal
pain, melena, hematochezia, dysuria, hematuria, change in
urinary habits, skin rash, flushing.
Past Medical History:
HTN
Alcoholism
Fatty liver
Obesity
Social History:
Lives in [**Location 36385**]. Has not seen a doctor for the past 20
years.
3-4 beers daily
Smokes 1 ppd
Denies illicit drug use
Family History:
Father with CAD, HTN, died from MI at age 75
Mother with DM
Maternal side of family with lung cancer in smoking individuals
Physical Exam:
Vitals - T:98.5 BP:182/106 HR:74 RR:20 02 sat: 100%RA
GENERAL: obese Caucasian male, lying in bed, NAD
SKIN: warm and well perfused, telangiectasias on cheeks and
eyebrows bilaterally, no other stigmata or liver disease
HEENT: NC/AT, EOMI, PERRLA, anicteric sclera,MMM, OP clear
CARDIAC: nl rate, S1/S2, no mrg
LUNG: CTA b/l no RRW
ABDOMEN: benign
M/S: no cyanosis, clubbing or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Admission Labs:
***************
[**2131-9-21**] 05:30PM GLUCOSE-158* UREA N-21* CREAT-1.1 SODIUM-136
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-12
[**2131-9-21**] 05:30PM ALT(SGPT)-59* AST(SGOT)-30 LD(LDH)-168 ALK
PHOS-62 TOT BILI-0.8
[**2131-9-21**] 05:30PM CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-2.5
[**2131-9-21**] 05:30PM TSH-0.74
[**2131-9-21**] 05:30PM FREE T4-1.2
[**2131-9-21**] 05:30PM WBC-12.1* RBC-3.80* HGB-13.1* HCT-37.2*
MCV-98 MCH-34.4* MCHC-35.1* RDW-13.5
[**2131-9-21**] 05:30PM NEUTS-88.3* LYMPHS-8.2* MONOS-3.2 EOS-0.2
BASOS-0
[**2131-9-21**] 05:30PM PLT COUNT-169
[**2131-9-21**] 05:30PM PT-15.2* PTT-21.1* INR(PT)-1.4*
[**2131-9-21**] 04:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
.
Pertinent Labs/Studies:
[**2131-9-22**]: Normal Renal ultrasound
.
[**2131-9-22**] Chest CT with contrast:
1. Consolidation within the superior segment of the left lower
lobe. No definite intraparenchymal or endobronchial mass is
identified within the lungs. Recommend comparison with prior
imaging to evaluate chronicity of consolidation. If persistent,
then bronchoscopy is recommended. Follow-up CT should be
performed in [**12-30**] months to ensure resolution.
2. 3-mm pulmonary nodule within the left lower lobe for which
followup with CT is recommended at 12 months if high risk. If
low risk, no followup is needed.
3. Diffuse low attenuation of the liver consistent with fatty
infiltration.
4. Subcentimeter low-density lesion within the interpolar region
of the right kidney, too small to characterize.
5. Right adrenal myelolipoma.
.
[**2131-9-22**] 04:22AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2131-9-22**] 04:22AM BLOOD HCV Ab-NEGATIVE
[**2131-9-23**] 08:39AM BLOOD Metanephrines (Plasma)-PND
[**2131-9-22**] 04:22AM BLOOD ALDOSTERONE-PND
[**2131-9-22**] 04:22AM BLOOD RENIN-PND
[**2131-9-24**] 02:15PM URINE VANILLYLMANDELIC ACID-PND
[**2131-9-23**] 04:41PM URINE 5-HIAA-PND
[**2131-9-23**] 04:41PM URINE METANEPHRINES-PND
[**2131-9-23**] 04:41PM URINE CATECHOLAMINES-PND
.
[**2131-9-24**] 3:00 pm BRONCHOALVEOLAR LAVAGE LUL.
GRAM STAIN (Final [**2131-9-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
.
RESPIRATORY CULTURE (Final [**2131-9-26**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
.
ACID FAST SMEAR (Final [**2131-9-25**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
.
ACID FAST CULTURE (Pending):
.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
POTASSIUM HYDROXIDE PREPARATION (Final [**2131-9-25**]):
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2131-9-25**]): NEGATIVE for Pneumocystis jirvovecii
(carinii).
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2131-9-25**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
.
Pathology: Left upper lobe of lung, endobronchial biopsy:
Fragments of bronchial wall tissue and pulmonary parenchyma with
no malignancy identified.
.
Discharge labs:
***************
[**2131-9-25**] 07:05AM BLOOD WBC-7.9 RBC-3.96* Hgb-13.6* Hct-39.3*
MCV-99* MCH-34.5* MCHC-34.7 RDW-13.6 Plt Ct-158
Brief Hospital Course:
45 yo gentleman with hemoptysis, hypertension, LUL mass ?
carcinoid scheduled for bronchoscopy.
.
.
#. Lung mass/Hemoptysis: The patient was transferred from OSH
with know endocronchial mass lesion which was identified for
evaluation of hemoptysis. Bronchoscopy on [**9-24**] showed an
endobronchial mass consistent with possible carcinoid tumor by
appearance. The patient did not report symptoms consistent with
carcinoid syndrome other than some diarrhea. Differential
diagnosis of the mass also includes other neoplasm vs.
infection. No other lesions were identified during
bronchoscopy. The patient underwent repeat bronch at [**Hospital1 18**] with
brush cytology, biopsy, and BAL. Prelim biopsy thus far has
revealed only normal bronchial tissue. Brushings and cytology
are pending at the time of discharge and will be followed up
with the patient at his appointment with Interventional
Pulmonary. Gram stain from BAL showed 1+ PMNs with no organisms
seen. AFB, legionella, and PCP were negative. The patient was
initially placed on TB precautions given history of nightsweats
and hemoptysis but induced sputum was negative and BAL negative
on concentrated smear. Respiratory culture showed normal
oropharyngeal flora only at time of discharge. The patient has
follow up appointment with Interventional Pulmonary in place to
review findings of bronch as well as to coordinate plans for
ongoing management.
.
#. HTN: Patient initially presented with BP of 240/160 at OSH
with no evidence of end-organ damage. He was intiially admitted
to the MICU to control BP with labetolol and nipride drip. At
[**Hospital1 18**], patient was weaned to oral medications (initially
requiring a beta blocker, captopril, and norvasc) with SBPs
slowly dropping to 140s-150s on an eventual regimen of labetalol
200 mg [**Hospital1 **], norvasc 10 mg PO Qday. Renal U/S was normal.
Cortisol was 2.3. A number of labs for secondary causes
including Renin, Aldosterone, Metanephrines are pending at the
time of discharge although more likely etiologies for patient's
hypertension include longstanding idiopathic hypertension
(undetected due to lack of consistent medical care) as well as
possible alcohol withdrawal. Patient has an upcoming appointment
with new PCP who will be able to continue to titrate blood
pressure medications as necessary and follow up results of
outstanding studies.
.
#. ID: The patient's imaging on admission revealed a possible
infiltrate in the upper portion of the left lower lobe,area of
known lesions, for which he was on Unasyn on transfer.
Antibiotics were discontinued given no definite evidence of
infection on arrival. The patient remained afebrile without
leukocytosis or worsening pulmonary symptoms through multiple
day hospital course. Cultures to date from BAL are thus far
unrevealing.
.
#. EtOH abuse: The patient has a history of significant EOTH use
with evidence of fatty liver and possible grade 1 varcies at
OSH. The patient received MVI/thiamine/folate during his
hospital course. He was maintained on a CIWA scale which was
discontinued after 1 to 2 days because of low [**Doctor Last Name **].
.
#. Abnormal CT: Chest CT performed for hemoptysis revealed a 3
mm lung nodule was seen in the LLL, separate from the patient's
known lesion, as well as a low-density attenuation in the right
kidney thought to represent a myoleiolipoma. A repeat CT scan
was recommended by radiology in 12 months to monitor for
interval change. The patient was additionally instructed about
these findings.
Medications on Admission:
At home: Excedrin PRN
.
Meds on transfer from OSH:
IV Unasyn
Solumedrol 50 IV q6
Protonix
Enalapril 20 [**Hospital1 **]
Thiamine 100
MVI
Folate
Ativan
Nipride gtt
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Endobronchial mass
Hemoptysis
Hypertensive Urgency
.
Seconday:
Alcohol Abuse/Dependence
Obesity
Fatty Liver
Discharge Condition:
Good. Patient afebrile, without repeat hemoptysis. Patient's
blood pressure still above goal but better controlled with plan
for ongoing titration of BP meds as outpatient (do not want to
normalize rapidly given likely long standing hypertension)
Discharge Instructions:
You were admitted to the hospital with blood in your sputum,
elevated blood pressure and a mass that was identified in one of
your airways. During this hospitalization you had your blood
pressure controlled with new medications and underwent repeat
Bronchoscopy with biopsy of this mass. You were also evaluated
for Tuberculosis with no evidence that you have TB at this time.
It is very important that you keep your follow up appointment
with Interventional Pulmonary so that the results of your biopsy
can be followed up.
.
1. Please take all medications as prescribed
.
2. Please keep all appointments as described below.
.
3. There was a small long nodule seen on your chest CT in
addition to your known airway mass. We recommend that you get
another chest CT in 12 months to evaluate whether this has
changed. There was also a small nodule in your right kidney
that was difficult to characterize and can also be reevaluated
with the repeat CT in 12 months. This can be coordinated through
your primary care physician who will be made aware of these
findings.
Followup Instructions:
You have a new Primary Care Physician (PCP) named Dr. [**Last Name (STitle) 75779**].
You have an appointment for follow up with your new PCP on
[**10-4**] at 11:00 a.m. Dr.[**Name (NI) 75780**] practice is the
Lunenberg Family Practice loactated at [**Street Address(2) 75781**],
Lunenberg MA. Please call this office at [**Telephone/Fax (1) 20587**] with any
questions or scheduling needs.
.
You have a follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] from the
division of Interventional Pulmonary Medicine to follow up on
your biopsy results. Your appointment is on [**10-10**] at
10:00. His office is loctated at the [**Hospital1 **] [**Last Name (Titles) 63824**] located
in the [**Hospital Ward Name 121**] building. Please call the interventional pulmonary
office at [**Telephone/Fax (1) 3020**] with any questions or scheduling needs.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"786.3",
"162.3",
"571.0",
"401.0",
"593.9",
"305.1",
"303.90",
"530.85",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
10688, 10694
|
6531, 10060
|
325, 379
|
10855, 11104
|
2840, 2840
|
12217, 13214
|
2213, 2340
|
10273, 10665
|
10715, 10834
|
10086, 10250
|
11128, 12194
|
6375, 6508
|
2355, 2821
|
5471, 6359
|
5433, 5438
|
275, 287
|
407, 1991
|
2856, 5404
|
2013, 2050
|
2066, 2197
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,141
| 153,413
|
9000
|
Discharge summary
|
report
|
Admission Date: [**2192-4-25**] Discharge Date: [**2192-6-4**]
Service: SURGERY
Allergies:
Vancomycin Hcl/D5w
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
SOB/DOE
Major Surgical or Invasive Procedure:
evacuation of retroperitoneal hematoma
excision of periaortic lymph nodes
ligation of [**Female First Name (un) 899**]
repair of iatrogenic splenic lac
History of Present Illness:
84 yo man w/ h/o AS, COPD, PVD who p/w SOB/dyspnea. Pt is a poor
historian, but per pt, describes decreased functional status
over sub-acute time course, with decrease mobility/increased
sedentary lifestyle over at least past 1 month due to increased
SOB/DOE. Pt states has had "more difficulty" with his breathing
over this past month, describes SOB at rest and with exertion,
to point where he became too uncomfortable so came to ED.
Otherwise denies CP/pressure, orthopnea, PND, lower extremity
edema, f/c, cough.
He presented to [**Hospital1 **] [**Location (un) 620**] with these complaints and was found
to have T 99.4, HR 100 (sinus), RR 40-50, BP 165/56, O2 84-86%
on RA, 100% on NRB. Labs notable for trop (trop 0.218). Pt given
80mg IV lasix with good UOP, combivent neb x 1, ASA 325mg x 1,
nitropaste 1 inch, and started on hep gtt and was transferred to
[**Hospital1 18**] [**Location (un) 86**] for further care.
On arrival to [**Hospital Ward Name 121**] 6 [**Hospital1 **], patient was noted to be tachypnic to
40's, visibly using accessory respiratory muscles to breath. He
was given another 80mg IV lasix x 1 with good UOP, but continued
resp distress. ABG was 7.34/67/70 on NRB and therefore was
transferred to CCU. Pt intubated. Has had been kept on
vent--thought to have COPD exacerbation, as well as CHF &
possible PNA. Question of PE also raised as D-Dimer elevated.
LENIs (-), though no CTA given renal dysfunction, nor V/Q given
underlying lung disease. Also, pt has been in and out of afib
(no record of it in past); started on dilt & heparin gtt for
this.
Past Medical History:
1.Aortic Stenosis (Moderate aortic valve stenosis by [**2188**] echo;
aortic valve area 1 cm squared. Maximal gradient of 42, with a
mean gradient of 26)
2.PVD s/p R fem-[**Doctor Last Name **] bypass
3.Carotid Artery disease
4.COPD
5.HTN
Social History:
Past history of tobacco use, none in past 25 years, no alcohol,
no drug use
Family History:
NC
Physical Exam:
VS: T afebrile BP 125/58 HR 83 RR 32 O2 95% on vent
Gen: Elderly man lying in bed, intubated & sedated
Neck: Supple with JVP of to angle of jaw
CV: Distant heart sound, S1, S2, with 2-3/6 SEM
Chest: vent sound
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Pertinent Results:
On admission:
[**2192-4-26**] 12:26AM BLOOD WBC-14.5* RBC-4.29*# Hgb-13.1*#
Hct-38.3*# MCV-89 MCH-30.5 MCHC-34.1 RDW-13.5 Plt Ct-307#
[**2192-4-26**] 12:26AM BLOOD PT-13.6* PTT-26.5 INR(PT)-1.2*
[**2192-4-27**] 05:10AM BLOOD D-Dimer-2592*
[**2192-4-26**] 12:26AM BLOOD Glucose-185* UreaN-36* Creat-1.5* Na-140
K-4.5 Cl-97 HCO3-34* AnGap-14
[**2192-4-26**] 06:00AM BLOOD ALT-46* AST-68* LD(LDH)-478* CK(CPK)-128
AlkPhos-76 TotBili-0.6
[**2192-5-1**] 09:37AM BLOOD Lipase-128*
[**2192-4-26**] 12:26AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.3
[**2192-4-25**] 11:23PM BLOOD Type-ART pO2-70* pCO2-67* pH-7.34*
calTCO2-38* Base XS-6
CHEST (PORTABLE AP)
The heart size is mildly enlarged but grossly unchanged. The
aorta is tortuous and calcified. The lungs are hyperinflated.
This most likely represent unlike emphysema. Perihilar opacities
involving the lower lobes are demonstrated, right slightly worse
than left and might represent pulmonary edema with asymmetric
appearance due to underlying emphysema. Small right pleural
effusion cannot be excluded. The slight asymmetry between the
lungs might represent underlying right lower lobe infectious
process which can be better characterized after resolving of
pulmonary edema.
On day# 7: when pt. developed acute renal failure/:
[**2192-5-1**] 05:02AM BLOOD Glucose-266* UreaN-105* Creat-3.0* Na-138
K-7.1* Cl-102 HCO3-19* AnGap-24*
[**2192-5-1**] 11:43PM BLOOD WBC-18.2* RBC-2.38* Hgb-7.4* Hct-20.5*
MCV-86 MCH-31.0 MCHC-36.0* RDW-14.8 Plt Ct-86*
[**2192-5-1**] 11:08AM BLOOD WBC-34.1* RBC-2.17* Hgb-6.7* Hct-19.6*
MCV-90 MCH-30.7 MCHC-34.1 RDW-14.0 Plt Ct-241
[**2192-5-1**] 02:08PM BLOOD ALT-7470* AST-9415* LD(LDH)-[**Numeric Identifier 31194**]*
AlkPhos-46 Amylase-700* TotBili-1.0
[**2192-5-1**] 12:30PM BLOOD Type-ART pO2-389* pCO2-65* pH-7.24*
calTCO2-29 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2192-5-1**] 05:43AM BLOOD Lactate-9.3*
[**2192-5-1**] 08:06PM BLOOD freeCa-0.95*
ABDOMEN (SUPINE & ERECT) PORT
IMPRESSION: No evidence of free air or pneumatosis, however,
plain radiograph is insensitive in the evaluation of bowel
ischemia and if there remains clinical concern, CT is
recommended to further evaluate.
Further pertinent evaluation:
CT ABDOMEN W/O CONTRAST [**2192-5-10**] 11:37 AM
1. Findings are consistent with hemorrhagic ascites; no fresh
hemorrhage or definitive source is evident on these images. The
hemorrhagic ascites does extend to the aorta and paraaortic
region, which were evacuated on the patient's recent surgery. A
splenic laceration is felt to be less likely.
A mass within the abdomen or underlying lesion cannot be
distinguished on this examination; a followup CT examination is
recommended. If the patient is stable, MRI may also be helpful.
2. Thickening of small bowel loops may be incident to ischemia,
edema, or hemorrhage.
3. Bilateral pleural effusions and pulmonary findings as
described above.
CT ABDOMEN W/CONTRAST [**2192-5-26**] 1:29 PM
1. Retroperitoneal hematoma extending along the left posterior
pararenal space inferiorly as far as the left groin and has
decreased in size when compared with the previous CT from two
weeks prior.
2. Ascites, which has increased in size when compared to the
previous CT.
3. Bilateral pleural effusions with associated atelectasis,
pleural calcification.
4. Splenic cysts.
5. Sigmoid diverticulosis without evidence of diverticulitis.
6. Anasarca.
[**2192-5-19**] 2:52 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2192-5-19**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2192-5-22**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- 16 I
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
Brief Hospital Course:
This patient had a very protracted and complicated hospital
course. Below is a review of hospital course by system. In
general, Mr. [**Known lastname **] arrived at [**Hospital1 **] [**Location (un) 620**] with increasing
SOB/DOE, tx for acute exacerbation of CHF, and t/f to [**Hospital1 18**] for
further care. In ICU, con't resp failure, intubated and tx for
COPD, CHF, PNA, afib, glycemic control, HTN and renal issues. On
day 7, Mr. [**Name13 (STitle) 1025**] developed ARF, a lactic acidosis, increased
ventilatory needs and worsening hemodynamic status. An abdominal
US was NEG and KUB gave no evidence. He developed increased
abdominal girth, and it was decided to take him for ex-lap for
sepsis, increased abdominal girth, ARF and lactic acidosis for
possible gut ischemia/infarct. Upon exploration, a
retroperitoneal hematoma was discovered and evacuated, a large
adhesed periaortic LN was excised and sent to path (found to be
paraganglioma) along with the the [**Female First Name (un) 899**] ligated and a iatrogenic
slenic lac controlled. Post operatively, the patient remained in
ICU setting on the vent. Renal function slowly resumed. He
developed a Klebsiella pneumonia which was treated w/
appropriate ABx. He had difficulty weening from vent and was
thus trached. Nutrition was maintained w/ TF's and a PEG placed.
Lastly access via PICC was established. Post op his neuro status
improved and on d/c is A/O and following commands. His hospital
course included ED eval and Tx at [**Location (un) 620**], [**Hospital1 18**] CCU, MICU and
ultimately the TSICU b/f d/c.
Neuro: Throughout hospital stay, pt was sedated appropriately
for ventilation and analgesia was maintained as appropriate.
Throughout his stay, neuro checks proved a waxing and [**Doctor Last Name 688**]
type picture with propofol for sedation, and haldol for
agitation as per the MICU team. Overall, his neuro status
improved throughout with improvement of other medical issues.
CV: Pt had new issue of atrial fibrillation. During MICU stay
needed pressors of DA and levophed to maintain BP on [**5-1**] at same
time became olguric and septic as described. This recovered
post-operatively. He experienced a bump in TnI, likely due to
demand ischemia. He was properly anticoagulated and rate
controlled with dilt. Around day 13-14, per chart review, he
reverted back to NSR and was continued on B-[**Last Name (LF) 7005**], [**First Name3 (LF) 14595**]
[**First Name3 (LF) 7005**], BP meds, ASA and Statin. He has runs of HTN which
responded well to BP meds including metop, hydralazine and
clonidine. Postoperatively he remained stable on his Rx and had
no further issues.
Pulm: With the initiating CC of SOB/DOE pt was treated for CHF
exacerbation with lasix, nitro, nebs and t/f to [**Hospital1 18**]. Here he
was intubated for increased resp distress, given IV steroids and
nebs for COPD, diuresed for CHF, and started emperically on
vanco/zosyn for PNA after pan Cx. He continued to remain on the
vent throughout his stay, with varying vent support. A
Klebsiella PNA was discovered on BAL, and tx w/ 2 week course of
meropenam. A trach was performed on [**5-9**] due to continued vent
needs. On d/c he remains on CPAP + PS(12) with Tv 550, rate 30,
FiO2 40%, and PEEP 5. The last week of admission, the patient
developed a pleural effusion and 2.5L of fluid that did not grow
organisms. This improved resp status and did not recur.
GI/FEN: Pt's fluid and electrolytes were replaced/maintained
throughout his hospital stay. Early diuresis for CHF was
aggressive and preceeded ARF. Pt was given a PEG on [**5-27**] and
continues to receive TF at goal of 65. The question of possible
bowel ischemia proved untrue with the ex-lap, but findings as
described above. Prior to the OR he received a ABd US, only
showing cholelithiasis w/o cholecystitis and NL portal flow.
Heme/ID: Pt was treated emperically early in the course for PNA
with vancomycin and zosyn. He was afebrile but had increased WBC
count of 47.9, 29% PMNs. Throughout his stay, ABx included
Flagyl, Linezolid and Fluconazole. Yeast grew in the urine,
blood cx were neg, the pt remained MRSA and C.Diff neg, but did
grow Klebsiella found on sputum and BAL, treated with 2 weeks of
Meropenam ending on the day of D/C. Pt had bouts w/ fever,
though has been stable and afebrile on d/c.
GU/Renal: As described, on day 7, pt experienced ARF and was
evaluated by renal. ARF was from ATN secondary to decreased
renal perfusion from hypotension and retroperitoneal bleed. Over
the hospital stay this improved and remains at a baseline of
BUN/Cr of 50/1.
Endocrine: Pt has been treated w SSI throughout hospital stay.
Early in hospital course, glucose rose to 180-200's likely
secondary to steroids. Has been well controlled and is 80-120 x
7-10 days.
Prophylaxis: The pt. was maintained on DVT/GI prophylaxis w/ H2
[**Month/Day (4) 7005**], SqH and SCD's throughout. LE US was NEG for DVT. Pt
maintained full code.
Medications on Admission:
Lasix 40 mg p.o. daily
Advair 50/250 [**Hospital1 **]
doxazosin 4 mg p.o. daily
folic acid 1 mg p.o. daily
81 mg of aspirin p.o. daily
lipitor 10mg daily
albuterol PRN
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
6. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Congestive heart failure
Chronic obstructive pulmunary disease
Acute Renal failure
Extra-adrenal paraganglioma
Retroperitoneal hematoma
Discharge Condition:
good
Discharge Instructions:
During your hospital stay, you were treated for acute
exacerbation of congestive heart failure and chronic obstructive
pulmonary disease. During your stay you suffered acute renal
failure and had to go to surgery for a retroperitoneal hematoma.
In the surgery, a large lymph node surrounding your aorta was
removed, an artery called the inferior mesenteric artery was
tied off in the process, and a small laceration to your spleen
occurred and was repaired without complication. The lymph node
was described by pathology as a paraganglioma, a type of
extra-adrenal tumor. The endocrinologists were unable to
definitively diagnose this mass in the setting of your acute
illness, and it is suggested that you follow up with this as an
outpatient after you rehabilitiation.
In your recovery, you have had a pneumonia that has been treated
with antibiotics. In addition, it has been difficult to ween
your breathing off of the ventilator. Consequently, you will be
going to a vent rehabilitation center to help you recover and
breath without the ventilator.
Following completion of vent rehab, you will follow up with both
the trauma surgery service and with the vascular surgery service
as listed below. Please continue all medications that you are
discharged on as listed below, and continue any home medications
that you were on prior to hospital admission once you return
home.
If you experience any worrisome symptoms including increased
shortness of breath or trouble breathing, chest pain, fever,
chills, severe abdominal or back pain, or anything else that
worries you please seek medical attention.
Followup Instructions:
1. Trauma surgery: please call [**Telephone/Fax (1) 6429**] and arrange an
appointment for 1-2 weeks.
2. Vascular surgery: please call [**Telephone/Fax (1) 1237**] and arrange an
appointment with Dr. [**Last Name (STitle) 3407**] in 2 weeks.
3. Endocrinology: please call [**Telephone/Fax (1) 31195**] and arrange an
appointment in [**12-31**] weeks.
Completed by:[**2192-6-4**]
|
[
"V64.1",
"433.10",
"574.20",
"553.3",
"998.12",
"518.81",
"250.92",
"491.21",
"557.0",
"237.3",
"584.9",
"424.1",
"562.10",
"E849.7",
"557.1",
"995.92",
"410.71",
"038.9",
"427.31",
"428.30",
"E870.0",
"998.2",
"440.20",
"401.9",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"43.11",
"33.24",
"07.21",
"05.29",
"83.31",
"96.04",
"31.1",
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"45.13",
"96.72",
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"41.42",
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"34.91",
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] |
icd9pcs
|
[
[
[]
]
] |
13577, 13658
|
7109, 12078
|
232, 385
|
13838, 13844
|
2692, 2692
|
15499, 15880
|
2369, 2373
|
12297, 13554
|
13679, 13817
|
12104, 12274
|
13868, 15476
|
2388, 2673
|
185, 194
|
413, 1997
|
2707, 7086
|
2019, 2260
|
2276, 2353
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,624
| 133,766
|
17095
|
Discharge summary
|
report
|
Admission Date: [**2143-1-22**] Discharge Date: [**2143-2-15**]
Date of Birth: [**2093-4-16**] Sex: M
Service: MEDICINE
Allergies:
Pseudoephedrine / Sulfa (Sulfonamides) / Ativan / Morphine
Sulfate
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
fever and SOB
Major Surgical or Invasive Procedure:
R sided diagnostic and therapeutic thoracentesis [**2143-1-23**]
Right Lung Thoracentesis with Drainage Catheter
Right Internal Jugular Central Venous Line
History of Present Illness:
49 year old male with CLL dx [**2137**], followed by Dr. [**First Name (STitle) 1557**], s/p
matched sibling donor allo-[**First Name (STitle) 3242**] in [**2-16**], and h/o HTN, CM with EF
20% (Echo in [**8-20**] with EF 50-55% and in [**9-19**] with EF 20-25%).
The patient was recently admitted from [**2142-11-28**] to [**2142-12-26**] for
resistant HSV c/b CHF exacerbation and aspergillus/enterobacter
on BAL. Pt was also recently discharged on [**2142-12-30**] after
presenting with nausea, chills, tachypnea, hypoxia, and
tachycardia after being given platelet transfusion and IVIG,
thought to be CHF exacerbation (improved with diuresis). He was
admitted again on [**12-5**] for shortness of breath due to
likely early signs of tamponade and had a pericardial drain
placed (removed after 1 day with no signs of reaccumulation). Pt
now presents with c/o fever and increased O2 requirement. Much
of the history was obtained from the pts wife. 3 days PTA, the
pts wife noted that the pt suddenly turned pale and his sats
were 78% on RA, HR 130s. After he layed down, his sats returned
to the 90s with HR in 120s. The pt started to use home O2
(delivered to his house) 3days PTA and was satting at 97% on 2L.
2 days PTA the pts wife again noted the pt turned pale and was
satting at 93% while watching TV. She placed him back on O2.
One day PTA the pt became increasingly SOB, even at rest and was
seen in clinic. He was told that his CXR appeared improved from
prior. Blood cultures were drawn on [**1-21**] now with 1/2 bottles +
for staph aureus. The pt has had low grade temps of 99.2/99.7
over the past several days. On ROS, both the pt and his wife
note increasing fatigue since his last discharge. He has had a
3 lb weight loss over the past several days, a persistent [**Month/Day (4) **]
(at times productive of light colored sputum) for several weeks,
continued chronic diarrhea. The pt also c/o pleuritic CP with
inspiration on the R side of his chest which started again
today, but he had noted during his last admission. Per the pts
wife, the pt also has increased leg pain and weakness which has
progressed to the point that the pt is unable to stand.
.
In the [**Name (NI) **], pt was noted to have a temp of 100.5, HR 140s-150s,
ANC 256. The pt was given Cefepime and Vancomycin, 1L fluids.
Lactate was 1.5. CXR revealed a R pleural effusion increased in
size from prior. CTA showed no PE, however did show BL patchy
and nodular opacities c/w an infectious process as well as a
large R pleural effusion TTE showed a small pericardial
effusion (no tamponade)new from [**1-10**]. The pts R PICC line
was d'c/d given + blood cx for coag +staph aureus from [**1-21**]. VBG:
7.43/48/39.
Past Medical History:
Oncologic history:
CLL, diagnosed in [**2137**] when incidentally noted to have elevated
WBC count. Treated with fludarabine then relapsed and required
four cycles of PCR and then again had five cycles of PCR, but
had persistent disease. He underwent reduced intensity allo-[**Year (4 digits) 3242**]
from his brother in [**2-16**] that was relatively uncomplicated,
though he did have grade I skin and hepatic GVHD, and febrile
neutropenia. In [**7-19**] his CLL relapsed and he underwent DLI in
[**9-18**] and [**10-19**]. in [**7-20**] his WBC rose and he developed
lyphadenopathy. It was decided to start campath (last dose
[**2142-10-16**] with total of `4 doses). He received 1 dose of
rituxan [**2142-12-8**] in lieu of campath. He has suffered from oral
HSV lesions, and has been on famvir and valacyclovir. Pt has now
been receiving IVIG.
.
Recent Admissions as per HPI:
The patient was recently admitted from [**2142-11-28**] to [**2142-12-26**] for
resistant HSV c/b CHF exacerbation and aspergillus/enterobacter
on BAL. During that admission he was started on captopril and
BB. Pt was also recently discharged on [**2142-12-30**] after presenting
with nausea, chills, tachypnea, hypoxia, and tachycardia after
being given platelet transfusion and IVIG, thought to be CHF
exacerbation (improved with diuresis). He was admitted again on
[**12-5**] for shortness of breath due to likely early signs of
tamponade and had a pericardial drain placed (removed after 1
day with no signs of reaccumulation).
.
Other Medical History:
-HTN
-Klebsiella sepsis
-C. Diff
-2nd degree, Mobitz I, heart block.
-s/p inguinal hernia repair
-Cardiomyopathy: Moderate pericardial effusion and markedly
reduced EF (20%) noted on echo in [**9-19**], presumed viral vs.
chemotherapy induced. Followed by cardiology. s/p pericardial
drain.
.
cardiac cath [**2143-1-2**]:
RIGHT ATRIUM 5
RIGHT VENTRICLE 30/5
PULMONARY ARTERY 25/15
PULMONARY WEDGE 14
.
-recent cultures:
.
blood cx [**Date range (1) 48045**] bottles with coag +staph aureus
pericardial fluid [**1-2**]-no growth
FNA of anterior chest fluid collection--neg; but cx was lost
pleural fluid [**2142-12-19**]-no growth
[**2142-12-11**] BAL: enterobacter (pansens except cipro-I), aspergillus
blood cx [**2142-12-3**]--enterobacter
throat cx [**11-28**]: HSV 2
sputum cx [**2142-8-29**]: MAC
stool [**2148-8-24**] +C diff
blood cx [**2141-8-22**]: 2/4 bottles with Klebsiella
Social History:
Married to a nurse, with 3 sons. Worked as a software engineer
and math teacher. No tobacco or etoh
Family History:
Father and uncle died of MI in 50s
Physical Exam:
Vitals-Tm 100.7 BP 124/73 HR 131 R 33 Sat 98%5L NC CVP 2
Gen-pale, cachetic, chronically ill appearing man, slightly
tachypneic
HEENT-dry MM, PERRL, healing ulceration in R buccal mucosa and
inner lip
Neck-no JVD, RIJ c/d/i, no cervical LAD
Lungs-absent BS R lung base 1/2 up R lung with rales 1/2 up R
lung base, rales L lung base
CV-tachy, no m/r/g
Ab-soft, NTND, NABS, no palpable HSM
Extrem-full DP/PT pulses, extrem warm, no c/c/e
Neuro-a and ox3
Skin-no rashes
Pertinent Results:
CXR [**1-22**]:
PORTABLE CHEST: Cardiac, mediastinal, and hilar contours are
stable.
Pulmonary vasculature is unremarkable. There has been interval
increase in size of the right pleural effusion. Basilar
atelectasis is again noted. A hazy left upper lobe opacity is
again noted. No evidence of pneumothorax. The right IJ CVL seen
extending out into the right axillary vein. Osseous and soft
tissue structures are unremarkable. IMPRESSION: Interval
increase in size of right pleural effusion. Right IJ CVL tip in
the right axillary vein.
.
TTE [**1-22**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is dilated. There is severe global left
ventricular hypokinesis (ejection fraction [**10-4**] percent). Right
ventricular chamber size is normal. Right ventricular systolic
function appears depressed. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. There is a small
pericardial effusion. There are no
echocardiographic signs of tamponade. Compared with the findings
of the prior study (images reviewed) of [**2143-1-9**], a very
small posterolateral pericardial effusion is now present (no
tamponade).
.
CTA [**1-22**]:
PA are patent without filling defect. BL patchy and nodular
opacities c/w an infectious process. Large R pleural effusion
and fluid along major and minor fissures. Small L pleural
effusion. Small Loculated collection in anterior R chest wall
is decreased in size.
.
EKG: tachycardia with rate 140s, leftward axis, LVH, LV strain
evidenced by ST depression in V2, V4 and V5
Brief Hospital Course:
49 y.o. man with CLL who presented with febrile neutropenia and
SIRS.
.
# SIRS/ID: The pt presented with fever up to 100.7, tachycardia
in 130s-150s, and tachpnea to the 30s on admission. The pt
however never experienced hypotension or had an elevated
lactate. The ddx for likely sources of infection included
parapneumonic effusion/PNA and bacteremia. The pt was growing
coag + staph aureus in [**12-17**] bottles from [**1-21**]. CTA on admission
also showed continued diffuse nodular opacities, a small
resolving loculated collection in anterior chest wall, and a
large R pleural effusion. UA was negative. The pts PICC line
was pulled in the ED given the +blood cx. In the ED the pt
received 2 L NS, Cefepime, and Vancomycin. Upon arrival to the
[**Hospital Unit Name 153**], the pt was still tachycardic and tachypneic. He was
bolused another 2 L NS overnight. The pt was continued on
cefepime and vancomycin given his febrile neutropenia and
potential staph aureus in the blood. He was continued on flagyl
for empiric c diff treatment given his chronic diarrhea.
Voriconazole was continued for resistant oral [**Female First Name (un) **] and
aspergillosis seen on BAL in the past, and valacyclovir was
continued for oral HSV treatment (the pt was on valacyclovir and
voriconazole from his previous admission in [**11-19**]). All of his
BP meds were held initially in the setting of infection. Urine
cx, stool cx, sputum cx for aerobic, fungal, afb, legionella,
blood cx were all drawn on admission. HSV, CMV, and
cryptococcus serologies were also drawn. On [**1-23**] the pts R sided
pleural effusion was tapped after US guided marking. 760cc of
semi-bloody/serosanguinous fluid was drawn off. The effusion
appeared exudative in nature given elevated LDH and protein
ratios. Diff was: 75 wbc, [**Numeric Identifier 48046**] RBC, 3 lymph, 2 mono, 95
macros. ID was consulted and felt that given his neutropenia, a
chest tube would be risky. However, thoracics felt that the pts
empyema would not be adequately treated with abx alone.
Decision was made for chest tube placement, so on [**1-24**] a pigtail
catheter was placed by IR. The pleural fluid grew MRSA, and it
is likely the pt seeded his pleural fluid by an infected PICC
line (given the MRSA on [**1-21**] blood cx prior to PICC line
removal). He was tranferred out of the [**Hospital Unit Name 153**] with the pigtail
catheter still in place, and he was on vancomycin, cefepime,
levofloxacin. Survelliance cultures were drawn that grew out
VRE. THe decision was made to NOT change his central right IJ
line, as he did not want any more procedures to be done. He was
started on IV linezolid and vanco was stopped. His pigtail
catheter drain eventually stopped draining, and repeat CT scan
showed that it was in good place, and radiology evaluated it and
it was working fine. He really wanted it removed, so it was
removed on [**2143-2-5**]. He remained afebrile. He was also on
empiric flagyl for diarrhea (c.dif neg; c.dif toxin b neg).
This was changed to PO vanco, which helped slow his stools. He
was discharged on Linezolid, Vorticonazole, Levofloxacin,
Famvir.
.
#Increased O2 requirement/tachypnea: The pts tachypnea was felt
to be related to either his R sided pleural effusions or his
overall infectious lung process. ABG on admission was
7.46/37/177. Although the pt had pleuritic CP, CTA was negative
for PE. There were no signs of pericarditis or recurrent
tamponade given TTE on admission which showed only a small
pericardial effucsion. The pt maintained sats of 98-100% on
5LNC. As per above his R pleural effusion was tapped on [**1-23**]. He
underwent chest tube placement by IR on [**1-24**] as per above, with
mild improvement in his breathing. He also required Lasix 20 mg
IV on both [**1-23**] and [**1-24**] for mild volume overload. His oxygen
requirement was stable on the floor, being kept at 3L NC or
shovel mask per his comfort, without any desaturations. He was
passing large phlegm, which could have been cause mucous
plugging. He was dosed with lasix if he was SOB and felt to be
fluid overloaded. He always responded to 20mg IV lasix.
.
#Febrile Neutropenia: ANC on admission was 256. The pt was
placed on neutropenic precautions and neutropenic diet. As per
above, the pt was started on cefepime and vanc. Cefepime and
vanc were changed to Linezolid and Voriconazole. Famvir was
continued for acyclovir resistant Herpes infection. He was also
discharged on Levofloxacin.
.
#Sinus Tachycardia: On the night of admission his HR was
initially 140s-150s. Following 4 L NS, his HR decreased to the
110s-130s. The pts tachycardia was likely due to a combination
of infection/dehydration as well as underlying cardiomyopathy.
He remained tachycardic during the admission which was felt to
be due to illness / cardiomyopathy. It was noted at some points
that his HR would increase and BP would decrease, so his beta
blockers were increased. He was discharged on toprol xL 25 and
lisinopril 10 for rate control and afterload reduction.
.
#Anemia/Thrombocytopenia: Hct has dropped slowly from 38 on
admission to 24.9 on [**1-25**]. Per pt, he requires frequent PRBC
transfusions and functions best at hct 26-27 at least. Likely
related to CLL. s/p 1 unit plt [**1-23**] prior to thoracentesis.
Received 10 mg Vit K on [**1-24**] for INR 1.5. He required infrequent
transfusions while on the floor, and was always followed by
lasix. He last got platlets the day of discharge. His hct was 33
on discharge.
.
#. Cardiomyopathy: The pt has known dilated cardiomyopthy with
EF 20%. Pt is s/p recent pericardial drain, however repeat TTE
on admission showed only small pericardial effusion and EF still
20%. Given SIRS on admission, his BB, Lasix, and ACE were all
held. The pt was monitored regularly while receiving 2L NS in
the [**Hospital Unit Name 153**] on the night of admission. His fluid status was
tenuous. He was eventually started back on his ace inhibitor
(captopril) and metoprolol, with lasix as needed. THis improved
the forward flow, and his HR actually decreased on this
regimen.He was discharged on toprol xL 25 and lisinopril 10 for
rate control and afterload reduction.
.
ALK PHOS ELEVATION / HYPERCALCEMIA: For unclear reasons, on
admission to the floor his alk phos was elevate to the
thousands, and he was hypercalcemic. His GGT indicated a
hepatic source. Imaging revealed only hemosiderin changes, and
no heptosplenic candidiasis (on MRI). IT was felt to be
infectious or an equivalent to AIDS cholangiopathy, and treated
conservatively. He did not want a biopsy, and his numbers
eventually returned toward normal. He was given a dose of
pamidronate, as well as kept on increased maintenance fluids and
lasix, which helped to correct his calcium. A bone scan did not
have any revealing source of new bone lesions ot account for
this incerase. He required another dose of pamidronate several
days prior to discharge. His Ca on discharge was 11.8.
.
#HTN: As per above, the pt Lasix, ace, and BB were all held on
admission, and eventually he was placed back on ace and bb. He
had no hypertensive issues during hospitalization.
.
#CLL: He received no more aggressive treatment for his resistant
CLL. He was continued on steroids (stress dose on D/C from
unit) and tapered down to 10mg per day.
.
# F/E/N: Neutropenic diet, TPN started on floor, with feeding
tube (NG) placed on [**2143-2-10**] for home care.
.
# PPx: Pneumoboots given thrombocytopenia, no bowel regimen
given loose stools, PPI, neutropenic precautions. He was given a
dose of pentamadine.
.
# Access: RIJ placed in ER [**12-22**]. It was removed on the day of
discharge.
.
# CODE: DNR/DNI - he made this decision with his wife and family
and DR. [**First Name (STitle) 1557**] during this hospitalization.
Medications on Admission:
1. Metronidazole 500 mg TID
2. Valacyclovir 1000 mg [**Hospital1 **]--for HSV acyclovir and gancyclovir
resistance
3. Metoprolol Succinate 50 mg qday
4. Ciprofloxacin 500 mg q12hrs--for neutropenia ppx
5. Captopril 25 mg TID
7. Voriconazole 200 mg q12--for aspergillus
8. Prednisone 5 mg qday--for GVHD
9. MVI
10. Lasix 20 mg po qd
11. Folic acid
12, Pentamadine q 2 wk
Discharge Medications:
1. Hospital Bed
Fully electric Hospital bed with Half Siderails
2. Tube Feeds
Peptamen VHP Full Strength
Rate as Tolerated
3. Infusion Pump
Tube feeds infusion pump
4. Syringes
Syringes to flush feeding tube
5. Tube Feed Bag and Tubing
6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO Q12hours
().
Disp:*360 Tablet(s)* Refills:*2*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
13. 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*
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Trazodone 50 mg Tablet Sig: Half Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Chronic Myelogenous Leukemia
Vancomycin Resistant Enterococal Bacteremia
MRSA Pneumonia with Empyema
Acyclovir Resistant Oral Herpes Simplex Virus
Pulmonary Aspergillosis
SIRS
Hypercalcemia
Anemia
Thrombocytopenia
Discharge Condition:
Stable.
Discharge Instructions:
Please let your doctor know if you are having uncontrolled pain.
Please take all medications as prescribed.
Please try to keep up with your fluids and feeding as best
possible.
Followup Instructions:
Palliative Care as Bridge to [**Last Name (Titles) **] Care
Completed by:[**2143-2-22**]
|
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[
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29,799
| 165,367
|
34623
|
Discharge summary
|
report
|
Admission Date: [**2200-7-15**] Discharge Date: [**2200-8-16**]
Date of Birth: [**2172-5-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
L subclavian central line placement
Left arterial line
Right Internal jugular central line placement
Intubation
Right forearm fasciotomy and wound vac placement
Right thoracentesis
Right chest tube placement
History of Present Illness:
Mr. [**Known lastname 7594**] is a 28yo male with morbid obesity and OSA not on
cpap presented to OSA late [**7-14**] with 3-4 weeks of progressive leg
edema and 72 lb weight gain. At the outside hospital he was
noted to have bilateral leg edema. He also got vanc and unasyn
at OSH for ?bilat cellulitis (doubtful). D-dimer at OSH was
positive at 341. [**Hospital1 **] unable to do LENIs given habitus and he
was sent to [**Hospital1 18**] for further evaluation.
Past Medical History:
Morbid obesity
OSA (not on CPAP)
Social History:
Smoker 1ppd x 10 yrs, occa etoh, no drugs. lives in [**Hospital1 **] with
GF. works in re-possesion.
Family History:
Non-contributory
Physical Exam:
Vitals: Temp:99 BP:129/58 HR:71 O2: 88-92/ventimask 35%
gen: Sleepy
chest: Breath sounds normal in anterior chest
heart: rrr, no M/R/G
abd: soft, NT, ND
extr: Lower extremity B/L edema, warmth/erythema
Pertinent Results:
[**2200-7-14**] 11:00PM BLOOD WBC-10.9 RBC-5.34 Hgb-15.0 Hct-49.7
MCV-93 MCH-28.0 MCHC-30.1* RDW-14.6 Plt Ct-289
[**2200-8-13**] 03:51AM BLOOD WBC-15.6* RBC-2.95* Hgb-8.7* Hct-25.9*
MCV-88 MCH-29.5 MCHC-33.6 RDW-18.2* Plt Ct-314
[**2200-7-14**] 11:00PM BLOOD Neuts-78.7* Lymphs-14.0* Monos-6.0
Eos-1.2 Baso-0.2
[**2200-8-9**] 04:31AM BLOOD Neuts-67 Bands-13* Lymphs-2* Monos-4
Eos-9* Baso-0 Atyps-0 Metas-4* Myelos-1* NRBC-4*
[**2200-7-14**] 11:00PM BLOOD PT-14.8* PTT-27.9 INR(PT)-1.3*
[**2200-7-14**] 11:00PM BLOOD Plt Ct-289
[**2200-7-14**] 11:00PM BLOOD Glucose-124* UreaN-12 Creat-0.9 Na-142
K-5.0 Cl-98 HCO3-38* AnGap-11
[**2200-7-14**] 11:00PM BLOOD ALT-22 AST-20 AlkPhos-66 TotBili-0.7
[**2200-7-26**] 04:29AM BLOOD Lipase-49
[**2200-7-14**] 11:00PM BLOOD CK-MB-3 proBNP-2420*
[**2200-7-17**] 03:00AM BLOOD Calcium-8.2* Phos-4.8* Mg-2.1
[**2200-8-2**] 04:29AM BLOOD VitB12-340 Folate-12.0 Hapto-57
[**2200-7-14**] 11:00PM BLOOD TSH-4.6*
[**2200-8-9**] 11:45AM BLOOD Cortsol-32.7*
Echocardiogram:
Due to severely limited suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is difficult to estimate but
appears at least mildly depressed (LVEF= 45-50 %). The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. The valvular structures are not well
visualized. There is no anterior pericardial effusion. The
remainder of the pericardium is not seen.
LE dopplers
Limited exam demonstrating normal variability and waveforms
except the left popliteal vein demonstrates limited variability
with normal augmentation. Non-occlusive thrombus in the lower
SFV or upper popliteal vein cannot be excluded in this area.
Microbiology:
[**2200-8-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
[**2200-8-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
[**2200-8-5**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
[**2200-7-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA, YEAST} INPATIENT
[**2200-7-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
[**2200-8-4**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL
[**2200-7-21**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL
[**2200-7-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram
Stain-FINAL
[**2200-8-2**] BRONCHIAL WASHINGS GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {PSEUDOMONAS AERUGINOSA, YEAST}; LEGIONELLA
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST}
[**2200-7-24**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {PROTEUS
MIRABILIS}; ANAEROBIC CULTURE-FINAL INPATIENT
Brief Hospital Course:
Mr. [**Known lastname 7594**] is a 28 yo male with morbid obesity and OSA admitted
on [**7-14**] with somnolence and mental status changes. Found to be
in hypercarbic respiratory failure. Patient was intubated on
[**7-15**]; he had a difficult airway and was intubated with help of
fiberoptics.
1)Hypercarbic respiratory failure: Several possible etiologies
were considered including heart failure, possible ACS or PE
(patient was apparently immobile and home for several months
prior to presentation), obesity hypoventilation and OSA. It was
thought that his respiratory failure was most likely a
combination of several of these including OSA, obesity
hypoventilation and heart failure. Patient was intubated for
hypercarbic respiratory failure on [**7-15**] and ABG were consistent
with both hypercarbia and hypoxia. He was put on albuterol and
ipratropium nebs. In terms of PE, the patient's weight excluded
him from undergoing a CTA. As a result, he was intubated and
empirically started on a heparin drip to treat presumptively for
PE. ACS was unlikely since his troponins were <0.01. Giving
difficulties weaning him off the ventilator due to high PEEP
requirements (28)and difficulties with the initial intubation,
the possibility of tracheostomy was entertained. His respiratory
course was complicated by high PEEP requirements to 28/30. An
esophageal balloon had been placed to measure his transpulmonary
pressures which showed that his high PEEP requirements were
appropriate for his body habitus. On [**7-22**], he was noted to have
almost white out of [**2-9**] of his right lung. Subsequent chest
x-rays showed mild improvement, but continued to have this
opacity. Interventional pulmonology was consulted for
thoracentesis and possible chest tube placement for concern of
hemothorax. The pleural fluid was consistent with hemothorax,
but chest tube was unable to be placed by IP, and thus had to be
placed by thoracic surgery. In hopes to eventually place a
tracheostomy tube, the patient's PEEPs were attempted to be
weaned. He initially tolerating weaning to a PEEP of 16,
however he acutely decompensated afterward with hypotension and
worsening oxygenation, and was turned back up to a PEEP of 25.
This was not an acceptable level for safe tracheostomy
placement. Mr. [**Known lastname 7594**] soon after passed away.
2)Sedation: After the patient was intubated, there were
difficulties with sedation given his body habitus. He was
initially placed on fentanyl and versed but there was concern
that these medications were being stored in his fat stores given
their pharmacokinetics. The decision was made to transition him
to Methadone; the regimen was safely created with the help of
the pharmacist. For a brief period of time the patient did well
on this regimen. As the patient's PEEP started to increase again
and the poor prognosis, the decision was made to transition him
back to Fentanyl and Versed.
3)Bleeding complications: After heparin was started empirically
for PE, the patient had several bleeding complications including
a right hemothorax, left forearm compartment syndrome, and
subcutaneous bleeding. Heparin was immediately stopped and each
of these issues were treated appropriately (as described below).
Hematology was consulted and they agreed with this decision. A
work up to find a possible bleeding diathesis was performed, but
did not reveal any underlying abnormalities.
4)Right heart failure: Echo on [**7-15**] was suboptimal [**2-8**] patient's
body habitus, but showed a depressed LVEF (45-50%), and a
dilated RV with severe global free wall hypokinesis. This
evidence of R heart failure was thought to most likely explained
by OSA/obesity hypoventilation leading to hypoxic pulmonary
vasoconstriction and increased R heart strain; PE was also
considered a possibility as per above. Diuresis was attempted
several times and was thought to help improve his respiratory
status, but was complicated by persistent hypotension.
5)Infectious disease: Around the time of [**7-20**], the patient was
spiking persistent fevers. His WBC slowly began to rise.
Cultures drawn at that time showed MSSE on [**7-20**] and [**7-21**]. At
that time, it was felt that his central line and arterial line
should be removed and replaced. On [**7-23**], a right IJ was placed
and the left subclavian line was removed. The a-line was also
removed, and replaced on [**7-24**]. The a-line catheter tip grew
MSSE as well. He completed a course of vancomycin for this.
Despite broad antimicrobial coverage, the patient continued to
spike high grade fevers. He was covered appropriately with
vancomycin, meropenem, and Cipro for ventilator-associated
pneumonia and myonecrosis, which were our most likely sources
based on sputum and wound cultures. Blood and urine cultures
remained negative. He eventually became hypotensive with these
fevers, and the team was concerned for sepsis. The patient was
started on Levophed and vasopressin to maintain MAPs >65.
Patient passed away on [**8-16**].
6)Right forearm Compartment syndrome: On [**7-23**], the patient was
noted to have ecchymosis and blistering at the site of his skin
graft on the volar surface of his right forearm. Plastic surgery
was immediately consulted for evaluation, and the patient was
found to have a compartment syndrome. He was taken to the OR
for repeated fasciotomy and wash-outs. Wound cultures grew
proteus. A wound vac was placed, and the patient completed a
course of antibiotics.
7)Right Hemothorax: As above, on [**7-22**], the patient's chest xray
showed significant white out. Thoracentesis fluid was
consistent with hemothorax. Thoracics was consulted for chest
tube placement. It was also noted that the patient had
continued frank bloody secretions from his ET tube. His heparin
was stopped once the compartment syndrome was noted.
Bronchoscopy was performed on [**7-25**] to evaluate for site of
bleeding, and it was thought to be from the RUL. Unfortunately,
the chest tube stopped effectively draining the effusion. TPA
was unsuccessful at breaking up the blood clots that had likely
formed. Thoracic surgery was consulted about the possibility of
a decortication, however, unfortunately this was not deemed a
safe procedure for the patient given his body habitus and high
PEEP requirements.
8)Acute renal failure: This was likely secondary to acute
tubular necrosis from his persistent hypotension. Once his
electrolyte derangements became severe, a renal consult was
obtained for possible dialysis. A family meeting was held about
the likely futile nature of this high risk intervention, as the
patient's prognosis had worsened at this point. The decision
was made to not proceed with dialysis.
Medications on Admission:
None
Discharge Medications:
Patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient deceased
Discharge Condition:
Patient deceased
Discharge Instructions:
Patient deceased
Followup Instructions:
Patient deceased
|
[
"998.11",
"999.31",
"486",
"958.8",
"511.8",
"584.9",
"354.0",
"459.0",
"999.9",
"415.19",
"511.9",
"E934.2",
"038.9",
"285.1",
"278.01",
"428.0",
"518.81",
"327.23",
"995.29",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.04",
"33.23",
"96.72",
"96.6",
"83.14",
"04.43",
"38.93",
"96.04",
"38.91",
"82.36",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
11306, 11315
|
4460, 11210
|
347, 556
|
11375, 11393
|
1497, 4437
|
11458, 11477
|
1241, 1259
|
11265, 11283
|
11336, 11354
|
11236, 11242
|
11417, 11435
|
1274, 1478
|
276, 309
|
584, 1051
|
1073, 1107
|
1123, 1225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,249
| 160,606
|
20185
|
Discharge summary
|
report
|
Admission Date: [**2156-12-31**] Discharge Date: [**2157-4-9**]
Date of Birth: [**2097-5-2**] Sex: M
Service: General Surgery
Patient is a 59-year-old male with coronary artery disease,
hypertension, asthma, and COPD. He was admitted to an outside
hospital with epigastric and chest pain, diagnosed with
cholecystitis, and underwent a laparoscopic cholecystectomy
on [**2156-11-30**]. This was complicated at the outside
hospital, but an early bleed and profound hypertension
requiring an exploratory laparotomy and splenectomy on
postoperative day one.
His course at the outside hospital was further complicated by
a bile leak leading to an exploratory laparotomy and drain
placement on postoperative day 15. This later developed into
a persistent biliocutaneous fistula accompanied by sepsis,
ARDS, and aspergillus pneumonia resulting in respiratory
failure. A tracheostomy was placed. He was transferred to
our institution on [**2156-12-31**] for treatment of a
persistent biliary leak.
On arrival to our ICU, he was hemodynamically unstable and
was started on pressor support. An ERCP demonstrated a
cystic duct leak. The common bile duct was stented, and the
leak resolved.
During his prolonged stay in our ICU, he presented with
multiple problems including persistent aspergillus pneumonia,
multiple episodes of sepsis and septic shock secondary to
pulmonary and line infections requiring vasopressor support,
renal failure with gross anasarca and challenging fluids and
electrolyte management, obscured GI bleed, and seizures.
Ultimately, he completed a full course of treatment with
AmBisome as well as multiple courses of broad-spectrum
antibiotics, required multiple bronchoscopies, multiple
imaging studies, and bilateral chest tube placements.
GI workup included four endoscopies, two colonoscopies, one
sigmoidoscopy, one push enteroscopy, two capsule endoscopies,
a small bowel follow-through and a bleeding scan. His
respiratory failure and GI bleeding persisted. He was unable
to wean from a vent and was transfused about 1 unit every
other day. Overall, he received more than 50 units of blood.
It was decided to attempt an intraoperative endoscopy.
The family understood the high risk of the procedure as well
as the inability to make any progress without it. On [**2157-4-6**], he underwent an exploratory laparotomy. Multiple
dense adhesions were encountered as well as significant
bleeding suggestive of portal hypertension. After multiple
attempts, the procedure was aborted. A J tube was placed and
its location was confirmed by intraoperative endoscopy, but
unfortunately, the abdomen could not be closed because of
bowel distention and his overall anasarca. The fascia was
brought together with a Vicryl mesh.
Postoperative, he again required some vasopressor support,
had worsening of his renal function with decreased urine
output and volume retention. Given his general condition and
the low likelihood of regaining an acceptable quality of
life, the family decided to make him comfort measures only.
On [**2157-4-9**], he expired.
[**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**]
Dictated By:[**Name8 (MD) 28532**]
MEDQUIST36
D: [**2157-5-30**] 13:16
T: [**2157-5-30**] 13:18
JOB#: [**Job Number 54248**]
|
[
"576.4",
"518.5",
"038.8",
"780.39",
"998.2",
"998.11",
"998.6",
"997.4",
"117.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"45.24",
"88.72",
"51.10",
"45.23",
"54.91",
"88.47",
"51.87",
"45.12",
"54.59",
"97.05",
"46.39",
"34.91",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,562
| 125,766
|
1416+55283
|
Discharge summary
|
report+addendum
|
Admission Date: [**2156-12-18**] Discharge Date: [**2156-12-31**]
Service: SURGERY
Allergies:
Lidocaine (Anest)
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
TIA
Major Surgical or Invasive Procedure:
left CEA w patch angioplasty [**2156-12-21**]
History of Present Illness:
89y/o male with known depression who was readmitted to GTU @
[**Hospital3 **] Ctr. /[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] campus because of
increasing depression and sucidal ideation. ([**2156-12-12**])with a
history of carotid disease s/p right CEA and cervical
laminectomy. noted on [**12-14**]-4 episode of left visual field loss
while [**Location (un) 1131**] the newspaper. Duration 10-15min. and recurrent
episode the next day. Transfered to [**Hospital1 8482**] for evaluation of
symptoms.Head CT negative for acute infract.admitted to
neurology and vascular consulted on admission.
Past Medical History:
history of hypertension
history of carotid stenosis s/p Rt. CEA'[**52**]
history of hypercholestremia
history of CAD with chronic angina-stable, s/p MI, s/p CABG's x2
history of chronic Atrial fibrillation
history of CHF, EF 50%, O2 dependant
history of chronic renal insuffiency ( 1.2-1.6)
history of on-Hodgkins lymphoma
History of Major depression with sucidal ideation
history of macrcytic anemia
history of chronic low back pain
history of cervical dissc disease s/p cervical laminectomy
history of bilateral catracts s/p surgery
Social History:
retired educator, wife with [**Name2 (NI) 8483**] in nursing home. Patient
lives alone
former smoker
Family History:
unknown
Physical Exam:
Gen: alert
HEENT: bilat. carotid bruitd. no thyroidmegly,lymphanopthy
CHEST: lungs clear to auscultation. well healed median
sternotomy wound
Heart: irregular irregular , no mumur
ABD: benign
EXT: bilat venous stasis changes.lower extremties
Pulses intact
Neuro: Ox3
PERRLA, EOMI, CN2-12 intact
Motor sensory intact
strength 5/5,except rt. shoulder abduction [**3-16**]+
reflexs 2=, absent ankle bilaterally toes downward
bilaterally
Pertinent Results:
[**2156-12-18**]
GLUCOSE-99 UREA N-73* CREAT-1.6* SODIUM-136 POTASSIUM-5.7*
CHLORIDE-103 TOTAL CO2-20* ANION GAP-19
[**2156-12-18**]
ALT(SGPT)-29 AST(SGOT)-32 LD(LDH)-326* CK(CPK)-61 ALK PHOS-92
AMYLASE-203* TOT BILI-0.3
[**2156-12-18**]
LIPASE-56
[**2156-12-18**]
CK-MB-NotDone cTropnT-0.02*
[**2156-12-18**]
ALBUMIN-4.3 CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-1.8
[**2156-12-18**]
TSH-1.9
[**2156-12-18**]
WBC-8.7 RBC-3.50* HGB-12.6* HCT-34.8* MCV-99* MCH-36.0*
MCHC-36.2*# RDW-16.0*
[**2156-12-18**]
PLT COUNT-162
Date: [**2156-12-29**]
REPEAT OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Thin liquid,
Nectar-thick
liquid, pureed consistency barium, and one cookie coated with
barium were administered. Results follow:
ORAL PHASE:
The oral phase was noted for overall mild deficits with regards
to decreased bolus control and formation, prolonged mastication,
decreased ap tongue movement with pumping behavior, mildly
prolonged oral transit with solids & liquids, and mild oral
residue remaining on the tongue. There was also intermittent
trace premature spillover of thin liquids to the laryngeal
vestibule with thin liquids.
PHARYNGEAL PHASE:
The pharyngeal phase [**Month/Day/Year 3780**] significant improvment from
the
prior exam, as the pt is now demonstrating mild pharyngeal
deficits overall. Hyolaryngeal excursion, laryngeal valve
closure
were both mildly reduced, though epiglottic deflection was
generally incomplete/absence which resulted in a moderate amount
of vallecular residue (solids/purees were greater than liquids).
Bolus propulsion was mildly weakened with mild pyriform sinus
residue noted, mainly with liquids.
ASPIRATION/PENETRATION:
Mild penetration occurred during the swallow with thin liquids
due to decreased laryngeal valve closure and also at times
premature spillover. Penetration occurred more with straw sips,
in comparison to cup sips. However, with cued throat clears, the
pt could clear penetration both with straw and cup sips.
No aspiration occurred during the study.
TREATMENT TECHNIQUES:
While the pt was not sensate to either presence of resiude in
his
throat or to penetration that was occurring, the use of repeat
swallows, alternating bites/sips and throat clearing removed
pharyngeal residue and penetration.
SUMMARY:
Mr. [**Known lastname 8484**] [**Last Name (Titles) 3780**] a significant improvement since the last
study. However, he still continues to present with a mild
oropharyngeal dysphagia with the main issues being slowed
mastication, the presence of pharyngeal residue and penetration
with thin liquids. The use of strategies was beneficial at
clearing residue and penetration however, and the pt
demonstrates
good cognitive ability to carryover strategies, even if he has
impaired sensation.
As such, at this time, I would recommend that the pt begin a po
diet consitency of ground consistency solids and thin liquids.
Given the presence of residue remaining in the valleculae with
solids, the 13 mm barium tablet was not administered out of
concern that it could lodge in his valleculae. Therefore, at
this
time, I would recommend that po meds be administered crushed or
in liquid form. Lastly, discussed with MD that given recent lack
of nutrition, team may wish to consider continuing NG tube
feedings for ~24 hrs more, and then d/c tube. Po diet can begin
today however.
RECOMMENDATIONS:
1. Po diet consistency of ground solids, thin liquids. PO meds
crushed or in liquid form.
2. Aspiration precautions, including:
a. Sit upright at meals.
b. Swallow 2 times after each bite.
c. For every sip, swallow-clear your throat - swallow again.
d. No straws.
e. Take a sip after each bite.
3. Follow up speech therapy at rehab for dysphagia, diet
advancement.
These recommendations were shared with the patient, the nurse
and
the medical team.
2:21:14 PM
Atrial fibrillation with a mean ventricular response, rate 84.
Diffuse
non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2156-12-23**] no definite change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 0 108 398/438.85 0 24 -157
[**2156-12-24**] 3:57 PM
INDICATION: Dobbhoff tube placement.
A feeding tube is in place, terminating within the right lower
lobe bronchus. There is no evidence of pneumomediastinum or
pneumothorax. The cardiac silhouette is enlarged but stable.
There has been interval improvement in bilateral lower lobe
areas of consolidation, and small bilateral pleural effusions
also appear improved in the interval.
IMPRESSION: Malpositioning of feeding tube within the airway as
described. Findings communicated by telephone to Dr. [**Known lastname 8484**] on
the date of the study.
PORTABLE ABDOMEN [**2156-12-23**] 2:36 PM
COMPARISON: Comparison was made to the prior CT scan dated
[**2153-12-28**].
FINDINGS: Study is somewhat limited due to motion artifact, and
also the present study does not include the left dome of the
diaphragm. The bowel gas pattern is unremarkable. Note is made
of surgical staples in the left upper quadrant. No free air is
identified in the visualized portion of the abdomen.
IMPRESSION: Somewhat limited study with motion artifact.
Nonspecific bowel gas pattern.
RADIOLOGY Final Report
[**2156-12-20**] 10:13 AM
CAROTID SERIES COMPLETE
REASON: Bruit and TIA.
FINDINGS: Duplex evaluation was performed of both carotid
arteries. On the left, significant plaque with calcification is
identified.
On the right, peak systolic velocities are 67, 55, 108 in the
ICA, CCA, ECA respectively. The ICA to CCA ratio is 1.2. This is
consistent with no stenosis.
On the left, peak systolic velocity in the internal carotid over
the diastolic velocity is 499/152. In the remainder of the
vessel, the peak systolic velocities are 78, 165 in the CCA, ECA
respectively. The ICA to CCA ratio is 6.3. This is consistent
with an 80-99% stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Significant left-sided plaque with an 80-99% carotid
stenosis. On the right, there is no evidence of carotid
stenosis.
[**2156-12-27**] 2:22 pm STOOL
CONSISTENCY: FORMED Source: Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2156-12-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
[**Date range (1) 8485**]
Admitted. coumadin held for INR 3.0 Vascular consulted. CT head
negative for new changes.MRA brain negative. U/S carotids 80-99%
[**Doctor First Name 3098**] stenosis [**Country **] without stenosis.
[**2156-12-21**]
DOS: ECHO: no thrombus. s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] CEA with dacron patch
angioplasty. hypotension requiring vasopressors and inotropics
support in the PACU.
[**2156-12-22**]
POD#1 vasopressors and inotropics weaned. Transfered to VICU for
continued care. lasix held. coumadin restarted for history of
AF.
[**Date range (1) 8486**]
POD#[**1-24**] Cardology consulted for rising troponis and CHF
managment. Renal consulted for acute renal failure managment.
Began on agressive diuresis with lasix and diuril IV with good
response. Slow improvement of both CHF and renal failure.Tube
for feeding placed N/g secondary to poor po intake and ?
aspiration.
Patient self d/c'd TF. Speech and swallow evaluated the patient@
bed side and with viedo swallow. A TF was replaced under
floroscopy. and tube feed restarted [**2156-12-25**].
Episodes of profound bradycardia without hemodynamic change.
lopressor held. digoxin dose adjusted. Continued with episode of
bradycardia and hypotension. Digoxin d/c'd [**2156-12-28**]. betablockers
continued to be held. Isordil 10mgm tid began for afterload
reduction. hydralazied was began [**2156-12-28**] with holding
parameters.Coumadization was slowly continued. Lasix dosing
adjused as renal function and volume overload improved.Repaeat
swallowing study
[**2156-12-29**]
diet advance to ground food consistancies and thin liquids with
instruction for aspiration precautions.secondary to mild
dysphagia with poooing of thin liquids in the valleculae.
Medications should be chrused or in liquid form. Followup at
rehab for swallowing evaluation when transfered.
[**2155-12-31**]
dopoff feeding tube discontinued. Calorie counts restarted.
[**2156-12-31**]
Pt stable for discharge
Medications on Admission:
same as d/c meds
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-13**]
Puffs Inhalation Q4H (every 4 hours) as needed.
11. Acetaminophen 160 mg/5 mL Solution Sig: 650mgm PO Q4-6H
(every 4 to 6 hours) as needed.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
18. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**]
Discharge Diagnosis:
Transient Ischemic Attack
Left Carotid Artery Stenosis
postoperative hypotension, resolved
AF
Depression
Discharge Condition:
Stable
Discharge Instructions:
Seek medical attention for weakness, numbness, difficulty
speaking, change in gait, dizziness, severe headache, sudden
change in vision or hearing, or for other concerns.
Take all medications as prescribed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2157-2-15**] 4:00
call for followup with Dr. [**Last Name (STitle) 1391**] 2 weeks. [**Telephone/Fax (1) 1393**]
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2157-2-15**] 4:00
call for followup with
Dr. [**Last Name (STitle) 1391**] 2 weeks. [**Telephone/Fax (1) 1393**]
folow - up with primary care physcian for coumadin dosing
adjustment and inr monitering after d/c from rehab.
Completed by:[**2156-12-31**] Name: [**Known lastname 1130**],[**Known firstname 63**] Unit No: [**Numeric Identifier 1131**]
Admission Date: [**2156-12-18**] Discharge Date: [**2156-12-31**]
Date of Birth: [**2067-1-20**] Sex: M
Service: SURGERY
Allergies:
Lidocaine (Anest)
Attending:[**First Name3 (LF) 231**]
Addendum:
Moniter dailt weights
Moniter I/O
Pt should be even in fluid status
Adjust Lasix accordingly.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1132**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2156-12-31**]
|
[
"V45.81",
"410.71",
"427.31",
"362.34",
"403.91",
"433.10",
"997.1",
"428.0",
"458.29",
"424.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"99.04",
"96.6",
"99.07",
"00.40",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
13711, 13920
|
8550, 10566
|
230, 278
|
12332, 12341
|
2132, 8527
|
12597, 13688
|
1626, 1635
|
10633, 12109
|
12204, 12311
|
10592, 10610
|
12365, 12574
|
1650, 2113
|
187, 192
|
306, 934
|
956, 1492
|
1508, 1610
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,400
| 175,031
|
36212
|
Discharge summary
|
report
|
Admission Date: [**2190-2-3**] Discharge Date: [**2190-2-16**]
Date of Birth: [**2147-6-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2190-2-4**] Cardiac catheterization
[**2190-2-9**] Repair of anomalous right coronary artery from
pulmonary
artery by reimplantation into ascending aorta.
Repair of the pulmonary artery with a bovine
pericardial
patch
[**2190-2-9**] Mediastinal re-exploration for bleeding
[**2190-2-12**] Emergency mediastinal exploration for cardiac
tamponade and repair of tear in the acute marginal branch of the
right coronary artery induced by pacing wire removal
History of Present Illness:
42 year old male with history of polysubstance abuse and PTSD,
current smoker who presents with chest pain. He reports that
the chest pain started this morning at 2am. It was located in
the left anterior chest and radiated to his neck, not back. It
was severe [**6-30**] and lasted for approximately an hour. Nothing
seemed to make it better, no change with position or deep
inspiration. He sat up and rested for a while and eventually it
went away. He went to his PCP's office this morning and again
had chest pain. It developed while he was on the subway. It
was worse with walking around. He reported some associated
nausea, SOB and dizziness. His PCP did an EKG and was concerned
re: STE in V2 & V3; unfortunately, this EKG was not sent with
the patient to the ED. He was given aspirin 325mg and NTG at
PCP's office with no relief of CP per patient. The chest pain
did not go away until he was in the ED and got some morphine.
Of note, patient reports that his last cocaine use was 4 days
prior to admission
Past Medical History:
Polysubstance abuse, most recent crack cocaine use was 1.5
months ago
History of Depression and PTSD
Social History:
works in landscaping
lives with girlfriend
[**Name (NI) 1139**] history: currently smokes [**11-22**] PPD
ETOH: currently drinks 1 beer/day
Illicit drugs: cocaine, last used 4 days ago.
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T= 97.5 BP= 124/39 HR= 53 RR= 16 O2 sat= 98% ra.
GENERAL: WDWN 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 6 cm.
CARDIAC: CP reproducible when palpating on the left sternal
border. PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial, DP 2+
Left: radial, DP 2+
Pertinent Results:
ADMISSION LABS
[**2190-2-3**] 02:01PM BLOOD WBC-5.1 RBC-4.59* Hgb-14.4 Hct-42.2
MCV-92 MCH-31.3 MCHC-34.1 RDW-12.7 Plt Ct-198
[**2190-2-3**] 02:01PM BLOOD Neuts-71.9* Lymphs-21.0 Monos-3.1 Eos-3.5
Baso-0.6
[**2190-2-3**] 02:01PM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2*
[**2190-2-3**] 02:01PM BLOOD Glucose-94 UreaN-11 Creat-1.2 Na-136
K-5.3* Cl-103 HCO3-26 AnGap-12
[**2190-2-4**] 07:45AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-27 AnGap-12
.
DRUG SCREEN
[**2190-2-4**] 12:17AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
.
CARDIAC ENZYMES
[**2190-2-3**] 02:01PM BLOOD cTropnT-<0.01
[**2190-2-3**] 09:15PM BLOOD CK-MB-10 MB Indx-4.3 cTropnT-0.12*
[**2190-2-4**] 07:45AM BLOOD CK-MB-2 cTropnT-<0.01
.
IMAGING
Coronary CT [**2190-2-3**]
Structure and Function
The myocardium appeared to have homogenous signal intensity
without evidence of abnormal perfusion. The pericardial
thickness was normal. The diameters of the ascending and
descending thoracic aorta were normal. The main pulmonary artery
diameter was normal. The left atrial AP dimension was mildly
increased.
The left ventricular end-diastolic dimension was moderately
increased. The
end-diastolic volume was moderately increased. The calculated
left ventricular ejection fraction was normal at 65% with normal
regional systolic function. The anteroseptal and inferolateral
wall thicknesses were normal. The left ventricular mass was
normal.
.
Coronary Imaging
CT coronary angiography revealed an anomalous origin of a
dominant right
coronary artery from the pulmonary artery. The right coronary
artery was
increased in size but not aneurismal. The origin and orientation
of the left main coronary artery was normal. The left main was
increased in size but not aneurismal. The left main trifurcated
into the LAD, LCx and ramus intermedius without evidence of
disease. The LAD was increased in size but not aneurismal, with
large septal branches and multiple bridging collaterals to the
right coronary artery. The LAD had 1 diagonal branch and was
free of disease. The LCx had 1 OM branch and was free of
disease. The calcium score was 0.
.
Additional Findings
Please see the separate chest CT report for any additional
findings.
.
Impression:
1. Moderately increased left ventricular cavity size with normal
regional left ventricular systolic function. The LVEF was normal
at 65%.
2. The diameters of the ascending and descending thoracic aorta
were normal. The main pulmonary artery diameter was normal.
3. Mild left atrial enlargement.
4. Anomalous right coronary artery arising from the pulmonary
artery. Normal origin and orientation of the left main, LAD and
LCx coronary arteries. Increased size of the left main and LAD
coronary arteries with abundant left to right bridging
collaterals. No evidence of CAD.
.
[**2190-2-15**] 09:54AM BLOOD Hct-26.8*
[**2190-2-15**] 05:46AM BLOOD WBC-7.3 RBC-2.58* Hgb-8.2* Hct-22.8*
MCV-89 MCH-32.0 MCHC-36.1* RDW-14.3 Plt Ct-231
[**2190-2-12**] 12:30PM BLOOD Neuts-80.9* Lymphs-13.0* Monos-4.3
Eos-1.4 Baso-0.3
[**2190-2-15**] 05:46AM BLOOD Plt Ct-231
[**2190-2-12**] 02:31PM BLOOD PT-13.4 PTT-26.6 INR(PT)-1.1
[**2190-2-15**] 05:46AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-29 AnGap-9
[**2190-2-10**] 12:39AM BLOOD ALT-44* AST-58* AlkPhos-43 Amylase-44
TotBili-0.6
[**2190-2-4**] 07:45AM BLOOD ALT-21 AST-24 LD(LDH)-132 CK(CPK)-157
AlkPhos-73 Amylase-77 TotBili-0.6
[**2190-2-4**] 07:45AM BLOOD CK-MB-2 cTropnT-<0.01
[**2190-2-10**] 12:39AM BLOOD Lipase-17
INDICATION: Reimplantation of right coronary artery,
postoperative day 6,
decreasing hematocrit.
COMPARISON: Radiographs dated back to [**2190-2-7**] and most recently
[**2190-2-14**].
FINDINGS: Right middle and lower lobe atelectasis, moderately
large right
pleural effusion, and moderate cardiomegaly are relatively
unchanged since
[**2190-2-14**]. Blunting of the left costodiaphragmatic angle is
consistent with
small pleural effusion. Median sternotomy wires and right
internal jugular
central venous catheter are unchanged.
IMPRESSION: Persistent right middle and right lower lobe
atelectasis and
moderately large right pleural effusion.
Brief Hospital Course:
Presented to emergency department with chest pain and dynamic
EKG changes. He underwent workup that revealed anomalous origin
of a dominant right coronary artery from the pulmonary artery
found on cardiac catheterization. Due to no coronary artery
disease the chest pain was considered possibly due to coronary
spasm with recent cocaine use, with positive toxicology screen.
He was referred for surgical intervention due to ongoing chest
pain assumed from anomalous right coronary artery. On [**2-9**] he
was brought to the operating room for replacement of RCA and
repair of PA with patch, see operative report for further
details. He was transferred to the intensive care unit for
postoperative management. He had increased chest tube output
and was taken back to the operating room for mediastinal
exploration, see operative report for further details. After
returning from operating room he improved and was weaned off
pressors over the next 24 hours. Additionally he was weaned
from sedation, awoke neurologically intact, and was extubated
without complications. He continued to progress and was
transferred to the floor on postoperative day two, however on
postoperative day three his epicardial wires were removed with
acute onset of chest pain and hypotension. Echocardiogram was
obtained which revealed right ventricular collapse and he was
transferred to the intensive care unit and then the operating
room for emergent mediastinal exploration, see operative report
for further details. He was weaned and extubated without
complications, and was monitored for bleeding. He continued to
progress clinically and was transferred to the floor two days
after exploration. Betablockers were stopped due to recent
cocaine use and risk for coronary spasm, and he was started on
cardiazem for rhythm management. He was ready for transfer to
[**Hospital1 **] on [**2-16**] with continued telemetry monitoring.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety: reduced from 1 mg to 0.5 mg on
[**2-15**] please continue to titrate down and discontinue .
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain: last decreased from 4 mg to 2mg on
[**2-15**] - please continue to decrease and then discontinue .
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
9. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for LE dry skin.
10. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
11. peripheral IV
right forearm - please flush per protocol
discharged with IV due to telemetry
12. bupropion HCl 150 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO QAM (once a day (in the
morning)): increase to twice a day [**2-19**].
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Anomalous origin of a dominant right coronary artery from the
pulmonary artery s/p replacement of RCA and repair of PA with
patch
Coronary spasm due to cocaine use
Post traumatic stress disorder
Polysubstance abuse
Depression
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid prn
Anxiety managed with ativan prn
Smoking cessation wellbutrin
Incisions:
Sternal - healing well, no erythema or drainage
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 170**] [**2190-2-22**] 1:15
Cardiologist: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] [**2190-3-15**] 9:20
Please call to schedule appointments with your
Primary Care Dr [**First Name (STitle) 31365**] in [**2-23**] weeks [**Telephone/Fax (1) 7976**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2190-2-16**]
|
[
"305.60",
"305.1",
"423.3",
"411.1",
"E878.8",
"311",
"746.85",
"309.81",
"998.11",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.99",
"34.03",
"39.56",
"88.55",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
10677, 10692
|
7329, 9253
|
319, 808
|
10962, 11198
|
3116, 7306
|
12038, 12696
|
2205, 2223
|
9308, 10654
|
10713, 10941
|
9279, 9285
|
11222, 12015
|
2238, 3097
|
269, 281
|
836, 1861
|
1883, 1985
|
2001, 2189
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,907
| 153,136
|
14430
|
Discharge summary
|
report
|
Admission Date: [**2187-5-29**] Discharge Date: [**2187-6-5**]
Date of Birth: Sex:
Service: PLASTIC SURGERY
ADMISSION DIAGNOSIS: Status post thumb amputation on the
left side.
DISCHARGE DIAGNOSIS: Status post left thumb replantation.
HISTORY OF THE PRESENT ILLNESS: The patient is a very
pleasant 70-year-old male who is right hand dominant and
retired. He was working in his garage on [**2187-5-29**] when
his left thumb was severed at a table saw at the level of the
midproximal phalangeal level. The patient was transferred
here from [**Hospital3 3583**]. This was a fairly high risk
replant candidate because of his age, the obliquity of the
amputation as well as some other characteristics outlined in
the operative note. However, the patient was taken to the
Operating Room immediately and replantation was performed.
PAST MEDICAL HISTORY: The patient avidly works at his garage
and has a very minimal degree of medical problems outlined in
the history and physical form.
PHYSICAL EXAMINATION ON ADMISSION: On examination, the
patient had the absence of his left thumb and a separate
piece containing the amputated part that was brought in with
him preserved on ice. He was alert and oriented, very
pleasant and cooperative.
HOSPITAL COURSE: After the thumb replantation was performed
there was a question of vascular compromise on the first
postoperative day. The patient was then taken back to the
Operating Room where the left thumb was re-explored. The
vessels were in fact patent and the cause of the apparent
vascular compromise was a low mean arterial pressure.
The patient was then returned back to the Intensive Care Unit
for monitoring and blood pressure control.
The patient did well and was discharged on [**2187-6-5**].
POSTOPERATIVE MEDICATIONS: Same as preoperatively.
FOLLOW-UP: The patient will follow-up next week in the
Plastic Surgery Clinic.
DR.[**Last Name (STitle) 2647**],[**First Name3 (LF) **] 24-145
Dictated By:[**Last Name (NamePattern4) 42719**]
MEDQUIST36
D: [**2187-10-21**] 16:06
T: [**2187-10-22**] 10:30
JOB#: [**Job Number **]
|
[
"458.2",
"414.01",
"V15.82",
"E878.4",
"885.0",
"412",
"E919.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09",
"38.91",
"84.21",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
227, 861
|
1291, 2153
|
157, 205
|
1053, 1273
|
884, 1038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,249
| 167,311
|
53450
|
Discharge summary
|
report
|
Admission Date: [**2179-4-29**] Discharge Date: [**2179-5-4**]
Date of Birth: [**2114-5-20**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 64 year-old woman with
a history of asthma and laryngeal dysfunction who presented
to the Emergency Department with a complaint of an asthma
exacerbation. She denies shortness of breath and wheezing.
She apparently uses frequent doses of Albuterol nearly
continuously prior to her visit to the Emergency Room. She
also took 80 mg of Prednisone the day of admission, although
her usual dose is around 20. In the Emergency Room she was
noted to have peak flows in the 180s. She received multiple
nebulizers with improvement of her peak flow to about 350,
which was her baseline. She subsequently stated she felt
better. Per the Emergency Department physician she was
reluctant to be discharged home and became very anxious, so
anxious to the point that she was found to develop worsening
respiratory distress, became diaphoretic and cyanotic and was
unable to speak. She was intubated and required multiple
doses of Ativan for sedation as she continued to be agitated
on the vent in the Emergency Room. She was admitted to the
Medical Intensive Care Unit on the [**Hospital Ward Name 516**].
PAST MEDICAL HISTORY: 1. Asthma. 2. Lower
gastrointestinal dysfunction. 3. Type 2 diabetes mellitus.
4. Hypertension. 5. Hypercholesterolemia. 6. Skin
cancer. 7. Anxiety.
MEDICATIONS: 1. Accolade 20 mg b.i.d. 2. Albuterol MDI.
3. Lipitor 10 mg po q.d. 4. Beconase 42 micrograms MDI. 5.
Calcium carbonate prn. 6. Lasix 80 mg q.d. 7. Glyburide 10
mg b.i.d. 8. Lisinopril 10 mg po q.d. 9. Prednisone 20 mg
po q.d. 10. Prempro 0.625 mg q.d. 11. Protonix 40 mg po
q.d. 12. Theophylline 300 mg t.i.d. 13. Triamcinolone MDI
12 puffs b.i.d.
ALLERGIES: Ibuprofen, Singulair, Avandia, Bactrim, Motrin
among other medications.
PHYSICAL EXAMINATION: Physical examination revealed an obese
woman who is intubated and sedated. She is afebrile with a
blood pressure of 126/80. Pulse 82. Oxygen saturation 98% on
AC 600, 12, 100% with a PEEP of five. She has a left
surgical pupil. Her chest is mostly clear with occasional
wheeze. Her heart is distant with regular rhythm and no
murmurs. Her abdomen is obese with many stria. Nontender
and nondistended. Her extremities revealed chronic venous
insufficiency changes and some edema. She is sedated on
neurological examination.
LABORATORY: White blood cell count 21.9, hematocrit 46.9,
platelets count 258. INR 1.0, PTT 23. Her chem 7 is within
normal limits except for a glucose of 276. Her urinalysis
has 500 glucose and 300 of protein. Her blood gas is 7.3, 57
and 422 on these vent settings. Chest x-ray is rotated with
endotracheal tube around 4 cm of the carina and no
infiltrates. Electrocardiogram is normal sinus rhythm at
around 93 with a slight leftward axis and poor R wave
progression. She has no acute ischemic changes.
HOSPITAL COURSE: Mrs. [**Known lastname 109911**] was intubated and easily
ventilated. There was a concern for vocal cord dysfunction
as the cause of her respiratory failure rather then asthma
given how well she has responded to nebulizers in the
Emergency Department. She was extubated and transferred to
the floor the day after intubation. She did well from a
respiratory standpoint and was seen by Dr. [**Last Name (STitle) 217**] her
pulmonologist while in the hospital. He recommended elective
outpatient tracheostomy so that if further episodes of vocal
cord dysfunction were to occur she would have recourse short
of intubation. Once her breathing returned to [**Location 213**], she
was discharged home to follow up with Dr. [**Last Name (STitle) 217**] and
Dr. [**Last Name (STitle) **] as an outpatient.
DISCHARGE CONDITION: Improved.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Respiratory failure secondary to laryngeal cord
dysfunction.
2. Asthma exacerbation.
[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**MD Number(1) 200**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2179-5-8**] 22:21
T: [**2179-5-10**] 11:16
JOB#: [**Job Number 109912**]
|
[
"493.92",
"300.00",
"276.8",
"276.1",
"599.0",
"518.81",
"288.8",
"250.00",
"478.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
3840, 3880
|
3901, 4259
|
3015, 3818
|
1949, 2997
|
162, 1271
|
1294, 1926
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,480
| 183,171
|
48243
|
Discharge summary
|
report
|
Admission Date: [**2157-2-21**] Discharge Date: [**2157-3-5**]
Date of Birth: [**2089-8-16**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old
African-American male with past medical history significant
for small bowel obstruction secondary to incarcerated
incisional hernia status post exploratory
laparotomy/reduction hernia/mesh repair [**2156-11-1**] who
presented to [**Hospital1 69**] on
[**2157-2-21**] with complaints of at least 24 hours of constant,
diffuse abdominal pain accompanied by nausea, nonbilious
vomiting. He reports that this episode is similar to the
small bowel obstruction that he suffered in [**2156-10-8**]
which was due to an incarcerated incisional hernia, but this
time, the pain is more intense. He does not feel a hernia. He
denies chest pain, shortness of breath, fever or chills. His last
BM was two days before. He has not passed any flatus within the
last 24 hours.
Past medical history is significant for hypertension, benign
prostatic hypertrophy, non insulin dependent diabetes
mellitus, osteoarthritis, gun shot to abdomen, small bowel
obstruction and ventral hernia.
Past surgical history includes:
1. Repair of ventral hernia with Alloderm in [**2156-10-8**].
2. Aortobifemoral bypass [**2155-8-9**].
ALLERGIES: No known drug allergies.
MEDICATIONS: Hydrochlorothiazide 25 mg once daily, glyburide
5 mg once daily, lisinopril 10 mg once daily, metoprolol 100
mg twice daily, metformin 500 mg twice daily, Celebrex 200 mg
once daily and Lipitor 20 mg once daily.
SOCIAL HISTORY: The patient smokes at least one pack of
cigarettes per day. He reports a 40 pack year history. He
reports that he occasionally drinks alcohol and he denies
illicit drug use.
REVIEW OF SYSTEMS: See HPI.
PHYSICAL EXAMINATION: Vitals signs are 98.7, 98.7, 94,
163/89, 18, 95 percent on room air. General - the patient is
alert and oriented. He is in no acute distress. Chest is
clear to auscultation bilaterally. Heart - regular rate and
rhythm without murmur. Abdomen is mildly distended, soft,
diffusely mildly tender to palpation without guarding, rebound
tenderness or masses noted. Rectal exam - normal tone, small
amount of stool in the vault, negative guaiac. Extremities -
distal neurovascular is intact.
BRIEF HOSPITAL COURSE: The patient presented to [**Hospital1 346**] on [**2157-2-21**] with complaints of
abdominal pain times 24 hours accompanied by nausea and
vomiting and without flatus. CT scan obtained in the
Emergency Department revealed a dilated jejunum with a clear
tapering, but not complete transition point, suggestive of small
bowel obstruction. The patient was admitted to the Surgery
Service. He was made NPO and an NG tube was placed. He was well-
hydrated with Lactated Ringers intravenous solution. Because the
patient was afebrile and in stable condition and his pain had
completely resolved with nasogastric decompression, it was
decided to observe him for resolution of his small bowel
obstruction. He continued to remain stable throughout his
hospital course. He felt well and passed gas and stool, however
he continued to belch. Small bowel follow through revealed
high grade near complete obstruction. Given his failure to
resolve the obstruction with conservative therapy, it was decided
to take Mr. [**Known lastname 3647**] to the Operating Room.
On hospital day No. 6, [**2157-2-26**], Mr. [**Known lastname 3647**] [**Last Name (Titles) 1834**]
exploratory laparotomy with lysis of a single band adhesion
overlying one loop of his proximal jejunum. The bowel was not
injured or ischemic under this band. The area of the band
represented a clear transition point with proximal dilated bowel
and distal decompressed bowel.
At the completion of the operation after the lysis of the
adhesion, of note, Mr. [**Known lastname 3647**] suffered a hypoxic,
bradycardic, hypotensive event most likely secondary to a tension
pneumothorax secondary to the placement of a central venous line
that had been placed before the case due to his poor peripheral
access. His probable pneumothorax was relieved initially by
placement of a 14 gauge angiocatheter in the right anterior chest
wall and then by the placement of a chest tube in the OR. In
addition he received albuterol via the endotrachial tube
simultaneously. Postoperatively, he was transferred to the ICU in
stable condition. He would remain intubated in the ICU until
early postop day No. 1 at which time he self-extubated himself.
However, he did tolerate this extubation well. He remained
clinically stable in the ICU. His chest tube was removed on
postop day No. 2 after confirmation that there was no air leak
and no enlargement of the small right apical pneumothorax. After
the removal of his chest tube, chest x-ray revealed that there
was no enlargement of his small apical pneumothorax. Again,
he continued to remain clinically stable. He was kept NPO on
IV fluids and TPN. He was transferred to the floor on postop
day No. 4. He did have issues with oxygen desaturation when
he got up to walk. This continued to improve throughout his
postoperative course and likely is secondary to his heavy
smoking history. He was started on clear liquids on postop
day No. 5 which he tolerated very well. He began passing
flatus. On postop day No. 5, he continued to ambulate well
with the assistance of Physical Therapy. On postop day No. 6,
he was advanced to a regular diet which again he tolerated
very well. He continued to pass flatus. He continued to
remain pain-free. On postop day No. 7, Mr. [**Known lastname 3647**] is in good
condition, tolerating a regular diet, is pain-free,
ambulating easily and often. He was discharged to home.
DISCHARGE INSTRUCTIONS: Mr. [**Known lastname 3647**] is to take all
medications as prescribed. He is to not perform any heavy
lifting for at least six weeks. He is to not drive while
taking narcotic pain medications such as Percocet. If he
develops fever, chills, nausea or vomiting or increased
abdominal pain, he is to contact medical assistance
emergently.
FINAL DIAGNOSIS: Small bowel obstruction, complete.
RECOMMENDED FOLLOW-UP: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 101657**] within one week after discharge to schedule a follow-up
appointment. As well, please contact your primary care
physician within the first few days after discharge for
diabetes management, etc.
MAJOR SURGICAL AND INVASIVE PROCEDURES: Exploratory
laparotomy, lysis of adhesions.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS: Percocet 5/325 mg one to two tablets
po q4-6h as needed for pain, Levaquin one tablet po q24h
times 7 days, Protonix 40 mg po once daily, metoprolol 100 mg
po twice daily, glyburide 15 mg po once daily, metformin 500
mg po bid, lisinopril 10 mg po once daily and Lipitor 20 mg
po once daily.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], [**MD Number(1) 19178**]
Dictated By:[**Last Name (NamePattern1) 16264**]
MEDQUIST36
D: [**2157-3-6**] 07:53:49
T: [**2157-3-6**] 08:29:16
Job#: [**Job Number 101658**]
|
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icd9cm
|
[
[
[]
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[
"34.04",
"54.59",
"99.15"
] |
icd9pcs
|
[
[
[]
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] |
2371, 5777
|
6630, 7207
|
6158, 6574
|
5802, 6140
|
1860, 2347
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1827, 1837
|
171, 188
|
217, 1615
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1632, 1807
|
6599, 6606
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,233
| 174,915
|
6191
|
Discharge summary
|
report
|
Admission Date: [**2120-12-12**] Discharge Date: [**2120-12-17**]
Date of Birth: [**2056-9-4**] Sex: F
Service: MEDICINE
Allergies:
Latex / Vancomycin / Sudafed / IVIG
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Left transverse patella fracture
Acute Respiratory Distress likely due to pneumonia and pulmonary
edema
Major Surgical or Invasive Procedure:
[**2120-12-11**]: Open reduction internal fixation with K-wires in
a figure-of-eight cerclage wire construct
History of Present Illness:
64 yo female with history of metastatic breast cancer to bone
and brain, SVC thrombus on lovenox for many years,
hypogammaglobulinemia and recurrent pneumonias with recent CAP
in [**11-11**] treated with levofloxacin who was transferred from St.
[**Doctor First Name **] for left parapatellar fracture. The patient underwent a
left patellar ORIF today in the OR. The procedure was quick and
noninvasive with a superficial incision and minimal blood loss
under general anesthesia. She received 1L of fluid and
cefazolin peri-operatively.
.
Tonight, on the floor, she had the acute onset of dypsnea and
tachypnea, with a sudden desaturation to the 70's and
tachycardia to the 110's. She was placed on 5L but was still in
the low 80's, so she was given a NRB. She had finished eating
[**Country 1073**] for dinner but denies any cough or choking event. She
missed one dose prior to surgery. She describes five days of
cough with sputum production since admission to St. [**Doctor First Name **]. She
also reports associated nausea and some vomiting with her
symptoms.
.
On arrival to the MICU, she is tachypneic and anxious. She
finds her left leg and the immobilization brace to be extremely
uncomfortable.
Past Medical History:
Past Oncologic History:
Metastatic breast cancer:
- [**2106**]: diagnosed at stage IV with mets to lymph nodes and
liver; initially treated with doxorubicin, a bone marrow
transplant,
and a partial mastectomy
- [**2108**]: had recurrence with multiple liver lesions seen in her
liver; treated with trastuzumab and paclitaxel
- remained in remission on trastuzumab and paclitaxel for 5
years, until [**2113**] when she had mets to her left hip and
underwent a partial hip replacement
- [**2114**]: noted to have brain mets, and she underwent surgical
resection and Cyberknife therapy
- [**2116**]: noted to have cancer in her femur and underwent more
surgery; received additional therapy (which she could not
recall) in the meantime, and she has continued to be on
trastuzumab
- [**5-/2118**]: underwent XRT for metastatic disease in her spine
- [**1-/2119**]: had L2 progressive metastases, underwent surgery and
then gamma knife radiation treatment in [**4-/2119**]; developed
thrombocytopenia after radiation
- combination of lapatinib and trastuzumab were tried, but
patient developed significant diarrhea as well as pneumonia;
lapatinib was discontinued
- [**5-/2119**]: started zolendronate again
- [**2119-6-2**]: re-staging showed no new systemic metastases; she has
old cerebellar met, which had been radiated.
- continued on fulvestrant every month and trastuzumab every
three weeks; zolendronate being held due to recent tooth pull
[**2-9**] Revision PSF T9-L4 related to increased pain.
--[**3-12**] PET scan showed two foci in the
left lateral thigh. ? mets vs post-surgical The area from
T11-L4 lights up, ? mets vs post surgical. right acetabulum
unchanged. CEA increasing. Switched to CPT-11 and herceptin
continued.
.
Other Past Medical History:
- HTN
- Dyslipidemia
- GERD
- RLS
- Depression
- Insomnia
- Chronic pain
- Hypercoagulability/SVC thrombus: possible borderline
protein C/S deficiency; on enoxaparin
- Hypogammaglobulinemia: previous reaction to IVIG, now on Doxy
ppx since [**2-9**]
Social History:
She is married. She lives with her husband. [**Name (NI) **] daughter and
grandchildren also live with her. She smoked 1ppd for a few
years, but quit ~30 years ago. She admits to occasional alcohol
use (about 2 dinks per week). She denies any illicit drug use.
Family History:
Her daughter had breast cancer at 29, and had a recurrence. Her
neice also had breast cancer. Her brother had lung cancer. She
denies any other family history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
.
LLE: Her exam reveals a closed fracture of the patella with some
effusion as expected and no abrasion or skin bridge. No
palpable defect.
.
Vitals: 103.5 103 133/76 93% on 50% FM
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL and
8mm bilaterally
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Rhonchi and crackles mid way up on the left side with
crackles and the right base
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly,
multiple bruises from lovenox injections
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no calf pain, left leg with [**Doctor Last Name **] locked in extention
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
.
DISCHARGE PHYSICAL EXAM:
afebrile, vital signs stable
exam unchanged except crackles are improved
Pertinent Results:
ADMISSION LABS:
[**2120-12-12**] 10:00PM BLOOD WBC-2.0*# RBC-4.46 Hgb-13.4 Hct-40.8
MCV-91 MCH-30.0 MCHC-32.9 RDW-16.7* Plt Ct-49*
[**2120-12-12**] 10:00PM BLOOD Neuts-86* Bands-0 Lymphs-11* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2120-12-13**] 04:24AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-OCCASIONAL
[**2120-12-12**] 10:00PM BLOOD Glucose-135* UreaN-13 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-24 AnGap-17
[**2120-12-12**] 10:00PM BLOOD CK(CPK)-223*
[**2120-12-12**] 10:00PM BLOOD CK-MB-8 cTropnT-<0.01
[**2120-12-12**] 10:00PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.4*
[**2120-12-12**] 10:00PM BLOOD IgG-322* IgA-24* IgM-13*
[**2120-12-12**] 09:02PM BLOOD Type-ART pO2-60* pCO2-43 pH-7.43
calTCO2-29 Base XS-3
[**2120-12-12**] 09:02PM BLOOD Glucose-120* Lactate-1.7 Na-137 K-3.9
Cl-98
.
[**12-12**] CXR: IMPRESSION: Bibasilar pneumonia
.
[**12-13**] TTE: The left atrium is mildly dilated. A patent foramen
ovale is present. A right-to-left shunt across the interatrial
septum is seen at rest. The estimated right atrial pressure is
at least 15 mmHg. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF 65%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with borderline normal free wall
function. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
The inferior vena cava is massively dilated. The entrance of the
inferior vena cava into the right atrium is narrowed with
extrinsic compression and possibly intraluminal mass/thrombus as
well.
Compared with the findings of the prior study (images reviewed)
of [**2120-6-19**], a right-to-left shunt across a patent foramen
ovale is present. The right ventricle is similarly dilated, with
at least moderate pulmonary hypertension. The findings suggest
acute-on-chronic right ventricular afterload excess consistent
with venous thromboembolic phenomena, pulmonary lymphangitic
spread of breast cancer, pulmonary parenchymal disease,
.
[**12-13**] CTA chest: IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic injury.
2. Bibasilar ground-glass opacification concerning for
aspiration versus
pneumonia.
3. 3-mm calcified nodule in the right upper lung (2, 13), stable
compared to
the prior PET-CT of [**2120-9-20**].
4. Upper lobe bronchus appears to arise directly from the
trachea (2, 13) and
may represent normal variant anatomy.
5. Large hiatal hernia.
6. Fluid-filled esophagus.
7. Extensive coronary calcifications.
8. A 12-mm right hilar lymph node (series 3, 24) is noted.
.
[**12-13**] bilateral lower extremity dopplers: no DVT
.
DISCHARGE LABS:
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Orthopedic service on [**2120-12-12**] for
a left transverse patella fracture after being evaluated in the
Orthopedic Trauma Clinic. She underwent open reduction internal
fixation of the fracture without complication on [**2120-12-11**]. Please
see operative report for full details. She was extubated
without difficulty and transferred to the recovery room in
stable condition. In the early post-operative course Ms. [**Known lastname **]
did well and was transferred to the floor in stable condition.
She had adequate pain management and worked with physical
therapy while in the hospital.
.
On [**2120-12-13**], the patient had an acute episode of hypoxia and
tachypnea on the floor. Her O2 saturations fell into the 70s,
but came back up with NRB. A CXR was concerning for bibasilar
pneumonia versus pulmonary edema. The patient was started on
broad spectrum Vanc, Cefepime, Cipro for treatment of HCAP. The
patient was also given some diuretics to augment her urine
output. For completeness of this episode, a TTE was ordered that
showed RV strain, slightly worse than a previous study. We were
concerned about possible acute on chronic pulmonary emboli, so a
CTA was performed that was negative for PE. The CT, however, did
find bibasliar opacities, concerning for lymphangetic spread of
her known breast cancer, pneumonia/aspiration, or edema. The
patient's breathing continued to improve and she was weaned off
the oxygen. Her abx were narrowed to levofloxacin after three
days since infection was less likely. It was thought that her
hypoxia and hypotensive episode was most concerning for an
aspiration event. She was discharged to complete a 7-day course
of empiric levofloxacin to be completed [**2120-12-19**].
.
CHRONIC PROBLEMS:
# Leukopenia, thrombocytopenia: Worsened in hospital acutely
but without symptoms. Possibly secondary to stress reaction
from pneumonia infection.
.
# Left parapatellar fracture: See discussion about ORIF above.
Did well with pain control and was discharged with oxycodone SR
and IR as well as standing tylenol. She has a LLE brace and is
non-weight bearing on left extremity. She was continued on her
lovenox for known SVC clot and new immobility.
.
# Metastatic breast cancer: Currently on herceptin as an
outpatient, with plans to restart irinotecan. Continued pain
management.
# Depression: continued sertraline and buproprion
# GERD: continued pantoprazole and ranitidine
# HTN: continued valsartan
# Med rec: continued pramipexole, vitamin D
.
# Communication: Husband [**Name (NI) **]: [**Telephone/Fax (1) 24145**] (c), [**Telephone/Fax (1) 24142**]
(h)
.
TRANSITIONAL ISSUES:
- Patient needs outpsatient video swallow study for chronic
intermittent aspiration and nighttime coughing
- Patient needs outpatient Pulmonary evaluation for chronic
cough and basilar scarring
Medications on Admission:
BONE STIMULATOR - - wear 2 hours daily
BUPROPION HCL [BUDEPRION SR] - 100 mg Tablet Extended Release -
1
Tablet(s) by mouth daily for additional benefit with zoloft
DEXAMETHASONE SODIUM PHOSPHATE - 4 mg/mL Solution - please give
to therapist for iontophoresis twice weekely
DIAZEPAM - (Prescribed by Other Provider: [**Name10 (NameIs) 86**] [**Name11 (NameIs) 24146**]
center) - 5 mg Tablet - 1 Tablet(s) by mouth up to 2 tablets
daily as needed for spasm wean as able.
DOXYCYCLINE HYCLATE - 100 mg Capsule - 1 Capsule(s) by mouth
twice a day
ENOXAPARIN [LOVENOX] - 80 mg/0.8 mL Syringe - Inject 80MG SC
TWICE A DAY
GABAPENTIN - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 2 Capsule(s) by mouth three times
daily
OXYCODONE - (Prescribed by Other Provider: [**Name10 (NameIs) 86**] [**Name11 (NameIs) 24146**]
[**Name12 (NameIs) **]) - 15 mg Tablet - 1 Tablet(s) by mouth as needed for as
needed up to 5 a day
OXYCODONE [OXYCONTIN] - (Prescribed by Other Provider) - 40 mg
Tablet Extended Release 12 hr - 1 Tablet(s) by mouth twice a day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day
PRAMIPEXOLE [MIRAPEX] - 0.25 mg Tablet - [**12-2**] Tablet(s) by mouth
at bedtime
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every 6 hours as needed for nausea
RANITIDINE HCL - 150 mg Tablet - 2 Tablet(s) by mouth at bedtime
SERTRALINE - 100 mg Tablet - 2 Tablet(s) by mouth once a day
take
2 tablets daily for total of 200mg
TRASTUZUMAB [HERCEPTIN] - (Prescribed by Other Provider) -
Dosage uncertain
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Left transverse patella fracture
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:
Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
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 the brace on your left leg and keep it dry. It
is locked to prevent you from bending your left knee.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. 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.
Physical Therapy:
Activity as tolerated
Left lower extremity: Non weight bearing in locked [**Doctor Last Name **]
Brace
Encourage turn, cough and deep breathe q2h when awake. [**Doctor Last Name **]
brace locked in extention at all times
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: change daily by RN; please overwrap any dressing
bleedthrough with ABDs and ACE
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up
appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks at [**Telephone/Fax (1) 1228**].
Please follow-up with your primary care physician regarding this
admission.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
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2,284
| 111,195
|
22581
|
Discharge summary
|
report
|
Admission Date: [**2165-6-24**] Discharge Date: [**2165-7-4**]
Date of Birth: [**2086-5-7**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 16590**] had undergone a
coronary artery bypass graft on [**2165-6-14**] and was
subsequently discharged to rehabilitation on [**2165-6-23**].
She was readmitted after being in rehabilitation for
approximately 36 hours on the evening of [**6-24**] with
complaints of the acute onset of shaking chills, rigors, a
fever to 103 at the rehabilitation facility, as well as
hypotension to the 70s systolic.
In the Emergency Department, she was found to be hypotensive
with a systolic blood pressure to the 70s. She had
complications of feeling very cold. She was febrile - I
believe - to 101.6 in the Emergency Department. The patient
had been pan-cultured at that time and was admitted to the
Cardiac Surgery Recovery Unit/Intensive Care Unit for
intravenous Neo-Synephrine to manage her hypotension.
PAST MEDICAL HISTORY: Significant for chronic lymphocytic
leukemia as well as a previous coronary artery bypass graft
(as previously stated), hypertension, hypercholesterolemia,
idiopathic pulmonary fibrosis, and a previous history of
esophageal dilatations. Please see previous Discharge
Summary for details of previous hospitalization during her
coronary artery bypass graft.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg by mouth once per day.
2. Pravastatin 40 mg by mouth once per day.
3. Colace 100 mg by mouth twice per day.
4. Metoprolol XL 25 mg by mouth once per day.
5. Prednisone 20 mg by mouth once per day.
6. Multivitamin.
7. Folic acid.
PHYSICAL EXAMINATION ON ADMISSION: The patient's temperature
was 101.6, her heart rate was 74 (in a normal sinus rhythm),
and her blood pressure was 83/44.
LABORATORY DATA ON ADMISSION: Urinalysis performed in the
Emergency Department was positive for leukocyte esterase as
well as nitrites.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Cardiac Surgery Recovery Unit with a presumed diagnosis of
urosepsis. The patient was placed on an intravenous Neo-
Synephrine drip. The patient was immediately started on
vancomycin and levofloxacin intravenously while waiting
bacteria. She was also given a stress dose of steroids in
the Cardiac Surgery Recovery Unit. She was placed on
intravenous hydrocortisone. She ultimately required
approximately 3 mcg/kilogram per minute of Neo-Synephrine and
had a brief period during the first night of hospitalization
where she was also requiring Levophed in addition for
hypotension into the 70s.
The patient had a central line placed. The patient had an
arterial line placed and was seen by the Critical Care staff
- Dr. [**First Name (STitle) **] [**Name (STitle) **] - who agreed with aggressive hydration and
pressors to support her blood pressure. The patient was also
transfused to a hematocrit of 30. She came in with a
hematocrit of 23.
Also of note, upon admission to the hospital, she did have a
white blood cell count in the 70s; and previously - because
of her leukemia - had been running 30s to 50s. We obtained
an Infectious Disease consultation, and it was at their
recommendation that we continue quinolone as well as
vancomycin initially. The levofloxacin was switched to
ciprofloxacin while we were waiting for the final cultures
because of the interaction with sotalol which she had been
placed on during her previous admission for atrial
fibrillation and a combination of prolongation of the Q-T
interval less likely to occur with the combination of
ciprofloxacin than it was with levofloxacin.
The patient subsequently had gram-negative rods in her blood
as well as in her urine, and this has turned out to all be
the same bacteria which was a resistant Escherichia coli
sensitive to meropenem - which she was ultimately placed on.
A Hematology/Oncology consultation was also obtained due to a
significantly elevated white blood cell count. It was their
recommendation to increase the steroids to 60 mg once per
day, and this was continued for a number of days.
Hemodynamically, over the next few days, the patient
considerably improved. In addition, at the request of the
family, a Urology consultation was obtained due to a history
of recurrent urinary tract infections - approximately three
in the past year. They did not have any significant
recommendations. They did recommend, however, that we could
obtain a CT urogram to evaluate for any source of a
mechanical cause of infection.
A computed tomography was obtained a couple days later, and
this did show air in the bladder which was felt by the
radiologist to be either as a result of a recent Foley
catheterization or bacteria. She was also noted to have
diverticular disease, although no active diverticulitis. She
did have diverticulosis. A General Surgery consultation was
obtained. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] did see the patient and
recommended that Urology follow up probably as an outpatient
to perform a cystoscopy at a later date. The patient was
also followed by the Electrophysiology Service because she
had some bradycardia into the 50s with her hypotension. The
sotalol was discontinued for a couple of days but was
ultimately resumed as her heart rate and blood pressure
improved. It was also the recommendation of the Urology
Service as well as the Infectious Disease Service to continue
suppressive antibiotic treatment due to her recurrent urinary
tract infections.
The patient continued to improve significantly from a
hemodynamic standpoint and was ultimately transferred out of
the Cardiac Surgery Recovery Unit to the Telemetry floor on
hospital day five where she continued to improve. The
patient ultimately had a PICC catheter placed. It was the
recommendation of the Infectious Disease Service to continue
meropenem intravenously for a total of a 2-week course and
then to convert her to Macrodantin by mouth for six months
for chronic suppression of urinary tract infections.
The patient has remained hemodynamically stable, ambulatory,
and ready to be discharged to a rehabilitation facility to
continue to progress with mobility and postoperative recovery
with physical therapy.
Today, the patient's condition is as follows. She remained
in a normal sinus rhythm with a pulse of 60. Her temperature
was 98.4, her respiratory rate was 18, her blood pressure was
112/66, and her oxygen saturation was 98 percent on room air.
Her weight today was 69 kilograms. The patient was alert and
oriented. The lungs were clear to auscultation bilaterally.
Her cardiovascular examination revealed a regular rate and
rhythm. No rubs or murmurs. Her abdomen was benign. Her
extremities were warm with no peripheral edema noted.
Most recent laboratory values included a white blood cell
count of [**Numeric Identifier 20597**], hematocrit was 32, and her platelets were
251. Sodium was 140, potassium was 3.9, chloride was 106,
bicarbonate was 28, blood urea nitrogen was 20, creatinine
was 0.4, and blood glucose was 77. Her INR was 2.1.
MEDICATIONS ON DISCHARGE:
1. Enteric coated aspirin 81 mg by mouth once per day.
2. Colace 100 mg by mouth twice per day.
3. Protonix 40 mg by mouth once per day.
4. Multivitamin one tablet by mouth once per day.
5. Folic acid 5 mg by mouth once per day.
6. Vitamin A 25,000 units one by mouth every day.
7. Sotalol 40 mg by mouth once per day.
8. Tylenol one to two tablets as needed (for pain).
9. Coumadin 2 mg by mouth once per day (this is to be
followed with INR checks at least twice per week and
titrated accordingly for a target INR of 2 to 2.5).
10. Bactrim double strength 150/800 one by mouth three
times per week (this is to continue as long as the patient
remains on greater than 40 mg or greater of prednisone per
day).
11. Prednisone 50 mg once per day (which was just
decreased today - [**7-3**]). The prednisone dose is to
be decreased by 10 mg once per week and ultimately tapered
off. She is to have complete blood counts followed during
this weaning period to be followed by her primary care
physician to aid in the weaning of the prednisone.
12. Meropenem 1 gram intravenously q.8h. (for five more
days after discharge; and this should conclude with her
last dose on [**7-7**]).
DISCHARGE FOLLOWUP: The patient was instructed to follow up
with her primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4281**]). The
patient was to call for an appointment as soon as she is
discharged from rehabilitation. She was also to follow up
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] (telephone number [**Telephone/Fax (1) 170**])
upon discharge from rehabilitation. She was also to follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] upon discharge from
rehabilitation (telephone number [**Telephone/Fax (1) 285**]). The patient
was to follow up with Dr. [**First Name8 (NamePattern2) 189**] [**Last Name (NamePattern1) **] from the
Hematology/Oncology Service here (office telephone number is
[**0-0-**]). She has an appointment with Dr. [**Last Name (STitle) **] on
[**8-5**] at 1:00 p.m. in the [**Last Name (un) 469**] Clinical Center on
the [**Hospital Ward Name **] of [**Hospital1 69**] on
the ninth floor. She was also to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 365**] from the Urology Service here (telephone number [**Telephone/Fax (1) 58565**]) on [**7-24**] at 11:40 a.m., and his office is located
at [**Hospital1 9384**] on the [**Location (un) 448**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Status post coronary artery bypass graft.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2165-7-3**] 17:24:51
T: [**2165-7-3**] 18:07:10
Job#: [**Job Number 58566**]
|
[
"599.0",
"401.9",
"038.42",
"V45.81",
"995.91",
"204.10",
"041.4",
"427.31",
"516.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9743, 10058
|
7138, 8369
|
1393, 1663
|
1967, 7112
|
8390, 9690
|
163, 986
|
1831, 1938
|
1009, 1367
|
9715, 9722
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,895
| 102,174
|
26575
|
Discharge summary
|
report
|
Admission Date: [**2136-5-14**] Discharge Date: [**2136-5-20**]
Date of Birth: [**2091-10-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25876**]
Chief Complaint:
Fever and left abdominal pain, transfer to [**Hospital Unit Name 153**] for hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44 yo M with metastatic melanoma s/p recent biochemotherapy
initiation (cisplatin/vincristine, IL-2, DTIC, IFN) on [**5-8**] who
presented last night with complaints of fevers, chills, and
abdominal pain. He was d/c'd on [**5-9**] and had fever and vomiting
but symptoms at that time were felt to be secondary to his
chemotherapy. He was on cephalexin 500 mg po tid during that
admission. (He also had an admission from [**Date range (1) 21389**] for
initiation of cycle 1 of biochemotherapy
cisplatin/vincristine/Dacarbazine/IL-2/IFN. During that
admission, his goal SBP was 80's and baseline likely 90-100). He
was admitted last night from clinic last night with fevers to
104 and also described having abdominal pain since his
discharge. This pain had been in control with his morphine. He
denies any nausea, vomiting, but does have a lot of diarrhea.
.
Overnight, his BP fell from 107/55 to 86/58 at 4:30 AM. He was
started on IVF and was given over 4L IVF and his BP remained
69/51. He was mentating throughout this whole episode and no
urine output was recorded and the patient doesn't remember how
much he urinated. He was transferred to the [**Hospital Unit Name 153**] for further
care. Prior to transfer to the [**Hospital Unit Name 153**], he had a lot of green
colored diarrhea and this was noted to be guiac negative.
Past Medical History:
Metastatic melanoma to lungs, liver, spleen, dx'd 4 wks ago as
stage IV. Presented with mole on back in [**2130**]
Social History:
SOCIAL HISTORY: He lives in [**Location **] in Great [**Country 65588**]. He is
married, with two children. He has two brothers. [**Name (NI) **] denies
smoking and drinks alcohol only socially
Family History:
FAMILY HISTORY: His mother is healthy and his father- is
unknown whether he had cancer or not.
Physical Exam:
Tm 104.6 Tc 98.1 HR 97 BP 89/59 (MAP 60) RR 20 O2 99% RA
Gen: AAOX3. lying in bed in NAD
Skin: no rashes noted everywhere
HEENT: PEERLA, dry MM, perrla, neck supple, no oral erythema
Lungs: Clear to auscultation bilaterally
Heart: RR, s1-s2 normal,
Abd: soft, tenderness to palpation diffusely in more in LLQ but
no rebound or guarding. Palpable liver and spleen.
Ext: No edema, distal pulses strong bilaterally.
Neuro: AOx3 CN II-XII intact
Pertinent Results:
Abdominal CT -
1. Multiple low attenuation lesions within the liver and spleen
with
splenomegaly, unchanged compared to prior study, with no
evidence of splenic bleed or free fluid.
2. Multiple pulmonary nodules consistent with metastatic
disease, unchanged.
3. Multiple peritoneal implants, unchanged, consistent with
metastatic disease.
4. slightly enhancing wall seen within the sigmoid colon as well
as descending colon that appeared present on prior study.
.
Abdominal U/s
1. Significant amounts echogenic material in the gallbladder
that likely represents sludge.
2. A 7-mm gallbladder wall lesion that could be a gallbladder
wall metastasis Vs. a polyp. There is no evidence for
cholecystitis.
AP single view of the chest has been obtained with the patient
in upright position and comparison is made with a similar
preceding study obtained on [**2136-5-13**]. Identified is a
right-sided PICC line seen to terminate in the lower SVC some 2
cm below the level of the carina. There is evidence of bilateral
pleural effusions blunting the lateral pleural sinuses
apparently slightly more on the right than the left. The
accessible lung fields do not demonstrate any pulmonary vascular
congestion and there is no evidence for any new parenchymal
abnormality. Bilateral there is no evidence of any apical
pneumothorax.
.
Abdomen X ray
FINDINGS: Supine and upright portable abdominal radiographs
demonstrate normal caliber large and small bowel. A small amount
of air is noted within the rectum. There is no evidence of
obstruction and no free intra-abdominal air is seen. Osseous and
surrounding soft tissue structures are unremarkable.
IMPRESSION: Normal caliber bowel without evidence of
obstruction.
[**2136-5-14**] 11:05AM BLOOD WBC-13.5* RBC-4.59* Hgb-12.4* Hct-38.1*
MCV-83 MCH-27.0 MCHC-32.5 RDW-14.7 Plt Ct-261
[**2136-5-16**] 04:30AM BLOOD WBC-19.8* RBC-3.47* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.3 Plt Ct-267
[**2136-5-14**] 11:05AM BLOOD Neuts-77* Bands-2 Lymphs-14* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-1*
[**2136-5-15**] 09:18AM BLOOD Fibrino-395 D-Dimer-3045*
[**2136-5-15**] 09:18AM BLOOD FDP-10-40
[**2136-5-14**] 11:05AM BLOOD Glucose-121* UreaN-15 Creat-0.9 Na-137
K-4.4 Cl-98 HCO3-30 AnGap-13
[**2136-5-16**] 04:30AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-139
K-3.5 Cl-111* HCO3-23 AnGap-9
[**2136-5-14**] 11:05AM BLOOD ALT-20 AST-26 LD(LDH)-625* AlkPhos-158*
TotBili-0.8 DirBili-0.3 IndBili-0.5
[**2136-5-14**] 05:40PM BLOOD Lipase-52
[**2136-5-14**] 11:05AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.9 Mg-1.9
[**2136-5-15**] 09:18AM BLOOD Cortsol-26.4*
[**2136-5-15**] 11:03AM BLOOD Cortsol-33.2*
[**2136-5-15**] 11:17AM BLOOD Cortsol-37.5*
[**2136-5-15**] 06:02AM BLOOD WBC-25.2*# RBC-3.60* Hgb-9.8* Hct-29.4*
MCV-82 MCH-27.3 MCHC-33.4 RDW-15.0 Plt Ct-250
[**2136-5-15**] 03:59PM BLOOD WBC-18.3* RBC-3.51* Hgb-9.4* Hct-29.1*
MCV-83 MCH-26.8* MCHC-32.3 RDW-15.1 Plt Ct-233
[**2136-5-16**] 04:30AM BLOOD WBC-19.8* RBC-3.47* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.3 Plt Ct-267
[**2136-5-17**] 03:20AM BLOOD WBC-11.8* RBC-3.40* Hgb-9.8* Hct-28.0*
MCV-82 MCH-28.8 MCHC-35.0 RDW-15.2 Plt Ct-285
[**2136-5-18**] 04:55AM BLOOD WBC-12.3* RBC-3.29* Hgb-9.4* Hct-27.0*
MCV-82 MCH-28.5 MCHC-34.7 RDW-15.2 Plt Ct-265
[**2136-5-19**] 05:18AM BLOOD WBC-17.7* RBC-3.35* Hgb-9.4* Hct-27.4*
MCV-82 MCH-28.0 MCHC-34.3 RDW-15.5 Plt Ct-249
[**2136-5-20**] 06:55AM BLOOD WBC-18.6* RBC-3.62* Hgb-10.4* Hct-29.9*
MCV-83 MCH-28.7 MCHC-34.8 RDW-15.7* Plt Ct-259
[**2136-5-14**] 05:40PM BLOOD Neuts-92.9* Lymphs-3.1* Monos-3.3 Eos-0.6
Baso-0.1
[**2136-5-20**] 06:55AM BLOOD Neuts-74* Bands-2 Lymphs-14* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2136-5-20**] 06:55AM BLOOD PT-13.6* PTT-30.6 INR(PT)-1.2*
[**2136-5-20**] 06:55AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-22 AnGap-15
[**2136-5-15**] 11:03AM BLOOD LD(LDH)-465*
[**2136-5-15**] 07:38AM BLOOD Lactate-2.0
Brief Hospital Course:
A/P: 44y/o M with Metastatic melanoma(liver, lung, spleen) s/p
recent biochemotherapy initiation who presents with fever and
abdominal pain.
.
# Fever/Hypotension: Likely source is abdominal given diarrhea
and abdominal pain. He had an abdominal CT which showed no
increased bleeding into the abdomen and but he did have slightly
enhancing wall seen within the sigmoid colon as well as
descending colon. His CXR showed no evidence of PNA. His Hct
drop was significant compare to day of admission however his
baseline hct is 31 thus the hct yesterday may have been
concentrated. He had no evidence of intraabdominal bleeding from
his last CT scan. Pt had a Abd u/s showing GB sludge w/ ?
metastasis to GB wall.
Patient was broadly covered on admission to [**Hospital Unit Name 153**], IV levo for
gram negative bowel coverage, PO flagyl for possible c diff and
IV vanco given hypotension .
[**Last Name (un) **] stim test was negative. Lactate 2.0. U.A was negative.
Stool cultures came back positive for C diff.
A central line was placed in the [**Hospital Unit Name 153**] and aggresive fluid
resucitation was given. No pressors were required. Surgery was
consulted and decision was made to follw serial physical exams.
Abdominal pain improved and blood Cx remained negative to day of
discharged.
Patient was transferred from the [**Hospital Unit Name 153**] on [**2136-5-18**] to the floor.
No more hypotensive episodes and fevers resolved.
.
# Elevated WBC: Patient with had a high WBC up to 25 during
hospital stayed. After a?B were started, WBC started to come
down. 2 days prior to discharged WBC started to go up despite
clear clinical improvement. On day of discharged WBC of 18 with
diff N 75, Bands 2%, L 14%, M 7%. It was decided to send patient
home with very close follow up. Day after discharged patient
will come to clinic to have blood drawn CBC and diff.
.
# Diarrhea: Patient started having diarrhea about 8 hours after
being admitted. Positive for C diff. Bowel movements decrease
over time and by the time of discharged he was having about [**4-14**]
more formed bowel movements. Patient was advised to keep and
adequate fluid intake to maintain his hydration.
.
#. Dehydration: Pt dehydrated on arrival in the setting of low
po intake and later on with abundant diarrhea. Iv fluids were
given to keep up with his output. Clinically improved.
.
#. Metastatic Melanoma:
Follow by Dr [**Last Name (STitle) 1729**]. Chemotherapy per oncology. His LDH is
improving as a response from chemotherapy (from around [**2130**] to
700). Further management will be discussed as an outpatient.
.
#.Coagulopathy - Initially increased INR and PTT. DIC labs were
sent- and were negative. Vitamin K was given and coagulation
test improved.\
.
Medications on Admission:
Home MEDS:
1. Morphine 30 mg Tablet Sustained Release q 12h
2. Pantoprazole 40 mg po qd
3. Ativan 0.5 mg po q4h prn nausea.
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for nausea for 4 days.
4. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
[**2136-5-21**] CBC + diff
Please send results to Dr [**Last Name (STitle) 1729**] office ([**Telephone/Fax (1) 65589**]
Discharge Disposition:
Home
Discharge Diagnosis:
1. Sepsis - abdominal source
2. Clostridium Difficile diarrhea
3. Metastatic Melanoma
Discharge Condition:
Good, tolerating PO's
Discharge Instructions:
Please continue your medications as prescribed
Please follow your appointments as scheduled.
Please continue drinking lots of fluids to keep your self
hydrated.
If fever, chills, shortnes of breath, abdominal pain, nausea,
vomit, please call Dr [**Last Name (STitle) 1729**] or come to the Emergency Department
Followup Instructions:
Please call Dr [**Last Name (STitle) 1729**] office on Monday for a follow up
appointment. Phone: ([**2136**]
Please come to [**Hospital Ward Name 23**] Building - 9 floor to get labs drawn.
Completed by:[**2136-5-20**]
|
[
"197.8",
"197.7",
"995.91",
"276.51",
"197.0",
"008.45",
"038.9",
"V10.82",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10281, 10287
|
6671, 9419
|
405, 411
|
10417, 10441
|
2711, 6648
|
10800, 11022
|
2153, 2234
|
9593, 10258
|
10308, 10396
|
9445, 9570
|
10465, 10777
|
2249, 2692
|
278, 367
|
439, 1771
|
1793, 1909
|
1941, 2121
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,973
| 175,597
|
35886
|
Discharge summary
|
report
|
Admission Date: [**2179-10-18**] Discharge Date: [**2179-10-29**]
Date of Birth: [**2121-1-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
acute onset back pain and syncope
Major Surgical or Invasive Procedure:
[**2179-10-18**] emergency repl. ascending aorta ( 28 mm Gelweave
graft)/ AVR ( 27 mm CE pericardial valve)
History of Present Illness:
58 yo man presented to OSH ER with one day history of acute
onset back pain and syncope with a witnessed collapse at work.
CTA showed acute Type A dissection at the level of the aortic
root to the left common iliac artery as well as moderate
hemopericardium. Hypotensive in ER.Transferred intubated and
sedated by [**Location (un) **] emergently to [**Hospital1 18**].
Past Medical History:
HTN
obesity
CRI
s/p pancreatitis
prostate CA
anemia
diverticulosis
CVA left caudate [**2170**]
adrenal hyperplasia s/p adrenalectomy [**2169**]
hypertriglyceridemia
pre-diabetic
Social History:
unknown
Family History:
unknown
Physical Exam:
Admission:Ht 68" Wt @100 kg
intubated, sedated
skin unremarkable
CTAB
RRR with murmur
obese abd, soft , NT, ND
cool extremities
no peripheral edema
unable to assess neuro status
PE on DISCHARGE:
VS:T 98.7/97.6, 143/90,P 89, 98% R/A O2SAT, 114KG
General: A&O x3,NAD
CVS:RRR
Lungs: (B)crackles
ABD: benign
EXTR: [**12-27**]+edema RUE, superficial thrombus of r cephalic, (B)LE
edema
Wound: sternal incision: C/D/I, stable
Neuro: continues to have rt sided weakness with lower extremity
weakness more pronounced than upper extremity. Facial droop
largely resolved. Passed swallow on [**10-28**]
Pertinent Results:
[**2179-10-18**] 07:49PM UREA N-29* CREAT-2.3* POTASSIUM-4.7
[**2179-10-18**] 07:49PM HCT-30.8*
[**2179-10-18**] 06:03PM WBC-7.0 HCT-28.1*
[**2179-10-18**] 05:35PM GLUCOSE-204* LACTATE-6.0*
[**2179-10-18**] 05:22PM ALT(SGPT)-23 AST(SGOT)-42* LD(LDH)-298* ALK
PHOS-35* TOT BILI-0.9
[**2179-10-18**] 05:08PM GLUCOSE-209* LACTATE-6.1* K+-4.7
[**2179-10-18**] 11:06AM GLUCOSE-115* NA+-137 K+-4.7
[**2179-10-18**] 10:59AM UREA N-28* CREAT-1.8* CHLORIDE-111* TOTAL
CO2-23
[**2179-10-18**] 10:59AM WBC-6.4 RBC-3.07* HGB-9.4* HCT-25.3* MCV-83
MCH-30.7 MCHC-37.3* RDW-14.6
[**2179-10-18**] 10:59AM PLT COUNT-126*
[**2179-10-18**] 10:59AM PT-15.0* PTT-45.5* INR(PT)-1.3*
[**2179-10-28**] 06:32AM BLOOD WBC-15.0* RBC-3.06* Hgb-9.4* Hct-27.9*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.8 Plt Ct-296
[**2179-10-28**] 06:32AM BLOOD Plt Ct-296
[**2179-10-27**] 04:50AM BLOOD PT-13.6* INR(PT)-1.2*
[**2179-10-28**] 06:32AM BLOOD Glucose-106* UreaN-57* Creat-2.1* Na-139
K-3.7 Cl-101 HCO3-31 AnGap-11
[**2179-10-23**] 02:56AM BLOOD ALT-8 AST-21 LD(LDH)-293* AlkPhos-65
Amylase-113* TotBili-0.7
MRI SCAN OF THE BRAIN WITH MR ANGIOGRAPHY OF THE HEAD
HISTORY: Status post aortic valve replacement following an
aortic dissection,
with a period of hypotension.
TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was
obtained, as
well as MR angiography of the circle of [**Location (un) 431**] and its
tributaries, utilizing a three-dimensional time-of-flight
imaging protocol, with multiplanar reconstructions.
COMPARISON STUDY ON PACS ARCHIVE: CT scan of the head from
[**2179-10-20**].
FINDINGS: There are numerous, largely subcentimeter foci of
elevated T2
signal scattered throughout the brain, including the centrum
semiovale
bilaterally. This region is more extensively involved on the
left side.
Additional foci of restricted diffusion are noted within the
right occipital lobe, left thalamic region anteriorly, the left
side of the pons (which was suspected on the prior CT scan) as
well as the inferolateral aspect of both cerebellar hemispheres.
As these abnormalities also manifest elevated T2 signal, they
are likely subacute infarctions. There are no areas of abnormal
susceptibility demonstrated.
There is no hydrocephalus or shift of normally midline
structures.
The principal vascular flow patterns are identified. There is
near-complete loss of aeration of the right maxillary sinus, and
to a moderate degree within the left maxillary sinus. Extensive
mucosal thickening and possibly fluid is noted within the
ethmoid sinuses, with moderate sphenoid sinus mucosal thickening
seen, and lastly minimal frontal sinus mucosal thickening. The
sinus abnormalities could represent the effects of intubation,
as well as an inflammatory process.
MR angiography of the circle of [**Location (un) 431**] and its tributaries shows
no overt sign of an area of hemodynamically significant
stenosis, or within the limitations of this technique, an
aneurysm.
CONCLUSION: Multiple small areas of subacute infarction. Given
the history
of protracted hypotension as well as recent aortic valve
surgery, both
hypotensive and embolic sources for the infarctions need to be
considered.
COMMENT: I discussed this case with Ms. [**Last Name (Titles) 38136**], the nurse
practitioner who requested this study, immediately after the
examination was completed, via telephone.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: FRI [**2179-10-22**] 8:09 AM
TEE
Conclusions
PRE-BYPASS:
1. The left atrium and right atrium are normal in cavity size.
No atrial septal defect is seen by 2D or color Doppler.
2. 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. The aortic root is markedly dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic arch is mildly
dilated. A mobile density is seen in the ascending aorta
consistent with an intimal flap/aortic dissection. A mobile
density is seen in the aortic arch consistent with an intimal
flap/aortic dissection. A mobile density is seen in the
descending aorta consistent with an intimal flap/aortic
dissection.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Moderate to severe (3+) aortic regurgitation is
seen.
6. Mild (1+) mitral regurgitation is seen.
7. There is a small pericardial effusion.
POST-BYPASS:
1. An aortic valve tissue prosthesis is in good position with
good leaflet excursion. The mean gradient is appropriate. There
is a trace paravalvular leak that improved with protamine.
2. MR is now trace.
3. Right and left ventricular function is preserved.
4. The remainder of the study is unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results at the
time of the examination.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2179-10-19**] 09:40
Radiology Report CHEST (PA & LAT) Study Date of [**2179-10-28**] 3:01 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2179-10-28**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 81544**]
Reason: eval pleural effusions
Final Report
CHEST PA AND LATERAL.
INDICATION: Status post aortic valve replacement, evaluate
chest.
FINDINGS: The patient's condition does not permit standard chest
technique
and the patient is examined in AP projection in semi-erect
position. A
lateral view was obtained with the patient barely sitting up.
Comparison is made with the next previous similar study of
[**9-27**],0 [**2178**]. Status post sternotomy is unchanged and the
position of the metallic components of a porcine aortic valve
prosthesis is a identified in unchanged position. Cardiac
enlargement persists and the left diaphragmatic contour and
lateral pleural sinuses are obliterated. Comparison with the
next preceding study suggests that the amount of effusion has
increased mildly. Size quantification, however, is difficult
considering patient's position and examination technique. Can,
however, identify pleural effusions in the posterior pleural
sinuses of the left side as seen on the lateral view. No
evidence of pneumothorax. The patient is extubated and the
previously identified NG tube has been removed. A left
subclavian approach central venous line persists and terminates
overlying the SVC at the level of the carina. No pneumothorax
has developed.
IMPRESSION: Persistent left-sided pleural effusion, possibly
increased
slightly. No pneumothorax, new infiltrates or other
complications.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2179-10-28**] 6:48 PM
[**Last Name (LF) **], [**First Name3 (LF) **] [**2179-10-28**]
RENAL SCAN Clip # [**Clip Number (Radiology) 81545**]
Reason: 58 YR OLD MAN WITH S/P ACUTE DISSECTION AND RENAL
FAILURE, EVAL FOR FLOW/SPLIT
Final Report
RADIOPHARMACEUTICAL DATA:
5.4 mCi Tc-[**Age over 90 **]m MAG3 ([**2179-10-28**]);
HISTORY: 58 y/o male s/p acute type A dissection extending to
common iliac
bifurcation and left common iliac artery. Involvement of renal
arteries is
unknown. Patient is presenting for evaluation of renal failure.
INTERPRETATION:
Flow and dynamic images were obtained after intravenous
administration of
tracer. Blood flow images show symmetric perfusion to both
kidneys. Renogram images show delayed excretion of tracer
bilaterally.
The differential function obtained by analysis of tracer
concentration in the parenchyma from 2 to 3 minutes post tracer
injection shows the left kidney to be performing 47 % of the
total renal function and the right kidney performing 53 %.
IMPRESSION: 1. Symmetric renal function. 2. Markedly delayed
tracer
excretion bilaterally. Findings consistent with poor parenchymal
function which
may reflect acute tubular necrosis in the setting of recent
hypotensive insult
or chronic medical renal disease. Repeat assessment could be
performed as
clinically indicated.
Findings discussed with Dr. [**Last Name (STitle) **] on the afternoon of
[**2179-10-28**] by Dr.
[**First Name (STitle) 7747**] over the telephone.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7747**], M.D.
Brief Hospital Course:
Admitted directly to the OR after [**Location (un) 7622**] from [**Hospital1 **]
emergency room .Was hypotensive on arrival to OR. Underwent
surgery with Dr. [**First Name (STitle) **], please see OR report for details. In
summary he had an ascending aorta replacement with an aortic
valve replacement. He tolerated the operation and was
transferred to the CVICU in fair conditiion following surgery.
Vascular surgery and general surgery both consulted for rising
lactate and abdominal distention. Renal service also consulted
for acute renal failure. He remained critically ill and very
volume overloaded and therefore remained intubated and sedated
for several days post-operatively. Drips titrated for BP and
glucose control. Neuro consult obtained for inability to respond
appropriately and right-sided weakness. CT obtained and then
subsequent MRI showed multiple areas of small infarcts. Tube
feedings started on POD #2. Pancultured for fever and Cipro
started for gram negative rods in sputum. OT eval done. He was
extubated POD #5. Patient had intermittant episodes of atrial
fibrillation and was started on amiodarone. He initially failed
a swallow evaluation however a repeat eval was done POD #7,
which he passed. Diet was advanced as tolerated. Coumadin was
discontinued with rhythm remaining in Sinus. Antihypertensives
optimized. POD#10 Renal ultrasound performed showed no eveidence
of hydronephrosis with symetric flow to both kidneys. Pt
continued to progress and on POD #11 he was ready for discharge
to rehab. All follow up appointments were advised.
Medications on Admission:
atenolol
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 7days then 200mg QD.
6. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection QAC&HS.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Atenolol 50 mg Tablet Sig: as directed Tablet PO twice a
day: 100mg QAM
50mg QPM.
14. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO every [**2-28**]
hours as needed.
17. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO PRN for
SBP>150.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) tx Inhalation Q4H (every 4 hours) as
needed.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Type A aortic dissection s/p AVR/replacement ascending aorta
CVA
postop A Fib
HTN
obesity
CRI
s/p pancreatitis
prostate CA
anemia
diverticulosis
CVA left caudate [**2170**]
adrenal hyperplasia s/p adrenalectomy [**2169**]
hypertriglyceridemia
pre-diabetic
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
call for fever greater than 100, redness, or drainage
no driving for at least one month and until off all narcotics
no lifting greater than 10 pounds for 10 weeks
shower daily and pat incisions dry
Followup Instructions:
see PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**11-25**] weeks
See Dr. [**Last Name (STitle) **] ( for Dr. [**First Name (STitle) **] for postop visit in 3 weeks at
[**Hospital1 **]- call for appt. [**Telephone/Fax (1) 6256**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2179-10-29**]
|
[
"584.5",
"585.9",
"V10.46",
"434.91",
"278.00",
"427.31",
"424.1",
"403.90",
"441.03",
"423.0",
"272.1",
"287.5",
"285.1",
"342.90",
"V12.54",
"276.2",
"790.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"35.21",
"96.6",
"99.07",
"99.05",
"38.91",
"38.45",
"88.72",
"96.72",
"99.04",
"39.61",
"39.64"
] |
icd9pcs
|
[
[
[]
]
] |
13395, 13469
|
10163, 11735
|
312, 423
|
13769, 13778
|
1701, 10140
|
14070, 14446
|
1063, 1072
|
11794, 13372
|
13490, 13748
|
11761, 11771
|
13802, 14047
|
1087, 1270
|
1284, 1682
|
239, 274
|
451, 821
|
843, 1022
|
1038, 1047
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,870
| 122,366
|
7201
|
Discharge summary
|
report
|
Admission Date: [**2204-12-13**] Discharge Date: [**2204-12-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
chest pressure, atrial fibrillation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. [**Known firstname 26693**] [**Known lastname **] is an 87yo retired male cardiothoracic
surgeon with h/o CAD with inoperable multivessel dz, 2 prior
anterolateral and inferior MI s/p BMS to pLAD in [**11/2195**], DES to
D1 in [**2-/2200**] c/b GIB in setting of anticoag, ICM with EF
30-40%, HTN, hyperlipidemia, colon and prostate CA, who awoke at
home at 4am with chest discomfort, diaphoresis and atrial
fibrillation to rate of 130s. He reported chest discomfort as a
pressure that was "moderate" in severity. He took nitro spray at
home without improvement and called EMS. He had received ASA
325mg po x11, morphine 5mg Iv, NTG x3 SL enroute with EMS.
.
In the ED, initial vitals were HR 130 BP 152/112 RR 21 POX 95%
on RA. A code STEMI was called when EKG revealed in III/aVF.
He received 600mg Plavix, integrellin bolus and was taken to the
cath lab. Prior to catheterization, his ST elevations were felt
to be rate related and he received metoprolol 5mg IV x3 and was
transferred to the CCU for esmolol gtt in the setting of EF 35%.
.
On review of systems, he has suprapubic fullness from bladder
distention and difficulty voiding lying flat. He denies any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, recent black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain but does report decrease energy tolerance
and use of a walker. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
# CAD: 3VD
- reportedly inoperable in [**2176**]
- BMS to pLAD in [**11/2195**]
- DES to D1 in [**2-/2200**]
- cath in [**2195**]: 90% pLAD s/p PCI->pLAD, 100% pLCx, 100% pRCA
- repeat PCI of an LAD diagonal branch lesion in [**2-/2200**]
- s/p recent NSTEMI [**3-/2204**]
- s/p anterolateral and inferior infarctions
# ischemic cardiomyopathy, EF 35-40%
# Paroxysmal atrial fibrillation
- not on coumadin d/t h/o GI bleeding, recently restarted
coumadin
# Hypertension
# Hyperlipidemia
# h/o GI bleeding in the setting of PCI [**2200**]
# Colon cancer status post sigmoidectomy in [**2175**]
# Prostate cancer [**2190**], status post XRT
# h/o hematuria secondary to radiation cystitis
# h/o Radiation proctitis
# MRI showed near occlusion of left subclavian artery in [**2194**]
# Pulmonary tuberculosis diagnosed in [**2143**] s/p treatment
# Right retinal hemorrhage status post AV crossing
# Glaucoma
Social History:
-Tobacco history: no tobacco
-ETOH: no alcohol
-Illicit drugs: no IVDA
retired cardiothoracic surgeon
lives in [**Hospital3 26701**] in [**Location 1268**]. His
wilfe is in the Alzheimer's unit there. Uses walker at baseline
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T= 96.6 BP= 138/93 HR=107 RR=12 O2 sat=96% on 2L NC
GENERAL: WDWN elderly male in NAD. Oriented x3. Mood, affect
appropriate. Very hard of hearing.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MMM. No
xanthalesma.
NECK: Supple with JVP at clavicle lying flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irreg irreg, tachy to 110s, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, mild suprapubic tenderness, ND. No HSM or
tenderness. Abd aorta not enlarged by palpation. No abdominial
bruits. GU: radiation skin changes present.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2204-12-14**] 06:30AM BLOOD WBC-7.3# RBC-3.82* Hgb-12.6* Hct-35.3*
MCV-92 MCH-33.0* MCHC-35.8* RDW-13.9 Plt Ct-158
[**2204-12-14**] 06:30AM BLOOD Glucose-116* UreaN-26* Creat-1.4* Na-145
K-3.9 Cl-109* HCO3-25 AnGap-15
[**2204-12-13**] 05:20AM BLOOD CK(CPK)-110
[**2204-12-13**] 05:20AM BLOOD cTropnT-<0.01
[**2204-12-13**] 01:11PM BLOOD CK(CPK)-431*
[**2204-12-13**] 01:11PM BLOOD CK-MB-46* MB Indx-10.7* cTropnT-2.22*
[**2204-12-13**] 11:44PM BLOOD CK(CPK)-406*
[**2204-12-13**] 11:44PM BLOOD CK-MB-32* MB Indx-7.9* cTropnT-4.63*
[**2204-12-14**] 06:30AM BLOOD CK(CPK)-295*
[**2204-12-14**] 06:30AM BLOOD CK-MB-18* MB Indx-6.1* cTropnT-3.59*
[**2204-12-14**] 06:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.3
CXR [**12-13**]: As compared to the previous radiograph, the
pre-existing right
pleural effusion has slightly increased. Also increased are the
pre-existing left basal areas of hypoventilation. Due to a
lesser inspiratory effort, the cardiac silhouette is slightly
larger than on the previous examination. There is no evidence of
focal parenchymal opacity suggesting pneumonia. The size of the
intrapulmonary vessels is borderline, overt overhydration is not
present, minimal pleural effusion.
ECG [**12-14**]:
Sinus rhythm. Since the previous tracing of [**2204-12-14**] inferior
and anterior
T wave inversions may be more prominent. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
58 160 134 504/500 52 26 -41
Labs on Discharge:
[**2204-12-17**] 07:00AM BLOOD WBC-5.6 RBC-3.99* Hgb-12.7* Hct-36.9*
MCV-92 MCH-31.8 MCHC-34.4 RDW-13.9 Plt Ct-195
[**2204-12-17**] 07:00AM BLOOD Glucose-128* UreaN-33* Creat-1.6* Na-140
K-4.6 Cl-106 HCO3-24 AnGap-15
[**2204-12-17**] 07:00AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.3
Brief Hospital Course:
# Atrial fibrillation with Rapid Ventricular Response - Patient
was initially started on esmolol gtt with limited success at
rate control. After discussion with the Electrophysiology
service, the patient was started on dofetilide with oral
beta-blockade to control rate. Patient cardioverted on
dofetilide. The need for anticoagulation (CHADS2=3) was
discussed with this patient, but he insisted that he did not
wish to be on AC given his h/o GI bleeds. He expressed
understanding re: stroke risk of not being on anticoagulation.
On [**12-16**], QTc was found to be prolonged at 0.51 on Dofetalide,
changed to Dronedarone at 400 [**Hospital1 **] with good rhythm control, in
NSR on discharge. Metoprolol was uptitrated to HR of 50's,
converted to Succinate on discharge. Pt has an appt with his
[**Last Name (LF) 26702**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for further medication adjustment.
.
# Coronary Artery Disease - Last cath [**2-10**] showed severe 3VD.
Cath films were reviewed again during this admission and it was
felt that he did not have intervenable targets. Patient had
troponin-T elevation, peaking to 4.63, during hospital admission
that was thought [**3-5**] demand ischemia in the setting of RVR. He
was continued on aspirin, Metoprolol and statin, Imdur was
restarted before discharge.
.
# Chronic Systolic COngestive Heart Failure - Appeared euvolemic
on admission. EF 35%, NYHA Class II. Cont on home dose of Lasix
and Valsartan. Metoprolol increased as noted above.
.
# H/o GI Bleed on anticoagulants: Guaiac negative in cath lab
after plavix/integrilin gtt. No evidence of bleeding during this
admission. Pt has refused IV heparin or coumadin because of
bleeding history. Aspirin was increased to 325mg.
.
# CKD: Baseline of 1.7, at baseline on admission and at
discharge.
.
# CODE: DNR/DNI confirmed w/ pt and son at bedside.
Medications on Admission:
Aspirin 81mg po daily
Lasix 20mg po daily
Isosorbide mononitrate 30mg SR daily
Metoprolol succinate 75mg SR daily
Simvastatin 40mg po daily
Diovan 40mg po BID
Nitro spray prn
Colace 100mg po BID prn constipation
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Nitrolingual 0.4 mg/Dose Spray, Non-Aerosol Sig: One (1)
spray Translingual every 5 minutes for total of 3 doses as
needed for chest pain.
7. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary Diagnosis: atrial fibrillation with rapid ventricular
response
Secondary:
1. chronic systolic heart failure
2. hypertension
3. coronary artery disease
4. hyperlipidemia
Discharge Condition:
Amb with rolling walker
alert and oriented
Discharge Instructions:
You were seen in [**Hospital1 18**] for atrial fibrillation with rapid
ventricular response. You were started on a medication,
dofetilide, which converted you back into normal sinus rhythm.
You were seen by the cardiac electrophysiology service, under
whose guidance your medications were changed to better control
your atrial fibrillation. The dofetalide was d/c'ed and
Dronedarone was started.
Medication changes:
1. START Dronedarone to keep in normal sinus rhythm.
2. Increase your Metoprolol to 150 mg daily
Weigh yourself every morning, call Dr. [**First Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: none
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2205-2-7**] 10:00
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2204-12-25**] at 9:20am.
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2205-4-30**] 11:00
Completed by:[**2204-12-17**]
|
[
"428.22",
"V45.82",
"V10.05",
"585.9",
"427.31",
"365.9",
"V10.46",
"272.4",
"412",
"414.01",
"403.90",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9146, 9281
|
6165, 8056
|
300, 306
|
9502, 9547
|
4399, 5846
|
10293, 10842
|
3247, 3362
|
8319, 9123
|
9302, 9302
|
8082, 8296
|
9571, 9968
|
3377, 4380
|
9988, 10270
|
225, 262
|
5865, 6142
|
334, 2055
|
9321, 9481
|
2077, 2985
|
3001, 3231
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,243
| 140,432
|
26201
|
Discharge summary
|
report
|
Admission Date: [**2191-4-19**] Discharge Date: [**2191-4-22**]
Date of Birth: [**2153-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
ETOH Withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
38 yo F wtih history of cocaine, ETOH abuse and prior suicide
attempt in [**2186**] previously admitted to the ICU [**3-7**] with ETOH
withdrawal and threat of suicide, was found on a train when he
presented to the conductor saying he wanted to kill himself. He
was brought to [**Hospital1 18**] ED for further management.
.
In ED, vitals were HR 105 BP 160/100 RR 22 POX 98 on RA. He
remained tachycardic and was given given 4L IVF. He became
violent and received haldol 10mg IM and ativan 4mg IV, required
restraints and continued to be persistently tachycardiac. Urine
was positive for cocaine and ETOH level 394. He reported
abdominal pain and a negative FAST exam was performed. Vital
Signs prior to transfer were T99 HR110 BP166/79 POx100% on RA
RR21. He was admitted to the ICU for tachycardia.
.
On arrival to the [**Hospital Unit Name 153**], he was somnolent but arousable and
without complaint. He reported smoking cocaine and drinking
alcohol last the evening prior to admission. He denied SI or HI.
Past Medical History:
1. ADHD
2. learning disorder (dyslexia)
3. major depression
4. bipolar affective disorder
5. antisocial personality disorder
6. hx head trauma [**1-31**] a beating during court-mandated vocational
program in TX
7. ethanol abuse - szs [**1-31**] ethanol withdrawal/DTs, per pt
8. ?heroin use
.
Psych hx: Bridgwater x2, "21" psych hospitalizations in [**State 2690**],
>50 detoxes, last 2yrs ago. Suicide attempt [**2186**] - hanging.
Social History:
Etoh: + since [**94**], reportedly up to 2pints of vodka/d 2-3 days/wk
Tobacco: 3ppd, smoking since age 13
Illicit Drug Use: cocaine/heroin, both IV. Last used cocaine
[**3-2**], heroin [**2-28**]. Pt reports multiple detox programs. Marijuana
once weekly, methamphetamine once weekly.
Denied sexual activity. Lives in [**Location **], lost job as
cook/prep employee of 17 years. Stated he is a registered sex
offender from an incident several years ago when intoxicated.
Mother lives in [**State 2690**], father disabled.
Family History:
NC
Physical Exam:
GENERAL - well-appearing young man in NAD, comfortable, drowsy
but arousable
HEENT - NC/AT, PERRLA, 2mm sluggish b/l, EOMI, sclerae
anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, tachy but regular, no MRG, nl S1-S2,
hyperdynamic on exam
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - limited exam [**1-31**] cooperation. Drowsy, oriented x3.
CNII-XII without focal deficit. Gait deferred.
Pertinent Results:
[**2191-4-19**] 03:37PM GLUCOSE-125* UREA N-15 CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2191-4-19**] 03:37PM CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-1.9
[**2191-4-19**] 08:01AM CALCIUM-7.2* PHOSPHATE-2.7# MAGNESIUM-1.9
[**2191-4-19**] 08:01AM CALCIUM-7.2* PHOSPHATE-2.7# MAGNESIUM-1.9
[**2191-4-19**] 08:01AM WBC-9.4 RBC-3.87* HGB-12.5* HCT-37.1* MCV-96
MCH-32.2* MCHC-33.6 RDW-12.7
[**2191-4-19**] 08:01AM PLT COUNT-303
[**2191-4-19**] 12:19AM GLUCOSE-80 UREA N-16 CREAT-0.9 SODIUM-147*
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-23 ANION GAP-19
[**2191-4-19**] 12:19AM estGFR-Using this
[**2191-4-19**] 12:19AM ALT(SGPT)-37 AST(SGOT)-41* LD(LDH)-205 ALK
PHOS-62 TOT BILI-0.3
[**2191-4-19**] 12:19AM ALBUMIN-4.8
[**2191-4-19**] 12:19AM ASA-NEG ETHANOL-394* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2191-4-19**] 12:19AM WBC-7.1 RBC-4.57* HGB-14.4 HCT-42.4 MCV-93
MCH-31.5 MCHC-33.9 RDW-13.0
[**2191-4-19**] 12:19AM NEUTS-50.0 LYMPHS-38.3 MONOS-4.3 EOS-6.4*
BASOS-1.1
[**2191-4-19**] 12:19AM PLT COUNT-422#
[**2191-4-18**] 11:30PM URINE HOURS-RANDOM
[**2191-4-18**] 11:30PM URINE HOURS-RANDOM
[**2191-4-18**] 11:30PM URINE GR HOLD-HOLD
[**2191-4-18**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2191-4-18**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
Brief Hospital Course:
38 yo male with long-standing cocaine and alcohol abuse, suicide
attempt in [**2186**] presents with suicidality in the setting of
cocaine/etoh intoxication.
.
#. ETOH Intoxication - Patient was admitted to the ICU with
alchohol intoxication and level > 300. Patient was also using
cocaine, likely the cause for his agitation in the ED. He has
prior history of heroin and methamphetamine use which may also
be playing a role although he denies. He was monitored
overnight in the ICU and did not score on his CIWA scale. He
had received Diazepam 10mg TID during his hospitalization and
also received 5L NS IVF resusitation, along with IV thiamine and
MVI. Upon transfer to the floor, he continued to be stable and
not score above 10 on his CIWAS scale.
#. Suicide ideation - Prior history of attempt in [**2186**] by
hanging. In ED reporting SI, currently denies. Patient was seen
by psychiatry and recommended inpatient placement for patient.
Patient had 1:1 sitter during his entire stay.
Medications on Admission:
None
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg/mL Solution Sig: One (1) Injection DAILY
(Daily) for 3 days.
4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 22870**] Treatment Center - [**Location (un) 3320**]
Discharge Diagnosis:
Primary
Alcohol intoxication
Suicidal Ideations
Secondary
- major depression
- bipolar affective disorder
- antisocial personality disorder
Discharge Condition:
Afebrile, vitals stable
Discharge Instructions:
You were hospitalized because you were intoxicated with alcohol.
After a thorough work up, you were not thought to be
withdrawing. You had mentioned that you wanted to harm
yourself, so you are being transferred to a facility where you
can receive treatment for your condition.
Followup Instructions:
Please follow up with the physician at the Psychiatric facility.
|
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29,236
| 111,880
|
6462+55758
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-8-19**] Discharge Date: [**2192-9-4**]
Date of Birth: [**2111-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
coffee-ground emesis
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
HPI: The patient is an 81 year old female who presented from a
nursing home with coffee ground emesis on [**2192-8-19**]. The patient
was unable to provide a history due to dementia but the MICU
admitting team was able to speak to her nursing home who
provided the following history. Per her nurse she had several
episodes of dark, coffee-ground emesis on the day prior to
admission. She did not complain of abdominal pain. Per report
from her nursing home she also fell two days prior to admission
and hit her forehead (no further history on her fall available).
Per the patient's daughter at baseline, pt is minimally verbal,
able to answer simple questions and interject into conversation
but does not speak spontaneously and has significant word
finding difficulties. She adds that the pt has been less active
in the few days preceeding admission.
.
In ED her vitals were BP 132/50, HR 76, O2 sat 95% on RA. She
was found to have a hematocrit of 37. She received 1L of NS and
IV protonix. An NG lavage per report was not performed because
there was no evidence of active vomiting. CT of the head
revealed no evidence of acute bleed.
.
While in the MICU her vital signs have been stable. Her
hematocrit on admission to the ER was 37 on [**8-19**] at 12 AM. This
decreased to 29.8 at 6 AM, 27.6 at 12 PM and 30.8 at 12 AM on
[**8-20**]. At no time did she require transfusion. Bilateral lower
extremity ultrasounds were performed given assymetric lower
extremity edema which were negative for clots. She was started
on high dose IV PPI for her presumed GI bleed. She underwent CT
of the abdomen which showed a large hiatal hernia with a
thoracic stomach and no evidence of pancreatitis despite
incidentally noted elevated pancreatic enzymes. She was
evaluated by gastroenterology who plan for her to under upper
endoscopy tomorrow AM.
.
Past Medical History:
# [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] aortic valve, not currently anticoagulated at
rehab/nursing home
# Atrial Fibrillation
# hiatal hernia with esophagitis
# hypoxic brain injury
# Dementia
# breast ca s/p lumpectomy
# osteoporosis
# CHF, EF unknown
# CAD s/p CABG
Social History:
Has been living at [**Hospital 19453**] Nursing Home & Rehab for past
month.
Family History:
Noncontributory
Physical Exam:
Vitals: 95.5 133/56 72 19 99% 3L NC
GEN: lying in bed, oriented to person, "hospital," and "Saturday
in [**Month (only) 205**]."
HEENT: ecchymosis over L lower eyelid, PERRL, EOMI, OP clear
NECK: jugular veins difficult to assess [**2-24**] body habitus
CV: mechanical valve sounds
CHEST: cta ant and lateral fields
ABD: soft, nontender, NABS
EXT: no c/c/e
SKIN: no rashes
Pertinent Results:
Admission Labs [**2192-8-19**]:
Hematology:
CBC: WBC-13.0*# RBC-4.38 HGB-12.5 HCT-37.2 MCV-85 MCH-28.4
MCHC-33.5 RDW-21.9* PLT COUNT-421#
Differential: NEUTS-80.7* LYMPHS-14.7* MONOS-3.4 EOS-0.9
BASOS-0.2
PT-11.6 PTT-21.6* INR(PT)-1.0
Chemistries:
Glucose-146* UreaN-30* Creat-0.9 Na-145 K-3.9 Cl-99 HCO3-37*
AnGap-13
Calcium-8.9 Phos-3.5 Mg-2.1
ALT-27 AST-37 AlkPhos-174* Amylase-326* TotBili-0.4 Lipase-276*
Albumin-4.1
.
Others [**2192-8-21**]:
ALT-17 AST-23 LD(LDH)-279* AlkPhos-149* Amylase-62 TotBili-1.0
Lipase-22 GGT-25
Triglyc-70 HDL-51 CHOL/HD-3.9 LDLcalc-133*
B12: 631 Folate: 9.0
TSH: 0.66
.
Discharge Laboratories:
[**2192-8-31**] CBC: WBC: 9.4 Hgb: 10.6* Hct: 31.6* Plts: 400
[**2192-9-3**] [**Name (NI) 2591**] PT: 21.2* PTT: 28.2 INR: 2.1*
.
Imaging:
.
CT Head [**2192-8-19**]:
Despite repetition, some of the posterior fossa scans are
degraded by patient motion. Within this limitation, there is no
significant interval change seen compared to the prior
examination. Specifically, there has been no interval
development of an intracranial hemorrhage or overt area of acute
brain ischemia. However, if the latter diagnostic consideration
is a possibility, an MRI scan would be a more sensitive means
for detecting an area of acute infarction. The multiple areas of
chronic small-vessel infarctions previously described are
re-demonstrated. No other new extracranial abnormalities are
discerned, either.
.
CT Abd [**2192-8-19**]:
1. Intrathoracic stomach which may represent gastric volvulus.
If the patient is not symptomatic these findings may be related
to chronic volvulus.
2. No CT evidence of pancreatitis
.
Bilateral LE US [**2192-8-19**]:
Grayscale and Doppler examination of bilateral common femoral,
superficial femoral, and popliteal veins were performed. Normal
compressibility, augmentation, waveforms, and Doppler flow is
demonstrated. There is no evidence of intraluminal clot.
.
Upper Endoscopy [**2192-8-21**]:
Findings: Normal esophagus, large hiatal hernia with [**Location (un) 3825**]
lesions, normal duodenum.
.
Upper GI with Small Bowel Follow Through [**2192-8-21**]:
1. Intrathoracic stomach with the pyloric at the level of the
diaphragmatic hiatus. No evidence of gastric outlet obstruction
or volvulus.
2. Small amount of barium aspiration noted in the central
airways. Followup chest x- ray is recommended if there is
concern for development of pneumonia.
.
Echocardiogram [**2192-8-22**]:
Conclusions: The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free
wall motion are normal. The ascending aorta is moderately
dilated. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
.
CT Head [**2192-8-24**]:
1. No significant interval change to brain parenchyma without
acute
hemorrhage identified.
2. Slight decrease to predominantly left supraorbital subgaleal
hematoma.
Brief Hospital Course:
Mrs. [**Known lastname 24831**] is an 81 year old female with a history of CAD,
atrial fibrillation, aortic valve replacement and dementia who
presents with evidence of an upper gastrointestinal bleed.
.
# Upper GI bleed: On presentation the patient had experienced
two episodes of coffee ground emesis at her nursing home. She
has a history of esophagitis but otherwise no history of
gastrointestinal disorders or bleeding events. In the emergency
room two large bore IVs were placed and she received IV fluids.
Her hematocrit on admission was 37.2. This fell over the course
of the following day decreased to 27.1 but the patient did not
require transfusion. She was hemodynamically stable and
asymptomatic throughout. She was started on high dose
intravenous PPI therapy. A CT scan of the abdomen was performed
in the emergency room which revealed the presence of a large
hiatal hernia with a complete intrathoracic stomach. The
patient underwent upper endoscopy on [**2192-8-21**] which revealed no
obvious bleeding sources but confirmed the presence of the large
hiatal hernia with the presence of [**Location (un) 3825**] lesions. Given that
her hematocrit had stabilized and there was no obvious bleeding
source on endoscopy no further workup was initiated. She was
discharged on an oral proton pump inhibitor. No further
episodes of bleeding were observed throughout this
hospitalization.
.
# Hiatal Hernia: The patient was noted to have a large hiatal
hernia on CT scan. The presence of an intrathoracic stomach was
confirmed on upper endoscopy. An upper GI with small bowel
follow through was obtained to further clarify her anatomy.
This again showed the hiatal hernia, but showed no evidence of
volvulus or gastric outlet obstruction. The possibility of
surgical intervention to prevent strangulation was discussed
with the patient's daughter. [**Name (NI) 227**] the patient's age and
comorbities and relatively low lifetime risk of adverse events
secondary to her hernia, surgical correction was not pursued
further. She should continue to take a proton pump inhibitor to
protect against future bleeding events.
.
# Dementia: The patient has a history of traumatic brain injury
as well as senile dementia. On admission she was taking
aricept, seroquel and namenda. While in house she was observed
to have reversal of her sleep/wake cycles with frequent episodes
of calling out at night. Psychiatry was consulted to assist
with her medication regimen. Her aricept and standing seroquel
were discontinued. She was started on Haldol 0.25 mg PO TID
with good effect. Behavioral interventions particularly
effective included allowing patient to sit in public areas where
she was able to interact with other people.
.
# Mechanical Aortic Valve: The patient has a St. [**Male First Name (un) 1525**]
mechanical aortic valve. She was not on anticoagulation on
admission. Her primary care physician was [**Name (NI) 653**] who
confirmed that anticoagulation was appropriate. She was started
on a heparin drip for anticoagulation which was quickly switched
to lovenox. She was also started on coumadin. Her lovenox was
discontinued when her INR was within therapeutic range. Over
the remainder of her hospitalization her coumadin was titrated
to a goal INR between 2.5 to 3.5 for patients with a mechanical
valve and atrial fibrillation. She was discharged on coumadin
1.5 mg T,Th,[**Last Name (LF) **],[**First Name3 (LF) **] and 2 mg M,W,F. She will need to have her INR
monitored every other day at her nursing home until her INR is
stable.
.
# Atrial Fibrillation: Currently well-rate controlled with
metoprolol. She was started on anticoaglation with coumadin as
described above.
.
# CHF: Patient has a past medical history of CHF but the details
of this diagnosis are unclear. As an outpatient she takes
Toprol XL and lasix. On admission her antihypertensive
medications were held in the setting of acute bleeding but were
restarted once serial hematocrits were stable. An
echocardiogram was performed during this admission which
revealed mild symmetric LVH, no regional wall motion
abnormalities, LVEF of > 55%, and a well-seated aortic valve
prosthesis with normal disc motion and transvalvular gradients.
She was started on lisinopril 5 mg daily during this admission
and this can further managed in the outpatient setting.
.
# CAD - The patient has an unclear cardiac history but on CT
scan she has evidence of CABG and takes a beta blocker as an
outpatient. A lipid profile was obtained to further assess her
cardiac risk. Her LDL was elevated at 133 and given her history
of CAD she was started on simvastatin 10 mg daily. She was also
started on lisinopril 5 mg daily. She was continued on her beta
blocker. She was not started on an aspirin on this admission
given her presentation with a GI bleed but this can be
considered as an outpatient.
.
# HTN: The patient has a history of hypertension treated with
metoprolol as an outpatient. On admission her antihypertensive
medications were held in the setting of acute bleeding but were
promptly restarted. Given that her blood pressures continued to
be elevated in the 140s on her outpatient regimen she was
started on lisinopril 5 mg daily during this admission with good
blood pressure control.
.
# Paget's Disease: Patient was incidentally noted to have
evidence of paget's disease in the right hemipelvis and L1
vertebral body on CT. She also has a mildly elevated alkaline
phosphatase and normal GGT consistent with this disorder. This
issue may be followed as an outpatient.
.
# Urinary Tract Infection: Patient was noted to have Klebsiella
UTI during this admission. She was asymptomatic but we opted to
treat with a three day course of ciprofloxacin given her waxing
and [**Doctor Last Name 688**] mental status.
.
# Osteoporosis: Patient has a history of osteoporosis. She
takes vitamin D and Calcium as an outpatient and these were
continued during this admission.
.
# Anemia: Patient has a history of iron deficiency anemia.
Baseline hematocrit is unknown. Further workup was not pursued
during this admission given her acute bleeding episode. She was
continued on her home iron supplementation.
.
# Prophylaxis: She was treated with subcutaneous heparin for DVT
prophylaxis.
.
# Code Status: DNR/DNI
Medications on Admission:
Namenda 10mg [**Hospital1 **]
Seroquel 12.5mg [**Hospital1 **]
trazodone 50mg prn
Aricept 10mg daily
Calcium with D 600/200 [**Hospital1 **]
Iron 325mg daily
Vit C 500mg daily
MVI
Lasix 40mg daily
KCl 20mEq [**Hospital1 **]
Toprol XL 25mg
Discharge Medications:
1. Namenda 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
2. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
3. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. Melatonin 3 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime.
9. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
10. Warfarin 1 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at bedtime):
Please take Tuesday, Thursday, Saturday and Sunday.
11. Warfarin 1 mg Tablet [**Hospital1 **]: Two (2) Tablet PO at bedtime:
Please take Monday, Wednesday and Friday.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a
day).
14. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO every eight (8)
hours as needed for aggitation .
15. Calcium 600 with Vitamin D3 Oral
16. Toprol XL 25 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
Armenian Nursing & Rehabilitation Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Upper GI bleed
Dementia
Urinary Tract Infection
.
Secondary
Atrial Fibrillation
Mechanical Aortic Valve
Hypertension
CHF
CAD
Discharge Condition:
Stable
Discharge Instructions:
You were seen and evaluated because you were vomiting blood.
You were given intravenous fluids and medication to decrease the
acid in your stomach. You underwent upper endoscopy which did
not identify a clear source of bleeding. You had a CT scan of
your head which showed no evidence of bleeding in the brain You
had a CT of your chest which showed that your stomach is located
above your diaphragm. You also had an upper GI study. You were
found to have a urinary tract infection which was treated with
antibiotics. You were started on coumadin for your mechanical
heart valve.
.
Please take all your medications as prescribed. The following
changes were made to your medications.
1. Your seroquel was discontinued
2 Your aricept was discontinued
3 Your trazadone was discontinued
4. You were started on Haldol 0.25 mg by mouth three times a day
5. You were started on lisinopril 5 mg daily
6. You were started on lansoprazole 30 mg daily
7. You were started on coumadin for your mechanical aortic
valve. You will have to have your INR checked daily until your
levels have stabilized.
8. You were started on simvastatin for your cholesterol
9. You were started on melatonin
.
You should been seen by your new primary doctor at your new
facility within one week
.
Please seek immediate medical attention if you experience any
chest pain, shortness of breath, vomiting blood, blood in your
stool or darkness of your stool, fevers, numbness, inability to
move your arms or legs, or any other concerning symptoms.
Followup Instructions:
You should seen by your new primary care physician at your new
nursing home within one week.
Name: [**Known lastname 4223**],[**Known firstname 4224**] Unit No: [**Numeric Identifier 4225**]
Admission Date: [**2192-8-19**] Discharge Date: [**2192-9-4**]
Date of Birth: [**2111-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4226**]
Addendum:
On the day of planned admission the patient was noted to be
somewhat lethargic. Throughout this admission her level of
alertness would wax and wane. Her sleep and wake cycles were
disturbed. She was also noted to be particularly sensitive to
low doses of Haldol. She was discharged on a regimen of 0.25 mg
of Haldol three times a day by mouth. She did well with this
regimen but on days that she was given additional doses she was
particularly lethargic. We thus tried to use this medication
sparingly. She was discharged the following morning.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4227**] - [**Location 2708**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4228**]
Completed by:[**2192-9-4**]
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|
2559, 2638
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,115
| 171,887
|
44205
|
Discharge summary
|
report
|
Admission Date: [**2108-6-21**] Discharge Date: [**2108-6-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
ORIF of left femur
History of Present Illness:
Mr. [**Known lastname 174**] is a [**Age over 90 **] y/o male with Alzheimer's disease, CAD, CHF,
AS, CRI, symptomatic bradycardia s/p PPM presents s/p witnessed
fall at his nursing home with left closed distal [**11-22**] displaced
spiral fracture of femur. The patient is unable to give a
history.
.
In the ED, a hip xray was done which showed an acute comminuted
distal left femoral shaft fracture. The patient was evaluated
by ortho who recommended surgical fixation. The patient is
admitted for cardiac risk assessment for possible fixation.
.
On the floor the patient is in no distress, however he is
extremely tender to palpation of lower extremities bilaterally.
He winces with any movement of lower extremities.
Past Medical History:
h/o falls
Alzheimer's Disease,
CAD
Symp Bradycardia s/p Pacemaker
Anemia
Thrombocytopenia
Cataracts
Glaucoma
PVD
CRI (baseline 1.5-1.7)
CHF
Social History:
Widower. Quit cigarettes in [**2086**]. Lives in nursing home
([**Last Name (un) 35689**] House: [**Telephone/Fax (1) 94835**]). Contact is [**Hospital1 18**] MD, who is his
son, Dr. [**First Name4 (NamePattern1) **] [**Known lastname 174**] at [**Telephone/Fax (1) 94836**].
Family History:
Non-contributory.
Physical Exam:
VS: 95.1(ax) 94/60 64 20 95%RA
Gen: frail appearing male lying in bed with ecchymoses covering
his body, multiple bandaged wounds. appears euvolemic.
Neck: no JVD
HEENT: EOMI, PERRL, dry MM, multiple ecchymoses
CV: RRR, nl s1s2, + crescendo decrescendo murmur
Chest: CTA anteriorly, but difficult to assess
Abd: +BS, NT/ND,
Ext: no edema, 2+ pulses
Neuro: Pt able to follow commands. focally intact.
Pertinent Results:
[**2108-6-24**] CXR: IMPRESSION: AP chest compared to [**6-21**] and
4th:
Large right pleural effusion has increased substantially.
Moderate
cardiomegaly stable. Left lung clear. Transvenous right atrial
lead has
changed its orientation, transvenous right ventricular lead is
unchanged in position. No pneumothorax.
.
[**2108-6-22**] CXR MPRESSION: Mild interval worsening of right basilar
opacity, which could represent atelectasis, aspiration, or
pneumonia. Unchanged, small, freely layering right pleural
effusion.
.
[**2108-6-21**] Hip Xray IMPRESSION: Acute comminuted distal left femoral
shaft fracture. Moderate degenerative changes of the hips
bilaterally. Findings communicated to the referring physician.
.
[**2108-6-21**] 01:15PM GLUCOSE-123* UREA N-33* CREAT-1.6* SODIUM-141
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
[**2108-6-21**] 01:15PM WBC-8.5 RBC-3.75* HGB-11.5* HCT-33.8* MCV-90
MCH-30.7 MCHC-34.0 RDW-14.8
[**2108-6-21**] 01:15PM NEUTS-70 BANDS-1 LYMPHS-8* MONOS-16* EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-1*
[**2108-6-21**] 01:15PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
SCHISTOCY-1+ BURR-OCCASIONAL BITE-OCCASIONAL ACANTHOCY-NORMAL
[**2108-6-21**] 01:15PM PLT SMR-LOW PLT COUNT-108*#
[**2108-6-21**] 01:15PM PT-13.5* PTT-28.4 INR(PT)-1.2*
Brief Hospital Course:
Mr. [**Known lastname 174**] is a [**Age over 90 **] year old male with CHF AD, CAD, s/p fall at
nursing home now with spiral fracture of the distal femur.
Fall: Mr. [**Known lastname 174**] had a witnessed fall in his nursing home which
resulted in a spiral fracture. He was admitted to medicine for
cardiac pre operative risk evaluation for ORIF of the left
femur. The patient was evaluated to be Class III (see below for
details) and after a discussion with his son who felt it would
be beneficial, he went for surgery. By report the patient
underwent uncomplicated fixation and repair of his left femur.
The initial blood loss estimate was 300cc, however, in the OR
the patient developed hypotension with systolics in the 80s,
resulting in an 800cc fluid bolus and the initiation of
neosynephrine. He was transferred to the PACU on neosynephrine,
which could not be weaned despite transfusion of 2U PRBC. The
post-transfusion hct was 27 (pre-op 30). CXR at the time showed
only mild worsening of R basilar opacity. ECG revealed a paced
rhythm without obvious signs of ischemia. The patient was
transferred to the SICU for further monitoring and volume
repletion. Immediately post-operatively the patient had a drop
in his hematocrit and became hypotensive. He received 2 units
with no resultant bump in his hematocrit and no improvement in
blood pressures. He was started on neosynephrine in the PACU
and transferred to the SICU. The patient remained hypotensive
in the SICU, requiring neosynephrine support until [**6-24**] am.
During his time in the SICU, the patient received an additional
unit of PRBCs on [**6-22**] without a change in hematocrit level and an
additional unit on [**6-23**], again without a response in his
hematocrit. The patient received an additional 2U packed RBCs
on [**6-24**] with an appropriate increase in hematocrit and one stable
hematocrit approximately 3 hours later. The patient's SICU
course was complicated by a low grade fever on the night of [**6-23**]
and ongoing hypoxia, requiring 2L nasal cannula. A CXR showed a
large right pleural effusion which had increased substantially,
stable moderate cardiomegaly with a clear left lung. In a
discussion with the patient's son, it was decided that as the
patient would be unable to cooperate with a thoracentesis, the
procedure would entail too much risk for the patient. On the
floor, he remained hemodynamically stable. His wounds remain
clean, dry and intact with no evidence of increasing hematoma or
blood loss. His hematocrit remained stable and his left knee is
immobilized. His pain was treated with acetaminophen and
oxycodone. PT saw the patient and felt that he would benefit
from a rehabilitation center.
.
CAD: As Mr. [**Known lastname 174**] was admitted with a femoral fracture which is
optimally treated with surgery, he needed medical evaluation for
risk related to the surgery. According to the [**Doctor Last Name **] criteria
for general surgery, the patient receives 15 points (Age>70
5pts, significant AS 3pts, rhythm other than sinus on preop ECG
7) which makes him Class III and gives him an 86% of none/minor
complications, 11% of serious complications, and 2% risk of
cardiac death. The patient has a history of AS and +murmur on
exam, however no ECHO on record. As ECHO will not likely change
management (valve replacement, etc) given a patient with already
high risk factors, no ECHO was ordered. His lasix and ace
inhibitor were held on admission. He was placed on a beta
blocker both pre and post operatively. Immediately post
operatively the patient became hypotensive (as above) and the
beta blocker was held temporarily. However, once his blood
pressure stabilized he was restarted on his beta blocker given
the mortality benefit in the peri-operative period. His beta
blocker was titrated up as tolerated. His ASA was restarted per
ortho and his ACEI will be started upon discharge. His lasix
was held, however may be restarted at the rehab in [**1-21**] days with
monitoring of his fluid status.
.
Nursing home acquired pneumonia, pleural effusion: Pneumonia is
the likely etiology of fever and elevated WBC as noted in the
SICU. The pneumonia was likely aquired in the setting of fall in
NH. He was started on a 14 day course of vancomycin and zosyn.
His WBC trended down, he remained afebrile. The option of
thoracentesis was discussed with the patient's son (health care
proxy) and the decision was made not to tap the effusion (as
above). A PICC was placed on the floor and the patient will be
continued on antibiotic therapy for 14 days.
.
Glaucoma: Mr. [**Known lastname 174**] was continued on levobunolol and xalatan
drops as per his outpatient regimen.
.
Thrombocytopenia: Mr. [**Known lastname 174**] has a history of low platelets. On
admission, his platelet count was 108, however over the course
of his hospitalization, his platelet count dropped to 58. A
heparin dependent antibody was sent which was negative. His
platelet count slowly began to rise and was felt to be secondary
to the post operative period.
.
Aortic Stenosis: The valve area is unknown in this patient.
Diuresis was done extremely carefully given the late peaking
nature of his murmur.
Medications on Admission:
levobunolol
xalatan drops
lasix 80mg PO
Lisinpril 2.5mg QD
Bacitracin
Docusate sodium 100mg QD
Vitamin D 400U
Acetaminophen
Loratadine 10mg QD
Fortical
trazodone
Discharge Medications:
1. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): 1 drop in both eyes daily.
4. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q48H (every 48 hours) for 11 days: 14 days will be
completed on [**7-7**].
5. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams of
Recon Solns Intravenous Q6H (every 6 hours) for 11 days: 14 day
course will be completed on [**7-7**].
6. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous
Q24H (every 24 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): Please put 1 drop in right eye.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
13. FORTICAL 200 unit/Actuation Aerosol, Spray Sig: One (1)
spray Nasal once a day: 1 spray alternating nostrils daily.
14. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Left femur fracture
h/o falls
Alzheimer's Disease
Hypotension
NH acquired PNA
Aortic stenosis
Thrombocytopenia
Secondary: CHF
CAD
symptomatic bradycardia s/p PPM
Discharge Condition:
Fair. Pt is s/p ORIF of left femur, healing well. Had recent
episodes of hypotension.
Discharge Instructions:
You came into the hospital because of a fall during which you
fractured your femur.
Please take all medications as prescribed. There have been some
changes to your outpatient regimen.
**You will not be taking Lasix for the first 3-4 days after
discharge. As you were hypotensive post operatively, your lasix
was held. The rehabilitation facility will reassess your fluid
status and restart the lasix as you are ready.
**You are now taking Metoprolol 25mg twice per day instead of
Atenolol once per day.
**You are taking 81mg of Aspirin once per day.
Please keep all outpatient appointments or schedule appointments
as needed.
If you fall again or begin to experience lightheadedness,
dizziness, or any redness or swelling at the wound site, please
[**Name6 (MD) 138**] your MD.
Physical Therapy:
Left leg immobilizer
Treatments Frequency:
Please reassess the patient's fluid status while a patient at
the rehab. He was on Lasix 80mg PO as an outpatient which was
held post operatively as the patient became hypertensive. Once
his volume status improves, please restart his lasix dose
(likely within 3-4 days.)
The patient has staples in place which should be removed in [**11-21**]
weeks. The wound may be covered in a dry dressing. He is
currently wearing a left leg immobilizer which should be worn
when the patient is out of bed, however, can be taken off while
in bed if the patient is not moving the leg too much.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1266**] [**Telephone/Fax (1) 608**] as needed.
|
[
"799.02",
"E849.8",
"458.29",
"440.20",
"365.9",
"511.9",
"V45.01",
"E888.9",
"287.5",
"585.9",
"331.0",
"821.01",
"428.0",
"424.1",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"79.35",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10259, 10325
|
3358, 8591
|
272, 292
|
10540, 10630
|
1977, 3335
|
12109, 12207
|
1517, 1536
|
8806, 10236
|
10346, 10519
|
8617, 8781
|
10654, 11439
|
1551, 1958
|
11457, 11478
|
11500, 12086
|
223, 234
|
320, 1045
|
1067, 1208
|
1224, 1501
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,749
| 138,488
|
31246
|
Discharge summary
|
report
|
Admission Date: [**2171-10-1**] Discharge Date: [**2171-11-19**]
Date of Birth: [**2149-1-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Transfer for tracheostomy & PEG tube placement
Major Surgical or Invasive Procedure:
Tracheostomy
PEG tube placement
Lumbar Puncture
Red blood cell transfusion
Platelet transfusion
Chemotherapy
History of Present Illness:
Mr. [**Known lastname **] is a 22yo male with PMH significant for mediastinal
germ cell tumor with airway obstruction s/p cycle 3 of cisplatin
& etoposide ([**Date range (1) 32684**])who presents for elective tracheostomy &
PEG tube placement. Patient was recently discharged from [**Hospital1 18**]
on [**9-20**] after undergoing stent placement in the left mainstem
bronchus and Y stent placement in the trachea.
.
Patient initially presented to OSH in respiratory distress and
was found to have an anterior mediastinal mass on CXR, confirmed
by CT. Patient continued to desat from 80s to low 50s and was
eventually intubated. Patient was transfered to [**Hospital1 2177**] on [**2171-7-22**]
per request of family. According to family, patient was in his
usual state of health until he started to have generalized
symptoms 6 months prior to presentation to OSH including sore
throat, cough, and respiratory symptoms. Patient had been
treated for 2 weeks for bronchitis without resolution.
.
At [**Hospital1 2177**], patient was intially intubated with double lumen ETT for
acute respiratory distress. Patient had multiple episodes of
desaturation requiring intervention with bronchoscopy for better
ETT positioning. On bronchoscopy, the anterior mass was noticed
to cause tracheal narrowing and obstruction of the mainstem
bronchi bilaterally. Patient's double lumen ETT was changed to a
single lumen on [**7-26**] for better ventilation. Course complicated
by bilateral pneumothoraces requiring bilateral chest tube
placement which were d/c'ed on [**8-24**] and [**8-25**]. Patient was
extubated on [**8-23**] but reintubation on [**8-30**] due to hypercarbic
respiratory failure. He was transferred at this time to [**Hospital1 18**]
for Y stent placement and then transferred back to [**Hospital1 2177**]. He was
extubated on [**9-21**] and initially did well but could not
adequately handle the secretions so he was taken to the OR on
[**9-27**] for tracheostomy by ENT. The procedure was technically
difficult since the Y stent was too high. He was reintubated
(nasotracheal tube) in OR with bronchoscopy to remove mucous
plugging in right middle and lower lobes.
.
He underwent an ultrasound guided biopsy of his anterior
mediastinal mass on [**7-23**]. Given elevated AFP (4093 on [**7-23**]) and
biopsy of undifferentiated carcinoma, patient was treated for
germ cell tumor with neoadjuvant cisplatin and etoposide from
[**Date range (1) 73635**]. Patient prophylaxed for TLS with alopurinol,
dexamethasone, and IV fluids. Chemotherapy complicated by
pancytopenia and neutropenic fever, requiring PRBC transfusions
on Neupogen. Cycle 2 of chemotherapy delayed due to development
of Pseudomonas sepsis and ARF. However, with stabilization,
patient underwent cycle 2 of carboplatinum and etoposide on
[**8-4**]. At the time of transfer, patient is reportedly at his
chemo-induced neutropenic nadir. However, Hct and platelets have
been stable.
.
From an ID perspective, following cycle 1 of chemotherapy,
patient was diagnosed with a VAP on [**7-28**] and was started on
vancomycin and cefepime. Both were continued with the addition
of fluconazole for neutropenic precautions following
chemotherapy. Cefepime was changed to Zosyn when patient's
sputum culture was (+) for Achromobacter on [**8-7**]. Patient then
developed an abscess in his R groin at the site of a prior line
which was I&Ded by surgery on [**8-16**] and was also the source of the
above mentioned MDR pseudomonas sepsis. Patient had pseudomonas
in blood, urine, and R groin abscess cultures. He completed a 15
day course of gentamicin and cefepime, despite nephrotoxicity as
pseudomonas in wound culture was only sensitive to Gentamicin.
Patient was then started on Vancomycin due to MRSA from R
quinton tip culture. Also started on Amikacin for Pseudomonas in
sputum and urine. Diarrhea started on [**8-17**]. C diff was negative x
3 and was thought to be secondary to chemotherapy. He was placed
on empiric Flagyl at this time. A CT scan was obtained on [**9-15**]
showing ileocecal thickening and ? typhlitis (necrotizing
enterocolitis) as well as some ? intusseception fo ascending
colon, although there was no evidence of obstruction. Patient
then had temp spike through above broad antibiotic coverage and
empiric caspofungin started on [**9-15**]. With persisting fevers
patient was continued on Cefepime, Amikacin, for pseudomonas in
sputum and urine.
.
[**Hospital **] hospital course was also complicated by ARF thought to
be secondary to pseudomonas sepsis and hypotension on [**8-8**].
Patient developed poor UOP and lasix gtt started with poor
response. Patient eventually required CVVH for volume overload
on [**8-11**] with 6L removal, and on [**8-15**] with 4L removal. R Quinton
placed in R IJ and patient was started on HD on [**8-17**]. Quinton
eventually clotted on [**8-25**] and he recent emergent dialysis
through a newly placed left femoral line. He then went to IR for
possible L quinton placement for HD, but was discovered to have
bilat DVTs in IJs which prevented placement. He eventually
responded to 140 mg IV lasix with good UOP on [**8-29**] and the L
femoral line was d/c'ed to prevent further infection. ARF
eventually resolved with normal Cr and good UOP.
Past Medical History:
# Germ cell tumor in mediastinum
- s/p 2 rounds of chemotherapy
# pancytopenia [**3-15**] chemotherapy
Social History:
Patient was a student at [**State 1558**] in
accounting. He was a non smoker, no alcohol or tobacco use.
Family History:
Non-contributory
Physical Exam:
vitals T 99.4 BP 181/107 AR 127 RR 21
vent AC FIO2 0.40 TV 400 RR 12 Peep 5
Gen: Patient awake, responsive to commands
HEENT: Nasopharyngeal tube in place
Heart: distant heart sounds, no audible m,r,g
Lungs:
Abdomen: soft, distended, NT/ND, decreased BSs
Extremities: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
[**2171-10-1**] 04:07PM PLT COUNT-411#
[**2171-10-1**] 04:07PM WBC-16.0*# RBC-3.06* HGB-9.2* HCT-29.6*#
MCV-97# MCH-30.0 MCHC-31.0# RDW-16.1*
[**2171-10-1**] 05:40PM PT-12.8 PTT-36.7* INR(PT)-1.1
[**2171-10-1**] 05:40PM PLT COUNT-402
[**2171-10-1**] 05:40PM WBC-16.3* RBC-3.13* HGB-9.6* HCT-28.2*
MCV-90# MCH-30.5 MCHC-33.9 RDW-16.4*
[**2171-10-1**] 05:40PM ALBUMIN-3.5 CALCIUM-10.2 PHOSPHATE-3.9
MAGNESIUM-1.9
[**2171-10-1**] 05:40PM LIPASE-40
[**2171-10-1**] 05:40PM ALT(SGPT)-35 AST(SGOT)-16 LD(LDH)-349* ALK
PHOS-182* AMYLASE-58 TOT BILI-0.6
[**2171-10-1**] 05:40PM estGFR-Using this
[**2171-10-1**] 05:40PM GLUCOSE-115* UREA N-22* CREAT-0.4* SODIUM-134
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-30 ANION GAP-15
[**2171-10-1**] 05:41PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0
[**2171-10-1**] 05:41PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2171-10-1**] 05:41PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
.
Infectious Disease Data:
[**2171-7-28**]: VAP/[**Month (only) **] Neuropenia (cefepime/Vanc/Fluc)
- (cefepime changed to Zosyn) for Achromobacter in sputum
[**2171-8-16**]: R Groin Abscess - MDR Pseudomonas (Gent and Cefepime)
Date?: R Quinton MRSA+ - Vancomycin
[**2171-9-22**]: Febrile Neutropenia - Vanc, Cefepime, Amikacin
- projected to complete 14day course [**10-1**], continued
indefinitely given sputum with ongoing growth
.
Microbiology Data:
[**2171-9-11**] - Sputum --> 2+GNR, 3+ Pseudomonas, 2+ MRSA, 3+
Achromobacter
- Pseudomonas
[**Last Name (un) **]: Amikacin, Tobramycin
Res: Colistin, Gent, Cefepime, Aztreonam, Pip-Tazo, Cipro,
Impenem
[**2171-9-13**]: Blood --> no growth
[**2171-9-13**]: Urine --> no growth
[**2171-9-15**]: Blood --> no growth
[**2171-9-16**]: C. Diff A+B Negative
[**2171-9-16**]: Blood --> no growth
[**2171-9-16**]: Urine --> no growth
[**2171-9-16**]: Sputum --> 1+ GNR, 3+ pseudomonas, 3+ stenotrephomonas
- Pseudomonas
[**Last Name (un) **]: Tobra, Amikacin, Gent
Res: Pip-Tazo, Cefepime, Cipro, Imi, Gent, Levo, [**Last Name (un) **]
[**2171-9-27**]: Spumtum --> 3+ MRSA, 3+ Pseudomonas, 3+ Achromobacter
- Pseudomonas
[**Last Name (un) **]: Tobra, Amikacin, Gent
Res: Aztreonam, Pip-Tazo, Cefepime, Cipro, Imi, Levo
.
.
IMAGING:
[**10-1**] CXR: IMPRESSION: AP chest compared to [**9-17**] through
[**9-20**]:
Infiltrative abnormality right mid and lower lung zones with the
suggestion of nodular coalescence as well as multiple nodules in
the left lower lobe and lingula have all increased extent since
[**9-20**] consistent with lymphoma and/or infection. The extent
of severe adenopathy in the upper mediastinum has not changed
appreciably. Stent positions, including the tracheal and left
main bronchus components, is unchanged. Tip of the upper
tracheal tube is at the level of the sternal notch,
approximately 2 cm higher than previously. Nasogastric tube is
looped in a very distended stomach.
.
[**10-2**] KUB: No evidence of obstruction is noted.
.
[**10-4**] CXR: Comparison is made to [**10-1**] and [**10-3**]
examinations. Amount of bilateral perihilar streaky opacities
is improved since most recent examination likely reflecting
resolving atelectasis or edema. Mild left lower lobe
atelectasis persists. Position of tracheostomy tube, right PICC
catheter, and anterior mediastinal widening is not significantly
changed. No evidence of pneumothorax or large effusions.
IMPRESSION: Interval improvement to perihilar opacities likely
reflect
resolving atelectasis or edema. Persistent mild left lower lobe
opacity.
.
[**2171-10-12**]. Brain MRI.
CONCLUSION: Multiple small enhancing lesions within the cerebral
hemispheres, but apparently sparing the posterior fossa
structures. Some of these may well be leptomeningeal in
location. Given the history of a malignancy elsewhere,
hemorrhagic metastatic lesions (where susceptibility is seen)
are suspected. Given the apparent negative head CT scan of
[**10-8**], it is possible that the hemorrhagic contents may not
be acute or, less likely, that they might have developed in the
relatively short interval between the two scans.
.
[**2171-10-23**]. Brain MRI.
IMPRESSION: Since [**2171-10-12**], increase in size of right parietal
leptomeningeal metastasis as well as the right frontal and left
superior parietal metastases.
No significant change in size of small metastases involving the
left centrum semiovale and the left occipital lobe.
.
[**2171-10-16**]. Total Spine MRI.
IMPRESSION: No spinal metastases seen. A focus of hyperintensity
on T1 and T2 but not on STIR likely represents focal fat or
hemangioma in the L5 vertebral body.
.
[**2171-10-23**]: Head MRI
MPRESSION: Since [**2171-10-12**], increase in size of right parietal
leptomeningeal
metastasis as well as the right frontal and left superior
parietal metastases.
No significant change in size of small metastases involving the
left centrum
semiovale and the left occipital lobe.
.
[**2171-10-31**]: CT head, neck, chest:
IMPRESSION:
1. Large mediastinal mass extending cranially through the
thoracic inlet up
to the level of the thyroid glands with thyroid invasion.
Cranial to this
level, no lymphadenopathy is seen.
2. Multiple pulmonary metastases, better evaluated on today's
chest CT.
.
IMPRESSION:
1. Interval progression in size of innumerable lung metastases.
2. Stable anterior mediastinal mass and hilar adenopathy.
3. Decreased posterior mediastinal mass component on the left.
.
IMPRESSION: Marked interval progression in size of all
metastatic lesions
since MRI of [**2171-10-23**]. The largest lesions
demonstrate internal
hemorrhage and surrounding vasogenic edema.
.
[**2171-11-7**]:
MRI Head
IMPRESSION:
New large hemorrhages with surrounding edema centered around the
previously
seen enhancing lesions. There is minimal mass effect upon the
right lateral
ventricle, but there is no subfalcine herniation.
The above findings likely represent hemorrhage related to tumor
necrosis
following radiation therapy. Extensive hemorrhage into
abscesses is thought
to be a much less likely possibility.
.
[**2171-11-7**]: Non-contrast head CT
MPRESSION:
1. No significant interval change from MRI. Hemorrhage and
surrounding edema
within multiple metastatic lesions, again likely related to
post-radiation
tumoral necrosis.
2. Mild mass effect on the right lateral ventricle but no
evidence of
herniation.
.
[**2171-11-10**]: Non-contrast head CT
IMPRESSION:
1. No evidence of significant interval change.
2. Multiple hyperdense foci with surrounding edema consistent
with metastatic
hemorrhagic parenchymal lesions.
3. Mild mass effect that is stable exerted on the right lateral
ventricle.
.
[**2171-11-12**]:
Non-contrast Head CT
MPRESSION: No significant change compared to prior study, with
multiple
hyperdense masses, with surrounding edema, consistent with
metastatic lesions.
Relatively stable-appearing mass effect on the right lateral
ventricle with
mild leftward shift.
[**2171-11-12**]:
Neck CT
MPRESSION: No significant change seen compared to prior study,
with large
mediastinal mass again identified. The SVC is narrowed as
before.
[**2171-11-12**]:
Chest CT
IMPRESSION:
1. No significant change compared to prior study, with large
anterior
mediastinal mass again identified, abutting the SVC, which
appears slightly
narrowed, however, appears to remain patent.
2. Innumerable pulmonary metastases again identified. Hilar
lymphadenopathy
also again seen.
[**2171-11-13**]: Non-contrast head CT
MPRESSION: No significant change in multiple hyperdense lesions
with
surrounding edema most consistent with metastatic disease.
Stable leftward
shift of the midline and subfalcine herniation.
[**2171-10-9**]. Sputum.
GRAM STAIN (Final [**2171-10-9**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2171-10-12**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH.
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
AMIKACIN-------------- 16 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- =>4 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S =>16 R
IMIPENEM-------------- =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- =>16 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 64 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Mr. [**Known lastname **] is a 22 yo male with PMH significant for a mediastinal
germ cell tumor s/p tracheostomy and PEG tube placement, who was
transferred to the oncology service, underwent radiation therapy
and chemotherapy, but unfortunately expired on [**2171-11-19**].
.
#. Respiratory failure: Respiratory distress secondary to
anterior mediastinal mass compressing the trachea. He was first
intubated in [**Month (only) **] and since then has been intubated/extubated
several times. He was recently discharged from [**Hospital1 18**] after a Y
stent was placed and extubated and did well for 1 week; he was
subsequently reintubated at [**Hospital1 2177**] due to increased secretions and
transferred to [**Hospital1 18**] for tracheostomy. He tolerated the
procedure well on [**10-3**] and has been stable post- tracheostomy.
He tolerated SBT and was placed on tracheal mask at 5pm on [**10-4**]
and tolerated well. Propofol was been weaned. He was put on
pressure support due to thick respiratory secretions, however
was weaned to trach mask after 5 days.
.
He was transferred to the [**Hospital Unit Name 153**] for increasing respiratory
secretions. He was found to have a MRSA and Pseudomonas PNA.
He was treated with vancomycin, cefepime, and tobramycin. He
completed a 3 week course of these antibiotics, finished on
[**11-4**]. He was initially requiring mechanical ventillation but
then tolerated trach collar mask after a few days.
.
Patient continued on trach collar during his stay, with a stable
oxygen requirement of 35-40%. He completed a course of treatment
for MRSA and pseudomonas pneumonia.
.
Internventional pulmonology downsized the patient's tracheostomy
during the last week of [**Month (only) **].
.
During the week prior to his death, patient was noted to have
worsening right lower lobe infiltrates, likely representing a
new pneumonia. Vancomycin, cefepime, tobramycin and flagyl were
all re-started.
.
#. Germ cell tumor: Patient was found to have an anterior
mediastinal mass consistent with a germ cell tumor. s/p 3 cycles
of etoposide & cisplatin ([**Date range (1) 24155**]). A tissue biopsy was
obtained during tracheostomy. He began XRT to chest wall on
[**10-16**]. He was found to have small brain metastases, but no
metastases to the spine. L Spine MRI showed no metastases in
the spine. An LP on [**2171-10-18**] was negative for malignant cells. A
repeat Brain MRI showed an increase in size of brain metastases
in just one week.
.
He completed a course of whole brain ([**6-15**]) and chest (15/15)
radiation therapy.
He then underwent another course of chemotherapy on [**2171-11-7**].
.
Patient was noted to have increasing weakness on left side of
body, with tingling feeling. A CT scan done revealed edema and
hemorrhage of known masses in the right parietal lobe. On
[**11-13**], patient had abrupt decline in his neurological
status, and resultant left sided total paralysis. A stat head CT
was completed at that time, and neurosurgery evaluated the
patient. It was felt that there would be no benefit in
neurosurgical intervention. The patient's platelet count was
monitored closely and he was transfused for a goal of 100 to
avoid further bleeding. Keppra was initiated and continued as
seizure prophylaxis. Steroids were also initiated and increased
at the time of the neurological decline.
.
# ARF. Renal function stable after initial bump in creatinine.
Creatinine had increased from 0.4 to 1.0 on [**10-10**]. Cause of
renal failure is unclear. [**Name2 (NI) **] is not pre-renal as FENa is
1.6. Renal sono showed renal parenchemal disease, but no
hydrophrosis. Patient has good urine output. Urine eos are
negative. It is possible that this is a drug toxicity from
chemotherapy (was given cisplatin and carboplatin) or that this
is related to IV contrast for abdominal CT. However, ARF
developed weeks after last chemo dose and 4 days after getting
contrast on [**10-6**].
.
# Anxiety and Depression: Significant anxiety per family. This
was also documented in his recent discharge summary from [**Hospital1 18**].
Depression was noted by family and staff, and patient also
related this. Psychiatry followed along closely and assisted
with management of his anxiety and insomnia.
.
# Tachycardia/HTN: Longstanding problem for patient. This was
thought to be due to underlying agitation, fevers, and illness.
.
# Anemia: Patient noted to have anemia, felt to be secondary to
his chemotherapy and chronic disease. He received several
transfusions to help with his anemia.
.
# Thrombocytopenia: Patient developed thrombocytopenia after his
chemotherapy, and was transfused frequently to keep his platelet
count around 100, to avoid any further bleeding from his brain
metastases.
.
# FEN: Given tube feeds via PEG. Was evaluated by speech and
swallow and found to tolerate solids and thin liquids. In the
days prior to his death, he was made NPO given that he appeared
to be aspirating and his mental status had declined.
.
# On [**11-14**], after extensive discussion with the patient's
mother and father, decision was made to make the patient
DNR/DNI, and frequently address goals of care depending on the
patient's progress. Social work was also involved to help
facilitate discussions and ensure that both of the patient's
parents' points of view were heard and addressed.
.
Sadly, the patient's status continued to deteriorate, and he
began to develop fevers, worsening respiratory, and mental
status. On the morning of [**11-18**], the patient's condition
had further deteriorated, and the decision was made to initiate
a morphine drip. The patient's father desired that antibiotics
and intravenous fluids be continued, and these wishes were
respected. Patient was made comfortable and denied any pain.
.
Overnight on [**11-18**], patient passed away with his family at
the bedside.
Medications on Admission:
Ipratropium Bromide MDI 4 PUFF IH QID
Acetaminophen 650 mg PO Q6H:PRN
Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Albuterol 10 PUFF IH Q4H
Lorazepam 1-3 mg IV Q1H:PRN anxiety
Albuterol 10 PUFF IH Q2H:PRN
Metoprolol 12.5 mg PO TID
Amikacin 1100 mg IV Q36H
Methadone HCl 20mg PO Q8H
CefePIME 2gm IV Q8H
Miconazole Powder 2% 1 Appl TP TID
Diazepam 10mg PO BID
Nephrocaps 1 CAP PO DAILY
Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
Nystatin Oral Suspension 5 ml PO QID
Haloperidol 5 mg IM Q4H:PRN agitation
Olanzapine 5 mg PO DAILY
Promethazine HCl 6.25 mg IV Q6H:PRN
Insulin SC Sliding Scale
Vancomycin 1.25gm IV Q 12H
.
Allergies: NKDA
Discharge Medications:
None.
Discharge Disposition:
Expired
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Metastatic Germ Cell Tumor.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
[
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"344.9",
"519.19",
"431",
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"482.1",
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"288.03",
"379.41",
"V09.0",
"191.9",
"787.01",
"197.0",
"482.41",
"E933.1",
"707.05",
"276.2",
"285.9",
"785.0",
"518.81",
"164.2",
"253.6"
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icd9cm
|
[
[
[]
]
] |
[
"99.21",
"38.93",
"96.71",
"31.1",
"97.23",
"88.91",
"01.13",
"33.21",
"99.05",
"03.31",
"96.6",
"99.04",
"96.05",
"92.29",
"99.25",
"43.11",
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] |
icd9pcs
|
[
[
[]
]
] |
22122, 22188
|
15528, 21397
|
362, 473
|
22259, 22269
|
6395, 15505
|
22326, 22459
|
6036, 6054
|
22092, 22099
|
22209, 22238
|
21423, 22069
|
22293, 22303
|
6069, 6376
|
276, 324
|
501, 5771
|
5793, 5898
|
5914, 6020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,649
| 190,802
|
28885
|
Discharge summary
|
report
|
Admission Date: [**2158-8-25**] Discharge Date: [**2158-9-1**]
Date of Birth: [**2082-7-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
+ ETT/CP
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->RCA, OM) [**2158-8-25**]
Past Medical History:
HTN
^chol.
LLL lung ca w/ mets
CRI
Social History:
The patient is married and has five children. He currently lives
with his family. He is a former teacher and denies any history
of
alcohol use. He has never smoked and has no known exposure to
asbestos.
Family History:
His family history is unremarkable with regards to pulmonary,
cardiac, or oncological history.
Physical Exam:
On physical examination, he is in no apparent distress. His
blood pressure is 140/52 with a heart rate of 65. He is
breathing
comfortably at 12 respirations per minute and is saturating 98%
on room air. His mucous membranes are moist and his jugular
venous pressure is estimated to be 7 cm. His lungs are clear to
auscultation bilaterally without appreciable crackles or
rhonchi.
His heart is regular in rate and rhythm and there are no
appreciable murmurs. His abdomen is soft and nontender without
guarding or distension. His lower extremities are warm and
well-perfused and have no evidence of edema. Exercise oximetry
traveling up three flights of stairs reveals a stable room air
saturation of 99%.
Pertinent Results:
[**2158-8-29**] 06:50AM BLOOD WBC-11.1* RBC-3.55* Hgb-10.4* Hct-31.1*
MCV-88 MCH-29.3 MCHC-33.5 RDW-14.0 Plt Ct-185#
[**2158-8-29**] 06:50AM BLOOD Glucose-91 UreaN-25* Creat-1.4* Na-140
K-4.1 Cl-100 HCO3-30 AnGap-14
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2158-8-27**] 8:01 AM
FINDINGS: Comparison is made to prior study from [**2158-8-26**].
The median sternotomy wires and the right IJ cordis is unchanged
in position. There is persistent cardiomegaly. There is
unchanged right upper lobe consolidation and left retrocardiac
opacity. Overall there has been no interval change.
Cardiology Report ECHO Study Date of [**2158-8-25**] Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
Left-to-right shunt across the interatrial septum at rest.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Focal calcifications
in ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
Conclusions:
PRE-BYPASS:
1. A patent foramen ovale is present. A left-to-right shunt
across the
interatrial septum is seen at rest. Bubble study performed with
release of
valsalva, reversal of shunt, with right to left flow noted.
2. Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are complex (>4mm) atheroma in the aortic arch. There
are complex
(>4mm) atroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. Mild (1+) mitral regurgitation is seen.
POST- BYPASS: The pt is receiving an infusion of phenylephrine
and is being A paced
1. Biventricular systolic function is preserved
2. Aorta is intact post decannulation
3. Other changes are unchanged
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2158-8-28**] 08:47.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2158-8-25**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively he was taken to the
intensive care unit for monitoring. On postoperative day one.
Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Aspirin,
a statin and beta blockade were resumed. His drains and wires
were removed without complication. On postoperative day three,
he was transferred to the step down unit for further recovery.
He was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. He had some mild
orthostasis which resolved with adjustment of his blood pressure
medications and discontinuation of his lasix. Mr. [**Known lastname **] continued
to make steady progress and was discharged home on postoperative
day seven. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist
and his primary care physician as an outpatient.
Medications on Admission:
Lipitor 20 mg PO daily
Cartia 180 mg PO daily
Lisinopril 30 mg PO daily
Terazosin 1 mg PO daily
ASA 325 mg PO daily
Plavix 600 mg PO x 1
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(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 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Lipitor 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Terazosin 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Good
Discharge Instructions:
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.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 10543**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Completed by:[**2158-9-8**]
|
[
"403.91",
"458.0",
"518.0",
"997.3",
"162.5",
"745.5",
"440.0",
"272.0",
"414.01",
"196.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"36.12",
"99.04",
"39.61",
"34.04",
"39.64"
] |
icd9pcs
|
[
[
[]
]
] |
6283, 6334
|
3984, 5145
|
328, 378
|
6402, 6409
|
1511, 3961
|
6687, 6933
|
674, 771
|
5332, 6260
|
6355, 6381
|
5171, 5309
|
6433, 6664
|
786, 1492
|
280, 290
|
400, 437
|
453, 658
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,299
| 151,582
|
32104
|
Discharge summary
|
report
|
Admission Date: [**2195-7-22**] Discharge Date: [**2195-7-29**]
Date of Birth: [**2178-7-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p stab wound assault
Major Surgical or Invasive Procedure:
[**2195-7-22**] Exploratory laparotomy and repair of diaphragmatic
injury; left chest thoracosotmy
History of Present Illness:
16 yo male s/p stab wound assault to left chest. He was taken to
an area hospital and later transfered to [**Hospital1 18**] for further care.
Past Medical History:
Denies
Social History:
In custody of Department of Youth Services
Family History:
Noncontributory
Pertinent Results:
[**2195-7-22**] 11:30PM TYPE-ART PO2-378* PCO2-41 PH-7.31* TOTAL
CO2-22 BASE XS--5 INTUBATED-INTUBATED
[**2195-7-22**] 11:30PM GLUCOSE-159* LACTATE-1.4 NA+-141 K+-3.6
CL--120*
[**2195-7-22**] 11:30PM HGB-10.1* calcHCT-30
[**2195-7-22**] 10:48PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2195-7-22**] 10:30PM UREA N-8 CREAT-1.0
[**2195-7-22**] 10:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2195-7-22**] 10:30PM GLUCOSE-192* LACTATE-1.7 NA+-143 K+-4.0
CL--112 TCO2-23
[**2195-7-22**] 10:30PM WBC-19.1* RBC-4.11* HGB-13.1* HCT-37.5*
MCV-91 MCH-31.9 MCHC-34.9 RDW-13.4
[**2195-7-22**] 10:30PM PLT COUNT-290
[**2195-7-22**] 10:30PM PT-14.7* PTT-23.8 INR(PT)-1.3*
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: CT abd and pelvis w/p.o. and IV contrast, please
evaluate fo
Field of view: 43 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
16 year old man POD4 s/p L diaphragmatic laceration repair
secondary to stab wound
REASON FOR THIS EXAMINATION:
CT abd and pelvis w/p.o. and IV contrast, please evaluate for
intraabdominal injury
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: CT abdomen and pelvis.
INDICATION: Status post stab wound to left upper quadrant.
Evaluate for intra-abdominal injury.
COMPARISON: No old CT available for comparison.
TECHNIQUE: CT of abdomen and pelvis was performed with axial
images taken from the lung bases to the symphysis pubis. Oral
and IV contrast was administered. Reconstructions were performed
in the coronal and sagittal planes.
CT ABDOMEN FINDINGS: Some bowel is situated in the left
hemithorax adjacent to the heart. Note is made of a left pleural
effusion and associated atelectasis. Some right basilar
atelectasis is also noted. The left hemidiaphragm is raised
which may represent paresis in this patient status post left
diaphragmatic rupture and repair.
Within the abdomen, the liver is visualized and is normal. The
gallbladder is normal. The spleen is visualized and is normal.
The stomach is located anterior to the spleen and extends up
close to the left ventricle. Some contrast is identified within
the stomach. Just posterior to the stomach, there is some fluid
which superiorly appear closely adherent to the stomach but
inferiorly appears to represent a separate fluid collection
containing some air. This is located just anterior to the
inferior pole of the spleen. It measures approximately 8.6 cm in
transverse x 2.2 cm in AP diameter. At this site, on series 2,
image 9, it is technically very difficult to percutaneously
drain this fluid. This fluid is situated just superior to the
pancreas. Some peripancreatic fluid may be a postoperative
result; serial monitoring of the amylase is advised.
The adrenals and kidneys are normal. The pancreas is normal.
There is a significant amount of free intraperitoneal air, which
may be secondary to both the trauma of the stab wound and the
surgery. The small bowel is diffusely dilated with some of the
small bowel loops measuring up to 3.5 cm. There is no point of
transition noted. The colon is also air filled.
No significant retroperitoneal lymphadenopathy. No significant
intraperitoneal fluid.
CT OF PELVIS FINDINGS: Some free fluid is seen in the pelvis.
The bladder is normal.
Bony windows show no definite fractures.
Multiplanar reconstructions were essential in depicting the
anatomy and identifying the pathology.
IMPRESSION:
1. No evidence of any solid organ injury in a patient status
post stab injury to left upper quadrant with status post repair
of left diaphragmatic rupture.
2. Fluid collection located just superior to the pancreas; it is
an difficult site of access for percutaneous drainage. If
clinically indicated consideration to endoscopic transgastric
drainage should be made.
3. Small bowel dilation consistent with ileus.
4. Free intraperitoneal air status post surgery.
5. Free fluid in the pelvis.
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN
Reason: please evaluate for cardiopulm process
[**Hospital 93**] MEDICAL CONDITION:
16 year old man with SW to chest, s/p ex lap & diaphragmatic
repair, now requring non-rebreather
REASON FOR THIS EXAMINATION:
please evaluate for cardiopulm process
HISTORY: Status post stab wound to chest with diaphragmatic
rupture repair requiring increased O2 requirements.
Comparison is made to [**7-26**] and [**7-27**] examinations.
UPRIGHT PORTABLE CHEST RADIOGRAPH
Left lower lobe atelectasis with elevation of left hemidiaphragm
and adjacent effusion may be minimally improved since most
recent radiograph with no new consolidations identified. Right
costophrenic angle is not included on current film. There is
unchanged gaseous prominence of the bowel which may suggest
postoperative ileus.
Cardiology Report ECG Study Date of [**2195-7-28**] 12:31:14 AM
Sinus tachycardia
ST-T wave changes are nonspecific
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
139 124 88 286/424 34 6 0
Brief Hospital Course:
He was admitted to the Trauma Service and taken directly to the
operating room form the Emergency room for an exploratory lap,
repair of diaphragm and left chest thoracostomy. There were no
intraoperative complications. Postoperatively he did have pain
control issues; he was initially on PCA Dilaudid and was later
transitioned to oral narcotics. he did not have relief with the
oral medications and required intermittent IV Dilaudid for
breakthrough pain. He was very slow to mobilize postoperatively,
often refusing to get out of bed and using the incentive
spirometer. Despite continuous encouragement and reinforcement
on the importance of getting out of bed he remained reluctant to
do so.
There was a trigger event called several days prior to his
discharge where he desaturated in the high 80's; chest xray
revealed atelectasis and an effusion. He was treated for a
pneumonia and initially required supplemental oxygen. He was
eventually weaned from the oxygen and became more compliant with
getting out of bed and using the incentive spirometer.
His left chest thoracostomy was removed without any
complications; his abdominal wound staples were intact and will
be removed next week when he returns to clinic. Despite a fair
appetite he was tolerating a regular diet; no bowel movement at
time of this dictation but abdominal exam was benign. He was
agreeable to oral laxatives but adamantly refused rectal
laxatives on multiple occasions. He and his parents were given
explicit instruction on a bowel regimen and were told to call
the trauma clinic if no bowel movement in the next 1-2 days.
He was evaluated by Physical therapy and deemed safe for
discharge to home. He is being discharged to home with skilled
nursing services.
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
6. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO TID (3
times a day): hold for loose stools.
Disp:*qs ML(s)* Refills:*2*
7. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as
needed for constipation: take by [**7-30**] if no bowel movement.
Disp:*15 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Southeastern MA
Discharge Diagnosis:
s/p Stab wound assault
Diaphragmatic laceration
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Because of your injuries and recent surgery it is expected that
you will have some discomfort that will subside over the next
week or so.
You should take your medications as prescribed and complete the
entire antibiotic course.
If you do not have a bowel movement in the next 1-2 days please
call Trauma Surgery, [**Telephone/Fax (1) 600**] to inform us.
It is important that you walk at least 4-5 times per day to
avoid some of the most common complications of inactivity such
as pneumonia, blood clots, constipation and skin breakdown.
Return to the Emergency room for fevers, chills, increased
shortness of breath, redness/drainage from your incision,
increased abdominal pain and/or any othe symptoms that are
concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in Surgery Clinic next week for
removal of your staples; call [**Telephone/Fax (1) 1864**] for an appointment.
Completed by:[**2195-8-5**]
|
[
"560.1",
"E966",
"997.3",
"997.4",
"922.1",
"486",
"868.09",
"862.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.82",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
8364, 8414
|
5823, 7567
|
336, 437
|
8516, 8523
|
751, 1661
|
9308, 9494
|
715, 732
|
7590, 8341
|
4850, 4947
|
8435, 8495
|
8547, 9285
|
274, 298
|
4976, 5800
|
465, 609
|
631, 639
|
655, 699
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,667
| 134,025
|
27117
|
Discharge summary
|
report
|
Admission Date: [**2159-1-29**] Discharge Date: [**2159-1-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Cough, Fever, Hypotension, Tachycardia
Major Surgical or Invasive Procedure:
Central Venous Access, [**2158-11-29**]
History of Present Illness:
89 year old male with recent gastrointestinal bleeds attributed
to gastric ulcer, status post mechanical aortic valve
replacement on Coumadin, chronic kidney disease, history of
NSTEMI in [**7-11**], who presented from [**Hospital **] rehab with fevers and
anemia. Of note, patient has a history of GI bleeds of unknown
etiology, so receives periodic transfusions at [**Hospital 100**] Rehab.
Earlier this week, he was noted to have HCT of 21. He was given
2u PRBCs over 2 days on [**1-23**] and [**1-24**]. On [**1-28**] he had a T
101.8 with dry, non productive cough. On morning of admission, T
99.6, HR 96 BP 80/60 RR 24. 95% on RA. He became tachycardic
with HR 147 and was transferred to [**Hospital1 18**].
.
In the ED, initial vs were: T 97.9 P 147 BP 89/57 RR 32 O2 99%
on RA. Patient became febrile to T 101, BP in 70s, HR in 150s.
This persisted for 2 hours despite 1.5L IV fluids. There was
some delay in transfusing the patient given crossmatching
requirements. Once the patient received 1u PRBCs, BP normalized,
as high as 160s. HR came down to 100s. Patient was notably
guaiac negative.
A CT Abdomen was performed to eval for mesenteric ischemia,
which was negative. The patient was given Vanc, Levo, Flagyl
empirically with concerns for sepsis.
A R IJ was placed in the ED.
.
After receiving 1.5L IVFs and 1u PRBCs, patient sounded slightly
fluid overloaded on exam. He was given 40mg IV lasix, and put
out 400cc urine.
.
Vitals prior to transfer were HR 105, BP 117/54 RR 22 O2 100%
on 5L nc.
.
On the floor, patient says that he feels weak. Denies pain. But
cannot provide further history.
.
Review of systems:
(+) Per HPI
(-) 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.
Past Medical History:
# Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped
due to hemolytic anemia, previously on prednisone [**11-9**]
# hx recent GI bleeds: colonoscopy [**9-9**]: noted normal colon,
hemorrhoids
# Aortic mechanical valve, last INR 2.0
# GERD: EGD [**7-11**] with non-bleeding ulcers in esophagus and
stomach
# Anemia from GI bleed of gastric ulcer vs. hemolytic anemia
from AVR
# CKD 1.6-2.0
# CAD s/p NSTEMI
# h/o likely diastolic CHF on diuretics
# Hyperlipidemia
# Hypertension
# Depression since death of his brother
# Prostate ca- s/p radiation
# Bladder/bowel incontinence
# Right lateral malleolus stage 1 pressure ulcer
Social History:
He was born in NY and has been a book binder all of his life. he
moved to [**Location (un) 86**] to be closer to his son. [**Name (NI) **] does not smoke or
drink currently. He was just transferred to [**Hospital 100**] rehab, but
also lived at the [**Hospital3 **]. His brother recently died. He
requires a significant degree of assistance in all his ADLs and
IADLs.
Family History:
Non contributory.
Physical Exam:
Vitals: T: 102.1 BP: 93/60 P:99 R: 30 O2:99% on 4L
General: A+Ox1. Mouth breathing, intermittently at rate of 40,
though denies dyspnea.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, though difficult to assess given
R IJ, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission:
[**2159-1-29**] 11:50AM BLOOD WBC-1.7*# RBC-1.86*# Hgb-6.5* Hct-21*
MCV-115*# MCH-34.8*# MCHC-30.4* RDW-15.6* Plt Ct-102*#
[**2159-1-29**] 11:50AM BLOOD PT-27.6* PTT-52.0* INR(PT)-2.7*
[**2159-1-29**] 08:16PM BLOOD Fibrino-462*
[**2159-1-29**] 08:16PM BLOOD Ret Man-5.6*
[**2159-1-29**] 08:16PM BLOOD Glucose-138* UreaN-27* Creat-1.5* Na-139
K-3.5 Cl-105 HCO3-23 AnGap-15
[**2159-1-29**] 11:50AM BLOOD ALT-11 AST-28 LD(LDH)-283* CK(CPK)-22*
AlkPhos-36* TotBili-0.7
[**2159-1-29**] 11:50AM BLOOD cTropnT-0.02*
[**2159-1-29**] 08:16PM BLOOD Calcium-7.2* Phos-3.4 Mg-1.7
[**2159-1-29**] 11:50AM BLOOD Hapto-<5*
[**2159-1-30**] 03:22AM BLOOD TSH-4.8*
[**2159-1-29**] 12:03PM BLOOD Glucose-113* Lactate-1.7 Na-137 K-3.4*
Cl-108 calHCO3-23
Labs on Discharge:
[**2159-1-31**] 04:21AM BLOOD WBC-3.5* RBC-2.26* Hgb-7.9* Hct-24.8*
MCV-109* MCH-34.7* MCHC-31.7 RDW-19.4* Plt Ct-101*
[**2159-1-31**] 04:21AM BLOOD PT-34.9* PTT-82.8* INR(PT)-3.6*
[**2159-1-31**] 04:21AM BLOOD Glucose-80 UreaN-28* Creat-1.4* Na-144
K-3.0* Cl-111* HCO3-21* Calcium-6.9* Phos-2.7 Mg-1.8
[**2159-1-31**] 01:07PM BLOOD Type-ART pO2-115* pCO2-34* pH-7.42
calTCO2-23
Microbiology:
Blood Cx: pending
Urine Cx: pending
Studies: Interstitial abnormality in the right lung including a
central bronchial cuffing and basal septal thickening is
probably pulmonary edema though heart is normal size and there
is no pleural effusion. The patient has had a cardiac valve
replacement, probably aortic.
Brief Hospital Course:
89 yom with history of GI bleeds, presenting with anemia,
hypotension, tachycardic episode in the ED, concerning for
septic shock.
.
# Hypotension, Tachycardia: patient had SBPs in 70's, with HR in
150's, along with documented fever at rehab and in the ED,
initially concerning for septic shock. The most likely source
was thought to be pneumonia given tachypnea and fevers; however,
there was no clear initial infiltrate on chest x-ray. CT abdomen
was performed evaluating for additional source of infection but
was negative. Patient was started on Vancomycin and Zosyn for
HCAP and Tamiflu for possible H1N1 infection. A nasal pharyngeal
aspirate was obtained for flu and was negative. Tamiflu was
discontinued. Urine legionella Ag was also obtained and was
negative. Cardiac enzymes were cycled, trended upward and
rapidly declined without MB fraction change, attributed to
likely demand ischemia. Patient received 1 unit of PRBC's for
demand ischemia. Patient was transiently started on pressors for
BP support but was quickly weaned off on day 2. By day 3, BP was
stable 110's and patient remained in NSR in 80's. ECHO was
performed to evaluate Aortic Valve which was unremarkable.
.
# Macrocytic Anemia: HCT 21. Patient has h/o of melanic stools,
though with recent Colonoscopy, EGD, and capsule study without
obvious source. Guaiac negative in the ED. Other etiologies that
were entertained included hemolysis [**3-6**] mechanical valve vs.
auto-immune process, vs. MDS. Initial haptoglobin was < 5.
Patient also had h/o hemolysis [**3-6**] amoxacillin. Patient
initially presented with pancytopenia which was felt to result
from MDS. SPEP, UPEP were performed. Coombs test was performed
and was possitive, suggesting auto-immune process.
.
# Aortic mechanical valve: patient on coumadin as outpatient
which was held for concern of bleeding. At the time of
discharge, INR remained therapeutic and Coumadin remained held.
.
# Respiratory status: Patient hypoxic in the ED in the setting
of IV fluids and PRBCs. CXR was consistent with mild fluid
overload. Patient was tachypneic, though denied discomfort. JVP
not obviously elevated, no crackles on exam. ABG in ED within
normal limits. Patient was diuresed with several boluses of IV
lasix with good output. Patient maintained good oxygen sats and
was saturating at 96% on RA at the time of discharge.
.
# CAD s/p NSTEMI: CP free. However hypotension and tachycardia
could be in the setting of new ischmic event. Cardiac enzymes
were cycled. Troponins initially increased but quickly
decreased not accompanied by MB fraction. This was thought to
have resulted from demand ischemia. Patient was continued on
outpatient statin and metoprolol.
.
Medications on Admission:
1. Simvastatin 80 mg po daily
2. Metoprolol Tartrate 12.5 mg po daily
3. Omeprazole 20 mg po daily
4. Vitamin D 1,000 unit po daily
5. Calcium Carbonate 650 mg (1,625 mg) po bid
6. Ferrous Sulfate 325 mg (65 mg Iron) po daily
7. Bisacodyl PR pod
8. Warfarin 3.5 mg po daily
9. Tylenol 325mg po q6h PRN pain, fever
10. Synthroid 50mcg po daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for constipation.
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 5 days.
10. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
- pneumonia
Secondary
- autoimmune hemolytic anemia (Coomb's +)
Discharge Condition:
Patient was alert and oriented, conversant, comfortable,
saturating at 96% on RA.
Discharge Instructions:
Mr. [**Known lastname 66590**],
You were admitted to the hospital for low blood levels, fever
and hypotension concerning for a serious infection. We do not
believe that you are bleeding from anywhere at this time.
Instead, we believe your blood levels may be low as a result of
an auto-destructive process. We also discovered that you likely
have a lung infection. This will require several days of IV
antibiotics.
Followup Instructions:
You will continue your treatment at a rehab facility. After
discharge from the rehab facility, you should follow up with
your primary care provider for further evaluation.
|
[
"V58.61",
"284.1",
"486",
"403.90",
"412",
"428.33",
"283.0",
"785.52",
"V10.46",
"038.9",
"585.9",
"428.0",
"995.92",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9600, 9666
|
5462, 8167
|
301, 342
|
9783, 9867
|
3959, 3964
|
10332, 10507
|
3317, 3336
|
8561, 9577
|
9687, 9762
|
8193, 8538
|
9891, 10309
|
3351, 3940
|
2000, 2254
|
223, 263
|
4732, 5439
|
370, 1981
|
3978, 4713
|
2276, 2915
|
2931, 3301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,808
| 125,352
|
37865
|
Discharge summary
|
report
|
Admission Date: [**2180-9-30**] Discharge Date: [**2180-10-10**]
Date of Birth: [**2105-11-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain radiating to upper back
Major Surgical or Invasive Procedure:
[**10-2**]: Emergency coronary artery bypass graft x4: Left internal
mammary artery to left anterior descending artery using the
off-pump technique, and saphenous vein grafts to obtuse marginal
1, 2 and posterior descending artery using bypass with a
beating heart.
Endoscopic harvesting of the long saphenous vein.
[**9-30**] cardiac catheterization
History of Present Illness:
74 yo male who developed chest pain radiating to back at 5 PM on
night prior to admission to OSH. Pt took Tums and woke up the
next morning with worsening chest pain. Pt was given 2 ASA and
wife called 911. At OSH, pt was noted to
have new BBB. He was placed on heparin and NTG and tx'd to [**Hospital1 18**]
for cath. CTA was done to rule out diseection, trop 0.31 on
admission, increased to 0.79. Pt was loaded with 300 mg plavix.
Cath revealed 50% LM dz, severe 3 V CAD. Pt has hx 10 years of
chest pain, relieved with rest and heat.
Past Medical History:
Gastric Esophogeal Reflux Disease, multiple pneumonias, sbestos
exposure, hyperlipidemia, hypertension
Social History:
Lives with: wife
Occupation:retired
Tobacco: 20pack/years, quit 30 years ago
ETOH: none
Family History:
Family History:none
Race: Caucasian
Physical Exam:
Pulse: 70 B/P: 94/56 Resp:20 O2 sat: 95%
Height: 5ft6" Weight: 165lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: sheath Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: x Left: x
Pertinent Results:
[**2180-9-30**] 08:10AM PT-12.2 PTT-25.5 INR(PT)-1.0
[**2180-9-30**] 08:10AM PLT COUNT-232
[**2180-9-30**] 08:10AM WBC-14.3* RBC-5.88 HGB-16.6 HCT-49.2 MCV-84
MCH-28.3 MCHC-33.8 RDW-14.6
[**2180-9-30**] 08:10AM TRIGLYCER-300* HDL CHOL-34 CHOL/HDL-8.1
LDL(CALC)-183*
[**2180-9-30**] 08:10AM ALBUMIN-4.4 CHOLEST-277*
[**2180-9-30**] 08:10AM CK-MB-13* MB INDX-9.6* cTropnT-0.31*
[**2180-9-30**] 08:10AM ALT(SGPT)-53* AST(SGOT)-42* LD(LDH)-182
CK(CPK)-135 ALK PHOS-52 TOT BILI-0.6
[**2180-9-30**] 08:10AM GLUCOSE-141* UREA N-21* CREAT-1.2 SODIUM-139
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
[**2180-9-30**] 01:53PM %HbA1c-6.3*
[**2180-9-30**] 02:11PM CK-MB-33* MB INDX-10.4* cTropnT-0.79*
===============================================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in ascending aorta. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Emergency CABG for unremitting ischemia, s/p failed IABP
placement.The patient was planned to have off-pump CABG because
of extensive aortic atherosclerosis. The patient did not
tolerate it and failed with severe ischemia demonstrated by
hypotension, bradycardia and low Sp-O2. CABG proceeded on-pump.
Prior to the failed attempt at OP-CABG:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 - 50%). Septal, anterior septal and apical segments
are hypokinetic.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the ascending aorta.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present.
The mitral valve leaflets are mildly thickened.
There is no pericardial effusion.
Post-CPB:
The patient is on low-dose Epi and NTG, and is AV-Paced.
Preserved biventricular systolic fxn. EF remains 45 - 50%. Good
RV fxn.
Trace MR, trace AI.
Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2180-10-2**] 05:02
========================================================
Brief Hospital Course:
He was transferred from an outside facility for emergent cardiac
catheterization and chest CTA on [**9-30**]. Cardiac cath revealed
LMain and 3VD with preserved EF. He ruled in for non ST
elevation myocardial infarction with peak troponin 0.57 and CTA
revealed no aortic dissection or PE. Additionally he was noted
to have incarcerated hernia vs bowel obstruction and a general
surgery consult was called. His hernia was manually reduced.
Post cath he continued to have chest pain, the cardiology team
attempted an intra aortic balloon pump placement but were
unsucessful and he was brought emergently to the operating room
for coronary artery bypasss grafting. Please see OR report for
details. He tolerated the operation and was transferred to the
cardiac surgery ICU for hemodynamic managment. Once in the ICU
his cardiac indicies were poor and his inotropes were changed
from Epinephrine to Milrinone, he stabilized but was kept
sedated over the next 36 hours. On POD2 diuretics were begun and
he was extubated, following extubation his inotropes were weaned
to off. He became febrile and sputum gm stain revealed gm
poitive cocci and rods and negative rods, he was started on
appropriate antibiotics. He remained in the ICU to monitor his
pulmonary status. On POD5 he was transferred to the stepdown
floor for continued post-op care. The remainder of his hospital
stay was uneventful and on POD day eight he was ready for
discharge to rehab for completion of antibiotic course for
treatment of pneumonia.
Medications on Admission:
Tums
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): completes [**10-17**].
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Ceftazidime 1 gram Recon Soln Sig: One (1) gram Intravenous
Q8H (every 8 hours): completes [**10-17**] and then picc can be
removed .
12. PICC line
per protocol
please remove after IV antibiotics complete [**10-17**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
coronary artery disease s/p emergent CABG
Non ST elevation myocardial infarction
Acute systolic heart failure
Inguinal and ventral hernias manually reduced postoperatively
Left lower lobe pneumonia
Gastric Esophageal Reflux Disease
pneumonias
asbestos exposure
hyperlipidemia
hypertension
Discharge Condition:
alert and oriented x3
Ambulating with assistance
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming
Monitor wounds for infection and report any redness, warmth,
swelling, tenderness or drainage
Please take temperature each evening and Report any fever 100.5
or greater
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
PICC line per protocol - please remove when antibiotic course
complete
Labs: CBC, Chem 7, and LFT please do [**10-12**] please call with
abnormal results [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) 7772**] 4 weeks [**Telephone/Fax (1) 1504**]
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] W. after discharge from rehab [**Telephone/Fax (1) 5457**]
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] after discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2180-10-10**]
|
[
"440.0",
"486",
"V15.82",
"552.21",
"272.4",
"285.9",
"440.8",
"550.10",
"401.9",
"V15.84",
"414.01",
"410.71",
"428.21",
"458.29",
"428.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.47",
"88.53",
"36.13",
"88.56",
"39.61",
"37.23",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
8228, 8280
|
5564, 7076
|
357, 715
|
8613, 8664
|
2214, 4030
|
9475, 9917
|
1550, 1573
|
7131, 8205
|
8301, 8592
|
7102, 7108
|
8688, 9452
|
4074, 5541
|
1588, 2195
|
283, 319
|
743, 1286
|
1309, 1413
|
1429, 1519
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,268
| 146,336
|
37815+37816
|
Discharge summary
|
report+report
|
Admission Date: Discharge Date:
Date of Birth: [**2128-6-20**] Sex: F
Service:
PREOPERATIVE DIAGNOSES: Bleeding from tracheostomy.
POSTOPERATIVE DIAGNOSIS: Bleeding from tracheostomy.
PROCEDURE: Flexible bronchoscopy and iced normal saline
lavage.
ESTIMATED BLOOD LOSS: Minimal.
OPERATIVE INDICATIONS: The patient is a 57-year-old woman
with multiple medical problems following tracheostomy
performed on [**2185-11-4**], with new-onset bleeding from
the tracheostomy site.
DESCRIPTION OF PROCEDURE: The patient was in the supine
position with normal oxygen saturation at 35% trache mask.
The patient was sedated with fentanyl and Versed and flexible
bronchoscope was introduced through the tracheostomy site
after a time-out was performed.
We then injected 1% lidocaine through the bronchoscope to
numb the airways and navigated the bronchoscope through the
right main stem carina initially. There was a large clot
seen at the bronchus intermedius at the opening of the right
lower lobe which we sucked out. We then saw evidence of
abrasive bleeding from the takeoff of the right lower lobe
which we irrigated multiple times.
Once we navigated the scope through the segments of the right
lung, we then moved our attention to the left lung and found
that that was clear. We then returned to the area which was
seen to be bleeding at the takeoff of the right lower lobe
and performed iced normal saline lavage. We monitored this
area for several minutes and found that the bleeding was not
continuous and was stable.
We then pulled the bronchoscope back through the tracheostomy
and pulled the tracheostomy itself back to look at the origin
of the trache and the stoma itself, and there was no evidence
of bleeding at that area and the site looked intact and well-
healed. We then terminated the bronchoscopy.
The patient tolerated the procedure well and a postoperative
chest x-ray was obtained which showed no change from prior
examination.
We informed the medical team that if the patient continued to
bleed, that interventional pulmonology should be contact[**Name (NI) **]
for possible intraoperative intervention.
SURGEON'S STATEMENT: Dr. [**Last Name (STitle) **] was present throughout
the entire procedure.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 25080**]
Dictated By:[**Doctor Last Name 9174**]
MEDQUIST36
D: [**2185-11-26**] 09:09:24
T: [**2185-11-26**] 10:10:07
Job#: [**Job Number 84626**]
Admission Date: [**2185-10-21**] Discharge Date: [**2185-12-13**]
Date of Birth: [**2128-6-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Outside Hospital Transfer for "Stable NSTEMI" - Unstable STEMI
when patient got to floor
Major Surgical or Invasive Procedure:
cardiac catheterization with 2 Bare Metal Stents
central venous access placement with Swan-Ganz catheter
PICC placement
intra-aortic balloon pump placement
endotracheal tube intubation
left lower extremity fasciotomy
left lower extremity surgical debridement
IR Guided Tunneled Catheterization
IR Guided Dobhoff feeding tube
tracheotomy
History of Present Illness:
This is a 57 year old female with a history of HTN, DM,
hyperlipidemia, and OSA who presented to [**Hospital6 **] on
[**2185-10-20**] with 3 days of HA, sorethroat, myalgias, and epigastric
pain with some associated nausea. Upon arrival to the OSH ED,
she had a temp of 101. Per report, initial EKG was
non-diagnostic but CEZ were initially positive with CPK of 574,
MB of 11.5, and TropI of 14.96. She denied chest pain initially
and shortness of breath. She had several ECGs performed there,
which show initial T wave inversions in lateral leads (10AM, no
symptoms), followed by an ECG with inferior ST elevations with
an RCA (III>II) occlusion pattern that apparently occurred with
chest pain. She was started on a nitro drip and Integrillin.
However, it appears that the ST elevations were missed and she
was transferred under the auspices of an "NSTEMI". She had also
developed acute renal failure, with a creatinine rise from 1.2
to 3.1 on [**10-21**].
.
Upon arrival at [**Hospital1 18**], she was found to be ashen in color, and
hypotensive with blood pressure of 95-105/50s, with sats of
90-93% on 5LNC. An ECG was performed, which showed the same
inferior STE, and at 2:45PM a code STEMI was called and she was
taken to the cath lab. In the cath lab, she was found to have
diffuse multivessel disease with 70% distal thrombotic left main
lesion, 60% RCA, diffuse disease in the LAD, and 60% RCA. Her
culprit lesion was felt to be the distal LAD lesion. While
preparing for a diagnostic IVUS of the LMCA and prior to LAD
PCI, the patient had an episode of hypotension, bradycardia, and
hypoxia. She was intubated and received atropine, epinephrine,
and emergency pacing with tempory pacer wire placed. Started on
dopamine and levophed. She received 1 BMS to her LMCA and 2 BMS
in her distal LAD. A right iliac angioplasty was also performed.
An IABP was placed. The levophed was able to be weened off and
milrinone was started with an increase in CI from 1.5 to 2.1
L/min.
.
Rest of ROS unable to be obtained due to intubation.
Past Medical History:
HTN
Hyperlipidemia
OSA on home O2
hypothyroidism
IDDM
GERD
anxiety/depression
diastolic CHF
Social History:
Lives with her daughter, no alcohol or smoking or illicits.
Family History:
Father with diabetes. Mother died at age 78 due to bladder
cancer. Father with CVA at age 73.
Physical Exam:
admission PE
VS: 95.7, 94/51, 85, 91% AC 100%, PEEP 5, TV 500, RR 18
GENERAL: Intubated and sedated. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Diffuse facial edema
NECK: Supple with JVP to jaw.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral rales.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 1 Femoral 1+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 1+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+
Pertinent Results:
ADMISSION LABS [**2185-10-21**]:
CBC: WBC 13.6 HCT 26.3 Plt 232
CHEM: Na 122 K 4.8 Cl 88 HCO3 17 BUN 53 Cr 3.3 Glucose 402
LFTs: ALT 2166 AST 3287 LD 9435 CK 967 AP 119 Tbili 0.5
Coags: PT 16 PTT 150 INR 1.4
MICRO:
Leg Deep Wound Cx: Yeast, sensitive to Fluconazole
Sputum Cx: colonized with Klebsiella and Stenotrophomonas
CDiff: negative
BCx: negative
IMAGING:
C. Cath [**10-21**]
COMMENTS:
1. Coronary angiography in this co-dominant system revealed
severe three
vessel coronary artery disease. The LMCA had a distal 70%
thrombotic
lesion. The LAD had diffuse disease with a proximal 60%
stenosis and
serial 40-50% stenoses throughout the remainder of the vessel,
which was
approximately 2.25mm in diameter. The LCX had a 60% stenosis at
the
origin, with diffuse disease in the OM1 and OM2, which were
approximately 2.0mm in diameter. The RCA had a proximal 60%
stenosis,
with a long 50% stenosis in the mid-vessel, which was 2.5mm in
diameter.
The PDA and PL were diffusely diseased and small.
2. Resting hemodynamics revealed elevated left- and right-sided
filling
pressures with mean RA pressure of 31 mmHg and mean PCW pressure
of 30
mmHg. There was moderate pulmonary hypertension, with systolic
PA
pressure of 48 mmHg. The cardiac output was low prior to
intervention
and placement of intra-aortic balloon pump at 2.85 L/min, and
increased
to 3.78 L/min following IABP placement and initiation of
milrinone.
3. Supravalvular aortography revealed no significant aortic
insufficiency, aortic dilation, or aortic dissection.
4. Distal aortography revealed diffuse severe disease with 50%
stenosis
below the renal arteries. The renal arteries themselves were
single
bilaterally and without significant stenosis. Difficulty was
encountered during passage of the access wire. Iliac
angiography
revealed mild disease in the left common iliac artery, with a
patent
internal iliac artery and widely patent common femoral artery.
The right
common iliac artery had an 80% stenosis, and the right internal
iliac
artery was occluded. The right common femoral artery was widely
patent.
5. Successful PTCA of the right CIA stenosis with a 5.0x20mm
Admiral
balloon.
6. Successful direct stenting of the LMCA with a 2.5x12mm Vision
stent.
Final angiography revealed no residual stenosis, no
angiographically
apparent dissection and TIMI III flow.
7. Successful direct stenting of the proximal and mid LAD with a
2.25x28mm and a 2.25x28mm Vision stents. Final angiography
revealed no
residual stenosis, no angiographically apparent dissection and
TIMI III
flow.
8. Successful placement of a temporary pacing wire in the RV
with pacing
required to restore heart rate.
9. Successful deployement of 30CC IABP.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Cardiogenic shock with low cardiac output, managed by IABP.
3. Acute inferior myocardial infarction, managed by PTCA of
vessel.
4. Elevated left- and right-sided filling pressures.
5. Aortic atherosclerosis with right iliac disease.
6. Successful PTA of the right CIA stenosis.
7. Successful PCI of the LMCA and LAD.
8. Successful deployment of IABP.
.
[**10-28**] CT A/P
CT ABDOMEN WITHOUT CONTRAST: The lung bases reveal small
bilateral pleural
effusions and associated compressive atelectasis.
Atherosclerotic coronary
calcifications are partially imaged. There is no evidence for
pericardial
effusion.
Limited non-contrast evaluation of the liver, spleen and adrenal
glands is
unremarkable. The pancreas demonstrates fatty atrophy but is
otherwise
unremarkable. Contrast from recent intravenous administration
persists within
the kidneys and renal collecting system, which are enhanced
symmetrically
without hydronephrosis or hydroureter. A nasoenteric tube
terminates in the
duodenum. Intra-abdominal loops of large and small bowel are of
normal caliber
and there is no pneumoperitoneum. Mild ascites is noted,
predominantly
perihepatically and perisplenically. There are no pathologically
enlarged
mesenteric or retroperitoneal lymph nodes. Severe
atherosclerotic
calcifications involve a hypoplastic aorta.
CT PELVIS WITH CONTRAST: The rectum, sigmoid colon is
unremarkable. The
uterus is unremarkable. The bladder contains a Foley and
non-dependent air. A
small amount of free pelvic fluid is noted.
Bone windows reveal no worrisome lytic or sclerotic osseous
lesions. Diffuse
subcutaneous edema is identified.
CT SINUS [**10-28**]
IMPRESSION:
1. No focal fluid collection or abscess identified.
2. Anasarca with bilateral small pleural effusions and small
ascites.
The study and the report were reviewed by the staff radiologist.
IMPRESSION: Extensive sinus soft tissue changes with
high-density material in
both ethmoid air cells and right frontal sinus, which could be
secondary to
blood. However, this could be due to inspissated secretions.
Presence of
fungal colonization should be excluded by clinical correlation.
Tissue from left leg [**11-21**]
The specimen is received fresh labeled with the patient's name,
"[**Known firstname 84627**] [**Known lastname 28942**]", the medical record number and "left calf." It
consists of multiple fragments of soft tissue and muscle which
measure in aggregate 14 cm x 8 cm x 5 cm. The skin surface
appears to be [**Doctor Last Name 352**] and grossly necrotic in areas. Serial
sectioning reveals [**Doctor Last Name 352**] necrotic appearing muscle and soft
tissue. Representative sections are submitted in cassettes A-C.
[**2185-11-21**] 11:35 am TISSUE LT LATERAL CALF.
GRAM STAIN (Final [**2185-11-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **] #[**Numeric Identifier 84628**] [**2185-11-21**] AT
2:10PM.
TISSUE (Preliminary):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE
GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
[**11-21**]
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echogenicity with no
focal masses. Layering sludge is seen within the gallbladder.
There is no
gallbladder wall thickening, distention, or fluid collections.
The common
bile duct measures 5 mm.
IMPRESSION: Gallbladder sludge. No evidence of cholecystitis.
ECHO [**11-12**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded (the
distal LV and apex not well seen). Overall left ventricular
systolic function is probably low normal (LVEF 50%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The 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.
Left calf debridement:
Skin with ulceration with underlying muscle and soft tissue with
necrosis, acute and chronic inflammation and yeast and hyphal
forms consistent with [**Female First Name (un) **].
[**2185-11-30**] MRI Spine:
IMPRESSION: Study is somewhat limited by persistent patient
motion artifact, as well as the lack of diffusion-weighted
sequence, with:
1. No finding to specifically suggest anterior spinal cord
infarction.
2. No evidence of acute spinal epidural or subdural hematoma, or
other cord compressive process.
3. Widely capacious spinal canal.
4. Grossly unremarkable appearance to the thoracoabdominal
aorta, with no
focal aneurysmal dilatation or evidence of occlusion or
significant stenosis.
[**2185-12-6**] ECHO:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. Left ventricular wall
thicknesses are normal. There is mild regional left ventricular
systolic dysfunction with distal apical hypokinesis. The
remaining segments contract normally (LVEF = 50 %). 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) 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. No mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is mild pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Regional dysfunction c/w distal LAD disease.
Impaired left ventricular relaxation. Mild pulmonary
hypertension.
[**2185-12-6**] EMG:
Clinical Interpretation: Complex abnormal study. There is
electrophysiologic evidence for a severe ongoing neurogenic
process in all 4 extremities. Given the severity of
abnormalities in the lower extremities as compared to the upper,
possibilites include critical illness neuropathy, with a
superimposed acute focal process involving the anterior [**Doctor Last Name 534**]
cell innervation to the lower extremities, as in an acute
myelopathy.
[**2185-12-9**] L tib/fib xray
IMPRESSION: No bony abnormality identified.
DISCHARGE LABS [**2185-12-13**]:
CBC: WBC 9.8 HCT 30.6 Plt 367
CHEM: Na 137K 4.6 Cl 98 HCO3 31 BUN 14 Cr 2.0 Glucose 229
Ca 8.4 Mg 1.8 Phos 3.3
Brief Hospital Course:
This is a 57 year old female with HTN, DM, hyperlipidemia who
presents with acute inferior STEMI and cardiogenic shock.
.
# s/p ST elevation MI: admitted [**10-21**] with chest pain, went to
cath lab, where cath revealed 70% RCA proximal lesion with good
flow and diffuse LMCA and prox LAD stenoses. She received 1 BMS
to her LMCA and 2 BMS in her distal LAD. A right iliac
angioplasty was also performed. During procedure, pt became
bradycardic and nearly coded, requiring atropine and a temporary
wire (dc'd on [**10-23**]). She was urgently intubated, and
dopamine/milrinone was started. She was continued on ASA,
plavix, integrellin and statin however BB was held given
hemodynamic instability. Balloon pump dc'd on [**10-23**] when pt was
discovered to have LLE compartment syndrome. She was on and off
of her BB with pressors. Eventually she required Amiodarone for
aflutter correction and this along with metoprolol both rate and
rhythm controlled her.
# Acute on chronic systolic heart failure: Pt was in cardiogenic
shock with poor cardiac output, requiring pressors/inotropes and
balloon pump, and became volume overloaded. Balloon pump had to
be d/c'd in the setting of LLE compartment syndrome. She was
eventually diuresed aggressively with CVVH, and was then felt to
be volume depleted. She was eventually weaned off of pressors,
her EF was largely preserved at 50%. She intermittently became
hypotensive with acute blood loss s/p multiple LLE debridment.
She was intermittently requiring pressors and CVVH in this
setting. She was eventually started on milrinone on HD days,
and metoprolol was held to allow for large volume shifts
associated with HD.
#Arrythmias: In NSR in the unit but had an episode of sinus
arrest in cath lab. Temp pacer in but now mostly native
complexes, pacer removed [**10-23**]. Her heart rate ranged from
tachycardic to normal sinus. She was observed to be at various
times in Atrial tachycardia, sinus tachycardia, atrial
fibrillation, atrial flutter, the atrial tachycardia, atrial
fibrillation, and atrial flutter eventually resolved with
amiodarone on board. She remained in NSR for the remainder of
her hospitalization.
# Acute renal failure: Likely started before presentation to
[**Hospital1 18**] from poor forward flow from initial cardiogenic failure
and probably exacerbated by 320 ccs of contrast recieved in cath
lab. She developed muddy brown casts on urine analysis. Due to
hyperkalemia to 6.8 and anuria immediately post cath, she was
treated with CVVHD for volume overload and hyperkalemia. She
failed repeated trials off of CRRT. Eventually it was felt that
she no longer required volume removal and she tolerated
intermittent HD without pressors. Likely now dialysis-dependent
with oliguria, however renal consultants believe that urine
output should be followed closely as she continues to have
potential to regain renal function.
# LLE compartment syndrome: treated with removal of balloon pump
and fasciotomy on [**10-23**]. In this setting she developed
rhabdomyolysis with a peak CK of >100,000. This eventually
trended down to normal ranges with CVVH and fasciotomy. Wound
Vac was placed by vascular surgery who observed her on a daily
basis. She was debrided on [**11-21**] and planned for closure
however the wound was felt to be too big and not appropriate for
grafting. At that time deep tissue cultures grew out [**Female First Name (un) 564**]
albicans. Vascular and plastics colaboratively decided to allow
for healing by secondary intention (vs. graft placement). She
was started on fluconazole, with duration of treatment for
osteomyelitis given proximity of this deep tissue infection to
bone. She received multple further debridments in the OR and at
the bedside. Wound vac was in place on both leg wounds. She
has follow up with vascular surgery and plastic surgery as
outpt.
# Respiratory Failure: Likely due to acute pulmonary edema in
the setting of cardiogenic failure. She required vent support
and was given lasix and ultimately CVVHD for volume overload.
After volume overload was corrected she eventually required less
and less respiratory support, however as she was intubated for
greater than 2 weeks, she was trach'd in the OR. She eventually
tolerated CPAP, and trach mask. Passy-Muir trials were
successful on [**11-23**].
# Elevated LFTs: Markedly elevated at admission. Likely shock
liver combined with rhabdo. Statin was temporarily held. Liver
function tests eventually trended down on there own. They again
started to trend upwards on fluconazole. However, she was also
on amiodarone and high dose statin at that time. LFTs should be
followed as outpt and medications should be adjusted if LFTs
continue to trend upwards.
# Anemia: S/p 27 units pRBC, 2 units FFT, 2 units platelets, 2
units cryo. Ms. [**Known lastname 28942**] had persistent anemia throughout her stay
which required greater than many units of of PRBC. DIC,
hemolysis, and anemia of chronic disease, were all worked up and
considered as causes, and eventually hepatic dysfunction was
settled on as the cause, given concomitant coagulopathy. As she
stabilized from a hepatic perspective, she continued to have
chronic anemia from renal disease, worsened by acute blood loss
anemia due to leg debridment. Currently receiving EPO with HD.
HCT has been stable for several days.
# GI bleed: on [**11-4**] she was noted to have frankly melanotic
stool. GI was called who felt she was oozing secondary to
hepatic dysfunction. The melena resolved with IV protonix for
72 hours, and then [**Hospital1 **]. GI bleed self resolved.
# ID: In the setting of intermittent fevers and WBC elevations
to the 30's she was empirically started on vanc and cefepime to
cover skin flora infecting her leg. She was ruled out for
C.Diff several times and cultures never revealed a source aside
from klebsiella in her sputum, and coag negative staph in her
A-line (thought to be contaminant). Her deep tissue cultures
revealed [**Female First Name (un) **] albicans. ID followed her and she was
discharged only on at least a 30 day course of fluconazole, with
instructions to follow up with ID in 3 weeks to determine if abx
regimen at that point is sufficient. Monitoring of liver
function, CBC, and markers of inflamation should be followed at
rehab and faxed to the ID doctor, Dr. [**Last Name (STitle) 7443**].
# IDDM: Initially high BS on admission. She was initially
treated with insulin gtt and then transitioned to long acting
with ISS. [**Last Name (un) **] was consulted and recomended ISS given her
highly variable insulin clearance given her volatile renal
function. Once a regular HD schedule is begun, it is expected
that her insulin requirements will stabilize. Discharged on 12u
lantus qAM + humalog SSI. Insulin sliding scale may be titrated
as outpt to achieve glucose of 150-250.
#Lower extremity plegia - Pt was in state of reduced mental
status during the critical portion of her hospital course. When
she aroused sufficiently to be able to participate in
questioning and physical exam maneuvers it was discovered that
she was unable to move either of her lower extremities and had
minimal to no sensation in both. Neurology was consulted.
Spinal MRI showed no sign of anterior spinal infarct given h/o
hypotension in setting of baloon pump. However, EMG showed
evidence of critical illness neuropathy with sign of anterior
[**Doctor Last Name 534**] involvement. Pt should be followed up with Neurology as
outpt in one month for reassesment of diagnosis and prognosis of
lower extremity function.
# FEN: Ms [**Known lastname 28942**] was fed through tube feeds. Multiple feeding
options were used throughout hospitalization, including OG/NGT,
Dobhoff, and attempted PEG placement which failed [**1-31**] body
habitus. Thoracic surgery felt that laparoscopic G-tube
placement was an option but that her medical issues should be
optimized further before surgery, as they felt that this was
somewhat risky. Goal is to maintain an albumin of > 2.5 to be
an operative candidate for PEG placement. She was discharged
with ability to take thin liquids and pureed foods. She also
had a dobhoff tube placed in the stomach for additional tube
feeds. Oral intake should be encouraged. Medications should not
be administered through NGT, as it tends to clog. Please
administer medications crushed in puree orally.
Medications on Admission:
Clonidine 0.3mg patch qwk
Lasix 40mg PO BID
Diovan 320mg PO daily
Zaroxolyn 2.5mg PO daily
ASA 81mg PO daily
Prozac 20mg PO daily
levothyroxine 100mcg PO daily
Prilosec 20mg PO daily
Atenolol 100mg PO daily
Zocor 80mg PO daily
meclizine 2.5mg PO daily
Potassium 10meq PO daily
Novolog ISS
Lantus 30 units qhs
Vit D 50K units qwk
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for at least one year ([**2186-9-29**]), if possible.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: 10 ml (100 mg) PO BID
(2 times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five (5)
ml (300 mg) PO BID (2 times a day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Started [**11-24**], to continue at least 30 days. F/u ID
recs at outpatient appointment.
On HD days, please administer dose after HD. .
10. Pantoprazole 40 mg IV Q12H
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Insulin Lispro 100 unit/mL Solution Sig: PER SLIDING SCALE
Subcutaneous ASDIR (AS DIRECTED).
13. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous qAM: Titrate as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
UNIT DWELL Injection PRN (as needed) as needed for line flush:
Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
15. Outpatient Lab Work
Please check weekly CBC with diff and LFTs and Fax to Dr. [**Last Name (STitle) 7443**]
at [**Telephone/Fax (1) 432**]. Start: Thursday [**12-15**]
16. Outpatient Lab Work
Please check CRP and ESR monthly and fax results to Dr. [**Last Name (STitle) 7443**] at
[**Telephone/Fax (1) 432**]. Start date: [**2186-1-6**]
17. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 30 days.
18. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): please hold the night dose prior to HD days and
all doses on HD days. thanks.
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
21. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
22. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
23. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
25. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
26. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): Three doses to be given once the night prior to HD, once
AM of HD, and one dose post-HD.
27. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
hold for sedation or SBP < 95 , RR < 10,
28. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150)
mg PO DAILY (Daily).
29. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for clogged NGT.
30. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet
Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for clogged
NGT.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary Diagnoses
STEMI
cardiogenic/distributive shock
Left Lower Extremity Compartment Syndrome
Discharge Condition:
The patient is hemodynamically stable without any pressor
requirement. She tolerates her tracheotomy well and
successfully passed a Passy-Muir placement trial. Her
neurologic status is difficult to determine; the patient
generally responds to simple commands but is intermittently
either uncooperative or otherwise nonresponsive to questioning.
She moves both upper extremities and her head spontaneously but
has not been noted to have spontaneous movement of either lower
extremity during this hospitalization.
Discharge Instructions:
Ms. [**Known lastname 28942**] was seen at [**Hospital1 18**] for ST-elevation myocardial
infarction complicated by shock. She spent an extended period
of time in the hospital's intensive care unit for treatment of
shock. An intra-aortic balloon pump was initially placed to aid
heart flow but this led to a complication of left lower
extremity compartment syndrome, which necessitated surgery on
the left leg.
Mrs. [**Known lastname 28942**] required mechanical ventilation for respiratory
failure. Because she was intubated for a prolonged time, a
tracheostomy was placed with a special valve so she could talk
through her tracheostomy hole.
Additionally, her hospital course was complicated by acute renal
failure. She required regular dialysis during her
hospitalization and it is felt that she will be dependent on
dialysis from this point.
She will need continued wound care for the left leg, and is
followed by vascular and plastic surgery. An ultimate plan has
not been decided as to how her wound will be closed at this
time; she will need to follow up with these services as an
outpatient.
During her hospital course, Mrs. [**Known lastname 28942**] was found to have severe
lower extremity weakness. She was seen by the neurologists who
believe that her weakness is due from her prolonged critical
illness. However, during her heart attack she may have suffered
from a stroke in the spinal cord. She will need to be followed
by neurology as an outpatient.
During surgical debridement, her deep tissue culture was found
to grow out [**Female First Name (un) 564**] albicans, sensitivities pending. Per the
recommendations of our infectious disease specialists, she was
placed on fluconazole, with instructions to continue for at
least 3 weeks through her next outpatient appointment, at which
time further recommendations will be made regarding duration of
treatment. While on the fluconazole, she will need to have
weekly monitored blood work with CBC with differential and LFTs.
She will need continued dialysis, most likely three times a
week.
Many changes were made to Mrs. [**Known lastname 28942**] medication regimen. PLease
see attached sheet for medication administration.
Please return to the emergency room or call Mrs.[**Doctor Last Name 84629**]
physician if she develops increased lower extremity pain or
discharge, fevers, chest pain, shortness of breath or any other
concerning symptom.
Followup Instructions:
Vascular Surgery - Please follow up with Dr. [**Last Name (STitle) 1391**] on
[**12-28**] at 10:15. [**Last Name (NamePattern1) **]. Suite 5C. Please call
[**Telephone/Fax (1) 1393**] with questions.
Plastic Surgery - Please follow up at the plastic surgery clinic
on [**1-20**] at 3:00pm.
Infectious Disease - follow up should be scheduled with Dr.
[**Last Name (STitle) 7443**] on [**1-4**] at 10AM. Please call [**Telephone/Fax (1) 457**] with
questions.
Neurology - follow up should be scheduled with Dr. [**Last Name (STitle) **]
in 1 month. [**Hospital 878**] clinic should call with appointment date/
time. Phone number: ([**Telephone/Fax (1) 2528**]
|
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68,425
| 190,272
|
36000
|
Discharge summary
|
report
|
Admission Date: [**2154-1-13**] Discharge Date: [**2154-1-22**]
Date of Birth: [**2096-12-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
diverticulitis
Major Surgical or Invasive Procedure:
Central venous line placement
History of Present Illness:
57 yo M was transferred from [**Hospital3 7571**]Hospital with
sigmoid
diverticulitis and partial small bowel obstruction. Wife
reports
that pt began experiencing abdominal pain and constipation on
Monday which progressed until pt admitted himself to the OSH on
Wednesday. Pt underwent CT scan on [**1-9**] which demonstrated
sigmoid diverticulitis and partial SBO. Pt left AMA on [**1-10**],
but
returned on [**1-11**] with bilious vomiting and diarrhea. Pt was
made
NPO and antibiotics were started. Cardiology was consulted and
performed an ECHO due to history of CAD with CABG. Repeat CT on
[**1-13**] demonstrated increased small bowel thickening and possible
abscesses. Due to concern over the patient's EtOH withdrawal in
the perioperative setting, the pt was transferred to [**Hospital1 18**] for
further care.
Past Medical History:
Alcoholism
CAD with 2-vessel CABG
Hypertension
Hypercholesterolemia
Oral cancer
Social History:
Chronic alcoholic, 5 large gin and tonic/day
Tobacco abuse
Married.
Family History:
Non-contributory
Physical Exam:
Upon Discharge:
VS: 98.9, 92, 102/60, 20, 95RA
NAD, AAO x 3
NCAT
RRR, S1S2
CTAB
Soft, ND, minimally tender to deep palpation. No rebound or
guarding
No C/C/E
Pertinent Results:
[**2154-1-13**] 05:16PM BLOOD WBC-11.9* RBC-3.20* Hgb-11.2* Hct-32.0*
MCV-100* MCH-35.1* MCHC-35.1* RDW-14.5 Plt Ct-290
[**2154-1-14**] 03:08AM BLOOD WBC-12.2* RBC-3.16* Hgb-10.8* Hct-31.5*
MCV-100* MCH-34.1* MCHC-34.2 RDW-14.7 Plt Ct-321
[**2154-1-16**] 01:59AM BLOOD WBC-22.1* RBC-3.44* Hgb-11.8* Hct-33.5*
MCV-98 MCH-34.2* MCHC-35.1* RDW-14.7 Plt Ct-478*
[**2154-1-17**] 05:55AM BLOOD WBC-20.6* RBC-3.47* Hgb-11.8* Hct-33.8*
MCV-97 MCH-34.1* MCHC-35.0 RDW-14.3 Plt Ct-505*
[**2154-1-17**] 04:44PM BLOOD WBC-18.2* RBC-3.79* Hgb-12.8* Hct-37.6*
MCV-99* MCH-33.8* MCHC-34.0 RDW-14.2 Plt Ct-717*
[**2154-1-18**] 06:16AM BLOOD WBC-14.5* RBC-3.30* Hgb-11.1* Hct-32.0*
MCV-97 MCH-33.7* MCHC-34.7 RDW-14.4 Plt Ct-557*
[**2154-1-19**] 02:53AM BLOOD WBC-14.4* RBC-3.22* Hgb-10.9* Hct-31.4*
MCV-97 MCH-33.7* MCHC-34.6 RDW-14.3 Plt Ct-555*
[**2154-1-20**] 06:00AM BLOOD WBC-14.3* RBC-3.33* Hgb-11.4* Hct-33.1*
MCV-99* MCH-34.2* MCHC-34.4 RDW-13.8 Plt Ct-632*
[**2154-1-21**] 08:40AM BLOOD WBC-11.8* RBC-3.39* Hgb-11.5* Hct-33.1*
MCV-98 MCH-33.8* MCHC-34.6 RDW-14.5 Plt Ct-636*
[**2154-1-13**] 05:16PM BLOOD PT-16.4* PTT-33.4 INR(PT)-1.5*
[**2154-1-13**] 05:16PM BLOOD Plt Ct-290
[**2154-1-16**] 01:59AM BLOOD PT-15.8* PTT-30.5 INR(PT)-1.4*
[**2154-1-13**] 05:16PM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-138
K-3.8 Cl-104 HCO3-24 AnGap-14
[**2154-1-14**] 03:08AM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-137 K-3.3
Cl-104 HCO3-24 AnGap-12
[**2154-1-14**] 03:00PM BLOOD Glucose-92 UreaN-5* Creat-0.6 Na-139
K-3.6 Cl-106 HCO3-24 AnGap-13
[**2154-1-15**] 04:22AM BLOOD Glucose-99 UreaN-3* Creat-0.6 Na-139
K-3.8 Cl-107 HCO3-24 AnGap-12
[**2154-1-16**] 01:59AM BLOOD Glucose-84 UreaN-4* Creat-0.6 Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
[**2154-1-17**] 05:55AM BLOOD Glucose-126* UreaN-8 Creat-0.6 Na-137
K-4.0 Cl-100 HCO3-26 AnGap-15
[**2154-1-17**] 04:44PM BLOOD Glucose-139* UreaN-8 Creat-0.8 Na-137
K-3.6 Cl-97 HCO3-20* AnGap-24*
[**2154-1-18**] 06:16AM BLOOD Glucose-133* UreaN-5* Creat-0.5 Na-136
K-3.8 Cl-102 HCO3-26 AnGap-12
[**2154-1-18**] 01:58PM BLOOD K-4.4
[**2154-1-19**] 02:53AM BLOOD Glucose-101 UreaN-4* Creat-0.6 Na-136
K-4.1 Cl-103 HCO3-25 AnGap-12
[**2154-1-19**] 02:37PM BLOOD K-3.8 HCO3-27
[**2154-1-20**] 06:00AM BLOOD Glucose-95 UreaN-4* Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-24 AnGap-16
[**2154-1-21**] 08:40AM BLOOD Glucose-165* UreaN-7 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
[**2154-1-13**] 05:16PM BLOOD ALT-5 AST-11 LD(LDH)-151 AlkPhos-58
TotBili-0.5
[**2154-1-14**] 03:08AM BLOOD ALT-3 AST-9 CK(CPK)-17* AlkPhos-56
TotBili-0.4
[**2154-1-14**] 11:09AM BLOOD CK(CPK)-34*
[**2154-1-15**] 04:37PM BLOOD ALT-4 AST-13 AlkPhos-60 TotBili-0.3
[**2154-1-17**] 05:55AM BLOOD ALT-6 AST-20 AlkPhos-69 TotBili-0.5
[**2154-1-17**] 09:56PM BLOOD CK(CPK)-36*
[**2154-1-18**] 06:16AM BLOOD CK(CPK)-23*
[**2154-1-18**] 01:58PM BLOOD CK(CPK)-35*
[**2154-1-14**] 03:08AM BLOOD CK-MB-2
[**2154-1-14**] 11:09AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-1-17**] 09:56PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-1-18**] 06:16AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-1-18**] 01:58PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-1-13**] 05:16PM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.1 Mg-1.8
[**2154-1-14**] 03:08AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2154-1-14**] 03:00PM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8
[**2154-1-15**] 04:22AM BLOOD Calcium-7.8* Phos-3.1 Mg-1.9
[**2154-1-16**] 01:59AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.8
[**2154-1-17**] 05:55AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.7
[**2154-1-17**] 04:44PM BLOOD Calcium-8.7 Phos-3.8 Mg-2.4
[**2154-1-18**] 06:16AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.9
[**2154-1-18**] 01:58PM BLOOD Calcium-7.9* Phos-3.0 Mg-1.7
[**2154-1-19**] 02:53AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9
[**2154-1-19**] 02:37PM BLOOD Calcium-8.2* Phos-3.9 Mg-1.7
[**2154-1-20**] 06:00AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.0
[**2154-1-21**] 08:40AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.7
[**2154-1-13**] 05:37PM BLOOD Type-[**Last Name (un) **] pH-7.44
[**2154-1-13**] 08:38PM BLOOD Type-ART Temp-37.4 pO2-288* pCO2-37
pH-7.43 calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2154-1-13**] 11:43PM BLOOD Type-ART pO2-184* pCO2-36 pH-7.45
calTCO2-26 Base XS-2
[**2154-1-14**] 03:31AM BLOOD Type-ART pO2-127* pCO2-36 pH-7.46*
calTCO2-26 Base XS-2
[**2154-1-15**] 04:34AM BLOOD Type-ART pO2-105 pCO2-34* pH-7.48*
calTCO2-26 Base XS-2
[**2154-1-15**] 01:51PM BLOOD Type-ART pO2-97 pCO2-39 pH-7.46*
calTCO2-29 Base XS-3
[**2154-1-15**] 03:12PM BLOOD Type-ART pO2-73* pCO2-33* pH-7.51*
calTCO2-27 Base XS-3
[**2154-1-13**] 05:37PM BLOOD freeCa-1.12
[**2154-1-15**] 03:12PM BLOOD freeCa-1.16
CXR [**1-14**]:
INDICATION: Nasogastric tube placement. No prior studies for
comparison.
Nasogastric tube terminates within the stomach, and an
endotracheal tube
terminates approximately 3.7 cm above the carina. Heart is
mildly enlarged, and interstitial pulmonary edema is present
within the lungs. No definite pleural effusion but left
costophrenic sulcus has been excluded, precluding assessment for
small effusion or peripheral left basilar abnormality.
CT abd/pelvis [**1-14**]:
IMPRESSION:
1. Sigmoid diverticulitis with a small contained performation.
2. Pelvic fluid collections associated with loops bowel, not
amenable to CT guided drainage.
3. Partial/early small bowel obstruction
4. Small bowel wall thickening, a non-specific finding in the
setting of
ascites and inflammation.
PORTABLE CHEST, [**2154-1-14**] WITH COMPARISON STUDY EARLIER THE SAME
DATE.
INDICATION: Line placement.
Left subclavian catheter terminates within the lower superior
vena cava, with no evidence of the pneumothorax. Interstitial
edema is improving, and discoid atelectasis at left lung base
has nearly resolved. Persistent right retrocardiac opacity, but
decrease in adjacent small right pleural effusion.
NON-CONTRAST HEAD CT [**1-17**]:
IMPRESSION: No acute intracranial pathology including no
hemorrhage. The study and the report were reviewed by the staff
radiologist.
CT Abd/Pelvis [**1-22**]:
Impression: Interval resolution of perihepatic ascites.
Previously described fluid collections are improved. No new
fluid collections are seen. Previoiusly seen dilated loops of
small bowel are no longer seen. Normal GB, kidneys, adrenals,
ureters, and spleen.
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from [**Hospital3 7571**]Hospital with a
diagnosis of sigmoid
diverticulitis and partial small bowel obstruction. He was
initially placed in the SICU with the concern that he would need
an imminent operation. He was NPO with IVF and an NGT. He was
also started on broad spectrum ABX. He was intubated for
respiratory distress and agitation. Over a few days, he improved
clinically and his WBC count decreased and he was transferred to
the general floor.
On the floor he continued to improve and he was continued on
Cipro/Flagyl. On [**1-17**] he had a seizure, and went into
respiratory and cardiac arrest. A "Code Blue" was initiated and
he was resuscitated on the floor. IV Ativan was given, given his
history of EtOH abuse and signs of previous alcohol withdrawal.
He was transferred back to the SICU and stabilized on a CIWA
scale. Psychiatry and neurology consults were initiated. A CT of
his head was negative for organic process. After he was
stabilized on a regimen, he again returned to the general floor.
He continued to improve clinically and his WBC continued to
drop. A repeat CT of his abdomen/pelvis showed improvement of
his intra-abdominal fluid collections.
He was tolerating a regular diet prior to discharge. He was
cleared for home by PT. He was deemed not a good candidate for
inpatient [**Hospital **] rehab as he was screened by social work and case
management. His pain was well controlled. Psychiatrically and
neurologically, he was back to his baseline at discharge. He was
discharged home on [**2154-1-22**].
Medications on Admission:
Flagyl 500 mg IV q 8 hours
Levaquin 500 mg IV daily
Lisinopril 20 mg daily
ASA 325 mg daily
Wellbutrin 150 mg po BID
Folic acid 1 mg po daily
Protonix 40 mg IV dialy
Coreg 25 mg po BID
Lorazepam 3 mg po q 4 hours + CIWA
Nicotine patch 21 mg dilay
Magnesium oxide 400 mg [**Hospital1 **]
KCl 40 mEq po BID
Xopenex nebs 1.25 mg QID
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 21 days.
Disp:*63 Tablet(s)* Refills:*0*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 21 days.
Disp:*42 Tablet(s)* Refills:*0*
10. Bupropion 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
perforated diverticulitis
ETOH withdrawal
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in 2 weeks. Call his office ASAP
to make an appointment. ([**Telephone/Fax (1) 6347**]. You do not need any new
imaging studies prior to your visit.
Completed by:[**2154-1-22**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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10978, 10984
|
7890, 9473
|
330, 362
|
11070, 11079
|
1634, 7867
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12274, 12511
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1422, 1440
|
9854, 10955
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11005, 11049
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9499, 9831
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11103, 12251
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1455, 1455
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276, 292
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1471, 1615
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390, 1217
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1239, 1320
|
1336, 1406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,201
| 151,201
|
13775
|
Discharge summary
|
report
|
Admission Date: [**2135-10-11**] Discharge Date: [**2135-10-14**]
Date of Birth: [**2077-3-20**] Sex: M
Service: .
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old man
with a history of a two vessel coronary artery bypass graft
in [**2129**], who presented to an outside hospital with substernal
chest pain and was sent here for catheterization.
The patient reports that at the time of presentation that his
pain was epigastric, started the morning prior to
presentation and was described as ten out of ten. The
patient had diaphoresis, nausea and vomiting but no
lightheadedness. The pain lasted into the next morning. The
patient's EKG at the outside hospital showed ST elevation in
the anterior V1 through V3 leads. The patient was sent here
for catheterization.
Catheterization showed total occlusion of the left anterior
descending, open LMCA, 80% obtuse marginal 1 lesion, total
occlusion of the proximal right coronary artery, 30% mid
saphenous vein graft to the obtuse marginal 1. The left
anterior descending was stented. Of note, there was no left
internal mammary artery graft.
The patient's EKG after the procedure showed normal sinus
rhythm at 80 beats per minute and normal axis. There was
persistent ST elevation in V1, V2 and V3, greater than 3 mm.
In addition, the patient had small Q waves in II, III and AVF
and large Q waves in V1 and V2, a right atrial abnormality
was evident.
In the catheterization laboratory the patient had a run of
nonsustaining ventricular tachycardia and was started on a
lidocaine drip. He was transferred to the Cardiac Care Unit.
PAST MEDICAL HISTORY:
1. Seizure disorder; last seizure seven months prior to
admission.
2. Coronary artery disease status post coronary artery
bypass graft in [**2129**] (question two vessels).
MEDICATIONS:
1. Dilantin 300 mg p.o. q. day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother died of myocardial infarction at 80.
Father died of myocardial infarction at 73. No diabetes
mellitus, no cerebrovascular accident.
SOCIAL HISTORY: The patient denies any tobacco use. He has
occasional alcohol use now but had a greater amount in the
past but the patient cannot quantify. The patient recently
retired from Lucent. He walks two miles daily.
PHYSICAL EXAMINATION: Vital signs on admission are
hematocrit 87, blood pressure 156/76; saturation of 100% on
two liters. The patient afebrile at 95.0 F. On examination,
no jugular venous distention. Regular rhythm; no murmurs;
positive for S3. Lungs examination clear to auscultation
bilaterally. Extremities no edema, palpable pulses.
LABORATORY: Significant labs were a total cholesterol of
265, HDL 59, triglycerides 232, LDL 160. The patient's
Dilantin level was 8.2. Hematocrit 45.9. CK were as
followed, 4655, 3895, 2274, 412. Troponin was greater than
50.
BRIEF HOSPITAL COURSE: The patient was started on aspirin,
Lipitor, Plavix. He was maintained on the heparin drip for
anterior akinesis and started on Coumadin. He was kept on an
Integrilin drip initially which was discontinued. The
patient showed no evidence of ectopy once in the unit so
lidocaine drip was discontinued as well. The patient was
initially hypotensive but once Physical Therapy began working
with him, he rapidly improved.
Nevertheless, an ACE inhibitor was not started as the patient
is too hypotensive. Ideally, he will be started on an ACE
inhibitor as an outpatient by his primary care physician or
his Cardiologist. The patient underwent a signal average EKG
as follows: Total QRS duration 99 milliseconds, duration of
HFLA signal 22 milliseconds, RMS voltage 47 microvolts, mean
voltage 33 microvolts. A hemoglobin A1C was checked and
found to be 5.5. The patient was determined not to be
diabetic.
He was discharged home in stable condition.
DISCHARGE DIAGNOSES:
1. Anterior myocardial infarction.
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg p.o. q. day.
2. Coumadin 5 mg p.o. q. h.s.
3. Dilantin 300 mg p.o. q. day.
4. Lipitor 10 mg p.o. q. day.
5. Enteric coated aspirin 325 mg p.o. q. day.
6. Plavix 75 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. Follow-up appointment with Dr. [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**],
Cardiologist, [**Telephone/Fax (1) 37284**]; appointment on [**2135-10-20**].
2. Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) 29065**], primary care physician, [**Telephone/Fax (1) 29068**],
on [**2135-10-18**] to follow-up Coumadin level.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 28053**]
MEDQUIST36
D: [**2135-10-14**] 17:59
T: [**2135-10-14**] 19:30
JOB#: [**Job Number 41430**]
|
[
"E879.0",
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"414.01",
"997.1",
"V45.81",
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"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
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"36.06",
"99.20",
"36.01",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
2894, 3849
|
1922, 2063
|
3870, 3907
|
3930, 4135
|
4159, 4794
|
2315, 2870
|
165, 1621
|
1643, 1905
|
2080, 2292
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,502
| 125,483
|
8
|
Discharge summary
|
report
|
Admission Date: [**2174-5-29**] Discharge Date: [**2174-6-9**]
Date of Birth: [**2093-11-17**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
cough, SOB
Major Surgical or Invasive Procedure:
RIJ placed
Hemodialysis
History of Present Illness:
Pt is an 80F with a history of severe AS, CAD, s/p nephrectomy
for RCC with ESRD recently started on HD and recent admission to
[**Hospital1 18**] for cough [**Date range (1) 135**] p/w cough. Today she woke up from
sleep with acute shortness of breath and cough. NO Chest pain.
Husband called 911. In the ER, afebrile HR 120s, SBP 110s. CXR
with ? PNA. She was given ceftriaxone 1 gram and levofloxacin
750mg IV X1. Given continued resp distress intubated (rocuronium
and etomidate).
On presentation to the CCU pt intubated unable to provide
history. Per husbandpt has had a severe cough since discharge
from hosp productive for clear sputum. Overall has had a cough
for ~3 mos (had been treated for PNA X2 most recently [**2174-5-15**]).
She saw her cardiologist and who stopped her ramipril and
switched her to losartan 1 day PTA. She has not had any fevers,
nausea, vomiting or diaphoresis. Of note she had aoritc
valvuloplasty on [**2174-5-10**] (initially valve area 0.56cm2, gradient
27 -> after the procedure the calculated aortic valve area was
0.74 cm2 and gradient 12 mmHg.) Pt has been on dialysis in the
past but with improvement in creatinine she was not dialysed on
Thursday (last dialysis [**2174-5-24**]).
Past Medical History:
Percutaneous coronary intervention, in [**2171**] anatomy as follows:
-- LMCA clean
-- LAD: mild disease
-- LCX: mild disease with origin OM1 and OM2 60-70% stenosis
-- RCA: ulcerated 50% proximal plaque w/ mild disease
-- severe AS: [**Location (un) 109**] 0.8 cm2, peak gradient 50
-- EF 60%
.
Other Past History:
-- severe AS: cardiac investigation in [**State 108**] by [**First Name8 (NamePattern2) 110**] [**Last Name (NamePattern1) 111**]
revealed calculated [**Location (un) 109**] of 1.0 cm2, valve gradient of 32 mm Hg.
LVEF is 45-50% with apical akinesis. She has 1+ MR. Cath at [**Hospital1 **]
revealed [**Location (un) 109**] 0.8 cm2, moderate CAD at 30-40% except for 60-70%
stenosis of OM1 and OM2. Peak aortic valve gradient is 50,
cardiac output is 3.2 liters/min. No signficant carotid
disease.
-- h/o MRSA from LLE trauma in [**2173-7-14**]
-- chronic systolic CHF, EF 30-40%
-- right nephrectomy [**2165**] due to renal cell carcinoma
-- ESRD on hemodialysis for one month
-- h/o cholelithiasis
-- osteoarthritis
-- herpes zoster of the right which was intracostal
-- h/o H. pylori
-- anemia
-- h/o right inguinal herniorrhaphy in [**2156**]
-- myositis s/p muscle biopsy at [**Hospital1 112**], possibly related to statin
use
.
Social History:
Social history is significant for the absence of current tobacco
use. She has a 50 pack-year smoking history but stopped in [**2155**].
There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS
Gen: Elderly woman in NAD, pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal [**2-17**] harsh early peaking systolic murmur.
Chest: No chest wall deformities, slight kyphosis. Resp were
unlabored, no accessory muscle use. CTAB, slight crackles at
bases.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: DP 2+
Left: DP 2+
.
Pertinent Results:
Percutaneous coronary intervention, in [**4-/2174**]:
COMMENTS:
1. Limited coronary angiography demonstrated heavily calcified
left
main, left anterior descending and left circumflex arteries. The
left circumflex had a heavily calcified proximal lesion.
2. LV ventriculography was deferred.
3. Successful Rotational atherectomy, PTCA and stenting of the
proximal left circumflex artery with a Cypher (3x13mm) drug
eluting stent postdilated to 3.5mm. Final angiography
demonstrated no
angiographically apparent dissection, no residual stenosis and
TIMI III flow throughout the vessel (See PTCA Comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful rotational atherectomy, PTCA and stenting of the
proximal LCX with a drug eluting stent (Cypher).
.
.
2D-ECHOCARDIOGRAM performed on [**2174-5-20**] demonstrated:The left
atrium and right atrium are normal in cavity size. There is
moderate symmetric left ventricular hypertrophy with normal
cavity size and moderate global hypokinesis (LVEF = 30-35 %).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are moderately thickened. There is
severe aortic valve stenosis (area 0.7cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-15**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is a very small circumferential pericardial
effusion.
IMPRESSION: Severe aortic valve stenosis. Moderate symmetric
left ventricular hypertrophy with moderate global hypokinesis.
Mild-moderate mitral regurgitation. Pulmonary artery systolic
hypertension.
.
[**2174-5-29**] 03:15AM BLOOD WBC-17.0*# RBC-3.46* Hgb-9.3* Hct-29.7*
MCV-86 MCH-26.9* MCHC-31.3 RDW-16.0* Plt Ct-567*#
[**2174-5-29**] 03:15AM BLOOD PT-14.1* PTT-22.3 INR(PT)-1.2*
[**2174-5-29**] 03:15AM BLOOD Glucose-337* UreaN-46* Creat-1.9* Na-138
K-4.9 Cl-104 HCO3-16* AnGap-23*
[**2174-5-29**] 03:15AM BLOOD CK(CPK)-21* Amylase-34
[**2174-5-29**] 03:15AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-[**Numeric Identifier 136**]*
[**2174-5-29**] 06:58AM BLOOD Type-ART Rates-14/22 FiO2-100 pO2-127*
pCO2-42 pH-7.28* calTCO2-21 Base XS--6 AADO2-558 REQ O2-91
-ASSIST/CON Intubat-INTUBATED
[**2174-6-3**] 04:06AM BLOOD WBC-6.5 RBC-3.06* Hgb-8.3* Hct-25.4*
MCV-83 MCH-27.0 MCHC-32.5 RDW-15.4 Plt Ct-193
[**2174-6-3**] 04:06AM BLOOD PT-16.0* PTT-39.5* INR(PT)-1.4*
[**2174-6-3**] 04:06AM BLOOD Glucose-96 UreaN-11 Creat-2.1* Na-139
K-4.2 Cl-105 HCO3-24 AnGap-14
[**2174-6-4**] 06:51AM BLOOD ALT-7 AST-13 LD(LDH)-176 AlkPhos-61
TotBili-0.3
[**2174-6-2**] 08:20AM BLOOD calTIBC-341 VitB12-963* Folate-6.6
Ferritn-41 TRF-262
[**2174-6-2**] 01:40AM BLOOD Type-ART pO2-104 pCO2-35 pH-7.46*
calTCO2-26 Base XS-1
.
EKG on admission-Sinus tachycardia with left bundle-branch block
with secondary ST-T wave
abnormalities. No diagnostic change from tracing #1.
.
[**Month/Day/Year **] on admission - The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with near akinesis of the inferior and inferolateral
walls and mild-moderate hypokinesis of the remaining segments
(LVEF = 30-35%). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis (area 0.9cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. At least mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is borderline pulmonary artery systolic
hypertension. There is a small, primarily anterior (?loculated)
pericardial effusion without evidence of hemodynamic compromise
with a prominent anterior fat pad.
.
[**6-6**] EKG - Sinus tachycardia. Left atrial abnormality. Left
bundle-branch block.
Left axis deviation. Secondary repolarization abnormalities.
Compared to the
previous tracing of [**2174-6-4**] heart rate has increased. Otherwise,
no major
change.
.
CXRs over the course of admission showed slowly improving
pulmonary edema, no major focal consolidations were seen.
.
Renal US - no hydronephrosis, patent renal artery.
Brief Hospital Course:
# PUMP/Chronic systolic congestive heart failure:
Patient presented with presumed acute exacerbation of chronic
systolic heart, which has improved after ultrafiltration. [**Date Range **]
with EF of 30-40% unchanged from prior. She currently appears
fairly euvolemic, however her fluid status has remained
difficult to manage given her low ejection fraction and poor
urine output.
- Continued home doses of carvedilol and losartan. Were held
initially for low blood pressures, but both restarted during her
admission.
- Hemodialysis was considered for fluid managment, but a trial
of lasix proved successful. She will now go home on 160 mg PO
daily lasix and follow up with Dr. [**Last Name (STitle) 118**], her nephrologist.
She will monitor daily weights/low sodium diet, pt had nutrition
consult during stay.
.
# CAD: No evidence ACS during hospitalization. Patient is s/p
recent LCx stent. She was continued on ASA, carvedilol, plavix,
and Losartan.
.
#. Valves. No active issues. Severe AS a/p valvuloplasty
[**2174-5-11**], stable AS per [**Month/Day/Year **]. Discussed with patient and family:
per their report, patient was previously evaluated by Dr.
[**Name (NI) 137**] in cardiac surgery and was not a candidate for valve
replacment due to "calcifications." Patient may be candidate for
new cath-assisted valve replacement. Also has mild MR on last
[**Name (NI) 113**]. Pt should likely be re-evaluated after discharge.
.
# Respiratory distress resolved -
Respiratory distress was suspected to be likely multifactorial
secondary to volume overload and also PNA as supported by
elevated WBC on presentation, fever, and now GNR in sputum gram
stain but not growing on culture. Increased sputum overnight
while afebrile, non-elevated white count likely represents
resolving infection. Received monotherapy with ceftazadime only
given GNR in sputum may be pseudomonas; antibiotics started
[**5-29**], continued for 7 days. She will continue lasix as
outpatient to try and prevent pulm edema.
.
# ANEMIA/GIB:
HCT drop was noted several two days into admission, unclear if
represented true blood loss. NGT removed [**5-31**] and this
demonstrated frank dark blood (+hemoccult) in NGT, likely
representing bleed several days ago from gastritis. LDH and
haptoglobin were checked with HCT drop and were within normal
limits which is inconsistent with hemolysis. She received 1 u
PRBCs soon after admission, and HCT has remained stable since.
Her Hcts were between 26 and 28. Stools were checked for guiac,
and were positive two days prior to dicharge. We discharged her
home with protonix and recommend follow up with her PCP to
continue to monitor CBCs for watch for blood loss. She is not
actively losing blood as seen by her stable Hcts. We also
recommend an outpatient colonoscopy. Although, she needs to be
very careful with the bowel prep, as that can cause large fluid
shifts and drive her into pulmonary edema.
.
# Acute on chronic renal failure (stable Cr):
Acute on chronic renal failure likely due to ATN secondary to
hypotension versus ongoing pre-renal state. Patient had been
initiated on HD in [**2174-3-15**]; was taken off HD ~1 week prior to
admission. Volume overload/CHF on admission, improved with UF,
now appears euvolemic. Creatinine 1.... on discharge. Pt has
history of RCC with nephrectomy. Renal function has seemed to
normalize. Will continue follow up with nephrologist and he
will also coordinate removal of dialysis catheter.
# Pt was discharge to home with services for PT and home health
care for dialysis catheter dressing changes.
Medications on Admission:
Aspirin 325 mg PO daily
Carvedilol 3.125 mg PO BID
Clopidogrel 75 mg PO daily
Losartan (switched from ramipril 5 mg on [**2174-5-27**])
B Complex-Vitamin C-Folic Acid 1 mg daily
Calcium Acetate 667 mg Capsule 1 po tid
Fexofenadine 60 mg daily
Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-15**] Sprays Nasal QID
Discharge Medications:
.
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**]
Drops Ophthalmic PRN (as needed).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 0.5-1 Tablet
PO every four (4) hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
10. 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*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
12. Furosemide 40 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
1. Respiratory Failure
2. CHF
3. Renal Failure
Secondary Diagnoses:
1. Aortic Stenosis
2. Anemia
3. HTN
Discharge Condition:
Stable, afebrile, pt walking with a walker, eating on her own,
with a normal mental status.
Discharge Instructions:
You were admitted for respiratory distress due to fluid in your
lungs from an acute episode of worsening heart failure. You
were intubated at the time, and when you were able to breath on
your own, we continued to remove fluid from your lungs with
diuretics. We also are continuing to give you the medicines
carvedilol and losartan for your heart failure.
You also will start taking lasix daily to ensure fluid stays off
your lungs.
In addition, you had acute renal failure during this admission.
Your kidney function improved, but you will continue to need
follow up with Dr. [**Last Name (STitle) 118**]. You also have a dialysis catheter in
your chest that will need to be taken care of by a home nurse.
Dr. [**Last Name (STitle) 118**] will discuss removal of the catheter as an
outpatient.
We also found a trace amount of blood in your stool. You should
meet with your PCP and discuss having a colonoscopy. Make sure
to tell them you have heart failure because it does affect the
bowel preparation they plan for you.
Once at home, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight >
3 lbs.
Adhere to 2 gm sodium diet. Call the nutritionist with any
questions.
Also, if you experience any worsening shortness of breath, chest
pain, dizziness or fainting or any other worrisome symptoms, do
not hesitate to call your doctor or call 911 in case of
emergency.
Completed by:[**2174-6-14**]
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[
[
[]
]
] |
13535, 13593
|
8366, 11951
|
283, 309
|
13761, 13855
|
3837, 4441
|
3047, 3129
|
12318, 13512
|
13614, 13681
|
11977, 12295
|
4458, 8343
|
13879, 15296
|
3144, 3818
|
13702, 13740
|
233, 245
|
337, 1562
|
1584, 2839
|
2855, 3031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,799
| 171,119
|
18754
|
Discharge summary
|
report
|
Admission Date: [**2140-9-15**] Discharge Date: [**2140-9-21**]
Date of Birth: [**2104-9-10**] Sex: F
Service: MEDICINE
Allergies:
Tape [**1-25**]"X10YD / Augmentin / Hydrocodone / Levofloxacin /
Ciprofloxacin / fentanyl / Keflex / ceftriaxone / Ativan
Attending:[**Last Name (NamePattern1) 9662**]
Chief Complaint:
Diabetic ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
36F with DMI (last A1c 11 on [**2140-8-22**]) and gastroparesis
presented with intractable nausea and vomiting on [**2140-9-15**] and
was admitted to the medicine service.
She endorsed a mild headache on [**2140-9-14**] and vomiting on
[**2140-9-15**], otherwise had been feeling well until development of
nausea. She has had non-bloody emesis x [**4-28**].
She denies abdominal pain or diarrhea, fever/chills, recent URI,
CP, SOB, dysuria, and diarrhea, new rash, joint pain.
Notably, believes increased stress yesterday triggered this
episode. She has previously responded well to ativan and
erythromycin.
In the ED, initial vitals 140/96 106 16 97% on RA and inital BS
was 248. While in the ED her BP rose to 196/106, which responded
well to labetalol 10mg, ativan 1mg IV x 2 doses, zofran 4mg x1,
and metoclopramide 10mg x1. She was given 2 units of humalog
initially, followed by an additional 4units 4 hours later. She
was also given 2 liters of IVF.
Vitals prior to transfer: 167/84 110 14 99% on RA
The patient was admitted by the medicine nightfloat service. In
the morning, she was noted to have elevated blood glucose on AM
labs:
Na 147 K 4.7 Cl 106 HCO3 13 BUN 36 Cr 1.6 Glucose 545 (from 171)
with anion gap
WBC 13 Hgb 10.5 (baseline 10.8-11.8) Plt 397
ABG 7.31/30/110/16 lactate 1.7
Past Medical History:
-Type 1 DM c/b retinopathy ("quiescent" proliferative on last
eye
exam, [**4-/2136**]), nephropathy (nodular glomerulosclerosis on renal
bx [**2139-9-15**]; baseline Cr ~1.0-1.1 in [**12/2139**]), and
gastroparesis. Diagnosed at age 11, multiple hospitalizations
for DKA. HbA1c was 7.8 on [**2140-2-15**].
-Barrett's esophagitis, GERD, gastritis, PUD (antral ulcer [**2132**])
-HLD
-HTN
-dCHF LVEF >60% in [**8-/2139**]
-normocytic anemia
-acquired hemophilia (FVIII inhibitor in [**2132**]) treated
w/steroids
and rituximab
-anti-E and warm autoantibody (negative Coombs)
-hydronephrosis
-osteoporosis ([**2138-11-12**] T-score L spine -2.2, femoral neck -3.1)
-migraines
-depression
-h/o avascular necrosis
-h/o severe hyperemesis gravidarum requiring TPN
-h/o PEA arrest during renal biopsy [**2139-9-15**] (on fentanyl and
versed)
Social History:
Re-married, lives at home with mother, husband, and 8-year-old
son from first marriage. Currently a homemaker. On disability
since [**2132**].
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No h/o bleeding disorder. Kidney cancer and colitis in maternal
grandfather.
Physical Exam:
ADMISSION PHYSICAL EXAM
T 97.6 HR 122 BP 156/97 RR 17 O2 97%RA
GENERAL - sleepy ill appearing F, but in NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - RRR, S1-S2 clear and of good quality without murmurs,
rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-28**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE PHYSICAN EXAM
T 98.1 HR 100 BP 140/50 RR 18 O2 98% RA
GENERAL - awake and alert in NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - RRR, S1-S2 clear and of good quality without murmurs,
rubs or gallops
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-28**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
ADMISSION LABS
[**2140-9-15**] 03:00PM BLOOD WBC-8.9 RBC-3.82* Hgb-11.8* Hct-35.5*
MCV-93 MCH-30.9 MCHC-33.3 RDW-13.4 Plt Ct-427
[**2140-9-15**] 03:00PM BLOOD Neuts-82.2* Lymphs-15.1* Monos-1.3*
Eos-0.7 Baso-0.7
[**2140-9-15**] 03:00PM BLOOD Glucose-222* UreaN-52* Creat-1.8* Na-141
K-4.3 Cl-99 HCO3-28 AnGap-18
[**2140-9-15**] 03:00PM BLOOD ALT-13 AST-16 AlkPhos-87 TotBili-0.2
[**2140-9-15**] 11:51PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2140-9-15**] 03:00PM BLOOD Albumin-3.7
[**2140-9-16**] 10:05AM BLOOD Type-ART pO2-110* pCO2-30* pH-7.31*
calTCO2-16* Base XS--9
[**2140-9-16**] 11:57PM BLOOD Glucose-159* Na-143 K-3.6 Cl-115*
calHCO3-23
DISCHARGE LABS
[**2140-9-21**] 05:51AM BLOOD WBC-7.2 RBC-2.89* Hgb-9.0* Hct-27.1*
MCV-94 MCH-31.1 MCHC-33.1 RDW-13.5 Plt Ct-299
[**2140-9-21**] 05:51AM BLOOD Glucose-115* UreaN-15 Creat-1.5* Na-139
K-4.0 Cl-106 HCO3-26 AnGap-11
[**2140-9-20**] 03:31AM BLOOD ALT-9 AST-12 AlkPhos-53 TotBili-0.1
[**2140-9-21**] 05:51AM BLOOD Calcium-8.2* Phos-4.8* Mg-1.7
[**2140-9-20**] 11:00PM BLOOD CK-MB-2 cTropnT-<0.01
PERTINENT LABS
[**2140-9-17**] 07:10AM BLOOD ALT-11 AST-17 LD(LDH)-298* AlkPhos-68
TotBili-0.1
[**2140-9-18**] 02:55AM BLOOD ALT-8 AST-13 AlkPhos-56 TotBili-0.1
[**2140-9-20**] 03:31AM BLOOD ALT-9 AST-12 AlkPhos-53 TotBili-0.1
[**2140-9-15**] 03:00PM BLOOD Lipase-12
[**2140-9-20**] 11:00PM BLOOD CK-MB-2 cTropnT-<0.01
Microbiology: no pertinent
PERTINENT STUDIES
CXR [**9-15**]
FINDINGS: PA and lateral views of the chest are compared to
previous exam
from [**2140-6-25**]. There are vague rounded opacities projecting
over the
right mid-to-lower lung seen over the anterior and lateral ribs,
suggesting healing fractures. The lungs are clear of focal
consolidation or effusion. Cardiomediastinal silhouette is
within normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: Multiple healing right-sided rib fractures. No
acute
cardiopulmonary process.
Brief Hospital Course:
36F history of poorly controlled DM1, Barrett's
esophagitis/gastritis, HTN, diastolic CHF with LVEF >60%, h/o
PEA arrest in [**2139**], here with symptoms consistent with
gastroparesis flair and transferred to MICU for diabetic
ketoacidosis with secondary issue of hemeatemsis likely from
[**Doctor First Name **]-[**Doctor Last Name **] tear.
ACTIVE ISSUES
# DKA: Poorly-controlled DM type one (last A1c 11). No clear
precipitant (infectious, no pancreatitis, MI) other than stress.
She had a slight leukocytosis on admission, but no other signs
of infection. Patient was found to be in DKA with anion gap on
hospital day 2, transferred to MICU where anion gap closed
within one day. Started on Insulin drip with q1hr glucose
checks, and insulin gtt . Remained on insulin drip due to
intolerance of PO diet. Able to tolerate PO overnight [**9-19**], DC'd
insulin gtt. While on the regular medicine floor, pt continued
to tolerate po diet fairly well. Her blood sugar was well
controlled with subcu insulin.
# Gastroparesis - Patient's presenting symptoms were consistent
with previous gastroparesis flairs (previously unresposive to
Ativan, Reglan, Zofran, and erythromycin). Patient was able to
tolerate PO's on [**2140-9-20**]. Currently nausea/vomiting is
well-controlled in-hospital with clonidine patch and PRN Ativan,
Zofran, and Dimenhydrinate. Her symptoms improved significantly
after transferring the regular medicine floor. We discontinued
her clonidine patch given the significant orthostatic
hypotension. Her gastroparesis has a characteristic
intermittent flare-up every two to three months. It is unclear
the long term benefit of clonidine in her given for the most
time in-between her flares, she is asymtpomatic.
# Hypertensive Urgency - Patient had labile pressures while in
the MICU with sBPs>200, which was controlled in MICU with
labetolol drop and IV labetolol. Prior the transfer to the
floor, patient was transitioned to amlodopine 5mg QD and
clonidine patch with adequate control of BP. On discharge, her
SBPs are 140s-160s. Pt had significant autonomic dysfunction
likely in the setting of long-term poorly controlled diabetes.
Her blood pressure medication has been weaned off by her PCP to
prevent hypotension. After discussion with her PCP, [**Name10 (NameIs) **] decided
to discontinue her blood pressure medication started as
inpatient and continue outpatient followup.
# Hypernatremia - Free water deficit of 1.2 was repleted with
1/2NS with slow correction of hypernatremia from 153 to 144 over
28 hours. On discharge, patient is asymptomatic with Na trending
down to 139.
# Anemia and Coffee ground emesis - Consistent with low-volume
upper GI bleed from [**Doctor First Name **]-[**Doctor Last Name **] tear. GI consult saw in-house,
and recommended conservative management with pantoprazole.
Throughout the hospital course, the patient remained
hemodynamically stable with stable Hct27-30. Patient was placed
on PPI and crossmatched with PIV in place.
# [**Last Name (un) **] - Baseline Cr 1.0. During this admission, Cr 1.2-1.8 most
likely due to pre-renal etiology given poor PO intake and
vomiting. Following IV hydration patient was noted to have a
down trend in her BUN and [**Last Name (un) **]. On discharge, BUN stable
at 12-15, Cr at 1.2-1.5, iet.
CHRONIC ISSUES
# Depression / anxiety - continued on home Sertraline and Ativan
# Neuropathy - continued on home gabapentin
TRANSIONAL ISSUES
# Code status: Full code
# Pending studies: None
# Medication changes:
- Dimenhydrinate 50 mg PO PRN nausea/vomiting
# FOLLOWUP PLAN
- PCP followup on [**9-27**]
- [**Last Name (un) **] diabetes followup on [**9-23**]
Attending addendum: After speaking with PCP, [**Name10 (NameIs) **] was decided to
stop all blood pressure medications upon discharge as patient
was profoundly orthostatic.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Gabapentin 800 mg PO HS
2. Sertraline 100 mg PO DAILY
3. Furosemide Dose is Unknown PO Frequency is Unknown
4. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Ferrous Sulfate 325 mg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
7. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
8. Simvastatin 20 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Metoclopramide 10 mg PO Frequency is Unknown
Discharge Medications:
1. Gabapentin 800 mg PO HS
2. Calcium Carbonate 500 mg PO QID:PRN upset stomach
3. Sertraline 100 mg PO DAILY
4. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Ferrous Sulfate 325 mg PO DAILY
6. Metoclopramide 10 mg PO HS:PRN heartburn
7. Omeprazole 40 mg PO DAILY
8. Atorvastatin 20 mg PO DAILY
9. Torsemide 10 mg PO DAILY
10. Vitamin D [**2128**] UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Diabetic ketoacidosis with gastroparesis
Secondary Diagnoses: Hypertensive urgency, anemia due to
[**Doctor First Name **]-[**Doctor Last Name **] tear, chronic kidney disease.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Last Name (Titles) **],
You were admitted at [**Hospital1 69**] for
nausea/vomiting. We found that you had diabetic ketoacidosis
with gastroparesis and hypertensive urgency. You are now safe
to go home.
Please note that there is no changes in your medication.
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2140-10-24**] at
8:20AM.
Followup Instructions:
Department: Endocrinology- [**Last Name (un) **] Diabetes Center
Name: Dr. [**First Name (STitle) 16433**] [**Name (STitle) **] for Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 20556**]
When: [**Last Name (NamePattern1) 2974**] [**2140-9-23**] at 9:30 AM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Apartment Address(1) 20557**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2490**]
Department: [**Hospital3 249**]
When: TUESDAY [**2140-9-27**] at 3:10 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2140-10-24**] at 8:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"584.9",
"V58.67",
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"250.63",
"272.4",
"346.90",
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"733.00",
"362.02",
"403.90",
"357.2",
"285.9",
"337.1",
"536.3",
"V12.53",
"250.43",
"250.53",
"300.4",
"585.9",
"530.7",
"250.13",
"276.69",
"458.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11089, 11095
|
6241, 9750
|
412, 419
|
11335, 11335
|
4280, 6218
|
11907, 13039
|
2841, 2920
|
10674, 11066
|
11116, 11116
|
10122, 10651
|
11486, 11884
|
2935, 4261
|
11197, 11314
|
9771, 10096
|
351, 374
|
447, 1755
|
11135, 11176
|
11350, 11462
|
1777, 2616
|
2632, 2825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,809
| 149,867
|
48880
|
Discharge summary
|
report
|
Admission Date: [**2133-1-7**] Discharge Date: [**2133-1-11**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Hyperglycemia
.
PCP: [**First Name8 (NamePattern2) 58216**] [**Name11 (NameIs) 7537**]
[**Name12 (NameIs) **]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Major Surgical or Invasive Procedure:
femoral central venous line
History of Present Illness:
54 yo F with history of type 1 DM, severe gastroparesis, HTN,
Grave's Ds and Hep C, presents with DKA for second time in 3
weeks. Patient was admitted at the end of [**Month (only) **] with
hyperglycemia and an anion gap acidosis in the setting of a
cough and fevers. She was discharged to home and in the last
several days noticed her blood sugars running high, this time
unaccompanied by fevers/coughing. She admits to +n/v and
abdominal pain. Before her electrolytes came back, she was
treated in the ED with three doses of Humalog. Once it was
evident that she had a gap acidosis, an insulin gtt was
initiated. Vitals in the ED were T 98.8, HR 125, BP 130/66, RR
16, Sats 100% RA.
Although she had no obvious focus of infection, blood cultures
and UA were sent and CXR ordered.
She was sent to the MICU for further management of DKA while on
an insulin gtt.
.
In the MICU, the patient is currently [**Month (only) **] non-bloody
bilious emesis, requiring a dose of zofran IV. She denies
SOB/CP, cough, dysuria, f/c's. No diarrhea. She admits to
abdominal pain, similar to her chronic gastroparesis pain, but
more severe. Patient claims she was taking all of her insulin as
directed.
Past Medical History:
1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**]
Several episodes of DKA (last one in [**2129**]), managed on 36U
Lantus plus HISS
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease s/p RAI [**2129**]
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
never been on antiviral therapy, acquired via blood transfusion
during surgery in [**2110**]
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-23**]
11.s/p TAH and pelvic floor surgery with bladder lift
12.Depression
13. Obesity
14. Bone spurs in feet
Social History:
No smoking/EtOH/drugs. Lives at home with 2 daughters. [**Name (NI) **] lives
downstairs
Family History:
Mother: died of colon cancer
Long h/o DM-2
Physical Exam:
VS: Temp: 98.3 BP: 174/91 HR: 120 RR: 18 O2sat 100% RA
GEN: pleasant, fatigued but NAD
[**Name (NI) 4459**]: [**Name (NI) 2994**], EOMI, anicteric, dry MM, op without lesions
NECK: Flat jvd, supple
RESP: CTA b/l with good air movement throughout
CV: Tachy but regular, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, diffusely tender but no rebound or
guarding, no masses. Neg [**Doctor Last Name 515**].
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Moves all extremities.
Pertinent Results:
[**2133-1-7**] 09:21PM GLUCOSE-83 UREA N-12 CREAT-1.1 SODIUM-133
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-9
[**2133-1-7**] 09:21PM CALCIUM-9.4 PHOSPHATE-1.3* MAGNESIUM-2.3
[**2133-1-7**] 01:10PM GLUCOSE-265* UREA N-11 CREAT-0.8 SODIUM-136
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15
[**2133-1-7**] 01:10PM CALCIUM-9.5 PHOSPHATE-1.8* MAGNESIUM-1.5*
[**2133-1-7**] 08:03AM GLUCOSE-296* UREA N-15 CREAT-0.8 SODIUM-134
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16
[**2133-1-7**] 08:03AM ALT(SGPT)-16 AST(SGOT)-17 LD(LDH)-149 ALK
PHOS-97 AMYLASE-49 TOT BILI-0.5
[**2133-1-7**] 08:03AM LIPASE-39
[**2133-1-7**] 08:03AM ALBUMIN-4.2 CALCIUM-10.0 PHOSPHATE-2.6*#
MAGNESIUM-1.7
[**2133-1-7**] 08:03AM TSH-LESS THAN
[**2133-1-7**] 03:49AM TYPE-ART PO2-109* PCO2-32* PH-7.31* TOTAL
CO2-17* BASE XS--9 INTUBATED-NOT INTUBA
[**2133-1-7**] 03:49AM LACTATE-2.1*
[**2133-1-7**] 03:38AM URINE HOURS-RANDOM
[**2133-1-7**] 03:38AM URINE UHOLD-HOLD
[**2133-1-7**] 03:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2133-1-7**] 01:09AM GLUCOSE-608* UREA N-19 CREAT-1.4* SODIUM-134
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-10* ANION GAP-34*
[**2133-1-7**] 01:09AM estGFR-Using this
[**2133-1-7**] 01:09AM CALCIUM-10.8* PHOSPHATE-4.2 MAGNESIUM-2.1
[**2133-1-7**] 01:09AM ACETONE-LARGE
[**2133-1-7**] 01:09AM WBC-5.4 RBC-4.43# HGB-13.1# HCT-40.2# MCV-91
MCH-29.6 MCHC-32.7 RDW-13.7
[**2133-1-7**] 01:09AM NEUTS-79.0* LYMPHS-19.2 MONOS-1.5* EOS-0.1
BASOS-0.1
[**2133-1-7**] 01:09AM PLT COUNT-381
.
CXR: IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
54 yo woman h/o type 1 DM w/ gastroparesis and neuropathy, HTN,
Hep C presents with DKA (initial Glc 777, AG 33) and fevers,
nausea, [**Month/Day/Year **] (nonbloody), worsening gastroparesis pain and
nonproductive cough. In the MICU, patient was placed on insulin
drip. She was restarted on lower dose lantus and placed on her
outpatient sliding scale. She was tolerating meals well and her
abdominal pain was improved.
.
1. Diabetes Melitus: On admission she was in DKA based on AG of
29, ketones in urine and Glc of 608 in ED. She reported
compliance w/ home insulin. ECG was unchanged from previous. She
had no f/c or leukocytosis. Alternatively worsened gastroparesis
with nausea, vomitting and abdominal pain also possible. Initial
UA and blood cultures were negative. Initial urine culture grew
gardnerella vaginalis. Subsequent UA equivocal with < [**2125**] GNR's
on culture. Final UA also equivocal but culture grew >100,000
e.coli (pan-sensitive) which developed with catheter in place so
treated with 1 week of ciprofloxacin. CXR unremarkable. One set
of blood cultures grew coag neg staph but subsequent cultures
were negative at the time of discharge so this was thought to be
a contaminant. Last A1c in [**3-26**] was 6.0, markedly elevated on
last admission to 10. In the MICU she was treated with an
insulin drip and electrolyte repletion. She was stabilized on
this, gap was closed, she was transferred to the floor, and
initially started on less than normal dose lantus with sliding
scale. She had fair glycemic control and was tolerating food.
She was discharged to resume her home dose of insulin (20 units
glargine twice daily, with humalog sliding scale. [**Last Name (un) **]
followed her in house and she will follow-up with them as an
outpatient. She was continued on reglan for gastroparesis.
2 Gastroparesis: She had nausea, [**Last Name (un) **] and abdominal pain on
presentation thought secondary to her diabetic gastroparesis
with no clear infectious process presenting itself. This was
controlled and she resumed home reglan.
3 Urinary tract infection: Noted after foley catheter placed in
MICU. She was started on cipro for pan-sensitive e.coli for a 7
day course, started [**1-9**]. She should have a repeat UA and
culture once she has completed the antibiotics.
4 Coag negative staph in blood cultures: Not present on initial
cultures or subquent surveillance cultures. Thought to be a
contaminant given lack of signs or symptoms of infection.
5 Acute Renal Failure: Normal On arrival creatinine was elevated
to 1.4. This improved to 0.9 with hydration so was thought to be
prerenal given dehydration. This did not recur during her
hospital course.
6 Headache: She has a history of migraine headaches and
developed unilateral pain typical of her usual migraine pain in
house. This was treated with morphine and tylenol in house and
resolved.
7 Leukopenia: She develped mild leukopenia, with a WBC count of
3.7 on discharge. She has had leukopenia to this level in the
past and will need follow-up with her PCP to have this repeated
and further evaluated as an outpatient.
8 Hypertension: She was noted to develop hypertension in the
MICU so was restarted on her losartan with excellent hemodynamic
control by the time of discharge.
9 History of Anemia: Baseline high 20's, normocytic, iron
studies suggestive of AOCD. At baseline on discharge.
10 Asthma: She was continuted on inhalers in house but no
evidence of asthma exacerbation.
11 Polyneuropathy: She was conintinued on neurontin for this in
house.
12 Grave's disease: She was continued on Methimazole in house at
home doses. Her TSH returned suppressed in the MICU and free T4
at that time was 2.7, which is mildly elevated. These should be
repeated as an outpatient and she may need her regimen
re-addressed. She was asymptomatic at these values.
.
13 Seronegative arthritis: No active issues in house, she was
restarted on sulfasalazine and prn naprosyn.
14 Depression: She was continued on amitriptylline.
Medications on Admission:
Trazodone 100 mg PO HS (at bedtime) as needed for insomnia.
Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for sob, wheezing.
Amitriptyline 25 mg PO HS (at bedtime).
Gabapentin 300 mg qP Q12H
Aspirin 81 mg Tablet, PO DAILY (Daily).
Methimazole 10 mg PO TID
Metoclopramide 10 mg PO QIDACHS
Montelukast 10 mg PO DAILY
Hexavitamin PO DAILY
Pantoprazole 40 mg PO Q24H
Salmeterol 50 mcg/Dose Disk Q12H
Simvastatin 10 mg PO DAILY
Sulfasalazine 500 mg PO 3 tabs [**Hospital1 **]
Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO q6H PRN
Hyoscyamine Sulfate 0.125 mg Tablet, SL [**Hospital1 **]
Losartan 50 mg PO DAILY
Lantus 20 Units [**Hospital1 **]
HISS
Flexeril
Zelnorm 6mg 1 tab PO TID
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous twice a day.
14. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
15. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.
16. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
Disp:*QS 1 month * Refills:*2*
17. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-25**]
hours as needed for pain.
18. Levsin 0.125 mg Tablet Sig: One (1) Tablet PO once a day.
19. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
20. Flexeril 10 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
21. zelnorm Sig: Six (6) mg PO three times a day.
22. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1)
inhalation Inhalation twice a day.
Disp:*QS 1 month * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
Primary: Diabetic ketoacidosis / Type 2 Diabetes mellitus with
complications and uncontrolled
.
Secondary: Urinary tract infection, hypertension,
polyneuropathy, depression, seronegative arthritis, asthma.
Discharge Condition:
Tolerating food, improved blood glucose control, hemodynamically
stable without fever.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. Please call your primary care doctor,
your [**Last Name (un) **] doctor, or return to the ED if you experience
fevers, chills, nausea, vomitting, diarrhea, pain with passing
your urine, back pain, or any symptoms that concern you.
Followup Instructions:
Please call [**Telephone/Fax (1) 7538**] to schedule follow-up with your primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 58216**] [**Name (STitle) 7537**] within the next week. You
should have a repeat urinalysis and culture after you finish
your ciprofloxicin for your urinry tract infection.
.
Please also call [**Last Name (un) **] to schedule follow-up this week.
|
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[
[]
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59,373
| 171,393
|
41022
|
Discharge summary
|
report
|
Admission Date: [**2162-12-21**] Discharge Date: [**2163-1-27**]
Date of Birth: [**2129-3-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Abdominal pain/ pancreatitis
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
History of Present Illness:
33 year old gentleman with h/o polysubstance abuse (EtOH,
cocaine, Xanax), DM2, seizure disorder (? withdrawal), severe
depression, alcoholic pancreatitis in [**6-/2162**] admitted to OSH w/
hypertriglyceridemic pancreatitis on [**12-18**]. Initially intubated
for agitation, ? withdrawal, course complicated by respiratory
failure and development of ARDS.
The patient initially presented on [**12-18**] with report of 24 hours
of acute onset abodominal pain accompanied by nausea. While he
denied EtOH use, a close friend endorsed recent EtOH abuse.
Serum and urine tox were negative on presentation. He denied
hematemes, BRBPR. Labs on presentation WBC 11, hct 31.2, lipase
1500, triglycerides >3600 (greater than assay), cholesterol was
over 1000 and normal LFTs. CT scan demosntrated acute
pancreatitis, with peripancreatic fluid wihtout loculated
collections in addition to a fatty liver. The patient was seen
by GI c/s who felt sx c/w severe pancreatitis likely [**2-3**]
hypertriglyceridemia. Felt transfer to tertiary care center for
plasma exchange of triglycerides if no improvement demosntrated.
The patients hospital course was complicated by severe agitation
and question of withdrawal seizure. On HD 3 he was intubated due
to sedation for agitation/management of withdrawal. He was
started on TPN for nutritional support and a triple lumen PICC
line was placed. He was started on gemfibrozil 600mg [**Hospital1 **]. Since
intubation serial chest xrays have demonstated worsening
bilateral infiltrates that have become diffuse in nature. He
was initially treated with aggressive IVF. He became febrile by
HD3, and was started on vancomycin and zosyn for empiric
anti-microbial coverage of hospital acquired pneumonia. By HD
5, he developed worsening hypoxia, and was noted to be
asyncronous with the vent requiring high PEEPs. His fluids were
decreased to 120cc per hour and he was given 40 of IV lasix for
concern that volume overload was contributing. 7.26/51/69 while
AC Vt 500 RR18 Fio2 of 80% and PEEP 10. His hospital course has
further been complicated by hyponatremia which corrected with NS
boluses in addition to acute on chronic anemia. Hemolysis labs
on HD2 were negative. He was transfused a total of 4 units of
pRBC. On HD 5, at the request of his family, transfer to [**Hospital1 18**]
was initiated. His labs on transfer were WBC 9.6, Hct 25.9, pts
157, bands 33, Na 134, Creatinine 1.6, cholesterol 463,
triglycerides 1477.
On arrival to the ICU, initial vitals were: 101.1; HR 120; BP
138/68; RR 18, O2 sat 96%.
Review of systems:
Unable to obtain
Past Medical History:
1. Insomnia
2. Obstructive Sleep Apnea
3. Major Depression
4. Seizure Disorder, ? [**2-3**] alcohol withdrawal
5. Pancreatitis [**2162-6-2**] (EtOH)
6. Etoh/cocaine abuse
7. Anemia
Social History:
Single, lives with roommates, works with his sister. [**Name (NI) **] been
struggling with polysubstance abuse for many years.
- Tobacco: Denies
- Alcohol: Heavy alcohol abuse per roommate
- Illicits: H/o cocaine, xanax abuse
Family History:
No family history of hypertriglyceridemia or pancreatitis
Physical Exam:
Admission exam:
VS 101.1; HR 120; BP 138/68; RR 18, O2 sat 96%
General: Intubated, sedated, not responsive to commands
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse crackles bilaterally, no wheezes.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, hypoactive bowel sounds, no organomegaly
GU: foley in place
Ext: trace edema to ankles, warm, well perfused, 2+ pulses
Discharge Exam:
Vitals: T Afebrile HR 90s-110s BP 130s-150s/90s RR 18 SaO2 98%
RA
General: Walking around. NAD.
Pulm: CTAB, good aeration
CV: nl s1 s2. tachy reg. no mrg
Abd: soft, NT, ND.
Ext: warm, no edema
Neuro: no tremor, following commands. Oriented x3.
Psych: Alert. Calm. Flat affect.
Pertinent Results:
Admission Labs:
[**2162-12-21**] 11:50PM BLOOD WBC-12.8* RBC-3.97* Hgb-9.6* Hct-29.9*
MCV-75* MCH-24.2* MCHC-32.2 RDW-18.7* Plt Ct-187
[**2162-12-22**] 10:17AM BLOOD WBC-10.5 RBC-3.49* Hgb-8.5* Hct-26.7*
MCV-77* MCH-24.5* MCHC-31.9 RDW-18.9* Plt Ct-193
[**2162-12-21**] 11:50PM BLOOD Neuts-74* Bands-3 Lymphs-8* Monos-8 Eos-2
Baso-1 Atyps-0 Metas-1* Myelos-1* Promyel-2* NRBC-1*
[**2162-12-21**] 11:50PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+
Target-1+ Tear Dr[**Last Name (STitle) 833**]
[**2162-12-21**] 11:50PM BLOOD PT-12.9* PTT-26.9 INR(PT)-1.2*
[**2162-12-21**] 11:50PM BLOOD Glucose-232* UreaN-13 Creat-1.4* Na-138
K-3.6 Cl-105 HCO3-24 AnGap-13
[**2162-12-22**] 10:17AM BLOOD Glucose-270* UreaN-14 Creat-1.1 Na-134
K-3.2* Cl-100 HCO3-26 AnGap-11
[**2162-12-21**] 11:50PM BLOOD ALT-10 AST-22 LD(LDH)-312* AlkPhos-69
TotBili-1.8*
[**2162-12-21**] 11:50PM BLOOD Lipase-107*
[**2162-12-21**] 11:50PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1 Cholest-353*
[**2162-12-22**] 10:17AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0
[**2162-12-21**] 11:50PM BLOOD Triglyc-1376* HDL-18 CHOL/HD-19.6
LDLmeas-LESS THAN
[**2162-12-22**] 10:17AM BLOOD Triglyc-1046*
[**2162-12-22**] 12:09AM BLOOD Type-ART pO2-90 pCO2-59* pH-7.27*
calTCO2-28 Base XS-0
[**2162-12-22**] 11:20AM BLOOD Type-ART pO2-74* pCO2-50* pH-7.35
calTCO2-29 Base XS-0
[**2162-12-22**] 12:09AM BLOOD Lactate-0.6
Notable Studies:
MICROBIOLOGY:
Blood culture [**12-22**] x 2 (OSH)- NGTD, pending
Sputum culture [**12-22**] (OSH)- abundant staph aureus, pansensitive
Blood culture [**12-22**]- NGTD, pending
Urine culture [**12-22**]- no growth
Endotracheal aspirate:
GRAM STAIN (Final [**2162-12-22**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED
Blood 12/21- NGTD, pending
Blood 12/22- NGTD, pending
Urine [**12-24**]- pending
IMAGING:
PORTABLE CXR [**2162-12-22**]- ETT tube ends approximately 5.7 cm above
the carina. An orogastric tube is seen coursing below the
diaphragm into the stomach; however, distal end is beyond the
radiograph view. A right PICC line terminates approximately at
the level of the lower SVC/cavoatrial junction. Bilateral lung
opacity is in the perihilar distribution suggesting moderate
pulmonary edema and presumed small left pleural effusion having
unchanged appearance since [**2162-12-22**]. Increased
retrocardiac density with obscuration of the left hemidiaphragm
margin reflecting left lower lung atelectasis is similar. Top
normal heart size, mediastinal and hilar contours are stable.
IMPRESSION: Moderate pulmonary edema, small left pleural
effusion and left lower lung atelectasis.
LIVER US [**2162-12-22**]- The liver is diffusely echogenic but no focal
lesions are identified. There is no intra, or extrahepatic
biliary duct dilation and the CBD measures 4 mm. The gallbladder
appears normal in size without stones or sludge. Normal
hepatopetal flow is seen in the main portal vein. The
intra-abdominal IVC appears normal. The visualized head and body
of the pancreas appear enlarged and echogenic. The spleen is
enlarged measuring 18.8 cm. The right kidney measures 14.6 cm
and appears normal in echotexture without stones, masses or
hydronephrosis. The left kidney was poorly visualized measuring
approximately 14.1 cm but evaluation of the left renal
parenchyma is severely limited. A small amount of fluid is
present in the deep pelvis. A small right-sided pleural effusion
was present.
Transthoracic echocardiogram [**2162-12-22**]- The left atrium and right
atrium are normal in cavity size. The left atrium is elongated.
The left atrial volume is normal. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild basal to mid
inferior and inferolateral hypokniesis. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. 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. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild focal LV systolic dysfunction. The right
ventricle is probably mildly dilated/hypokinetic. Mild pulmonary
artery systolic hypertension. No significant valvular
abnormality seen.
CT head without contrast [**2162-12-22**]- There is questionable mild
blurring of the [**Doctor Last Name 352**]-white matter interface, which could be
compatible with cerebral edema in the correct clinical setting.
[**Doctor Last Name **]-white attenuation ratio also appears decreased at 1.1-1.3.
However, ventricles and sulci are normal in size and morphology.
There is no acute intracranial hemorrhage, mass effect, or
vascular territorial infarct. No evidence of cerebral
herniation.
The patient is intubated, with retained [**Last Name (un) **]- and
oropharyngeal secretions. There is mild mucosal thickening
throughout multiple ethmoid air cells. Small retention cyst is
also noted in the right maxillary sinus. Mastoid air cells and
middle ear cavities are clear. Orbits and intraconal structures
are symmetric.
IMPRESSION: Possible mild cerebral edema; please correlate
clinically. No evidence of intracranial hemorrhage, infarct, or
herniation.
ATTENDING NOTE: There is no herniation or compression.
Although there are no definite CT signs of brain edema,
correlate clinically.
Bilateral lower extremity venous doppler ultrasound [**2162-12-23**]-
CT angiogram chest [**2162-12-23**]-
IMPRESSION: 1. No evidence of pulmonary embolism. 2. Multifocal
pneumonia. 3. Mild-to-moderate bilateral pleural effusions. 4.
Multiple borderline sized and enlarged mediastinal lymph nodes,
likely reactive considering multifocal infection.
[**2162-12-29**] Radiology CT ABD & PELVIS WITH CO
IMPRESSION: 1. Extensive pancreatitis with peripancreatic
collections in the retroperitoneum and transverse mesocolon not
organized. As compared to the [**2162-12-17**] study from an
outside hospital, the radiographic signs of pancreatitis have
worsened. There are no signs of pancreatic necrosis. 2. Ascites
increased. 3. Multifocal lung injury, improved since [**12-24**], [**2162**]. 4. Mild-to-moderate bilateral pleural effusions.
[**2163-1-7**] Radiology CT Chest, ABD & PELVIS W/O CON
IMPRESSION: 1. Large bilateral non-hemorrhagic pleural effusions
with adjacent areas of compressive atelectasis, appear
progressed from [**2162-12-29**] exam. 2. Diffuse bilateral
consolidations and ground-glass opacities appear stable and are
compatible with acute lung injury. 3. Pancreatic edema,
peripancreatic fat stranding and fluid collections are
compatible with pancreatitis. Due to lack of intravenous
contrast, pancreatic enhancement pattern cannot be assessed to
evaluate for possible necrosis. 4. Moderate amount of ascites is
unchanged from prior exam and is likely related to underlying
disease process. 5. Inflamed descending colon likely reactive
colitis.
[**2163-1-15**] Radiology CHEST (PORTABLE AP)
1. Persistent marked low lung volumes with elevation of the left
hemidiaphragm with patchy and linear opacities throughout the
lungs, likely reflecting patchy atelectasis, although a diffuse
infectious process cannot be entirely excluded. Pulmonary edema
would be less likely given the patient's stated age of 33 years.
Overall cardiac and mediastinal contours are stable. No
pneumothorax.
Discharge/Notable Labs:
CBC
[**2163-1-22**] 08:30AM BLOOD Hct-20.1*
[**2163-1-23**] 07:25AM BLOOD WBC-7.9 RBC-2.75* Hgb-7.1* Hct-20.0*
MCV-73* MCH-25.8* MCHC-35.5* RDW-20.7* Plt Ct-260
[**2163-1-24**] 06:15AM BLOOD WBC-10.6 RBC-2.82* Hgb-7.2* Hct-20.2*
MCV-72* MCH-25.6* MCHC-35.8* RDW-20.7* Plt Ct-302
[**2163-1-25**] 05:59AM BLOOD WBC-8.5 RBC-2.45* Hgb-6.2* Hct-17.3*
MCV-71* MCH-25.2* MCHC-35.6* RDW-21.2* Plt Ct-252
[**2163-1-26**] 05:40AM BLOOD WBC-16.7*# RBC-3.19*# Hgb-8.3*#
Hct-22.7*# MCV-71* MCH-26.0* MCHC-36.6* RDW-20.1* Plt Ct-340
[**2163-1-27**] 07:54AM BLOOD WBC-15.9* RBC-3.07* Hgb-7.7* Hct-22.0*
MCV-72* MCH-25.0* MCHC-34.9 RDW-20.8* Plt Ct-349
[**2163-1-26**] 05:40AM BLOOD Neuts-84* Bands-0 Lymphs-9* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2163-1-26**] 05:40AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
Coagulation:
[**2162-12-28**] 02:51PM BLOOD Fibrino-729*
[**2163-1-10**] 03:00AM BLOOD Fibrino-711*
[**2163-1-24**] 12:40PM BLOOD Fibrino-340#
Inflammatory:
[**2163-1-22**] 08:30AM BLOOD ESR-70*
Iron studies:
[**2163-1-21**] 11:56AM BLOOD calTIBC-260 Ferritn-3122* TRF-200
[**2163-1-21**] 11:56AM BLOOD Iron-237*
[**2163-1-26**] 05:40AM BLOOD Ferritn-3297
Anemia:
[**2163-1-8**] 03:44AM BLOOD PEP-NO SPECIFI IgG-1168 IgA-234 IgM-59
IFE-NO MONOCLO
[**2163-1-19**] 07:00AM BLOOD VitB12-1711* Folate-15.9
[**2163-1-21**] 11:56AM BLOOD Ret Aut-0.3*
[**2163-1-25**] 05:59AM BLOOD Ret Aut-0.2*
[**2163-1-27**] 07:54AM BLOOD Ret Aut-1.1*
[**2163-1-10**] 03:00AM BLOOD Hapto-474*
[**2163-1-24**] 06:15AM BLOOD Hapto-<5*
[**2163-1-24**] 12:40PM BLOOD Hapto-<5*
[**2163-1-27**] 07:54AM BLOOD Hapto-<5*
Test Result Reference
Range/Units
ERYTHROPOIETIN 270.0 H 4.1-19.5
mIU/mL
Chemistries:
[**2163-1-25**] 05:59AM BLOOD Glucose-99 UreaN-22* Creat-1.5* Na-133
K-3.8 Cl-95* HCO3-28 AnGap-14
[**2163-1-26**] 05:40AM BLOOD Glucose-108* UreaN-17 Creat-1.5* Na-128*
K-4.0 Cl-90* HCO3-27 AnGap-15
[**2163-1-27**] 07:54AM BLOOD Glucose-111* UreaN-16 Creat-1.5* Na-134
K-4.2 Cl-97 HCO3-25 AnGap-16
[**2163-1-18**] 02:59AM BLOOD ALT-22 AST-21 LD(LDH)-331* AlkPhos-81
TotBili-0.7
[**2163-1-24**] 06:15AM BLOOD ALT-16 AST-20 LD(LDH)-728* AlkPhos-100
TotBili-1.2
[**2163-1-25**] 05:59AM BLOOD ALT-16 AST-18 LD(LDH)-599* AlkPhos-90
TotBili-0.9
[**2163-1-27**] 07:54AM BLOOD ALT-12 AST-18 LD(LDH)-593* AlkPhos-95
TotBili-1.0
[**2162-12-24**] 03:18AM BLOOD CK-MB-1 cTropnT-<0.01
[**2163-1-22**] 08:30AM BLOOD CK-MB-5 cTropnT-0.03*
[**2163-1-22**] 09:30PM BLOOD [**2163-1-24**] 06:15AM BLOOD Albumin-4.4
CK-MB-2 cTropnT-<0.01
Lipids:
[**2163-1-22**] 08:30AM BLOOD %HbA1c-6.7* eAG-146*
[**2162-12-21**] 11:50PM BLOOD Triglyc-1376* HDL-18 CHOL/HD-19.6
LDLmeas-LESS THAN
[**2162-12-22**] 05:52PM BLOOD Triglyc-1106*
[**2163-1-10**] 03:00AM BLOOD Triglyc-261*
[**2163-1-26**] 05:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
Infectious:
[**2163-1-9**] 01:41PM BLOOD HIV Ab-NEGATIVE
[**2163-1-26**] 05:40AM BLOOD HCV Ab-PND
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY 5.69 H
(IGG)
Reference Range
---------------
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider a Parvovirus
B19 DNA, PCR test.
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY 1.28 H
(IGM)
Reference Range
---------------
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
Studies Pending on Discharge:
Hgb electropharesis
HCV Abs
G6PD
Pathology from bone marrow biopsy
Brief Hospital Course:
33 y/o M with h/o polysubstance abuse (EtOH, cocaine, Xanax),
DM2, seizure disorder (? withdrawal), and severe depression
transferred from OSH with acute pancreatitis due to
hypertriglyceridemia and alcohol/benzodiazpeine withdrawal.
Complicated and prolonged (~6weeks) hospital course was notable
for drug (etoh, benzodiazepine, opioid) withdrawal, respiratory
failure, ventilator-associated pneumonia, renal failure/ATN,
hyponatremia, encephalopathy, and anemia.
#Hypoxemic Respiratory Failure/Acute respiratory distress
syndrome/MSSA and MRSA pneumonia:
Patient arrived intubated for his respiratory failure, due to
combination of ARDS, multifocal pneumonia, and pulmonary edema
from fluid overload. He was initially treated with
Vancomycin/Levaquin/Cefepime. He was ventilated with ARDSnet
ventilation. His ventilatory course was notable for agitation
and delirium (see below), but he was eventually extubated on
[**2163-1-11**]. He was weaned off oxygen and was discharged breathing
room air with oxygen saturations in the high 90s without
complaints of dyspnea. He completed an 8 day course of
antibiotics for MRSA/MSSA pneumonia.
#Agitation/Encephalopathy/Benzodiazipine and alcohol
withdrawal/opioid withdrawal:
Patient's ventilation was complicated by agitation and
dyssynchrony with ventilator. He was treated with haldol and
paralytics but continued to have tachycardia and hypertension
despite fentanyl/midazolam and precidex. He was treated with
aggressive midazolam boluses and IV methadone. Following
extubation the patient was felt to have persistent
encephalopathy due a combination of drug intoxication and
intermittent withdrawal. Psychiatry was consulted and the
decision was made to start standing Haldol and taper
benzodiazpines with an Ativan taper along with a methadone
taper. The patient's mental status improved significantly over
the course of the hospitalization and he was discharged off all
narcotics, benzodiazepines, and antipsychotic medications. He
was oriented x3 and passed a neurocognitive evaluation with OT
prior to discharge however he was not felt by his family to be
back to his baseline. It was felt this mental status change was
due to a resolving hospital/ICU delirum vs. clearance of
psychotropic medications. He was discharged to follow up in
neurocognitive clinic.
#Acute Pancreatitis/Hypertriglyceridemia:
Pancreatitis was felt to most likely be due to a combination of
alcohol and hypertriglyceridemia given TGs>1000. Although he had
a history of insulin dependent diabetes, his A1c was 6.7. He was
treated with IVF at OSH and then maintained at euvolemia
following respiratory failure. He was maintained on TPN
transiently but was able to take pos prior to discharge and was
able to eat a regular diet without pain prior to discharge. His
albumin just prior to discharge was 4.2. He was discharged on a
low fat diet to have his lipid panel rechecked by his PCP in the
outpatient setting at which time the decision to start
gemfibrozil can be made.
# Persistent fevers: Pt spiked intermittent fevers up to 103F
despite being on broad antibiotic with vanc, cefepime, and levo.
Urine and blood cultures were negative and his CXR and
respiratory status improved. Infectious disease service was
consulted, who felt that pt had been treated adequately for both
ventilator associated pneumonia and possible GI infection
related to his pancreatitis. They agreed that his fevers may be
due to medications, possibly from vancomycin, which remained in
his system due to his renal failure (see below). Aside from his
sputum cultures, which grew MRSA at [**Hospital1 18**], none of his other
multiple blood or urine cultures have ever grown any organisms.
They suggested checking a C diff PCR, which was negative as were
multiple C diff stool toxin tests. Pt remained afebrile since
[**1-16**].
.
#Acute renal failure/acute tubular necrosis:
Patient presented with unclear baseline Cr, and on admission,
his Cr was elevated at 1.4 with BUN of 13. His creatinine
decreased to 1.1 on [**12-29**], but then increased slowly to 1.7 by
[**1-2**], jumping to 2.8 on [**1-2**] and increased to a peak of 5.7
by [**1-6**]. Renal was consulted and felt that his urine and serum
studies were consistent with acute tubular necrosis. He did not
require hemodialysis or CVVH and his Cr slowly decreased to a
new baseline of 1.5. Creatinine was stable at this level for a
number of days prior to discharge.
.
#Hyponatremia, due to primary polydypsia:
Patient had hyonatremia with a low urine osmolarity and low
urine sodium in the setting of heavy fluid intake. He was placed
on a fluid restriction but would sneak free water intake.
Eventually, the fluid restriction was removed and the patient
was educated that he should take in appropriate amounts of
solute if he is drink large amounts of fluids. The sodium level
remained stable off fluid restriction for 5 days prior to
discharge.
.
# Tachycardia/Hypertension:
Patient had tachycardia and hypertension throughout
hospitalization. This was felt to be due to a combination of
anxiety and drug withdrawal as well as due to anemia (see
below). The tachycardia and hypertension gradually improved over
the course of the hospitalization although he was mildly
tachycardic (90s-100s) and hypertensive (SBPs 130s-150s) prior
to discharge.
.
#Anemia:
Patient had a mild microcytic anemia on arrival which was felt
to be due to underlying thalassemia trait based on a family
history of blood disorder. Hgb electrophoresis was checked and
pending at discharge. Initially iron studies, B12, folate, TSH,
reticulocyte count were all consistent marrow suppression from
inflammatory state. However, over course of hospitalization the
hematocrit continued to fall without obvious source of bleeding
(negative guaiac, CT abdomen/pelvis). On [**1-22**] he required red
cell transfusion for Hct of 20 but did not bump appropriately.
He did have a fever during this transfusion. Repeat hemolysis
labs were notable for persistent haptoglobin <5 and elevated LDH
without significant hyperbilirubinemia. Reticulocyte count
continued to be low consistent with an at least partially
suppressed marrow. There were spherocytes seen on smear as well
as tear drop cells. Hematology was consulted and serologies were
notable for negative hepatitis serologies and positive
Parvovirus serologies (both IgM and IgG). It was unclear the
exact cause of anemia but was felt to be multifactorial from
probable baseline thalassemia, acute infection/resolving
inflammation, and possible parvovirus infection plus concurrent
hemolysis. Investigation for cause of hemolysis was unrevealing
with negative direct coombs and negative antibody screen on type
and screen. Urine hemosiderin was checked but was collected
improperly. Given the unclear picture a bone marrow biopsy was
performed. Final pathology was pending at discharge, but bone
marrow showed erythroid precursors. Folate was started when labs
were suggestive of hemolysis. Splenic sequestration due to
splenomegaly was considered but felt to be less likely.
In the future, further study of intrinsic causes of hemolysis
and UA for blood (hemoglobinuria) and hemosiderin could be
considered as well as repeating direct Coombs with dilutions.
.
# EtOH abuse/Opioid and benzodiazepine abuse:
Patient was noted to have splenomegaly and fatty liver. Patient
was discharged on thiamine and folate. He should have a follow
up with consideration of biopsy to assess for underlying
cirrhosis/portal hypertension once he is closer to his baseline
in the outpatient setting.
Additionally, patient will be set up with addictions counseling
in the outpatient setting.
# Diabetes mellitus, type 2, controlled: H/o insulin-dependant
diabetes several years ago. Now off all meds with reportedly
good glucose control. Pt was initially on an insulin drip to
treat hypertriglyceridemic pancreatitis but this was changed to
insulin sliding scale after his clinical condition improved, and
his sugars have remained stable.
.
# Major Depression: h/o major depression and polysubstance
abuse. Social work consulted.
#CODE: FULL
#Disposition:
Patient received 2 units of PRBCs on the day of discharge with
instructions to follow up in [**Hospital **] clinic 5 days from
discharge for follow up of symptoms and review findings of bone
marrow biopsy etc and consideration of blood transfusions as
needed. Patient will also see his PCP 4 days from discharge.
#Transitional:
Patient should have in the outpatient setting:
1) Follow up lipid panel.
2) Follow up ultrasound to assess for persistent splenomegaly
and consideration of liver biopsy to rule out cirrhosis
3) Follow up with [**Hospital **] clinic re: pancreatitis
4) Addictions counseling
Medications on Admission:
Medications: (home)
1. Celexa 20mg daily
2. Omeprazole 20mg [**Hospital1 **]
.
Medications: (transfer)
1. Combivent Inhaler 4 puff q4hrs
2. D5W and D5NS
3. Thiamine 500mg IV q24 hrs
4. Folic acid 1mg IV q24hrs
5. Vancomycin 1.5gms?
6. Zosyn
7. Tylenol
8. Vasotec 1.25mg q6hrs prn for SBP > 180
9. Fentanyl 13mcg q1hr prn sedation
10. lopid 600mg [**Hospital1 **]
11. haldol 1mg IV prn
12. dilaudid 0.5-2mg q2hrs for pain
13. Humulog prn q4hrs
14. Humuloh N 8 units q12 hrs
15. Ativan 2mg q4hrs prn anxiety
16. Mylanta 30mL q4hrs
17. Narcan 0.4 mg prn
18. IV zofran 4mg prn
19. Protonix 40mg q24hrs
20. TPN
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
-Pancreatitis
-Hypertriglyceridemia
-Encephalopathy/Delirium: benzo intoxication and resolving ICU
delirium
-Hyponatremia
-Anemia
-Acute renal failure
-Tachycardia
-Drug dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to the ICU here from another hospital with
pancreatitis. You were intubated, and developed pneumonia,
anemia, alterations in your sodium levels, and a decline in your
kidney function. These issues improved. Your kidney function is
now close to your previous level although not quite at your
pre-admission functioning.
Your pancreatitis and pneumonia has resolved.
To keep your sodium at the appropriate level make sure to eat
enough salt if you are drinking lots of fluids.
Your pancreatitis was felt to be due to high triglyceride levels
which can occur due to diabetes or diet. Your labs do not
indicate significant diabetes. Therefore, you may require
triglyceride lowering medications when you follow up with your
PCP. [**Name10 (NameIs) 2172**] triglycerides should be checked at your follow up
appointment with your PCP.
Regarding your anemia, it is not clear exactly why your blood
counts are still low. You were seen by the Hematology service
and it is felt that your blood counts are low for a number of
reasons including probable underlying blood disorder and bone
marrow suppression from infection and inflammation as well as
likely hemolysis. You were given blood transfusions while in the
hospital and may require transfusions after you leave.
Therefore, you are discharged with follow up in the [**Hospital 18**]
[**Hospital **] clinic for follow up of your blood counts and to
receive red blood cell transfusions as needed.
Please call your PCP or your [**Hospital **] clinic if you experience
any chest pain, shortness of breath, dizziness or
lightheadedness, notice blood in your stools, or feel as if you
are going to pass out.
You also have a PCP appointment the day prior to your Hematology
appointment.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] Y.
Location: STRATHAM FAMILY HEALTH
Address: [**Location (un) 89467**], STRATHAM,[**Numeric Identifier 89468**]
Phone: [**Telephone/Fax (1) 89469**]
When: [**Last Name (LF) 766**], [**2163-1-31**] at 11:00 AM
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-2-1**] at 9:30 AM
With: DR. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-2-1**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**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: COGNITIVE NEUROLOGY UNIT
When: [**Hospital Ward Name **] [**2163-3-28**] at 2:30 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**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
|
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27,400
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21844
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Discharge summary
|
report
|
Admission Date: [**2118-8-29**] Discharge Date: [**2118-9-16**]
Date of Birth: [**2058-3-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pericardiocentesis
Placement of of Rt and Lt pleurex drains in your lungs.
History of Present Illness:
60 y/o F with mantle-cell lymphoma s/p RCHOP (4 cycles), s/p
R-[**Hospital1 **] (2 cycles), and s/p RICE (Day 1 on [**2118-6-29**]) who was
seen in clinic on [**2118-8-29**]. she complained of feeling sick since
Saturday morning when she vomited after breakfast. She vomited
two to three times a day over the weekend and is eating very
little. She says she has no difficulty with swallowing and her
oral intake is only limited by nausea and vomiting and not
inability to swallow. She has taken no antiemetics today but is
very nauseous upon presentation. She also has a cough, which
started over the weekend. It is productive of clear sputum and
is keeping her awake at night. She states that it is not quite
as bad as it was the last time she was admitted, however, her
husband is nervous that she will again start choking. She also
reports shortness of breath. On the way to clinic today, she had
to stop several times and ended up coming up in a wheelchair as
every few steps she needed to sit down and take a break due to
shortness of breath. This is new. She has taken no medications
this morning including her metoprolol. She has no fevers and she
has been checking diligently. She continues to put a gauze and
bacitracin to the area on her labia and [**First Name8 (NamePattern2) **] [**Last Name (un) **] baths three
times a day. She has no discomfort in this area. She has no
headache. She has no chest pain. She has no diarrhea, or rash.
CXR done prior to clinic visit revealed a large left pleural
effusion and was therefore planned for admission on 11r for
pleurocentesis. However prior to transfer she developed acute
respiratory distress with stridor requiring 100mg of iv
solumedrol and o2 therapy. She responded well to these but
continued to have audible stridor so was transferred to ED for
further work-up prior to admission. In [**Name (NI) **] pt was feeling fine,
breathing easy, no throat tightness, no dysphagia/odynophagia.
she was seen by ENT consult who recommended humidified air / O2
via shovel mask to soothe airway, prevent mucous plugging.
Past Medical History:
- dx mantle cell lymphoma in [**2114**]
- completed four cycles of R-CHOP followed by Zevalin by [**4-9**]
- progressed by [**7-11**] -> began velcade/rituxan ** had L cervical
LN
- again progressed by 5th cycle velcade/rituxan/dex in L
cervical LN
- admitted for [**Hospital1 **] on [**2117-12-11**], [**2118-1-10**] and R-[**Hospital1 **] on [**2118-2-4**]
- PET showed good response initially
- planned for autoSCT on [**2118-3-15**] but CT on admit showed
progressive dz
- received ESHAP w/ plans for autoSCT if dz stable post ESHAP
- PET on [**2118-4-11**] reported progression of her disease
- BMB on [**2118-3-15**] showed a mildly hypocellular marrow with
trilineage hematopoiesis, no evidence of mantle cell, NL
cytogenetics
- admitted for 2nd cycle of ESHAP [**Date range (1) 57305**]
- given rituxan on [**5-6**] and 3rd cycle ESHAP [**Date range (1) 57306**]
- C1D1 Rituxan/Bendamustine on [**2118-6-6**]
- CT showed disease progression [**2118-6-28**]
.
Other PMHx:
- lyme [**2117**]
- herpes zoster [**2117**]
.
Social History:
Patient lives with her husband. She is a retired (as of [**6-12**])
computer teacher in an elementary school, but took a leave of
absence recently. She has two sons, both married. She lives in
[**Location 57307**]. She does not drink alcohol, smoke tobacco, or use
illicit drugs.
Family History:
Mother [**Location 499**] CA,
Father pancreatic mass 87 y.o. still living, CAD,
hypercholesterolemia, HTN.
Physical Exam:
Vitals: T: 98.0 BP: 104/82 P: 118/min R: 16/min SaO2: 96% on 3l
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: reduced air entry bilaterally left more than right
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
cns [**2-15**] intact
Pertinent Results:
CXR [**8-29**]: Since [**2118-7-28**], anterior mediastinal mass
decreased in thickness on the left, adjacent to the aortic knob,
from 2.7 cm to 1.5 cm. Small right pleural effusion is new.
Moderate to large left pleural effusion significantly increased
with associated basilar consolidation mostly on the left,
probably due to atelectasis. Right pleural effusion insinuates
along the right major fissure. Slight lobulated appearance of
right basilar axillary chest wall is probably due to loculated
fluid. New pleural thickening due to lymphoma is less likely due
to rapid change and improvement of the anterior mediastinal
mass. Short- term follow up is recommended.
TTE [**8-31**]: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
estimated cardiac index is borderline low (2.25L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
pulmonary artery systolic pressure could not be determined.
There is a moderate sized circumferential pericardial effusion
most prominent (2cm) inferior to the left ventricle, 1.4 cm
around the right ventricle and right atrium. There is
intermittent right ventricular diastolic collapse, consistent
with impaired fillling/tamponade physiology.
Compared with the prior study (images reviewed) of [**2118-7-26**],
the pericardial effusion is much larger and tamponade physiology
is now suggested. The heart rate is much faster.
Labs:
[**2118-8-29**] 04:45PM GLUCOSE-133* UREA N-7 CREAT-0.5 SODIUM-137
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2118-8-29**] 04:45PM WBC-2.3* RBC-3.20* HGB-10.3* HCT-29.1* MCV-91
MCH-32.2* MCHC-35.4* RDW-18.1*
[**2118-8-29**] 04:45PM NEUTS-87.1* LYMPHS-7.5* MONOS-4.1 EOS-1.1
BASOS-0.2
[**2118-8-29**] 04:45PM PLT COUNT-53*
[**2118-8-29**] 04:52PM freeCa-1.02*
[**2118-8-29**] 10:45AM ALT(SGPT)-22 AST(SGOT)-21 LD(LDH)-392* ALK
PHOS-62 TOT BILI-1.2
[**2118-8-29**] 10:45AM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-3.2
MAGNESIUM-1.7 URIC ACID-2.5
[**2118-8-29**] 10:45AM GRAN CT-1710*
Brief Hospital Course:
60 yo F with h/o mantle cell lymphoma s/p multiple chemotherapy
regimens who presented on [**2118-8-29**] with an episode of acute
respiratory distress, found to have pericardial effusion with
bilateral pleural effusions and cardiac tamponade s/p
pericardial drainage. The patient received XRT and two doses of
gemcitabine during her hospitalization, however her pericardial
effusion reaccumulated with consolidation and the patient was
transitioned to comfort care.
#. Mantle cell Lymphoma: Patient was diagnosed with mantle cell
lymphoma in [**2114**]. She has had one episode of radiation of an
anterior mediastinal mass during this hospitaliztion. Long-range
plan is for allogeneic SCT from sib donor with TLI, ATG.
Patient had daily XRT held while in CCU. She received Gemzar on
[**9-4**] for palliation of her MCL. Her allopurinol was
discontinued on [**9-10**] and her atovaquone was stopped per her
request due to intolerance of the taste and she was switched to
PCP prophylaxis with [**Name9 (PRE) 57308**]. She remained pancytopenic
during her hospitalization and required multiple platelet and
PRBC transfusions. On [**9-13**] she noticed a large mass the medial
side of her left breast which was likely a mass of enlarged
lymph nodes due to her lymphoma. She was treated with Gemzar
again on [**9-13**]. On [**9-14**] she had a TTE which showed a
reaccumulation of her pericardial effusion with consolidation.
She began to become hypotensive and was bolused with fluids.
Her dilt was held due to hypotension and her HR slowly came up
to the 140's to 160's. A discussion was had with her, and then
with her and her family about her prognosis: the inability to
drain her pericardial effusion and the fact that her lymphoma
was not responding well to the chemotherapy. It was explained
to her that there were no more chemotherapeutic agents which
were likely to induce remission and that a bone marrow
transplant at this time would have a very low likelihood of
inducing remission while exposing her to toxicity from the
chemotherapy. She and her family decided they prefered to have
her brought home on hospice and she was discharged with hospice
on [**9-16**].
#. Respiratory distress:
ENT was called to evaluate and started her on humidified oxygen
mask. Patient was stabalized overnight and underwent a
thorocentesis by the procedure team the next morning. This had
to be stopped [**2-5**] an acute episode of cough. Patient had an ECHO
which showed tamponade physiology. She was sent to the cath lab,
where 370 cc of blood-tinged fluid was removed. Fluid was sent
for cytology and cultures, and a pericardial drain was placed.
Patient subsequently also developed bilateral pleural effusions,
a pleurex drain was placed on the left for extended drainage and
a thoracentesis was done on the right for 1.9L of fluids.
Malignant cells were positive in the pericardial fluid, L.
pleural effusion, and R. pleural effusion. Her shortness
resolved over time and she was weaned off oxygen on the BMT
floor. She had some remaining DOE. A CXR on [**9-8**] showed no
reaccumulation of the pleural effusions. She had a TTE on [**9-6**]
which showed no reacccumulation of her pericardial effusion.
She had a CXR on [**9-11**] done due to increasing cough which showed
reaccumulation of her pleural effusions so she had a pleurex
drain placed by IP on [**9-12**] for drainage. A TTE on [**9-12**] showed a
small pericardial effusion. Due to episodes of hypotension and
tachycardia another TTE was done on [**9-14**] which showed a
reaccumulation of a moderate to large pericardial effusion with
consolidation. The cardiologist who read the echo did not feel
that it could be drained percutaneously and that an invasive
surgery would be needed for decompression eventually.
#. Tachycardia:
Patient's HR had been in 120's, and was initally thought to be
secondary to dehydration, however the HR did not respond to
fluids. However, patient acutely rose into 170's with decrease
in SBP to 60's, Metoprolol was pushed and rate was controlled
with resultant hemodynamic stability. EKG at the time showed
possible SVT versus sinus tachy. CTA was negative for PE on
[**8-31**]. She was then transferred from the CCU to the MICU. On
night of transfer, she went into SVT with HR of 180. Boluses of
IV Metoprolol and diltiazem only breifly reduced HR. Patient
eventually required a diltiazem drip to control HR and BP was
closely monitored as it dipped to the 80/40 range, but patient
was mentating well with good UOP. By day 2 in the MICU, the
patient was weaned off gtt and converted to PO diltiazem without
further episodes of SVT. She has been maintained on 60 mg po
diltiazem q6h throughout her hospitalization with her rate
remaining in the 110's to 120's. On [**9-11**] she went into atrial
flutter with rates in the 140's. Her vital signs were stable
and she was asymptomatic except for palpitations. She reverted
back to sinus tachycardia after receiving 5 mg IV verapamil. A
TTE on [**9-12**] showed a small pericardial effusion. Due to episodes
of hypotension and tachycardia another TTE was done on [**9-14**]
which showed a reaccumulation of a moderate to large pericardial
effusion with consolidation.
#. Hypotension: Patient with pressures occasionally in the 80/40
range while on diltiazem gtt, but patient was asymptomatic with
good UOP. This was initially concerning as patient had a recent
pericardial effusion, but pulsus measured by doppler was never
above 6 mmHg. BP was controlled with gentle fluid boluses as
patient had multiple thoraceneces to remove fluid in the CCU.
In the end, pressures gradually increased and were likely due to
diltiazem. On the BMT floor her SBP remained in the low 100's
to 110's. On [**9-12**] and [**9-13**] she had a few episodes of hypotension
in response to pain medications which responded to IVF boluses.
After these episodes her diltiazem was discontinued and she was
monitored on tele, however the dilt was started at a lower dose
as she became tachycardic. She continued to become hypotensive,
likely due to the reaccumulation of her pericardial effusion and
was supported by fluid boluses.
Medications on Admission:
Allopurinol 300 daily
ativan 0.5 q6h prn
compazine 10 q8h prn
Potassium 20 [**Hospital1 **]
albuterol prn
benzonatate 100 tid
acyclovir 400 tid
lipitor 80mg daily
metoprolol 25mg [**Hospital1 **]
nystatin swish and spit four times a day
omeprazole 20mg daily
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*1 bottle* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO every
2 hours as needed for pain.
Disp:*500 mL* Refills:*0*
6. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for anxiety.
Disp:*50 Tablet(s)* Refills:*0*
7. home oxygen
Portable oxygen for sats on RA of 88%.
8. Beside commode
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**4-10**]
hours.
Disp:*30 Tablet(s)* Refills:*2*
12. Compazine 25 mg Suppository Sig: One (1) suppository Rectal
twice a day.
Disp:*10 suppositories* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary -
Cardiac tamponade
Mantle cell lymphoma complicated by bilateral malignant
effusions
Secondary -
Tachycardia
Discharge Condition:
Stable, progressive lymphoma, comfort, hospice, DNR/DNI
Discharge Instructions:
You were admitted to the hospital due to shortness of breath and
found to have bilateral pleural effusions (fluid in the sacs
around your lungs) related to your lymphoma. Fluid was removed
and drainage tubes were placed on your right and left sides.
You were also found to have a pericardial effusion (fluid in the
sac around your heart) which was impairing the ability of your
heart to beat so you had a pericardiocentesis for removal of the
fluid. You underwent radiation therapy for your lymphoma and
received two doses of chemotherapy. The fluid reaccumulated in
the sac around your heart and is now thicker, and unable to be
drained. There was also radiographic evidence of rapid regrowth
of lymphoma, and after discussion with the patient, her husband
and sons it was decided that patient will have no further
chemotherapy or radiation and will have comfort measures and
hospice arranged at home.
You will be on nystatin for thrush (the white coating in the
mouth) treatment as needed, ativan prn for anxiety or insomnia,
morphine and oxycodone as needed for pain, morphine as need for
respiratory distress, omeprazole for GERD, compazine as needed
for nausea, and albuterol inhaler as needed for shortness of
breath. You can also take colace [**Hospital1 **] and senna prn for
constipation.
Patient has elected to go home with hospice, arrangements are
being made for this to occur.
Completed by:[**2118-9-17**]
|
[
"427.32",
"197.2",
"423.3",
"427.1",
"420.90",
"284.1",
"518.82",
"200.40",
"287.5",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"37.21",
"37.0",
"92.29",
"34.91",
"34.04",
"38.93",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
14435, 14454
|
6699, 12879
|
322, 399
|
14617, 14675
|
4553, 6676
|
3866, 3974
|
13189, 14412
|
14475, 14596
|
12905, 13166
|
14699, 16127
|
3989, 4534
|
275, 284
|
427, 2501
|
2523, 3551
|
3567, 3850
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,142
| 139,780
|
28133
|
Discharge summary
|
report
|
Admission Date: [**2177-9-30**] Discharge Date: [**2177-10-1**]
Date of Birth: [**2112-5-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Acute desaturation to 40% during ERCP
Major Surgical or Invasive Procedure:
ERCP aborted secondary to hypoxia
History of Present Illness:
65F w/ hx of HTN and asthma who presented today for an ERCP for
recent dx of ampullar adenoma. Prior to the procedure the
patient had received 12.5mg of phenergan, 150mcg of fentanyl and
3mg of versed. She acutely desatted to 40% on room air. Her O2
sats picked up with bag ventilation. She was placed on 100%NRB
and her O2 sats improved to 100%. Her remaining vitals were as
stable HR 49 BP 138/70.
Past Medical History:
HTN
GERD
Asthma
.
Shx:
Appendectomy
CCy
Family History:
non contributory
Physical Exam:
afeb, HR 62, BP131/64 R21, O2 sat 100% on 2l
gen: nad
heart: nl rate, S1S2, no gmr
lungs: cta b/l, no rrw
abd: soft, non-tender, non-distended, hypoactive bs
ext: no cce, 2+ dp b/l
Pertinent Results:
CXR: IMPRESSION: No acute cardiopulmonary process.
.
Brief Hospital Course:
1. Transient hypoxemia: Her transient hypoxemia was most likely
secondary to oversedating medications. There was no clinical
evidence to suggest brochospasm [**1-2**] to preexisting asthma, and
cardiac enzymes were negative ruling out an ischemic event. CXR
was unremarkable. She was monitored in the ICU overnight, and
saturated well overnight and by discharge was sating 98% on RA.
.
2. HTN: Her home dose of HCTZ was restarted on the day of
discharge. Her SBP in 120-130.
.
3. Bradycardia: While monitored overnight on telemetry, patient
was noted to be bradycardic to 40's. She was sleeping and
asymptomatic the entire time. Once awak, she returned to HR
60's. This was felt to be most likely secondary to decreased
vagal tone. In addition, she was noted to have two episodes of
reflex tachycardia to HR 100 for a few seconds. There was
concern for tachbrady syndrome vs. wandering ectopic pacemaker.
The tachcardic episodes were not documented on EKG. She was
advised to follow-up with her primary care physician regarding
her bradycardia.
.
4. Ampullar adenoma: The ERCP was aborted. Per ERCP, she should
reschedule the procedure as an outpatient.
.
5. GERD: continue PPI
.
6. FEN: regular diet
.
7. Presumed full code
Medications on Admission:
Prilosec, HCTZ 12.5
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
hypoxia
bradycardia
Secondary:
ampullar adenoma
asthma
Discharge Condition:
good
Discharge Instructions:
You had an episode of hypoxia due to slight oversedation from
the medications used during your ERCP procedure.
Please resumes all of your home medications.
Followup Instructions:
Please call to make an appointment to see your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68389**] within the next 2 weeks to follow-up on
your recent hospitalization. In addition, you should ask Dr.
[**Last Name (STitle) 68390**] to evaluate your alternately fast and slow heart rate.
Please call your biliary physician to reschedule your repeat
ERCP procedure.
|
[
"493.90",
"V64.1",
"211.5",
"799.02",
"401.9",
"427.89",
"E937.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2508, 2514
|
1211, 2438
|
353, 389
|
2622, 2629
|
1133, 1188
|
2834, 3237
|
898, 916
|
2535, 2601
|
2464, 2485
|
2653, 2811
|
931, 1114
|
276, 315
|
417, 818
|
840, 882
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,568
| 144,356
|
45382
|
Discharge summary
|
report
|
Admission Date: [**2168-12-14**] Discharge Date: [**2168-12-21**]
Date of Birth: [**2095-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
R->L carotid bypass with ligation of L CCA/thoracic aortic stent
graft [**2168-12-14**]
History of Present Illness:
73 y/o female with progressive DOE, CXR showed enlarged aorta,
CT revealed aneurysm
Past Medical History:
HTN
COPD
hypothyroidism
anxiety
depression
GERD
scoliosis
arthritis
hemochromotosis
anemia
osteoporosis
Social History:
remote smoker, quit 10 years ago
ETOH: 1 drink/day
Family History:
non-contributory
Physical Exam:
unremarkable upon admission
Pertinent Results:
[**2168-12-19**] 06:30AM BLOOD WBC-7.5 RBC-3.43* Hgb-8.4* Hct-26.0*
MCV-76* MCH-24.5* MCHC-32.3 RDW-19.9* Plt Ct-258
[**2168-12-19**] 06:30AM BLOOD Glucose-88 UreaN-22* Creat-0.8 Na-140
K-3.9 Cl-101 HCO3-27 AnGap-16
RADIOLOGY Preliminary Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2168-12-19**] 6:38 PM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
Reason: Please evaluate for dissection
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman s/p thoracic aortic stent graft with back
pain.
REASON FOR THIS EXAMINATION:
Please evaluate for dissection
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 73-year-old woman with thoracic aortic stent graft with
back pain evaluate for dissection.
COMPARISON: [**2168-11-24**] and [**2168-11-17**].
TECHNIQUE: Multidetector contiguous axial images of the chest,
abdomen and pelvis were obtained prior to and following the
administration of intravenous contrast.
CTA: No aortic dissection is identified. The patient has a
thoracic aortic stent graft at the level of the aortic arch
which excludes the previously seen eccentric aneurysm at this
level. The maximal diameter of this focal eccentric nonenhancing
aneurysm in the AP dimension is 3.8 cm, relatively unchanged
from the prior two studies.
Again seen are atherosclerotic changes in the abdominal aorta.
The celiac, superior mesenteric artery, both renal arteries,
inferior mesenteric arteries, and common iliac arteries are
patent.
CT CHEST: There are small axillary lymph nodes bilaterally, with
fatty hila measuring up to 7 mm in short-axis diameter. There
are small shotty mediastinal lymph nodes, as well as a small
right hilar lymph node measuring up to 7 mm in diameter series 3
image 23. Largest mediastinal lymph node measures 7 x 9 mm
(series 3 image 19) is right paratracheal in location. No
pericardial effusions are present.
Lung windows demonstrate extensive emphysematous changes in both
lungs, and a small left pleural effusion is seen. There is small
amount of basilar atelectasis present at the left base. There
are dependent changes seen in the portions of the left upper and
right upper lobes.
CT ABDOMEN WITH IV CONTRAST: The gallbladder, liver, pancreas,
spleen, adrenal glands are normal in appearance. Small cyst
(6mm) is seen in the interpolar region of the left kidney
(series 3 image 60), there is no hydronephrosis or hydroureter
on either side.
There is no free air or free fluid in the pelvis. No enlarged
retroperitoneal lymph nodes are present. The caliber of the
loops of small and large bowel are normal in appearance.
CT PELVIS: There is air seen in the bladder of uncertain origin.
The bladder is not fully distended. The uterus and visualized
adnexa are normal. The sigmoid colon is not distended. There is
diverticulosis of the sigmoid colon without diverticulitis.
BONE WINDOWS: No suspicious lytic or blastic lesions.
IMPRESSION:
1. No aortic dissection. No evidence of endoleak. Stable
appearance of the stent graft at the level of the aortic arch.
2. Emphysema.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
RADIOLOGY Final Report
CHEST (PA & LAT) [**2168-12-18**] 11:53 AM
CHEST (PA & LAT)
Reason: ?interval change
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman s/p carotid-carotid bypass & thoriacic aortic
stent graft, n/w chest pain
REASON FOR THIS EXAMINATION:
?interval change
CHEST TWO VIEWS ON [**12-18**]
HISTORY: Status post carotid bypass and thoracic aorta stent
graft, now with chest pain.
REFERENCE EXAM: [**12-15**]
FINDINGS: There has been interval removal the endotracheal tube
and skin staples. The appearance of the aortic graft is
unchanged. The cardiac and mediastinal silhouettes are
unchanged. There are small bilateral pleural effusions. No focal
infiltrates identified.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Brief Hospital Course:
Ms. [**Known lastname **] is a 73 year-old woman who presented to [**Hospital1 **] Center's cardiac surgery clinic with
progressive dyspnea on exertion and a chest CT revealing a
saccular aortic aneurysm. She was taken to the operating room
on [**2168-12-13**] and underwent a carotid to carotid bypass graft with
endovascular thoracic abdominal aneurysm repair with a 34 x mm
15 graft. This procedure was performed by Drs. [**Last Name (STitle) 22423**] and
[**Name5 (PTitle) **]. The patient tolerated this procedure well and was
transferred in critical but stable condition to the surgiccal
intensive care unit.
In the surgical intensive care unit she failed intitial
extubation on post operative day 1 requiring re-intubation. On
post-operative day 2 she was successfully extubated but was
hoarse. She was seen in consultation by the speech and swallow
service, which suggested that her post-op dysphagia was due to
post-op swelling. Her pressors were weaned and she was gently
diuresed. By post-operative day 4 she was ready for transfer to
the step-down floor.
On the step-down floor Ms. [**Known lastname **] was seen in consultation by
physical therapy. Her oxygen was weaned and she was further
diuresed. She was seen a second time by speech and swallow,
which recommended advancing her diet as tolerated as she no
longer exhibited signs of aspiration. By post operative day 7
she was ready for discharge to a rehabilitation facility.
Medications on Admission:
Librium 25'
Prozac 40'
Omeprazole 20'
Avalide 150/12.5'
Caltrate
MgOxide
Kcl
ASA 81'
Levothyroxine 25'
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Chlordiazepoxide HCl 25 mg Capsule Sig: One (1) Capsule PO
QHS (once a day (at bedtime)).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO Daily ().
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO BID (2 times a day) for 10
days.
11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
14. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Aortic aneurysm
Hypothyroid
GERD
HTN
COPD
anxiety
depression
anemia
hemochromatosis
scoliosis
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive while taking narcotics
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use powders, lotions, or creams on wounds.
Call our office for temp>101.5, wound drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 42167**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2168-12-21**]
|
[
"441.2",
"996.1",
"530.81",
"401.9",
"244.9",
"311",
"518.5",
"300.00",
"496",
"275.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"39.73",
"39.22"
] |
icd9pcs
|
[
[
[]
]
] |
7754, 7820
|
4875, 6332
|
326, 416
|
7958, 7966
|
821, 1254
|
8259, 8506
|
740, 758
|
6485, 7731
|
4235, 4327
|
7841, 7937
|
6358, 6462
|
7990, 8236
|
773, 802
|
283, 288
|
4356, 4852
|
444, 529
|
551, 656
|
672, 724
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,019
| 130,503
|
12904
|
Discharge summary
|
report
|
Admission Date: [**2170-5-19**] Discharge Date: [**2170-5-29**]
Date of Birth: [**2102-2-11**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
General weakness
Major Surgical or Invasive Procedure:
RIJ placement
Arterial line placement
Ultrasound guided liver biopsy
History of Present Illness:
68 YO F w possible lupus arthritis, NIDDM, distant breast
cancer, and PE on coumadin transferred from [**Location (un) **] for abnomal
labs. The patient reports feeling unwell for the past 2 weeks.
She has had weakness, malaise, and occasional chills. She has
fallen a couple of times due to generalized weakness without
trauma. Given her symptoms, she was planning to see her doctor.
When walking out to her car, she fell and was unable to get up.
Her husband called EMS who took her [**Hospital3 **]. At
[**Location (un) **], she was found to have pyuria, hyponatremia (high 120s)
and hypoglycemia. Her labs were also notable for AST/ALT of
several hundred and a bili of 10. She was given zosyn and
transferred to [**Hospital1 18**].
.
Upon arrival to [**Hospital1 18**] ED, the patient's VS were: 97.5 109 102/76
20 99% RA. Her fingerstick was 25 so she was given D50. She
required a D10 drip as well as multiple amps of D50 but remained
hypoglycemic. In addition to the above abnormal labs, her creat
was elevated at 1.4, her lipase was 271, her INR was 5.6 and
lactate 2.0. Of note,the patient has held her coumadin for the
past week for elevated INRs. While in the ED, liver and ERCP
were contact[**Name (NI) **] and she had a CT head which was negative for
acute intracranial pathology and a CT torso which showed a
tree-in-[**Male First Name (un) 239**] lung pattern, multiple areas of LAD and "vicarious
excretion of contrast into GB, but no radiopaque stone
identified and no e/o intra-hepatic biliary dilatation." Given
her persistent hypoglycemia, she was transferred to the MICU.
Her VS prior to transfer were: 97.8 88 129/89 18 100% FS 63.
.
Upon arrival to the floor, the patient reports being tired. She
endoreses recent weightloss of a few pounds and decreased
appetite over the past couple of weeks. She denies taking more
than 3 tylenol daily. She denies taking percocet or valium. She
denies any recent raw fish or wild mushroom injestions.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria.
Past Medical History:
Non-insulin dependent diabetes mellitus
splenectomy secondary to "splenic fluid accumulation"
breast cancer s/p masectomy 27 years ago; treated with tamoxifen
for 7 years
obesity
pulmonary emboli
depression
lupus
arthritis
Gastroesophageal reflux disease
Hypertension
Social History:
The patient lives with her husband and son. She does not work.
She walks with a walker. She denies tobacco, etoh or illicits.
Family History:
No history of liver cancer or unexplained liver failure in the
family.
Physical Exam:
Physical Exam:
Vitals: T97.5 HR 87 BP 130/71 RR 19 98% RA
General: Morbidly obese. Alert, oriented, no acute distress
HEENT: Icteric sclera, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD. IJ central line on
Right.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Distant heart sounds. RRR. NL S1 + S2, no murmurs, rubs,
gallops.
Abdomen: OBese. Centrally located ostomy bag. soft, non-tender,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly appreciated.
GU: foley. Concenetrated urine.
Ext: warm, 2+ pulses, no clubbing. Spider vv's and varicosities
of lower extremity. 1+ pitting edema to mid shin.
Skin: Jaundiced. Warm and dry.
Pertinent Results:
[**2170-5-18**] 07:05PM BLOOD WBC-10.4 RBC-4.55 Hgb-12.7 Hct-41.8
MCV-92 MCH-27.8 MCHC-30.3* RDW-20.1* Plt Ct-365
[**2170-5-18**] 07:05PM BLOOD Neuts-75* Bands-0 Lymphs-16* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2170-5-18**] 07:05PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Target-1+
[**2170-5-18**] 07:05PM BLOOD PT-51.2* PTT-47.0* INR(PT)-5.6*
[**2170-5-18**] 07:05PM BLOOD Plt Smr-NORMAL Plt Ct-365
[**2170-5-18**] 07:05PM BLOOD Glucose-69* UreaN-31* Creat-1.4* Na-129*
K-5.0 Cl-105 HCO3-15* AnGap-14
[**2170-5-18**] 07:05PM BLOOD ALT-533* AST-706* LD(LDH)-411*
AlkPhos-196* TotBili-11.1*
[**2170-5-18**] 07:05PM BLOOD Lipase-271*
[**2170-5-18**] 07:05PM BLOOD Albumin-2.4*
[**2170-5-19**] 03:26AM BLOOD Hapto-22*
[**2170-5-20**] 05:00AM BLOOD calTIBC-198* Ferritn-480* TRF-152*
[**2170-5-19**] 05:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE
[**2170-5-19**] 05:10AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2170-5-19**] 05:10AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:320
[**2170-5-19**] 05:10AM BLOOD IgA-823*
[**2170-5-23**] 06:30AM BLOOD IgG-3230*
[**2170-5-18**] 07:05PM BLOOD Acetmnp-NEG
[**2170-5-19**] 05:10AM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-POS
.
[**2170-5-29**] 09:00AM BLOOD WBC-16.2* RBC-4.54 Hgb-13.7 Hct-44.7
MCV-98 MCH-30.2 MCHC-30.7* RDW-22.1* Plt Ct-239
[**2170-5-28**] 05:59AM BLOOD PT-19.9* PTT-37.3* INR(PT)-1.8*
[**2170-5-28**] 05:59AM BLOOD Plt Ct-231
[**2170-5-29**] 09:00AM BLOOD ALT-266* AST-233* AlkPhos-162*
TotBili-13.2*
.
Liver BIopsy [**2170-5-24**]
Liver, needle core biopsy:
1. Severe portal/periportal and moderate lobular mixed
inflammation including many plasma cells, neutrophils,
lymphocytes, and rare eosinophils with scattered apoptotic
hepatocytes.
2. Prominent bile duct damage and proliferation with
infiltrating neutrophils and lymphocytes. No venulitis seen.
3. Hepatocellular cholestasis.
4. Minimal steatosis.
5. Trichrome stain shows increased protal and sinusoidal
fibrosis (Stage 1 fibrosis) with areas of collapse involving 20%
of tissue. Reticulin confirms areas of collapse.
6. Iron stain shows no stainable iron.
Note: The main findings in this biopsy are the presence of
moderately active hepatitis with prominent bile duct damage and
proliferation associated with mixed inflammation including
plasma cells. These features are suggestive of immune-mediated
injury either primary or secondary to a drug. The inflammatory
component shows plasma cells and neutrophils. Possible
etiologies include overlap syndrome of autoimmune hepatitis and
PBC or PSC. Clinical correlation to exclude a drug-induced
injury.
Clinical: Worsening liver function. Non-targeted core biopsy.
Gross:
Brief Hospital Course:
68 YO F w possible lupus arthritis, NIDDM, distant breast
cancer, and PE on coumadin transferred from [**Location (un) **] for abnomal
labs.
#. Acute liver insufficiency: The pt. was transferred from
[**Hospital3 7569**] for the management of elevated liver enzymes of
unknown etiology. On admission, the pt's hepatic panel was: ALT
533, AST 706, LD 411, AlkPhos 196, Total Bili 11.1, and INR was
11.1. CT scan did not show any liver pathology, but did show
tree-in-[**Male First Name (un) 239**] and nodular opacities significatn for small airway
dz or infection, as well as righ axillary/mediastinal inguinal
adenopathy, no evidence of intrahepatic biliary ductal diltation
(but vicarious excretionof contrast into the GB), and a fatty
pancreas. The pt. was placed in the MICU, and her home
medications were held. Upon arrival to the MICU, endored recent
weightloss of a few pounds and decreased appetite over the past
couple of weeks. She denied taking more than 3 tylenol daily.
She denied taking percocet or valium. She denied any recent raw
fish or wild mushroom ingestions. She did report mistankingly
taking her plaquenil at 2x the prescribed dose. All of the pt's
home medications were held at this time. hepatology was
consulted and suggested initiating a workup for hemochromatosis,
wilson's, Budd Chiari syndrome, and autoimmune hepatitis. RUQ US
was performed which was negative for hepatic congestion. Iron
studies were provactive, with Iron: 174 calTIBC: 198 leading to
Iron saturations of about 89%. HFE gene mutations were sent to
check for possible hemochromatosis. On [**2170-5-20**], the pt. remained
stable. Mild asterixis was noted but no mental status changes
occurred. THe pt's INR trended down to 3.5. The pt. was called
out of the MICU to CC7 in stable condition. Her abnormal labs
were originally thought to be most likely due to medication
effect given improvement with holding possible offending meds.
Alternative etiologies included autoimmune phenomena,
lupus-related hepatitis, infection, toxins, budd-chiari; lesss
likely alpha-1 heterozygosity, hemochromatosis, Wilson's. The
pt's LFTs improved mildly, but by hospital day 6 her liver panel
showed ALT 390 AST 623 AlkPhos 146 TotBili 12.6. Her hepatitis
panels were all negative, her anti-smooth mm. marker was
positive, [**Doctor First Name **] was1:320, serum CMV IgG was positive with pending
viral load. At this point, given the worsening liver function
tests and non- specific serology results, the decision to
perform a ultrasound guided liver biopsy was made to determine
an etiology of the pt's liver failure. Results were suggestive
of autoimmune hepatits,
showing severe portal/periportal and moderate lobular mixed
inflammation including many plasma cells, neutrophils,
lymphocytes, and rare eosinophils with scattered apoptotic
hepatocytes, prominent bile duct damage and proliferation with
infiltrating neutrophils and lymphocytes, hepatocellular
cholestasis, minimal steatosis, and Stage 1 sinusoidal fibrosis.
THe pt. was started on Prednisone 40 mg q day, and her enzymes
were trended for 2 days before allowing her to be discharged
with follow up with Dr. [**Last Name (STitle) 497**] in the out patient arena. THe
patient was also started on Vitamin D, Calcium, and omeprazole
to aid in the expected side effects of long term prednisone use.
.
# UTI. UA positive on admission. Started on Ceftriaxone given
levaquin allergy. Cultures grew yeast, which was most likely a
ocntaminant. Pt's UTI resolved without issue.
.
#. Hypoglycemia. Likely [**12-26**] glyburide use in the setting of
progressive hepatic dysfunction and renal insufficiency.
Improved with holding glyburide and D5W with bicarb.
Hyperglycemic on [**5-19**] so started on sliding scale and drip
discontinued. Pt. had no further issues of hypoglycemia during
hospital stay.
.
#. Renal insufficiency. Urine lytes consistent with prerenal
etiology. Creatitine of 1.4 on admission down to 1.2 on
discharge. Issue treated conservatively with with IVF.
.
# Diabetes Mellitus: pt's blood sugars were controlled during
most of her hospital stay with sliding scale insulin. When the
patient started her prednisone course, her blood sugars were
consistenetly elevated. She was started on Glargine in addition
to her SSI regimen. THe pt. was discharged on 22 [**Location 39665**]
at night with SSI management during the day for management of
her blood sugars. She was scheduled to follow up with her
primary care doctor within 10 days of discharge to see if her
blood sugars are adequately managed with her current insulin
regimen. Pt. was also encouraged to keep a diabetes journal to
better help her recognize how her blood sugars are controlled
with her current insulin regimen.
.
#. PE on coumadin. Coumadin held given elevated INR during
course of hospital stay. COumadin was discontinued on discharge
as pt. had PE over five years ago and her risk of ddeveloping a
2nd PE was deemed low enough to discontinue anticoagulation
therapy.
.
#. Depression. Held celexa & amitryptyline during course of
hospital stay. Pt. did well off medicaiton. Celexa was
discontinued on discharge given pt's lack of depressive symptoms
and pt's request not to be on anti depression medicaiton.
.
#. Lupus. Held plaquenil during course of hosptial stay and on
discharge. Pt. will follow up with her rheumatologist in the
out patient arena.
.
#. GERD. Held PPI during course of hospital stay. Was restarted
on Omeprazole when ptatient started prednisone due to increased
risk of gastric ulcers while on chronic steroids.
.
#. HTN. Relatively hypotensive during hospital course. Pt
restarted on antihypertensive medications on discharge.
.
Medications on Admission:
protonix 40mg daily
pravastatin 20mg daily
amitryptyline 50mg daily
cymbalta 60mg daily
vitamin D
plaquenil - unknown dose
tramadol
glyburide - unknown dose
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. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*QS * Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*1*
7. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
8. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
Two (22) Units Subcutaneous at bedtime: Administer 22 Units of
Insulin Glargine before bed.
Disp:*qs 3 pens* Refills:*1*
9. Insulin Lispro 100 unit/mL Insulin Pen Sig: Sliding Scale
INsulin Follow Sliding Scale Subcutaneous Before Breakfast,
Lunch, & Dinner.
Disp:*qs 10 Pens* Refills:*1*
10. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary:
Autoimmune Hepatitis
Hypoglycemia (low blood sugars)
.
Secondary:
Diabetes Mellitus
Hypertension
Hypercholesterolemia
Obesity
Entero-cutaneous fistula
Lupus
Depression
Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were transferred to [**Hospital1 69**]
from [**Hospital3 **] for abnormal liver tests and low blood
sugar (hypoglycemia) of unknown cause. In the intensive care
unit, you developed a urinary tract infection and were treated
with antibiotics (Ceftriaxone). You spent several days in the
intensive care unit because of your hypoglycemia, and were
eventually transferred to the general medical floors once you
were stable. Your blood sugar levels eventually stabilized with
an insulin regimen. Several blood tests were sent to try to
find a cause for your abnormal liver tests. That, in addition
to a liver biopsy that was performed, strongly suggested that
your abnormal liver tests were due to a condition called
"Autoimmune Hepatitis". This condition is due to your immune
system not recognizing your liver as a part of your body, and
mounting an immune response against parts of your liver,
resulting in liver damage. You were immediately started on
medication (called Prednisone) to treat this condition.
.
Prednisone belongs to a class of drugs called steroids. This
drug is used to decrease the effects of your immune system on
your liver. However, this drug has many side effects which you
were counseled on and should continue to be aware of. These
side effects include but are not limited to:
.
Hyperglycemia (high blood sugar)
Osteopenia/Osteoperosis (weakening of the bones)
Mania/Psychosis (episodes of extreme excitement or enthusiasm)
Weight Gain
Skin changes (fat deposits on the back of the neck, in the face,
and abdominal striae or "striping")
Increased risk of infection
Stomach Ulcers
Poor wound healing
Muscle aches
High Blood Pressure
.
You will need to take medications in addition to the prednisone
to try to combat anticipated side effects. These include:
.
Calcium/Vitamin D (to aid in bone strength)
Omeprazole (to prevent stomach ulceration)
.
You will need to follow up with your primary care doctor within
the week, as well as a liver doctor (hepatologist) for the
management of your Autoimmune Hepatitis. (see below)
.
THE FOLLOWING MEDICATIONS HAVE BEEN DISCONTINUED SINCE YOU HAVE
BEEN IN THE HOSPITAL. DO NOT TAKE THESE MEDICATIONS UNLESS
INSTRUCTED TO DO SO BY YOUR PRIMARY CARE DOCTOR:
.
protonix 40mg daily
pravastatin 20mg daily
amitryptyline 50mg daily
cymbalta 60mg daily
plaquenil - unknown dose
glyburide - unknown dose
.
YOU HAVE BEEN STARTED ON SEVERAL NEW MEDICATIONS SINCE YOUR
HOSPITALIZATION:
.
prednisone 40 mg daily
Lantus (aka Glargine) Insulin (long acting)
Humalog (aka Lispro) Insulin (short acting)
Vitamin D 800 Units/Daily
Omeprazole 40 mg daily
Calcium Carbonate 500 mg three times a day
.
It has been a pleasure taking care of you [**Known firstname **].
Followup Instructions:
Please follow up with your primary care doctor:
Primary Care Physician Appointment
Name: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
When: [**6-4**], Monday, 10am
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) 21638**], [**Location (un) **],[**Numeric Identifier 21639**]
Phone: [**Telephone/Fax (1) 21640**]
*Dr. [**Last Name (STitle) 21136**] is on maternity leave; Dr. [**Last Name (STitle) **] will fill in
for her for this appointment.
.
It is also important that you follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
in the Liver Clinic for your auto-immune hepatitis.
You have an appointment for:
Department: LIVER CENTER
When: THURSDAY [**2170-6-7**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"112.3",
"276.1",
"311",
"569.81",
"599.0",
"V10.3",
"401.9",
"593.9",
"710.0",
"272.0",
"530.81",
"278.01",
"250.82",
"570",
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] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13962, 14030
|
6696, 12403
|
288, 358
|
14283, 14283
|
3888, 6673
|
17211, 18193
|
3085, 3157
|
12611, 13939
|
14051, 14262
|
12429, 12588
|
14459, 17188
|
3187, 3869
|
232, 250
|
2367, 2634
|
386, 2349
|
14298, 14435
|
2656, 2926
|
2942, 3069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,474
| 105,979
|
31715
|
Discharge summary
|
report
|
Admission Date: [**2136-2-23**] Discharge Date: [**2136-2-29**]
Date of Birth: [**2063-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
congestive heart failure in past, referred for cabg/mvr after
cardiac catheterization
Major Surgical or Invasive Procedure:
CABG x4(LIMA-LAD,SVG-OM,SVG-Diag, SVG-PDA0MVR(#31 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
porcine)[**2-23**]
Re-exploration for bleeding [**1-/2057**]
History of Present Illness:
multiple episodes of CHF before cardiac cath in [**September 2135**],
then referred for surgical evaluation. Currently symptom free.
Past Medical History:
CAD
Ischemic Cardiomyopathy
CHF
DM2
CRI(2.2)
Nephrolithiasis
s/p Lithotripsy
s/p cystoscopy
Social History:
Retired insurance [**Doctor Last Name 360**]. Lives w/wife in [**Name (NI) 14840**], MA
Denies tobacco, rare ETOH use
Family History:
Brother w/CAD in 50's
Physical Exam:
Admission
VS: T HR 63 BP 136/74 RR 12
Ht 6'1" Wt 202lbs
Gen NAD
Neuro A&Ox3, MAE, nonfocal
Skin unremarkable
HEENT EOMI, PERRL, OP benign
Neck supple no JVD
Pulm CTA bilat
CV RRR distant heart sounds
Abdm soft, NT/+BS
Ext warm, well perfused, no varicosities or edema
Discharge
Pertinent Results:
[**2136-2-27**] 03:07AM BLOOD WBC-6.7 RBC-2.99* Hgb-9.0* Hct-25.8*
MCV-86 MCH-30.2 MCHC-35.0 RDW-13.7 Plt Ct-68*
[**2136-2-29**] 08:30AM BLOOD PT-24.5* INR(PT)-2.4*
[**2136-2-28**] 01:14PM BLOOD PT-15.2* INR(PT)-1.3*
[**2136-2-29**] 08:30AM BLOOD UreaN-47* Creat-1.7* K-3.5
[**2136-2-28**] 01:14PM BLOOD Glucose-199* UreaN-48* Creat-1.6* Na-137
K-3.4 Cl-102 HCO3-27 AnGap-11
[**2136-2-27**] 03:07AM BLOOD Glucose-151* UreaN-42* Creat-1.6* Na-136
K-4.0 Cl-102 HCO3-26 AnGap-12
[**2136-2-26**] 04:57AM BLOOD Glucose-164* UreaN-35* Creat-1.7* Na-133
K-4.6 Cl-102 HCO3-22 AnGap-14
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2136-2-27**] 10:00 AM
CHEST (PORTABLE AP)
Reason: s/p ct removal ?ptx
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
s/p ct removal ?ptx
HISTORY: Status post CABG with removal of chest tube.
FINDINGS: In comparison with the study of 2/29, there has been
removal of all of the tubes except for residual right IJ stent
and right chest tube. No evidence of pneumothorax or change in
the appearance of the heart and lungs.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 74493**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74494**]Portable TEE
(Complete) Done [**2136-2-24**] at 3:29:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2063-9-2**]
Age (years): 72 M Hgt (in): 73
BP (mm Hg): 100/60 Wgt (lb): 220
HR (bpm): 60 BSA (m2): 2.24 m2
Indication: Congestive heart failure. Coronary artery disease.
H/O cardiac surgery. Pericardial effusion. Mitral valve disease.
ICD-9 Codes: 423.3, 423.9
Test Information
Date/Time: [**2136-2-24**] at 15:29 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W99-9:9 Machine: Vivid i-4
Sedation: (See comments below for other sedation.)
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3).
MITRAL VALVE: MVR well seated, with normal leaflet/disc motion
and transvalvular gradients.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: Effusion is loculated.
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. 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). 0.2 mg of IV glycopyrrolate was given as an
antisialogogue prior to TEE probe insertion. No TEE related
complications. The patient appears to be in sinus rhythm.
Conclusions
Overall left ventricular systolic function is moderately
depressed. 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. The mitral prosthesis appears well
seated, with normal leaflet motion. There is a large echodense
(>2cm) collection (likely clot) in the pericardium. This
echodense mass is impinging on the right atrium and right
ventricle.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2136-2-24**] 16:08
Brief Hospital Course:
Mr [**Name13 (STitle) 74495**] was a direct admission to the operating room where
he had a CABGx4/MVR on [**2-23**]. Please see OR report for details.
In summary he had CABG x4 with LIMA-LAD, SVG-OM, SVG-Diag,
SVG-PDA and MVR with #31 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic porcine valve. His bypass
time was 181 minutes with a cross-clamp of 107 minutes. He
tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
He had marked bleeding from the chest tubes on the day of
surgery and returned to the operating room for reexploration. He
tolerated this well and again returned to the ICU in stable
condition. He was kept sedated after the reexploration and on
POD2/1 was allowed to wake, weaned from the ventilator and
extubated. Over the next 24 hours he was weaned from his iv
drips and his PA catherter removed. He was noted to have
intermittant episodes of Atrial fibrilation and was started on
Amiodarone and Warfarin. On POD [**3-29**] he was transferred to the
step down floor for continued care. Once on the floors his
activity level was advanced with PT and nursing, his chest tubes
and epicardial wires were removed and on POD 6 he was ready for
discharge to rehab.
Medications on Admission:
ASA 81'
Lipitor 80'
Januvia 100'
Toprol XL 25'
Avapro 150'
Urocrit-K 20"
Aldactone 25'
Humalog75/25 20 QAM
Lasix 40'
Discharge Medications:
1. Sitagliptin 100 mg Tablet Sig: 0.5 Tablet PO daily ().
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg QD x7 days then 200mg QD.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. Lantus 100 unit/mL Solution Sig: Thirty (30) Subcutaneous
at bedtime.
11. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days: 40 [**Hospital1 **] for 10 days then 40 daily as prior to
surgery.
13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
14. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
check INR [**3-1**]. Goal INR [**1-29**] for atrial fibrillation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**]
Discharge Diagnosis:
s/p CABGx4/MVR [**2-23**]
re-explored for bleeding [**1-/2057**]
Chronic systolic heart failure
PMH: ICM, DM, CRI(2.2), Nephrolithiasis, CHF
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean nad dry. OK to shower, no bathing or
swimming.
Take all medication as prescribed
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Dr. [**Last Name (STitle) 17369**] in [**1-29**] weeks
Dr. [**Last Name (STitle) 7772**] in 4 weeks
Dr. [**Last Name (STitle) 10543**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2136-2-29**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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8504, 8598
|
5714, 6989
|
361, 539
|
8783, 8792
|
1308, 2004
|
8993, 9258
|
967, 990
|
7156, 8481
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2041, 2071
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8619, 8762
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|
2100, 5691
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567, 701
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723, 816
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832, 951
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61,420
| 145,419
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35130
|
Discharge summary
|
report
|
Admission Date: [**2197-8-2**] Discharge Date: [**2197-8-11**]
Date of Birth: [**2148-6-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
COnfusion, lethargy, poor PO intake
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Information is gathered from her brother, [**Name (NI) **] [**Name (NI) 80209**], and
records from visits with Dr. [**Last Name (STitle) **].
Ms. [**Known lastname 80210**] is a 49 y.o. female with history of metastatic
infiltrating ductal CA of the breast (metastases to lungs, liver
and bones) admitted to the [**Hospital Unit Name 153**] for confusion and lethargy. She
has had poor POs for several weeks, drinks 1 cup of water a day.
Lost 20 Ib in 1 month. Denies any fevers. She has been acting
more lethargic and forgetful over the last month. Per brother,
she has not had any falls, no balance problems, no vision
issues, no incontinence. She had an appt this morning to get an
abdominal and chest CT and was acting very confused. Her brother
brought her to the [**Name (NI) **] where they did a head CT. Report showed
metastatic lesions throughout brain. Neurosurgery was consulted
and did not feel surgical intervention was appropriate.
While in ED, vitals: 97.5 71 114/62 15 100%RA, alert/oriented x
3. Given Keppra/Dexamethasone. Brother a MICU nurse, is with
her.
On admission to the ICU: T 9.1, HR 57, BP 123/66, RR 14, 100% RA
She was started on IVF.
Past Medical History:
Breast Cancer history:
[**Known firstname 80211**] was initially diagnosed while living in [**Country **] in [**2193**]
with infiltrating ductal carcinoma, stage II B T2 N1 M0 with a
partial mastectomy.
She received AC and Taxol with radiotherapy followed by
Tamoxifen
since. In [**2196-4-3**] she was diagnosed with Metastatic
disease. Her torso CT revealed multiple liver and lung mets and
osseous lesion at L5.
[**4-11**]-CT and Bone scan - extensive metastatic disease
now on Doxilx4.
Anemia
Thoracic spondylosis
Gastritis
Status post uterine ptosis
Osteopenia
PAST SURGICAL HISTORY: Partial mastectomy, axillary lymph node
dissection, and hysterectomy.
Social History:
Never smoked. She lives with her husband. [**Name (NI) **] a son in his 20s.
Born in [**Country 532**], lived in [**Country **] for 18 yrs, moved to [**Location (un) 86**].
Used to teach high school
Family History:
no FH of any cancers. Parents are well, per brother.
Physical Exam:
Vitals: T 95.1, HR 57, BP 123/66, RR 14, 100%RA
General: pale, confused, tearful, difficult word finding,
agitated, says she wants to go home.
Cardiac: RRR, no m/r/g
Pulm:CTAB, no crackles, rhonchi or wheezes
Abd: soft, nt, nd
Ext:cool , palp radial pulses bilaterally, no pedal edema
Neuro: Generalized weakness. not oriented to place or time.
Oriented to self. Confused. CN 5 normal, sensation throughout,
[**3-9**] patellar reflexes, no clonus. Difficult to assess complete
neuro exam because she is confused and agitated and tearful. In
addition, there is a language barried (russian tranlator called
but not on campus).
Pertinent Results:
Reports:
.
Head CT [**2197-8-2**]: Multiple hyperdense lesions seen throughout the
brain. A large lesion in the left thalamus has surrounding
edema and mild mass effect on the third ventricle without
hydrocephalus. Basal cisterns are patent, no evidence of
herniation or midline shift. Left frontal lucent lesion are
concerning for metastatic disease.
.
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 80212**]
Reason: Please comment on the location of lesions in the brain
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with metastatic breast cancer to liver,
lungs, brain who was
admitted with confusion and altered mental status experienced
at an outpatient
scheduled CT scan.
REASON FOR THIS EXAMINATION:
Please comment on the location of lesions in the brain
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: CXWc TUE [**2197-8-8**] 3:46 PM
Large number of enhancing lesions throughout the brain as on the
prior CT,
with relatively little edema or mass effect. Th largest is a 2
cm left
thalamic lesion with mild mass effect on 3rd ventricle. Other
lesions are
found predominantly throughout the cerebral hemispheres at the
[**Doctor Last Name 352**]-white
junction, along the ventricles, in the cerebellum, and a few in
the midbrain.
PFI AUDIT # 1
Final Report
INDICATION: 49-year-old woman with confusion and altered mental
status,
history of metastatic breast cancer.
COMPARISON: Head CT [**2197-8-2**]. Brain MR, [**2196-5-2**].
TECHNIQUE: Pre- and post-contrast sequences were obtained
through the brain.
MP-RAGE sequences could not be obtained due to patient
discomfort.
Diffusion-weighted sequences were acquired.
BRAIN MRI: Innumerable round, enhancing lesions are present
throughout the
brain. Many demonstrate increased signal on both T1- and
T2-weighted
sequences. Many of these lesions, however, demonstrate only
minimal to no
surrounding edema. The largest lesion is located in the left
thalamus,
measuring 1.8 x 2.1 cm, which exerts mild mass effect on the
third ventricle.
Most of the lesions are located in the bilateral cerebral
hemispheres,
predominantly at the [**Doctor Last Name 352**]-white matter junction. Some lesions
are situated
along the subependymal surface along the lateral ventricles. A
few smaller
lesions are present within the subcortical white matter.
Innumerable
additional lesions are present within the cerebellar
hemispheres. A few
scattered lesions are noted in the mid brain. Abnormal signal
within the left
frontal calvarium indicates a site of bony metastasis, as
indicated on the
[**2197-8-2**] head CT.
There is no intracranial hemorrhage or large mass effect. There
is no
infarction. Ventricles and sulci are normal in size and
configuration. The
major intracranial vascular flow voids are unremarkable. The
globes are
intact, without abnormal enhancement.
IMPRESSIONS: Innumerable enhancing lesions throughout the brain,
as on the
prior CT, with relatively little edema or mass effect. Largest
lesion is a
2-cm left thalamic lesion with mild mass effect on the third
ventricle. These
are compatible with metastases, not appreciably changed from the
[**2197-8-2**]
head CT.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 2671**] [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: TUE [**2197-8-8**] 7:38 PM
.
OBJECT: EVALUATE EPILEPSY IN A 49-YEAR-OLD WOMAN.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
FINDINGS:
ABNORMALITY #1: There were bursts and runs lasting up to 45
seconds at
a time generalized monomorphic delta frequency slowing,
occasionally
with notched features bifrontally.
ABNORMALITY #2: The background was slow and disorganized
throughout the
recording reaching a maximum frequency of about 5 Hz.
BACKGROUND: As described above in Abnormality #2.
HYPERVENTILATION: Was not performed.
INTERMITTENT PHOTIC STIMULATION: Was not performed.
SLEEP: No normal sleep morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This is an abnormal EEG due to the presence of
bursts and
runs of generalized slowing as well as a slow and disorganized
background. These findings indicate the presence of a moderate
encephalopathy. Encephalopathies represent non-specific diffuse
cerebral dysfunction that may be caused by medications,
metabolic
disturbances, hypoxic ischemic injury, and other etiologies.
.
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 80213**]
Reason: eval for acute process
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with confusion/AMS, h/o breast CA
REASON FOR THIS EXAMINATION:
eval for acute process
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: KKgc WED [**2197-8-2**] 4:36 PM
Multiple hyperdense lesions seen throughout the brain. A large
lesion in the
left thalamus has surrounding edema and mild mass effect on the
third
ventricle without hydrocephalus. Basal cisterns are patent, no
evidence of
herniation or midline shift. Left frontal lucent lesion are
concerning for
metastatic disease.
Final Report
INDICATION: 49-year-old woman with confusion and altered mental
status, has a
history of metastatic breast cancer.
COMPARISON: MRI of the brain and orbit [**2196-5-3**].
TECHNIQUE: Contiguous axial images were acquired through the
head without
intravenous contrast. However, the patient has had contrast
enhanced CT of
the torso an hour ago, limiting evaluation for subarachnoid
bleed.
Innumerable hyperdense lesions are seen diffusely distributed
throughout the
cerebral hemispheres and the cerebellum. The largest of these
lesions is
present within the left thalamus (2:15), measuring 2.3 x 1.8 cm,
causing mass
effect on the third ventricle. Some vasogenic edema is seen
surrounding this
lesion. No shift of midline structures or herniation is
detected. Within the
limitations of this study, no large extra-axial hematomas are
detected. There
is no hydrocephalus. The ventricles and sulci are normal in
caliber and
configuration, except for mild compression of the third
ventricle.
OSSEOUS STRUCTURES AND SOFT TISSUE: There is a lucent lesion in
the left
frontal vertex (2:25), which, given additinal findings is
suspicious for
metastatic disease. The visualized paranasal sinuses and mastoid
air cells
are clear.
IMPRESSION:
1. Innumerable hyperdense lesions distributed throughout the
brain with mild
mass effect and edema surrounding the largest lesion in the left
thalamus.
The study and the report were reviewed by the staff radiologist.
.
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Clip # [**Clip Number (Radiology) 80214**]
Reason: restaging, please compare with prior scans from [**Month (only) 958**]
and Ap
Contrast: OPTIRAY Amt: 100
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with met breast cancer
REASON FOR THIS EXAMINATION:
restaging, please compare with prior scans from [**Month (only) 958**] and
[**Month (only) 547**]
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
HISTORY: Metastatic breast cancer, restaging.
COMPARISON: [**2197-5-7**].
TECHNIQUE: MDCT axial images were obtained from the thoracic
inlet to the
symphysis pubis with the administration of IV contrast only.
Coronal and
sagittal reformations were obtained.
CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are
without
pericardial effusion. The great vessels are within normal
limits. A few
scattered mediastinal lymph nodes are not significantly changed,
and not
enlarged by size criteria, measuring up to 6 mm in the
paratracheal station.
Redemonstrated are innumerable bilateral pulmonary nodules,
which are only
minimally larger compared to prior study. For example, a nodule
within the
right upper lobe (2:14) measures 9 mm x 9 mm, previously
measured 8 mm x 8 mm.
A nodule within the left upper lobe measures 11 mm x 9 mm,
previously measured
10 mm x 8 mm. A nodule within the left lower lobe (2:33)
measures 16 mm x 14
mm, previously measured 15 mm x 14 mm. No new lesion is
identified. There is
no pleural effusion.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver is infiltrated by
numerous
metastatic lesions. There is a different enhancement pattern of
the lesions
compared to prior study, making direct comparison difficult.
Many of the
lesions demonstrate low attenuation, compatible with necrosis.
Though direct
comparison is difficult, there is an increase in number of the
lesions, as
well as an increase in size of several of the lesions. For
example, a lesion
within the right lobe of the liver (2:51) measures 18-mm,
previously measured
approximately 10 mm. There is also increasing capsular
retraction of the
liver. The portal venous system is patent without evidence of
thrombus. The
gallbladder, spleen, pancreas, adrenal glands, and kidneys are
unremarkable.
The stomach, small bowel, and large bowel are unremarkable.
There is no free air or free fluid. A few scattered
retroperitoneal lymph
nodes are not enlarged by CT size criteria, with the aortocaval
nodes
measuring up to 5 mm in short axis.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and
rectum are
unremarkable. There is no pelvic lymphadenopathy or free fluid.
OSSEOUS STRUCTURES: Redemonstrated are innumerable sclerotic
metastatic
lesions throughout the thoracolumbar spine, sternum, femurs, and
pelvis, which
are not significantly changed from prior study. There is no
evidence for
pathologic fracture.
IMPRESSION:
1. Innumerable hepatic metastases, which are increased in number
and slightly
increased in size compared to prior study.
2. Innumerable bilateral pulmonary nodules, which are also
minimally larger
in size, without evidence of new lesions.
3. Stable diffuse osseous metastases.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: [**Doctor First Name **] [**2197-8-3**] 9:25 PM
Brief Hospital Course:
49yo F with h/x of metastatic breast cancer to liver, lungs,
brain who was admitted with confusion and altered mental status
experienced at an outpatient scheduled CT scan. Currently on
cycle #4 Doxil Day #30 and recieving whole brain treatment.
First whole brain radiation was [**8-9**] (5 treatments thus far,
cycle is complete as of [**8-11**]).
.
# Altered Mental Status- most likely caused by the mutliple new
brain massess from her breast cancer metastases. Patient has
been very depressed with confusion at times.Head CT scan showed-
1. Innumerable hyperdense lesions distributed throughout the
brain with mild mass effect and edema surrounding the largest
lesion in the left thalamus. Started whole brain radiation in
house, recieved 5 treatments the last being [**8-11**].Did not place
patient on anti seizure medications because she had no history
of seizures and there is no evidence in patients with brain
mets prophylactic anti seizure meds are benficial.Continued
Dexamethasone 4 mg Q6H IV to decrease intracranial pressure.
Dexamethasone will be tapered per radiation oncology
recommendations on discharge.Got Palliative Care consult- which
followed the case, have decided to start home w/ nursing
services and home resources.
Husband was made the proxy via interpreter [**8-4**] Dr. [**Last Name (STitle) 724**] had seen
the patient and recommended EEG which revealed no seizure
activity(indicated moderate encephalopathy). We started Ritalin
in attempt to raise her affect and activity level (which was
started [**8-9**]). We got a head MRI to better stage her disease
which showed :Innumerable enhancing lesions throughout the
brain, as on the
prior CT, with relatively little edema or mass effect. Largest
lesion is a 2-cm left thalamic lesion with mild mass effect on
the third ventricle. These are compatible with metastases, not
appreciably changed from the [**2197-8-2**] head CT.
.
# Breast Cancer: metastatic, currently on Doxil Cycle # 4 Day #
30 with zometa.
-Patient is BRCA1/2 negative.
- f/u per primary oncologist Dr. [**Last Name (STitle) **]
.
# Right arm and right leg weakness- most likely caused by her
brain metastases, especially given large lesion in the left
thalamus.
.
- the weakness is [**5-8**] power in the right upper and lower
extremities
compared to the left which is [**6-7**] power. Her right hand however
is limp, unless she is told to move it and the grasp is much
weaker than the left hand. These symptoms correlate with her
lesion in her thalamus.
.
# FEN: regular diet
# PPx: Pain controlled with morphine, DVT PPx with sc heparin
# Code: presumed FULL
# Dispo: home with services
Medications on Admission:
Lidocaine vit E 2% apply to toes
Lorazepam 1mg q 8 hrs prn for nausea
Megestrol 400 mg/10 mL (40 mg/mL) Suspension 10 cc by mouth two
to three times a day
Prochlorperazine Maleate 10 mg Tablet 1 Tablet(s) by mouth every
12 hrs as needed for nausea
B Complex Vitamins 1 Capsule(s) by mouth once a day
Calcium Carbonate-Vitamin D3 [Calcium 500 + D]
Discharge Medications:
1. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
2. Standard Wheelchair
3. 3 in 1 Commode
4. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
TID (3 times a day): Please take 2 teaspoons at each dose time
or 6 teaspoons per day.
Disp:*500 ml* Refills:*2*
5. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): Please take 1 teaspoon at each dose time or 2
teaspoons/day.
Disp:*500 ml* Refills:*2*
7. Senna 8.8 mg/5 mL Syrup Sig: One (1) PO twice a day: Please
take 1 teaspoon each dose time or 2 teaspoons/day.
Disp:*500 ml* Refills:*2*
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO use as
directed : Decrease to 4mg twice / day starting [**8-12**] for 3 days.
On [**8-15**] decrease to 2mg twice/ day for 3 days.
On [**8-18**] take 2mg once/ day for 3 days and stop [**8-21**].
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Metastatic breast cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to care for you as your doctor
.
You were brought to the hospital with altered mental status and
depression. We found masses in your brain from your metastatic
breast cancer. You started brain radiation treatment at the
hospital. We also conducted a EEG to assess the electircal
activity of the brain, which showed no seizure activity, but
signs of brain swelling.
.
We made no changes to your medications you were taking before
coming to the hospital except:
.
We added: Dexamethasone 4mg p.o every 6 hours by mouth, to
decrease brain swelling.
.
Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
TID (3 times a day): Please take 2 teaspoons at each dose time
or 6 teaspoons per day.
.
Ritalin 2.5mg Twice/day by mouth in attmept to increase activity
level and appetite.
.
Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
.
Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): Please take 1 teaspoon at each dose time or 2
teaspoons/day.
.
Senna 8.8 mg/5 mL Syrup Sig: One (1) PO twice a day: Please
take 1 teaspoon each dose time or 2 teaspoons/day.
.
and the following support equipment:
Standard wheelchair and 3 in 1 Commode
.
Please attend the following outpatient appointments.
.
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 17688**],
MD Phone:[**0-0-**]
Date/Time:[**2197-8-16**] 4:30PM
Location: [**Hospital Ward Name 23**] Building [**Location (un) **]
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73088**],
NP[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-8-16**] 4:30PM
.
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**],
RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-8-16**] 4:30PM
Followup Instructions:
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 17688**],
MD Phone:[**0-0-**]
Date/Time:[**2197-8-16**] 4:30PM
Location: [**Hospital Ward Name 23**] Building [**Location (un) **]
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73088**],
NP[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-8-16**] 4:30PM
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**],
RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-8-16**] 4:30PM
|
[
"733.90",
"348.5",
"348.30",
"V10.3",
"198.3",
"197.7",
"198.5",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
17420, 17468
|
13311, 15952
|
303, 309
|
17537, 17537
|
3141, 3653
|
19557, 20068
|
2426, 2480
|
16350, 17397
|
10088, 10129
|
17489, 17516
|
15978, 16327
|
17724, 19534
|
2122, 2194
|
2495, 3122
|
228, 265
|
10161, 13288
|
337, 1510
|
17552, 17700
|
1532, 2099
|
2210, 2410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,207
| 140,852
|
36912
|
Discharge summary
|
report
|
Admission Date: [**2121-7-20**] Discharge Date: [**2121-7-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Groin pain/hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 38758**] is an 85 year old woman with recent right total hip
replacement (~6 days ago) at [**Hospital1 **] [**Location (un) 620**].
On the day prior to admission, she presented with groin pain and
was found to be hypotensive (81/35) without obvious etiology.
She was given levofloxacin and metronidazole for possible
infection, calcium for possible Beta blocker toxicity (unclear
how many beta blockers she is on, but she was never
bradycardic); her hematocrit was noted to be stable since
discharge. She had no reported history of abdominal pain.
Peripheral dopamine and norepinephrine were initiated. Per
report, the BIN non-contrast CT abd/pelvis showed atelectasis, a
minimally enlarged gall bladder, and a question of colitis,
without RP bleed. She received 3-4L IVF, and she was transferred
to [**Hospital1 18**] for further evaluation.
At [**Hospital1 18**] ED, her triage vitals were pain [**9-22**], HR 70, BP 124/70
(on pressors), RR 12, Sat 99%RA. A CT with IV contrast (Mucomyst
given) was ordered given a slightly lower creatinine on repeat
labs. An echo (by cards fellow) to evaluate for RV strain
demonstrated minimal RV dilatation with no focal wall
abnormality. A dose of vancomycin was given. CT torso
demonstrated no PE, atelectasis, CBD dilation without
obstruction, cholelithiasis, and peripancreatic stranding less
prominent than on [**Location (un) 620**] CT. A RUQ ultrasound demonstrated a
distended gall bladder with pericholecystic and perihepatic
fluid, with gallstone and mild GB wall thickening, consistent
with acute cholecystitis. She was seen by surgery, who thought
she didn't appear clinically to have cholecystitis or
pancreatic, so she was admitted to medicine with surgery
following.
On arrival to the unit, she complains of terrible pain in her
right groin and leg. She denies fevers, chills, dysuria
(although she reports not being able to urinate on her own since
leaving the hospital), constipation, mild abdominal discomfort,
nausea, and a chronic cough (months) that is non-productive. Her
phenylephrine was at 0.1mcg and quickly removed.
Past Medical History:
- s/p Right total hip replacement [**2121-7-14**]
- s/p Left total hip replacement
- h/o "colitis", possibly current, per the [**Hospital1 **]-N d/c summary
- Gout
- h/o herpes zoster
- hypertension
- hypercholesterolemia
- GERD
Social History:
Lives in [**Location 620**]. Denies tobacco, EtOH, IVDU.
Family History:
non contributory
Physical Exam:
General Appearance: No acute distress, Anxious
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , Crackles : Bases bilaterally)
Abdominal: Soft, Bowel sounds present, Distended, Tender: In
right lower quadrant, no rebound, no guarding
Extremities: Right: 1+, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
[**2121-7-21**] 12:03PM BLOOD Hct-27.5*
[**2121-7-21**] 04:47AM BLOOD WBC-7.9 RBC-3.28* Hgb-10.0* Hct-28.8*
MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-232
[**2121-7-20**] 10:51PM BLOOD Hct-26.8*
[**2121-7-20**] 01:46PM BLOOD WBC-6.4 RBC-2.71* Hgb-8.4* Hct-23.9*
MCV-88 MCH-30.9 MCHC-35.0 RDW-15.1 Plt Ct-226
[**2121-7-19**] 09:00PM BLOOD WBC-8.1 RBC-3.06* Hgb-9.4* Hct-27.4*
MCV-90 MCH-30.8 MCHC-34.5 RDW-14.9 Plt Ct-225
[**2121-7-20**] 01:46PM BLOOD Neuts-71.0* Lymphs-17.0* Monos-10.1
Eos-1.6 Baso-0.3
[**2121-7-19**] 09:00PM BLOOD Neuts-83.6* Lymphs-10.3* Monos-5.6
Eos-0.5 Baso-0
[**2121-7-21**] 04:47AM BLOOD PT-31.0* PTT-34.5 INR(PT)-3.2*
[**2121-7-20**] 01:46PM BLOOD PT-49.1* PTT-49.7* INR(PT)-5.6*
[**2121-7-19**] 10:45PM BLOOD PT-57.5* PTT-48.4* INR(PT)-6.8*
[**2121-7-19**] 10:45PM BLOOD Fibrino-580*
[**2121-7-20**] 03:35PM BLOOD Ret Aut-1.9
[**2121-7-21**] 04:47AM BLOOD Glucose-95 UreaN-35* Creat-1.7* Na-130*
K-4.8 Cl-99 HCO3-23 AnGap-13
[**2121-7-19**] 09:00PM BLOOD Glucose-120* UreaN-37* Creat-1.9* Na-131*
K-5.1 Cl-103 HCO3-18* AnGap-15
[**2121-7-21**] 04:47AM BLOOD ALT-37 AST-46* LD(LDH)-221 AlkPhos-93
TotBili-0.5
[**2121-7-19**] 09:00PM BLOOD ALT-42* AST-56* LD(LDH)-237 CK(CPK)-354*
AlkPhos-102 TotBili-0.5
[**2121-7-19**] 09:00PM BLOOD Lipase-69*
[**2121-7-19**] 09:00PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-3252*
[**2121-7-20**] 03:10AM BLOOD CK-MB-6 cTropnT-<0.01
[**2121-7-21**] 04:47AM BLOOD Albumin-2.8* Calcium-7.9* Phos-3.6 Mg-1.7
[**2121-7-20**] 01:46PM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.5 Mg-1.8
Iron-73
[**2121-7-20**] 01:46PM BLOOD calTIBC-212* VitB12-514 Folate-14.2
Hapto-246* Ferritn-155* TRF-163*
[**2121-7-19**] 09:05PM BLOOD Lactate-1.0
RLE ultrasound [**2121-7-20**]: No evidence of right lower extremity DVT,
however, the calf veins were not visualized due to body habitus.
CT SCAN PELVIS / LOWER EXTREMITY ON [**2121-7-20**]:
1. No evidence of retroperitoneal, pelvic or intramuscular
hematoma or
hardware complication. Please note that following thigh
circumference may be used to monitor for hematoma in this
patient who has had two CTs in the last 24 hours for this.
2. Slight interval increase in anasarca.
3. Scattered sigmoid diverticula without evidence of
diverticulitis.
RUQ ULTRASOUND:
1. Distended gallbladder with single mobile gallstone, without
gallbladder
wall thickening or specific sign of acute cholecystitis. If
there is concern for acute cholecystis, nuclear medicine
hepatobiliary scan could be useful.
2. Mild pericholecystic and perihepatic fluid, and right pleural
effusion,
likely related to third spacing.
3. CBD dilatation to 11 mm, without discrete obstructing stone
or lesion
identified. No intrahepatic or pancreatic ductal dilatation.
MRCP can provide further information about the bile ducts if
necessary.
[**2121-7-20**] CTA CHEST, CT ABD/PELVIS W/ CONTRAST: ]
1. No pulmonary embolus or acute aortic abnormality.
2. Asymmetric atelectasis at the lung bases, right greater than
left.
Subacute fractures of lateral right 9th and 10th ribs.
3. Interval increase in perihepatic and pericholecystic fluid,
with trace
fluid with subcutaneous edema suggesting diffuse third spacing.
4. Minimal gallbladder distention and cholelithiasis. However,
no gallbladder
wall thickening. Nuclear medicine hepatobiliary scan could be
obtained if
there is clinical concern for acute cholecystitis.
5. Dilated common bile duct measuring up to 12 mm, without
visible
obstruction. No intrahepatic or pancreatic ductal dilatation.
MRCP can
provide further assessment of the biliary tree if needed.
6. Diverticulosis without diverticulitis.
7. Findings consistent with tracheomalacia.
Brief Hospital Course:
85yF with history of hypertension, hypercholesterolemia, GERD,
and "colitis", with recent right total hip replacement
approximately 6 days ago, now with hypotension of unclear
etiology. She was on carvedilol, lisinopril and lasix and these
medications were held. The patient did not have a fever,
leukocytosis or any localizable source for infectin. She
initially had a R IJ central line placed and was rehydrated with
IVF. She was briefly on vasopressor medications. These were
stopped. She was hypovolemic on exam. After fluid repletion she
was observed off of IVF and her SBP maintained between 100-110.
Given lack of infectious si/sx along w/ negative thorax CT her
antibiotics were discontinued. She has blood cultures from [**7-20**]
pending and a negative urinalysis. Her CTA had no PE. She had
a RLE ultrasound which was negative for DVT. Hematocrit was
stable and 28. Her initial HCT was 27, dropped to 23 and she
rec'd 1 unit of PRBC and for the next 3 hcts was stable between
27-28. Her INR was elevated to 6 without signs of bleeding, CT
without any RP or thigh bleeding. Coumadin was held and should
be restarted when INR in range 2-3. INR upon discharge on [**7-21**]
was 3.2.
Distended gall bladder/elevated lipase/peripancreatic stranding
on CT: per surgery not clinically pancreatitis or acute
cholecystitis. Lipase very mildly elevated and patient without
any epigastric pain. The paitent was tolerating PO food well.
Transaminases were at the upper limit of normal (40-50) and
trended slightly down prior to discharge, bili and alk phos were
normal.
CAD: aspirin switched to 81mg daily from 325mg daily as patient
is currently on coumadin as well and this will decrease her
bleeding risk.
Medications on Admission:
- Coumadin 3 mg Daily
- Darvocet-N 100 100 mg-650 mg Tab q4-6 hrs prn
- Carvedilol 12.5 mg [**Hospital1 **]
- Omeprazole 20 mg Daily
- Evista 60 mg Daily
- Lipitor 10 mg Daily
- Amitriptyline 25 mg qhs
- Asacol 400 mg Tab TID
- Lisinopril 20 mg Daily
- Furosemide 20 mg Daily
- Betoptic S 0.25 % Eye Drops [**Hospital1 **] both eyes
- Aspirin 325mg Daily
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis:
Dehydration
Anemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a low blood pressure in the setting of a
dehydration and blood pressure medications. These meds were
held, you were given IV fluids and your blood pressure returned
to a normal range. You were given 1 unit of blood.
Please inform your rehab doctors if [**Name5 (PTitle) **] have any
lightheadedness, chest pain, shortness of breath, fevers, chills
or any other symptoms that concern you.
Followup Instructions:
Please follow up with your primary care physician and your
orthopedic surgeon within 2 weeks of your discharge from the
hospital.
|
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3,491
| 152,520
|
51727
|
Discharge summary
|
report
|
Admission Date: [**2109-9-14**] Discharge Date: [**2109-9-23**]
Date of Birth: [**2064-8-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Bilateral Calf Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45F with possible lupus (diagnosis unclear), prior hx
rhabdomyolysis who p/w b/l leg pain diffusely. Pt followed by
rheum [**8-13**] re w/[**Location 107153**] c/w polymyositis but more c/w
narcotic induced rhabdo or rare enzyme abnormality. On chronic
narcotics for fibromyalgia, and chronic b/l leg pain, using up
to 180mg MS Contin [**Hospital1 **]. Pt noticed increased calf pain b/l for 4
days, gradual in onset. Pt feels like this is a Lupus flare, she
gradually stopped walking due to pain. She denies any fevers, no
leg ulcers or skin breakdown. Can't walk because of pain, she's
been bed bound x3days per pt report. She denies taking any
Motrin or Ibuprophen or more MS Contin than her usual dose of
180mg [**Hospital1 **]. She denies any recent Abx use. Pt also has diminished
PO intake due to nausea.
.
Further ROS: Denies constitutional sx, no fevers, weight
changes, no CP/Palpitations/SOB. Occasional atypical CP, but not
now. +N/no emesis. No abdominal pain, diarrhea or constipation.
Normal BMs daily, no BRBPR, no melena. No dysuria. No HA,
Confusion, LH, dizziness.
.
ED Course: Pt's intial CK 91,950. Received 4L IVNS, Received
28mg IV Morphine,6mg IV Dilaudid and 12.5mg Anzemet x1. Renal
consult in ED, started aggressive fluid hydration, rec to start
NaHCO3 for bicarb<15, w/aggressive lyte repletion. Tox screen +
for benzos and optioates 9/[**2108**].
Past Medical History:
-Atypical CP
-Myocarditis/CHF EF >55%, no wall motion abnormalities
-HTN
-hyperlipidemia
-hypothyroidism
-Avascular necrosis on knees b/l
-Steroid induced DM
-Chronic/Recurrent Rhabdomyolysis, CPK trend from 400s-48,000
current, since [**2108-2-7**] w/normal CPK [**Month (only) **]-[**2108-10-9**], thereafter
persisitently elevated 400s until current presentation 91,000
-Asthma
-Anemia
-Cholycystectomy
-HCV-chronic hepatitis C with grade [**1-11**] inflammation and stage 3
fibrosis
-? Lupus-no definative dx, no clinical evidence for this, lack
of [**Doctor First Name **] titer and compliment levels
-Significant Narcotic Abuse, h/o Heroin use (pt denies h/o IVDA)
-Narcotics Contract and violation of narcotics contract
(termination of care at [**Company 191**] for several Narcotic violations)
- fybromyalgia
Social History:
lives in [**Location 4628**] with two children (20yo, 16yo). Not currently
working, used to work licensing TV footage. Remote h/o cocaine
and heroin abuse reported in OMR, denies current use. 1 ppd x
32 years. Denies alcohol. Husband died of leukemia 2y ago.
Family History:
Her mother died of an MI at the age of 60. Her father died of an
abdominal aortic aneurysm at the age of 74. She has one sister
in good health. Her husband died in [**2105**] of AML.
Physical Exam:
Vitals- 93.0 po, BP 116/75 HR 77 RR28 96%RA
General-NAD, Speaking in short sentences, blunted affect, teary
eyed
HEENT-Dry MM, PERRL, minimally icteric sclera, No thyromegaly or
cervical LAD
RESP: CTABL ANT'LY
CV: Reg, Nml S1,S2, No M/R/G
Abd: Soft, obese, ND, NT w/distraction, no rebound, no guarding
Extrem: No C/C/E, warm, 2+DP pulses B/L, pt uncooperative due to
pain, asking for pain medication to be able to move legs, no
femoral bruits
Neuro: A&OX3, no focal neuro deficits
Pertinent Results:
[**2109-9-14**] 01:15PM PLT COUNT-313
[**2109-9-14**] 01:15PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
[**2109-9-14**] 01:15PM NEUTS-84.9* BANDS-0 LYMPHS-10.6* MONOS-2.1
EOS-1.8 BASOS-0.7
[**2109-9-14**] 01:15PM WBC-9.2 RBC-4.55# HGB-11.8* HCT-36.2# MCV-80*
MCH-26.0* MCHC-32.6 RDW-18.0*
[**2109-9-14**] 01:15PM CK(CPK)-[**Numeric Identifier 107154**]*
[**2109-9-14**] 01:15PM GLUCOSE-101 UREA N-20 CREAT-1.6*# SODIUM-136
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-15* ANION GAP-19
[**2109-9-14**] 01:35PM URINE AMORPH-FEW
[**2109-9-14**] 01:35PM URINE RBC-0 WBC-[**2-10**] BACTERIA-RARE YEAST-NONE
EPI-[**2-10**]
[**2109-9-14**] 01:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2109-9-14**] 01:35PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2109-9-14**] 02:53PM CALCIUM-5.0* PHOSPHATE-3.9 MAGNESIUM-1.9
[**2109-9-14**] 02:53PM GLUCOSE-80 UREA N-13 CREAT-1.0 SODIUM-144
POTASSIUM-3.8 CHLORIDE-125* TOTAL CO2-10* ANION GAP-13
[**2109-9-14**] 04:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2109-9-14**] 04:10PM TSH-1.4
[**2109-9-14**] 04:10PM CALCIUM-5.3* PHOSPHATE-4.8*
.
.
[**9-14**] CXR
SINGLE VIEW OF THE CHEST: Cardiac and mediastinal contours
appear stable, with persistent enlarged cardiac silhouette.
Pulmonary vascularity appears within normal limits. No focal
consolidations are seen within the lungs. No evidence of pleural
effusion.
IMPRESSION: No evidence of acute cardiopulmonary process or
significant change from prior.
.
[**9-16**] CXR
FINDINGS: There is no significant interval change in the frontal
view when compared to prior. The lateral projection shows some
pleural thickening which could be some loculated fluid
posteriorly and some discoid atelectasis as well.
IMPRESSION: No change from prior. No new consolidation.
.
[**9-17**] LE U/S neg for DVT
.
[**9-20**] CXR
PA and lateral views of the chest are obtained on [**2109-9-20**] and
compared with the prior radiograph of [**2109-9-16**]. There is
cardiomegaly with tortuosity of the aorta. The right lung
appears clear. There is some patchy increase in density in the
left lower lung field, probably in the lingula, which is
unchanged from prior examination and likely represents
subsegmental atelectasis. No frank consolidation is seen.
IMPRESSION:
No significant change in the appearances since the study of
[**2111-9-17**] with atelectasis/airspace disease in the left lower lung
zone.
.
[**2109-9-23**] 04:45AM BLOOD WBC-9.0 RBC-3.52* Hgb-9.6* Hct-28.1*
MCV-80* MCH-27.2 MCHC-34.0 RDW-18.1* Plt Ct-276
[**2109-9-23**] 04:45AM BLOOD Glucose-101 UreaN-24* Creat-1.9* Na-140
K-3.2* Cl-103 HCO3-25 AnGap-15
[**2109-9-23**] 04:45AM BLOOD CK(CPK)-1080*
[**2109-9-23**] 04:45AM BLOOD Calcium-7.4* Phos-5.0* Mg-1.6
[**2109-9-17**] 04:30AM BLOOD calTIBC-260 Ferritn-66 TRF-200
[**2109-9-17**] 04:30AM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
45 year old female with a history of fibromyalgia, possible
lupus, significant marcotic abuse history, and hypothyroidism
presents with recurrent rhabdomyolysis.
#. Rhabdomyolysis: The patient's CK peaked at [**Numeric Identifier 107155**] and, with
aggressive hydration, trended down to 1080 on discharge.
Orthopedics followed her throughout her hospital stay given
concern that she might develop compartment syndrome; serial
exams were without evidence of this. The patient has a history
of recurrent rhabdomyolysis with extensive prior work-up. In the
past, rheumatology has suspected narcotic-related myotoxicity
(prolonged treatment with high dose opioids for chronic pain),
although adult-onset metabolic myopathy was an another unlikely
possibility. 2 prior muscle biopsies were not consistent with
polymyositis. Per patient, she was only taking MS contin,
discussion with her pharmacy revealed she was also filling
scripts for percocet and oxycodone. She has been reluctant to
taper off MSContin, but now agrees to do so. Over the course of
her hospital stay, she was tapered from MSContin 150 mg PO BID
to 90 mg PO BID. This should continued to be tapered as an
outpatient when she follows up with her new PCP.
#. Acute renal failure: Creatinine peaked at 2.1 from a baseline
Cr 0.5, likely secondary to rhabdomyolysis. Urine electrolytes
were consistent with a renal etiology (FENA 11 %) and the renal
service followed her throughout her hospital course. At time of
discharge, her creatinine was stable at 1.9. This will need to
continue to be monitored as an outpatient. She will follow-up
with Dr. [**First Name (STitle) 805**] at [**Last Name (un) **] as an outpatient; next creatinine to
be checked [**9-27**] and faxed to Dr. [**First Name (STitle) 805**].
#. Urinary tract infection: She will complete a 7 day course of
ampicillin for an enterococcal urinary tract infection.
#. Pneumonia: Given a persistent cough, a chest X-ray was
obtained, which showed a left lower lung opacity (atelectasis
versus infiltrate). She will complete a 10 day course of
levofloxacin for presumed pneumonia
#. Chronic Pain: The patient has a history of naroctic abuse,
and has multiple violations of her PCP-[**Name10 (NameIs) 107156**] narcotic
contract. The pain management service was consulted and followed
her closely throughout her hospital stay. Her pain was managed
with Tylenol, hydromorphone 2-mg PO q3-4 PRN; MS contin was
decreased from 150 [**Hospital1 **] to 90 [**Hospital1 **] over her hospital course. She
was started on amitriptyline, which was titrated up to 50 mg
daily.
#. HTN: She was maintained on beta-blocker and clonidine.
#. Possible Lupus: This diagnosis has been questioned by
rheumatology in the past given absence of clear clinical signs,
despite a positive [**Doctor First Name **] in 5/[**2107**]. Her cellcept was discontinued
and her prednisone tapered to 5 mg daily. She will need to
re-institute rheumatology follow-up as an outpatient.
#. Type II diabetes: This was steroid-induced, and she was
diet-controleld at home. Her hemoglobin A1C was 6, and her
fingersticks remained well-controlled throughout her hospital
stay.
#. Hypothyroid: continue levothyroxine 88mcg. TSH 1.4 on
admission.
#. Anemia: Hematocrit trended down from 36 on admission,
although at time of discharge it was stable at 28.1. Her iron
studies were consistent with iron-deficiency anemia. She was
started on iron and will need a colonoscopy as an outpatient.
#. Dispo: The patient was discharged home with home physical
therapy. She has a a follow-up appointment with Dr. [**First Name (STitle) 805**]
from Nephrology but will need to establish care with a new PCP.
[**Name10 (NameIs) **] have given her the numbers for [**Hospital1 336**] and [**Hospital1 2025**].
Medications on Admission:
(confirmed with pharmacy - [**Company 4916**]: [**Telephone/Fax (1) 107157**] - [**Location (un) 3146**])
-Ativan 1mg (last filled [**8-16**])
-Ambien 10mg ([**8-16**])
-Cellcept 1gm [**Hospital1 **] (last filled [**8-13**])
-Levothyroxine 88mcg ([**7-27**])
-Prednisone 20mg taper ([**8-25**])
-Clonidine 0.1mg daily ([**9-6**])
-Potassium 10mEQ ([**5-23**])
-Atenolol 50mg daily ([**5-23**])
-Lisinopril 10mg qd ([**8-23**])
.
-[**9-13**] Suboxone 8mg #13 tabs - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 107158**])
-[**9-9**] Suboxone-8mg #4 - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
-[**9-6**] Suboxone-8mg #5 - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
-[**8-25**] Percocet 10/325mg # 20 - Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1022**] ([**Telephone/Fax (1) 107159**])
-[**8-23**] Oxycodone 5mg #30 - Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 38490**])
-[**8-23**] MS [**Last Name (Titles) 1367**] 30mg #50 - [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
-[**8-18**] Oxycodone 5mg #20 - [**Doctor Last Name **]
-[**8-16**] Oxycodone 5mg #30 - [**Doctor Last Name **]
-[**7-23**] MS Contin 30mg #360 - [**Doctor Last Name **]
-[**7-23**] Dilaudid #90 - [**Doctor Last Name **]
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every
3 to 4 Hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*42 Tablet(s)* Refills:*0*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Lorazepam 1 mg Tablet Sig: [**12-10**] - 1 Tablet PO q 8 hrs prn as
needed for anxiety.
Disp:*21 Tablet(s)* Refills:*0*
9. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Morphine 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q12H (every 12 hours).
Disp:*126 Tablet Sustained Release(s)* Refills:*0*
13. Outpatient Lab Work
Chem 10
Please fax results to Dr. [**First Name (STitle) 805**] [**Telephone/Fax (1) 77460**].
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary: Rhabdomyolysis
Secondary: acute renal failure, hypertension, hypothyroidism,
urinary tract infection, pneumonia, asthma, steroid-induced type
II diabetes, iron-deficiency anemia, fibromyalgia
Discharge Condition:
Hemodynamically stable
Ambulatory
Discharge Instructions:
Please take all medications as instructed. There were several
changes made to your current medications regimen.
If you experience any fever, increased leg pain, nausea,
vomiting, lightheadedness, chest pain, shortness of breath, or
any other concerning symptoms please seek medical attention
immediately.
Followup Instructions:
Please have your Creatinine and other electrolytes drawn on
[**9-27**] and faxed to Dr. [**First Name (STitle) 805**] at ([**Telephone/Fax (1) 77460**].
Please make a follow-up appointment with a primary care doctor
within the next week. [**Hospital 4415**]: ([**Telephone/Fax (1) 107160**]. [**Hospital1 2025**] ([**Telephone/Fax (1) 107161**].
The following appointments have already been made for you:
Dr. [**First Name (STitle) 805**] (Nephrology). [**2109-10-3**]. 12:00 pm. Tel ([**Telephone/Fax (1) 806**].
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2109-12-12**] 8:45
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
|
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"729.1",
"250.00",
"401.9",
"304.90",
"V17.3",
"584.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13105, 13124
|
6638, 10426
|
335, 341
|
13368, 13404
|
3587, 6615
|
13760, 14541
|
2883, 3068
|
11837, 13082
|
13145, 13347
|
10452, 11814
|
13428, 13737
|
3083, 3568
|
276, 297
|
369, 1747
|
1769, 2588
|
2604, 2867
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,885
| 108,733
|
42190
|
Discharge summary
|
report
|
Admission Date: [**2188-7-25**] Discharge Date: [**2188-7-30**]
Date of Birth: [**2148-4-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for Pcom aneurysm clipping
Major Surgical or Invasive Procedure:
[**2188-7-25**] Open right-sided hemicraniotomy and Pcom aneurysm
clipping [**2188-7-25**] Diagnostic cerebral angiogram
History of Present Illness:
Ms. [**Known lastname 91495**] is a 40-year-old right-handed female with h/o
aneurysmal subarachnoid hemorrhage s/p Pcom aneurysm coiling
([**2187-11-6**]). Follow-up angiogram on [**2188-6-30**] revealed that
the aneurysm had recanalized at the base. Though this does not
pose any risk for rupture at this point, given patient's young
age this would have to be treated at some point. It was felt
that this would be best treated through an open craniotomy and
clipping as the aneurysm could be recanalized again and coiled.
Patient is therefore now electively admitted to undergo open
craniotomy and clipping of her PCom aneurysm.
Past Medical History:
Migraines
Depression
Hypercholesterolemia
Appendectomy
Tonsillectomy
Social History:
She works as a dental assistant and is currently laid off. She
quit smoking after subarachnoid hemorrhage and takes about four
glasses of wine a few times a week.
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM PRIOR TO ADMISSION ([**2188-7-10**], per Dr. [**First Name (STitle) **] clinic
note):
Patient awake, alert, oriented x3. Her memory recent and remote
is good. Attention and concentration is appropriate. Language
and fund of knowledge is good. Cranial nerves were intact. Her
motor strength is [**5-10**] in all four
extremities. Gait and coordination were normal.
PHYSICAL EXAM ON DISCHARGE:
AVSS, NAD, AxOx4
symmetric chest rise, breathimg comfortably
incision on scalp, c/d/i
symmetric smile
CNII-XII intact
EOMI, PERRL
Strength/motor: LUE: 4+ D/B/Tr, 4-IO, LLE: 5 IS/Q/H/[**Last Name (un) 938**]/TA/GS,
RUE: 5 D/B/Tr/WF/WE/IO, RLE: 5 IL/Q/H/TA/[**Last Name (un) 938**]/GS
SITLT R U M Sa [**Doctor First Name **] SP DP Bilat
BL wwp, 2+cr, 2+dp/pt BL, 2+ R
Pertinent Results:
CEREBRAL ANGIOGRAM ([**2188-6-30**]):
-IMPRESSION: Previously coiled right posterior communicating
artery aneurysm has recanalized and the left internal carotid
artery posterior communicating segment aneurysm is unchanged.
POST-OP NONCONTRAST HEAD CT ([**2188-7-25**]):
1. Probable small amount of blood in the right sylvian fissure
s/p clipping of the right posterior communicating artery
aneurysm. Evaluation is limited by streak artifacts from the
clips and coils.
2. Mostly air-filled extraaxial collection underlying the right
craniotomy, with mild right frontal sulcal effacement, mild
ventricular effacement, and 3 mm leftward shift of midline
structres.
3. Apparent low density projecting over the right frontal lobe
may be related to artifacts from the overlying scalp staples.
Recommend close attention on follow up imaging to exclude the
possibility of edema.
NONCONTRAST HEAD CT ([**2188-7-26**]): Allowing for streak artifacts,
there is no evidence of new hemorrhage or edema. The extraaxial
collection underlying the right craniotomy has slightly
decreased in size.
CT Perfusion/CT Angiogram ([**2188-7-26**]):
Status post coiling and clipping of the right PCOM aneurysm, it
is difficult to assess for residual aneurysm at this location
due to artifact.
The remaining neck vasculature appears patent.
New hemorrhage in the right basal ganglion.
No large territorial perfusional defects on the CTP.
CT HEAD W/O CONTRAST [**2188-7-27**]
1. Stable right basal ganglia hemorrhage measuring 2.2 cm. No
new area of hemorrhage.
2. Stable 5-mm leftward shift of midline structures.
3. Post-surgical changes from right frontoparietal craniotomy.
Brief Hospital Course:
Patient was admitted to the hospital on [**7-25**]. That day she
underwent elective right craniotomy with clipping of right
posterior communicating artery aneurysm. Intraoperatively there
were no complications, but the right PComm did have to be partly
sacrificed with expectectation that collateral circulation would
provide perfusion. Post-op neuro exam was non-focal. Post-op
head CT showed minimal blood in right sylvian fissues s/p
aneurysm clipping as well as expected post-op changes; no
hemorrhage or edema. SBP was strictly controlled between
140-160mmHg postoperatively.
On HD #2 (POD #1) patient was noted to have decreased strength
([**2-10**]) in distal left lower extremity. Repeat head CT showed no
new hemorrhage or edema. However, as there was concern for
ischemia secondary to partial PComm sacrifice, but collaterals
were seen on angio that which showed there was adequate flow.
She was started on heparin drip and her SBP parameters were
increased to 160-180. Later that evening, patient was seen to
have new LUE weakness and lethargy. A stat head CT was performed
which showed a new R basal ganglia hemorrhage. Heparin was
discontinued and protamine was given. Her systolic blood
pressure parameters were lowered to 100-140 and IVF were also
decreased.
On [**7-27**], aspirin was stopped and repeat head CT showed stable
hemorrhage. On [**7-28**], her exam improved with LUE 4-/5 and LLE
5-/5. Pt was then transferred to the floor with continued
improvement in exam as depicted in final exam upon discharge
above. The patient made steady progress with PT and was deemed
safe to go home with physical therapy services. The patient at
time of discharge expressed readiness for discharge and all
questions were answered. The patient will require follow-up as
listed below for her medical conditions. She was discharged home
on [**2188-7-30**].
Medications on Admission:
ASA 325
Zantac qd
Topomax (dose unknown)
Zoloft (dose unknown)
Loratadine 10mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
do not exceed 4 grams in 24 hours
2. Bisacodyl 10 mg PO/PR DAILY
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 400 mg PO Q8H:PRN Pain
5. LeVETiracetam 1000 mg PO BID
RX *Keppra 1,000 mg 1 tablet(s) by mouth twice a day Disp #*90
Tablet Refills:*0
6. Loratadine *NF* 5 mg Oral daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID
9. Simvastatin 10 mg PO DAILY
home medication
10. Topiramate (Topamax) 25 mg PO QAM pain
home medication
11. Topiramate (Topamax) 50 mg PO QPM
home medication
12. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN headcahe
hold rr < 12
RX *Dilaudid 2 mg 1 tablet(s) by mouth Q4hr Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right Pcom aneurysm
Right BG hemorrhage
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:
Craniotomy for aneurysm clipping
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? **Your wound was closed with sutures/staples. You may wash
your hair only after sutures and/or staples have been removed.
?????? **Your wound was closed with dissolvable sutures, you must
keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? **You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? **You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? 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, unless you have been instructed not to.
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 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office at 10 days from your date of
surgery for removal of your staples/sutures. This appointment
can be made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**].
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????**You may also have them removed at your rehab facility.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 4 weeks.
??????You will not need a CT scan of the brain.
Completed by:[**2188-8-4**]
|
[
"V15.82",
"437.3",
"E878.1",
"729.89",
"V12.54",
"311",
"997.02",
"272.0",
"431",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
6776, 6834
|
3920, 5785
|
333, 455
|
6918, 6918
|
2233, 3897
|
9106, 9835
|
1407, 1424
|
5920, 6753
|
6855, 6897
|
5811, 5897
|
7101, 9083
|
1439, 1819
|
1847, 2214
|
248, 295
|
483, 1117
|
6933, 7077
|
1139, 1210
|
1226, 1391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,116
| 101,379
|
5879
|
Discharge summary
|
report
|
Admission Date: [**2127-3-24**] Discharge Date: [**2127-4-1**]
Date of Birth: [**2053-3-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Location (un) 1279**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
ECMO
History of Present Illness:
74yo F referred to [**Hospital1 18**] for chest tightness and dyspnea for the
past month. It occurs both at rest and with exertion, related to
stress. She reports associated dizziness. She has episodes [**3-28**]
times per week. They last for a few minutes and resolve when she
lies down and relaxes.
During cardiac catheterization, she clotted off her left
circumflex artery and left anterior descending artery. Patient
became hypotensive requiring atropine and dopamine. Code was
called. Patient required 7 defibrillations.An IABP was placed. A
temporary RV pacing wire was placed. The patient was intubated.
Cardiopulmonary support (ECMO)was initiated via CPS perfusion
catheters placed in the RFA and RFV (the IABP and RV pacing wire
were removed). Access obtained in the LFA and LFV. Emergent
bedside echo showed no evidence of tamponade.She was
successfully resuscitated using CPS with emergent deployment of
drug eluting stents in LAD and LCx(Kissing stenting of the LMCA
into the LAD and LCX ).Patient had resumption of pulsatile
central aortic pressure after stenting of the LAD and LCx. An
IABP was placed.PA cath c/w ischemic MR.
She has massive blood loss during the procedure and has recieved
5U PRBC and 1u platelet prior to transfer to CCU. Echo post cath
showed small pericardial effusion, mild aymmetric LVH, nl LV
size, mildly depressed LVEF
Patient did well in cath lab and ECMO weaned off. Given the ACT
of >900, it was determined to be safer to have the ECMO
catheters removed in OR. Patient went to the OR and vascular
surgery removed the ECMO catheters
Past Medical History:
Diabetes mellitus
Hypertension
C section
hysterectomy
mild LV systolic dysfunction at baseline
Social History:
Married, lives with her husband in [**Location (un) 686**]. No
stairs. Daughter lives on the [**Location (un) **] of her house.
Family History:
noncontributory
Physical Exam:
T 93.6 P88-96 BP 114/70 IABP 1:1
vent: Fi)2 0.8 550 x 16, PEEP5
Gen-sedated
HEENT-anicteric, mmm, JVD hard to visualizes
CV-RRR, no r/m/g
resp-CTAB(anterior exam)
[**Last Name (un) 103**]-soft, NT/ND, mostly in bandage
extremities-cold extremities, no pitting edema, pulses
dopplerable bilaterally, left groin hematoma noted
Pertinent Results:
-echo [**2127-3-24**]
1. The left atrium is normal in size.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. LV appears underfilled.
Overall left ventricular systolic function is mild to moderately
depressed. Resting regional wall motion abnormalities include
inferior and inferoseptal akinesis.
3. Right ventricular chamber size is normal. Right ventricular
systolic function appears depressed with apical akinesis.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 5.The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
6.There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
7. There is an echogenic density in the right ventricle
consistent with a catheter.
PROCEDURE DATE: [**2127-3-24**]
INDICATIONS FOR CATHETERIZATION:
chest pain
FINAL DIAGNOSIS:
1. Acute embolic occlusion of the LCx artery during cardiac
catherization complicated by cardiac arrest requiring initiation
of
cardiopulmonary support.
2. Kissing stenting of the LMCA into the LAD and LCX.
COMMENTS:
1. Initial resting hemodynamics revealed normal right and left
sided
filling pressures.
2. Left ventriculography revealed normal systolic function.
3. In preparation for selective coronary angiography, the JL4
was
advanced into the ascending aorta. This was done without
difficulty and
the catheter was cleared and flushed per routine, with contrast
clearing
in the ascending aorta (well outside the sinuses of Valsalva).
The
first puff in the LMCA suggested occlusion of the LCx. The first
cineangiogram showed mild LMCA plaquing with abrupt cutoff and
total
occlusion of the LCx. There was mild diffuse plaqing in the LAD.
4. The patient became progressively bradycardic and hypotensive
(SBP <
40mmHg) and a code was called. Atropine, dopamine and
epinephrine were
given. Chest compressions were started. The patient developed
recurrent VT and VF and the patient was defibrillated at 360J
approximately 7 times. An IABP was placed. A temporary RV pacing
wire
was placed. The patient was intubated.
5. CT surgery was emergently consulted. Cardiopulmonary support
(ECMO)
was initiated via CPS perfusion catheters placed in the RFA and
RFV (the
IABP and RV pacing wire were removed). Access obtained in the
LFA and
LFV. Emergent bedside echo showed no evidence of tamponade.
6. Limited angiography of the RCA showed minimal CAD.
7. Successful kissing stenting of the LAD/LCX back to the ostium
of
the LMCA was performed with a 3.0 x 33 mm Cypher DES (LAD) and
LCX 2.5 x
28 mm Cypher DES (LCX).
8. Patient had resumption of pulsatile central aortic pressure
after
stenting of the LAD and LCx. An IABP was placed.
9. HCt from ABG 20%. Transfusion with emergency release blood
products
was begun.
10. PA catheterization was performed via the LFV. It showed a
marked
increase in filling pressures (RA mean 23mmHg, PCWP mean 40 with
tall
v-waves and rounded dicrotic notch on PA pressure tracing.
Findings
consistent with iscehmic mitral regurgitation.
11. Repeat emergent echo showed a small pericardial space,
posterobasal
hypokinesis and a hyperdynamic anterior wall with moderate
mitral
regurgitation.
12. Hand injection of the LFA showed no obvious major
extravasation.
13. Vascular surgery consulted (together with CT surgery)
regarding
weaning of CPS and removal of CPS catheter
CT abdomen and pelvis [**2127-3-25**]:
CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral pleural
effusions and
bibasilar collapse/consolidation. An NG tube is noted coiled
within the
stomach. The inflated portion of the intraaortic balloon pump
terminates just
above the aortic bifurcation. Note is made of a non-calcified
gallstone.
There is biliary excretion of previously administered contrast.
The liver is
unremarkable on this noncontrast study. The adrenal glands,
pancreas,
kidneys, spleen, and intraabdominal loops of bowel are
unchanged. There is
high attenuation fluid in the anterior and posterior pararenal
spaces
consistent with hemorrhage. There is perihepatic ascites. No
pathologically
enlarged lymph nodes are identified.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is diffuse stranding
in the
subcutaneous tissues in the left groin with obliteration of the
normal fat
planes with asymmetry with expansion of the anterior thigh
musculature
consistent with a hematoma. There is low-density free pelvic
fluid. A Foley
catheter is noted in the bladder. There is sigmoid
diverticulosis, without
evidence of diverticulitis.
Bone windows reveal no suspicious lytic or sclerotic foci. There
are
degenerative changes.
IMPRESSION:
1) Left groin hematoma.
2) Retroperitoneal hemorrhage as described above.
3) Apparent low position of intraaortic balloon pump terminating
with its
inflated portion just above the aortic bifurcation.
Echo [**2127-3-28**]:
1. The left atrium is mildly dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. No left ventricular aneurysm
is seen. There is mild regional left ventricular systolic
dysfunction. Overall left ventricular systolic function is
modertately depressed. Resting regional wall motion
abnormalities include basal and mid inferior hypokinesis with
basal and mid inferolateral and lateral akinesis.
3. Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen.
5.The mitral valve leaflets are structurally normal. Mioderate
(2+) mitral regurgitation is seen.
6.There is mild pulmonary artery systolic hypertension.
[**2127-3-24**] 07:42PM TYPE-ART TEMP-33.7 PO2-135* PCO2-35 PH-7.35
TOTAL CO2-20* BASE XS--5 INTUBATED-INTUBATED
[**2127-3-24**] 07:42PM LACTATE-7.3*
[**2127-3-24**] 07:42PM O2 SAT-98
[**2127-3-24**] 07:42PM freeCa-1.13
[**2127-3-24**] 07:28PM GLUCOSE-188* UREA N-17 CREAT-1.0 SODIUM-146*
POTASSIUM-3.1* CHLORIDE-112* TOTAL CO2-20* ANION GAP-17
[**2127-3-24**] 07:28PM ALT(SGPT)-1093* AST(SGOT)-2155* LD(LDH)-[**2149**]*
CK(CPK)-4492* ALK PHOS-54 TOT BILI-0.6
[**2127-3-24**] 07:28PM cTropnT-13.41*
[**2127-3-24**] 07:28PM ALBUMIN-2.4* CALCIUM-8.0* PHOSPHATE-3.7
MAGNESIUM-1.1*
[**2127-3-24**] 07:28PM WBC-16.2* RBC-5.00 HGB-15.4 HCT-43.1 MCV-86
MCH-30.8 MCHC-35.7* RDW-14.8
[**2127-3-24**] 07:28PM NEUTS-71* BANDS-16* LYMPHS-10* MONOS-1* EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2127-3-24**] 07:28PM PLT SMR-LOW PLT COUNT-122*
[**2127-3-24**] 07:28PM PT-18.3* PTT-72.1* INR(PT)-2.1
[**2127-3-24**] 07:28PM FIBRINOGE-201
[**2127-3-24**] 05:45PM WBC-14.7* RBC-4.48# HGB-13.8# HCT-39.4#
MCV-88# MCH-30.8 MCHC-35.0# RDW-14.7
[**2127-3-24**] 05:45PM PLT COUNT-115*
[**2127-3-24**] 05:45PM PT-17.0* PTT-66.1* INR(PT)-1.8
[**2127-3-24**] 05:45PM FIBRINOGE-178
[**2127-3-24**] 05:41PM TYPE-ART PO2-143* PCO2-39 PH-7.26* TOTAL
CO2-18* BASE XS--8 INTUBATED-INTUBATED VENT-CONTROLLED
[**2127-3-24**] 05:41PM GLUCOSE-317* NA+-139 K+-4.2
[**2127-3-24**] 05:41PM HGB-13.4 calcHCT-40
[**2127-3-24**] 05:41PM freeCa-1.16
[**2127-3-24**] 05:02PM TYPE-ART PO2-131* PCO2-47* PH-7.26* TOTAL
CO2-22 BASE XS--5 INTUBATED-INTUBATED
[**2127-3-24**] 05:02PM GLUCOSE-370* NA+-140 K+-3.5
[**2127-3-24**] 05:02PM HGB-10.3* calcHCT-31
[**2127-3-24**] 05:02PM freeCa-1.41*
[**2127-3-24**] 04:31PM TYPE-ART PO2-427* PCO2-20* PH-7.43 TOTAL
CO2-14* BASE XS--7 INTUBATED-INTUBATED
[**2127-3-24**] 04:31PM GLUCOSE-428* NA+-137 K+-2.8*
[**2127-3-24**] 04:31PM HGB-9.8* calcHCT-29
[**2127-3-24**] 04:31PM freeCa-0.84*
[**2127-3-24**] 02:45PM GLUCOSE-569* UREA N-17 CREAT-1.1 SODIUM-136
POTASSIUM-2.7* CHLORIDE-99 TOTAL CO2-14* ANION GAP-26*
[**2127-3-24**] 02:45PM ALT(SGPT)-1177* AST(SGOT)-874* CK(CPK)-460*
ALK PHOS-54 AMYLASE-162* TOT BILI-0.3
[**2127-3-24**] 02:45PM CK-MB-28* MB INDX-6.1* cTropnT-0.66*
[**2127-3-24**] 02:45PM ALBUMIN-2.1*
[**2127-3-24**] 02:45PM WBC-11.9*# RBC-2.65*# HGB-7.8*# HCT-25.2*#
MCV-95 MCH-29.5 MCHC-30.9* RDW-13.0
[**2127-3-24**] 02:45PM NEUTS-60 BANDS-12* LYMPHS-19 MONOS-4 EOS-1
BASOS-1 ATYPS-3* METAS-0 MYELOS-0
[**2127-3-24**] 02:45PM HYPOCHROM-2+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2127-3-24**] 02:45PM PLT SMR-NORMAL PLT COUNT-177
[**2127-3-24**] 02:45PM PT->100* PTT->150* INR(PT)->63
[**2127-3-24**] 02:25PM TYPE-ART RATES-16/ TIDAL VOL-500 PEEP-5 O2
FLOW-100 PO2-389* PCO2-27* PH-7.30* TOTAL CO2-14* BASE XS--11
-ASSIST/CON INTUBATED-INTUBATED COMMENTS-VENTED
[**2127-3-24**] 02:25PM GLUCOSE-565* LACTATE-13.2* K+-2.6*
[**2127-3-24**] 02:25PM HGB-6.7* calcHCT-20 O2 SAT-97
[**2127-3-24**] 01:30PM RATES-16/ TIDAL VOL-500 PEEP-5 O2 FLOW-100
PO2-582* PCO2-29* PH-7.25* TOTAL CO2-13* BASE XS--12 -ASSIST/CON
INTUBATED-INTUBATED
[**2127-3-24**] 01:30PM GLUCOSE-496* LACTATE-13.1* NA+-132* K+-3.2*
CL--105
[**2127-3-24**] 01:30PM HGB-7.5* calcHCT-23 O2 SAT-99
Brief Hospital Course:
74yo female with history of hypertension and nonobstructive
coronary artery disease referred to [**Hospital1 18**] for cardiac
catheterization because of increasing dyspnea. During procedure,
she clotted off her LCx and LAD. She had 7 ventricular
fibrillation arrest requiring ECMO being placed by surgery. She
had emergent placement of kissing stents to LAD and LCx. Post
procedure, she went to the OR to have ECMO catheters removed on
the right groin, IABP and PA catheter placed on the left groin.
She recieved a total of 6 units of blood during the procedure.
On arrival to the CCU, she was on pressors and intubated. Over
the course of the next few days, her hemodynamics were monitored
by swan and improved. She was eventually extubated. IABP and
pressors were removed on [**2127-3-26**] with good hemodynamics. However,
she developed acute respiratory distress on the night of [**2127-3-26**]
responsive to lasix, nitroglycerin drip and positive pressure
ventilation with CPAP. Her blood pressure dropped drastically
requiring a brief period of pressure support with levophed,
which was quickly weaned off. It was thought that she could have
had acute pulmonary edema. She continues to improve thereafter
and was eventually transferred to regular floors for a few days.
She is currently on aspirin, lipitor, plavix(minimal 3 months).
SHe was also started on lisinopril and toprol. Echo was
performed on [**2127-3-28**] with the concern of posterior wall aneurysm
seen by ECG changes. That turned out to be negative. SHe was
started on daily lasix for heart failure. SHe also had a short
run of atrial fibrillation which spontanouesly converted on
[**2127-3-29**]. Her blood pressure control is satisfactory with
metoprolol, lisinopril and imdur. During this hospitalization,
she also had retroperitoneal bleed. She was transfused to keep
her hematocrit above 30. Her hematocrit remained stable
thereafter.
Vancomycin, levofloxacin and metronidazole was initially started
for presumed aspiration penumonia given that she spiked
temperature, had increased WBC and increasing sputum production.
She continued the course of levofloxacin and metronidazole for 7
days. Vancomycin was discontinued since sputum culture did not
grow any organism. SHe was also c.diff negative.
Medications on Admission:
Lisinopril 40mg daily
Nifedical 60mg daily
Metformin HCL 1000mg qam, 500mg qlunch, 1000mg qpm
Lipitor 40mg daily
Atenolol 25mg daily
Protonix 40mg daily
Aspirin 325mg daily
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 Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 300 days.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. 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*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
acute coronary syndrome
diabetes
hypertension
retroperitoneal bleed
Discharge Condition:
stable
Discharge Instructions:
PLease return to the hospital or call your doctor if you
experience chest pain or shortness of breath or if there are any
concerns at all
Please take all prescribed medication
Followup Instructions:
please follow up with your cardiologist(Dr. [**Last Name (STitle) 1911**] within
one month of your discharge
Completed by:[**2127-4-1**]
|
[
"250.00",
"410.81",
"402.91",
"276.2",
"424.0",
"285.9",
"780.6",
"998.12",
"427.5",
"570",
"287.4",
"785.51",
"427.41",
"428.0",
"507.0",
"E879.0",
"997.1",
"414.01",
"998.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"37.61",
"96.71",
"99.04",
"39.32",
"88.72",
"38.93",
"88.53",
"38.91",
"89.64",
"39.31",
"99.63",
"36.07",
"88.56",
"39.65",
"39.64",
"96.04",
"36.05",
"86.09",
"37.23",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
15407, 15465
|
11696, 13979
|
321, 351
|
15577, 15585
|
2618, 3503
|
15810, 15949
|
2241, 2258
|
14203, 15384
|
15486, 15556
|
14005, 14180
|
3564, 11673
|
15609, 15787
|
2273, 2599
|
3536, 3547
|
271, 283
|
379, 1960
|
1982, 2079
|
2095, 2225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,012
| 134,915
|
50950
|
Discharge summary
|
report
|
Admission Date: [**2118-2-26**] Discharge Date: [**2118-3-31**]
Date of Birth: [**2042-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
75 yo M w/ COPD, CRI transitioning to HD, mult CVA, ongoing EtOH
abuse, esophageal varices presents with 1 day history of CP.
The patient is a poor historian and most of the history was
obtained from his wife. The pain is described as a substernal
pressure which radiates to the back. The pain was not related
to activity and did not improve with rest. It persisted from
early this am until he arrived in the ED and received nitro. He
also had N/V, chills but no diaphoresis. At this point in time
the patient is pain free. His wife claimed the pain was
worsened with deep inspiration and he was coughing productive of
dark sputum.
.
Also the patient recently had an AV fistula placed in his L arm
for HD on [**2-11**]. He had cellulitis which was tx with oxacillin
[**Date range (1) **] and then augmentin since. Wife tells that patient is
non compliant with meds despite her urging.
.
Patient denies LH, dizziness, changes in vision/hearing,
dysphagia, decreased appetite, SOB, abd pain, dysuria, blood in
sputum/urine/stool. He continues to drink 10 drinks a day. His
last drink was 1am night prior to admission. Also has a chronic
cough.
Past Medical History:
Afib
CVA - weakness on R side
HTN
Espohageal Varices
PM [**2-2**] brady
COPD
CRI -> recent placement of AV fistula for HD
Gout
Social History:
former policeman, lives with wife
EtOH - drinks 10 drinks per day, last drink 1am night prior to
admission
Tob - 1ppd x many years
Family History:
NC
Physical Exam:
T 100.4 P 70 BP 170/80 R 24 O2 95 on 3L
Gen - confused but baseline mental status as described by wife.
NAD
[**Name2 (NI) 4459**] - EOMI, PERRL, OP clear, extremely poor dentition
Neck - supple, no carotid bruit
Cor - RRR sys murmur
Chest - Decreased breath sounds on bases R worse than L
Abd - distended tympanetic, non painful, liver edge palp, +BS
Ext - w/wp, +1 edema to knees
left arm with incision no erythema, but pain, thrill over
fistula
Pertinent Results:
[**2118-2-26**] 05:00AM WBC-11.7*# RBC-3.55* HGB-12.6* HCT-36.1*
MCV-102* MCH-35.6* MCHC-35.0 RDW-16.7*
[**2118-2-26**] 05:00AM NEUTS-85.9* LYMPHS-10.0* MONOS-3.5 EOS-0.5
BASOS-0.1
[**2118-2-26**] 05:00AM PLT COUNT-182
[**2118-2-26**] 05:00AM PT-13.6 PTT-30.9 INR(PT)-1.2
[**2118-2-26**] 05:00AM D-DIMER-6953*
[**2118-2-26**] 05:00AM CK(CPK)-54
[**2118-2-26**] 05:00AM cTropnT-0.05*
[**2118-2-26**] 05:00AM CK-MB-3
[**2118-2-26**] 05:00AM GLUCOSE-107* UREA N-36* CREAT-4.7* SODIUM-140
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-16* ANION GAP-23*
[**2118-2-26**] 06:28AM LACTATE-3.7*
[**2118-2-26**] 08:42AM LACTATE-1.8
[**2118-2-26**] 11:45AM CALCIUM-8.3* PHOSPHATE-4.9*# MAGNESIUM-0.9*
[**2118-2-26**] 11:45AM CK-MB-NotDone
[**2118-2-26**] 11:45AM cTropnT-0.04*
[**2118-2-26**] 11:45AM CK(CPK)-37*
.
CXR - RLL infiltrate
.
TEE- no dissection
.
CTA:
1. No evidence of pulmonary embolism or aortic dissection.
2. Small bilateral pleural effusions with associated compressive
atelectasis.
3. Moderate- sized pericardial effusion.
4. Bilateral lower lobe opacities, which may represent infection
vs. aspiration pneumonia.
5. Multiple enlarged mediastinal lymph nodes. These may be
reactive in nature.
.
CT abdomen
1. Very limited study. There is no evidence of dissection,
though it is not excluded given that no IV contrast was
administered.
2. Consolidation vs. atelectasis in the right lower lobe
posteriorly. Small pleural effusions bilaterally.
3. Irregular contour of the left kidney. This was noted on a
prior report, though the images are not available for direct
comparison. Etiology is not clear.
4. Diffuse atherosclerotic disease.
5. Small lymph nodes in the axilla and retroperitoneum that do
not meet CT criteria for pathologic enlargement.
6. L4 compression deformity. The acuity of this finding is not
clear, as the prior study images are not available for direct
comparison.
7. Sclerotic lesions within the pelvis as described. Correlation
with PSA requested.
.
TEE- no evidence of aortic dissection.
.
Video Swallow- Significantly delayed oral transit and pharyngeal
swallow initiation. Piecemeal bolus handling. Aspiration
observed with swallowing materials and thin liquid. Acute cough
was effective in clearing the aspirated material. For a more
detailed report, please refer to the speech pathology report.
.
TTE- 1. The left atrium is moderately dilated. The left atrium
is elongated.
2.The right atrium is markedly dilated.
3.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly
depressed. Resting regional wall motion abnormalities include
apical distal
inferior, basal and mid inferolateral hypokinesis.
4. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
5.The aortic valve leaflets are mildly thickened. There is a
minimally
increased gradient consistent with minimal aortic valve
stenosis.
6. Trivial mitral regurgitation is seen.
7.There is mild pulmonary artery systolic hypertension.
8.There is a small pericardial effusion. There are no
echocardiographic signs
of tamponade.
9. There is an echogenic density in the right atrium consistent
with a
pacemaker lead.
Brief Hospital Course:
75 yo M w/ COPD, CRI transitioning to HD, mult CVA, ongoing EtOH
abuse, new dx of adenoca now txfx'd from the ICU following CHF
exacerbation.
Originally admitted w/ pna after being ruled out for MI, neg
CTA, hct drop during admission led to colonoscopy w/
polypectomy- one of which was positive for adenoca ([**Location (un) 6553**] B).
Neg liver u/s. Course c/b by mult episodes of GIB, stable over
the last week. During that time pt rec'd lg volume resusciation
after which he became increasingly SOB after diuresis held.
Transferred to ICU, underwent UF and HD w/ subsequent dramatic
improvement in resp status.
.
1) PNA- patient initially admitted with diagnosis of pneumonia.
Found to be requiring 3-4L O2 via NC to maintain oxygenation.
Given that patient originally presented with pleuritic chest
pain he underwent CTA to rule out PE, which was negative. TEE
was ordered from ED to r/o ao dissection. Completed 7 day
course of ceftriaxone and azithromycin, w/ subjective
improvement and decreased O2 requirement. Given intial
findings on CT felt that aspiration was possibly playing a role
in the patient's lung disease. During transfer to ICU [**2-2**] resp
failure/CHF (see below) the patient was started on steroids for
presumed COPD contribution (although no PFTs ever performed by
PCP, [**Name10 (NameIs) **] previous O2 sat ever recorded in office, CT w/o bullae
or hyperinflation). He will complete the steroid taper tomorrow.
.
2) CHF- following volume resusciation for GIB (as discussed
below) the patient was noted to have continued 2L oxygen
requirement. Pt had no h/o CHF but TTE showed mild systolic
dysfxn. During week 3 of hospitalization the patient developed
increasing SOB. The attending physician had asked that diuresis
be stopped as it was felt that the patient had a primary
pulmonary process. In the interim, as further w/u, BNP and
repeat CXR were obtained. BNP returned elevated at 21K, w/
increasing vol congestion on CXR. The patient was developing
increasing SOB and was transferred to the ICU for emergent HD.
A Quintan catheter was placed and the patient underwent UF and
HD w/ subsequent resolution of his SOB. On transfer back to the
floor the patient was oxygenting well on RA. Plan to complete a
steroid taper, as above.
.
3) Adenocarcinoma of colon- during admission, pt developed
ongoing HCT drop w/ guiac positive stools. Colonoscopy revealed
multiple polyps, 8 of which were removed. The pathology on a
polyp removed from the transverse colon revealed adenocarcinoma
within several millimeters of the margin. Following polypectomy
the patient had several episodes of BRBPR, one of which
necessitated transfer to the ICU. The patient underwent
multiple repeat colonoscopies which were unrevealing. HCT
remained stable and the patient should receive follow up
colonoscopy in 3 months. Heme/onc was consulted. The patient
underwent staging u/s of the liver, which did not reveal any
lesions. CEA was elevaed but of unclear significance in the
setting of renal failure. Colonic resection was discussed with
the surgical consultants on multiple occasions but it was felt
that patient was not a surgical candidate. This was discussed
with the patient and his family and they concurred with the
management plan.
.
4) CRF- on admission pt was being transitioned to HD and had
already had an AVF placed. However, the fistula was not yet
mature and when he developed resp failure it was necessary to
place a quintan catheter. He subsequently had a tunnelled HD
catheter placed, which was functioning well on discharge. He
will require TIW dialysis, which was arranged prior to d/c.
.
5) [**Name (NI) 11053**] Pt was discharged home once all of his medical issues
were atble and he was cleared by PT. He will follow-up with
Dr.[**Last Name (STitle) 1270**] in [**1-2**] weeks and has a f/u appointment with
heme/onc next week. He will continue outpt dialysis TIW. Pt will
need VNA services for med teaching and FS checks, as his BG has
been running high while on the prednisone taper. He should be
assessed for DM as an outpt and started on oral hypoglycemics,
if necessary.
Medications on Admission:
allopurinol 150mg qday
thiamine
mvi
folic acid
norvasc 10mg qday
lasix 80mg po bid
protonix 40mg qday
aldomet 500mg qam/250mg qafternoon/250mg qevening
calcitriol 0.5mcg qday
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 caps* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) GIB
2) PNA
3) colonic adenocarcinoma
4) COPD
Discharge Condition:
Good, VSS.
Discharge Instructions:
1) Please take your medicatations as directed
2) Please attend your follow up appointments
3) Return to medical care if you develop increased wheezing,
sob, fever, bleeding per rectum, or abdominal pain.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2118-4-21**] 11:30
.
Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital6 29**]
[**Hospital6 **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2118-4-4**] 10:30
.
Provider: [**Name10 (NameIs) 8848**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Where: [**Hospital 4054**] [**Hospital **]/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2118-4-4**] 10:30
.
Call to make an appointment to follow up with Dr. [**Last Name (STitle) 1270**]
[**2118**] within the next two weeks.
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
|
[
"274.9",
"V45.01",
"V15.81",
"E879.8",
"438.89",
"455.0",
"403.91",
"V45.1",
"211.3",
"486",
"428.0",
"518.81",
"578.9",
"153.1",
"427.31",
"491.21",
"998.11",
"428.20",
"535.50",
"305.01",
"456.1",
"305.1",
"285.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.42",
"99.04",
"88.72",
"45.16",
"39.95",
"45.25",
"45.23",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11554, 11611
|
5610, 9748
|
326, 331
|
11702, 11714
|
2332, 5587
|
11966, 12886
|
1834, 1838
|
9973, 11531
|
11632, 11681
|
9774, 9950
|
11738, 11943
|
1853, 2313
|
276, 288
|
359, 1514
|
1536, 1665
|
1681, 1818
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,712
| 119,752
|
25391
|
Discharge summary
|
report
|
Admission Date: [**2176-12-9**] Discharge Date: [**2177-1-31**]
Date of Birth: [**2128-3-17**] Sex: F
Service: MEDICINE
Allergies:
Cefepime / Vancomycin
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
CC: Fever to 101
Major Surgical or Invasive Procedure:
Bronchoscopy with BAL x 2 - Pulmonary biopsy on 2nd bronchoscopy
History of Present Illness:
Mrs. [**Known lastname **] is a 48 yo female h/o M4 AML s/p 7+3 and 4 cycles of
HIDAC (last [**2176-11-26**]). She has been seen periodically since
discharge to follow her counts and transfused with platelets and
RBC transfusions. She reports that yesterday she started to
feel nauseous and induced vomiting x1 (no hematemesis) without
benefit. She began to feel better last evening, but this
morning she reports a continued upset stomach with nausea and
found her temperature to be 101. She denies abdominal pain,
diarrhea or constipation. Last BM was yesterday and was not
black or bloody. She has had a cough for the last 2 weeks and
has been producing clear phelgm with yellowish tinge. She also
reports that she has been in various stages of a cold over the
last month with a runny nose. No sinus tenderness, SOB, CP.
Her daughter and husband have both recently had colds. She has
had no recent travel. She denies any new rashes.
Past Medical History:
Onc Hx: 48 yo female w/ newly diagnosed AML, dx by BM biopsy on
[**6-28**]. Her initial bone marrow was morphologically consistent
with AML (type M4) with some monocytic differentiation and her
cells were CD34, HLA-DR, CD11c, CD33, CD13, CD64, and CD117
positive and CD41, CD56, and glycophorin A negative. In terms of
cytogenetics, no mitoses were available for metaphase chromosome
analysis. FISH analysis for an AML1-ETO rearrangement, PML-RARA
rearrangement, and a CBFB rearrangement were all negative. On
[**6-28**] she began 7+3 induction chemotherapy with three days of
idarubicin 20 mg and seven days of cytarabine 170 mg. A day 14
bone marrow biopsy revealed no evidence of leukemia. Patient's
repeat bone marrow biopsy on [**7-30**] showed mildly hypercellular
bone marrow with maturing trilineage hematopoiesis. She has
completed 4 cycles of HIDAC.
Social History:
She lives with her husband and 8 year old adopted daughter from
[**Name (NI) 651**]. No smoking, no ETOH use. Prior to her diagnosis, she was
quite physically active bicycling and running.
Family History:
No family history of leukemia, mother dx w/ breast cancer at age
62 and 2 cousins also dx with breast cancer around age 50.
Physical Exam:
T 101.9 P 95 RR 26 BP 103/60 98% RA
Gen: WDWN woman lying in bed in NAD
HEENT: PERRLA, EOMI, OP clear, MMM
CV: RRR nl s1, s2, no m/g/r
Lungs: CTAB, no w/r/r
Abd: BS+, soft, NT, ND
Ext: no c/c/e
Pulses: 2+ radial bilaterally, warm LE
Skin: no rashes
Neuro: A&O, CN 2-12 intact, [**4-11**] UE and LE strength, no gross
deficits to Light Touch, FNF and HKS WNL, tandem walk normal
Pertinent Results:
ECHO: [**2176-12-12**]:
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
2. No evidence of endocarditis seen.
3. Compared with the findings of the prior study of [**2176-7-9**],
there has been no significant change
.
ECHO: [**2176-12-31**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF 50-60%). The
left ventricular cavity size is top normal/borderline dilated.
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 valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion. Compared
with the findings of the prior reportof [**2176-12-12**], the left
ventricle is now borderline dilated with a low normal ejection
fraction.
.
CT Chest with contrast:
[**2176-12-13**]:
Numerous ground glass and solid nodules with upper lobe
predominance with more confluent areas in the right apex. In
this immunocompromised patient, an opportunistic infection such
as invasive aspergillosis is considered most likely, but
differential diagnosis includes mycobacterial, bacterial, and
viral organisms
.
CT Chest without contrast:
[**2176-12-18**]:
1. Improving ground-glass and solid nodules, which have a right
upper lobe predominance. Again, in this immunocompromised
patient the differentials are invasive aspergillosis,
mycobacteria , fungal or virus infections.
2. Congestive heart failure with pulmonary edema with small
bilateral effusions, cardiomegaly, and small pericardial
effusion.
.
CT Chest w/o contrast:
[**2176-12-24**]:
IMPRESSION:
1. Decreased nodular opacities in the bilateral upper lobes
representing improvement of infection, most likely fungal.
2. Increased pulmonary edema and small-to-moderate bilateral
pleural effusions.
3. New left basilar consolidation probably representing
atelectasis. A pneumonia cannot be excluded, particularly in an
immunocompromised patient
.
CT Chest w/o contrast:
[**2177-1-2**]:
IMPRESSION:
1. There has been significant improvement in the upper lobe
opacities as well as the left lower lobe
consolidation/atelectasis and bilateral pleural effusions seen
on the prior studies.
2. There is a new micronodular pattern of predominantly
centrilobular opacities diffusely involving the lungs, more so
at the upper lobes than the lower lobes. These findings are most
suggestive of atypical infection, which include mycobacterial
(tuberculosis or atypical), fungal, pyogenic bacterial, or viral
infection. Other causes such as parasitic or lymphoid
infiltration are unlikely based on the imaging appearances. The
findings were discussed with Dr. [**First Name (STitle) **] at the completion of the
examination, [**2177-1-2**].
Transbronchial biopsy may provide additional diagnostic value if
these findings do not respond appropriately to treatment.
.
CT Chest with contrast:
[**2177-1-6**]:
IMPRESSION:
1. Interval progression of diffuse interstitial and alveolar
airspace opacities with new scattered areas of consolidation.
The progression in the short interval is compatiable with an
infectious process.
2. 4.8-cm left adnexal cyst. A followup ultrasound is
recommended in six weeks to assess for resolution.
3. Bilateral, hypoattenuating areas within the kidneys
bilaterally. These likely represent cysts and could be further
evaluated with ultrasound or MRI.
.
CT Head with contrast:
[**2177-1-6**]:
IMPRESSION: No evidence of intracranial hemorrhage or edema. No
abnormal post-contrast enhancement identified.
.
L Shin Biopsy [**2176-12-30**]:
Septal panniculitis most consistent with erythema nodosum
.
Bronchial Washings [**2177-1-3**]:
An abundant monomorphic population of intermediate sized
mononuclear cells with folded nuclei, pale chromatin and
variably prominent nucleoli, are suspicious for involvement
by the patient's AML.
.
Flow Cytometry of cells from Bone MArrow Bx of: [**2176-12-26**]:
Immunophenotypic findings consistent with persistent acute
myelogenous leukemia with an immunophenotype similar to that
seen at first diagnosis. Three-color gating is performed (light
scatter vs. CD45) to optimize blast/lymphocyte yield.
Cell marker analysis demonstrates that the majority of the cells
isolated from this bone marrow express immature antigens CD34,
myeloid associated antigens CD33-bright, CD13-dim, CD117-dim
.
Bone MArrow Biopsy: [**2176-12-26**]:
Markedly hypocellular bone marrow with large aggregates of
myeloblasts, consistent with persistent acute myeloblastic
leukemia.
.
Bone Marrow Biopsy: [**2176-12-16**]:
Hypercellular bone marrow for age with extensive involvement by
patient's known acute myelogenous leukemia.
.
Three-color gating is performed (light scatter vs. CD45) to
optimize blast yield. Cell marker analysis demonstrates that the
majority of the cells isolated from this bone marrow express
immature antigens CD34, CD117, myeloid associated antigens CD33,
CD11c, CD64 (dim), CD15 (dim), CD13 (dim), and lack the myeloid
antigen CD14.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 48 yo woman with M4 AML, s/p 7+3 induction and
four cycles of HiDAC consolidation who was initially admitted
for febrile neutropenia and had a complicated hospital course.
1. M4 AML:
She was admitted for febrile neutropenia and was cultured and
started on empiric broad spectrum antibiotics. On [**2176-12-12**] she was
found to have blasts in her periphery. The discovery of these
blasts post HiDAC consolidation implied that she never entered a
complete remission. At this point, both MEC re-induction and a
Flt3 inhibitor were considered for treatment options and a bone
marrow biopsy was performed on [**2176-12-16**] in hopes of putting her on
a Flt3 ligand inhibitor trial.
At this time, her WBC count started to climb exponentially
rising to 57,000 and she began to develop DIC and leukostasis.
She was treated with leukopheresis, hydrea, and blood product
support and eventually her DIC stabilized. At this point she
was reinduced with MEC (mitoxantrone, etoposide, and cytarabine)
and, although her WBC count fell, she continued to have
peripheral blasts. A repeat bone marrow biopsy on [**12-26**] showed
residual clusters of blasts.
At this time, potential treatment options were additional MEC
or clofarabine. Due to the lack of a response to MEC, the
decision was made to start clofarabine. In the background of
this discussion was the knowledge that her cytogenetics now
revealed an abnormality in the p53 gene, implying more
aggressive disease. Prior to starting clofarabine on [**1-3**], she
developed a productive cough and was found to have multiple
diffuse pulmonary nodules on chest CT, suspicious for fungal
infection vs miliary tuberculosis. Tuberculosis was ruled out
with sputum samples and a bronchoscopy, including a
transbronchial biopsy, was negative for an infectious source.
The BAL from the bronchoscopy was suspicious for malignant
cells, suggesting that the pulmonary process was due to her
underlying leukemia. In this setting, as well as a rising WBC
count, she was started on a five day course of clofarabine. She
tolerated clofarabine fairly well developing described side
effects of elevated LFTs (one dose was held for one day) and
palmar-plantar erythema-dysesthesia. Initially her WBC count
began to decrease, although she continued to have peripheral
blasts. Eventually her WBC count and blast percentage began to
rise again and at this point, combined with her poor respiratory
status (see below), her care was transitioned towards comfort
measures.
2. Febrile neutropenia:
On admission, she was started on empiric antibiotics but she
continued to have low grade fevers around 100 to 101 with
occasional elevations to 103-104. The ID service was involved
throughout her hospitalization and her antibiotic coverage was
gradually expanded to include several antibiotics including
courses of levofloxacin, aztreonam, flagyl, caspofungin,
voriconazole, ambisome, vancomycin, daptomycin, meropenem, and
acyclovir. All studies, including multiple blood and urine
cultures, induced sputum cultures, serologies, and bronchoscopy
results were negative. It was eventually thought that her
fevers were most likely due to her leukemia and when she was
transitioned to comfort measures, she was given tylenol around
the clock to control her temperature.
3. Pulmonary:
She was relatively free of respiratory complaints until [**1-3**]
when she developed a productive cough and was found to have
multiple diffuse pulmonary nodules on chest CT. A fungal or
mycobacterial infection was suspected but all infectious
studies, including induced sputums and a bronchoscopy, were
negative. Later imaging revealed bilateral basilar infiltrates
more suggestive of a bacterial infection. On [**1-16**] she began to
have respiratory distress and was transferred to the [**Hospital Unit Name 153**] for
closer monitoring. She was stabilized on BiPAP and transferred
back to the oncology floor. On [**1-18**] she again began to develop
respiratory distress and was transferred back to the [**Hospital Unit Name 153**]. She
was comfortable alternating between a BiPAP machine and a
non-rebreather. Over the next several days, her wbc count began
to rise and her CXR showed worsening bilateral infiltrates.
After multiple discussions with the patient and her family,
given the refractoriness of her leukemia and her progressing
respiratory distress, that the goals of care should be shifted
towards comfort measures. She was transferred back to the
oncology floor on [**1-24**], her antibiotics were discontinued, a
morphine drip was started and she passed away on [**2177-1-31**]. An
autopsy was declined by the family.
Medications on Admission:
none
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Acute myelogenous leukemia, refractory to chemotherapy.
Discharge Condition:
Expired.
Discharge Instructions:
N/A.
Followup Instructions:
N/A.
Completed by:[**2177-1-31**]
|
[
"E933.1",
"695.2",
"518.84",
"286.6",
"511.8",
"276.6",
"372.72",
"573.3",
"362.81",
"205.00",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"41.31",
"99.25",
"33.27",
"99.72",
"33.24",
"99.07",
"99.05",
"86.11",
"38.93",
"93.90",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
13226, 13235
|
8441, 13143
|
299, 365
|
13337, 13347
|
2985, 8418
|
13400, 13435
|
2447, 2572
|
13198, 13203
|
13256, 13316
|
13169, 13175
|
13371, 13377
|
2587, 2966
|
243, 261
|
393, 1339
|
1361, 2223
|
2239, 2431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,454
| 167,076
|
6924
|
Discharge summary
|
report
|
Admission Date: [**2165-7-11**] Discharge Date: [**2165-7-14**]
Date of Birth: [**2095-5-14**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with placement of 2 Minivision bare
metal stents
History of Present Illness:
70 year old female with recent ([**6-27**]) mitral valve replacement
and CABG with SVG to OM1. Developed sudden onset of SSCP and
mild SOB while ambulating to bathroom this morning. She went to
OSH where an EKG showed STE inferiorly, V5, V6, STD V1/2. [**Hospital1 18**]
cath lab was activated and pt was transferred for urgent cath.
In the cath lab the patient was found to have an acute occlusion
of SVG to OM. Due to risk of intervention/peripheral
embolization decision was made to intervene on native vessel,
and 2 bare metal stents were placed in OM1 and dilated. Patient
was started on integrillin in the cath lab. Patient had been
taking ASA and plavix on a regular basis.
Past Medical History:
1. HTN
2. CAD s/p stenting (see below)
3. DM
4. s/p hip and [**Last Name (un) **] fracture secondary to fall, recently
d/c'ed from Rehab
5. former smoker
[**9-17**]: LAD 50%, LCx 40%, mid RCA 99% - stented
[**2165-6-25**]: Totally occluded OM1, but otherwise no flow limiting
stenoses. No stent placed, sent for repair of [**Month/Day/Year **] mitral
valve and CABG to OM1.
[**2165-7-11**]: Successful placement of overlapping Minivision bare
metal stents in the OM1
Social History:
Patient is a housewife. She lives at home with her husband, and
her son and daughter's family live in the same house. Patient
smoked [**12-16**] PPD for 33 years, and she quit 18 years ago.
Family History:
Mother died of an MI at 86.
Father died of an accident
Sister has history of premature CAD
Physical Exam:
Vit: BP 105/56 HR 104 PO2 100% on RA
Gen: pale, uncomfortable
Neck: no JVD
CV: regular, nl S1, S2, no rub, no murmur
Pulm: clear bilaterally
Abd: benign
Ext: 2+ pulses B
Skin: Groin site clean, sheath in place
Pertinent Results:
<B>Admit Labs:</B>
135 / 102 / 8
------------< 121
4.5 / 20 / 0.3
.
CK: 923 -->680 MB: 122 -->40 MBI: 13.2 --> 11.9 Trop-*T*: 2.32
-->1.41
.
Ca: 8.6 Mg: 1.7 P: 4.0
.
9.9 > 9.5/28.3 < 736 MCV-86
.
PT: 13.8 PTT: 32.7 INR: 1.3
.
EKG:
Sinus tachycardia. Baseline artifact. ST segment elevations in
leads V4-V6 with small Q waves - consider acute myocardial
infarction. Compared to the previous tracing of [**2165-7-2**] ST
segment elevations are present.
.
<B>CATH REPORT [**7-11**]:</B>
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system and
acute occlusion of the SVG to OM. The LMCA had no angiographic
evidence
of CAD. The LAD had diffuse luminal irregularities - the
previously
placed stent was widely patent. The Lcx was non-dominant, it
gave off a
moderate sized OM1 branch. This had previously been bypassed and
was
100% stenotic at its ostium. The RCA had a 50% stenosis between
the
previously placed stents. The SVG to OM was a very large vein
graft and
was totally occluded with fresh thrombus.
2. Hemodynamics revealed mildly elevated filling pressures,
cardiac
output/index was preserved.
3. Left ventriculography was not performed.
4. Successful placement of a 2.25 x 28 Minivision bare metal
stent
overlapped with a more distal 2.0 x 18 mm Minivision stent in
the OM1
both postdilated with a 2.25 mm balloon. Final angiography
demonstrated
no residual stenosis, no angiographically apparent dissection,
and
normal flow (See PTCA Comments).
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
3. Acute inferior myocardial infarction, managed by acute ptca.
PTCA of vessel.
4. Successful placement of bare metal stents to the OM1.
.
<B>ECHO [**7-12**]:</B>
Conclusions:
1. The left atrium is normal in size.
2.The left ventricular cavity size is normal. Overall left
ventricular
systolic function is preserved (LVEF=55%). Resting regional wall
motion
abnormalities include inferolateral akinesis with inferior and
basal and mid inferoseptal hypokinesis. The rest of the walls
are hyperdynamic.
3.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation seen.
4.A bioprosthetic mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc
motion. The transvalvular gradients are higher than expected
for this type of prosthesis. Physiologic
mitral regurgitation is seen (within normal limits).
6.There is borderline pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Brief Hospital Course:
# CAD/MI - Patient was admitted to the CCU after her cardiac
catheterization where she had two bare metal stents placed in
her OM1. Her enzymes were monitored and peaked during her first
day of admission. She was continued on ASA, plavix, and
atorvastatin. She was started on low dose of metoprolol and
changed to Toprol XL 25 mg QD on day of discharge. Would add
back captopril as an outpatient if pressure tolerates.
.
# Pump - ECHO showed EF of 55% and physiologic MR with no change
in wall motion abnormalities from previous ECHO. Patient
auto-diuresed well.
.
# Rhythm - No issues during this admission. Patient continued
to be in sinus tachycardia throughout admission without
symptoms.
.
# Post CABG - Patient was 2 weeks post op mitral valve repair
with 1 vessel CABG with SVG. Her incision was healing well and
she did not require additional pain medications.
.
# DM2 - Maintained on insulin sliding scale during
hosptalization.
.
# FEN - Electrolytes maintained at Mg >2 and K > 4. Patient was
advanced to regular diet without difficulty.
.
# Dispo - PT consult: therapy 1-3x/week for 1 week, patient safe
to return home with home PT and VNA care.
Medications on Admission:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
7. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
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:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. 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*
5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Inferolateral myocardial infarction
Discharge Condition:
Good
Discharge Instructions:
If you have any recurrent chest pain, chest pressure, shortness
You had a stent placed in one of the blood vessels in your heart
and you must continue taking apirin and plavix until your doctor
tells you to stop.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet and diabetic diet
Followup Instructions:
1) Please make a follow up appt with your PCP ([**Last Name (LF) **],[**First Name3 (LF) **] B
[**Telephone/Fax (1) 26057**]) in [**12-16**] weeks.
2) Please make a follow up appt with your diabetes doctor in [**12-16**]
weeks.
3) Please make a follow up appt with your cardiologist in [**2-15**]
weeks.
4) You have a follow up appt with [**Name6 (MD) **] [**Name8 (MD) 7045**], MD Where:
CARDIAC SURGERY LMOB 2A Date/Time:[**2165-7-23**] 3:00
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2165-8-9**]
|
[
"V42.2",
"250.00",
"410.41",
"412",
"V45.81",
"311",
"414.01",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.06",
"88.56",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
7863, 7938
|
4749, 5916
|
292, 367
|
8018, 8024
|
2142, 3629
|
8404, 9004
|
1799, 1891
|
6944, 7840
|
7959, 7997
|
5942, 6921
|
3646, 4726
|
8048, 8381
|
1906, 2123
|
242, 254
|
395, 1083
|
1105, 1576
|
1592, 1783
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,732
| 121,699
|
47122
|
Discharge summary
|
report
|
Admission Date: [**2167-12-26**] Discharge Date: [**2168-1-3**]
Date of Birth: [**2111-8-8**] Sex: F
Service:
ADMISSION DIAGNOSIS: Abdominal pain.
DISCHARGE DIAGNOSIS: Perforated appendicitis, status post
appendectomy and exploratory laparotomy, hypovolemia, acute
renal failure
HISTORY OF THE PRESENT ILLNESS: The patient is a 56-year-old
woman who had complaints of nausea, vomiting, and abdominal
pain for two to three days prior to admission. The abdominal
pain continued to progress and localized to the right lower
quadrant. The patient had not taken anything orally for two days
prior to admission. The patient had no history of bloody
bowel movements or otherwise change in bowel habits.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diverticulitis.
MEDICATIONS:
1. Zestril.
2. Hydrochlorothiazide 25 mg q.d.
PHYSICAL EXAMINATION ON ADMISSION: The patient was a
middle-aged black woman in distress. HEENT: Normocephalic,
atraumatic. Anicteric. EOMI. PERRL. Neck: Midline.
Supple. No masses or lymphadenopathy. Chest: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm without murmurs, rubs, or gallops. Abdomen: Obese.
Significant tenderness in the right lower quadrant with
positive peritoneal signs. Extremities: Warm, noncyanotic,
nonedematous times four. There were 2+ dorsal pedal, radial,
and posterior tibial pulses bilaterally. Neurological:
Alert and oriented times three. No focal or sensory motor
deficits.
ADMISSION LABORATORY DATA: CBC 26.5/38.7/293 with a
neutrophil of 98%. PT 15.1, INR 1.5, PTT 31.3. The U/A was
negative, possibly contaminated with 11-20 squamous epithelial
cells per [**Known lastname **]-powered field. Chemistries: 132/7.9,
hemolyzed, repeat showed 3.6/92/25/32/2.9/98. ALT 26, AST
83, alkaline phosphatase 74, total bilirubin 1.4, amylase 29.
Admission CT revealed a focal area of fat stranding, free
fluid and extraluminal gas in the right lower quadrant.
These findings are consistent with a perforated appendicitis
or other perforated viscus.
HOSPITAL COURSE: The patient was taken emergently to the
Operating Room for exploratory laparotomy and was found to
have a perforated gangrenous appendix. There was not stool
spillage into the abdomen. The abdomen was washed out.
There were no complications during the operation.
Postoperatively, the patient required multiple fluid boluses
in the immediate postoperative period in order to maintain a
good urine output. Later in the evening, on postoperative
day number one, the patient had issues with a subjective
feeling of shortness of breath. Her oxygen saturation also
decreased from 98% on 3 liters down to 91-92% on 3 liters.
The patient had an ABG at that time which was normal. Chest
x-ray showed elevation of both hemidiaphragms.
The decision was made to continue attempting fluid
resuscitation and simultaneously give 10 mg of Lasix. The
patient was transferred to the PACU for closer monitoring as
all available ICU beds were taken.
Overnight, on postoperative day number one, the patient did
well and continued to make good urine, especially in response
to the Lasix. The patient was transferred back to the floor
on postoperative day number two and seemed to do well. The
rest of her postoperative course was fairly unremarkable.
She did require IV fluid resuscitation to maintain a good
urine output. Her subjective symptoms of shortness of breath
and objective slight decrease in oxygen saturation returned
with the chest physical therapy, Albuterol nebulizers, and
ambulation.
Her course was marked by a slow return of bowel function.
Once the patient began passing flatus, her diet was advanced
as tolerated. There were also some difficulties with
electrolyte maintenance. She required periodic replacement
of potassium and magnesium. The patient was maintained on
Levaquin and Flagyl throughout the postoperative period and
transitioned to p.o. formulations when her diet would allow.
The patient was subsequently discharged on postoperative day
number eight tolerating a regular diet, under good pain
control with p.o. pain medications, and subjectively feeling
well. She had been restarted on her Zestril and
hydrochlorothiazide prior to discharge and tolerated this
well. Her white count on discharge was 11.4 and her
potassium was 4.0.
DISCHARGE CONDITION: Good.
DISPOSITION: To home.
DIET: Ad lib.
DISCHARGE MEDICATIONS:
1. Zestril 5 mg q.d.
2. Hydrochlorothiazide 25 mg q.d.
3. Percocet p.r.n.
4. Colace 100 mg b.i.d.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr.
[**First Name (STitle) 2819**] in one to two weeks. It was decided not to continue the
patient on outpatient antibiotics given her white count and
the fact that she had been afebrile for more than 24 hours
prior to discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2168-1-4**] 10:22
T: [**2168-1-10**] 13:35
JOB#: [**Job Number 99883**]
|
[
"997.3",
"282.4",
"276.5",
"511.9",
"584.9",
"518.0",
"540.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.09"
] |
icd9pcs
|
[
[
[]
]
] |
4373, 4420
|
4443, 4546
|
186, 718
|
2087, 4351
|
4571, 5108
|
147, 164
|
877, 2069
|
740, 862
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,389
| 165,355
|
51667
|
Discharge summary
|
report
|
Admission Date: [**2162-8-24**] Discharge Date: [**2162-8-31**]
Date of Birth: [**2108-8-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin / Compazine / Bactrim Ds / Sulfa
(Sulfonamides) / Dapsone / Levaquin
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 54 yo female with history of sarcoidosis and
chronic systolic heart failure with worsening SOB over the past
two weeks. She reports being bed bound for the past week and
only being able to walk 10 steps before becoming SOB while on
continuous O2. Previously she could walk about 20 steps. For the
past few days she has taken extra doses of lasix 20mg PO. She
reports reduced fluid intake during this time as well. She
denies any fevers, chills, night sweats. She has a dry cough at
baseline that is not worse. No n/v/d. No CP, palpitations,
orthopnea.
In the ED, initial vital signs were T:98.5 HR:96 BP:120/71 RR:18
O2 Sat 85% on 2L NC. On room air sat dropped to 65%. ED resident
felt CXR looked worse than baseline. She received 125 mg
solumedrol and Vanco x 1g IV for empiric coverage of possible
PNA. ECG with known LBBB, slight ST dep v4-v6 all <1mm. Trop of
0.02 and CK 24.
Review of systems:
(+) Per HPI and + 3lb wt loss past two weeks, +HA
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea or congestion. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Sarcoidosis: tx hx: methotrexate [**12/2160**], stopped [**1-/2161**] due
to reaction prednisone 10-20-10-7.5mg [**1-/2161**] - [**5-/2162**]
2. Sulfa allergy.
3. Mild sleep apnea.
4. Factor-5 Leiden abnormality.
5. Pulmonary embolism.
6. Multiple environmental allergies.
7. History of Bleomycin lung toxicity.
8. Status post chemotherapy for non-Hodgkin's lymphoma: total
body irradiation and bleomycin, with subsequent bone marrow tx
with high-dose myeloablative total body irradiation.
9. Status post CVA with memory deficit.
10. Iron overload.
11. Gout.
12. Hypertension.
13. Anxiety
14. Systolic CHF with ejection fraction 30%.
15. Stage II chronic kidney disease.
16. Hyperlipidemia.
Social History:
Married. Non-smoker (no significant history), no alcohol
intake.
Family History:
Maternal ?????? clots, PE, TIA, Factor V Leiden
Paternal ?????? D/Ced pancreatic ca in 80s
Siblings ?????? sister#1: obese, DM; sister#2: unknown health;
brother: healthy
Children - one healthy daughter w/o Factor V Leiden
Physical Exam:
General: Cushingoid appearing female, alert, oriented, no acute
distress
HEENT: Sclera anicteric, PERRL/EOMI, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles at bilateral bases with high pitched inspiratory
wheeze on left, good air movement
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, CN II-XII grossly intact, 5/5 strength in all 4 ext
Pertinent Results:
[**2162-8-24**] 02:21PM PT-36.6* PTT-28.1 INR(PT)-3.8*
[**2162-8-24**] 02:08PM LACTATE-3.2*
[**2162-8-24**] 02:00PM GLUCOSE-172* UREA N-68* CREAT-3.2*#
SODIUM-136 POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-34* ANION GAP-16
[**2162-8-24**] 02:00PM CK(CPK)-24*
[**2162-8-24**] 02:00PM cTropnT-0.02*
[**2162-8-24**] 02:00PM CK-MB-NotDone proBNP-2531*
[**2162-8-24**] 02:00PM CALCIUM-15.1* PHOSPHATE-4.7* MAGNESIUM-2.2
[**2162-8-24**] 02:00PM WBC-12.7* RBC-3.54* HGB-11.1* HCT-33.2*
MCV-94 MCH-31.4 MCHC-33.5 RDW-13.8
[**2162-8-24**] 02:00PM NEUTS-68.8 LYMPHS-24.0 MONOS-4.8 EOS-1.7
BASOS-0.6
[**2162-8-24**] 02:00PM PLT COUNT-331
[**2162-8-28**] 05:10AM BLOOD WBC-10.4 RBC-3.00* Hgb-9.3* Hct-28.5*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.8 Plt Ct-292
[**2162-8-28**] 05:10AM BLOOD PT-25.2* PTT-26.1 INR(PT)-2.4*
[**2162-8-28**] 05:10AM BLOOD Glucose-128* UreaN-44* Creat-1.5* Na-145
K-4.0 Cl-106 HCO3-32 AnGap-11
[**2162-8-28**] 05:10AM BLOOD Calcium-9.5 Phos-1.9* Mg-2.0
Brief Hospital Course:
54 year old female with a history of sarcoidosis, chronic
systolic heart failure with EF 35%, and pulmonary hypertension
who presented with shortness of breath, hypoxia, acute on
chronic renal failure, and hypercalcemia.
#. Shortness of Breath: On admission, she had hypoxia requiring
O2 supplementation (greater than at baseline) and was treated
with intravenous fluids. It was felt that her shortness of
breath was related to her sarcoidosis and complicated by acute
renal failure and hypercalcemia. She did not appear volume
overloaded on exam and responded well with symptomatic
improvement after IV fluids and prednisone. Her prednisone dose
was increased from her home dose of 5mg to 40mg and later
tapered to 20mg daily. She had a CT chest which did not show
progression of her sarcoidosis since [**Month (only) **]. A multidisciplinary
approach was taken to determine the best course of treatment
with input from her primary medicine team, pulmonology,
cardiology, and nephrology. It was decided that she would
likely benefit from supplemental oxygen, prednisone at higher
doses than previous, and afterload reduction and CHF management
with metoprolol and losartan. At discharge, she required her
baseline 2L of oxygen but still had shortness of breath with
ambulation.
#. Hypercalcemia: On admission, she had a calcium level of 15.1.
This was likely caused by a combination of sarcoidosis and
taking 1500mg Ca daily at home. Her calcium levels decreased to
normal while in the hospital with aggressive rehydration and
prednisone therapy. UPEP was normal, her 1,25(OH) vitamin D
level, SPEP, and PTHrP levels are still pending at discharge.
#. Acute on Chronic Renal Failure: On admission, her creatinine
was increased to 3.2 (baseline is 1.7-1.9). She was given IV
fluids and her lasix was held and her creatinine returned back
to baseline by the time of discharge. Her renal failure was
thought to be predominantly of prerenal etiology due to overuse
of Lasix prior to admission with a secondary contribution of
hypercalcemia.
#. Chronic systolic Heart Failure: She has known systolic heart
failure with an EF of 35%. However, her shortness of breath was
not thought to be related to worsening heart failure. Her Lasix
was stopped and she was volume repleted resulting in symptomatic
improvement. She was advised to continue without Lasix after
discharge. Her atenolol was swithced to metoprolol and
losartan, which she tolerated well prior to discharge.
#. History of PE/Factor V Leiden: Warfarin was initially held
due to a high INR of 3.9. It was restarted at her home dose of
2.5mg po daily after her INR decreased to therapeutic range.
#. Anxiety: She was anxious throughout her hospitalization which
may have contributed to her shortness of breath. Her outpatient
regimen of lorazepam was continued and she was encouraged to
take lorazepam as needed.
#. Nosebleed: She had one episode of anterior epistaxis one day
prior to discharge. She had a slow trickle of blood from her
right nostril, likely related to her use of oxygen that was not
humidified. She was given Afrin nasal spray and held pressure
with resolution of her symptoms.
#. Code Status: Patient was FULL CODE throughout this
hospitalization.
Medications on Admission:
ASA 325mg daily
Atenolol 50mg daily
Atorvastatin 20 [**Hospital1 **]
Furosemide 20 mg daily
Lorazepam 0.5 mg PO BID:PRN anxiety
Prednisone 5 mg PO daily
Warfarin 2.5 mg po daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety. Disp:*90 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Sarcoidosis
Secondary Diagnosis:
Acute on Chronic Renal Failure
Hypercalcemia
Chronic Systolic Heart Failure
Discharge Condition:
Stable, vital signs stable, ambulating independently
Discharge Instructions:
You were admitted to the hospital with shortness of breath. You
also had acute kidney failure and high levels of calcium in your
blood. You were given IV fluids and prednisone, and your kidney
function and calcium levels improved.
Changes to your medications:
Your Lasix was STOPPED
Your atenolol was STOPPED
You were started on metoprolol succinate 75mg by mouth daily
You were started on Cozaar 50mg by mouth daily
Your prednisone was increased to 20mg by mouth daily
You should NOT take Tums or other medications or supplements
that contain Calcium.
It is important that you weigh yourself every morning, and call
your cardiologist, primary care doctor, or pulmonologist if your
weight is increased by over 3 pounds. It is also important that
you adhere to a 2 gram per day sodium diet. You do not need to
restrict your fluid intake at this time, but it is important
that you have close follow-up with your doctors.
If you have increasing shortness of breath, need for oxygen,
chest pain, lower extremity swelling, or fevers, you should go
the nearest emergency room, call 911, or call your doctor.
You will need to have your Coumadin level (INR) checked as you
had before.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2162-9-6**]
1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. Date/Time:[**2162-9-9**] 12:20
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2162-10-28**] 11:30
It is also important that you follow-up with your pulmonologist,
Dr. [**Last Name (STitle) 575**]. Since you were discharged on a weekend, we were
unable to make an appointment for you today. However, on the
next business day, we will schedule an appointment for you with
Dr. [**Last Name (STitle) 575**] and contact you with the appointment time. If you
do not hear from us, please call Dr.[**Name (NI) 4025**] office and make
a follow-up appointment in one month.
|
[
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"403.90",
"V42.81",
"289.81",
"780.57",
"300.00",
"428.22",
"784.7",
"274.9",
"V58.65",
"438.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8542, 8599
|
4337, 7590
|
377, 383
|
8771, 8826
|
3336, 4314
|
10059, 11022
|
2504, 2728
|
7818, 8519
|
8620, 8620
|
7616, 7795
|
8850, 9084
|
2743, 3317
|
9113, 10036
|
1344, 1688
|
318, 339
|
411, 1325
|
8673, 8750
|
8639, 8652
|
1710, 2405
|
2421, 2488
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,601
| 104,264
|
44732
|
Discharge summary
|
report
|
Admission Date: [**2171-5-1**] Discharge Date: [**2171-5-15**]
Date of Birth: [**2120-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2171-5-6**] - CABGx3 (Free RIMA->PDA, LIMA-LAD, (L) Radial->Obtuse
Marginal 2)
[**2171-5-2**] - Cardiac Catheterization
History of Present Illness:
50 yo man with PMH of HTN, hyperlipidemia, 35 pack yr smoking
history, transferred from [**Hospital 6930**] Hospital in [**Location (un) 3844**] for
further management. The pt states that he was in his usual
state of health until 1 month PTA when he noted CP while sitting
at his computer. He has now had CP intermittently every day for
the past month. His CP lasts hrs at a time and is described as
a substernal, sharp, pressure-like, burning pain. He
occasionally has associated SOB and radiation to his L shoulder,
but he has no associated nausea. His pain can be alleviate with
3 NTG tabs at a time. Per pt report, he presented to [**Hospital 6930**]
hospital 1 month ago and was observed overnight. He was sent
home and he returned the following day for persistent chest
pain. Again, the pt was sent home and he followed up with his
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78049**]. The pt says he was sent for stress test
with imaging, and he was told it was inconclusive. The pt was
seen by a cardiologist on [**4-29**], and while in the doctors office
the pt had CP. He was then sent to Catholic [**Hospital1 107**]. Had
?NSTEMI. He underwent cardiac cath on [**4-29**] and was noted to have
3 vessel disease. He developed anaphylaxis in which his face
swelled, so cardiac cath was aborted at this point. Today pt
was seen in [**Hospital 6930**] Hospital as he [**Hospital 5058**] at 10 am with severe
CP today. He was given ASA, NTG x2, IV morphine, nitro gtt, and
heparin gtt. EKG was reportedly without ST changes. Cardiac
enzymes were negative. In the ambulance here the pt was having
intermittent chest pressure and low blood pressure.
Past Medical History:
HTN
DJD
s/p R Total Knee Replacement
lumbar surgery in [**2158**] with L3-L4 diskectomy
L maxillary reconsturction in 1970a
hyperlipidemia
Cardiac Cath 4/17 per Dr. [**Last Name (STitle) **]: occl rca, 90% circ, 50% LAD
?NSTEMI [**4-29**] at OSH per Dr. [**Last Name (STitle) **]
Social History:
Lives in [**Location **] with his wife, on disability due to back injury,
quit tobacco 3 days ago but prior smoked 1.5 ppd for 35 years,
no ETOH or illicits
Family History:
Father died of MI at 57
Brother is s/p CABG age 35
Father with DM, brother with DM
Physical Exam:
VS: T97.9 BP 125/49 in L arm, 115/41 in R arm P 71 R 22 Sat
93%RA
GEN: obese man, lying in bed, NAD
HEENT: PERRL, conjunctivae anicteric/noninjected, MMM
Neck: obese, no JVD appreciated
CV: distant heart sounds, barely audible S1/S2, +chest wall
tenderness to palpation partially mimicking pts pain
PUL: CTAB with decreased breath sounds throughout
ABD: protuberant, soft, NTND, NABS
EXT: no c/c/e, wwp, 2+dp/pt pulses
Pertinent Results:
Labs at OSH:
WBC 14, Plt 231, Troponin I 0.01
.
EKG: NSR, normal axis, isolated Q wave in III
.
[**2171-5-1**] 09:05PM GLUCOSE-120* UREA N-24* CREAT-1.0 SODIUM-144
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-28 ANION GAP-14
[**2171-5-1**] 09:05PM ALT(SGPT)-40 AST(SGOT)-19 CK(CPK)-106 ALK
PHOS-68
[**2171-5-1**] 09:05PM CK-MB-2 cTropnT-<0.01
[**2171-5-1**] 09:05PM CALCIUM-8.6 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2171-5-1**] 09:05PM WBC-12.7* RBC-4.84 HGB-14.2 HCT-41.1 MCV-85
MCH-29.3 MCHC-34.4 RDW-14.3
[**2171-5-1**] 09:05PM NEUTS-50.1 LYMPHS-44.7* MONOS-4.2 EOS-0.8
BASOS-0.3
[**2171-5-1**] 09:05PM PLT COUNT-230
[**2171-5-1**] 09:05PM PT-11.4 PTT-25.5 INR(PT)-1.0
.
Cardiac Catheterization [**2171-5-2**]:
COMMENTS:
1. Selective coronary angiography showed a right dominant system
with
60-70% proximal LAD ulcerated plaque extending back into the
left main
coronary artery. The left circumflex artery and the OM1 were
totally
occluded and filled via L->L collaterals. The RCA was totally
proximally
occluded over a very long segment. Distal PDA and PLV were
diffusely
diseased and filled via L->R collaterals.
2. Left ventriculography was deferred given allergic reaction to
iodine
contrast.
3. Limited hemodynamic assessment showed normal aortic systemic
pressure.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal ventricular function.
[**2171-5-13**] CXR
Right lower lobe atelectasis is improving. Pulmonary vascular
congestion has worsened. Postoperative cardiomediastinal
silhouette unremarkable and unchanged. Small left pleural
effusion is stable. No pneumothorax. Sternal wires are intact
and unchanged.
[**2171-5-6**] ECHO
Prebypass:
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. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Resting regional wall motion abnormalities
include mildly hypokinetic basal and midportions of the inferior
wall. 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 but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. The transgastric views were very poor.
Post Bypass:
Patient is receiving an infusion of phenylephrine.
Biventricular systolic fuction is preserved. Aorta intact post
decannulation. Mild mitral regurgitation persists.
[**2171-5-3**] Carotid Ultrasound
Patent bilateral brachial arteries and ulnar arteries with
diameters as noted above
Brief Hospital Course:
Mr. [**Known lastname 63915**] was admitted to the [**Hospital1 18**] on [**2171-5-1**] for further
management and evaluation of his chest pain. Heparin and
nitroglycerin were given with relief of his symptoms. A cardiac
catheterization was performed which revealed severe three vessel
coronary artery disease. A plavix load was given. Given the
severity of his disease, the cardiac surgery service was
consulted for surgical revascularization. Mr. [**Known lastname 63915**] was
worked-up in the usual preoperative manner including a carotid
duplex ultrasound which did not reveal any flow limiting disease
of the bilateral internal carotid arteries. Given his young age
arterial conduit was elected. A radial artery ultrasound was
performed which showed patent bilateral radial arteries with an
acceptable diameter. On [**2171-5-6**], Mr. [**Known lastname 63915**] was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels using a left internal mammary artery,
a free right internal mammary artery and a left radial artery.
Grafts went to the left anterior descending artery, the obtuse
marginal artery and the posterior descending artery.
Postoperatively he was taken to the cardiac intensive care unit
for monitoring. On postoperative day one, Mr. [**Known lastname 63915**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. He remained in the
intensive care unit for several extra days with a small Levophed
requirement. He was transfused with packed red blood cells for
postoperative anemia. Vancomycin and levofloxacin were started
for serous drainage from his sternum. He was gently diuresed
towards his postoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. On postoperative day six, Mr. [**Known lastname 63915**] was transferred
to the cardiac service nursing floor for further recovery.
Strict sternal precautions were maintained for a mild sternal
click noted on exam. Mr. [**Known lastname 63915**] continued to make steady
progress and was discharged home on postoperative day nine. He
will return to the nursing floor in 1 week for a wound check and
continue levofloxacin for week. He will follow-up with Dr.
[**Last Name (STitle) **], his cardiologist and his primary care physician as an
outpatient. of note, an attempt was made to medicate with
isosorbide for his arterial conduit however, his blood pressure
would not tolerate this. It is recommended to attempt to start
isosorbide and a beta blocker as an outpatient on follow-up with
his cardiologist in 1 to 2 weeks.
Medications on Admission:
Norvasc 5 mg po qd
Zocor 40 mg po qd
Metoprolol 100 mg po bid
Ranitidine 150 mg po bid
Oxycontin 60 mg qam, 80 mg q midday, 60 mg po qpm
Oxycodone prn
ASA 325
Discharge Medications:
1. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while taking narcotics to prevent
constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days:
Take with lasix and stop when lasix stopped.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community health and hospice
Discharge Diagnosis:
Coronary Artery Disease
Hypercholesterolemia
HTN
NSTEMI
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wound for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain greater then 2 pounds in 24 hours or 5
pounds in 1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month and while taking narcotics.
6) Take levofloxacin for 1 week (until no pills left).
7) Eventually you will need to be started on Isosorbide and a
beta blocaker. This will be done by your cardiologist as an
outpatient as your blood pressure tolerates.
8) Take lasix twice daily and potassium once daily for five days
and then stop.
9) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with Cardiologist Dr. [**Last Name (STitle) 11250**] in [**1-14**] weeks. ([**Telephone/Fax (1) 78961**]
Follow-up with primary care physician [**Last Name (NamePattern4) **] [**2-16**] weeks. Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Follow-up on [**Hospital Ward Name 121**] 2 with nurses for wound check in 1 week.
Please call all providers for appointments.
Completed by:[**2171-5-15**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"36.11",
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icd9pcs
|
[
[
[]
]
] |
10006, 10065
|
6018, 8644
|
302, 427
|
10165, 10172
|
3214, 4492
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10882, 11401
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2674, 2759
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8854, 9983
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10086, 10144
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8670, 8831
|
4509, 5995
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10196, 10859
|
2774, 3195
|
252, 264
|
455, 2179
|
2201, 2483
|
2499, 2658
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,823
| 157,864
|
10832
|
Discharge summary
|
report
|
Admission Date: [**2161-9-25**] Discharge Date: [**2161-9-27**]
Date of Birth: [**2113-3-23**] Sex: M
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Chest pain.
IDENTIFICATION: This is a 48-year-old male with inferior MI.
HISTORY OF THE PRESENT ILLNESS: This is a 48-year-old male
with a past medical history of type 2 diabetes, tobacco use,
hypercholesterolemia, with a positive family history for CAD
who was in his usual state of health until two days ago when
he noted the onset of substernal/epigastric indigestion-like
discomfort with minimal exertion. The episode lasted several
minutes and was always relieved with rest. Tonight, at
approximately 8:00 p.m., The patient was watching TV and
developed acute onset of substernal chest pain described as
being punched in the chest which gradually worsened to [**11-15**]
pain associated with diaphoresis, shortness of breath,
nausea, and radiating to jaw and left arm. The patient
called 9-1-1 and EMS arrived at approximately 10:00 p.m. The
patient received sublingual nitroglycerin times three,
aspirin, and morphine in the ambulance without relief.
In the Emergency Room, the patient presented with a heart
rate of 83, blood pressure 134/44, respirations 20. EKG
revealed ST elevations of 2 mm in the inferior leads, II,
III, and aVF. He received morphine 24 mg IV total in the
Emergency Room with some relief of pain, and was started on a
heparin drip. The patient was given Lopressor 5 mg IV.
The patient was taken to the Catheterization Laboratory where
they noticed RA pressure of 14, RV pressures of 27/6, PA
pressure of 27/16, wedge 19. Cardiac output 3.3, cardiac
index of 1.67, and a totally occluded proximal RCA, otherwise
minimal coronary artery disease. A 3 by 5 times 18 mm
Hepacoat stent was placed in the RCA with no residual
blockage. He was treated with Plavix, Integrelin, and
admitted for post MI observation to the CCU given concern for
RV infarct physiology. Currently, he was pain-free.
He was then transferred to the [**Hospital Unit Name 196**] Service on [**2162-9-26**] after doing well after his catheterization. He was
given fluids in the CCU to maintain his preload and had
several episodes of decreasing intense chest pain without EKG
changes or increase in enzymes. He was treated with morphine
and Ativan.
Currently, on transfer to the floor on the [**Hospital Unit Name 196**] Service had
[**3-15**] chest pressure/epigastric pain.
REVIEW OF SYSTEMS: No shortness of breath, headache, nausea,
or vomiting.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.6, heart rate 90, blood pressure 118/50, respirations 18,
02 saturation 96%, fingerstick 237. General: The patient
was awake, alert, in no acute distress. HEENT:
Normocephalic, atraumatic. The pupils were equal, round, and
reactive to light. Oropharynx clear. Neck: No JVD, supple.
CV: Regular rate and rhythm, normal S1, S2, no murmurs,
rubs, or gallops. Respirations: Clear to auscultation
bilaterally. Abdomen: Normoactive bowel sounds, soft,
obese, nontender, nondistended, except mild epigastric
tenderness to deep palpation. Extremities: No clubbing,
cyanosis or edema, +2 dorsalis pedis bilaterally.
PAST MEDICAL HISTORY:
1. Type 2 diabetes times 18 years without complications.
2. Hypercholesterolemia.
3. Chronic pancreatitis.
4. Diverticulitis, status post sigmoid resection with
appendectomy 20 years ago.
5. Question of benign prostatic hypertrophy.
6. Status post chole.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Lipitor 20 b.i.d.
2. Glucotrol XL 20 question if b.i.d.
3. Actos 20 q.d.
4. Prilosec 20 q.d.
5. Flomax 0.4 q.d.
MEDICATIONS ON TRANSFER FROM THE CCU:
1. Aspirin 325 q.d.
2. Plavix 75 q.d.
3. Lipitor 40 q.d.
4. Glipizide XL 20 q.d.
5. Captopril 6.25 t.i.d.
6. Protonix 40 q.d.
7. Flomax 0.4 q.d.
8. Regular insulin sliding scale.
9. Wellbutrin 150 b.i.d.
10. Ativan, per CIWA scale.
11. Lopressor 50 b.i.d.
12. IV morphine p.r.n.
13. Ativan q. four hours p.r.n. CIWA greater than ten.
14. Actos 15 b.i.d.
15. Ambien 5 q.h.s.
FAMILY HISTORY: Brother had an MI at the age of 38. Father
with CAD, CABG times four at the age of 60 and diabetes.
Mother died in her 60s of SLE.
SOCIAL HISTORY: Denied ever using alcohol, tobacco 30 years,
one pack per day, lives with his wife and two sons, a nurses
aid in [**Name (NI) 1268**] VA.
LABORATORY/RADIOLOGIC DATA: White blood cell count 9.5,
hematocrit 36.3, platelets 168,000, INR 1.2. Chem-10
unremarkable. Total cholesterol 164, triglycerides 124, LDL
106, HDL 40. CK initial 93, peaked at 2,117, and has been
trending down. Troponin I initially less than 0.3 and then
peaked to greater than 50.
Echocardiogram on [**2161-9-25**] revealed mild LVF
dysfunction with inferior/inferolateral akinesis and
hypokinesis, 1+ MR, EF 40-45%.
Electrocardiogram on admission revealed sinus, rate 90,
normal axis, normal PR and QRS intervals, ST elevation in II,
III, aVF with Qs in II, aVF, and ST depressions in I and aVL.
Elevations also in V5 and V6.
Right-sided EKG revealed elevations in V3 and V4.
ASSESSMENT: This is a 48-year-old male with diabetes type 2
and hypercholesterolemia admitted to the CCU on [**2161-9-25**] status post an inferior MI with an RV infarct with a
catheterization on [**2161-9-25**] where a stent was
placed to the proximal RCA. He was doing well and was called
out to the [**Hospital Unit Name 196**] Team on [**2161-9-26**].
CARDIAC: For this ischemia, he was continued on aspirin.
His beta blocker was titrated up and he was continued on
Plavix and an ACE inhibitor was also titrated up.
Nitroglycerin was avoided because of RV involvement. He did
continue to have less severe episodes of chest pain and his
EKG and enzymes were followed while he was on the floor.
Lipitor was continued at 40 q.d. and his Lipid panel was
checked.
Her underwent a stress test prior to discharge in order to
evaluate his continued chest pain. The stress test was
unfortunately submaximal and revealed a fixed defect. He
will need a full stress test as an outpatient.
2. ENDOCRINE: He was continued on his diabetes medications,
fingersticks four times a day as well as a regular insulin
sliding scale.
3. GASTROINTESTINAL: He was continued on Protonix and
underwent a nutrition consult. There was no evidence of
pancreatitis on admission. He had a normal amylase.
4. PSYCHIATRY: The patient was counseled on smoking
cessation and was started on Wellbutrin 150 b.i.d.
DISCHARGE STATUS: Good.
CONDITION ON DISCHARGE: The patient was discharged to home.
He will need a maximum stress test in two weeks. He will
follow-up with Dr. [**Last Name (STitle) **] in three to four weeks and until
he is seen by Dr. [**Last Name (STitle) **], he was advised not to work as a
nurses aid.
DISCHARGE DIAGNOSIS: Inferior myocardial infarction, status
post right coronary artery proximal stent.
DISCHARGE MEDICATIONS:
1. Celebrex 100 b.i.d.
2. Captopril 12.5 mg t.i.d.
3. Glipizide XL 20 q.d.
4. Glitazone p.o. 30 q.d.
5. Aspirin 325 q.d.
6. Plavix 75 q.d. for a total of 30 days.
7. Lipitor 40 q.d.
8. Protonix 40 q.d.
9. Flomax 0.4 q.h.s.
10. Wellbutrin 150 b.i.d.
11. Metoprolol 50 b.i.d.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2162-6-4**] 04:24
T: [**2162-6-4**] 18:22
JOB#: [**Job Number 35331**]
|
[
"410.71",
"577.1",
"305.1",
"250.00",
"272.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.01",
"99.20",
"88.56",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
4155, 4288
|
7002, 7575
|
6896, 6979
|
3595, 4138
|
2492, 2569
|
179, 2472
|
2584, 3235
|
3257, 3572
|
4305, 6588
|
6613, 6875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,328
| 130,860
|
29969
|
Discharge summary
|
report
|
Admission Date: [**2161-4-30**] Discharge Date: [**2161-5-4**]
Date of Birth: [**2126-6-30**] Sex: M
Service: PLASTIC
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
Right thigh heterotopic ossification
Major Surgical or Invasive Procedure:
Right thigh heterotopic ossification neurolysis of femoral nerve
branches; local tissue rearrangement
History of Present Illness:
This is a 34 year old gentleman with a long history of shoulder
and lower extremity issues requiring multiple surgeries. See
PMH for chronicity of events and subsequent surgeries. Briefly,
patient has a history of congenital tarsal collusion for which
he has had surgery to both feet including triple fusions. On
[**2159-7-4**], patient had right hind foot triple fusion surgery
which was complicated by compartment syndrome. Patient
subsequently required multiple debridements and wound vac
changes with eventual closure of the right thigh wound on
[**2159-8-16**] with split-thickness skin graft by Plastic Surgery. In
[**2160-2-14**] patient underwent excision of tissue
ossification with local tissue rearrangement as well as
neurolysis of cutaneous right femoral nerve. Patient continued
to have pain to this area and a CT scan revealed heterotopic
ossification of the right thigh/groin area.
Past Medical History:
hypertension
congenital tarsal collusion
chronic pain issues (shoulder, BLEs, lumbar/thoracic)
Left calcaneocuboid arthritis
right shoulder pain
left triple fusion
depression
right heterotopic ossification
chronic sinusitis-->MRSA
Sickle Cell Trait
[**12-20**] Upper extremity DVT (from PICC Line)
[**2156-10-19**] acromioplasty right shoulder, subdeltoid bursectomy, and
distal clavicle resection
[**2158-5-12**] Right calcaneonavicular coalition.
[**9-19**] tear of the rotator cuff on the right, Recurrent AC joint
arthropathy, Biceps tenosynovitis, Impingement syndrome.
[**11-19**] Arthroscopic subacromial decompression, Arthroscopic
distal clavicle excision, Open repair of near full-thickness
rotator cuff tear.
[**12-20**] Septic right shoulder, Full-thickness rotator cuff tear,
supraspinatus just posterior to the bicipital groove.
[**2159-1-2**] Arthroscopic I&D of right glenohumeral joint and right
subacromial space with open repair of full-thickness rotator
cuff tear.
[**2159-1-10**] clot/thrombus within the distal left basilic vein
from PICC line.
[**2159-7-4**] Right hind foot triple fusion (subtalar fusion,
calcaneocuboid joint fusion, talonavicular joint fusion) and
Iliac crest bone grafting c/b Compartment syndrome, right thigh
requiring urgent compartment release.
[**Date range (1) 71555**]/[**2159**] Multiple Irrigation and debridements to right
thigh tissue and placement of vacuum dressings.
[**2159-8-16**] Right split-thickness skin graft to right lower
extremity (2 inches x 15 cm)and closure of medial thigh wound.
[**2160-3-13**] Exploration of right medial thigh; excision of tissue
ossification with partial closure and local tissue rearrangement
of right lower extremity. Neurolysis of cutaneous right femoral
nerve.
[**2161-4-30**] 750 cGy pre surgery
[**2161-4-30**] right thigh heterotopic ossification neurolysis of
femoral nerve branches c/b intraoperative bleeding
Social History:
He is currently living in [**Location (un) 583**] with his girlfriend of many
years and is on disability. He was previously employed as a
forklift driver. He has a 9-pack-year tobacco history and is
currently still smoking about a half a pack a day. He has two
daughters, ages 5 and 10.
Family History:
Mother suffered MI at age 42, aunt MI in her 40's.
Physical Exam:
Pre-procedure PE from Anesthesia Record [**2161-4-30**]:
Temp-37C Pulse- 71/min resp-20/min b/p-139/84 O2sat-98% RA
General: NAD
Mental/psych: a/o
Airway: as documented in detail on Anesthesia record
Dental: Good
Head/neck Range of motion: Free range of motion
Heart: rrr no M or bruits
Lungs: clear to auscultation
extremities: R pedal edema
Other: anicteric, no thyromeg, no LAD, short beard, ortho: see
note [**2161-3-11**]
Pertinent Results:
[**2161-4-30**] 06:42PM GLUCOSE-190* UREA N-9 CREAT-1.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-28 ANION GAP-9
[**2161-4-30**] 06:42PM estGFR-Using this
[**2161-4-30**] 06:42PM CALCIUM-7.5* PHOSPHATE-4.3 MAGNESIUM-1.5*
[**2161-4-30**] 06:42PM WBC-19.3*# RBC-3.73* HGB-11.1*# HCT-32.9*
MCV-88 MCH-29.7 MCHC-33.7 RDW-14.8
[**2161-4-30**] 06:42PM NEUTS-78.5* LYMPHS-17.2* MONOS-2.7 EOS-1.4
BASOS-0.2
[**2161-4-30**] 06:42PM PLT COUNT-166
[**2161-4-30**] 06:42PM PT-12.8 PTT-25.1 INR(PT)-1.1
[**2161-5-3**] 08:41AM BLOOD WBC-12.4* RBC-3.07* Hgb-9.2* Hct-26.8*
MCV-87 MCH-29.8 MCHC-34.2 RDW-14.5 Plt Ct-189
[**2161-5-3**] 08:41AM BLOOD Plt Ct-189
.
[**2161-4-30**] FEMORAL VASCULAR US RIGHT
IMPRESSION: Unremarkable appearance of vasculature of the
proximal right thigh, with no evidence of pseudoaneurysm,
fistula or hematoma.
.
[**2161-5-3**] FEMORAL VASCULAR US RIGHT
IMPRESSION: No evidence of pseudoaneurysm, fistula or hematoma.
Normal appearance of proximal right thigh vasculature.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2161-4-30**] and had a right thigh heterotopic ossification
neurolysis of femoral nerve branches. Briefly, the patient
underwent this elective procedure which was complicated
intraoperatively by a venous injury to the anteriomedial thigh
requiring an intra-op vascular surgery consult. There was
concern for femoral vein injury, however post-operative U/S of
RLE showed no injury to the femoral vein. Patient had an
estimated blood loss of 1800 cc during the case and was given 2
units of packed red blood cells. The patient was admitted to the
ICU overnight for Q1h neurovascular checks to RLE and then
transferred to the floor.
.
Neuro: Post-operatively, the patient received Dilaudid PCA with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on POD#1. Intake
and output were closely monitored.
.
ID: Post-operatively, the patient was started on IV Vancomycin
and Levaquin, then switched to PO Levaquin for discharge home.
The patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient was initially started on subcutaneous
heparin status post ultrasound and was then changed to Lovenox
for remainder of stay. The patient was also encouraged to get
up and ambulate as early as possible.
.
At the time of discharge on POD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
1. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
3. Neurontin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Mucinex D 60-600 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO twice a day.
5. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime)
as needed for insomnia.
6. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical every twelve (12) hours.
8. Tramadol Oral
9. Tizanidine
Discharge Medications:
1. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
3. Neurontin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Mucinex D 60-600 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO twice a day.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*45 Capsule(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime)
as needed for insomnia.
7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*1*
8. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical every twelve (12) hours.
10. Tramadol Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Right thigh heterotopic ossification
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 on [**2161-4-30**] for surgery on your right thigh
area. Please follow these discharge instructions.
.
Personal Care:
1. Clean around the drain site(s), where the tubing exits the
skin, with hydrogen peroxide.
2. Strip drain tubing, empty bulb(s), and record output(s) [**3-18**]
times per day.
3. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
4. You may shower daily. No baths until instructed to do so by
Dr. [**Last Name (STitle) 23606**].
.
Activity & Diet:
1. You may resume your regular diet.
2. DO NOT engage in strenuous activity until instructed by Dr.
[**Last Name (STitle) 23606**] and avoid pressure to right thigh surgical area.
.
Medications:
1. Resume your regular medications unless instructed otherwise
(see below) and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
4. Take prescription pain medications for pain not relieved by
tylenol.
5. Take your antibiotic as prescribed.
6. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
7. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
****Do NOT resume your Ibuprofen until advised by Dr. [**Last Name (STitle) 23606**].
****Do NOT take your Tizanidine until you are finished with your
antibiotic, Levaquin due to interaction of these two
medications.
****please note that Levaquin is associated with an increased
risk of tendinitis and tendon rupture. Should you start to
experience muscular aches/pains then please call your doctor
immediately.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
welling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain
Followup Instructions:
Please call Dr.[**Name (NI) 29526**] office to make a follow up
appointment for 1 week from now.
.
Dr. [**First Name (STitle) **] [**Name (STitle) 23606**]
Office: ([**Telephone/Fax (1) 26412**]
Completed by:[**2161-5-4**]
|
[
"282.5",
"V17.3",
"998.11",
"311",
"E878.8",
"V12.04",
"728.13",
"998.2",
"305.1",
"338.29",
"401.9",
"338.18",
"V12.51",
"V45.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"83.32",
"39.32"
] |
icd9pcs
|
[
[
[]
]
] |
8784, 8790
|
5150, 7154
|
306, 410
|
8871, 8871
|
4117, 5127
|
12562, 12787
|
3603, 3655
|
7878, 8761
|
8811, 8850
|
7180, 7855
|
9051, 12539
|
3670, 4098
|
230, 268
|
438, 1343
|
8886, 9027
|
1365, 3279
|
3295, 3587
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,504
| 154,476
|
31482
|
Discharge summary
|
report
|
Admission Date: [**2114-5-18**] Discharge Date: [**2114-5-24**]
Service: MEDICINE
Allergies:
Prednisone / Isordil / Ace Inhibitors
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
lethargy, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 29250**] is a [**Age over 90 **] yo M with PMH CAD, CHF, Cdiff, CKD
(3.2-3.7) presenting with two days of increasing lethargy and
weakness. According to his daughter several days PTA he was
noted to have nasal congestion and cough. This progressed to
increasing weakness as well as lethargy. On the day of
admission he was so weak that he slipped to the ground while
trying to get from his wheelchair to the commode and was then
noted to be gasping for breath so he was sent to the ED for
further evaluation. When EMS arrived he was noted to be
saturating in the 80's on 2L NC. Of note he has had persistent
C diff infection for which he is being treated with po
vancomycin.
.
On arrival in the ED T 98.5 BP 113/55 HR 78 RR 24 95% NRB. CXR
was done which showed RLL infiltrate, foley was placed and urine
was noted to be purulent. He was given 1.5L NS, vancomycin 1g
IV, and zosyn 4.5g IV.
.
Of note he was just admitted from [**4-8**]- [**2114-4-13**] to the cardiology
service for flash pulmonary edema [**3-12**] poorly controlled
hypertension. During that admission he was found to have C diff
and was started on flagyl.
Past Medical History:
CAD: S/p at least 2 MIs per patient, first at age 58
Hypertension
CHF: EF 30-40% & 1+ MR [**First Name (Titles) **]
[**Last Name (Titles) 3593**]: s/p angioplasty?
H/o TIA
Stage IV Chronic Kidney Disease: Baseline Cr ~3.7
Diabetes Mellitus Type II
COPD: Smoked [**3-14**] ppd for 50 years, on 2L home O2
Peptic ulcer disease: S/p rx for H.pylori
Recurrant C. diff now on po vanco
H/o testicular cancer
H/o pancreatitis
S/p cholecystectomy
S/p L parotidectomy: complicated by facial nerve paralysis
Social History:
Just accepted into long term care at [**Hospital 100**] Rehab. Social
history is significant for the absence of current tobacco use.
Pt quit smoking in [**2080**]; prior to that, he smoked [**3-14**] ppd x 50
years. There is no history of alcohol abuse.
Family History:
There is a family history of premature coronary artery disease
or sudden death - multiple relatives have hypertension, coronary
artery disease, and diabetes.
Physical Exam:
VS: T98 HR 76 BP 123/45 RR 16 99% 40% high flow mask
Gen: sleeping, opens eyes to voice, oriented x3
HEENT: NC AT Pupils 1-2 mm equal and reactive
Neck: supple
CV: regular rate and rhythm, [**3-16**] soft systolic murmur
Lungs: bronchial breath sounds at the left base to [**2-9**] way, no
wheezing
Abd: soft, slight RLQ tenderness, no guarding, BS+
Ext: 2+ pitting edema of LE's bilaterally
Sking: no rash or lesions
Pertinent Results:
[**2114-5-18**] 04:45PM CK-MB-NotDone proBNP-9109*
[**2114-5-18**] 04:45PM LIPASE-46
[**2114-5-18**] 04:45PM ALT(SGPT)-18 AST(SGOT)-19 CK(CPK)-41 ALK
PHOS-82 TOT BILI-0.5
[**2114-5-18**] 04:45PM estGFR-Using this
Brief Hospital Course:
Mr. [**Known lastname 29250**] was admitted initially to the MICU with pneumonia
in the RLL requring high level of supplemental oxygen. He also
had a UTI. He had worsening of his renal function likely
secondary to worsening acute systolic heart failure and ATN. He
required vasopressors the first 48 hours of admission. He was
then trialed on lasix drip to remove fluid given he developed
flash plmonary edema. He was unresponsive to high doses of
diuretic. At this point his outpatient nephrologist and
cardiologist were contact[**Name (NI) **] and came by to see him. He was
intermitently somnolent at this point but able to relay during
lucid periods that he clearly would not want dialysis or further
invasive lines. He was given a final 24 hour period to respond
to aggressive diuretic regimen with no success. At this point
there was a family discussion with his daughter who is the HCP,
his wife and the decision was made to make him comfortable on a
morphine drip. He expired on [**2114-5-24**] at 0430 AM in a peaceful
setting.
Medications on Admission:
furosemide 80mg po qam
gabapentin 300mg QOD
Glipizide XL 2.5mg daily
Hydralazine 50mg q8 hours (hold for sbp <90)
Vancomycin oral liquid 125mg q6
acetaminophen 650mg q4 hours prn
albuterol nebs q4 prn
bisacodyl supp 10mg pr daily prn
amlodipine 5mg qday
asa 81 mg qday
atorvastatin 80mg qhs
calcitriol 0.25mg daily
calcium carbonate 650mg [**Hospital1 **]
carvedilol 25mg [**Hospital1 **]
folic acid 1mg qday
ipratropium bromide nebs q4h prn
senna one tab [**Hospital1 **] prn
percocet 5/325 one po q6h prn pain
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"599.0",
"008.45",
"584.5",
"V10.87",
"428.23",
"041.04",
"995.92",
"424.0",
"428.0",
"414.8",
"038.9",
"585.4",
"496",
"785.52",
"354.9",
"250.00",
"443.9",
"533.90",
"486",
"412",
"355.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4753, 4762
|
3119, 4157
|
263, 269
|
4813, 4822
|
2874, 3096
|
4878, 4888
|
2261, 2421
|
4721, 4730
|
4783, 4792
|
4184, 4698
|
4846, 4855
|
2436, 2855
|
205, 225
|
297, 1453
|
1475, 1974
|
1990, 2245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,045
| 174,287
|
22919
|
Discharge summary
|
report
|
Admission Date: [**2162-2-16**] Discharge Date: [**2162-2-25**]
Date of Birth: [**2100-3-16**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61yo woman from group home with a hx of mental retardation,
DMII, HTN, nephrolithiasis was brought to [**Hospital1 18**] ED for acute
renal failure. She was brought to [**Hospital1 3494**] ED for failure to
thrive (decreased appetite, malaise) x 1 month. At [**Location 17065**]
(97.2 105 16 110/64 88% RA) she was found to
have multiple lab abnormalities: K+ 7.4, glucose 388, WBC 14.4
with 92.7% polys, HCO3 14, AST 102, ALT 50, U/A with >50
bacteria, 0-2 WBC, -nitrate, -leuk esterase, and ?????? bottles blood
cx aerobic + for Gram+ cocci, ABG 7.296/26/2/90.1 and base
excess ??????12. Received D50/insulin/bicarbonate/calcium
gluconate/kayexelate. Dopamine gtt @ 20 started for SBP
80-90/palp. Abdominal CT: no hydronephrosis. Head CT were
negative. Lab abnormalities from triage assessment: CK 5336 Trop
0.38 CKMB 60 BUN/CR = 130/11.6. Her initial [**Hospital1 18**] ED vitals on
dopamine gtt @ 20 were:
97F 111 123/92 18 92% RA
She was alert, oriented to person and place, answering simple
questions, and denied pain. She had just finished a 10d course
of Bactrim for UTI. In the [**Hospital1 18**], she received 1L NS, 1L D5W +
3amps NaHCO3, CTX 1g IV, kayexylate, and a Foley was placed.
Dopamine gtt weaned to 5. Mixed venous O2 sat: 71%. Admitted to
[**Hospital Unit Name 153**] for hypotension of unknown etiology.
[**Hospital Unit Name 153**] course: Weaned off dopamine. Renal consult: no need for
acute dialysis. Renal U/S showed R kidney stone with mild
hydronephrosis. NS IVF given for CVP goal [**1-19**]. FENA 3.8%
pointed away from pre-renal etiology for ARF. Admission CR was
10.2 CR fell rapidly.
Past Medical History:
1. HTN
2. mental retardation
3. Type II DM
4. Recent UTI and PNA
5. hypercholesterolemia
6. nephrolithiasis - R kidney stone, staghorn calculus - planned
for surgical removal in the next several months. Dr. [**Last Name (STitle) 59213**]
plans to do surgery in 2 months.
7. depression
8. hx cystitis
9. s/p L TKR
10. depression
11. s/p recent hospitalization at [**Hospital3 **] for hitting herself
and attempting to bite others - "psychotic episode" - per
patient brother - started on risperidone and celexa at this time
Social History:
Lives in group home. Used a walker after her knee replacement
several weeks ago. No EtOH. No tobacco or other drug use per
brother.
Family History:
Sister is deaf and has UC. Mother with DM II. Father with [**Name2 (NI) **].
Physical Exam:
Vitals: 97.9 134/78 86 26 96% on 2L
General: 61yo obese [**Known lastname **] male lying in NAD with head deviated
to the L, R IJ central line
Neuro: Alert. Pupils 3-->1 bilaterally. Was able to get her to
say only one word: "hello." Follows simple midline commands like
stick out your tongue and wiggle your toes. Nods to questions
inconsistently. No blink to R visual field confrontation. Blinks
to L visual field confrontation. EOMI. Tongue midline.
Neck: JVP hard to assess. No lymphadenopathy.
CV: RRR. No thrill. Normal S1, S2. JVP difficult to assess
because of obese neck and brisk carotid pulsation.
Lungs: Difficult to assess because could not get patient to sit
up. Listening near the axilla bilaterally, could hear air
movement and did not hear any crackles or wheezes.
Abd: Distended and tympany to percussion. +BS. No scars.
Difficult to assess tenderness as patient would nod
inconsistently. But patient tolerated deep palpation without
obvious distress.
Ext: 2+ pitting edema bilaterally in the LE.
Pertinent Results:
[**2162-2-19**] 09:30AM BLOOD WBC-9.9 RBC-3.24* Hgb-9.8* Hct-29.4*
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.4 Plt Ct-246
[**2162-2-18**] 04:45AM BLOOD WBC-9.1 RBC-3.24* Hgb-9.4* Hct-28.3*
MCV-87 MCH-29.0 MCHC-33.2 RDW-12.7 Plt Ct-265
[**2162-2-17**] 06:01AM BLOOD WBC-10.0 RBC-3.27* Hgb-10.0* Hct-28.8*
MCV-88 MCH-30.5 MCHC-34.7 RDW-13.7 Plt Ct-244
[**2162-2-16**] 11:06PM BLOOD WBC-10.2 RBC-3.24* Hgb-9.3* Hct-28.2*
MCV-87 MCH-28.6 MCHC-32.9 RDW-12.9 Plt Ct-259
[**2162-2-16**] 02:00PM BLOOD WBC-9.7 RBC-3.27* Hgb-9.6* Hct-29.2*
MCV-89 MCH-29.4 MCHC-32.9 RDW-13.7 Plt Ct-252
[**2162-2-16**] 12:39AM BLOOD WBC-16.0* RBC-3.61* Hgb-10.6* Hct-32.2*
MCV-89 MCH-29.2 MCHC-32.7 RDW-13.6 Plt Ct-302
[**2162-2-16**] 11:06PM BLOOD Neuts-80.6* Lymphs-12.1* Monos-5.9
Eos-1.2 Baso-0.2
[**2162-2-16**] 02:00PM BLOOD Neuts-79.3* Lymphs-14.0* Monos-5.9
Eos-0.7 Baso-0.1
[**2162-2-16**] 12:39AM BLOOD Neuts-87.1* Lymphs-9.0* Monos-3.7 Eos-0.1
Baso-0.1
[**2162-2-19**] 09:30AM BLOOD Plt Ct-246
[**2162-2-19**] 09:30AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2162-2-18**] 04:45AM BLOOD Plt Ct-265
[**2162-2-18**] 04:45AM BLOOD PT-13.3 PTT-25.0 INR(PT)-1.1
[**2162-2-17**] 06:01AM BLOOD Plt Ct-244
[**2162-2-17**] 06:01AM BLOOD PT-13.9* PTT-24.8 INR(PT)-1.2
[**2162-2-16**] 11:06PM BLOOD Plt Ct-259
[**2162-2-16**] 02:00PM BLOOD Plt Ct-252
[**2162-2-16**] 12:39AM BLOOD Plt Ct-302
[**2162-2-16**] 12:39AM BLOOD PT-13.9* PTT-24.3 INR(PT)-1.2
[**2162-2-19**] 09:30AM BLOOD Glucose-136* UreaN-28* Creat-0.8 Na-145
K-4.6 Cl-112* HCO3-25 AnGap-13
[**2162-2-18**] 04:45AM BLOOD Glucose-136* UreaN-59* Creat-1.6* Na-148*
K-3.9 Cl-114* HCO3-29 AnGap-9
[**2162-2-17**] 05:52PM BLOOD Glucose-119* UreaN-79* Creat-2.5*#
Na-150* K-3.6 Cl-115* HCO3-26 AnGap-13
[**2162-2-17**] 06:01AM BLOOD Glucose-138* UreaN-91* Creat-4.1*#
Na-149* K-3.7 Cl-112* HCO3-27 AnGap-14
[**2162-2-16**] 11:06PM BLOOD Glucose-131* UreaN-98* Creat-5.4*#
Na-148* K-3.8 Cl-111* HCO3-27 AnGap-14
[**2162-2-16**] 02:00PM BLOOD Glucose-226* UreaN-112* Creat-8.0* Na-144
K-4.3 Cl-104 HCO3-25 AnGap-19
[**2162-2-16**] 08:30AM BLOOD Glucose-144* UreaN-113* Creat-8.8* Na-145
K-4.8 Cl-103 HCO3-24 AnGap-23*
[**2162-2-16**] 04:25AM BLOOD Glucose-159* UreaN-113* Creat-9.3* Na-144
K-5.0 Cl-103 HCO3-22 AnGap-24*
[**2162-2-16**] 12:39AM BLOOD Glucose-159* UreaN-123* Creat-10.1*
Na-142 K-6.0* Cl-102 HCO3-18*
[**2162-2-19**] 09:30AM BLOOD ALT-22 AST-23 LD(LDH)-315* CK(CPK)-184*
AlkPhos-51 Amylase-131* TotBili-0.2
[**2162-2-18**] 04:45AM BLOOD ALT-29 AST-31 LD(LDH)-281* CK(CPK)-566*
AlkPhos-49 Amylase-223* TotBili-0.1
[**2162-2-17**] 06:01AM BLOOD CK(CPK)-1553*
[**2162-2-16**] 11:06PM BLOOD ALT-35 AST-49* LD(LDH)-315* CK(CPK)-1888*
AlkPhos-49 Amylase-156* TotBili-0.1
[**2162-2-16**] 02:00PM BLOOD LD(LDH)-342* CK(CPK)-2860* Amylase-116*
[**2162-2-16**] 08:30AM BLOOD CK(CPK)-3454*
[**2162-2-16**] 04:25AM BLOOD ALT-43* AST-75* LD(LDH)-356*
CK(CPK)-3656* AlkPhos-54 TotBili-0.2
[**2162-2-16**] 12:39AM BLOOD CK(CPK)-4468*
[**2162-2-19**] 09:30AM BLOOD Lipase-181*
[**2162-2-18**] 04:45AM BLOOD Lipase-453*
[**2162-2-16**] 11:06PM BLOOD Lipase-368*
[**2162-2-16**] 02:00PM BLOOD Lipase-167*
[**2162-2-18**] 04:45AM BLOOD CK-MB-4 cTropnT-<0.01
[**2162-2-17**] 06:01AM BLOOD CK-MB-11* MB Indx-0.7 cTropnT-0.02*
[**2162-2-16**] 11:06PM BLOOD CK-MB-14* MB Indx-0.7 cTropnT-0.03*
[**2162-2-16**] 02:00PM BLOOD CK-MB-24* MB Indx-0.8 cTropnT-0.06*
[**2162-2-16**] 08:30AM BLOOD CK-MB-31* MB Indx-0.9 cTropnT-0.11*
[**2162-2-16**] 04:25AM BLOOD cTropnT-0.12*
[**2162-2-16**] 12:39AM BLOOD CK-MB-43* MB Indx-1.0
[**2162-2-16**] 12:32AM BLOOD cTropnT-0.13*
[**2162-2-19**] 09:30AM BLOOD Calcium-8.8 Phos-1.2*# Mg-1.4*
[**2162-2-18**] 04:45AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8
[**2162-2-17**] 05:52PM BLOOD Calcium-8.6 Phos-3.9# Mg-2.0
[**2162-2-17**] 06:01AM BLOOD Calcium-8.5 Phos-5.6* Mg-2.1
[**2162-2-16**] 11:06PM BLOOD Calcium-8.4 Phos-6.4*# Mg-2.2
[**2162-2-16**] 02:00PM BLOOD Calcium-8.5 Phos-8.3* Mg-2.2
[**2162-2-16**] 04:25AM BLOOD Albumin-3.2* Calcium-8.5 Phos-8.9* Mg-2.3
[**2162-2-18**] 04:45AM BLOOD Triglyc-127
[**2162-2-16**] 11:06PM BLOOD Triglyc-130
[**2162-2-16**] 04:25AM BLOOD TSH-0.36
[**2162-2-16**] 08:30AM BLOOD C3-138 C4-39
[**2162-2-16**] 02:00PM BLOOD GreenHd-HOLD
[**2162-2-16**] 02:00PM BLOOD Type-MIX
[**2162-2-16**] 11:04AM BLOOD Type-MIX
[**2162-2-16**] 02:00PM BLOOD Lactate-1.6
[**2162-2-16**] 12:38AM BLOOD K-5.7*
[**2162-2-16**] 11:04AM BLOOD O2 Sat-71
[**2162-2-16**] 02:00PM BLOOD O2 Sat-78
CHEST (PORTABLE AP) [**2162-2-18**] 4:48 PM
IMPRESSION:
1) No CHF.
2) Left base atelectasis/consolidation.
3) Hazy opacity at the right base, medially, unchanged.
ECG Study Date of [**2162-2-17**] 10:13:32 AM
Poor quality tracing. Sinus rhythm. Since the previous tracing
of [**2162-2-16**] the
rate has decreased, the axis is more leftward and ST segments
are probably
improved. Clinical correlation is suggested.
TTE/ECHO Study Date of [**2162-2-17**]
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. There is mild pulmonary artery systolic hypertension.
UNILAT UP EXT VEINS US RIGHT PORT [**2162-2-17**] 1:23 PM
IMPRESSION:
Short segment of thrombus within the cephalic vein superior to
the antecubital fossa. The remainder of the upper extremity
veins are widely patent.
ECG Study Date of [**2162-2-16**] 12:14:12 AM
Baseline instability makes identification of P waves difficult.
The rhythm is
likely sinus tachycardia, rate 133. Another possibility (though
less likely) is
atrial flutter, atrial rate 265, with 2:1 A-V block. Possible
old inferior
myocardial infarction. Possible old anterior myocardial
infarction.
Intraventricular conduction delay of right bundle-branch block
type, possibly
rate-related.
CHEST (PORTABLE AP) [**2162-2-16**] 3:34 AM
IMPRESSION: Technically limited, but no overt CHF. Recommmend PA
and lateral to evaluate right base (see above).
RENAL U.S. [**2162-2-16**] 7:05 AM
CONCLUSION:
Normal sized kidneys with mild right hydronephrosis secondary to
a stone or stones in the right renal pelvis. No evidence of left
hydronephrosis.
Brief Hospital Course:
61yo female with mental retardation, DM II, HTN, nephrolithiasis
was brought from the [**Hospital 17065**] hospital ED to the [**Hospital1 18**] ED for
acute renal failure (Cr 11.6) and hypotension on dopamine gtt.
She was admitted to the [**Hospital Unit Name 153**], quickly weaned off dopamine, a
central venous line was placed, and she was aggressively fluid
resuscitated to a goal CVP 8-12. A renal U/S showed R kidney
stone with mild hydronephrosis. Nephrology was consulted and
decided that the patient has no acute need for dialysis despite
a very elevated creatinine. In the ICU she received a 3 day
course of levofloxacin for possible urinary tract infection and
a single dose of vancomycin for a single coag-neg Staph negative
culture bottle from the outside ED from where she was
transferred. Her renal function improved rapidly and she
remained afebrile and hemodynamically stable in the ICU. She
was transferred to the medicine floor with the following vitals:
97.9 134/78 86 26 96% on 2L. CXR showed
questionable opacification at the L and R bases and she was
continued on levofloxacin (for total 10d course) for empiric
coverage of community-acquired pneumonia. Her lipase and
amylase had risen while she was in the ICU but began to decrease
when she came to the floor; she never had clinical signs of
pancreatitis. All blood cultures remained negative. The
patient's kidney function continued to improve on the floor.
She was weaned off oxygen. Her medications for hypertension and
diabetes were reinstituted without complication. Psychiatry
consultation recommened the addition of remeron and seroqual for
depression and and anxiety respectively.
Medications on Admission:
1. lisinopril 20mg PO qd
2. metformin 500mg PO qd
4. trazadone 50mg PO qd
5. colace 100mg PO bid
6. lipitor 10mg PO qd
7. risperdal 0.5mg PO bid - started 10d ago
8. celexa 30mg PO qd - started 10d ago
9. senna 2 tabs qhs
10. iron sulfate 325mg PO qd
11. estrace vaginal cream 1x/week
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
7. Quetiapine Fumarate 25 mg Tablet Sig: 0.5-1 Tablet PO BID PRN
() as needed for anxiety.
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. Acute Prerenal Failure
2. Hypotension
3. Pneumonia/Sepsis
4. Recurrent UTI's, with nephrolithiasis and right sided
nephrolithiasis causing mild hydronephrosis
4. Type II Diabetes
5. Hypertension
6. Mental Retardation
7. Depression and Anxiety
8. Superficial thrombophlebitis
Discharge Condition:
Fair
Discharge Instructions:
Please return to the emergency room should you experience high
fever > 101F and shaking chills, shortness of breath, chest
pain, abdominal pain, or other alarming symptom.
Followup Instructions:
1) Please follow-up with your Urologist Dr. [**Last Name (STitle) 59213**] for
planned treatment for your renal calculi.
2) Please arrange for formal neuropsychological testing to
further evaluate cognitive function and capacity to care for
self.
3) Have Hct re-checked along with an anemia evaluation. You
should also have a colonoscopy to assess for a potential cause
for the anemia
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2162-2-25**]
|
[
"486",
"518.81",
"584.9",
"416.8",
"591",
"272.0",
"250.00",
"276.5",
"319",
"592.9",
"300.00",
"518.0",
"995.91",
"453.8",
"038.9",
"458.9",
"788.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
12726, 12799
|
9974, 11669
|
279, 286
|
13121, 13127
|
3813, 9951
|
13347, 13894
|
2667, 2745
|
12005, 12703
|
12820, 13100
|
11695, 11982
|
13151, 13324
|
2760, 3794
|
228, 241
|
314, 1954
|
1976, 2502
|
2518, 2651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,737
| 108,611
|
46900
|
Discharge summary
|
report
|
Admission Date: [**2111-1-31**] Discharge Date: [**2111-2-5**]
Date of Birth: [**2048-7-17**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Conray
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
fever and shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
62M with h/o CML in remission on Gleevec, chronic A.fib on
coumadin, DM2, chronic dizziness/vertigo p/w fever at home to
104, fatigue and malaise x 1 week. His wife finally measured his
temperature today which prompted him to come to call [**Company 191**] with
referral to the ED. He states that he did not seek medical
attention since he felt his symptoms were secondary to the
Topamax he has been taking for his vertigo/migraines for the
last several months. Patient has been fatigued, having chills
and sweats at home, staying mostly in bed x 1 week. He also
endorses chronic headaches, slightly worse recently, no neck
stiffness, no photophobia. He c/o SOB at rest, not worse with
exertion, usually a/w his headaches. No recent cough, no sputum
production. No orthopnea/pnd, stable leg edema [**2-6**] to Glevec.
Patient reports his A.fib is sometimes out of control but he is
unaware of it, no palpitations, rare CP, none recently. He has
chronic diarrhea daily, not recently changed. His FS at home
have been well controlled 150's in AM down to 100's in PM.
Reports little PO intake due to fatigue/malaise. No abdominal
pain, no nausea or vomiting. No recent melena, blood in stool.
Also no dysuria or frequency. No rash. No recent travel.
Past Medical History:
1) BPH with recurrent UTIs and h/o perinephric abscess.
2)Atrial fibrillation.
3)CML- in remission on Gleevac
3) DM-insulin dependent
4) Recurrent DVT with PEs dating from [**2089**]. His previous DVT
involved the right leg.
5) Low HDL. Statins were stopped when he began Gleevec.
6) Chronic diarrhea attributed to Gleevec.
7) Negative prostate biopsies on [**2109-1-19**] for re-evaluation of an
elevated PSA of 5.5 on [**2108-12-3**]
8) Macular degeneration.
9)osteoarthritis
10)Internal hemmorhoids and diverticulosis seen on prior
colonscopy
11)Peripheral edema.
12) Ongoing problems with vertigo/syncope
Social History:
He works at [**University/College 5130**]. He teaches classes and does
accounting on the side as well. Does not smoke, does not drink.
He is married.
Family History:
[**Name (NI) 99486**], [**Name (NI) 99487**] cancer
Physical Exam:
VS: T 102.6 BP 127/75 HR 150 RR 30 O2 sat 99% 2L
GEN: obese, pale, tachypneic, not using accessory muscles, NAD,
fatigued and weak appearing
HEENT: OP dry, erythematous, no lesions/exudates, PERRL brisk,
no icterus, no pallor
AXILLAE: +moisture, no LAD palpable
NECK: supple, no lymphadenopathy
RESP: trace wheezing anteriorly, dull to auscultation over LUL,
+egophony, trace rhonchi over right lung fields, clear at bases
CV: nl S1 S2, tachy, [**2-10**] ESM at LSB/apex
ABD: obese, soft NT x 4, unable to appreciate any HSM, BS+
EXT: 2+ edema to below the knee, dry skin, no rashes, warm
BACK: focal tenderness over mid thoracic spine and left
paraspinal/flank area, + CVA tenderness on left, non tender over
cervical/lumbar paraspinal/spinal areas
NEURO: Awake, drowsy but arousable, speaking slowly, oriented,
CN II-XII intact, strength full, gait not observed, slightly off
balance while trying to sit up in bed
Pertinent Results:
[**2111-1-31**] CT- Head Without Contrast
1. A tiny area of high attenuation projecting in the area of the
temporal [**Doctor Last Name 534**] of the left lateral ventricle, most likely
representing a small area of calcification from chroid plexus.
However, small amount of acute hemorrhage in this area cannot be
excluded, but considered extremely less likely. If clinically
indicated, a repeat CT could be performed in 6 hours.
2. Otherwise, unremarkable non-contrast head CT scan.
- Scan was repeated on [**2111-2-1**] without new findings.
[**2111-1-31**] CXR - (PA and LAT)
IMPRESSION: Left upper lobe pneumonia.
[**2111-1-31**] EKG
Atrial fibrillation with rapid ventricular response
Incomplete right bundle branch block
Premature ventricular contractions
Inferior T wave changes are nonspecific
Repolarization changes may be partly due to rate/rhythm
Since previous tracing, ventricular response faster
[**2111-2-1**] - CT chest without contrast.
IMPRESSION:
1. Severe left upper lobe consolidation, nonobstructive, of
uncertain chronicity, except that it was not present on [**1-30**], [**2110**].
2. Mild distal tracheomalacia.
[**2111-2-1**] MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2111-2-1**] 11:50 AM
IMPRESSION: No evidence of epidural abscess in the lumbar
region. Signal changes at L2-3 disc most likely due to
degenerative change. However, given the clinical history, if
persistent back pain, a followup study is recommended.
Degenerative changes at other levels with compression of the
exiting right L4 nerve root at L4-5 level as described in the
full report.
[**2111-2-1**] Renal ultrasound.
IMPRESSION:
The left kidney contains a new 1.5-cm hypoechoic area that is
surrounded by a hyperechoic rim. This is not the appearance of
the focal nephritis. This might be an unusual appearing stone.
Followup by MRI is recommended.
[**2111-2-2**] Chest X-ray (AP portable).
IMPRESSION: Findings concerning for worsening left upper lobe
pneumonia. Follow-up to resolution after treatment is
recommended to exclude an underlying mass.
[**2111-2-2**] ECG
Atrial fibrillation with rapid ventricular response
Ventricular premature complexes
Incomplete right bundle branch block
T wave changes are nonspecific
Since previous tracing, slower ventricular rate noted
[**2111-1-31**] 09:17PM LACTATE-2.4*
[**2111-1-31**] 09:05PM GLUCOSE-229* UREA N-32* CREAT-1.8* SODIUM-133
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-22 ANION GAP-16
[**2111-1-31**] 09:05PM CK-MB-2 cTropnT-<0.01
[**2111-1-31**] 09:05PM CK(CPK)-125
[**2111-1-31**] 09:05PM WBC-15.7*# RBC-4.92 HGB-13.8* HCT-40.3 MCV-82
MCH-28.1 MCHC-34.4 RDW-16.3*
[**2111-1-31**] 09:05PM NEUTS-89.4* LYMPHS-6.8* MONOS-3.5 EOS-0.1
BASOS-0.2
[**2111-1-31**] 09:05PM PLT COUNT-166
[**2111-2-1**] 02:43AM BLOOD Lactate-1.8
[**2111-2-1**] 04:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2111-2-5**] 07:05AM BLOOD Glucose-93 UreaN-21* Creat-1.1 Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
[**2111-2-5**] 07:05AM BLOOD WBC-5.4 RBC-4.10* Hgb-11.3* Hct-34.7*
MCV-85 MCH-27.7 MCHC-32.6 RDW-16.6* Plt Ct-156
[**2111-2-2**] 12:56 pm URINE
**FINAL REPORT [**2111-2-3**]**
Legionella Urinary Antigen (Final [**2111-2-3**]):
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
Performed by Immunochromogenic assay.
Reference Range: Negative.
Clinical correlation and additional testing suggested
including
culture and detection of serum antibody.
REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor First Name **] [**2111-2-3**] 14:54.
Brief Hospital Course:
As this patient presented with a complex clinical picture his
problems will be dealt with individually in this Brief Hospital
course.
.
1.Fever/Leukocytosis. The likely source of these were the
patient's pneumonia based on the radiograph findings and
physical exam which was significant for rhales. Furthermore,
the patient's urinary legionella antigen test was positive.
Furthermore, he was treated with levofloxacin which led to
resolution of his symptoms.
.
2 Shortness of Breath. The cause of this symptom was likely
multifactorial. Possible etiologies included pneumonia as
discussed above as well as rapid ventricular rate. Happily
ischemia was ruled out by serial sets of cardic enzymes.
.
3. Atrial Fibrillation with rapid ventricular response. This
was difficult to mannage early on in the patient's course as it
seemed that the patient's febrile illness was exacerbating his
heart's underlyiing tendency to beat fast in response to
fibrillating atria - his heart rate reached the 160s. The
patient was maintained on telemetry and his rate was controlled
with metoprolol at varying dosages from 50 to 100mg TID. The
patient's INR was kept between 2 and 3 on his home dose of
coumadin.
.
# Back pain. The patient intially presented with focal pain over
his left flank and mid thoracic spine. Ultrasound of the left
kidney failed to show a clear cause of the patient's discomfort,
but did reveal a new 1.5-cm hypoechoic area that is surrounded
by a hyperechoic rim. Followup by MRI was recommended to the
attending, who also happens to be the patient's PCP. [**Name10 (NameIs) **]
patient's back pain was ultimately attributed to prolonged bed
rest and it resolved spontaneously.
.
# CML. The patient was maintained on his home regimen of Gleevec
without incident during this hospitalization.
Medications on Admission:
Gleevec 400 daily
Coumadin 7.5 mg daily
Humalog SS/60 units long acting qHS, ?brand
Lasix 60 daily
Lopressor 100 [**Hospital1 **]
Protonix 40 daily
Ultram 50 1-2 tabs qid prn
Imodium 2mg prn
Compazine 10 mg tid prn
Topamax 50 mg daily (recently tapering for concerns of
dizziness)
Vicodine 5/500 mg tid prn
Discharge Medications:
1. Robitussin Allergy-Cough [**2114-03-04**] mg/5 mL Syrup Sig: Ten (10)
ml PO every 4-6 hours as needed for pain.
Disp:*QS QS* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing: Please note that this medication can increase your
heart rate. Please do not more frequently. Also, please note
that there are other causes for shortness of breath and should
this medication not help you should seek medical care
immediately. .
Disp:*1 inhaler* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. Metoprolol Tartrate 25 mg Tablet Sig: Four (4) Tablet PO
twice a day.
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for headache.
8. Gleevec 400 mg Tablet Sig: One (1) Tablet PO once a day.
9. Insulin instruction.
Please take your insulin as directed by your [**Last Name (un) **] attending.
10. Med D/C
Please don't take your Topamax as it is not clear that this was
helping you. Please review your need to take this medication
with the physician who prescribed it.
11. Other Meds
Please resume taking Ultram, Imodium, Compazine, and Vicodin as
prescribed previously.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Legionella PNA
2. 1.5cm incidental left kidney mass seen on renal ultrasound
will need MRI follow up. Please talk with your primary
physician [**Name9 (PRE) 93094**] this issue.
Discharge Condition:
Stable. Patient ambulating without oxygen. Afebrile.
Discharge Instructions:
Please take the levofloxacin for 10 more days.
Please follow up with Dr. [**Last Name (STitle) 1968**]. in his clinic on [**2-18**].
If you have more difficulty breathing, lightheadedness, fever,
chills, or nightsweats - please return to the hospital or call
Dr.[**Name (NI) 11632**] clinic.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2111-2-18**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2111-3-31**] 3:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 540**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2111-2-17**] 4:00
Completed by:[**2111-2-9**]
|
[
"427.31",
"250.00",
"593.9",
"205.11",
"482.84"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10676, 10682
|
7012, 8822
|
311, 319
|
10908, 10965
|
3420, 6989
|
11305, 11786
|
2414, 2467
|
9180, 10653
|
10703, 10887
|
8848, 9157
|
10989, 11282
|
2482, 3401
|
242, 273
|
347, 1595
|
1617, 2227
|
2243, 2398
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,259
| 145,035
|
7405
|
Discharge summary
|
report
|
Admission Date: [**2110-5-6**] Discharge Date: [**2110-5-12**]
Date of Birth: [**2026-12-30**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Cefazolin / Aminophylline
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal Pain and Diarrhea
Major Surgical or Invasive Procedure:
[**2110-5-7**] - Flexible sigmoidoscopy
History of Present Illness:
Pt is 83 y/o F with h/o severe peripheral [**Month/Day/Year 1106**] disease s/p
multiple [**Month/Day/Year 1106**] surgeries who presents with complaints of abd
pain and diarrhea over the past few days. Pt has had multiple
episodes of dark black diarrhea. She states that she has had
bloody bowel movements due to hemorrhoids and rectal
prolapse over the past year. Her hct at OSH was 27.2. The abd
pain is sharp and diffuse and has continued to worsen. Pt's
symptoms are associated with dry heaves. Pt also has felt more
short of breath over today and feels that her lungs are wet. Pt
denies fevers or chills, lightheadedness, or dizziness. No
chest pain or cough. No dysuria or hematuria.
Pt states that she had recent admission at OSH for worsening
dyspnea and was recently discharged to rehab.
Past Medical History:
1) Peripheral [**Month/Day/Year 1106**] disease
2) left axillary profunda bypass and left axillary to mid cross-
femoral bypass
3) Thrombectomies of left ax-fem bypass graft, fem-fem bypass
graft, right fem-peroneal bypass graft
4) left axillary-femoral graft to distal profunda femoris artery
bypass
5) Left common femoral thrombectomy, left axillary bifemoral
bypass with 8 mm PTFE graft
6) thrombectomy of left iliofemoral graft, left iliac artery,
and
left profunda artery
7) left iliofemoral bypass
8) aortic insufficiency
9) ischemic cardiomyopathy
10) congestive heart failure
11) HTN
12) DM2 diet controlled
13) coronary artery disease s/p remote CABG and MI
[**15**]) hypothyroidism on no supplement at this time
15) hysterectomy
Social History:
She denies alcohol, drug or tobacco use
Family History:
Noncontributory
Physical Exam:
On Admission
T 98 P 84 BP 103/49 R 18 SaO2 94% 2 L nc
Gen: uncomfortable appearing
Heent: an-icteric
neck: supple
Lungs: coarse with scattered crackles
Heart: RRR
Abd: soft, nondistended, diffuse tenderness, most severe in RLQ,
pt has rebound tenderness, nonrigid
Rectal: no masses; guaiac negative
Extrem: palpable right femoral pulse, right DP/PT with
dopplerable signals, pt had clean right heal ulcer; left femoral
pulse weakly palpable, left BKA stump healing well
Pertinent Results:
[**2110-5-6**] 10:41PM BLOOD WBC-10.9 RBC-3.56* Hgb-10.4* Hct-32.0*
MCV-90 MCH-29.3 MCHC-32.7 RDW-17.9* Plt Ct-235#
[**2110-5-7**] 02:13AM BLOOD WBC-9.1 RBC-3.32* Hgb-9.7* Hct-29.8*
MCV-90 MCH-29.3 MCHC-32.6 RDW-18.2* Plt Ct-212
[**2110-5-7**] 09:24AM BLOOD Hct-32.0*
[**2110-5-7**] 02:53PM BLOOD Hct-31.2*
[**2110-5-7**] 09:09PM BLOOD Hct-27.9*
[**2110-5-8**] 03:12AM BLOOD WBC-12.9* RBC-2.98* Hgb-8.9* Hct-27.0*
MCV-91 MCH-29.9 MCHC-32.9 RDW-17.9* Plt Ct-204
[**2110-5-8**] 02:20PM BLOOD Hct-33.3*
[**2110-5-9**] 07:03AM BLOOD WBC-8.3 RBC-3.48* Hgb-10.3* Hct-31.0*
MCV-89 MCH-29.7 MCHC-33.3 RDW-18.4* Plt Ct-205
[**2110-5-11**] 04:15AM BLOOD WBC-8.4 RBC-3.51* Hgb-10.5* Hct-30.9*
MCV-88 MCH-29.9 MCHC-33.9 RDW-17.6* Plt Ct-197
[**2110-5-12**] 03:59AM BLOOD WBC-8.9 RBC-3.35* Hgb-10.1* Hct-30.2*
MCV-90 MCH-30.1 MCHC-33.4 RDW-18.4* Plt Ct-209
[**2110-5-7**] Sigmoidoscopy Impression: Diverticulosis of the sigmoid
colon.
Normal mucosa in the entire examined colon up to transverse.
Otherwise normal sigmoidoscopy to mid transverse.
Brief Hospital Course:
Pt admitted to the [**Month/Day/Year 1106**] surgery service on [**2110-5-6**] for
abdominal pain and dark stool. HCT on admission was 32.0. HCT
was monitored on a daily basis. On [**5-7**] a flexible sigmoidoscopy
was done whcih showed no eveidence of bowel ischemis. Empiric PO
Vanc and Flagyl were started for coverage for D.Diff whcih was
eventually negative and ABX were discontinued prior to
discharge. ASA and Plavix were temporarily held during admission
and pt was started on SC Heparin. The pt did recieve 1 unit of
PRBC on [**5-8**] for a HCT of 27 whcih rose to 33.3. HCT remained
stable and was 30.2 on the day of discharge. Pt had an otherwise
uncomplicated hospital course and was discharged back to rehab
on [**5-12**]. Services consulted during her admission include
gastroenterology, wound care, and cardiology.
Wound Care Recommendations:
Recommendations: Instructed patient that she needs a new eval
prior to wearing
her prosthesis. Pressure relief per pressure ulcer guidelines.
Support surface Atmos Air mattress. Turn and reposition every
1-2 hours and prn. Heels off bed surface at all times,waffle
boot to(R)LE. If OOB, limit sit time ,encourage patient to
change her position and use a foam cushion.
Moisturize LE and foot [**Hospital1 **],as well (L) stump. Commercial wound
cleanser to cleanse open wound. Pat the tissue dry with dry
gauze. Apply Santyl to ulcer above the patella. Cover with 2 x 2
Secure with Medipore tape. Change dressing 1 x a day
Medications on Admission:
Chlorpropamide 100 mg daily
Plavix 75 mg daily
Fluticasone 110 mcg 2 puffs [**Hospital1 **]
lasix 160 mg qAM
isosorbide dinitrate 30 mg tid
lisinopril 5 mg daily
metolazone 2.5 mg qweek
metoprolol 25 mg tid
nitro sl prn
potassium chloride 20 mEq [**Hospital1 **]
simvastatin 20 mg daily
aspirin 325 mg daily
ferrous sulfate 325 mg daily
Discharge Medications:
1. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO BID
(2 times a day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Chlorpropamide 100 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
9. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
15. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Abdominal Pain and Diarrhea
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please call the office of Dr.[**Last Name (STitle) **] ([**Last Name (STitle) 1106**] surgery) at
([**Telephone/Fax (1) 18181**] to schedule a follow-up appointment.
Provider: [**First Name11 (Name Pattern1) 5557**] [**Last Name (NamePattern4) 20012**], MD Phone:[**Telephone/Fax (1) 9347**]
Date/Time:[**2110-5-23**] 11:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2110-6-19**]
10:45
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2110-6-19**] 11:15
|
[
"458.9",
"414.8",
"562.10",
"414.01",
"578.9",
"V49.75",
"412",
"440.20",
"250.00",
"787.91",
"789.03",
"707.14",
"276.2",
"707.11",
"428.0",
"414.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
6929, 6995
|
3638, 4475
|
336, 378
|
7067, 7074
|
2580, 3615
|
8441, 9067
|
2052, 2070
|
5515, 6906
|
7016, 7046
|
5153, 5492
|
4497, 5127
|
7098, 8418
|
2085, 2561
|
269, 298
|
406, 1215
|
1237, 1978
|
1994, 2036
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,119
| 106,372
|
50727
|
Discharge summary
|
report
|
Admission Date: [**2174-9-15**] Discharge Date: [**2174-9-29**]
Date of Birth: [**2099-1-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Allopurinol / Levaquin /
Keflex / Zosyn / tamsulosin / Tipranavir / Probenecid / Ambien
Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75yo F PMHx ESRD s/p LR Renal tx, w multiple recent admissions
[**Date range (1) 105532**] E. coli UTI and bacteremia, AMS [**Date range (1) 16006**], AMS
discharged [**9-1**] for UTI w AMS re-presents w persistent fatigue
since previous discharge and AMS x 2d. Per patient's family, pt
has been disoriented and displaying erratic behavior; no
associated fever/chills/dysuria, N/V/D, chest pain, cough, HA.
Family brought her to ED for further evaluation. She completed
a course of cefpodoxime on [**9-7**]
Of note patient has a hsitory of resistant hypertension with
blood pressures at baseline in the 180s despite
multi-antihypertensives. On recent admission her BP was elevated
at 200s during her admission, and was 150-190s at the time of
discharge.
In ED, initial vital signs were 98.3 64 187/72 16 97%RA. Labs
notable for WBC 15.1 (N83), Hct 31 (baseline), Cr 4.3 (baseline
high 2s, low 3s), lactate 1.0, Trop .04, UA <1wbc, few bacteria.
Patient had unremarkable CXR, transplant kidney u/s grossly
unchanged. Her blood pressure went up to 230s and was staying
in the 200s despite getting her home medications. She received
.2mg clonidine, 20 furosedmide,100mg hydralazine and 100mg of
labetalol at 10pm. She made urine but the volume was not
recorded. Given that her blood pressures were still elevated in
the 200s she was started on a labetalol drip and transferred to
the MICU. At the time of transfer her sBP was 186.
On arrival to the MICU she was on the labetalol drip at 2mg/min
with a BP of 170/110 and she was A+ox3 and aware of why she was
in the hospital. She had no complaints specifically no headache,
blurred vision, abd pain n/v.
Review of systems:
She denies any dysuira, fevers, chills, changes in urine output
or abdominal pain. She denies headache, changes in vision,
dizziness. She denies any recent falls or unsteadyness on her
feet. Denies any changes in bowel mvoements or hematochezia.
Past Medical History:
s/p LR Renal Tx [**2160**] secondary to Chronic recurrent UTIs,
analgesic nephropathy and nephrocalcinosis
HTN - uncontrolled
Isolated Seizure episode - thought to be secondary to Zosyn
administration
Anemia of Chronic Disease
Thrombocytopenia
Diverticulosis and Dieulafoy Lesions
Osteoporosis
Squamous Cell Cancer s/p Mohs
Lower back pain due to lumar spinal stenosis
Herpes Encephalitis
Hyperlipidemia
Hypothyroidism
h/o TIA
Peptic ulcer disease
Chronic Tophaceous Gout
h/o right rectus sheath hematoma
s/p cataract surgery
h/o colonic polyps
Social History:
She is married and lives with her husband. Retired [**Name2 (NI) **]. They
winter in [**State 108**], and she enjoys golfing. Remote history of
smoking tobacco- quit 40 yrs ago, smoked x20yrs. Old outside
hospital records indicate prior ETOH use, though she denies any
current use.
Family History:
Mother died from melanoma. No h/o colon cancer in family.
Physical Exam:
ADMISSION EXAM
Vitals: 98.7, 170/110, 68, 13 98RA
General: Alert, somulent nodding off, ill and cachectic but in
NAD.
HEENT: Sclera cloudy yellow. Ptosis bilaterally, MMM, oropharynx
clear with own dentition in place, unable to cooperate with EOM
exam
Neck: supple, JVP elevated to earlobe while at 15deg recumbency
no LAD
CV: Regular rate and rhythm, normal S1 + S2,systolic murmur,
rubs, gallops
Lungs: Faint crackles bilaterally throughout
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, dusky and echomotic on circumfrential lower
extremities and lower arms bilaterally. One sore on mid back.
2+DP/PT pulses bilaterally. No peripheral edema.
Neuro: CNII-XII intact, movign all extremities without problems,
following commands. Tremulous with astreixis when attempting
sustained grip
Discharge Exam:
Vitals; T-97.6 BP-155/85 HR-70 RR-20 O2-97%RA
PE: Gen: No acute distress. Laying in bed with covers pulled
around her.
HEENT: MMM. EOMI. NCAT
Neck: Supple. No JVD
CV: RRR. NS1&S2. 3/6 SEM heard best at LUSB.
Resp: Poor inspiratory effort. b/l crackles consistent with
atelectasisGI: BS+4. Soft. Non-tender. Non-distended. no
organomegaly
Ext: 2+ pitting edema. Dark, dusky skin on all extremities.
Pertinent Results:
ADMISSION LABS
[**2174-9-15**] 03:10PM PT-11.0 PTT-41.7* INR(PT)-1.0
[**2174-9-15**] 03:10PM PLT COUNT-194
[**2174-9-15**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2174-9-15**] 03:10PM NEUTS-83* BANDS-1 LYMPHS-7* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2174-9-15**] 03:10PM WBC-15.1*# RBC-3.26* HGB-9.8* HCT-31.0*
MCV-95 MCH-30.2 MCHC-31.7 RDW-13.9
[**2174-9-15**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2174-9-15**] 03:10PM ALBUMIN-3.8
[**2174-9-15**] 03:10PM CK-MB-2 cTropnT-0.04*
[**2174-9-15**] 03:10PM ALT(SGPT)-39 AST(SGOT)-41* CK(CPK)-20* ALK
PHOS-125* TOT BILI-0.8
[**2174-9-15**] 03:10PM estGFR-Using this
[**2174-9-15**] 03:10PM GLUCOSE-112* UREA N-97* CREAT-4.3*#
SODIUM-137 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-18* ANION GAP-17
[**2174-9-15**] 03:20PM LACTATE-1.0
[**2174-9-15**] 03:20PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2174-9-15**] 05:00PM URINE MUCOUS-RARE
[**2174-9-15**] 05:00PM URINE HYALINE-1*
[**2174-9-15**] 05:00PM URINE RBC-2 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2174-9-15**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2174-9-15**] 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.009
[**2174-9-15**] 05:00PM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2174-9-15**] 05:00PM URINE HOURS-RANDOM UREA N-467 CREAT-45
SODIUM-33 POTASSIUM-31 CHLORIDE-31
Urine lytes [**2174-9-15**]: UreaN:467 Creat:45 Na:33 K:31 Cl:31
FeUrea calculated at 46%
.
U/A [**9-15**]: Yellow Hazy 1.009 pH 5.5 UrobilNeg BiliNeg LeukNeg
BldNeg NitrNeg Prot100 GluNeg KetNeg RBC2 WBC<1 BactFew
YeastNone Epi<1
.
Discharge Labs:
[**2174-9-28**] 05:58AM BLOOD WBC-10.9 RBC-2.17* Hgb-6.5* Hct-20.6*
MCV-95 MCH-30.1 MCHC-31.8 RDW-14.6 Plt Ct-181
[**2174-9-28**] 05:58AM BLOOD Neuts-72.4* Lymphs-19.7 Monos-4.4 Eos-3.2
Baso-0.3
[**2174-9-28**] 05:58AM BLOOD PT-11.5 PTT-33.3 INR(PT)-1.1
[**2174-9-28**] 05:58AM BLOOD Glucose-99 UreaN-42* Creat-2.8* Na-141
K-4.1 Cl-106 HCO3-27 AnGap-12
[**2174-9-28**] 05:58AM BLOOD ALT-26 AST-17 AlkPhos-92 TotBili-0.7
[**2174-9-28**] 05:58AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.3
[**2174-9-23**] 02:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2174-9-22**] 11:56AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
.
Pertinent Labs:
[**2174-9-22**] 02:27AM BLOOD CK-MB-1 cTropnT-0.04*
[**2174-9-21**] 05:45PM BLOOD CK-MB-1 cTropnT-0.04*
[**2174-9-16**] 01:32AM BLOOD cTropnT-0.04*
[**2174-9-15**] 03:10PM BLOOD CK-MB-2 cTropnT-0.04*
[**2174-9-22**] 11:56AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
[**2174-9-23**] 02:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2174-9-23**] 02:46PM BLOOD HCV Ab-NEGATIVE
.
PPD: Negative
.
Micro:
[**2174-9-27**] Blood Culture, Routine-PENDING INPATIENT
[**2174-9-27**] Blood Culture, Routine-PENDING INPATIENT
[**2174-9-26**] URINE CULTURE-Neg
[**2174-9-22**] URINE CULTURE-Neg
[**2174-9-22**] Blood Culture, Routine-Neg
[**2174-9-22**] Blood Culture, Routine-Neg
[**2174-9-21**] Blood Culture, Routine-Neg
[**2174-9-16**] URINE CULTURE-Neg
[**2174-9-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2174-9-15**] URINE CULTURE-FINAL ESBL {ESCHERICHIA COLI}
[**2174-9-15**] Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **]
[**2174-9-15**] Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **]
.
Images:
Head CT [**2174-9-15**] - no infarct nor intracranial hemorrhage
RUQ U/S [**2174-9-16**]- Unremarkable appearance of the liver and
gallbladder. No biliary dilatation. No hydronephrosis seen in
the transplanted kidney. Elevated resistive indices again noted
as were reported on the prior transplant kidney ultrasound.
R shoulder XR [**2174-9-17**]: There is some AC joint arthropathy. This
is stable since the [**2171-6-6**] study. The glenohumeral
joint is within normal limits. There are some cystic changes at
the humeral head. There is also degenerative change of the
glenohumeral joint with spurring anteriorly, new since [**2171**]
study. The visualized right lung apex is clear. No acute bony
injury is noted
KUB Portable [**2174-9-18**]: Nonspecific bowel gas pattern. No findings
to suggest ileus or obstruction. Limited assessment for free
air.
Status post laminectomy and fusion at L4-5, with findings
suggestive of
hardware loosening. Clinical correlation is requested.
CXR portable [**2174-9-22**]: In comparison with the study of [**9-21**],
cardiac silhouette is within normal limits and there is no
definite pulmonary vascular congestion. Hazy opacification at
the bases, more prominent on the right, suggests small pleural
effusions with compressive atelectasis. No discrete pneumonia
is appreciated. Central catheter tip again extends to the
mid-to-lower portion of the SVC.
EKG [**2174-9-23**]: Sinus rhythm. Within normal limits. Compared to the
previous tracing of [**2174-9-22**]
no interval change.
U/S RUE [**2174-9-27**]:
Brief Hospital Course:
75 year old female with a past medical history of end stage
renal disease and transplant with chronic kidney disease and
resistant hypertension with baseline blood pressure in the 180s
who presented for altered mental status to the ED and developed
hypertensive urgency with blood pressures in the 200s requiring
labetalol drip for control. Admitted to the ICU for management
of her blood pressure. Diagnosed with ESBL E.coli UTI in ED and
started on IV meropenem. Transferred to floor after BP
stabilized. Pt became very lethargic and hypotensive on floor,
and transferred back to MICU. Started HD and improved. Some AMS
after transfer back to the floor, but clear on discharge.
.
Active Issues:
#Hypertensive urgency - Patient has baseline resistant
hypertension with SBPs often in the 180s. Per patient, she
manages all of her medications herself, however, was missing her
clonidine patch per ED. Her hypertension could have been due to
missing medications. There was concern that her altered mental
status was related, however no evidence on CT head of
hemorrhage. Her renal function was also worsening, concerning
for decreased perfusion to the kidneys leading to acute on
chronic renal failure however a renal ultrasound of her
transplanted kidney was normal. Given her worsening renal
function, losartan was held in the MICU. She responded well to
the labetalol, and her systolic blood pressure remained stable
in the 150s-180s, which seems to be her baseline. She was
transferred to the general medicine service once her blood
pressure stabilized. Unfortunately, as her home meds were
restarted by the general medicine team, she developed relative
hypotension to the 130s and altered mental status. She was
transferred back to the MICU, where her home verapamil and
clonidine were withheld and she was bolused with IVF. Low-dose
verapamil and clonidine patch were slowly reintroduced, and SBP
was again stabilized. Transferred back to the floor. SBP ranged
between 120's-170's on floor.
.
#Altered mental status - There was concern that the patient was
not acting like herself at home. She has a history of AMS in the
setting of UTI and with her recent hospitalization for UTI.
Initial concern for underlying infection. Her urine was found to
have a resistant strain of E.Coli. Meropenem was started and AMS
began to clear. After transfer to the floor she was oriented x3.
AMS developed again on the floor and pt became relatively
hypotensive. See above. Antibiotics were then broadened include
vancomycin in the MICU due to concern that her AMS represented a
worsening or new infection. She was pancultured, which found no
infection. Both meropenem and vancomycin were d/c'ed as they
were thought to be contributing to confusion. After being
transferred back to the floor, she was again pan-cultured and
fever/WBC were trended. She had no signs/symptoms of active
infection, so PICC line was pulled. Thought that AMS likely
secondary to uremia. After hemodialysis, patient lethargy and
disorientation improved dramatically. AMS may have also had a
component of ICU delirium. At time of discharge she was alert,
responsive, and oriented x3.
.
#ESBL E. coli UTI: See above. History of multiple UTIs in the
past requiring hospital admission. Found to have ESBL E. coli
UTI on this admission. Started on 14 day course of IV meropenem,
but only received 8 days total. Thought that abx may be
contributing to AMS. She was recultured multiple times with no
growth. Her PICC line was discontinued on day of discharge. ID
was consulted for prophylactic therapy and recommended that she
not have prophylaxis at this time, and recommend urology
follow-up. She had no fever or leukocytosis.
.
#Diarrhea: Pt developed watery diarrhea on day of discharge. C.
diff pending.
.
Chronic Issues:
#Acute on chronic renal failure s/p transplant - She has chronic
kidney disease with a baseline creatinine of ~3.1 over the past
few months. Repeat renal ultra sound in the ED was
unremarkable. This acute worsening of renal function could be
due to hypertension. Urine lytes with FeUrea of 46% which is not
clearly prerenal or ATN. During her MICU stay a foley was placed
monitored urine output, we renally dosed medications, creatinine
was trended daily, renal transplant was consulted, her
immunosuppresive agents prednisone and cyclosporine were
continued. The renal transplant team felt that her [**Last Name (un) **] may be a
result of [**Last Name (un) **] failure. The hope was to prolong time to
hemodialysis, and undergo AV [**Last Name (un) **]. However, her delirious state
on the floor, compunded with hyperkalemia prompted initiation of
HD via tunneled HD catheter. Her AMS improved quite dramatically
and Cr trended down to ~2. Her HD schedule is MWF. Transplant
surgery has completed the work-up for AV [**Last Name (un) **]. They will
contact the rehab facility with time and date for surgery
.
#Hx Gout/foot pain: Currently pain free. Extensive h/o gouty
flares and allergic to allopurinol. After discussion with
pharmacy, decided to restart low dose uloric at 20mg daily.
.
# Hypothyroidism - This is a chronic issue. Her thyroid function
tests were checked and she was continued on her home
levothyroxine.
.
#Anemia of chronic disease- Her hematocrit was higher on
admission than her previous discharge hematocrit at 31.0, given
that all of her hematologic cell lines are elevated she was
likely hemoconcentrated at admission. She remained stbale during
this admission with hct ~27-30%
.
#H/o seizure disorder: On Keppra. In setting of zosyn use
previous seizure ,and then again at OSH earlier in [**Month (only) 205**] when
received another dose of zosyn. Was followed by neurology on
previous admission who recommended continuing keppra and will
follow-up with them.
.
#H/o GI bleed: No GIB during this admission. On protonix 40mg
qday
.
TRANSITIONAL ISSUES:
- Was very obstinate to care (refused any blood draws or
medications multiple times), per transplant this is her pattern
when infected.
- outpatient ID for consideration of suppressive therapy for
recurrent UTIs
- Hemodialysis MWF
- Will be called Re: Surgery appt for AV [**Month (only) **]
- F/u C. diff
- Please continue uloric in this pt with extensive h/o gout
- downtrending HCT, check CBC tomorrow, may continue to monitor
twice weekly until ensure stability
- h/ multiple UTI's. No ppx recommended
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. CloniDINE 0.2 mg PO BID
hold for sbp<100 or hr<60
5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
hold for sbp<100 or hr<60
6. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
7. Febuxostat 40 mg PO DAILY
8. HydrALAzine 100 mg PO TID
hold for sbp<100 or hr<60
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
hold for sbp<100 or hr<60
11. PredniSONE 5 mg PO EVERY OTHER DAY
12. Propranolol 120 mg PO BID
hold for sbp<100 or hr<60
13. Sodium Bicarbonate 1300 mg PO TID
14. Verapamil 120 mg PO Q8H
hold for sbp<100 or hr<60
15. LeVETiracetam 500 mg PO BID
16. Acetaminophen-Caff-Butalbital Dose is Unknown PO BID:PRN
headache
17. Mirtazapine 15 mg PO HS
18. Furosemide 20 mg PO PRN edema
19. Proparacaine HCl 0.5% Opth. 1 DROP BOTH EYES Q 8H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CloniDINE 0.2 mg PO TID
Hold for SBP <120 mmHg
3. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
4. Febuxostat 20 mg PO DAILY
5. HydrALAzine 100 mg PO TID
hold for sbp<100 or hr<60
6. LeVETiracetam 500 mg PO BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. PredniSONE 5 mg PO EVERY OTHER DAY
9. Proparacaine HCl 0.5% Opth. 1 DROP BOTH EYES Q 8H
10. Verapamil 20 mg PO Q8H
hold for sbp<140 or hr<60
11. Propranolol 120 mg PO BID
hold for sbp<100 or hr<60
12. Bengay 1 Appl TP [**Hospital1 **]:PRN back muscle pain
13. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
apply to back
14. Nephrocaps 1 CAP PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Calcitriol 0.25 mcg PO EVERY OTHER DAY
17. Atorvastatin 20 mg PO DAILY
18. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
hold for sbp<100 or hr<60
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary diagnosis:
End stage renal disease
E.coli urinary tract infection
Altered mental status
Resistant hypertension
hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted
because you were confused and had very high blood pressure. You
were admitted to the intensive care unit and started on
medication through your veins to bring your blood pressure down.
Once it was down you were transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
service and your home blood pressure medications were slowly
added back. Your blood pressure dropped too low on this service
and you were transferred back to the intensive care unit. Your
blood pressure medications were added back slowly, and you came
back to [**Doctor Last Name 3271**] [**Doctor Last Name 679**]. Here your blood pressure remained stable
and you were discharged. On most of your home BP medications.
Because your kidney function is not as good as it should be,
your furosemide and losartan were stopped. Please stop taking
these medications for now. They may need to be added back on at
a later date depending on your BP.
You had another infection of your urinary tract on this
admission. You were started on antibiotics through your veins,
but was stopped because the antbiotics might have been making
you confused. You do not currently have an infection, but let
your doctor know if you have any burning, difficulty urinating,
or worsening confusion.
Your kidney function was decreased at time of admission. We
thought this might be causing some confusion for you. You were
started on hemodialysis, and your confusion got better. You will
need hemodialysis on Monday, Wednesday, and Friday. You will be
scheduled with surgery to implant a [**Last Name (LF) **], [**First Name3 (LF) **] that you won't
need a HD catheter. They will call you with this appointment.
Medications to CHANGE:
Clonidine 0.2mg twice a day to 0.2mg three times a day
Verapamil 120mg three times a day to 20mg three times a day
Uloric 40mg daily to 20mg daily
Cyclosporine 100mg twice a day to 75mg twice a day
Medications to START:
Pantoprazole 40mg daily
Nephrocaps daily
Bengay apply to back daily
lidocaine patch apply to back daily
Medications to STOP:
STOP losartan
STOP furosemide
STOP sodium bicarbonate
STOP butalbital
STOP mirtazipine
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2174-12-19**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD [**Telephone/Fax (1) 2928**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
****We realize you have dialysis on this day but the appt is
earlier in the morning in hopes that you could go before your
dialysis. If this appt still does not work for you, please feel
free to call the office to reschedule.
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2174-10-12**] at 4:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2174-11-8**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Transplant
Name: Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]
When: Dr. [**Last Name (STitle) 105535**] office is working on a follow up appointment
for you in [**5-22**] days after your hospital discharge. You will be
called with the appointment date and time. If you have not heard
from the office in 2 business days please call the number listed
below.
Location: [**Hospital1 **]
Address: [**Doctor First Name **], 7TH FL, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 673**]
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]
|
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45,885
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39989
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Discharge summary
|
report
|
Admission Date: [**2144-5-25**] Discharge Date: [**2144-6-3**]
Date of Birth: [**2095-1-9**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
Exploratory laparotomy, small bowel resection, end-ileostomy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 49 year old male who complains of
FEVER/ABD PAIN.
49M with hx of T2DM and previous hx of unexplained
neutropenia who now presents with 3-4 days of fever and
chills with one day of right sided abdominal pain.
+ nausea, - Vomiting.
Pt with previous neutropenia that was possibly attributed to
his glipizide use, and subsequent BMBx was unrevealing. He
was hospitalized in [**Month (only) **] for neutropenia again, and this
was possibly attributed to ongoing cocaine use -- "Recently,
numerous case reports have related neutropenia and ANCA
positivity with cocaine mixed with an anti-helminthic [**Doctor Last Name 360**]
known as levamisole (a cutting [**Doctor Last Name 360**]).
The patient was reluctant to divulge his recent use, but
eventually admitted to
ongoing cocaine use over the past year at least. A serum
test
for levamisole was pending at discharge."
here w/ rigors, hypotensivge and abd pain- TRIGGER
Timing: Gradual
Quality: Dull
Duration: Hours
Past Medical History:
Type 2 diabetes-on oral medications
Chronic back pain-evidence of DJD
Status post tonsillectomy
Status post appendectomy
Recent admission in [**Month (only) **] for chin abscess/neutropenia
Microscopic hematuria with neg w/u
Social History:
The patient is married. Patient lives with his wife and his 12
year old son. [**Name (NI) **] currently takes care of his sister who is
ill. He works as an electrical engineer and travels to NH three
times weekly which is adding stress. Sister has a dog and a cat
but no scratches or bites recently. Drinks 0-1 drinks a week. No
tobacco history. He denied illicit drug use on admission, but
later admitted to recent and ongoing cocaine use during this
past year, with unclear details as to the duration of use.
Family History:
Sister with ALS
Dad with DM CVA MI
Mom with DM
Physical Exam:
PHYSICAL EXAMINATION
HR:132 BP:86/44 Resp:26 O(2)Sat:98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm- tachy
Abdominal: Soft, diffusely tender r>L no rebound.
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2144-5-31**] 05:38AM BLOOD WBC-11.2* RBC-4.35* Hgb-11.4* Hct-35.3*
MCV-81* MCH-26.2* MCHC-32.3 RDW-15.6* Plt Ct-70*
[**2144-5-30**] 04:59AM BLOOD WBC-9.6 RBC-4.49* Hgb-11.9* Hct-36.0*
MCV-80* MCH-26.4* MCHC-33.0 RDW-15.9* Plt Ct-90*
[**2144-5-29**] 05:20AM BLOOD WBC-12.5*# RBC-4.71# Hgb-12.5* Hct-38.0*
MCV-81* MCH-26.6* MCHC-33.0 RDW-15.4 Plt Ct-116*
[**2144-5-25**] 03:44PM BLOOD WBC-0.7* RBC-3.98* Hgb-10.7* Hct-30.6*
MCV-77* MCH-27.0 MCHC-35.1* RDW-15.0 Plt Ct-190
[**2144-5-25**] 05:12AM BLOOD WBC-0.9* RBC-4.00* Hgb-11.0* Hct-31.3*
MCV-78* MCH-27.5 MCHC-35.2* RDW-14.8 Plt Ct-247
[**2144-5-24**] 08:17PM BLOOD WBC-0.5*# RBC-3.86* Hgb-10.4* Hct-29.8*
MCV-77* MCH-27.0 MCHC-35.1* RDW-14.4 Plt Ct-281
[**2144-5-27**] 02:03AM BLOOD Neuts-48* Bands-6* Lymphs-23 Monos-17*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-5* NRBC-1*
[**2144-5-26**] 01:54AM BLOOD Neuts-11* Bands-20* Lymphs-48* Monos-10
Eos-0 Baso-0 Atyps-9* Metas-2* Myelos-0
[**2144-5-31**] 05:38AM BLOOD Plt Ct-70*
[**2144-5-30**] 04:59AM BLOOD Plt Smr-LOW Plt Ct-90*
[**2144-5-29**] 05:20AM BLOOD Plt Ct-116*
[**2144-5-27**] 02:03AM BLOOD PT-16.3* PTT-37.3* INR(PT)-1.4*
[**2144-5-26**] 01:54AM BLOOD Plt Smr-NORMAL Plt Ct-198
[**2144-6-3**] 06:15AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-135
K-3.8 Cl-98 HCO3-31 AnGap-10
[**2144-5-31**] 05:38AM BLOOD Glucose-204* UreaN-24* Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-31 AnGap-9
[**2144-5-30**] 04:59AM BLOOD Glucose-213* UreaN-29* Creat-1.0 Na-140
K-3.7 Cl-103 HCO3-32 AnGap-9
[**2144-5-24**] 08:17PM BLOOD Glucose-138* UreaN-32* Creat-1.7* Na-135
K-3.9 Cl-95* HCO3-26 AnGap-18
[**2144-5-27**] 02:03AM BLOOD ALT-69* AST-61* AlkPhos-40 TotBili-3.9*
DirBili-3.5* IndBili-0.4
[**2144-5-26**] 06:15AM BLOOD DirBili-3.5*
[**2144-5-26**] 06:15AM BLOOD DirBili-3.5*
[**2144-5-26**] 01:54AM BLOOD ALT-73* AST-54* LD(LDH)-162 AlkPhos-31*
TotBili-4.4* DirBili-3.6* IndBili-0.8
[**2144-5-24**] 08:17PM BLOOD ALT-22 AST-23 AlkPhos-46 TotBili-1.1
[**2144-5-25**] 05:12AM BLOOD CK-MB-3 cTropnT-<0.01
[**2144-6-3**] 06:15AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.7
[**2144-5-31**] 05:38AM BLOOD Calcium-7.5* Phos-3.3 Mg-1.9
[**2144-5-30**] 04:59AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1
[**2144-5-27**] 02:12AM BLOOD Lactate-2.2*
[**2144-5-25**] 03:20AM BLOOD Glucose-213* Lactate-2.9* Na-133* K-4.6
Cl-103
[**2144-5-26**] 03:24AM BLOOD freeCa-1.17
[**2144-5-25**] 09:05PM BLOOD freeCa-1.18
[**2144-5-24**]: x-ray of the abdomen:
IMPRESSION: Nonspecific bowel gas pattern, with a few mildly
dilated loops of
small bowel and small scattered air-fluid levels, which could
reflect
gastroenteritis or ileus. Early or partial obstruction cannot be
excluded and
could be further evaluated on CT as clinically warranted.
[**2144-5-24**]: chest x-ray:
IMPRESSION: Low lung volumes, but no focal consolidation. No
evidence of
free air beneath the diaphragm.
[**2144-5-25**]: Echo:
CLINICAL IMPLICATIONS:
The patient has moderate mitral regurgitation. Based on [**2139**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 1 year.
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2140**] 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.
[**2144-5-25**]: cat scan of the abdomen:
IMPRESSION: Findings concerning for distal ileal
inflammation,perforation,
and ischemia. Potential etiologies include neutropenic
enterocolitis, cocaine vasculopathy, and inflammatory bowel
disease.
[**2144-5-28**]: Echo:
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. Normal interatrial septum by
color doppler. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. No mitral regurgitation is seen. Tricuspid valve is
normal. No tricuspid regurgitation. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations demonstrated. Preserved
biventricular systolic function. Normal cardiac valves.
[**2144-5-29**]: x-ray of the abdomen:
Stacked dilated loops of small bowel with distal air seen in the
colon and
rectum may be postoperative ileus but concerning for partial or
evolving
small-bowel obstruction is also considered. Followup radiographs
should be
considered as clinically indicated.
[**2144-5-29**]: chest x-ray:
IMPRESSION: Bilateral subsegmental atelectasis. Small left
effusion.
Minimal right pleural effusion. Increased density at the left
lung base
consistent with worsening atelectasis or consolidation.
Brief Hospital Course:
49 year old gentleman admitted to the acute care service with
abdominal pain and fever. Upon admission, he was found to be
hypotensive, tachycardic and neutropenic. He was admitted to
the intensive care unit where he required pressor support to
maintain his blood pressure. He was made NPO, given intravenous
fluids antibiotics, and had imaging studies of his abdomen which
were concerning for a perforation of his ileum. Infectious
disease was consulted and made recommendations regarding his
managment.
He was emergently taken to the operating room where he was
found to have a perforated terminal ileum. He underwent an
exploratory laparotomy, lysis of adhesions, distal ileum
resection, ileostomy, and [**Doctor Last Name 3379**] pouch. He also had placment
of a right sided abdominal drain. His operative course was
stable with a 500cc blood loss. He required blood products
,crystalloid, and pressors for maintainence of his blood
pressure. He was transported to the intensive care unit after
his surgery for monitoring where he was hypotensive and
tachycardic. He underwent a bedside Echo which showed
hypokinesis. He also had blood cultures drawn which showed
GPR's and recommendations were made for vancomycin, meropenum,
and micafungin.
His vital signs stablized, pressors weaned off, and he was
successfully extubated on POD #1. His post-operative pain was
managed with dilaudid PCA. His micafungin was discontinued on
POD #1 and his vancomycin discontinued on POD #2, meropenum on
POD #6.
He was transferred to the surgical floor on POD # 2. He did
continue to have episodes of tachycardia and underwent a TEE
which showed no valvular vegatation and an LVEF >55%.
Infectious disease continued to monitor his progress. The
abdominal drain was discontinued on POD# 3. The ostomy nurse
was consulted and provided care and supervison in the management
of his ostomy. Because of his deconditioning, physical and
occupational therapy were consulted and evaluated his physical
status for discharge. He was started on clear liquids with
advancement to a regular diet.
His vital signs are stable and he is afebrile. His white blood
cell count is 10. He has been ambulating in the [**Doctor Last Name **] with
assistance. He is tolerating a regular diet and is voiding
without difficulty. His ostomy was draining a large amount of
watery stool, but now slightly formed stool. He has not resumed
his daily home dose of insulin because of his tenuous GI status
but his blood sugars have been closely monitored.
He is preparing for discharge home with VNA services. He will
follow-up in the acute care clinic in 2 weeks.
Medications on Admission:
[**Last Name (un) 1724**]: glargine 25 units QHS, Lispro, Vicodin prn, ASA 81, ferrous
sulfate 325'
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
4. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous daily: please monitor blood sugars and increase
dose to pre-hospital as per blood sugars.
5. insulin lispro 100 unit/mL Cartridge Sig: 2-30 units
Subcutaneous prior to meals: as per sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bowel ischemia
neutropenia
sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were cared for in our hospital for neutropenia and
enterocolitis requiring surgery. Your illness may have been
attributed to a unhealthy lifestyle. You have been advised to
alter your lifestyle to prevent a recurrence.
Our general surgery team performed surgery on you first with an
exploratory laporatomy. Part of your small bowel was removed
and an end-ileostomy was performed. You were monitored in the
intensive care unit after the procedure, requiring antibiotics.
Your clinical status has improved and you are now preparing for
discharge home with VNA assistance. Please follow these
instructions:
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.
*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 [**6-16**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Please notify us if you have an increase in your ostomy
drainage, any change in your ostomy.
Followup Instructions:
Please follow-up with the acute care service in 2 weeks. You
can schedule this appointment by calling # [**Telephone/Fax (1) 600**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2144-6-10**]
|
[
"E878.3",
"568.0",
"997.4",
"785.52",
"560.1",
"288.03",
"569.83",
"977.8",
"305.61",
"038.9",
"789.59",
"250.00",
"E849.7",
"557.0",
"995.92",
"E858.8",
"721.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"46.20",
"54.59",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11526, 11584
|
8078, 10735
|
322, 385
|
11662, 11662
|
2900, 5760
|
14091, 14363
|
2285, 2333
|
10887, 11503
|
11605, 11641
|
10761, 10864
|
11813, 13586
|
13602, 14068
|
2348, 2881
|
5783, 8053
|
261, 284
|
413, 1492
|
11677, 11789
|
1514, 1740
|
1756, 2269
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,119
| 156,152
|
48403
|
Discharge summary
|
report
|
Admission Date: [**2115-7-5**] Discharge Date: [**2115-7-12**]
Date of Birth: [**2032-3-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Septic Shock requiring intubation/pressors/icu stay
Major Surgical or Invasive Procedure:
Intubation - [**2115-7-5**]
Central line - [**2115-7-5**]
PICC Line - [**2115-7-12**]
DEBRIDEMENT AND BIOPSY OF OSTEOMYELITIS LESIONS
History of Present Illness:
83M history of hypertension, CAD, hyperthyroidism with resultant
hypothyroidism, depression, prior right basal ganglia bleed with
significant residual deficits including non-verbal at baseline
and suspected chronic aspiration and aspiration pneumonitis with
G-tube for severe malnutrition.
Patient is non-verbal at baseline so history was limited and
obtained from medical records and nursing home. Per EMS, it was
reported that he had increased shortness of breath. On EMS
arrival, initial pOx was 80% on RA. O2 sat en route was 85 % on
4 L NC and transitioned to CPAP for increasing respiratory
distress with pOx mid 90s. He was reported to have thick
purulent sputum with cough but no fevers. There were no other
localizing signs/symptoms of infection such as vomiting,
diarrhea, dark/bloody stools.
Of note, he was admitted from [**2115-5-20**] to [**2115-5-22**]. He was
brought in from nursing home for desats and displaced G-tube.
His hypoxemia was attributed to ? HCAP initially but he did not
complete an antibiotic course. Other causes were evaluated such
as volume overload. A prior ECHO performed on [**2-28**] showed only
mild regional left ventricular systolic dysfunction with
anterior and anteroseptal hypokinesis, EF 40-50 %. It was
overall thought that the most likely cause of his transient
hypoxemia was aspiration pneumonitis given rapid improvement (3L
O2 on admission --> weaned to room air by discharge). Hospital
course was complicated by hypernatremia from dehydration
In the ED, initial VS were: 09:56 98.4 107 96/58 38 94% biPAP.
He had pulse ox anywhere from 89-95 on biPAP. He was tachycardic
to 110s and tachypneic to 30s satting high 80s and mid-90s on
biPAP. At baseline, he can squeeze hand on command but unable to
follow commands currently.
He was emergently intubated with 7.0 tube, 25 cm at lip with
usage of etomidate 20 mg IV x 1 and succinylcholine 100 mg IV x
1. Intubation was not difficult. An OG tube was placed. A right
IJ CVL was placed under sterile technique (documentation
received from ER). He was noted to have thick purlent sputum
from ETT.
He was given vancomycin 1 gm IV, cefepime 2 gm IV, levofloxacin
500 mg IV.
Even before intubation, his blood pressure was SBP 60-80s. He
received 2L IVF. He was placed on dopamine and levophed, weaned
off dopamine, and now only on levophed at 0.08 mcg/kg/min with
resultant SBP 110s. Fentanyl and midazolam were used for
sedation.
ECG was performed that showed [**2115-7-5**] NSR 93, NI, NA except
slightly leftward axis. TWF I, aVR, V1, TWI in V5-V6. Compared
to prior dated [**2115-4-30**], no significant change.
Past Medical History:
-Hypothyroidism
-Depression
-Coronary artery disease
-History of depressed EF (40-45%)
-Hypertension
-s/p left total hip replacement [**2106**]
-s/p right inguinal hernia repair [**2112**]
-History of arthritis of hips/knees
-Cataracts
-History of right basal ganglia bleed
Social History:
Has been living at [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Care Facility in [**Location (un) 538**]
since stroke this year, prior was living in [**Location (un) 669**]. Wife died
in [**2111**]. Has 2 children. HCP is son, [**Name (NI) **] [**Name (NI) 101787**]
([**Telephone/Fax (1) 101927**])
Family History:
Non-contributory
Physical Exam:
Admission physical exam:
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition,
Endotracheal tube, OG tube
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Bowel sounds present, Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, bilateral foot ulcerations secondary to
pressure injury, pus expressed from left foot ulcer
Musculoskeletal: Muscle wasting, appears malnourished
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
DISCHARGE:
VS - 97.6 116/66 79 20 97 RA
GEN non-verbal at baseline, no acute distress, not repsonding to
commands
HEENT sclera anicteric
NECK supple, no JVD, no LAD
PULM poor air entry, dry ronchi ausculated bilaterally
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g, g-tube in
place, normal site
EXT WWP 2+ pulses palpable bilaterally, no c/c/e, rt foot toe
ulcerated; sites of osteo bandaged
NEURO unable to perform formal exam due to pt unresposniveness.
Pupils round and reactive. Pt not following commands.
SKIN no ulcers or lesions
Pertinent Results:
ADMIT LABS-
[**2115-7-5**] 10:40AM BLOOD WBC-13.6*# RBC-3.69* Hgb-9.3* Hct-31.4*
MCV-85 MCH-25.1* MCHC-29.5* RDW-20.7* Plt Ct-441*
[**2115-7-5**] 10:40AM BLOOD Neuts-83.9* Lymphs-13.9* Monos-1.1*
Eos-0.9 Baso-0.3
[**2115-7-5**] 10:40AM BLOOD Plt Ct-441*
[**2115-7-5**] 10:40AM BLOOD PT-12.3 PTT-51.2* INR(PT)-1.1
[**2115-7-5**] 10:40AM BLOOD cTropnT-0.14*
[**2115-7-5**] 11:58AM BLOOD Type-ART Tidal V-450 PEEP-5 FiO2-100
pO2-228* pCO2-54* pH-7.34* calTCO2-30 Base XS-2 AADO2-434 REQ
O2-75 -ASSIST/CON Intubat-INTUBATED
[**2115-7-5**] 11:28AM BLOOD Lactate-2.9*
RELEVENT LABS-
[**2115-7-5**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2115-7-5**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2115-7-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2115-7-5**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
EMERGENCY [**Hospital1 **]
08/17/2012BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY
[**Hospital1 **]
DISCHARGE LABS:
[**2115-7-11**] 04:34AM BLOOD WBC-9.9 RBC-3.12* Hgb-8.1* Hct-26.1*
MCV-84 MCH-26.0* MCHC-31.0 RDW-20.4* Plt Ct-276
[**2115-7-9**] 02:56AM BLOOD PT-14.9* PTT-44.9* INR(PT)-1.4*
[**2115-7-11**] 04:34AM BLOOD Glucose-98 UreaN-43* Creat-1.2 Na-139
K-4.0 Cl-101 HCO3-32 AnGap-10
[**2115-7-11**] 04:34AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0
Imaging:
CXR [**2115-7-5**]: IMPRESSION: Status post endotracheal intubation.
Substantial worsening of bilateral right mid lung opacities
worrisome for pneumonia.
TTE [**2115-7-7**]: There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic root is 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
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormalities. Dilated thoracic
aorta.
No abnormalities are seen within the distal phalanges of any of
the toes. There is no evidence of osteomyelitis.
MICRO:
[**2115-7-5**] 4:42 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2115-7-8**]**
GRAM STAIN (Final [**2115-7-5**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS SINGLY.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2115-7-8**]):
Commensal Respiratory 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.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
BETA STREPTOCOCCI, NOT GROUP A. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 2 I
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2115-7-8**] 7:02 am SWAB Site: FOOT Source: right foot
ulcer.
**FINAL REPORT [**2115-7-12**]**
GRAM STAIN (Final [**2115-7-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2115-7-11**]):
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 352-9118W [**2115-7-8**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2115-7-12**]): NO ANAEROBES ISOLATED.
/20/12 7:02 am SWAB Site: FOOT Source: left foot ulcer.
**FINAL REPORT [**2115-7-12**]**
GRAM STAIN (Final [**2115-7-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2115-7-11**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- =>320 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2115-7-12**]): NO ANAEROBES ISOLATED.
[**2115-7-10**] 1:51 pm TISSUE Site: BONE
Source: left 5th metatarsal bone.
GRAM STAIN (Final [**2115-7-10**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 352-9118W [**2115-7-8**].
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
This is an 83 year old male with a past medical history of
hypertension, coronary artery disease, hyperthyroidism with
resultant hypothyroidism, depression, prior right basal ganglia
bleed with significant residual deficits including non-verbal at
baseline and suspected chronic aspiration and aspiration
pneumonitis with G-tube for severe malnutrition presenting with
acute hypoxemic respiratory failure requiring intubation and
mechanical ventilation from underlying pneumonia. Course
significant for sepsis from aspiration penumonia and
osteomyelitis with transient pressor requirement, hypernatremia
from dehydration, and elevated troponin from likely demand
ischemia. Pt responded well to IV antibiotics and was dc-ed back
to rehab facility on 6 weeks of vanc/zosyn as grew out
MRSA/pseudomonas from foot osteo wound.
# Acute hypoxemic respiratory failure: Likely secondary to acute
aspiration event with resulting pneumonitis. He was intubated on
arrival to the MICU. Arterial blood gases were notable for a
chronic (compensated) primary respiratory acidosis.
# Septic shock: Likely from aspiration pneumonia although the
patient also has confirmed osteomyeltiis. was initially started
on iv vanc and cefepime and broadened to include falgyl. Patient
improved and was trasnferred to med floor. Podiatry performed
bedside debridement and biospy. Grew out MRSA/pseudomonas from
foot osteo wound. Was transitioned to vanc/zosyn at time of
discharge and will need a total 6 weeks of therapy.
# Chornic Aspirator: Patient is a chronic aspirator and has had
several recent admissions for this. His aspiration is likely a
result of neurologic dysfunction following his stroke in 1/[**2114**].
He had a speech and swallow evaluation in [**12/2114**] who felt that
it was unsafe for him to eat thus recommended placement of a
G-tube. He had his G tube converted to GJ tube with IR on [**5-21**]
to reduce risk of aspiration (no delayed gastric emptying) and
possibly also improve respiratory mechanics by
reducing gastric distention.
#Osteomyelitis- patient with bilateral osteomyeltiis. Podiatry
was able to probe to bone so clinically he meets criteria for
it. There wasconcern for possible decreased blood flow as the
cause as this started as blood blisters and is not clearly a
pressure sore leading to it. However, ABIs ordered were normal.
ID recs include ESR and CRP which are elevated to use in
treatment progress of osteomyelitis. Podiatry signed off after
performing bedisde biopsy and debridement and recommended
continued IV abx treatment as per ID. THe patient required
extensive wound care which will need to be continued as outpt.
Pt was not considered a surgical candidate to be taken to the
OR.
# Goals of care - Family had stated that full code to get back
to nursing home. However, were amenable to further discussion.
[**Name (NI) **] HCP familiar with end of life discussions but not in
the context of this patient. While the family was open to
discussion, it appeared that there had not been many prior
discussions so likely were not ready at present. However, may be
more agreeable if such discussions are continued particularly if
the patient gets acutely ill again. The family was informed that
the prognosis was very grim.
# Hypernatremia: Likely from dehydration from inadequate
hydration. Resolved 250cc q4 g-tube flushes.
# Acute renal failure -Baseline Cr 0.9 - 1.1 with admission Cr
1.4, improved to 1.2 with IVF. Likely pre-renal given exam
suggestive of hypovolemia and UA with hyaline casts.
# Normocytic, hypochromic anemia: No active signs/symptoms of
bleeding. Baseline is 29-32. Hct 26.1 at d/c. Could benefit from
iron studies, but this can be done as an outpatient
# Hypothyroidism ?????? TSH was elevated, levothyroxine was increased
to 125 from 100
# Depression - celexa 20 mg PO qD
# Hypertension - we halved metoprolol dose
# Severe protein-calorie malnutrition: Based on BMI < 18, Weight
< 90 % IBW, clinical signs of malnutrition, and albumin < 3. We
continued tube feeds per nutriton recs
TRANSITIONAL ISSUES:
- check TSH in stable condition as outpt
- Before pt's appointment with Dr [**Last Name (STitle) 26056**], please draw CBC and
BUN/Cr and fax these results to [**Telephone/Fax (1) 1419**] and cc to Dr [**Last Name (STitle) 26056**].
- Hospice care needs to be discussed again with pt's family. [**Month (only) 116**]
be more amenable as priorly didnt know pt's poor prognosis
- aggressive and regular wound care needed
- Pt will need zosyn and vanco for 6 weeks.
Medications on Admission:
[Reconciled from nursing home records]
- Jevity 1.2 cal at 65 mL/hour GT for 22 hours off from 8 AM-10
AM
with 180 cc free water flushes via tube every shift
- Protein powder 1 scoop GT [**Hospital1 **]
- Metoprolol tartrate 25 mg PO TID
- Levothyroxine 100 mcg PO qD
- Heparin 5000 SC units TID
- Celexa 20 mg GT qD
- Multivitamin
Discharge Medications:
1. protein supplement *NF* Oral [**Hospital1 **]
I SCOOP GT
2. Metoprolol Tartrate 12.5 mg PO TID
3. Multiple Vitamins Liq. 5 mL PO DAILY
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Heparin 5000 UNIT SC TID
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
7. Citalopram 20 mg PO DAILY
8. Piperacillin-Tazobactam 4.5 g IV Q8H
9. Vancomycin 750 mg IV Q 24H
PLease give dose in AM of [**2115-7-11**]; d1 [**7-5**]
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
SEPTIC SHOCK
respiratory failure requiring mechanical ventillation
staph aureus/pseudomonal pneumonia
ASPIRATION PNEUMONIA
acute OSTEOMYELITIS
S/P BASAL GANGLIAR BLEED
HYPERTENSION
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr [**Known lastname 101787**],
You were admitted to [**Hospital1 18**] with breathing difficulty and low
blood pressure and were found to have both a lung infection from
aspiration as well as chronic infection in the bones of your
feet. You were intubated and transferred to the intensive care
unit where you were started on antibiotics. You responded to the
the medications. The podiatry service was also invovled in
hleping clean your foot infection wounds. You were discharged
back to the rehab facility on intravenous antibiotics.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2115-7-23**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6756**], MD
Specialty: Primary Care
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
|
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[
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7,097
| 163,631
|
22918
|
Discharge summary
|
report
|
Admission Date: [**2139-2-17**] Discharge Date: [**2139-2-20**]
Date of Birth: [**2061-10-14**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Tape / Augmentin
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 yo manwith pmh sig for HTN, CAD s/p MI [**2121**], AV Pacer [**2136**],
PVD with Aortobifem [**7-/2138**], CHF, COPD, colitis with recent
prolonged hospitalization at OSH [**Date range (1) 18662**] for bacteremia
thought due to GI colitis source requiring planned hemicolectomy
who presented to OSH on [**2139-2-16**] with 2d constant sharp Band like
CP worse when supine not affected by exertion. At OSH CT with
possible contained aortic rupture, tx here for surgical eval.
Past Medical History:
HTN, CAD s/p MI [**2121**], AV Pacer [**2136**], PVD with Aortobifem [**7-/2138**],
CHF, COPD, colitis
Social History:
lives with wife
Physical Exam:
NAD
Horse voice, no stridor or accessory muscle use
No JVD
Cardiac: RRR, nl s1s2, 2/6 sem at aortic space
Lungs: clear
Abd: no pain
Ext: no edema, bka w/o wound
Pertinent Results:
CT CHEST W/O CONTRAST
Reason: Please evaluate for enlarging aortic pseudaneurysmPlease
do
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with aortic pseudaneurysm and pacer with
positive blood cultures
REASON FOR THIS EXAMINATION:
Please evaluate for enlarging aortic pseudaneurysmPlease do I
minus study
CONTRAINDICATIONS for IV CONTRAST: Please do without contrast
INDICATION: Aortic arch pseudoaneurysm. The patient with
positive blood cultures.
TECHNIQUE: Axial noncontrast CT imaging of the chest. Comparison
is made with CT of the chest performed on [**2139-2-16**].
CT OF THE CHEST WITHOUT CONTRAST: There is a large soft tissue
density consistent with a hematoma adjacent to the lateral
aspect of the aortic arch, which measures approximately 5.6 x
3.7 cm. On the prior examination of [**2139-2-16**] this periaortic
hematoma measured approximately 3.6 x 1.7 cm. There is apparent
disruption of calcification along the lateral contour of the
aorta that is new when compared to the prior examination of
[**2139-2-16**] seen best on (series 2, image 21). There is an
significantly increased size of a left-sided pleural effusion.
The pleural fluid on the left measures approximately 20
Hounsfield unit. A small left-sided pneumothorax was seen on the
prior examination with the left- sided pleural fluid measuring
approximately 40 Hounsfield units. A small right-sided pleural
effusion appears unchanged. Multiple calcified pleural plaques
are seen bilaterally. The heart is enlarged with a pacemaker in
place. The stomach is dilated and fluid fills the lower
esophagus. Likely atelectasis is present within the left lung
base. No pulmonary nodules are seen. No pericardial effusion is
seen.
In the visualized portions of the upper abdomen, a distended
stomach is seen. The spleen and visualized portion of the liver
are within normal limits. There are dense nephrograms seen
bilaterally. A stone versus retained contrast is seen within the
mid left kidney.
Bone windows show no suspicious lytic or sclerotic lesions.
IMPRESSION:
1) Increased size of a mediastinal hematoma adjacent to the
patient's known aortic arch pseudoaneurysm. This finding cannot
be further evaluated without IV contrast; however, however, this
suggests worsening of mediastinal hemorrhage.
2) Increased size of left-sided pleural effusion with associated
Hounsfield units of 20. This finding could represent a reactive
pleural effusion or subacute hemothorax given the presence of
blood within the pleural space on the prior CT of [**2139-2-16**].
3) Dense bilateral nephrograms presumably reflecting contrast
nephropathy in the absence of recent contrast administration.
4) Calcified pleural plaques are consistent with prior asbestos
exposure.
These findings were discussed with the clinical team responsible
for this patient's care at the time of interpretation.
Brief Hospital Course:
Pt was admitted to surgery found pseudoaneurysm/contained aortic
rupture at aortic arch, treated for low hct withtransfusion,
found to have high wbc and was cultured. As the lesion was not
suitable for surgery in this patient with multiple
co-morbidities, pt was transferred to the CCU team for medical
management. Treated for pseudoaneurysm with bp control, blood
cultures here with SA (MRSA in blood in past) tx with Linezolid
as "allergic" to Vancomycin. Concern for mycotic aneurysm v.
endocarditis, TTE negative, TEE planned for am. Pacer felt to be
unlikely source and considering CT abdomen with contrast once
renal function improves to evaluated possibility that bifem
graft is site of infection. Pt developed more horseness - ENT
consulted and found some paralysis of left vocal cord,
consistent with left recurrent laryngeal nerve compression
Repeat CT was obtained as this new horseness made the team
concerned for growth of pseudoaneurysm. This showed that the
previously observed hematoma adjacent to the aortic
pseudoaneurysm was increasing.
Confirmed with Dr. [**Last Name (STitle) **] of CT surgery that he is not
operative candidate. Pt developed hematemesis later in the
night and later expired.
Medications on Admission:
Linezolid from OSH
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2139-3-27**]
|
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[
[
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icd9pcs
|
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,753
| 160,746
|
29983
|
Discharge summary
|
report
|
Admission Date: [**2141-3-22**] Discharge Date: [**2141-3-28**]
Date of Birth: [**2103-7-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Sepsis, Right leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37 yo m with morbid obesity, DMII, s/p L BKA transferred for
sepsis from [**Hospital3 **]. He presented to MVH in the AM of
[**3-22**] after having had rigors and pain in his right leg. He was
hypotensive in the ED and thought to be septic. He also said
that "my kidneys are killing me" in the admission note there,
but here denies that he had any kidney pain or urniary problems.
[**Name (NI) **] was given 9 L NS, dopamine for 10 hours through a PIV in his
R anticubital vein, vancomycin, levaquin, and Lovenox for a
presumed PE. He was febrile in the morning of [**3-22**] and was
satting 93-96 on 4L NC. No RA sat recorded. His attending was
concerend for PE and MVH has no CT scanner, therefore he was
tranferred to [**Location (un) 86**].
Past Medical History:
1. DM II dx after amputation - on insulin
2. s/p BKA on left at [**Hospital 6136**] Hospital in [**9-6**] after severe
cellutis. CTX [**Last Name (un) 36**] klibesella was cultured.
3. Recurrent cellulitis of left leg after severe road rash from
a MVC in [**2129**].
4. HTN
5. Anemia
6. Morbid obesity (weight went from 200 -> 650 in 10 years, then
dropped to 450 with diet, then current weight after amputation)
7. Hyperlipidemia
8. neuropathy/phantom pain in L leg
Social History:
Worked in past as a taxi driver, cook. Now on SSDI, lives alone
on MV. Smokes 5 cig/day. No ETOH.
Family History:
Dad died of lung cancer. extensive FH of DM, CAD
Physical Exam:
Vitals: T 99 HR 90/min BP 124/76 O2 97% RA
Gen: well nourished patient in no apparent distress
HEENT: PERLAA, oropharynx clear
Neck: JVP difficult to visualise
Lung: CTAB, nl effort
Cor: RRR, nl s1+s2, no m/r/g
Abd: soft, non tender, nl bs,
Ext: L leg s/p BKA. well healed stump scar. entire R leg covered
with cellulits down to toes. 2 cm ulcer on the foot with
granulation tissue. large area of cellulitis in the inner
portion of the R thigh. Areas were marked.
Neuro: A&Ox3, nl mood and affect
Pertinent Results:
[**2141-3-22**] RIGHT FOOT WOUND SWAB: STAPH AUREUS COAG +, SPARSE
GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
.
[**2141-3-22**] URINE CX: KLEBSIELLA PNEUMONIAE. 10,000-100,000
ORGANISMS/ML.
.
[**2141-3-22**] CXR: Mild-to-moderate pulmonary edema.
Resolved on subsequent CXR.
.
[**2141-3-26**] ANKLE X-RAY: Limited study secondary to habitus. No
underlying osseous involvement noted. Alignment anatomic.
[**2141-3-27**] 07:50AM BLOOD WBC-10.4 RBC-3.65* Hgb-9.7* Hct-29.1*
MCV-80* MCH-26.6* MCHC-33.3 RDW-14.5 Plt Ct-229
[**2141-3-26**] 06:30AM BLOOD Neuts-67.4 Lymphs-23.3 Monos-5.1 Eos-3.5
Baso-0.6
[**2141-3-27**] 07:50AM BLOOD Plt Ct-229
[**2141-3-24**] 03:08AM BLOOD PT-11.9 PTT-32.8 INR(PT)-1.0
[**2141-3-27**] 07:50AM BLOOD Glucose-91 UreaN-18 Creat-1.2 Na-141
K-4.7 Cl-107 HCO3-24 AnGap-15
[**2141-3-27**] 07:50AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9 Iron-30*
[**2141-3-27**] 07:50AM BLOOD calTIBC-217* Ferritn-507* TRF-167*
.
[**2141-3-22**] 08:10PM BLOOD Glucose-152* UreaN-38* Creat-1.7* Na-136
K-4.2 Cl-107 HCO3-18* AnGap-15
[**2141-3-22**] 08:10PM BLOOD WBC-21.2* RBC-3.82* Hgb-10.4* Hct-31.0*
MCV-81* MCH-27.2 MCHC-33.6 RDW-14.5 Plt Ct-148*
[**2141-3-27**] 07:50AM BLOOD WBC-10.4 RBC-3.65* Hgb-9.7* Hct-29.1*
MCV-80* MCH-26.6* MCHC-33.3 RDW-14.5 Plt Ct-229
Brief Hospital Course:
#Sepsis: Patient was septic at OSH requiring pressor support and
fluid resusictation. Source likely cellulitis. BP remained
stable in ICU and on floor without pressors. Restarted ACE on
d/c.
.
# Celluitis: The patient has a h/o multiple cellulitis events in
his R leg, though not for some time. Likely source was his open
wound on the foot. Chronic lymphedema of RLE also contributing.
Continued on IV Vancomycin with marked improvement in his leg
and rapid decrease in WBC count. Foot xray without osteo; wound
did not probe to bone. Though wound culture grew MSSA, he was
continued on Vanco given marked clinical improvement. Will
complete a 14 day course.
.
#UTI: Ucx grew Klebsiella. Treated with Bactrim.
.
# Tachycardia/tachypnea and elevated D-Dimer and hypoxic at OSH:
Tachycardia likely related to fever and hypotension. Pt also
reports tachypnea when he is febrile which resolves when the
fever breaks. No documented hypoxia at this hospital. The OSH
was concerned for PE and treated with Lovenox; LENI of the R was
negative at OSH. Tachycardia and hypoxia resolved at [**Hospital1 18**]
therefore further w/u for PE not pursued. Pt without complaints
of CP/SOB.
.
#ARF: likely secondary to sepsis. Resolved with IVF.
.
#Anemia: Chronic dz by Fe studies. Outpt f/u.
.
#Lymphedema: made appt for patient at [**Hospital 19163**] clinic @ [**Hospital1 **].
Medications on Admission:
1. 70/30 40 q AM, 20 qdinner. NPH 30 at night.
2. Zestril po
3. Percocet prn LLE phantom pain
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
2. Lisinopril Oral
3. Insulin
70 / 30 40 qam
70 / 30 20 qdinner
NPH 30 Units qhs
4. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): to continue until [**4-4**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Sepsis secondary to RLE cellulitis
2. Urinary Tract Infection
3. Anemia of Chronic Disease
4. Lymphedema
5. Acute Renal Failure, resolved
Secondary Diagnoses
Type 2 Diabetes
Morbid Obesity
Hypertension
Discharge Condition:
stable, afebrile
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 65853**] or proceed back to the Emergency Room
should you develop worsening redness in your leg, fevers,
chills, sweats, or any other complaints.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2141-4-21**] 1:00
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] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5504, 5510
|
3589, 4968
|
295, 302
|
5784, 5803
|
2282, 3566
|
6035, 6215
|
1699, 1749
|
5113, 5481
|
5531, 5763
|
4994, 5090
|
5827, 6012
|
1764, 2263
|
233, 257
|
330, 1076
|
1098, 1568
|
1584, 1683
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,638
| 127,317
|
41561
|
Discharge summary
|
report
|
Admission Date: [**2108-4-3**] Discharge Date: [**2108-4-15**]
Date of Birth: [**2035-6-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 3(LIMA-LAD,SVG-OM,SVG-PDA),
closure patent foramen ovale, aortic valve replacement(21 CE
Magna Epic),Tricuspid valve repair(Annuloplasty ring) [**2108-4-9**]
History of Present Illness:
This 72 year old white female was admitted to another
institution with a syncopal event. She has had recent episodes
of standing up from wheelchair and feeling lightheaded. One
episode with possible loss of consciousness for approximately 1
minute. She denies other symptoms. Echocardiogram in [**2108-1-14**]
showed aortic valve area of 0.6, EF 50-55%. She was
catheterized at [**Hospital 5279**] Hospital today which revealed multivessel
disease and critical aortic stenosis. She was transferred to
[**Hospital1 18**] for surgery.
Past Medical History:
Calcified AS with normal LV function
PVD with moderate Left carotid artery stenosis
Osteopenia
Depression
stroke in2003 with right sided hemiparesis residual
Hypercholesterolemia
Polio as child - wears right sided leg brace
Right foot surgery in [**2052**]
Left ankle surgery for fracture
Cholecystectomy
Social History:
Lives with: Husband - married 49 years
Occupation:
Tobacco: none
ETOH: none
Walks ~ 1 mile/day
Family History:
Family History: Parents both died in 60's
Race: Caucasian
Last Dental Exam: 2 months ago - upper dentures
Physical Exam:
T 98.2
Pulse:66 Resp:18 O2 sat: 98% RA
B/P Right: 127/81 Left:
Height:5'1" Weight:152#
General:AAOx 3 in NAD, pleasant
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur IV/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x] Deformities of B/L feet
Neuro: Grossly intact, right sided strength 3/5 upper and lower
extremity, left sided 5/5 strength
Pulses:
Femoral Right:minimal bleeding at cath site Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Transmitted murmur b/l
Pertinent Results:
[**4-9**] Echo: Prebypass: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage. A patent foramen ovale is
present with a left-to-right shunt seen at rest. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is dilated with borderline normal free wall function.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] The
ascending aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild to moderate ([**1-15**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild valvular mitral stenosis (area
1.5-2.0cm2) and moderate MAC. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. Severe
[4+] tricuspid regurgitation is seen. There is no pericardial
effusion.
Postbypass: The patient is A paced and is on an infusion of
epinephrine. There is a bioprosthetic valve in the aortic
position which appears well-seated without evidence of
perivalvular leak. There is a trace amount of central aortic
regurgitation. Gradients are peak/mean 21/11 mmHg at a CO of 5
L/min. There is a ring around the tricuspid annulus. Tricuspid
regurgitation is now trace. Mitral regurgitation continues to be
trace. Biventricular systolic function is unchanged. The
thoracic aorta is intact post decannulation.
[**4-3**] Carotid U/S: Findings consistent with less than 40%
stenosis on the right and 60-69% stenosis on the left.
[**4-3**] Head CT: 1. Large chronic infarction in the left posterior
cerebral artery territory, which also involves the parasagittal
left parietal lobe, likely due to vascular variation. 2.
Numerous chronic microvascular infarcts in the supratentorial
white matter and deep [**Doctor Last Name 352**] nuclei. 3. No evidence of acute
intracranial abnormalities.
[**4-3**] Chest CT: 1. Extensive calcifications of the very proximal
ascending aorta with sparing of the rest of the anterior wall of
the ascending aorta and the proximal arch. 2. Severe aortic
valve calcifications. Severe coronary artery calcifications.
Papillary muscle calcifications that in conjunction with some
aneurysmatic configuration of the left ventricle would be
concerning prior myocardial infarction. 3. Several pulmonary
nodules that should be further followed in one year for
documentation of stability based on their size. 4. Several renal
lesions, one of them being hyperdense and eccentric that should
be correlated with renal ultrasound.
[**4-5**] Abd U/S: 1. Unremarkable pancreas; however, the
visualization of the pancreas is very limited due to overlying
bowel. 2. No biliary dilatation. 3. Simple bilateral renal
cysts. 4. Atherosclerotic aorta with no AAA.
[**2108-4-3**] 07:05PM BLOOD WBC-5.5 RBC-4.07* Hgb-12.7 Hct-37.6
MCV-93 MCH-31.1 MCHC-33.6 RDW-13.8 Plt Ct-156
[**2108-4-11**] 04:01AM BLOOD WBC-6.5 RBC-2.68* Hgb-8.3* Hct-23.2*
MCV-86 MCH-31.1 MCHC-36.0* RDW-17.4* Plt Ct-94*
[**2108-4-12**] 07:55PM BLOOD WBC-6.3 RBC-3.17* Hgb-9.8* Hct-28.2*
MCV-89 MCH-31.0 MCHC-34.8 RDW-16.8* Plt Ct-112*
[**2108-4-15**] 05:26AM BLOOD WBC-6.9 RBC-3.50* Hgb-10.9* Hct-31.2*
MCV-89 MCH-31.0 MCHC-34.8 RDW-16.7* Plt Ct-149*
[**2108-4-3**] 07:05PM BLOOD PT-14.9* PTT-26.6 INR(PT)-1.3*
[**2108-4-9**] 01:39PM BLOOD PT-18.3* PTT-117.9* INR(PT)-1.6*
[**2108-4-14**] 05:45AM BLOOD PT-14.5* INR(PT)-1.2*
[**2108-4-15**] 05:26AM BLOOD PT-20.7* PTT-29.1 INR(PT)-1.9*
[**2108-4-3**] 07:05PM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-142
K-3.7 Cl-106 HCO3-30 AnGap-10
[**2108-4-15**] 05:26AM BLOOD Glucose-104* UreaN-33* Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-28 AnGap-11
[**2108-4-12**] 01:39AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.8
Brief Hospital Course:
Following admission the usual preoperative workup was
undertaken. On [**4-9**] she went to the operating room where surgery
was performed as noted. She weaned from bypass on Propofol, Neo
Synephrine and Epinephrine in sinus rhythm. She was transferred
to the CVICU for invasive monitoring in stable condition. She
remained stable, was weaned from pressors and sedation, awoke
neurologically intact and extubated easily. Beta blockade was
resumed, she was diuresed towards her preoperative weight and
physical therapy was consulted. She had an orthostatic episode,
without loss of consciousness on post-op day four. One unit of
blood was transfused for a hematocrit of 28. Diuresis was
continued due to significant extravascular fluid overload.
Chest tubes and wires were removed per protocol. Follow up
appointments were made with surgery and cardiology. She was
screened for rehab to allow further recovery prior to return
home. On post-op day six she was discharged to Colonial Poplin
in NH with the appropriate medications. She was restarted on
Coumadin post-op d/t history of CVA.
Medications on Admission:
Calcium with Vit D
Coumadin 4.5 mg daily for hx CVA - LD Friday [**3-30**]
Zocor 40 daily
HCTZ 12.5 daily
ASA 325 daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily) as
needed for CVA hx.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Colonial Poplin Nursing
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Aortic stenosis s/p Aortic valve replacement
Tricuspid regurgitation s/p Tricuspid valve repair
Closure of patent foramen ovale
Past medical history:
Peripheral vascular disease w/ moderate Left carotid artery
stenosis
Osteopenia
Depression
CVA [**2100**] with right sided hemiparesis residual
Hypercholesterolemia
Polio as child - wears right sided leg brace
s/p Right foot surgery in [**2052**]
s/p Left ankle surgery for fx
s/p Cholecystectomy several years ago
Discharge Condition:
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**4-24**] at 1:45pm
Cardiologist: Dr. [**Last Name (STitle) 39975**] on [**4-30**] at 11am
Please call to schedule appointments with your
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 83943**]) in [**4-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2108-4-15**]
|
[
"V58.61",
"397.0",
"414.01",
"458.29",
"414.2",
"443.89",
"736.79",
"440.0",
"272.0",
"790.5",
"293.0",
"745.5",
"424.1",
"433.10",
"599.0",
"438.20",
"276.69",
"138"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"35.33",
"38.14",
"00.41",
"36.15",
"36.12",
"00.44",
"35.71"
] |
icd9pcs
|
[
[
[]
]
] |
8805, 8855
|
6530, 7617
|
315, 506
|
9424, 9548
|
2453, 4320
|
10443, 11036
|
1546, 1637
|
7787, 8782
|
8876, 9065
|
7643, 7764
|
9596, 10420
|
1652, 2434
|
268, 277
|
534, 1074
|
4329, 6507
|
9087, 9403
|
1418, 1514
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,441
| 121,169
|
12637
|
Discharge summary
|
report
|
Admission Date: [**2170-2-23**] Discharge Date: [**2170-3-7**]
Date of Birth: [**2139-11-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / Compazine / Morphine / Levaquin / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal stricture, gastric atony and duodenal ulcer
Major Surgical or Invasive Procedure:
s/p distal esophagectomy/total gastrectomy/[**Last Name (un) **]
esophagojejunostomy/J tube placement [**2-23**], with takeback for
abdom compartment syndrome, oversewing of anastomoses & revision
of J tube site [**2-24**] s/p washout on [**3-5**]
History of Present Illness:
30 F with ALL s/p BMT/chemo/XRT, esophagitis, GERD, Barrett's,
Esophageal perf with ileal patch, esophageal dysmotility with
multiple dilations; Gastric atony, hypergastrinemia; Duodenal
ulcer. Recurrent esophogeal stricture requiring dilitation q2-3
weeks x4 over past 3-4 months. Limited po intake, High gastrin
level presents for total gastrectomy
Past Medical History:
ALL, status post BMT [**2151**], esophageal strictures and ulcers,
duodenal ulcers, elevated gastrin levels, Ocreotide scan [**1-11**]
negative for gastronoma, MRSA right hip on chronic doxycycline,
hypothyroid, hypercholesterol, COPD, depression, seizure
disorder.
[**Doctor First Name **] Hx: esophageal dilatation, perf, jejunal patch [**2158**], CCY,
Appy
Social History:
lives with parents
Physical Exam:
General- Sedated,intubated, edemetous, very ill appearing female
lying flat in ICU bed.
Neuro- Pupils reactive R>L, + incteric sclera. Sedated
HEENT- Bloody packing present in nares, + oral bleeding, ETT in
place. generalized cervical edema.
Cor- RRR, tachycardia
REsp- course BS bilat, diminished
ABD- Surgical open abd, clear adhesive barrier in place,++
distention,+ firm, + edema,no BS.
Skin- + edema peripherally, + jaundice.
Extremities- +edema
Pertinent Results:
[**2170-2-23**] 12:06PM GLUCOSE-154* LACTATE-4.2* NA+-139 K+-3.6
CL--102
[**2170-2-23**] 08:57PM LACTATE-5.0*
[**2170-2-23**] 06:03PM HGB-8.0* calcHCT-24
[**2170-2-23**] 07:00PM HGB-10.7* calcHCT-32
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2170-3-7**] 10:50AM 27.5*1 3.18* 9.9* 27.5* 86.5 31.3 36.2*
18.5* 53*2
[**2170-3-7**] 03:32AM 26.0*1 3.15* 10.2* 27.3* 87 32.2* 37.3*
18.8* 59*2
1 CORRECTED FOR 41 NRBC
2 VERIFIED BY SMEAR
[**2170-3-7**] 12:04AM 38.8* 3.33* 10.6* 28.6* 86 31.7 37.0*
17.9* 43*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos Promyel NRBC Plasma
[**2170-3-7**] 10:50AM 55 17* 20 6 0 0 1* 0 0 54* 1*
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2170-3-7**] 10:58AM 4.3*1
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2170-3-7**] 10:50AM 121* 93* 1.2*1 133 6.6*2 99 19* 22*
SLIGHT HEMOLYSIS
[**2170-3-7**] 03:32AM 115* 89* 1.5*1 1362 5.8*2 1022 20* 20
SPECIMEN LIPEMIC
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2170-3-7**] 10:50AM 79* 233* 138* 26.5*1 18.1*2 8.4
[**2170-3-7**] 03:32AM 75* 214* 127* 23.9*1 17.6*2 6.3
SPECIMEN LIPEMIC
OTHER ENZYMES & BILIRUBINS Lipase
[**2170-3-2**] 04:07AM 99*
CPK ISOENZYMES CK-MB cTropnT
[**2170-2-25**] 02:02AM 4 0.12*1
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2170-3-7**] 10:50AM 2.9* 9.3 4.7* 2.4
SLIGHT HEMOLYSIS
[**2170-3-7**] 03:32AM 3.3* 9.5 4.6* 2.4
SPECIMEN LIPEMIC
HEMATOLOGIC Hapto
[**2170-2-28**] 07:44AM 160
LIPID/CHOLESTEROL Triglyc
[**2170-2-24**] 10:15AM 911
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
OTHER CHEMISTRY Ammonia
[**2170-3-2**] 11:11AM 44
HEPATITIS HBsAg HBsAb HBcAb HAV Ab
[**2170-2-24**] 04:07AM NEGATIVE POSITIVE NEGATIVE POSITIVE
GASTROINTESTINAL Gastrin
[**2170-2-24**] 08:53PM [**2164**]*1
1 VERIFIED BY DILUTION
HEPATITIS C SEROLOGY HCV Ab
[**2170-2-24**] 04:07AM NEGATIVE
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2170-3-7**] 2:28 AM
Reason: please eval for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
30F with esophageal stricture s/p esophagogastrectomy, worsening
saturation and ventilation
INDICATION: Esophageal stricture status post
esophagogastrectomy.
COMPARISON: Radiograph dated [**2170-3-5**].
AP SUPINE VIEW OF THE CHEST: The lines and tubes are unchanged.
There are low lung volumes. Pleural-based right apical opacity
is unchanged. There is persistent left lower lobe atelectasis.
IMPRESSION: No significant interval change compared to the study
of 2 days prior with persistent left lower lobe atelectasis and
right apical pleural- based density.
RADIOLOGY Final Report
ABDOMEN U.S. (COMPLETE STUDY) [**2170-2-28**] 8:16 AM
Reason: PT WITH [**Name (NI) 39043**], ? BILIARY OBSTRUCTION & SIGNS OF
SHOCK LIVER
[**Hospital 93**] MEDICAL CONDITION:
30F s/p ex lap x 2, with gross cirrhosis, who is now developing
hyperbili.
REASON FOR THIS EXAMINATION:
eval for biliary obstruction & signs of shock liver.
ABDOMINAL ULTRASOUND:
INDICATION: Cirrhosis, hyperbilirubinemia.
FINDINGS: A bedside portable examination was performed. The
study is markedly limited due to body habitus.
Portal vein is patent, but demonstrates reversal of flow, new
since [**2168-10-11**], probably related to underlying cirrhosi. No
gross intrahepatic biliary ductal dilatation.
Spleen is slightly enlarged, measuring 12.1 cm in length.
Limited examination of the kidneys shows no frank evidence of
hydronephrosis.
IMPRESSION: 1) Limited examination, showing reversal of portal
venous blood flow, new since [**2168-10-11**].
2) No gross evidence of hydronephrosis.
Brief Hospital Course:
Patient underwent esophagogastectomy with rou-en-y
reconstruction for longstangind history of esophageal stricture
and gastric atony on [**2170-2-22**]. Overnight patient develop increase
in need for fluid to support blood pressure as well as a bile
leak from one of the anastomosis. Then patient developed
increased in abdominal bladder pressure. She was taken urgently
to the operating room for the revision of the anastomosis and
wash out. Her abdomin was unable to be closed so bogata bag was
placed. After the operation, patient continued to require fluid
and pressors for blood pressure support. Then patient became
septic. She was started on Xigris for treatment of septic
shock. She improved but continued to require full ICU care.
Neurologically, she moved all extremities but required sedation
and paralysis to help with oxygenation. Cadiovascularlly, she
was started on Xigris which initally helped with decreased in
need for pressors but she continued to need pressors for blood
pressure support. She also developed atrial fibrillation which
lead to need for amiodarone drip for a period of time. She
continued to need mechanical support and the need for supported
increased for both oxygenation and ventilation over time.
Patient also developed renal insuffiency. Patient also
developed shocked liver with coagulation parameters not
responding to replacements. On [**2170-3-5**], she developed
leukocytosis to 40s and she was taken to the operating room for
a washout. Subsequently she developed multi-organ failure.
After a discussion with family patient was made comfort measures
only and she died after withdrawing her ventilation.
Medications on Admission:
Metoprolol, levoxyl, amytriptyline, paxil, colace, sulcrafate,
doxycycline, lantus
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Hypergastrinemia
Esophageal Strictures
Esophageal dysmotility
Gastric Atony
Duodenal ulcer
Asthma
COPD
Sinus tachycardia
Gallstone panreastitis
s/p cholecystectomy
s/p appendectomy
Right hip MRSA
s/p gastrectomy with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39044**] and J tube
placement
Abdominal compartment syndrome
Multiorgan failure
Discharge Condition:
Death
Completed by:[**2170-3-8**]
|
[
"530.19",
"584.5",
"557.0",
"038.8",
"570",
"536.3",
"995.92",
"427.31",
"251.8",
"V10.61",
"285.1",
"518.81",
"E932.0",
"997.4",
"530.3",
"571.5",
"729.9",
"785.52",
"286.7",
"568.0",
"V42.81",
"909.2",
"251.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.99",
"33.24",
"46.93",
"00.11",
"46.41",
"99.05",
"46.39",
"45.62",
"99.15",
"99.04",
"50.11",
"43.99",
"89.64",
"54.59",
"45.61"
] |
icd9pcs
|
[
[
[]
]
] |
7526, 7541
|
5729, 7393
|
396, 645
|
7943, 7978
|
1932, 4113
|
4913, 4988
|
7562, 7922
|
7419, 7503
|
1461, 1913
|
302, 358
|
5017, 5706
|
673, 1026
|
1048, 1410
|
1426, 1446
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,872
| 199,838
|
54333
|
Discharge summary
|
report
|
Admission Date: [**2161-9-12**] Discharge Date: [**2161-9-19**]
Date of Birth: [**2074-5-25**] Sex: F
Service: MEDICINE
Allergies:
Tramadol / Nsaids / Oxycodone
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87F with history of CAD s/p CABG in [**2143**], PCI in [**2153**], and
NSTEMI [**9-/2160**] with inability to stent, systolic CHF (EF 25-30%),
ESRD on dialysis (TTS), DM type II, and chronic UTIs with SOB
starting around 9pm this evening. Per d/w pt and daughter she
was feeling well until one day prior to arrival. She woke up her
daughter who called EMS, who noted [**Name (NI) 13866**] > 500 and significant
SOB. Her symptoms were somewhat relieved by nebulizers.
.
No recent illnesses or triggers. Had a slice of pie this evening
but often does. Took her insulin as she usually does. No
preceding fever, cough, dysuria. Had some diarrhea after HD on
Thursday but often does and this has not continued. Notes that
her FS were normal (100s-200s) until this evening when she had a
FS in the 300s.
.
She also explains that this evening after dinner she had a large
glass of water and some ice chips which was more than her fluid
restriction of 5 cups per day. She is wondering if this is what
set her over in terms of her pulmonary edema.
.
In the ED, initial vitals were 97.8 101 154/76 34 99% on a NRB.
Labs notable for a glucose of 795, AG acidosis of 20, Na 126,
BNP [**Numeric Identifier 4914**] (Last [**Numeric Identifier 17514**] in [**Month (only) **]), WBC 12.8. ECG showed sinus
at 102, old LBBB and CXR showed bilateral pulmonary edema. She
was started on a Nitro gtt and BiPAP, as well as an insulin gtt.
.
At time of transfer VS 95 140/59 97/BipAP 10/5 FiO2 40% on nitro
1 mcg/kg/min and insulin 8/hr.
.
On arrival to the MICU she was on BiPAP and in NAD. She was
requesting ice chips. No other complaints
Past Medical History:
- CAD w/CABG in [**2143**] with LIMA to proximal LAD, SVG to distal
LAD, SVG to OM2 AND OM3
- PCI: DES to proximal LAD in [**2153**].
- CHF: Systolic CHF with mild symm LVH, most recent EF 25-30%
(TTE [**11/2160**])
- ESRD [**2-26**] likely diabetic nephropathy on HD since [**2160-9-25**]
- Type 2 Diabetes, insulin-dependent, complicated by nephropathy
- Dyslipidemia
- Hypertension
- asthma
- sciatica
- arthritis s/p knee replacement
- gout
- GERD
- osteoporosis
- colonic adenomas with last colonoscopy [**6-/2159**] (hyperplastic
only, next colonoscopy [**6-/2164**])
- low back pain
- recurrent UTIs (klebsiella, e.coli, VRE)
Social History:
She lives with her daughter. [**Name (NI) **] husband passed away in [**Name (NI) **]
[**2160**]. Used to work in a bank.
-Tobacco history: prior - stopped 30-40 years ago and smoked 1
pack/week before that
-ETOH: none
-Illicit drugs: none
Family History:
Her daughter has a history of a horse-shoe kidney and her
grandson has a history of ureteral reflux. + Colon Cancer.
Mother, coronary artery disease. Father, stroke. Brother,
cancer. Sister, cancer
Physical Exam:
ADMISSION PE:
Vitals: T: 99.0 BP: 125/65 P: 78 R: 18 O2: 97/2L on the floors
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, unable to appreciate elevated JVP, no LAD
CV: Regular rate and rhythm, ? S4, no murmurs, rubs, gallops
Lungs: bibasilar crackles, no wheeze
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: 2+ edema, W/W/P, dital pulses palpable
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE:
Vitals - T98.3 (98.2-99.0), BP 138/53 (113/44 - 166/74), HR 61
(51-79), RR 20, O2 98%RA (96-100%)
[**Year (4 digits) 13866**]: 197<201<325
General- Slightly obese woman laying comfortably in bed, Alert
and orientedx3, in no acute distress. initially asleep
HEENT- anicteric sclera, moist mucous membranes, oropharynx
clear
Neck- supple, JVP not elevated, no lymphadenopathy
Lungs- Clear to auscultation bilaterally. No rales, crackles, or
ronchi
CV- regular, normal S1 + S2; no murmurs, rubs, or gallops
Abdomen- soft, non-tender, non-distended, normoactive bowel
sounds, no rebound tenderness or guarding. No CVA tenderness.
scar from prior hystorectomy
GU- no foley
Ext- mildly cool with 2+ pulses palpable bilaterally. mild ankle
edema. bruising on lower extremities resolving. no clubbing or
cyanosis. scars from bilateral knee surgeries
Neuro- CNsII-XII intact, motor and sensory function grossly
intact.
Pertinent Results:
ADMISSION LABS:
[**2161-9-12**] 04:19AM BLOOD WBC-10.5 RBC-3.15* Hgb-10.6* Hct-32.4*
MCV-103* MCH-33.7* MCHC-32.8 RDW-14.0 Plt Ct-153
[**2161-9-12**] 12:31AM BLOOD WBC-12.8* RBC-3.60*# Hgb-12.4# Hct-37.7#
MCV-105* MCH-34.5* MCHC-32.9# RDW-14.0 Plt Ct-184
[**2161-9-12**] 12:31AM BLOOD Neuts-80.0* Lymphs-15.9* Monos-3.2
Eos-0.4 Baso-0.5
[**2161-9-12**] 04:19AM BLOOD Plt Ct-153
[**2161-9-12**] 04:19AM BLOOD PT-11.3 PTT-25.9 INR(PT)-1.0
[**2161-9-12**] 12:31AM BLOOD Plt Ct-184
[**2161-9-12**] 12:31AM BLOOD PT-10.9 PTT-26.8 INR(PT)-1.0
[**2161-9-12**] 04:19AM BLOOD Fibrino-434*
[**2161-9-12**] 04:19AM BLOOD
[**2161-9-12**] 11:07AM BLOOD Glucose-221* UreaN-51* Creat-4.0* Na-134
K-4.0 Cl-92* HCO3-25 AnGap-21*
[**2161-9-12**] 06:12AM BLOOD Glucose-631*
[**2161-9-12**] 04:19AM BLOOD Glucose-629* UreaN-49* Creat-3.9* Na-126*
K-4.1 Cl-86* HCO3-23 AnGap-21
[**2161-9-12**] 12:31AM BLOOD Glucose-735* UreaN-47* Creat-3.9* Na-126*
K-4.6 Cl-83* HCO3-23 AnGap-25*
[**2161-9-12**] 04:19AM BLOOD CK(CPK)-41
[**2161-9-12**] 04:19AM BLOOD CK-MB-3 cTropnT-0.09*
[**2161-9-12**] 12:31AM BLOOD cTropnT-0.04*
[**2161-9-12**] 12:31AM BLOOD proBNP-[**Numeric Identifier 4914**]*
[**2161-9-12**] 11:07AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.9
[**2161-9-12**] 04:19AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.8
[**2161-9-12**] 12:47AM BLOOD pO2-72* pCO2-45 pH-7.36 calTCO2-26 Base
XS-0 Comment-GREEN TOP
STUDIES:
( TTE: )
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). Right ventricular
chamber size is normal. with borderline normal free wall
function. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Severe (4+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension
( TEE - Pre Cardioversion)
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Moderate (2+)
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No spontaneous echo contrast or thrombus in the
LA/LAA/RA/RAA. moderate mitral regurgitation. Complex atheroma
in the aortic arch and descending aorta.
DISCHARGE LABS:
[**2161-9-19**] 12:49PM BLOOD WBC-11.2* RBC-3.24* Hgb-10.9* Hct-33.8*
MCV-104* MCH-33.7* MCHC-32.4 RDW-14.1 Plt Ct-158
[**2161-9-19**] 12:49PM BLOOD Neuts-80.5* Lymphs-14.5* Monos-3.5
Eos-0.8 Baso-0.7
[**2161-9-19**] 12:49PM BLOOD PT-27.7* PTT-53.0* INR(PT)-2.7*
[**2161-9-19**] 12:49PM BLOOD Glucose-222* UreaN-14 Creat-1.8*# Na-137
K-4.8 Cl-98 HCO3-27 AnGap-17
[**2161-9-19**] 12:49PM BLOOD Calcium-9.0 Phos-2.7# Mg-1.9
[**2161-9-19**] 02:58AM BLOOD TSH-2.2
Brief Hospital Course:
Ms. [**Known lastname 20561**] is an 87F with a history of CAD s/p CABG in [**2143**],
PCI in [**2153**], and NSTEMI [**9-/2160**] with inability to stent, systolic
CHF (EF 25-30%), ESRD on dialysis (TTS), DM type II presenting
with DKA (AG 20), shortness of [**Year (4 digits) 1440**], pulmonary edema, 1 month
of dysuria, and brief fever. Pt required 2 days in ICU without
intubation to remove excess fluid and manage DKA. Also had new
onset Afib managed with DCCV, Warfarin, and Amiodarone.
.
#. DKA: Patient with history of type 2 diabetes diagnosed 30
years ago (insulin dependent) who presented with DKA (AG 20),
possibly triggered by her UTI. Started on insulin drip in ED and
tx to MICU. She was not given IVF as she also had pulm edema due
to ESRD and poor urine ouptut. Her anion gap closed to 12 and
dyspnea/pulm edema resolved with insulin and nitro drip in MICU.
Patient was transfered to Medicine [**Hospital Ward Name 121**] 5 for further management
of unstable blood glucose levels. [**Last Name (un) **] was involved early and
titrated her insulin regimen daily. Please see the discharge
insulin scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] as she ranged 100s-190s on day of
discharge.
.
# NEW ONSET AFIB- S/P successful DCCV on [**2161-9-18**]. Pt's EKGs on
[**9-14**] and [**9-15**] were significant for afib; EKG on ([**9-17**])
demonstrated aflutter. Prior EKGs taken on admission and in
[**Month (only) **], [**Month (only) 958**], and [**2161-2-25**] were negative for
afib/aflutter. As patient has CHF, hypertension, age >75, she
has a CHADS score=4 she was started on Warfarin therapy after
bridging with Heparin. She had TTE, TEE that did not show
thrombus and then cardioversion that induced sinus rhythm on
[**2161-9-18**]. She was placed on Amiodarone 400mg [**Hospital1 **] x 1 mo, then
200mg [**Hospital1 **] for 2 weeks thereafter. Pt was continued on home dose
of metoprolol 12.5mg [**Hospital1 **], warfarin 2mg, and home [**Hospital1 **] 325mg. Pt's
cardiologist, Dr. [**Last Name (STitle) **] was informed of this procedure and
pt was made aware to contact the office for close follow up.
Pt's INR will be checked at [**Hospital3 4107**] and titrated by [**Company 191**]
anticoag nurses.
.
# PYURIA - With dysuria x 1 month. Pt was started on Linezolid
given UCx grew VRE sensitive to Linezolid. Pt has history of
chronic UTIs, and 1 month pain on urination. Pt has been a
symptomatic for past 4 days, but noted some mild morning of
admission. No CVA or suprapubic tenderness on exam. Pt is
afebrile, normal WBC. BCx negative, no sepsis physiology. Pt
treated with Linezolid PO 600mg/day (Day 1: [**9-16**], Day 7: [**9-23**]).
BCx were negative.
.
## ESRD (HD Tuesday, Thursday, Saturday)- Patient is on strict
fluid restrictions (no more than 5 cups/day). She has poor urine
output. Nephrology followed patient during admission. Continued
renal med dosing, low na diet, and nephrocaps.
.
## SOB WITH RESPIRATORY DISTRESS - Resolved after MICU
admission. [**2-26**] DKA with osmotic fluid overload. Pt originally
presented with severe dyspnea, required BiPAP; found to have
bilateral pulmonary edema likely secondary to fluid shifts d/t
hyperglycemia in setting of ESRD. Pulmonary edema resolved per
CXR [**9-13**]. Patient remained asymptomatic and 97-99% on RA on
discharge.
.
## MACROCYTIC ANEMIA - Macrocytic anemia present at baseline.
Baseline HCT high 20s to low 30s. Was normocytic until [**Month (only) **] of
[**2161**]. HCT trend 31.5<33.7<34.5, MCV 102<101<102. Consider Epo
therapy as an outpatient due to ESRD. We started empiric B12 and
Folate [**9-14**]
.
#### TRANSITIONAL
- Pt new diagnosis of Afib, started on Warfarin and Discharged
on Warfarin 2mg/day (Day1 [**9-16**] 5mg, [**9-17**] 5mg, [**9-18**] 0mg INR 3.1,
[**9-19**] 2mg INR 2.7), INR to be checked on [**2161-9-21**] before PCP visit
[**Name Initial (PRE) **] Please d/w pt about frequency of checking INR
- Please determine the need to keep patient on/off Plavix given
she is on [**Name Initial (PRE) **] and Warfarin (last Cardiology note on discharge
stated to keep Plavix off, and given [**Name Initial (PRE) **] and Warfarin we kept
Plavix off at discharge, last stent > 1 year ago)
- Consider 12 Lead EKG to see if pt still in sinus at every
outpatient appointment
- Started on Amiodarone 400mg [**Hospital1 **] until [**10-18**], followed by 2
weeks of 200mg [**Hospital1 **]
- [**Last Name (un) **] followed patient during her hospital stay and
recommends follow up with her PCP in regards to blood sugar
control, did not feel strongly about [**Hospital **] clinic follow up
- Consider starting/continuing EPO, given chronic anemia (HCT
low 30s) in the setting of ESRD.
Medications on Admission:
1. Allopurinol 100 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Citalopram 10 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Lisinopril 5 mg PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR)
10. Vitamin D 1000 UNIT PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
13. Vagifem *NF* (estradiol) 10 mcg Vaginal qWeek
14. Metoprolol Succinate XL 25 mg PO BID
15. Nitroglycerin SL 0.4 mg SL PRN chest pain
may repeat every 5 minutes x 3 doses
16. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO TID:PRN pain
17. Docusate Sodium 100 mg PO BID
18. NPH insulin human recomb *NF* 100 unit/mL Subcutaneous [**Hospital1 **]
10 units in AM, 26 units in PM
19. insulin regular human *NF* 100 unit/mL Injection [**Hospital1 **]
6 units in AM then in evening, dose according to sliding scale
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Allopurinol 100 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Outpatient Lab Work
ICD9: 427.31
LAB: INR
WHEN: [**9-20**] or [**9-21**] before PCP appointment
FAX TO: [**Last Name (LF) 1683**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Fax: [**Telephone/Fax (1) 6443**]
6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
7. Lisinopril 5 mg PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR)
8. Nephrocaps 1 CAP PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
12. Amiodarone 400 mg PO BID
for 30 days (last day [**2161-10-18**]) then 200mg PO BID x 2 wks
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*58
Tablet Refills:*0
13. NPH 20 Units Breakfast
NPH 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen] 100 unit/mL Up to 18 Units
per sliding scale four times a day Disp #*3000 Unit Refills:*0
RX *NPH insulin human recomb [Humulin N Pen] 100 unit/mL (3 mL)
20 Units before Breakfast; 16 Units before bedtime; via
subcutaenous injection 20 Units before BKFT; 16 Units before
BED; Disp #*1200 Unit Refills:*0
14. Linezolid 600 mg PO Q12H
GIVE AFTER HEMODIALYSIS on those days
last dose 8/29
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
16. Citalopram 10 mg PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
may repeat every 5 minutes x 3 doses
19. Vagifem *NF* (estradiol) 10 mcg Vaginal qWeek
20. Warfarin 2 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
21. Metoprolol Tartrate 12.5 mg PO BID
Hold for SBP <100, HR <60
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Diabetic Ketoacidosis
Acute on chronic systolic heart failure (EF 25-30)
New onset Atrial Fibrillation
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 Mrs. [**Known lastname 20561**],
Thank you for choosing [**Hospital1 18**]. You were admitted because you had
difficulty breathing and your blood sugar level was very high.
You also had a urinary tract infection, which may have
precipitated the increase in your blood sugar. An x-ray on [**9-12**]
showed some fluid in your lungs, which has since resolved. While
you were here, you developed a dysfunction in the beating of
your heart called atrial fibrillation. We treated this with a
shock that returned your heart back to a normal rhythm.
You were followed by [**Hospital **] [**Hospital 982**] Clinic and they recommended
a new insulin regimen for you: AM: 20 Units NPH; Insulin Sliding
Scale during the day; HS:16 Units NPH. The details are attached.
We also started you on a new medicine called coumadin
(warfarin), which requires you to check a blood lab called INR.
We wrote a prescription for you to have this done on [**2161-9-21**]
(before seeing your primary care doctor on that same day). Your
INR on [**9-19**] after Hemodialysis was 2.7.
We reduced your metoprolol dose due to concerns about your blood
pressure. When you see your PCP for your followup appointment,
please have them recheck your blood pressure and discuss
restarting your home dose of metoprolol at that time.
We set up appointments for you to follow up with your PCP and
cardiologists. Please see details below.
MEDICATIONS:
START Warfarin 2 mg by mouth once daily
START Amiodarone 400 mg by mouth twice per day (last dose
[**2161-10-19**], then switch to 200 mg twice per day for two weeks)
START Linezolid 600 mg by mouth twice/day (last dose [**2161-9-23**])
STOP Plavix (Clopidogrel)
CHANGED Metoprolol succinate 25 mg twice daily to Metoprolol
tartrate 12.5 mg twice daily.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED
When: MONDAY [**2161-9-21**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 103167**], MD [**Telephone/Fax (1) 6662**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Dr. [**Last Name (STitle) 1683**] is on vacation so you will see Dr. [**Last Name (STitle) 4682**] for this
visit.
Department: CARDIAC SERVICES
When: FRIDAY [**2161-10-2**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr. [**Last Name (STitle) **] is not available so you will see the nurse
practitioner for this visit.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2161-9-24**]
|
[
"397.0",
"412",
"493.90",
"V15.82",
"425.4",
"V45.11",
"530.81",
"585.6",
"403.91",
"428.23",
"618.01",
"428.0",
"041.04",
"250.12",
"V58.67",
"V45.81",
"599.0",
"276.1",
"424.0",
"427.31",
"250.42",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
15832, 15889
|
8105, 12826
|
298, 304
|
16036, 16036
|
4644, 4644
|
18017, 19037
|
2886, 3085
|
13843, 15809
|
15910, 16015
|
12852, 13820
|
16219, 17994
|
7621, 8082
|
3100, 4625
|
251, 260
|
332, 1955
|
4660, 7604
|
16051, 16195
|
1977, 2612
|
2628, 2870
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,071
| 174,677
|
6618
|
Discharge summary
|
report
|
Admission Date: [**2175-8-5**] Discharge Date: [**2175-8-16**]
Date of Birth: [**2094-6-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Iodine / Dicloxacillin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
Mr. [**Known lastname 25280**] is an 81 y/o M with extensive past cardiac history
including CAD (s/p CABG, prior PCIs with stenting), ischemic
cardiomyopathy with LVEF of 20% and NYHA class III CHF (s/p [**Known lastname 3941**]
placement), DM, HLD, HTN, A.fib (on Coumadin), PVD (chronic
lower extremity ulcers) who presented with chest pain.
The patient was at [**Hospital 100**] Rehab and at 02:10 AM was noted to
have acute onset substernal chest pressure without radiation,
[**8-18**] in intensity, BP 106 mmHg systolic at that time. EMS called
and received report that patient had an episodic HR of 160 bpm
without symptoms (unverified). Received nitro SL with
improvement in pain. Also got ASA. On arrival, CP was [**2-17**] and
substernal without dyspnea. No nausea, palpitations or
diaphoresis. Denied shortness of breath or leg swelling.
Of note, the patient was recently admitted here [**Date range (1) 25296**] with
hypotension. No clear etiology identified during that admission
but suspected to be cardiac. An echo showed a reduction in LVEF
to 20% from ~30%. There were intermittent NSVT episodes. Also
had slowly downtrending crit related to possible GIB. Mildly
anemic and received 1 unit PRBCs. No scope performed but scope
in [**2-19**] showed moderate gastritis, duodenal ulcer. He has known
diverticuli.
Mr. [**Known lastname 25280**] saw his cardiologist, Dr. [**Last Name (STitle) **], on the day PTA
where he was noted to be doing well. An [**Last Name (STitle) 3941**] interrogation did
reveal on VF episode requiring shock.
In the ED, initial VS were 98.3 110 106/62 16 94% 2L Nasal
Cannula. Labs revealed hct of 27.0, lactate of 5.7, Cr 2.0
(baseline 1.3), BNP 11,422 (baseline ~5,000), trop 0.04 (c/w
prior). ECG showed a.fib @ 114, LAD, occassional PVCs and IVCD,
non-specific ST-changes with peaked T-waves (similar to
previous). CXR without acute process. Guiac (+) with maroon
stool in vault. The patient received vanc/levo/flagyl in the ED
due to concern for sepsis.
On arrival to the [**Last Name (STitle) **] initial VS were 97/55 109 100%2L. Patient
is mentating well and [**Last Name (STitle) **] any CP/palp/SOB. Reports feeling
cold. No signs of active infection and broad spectrum abx not
continued in [**Last Name (STitle) **]. Can re-start if becoming febrile.
Past Medical History:
# Diabetes
# Hyperlipidemia
# Hypertension
# Peripheral [**Last Name (STitle) 1106**] disease with chronic LE ulcers
# s/p resection of R 1st MT joint [**2-/2166**]
# s/p R BK [**Doctor Last Name **] -DP w/nrsvg [**4-11**]
# s/p plasty of bpg [**4-13**]
# s/p agram [**3-14**]
# arteriogram [**12-18**]
# [**2174-2-10**] R 3rd toe debrid by podiatry
# [**2174-2-8**] right BK [**Doctor Last Name **] to PT bypass w/ NRSVG
# [**Last Name (LF) 19874**], [**First Name3 (LF) **] 20% (echo [**7-9**])
# CAD s/p CABG x 4 in [**2-/2166**]
# VT s/p dual-chamber [**Year (4 digits) 3941**] placement
# Atrial fibrillation on warfarin
Social History:
Married, has 6 children. [**Year (4 digits) 4273**] tobacco. Quit EtOH 25 years
ago. [**Year (4 digits) 4273**] illicits. Lives alone at [**Doctor Last Name 406**] Estates [**Location (un) 8608**] retirement community. Has occasional nursing help.
Manages his own finances. Per daughter, he usually has fair
understanding of his medical conditions, but has had a few
episodes of confusion; he was found confused and wandering on
previous admission
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
Vitals: 97/55 109 100%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 + S2, II/VI systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Condom cath
Ext: Poor pulses b/l with eschar over ulcer on right
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
On discharge:
98 36.7 71 104/67 20 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: A-paced on monitor (regular), normal S1 + S2, II/VI systolic
murmur
Lungs: bilateral crackles lower lung field
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Poor pulses b/l with eschar over ulcer on right
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
Pertinent Results:
Labs:
[**2175-8-5**] 03:22AM BLOOD WBC-9.4 RBC-3.35* Hgb-8.4* Hct-27.0*
MCV-81* MCH-24.9* MCHC-31.0 RDW-23.8* Plt Ct-252
[**2175-8-5**] 03:22AM BLOOD Neuts-66 Bands-0 Lymphs-29 Monos-4 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2175-8-5**] 03:22AM BLOOD PT-40.4* PTT-33.7 INR(PT)-4.0*
[**2175-8-5**] 03:22AM BLOOD Glucose-145* UreaN-56* Creat-2.0* Na-137
K-5.7* Cl-94* HCO3-25 AnGap-24*
[**2175-8-5**] 03:22AM BLOOD CK-MB-2 proBNP-[**Numeric Identifier **]*
[**2175-8-5**] 03:22AM BLOOD cTropnT-0.04*[**2175-8-5**] 11:20AM BLOOD
CK-MB-3 cTropnT-0.15*
[**2175-8-5**] 06:25PM BLOOD cTropnT-0.15*
[**2175-8-6**] 01:28AM BLOOD CK-MB-2 cTropnT-0.13*
[**2175-8-5**] 03:22AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.7
[**2175-8-5**] 03:42AM BLOOD Lactate-5.7* K-4.3
[**2175-8-5**] 11:44AM BLOOD Lactate-1.7
[**2175-8-6**] 01:43AM BLOOD Lactate-2.4*
[**2175-8-6**] 09:32AM BLOOD Lactate-1.4
Radiology:
CXR [**2175-8-5**]
No acute cardiopulmonary process.
CXR [**2175-8-7**]
IMPRESSION: AP chest compared to [**6-25**] through [**2175-8-5**]:
Lungs grossly clear. There could be a new small left pleural
effusion. Heart size is top normal. No pulmonary edema.
Transvenous right ventricular pacer
defibrillator lead follows the expected course. The right
atrial lead is more medially oriented than generally seen, but
unchanged since at least [**2174-2-8**].
IMPRESSION:
XRAY Right Foot [**2175-8-7**]
1. Ulcer at the distal aspect of the 3rd toe without
radiographic signs of acute osteomyelitis.
Micro:
URINE CULTURE (Final [**2175-8-14**]):
GRAM NEGATIVE ROD(S). ~[**2163**]/ML.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification.
Discharge Labs:
[**2175-8-16**] 04:30AM BLOOD WBC-8.4 RBC-4.02* Hgb-10.6* Hct-33.4*
MCV-83 MCH-26.5* MCHC-31.9 RDW-22.3* Plt Ct-200
[**2175-8-16**] 04:30AM BLOOD PT-19.8* PTT-33.4 INR(PT)-1.9*
[**2175-8-16**] 04:30AM BLOOD Glucose-103* UreaN-12 Creat-1.4* Na-133
K-3.4 Cl-103 HCO3-27 AnGap-6*
[**2175-8-16**] 04:30AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 25280**] is an 81 y/o M with extensive [**Known lastname 1106**] history who
presented with chest pain and anemia. Transferred to MICU due to
concern of demand ischemia in setting of LGIB.
#Chest Pain - The patient has an extensive coronary history. His
present episode of chest pain ocurred in the setting of
tachycardia to the 160s (reported by EMS) and a hematocrit below
his baseline. Given pt's EKG and clinical picture, the elevated
troponin was most likely demand ischemia. He was given packed
RBCs to increase oxygen supply for increased demand. A CHF
exacerbation despite an elevated BNP, but unclear likely given
clear lungs and no fluid overload on CXR. Other etiologies
including PE was considered but his INR was supratherepeutic and
pt was not hypoxic. Cardiology was [**Known lastname 4221**] and did not believe
that this was ACS and did not recommend coronary angiography.
# Anemia - The patient has a long history of anemia and has
known history of gastric erosions, but no ulcers, and
diverticuli. CT Abdomen this month has no evidence of
malignancy. Pt is presently on iron supplementation. Guaiac (+)
stool in ED and on the floor. Pt was transfused several units of
RBCs (followed by lasix) to maintain a goal of hct>30 for demand
ischemia.
# A. Fib - CHADS2 score of 4. The patient presented in afib with
a rate in the 110s, and hemodynamically stable. Pt may have had
an episode of NSVT with EMS before arriving to ED since he had
SVT during last admission. No SVT episodes during [**Known lastname **] course. Pt
was continued on metoprolol with rates maintained below 100,
until the patient developed the GI bleed. Metoprolol was held
given blood pressures in 90/50 and his heart rate was well
controlled without it. Given his GI bleed, his coumadin and
metoprolol were held at the time of discharge.
#. C.diff colitis- The patient was found to have C. diff colitis
and started on metronidazole on [**2175-8-9**]. He will need to
complete 14 days of metronidazole.
# PVD - Patient with PVD leading to ulcerations. Patient with
stent placed recently and it was of high priority that he
continued anti-platelet and AC with plavix and warfarin at
present. With pt's GI bleed, [**Date Range 1106**] team was amenable to
discontinuing Plavix. Wound care team followed pt throughout
course.
# Acute on Chronic Kidney Disease - Cr elevated to 2.0 on
admission. Also with BUN elevation to suggest pre-renal state.
[**Month (only) 116**] also be due to renal vein congestion in the setting of CHF.
After receiving blood products, his Cr improved and was 1.4 at
the time of discharge.
# [**Month (only) 19874**]/CAD - Worsening EF thought to be due to progressive CAD.
It was imperative to give blood/fluid slowly and diurese as
needed. CXR and lungs presently clear with absent JVD on my
exam. Pt's home torsemide was held. The statin and ACE
inhibitor were restarted by the time of discharge. The patient
should follow up with his cardiology within 2-3 weeks after
discharge to assess the need to restart his torsemide.
# Delirium - Had difficulty with sundowning on prior admission.
Seen by [**Female First Name (un) **] consult and was started on zyprexa PRN agitation at
night.
# DMII: Pt's home metformin was hekd and BG were monitored four
times a day. He was discharge on an Insulin sliding scale.
Transitional issues:
- Reassesment regarding restarting Coumadin, metoprolol and
torsemide
- F/u with his PCP [**Name Initial (PRE) 176**] 1 week of discharge from rehab
- F/u with his cardiology within 2-3 weeks of discharge from the
hospital
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Bisacodyl 10 mg PO DAILY:PRN Constipation
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Torsemide 20 mg PO BID
7. Warfarin 5 mg PO DAILY16
8. Atorvastatin 80 mg PO DAILY
9. Lisinopril 2.5 mg PO DAILY
10. MetFORMIN (Glucophage) 850 mg PO BID
11. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
12. OLANZapine 2-5 mg PO HS:PRN Delerium
13. Pantoprazole 40 mg PO Q12H
14. Metoprolol Tartrate 12.5 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN Constipation
4. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding
Scale using HUM Insulin
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
Started on [**2175-8-9**]; Please continue to take this medication
until [**2175-8-23**]
7. Lisinopril 2.5 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN Constipation
9. Ferrous Sulfate 325 mg PO BID
10. OLANZapine *NF* 2.5 mg Oral qhs
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] centre
Discharge Diagnosis:
gastrointestional bleed
coronary artery disease
chronic congestive heart failure
clostridium difficile infection
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:
Mr. [**Known lastname 25280**],
You were admitted to [**Hospital1 69**] for
chest pain. We don't believe you had a heart attack, but the
chest pain was likely related to lower oxygen to your heart.
You are now chest pain free after receiving blood.
We also found that you had a bleed within your gastrointestional
system. You underwent endoscopy, in otherword we looked with a
camera at your gastrointestion system, which did not find the
source of your bleeding. We have stopped your plavix and
currently stopping your coumadin after discharge. We have also
stopped your torsemide and metoprolol given lower blood
pressure. You should follow up with your cardiology and
determine if you should restart the torsemide, metoprolol, and
coumadin.
We also found that you had an infection of your colon caused by
a bacteria, clostridium difficle. You will need to take
antibiotics to treat this infection.
Finally, it is important that you rebuild your strength after
discharge at the rehab extended care facility.
We are stopping your torsemide and metoprolol given your recent
GI bleed. Please talk with your cardiology about restarting
metoprolol, torsemide and coumadin within 2-3 weeks of
discharge. Also, please see your primary care doctor within 1
week of discharge from rehab.
Followup Instructions:
Please see your cardiology after discharge within 2-3 weeks of
discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,625
| 186,994
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7710+7711+55868
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2193-12-14**] Discharge Date: [**2193-12-30**]
Date of Birth: [**2127-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tylenol
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increased fatigue over past 2 years
Major Surgical or Invasive Procedure:
Bentall Procedure [**2193-12-17**]
History of Present Illness:
66 yo male with increased fatigue and weight gain over past [**12-23**]
years. He has cardiomyopathy and has been followed by serial
echos. Recently his ascending aorta was found by scan to be
increasing in size from 4.0 to 5.2 cm, and is currently 5.7 cm
at the level of the coronary ostia. Referred after
catheterization for surgical repair of his aorta by Dr.
[**Last Name (STitle) 1290**].
Past Medical History:
ascending aortic aneurysm
CAD
LAD stent [**2186**]
AMI [**2186**]
elev. chol. HTN
cardiomyopathy
AFib s/p cardioversion [**5-26**]
s/p tonsillectomy
s/p anal fissurectomy
LLE vein stripping
s/p RIH repair
Social History:
lives with wife
retired [**Name2 (NI) 28010**]
quit smoking 20 years ago with 70 pack/yr Hx
one drink per week
Family History:
N/A
Physical Exam:
NAD
PERRLA, no LAD, full ROM, no bruits
CTAB
RRR S1 S2 with no m/r/g
protuberant abd, soft, NT , ND
no c/c/e, extrems warm, well perfused
CN II- XII intact
T 98.7 RA sat 93% RR 20 126/64 HR 60
68" 123.8 kg
Pertinent Results:
[**2193-12-25**] 07:30AM BLOOD WBC-9.0 RBC-3.17* Hgb-9.9* Hct-27.8*
MCV-88 MCH-31.4 MCHC-35.8* RDW-14.4 Plt Ct-271
[**2193-12-16**] 03:30PM BLOOD WBC-5.7 RBC-3.77* Hgb-11.8* Hct-33.0*
MCV-88 MCH-31.4 MCHC-35.9* RDW-13.2 Plt Ct-189
[**2193-12-25**] 07:30AM BLOOD Glucose-119* UreaN-85* Creat-2.1* Na-134
K-4.8 Cl-99 HCO3-23 AnGap-17
[**2193-12-16**] 03:30PM BLOOD ALT-19 AST-25 LD(LDH)-201 AlkPhos-73
TotBili-0.2
[**2193-12-16**] 03:30PM BLOOD Albumin-3.9
[**2193-12-14**] 05:42PM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1
[**2193-12-16**] 03:30PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
cath [**10-26**] LAD stent patent, no significant CAD
echo [**8-26**] EF 35-40%
CT scan [**2193-10-23**]: Asc. aorta 5.7 cam at coronary ostia, 3.4 cm
at arch, 2.7 at descending, abdomen normal
[**2193-12-29**] 05:10AM BLOOD WBC-8.7 RBC-3.26* Hgb-9.7* Hct-28.6*
MCV-88 MCH-29.6 MCHC-33.8 RDW-14.8 Plt Ct-260
[**2193-12-30**] 07:05AM BLOOD PT-20.5* INR(PT)-3.0
[**2193-12-30**] 07:05AM BLOOD Glucose-109* UreaN-62* Creat-1.8* Na-137
K-5.0 Cl-100 HCO3-28 AnGap-14
Brief Hospital Course:
Admitted on [**12-14**] pre-operatively for heparin bridge to surgery
after coumadin was stopped at home (last dose 12/22). When INR
dropped to 1.1, he underwent Bentall procedure with Dr.
[**Last Name (STitle) 1290**] on [**12-17**]. He was transferred to the CSRU in stable
condition on a titrated propofol drip. He was extubated early
the next morning and was alert and oriented with no deficits
noted, in sinus rhythm. Glucose managed with an insulin drip.
Chest tubes were removed on POD #2 and coumadin was restarted
for coverage of his mechanical aortic valve. He was transferred
to the floor that afternoon. He went into AFib on POD #3 and
remained on a heparin drip for coverage until INR therapeutic
with coumadin. He also began betablockade and a diltiazem drip
was started briefly for rate control. Amiodarone was also
started.
Creatinine rose to 2.1 on POD #4, and lasix was held. A renal
consult was obtained, and the foley ws DCed. he was transfused
one unit PRBCs.He also began receiving albuterol nebs for some
expiratory wheezing.CXR showed fluid overload. Natrecor started
on [**12-24**] and lasix was restarted also. He continued to work on
increasing his ambulation. Heparin stopped on POD #9 when INR
above 2 and he remained in afib. Oral diltiazem was also added
on POD #10 for better rate control. INR 3.0 on [**12-30**] and patient
cleared for discharge to rehab.
Medications on Admission:
accupril 40 mg daily
atenolol 50 mg daily
lasix 40 mg daily
coumadin 7.5 mg ( LD [**12-12**])- followed by Dr. [**Last Name (STitle) 20222**]
MVI daily
lipitor 10 mg daily
ECASA 81 mg daily
Vit C daily
Folic acid daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
s/p Bentall procedure [**12-17**]
CAD with LAD stent
obesity
s/p AMI
elev. chol.
htn
cardiomyopathy
AFib
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
may shower and pat dry
no driving for one month
no lfting greater than 10 pounds for 10 weeks
call for fever or redness of wounds
Followup Instructions:
see Dr. [**Last Name (STitle) 27187**] in [**12-23**] weeks
see Dr. [**Last Name (STitle) 20222**] in [**1-24**] weeks (please confirm that he will
follow INR post-rehab)
see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2193-12-30**] Admission Date: [**2193-12-14**] Discharge Date: [**2193-12-30**]
Date of Birth: [**2127-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tylenol
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increased fatigue over past 2 years
Major Surgical or Invasive Procedure:
Bentall Procedure [**2193-12-17**]
History of Present Illness:
66 yo male with increased fatigue and weight gain over past [**12-23**]
years. He has cardiomyopathy and has been followed by serial
echos. Recently his ascending aorta was found by scan to be
increasing in size from 4.0 to 5.2 cm, and is currently 5.7 cm
at the level of the coronary ostia. Referred after
catheterization for surgical repair of his aorta by Dr.
[**Last Name (STitle) 1290**].
Past Medical History:
ascending aortic aneurysm
CAD
LAD stent [**2186**]
AMI [**2186**]
elev. chol. HTN
cardiomyopathy
AFib s/p cardioversion [**5-26**]
s/p tonsillectomy
s/p anal fissurectomy
LLE vein stripping
s/p RIH repair
Social History:
lives with wife
retired [**Name2 (NI) 28010**]
quit smoking 20 years ago with 70 pack/yr Hx
one drink per week
Family History:
N/A
Physical Exam:
NAD
PERRLA, no LAD, full ROM, no bruits
CTAB
RRR S1 S2 with no m/r/g
protuberant abd, soft, NT , ND
no c/c/e, extrems warm, well perfused
CN II- XII intact
T 98.7 RA sat 93% RR 20 126/64 HR 60
68" 123.8 kg
Pertinent Results:
[**2193-12-25**] 07:30AM BLOOD WBC-9.0 RBC-3.17* Hgb-9.9* Hct-27.8*
MCV-88 MCH-31.4 MCHC-35.8* RDW-14.4 Plt Ct-271
[**2193-12-16**] 03:30PM BLOOD WBC-5.7 RBC-3.77* Hgb-11.8* Hct-33.0*
MCV-88 MCH-31.4 MCHC-35.9* RDW-13.2 Plt Ct-189
[**2193-12-25**] 07:30AM BLOOD Glucose-119* UreaN-85* Creat-2.1* Na-134
K-4.8 Cl-99 HCO3-23 AnGap-17
[**2193-12-16**] 03:30PM BLOOD ALT-19 AST-25 LD(LDH)-201 AlkPhos-73
TotBili-0.2
[**2193-12-16**] 03:30PM BLOOD Albumin-3.9
[**2193-12-14**] 05:42PM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1
[**2193-12-16**] 03:30PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
cath [**10-26**] LAD stent patent, no significant CAD
echo [**8-26**] EF 35-40%
CT scan [**2193-10-23**]: Asc. aorta 5.7 cam at coronary ostia, 3.4 cm
at arch, 2.7 at descending, abdomen normal
[**2193-12-29**] 05:10AM BLOOD WBC-8.7 RBC-3.26* Hgb-9.7* Hct-28.6*
MCV-88 MCH-29.6 MCHC-33.8 RDW-14.8 Plt Ct-260
[**2193-12-30**] 07:05AM BLOOD PT-20.5* INR(PT)-3.0
[**2193-12-30**] 07:05AM BLOOD Glucose-109* UreaN-62* Creat-1.8* Na-137
K-5.0 Cl-100 HCO3-28 AnGap-14
Brief Hospital Course:
Admitted on [**12-14**] pre-operatively for heparin bridge to surgery
after coumadin was stopped at home (last dose 12/22). When INR
dropped to 1.1, he underwent Bentall procedure with Dr.
[**Last Name (STitle) 1290**] on [**12-17**]. He was transferred to the CSRU in stable
condition on a titrated propofol drip. He was extubated early
the next morning and was alert and oriented with no deficits
noted, in sinus rhythm. Glucose managed with an insulin drip.
Chest tubes were removed on POD #2 and coumadin was restarted
for coverage of his mechanical aortic valve. He was transferred
to the floor that afternoon. He went into AFib on POD #3 and
remained on a heparin drip for coverage until INR therapeutic
with coumadin. He also began betablockade and a diltiazem drip
was started briefly for rate control. Amiodarone was also
started.
Creatinine rose to 2.1 on POD #4, and lasix was held. A renal
consult was obtained, and the foley ws DCed. he was transfused
one unit PRBCs.He also began receiving albuterol nebs for some
expiratory wheezing.CXR showed fluid overload. Natrecor started
on [**12-24**] and lasix was restarted also. He continued to work on
increasing his ambulation. Heparin stopped on POD #9 when INR
above 2 and he remained in afib. Oral diltiazem was also added
on POD #10 for better rate control. INR 3.0 on [**12-30**] and patient
cleared for discharge to rehab.
Medications on Admission:
accupril 40 mg daily
atenolol 50 mg daily
lasix 40 mg daily
coumadin 7.5 mg ( LD [**12-12**])- followed by Dr. [**Last Name (STitle) 20222**]
MVI daily
lipitor 10 mg daily
ECASA 81 mg daily
Vit C daily
Folic acid daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
s/p Bentall procedure [**12-17**]
CAD with LAD stent
obesity
s/p AMI
elev. chol.
htn
cardiomyopathy
AFib
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
may shower and pat dry
no driving for one month
no lfting greater than 10 pounds for 10 weeks
call for fever or redness of wounds
Followup Instructions:
see Dr. [**Last Name (STitle) 27187**] in [**12-23**] weeks
see Dr. [**Last Name (STitle) 20222**] in [**1-24**] weeks (please confirm that he will
follow INR post-rehab)
see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2193-12-30**] Name: [**Known lastname **],[**Known firstname 1340**] Unit No: [**Numeric Identifier 4885**]
Admission Date: [**2193-12-14**] Discharge Date: [**2193-12-30**]
Date of Birth: [**2127-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tylenol
Attending:[**First Name3 (LF) 674**]
Addendum:
A CXR was obtained on [**12-30**] as part of discharge planning which
showed a worsening L pleural effusion. As the patient was
asymptomatic with improving renal function and no oxygen
requirement, the decision was made to discharge the patient to
rehab with diuretics.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4886**] Long Term Health - [**Location (un) 4887**]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2193-12-30**]
|
[
"428.0",
"V45.82",
"427.31",
"441.2",
"584.9",
"401.9",
"414.00",
"424.1",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"00.13",
"35.22",
"39.61",
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] |
icd9pcs
|
[
[
[]
]
] |
10400, 10628
|
7347, 8739
|
5192, 5228
|
9248, 9256
|
6277, 7324
|
9480, 10377
|
6024, 6029
|
9119, 9227
|
8765, 8985
|
9280, 9457
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6044, 6258
|
5117, 5154
|
5256, 5651
|
5673, 5880
|
5896, 6008
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,713
| 119,999
|
7390
|
Discharge summary
|
report
|
Admission Date: [**2181-12-13**] Discharge Date: [**2181-12-19**]
Date of Birth: [**2113-1-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
PICC Line Placement, [**2181-12-19**]
History of Present Illness:
Adapted from Dr. [**First Name8 (NamePattern2) 1356**] [**Last Name (NamePattern1) 27175**] admission note. Ms. [**Known lastname 1683**] is a
68F with a PMH s/f COPD (frequent exacerbations), who presents
with one week of worsening [**Known lastname **] and shortness of breath. The
patient reports that she has a chronic [**Known lastname **], of seven months
duration since her valve surgery, which is usually a dry hacking
[**Known lastname **]. This [**Known lastname **], she states, has been evaluated at length
without clear etiology. Since Monday (~4 days ago), she has had
new onset, gradually worsening dyspnea, described as a feeling
that "I can't catch my breath", and a more productive [**Known lastname **]. She
states sputum is clear/black. ROS is notably positive for
congestion, wheezing, occasional paroxysmal nocturnal dyspnea,
and new three pillow orthopnea (over the past week). Her ROS is
notably negative for myalgias, sore throat, chest pain, LE
edema, nausea, vomiting, or diarrhea. She does note improvement
in symptoms after nebulizers at home and felt her [**Known lastname **] improved
after antibiotics were started. She has had sick contacts in her
grandchildren, but thinks that they did not have the flu (they
were all vaccinated for both seasonal and H1N1). Her PCP started
her on moxifloxacin on Wednesday (yesterday)for "bronchitis".
.
Review of systems is otherwise negative.
.
In the emergency department presenting vital signs were T=101.2,
BP=153/71, HR=134, RR=31, O2sat=83%RA. On exam, the ED resident
reports that she had diffuse wheezes. She was treated with
albuterol/ipatropium nebs, 125mg IV solumedrol, and
levofloxacin. Her O2 sats improved to 100% on 2L and she
appeared more comfortable. Labs were notable for a creatinine of
1.6 (baseline 0.9), and a leukocytosis of 16.6. Urine and blood
cultures were not sent. A CXR showed no consolidation, though
the film was of poor quality.
.
On the floor this AM, patient is comfortable and feels her
shortness of breath is much better. She would like to go home
today.
Past Medical History:
Aortic valve replacement (21mm CE Magma Tissue) [**2181-3-8**]
Atrial Fibrillation s/p AVR started on coumadin [**2-26**]
Hypertension
COPD/Asthma
Breast CA s/p L mastectomy 20yrs ago, s/p XRT, LN resection.
Hyperlipidemia
Hyperthyroid (toxic multinodular goiter)
Social History:
Retired, used to work in electronics company as tester. Denies
alcohol use. 20 pack year history of tobacco use, quit > 20
years ago, lives with her daughter who helps her with her meds.
Family History:
Reviewed and NC
Physical Exam:
T=97% BP=146.72 HR=78 O2=97%RA RR: 20
.
.
PHYSICAL EXAM
GENERAL: NAD, Pt does not appear short of breath, Very Pleasant
HEENT: No conjunctival pallor. No scleral icterus. PERRLA/EOMI.
MMM. OP clear. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, tachycardic. Low pitched 2/6 systolic
murmur at RUSB, with pronounced S2, JVP ~7cm
LUNGS: Poor air movement, no audible wheezes
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
LABS ON ADMISSION:
[**12-13**]: WBC-16.6* RBC-4.09*# Hgb-12.3# Hct-38.0# MCV-93 MCH-30.2
MCHC-32.5 RDW-14.0 Plt Ct-328
[**12-13**]: PT-14.2* PTT-25.5 INR(PT)-1.2*
[**12-13**]: Glucose-192* UreaN-31* Creat-1.6* Na-140 K-4.0 Cl-97
HCO3-30
[**12-13**]: CK(CPK)-197*
[**12-13**]: CK-MB-3 proBNP-1425*
[**12-13**]: cTropnT-<0.01
LABS ON DISCHARGE:
[**12-18**]: WBC-27.5* RBC-3.40* Hgb-10.3* Hct-30.9* MCV-91 MCH-30.2
MCHC-33.1 RDW-13.5 Plt Ct-351
[**12-18**]: Glucose-111* UreaN-56* Creat-1.2* Na-146* K-4.0 Cl-105
HCO3-31 AnGap-14
Studies:
CXR ([**12-13**]):
One view. Comparison with [**2181-12-15**]. Patchy increased density in
the right
upper lobe is unchanged. Streaky density at the lung bases is
stable. The
lungs are otherwise clear and unchanged. The heart and
mediastinal structures
are stable in appearance as well.
([**12-15**]) Focal consolidation in the right upper lobe, possibly
somewhat
worse than on the earlier study. Streaky density at the lung
bases consistent
with subsegmental atelectasis or scarring. Evidence for COPD.
Brief Hospital Course:
Ms. [**Known lastname 1683**] is a 68F with a PMH s/f COPD with frequent
exacerbations who presents with four days of worsening dyspnea,
and productive [**Known lastname **]. Now noted to be febrile, hypoxic, and
tachypneic.
.
#. Respiratory distress: On admission CXR pa/lat was performed
and identified a right upper lobe infiltrate concerning for
infection. Pt started on levofloxacin daily, nebulizers, and
prednisone taper. On patient's second day of admission she
spiked a fever and developed respiratory distress. She was
transfered to the ICU. In the ICU antibiotics were changed to
Vanc/Ceftaz/Azithromycin. She improved overnight and returned to
the floor without intubation. She was continued on
Vanc/Ceftaz/Azithromycin and steroid taper. Her breathing slowly
improved. Sputum cultures revealed pseudomonas. PICC line was
placed and antibiotics were changed to Vanc/Cefepime and patient
was discharged to complete a two week course of antibiotics. She
will also complete a rapid prednisone taper. She will follow up
with her PCP and have [**Name Initial (PRE) **] chest xray repeated at 6 weeks.
.
#. Acute kidney injury- Likely related to decreased volume
status. Given 1 liter NS in ED and creatinine decreased to 1.5.
Unclear baseline however patient has had creatinine of 0.9 in
[**Month (only) **]. FE Urea 27% pointing toward pre renal etiology. At
discharge creatinine was 1.2 on 80mg daily lasix. Of note,
during hospitalization did not require potassium
supplementation, so this was held on discharge. PCP should check
level next week and determine if this may be needed in the
future.
.
#. H/o Atrial fibrillation: Continued on metoprolol and
diltiazem
.
#. Hyperlipidemia- continued on simvastatin
.
#. Hyperthyroid (toxic multinodular goiter- continued
methimazole
.
# Hyperglycemia: While on steroids patient developed
significant hyperglycemia which reguired sliding scale insulin.
She was discharge with insulin sliding scale which should be
continued until rapid steroid taper is complete. She should
follow up with PCP in one week to determine if insulin is
required.
Medications on Admission:
-MOXIFLOXACIN 400MG DAILY
-CODEINE-GUAIFENESIN 5-10cc q6hprn
-FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose [**Hospital1 **]
-FUROSEMIDE 80mg daily
-METHIMAZOLE 5mg daily
-METOPROLOL SUCCINATE 25mg daily
-DILTIAZEM 120mg daily
-PROMETHAZINE PRN
-POTASSIUM 10MEQ TID
-SIMVASTATIN 80 mg [**Hospital1 **]
-TIOTROPIUM BROMIDE 18 mcg Capsule daily
-ASPIRIN 325 mg daily
Discharge Medications:
1. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for [**Hospital1 **]. ML(s)
2. Methimazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once
a day for 9 days: For 9 more days.
Last day [**2181-12-28**]. .
Disp:*9 qs* Refills:*0*
8. Cefepime 2 gram Recon Soln Sig: One (1) Intravenous every
twenty-four(24) hours for 9 days: Continue for 9 days.
Last day [**2181-12-28**]. .
Disp:*9 qs* Refills:*0*
9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 days: Please take 40mg Prednisone [**2181-12-20**]. .
Disp:*2 Tablet(s)* Refills:*0*
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Please take 20mg Prednisone on [**12-21**] and [**12-22**].
Disp:*2 Tablet(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Please take 10mg of prednisone on [**12-23**] and [**12-24**]. .
Disp:*2 Tablet(s)* Refills:*0*
14. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous ASDIR (AS DIRECTED) for 10 days: Please refer to
sliding scale to determine correct number of units.
Continue insulin until you follow up with your primary care
physician next week. .
Disp:*qs qs* Refills:*0*
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Glucometer
Please provide patient with glucometer. Please check blood
sugars in the before breakfast, before lunch, before dinner, and
at bedtime.
17. Lancets
Please provide patient with lancing device in order for patient
to check blood sugar.
18. Alcohol Prep Pad
Please wipe area with alcohol prep before checking blood sugar.
19. Syringe
Please provide patient with syringes for insulin injection.
Number: 50
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary:
Pneumonia - Pseudomonas
COPD Exacerbation
Secondary: Acute Kidney Injury
Discharge Condition:
Stable. Afebrile. Sating 95% on Room Air.
Discharge Instructions:
Dear Ms. [**Known lastname 1683**]
It was a pleasure caring for you while you were hospitalized
with shortness of breath. On admission to the hospital you were
found to have a fever. You were ruled out for the H1N1 virus.
Chest xray was performed a pneumonia was identified in the right
upper lobe. You were placed on antibiotics, nebulizer
treatments, and steroids. During your admission your breathing
worsened and you were transferred overnight to the intensive
care unit. Your breathing slowly improved. At discharge you
should continue to use your inhalers as prescribed, continue the
steroid taper started in the hospital, and finish the course of
IV antibiotics started in the hospital. Further, secondary to
steroids you developed high blood sugars which will require
insulin until you complete your steroid course. You should
follow up with your PCP in the next week. Further a chest xray
needs to be repeated in 6 weeks and should be followed by your
PCP.
You should check your blood sugars 4 times a day: before
breakfast, before lunch, before dinner, and befor bedtime. Use
the insulin sliding scale provided to determine the correct
amount of insulin. If your blood sugar drops less than 80 please
drink [**Location (un) 2452**] juice and recheck your blood sugar level until it
increases. Warning signs of low blood pressure include:
confusion, fatigue, sweating, feeling warm/cold, or feeling
dizzy.
The following changes were made to your medications:
- START Prednisone taper
- START IV Cefepime and Vancomycin
- START Insulin, until steroid taper is complete
- STOP Moxifloxacin
- STOP Potassium
Please return to the hospital or contact your physician if you
develop increased shortness of breath, chest pain, dizziness,
fever, nausea, vomiting, or diarrhea.
Followup Instructions:
1. Please follow up with [**Last Name (LF) **],[**First Name3 (LF) **] D. ([**Telephone/Fax (1) 6699**]) @
2pm, [**12-26**].
1. Labs to evaluate your need for potassium suplementation. This
was held in the hospital given normal potassium levels.
2. CXR in 6 weeks to follow up pneumonia
3. Referrel to plastic surgery regarding chest wall healing.
4. Further need for insulin after steroid taper is complete
|
[
"276.51",
"V58.61",
"V42.2",
"790.29",
"482.1",
"276.3",
"518.81",
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"585.2",
"403.90",
"493.22",
"427.31",
"V10.3",
"272.4",
"242.20",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9615, 9684
|
4674, 6773
|
337, 377
|
9811, 9855
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3606, 3611
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3950, 4651
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3625, 3931
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,302
| 181,486
|
42724
|
Discharge summary
|
report
|
Admission Date: [**2174-11-17**] Discharge Date: [**2174-12-7**]
Date of Birth: [**2127-7-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Fish derived / Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Seizure/ SAH/ L ACA aneurysm
Major Surgical or Invasive Procedure:
[**2174-11-17**] COILING OF PERCOLLOSAL ANEURYSM
[**2174-11-17**] RIGHT FRONTAL EXTERNAL VENTRICULAR DRAIN PLACED
[**2174-11-21**] ANGIOGRAM WITH COILING
[**2174-11-21**] CEREBRAL ANGIOGRAM
[**2174-11-21**] LEFT FRONTAL INTRACRANIAL PRESSURE MONITOR PLACEMENT
[**2174-11-25**] BIFRONTAL CRANIECTOMY
History of Present Illness:
47f who was getting ready to drive home from a meeting when she
had a witnessed seizure. The seizure last approximately 1
minute. According to reports she was awake and alert after
seizure ended and she told paramedics she had never had a
seizure before. She was taken to OSH where CT head showed SAH.
She was intubated for declining mental status but was reported
to be moving all extremities. She was transferred to [**Hospital1 18**] for
further evaluation.
Past Medical History:
none known
Social History:
IVDA has been clean x 11 [**Hospital1 1686**] prior to admission
has a daughter (approx 20 [**Hospital1 1686**] old)
has a significant other x 20+[**Name2 (NI) 1686**]
Works as a CNA in [**Hospital 1474**] hospital
Family History:
unknown
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: [**Doctor Last Name **]:3 GCS E: V: Intubated Motor:
T: BP: 105/70 HR: 84 R O2Sats 100%
Gen: Intubated.
Physical exam: +cough. Bilateral corneal reflexes. No eye
opening/commands. Face appears symmetric. PERRLA [**1-20**]. No
movement
in BUE and BLE to noxious stimuli.
On Discharge:
Awake, alert, nonverbal (trach), follows commands on R side > L
side. R side is spont/purposeful, L side withdraws, LUE is weak
antigravity if challenged. Nods appropiately to name and place.
Pupils equal/reactive, tracks. Head incision C/D/I
Pertinent Results:
[**2174-11-17**] CTA:
1. Short interval progression of right frontal hematoma and
intraventricular extension of hemorrhage. Largely stable
subarachnoid hemorrhage along the falx, medial superior sulci,
inferior frontal lobe, and basal cisterns.
2. 2.5-mm aneurysm originating from the A2 segment with a faint
tail of
contrast tracking towards the intraparenchymal hemorrhage.
3. Unchanged obliteration of cerebral sulci and basal cisterns,
concerning for cerebral edema.
4. Incedential finding of multiple lung cysts that should be
further addressed by chest CT. Inhomogeneous thyroid with
abnormally reduced enhancement, suggestive of chronic thyroditis
[**2174-11-17**] CXR:
1. ET tube terminating 4.1 cm above the carina.
2. Orogastric tube within the stomach.
3. No acute intrathoracic process.
[**2174-11-18**] CT Brain:
1. Unchanged position of a right frontal approach
ventriculostomy catheter in comparison to [**2174-11-17**] 5:20
p.m. study.
2. Decreased visibility of blood products along the tentorial
leaflets. The remainder of the examination, including
demonstration of a large right frontal and vertex hematoma,
appears stable.
[**2174-11-18**] ECHO:
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 35 cm from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations or clinically-significant
valvular disease seen.
[**2174-11-19**] CTA Brain:
Wet Read: LLTc SAT [**2174-11-19**] 1:14 AM
NCCT: 1. New trace pneumocephalus along the right
ventriculostomy catheter. 2.
Unchanged ventriculostomy position. 3. New trace
intraventricular blood, possibly reflecting redistribution. No
change in the caliber of the ventricles. 4. Unchanged appearance
of the main right frontal and midline vertex hematoma and
frontal sulcal blood. 5. No new mass effect. CTA: No vasospasm
detected. No dissection seen. s/p left A2 segment ACA coiling.
3D reconstructions pending.
[**2174-11-20**] BUE Venous U/S:
IMPRESSION:
1. Partially occlusive thrombi within the left brachial and
cephalic veins.
2. No evidence for DVT of the right upper extremity.
[**2174-11-21**] TCD:
Impression: Abnormal TCD evaluation. Increased velocities in the
ACA bilaterally, MCA bilaterally, PCA bilaterally, vertebral
arteries, and basilar artery are most likely due to reactive
hyperemia or the effects of triple H therapy. There was no
vasospasm seen. Clinical correlation is needed.
[**2174-11-21**] Angiogram: No vasospasm
[**2174-11-22**] US UE
IMPRESSION: Occlusive thrombus seen within the left basilic
vein. No
thrombus identified within the deep veins of the left arm. Note
is made that the left cephalic vein could not be identified
[**2174-11-23**] CXR
In comparison with the study of [**11-21**], the monitoring and support
devices remain in place. Minimal indistinctness of pulmonary
markings could reflect some residual elevation of pulmonary
venous pressure. No evidence of acute focal pneumonia.
HEAD CT W/O CONTRAST [**2174-11-24**]
Unchanged appearance of intraparenchymal hematoma compared with
[**2173-11-22**]. Ventricular drain and ICP monitoring device are
in
appropriate positions.
HEAD CT [**2174-11-25**]:
IMPRESSION:
1. Status post craniotomy with expected post-surgical changes
including
pneumocephalus and effacement of cerebral sulci.
2. Persistence of intraparenchymal, subarachnoid, and
intraventricular
hemorrhage. No evidence of new hemorrhage or infarction.
3. ICP monitoring device and ventriculostomy catheter have been
removed.
Interventional radiology coil is in stable position compared
with prior study.
HEAD CT [**2174-11-26**]:
IMPRESSION: No significant short interval change since [**11-25**], [**2174**] of extent of intraventricular and subarachnoid
hemorrhage with similar
degree of mass effect. No new hemorrhage or infarct.
LIVER/GALLBLADDER ULTRASOUND [**2174-11-28**]:
IMPRESSION:
1) Gallbladder wall edema with layering stones/sludge. Edema is
nonspecific in the setting of documented hypoalbuminemia.
Pericholecystic fluid is nonspecific in the setting of a small
amount of abdominal ascites elsewhere. If clinically indicated,
a HIDA scan would be beneficial to exclude acute cholecystitis.
2) Hyperechoic left hepatic lobe lesion measuring 1.8 cm. If
there is no
known history of liver disease, this likely represents a
hemangioma. If there is a history of liver disease, MRI or CT
would be indicated for further evaluation when clinically
feasible.
3) Incidental left and right pleural effusions noted.
LENIS [**2174-11-28**]:
IMPRESSION:
No right or left lower extremity DVT.
CTA HEAD [**2174-11-28**]:
HEAD CTA: Study is limited due to streaking artifact secondary
to surgical
staples. Of note, proximal vessels including vertebral and
carotid arteries
show a markedly reduced caliber compared with prior CTA. The
rotational
volume-rendered 3D-reconstructions show diffuse decrease in
caliber of the
vessels of the posterior and anterior circulation, without
evidence of
occlusion or new aneurysm.
IMPRESSION:
1. CT angiography of the head demonstrates diffuse decrease in
caliber and
irregulariy of proximal and distal vessels of both the anterior
and the
posterior circulation, compared with prior exam. This may be
related to
diffuse vasospasm, to decrease in blood flow to the brain due to
CNS
auto-regulatory mechanisms in the setting of decreased function,
or it mighft be secondary to inhibitory effect of induced
barbiturate coma. Technical issues may also have contributed to
this overall appearance.
2. Interval improvement of diffuse cerebral edema with interval
decrease in effacement of sulci.
3. Interval improvement of intraventricular hemorrhage.
4. No interval change in extent of parenchymal hemorrhage.
Brain MRI [**2174-11-29**]:
FINDINGS: The patient is status post bilateral craniectomies.
Again blood
products are demonstrated along the corpus callosum, restricted
diffusion is noted in the genu and also in the splenium of the
corpus callosum (image #17, series 402), also areas with high
signal intensity in the lateral ventricles, related with
residual intraventricular hemorrhagic changes. Again a 21 mm by
25 mm, right frontal hematoma is redemonstrated and unchanged
since the most recent head CT. There is mild asymmetry of the
ventricular horns with mild mass effect in the right frontal
ventricular [**Doctor Last Name 534**] with no evidence of transependymal migration of
CSF. Small area of low signal intensity is identified in the
anterior cerebral artery, consistent with coils. The
perimesencephalic cisterns are patent, there is no evidence of
thalamic or pontine infarcts. The orbits are unremarkable,
bilateral mucosal thickening is noted at the mastoid air cells
and also in the sphenoid sinus, the patient is intubated.
IMPRESSION:
1. Areas of restricted diffusion identified in the corpus
callosum suggesting ischemic changes, more significant in the
splenium, there is no evidence of thalamic hemorrhage.
2. Residual blood products are redemonstrated in the lateral
ventricles,
unchanged right frontal lobe hematoma with associated vasogenic
edema, causing mild mass effect on the right frontal ventricular
[**Doctor Last Name 534**], relatively stable since the prior head CT. The patient is
status post bilateral frontal craniectomies and left anterior
cerebral artery aneurysm coiling. Mucosal thickening identified
in the mastoid air cells and sphenoid sinus.
Head CT [**2174-12-1**]:
FINDINGS: Patient is status post bilateral frontal craniectomies
and left
anterior cerebral artery aneurysm coil with related artifacts.
There is
residual bilateral focal subarachnoid hemorrhage. Residual blood
is seen in the lateral ventricles. There is similar right
frontal lobe hematoma with associated vasogenic edema, causing
mass effect on the frontal [**Doctor Last Name 534**] of the right lateral ventricle.
The focal abnormality seen on recent MRI in corpus callosum is
better evaluated on the MR. There is unchanged small focus of
calcification in the left caudate. There is no new acute
hemorrhage. There is no shift of midline structures.
IMPRESSION: Residual blood products in lateral ventricles.
Similar right
frontal lobe hematoma with vasogenic edema and mass effect on
the frontal [**Doctor Last Name 534**] of the right lateral ventricle. No acute
hemorrhage. No shift of midline structures. Residual
subarachnoid hemorrhage bilaterally.
Gallbladder scan [**2174-12-5**]:
INTERPRETATION: Serial images over the abdomen show prompt
uptake of tracer into the hepatic parenchyma in a homogeneous
pattern.
At 100 minutes, the small bowel is visualized with tracer
activity noted in the gallbladder at 15 minutes.
IMPRESSION:
Delayed tracer activity in the small bowel, compatible with
possible
intermittent biliary obstruction. No evidence of acute
cholecystits.
[**2174-12-7**] 08:35AM BLOOD WBC-12.5* RBC-3.56* Hgb-10.9* Hct-33.0*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.9 Plt Ct-885*
[**2174-12-6**] 06:10AM BLOOD WBC-15.7* RBC-3.75* Hgb-11.4* Hct-35.1*
MCV-93 MCH-30.5 MCHC-32.6 RDW-15.1 Plt Ct-739*
[**2174-12-5**] 04:25AM BLOOD WBC-12.8* RBC-3.52* Hgb-10.8* Hct-32.6*
MCV-92 MCH-30.6 MCHC-33.2 RDW-14.9 Plt Ct-550*
[**2174-12-4**] 02:12AM BLOOD WBC-16.9* RBC-3.40* Hgb-10.5* Hct-31.2*
MCV-92 MCH-30.8 MCHC-33.6 RDW-15.4 Plt Ct-380
[**2174-12-3**] 01:51AM BLOOD WBC-17.7* RBC-3.17* Hgb-10.0* Hct-28.8*
MCV-91 MCH-31.4 MCHC-34.6 RDW-15.2 Plt Ct-282#
[**2174-12-2**] 02:30AM BLOOD WBC-15.1* RBC-3.00* Hgb-9.5* Hct-27.2*
MCV-91 MCH-31.7 MCHC-34.9 RDW-15.2 Plt Ct-187
[**2174-12-7**] 08:35AM BLOOD Glucose-122* UreaN-15 Creat-0.4 Na-139
K-4.8 Cl-102 HCO3-28 AnGap-14
[**2174-12-6**] 06:10AM BLOOD Glucose-116* UreaN-16 Creat-0.4 Na-138
K-4.3 Cl-101 HCO3-28 AnGap-13
[**2174-12-5**] 04:25AM BLOOD Glucose-131* UreaN-15 Creat-0.4 Na-141
K-4.3 Cl-104 HCO3-27 AnGap-14
[**2174-12-4**] 02:12AM BLOOD Glucose-119* UreaN-10 Creat-0.4 Na-139
K-4.0 Cl-103 HCO3-24 AnGap-16
[**2174-12-6**] 06:10AM BLOOD ALT-119* AST-52* LD(LDH)-287*
AlkPhos-146* Amylase-125* TotBili-0.2
[**2174-12-5**] 04:25AM BLOOD ALT-143* AST-62* AlkPhos-149* TotBili-0.2
[**2174-12-4**] 02:12AM BLOOD ALT-163* AST-64* LD(LDH)-293*
AlkPhos-150* TotBili-0.2
[**2174-12-3**] 01:51AM BLOOD ALT-216* AST-79* LD(LDH)-277*
AlkPhos-165* TotBili-0.3
[**2174-12-2**] 02:30AM BLOOD ALT-286* AST-124* AlkPhos-167*
TotBili-0.2
[**2174-12-1**] 01:09AM BLOOD ALT-449* AST-457* LD(LDH)-344*
AlkPhos-201* TotBili-0.2
[**2174-11-30**] 01:26AM BLOOD ALT-442* AST-676* AlkPhos-210*
TotBili-0.2
[**2174-11-28**] 11:58PM BLOOD ALT-158* AST-227* LD(LDH)-363*
AlkPhos-156* TotBili-0.2
[**2174-11-27**] 11:20AM BLOOD Amylase-78
[**2174-11-24**] 03:16AM BLOOD ALT-30 AST-22 LD(LDH)-127 AlkPhos-46
TotBili-0.1
[**2174-11-18**] 02:43AM BLOOD ALT-23 AST-22 AlkPhos-46 TotBili-0.2
Brief Hospital Course:
Pt was transferred to [**Hospital1 18**] after witnessed sz and OSH CT scan
reveal SAH.
On [**11-18**], She was intubated for worsening exam. An EVD was
placed and set at 20Cm H2O. She was started on Dilantin and
nimodipine, an A-line was secured and she was admitted to the
ICU. On inital exams she had reactive pupils with grimacing.
There was no eye opening nor command follwing. She was extensor
posturing. This improved slightly after evd placement. The HCG
was negative
Diangostic cerebral angiogram with coiling of Pericollosal
aneurysm was performed and the pt tolerated this procedure well.
The intracranial pressures were elevated and a repeat Head CT
was performed which was consistent with stable hemorrhage. The
ICPs were in the 30s and the patient was hyperventilated and
mannitol was given. The Dilantin level was dilantin 18.
On [**11-19**], The patient was transitioned to Keppra from Dilantin.
In the morning there were transient ICP increases when the
patient was off sedation. Neurology consult was requested for
prognosis and felt she needed time for recovery. Transcranial
Doppler Studies were performed and showed no vasospasm.
The External Ventricular Drain stopped working and TPA 2mg was
instilled in the EVD catheter for clot clearance and the EVD was
clamped at 230 pm x30 mins. The TPA was successful and the EVD
began to drain again. The ICPs were elevated and the patient
was Cooled to 35C and mannitol 50gms IV was given and the
patient was chemically paraylzed in an attempt to decrease the
ICP. The outside hospital where the patient originally
presented notified the ICU team that the patients blood cultures
were consistent with gm + Postive Cocci and the patient was
started on triple antibiotic therapy which included: vancomycin,
cipro, and flagyl. The course of antibiotic therapy goal is for
two weeks. The patient was recultured prior to starting the
triple antibiotic therapy. Cooling was stopped at 430 pm. The
EEG was negative. The exam was consistent with no eye opening,
The patient was spontaneously extensor posturing. The patient
made weak attempts to localize with the left upper extremity.
The pupils were 2-1mm bilaterally. To noxious stimulus the
patient grimaced.
On [**11-20**], The ICPs were again elevated to 30's associated with
tachycardia and hypertension. A CTA of the Head was performed
which was stable. In an attempt to decrease the ICP the Artic
Sun was initiated to cool the patient and Mannitol 25gm x1 was
given. The ICPs responded to the treatment and were [**10-4**]. The
patient was taken off paralytics at 0600 to assess a
neurological exam and this was not tolerated. After one hour,
the patient became hypertensive with ICPs up to 40's and
subsequently paralytics were restarted. The Neurology service
saw the patient and stated that the 24 hour EEG was consistent
with right frontal rythmic sharps but not full seizure. It was
recommended that the patient's Keppra be increased to 1000mg [**Hospital1 **]
and Dilantin remain at 100 mg TID. At 1000am the urine output
was 400cc and 1100 500cc. A serum sodium and Osmoality and urine
specific gravity were sent. The specific gravity of the urine
was 1.005 and the repeat was 1.027cooling. At 1145 am the ICP
was again elevated at 32 and 25 grams mannitol given and 3% NACL
IV was started at a rate of 20cc/hr.
On [**11-20**], The EVD stopped draining CSF 10 am. The External
Ventricular Drain was flushed and began working again, but
persistent ICP were 25-30 with concurrent heart rate of 40-50.
The patient was given 1 mg ativan, 25 grams mannitol IV x 1 and
the ICP decreased to 16 with a good waveform. The patient
continued to be cooled at 34 degrees /paralyzed with IV
cistracurium/sedated with propofol/and remained on neosynephrine
IV gtt to maintain SBP at a minimum of 110 with a goal 110 to
200. The EEG was reported to be unchanged and the
recommendation per neurology was to keep the patient on dilantin
and keppra.At 1600, ICP was again elevated to 30, fentanyl was
increased 50mcq/hr,NACL gtt increased 60cc/hr, mannitol 25 gm IV
x1 given and ICP decreased to 16. A Bilateral Upper Extremity
Ultrasound was performed and the preliminary report was
consistent with left upper extremity deep vein thrombosis in the
brachial and cephalic vein. Corrected Dilantin level 23 and
dilantin pm dose held.
On [**11-21**], the EVD was flushed again with elevated ICP and she was
found to have severe MCA vasospasm on TCD. The patient was
cooled further to 33 degrees, continued neo gtt to maintain SBP
180-200 and goal CPP>60. 3% saline was reduced from 60 to 30 per
hour with q4hr electrolytes. [**Last Name (un) **] bolt was placed with ICP's
up to 27. An angiogram was performed which showed no vasospasm.
On [**11-22**], There was concern that her ICP bolt transducer was not
functioning properly as there was a dampened waveform. A repeat
Head CT was obtained which confirmed placement. Her ICPs spiked
to the 30's in the AM, and she received Mannitol 25gm IV x1 with
good effect. A second dose of Mannitol was started but stopped
as her ICPs were < 20. She remained on the cooling blanket for
goal temp of 34 degrees. Hypertonic Saline continued to infuse
at 30cc/hr and NEO was used to keep her SBP > 100. Vancomycin
was discontinued given there was no evidence of gram negative
rods. Early afternoon, her ICPs began climbing slowly to 20-23.
In the evening around 5pm her ICPs were > 23 upto 30, there was
no response with interm boluses of profolol and Fentanyl,
Mannitol 25gm was given and pentobarb was started. The 3% NS was
increased with a goal to titrate for serum NA 145-150.
On [**11-23**]% saline increased to 75cc/hr. The dilantin was
discontinued per neurology and her pentobarb was increased to 3
for burst suppression. On [**11-24**], ICP remained stable on pentobarb
and her paralytics were discontinued. The pentobarb was also
decreased to 2 and rewarming to normothermic was started. Over
the course of the day, her ICPs began to climb to high teens,
20s. Fentanyl was given to treat pain which did not help ICPs.
Over the night, ICPs continued to climb, mannitol 25g was given
with short term effect. One unit of PRBCs was given with lasix
to help and ICPs remained in the 20s.
On [**11-25**], ICPs increased to 30, mannitol 25g was given once again
and pentobarb was again increased to 3. A family meeting was
held on [**11-23**] which resulted in the family deciding to be
aggressive. Patient was taken for an emergent bifrontal
craniectomy. An EVD could not be placed post-op. She remained
stable overnight in the ICU. The pentobarb was decreased to 2.
Post-op CT was stable.
On [**11-26**], on exam her craniectomy site was full/tense, her pupils
were 3mm with hippus. The pentobarb was discontinued. A repeat
Head CT was ordered which remained stable and showed no
infarcts. In the afternoon her pupils appeared to be 3mm and
nonreactive. 3% saline was restarted at 40cc/hr with a goal NA
of 140-145.
On [**11-27**], she was febrile and cultures were sent. Her HCT had
dropped to 23 and she was transfused with 1 unit PRBC. Pupils
were reactive. On [**11-28**], her exam remained unchanged and pupils
remained reactive. 3% at 40cc/hr continued for a serum NA goal
of 140-145. She also had a liver/gallbladder ultrasound as her
LFTs were elevated. The ultrasound showed some gallbladder wall
edema with sludge/stones. No further testing was done. An MRI
brain was ordered for prognosis assessment as the next step
would be trach/peg and the family does not wish to continue if
her prognosis appears poor and she would be dependent on a
trach/feeding tube. A CTA Head was also done which showed no
vasospasm or new infarcts.
On [**11-29**], her 3% was dropped to 30cc/hr and her NA remained
stable. Her exam remained unchanged. An MRI brain was done
overnight which showed no infarcts. On [**11-30**], the team pursued
trach/PEG. A helmet was ordered. Her 3% was discontinued.
Patient underwent a HIDA scan on the 16th for persistantly
elevated LFTs. This study showed some sludge in the galbladder
with intermitant biliary obsturction. General surgery was
consulted for input, they indicated that no follow was needed.
Patient continued to have an elevated WBC, sputum cultures from
the [**12-5**] came back with continued GPC and GNR. An ID consult was
called and tx to rehab was postponed. ID felt there was no
infection and the fevers were medication related and recommended
we discontinue pepcid. On [**12-7**], her WBC trended down once again.
On DOD, her exam remained stable and she was discharged to
rehab.
Medications on Admission:
none
Discharge Medications:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours): [**Month (only) 116**] d/c on [**12-9**] AM.
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO HS (at
bedtime).
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. acyclovir 400 mg Tablet Sig: Two (2) Tablet PO 5X/DAY (5
Times a Day) for 7 days: Started on [**12-1**].
6. ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO BID (2 times a day).
7. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
9. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO every
eight (8) hours: Hold if NA > 145.
10. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-21**]
Drops Ophthalmic Q4H (every 4 hours) as needed for dry eyes.
11. acetaminophen 650 mg/20.3 mL Suspension Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q2H (every 2 hours) as needed for wheezing.
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast.
16. ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours).
17. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
SUBARACHNOID HEMORRHAGE
HYDROCEPHALUS
CORPUS COLLOSUM BLEED
RESPIRATORY FAILURE
PERICOALLOSAL ANEURYSM (RUPTURED)
SEIZURE
INTRAVENTRICULAR HEMORRHAGE
LEFT BRACHIAL-CEPHALIC THROMBUS
ELEVATED INTERCRANIAL PRESSURES
DIFFUSED CEREBRAL EDEMA
FEVERS
Discharge Condition:
Mental Status: interactive, nonverbal
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
?????? 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.
?????? 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 were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this once cleared by your Neurosurgeon.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] in 4 weeks with an MRI/ MRA of the
brain (Dr. [**First Name (STitle) **] protocol). Please call [**Telephone/Fax (1) 4296**] to make
this appointment.
Follow up with your primary care physician within two weeks of
discharge.
Completed by:[**2174-12-7**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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icd9pcs
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23839, 23936
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318, 619
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24225, 24225
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2033, 13405
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22070, 22076
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1603, 1755
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250, 280
|
647, 1110
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24240, 24380
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1132, 1144
|
1160, 1376
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,083
| 158,793
|
41248
|
Discharge summary
|
report
|
Admission Date: [**2106-1-30**] Discharge Date: [**2106-2-24**]
Date of Birth: [**2046-5-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Abdominal pain, ARF, LE purpura
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Central line placement
Arterial line placement
Bronchoscopy
CVVH
History of Present Illness:
The patient is a 59 yo woman with h/o HCV (last VL 22
million)and B-cell lymphoma who presented from [**Hospital 1281**] Hospital
for further workup of bloody diarrhea, abdominal distension, and
BLE purpura. Ms. [**Known lastname 89843**] states that she was in her normal
state of health until approximately 3 weeks ago when she
developed a bronchitis. She presented to her PCP, [**Name10 (NameIs) **] she was
initially treated with Cefetin. She states that her symptoms did
not improve, so she presented to an [**Hospital **] Care center on [**1-20**]
and was started on Tamiflu for presumed influenza. She then
developed periorbital edema and discontinued this medication.
This was followed by the onset of arthritic pains, abdominal
pain and distention, and then nausea, vomiting, and bloody
diarrhea with clots. She thus presented to the OSH for further
evaluation.
.
At [**Hospital 1281**] Hospital, she developed ARF with a creatinine peak of
2.4, which improved with aggressive hydration. She also
developed anemia with a Hct decrease from 46 to 38. Hct at
presentation was 38 from a baseline of 46, and is now 32. She
had two CT abdomens, which were unremarkable, and she was
started on Levofloxacin for a presumed CAP. Yesterday, she
developed a purpuric rash on her lower extremities, so she was
started on IV Solumedrol for a presumed vasculitis. Given her
uncertain diagnosis, she was transferred to [**Hospital1 18**] for further
workup and evaluation.
.
On arrival to [**Hospital1 18**], she was reporting worsening shortness of
breath and increasing abdominal distension. She was continued on
Levofloxacin and Solumedrol. At approximately 7 am, she had a
short run of VTach in the 250s that the converted into AFib with
RVR. She was noted to desat to 85% with movement. She was given
Diltiazem 30 mg PO x1 and then developed a 7 second pause. She
complained of chest pain, so an EKG was obtained, which
demonstrated AFib with a rate of [**Street Address(2) 89844**]/T wave changes.
She then was noted on telemetry to be persistently in the 50s.
Given her bradycardia and hypoxia, she was transferred to the
MICU for further management.
.
In the MICU, the patient states that she continues to have
diffuse abdominal pain. She also has 4/10 chest pain that is
non-radiating and is associated with SOB.
.
Review of systems:
(+) Per HPI. In addition, she endorses a 30 lb weight gain,
productive cough, abdominal distension, abdominal tenderness,
chills
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Hep C [**2093**] (VL to 22 million no [**9-11**], s/p treatment with
interferon and ribavirin but dc'd due to side effects - followed
by Dr. [**Last Name (STitle) 89845**] at [**Hospital1 2025**])
- Splenomegaly
- Cryoglobulinemia diagnosed in [**2098**] treated with Rituxan
- Low grade B-Cell Lymphoma followed by Dr. [**Last Name (STitle) 89846**]
- HLD
- Colitis
- COPD
- GERD
- remote hx of IVDU
Social History:
She is widowed since [**2092**], has 3 daughters. works at [**Company **] in
[**Hospital3 **].
Family History:
Mother had diabetes and cervical cancer. Father had MI and CHF.
Physical Exam:
On Admission:
VS - T 95.2 BP 120/80 HR 72 RR 22 Sat 94 RA
Gen: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 7 cm.
CV: S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: CTAB, no crackles, wheezes or rhonchi, diminished at the
bases.
Abd: no BS, distended, diffusely tender to palpation and
percussion with rebound.
Ext: No c/c/e.
Skin: b/l LE purpura noted, non-puritic
Neuro: CN II-XII intact
Pertinent Results:
ADMISSION LABS:
.
OTHER PERTINENT LABS:
[**2106-2-15**] 04:00AM BLOOD [**Doctor Last Name 17012**]-NEGATIVE
[**2106-2-13**] 03:35AM BLOOD Ret Aut-0.6*
[**2106-2-7**] 06:59AM BLOOD Lupus-NEG
[**2106-2-7**] 03:44AM BLOOD ACA IgG-2.0 ACA IgM-6.0
[**2106-2-1**] 03:44PM BLOOD Cryoglb-POSITIVE *
[**2106-1-31**] 05:00AM BLOOD ANCA-NEGATIVE B
[**2106-2-1**] 03:46AM BLOOD RheuFac-32*
[**2106-1-31**] 05:00AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2106-2-6**] 02:11PM BLOOD IgG-251* IgA-75 IgM-62
[**2106-2-7**] 03:44AM BLOOD C3-47* C4-2*
[**2106-2-2**] 07:36PM BLOOD C3-50* C4-<2
[**2106-1-31**] 05:00AM BLOOD C3-52* C4-LESS THAN
[**2106-2-4**] 02:35AM BLOOD ANTI-GBM-Test GLOMERULAR BASEMENT
MEMBRANE ANTIBODY (IGG) <1.0 [Ref <1.0 AI]
[**2106-2-15**] 12:36PM BLOOD O2 Sat-71 MetHgb-0
[**2106-2-9**] 01:00PM BLOOD B-GLUCAN- 61 pg/mL (Negative= Less than
60 pg/mL; Indeterminate= 60 - 79 pg/mL; Positive= Greater than
or equal to 80 pg/mL)
[**2106-2-9**] 01:00PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1
[Ref <0.5]
[**2106-2-7**] 03:44AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG- <9
[Ref <=20 SGU]
.
FINAL LABS:
...............................................................
MICROBIOLOGY:
[**2106-1-30**] HCV Viral Load: 43,700,000 IU/mL
[**2106-2-3**] Urine Cx: Yeast >100,000 organisms/ml
[**2106-2-4**] Urine Cx: Yeast >100,000 organisms/ml
[**2106-2-7**] Urine Cx: Yeast >100,000 organisms/ml
[**2106-2-8**] Urine Cx: Yeast >100,000 organisms/ml
[**2106-2-9**] BAL: no growth
[**2106-2-9**] Respiratory Viral Culture: +Influenza A
[**2106-2-10**] Labia Majora: +HSV2
[**2106-2-21**] Sputum Cx: Sparse coag + Staph aureus
**All other cultures negative**
................................................................
PATHOLOGY:
[**2106-2-1**] Skin Biopsy, right leg: Leukocytoclastic vasculitis with
thrombi containing deposits consistent with cryoglobulinemia.
.
[**2106-2-1**] Skin, right leg for direct immunofluorescence: There are
deposits staining with IgG, IgA, and IgM within the material in
the vascular lumens. There is weak C3 staining in the vascular
lumens. There is fibrinogen staining in some vessels and in
perivascular areas consistent with vasculitis. The staining of
the luminal material is consistent with cryoglobulinemia. The
mixed Ig staining and finding of IgA in the luminal material and
not actually within the vessel wall speaks against an IgA
vasculitis.
................................................................
IMAGING/PROCEDURES:
[**2106-1-31**] CXR: The heart is mildly enlarged. There are bilateral
pleural
effusions. There are small right greater than left. There is
bilateral lower lobe volume loss/infiltrate, and pulmonary
vascular re-distribution. There is right-sided PICC line with
tip at the cavoatrial junction.
IMPRESSION: CHF, an underlying infectious infiltrate cannot be
excluded.
.
[**2106-2-1**] TTE: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is mild-moderate tricuspid
regurgitation. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Right ventricular cavity enlargement. Mild-moderate
tricuspid regurgitation. Pulmonary artery systolic hypertension.
Normal left ventricular cavity size and regional/global systolic
function.
This constellation of findings is suggestive of an acute
pulmonary process (e.g., pulmonary embolism, bronchspasm, etc.).
.
[**2106-2-1**] CT ABD/PELVIS:
1. No evidence of intussusception or other acute bowel
pathology.
2. Moderate bilateral pleural effusions and atelectasis.
3. Splenomegaly, which may be related to the patient's lymphoma
or HCV-related liver disease.
.
[**2106-2-5**] Bronchoscopy: General impression: Area of narrowing in
ETT3-4 cm above end - no secretions and no obvious external
compression. All segments and subsegments visualized and patent.
Airways are diffusely inflamed, very collapsible. No blood
visualized in airways.
.
[**2106-2-6**] CXR: After the initial development of pulmonary edema
between [**1-31**] and 14th, heart size and mediastinal
vascular engorgement have returned to [**Location 213**] and yet severe
pulmonary abnormalities remain. What looks like a combination of
lung nodules, large and small and diffuse interstitial
abnormality was present on [**2-4**], and all of it has
improved. I suspect the residual is due to areas of pulmonary
hemorrhage and conceivably disseminated infection. Chest CT
scanning would be helpful to exclude cavitation, a clear
indication of infection, or the development of lung abscess,
particularly in the lingula. ET tube is in standard placement.
Right internal jugular line ends in the low SVC and nasogastric
tube passes below the diaphragm and out of view. No
pneumothorax.
.
[**2106-2-9**] CT HEAD: 1. No acute intracranial process. 2. Extensive
paranasal mucosal opacification with associated bony sclerosis
indicative of a chronic component.
.
[**2106-2-9**] CT ABD/PELVIS: 1. Bibasilar consolidations, increased
from the prior examination concerning for infection.
2. Diffuse ground glass opacities, likely pulmonary edema.
3. No evidence of bowel obstruction.
4. Splenomegaly.
5. Multiple nonobstructing renal stones bilaterally.
6. Diverticulosis.
.
[**2106-2-9**] CT Chest w/o con:
1. Bibasilar consolidations, increased from the prior
examination concerning
for infection.
2. Diffuse ground glass opacities, likely pulmonary edema.
3. No evidence of bowel obstruction.
4. Splenomegaly.
5. Multiple nonobstructing renal stones bilaterally.
6. Diverticulosis.
.
[**2106-2-22**] Abdominal X-ray: Non-diagnositc abdominal radiograph.
Imaging should be repeated.
.
[**2106-2-24**] CXR: In comparison with the study of [**2-23**], there is little
change.
Monitoring and support devices remain in place and diffuse
bilateral pulmonary opacifications persist. The appearance is
consistent with severe pneumonia with vascular congestion and
possibly ARDS.
Brief Hospital Course:
59 yo woman with h/o HCV and B-cell lymphoma who presented to an
OSH with increasing abdominal distension, shortness of breath,
and bloody diarrhea. She was transferred to the [**Hospital1 18**] MICU for
increasing hypoxia, hypotension, and a junctional bradycardia.
.
# Hypoxic respiratory failure: Patient desaturated to high
80??????s-mid 90??????s on high flow oxygen and was tachypnic leading to
intubation. Patient satisfied criteria for ARDS. Initial
consensus opinion among consulting teams was that the patient??????s
constellation of findings and history are consistent with
cryglobulinemia, manifesting with particularly active pulmonary
vasculitis, which is an uncommon but documented phenomenon.
Patient was intubated, put on ARDS low tidal volume protocol,
though eventually required increased vent support and paralysis.
She was diagnosed with cryoglobulinemia by serum test as well as
skin biopsy and was treated with solumedrol, underwent 5
sessions of plasmapheresis and received 1 dose of rituxan per
rheumatology and heme/onc recs. Her oxygenation did not improve,
which raised concern for an alternate or secondary process.
Pulmonary edema was felt to be a possible contributor so the
patient was gently diuresed on a lasix drip with minimal
improvement. She eventually stopped diuresing to lasix and
required CVVH to remove volume. Fungal markers were sent
(concern increased in setting of her immunosuppression) and were
negative. Patient underwent bronchoscopy on [**2-5**] which showed
diffusely inflamed collapsible airways without any blood
visualized. Micro data was notable for yeast on sputum and BAL,
as well as a positive influenza A assay. She was started on
oseltamivir per ID recs. She was also empirically started on
antibiotics (first broadly w/ vanco and cefepime, then narrowed
to levofloxacin) to treat a possible superimposed ventilator
associated bacterial pneumonia. She did not improve on the
oseltamivir and was switched to zanamivir for a 10-day course,
out of concern for possible drug resistance. Despite treatment
for the influenza, pneumonia, and cryoglobulinemia, she
continued to have worsening respiratory status.
.
# Cryoglobulinemia vasculitis: Patient with a history of
cryoglobulinemia, previously treated with rituximab. Was
diagnosed with serum test as well as skin biopsy. She was
treated with high dose solumedrol, which was eventually tapered.
Completed 5 sessions of plasmapheresis per rhematology, heme/onc
and derm. She also received one dose of rituxan per rheum, but
this was later discontinued as it was not felt to be indicated
for her pulmonary distress.
.
# Purpura: The patient developed a lower extremity rash that
appears to be consistent with purpura. Dermatology was consulted
and performed a biopsy which showed leukocytoclastic vasculitis
and Ig deposition consistent with cryoglobulinemic vasculitis.
She later developed worsening purpura over her back and
buttocks.
.
# ARF/Azotemia: Initially attributed to possible pre-renal
picture given low urine Na and FeUrea of 17%. Urine output
improved with fluid rehydration, but then dropped again and
azotemia was then attributed to steroids and later acyclovir.
She was started on CVVH when urine output dropped (though BUN,
creatinine normal) and respiratory distress increased. Urine
with muddy brown casts suggestive of ATN.
.
# Thrombocytopenia: Platelets noted to be declining. HIT
antibody was negative. Cytopenia attributed to drugs,
vasculitis, acute illness, and marrow suppression. Bactrim
(started for prophylaxis) was discontinued.
.
# Abdominal pain/distension: Patient was noted to have abdominal
distension and increased NG tube drainage. CT abdomen negative
for obstruction. Symptoms improved with aggressive bowel
regimen.
.
# AFib with RVR: Throughout the hospitalization she had numerous
episodes of AFib with RVR requiring boluses of IV metoprolol.
She was started on amiodarone.
.
# Hepatitis C: Patient with known history of HCV, viral load
43.7 million. Hepatology was consulted and did not recommend
acute treatment of HCV. She was treated with 1 dose of rituximab
per heme/onc and rheumatology, with hepatology's support that
therapy would not worsen viral hepatitis. Rituximab was
discontinued when it was felt that the primary pulmonary process
was not cryoglobulinemia.
.
# B-Cell lymphoma: Hematology/oncology was consulted and felt
there was not indication for acute intervention.
.
# Labial ulcer: Positive for HSV2. Patient was treated with a
course of acyclovir.
.
# Funguria: Patient with multiple urine cultures with fungus.
Received a dose of fluconazole but felt that was likely fungal
colonization of the Foley. Foley catheter was changed.
# On [**2106-2-24**] following extensive discussions with the family,
consistent with the patient's previously expressed wishes,
decision to move to focus on patient comfort as the priority.
Patient expired peacefully at 7:10pm. The family declined
autopsy.
Medications on Admission:
1. Prozac 20mg daily
2. Lipitor 20mg daily
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia, ARDS, cryoglobulinemia, hepatitis C
Discharge Condition:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2106-2-25**]
|
[
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"070.51",
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"427.1",
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"584.5",
"518.4",
"305.1",
"276.51",
"E947.9",
"518.82",
"997.31",
"458.8",
"287.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"99.71",
"86.11",
"39.95",
"38.91",
"96.6",
"96.72",
"33.23",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15913, 15922
|
10815, 15780
|
336, 441
|
16012, 16177
|
4441, 4441
|
3813, 3878
|
15874, 15890
|
15943, 15991
|
15806, 15851
|
3893, 3893
|
2806, 3259
|
265, 298
|
469, 2787
|
9636, 10792
|
4457, 4459
|
4481, 9627
|
3907, 4422
|
3281, 3685
|
3701, 3797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,027
| 102,951
|
23607
|
Discharge summary
|
report
|
Admission Date: [**2163-6-7**] Discharge Date: [**2163-6-11**]
Date of Birth: [**2084-12-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal wall hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 1683**] is a 78 year old woman on coumadin for Afib currently
on a lovenox bridge for upcoming surgery now w/expanding
hematoma of her right abdominal wall. Patient took last dose of
coumadin on Saturday and took lovenox [**Hospital1 **] Sunday and her first
dose on [**Hospital1 766**] (80mg and 70mg respectively). Noted a small
hematoma at injection site [**Hospital1 766**]. Saw her PCP today who
referred her for ED eval as the hematoma was expanding. No
bleeding from skin. No diffuse abdominal pain, just discomfort
over hematoma sites. No palpitations, no
SOB, no dizziness.
Past Medical History:
Past Medical History: Lymphoma '[**55**], Afib, "ministrokes" on MRI
Past Surgical History: ?partial nephrectomy '80s for
nephrolithiasis
Social History:
Unknown
Family History:
Unknown
Physical Exam:
Vitals: Tm 99.3, Tc 98.5, HR 73, BP 118/81, RR 16, SaO2 97%RA
General: in no acute distress, alert and oriented x 3
Cardiac: regular rate and rhythm
Lungs: Clear to auscultation bilaterally
Abdomen: soft, non-tender, hematoma present on left lower
abdomen
Pertinent Results:
[**2163-6-7**] CT abd/pelvis R rectus sheath hematoma, rupture into
subcutaneous tissue
[**2163-6-7**] 11:16PM HCT-27.1*# HGB-11.2* calcHCT-34
[**2163-6-7**] 01:00PM GLUCOSE-113* UREA N-24* CREAT-1.5* SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12
[**2163-6-7**] 01:00PM PT-17.1* PTT-25.8 INR(PT)-1.5*
Brief Hospital Course:
Ms. [**Known lastname 1683**] was managed conservatively and had her
anti-coagulation held throughout her hospitalization. She
received 2 units of PRBCs in the emergency department due to a
low hematocrit caused by the massive extravasation of blood into
the wall of abdomen. Her hematocrit rose appropriately and
stabilized. Her pain was well managed. She had an episode of
orthostatic hypotension that resolved with fluid and a unit of
PRBC. Her abdominal wall hematoma remained stable and began to
resorb during her admission. The patient's hematologist and PCP
felt that it would be ideal to continue holding anti-coagulation
until after the breast lumpectomy scheduled for [**7-1**]. The
patient agreed with this decision, and she was instructed to
contact her cardiologist to confirm the decision making.
Medications on Admission:
Digoxin .125 qday, lsinopril 5 qya, metoprolol XL 50mg qday,
zocor 40mg qday, tricor 48mg qday, levothyroxine 175mcg qday,
coumadin 2.5mg qM-F/1.5 qSa/[**Doctor First Name **]
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal wall hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service for your abdominal wall
hematoma, which developed while you were on Lovenox. We would
like you to call your cardiologist on [**Doctor First Name 766**] [**2163-6-13**] to confirm
holding your anticoagulation until after you procedure scheduled
on [**2163-7-1**].
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
You will receive a call from Dr.[**Name (NI) 6045**] secretary next
week regarding a follow-up appointment.
Please contact your cardiologist on [**Name (NI) 766**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"E879.8",
"311",
"401.9",
"174.9",
"202.78",
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"V58.61",
"425.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
3360, 3366
|
1838, 2656
|
338, 345
|
3434, 3434
|
1489, 1815
|
5581, 5857
|
1188, 1197
|
2883, 3337
|
3387, 3413
|
2682, 2860
|
3585, 4779
|
1099, 1147
|
1212, 1470
|
4811, 5558
|
275, 300
|
373, 985
|
3449, 3561
|
1029, 1076
|
1163, 1172
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,392
| 185,535
|
4872
|
Discharge summary
|
report
|
Admission Date: [**2152-8-8**] Discharge Date: [**2152-8-10**]
Date of Birth: [**2112-2-18**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Patient is a 40 year old right handed female pediatrician
with past medical history of metastatic breast cancer with known
brain mets who presented to [**Hospital1 18**] ED on [**2152-8-8**] with altered
mental status and seizure activity.
Normally gets care at [**University/College **] Hitchock. Patient diagnosed with
locally advanced left breast cancer in [**2150**]. Staging showed
large
ill defined cancer in left breast along with lymphadenopathy.
Biopsy with 2.2 high grade ductal carcinoma with invasion.
Underwent lymph node dissection and adjuvant chemotherapy
[**2150-8-8**]. Underwent mastectomy [**12-30**]. Cerebellar met discovered
[**5-30**]. Surgically resected followed by radiotherapy. Pulmonary
and
mediastinal mets [**7-1**]. Progessive brain mets noted [**10-1**] and
underwent whole brain XRT [**10-31**] with some regression. Routine
follow up scan [**6-1**] with interval increase in brain mets.
Asymptomatic at that time, but over past one month, apparently
has had episodes of wavy lines in her vision. Started on [**Doctor Last Name **]
AUC 6/docetaxel q3 weeks, with 4 infusions thus far, last on
Thursday [**2152-8-3**].
She was in [**Location (un) 86**] today shopping with a friend. Around 11:30 am,
friend reports that she complained of the wavy lines in her
vision. Then ate lunch okay and accompanied friend to friend's
doctor's appointment on [**Hospital Ward Name 516**]. While there, complained of
nausea in the waiting room. Friend went to see doctor. When she
came out, patient looked glazed over, was unable to get up out
of
chair, ?due to weakness. Friend went to get car while [**Hospital Ward Name **]
staff helped patient into wheelchair and took her down to lobby.
When friend pulled up, patient was reportedly unresponsive.
Transferred to ED. After arrival to ED, noted to have several
minutes of bilateral tonic clonic movements of the extremities
with eye deviation up to the left. Associated with stool
incontinence. Given 2 mg Ativan. Afterwards, reportedly opened
eyes, but never conversant, did not follow commands. Noted to
have persistent tonic extension of her left arm per ED staff.
About 30 minutes later, had second seizure with left eye
deviation and left face and eye rhythmic twitching. Witnessed by
me. Extremities flaccid at time. Unresponsive. Given another 2
mg
Ativan. Loaded with 1 gram Dilantin. Given 10 mg Decadron IV.
Head CT with multiple areas of vasogenic edema concerning for
mets with minimal mass effect, no midline shift, no signs of
herniation, no hemorrhage.
Upon reasssessment 30 minutes later, patient remained
unresponsive and flaccid. No withdrawal to pain. Code status
confirmed with husband. [**Name (NI) 227**] another 4 mg Ativan and then
intubated for depressed mental status and inability to protect
airway.
Thirty minutes post intubation was fight ETT, gagging and
withdrawing to pain. Bolused with additional 500 mg IV Dilantin
while in ED.
Past Medical History:
1. Metastatic breast cancer as above
2. Cellulits [**5-30**]
3. Reactive airway disease
Social History:
Married. 2 small children. Works as a pediatrician.
Husband phone number is [**Telephone/Fax (1) 20347**]. Full code status confirmed
with husband prior to intubation.
Family History:
Non-contributory
Physical Exam:
Tc: 99.2 BP: 172/69 HR: 100
RR: 18 O2Sat.: 99%/RA
Gen: WD/WN, unresponsive.
HEENT: Alopecic. NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Bibasilar rales. Otherwise CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, obese, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Post intubation, grimaces to noxious stimuli. No
verbal output. Not following commands.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Blinks to threat bilaterally.
III, IV, VI: +Oculocephalic reflex.
V, VII: Facies grossly symmetric. +Corneal reflex bilaterally.
VIII: Unable to assess.
IX, X: +Gag
[**Doctor First Name 81**]: Unable to assess.
XII: Unable to assess with ETT.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Withdraws and localizes to pain in LUE>RUE. Internal
rotation of bilateral LEs to noxious.
Sensation: Withdraws and localizes to pain in LUE>RUE. Internal
rotation of bilateral LEs to noxious.
Reflexes: Trace throughout. Toes upgoing bilaterally.
Coordination/Gait: Unable to assess.
Pertinent Results:
wbc 4.3/hct 34.4/plt 186
Na 140/K 3.5/Cl 100/Bicarb 23/BUN 23/Cr 0.8/Gluc 136
U/a neg
Tox neg
Ca 9.4/Mg 1.9/Phos 4.0
CT head [**2152-8-7**]: There is no evidence of acute intracranial
hemorrhage. There are multiple areas of vasogenic edema in the
frontal lobes bilaterally, in the occipital lobes bilaterally,
and more subtle regions within the parietal lobes and left
cerebellum. There are subtle soft tissue attenuation nodules,
isodense to the [**Doctor Last Name 352**] matter, seen centered in these areas, best
seen on series 2, image 20 and series 2, image 19. There are
several areas of loss of [**Doctor Last Name 352**]-white differentiation, most
prominently in the left frontal lobe. These findings in this
patient with history of breast cancer are likely consistent with
metastatic disease. There is local mass effect in the areas of
vasogenic edema but no shift of normally midline structures.
There is no hydrocephalus. The cisterns and sulci are preserved.
BONE WINDOWS: No suspicious lytic or blastic lesions are seen
within the osseous structures. IMPRESSION: Multiple foci of
vasogenic edema, with a suggestion of soft tissue nodules
centered within these areas; these findings are likely
consistent
with metastatic disease in this patient with known breast
cancer.
Followup MRI is recommended for confirmation. There is no
evidence of intracranial hemorrhage, shift of normally midline
structures, or evidence of impending herniation.
PET scan [**2152-5-31**]: Multiple new hypermetabolic lesions in the
bilateral posterior occipital lobes, midline infrathalamic
region, and at least three regions in the left cerebellar
hemisphere. Suspicious small focus in the right pedicle of L3,
possibly on the left side of L3 body. Likely benign healing rib
fracture in left anterior second rib.
MRI Scan [**2152-3-28**]: Multiple metastases including left frontal
ares, left posterior cerebellar.
EEG - [**2152-8-9**] - preliminary findings show no epileptiform
activity, finalized report pending at the time of d/c.
Brief Hospital Course:
Patient is a 40 year old right handed woman with past medical
history of metastatic breast cancer with known brain mets who
presents to [**Hospital1 18**] after having generalized tonic clonic seizure
followed by focal seizure of left face. No return to lucid
baseline in between events and failure to return to lucid
baseline in appropriate time frame after second seizure.
Necessitated increased doses of Ativan as well intubation for
airwary protection. Now with grimacing and localization on exam
so less concern for persistent seizure activity. CT head with
multiple areas of vasogenic edema consistent with mets but no
hemorrhage, midline shift, mass effect.
She was admitted to the Neuro ICU for further monitoring. The
patient had no further seizure activity in the ICU. [**8-9**] the
patient was extubated without difficulty. She had an EEG that
was found to be negative for subclincal seizures. Her dilantin
level remained therapeutic at 15. An MRI study was deferred as
the patient care was assumed by her primary oncologist in New
[**Location (un) **]. She was d/c to home with prescriptions for dilantin
and decadron. Arrangements were made to have the patient follow
with her oncologist upon discharge.
Medications on Admission:
1. Chemo
2. Ambien 10 mg po qHS prn
3. Ativan 0.5-1 mg po bid prn
4. Celexa 20 mg po qd
5. Decadron 4 mg [**Hospital1 **] x 3 days, to finish [**8-6**]
6. Compazine 10 mg po q8h prn
Discharge Medications:
1. Dilantin 100 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours.
Disp:*90 Capsule(s)* Refills:*2*
2. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
generalized tonic clonic seizure
Discharge Condition:
stable
Discharge Instructions:
Dr. [**Last Name (STitle) 3100**] will contact you at home tomorrow regarding a follow
up appointment with his office within the next week.
Please call your Dr.[**Name (NI) 20348**] office or go to the emergency
room if you experience confusion, limb shaking, intractable
headache, difficulty walking, increasing weakness, loss of
sensation.
Followup Instructions:
As above
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"V10.3",
"198.3",
"197.1",
"493.90",
"780.39",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8647, 8653
|
6951, 8177
|
322, 334
|
8730, 8738
|
4890, 6928
|
9129, 9233
|
3625, 3643
|
8410, 8624
|
8674, 8709
|
8203, 8387
|
8762, 9106
|
3658, 4057
|
275, 284
|
362, 3311
|
4178, 4871
|
4072, 4162
|
3333, 3422
|
3438, 3609
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,473
| 109,748
|
39390
|
Discharge summary
|
report
|
Admission Date: [**2128-5-7**] Discharge Date: [**2128-5-10**]
Date of Birth: [**2044-9-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Chief Complaint: Respiratory Distress
Reason for MICU transfer: BIPAP
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 83 year old gentleman with a history of recent
shoulder fracture, afib (not on coumadin), HTN, esophageal
stricture, prostate cancer who is admitted from his rehab with
respiratory distress.
In brief, Mr. [**Known lastname 87081**] has experienced significant cognitive and
functional decline over the past 2 years after sustaining a
cervical fracture. Most recently he was admitted to an OSH in
[**Month (only) 116**] with a R. humerus fx. Admission was complicated by mental
status changes, pneumonia and a left sided pleural effusion. He
was treated with a 7 day course of ctx/azithromycin with good
clinical improvement. He was seen by s+s and was cleared for a
regular diet. An MRI head was unremarkable. He was followed by
ortho-hand and discharged in late [**Month (only) 116**] to [**Hospital3 2558**] rehab
where he had done well with clinical improvement alhtough his
mental status has waxed and waned.
Yesterday, the patient was noted to have a runny nose, loss of
appetite and he complained of abdominal pain. This morning the
patient was found slumped and tachypneic. EMS was called and
found the patient hypoxic on room air to the 60s. Vitals were
100/60 115 15 97.7 74% on 15L o2. CPAP was started en route w/
improvement in his saturations. At Coolige House, his last labs
on [**5-4**] were significant for WBC 5.2, hct 34.4 (diff N 58.6 L
23.6 M 12.9 E 4.0 B 1.2)
In the ED, pressures 110/60 from 85/67, 98/37 and the patient
was afebrile. he was initially unreponsive to sternal rub. Exam
was significant for rhoncherous bilateral breath sounds. Labs
demonstrated wbc 20.6, hct 43.4, plts 351, Cr 1.5 and trop
<0.01. A lactate was 6.9. A UA was positive for ketones and
few bacteria. He was started on bipap 100/60 with improvement
in his o2 to 100%. A CXR revealed a RLL opacity concerning for
pna. The patient was given 1g Vancomycin and cefepime was
ordered but not yet given. An albuterol neb was given w/ no
improvement. The wife and primary care were contact[**Name (NI) **] and
confirmed the patient has baseline severe dementia and unable to
make understandable speech and further both confirmed the
patient is DNR/I. A bedside ultrasound revealed no GB and
dilated loops of bowel and murphys sign was negative. After 1L
of NS the patient's blood pressure improved to the 110s/80s and
his mentation improved. Vitals on transfer were: 120 26 100% on
bipap 100/60 and rectal temp 98.8.
On arrival to the MICU, initial vitals were: 98.1 125 147/82
98% on BiPAP and RR 24. He appeared uncomfortable on the
non-invasive and was weaned to a non-rebreather. He was alert
and smiling and denied pain. He had course rhoncherous breath
sounds and bed-side suctioning reveaed dark brown secretions. An
NG tube was placed and 700cc of coffee ground fluid was
aspirated. The patients wife and a family member accompanied
the patient and indicated the patient was DNR/I and would not
like invasive or heroic measures including no blood
transfusions.
Review of systems: Unable to Obtain
Past Medical History:
PAST MEDICAL HISTORY:
?????? Hip fracture, intertrochanteric
?????? Atrial fibrillation
?????? Hypertension
?????? Vitamin D deficiency
?????? Hyperlipidemia LDL goal < 100
?????? Anemia
?????? Prostate cancer: '[**15**] psa>9 had bx (neg), and in '[**19**] again
climbing and urol was considering another bx late '[**19**] but then
psa declined again; regular f/u urol [**2121-10-8**]; 3rd bx had 1 of
5 cores CA - not felt needs 'ectomy nor bracytx - referred for
xrt at [**Last Name (un) 1724**] by urol; it is felt that this will remain
encapsulated and so unlikely to bring probs lifetime
?????? Esophageal stricture: Ring with recurent dilatations by egd,
last seen [**10-26**] and was advised prilosec 20 and call GI if gerd
sx/dysphagia but o/w just cont ppi [**2121-10-8**]; taking ppi, no sx
[**2122-10-13**] ;[**2123-12-27**]- egd with ring dilated , 5 cm hh and gastric
erosions on qd ppi-
?????? Actinic keratosis
?????? Cervical vertebral fracture: s/p hospitalization for fractures
C5,6,7 and right rib fractures d/t fall down stairs on
[**2126-6-8**]. He underwent decompression laminectomy with posterior
instrumentation to C4-T1 at the [**Hospital1 18**].
?????? Rib fracture
?????? Sciatica: MRI [**2-/2126**]: multilevel degenerative disk disease
with mild impingement of the nerve roots. No mets.
Past Surgical History:
1. Posterior laminotomy bilaterally at C3. [**2125**]
2. Cervical posterior laminectomy at C4, C5, C6, C7. [**2125**]
3. Hip Fracture
4. Shoulder Fracture [**3-/2128**] [**Hospital6 **]
Social History:
Lives with his wife of 15 years. Baseline dementia. Recognizes
only his wife. Extremely hard of hearing. Former painter. No
tobacco, etoh or illicits. No children.
Family History:
Did not obtain.
Physical Exam:
PHYSICAL EXAM ON ADMISSION TO MICU:
Vitals: 98.1 125 147/82 98% on BiPAP and RR 24
General: Somnolent, a+o x 0
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregular rate and rhythm, normal S1 + S2
Lungs: Rhoncherous transmitted BS, decreased BS on left lung
base w/ course BS, no wheeze
Abdomen: abdmonen distended and mildly tender to diffuse
palpation
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema no cyanosis
Neuro: CNII-XII grossly, unable to cooperate w/ exam
.
Pertinent Results:
ADMISSION LABS:
[**2128-5-7**] 09:54AM BLOOD WBC-20.6* RBC-4.62 Hgb-13.2* Hct-43.4
MCV-94 MCH-28.5 MCHC-30.4* RDW-14.3 Plt Ct-351
[**2128-5-7**] 09:54AM BLOOD Neuts-79* Bands-4 Lymphs-15* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2128-5-7**] 09:54AM BLOOD PT-10.7 PTT-24.9* INR(PT)-1.0
[**2128-5-7**] 09:54AM BLOOD Glucose-192* UreaN-35* Creat-1.5* Na-135
K-4.3 Cl-93* HCO3-24 AnGap-22*
[**2128-5-7**] 09:54AM BLOOD Lipase-72*
[**2128-5-7**] 09:54AM BLOOD cTropnT-<0.01
[**2128-5-7**] 09:54AM BLOOD Calcium-10.1 Phos-6.8* Mg-2.3
[**2128-5-7**] 09:54AM BLOOD Lactate-6.9*
CHEST X-RAY ([**2128-5-7**]): Multifocal infiltrates in the right lung
with possible left retrocardiac opacity as well suspicious for
pneumonia in the proper clinical setting. Recommend repeat after
treatment to document resolution.
KUB ([**2128-5-7**], 1:53 PM): Dilated small bowel loops concerning for
obstruction.
KUB ([**2128-5-7**], 3:35 PM): Single left lateral decub radiograph was
provided. There is no evidence of free air. Again seen are
multiple stacked loops of dilated bowel concerning for
obstruction. NG tube is incompletely visualized.
Brief Hospital Course:
This is an 87 year old gentleman with severe dementia who
presented from a nursing facility with hypoxic respiratory
distress in the setting of pneumonia.
# Goals of Care: Patient continues to have significant
respiratory secretions and high o2 requirment. He is likely
chronically aspirating in setting of severe dementia. His wife
[**Name (NI) **] reported she did not want him to suffer, stated death would
be preferred over prolonged suffering. Given his profound
hypoxia and respiratory distress a family meeting was held to
discuss goals of care in which it was decided to focus his care
around comfort. All medications including antibiotics were
discontinued except for morphine, ativan and scopolamine.
Patient ultimately died on [**2128-5-10**] at 1714. Family was at
bedside and declined autopsy.
Medications on Admission:
1. Celebrex 200mg daily
2. MVT one tablet daily
3. Vantin? 200mg daily
4. Tylenol 650mg q6hrs pain
5. Omeprazole 20mg daily
6. Calcium + vit D 600-400mg daily
7. Aspirin 81 mg daily
8. Metoprolol XR 50mg daily
9. Amlodipine 2.5mg daily
10. Namenda 5mg daily
11. Levothyroxine 25 mcg daily
12. Lidocaine topically on l shoulder daily 5%
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2128-5-11**]
|
[
"578.1",
"294.20",
"185",
"427.31",
"244.9",
"272.4",
"560.9",
"268.9",
"285.1",
"584.9",
"518.81",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
8175, 8184
|
6947, 7756
|
376, 382
|
8236, 8246
|
5788, 5788
|
8303, 8342
|
5195, 5213
|
8142, 8152
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8205, 8215
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7782, 8119
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8270, 8280
|
4809, 4997
|
5228, 5769
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3426, 3444
|
281, 338
|
410, 3406
|
5805, 6924
|
3488, 4786
|
5013, 5179
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,723
| 146,616
|
37302
|
Discharge summary
|
report
|
Admission Date: [**2100-7-9**] Discharge Date: [**2100-7-17**]
Date of Birth: [**2078-8-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
abdominal pain and ascites
Major Surgical or Invasive Procedure:
paracentesis
Past Medical History:
Hereditary cholestatic liver disease - Symptoms first developed
at age 3 months, with recurrent episodes of pruritus and
jaundice thereafter; severe cholestasis following EBV infection
at age 18 years. Initial symptomatic improvement with rifampicin
and WelChol as part of [**Hospital1 1872**] study - no longer effective.
Social History:
Lives with father. [**Name (NI) **] 1 twin brother, healthy. Previously
attended NHCI college; unable at present due to illness. Denies
alcohol, tobacco, or illicit drug use.
Family History:
No family members with liver disease.
Pertinent Results:
[**2100-7-9**] 06:35AM PT-19.1* PTT-31.6 INR(PT)-1.7*
[**2100-7-9**] 06:35AM PLT SMR-NORMAL PLT COUNT-190
[**2100-7-9**] 06:35AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-2+ OVALOCYT-1+
TARGET-OCCASIONAL ACANTHOCY-1+
[**2100-7-9**] 06:35AM NEUTS-71* BANDS-2 LYMPHS-17* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2100-7-9**] 06:35AM WBC-6.5 RBC-4.61 HGB-14.1 HCT-41.9 MCV-91
MCH-30.5 MCHC-33.6 RDW-20.8*
[**2100-7-9**] 06:50AM ALBUMIN-2.9* CALCIUM-8.7 PHOSPHATE-2.2*
MAGNESIUM-1.9
[**2100-7-9**] 06:50AM LIPASE-28
[**2100-7-9**] 06:50AM ALT(SGPT)-260* AST(SGOT)-385* LD(LDH)-265*
ALK PHOS-226* TOT BILI-25.4*
[**2100-7-9**] 06:50AM estGFR-Using this
[**2100-7-9**] 06:50AM GLUCOSE-95 UREA N-9 CREAT-0.4* SODIUM-136
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-19* ANION GAP-19
[**2100-7-9**] 06:57AM LACTATE-2.0
[**2100-7-9**] 11:26AM PO2-63* PCO2-33* PH-7.42 TOTAL CO2-22 BASE
XS--1 INTUBATED-NOT INTUBA
[**2100-7-9**] 11:36AM ASCITES WBC-3500* RBC-1575* POLYS-84*
LYMPHS-1* MONOS-14* MACROPHAG-1*
[**2100-7-9**] 11:36AM ASCITES TOT PROT-1.2 GLUCOSE-95 LD(LDH)-64
AMYLASE-27 ALBUMIN-LESS THAN
[**2100-7-9**] 01:25PM URINE MUCOUS-RARE
[**2100-7-9**] 01:25PM URINE AMORPH-RARE
[**2100-7-9**] 01:25PM URINE RBC-12* WBC-19* BACTERIA-FEW YEAST-NONE
EPI-0
[**2100-7-9**] 01:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-LG UROBILNGN-NEG PH-6.0 LEUK-TR
[**2100-7-9**] 01:25PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.050*
[**2100-7-9**] 01:25PM URINE GR HOLD-HOLD
[**2100-7-9**] 01:25PM URINE HOURS-RANDOM
[**2100-7-9**] 01:33PM LACTATE-2.5*
[**2100-7-9**] 04:57PM LACTATE-2.1*
.
[**2100-7-9**] 01:25PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.050*
[**2100-7-9**] 01:25PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-LG Urobiln-NEG pH-6.0 Leuks-TR
[**2100-7-9**] 01:25PM URINE RBC-12* WBC-19* Bacteri-FEW Yeast-NONE
Epi-0
[**2100-7-15**] 06:18PM ASCITES WBC-676* RBC-788* Polys-1* Lymphs-51*
Monos-0 Macroph-48*
[**2100-7-9**] 11:36AM ASCITES WBC-3500* RBC-1575* Polys-84* Lymphs-1*
Monos-14* Macroph-1*
Micro
[**2100-7-9**] 6:35 am BLOOD CULTURE
**FINAL REPORT [**2100-7-12**]**
Blood Culture, Routine (Final [**2100-7-12**]):
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN <=0.12 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2100-7-10**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 00:11A
[**2100-7-10**].
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2100-7-10**]):
GRAM POSITIVE COCCI IN SHORT CHAINS.
.
Peritoneal fluid [**7-9**] and [**7-15**]: no growth
.
Blood cx [**Date range (1) 62150**]: no growth
.
imaging:
.
abd duplex
[**7-9**]
MPRESSION:
1. Nonspecific dilatation of the gallbladder with sludge. Wall
edema may be
related to ascites however prior studies demonstrating a
distended gallbladder
in the setting of ascites did not demonstrate wall edema. New
intrahepatic
biliary ductal dilatation. If there is persistent clinical
concern for acute
cholecystitis, HIDA can be obtained for further evaluation.
2. Evidence of portal hypertension including ascites,
recanalized umbilical
vein and splenomegaly.
3. 1.7 mm gallbladder polyp.
.
[**7-9**]
CT abd/pelv
IMPRESSION:
1. Interval development of small-to-moderate volume ascites with
findings of
cirrhosis and hypertension including varices and splenomegaly.
2. No acute intraabdominal process. Normal caliber appendix
without wall
thickening or hyperemia with two foci of hyperdensity possibly
reflecting
appendicoliths without evidence for appendicitis.
3. Unchanged massive gallbladder distention as on the prior
study.
4. Mild colonic wall thickening as on the prior study likely
reflects third
spacing.
.
[**7-13**]
echo
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. 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
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal.
Significant pulmonic regurgitation is seen. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
No vegetation seen.
Compared with the prior study (images reviewed) of [**2099-11-12**],
the pulmonic regurgitation now appears more prominent. .
.
[**7-13**]
repeat gallbladder/liver US
IMPRESSION: Unchanged appearance of the gallbladder
demonstrating persistent
wall thickness, tumefactive sludge and a single stone.
.
[**7-15**]
peritoneal fluid cytology:
negative for malignant cells
.
Discharge labs:
.
[**2100-7-17**] 05:55AM BLOOD WBC-3.1* RBC-3.67* Hgb-11.1* Hct-33.1*
MCV-90 MCH-30.1 MCHC-33.4 RDW-21.0* Plt Ct-112*
[**2100-7-17**] 05:55AM BLOOD Plt Ct-112*
[**2100-7-17**] 05:55AM BLOOD PT-21.1* PTT-39.5* INR(PT)-1.9*
[**2100-7-17**] 05:55AM BLOOD Glucose-79 UreaN-12 Creat-0.5 Na-137
K-4.2 Cl-103 HCO3-24 AnGap-14
[**2100-7-17**] 05:55AM BLOOD ALT-209* AST-367* AlkPhos-124
TotBili-18.1*
[**2100-7-17**] 05:55AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.0
Brief Hospital Course:
21 yo male with congenital intrahepatic cholestasis type 1 and
cirrhosis (MELD 25, Child's C) admitted with SBP and elevated
lactate.
.
SBP: On presentation pt had extremely tender abdomen with
distention and ascites. Pt was also found to have elevated
lactate, so surgery was consulted for workup of possible acute
abdomen. CT scan did not show acute intra-abdominal process.
Pt underwent paracentesis which was positive for SBP. Ascitic
fluid did not speciate but blood cx from ER grew strep viridans.
Pt was treated with CTX and albumin for SBP. Surveillance
blood cultures remained sterile and a repeat paracentesis on
[**7-15**] revealed WBC of 676 and 1% polys. At time of discharge,
pts abdominal pain had improved drastically but he was still
distended. He was treated with an additional 7 days of zosyn,
and after course will start prophylaxis with cipro 500 daily.
.
Intrahepatic cholestasis type 1 cirrhosis. On admission MELD is
25. Clearly his disease is progressing and will need to be
worked up for liver transplantation after he finishes course of
abx. Transplantation was discussed with family and pt and they
are considering moving to [**State 108**] for more urgent transplant.
Pt was started on ursodiol during admission and did not show any
adverse side effects. His tbili had trended from 25 on
admission down to 18 at time of discharge. He was discharged on
all home medications with addition of ursodiol and he will begin
SBP prophylaxis with cipro as discussed above.
.
Transitional:
- continue workup for transplantation
- will need PICC removed after completes zosyn
Medications on Admission:
# colesevelam 625 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
# calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
# cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
# multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
.
Disp:*60 Tablet(s)* Refills:*2*
# phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) dose Intravenous Q8H (every 8 hours) for 7 days.
Disp:*7 day supply* Refills:*0*
2. colesevelam 625 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day: please start when you finish your course of IV antibiotics.
Disp:*30 Tablet(s)* Refills:*2*
9. Heparin Flush 10 unit/mL Kit Sig: [**1-9**] mL Intravenous three
times a day for 7 days: flush after access and daily when not in
use.
Disp:*1 kit* Refills:*0*
10. Saline Flush 0.9 % Syringe Sig: [**4-13**] mL Injection three
times a day for 7 days: please flush before and after medication
admin.
Disp:*330 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Spontaneous bacterial peritonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 83939**],
Your were admitted to the hospital for abdominal pain and you
were found to have an infection called spontaneous bacterial
peritonitis. This occurred because your liver disease can cause
congestion in the veins exiting your GI tract which puts you at
risk for bacteria to leak into your abdominal space. This is
what happened to you. We treated your infection with IV
antibiotics and you got better. You will still need additional
antibiotics and when they are finished you will need to start
prophylactic antibiotics to prevent this infection from
happening again.
We have made the following changes to your medication list:
START: Ursodiol 250 mg tablet take one by mouth twice daily
START: Zosyn 4.5mg IV every 8hrs for 7 days
START: Ciprofloxacin 500mg tab take one tablet daily after you
finish your course of zosyn.
No other changes were made to your home medications
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 83940**], MD
Specialty: Family Practice
When: Wednesday [**7-28**] at 12pm
Location: [**Doctor First Name **] FAMILY MEDICINE AT [**Doctor First Name **] [**Doctor Last Name **]
Address: [**Street Address(2) 83941**], [**Location **],[**Numeric Identifier 83942**]
Phone: [**Telephone/Fax (1) 83943**]
Please call your insurance company to let them know that Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is your PCP. [**Name10 (NameIs) **] currently have listed Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37559**] who is in the same practice as Dr. [**First Name (STitle) **].
Department: TRANSPLANT
When: THURSDAY [**2100-8-5**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"573.8",
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
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icd9pcs
|
[
[
[]
]
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10212, 10264
|
6926, 8535
|
330, 345
|
10342, 10342
|
958, 6432
|
11433, 12571
|
900, 939
|
9031, 10189
|
10285, 10321
|
8561, 9008
|
10493, 11410
|
6448, 6903
|
264, 292
|
10357, 10469
|
367, 691
|
707, 884
|
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