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55
| 190,665
|
44431
|
Discharge summary
|
report
|
Admission Date: [**2136-4-3**] Discharge Date: [**2136-4-5**]
Date of Birth: [**2072-2-4**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Keflex / Catapres / Trazodone
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Admit for carotid angiography and possible intervention.
Major Surgical or Invasive Procedure:
S/P stenting of left carotid artery
History of Present Illness:
64 year-old woman, patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Dr. [**First Name8 (NamePattern2) 122**]
[**Last Name (NamePattern1) **], Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], with an extensive history of CAD,
now s/p recent left upper lobectomy for lung cancer with an
incidental finding of an old CVA on head CT postoperatively
prompting a workup that revealed 90% left internal carotid
stenosis on duplex, vs 55% on CTA of neck, now referred for left
carotid angiography to more clearly define her carotid anatomy,
and carotid intervention, if appropriate. Events were as
follows:
[**2128-9-28**] IMI - Treated with stenting of the RCA and LCx. Found
to have severe MR [**First Name (Titles) **] [**Last Name (Titles) 12876**] and was referred for
surgical repair.
[**2128-10-27**] Mitral valve surgery aborted after TEE at time of
surgery revealed largely normal mitral valve with improvement of
inferior hypokinesis compared to month prior.
[**3-/2129**] Cardiac Catheterization - Total occlusion of RCA stent and
patent LCX stent, mild to mod MR
[**7-/2129**] Pulmonary edema requiring intubation at an OSH. Transferred
to [**Hospital1 18**] and had a cardiac cath revealing T.O RCA and 40% CX
stenosis in prior stent. EF of 30%
[**2129**] AICD placement
[**2135-10-24**] Cath d/t worsening chronic angina and DOE and inferior
ischemia on dobutamine viability study. Angiography revealed 40%
LAD, 40% LCX ISRS, RCA totally occluded with distal filling via
left to right collaterals. S/P Unsuccesful recanalization of the
RCA. FFR of CX lesion demonstrated it to be a hemodynamically
insignificant lesion.
[**2136-2-2**] s/p VATS, left upper lobectomy and mediastinal lymph node
dissection d/t adenocarcinoma. Patient d/c'd on [**2-8**] and
readmitted on [**2-13**] d/t mental status changes and hypotension. A
chest CT was done which was negative for a PE. A CT of the head
was done revealing no evidence of intracranial hemorrhage, but a
hypodensity at the right temporo-occipital junction. This could
represent a late subacute to chronic infarct vs metastatic
disease. A CT with contrast was done the following day revealing
the same findings. A carotid series was therefore ordered and
done on [**2136-2-15**]. This revealed an 80-99% stenosis of the left
internal carotid artery and a <40% stenosis of the right
internal carotid artery. A TTE was done on [**2136-2-15**]. This
revealed an ef of 40% with 1+MR, small to moderate sized
pericardial effusion. Mild symmetric LVH. Hypokinesis noted in
the infero-septum, inferior and infero-lateral walls. Akinesis
noted in the basal infero-septum and inferior wall.
.
The patient was subsequently referred to see Dr [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]
as an outpatient who has recommended her for carotid angiography
and intervention. The patient was then seen in clinic by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of neurology who is in agreement that the head
CT scan abnormality is very likely an embolic stroke and feels
that left carotid intervention is appropriate. The patient was
also seen by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of neurosurgery who felt that
it is exceedingly unlikely that the lesion on CT scan represents
a malignancy vs. metastasis and cleared her to undergo a carotid
procedure. He recommended repeat head CT in 3 months.
.
Follow up studies have included:
[**2136-2-23**] Chest XRAY: Normal post left upper lobectomy appearance.
No evidence of any cardiopulmonary process.
[**2136-3-8**] CTA of neck: approximately 55% left sided carotid
stenosis at the bifurcation
[**2136-3-20**] CT of brain with and without contrast: No change of
right posterior temporal-occipital region, likely represents a
chronic infarct. Noted to have tortuous basilar artery. Basilary
artery summit positioned to the left of the midline. Just
anterior to the summit is a 2-mm area of contrast
enhancement--Finding could represent very tortuous origin of
left posterior cerebral artery or contigious tiny aneurysm.
.
In terms of symptoms, the patient denies any neurological
deficits, confusion,or lightheadedness. She further denies any
chest pain. She does report having dyspnea after climbing one
flight of stairs.
.
On day of admission, she underwent carotid angiography with
stent placement
Past Medical History:
s/p bronch/meds, 70 pck yr smoker, CAD s/p MI x 2 and stenting x
2, s/p AICD implant, EF 33%, hypothyroid, DM< s/p hysterectomy,
s/p appy, s/p varicose vein removal
Social History:
Married with two children who live close by.
Husband will drive her to the procedure.(+) cigarette smoking 80
ppy
history, quit in [**2128**], restarted in [**2129**], quit again [**9-6**]
Family History:
(+) [**Name (NI) 41900**] CAD Father had MI at 42yo and died.
Mother had CVA 54yo. Both sisters are healthy.
Physical Exam:
GEN: WD female in NAD
HEENT: PERRL, EOMI
NECK: No bruits, No LAD
CV: RRR no m,r,g
LUNG: CTA Bilat
ABD: Soft, NT, ND BSNA
EXT: No C/C/E
Neuro: CN II-XII intact, A and O x 3, no focal defecits
Pertinent Results:
[**2136-4-3**] 09:22PM WBC-11.6* RBC-3.81* HGB-11.2* HCT-32.4*
MCV-85 MCH-29.4 MCHC-34.5 RDW-14.9
[**2136-4-3**] 09:22PM PLT COUNT-343
.
Cardiac Cath COMMENTS:
1. Access was retrograde via the RCFA with catheter placemnt
to the
aortic arch and bilateral common carotid arteries.
2. The aortic arch was a Type I arch with mild tortuosity of
the great
vessels and no angiographically significant lesions.
3. The right CCA was angiographically normal. The [**Country **] had a
mild 30%
lesion at the bifurcation. The [**Country **] filled the ipsilateral ACA
and MCA
without cross-filling. There was mild tortuosity of the
proximal
intracerebral vessels.
4. The left CCA was angiographically normal. The [**Doctor First Name 3098**] had a
calcified
eccentric 90% lesion at the bifurcation and filled the
ipsilateral ACA
and MCA.
5. Successful stenting of the [**Doctor First Name 3098**] with a [**5-10**] x 30 mm Acculink
stent
(see PTA comments).
FINAL DIAGNOSIS:
1. Severe left internal carotid artery stenosis.
2. Successful stenting of the left internal carotid artery.
.
ECG Sinus rhythm with ventricular premature complexes
Low QRS voltages - clinical correlation is suggested
Brief Hospital Course:
A/P: 64 year-old woman with question of significant carotid
stenosis, referred for carotid angiography.
.
PLAN:
.
# S/P Carotid Angiography with stent placement: She had left
ICA stent placed on day of admission without event. Developed
reflex hypotension and was placed on a low dose of
Neo-synephrine. This was weaned and by HD #1, her BP was
elevated and we resumed Carvedilol and ACE/Lasix at home doses
which were well tolerated. We continued continue ASA, Statin,
Plavix throughout admission. Her mental status remained
unchanged and her neuro exam was without focal defecits. She
did report occasional headache which responded well to PO meds.
She was discharged to home on HD #2 without event.
.
# Hypothyroidism: Levothyroxine Sodium 112 mcg PO DAILY
continued throughout admission.
.
#. DM: RISS and FS QACHS continued throughout admission.
.
# GERD: Cont. PPI throughout admission.
.
# PPx: PPI, Plavix, ASA
.
# CODE: FULL
.
# COMM: With pt
.
# DISP: To home with planned follow up as outlined above.
.
Medications on Admission:
ECASA 325mg daily
Lorazepam 0.5mg PRN anxiety
Metformin 850mg TID
Prilosec 20mg daily
Coreg 12.5mg [**Hospital1 **]
Lipitor 60mg daily
Lisinopril 10mg daily
Celexa 60mg daily
Levoxyl .112mcg daily
Sprinolactone 25mg daily
Lasix 20mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Fioricet [**Medical Record Number 3668**] mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for headache for 1 weeks: Max dose 6 tablets
in 24 hours. .
Disp:*48 Tablet(s)* Refills:*0*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day: to be restarted [**2136-4-6**].
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: to be
restarted [**2136-4-6**].
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day: to be restarted [**2136-4-8**].
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Lipitor 20 mg Tablet Sig: Three (3) Tablet PO once a day.
11. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
S/P stenting of the left carotid artery
Secondary diagnosis:
Hypotension
Hypertension
Hypercholesterolemia
Hypothyroidism
Anxiety
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please keep all follow up appointments.
Please take all medications as prescribed. You should restart
you lasix and spironolactone tomorrow (Friday), you should not
restart your metformin until Saturday [**2136-4-9**].
Seek medical attention for fevers, chills, chest pain, shortness
of breath, lightheadedness, or any other concerning symtpoms.
Followup Instructions:
2. Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2136-4-12**] 9:30
3. Provider: [**Name Initial (NameIs) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2136-4-19**] 4:30
4. Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2136-5-10**] 2:40
|
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53,417
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35960
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Discharge summary
|
report
|
Admission Date: [**2134-8-16**] Discharge Date: [**2134-8-22**]
Date of Birth: [**2068-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing fatigue and shortness of breath
Major Surgical or Invasive Procedure:
[**2134-8-16**] Cardiac Catheterization
[**2134-8-17**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] mechanical)
History of Present Illness:
This 65 white male has had increasing fatigue and shortness of
breath. He has a history of CAD and is s/p MI. He has been
followed with serial echocardiograms for aortic stenosis and his
most recent study showed severe AS. He is now admitted for
cardiac cath prior to aortic valve replacement surgery.
Past Medical History:
Past medical history is significant for coronary artery disease
with myocardial infarction and RCA stenting, aortic stenosis,
non-insulin-dependent diabetes mellitus, peptic ulcer disease,
hypertension, hyperlipidemia, osteoarthritis, and lumbar disc
disease with spondylosis. Past surgeries include anterior
cervical neck surgery and pilonidal cyst removal.
Social History:
He is currently retired. His last dental examination is many
years ago. He very rarely uses alcohol and has a 20-pack-year
history of smoking but quit 20 years. He is currently living
with his wife. Also denies any use of recreational drugs.
Family History:
His family history is significant as his mother died of
complications of rheumatic heart disease at age 48.
Physical Exam:
Pulse: 72 Resp: 18 O2 sat: 99% RA
B/P Right: 119/65
General: No acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur: IV/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [xx], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: + rad murmur Left: +rad murmur
Pertinent Results:
[**2134-8-16**] Carotid Ultrasound: Minimal plaques bilaterally, but no
evidence of stenosis in the internal carotid arteries on both
sides.
[**2134-8-16**] Cardiac Cath: 40% Diagonal lesion, 50% proximal RCA
lesion. no official report yet
[**2134-8-16**] BLOOD WBC-11.2* Hgb-13.3* Hct-39.5* Plt Ct-246
[**2134-8-16**] BLOOD PT-12.2 PTT-28.4 INR(PT)-1.0
[**2134-8-16**] BLOOD Glucose-173* UreaN-18 Creat-1.0 Na-138 K-5.0
Cl-101 HCO3-26
[**2134-8-16**] BLOOD ALT-92* AST-65* AlkPhos-154* TotBili-0.7
[**2134-8-16**] BLOOD %HbA1c-6.9*
[**2134-8-16**] BLOOD Albumin-4.7
[**2134-8-16**] BLOOD Calcium-9.6 Phos-3.6 Mg-2.1
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Right ventricular chamber size and
free wall motion are normal. There are complex (>4mm) 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). No aortic regurgitation is seen. The
mitral valve leaflets are severely thickened/deformed. There is
severe mitral annular calcification. There is severe thickening
of the mitral valve chordae. There is moderate valvular mitral
stenosis (area 1.0-1.5cm2). Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
POST-CPB:
[**2134-8-20**] 04:55AM BLOOD WBC-10.8 RBC-3.26* Hgb-9.1* Hct-27.3*
MCV-84 MCH-28.0 MCHC-33.5 RDW-14.0 Plt Ct-157
[**2134-8-20**] 04:55AM BLOOD PT-32.2* INR(PT)-3.2*
[**2134-8-19**] 05:15AM BLOOD PT-25.7* PTT-38.9* INR(PT)-2.5*
[**2134-8-19**] 05:15AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-136
K-4.3 Cl-100 HCO3-25 AnGap-15
[**2134-8-21**] 07:30AM BLOOD WBC-10.3 RBC-3.13* Hgb-8.8* Hct-26.7*
MCV-86 MCH-28.1 MCHC-32.9 RDW-13.8 Plt Ct-214
[**2134-8-22**] 06:45AM BLOOD PT-30.6* INR(PT)-3.1*
[**2134-8-21**] 07:30AM BLOOD PT-28.5* INR(PT)-2.8*
[**2134-8-20**] 04:55AM BLOOD PT-32.2* INR(PT)-3.2*
[**2134-8-21**] 07:30AM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-134
K-4.8 Cl-96 HCO3-29 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service
following his discontinuation of Plavix on [**8-9**]. Prior to
aortic valve replacement, he underwent cardiac catheterization
which revealed 50% lesion in the right coronary artery and 40%
stenosis in the diagonal branch. Coronary arteries were
otherwise without significant disease - please see result
section for additional detail. Preoperative evaluation was
otherwise unremarkable and he was cleared for surgery.
On [**8-17**], Dr. [**Last Name (STitle) **] performed an aortic valve replacement
with a 21mm St. [**Male First Name (un) 923**] mechanical valve. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for further
monitoring. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. He was neurologically
intact and hemodynamically stable on no inotropic or vasopressor
support. He was found suitable for transfer to telemetry on POD
1. Chest tubes and pacing wires were discontinued without
complication. Coumadin was started for anticoagulation for
mechanical valve. Beta blocker was initiated and the patient
was diuresed toward his preoperative weight. The patient
progressed through the cardiac surgery pathway without
complication. Physical therapy was consulted for assistance
with strength and mobility. The patient was discharged home
with VNA and appropriate follow up instructions on POD 5.
Medications on Admission:
Plavix 75 mg PO daily - last dose: [**2134-8-9**]
Lisinopril 5 mg PO daily
Metformin 500 mg PO BID
Simvistatin 40 mg PO daily
Atenolol 25 mg PO daily
Omeprazole 20 mg PO daily
ASA 81 mg PO daily
Discharge Medications:
1. Outpatient Lab Work
First INR draw on [**2134-8-23**] with results sent to the office of the
[**Hospital **] [**Hospital3 **] at
([**Telephone/Fax (2) 81652**]/Fax([**Telephone/Fax (1) 81653**]. Goal INR for aortic valve
replacement is 2.5-3.5. Plan confirmed with [**Doctor First Name **] on [**2134-8-20**].
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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:*60 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: 2x/day for 1 week, then daily for 1 week.
Disp:*21 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dose
will change daily per [**Hospital **] [**Hospital3 **] for goal
INR 2.5-3.5.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
- Aortic Stenosis, s/p AVR
- Coronary artery disease with prior history of myocardial
infarction and RCA stenting,
- Non-insulin-dependent diabetes mellitus
- Hypertension
- Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-9**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-9**] weeks, call for appt [**Telephone/Fax (1) 14328**]
Dr. [**Last Name (STitle) 57415**] in [**3-9**] weeks, call for appt
First INR draw on [**2134-8-23**] with results sent to the office of the
[**Hospital **] [**Hospital3 **] at
([**Telephone/Fax (2) 81652**]/Fax([**Telephone/Fax (1) 81653**]. Goal INR for aortic valve
replacement is 2.5-3.5. Plan confirmed with [**Doctor First Name **] on [**2134-8-20**].
Completed by:[**2134-8-22**]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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8242, 8300
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|
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|
8533, 8540
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
605
| 115,545
|
3967
|
Discharge summary
|
report
|
Admission Date: [**2197-11-9**] Discharge Date: [**2197-11-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Altered mental status, hypoxia
Major Surgical or Invasive Procedure:
Intubation x 2, central line insertion, tracheostomy [**11-23**], PEG
placement [**11-23**]
History of Present Illness:
Ms. [**Known lastname **] is an 89 yo female with PMH of Alzheimer's disease,
depression, hypernatremia, paroxysmal afib who presents from her
NH. Her son was called by the nursing home reporting a fever to
101 and O2 sat 84-86%. She was then sent to the ED.
.
In the ED, she was noted to have altered mental status. She was
nonverbal but responded to pain. Exam was reported as otherwise
unremarkable other than rhonchi. She was noted to be hypoxic to
89%. Her CXR was ok. Her ABG at that time was 7.37/58/178.
Subsequent ABG showed worsening hypercarbia at 66, so she was
intubated. She was transiently hypotensive after intubation.
This improved with fluid. Her HCT was in the 50s and her serum
sodium was 170. She received 2L NS in the ED with 2 more
hanging upon transport to the ICU. She was noted to have pyuria
and was givne vanc and zosyn. Lactate in the ED was 1.4. VS in
the ED: T 103.6 rectal 115/60 HR 52 RR 16 98% on 100%FiO2,
Peep 5 Tv 400.
Past Medical History:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b
Social History:
Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily.
Family History:
N/A
Physical Exam:
Admission PE:
vitals: 97.3 89/49 99% on 100% FiO2
gen: resting, ill appearing
heent: ncat, mmd, pupils 2mm
neck: no elevated JVD
pulm: ctab, no w/r/r
cv: brady, 2/6 SEM, no r/g
abd: s/nt/nd/nabs
extr: no c/c/e, pulses thready
neuro: intubated, sedated. does not respond to voice.
withdrawals from pain.
Pertinent Results:
[**2197-11-9**] 10:30AM BLOOD WBC-9.1 RBC-5.03# Hgb-16.7*# Hct-52.6*#
MCV-105*# MCH-33.3* MCHC-31.8 RDW-15.3 Plt Ct-242
[**2197-11-9**] 10:30AM BLOOD Neuts-85.3* Bands-0 Lymphs-8.3* Monos-5.8
Eos-0.1 Baso-0.6
[**2197-11-9**] 03:00PM BLOOD PT-17.4* PTT-39.3* INR(PT)-1.6*
[**2197-11-9**] 10:21AM BLOOD Type-ART pO2-178* pCO2-58* pH-7.37
calTCO2-35* Base XS-6 Intubat-NOT INTUBA
[**2197-11-9**] 10:21AM BLOOD Lactate-2.0
[**2197-11-9**] 10:30AM BLOOD ESR-31*
[**2197-11-9**] 10:30AM BLOOD Glucose-128* UreaN-82* Creat-2.7* Na-170*
K-4.6 Cl-128* HCO3-33* AnGap-14
[**2197-11-9**] 10:30AM BLOOD ALT-30 AST-26 CK(CPK)-257* AlkPhos-55
Amylase-53 TotBili-1.3
[**2197-11-9**] 10:30AM BLOOD CK-MB-3 cTropnT-0.05*
[**2197-11-9**] 10:30AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.1# Mg-3.7*
.
[**2197-11-12**] 10:10AM BLOOD FDP-0-10
[**2197-11-12**] 10:10AM BLOOD Fibrino-397 Thrombn-14.3*
.
[**2197-11-22**] 05:09PM BLOOD Type-ART Temp-37.2 Rates-18/0 Tidal V-380
PEEP-5 FiO2-40 pO2-128* pCO2-38 pH-7.45 calTCO2-27 Base XS-3
-ASSIST/CON
[**2197-11-22**] 05:09PM BLOOD Lactate-1.4
.
[**2197-11-23**] 03:16AM BLOOD Cortsol-20.1*
.
[**2197-11-24**] 03:26AM BLOOD WBC-7.8 RBC-2.55* Hgb-8.5* Hct-25.3*
MCV-99* MCH-33.4* MCHC-33.7 RDW-16.1* Plt Ct-354
[**2197-11-24**] 03:26AM BLOOD PT-13.7* PTT-35.3* INR(PT)-1.2*
[**2197-11-24**] 03:26AM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
[**2197-11-24**] 03:26AM BLOOD Calcium-8.2* Phos-3.6# Mg-2.2
.
Radiographic studies:
.
CXR [**11-12**]: Interstitial edema increased. Left retrocardiac
atelectasis also worsened. Small bilateral pleural effusions,
more marked on the left are unchanged. Calcifications of the
aortic arch and old right rib fractures are stable. Heart size
remains normal. Hilar contours are unchanged.
.
CXR [**11-20**]: FINDINGS: Endotracheal tube, right internal jugular
central venous catheter and nasogastric tube appear unchanged.
There has been an interval worsening of the bilateral perihilar
opacities and probable slight increase in the layering bilateral
large pleural effusions. This could reflect developing pulmonary
edema although multifocal infection cannot be entirely excluded.
.
ECHO [**11-22**]: The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. Pulmonary artery systolic
hypertension. Mild mitral regurgitation.
.
Micro Data:
[**11-9**]: UCx w/proteus, sputum w/MRSA
[**11-18**]: sputum w/stenotrophomonas
BCx [**11-12**] negative
BCx [**11-18**], [**11-19**], [**11-20**], [**11-21**] pending
R IJ tip [**11-22**] culture negative
UCx x2 [**11-19**] negative
3x CDiff negative ([**11-12**], [**11-13**], [**11-14**])
Brief Hospital Course:
A/P: 89 yo with PMH of Alzheimer's dementia, hypernatremia, UTI
presents with AMS, sepsis physiology, UTI, and impressive
hypernatremia
.
#1 Sepsis: Initially presenting with fever, hypotension,
hypoxia. Source was likely urine given pyuria, though may have
pneumonia as well given MRSA in sputum. UCx grew out pan
sensitive proteus mirabilis, initial sputum grew MRSA. BCx from
[**11-9**], [**11-12**] negative. BCx from [**11-18**], [**11-19**], [**11-20**], [**11-21**] all
pending. Patient had short additional time in MICU when
required pressors for approx 48 hours. Started on empiric zosyn
and gent for VAP. UCx during this time were negative and sputum
grew out Stenotrophomonas sensitive to Bactrim. IV Bactrim
started and zosyn/gent d/c. Although blood pressure is low at
baseline, patient always makes urine. Stool tests for C. diff
negative x 3 & flagyl stopped [**11-15**].
- completed 15d of vanco, was treated for 14d total for UTI
starting w/cipro/unasyn and switching to gent/zosyn (to double
cover for VAP)
- IV Bactrim 250mg Q8h for 14 days, starting [**11-24**] and finishing
on [**12-8**].
.
#2 Respiratory failure: Hypoxia and hypercarbia with spontaneous
breathing trials. [**Month (only) 116**] now be volume overloaded due to fluid
resuscitation. PNAs and deconditioning likely also contribute.
Patient failed SBTs due to RSBIs >130 and increasing acidosis.
Unclear why patient unable to be weaned off vent. Patient with
slightly hyperinflated [**Known lastname **]s and CO2 retention without acidosis
on admission. No Hx of COPD given but may be undiagnosed thus
far. NIF poor at 16 with large amount of dead space ventilation
(70% on PSV). Difficulty of weaning from the vent likely a mix
of decreased respiratory muscle strength combined with
underlying intrinsic [**Known lastname **] disease.
- Continue on Pressure support as tolerated and wean as
tolerated.
.
#3 Hypernatremia: likely from extreme dehydration. Now
resolved.
Patient is currently getting free water boluses 100ml every 6
hours with tube feeds. Continue to monitor sodium and adjust as
necessary.
.
#4 AMS: likely [**2-4**] toxic/metabolic, though other etiologies
could include stroke, and underlying dementia. Patient
increasingly alert as she is treated
.
#5 Hypotension: Resolved currently. Dopamine drip weaned off.
ECHO relatively unremarkable given patient??????s age and does not
explain hypotension or bradycardia. unclear etiology. Lactate
and mixed venous do not suggest infection. Pt did not respond
to fluid boluses and CVPs do not point to hypovolemia. Repeat
ECHO w/normal biventricular cavity sizes with preserved global
and regional biventricular systolic function. Pulmonary artery
systolic hypertension. Mild mitral regurgitation. [**Month (only) 116**] also be
unable to mount HR response with conduction disorder. EP
consulted twice and do not want to intervene given her hx of
sepsis. Adrenal insufficiency also a possibility but AM
cortisol was normal.
.
Fluid balance should be maintained. She has been both very
hypervolemic and exterienced flash pulmonary edema during her
stay, and fluid balance has been difficult. Any PRN IVF should
be given with caution and extubation was probably in part
limited [**2-4**] to pulm edema. Her sodium and other electrolytes
should be monitored every other day until stable and PO intake
of fluids encouraged.
.
Would reassess fluid status daily and give small doses of Lasix
as tolerated by blood pressure. The patient has been
hypotensive with Lasix in the past, therefore small doses should
be given.
.
#6 Bradycardia, HR consistently in 50's but asymptomatic: Not
new ?????? old records show ekg w/nsr at 65 w/1st degree AV block 3
years ago. Initially EP commented that her rhythm could be a
variation of normal or tied to her underlying illness and
recommended treating her sepsis and re-evaluating once she has
recovered or becomes unstable.
.
#7 Paroxysmal afib: not on anticoagulation on admission for
unclear reason (fall risk?) The reason for this should be
followed up with her PCP. [**Name10 (NameIs) **] was not investigated during this
stay.
.
#8 Alzheimer's: cont home meds of Namenda and Aricept.
.
#9 Anemia: hemoconcentrated upon admission, HCT trended to mid
to upper 20s during here stay. Further workup should be
initiated by her PCP. [**Name10 (NameIs) 357**] monitor her HCT every other day
until stable.
.
# PPx: H2 blocker, sc heparin, bowel regimen
.
# FEN: Tolerated TF at goal.
.
# Code: full code. Discussed with patient??????s son [**Name (NI) **] who
wants ??????everything done?????? including reintubation if patient fails
extubation.
Medications on Admission:
bisocodyl supp 10mg daily prn
albuterol q 6 prn
ipratropium q 6 prn
tylenol 500 q 6 prn
guiatuss q 6 prn
tylenol suppos 650mg q 6 prn
lactulose 15ml po daily
vit E 800 po daily
caltrate 600 + D [**Hospital1 **]
aricept 10mg po daily
colace 100 qday
zyprexa 5mg qday
namenda 10mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation q4hrs prn as needed.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Solution Sig:
Two [**Age over 90 1230**]y (250) mg Intravenous q8hrs for 13 days:
through [**2197-12-7**].
13. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a
day.
14. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
15. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
once a day.
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation PRN (as needed) as needed for shortness of
breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 86**]
Discharge Diagnosis:
Primary:
proteus mirabilis urosepsis
bradycardia
stenotrophomonas pneumonia
.
Secondary:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b
Discharge Condition:
good, afebrile
Discharge Instructions:
Ms. [**Known lastname **] was seen at [**Hospital1 18**] for urosepsis for which she finished
a course of vanc, gent, zosyn. She required pressors
intermittently for hypotension. She was also extremely
hypernatremic. She also was bradycardic with a mid-grade block.
She is receiving bactrim for stenotrophomonas pna. She will
need bactrim until [**2197-12-7**]. She will need ongoing nebulizers,
sc heparin, and bowel regimen per medication orders. Please see
discharge [**Last Name (un) 17576**] for full details.
.
Vital signs should be monitored daily. Fluid balance should be
maintained. She has been both very hypervolemic and exterienced
flash pulmonary edema during her stay, and fluid balance has
been difficult.
.
She has not been anticoagulated for her PAF in the past. The
reason for this should be followed up with her PCP as below.
This was not investigated during this stay.
.
She will need every other day electrolytes and CBC checked until
stable. Other discharge orders per medication sheet and page 1
referral.
.
She should return to the ED if she develops altered mental
status, fever, hypotension, bradycardia.
Followup Instructions:
she should follow-up with her Primary Care Provider, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10145**], in the next 1-2 weeks. His office number is
[**Telephone/Fax (1) 10573**].
|
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[
[]
]
] |
11864, 11930
|
5362, 10020
|
294, 387
|
12177, 12194
|
2030, 5339
|
13384, 13588
|
1684, 1689
|
10367, 11841
|
11951, 12156
|
10046, 10344
|
12218, 13361
|
1704, 2011
|
224, 256
|
415, 1391
|
1413, 1529
|
1545, 1668
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,913
| 128,124
|
4471
|
Discharge summary
|
report
|
Admission Date: [**2137-4-30**] Discharge Date: [**2137-5-2**]
Date of Birth: [**2087-10-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Leg laceration
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 47-year-old man
with a history of diabetes mellitus type 2 times 20 years
status post right below the knee amputation in [**2127**]
Past Medical History:
Also, of note, the patient has a history of CAD, status post
MI in [**2132**] plus CHF with an EF of around 20% and pulmonary
hypertension.
1. Hypertension.
2. CHF with an EF equal to 20% in [**2133-2-5**].
3. Mild pulmonary hypertension.
4. Diabetes mellitus for greater than 20 years.
5. Chronic renal insufficiency, creatinine 2.3 to 4.7.
6. History of upper GI bleed secondary to gastritis.
7. Asthma.
8. Right below the knee amputation in [**2127**].
9. Left eye blindness.
10. Coronary artery disease, status post non ST wave MI,
status post catheterization showing 50% D1 stenosis,
pulmonary hypertension, increased right and left filling
pressures, pulmonary artery pressure 70/35/51, wedge equal to
29.
11. Recent pneumonia.
12. Anemia.
13. Left elbow septic joint.
14. Peripheral neuropathy.
15. Hand/elbow arthritis.
Social History:
No alcohol, tobacco, or drugs. Lives in
[**Location 3146**] with wife and kids.
Family History:
Noncontributory.
Physical Exam:
t98.3, bp 150/75, p 65, r 14, 94%ra
Obese male resting comfortably in chair.
PERRL. +strabismus
OP clr.
JVP not appreciable
Regular s1,s2. no m/r/g
LCA b/l
+bs. soft. nt. nd.
4cm laceration of L leg. c/d/i
R leg bandagaed, s/p BKA
Pertinent Results:
140 99 75 /102 AGap=17
4.1 28 7.3 \
Ca: 8.5 Mg: 2.2 P: 6.9
ALT: 18 AP: 162 Tbili: 0.6 Alb: 3.2
AST: 18 LDH: 201 Dbili: TProt:
[**Doctor First Name **]: 35 Lip: 16
Dig: <0.2
81
9.4 \7.9 /310
/25.5 \
N:82.0 L:12.0 M:3.4 E:2.2 Bas:0.3
Hypochr: 3+ Anisocy: 2+ Poiklo: 1+ Microcy: 2+
PT: 17.6 PTT: 31.6 INR: 2.0
[**2137-4-30**] 10:07PM DIGOXIN-<0.2
CXR: No evidence for CHF or pneumonia. Tortuous aorta. Anterior
eventration right hemidiaphragm.
Brief Hospital Course:
A/P:
49 y.o. man with MMP, incl ESRD, DM, CAD who presents with Left
leg lac and coagulopathy, for simple PD. Pt appeared well, with
no sign of infection. Leg lac was not bleeding significantly.
1) ESRD: Pt was started on PD following admission. Course was
w/o absolute indications for dialysis or complications.
-
2) Hypotension: Resolved with blood products and IVF at OSH so
likely due to hypovolemia. No sign of sepsis. BP remained
stable throughout admission.
-
3) Leg laceration: On admission no bleeding. However, Hct had
dropped to 25 so patient was transfused to hct>30. There did
not appear to be any cellulitis in the area--pt did have chronic
venous stasis changes. By admission, INR had corrected. On
discharge, patient was continued on [**12-9**] dose of coumadin, w/
plan to have level checked on [**Last Name (LF) 766**], [**5-3**].
-
4) Hypoglycemia/DM2: Likely due to receiving insulin in setting
of decreased PO intake. Euglycemic without insulin on
admission.
-
5) CV: No sign of acute ischemia or CHF currently. Will hold
antihypertensives. ? not on ASA. Cont lasix, metolazone,
statin. For afib, hold coumadin for now but if not bleeding
keep inr [**1-10**]. Cont dig.
-
6) F/E/N: [**Doctor First Name **], cardiac diet. Phoslo. No IVFs.
-
7) PPx: Already anticoagulated. PPI. Vitamins. Iron.
-
8) Code: FULL
-
Medications on Admission:
Adalat 60 mg PO QD
Digoxin 0.125 mg PO QD except Sunday
Cozaar 50 mg PO QD
Pravachol 40 mg PO QD
Humulin NPH 84 units qam
Humulin NPH 70 units qpm
RIS 16 units qam
SSI
Percocet i PO BID
Folic acid
Lopressor 100 mg PO BID
Lasix 80 mg PO BID
Zaroxolyn 2.5 mg PO BID
B complex
Fosrenol 250 mg PO with meals
Protonix 40 mg PO QD
Phoslo 1334 mg PO with meals
Imdur 120 mg PO QD
Niferex 150 mg PO BID
Discharge Medications:
1. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
3. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pravastatin Sodium 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every twelve (12) hours as needed.
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
12. Coumadin 5 mg Tablet Sig: [**12-9**] Tablet PO at bedtime.
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. Humulin N 100 unit/mL Suspension Sig: 80 qam, 70 qpm U
Subcutaneous twice a day.
15. Insulin Regular Human 100 unit/mL Solution Sig: Sixteen (16)
U Injection qam.
16. Lanthanum Carbonate 250 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO qac.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Coagulopathy
2. ESRD -- continuous ambulatory peritoneal dialysis
Discharge Condition:
Good, VSS, hct stable.
Discharge Instructions:
1) Please take your medications as directed.
2) Please attend your follow up appointments.
3) Return to medical care if you develop any bleeding.
4) Discuss with Dr. [**Last Name (STitle) 19154**] restarting nifedipine as you BP was
slightly high while in the hospital.
Followup Instructions:
1. Please have your INR/PT checked at [**Hospital6 19155**]
on [**Last Name (LF) 766**], [**5-6**] at the [**Hospital6 19155**] Laboratory.
2. Please follow up with your PMD, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19154**] ([**Telephone/Fax (1) 19156**]). An appointment has been made for you on [**Last Name (LF) 2974**], [**5-9**]
at 11:00AM ([**Hospital6 19155**]).
|
[
"357.2",
"583.81",
"250.51",
"250.41",
"416.8",
"286.9",
"428.0",
"V49.75",
"285.9",
"412",
"250.61",
"250.81",
"427.31",
"891.1",
"276.5",
"369.60",
"E932.3",
"414.01",
"V45.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5418, 5424
|
2247, 3610
|
297, 305
|
5537, 5561
|
1737, 2224
|
5879, 6278
|
1452, 1470
|
4056, 5395
|
5445, 5516
|
3636, 4033
|
5585, 5856
|
1485, 1718
|
243, 259
|
333, 476
|
498, 1337
|
1353, 1436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,067
| 143,308
|
41295
|
Discharge summary
|
report
|
Admission Date: [**2130-9-22**] Discharge Date: [**2130-9-30**]
Date of Birth: [**2087-11-11**] Sex: F
Service: SURGERY
Allergies:
Prochlorperazine / Vancomycin
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatic pseudocyst
Major Surgical or Invasive Procedure:
[**2130-9-22**]: Exploratory laparotomy with pancreatic debridement,
wide external drainage of the pancreatic pseudocyst, and loop
ileostomy.
History of Present Illness:
Ms. [**Known lastname 89915**] is a 42 year old woman with a history of alcoholic
pancreatitis w/ pseudocyst s/p laparoscopic and CT-guided
drainage in [**Month (only) **] and [**2130-7-28**] who is now s/p loop ileostomy and
pancreas debridement for colonic obstruction secondary to
pancreatic inflammation.
Past Medical History:
Past Medical History:
# Recurrent pancreatitis (secondary to hypertriglyceridemia and
alcohol, complicated by pseudocyst)
# hypertension
# hyperlipidemia
# obesity
# polysubstance abuse
.
Past Surgical History:
# laparoscopic pseudocyst drainage ([**Last Name (NamePattern4) 89914**]
- [**2130-7-4**])
# c-section
Social History:
Married with 2 children. Prior history of IVDU, heroin use in
the past. tobacco use 1-1.5 PPD. Current alcohol: uses 2 pints
of vodka daily for last several years. There is concern for
domestic violence in her household.
Family History:
Non-contributory.
Physical Exam:
VS: 99.2 99.2 88 116/74 18 97RA
Gen: NAD, comfortable
Neuro: A&Ox3
CV: RRR, nml s1/s2, no m/r/g
Resp: CTAB
Abd: soft, appropriately tender, non-distended, incisions c/d/i.
JP and malecot drain in place, productive. Ostomy site clean,
productive of stool.
Ext: slight edema, no e/o c/c. wwp.
Pertinent Results:
[**2130-9-22**] 06:11PM WBC-13.4* RBC-3.44* HGB-11.0* HCT-32.0*
MCV-93 MCH-32.1* MCHC-34.5 RDW-17.7*
[**2130-9-22**] 06:11PM ALT(SGPT)-6 AST(SGOT)-13 ALK PHOS-78
AMYLASE-24 TOT BILI-0.3
[**2130-9-22**] 06:11PM CALCIUM-8.5 PHOSPHATE-4.1 MAGNESIUM-1.3*
[**2130-9-26**]: 7.5>8.5/25.9<325
Brief Hospital Course:
Ms. [**Known lastname 89915**] was admitted to [**Hospital1 18**] on [**2130-9-22**] for pancreatic
debridement and loop ileostomy to alleviate colonic obstruction
secondary to pancreatic inflammation. Pt tolerated the procedure
well with no complications. She was admitted to the floor
immediately post-op. While initially with poor pain control, Ms.
[**Known lastname 89917**] pain pain was controlled via a combination of a ketamine
drip, bupivicane epidural, and dilaudid PCA. During her first
post-operative night she received several 500 cc boluses due to
low blood pressure and low urine output, both of which resolved
quickly and appropriately following continue hydration. On POD
2, Ms. [**Known lastname 89917**] epidural and NGT were removed. She experienced one
transient episode of desaturation to low 90s with a heart rate
to 120s. She was otherwise asymptomatic. A CXR was obtained
which was unremarkable, and her symptoms improved with better
pain control and supplemental O2. The remainder of her
post-operative course was unremarkable. She was advanced to sips
and clears on PODs 3 and 4. By POD 5 she was tolerating a
regular diet. On POD 7 she was fully transitioned to a PO pain
regimen, consisting of 20mg oxycontin TID and 8mg PO dilaudid q3
hours, with good results. At this time her second JP drain was
noted to have continued low out-put and was therefore removed.
At the time of discharge, Ms. [**Known lastname 89915**] had 2 remaining drains
located on the left side of her abdomen (JP and Malencot), both
of which were productive and securely fashioned with no signs of
infection.
By the end of her hospital stay, Ms. [**Known lastname 89915**] felt prepared and
educated enough to manage her ostomy and drains following
teaching by the wound care/ostomy nurse. Her pain was
well-controlled and she was tolerating a regular diet. She was
ambulating, mentating, and functioning at her baseline. At the
time of discharge, Ms. [**Known lastname 89915**] expressed understanding of her
condition and signs to look out for which would warrant further
medical evaluation. She has expressed verbal understanding of
her follow-up plans. She has remained stable, afebrile, with
unremarkable laboratory values throughout her hospitalization.
On [**2130-9-30**] Ms. [**Known lastname 89915**] signed a narcotic agreement with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and verbally expressed understanding regarding her
post-operative pain management, which was formulated with the
help of the Chronic Pain Service.
Medications on Admission:
- pantoprazole 40 mg PO QD
- oxycodone 10mg PO Q4h PRN pain
- Lidocaine 5% patch applied to skin QD
- gemfibrozil 600 mg PO BID
- simvastatin 20 mg PO QHS
- colace 100 mg [**Hospital1 **] and senna prn
Discharge Medications:
1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release 12 hr(s)* Refills:*0*
4. hydromorphone 2 mg Tablet Sig: Four (4) Tablet PO Q3H (every
3 hours) as needed for pain for 21 days.
Disp:*225 Tablet(s)* Refills:*2*
5. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) for 21 days.
Disp:*168 Tablet(s)* Refills:*0*
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
1. Chronic pancreatitis
2. Pancreatic pseudocyst
3. Chronic partial bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision 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.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
*Follow instructions from "Written educational ileostomy
hand-outs" given to you by the ostomy nurse.
.
Malecot Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
* Pt to follow-up with Dr. [**First Name (STitle) **] on Wednesday [**2130-10-4**]
for staple removal.
* You should follow up with your surgeon and Primary Care
Provider (PCP) as needed and advised.
Completed by:[**2130-9-30**]
|
[
"305.90",
"560.89",
"272.4",
"272.1",
"577.1",
"577.2",
"401.9",
"303.90",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.01",
"52.22"
] |
icd9pcs
|
[
[
[]
]
] |
5820, 5887
|
2050, 4614
|
312, 456
|
6017, 6017
|
1734, 2027
|
9386, 9615
|
1388, 1407
|
4866, 5797
|
5908, 5996
|
4640, 4843
|
6168, 6748
|
6763, 9363
|
1028, 1133
|
1422, 1715
|
251, 274
|
484, 795
|
6032, 6144
|
839, 1005
|
1149, 1372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,550
| 174,248
|
53855
|
Discharge summary
|
report
|
Admission Date: [**2137-10-4**] Discharge Date: [**2137-10-15**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 80-year-old male with
history of congestive heart failure, coronary artery disease,
diabetes mellitus and pneumonia who was admitted to [**Hospital1 1444**] for dyspnea and found to have
a right pneumothorax. He had a chest tube placed during
hospital course. The patient has a history of multiple prior
admissions in the past few months for pneumonias. Chest tube
was placed during this hospital course. The chest tube was
discontinued shortly afterwards after discovery that it was
misplaced. The right lung was re-expanded. Pleural
effusions managed with diuresis.
A renal consult was obtained for an increasing BUN and
creatinine. It was thought that there was a prerenal picture
was developing. Renal ultrasound was recommended. Heart
Failure Service was consulted and recommended transfer to CCU
for aggressive diuresis, pressor support and Swan-Ganz
placement. During hospital course, the patient also had 2/4
bottles positive for MRSA, sputum positive for MRSA,
increased white blood cell count to 22. While on the floor
the patient was started on Levofloxacin and Vancomycin prior
to transfer to CCU.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft in [**2123**], four vessel disease, LIMA to LAD, SVG
to D2, SVG to circumflex and SVG to PDA.
2. Congestive heart failure.
3. Diabetes mellitus.
4. Chronic renal insufficiency.
5. CTCL.
6. Bilateral renal artery stenosis 60% on the left, 70% on
the right.
7. Osteoarthritis.
8. Gout.
9. Recent echocardiogram revealed LV ejection fraction of
less than 20%
ALLERGIES:
1. Penicillin.
2. Ambien which leads to confusion.
MEDICATIONS ON TRANSFER TO CCU:
1. Dopamine drip.
2. Metoprolol 25 mg p.o. b.i.d.
3. Levofloxacin 250 mg p.o. q. 48 hours.
4. Vancomycin 1 gram IV dosed by levels.
5. Regular insulin sliding scale.
6. Morphine p.r.n.
7. Zofran p.r.n.
8. Compazine.
PHYSICAL EXAMINATION: Vital signs with a temperature of 98.2
F, pulse 60, blood pressure 107/36, respirations 16. Pulse
oximetry 92%. In general elderly male who is lethargic.
Head, eyes, ears, nose and throat: Moist mucous membranes.
Cardiovascular: S1, S2, no murmurs, rubs, or gallops
appreciated. Pulmonary: Loud breath sounds, rhonchorus.
Abdomen is obese and soft. Extremities: Pitting edema
bilaterally.
INITIAL LABORATORY: White blood cell count of 19.2,
hematocrit of 29.6, platelets 252. INR 1.1. Fibrinogen 581.
INITIAL ASSESSMENT: This is an 80 year-old male admitted to
CCU for aggressive congestive heart failure management, MRSA
bacteremia.
HOSPITAL COURSE:
1. HEART FAILURE: Patient required pressor support with
Dopamine and eventually Norepinephrine as a bridge for
dialysis. After dialysis, the patient's heart function
eventually improved and he was able to be weaned off all
pressures. Patient had no chest pain or chest discomfort
during the entire hospital course. The patient was monitored
on telemetry during hospital course with no known
abnormalities or runs of ectopy. The patient was known to
have severe coronary artery disease and was kept on aspirin
and Lipitor throughout hospital course.
2. RENAL: Patient with increasing BUN and creatinine in the
setting of congestive heart failure thought to be a prerenal
condition. Acute renal failure on top of a chronic renal
failure. Patient's mental status and renal function improved
after a session of dialysis, however patient refused further
dialysis sessions as he thought it would be a new chronic
management that he would need.
3. PULMONARY: Patient with decreasing O2 saturations on
presentation. Patient is known to have coronary artery
disease and it was felt that his decreased pulmonary function
was secondary to congestive heart failure. Pulmonary
function did improve after dialysis and removal of fluid.
The patient also noted to have MRSA positive sputum and MRSA
positive blood cultures. The patient was kept on Vancomycin
therapy until the end of hospital course.
4. ENDOCRINE: Patient is a known diabetic who placed on
fingersticks q.i.d. with regular insulin sliding scale until
he changed his code status later in hospital course.
5. CODE STATUS: Patient and patient's family initially
wanted "everything done", however after a session of dialysis
and a clearing of mental status, the patient and patient's
family were extensively counseled in what lay probably in his
medical future in terms of his extremely grim prognosis given
his multiple medical conditions. Decision was made by the
patient to become DNR, DNI and to institute comfort measures
only. All non-necessary medications were discontinued. The
patient was kept only on comfort medications such as
Morphine, Scopolamine patch. Fingersticks were discontinued
and a palliative care nurse consultation was performed.
The patient requested not to be transferred out of the
hospital to a Hospice type setting, but rather requested to
remain in the hospital to pass away there. Overall, once
patient was transferred to CMO type care, the patient
lingered for approximately 30 hours before expiring.
CONDITION ON DISCHARGE: Expired.
DISCHARGE STATUS: Autopsy refused by family. Attending and
family made aware of patient's expiration.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Name8 (MD) 110497**]
MEDQUIST36
D: [**2137-11-5**] 14:00
T: [**2137-11-7**] 10:24
JOB#: [**Job Number 110498**]
|
[
"250.00",
"585",
"512.8",
"584.9",
"038.11",
"511.9",
"202.10",
"428.0",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.04",
"38.95",
"89.64",
"39.95",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2718, 5229
|
2052, 2701
|
117, 1251
|
1273, 2029
|
5254, 5634
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,092
| 164,977
|
23990
|
Discharge summary
|
report
|
Admission Date: [**2141-7-2**] Discharge Date: [**2141-7-15**]
Date of Birth: [**2090-4-26**] Sex: M
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Dr. [**Known lastname **] was first seen by Dr.
[**Last Name (Prefixes) **] in consultation on [**2141-5-4**]. He is a 51-year-
old male who underwent a St. [**Male First Name (un) 923**] mechanical aortic valve
replacement in [**2130**] secondary to bacterial endocarditis.
Since that time, he has been followed by serial
echocardiograms for mitral regurgiation which had shown
progression of this disease. He is symptomatic with fatigue,
which seems to be worsening over the past year.
Echocardiogram performed in [**2141-1-28**] showed an EF of 55%,
3+ MR, with a calcified nodule protruding into the left
atrium, 3+ tricuspid regurg, with a well-seated St. [**Male First Name (un) 923**]
aortic valve, a mean gradient of 8 mmHg, a peak gradient of
14 mmHg, 1+ AI and bilateral atrial enlargement.
PAST MEDICAL HISTORY: DDD pacemaker, status post St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 1291**] secondary to bacterial endocarditis in [**2130**] at [**Hospital3 28333**] [**Hospital3 **], status post kidney transplant, status post
myocardial infarction, status post renal failure, peripheral
neuropathy of lower extremities, gout, hypertension, hard of
hearing, a former right arm AV fistula.
PAST SURGICAL HISTORY: Also includes cholecystectomy and
pacemaker placed for bradycardia, as well as for a sick sinus
syndrome and atrial fibrillation under medical history.
MEDICATIONS AT TIME ORIGINALLY SEEN: Digoxin 0.0625 mg p.o.
once a day, Lasix 40 mg p.o. once a day, Lopressor 12.5 mg
p.o. b.i.d., lisinopril 20 mg p.o. once a day, azathioprine
125 mg p.o. once a day, prednisone 5 mg p.o. once a day,
Coumadin 10 mg alternating with 12.5 mg p.o. once a day,
colchicine 0.6 mg p.o. once a day, and Neurontin 200 mg p.o.
b.i.d.
ALLERGIES: He had no known drug allergies.
FAMILY HISTORY: Endocarditis and stroke for his mother.
SOCIAL HISTORY: He is a veterinarian, lives alone in
[**Location (un) 5110**], single, did not ever smoke, and only uses alcohol
occasionally.
EXAM: He was 60 in sinus rhythm, with blood pressure of
108/68 on the right, 104/64 on the left, height 70 inches,
weight 170 pounds. He was in no apparent distress. His skin
exam revealed flushed cheeks, but were warm and dry. He had a
very well-healed sternotomy. He had some bruising in his
right forearm scar. His pupils were equally round and
reactive to light and accommodation. EOMs were intact. His
sclerae were anicteric. He had a hearing aid in place. His
neck was supple, no JVD. He had a transmitted murmur versus a
carotid bruit in his neck. Bilaterally, his lungs were clear.
His heart was regular rate and rhythm with crisp valve sounds
and a grade II/VI late systolic murmur and a diastolic
rumble. He had soft, nontender, nondistended abdomen, with
normal-sounding bowel sounds, and a right upper quadrant scar
was well-healed. His extremities had no clubbing, cyanosis or
edema. He had an old right forearm AV fistula, and no right
radial pulse. His greater saphenous appeared suitable
bilaterally. He was alert and oriented x3 with no focal
neurologic deficits. His gait was steady. He had
approximately 5/5 strength of upper and lower extremities
bilaterally. He had 2+ bilateral femoral pulses, DP pulses,
PT pulses. No radial pulse on the right and 2+ on the left.
He had a transmitted murmur to both right and left carotids.
[**Last Name (STitle) 40480**]he patient was to have carotid nonivasives done if
cardiac cath showed any left main or severe coronary artery
disease, and the plan was to do mitral valve replacement with
Dr. [**Last Name (Prefixes) **] via right thoracotomy to avoid a redo
sternotomy. The patient is to be admitted to the hospital for
heparin bridge off Coumadin in preparation for his operation.
HOSPITAL COURSE: He was admitted to the hospital on [**2141-7-2**]. Heparin was started, as the patient had stopped his
Coumadin. His INR dropped to 1.1 the day before operation on
[**7-3**].
Additional preop lab work showed an INR of 1.1. On [**6-15**],
his platelet count was 120,000. A preop fibrinogen of 288.
Urinalysis was negative. Preop sodium 138, K 4.8, chloride
106, bicarbonate 23, BUN 43, creatinine 1.6, with a blood
glucose of 95. Additional preop lab work showed AST 18, ALT
30, alkaline phosphatase 47, amylase 48, total bilirubin 1.0.
Preop albumin was 3.8. Preop digoxin level was 0.5. A preop
white count 5.1, hematocrit 36.2. Preop chest x-ray showed no
acute cardiopulmonary abnormalities with a small suspicion
for COPD with abutting of the diaphragms. Please refer to the
official x-ray report dated [**2141-7-2**].
The patient was also seen by the renal service for his
history of renal transplant. Last creatinine before operation
was 1.5, with his baseline creatinine being in the 1.5-1.6
range. The patient was also seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who
recommended steroid dosing for his perioperative course.
On[**Last Name (STitle) **] day 2, he remained on heparin drip, waiting for his
INR to drop in preparation for surgery, and on [**7-4**] he
underwent right thoracotomy for mitral valve replacement with
a [**Street Address(2) 44058**]. [**Male First Name (un) 923**] mechanical valve by Dr. [**Last Name (Prefixes) **]. He was
transferred to the cardiothoracic ICU in stable condition on
propofol and Neo-Synephrine titrated drips. Postoperatively,
in the ICU his pacemaker was interrogated by the
electrophysiology fellow. On postoperative day 1, his PA
catheter was discontinued. He was transferred over to p.o.
meds, as he had been extubated successfully. The evening
prior, he had some edema of his extremities, but had a
cardiac index of 3.59. He was A-paced at 80, his blood
pressure 99/52, and his exam was relatively unremarkable. He
was seen again postoperatively by the renal service.
On postop day 2, he began beta blockade at 12.5 mg p.o.
b.i.d. and started Lasix diuresis. He was satting 100% on
room air, with blood pressure 116/53, paced at 80 from his
intrinsic pacemaker. On the floor, he began to work with the
nurses and the physical therapists on increasing ambulation
and his activity level. He continued to be seen by the renal
service, with their recommendations for additional lab work.
Postoperatively, his creatinine was 1.2. His white count was
normal at 5.5, hematocrit 23.6, platelet count 118,000, blood
sugar 159. He continued to increase his ambulation.
On postoperative day 3, he continued to have significant
improvement. He was transfused 2 units of packed red blood
cells for a hematocrit of 23.6. Additional iron studies were
ordered per renal. He remained V-paced through his pacemaker
with A-flutter rhythm showing. He was restarted on Coumadin
therapy on postoperative day 3, and remained in the hospital,
within the course of the next several days increasing his
mobility, on heparin, waiting for his INR to increase to
therapeutic levels for his double mechanical valves. He
continued to receive his prednisone and Imuran as per
transplant dosing throughout the postoperative period.
Coumadin was increased to 10 mg. The patient was alert and
oriented with a somewhat flat affect, was managing his pain
with p.o. Percocets.
On [**7-1**], it was noted that the patient was complaining of a
tender, swollen area around his incision which was
noncellulitic. There was no crepitus and no discharge. It was
likely a pleural bleeder, and the patient was evaluated by
the cardiac surgery team for this area of hemorrhage. This
area of right incisional hematoma did increase his pain. He
continued to be dosed with Dilaudid and Percocet. His INR
remained at 1.1 on postoperative day 6. At that time, the
right thoracotomy incision was tender to palpation. Chest x-
ray showed no hemothorax. Hematocrit remained stable post-
transfusion at 27.6. Coumadin was increased to 12.5 mg that
evening. The patient was urged to continue working with
incentive spirometry, ambulating and increasing his pulmonary
toilet. This tenderness on the right side from the hematoma
did continue to bother the patient over the next couple of
days. His hematocrit dropped to 22.4 on postoperative day and
was transfused 2 more units of packed red blood cells.
Heparin was held during that period while his hematoma was
evaluated and was then restarted at 1,300 units/h.
Thoracic surgery saw the patient in consultation. A chest x-
ray also showed a probable rib fracture at the area of the
incision and retractor. Thoracic surgery recommended just
following the patient at this point, but there was no
specific plan of action that needed to be taken at that time.
His pain was much better controlled on the 14th. Abdominal
binder was placed on his chest to help him with supporting
that tender area. He was transfused a single unit of packed
red blood cells. His hematocrit rose to 26.1, and his INR
rose to 2.0. On the 15th, he was encouraged to continue
ambulating, with a therapeutic range of at least 3.0 for his
double mechanical valve. His heparin was discontinued on
postoperative day 9 with an INR of 1.8 which had dropped
slightly. His heparin was restarted later in the day when
labs returned with PT of 36.7 and INR of 1.8.
He continued to remain in the hospital, as this was the only
issue keeping him, awaiting his INR to become therapeutic. He
remained afebrile. He was seen again by thoracic surgery for
follow-up with no new issues. He continued to feel better
from his incisional hematoma. His INR bumped to 2.8 on [**7-14**]. Heparin was discontinued. He continued Coumadin dosing
that evening of 12.5 mg. The plan was if his INR remained
above 2.5, he could be discharged to home.
On[**Last Name (STitle) 61084**] of discharge, [**7-15**], the patient was alert and
oriented, with blood pressure 124/72, heart rate 80/paced,
with overlying atrial flutter, temperature 98.7, respiratory
rate 20, satting 100% on room air. His weight was 76.7 kg.
His INR was 3.1 on the day of discharge. His incisions were
clean, dry and intact. He had no peripheral edema. His
central venous line had been removed, his epicardial pacing
wires had been removed, and he was discharged to home with
VNA services for follow-up of his INR and Coumadin dosing.
The patient's INR/Coumadin dosing was to be followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**], his primary care and cardiologist.
Instructions were given to patient for blood draws on the
first [**Last Name (NamePattern1) 766**] after discharge, and then for periodically after
that according to Dr. [**Last Name (STitle) 7047**]. VNA was also instructed to
call Dr.[**Name (NI) 9654**] office with the results. The patient was
instructed to follow-up also in Dr.[**Name (NI) 9654**] office in 2
weeks for a postop visit, and to see Dr. [**Last Name (Prefixes) **] in the
office at 4 weeks for postop surgical visit.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation, status post mitral valve replacement
on [**2141-7-4**] via right thoracotomy with St. [**Male First Name (un) 923**]
mechanical valve.
2. Hypertension.
3. Gout.
4. Atrial fibrillation/bradycardia, sick sinus syndrome,
status post DDD pacemaker.
5. Status post kidney transplant.
6. Status post myocardial infarction.
7. Status post St. [**Male First Name (un) 923**] mechanical aortic valve replacement
in [**2130**].
8. Neuropathy of bilateral lower extremities.
9. Status post cholecystectomy.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 81 mg p.o. once daily.
2. Zantac 150 mg p.o. b.i.d.
3. Lipitor 10 mg p.o. once daily.
4. Azathioprine 125 mg p.o. daily.
5. Vitamin C 500 mg p.o. b.i.d.
6. Colace 100 mg p.o. t.i.d.
7. Ferrous gluconate 300 mg p.o. t.i.d.
8. Neurontin 300 mg p.o. once daily.
9. Percocet 5/325, 1-2 tablets p.o. p.r.n. for pain q. [**3-31**] h.
10. Prednisone 5 mg p.o. once daily.
11. Atenolol 12.5 mg p.o. once daily.
12. Coumadin--The patient was instructed to take 10 mg
once a day for 2 days on [**7-15**] and [**7-16**], and an INR
blood check on [**Last Name (LF) 766**], [**7-16**], with further dosing by Dr.
[**Name (NI) 9654**] office for a target INR of 3.0-3.5.
13. Digoxin 0.0625 mg p.o. once a day.
14. Lasix 20 mg p.o. once a day for 7 days.
15. Potassium chloride 20 mEq p.o. once a day for 7
days.
Again, the patient was discharged to home with VNA services
on [**2141-7-15**] in stable condition.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2141-8-23**] 15:37:49
T: [**2141-8-23**] 16:39:38
Job#: [**Job Number 61085**]
|
[
"427.31",
"401.9",
"V45.01",
"V42.0",
"355.8",
"424.0",
"280.9",
"274.9",
"V43.3",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
2017, 2058
|
11087, 11623
|
11646, 12866
|
3969, 11066
|
1439, 2000
|
1012, 1415
|
2075, 3951
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,451
| 102,698
|
31955
|
Discharge summary
|
report
|
Admission Date: [**2152-10-18**] Discharge Date: [**2152-10-23**]
Date of Birth: [**2104-10-21**] Sex: M
Service: SURGERY
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
tramatic fx of left fibula
Major Surgical or Invasive Procedure:
revision of Left BKa [**10-19**]
s/p epidural [**10-19**],d/c'd [**10-20**]
Import Major Surgical or Invasive Procedure
History of Present Illness:
Patient who under went Left BKA for left charchot foot
deforimity which was refractory to multiple
reconstructions.Experienced a tramatic left tibular fx while
climbing stair without prothesis on at the time.Admitted for
peroperative Ketamin gtt and BKA revision
Past Medical History:
PMH: Charcot, degenerative disease of the foot, ankle, central
cord syrinx, polyneuropathy. He also received left foot fusion
and the two other operations of the left foot and ankle and a
right foot surgery.
PSH: Fat pad biopsy (Amyloidosis ruled out), left foot fusion in
[**2148**], exostectomy of the left foot in [**2149**], another exostectomy
in [**2150**] and a more recent exostectomy in later [**2150**].
Social History:
SocHx: He has a MA degree. He is now not working because of
his problems. [**Name (NI) **] is single. He smokes less than half a pack a
day to one pack a day for the last 10 to 15 years. Drinks two
to five drinks a week of usually wine; occasional marijuana use.
Family History:
FamHx: His mother who is 83 has moderate Alzheimer's disease.
Father died at 84 of stroke. Two sisters and a brother in good
health without any neurological problems. Father's side of the
family history is really not very well known.
Physical Exam:
Vital signs: stable, afebrile
HEENT: no carotid bruits
Lungs: clear to auscultaation
Heart: RRR
Abd: bengin
EXT: well healed left BKA stump,no erythema,no fluctance. right
charchot foot deformity without tenderness or erythema.
Pulses4+
neuro: nonfocal
Pertinent Results:
[**2152-10-18**] 10:44PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2152-10-18**] 10:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2152-10-18**] 10:44PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2152-10-18**] 10:44PM URINE AMORPH-FEW CA OXAL-OCC
[**2152-10-18**] 10:44PM URINE MUCOUS-RARE
[**2152-10-18**] 05:30PM GLUCOSE-82 UREA N-16 CREAT-1.0 SODIUM-141
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-23 ANION GAP-15
[**2152-10-18**] 05:30PM CALCIUM-9.5 PHOSPHATE-3.5 MAGNESIUM-2.1
[**2152-10-18**] 05:30PM WBC-5.8 RBC-4.89 HGB-14.3 HCT-40.1 MCV-82
MCH-29.3 MCHC-35.7* RDW-13.6
[**2152-10-18**] 05:30PM PLT COUNT-199
[**2152-10-18**] 05:30PM PT-14.4* PTT-26.4 INR(PT)-1.3*
[**2152-10-22**] 07:35AM BLOOD WBC-3.1* RBC-4.29* Hgb-12.8* Hct-36.1*
MCV-84 MCH-29.7 MCHC-35.3* RDW-13.6 Plt Ct-124*
[**2152-10-22**] 07:35AM BLOOD PT-13.8* PTT-26.6 INR(PT)-1.2*
[**2152-10-22**] 07:35AM BLOOD Glucose-104 UreaN-9 Creat-0.9 Na-141
K-3.9 Cl-108 HCO3-25 AnGap-12
[**2152-10-22**] 07:35AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
Brief Hospital Course:
[**2152-10-18**] Admitted. IV Kefzol began perioperatively. Iv ketamin
began by Pain service. prepared for surgery.
[**2152-10-19**] Revision og Left BKA
[**2152-10-20**] POD#1. no overnight events. Inital dressing removed.
Stump clean dry and intact. Epidural d/c'd. foley d/c'd diet
advance. PT to evaluate.
developed temp 102.5 not resonded to tylenol, repeat 102.7 blood
and urine c/s obtained, cbc obtained. antibiotics covereage
brodened from kefzol to vanco/cipro/flagyl. Patient developed
subjective sx of SOB,. developed rash on chest and hives on neck
shortly after starting antibioitcs.Atbx discontinued. wbc 3.6
UA negative for wbc,bacti,nitrates,leuk/rbc 20-50. he than
develope temperature of 104 which continued to rise to 105.6
repeat labs obtained.patient PA cxr no infiltrates. placed on
cooling blanket and transfered to ICU. ID consulted. ID
recommended Daptomycin and Ceftazidime until 24hours afebrile.
Blood cultures were sent.
[**2152-10-21**] Ketamine drip dose was tapered. Pt was afebrile.
[**2152-10-22**] Pt was afebrile for more than 24 hours. Antibiotics
were discontinued.
[**2152-10-23**] Pt remained afebrile. Blood cultures had no growth to
date. Pt being discharged in good condition, tolerating regular
diet, having bowel movements and voiding and pain well
controlled. Pt to follow up in three weeks.
Medications on Admission:
clonazepam 1mgm tid,topiramate 100mgm tab [**12-15**] @HS,tramadol 50mgm
q4h,
Discharge Medications:
1. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime)
as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 3 weeks.
Disp:*42 Capsule(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO 3-6 hours for 2
weeks: Do not drive, drink or operate heavy machinery while
taking oxycodone.
Disp:*200 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
tramatic left fibular fx with migration
history of charchot feet,s/p multiple left foot
resonstructions-failed,s/p left BKA [**4-20**]
histroy of poly neuropathies
Discharge Condition:
Stable
Discharge Instructions:
no stump shrinkers
no tub baths
please do not wear prothesis until seen in followup with Dr.
[**Last Name (STitle) 1391**]
call if develope fever >101.5
call if wound site becomes red,swollen or drains
.
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 3 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
An appointment will be made for you to return for suture
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.
.
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:
7-14 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**]
3weeks for removal of sutures in Dr.[**Name (NI) 1392**] office
Provider: [**Name10 (NameIs) **] INFUSION Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2152-11-14**]
7:50
Completed by:[**2152-10-24**]
|
[
"E930.8",
"823.81",
"713.5",
"997.69",
"693.0",
"780.62",
"094.0",
"998.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.3",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
5232, 5280
|
3127, 4472
|
300, 422
|
5488, 5497
|
1982, 3104
|
10960, 11265
|
1456, 1694
|
4601, 5209
|
5301, 5467
|
4498, 4578
|
5521, 7404
|
1709, 1963
|
234, 262
|
7416, 10260
|
10283, 10937
|
450, 714
|
736, 1154
|
1170, 1440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,905
| 157,474
|
49900+49901
|
Discharge summary
|
report+report
|
Admission Date: [**2156-12-19**] Discharge Date: [**2156-12-21**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 85-year-old
gentleman presenting with epigastric pain who felt well upon
waking on the morning of admission.
He said he had breakfast on the morning of admission and then
shortly thereafter noticed the immediate onset of achy/crampy
epigastric pain associated with belching. He denied any
nausea, vomiting, diarrhea, or constipation. His last bowel
movement was on the day prior to admission.
He denied having any flatus. No radiating pain. No fevers
or chills. No dysuria. No hematuria. No flank pain. He
acknowledged having anorexia. The patient denied any other
symptoms including shortness of breath, cough, sputum, chest
pain, or palpitations. The patient tried taking some Gas-X
without relief. He was then brought to the Emergency
Department by his daughter.
On arrival in the Emergency Department, his blood pressure on
the right side was noted to be 247/132 and on the left side
was 214/127. Repeated and found to be 250/140 in both arms.
The patient then received labetalol 20 mg intravenously times
two without resolution and was then started on a
nitroprusside drip with a blood pressure initially at
247/140.
The patient was evaluated by the Medical Intensive Care Unit
team and admitted to the Medical Intensive Care Unit with a
blood pressure of 170/119 on a Nipride drip.
PAST MEDICAL HISTORY:
1. Abdominal aortic aneurysm, status post repair times
three in [**2139**], [**2146**], and [**2155**].
2. Hypertension.
3. History of transient ischemic attack.
4. Left carotid stenosis; status post carotid
endarterectomy.
5. History of renal artery aneurysm; status post repair in
[**2144**].
6. Peripheral vascular disease.
7. History of cerebellar and pontine hemorrhages.
8. Benign prostatic hypertrophy; status post transurethral
resection of prostate.
9. Hepatitis C with a negative viral load.
10. Right hip fracture; status post open reduction/internal
fixation in [**2156-9-3**].
11. Peripheral neuropathy.
12. Cholecystitis.
13. Diverticulosis.
14. Right lower lobe pulmonary nodule.
15. Anxiety.
ALLERGIES: Allergy to PENICILLIN.
MEDICATIONS ON ADMISSION: (Medications included)
1. Labetalol 200 mg by mouth twice per day.
2. Colace.
3. Multivitamin.
4. Senna.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed the patient's temperature was 95.4 degrees
Fahrenheit, his heart rate was 82, his noninvasive blood
pressure was 220/120, respiratory rate was 18, and his oxygen
saturation was 95% on room air. On examination, the patient
was awake and alert. He appeared comfortable. He was in no
acute distress. He was alert and conversant. The patient's
extraocular movements were intact. The sclerae were
anicteric. The fundi were not visualized on a nondilated
funduscopic examination. The neck was supple without any
jugular venous distention. The lungs were clear to
auscultation bilaterally with no rales. The heart was
regular in rate and rhythm. There were normal first heart
sounds and second heart sounds. There was a 2/6 systolic
murmur at the left upper sternal border. The abdomen was
soft, mildly distended, with slight tenderness to palpation
in the suprapubic and lower abdominal areas. There was no
rebound or peritoneal signs. There were decreased bowel
sounds noted. The extremities were cool. No edema was
noted. The patient was alert and oriented times three.
Cranial nerves II through XII were intact. Strength was [**6-7**]
bilaterally. Sensory examination was unremarkable.
PERTINENT LABORATORY VALUES ON PRESENTATION: On laboratory
examination, complete blood count was significant for a
slightly elevated white blood cell count of 14.3. His
hematocrit was 48.7. Chemistry panel revealed sodium was
133, potassium was 5.4, chloride was 98, bicarbonate was 26,
blood urea nitrogen was 23, creatinine was 1.1, and blood
glucose was 189. Liver function tests revealed his
alanine-aminotransferase was 16, aspartate aminotransferase
42, and his alkaline phosphatase was 95, amylase was 62,
lipase was 25, and his total bilirubin was 0.9.
PERTINENT RADIOLOGY/IMAGING: On electrocardiogram, the
patient was in a sinus rhythm at 77, with left axis, left
anterior fascicular block, prolonged P-R interval, left
ventricular hypertrophy with strain.
On computed tomography of the abdomen and pelvis there was
noted to be an aorta of approximately 6.8 cm X 4.6 cm;
unchanged since the prior study. There were bilateral iliac
aneurysms and mildly prominent small bowel loops located in
the middle third of the small bowel with no definite
transition point suggestive of a small bowel obstruction.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was
admitted to the Medical Intensive Care Unit with a
hypertensive urgency as well as with signs of a potential
small-bowel obstruction. He was admitted for a Nipride drip
as well as for administration of by mouth contrast for an
abdominal computed tomography with by mouth contrast to
better define the likely small-bowel obstruction and
transition point.
In the Intensive Care Unit, the patient's blood pressure was
well controlled on the Nipride drip. However, several hours
after he was admitted to the Intensive Care Unit the
patient's oxygen saturation began to decline precipitously.
On examination at that time, the patient had been developing
diffuse rales bilaterally with an oxygen saturation dropping
to the high 80s and low 90s despite 100% nonrebreather.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 13389**]
MEDQUIST36
D: [**2157-3-15**] 11:43
T: [**2157-3-15**] 13:26
JOB#: [**Job Number 104250**]
Admission Date: [**2156-12-19**] Discharge Date: [**2156-12-21**]
Date of Birth: Sex: M
Service: Medical Intensive Care Unit
HISTORY OF PRESENT ILLNESS: The patient was an 85-year-old
gentleman presenting with epigastric pain who felt well upon
waking.
On the morning of admission, he had breakfast and thereafter
noticed the onset of achy/crampy epigastric pain associated
with belching. He denied any nausea, vomiting, diarrhea, or
constipation. His last bowel movement was on the day prior
to admission. He did not any flatus on the day of admission.
The pain was nonradiating and not associated with any fevers
or chills. The patient also denied dysuria, hematuria, flank
pain, shortness of breath, cough, sputum, chest pain, or
palpitations. The patient attempted to take Gas-X times two
and had no relief. The patient was then brought to the
Emergency Department.
On arrival in the Emergency Department, his blood pressure
was noted to be 247/132 and on repeat and found to be
250/140. The patient then received labetalol 20 mg
intravenously times two without resolution. A Nipride drip
was started, and the patient was admitted to the Medical
Intensive Care Unit with blood pressure under better control
at 170/119.
PAST MEDICAL HISTORY:
1. Abdominal aortic aneurysm, status post repair times
three.
2. Hypertension.
3. History of transient ischemic attack.
4. Left carotid stenosis; status post carotid
endarterectomy.
5. History of renal artery aneurysm; status post repair in
[**2144**].
6. Peripheral vascular disease.
7. History of cerebellar and pontine hemorrhages.
8. Benign prostatic hypertrophy; status post transurethral
resection of prostate.
9. Hepatitis C with a negative viral load.
10. Right hip fracture; status post open reduction/internal
fixation.
11. Peripheral neuropathy.
12. Cholecystitis.
13. Diverticulosis.
14. Right lower lobe pulmonary nodule.
15. Anxiety.
ALLERGIES: The patient has an allergy to PENICILLIN.
MEDICATIONS ON ADMISSION: (Medications included)
1. Labetalol 200 mg by mouth twice per day.
2. Colace.
3. Multivitamin.
4. Senna.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed the patient's temperature was 95.4 degrees
Fahrenheit, his heart rate was 82, his noninvasive blood
pressure was 220/120, respiratory rate was 18, and his oxygen
saturation was 95% on room air. On examination, the patient
was awake and alert. He appeared slightly uncomfortable but
he was in no acute distress. The sclerae were anicteric.
The patient's extraocular movements were intact. The neck
was supple. There was no jugular venous distention. The
lungs were clear to auscultation bilaterally with no rales.
The patient's first heart examination revealed a regular rate
and rhythm. There were normal first heart sounds and second
heart sounds. There was a 2/6 systolic murmur at the left
upper sternal border. The abdomen was soft, mildly
distended, with slight tenderness to palpation in the
suprapubic and lower abdominal areas. There was no rebound
or peritoneal signs. There were decreased bowel sounds noted
but present. The extremities were cool. No edema was noted.
The patient was alert and oriented times three with a
nonfocal neurologic examination.
PERTINENT LABORATORY VALUES ON PRESENTATION: Relevant
laboratory studies revealed the patient had a white blood
cell count on admission of 14.3. His hematocrit was 48.7.
His platelets were 324. Coagulations were unremarkable. On
chemistry panel sodium was 133, potassium was 5.4, chloride
was 98, bicarbonate was 26, blood urea nitrogen was 23,
creatinine was 1.1, and his blood glucose was 123. Liver
function tests were done and were all normal.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
abdomen and pelvis showed an unchanged abdominal aorta as
well as unchanged bilateral iliac aneurysms. There was a
mildly prominent small bowel loops in the middle third of the
small bowel, but with no definite transition point; although,
suggestive of a small-bowel obstruction.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Medical Intensive Care Unit with a hypertensive
urgency as well as with signs of a possible small-bowel
obstruction; although, with no nausea or vomiting up to this
point.
For his hypertensive urgency, the patient was continued on
the Nipride drip and remained stable. For the likely
small-bowel obstruction, the patient was to have a repeat
abdominal computed tomography done with by mouth contrast.
Therefore, the patient was able to take orally the contrast
material, and the option to place an nasogastric tube was
deferred for the time being given that the patient had no
nausea or vomiting. Found only mild small-bowel obstruction
and was able to tolerate the contrast well.
Several hours into the hospital admission, the patient began
to desaturate. His oxygen saturations fell into the high
80s. Despite increase in oxygen requirements, the patient
was placed on a nonrebreather and still had an oxygen
saturation of approximately 89%. A blood gas was done and
showed 7.48, PCO2 of 31, and PO2 of 49.
Given the unimproving oxygen saturation even with some Lasix,
it was felt the patient might be in some congestive heart
failure with rales bilaterally. The oxygen saturation did
not improve. Therefore, preparations were made to intubate.
The patient was successfully intubated. However, during
intubation after visualization of the vocal cords and
placement of an endotracheal tube down the trachea copious
gastric contents filled the endotracheal tube which was then
removed and replaced by the covering attending without any
complications. However, on replacement of the endotracheal
tube there was still a significant amount of gastric contents
emanating from the endotracheal tube. At that point, 2 mg of
[**Year (4 digits) 104247**] and 60 mg of propofol were given. The blood pressure,
therefore, decreased to approximately 80 systolic which was
corrected wit fluid boluses and some dopamine and
discontinuation of the Nipride drip. The endotracheal tube
position was then confirmed by chest x-ray.
The patient's status continued to deteriorate over the next
several hours. On a chest x-ray repeated the next day, there
were signs of bilateral diffuse infiltrates suggestive of
acute respiratory distress syndrome likely due to the
aspiration of gastric contents. The patient's blood pressure
continued to require pressors for blood pressure support.
For the aspiration pneumonitis, he was covered with
vancomycin, levofloxacin, and Flagyl. For the respiratory
failure, the patient was kept on an FIO2 of 100% and was
requiring continuous positive end-expiratory pressure.
Aggressive care was continued for the time being. However,
in discussion with the family it was decided to make the
patient do not resuscitate given the dismal prognosis from
the massive aspiration and acute respiratory distress
syndrome developing.
On hospital day three, despite the continuation of pressors,
and antibiotics, as well as oxygen supplementation the
patient succumb to the septic shock, actually via a cardiac
arrest and deceased on hospital day three. Direct contact
and communication was maintained with the family as well as
the attending (Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]) throughout the hospital course.
FINAL DIAGNOSES:
1. Likely small-bowel obstruction.
2. Massive gastric aspiration with development of acute
respiratory distress syndrome.
3. Shock with multiple organ failure.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 13389**]
MEDQUIST36
D: [**2157-3-15**] 11:56
T: [**2157-3-15**] 15:16
JOB#: [**Job Number 104251**]
|
[
"507.0",
"300.00",
"518.81",
"288.8",
"401.9",
"458.9",
"785.52",
"070.51",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7888, 9954
|
13314, 13699
|
9984, 13297
|
6030, 7111
|
7134, 7861
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,003
| 195,625
|
47568
|
Discharge summary
|
report
|
Admission Date: [**2124-7-18**] Discharge Date: [**2124-7-19**]
Date of Birth: [**2057-3-17**] Sex: M
Service: MEDICINE
Allergies:
Latex / Cymbalta
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 67 year old man with a history of ESRD on HD
(T/Th/S), sCHF, DM2, Afib (not on [**Known lastname **]) presents after a
fall with report of weakness. He describes trying to stand with
the help of his walker and falling back on his back side. He
denies any head trauma or injury. He denies any dizziness,
change in vision, loss of consciousness, chest pain, or
shortness of breath. He reports calling EMS because he knew
that his weakness was likely due to missing his HD session today
and his symptoms were consistent with prior episodes of
hyperkalemia.
.
In ED VS were T 98.4 HR 90 BP 84/41 RR 12 SpO2 96. EKG was
consistent with priors showing LBBB and slow afib. Labs were
notable for potassium of 7.6. He was given insulin 10 u IV, 1
amp D50, kayexalate 30 g po, calcium gluconate 1 amp IV with
repeat potassium of 4.3. Renal team was notified and planned for
HD. Due to persistently low blood pressures he was given 2 L
IVF, pancultured and started on empiric vancomycin 1 g IV and
Zosyn 4.5 mg IV. On review of systems he noted intermittent
blood tinged sputum over the last week. He denies any recent
infections, chest pain, or shortness of breath. A CTA was
performed revealing right subsegmental pulonary embolisms. He
was transferred to the ICU for HD and further monitoring.
.
.
Review of systems:
(+) Per HPI, occasional constipation, bilateral leg cramping
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.
.
Past Medical History:
-CKD on HD , Tuesday/Thursday/Saturday
-chronic systolic CHF with EF 20% in [**5-/2124**]
-DM II
-Atrial fibrillation not on [**Year (4 digits) **]
-Gout
-BPH
-MRSA bacteremia [**2115**]
-Fungemia secondary to HD line infection [**5-/2124**]
Social History:
(Per OMR)
Patient is retired from a career in selling/buying college text
books. Patient smokes 1 pack cigarettes a day x 3 years, drinks
alcohol occasionally. No recent drug use but has hx of marijuana
and LSD. He uses multiple herbal medications. He lives alone in
an [**Hospital3 4634**] apartment complex. Does not have VNA.
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
V/S 98.6 79 82/49 16 94%RA
GEN: AOx3, NAD
HEENT: PERRLA, EOMI MMM, poor dentition, no cervical LAD, no
JVD. neck supple.
Cards: RRR
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS, no rebound/guarding, + bs
Skin: bilateral significant icthyosis and venous stasis changes
of bilateral lower extremities, scattered telangectasias of
bilateral forearms
Extremities: no edema, dry skin, 1 + distal pulses, open 1 cm
ulcer of left lateral metatarsal with yellow base, no
surrounding induration, edema, fluctuance, erythema, or warmth.
Neuro/Psych: CNs II-XII intact. Moving all 4 extremities.
Peripheral nephropathy
Drains/Tubes: R IJ tunnelled line without evidence of infection,
foley catheter, R PIV x 1
Pertinent Results:
[**2124-7-18**] CTA - 1. Filling defects within segmental and
subsegmental branches of the pulmonary vessels in the right
lower lobe concerning for pulmonary embolism.
2. Wedge shaped opacification within the right basal segment is
concerning for pulmonary infarction.
3. Retained secretions noted within the trachea.
4. Opacification with calcified rim in the periphery of the
liver (3, 60) is concerning for old torsed epiploic appendage or
pseudolipoma of Glisson's capsule.
.
[**2124-7-18**] CXR
FINDINGS: A right-sided hemodialysis catheter tip ends at the
cavoatrial
junction, unchanged from prior study. The heart size is mildly
enlarged,
likely exaggerated by technique. The mediastinal contours are
normal
appearing and unchanged. The hila are normal bilaterally. The
lungs are
clear of masses or consolidations. There is no large pleural
effusion or
pneumothorax. There is likely an old left clavicle fracture.
IMPRESSION: No acute cardiopulmonary process.
[**2124-7-18**] 02:40PM BLOOD WBC-19.1*# RBC-3.23* Hgb-10.8* Hct-32.4*
MCV-100* MCH-33.5* MCHC-33.5 RDW-16.3* Plt Ct-208
[**2124-7-18**] 02:40PM BLOOD Neuts-91.6* Lymphs-4.1* Monos-3.5 Eos-0.7
Baso-0.2
[**2124-7-19**] 04:20AM BLOOD WBC-13.0* RBC-3.44* Hgb-11.3* Hct-35.5*
MCV-103* MCH-32.9* MCHC-31.8 RDW-16.5* Plt Ct-193
[**2124-7-19**] 04:20AM BLOOD PT-15.3* PTT-27.5 INR(PT)-1.3*
[**2124-7-18**] 02:40PM BLOOD Glucose-133* UreaN-61* Creat-7.5*#
Na-127* K-8.3* Cl-88* HCO3-24 AnGap-23*
[**2124-7-18**] 06:25PM BLOOD Glucose-75 UreaN-58* Creat-7.1* Na-135
K-4.8 Cl-96 HCO3-25 AnGap-19
[**2124-7-19**] 04:20AM BLOOD Glucose-79 UreaN-40* Creat-5.2*# Na-137
K-3.8 Cl-96 HCO3-26 AnGap-19
[**2124-7-18**] 02:40PM BLOOD CK(CPK)-293
[**2124-7-19**] 04:20AM BLOOD CK(CPK)-118
[**2124-7-18**] 06:25PM BLOOD Digoxin-1.0
[**2124-7-18**] 02:52PM BLOOD Glucose-130* Lactate-2.0 Na-129* K-7.6*
Cl-88* calHCO3-24
.
[**2124-7-18**] 05:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2124-7-18**] 05:45PM URINE Blood-NEG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-SM
[**2124-7-18**] 05:45PM URINE RBC-[**2-4**]* WBC-21-50* Bacteri-OCC
Yeast-NONE Epi-0
.
[**2124-7-18**] 5:45 pm URINE Site: CATHETER
URINE CULTURE (Pending):
Brief Hospital Course:
Pulmonary embolus with pulmonary infarct - CTA chest showed RLL
segmental and subsegmental PE with a wedge shaped opacification
within the right basal segment concerning for pulmonary
infarction. Treated with heparin and [**Month/Day/Year **]. Left AMA prior to
achieving a therapeutic INR. Referred to the [**Company 191**] anticoagulation
management clinic, who will coordinate INR monitoring with
[**Location (un) **] [**Location (un) **].
.
Hyperkalemia - Treated with hemodialysis. Plans to resume usual
HD schedule, Tues/Thurs/Sat.
.
Acute complicated cystitis - Treated with vanc/cipro empirically
for 7 days (end [**7-25**]) pending results of urine culture which are
pending at the time of discharge.
.
Nonischemic cardiomyopathy - Continued digoxin, metoprolol, and
enalapril after K returned to [**Location 213**] range.
.
Type 2 diabetes mellitus - Continued basal and sliding scale
insulin.
.
Atrial fibrillation - Continued metoprolol and started [**Location **].
.
End stage renal disease on hemodialysis - Received HD on
[**2124-7-18**].
Medications on Admission:
ALLOPURINOL - 300 mg Tablet - 0.5 Tablet(s) by mouth daily
B COMPLEX-VITAMIN C-FOLIC ACID [RENALPREN] - (NOT TAKING) - 1
mg
Capsule - 1 Capsule(s) by mouth daily
BUMETANIDE - 2 mg Tablet - 3 Tablet(s) by mouth twice a day
CARVEDILOL [COREG] - 3.125 mg Tablet - 1 Tablet(s) by mouth
twice
a day
DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth every other
day
ENALAPRIL MALEATE - 5 mg Tablet - one Tablet(s) by mouth daily
FLUTICASONE - (Prescribed by Other Provider) - 50 mcg Spray,
Suspension - 1 Spray(s) intranasally twice a day
FOLIC ACID-VIT B6-VIT B12 - (NOT TAKING) - 1 mg-2.5 mg-25 mg
Tablet - 1 Tablet(s) by mouth daily
GABAPENTIN [NEURONTIN] - 400 mg Capsule - 1 Capsule(s) by mouth
three times a day
LANTHANUM [FOSRENOL] - 1,000 mg Tablet, Chewable - one Tablet(s)
by mouth three times a day with meals - No Substitution
OXYCODONE - 5 mg Tablet - one Tablet(s) by mouth tid prn
OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 1 Tablet(s)
by
mouth twice a day
TOPIRAMATE [TOPAMAX] - 50 mg Tablet - one Tablet(s) by mouth
twice a day take one extra dose on all [**Date Range 2286**] days
Herbal Medications:
3 tablets [**Hospital1 **] of mixed herbal supplements provided to him by his
herbalist/accupunturist
Ginger for anticoagulation
Rubarb for constipation
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day.
2. Bumetanide 2 mg Tablet Sig: Three (3) Tablet PO twice a day.
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: with meals.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
10. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
11. Topamax 50 mg Tablet Sig: One (1) Tablet PO twice a day:
take one extra dose on all [**Hospital1 2286**] days.
12. Vancomycin 1,000 mg Recon Soln Sig: One (1) grams
Intravenous QHD for 7 days: on [**Hospital1 2286**] days through [**2124-7-25**].
13. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
14. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: take after [**Month/Day/Year 2286**] on HD days.
Disp:*7 Tablet(s)* Refills:*0*
15. Novolin N 100 unit/mL Suspension Sig: Eighteen (18) units
Subcutaneous QAM.
16. Novolin N 100 unit/mL Suspension Sig: Fourteen (14) units
Subcutaneous at bedtime.
17. Novolin R 100 unit/mL Solution Sig: as directed units
Injection four times a day: per sliding scale .
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolus with pulmonary infarct
Hyperkalemia
Acute complicated cystitis
Nonischemic cardiomyopathy
Type 2 diabetes mellitus
Atrial fibrillation
End stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
AGAINST MEDICAL ADVICE
Discharge Instructions:
You were admitted to the hospital with an elevated potassium
level (hyperkalemia) and found to have a blood clot in the lung
(pulmonary embolus, or PE) and a urinary tract infection (UTI).
You were started on blood thinners and antibiotics, both of
which we recommend that you continue for the specified duration.
It was recommended that you remain in the hospital for further
evaluation and treatment but you have elected to leave against
medical advice having acknowledged the risks inherent in doing
so, including another blood clot, stroke, worsening heart
function, worsening of infection, or death.
The following medication changes were recommended:
1) Vancomycin infusion at each [**Month/Day/Year 2286**] session (through
[**2124-7-25**])
2) Ciprofloxacin 250 mg daily after [**Month/Day/Year 2286**] (through [**2124-7-25**]).
3) Take [**Month/Day/Year **] 5 mg until instructed by your doctors [**Name5 (PTitle) **] the
[**Name5 (PTitle) **] clinic to change your dose.
Please ensure that your [**Name5 (PTitle) **] level (INR) is checked
tomorrow, [**2124-7-20**] at [**Month/Day/Year 2286**], with the results faxed to the
number below. Please also have your level checked on Monday
[**2124-7-24**].
Please notify your healthcare providers about any herbal
supplements or nonprescription medications that you may be
taking, as these can interact with [**Month/Day/Year **].
The contact information for the [**Hospital3 **] (Dr. [**Name (NI) 100545**] office) [**Name (NI) **] clinic is [**Telephone/Fax (1) 2173**] (phone) and
[**Telephone/Fax (1) 3534**].
Please weigh yourself daily and call your doctor if your weight
goes up more than 3 lbs.
You were admitted to the hospital with an elevated potassium
level (hyperkalemia) and found to have a blood clot in the lung
(pulmonary embolus, or PE) and a urinary tract infection (UTI).
You were started on blood thinners and antibiotics, both of
which we recommend that you continue for the specified duration.
It was recommended that you remain in the hospital for further
evaluation and treatment but you have elected to leave against
medical advice having acknowledged the risks inherent in doing
so, including another blood clot, stroke, worsening heart
function, worsening of infection, or death.
The following medication changes were recommended:
1) Vancomycin infusion at each [**Telephone/Fax (1) 2286**] session (through
[**2124-7-25**])
2) Ciprofloxacin 250 mg daily after [**Month/Day/Year 2286**] (through [**2124-7-25**]).
3) Take [**Month/Day/Year **] 5 mg until instructed by your doctors [**Name5 (PTitle) **] the
[**Name5 (PTitle) **] clinic to change your dose.
Please ensure that your [**Name5 (PTitle) **] level (INR) is checked
tomorrow, [**2124-7-20**] at [**Month/Day/Year 2286**], with the results faxed to the
number below. Please also have your level checked on Monday
[**2124-7-24**].
Please notify your healthcare providers about any herbal
supplements or nonprescription medications that you may be
taking, as these can interact with [**Month/Day/Year **].
The contact information for the [**Hospital3 **] (Dr. [**Name (NI) 100545**] office) [**Name (NI) **] clinic is [**Telephone/Fax (1) 2173**] (phone) and
[**Telephone/Fax (1) 3534**].
Please weigh yourself daily and call your doctor if your weight
goes up more than 3 lbs.
Followup Instructions:
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2124-7-24**]
1:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2124-7-25**] 6:40
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2124-8-22**] 11:50
Completed by:[**2124-7-19**]
|
[
"V64.2",
"V45.12",
"304.83",
"274.9",
"V58.67",
"427.31",
"458.8",
"305.1",
"459.81",
"585.6",
"595.0",
"600.00",
"415.19",
"707.14",
"250.00",
"428.0",
"425.4",
"276.7",
"428.22",
"V45.11",
"E885.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9744, 9750
|
5756, 6814
|
286, 294
|
9987, 9987
|
3486, 5733
|
13549, 13946
|
2700, 2717
|
8143, 9721
|
9771, 9966
|
6840, 8120
|
10194, 13526
|
2732, 3467
|
1693, 2071
|
238, 248
|
322, 1674
|
10002, 10170
|
2093, 2337
|
2353, 2684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,238
| 167,433
|
6645+55741+55776
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2166-9-12**] Discharge Date: [**2166-9-17**]
Date of Birth: [**2099-9-12**] Sex: M
Service: MEDICAL ICU
HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old man
with a history of metastatic gastric carcinoma who was
recently started on hospice care and then presented to the
[**Hospital1 69**] Emergency Department on
[**2166-9-7**] with severe left hip pain and inability to
ambulate. The onset of these symptoms were precipitated by a
fall from a chair four hours prior to admission. While in
the Emergency Department the patient continued to complain of
excruciating pain. An x-ray of his left hip demonstrated a
left femoral neck fracture with displacement.
PAST MEDICAL HISTORY: 1. Metastatic gastric carcinoma
diagnosed approximately one year ago. 2. Status post
partial gastrectomy. 3. Chronic obstructive pulmonary
disease. 4. History of deep venous thrombosis. 5. History
of coronary artery disease.
ALLERGIES: Penicillin and aspirin.
MEDICATIONS: 1. Fentanyl patch 50 micrograms transdermal q
72 hours. 2. Hydromorphone 4 mg po prn pain. 3.
Pantoprazole 40 mg po q.d. 4. Metoclopramide 10 mg po prn
nausea. 5. Warfarin 2 mg po q.h.s. 6. Diltiazem 60 mg po
q.i.d. 7. Compazine 5 to 10 mg po q 6 hours prn. 8.
Cosopt eye drops one drop to each eye q.d.
SOCIAL HISTORY: The patient denies current alcohol or
tobacco use, although he reportedly has a significant smoking
history. He is married and he lives at home with his wife.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: The patient's temperature was 99.8
degrees. Blood pressure 128/54. Heart rate 91.
Respirations 20. Oxygen saturation 97% on 6 liters face
mask. In general, the patient was calm, however, he was
clearly short of breath and in obvious pain. On HEENT
examination his pupils were equally round and reactive to
light and accommodation. His extraocular movements intact.
His oral mucosa were dry. His neck was supple. There was no
JVD. No carotid bruits. No adenopathy. His heart was a
regular rate and rhythm. There was normal S1 and S2 heart
sounds and there were no murmurs, rubs or gallops. He had
decreased breath sounds at the bases with mild crackles and
wheezes bilaterally. His abdomen was soft, nontender,
nondistended. There were active bowel sounds and there was
no palpable hepatosplenomegaly. Neurological examination he
was alert and oriented times three. He had decreased
strength in his left lower extremity, because of pain, and
his sensory examination was grossly intact. He had no
peripheral edema and he had 2+ dorsalis pedis pulses
bilaterally.
INITIAL LABORATORY EVALUATION: The patient's white blood
cell was 16, hematocrit 20.2, platelets 739. His PT was
13.7, PTT 28.6 and INR 1.3. Initial serum chemistries
demonstrated a sodium of 129, potassium 4.5, chloride 93,
bicarbonate 22, BUN 40, creatinine 1.5, glucose 135. Initial
arterial blood gas demonstrated a pH of 7.37, PCO2 74, PAO2
of 46 on 6 liters by face mask. His serum lactate was 1.1.
HOSPITAL COURSE: Although the patient had recently been
initiated on hospice care, the decision was made for the
patient to undergo a left hemiarthroplasty for repair of his
left femoral neck fracture, given that this procedure would
give the patient the best chance of early ambulation with
full weight bearing. However, given his reported history of
coronary artery disease, a cardiology consult was obtained
for clearance prior to this operative procedure. The
Cardiology Service felt that the patient was asymptomatic
from a cardiovascular standpoint at a low functional level.
They felt that his baseline dyspnea on exertion was likely
secondary to his chronic obstructive pulmonary disease. They
felt that given his recent cardiac catheterization in [**2163-9-16**], which demonstrated normal coronaries and an absence
of symptoms, the patient was unlikely to have a flow limiting
coronary artery disease. They recommended changing his
Diltiazem to a beta blocker perioperatively. This adjustment
was made. Given his significant anemia on presentation to
the [**Hospital1 69**], the patient was
also transfused 3 units of packed red blood cells prior to
the operative procedure.
The patient went to the Operating Room on [**2166-9-13**]
for his left hemiarthroplasty. Although this procedure was
uncomplicated from an orthopedics point of view, while in the
Operating Room the patient reportedly dropped his oxygen
saturation to 75 to 80%. Airway suctioning done at that time
reportedly demonstrated copious amounts of coffee ground
emesis. A repeat chest x-ray done following the procedure
demonstrated diffuse, patchy opacification of the right
middle and lower lobes consistent with an aspiration
pneumonia. Given the appearance of this chest x-ray and the
patient's history of chronic obstructive pulmonary disease,
he was deemed to be a poor candidate for weaning off of
mechanical ventilation and was therefore transferred to the
MICU for continued monitoring.
The remainder of the hospital course by systems:
1. Respiratory failure: As noted above the patient
aspirated coffee ground emesis (likely gastric contents given
his history of gastric cancer) during his left
hemiarthroplasty and was therefore intubated for further
airway protection. He initially required frequent suctioning
of coffee ground emesis, but he gradually required less and
less suctioning following his successful extubation on
[**2166-9-15**]. By the time of discharge from the
hospital the patient was requiring minimal self suctioning of
tannish secretions. A repeat chest x-ray done on [**9-15**] demonstrated marked interval improvements in his right
middle lobe and right lower lobe atelectatic changes. There
was also evidence of patchy left lower lobe consolidation and
a right perihilar consolidation possibly consistent with a
multifocal aspiration pneumonia. On physical examination,
however, his lungs were clear to auscultation bilaterally and
the patient was maintaining good oxygen saturation on room
air. He was continued on his baseline chronic obstructive
pulmonary disease medications (Fluticasone, Salmeterol, and
Combivent inhalers). He was also started on Clindamycin 600
mg intravenous q 8 hours following his orthopedic procedure
for empiric coverage of his aspiration pneumonia. This
medication was changed to an oral formulation prior to his
discharge from the hospital.
Overall, at the time of discharge from the hospital the
patient's respiratory status was markedly improved and
appeared to be at its baseline.
2. Gastric cancer: The patient has a known metastatic
gastric cancer and was recently begun on hospice care. His
gastric cancer was the presumed source of his coffee ground
emesis. Although his hematocrit was found to be 20 on
admission he was subsequently transfused a total of 4 units
of packed red blood cells throughout the admission and his
hematocrit subsequently increased to 32. At the time of
discharge the patient's hematocrit was stable at
approximately 27.5. He was continued on Pantoprazole 40 mg
intravenous q 12 hours given his coffee ground emesis. Plans
were discussed with the patient and his wife for transfer and
reinitiation of hospice care following his discharge from the
hospital.
3. Left femoral neck fracture: At the time of discharge the
patient was postoperative day number four following a left
hemiarthroplasty for his left femoral neck fracture. He
began working with physical therapy on [**9-15**], the
physical therapist recommended inpatient rehabilitation with
transition to home hospice care following discharge from the
hospital. Although he continued to experience left hip and
knee pain, the patient began transferring from bed to chair
with the assistance of the physical therapist. Although the
patient ideally would have been resumed on anticoagulative
therapy with Warfarin following his orthopedic procedure,
given that he was having continued coffee ground emesis
presumably from his gastric cancer, the patient was not
restarted on anticoagulative medications following his
orthopedic procedure. He was instead maintained on
sequential compression devices of his bilateral lower
extremities for deep venous thrombosis prophylaxis. At the
time of discharge, however, the patient no longer had coffee
ground emesis and he was therefore restarted on heparin 5000
units subQ b.i.d. for deep venous thrombosis prophylaxis.
4. Cardiovascular: The patient had a transient episode of
hypotension while on a propofol drip while he was still
intubated. This episode spontaneously resolved and did not
recur once off of the Propofol drip. He remained
hemodynamically stable throughout the remainder of his
admission. Although he had previously taken Diltiazem 60 mg
po q.i.d. for a history of hypertension the patient was not
hypertensive during this admission and this medication was
not restarted. Plans were made to reinitiate this medication
following his discharge from the hospital.
5. Neurological: The patient continued to complain of
abdominal pain as well as left hip and knee pain
postoperatively. His Fentanyl patch was therefore increased
to 75 micrograms q 72 hours and the patient was initiated on
intravenous morphine 1 to 2 mg q one hours prn as needed for
pain. The patient achieved adequate pain control with this
regimen.
6. Renal: The patient's BUN and creatinine remained stable
throughout the admission. His creatinine decreased to 0.5 at
the time of discharge from the hospital, indicating that he
likely had a component of acute renal failure at the time of
his presentation to the hospital. This acute renal failure
was most likely secondary to hypovolemia.
7. FEN: The patient was maintained on maintenance
intravenous fluids throughout this hospitalization given his
relatively poor po intake. His electrolytes were repleted as
needed. He was started on a clear liquid diet on the day
prior to discharge, however, the patient did not have
significant po intake during this hospitalization.
8. Infectious disease: The patient had a presumed aspiration
pneumonia as noted above. His white blood cell count
gradually decreased throughout his hospitalization and he
remained afebrile. He was continued on Clindamycin as noted
above.
DISCHARGE CONDITION: Stable.
DISCHARGE PLACEMENT: The patient was discharged to a
rehabilitation nursing facility for further physical therapy
to increase his strength and gait mobility. The plan was for
subsequent discharge to home hospice following this
rehabilitation stay.
DISCHARGE DIAGNOSES:
1. Displaced left femoral neck fracture status post left
hemiarthroplasty.
2. Metastatic gastric cancer status post partial
gastrectomy.
3. Chronic obstructive pulmonary disease.
4. History of deep venous thrombosis.
5. Hypertension.
6. Aspiration pneumonia.
DISCHARGE MEDICATIONS: 1. Fentanyl patch 75 micrograms q 72
hours. 2. Combivent inhaler two puffs b.i.d. 3.
Fluticasone inhaler three puffs b.i.d. 4. Salmeterol
inhaler two puffs b.i.d. 5. Clindamycin 300 mg po q.i.d.
6. Pantoprazole 40 mg po b.i.d. 9. Brimonidine drops to
each eye q 8 hours. 10. Dorzolamide drops to each eye q.d.
11. Morphine sulfate 1 to 2 mg intravenous q one hour prn
pain.
The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
as necessary for further follow up of his metastatic gastric
carcinoma. He was also given a telephone number for the
[**Hospital **] Clinic to follow up with them as directed for
further management of his left hemiarthroplasty following his
left femoral neck fracture.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Doctor Last Name 25381**]
MEDQUIST36
D: [**2166-9-17**] 12:09
T: [**2166-9-17**] 12:43
JOB#: [**Job Number 25382**]
Name: [**Known lastname 10**], [**Known firstname 33**] A. Unit No: [**Numeric Identifier 4134**]
Admission Date: [**2166-9-12**] Discharge Date: [**2166-9-17**]
Date of Birth: [**2099-9-12**] Sex: M
Service:
ADDENDUM:
This is an addendum to a previous discharge summary. Please
note the following addenda.
1. The patient refused subcutaneous heparin prior to
discharge. Given that he was having significant coffee
ground emesis earlier during this admission most likely
secondary to his known metastatic gastric carcinoma, he was
not deemed to be a candidate for anticoagulation with
Warfarin at this time. He was therefore continued on
sequential compression devices to his bilateral lower
extremities for deep venous thrombosis prophylaxis. The
instructions were given to continue these devices at the
rehabilitation facility.
2. Given that the patient cannot receive intravenous
medications at the rehabilitation facility, he was
transitioned to Oxycodone 5 to 10 mg p.o. q. four to six
hours p.r.n. for pain.
3. The patient was instructed to follow up with Dr.
[**Last Name (STitle) 998**] in the Department of Orthopedics. He was
instructed to call 617-[**Medical Record Number 4135**] to schedule follow up
appointment in five weeks. Instructions were given for the
patient to have his operative staples removed on [**2166-9-27**] while at the rehabilitation facility.
Extensive conversations were had with the patient and his
wife throughout this hospitalization regarding the patient's
code status. After these extensive conversations, the
patient ultimately decided to maintain his status as DNR /
DNI. Therefore, please note the patient is "DO NOT
RESUSCITATE", "DO NOT INTUBATE".
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**First Name3 (LF) 4136**]
MEDQUIST36
D: [**2166-9-17**] 14:39
T: [**2166-9-18**] 11:03
JOB#: [**Job Number 4137**]
Name: [**Known lastname 10**], [**Known firstname 33**] A. Unit No: [**Numeric Identifier 4134**]
Admission Date: [**2166-9-12**] Discharge Date: [**2166-9-17**]
Date of Birth: [**2099-9-12**] Sex: M
Service:
ADDENDUM:
This is an addendum to a previous discharge summary. Please
note the following addenda.
1. The patient refused subcutaneous heparin prior to
discharge. Given that he was having significant coffee
ground emesis earlier during this admission most likely
secondary to his known metastatic gastric carcinoma, he was
not deemed to be a candidate for anticoagulation with
Warfarin at this time. He was therefore continued on
sequential compression devices to his bilateral lower
extremities for deep venous thrombosis prophylaxis. The
instructions were given to continue these devices at the
rehabilitation facility.
2. Given that the patient cannot receive intravenous
medications at the rehabilitation facility, he was
transitioned to Oxycodone 5 to 10 mg p.o. q. four to six
hours p.r.n. for pain.
3. The patient was instructed to follow up with Dr.
[**Last Name (STitle) 998**] in the Department of Orthopedics. He was
instructed to call 617-[**Medical Record Number 4135**] to schedule follow up
appointment in five weeks. Instructions were given for the
patient to have his operative staples removed on [**2166-9-27**] while at the rehabilitation facility.
Extensive conversations were had with the patient and his
wife throughout this hospitalization regarding the patient's
code status. After these extensive conversations, the
patient ultimately decided to maintain his status as DNR /
DNI. Therefore, please note the patient is "DO NOT
RESUSCITATE", "DO NOT INTUBATE".
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**First Name3 (LF) 4136**]
MEDQUIST36
D: [**2166-9-17**] 14:39
T: [**2166-9-18**] 11:03
JOB#: [**Job Number 4137**]
|
[
"997.3",
"414.01",
"276.5",
"507.0",
"820.8",
"584.9",
"151.9",
"199.1",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
10372, 10632
|
1532, 1550
|
10653, 10919
|
10943, 16014
|
3082, 5070
|
5099, 10350
|
1573, 3064
|
173, 710
|
733, 1337
|
1354, 1515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,472
| 190,900
|
26519
|
Discharge summary
|
report
|
Admission Date: [**2113-11-28**] Discharge Date: [**2113-12-9**]
Date of Birth: [**2053-3-9**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 60 year of female with longstanding h/o
pancreatitis and pancreatic insufficiency who was transferred to
[**Hospital1 18**] for further care from [**Hospital6 204**] (LGH). She
presented [**2113-11-27**] to LGH for lethargy and fatigue. At the
referring facility, she was found to have a blood glucose >900
and positive ketones. She was admitted, volume resuscitated and
started on an insulin drip. She is was transferred for further
care.
Past Medical History:
PMHx: HTN, Hypercholesterolemia, PVD, Chronic pancreatitis with
possible pseudocyst at pancreatic head
.
PSHx: Right lower extremity femoral-popliteal artery
bypass([**2109**]), Basal cell carcinoma from the nose, Endoscopic
ultrasound ([**Month (only) 205**] and [**2113-7-18**])
Social History:
Former smoker 1 PPD prior to Bypass Graft. No EtOH, No Drugs.
Family History:
Non-contributory. No family h/o diabetes.
Physical Exam:
On Admission:
VS: 98.2 92SR 158/76 18 100%2LNC
General: awake and alert
CV: RRR
Lungs: CTA bilaterally
Abdomen: Soft, diffusely tender, no rebound/guarding,
non-distended, hypoactive bowel sounds
Ext: warm, no edema
Pertinent Results:
On Admission:
[**2113-11-28**] 09:52PM TYPE-ART PO2-114* PCO2-20* PH-7.37 TOTAL
CO2-12* BASE XS--10
[**2113-11-28**] 09:52PM LACTATE-1.1
[**2113-11-28**] 09:52PM freeCa-1.14
[**2113-11-28**] 08:47PM GLUCOSE-105* UREA N-20 CREAT-0.7 SODIUM-136
POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-12* ANION GAP-15
[**2113-11-28**] 08:47PM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-85
AMYLASE-101* TOT BILI-0.2
[**2113-11-28**] 08:47PM LIPASE-27
[**2113-11-28**] 08:47PM ALBUMIN-3.5 CALCIUM-8.2* PHOSPHATE-0.8*#
MAGNESIUM-2.5
[**2113-11-28**] 08:47PM WBC-33.3*# RBC-3.65* HGB-11.2* HCT-31.6*
MCV-87# MCH-30.6 MCHC-35.4* RDW-12.5
[**2113-11-28**] 08:47PM PLT COUNT-233
[**2113-11-28**] 08:47PM PT-12.3 PTT-20.5* INR(PT)-1.0
.
IMAGING:
[**2113-11-28**] ECG:
Probable ectopic atrial rhythm with borderline tachycardia but
cannot exclude possible atrial tachycardia with 2:1 block.
Delayed R wave progression. Modest ST-T wave changes. Findings
are non-specific. Since the previous tracing of [**2113-6-12**] sinus
bradycardia has been replaced by rhythm as outlined and the QTc
interval appears shorter but is difficult to measure.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
98 120 80 344/410 -86 63 67
.
[**2113-11-28**] AP Chest:
No evidence of acute cardiopulmonary disease or change from the
study of [**2110-1-15**]. There has been placement of a left subclavian
catheter that extends to the mid portion of the SVC. No evidence
of pneumothorax.
.
[**2113-12-4**] Carotid Series:
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is mild heterogeneous plaque in the
ICA. On the left there is mild heterogeneous plaque seen in the
ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 104/29, 117/35,
112/35, cm/sec. CCA peak systolic velocity is 108 cm/sec. ECA
peak systolic velocity is 113 cm/sec. The ICA/CCA ratio is 1.1.
These findings are consistent with 40-59% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 86/25, 106/33, 121/34
cm/sec. CCA peak systolic velocity is 125 cm/sec. ECA peak
systolic velocity is 123 cm/sec. The ICA/CCA ratio is .97. These
findings are consistent with 40-59% stenosis.
Right vertebral antegrade artery flow.
Left vertebral antegrade artery flow.
Impression: Right ICA stenosis 40-59%.
Left ICA stenosis 40-59%.
.
MICROBIOLOGY:
[**2113-11-28**] MRSA Screen: Negative.
[**2113-11-29**] Urine Cx: No growth.
Brief Hospital Course:
[**2113-11-28**]:
Patient was transferred from [**Hospital **] [**Hospital3 **] evaluated
and admitted to the SICU under the care of Dr.[**Name (NI) 2829**] [**Name (STitle) **]
General Surgery service. Patient is a 60 year old woman with
chronic pancreatitis, pancreatic insufficiency, admitted with
diabetic ketoacidosis. She was made NPO, Foley with aggressive
fluid hydration, PICC line already placed in left arm, IV
Dilaudid for pain, and placed on IV insulin drip.
.
[**2113-11-29**]:
Patient remained in SICU. Nutrition consult was made. ABG and
Labs were routinely monitored and electrolytes replaced
appropriately. Patient persisted on insulin drip and was
closely monitored with SICU care.
.
[**2113-11-30**]:
Patient remained stable and her labs showed improvement. She
was started on first day TPN and allowed a diabetic diet. The
patient was then transferred to the floor in stable condition.
On transfer from the SICU, the patient status was as follows:
.
Neurologic: Alert and oriented x 3, Hydromorphone for pain.
Cardiovascular: HTN controlled on Beta blockade, home
medications, Hemodynamically stable.
Pulmonary: Near complete respiratory compensation of metabolic
acidosis.
Gastrointestinal/Abdomen: Chronic pancreatitis.
Nutrition: Continued on continuous TPN and diabetic diet.
Started on Creon.
Renal: Foley in place, adequate urine output, electrolytes
being repleted.
Hematology: Hemodynamically stable; on SQH, Plavix, Aspirin.
Endocrine: Insulin infusion discontinued, on Lantus with
improved glycemic control. [**Last Name (un) **] Diabetes Team and Nutrition
following.
ID: Trending WBC and fever curves, which were stable.
.
[**2113-12-1**] -[**2113-12-8**]:
The patient remained stable on the floor. Her finger sticks and
labs were regularly monitored and corrected appropriately.
[**Hospital **] clinic was active in monitoring and managing the patients
insulin types and levels. Nutrition was consulted for education
instruction for which the patient received. Physical therapy
was consulted and deemed the patient safe for ambulation and
home. Her Foley was discontinued on [**2113-12-2**] and she was
advanced to full TPN with fats on [**12-4**]. Her TPN was then
cycled, glycemic control followed closely, and insulin in the
TPN and her insulin regimen was adjusted appropriately. Her pain
was well controlled with Dilaudid PO and she remained on
prophylactic DVT and Ulcer treatments. On hospital day [**2113-12-7**],
the patient had demonstrated proper understanding and control of
her glucose levels, and it was deemed safe to discharge the
patient home with [**Month/Day/Year 269**] services. TPN was cycled over 12 hours
starting the evening of [**2113-12-7**], and her insulin regimen was
updated.
.
At the time of discharge, the patient's vitals signs were
stable, and she was appropriately monitoring her fingerstick
blood sugars and self-administering insulin as prescribed. TNP
was cycled over 12 hours at goal, she was able to ambulate on
her own, and her pain was controlled with PO pain medications.
She will return on [**2113-12-20**] for planned surgery. At the time of
discharge, the patient was doing well, afebrile with stable
vital signs. The patient received discharge teaching and
follow-up instructions and verbalized understanding and was in
agreement with the discharge plan.
Medications on Admission:
Plavix 75 mg PO Daily
Hydrochlorothiazide 12.5 mg PO Daily
Zoloft 50 mg PO Daily
Folate 1 mg PO Daily
Moexipril 30 mg PO Daily
Zocor 20 mg PO Daily
Ambien 10 mg PO QHS
Aspirin 81 mg PO Daily
OxyContin p.r.n.
Pancrease 1-4 tabs QAC
Discharge Medications:
1. Precision Xtra Test Strip Sig: One (1) strips In [**Last Name (un) 5153**]
four times a day.
Disp:*100 strips* Refills:*2*
2. Lancets,Ultra Thin Misc Sig: One (1) lancet Miscellaneous
As directed.
Disp:*1 bag/box* Refills:*2*
3. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical As
directed.
Disp:*1 box/bag* Refills:*2*
4. Insulin Syringe-Needle U-100 1 mL 30 x [**11-18**] Syringe Sig: One
(1) syringe Miscellaneous As directed for insulin injection.
Disp:*1 bag/box* Refills:*2*
5. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): Stop taking this medication on [**2113-12-13**] - one
week before your surgery.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Stop taking this medication on [**2113-12-13**] - one week
before your surgery.
8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
12. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*180 Cap(s)* Refills:*2*
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
15. Precision Xtra Monitor Misc Sig: One (1) kit
Miscellaneous As directed.
Disp:*1 kit* Refills:*0*
16. Dextrose 40 % Gel Sig: One (1) single-dose tube PO
Administer as directed for a blood sugar less than 60 or if
experiencing symptoms of hypoglycemia.
Disp:*1 box (3 single-dose tubes)* Refills:*2*
17. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4HOURS:
PRN as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
18. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*2*
19. Insulin Lispro 100 unit/mL Solution Sig: 2-14 units
Subcutaneous As directed per Humalog Insulin Sliding Scale.
Disp:*1 vial* Refills:*2*
20. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
21. Multivitamin Tablet Sig: One (1) Tablet PO once a day:
Recommend that you purchase a multi-vitamin of your choice.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1. Diabetic Ketoacidosis
2. Type II DM
3. Chronic pancreatitis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Given your low blood pressures during this hospital admission,
we have stopped your Moexipril and hydrochlorothiazide for
hypertension. You should have Dr. [**Last Name (STitle) 65502**] (PCP) evaluate
whether you still require these medications in the future after
your surgery.
Please STOP taking the aspirin and Plavix on [**2113-12-13**], one week
before your surgery. Also, please do NOT take any NSDAIS
(Motrin, Ibuprofen, Aleve, Naprosyn, etc) one week before your
surgery date. Otherwise, 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 [**3-26**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Your surgery has been scheduled for Wednesday, [**2113-12-20**]. You
will be contact[**Name (NI) **] by Dr.[**Name (NI) 2829**] office with the pre-operative
instructions and instructions regarding the time and location to
return to the hospital. Please call ([**Telephone/Fax (1) 2828**] if you have
any questions.
.
Please call ([**Telephone/Fax (1) 65503**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 65502**] (PCP) in [**3-22**] weeks (2-3 weeks after
up-and-coming surgery).
.
Other Appointments:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2114-10-8**]
9:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2114-10-8**] 10:10
|
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icd9cm
|
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[
[]
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[
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,439
| 129,586
|
29050
|
Discharge summary
|
report
|
Admission Date: [**2200-11-14**] Discharge Date: [**2200-11-25**]
Date of Birth: [**2142-8-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Upper GI bleed.
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
A 58 yo female with MMP including recently diagnosed AV
endocarditis and recent left parietal infarct ([**10-20**]), HTN, CAD
s/p CABG, DM2, GIB on anticoagulation,recent sepsis who is
transferred from OSH with new CNS lesions.
Ms [**Known lastname 21822**] has had 2 recent admissions to OSH; first on [**10-20**]
for parietal infarct. Stroke w/u only revealed aortic plaque so
she was started on coumadin and eventually discharged. She had
another admission on [**2116-10-29**] for chest pain and was found to
have [**12-18**]+ bld cx for strep viridans and an eccho which revealed
AV endocarditis. She was started on penicillin. She was note to
have altered mental status at that time but no CNS imaging was
pursued. Her coumadin was d/c'd? She was transferred to
[**Hospital3 **] Hospital on [**2200-11-5**] on penicillin. Per
report, has "seizure activity" on [**2200-11-10**] "left arm spastic,
eyes rolled back." Loaded with dilantin and has been on 100 mg
po tid since then. She got CT wet read "1.7 cm high density
focus in left cerebral whiet matter vs. cortex. Looks
hemorrhagic. Could be primary hemorrhage or hemorrghaic tumor."
She was taken back to [**Location 69980**], then tx to [**Hospital1 18**].
She was seen by neurology and neurosurgery; on examination she
was encephalopathic with evidence of right hemiparesis/ prior
stroke.
In the ED, VS on arrival were: T: 97.9; Hr: 80; BP: 116/60; RR:
16; O2 100 4L NC. She was given ASA 325 mg po x 1, protonix 40
mg IV, 1 L of NS. at 10 am, found to have large maroon/black
stool. HCT 22 from 29 on admission (27 at OSH). INR was 1.2 with
normal platelets. NG lavage showed bright red blood. Pt was
hemodyanamically stable in the ED. Per report she was oriented x
2.
Past Medical History:
1. Coronary artery disease s/p CABG
2. Left parietal infarct, early [**Month (only) **]. Residual right
hemiparesis.
3. Hypertension
4. Diabetes mellitus
5. Chronic non healing right heel ulcer
6. Chronic LE edema
7. Hypothyroidism
8. History of gastrointestinal bleeding on anticoagulation
9. History of recent ARF requiring temporary dialysis
10. History of colonic resection with colostomy 5-6 years ago,
reversed. This was complicated by prolonged intubation with
trach and eventual decannulation.
Social History:
Lives with her son-wheelchair bound few years (due to open wound
on heal of foot).
Family History:
Non-contributory.
Physical Exam:
VS: T: 96.6; HR: 87; BP: 103/53; RR: 15; O2: 100 2L
Gen: Can arouse with touch, though speaking one-two words, not
always sensicle
HEENT: Dilated but minimally responsive 4-->3 mm, OP dry, unable
to fully assess
Neck: No LAD. Wide neck girth.
CV: RRR S1S2. ?systolic murmur. Heart sounds are distant.
Lungs: CTA b/l anteriorly
Abd: Obese, distended slightly.
Back: unable to assess
Ext: b/l surgeries with multiple scares in LE (likely bypasses
for PVD). Missing left great toe, other toes. Left heal ulcer
small with granulation. There is bandage over right heal
Neuro: Could not assess CN as pt was non-cooperative with exam
and lethargic. Thought we were in "[**Hospital1 392**]" that it was [**Month (only) 404**]
1900. Knew her name. Unable to move right side. Left side: hand
grip [**3-19**]. Other [**4-18**] though limited by inattention and lethargy.
Pertinent Results:
LAB DATA:
CBC:
[**2200-11-13**] 07:30PM WBC-10.3 RBC-3.90* HGB-9.5* HCT-29.9* MCV-77*
MCH-24.5* MCHC-31.9 RDW-25.5*
[**2200-11-13**] 07:30PM NEUTS-71.4* LYMPHS-19.0 MONOS-7.0 EOS-2.3
BASOS-0.3
LFTS:
[**2200-11-13**] 07:30PM ALT(SGPT)-11 AST(SGOT)-27 CK(CPK)-66 ALK
PHOS-126* AMYLASE-23 TOT BILI-0.4
[**2200-11-13**] 07:30PM LIPASE-10
CHEMISTRIES:
[**2200-11-13**] 07:30PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.3*
[**2200-11-13**] 07:30PM GLUCOSE-107* UREA N-6 CREAT-0.7 SODIUM-128*
POTASSIUM-3.8 CHLORIDE-87* TOTAL CO2-30 ANION GAP-15
CULTURE DATA:
[**2200-11-15**]: [**1-18**] Blood cultures with e.coli (sensitive to
meropenem; zosyn)
[**2200-11-15**]: Urine culture with pseudomonas (sensitive to zosyn; I
sensitivity to meropenum)
EKG:
[**11-18**] Afib in 100s. RBBB with PACS. Seems to be in and out of
afib on tele
MRI head ([**2200-11-14**]):
Signal abnormalities in left frontal and parietal lobes on the
left, with anatomic distribution and imaging characteristics
consistent with subacute infarctions of embolic etiology.
RUE Ultrasound: ([**2200-11-14**]):
No evidence of DVT in the right upper extremity
TTE ([**2200-11-15**]):
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. Left ventricular systolic function
appears grossly preserved in suboptimal views. Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2) Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is a trivial pericardial effusion.
CT ABD/PELVIS ([**2200-11-16**])
1. Moderate bilateral pleural effusions. Probable bibasilar
atelectasis, although consolidation cannot be excluded.
2. Multiple splenic infarctions.
3. 8-mm hypodensity in the right kidney, which is too small to
characterize.
4. Status post subtotal colectomy with a diastasis in the
anterior pelvic
wall containing small bowel loops. While some of the distal
small bowel loops are distended with air/fluid levels, oral
contrast reaches the rectum without evidence of bowel
obstruction.
5. Anasarca.
6. No free fluid and no drainable fluid collection in the
abdomen or pelvis.
CXR ([**2200-11-16**]):
Bilateral lower lobe atelectasis or consolidation with interval
worsening at the right base. No other significant change.
Bilateral foot x-ray ([**2200-11-17**]):
1. Diffuse osteopenia limiting fine the bony detail to diagnose
nondispaced fractures and osteomyelitis changes. No definite
evidence of lytic or sclerotic changes underlying areas of soft
tissue defects within the heels bilaterally.
2. A tiny cortical defect seen along the base of the fifth
metatarsal on the left. Recommend correlating clinically to
determine if there is point tenderness or an ulcer underlying
this lesion.
Brief Hospital Course:
1. Endocarditis:
Ms [**Known lastname 21822**] has AV endocarditis (strep viridans) with resultant
CNS and splenic embolism. Ms [**Known lastname 21822**] was continued on penicillin
3million U IV q4 hrs. Surveillance blood cultures were negative
for strep viridans; however she was found to have ecoli
bacteremia which was sensitive to meropenem. Therefore, she was
changed to meropenem at the advice of the infectious diseases
service. Repeat echocardiogram at [**Hospital1 18**] did not show evidence
of endocartidis. The plan at the time of discharge included the
following:
--Meropenum 500 mg IV Q6H through [**11-29**]
--Penicilllin 3 million units IV Q4H to start after completion
of Meropenum and to be used until [**2200-12-11**]
2. Cerebral emboli:
These likely represented septic emboli in the setting of
endocarditis. Ms [**Known lastname 21822**] was loaded on dilantin and was given
IV decadron to decreased cerebral edema. This was tapered with
resolving lethargy/headache. Her antibiotics were dosed for CNS
infection. Regarding steroids, plan was for a swift taper with
4 additional days of prednisone, 10mg daily to be finished after
discharge. Dilantin was continued at 100mg TID, per neurology
recommendations. Ms [**Known lastname 21822**] is expected to have a persistant R
hemiparisis but may regain some other functions. Her mental
status greatly improved from stuporus on admission to conversant
at the time of discharge.
3. Ecoli bacteremia:
Ms [**Known lastname 21822**] was noted on [**11-15**] to have [**1-18**] + bld cx for Ecoli.
This is suspected to be from translocation through esophagus or
gut. She was started on meropenem. Repeat surveillance
cultures were negative. CT abdomen was negative, urine did not
reveal E coli; abd/pelvis CT scan was negative; podiatry felt
her heel ulcers were not the source.
4. Pseudomonas UTI:
Although the organism had intermediate [**Last Name (un) 36**] to meropenem, ID
service wanted to continue meropenem alone with the idea that
meropenem is concentrated in the Urine.
5. Upper GIB:
Ms [**Known lastname 21822**] had a massive upper GIB on admission; she was
intubated for airway protection and urgently scoped which showed
multiple severe ulcers. She was transfused several units blood
and started on sucralfate, PPI, with stabilization of her. At
the time of discharge, she was continued to remain OFF aspirin
and coumadin. The decision for future anticoagulation in the
setting of atrial fibrillation was to be made in the future in
consultation with the patient's PCP.
6. Chronic pain:
The patient's pain was felt to be secondary to her diabetic
neurpathy. She presented on a fentanyl patch at 50mcg every 72
hours. This appeared in adequate and the dose was subsequently
increased to 75mcg every 72 hours with improved effect. PO
narcotic PRN was used for breakthrough pain. The pain states
that she had previously been on gabapentin, but that she did not
tolerate this medication.
7. b/l heal ulcers:
Patient presented with a history of chronic non-healing ulcers.
X-rays with no evidence of osteomyelitis. Podiatry did not feel
there was any need for debridement. Daily wound care was used.
8. Hypothyroidism:
The patient did not present on thyroid medication. Upon review
of her discharge summaries from her OSH courses, it appeared
that she had a history of hypothyroidism; as such, a TSH was
checked and found to be elevated. She was started on
levothyroxine, 50mcg daily. Plan was for repeat TFTs in [**3-20**]
weeks to determine the need for increased dosing.
9. Diabetes mellitus:
The patient presented with type II diabetes, on insulin. While
an inpatient, she was continued on insulin with, initially,
lantus and a HISS; this later changed to lantus, regular insulin
with meals and a HISS. Part of her hyperglycemia was felt to be
secondary to steroids. As such, she may require less insulin
upon discharge and thereafter, as her steroids are tapered and
stopped. Her regimen at the time of discharge included:
--Lantus 15units QHS
--Regular 5units with meals
--Humalog slidind scale
As above, her also has a diabetic neuropathy treated with
fentanyl patch.
10. Coronary artery disease:
The patient had been on a beta-[**Last Name (LF) 7005**], [**First Name3 (LF) **] ACEI and ASA. The
first two medications were held initially as she was
hypotensive. The beta-[**First Name3 (LF) 7005**] was restarted later in her
course, then changed to a CCB given her hyperkalemia. The ACEI
was held throughout the admission. The ASA was held in the
setting of her GI bleed. Future decisions regarding resumption
of this medication were left to her primary care.
11. Atrial fibrillation:
During the admission, the patient was intermittantly in atrial
fibrillation; at times were rate would increase to the 120s so,
once her blood pressure stabilized, she was rate controlled with
a beta-[**First Name3 (LF) 7005**]. On [**11-25**] she was switched to a CCB given
possibility that her hyperkalemia was BB induced.
12. Right upper extremity edema:
The patient had persistent RUE edema. An ultrasound was
performed on [**11-14**] and did not show any evidence of DVT. The
edema remained at the time of discharge.
13. Hypertension:
The patient presented with a diagnosis of hypertension, on a BB
and an ACEI. During most of her admission, her blood pressures
were in the low 100s. As above, a BB (and later a CCB) were
used for rate control. Her BP remained stable thereafter.
14. Mental status change:
The etiology of this was unclear. It may have been secondary to
septic emboli, but it may also have been associated with her
untreated hypothyroidism. At the time of discharge, the patient
was oriented to person, "[**Location (un) 86**]; [**Hospital3 **]" and "[**Month (only) 1096**]
[**2189**]". She was repeatedly reminded that it was [**2199**]. Her
short-term memory was poor, although she did recall the name of
her resident physician after repeated reminders.
Initially, the patient would become agitated at times; haldol
and/or olanzapine were used. The patient did not require these
medications over hte final 4 days of her admission.
15. Anxiety:
The patient complained of intermittant anxiety during her
hospitalization. Low dose lorazepam was used with good effect
and no apparent paradoxical agitation.
Medications on Admission:
-NPH insulin 20units qam, 20 units qpm
-regular insulin sliding scale starting at 200 at 2 units, by 2
units every 50
-zinc sulfate 220mg po daily
-ASA 325mg po daily
-heparin sc 5000 units sc tid
-nitrobid 1 inch q6 hour topical
-MVI 1tab po daily
-vitamin C 500mg po bid
-lasix 20mg po daily
-fentanyl patch 50mcg/h q72h
-protonix 40mg po daily
-lisinopril 10mg po daily
-lopressor 25mg po bid
-tylenol prn
-percocet prn
-advair 1puff [**Hospital1 **]
-dilantin 100mg po tid
-PCN 3million units IV q4h
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
twice a day.
3. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane PRN (as needed).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 4 days.
12. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 5 days: Please continue
through [**2200-11-29**].
15. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
16. Insulin Regular Human 100 unit/mL Solution Sig: Five (5)
units Injection with meals.
17. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
1. Strep viridens endocarditis
2. E.coli bacteremia
3. Pseudomonal UTI
4. Upper GI bleed
5. s/p parietal stroke
6. Cerebral emboli
7. Atrial fibrillatin
8. Coronary artery disease
9. Hypothyroidism
10. Diabetes mellitus
11. Bilateral heal ulcers
12. Right upper extremity edema
13. Mental status change
14. Anxiety
Discharge Condition:
Improved; off oxygen.
Discharge Instructions:
You are being discharged to an extended care facility where you
will continue to have ongoing care for your active medical
issues.
You have appointments scheduled with a new Primary Care Doctor
(Dr. [**Last Name (STitle) **] at [**Hospital1 18**].
Followup Instructions:
You have the following appointment scheduled:
PRIMARY CARE FOLLOW-UP: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2200-12-16**] 8:00 - This is located on the [**Hospital Ward Name 516**],
[**Hospital Ward Name 23**] Building, [**Location (un) 453**]
[**Hospital **] CLINIC: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2200-12-16**] 9:00 - This is located on the [**Hospital Ward Name 516**],
[**Hospital Ward Name 23**] Building, [**Location (un) **].
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2200-12-31**]
8:30 - This is located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]
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75,817
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43585
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Discharge summary
|
report
|
Admission Date: [**2185-6-12**] Discharge Date: [**2185-7-29**]
Date of Birth: [**2139-4-25**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 11784**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
1. Transcranial magnetic brain stimulation
2. Pentobarbital induced coma ([**6-17**] - [**2185-7-6**])
History of Present Illness:
46 yo M with longstanding history of intractable epilepsy,
followed by Dr. [**Last Name (STitle) **] transferred from [**Hospital 1474**] Hospital for
increasing seizure frequency.
As per patient's mother the patient has been having increasing
seizure freuqency over the past 2-3 months. At baseline, he gets
[**2-24**] seizures a day as baseline. However over last few months, he
has been getting progressively more episodes of seizues. He is
getting [**11-2**] seizures every day afor last 1 month and nearly
40-50 [**Last Name (un) **] day in last 3-4 days. Events are typically brief
(less than 30 secs) and include drop attacks, brief shaking,
stiffening, and occasional generalized seizures. There is no h/o
fevers, neck pains , falls or travels. He was tried on Benzal as
OPT in [**Month (only) 958**] by Dr. [**Last Name (STitle) 2442**] which wasnt very helpful in sz
control and was stopped in few weeks. Due to these concerns he
was taken to OSH. He was given 3 mg of ativan there in addition
to 2 mg at the [**Hospital1 18**] ED. CBC and Chem 7 were normal. Phenobarb
level was 28. He was sent to [**Hospital1 18**] for eval. Next, neurology was
called.
Prior medications include Tegretol, Depakote, Gabitril, keppra,
zonisamide, topiramate, felbamate, gabapentin, and vimpat.
Past Medical History:
-intractable epilepsy as described above
Social History:
-lives with mother and sister
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Examination;
VS; 98.6 88 130/80 20 97%
Gen; lying in bed, NAD
HEENT; NC/AT, mucous membranes moist, oropharynx clear
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; drowsy and needs to be waken up, answers his name, DOB, that
he is in hopsital, oriented to person, place. inattentive.
Speech is slow and dysarthric. Able to name thumb. Follows
basic
commands.
CN; PERRL 3mm-->2mm, EOMI, b/l endgaze nystagmus. Face sensation
intact V1-V3. Mild L NLF flattening. Palate symmetric, tongue
midline.
Motor; normal bulk and tone, left pronator drift. Strength is
somewhat limited by effort but appears [**5-26**] at R delt, bicep,
tricep, WrE, FE, FF. 5-/5 at L tricep and finger extensors,
otherwise [**5-26**] at delt, bicep, WrE, FF. [**5-26**] at R and L IP, ham,
quad, and gastrocs.
Sensory; intact to light touch throughout.
Coordination; mild dysmetria in LUE and slower with RAMs on
left.
Gait; deferred
DISCHARGE PHYSICAL EXAM:
VS: T 96.6 (ax), BP 115/71, HR 90, RR 14, 100% on 35% FiO2 mask
GEN: middle aged male lying in bed trached and PEG'd.
CV: RRR
PULM: crackles at R lung base, prior chest tube site on R c/d/i
ABD: soft, NT, ND
EXT: no peripheral edema
.
NEUROLOGICAL EXAM:
MENTAL STATUS: able to follow simple commands like "stick out
your tongue" and "point to the window". He is non-verbal, but
is able to nod his head or shake his head no to certain
questions. Is more interactive today.
.
Cranial Nerves:
I: Olfaction not tested
II: PERRL 3->2mm and brisk
III, IV, VI: EOMI
V: facial sensation intact
VII: face symmetrical
VIII: hearing intact bilat.
IX, X: unable to test
[**Doctor First Name 81**]: shrug [**5-26**] bilat.
XII: tongue protrudes in midline
.
Motor: normal bulk, able to move RUE and LUE spontaneously
Delt [**Hospital1 **] Tri Grip
R 5 5 4+ 5
L. 4- 4- 4 4
Sensory: patient sensation to light touch intact throughout
.
Coordination and Gait: patient bedbound, unable to test
Pertinent Results:
ADMISSION LABS:
[**2185-6-12**] 03:15PM BLOOD WBC-6.2 RBC-5.24 Hgb-16.9 Hct-48.1 MCV-92
MCH-32.3* MCHC-35.2* RDW-14.0 Plt Ct-249
[**2185-6-12**] 03:15PM BLOOD Neuts-64.2 Lymphs-27.5 Monos-5.5 Eos-1.8
Baso-1.0
[**2185-6-12**] 03:15PM BLOOD Glucose-91 UreaN-9 Creat-0.9 Na-137 K-4.1
Cl-102 HCO3-28 AnGap-11
[**2185-6-12**] 03:15PM BLOOD ALT-20 AST-17 LD(LDH)-153 AlkPhos-116
TotBili-0.4
[**2185-6-12**] 03:15PM BLOOD Lipase-53
[**2185-6-12**] 03:15PM BLOOD Calcium-9.2 Phos-3.2 Mg-2.2
[**2185-6-12**] 03:15PM BLOOD Phenoba-31.1 Phenyto-13.5
[**2185-6-12**] 05:50PM BLOOD Type-ART pO2-164* pCO2-42 pH-7.40
calTCO2-27 Base XS-1 Intubat-NOT INTUBA
[**2185-6-13**] 04:49AM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-5
FiO2-50 pO2-230* pCO2-39 pH-7.42 calTCO2-26 Base XS-1
Intubat-INTUBATED
[**2185-6-15**] 05:22PM BLOOD Lactate-0.7
DISCHARGE LABS:
[**2185-7-29**] 05:03AM BLOOD WBC-5.8 RBC-3.06* Hgb-10.1* Hct-29.1*
MCV-95 MCH-32.9* MCHC-34.7 RDW-13.9 Plt Ct-405
[**2185-7-29**] 05:03AM BLOOD Glucose-113* UreaN-13 Creat-0.5 Na-138
K-4.2 Cl-101 HCO3-31 AnGap-10
[**2185-7-29**] 05:03AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
[**2185-7-29**] 05:03AM BLOOD Phenoba-44.7* Phenyto-12.1
IMAGING: CT SPINE [**2185-6-12**] IMPRESSION:
1. Prominent multilevel anterior osteophytes without critical
spinal canal or neural foraminal narrowing.
2. Remote healed right C1 anterior arch and lamina fractures.
3. Thyroid nodules, to be further evaluated by ultrasound in
non-emergent
setting if not already performed.
CT HEAD [**2185-6-12**]:
IMPRESSION:
1. No intracranial hemorrhage.
2. Asymmetric sulcation of right parieto-occipital region as
compared to the left, raising question of cerebral edema in this
region versus increased atrophy in the rest of the brain.
Comparison with prior exams when available would be helpful to
assess for chronicity of this appearance. If persistent concern
for acute process, MRI could be considered.
3. Status post right craniotomy and right parietotemporal
resection.
CXR [**2185-6-12**]: IMPRESSION: Subtle opacities in the lower lungs
could represent early pneumonia, though given low lung volumes,
may reflect atelectasis versus bronchovascular crowding.
Correlate clinically.
CXR [**2185-6-13**]: FINDINGS: In comparison with the earlier study of
this date, there has been placement of an endotracheal tube that
projects at the supraclavicular level, approximately 7 cm above
the carina. Nasogastric tube extends to the stomach where it
crosses the lower margin of the image. There is minimal
asymmetry at the bases with more opacification on the left and
possible silhouetting of the
outer aspect of the hemidiaphragm, again raising the possibility
of
consolidation in this region. Unfortunately, the external
stimulator device somewhat obscures this region.
EEG [**2185-6-13**]: IMPRESSION: This is an abnormal continuous EEG due
to the presence of 44
electrographic seizures, characterized by rhythmic [**1-3**] Hz
activity
starting over the right frontotemporal region, 176262with
subsequent
spread to the left hemisphere and evolution into diffuse
rhythmic sharp
theta activity, lasting between 30 seconds to 3 minutes. These
seizures
occurred between 4-5 times per hour during the initial part of
the
recording. At approximately 9 pm, the frequency of the
electrographic
seizures decreased to approximately 1 event per hour. In
addition, for
most of the recording, a mixed diffuse [**1-5**] Hz alpha-beta
frequency
activity and [**4-26**] Hz theta frequency activity, with frequent
bursts of
generalized suppression, is observed, consistent with
pharmacologic
sedation. There are frequent spike interictal discharges seen
over the
right frontotemporal region, phase reversing at F8-T4, are
indicative of
a focal region with high epileptogenic potential. Finally, the
activity over the entire right hemisphere appears more
attenuated with
more delta slowing compared to the left, suggestive of a large
underlying structural defect involving the cortex.
EEG [**2185-6-14**]: IMPRESSION: This is an abnormal continuous EEG due
to the presence of 33
electrographic seizures, characterized by rhythmic [**1-3**] Hz
activity
starting over the right frontotemporal region, with spread to
the left
hemisphere and evolution in diffuse rhythmic sharp theta,
lasting
between 30 seconds to 2 minutes. These seizures occurred
approximately
4 times per hour during the initial part of the recording, but
decreased
to 1-2 per hour after 1 pm. In addition, for most of the
recording, a
mixed diffuse [**1-5**] Hz alpha-beta frequency activity and [**4-26**] Hz
theta
frequency activity, with frequent bursts of generalized
suppression, is
observed, consistent with pharmacologic sedation. There are
frequent
interictal spike discharges occuring in brief runs seen over the
right
frontotemporal region, phase reversing at F8-T4, indicative of a
focal
region with high epileptogenic potential. Finally, the activity
over
the entire right hemisphere appears more attenuated with more
delta
slowing compared to the left, suggestive of a large underlying
structural defect involving the cortex.
HEAD CT [**2185-6-14**]: IMPRESSION: Persistent asymmetry of the
parietal and occipital sulci, suggesting mild edema on the
right. Recommend MRI for further evaluation.
MRI [**2185-6-14**]: IMPRESSION:
1. Right parietal and occipital cortical thickening with mild
restricted
diffussion, most likely ictal changes.
2. Status post remote right pterional craniotomy with resection
of much of
the right temporal lobe.
3. Calvarial thickening and posterior fossa volume loss likely
sequela of
chronic anticonvulsant therapy.
ECHO [**2185-6-15**]: IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function. Mildly dilated aortic root.
KUB [**2185-6-23**]: IMPRESSION: Findings concerning for small bowel
obstruction. Consider CT for further evaluation.
CT CHEST [**2185-6-25**]: IMPRESSION:
1. Interval mild increase of bilateral pleural effusions and
bibasilar
opacities, likely representing atelectasis.
2. Enlarged main pulmonary artery, likely representing chronic
pulmonary
hypertension.
3. Interval decrease of ascending colon and small bowel
dilatation.
4. Moderate anasarca and free fluid in the upper abdomen
remains.
EEG [**2185-6-28**]: IMPRESSION: This is an abnormal 24-hour video EEG
telemetry due to the
presence of prolonged periods of generalized periodic
epileptiform
discharges (GPEDs) with a right temporal predominance at 1 Hz,
indicative of generalized cortical irritability. Furthermore,
there
were prolonged and repetitive focal epileptiform discharges in
the right
temporal region isoelectric at F8/T4 and, at times, these were
better
rhythmic at 2-3 Hz. However, the right temporal discharges were
less
organized and less continuous compared to the previous day. Both
the
right temporal discharges and GPEDs were accentuated by bedside
care,
consistent with SIRPIDs. There wereno clear electrographic
seizures
seen. The background was otherwise slow at 4-5 Hz with periods
of
burst-suppression pattern, due to pharmacologic therapy.
Overall, the
record showed a slight improvement compared to the previous
day's
recording.
CXR [**2185-6-29**]: IMPRESSION: AP chest compared to [**6-28**]:
Positioning, now supine, may account in part for increased
opacification in both hemithoraces due to posteriorly layering
pleural effusions, as well as greater distention of mediastinal
vessels, nevertheless it looks like these findings are more
pronounced suggesting volume overload. Mild edema may be
present.
Tip of the tracheostomy tube abuts the right tracheal wall,
nasogastric tube still passes as far as at least the upper
stomach and out of view. Right jugular line ends in the SVC. No
pneumothorax.
MR HEAD [**2185-7-11**]: IMPRESSION:
Interval resolution of diffusion signal changes in the right
parietal and
occipital region with minor cortical thickening. Status post
right pterional craniotomy with a large resection of the right
temporal lobe and volume loss of the cerebellar hemisphere is
stable. No abnormal enhancement is demonstrated.
KUB [**2185-7-14**]: IMPRESSION:
1. Large amount of stool diffusely throughout the colon and most
predominantly within the ascending colon.
2. Resolving right lower lobe pleural effusion.
EEG [**2185-7-22**]: IMPRESSION: This is an abnormal 24-hour continuous
video EEG telemetry
due to the presence of interictal spike discharges seen broadly
over the
R>L fronto-temporal region as well as slowing seen more focally
over
this region. These patterns are suggestive of an underlying
focus with
epileptogenic potential. In addition, the frequent periods of
[**3-26**] Hz
frontal delta activity is suggestive of a moderate diffuse
encephalopathy commonly seen with medication effect, metabolic
disturbance, or infection. There may be a slight increase in the
focal
frontal temporal slowing today compared to the prior day's
telemetry
CXR [**2185-7-25**]: IMPRESSION: Frontal and lateral chest radiographs
compared to [**7-24**] and [**7-25**] at 2:38 p.m.:
Moderate to large right pleural effusion is appreciably smaller
than it was four hours ago and there is no pneumothorax. I do
not see an indwelling right pleural drain. Except for the
pleural effusion projecting over the right lower chest lungs are
clear. Heart size is top normal. Tracheostomy tube in standard
placement.
CT CHEST [**2185-7-27**]: IMPRESSION:
1. Small right pleural effusion, decreased since recent
thoracentesis. Ground glass and consolidative opacities in the
right lung (most marked in the RLL) may be due to pneumonia, but
given the recent large volume right
thoracentesis, reexpansion pulmonary edema is an additional
diagnostic
consideration.
2. Small left pleural effusion and adjacent atelectasis.
3. Secretions in the central airways. No obstructing lesion.
4. Chest tube in place with small pneumothorax.
5. 3mm right apical nodule is unchanged from [**2185-6-12**]. If the
patient has no risk factors for lung malignancy, no follow up is
needed. If the patient has risk factors for lung malignancy,
recommend follow upwith dedicated chest CT in [**2186-5-23**].
6. 10mm left thyroid nodule can be evaluated by nonemergent
ultrasound if
clinically indicated.
CXR [**2185-7-28**]:
REASON FOR EXAM: Assess right chest tube.
Comparison is made with prior study CT [**7-27**].
Cardiomediastinal contours are normal. Right chest tube is not
visualized.
There is a small right pneumothorax. Bibasilar opacities, right
greater than left, are unchanged ; on the left likely
atelectasis, on the right could also be due to pneumonia or
re-expansion pulmonary edema. ET tube is in a standard position.
Gastric tube is in place.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 11679**] is a 46M h/o intractable epilepsy since
childhood, s/p 2 epilepsy surgeries, admitted for status
epilepticus.
# NEURO: status epilepticus
46 year old man with intractable epilepsy since childhood,
recent increase in seizure frequency, admitted with status
epilepticus with seizures every 10-20 minutes over the past [**3-25**]
days. On initial examination, his speech was slow and dysarthric
with mild left hand weakness and clumsiness, which appears to be
at baseline. He had no improvement in seizure frequency after
intravenous lorazepam, but developed some respiratory depression
and sedation. He was therefore admitted to the ICU, where
loading doses of phenytoin and phenobarbital did not stop his
seizures. He was then intubated and started on intravenous
propofol, but
continued to have electrographic seizures every 10-20 minutes. A
switch to midazolam resulted in bradycardia without improvement
in seizure control, so he was switched back to propofol. However
he continued to have very frequent seizures despite maximum
doses of propofol, and he was therefore switched to
pentobarbital drip.
On head CT there were findings of possible edema in the right
posterior quadrant. On brain MRI with and without contrast,
there were some changes in the right posterior quadrant,
possibly related to seizures, but also raising the possibility
of an underlying cortical dysgenesis. Lumbar puncture did not
show any evidence of inflammatory disorder or infection.
It has therefore remained unclear what precipitated the increase
in seizure frequency. He was continued on pentobarbital drip,
and was put into burst suppression. A ketogenic diet was
attempted, but this was limited by his developing ileus and had
to eventually be completely stopped. We continued to add on
antiepileptic medications including Keppra and Vimpat. He then
underwent transcranial magnetic stimulation (TMS). After this,
his EEG started to improve, and his pentobarbital drip was
slowly tapered off, then stopped on [**7-7**]. His EEG remained
stable with only a few very short seizures each day. We
therefore attempted to gradually decrease his phenobarbital
levels to allow him to wake up.
He had repeat brain MRI with and without contrast on [**7-12**], which
showed interval resolution of diffusion signal changes in the
right parietal and occipital region with minor cortical
thickening, and no abnormal enhancement.
His PHB level peaked in the low 90s, and the dose was gradually
decreased. As he awakened from the PTB and PHB, his PHT level
remained relatively stable on stable dosing. Once his PHB fell
to the 40s-50s, he began opening and closing his eyes and
gripping with both hands on command, which then improved to
ability to complete midline, appendicular commands and
cross-body commands. He still has LUE and LLE weakness, which
he thinks is worse since he woke up from his phenobarb coma.
This is likely related to his prior epilepsy surgery and will
hopefully improve over time back to baseline. His primary
neurologist, Dr. [**Last Name (STitle) 2442**] is aware of this problem, and will
follow.
# ID:
The patient developed fevers of unknown origin. Initially, BAL
grew MSSA and Enterobacter and he completed a course of
vancomycin and cefepime. However, he continued to spike fevers
after treatment. ID was consulted and an extensive workup was
completed with no evidence of infectious etiology. There was a
concern this was drug fever, but none of the AEDs that may be
responsible could be stopped at this time. His fevers and WBC
began to trend down, then spiked again when he was found to have
2 positive blood cultures and his central line catheter culture
all grew coag negative staph. He was treated with vancomycin for
a 14-day course ending [**7-21**] (for suspected pathogenic
coagulase-negative staph epi). On [**7-13**] pt's CXR showed a
R-sided pleural effusion, for which he had a thoracentesis on
[**7-25**] with 1L of fluid drained. He was started empirically on
vanc for suspicion of PNA, but chest CT showed only atelectasis.
He then had a chest tube placed on [**7-26**], which he pulled out on
[**7-28**]. He then had no further reaccumulation of his fluid seen
after that date. Interventional pulmonary felt that he did not
need a repeat chest tube, but if the pleural effusion
reaccumulates and effects pt's respiratory status he may need a
repeat chest tube placed in the future. His vanc was stopped on
discharge ([**7-29**]) per ID recs.
# GI:
Patient developed severe ileus, thought to be due to
pentobarbital. Surgery was consulted and did not recommend acute
intervention. He was monitored closely, given aggresive bowel
meds, and made strictly NPO with NGT to suction. This finally
resolved the ileus and he was able to undergo PEG placement and
tolerate tube feeds, though he continued to have some
intermittent high residuals. Later, on the floor at the end of
[**Last Name (LF) **], [**First Name3 (LF) **] increased bowel regimen was used along with restarting
Reglan (10 [**Hospital1 **]) to good effect, with reduced gastric residuals
and increased stooling with a benign exam. His residuals
improved while on the floor and he no longer need the reglan,
but if this problem occurs again at rehab, reglan will be
helpful for this issue. He began having loose stools on [**7-28**], so
his bowel regimen was made entirely PRN.
# RESP:
In the ICU patient developed bilateral pleural effusions which
were not loculated on chest CT. They were likely transudative in
the setting of hypoalbuminemia and third spacing, as he did also
develop anasarca. This improved with autodiuresis. Tracheostomy
was placed. He developed a pleural effusion as above between
[**Date range (1) 16834**] and this was drained via thoracentesis on [**7-25**] and a
chest tube places on [**7-26**].
# RENAL:
Acute kidney injury, ATN vs. prerenal, resolved.
# PENDING LABS:
ACID FAST Cx of pleural fluid from [**7-25**] (but suspicion is low for
TB)
# TRANSITIONAL CARE ISSUES: Pt had a lung nodule found on chest
CT (see results section) that will require a repeat CT chest in
[**2186-5-23**] for further evaluation.
Pt had 10mm L thyroid nodule that should be evaluated by a
nonemergent U/S as an outpatient or at rehab.
Patient will need his phenytoin levels maintained between [**11-10**]
and phenobarb between 40-50. His phenobarb can be transitioned
to PO on [**8-5**], but his levels will need to be monitored more
closely at this point to ensure stability.
If patient decomenstates from a respiratory standpoint, he may
need a repeat chest tube to drain previously noted R sided
pleural effusion.
Medications on Admission:
-phenobarbital 50/50/50
-phenytoin 100/100/30
-lyrica 150 mg tid
-lamotrigine 200 mg tid
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. pregabalin 75 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
7. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day) as needed for trach in
place.
8. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
11. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation, recent ileus.
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. lacosamide 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed for constipation.
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
18. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash.
20. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
21. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain, fever.
22. phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 1230**]y
(150) mg PO QNOON (): Please give Q8H as follows: 200mg, 150mg,
100mg.
23. phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg
PO BID (2 times a day): Please do Q8H dosing as follows: 200mg,
150mg, 200mg.
24. PHENObarbital 50 mg IV Q8H Start: next dose
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Refractory epilepsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
NEURO EXAM:
Notable for being non-verbal, LUE weakness worse on distal LUE.
Difficult to assess LE's, but able to move both legs bilaterally
spontaneously.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for increased seizure frequency, with
seizures that were refractory to multiple anti-seizure drugs and
you therefore admitted to the ICU to be placed in a
phenobarbital coma. This helped with your seizures and your
phenobarbital level was subsequently decreased. You are able to
be discharged to rehab in your current condition.
We made the following changes to your medications:
1) We INCREASED your PHENYTOIN dose to every 8 hours as follows:
200mg/150mg/200mg
2) We STARTED you on HEPARIN 5,000mg subcutaneously three times
a day for DVT prophylaxis
3) We STARTED you on ALBUTEROL NEBULIZER treatments every 6
hours as needed for wheezing or shortness of breath.
4) We STARTED you on ARTIFICIAL TEARS in both eyes as needed for
dry eyes.
5) We STARTED you on ALBUTEROL INHALER 1-2 PUFFS Q4H as needed
for wheeze.
6) We STARTED you on SIMVASTATIN 40mg once a day.
7) We STARTED you on CHLORHEXIDINE GLUC 0.12% oral rinse 15mL
twice a day while trach is in place.
8) We STARTED you on SENNA 1 tab twice a day as needed for
constipation.
9) We STARTED you on BISACODYL 10mg per day as needed for
constipation.
10) We STARTED you on LACOSAMIDE 200mg twice a day.
11) We STARTED you on DOSCUSATE 100mg twice a day as needed for
constipation
12) We STARTED you on FAMOTIDINE 20mg every 12 hours
13) We STARTED you on MIRALAX 17gm per day as needed for
constipation.
14) We STARTED you on LACTULOSE 30mL twice a day as needed for
constipation.
15) We STARTED you on TUMS 500mg four times a day.
16) We STARTED you on KEPPRA 2grams twice a day.
17) We STARTED you on MICONAZOLE POWDER as needed for groin
rash/itch.
18) We STARTED you on OXYCODONE 5mg every 6 hours as neede for
pain
19) We STARTED you on TYLENOL 325-650mg every 6 hours as needed
for fever or pain.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
call your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospital admission.
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2185-9-20**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 3506**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"999.31",
"518.0",
"997.31",
"584.5",
"518.81",
"345.3",
"511.9",
"560.1",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.29",
"03.31",
"96.72",
"34.04",
"33.23",
"43.11",
"31.1",
"34.91",
"96.6",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
24070, 24142
|
14732, 20760
|
323, 428
|
24206, 24206
|
3956, 3956
|
26588, 26914
|
1881, 1899
|
21558, 24047
|
24163, 24185
|
21444, 21535
|
24500, 24894
|
4800, 14709
|
1939, 2906
|
24923, 26565
|
3186, 3186
|
275, 285
|
20786, 21418
|
456, 1752
|
3424, 3937
|
3973, 4783
|
24221, 24476
|
1774, 1817
|
1833, 1865
|
2932, 3167
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,059
| 126,418
|
18628
|
Discharge summary
|
report
|
Admission Date: [**2133-2-4**] Discharge Date: [**2133-2-18**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2133-2-4**] Cardiac Catherization
[**2133-2-6**] Coronary artery bypass graft x5 (Left internal mammary >
left anterior descending, saphenous vein graft > diagonal 1,
saphenous vein graft > diagonal 2, saphenous vein graft > obtuse
marginal, saphenous vein graft > PLB, Aortic valve replacement
(21mm CE magna tissue)
[**2133-2-16**] Dual Chamber Pacemaker Implantation([**Company 1543**] Sensia)
History of Present Illness:
Mr. [**Known lastname 51134**] is an 83 year old male with chest pain,
transferred from [**Location (un) 620**] for cardiac catherization after having
left sided chest pain for approximately 12 hours. There was no
history of SOB, back pain, or diaphoresis. EKG at [**Location (un) 620**] showed
T wave inversions on precordial leads. He ruled out for MI. He
was started on intravenous Heparin and transferred for further
evaluation and treatment.
Past Medical History:
Hypertension
Abdominal Aortic Aneurysm
Type II Diabetes Mellitus - diet controlled
History of Leg cramps
Benign Prostatic Hypertrophy
Social History:
Denies tobacco. Admits to occasional ETOH. He lives alone.
Family History:
Father - sudden cardiac death at age 60.
Physical Exam:
On Admission: Vitals 99.7, 116/62, 65, 20, 96% 2L
General - WDWN male in no acute distress
Skin - unremarkable
HEENT - unremarkable
Neck - supple full rom, no jvd, transmitted murmur noted
bilaterally
Chest - CTA bilat
Heart - RRR, normal s1s2, 3/6 systolic ejection murmur noted
Abdomen - soft nt, nd, +BS
Ext - warm well perfused no edema
neuro - alert and oriented, grossly intact, no focal deficits
Pertinent Results:
[**2133-2-4**] 12:51PM BLOOD WBC-8.2 RBC-4.06* Hgb-12.8* Hct-37.4*
MCV-92 MCH-31.5 MCHC-34.2 RDW-13.3 Plt Ct-191
[**2133-2-4**] 12:51PM BLOOD PT-13.6* PTT-35.6* INR(PT)-1.2*
[**2133-2-4**] 12:51PM BLOOD Glucose-131* UreaN-17 Creat-1.2 Na-142
K-4.2 Cl-107 HCO3-24 AnGap-15
[**2133-2-4**] 12:51PM BLOOD cTropnT-<0.01
[**2133-2-4**] 12:51PM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
[**2133-2-5**] 04:40AM BLOOD %HbA1c-6.2*
[**2133-2-5**] 04:40AM BLOOD Triglyc-104 HDL-42 CHOL/HD-4.0
LDLcalc-103
[**2133-2-16**] 10:00AM BLOOD WBC-7.9 RBC-3.13* Hgb-9.8* Hct-29.3*
MCV-93 MCH-31.4 MCHC-33.6 RDW-14.5 Plt Ct-391
[**2133-2-17**] 07:10AM BLOOD WBC-5.9 RBC-2.73* Hgb-8.0* Hct-25.2*
MCV-92 MCH-29.2 MCHC-31.6 RDW-13.9 Plt Ct-253
[**2133-2-18**] 07:20AM BLOOD WBC-8.6 RBC-3.04* Hgb-9.2* Hct-28.5*
MCV-94 MCH-30.4 MCHC-32.5 RDW-14.8 Plt Ct-318
[**2133-2-13**] 03:31PM BLOOD PT-14.4* PTT-54.1* INR(PT)-1.3*
[**2133-2-14**] 12:50AM BLOOD PT-14.6* PTT-58.5* INR(PT)-1.3*
[**2133-2-16**] 07:10AM BLOOD PT-14.3* PTT-90.4* INR(PT)-1.2*
[**2133-2-17**] 07:10AM BLOOD PT-14.0* PTT-29.4 INR(PT)-1.2*
[**2133-2-13**] 06:30AM BLOOD Glucose-130* UreaN-22* Creat-1.1 Na-139
K-4.6 Cl-103 HCO3-27 AnGap-14
[**2133-2-15**] 07:30AM BLOOD Glucose-114* UreaN-22* Creat-1.3* Na-141
K-4.6 Cl-105 HCO3-27 AnGap-14
[**2133-2-16**] 07:10AM BLOOD Glucose-124* UreaN-20 Creat-1.4* Na-142
K-4.6 Cl-104 HCO3-30 AnGap-13
[**2133-2-17**] 07:10AM BLOOD Glucose-106* UreaN-19 Creat-1.4* Na-144
K-4.7 Cl-105 HCO3-29 AnGap-15
[**2133-2-18**] 07:20AM BLOOD Glucose-111* UreaN-21* Creat-1.4* Na-141
K-4.2 Cl-103 HCO3-28 AnGap-14
[**2133-2-17**] Discharge Chest x-ray: In the interim, a pacemaker has
been placed with dual lead, the distal tip of the left atrial
lead is in the atrium . The ventricular lead is within the right
ventricle. The patient is status post aortic valve replacement
with multiple sternotomy wires. There is no left pneumothorax
status post pacemaker implantation. There is persistent
small-to-moderate left pleural effusion with adjacent
atelectasis of the left lower lobe. The right costophrenic angle
is unremarkable. The visualized portions of the lungs do not
show any airspace disease or interstitial disease with the
exception of the left lower lobe. The heart is not enlarged. The
aorta is tortuous and ectatic. The osseous structures do not
show any lesions suspicious for malignancy.
[**2133-2-16**] Discharge EKG: Sinus rhythm with ventricular premature
depolarizations. Marked T wave inversions in the precordial
leads. Compared to the previous tracing of [**2133-2-14**] multiple
abnormalities as previously noted persist without major change.
[**2133-2-12**] Abdominal CT Scan: 1. Small amount of fluid and gas in
the anterior mediastinum as above. Small amount of
intraperitoneal air also likely reflecting recent postoperative
state. 2. Small bilateral pleural effusions with associated
atelectasis. 3. New wedge-shaped hyperenhancing area in the left
kidney, most compatible with an infarct. 4. Slight interval
increase in size of abdominal aortic aneurysm which now measures
4.3 cm in maximum diameter.
Brief Hospital Course:
Transferred in from OSH for cardiac catherization that revealed
severe coronary artery disease. Cardiac surgery was consulted
and he underwent preoperative workup. He was taken to the
operating [**2133-2-6**] and underwent coronary artery bypass graft
and aortic valve replacement. See operative report for further
details. He received Vancomycin as perioperative antibiotic
since he was an inpatient greater than 24 hours. Following the
operation, he was taken to the ICU for hemodynamic monitoring.
In the first twenty four hours he was weaned from sedation,
awoke neurologically intact, and was extubated. He remained in
the ICU for atrial fibrillation management. On post operative
day three he was transferred to the floor for the rest of his
stay. Given a slight increase in creatinine, his ACE inhibitor
was discontinued. Creatinine peaked to 1.4 postop, and ranged
between 1.0 - 1.4 throughout his hospital stay. He was gently
diuresised towards his preoperative weight. He continued with
intermittent episodes of rapid atrial fibrillation associated
with significant pauses and bradycardia. EP service was
consulted and medications adjusted. Despite medical therapy, he
continued to experience rapid atrial fibrillation, and
conversion pauses. Due to sick sinus sydrome/tachy-brady
arrhythmias, he underwent successful placement of a permanent
pacemaker on [**2-16**], see report for further details. Post
procedure, his betablockers were increased and he had no further
episodes of atrial fibrillation. At one point postoperatively,
he complained of difficulty swallowing pills. Bedside swallow
examination revealed no signs of aspiration but was notable for
esophageal dysphagia. A soft solid diet was recommended along
with thin liquids. During his postoperative course, he also
temporarily required a Heparin bridge for a subtherapeutic INR.
Warfarin was dosed daily for a goal INR between 2.0 - 3.0. His
postoperative course was otherwise uneventful. Due to steady
clinical improvements with diuresis and steady progress with
physical therapy, he was medically cleared for discharge to
rehab on POD 12. Dr. [**Last Name (STitle) 3142**] should management his Warfarin as
an outpatient after discharge from rehab.
Medications on Admission:
omega 3
cardizem
avodart
betacarotene
colace
asa
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: Then decrease to 1 tab(200mg) daily. Continue this
dose until follow up with MD.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days: Then titrate accordingly - please monitor daily
weights along with BUN/CR.
10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 5 days: Please titrate accordingly with
Lasix.
11. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO every evening:
Please adjust daily dose for goal INR between 2.0 - 3.0. Daily
dose may vary according to INR.
12. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Coronary Artery Disease and Aortic Stenosis - s/p CABG and AVR
Postop Atrial fibrillation, Sick Sinus Syndrome with Significant
Conversion Pauses - s/p PPM
Hypertension
Abdominal Aortic Aneurysm
Diabetes mellitus type II
Benign Prostatic Hypertrophy
Mild Renal Insufficiency
Esophageal Dysphagia
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101. Report any weight gain of
greater than 2 pounds in 24 hours or 5 pounds in a week. No
creams, lotions, powders, or ointments to incisions. No driving
for approximately one month. No lifting more than 10 pounds for
10 weeks. Please call with any questions or concerns
[**Telephone/Fax (1) 170**]. Please arrange Coumadin follow up prior to
discharge from rehab with Dr. [**Last Name (STitle) 3142**]. Coumadin should be
adjusted for goal INR between 2.0 - 3.0.
Followup Instructions:
Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) - call for appt
Dr [**Last Name (STitle) 3142**] after discharge from rehab ([**Telephone/Fax (1) 19980**]) - call for
appt
Dr [**Last Name (STitle) 51135**], Thursday [**2133-3-4**] at 9:30am [**Hospital1 18**] [**Location (un) 620**]
[**Telephone/Fax (1) 4105**]
EP DEVICE CLINIC, [**Telephone/Fax (1) 59**] Appt Date/Time:[**2133-2-24**] 10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2133-2-18**]
|
[
"441.4",
"427.31",
"443.9",
"401.9",
"440.0",
"593.9",
"272.4",
"427.81",
"411.1",
"250.00",
"997.1",
"424.1",
"787.20",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"36.14",
"37.22",
"99.04",
"88.56",
"89.60",
"39.61",
"36.15",
"37.72",
"35.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8611, 8688
|
4999, 7236
|
277, 679
|
9028, 9035
|
1886, 4976
|
9716, 10257
|
1405, 1447
|
7336, 8588
|
8709, 9007
|
7262, 7313
|
9059, 9693
|
1462, 1462
|
227, 239
|
707, 1155
|
1476, 1867
|
1177, 1313
|
1329, 1389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,283
| 154,086
|
50533
|
Discharge summary
|
report
|
Admission Date: [**2129-1-5**] Discharge Date: [**2129-1-10**]
Date of Birth: [**2059-11-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
Therapeutic paracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 69-year-old gentleman with chronic systolic
and diastolic heart failure with LVEF of 45%, worsening right
ventricular dilatation and hypokinesis with moderate-to-severe
tricuspid regurgitation, and left/right heart failure, admitted
to [**Hospital1 18**] in mid [**11-29**] for diuresis and paracentesis. He reports
having a cough productive of very small amounts of
white-yellowish sputum since 7 days ago, which has been
worsening gradually. This morning, he had a bout of coughing,
following which he became increasingly short of breath and also
developed some chills. He has
been seen on a regular basis for many months at outpatient heart
failure clinic for weekly IV push furosemide, however his last
visit was on [**2128-12-23**]. He was scheduled for diuresis this week
but the nurse has been away on holiday so he was unable to get
an appointment. He ntoes that he feels heavier by about 10
pounds sicne his last visit. Of note, his wife of 42 years, who
had been battling cancer for the last 6 months, passed away last
week and he has been feeling very low and eating poorly over the
last week.
In the ED, initial vitals were: 23:20 0 99.9 78 130/69 26 88%
RA. EKG was unchanged from prior. Labs were remarkable only
for a WBC count of 12.2, creatinine was stably elevated at 2.2.
CXR showed pulmonary edema with possible left lower lobe
infiltrate. Oxygen via nasal cannulae was not attempted, and he
was placed on BIPAP with improvement of his oxygen saturation to
100%. He was given 750 mg levofloxacin adn 1g ceftriaxone as
well as 40 mg IV furosemide, and transferred to the CCU.
.
In the CCU, he was alert and orientated x 3. BIPAP was replaced
with nasal cannulae, and he was saturating 97% on 2L. He was
alert and orientated x 3, denied chest pain, palpitations,
abdominal pain, nausea, vomiting. Complaining only of dyspnea
and mild cough.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. Congenital heart disease: Primum ASD with cleft mitral
valve, ASD repair in [**2099**], MVR for associated cleft mitral
leaflet in [**2118**] with porcine valve.
2. Chronic atrial fibrillation, AV ablation, permanent
[**Year (4 digits) 4448**], failed amiodarone, on warfarin.
3. PEA/V-fib arrest [**2123**] secondary to enterococcal
bacteremia, endocarditis.
4. BiV ICD.
5. Systolic and diastolic heart failure with LVEF of 45-50%.
resting hemodynamics revealed elevated right and left sided
filling pressures with a PCWP of 33 mmHg and a RVEDP of 30 mmHg.
The pulmonary pressures were elevated with a mean PA pressure of
46 mmHg and a systolic of 76 mmHg. The cardiac index was
depressed at 1.9 L/min/m2.
At [**Hospital 1902**] clinic, pt loses about 10 pounds after diuresis; however,
after one week states he gains all weight back. Best dry weight
228 pounds. Weight at last discharge 97kg. Also has abdominal
ascites, refractory to diuretics, recent admission for
paracentesis
6. Worsening right ventricular dilatation and hypokinesis with
moderate-to-severe tricuspid regurgitation.
7. Hyperthyroidism, amiodarone induced.
8. Gout.
9. Chronic kidney disease.
10. Osteoporosis.
11. Past hypertension.
Social History:
no current tobacco, quit [**2082**]. 3+ drinks daily vs. weekly. Lives
with wife, has daughter, son and 3 grandchildren. He is a
businessman who liquidates retail stores
Family History:
His mother died of coronary artery disease. His
grandmother died of some cancer at the age of 98. His father
died of colon cancer at the age of 68.
Physical Exam:
On admission:
GENERAL: NAD. Oriented x3. Low mood, depressed affect.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of at least 16 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 and S2. Holosystolic murmur heard best at LLSB. No
S3 or S4.
LUNGS: Bilateral basal crackles, diffuse wheeze.
ABDOMEN: Soft, not tender, no organomegaly. Grossly distended
with dullness at flanks.
EXTREMITIES: bilateral pitting edema to mid thigh. bilateral
erythema, left shin with dressing covering possible blood
blister - patient reports this is secondary to scraping his leg
on a taxi door.
SKIN: Stasis dermatitis bilaterally on flanks, ulcers, scars, or
xanthomas.
PULSES: Palpable DP pulses.
At discharge:
Vitals 97.6, 90/56, 78, 12, 94% RA
In/Out: o/n -4.2net negative, -1.4 net negative since
midnight.
Weight: 104.1 kg (113 on admission, dry weight is 97 kg)
.
GENERAL: no acute distress, breathing comfortably
HEENT: mucous membs moist, JVP 14cm
CHEST: no basal crackles.
CV: RRR, distant HS
ABD: firm, distended, NT, less tense. Pos BS.
EXT: improved bilat. Reddened discoloration on ant shins bilat.
Stage 2 traumatic ulcer on ant aspect of left shin, covered with
drsg, minimal brown drainage.
NEURO: 5/5 strength in U/L extremities. Gait WNL.
PSYCH: alert, oriented, more upbeat today
Pertinent Results:
[**2129-1-5**] 11:35PM BLOOD WBC-12.2*# RBC-4.39* Hgb-13.4* Hct-41.2
MCV-94 MCH-30.5 MCHC-32.5 RDW-16.8* Plt Ct-262
[**2129-1-6**] 05:54AM BLOOD WBC-12.1* RBC-3.73* Hgb-11.6* Hct-34.7*
MCV-93 MCH-31.1 MCHC-33.4 RDW-16.1* Plt Ct-213
[**2129-1-7**] 06:20AM BLOOD WBC-8.2 RBC-3.61* Hgb-11.3* Hct-34.3*
MCV-95 MCH-31.3 MCHC-32.9 RDW-16.3* Plt Ct-197
[**2129-1-8**] 06:06AM BLOOD WBC-8.6 RBC-3.69* Hgb-11.7* Hct-35.3*
MCV-96 MCH-31.7 MCHC-33.2 RDW-16.2* Plt Ct-214
[**2129-1-9**] 06:25AM BLOOD WBC-7.7 RBC-3.93* Hgb-12.2* Hct-37.3*
MCV-95 MCH-31.0 MCHC-32.7 RDW-16.0* Plt Ct-230
[**2129-1-10**] 06:40AM BLOOD WBC-8.2 RBC-3.94* Hgb-12.1* Hct-36.5*
MCV-93 MCH-30.6 MCHC-33.0 RDW-16.4* Plt Ct-255
[**2129-1-5**] 11:35PM BLOOD Neuts-87.0* Lymphs-7.8* Monos-3.8 Eos-0.8
Baso-0.6
[**2129-1-9**] 06:25AM BLOOD Neuts-81.8* Lymphs-8.5* Monos-6.2 Eos-2.8
Baso-0.7
[**2129-1-5**] 11:35PM BLOOD Plt Ct-262
[**2129-1-6**] 05:54AM BLOOD PT-48.3* PTT-39.4* INR(PT)-4.8*
[**2129-1-6**] 05:54AM BLOOD Plt Ct-213
[**2129-1-7**] 06:20AM BLOOD PT-42.8* INR(PT)-4.2*
[**2129-1-7**] 06:20AM BLOOD Plt Ct-197
[**2129-1-8**] 06:06AM BLOOD PT-32.9* INR(PT)-3.2*
[**2129-1-8**] 06:06AM BLOOD Plt Ct-214
[**2129-1-9**] 06:25AM BLOOD PT-22.6* PTT-32.8 INR(PT)-2.2*
[**2129-1-9**] 06:25AM BLOOD Plt Ct-230
[**2129-1-10**] 06:40AM BLOOD PT-16.8* PTT-29.9 INR(PT)-1.6*
[**2129-1-10**] 06:40AM BLOOD Plt Ct-255
[**2129-1-5**] 11:35PM BLOOD Glucose-123* UreaN-80* Creat-2.2* Na-139
K-5.0 Cl-99 HCO3-24 AnGap-21*
[**2129-1-6**] 05:54AM BLOOD Glucose-135* UreaN-78* Creat-1.9* Na-140
K-4.2 Cl-99 HCO3-28 AnGap-17
[**2129-1-6**] 05:30PM BLOOD Glucose-94 UreaN-65* Creat-1.7* Na-139
K-4.8 Cl-103 HCO3-27 AnGap-14
[**2129-1-7**] 06:20AM BLOOD Glucose-130* UreaN-70* Creat-2.1* Na-140
K-3.5 Cl-99 HCO3-32 AnGap-13
[**2129-1-7**] 05:20PM BLOOD UreaN-68* Creat-2.1* Na-139 K-5.2* Cl-104
[**2129-1-8**] 06:06AM BLOOD Glucose-138* UreaN-70* Creat-2.1* Na-141
K-3.9 Cl-97 HCO3-34* AnGap-14
[**2129-1-8**] 04:10PM BLOOD UreaN-72* Creat-2.1* Na-140 K-3.7 Cl-94*
HCO3-33* AnGap-17
[**2129-1-9**] 06:25AM BLOOD Glucose-127* UreaN-76* Creat-2.2* Na-140
K-3.6 Cl-94* HCO3-36* AnGap-14
[**2129-1-9**] 05:05PM BLOOD Glucose-111* UreaN-80* Creat-2.3* Na-138
K-4.2 Cl-90* HCO3-35* AnGap-17
[**2129-1-10**] 06:40AM BLOOD Glucose-133* UreaN-88* Creat-2.2* Na-138
K-3.5 Cl-89* HCO3-40* AnGap-13
[**2129-1-5**] 11:35PM BLOOD ALT-22 AST-31 AlkPhos-76 TotBili-0.5
[**2129-1-6**] 05:54AM BLOOD CK(CPK)-83
[**2129-1-5**] 11:35PM BLOOD proBNP-[**Numeric Identifier 72497**]*
[**2129-1-5**] 11:35PM BLOOD cTropnT-0.02*
[**2129-1-6**] 05:54AM BLOOD CK-MB-3 cTropnT-0.02*
[**2129-1-5**] 11:35PM BLOOD Albumin-4.5 Calcium-9.3 Phos-4.5 Mg-2.5
[**2129-1-10**] 06:40AM BLOOD Calcium-10.1 Phos-3.9 Mg-2.4
[**2129-1-5**] 11:47PM BLOOD Lactate-2.0
.
EKG [**2129-1-5**]
Ventricularly paced rhythm. Underlying rhythm is difficult to
determine but is most likely atrial fibrillation. Occasional
ventricular premature beats. Compared to the previous tracing of
[**2127-11-30**] there is no significant diagnostic change.
.
CXR [**2129-1-5**]
PORTABLE AP CHEST RADIOGRAPH: Severe cardiomegaly, is stable
since the prior
study. The hilar and mediastinal contours are stable, with a
dilated tortuous
thoracic aorta. Mild pulmonary congestion is seen. No focal
consolidation,
pleural effusion, or pneumothorax is seen. A left chest wall
pacer with leads
in the right atrium and right ventricle are noted. An abandoned
lead is seen
in the right anterior chest wall. Pulmonary congestion.
IMPRESSION: Chronic severe cardiomegaly and chronic and/or
recurrent
pulmonary congestion. No edema.
.
CXR [**2129-1-6**]
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Old right [**Month/Day/Year 4448**] leads, new left pectoral generator.
Substantial
cardiomegaly with signs of mild fluid overload but no evidence
of pleural
effusions. No pneumonia. Mild retrocardiac atelectasis.
.
CXR PA and Lateral [**2129-1-6**]
FINDINGS: Old right [**Month/Day/Year 4448**] leads and a left pectoral
generator are
unchanged in appearance. Severe cardiomegaly is stable. Mild
edema persists
without evidence of pleural effusions. A small retrocardiac
opacity is
unchanged and has the appearance of atelectasis. There is no new
consolidation. There is no pneumothorax. Sternal wires are
intact.
IMPRESSION:
1. Stable mild pulmonary edema.
2. Stable severe cardiomegaly.
3. Unchanged small retrocardiac opacity is most likely
atelectasis
.
THERAPEUTIC PARACENTESIS [**2129-1-10**]
Successful therapeutic paracentesis yielding 4.9 liters of
straw-colored ascitic fluid.
Brief Hospital Course:
69 yo M with acute on chronic congestive heart failure after
dietary indiscretion and 2 weeks without outpatient infusion
clinic visits who presents with anasarca, cough, hypoxia and
approximately 20 pound weight gain.
.
#Acute on chronic systolic congestive heart failure with right
and left sided failure: Dry weight is 229 pounds, pt on
admission was at 244 pounds, estimate 15 pounds over dry weight.
He was started on a lasix drip, uptitrated to 20 cc/hr, with
excellent diuretic response. On the morning of discharge his
weight was 104.1 pounds, down from 113 on admission. We
continued his home spironolactone. Torsemide was held during
his admission, but restarted at 200 mg daily, 50% greater than
home dose, upon dishcarge. He underwent a therapeutic
paracentesis, with removal of 4.9L straw=coloured fluid. He
will continue to followup with Dr. [**First Name (STitle) 437**].
.
# Rhythm: Atrial fibrillation s/p AVJ ablation ICD/[**First Name (STitle) **].
Underlying rhythm is atrial fibrillation. He had good rate
control, but frequent ventricular ectopy with multiform
complexes. We continued his metoprolol XL, monitored him on
telemetry. INR was supratherapeutic on admission, warfarin was
held during his stay. INR trended down to 1.6 on the day of
discharge and warfarin was restarte following paracentesis.
.
# Anticoagulation: INR on wrfarin was 4.8 on admission, likely
secondary to abnormal PO intake during the weeks leading to and
after his wife's death. We held his coumadin and INR trended
down appropriately, was 1.6 on the mkonring of discharge.
Following paracentesis, we restarted his coumadin at his home
doe. He was cunselled regarding regular eating, and will
continue to folllowup with Dr. [**First Name (STitle) 437**].
.
#Leukocytosis: He had a WBC count of 12.2 on admisison, and
given coughs, dyspnea and some concern for possible pneumonia,
he was started on vancomycin/cefepime/levofloxacin for possible
HCAP. However, he remained afebrile,now resolved. sputum grew
only scant amounts of gram positive rods, likely contaminant.
U/A benign and BS NGTD. CXR suggestive of atelectasis instead of
infiltrate. Hypoxia resolved with diuresis. We discontinued
antibiotics and his symptoms improved with diuresis alone.
.
# Abdominal distension: Likely ascites from CHF exacerbation.
His distension improved slightly with diuresis. He underwent an
ultrasound guided paracentesis on [**2129-1-10**] prior to discharge
once his INR had trended down to below 2. 4.9L fluid was
removed.
.
# CKD: Baseline is about 2.0. with diuresis, his creatinine
trended up to a peak of 2.3, but was down to 2.2 at the time of
discharge.
.
# Coronary Artery Disease: No known CAD based on [**2118**] cath
results. Complained of no chest pain. Troponins were engative
and ruled out an MI. We continued simvastatin for his
dyslipidemia.
.
# Gout: continued allopurinol
.
# Dyslipidemia: continued simvastatin
.
# Depression: Wife passed away last week, patient feeling very
low. We offered him bereavement service consultation, but he
declined. We continued escitalopram and consulted social work.
.
TRANSITIONAL ISSUES:
- He will need ongoing followup in coumadin clinic for
management of his warfarin, given that his INR was
supratherapeutic on admission.
- He will followup with Dr. [**First Name (STitle) 437**] for weekly diuresis and
further managemetn of his heart failure
- He will followup with his PCP
Medications on Admission:
-Allopurinol 150 mg daily,
-Escitalopram 20 mg daily
-metoprolol succinate 200 mg daily
-simvastatin 20 mg daily
-spironolactone 25 mg daily
-torsemide 140 mg daily
-warfarin daily
-calcium with vitamin D daily
-multivitamin daily.
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. torsemide 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: On
Monday, Wednesday, Thursday, [**First Name (STitle) 2974**], sunday.
9. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: On
Tuesdays and Saturdays, or as directed by coumadin clinic.
10. Calcium-Vitamin D 600 mg calcium- 400 unit Tablet Sig: One
(1) Tablet PO once a day. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of
breath, cough and weight gain, symptoms of an exacerbation of
your chronic congestive heart failure. We treated you with
diuretics, and your symptoms improved rapidly. We also
performed a paracentesis to remove fluid from your abdomen.
We were initially also concerned that you might have a chest
infection, and started treating you with antibiotics.
Antibiotics were later discontinued when your symptoms began to
improve.
We made the following changes to your home medications:
-INCREASED Torsemide to 200 mg daily.
Please continue taking your other medications as usual.
Please followup with your doctors, see below. Please call Dr. [**Name (NI) 10875**] clinic to schedule you regular weekly diuresis
appointment.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: PERSONAL [**Hospital **] HEALTH CARE, P.C.
Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1408**]
Appt: [**Last Name (LF) 2974**], [**1-14**] at 11:30am
Department: CARDIAC SERVICES
When: MONDAY [**2129-1-24**] at 2:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2129-4-22**] at 2:00 PM
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 **] [**2129-4-22**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2129-1-11**]
|
[
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"416.8",
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"428.43",
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"585.9",
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icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
15122, 15128
|
10464, 13596
|
326, 353
|
15197, 15197
|
5847, 10441
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16322, 17595
|
4246, 4396
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14192, 15099
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15149, 15176
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13936, 14169
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15348, 15949
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4411, 4411
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15967, 16299
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13617, 13910
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272, 288
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381, 2807
|
4425, 5224
|
15212, 15324
|
2829, 4042
|
4058, 4230
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,836
| 165,212
|
49517
|
Discharge summary
|
report
|
Admission Date: [**2188-3-12**] Discharge Date: [**2188-3-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
CVL placement
Intubation
History of Present Illness:
84M with metastatic pancreatic cancer, recent diagnosis of IVC
thrombus; presenting to the ED with after found to be
hypotensive at [**Hospital1 1501**]. During early ED course was hypoxic and
continued to be significantly hypotensive requiring several
liters of IVFs, maximum dose of levophed, neo, and dopamine.
Intubated for airway protection due to altered mental status.
RIJ placed. Workup significant for bandemia to 42%, lactate up
to 4.8, hypoglycemia requiring D50. Surgery consulted. CT
abdomen performed with pneumoperitoneum. Heme onc saw; after
discussions with the family, decision made for patinet to be
DNR, but not CMO, with hopes of trying to get the rest of the
family in.
Past Medical History:
- unresectable pancreatic CA
- recent diagnosis of IVC thrombus ([**2188-2-20**])
- Zencker's
- failure to thrive
- s/p inguinal hernia repair
- s/p prostatectomy ~98
- s/p portacath [**4-4**]
- s/p exlap, splenoraphy ~88
Social History:
He used to work as a clinical psychologist. He lives with his
wife, [**Name (NI) **]. [**Name2 (NI) **] does not smoke and he very rarely drinks.
Family History:
He had a brother with prostate cancer. His mother died at 102
of an embolism and his father died in his 50s of congestive
heart failure.
Physical Exam:
BP: 46/36(41) {46/36(41) - 46/36(41)} mmHg
RR: 11 (11 - 11) insp/min
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 100%
PIP: 20 cmH2O
Ve: 13.4 L/min
.
General: intubated, sedated, moving little spontaneously.
HEENT: Pupils slightly asymmetric, reactive. MM dry, ETT in
place.
Neck: RIJ in place, otherwise difficult to assess JVP.
Chest: Bilat rhonchi with dullness at the bases, L >R. No
wheeze. L port.
Heart: Regular but diminished, no appreciable murmur.
Abdomen: Markedly distended, tense, absent bowel sounds. Appears
tender to palpation.
Extrem: 3+ edema, slightly cool feet, warm hands.
Neuro: intubated and sedated, moving extrem spontaneously.
Pertinent Results:
Admission labs:
[**2188-3-12**] 05:30PM WBC-6.6 RBC-3.96* HGB-11.0* HCT-34.9* MCV-88
MCH-27.8 MCHC-31.6 RDW-22.6*
[**2188-3-12**] 05:30PM NEUTS-43* BANDS-42* LYMPHS-13* MONOS-1* EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-3-12**] 05:30PM PLT SMR-NORMAL PLT COUNT-318
[**2188-3-12**] 05:30PM GLUCOSE-40* UREA N-24* CREAT-1.3* SODIUM-142
POTASSIUM-4.5 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14
[**2188-3-12**] 05:30PM CALCIUM-7.4* PHOSPHATE-4.5# MAGNESIUM-2.2
[**2188-3-12**] 05:30PM ALT(SGPT)-19 AST(SGOT)-30 CK(CPK)-28* ALK
PHOS-253* TOT BILI-1.4
[**2188-3-12**] 05:30PM PT-21.7* PTT-105.0* INR(PT)-2.1*
.
[**2188-2-20**] CT abd/pelv: 1. IVC thrombus within the infrahepatic IVC
extending to approximately 4 cm from the inferior cavoatrial
junction. The IVC is severely narrowed in its intrahepatic
portion, just at the cavoatrial junction. 2. New liver lesion
within the dome as described above, suspicious for a new liver
metastasis. Several other poorly defined hypodensities are newly
identified. These are too small to fully characterize, however,
may represent additional foci of metastatic disease. 3.
Hypodensity within the inferior portion of the spleen, as well
as vague hypodensity within the upper portion which may also
represent site of metastasis. 4. Bilateral pleural effusions,
ascites, and diffuse soft tissue edema. 5. Peritoneal and
omental implants.6. Pancreatic mass, essentially unchanged. 7.
No evidence of pulmonary embolism.
.
CT head: no bleed or edema.
.
CXR: AP portable supine chest radiograph is obtained. There has
been interval placement of a right IJ central venous catheter
with its tip in the approximate location of the cavoatrial
junction. Endotracheal tube, NG tube, left subclavian
Port-A-Cath are unchanged. Bilateral pleural effusions are
stable with a layering effect and likely bibasilar atelectasis.
Heart size cannot be assessed. Aorta is unfolded. Bones appear
osteopenic though grossly intact.
.
CTA torso: Pneumoperitoneum of unclear source. No PE. Large
bilateral effusion, ascites and anasarca in setting of known
metastatic pancreatic cancer.
Brief Hospital Course:
A/P: 84M with known metastatic pancreatic cancer with recent
radiographic improvements s/p chemo, presents with septic shock
and multiorgan dysfunction. Multiple sources possible and with
pneumoperitoneum, highly suspicious for perforation. Presented
with multiorgan dysfunction with ARF, lactic acidosis,
coagulopathy, and respiratory failure. Surgery was consulted
but patient clearly too unstable for intervention. Family aware
of grave prognosis but hoping to allow time for full family to
arrive. For this reason vasopressin, neosynephrine, levophed,
and dopamine were given at high doses in addition to
zosyn/vanc/flagyl for antibiotics. Oncology also saw patient
and family in the ED. Family clearly expressed wishes for
patient to be DNR given poor prognosis. Despite this, blood
pressure continued to decline with eventual degeneration to
PEA/asystolic rhythm. Family present at bedside. Patient
pronounced at 6:23am. Family and ME declined autopsy.
Medications on Admission:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
8. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. MVI
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"V45.77",
"785.52",
"995.92",
"568.89",
"197.6",
"038.9",
"V87.41",
"584.9",
"518.81",
"157.8",
"197.7",
"338.3",
"511.81",
"V12.51",
"783.7",
"276.2",
"789.51",
"569.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
6207, 6216
|
4530, 5501
|
274, 300
|
6262, 6271
|
2389, 2389
|
6322, 6327
|
1447, 1586
|
6180, 6184
|
6237, 6241
|
5527, 6157
|
6295, 6299
|
1601, 2370
|
223, 236
|
328, 1021
|
3872, 4507
|
2405, 3863
|
1043, 1267
|
1283, 1431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,046
| 199,674
|
21826
|
Discharge summary
|
report
|
Admission Date: [**2152-12-11**] Discharge Date: [**2152-12-23**]
Date of Birth: [**2092-8-7**] Sex: M
Service: SURGERY
Allergies:
Imuran
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Enterocutaneous fistula
Major Surgical or Invasive Procedure:
[**2152-12-12**] Exploratory laparotomy, lysis of adhesionsenterectomy
and enteroenterostomy, ileocolostomy (following resection of the
stenotic ileocolonic anastomosis), curretting of abscess and
fistula.
History of Present Illness:
This is the first admission to [**Hospital1 18**] for this 60 year old former
gambler with a 30 year history of Crohn's disease who presents
with an enterocutaneous fistula. The patient had previously had
an ileocolectomy for a fistula to his bladder and then a sigmoid
colostomy in [**2146**]. He also has a recent history of multiple
small bowel obstructions treated with steroids but ultimately
requiring operative resection, including the anastamosis site
which was shown to have recurrent Crohn's. He did well initially
but then developed an enterocutaneous fistula several weeks
post-operatively which was thought to be due to an
intra-abdominal abscess which had developed. A fistulagram on
[**2152-11-14**] demonstrated an enterocutaneous fistula within the right
lower quadrant of the abdomen with contrast injected passing
freely into multiple small bowel loops and extending into colon
in the region of a presumed anastomosis site near the splenic
flexure. Symptomatically he denies any nausea/vomitting or
change in output from his ostomy. He has had some output of
fluid from his enterocutaneous fistula. He presents for
operative management.
Past Medical History:
Crohn's Disease x 30 years
s/p Ileocolectomy with sigmoid colostomy
Parapelegia s/p Fall [**2126**]
Neurogenic Bladder requiring self-catheterization
EC Fistula
Depression
Colonic tubular adenomas
Sacrodecubitus ulcers
Small Bowel obstruction with small bowel resection '[**52**]
Intra-abdominal abscess '[**52**]
Social History:
The patient has been a paraplegic for over 20 years. He lives at
home with his wife who assists with his care. He states he is a
former gambler. He denies any history of alcohol or tobacco use.
Family History:
Negative for inflammatory bowel disease or colon cancer
Physical Exam:
ON admission:
V/S 97.3, pulse 85, 100/52, 18, 90% room air, fingerstick blood
sugar 91/78
Gen: pleasant elderly male in no acute distress, slightly
anxious, comfortable
Neuro: decreased sensation and impaired mobility in bilateral
lower extremities, cranial nerves [**2-24**] grossly intact
HEENT: moist mucous membranes, PERRLA, no icterus, no
conjunctival pallor
CV: regular rate and rhythm, no murmurs
Pulm: clear to auscultation bilaterally
Abd: soft, minimal epigastric tenderness, fistula intact with
duoderm surrounding, no rebound/guarding, no masses
Derm: stage 2 decubitus on sacram, stage 1 on right buttocks
Extr: no edema, warm
Pertinent Results:
SEROLOGIES
[**2152-12-11**] 04:00PM BLOOD WBC-7.7 RBC-3.99* Hgb-10.7* Hct-33.5*
MCV-84 MCH-26.7* MCHC-31.8 RDW-16.8* Plt Ct-207
[**2152-12-12**] 06:28PM BLOOD WBC-16.8*# RBC-3.43* Hgb-9.4* Hct-29.2*
MCV-85 MCH-27.4 MCHC-32.2 RDW-16.6* Plt Ct-227
[**2152-12-15**] 03:32AM BLOOD WBC-7.1# RBC-2.67*# Hgb-7.8* Hct-25.6*
MCV-96# MCH-29.1 MCHC-30.4*# RDW-16.7* Plt Ct-126*
[**2152-12-16**] 02:33AM BLOOD WBC-7.4 RBC-3.45* Hgb-9.8* Hct-29.7*
MCV-86 MCH-28.4 MCHC-32.9 RDW-16.2* Plt Ct-162
[**2152-12-17**] 09:45AM BLOOD WBC-7.6 RBC-3.49* Hgb-10.3* Hct-30.6*
MCV-88 MCH-29.5 MCHC-33.6 RDW-16.6* Plt Ct-195
[**2152-12-19**] 05:12AM BLOOD WBC-8.7 RBC-3.60* Hgb-10.4* Hct-31.7*
MCV-88 MCH-28.8 MCHC-32.7 RDW-16.2* Plt Ct-227
[**2152-12-20**] 05:05AM BLOOD WBC-9.7 RBC-3.63* Hgb-10.4* Hct-32.0*
MCV-88 MCH-28.6 MCHC-32.5 RDW-16.8* Plt Ct-320
[**2152-12-21**] 05:12AM BLOOD WBC-8.9 RBC-3.48* Hgb-10.1* Hct-30.6*
MCV-88 MCH-28.9 MCHC-32.8 RDW-17.2* Plt Ct-338
[**2152-12-22**] 05:42AM BLOOD WBC-8.3 RBC-3.61* Hgb-10.6* Hct-31.6*
MCV-88 MCH-29.4 MCHC-33.5 RDW-17.2* Plt Ct-360
[**2152-12-13**] 11:46PM BLOOD Neuts-93.1* Bands-0 Lymphs-3.4* Monos-3.3
Eos-0.1 Baso-0.1
[**2152-12-16**] 02:33AM BLOOD PT-13.4 INR(PT)-1.1
[**2152-12-11**] 04:00PM BLOOD Glucose-82 UreaN-19 Creat-0.5 Na-140
K-4.6 Cl-104 HCO3-28 AnGap-13
[**2152-12-12**] 04:46AM BLOOD Glucose-79 UreaN-18 Creat-0.6 Na-137
K-4.6 Cl-104 HCO3-26 AnGap-12
[**2152-12-13**] 11:46PM BLOOD Glucose-165* UreaN-14 Creat-0.4* Na-137
K-3.8 Cl-103 HCO3-26 AnGap-12
[**2152-12-14**] 03:55AM BLOOD Glucose-125* UreaN-14 Creat-0.5 Na-137
K-3.5 Cl-103 HCO3-28 AnGap-10
[**2152-12-15**] 03:32AM BLOOD Glucose-717* UreaN-16 Creat-0.5 Na-128*
K-4.3 Cl-100 HCO3-28 AnGap-4*
[**2152-12-16**] 02:33AM BLOOD Glucose-98 UreaN-17 Creat-0.4* Na-141
K-4.2 Cl-106 HCO3-29 AnGap-10
[**2152-12-17**] 09:45AM BLOOD Glucose-101 UreaN-21* Creat-0.4* Na-140
K-4.6 Cl-104 HCO3-30* AnGap-11
[**2152-12-18**] 09:30AM BLOOD Glucose-83 UreaN-21* Creat-0.4* Na-135
K-4.6 Cl-101 HCO3-29 AnGap-10
[**2152-12-19**] 05:12AM BLOOD Glucose-111* UreaN-19 Creat-0.4* Na-139
K-4.8 Cl-107 HCO3-27 AnGap-10
[**2152-12-20**] 05:05AM BLOOD Glucose-122* UreaN-16 Creat-0.4* Na-138
K-4.7 Cl-106 HCO3-26 AnGap-11
[**2152-12-21**] 05:12AM BLOOD Glucose-115* UreaN-18 Creat-0.4* Na-137
K-4.7 Cl-105 HCO3-25 AnGap-12
[**2152-12-22**] 05:42AM BLOOD Glucose-123* UreaN-16 Creat-0.4* Na-135
K-4.6 Cl-104 HCO3-26 AnGap-10
[**2152-12-13**] 11:46PM BLOOD ALT-7 AST-12 CK(CPK)-172 AlkPhos-68
TotBili-0.8
[**2152-12-11**] 04:00PM BLOOD Albumin-3.1* Calcium-9.0 Phos-4.3 Mg-1.6
Iron-26*
[**2152-12-18**] 02:49PM BLOOD Albumin-3.0* Iron-31*
[**2152-12-21**] 05:12AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.7
[**2152-12-22**] 05:42AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7
[**2152-12-11**] 04:00PM BLOOD calTIBC-222* TRF-171*
[**2152-12-13**] 11:46PM BLOOD VitB12-303 Folate-7.9
[**2152-12-18**] 02:49PM BLOOD calTIBC-186* Ferritn-268 TRF-143*
[**2152-12-13**] 11:46PM BLOOD TSH-3.2
[**2152-12-13**] 06:00AM BLOOD Triglyc-87
RADIOLOGY
[**2152-12-12**] Chest Xray: 1. Left PICC line apparently abutting the
wall of the SVC with tortuosity and redundancy within the venous
system. Retraction may be considered.
2. New probable bilateral pleural effusions with bibasilar
atelectasis
PATHOLOGY [**2152-12-12**]
1. Fistula #1, excision (A-C):
Skin and subcutaneous tissue with changes consistent
with fistula tract.
2. Fistula #2, excision (D-F):
Subcutaneous tissue with changes consistent with
fistula tract.
3. Catheter, removal:
One plastic catheter, gross description.
4. Ileo-colic anastomosis, resection (G-L, R-Y):
A. Large and small bowel with reactive changes consistent
with anastomotic site.
B. Serositis. See note.
C. Intimal sclerosis and focal recanalized thrombus of
mesenteric arteries.
D. Two benign lymph nodes.
5. Small bowel, fistula, resection (M-Q):
Small bowel with serositis and mural inflammation. See note.
MICROBIOLOGY
[**2152-12-14**] Urine Culture: negative
[**2152-12-14**] Blood Culture: negative
Brief Hospital Course:
This is a 60 year old male with active Crohn's disease who
presents for operative management of an enterocutaneous fistula
which developed over the last few months after a resent small
bowel resection. He underwent a fistulectomy on hospital day 2
with exploratory laparotomy,lysis of adhesions, and
ileo-right-colectomy around a stenosed prior ileocolonic
anastamosis. He was extubated in the recovery unit and had good
pain control throughout his post-operative period. On
post-operative day 1 the patient was noted to be tachycardic
with aggitation and mental status changes and he was transfered
to the intensive care unit with presumed early sepsis. He
received 2 units of PRBC over the next 2 days for stable but low
hematocrits. He remained afebrile and blood cultures were
negative. His aggitation improved with prn Haldol and Ativan and
by post-operative day 4 he was transferred back to the floor
with good pain control, normal mental status, hemodynamically
stable, and good nutrional support via TPN. He received Lasix
diuresis as he was found to have some rales on pulmonary
examination and he was nearly 7 kg above his pre-operative
weight. He was started on a sips diet on post-operative day 8
which was advanced to a soft diet by post-operative day 9 which
he tolerated well; TPN was weaned off. The patient worked with
physical therapy and was found to return to his baseline
functional activity by post-operative day 10. He was evaluated
by rheumatology for left shoulder pain on post-operative day 9
and it was determined that this was not a recurrence of his
pseudogout but rather a muscle strain. His JP drains were
removed on post-operative days 9 and 10. He was discharged to
home on post-operative day 11 with planned follow-up with
Surgery within the next month. His medications on discharge
remained essentially the same, though his pain medications were
modified and he was continued on Levoquin for prophylaxis while
Linezolid was discontinued after he had completed the adequate
treatment course. All questions were answered to his
satisfaction on day of discharge.
Medications on Admission:
Linezolid 600 mg oral [**Hospital1 **]
Quinine 325 mg oral QHS
Neurontin 300 mg oral TID
Diazepam prn
Methenamine 1 g or QID
Temazepam 15 qhs
Flexeril 10 mg oral daily
Protonix 40 mg oral daily
Ibuprofen 800 oral [**Hospital1 **]
Oxycontin 10 mg oral [**Hospital1 **]
ALLERGIES: Imuran
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
Disp:*100 Tablet(s)* Refills:*2*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. Methenamine Mandelate 1 g Tablet Sig: One (1) Tablet PO QID
(4 times a day).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*80 Tablet(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
Disp:*200 Capsule(s)* Refills:*2*
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
8. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO once a
day.
9. Flexeril 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO Q3-4H prn as
needed for pain.
Disp:*150 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
(1) Crohn's disease
(2) Stenotic ileo-colonic anastamosis
(3) Adhesions
(4) Multiple fistulas
(5) Paraplegia
(6) Depression
(7) Pseudogout
(8) Left shoulder strain
Discharge Condition:
Good
Discharge Instructions:
Please contact the office or come to the emergency room with any
worsening abdominal pain, bloody stools, worsening
nausea/vomitting, increased redness or drainage from your
incision, pain not improved with narcotic pain medications, or
fever > 101.5. Note that narcotic pain medications may make you
drowsy. You may eat a regular diet. Please keep your dressings
on until your follow-up appointment with Dr. [**Last Name (STitle) 957**]. Please
call with any questions.
Followup Instructions:
You will be contact[**Name (NI) **] by [**Name (NI) 2270**] [**Name (NI) 57281**] at [**Telephone/Fax (1) 980**] regarding
your follow-up appointment with Dr. [**Last Name (STitle) 957**].
Completed by:[**2152-12-24**]
|
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icd9cm
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,685
| 113,693
|
41028
|
Discharge summary
|
report
|
Admission Date: [**2136-2-29**] Discharge Date: [**2136-3-6**]
Date of Birth: [**2072-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic, dilated aorta found on routine CT
Major Surgical or Invasive Procedure:
1. Aortic valve replacement with a 29 mm [**Company 1543**] Mosaic
Ultra aortic valve bioprosthesis, model number 305,
serial number [**Serial Number 89487**].
2. Replacement of ascending aorta and hemiarch with a 28 mm
Dacron tube graft and deep hypothermic circulatory
arrest.
Graft data: Catalog number [**Numeric Identifier 31950**]. Lot number [**Telephone/Fax (3) 89488**],
serial number [**Serial Number 89489**].
1. Coronary artery bypass grafting x1 with left internal
mammary artery to the first diagonal coronary artery.
2. Pericardial reconstruction with CorMatrix product.
History of Present Illness:
63 year old male with history of Henoch-Schonlein purpura and
hypertension who was incidentally found to have dilated
ascending aorta on CT scan in [**2135-1-15**]. His aneurym came to
fruition when he had lost 30 pounds in the summer of [**2134**] in the
wake of his wife's passing. An abdominal CT suggested pulmonary
nodules and a dedicated chest CT was obtained in [**2135-1-15**]
which revealed the ascending aortic aneurysm. He was seen by Dr.
[**Last Name (STitle) **] and it appears that his lung nodules are stable.
Given the size of his ascending aortic aneurysm (5.6cm), he was
referred for surgical consultation.
Past Medical History:
1. Migraine-optical(flashing lights-resolves after 5 min-occurs
Q2 mo)
2. Essential hypertension
3. Dyslipidemia.
4. Prior history of Henoch-Schonlein purpura.
5. Sciatica.
6. Seborrheic keratosis.
7. Erectile dysfunction
8. Colonic adenoma.
9. Gout.
10. Elevated PSA.
11. Glucose intolerance, diet controlled
12. Primary hyperparathyroidism
13. Ventral hernia.
14. Vasovagal episode -felt to be from Bblockers diminished
after
medications adjusted
15. Aortic Aneurysm
16. Lung nodule - Followed by Dr. [**Last Name (STitle) **] (Not consistent
with malignancy as it has decreased in size)
17. Depression -following death of wife
18. Bicuspid aortic valve with calcified leaflets.
Social History:
Race: Caucasian
Last Dental Exam: 5 months ago
Lives with: The patient is widowed. He has been widowed for a
year and a half. His wife died of metastatic esophageal cancer.
Contact:[**Last Name (NamePattern4) **] (cousin) Phone #[**Telephone/Fax (1) 89490**]
Occupation: Part- Time Chief engineer at [**Doctor Last Name **] Controls
Cigarettes: Smoked no [X] yes []
Other Tobacco use: none
ETOH: < 1 drink/week [X] 1 glass wine/night
Illicit drug use: none
Family History:
Family History: grandfather had MI
Mother: died CHF at age 87
Father: died prostate CA age 77
Physical Exam:
Physical Exam
Pulse:57 Resp:12 O2 sat:98/RA
B/P Right:149/78 Left: 145/75
Height:6'1" Weight:195 lbs
General: NAD
Skin: Warm [x] Dry [x] intact [x]
HEENT: NCAT [x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] JVD []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [x] Murmur - systolic murmur at sternum
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS []
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit - none Right: Left:
Pertinent Results:
[**2136-3-4**] 05:08AM BLOOD WBC-11.8* RBC-2.53* Hgb-7.7* Hct-22.6*
MCV-89 MCH-30.4 MCHC-34.0 RDW-12.9 Plt Ct-180
[**2136-3-4**] 05:08AM BLOOD Plt Ct-180
[**2136-3-4**] 05:08AM BLOOD Glucose-126* UreaN-21* Creat-0.9 Na-136
K-3.7 Cl-103 HCO3-27 AnGap-10
[**2136-2-29**] 09:33PM BLOOD ALT-19 AST-38 LD(LDH)-256* AlkPhos-33*
Amylase-20 TotBili-1.7*
[**2136-3-4**] 05:08AM BLOOD Mg-2.1
[**3-2**] CXR:
FINDINGS: In comparison with study of [**3-1**], there is little
overall change
except for the right IJ catheter that extends to the mid portion
of the SVC.
Retrocardiac opacification persists, consistent with atelectasis
and effusion.
EKG [**2-29**]:
Sinus bradycardia. Prolonged P-R interval. Compared to the
previous tracing
of [**2136-1-31**] there is no change.
[**2136-3-6**] 03:19AM BLOOD Hct-26.2*
[**2136-3-6**] 03:19AM BLOOD PT-13.9* INR(PT)-1.3*
[**2136-3-6**] 03:19AM BLOOD Na-136 K-4.5 Cl-104
Brief Hospital Course:
Patient with Hx of htn who was incidently found to have dilated
ascending aorta on Ct scan [**1-/2135**] cardiac cath confirmed
findings and revealed 70% lesion of the lAD. The patient was
admitted to the hospital on day of surgery and brought to the
operating room on [**3-1**] where the patient underwent: aortic valve
replacement with a 29 mm [**Company 1543**] Mosaic, replacement of
ascending aorta and hemiarch with a 28 mm
Dacron tube graft and deep hypothermic circulatory arrest,
coronary artery bypass grafting x1 with left internal mammary
artery to the first diagonal coronary artery and pericardial
reconstruction with CorMatrix product.
Overall the patient tolerated the procedure well, see
operative report for further details. Of note, Mr.[**Known lastname 4886**] had an
intraop anaphalactoid reaction during his platlet transfusion.
Post-operatively he was transferred to the CVICU intubated and
sedated. He continued to be hypotensive/post-op shock that
resolved with volume resuscitation and pressor support. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient remained neurologically intact. His
neo was weaned off slowly. Low dose Beta blocker was initiated
and the patient was gently diuresed towards the preoperative
weight. He was transferred to the telemetry floor for further
recovery on POD #2. Chest tubes and pacing wires were
discontinued per protocol, without complication. On POD#3 he
went into rapid a-fib and was started on Amiodarone. He
converted within 24hrs however had other transient episodes of
atrial fibrillation. He was placed on anticoagulation for
paroxysmal AF. It was arranged with his PCP's office for
Coumadin follow up. Electrophysiology was consulted due to a
conversion pause >4 seconds. Amio was discontinued and
beta-blocker remains. His Hct was low but was not signifcantly
symptomatic and the decision was made not to transfuse him, he
was started on Iron/Folate and multivitamin. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD #6 he
was ambulating freely. His wounds were healing well and pain was
controlled with oral analgesics. He was discharged to home with
VNA services in good condition with appropriate follow up
instructions advised.
Medications on Admission:
AMLODIPINE 10 mg Daily
ATORVASTATIN 40 mg Daily
CITALOPRAMb 20 mg Daily
LOSARTAN 50 mg Daily
METOPROLOL SUCCINATE 25 mg Daily
TERAZOSIN 10 mg Daily
ASPIRIN 81 mg Daily
VITAMIN D3 1,000 unit Daily
MULTIVITAMIN 1 Capsule Daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*2*
4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. 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*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
Disp:*20 Tablet Extended Release(s)* Refills:*2*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: [**1-16**] Mucous
membrane four times a day as needed for sore throat.
Disp:*60 * Refills:*0*
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
16. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
day.
Disp:*150 Tablet(s)* Refills:*2*
19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Migraine-optical(flashing lights-resolves after 5 min-occurs
Q2 mo)
2. Essential hypertension
3. Dyslipidemia.
4. Prior history of Henoch-Schonlein purpura.
5. Sciatica.
6. Seborrheic keratosis.
7. Erectile dysfunction
8. Colonic adenoma.
9. Gout.
10. Elevated PSA.
11. Glucose intolerance, diet controlled
12. Primary hyperparathyroidism
13. Ventral hernia.
14. Vasovagal episode -felt to be from Bblockers diminished
after
medications adjusted
15. Aortic Aneurysm- s/p ascending aorta replacement [**2136-2-29**]
16. Lung nodule - Followed by Dr. [**Last Name (STitle) **] (Not consistent
with malignancy as it has decreased in size)
17. Depression -following death of wife
18. Aortic stenosis-s/p AVR [**2136-2-29**]
19. CAD-s/p CABG - [**2136-2-29**]
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema +1 Teds applied
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:
Recommended Follow-up:
You are scheduled for the following appointments:
Wound check [**2136-3-15**] at 10:30am at [**Last Name (un) 2577**] building, [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) 914**] [**2136-3-26**] at 1:45p
Cardiologist:Dr. [**First Name (STitle) **] [**2136-3-19**] at 3:00p
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 61741**] in [**4-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication :Atrial fibrillation
Goal INR 2-2.5
First draw:[**2136-3-7**]
Results to PCP [**Last Name (un) 89491**] phone:[**Telephone/Fax (1) 68410**]: Coumadin
RN=[**Doctor Last Name 501**]
Completed by:[**2136-3-6**]
|
[
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icd9cm
|
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[
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icd9pcs
|
[
[
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9360, 9411
|
4533, 6871
|
318, 928
|
10234, 10478
|
3602, 4510
|
11319, 12165
|
2802, 2882
|
7148, 9337
|
9432, 10192
|
6897, 7125
|
10502, 11296
|
2897, 3583
|
231, 280
|
956, 1582
|
1604, 2286
|
2302, 2770
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,497
| 177,294
|
46270
|
Discharge summary
|
report
|
Admission Date: [**2147-7-22**] Discharge Date: [**2147-7-26**]
Date of Birth: [**2074-6-25**] Sex: F
Service: MED
Allergies:
Penicillins / Compazine / Benadryl / Dilantin / Reglan /
Klonopin / Depakote / Neurontin / Lamictal / Lithium
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
acute SOB,tachycardia, fever, and witnessed seizure
Major Surgical or Invasive Procedure:
PICC placement
Arterial line
History of Present Illness:
73F PMH bipolar d/o, sz d/o, depression, CVA x2, and recent
humerus fracture s/p screw placement ([**7-17**]) presents with acute
SOB and witnessed seizure. Pt was found in bed tachypneic with
RR 40, Sat 60%, and HR 160's. She had 1 1-min seizure in amb on
the way to the hospital that resolved on its own, and sat 100%
on bag mask. Pt [**Name (NI) **] 105 PR, received Tylenol. Upon arrival at
the [**Name (NI) **], pt given 1 mg Ativan and intubated for post-ictal airway
protection. ABG on 100% NRB prior was 7.03/89/281. S/P
intubation on AC 450x22, FiO2 50%, PEEP 5, MV 8.7 - ABG
7.49/30/145. On minimal sedation-Propofol. Received 5L fluids,
Vanco 1g and CTX 2g for possible meningitis. Temp decr to 99.2,
BP 140/85, HR 108. Ortho consulted about possible septic joint:
recommended humerus films and CT humerus to r/o necrotizing
fascitis. Pt has past drug overdoses and medication abuse with
ETOH.
Past Medical History:
Depression-s/p ECT [**2147**]; CVAx2; s/p appy; TAH/BSO; Subtotal
Colectomy; Nl Cors ([**5-29**])-EF 65%; Chronic Abd Pain;
Osteoporosis; Grade III esophagitis-nl EGD in [**6-29**]; HTN;
Migraine; PMR; Sjogren's; Seizure d/o; Bipolar; PTSD; h/o SA
Social History:
Pt was born in [**Country 2559**] to [**Hospital1 **] parents, put in concentration
camp at age 10 for a year, and prior to that in work camps. Pt
has 1 living brother in [**Name (NI) **]. Married, and divorced in [**2113**].
Daughter, 46, refuses to stay in contact with her. Currently,
has a legal guardian, [**Name (NI) 2411**] [**Name (NI) 9192**] (HCM) [**Telephone/Fax (1) 69964**] cell.
Family History:
Father died diabetes complications. Mother died of melanoma.
Physical Exam:
VS (ED): T 105 P 108 BP 148/84 R 22 p/t intubation
Vent: AC 450x22 FiO2 50%, PEEP 5 -> ABG 7.49/30/145
PE: G: Intubated, sedated
H: Pupils non-reactive (L<R), Neck stiff-able to lift pt up
by head, NC/AT, No JVD, No [**Doctor First Name **]
L: Coarse BS BL, no w/r/c
H: tachy, Nl S1, S2, no M/R/G
A: Soft, NT, ND, BS+
E: 2+ distal pulses, good cap refill ~2 sec, warm, dry
LUE: staple in place in wound, appears C/D/I, no
erythema, mildly warmer over site. 2+ pitting edema distal to
arm.
Neuro: Intubated, sedated. No Babinski
Pertinent Results:
[**2147-7-25**] 04:05AM BLOOD WBC-16.7* RBC-3.11* Hgb-9.0* Hct-27.8*
MCV-89 MCH-29.0 MCHC-32.5 RDW-14.9 Plt Ct-256
[**2147-7-24**] 03:25AM BLOOD WBC-14.3* RBC-3.44* Hgb-10.0* Hct-30.7*
MCV-90 MCH-29.0 MCHC-32.5 RDW-14.8 Plt Ct-248
[**2147-7-23**] 04:00AM BLOOD WBC-15.5* RBC-4.02* Hgb-11.6* Hct-36.7
MCV-91 MCH-28.9 MCHC-31.7 RDW-14.7 Plt Ct-279
[**2147-7-22**] 07:14PM BLOOD WBC-14.8* RBC-4.08* Hgb-12.0 Hct-36.7
MCV-90 MCH-29.4 MCHC-32.6 RDW-14.7 Plt Ct-295
[**2147-7-22**] 04:00PM BLOOD WBC-14.4* RBC-4.03* Hgb-12.1 Hct-36.2#
MCV-90# MCH-29.9 MCHC-33.4# RDW-14.7 Plt Ct-258
[**2147-7-22**] 09:46AM BLOOD WBC-22.3*# RBC-4.67 Hgb-13.4 Hct-46.9#
MCV-101*# MCH-28.7 MCHC-28.6*# RDW-14.3 Plt Ct-327#
[**2147-7-22**] 07:14PM BLOOD Neuts-64.4 Lymphs-32.2 Monos-2.7 Eos-0.3
Baso-0.3
[**2147-7-22**] 04:00PM BLOOD Neuts-75.1* Lymphs-21.6 Monos-3.0 Eos-0.1
Baso-0.3
[**2147-7-22**] 09:46AM BLOOD Neuts-54 Bands-0 Lymphs-24 Monos-8 Eos-2
Baso-0 Atyps-12* Metas-0 Myelos-0
[**2147-7-22**] 07:14PM BLOOD Hypochr-1+
[**2147-7-22**] 04:00PM BLOOD Hypochr-1+
[**2147-7-22**] 09:46AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Burr-1+
[**2147-7-25**] 04:05AM BLOOD Plt Ct-256
[**2147-7-24**] 03:25AM BLOOD Plt Ct-248
[**2147-7-23**] 04:00AM BLOOD Plt Ct-279
[**2147-7-22**] 07:14PM BLOOD Plt Ct-295
[**2147-7-22**] 04:00PM BLOOD Plt Ct-258
[**2147-7-22**] 04:00PM BLOOD PT-12.4 PTT-22.1 INR(PT)-1.0
[**2147-7-22**] 09:46AM BLOOD Plt Smr-NORMAL Plt Ct-327#
[**2147-7-22**] 09:46AM BLOOD PT-13.2 PTT-20.5* INR(PT)-1.1
[**2147-7-22**] 09:46AM BLOOD Fibrino-571*
[**2147-7-23**] 04:00AM BLOOD ESR-0
[**2147-7-25**] 04:05AM BLOOD Glucose-122* UreaN-11 Creat-0.8 Na-141
K-3.7 Cl-110* HCO3-19* AnGap-16
[**2147-7-24**] 03:25AM BLOOD Glucose-145* UreaN-11 Creat-0.7 Na-134
K-3.3 Cl-103 HCO3-17* AnGap-17
[**2147-7-23**] 10:02AM BLOOD K-4.5
[**2147-7-23**] 04:00AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-139
K-3.3 Cl-107 HCO3-22 AnGap-13
[**2147-7-22**] 07:14PM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-143
K-4.4 Cl-112* HCO3-20* AnGap-15
[**2147-7-22**] 04:00PM BLOOD Glucose-133* UreaN-11 Creat-0.7 Na-143
K-3.2* Cl-110* HCO3-20* AnGap-16
[**2147-7-22**] 09:46AM BLOOD Glucose-231* UreaN-16 Creat-1.2* Na-144
K-5.4* Cl-103 HCO3-15* AnGap-31*
[**2147-7-22**] 09:46AM BLOOD ALT-13 AST-55* LD(LDH)-679* CK(CPK)-98
AlkPhos-184* TotBili-0.4
[**2147-7-22**] 09:46AM BLOOD Lipase-18
[**2147-7-22**] 09:46AM BLOOD CK-MB-4 cTropnT-0.07*
[**2147-7-25**] 04:05AM BLOOD Mg-1.7
[**2147-7-24**] 03:25AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.5*
[**2147-7-23**] 04:00AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
[**2147-7-22**] 07:14PM BLOOD Albumin-2.9* Calcium-7.9* Phos-3.1
Mg-1.3*
[**2147-7-22**] 04:00PM BLOOD Calcium-7.9* Phos-2.6*# Mg-1.3*
[**2147-7-22**] 09:46AM BLOOD Calcium-9.6 Phos-5.7*# Mg-1.8
[**2147-7-22**] 09:46AM BLOOD Osmolal-307
[**2147-7-23**] 10:02AM BLOOD CRP-17.85*
[**2147-7-25**] 11:50AM BLOOD Vanco-5.3*
[**2147-7-23**] 10:02AM BLOOD Vanco-25.9*
[**2147-7-22**] 09:46AM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-14.9
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2147-7-22**] 09:46AM BLOOD GreenHd-HOLD
[**2147-7-24**] 11:49AM BLOOD Type-ART Temp-36.2 O2-90 pO2-149*
pCO2-25* pH-7.46* calHCO3-18* Base XS--3 AADO2-481 REQ O2-80
Intubat-NOT INTUBA
[**2147-7-24**] 06:07AM BLOOD Type-ART O2-70 pO2-71* pCO2-23* pH-7.46*
calHCO3-17* Base XS--4 Intubat-NOT INTUBA
[**2147-7-24**] 05:12AM BLOOD Type-ART Temp-37.7 O2-35 O2 Flow-6
pO2-66* pCO2-26* pH-7.31* calHCO3-14* Base XS--11 Intubat-NOT
INTUBA Vent-SPONTANEOU
[**2147-7-23**] 01:16AM BLOOD Type-ART Temp-38.7 O2-40 pO2-125* pCO2-35
pH-7.38 calHCO3-22 Base XS--3
[**2147-7-22**] 10:53PM BLOOD Type-ART Temp-38.1 Rates-/24 Tidal V-420
PEEP-5 O2-40 O2 Flow-12 pO2-149* pCO2-26* pH-7.46* calHCO3-19*
Base XS--2 Intubat-INTUBATED Vent-SPONTANEOU
[**2147-7-22**] 04:13PM BLOOD Type-ART Tidal V-400 O2-50 pO2-223*
pCO2-25* pH-7.52* calHCO3-21 Base XS-0 Intubat-INTUBATED
[**2147-7-22**] 12:24PM BLOOD Type-ART PEEP-5 O2-100 pO2-145* pCO2-30*
pH-7.49* calHCO3-23 Base XS-1 AADO2-555 REQ O2-90
Intubat-INTUBATED
[**2147-7-22**] 10:04AM BLOOD Type-ART pO2-281* pCO2-89* pH-7.03*
calHCO3-25 Base XS--9
[**2147-7-24**] 06:07AM BLOOD Lactate-3.8*
[**2147-7-24**] 05:12AM BLOOD Lactate-9.7*
[**2147-7-22**] 10:53PM BLOOD Lactate-1.7
[**2147-7-22**] 04:13PM BLOOD Lactate-2.2*
[**2147-7-22**] 12:24PM BLOOD Lactate-2.5* K-3.3*
[**2147-7-22**] 09:54AM BLOOD Lactate-1.3
[**2147-7-24**] 06:07AM BLOOD O2 Sat-96
Brief Hospital Course:
Pt intubated and admitted to ICU. LP performed, normal findings
r/o meningitis. Pt put on Vanco and CTX, and blood, urine,
sputum cultures obtained. Pt extubated without complications.
Ortho consulted, determined low likelihood of infection wound
infection. Pt experienced episode of aggitation in AM, fever
spike and tachycardia. Re-cultured and bolused with fluid. UC
returned E.Coli [**Last Name (un) 36**] to everything, other cultures were still
pending. Psychiatry consulted and recommended holding Seroquel
and Trazodone, avoiding Benzos if possible, giving Fentanyl only
for obvious pain, and using Haldol ladder (1mg, 1/2 hr wait,
then 2mg, then 1/2 hr, then 5mg, 10mg, then if no relief 10mg
and 0.5 mg Ativan). Pt lost access and required PICC insertion
as pt had no PO intake. Pt is d/c with PICC in place for
completion of Ab (CTX) course for UTI. Psychiatrist, [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 16471**], encouraged to restart Seroquel and Trazodone upon d/c
and recovered MS, if no PO intake can use Haldol IV as
equivalent to Seroquel. No IV anti-depressent available if pt
can't take PO Celexa. As per ortho, staples should be removed in
4 days, pt should follow up with Dr. [**First Name (STitle) **] in [**1-27**] weeks. On
morning of d/c, patient had 3 episodes of watery diarrhea, stool
sent for CDiff toxin. Need to f/u results so pt can be started
on appropriate ab.
Medications on Admission:
Acetominophen, Percocet, [**Last Name (LF) 98369**], [**First Name3 (LF) **], Seroquel, Trazodone,
Citalopram, Ambien, Fentanyl patch, Prednisone
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
8. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Q2-3H (every 2-3 hours) as needed for Agitation.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
Urinary tract infection, Delirium
Discharge Condition:
Stable
Discharge Instructions:
continue antibiotics, follow up CDiff toxin results
Followup Instructions:
As needed
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"725",
"599.0",
"518.81",
"038.9",
"401.9",
"995.91",
"733.00",
"710.2",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04",
"03.31",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9786, 9864
|
7265, 8694
|
424, 455
|
9942, 9950
|
2755, 7242
|
10050, 10199
|
2093, 2156
|
8891, 9763
|
9885, 9921
|
8720, 8868
|
9974, 10027
|
2171, 2736
|
333, 386
|
483, 1394
|
1416, 1666
|
1682, 2077
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,846
| 149,218
|
7866
|
Discharge summary
|
report
|
Admission Date: [**2187-5-30**] Discharge Date: [**2187-6-4**]
Date of Birth: [**2123-12-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE/ angina
Major Surgical or Invasive Procedure:
[**2187-5-30**] CABG X 3 (LIMA to LAD, SVG to OM, SVG to RCA)
History of Present Illness:
63 yo male with multiple cardiac risk factor including CHF. He
has had DOE and angina for 4-5 months. Had + ETT and this led to
cath which revealed 3VD. Referred for surgery.
Past Medical History:
IDDM
HTN
Hypercholesterolemia
CHF
Obesity
Peripheral Neuropathy
Chronic renal insufficiency ( baseline creat 2.2)
Social History:
Employed as facilities manager, married 30+ years. No
smoking/drinking/IVDU.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died at 69 of colon CA, Father died at
72 of CVA
Physical Exam:
Pulse:88 Resp: 18 O2 sat: 94% RA
B/P Right:171/61 Left:186/60
Height:69 inches Weight:323 lbs
General:
Skin: Dry [x] intact [x] Well healed scar left forearm
HEENT: PERRLA [x] EOMI [x] teeth in poor repair
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] Distant heart sounds
Heart: RRR [x] Irregular [] Murmur Distant heart sounds
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Obese
Extremities: Warm [x], well-perfused [x] 2+ Edema Varicosities:
None [x] superficial veins bilateral thighs, erythema B/L lower
extremities with ~ 2 cm eschar on anterior LLE
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic root. There are focal
calcifications in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on JG before
surgical incision.
POST-BYPASS:
Preserved biventricular systolic function.
LVEF 55%.
Trivial MR, TR and AI.
Intact thoracic aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2187-5-30**] 14:18
[**2187-6-4**] 09:36AM BLOOD WBC-15.4*
[**2187-6-4**] 04:00AM BLOOD WBC-15.2* RBC-3.12* Hgb-8.9* Hct-26.2*
MCV-84 MCH-28.6 MCHC-34.1 RDW-15.3 Plt Ct-309
[**2187-6-4**] 04:00AM BLOOD Plt Ct-309
[**2187-6-2**] 03:52AM BLOOD PT-12.2 PTT-20.7* INR(PT)-1.0
[**2187-6-4**] 04:00AM BLOOD Glucose-77 UreaN-56* Creat-1.4* Na-138
K-4.0 Cl-103 HCO3-24 AnGap-15
[**2187-6-4**] 04:00AM BLOOD Mg-2.7*
Brief Hospital Course:
Admitted [**5-30**] and underwent surgery with Dr. [**Last Name (STitle) **]. Please
separately dictated op note. Transferred to the CVICU in stable
condition. Awoke neurologically intact and was extubated.
Transferred to floor on POD to begin increasing his activity
level. Beta blockade was titrated and he was gently diuresed
toward his pre-op weight. His creatinine slowly decreased to
1.4. Keflex for a 2 week course per Dr. [**Last Name (STitle) **] given his
significant risk factors for infection. Cleared for discharge to
home with VNA on POD #5. Pt. is to make all postop appts as per
discharge instructions.
Medications on Admission:
Lasix 120mg twice a day
lisinopril 40mg daily
diltiazem ER 240mg daily
simvastatin 40mg daily
Fenobriate 54mg daily
ASA 325mg daily
Lantus 200 units in am 276 units in PM
sliding scale Novolog 40 units per 100pts
MVI daily
Vit C 1000mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
10. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
12. Lantus 100 unit/mL Solution Sig: 100 units Subcutaneous
qam : dose below preop may need to be increased .
13. Lantus 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous at bedtime.
14. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
15. sliding scale
Insulin SC Fixed Dose Orders
Breakfast Bedtime
Glargine 140 Units Glargine 60 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-90 mg/dL 0 Units 0 Units 0 Units 0 Units
91-120 mg/dL 6 Units 6 Units 6 Units 0 Units
121-150 mg/dL 10 Units 10 Units 10 Units 0 Units
151-180 mg/dL 14 Units 14 Units 14 Units 0 Units
181-210 mg/dL 18 Units 18 Units 18 Units 4 Units
211-240 mg/dL 22 Units 22 Units 22 Units 6 Units
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
CAD s/p CABG
IDDM
HTN
Hypercholesterolemia
CHF
Obesity
Peripheral Neuropathy
Chronic renal insufficiency ( baseline creat 2.2)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait with walker
Incisional pain managed with dilaudid prn
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema + 2 bilateral LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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
[**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2187-6-25**]
1:20
[**Name6 (MD) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2187-9-27**] 10:15
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**12-2**] weeks [**Telephone/Fax (1) 4775**]
Surgeon Dr [**Last Name (STitle) **] 3-4 weeks [**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**
Completed by:[**2187-6-5**]
|
[
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"585.9",
"403.90",
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"250.00",
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"272.0",
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"428.22",
"276.7",
"278.00",
"V58.67",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
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icd9pcs
|
[
[
[]
]
] |
6717, 6800
|
3576, 4196
|
333, 397
|
6971, 7218
|
1858, 3553
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|
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|
7242, 7949
|
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|
282, 295
|
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|
623, 739
|
755, 835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,286
| 126,531
|
41496
|
Discharge summary
|
report
|
Admission Date: [**2165-3-14**] Discharge Date: [**2165-3-18**]
Date of Birth: [**2104-1-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 88582**]
Chief Complaint:
SVC Syndrome
Major Surgical or Invasive Procedure:
Stent placement in SVC
Stent placement in right mainstem bronchus
History of Present Illness:
The patient is a 61 yo man with h/o IBS and "irratic heart
rate," who presented to the IR suite today for elective SVC
stent placement. The patient was reportedly in his normal state
of health until approximately [**Month (only) **], when he developed a
non-productive cough. The cough worsened and he had occasional
blood flecked clear expectorate. Three weeks ago, he then
developed RUE and facial swelling. A CT performed at an OSH
revealed a large RUL mass with compression of the right mainstem
bronchi and SVC. He was also noted to have a large pleural
effusion. He was then seen on [**3-12**] by Dr. [**Last Name (STitle) **] and was
scheduled for a SVC venogram with stenting prior to rigid
bronchoscopy tomorrow. He thus presented today for SVC
stenting.
.
In the IR suite, he was given Fentanyl and Verset and the
obstructed SVC was stented with 3 stents (the first two were in
suboptimal position, so a third was placed). Per report, the
patient then developed sinus tachycardia at the end of the
procedure, which was reportedly thought to be secondary to
either pain or dehydration. There was concern because the
patient was in sinus tach at the end of the procedure. He was
admitted overnight to medicine for observation until the rigid
bronchoscopy tomorrow morning.
.
On the floor, the patient immediately triggered for AFib with
RVR with rates to the 140s and stable BP. He states that he has
a history of AFib, but he does not take any medication for it.
He was incredibly anxious and stated that he wanted to leave the
hospital and no longer wants the procedure tomorrow. After
discussion with the patient and his wife, he agreed to take
medication for treatment of his anxiety but otherwise deferred
further medical management for his AFib.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
s/p CCY 25 years ago.
AFib
Systolic CHF (EF 30-35% per recent TTE)
PUD
IBS
Glaucoma
Social History:
Lives with his wife and son. Occupation: retired painter.
Smoking history: 35 pck/y. Alcohol: denies current.
Family History:
Father with lymphoma.
Physical Exam:
Vitals: T: afebrile, BP: 160/90, P: 140 R: 16
General: Alert, oriented, very anxious, in NAD
HEENT: Sclera anicteric, dry mucous membranes, facial plethora
Neck: Distended bilaterally.
Lungs: Decreased breath sounds in the right hemithorax. No
w/c/r appreciated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Swelling in the RUE, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
[**2165-3-14**] 08:34AM BLOOD WBC-5.2 RBC-4.15* Hgb-13.8* Hct-39.4*
MCV-95 MCH-33.2* MCHC-35.0 RDW-15.4 Plt Ct-295
[**2165-3-14**] 08:34AM BLOOD PT-12.9 INR(PT)-1.1
[**2165-3-14**] 08:34AM BLOOD Plt Ct-295
[**2165-3-14**] 08:34AM BLOOD UreaN-9 Creat-0.9 Na-136 K-3.8 Cl-97
HCO3-28 AnGap-15
[**2165-3-14**] 08:34AM BLOOD Glucose-117*
[**2165-3-15**] 07:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
.
.
PERTINENT LABS/STUDIES:
Cytology (pleural fluid [**3-12**]):
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes, and lymphocytes.
.
.
DISCHARGE LABS:
[**2165-3-18**] 07:50AM BLOOD WBC-3.8* RBC-3.92* Hgb-12.4* Hct-37.1*
MCV-95 MCH-31.6 MCHC-33.3 RDW-14.7 Plt Ct-211
[**2165-3-18**] 07:50AM BLOOD Glucose-100 UreaN-4* Creat-0.7 Na-136
K-3.7 Cl-99 HCO3-29 AnGap-12
[**2165-3-18**] 07:50AM BLOOD CK-MB-4 cTropnT-0.16*
[**2165-3-18**] 07:50AM BLOOD CK(CPK)-57
[**2165-3-18**] 07:50AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7
.
RLL lung pathology pending at the time of discharge.
Brief Hospital Course:
Assessment and Plan: The patient is a 61 yo man with h/o AFib
who presented to the IP suite for SVC venogram and bronchoscopy
with right mainstem stent placement.
.
The obstructed SVC was stented with 3 stents; pt then developed
sinus tachycardia and was admitted to SIRS (medical floor) on
[**2165-3-14**] for observation until rigid bronchoscopy planned for the
next morning. Upon admission to SIRS, pt triggered for AFib with
RVR (HR 140s, BPs stable). He initially refused cardiac meds and
would only accept Ativan. Tachycardia subsequently resolved and
pt was taken for rigid bronchoscopy with biopsy on [**2165-3-15**]. Plan
was to stent right mainstem bronchus but this was not possible
given obstructive nature of tumor and its friability. Biopsy was
taken and sent for stat pathology. Pt was intubated for the
procedure and extubated afterwards but became agitated and
hypoxic. Due to worsening hypercapnia and agitation, he was
re-intubated and transferred to MICU. He was re-extubated
without difficulty at the MICU. He did also have a troponin leak
that was believed to be [**1-23**] demand ischemia in setting of afib.
Plan initially was to have pt go home and return for XRT as
outpatient, particularly as pt reluctant to stay in hospital.
However, pt's HR was unstable and he was transferred to OMED for
further management and initiation of radiation. Final RLL lung
pathology pending at the time of discharge.
.
Pt was seen by radiation oncology and had XRT mapping as well as
his first session of XRT on [**2165-3-18**] prior to discharge. He did
have an episode of AF with RVR he morning prior to discharge,
which was managed with po metoprolol. He was also given Ativan
for anxiety, which was felt to be precipitating the rapid HR. He
will be discharged on 100mg of metoprolol succinate for rate
control.
.
Pt was confirmed full code this admission.
Medications on Admission:
Lorazepam 0.5 mg PO prn for anxiety
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
4. dexamethasone 4 mg Tablet Sig: Five (5) Tablet PO every six
(6) hours: Please take 5 pills (20mg) 12hour and 6 hours (at
dinner and at breakfast) before chemotherapy.
Disp:*60 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Superior Vena Cava Syndrome
Atrial Fibrillation with rapid ventricular response
.
Secondary:
Hypertension
Chronic systolic congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 10010**],
It has been a pleasure taking care of you here at [**Hospital1 771**]. You were admitted to the hospital
because you have a mass in your lungs that is causing
compression on your right mainstem bronchus (the large airway).
While you were here, you underwent a stent placement in your
superior vena cava, one of the large veins returning blood to
the heart. Furthermore, you had a stent placed in your right
mainstem bronchus to improve your breathing. You also had an
episode of a fast heart rate, called AFib (atrial fibrilation)
with rapid ventircular rate or RVR, which we think was worsened
by your anxiety. We gave you a medication called Ativan for
anxiety, and started a medicine called metoprolol for your heart
rate.
.
While you were here, we made the following changes to your
medications:
- You may start lorazepam (Ativan), as needed, for anxiety. We
gave you a small number of pills. You should talk about whether
or not to continue this medicine with your primary care doctor.
- Please START metoprolol succinate 100mg daily
- Please take 20mg (5 pills) of dexamethasone with dinner the
night before and breakfast the day of chemo.
- Please START taking a baby aspirin (81mg) daily.
- Please START taking omeprazole 40mg daily. This is to help
protect your stomach while you are taking dexamethasone. Your
first dose of chemo will be Thursday at [**Hospital1 **].
- You did a great job not smoking while you were here in the
hospital. We highly recommend you continue to not smoke, and
have given you a prescription for nicoteine pathces to help. All
of your doctors are here to support you in quitting!
.
Followup Instructions:
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD (works with [**Last Name (LF) **],[**First Name3 (LF) **] R. )
Location: [**Location (un) 2274**] [**Hospital1 **]
Address: [**Hospital1 34796**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 90266**]
Appt: [**3-19**] at 9:50am
.
Name: [**Last Name (LF) **], [**First Name3 (LF) **] C. MD
Location: [**Hospital1 18**]-INTERVENTIONAL PULMONARY
Address: [**Hospital1 85781**], [**Hospital1 **] 201, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3020**]
Appt: We are working on an appt for you within the next few
weeks. The office will call you at home with an appt. If you
dont hear from them by Monday, please call them directly to
book.
.
You should have appointments scheduled for radiation therapy and
chemotherapy as well.
|
[
"300.00",
"428.0",
"285.22",
"518.81",
"305.1",
"511.9",
"427.31",
"428.22",
"427.1",
"427.89",
"162.3",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"92.29",
"33.24",
"96.04",
"00.40",
"96.71",
"00.47",
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] |
icd9pcs
|
[
[
[]
]
] |
7416, 7422
|
4455, 6326
|
318, 386
|
7623, 7623
|
3438, 3438
|
9453, 10322
|
2840, 2864
|
6413, 7393
|
7443, 7602
|
6352, 6390
|
7774, 9430
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4013, 4432
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2879, 3419
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2207, 2586
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266, 280
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414, 2188
|
3454, 3997
|
7638, 7750
|
2608, 2694
|
2710, 2824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,282
| 100,063
|
37381
|
Discharge summary
|
report
|
Admission Date: [**2181-4-20**] Discharge Date: [**2181-4-22**]
Date of Birth: [**2135-4-5**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 23197**]
Chief Complaint:
intoxication / seizure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
46 y/o M with hx of etoh abuse (per ED signout) and possible
depression presented to the emergency room at around 6pm this
evening. He was obviously intoxicated. Was found by EMS in
front of a liquor store and brought in for eval. Initial vitals
were t 98.1, p 100, bp 112/94, r 20, 95% on RA. While in the
ED, he climbed over his side rails on his bed and fell. He was
transferred to the Red Zone after his fall and was found to be
mostly non-responsive despite noxious stimuli. He had a CT scan
of his head and C-spine at that time that were negative. He had
an EJ and femoral line place. He was almost intubated but then
became arousable.
.
Over the next few hours, he was alert and interactive. His
speech was slurred and he appeared drunk. On interview and
exam, the patient was complaining of abdominal pain, bloody
vomit and stool (was guiac negative), and suicidal ideation. He
had a fight with his brother-in-law and was feeling very
depressed because of that. He also claimed that he wanted to
hurt his brother-in-law, too. Psych was consulted for the SI/HI
but were waiting to interview him until he was sober.
.
While in the yellow zone waiting for evaluation, he had an
abrupt onset fall where he went to the ground and was
unresponsive for about a minute or two. He then had a witnessed
tonic-clonic seizure. He received 2 mg ativan at that time.
Several minutes later he had another tonic-clonic seizure, and
he was again given 2 mg ativan. He was intubated at that time
for airway protection. He was initially started on a midazolam
gtt but was aggitated. He was switched to a propofol gtt. He
had another CT head and C-spine that were preliminarily read as
normal.
.
On arrival to the floor, he was intubated and sedated. He was
moving all 4 extremities but would not follow commands
appropriately.
.
Past Medical History:
ETOH abuse
Hx of pancreatitis
Depression
Social History:
smokes occasionally, drinks heavily on a daily basis, also
history of ?heroin v. cocaine use in [**Male First Name (un) 1056**] (moved here 2
months ago), unmarried
Family History:
per brother-in-law, HTN
Physical Exam:
Vitals - afebrile, 141/96, 81, 18, 100% on cmv 18 x 550, 100% x5
Gen - thin man, intubated, sedated, intermittently aggitated and
trying to pull at his restraints
HEENT - PERRLA, ET tube in place
CV - RRR, no m,r,g
Lungs - CTA B, referred vent sounds
Abd - soft, NT, ND, no hsm or masses
Ext - warm, well perfused, palp pulses, track marks; LE scarring
Neuro - could not obtain secondary to infection
Pertinent Results:
[**2181-4-20**] 07:30PM ASA-NEG ETHANOL-295* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2181-4-20**] 07:30PM LIPASE-78*
[**2181-4-20**] 07:30PM cTropnT-<0.01
[**2181-4-20**] 07:30PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-182 ALK
PHOS-64 TOT BILI-0.1
[**2181-4-20**] 07:30PM WBC-6.3 RBC-5.35 HGB-15.1 HCT-46.1 MCV-86
MCH-28.1 MCHC-32.7 RDW-14.4
CT C-SPINE W/O CONTRAST Study Date of [**2181-4-21**] 1:05 AM
IMPRESSION: No evidence of acute injury to the cervical spine.
Head CT
NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass
effect, or
[**Doctor Last Name 352**]-white matter differentiation, abnormality. The ventricles
and
extra-axial spaces are within normal limits. There is no
evidence of
fracture. Mucosal thickening within bilateral maxillary sinuses
and ethmoid
sinus air cells and sphenoid sinuses are mild. There are
aerosolized
secretions in the nasopharynx.
IMPRESSION: No acute intracranial abnormality.
Brief Hospital Course:
46 y/o M with hx of etoh abuse (per ED reports), coming in
intoxicated and then complaining of abdominal pain,
n/v/diarrhea, and suicidal ideation. Had a seizure and was
intubated for airway protection.
.
# Seizure: No further seizure activity after initial one in ED.
[**Month (only) 116**] have been due to EtOH intoxication. CT head, labs were
unremarkable.
.
# Abdominal Pain: Resolved once pt was extubated.
.
# Respiratory Failure: The pt had to be intubated for altered
mental status and airway protection in the setting of a seizure.
Was successfully extubated the morning following admission, with
no further respiratory problems.
.
# EtOH/SI: The pt was seen by psychiatry and was found to have
capacity to make medical decisions. He declined rehab/detox and
reported that he had psychiatric follow up at [**Hospital1 **] CHC on
Tuesday. The pt was discharged in the care of his girlfriend who
planned to take him to her church to stay overnight.
Medications on Admission:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Intoxication
Discharge Condition:
Mental Status: Clear and coherent, fluent Spanish
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with intoxication. You were intubated (a
breathing tube was placed) to protect your airway. You were
evaluated by psychiatry, and they felt that you were safe to
return home with your family, with close psychiatric follow up.
.
Please continue to take your seroquel and wellbutrin. We have
added folate and thiamine for your nutritional status.
Followup Instructions:
Please follow up with your psychiatrist at [**Hospital1 **] St.
Community Health Center as planned on Tuesday.
|
[
"518.81",
"311",
"780.39",
"303.01",
"577.1",
"401.9",
"780.97",
"V62.84",
"291.81",
"E884.4",
"304.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5469, 5475
|
3913, 4871
|
319, 332
|
5532, 5532
|
2931, 3445
|
6083, 6197
|
2465, 2491
|
5085, 5446
|
5496, 5511
|
4897, 5062
|
5696, 6060
|
2507, 2912
|
257, 281
|
360, 2200
|
3454, 3890
|
5547, 5672
|
2222, 2264
|
2281, 2448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,987
| 183,823
|
4083
|
Discharge summary
|
report
|
Admission Date: [**2152-4-5**] Discharge Date: [**2152-4-5**]
Date of Birth: [**2096-9-3**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Penicillins / Lipitor
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
pain, shortness of breath
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
Presented intubated to ED for shortness of breath.
Past Medical History:
1. rotator cuff repair [**9-4**]
2. s/p right total knee replacement with subsequent excion
arthroplasty of septic total knee with mobile spacer placed
3. poorly healing ulcers in legs
4. IDDM
5. Hep C, liver failure
6. h/o ETOH use
7. anemia
8. [**11-3**] admission with septic arthritis c/b decompensated liver
failure requriring MICU
9. thigh hematoma requiring 7 units of PRBC's
10. renal insufficiency
11. ? COPD
12. Diastolic CHF
Social History:
Lives with his daughter. Drinks 5-6 [**Name2 (NI) 17963**] daily, prior heavy
alcohol use ([**2-1**] gallon/day). Decreased last fall. Prior
Cocaine and Marijuana use years ago.
Family History:
NC
Pertinent Results:
[**2152-4-5**]
2:19p
pH
6.88 pCO2
59 pO2
42 HCO3
12 BaseXS
-25
Comments: pH: Verified
pH: Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art; Intubated; FiO2%:100; AADO2:623; Req:100; TV:600;
PEEP:5
K:5.9
Lactate:5.5
[**2152-4-5**]
2:09p
Source: Line-central
151 111 118 219 AGap=19
5.6 27 5.2
Comments: Na: Notified G.[**Doctor Last Name **] @ 1546 [**2152-4-5**]
estGFR: [**1-12**] (click for details)
CK: 75 MB: Notdone
Ca: 7.8 Mg: 2.5 P: 9.6 D
Source: Line-central
104
16.5 D 10.5 D 124
32.0 D
N:67 Band:22 L:4 M:0 E:1 Bas:0 Metas: 4 Myelos: 2
Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Polychr: 1+ Schisto:
OCCASIONAL Stipple: 1+
Plt-Est: Low
[**2152-4-5**]
11:41a
pH
6.86 pCO2
69 pO2
119 HCO3
14 BaseXS
-23
Comments: pH: Verified
pH: Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art; Intubated; FiO2%:100; AADO2:536; Req:88; Rate:/15;
TV:500
K:5.2
[**2152-4-5**]
10:07a
pH
6.87 pCO2
51 pO2
115 HCO3
10 BaseXS
-25
Comments: pH: Verified
pH: Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art; Intubated
Na:140
K:5.7
Cl:118
Glu:193 freeCa:1.35
Lactate:5.0
Hgb:14.5
CalcHCT:44
[**2152-4-5**]
10:00a
K:6.1
Glu:170
Hgb:14.8
CalcHCT:44
Comments: K: Verified
[**2152-4-5**]
09:59a
Trop-T: 0.27
Comments: cTropnT: Notified [**First Name5 (NamePattern1) 17965**] [**Last Name (NamePattern1) 17966**] At 1115 On [**2152-4-5**]
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
SPECIMEN SLIGHTLY HEMOLYZED
131
5.5 D
estGFR: [**12-12**] (click for details)
CK: 102 MB: 8
ALT: 50 AP: Tbili: Alb:
AST: 54 LDH: Dbili: TProt:
[**Doctor First Name **]: 36 Lip: 27
Comments: ALT: Hemolysis Falsely Increases This Result
AST: Hemolysis Falsely Elevates Ast
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Opiates Pos
Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative
103
6.0 15.0 185 D
45.7
Comments: Plt-Ct: Verified
PT: 19.4 PTT: 36.5 INR: 1.9
Fibrinogen: 390
Color
Yellow Appear
Clear SpecGr
1.015 pH
5.0 Urobil
Neg Bili
Neg
Leuk
Neg Bld
Neg Nitr
Neg Prot
Tr Glu
Neg Ket
Neg
RBC
0-2 WBC
0-2 Bact
Few Yeast
None Epi
0
Imaging per OMR
Brief Hospital Course:
Mr. [**Known lastname **] presented had respiratory distress in the field. He
was intubated in the field and pan-CT showed no large abdominal
or chest catastrophe. He was found to be extrememly acidotic
despite ventilation (Ph 6.86). His blood pressure started
dropping just prior to transfer to the ICU. He received
vancomycin and levofloxacin. He received a fluid bolus. In the
ICU, a central line was urgently placed. An A-line could not be
obtained. his blood pressure continued to drop and he became
bradycardic. CXR revealed adequate line placement. He was coded
for 30 mintues and was pronounced dead within hours of arrival
to the ICU. Postmortem was refused by the family. Blood cultures
grew out anaerobic GNR which could not be further characterized.
It is possible that some sort of bowel rupture/abdominal process
caused his death, but hard to tell.
Discharge Disposition:
Expired
Discharge Diagnosis:
anaerobic bacteremia
Discharge Condition:
dead
|
[
"428.0",
"571.2",
"584.9",
"276.2",
"518.81",
"585.9",
"428.32",
"496",
"416.8",
"070.54",
"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.60",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4211, 4220
|
3324, 4188
|
315, 339
|
4284, 4291
|
1116, 3301
|
1093, 1097
|
4241, 4263
|
250, 277
|
367, 419
|
441, 880
|
896, 1077
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,224
| 174,680
|
1+55178
|
Discharge summary
|
report+addendum
|
Admission Date: [**2147-11-17**] Discharge Date: [**2147-12-5**]
Date of Birth: [**2092-11-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
headache and neck stiffness
Major Surgical or Invasive Procedure:
central line placed, arterial line placed
History of Present Illness:
54 year old female with recent diagnosis of ulcerative colitis
on 6-mercaptopurine, prednisone 40-60 mg daily, who presents
with a new onset of headache and neck stiffness. The patient is
in distress, rigoring and has aphasia and only limited history
is obtained. She reports that she was awaken 1AM the morning of
[**2147-11-16**] with a headache which she describes as bandlike. She
states that headaches are unusual for her. She denies photo- or
phonophobia. She did have neck stiffness. On arrival to the ED
at 5:33PM, she was afebrile with a temp of 96.5, however she
later spiked with temp to 104.4 (rectal), HR 91, BP 112/54, RR
24, O2 sat 100 %. Head CT was done and relealved attenuation
within the subcortical white matter of the right medial frontal
lobe. LP was performed showing opening pressure 24 cm H2O WBC of
316, Protein 152, glucose 16. She was given Vancomycin 1 gm IV,
Ceftriaxone 2 gm IV, Acyclovir 800 mg IV, Ambesone 183 IV,
Ampicillin 2 gm IV q 4, Morphine 2-4 mg Q 4-6, Tylenol 1 gm ,
Decadron 10 mg IV. The patient was evaluated by Neuro in the
ED.
.
Of note, the patient was recently diagnosed with UC and was
started on 6MP and a prednisone taper along with steroid enemas
for UC treatment. She was on Bactrim in past but stopped taking
it for unclear reasons and unclear how long ago.
.
Past Medical History:
chronic back pain, MRI negative
osteopenia - fosamax d/c by PcP
leg pain/parasthesias
h/o hiatal hernia
Social History:
No tob, Etoh. Patient lives alone in a 2 family home w/ a
friend. She is an administrative assistant
Family History:
brother w/ ulcerative proctitis, mother w/ severe arthritis,
father w/ h/o colon polyps and GERD
Physical Exam:
VS: 101.4 ; 101/55; 87; 20; 100% at 2L NC
Gen: Middle aged, ill-appearing woman, restless in bed,
rigoring, in moderate distress
HEENT: NC/AT, PEERL, MM dry, no lesions, OP clear, sclera
non-icteric
Neck: stiff; palpable small LN in right supraclavicular area
CV: regular, Nl S1, S2, 3/6 systolic murmur at left lower
sternal border
Pulm: crackles at base of right lung
Abd: + BS, soft, mildly tender in periumbilical area, ND, no
rebound, no guarding
Ext: 2+ bilateral pitting edema in lower extremities
bilaterally, warm skin
Skin: no exanthems
Neuro: A&O x3, expressive aphasia, CN 2-12 intact, patient has
2+ patellar reflexes bilaterally, no gross motor or sensory
deficits.
Pertinent Results:
[**2147-11-16**] 05:55PM BLOOD WBC-6.5 RBC-2.64* Hgb-8.2* Hct-24.6*
MCV-93 MCH-31.0 MCHC-33.3 RDW-20.1* Plt Ct-577*
[**2147-11-16**] 05:55PM BLOOD Neuts-92.2* Bands-0 Lymphs-5.3*
Monos-1.4* Eos-0.9 Baso-0.2
[**2147-11-16**] 05:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
[**2147-11-16**] 05:55PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1
[**2147-11-18**] 04:52AM BLOOD Fibrino-782*
[**2147-11-16**] 05:55PM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-140
K-3.7 Cl-99 HCO3-29 AnGap-16
[**2147-11-16**] 05:55PM BLOOD LD(LDH)-288*
[**2147-11-17**] 05:14AM BLOOD ALT-28 AST-42* LD(LDH)-424* AlkPhos-33*
Amylase-63 TotBili-0.6
[**2147-11-18**] 04:52AM BLOOD ALT-25 AST-25 LD(LDH)-315* AlkPhos-34*
TotBili-0.3
[**2147-11-17**] 05:14AM BLOOD Lipase-25
[**2147-11-17**] 05:14AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.6
Mg-1.5* Iron-8*
[**2147-11-21**] 06:43PM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.6 Mg-1.7
[**2147-11-17**] 05:14AM BLOOD calTIBC-152* Ferritn-298* TRF-117*
[**2147-11-17**] 08:01PM BLOOD Type-ART Temp-38.9 Rates-/24 FiO2-100
pO2-58* pCO2-33* pH-7.47* calHCO3-25 Base XS-0 AADO2-645 REQ
O2-100 Intubat-NOT INTUBA
[**2147-11-18**] 12:44AM BLOOD Type-ART Temp-39.1 Rates-/24 FiO2-100
pO2-69* pCO2-35 pH-7.48* calHCO3-27 Base XS-2 AADO2-632 REQ
O2-99 Intubat-NOT INTUBA Comment-NON-REBREA
[**2147-11-18**] 04:18PM BLOOD Type-ART FiO2-100 pO2-222* pCO2-31*
pH-7.47* calHCO3-23 Base XS-0 AADO2-478 REQ O2-79 Intubat-NOT
INTUBA
[**2147-11-18**] 04:38PM BLOOD Type-ART pO2-61* pCO2-33* pH-7.45
calHCO3-24 Base XS-0 Intubat-NOT INTUBA
[**2147-11-19**] 12:11AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-350
FiO2-100 pO2-137* pCO2-35 pH-7.47* calHCO3-26 Base XS-2
AADO2-559 REQ O2-90 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2147-11-19**] 10:29AM BLOOD Type-ART PEEP-8 pO2-89 pCO2-33* pH-7.51*
calHCO3-27 Base XS-3 Intubat-NOT INTUBA
[**2147-11-21**] 05:25AM BLOOD Type-ART Temp-38.4 Rates-/24 FiO2-100
pO2-58* pCO2-36 pH-7.52* calHCO3-30 Base XS-5 AADO2-638 REQ
O2-100 Intubat-NOT INTUBA
[**2147-11-22**] 04:52AM BLOOD Type-ART Temp-37.3 Rates-0/24 O2 Flow-5
pO2-64* pCO2-29* pH-7.50* calHCO3-23 Base XS-0
[**2147-11-16**] 06:01PM BLOOD Lactate-2.1* K-3.4*
[**2147-11-21**] 08:04PM BLOOD Lactate-0.8
[**2147-11-18**] 08:41AM BLOOD freeCa-1.01*
[**2147-11-22**] 04:16AM BLOOD WBC-9.4# RBC-3.77* Hgb-11.5* Hct-33.4*
MCV-89 MCH-30.5 MCHC-34.5 RDW-20.0* Plt Ct-597*
[**2147-11-17**] 05:14AM BLOOD WBC-7.6 RBC-2.16* Hgb-6.8* Hct-20.0*
MCV-92 MCH-31.6 MCHC-34.2 RDW-20.0* Plt Ct-415
[**2147-11-17**] 03:57PM BLOOD Hct-23.2*
[**2147-11-18**] 04:11PM BLOOD WBC-5.1 RBC-2.60* Hgb-7.8* Hct-22.7*
MCV-87 MCH-30.1 MCHC-34.4 RDW-21.0* Plt Ct-395
[**2147-11-19**] 05:52AM BLOOD WBC-4.8 RBC-3.08* Hgb-9.0* Hct-26.5*
MCV-86 MCH-29.2 MCHC-33.9 RDW-20.7* Plt Ct-409
[**2147-11-21**] 06:43PM BLOOD Neuts-91.0* Bands-0 Lymphs-7.3*
Monos-1.4* Eos-0.2 Baso-0
[**2147-11-22**] 04:16AM BLOOD Plt Ct-597*
[**2147-11-21**] 04:39AM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0
[**2147-11-21**] 04:39AM BLOOD Plt Ct-498*
[**2147-11-18**] 04:11PM BLOOD Plt Ct-395
[**2147-11-22**] 04:16AM BLOOD Glucose-104 UreaN-19 Creat-1.1 Na-136
K-4.1 Cl-104 HCO3-21* AnGap-15
[**2147-11-21**] 06:43PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-133
K-4.3 Cl-100 HCO3-24 AnGap-13
[**2147-11-20**] 04:41PM BLOOD Glucose-161* UreaN-15 Creat-1.0 Na-138
K-4.3 Cl-99 HCO3-28 AnGap-15
[**2147-11-19**] 05:52AM BLOOD Glucose-81 UreaN-16 Creat-0.8 Na-138
K-5.0 Cl-106 HCO3-23 AnGap-14
[**2147-11-18**] 04:52AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-136
K-4.3 Cl-103 HCO3-23 AnGap-14
[**2147-11-17**] 05:14AM BLOOD Glucose-223* UreaN-21* Creat-1.0 Na-135
K-4.3 Cl-99 HCO3-27 AnGap-13
.
.
.
Radiology:
CXR [**11-16**]: Diffusely increased opacities at the lung fields
bilaterally. In an immunocompromised patient, this is concerning
for PCP [**Name Initial (PRE) 2**]. Radiographically, the differential includes
pulmonary edema. Additionally, there is a faint opacity at the
right lung base, which may represent atelectasis or focal
pneumonic process.
.
CT-Head [**11-16**]: Focus of low attenuation within the subcortical
white matter of the right medial frontal lobe. This may
represent a subacute infarction; however, an underlying mass
lesion cannot be completely excluded. An MRI examination with
gadolinium and diffusion-weighted imaging is recommended for
further evaluation. No intracranial hemorrhage noted.
.
MR-head-w&w/o gadolinium [**11-18**]:
Signal abnormality in the medial right frontal lobe involving
the corpus callosum does not demonstrate enhancement. This
finding most likely represent a small infarct. However, in
absence of ADC map, age of the infarct could not be determined.
No abnormal enhancement is seen. Follow up is suggested, if
clinically indicated.
.
Echo [**11-18**]:
1.The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. Trace aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. While difficult to
assess given the limited views suspect Mild (1+) mitral
regurgitation is seen.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
.
If clinically indicated, would recommend a TEE.
.
CXR [**11-21**]:
Resolution of congestive failure with persistent small bilateral
pleural effusions and bibasilar atelectasis
.
Studies:
EEG [**11-17**]: This is a mildly abnormal EEG due to the presence of
a slow
and disorganized background with bursts of generalized slowing -
all
consistent with a mild encephalopathy of toxic, metabolic, or
anoxic
etiology. No evidence for ongoing seizures is seen.
Brief Hospital Course:
A/P: 54 woman on immunosuppressive therapy for UC (prednisone,
6MP) who presents with new onset HA, fever with bacterial
meningitis and gram positive rod bacteremia.
.
#. Listeriosis - meningitis and bacteremia. Patient presented
with headache, nuchal rigidity, expressive aphasia, afebrile on
admission but temp to 104.4 in the ED, where she also started to
have rigors. LP showed >300 WBC, poly predominant with 5%
monocytes, protein 152 glucose 16. CSF gram stain showed gram
positive rods, blood culture grew gram positive rods, speciation
eventually grew listeria. Empiric treatment based on gram stain
was started: ampicillin and bactrim (to cover both nocardia and
question of PCP, [**Name10 (NameIs) 3**] below), vanc and ceftriaxone as well pending
confirmation of gram stain and culture results. Once
speciations was confirmed, a five day course of gentamicin was
started for synergy, and vancomycin and ceftriaxone d/c'd.
Bactrim was maintained on treatment dose for concern for PCP
[**Name Initial (PRE) 4**] [**11-21**], when it was changed to prophylaxis dose. Early on
admission, she developed hypotension that required levophed, but
was weaned off of pressors within the first couple of days of
admission with PRBCs (total of 4 units) and volume
resussitation. Given bacteremia, TTE was done, no vegetations
or lesions noted. Head CT on admission showed right medial
frontal lobe likely infarct versus mass lesion, no hemorrhage.
Subsequent MRI confirmed infarct, unclear date, and EEG
consistent with meningitis. Neurology was consulted, and the
patient was placed on dilantin for seizure prophylaxis given
meningoencephalitis. She spiked fevers to 101-102 over the first
several days of admission. By [**11-19**], her neurological exam was
markedly improved, and by [**11-21**] her headache was gone, no
meningeal signs noted, although her baseline essential tremor
was slightly more severe. Surveillance blood cultures reamined
negative from [**11-17**] on. Notably, she was transferred from ICU
to floor on [**11-21**], but noninvasive BP was read as 60/d, patient
mentating well, sent back to ICU. In the ICU, an arterial line
was placed, and consistently read 20-30 mmHg higher than
sphyngomanometer. This discrepancy was of unclear etiology, but
persistent. Patient maintained normal mentation, good urine
output, no tachycardia, and it was judged that, for some unclear
reason, the cuff pressures underestimated by 20-30 points. On
[**11-23**], she was sent to the floor for further care and management.
.
#. Bilateral lung opacities/hypoxia. Initial chest film read as
increased opacities bilaterally concerning for PCP (given
steroids and no PCP [**Name Initial (PRE) 5**]) vs. bacterial pneumonia vs. pulmonary
edema. She had signifcant oxygen requirement, and her
respiratory distress led to her being placed on CPAP+PS. The
origin of her significant hypoxia was originally thought to be
secondary to likely vascular leak from sepsis/CHF versus PCP. [**Name10 (NameIs) 6**]
induced sputum was attempted, but was unsuccessful, and was not
repeated initally given her unstable respiratory status, and
susbsequent evaluation that likelihood of PCP was small. She
responded well to lasix diuresis, with reduced O2 requirements.
.
#. UC: She continued to receive her outpatient dose of
prednisone, which was changed on [**11-22**] to dexamethasone IV; her
outpatient 6-MP was held. After several days with no diarrhea,
it recurred on [**11-22**] soon after her diet had advanced. C.diff was
negative. She was made NPO, and fed via TPN for bowel rest. On
[**11-24**], it was noted that she began passing BRBRP, her hematocrit
was noted to drop two points and pt was typed and crossed and
consent for blood transfusion.
.
#. Anemia. On admission, she was found to be anemic. She
received PRBCs for anemia on admission and again [**11-19**] for mixed
venous sat <70%. She was found to have iron binding studies c/w
anemia of chronic disease. Her HCT was followed closely, and
remained stable for the remainder of her admission.
.
#. FEN: Her diet was advanced as tolerated, but she was made NPO
with TPN on [**11-22**] after she developed diarrhea, thought secondary
to continued UC activity.
.
#. Prophylaxis: PPI. Hold SQ Hep, pneumoboots. Initially on
droplet precautions.
.
#. Code status: FULL
.
#. Communication: patient, her sister, brother, and mother
.
#. Lines: peripheral IV x 2. left subclavian CC. A-line. Eval
for PICC; once in place, can d/c central line, a-line.
Surgery Discharge part:
Pt underwent total abdominal colectomy with ileoostomy on
[**2147-11-26**]. She was on Clinda/Gent peri-procedure and Amplicillin
for 21 days at first. She was seen by PT/OT and was NPO until
the ostomy started to function. SHe had c/o nausea as diet was
tolerated and it was slowed down. MRI was suspicious for an
abcess and amplicillin was started for at least a total of 6
weeks as per ID. She was given a PICC. On [**12-5**] she was
cleared by PT and was in good condition for d/c to rehab on
[**2147-12-5**].
Medications on Admission:
AMBIEN 10 mg--1 tablet(s) by mouth at bedtime
CLONAZEPAM 1 MG--One twice a day
FLUOXETINE 20 MG--2 every day
FOSAMAX 70MG--One qweek as directed
FUROSEMIDE 20 mg--1 tablet(s) by mouth once a day
MERCAPTOPURINE 50 mg--1 tablet(s) by mouth twice a day
PREDNISONE 20 mg--2 tablet(s) by mouth once a day as per
gastroenterologist
PROTONIX 40 mg--1 tablet(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2-4HPRN ().
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
13. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours): Please take until at least
[**12-28**]. You will be further instructed by the infectious
disease doctors.
14. PREDNISONE TAPER
(see included sheet)
10 mg in morning and 10 mg in evening for 3 days
Next take 10 mg in the morning and 7.5 mg in evening for 3 days
Next take 7.5 mg in the morning and 7.5 mg in the eveing for 3
days
Then take 7.5 mg in the morning and 5 mg in the evening
Next take 5 mg in the morning and 5 mg in the evening for 3 days
Then take 5 mg in the morning and 2.5 mg in the evening for 3
days
Next take 2.5 mg in the morning and 2.5 mg in the evening for 3
days
Finally take 2.5 mg in the morning and none in the evening for 3
days.
Then take no more prednisone
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Listeria meningitis
Ulcerative colitis
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor if you have a fever >101.4, inability to
pass gas or stool into the ostomy, severe pain, persistent
nausea, vomiting, or any other concerns. Please take all
medications as prescribed and complete the course of
antibiotics.
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in 2 weeks,
telephone [**Telephone/Fax (1) 9**]. Please follow up with your primary care
MD in [**1-22**] weeks.
You have an appointment with Infectious disease on [**12-25**] ([**Telephone/Fax (1) 10**].
You have an MRI scheduled on [**2147-12-22**] [**Telephone/Fax (1) 11**].
Name: [**Known lastname 1**],[**Known firstname 2**] Unit No: [**Numeric Identifier 3**]
Admission Date: [**2147-11-17**] Discharge Date: [**2147-12-5**]
Date of Birth: [**2092-11-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4**]
Addendum:
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2147-12-1**] 3:07 PM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Please evaluate for ischemic disease/infarction
Contrast: MAGNEVIST
[**Hospital 5**] MEDICAL CONDITION:
54 year old woman admitted with listeria meningitis, question
infarct in medial R frontal lobe. Please get MRI with gadolinium
and diffusion weighted imaging.
REASON FOR THIS EXAMINATION:
Please evaluate for ischemic disease/infarction
EXAM: MRI of the brain.
CLINICAL INFORMATION: The patient with listeria meningitis,
question of infarct in the right medial frontal lobe, for
further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were obtained before
gadolinium. T1 axial, sagittal and coronal images were obtained
following the administration of gadolinium. Comparison was made
with the previous MRI of [**2147-11-18**].
FINDINGS: Again a small well circumscribed T2 hyperintensity is
seen in the medial right frontal lobe involving the corpus
callosum. Following gadolinium, irregular enhancement is seen in
this region. There is subtle increased signal seen in this
region on diffusion images, indicating T2 shine through. The
diffusion signal changes have decreased since the previous
study, but the T2 abnormalities have increased with well-defined
margins. The enhancement is also new since the previous study.
The appearances could still be suggestive of an evolving
subacute infarct. However, given the clinical history of
listeria meningitis, an associated infection in this area could
not be excluded. Therefore, correlation with lumbar puncture
findings and a followup are recommended.
There are no other areas of abnormal enhancement seen. There is
no mass effect, midline shift or hydrocephalus.
IMPRESSION: Slightly increased T2 hyperintensity and new
enhancement in the medial right frontal lobe since the previous
MRI examination of [**2147-11-18**]. The enhancement, which is new since
the previous study could represent enhancement within a subacute
infarct. However, given the clinical history of listeria
meningitis, associated infection could not be excluded and
correlation with CSF findings and followup up are recommended.
No other areas of abnormal enhancement are seen.
DR. [**First Name (STitle) 6**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7**]
Approved: SAT [**2147-12-2**] 1:20 PM
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 8**] [**Known lastname 9**],[**Known firstname 2**] [**2092-11-28**] 54 Female [**-5/4005**]
[**Numeric Identifier 3**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10**]/mtd
SPECIMEN SUBMITTED: COLON.
Procedure date Tissue received Report Date Diagnosed
by
[**2147-11-26**] [**2147-11-27**] [**2147-11-29**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 11**]/cla
Previous biopsies: [**-5/3197**] SIGMOIDOSCOPY.
[**-5/2956**] COLON BX.
[**Numeric Identifier 12**] SKIN BX, RIGHT UPPER EYELID.
[**-3/3466**] ENDOMETRIAL BIOPSY, EMC.
DIAGNOSIS:
Ileocolectomy:
1. Ulcerative colitis, chronic active, with mucosal disease
extending from right colon to distal margin.
2. There are numerous inflammatory pseudopolyps.
3. No granulomas or dysplasia.
4. Fibrous obliteration of the appendix.
5. Ileal segment, within normal limits.
Clinical: Inflammatory bowel disease.
Gross:
The specimen is received in one part labeled with the patient's
name and medical record number and additionally labeled "colon".
The specimen consists of an 89 cm segment of colon. The serosal
surface is tan-pink and unremarkable as is the pericolic fat.
The specimen is opened longitudinally to reveal a small segment
of distal ileum measuring 1.5 x 1.5 cm. The cecum measures 5.5
cm in diameter. The remainder of the colon has a diameter of 3.0
cm. The proximal 11 cm of the colon has unremarkable tan-pink
mucosa, while the remainder of the specimen shows a dark red and
granular mucosa with numerous small polyps. Additionally, there
is a 6.0 cm x 0.5 cm appendix found at the proximal cecum. The
specimen is sectioned and represented as follows: A = proximal
ileal margin, B = representation of appendix, C = representation
of uninvolved cecum, D-G = representation of remainder of bowel
at 10 cm intervals, H = distal margin, I = representation of
possible lymph nodes.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) [**2147-11-25**] 7:05 PM
ABDOMEN (SUPINE & ERECT)
Reason: r/o toxic megacolon
[**Hospital 5**] MEDICAL CONDITION:
54 year old woman with UC now with worsening diarrhea, abd pain
and distension.
REASON FOR THIS EXAMINATION:
r/o toxic megacolon
SUPINE AND ERECT - ABDOMEN
HISTORY: 54-year-old woman with ulcerative colitis and abdominal
pain, rule out megacolon.
IMPRESSION: Two views of the abdomen show centrally clustered
small bowel loops moderately distended with air concerning for
small bowel obstruction. The colon may be diffusely thick
walled, but it is not distended and there is no evidence of
intraperitoneal free air. Lung bases demonstrate small bilateral
pleural effusions, new since [**10-20**].
Dr. [**Last Name (STitle) 13**] was paged to discuss these findings at the time of
dictation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16**] MD [**MD Number(1) 17**]
Completed by:[**2147-12-5**]
|
[
"027.0",
"320.7",
"518.82",
"428.0",
"V58.65",
"733.90",
"280.9",
"453.8",
"996.74",
"556.6",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.19",
"45.8",
"03.31",
"38.93",
"46.21",
"93.90",
"99.15",
"99.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
22794, 23028
|
8901, 13965
|
341, 384
|
16323, 16332
|
2817, 8878
|
16627, 17552
|
1995, 2093
|
14389, 16138
|
16261, 16302
|
13991, 14366
|
16356, 16604
|
2108, 2798
|
274, 303
|
22184, 22771
|
22075, 22155
|
412, 1733
|
1755, 1860
|
1876, 1979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,743
| 162,994
|
53827
|
Discharge summary
|
report
|
Admission Date: [**2178-5-21**] Discharge Date: [**2178-6-7**]
Date of Birth: [**2142-1-9**] Sex: F
Service: GEN MED
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 36 year old black
female with a history of polycystic kidney disease with end
stage renal disease status post cadaveric renal transplant,
who presents with two to three days of worsening nausea,
vomiting and weakness. Ms. [**Known lastname **] notes that the nausea,
three days. She reports that the emesis is bilious in nature
and without blood. Nausea, vomiting are also associated with
abdominal pain which is diffuse, but mainly localized in the
right upper quadrant and right lower quadrant. She denies
any melena, bright red blood per rectum, diarrhea or
constipation. However, Ms. [**Known lastname **] also reports worsening
hematuria over the past two to three days which was also
increased fluid retention over the past two weeks and has had
mild episodes of chest pressure and shortness of breath.
Otherwise she denies any recent fever, chills, dysuria,
urgency, frequency, cough or sputum production. Ms. [**Known lastname **]
recently was admitted at the end of [**2178-3-19**] for hematuria
and flank pain and was diagnosed at that time with
C.difficile colitis. She has completed a treatment regimen
since that time as well. Additionally the patient reports
she has been unable to take her p.o. medicines for the past
24 hours prior to admission secondary to nausea.
PAST MEDICAL HISTORY:
1. Polycystic kidney disease resulting in end stage kidney
disease. The patient is status post cadaveric renal
transplant in [**2175**] and is currently on an immunosuppressive
regimen of prednisone, Rapamune and CellCept.
2. Persistent hematuria. The patient has known hemorrhagic
cysts primarily in the right kidney. She is status post
embolization in [**2174**]. The patient has been previously
planned to have elective nephrectomy, but this has been
postponed due to the episode of C.diff.
3. Hypertension.
4. Peritoneal endometriosis.
5. History of VRE infection.
6. History of UTI.
7. Cervical dysplasia in situ II.
8. Anemia of chronic renal disease.
9. History of C.difficile colitis in [**2178-4-19**] which was
treated with a 14 day course of Flagyl.
10. History of frequent UTIs not currently on a regimen of Cipro
and Bactrim prophylaxis 2ndary to C. diff
ALLERGIES: PCN and FK-506 which cause hemolytic uremic
syndrome.
SOCIAL HISTORY: The patient lives with her four children.
She denies current tobacco, alcohol or IV drug abuse.
FAMILY HISTORY: The patient notes a family history on her
paternal side of polycystic kidney disease.
PHYSICAL EXAMINATION: On admission the patient was afebrile
with temperature of 99.5, heart rate 108, respiratory rate
18, blood pressure 244/147, O2 sat 97% in room air. In
general, Ms. [**Known lastname **] is a depressed appearing, black female with
a flat affect who is obese, but otherwise in no acute
distress. HEENT: pupils equal, round and reactive to light
and accommodation. Extraocular motions intact. Oropharynx
was unremarkable. Neck was supple with no appreciable
lymphadenopathy, thyromegaly or jugular venous distension.
Carotid pulses are 2+ bilaterally with no bruits. Heart had
regular rate and rhythm with normal S1, S2. There is a 2/6
systolic ejection murmur appreciable at the left lower and
upper sternal borders without radiation. Lungs were clear to
auscultation and percussion bilaterally. Abdomen was soft
and obese. Abdomen was nondistended, but mildly tender to
palpation over the right upper quadrant. Otherwise there was
no rebound or guarding tenderness appreciable. There was no
appreciable hepatosplenomegaly. Extremities showed trace
pitting edema of the lower extremities bilaterally.
Peripheral pulses were palpable and 2+ at the dorsalis pedis
and radial pulses bilaterally. On neurologic exam the
patient was alert and oriented times three. Cranial nerves
II-XII were intact bilaterally. The patient showed 5/5
strength in all extremities both proximally and distally.
Light touch sensation was intact over all extremities.
LABORATORY DATA: On admission white blood cell count was
7.3, hematocrit 25.1, platelet count 491. Sodium was 146,
potassium 3.9, chloride 111, bicarb 17, BUN 63, creatinine
5.6, glucose 107. ALT was 10, AST 14, alkaline phosphatase
104, amylase 59, lipase 66, total bilirubin 0.3. UA showed
red urine which was cloudy with a large amount of blood,
positive nitrites, greater than 300 protein, trace glucose,
15 ketones, greater than 1000 red blood cells present on
microscopic review with 58 white blood cells and occasional
bacteria. CT scan of the abdomen showed interval development
of a large pericardial effusion since [**2178-4-17**]. There
were small right and tiny left pleural effusions. Otherwise
there was known hepatic cysts and a large cystic native
kidney, but no new hemorrhagic cysts were present. KUB
showed no evidence of free air or obstruction. Chest x-ray
PA and lateral showed increased cardiomegaly with a moderate
amount of interstitial edema with new, small, bilateral,
pleural effusions and associated bibasilar atelectasis.
HOSPITAL COURSE: Ms. [**Known lastname **] was admitted to the [**Hospital1 **] general
medicine firm as a night E.R. admission after evaluation in
the E.R. The remainder of the hospital course will be
dictated by issue.
1. Cardiovascular. Ms. [**Known lastname **] initially arrived on the floor
as a transfer from the E.R. on the [**Hospital Ward Name **] with blood
pressure of 244/147. The patient had reportedly received
15 mg of IV Lopressor in the E.R. prior to transfer with this
blood pressure. Upon reevaluation in the morning, the
patient's blood pressure had only dropped to 230/130. She
was immediately given 2" of nitropaste, 10 mg of IV
hydralazine times two and 15 mg total of IV Lopressor with no
appreciable improvement in her blood pressure. It was felt
that her high blood pressure was most likely secondary to
acute and chronic renal failure. During the attempts to
control her blood pressure a stat echocardiogram was also
obtained due to concern for the presence of the large
pericardial effusion appreciated on abdominal CT. This
echocardiogram showed a large pericardial effusion with right
ventricular collapse on diastole with normal EF. It was felt
that Ms. [**Known lastname **] should be transferred to the CCU for improved
blood pressure control and further evaluation of the
effusion. Over the next 36 hours Ms. [**Known lastname **] blood pressure
was controlled in the cardiac intensive care unit with a
labetalol drip and was subsequently changed to a p.o. regimen
of labetalol, clonidine and hydralazine. Ms. [**Known lastname **] was then
transferred back out to the floor and was subsequently taken
over the next day to the cath lab to have the pericardial
effusion drained. A pigtail catheter initially was kept in
place overnight while Ms. [**Known lastname **] was monitored in the unit, but
this was removed and the patient was subsequently transferred
out the next day. The fluid analysis itself showed
transudative features, but there were approximately 400 white
blood cells in the cell count differential. Otherwise the
patient continued on her p.o. blood pressure meds with
marginal control on the floor. The p.o. labetalol was
titrated up gradually to a max dose of 1 gm p.o. t.i.d. with
systolic blood pressure usually ranging from 150 to 170.
Repeat echocardiogram was obtained four days later which
showed no significant reaccumulation of the pericardial
effusion. The etiology of the pericardial effusion was felt
secondary to either uremia or viral pericarditis. It was
felt that this was most likely not due to a lupus-like
syndrome from hydralazine due to negative [**Doctor First Name **] and negative SM
antibodies.(Id was consulted and cx's remain neg to date) Over
the remainder of the admission Ms. [**Known lastname **]
blood pressure improved after the initiation of dialysis.
Hydralazine was discontinued and she will be discharged on
p.o. labetalol and clonidine with close followup.
2. Renal. Throughout the course of admission the patient
showed very slowly, but progressive, worsening of her renal
function. Creatinine rose from initial on admission of 5.1
to approximately 6.8 to 7 prior to the initiation of
dialysis. It was felt that her rising creatinine was most
likely secondary to chronic graft rejection. It was the
feeling of the renal service upon initial consult that the
graft would continue to fail and that Ms. [**Known lastname **] would
eventually need to be placed on hemodialysis. Her
immunosuppressives were otherwise continued with a reduced
dose of prednisone. Transplant renal ultrasound was obtained
on day one which was felt to be normal with no significant
evidence of hydronephrosis. Throughout the later days of the
admission Ms. [**Known lastname **] continued to grow progressively more
nauseous with relatively normal blood pressure at the time.
This was felt most likely secondary to worsening uremia. The
patient subsequently had a dialysis catheter placed by the
vascular access team. She underwent hemodialysis without
event times two prior to discharge. She will follow up with
the renal service for continued dialysis three times a week.
3. Hematuria. The patient has known hemorrhagic cysts in
her native right kidney. A planned nephrectomy had been
postponed prior to admission due to C.difficile colitis. No
active interventions were taken to slow down the hematuria.
However, the hematuria gradually slowed down throughout the
course of admission. Ms. [**Known lastname **] will eventually need a
reconsult for elective nephrectomy of her native kidney to
prevent further episodes of significant hematuria.
4. Neuro. The patient was initially ready for discharge one
week prior to [**6-7**]. However, Ms. [**Known lastname **] was observed to have
an episode where she grew unresponsive for approximately
three to four minutes. This was accompanied by urinary
incontinence and tongue lacerations. It was felt that the
patient most likely had a seizure event, although no tonic
clonic motions were witnessed at the time. Neurology consult
was obtained and EEG subsequently showed evidence of some
abnormal activity suggestive of seizure disorder. The
patient was otherwise started on Dilantin per the neurology
team and this was titrated to a therapeutic level. MRI of
the brain was obtained which showed no further evidence of
any structural lesions. LP was also performed at the bedside
with a very long spinal needle. Approximately 1 to 2 cc of
cloudy fluid was obtained and sent for analysis which
subsequently showed protein of approximately 5000. Due to
unusual concern for bacterial meningitis, the patient was
started on 2 gm of IV ceftriaxone for coverage. Due to
confusion as to the etiology of the LP, another LP was
performed under fluoroscopic guidance. This fluid
subsequently came back as completely normal. It was felt
that the initial bedside tap had possibly aspirated a cyst
from her native kidney and did not represent true spinal
fluid. Otherwise the patient was felt to be stable for
discharge on p.o. Dilantin.
5. ID. The patient had previously completed her treatment
for C.diff and remained without signs or symptoms of
infection throughout the admission. Infectious disease
consult was obtained to consult on the etiology of the
pericardial fluid. It was their opinion that there were no
active ID concerns for this effusion.
6. GI. The patient was known to have guaiac positive stools
and initially low hematocrit of 25 down to 23. Toward the
end of the admission upper GI and lower GI exams were
performed by the GI service. EGD showed no evidence of
gastritis or ulcers. Colonoscopy was felt to be
subdiagnostic due to poor preparation. Ms. [**Known lastname **] will
otherwise need followup for lower GI workup as an outpatient.
7. Heme. The patient had decreased hematocrit upon
admission which was felt most likely secondary to a
combination of hematuria, guaiac positive stools and chronic
renal disease. She was continued on her Epogen dose as
scheduled. She required periodic transfusions, but her
hematocrit remained stable for the last week of admission and
was felt stable for discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS:
1. Labetalol 400 mg p.o. t.i.d.
2. Clonidine 1.2 mg p.o. b.i.d.
3. Catapres patch 0.3 mg q.week.
4. Zoloft 50 mg p.o. q.day.
5. Dilantin 300 mg p.o. q.day.
6. Rapamune 4 mg p.o. q.day.
7.d/c'd CellCept [**Pager number **] mg p.o. b.i.d.
8. Prednisone 10 mg p.o. q.day.
9. Sodium bicarbonate three tablets p.o. t.i.d.
10. Epogen 6000 units twice a week.
11. Tums 1 gm p.o. t.i.d.
DISCHARGE DIAGNOSES:
1. Acute and chronic renal failure.
2. Hypertensive emergency.
3. Idiopathic pericardial effusion.
4. Chronic anemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17014**], M.D. [**MD Number(1) 17015**]
Dictated By:[**Name8 (MD) 22406**]
MEDQUIST36
D: [**2178-6-15**] 18:20
T: [**2178-6-15**] 20:28
JOB#: [**Job Number 43012**]
|
[
"996.81",
"423.9",
"403.91",
"780.39",
"584.5",
"578.1",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"37.0",
"45.13",
"03.31",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
2586, 2673
|
12918, 13310
|
12508, 12897
|
5235, 12422
|
2696, 5217
|
162, 1484
|
1506, 2455
|
2472, 2569
|
12447, 12485
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,569
| 152,100
|
11694
|
Discharge summary
|
report
|
Admission Date: [**2139-5-17**] Discharge Date: [**2139-7-3**]
Date of Birth: [**2070-7-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Benadryl / Winrho Sdf / Heparin Agents
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2139-6-15**] - Flexible bronchoscopy and 8-0 Portex tracheostomy
tube placement.
[**2139-5-21**] - Aortic valve replacement with a size 21 Magna tissue
valve, mitral valve replacement with a size 25 [**Company 1543**] bovine
tissue valve, and tricuspid valve repair with size 30 [**Doctor Last Name **]
ring.
History of Present Illness:
This 68-year-old patient with severe aortic stenosis, mitral
stenosis and mitral regurgitation plus significant tricuspid
regurgitation with normal coronary arteries with preserved
ventricular function was electively admitted for triple valve
surgery. The major significant history was history of cirrhosis
with the child B bordering on C calcification occasionally with
the prior gastrointestinal bleeding and esophageal varices and
splenomegaly and also idiopathic thrombocytopenia. Because of
the co-morbidities, she was optimized for surgery for quite a
few months where she underwent a recurrent tapping of the
ascites and also had treatment for the thrombocytopenia by
way of steroids and platelet infusion and immunoglobulin
injection. Once the liver function was optimized as best as
possible almost to a child A bordering on B status and some
response of the platelet count to hematological management,
further discussion was had with the patient about the high- risk
of the surgery. The patient was very keen to proceed with the
operation because of the recurrent admissions for congestive
cardiac failure and a very poor quality of life and was willing
to take the high risk operation. She was electively admitted for
surgery. On the day before surgery, she had further dose of
hemoglobin given to increase the platelet count to above
100,000. This was done successfully and the patient was taken to
operating room.
Past Medical History:
1. Severe valvulopathies, including at least moderate aortic
stenosis
with estimated aortic valve area of 1 cm2, mixed mitral valve
disease with moderate MR and mild MS (MVA 1.5-2.0 cm2), followed
by Dr. [**Last Name (STitle) 171**]. Felt to be a poor candidate for a complex
multi-valve surgery.
2. Severe secondary pulmonary hypertension, on home oxygen
therapy at home 2.5 liters per minute. Her last pulmonary
pressures were 53/25/37 on catheterization in [**2138-9-21**].
Portopulmonary hypertension is felt to be a contributor.
3. Congestive heart failure, echo with preserved systolic
function in [**1-/2139**] albeit in setting of mitral regurgitation.
4. Longstanding diabetes type 2, last hemoglobin A1c 5.7 on
[**2138-10-7**].
5. Liver cirrhosis, followed by Dr. [**Last Name (STitle) 34448**], presumed
secondary to NASH with contribution from cardiac cirrhosis,
complicated by ascites, splenomegaly, and varices on EGD
[**2139-1-22**] (grade 2 and one grade [**12-23**] in the distal 3-4 cm of the
esophagus)
6. ITP, compounded by severe liver disease and splenomegaly,
followed by Dr. [**Last Name (STitle) 6944**]. No response to IVIG, low and high dose
Prednisone therapy, and life-threatening intravascular hemolysis
following WinRho. On no therapy at present.
7. Osteoporosis, on Fosamax.
8. Basal Cell Carcinoma.
Social History:
She lives alone at home, with extensive VNA services
(telemonitoring). Her daughter is very involved in her care. She
used to work in consumer services, has been unable to work in
recent months.
Family History:
Not reviewed with patient during this admission.
Physical Exam:
PE 98.9 90/48 98 20 99RA
Gen: laying in bed, non-toxic, well-appearing
HEENT: NCAT, MMM
Neck: supple, JVD ~ 9 cm, no carotid bruits
Chest: Rales in lower [**12-24**] of lung fields
CVS: rrr, Grade II/VI SEM @ RUSB with radiation to carotids and
clavicle, blowing HSM @ apex
Abd: soft, NABS, NT,no rebound/gaurding but marked distended
(ascites)
Extrem: no c/c; [**1-24**]+ (B)LE edema. RLE Erythema along leg
extending to foot
Neuro: CN II-XII intact
MSK: no joint effusions, normal ROM
Pertinent Results:
[**2139-5-17**] 02:45PM PLT SMR-VERY LOW PLT COUNT-62*#
[**2139-5-17**] 02:45PM PT-14.5* PTT-30.9 INR(PT)-1.3*
[**2139-5-17**] 02:45PM WBC-5.9 RBC-2.88* HGB-8.6* HCT-24.8* MCV-86
MCH-29.9 MCHC-34.8 RDW-18.9*
[**2139-5-17**] 02:45PM GLUCOSE-229* UREA N-29* CREAT-0.8 SODIUM-126*
POTASSIUM-5.0 CHLORIDE-89* TOTAL CO2-31 ANION GAP-11
[**2139-5-18**] - Ultrasound and paracentesis
The liver is shrunken and slightly nodular in appearance
consistent with cirrhosis. No dilated ducts are noted. The left,
middle and right hepatic veins are patent. The IVC is patent.
The left main, right anterior and right posterior portal veins
are patent. Flows are in appropriate directions.
There is a moderate amount of ascites, and a spot was marked in
the left lower quadrant for a paracentesis to be done by the
clinical service.
[**2139-5-21**] ECHO
PRE-BYPASS:
1. The left atrium is markedly dilated. No atrial septal defect
is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.]
3. The right ventricular cavity is mildly dilated. There is mild
global right ventricular free wall hypokinesis.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area
<0.8cm2). No aortic regurgitation is seen.
6. The mitral valve leaflets are severely thickened/deformed.
There is severe mitral annular calcification. There is a
minimally increased gradient consistent with trivial mitral
stenosis. Moderate to severe (3+) mitral regurgitation is seen.
7. Moderate to severe [3+] tricuspid regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
1. A well-seated bioprosthetic valve is seen in the Aortic
position with
normal leaflet motion. Given suboptimal echo windows gradients
could not be obtained across the aortic valve. No aortic
regurgitation is seen.
2. A well-seated bioprosthetic valve is seen in the mitral
position with
normal leaflet motion and gradients (mean gradient = 9 mmHg). CO
was 8 l/min No mitral regurgitation is seen.
3. A well-seated Tricuspid ring is seen. Trace to mild TR was
seen. Mean
gradient across the valve is 5 mm of Hg.
4. LV function is unchanged.. RV function is mild to moderately
depressed.
5. Aortic contours appear intact post decannulation.
[**2139-6-11**] Head CT
No acute hemorrhage or mass effect. Chronic lacune left
thalamus.
[**2139-6-10**] Chest/Abdomen CT Scan
1. Status post CABG for mitral and aortic valve replacements.
Moderate pleural effusion are present bilaterally. Compressive
atelectasis are also present at both lung bases.
2. Significant amount of ascites is noted within the abdomen.
There is hyperdense fluid within the pelvis suggesting the
presence of the hemoperitoneum. Left rectus sheet hematoma is
also noted.
3. Small liver and multiple collateral vessels and enlarged
spleen suggesting cirrosis.
4. Cholelithiasis with no evidence of cholecystitis.
5. Pulmonary arterial hypertension with main pulmonary artery
measuring 4.2 cm.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2139-5-17**] for surgical
management of her valve disease. After extensive discussion, Ms.
[**Known lastname **] agreed to surgery despite the fact that it would be a
high risk surgery. She was prepared for surgery by diuresis and
multiple ultrasound guided paracentesis by the Liver service.
IVIG was given prior to surgery given he history of ITP. The
[**Last Name (un) **] diabetes service was [**Last Name (un) 4221**] for assistance with her
diabetes management. On [**2139-5-21**], Ms. [**Known lastname **] was taken to the
operating room where she underwent an Aortic and mitral valve
replacement using tissue valves and a tricuspid valve repair
with a ring. Please see operative note for further details.
Postoperatively she was taken to the intensive care unit for
monitoring. Given the complexity and length of her postoperative
course, the remainder of her discharge summary will be divided
into systems.
Cardiac:
Postoperatively her pressors and inotropes were slowly weaned.
She remained volume overloaded and cautiously diuresed. She
developed atrial fibrillation for which amiodarone was started.
She continued to have paroxysmal runs of atrial fibrillation
however beta blockade was used in place of amiodarone. As she
was already auto-anticoagulated given her liver failure, no
further anticoagulation with heparin or coumadin was used. On
[**2139-6-12**], Ms. [**Known lastname **] became septic and pressors were resumed.
On [**2139-6-17**], Ms. [**Known lastname **] developed a junctional bradycardia and
her diltiazem and beta blockade were held. Her rhythm later
returned to [**Location 213**] sinus rhythm and her cardiac medications were
slowly resumed. As her sepsis picture resolved, her pressors
were slowly weaned off without issue. She continued to have
atrial fibrillation throughout her postoperative course and
diltiazem sufficiently controlled her rate.
Liver:
The hepatology followed Ms. [**Known lastname **] throughout her hospital
course. She required several therapeutic paracentesis for
drainage of ascites fluid. Albumin and lactulose were given
therapeutically. Rifaximin was also used prophylactically and
will continue per the hepatology service.
Renal:
Postoperatively, Ms. [**Known lastname **] developed renal failure with a
rising creatinine. The renal service was [**Known lastname 4221**] who followed
her closely throughout the remainder of her hospital stay. As
the concern was for hepatorenal syndrome, midodrine and
octreotide were used for blood pressure support. Her
electrolytes were closely monitored and her medications were
renal dosed. Epogen was used for anemia. Slowly her renal
function began to improve. Aldactone was later used in place of
lasix for diuresis. On [**2139-6-8**], Ms. [**Known lastname 37019**] renal function
again began to deteriorate. As her BUN/Creatinine continued to
rise in the setting of oliguria and volume overload, CVVH
(hemodialysis) was initiated on [**2139-6-17**]. A tunnelled line was
placed on [**2139-6-26**] for hemodialysis. She tolerated hemodialysis
well and her estimated dry weight was 86.5kg.
Hematology:
Postoperatively Ms. [**Known lastname **] became thrombocytopenic. A HIT
assay was sent which returned positive and a hematology consult
was obtained. Anticoagulation was started with argatroban as a
bridge to coumadin. As her platelets continued to fall given her
ITP and her continued anemia, it was decided not to
anticoagulate her further. She was transfused with packed red
blood cells for postoperative anemia. Interestingly, a serotonin
release assay for HIT returned negative thus heparin could be
used for anticoagulation. Over time, her platelets continued to
fall which was thought to be a result of infection superimposed
on her ITP. IVIG was given with platelets for treatment.
Diabetes:
The [**Last Name (un) 387**] diabetes service was [**Last Name (un) 4221**] and followed Ms.
[**Known lastname **] throughout her postoperative course. An insulin drip
was maintained postoperatively to regulate her blood sugars
while intubated. As she recovered and was fed via tube feeds as
well as an oral diet while her passe muir valve was in place,
lantus was used at bedtime while a regular insulin sliding scale
was also used.
Respiratory:
On [**2139-5-24**], Ms. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. She slowly decompensated during the day and needed to
be reintubated for respiratory failure later that day. She went
on to tolerate short courses of CPAP however was unable to fully
wean from the ventilator due to hypercarbia and acidosis. She
was extubated again on [**2139-6-2**]. She did well until her level of
consciousness began to decline. She was electively re intubated
on [**2139-6-12**]. The thoracic surgery service was [**Date Range 4221**] for
placement of a tracheostomy tube. This was successfully placed
on [**2139-6-15**]. Her vent was slowly weaned as she tolerated. A passe
muir valve was placed which she was able to tolerate for short
periods of time.
Infectious disease:
Ciprofloxacin and flagyl were started for leukocytosis. She was
cultured and found to have a klebsiella urinary tract infection
as well as C. difficile. She later developed gram positive
bacteremia and the infectious disease service was [**Date Range 4221**]. A
single dose of vancomycin was given and it was recommended to
not treat until repeat blood cultures were obtained. Her repeat
blood cultures were negative. A sputum culture on [**2139-6-21**] grew
serratia marcescens and vancomycin and cefepime were started.
Ciprofloxacin replaced the former two medications when
sensitivities returned. Flagyl was started for treatment of C.
Diff colitis. By the time of discharge, she had completed all
antibiotic treatment and had no active infectious issues.
Rifaximin was continued prophylactically.
Neurologic:
On [**2139-6-11**], Ms. [**Known lastname 37019**] level of consciousness declined. An
urgent head CT was obtained which showed no acute events. Given
the normal CT scan of her head, it was suspected that her renal
and liver function were worsening. With antibiotic treatment and
dialysis her neurologic status cleared. Anti anxiolytics and an
antidepressant were prescribed for her depressed state.
Nutrition:
Tube feeds were started while she was intubated for nutritional
support. When extubated, she began an oral diet however was
unable to adequately nourish herself. Tube feeds were resumed on
[**2139-6-9**]. As she improved, a swallowing evaluation was performed
which showed her able to take solids. As she was only able to
take a small amount of solids, her tube feeds were continued for
nutritional support.
Wound Care:
The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for assistance with her skin
breakdowns on her bilateral lower extremities, left upper
extremity and back. She was evaluated daily and efforts were
made to maintain the integrity of her skin and promote healing
of her wounds.
Ms. [**Known lastname **] continued to make steady progress. The physical
and occupational therapy service worked with her daily to help
increase her strength and mobility. On postoperative day 43, she
was discharged to [**Hospital **] rehabilitation for further recovery.
She will follow-up with Dr. [**First Name (STitle) **], her cardiologist, the renal
service, the liver service and her primary care physician as an
outpatient. Hemodialaysis will be continued at rehabilitation as
well as her vent wean.
Medications on Admission:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
take at 5 p.m.
3. Insulin Glargine 100 unit/mL Solution Sig: Seventy Five (75)
units Subcutaneous at bedtime.
4. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous as directed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
8. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)) as needed.
9. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
10. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Ampicillin-Sulbactam [**1-22**] g Recon Soln Sig: Three (3) g
Injection Q8H (every 8 hours) for 6 days.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
AS/MR/TR s/p AVR/MVR/TVR [**2139-5-21**]
Type 2 diabetes
Pulmonary HTN
CHF
Steatohepatitis (Non-Alcoholic)
Cirrhosis
Renal failure
Respiratory failure
AF
Wound infection
C. Difficile
Skin breakdown
Pulmonary edema
Sepsis
Ascites
Thrombocytopenia
Discharge Condition:
Stable
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2139-7-3**]
|
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14485, 15300
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|
3448, 3645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,873
| 151,868
|
3478
|
Discharge summary
|
report
|
Admission Date: [**2148-9-5**] Discharge Date: [**2148-9-12**]
Service: MEDICINE
Allergies:
Levofloxacin / Codeine
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
# Hematemesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
85F h/o [**8-29**] [**Doctor First Name **]-[**Doctor Last Name **] tear and grade I esophagitis per
[**2148-8-29**] EGD, paraesophageal hernia s/p repair [**5-/2147**], GERD,
admitted from NH (Tawerhill, [**Location (un) 2624**] MA) with Hct = 23.8
(baseline >30) on routine lab check. Pt described vomiting an
unknown quantity of blood x [**2-10**] the previous night, which she
did not report to NH staff. Pt noted she remained asymptomatic
during those episodes besides chronic SOB and chronic B ankle
edema. Because of [**8-29**] EGD revealing M-W tear, pt was admitted
to [**Hospital1 18**] MICU for observation and repeat [**9-6**] EGD, which
demonstrated old clotted blood in the stomach. Pt's Hct
remained stable in the MICU and she was transferred to the
floor.
.
ROS:
(+) Left neck/shoulder pain x few weeks, chronic SOB, chronic
groin rash, chronic B ankle edema
(-) Changes in bowel/urinary habits, f/c, n, HA, sensory changes
.
ED: VS T99.0, HR 78, BP 101/33, RR 18, O2Sat 100%. NGTube was
placed with 500 cc coffee-ground emesis removed. Pt received 1L
NS, pantoprazole drip, Percocet for lower back and neck pain,
and O2 NC for mild SOB.
Past Medical History:
--GI
# [**Doctor First Name **]-[**Doctor Last Name **] tear ([**8-13**])
# Paraesophogeal hernia ([**4-12**]), G-J tube repair
# GERD
# GIB
.
--CV
# CAD: 3VD
# MI
# CABG [**2141**]
# CHF: EF 50-55%, MR/TR
# Paroxysmal AFib: Warfarin held [**2-9**] GIB
# HTN
# PVD
# TIA
# Dyslipidemia
.
--Respiratory
# COPD
.
--Musculoskeletal
# Rheumatoid arthritis: Prednisone held [**2-9**] GIB
.
--DM2
Social History:
# Tobacco: 20y x 4 packs/day. No current smoking, unclear when
last cigarette was.
# Alcohol: Social use
# Recreational drugs: Never
# Personal: [**Hospital **] nursing home resident
Family History:
# Mother d60s: MI
# Father d80s: Liver cancer
# 9 siblings: Lung CA, ?MI
Physical Exam:
VS: T 98.1, BP 110/60, HR 82, RR 18, O2 95RA, FS 110
Gen: NAD
HEENT: NCAT, rash at midbrow, pale
CV: Irreg irreg, 2/6 systolic murmur at BUSB
Chest: Bibasilar rales, decreased breath sounds at R, no
dullness to percussion
Abd: Soft, NTND, BS+
Ext: 1+ BLE edema, L neck/shoulder with lidocaine patch
Skin: RUE bruising
Pertinent Results:
Admission labs:
[**2148-9-5**] 11:11PM HCT-29.0*
[**2148-9-5**] 07:26PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2148-9-5**] 07:26PM URINE BLOOD-SM NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2148-9-5**] 07:26PM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-[**3-11**]
[**2148-9-5**] 03:23PM COMMENTS-GREEN TOP
[**2148-9-5**] 03:23PM GLUCOSE-137* K+-4.3
[**2148-9-5**] 03:23PM HGB-8.6* calcHCT-26
[**2148-9-5**] 03:20PM GLUCOSE-142* UREA N-30* CREAT-1.1 SODIUM-141
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2148-9-5**] 03:20PM estGFR-Using this
[**2148-9-5**] 03:20PM WBC-7.7 RBC-2.71* HGB-8.3* HCT-26.0* MCV-96
MCH-30.7 MCHC-32.0 RDW-15.3
[**2148-9-5**] 03:20PM NEUTS-78.0* LYMPHS-14.9* MONOS-6.0 EOS-1.0
BASOS-0.2
[**2148-9-5**] 03:20PM PLT COUNT-264#
[**2148-9-5**] 03:20PM PT-12.7 PTT-27.5 INR(PT)-1.1
================================================
Studies:
.
# ECG Study Date of [**2148-9-5**] 4:13:16 PM
Sinus rhythm. Atrial ectopy. P-R interval 210 milliseconds which
is prolonged. Left axis deviation. Left ventricular hypertrophy.
Diffuse non-specific ST-T wave changes. Compared to the previous
tracing no significant change.
.
# UNILAT LOWER EXT VEINS RIGHT [**2148-9-7**] 12:09 PM
FINDINGS: Grayscale and color Doppler imaging of the right
common femoral, superficial femoral and popliteal veins are
performed. A venous catheter is identified within the right
common femoral vein and evaluation for compression of this vein
is limited. The superficial femoral and popliteal veins compress
normally. Venous flow and waveforms are normal and there is no
evidence of intraluminal thrombus. There are diffuse arterial
atherosclerotic calcifications.
.
IMPRESSION: No evidence of DVT
.
# CT HEAD W/O CONTRAST [**2148-9-7**] 11:44 AM
CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage or
shift of normally midline structures or evidence of acute major
vascular territorial infarct. There is ventricular and sulcal
prominence consistent with age- related atrophy. A 3mm low
density region above the body of the left lateral ventricle is
consistent with a chronic lacunar infarct. Atherosclerotic
calcification of the cavernous carotid and vertebral arteries
are noted bilaterally.
.
Osseous structures are unremarkable. A 1cm lucent region in the
left frontal bone at the vertex is likely a pacchionian
granulation. Fluid within sphenoid air cells is observed. The
imaged portions of the maxillary, frontal, ethmoid sinuses and
mastoid air cells are well aerated.
.
IMPRESSION: No intracranial hemorrhage or edema. Sphenoid sinus
fluid, possibly representing an acute inflammatory process.
.
# CT C-SPINE W/O CONTRAST [**2148-9-7**] 11:44 AM
ADDENDUM
On the most caudal axial scans, there appears to be few bubbles
of gas anterior to the right second rib. These findings could
represent a tiny amount of soft tissue emphysema, as opposed to
gas within a vein. Given that they are in the most caudal axial
sections, their full extent may not have been imaged.
.
This finding was discussed with Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 16011**], MICU
resident, this evening.
NON-CONTRAST CERVICAL SPINE: There is no fracture or evidence of
an acute alignment abnormality. The atlanto-occipital and
atlantoaxial articulations are maintained, aside from
approximately 1mm rightward shift of C1 relative to [**Name (NI) 12952**], likely
related to extensive degenerative changes of the left C1/2
articulation.
.
There is moderate- to- severe multilevel cervical spondylosis
with grade I anterolisthesis of C3 onto C4 likely related to
degenerative facet changes. Cervical spondylosis is most
prominent at C4/5 and C5/6 where there is moderate-to-severe
central spinal canal stenosis secondary to posterior osteophytes
and disc disease. Narrowing of the neural foramina at these
levels is most severe at C4/5 on the right.
.
There is diffuse atherosclerotic calcification of the carotid
systems bilaterally, with near midline position of an ectactic,
heavily calcified common carotid artery indenting the posterior
aspect of the supraglottic larynx.
.
A coarse round calcification is noted within the right lobe of
the thyroid-further evaluation with son[**Name (NI) 867**] is suggested. A
small amount of fluid thickening is noted within several
sphenoid air cells, which could represent an acute inflammatory
process.
IMPRESSION:
1. No fracture or acute alignment abnormality.
2. Moderate-to-severe cervical spondylosis as described with
grade I anterolisthesis of C3 onto C4.
.
NOTE AT ATTENDING REVIEW: There is a mixed gas/soft tissue
density region along the posterior wall of the supraglottic
space- it is unclear whether this finding is some sort of
retained secretions, or an actual mass. Correlation by direct
visualization by ENT would be helpful.
.
# CHEST (PORTABLE AP) [**2148-9-7**] 1:48 AM
FINDINGS:
There is no pneumothorax on the right. There is biapical pleural
thickening. The heart is enlarged. The patient is status post
median sternotomy with multiple clips in the mediastinum. Since
the prior study, there is some development of bibasilar
atelectasis. The upper lung zones are clear.
IMPRESSION:
1. No pneumothorax on the right in the area of line placement.
2. Cardiomegaly.
3. Bibasilar atelectasis, new since the prior study.
.
# CHEST (PORTABLE AP) [**2148-9-8**] 9:07 PM
No pneumothorax identified. There is a small amount of air seen
in the left side of the neck in the soft tissues. There is
biapical pleural thickening. There is diffuse underlying
interstitial lung disease. Mild bibasilar atelectasis. There is
cardiomegaly with calcification of the aortic arch.
IMPRESSION:
1. No pneumothorax.
2. Underlying interstitial lung disease. Mild bibasilar
atelectasis.
3. Cardiomegaly.
.
# ECG Study Date of [**2148-9-8**] 10:17:20 AM
Sinus rhythm. Frequent atrial and ventricular ectopy. A-V
conduction delay. Left axis deviation. Compared to the prior
tracing of [**2148-9-5**] no diagnostic interim change.
.
# MR CERVICAL SPINE W/O CONTRAST [**2148-9-11**] 4:44 PM
FINDINGS: Comparison is made to CT of the cervical spine from
[**2148-9-7**].
.
The visualized brainstem and cervical cord and the upper
thoracic cord are normal in signal intensity and caliber.
.
There is bone marrow edema of the left lateral mass of C1 as
well as the left side of the body and posterior elements of C2.
These findings likely represent bone marrow edema related to
degenerative change.
.
At C2/3, there is a small central and right central disc
protrusion which are not contacting the ventral cord and not
causing canal or foraminal stenoses.
.
At C3/4, there is mild anterior spondylolisthesis of C3 on C4 as
well as a moderate-sized central disc protrusion which is
contacting the ventral cord. There is mild right foraminal
stenosis.
.
At C4/5, there is severe loss in disc space height with a mild
disc osteophyte complex which is contacting the ventral cord.
There is also thickening of the ligamentum flavum posteriorly,
the combination of which is causing mild canal stenosis. There
appears to be moderate bilateral foraminal stenoses.
.
At C5/6, there is severe loss of disc space height as well as
mild disc osteophyte complex which is contacting the ventral
cord. There are degenerative changes of the ligamentum flavum
posteriorly and the combination of these findings is causing
moderate canal stenosis.
.
At C6/7, there is a mild disc osteophyte complex which is not
contacting the ventral cord. There is mild bilateral foraminal
stenoses.
.
No paraspinal soft tissue abnormalities are seen. Partially
imaged is what appears to be bursal fluid in the subacromial
region of the right shoulder.
.
There is also mucosal thickening/air fluid level within the
sphenoid sinus.
.
IMPRESSION: Degenerative changes of the cervical spine causing
mild canal stenosis at C4/5 and moderate canal stenosis at C5/6.
Multilevel foraminal stenoses as described above. Partially
imaged is bursal fluid of the right subacromial region.
.
# CTA CHEST, ABD, PELVIS W&W/O C&RECONS, NON-CORONARY [**2148-9-12**]:
Per radiologist wet read, significant atherosclerosis found. No
abdominal or thoracic aneurysm, and no coarctation found.
Brief Hospital Course:
85F recent [**Doctor First Name **]-[**Doctor Last Name **] tear and grade I esophagitis, admitted
with hematemesis and found to have clotted blood in stomach.
.
# GIB: Pt reported hematemesis at NH about which she did not
notify staff, and which was likely [**2-9**] previous [**Doctor First Name **]-[**Doctor Last Name **]
tear. [**9-6**] EGD demonstrated old blood in stomach but no active
bleeding or ulcer. In MICU, pt received 4 units PRBC, with
stable Hct since [**2148-9-7**]. Pt also had one guaiac-positive BM on
[**2148-9-8**] but Hct remained stable. Pt received pantoprazole drip
in ED but was changed to pantoprazole 40mg PO BID, with diet
advanced to regular as tolerated. Because of concern for
incompletely healed esophageal mucosa, and potential for
rebleeding, two medications were held on this admission:
prednisone (which pt had been taking for rheumatoid arthritis),
and warfarin (which pt had been taking for anticoagulation given
atrial fibrillation and history of TIA).
.
# Cervical spondylosis: Pt reported acute worsening of chronic
neck pain, and CT scan demonstrated cervical spondylosis without
evidence of acute bony changes. Pt was started on lidocaine
patch 5% and acetaminophen 625mg every six hours PRN for pain.
Pt was also given a soft cervical collar to use up to 8 hours
daily during waking hours as needed for pain control. Pt did
not require morphine IV PRN for breakthrough, and this regimen
was considered adequate pain control for her neck.
.
# HTN: Pt continued on home regimen of metoprolol 12.5mg [**Hospital1 **].
Furosemide was originally held to avoid further aggravating
intravascular depletion in the setting of GIB, but was restarted
on discharge. As it was restarted on the day of discharge, [**Hospital **]
nursing home was instructed via discharge planning paperwork to
monitor closely for hypotension and dehydration.
.
# Uncomplicated UTI: UCx demonstrated E.coli sensitive to
ceftriaxone IV; pt completed a six-day course of ceftriaxone IV.
.
# Paroxysmal AFib: Pt's original regimen of digoxin was
initially held to avoid masking a tachycardic response to
anemia, but before discharge, was restarted at her home dose of
digoxin 0.125mg daily. Pt was monitored on telemetry throughout
this admission, with no events noted.
.
# COPD: Pt reported an extensive tobacco history, and had been
on 2L home O2 until several months ago. Pt was therefore
continued on albuterol inhaler PRN.
.
# CAD: Pt's home regimen of ASA was initially held given GIB,
but was restarted at ASA-EC 325mg daily for antiplatelet
effects, in the setting of her history of paroxysmal atrial
fibrillation and TIA.
.
# Hypercholesterolemia: Pt continued on simvastatin 40mg daily.
.
# Rheumatoid arthritis: Pt was continued on hydroxychloroquine
200mg [**Hospital1 **] and sulfasalazine 500mg daily; prednisone 10mg daily,
however, was held given concern over the possibility of impaired
healing of the site of her recent GIB.
.
# DM2: Pt continued on home regimen of glargine 6 units and RISS
after MICU transfer.
.
# Full code
** A pulmonary nodule was noted on CT chest and 6 month follow
is recommended. Defer to PCP for arranging this.
** Also a area of soft tissue density seen in the supra glottic
space (incidentally seen on CT C spine - read below). A direct
ENT evaluation is recommended. Deferred to PCP.
Medications on Admission:
Albuterol IH Q6H
Metoprolol 12.5mg [**Hospital1 **]
Simvastatin 40mg daily
Vitamin D3 800mg daily
Hydroxychloroquine 200mg [**Hospital1 **]
Sulfasalazine 500mg [**Hospital1 **]
Glargine 6 units QHS + RISS
CaCarbonate 1000mg TID
Furosemide 20mg daily
Digoxin 0.125mg daily
Pantoprazole 40mg [**Hospital1 **]
Nystatin cream [**Hospital1 **]
Oxazepam 10mg QHS PRN
Lidocaine patch
Acetaminophen 650 q6h PRN
.
Medications being held in setting of GIB:
Prednisone 10mg daily
ASA 325mg daily
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Adhesive Patch, Medicated(s)
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO Q 8H (Every 8 Hours).
6. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to areas of groin and underneath breasts
for tinea (fungal infection of skin).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day): Apply to areas of groin and underneath breasts
for tinea (fungal infection of skin).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for Pain.
15. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
Disp:*180 units* Refills:*2*
18. Humalog insulin sliding scale
# 51-150 mg/dL: Breakfast 0 unit(s), lunch 0 unit(s), dinner 0
unit(s), bedtime 0 unit(s)
# 151-200 mg/dL: Breakfast 2 unit(s), lunch 2 unit(s), dinner 2
unit(s), bedtime 2 unit(s)
# 201-250 mg/dL: Breakfast 4 unit(s), lunch 4 unit(s), dinner 4
unit(s), bedtime 4 unit(s)
# 251-300 mg/dL: Breakfast 6 unit(s), lunch 6 unit(s), dinner 6
unit(s), bedtime 6 unit(s)
# 301-350 mg/dL: Breakfast 8 unit(s), lunch 8 unit(s), dinner 8
unit(s), bedtime 8 unit(s)
# 351-400 mg/dL: Breakfast 10 unit(s), lunch 10 unit(s), dinner
10 unit(s), bedtime 10 unit(s)
# >400 mg/dL: Notify MD
19. Soft cervical collar
Wear up to 8 hours daily during waking hours as needed for neck
pain.
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
# Acute blood loss anemia from upper gastrointestinal bleeding
# Cervical spondylosis
# Peripheral vascular disease
# Hypotension - resolved
# Pulmonary nodule
Secondary diagnosis
# Coronary artery disease
# Hypertension
# Paroxysmal atrial fibrillation
# Hyperlipidemia
# Rheumatoid arthritis
# COPD
# Diabetes mellitus type 2
# GERD
# Tinea corporis
# Paraesophageal hernia s/p [**5-/2147**] repair
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because you vomited blood and your level of
red blood cells decreased. We gave you red blood cells and
looked at your esophagus and stomach again. We found that you
had blood in your stomach but you were not actively bleeding.
.
We also discovered that your measured blood pressures are
significantly different between your right and left arms. We
therefore looked at the large vessels in your torso to evaluate
why your measured blood pressures would be so different. We
found that you have significant atherosclerosis in the vessels
in your arms.
.
Finally, we examined your neck and found that you have cervical
spondylosis. This means that the bones in your upper neck are
pressing on your nerves and causing pain. We gave you a soft
neck brace that you can wear for up to 8 hours daily.
.
We **CHANGED** some medications:
.
# Warfarin: We STOPPED this medication because of your GI
bleeding, as warfarin can lead to bleeding (you were taking this
medication to thin your blood because you have a history of
irregular heart beat as well as mini-stroke). You will need to
talk to your cardiologist, Dr. [**Last Name (STitle) **], to see what to do
about thinning your blood because you have atrial fibrillation
(irregular heart beat) as well as a history of mini-stroke.
.
# Aspirin EC 325mg daily: We STARTED this medication to help
your blood not to clot. Please take this daily. It is coated
so that it does not irritate your stomach lining.
.
# Prednisone: We STOPPED this medication which you had been
taking for your rheumatoid arthritis, because this medication
could impair healing of your esophagus which had been bleeding.
.
# Lidocaine patch: We STARTED this medication to control your
neck pain which is caused by your cervical spondylosis.
.
# Acetaminophen: We STARTED this medication to control your neck
pain which is caused by your cervical spondylosis.
.
Otherwise, you should continue taking your medications as usual.
.
If you vomit blood, have blood in your stools, have black or
tarry stools, fevers, chills, severe nausea and vomiting, or any
other symptom you are concerned about, call your primary care
doctor immediately and go to the nearest emergency room.
Followup Instructions:
We attempted to reach your cardiologist, Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **],
tel. ([**Telephone/Fax (1) 16005**], but were unsuccessful. Please make an
appointment with your cardiologist AS SOON AS POSSIBLE,
preferably within a few days of leaving the hospital.
.
Also, please make sure to see your primary care physician [**Last Name (NamePattern4) **].
[**First Name (STitle) 5192**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5193**] as soon as possible.
Completed by:[**2148-9-12**]
|
[
"272.4",
"530.10",
"530.7",
"443.9",
"041.4",
"714.0",
"250.00",
"V45.81",
"401.9",
"599.0",
"496",
"428.0",
"V58.61",
"427.31",
"530.81",
"738.4",
"414.01",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
17202, 17267
|
10856, 14214
|
243, 272
|
17713, 17722
|
2521, 2521
|
19986, 20530
|
2093, 2167
|
14749, 17179
|
17288, 17692
|
14240, 14726
|
17746, 19963
|
2182, 2502
|
190, 205
|
300, 1461
|
2537, 10833
|
1483, 1875
|
1891, 2077
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,001
| 102,058
|
14300+14301
|
Discharge summary
|
report+report
|
Admission Date: [**2133-1-5**] Discharge Date: [**2133-1-7**]
Date of Birth: [**2062-5-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Biaxin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Increased ventricular size
Major Surgical or Invasive Procedure:
Removal of VP shunt
Placement of VP shunt
History of Present Illness:
70 y/o former physician at [**Name9 (PRE) 756**] presents to ED after being
found walking outside without a shirt, he was thought to be
dehydrated after being left alone over the weekend. No food was
noted to be eaten in his home, his wife was in [**Name (NI) **]. He has
short term memory loss after a right frontal AVM hemorrhage and
had shunt placed. It is a programmable shunt from [**Hospital1 **], last adjusted to 120 in [**2131-9-13**]. Per patients son and
daughter he is high functioning but has short term memory loss.
He can be trusted to live alone. He has week neurocognitive
training.
Past Medical History:
Right frontal AVM hemorrhage in [**2126**] requiring VP shunt
(programmable from [**Hospital6 **]), cavernous angiomas
Social History:
Retired physician, [**Name10 (NameIs) **] with wife, know short term memory loss
gets continuous cognitive therapy
Family History:
Congential AVMs
Physical Exam:
O: T:97 BP:160/96 HR:96 R 11 O2Sats 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:4.5 bil min reactive EOMs no bilateral upward
gaze; Shunt in place unable to feel reservoir
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person only
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4.5 min reactive
. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements restricted in upgaze (not new
according to family)
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-16**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Upon discharge:
a and o x 3, cn 2-12 intact, incision cdi, motor full,
ambulating independently
Pertinent Results:
[**2133-1-6**] 01:00AM BLOOD WBC-8.3 RBC-4.98 Hgb-15.2 Hct-45.0 MCV-90
MCH-30.5 MCHC-33.8 RDW-13.4 Plt Ct-179
[**2133-1-5**] 03:25PM BLOOD Neuts-73.1* Lymphs-20.2 Monos-4.6 Eos-1.5
Baso-0.6
[**2133-1-6**] 01:00AM BLOOD Plt Ct-179
[**2133-1-6**] 01:00AM BLOOD Glucose-114* UreaN-20 Creat-1.1 Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
[**2133-1-5**] 03:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Mr [**Known lastname 1940**] was assessed in the ED, his programmable shunt was
felt not to be working. A CT of his abdomen was completed it did
not show any psuedocyst. He was brought to the OR and his shunt
pressure measured 180 as compared to his previous setting which
should have been 120. His shunt was removed and replaced with a
[**Company 1543**] shunt. Post operatively he recovered in the SICU and
was found to be orientated X3 within 24 hours of his surgery.
His CT showed decrease ventricular site. He transferred to the
floor. Diet and activity were advanced. he was much brighter
on exam and with functioning. He was seen by PT and cleared for
discharge to home. He will return for suture removal.
Medications on Admission:
Wellbutrin, Lexapro and Simivastatin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on narcotic.
Disp:*60 Capsule(s)* Refills:*0*
2. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
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.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-21**] days(from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast
* Please follow up with your urologist for urination issues.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2133-1-7**] Admission Date: [**2133-1-13**] Discharge Date: [**2133-1-15**]
Date of Birth: [**2062-5-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Biaxin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Distal revision of VP shunt
History of Present Illness:
This is a 70 year old man with a history of hemorrhage from a
AVM and sussequent necessity of a VP shunt. This was revised
proximally in [**Month (only) 404**] and replaced with a programmable [**Company 1543**]
valve at 1.0. He was discharged to home at his normal cognitive
level. He returned to the ED on [**1-12**] with increasing confusion
and a CT with increased ventricular size.
Past Medical History:
Right frontal AVM hemorrhage in [**2126**] requiring VP shunt
cavernous angiomas
Social History:
Retired physician, [**Name10 (NameIs) **] with wife, know short term memory loss
gets continuous cognitive therapy
Family History:
Congential AVMs
Physical Exam:
On admission:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements limited - no bilateral upward
gaze (not new).
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-16**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
At discharge: He was oriented x 3. He had no motor or sensory
deficit. His upgaze palsy persisted. His wound was clean and dry
with sutures in place.
Pertinent Results:
CT head [**1-12**]:
Interval enlargement of ventricular size consistent with mild
hydrocephalus, concerning for shunt malfunction.
shunt series [**1-12**]:
Very distal aspect of the VP shunt is not included on the
images, the shunt tubing courses beyond the inferior most aspect
of the abdominal radiograph, out of the field of view. Consider
imaging the more inferior pelvis if clinically warranted, to see
full extent of the catheter. No radiographic evidence of
disruption/fracture along the visualized portions of the
ventriculostomy catheter.
CT head [**1-13**]:
Increasing hydrocephalus when compared to the most recent study,
performed some seven hours prior.
Findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 9:50 p.m. on
[**2133-1-13**].
NOTE ADDED IN ATTENDING REVIEW: Again demonstrated is the
somewhat ill-defined hyperattenuating focus in the midline
tectum of the midbrain, measuring at least 8.5 mm (TRV) (2:13).
This corresponds to the known cavernous angioma at this site, in
this patient with known multiple cavernomas (as demonstrated on
the MR), with likely compression of the aqueduct.
CT head [**1-14**]:
Mild improvement in the degree of hydrocephalus compared to
study obtained roughly 13 hours earlier.
CT head [**1-15**]:
Significant improvement of hydrocephalus comparison to the study
obtained the day prior.
CXR [**1-15**]:
Right middle lobe atelectasis, no convincing evidence of
pneumonia.
Brief Hospital Course:
Dr. [**Known lastname 1940**] was admitted to [**Hospital1 18**] on [**1-12**]. A CT showed increase
and ventricular size. His shunt was programmed from 1.0 to 0.5.
A butterfly needle was inserted and connected to a bag drainage
at 20cc/hr. He was taken to the OR on [**1-13**] for a distal VP shunt
revision. He was transferred to the TSICU postoperatively. A CT
head showed some decrease in ventricular size. The night of [**1-13**],
he had increasing agitation. A CT head showed increase in
ventricular size. The shunt was tapped with a pressure of 9. CSF
was sent for culture. His home medications, Lexapro and
Wellbutrin, were restarted. His neurologic exam returned to
baseline. CT head on [**1-14**] showed a decrease in ventricular size.
A CT on [**1-15**] demonstrated continued improvement. He neurologic
status returned to baseline and he was discharged to home on
[**2133-1-15**].
Medications on Admission:
escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
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. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no BM 24hrs: OTC. ML(s)
3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no
BM 24hrs.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Shunt Malfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? 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
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with
Dr.[**Last Name (STitle) 739**] to be seen in 1 week.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2133-1-15**]
|
[
"331.4",
"272.4",
"V12.51",
"996.2",
"780.93",
"228.02",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.42",
"54.95"
] |
icd9pcs
|
[
[
[]
]
] |
11591, 11597
|
9656, 10551
|
6522, 6552
|
11659, 11659
|
8151, 9633
|
13264, 13619
|
7222, 7240
|
10787, 11568
|
11618, 11638
|
10577, 10764
|
11810, 13241
|
7255, 7255
|
7994, 8132
|
6473, 6484
|
2558, 2642
|
6580, 6968
|
1785, 2542
|
7269, 7980
|
11674, 11786
|
6990, 7073
|
7089, 7206
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,443
| 144,663
|
792
|
Discharge summary
|
report
|
Admission Date: [**2149-10-15**] Discharge Date: [**2149-10-20**]
Date of Birth: [**2083-9-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niaspan Extended-Release
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Exertional chest heaviness
Major Surgical or Invasive Procedure:
[**2149-10-15**] Coronary artery bypass grafting x4 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein grafts to the distal right coronary
artery, first and second obtuse marginal arteries.
History of Present Illness:
66 year old male with a 2 week history of chest burning which
occurs about 10-15 minutes into his daily 1 mile walk. It lasts
for 20-30 seconds and then resolves and he is able to finish
walking his mile. He notes that he does not get the symptoms
everytime he walks. He denies any symptoms at rest. He does note
waking up with bilateral ankle/feet pain/throbbing at night. He
was referred for a cardiac catheterization and was found to have
coronary artery disease. He is now being referred to cardiac
surgery for revascularization.
Past Medical History:
Diabetes Type II
Hypertension
Hyperlipidemia
Osteoarthritis
Lumbar disc disease
Proteinuria
Polyps on colonoscopy
s/p left knee scope x 4
Social History:
Race:Caucasian
Last Dental Exam: 10 years ago
Lives with:Wife
Contact:[**Name (NI) 4457**] (wife) Phone #[**Telephone/Fax (1) 5671**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: denies
Illicit drug use:denies
Family History:
Premature coronary artery disease - uncle had a
heart transplant in his early 50's. Father had 3 MI's, first in
his 40's. Brother had CABG at age 59.
Physical Exam:
Pulse:60 Resp:16 O2 sat:100/RA
B/P Right:168/87 Left:179/80
Height:5'8" Weight:175 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]diminished (R)base
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none, pulses Right: 2+ Left:2+
Pertinent Results:
[**2149-10-15**] Echo: PRE-BYPASS: The left atrium is elongated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No spontaneous echo
contrast or thrombus is seen in the body of the right atrium or
the right atrial appendage. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricle
displays normal free wall contractility. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Very trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
POST- BYPASS: There is normal biventricular systolic function.
The thoracic aorta is intact after decannulation. No other
significant changes from the pre-bypass examination.
Admission labs:
[**2149-10-15**] 09:27AM HGB-14.1 calcHCT-42
[**2149-10-15**] 09:27AM GLUCOSE-231* LACTATE-2.2* NA+-136 K+-4.4
CL--102
[**2149-10-15**] 02:12PM PT-13.8* PTT-34.1 INR(PT)-1.2*
[**2149-10-15**] 02:12PM WBC-9.6# RBC-3.62* HGB-11.6*# HCT-29.8*
MCV-82 MCH-32.0 MCHC-39.0* RDW-14.3
[**2149-10-15**] 02:12PM UREA N-19 CREAT-0.7 SODIUM-140 POTASSIUM-3.6
CHLORIDE-111* TOTAL CO2-25 ANION GAP-8
[**2149-10-15**] 02:31PM GLUCOSE-143* NA+-137 K+-3.6
Discharge labs:
[**2149-10-20**] 06:30AM BLOOD WBC-6.7 RBC-3.33* Hgb-10.4* Hct-28.1*
MCV-84 MCH-31.2 MCHC-37.1* RDW-13.6 Plt Ct-276
[**2149-10-20**] 06:30AM BLOOD Plt Ct-276
[**2149-10-20**] 06:30AM BLOOD UreaN-24* Creat-1.1 Na-133 K-5.2* Cl-97
[**2149-10-19**] 06:50AM BLOOD Glucose-164* UreaN-28* Creat-1.0 Na-133
K-4.7 Cl-95* HCO3-28 AnGap-15
[**2149-10-20**] 06:30AM BLOOD Mg-2.0
Radiology Report CHEST (PA & LAT) Study Date of [**2149-10-20**] 10:23
AM
Final Report : In comparison to the prior examination, there is
little interval change. The left apical pneumothorax is
unchanged in size. Bibasilar atelectasis remains as well as
small pleural effusions remain. There is a left upper lobe
opacity that likely represents pleural effusion within an
adhesion. Sternal wires are intact.
Brief Hospital Course:
Mr [**Known lastname 5672**] was a same day admission for coronary bypass grafting
on [**2149-10-15**]. Please see operative report for details, in
summary he had: Coronary artery bypass grafting x4 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein grafts to the distal right coronary
artery, first and second obtuse marginal arteries. His bypass
time was 98 minutes, with a crossclamp time of 85 minutes. He
tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
Once in the ICU he remained hemodynamically stable, anesthesia
was reversed, he woke neurologically intact and was extubated.
On POD1 the patient remained hemodynamically stable and was
transferred from the ICU to the stepdown floor. His chest tubes
remained to suction as he was noted to have na airleak.
Otherwise he was begun on Bblockers and diuretics and his
activity was advanced. On POD2 the chest tubes were put to water
seal, a follow up chest XRay revealed a pneumothorax and the
chest tubes were put back to suction. The chest tubes were
finally removed on POD4 All other tubes lines and drains were
removed per cardiac surgery protocols.
The remainder of his hospital course was uneventful, he worked
with nursing and physical therapy to increase his activity and
endurance. He was discharged home on POD5. He is to followup
w/Dr [**Last Name (STitle) **] in 1 month.
Medications on Admission:
GLYBURIDE 5 mg Tablet - 2 Tablet(s) by mouth twice a day
LISINOPRIL 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day
METFORMIN 1,000 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day
METOPROLOL TARTRATE 25 mg Tablet - 1 Tablet(s) by mouth daily
PIOGLITAZONE [ACTOS] 30 mg Tablet - 1 Tablet(s) by mouth daily
ROSUVASTATIN [CRESTOR] 10 mg Tablet - 1 Tablet(s) by mouth daily
ASPIRIN 81 mg Tablet 1 Tablet(s) by mouth daily
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 BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
13. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
15. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 4
Past medical history:
Diabetes Type II
Hypertension
Hyperlipidemia
Osteoarthritis
Lumbar disc disease
Proteinuria
Polyps on colonoscopy
s/p left knee scope x 4
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2149-11-20**] at 1PM [**Telephone/Fax (1) 170**] in the [**Hospital **]
medical office building [**Hospital Unit Name **]
[**2149-10-28**] chest xray in the clinical center [**Hospital Ward Name **] [**Location (un) 470**]
radiology at 9:45am then proceed to Wound check on [**10-28**] at
10:30AM [**Telephone/Fax (1) 170**] in the [**Hospital **] medical office building [**Hospital Unit Name **] -
Please call your cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] and make an
appointment to be seen in the next 2 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:[**2149-10-21**]
|
[
"715.90",
"401.9",
"414.01",
"512.1",
"E878.2",
"250.00",
"V17.3",
"V12.72",
"272.4",
"722.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8416, 8474
|
4890, 6353
|
320, 560
|
8738, 8964
|
2410, 3607
|
9887, 10730
|
1565, 1716
|
6830, 8393
|
8495, 8556
|
6379, 6807
|
8988, 9864
|
4089, 4867
|
1731, 2391
|
254, 282
|
588, 1123
|
3623, 4073
|
8578, 8717
|
1300, 1549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,370
| 101,266
|
343
|
Discharge summary
|
report
|
Admission Date: [**2125-2-1**] Discharge Date: [**2125-2-19**]
Service: MEDICINE
Allergies:
Ultram
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Hematuria, cough, abdominal pain
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
85 F h/o stage 0 CLL, not requring tx previously, presents to ED
for persistent cough/abdominal pain, and hematuria.
.
Pt notes about 2 months of increasing fatigue, nightsweats,
decreased appetite, and increasing left side abdominal pain
(intermittent, no relation to food, BM, sharp, no diarrhea,
constipation, melena). She was seen by PCP [**2125-1-9**], felt to have
viral URI, symptoms persisted, and seen again [**2125-1-23**] with
persistent cough (intermittently productive, yellow-white),
single episode of hematuria (clear red, not clot), and LLQ
abdominal pain, treated with azithromycin, and abdominal US
obtained which revealed new splenomegaly with new 1.5-cm
echogenic area.
On [**1-31**], pt noted recurrent episode of "strong blood in urine."
Describes clear red +clots, +feeling incomplete voiding, no
suprapubic pain, no CVA tenderness. Also notes transient R LE
shooting pain last night which has resolved.
Pt presented to the ED with VS: 98.1 79 113/69 16 100%RA. In the
ED, CXR with LUL collapse, CT ABD/PELVIS with multiple new
metastasis, and new mass in bladder. Also RLL PE. UA +hematuria,
+ UTI. pt given levo, flagyl, morphine 2mg x3 for pain. BP then
noted to drop to 70/37, pt received total 2L IVF, although
timing unclear, with BP improved to 102/55s (?dehyration vs
sepsis vs morphine). No central line placed. CT head obtained in
anticipation of possible anticoagulation.
Past Medical History:
- CLL - referred to heme/onc (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]), for anemia,
leukocytosis, found on [**2123-6-3**] flow cytometry confirmed B-cell
chronic lymphocytic leukemia, stage 0, asymptomatic (no LAD,
thrombocytopenia, splenomegaly), so no plan for treatment as of
[**10-12**].
- htn
- asthma
- hyperlipidemia
- OA - left hip, knee, previously on vioxx.
- tah/bso [**1-6**] fibroids.
- glucose intolerance (not on meds, a1c 6.1->5.5)
- glaucoma
- cancer screening: colonoscopy on [**2123-5-26**] showed 2 adenomatous
polyps, one in the transverse colon and the other in the
descending colon. Annual mammographies have been negative.
Social History:
- deniess tobacco, denies alcohol, IVDU.
- she lives with her husband. They have 2 children, 1 son and 1
daughter, in their 50s and 60s, respectively.
- Worked as a pharmacist in [**Location (un) 3155**], [**Location (un) 3156**]. She was 80 miles from
the Chernobyl accident in [**2102**], leaving on the 3rd day of the
radiation exposure, although she's not certain if she was in
fact exposed to radiation. 3 months later, she returned to her
residence. Some of her co-workers had thyroid concerns after the
Chernobyl accident. She moved to the U.S. in [**2108**].
Family History:
No family history of hematologic or oncologic dyscrasias. Both
parents died of strokes. A sister, her only sibling, had
"pancreatic" obstruction, not cancer related, and died at age
64. The patient's daughter had breast cancer at age
54.
Physical Exam:
VS: 97.3 97 116/56 26 96%2L
GEN: NAD
HEENT: PERRLA, sclera anicteric, OP clear, MMM, no carotid
bruits. 8-10 cm JVD. left cervical 1cm LN, right axillary 1-2cm
LN against chest wall.
CV: regular, nl s1, s2, no r/g. 3/6 SEM.
PULM: decreased BS L base, otherwise good air movement through.
ABD: soft, NT, + BS, +splenomegaly, ~5inches from CV angle.
EXT: warm, 2+ dp/radial pulses BL. trace B LE edema.
NEURO: alert & oriented x 3, CN II-XII grossly intact.
Pertinent Results:
SPECIMEN SUBMITTED: urine for immunophenotyping
Procedure date Tissue received Report Date Diagnosed
by
[**2125-2-9**] [**2125-2-9**] [**2125-2-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/cma??????
Previous biopsies: [**Numeric Identifier 3158**] CYTOSPIN
[**Numeric Identifier 3159**] Cell blocks from catheterized urine; three cell
blocks
[**-6/3303**] CATARACT RT. EYE.
[**-5/2577**] Peripheral blood for immunophenotyping.
(and more)
DIAGNOSIS
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens: 3, 5, 10, 19, 20, 23, 38, 45.
RESULTS:
Three-color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. Lymphocytes comprise <1% of total
analyzed events.
B-cells are scant in number precluding evaluation of clonality.
Approximately 77% of total analyzed events show dim CD45 and
high side scatter, representing neutrophils.
INTERPRETATION
Non-diagnostic study. Clonality could not be assessed in this
case due to insufficient numbers of B-cells. Cell marker
analysis was attempted, but was non-diagnostic in this case due
to insufficient numbers of cells. If clinically indicated, we
recommend a repeat specimen (fresh) be submitted directly to the
flow cytometry laboratory.
AP AND LATERAL CHEST [**2125-2-8**]:
COMPARISON: [**2125-2-5**].
INDICATION: Metastatic cancer.
Bilateral small to moderate pleural effusions are present, with
slight improvement on the left. Cardiomediastinal contours are
unchanged. Bibasilar areas of atelectasis adjacent to the
effusions are also without change.
IMPRESSION: Bilateral small to moderate pleural effusions with
slight improvement on the left.
Cytology Report URINE/INSTRUMENTATION Procedure Date of
[**2125-2-7**]
REPORT APPROVED DATE: [**2125-2-12**]
SPECIMEN RECEIVED: [**2125-2-8**] 08-[**Numeric Identifier 3160**] URINE/INSTRUMENTATION
SPECIMEN DESCRIPTION: Received 60 ml brown fluid
Prepared 1 ThinPrep slide. Catheter urine.
CLINICAL DATA: Bladder tumor and CLL.
PREVIOUS BIOPSIES:
[**2125-2-5**] 08-[**Numeric Identifier 3161**] URINE/INSTRUMENTATION
[**2125-2-5**] 08-[**Numeric Identifier 3162**] URINE/VOIDED
[**2125-2-5**] 08-[**Numeric Identifier 3163**] URINE/VOIDED
[**2125-2-2**] 08-[**Numeric Identifier 3164**] URINE/INSTRUMENTATION
[**2125-2-2**] 08-[**Numeric Identifier 3165**] URINE/INSTRUMENTATION
[**2117-10-1**] 00-[**Numeric Identifier 3166**] PAP
[**2115-4-16**] 98-[**Numeric Identifier 3167**] PAP
96-[**Numeric Identifier 3168**] PAP
93-[**Numeric Identifier 3169**] URINE
93-[**Numeric Identifier 3170**] URINE
93-[**Numeric Identifier 3171**] URINE
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DIAGNOSIS: Urine:
ATYPICAL.
Atypical but very degenerated urothelial cells, cannot
exclude urothelial dysplasia/neoplasia.
A few squamous cells, histiocytes, scattered lymphocytes,
and many red blood cells.
Urine cytology:
DIAGNOSIS:
A. Cell block, "[**2125-2-2**]":
Blood and rare atypical but markedly degenerated urothelial
cells and a few lymphoid cells, see note.
B. Cell block, "[**2125-2-3**]":
Blood and rare atypical but markedly degenerated urothelial
cells and a few possible lymphoid cells, see note.
C. Cell block, "[**2125-2-4**]":
Insufficient material for diagnosis.
Portable AP chest dated [**2125-2-5**] is compared to the chest CT from
[**2125-2-2**] and chest radiograph of [**2125-2-1**]. Patient respiratory
motion degrades the image. The heart is normal in size; however,
there is marked opacification of the left heart border and
retrocardiac region which may represent
atelectasis/consolidation and pleural effusion. The right lung
is grossly clear, but there is probably a small right pleural
effusion. There is no pneumothorax.
IMPRESSION:
1. Patient respiratory motion degrades the quality of the image.
2. Left lower lobe opacification likely represents
atelectasis/consolidation plus effusion.
Cytology Report URINE/VOIDED Procedure Date of [**2125-2-3**]
REPORT APPROVED DATE: [**2125-2-8**]
SPECIMEN RECEIVED: [**2125-2-5**] 08-[**Numeric Identifier 3162**] URINE/VOIDED
SPECIMEN DESCRIPTION: Received 200 ml. brown fluid.
Prepared one ThinPrep slide.
6 specimens collected on [**2125-2-3**].
CLINICAL DATA: 85 year old female with known CLL and new
large bladder mass with peritoneal mets,
diff between CLL and TCC.
PREVIOUS BIOPSIES:
[**2125-2-5**] 08-[**Numeric Identifier 3163**] URINE/VOIDED
[**2125-2-2**] 08-[**Numeric Identifier 3164**] URINE/INSTRUMENTATION
[**2125-2-2**] 08-[**Numeric Identifier 3165**] URINE/INSTRUMENTATION
[**2117-10-1**] 00-[**Numeric Identifier 3166**] PAP
[**2115-4-16**] 98-[**Numeric Identifier 3167**] PAP
96-[**Numeric Identifier 3168**] PAP
93-[**Numeric Identifier 3169**] URINE
93-[**Numeric Identifier 3170**] URINE
93-[**Numeric Identifier 3171**] URINE
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3172**]
DIAGNOSIS: SUSPICIOUS.
Atypical but markedly degenerated urothelial cells and
scattered atypical lymphoid cells present.
Squamous cells, anucleate squames, red blood cells,
crystals.
ECHO: Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular systolic function
is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. The gradient increased
with the Valsalva manuever. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Hyperdynamic left ventricular function with mild
left ventricular outflow tract obstruction. No significant
valvular disease.
NONCONTRAST CT, (has had recent dye load), please evaluate l
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with CLL admitted with multiple abdominal
mets, and LLL obstruction [**1-6**] hilar LAD on CT abdomen.
REASON FOR THIS EXAMINATION:
NONCONTRAST CT, (has had recent dye load), please evaluate
lymphadenopathy, LLL collapse, infiltrate.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: 85-year-old woman with chronic lymphocytic
leukemia, admitted with abdominal metastases and left lower lobe
obstruction secondary to hilar lymphadenopathy on the abdomen
CT.
Question lymphadenopathy, left lower lobe collapse and
infiltrate.
At the request of the referring physician, [**Name10 (NameIs) 3173**] contrast
was not administered because of a recent dye load.
COMPARISONS: Limited comparison to a recent CT of the abdomen
from [**2125-2-1**] which depicted the lung bases.
TECHNIQUE: Axial CT images of the chest were obtained without
[**Year (4 digits) 3173**] contrast, and coronal and limited sagittal
reformatted images, including the spine, were also performed.
CT OF THE CHEST WITHOUT IV CONTRAST: The patient was
inadvertently imaged during submaximal inspiration/partial
expiration; there is apparently slightly greater than 50%
narrowing of the anteroposterior dimension of the mid trachea,
an appearance suggestive of tracheomalacia.
A coarse calcification is noted the right lobe of the thyroid.
There are calcifications along the right, the left anterior
descending, and the left circumflex coronary arteries. The
pulmonary arteries cannot be assessed for filling defects. There
is only trace pericardial fluid but a small-to- moderate left-
sided pleural effusion of low density is somewhat larger.
Although the left anteromedial basal segment appears spared, all
other portions of the left lower lobe are collapsed, likely due
to post-obstructive atelectasis. The overall degree of
atelectasis has progressed since the prior day.
A large subcarinal mass of 51 x 26 mm in axial dimensions
(2a:27) is now fully visualized, although not as well depicted
without [**Year (4 digits) 3173**] contrast. It can be seen to extend to the
carina and also abuts the posteromedial aspects of each mainstem
bronchus. A large mass along the right infrahilar region and
adjacent portion of the lower left mediastinum measures 61 x 37
mm (2c:74), but was better depicted with contrast. The mass
likely obstructs one or more descending basal segmental airways,
but its precise origin is not fully clear.
There are multiple enlarged mediastinal lymph nodes. The largest
is a paraaortic node measuring 12 mm in shortest axis dimension.
There is marked lymphadenopathy in the left axilla. The largest
node (2A:97) measures 30 x 23 mm in axial dimensions. There are
also several slightly prominent right hilar lymph nodes, but
these are not over 8 mm in diameter.
A small right-sided pleural effusion with associated atelectasis
appears unchanged. Two calcified granulomas are noted in the
right lung.
Limited views of the upper abdomen again depict multiple masses,
marked lymphadenopathy, a right adrenal mass, and marked
splenomegaly. There are also gallstones and a new small amount
of ascites. This appearance was better depicted on the prior CT
of the abdomen.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Subcarinal nodal mass.
2. Mass in the left infrahilar region with post- obstructive
atelectasis, which has progressed to near left lower lobe
collapse.
3. Marked left axillary lymphadenopathy, amenable to biopsy.
4. Somewhat larger bilateral pleural effusions.
5. Collapsibility of the trachea suggesting tracheomalacia.
6. Coronary artery calcifications.
7. Multiple abnormal masses in the upper abdomen, better
depicted on the recent abdominal CT. The only new finding is
trace ascites.
8. Known pulmonary embolism not visualized given the lack of
contrast administration. The extent of pulmonary emboli,
accordingly, cannot be assessed.
CT PELVIS W/CONTRAST [**2125-2-1**] 4:14 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval for diverticulitis, signs of C-diff
Field of view: 45 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
85 yo F w/ CLL and climbing WBC, fatigue, cough, T 99, LLQ pain,
recent Azithro
REASON FOR THIS EXAMINATION:
eval for diverticulitis, signs of C-diff
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of CLL with leukocytosis, left upper
quadrant pain, and cough. Additional history from the online
medical record indicates that there is hematuria.
TECHNIQUE: Contrast-enhanced MDCT of the abdomen and pelvis
displayed in multiplanar collimation.
COMPARISON: [**2118-3-23**].
CT ABDOMEN WITH CONTRAST: There is a large 5.6 x 3.2 cm mass in
the inferior mediastinum at the G-E junction. There is a large
4.2 x 1.9 cm subcarinal mass that compressess the esophagus. The
most superior slice also suggests an additional visualization of
a left hilar node, which is compressing the superior segment
bronchus of the left lower lobe resulting in postobstructive
collapse. There is additional atelectasis at the left base with
a moderate left-sided pleural effusion. There is a trace
pericardial fluid. A nonocclusive pulmonary embolism is present
in the visualized portions the right lower lobe pulmonary
artery, partially visualized on this study.
Widespread metastatic disease is identified, with a large, 5.9 x
3.7 cm heterogenous mass in the left upper quadrant, overlying
the spleen, with a small amount of associated ascites.
Innumerable additional omental, peritoneal, mesenteric, and
retroperitoneal soft tissue nodules/masses consistent with
metastases are also noted. There is an enlarged 2.7 cm mass/node
in the gastrohepatic space. Multiple metastatic deposits are
noted about and within the right adrenal gland. The spleen is
markedly enlarged measuring 19 cm in long axis and contains
multiple sub- centimeter hypoattenuating, indeterminate lesions.
There is no free air or free fluid. The small bowel loops appear
normal. Multiple hypodense lesions are present in the kidneys,
all probably simple or dense cysts. No lesions are identified in
the liver. There is no intrahepatic biliary ductal dilation. The
gallbladder and pancreas appear normal.
CT PELVIS WITH CONTRAST: There is a large lobulated mass within
the right superior lateral wall of the bladder measuring 6.0 x
2.9 cm. There are multiple markedly enlarged lymph nodes along
the right external iliac, right common iliac, and left
paraaortic lymph node distributions. The rectum, colon and
uterus appear normal. The ovaries are not identified without
definite adenexal mass.
BONE WINDOWS: No suspicious lesions are identified. Sclerosis is
noted at the pubic symphysis.
IMPRESSION:
1. Widely metastatic disease with innumerable peritoneal
implants, including a large left upper quadrant mass, and bulky
iliac and retroperitoneal lymph nodes. Lobulated mass within the
bladder wall. While a primary bladder malignancy remains a
consideration, other primary neoplasms (such as lung or ovarian)
with implants on the bladder should also be considered.
2. Mediastinal adenopathy with likely left hilar adenopathy
(partially visualized) causing post- obstructive collapse of the
superior segment of the left upper lobe.
3. Nonocclusive pulmonary embolism of the right lower lobe
pulmonary artery.
4. Massive splenomegaly with multiple indeterminate 1-cm
lesions, either metastases or small foci of infarction secondary
to splenomegaly.
[**Numeric Identifier 3174**] INTERUP IVC [**2125-2-1**] 4:14 PM
Reason: please place IVC filter.
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with CLL, multiple new abdominal masses, new
bladder mass, with RLL PE, with concern for anticoagulation
given hematuria.
REASON FOR THIS EXAMINATION:
please place IVC filter.
PROCEDURE: IVC filter placement.
INDICATION: 85-year-old woman with CLL, multiple new abdominal
masses, and with new bladder mass. Patient has now presented
with right lower lobe pulmonary embolism and with concern for
anticoagulation given hematuria. IVC filter placement was
requested.
RADIOLOGISTS: This procedure was performed by Dr. [**First Name (STitle) 1022**] and Dr.
[**First Name (STitle) 3175**], the attending radiologist, who was present and
supervising throughout the entire procedure.
PROCEDURE AND FINDINGS: After explaining the risks and benefits
of the procedure, an informed consent was obtained from the
patient. The patient was placed supine on the angiographic table
and the right groin was prepped and draped in standard sterile
fashion. A preprocedure timeout was performed.
After injection of local anesthesia with 1% lidocaine and using
ultrasound guidance, access was gained into right femoral vein
with a 19-gauge needle. A 0.035 Bentson guidewire was advanced
into the IVC under fluoroscopic guidance and the needle was
exchanged for a 5 French Omniflush catheter. Using Omniflush
catheter and guidewire, access was gained into left common iliac
vein and IVC venogram was obtained. IVC venogram demonstrated no
thrombosis in left iliac, IVC, and both renal veins were noted
at L2 level. Based on these venographic findings, it was decided
to place IVC filter at L3 level.
A 5 French catheter was removed and guidewire advanced into the
upper IVC under fluoroscopic guidance. A 7 French delivery
catheter was advanced over the wire into the IVC. A G2 IVC
filter was advanced through the catheter, and it was deployed in
the immediate infrarenal IVC at L3 level. Final abdominal x- ray
demonstrated proper location and position of IVC filter in
infrarenal IVC.
Vascular catheter was removed and manual compression was held
until hemostasis was achieved. The patient tolerated the
procedure well and there were no immediate complications.
IMPRESSION: Patent IVC and single renal veins at L2 level.
Successful G2 IVC filter deployment in immediate infrarenal IVC.
Brief Hospital Course:
85 y/o russian woman with history of Stage 0 CLL presented with
cough, abd pain, and hematuria, found to have LUL collapse
secondary to LAD, multiple abd mets, and new bladder mass.
Metastatic cancer of unknown primary
Presented with hematuria, found to have new bladder mass on CT
scan, in addition to peritoneal and lung mass. Urology consult
service followed, recommended urine cytology for diagnosis.
3-way foley placed and clots ultimately cleared and urine
returned to regular color. Per urology, biopsy of mass not
advisable given risk of procedure (bleeding, poor functional
status). Instead, urine cytology collected (multiple samples),
which were not diagnostic by pathology. ASA was held. Patient
was transfused with 1U PRBCs.
Given inability to obtain a diagnosis, and extent of metastatic
cancer (as well as unliklihood it is progressive CLL or
transformation), comfort/palliative care was recommended. Her
oncologist Dr. [**Last Name (STitle) **], and primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] were
instrumental in decision-making and recommendations for goals of
care and prognosis. Mrs. [**Known lastname 3176**] was very clear in her desire
to pursue comfort measures only. The main symptoms were pain and
dyspnea both were treated with oxycontin and oxycodone. On day
of discharge, oxycontin was increased to 20 mg [**Hospital1 **]. She did not
want to take morphine secondary to previous side effects.
Palliative care team was involved as well and they recommended
starting ritalin, dexamethasone as well.
Constipation - on senna, colace and lactulose. Please give a
dose of lactulose when patient arrives at rehab today([**2125-2-19**])
as pt had not had a bowel movement in 2 days.
LLL collapse/possible post-obstructive pneumonia: was treated
for pneumonia with antibiotics that were stopped when patient
requested they be discontinued. O2 continued for comfort.
Pulmonary embolism: IVC filter placed [**2-1**]. Systemic
anticoagulation deferred in setting of hematuria.
Leg edema is likely from IVC filter and abdominal metastases
compressing on the venous return. Leg elevation recommended.
CLL/hemolytic anemia: The patient's labs showed evidence of a
hemolytic anemia. Prednisone was not administered given stable
hematocrit and risk of steroids with unknown malignancy, on
recommendations of Dr. [**Last Name (STitle) **]. (However, eventually dexamethasone
was started per palliative care recommendations.)
Celexa, klonapin continued at home doses.
Son, [**Name (NI) **] ([**Name2 (NI) 3177**] Kopelev h-[**Telephone/Fax (1) 3178**], cell [**Telephone/Fax (1) 3179**].)
is the proxy and aware of all issues. constant communication was
maintained with him during the hospital stay.
Patient will be discharged to rehab with hospice support.
Medications on Admission:
ALBUTEROL 17 GM--Take 2 puff twice a day as needed
AMBIEN 10MG--One by mouth at bedtime as needed
ASPIRIN 81 MG--One by mouth every day
ATENOLOL 25 mg--1. tablet(s) by mouth once a day
Atorvastatin 10 mg--0.5 tablet(s) by mouth once a day
CLONAZEPAM 0.5 mg--one tablet(s) by mouth every evening as
needed
COSOPT 0.5 %-2 %--1 gtt os twice a day
COZAAR 50 mg--1 tablet(s) by mouth once a day
Citalopram 20 mg--0.5 tablet(s) by mouth at bedtime
Flovent HFA 110 mcg/Actuation--take 2 puffs twice a day
HYDROCHLOROTHIAZIDE 12.5MG--Take one by mouth daily
LORATADINE 10 mg--1 tablet(s) by mouth once a day as needed for
congestion, ear discomfort
NITROGLYCERIN 0.3 mg--11 tablet(s) sublingually for chest pain;
repeat x 1 after 5 minutes
PHYSICAL THERAPY FOR LEFT KNEE OSTEOARTHRITIS--Evaluation and
treatment; injection therapy
RANITIDINE HCL 150 mg--1 tablet(s) by mouth daily
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): hold if somnolent.
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every 4-6 hours as needed for wheezing.
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
10. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
QDAY ().
11. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every twelve (12) hours.
12. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ml PO
once a day as needed for constipation: Give if no stool for 2
days. .
13. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO 2 PM ().
14. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
15. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times
a day) as needed for nausea.
17. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2
hours) as needed for dyspnea or pain.
18. Oxycodone 5 mg/5 mL Solution Sig: Five (5)
mg PO Q3H (every 3 hours): patient may refuse if she is not in
discomfort from pain or dyspnea. Do not wake patient up if
sleeping to give medication. .
19. Senna 8.6 mg Capsule Sig: Two (2) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Metastases from unknown primary malignancy
Symptoms of pain, dyspnea, leg edema - possibly related to
wodespread cancer
History of CLL, autoimmune hemolytic anemia
Pulmonary embolism
Discharge Condition:
fair, going for ongoing hospice care
Discharge Instructions:
You are being discharged to extended care facility for further
care. Hospice care will be provided at the facility. They can be
in touch with your primary care physician, [**Name10 (NameIs) **] [**Last Name (STitle) **] and/or
the palliative care team here at [**Hospital1 18**] for further
recommendations for your care.
Followup Instructions:
The facility - [**Hospital1 599**] of [**Location (un) 55**] will care for your further
hospice needs. They can be in touch with your primary care
physician, [**Name10 (NameIs) **] [**Last Name (STitle) **] and/or the palliative care team here at
[**Hospital1 18**] for further recommendations for your care.
|
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"272.4",
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"204.10",
"199.1",
"197.0",
"239.4",
"493.90",
"197.6",
"276.8",
"486",
"415.19",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"88.51",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
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|
20005, 22825
|
246, 269
|
25911, 25950
|
3743, 10047
|
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|
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|
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|
25974, 26297
|
3263, 3722
|
174, 208
|
17858, 19982
|
297, 1707
|
1729, 2408
|
2424, 2992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,972
| 152,916
|
18937
|
Discharge summary
|
report
|
Admission Date: [**2138-5-30**] Discharge Date: [**2138-6-8**]
Date of Birth: [**2068-3-23**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
bloody bowel movement
Major Surgical or Invasive Procedure:
EGD
colonscopy
History of Present Illness:
70 F with pmhx of GIB, hypoplastic MDS/aplastic anemia on
immunosuppression, angiodysplia in the cecum/prox ascending
colon, ? ileal resection [**3-26**] in [**State 108**] for bleeding ulcers.
Possible angiodysplasia presents with 1 episodes of BRBPR after
dinner, with clots with brown stool. She recently had some
nausea no vomitting over past 3 days, with some diarrhea/normal
stools.
.
She otherwise denied N/V, abd pain, CP, SOB.
.
She recently was long hospitalized in [**State 108**] for GIB,
complicated by multiple cscope, EGD, push enteroscopy, pill
endoscopy and finally an distal ileal resection for bleeding
ulcers, complicated by [**Female First Name (un) **] torulopsis fungemia, treated with
fluconazole. She was discharged but was readmitted in [**State 108**] 3
days later for additional GIB, which resolved without
intervention. She then recently was admitted to [**Hospital1 18**] on [**5-21**],
for acute on chronic RF, also noted to have GIB, which did
resolve spontaneously.
.
In the ED, VS 96 66 106/86 17 99RA, was noted to have an initial
HCT of 38 which trended to 31 over 18hrs, an NGL was performed
negative for heme, protonix administered, GI, Heme, [**Doctor First Name **]
Consulted, given 1 UPRBC, 2 U Plts, and sent for tagged RBC
scan.
Past Medical History:
aplastic anemia
HTN
GERD
ulcerative ileitis s/p terminal ileum and proximal ascending
colon resection
Hypercholesteremia
Social History:
Denies tobacco, EtOH, illicits, IVDA. Lives with husband.
Family History:
Father deceased from MI at age 71. Mother with scleroderma. No
h/o malignancies.
Physical Exam:
VS 98 127/67 69 12 100% 2L
GEN, AAOx3 NAD, speaking in full sentences,
HEENT: supple, aniceteria, dry MM, OP clear, NGT placed,
CV: RRR no mrg s1 s2
Chest: CTA b/l no mrg
ABd + BS soft, nondistended, no RT
Rectal: Per ED brb
Ext; no c/c/e
Pertinent Results:
[**2138-5-29**] 11:05AM WBC-14.7* RBC-3.79* HGB-12.4 HCT-38.9
MCV-103* MCH-32.7* MCHC-31.8 RDW-22.8*
[**2138-5-29**] 11:05AM PLT SMR-VERY LOW PLT COUNT-55*
[**2138-5-29**] 11:05AM NEUTS-75.2* LYMPHS-7.9* MONOS-13.9* EOS-0
BASOS-0 METAS-2.0* MYELOS-1.0*
[**2138-5-29**] 11:05AM GLUCOSE-95 UREA N-27* CREAT-2.1* SODIUM-137
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2138-5-29**] 11:05AM ALT(SGPT)-432* AST(SGOT)-269* LD(LDH)-346*
ALK PHOS-84 AMYLASE-48 TOT BILI-0.9
[**2138-5-29**] 11:05AM LIPASE-58
[**2138-5-30**] 05:30AM HBsAg-NEGATIVE HBs Ab-POSITIVE
[**2138-5-30**] 05:30AM HCV Ab-NEGATIVE
[**2138-5-30**] 09:24AM CYCLSPRN-184
Micro:
Blood Cx [**5-30**], [**6-3**] - no growth
Urine Cx [**6-3**] -
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Stool cx [**6-7**] - neg for C. diff
CMV VL [**6-4**] - not detectable
HCV VL [**6-4**] - not detectable
Imaging:
GI bleed study [**6-2**] - Following intravenous injection of
autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and
dynamic images of the abdomen for 102 minutes were obtained. A
left lateral view of the pelvis was also obtained. An
additional anterior planar image was obtained after an
approximately 5 hour delay. Blood flow images show no focal
perfusion abnormality. Dynamic blood pool images and the
delayed image show no abnormal radiotracer localization to
suggest active gastrointestinal bleeding.
IMPRESSION: No scintigraphic evidence of active gastrointestinal
bleeding.
.
Colonoscopy [**6-2**] - Previous side to side ileo-colonic
anastomosis of the ascending colon. No evidence of bleeding and
no bleeding source was seen. There were no angioectasias in the
remaining colon and the distal 5 cm of terminal ileum appeared
normal. Internal & external hemorrhoids. Otherwise normal
colonoscopy to ascending colon (ileo-colonic anastamosis)
.
Small bowel enteroscopy [**6-2**] - Mild erythema in the
gastroesophageal junction compatible with esophagitis. Large
hiatal hernia. Abnormal mucosa in the stomach. The small bowel
mucosa was normal to the proximal jejunum.
Otherwise normal small bowel enteroscopy to proximal jejunum.
.
RUQ US [**6-3**] - The liver is normal in size and echogenicity.
There is patent hepatopetal flow. Visualized hepatic veins are
patent. There is no intra- or extra- hepatic biliary dilatation.
The common bile duct measures 0.39 cm. The gallbladder is
distended but maintains a thin wall without evidence for
intraluminal stones or sludge. There is no pericholecystic
fluid. The uncinate process, head and body of the pancreas are
normal. The tail is not visualized due to overlying bowel gas.
The right kidney measures 10.2 cm in maximal craniocaudad
dimension. There is no ascites.
IMPRESSION: Normal liver without evidence for infiltrative
process. Patent hepatopetal flow.
.
CXR (port) [**6-5**] - 1. No pneumothorax.
2. Widened superior mediastinum, probably due to distention of
vessels
accentuated by apical lordotic projection. However, given
recent
intervention, attention to this area on a short-term followup
radiograph with standard positioning would be helpful to exclude
mediastinal hematoma.
.
CXR (port) [**6-5**] - There continues to be prominence of the right
superior mediastinum which likely reflects a small hematoma. It
is not expanded significantly in size compared to the prior
exam. Alternatively, this also could represent prominent
vascular structures. The heart is mildly enlarged. The lungs
are grossly clear and there is no effusion or pneumothorax.
IMPRESSION: Prominence of the right superior mediastinum may
reflect a small hematoma or aberrant vascular structure and is
not significantly changed compared to one hour prior. Recommend
followup radiograph as clinically indicated to exclude expanding
hematoma. Findings were conveyed to the PACU at the time of the
exam.
.
IR guided port placement [**6-6**] - Placement of a 7 French right
internal jugular double-lumen Port-a-Cath with tip in superior
vena cava. The line is ready for use.
.
MRI liver [**6-6**] - results pending at time of discharge
Brief Hospital Course:
In brief, the patient is a 70 with history of GI bleed secondary
to angioectasias and ulcerative ileitis, aplastic anemia, and
hypertension who presented with bright red blood per rectum.
1) GIB - The pt presented with BRBPR with an 8 point Hct drop
and required 4 units of pRBCs and 4 bags of platelet tranfusions
during the first 24 hours of hospitalization. A GI bleed study
was negative for active bleeding. GI was emergently consulted
and a colonscopy and small bowel enteroscopy performed on the
day of admission were also negative for a source of bleeding. A
capsule endoscopy for a more thourough evaluation was
recommended. However, the pt subsequently had no furhter
episodes of BRBPR and her Hct remained stable without need for
further pRBC transfusions after the second hospital day. Thus, a
capsule endoscopy was deferred as an outpatient.
.
2) MDS/Aplastic Anemia - The pt was continued on 50 mg
cyclosporine daily. Her prednisone dose was increased from 10 mg
daily to 60 mg daily to give the pt stress dose steroids in the
setting of GI bleed, which was eventually titrated back down to
10 mg daily by the time of discharge. Her counts were monitored
daily and she was transfused to keep her Hct > 30 and plts >
50K. A R sided port was placed by IR prior to d/c (see below for
details). She will f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] as an outpatient
for further care.
.
3) Chronic Renal Insufficiency : With Cr elevated to 1.9 on
admission and baseline Cr between 1.2 to 1.5. Urine lytes were
c/w a prerenal etiology, likely in the setting of blood loss due
to GI bleed. She was given blood products as above and IVFs with
a decrease in her Cr back to baseline.
.
4) Elevated transaminases - Had been noted as an outpatient in
[**4-26**] and medications, including fluconazole, danazol, and a
statin were d/c'd. The transaminitis had been resolving; however
during the hospital course was noted to have a bump in her liver
enzymes (AST, ALT) up to the 600s and a TBili up to 4.5.
Although the pt did have a significant GI bleed on presentation,
she was never hypotensive, thus making shock liver an unlikely
etiology. A RUQ US was unremarkable and a liver MRI was obtained
to r/o any evidence of fungal infection given her recent h/o
candidemia, the results of which were pending at the time of
discharge. The liver service was also consulted and she was
ruled out for autoimmune hepatitis as well as acute hepatitis C,
CMV, hemochromatosis, and EBV. The pt was hepatitis B immune. By
the time of discharge, her transaminitis was resolving and was
thought to be secondary to medication effect. She will need to
have the final results of the liver MRI followed up on as an
outpatient.
.
5) UTI - The pt was noted to have a fever up to 102F on hospital
day 4 and was pan cultured which revealed a Klebsiella UTI
sensitive to cipro. She was placed on cipro with resolution of
fevers and will complete a 7 day course of antibiotics as an
outpatient.
.
6) Vascular Access - The pt has a history of poor vascular
access. She previously had a L sided port which was removed
during a hospitalization in [**State 108**] in [**3-26**], which was
complicated by candidemia, presumably from a line infection. On
presentation, 2 large bore IVs were placed in the setting of GI
bleed. However, maintaining IV access was a problem in this pt.
Due to her need as an outpatient to receive frequent blood
tests, it was decided by her primary oncologist and the team to
place another port in the patient once her fevers resolved on
the cipro (as above). Surgery attempted port placement on [**6-5**],
which had to be aborted due to technical difficulty. A CXR
performed after the procedure was significant for a question of
a possible R sided mediastinal hematoma. The pt remained HD
stable and assymptomatic. A repeat CXR 1 hr later did not show
any increase in the area of questionable hematoma. The pt
underwent a successful IR guided R sided port placement the
following day without any complications.
.
7) Hyponatremia - Na noted to be 120 on hospital day 3 in the
setting of being hypovolemic, likely from GI bleed. This
resolved well with hydration with normal saline. The pt never
had any mental status changes that were noted. By the time of
discharge, her Na was normal at 135.
.
8) Hypercholesterolemia - Placed on heart healthy diet. Statin
had been held as an outpatient due to elevated liver function
tests as above.
.
9) HTN - Lopressor and HCTZ were held on admission in the
setting of GI bleed, and were restarted by the time of
discharge.
.
10)GERD - Continued on protonix.
CODE: DNR/DNI
Communications: Husband [**Name (NI) **] [**Telephone/Fax (1) 51767**]
Surgeon [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at [**Last Name (un) 51768**] [**Hospital3 51769**]
[**Telephone/Fax (1) 51770**], performed ileal surgery
Medications on Admission:
1. Cyclosporine (SandImmune) 50 mg twice daily
2. Folic acid 1 mg daily
3. Hydrochlorothiazide 25 daily
4. Lopressor 50 mg twice daily
5. Multivitamin 1 tab. daily
6. Pantoprazole 40 mg daily
7. Prednisone 10 mg daily
8. Slow Magnesium
9. Vitamin b6 50 mg daily
Discharge Medications:
1. Cyclosporine 25 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 5 days: take as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
GI bleed
Transaminitis [**2-21**] med effect
UTI
Secondary Diagnosis:
Aplastic Anemia
HTN
Discharge Condition:
Good, ambulating, eating well, breathing well on room air.
Discharge Instructions:
You were admitted for a GI bleed and had a GI bleed study,
colonoscopy, and small bowel enteroscopy that did not find a
source of bleed. Your GI bleed has since resolved and your blood
counts have been stable for 1 week.
Please take all of your medications as presribed. You need to
finish a 7 day course of an antibiotic called ciprofloxacin for
treatment of an UTI.
Please call your doctor or return to the emergency room if you
experience any of the following: GI bleeding, dizziness, fever >
101, chills, night sweats.
Followup Instructions:
You are scheduled for a follow-up appointment in the 7 [**Hospital 1826**]
[**Hospital 6669**] clinic on [**6-9**] at 9am. You will need to follow-up
with Dr. [**First Name (STitle) 1557**] as well this coming week. Please call
[**Telephone/Fax (1) 51771**] to set up an appointment. You will also need
a capsule endoscopy to try to further work-up the cause of the
gastrointestinal bleeding.
Completed by:[**2138-6-10**]
|
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icd9pcs
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[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,761
| 183,317
|
33491
|
Discharge summary
|
report
|
Admission Date: [**2144-5-25**] Discharge Date: [**2144-5-29**]
Service: CARDIOTHORACIC
Allergies:
Procardia / Penicillins
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
angina/? aortic aneurysm
Major Surgical or Invasive Procedure:
left tube thoracostomy [**2144-5-28**]
History of Present Illness:
84 yo female with several episodes of chest pain since the AM.
Went to [**Hospital3 **] and was found to have mental status
changes with a right facial droop. Head CT was negative but
non-contrast chest CT showed an aortic arch aneurysm. No TEE
performed at [**Hospital1 487**] as pt. was hypotensive. Scan also showed a
pleural effusion. ? GI bleed at OSH. TTE there showed no
pericardial effusion. Transferred by Med-Flight to ER here for
further evaluation.
Past Medical History:
HTN
CRI
CHF
NIDDM
Social History:
no tobacco use
no ETOH use
widow, lives alone
Family History:
non-contrib.
Physical Exam:
HR 71 RR 16 on nipride drip 134/63 O2 sat 99% 4L NC
lethargic, but responsive and appropriate
skin unremarkable
neck full ROM, no carotid bruits appreciated
bilat. occasional wheezes, decreased BS on left
RRR, no murmur
abs soft, NT, ND, + BS
warm,well-perfused
no facial droop at time of exam
2+ bil. fems
faint bilat. DP/PT/Radials
Pertinent Results:
[**2144-5-28**] 10:50AM BLOOD WBC-10.4 RBC-3.02* Hgb-8.7* Hct-26.4*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.5 Plt Ct-143*
[**2144-5-28**] 10:50AM BLOOD Plt Ct-143*
[**2144-5-27**] 03:12AM BLOOD PT-11.9 PTT-30.2 INR(PT)-1.0
[**2144-5-25**] 05:00PM BLOOD Fibrino-201
[**2144-5-28**] 10:50AM BLOOD Glucose-114* UreaN-94* Creat-3.9* Na-135
K-6.0* Cl-103 HCO3-19* AnGap-19
[**2144-5-28**] 08:25PM BLOOD UreaN-95* Creat-3.8* K-6.6*
[**2144-5-27**] 03:12AM BLOOD CK(CPK)-135
[**2144-5-27**] 03:12AM BLOOD CK-MB-5 cTropnT-0.07*
[**2144-5-27**] 03:12AM BLOOD Calcium-7.7* Phos-8.9*# Mg-2.4
[**2144-5-25**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2144-5-25**] 5:23 PM
CTA CHEST W&W/O C&RECONS, NON-
Reason: eval for thoracic AD/aneurysm
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with ?aneursym on CT from OSH, had Cp and R
facial/arm weakness, equivocal TTE. Has CRI, pt aware of risk to
kidneys with contrast, agrees to study
REASON FOR THIS EXAMINATION:
eval for thoracic AD/aneurysm
CONTRAINDICATIONS for IV CONTRAST: None.
CTA CHEST
INDICATION: 84-year-old woman with aortic aneurysm.
COMPARISON: Not available.
TECHNIQUE: MDCT axial images of the chest were obtained prior to
and following administration of 100 cc of Optiray intravenously.
Multiplanar reformatted images were obtained.
CT CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: The study is
compared to an OSH NECT obtained several hours earlier. Again
demonstrated is a large saccular aneurysm, involving and
essentially limited to the aortic arch, measuring 8.6 x 6.1 cm.
The appearance of the aneurysmal wall is very irregular, though
only minimally calcified, and it involves origins of left common
carotid and left subclavian arteries, with the brachiocephalic
trunk apparently arising just anterior to the anterior aspect of
the aneurysm (best demonstrated on the reformations). There is
small amount of atherosclerotic plaque involving the arch of the
aorta. No active extravasation of contrast is noted at the time
of the study. There is no dissection. There is a large left
hemothorax.
There is no pericardial effusion. There is no evidence of
pulmonary embolism.
Central airways are patent to the segmental levels bilaterally.
There is extensive compression atelectasis of the left lung.
Small right effusion is also present. The right lung is clear.
There are no pathologically enlarged mediastinal, axillary, or
hilar lymph nodes.
BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic
lesions. Degenerative changes are noted in the thoracic spine.
IMPRESSION: Large and very irregular saccular aneurysm,
essentially limited to the arch of the aorta, and take-offs of
the left common carotid and subclavian arteries, while sparing
the brachiocephalic trunk. No active extravasation is
demonstrated at this time. Large left hemothorax, consistent
with prior rupture or leak. The constellation is suggestive of
mycotic aneurysm.
Findings were reviewed in detail, in-person with Dr. [**Last Name (STitle) **]
(Cardiothoracic Surgery) immediately following completion of the
study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: WED [**2144-5-27**] 12:41 AM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2144-5-28**] 10:08 AM
CHEST (PORTABLE AP)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman work-up for aortic arch aneurysm
REASON FOR THIS EXAMINATION:
eval for pleural effusions
CHEST RADIOGRAPH
INDICATION: Follow up.
There are no previous radiographs for comparison.
There is complete opacification of the left hemithorax with
moderate displacement of the mediastinum towards the
contralateral hemithorax. This finding suggests massive fluid
accumulation in the left hemithorax. On the left, no ventilated
lung parenchyma is seen. On the left, the mediastinal structures
are not seen. In the right lung, there are no abnormalities, no
focal parenchymal opacities suggestive of pneumonia.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: [**Doctor First Name **] [**2144-5-28**] 10:41 PM
Brief Hospital Course:
Admitted and underwent CT with contrast which showed a 6 cm arch
aneursym with no extravasation, and a left pleural effusion. Pt.
stated she did not want surgery and Dr. [**Last Name (STitle) **] discussed this
with her sons. She was deemed to be exceedingly high risk for a
complex aortic operation. Drs. [**Last Name (STitle) 914**] and [**Name5 (PTitle) **] were consulted
about the possible option of endo stent-grafting with
re-implantation of the arch vessels. She was not a candidate for
stenting either, and medical management with tight BP control in
the CVICU was the option chosen. She was weaned to oral agents
and transferred to the floor on [**5-27**]. Left chest tube was placed
on [**5-28**] for hemothorax drainage. On [**5-29**], she acutely developed
respiratory distress and was unable to clear her secretions. She
was transferred to the CVICU emergently where she was noted to
have a large amount of frank blood draining from the left chest
tube.
Plan was not to perform prolonged resuscitatation per Dr.
[**Last Name (STitle) **]. She expired at 1:45 AM.
Medications on Admission:
actonel 30 mg q weekly
actos 30 mg daily
propranolol 80 mg [**Hospital1 **]
clonidine 0.2 mg daily
lasix 40 mg daily
diovan 160 mg daily
ASA 160 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
aortic arch anuerysm
HTn
CHF
NIDDM
CRI
Discharge Condition:
expired
Completed by:[**2144-6-19**]
|
[
"428.0",
"584.9",
"441.01",
"585.9",
"250.00",
"511.8",
"511.9",
"403.90",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6992, 7001
|
5710, 6788
|
262, 302
|
7083, 7121
|
1299, 2151
|
912, 926
|
4923, 4974
|
7022, 7062
|
6814, 6969
|
941, 1280
|
198, 224
|
5003, 5687
|
330, 792
|
814, 833
|
849, 896
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,861
| 120,535
|
40931
|
Discharge summary
|
report
|
Admission Date: [**2191-3-27**] Discharge Date: [**2191-4-7**]
Date of Birth: [**2130-11-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2191-3-30**] L VATS pericardial window
[**2191-3-4**] mechanical AVR
History of Present Illness:
This 60 year old white female underwent mechanical aortic valve
replacement on [**2191-3-4**] for aortic stenosis. She did well and
was discharged home uneventfully. She presented elsewhere with
dyspnea on exertion and a CXR demonstrated a left pleural
effusion. She was transferred here for evaluation with stable
vital signs and an INR of 2.5. An echocardiogram in the ED
suggested a pericardial effusion but no evidence of tamponade.
Past Medical History:
Aortic stenosis
s/p aortic valve replacement
hyperlipidemia
hypertension
Diabetes mellitus
fibromyalgia
s/p right knee menicus repair
s/p right carpal tunnel repair
s/p tonsilectomy
Social History:
Last Dental Exam: > 6months
Lives with: significant other
Occupation: program counselor - community action
Tobacco: 30 pack year history
ETOH:1-2 drinks a month
Family History:
grandfather deceased MI at 60
Physical Exam:
Pulse: 80 Resp:18 O2 sat: 99%
B/P Right: 132/64
General: awake, not in distress while sitting
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 [] no Murmur
Abdomen: Soft [x] non-distended [x] non-tender
[x] bowel sounds
Extremities: Warm [x], well-perfused [x]
no Edema Varicosities: None
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
Admission labs
[**2191-3-27**] 05:25AM BLOOD WBC-7.1 RBC-3.48* Hgb-10.3* Hct-29.7*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.6 Plt Ct-443*
[**2191-3-27**] 10:40AM BLOOD PT-27.4* PTT-32.7 INR(PT)-2.6*
[**2191-3-27**] 05:25AM BLOOD PT-26.2* PTT-34.3 INR(PT)-2.5*
[**2191-3-27**] 05:25AM BLOOD Glucose-118* UreaN-11 Creat-0.7 Na-140
K-4.6 Cl-101 HCO3-30 AnGap-14
[**2191-3-28**] 03:35PM BLOOD ALT-40 AST-28 LD(LDH)-251* AlkPhos-114*
Amylase-51 TotBili-0.4
[**2191-3-27**] 05:25AM BLOOD proBNP-1111*
Discahege labs
[**2191-4-5**] 04:56AM BLOOD WBC-7.4 RBC-3.57* Hgb-10.0* Hct-30.7*
MCV-86 MCH-28.0 MCHC-32.6 RDW-14.4 Plt Ct-424
[**2191-4-7**] 03:49AM BLOOD PT-26.3* PTT-98.8* INR(PT)-2.5*
[**2191-4-6**] 03:56AM BLOOD PT-19.8* PTT-82.4* INR(PT)-1.8*
[**2191-4-5**] 04:56AM BLOOD UreaN-15 Creat-1.0 Na-141 K-4.0 Cl-99
Radiology Report CHEST (PA & LAT) [**2191-4-4**] 3:00 PM Clip #
[**Clip Number (Radiology) 89350**]
Final Report: As compared to the previous radiograph, there is
no relevant
change. No evidence of pneumothorax. Bilateral basal atelectatic
opacities, left more than right. Presence of small bilateral
pleural effusions cannot be excluded. Unchanged course of the
left-sided PICC line. Unchanged mild cardiomegaly. Sternal wires
are in constant position.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aortic Valve - Peak Gradient: 13 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: No AS. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Trivial MR.
TRICUSPID VALVE: Mild to moderate [[**11-21**]+] TR.
PERICARDIUM: Small 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.
Conclusions
This is a directed study to confirm function of heart and
prosthetic aortic valve.
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen.
The mitral valve leaflets are moderately thickened. Trivial
mitral regurgitation is seen.
There is a small pericardial effusion.
There is 1 - 2+ TR.
The prosthetic aortic valve is well-seated with trace AI and a
normal residual mean gradient.
There is a small pericardial effusion which was drained in the
OR.
A large left pleural effusion was drained in the OR.
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) **] [**2191-4-5**] 14:57
Brief Hospital Course:
Following admission a CTA done which revealed a large
pericaridial effusion and a moderate left pleural effusion.
Coumadin was held and heparin begun in light of the mechanical
valve.
Thoracic Surgery was consulted and on [**2191-3-30**] she went to the
Operating Room for:
Left video-assisted thoracic surgery (VATS)/pericardial window.
Please see operative report for details. She tolerated the
operation well and post-operatively was initially transferred to
the PACU and extubated however she required reintubation
secondary to hypercapnia. She was then transferred to the
cardiac surgery ICU for care. She woke neurologically intact,
she was weaned from the ventilator and extubated. On POD1 she
remained hemodynamically stable and was transferred to the
cardiac surgery stepdown floor. The next several days were
largely uneventful, heparin and coumadin were resumed. Her drain
was removed on POD3. She worked with physical therapy to improve
her strength and endurance. On POD8 her INR was within range to
be discharged home with VNA. Her Coumadin dosing and INR will be
followed by Dr [**Last Name (STitle) 35852**].
Medications on Admission:
ezetimibe 10 mg Tablet
duloxetine 30 mg Capsule, Delayed Release(E.C.)
simvastatin 40 mg Tablet
aspirin 81 mg Tablet, Delayed Release
metformin 500 mg Tablet
metoprolol tartrate 25 mg Tablet
furosemide 40 mg Tablet
potassium chloride 10 mEq Tablet Extended Release
hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H
Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
coumadin for mechanical AVR, goal [**12-23**].
Discharge Medications:
1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever/pain.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
13. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Disp:*1 bottle* Refills:*0*
15. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
16. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 tube* Refills:*0*
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
18. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day.
Disp:*100 Tablet(s)* Refills:*2*
19. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO on [**4-7**] for
1 days.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
pericardial effusion s/p Left VATs/pericardial window
s/p aortic valve replacement
jhyperlipidemiahypertension
noninsulin dependent diabetes mellitus
fibromyalgia
s/p carpal tunnel release
s/p tonsillectomy
s/p right knee arthroscopy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid and Ultram
Incisions:
left VATS incision - healing well, no erythema or drainage
Edema: trace bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2191-4-21**] 1:15
Cardiologist: Dr. [**Last Name (STitle) 4922**] on [**2191-4-15**] at 1:45pm
Thoracic surgeon: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2191-4-19**] 9:30
Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) 35852**] ([**Telephone/Fax (1) 34088**]) in [**2-22**] 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**
Labs: PT/INR for Coumadin ?????? indication is mechanical AVR
Goal INR 2.5-3.0
First draw day after discharge, [**4-8**]
Results to Dr. [**Last Name (STitle) 35852**] phone [**Telephone/Fax (1) 34088**] fax [**Telephone/Fax (1) 89349**]
Completed by:[**2191-4-7**]
|
[
"110.5",
"250.00",
"729.1",
"V58.61",
"997.39",
"511.9",
"E878.1",
"518.5",
"420.91",
"401.9",
"V15.82",
"272.4",
"611.79",
"493.90",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.12",
"34.21",
"96.71",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9269, 9352
|
5447, 6575
|
337, 411
|
9630, 9830
|
1952, 5424
|
10754, 11708
|
1281, 1313
|
7044, 9246
|
9373, 9609
|
6601, 7021
|
9854, 10731
|
1328, 1933
|
278, 299
|
439, 881
|
903, 1086
|
1102, 1265
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,184
| 148,840
|
31595
|
Discharge summary
|
report
|
Admission Date: [**2197-8-30**] Discharge Date: [**2197-9-5**]
Date of Birth: [**2126-9-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Zocor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2197-8-30**] Two Vessel Coronary Artery Bypass Grafting(left internal
mammary artery to left anterior descending artery, and vein
graft to posterior descending artery)
History of Present Illness:
This is a 70 year old male with exertional chest pain and
abnormal stress test. He recently underwent cardiac
catheterization which revealed two vessel coronary artery
disease. He was therefore referred for surgical
revascularization. Prior to this admission, he underwent full
preoperative evaluation and was cleared for surgery.
Past Medical History:
Coronary Artery Disease
Hypercholesterolemia
Parkinsons Disease
GERD
History of Detached Retina
History of Hydrocele
Low Back Pain
Prior Hernia Repair
Prior Cataract Surgery
Prior Tonsillectomy
Social History:
Denies history of tobacco. Admits to occasional ETOH. He is
retired.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: T - afebrile, BP 130-140/70-80, HR 60, RR 20
General: elderly male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, no carotid bruit
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: tremors noted, otherwise nonfocal
Pertinent Results:
[**2197-9-5**] 05:50AM BLOOD WBC-8.6 RBC-3.14* Hgb-9.9* Hct-28.8*
MCV-92 MCH-31.4 MCHC-34.2 RDW-14.6 Plt Ct-327#
[**2197-9-5**] 05:50AM BLOOD Plt Ct-327#
[**2197-9-5**] 05:50AM BLOOD Glucose-85 UreaN-22* Creat-1.1 Na-142
K-4.4 Cl-103 HCO3-33* AnGap-10
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting by Dr. [**Last Name (STitle) **]. For surgical details, please see
seperate dictated operative note. Following the operation, he
was brought to the CSRU for invasive monitoring. Within 24
hours, he awoke neurologically and was extubated without
incident. He maintained stable hemodynamics and weaned from
pressor support without difficulty. His CSRU course was
otherwise uneventful and he transferred to the SDU on
postoperative day one. On POD #2 he had atrial fibrillation, he
was treated with amiodarone and beta blocker and converted to
sinus rhythm. He did well postoperatively and was ready for
discharge home on POD #5.
Medications on Admission:
Crestor 5 qd
Omeprazole 20 qd
Mirapex 0.25 qd
Aspirin 325 qd
Sudafed prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily ().
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**2-14**]
Tablets PO Q6H (every 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg [**Hospital1 **] x 5 days, then 400 mg QD x 1 week,
then 200 mg daily ongoing until dc'd by cardiologist.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Hypercholesterolemia
Parkinsons Disease
GERD
Discharge Condition:
Good
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**5-18**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11487**] in [**3-18**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**3-18**] weeks.
Completed by:[**2197-9-5**]
|
[
"E878.2",
"272.0",
"997.1",
"530.81",
"427.31",
"332.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.11",
"99.04",
"99.07",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4109, 4172
|
1910, 2623
|
316, 489
|
4296, 4303
|
1634, 1887
|
4686, 4951
|
1169, 1212
|
2746, 4086
|
4193, 4275
|
2649, 2723
|
4327, 4663
|
1227, 1615
|
255, 278
|
517, 849
|
871, 1067
|
1083, 1153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,063
| 177,300
|
6298
|
Discharge summary
|
report
|
Admission Date: [**2156-7-14**] Discharge Date: [**2156-7-24**]
Date of Birth: [**2085-3-31**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
male with a history of coronary artery disease, status post
myocardial infarction times four, coronary artery bypass
graft with multiple PCA interventions, atrial fibrillation,
congestive heart failure with several recent admissions
presenting with syncope. At the time of initial interview
the patient was unable to give further events secondary to
Ativan administration, although the following day the patient
described a syncopal event on the couch witnessed by his
wife. [**Name (NI) **] denied chest pain or shortness of breath throughout
the episode. While in the Emergency Room the patient had
multiple episodes of V tach lasting at least 16 seconds which
were witnessed by the RN who stated patient's eyes rolled
back in his head. The patient does have an implantable
defibrillator that did not fire and received 150 mg of
Amiodarone in the Emergency Room.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, had a coronary artery bypass graft in [**2133**] which was
[**Year (4 digits) 5659**] to LAD, continuous to OM1, RCA, [**6-/2154**] had PTCA with stent
to the [**Last Name (LF) 5659**], [**First Name3 (LF) **] graft. In [**2146**] had PTCA again to [**Year (4 digits) 5659**] to OM
and RCA. Congestive heart failure had a recent admission to
[**Hospital1 69**]. [**4-1**] had instent
stenosis with stent to the [**Month/Year (2) 5659**] to RCA and EF was 15% at that
time. [**2156-7-1**] a cath showed [**Year (4 digits) 5659**] to RCA 99% with PTCA
done, patent [**Year (4 digits) 5659**] to LAD and [**Year (4 digits) 5659**] to OM1. The patient has
automatic implanted defibrillator secondary to cardiac arrest
that occurred in [**2153**]. Also has benign prostatic
hypertrophy.
MEDICATIONS: On admission, Aspirin 325 mg, Lasix 80 mg in
the morning, 40 mg at night, Zestril 2.5 mg, Toprol XL 12.5,
Lipitor 10 mg, Coumadin 2 mg, Proscar 5 mg, Ticlid 250 mg
[**Hospital1 **], home oxygen 2 liters and initial blood pressure 94/61,
pulse 74, respirations 20, 100% on two liters. In general
the patient is sleepy, arousable to pain, anicteric, heart
was regular, 2/6 systolic murmur. Chest, decreased breath
sounds at the bases with decent air exchange. Abdomen,
positive bowel sounds, nontender, nondistended. Extremities
showed [**12-3**]+ edema to the mid calf.
LABORATORY DATA: Hematocrit 39.9, white count 10.5, platelet
count 116,000, sodium 134, potassium 5.0, chloride 99, CO2
30, BUN 67, creatinine 2.1, glucose 125, initial CK 77 with
troponin of 1.2. Chest x-ray showed increased perihilar
haziness, bibasilar opacities suggestive of pulmonary edema.
EKG initially showed a left bundle branch block at 82.
HOSPITAL COURSE:
1. The patient was admitted to the floor and placed on
telemetry for syncope and V tach arrest. The patient was
continued with the diuresis of IV Lasix. The next day the
patient was taken to the EP lab for ablation of his V tach
focus and mapping of his V tach. The day before the patient
received adjustment of his pacer, defibrillator settings to
shock at a lower rate. On the morning after the ablation,
the patient was found to be less oriented, not saturating
well, cyanotic toes and was transferred to the CCU for
administration of Milrinone. While in the CCU the patient
received 24 hours of Milrinone without much response. After
two days the patient was called out to the floor. On the
floor the patient continued in congestive heart failure. An
echo done previously on this admission had showed an EF
around 10%. The patient was started on a Natrecor drip and
was evaluated for receiving a biventricular pacer. The
patient received the pacer and on the day after continued to
do well. A repeat echo showed an EF of [**9-19**]%. The patient
was mentating well and was no longer as cyanotic and was
saturating well off oxygen. None of these events were
thought to be ischemic. Elevated enzymes post ablation were
thought secondary to the ablation itself and came down
appropriately.
2. Pulmonary: Patient had congestive heart failure
throughout his admission, had good response to Natrecor,
Lasix, Spironolactone was started to increase this diuresis.
Of note, the patient also had episodes of sleep apnea with O2
sats down to 89% and we avoided giving him Ambien for the
rest of his admission.
3. Hematology: A) Thrombocytopenia - The patient's platelet
count started dropping during his CCU stay. It was monitored
and had a nadir in the 70's. We were considering
discontinuing anti-platelet agents if the downward trend
continued, although patient very much needed his Ticlid for
his stents. No signs of symptoms of bleeding were noted.
B) Leukocytosis - patient accidentally received a dose of
Solu-Medrol while initially on the floor due to a nursing
error. Although the white count remained elevated, there
were no signs or symptoms of other systemic infections.
4. Infectious Disease: The patient had thrush throughout
his admission. He was tried on Clotrimazole troches and
Nystatin swish and swallow although still complained of mouth
burning with some visible thrush. On the day of his
discharge he was started on Diflucan 200 mg po the first day,
then 100 mg a day after.
CODE STATUS: The patient's code status changed during this
admission. He was initially full code and after careful
discussion with his family, was changed to DNR/DNI.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. V tach.
3. Syncope.
4. Congestive heart failure exacerbation secondary to
ventricular tachycardia and ischemic cardiomyopathy.
5. Benign prostatic hypertrophy.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Lipitor 10 mg
po q d, Finasteride 5 mg po q d, Ticlid 250 mg po bid,
Amiodarone 400 mg a day until [**8-21**], then 200 mg a day,
Protonix 40 mg a day, Tylenol 325 to 650 mg po q 4-6 hours
prn, Nystatin oral suspension 5 ml po qid, Spironolactone 25
mg po q d, Viscus Lidocaine 2%, 20 ml po tid prn, Ambien 5 mg
po h.s., Captopril 6.25 mg po tid, Lasix 80 mg IV bid,
Fluconazole 100 mg po q day for 7 days, Carvedilol 3.125 mg
po bid.
FOLLOW-UP: In Device Clinic in one week. The patient has an
appointment at Device Clinic [**2156-8-23**] at 11 a.m. on [**Hospital Ward Name 23**]
[**Location (un) **] and can call to confirm at [**Telephone/Fax (1) **]. He should
also be brought back for ICD testing. Patient to follow-up
with Dr. [**Last Name (STitle) 2912**] or coverage in one week.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: To rehabilitation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2917**]
Dictated By:[**Last Name (NamePattern1) 6834**]
MEDQUIST36
D: [**2156-7-24**] 09:24
T: [**2156-7-24**] 09:32
JOB#: [**Job Number 24431**]
|
[
"263.9",
"427.31",
"V45.81",
"427.5",
"112.0",
"427.1",
"287.5",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
6643, 6993
|
5803, 6621
|
5582, 5779
|
2872, 5561
|
160, 1059
|
1082, 2855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,338
| 127,713
|
44258
|
Discharge summary
|
report
|
Admission Date: [**2163-12-9**] Discharge Date: [**2164-1-5**]
Date of Birth: [**2089-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Altered mental status, cough, diarrhea
Major Surgical or Invasive Procedure:
Tracheostomy
Left AV fistula repair
Right femoral tunnelled dialysis line catheter placement
History of Present Illness:
Mr. [**Known lastname 66189**] is a 74M with an extensive past medical history, and
multiple recent hospitalizations for altered mental status and
Group B strep sepsis, who was recently discharged on [**11-26**] after
two serial hospitalizations for this. He was doing well after
discharge from the hospital on until Wednesday (two days PTA),
when he developed pain with his tube feeds, nausea, and
vomiting. His daughter reports that he would experience
abdominal pain soon after the onset of his tube feeds, which
would resolve soon after she shut them off. He vomited on
wednesday. Later that day at dialysis, he required supplemental
oxygen, which is new for him. On thursday, he developed a
productive cough, and was unable to clear his secreations.
Today, he developed worsening shortness of breath.
.
Review of systems is otherwise notable for bleedig (~1pint) from
his fistula, increased somnolence. She denies any fevers,
chills, sweats, skin rashes, diarrhea, or LE edema.
.
In the emergency department presenting vital signs were T=96.6,
BP=122/54, HR=72, O2sat=90%RA. On exam, he was initially
non-responsive to sternal rub, then became verbal during an
attempt at an ABG. Laboratory data is notable for mild
hypernatremia (147), elevated bicarb to 42 ([**Month/Year (2) 5348**] in the low
30s), HCT drop to 26.7 ([**Month/Year (2) 5348**] ~30), and a poistive UA. A CXR
was abnormal but unchanged with his known large right loculated
pleural effusion. A left sided IJ was placed as the patient has
limited access, blood cultures were drawn, and he recieved
Ceftriaxone and vancomycin for possible urine source vs.
aspiration PNA.
Past Medical History:
-CABG [**1-20**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-S/p sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago, complicated
by nephropathy, neuropathy (sensory and autonomic leading to
urinary retention) and retinopathy (s/p bilat vitrectomies, L
eye blindness).
-ESRD initially secondary to diabetic nephropathy starting
dialysis in [**2148**].
- s/p chronic allograft insufficiency s/p R cadaveric kidney
transplant, complicated by postinfectious GN (negative [**Doctor First Name **],
ANCA, low complemt), signs of chronic rejection (sclerotic
glomeruli, interstitial fibrosis 3/[**2158**]).
-Chronic Anemia
-Neurogenic bladder
-BPH status-post TURP [**2157**].
-Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
-HSV stomatitis/genital
-Recurrent UTI
-blindness in R eye following CVA (both eyes [**Year (4 digits) 11345**])
-Adrenal insufficiently diagnosed this year.
-PACER/ICD placed for CHB or mobitz II (records conflicting)
Social History:
Originally from [**Country **], emigrated in [**2141**]. Retired civil
engineer. Lives at home with family, who provide chronic care.
At [**Year (4 digits) 5348**], is [**Last Name (LF) **], [**First Name3 (LF) 282**] tube dependent, and does verbalize
with his family. Prior ETOH and tobacco, not currently.
Family History:
Mother and brother with DM Type 2. He also has a cousin with
asthma and brother with lung cancer.
Physical Exam:
T=97.2 rectally... BP=125/60... HR=67... RR=20... O2=100% 2LNC
GENERAL: Somnolent, does not respond to voice, does respond to
sternal rub, but does not answer questions. Cold to touch.
[**First Name3 (LF) 4459**]: Right pupil reactive to light. Will not open his mouth
for exam.
CARDIAC: Bradycardic, with frequent PVCs. No murmurs. No JVD.
LUNGS: Moving air anteriorly. Decreased BS at right base.
ABDOMEN: [**First Name3 (LF) **] tube C/D/I, NABS, No wincing or guarding with deep
palpation. Non-distended
EXTREMITIES: Cool, with diminished pulses.
Pertinent Results:
[**2163-12-9**] ADMISSION LABS:
WBC-5.0 RBC-2.82* Hgb-8.2* Hct-26.7* MCV-95 MCH-29.2 MCHC-30.8*
RDW-18.1* Plt Ct-232
Neuts-81.9* Lymphs-12.9* Monos-3.9 Eos-1.1 Baso-0.2
PT-15.6* PTT-50.4* INR(PT)-1.4*
Glucose-168* UreaN-27* Creat-3.1* Na-147* K-3.1* Cl-102 HCO3-42*
AnGap-6* Calcium-8.9 Phos-2.6* Mg-2.3
ALT-0 AST-8 LD(LDH)-105 CK(CPK)-8* AlkPhos-80 TotBili-0.2
Lipase-13
Lactate-1.1
.
Discharge labs:
[**2164-1-5**] 03:45AM BLOOD WBC-9.8 RBC-2.67* Hgb-8.3* Hct-26.8*
MCV-100* MCH-31.2 MCHC-31.2 RDW-21.4* Plt Ct-180
[**2164-1-5**] 03:45AM BLOOD PT-14.0* PTT-35.3* INR(PT)-1.2*
[**2164-1-5**] 03:45AM BLOOD Glucose-136* UreaN-27* Creat-2.2* Na-140
K-3.5 Cl-108 HCO3-24 AnGap-12
[**2163-12-30**] 07:28AM BLOOD ALT-24 AST-31 LD(LDH)-196 AlkPhos-122*
TotBili-0.2
[**2164-1-4**] 04:53AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8
[**2163-12-15**] 06:50AM BLOOD calTIBC-138* Ferritn-428* TRF-106*
[**2163-12-16**] 12:32PM BLOOD calTIBC-144* Ferritn-367 TRF-111*
[**2163-12-10**] 11:40AM BLOOD TSH-2.3
[**2163-12-20**] 04:09AM BLOOD Cortsol-7.3
[**2163-12-16**] 06:56PM BLOOD HIV Ab-NEGATIVE
[**2164-1-5**] 04:14AM BLOOD Type-ART Temp-36.7 Rates-/28 Tidal V-400
PEEP-5 FiO2-40 pO2-201* pCO2-38 pH-7.43 calTCO2-26 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2164-1-3**] 07:55PM BLOOD Lactate-1.6
.
MICRO
[**2163-12-10**] 1:59 am URINE Source: CVS.
**FINAL REPORT [**2163-12-13**]**
URINE CULTURE (Final [**2163-12-13**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
.
Time Taken Not Noted Log-In Date/Time: [**2163-12-10**] 5:56 pm
SEROLOGY/BLOOD TAKEN FROM # 60614G.
.
[**2163-12-10**] 4:41 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2163-12-12**]**
Respiratory Viral Culture (Final [**2163-12-12**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2163-12-10**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
.
**FINAL REPORT [**2163-12-22**]**
RAPID PLASMA REAGIN TEST (Final [**2163-12-12**]):
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final [**2163-12-22**]):
REACTIVE AT A TITER OF 1:8.
TEST PERFORMED BY STATE LAB.
TREPONEMAL ANTIBODY TEST (Final [**2163-12-22**]):
TP-PA REACTIVE.
TEST PERFORMED BY STATE LAB.
.
[**2163-12-19**] 5:29 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2163-12-22**]**
GRAM STAIN (Final [**2163-12-19**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2163-12-22**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- 4 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I <=0.25 S
GENTAMICIN------------ 4 S <=1 S
MEROPENEM------------- 1 S <=0.25 S
PIPERACILLIN/TAZO----- 32 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2164-1-2**] 3:54 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2164-1-2**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2164-1-2**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2164-1-2**] 12:32 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2164-1-2**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
GRAM NEGATIVE ROD #2. MODERATE GROWTH.
.
CT Chest w/o [**2163-12-10**]
1. Reaccumulation of large right loculated pleural effusion,
simple in
attenuation. The pleura appears is smooth but thikc; evaluation
for infection
is limited without contrast.
2. Complete collapse of the right lower lobe and incomplete
collapse of the
right middle lobe.
3. Nodular consolidative opacity at the right apex raises the
possibility of
an infectious process.
4. Enlarged thyroid. Consider outpatient thyroid function tests
and
ultrasound if needed.
5. Atherosclerotic aortic and coronary artery calcifications.
6. Persistent cholelithiasis, atrophic kidneys and splenic
calcifications.
CT head w/o contrast [**2163-12-10**].
1. No acute intracranial hemorrhage. No mass effect. Stable
large territory
chronic infarction MR is more sensitive in the detection of
acute stroke. MR
[**First Name (Titles) 151**] [**Last Name (Titles) **] is more sensitive in the detection of sequelae
of intracranial
infarction.
2. Small amount of fluid in the right maxillary sinus raises the
possibility of sinusitis.
CT Head [**12-21**] w/o contrast:
1. No acute hemorrhage, mass effect, large mass, edema, or acute
infarction is noted.
2. Stable large region of cystic encephalomalacia and volume
loss, consistent with remote right MCA territorial infarction.
3. No pathologic enhancement.
.
EEG [**12-22**]:
This is an abnormal portable EEG due to slowing and
disorganization of the background rhythm and intermittent focal
slowing
in the left frontal and anterior sylvian regions. These findings
suggest a possible focus of subcortical dysfunction in this area
and an
underlying moderate to severe encephalopathy. Medications,
toxic/metabolic disturbances and infections are common causes.
There
were no epileptiform discharges or electrographic seizures seen
in this
recording.
.
CXR [**12-19**]:
As compared to the previous radiograph, there is now complete
opacification of the right hemithorax. The absence of
mediastinal shift to
the left suggests a combination of pleural effusion and
atelectasis. The left lung shows unchanged apical thickening and
a just minimal pleural effusion as well as a small retrocardiac
atelectasis. Focal parenchymal opacity suggesting pneumonia are
not present. The left-sided central venous access line has been
removed in the interval
.
CXR [**1-3**]:
The endotracheal tube measures 4.4 cm above the
carina. The right pleural effusion and partial collapse of the
right lung are unchanged since [**2164-1-2**]. The cardiac
and mediastinal silhouette is stable. The left lung is well
expanded. There is no pneumothorax. The right-sided pacemaker
and lead is unchanged in position.
Brief Hospital Course:
# Altered Mental Status: The patient was initially brought in to
be evaluated for possible confusion per his family. However on
further questioning, he initially appeared to be at his relative
[**Year (4 digits) 5348**] ([**Name2 (NI) 11345**], nearly deaf, left hemiplegia, intermittently
saying [**1-14**] words with signficant stimulation but rarely
oriented). An RPR was found to be mildy positive and
neurosyphyllis was thought to be possibly contributing to his
confusion. To this end a lumbar puncture under fluoroscopic
guidance was pursued. However, due to decompensation (see below)
the LP was not completed. Given the risk of a repeat LP, under
guidance from the infectious disease department, it was decided
to treat him for presumed neurosyphyllis. He received 2 weeks of
IV ceftriaxone, completed in house, with little improvement of
his mental status after his arrest. After his arrest, the
patients mental status became essentially unresponsive to any
stimuli. Repeat CT head and EEG showed no acute process. The
patient could not receive an MRI due to a pacemaker. In
consultation with neurology, his new [**Month/Day (2) 5348**] may be a result of
some anoxic brain injury.
.
# PEA arrest: The morning of his lumbar puncture, a CXR showed
complete opacification of his right lung, likely indicating a
significant mucous plug at that time. At [**Month/Day (2) 5348**], he has a
large, chronic, loculated pleural effusion that compresses most
of the right lung, leaving only a small section aerated. During
his lumbar puncture procedure, the patient suffered a PEA arrest
and was down for approximately 5 minutes. He was resuscitated
with CPR. As above, after the arrest, his mental status was
essentially unresponsive. His ability to protect his airway was
significantly decreased. After initial extubation after his
arrest, he required frequent nasal trumpet suctioning to prevent
recurrent mucous plugging. Even with frequent suctioning, he had
several further mucous plugging events with significant
desaturations requiring acute suction. The last such event was a
near respiratory arrest on the general medical floor requiring
re-intubation. After lengthy discussion with his family, it was
decided to place a tracheostomy to attempt to minimize further
mucous plugging events and ease suctioning, as he was having
significant nasopharyngeal trauma from NT suctioning. Hyocamine
tabs and mucomyst nebs were added to decrease and help clear
secretions. He will require frequent suctioning and close
monitoring of his airway to minimize further plugging events.
The family was made aware that the tracheostomy may not prevent
further events and that his overall mortality in the next year
is significant. They feel strongly that the patient would want
to continue living no matter what the cost. Extensive
discussions were held regarding goals of care and code status
with no change in his full code status. The family's overall
goal is to bring the patient home if at all possible.
.
# Respiratory Failure: As noted above, his last mucous plugging
event resulted in reintubation. He is in the process of weening
ventilatory support, currently on PS ventilation, 14/5, 40% with
good respiratory mechanics. His ventilatory support should
continue to be weened as tolerated with possible trach collar
soon. Of note, given his poor right lung, it is unlikely that
the patient will ever have a satisfactory RSBI. Sputum culture
from [**12-19**] grew pseudomonas and pan-sensitive klebsiella. The
patient had no evidence of actual pneumonia at that time. It was
felt that the pseudomonas was likely a colonizer given that the
exact same strain has been isolated from sputum cultures months
prior. The klebsiella was concurrently treated during his 2 week
course of ceftriaxone as above. Prior to discharge, a sputum
culture was growing pseudomonas and one other gram negative rod.
Again, he had no other clinical signs of pneumonia so new
antibiotics were not started. Further follow of sputum culture
should occur and if the patient decompensates, consideration of
antibiotics treating pseudomonas should occur.
.
# Pyuria: Patient had a grossly positive UA. Ceftriaxone and
vancomycin were given initially. Piperacillin-tazobactam was
added and ceftriaxone discontinued when he became hypothermic
and altered requiring ICU transfer. He was ultimately found to
have a VRE urinary tract infection. He was treated with
linezolid, with a recommended course of 7 days. .
.
# Hypothermia: On the first hospital day the patient's
temperature dropped to <96 farenheit. Other vital signs were
stable. Given concominant leukopenia and positive UA, this was
concerning for sepsis. Blood cultures were sent, and warming
blankets were placed. The patient was transferred to the
intensive care unit for closer monitoring in the setting of
likely sepsis, his antibiotic regimen was broadened to
vancomycin/zosyn. His hypothermia improved. He has been
hypothermic on his last several admissions. It may be that his
physiologic response to infection is hypothermia rather than
hyperthermia, or he is an outlier at the lower extreme of
temperature at [**Month/Day (4) 5348**]. On the floor after transfer out of the
ICU he initially needed a bearhugger to maintain temperatures
>96 and cultures done at that time were negative. He eventually
was able to maintain temperatures ranging 96-98 without the
assistance of a bear hugger.
.
#. ESRD: Family reported episode of fistula bleeding the
previous day. Pressure dressing was in place on admission. Hct
was decreased, possible secondary to this. Transplant surgery
initially evaluated the fistula and determined that it was
functional and ready for use. However, later on re-evaluation
transplant surgery felt that his fistula needed revision prior
to discharge. This was done and further hemodialysis should be
avoided from his fistula for 2 weeks from [**2164-1-2**]. A tunnelled
femoral HD line was placed for HD access until that time under
IR guidance.
Dialysis was continued MWF schedule. Midodrine was added to help
improve his BP prior to dialysis to assist with volume removal
and to combat possible autonomic dysfunction given wide swings
in blood pressure.
.
Enlarged Thyroid: He had chest imaging to evaluate pulmonary
function. An incidential finding of thyromegaly was noted. TFTs
are recommended as an outpatient.
.
#. Hypernatremia: This was likely secondary to hypovolemia and
resolved.
.
#. Coronary artery disease: Aspirin, and simvastatin were
continued.
.
#. Hypertension: Lisinopril was continued.
.
#. Type II DM: Oral hypoglycemics were initially held and ISS
given, but restarted as his blood sugars became elevated. His
lantus was increased from 12 U QHS to 16 U QHS with effect.
.
.
#. Adrenal insufficiency- He is on 5mg prednisone daily at
[**Month/Day/Year 5348**]. There was an initial concern for sepsis, thus he got
high dose steroids,however [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was wnl. He was thus
tapered, and returned to his home dose of 5mg daily prior to
discharge.
.
#. Access: He has poor vasculature. Initial PICC was placed
which was pulled back to midline prior to discharge as it was
coming out a little.
.
#. CODE STATUS: Full code status was confirmed with the family.
Medications on Admission:
Senna [**Hospital1 **] prn
Prednisone 5 mg daily
Lisinopril 5 mg daily
Lansoprazole 30 mg daily
Simvastatin 10 mg daily
Aspirin 81 mg daily
Simethicone 80 mg [**Hospital1 **]
Cefazolin 2g HD protocol until [**12-11**]
Insulin Glargine 12 units Qhs
Insulin Lispro sliding scale
Tube feeds: [**Month/Year (2) 94925**] renal full strength, 50cc/hr, 150cc q4H
Discharge Medications:
1. Insulin Lispro 100 unit/mL Cartridge [**Month/Year (2) **]: Sliding Scale
Subcutaneous amount delivered depends on blood sugar.
2. [**Month/Year (2) **] renal full strength [**Month/Year (2) **]: One [**Age over 90 1230**]y (150)
cc every four (4) hours: at 50cc/hr.
3. B Complex Vitamins Capsule [**Age over 90 **]: One (1) Cap PO DAILY
(Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Folic Acid 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2
times a day).
8. Sodium Chloride 0.65 % Aerosol, Spray [**Age over 90 **]: [**1-14**] Sprays Nasal
TID (3 times a day) as needed for congestion.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB, wheeze.
10. Simethicone 80 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for nausea, high
residual.
11. B-Complex with Vitamin C Tablet [**Month/Day (2) **]: One (1) Tablet PO
DAILY (Daily).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
13. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual QHS (once a day (at bedtime)).
14. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
15. Midodrine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
16. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Five (5) ML
Miscellaneous Q6H (every 6 hours) as needed for mucous.
17. Prednisone 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
18. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Nineteen (19)
units Subcutaneous at bedtime.
19. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Mid-line, non-heparin dependent: Flush with 10 mL Normal
Saline daily and PRN per lumen.
23. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Hospital1 **]: 25-50 mcg
Injection Q2H (every 2 hours) as needed for pain, agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary
Recurrent Urinary Tract Infection
Hypoxemic PEA arrest
Respiratory failure
Anoxic brain injury/altered mental status
Neurosyphillis
.
Secondary
End Stage Renal Disease
Diabetes
Hypertension
Peripheral Vascular Disease
Adrenal Insufficiency
Discharge Condition:
Hemodynamically stable
Tracheostomy in place, on PS ventilation 14/5, 40%
Non-responsive mental status (new [**Location (un) 5348**])
Afebrile
Discharge Instructions:
You were admitted to the hospital because you were confused, and
had also been having some vomiting, and bleeding from your
fistula. You were found to have an infection of your urine which
was treated with antibiotics. In the setting of working up your
confusion, a lumbar puncture was attempted. During this you had
low oxygen levels and your heart stopped. This was likely due to
mucous plugging. To attempt to prevent further plugging events,
a tracheostomy was performed. Your fistula was also surgically
repaired and a tunnelled dialysis catheter was placed in your
groin.
.
Please call your doctor or return to the hospital if you
experience confusion, shortness of breath, nausea, vomiting,
diarrhea, headache, fever, chills, changes in your bowel
movements, chest pain, or any other symptoms that are concerning
to you.
Followup Instructions:
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2164-1-12**] 2:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2164-1-12**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2164-1-12**] 3:00
|
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"518.81",
"438.11",
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"427.5",
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"996.81",
"250.42",
"041.04",
"285.9",
"V02.9",
"583.81",
"286.9",
"276.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.42",
"96.04",
"38.95",
"96.72",
"33.23",
"89.45",
"31.42",
"39.95",
"31.1",
"38.93",
"96.6",
"99.60",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
22898, 22980
|
12386, 12396
|
353, 448
|
23272, 23417
|
4578, 4594
|
24293, 24727
|
3891, 3991
|
20112, 22875
|
23001, 23251
|
19732, 20089
|
23441, 24270
|
4980, 9533
|
4006, 4559
|
9574, 12363
|
275, 315
|
476, 2121
|
4610, 4964
|
12411, 19706
|
2143, 3549
|
3565, 3875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,057
| 132,465
|
11003+11004
|
Discharge summary
|
report+report
|
Admission Date: [**2194-4-28**] Discharge Date:
Date of Birth: [**2122-12-21**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old male
with a past medical history significant for asthma,
hypothyroidism, and aortic stenosis, who presents with acute
onset of shortness of breath and wheezing. The patient was
diagnosed five years ago with aortic stenosis. The patient
states that over the last two years he has had increasing
dyspnea on exertion limited to walking 150 yards at baseline.
The patient was at a picnic outdoor on the night prior to
admission. After arriving home he noted mild shortness of
breath which he thought was secondary to an environmental
asthma flare. The patient used meter-dosed inhalers without
relief, went to sleep with the sensation that he could not
lay down flat secondary to difficulty breathing. Thus, he
slept in a chair overnight. The patient states that on the
morning of admission his breathing was much worse, especially
after taking a shower. He could speak in full sentences, and
emergency medical technician was called.
The patient was brought to [**Hospital 882**] Hospital where he was
started on Solu-Medrol and nebulizers for asthma. He was
diuresed with 40 mg of intravenous Lasix, and an
echocardiogram done in the Emergency Room showed an aortic
valve area of 0.5 cm2 with an ejection fraction of 40%,
concentric left ventricular hypertrophy, and global
hypokinesis. The patient was transferred to [**Hospital1 346**] for catheterization and
Cardiothoracic Surgery consultation.
REVIEW OF SYSTEMS: On review of systems, the patient denies
any recent chest pain, orthopnea beyond one day. He also
denies paroxysmal nocturnal dyspnea but does state that he
has had increased lower extremity edema. He has not had any
upper respiratory infection symptoms, fever, chills, or
change in urinary habits.
PAST MEDICAL HISTORY:
1. Asthma. Triggers are all environmental.
2. Aortic stenosis. Echocardiogram in [**2192-9-17**]
showed an ejection fraction of 55% to 60% with a maximum
gradient of 53 mmHg and an aortic valve area of 1.1 cm2.
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Gout. No flare in several years.
MEDICATIONS ON ADMISSION:
1. Albuterol 1 puff q.4h.
2. [**Last Name (un) **]-Dur 300 mg p.o. b.i.d.
3. Atorvastatin 10 mg p.o. q.d.
4. Levothroid 0.125 mg p.o. q.d.
5. Beclovent 3 puffs b.i.d.
6. Indomethacin 25 mg p.o. p.r.n.
7. Xalatan 0.005% 1 drop OU.
8. Doxazosin 2 mg p.o. q.d.
9. Glucosamine.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] has a distant approximately 40-pack-year tobacco
history, having quit 25 years ago. The patient states that
he used to drink beer but quit approximately 12 years ago.
He is currently retired.
PHYSICAL EXAMINATION ON ADMISSION: Temperature of 99.7,
blood pressure of 120/86, pulse of 87, oxygen saturation
of 97% on 4 liters. In general, this was an elderly male
speaking in full sentences, comfortable, and in no apparent
distress. HEENT examination was unremarkable. Neck
examination revealed a supple neck with diminished carotid
upstrokes. He had no appreciable jugular venous distention.
Heart examination revealed a regular rate and rhythm with
late peaking [**1-21**] holosystolic murmur at the left lower
sternal border radiating to his axilla and up to his neck.
On lung examination he had rales one-third of the way up
bilaterally but decreased breath sounds throughout. Abdomen
was benign. Extremities showed dry skin with trace pretibial
edema. There were palpable dorsalis pedis pulses.
Neurologic examination was unremarkable.
LABORATORY ON ADMISSION: White blood cell count was 14.4
with a differential of 78 neutrophils, 15 lymphocytes, and
6 monocytes. Hematocrit was 50.6, platelets of 196. Chem-7
was only remarkable for a creatinine of 1.5 and a serum
glucose of 203. Theophylline level was 17.8.
RADIOLOGY/IMAGING: Electrocardiogram on admission showed a
sinus rhythm with tachycardia. He had a left bundle-branch
block, but there were no ST-T wave changes.
HOSPITAL COURSE: The patient was taken to catheterization
which showed left main disease, distal as well as ostial 50%,
left circumflex disease and an aortic valve are of 0.8 cm2
with a peak gradient of 32 mmHg. Pulmonary capillary wedge
pressure was 37, and there was mild pulmonary hypertension.
The patient was evaluated by Cardiothoracic Surgery for a
2-vessel coronary artery bypass graft and aortic valve
replacement and was approved for surgery.
His hospital course was complicated by a fever that was
worked up without any clear etiology. A Pulmonary
consultation was obtained at the request of Cardiothoracic
Surgery as well as an Infectious Disease consultation.
Pulmonary function tests showed emphysematous changes. Urine
and blood cultures grew no organisms. No antibiotics were
ever started. Liver function tests were within normal
limits. There were no findings on chest x-ray. The
patient's fever defervesced on its own, and the patient was
transferred to the Cardiothoracic Surgery team for bypass
grafting and aortic valve replacement. Of note, carotid
studies were done revealing clean carotid arteries.
DIAGNOSES ON TRANSFER:
1. Critical aortic stenosis.
2. Two-vessel coronary disease.
3. Emphysema.
4. Hypothyroidism.
5. New diagnosis of diabetes.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Name8 (MD) 10039**]
MEDQUIST36
D: [**2194-5-7**] 19:47
T: [**2194-5-8**] 07:11
JOB#: [**Job Number **]
Admission Date: [**2194-4-28**] Discharge Date: [**2194-5-9**]
Date of Birth: [**2122-12-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 71 year old male with
a history of asthma who presents to the [**Hospital 882**] Hospital
with acute shortness of breath. On the day prior to
admission he was treated for his asthma. He has a known
history of aortic stenosis for approximately five years. He
was referred to the [**Hospital6 256**] for
further assessment and cardiac workup. He was admitted on
[**4-28**] where a cardiac catheterization was performed showing
aortic stenosis with valvular gradient with 36 mm of mercury
with a valve area of approximately 0.8 to 0.9 cm squared. He
had notably increased filling pressures with a wedge of 37
but a relatively preserved cardiac output of 5.5 and cardiac
index of 2.7. He also had coronary artery disease with a 50%
proximal left anterior descending and distal left main
lesion. He had an ostial obtuse marginal 1 70 to 80%
stenosis and insignificant right coronary artery disease.
His ejection fraction was depressed at approximately 30%. He
was evaluated by cardiothoracic surgery for aortic valve
replacement and coronary artery bypass graft. He has no
known history of syncope, occasional chest pain associated
with shortness of breath.
PAST MEDICAL HISTORY: Aortic stenosis, asthma,
hypercholesterolemia, hypothyroidism, gout, newly diagnosed
diabetes mellitus.
MEDICATIONS ON ADMISSION: Albuterol metered dose inhaler 1
puff p.o. q. 4 hours, [**Last Name (un) **]-Dur 300 mg p.o. b.i.d., Ativan 10
mg p.o. q.h.s., Synthroid 0.25 mg p.o. q.d, Beclovent 3 puffs
b.i.d., Indomethacin 25 mg prn, Xalatan .005%, GGT 1 o.u.
q.d., Doxazosin unknown dose and Glucosamine.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: Significant for tobacco which he quit 25
years ago and alcohol which he quit 12 years ago.
REVIEW OF SYSTEMS: Negative for claudication, negative for
transient ischemic attack, stroke, syncope.
PHYSICAL EXAMINATION: Afebrile, vital signs stable.
His lungs were clear to auscultation. His cardiac
examination, S1 and S2 regular rate and rhythm with a
systolic ejection murmur radiating to the neck. His
extremities showed minimal edema. He had palpable dorsal
pedal pulses.
LABORATORY DATA: His baseline creatinine was 1.5.
ASSESSMENT: At this point it was felt that he had
significant aortic stenosis with two vessel coronary artery
disease amenable to coronary artery bypass grafting.
HOSPITAL COURSE: A cardiology consult was obtained. A
pulmonology consult was obtained for his asthma and an
infectious disease consult was obtained given that he would
undergo an aortic valve replacement.
The patient was taken to the Operating Room on [**2194-5-5**]
by Dr. [**First Name (STitle) 10102**] where a coronary artery bypass graft times
two was performed as follows, saphenous vein graft to left
anterior descending, saphenous vein graft to obtuse marginal
as well as an aortic valve replacement with a 21 mm
pericardial tissue valve. The cardiopulmonary bypass time
was 213 minutes with a crossclamp time of 166 minutes.
Postoperatively the patient did well requiring Levophed for
pressure with some inotropic support and Amiodarone for
postoperative atrial fibrillation. He was also placed on an
insulin drip. His chest tubes were removed on postoperative
day #1 without complications and the patient was transferred
to the floor on postoperative day #2. He at the time was on
Amiodarone for postoperative atrial fibrillation as well as
Coumadin. He had a UM which was significant for white blood
count of 37 with positive bacteria which was treated with
Ciprofloxacin. While on the floor he had a brief episode of
atrial fibrillation but remained well rate controlled. His
electrolytes were checked and corrected and his rate was
controlled with Lopressor. Other than that he did well,
ambulating early. On postoperative day #4 it was felt that
he was stable for discharge. He had remained afebrile with a
stable rate in the 70s and blood pressure of 100s/60s. He
was making adequate urine and was clear to auscultation with
a regular rhythm. His sternotomy site was without any
erythema, edema, induration or drainage and was stable. His
extremities were well perfused with 1+ edema and his
saphenous vein graft site was well healed.
DISCHARGE MEDICATIONS:
1. Flovent 110 mcg metered dose inhaler 4 puffs b.i.d.
2. Atrovent 2 puffs metered dose inhaler q.i.d.
3. Amiodarone 400 mg b.i.d. times two weeks and then 400 mg
q.d. times two weeks and then 200 mg q.d.
4. Synthroid 0.125 mg p.o. q.d.
5. Xalatan 0.005% one GGT o.u. q.d.
6. Atorvastatin 10 mg p.o. q.h.s.
7. Lasix 20 mg p.o. b.i.d. for seven days
8. Potassium chloride 20 mEq p.o. b.i.d. for 7 days
10. Colace 100 mg p.o. b.i.d.
11. Zantac 150 mg p.o. b.i.d.
12. Aspirin 81 mg p.o. q.d.
13. Coumadin 5 mg p.o. q.d. for a target for INR of 2 to 3
14. Motrin
15. Serevent metered dose inhaler three puffs b.i.d.
16. Lopressor 12.5 mg p.o. b.i.d.
17. Ciprofloxacin 500 mg p.o. q.d. for one day and Percocet
one to two p.o. q. 4 hours prn pain.
DISCHARGE INSTRUCTIONS: He is discharged with instructions
to follow up with [**Hospital6 407**] and his primary
care provider for his Coumadin dosing for a target INR of 2
to 3. He was to follow up with his cardiologist and to
follow up with Cardiothoracic Surgery in four weeks.
DISCHARGE DIAGNOSIS:
1. Asthma
2. Aortic stenosis status post aortic valve replacement
3. Coronary artery disease status post coronary artery
bypass graft times two on [**5-5**]
4. Hypercholesterolemia
5. Hypothyroidism
6. Gout
His INR on discharge was 1.1 after receiving two doses of
Coumadin 5 mg.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2194-5-9**] 16:45
T: [**2194-5-9**] 22:16
JOB#: [**Job Number **]
|
[
"424.1",
"780.6",
"272.0",
"493.90",
"414.01",
"427.31",
"428.0",
"997.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"42.23",
"35.21",
"37.23",
"39.61",
"88.72",
"88.57",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
10149, 10901
|
11206, 11747
|
7220, 7543
|
8276, 10126
|
10926, 11185
|
7780, 8258
|
7672, 7757
|
5892, 7065
|
3767, 4187
|
7088, 7193
|
7560, 7652
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,534
| 146,866
|
36028
|
Discharge summary
|
report
|
Admission Date: [**2127-2-5**] Discharge Date: [**2127-2-11**]
Date of Birth: [**2060-10-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Struck by auto
Major Surgical or Invasive Procedure:
[**2127-2-7**] IVC filter placement & Intermedullary rod placement
History of Present Illness:
66 yo female s/p transfer from a referring hospital after car
rolled back and struck patient. She is anticoagulated on
coumadin for lower extremity DVT and her INR was 3.0 at the
referring hospital. She was transported to [**Hospital1 18**] for further
managment. She was reversed with 2 units of FFP and Vit K and
received 2 units PRBC's. Right femur fracture was placed in
traction in [**Name (NI) **], pt then went to IR for pelvic (mesenteric)
angiogram given CT with active extravasation. No active bleeding
in angio.
Past Medical History:
Glaucoma, HTN, DVT
Family History:
Noncontributory
Physical Exam:
Upon admission:
HR 92 BP 120/pal RR 20 O2 Sats 96% room air
Gen: Uncomfortable
Heent: pERRLA
Neck: cervical collar on
Chest: CTA bilat; + TTP right ant chest
Cor: tachy
Abd: soft
Extr: hematoma RLE
Skin: warm
Pertinent Results:
Head and CT L & S-spine negative from [**Hospital 48825**] hospital
[**2127-2-5**]: CT Pelvis and abdomen: 1. Left pubic rami fractures,
with associated soft tissue hematoma, causing mass effect on the
bladder. Size of this hematoma may be slightly increased
compared to outside hospital CT. On outside hospital CD ROM,
contrast study showed high-density material within this
hematoma, however, delayed images were not obtained to confirm
active extravasation. The bladder appears intact. 2. Left
sacroiliac diastasis with small anterior sacral fracture
adjacent to the sacroiliac joint. 3. Left lower anterior rib
fractures, with small left pneumothorax again seen. Right-sided
hemothorax. Known right tiny pneumothorax not seen. 4. Left
lower lobe subsegmental atelectasis or aspiration. 5. Grade I
retrolisthesis of L5 on S1, could be chronic
[**2127-2-5**]: X-ray pelvis AP/lat Left pubic rami fractures with
adjacent soft tissue hematoma
[**2127-2-5**]: X-ray knee Comminuted displaced right femoral shaft
fracture
[**2127-2-5**]: X-ray femur Comminuted displaced right femoral shaft
fracture
[**2127-2-5**]: Chest Port Left basilar opacity with air bronchogram is
unchanged, could be atelectasis or less likely pneumonia.
Standard PA and lateral view could be helpful to further
characterize this.
[**2-5**] bilat LENI: negative for DVT bilaterally
[**2-6**] CXR: no change, R chest tube in place
[**2-6**] Echo: Focal apical hypokinesis of RV free wall, LVEF >75%
(poor image quality)
[**2-7**] cxr: Persistent retrocardiac opacity, with increased
haziness suggesting pleural effusion atop either atelectasis
and/or consolidation
[**2-8**] cxr: Tiny right apical ptx, more apparent, Otherwise, no
significant change, Recommend attention to aortic knob on
follow-up films [**3-3**] poor definition likely [**3-3**] fluid layering,
atelectasis
[**2127-2-5**] 09:31PM GLUCOSE-141* UREA N-12 CREAT-0.6 SODIUM-140
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-24 ANION GAP-10
[**2127-2-5**] 09:31PM CK(CPK)-2194*
[**2127-2-5**] 09:31PM CK-MB-11* MB INDX-0.5 cTropnT-<0.01
[**2127-2-5**] 09:31PM CALCIUM-7.5* PHOSPHATE-2.2* MAGNESIUM-1.3*
[**2127-2-5**] 09:31PM WBC-8.6 RBC-2.85*# HGB-9.0*# HCT-24.5* MCV-86
MCH-31.5 MCHC-36.6* RDW-16.0*
[**2127-2-5**] 09:31PM PLT COUNT-121*
[**2127-2-5**] 09:31PM PT-14.1* PTT-29.2 INR(PT)-1.2*
[**2127-2-5**] 03:10AM ASA-NEG ETHANOL-48* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
She was admitted to the Trauma Service and transferred to the
Trauma ICU. Orthopedics was consulted given her right femur
fracture. An attempt at operative repair was made on day of
admission and patient became bradycardic and was brought back to
the Trauma ICU for resuscitation.
On [**2-7**] she was taken to the operating room for IVC filter
placement and IM rod of the right femur fracture. There were no
intraoperative complications. Postoperatively she has done well.
She was evaluated by Physical therapy and is being recommended
for acute rehab after her hospital stay.
Initially she was started on Lovenox postoperatively and this
was later stopped and she was started on Mini dose Coumadin 1 mg
daily. INR does not need to be checked on the Mini dose
Coumadin. She was previously on Coumadin for approximately 6
months for treatment of a DVT.
Her pain is adequately controlled on an oral regimen which
included Dilaudid po prn.
She was noted with a right antecubital thrombophlebitis and was
treated with Ancef. A UTI that she developed was also treated as
it was sensitive to the Ancef as well.
She did require transfusion with PRBC's for acute blood loss
anemia; her last hematocrit was 26.4 on [**2-10**].
A Social work consult was placed. She was evaluated by Physical
and Occupational therapy and was recommended for short term
rehab post acute hospital stay.
Medications on Admission:
Coumadin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Mini
Coumadin dose; INR does not need to be followed with Mini dose.
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): Instill in both eyes.
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic QHS (once a day (at bedtime)): Instill in both eyes.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Hydromorphone 4 mg Tablet Sig: [**1-30**] [**1-31**] Tablet PO Q3H (every
3 hours) as needed for pain.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
s/p Struck by auto
Bilateral rib fractures (left ribs [**2-4**]; right 1st rib)
Right small-moderate hemothorax
Right mid shaft femur fracture
Left inferior & superior pubic rami fracture
Urinary tract infection
Thrombophlebitis
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Followup Instructions:
Follow up in 2 weeks in [**Hospital 5498**] Clinic, call [**Telephone/Fax (1) 1228**]
for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 6429**] for an appointment. Inform the office that you will
need an AP chest xray on day of your appointment just prior to
seeing Dr. [**Last Name (STitle) **].
Completed by:[**2127-3-11**]
|
[
"V64.1",
"805.6",
"E849.5",
"E849.7",
"041.19",
"E814.7",
"041.04",
"860.4",
"821.01",
"401.9",
"458.29",
"E878.8",
"808.2",
"807.06",
"599.0",
"451.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"79.05",
"78.15",
"34.04",
"99.07",
"78.65",
"38.7",
"99.04",
"79.35",
"84.71"
] |
icd9pcs
|
[
[
[]
]
] |
6312, 6424
|
3738, 5121
|
333, 401
|
6721, 6801
|
1276, 3715
|
6824, 7221
|
1012, 1029
|
5180, 6289
|
6445, 6700
|
5147, 5157
|
1044, 1046
|
275, 295
|
429, 954
|
1060, 1257
|
976, 996
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,936
| 144,371
|
45580
|
Discharge summary
|
report
|
Admission Date: [**2157-11-12**] Discharge Date: [**2157-11-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 97194**] is an 89 year-old man with a history of CHF (EF 30%,
NYHA class III), CAD s/p CABG and recent PCI, and atrial
fibrillation, admitted with hypotension. He has had several
recent extended admissions at this hospital. Most recently, he
was admitted [**10-15**] - [**10-20**] after a fall when he was found to have
a bloody R effusion (Hct 2%). This was tapped, but fluid
immediately reaccumulated. He was then re-admitted [**10-22**] - [**11-2**]
for CHF and NSTEMI with PCI. At that time part of his hypoxia
was thought to be due to his reaccumulated effusion, and it was
again tapped, removing 1.5 L of blood-tinged sputum. His
symptoms improved, and he was discharged on increased dose of
diuretics. He has remained quite frail with a poor functional
status, using a walker but unable to get far due to shortness of
breath. His wife (25 years younger) meticulously cares for him
including 6 cup daily fluid restriction. He followed up with Dr.
[**First Name (STitle) 437**] on [**11-7**], and spironolactone was added to his regimen. His
blood pressure at home has been mostly 110s but sometimes as low
as 90. For this reason his wife seldom gives his valsartan.
.
Because of recurrent R effusion, he underwent large volume (2600
cc) thoracentesis in [**Hospital **] clinic. The procedure was stopped due to
low pressures, but the patient was asymptomatic. CXR showed a
well-expanded lung and a small pneumothorax that was thought to
be clinically insignificant.
.
Mr. [**Known lastname 97194**] was feeling better after the procedure, less short
of breath. However, this morning his wife found him very weak
and unable to climb the stairs as he usually does. She took his
blood pressure and it was >100. However, he seemed very weak and
not himself so he brought her to the ED.
.
In the ED, initial VS: 96.8 92 86/42 24 100% 3L RA. CXR was
concerning for pneumonia. He was given vancomycin and
levofloxacin. IP wanted to keep him dry, but he was given 1 L NS
for low urine output. SBP 100 lying, 80 sitting. EKG was similar
to prior.
VS prior to transfer: HR 63, BP 101/46, RR 16, O2 100% on 2L
Past Medical History:
CHF ([**9-/2157**] LVEF = 30 %, NYHA class III)
- CAD h/o MI s/p CABG s/p PCI, most recently [**10-16**]
- R>L leg swelling (after CABG vein harvest)
- DM, diet controlled
- Afib following CABG not anticoagulated
- HTN
- Colon cancer, s/p partial colectomy with colostomy
- hyperlipidemia
- Anemia
- OA
- BPH s/p TURP
- h/o scrotal hydrocele
- spinal stenosis
- carotid stenosis
- diverticulosis
- GERD
- h/o hernia repair
- h/o stroke
- h/o colon polyps
- labyrinthitis
- s/p detatched retina
- s/p tonsillectomy
Social History:
Non smoker. No EtOH. Married with 5 adult children. He is
retired. Prior to retiring he sold life insurance.
Family History:
non-contributory
Physical Exam:
VS: T 97.4, BP 122/53, HR 62, RR 11, O2 100%
GEN: pleasant man lying in bed at ~20 degrees with eyes closed,
easily arousable to voice
HEENT: moist mucosa, JVP not elevated
RESP: Crackles throughout the lower and middle right lung field,
otherwise clear with distant breath sounds
CV: 3/6 systolic murmur heard best at LUSB
ABD: empty colostomy bad, soft, nontender
EXT: no edema
NEURO: oriented x3
Pertinent Results:
ADMISSION LABS [**2157-11-12**]
[**2157-11-12**] 09:25AM BLOOD WBC-9.9# RBC-3.50* Hgb-10.6* Hct-30.8*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.8* Plt Ct-290
[**2157-11-12**] 09:25AM BLOOD Neuts-77.4* Lymphs-15.3* Monos-5.4
Eos-1.5 Baso-0.5
[**2157-11-12**] 09:25AM BLOOD PT-14.4* PTT-28.2 INR(PT)-1.2*
[**2157-11-12**] 08:42PM BLOOD Glucose-145* UreaN-24* Creat-0.9 Na-138
K-3.3 Cl-101 HCO3-29 AnGap-11
[**2157-11-12**] 09:25AM BLOOD ALT-17 AST-55* AlkPhos-63 TotBili-0.8
[**2157-11-12**] 09:25AM BLOOD Lipase-23
[**2157-11-12**] 09:25AM BLOOD cTropnT-0.03*
[**2157-11-12**] 04:35PM BLOOD cTropnT-0.03*
[**2157-11-13**] 06:16AM BLOOD cTropnT-0.03*
[**2157-11-12**] 08:42PM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1
[**2157-11-12**] 09:13AM BLOOD Glucose-127* Lactate-1.3 Na-138 K-3.3*
Cl-95* calHCO3-33*
DISCHARGE LABS [**2157-11-16**]
[**2157-11-16**] 06:00AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.7* Hct-30.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-15.2 Plt Ct-243
[**2157-11-16**] 06:00AM BLOOD Glucose-127* UreaN-30* Creat-0.8 Na-137
K-3.9 Cl-100 HCO3-31 AnGap-10
[**2157-11-16**] 06:00AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
EKG [**2157-11-12**] 8:52AM
Atrial fibrillation. Left axis deviation. Left ventricular
hypertrophy with secondary repolarization abnormality. Compared
to the previous tracing
of [**2157-10-28**] no diagnostic interim change.
EKG [**2157-11-12**] 4:45PM
Underlying rhythm is probably sinus, although baseline artifact
makes this
difficult to determine. Premature ventricular contractions and
premature
atrial contractions are probably present. Possible prior septal
myocardial
infarction, age undetermined.
CXR [**2157-11-12**]
IMPRESSION:
1. Tiny right apical pneumothorax.
2. New right lower lung opacity concerning for
asymmetric/reexpansion
pulmonary edema vs pneumonia.
3. Bilateral small-to-moderate pleural effusions with associated
compressive atelectasis.
Brief Hospital Course:
Mr. [**Known lastname 97194**] is an 89y/o man with an extensive cardiac history
including chronic systolic CHF (last EF 30%), CAD s/p CABG in
[**2149**], last PCI in [**10/2157**] with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] to LIMA, Afib not
on coumadin and recurrent pleural effusions s/p recent large
volume thoracentesis, who presented with hypotension and
weakness in the setting of increased diuretic regimen.
.
ACTIVE ISSUES:
.
# Hypotension: Was likely related to large volume thoracentesis
on [**11-11**], hypovolemia from being NPO and poor PO intake since
last discharge, strict 6 cup fluid restriction, and recent
change and titration up of diuretics and antihypertensive
regimen. He would clearly benefit from Spironolactone and
Valsartan but his BP does not tolerate these medications. He
was discharged on a less aggressive BP/CHF regimen: stopped
Valsartan, stopped Spironolactone. I addition, Tamsulosin was
stopped (he had no trouble urinating). He will continue on his
home dose of Torsemide and Sotalol. He has close follow-up with
his PCP, [**Name10 (NameIs) **] will also follow up in Heart Failure clinic.
.
# Chronic systolic CHF: last EF 30% on [**9-/2157**] TTE, NYHA class
III. No evidence of overload now. Effusions most likely due to
CHF. Patient would [**Doctor Last Name **] benefit from Spironolactone but does
not seem to tolerate. He will follow up in Heart Failure
clinic. In addition, he has Pulmonology follow-up to see if the
effusions have resolved.
.
# Atrial fibrillation: he was rate controlled (60-80). He
declines coumadin at home. He was continued on Sotalol.
.
# Coronary artery disease: Troponin was stable at .03 x3, most
likely demand ischemia in the setting of hypotension, less
likely [**2-8**] atrial stretch given no evidence of overload. Last
cath [**10/2157**] with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. He was continued on ASA 325
and plavix 75.
.
INACTIVE ISSUES:
.
# Hyperlipidemia: stable. He was continued on simvastatin.
.
# Anemia: Hct remained near 30, similar to baseline.
.
# BPH s/p TURP: holding Tamsulosin due to low
BP/lightheadedness, but hehad no trouble urinating.
.
#. GERD: stable. Continue Omeprazole.
.
TRANSITIONAL ISSUES:
.
#. Goals of Care: Unfortunately, the patient has been readmitted
frequently to the hospital; this time it was because of
asymptomatic low SBP readings. In discussions with Mr. and Mrs.
[**Known lastname 97194**], it was clear that they understand the prognosis of
advanced heart failure, especially in the setting of needing to
cut back on medications such as Spironolactone that would
benefit him in the long run. They declined a discussion about
goals of care, but said they would consider this and will
discuss it with the PCP.
Medications on Admission:
ASA 325 mg daily
clopidogrel 75 mg daily
docusate 100 mg [**Hospital1 **]
MVI
nitroglycein .3 mg prn
omeprazole 20 mg daily
simvastatin 40 mg daily
sotalol 20 mg [**Hospital1 **]
tamsulosin .4 mg qhs
torsemide 20 mg daily
valsartan 80 mg daily
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. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. sotalol 80 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day):
equivalent of 20mg dose [**Hospital1 **].
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once as needed for chest pain: may repeat every 5
minutes for 3doses; please seek help if having chest pain.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
-hypotension
-chronic systolic congestive heart failure
-fatigue
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane); has been using a wheelchair.
Discharge Instructions:
You came to the hospital because of low blood pressures. After
changing the doses of your blood pressure and heart failure
medications, your blood pressure has improved. You would likely
benefit from some of these medications in the long term; please
follow up with Cardiology.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. You have been set up with home telemonitoring.
.
You will follow up with your PCP, [**Name Initial (NameIs) **] (for blood
pressure, coronary artery disease, and heart failure
management), and also Pulmonology (to follow up your pulmonary
effusion).
.
We made the following changes to your medications:
-stop Valsartan
-stop Spironolactone
-stop Tamsulosin
Followup Instructions:
PRIMARY CARE
Name: [**Last Name (LF) 311**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: COMPREHENSIVE HEALTHCARE LLC
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 53711**]
When: Friday, [**11-18**], 1:30
CARDIOLOGY
Department: CARDIAC SERVICES
When: WEDNESDAY [**2157-11-30**] at 11:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
PULMONOLOGY
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2157-11-29**] at 10:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"799.02",
"250.00",
"272.4",
"458.9",
"428.0",
"410.72",
"285.9",
"412",
"V12.72",
"585.9",
"562.10",
"V12.54",
"530.81",
"433.10",
"V45.72",
"276.52",
"427.31",
"403.90",
"715.90",
"V45.82",
"V45.81",
"428.22",
"V13.02",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
9379, 9437
|
5459, 5900
|
273, 279
|
9565, 9565
|
3571, 5436
|
10532, 11564
|
3118, 3136
|
8550, 9356
|
9458, 9544
|
8281, 8527
|
9779, 10425
|
3151, 3552
|
7719, 8255
|
10454, 10509
|
225, 235
|
5915, 7422
|
307, 2436
|
7439, 7698
|
9580, 9755
|
2459, 2975
|
2991, 3102
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,995
| 144,511
|
1617
|
Discharge summary
|
report
|
Admission Date: [**2117-9-22**] Discharge Date: [**2117-9-29**]
Date of Birth: [**2070-3-9**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
WHOL
Major Surgical or Invasive Procedure:
[**2117-9-23**] DIAGNOSTIC CEREBRAL ANGIOGRAM
[**2117-9-28**] DIAGNOSTIC CEREBRAL ANGIOGRAM
History of Present Illness:
HPI:
47F with no significant PMH who developed a sudden onset severe
headache this afternoon around 4pm. She was driving with her
friend when she suddenly complained of severe pain at the top of
her head. She got to her friend's house and took 600mg ibuprofen
but the pain continued to be so severe she was lying on the
floor. The pain began to radiate down into her neck and she also
developed some nausea but no vomiting. Her friend called 911 and
she was brought to the ED. She has never had a headache like
this
before. Denies any dizziness/lightheadedness, changes in vision,
weakness, numbness/tingling, difficulty speaking, difficulty
walking.
Past Medical History:
PMHx:
Seasonal allergies
Social History:
Social Hx:
Lives with 16-year-old daughter. Ex-husband lives in [**Location **]. Also
has
a sister who lives in [**Location **].
Works as a realtor. Does not smoke, drinks about 6 alcoholic
beverages per week. No illicit drugs.
Family History:
Family Hx:
Maternal cousin died of an aneurysmal bleed in her 30's or 40's
Father with TIA's
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: Grade 2 [**Doctor Last Name **]: Group 2 GCS 15
T 98.8 HR 78 BP 126/77 RR 16 O2 100% RA
Gen: WD/WN, somewhat anxious, NAD.
HEENT: Pupils: 3mm to 2mm bilaterally. EOMs full.
Neck: +Pain and stiffness on neck flexion
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-13**] throughout. No pronator drift.
Sensation: Intact to light touch throughout.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
ON DISCHARGE:
Non focal exam
Pertinent Results:
[**2117-9-22**] CT Head:
FINDINGS: There is a small amount of subarachnoid blood in the
right
quadrigeminal, ambient, and suprasellar cisterns, as well as
within the
interpeduncular fossa. No other areas of hemorrhage are noted.
There is no
edema, shift of midline structures, or mass effect. The
ventricles and sulci are normal in size and there is no
intraventricular hemorrhage. Paranasal sinuses show mucosal
thickening within the ethmoid air cells, likely due to
inflammation. Mastoid air cells are clear. There is no evidence
of fracture.
[**2117-9-22**] CTA Head:
No evidence of aneurysm or vascular malformation.
[**2117-9-23**] cerbral angiogram final report pending at time of
dsicharge
[**2117-9-26**] MRI MRA brain
Final Report
STUDY: MRI and MRA of the brain.
CLINICAL INDICATION: History of subarachnoid hemorrhage, CTA and
angio
negative for aneurysm, reevaluate for subarachnoid hemorrhage.
COMPARISON: Prior MRI of the cervical spine dated [**2117-9-24**] and
prior cerebral angiogram dated [**2117-9-23**], prior CTA of
the head dated [**2117-9-22**].
TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic
susceptibility and axial diffusion-weighted sequences were
obtained.
MRA OF THE HEAD: 3D time-of-flight arteriography of the head was
obtained,
multiple rotational images and axial source images were
provided.
FINDINGS:
MRI OF THE HEAD: There is no evidence of intracranial
hemorrhage, mass, mass effect, or shifting of the normally
midline structures. The ventricles and sulci are normal in size
and configuration for the patient's age. No diffusion
abnormalities are detected. Metal artifact is demonstrated at
the convexity. The orbits are grossly unremarkable. The
paranasal sinuses and mastoid air cells are normal.
MRA OF THE HEAD:
There is evidence of vascular flow in both internal carotid
arteries as well as the vertebrobasilar system, the left
posterior communicating artery appears patent, no aneurysms or
stenotic lesions are identified. The anterior, middle and
posterior cerebral arteries are grossly normal. The basilar
artery appears normal as well as both vertebral arteries.
IMPRESSION:
Essentially normal MRA of the circle of [**Location (un) 431**] with no evidence
of flow
stenotic lesions or aneurysms larger than 2 mm in size. No
evidence of
intracranial hemorrhage or mass effect. No diffusion
abnormalities are
detected.
[**2117-9-28**] diagnostic cerebral angiogram
report not completed at time of discharge/ there was no evidence
of vasospasm during the case.
Brief Hospital Course:
Pt was admitted after being BIBA to [**Hospital1 18**] after c/o worst
headache of life. She was admitted to the ICU and started on
AED / Nimodipine and antiemetics. Her exam on arrival was non
focal except for some headahces and mild nuchal rigidity. She
suffered with some nausea and vomiting as well. The following
morning she was brought to the angio suite for a diagnostic
cerebral angiogram. This was without incident and she tolerated
it well. The Angiogram was negative for aneurysm. Her groin
sheath was pulled up in the ICU and closed via direct pressure.
Post-angio she remained stable. She had some complaints of
nausea and received multiple antiemetics as well as
dexamethasone.
On hospital day #3 she was transferred to the step down unit.
The patient voiced feelings of anxiety due to her hospital stay
and what she has been through over the past few days and asked
for a social work consultation which was placed.
The following day she was made floor status. The patient denied
nausea and the Decadron was weaned. The patient had mild
complaints of intermittent left foot pain and mild numbness and
tingling sensation. The neurological exam was non focal. There
was no pronator drift, strength was full, the angio groin site
clean dry and intact.
On hospital day #6 she returns to the angio suite for second
diagnostic cerebral angiogram. This study was normal. Her
nimodipine was discontinued. She was discharged home on [**9-29**].
Medications on Admission:
Medications prior to admission:
None
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. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-10**]
Tablets PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
3. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
subarachnoid hemorrhage
headache
Nausea/Vomitting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 4 weeks, you may resume sexual activity.
?????? After 2 weeks, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks / you will not any
imaging at that time. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Also please follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in [**1-10**] weeks.
Department:Neurology
Division:Behavioral Neurology Unit
Organization:[**Hospital1 18**]
Office Location:E/KS 284
Office Phone:([**Telephone/Fax (1) 1703**]
Office Fax:([**Telephone/Fax (1) 9382**]
Patient Location:[**Hospital Ward Name 860**] 253 / [**Hospital Ward Name **]
please set up an appointment for neurology eval after your
subarachnoid hemorrhage
PLEASE CALL THE OFFICE AT [**Telephone/Fax (1) **] TO SCHEDULE THIS
APPOINTMENT
Completed by:[**2117-9-29**]
|
[
"285.9",
"787.02",
"430",
"781.6",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
7501, 7507
|
5535, 7003
|
310, 404
|
7601, 7601
|
2977, 2993
|
9920, 10665
|
1396, 1491
|
7091, 7478
|
7528, 7580
|
7029, 7029
|
7752, 8978
|
9004, 9897
|
1521, 1896
|
7061, 7068
|
2941, 2958
|
266, 272
|
432, 1085
|
2133, 2927
|
3002, 4186
|
4759, 5512
|
7616, 7728
|
1107, 1134
|
1150, 1380
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,466
| 185,407
|
22935
|
Discharge summary
|
report
|
Admission Date: [**2200-4-24**] Discharge Date: [**2200-5-3**]
Date of Birth: [**2121-8-31**] Sex: F
Service: MEDICINE
Allergies:
Kefzol / Solarcaine / Polocaine
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Tx from OSH for cardiac catheterization
Major Surgical or Invasive Procedure:
[**4-25**]: cardiac cathetirization with stenting of the LAD with
Cypher DES
Central Line placement
[**5-2**]: exploratory laparotomy, diagnostic angiography, placment of
celiac stent
History of Present Illness:
This is a 78 yr old woman with ESRD on dialysis, h/o AAA repair
([**2192**]) who is referred by Dr. [**Last Name (STitle) 4469**] for cardiac
catheterization. Pt presented to OSH Tues [**2200-4-22**] w/progressive
SOB after several days of URI sx. She notes that she had
returned from vacationing in FL where she felt well, she had
nasal congestion and nonproductive cough, no fever/chills. She
awoke on day of presentation w/SOB without improvement after
sitting up and called 911. She denies CP/palpitations, no
HA/dizzyness/n/v/visual changes/diaphoresis. She also denies LE
edema, orthopnea, PND. She notes that she had had complete HD on
Monday, day PT presentation.
.
On presentation to the OSH, she had bp in 90s/50s which quickly
resolved. EKG showed LAD, atrial flutter at 143 bpm and peaked T
waves BNP was 2060. Her K was 7.0 and she was found to have a
TNI 0.23 which increased to 1.31, CK 133 later that day. She was
started on ASA and Metoprolol as well as Diltiazem for rate
control, had another HD session and was treated for a presumed
COPD flare w/steroids and levofloxacin.
.
On HD2, TNI increased to 2.93 and EKG showed ST depressions in
II, III, AVF although there is a question of lead placement
after repeat EKG here. She continued to be CP free.
Echocardiogram revealed mid to low septal akinesis, apical
hypokinesis new from prior echo in [**2196**]. Today, her TNI was 4.34
because of hypoxia, she was placed on CPAP but weaned down to 5L
NC prior to tx. She received 300mg Plavix. There is no OSH EKG
from today. However, EKG here shows deep TWI in precordial
leads.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
+ dyspnea on exertion, no paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope. +
fatigue.
Past Medical History:
ORIF for L hip fx. - [**2195**]
AAA repair (also by Dr. [**Last Name (STitle) 43078**] - [**2192**]
HTN - dx. about 15 yrs. ago
COPD
Hyperlipidemia
Anemia
Hydradenitis of axillae - surgically treated
ESRD on HD MWF
Social History:
Social history is significant for +tobacco 1 ppd X 60 yrs. +
etoh, 5 glasses of wine/week. There is no history of alcohol
abuse.
Family History:
+ sister w/MI at 58y.
sister - d. of pancreatic ca. in [**2192**]
brother - d. from DM
Rest of family hx. not assessed
Physical Exam:
VS: T 99.2, BP 124/49, HR 97, RR 27, O2 98% on 3LNC, 0/10 pain
Gen: NAD, resp or otherwise. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, dry MM.
Neck: Supple with JVP of 6cm, + right carotid bruits
CV: PMI located in 5th intercostal space, midclavicular line.
irregularly irregular, 2/6 systolic murmur, normal S2. No S4, no
S3; Chest: No chest wall deformities, scoliosis or kyphosis.
Resp were unlabored, no accessory muscle use. Decreased BS BL,
No crackles, wheeze, rhonchi.
Abd: Midline scar from AAA repair. Obese, soft, + RUQ
tenderness, ND, No HSM or tenderness. + abdominial bruit.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: CN's intact A&O x 3; 5/5 strength upper and lower
extremities symmetric BL
Pertinent Results:
EKG demonstrated a.flutter at 85bpm deep TWI in V2-V6 new
compared with prior dated [**2197-2-10**]
.
2D-ECHOCARDIOGRAM performed on [**2200-4-23**] at OSH demonstrated:
EF 50%, normal LV size and mild systolid dysfunction with mid to
low septal akinesis, apical hypokinesis new from prior echo in
[**2196**]. Fibrosclerotic aortic valve change without significant
stenosis
Trace MR, trace TR
.
2D-ECHOCARDIOGRAM performed on [**2200-4-23**] at OSH demonstrated:
EF 50%, normal LV size and mild systolid dysfunction with mid to
low septal akinesis, apical hypokinesis new from prior echo in
[**2196**]. Fibrosclerotic aortic valve change without significant
stenosis
Trace MR, trace TR
.
CXR [**4-24**]: no acute process
.
Cardiac cath [**4-25**]:
The initial angiography revealed an 80% calcified proximal LAD
lesion. Bivalirudin was administered for anticoagulation. The
strategy to attempt to predilate and stent the lesion with
provisional rotablation if the balloon were to fail to expand.
XBLAd 3.5 Guide provided good support. Prowater wire crossed the
lesion easily. 2.5 X 12 mm Quantum Maverick balloon appeared to
expand well although somewhat differentially at 12 atms. 3.0 X
13 mm Cypher DES was deployed at 16 atms with some mid-stent
residual stenosis but good stent apposition at stent edges. 3.0
X 9 mm NC Ranger balloon was used for mid stent post-dilated at
30 atms. There was a 20% residual stenosis with normal flow and
no dissection. The patient left the cath lab in stable
condition.
.
1. One vessel coronary artery disease.
2. Normal ventricular function.
3. Successful stenting of the LAD with Cypher DES.
.
CT abdomen [**5-1**]:
1. Bibasilar patchy airspace opacities, left greater than right,
may represent infectious process, possible aspiration. Other
entities cannot be ruled out. Follow up study after appropriate
treatment is recommended to document resolution.
2. 4.6 x 4.4 cm right adnexal cyst. If clinicaly indicated, US
and or MRI could be performed for further characterization.
3. Mild distal small bowel mucosal wall thickening may represent
ischemia given the extensive vascular calcifications, infection
or inflammatory process.
4. Fluid-filled mildly distended descending colon and sigmoid.
5. Infrarenal AAA status post repair.
6. L3 compression fracture with retropulsion of the fracture
fragments narrowing the thecal sac at this level.
[**4-27**], [**4-28**], [**4-30**]: c.diff negative x3, stool cx neg.
.
[**5-2**] blood cxs x2: NTD
Brief Hospital Course:
78 yr old woman with hx ESRD on dialysis, dyslipidemia, HTN, s/p
AAA repair, no previously known h/o CAD who was transferred for
cardiac catheterization after she was found to be in new onset
atrial flutter, elevated Troponin I, and new wall motion
abnormalities seen on echo at OSH.
.
# NSTEMI - the patient was diagnosed with NSTEMI based on
elevated cardiac enzymes, new wall motion abnormalities. She
had cardiac cathetirization on [**4-25**] showing an 80% calcified
proximal LAD lesion. She had a cypher DES placed. She was
maintained on ASA, plavix (initially loaded at OSH). She was
not treated with integrillin because of renal failure.
.
# Ischemic colitis - the day after cardiac cathetirization the
patient developed diarrhea and the onset of BRBPR, approximately
600cc of bloody stool. She remained hemodynamically stable.
The patient had an NG lavage which was negative. A blood
transfusion was started but pt developed fever from 97 to 100
degrees F, so transfusion was stopped. Transfusion reaction
labs were sent. A subsequent HCT was noted to rise from 31 to
34 and remained stable. Potential etiologies for her LGIB were
felt to be diverticular bleed/AVM or mesenteric ischemia/colonic
ischemia. Of note, pt had transient hypotension earlier that
day at dialysis from 140's to 90's, she had a recent cath with
known aortic calcifications and had new onset AF. GI was
consulted and plans were made for colonscopy while
hemodynamically supporting her and monitoring her abdominal
exam. Pt was started on golytely prep which she had difficulty
tolerating and bowel movements did not clear, although pt only
able to drink about 2.5 L of golytely. Pt refused an NGT to
help with the prep. Pt remained afebrile and abdominal exam was
benign during this time, hemodynamically stable. Her WBC was
noted to rise to 24 and she was empirically started on flagyl,
c.diff toxin was negative x3 as was a stool cx. She had
diarrhea attributed to golytely during this time. On [**5-1**] pt
became progressively tachypneic, an ABG initially was 7.52/30/69
with lactate 3.4, but gradually increased to lactate of 11. A
non-contrast abd CT was performed which showed mild distal small
bowel mucosal wall thickening. The patient had progressive
dyspnea requiring intubation and progressive hypotension,
started on levophed and fluid resuscitation. She was given
about 8L total of IVF, including 2units PRBCs, 2 Units of FFP
however continued to be hypotensive to 80s and lactate continued
to rise. GI performed sigmoidoscopy on [**5-2**], consistent with
ischemic colitis and decision was made to take pt to surgery.
On exploration pt was found to have compromised bowel. The
stomach, liver, small bowel and large bowel appeared ischemic.
Only the cecum appeared to have transmural necrosis. There was
no palpable or dopplerable celiac or SMA pulses. An intraop
Vascular Surgery consult was obtained. It was determined she
may benefit from a vascular intervention. Her abdomen was
closed. She was taken to the angiography suite. An angiogram
showed no branches off the aorta. It was possible to place a
celiac stent, but the SMA could not be crossed. She was taken
to the SICU for rescusitation. Over night, she became more
acidemic and had an increased pressor requirement. She
continued to decline and the patient's family came to the
hospital. A discussion was had and a decision to make her CMO
was made by the HCP, sister, [**Name (NI) **] [**Name (NI) **]. She expired
shortly after removing support.
.
# A. fib/flutter: new onset in setting of ischemia noted on
admission - the patient was started on metoprolol for rate
control, not candidate for current anticoagulation given GI
bleeding.
.
# s/p AAA repair - no evidence of acute process, focused on BP
control and lipid control.
.
# HTN: pt continued BB, plans for adding ACE-i when tolerated.
.
# Dyslipidemia: continue antihyperlipidemic
.
# COPD: treated for flare at OSH w/ABx and steroids.
Continued ipratropium/albuterol nebs, supplemental oxygen as
needed.
.
# FEN: cardiac diet, renal diet
.
# Code: Full
.
# Communication: sister, [**Name (NI) **] [**Name (NI) **](HCP) [**Telephone/Fax (1) 59251**]
Medications on Admission:
Medications at Home:
ASA 81mg once daily
Renagel 1600 mg TID w/meals
Labeolol 200mg once daily
zocor 40mg once daily
.
ALLERGIES: Kefzol / Solarcaine / Polocaine
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"557.0",
"286.6",
"403.91",
"518.81",
"785.52",
"414.01",
"285.21",
"427.31",
"410.71",
"491.21",
"272.4",
"995.92",
"585.6",
"584.9",
"038.9",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"39.50",
"96.04",
"88.48",
"45.24",
"37.22",
"00.45",
"36.07",
"39.90",
"96.71",
"39.95",
"88.55",
"88.52",
"00.40",
"89.64",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
11214, 11223
|
6764, 10968
|
330, 515
|
11275, 11285
|
4257, 6741
|
11342, 11353
|
3085, 3205
|
11181, 11191
|
11244, 11254
|
10994, 10994
|
11309, 11319
|
11015, 11158
|
3220, 4238
|
251, 292
|
543, 2685
|
2707, 2923
|
2939, 3069
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,102
| 192,463
|
24985
|
Discharge summary
|
report
|
Admission Date: [**2199-7-26**] Discharge Date: [**2199-7-29**]
Date of Birth: [**2171-3-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hypokalemia, lower extremity weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
28 y/o F with hx L5 spondylolithiasis, who returned from
[**First Name4 (NamePattern1) 32814**] [**Last Name (NamePattern1) 766**]. During that flight, noted severe LBP and
nausea/vomited X 1. Back pain went away by the next AM, but she
vomited all day Tuesday; this stopped Tuesday night. Also had
mild diarrhea Tuesday, also improved. Patient does note
persistent vomiting for several days last week subsequent to
taking Cipro for a UTI. Patient denies any diuretic use but
husband reports that she has been dieting recently with
decreased po intake. Prior to coming to ED patient was unable to
walk [**1-2**] instability and LE "weakness." Patient notes cramping
in her hamstrings prior to the onset of her weakness. Patient
denies any saddle anesthesia. Patient does note being
hospitalized for hypokalemia last year after a presumed
gastroenteritis.
.
On arrival to the ED vitals were 98.8, HR 78, BP 112/59, RR 18,
99% RA. Labs on arrival significant for potassium of 1.8 and CK
8619. She was given 160 mEq K in total, as well as 2L of NS,
currently finishing her 3rd bag. She was seen by neurology in
the ED. Only objective neuro signs are decreased ankle jerks,
and frankly positive romberg. Also with relative hypotension SBP
~80 responsive to IVF. Her repeat K after repletion was 2, and
she was sent to the [**Hospital Unit Name 153**] for closer monitoring during aggressive
repletion.
Past Medical History:
- L5 spondylolithesis since age 12, chronic low back pain
treated with tylenol or ibuprofen prn, no surgery
- heart murmur "since birth", was told it was benign
Social History:
Married, no kids, is an interior design student, has one
cat, +social tob, no etoh, no illicit drugs
Family History:
Back pain and disc herniation in her mother and brother.
Mother also had stroke in her 50's, wallenberg syndrome (lateral
medullary infarct secondary to PICA occlusion). GM with breast
cancer.
Physical Exam:
VS: 98.3 74-80 96/49 16-19 99%RA
General: slightly overweight, comfortable, NAD
HEENT: PERRLA, EOMI, dry MM
Neck: supple, no [**Doctor First Name **]
CVS: RRR, S1, S2, no m/r/g
Pulmonary: CTAB with no wheezes or crackles
Abd: normoactive BS, soft, NT, ND
Extremities: wwp, no lower extremity edema bilaterally
neuro: CNII-XII grossly intact with no focal deficits, toes
downgoing bilaterally, no clonus, 5/5 strength throughout, no
sensory deficits appreciated, reflexes symmetric
Pertinent Results:
Admission Labs: [**2199-7-25**]
ESR - 10
CRP - 4.5
[**Name (NI) 2591**] - PT-12.5 PTT-27.7 INR(PT)-1.0
CBC - WBC-10.3 RBC-4.13* HGB-12.5 HCT-32.9* MCV-80* MCH-30.2
MCHC-37.9* RDW-13.2 PLT COUNT-381
Diff - NEUTS-64.3 LYMPHS-29.0 MONOS-4.4 EOS-2.0 BASOS-0.4
UTox - ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS
barbitrt-NEG tricyclic-NEG
CALCIUM-9.6 PHOSPHATE-3.1 MAGNESIUM-2.6
LD(LDH)-544* CK(CPK)-8619*
GLUCOSE-101 UREA N-11 CREAT-0.6 SODIUM-142 POTASSIUM-1.8*
CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
ABG: PO2-115* PCO2-35 PH-7.52* TOTAL CO2-30 BASE XS-6
.
.
Hospital Course Labs/Studies
Serum Aldoseterone : <1 (ref [**12-16**] supine, 14-31 standing)
Serum renin: 1.9 (nml rnge: .65-5.0)
Urine diuretic screen: Pending
.
CPK Trend: 919 <- 6528 <- [**Numeric Identifier 62761**] <- [**Numeric Identifier 62762**] <- [**Numeric Identifier **] <- [**Numeric Identifier **] <-
[**Numeric Identifier 62763**] <- [**Numeric Identifier **] <- [**Numeric Identifier **] <- 8086
.
K+ Trend: 5.0 <- 4.1 <- 4.2 <- 3.4 <- 4.0 <- 3.1 <- 3.4 <- 3.4
<- 3.1
<- 3.0 <- 2.6 <- 2.1 <- 2.0 <- 1.8
.
TSH = 1.4
HBsAb - Negative HBcAb - Negative IgM HAV - Negative
[**Doctor First Name **] - Negative
HgA1C: 5.6
.
Microbiology
[**2199-7-26**] Urine Cx: no growth
[**2199-7-26**] Lyme Serology - Negative
.
.
Cardiology
[**2199-7-25**] ECG: Sinus rhythm. The QTc interval is prolonged.
Diffuse non-specific ST-T wave changes. No previous tracing
available for comparison.
.
[**2199-7-26**] ECG: Sinus rhythm. Top normal Q-T interval. Compared to
the previous tracing
of [**2199-7-25**] the QTc interval is no longer frankly prolonged.
.
.
Discharge Labs: [**2199-7-29**]
CBC: WBC-7.1 RBC-3.91* Hgb-11.8* Hct-32.7* MCV-84 MCH-30.2
MCHC-36.0* RDW-13.2 Plt Ct-282
Chem-10: Glucose-109* UreaN-6 Creat-0.4 Na-143 K-4.1 Cl-108
HCO3-29 AnGap-10 Ca-8.2* Phos-2.6* Mg-1.9
LFTs: ALT-106* AST-243* CK(CPK)-6528* AlkPhos-45 TotBili-0.2
Brief Hospital Course:
A/P: 28 y/o F with history of L5 spondylolithiasis who presented
with LE weakness and found to have K of 1.8 while in ED.
#. Hypokalemia: Patient upon presentation was found to have a K
concentration of 1.8 and elevated CK consistent with
rhabdomyolysis as well as a prolonged QT interval. The
hypokalemia was agressively repleted IV in the ED on arrival and
required transfer to the [**Hospital Unit Name 153**] for further monitored repletion.
Differerential diagnosis entertained on admission included
vomiting/diarrhea possibly from surrepticious laxative use,
Gittlemans, RTA, hyperaldosteronism, hypokalemic periodic
paralysis. While in the [**Hospital Unit Name 153**], a renal consult was called to see
the patient, the impression of which was that the patient's
clinical picture was most likely conistent with vomiting and
less likely a state of hyperaldosternosim given she was not
hypertensive. The patient continued to receive aggressive KCl
repletion as well as hydration to prevent ARF in the setting of
rhabdomyolysis. Once stable at 3.4, the patient's K+
supplementation was siwtched to PO. Urine electrolytes on
admission were consistent with extrarenal losses as the
trans-tubular potassium gradient was 1.2 (>3 c/w renal losses).
In addition to electrolyte repletion and urine lytes, additional
labs were sent including diuretic panel and plasma aldosterone
and renin. Plasma aldosterone and renin were not elevated and
the results of the diuretic panel are still pending. The patient
continued to receive aggressive hydration and was eventually
switched to PO potassium supplementation. The patient was
discharged from the [**Hospital Unit Name 153**] to the [**Female First Name (un) 1634**] Med service for additional
observation before discharge. The patient on transfer had a
potassium of 4.2 and CK of 14,494 (which was trending downward).
The ultimate impression by the consulting Nephrology team was
that the patient's potassium loss represented GI losses, likely
from vomiting and diarrhea.
.
#. Lower extremity weakness: Upon admission, the patient
presented with low back pain and lower extremity weakness,
including a left foot drop. A neurology consult was requested
and in the setting of the patients hypokalemia as well as known
history of L5 spodylolithesis, the ddx included viral myositis,
familial hypokalemic periodic paralyisis, L5/S1 radiculopathy,
compression of the sciatic nerve, and mononeuropathy multiplex.
Suggessted labs and studies included ESR and CRP, neither of
which were elevated as well as [**Doctor First Name **], lyme titers, and A1C. Lyme
titers and [**Doctor First Name **] were negative, and HgA1C = 5.6, not consistent
with underlying diabetes. An MRI of the L-spine was suggested
given the patient's left foot drop. However, with potassium
repletion and hydration the patient's bilateral leg weakness
resolved as did her left foot drop. Therefore, an MRI was not
obtained before admission, but the patient was discharged with
plans for close follow up.
.
#. Metabolic/Respiratory alkalosis: Patient was admitted with a
mixed acid base disorder. Metabolic alkalosis was though likely
related to vomiting and volume contraction. Urine panel for
diuretics was sent, but is currently pending. The patient
additionally was found to have a respiratory alkalosis of
unclear etiology but possibly from anxiety/hyperventilation.
With hydration and electroylte repletion, the patient's
acid/base disorders resolved.
.
#. Increased CK: Patient was admitted with an elevated CK of
8086 on admission which peaked at 20,411, thuoght likely to be
secondary to rhabdomyolysis in setting of hypokalemia. The
patient received aggressive hydration with alkaline fluids to
prevent ARF in the setting of rhabdomylysis. With continued
hydration and time, the patient's CK continued to fall, at a
value of 919 upon discharge, without any evidence of renal
failure.
Medications on Admission:
Prn ibuprofen or tylenol for back pain
Discharge Medications:
No Medications:
Outpatient Lab Work: [**2199-7-31**]:
Chem 7, Magnesium, CK, ALT, AST, Alk phos, Total bili.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hypokalemia, from gastrointestinal losses
2. Rhabdomyolysis secondary to hypokalemia
3. Elevated liver function tests
Secondary:
1. Spondylolisthesis
Discharge Condition:
Labs and vital signs stable.
Discharge Instructions:
Please follow up as listed below.
Please eat foods [**Doctor First Name **] in Potassium such as bananas and [**Location (un) 2452**]
juice.
Please return to care if you develop weakness, fever, chills,
vomiting, or any other concerning symptoms.
Followup Instructions:
Please returnt to [**Hospital Ward Name 23**] 6 th floor on [**2199-7-31**] for
repeat labs. Dr. [**Last Name (STitle) 9526**] will notify you of the results.
Please call ([**Telephone/Fax (1) 1300**] to schedule an appointment with Dr.
[**Last Name (STitle) 9526**] to establish with a primary care provider.
|
[
"276.8",
"276.3",
"728.88"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8857, 8863
|
4721, 8633
|
316, 322
|
9070, 9101
|
2784, 2784
|
9398, 9712
|
2072, 2267
|
8722, 8834
|
8884, 9049
|
8659, 8699
|
9125, 9375
|
4427, 4698
|
2282, 2765
|
239, 278
|
350, 1753
|
2800, 4411
|
1775, 1938
|
1954, 2056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,849
| 167,040
|
48568
|
Discharge summary
|
report
|
Admission Date: [**2194-4-10**] Discharge Date: [**2194-4-12**]
Date of Birth: [**2138-6-18**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a pleasant 55-year-old
female who underwent a bilateral mastectomy with latissimus
dorsi flaps on [**2194-4-10**] by Dr. [**Last Name (STitle) 11635**] and Dr.
[**First Name (STitle) **]. Please see the operative note for further
information in terms of intraoperative procedure and
findings. This is a pleasant 55-year-old female who was
admitted postoperatively after undergoing the procedure with
breast cancer with a strong family history who
postoperatively developed a temperature of 102.3. She was
started on some IV Kefzol. She became tachycardiac to the
120s in the PACU and had decreased urine output down to
approximately 20 cc an hour. A crit was checked which was 35
preoperatively to 31.4. An EKG did not illustrate any atrial
fibrillation but illustrated some sinus tachycardia. She was
given approximately 1-2 liters of IV fluid bolus and her
tachycardia and urine output improved. The patient was
transferred to the SICU on the [**Hospital Ward Name **] of the [**Hospital1 346**] for close monitoring overnight. She
had no problems overnight and in the morning was afebrile
with stable vital signs. Her JP drains continued to have
output but were doing well; JP one, two, three, and four, all
were between approximately 70-190 cc of fluid but the patient
will be going home with these JPs in place. She was given a
clear liquid diet and advanced to a house diet on [**2194-4-11**] in
which she had no difficulty. On [**2194-4-12**] it was felt between
the plastic surgery service as well as the breast surgery
service that the patient could go home with JP drain in
place. She had a Foley placed during the procedure in the
operating room which was discontinued on the morning of
[**2194-4-8**] and the patient voided prior to discharge. She was,
however, complaining of some urinary retention and reticent
dysuria but was able to void and states that she did not have
any difficulty voiding. The patient will be discharged to
home with VNA services for JP teaching and wound assessment.
DISCHARGE MEDICATIONS:
1. Celexa 20 mg p.o. daily.
2. Percocet one to two tablets p.o. every four to six hours,
dispensed 30.
3. Reglan 10 mg p.o. four times a day.
4. Pyridium 100 mg p.o. three times a day times three days.
5. Colace 100 mg tablet p.o. twice daily while taking
Percocet.
FOLLOW UP: The patient is to follow-up with Dr. [**First Name (STitle) **]. She
is to call and schedule a follow-up appointment and secondly
she is to follow-up with Dr. [**Last Name (STitle) 11635**] in approximately two
weeks. She is aware and in agreement with this.
DISCHARGE CONDITION: Good. Discharged to home with VNA
services.
DISCHARGE DIAGNOSIS:
1. Status post bilateral mastectomy with latissimus dorsi
flaps.
2. Breast cancer.
3. Postoperative hypovolemia.
[**Name6 (MD) 17486**] [**Name8 (MD) 11635**], [**MD Number(1) 18026**]
Dictated By:[**Doctor Last Name 22186**]
MEDQUIST36
D: [**2194-4-12**] 12:38:05
T: [**2194-4-12**] 13:29:14
Job#: [**Job Number **]
|
[
"276.5",
"V16.3",
"V50.41",
"174.3",
"998.89",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.42",
"85.54",
"85.85"
] |
icd9pcs
|
[
[
[]
]
] |
2806, 2852
|
2236, 2510
|
2873, 3225
|
2522, 2784
|
183, 2213
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,829
| 102,436
|
44235+58692
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-2-10**] Discharge Date: [**2142-2-14**]
Date of Birth: [**2092-11-24**] Sex: F
Service: [**Company 191**] Medicine
HISTORY OF PRESENT ILLNESS: (Per admitting ICU house staff):
[**First Name8 (NamePattern2) **] [**Known lastname **] is a 49-year-old woman with a past medical history
significant for diabetes mellitus type 1 with triopathy, as
well as history of DKA, end stage renal disease, CAD, and
CABG, who presented with loose bowel movements and abdominal
discomfort from her nursing home. The patient was dialyzed
on the Friday before presentation and reported that
approximately 8 lbs had been dialyzed off of her. The
history from the patient was limited by her sleepiness
(although she was arousable); the patient was responsive to
questions when prompted repeatedly. According to records,
the patient had eaten a tuna [**Location (un) 6002**] during her above noted
dialysis session and had felt "bad" afterwards, with
increased abdominal discomfort, loose stools. The patient
denied history of blood or mucus in her stools. She also
denied history of fevers, chills, cough, shortness of breath,
chest pain.
PAST MEDICAL HISTORY: 1) Diabetes mellitus type 1:
Complicated by neuropathy, retinopathy, blindness; end stage
renal disease. 2) End stage renal disease, status post
failed renal transplant ([**2126**]); on hemodialysis three times a
week; left AV fistula placed in [**2140-3-28**]. 3) Coronary artery
disease: Status post CABG ([**2132**]); status post MI in [**9-28**],
status post cardiac catheterization in [**11-28**], which revealed
three vessel disease, with patent LIMA to LAD. 4) Systolic
dysfunction: Echocardiogram in [**9-28**] revealed left
ventricular ejection fraction of 20-30% with 3+ MR, 1+ TR,
mild pulmonary hypertension, and global hypokinesis. 5) Left
bundle branch block. 6) Squamous cell carcinoma. 7)
Hepatitis C: Diagnosed in [**2-26**]. 8) MRSA bacteremia
(attributed to fistula in [**9-28**]). 9) VRE in urine. 10)
Acute on chronic cholecystitis diagnosed [**10-28**]; no
cholecystectomy was performed. 11) Peripheral vascular
disease, status post left femoral tibial bypass. 12)
Hypercholesterolemia.
ALLERGIES: Demerol, ? IV Ciprofloxacin, ? Ambien (as of this
current admission).
MEDICATIONS: Outpatient medications: Vicodin, Compazine,
Neurontin, Insulin, Nepro, Prevacid, Celexa, Nephrocaps.
SOCIAL HISTORY: The patient is a disabled nurse. She lives
in a skilled nursing facility. She denied any history of
tobacco or alcohol use.
HOSPITAL COURSE: [**First Name8 (NamePattern2) **] [**Known lastname **] was admitted to the ICU from her
skilled nursing facility on [**2142-2-10**] with diabetic
ketoacidosis; also she subsequently ruled in for a non Q wave
MI.
To summarize, the patient presented with an approximate 24
hour history of gastroenteritis which included diarrhea; the
patient was somewhat somnolent though arousable on arrival.
Her anion gap on presentation was 27 and subsequently closed
to 25 and then 20 shortly after arrival. The patient's
troponin was 9.4 on arrival and rose to a peak of 13.8 before
trending downward. The patient's CKs were negative, although
MB index was 12.7. The patient's glucose was 699 on arrival.
The patient was treated with IV fluid and an insulin drip,
and subsequently her anion gap closed within approximately 24
hours; thereafter, the patient's outpatient insulin regimen
was resumed and her fingerstick blood sugars remained for the
most part stable (although on occasion, the patient did
refuse to take her insulin). The patient was able to advance
her diet without difficulty.
Regarding the patient's non Q wave MI, the cardiology service
was consulted. Cardiology staff felt that the patient would
benefit most from medical management; thus the patient was
maintained on Aspirin and Lopressor. For a brief period, the
patient was on a Heparin drip which was subsequently
discontinued once her enzymes were convincingly trending
downward, and she remained without chest pain. (It should be
noted that the patient remained chest pain free during her
hospitalization).
The patient's ICU course was, for the most part, uneventful.
She did exhibit some mild hypotension; and chest x-ray on
[**2142-2-11**] at 2 p.m. revealed some new CHF as well as some small
bilateral pleural effusions. The patient was eventually felt
to be somewhat fluid overloaded, and thus she had
approximately 5 kg of fluid removed at dialysis on [**2142-2-14**],
with much improvement and feeling bloated.
Also of note, the patient was given Ambien on one evening, to
help her sleep; the next morning the patient was somewhat
confused on awakening and this was attributed to her having
taken Ambien.
On [**2142-2-12**] the patient was transferred from the ICU to the
medicine floor. Thereafter the patient's course remained
fairly stable. Her insulin regimen was maintained, although,
as noted above, the patient did on occasion refuse to take
her insulin. It should also be noted that the patient had
refused telemetry as well on transfer to the medicine floor.
Ultimately, the patient did well with hemodialysis, and her
fingersticks improved on the morning of discharge.
Of note, the patient's potassium was somewhat elevated on
[**2142-2-14**] (6.3 and then 5.6); patient's potassium will be
checked at 1 p.m. on [**2-14**] prior to discharging her to skilled
nursing facility.
Also of note, on transfer to the medicine floor a urinalysis
revealed that the patient did have significant number of
white cells in her urine; thus patient was prescribed renal
dose of Levofloxacin.
CONDITION ON DISCHARGE: Vital signs stable, afebrile, free
of chest pain and shortness of breath, anxious to be
discharged to her skilled nursing facility.
DISCHARGE DIAGNOSIS:
1. Diabetic ketoacidosis.
2. Non Q wave myocardial infarction.
3. Diabetes mellitus type 1.
4. End stage renal disease on hemodialysis three times a
week.
5. Coronary artery disease.
6. Hepatitis C.
7. Ejection fraction of 20-30%.
8. Left bundle branch block.
9. Urinary tract infection.
DISCHARGE MEDICATIONS: Levofloxacin 250 mg po q o day (next
dose to be given on [**2142-2-16**]), times four more doses, Heparin
5,000 units subcu [**Hospital1 **], Protonix 40 mg po q day, enteric
coated Aspirin 325 mg po q day, Lopressor 25 mg po bid,
Reglan 5 mg po before meals and q h.s., Pravachol 10 mg po q
day, Percocet 1-2 tabs (5/325 mg strength) po q 6 hours prn,
Benadryl 25 mg po q h.s. prn for insomnia, NPH insulin 10
units subcu q a.m. and 4 units subcu q p.m., Regular insulin
4 units subcu q a.m. and 2 units subcu q p.m. Regular
insulin sliding scale for qid fingersticks, as follows: for
fingerstick of 201-250 give 2 units regular insulin subcu,
for fingerstick 251-300 given 4 units regular insulin subcu,
for 301-350 given 6 units regular insulin subcu, for 351-400
give 8 units regular insulin subcu, for greater than 400 give
fingerstick less than 60, give [**Location (un) 2452**] juice and/or one amp of
D50, and notify M.D.
DISCHARGE DIET: The patient should be maintained on a renal
diet, a well as [**First Name8 (NamePattern2) **] [**Doctor First Name **] and low sodium diet, also, it is
important that the patient remain fluid restricted to one
liter of fluid per day.
FOLLOW-UP: The patient is to continue follow-up at dialysis
three times per week. Also, the patient is to follow-up with
her cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2142-2-21**] at 9:20 a.m.
Dr. [**Last Name (STitle) **] may decide to adjust the patient's cardiac regimen
further. Also, ultimately, the patient may benefit from
cardiac rehabilitation.
DR.[**First Name (STitle) **],[**First Name3 (LF) 251**] 11-692
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2142-2-14**] 13:36
T: [**2142-2-14**] 13:45
JOB#: [**Job Number **]
Name: [**Known lastname 539**], [**Known firstname 540**] A. Unit No: [**Numeric Identifier 14990**]
Admission Date: [**2142-2-10**] Discharge Date: [**2142-2-14**]
Date of Birth: [**2092-11-24**] Sex: F
Service: [**Company 112**] MEDICI
PLEASE NOTE: This is a Discharge Summary Addendum (Physical
examination and admission laboratory studies were omitted on
the prior recording).
PHYSICAL EXAMINATION: On presentation for the above-noted
admission is as follows (per admitting Intensive Care Unit
house staff): Vital signs: Heart rate 83; blood pressure
126/63; respirations 23; saturation 97% on room air. In
general, ill appearing although non-toxic woman lying in bed,
moaning. Skin and Nails: Mucous membranes dry and pink. No
clubbing. Multiple squamous cell lesions. HEENT: Right eye
prosthesis. Left eye with little or no reaction to light.
Neck: Supple, no jugular venous distention. Cardiovascular:
III/VI systolic ejection murmur at the left lower sternal
border to the apex. Lungs: Clear anteriorly. Abdomen:
Soft, nontender, positive bowel sounds. Extremities: No
clubbing or cyanosis. Trace edema.
LABORATORY DATA: On presentation: CBC revealed a white
count of 5.6, hematocrit 36.9, platelets 199, RDW 16.4.
Coagulation studies revealed an INR of 1.2, PTT of 37.2.
Initial Chem-7 revealed sodium 131, potassium 6.1, chloride
86, bicarbonate 18, BUN 29, creatinine 2.8, and glucose 699;
initial anion gap was 27. Blood cultures were drawn and are
pending at the time of this discharge summary.
EKG revealed left bundle branch block with a rate of 90 beats
per minute; first degree AV block, left axis deviation. No
significant change from study of [**2141-10-28**].
Chest x-ray revealed no congestive heart failure or
pneumonia; status post coronary artery bypass graft; no
significant change from prior studies.
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D. [**MD Number(1) 1532**]
Dictated By:[**Last Name (NamePattern1) 5803**]
MEDQUIST36
D: [**2142-2-14**] 13:47
T: [**2142-2-14**] 14:08
JOB#: [**Job Number **]
|
[
"250.53",
"070.51",
"585",
"428.0",
"362.01",
"410.71",
"276.5",
"599.0",
"250.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6158, 8410
|
5836, 6134
|
2578, 5657
|
2338, 2416
|
8433, 10141
|
189, 1171
|
1194, 2314
|
2433, 2560
|
5682, 5815
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,306
| 105,437
|
6827
|
Discharge summary
|
report
|
Admission Date: [**2191-1-10**] Discharge Date: [**2191-1-13**]
Date of Birth: [**2143-2-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
shortness of breath, difficulty sleeping
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
47 yo M hx CAD s/p MI, DM II, who presented to OSH c/o
difficulty sleeping for the last 2-3 weeks, associated with some
difficulty breathing. The pt notes he has been having difficulty
staying asleep, wakes up at night and has to sit at the side of
the bed. He notes difficulty with lying flat, but denies actual
SOB. In addition, he has been getting SOB with minimal activity,
and recently has PFTs done by his PCP. [**Name10 (NameIs) **] notes increased cough
and some increased sputum production over the last few days, no
fever or chills. He denies any episodes of chest pain, although
did have some L jaw pain 3days ago, relieved with NTG x1, lasted
several minutes. His MI in '[**83**] was associated with severe CP, L
arm pain and L jaw pain.
The pt initially presented to [**Hospital 1474**] Hospital where an ABG was
7.19/96/83. He was also noted to be hypoxemic to 80's on RA. He
was placed on BiPAP. In addition, cardiac enzymes were drawn and
troponin T noted to be 0.7. He was given ASA, lovenox SC,
solumedrol, lasix 40mg IV and transferred to [**Hospital1 18**]. No ECG
changes were noted.
On arrival to [**Hospital1 18**] ED, repeat ABG was 7.24/78/64 with HCO3 of
32. He was continued on BiPAP, CXR was felt to show CHF, given
additional lasix 20mg IV with total response of 700cc urine out,
and transferred to MICU
Past Medical History:
CAD s/p STEMI '[**83**] treated with stent to LCx
DM II
Hypercholesterolemia
PVD: ABI 0.89 in 10/99 mod R tibial dz,
s/p R common iliac stenting [**7-/2183**]
Social History:
The patient is single, has one daughter. [**Name (NI) 25835**] unemployed,
worked as machinist. 50 pck year smoker, 1ppd, denies EtOH or
recreational drug use.
Family History:
Mother died in her 70's of an myocardial infarction. Father died
in his 50's of an myocardial infarction. Sister had a
cerebrovascular accident in her 30's.
Physical Exam:
VS: 97.7, HR 96, BP 124/84, RR 18, O2 sat 94% on BiPAP 5/9, 50%
FiO2
Gen: very obese middle aged male, awake, alert, tolerating
BiPAP, no accessory muscle use, does not appear dyspneic.
HEENT: anicteric, OP clear
Neck: unable to see JVP 2/2 beard
Resp: good air movement, decreased BS L base, mild crackles b/l,
no wheezes
CV: RRR nl s1, s2, no m/r/g
Abd: obese, soft, NT, ND, no HSM
Extr: 1+ pittin edema b/l, 1+ distal pulses
Neuro: [**6-11**] motor strenth, no focal abnormalities
Pertinent Results:
Admission Labs:
[**2191-1-10**]
11:28p
pH
7.35 pCO2
68 pO2
78 HCO3
39 BaseXS
8
Comments: No Calls Made - Same Abnormality Previously Noted
Today
Type:Art; Not Intubated; Temp:36.2
Other Blood Gas:
O2-Flow: 3
[**2191-1-10**]
8:35p
CK: 47 MB: Notdone Trop-*T*: 0.04
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
[**2191-1-10**]
2:42p
5.2 34
CK: 48 MB: Notdone Trop-*T*: 0.04
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Mg: 1.8
PT: 12.7 PTT: 21.9 INR: 1.1
Other Hematology
D-Dimer: 3458
[**2191-1-10**]
10:16a
pH
7.29 pCO2
70 pO2
91 HCO3
35 BaseXS
4
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art
[**2191-1-10**]
08:32a
pH
7.31 pCO2
66 pO2
165 HCO3
35 BaseXS
4
Comments: Verified
No Calls Made - Same Abnormality Previously Noted Today
Type:Art; Bipap
Na:140 K:5.0 Cl:95 Glu:155 freeCa:1.17 Lactate:1.2
[**2191-1-10**]
06:22a
pH
7.24 pCO2
78 pO2
64 HCO3
35 BaseXS
2
Comments: Qns To Verify
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art; Not Intubated
[**2191-1-10**]
06:16a
139 98 24 146 AGap=14
5.0 32 0.8
estGFR: >75 (click for details)
CK: 70 MB: Notdone Trop-*T*: 0.05
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Other Blood Chemistry:
proBNP: 1755
Reference Values Vary With Age, Sex, And Renal Function;At 35%
Prevalence, Ntprobnp Values; < 450 Have 99% Neg Pred Value;
>1000 Have 78% Pos Pred Value;See Online Lab Manual For More
Detailed Information
94 D
15.7 18.6 221
58.8 D
N:89.2 Band:0 L:5.5 M:4.4 E:0.2 Bas:0.6
Anisocy: 1+
Plt-Est: Normal
DD ADDED 11:45AM
PT: 15.8 PTT: 32.1 INR: 1.4
.
ECG: NSR, right axis, nl intervals, small Q in III, aVF, no ST
or T wave changes
.
CXR: mild CHF, elevated L diaphragm.
.
Echo [**5-/2183**]: Preserved left ventricular systolic function. Normal
valvular function.
.
Exercise MIBI [**5-/2184**]:
IMPRESSION: Exercise myocardial perfusion scan is performed and
read without comparison and demonstrates an ejection fraction of
57% with normal wall motion. There is normal perfusion during
rest and stress imaging.
.
Cath [**5-/2183**]:
1. Coronary arteriography of this right dominant system reveals
two vessel disease. The left main is normal. The LAD has mild
luminal irregularities. The left circumflex has a long 90%
stenosis in its mid portion, with thrombus and appearance of
plaque rupture. The flow was TIMI 2. The OM1 is tiny and
diffusely diseased. The OM2 has a distal 60% stenosis. The OM3
has a proximal 30% stenosis. The RCA is dominant and diffusely
diseased up to 60% in its mid portion.
2. Hemodynamic measurements reveal elevated filling pressures,
with mean RA of 15 mmHg, mean PCWP of 26 mmHg, PA 42/26 mmHg.
The cardiac index, SVR, and PVR are within normal limits.
3. The right iliac was subtottally occluded just proximal to the
bifurcation of the femoral artery and could not be crossed with
[**Last Name (un) 25836**]
wire. Therefore, the left femoral artery approach was used.
4. Successful acute PTCA and Stenting of Mid Circumflex.
.
CXR [**2191-1-10**]: Mild congestive heart failure, elevated L
diaphragm.
.
CXR [**2191-1-11**]: Left hemidiaphragm is elevated and could be
paralyzed or eventrated. Mild pulmonary edema and small left
pleural effusion are present. Heart size is top normal. Fullness
in the right lower paratracheal region is probably due to
distended mediastinal veins.
.
Echo [**2191-1-10**]: The left atrium is mildly elongated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
right ventricular cavity is mildly dilated. Free wall motion is
depressed (?mild). The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve is grossly normal. No
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokineiss. Pulmonary artery systolic hypertension. Preserved
global left ventricular systolic function. Is there a history to
suggest a primary pulmonary process (e.g., pulmonary embolism,
COPD, bronchospasm, etc.)
.
CTA [**2191-1-10**]: 1. Study limited by motion and bolus timing with no
definite evidence of segmental or main pulmonary artery
embolism.
2. Opacity in the left lower lobe with shift in the major
fissure posteriorly consistent with near total
collapse/atelectasis.
3. Opacities in the inferior lingula and right lower lobe also
suggestive of atelectasis.
Brief Hospital Course:
A&P: 47 yo M hx CAD, DM p/w mild dyspnea, orthopnea x [**3-12**]
weeks, with hypercarbia, hypoxia and new Aa gradient and right
heart failure.
.
1 Hypercarbia - appears to be acute on chronic based on his ABG
and bicarbonate. Likely his pCO2 baseline elevated (mid 60's).
This may be [**3-11**] chronic COPD with concominant OSA/obesity
hypoventialaion that may have been acutely exacerbated by left
hemidiaphragm paresis or acute bronchitis. He was seen by sleep
medicine and set up for outpatient sleep study. Additionally he
was started on BIPAP in house with settings of 9/5cm H2O, that
he was minimally compliant with while here. He was set up to
have home BIPAP on discharge. He was also started on albuterol
and iprtropium. He was started on azithromycin to complete a 5
day course which seemed to improve his productive cough.
Supplemental oxygen was used to maintain a goal o2 sat >88% but
<92%. He will follow-up in sleep disorders clinic and
additionally was set-up to have primary care at [**Company 191**].
.
2 Hypoxia - pt may have obesity hypoventilation syndrome, also
may have an element of CHF and COPD, CTA negative for PE.
Polycythemia suggests chronic hypoxia. O2 sat on room air
without ambulation was 84%, with 3-4 L by nasal canula he
maintained goal O2 sat of 88%-92%. He was discharged with home
O2 to wear at all times and advised of the dangers of smoking on
oxygen.
.
3 conjunctivitis-per pt at baseline, suspect [**3-11**] BIPAP causing
OP inflammation, increased lacrimal obstruction. Will encourage
saline nasal spray, to decrease inflammation, no other
signs/symptoms of viral URI.
.
4 CAD - elevated troponin may be explained by pulmonary process.
No evidence of ACS based on lack of symptoms, no EKG changes, CE
flat x3. Continue ASA, statin, B-blocker at low dose. Lipid
panel WNL.
.
5 DM - restart glipizide, use sliding scale insulin, hgb A1C
6.0.
.
6 Ppx - heparin sc, bowel regimen, no GI ppx indicated
currently.
.
7 Code: Full.
Medications on Admission:
ASA, glipizide, lopressor, atorvastatin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*QS 1 unit* Refills:*2*
4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Capsule(s)* Refills:*0*
5. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal TID (3 times a day) as needed.
Disp:*QS 1 bottle* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. home oxygen
Mr. [**Known lastname 174**] will require home oxygen therapy by nasal canula at
all times at a rate of [**4-11**] liters per minute to maintain oxygen
saturation >88% but <92%.
9. home BIPAP therapy
Mr. [**Known lastname 174**] will need home BIPAP therapy with set at 9cm H2O over
5cm of H2O, with 3 liters per minute of oxygen, to be worn at
night while sleeping for obstructive sleep apnea.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypercarbia, hypoxia
.
Obstructive sleep apnea, chronic obstructive pulmonary disease,
obesity hyperventilation.
Discharge Condition:
Stable.
Discharge Instructions:
Please keep all follow-up appointments. Please take all
medications as prescribed. Please call your primary care doctor,
Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 25837**] ([**Telephone/Fax (1) 25838**] if you experience any
chest pain, shortness of breath, worsened cough, fevers, chills,
nausea, vomitting, night sweats, or any symptoms that are
concerning to you.
Followup Instructions:
Please also follow-up with sleep disorders clinic on [**1-19**], [**2190**] at 10:30am-[**Location (un) **] (neurology) of the [**Hospital Ward Name 23**]
building, please call ([**Telephone/Fax (1) 513**] if you need to change this
appointment or if you have questions.
.
Please also follow-up with your new primary care doctor here,
Dr. [**Known firstname **] [**Last Name (NamePattern1) **] on the [**Location (un) **] of the [**Hospital Ward Name 23**] building on
[**2191-1-19**], at 2:00pm.
.
You should recieve a phone call tomorrow by Sleep Health Center
to schedule you for sleep study.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"V45.82",
"289.0",
"412",
"327.26",
"428.0",
"518.84",
"491.22",
"416.9",
"327.23",
"272.0",
"414.01",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10699, 10705
|
7438, 9410
|
354, 362
|
10862, 10872
|
2780, 2780
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2101, 2260
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10726, 10841
|
9436, 9477
|
10896, 11291
|
2275, 2761
|
274, 316
|
390, 1725
|
2796, 7413
|
1747, 1908
|
1924, 2085
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,711
| 143,201
|
9054+9055+9056
|
Discharge summary
|
report+report+report
|
Admission Date: [**2186-11-2**] Discharge Date: [**2186-11-14**]
Service: Gold
The patient is an 85-year-old woman referred to Dr. [**Last Name (STitle) 468**]
by a gastroenterologist, Dr. [**Last Name (STitle) **] for an ampullary mass.
The patient had noticed painless jaundice with dark urine,
pruritus, constipation and decreased appetite along with
early satiety and a 10 pound weight loss. She presented for
ERCP with biopsy on [**2186-10-13**], during which an
ampullary mass was noted.
Her past medical history is significant for two breast lumps,
varicose veins, a tonsillectomy and adenoidectomy. She has
no known drug allergies. Her only medications are
multi-vitamin and Tums. She does not use alcohol or tobacco.
Social history - she used to work for a surgeon.
She presented on [**2186-11-2**] to the preoperative
holding area and from there underwent a pylorus preserving
pancreaticoduodenectomy, aka Whipple procedure along with an
open cholecystectomy. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was left in the right
upper quadrant near the site of biliary anastomosis.
Postoperatively she was fluid requiring and it was noted that
she seemed to have a slow oozing requiring blood products at
a rate of several units a day. Her vital signs remained
stable and her exam remained benign until postoperative day
two when her hematocrit started to fall without appropriate
bumping in response to blood products. Her abdomen became
firm and more tender. It was decided at that point that she
should be returned to the operating room and look for a
source of bleeding. Therefore on [**2186-11-4**], she
underwent exploratory laparotomy with findings of
hemoperitoneum, but no active arterial or venous bleeding.
All anastomoses were intact. The abdomen was washed out and
the patient was returned to an ICU setting still intubated.
She remained intubated on Levo and Flagyl for a question of
aspiration pneumonia as well as a friendly environment in a
re-operated abdomen for infection. Over the ensuing several
days her fluids were management, following her CBP and urine
output and eventually we were able to diurese her to the
point where extubation was feasible. She was extubated on
postoperative day seven and five, however, remained in the
ICU for pulmonary toilette and continued diuresis. On
postoperative day ten and eight, her white count started to
increase and we noted that her [**Location (un) 1661**]-[**Location (un) 1662**] drain output had
become bilious. Octreotide was re-started, her lines were
re-sited. TPN was started and she was pan-cultured. None of
the cultures grew anything and her white count started to
decrease.
By systems neurologically she is receiving morphine
periodically for pain control. She is getting low dose
Lopressor 2.5 mg IV q6 hours for heart rate control
Respiratory wise she is getting pulmonary toilette, incentive
spirometry, PT has been working with her, she has been
getting out of bed for a number of hours each day.
Gastrointestinal system - she is on TPN, Reglan and
octreotide. Her genitourinary system - she is making
adequate urine and has been receiving small doses of Lasix 10
mg IV as often as three times per day to keep her even to
slightly negative in volume status. Infection disease - we
have her on Zosyn, she is now on Zosyn day three. Heme - she
has no current issues.
DISPOSITION: Currently she is in the ICU, however, she is
scheduled to go to the floor tomorrow and will be ready for
rehab.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2186-11-13**] 17:08
T: [**2186-11-17**] 13:44
JOB#: [**Job Number 31296**]
Admission Date: [**2159-4-9**] Discharge Date: [**2186-12-4**]
Date of Birth: Sex: F
Service:
ADDENDUM TO HOSPITAL COURSE: The patient was discharged to
rehab on postoperative day 31 in stable condition. Her
V.A.C. was changed by the house officers prior to discharge
who noted that her wound continued to heal well. The
patient's main active issue at this point continues to be her
deconditioning and generalized weakness secondary to her
operative interventions, in addition to her poor po intake
requiring total parenteral nutrition.
DISCHARGE STATUS: To rehab.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Insulin sliding scale, if the glucose is 120 to 160 mg
per deciliter please give 2 units of regular insulin,
glucoses 160 to 200 mg per deciliter please give 4 units of
regular insulin, please continue this scale and continue to
give an additional 2 units of regular insulin for every
increase of glucose by 40 mg per deciliter.
2. Dulcolax 10 mg rectal suppository one suppository q day
prn constipation.
3. Tylenol 325 mg tablet one to two tablets po q 4 to 6
hours prn.
4. Sucralfate 1 gram tablet one tablet oral q.i.d.
5. Nystatin oral suspension 5 cc q.i.d., please swab the
patient's mouth to prevent aspiration.
6. Zoloft 50 mg tablet one tablet po q day, please crush the
tablet in puree.
7. Miconazole topical powder apply t.i.d. to the redness on
the abdomen right lateral to her wound and to her skin folds
adjacent to the wound.
8. Reglan 10 mg tablet one tablet po q 6 hours.
9. Metoprolol 100 mg tablet 1.25 tablets po b.i.d., hold for
heart rate less then 60, systolic blood pressure less then
110.
10. Protonix 40 mg tablet one tablet po b.i.d.
DISCHARGE INSTRUCTIONS: Diet, clear liquids, pureed solids.
Consistency, pureed thin liquids with Boost for breakfast,
lunch and dinner. Crush medications in puree. Activity, out
of bed three times a day with physical therapy. Call your
physician or return to the Emergency Department if fevers,
chills, temperature greater then 101.5, redness, swelling,
drainage from the incision site or persistent nausea and
vomiting.
FINAL DIAGNOSES:
1. Pancreatic periampullary carcinoma.
2. Biliary leak.
3. Hemoperitoneum.
4. Bilateral pleural effusions.
5. Intraabdominal hematoma.
6. Ischemic gastrojejunal anastomosis.
7. Upper gastrointestinal bleed.
8. Depression.
9. Wound infection.
FOLLOW UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) 468**] in two weeks. Please call his office to schedule
this follow up appointment.
MAJOR SURGICAL OR INVASIVE PROCEDURES:
1. Status post Whipple [**2186-11-2**].
2. Status post exploratory laparotomy for hemoperitoneum
[**2186-11-4**].
3. Status post peritoneal hematoma IR drainage [**2186-11-16**].
4. Status post right thoracentesis [**2186-11-16**].
5. Status post left thoracentesis [**2186-11-17**].
REHAB TREATMENTS AND FREQUENCY:
1. Continue total parenteral nutrition for nutritional
needs. Her most recent total parenteral nutrition order is
volume of 1500 mls per day, amino acids 90 grams per day,
branch chain amino acid 0 grams per day, dextrose 255 grams
per day, fat 30 grams per day, parenteral multivitamins and
trace elements q day, vitamin K 10 mg q Monday, sodium
chloride equals 75, sodium acetate equals 0, sodium phosphate
equals 30, potassium chloride equals 20, potassium acetate
equals 30, potassium phosphate equals 35, magnesium sulfate
equals 20, calcium gluconate equals 10, heparin equals 0,
insulin equals 16 units, zinc equals 10 mg.
2. Please check a chem 10 panel q.o.d. or three times a week
to adjust total parenteral nutrition.
3. Foley to gravity.
4. Oxygen nasal cannula to keep O2 sats greater then 92%.
5. Close suction biliary drain to JP bulb. Please ensure
that the bulb is to suction, empty t.i.d. and prn and record
drain output.
6. Wound care, continue V.A.C. dressing to abdominal wound
site and please change q three to four days.
7. Physical therapy for out of bed t.i.d. and to improve
strength, conditioning and rehabilitation.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 31297**]
MEDQUIST36
D: [**2186-12-4**] 09:51
T: [**2186-12-4**] 11:08
JOB#: [**Job Number 31298**]
Admission Date: [**2186-11-2**] Discharge Date: [**2186-12-4**]
Service: General Surgery - Gold
PRINCIPLE CARE PROVIDER: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Phone
#[**Telephone/Fax (1) 25832**].
CHIEF COMPLAINT: Periampullary carcinoma.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 31299**] is an 85 year old
woman referring to Dr. [**Last Name (STitle) 468**] by a gastroenterologist, Dr.
[**Last Name (STitle) **] for an ampullary mass. The patient had noticed
painless jaundice for one monthly with dark urine, pruritus,
constipation and decreased appetite along with early satiety
and a ten pound weight loss. She presented for an endoscopic
retrograde cholangiopancreatography with biopsy on [**2186-10-13**], during which an ampullary mass was noted and
positive for pathology-revealing adenocarcinoma.
PAST MEDICAL HISTORY: Significant for two breast lumps,
varicose veins, tonsillectomy and adenoidectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: She was only taking Multivitamins
and TUMS.
SOCIAL HISTORY: She used to work for a surgeon prior to
retirement.
PHYSICAL EXAMINATION: Vital signs revealed temperature 96.0,
pulse 66, blood pressure 145/44, respiratory rate 20 and 96%
on room air. Head, eyes, ears, nose and throat, pupils
equally round and reactive to light and accommodation,
extraocular muscles intact. Lungs clear to auscultation
bilaterally. Cardiovascular, regular rate and rhythm.
Abdomen, soft, nontender, nondistended.
HOSPITAL COURSE: The patient presented on [**2186-11-2**]
for her planned procedure of a pylorus-preserving
pancreaticoduodenectomy, aka Whipple procedure, along with an
open cholecystectomy. The procedure went as planned without
any complications and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was left in the right
upper quadrant site near the site of her biliary anastomosis.
Please see the operative report for further details.
Additionally, please see the discharge summary by Dr. [**Last Name (STitle) 468**]
for the dates of [**11-2**] to [**11-14**] for information
regarding immediate postoperative event. As a summary of
these events in brief - The patient was postoperatively
fluid-requiring and noticing that she was having slow oozing
requiring blood products at a rate of several units a day
postoperatively. She was stable until postoperative day #2
when her hematocrit fell without appropriate response to
blood products and her abdomen had become firm and tender. A
decision was made to take the patient back to the Operating
Room to look for a source of bleeding, and on [**2186-11-4**], on postoperative day #2 she underwent an exploratory
laparotomy with findings consistent with a hemoperitoneum,
but no evidence of any active arterial or venous bleeding.
It was thought that the patient likely had a low ooze after
her operation from the posterior-SMV divided mesenteric base
of the afferent limb. Her abdomen was washed out and she was
returned to the Intensive Care Unit setting still intubated
on Levofloxacin and Flagyl for concern of an aspiration
pneumonia. Over the ensuing days her fluids were managed
following her central venous pressure and urine output and
she was diuresed successfully and extubated on postoperative
day #7. She remained in the Intensive Care Unit for
pulmonary toilet and continued diuresis. On postoperative
day #10 it was noticed that her [**Location (un) 1661**]-[**Location (un) 1662**] output had
become bilious and Octreotide was restarted and her lines
were changed. Total parenteral nutrition was started at this
time and she was pancultured with all cultures later
revealing no growth.
On postoperative day #12, the patient underwent a swallow
study to assess her swallowing ability and she aspirated thin
liquids and failed the study. On postoperative day #13, the
patient underwent a video swallow study revealing aspiration
of thin liquids that reversed with postural maneuvers in a
chin tuck. Therefore recommendations were made by a
nutritionist to continue the patient on a p.o. diet
consisting of thin liquids with chin tuck and strict
aspiration precautions in addition to pureed solids and all
medications in pureed form. The patient was transferred to
the floor on postoperative day #12 on Zosyn for Serratia that
grew out of the sputum on [**2186-11-7**] and she was
continued on her total parenteral nutrition because of slow
p.o. intake. She was additionally continued on Lasix for
pulmonary diuresis. At this time the patient remained very
deconditioned and weak status post her two operations and she
was found to have marginal mental status where she was able
to understand questions but had trouble responding with
speech which she attributes to a dry mouth. A neurology
consult was obtained on postoperative day #12 and revealed no
focal findings, but they found that likely etiologic agents
involved generalized weakness and deconditioning in addition
to intervascular dehydration. A computerized tomography scan
of the head was performed which revealed no stroke or
hemorrhage. A follow up magnetic resonance imaging scan
revealed only mild to moderate atherosclerotic changes of the
cavernous portion of her right internal carotid artery, but
otherwise normal. Her Octreotide was discontinued as it was
having no effect on the biliary leak.
On postoperative day #13, a computerized tomography scan of
the abdomen was performed because of persistently elevated
white count in the low 20s. This computerized tomography
scan revealed fluid collection in her mid abdomen which was
concerning for an abscess, persistent bilateral pleural
effusions, ascites and extensive subcutaneous edema. She
therefore underwent computerized tomographic-guided drainage
of the fluid collection which turned out to be a hematoma.
40 cc of dark bloody material was successfully drained by IR
and this later grew out [**Female First Name (un) 564**]. Additionally, on this day
the patient underwent a right thoracentesis for her right
pleural effusion and under ultrasound guidance the
interventional radiologist was able to successfully drain 650
cc of clear straw-colored fluid. On postoperative day #14,
Methicillin-sensitive resistant Staphylococcus aureus swabs
of her rectum and nasal cavities revealed
Methicillin-sensitive resistant Staphylococcus aureus and at
this time Zosyn was changed to Vancomycin. She also
underwent a left thoracentesis for 450 cc of clear fluid with
her postoperative chest x-ray revealing no evidence of
pneumothorax.
About four hours after returning from her left thoracentesis
the house officer was emergently called as the patient had
experienced question hemoptysis versus hematemesis where the
nurse noted 50 cc of bright red blood coming out of the
patient's mouth. The patient denied any shortness of breath
or difficulty breathing but was found to have an oxygen
saturation that had decreased to the low 80s and high 70s
with hypotension of 100/50. The patient was placed on a
nonrebreather of 100% and emergently transferred to the
Intensive Care Unit where a hematocrit showed a drop from 30
to 24. The patient received 3 units of packed red cells and
2 units of fresh frozen plasma and she was continued on
Vancomycin in addition to starting Levofloxacin and
Fluconazole. On postoperative day #15 an
esophagogastroduodenoscopy was performed revealing blood in
the stomach body. It revealed dark red blood just distal to
the surgical anastomosis with erythematous, edematous,
friable small intestinal loop just beyond her anastomosis
which all suggested ischemia of her anastomosis.
Esophagogastroduodenoscopy was also significant for an ulcer
in the lesser curvature. She therefore was started on
Sucralfate 1 gm q.i.d. and Pantoprazole 40 mg intravenously
b.i.d. Additionally Flagyl was started for broad-spectrum
intravenous antibiotic coverage. On postoperative day #16,
the patient received 2 units of packed red blood cells during
the night. Extensive discussions were made with the family
including her sister [**Name (NI) 2127**] was her health proxy as well as
her nephew about future plans and recovery for the patient.
After a discussion, the decision was made that the patient
would be Do-Not-Resuscitate, Do-Not-Intubate without any
further operative interventions, and that her
gastrointestinal bleed would be managed medically with
transfusions of red cells as necessary.
On postoperative day #17 the patient's hematocrit stabilized.
She required no further transfusions, but her wound was
opened revealing thick biliary secretions on top of a small
bed of necrotic tissue, therefore the wound was packed with
wet to dry dressings t.i.d. The patient stabilized on
postoperative day #18 to 20 and was later transferred to the
floor on postoperative day #21 with a stable hematocrit on
four antibiotic regimen, consisting of Fluconazole,
Levofloxacin, Vancomycin and Flagyl. Her Metoprolol was
initially increased to 15 intravenously q. 6 hours for
tachycardia and hypertension, but once she was able to take
p.o. her Metoprolol was changed to 75 mg p.o. b.i.d. The
Zoloft was started at this time, as the patient was
exhibiting symptoms of depression.
Additionally marked erythema was noted on the right lateral
side of her abdomen over her extensive subcutaneous edema.
On postoperative day 22 to 28, noticeable findings included
placement of a vacuum-assist closure device on her open wound
that was changed every three days with good success revealing
a nicely healed wound. Her [**Location (un) 1661**]-[**Location (un) 1662**] drain that was
draining copious amounts of bilious secretions was placed to
wall suction. Additionally, the patient was continued on
total parenteral nutrition as nutrition continued to be her
biggest problem with poor p.o. intake. Discussions were made
with her sister and family members regarding the option of a
feeding tube placement, but the decision was collectively
made that the patient would not agree to a feeding tube
placement and that she would continue to try to increase her
p.o. intake by mouth. Her erythema had stabilized on
broad-spectrum antibiotics and her white count had eventually
decreased from the low 20s. A PICC line was placed on
postoperative day #25 and her left internal jugular central
venous line was discontinued at this time.
On postoperative day #28 to 30 her white count continued to
decrease from 20 to 14.6 and the right lateral abdominal
erythema had virtually resolved on her antibiotic course.
Her biliary drain remained with a stable output of about 300
cc/day. Her wound appeared much better after vacuum-assisted
closure device and required occasional debridement prior to
vacuum-assisted closure dressing changes. Additionally the
patient began to auto-diuresing at this time, being 1 liter
to 1.5 liters negative per day and her whole body total edema
had tremendously improved. The patient's Metoprolol was
increased from 75 b.i.d. to 100 b.i.d., and was later
increased again to 125 b.i.d. for heartrates in the mid 90s
and systolic blood pressures in the 140s. On postoperative
day #31, the patient was discontinued to rehabilitation in
stable condition. Her right lateral erythema had virtually
resolved and her total body edema had much decreased after
her auto diuresis for the past four days. Her
vacuum-assisted closure dressing was changed on the day of
discharge by surgical house officers who noted that the wound
continued to heal well. The patient's primary issue at this
point
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 22434**]
MEDQUIST36
D: [**2186-12-4**] 09:43
T: [**2186-12-4**] 09:53
JOB#: [**Job Number 31300**]
|
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49,925
| 108,718
|
40878
|
Discharge summary
|
report
|
Admission Date: [**2151-5-25**] Discharge Date: [**2151-6-24**]
Date of Birth: [**2101-2-27**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin / Zosyn
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Right abdominal pain, Left lower leg cellulitis
Major Surgical or Invasive Procedure:
PICC line placement
Incision and Drainage of left ankle infection - [**6-9**]
History of Present Illness:
Patient is a 50 yo male with hx of alcohol abuse,hepatitis C
diagnosed three years ago presented to an OSH for evaluation of
a swollen left leg. Patient presents with jaundice and
abdominal distension which he states started three weeks ago. He
was sent for CTA to rule out PE and also an abdominal CT to
further evaluate his cause of jaundice and abdominal distension.
At the OSH, he was found to have perforated duodenal ulcer on
CT scan from outside hospital. Patient transferred to [**Hospital1 18**] for
further evaluation and treatment Patient denies any recent
trauma to his left lower extremity and states that he has
noticed the the edema starting 10 days prior. He denies any
fevers or chills. He denies any nausea, vomiting or abdominal
pain. He has had regular bowel habits and tolerating a regular
diet. No difficulty swallowing or pain with swallowing. He
denies any shortness of breath or chest pain.
Past Medical History:
GERD
HTN
Gout
CAD
PSH:
Cervical laminectomy
Social History:
+ Tobacco
+ ETOH - 6-9 beers/day
Family History:
Father Hx MRSA
Physical Exam:
ADMISSION EXAM:
Vitals: T 100.1 103 116/60 20 100% 4L
Gen: NAD, Awake, Alert Ox3, jaundiced
HEENT: Scleral icterus, mucosa moist
CVS: Tachycardic, S1&S2
Pulm: CTA BL
Abd: Soft, greatly distended, nontender, tympanic, no guarding,
no rebound, Caput Medusa
Ext: BL LE edema with left LE greater then right. Left lower
extremity with erythema at planter surface. Tender to
palpation. Palpable pulses BL DP.
.
DISCHARGE EXAM:
Vitals: O2 sat 98%RA
Lungs: Mild crackles at bases
CVS: 3/6 systolic murmur
EXT: [**3-18**]+ pitting edema b/l
Pertinent Results:
Admission Labs:
[**2151-5-25**] 04:53AM BLOOD WBC-9.4 RBC-3.35* Hgb-11.1* Hct-31.2*
MCV-93 MCH-33.2* MCHC-35.7* RDW-16.9* Plt Ct-45*
[**2151-5-25**] 05:05PM BLOOD WBC-7.9 RBC-3.15* Hgb-10.6* Hct-29.5*
MCV-94 MCH-33.7* MCHC-36.0* RDW-17.1* Plt Ct-39*
[**2151-5-25**] 04:53AM BLOOD PT-20.2* PTT-37.8* INR(PT)-1.8*
[**2151-5-25**] 04:53AM BLOOD Glucose-114* UreaN-31* Creat-1.1 Na-131*
K-4.4 Cl-102 HCO3-21* AnGap-12
[**2151-5-25**] 04:53AM BLOOD ALT-78* AST-133* AlkPhos-182*
TotBili-10.1* DirBili-6.7* IndBili-3.4
[**2151-5-25**] 04:53AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.5 Mg-1.9
[**2151-5-25**] 05:05PM BLOOD Calcium-7.8* Phos-3.2 Mg-1.9 Iron-128
[**2151-6-5**] 06:11AM BLOOD VitB12-GREATER TH Folate-12.7
[**2151-5-25**] 05:05PM BLOOD calTIBC-163* Ferritn-582* TRF-125*
[**2151-5-25**] 05:05PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2151-5-25**] 05:05PM BLOOD Smooth-POSITIVE *
.
Ceruloplasmin 32
IMMUNOGLOBULIN G SUBCLASS 1 1310 H 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 327 241-700 mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 98 22-178 mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 119.0 H 4.0-86.0 mg/dL
IMMUNOGLOBULIN G, SERUM 1700 H [**Telephone/Fax (1) **] mg/dL
.
HCV GENOTYPE, LIPA 1a
.
IMAGING:
LENI [**2151-5-25**]:
IMPRESSION: No deep vein thrombosis in bilateral lower
extremities. Left
calf edema.
.
RUQ U/S [**2151-5-25**]:
IMPRESSION:
1. Enlarged heterogeneous macronodular liver consistent with
history of
hepatitis/cirrhosis.
2. Significant gallbladder wall edema in a nondistended
gallbladder may be
suggestive of acute on chronic hepatitis. Diagnostic
cosnideraitons may
include acalculous cholecystitis, but that is felt much less
likely.
3. Splenomegaly.
4. Patent portal and hepatic veins as well as superior
mesenteric vein and
inferior vena cava.
.
[**2151-6-2**]:
IMPRESSION:
1. Distended gallbladder with gallbladder wall edema,
nonspecific in the
setting of liver disease and perihepatic ascites, but could be
compatible
with cholecystitis. Of note there was a probable gallstone seen
on CT that
was not visualized on this examination. Clinical correlation
recommended and a HIDA scan may be performed for further
clarification if indicated.
2. Marked splenomegaly.
3. Cirrhotic liver with perihepatic ascites.
.
CT A/P [**2151-5-25**]:
IMPRESSION:
1. No findings of perforated duodenal ulcer identified.
2. Cirrhotic liver with sequelae of portal hypertension
including
intra-abdominal collateral vessels, splenomegaly, and ascites.
Within the
limits of this single phase examination, no concerning hepatic
lesion is
noted.
3. Small gallstone with marked third spacing of the gallbladder
wall likely related to underlying hepatic dysfunction and low
albumin. If there remains a high clinical concern for acute
cholecystitis, suggest correlation with a HIDA scan.
.
MRI [**2151-5-30**]:
IMPRESSION:
1. Abnormal bone marrow signal with some cortical disruption
within the
distal posterolateral tibia with adjacent abnormal bone marrow
signal within the fibula, this is concerning for osteomyelitis.
2. Adjacent fluid collection, which may be infected. Note MRI is
insensitive to distinguish between infected and noninfected
fluid.
3. Small tibiotalar and subtalar joint effusions. Note again MRI
is
sensitive to distinguish between infected and noninfected fluid.
4. Reactive edema within the talus and calcaneus.
5. Subcutaneous edema, which may represent cellulitis.
6. Tenosynovitis of the flexor tendons as described above.
7. Tendinosis and/or split tear of the peroneus tendons, as
above.
.
MICROBIOLOGY:
Blood Culture, Routine (Final [**2151-6-11**]):
STAPH AUREUS COAG +.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2151-6-2**] 12:20 pm JOINT FLUID Site: ANKLE
LEFT ANKLE JOINT FLUID.
GRAM STAIN (Final [**2151-6-4**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2151-6-3**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FLUID CULTURE (Final [**2151-6-5**]):
Reported to and read back by [**Doctor Last Name **] [**Doctor Last Name **] 9-0929 [**2151-6-3**]
1:40PM.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2151-6-5**] 3:00 pm JOINT FLUID Source: left ankle.
GRAM STAIN (Final [**2151-6-5**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2151-6-8**]):
Reported to and read back by DR. [**Last Name (STitle) **], J. [**2151-6-6**] 12:30PM.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 320-5091K [**2151-6-2**].
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2151-6-8**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary
.
[**2151-6-9**] 1:24 pm ABSCESS
GRAM STAIN (Final [**2151-6-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2151-6-12**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood cx [**Date range (1) 89282**] - negative
C dificile PCR negative
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2151-6-24**] 05:39 2.5* 2.24* 7.7* 21.3* 95 34.2* 35.9* 17.4*
35*
[**2151-6-24**] 05:39 ANC
1275*
Gluc UreaN Creat Na K Cl HCO3 AnGap
[**2151-6-24**] 05:39 111*1 30* 2.0* 134 3.3 100 26 11
ALT AST AlkPhos TotBili
[**2151-6-24**] 05:39 19 52* 93 8.0*
Brief Hospital Course:
Surgical course:
.
The patient was initially admitted to the Hepatobiliary Surgical
Service for evaluation and treatment of "perforated duodenal
ulcer" noted at OSH CT scan. Repeat admission CT demonstrated no
concern for free air or duodenal perforation. Admission
examination was concerning for LLE swelling and cellulitis.
.
Admission CT demonstrated no evidence of perforated duodenal
ulcer, but did demonstrate an edematous GB consistent with
cirrhosis. Hepatology consultation obtained given history of
liver failure. LFTs trended upward, which demonstrated concern
for liver failure. He was then transferred to the Medicine
service
.
Medicine course:
.
# Alcoholic hepatitis: Clinical picture and laboratory results
believed to be consistent with alcoholic hepatitis. The patient
had a discriminant function that peaked > 100, however steroids
were not given (received 1 dose of prednisone) as there was
concern regarding worsening infection (see below). The patient
was treated with supportive care while his other issues were
managed. He was able to maintain adequate nutrition through POs
and did not require placement of an NG or Dobhoff tube.
Bilirubin and INR were trending down at the time of discharge
from a peak of 47 and 3.7 to 8.0 and 2.3 respectively.
.
# Left ankle septic joint and tibial osteomyelitis: The patient
had positive admission blood cultures for MSSA. He was
initially started on nafcillin, but this was transitioned to
vancomycin for broadened coverage. He had an MRI that was
concerning for left tibial osteomyelitis and on further review
by radiology, appeared to have surrounding fluid pockets that
were contiguous with the joint space, concerning for a septic
joint. IR was able to aspirate the joint on [**6-2**] which grew
MSSA. Orthopedics peformed a bedside aspiration 3 days later
which also grew MSSA, while the patient was on vancomycin.
Because of persistenly positive cultures, and concern that
infection was driving worsening liver failure, the patient was
taken to the OR on [**6-9**] for left ankle incision and drainage.
He tolerated the procedure well, although had significant post
operative bleeding while his coagulopathy was resolving. He was
scheduled to complete a 6 week course of vancomycin from the
date of I&D. On [**6-21**], the patient was transitioned from
vancomycin to cefazolin out of concern for vancomycin-induced
leucopenia. He will complete his course of cefazolin on [**7-21**]. The
patient will be followed by Infectious Disease as an outpatient.
.
# Acute kidney injury secondary to allergic interstitial
nephritis and acute tubular necrosis: The patient's creatinine
rose from 1.0 to 2.7. Renal was consulted and felt this initial
insult was secondary to AIN as he had numerous WBC casts in the
urine sediment. The offending [**Doctor Last Name 360**] was believed to be pip-tazo
or nafcillin. Once both drugs had been stopped, his creatinine
plateaued at 2.4 for several days, until a second acute rise to
a peak of 3.3. This was felt to be secondary to ATN as he had
cellular debris and a few granular casts in his urine sediment.
The patient was making very adequate urine throughout his
hospitalization and dialysis was never indicated. His
creatinine at discharge was 2.0.
.
# Anemia: The patient had a drop in hematocrit to 19 early
during hospitalization. An EGD showed non-bleeding Grade I
varices with portal gastropathy but no active bleeding. He had
guaiac positive brown stool. It was felt that his anemia was
secondary to oozing from ankle wound and renal failure. He was
supported with blood products to maintain his Hct > 21.
.
# Leukopenia: The patient's WBC downtrended in the setting of
ongoing vancomycin use. His ANC nadir was roughly 800. He was
placed on neutropenic precautions and diet temporarily. His
vancomycin was transitioned to cefazolin in this setting, as his
leukopenia was deemed vancomycin-induced. His ANC at the time of
discharge was uptrending, and greater than 1000.
.
# Volume Overload: Patient retained significant fluid in the
setting of liver failure and volume resusitation. After
stabilization, he was aggressively diuresed with lasix and
spironolactone. His doses were titrated to lasix 80 mg daily and
spironolactone 25 mg daily with stable creatinine and serum
sodium.
.
Transitional Issues:
- Please transfuse RBCs to maintain HCT>21.
- Please draw the following labs weekly and fax to Infectious
Disease R.N.s at ([**Telephone/Fax (1) 1353**]: CBC with diff, BUN, Cr, LFTs,
ESR, CRP.
- Patient will follow-up in ID, Hepatology, and [**Hospital **]
clinic as an outpatient.
Medications on Admission:
Percocet
Atenolol
Prilosec
Colchicine
Lasix
Indomethacin
ASA 81 mg
Discharge Medications:
1. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. cefazolin 10 gram Recon Soln Sig: Two (2) gram Recon Soln
Injection Q12H (every 12 hours) for 27 days: Please continue
through [**2151-7-21**].
13. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Outpatient Lab Work
Please draw the following labs weekly and fax to Infectious
Disease R.N.s at ([**Telephone/Fax (1) 1353**]: CBC with diff, BUN, Cr, LFTs,
ESR, CRP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary Diagnosis:
- Septic left ankle joint
- Osteomylitis (left tibia)
- Acute Interstitial Nephritis
- Acute Tubular Necrosis
- Anemia
- Leukopenia
- Alcoholic Hepatitis
.
Secondary Diagnosis:
- Alcohol-Induced Cirrhosis
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with an
infection in your left ankle joint and an infection in your
blood. During your hospital stay, you also developed damage to
your kidneys, which has slowly improved over the last week. You
were given water pills in order to remove excess fluid from your
body.
.
Please discontinue the following medications after discharge:
- Colchicine
- Indomethacin
- Aspirin
.
Please adhere to the medication list provided. Should you
experience any symptoms that concern you after discharge from
the hospital, please return to the Emergency Room or call your
liver doctor.
Followup Instructions:
Dr.[**Name (NI) 948**] office will contact you regarding a follow-up
appointment for your liver disease. Please follow up with the
Infectious Disease specialists and orthopedic surgeons at the
following time and place:
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2151-7-5**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2151-7-19**] at 10:00 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], 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: ORTHOPEDICS
When: WEDNESDAY [**2151-6-30**] at 9:30 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ORTHOPEDICS
When: WEDNESDAY [**2151-6-30**] at 9:50 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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[
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14782, 14856
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8722, 13034
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325, 405
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,737
| 103,853
|
45332
|
Discharge summary
|
report
|
Admission Date: [**2201-3-28**] Discharge Date: [**2201-3-31**]
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Hypothermia, hypotension, bradycardia
Major Surgical or Invasive Procedure:
central venous catheter placement
History of Present Illness:
[**Age over 90 **] yo female with PMH of afib on coumadin, htn, and dementia,
was found at home yesterday [**3-28**] being brady to 40s and
hypothermic 86.7F and hypotensive 60/dop in field. Patient was
given atropine and external paced by EMS. She was brought to ED,
and admitted to MICU. Within an hour after MICU admission, she
was normothermic on Bair hugger and with warmed IVF, and off
pressors (levophed). HR improved as well.
.
She had garbled speech in the ED, code stroke was called.
Neurology recommended MRI and felt her symptoms were likely
unrelated to an acute stroke. Garbled speech is her baseline.
It appears that patient has been having increasing agitation at
home recently, and was started on seroquel and had a recent
fall. CTA of brain was negative.
.
Patient was given vanc/zosyn in the ED, which were continued
overnight last night in the MICU, and discontinued this morning.
Infectious workup is negative so far. Thyroid function was
normal, and tox screen was negative. She was found to have INR
of 12, got 10 of IV vitamin K. On transfer to medicine floor,
her BP, HR and body temperature all returned normal.
.
On arrival to the medicine floor, pt was very drowsy. Her eyes
were closed despite sternal rubs, but she does withdraw to
painful stimuli. She is not requiring oxygen, and her vital
signs are stable. She moaned and grimaced when her abdomen was
palpated.
Past Medical History:
- Alzheimer and [**Last Name (un) 309**] Body Dementia (Dr. [**First Name (STitle) **] neurologist)
Hypertension
- Atrial fibrillation, on coumadin
- Urinary incontinence - detrusor instability
- Diastolic CHF
- Degenerative joint disease/osteoarthritis
- Right hip fracture
- Bilateral knee replacements
- Ventral hernia
- Depression/post-traumatic stress disorder
- Left sided carotid bruit
- Cervical spondylosis, spinal stenosis
Social History:
Lives alone with home health care aide who visits. Recent fall
on [**3-19**] and prior pneumonia in [**Month (only) 404**] caused decline in her
ADLs - unable to feed self anymore and unsteady on feet,
requiring assistance to getting to her walker. Since her fall,
patient has become increasingly agitated and incoherent; was
recently started on Seroquel.
Family History:
Diabetes, arthritis
Physical Exam:
Vitals - T:98.5 BP:107/57 HR:50-68 RR:16 02 sat:100% on room air
GENERAL: not responsive to commands, eyes closed despite sternal
rubs. moans to pain stimuli.
HEENT: RIJ in place. Eyes closed. when opened, PERRL. No LAD.
CARDIAC: bradycardic, irregularly irregular, normal s1, s2, no
m/r/g
LUNG: clear from anterior
ABDOMEN: normoactive BS, soft, nondistended. Pt moans and
grimaces when abdomen was palpated.
EXT: No LE edema, no cyanosis, no clubbing.
NEURO: Not responsive to commands. PERRL. moans to pain
stimuli. moves all 4 extremities.
DERM: No skin rash.
On discharge:
Pt opens eyes, awake able to make requests. Able to follow some
commands.
Abdomen no longer tender.
Otherwise exam unchanged.
Pertinent Results:
[**2201-3-28**]
WBC-4.6 RBC-3.47* Hgb-9.9* Hct-30.7* MCV-88 MCH-28.5 MCHC-32.3
RDW-16.1* Plt Ct-104*
Glucose-124* UreaN-64* Creat-2.0* Na-147* K-4.4 Cl-107 HCO3-30
AnGap-14
ALT-69* AST-55* LD(LDH)-679* CK(CPK)-81 AlkPhos-70 TotBili-0.2
Lipase-66*
cTropnT-0.02*
Calcium-8.8 Phos-4.3 Mg-2.5
Hapto-143
TSH-4.2 T4-7.0 T3-73*
Lactate-2.0
FIBRINOGE-507*
PT-97.1* PTT-88.7* INR(PT)-12.0*
[**2201-3-30**]
WBC-6.5 RBC-3.19* Hgb-8.9* Hct-28.1* Plt Ct-94*
PT-17.5* PTT-38.9* INR(PT)-1.6*
Glucose-88 UreaN-29* Creat-1.4* Na-147* K-3.5 Cl-116* HCO3-26
AnGap-9
ALT-55* AST-46* CK(CPK)-64 AlkPhos-56 TotBili-0.3
Calcium-8.4 Phos-2.5* Mg-2.2
FDP-0-10
CT Brain Perfusion/ CTA Neck:
1. No acute hemorrhage or evidence of acute territorial
infarction, with no evidence of asymmetric perfusion.
2. Central and cortical involutional changes as expected for the
patient's
age of [**Age over 90 **] years.
3. Approximately 40% narrowing of the left internal carotid
artery origin by NASCET criteria. The remaining intra- and
extra-cranial arterial vasculature demonstrates no evidence of
flow-limiting stenosis.
4. Infundibulum at the junction of the A1 segment of the right
ACA and the
ACom vessel.
5. Chronic microvascular ischemic white matter disease.
CXR: Cardiomegaly, mild central congestion. Left basilar
atelectasis.
Limited exam.
CT Head: No evidence of hemorrhage or infarction. No evidence
of change
since a head CT of [**2201-3-28**].
Brief Hospital Course:
[**Age over 90 **] yof w hypertension, atrial fib, Alzheimer's and [**Last Name (un) 309**] Body
dementia who hypothermia, hypotension, bradycardia, and AMS.
.
#AMS - Ddx includes poor cerebral perfusion, oversedating
medications (seroquel), infection on underlying dementia. There
was no evidence of infection and no history of any toxin
ingestion. CTA of the head/neck could not explain her
somnolence. She is having some episodes of improvement at time
of discharge when she was she was alert and able to make
requests.
.
# Hypothermia: Resolved. Working differential includes sespis,
neurogenic hypothermia, ingestion. Less likely is adrenal
insufficiency, thiamine deficiency, hypoglycemia,
hypothyroidism. No evidence of infection. Monitoring on
telemetry was unremarkable.
.
# Coagulopathy: Patient presented with INR 12.0, which corrected
by time of discharge. Her PT/PTT also elevated also elevated.
She was given 10mg IV vitamin K. Thorough evaluation of
coagulation abnormalities was not evaluated further given pt's
overall poor prognosis as it was unlikley to change managemnet.
Pt's family expressly does not want pt to receive blood
transfusion.
# Hypotension: Resolved after rewarming. No evidence after
broad workup for infection, as stated above.
.
# Bradycardia: Resolved. Patient received atropine received in
the field. Her heart rate normalized, although she generally
remains slow. HR drops to high 30s during sleep and she
otherwise asymptomatic. Pt not to be paced if becomes
bradycardic, may receive atropine if necessary.
# Hypernatremia: Pt was hypernatremic on admission, improved
with free water boluses.
.
# Acute renal failure: improving with IVF. Likely pre-renal (on
lasix as outpt). Pt was discharged with prn lasix for signs of
volume overload such as increasing oxygen requirement,
respiratory distress, or lower extremity edema.
# Abd discomfort: Pt presented with abdominal discomfort. KUB
shows non obstructive gas pattern, but consistent with
constipation. She was initiated on a bowel regimen.
.
# Thrombocytopenia: Since hospitalization plt count 80-90s. DIC
workup in ICU negative. Platelets remained low but stable.
.
# Atrial fibrillation: Pt is afib with slow ventricular response
on tele. Coumadin was discontinued on this admission due to
high maintenance required with this medication. This is
consistent with the overall plan to focus on comfort care.
.
# Alzheimer and [**Last Name (un) 309**] Body Dementia: Pt was admitted on Aricept
which was discontinued to reduce unnecessary medications.
.
# Hypertension: Pt's blood pressure was low on admission. All
BP meds were held. They were discontinued prior to discharge to
reduce medications that are not directed towards comfort care.
.
# Diastolic CHF: Compensated currently. Cardiac medications
minimized to prn lasix.
.
# Degenerative joint disease/osteoarthritis: Tylenol and
Mortrin prn for pain control.
# Goals of care: Pt is DNR/DNI, with the understanding that pt
does not want advancement of care. Treatment should be focused
on comfort based care. Family would not want rehospitalization
without communication with health care proxy.
# Code: DNR/DNI
# Communication:
Daughter [**Name (NI) **] HCP [**Telephone/Fax (1) 96812**]
Son [**Name (NI) 18330**]: [**Telephone/Fax (1) 96813**]
[**Name2 (NI) **]-Daughter [**Name (NI) **]: [**Telephone/Fax (1) 96814**]
Medications on Admission:
* Coumadin 2.5mg Sat/Sun/Tues/Th, 5mg M/W/F
* Alendronate 35 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
* Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
* Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
* Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
* Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime))
* Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
* Trandolapril 4 mg Tablet Sig: One (1) Tablet PO twice a day.
* Multivitamin DAILY
* Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day)
* Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day
* Zinc Sulfate 220mg daily
* Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
* Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed
for agitation.
6. Motrin 400 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day as
needed for volume overload: please base on symptoms, physical
exam, and daily weights.
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) unit Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] healthcare
Discharge Diagnosis:
Primary:
hypothermia
hypotension
bradycardia
[**Last Name (un) **] body dementia
Secondary:
- Alzheimer and [**Last Name (un) 309**] Body Dementia (Dr. [**First Name (STitle) **] neurologist)
Hypertension
- Atrial fibrillation, on coumadin
- Urinary incontinence - detrusor instability
- Diastolic CHF
- Degenerative joint disease/osteoarthritis
- Right hip fracture
- Bilateral knee replacements
- Ventral hernia
- Depression/post-traumatic stress disorder
- Left sided carotid bruit
- Cervical spondylosis, spinal stenosis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Lethargic but arousable
Discharge Instructions:
You were seen at [**Hospital1 18**] for low temperature. You were also noted
to have low blood pressure, and slow heart rate. No reason for
these was found, but you improved spontaneously. Your mental
status was initially quite poor, though improved on the day of
your discharge. Because of your recent worsening, your family
made a decision to focus on comfort.
You are going to a skilled nursing facility.
Followup Instructions:
please schedule an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] at [**Telephone/Fax (1) 250**]
in the next 2-3 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2201-4-27**] 10:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2201-7-22**] 10:50
Completed by:[**2201-4-1**]
|
[
"458.9",
"311",
"331.0",
"E934.2",
"584.9",
"564.09",
"427.89",
"331.82",
"276.0",
"427.31",
"790.92",
"287.5",
"428.0",
"V43.64",
"780.65",
"721.0",
"294.10",
"V58.61",
"401.9",
"428.32",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10096, 10149
|
4801, 8208
|
262, 298
|
10719, 10719
|
3344, 4667
|
11263, 11780
|
2577, 2598
|
9227, 10073
|
10170, 10698
|
8234, 9204
|
10826, 11240
|
2613, 3184
|
3198, 3325
|
185, 224
|
327, 1732
|
4677, 4778
|
10734, 10802
|
1754, 2188
|
2204, 2561
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,850
| 164,685
|
10792+10793+10794+56183
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2194-3-14**] Discharge Date: [**2194-3-25**]
Date of Birth: [**2142-2-10**] Sex: M
Service: [**Hospital1 212**] INTERNAL MEDICINE FIRM
ADDENDUM:
The following describes the [**Hospital 228**] hospital course from
[**2194-3-21**] through [**2194-3-24**].
1. INFECTIOUS DISEASE/PULMONARY: BAL washings from the
patient's bronchoscopy on [**3-20**] were positive for
Methicillin resistant Staphylococcus aureus. The patient was
continued on vancomycin with an anticipated six week course
of treatment. He was also continued on metronidazole to
cover aspiration organisms. This was to be continued for a
total of two weeks, ending on [**2194-3-26**].
Transesophageal continued to improve from a pulmonary
standpoint and had returned to his baseline at the
anticipated time of discharge.
2. PAIN CONTROL: The patient was seen by the pain service
who recommended starting him on Neurontin, Celebrex and
standing dose Tylenol in addition to his oxycodone. The
patient reported significant improvement in his hip and back
pain on this pain control regimen.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient
underwent a video swallowing study on [**2194-3-24**]. This
study indicated the patient remains a high aspiration risk
and it was recommended to him that he receive all nutrition
via tube feeds at this time however, the patient, cognizant
of the risks of doing so, is electing to continue po intake
of thickened liquids at this time. It was recommended that
the patient have his po intake carefully monitored by the
speech and swallow department at [**Hospital3 2558**] upon his
return there, as well as a repeat video swallowing study in
one to two months as his condition improves.
4. HEMATOLOGY: On [**3-24**], the patient was noted to have
a slowly diminishing hematocrit to a level of 24.7. No
active bleeding source was identified. The patient was
transfused 2 units of packed red blood cells and a post
transfusion hematocrit was pending at the time of this
dictation. The patient's INR was also noted to be
supertherapeutic on [**3-24**] at 4.5. His Coumadin dose was
held and he was to have follow up INR checks. His Coumadin
was to be restarted at 1 mg po q hs when his INR returned to
a therapeutic range of 2 to 3.
5. DISPOSITION: At the time of this dictation, it was
anticipated that the patient would return to [**Hospital3 2558**]
on [**2194-3-25**] where he was to follow up with his primary
care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**].
DISCHARGE DIAGNOSES:
1. Pneumonia
2. Aspiration risk
3. Status post cerebrovascular accident with left sided
residual hemiparesis
4. History of seizure disorder
5. Congestive heart failure
6. Coronary artery disease
7. Depression
8. History of bilateral hip fractures
9. History of paroxysmal atrial fibrillation status post
cardioversion
DISCHARGE MEDICATIONS:
1. Oxycodone 10 mg po q6h prn
2. Celebrex 200 mg po bicarbonate
3. Tylenol 500 mg po tid
4. Neurontin 300 mg po bid x3 days, then 300 mg po tid
5. Vancomycin 1 gm intravenous q 24 hours x5 weeks
6. Flagyl 500 mg po tid x2 days
7. Colace 100 mg po bid
8. Spironolactone 25 mg po q day
9. Valproic acid 500 mg po q a.m., 750 mg po q noon, 500 mg
po q hs
10. Enteric coated aspirin 81 mg po q day
11. Synthroid 0.125 mg po q day
12. Multivitamin 1 tablet po q day
13. Protonix 40 mg po q day
14. Dulcolax 10 mg po q od
15. Captopril 50 mg po tid
16. Lasix 20 mg po bid
17. Zoloft 200 mg po q day
18. Vitamin C 500 mg po q day
19. BuSpar 10 mg po q day
20. Senna 2 tablets po q day
21. Zinc sulfate 220 mg po q day
22. Combivent metered dose inhalers 2 puffs q6h
The patient was to have a daily INR check until his level was
found to be 2 to 3 and then restart Coumadin at 1 mg po q hs.
DISCHARGE DISPOSITION: The patient was to be discharged to
[**Hospital3 2558**].
DISCHARGE CONDITION: Improved
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Last Name (NamePattern1) 35244**]
MEDQUIST36
D: [**2194-3-24**] 16:49
T: [**2194-3-24**] 18:54
JOB#: [**Job Number 35245**]
Admission Date: [**2194-3-26**] Discharge Date: [**2194-4-5**]
Date of Birth: [**2142-2-10**] Sex: M
Service: [**Hospital1 212**] INTERNAL MEDICINE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 35246**] is a 57-year-old man
with a complicated past medical history including
cerebrovascular accident, seizure disorder, coronary artery
disease, congestive heart failure and recurrent aspiration
pneumonia who was discharged from [**Hospital6 649**] on [**3-24**] with aspiration pneumonia. He
was at his nursing home where he desaturated to 70% on 5
liters nasal cannula and became tachypneic and uncomfortable.
He was also febrile and transferred back to [**Hospital6 1760**] for further management. In
the Emergency Department, he was given albuterol and Atrovent
nebulizers with some relief. His most recent hospital course
was significant for Methicillin resistant Staphylococcus
aureus pneumonia diagnosed on BAL washings. He was started
on vancomycin for a six week course of treatment. He also
had a video swallowing study which showed a high risk of
aspiration, however at that time the patient elected to take
continued po intake with thickened liquids.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident in [**2189**] with residual left sided
hemiparesis
2. History of seizure disorder
3. Borderline diabetes mellitus
4. Coronary artery disease
5. Depression
6. Congestive heart failure with an ejection fraction of
30%.
7. Hypertension
8. Hypothyroidism
9. Bilateral hip fractures.
10. Paroxysmal atrial fibrillation, status post cardioversion
in [**2193-7-21**]
11. Recurrent aspiration pneumonia
ADMISSION MEDICATIONS:
1. Oxycodone 10 mg q6h prn
2. Celebrex 200 mg po q day
3. Tylenol 500 mg po tid
4. Neurontin 300 mg po bid
5. Vancomycin 1 gm intravenous q 24 hours
6. Flagyl 500 mg po tid
7. Colace 100 mg po bid
8. Spironolactone 25 mg po q day
9. Valproic acid 500 mg po q a.m., 750 mg po q noon, 500 mg
po q p.m.
10. Enteric coated aspirin 81 mg po q day
11. Synthroid 0.125 mg po q day
12. Dulcolax prn
13. Captopril 50 mg po tid
14. Lasix 20 mg po bid
15. Zoloft 200 mg po q day
16. Vitamin C 500 mg po q day
17. BuSpar 10 mg po bid
18. Senna 2 tablets po q hs
19. Zinc sulfate 220 mg po q day
20. Combivent metered dose inhaler 2 puffs q6h
21. Multivitamin 1 tablet po q day
22. Protonix 40 mg po q day
ALLERGIES: THE PATIENT HAS DOCUMENTED HEPARIN INDUCED
THROMBOCYTOPENIA.
SOCIAL HISTORY: The patient is currently a resident of
[**Hospital3 2558**]. He denies alcohol or tobacco use. His code
status is do not resuscitate, however intubation, unit and
pressors are permitted.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 100.8??????, heart rate 79, blood
pressure 94/63, oxygen saturation 90% on a 100%
nonrebreather, respiratory rate 22.
GENERAL: The patient was a middle aged man in mild
respiratory distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils were equal, round
and reactive to light. Sclerae were anicteric. Oromucosa
was dry. The oropharynx was without lesion.
NECK: Supple with no lymphadenopathy or jugular venous
distention.
CHEST: Notable for rancorous breath sounds with no wheezes.
CARDIOVASCULAR: Irregularly irregular rhythm with a normal
S1 and S2 and a 2/6 systolic ejection murmur.
ABDOMEN: The abdomen was soft, nontender, nondistended with
hypoactive bowel sounds and no hepatosplenomegaly.
EXTREMITIES: The patient had palpable peripheral pulses with
no cyanosis, clubbing or edema.
NEUROLOGIC: The patient was somnolent, but arousable and not
cooperative with neurologic exam. He was moving all four
extremities.
INITIAL LABORATORY STUDIES: Chest x-ray indicated near
complete opacification of the left hemithorax with a small
portion of minimally aerated lungs seen laterally at the apex
with progression of left upper lobe air space opacification
since the prior study. There is also diffuse increased
density of the right hemithorax with apical capping most
likely representing a layering pleural effusion on the right.
Arterial blood gases indicated a pH of 7.43, PACO2 of 48 and
PAO2 of 36. CBC was notable for a white count of 6.6 and a
history of 29.3. INR was elevated a 4.8. PTT was 58.7.
Chem-7 was notable for a BUN of 15, creatinine of 1.0,
bicarbonate of 31 and glucose of 59. Phosphate was elevated
at 4.6.
HOSPITAL COURSE: The patient was transferred to the Medical
Intensive Care Unit within hours of his admission secondary
to worsening hypoxia and respiratory distress. Following is
a description of the [**Hospital 228**] hospital course in the Medical
Intensive Care Unit by system.
1. PULMONARY: The patient's oxygen saturation remained
stable on a 100% face mask and shovel mask. A chest CT
indicated severe tracheomalacia involving the carina and
origin of the main stem bronchus bilaterally. Bilateral
pleural effusions which were increased since the last study
were also noted, as well as widespread atelectasis in the
right lower lobe, right middle lobe, lingula and left lower
lobe. There were scattered ground glass opacities and
enlarged pulmonary arteries. The patient was weaned down to
a 70% face mask with oxygen saturation in the mid 90s. The
medical team felt that the patient's respiratory status would
not significantly improve with thoracentesis.
2. CARDIOVASCULAR: The patient was noted to be hypotensive
in the Medical Intensive Care Unit with a systolic blood
pressure of 70. He was therefore started on Levophed. His
hypertension was thought to be most likely related to his
circulating volume. He was therefore treated with
intravenous fluids and Levophed was weaned. He was also
evaluated by the cardiac electrophysiology service for an
episode of asymptomatic nonsustained ventricular tachycardia
as well as for the question of whether the patient would
benefit from cardioversion given his atrial fibrillation and
hypotension. The electrophysiology service elected not to
place a defibrillator secondary to the patient's do not
resuscitate wishes. The also did not believe the patient
would benefit from cardioversion.
3. RENAL: The patient remained stable from a renal
perspective with his creatinine in the range of 1.1 to 1.4.
4. INFECTIOUS DISEASE: The patient was continued on
vancomycin and Flagyl for treatment of his aspiration
pneumonia. Blood cultures were sent and were negative.
Sputum cultures were sent and grew out only oropharyngeal
flora and sparse gram negative rods. Flagyl was discontinued
on hospital day #5. The patient's white blood count remained
stable and he remained afebrile.
5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient remained
NPO while he was in the Intensive Care Unit receiving only D5
normal saline for nutrition.
6. HEMATOLOGY: The patient remained coagulopathic initially
with an INR of 4.8. He was corrected to a value of 2.6 with
vitamin K. His coagulopathy was thought likely secondary to
his decreased nutrition. The patient's hematocrit remained
stable.
7. ENDOCRINE: Given the patient's persistent hypotension,
an a.m. cortisol was sent and found to be 5. However, on
repeat testing with a cosyntropin stimulation test, the
patient ruled out for adrenal insufficiency. He was
continued on regular insulin sliding scale and Synthroid.
8. NEUROPSYCHIATRIC: The patient was continued on valproic
acid. Pain control was initially achieved with a patient
controlled analgesic pump which was weaned. The patient's
pain control was adequately treated subsequently with a
fentanyl patch and Dilaudid prn for breakthrough pain.
Psychiatry was consulted and the patient was found to be
competent to make decisions about his medical care.
9. DERMATOLOGY: Plastic surgery service was consulted and
debrided a left elbow pressure ulcer. The patient was to k2
having dressing changes wet to dry [**Hospital1 **].
10. PROPHYLAXIS: The patient was maintained on Protonix and
auto anticoagulated.
On hospital day #5, the patient was transferred to the floor
for continued management. Interventional radiology was
consulted for placement of a gastrojejunostomy tube. The
interventional radiology service was not able to place the
tube until the patient's INR fell to a level of approximately
1.5. The patient's Coumadin continued to be held and on
hospital day #9 he was taken to the interventional radiology
suite for placement of the GJ tube. The patient tolerated
the procedure well and there were no complications. The
patient was subsequently started on Coumadin 1 mg po q hs and
started on tube feeds the following morning.
At the time of this discharge dictation, it was planned that
the patient would be transferred back to [**Hospital3 2558**].
DISCHARGE DIAGNOSES:
1. Recurrent aspiration pneumonia
2. Status post cerebrovascular accident
3. Methicillin resistant Staphylococcus aureus pneumonia and
bacteremia
4. Atrial fibrillation
5. Tracheomalacia
6. Code status do not resuscitate, may intubate
7. Seizure disorder
8. Borderline diabetes mellitus
9. Coronary artery disease
10. Congestive heart failure
11. Hypertension
12. Hypothyroidism
13. History of bilateral hip fractures
DISCHARGE MEDICATIONS:
1. Coumadin 1 mg per GJ tube q hs
2. Vancomycin 1 gm intravenous q 24 hours x26 days for a
total course of 6 weeks
3. Morphine sulfate 1 mg intravenous q4h prn pain
4. Tylenol 650 mg per GJ tube q 4 to 6 hours prn
5. Fentanyl 25 mcg transdermal q 72 hours
6. Synthroid 0.125 mg per GJ tube q day
7. Dulcolax 10 mg pr prn constipation
8. Nystatin powder prn groin rash
9. ASA 81 mg per GJ tube q day
10. Atrovent metered dose inhaler 2 puffs qid
11. Albuterol metered dose inhaler 2 puffs q4h prn
12. Protonix 40 mg per GJ tube q day
13. Zinc sulfate 220 mg per GJ tube q day
14. Senna 2 tablets per GJ tube q hs prn
15. Vitamin C 500 mg per GJ tube q day
16. Zoloft 200 mg per GJ tube q day
17. Multivitamin 1 tablet per GJ tube q day
18. Valproic acid 500 mg q a.m., 750 mg q noon, 500 mg q hs
via GJ tube
19. Colace 100 mg per GJ tube [**Hospital1 **]
20. Neurontin 300 mg per GJ tube tid
The patient would need daily dressing changes for his GJ tube
and [**Hospital1 **] wet to dry dressing changes for his left elbow
pressure ulcer. The patient would also require chest
physical therapy [**Hospital1 **]. His tube feeds were started at ProMod
with fiber with a goal of 55 cc per hour, hold for abdominal
distention or abdominal pain. The patient also required
oxygen via 70% face mask.
DISCHARGE CONDITION: Stable
DISPOSITION: The patient was transferred back to [**Hospital3 7511**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2194-4-4**] 13:51
T: [**2194-4-4**] 14:28
JOB#: [**Job Number **]
Admission Date: [**2194-3-26**] Discharge Date: [**2194-4-5**]
Date of Birth: [**2142-2-10**] Sex: M
Service: [**Hospital1 212**] I
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2194-4-4**] 13:51
T: [**2194-4-4**] 14:26
JOB#: [**Job Number **]
Name: [**Known lastname 6260**], [**Known firstname 947**] Unit No: [**Numeric Identifier 6261**]
Admission Date: [**2194-3-26**] Discharge Date: [**2194-4-16**]
Date of Birth: [**2142-2-10**] Sex: M
Service: [**Hospital1 1098**] I
ATTENDING:[**Name8 (MD) 6283**]
ADDENDUM: The following is a discharge summary covering the
period from [**2194-3-26**] through [**2194-4-5**].
HISTORY: On [**4-5**], the patient was noted to desaturate to
78% on a 70% face mask. Oxygen saturation improved only to
88% on 100% nonrebreather, although there was some
improvement with further suctioning. Chest x-ray indicated
worsening congestive heart failure. The patient was
subsequently given IV Lasix with good diuresis. The patient
was also noted to be coagulopathic with thrombocytopenia.
DIC labs were sent and they were negative. Aspirin was
discontinued. It was suggested that the patient's
thrombocytopenia might be secondary to his valproic acid.
The patient was, therefore, loaded on Dilantin and his
valproic acid was slowly weaned.
On [**4-10**], the patient was noted to be increasingly
lethargic with increasing oxygen requirement and arterial
blood gas indicated a pH of 7.27 with PACO2 of 75 and pAO2 of
63. The patient was, therefore, transferred to the Medical
Intensive Care Unit for hypercarbic respiratory failure. He
was maintained on 100 nonrebreather in the Intensive Care
Unit, where he was subsequently subject to bronchoscopy,
which indicated diffuse mucous plugging. The patient's
respiratory status improved following additional suctioning,
as well as the initiation of BiPAP at night. The patient was
also started on a Lasix drip for additional diuresis and
started on Ceftriaxone and Flagyl to broaden coverage of his
aspiration pneumonia. As the patient's pulmonary status and
mental status improved, he was transferred back to the floor
on [**4-13**]. On [**4-14**], the patient underwent a
left-sided thoracentesis during which 1800 cc of
serosanguinous fluid was removed. This fluid was found to be
transudative.
The patient's respiratory status continued to improve. On
[**4-15**], a sputum culture revealed moderate grow of the
Acinetobacter baumannii, as well Morganella morganii
sensitive to Ceftriaxone.
At the time of this discharge dictation, it was anticipated
that the patient would be discharged back to [**Location (un) 6284**].
He was to continued triple antibiotic treatment for his
pneumonia, continuing Vancomycin for a total of a six-week
course and Ceftriaxone and Flagyl for a total of a two-week
course.
MEDICATIONS ON DISCHARGE: (revised medications on
discharge).
1. Coumadin 1 mg per J tube q.h.s.
2. Vancomycin 1 gram IV dose per level of less than 15
through [**5-1**] and then discharged.
3. Valproic acid taper, currently 500 mg per GJ tube q.a.m.;
250 mg per GJ tube q noon, 500 mg per GJ tube q.p.m.; reduce
total daily dose by 250 mg q.5 days until off with the next
scheduled reduction on [**4-18**].
4. Free-water bolus 150 cc per GJ tube t.i.d.
5. Lasix 60 mg per GJ tube q.d.
6. Synthroid 0.125 mg per GJ tube q.d.
7. Ceftriaxone 1 gram IV q.24 hours times 7 days.
8. Flagyl 500 mg per GJ tube t.i.d. times 7 days.
9. Ultram 50 mg per GJ tube q.4h. to 6h.p.r.n.
10. Dilantin 100 mg per GJ tube b.i.d. and 150 mg per GJ tube
q. noon.
11. Captopril 12.5 mg per GJ tube t.i.d., hold for systolic
blood pressure of less than 90.
12. Promote with fiber tube feeds at 70 cc over 18 hours per
day, hold one hour pre and post Dilantin doses.
13. Neurontin 100 mg per GJ tube t.i.d.
14. Vitamin C 500 mg p.o. GJ tube b.i.d.
15. Prevacid 30 mg p.o. GJ tube q.d.
16. Tylenol 500 mg per GJ tube q.8h. around the clock.
17. Silvadene cream to the left elbow b.i.d. with Xeroform
dressing changes b.i.d.
18. Fentanyl patch 25 mcg transdermal q.72 hours.
19. Atrovent metered dose inhaler 2 puffs q.i.d.
20. Colace 100 mg per GJ tube b.i.d.
21. Multivitamin one tablet per GJ tube q.d.
22. Senna two tablets per GJ tube q.h.s.p.r.n.
23. Albuterol MDI 2 puffs q.4h.p.r.n.
24. Dulcolax 10 mg pr, p.r.n. constipation.
[**First Name8 (NamePattern2) 3294**] [**Last Name (NamePattern1) 3295**], M.D. [**MD Number(1) 6285**]
Dictated By:[**Last Name (NamePattern1) 5798**]
MEDQUIST36
D: [**2194-4-15**] 15:52
T: [**2194-4-15**] 16:02
JOB#: [**Job Number 6286**]
|
[
"438.20",
"428.0",
"780.39",
"287.5",
"427.31",
"707.0",
"507.0",
"518.81",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.05",
"46.32",
"38.91",
"96.6",
"34.91",
"86.28",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
3886, 3945
|
14772, 18149
|
12995, 13423
|
13446, 14750
|
18176, 19948
|
8621, 12974
|
5924, 6701
|
6930, 8603
|
4450, 5446
|
5468, 5901
|
6718, 6908
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,642
| 164,551
|
7116
|
Discharge summary
|
report
|
Admission Date: [**2136-12-6**] Discharge Date: [**2136-12-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
cough, hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo portugues speaking male with Type II DM, HTN,
hyperlipidemia, and temporal arteritis (on prednisone taper
started on [**2136-11-9**]) who presents to the ED with worsening cough
x 4 days, generalized weakness for 10 days with blood sugars to
850s.
.
Mr. [**Known lastname 25456**] was in his USOH until approximately one month ago
when he presented to his PCP complaining of two weeks of
throbbing left temporal headache, nausea/vomiting but no vision
changes or jaw claudication. Given his left temporal artery
tenderness and high ESR (87), there was a strong suspicion for
temporal arteritis. He was admitted to [**Hospital1 18**] and started on a
Prednisone taper at 60mg PO daily with improvement of his
sypmtoms. A temporal artery biopsy performed on [**2136-11-9**] by the
vascular surgery service was negative for inflammation but was
thought to be falsely negative (biopsy was not thought to
capture inflammation). Mr. [**Known lastname 25456**] was continued on his
Prednisone taper and was warned about high blood sugars while on
the Prednisone taper. A rheumatology followup consult note on
[**2136-11-16**] reported blood sugars to be 130s to high of 200.
.
The patient reports that he has had a chronic cough for over a
month but in the last 4 days prior to this admission he began to
have worsening SOB and increased cough. His cough has not been
productive and he denies fevers, chills, nausea or vomiting. He
admits to decreased appetite and increased urinary frequency
over the last few days. Additionally, he reports he has
experienced some weakness in his lower extremities for about 4
days. He denies chest pain, jaw pain or diaphoresis. He
reports he sleeps on 2 pillows and this is baseline for him. He
has been taking all of his medications including metformin until
yesterday. He was scheduled for a rheum appt [**12-5**] but was "too
weak" to attend.
.
In the ED, vital signs: 98.5, 100, 180/100, 20, 98% RA. Finger
sticks were found to be elevated to 854 with anion gap 20 and
ketones on UA. An EKG showed ST depressions in the lateral
leads compared to EKG from [**2136-11-8**]. He was given IVFs, insulin,
and aspirin. His blood sugar improved from 854 to 572. His
potassium was 5.6 initially but was 4.5 after insulin and IVFs.
His creatinine was elevated to 2.2 from his basline of 1.5-1.7.
Additionally, he was found to have an elevated Tnt 0.04, CK 100
(MB 9), lactate 2.5, WBC 12.1. A chest PA/Lat negative for
acute infiltrate or effusion.
.
Of note, he was given a flu shot on [**2136-11-21**] from his PCP.
Past Medical History:
- Diabetes mellitus, Type II
- HTN
- Sinusitis
- Hyperlipidemia
- Osteoarthritis
- Hemorrhoids
- Chronic renal insufficiency (baseline Cr 1.5-1.7)
- Chronic left hip pain
- Peripheral vascular disease
- Temporal arteritis (presented in early [**Month (only) **] with thrombing
temporal artery pain, biopsy found to be negative but this was
thought to be secondary to the biopsy not capturing inflammation
and he was continued on steroids)
Social History:
Lives at home with his wife in [**Name (NI) 86**]. Originally from [**Location 12187**] Islands. Smoked cigarettes in his youth but quit at age
15. Does not drink EtOH or use IVDA.
Family History:
Both parents lived to over [**Age over 90 **] years of age. Has three children
who are are alive and well. No history of cancer, or heart
diseased.
Physical Exam:
VS: Temp 97.1 BP 153/68 HR 88 RR 14 O2sat 98% 2L NC
.
Gnl: pleasant, comfortable, NAD
HEENT: Mucous membraines dry, No JVD at 30 degrees, PERLLA,
EOMI, anicteric, no sinus tenderness, No supraclavicular or
cervical lymphadenopathy
lungs: CTA b/l with poor inspiratory effort
heart: RR, S1 and S2 wnl, no m/r/g
abdomen: soft, mildly distended, no tenderness to palpation, +
BS
extremities: No edema, Dry skin bilaterally; No evidence of foot
ulcerations. Lower legs without hair, Warm, Faint DP pulses,
could not palpate PT
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. gait
not observed
Pertinent Results:
Chest xray, [**2136-12-6**]: Cardiac size is normal. The aorta is
tortuous and dilated. Lungs are hyperinflated with flattening
of the diaphragms. Lungs are clear. There are no pleural
effusions.
Pulmonary vascularity is normal. Lung hyperinflation, suggestive
of emphysema or small airways obstruction disease.
.
EKG, [**2136-12-6**]: Sinus tach, NA, ST depressions I and V4-V6
.
Left temporal artery, biopsy, [**2136-11-9**]: Artery segment with
intimal fibroplasia. No inflammation seen. Arteritis is not
present.
.
Echo, [**2133-1-29**]: Mild symmetric LVH, EF 60-70%, 2+MR
Brief Hospital Course:
# Hyperglycemia, Type II Diabetes: Patient is a Type II
diabetic with elevated BG to 800s with ketones and elevated
anion gap. Acidosis was felt secondary to DKA. Prednisone was
felt likely exacerbating elevated blood sugars. Nevertheless, pt
was started on a 7d course of levaquin for atypical pneumonia
given his persistent cough. Pt was started on insulin gtt which
was weaned off overnight. Pt was then transitioned to glargine
+ ISS, with [**Last Name (un) 387**] consult. He was tolerating oral diet on [**12-8**]
without difficulty. His gap was closed, and repeat UA showed no
ketones. Small troponin leak (peak 0.02) was felt [**3-8**] demand
ischemia from htn.
.
.
.
# Worsening cough: No evidence of PNA on admission chest xray
but patient reporting cough over last 1 month worsening over the
last 4 days. Given persistent cough, but clear chest xray, pt
started on levaquin x 7 day (day 1 [**12-5**]) for atypical pneumonia,
however this was d/c'd on [**12-8**] as it was not felt that pt was
likely to have pneumonia.
.
.
# bactermia - pt with gpc's in bacteria in [**3-10**] bottles, source
unclear. no s/sx sepsis/sirs as pt is without
fever/hypothermia, hypotension. UOP is good today, although pt
had a traumatic foley insertion in ED with subsequent bloody
clot. foley removed, and UOP cleared, and improved. Pt was
continued on IV vanco, with plan to obtain surveillence cultures
on [**12-8**] and TTE which was negative for endocarditis.
.
.
# Elevated Tnt: Pt with slight bump in troponin (peak 0.02),
felt likely [**3-8**] demand ischemia in setting of hypertension as
well as dehydration resulting in acute on chronic renal failure.
CK-MB with slight bump as well. EKG showing TWI and ST
depressions with resolution of TWI on repeat EKG overnight.
Enzymes trending down overnight. Pt was discussed with
cardiology overnight, who agree likely demand ischemia and no
need for heparin. Follow up with PCP.
.
.
# Acute on Chronic Renal Insufficiency: Patient with baseline Cr
1.5-1.7. Likely dry from decreased PO intake and polyuria in
setting of hyperglycemia. Cr back to baseline (peak 2.2) on
morning after admission. Cr back down to 1.2 on discharge. He
will need to follow up with his PCP regarding restarting his
ASA, lasix, and ACEI.
.
# hematuria - pt s/p traumatic foley placement in ED with blood
+ clot in foley on [**12-7**]. foley was removed, and urine output
has improved subsequently, with no signs of obstruction.
.
# Weakness: Patient reporting subjective weakness. On PE,
patient has 5/5 strength. DDx includes weakness secondary to:
prednisone induced myopathy vs polymyalgia rheumatica
(association with temporal arteritis) vs dehydration. CK
trending up, maybe [**3-8**] steroids.
- Will give rheum heads up (since pt missed appt yesterday)
- Physical therapy consult
.
.
# Temporal arteritis: Patient with negative biopsy but still
being treated for temporal arteritis given high suspicion and
elevated ESR. Currently on Prednisone taper, last rheum note
[**2136-11-21**] ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 18**]): should be at 30mg PO daily
Prednisone. Patient sent home on 20 mg daily prednisone. To
follow up with Dr. [**Last Name (STitle) **] in rheum clinic [**1-2**].
.
.
# HTN: Patient on Metoprolol XL, Lisinopril, Lasix, Norvasc at
home. BP upon admission 150s/60s and were as high as SBP 180s
in the ED. Pt was converted to metoprolol, started on
lisinopril (on [**12-8**]) and norvasc. holding off on lasix as
creatine returns to baseline. F/u chem 7 next week with PCP.
.
.
# Anemia: Chronic anemia with baseline 30-33. Gets ferrous
sulfate as an outpatient. Underwent EGD and colonoscopy given
Fe def anemai and guiac pos stools. EGD revealed nodular
gastritis. He will continue protonix [**Hospital1 **] for at least 2 months.
Follow up CBC in next week.
.
# Osteoarthritis: Tylenol PRN
.
# FEN: Replace lytes as necessary. Lytes q4 hours. Diabetic
diet.
.
# Prophylaxis:
- GI: Protonix
- Bowels: Docusate, PRN Senna
- DVT: Heparin SQ
.
# Code Status: Full code, Reviewed with patient
Medications on Admission:
Fluticasone nasal spray 1 spray NU [**Hospital1 **]
Metformin 500mg PO BID
Norvasc 5mg PO daily
Aspirin 81mg PO daily
Tylenol 650mg PO BID PRN
Ferrous sulfate 325mg PO daily
Protonix 40mg PO daily
Toprol XL 50mg PO BID
Lipitor 40 mg PO daily
Lisinopril 40mg PO daily
Lasix 40mg PO QOD
Prednisone started 60mg PO daily for temp arteritis (Script
filled on [**2136-11-10**]); Taper from [**11-21**] OMR note: 5 tablets by
mouth once a day x 7 days, then 4 tablets once a day x 7 days,
then 3 tablets once a day until your next appointment
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO BID (2 times a day).
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Outpatient Lab Work
Please have CBC, Chem 7 checked in one week and faxed to Dr.
[**Last Name (STitle) **] office.
9. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Fifty
Two (52) units Subcutaneous qam: to be taken with breakfast.
Disp:*qs 1 month* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: 30-40 units Subcutaneous
qpm: to be taken with dinner, please take 40 units if eating a
regular dinner, or take 30 units if taking a lighter dinner.
Disp:*qs 1 month* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
DM2 with ketoacidosis
Temporal arteritis
Anemia of chronic disease and iron deficiency
Gastritis
Discharge Condition:
stable
Discharge Instructions:
Please continue your medications as listed below. Please make
sure you follow up with Dr. [**Last Name (STitle) **] and with your rheumatologist.
Please avoid over the counter pain medications other than
tylenol. Call your doctor if you experience increasing fatigue,
lightheadedness, shortness of breath, chest pain, or blood sugar
<70 or >200.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7980**] Call tomorrow
for an appointment in the next week. You will need to have your
CBC and Chem 7 checked in the next week. Please also follow up
with Dr. [**Last Name (STitle) **] regarding when to restart your aspirin,
lisinopril, and lasix as these were held while you were in the
hospital.
2. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 2206**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2137-1-2**] 12:00. Please follow up on what to do with
the dosage of your prednisone.
|
[
"401.9",
"414.8",
"584.9",
"790.7",
"446.5",
"272.4",
"396.3",
"V58.65",
"250.12",
"585.9",
"440.0",
"562.10",
"535.50",
"599.7",
"112.84",
"285.21",
"041.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.16",
"45.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11024, 11099
|
5025, 9150
|
284, 290
|
11240, 11249
|
4419, 5002
|
11643, 12292
|
3581, 3732
|
9737, 11001
|
11120, 11219
|
9176, 9714
|
11273, 11620
|
3747, 4400
|
224, 246
|
318, 2902
|
2924, 3364
|
3380, 3565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,711
| 133,912
|
12217
|
Discharge summary
|
report
|
Admission Date: [**2141-3-18**] Discharge Date: [**2141-3-26**]
Service:
CODE STATUS: DNR/DNI.
PRIMARY DIAGNOSIS:
Sepsis with MRSA and MMSA and congestive heart failure.
SECONDARY DIAGNOSES:
Multiple myeloma, depression, anxiety, osteoporosis, status
post left hip hemiarthroplasty, left knee surgery in autumn
of [**2140**].
HISTORY OF PRESENT ILLNESS: This is a 79 year-old woman with
atrial fibrillation, congestive heart failure, multiple
myeloma, depression, anxiety, osteoporosis, status post left
hip hemiarthroplasty, left knee surgery in autumn of [**2139**]
with prolonged recovery who presented [**3-18**] to the
Emergency Department at [**Hospital1 18**] with shortness of breath
followed by respiratory distress, lead to arrest and rapid
atrial fibrillation. A Diltiazem drip and lasix were given
to the patient on the [**Hospital Unit Name 196**] floor. Her sickness improved for
a day, but then was followed by respiratory distress that
required intubation and Coronary Care Unit transfer with a
diagnosis of pneumonia with thick green secretions from the
endotracheal tube. Sepsis ensued with multiple cultures
positive. Sputum culture on [**3-19**] showed MMSA. Blood
cultures on [**3-19**] showed MRSA and urine culture on
[**3-18**] showed MRSA. Of note the blood cultures
surveillance on [**3-22**] and [**3-24**] have shown no
growth to date.
The patient required blood pressure support with no
epinephrine for a brief period of time. She was covered with
Vancomycin, Levofloxacin and Flagyl until cultures showed
MRSA and MMSA and she was converted then to just Vancomycin.
The patient was assessed by orthopedics to have a left
shoulder anterior dislocation with no intervention indicated.
She was ruled out for myocardial infarction and endoscopy
echocardiogram showed an left ventricular ejection fraction
of 55% with mild left ventricular hypertrophy and MR
suggesting that it was the stat sepsis that caused
respiratory distress and hypotension. surveillance blood
cultures again were negative and hypotension improved and the
patient's son and health care proxy Dr. [**First Name4 (NamePattern1) **] [**Known lastname **] a
gerontologist from [**State 4565**] led to the decision to extubate
the patient on [**3-25**] based on the likely need for
prolonged intubation, which the patient would not have
wanted. The patient was transferred to the general medical
floor for more conservative management and some pain control
and comfort, though she is DNR/DNI and not comfort measures
only.
On examination this morning [**3-26**] she wants coffee, she
has mild throat pain from the endotracheal tube, otherwise
minor shortness of breath and no chest pain. Physical
examination, 97.8, 99, 130/68, 70 and 95% on 3 liters.
Anicteric. Extraocular movements intact. Pupils are equal,
round and reactive to light. Oropharynx is clear. She had
wet inspiratory and expiratory crackles on bronchial breath
sounds. Occasional wheezes bilaterally. Regular rate and
rhythm. No murmurs, rubs or gallops. Distended, bowel
sounds positive, soft, nontender. No cyanosis or clubbing.
1+ edema. 15 cm eschar/hematoma of the left arm much less
prominent then yesterday.
Laboratories, none were being drawn today.
ALLERGIES: Bactrim, Talwin, codeine and Pen-Vee.
MEDICATIONS: Vancomycin 750 mg q 18 hours intravenous,
Scopolamine 1.5 mg two patches transdermally every 72 hours,
Hyoscyamine 1 milliliter sublingual q 4 hours, enteric coated
aspirin 325 mg po q.d., Duragesic patch ___ to 5 mg
transdermally q 72 hours, Diltiazem 30 mg po q.i.d.,
______________ 40 mg po q day, Remeron 30 mg po q.h.s,
Zyprexa 5 mg po q.h.s., Prednisone 20 mg po q.d., Digoxin
0.125 mg po q.d., Lasix 40 mg po b.i.d., Atrovent q 4 hours
nebs, Silvadene cream. She also gets Tylenol and morphine
sulfate prn. Please see the page one of the exact doses of
all of the medications as well as the prns.
HOSPITAL COURSE: Cardiovascularly, she was continued on
Diltiazem. She has been switched to po and can be titrated
up as necessary for appropriate rate control. For her
coronary artery disease she is having no medications. For
congestive heart failure she is getting Lasix and Digoxin.
Hypertension is being controlled with Diltiazem. Pulmonary,
she is on oxygen with meter dose inhalers, Prednisone. She
also has aspiration precautions, understood that the patient
will aspirate. No intubation is planned. As mentioned
continue the Vancomycin for her staph pneumonia. Renal, we
are following her electrolytes. Psychiatric, the patient
gets Remeron, Zyprexa and a Duragesic patch for pain.
Gastrointestinal, Protonix to allow the patient to eat when
she wants with aspiration precautions and nectar thickened
fluids. She should have nectar thickened liquids as often as
possible in terms of the kinds of foods she is to eat. She
also should sit bolt upright while eating and sit upright for
20 to 30 minutes after eating food. Dermatologically, she
should have warm packs applied to the left hematoma and
according to the dermatology consult that we obtained here
that is expected to drain spontaneously.
DISPOSITION: The patient is DNR/DNI. She has a right IJ
triple lumen catheter. Her health care proxy is Dr. [**First Name4 (NamePattern1) **]
[**Known lastname **]. Various phone numbers for him are [**Telephone/Fax (3) 38199**], [**Telephone/Fax (1) 38200**], [**Telephone/Fax (1) 38201**]. In [**Location (un) 86**] the
secondary health care proxy is [**Name (NI) **] [**Name (NI) 9955**] at
[**Telephone/Fax (1) 38202**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 10146**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2141-3-26**] 09:58
T: [**2141-3-26**] 10:11
JOB#: [**Job Number 38203**]
|
[
"996.74",
"518.82",
"482.40",
"038.19",
"428.0",
"726.10",
"427.31",
"203.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
3949, 5857
|
205, 341
|
370, 3931
|
127, 184
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,496
| 191,022
|
50636
|
Discharge summary
|
report
|
Admission Date: [**2196-9-3**] Discharge Date: [**2196-9-4**]
Date of Birth: Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
Haitian woman with baseline dementia, end-stage renal
disease, on hemodialysis, type 2 diabetes mellitus, hepatitis
C, history of peritoneal tuberculosis, with five [**First Name4 (NamePattern1) 3867**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] admissions in the past nine months,
who presents after dialysis with respiratory distress.
The patient was in her usual state of poor health and, after
dialysis on the day of admission, vomited during transport
home. She became tachypneic and diaphoretic and was brought
to the Emergency Room. There, she had BIPAP placed, which
she tolerated well. Arterial blood gases on four liters
nasal cannula showed a pH of 7.32, pCO2 52 and pO2 79. This
improved to a pH of 7.39, pCO2 39 and pO2 68 on BIPAP 10/5
and 70% FiO2.
After long discussions with the patient's son and the house
staff, it was decided that the family would like the patient
to receive the BIPAP if necessary, and she was admitted to
the Intensive Care Unit. The patient also developed a fever
to 104. Blood cultures were sent and the patient was given
levofloxacin 500 mg times one.
PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2.
End-stage renal disease, on hemodialysis. 3. Hepatitis C.
4. Congestive heart failure with diastolic dysfunction, left
ventricular ejection fraction 55% in [**2196-7-10**]. 5.
Multi-infarction dementia. 6. Peritoneal tuberculosis,
status post INH and Rifampin treatment. 7. Enterococcus
faecium line infection [**2196-2-11**], vancomycin resistant.
8. Multiple pneumoniae. 9. Pericardial cyst.
MEDICATIONS ON ADMISSION: Zantac 150 mg p.o.q.d., regular
insulin 4 units q.a.m., NPH insulin 18 units q.h.s.,
Nephrocaps one p.o.q.d., Nepro tube feeds, Norvasc 10 mg
p.o.q.d., Plavix 75 mg p.o.q.d.
ALLERGIES: ACE inhibitor (cough).
SOCIAL HISTORY: The patient is Creole speaking and does not
speak English. Her son is involved in her care. The patient
lives in a nursing home and has had declining health in the
past year. She is "Do Not Resuscitate", "Do Not Intubate".
PHYSICAL EXAMINATION: On physical examination, the patient
is cachectic and minimally responsive, lying in the fetal
position, appears frightened. Head, eyes, ears, nose and
throat: Sclerae clear, mucous membranes dry. Lungs:
Crackles heard one-half up from base on the right more than
left, no wheezes, poor air movement, using accessory muscles
to breath. Cardiovascular: Tachycardiac, normal S1 and S2,
no murmur. Abdomen: Soft, nontender, positive bowel sounds,
liver palpable, gastrostomy tube in place. Extremities:
Thin with pounding distal pulses bilaterally, bilateral lower
extremity contractures. Neurologic: Patient groaning but
following simple commands.
LABORATORY DATA: Admission laboratory data were hemolyzed.
Arterial blood gases were as noted above. Electrocardiogram
showed sinus rhythm at 120 beats per minute with left axis
deviation and normal intervals, old Q waves in leads II, III
and AVF, baseline artifact, no acute changes from previous
electrocardiograms. Chest x-ray revealed right middle lobe
opacity and an old pericardial cyst.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for a chief complaint of tachypnea. She
was placed on BIPAP ventilation for respiratory acidosis,
which improved, and her oxygenation was good. She received
Levaquin for presumed pneumonia.
The patient's temperature, however, continued to rise,
reaching levels above 106. She was tachycardiac to a rate
greater than 150. She was treated with ice packs,
intravenous fluid and her antibiotics were broadened to
include vancomycin and Flagyl.
Despite these treatments, the patient remained tachypneic and
tachycardiac and became increasingly hypotensive. On the
first hospital day, the patient's primary care physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) **], spoke with the family and it was agreed that the
patient should be taken off the BIPAP ventilation and started
on a morphine drip because of her extremely poor prognosis.
The family was at her bedside at the time of her death at
5:04 p.m.
CAUSE OF DEATH:
Respiratory failure from an aspiration pneumonia.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2196-1-17**] 17:50
T: [**2197-1-19**] 11:09
JOB#: [**Job Number **]
|
[
"V45.1",
"070.54",
"276.5",
"428.0",
"507.0",
"250.40",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1823, 2034
|
3374, 4723
|
2301, 3356
|
159, 1333
|
1356, 1796
|
2051, 2278
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,922
| 191,835
|
53053
|
Discharge summary
|
report
|
Admission Date: [**2177-7-22**] Discharge Date: [**2177-7-24**]
Date of Birth: [**2109-3-30**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 824**]
Chief Complaint:
Bladder Mass. Admitted following TURBT due to post-anesthesia
respiratory distress requiring re-intubation.
Major Surgical or Invasive Procedure:
TURBT
History of Present Illness:
68M admitted to [**Hospital Unit Name 153**] due to required re-intubation for
hypercarbic respiratory distress.
PMH: bladder Cancer, hyperthyroidism
Meds: None
All: None
Soc: + tobacco, 1ppd
Physical Exam:
NAD
Soft, NT, ND
Urine Clear, Voiding spontaneously
Brief Hospital Course:
Pt admitted to Urology service following TURBT. Pt transferred
to [**Hospital Unit Name 153**] intubated following hypercarbic respiratory distress
with aggitation and combatativeness. Pt recieved perioperative
antibiotics, aggressive chest PT and RT, and CBI was instituted.
On POD1 he was extubated without issue. His CBI cleared and he
was advanced to a regular house diet. On POD2 he had a low grade
fever, his CXr was clear and his Foley was D/C'd. He was D/C'd
home in stable condition, voiding spontaneously, ambulating
without assistance, and tolerating a house diet with adequate
analgesia on oral meds. He will finish 3 days of Cipro and
follow up in clinic with Dr. [**Last Name (STitle) 770**].
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for dysuria for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*2*
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
Disp:*1 inhaler* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
Disp:*50 Tablet(s)* Refills:*0*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
15 days.
Disp:*30 Capsule(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day: Take
while taking oxycodone. Stop taking if you have loose stools.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bladder Cancer
Discharge Condition:
Stable
Discharge Instructions:
The operation you have experienced is a "scraping" operation;
that is to say, the bladder tumor or biopsy sample was "scraped"
off the bladder wall. Bleeding was controlled with
electrocautery which will produce a "scab" in the inside bladder
wall. About 1-2 weeks after the operation, pieces of the scab
will fall off and come out with the urine. As this occurs,
bleeding may be noted which is normal. You should not worry
about this. Simply lie down and increase your fluid intake for a
few hours. In most cases, the urine will clear. Because of this
tendency for bleeding, aspirin and Advil must be avoided for 2
weeks following your operation, but Tylenol is okay. If bleeding
occurs and persists for more than 12 hours or if clots impair or
block your stream, call your urologist. If the stream is
completely blocked and you cannot contact your urologist, go to
the ER for Foley flushing.
If you develop a fever over 101?????? or chills, call your urologist.
Although not common, this may indicate infection that has
developed beyond the control of the antibiotics that you have
taken.
It will take 6 weeks from the date of surgery to fully recover
from your operation. This can be divided into two parts -- the
first 2 weeks and the last 4 weeks. During the first 2 weeks
from the date of your surgery, it is important to be "a person
of leisure". You should avoid lifting and straining, which also
means that you should avoid constipation. This can be done by in
3 ways: 1) modify your diet, 2) use stool softeners (Colace and
Senna) which have been prescribed for you, and 3) use gentle
laxatives such as Milk of Magnesia which can be purchased at
your local drug store. It is important for you to avoid
prolonged sitting. You should avoid sexual activity during this
time. Also, avoid driving. The danger is not so much the
driving, but it may delay you from urinating if you have the
urge; and, "holding" urine may cause bleeding. If you return to
work before 2 weeks, you may feel fatigued and require a
decreased work load.
During the second 4 week period of your recovery, you may begin
regular activity, but only on a graduated basis. For example,
you may feel well enough to return to work, but you may find it
easier to begin on a half-day basis. It is common to become
quite tired in the afternoon, and if such occurs, it is best to
take a nap! Also, you may begin to drive as well as lift objects
such as a briefcase, etc. If you are a golfer, you may begin to
swing a golf club at this time. Sexual activity may be resumed
during this time, but only on a limited basis. In general, your
overall activity may be escalated to normal as you progress
through this second time period, such that by 6-8 weeks
following the date of surgery, you should be back to normal
activity. If you take aspirin as a regular medication, it may be
resumed at this time.
Finally, call your urologist in one week after your surgery for
the results of your biopsy and your next appointment.
You have significant lung disease and emphysema which
contributed to the difficulty extubating you after your surgery.
You are being discharged with prescriptions for inhalers which
you should use as directed to help treat your lungs. Please
also talk with your primary care doctor about a referral to a
pulmonologist.
Followup Instructions:
Follow up in clinic with Dr. [**Last Name (STitle) 770**] in [**1-22**] weeks. Call
[**Telephone/Fax (1) 5727**] for an appointment as soon as you get home.
You have an appointment to follow up with an endocrinologist for
your thyroid. Please make every effort to attend this
appointment: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2177-8-11**] 3:30
You have an appointment to follow up with your primary care
doctor. Please talk with your doctor about seeing a
pulmonologist for your lungs. There is evidence of signficiant
emphysema on your Cat Scan which likely contributed to the
difficulty removing the ventillator after your surgery and the
need for reintubation.
Provider: [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2177-8-26**] 1:55
Completed by:[**2177-7-24**]
|
[
"496",
"188.1",
"518.5",
"242.90",
"293.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"57.49",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2557, 2563
|
741, 1450
|
421, 429
|
2622, 2631
|
5992, 6929
|
1473, 2534
|
2584, 2601
|
2655, 5969
|
665, 718
|
274, 383
|
457, 650
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,282
| 189,727
|
18845+56993
|
Discharge summary
|
report+addendum
|
Admission Date: [**2147-8-28**] Discharge Date: [**2147-9-3**]
Date of Birth: [**2097-5-8**] Sex: F
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: This is a 50 year old female who
was brought in by EMS after a syncopal episode leading to a
head-on collision against a tree at approximately 30 mph.
The patient was restrained and the airbag deployed. The
patient was hemodynamically stable with a GCS of 15 in the
Emergency Department. In the Emergency Department, she was
complaining of left chest pain, shortness of breath, and in
the field left crepitus was noted as well. In the trauma
bay, the patient was hemodynamically stable with a GCS of 15,
however, her oxygen saturation rate initially was between 80
and 90%. It was also noted at that time that her breath
sounds on the left side were markedly decreased. A tube
thoracostomy was then performed on the left side without
complications. After the placement of the tube thoracostomy,
the patient's oxygen saturation rate improved to 97%, her
shortness of breath improved, and lung sounds improved on the
left side as well. She remained hemodynamically stable
throughout the procedure and tolerated it well. As far as
her syncopal episode that led to the accident, the patient
reports feeling lightheaded and then blacked out and woke up
immediately after her motor vehicle collision without any
confusion, no loss of continence, and denied symptoms of
chest pain, palpitations, diaphoresis, or headache. She also
notes the use of cocaine three days prior to the accident,
and previously, one year ago without any sequelae at that
time. She had one previous episode of syncope during
pregnancy. There is no history of syncope in her family, but
there is a significant history of myocardial infarction, both
in her father and mother at an early age.
PAST MEDICAL HISTORY: Consistent bilateral pyelonephritis.
PAST SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: Codeine which causes nausea and vomiting.
SOCIAL HISTORY: Consists of occasional alcohol as well as
occasional cocaine ingestion, last was three days prior to
the accident, and previously was one year ago.
FAMILY HISTORY: Significant for her mother having a
myocardial infarction around age 50 and her father dieing of
a myocardial infarction in the [**2114**]'s.
PHYSICAL EXAMINATION: GCS 15; vital signs 105/palp; heart
rate 105; respiratory rate 22; oxygen saturation rate 85%
which then improved to 97% after chest tube placement. Head
eyes, ears, nose and throat: pupils were equally round and
reactive to light, extraocular movements intact. TM's were
clear. Face stable. Neck: trachea was midline. Chest:
decreased breath sounds to the left chest, no crepitus noted.
Cardiovascular: slightly tachy, 2 out of 6 systolic murmur
noted, loudest at the apex. Abdomen: soft, no tenderness to
palpation, rectal tone normal with no gross blood, guaiac
negative. Back: no tenderness to palpation, no step-offs
noted. Extremities: there was an open fracture noted to the
right wrist, otherwise she was moving extremities freely,
sensation and capillary refill to the right hand and fingers
was completely intact. Neurological examination: non-focal,
strength and sensation grossly intact. Her EKG was sinus at
106 beats per minute with normal axis intervals, showing some
[**Hospital1 **]-atrial abnormalities, poor R-wave progression, no acute
STT wave changes.
LABS: Initial blood gas 7.38; CO2 46; oxygen 35; bicarbonate
28;
base deficit 0. After the chest tube this improved to 7.40, 4
1, 382,
26, 0. Other notable laboratory findings was positive urine c
ocaine.
Also, three sets of enzymes were obtained for the syncopal epi
[**Last Name (un) **]
which were all within normal limits.
RADIOLOGY: Chest x-ray showed small apical pneumothorax and
proper placement of chest tube. Pelvis showed no fracture.
Head CT showed no bleed, no fracture. Spine CT showed no
fracture. Follow-up flexion extension films showed
subluxation of C2 to C3 and C3 C4 likely consistent with
degenerative changes as improved on extension. Chest CTA
showed no great vessel injury, a left upper lobe contusion.
Abdominal CT was normal. Right arm and wrist plain film
showed a distal, radial, and ulnar fracture with 100%
displacement.
HOSPITAL COURSE: Given the normal spine CT and the flexion
extension films which were most likely considered to be
associated with degenerative changes of the spine, we opted
to clear the patient clinically as she had no pain in the
spine at the time. On examination of the spine, she had no
tenderness and had free range of motion. Thus, the hard
cervical collar was removed. The patient has tolerated this
well.
The left tube thoracostomy that was placed was followed with
serial chest x-rays showing stabilization and eventually full
improvement of the apical pneumothorax, thus the chest tube
was removed on hospital day four. The patient has tolerated
this well and the chest tube has remained out.
Plastic Surgery was consulted for the right wrist fracture.
They opted to take the patient to the Operating Room for a
full examination and repair of the wound. The patient was
taken to the Operating Room on hospital day one and underwent
a right open reduction and internal fixation of the radius
and ulna. The patient tolerated the surgery well. She was
then started on Kefzol 1 gram q8 hours and gentamycin 100 mg
q8 hours for prophylaxis. Plastic Surgery has followed her
throughout the hospital course, remarking that the wound was
intact and the hand vasculature and nerves were intact. They
recommended follow-up in two weeks with Dr. [**Last Name (STitle) **].
Status post removal of the chest tube, there was a chest
x-ray done that showed a not previously seen fracture of the
left clavicle that was non-displaced. For this, Orthopedics
was consulted who recommended that a sling and swathe was not
necessary due to the desire to keep one arm slightly
mobilized. Thus a sling was provided for comfort and
recommendations were given for follow-up in three weeks.
For the syncopal episode, Cardiology was initially consulted
given the patient's significant family history. Cardiology,
after being consulted, decided to place the patient back on
continuous telemetry monitoring and ordered an
echocardiogram, the results of which showed one plus aortic
regurgitation, trivial mitral regurgitation, and a small
pericardial effusion which was noted to most likely be due to
trauma and not leading to any signs of tamponade. Cardiology
also suggested a consultation of the Electrophysiology
Service which was then done. Electrophysiology, after seeing
the patient, suggested the following course of action which
took place during the hospital stay:
1. There was a Persantine sestamibi test performed on
hospital day four. The sestamibi showed normal profusion of
the myocardium as well as normal wall motion and an ejection
fraction of 78%, considered to be a normal examination. They
also recommended a carotid ultrasound study which showed
normal flow of the carotid bilaterally. On hospital day
five, they took the patient for an electrophysiology study
which, per the attending electrophysiologist was also normal.
They decided at that time to place an implantable monitor
called a Reveal monitor which was placed during the
electrophysiology study which the patient tolerated well.
They also provided recommendations for follow-up on the
implantable monitor which will stay in for at least one year
in all likelihood.
The final consult was a physical therapy consult to improve
the patient's ability to ambulate and provide exercises for
both upper extremities as well as restrictions in activity
for her bilateral upper extremity fractures.
A final consult was done for social work regarding the
patient's history of cocaine use. The patient acknowledged
her use of cocaine and acknowledged that it was not a
problem, that she had only used it twice in the past. The
first time without sequelae and that she "did not even like
using it." The patient refused any further social work
follow-up or substance abuse assistance outside of the
hospital.
The patient remained stable throughout the hospital course.
She was then determined to be suitable for discharge on
hospital day seven.
DISCHARGE DIAGNOSIS:
1. Syncope, etiology undefined. In all likelihood, the
syncope was due to either a vasovagal reaction, some relation
to her cocaine use, although less likely given that it was
three days prior to the syncopal episode, or some cardiac
etiology which cannot be defined by the studies performed in
the hospital such as a prolonged QT leading to ventricular
tachycardia. It was considered unlikely that there was a
neurologic etiology such as seizure leading to the syncopal
episode. Given the normal cardiac work-up and the implanted
monitor placed, the patient was discharged with plans for
follow-up with Cardiology and Electrophysiology.
2. Traumatic left pneumothorax improved status post
placement of tube thoracostomy.
3. Right radial and ulnar fracture with complete
dislocation, status post open reduction and internal
fixation.
4. Left clavicle fracture treated with a sling and activity
restriction.
5. Tox screen positive for cocaine use.
DISCHARGE MEDICATIONS:
1. Augmentin 500 by mouth twice a day times seven days.
2. Percocet 5 mg 1 to 2 tablets by mouth q4-6 hours as
needed pain.
3. Oxycodone 10 mg by mouth q4-6 hours as needed
breakthrough pain.
4. Ibuprofen 600 mg q8 hours as needed pain.
5. Docusate 100 mg twice a day as needed constipation.
DISCHARGE INSTRUCTIONS:
1. Follow-up plans were scheduled with Dr. [**Last Name (STitle) **] of Plastic
Surgery in two weeks for re-evaluation of the right radial
and ulnar fracture.
2. Follow-up with Orthopedics was scheduled in three weeks
for follow-up on the left clavicle fracture. A sling was
provided for comfort and instructions were given to restrict
motion to no greater than 90 degrees and no heavy weight
bearing on the left side.
3. Follow-up with trauma clinic was provided for two weeks
from date of discharge from hospital.
4. Electrophysiology follow-up was provided for one week
from date of discharge. The patient will make an appointment
to be seen in the pacemaker center and further follow-up will
be decided on at that time.
5. Other instructions include that the patient should be
closely monitored over the next several days after discharge
and should refrain from driving a car for one to two months
given the syncopal episode. The patient also will receive
instructions to limit weight bearing to the right and left
upper extremities and to continue ambulation as much as
possible.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. 2923
Dictated By:[**Last Name (NamePattern1) 50087**]
MEDQUIST36
D: [**2147-9-1**] 14:00
T: [**2147-9-4**] 21:17
JOB#: [**Job Number 51576**]
Name: [**Known lastname 9598**], [**Known firstname 4193**] Unit No: [**Numeric Identifier 9599**]
Admission Date: [**2147-8-29**] Discharge Date: [**2147-9-6**]
Date of Birth: [**2097-5-8**] Sex: F
Service: Trauma Surgery
ADDENDUM: During the hospital course the patient was changed
from Kefzol and gentamicin intravenously to oral antibiotics
in preparation for discharge. The antibiotic given was
Augmentin which was given on hospital day six. Thirty
minutes after the Augmentin the patient experienced an
episode of hypoxia as well as hypotension witnessed by Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
The patient responded to fluid boluses and oxygen via nasal
cannula and was transferred to the Medical Intensive Care
Unit where she responded without further resuscitative
measures.
To rule out other causes, the patient had a chest computed
tomography angiogram, a repeat echocardiogram, and an
investigation of her implantable cardiac monitor. The chest
computed tomography angiogram was normal. The echocardiogram
showed no changes from the prior study. The investigation of
the intracardiac monitor revealed no abnormal cardiac
activity.
Given the association with the Augmentin, it was decided that
the episode of hypotension and hypoxia was due to an
anaphylactic reaction to the Augmentin.
The patient remained stable throughout the one day in the
Medical Intensive Care Unit and was transferred back to floor
where she remained stable and experienced no further issues.
The patient was started on clindamycin 300 mg by mouth four
times per day and experienced no side effects to this
medication.
The patient did well throughout the rest of her hospital
stay. The patient was suitable for discharge on hospital day
nine.
The rest of the hospital course and follow-up plans are the
same as the previous dictation. The patient was to follow up
with Orthopaedics as well as Trauma in the clinic within two
weeks.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D. [**MD Number(1) 3596**]
Dictated By:[**Last Name (NamePattern1) 9596**]
MEDQUIST36
D: [**2147-9-5**] 15:40
T: [**2147-9-5**] 16:05
JOB#: [**Job Number 9600**]
|
[
"E815.0",
"305.60",
"780.2",
"810.00",
"807.02",
"860.0",
"813.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.50",
"04.43",
"38.93",
"79.32",
"34.04",
"37.26",
"86.09",
"79.62"
] |
icd9pcs
|
[
[
[]
]
] |
2192, 2335
|
9346, 9644
|
8363, 9323
|
4332, 8342
|
9668, 13262
|
1926, 2009
|
2358, 4314
|
170, 1841
|
1864, 1902
|
2026, 2175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,217
| 163,753
|
36704
|
Discharge summary
|
report
|
Admission Date: [**2112-7-16**] Discharge Date: [**2112-7-21**]
Date of Birth: [**2048-4-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Craniotomy
History of Present Illness:
HPI: 64y/o female on Coumadin was brought to [**Hospital1 18**] s/p fall at
[**Last Name (un) **] range today. Family members report that the patient
tripped while outside of the [**Last Name (un) **] range and fell hitting the
back of her head. She was able to stand, but then fell to the
floor as if she was having a seizure and lost consciousness. EMS
on scene states that she had a GCS of 4 and was intubated,
sedated and brought to [**Hospital1 18**]. CT scan shows L SDH and she taken
to the OR for an emergent evacuation of L SDH.
Past Medical History:
PMHx:seizure, HTN, bypass
Social History:
unknown
Family History:
unknown
Physical Exam:
PHYSICAL EXAM:
ON ARRIVAL
Gen: Patient is intubated s/p craniotomy for evacuation of L
SDH.
HEENT: Pupils: 3-2mm bilaterally EOMs:unable to access
Neuro:
Mental status: patient is intubated,
Orientation: unable to access
Recall: Unable to access
Language: unable to access
Naming intact. unable to access
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: unable to access
V, VII: unable to access
VIII: unable to access
IX, X: unable to access
[**Doctor First Name 81**]: unable to access
XII: unable to access
Motor: RUE- attempts to localize to noxious stimuli, LUE-
extensor posturing, LE- triple flexion bilaterally
Positive corneal reflex bilaterally
Positive cough
ON DISCHARGE:
pt awake alert oriented x 3 - CN II - XII intact, slight right
drift, speech clear. Motor 4+ throughout.
Pertinent Results:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 83004**],[**Known firstname **] [**2048-4-2**] 64 Female [**-9/2721**]
[**Numeric Identifier 83005**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/dif
SPECIMEN SUBMITTED: SUBDURAL HEMATOMA (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
[**2112-7-16**] [**2112-7-18**] [**2112-7-19**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/mtd
DIAGNOSIS:
"Subdural hematoma" (A):
Erythrocytes and fibrin consistent with hematoma.
Rare and minute fragments of bone.
Clinical: 64 year old woman, cranial bleed. Specimen submitted:
Subdural hematoma.
Gross:
The specimen is received fresh labeled with the patient's name,
"Eu, Critical / [**Known lastname **], [**Known firstname **]," her medical record number and
"subdural hematoma." It consists of multiple fragments of blood
clot measuring 6.9 x 5.5 x 0.6 cm in aggregate. On sectioning
the clots are grossly unremarkable. The specimen is serially
sectioned and represented in cassette A.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 83004**],[**Known firstname **] [**2048-4-2**] 64 Female [**-9/2721**]
[**Numeric Identifier 83005**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/dif
SPECIMEN SUBMITTED: SUBDURAL HEMATOMA (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
[**2112-7-16**] [**2112-7-18**] [**2112-7-19**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/mtd
DIAGNOSIS:
"Subdural hematoma" (A):
Erythrocytes and fibrin consistent with hematoma.
Rare and minute fragments of bone.
Clinical: 64 year old woman, cranial bleed. Specimen submitted:
Subdural hematoma.
Gross:
The specimen is received fresh labeled with the patient's name,
"Eu, Critical / [**Known lastname **], [**Known firstname **]," her medical record number and
"subdural hematoma." It consists of multiple fragments of blood
clot measuring 6.9 x 5.5 x 0.6 cm in aggregate. On sectioning
the clots are grossly unremarkable. The specimen is serially
sectioned and represented in cassette A.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F 64 [**2048-4-2**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-16**]
9:59 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2112-7-16**] 9:59 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 83007**]
Reason: S/P FALL, ? BLEED
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
? bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SPfc SAT [**2112-7-16**] 10:32 AM
Large left, primarily subdural, extra-axial hemorrhage with
associate right
sub-falcine herniation of ~10mm. D/w Trauma surgery service.
Final Report
HISTORY: Fall.
COMPARISON: No prior studies available for comparison.
TECHNIQUE: Axial CT images were acquired through the head in the
absence of intravenous contrast. Coronal and sagittal
reformatted images were also
reviewed.
FINDINGS:
A large area of subdural blood extends over the entire left
cerebral
hemisphere, including parafalcine extension. At maximal depth,
this subdural collection appears to measure approximately 21 mm
(2:23). There is associated effacement of the ipsilateral sulci
and lateral ventricle as well as subfalcine herniation measuring
approximately 10 mm at greatest deviation (2:18). Small areas of
hyperdensity extending along the gyral surface overlying the
right parietal lobe (2:23) may represent foci of parenchymal
contusion or small amount of subarachnoid blood. There is no
evidence of entrapment of the contralateral lateral ventricle.
The third ventricle appears partially effaced as well as
displaced secondary to the subdural blood. The posterior fossa
appears unremarkable. There are no other foci of hemorrhage.
Extracranial soft tissue structures reveal a mild amount of soft
tissue prominence overlying a surgical defect in the left
parietal bone, possibly related to the recent fall or remote
surgery. Visualized osseous structures reveal the surgical
defect, overlying the subdural blood as previously depicted.
There is no other evidence of fracture. The included paranasal
sinuses reveal a hypoplastic left frontal sinus as well as
circumferential mucosal thickening in the ethmoidal air cells,
bilaterally, as well as in the maxillary sinuses bilaterally. A
large amount of fluid and secretions is seen in the included
portion of the nasopharynx and should be clinically correlated
for possibility of aspiration.
IMPRESSION:
1. Large primarily subdural extra-axial hemorrhage, with
associated right
deviation of normal midline anatomy of approximately 10 mm.
2. Hypodensity left frontoparietal lobe indicating
encephalomalacia.
3. S,all hyperdensity adjacent to left anterior [**Doctor Last Name 534**] due to
axonal injury or contusion.
4. Large amount of retained secretions in the nasopharynx which
should be
correlated for concern of possible aspiration. These findings
were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] from the trauma surgery
service at 10:30 a.m. on [**2112-7-16**].
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F 64 [**2048-4-2**]
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2112-7-16**]
10:00 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2112-7-16**] 10:00 AM
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 83008**]
Reason: S/P FALL, ? C SPINE FX
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
? fx
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SPfc SAT [**2112-7-16**] 10:50 AM
no fracture or traumatic malalignment.
Final Report
HISTORY: Fall.
COMPARISON: Comparison is made to concurrent CT of the head as
well as torso.
TECHNIQUE: Axial CT images were acquired through the cervical
spine in the
absence of intravenous contrast. Coronal and sagittal
reformatted images were also reviewed.
FINDINGS: There is no fracture or traumatic malalignment. There
is no
prevertebral soft tissue swelling. Intracranial contents are
better
characterized on a concurrent CT head dictated separately.
Vertebral body
heights are well preserved. The regional soft tissue and
vascular structures appear unremarkable. The portions of the
lung apices included are better characterized on the concurrent
CT of the torso.
Moderate amount of retained secretions in the hypo- and
[**Last Name (un) **]-pharynx are
redemonstrated.
IMPRESSION: No fracture or traumatic malalignment. Findings were
discussed
in person by Dr. [**Last Name (STitle) 14804**] with Dr. [**Last Name (STitle) 1132**] from the trauma surgery
service at
approximately 10:50 a.m. on [**2112-7-16**].
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F 64 [**2048-4-2**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2112-7-16**] 9:59
AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2112-7-16**] 9:59 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 83009**]
Reason: ? cp process
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
? cp process
Final Report
HISTORY: 66-year-old woman status post fall.
PORTABLE CHEST RADIOGRAPH.
COMPARISON: None.
FINDINGS: Evaluation is limited by presence of trauma backboard
underlying
the patient. There are sternal wires as well as surgical clips
in the upper mediastinum. There is an endotracheal tube whose
tip abuts the carina and should be withdrawn approximately 3 to
4 cm. A nasogastric tube courses through the esophagus and into
the stomach. The cardiomediastinal silhouette appears abnormal
with abnormal widening of the upper mediastinum and an
indistinct aortic knob. There is opacification which obscures
the retrocardiac silhouette as well as the left heart border.
Additional opacity noted in right upper hemithorax. There is no
pneumothorax. There are no obvious rib fractures.
IMPRESSION:
1. Endotracheal tube abutting the carina and should be
re-positioned.
2. Abnormal widening of the mediastinum, in the setting of
trauma cannot
exclude possible aortic injury and recommend chest CT for
further evaluation.
3. Increased density in the retrocardiac region as well as
abutting the left heart border and in right upper lung.
Aspiration and/or contusion are
principal diagnostic considerations.
4. No displaced rib fracture or pneumothorax.
Findings were communicated via telephone to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3827**] at 10:15
a.m. [**2112-7-16**].
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F 64 [**2048-4-2**]
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2112-7-16**]
10:02 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2112-7-16**] 10:02 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Clip # [**Clip Number (Radiology) 83010**]
Reason: S/P FALL, ? INJURY
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
? thoracic injury
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SPfc SAT [**2112-7-16**] 10:59 AM
ETT is only 12-15mm above the carina and should be retracted.
Bilateral
pulmonary opacities are some combination of atelectasis and
aspiration. Note
is made of cholelithiasis.
Final Report
HISTORY: Fall.
COMPARISON: Comparison is made to concurrent CT of the cervical
spine.
TECHNIQUE: Axial CT images were acquired through the torso
following
administration of 130 cc of intravenous Optiray contrast.
Coronal and
sagittal reformatted images were also reviewed.
CT CHEST WITH CONTRAST: The patient is intubated with the tip of
the
endotracheal tube terminating approximately 12 mm above the
carina (301B:41). This tip could be retracted slightly.
Otherwise, airways are patent to segmental levels bilaterally.
Consolidative opacities are noted in the upper lobes bilaterally
as well as dependently in the lower lobes, likely reflecting
some combination of atelectasis and aspiration. The heart and
great vessels are notable for postoperative change, following an
apparent mitral valve replacement. Atherosclerotic calcification
is visualized along the aortic annulus as well as at the aortic
arch. There is no axillary or mediastinal lymphadenopathy.
CT ABDOMEN WITH CONTRAST: An orogastric tube terminates in the
stomach which is otherwise unremarkable. The duodenum, spleen,
fatty pancreas, adrenal glands, liver, kidneys are unremarkable.
The gallbladder contains numerous hyperattenuating foci
consistent with layering gallstones. There is no free gas or
fluid in the abdomen. There is no retroperitoneal or mesenteric
lymphadenopathy.
CT PELVIS WITH CONTRAST: The rectum, colon, uterus, adnexa are
unremarkable. The urinary bladder contains a Foley catheter.
There is no free gas or fluid in the abdomen. There is no pelvic
sidewall or inguinal lymphadenopathy.
OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic
osseous lesion. Note is made of multiple sternotomy wires. There
is a mild anterior wedge compression deformity of the T8
vertebral body of unknown chronicity.
IMPRESSION:
1. Bilateral pulmonary opacities are consistent with some
combination of
atelectasis and aspiration.
2. Endotracheal tube is approximately 12 mm above the carina and
could be
retracted slightly.
3. Cholelithiasis.
These findings were discussed in person by Dr. [**Last Name (STitle) 14804**] with Dr.
[**Last Name (STitle) 1132**] from
trauma surgery at approximately 10:50 a.m. on [**7-16**],
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F 64 [**2048-4-2**]
Neurophysiology Report EEG Study Date of [**2112-7-18**]
OBJECT: History of epilepsy status post evacuation of subdural
hemorrhage with recurrent seizures on dilantin.
REFERRING DOCTOR: DR. [**First Name (STitle) 7495**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: In the awake state, there was voltage reduction
in the
right parasagittal region and occasional slowing on the right
accompanying drowsiness. There was earlier onset of drowsiness
on the
right versus the left.
ABNORMALITY #2: Later in the study, there were runs of
polymorphic theta
with rare sharps over the left central region during drowsiness.
BACKGROUND: Throughout the recording the background rhythm
remained slow
typically reaching a 7.5 Hz maximum.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 96 bpm.
IMPRESSION: This is an abnormal routine EEG due to persistent
decreased
voltage in the right parasaggital and frontal region.
Additionally, the
slow background suggests a mild encephalopathy affecting both
cortical
and subcortical structures. Medications, metabolic disturbances,
and
infection are among the most common causes. There were no
clearly
epileptiform feature.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83011**]Portable TTE
(Complete) Done [**2112-7-18**] at 1:34:40 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 742**]
[**Hospital1 18**]-Division of Neurosurgery
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2048-4-2**]
Age (years): 64 F Hgt (in):
BP (mm Hg): 121/55 Wgt (lb): 182
HR (bpm): 95 BSA (m2):
Indication: Aortic valve replacement. Mitral valve replacement.
ICD-9 Codes: 424.1, 424.0, 424.2
Test Information
Date/Time: [**2112-7-18**] at 13:34 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2009W055-0:00 Machine: Vivid [**7-11**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.8 cm
Left Ventricle - Fractional Shortening: 0.56 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *64 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 36 mm Hg
Mitral Valve - Peak Velocity: 1.9 m/sec
Mitral Valve - Mean Gradient: 7 mm Hg
Mitral Valve - Pressure Half Time: 70 ms
Mitral Valve - E Wave: 1.7 m/sec
Mitral Valve - A Wave: 1.6 m/sec
Mitral Valve - E/A ratio: 1.06
Mitral Valve - E Wave deceleration time: 182 ms 140-250 ms
TR Gradient (+ RA = PASP): *38 to 48 mm Hg <= 25 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm)
with >55% decrease during respiration (estimated RA pressure
(0-5mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR).
Increased AVR gradient. No AR.
MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Normal
MVR leaflet motion. Increased MVR gradient. No MR. [Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The estimated right atrial pressure is 0-5 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
cavity size and systolic function are normal. A mechanical
aortic valve prosthesis is present. The transaortic gradient is
higher than expected for this type of prosthesis. No aortic
regurgitation is seen. A bileaflet mitral valve prosthesis is
present. The motion of the mitral valve prosthetic discs appeas
normal. The gradients are higher than expected for this type of
prosthesis. No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mechanical aortic valve
prosthesis with increased gradient. Bileaflet mitral valve
prosthesis with good disc motion, but increased gradient.
Moderate pulmonary artery systolic hypertension. Preserved
global biventricular systolic function.
CLINICAL IMPLICATIONS:
Based on [**2110**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F 64 [**2048-4-2**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-19**]
6:56 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2112-7-19**] 6:56 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 83012**]
Reason: ? change in bleed
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman s/p SDH w evacuation, seizure
REASON FOR THIS EXAMINATION:
? change in bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: JMGw TUE [**2112-7-19**] 8:05 PM
IMPRESSION:
1. Unchanged appearance to left temporoparietal intraparenchymal
hemorrhage with hypodensity and small left subdural hematoma. No
new areas of hemorrhage. No midline shift.
2. Stable hyperdense foci anterior to the left lateral
ventricular [**Doctor Last Name 534**] may represent area of contusion injury or [**Doctor First Name **].
Final Report
HISTORY: 64-year-old woman status post subdural hematoma with
evacuation and seizure. Evaluate for change in bleed
HEAD CT: Axial imaging was performed through the brain without
IV contrast.
COMPARISON: CT head [**2112-7-17**]. There is unchanged appearance
to small
left frontoparietal subdural hematoma measuring approximately 4
mm in
thickness.
FINDINGS: There is no shift of normally midline structures.
There is
unchanged appearance to intraparenchymal hemorrhage and
hypodensity in the
right temporoparietal lobe (2A:17). The ventricles appear stable
in size
without evidence for hydrocephalus. There are no new areas of
hemorrhage.
[**Doctor Last Name **]-white matter differentiation appears well preserved. There
are
persistent hyperdense foci anterior to the anterior [**Doctor Last Name 534**] of the
left lateral ventricle (2A:16). There is no evidence for
herniation, ambient and basilar cisterns are widely patent.
Patient is status post left craniotomy. There is mucosal
thickening of ethmoid air cells and maxillary sinuses. There is
decreased hematoma with decreased subcutaneous gas along the
left frontal scalp. There is minimal pneumocephalus adjacent to
the left subdural
hematoma.
IMPRESSION:
1. Unchanged appearance to left temporoparietal intraparenchymal
hemorrhage with internal hypodensity, now with small layering
blood/flood levels, and small extra-axial hematoma over the left
convexity.
2. No new foci of hemorrhage or shift of midline structures.
3. Stable more punctate hyperdense focus anterior to the left
lateral
ventricular frontal [**Doctor Last Name 534**] may represent additional contusion, or
[**Doctor First Name **].
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F 64 [**2048-4-2**]
Neurophysiology Report EEG Study Date of [**2112-7-20**]
OBJECT: Bedside LTM w/video ekg [**Date range (1) 23533**]. THERE WERE NO
PUSHBUTTON
ACTIVATIONS. ROUTINE SAMPLING AND SPIKE AND SEIZURE DETECTION
PROGRAMS
WERE UTILIZED.
REFERRING DOCTOR: DR. [**First Name (STitle) 7495**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: There was prominent fast activity in the left
temporal
region.
ABNORMALITY #2: Intermittent and isolated slow sharp waves were
noted in
the left posterior temporal region.
ABNORMALITY #3: Throughout the recording the background rhythm
remained
slow typically reaching a 7 Hz maximum.
ABNORMALITY #4: There was decreased voltage noted in the right
parasagittal and frontal regions.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This is an abnormal EEG telemetry study due to a
slow
background in the theta range which suggests a widespread
encephalopathy
affecting both cortical and subcortical structures. There was
breech
artifact as well as isolated slow sharp wave activity in the
left
temporal region. Finally, the decreased voltage in the right
parasagittal and frontal regions may present diffuse cortical
injury or
possible residual subdural hematoma. There were no epilpetiform
features.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Brief Hospital Course:
This pt was admitted through the emergency department for acute
left sdh / on coumadin. INR was reversed on admission - She was
taken to the OR emergently for evacuation of the collection.
Post operative day # 1 she had focal sz activity that was
described as twitching movements of angle of mouth on the right
side. This was
followed by twitching movement of her Right upper limb upto hand
after few seconds. The entire episode lasted for less than 1
minute. She was seen by the neurology service and their
recommendations were followed. Cardiology consult was obtained
for guidance in anticoagulation for her mechanical heart valves.
She started on ASA on [**Doctor Last Name **] day #2. On [**Doctor Last Name **] day # 4 a heparin
drip was started / wt based, for her mechanical heart valves.
Surface echo was performed. She is due to start coumadin on
monday the [**3-25**] while in rehab. Her goal PTT is 50 at
which time she should have a CT scan of the brain. Her diet and
sctivity were advanced and she was seen by PT. She did have a
24 hour EEG which did not show any sz activity. Her home med of
dilantin was discontinued and only keppra remains.
Her exam steadily improved and she was transferred to the step
down unit.
PT/OT/ST evals deem pt a rehab candidtate. She is to be d/c's
to rehab and agrees with plan.
Medications on Admission:
Medications prior to admission: fosamax, dilantin, amoxicillin,
lisinopril, Coumadin
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing .
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Lorazepam 0.5 mg IV PRN seizure > 3 minutes
PLEASE CALL HOUSE OFFICE PRIOR TO USING. [**Month (only) **] REPEAT X 1 IF
NEEDED.
10. 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.
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. heparin drip sliding scale
Heparin solution: 25,000 in 250cc of D5W
Goal PTT = 50
PTT (sec) RATE CHANGE (UNITS/HR)
PTT <30 INCREASE INFUSION RATE BY 200
//
PTT 31-45 INCREASE INFUSION RATE BY 100
//
PTT 46-55 DO NOT CHANGE THE RATE //
PTT 56-70 DECREASE INFUSION RATE BY 200
//
PTT >71 DECREASE INFUSION RATE BY 400
//
WHEN PTT IS AT GOAL OF 50 - PLEASE OBTAIN NON CONTRAST BRAIN CAT
SCAN
DO NOT RESTART COUMADIN DOSING UNTIL MONDAY [**2112-7-25**] PER DR.
[**Last Name (STitle) **] / NEUROSURGERY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
left SDH
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
PLEASE HAVE YOUR STAPLES REMOVED ON [**2112-7-26**] AT THE REHAB
FACILITY OR RETURN TO THE OFFICE ON THAT DAY [**Telephone/Fax (1) **]
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) 739**] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2112-7-21**]
|
[
"438.89",
"V58.61",
"345.50",
"401.9",
"E885.9",
"348.4",
"728.89",
"V43.3",
"412",
"852.26"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
27406, 27476
|
24055, 25394
|
323, 336
|
27529, 27553
|
1899, 4747
|
28976, 29289
|
994, 1003
|
25529, 27383
|
20104, 20152
|
27497, 27508
|
25420, 25420
|
27577, 28953
|
1033, 1175
|
19473, 20064
|
25452, 25506
|
1774, 1880
|
279, 285
|
20184, 20793
|
364, 904
|
1343, 1760
|
20802, 24032
|
1190, 1327
|
926, 953
|
969, 978
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,476
| 119,862
|
27004
|
Discharge summary
|
report
|
Admission Date: [**2109-5-2**] Discharge Date: [**2109-7-2**]
Date of Birth: [**2052-4-3**] Sex: M
Service: SURGERY
Allergies:
Compazine
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
[**2109-5-3**]: transplant kidney biopsy
[**2109-5-17**]: ERCP
History of Present Illness:
57 y/o male with ESRD s/p cadaveric renal transplant [**2109-4-19**]
that required mesh placement intraoperatively due to large size
of transplant kidney.
Postop course was complicated by delayed graft function and he
was discharged on [**4-25**] with continued HD requirement. Since
discharge he denies fever,
cough, diarrhea or rash.
At dialysis on [**5-2**] he developed rigors, chills, and fever and
was sent to the ED for further evaluation. He was febrile to
102.5 in the ER. He received Vanco and Zosyn and is admitted for
further evaluation.
Past Medical History:
HTN
ESRD now s/p cadaveric kidney transpalnt [**2109-4-19**] with delayed
graft function
h/o Hepatitis B
Social History:
From [**Country 2045**], denies any ETOH, Cig, or illicit drug use. Used to
be a cab driver until became too weak to work.
Family History:
DM, HTN
Physical Exam:
VS: 100.7, 89, 170/97, 98%RA
Card: RRR
Lungs: CTA bilaterally
Abd: Soft, non-tender, RLQ: mild induration, staples in place,
mild discomfort, no drainage
Extr: warm, no edema, Left AVF positive bruit/thrill
Pertinent Results:
On Admission: [**2109-5-2**]
WBC-4.3 RBC-3.39* Hgb-11.1* Hct-32.7* MCV-97 MCH-32.7* MCHC-33.9
RDW-14.8 Plt Ct-318
PT-13.1 PTT-33.8 INR(PT)-1.1
Glucose-133* UreaN-26* Creat-6.2*# Na-139 K-5.0 Cl-95* HCO3-33*
AnGap-16
Lipase-60 Calcium-8.2* Phos-3.5 Mg-1.6
ALT-39 AST-67* AlkPhos-189* TotBili-0.4
Brief Hospital Course:
57 y/o male s/p kidney transplant c/b delayed graft function who
returns with fever/chills while undergoing hemodialysis in the
outpatient setting. Initially given Vanco and Zosyn in the ER.
He had an U/S of the transplant kidnbey on admission showing:
-Small collection adjacent to the inferior pole of the
transplant kidney which likely represents a developing urinoma
or seroma based on patient's operative date.
-No hydronephrosis and appropriate vascular flow.
Blood cultures drawn daily from [**Date range (1) 61523**] were all no growth
Urine Culture [**5-8**] and [**5-10**] both grew Vanco resistant
enterococcus.
New urine culture obtained on [**5-14**] grew Enterococcus and yeast,
and then another urine culture from [**5-16**] grew out yeast.
Linezolid was continued for 14 days
CMV on [**4-8**] was negative. C Diff was negative x 3, Throughout
the hospitalization he would have low grade to frank fever
spikes daily (102.8 max on HD 5)
A kidney transplant biopsy was performed on [**2109-5-3**] showing no
acute rejection
On [**2109-5-4**] he underwent CT guided drainage of the perinephric
fluid collection with approximately 20 cc of serosanguinous
fluid removed. Culture on this fluid was no growth.Additionally,
liver U/S was obtained and then a gallbladder scan due to
findings of sludge. He continued to spike fevers despite
continued antibiotic treatment. ERCP was done on [**5-17**] which
showed: Sludge at the CBD (sphincterotomy and stone extraction).
On [**2109-5-17**] urology was consulted. The ureteral stent was removed
due to concern for Enterococcus that was present in the urine.
A CT was performed on [**5-18**] of the abdomen/pelvis:- No evidence
of free contrast within the peritoneum to suggest leakage from
the bladder or transplanted kidney or ureter. The density seen
on the previous chest x-ray was contained within the bowel.
- Interval increase in density in a right lower abdominal
subcutaneous
collection most likely represents hemorrhage into an existing
collection. He underwent repeat kidney biopsy on [**5-21**] as solute
clearance continued to remain low and urine output which had
increased for awhile again was low.
[**5-24**] pt developed a significant hypotensive event x2 and
tachycardia with a
major hematocrit drop. On examination, he wais in extremis,
cold, coagulopathic. He underwent an Exploratory laparotomy,
cauterization of bleeding liver biopsy sites and evacuation of
hematoma. liver bx - VRE
[**5-26**] ERCP showed hemobilia secondary to liver bx, embolized.
[**7-1**] max doses of vasopressors
[**5-27**] ERCP for biliary stent removal/clot extraction also s/p HD.
[**5-25**] BCx VRE, [**5-26**] Quentin Cx/BCx VRE, [**5-27**] HD Cath Cx/BCx VRE,
[**5-28**], [**5-30**],
[**6-3**] Head CT: no acute intracranial processes,
[**6-6**]: normal renal and hepatic u/s
[**6-8**]: bld cx positive for burkholderia
5/5,[**9-16**]: bcx pos VRE
[**6-13**] PICC line placed.
5/15,18-22: burkholderia bld cx
[**6-25**]: trach
[**6-27**]: Endoscopy has shown an ischemic stomach and descending
colon.
[**6-28**]: CTA ABD/PELV- Bilateral pleural effusions and areas of
adjacent passive atelectasis, Infarct involving liver, kidneys,
and spleen, Large ascites, Thickening of the bowel, not
significantly changed since prior exam, Atherosclerotic
narrowing involving celiac axis and SMA. vascular consult for
mesenteric ischemia. nothing to do in setting of critical
illness
[**6-28**] PERITONEAL FLUID GNRs
[**6-29**] bronch for collapsed RUL, bloody secretions
[**6-30**] RUL collapse, intrabronchial blood clot, bronch,
hypotension
ANTIBIOTIC COURSE:
RIBAVIRIN: [**5-28**] 200po, [**5-29**] 200po, [**5-30**] 100IV, [**5-31**] 300IV, [**6-1**]
400IV, [**6-2**] 600IV, [**6-3**] 600IVq12, ([**Date range (1) 66374**]) 600IVq8, ([**Date range (1) 66375**])
240IVq8, ([**Date range (1) 66376**]) 240IV Q12; Vancomycin 1000 mg IV HD PROTOCOL
([**Date range (1) 46143**]); Linezolid ([**Date range (1) 615**]) ([**Date range (1) 66377**]) (dropped
platelets)([**Date range (1) 55077**]); Daptomycin
([**Date range (1) 66378**])([**Date range (1) 66376**]);MetRONIDAZOLE (FLagyl) 500 mg IV Q12H
[**5-7**]; Piperacillin-Tazobactam Na 2.25 g IV Q12H ([**Date range (1) 66379**])
([**Date range (1) 66380**]);Levoflox ([**Date range (1) 27111**]) ([**Date range (1) 66381**]);meropenem [**Date range (1) 21716**])
([**Date range (1) 66382**]);Doxycycline ([**Date range (1) 66383**]);s/p Sulfameth/Trimethoprim SS
1 TAB PO DAILY [**5-3**];Valgan([**Date range (1) 66384**]) ([**Date range (1) **]);dapsone (PCP
[**Name Initial (PRE) **]) 4/22Inhaled pentam ([**5-17**]); ABX at time of passing:
Meropenem ([**6-21**]--> Daptomycin ([**6-28**]---> Tigecycline([**6-27**]-->
Flagyl ([**6-12**]- Caspofungin ([**6-19**]--> Ribavirin 240 mg IV Q 12
([**6-28**]-->
In summary the patient remained critically ill in the SICU for
over a month with multiorgan system failure, coagulopathy,
persistent bacteremia, pneumobilia
following a liver bx, and a rising lactate. He was being
supported by vasopressors and CVVHD and receiving TPN for
nutrition. There were daily conversation with the family in
terms of the patient's grim prognosis. Social work was alos
involved throughout. The patient finally suffered a PEA arrest
at 1551 on [**2109-7-2**]. The wife was present along with multiple
physicians that had been involved in his care. The family is
currently deciding on whether to pursue an autopsy.
Medications on Admission:
Bactrim 80-400 mg Daily; Nystatin 5 ML PO QID; MMF 1000 mg [**Hospital1 **];
Metoprolol 100 mg TID; Valganciclovir 450 mg 2X/WEEK (MO,FR);
Nifedipine 180 mg SR Daily; Tacrolimus 6 mg Q12H; Prilosec 40
daily; Aspirin EC 81 Daily, renagel 800 TID, nephrocap 1 daily
Discharge Disposition:
Home
Discharge Diagnosis:
deceased. LCMV infection s/p CKD
Discharge Condition:
deceased
Completed by:[**2109-7-2**]
|
[
"V18.0",
"286.9",
"995.92",
"578.0",
"038.8",
"V17.49",
"530.10",
"599.0",
"117.9",
"570",
"518.5",
"998.11",
"573.4",
"996.62",
"585.6",
"998.12",
"285.1",
"997.5",
"518.0",
"574.21",
"403.91",
"E870.8",
"E878.0",
"070.30",
"531.90",
"557.9",
"576.1",
"998.2",
"996.81",
"038.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"50.11",
"31.1",
"54.19",
"99.04",
"00.14",
"87.76",
"96.04",
"97.62",
"39.98",
"99.05",
"97.05",
"51.87",
"99.07",
"55.23",
"51.88",
"88.47",
"51.85",
"38.95",
"33.21",
"96.72",
"99.21",
"39.79",
"54.91",
"45.13",
"38.93",
"48.23",
"51.10",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7533, 7539
|
1771, 4522
|
272, 336
|
7615, 7653
|
1452, 1452
|
1201, 1210
|
7560, 7594
|
7244, 7510
|
1225, 1433
|
227, 234
|
364, 915
|
4531, 7218
|
1466, 1748
|
937, 1044
|
1060, 1185
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,282
| 156,578
|
12963
|
Discharge summary
|
report
|
Admission Date: [**2136-6-23**] Discharge Date: [**2136-7-11**]
Date of Birth: [**2064-4-30**] Sex: M
Service: SURGERY
Allergies:
Methotrexate
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Status post fall
Major Surgical or Invasive Procedure:
[**2136-6-23**]
1. Bilateral C3 laminotomy.
2. Laminectomy C4, C5, C6, C7, T1.
3. Open reduction, manual, of C5-C6 fracture dislocation.
4. Posterior cervical arthrodesis C4-T1.
5. Application of local autograft for fusion augmentation.
6. Application of allograft for fusion augmentation.
[**2136-6-23**]
Left hand compartment release, specifically
the thenar compartment, the thumb adductor compartment, the
first dorsal interosseous compartment, the second dorsal
interosseous compartment and the first palmar interosseous
compartment.
[**2136-6-28**]
1. Percutaneous tracheostomy.
2. Percutaneous endoscopic gastrostomy insertion with
esophagogastroduodenoscopy.
3. Bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
72M s/p fall at home, down for 10 hours, found to not move LE
with minimal strength in UE, motor level C6. He presented with
hypotension SBP 80's was resucitated with cristaloids and
transferred from OSH. At the moment of arrival he was alert, no
movement of lower extremities, minimal movement of upper
extremities.
Past Medical History:
CABG in past
Social History:
Married. Lives with wife .
Family History:
NC
Physical Exam:
At the moment of admission
Alert, Neck collar in place.
[**Location (un) 2611**] 15
Eyes: Pupils 4 to 2m, normo reactive
Cheat CTA blt. Sternum scar
Cardiac: rrr's
Abdomen: No tender on palpation
Rectal exam: Normal tone, no gross blood
Left hand: Compartment syndrome
Lower exteemities, sensory intact motor [**4-6**] blt
Upper extremities: minimal movement
Distal pulses positives
Pertinent Results:
Date: 06/09/1
PMV and Swallowing Follow-up
We returned to follow-up with pt re: PMV toleration and
swallowing status. Pt was recommended for small amounts of puree
only with PMV in place on [**7-9**]. [**Name8 (MD) **] RN, pt has been tolerating
trach collar since yesterday (approx. 24 hours). RN reportedly
gave pt thickened soda once, but no puree. Pt awaiting d/c to
rehab this afternoon or tomorrow am. Recommend continued PMV use
as tolerated. Continue tube feeds as primary means of
nutrition/hydration/medication. Recommend instrumental
swallowing
evaluation upon arrival to rehab [**3-6**] silent aspiration noted on
FEES evaluation.
__________________________
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 39767**], MS, CF-SLP
Pager #: [**Numeric Identifier 39768**]
[**2136-7-11**] 01:55AM BLOOD WBC-8.4 RBC-3.18* Hgb-9.9* Hct-29.7*
MCV-93 MCH-31.2 MCHC-33.4 RDW-14.5 Plt Ct-598*
[**2136-7-11**] 01:55AM BLOOD Glucose-146* UreaN-22* Creat-0.5 Na-134
K-3.5 Cl-100 HCO3-28 AnGap-10
[**2136-6-29**] 07:37AM BLOOD ALT-101* AST-52* AlkPhos-214*
TotBili-3.0* DirBili-2.2* IndBili-0.8
[**2136-7-1**] 02:02AM BLOOD ALT-107* AST-92* AlkPhos-351*
TotBili-5.0*
[**2136-7-2**] 02:58AM BLOOD ALT-106* AST-65* AlkPhos-380*
TotBili-4.2*
[**2136-7-3**] 01:22AM BLOOD ALT-116* AST-90* AlkPhos-455*
TotBili-3.4*
[**2136-7-4**] 01:44AM BLOOD ALT-264* AST-246* AlkPhos-643*
TotBili-3.9*
[**2136-7-5**] 03:07AM BLOOD ALT-281* AST-165* AlkPhos-574*
TotBili-2.2*
[**2136-7-6**] 02:59AM BLOOD ALT-201* AST-56* AlkPhos-510* TotBili-1.5
[**2136-7-7**] 02:34AM BLOOD ALT-136* AST-42* AlkPhos-430* TotBili-1.2
[**2136-7-8**] 02:54AM BLOOD ALT-114* AST-45* AlkPhos-381* TotBili-1.4
[**2136-7-9**] 02:39AM BLOOD ALT-97* AST-45* AlkPhos-355* TotBili-1.0
[**2136-7-11**] 01:55AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.1
Brief Hospital Course:
At the moment of admission he had :
EKG that showed: Sinus bradycardia. Borderline P-R interval
prolongation. Consider left atrial abnormality. Borderline low
limb lead voltage. Intraventricular conduction delay of right
bundle-branch block type. No previous tracing available for
comparison. Clinical correlation is suggested.
CT head: No acute intracranial abnormality.
CT spine: No fracture or malalignment of the thoracic or lumbar
spine. Mild
degenerative changes in the thoracic and lumbar spine. Bilateral
renal cystic
formations
Spinal fluoro: There is increased disc space at C5-6 and
anterolisthesis of C5 on
C6 with a small amount of angulation. Please see CT and MR from
the same day
for further description of C-spine abnormalities.
MRI: At least 50% of anterolisthesis is demonstrated at C5/C6
level
with bilateral facet dislocation as previously demonstrated by
cervical CT on
[**2136-6-23**].
Ortho spine took him to the operation room. He had:
1. Bilateral C3 laminotomy.
2. Laminectomy C4, C5, C6, C7, T1.
3. Open reduction, manual, of C5-C6 fracture dislocation.
4. Posterior cervical arthrodesis C4-T1.
5. Application of local autograft for fusion augmentation.
6. Application of allograft for fusion augmentation
Also he had: Left hand compartment release, specifically the
thenar compartment, the thumb adductor compartment, the first
dorsal interosseous compartment, the second dorsal interosseous
compartment and the first palmar interosseous compartment.
After surgery patient was transferred to the Surgical ICU
Imagines
[**6-24**] CXR= The endotracheal tube tip is 7 cm above the carina.
There is a left subclavian line with tip just crossing midline,
almost at the SVC. The NG tube tip is in the proximal stomach
[**6-25**] MRI neck: good decompression of the spinal canal C4 through
C7. There is persistent cord signal abnormality from C4 through
C7 and the cord remains moderately swollen.
[**6-26**] EKG: Aflutter RVR IVCD
[**6-27**] CXR: FINDINGS MOST COMPATIBLE WITH PULM EDEMA.
[**6-28**] CXR: Stable appearance in diffuse perihilar opacification.
[**6-29**] RUQ us: Neg
[**6-29**] CXR: Interval right lower lobe collapse. Stable diffuse
multifocal opacification that favors an infectious process.
[**6-30**] CXR: Improved RLL, Sl. improved L PNA airspace opacities
[**6-30**] KUB: ileus or developing small-bowel obstruction
[**7-1**] CT torso: Diffuse multifocal PNA. Mild rectal thickening.
[**7-2**] CXR: diffuse multifocal airspace opacities bilaterally
[**7-4**]: RUQ US: gallbladder sludge without cholecystitis. No bil
dil, CBD 2mm
[**7-5**] CXR: Improvement in multifocal pneumonia.
[**7-7**] CXR: Cardiomediastinal contours are normal. Patient is
status post CABG. Right central catheter tip is in the upper to
mid SVC. Tracheostomy tube is in standard position. Sternal
wires are aligned. Cervical hardware is noted. Extensive
multifocal opacities larger in the left lung is stable
consistent with multifocal pneumonia.
[**7-8**] CXR: Unchange, Picc well placed.
EVENTS:
[**6-23**]: C4-T1 post lami/decompression/fusion.
[**6-24**]: Left SCL placed, Aline replaced. IVF 200->100. TFs. [**Last Name (un) **]
cycled. Neo for spinal shock. Quick TTE=full SVC/atria, good
contractility of RV, LV. No SCH per orthospine. ?IVC [**Last Name (un) 7448**]?
MRI neck ordered.
[**6-25**]: [**6-25**] Family meetings regarding trach/peg, IVC [**Last Name (LF) 7448**], [**First Name3 (LF) **]
start heparin sub q 5/25. Sedation to midazolam and fentanyl.
[**Male First Name (un) 14261**] placed. This Am A fib with rvr, responded to diltiazem.
[**6-26**]: Started HSQ, Family meeting re living will, Febrile to
101.3 with increased sputum. Pulmonary edema vs PNA, 4+GNR on
sputum started on cipro.
[**6-27**]: 2U PRBCs for Hct 25.5 and h/o CAD. Consented for
trach/PEG. No IVC birdsnest by IR. Desat back from
CT->increased PEEP
[**6-28**]: Trach/ Peg, BAL and bronch. Added Vancomycin to converage
for suspected HAP. Episode of desat c/ turning, inc PEEP and
FiO2 with resolution.
[**6-29**]: Restarted Tf through G tube, Resited line due to GPC [**3-6**]
bottles from left CVL. RUQ us due to bili 3 and dbili2.2 wih
elevated alk phos. Culuture for fever 101.7
[**6-30**]: Desats early AM w/turns. Copious thicker green sputum.
Jaundiced-appearing. RISS tightened. Aline replaced. ?Bronch
in AM. ?faciotomy wound care plan, trauma to d/w plastics.
T103, recx.
[**7-1**]: Bronched. CT torso performed. Afib c/ RVR o/n, given 20 IV
dil.
[**7-2**]: Converted to SR with po dilt. Bili down from 5 to 4.
Started on methylnaltrexone, Mucomyst. Restarted TF
[**7-3**]: Cont febrile, ID consulted. C.diff ordered. D/c vanco,
started nafcillin. Lasix 10 IVx1.
ID recs: Panculture/dc cefepime,nafcillin,cipro.
start meropenem and Flagyl
[**7-4**]: KUB->stool, man disimpact ed. PEEP weaned 10->12. Lasix
10. Plastic recs xeroform dressings. Switched TF to Isosource
1.5 w/o beneprotein Nit goal 1gm/kg. OOB. RUQ with sludge, no
chole. Diamox.
[**7-5**]: d.c lactulose. Rectal tube placed. Cuff leak. Aline dcd
[**7-7**]: Transfuse 1u PRBC. No events.
[**7-8**] : picc placed, significant colonic distension on CXR,
continued cuff leak. Tolerated [**First Name9 (NamePattern2) **] [**Last Name (un) **] PS.
[**7-9**]: family meeting.Plan for rehab
[**7-10**]: d/c CVL. Lasix 20 [**Hospital1 **]. Diamox. case management recs likely
[**Hospital1 1319**] tomorrow
[**7-11**]: Decreased dilt to 30mg QID for bradycardia into the 40s.
.
Assessment and Plan: 72 YOM s/p fall with paraplegia and L hand
compartment syndrome with C5/6 SCI, now s/p C4-T1 lami/fusion
and L hand fasciotomy. Course c/b respiratory insufficiency and
PNA; now s/p trach/PEG.
Neurologic: Neuro checks Q: 4 hr, Pain controlled, C5/6 fx now
s/p reduction and C4-T1 post lami/decompression/fusion.
Pain: Oxycodone, Neurontin
Sedation: lorazepam q HS prn
Cardiovascular: HX Afib RVR. No new events, HR well controlled
on oral diltiazem at current dose.
-cont Dilt 30 QID
Pulmonary: Trach, tolerating trach collar
Gastrointestinal / Abdomen: Distension resolved.
- Continue current bowel regimen
-Can have apple sauce and Jello with cuff down and with speaking
valve. No liquids due to aspiration.
Nutrition: TF Isosource 1.5 goal @ 55 cc/hr for goal Nitrogen
1gm/kg
Renal: Foley, Lasix 20 PO BID for goal daily net neg 1L
Hematology: Chronic anemia, no active blood loss- daily labs
Endocrine: RISS
Infectious Disease: MSSA VAP E.coli VAP and non lactose
fermenter GNR On meropenem single therapy until [**7-18**]
Lines / Tubes / Drains: Foley, G-tube, Trach, PICC
Wounds: Posterior fusion, left hand
Fluids: KVO
Tube feeds 55ml/hr at goal
Consults: Trauma surgery, Ortho-spine, Plastics, ID dept
Billing Diagnosis: (Respiratory distress: Failure), Multiple
injuries (Trauma)
Medications on Admission:
ASA 325 mg po qd
Diltiazem ER 120 mg po bid
Metalipoate 300 mg po qd
MVI
Prilosec qd
Tricor 145 mg tid
Simvstatin 20 mg po qd
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. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes.
10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Lorazepam in 0.9% Sod Chloride 60 mg/60 mL (1 mg/mL)
Solution Sig: 0.5-2 mg Intravenous HS (at bedtime) as needed for
Sedation.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for cosntipation.
14. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for pain.
15. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
16. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
19. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Motor vehicle accident with C5/C6 fracture
Left hand compartment syndrome
Respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Trach mask and paci muir valve trials
Instrumental swallowing evaluation upon arrival to rehab
secondary to silent aspiration noted on FEES evaluation
Followup Instructions:
f/u with ortho spine, Dr. [**Last Name (STitle) 1007**] ([**Telephone/Fax (1) 2007**]
f/u with hand surgery Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2007**] in 1 week, suture
will be remoced at that [**Doctor First Name **].
f/u with trauma clinic, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2537**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2136-7-11**]
|
[
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"790.7",
"478.31",
"344.00",
"518.5",
"041.4",
"E878.8",
"E884.4",
"560.1",
"958.91",
"202.80",
"997.4",
"997.31",
"728.88",
"999.31",
"806.09",
"482.41",
"782.4",
"427.31",
"482.82",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"02.94",
"96.72",
"03.53",
"81.63",
"43.11",
"96.6",
"33.24",
"84.52",
"31.1",
"82.19",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
12623, 12693
|
3715, 4044
|
289, 1012
|
12831, 12831
|
1877, 3692
|
13142, 13621
|
1454, 1458
|
10718, 12600
|
12714, 12810
|
10568, 10695
|
12966, 13119
|
1473, 1858
|
233, 251
|
1040, 1358
|
4053, 10542
|
12846, 12942
|
1380, 1394
|
1410, 1438
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,526
| 141,233
|
3944
|
Discharge summary
|
report
|
Admission Date: [**2179-6-19**] Discharge Date: [**2179-7-14**]
Date of Birth: [**2115-6-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Agitation, s/p fall with right shoulder dislocation
Major Surgical or Invasive Procedure:
Right shoulder close reduction under anesthesia on [**2179-6-19**]
History of Present Illness:
64 yoM with history of IDDM, seizure d/o, had fall at home last
night. Has fairly frequent falls per wife ([**2-3**] x month),
especially when taking excess benzos (per wife, will often go
through a one month prescription in 10 days). Last night fell
and told wife to call 911; initially at MWMC where found to have
right shoulder dislocation. They were unable to reduce (given
etomidate for sedation) thus transferred to [**Hospital1 **]. Also unable to
reduce in our ED. While in the ED, noted to be confused and
intermittently agitated. Took to OR for closed reduction under
sedation, post intervention pt severely agitated and combative.
Given risk for damage to shoulder joint, patient was intubated
and sedated. In the [**Name (NI) 13042**] pt was also found to have groin and
scrotal wounds and was given antibiotic. Central line place as
no other access available.
Past Medical History:
Hypertension s/p CVA
***per VA neuro, some sxs c/w Parkinson's --> Sinnemet***
(AVOID ANTI-DOPA AGENTS!)
Depression
Anxiety
PTSD
Social History:
Pt is married and lives with his wife. [**Name (NI) **] has many psych
hospitalizations for depression overtakes home benzos (i.e.,
full month of klonopin gone in 10 days). He states to smokes occ
and denies using alcohol.
Family History:
NC
Physical Exam:
Vitals: T: 96.8 BP: 110/52 P: 62 O2 100% on AC 550/15 peep 5
fio2 0.5
General: sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils 2 mm
reactive to light
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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, right arm in orthopedic sling
Pertinent Results:
ADMISSION LABS:
[**2179-6-19**] 08:00AM BLOOD WBC-26.4*# RBC-4.61 Hgb-11.7*# Hct-35.8*#
MCV-78* MCH-25.3* MCHC-32.6 RDW-14.4 Plt Ct-448*#
[**2179-6-19**] 08:00AM BLOOD Neuts-87.3* Lymphs-10.1* Monos-2.1
Eos-0.1 Baso-0.3
[**2179-6-19**] 08:00AM BLOOD Plt Ct-448*#
[**2179-6-19**] 09:29AM BLOOD PT-13.6* PTT-26.9 INR(PT)-1.2*
[**2179-6-19**] 08:00AM BLOOD Glucose-148* UreaN-18 Creat-1.2 Na-136
K-4.5 Cl-99 HCO3-26 AnGap-16
[**2179-6-19**] 08:00AM BLOOD ALT-21 AST-62* LD(LDH)-417* CK(CPK)-1748*
AlkPhos-109 TotBili-0.3
[**2179-6-19**] 08:00AM BLOOD CK-MB-17* MB Indx-1.0
[**2179-6-19**] 08:00AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.7
[**2179-6-20**] 08:30PM BLOOD %HbA1c-10.8* eAG-263*
[**2179-6-19**] 08:00AM BLOOD TSH-0.94
[**2179-6-20**] 02:40AM BLOOD CRP-100.2*
[**2179-6-19**] 08:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICRO DATA:
-
[**2179-6-20**] SWAB WOUND CULTURE- SWAB Source: right groin
cyst.
WOUND CULTURE (Preliminary): RESULTS PENDING.
[**2179-6-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-6-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-6-20**] URINE URINE CULTURE-FINAL INPATIENT
[**2179-6-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-6-20**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2179-6-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-6-19**] URINE URINE CULTURE-**FINAL REPORT [**2179-6-20**]**
URINE CULTURE (Final [**2179-6-20**]): NO GROWTH.
IMAGING:
FOREARM (AP & LAT) RIGHT Study Date of [**2179-6-19**] 4:53:
RIGHT SHOULDER, TWO VIEWS; RIGHT ELBOW, TWO VIEWS: The humeral
head is
located anteriorly and inferomedially to the glenoid fossa
difficult to assess on the axially view. There is a lucency
through the glenoid fossa concerning for a fracture. There is an
large bone fragment proximal to this lucency suggestive of a
greater tubercle fracture The acromioclavicular joint appears
intact. No rib fractures are visualized in the field of view.
The upper lung visualized appears normal.
IMPRESSION:
1. Right shoulder dislocation with greater tubercle fracture and
possible
fracture of the glenoid fossa.
2. Chondroid lession of the humeral head.
CT HEAD W/O CONTRAST Study Date of [**2179-6-19**] 6:46 AM
Non-contrast head CT was performed. There is no intracranial
hemorrhage, and no parenchymal edema or mass effect. Prominence
of the sulci and ventricles, most likely reflects parenchymal
atrophy. There is minimal periventricular white matter
hypodensity, compatible with sequelae of chronic small vessel
infarction, and a more focal lacunar infarct in the left centrum
semiovale. There is no shift of normally midline structures,
and the basal cisterns are preserved. [**Doctor Last Name **]-white matter
differentiation is preserved, without CT evidence of acute large
vascular territory infarction.
There are no acute fractures identified. Deformity of the left
zygomatic arch may reflect prior trauma. There is partial
opacification of the left mastoid air cells, without apparent
temporal bone fracture. Mucus retention cystversus polyp is seen
in the left sphenoid sinus. The remainder of the paranasal
sinuses are normally aerated.
IMPRESSION:
1. No acute intracranial process, including no hemorrhage.
2. Partial opacification of the left mastoid air cells. No
evidence for
fracture. Deformity of the left zygomatic arch, without
associated soft
tissue contusion, may reflect chronic injury.
3. Parenchymal atrophy and mild chronic small vessel
infarcts.Medial temporal
atrophy.
CT C-SPINE W/O CONTRAST Study Date of [**2179-6-19**] 6:47 AM
IMPRESSION: No definite fracture or traumatic malalignment
involving the
cervical spine. Degenerative at C4-5 and C5-6 is noted, with
posterior disc osteophyte causing moderate canal stenosis at
C4-5, and some anterior disc space widening at C5-6 with
fragmented osteophytes, which appear well
corticated and likely chronic. There is no prevertebral soft
tissue swelling.
CT UP EXT W/O C Study Date of [**2179-6-19**] 7:21 AM
FINDINGS: There is anterior inferior dislocation of the humeral
head which
lies inferior to the glenoid. There is a comminuted fracture of
the greater tuberosity with superior lateral displacement. The
fracture fragment measures 3.4 x 2.2 cm (series 2:30). The
glenoid is grossly intact. There are mild degenerative changes.
A chondroid lesion is seen within the humeral head, suggestive
of an enchondroma. There is a large lipohemarthrosis.
This examination is not dedicated to evaluation of the soft
tissues. There is edema and hematoma within the adjacent
muscles. The supra- and infra-spinatus tendons insert upon the
greater tuberosity fracture fragment.
The visualized lung fields demonstrate dependent atelectasis.
IMPRESSION:
1. Anterior inferior glenohumeral joint dislocation with humeral
head lying inferior to the glenoid.
2. 3.4 cm displaced greater tuberosity fracture fragment.
CT ABDOMEN W/O CONTRAST Study Date of [**2179-6-20**] 5:16 PM
CT ABDOMEN: The heart is top normal in size. There is
atherosclerotic
calcification of the coronary arteries. There is a trace amount
of
pericardial fluid. Bibasilar airspace disease is identified,
right greater
than left. The spleen, liver, adrenal glands, gallbladder,
pancreas, and
kidneys are normal in appearance given lack of intravenous
contrast.
Incidentally noted is a small duodenal diverticulum. The
remainder of the
bowel is unremarkable in appearance with no evidence of bowel
obstruction or bowel wall thickening. Calcification is noted
within the descending aorta. There is no retroperitoneal or
mesenteric lymphadenopathy. No free air or free fluid is noted
in the abdomen.
CT PELVIS: There are no pelvic masses or lymphadenopathy.
Calcifications are noted centrally within the prostate gland. A
tiny focus of air is noted within the bladder which may be
related to recent Foley catheterization. The seminal vesicles
and rectum are normal in appearance. Several prominent left
inguinal lymph nodes are identified which are not enlarged by
size criterion. The penile urethra appears dilated proximally
with an abrupt termination of the dilation distal to the
external [**State 2690**] catheter. There is a tiny punctate calcification
within the right scrotal sac. Further evaluation with ultrasound
is recommended if there isclinical concern for scrotal abscess.
No air is noted within the scrotum/perineal soft tissues. No
focal fluid collection is identified within the pelvis or
inguinal regions.
CT BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
Mild degenerative change is noted within the lumbar spine.
IMPRESSION:
1. No evidence of pelvic abscess or air within the perineal soft
tissues. A
scrotal ultrasound may be obtained for further evaluation of the
scrotal
contents and is planned for the following day.
2. Dilated proximal penile urethra which abruptly terminates at
the point
distal to the external [**State 2690**] catheter.
3. Bibasilar airspace disease, right greater than left.
CXRAY ON [**2179-6-21**]:
FINDINGS: Cardiomediastinal contours are stable in appearance.
Worsening
atelectasis at right lung base, accompanied by small right
pleural effusion.
Improving aeration in left lung base with better visualization
of left
hemidiaphragm. Remainder of lungs are grossly clear.
Brief Hospital Course:
1. PNEUMONIA: Treated with vanc/zosyn for a total of seven days.
2. MENTAL STATUS CHANGE: Most likely acute delirium due to
sedating medication effect versus infection/pneumonia. Patient's
sensorium cleared upon arrival to the general medicine floor,
and he was oriented x 3 and able to state the days of the month
backward with minimal difficulty. He was continued on CIWA with
short acting ativan for two days, but did not require any
Ativan. He was also continued on his home clonazepam,
fluoxetine, keppra, and carbidopa-levodopa. Antispychotics were
avoided given history of mild parkinsons disease.
3. SHOULDER DISLOCATION: Fall thought to be secondary to
Klonopin in excess. Underwent closed reduction glenohumeral
dislocation and closed treatment greater tuberosity fracture on
[**6-19**]. Post-op was non-weight bearing status, in sling. He
did have persistent weakness and mild sensory deficit in the
right hand and required significant physical therapy. The
patient requires a walker to walk and therefore is unable to
ambulate independently given the ability to only use 1 arm for
the walker.
4. Seizure disorder: Controlled with Keppra, no witnessed
seizures this admission.
5. Hydratinitis suppurativa of groin: Planned treatment with
doxycylcine for 6 months (to be complete in [**2179-12-1**])
6. Leukocytosis: Despite treatment for presumptive hospital
acquired pneumonia and hydratinitis, remained elevated.
Afebrile without signs of infection.
7. Hypertension: Discharged on lisinopril and amlodipine.
8, Diabetes: Discharged on NPH 22 u qam and NPH 12 u qpm and
Humalog sliding scale, his BG were very well controlled on this
regimen, he had been on much higher doses at home and the
differences in insulin requirements are likely due to change in
dietary intake.
Medications on Admission:
Home meds (per wife, then confirmed with VA list)
Prozac 40 mg daily
Atenolol 75 mg daily
amlodipine 10 mg daily
asa 81
levetiracetam 500 mg [**Hospital1 **]
doxazosin 4 mg daily
carbidopa/levidopa 25/100 1 tab TID
calcium, vitamin d
hctz 25
lisinopril 40 mg daily
klonopin 0.5 mg daily
Ambien 10
NPH insulin 60-65 units qAM, 60 units qHS
travoprost eye drops both eyes
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): for 6 months.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours): for 1 additional week.
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection four times a day: NPH 22u qam, NPH 12u qpm.
Humalog sliding scale with 2u Humalog starting at BG of 151-200.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
1) Shoulder dislocation and fracture s/p reduction
2) Diabetes
3) Seizure disorder
4) Leukocytosis
5) Hiadrenitis Supporitiva
6) Possible Hospital Acquired PNA
Discharge Condition:
stable, pain and mobility improving
Discharge Instructions:
You were admitted following a fall and dislocated and fractured
your shoulder. You had a reduction of your shoulder, but this
was complicated by nerve injury. You werea also noted to have
an elevated white count.
Followup Instructions:
Department: ORTHOPEDICS
[**Telephone/Fax (1) 1228**]
please call for an appointment within 2 weeks of your discharge
from the hospital. [**Last Name (LF) 17528**],[**First Name3 (LF) 17529**] [**Telephone/Fax (1) 17530**]
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 4 weeks
of your discharge from the hospital.
|
[
"812.03",
"293.9",
"E888.9",
"518.5",
"953.4",
"486",
"831.09",
"250.02",
"345.90",
"287.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.01",
"79.71",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13336, 13379
|
9768, 11564
|
367, 435
|
13583, 13621
|
2357, 2357
|
13883, 14234
|
1746, 1750
|
11984, 13313
|
13400, 13562
|
11590, 11961
|
13645, 13860
|
1765, 2338
|
276, 329
|
3338, 9745
|
463, 1338
|
2373, 3306
|
1360, 1490
|
1506, 1730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,065
| 185,791
|
41190
|
Discharge summary
|
report
|
Admission Date: [**2176-12-12**] Discharge Date: [**2176-12-20**]
Date of Birth: [**2155-8-28**] Sex: M
Service: MEDICINE
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Plasmapheresis catheter placement.
History of Present Illness:
Patient is a 21 yo man with PMHx sig. for ADHD, liver failure,
and prior IVDU who was originally admitted to [**Hospital3 3765**]
on [**2176-12-11**] with 3 days of fever (up to 101), chills,
nightsweats, nausea/vomiting, black diarrhea, and jaundice. He
had 1 episode of vomiting on Sunday, nonbloody. He also had
diarrhea on Sunday, which resolved on Wednesday. He had L-sided
abdominal pain starting on Wednesday, described as a "gas
pains," worse with eating and leaning towards the left, rating
[**2-6**]. His partner has [**Name2 (NI) 84027**] symptoms--nausea/vomiting,
diarrhea--which have since resolved. He then developed jaundice
and dark urine, prompting his presentation to [**Hospital1 **]. He also
had poor po intake. He had noted some gingival bleeding with
toothbrushing. Otherwise, he had no bruising, epistaxis.
At [**Hospital1 **], his labs were notable for: hct 31, plts 13, cr 2.0,
bilirubin 6.4, 0.3. alk phos 45, ast 91, alt normal. His smear
had a few schistocytes. He was seen by Hematology. He was
transferred for concern for ttp/hus, requiring plasmapheresis.
Review of Systems:
(+) Per HPI plus: headache, nasal congestion, rhinorrhea,
(-) Denies sinus tenderness. Denies chest pain or tightness,
palpitations. Denies cough, shortness of breath. No dysuria,
urinary frequency. Denies arthralgias or myalgias. Denies
rashes. All other review of systems negative.
Past Medical History:
ADHD
Cirrhosis [**1-1**] acetaminophen toxicity
Sleep disorder
Migraines
Social History:
Patient lives with his partner.
[**Name (NI) 1139**]: quit 2 months ago, 1ppd x 6 years
ETOH: [**1-31**] glasses of wine daily
Family History:
His mother was diagnosed with colon cancer at age 46.
Physical Exam:
Vitals: 98.7, 133/84, 82, 18, 100RA
Gen: NAD, AOX3
HEENT: PERRL, EOMI, MMM, sclera icteric, not injected
Neck: no LAD, no JVD
Cardiovascular: RRR normal s1, s2, no murmurs appreciated
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: normoactive bowel sounds, soft, non-tender, non distended
Extremities: No edema, 2+ DP pulses
NEURO: PERRL, EOMI, face symmetric, no tongue deviation
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Pertinent Results:
[**Hospital1 **] labs:
[**12-11**]
6.3>-----<13
31.2
Rare schistocytes
About 10-15% abnds noted/100 cell scan
138 104 61
-------------------<
3.7 29 2.0
Ca 9.3
TB 6.4, DB 0.3, alk phos 45, ast 91, alt 23
INR 0.98
Monospot neg.
Parvovirus AB pending
[**12-12**]
4.6>-----<9, 13, 9
25.4, 24.4, 24.3
5% bands, 42% neutrophils, 31% lymphocytes, 1% reactive
lymphocytes, 2%metamyelocytes
Few schistocytes, large platelets
Retic 2.8
CXR: No active disease.
[**2176-12-20**] 07:35AM BLOOD WBC-11.3* RBC-3.24* Hgb-10.0* Hct-28.3*
MCV-87 MCH-30.7 MCHC-35.2* RDW-16.9* Plt Ct-346
[**2176-12-20**] 07:35AM BLOOD LD(LDH)-191
Brief Hospital Course:
21 yo man with PMHx sig. for ADHD, liver failure, and prior IVDU
who was originally admitted to [**Hospital3 3765**] on [**2176-12-11**] with
3 days of fever (up to 101), chills, nightsweats,
nausea/vomiting, black diarrhea, and jaundice, found to have
profound thrombocytopenia, falling HCT, and acute renal failure,
concerning for TTP.
Thrombocytopenia, Hemolytic anemia: TTP, treated with steroids
and several sessions of plasmapheresis and his plts improved to
normal and his LDH returned to [**Location 213**]. He was discharged on
prednisone 70mg po daily, calcium / vitamin d and bactrim for
PCP [**Name Initial (PRE) 1102**]. He had taken omeprazole 1 week prior to the
onset of his symptoms so was rightfully hesitant to use a PPI
for peptic ulcer disease prophylaxis so warning signs were
adressed and he was told to avoid ETOH and NSAIDS. He will have
his CBC rechecked on Monday [**12-23**] and be closely followed by
hematology as an outpatient. Last session of plasmapheresis was
Wednesday [**2176-12-18**].
Acute renal failure: Hypovolemia likely main contributor as has
improved significantly with IVFs however concern for [**Last Name (un) **]
secondary to TTP as well. Resolved.
ADHD: Vyvanse continued.
Sleep disorder: Clonidine continued qhs, also this was increased
to 0.3mg po bid for benign hypertension which improved with this
therapy, this may need to be weaned down when his steroids are
weaned as the steroids may be contributing to his hypertension.
Medications on Admission:
Vyvanse 100 mg daily
Clonidine 0.3 mg qhs
Melantonin
Fastin for 3 days (Friday-Sunday)
Immodium
Peptobismo
Tylenol
Chantix (on and off)
Prevacid
Discharge Medications:
1. Vyvanse Oral
2. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
5. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
6. prednisone 10 mg Tablet Sig: Seven (7) Tablet PO once a day:
this medication will be tapered down by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
hematology.
Disp:*210 Tablet(s)* Refills:*2*
7. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
TTP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with low platelets and found
to have "TTP" which is an illness which causes your platelets to
drop.
Please make your follow up appointments and take your
medications as prescribed. Avoid alcohol and ibuprofen / aspirin
/ advil / motrin / naproxen / aleve.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2176-12-26**] at 1 PM
With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], 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: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2176-12-26**] at 1 PM
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
Also, please return to the hospital ([**Hospital Ward Name **] of [**Hospital3 **],
[**Hospital Ward Name 1826**] building [**Location (un) 436**]) on Monday [**2176-12-23**] to have your labs
drawn, the hematology fellow on call will call you with the
results.
|
[
"786.05",
"780.50",
"446.6",
"786.50",
"401.1",
"314.01",
"584.9",
"288.60",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.71"
] |
icd9pcs
|
[
[
[]
]
] |
5718, 5724
|
3273, 4763
|
280, 317
|
5791, 5791
|
2610, 3250
|
6257, 7173
|
2008, 2063
|
4958, 5695
|
5745, 5745
|
4789, 4935
|
5942, 6234
|
2078, 2591
|
1464, 1750
|
232, 242
|
345, 1445
|
5764, 5770
|
5806, 5918
|
1772, 1846
|
1862, 1992
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,589
| 177,815
|
51157
|
Discharge summary
|
report
|
Admission Date: [**2103-3-30**] Discharge Date: [**2103-4-11**]
Date of Birth: [**2032-7-18**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
T3, N0 distal esophageal cancer
Major Surgical or Invasive Procedure:
[**2103-3-30**] Minimally-invasive esophagectomy.
History of Present Illness:
Mr. [**Known lastname 106187**] is a 70-year-old
gentleman with a T3, N0 distal esophageal cancer. He was
treated with neoadjuvant chemotherapy and radiation and had a
good response and presents for resection.
Past Medical History:
POncHx
# Diagnosis: [**11-28**] EGD demonstrated bleeding 1.5 x 3 cm GE
junction mass with partial obstruction. Biopsy demonstrated
moderately differentiated adenocarcinoma at the GE junction.
Gastric body polyp, antrum, duodenum benign per biopsy.
# PET CT [**2102-12-7**]: Mural thickening, FDG avidity at distal
esophagus in the GE junction. No FDG avid nodal disease noted
distally. Multiple non-FDG avid lucent foci with sclerotic
margins at pelvic bones. FDG avidity at L thyroid without mass
# EGD/EUS [**2102-12-14**]: 2 cm mass at GE junction and cardia,
staged T3, N0 lesion with invasion beyond muscularis and no
abnormal nodes
# Cisplatin/5FU: Cycle 1 @ [**2103-1-9**], cycle 2 @ [**2103-2-5**].
.
PMH
# Prostate cancer ([**6-/2101**])
--PSAs [**2-24**], bx [**Doctor Last Name **] 3+3 in [**1-31**] cores.
--CyberKnife [**10/2101**]
# DM2 s/p chemotherapy
# Hypercholesterolemia
# Hypothyroidism
# Renal insufficiency
# Chronic hematuria
# Sleep apnea
# s/p B cataract surgery
Social History:
# Personal: Lives with his wife
# Professional: Attorney
# Tobacco: Never
# Alcohol: Rare
Family History:
# Mother: Esophageal cancer
# Sister: [**Name (NI) **] cancer
Physical Exam:
afebrile hemodynamically stable
A+Ox 3 NAD
RRR no MRG
S NT ND no HSM
CTAB
MAE B LE and UE [**3-26**]
Pertinent Results:
[**2103-4-7**] 05:50AM BLOOD WBC-8.9 RBC-2.82* Hgb-8.7* Hct-25.9*
MCV-92 MCH-30.7 MCHC-33.4 RDW-16.4* Plt Ct-511*
[**2103-4-6**] 03:11AM BLOOD WBC-9.2 RBC-2.86* Hgb-8.9* Hct-25.9*
MCV-91 MCH-31.1 MCHC-34.3 RDW-16.1* Plt Ct-441*
[**2103-4-5**] 02:21AM BLOOD WBC-8.4 RBC-3.00* Hgb-9.3* Hct-27.2*
MCV-91 MCH-31.0 MCHC-34.1 RDW-16.1* Plt Ct-394
[**2103-4-4**] 02:16PM BLOOD WBC-7.1 RBC-2.86* Hgb-9.0* Hct-26.0*
MCV-91 MCH-31.3 MCHC-34.4 RDW-16.1* Plt Ct-326
[**2103-4-4**] 01:28AM BLOOD WBC-8.3 RBC-3.01* Hgb-9.3* Hct-26.9*
MCV-90 MCH-30.9 MCHC-34.6 RDW-16.3* Plt Ct-369
[**2103-4-3**] 02:49AM BLOOD WBC-7.9 RBC-3.37* Hgb-10.3* Hct-30.9*
MCV-91 MCH-30.5 MCHC-33.4 RDW-16.5* Plt Ct-415
[**2103-4-2**] 08:47PM BLOOD WBC-7.8 RBC-3.42* Hgb-10.7* Hct-31.0*
MCV-90 MCH-31.3 MCHC-34.6 RDW-16.4* Plt Ct-366
[**2103-4-2**] 09:13AM BLOOD WBC-8.7 RBC-3.35* Hgb-10.3* Hct-30.3*
MCV-91 MCH-30.6 MCHC-33.8 RDW-16.4* Plt Ct-300
[**2103-4-2**] 02:32AM BLOOD WBC-8.3 RBC-2.89* Hgb-9.2* Hct-26.3*
MCV-91 MCH-31.9 MCHC-35.1* RDW-16.6* Plt Ct-262
[**2103-4-1**] 08:18PM BLOOD WBC-6.9 RBC-2.82* Hgb-9.0* Hct-25.6*
MCV-91 MCH-32.0 MCHC-35.3* RDW-16.7* Plt Ct-238
[**2103-4-1**] 02:24PM BLOOD WBC-6.4 RBC-2.88* Hgb-9.2* Hct-26.0*
MCV-90 MCH-31.9 MCHC-35.4* RDW-16.9* Plt Ct-234
[**2103-4-1**] 12:54AM BLOOD WBC-6.7 RBC-2.71* Hgb-8.6* Hct-25.6*
MCV-95 MCH-31.5 MCHC-33.4 RDW-16.4* Plt Ct-277
[**2103-3-31**] 02:40PM BLOOD Hct-27.5*
[**2103-3-31**] 03:11AM BLOOD WBC-4.5 RBC-2.68* Hgb-8.5* Hct-24.7*
MCV-92 MCH-31.8 MCHC-34.5 RDW-16.4* Plt Ct-245
[**2103-3-30**] 05:11PM BLOOD WBC-7.8# RBC-2.76* Hgb-9.0* Hct-26.0*
MCV-94 MCH-32.4* MCHC-34.4 RDW-16.4* Plt Ct-269
[**2103-4-2**] 08:47PM BLOOD Neuts-84* Bands-7* Lymphs-2* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2103-4-2**] 08:47PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-1+
[**2103-4-9**] 06:00AM BLOOD PT-14.4* PTT-31.6 INR(PT)-1.3*
[**2103-4-8**] 06:02AM BLOOD PT-14.5* PTT-106.1* INR(PT)-1.3*
[**2103-4-7**] 05:50AM BLOOD Plt Ct-511*
[**2103-4-7**] 05:50AM BLOOD PT-14.0* PTT-78.7* INR(PT)-1.2*
[**2103-4-6**] 09:06PM BLOOD PTT-61.7*
[**2103-4-6**] 03:11AM BLOOD Plt Ct-441*
[**2103-4-6**] 03:11AM BLOOD PT-13.4 PTT-69.9* INR(PT)-1.2*
[**2103-4-5**] 08:56PM BLOOD PT-13.4 PTT-80.7* INR(PT)-1.1
[**2103-4-5**] 02:41PM BLOOD PT-13.5* PTT-59.8* INR(PT)-1.2*
[**2103-4-5**] 05:20AM BLOOD PTT-50.2*
[**2103-4-4**] 09:59PM BLOOD PTT-54.5*
[**2103-4-4**] 02:16PM BLOOD Plt Ct-326
[**2103-4-4**] 02:16PM BLOOD PT-13.5* PTT-60.7* INR(PT)-1.2*
[**2103-4-4**] 10:00AM BLOOD PTT-67.8*
[**2103-4-4**] 02:57AM BLOOD PTT-75.9*
[**2103-4-4**] 01:28AM BLOOD Plt Ct-369
[**2103-4-3**] 07:20PM BLOOD PTT-60.2*
[**2103-4-3**] 12:27PM BLOOD PTT-55.0*
[**2103-4-3**] 06:30AM BLOOD PT-12.4 PTT-43.4* INR(PT)-1.0
[**2103-4-3**] 02:49AM BLOOD Plt Ct-415
[**2103-3-30**] 10:00AM BLOOD PT-20.2* PTT-150* INR(PT)-1.9*
[**2103-3-30**] 05:11PM BLOOD Plt Ct-269
[**2103-3-31**] 03:11AM BLOOD Plt Ct-245
[**2103-3-31**] 08:21PM BLOOD Plt Ct-214
[**2103-4-1**] 12:54AM BLOOD Plt Ct-277
[**2103-4-1**] 02:24PM BLOOD Plt Ct-234
[**2103-4-1**] 08:18PM BLOOD Plt Ct-238
[**2103-4-8**] 03:20AM BLOOD Glucose-140* UreaN-34* Creat-1.3* Na-141
K-4.3 Cl-105 HCO3-25 AnGap-15
[**2103-4-6**] 03:11AM BLOOD Glucose-142* UreaN-31* Creat-1.1 Na-136
K-3.9 Cl-102 HCO3-24 AnGap-14
[**2103-4-5**] 02:21AM BLOOD Glucose-148* UreaN-25* Creat-1.0 Na-137
K-3.9 Cl-102 HCO3-26 AnGap-13
[**2103-4-4**] 02:16PM BLOOD Glucose-127* UreaN-26* Creat-1.1 Na-137
K-3.8 Cl-100 HCO3-28 AnGap-13
[**2103-4-4**] 01:28AM BLOOD Glucose-212* UreaN-30* Creat-1.3* Na-134
K-3.6 Cl-99 HCO3-24 AnGap-15
[**2103-4-3**] 12:28PM BLOOD Creat-1.2 Na-136 K-4.2
[**2103-4-3**] 02:49AM BLOOD Glucose-164* UreaN-27* Creat-1.3* Na-137
K-4.2 Cl-98 HCO3-29 AnGap-14
[**2103-4-2**] 08:47PM BLOOD Glucose-186* UreaN-21* Creat-1.2 Na-137
K-4.2 Cl-100 HCO3-26 AnGap-15
[**2103-4-2**] 09:13AM BLOOD UreaN-18 Creat-1.1 Na-135 K-3.9
[**2103-4-2**] 02:32AM BLOOD Glucose-150* UreaN-17 Creat-1.0 Na-136
K-4.3 Cl-104 HCO3-27 AnGap-9
[**2103-4-1**] 02:24PM BLOOD UreaN-16 Creat-1.0 Na-136 K-4.0
[**2103-4-1**] 12:54AM BLOOD Glucose-177* UreaN-19 Creat-1.2 Na-137
K-4.3 Cl-104 HCO3-27 AnGap-10
[**2103-3-31**] 08:21PM BLOOD Glucose-140* UreaN-20 Creat-1.1 Na-138
K-4.0 Cl-104 HCO3-27 AnGap-11
[**2103-3-31**] 03:11AM BLOOD Glucose-109* UreaN-27* Creat-1.2 Na-140
K-4.3 Cl-108 HCO3-25 AnGap-11
[**2103-3-30**] 05:11PM BLOOD Glucose-207* UreaN-33* Creat-1.3* Na-141
K-4.3 Cl-107 HCO3-19* AnGap-19
[**2103-3-30**] 05:11PM BLOOD estGFR-Using this
[**2103-4-4**] 01:28AM BLOOD CK(CPK)-71
[**2103-4-1**] 12:54AM BLOOD CK(CPK)-219*
[**2103-3-31**] 08:21PM BLOOD CK(CPK)-258*
[**2103-4-4**] 01:28AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2103-4-2**] 09:13AM BLOOD cTropnT-<0.01
[**2103-3-31**] 08:21PM BLOOD CK-MB-3 cTropnT-<0.01
[**2103-4-8**] 03:20AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.5
[**2103-4-7**] 05:50AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.0
[**2103-4-6**] 03:11AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0
[**2103-4-5**] 02:21AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.4
[**2103-4-4**] 02:16PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
[**2103-4-4**] 01:28AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.2
[**2103-4-3**] 12:28PM BLOOD Mg-2.0
[**2103-4-3**] 02:49AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
[**2103-4-2**] 08:47PM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
[**2103-4-2**] 09:13AM BLOOD Mg-2.4
[**2103-4-2**] 02:32AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1
[**2103-4-1**] 08:18PM BLOOD Mg-2.4
[**2103-4-1**] 12:54AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.4
[**2103-3-31**] 08:21PM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
[**2103-3-31**] 03:11AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3
[**2103-4-9**] 06:00AM BLOOD Vanco-13.0
[**2103-4-8**] 06:02AM BLOOD Vanco-17.0
[**2103-4-7**] 05:56PM BLOOD Vanco-12.7
[**2103-4-7**] 05:50AM BLOOD Vanco-23.7*
[**2103-4-5**] 05:20AM BLOOD Vanco-14.2
[**2103-4-7**] 05:50AM BLOOD Digoxin-0.9
[**2103-4-5**] 02:21AM BLOOD Digoxin-1.2
[**2103-4-5**] 03:24PM BLOOD Type-ART pO2-68* pCO2-34* pH-7.52*
calTCO2-29 Base XS-4
[**2103-4-4**] 05:06AM BLOOD Type-ART pO2-105 pCO2-34* pH-7.53*
calTCO2-29 Base XS-6
[**2103-4-3**] 12:40PM BLOOD Type-ART Temp-37.8 Rates-/25 FiO2-100 O2
Flow-15 pO2-195* pCO2-35* pH-7.52* calTCO2-30 Base XS-6
AADO2-509 REQ O2-82 Intubat-NOT INTUBA
[**2103-4-2**] 11:34PM BLOOD Type-ART pO2-68* pCO2-36 pH-7.51*
calTCO2-30 Base XS-5
[**2103-4-2**] 04:06PM BLOOD pH-7.47* Comment-PLEURAL FL
[**2103-4-2**] 09:27AM BLOOD Type-ART pO2-66* pCO2-35 pH-7.51*
calTCO2-29 Base XS-4 Intubat-NOT INTUBA
[**2103-3-30**] 02:38PM BLOOD pO2-103 pCO2-56* pH-7.24* calTCO2-25 Base
XS--4
[**2103-4-5**] 03:24PM BLOOD K-4.2
[**2103-4-4**] 05:06AM BLOOD Lactate-1.5 K-4.1
[**2103-4-2**] 11:34PM BLOOD Lactate-2.2*
[**2103-4-2**] 09:27AM BLOOD Lactate-1.2
[**2103-3-30**] 02:38PM BLOOD Hgb-9.8* calcHCT-29
[**2103-4-5**] 03:24PM BLOOD freeCa-1.16
[**2103-4-5**] 06:13AM BLOOD freeCa-1.04*
[**2103-4-4**] 05:06AM BLOOD freeCa-1.08*
[**2103-4-2**] 11:34PM BLOOD freeCa-1.06*
[**2103-3-30**] 02:38PM BLOOD freeCa-1.11*
Brief Hospital Course:
Patient was admitted with the cancerous lesion noted in the HPI
and worked up as an outpatient for his surgery here at the
[**Hospital1 18**]. The patient had no immediated complications post-op and
was transferred to the Surgican Intensive Care Unit for
monitoring. While in the unit the patient suffered a pulmonary
embolus and suffered from recalcitrat atrial fibrillation, not
responsive various changes of medications. An optimal regimen
was suggested and institutded by the cardiology consult team,
and the patient was stable for transfer to the floor.
While on the floor, the patient's course proceded well, and he
was examined and found fit for discharge to home with visitng
nurse services. he is to continue his levofloxacin course for
one week while at home, and he is to utilize cycled tube feeds
to supplement his oral diet
Medications on Admission:
lipitor 80', synthroid 100', prilosec 20', colace, senna
Discharge Medications:
1. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
2. Levofloxacin 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*350 ML(s)* Refills:*0*
4. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
13. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
14. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*40 syringes* Refills:*2*
15. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for
1 doses.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
esophageal ca s/p chemo
pulmonary embolus
respiratory insufficiency
atrial fibrillation
pleural effusion
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.
* 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 becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
Diet Instruction: (after Nissen Fundoplication or [**Doctor Last Name **]
Myotomy)
Please AVOID carbonated beverages and hard foods (bread, cake,
coarse cereals, seeds/nuts, dried fruits, crackers, & tough
meat) until your follow-up appointment with your surgeon.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness, swelling, tenderness, odorous or purulent
discharge).
*Maintain the bulb deflated to provide adequate suction.
*Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
*Be sure to empty the drain frequently and record the output.
*Maintain the site clean, dry, and intact.
*Keep drain attached safely to body to prevent pulling and
possible dislodgement.
Followup Instructions:
You are to call Dr.[**Name (NI) 1482**] office ASAP for a follow-up
appointment.
You are to call your primary care physician's office ASAP for a
follow-up appointment.
|
[
"272.4",
"518.0",
"244.9",
"E879.9",
"V15.3",
"585.9",
"150.5",
"427.31",
"997.1",
"511.9",
"285.21",
"250.00",
"518.82",
"799.02",
"272.0",
"427.32",
"415.19",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.42",
"96.6",
"46.39",
"34.04",
"38.91",
"33.23",
"38.93",
"42.52",
"99.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11543, 11601
|
8967, 9811
|
327, 379
|
11749, 11758
|
1962, 8944
|
13759, 13930
|
1761, 1824
|
9918, 11520
|
11622, 11728
|
9837, 9895
|
11782, 12878
|
12893, 13736
|
1839, 1943
|
255, 288
|
408, 620
|
642, 1637
|
1653, 1745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,900
| 172,435
|
12785
|
Discharge summary
|
report
|
Admission Date: [**2124-6-5**] Discharge Date: [**2124-6-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
1. Mental status change
2. Bright red blood per rectum
3. Hypotension
Major Surgical or Invasive Procedure:
1. EGD [**2124-6-6**]
2. EGD [**2124-6-8**]
History of Present Illness:
HPI - This is an 87 y/o female with dementia, HTN, who resides
at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] and was found to be hypotensive to BP 73/40,
"gasping for air" with SaO2 79%/RA. Patient was placed on
supplemental O2. VS at that time T 97.6, BP 78/43, HR 70, RR 16,
SaO2 90-95%/oxygen (not documented how much O2), FS 214. Per [**Name (NI) **],
pt also had BRBPR in diaper with few clots. She was sent to the
ED for further evaluation.
In the ED, initial VS T 97, BP 104/33, HR 68, RR 24, SaO2 97%/2L
NC. Exam significant for black, guiac positive stool. Labs
significant for a Hct of 17.9, WBC 14.2, Cr 2.5. NGL lavage
negative with 250 cc irrigation. CXR read as RLL infiltrate,
patient given 750 mg IV levaquin and 1 U PRBCs. Patient also
pan-cultured. 2 18-guage PIV's were placed. Per ED, GI was made
aware of patient and will see patient in AM. Patient was then
transferred to the MICU for further management.
At this time, patient only c/o slight lower abdominal pain, no
n/v/diarrhea. No CP, SOB, cough, f/c/s. No dysuria. Patient not
aware of where she is.
Past Medical History:
1. Dementia
2. NIDDM
3. Renal insufficiency (bl Cr 2.0)
4. Vitamin D deficiency
5. HTN
6. ? UC
7. Iron deficiency anemia
Social History:
Lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] recently, unknown tobacco or EtOH
history. Reportedly per daughter was at [**Hospital1 2177**] recently although
unclear why.
Family History:
NC
Physical Exam:
VS: Tc 97.0, BP 154/68, HR 81, RR 15, SaO2 100%/2L NC
General: Pleasant AAF in NAD, AO x 1
HEENT: NC/AT, b/l cataracts. MM dry, poor dentition
Neck: supple, no LAD
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, [**2-1**] SM throughout (?flow murmur)
Abd: soft, NT/ND, NABS; rectal with black stool, guiac positive
Ext: no c/c/e, wwp
Neuro: AO x 1 (person only). Non-focal exam otherwise.
Pertinent Results:
Admit Labs: [**2124-6-5**]
WBC-14.2* RBC-2.08* Hgb-5.6* Hct-17.9* MCV-86 MCH-26.9*
MCHC-31.3 RDW-19.4* Plt Ct-426
PT-10.8 PTT-23.6 INR(PT)-0.9
Glucose-258* UreaN-62* Creat-2.5* Na-146* K-4.2 Cl-109* HCO3-25
AnGap-16
Calcium-8.1* Phos-5.5* Mg-2.3
calTIBC-200* VitB12-657 Folate-17.4 Ferritn-534* TRF-154*
TSH-3.8
Discharge Labs: [**2124-6-12**]
WBC-7.3 RBC-2.86* Hgb-8.4* Hct-25.3* MCV-88 MCH-29.3 MCHC-33.2
RDW-17.1* Plt Ct-247
Glucose-204* UreaN-84* Creat-2.8* Na-143 K-4.4 Cl-113* HCO3-21*
AnGap-13
CT HEAD ([**2124-6-4**]): Right cerebral hemispheric chronic subdural
hematoma or hygroma. No evidence of acute intracranial
pathology.
CXR ([**2124-6-4**]): Right lower lobe pneumonia and probable left
lower lobe pneumonia. Background mild pulmonary edema.
ABD ([**2124-6-5**]): No evidence of obstruction.
RUE US ([**2124-6-7**]): No evidence of deep venous thrombosis
involving the right upper extremity.
EKG ([**2124-6-4**]): Sinus rhythm. Diffuse non-specific ST-T wave
flattening. Delayed precordial R wave progression. No previous
tracing available for comparison.
Brief Hospital Course:
1. GIB:
GI was consulted and took the patient for EGD which showed 2
duodenal ulcers. She received 4 units pRBC in first 24 hours
with appropriate increase in her hct from 17 --> 26. Iron
studies were consistent with AOCD despite her history of iron
deficiency anemia. She was placed on a PPI due to her EGD. An
h.pylori antibody was sent which was positive; eradication
therapy was begun on [**6-11**].
She had an additional drop in her hematocrit 1 day after her
EGD, and she was transfused an additional 2u pRBC. She was
taken for another EGD on [**6-8**] which showed stable non-bleeding
duodenal ulcer. Thereafter her hematocrit was stable with a
discharge value of 25.3%
2. Pneumonia:
Initially presented with leukocytosis. CXR revealed RLL
infiltrate which was suspicious for a pneumonia. She was
treated with 1 week of levofloxacin 250mg; the course was
completed on [**6-12**].
3. Demential/Delerium:
Prior discharge summary from [**Hospital1 2177**] documented known dementia. She
appeared to have fairly advanced dementia and was not oriented
to her surroundings or to time. A head CT showed a chronic SDH
vs. hygroma with no active issue. She was started on standing
haldol with olanzapine PRN; a sitter was used in the ICU but was
not needed towards the end of the patient's floor stay.
4. Renal failure:
Cr baseline in the 2s per a discharge summary from [**Hospital1 2177**]. SCr
fluctuated during the stay. Urine output remained >600cc/day,
but the patient needed reminders to continue taking PO. She
will likey need outpatient renal follow-up for EPO therapy,
vitamin D, calcium and phos monitoring and for possible
discussions of dialysis given that she has stage V CKD.
Medications on Admission:
1. Lantus 6 U qhs, Novalog SS
2. ASA 81 mg daily
3. Labetolol 400 mg [**Hospital1 **]
4. Hydralazine 50 mg qid
5. Nifedipine XL 90 mg daily
6. Clonidine 0.3 mg patch - 2 patches qWed
7. Ranitidine 150 mg daily
8. Mirtazipine 15 mg qhs
9. Bisacodyl 10 mg prn daily prn
10. MOM prn
11. [**Name2 (NI) **] 100 mg [**Hospital1 **]
12. Tylenol prn
13. Fe Sulfate 325 mg daily
14. MVI daily
Discharge Medications:
1. Mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
2. Hydralazine 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours).
3. Labetalol 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
once a day.
7. Multi-Vitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. Haloperidol 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6PM ().
10. Nifedipine 90 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: as per
attached sliding scale units Subcutaneous three times a day.
13. Amoxicillin 250 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO Q24H
(every 24 hours) for 11 days.
14. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
Agitation.
15. Clarithromycin 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 12 days: 11 days plus PM dose on [**6-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. Upper gastrointestinal bleed, likey from duodenal ulcer
2. Anemia, acute blood loss
3. Helicobacter pylori postive
4. Pneumonia, community acquired
5. Delirium
Secondary:
1. Right cerebral hemispheric chronic subdural hematoma
2. Chronic Kidney Disease Stage V
3. Diabetes Mellitus Type II
4. Hypertension
Discharge Condition:
Hemodynamically stable with stable hematocrit.
Discharge Instructions:
You were admitted with gastrointestinal bleeding from a duodenal
ulcer and pneumonia. Please continue to take lansoprazole twice
daily until told to stop by a doctor. Please avoid taking
anti-inflammatory medications (Aleve, Advil, Ibuprofen, Motrin)
as this may exacerbate your ulcer.
The most likely cause of your ulcer was infection with h.pylori.
Given this, you are to be treated with antibiotics for a total
of 2 weeks. Please be sure to take this, as prescribed.
If you develop shortness of breath, fever, bloody stool,
abdominal pain, nausea, vomiting, or any other concerning
symptoms, please contact your doctor or report to the nearest
ER.
In addition, given your poor kidney function, you should be sure
to follow-up with a nephrologist (kidney doctor).
Followup Instructions:
Please contact Dr. [**Last Name (STitle) **] to schedule a follow up appointment
after discharge.
|
[
"250.00",
"285.1",
"276.0",
"585.5",
"294.8",
"403.91",
"041.86",
"486",
"532.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.13",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7204, 7277
|
3434, 5143
|
329, 375
|
7640, 7689
|
2322, 2640
|
8510, 8611
|
1895, 1899
|
5578, 7181
|
7298, 7619
|
5169, 5555
|
7713, 8487
|
2657, 3411
|
1914, 2303
|
220, 291
|
403, 1511
|
1533, 1657
|
1673, 1879
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,685
| 155,533
|
3353
|
Discharge summary
|
report
|
Admission Date: [**2121-7-7**] Discharge Date: [**2121-8-5**]
Date of Birth: [**2071-7-4**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
50yo M with non-ischemic, valvular cardiomyopathy (EF 30% on
echo in [**2-27**]), severe AS (s/p valvuloplasty x2), PAF, ESRD on
HD, HTN, hyperlipidemia, PVD, anemia of chronic disease, s/p PEA
with anoxic brain injury tranferred from [**Hospital6 **]
for management of hypotension.
Patient's history notable for complicated admission to [**Hospital1 18**] CCU
from [**2-20**] to [**2121-4-1**]. Briefly, admitted wtih CHF exacerbation
with pulmonary edema. Pt became febrile and develeoped new onset
murmurs. Pt presumed to have endocardititis, TEE was obtained
which showed severe aortic stenosis. Valvuloplasty performed on
[**2-20**] unsuccessful. Second valvuloplasty performed on [**2-21**] which
successfully decreased aortic gradient from 61 to 31 mmHg. After
procedure, pt suffered PEA arrest, was coded for 40min, and had
subsequent anoxic brain injury. Pt underwent prolonged
intubation (1 mo) and was d/c'ed to rehab with plans for f/u of
aortic valve surgery (felt not to be good surgical candidate).
Pt doing well at rehab on HD and lasix for fluid removal. 2d PTA
went on leave from rehab had large salty meal. On return to
rehab, had episode of acute SOB with LH, but no CP. Taken to
[**Hospital3 **] hosp, where found to have mildly decompensated heart
failure with BP's in 80;s-90's. No [**Last Name (un) **] on cardiac w/u. Dialysis
removed another 9kg fluid total over 2d and pressure dropped to
70's; pt started on pressors. Came to [**Hospital1 18**] for mgmt of
hypotension on pressors. MAP 75 on .2mcg/kg/min Levophed. Denies
CP, severe SOB.
Past Medical History:
1) End stage renal dialysis on
hemodialysis. 2) Hypertension. 3) Hypercholesterolemia. 4)
AS, status post valvuloplasty. 5) Congestive heart failure
with ejection fraction of 20 percent with normal coronary
arteries as of [**2121-2-21**]. 6) Paroxysmal atrial fibrillation on
Coumadin. 7) History of left lower extremity osteomyelitis.
8) History of intravenous drug use. 9) History of hepatis-C.
10) Peripheral vascular disease, status post left below the
knee amputation. 11) Presumed endocarditis, status post
treatment. 12) Right internal jugular thrombosis, status
post thrombolysis. 13) Anoxic brain injury to PEA arrest.
14) History of vasculitis.
Social History:
Lived with wife prior to admission of [**2121-2-20**], at
[**Hospital 38**] Rehab hosp after a long hospitalization. Occ. etoh,
h/o etoh abuse. H/o 1.5 ppd Tob (quit 4 months PTA). Remote h/o
IVDU, not for many years.
Daughter and son very supportive. Participating in vent
training.
Physical Exam:
Chronically ill appearing M laying in bed with moderate dysnea
98.8 116 100/64 on levophed, RR 30, O2 sat 98%2L
Scleara nonictric, MMM JVD 8-9cm LIJ triple lumen
Dyspnic, no wheezes, moderate crackles at bases L>R
Tachycardia, RR. [**3-1**] holosystolic murmur loudest at L sternal
border, no radiation.
Obese, soft, NT, ND, +BS
Trace edema in LE, L BKA, R antebrachial fistula with good
thrill, 1+R radial pulse, dopplerable R DP and R PT
A+Ox3, grossly intact
Brief Hospital Course:
On admission to the [**Hospital1 18**], the patient was evaluated for AVR but
considered not to be a candidate as a result of poor mental
status. Pressure and CHF were controlled in the CCU with
midodrine and HD, and the patient was transferred to the medical
floor. The patient developed a fever to 101.5 on [**7-12**] at which
time his CXR showed worsening RLL infiltrate. He was started on
azitrho/ceftriaxone on [**7-12**] but was switched to vanc/levo/flagyl
on [**7-16**]. On [**7-17**] he had a diagnostic thoracentesis showing no
empyema. Pulmonary was consulted and CT chest was obtained. CT
showed RUL consolidation with large effusion and RML/RLL
atelectasis. On [**2121-7-15**] he developed delirium and neuro was
consulted. Review of his previous MRI scan suggested
microhemorrhages.
On [**2121-7-20**] he devloped acute respiratory distress with
increased O2 requirements. He was intubated for hypercarbic
respiratory failure and airway protection. On [**2121-7-26**] patient
self-extubated and was electively reintubated on [**2121-7-27**] due to
respiratory distress. On [**2121-7-29**], trach was placed, NGT was
placed and TF's were begun. Towards the last week of his
hospitalization, the patient and his family had many discussions
with housestaff re: the patient's goals on discharge. Palliative
care, social work, and case managment was also involved. The
patient was clear in his wishes to return home and not to a
chronic vent facility but had difficulty with accepting end of
life care. It was discussed that he would not be able to have HD
at home. After several days of discussion, he chose to return
home on a ventilator and forego hemodialysis, knowing that this
meant end of life care. The pt's daughter and son were trained
on a home vent, and pain control and patient comfort in the
hospital were priority goals. The patient wished to eat in the
hospital, despite numerous sessions advising him not to do so
given the high risk of aspiration. After the pt decided on end
of life care, he decided to eat in the hospital. The patient and
family were coached in eating only very small amounts, with
aspiration precautions. Hemodialysis was continued while the
patient remained in the hospital.
On [**2121-8-5**], the patient was d/c'ed to home on ventilator,
without hemodialysis, with medications only intended for comfort
and pain relief, eating a full diet knowing of the aspiration
risk, with home services. The patient was d/c'ed on no po or IV
meds, intended for end of life care.
Medications on Admission:
1. Clonidine 25 mg by mouth twice per day.
2. Lansoprazole 30-mg capsules one capsule by mouth every
day.
3. Aspirin 325 mg by mouth once per day.
4. Albuterol 1 to 2 puffs q.6h. as needed.
5. Calcium 667 mg one by mouth three times per day (with
meals).
6. Vitamin D/vitamin C/folic acid combination one capsule
once per day.
8. Tylenol 325-mg tablets one to two tablets by mouth
q.4-6h. as needed (total dose per 24 hours not to exceed 4
grams).
9. Docusate sodium 100-mg capsule one capsule by mouth
twice per day.
10. Senna one tablet by mouth twice per day.
11. Dulcolax 5-mg tablets two tablets by mouth every day as
needed.
12. Metoprolol 50-mg tablets 0.5 tablets by mouth twice per
day.
13. Hydromorphone 4-mg tablets one tablet by mouth q.4-6h.
as needed.
14. Lactulose 30 mL by mouth q.6h. as needed.
15. Coumadin 1-mg tablets three tablets by mouth at hour of
sleep (titrated to an INR goal of 2 to 3).
Discharge Medications:
Roxanol liquid 20mg/ml, taking 5-20mg every 2-4hrs prn as needed
for pain
Fentanyl patch 75mcg, change every 72hrs, last changed [**8-5**] at
8am
Benadryl liquid 12.5mg/5ml, 25-50mg every 6 hrs as needed for
itching
Tylenol suppository 650mg every 4hrs as needed for fever
Ativan 1mg tab every 4-6hrs as needed for anxiety, taken under
the tongue
Haldol 2mg/1ml, 1-2mls every 2-4hrs as needed for anxiety
Hyoscyanine .125mg, 1tab every 4-6hrs as needed, taken under the
tongue
ABHR suppository (ativan, benadryl, haldol, roxanol), to be
taken in case patient is unable to take pills/liquids
Discharge Disposition:
Home With Service
Facility:
PALLIATIVE AND Hospice of [**Hospital3 **]
Discharge Diagnosis:
Nonischemic valvular cardiomyopathy
Severe AS
PAF
ESRD on HD
HTN
PVD
Anemia of chronic disease
S/p PEA with anoxic brain injury
Tracheostomy placement
Discharge Condition:
Fair
Discharge Instructions:
Please call your PCP if you have any pain.
Please eat only as you have been shown, sitting upright and
eating slowly.
Followup Instructions:
Home with hospice services
|
[
"507.0",
"428.23",
"518.84",
"571.2",
"424.1",
"458.21",
"403.91",
"427.31",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95",
"96.6",
"34.91",
"38.93",
"99.04",
"96.72",
"96.04",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
7513, 7587
|
3415, 5933
|
318, 334
|
7782, 7788
|
7954, 7984
|
6898, 7490
|
7608, 7761
|
5959, 6875
|
7812, 7931
|
2924, 3392
|
267, 280
|
362, 1929
|
1951, 2608
|
2624, 2909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,310
| 179,238
|
23383
|
Discharge summary
|
report
|
Admission Date: [**2110-11-4**] Discharge Date: [**2110-11-12**]
Date of Birth: [**2061-11-11**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Estolate / Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer for EP study/VT ablation
Major Surgical or Invasive Procedure:
EP study s/p mapping/ablation
History of Present Illness:
48 yo M with hx of CAD, MI x2, CABG x4 [**1-13**], EF 15-20%, hx of VT
s/p ICD, multiple ICD shocks and noted slow VT, admitted to
[**Hospital3 17921**] Center in NH on [**2110-11-1**] after having his ICD
fire 10 times followed by few seconds of syncope despite being
on amiodarone and quinidine. He has been having recurrent VT
which was treated with amiodarone dose, quinidine, and increased
Beta-blocker. He reports that he could feel the PVC's and slow
VT's and could tell the threshold before having the syncopal
episode. He was recently cathed on [**9-12**] to rule out ischemic
component of dysrrhythmia which showed patent grafts. Since he
was discharged, he has had several ICD shocks and was treated
with increasing dose of B-blocker. On the day of admission to
[**Hospital3 17921**] Center, he had 10 ICD firings, one of which was
associtated with loss of consciousness for few seconds. At
[**Hospital3 17921**], pt was started on amiodarone and lidocaine
drips. ICD interrogation revealed a slow VT which was
terminated with pacing. He was also found to have another fast
VT. Now with AV (atrial/biventricular) pacing after device
reprogramming. Pt was transferred to [**Hospital1 18**] for VT ablation.
In the EP lab here, aggressive attempts were made to induce the
sustained VT but only short runs of short VT were induced.
Mapping and ablation of multiple foci of slow VT were done.
Fast monomorphic VT w/ LBBB/L axis occurred (not induced) which
were not pace terminable requiring shock 360 J x3 and then
converted to sinus rhythm.
EP History:
History of VT '[**08**] s/p ICD placement, hx of multiple recurrent
ICD shock between [**2108**]-[**2109**], hx of slow monophasic VT (580-590
msec) noted in 4/'[**09**], which was pace terminated and ICD
reprogrammed, upgrade to biventricular ICD [**2110-7-30**], VT ablation
[**2110-8-5**]. EP study on [**2110-9-10**] after having ICD firing after
rapid VT 320-360 msec which failed to terminate with pacing.
Study showed 4 episodes of sustained monomorphic VT (320-340
msec), series of ATP algorithms tested but no successful
termination + was ultimatley terminated with shock.
Past Medical History:
-CAD-remote IMI, anterior MI [**1-13**], s/p CABG [**1-13**]: LIMA-LAD,
SVG-ramus+PDA, SVG-OM.
-Cath [**2110-9-12**]: 100% LAD; 100% LCx; 100% RCA; LIMA-LAD patent;
AO-OM patent; AO-ramus-PDA patent.
-CHF: Echo [**7-19**] w/ EF 15-20% regional wall motion abnl c/w
ischemic dz, mod biatrial enlargement, mild MR, LVH. RVH w/
hypokinesis
-HTN
-Hypothyroidism
-CRI (baseline 1.6-1.8 in [**2-16**])
-Obstructive sleep apnea
-Obesity
-Hypercholesterolemia
-COPD
-Paroxismal a-fib
Social History:
Pt lives in [**Location 5450**], NH with his wife, has 7 kids (2 step
kids, 2 adopted kids, and 3 biological kids), 35 yr of smoking 1
pack/day and quit 1 yr ago, occasional EtOH, no recreational
drug
Family History:
Pt was adopted, and does not know about his biological
paterents.
Physical Exam:
VS: T 99.6 BP 110/61 HR 60 RR 18 O2sat 93% RA
GEN: Obese, cheerful male lying in bed post-cath in NAD
HEENT: NC/AT, PERRL, EOMI, MMM, no visible JVP
COR: RRR, distant S1, S2, no audible murmurs or rubs
LUNGS: CTA on anterior exam
ABD: +BS, obese, soft, NTND
EXT: R groin with no hematoma or eccymosis, no femoral bruits,
2+DP bilaterally, no edema
NEURO: A+Ox3, CN intact, nonfocal.
Pertinent Results:
[**2110-11-4**] WBC-11.9* RBC-3.58* Hgb-9.9* Hct-31.2* MCV-87 MCH-27.7
MCHC-31.8 RDW-17.3* Plt Ct-216
[**2110-11-7**] WBC-14.0* RBC-3.35* Hgb-9.5* Hct-29.1* MCV-87 MCH-28.4
MCHC-32.8 RDW-17.5* Plt Ct-205
[**2110-11-8**] WBC-11.9* RBC-3.32* Hgb-9.6* Hct-28.8* MCV-87 MCH-28.8
MCHC-33.2 RDW-17.4* Plt Ct-245
[**2110-11-9**] WBC-9.7 RBC-3.53* Hgb-9.9* Hct-31.5* MCV-89 MCH-27.9
MCHC-31.3 RDW-16.9* Plt Ct-250
[**2110-11-12**] WBC-13.2* RBC-3.84* Hgb-10.6* Hct-34.0* MCV-89 MCH-27.5
MCHC-31.1 RDW-16.6* Plt Ct-391
[**2110-11-6**] Neuts-85* Bands-9* Lymphs-2* Monos-4 Eos-0 Baso-0
Atyps-0 Metas-0 Myelos-0
[**2110-11-9**] Neuts-89.7* Lymphs-4.9* Monos-3.6 Eos-1.7 Baso-0.1
[**2110-11-4**] PT-18.6* PTT-54.7* INR(PT)-2.2
[**2110-11-8**] PT-16.5* PTT-36.7* INR(PT)-1.7
[**2110-11-12**] PT-22.9* PTT-73.4* INR(PT)-3.3
[**2110-11-4**] Glucose-108* UreaN-32* Creat-1.9* Na-138 K-4.4 Cl-101
HCO3-25
[**2110-11-6**] UreaN-45* Creat-2.9* Na-135 K-4.8 Cl-99
[**2110-11-6**] Glucose-89 UreaN-52* Creat-3.9* Na-137 K-4.9 Cl-99
HCO3-26 [**2110-11-8**] Glucose-101 UreaN-49* Creat-2.2* Na-140 K-4.7
Cl-104 HCO3-25
[**2110-11-10**] Glucose-84 UreaN-29* Creat-1.7* Na-140 K-4.3 Cl-104
HCO3-27 [**2110-11-12**] Glucose-104 UreaN-15 Creat-1.3* Na-138 K-4.4
Cl-103 HCO3-22
[**2110-11-6**] ALT-25 AST-24 AlkPhos-64 Amylase-28 TotBili-0.9
[**2110-11-4**] CK(CPK)-218* CK-MB-16* MB Indx-7.3* cTropnT-2.06*
[**2110-11-7**] Calcium-8.9 Phos-4.8*# Mg-2.2
[**2110-11-12**] Calcium-9.3 Phos-3.9 Mg-2.0
[**2110-11-4**] Calcium-8.2* Phos-3.0 Mg-1.9
[**2110-11-8**] VitB12-203* Folate-7.3
[**2110-11-7**] Iron-26* calTIBC-281 Hapto-447* Ferritn-459* TRF-216
AEROBIC BOTTLE (Final [**2110-11-11**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2110-11-11**]): NO GROWTH.
URINE CULTURE (Final [**2110-11-6**]): <10,000 organisms/ml.
FECAL CULTURE (Final [**2110-11-8**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2110-11-8**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2110-11-6**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
CXR [**11-5**]: There is moderate cardiomegaly in a patient with
dual lead pacemaker insertion. The pacemaker chips overlie the
right atrium and ventricle. Patient has undergone prior CABG.
There is bilateral moderate pulmonary vascular redistribution
and perihilar haziness. The osseous structures are unremarkable.
CXR [**11-6**]: Stable moderate-to-severe cardiomegaly in a patient
status post CABG. The dual-lead pacemaker tips overlie the right
atrium and ventricle. There is a slightly improved pulmonary
vascular redistribution and interstitial edema. The osseous
structures are unremarkable.
IMPRESSION:
Slight interval improvement in CHF.
[**11-6**]: CT OF THE ABDOMEN WITHOUT CONTRAST: Patchy opacity is
present within the right lung base which could represent
atelectasis. The liver, spleen, pancreas, gallbladder, adrenal
glands, kidneys, and small bowel are normal in appearance. No
pathologically enlarged retroperitoneal or mesenteric lymph
nodes are seen.
CT OF THE PELVIS WITH CONTRAST: There is focal fat stranding
within the pelvic fat surrounding the sigmoid colon. There are
multiple diverticula. There is extraluminal gas adjacent to this
area of fat stranding. There is no drainable fluid collection.
Oral contrast reaches the transverse colon indicating no
evidence of obstruction.
Bone windows show no suspicious lytic or sclerotic lesions.
REFORMATTED IMAGING: Images reformatted in the coronal and
sagittal plane were essential in evaluating the patient's
abdomen and pelvis and show fat stranding within the deep pelvis
adjacent to the sigmoid colon, indicating diverticulitis.
IMPRESSION: Sigmoid diverticulitis with a suggestion of
microperforation. No drainable fluid collection present.
AXR [**11-6**]: Left upper chest pacemaker device, sternal wires and
mediastinal clips are noted. The heart appears enlarged. There
is no free air. Images of the abdomen are of poor technical
quality. A nonspecific bowel gas pattern is noted.
AXR [**11-8**]: Gaseous distention of stomach and moderate gaseous
distention of multiple loops of small bowel with retained
contrast in the rectosigmoid colon. Findings could be related to
ileus in the presence of intra-abdominal inflammatory process
but correlate clinically. The gaseous distention of the stomach
could be re- evaluated after passage of NG tube if clinically
indicated.
Brief Hospital Course:
1)Rhythm: As stated in HPI, pt underwent EP study with multiple
ablation of slow VT foci, but unable to map and ablate the focus
of fast VT. Mapping and ablation of multiple foci of slow VT
were done. Fast monomorphic VT w/ LBBB/L axis occurred (not
induced) which were not pace terminable requiring shock 360 J x3
and then converted to sinus rhythm.
VT occurred during the study which was not induced, not
terminable with pacing, and had to be shocked with 360 J x3. Pt
was transferred to the CCU and to the floor with no significant
event. Pt remained AV paced at a rate of 60 BPM, increased to
80 bpm subsequently. Pt was initially scheduled to return to
NIPS and DFT. However, pt developed fever and abdominal pain,
and therefore NIPS and DFT were canceled. The EP team felt that
NIPS were not urgent, and they have spoken with his cardiologist
Dr. [**Last Name (STitle) 23246**] who will follow up with him in 4 weeks to do the
NIPS. He was continued on amiodarone 400 mg po qd but quinidine
was discontinued. Due to hypotention, Coreg was reduced to 12.5
mg [**Hospital1 **] from 50 mg [**Hospital1 **]. Pt was continued on coumadin for his
paroxysmal a-fib - he will need frequent INR checks while on
antibiotics for diverticulitis (see below).
2)Pump: Recent Echo 15-20%. As above, pt will be discharged
with reduced dose of Coreg, and will be continued on his home
meds of lisinopril, torsemide, and spironolactone. Pt appeared
euvolemic/hypovolemic clinically with hypotension to SBP 80's
but the CXR showed moderate CHF with increased interstitial
markings and vascular redistribution. Pt got one dose of Lasix
which increased the creatinine from 1.9 to 2.9. Pt later
received IVF which lowered the creatinine. Additionally, his
torsemide was held during the hospitalization, as well as
spironolactone and lisinopril secondary to hypotension, and
rising creatinine. He was started on digoxin 3 days before
discharge and had improvement in his blood pressure enough to
tolerate the lisinopril and spironolactone. Additionally, his
creatinine had normalized, also allowing reintroduction of these
meds. His creatinine had been stable at 1.3 for two days prior
to discharge, with SBP around 120.
3)CAD: Hx of prior inferior and anterior MI. Patient was
continued on ASA, Zocor, Coreg, and lisinopril.
4)Diverticulitis: On the second day of admission, pt developed
fever of 102, abdominal pain, loose stools, and leukocytosis.
Patient had tender lower quadrant abdominal pain to palpation
but with no peritoneal signs. Pt underwent CT abdomen which
showed sigmoid diverticulitis with possible microperforation.
An AXR did not demonstrate any free air. He was made NPO, and
started on levaquin and flagyl. His abdominal pain improved
significantly, and had completely resolved, with only residual
mild tenderness to palpation on discharge. Reglan was started
when an AXR revealed gaseous distention of his stomach and
intestine. His diet was slowly able to be advanced to low
residue, which he was tolerating prior to discharge. His wbc
count rose on the day of discharge, however the patient remained
afebrile and was clinically improved; additionally, the hct and
platelets also rose, making it most likely secondary to
dehydration after restarting his diuretics. The patient was
instructed to increase his fluid intake slightly over the next
couple of days while he isn't taking in a full diet. He should
remain on a low residue, heart healthy diet until he sees a
gastroenterologist, at which time they may want to place him on
a high fiber diet.
5)HTN: Pt was continued on Coreg, lisinopril, Torsemide +
spironolactone.
6)Hypercholesterolemia: Pt was continued on Zocor.
7)COPD: initially, albuterol was held since it could potentially
trigger VT. Pt was continued on Flovent and Atrovent, but
continued to have diffuse wheezing. Pt was discharged with his
home meds of Comvient and Flovent.
8)Sleep apnea: Pt was continued on BIPAP 15 cm. Overnight, pt
showed episodes of apnea and desaturation to the 70's and 80's.
7)Hypothyroid: Patient was continued on Synthroid.
8)CRI: Baseline Cr 1.6-1.8. Creatinine on admission was 1.9 but
Creatinine increased to 2.9 after patient was NPO for planned
NIPS. Pt also appeared intravscularly dry especially after
getting a dose of IV Lasix. Pt got IVF bolus but creatinine
continued to be elevated. His lisinopril and aldactone were
held, and as his diverticulitis resolved his creatinine returned
to baseline. His renal insult may have been a combination from
his VT with hypoperfusion, as well as dehydration. His
creatinine was 1.3 for two days prior to discharge.
Medications on Admission:
Meds on Transfer:
Amiodarone 400 mg po qd
Spironolactone 25 mg po bid
Synthroid 100 mcg po qd
Flovent 110 mcg 2 puffs [**Hospital1 **]
Combivent 3 puffs prn
Zocor 40 mg po qhs
ASA 325 mg po qd
Coreg 12.5 mg po bid
Toresmide 50 mg po qd
Amiodarone drip 0.5 mg/hr
Lidocaine drip 1 mg/min
Home Meds:
Amiodarone 400 mg po qd
QuinoGlute 324 mg po bid
Coreg 50 mg po bid
Lisinopril 10 mg po qd
Torsemide 50 mg po bid
Spironolactone 25 mg po bid
Lexapro 10 mg po qd
Combivent 14.7g 3 puffs PRN
Flovent 110 mcg 2 puffs [**Hospital1 **]
ASA 325 mg po qd
Warfarin 2.5 mh po qd
Zocor 40 mg po qd
Synthroid 100 mcg po qd
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Combivent 103-18 mcg/Actuation Aerosol Sig: Three (3)
Inhalation Q4H:PRN.
10. Torsemide 20 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Digoxin 250 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
15. Warfarin Sodium 1 mg Tablet Sig: 1-2 Tablets PO DAILY
(Daily): 2.5 mg, except for Tues, Thurs, Sat. 1.5 mg, and as
dictated by your INR checks. Tablet(s)
16. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
VT s/p EP study
Diverticulitis
CAD
Congestive heart failure
COPD
Hypertension
Hypothyroidism
Discharge Condition:
Hemodynamcially stable, improved, having bowel movements,
urinating on his own.
Discharge Instructions:
Take all of your medications as directed - we have resumed all
of your previous medications - except for the QUINIDINE. We
have decreased your dose of carvedilol to 12.5 mg twice a day
(instead of 50).
We have started two new medications: 1) digoxin - this is for
your heart. 2) Cyanocobalamin (Vitamin B12) - this is for your
anemia.
You will also be on two antibiotics called levaquin and flagyl
for the next 9 days.
Seek medical attention (PCP, [**Last Name (NamePattern4) **]) if you develop worsening
abdominal pain, nausea/vomiting, fever, chills, chest pain,
palpitation, ICD firing, SOB, or any other concerning symptoms.
You will need to follow up with your cardiologist Dr. [**First Name4 (NamePattern1) 30512**]
[**Last Name (NamePattern1) 23246**] in 4 weeks. If she has any questions, she can reach
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 285**].
You will also need to see Dr. [**Last Name (STitle) 519**] (surgery), or another
gastroenterologist in a couple of weeks to follow how your
diverticulitis is doing. They will schedule you for a
colonoscopy in the next 2-3 months. Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) **] number
is [**Telephone/Fax (1) 6554**].
You will need to have your INR checked on Friday, and every 3
days while you are on the antibiotics.
You will need to stay on a low residue diet until you see Dr.
[**Last Name (STitle) 519**] or another surgeon, at which time they should place you on
a high fiber diet which you should stay on to help avoid future
episodes of diverticulitis.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) **]. Please make an
appointment with her in the next 2 weeks.
Please have your PCP make an appointment for you with a
gastroenterologist in your area. If they have any questions, or
you would like to see a doctor here for your diverticulitis,
call Dr. [**Last Name (STitle) 519**] at [**Telephone/Fax (1) 6554**]. You will need a colonoscopy in
[**12-17**] months, which they can set you up with.
Please see your primary care doctor in the next week or two - he
should check your blood pressure, among other things, and
consider going back to your usual carvedilol dosage.
|
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icd9cm
|
[
[
[]
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[
"37.26",
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] |
icd9pcs
|
[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,667
| 148,819
|
13634
|
Discharge summary
|
report
|
Admission Date: [**2153-12-30**] Discharge Date: [**2154-1-8**]
Date of Birth: [**2091-9-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
HCV cirrhosis
HCC
Major Surgical or Invasive Procedure:
[**2153-12-31**] liver transplant
History of Present Illness:
Mr. [**Known lastname 17669**] is a 62-year-old male with hepatitis C,
cirrhosis, portal hypertension and HCC who presents to [**Hospital1 18**]
today for liver transplant. He is s/p chemoemolization and
intereferon therapy
Past Medical History:
- Cirrhosis
- HCC
- ? hx of Crohn's (aphthous ulcers and small bowel ulcers seen
on a capsule endoscopy done at an outside hospital. Colonoscopy
showed normal colon. Maintained on Pentasa)
- Diabetes - insulin dependent
- CAD s/p bypass graft surgery in [**2139**] complicated by a chest
wall infection with abscesses felt secondary to allergies from a
[**Doctor Last Name 4726**]-Tex patch treated in [**Hospital3 **] Medical Center.
- Hemorrhoids
- Rotator cuff problems
- Arthritis/bursitis/old trauma
- Hypertension
- Cholecystectomy, hand surgery, penile implant, and bilateral
inguinal hernia repairs
-[**2153-12-31**] liver transplant
Social History:
Works as an administrator in the Radiation Oncology Department
at [**Hospital3 328**] / [**Hospital1 **]. Married and lives with his wife.
Recovering alcoholic and IVDU; sober for 20 years. Quit smoking
15 years ago before which he smoked heavily although does not
quantify.
Family History:
His sister had irritable bowel syndrome. Familiy history not
well known. Brother with thyroid cancer.
Physical Exam:
Temp 99.6, HR 78, BP 137/83, RR20, 98% RA
Gen: Well, NAD, Alert and oriented x3
CV: RRR, no R/G/M, well healed sternotomy incision, stable
sternum
RESP: Lungs CTAB
ABD: Full/protruberant, ascites, Soft, Non-tender, Well healed
lap CCY port sites
EXT: Feet WWP B/l. Palpable PT DLE. No edema, well healed RLE
SVG
harvest site.
.
UA: Negative
.
139 | 103 | 19 AGap=16
----------------< 162
4.6 | 25 | 1.0
estGFR: >75 (click for details)
.
Ca: 9.6 Mg: 1.7 P: 2.7
ALT: 104 AP: 89 Tbili: 0.4 Alb: 4.5
AST: 124 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
.
6.1 >12.6< 153
36.8
.
PT: 13.9 PTT: 24.6 INR: 1.2
Fibrinogen: 388
.
MELD = 8
.
Pertinent Results:
[**2153-12-30**] 05:00PM BLOOD WBC-6.1# RBC-4.86 Hgb-12.6* Hct-36.8*
MCV-76* MCH-25.8* MCHC-34.2 RDW-15.8* Plt Ct-153
[**2154-1-8**] 05:14AM BLOOD WBC-12.1* RBC-3.34* Hgb-9.6* Hct-27.7*
MCV-83 MCH-28.7 MCHC-34.6 RDW-16.5* Plt Ct-184
[**2154-1-6**] 05:37AM BLOOD PT-12.0 PTT-21.3* INR(PT)-1.0
[**2154-1-8**] 05:14AM BLOOD Glucose-90 UreaN-43* Creat-1.3* Na-136
K-5.0 Cl-108 HCO3-21* AnGap-12
[**2154-1-7**] 05:21AM BLOOD Albumin-2.9* Calcium-8.1* Phos-2.9 Mg-2.1
[**2154-1-8**] 05:14AM BLOOD Albumin-3.0*
[**2154-1-8**] 05:14AM BLOOD tacroFK-14.5
Brief Hospital Course:
Pt was admitted to the ICU directly after liver transplant by
Dr. [**Last Name (STitle) 816**] on [**2153-12-31**] for end stage liver disease.
Intraoperatively, the patient had a cavo-caval anastomosis
obstruction that required reclamping of the transplant liver,
but was resolved intraoperatively. The patient was taken to the
unit and was hemodynamically stable throughout his admission. He
maintained on propofol while intubated, but was extubated the
morning after his transplant. His transaminases were noted to be
severely elevated, and these were followed throughout admission
with eventual resolution prior to discharge. His admission to
the icu was complicated by persistent mental status changes, and
he was followed by the neurology service for this issue. A CT
head was obtained that showed no acute pathology. Ultrasound of
the transplanted liver was also obtained and indicated no
thrombus or outflow obstruction. The patient also self DC'd two
JPs that had been left intraperatively while in the unit. He was
transferred to the floor on POD #4 once his mental status was
significantly improved. These changes were attributed to
continued ecephalopathy after transplant, and resolved
concurrent with significant improvements in the patients
transamanitis. The patient required suturing of his JP sites
while on the floor in addition to suture placement in the
incision site for drainage. The remainder of the patients
recovery was uncomplicated and he was discharged to home on
[**1-8**] with plans to follow up for lab work and in the clinic as
well as on 5 d of IV lasix for diuresis in addition to his
normal post-transplant medications. At the time of discharge the
patient was tolerating a normal diet, had moderate asymptomatic
abdominal distention. He had staples in place along with sutures
in 2 JP sites and one in his abdominal incision, but no drains
in place. He was A&Ox3 and had demonstrated good understanding
of his medication regimen.
Medications on Admission:
Nadolol 20, Omeprazole 20, Simvastatin 40, Trazodone
100 QHS, Wellbutrin SR 200, ASA 81, MV, Clomitrazole 10 PO 5x
Day, Lomotil PRN, Enalapril 5, Insulin Lantus 48QHS, Humalog SS,
Pentasa 1500 QAM, 1000QPM, 1500 QHS, Metformin 500
.
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
3. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO once a day.
12. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
17. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous at bedtime.
18. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
HCV cirrhosis
HCC
delerium
DM
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
jaundice, increased abdominal pain/abdominal distension,
incision redness or increased incision drainage.
You will need to get labs drawn twice weekly on Mondays and
Thursdays at [**Last Name (NamePattern1) 439**] Lab
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-1-14**]
8:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-1-21**]
9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2154-1-21**]
10:00
|
[
"V45.81",
"572.3",
"303.93",
"272.4",
"250.00",
"287.5",
"401.9",
"555.0",
"155.0",
"070.54",
"571.5",
"348.30",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
6866, 6924
|
2957, 4926
|
332, 368
|
6998, 7005
|
2387, 2934
|
7413, 7836
|
1596, 1699
|
5210, 6843
|
6945, 6977
|
4952, 5187
|
7029, 7390
|
1714, 2368
|
275, 294
|
396, 621
|
643, 1288
|
1304, 1580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,812
| 109,900
|
3783
|
Discharge summary
|
report
|
Admission Date: [**2131-9-5**] Discharge Date: [**2131-9-14**]
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right colectomy, ileocolic anastomosis,
open cholecystectomy and transgastric feeding jejunostomy.
History of Present Illness:
This is a [**Age over 90 **] yo F with complicted past medical history but no
abdominal operations, comes in with 3 days history of "feeling
lousy." States she cannot recall the onset, but for the past
few days she has felt weak, tired and generally unwell. Denies
fevers, chills, sweating. Has had some nausea, and vomited a
small amount last night, though she could not describe it.
Denies abdominal pain, but endorses discomfort. Normal
urination, normal BM (yesterday), no diarrhea. No chest pain or
SOB.
Of note, she is DNR, DNI and states she has no intention of
having any operations even if it were to save her life. In
addition, she states her lawyer drafted a document to this
effect. She has no proxy and no family memebers in the area.
Dr. [**First Name (STitle) 2819**] has seen the patient and discussed the diagnosis with
the patient and family. The patient was previously DNR/DNI and
was initially refusing surgery. However, after discussion with
Dr. [**First Name (STitle) 2819**], who explained the benefits, alternative, and risks to
the patient and her family, the decision to proceed with surgery
was made. Her DNR/DNI order will be suspended for the
perioperative period.
Past Medical History:
PMH: Afib, CHF, diabetes, asthma, coronary artery disease, hx of
falls.
PSgH: status post left cataract, B/L shoulder surgery, R hip
surgery.
Social History:
Lives in [**Location (un) **] [**Hospital3 400**] for 8 years.
Family History:
Non-contributary
Physical Exam:
AAO x 3, NAD
RRR no MRG
CTA B/L, some ronchi at bases. ? emphysema
Soft, NT, ND, no tympany, mildly protuberant (patient states it
is baseline) + B/S, no hernias
Rectal exam: NT, no masses, no stool in rectal vault, guaiac
negative, + edema B/L
Pertinent Results:
[**2131-9-6**] 02:25PM BLOOD WBC-13.2*# RBC-3.61* Hgb-11.3* Hct-33.2*
MCV-92 MCH-31.4 MCHC-34.2 RDW-13.9 Plt Ct-327
[**2131-9-11**] 04:16AM BLOOD WBC-10.4 RBC-3.60* Hgb-11.2* Hct-33.5*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.0 Plt Ct-292
[**2131-9-12**] 04:05AM BLOOD Glucose-136* UreaN-22* Creat-0.7 Na-135
K-3.7 Cl-107 HCO3-25 AnGap-7*
[**2131-9-11**] 04:16AM BLOOD Calcium-7.6* Phos-3.4 Mg-1.6
[**2131-9-11**] 03:51PM BLOOD Digoxin-1.3
.
Portable TTE (Complete) Done [**2131-9-7**] at 8:32:16 AM FINAL
Conclusions
The left atrium is elongated. The patient is mechanically
ventilated. The IVC is small, consistent with an RA pressure of
<10mmHg. Left ventricular wall thicknesses and cavity size are
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Probably low normal overall systolic function. Mild
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension.
.
Radiology Report UNILAT UP EXT VEINS US Study Date of [**2131-9-10**]
10:28 AM
IMPRESSION: No evidence of right upper extremity DVT.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-9-10**]
10:56 AM
The right internal jugular line tip is most likely at the
cavoatrial junction.
The cardiomediastinal silhouette is difficult to appreciate
given the
bilateral increase in pleural effusion and perihilar opacities
consistent with worsening of pulmonary edema. Aspiration can
also be included in differential diagnosis. The patient is after
recent abdominal surgery. Contrast material is demonstrated in
the bowel.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2131-9-10**]
11:58 AM
IMPRESSION: No acute intracranial process.
.
**FINAL REPORT [**2131-9-10**]**
URINE CULTURE (Final [**2131-9-10**]):
GRAM NEGATIVE ROD(S). ~1000/ML.
STAPHYLOCOCCUS SPECIES. ~1000/ML.
Brief Hospital Course:
This is a [**Age over 90 **] year old female with abdominal pain, nausea,
vomiting. Imaging at
[**Location (un) 620**] noted an ileocolic intussuception that is likely due to
a lead point of tumor or polyp. This is causing a small bowel
obstruction. She agreed to surgery and went to the OR on [**2131-9-6**]
for: Exploratory laparotomy, right colectomy, ileocolic
anastomosis, open cholecystectomy and transgastric feeding
jejunostomy
Post-op Acute Respiratory Failure: Post-operatively she went
into respiratory failure mid day. TTE done by fellow [**Last Name (un) 16997**] Tan
showed mild global hypokinesis and worsened TR (baseline 2+).
She received 1U PRBC for acute post-op blood loss anemia.
She was reintubated.
Post-op Atrial Fibrillation/Tachycardia: She was cardioverted in
PACU for chronic afib with RVR to 120s as her BP dropped to 70s.
She was flipping between sinus 40-60s and afib with slow
ventricular response to 40-60s. She eventually was in sinus
rhythm. Once on the floor, she had episodes of post-op
bradycardia and so her Lopressor was held. On POD 8, her
Lopressor was restarted secondary to tachycardic episodes.
She went to the ICU post-op for close monitoring.
She was transferred out of ICU on [**9-8**].
Post-op UTI: On [**9-9**]: UA+-->GNR & Staph <1000/mL. She was
treated with Cipro for a UTI.
Difficult to Arouse: The patient was triggered for nursing
concern. The patient was hard to arouse and not waking to
sternal rub, but had stable vital signs. She went for imaging on
[**9-10**] HEAD CT: No hemmorhage. CXR: incr b/l effusion, worseing
pulm edema vs. aspiration.
This episode passed and she was alert and oriented and back at
her baseline.
FEN: She was NPO with IVF. She was started on trophic
tubefeedings and the tubefeedings were ramped up to goal. Once
more awake and alert, her diet was slowly advanced and she was
tolerating a regular diet at time of discharge. Her tubefeedings
should continue for at least 3 months.
Abd: Her abdomen was soft and nontender. The staples were
removed prior to discharge and steri strips applied.
Medications on Admission:
digoxin 0.125', furosemide 40', MVI', toprol XL 12.5', enalapril
2.5", plus calcium supplementation, metformin 500"
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for delerium.
5. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Ileocolic intussusception secondary to submucosal mass, chronic
cholecystitis with cholelithiasis.
Post-op Bradycardia
Post-op Tachycardia
Acute Respiratory Failure
Discharge Condition:
Good
Tolerating a regular diet
Tolerating tubefeedings
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 take all new meds as ordered.
* No heavy lifting (>10lbs) for 6 weeks.
* Continue to increase activity daily
* Monitor your incision for signs of infection (redness or
drainage).
* Continue tubefeedings
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**11-29**] weeks. Call to schedule an
appointment.
Please follow-up with Dr. [**First Name (STitle) 2819**] on [**2131-9-24**] at 9:45am in [**Location (un) 620**].
Call ([**Telephone/Fax (1) 6347**] with questions or concerns.
Completed by:[**2131-9-14**]
|
[
"997.1",
"041.10",
"428.0",
"427.31",
"428.33",
"427.89",
"518.5",
"780.09",
"211.2",
"599.0",
"584.9",
"041.85",
"285.1",
"560.0",
"414.01",
"V15.88",
"250.00",
"574.10",
"493.90",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"51.22",
"45.73",
"38.91",
"99.04",
"96.71",
"93.90",
"96.04",
"38.93",
"96.6",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
7494, 7567
|
4560, 6087
|
247, 372
|
7776, 7833
|
2167, 4537
|
9011, 9335
|
1868, 1886
|
6813, 7471
|
7588, 7755
|
6673, 6790
|
7857, 8988
|
1901, 2148
|
174, 209
|
400, 1605
|
6096, 6647
|
1627, 1772
|
1788, 1852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,786
| 199,844
|
5966
|
Discharge summary
|
report
|
Admission Date: [**2168-7-26**] Discharge Date: [**2168-7-31**]
Date of Birth: [**2088-10-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
ST Elevations s/p fall
Major Surgical or Invasive Procedure:
Transvenous pacing wire
Left femoral central venous line
Right Subclavian venous line
History of Present Illness:
79 y/o M with PMH of DM type II, MI, TIA who presented to OSH
with syncope. Pt reports feeling fatigued for past few weeks.
Was walking back to bed from bathroom this am and fell. Does not
recall lightheadedness of palpatations prior to fall. His wife
heard him fall and called EMS and pt was taken to OSH. No OSH
records available. Per report from [**Name (NI) **] pt was found to have
troponin of 1.06 and ECG with 1mm STE v1-v2, ST depression II
and AVF, V4-v6. Head CT negative. Pt transferred to [**Hospital1 18**] for
further management. In the ED, initial vitals were T 97.4 HR 52
RR 18, O2 sat 100% BP 173/99. Pt evaluated by Cardiology. Given
ASA 325mg. Given INR of 2.4 heparin gtt and plavix was held. As
he was clinically stable and with Cr of 3.3, planned cath in am
with renal consult. Repeat Head CT repeated with no evidence of
acute infarct or bleed.
.
On review of systems, positive for prior history of stroke and
TIA, no hx of deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. DM(II) c/b neuropathy s/p partial R toe amp ('[**65**])
2. PVD s/p R AK [**Doctor Last Name **]-DP BPG ('[**65**]) and L [**Doctor Last Name **]-DP ('[**63**])
3. HTN
4. lipid
5. seizure d/o
5. Fe deficiency anemia
6. CKD
7. h/o squamous cell carcinoma s/p excision
Social History:
He quit smoking over 30 years ago and he does not drink
alcoholic
drinks. He currently lives at home with his wife. Retired sales
marketing consultant.
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: T 96.1, BP 144/90, HR 50, RR 20, 100% 4L NC
GENERAL: elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC. Midline frontal scalp laceration. Sclera anicteric.
PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with JVP to earlobe
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. bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
CXR line placement [**7-30**]: In comparison with study of [**7-26**],
there is now an endotracheal tube in place with its tip
approximately 6 cm above the carina. Right subclavian catheter
extends to the mid-to-lower portion of the SVC. Nasogastric tube
extends at least to the upper body of the stomach.The cardiac
silhouette remains at the upper limits of normal in size. The
pulmonary vasculature is within normal limits and there is no
acute pneumonia.
.
CXR [**7-31**]: In comparison with the study of [**7-30**], the endotracheal
tube tip
again is well above the carina, about 5.8 cm. Nasogastric tube
and right
jugular catheter remain in place. Little change in the
appearance of the
heart and lungs.
[**2168-7-29**] 07:10AM BLOOD WBC-4.8 RBC-3.58* Hgb-10.7* Hct-33.6*
MCV-94 MCH-30.0 MCHC-31.9 RDW-15.0 Plt Ct-133*
[**2168-7-30**] 07:58PM BLOOD WBC-6.9 RBC-3.31* Hgb-9.9* Hct-31.2*
MCV-94 MCH-29.8 MCHC-31.6 RDW-15.0 Plt Ct-88*
[**2168-7-30**] 08:22PM BLOOD WBC-5.5 RBC-3.11* Hgb-9.4* Hct-30.0*
MCV-97 MCH-30.1 MCHC-31.2 RDW-14.9 Plt Ct-121*
[**2168-7-31**] 05:23AM BLOOD WBC-6.2 RBC-3.08* Hgb-9.3* Hct-28.3*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.5 Plt Ct-138*
[**2168-7-26**] 07:50PM BLOOD Glucose-102 UreaN-72* Creat-3.3* Na-143
K-4.5 Cl-102 HCO3-28 AnGap-18
[**2168-7-30**] 07:30AM BLOOD Glucose-163* UreaN-85* Creat-3.8* Na-136
K-4.9 Cl-101 HCO3-25 AnGap-15
[**2168-7-30**] 07:58PM BLOOD Glucose-238* UreaN-89* Creat-3.9* Na-134
K-5.8* Cl-101 HCO3-18* AnGap-21*
[**2168-7-31**] 05:23AM BLOOD Glucose-83 UreaN-89* Creat-4.2* Na-137
K-5.7* Cl-105 HCO3-22 AnGap-16
[**2168-7-27**] 05:45AM BLOOD ALT-128* AST-117* CK(CPK)-191*
AlkPhos-217* TotBili-0.6
[**2168-7-27**] 05:45AM BLOOD CK-MB-9 cTropnT-0.45*
[**2168-7-27**] 05:15PM BLOOD CK(CPK)-243*
[**2168-7-27**] 05:15PM BLOOD CK-MB-10 MB Indx-4.1 cTropnT-0.74*
[**2168-7-28**] 03:10PM BLOOD CK(CPK)-293*
[**2168-7-28**] 03:10PM BLOOD CK-MB-10 MB Indx-3.4 cTropnT-0.63*
.
[**2168-7-30**] 08:22PM BLOOD CK(CPK)-216*
[**2168-7-30**] 08:22PM BLOOD CK-MB-11* MB Indx-5.1 cTropnT-0.56*
[**2168-7-31**] 05:23AM BLOOD CK(CPK)-206*
[**2168-7-31**] 05:23AM BLOOD CK-MB-13* MB Indx-6.3* cTropnT-0.71*
.
[**2168-7-30**] 08:21PM BLOOD Type-ART pO2-370* pCO2-35 pH-7.26*
calTCO2-16* Base XS--10
[**2168-7-30**] 09:44PM BLOOD Type-ART Temp-36.7 pO2-394* pCO2-31*
pH-7.43 calTCO2-21 Base XS--2 Intubat-INTUBATED
[**2168-7-31**] 12:33AM BLOOD Type-ART Temp-35.6 Rates-20/20 Tidal
V-500 PEEP-8 FiO2-50 pO2-100 pCO2-32* pH-7.45 calTCO2-23 Base
XS-0 -ASSIST/CON Intubat-INTUBATED
[**2168-7-31**] 05:22AM BLOOD Type-ART Temp-35.6 Rates-14/8 Tidal V-500
PEEP-8 FiO2-50 pO2-164* pCO2-36 pH-7.43 calTCO2-25 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2168-7-31**] 09:31AM BLOOD Type-ART pO2-64* pCO2-40 pH-7.29*
calTCO2-20* Base XS--6
[**2168-7-30**] 08:21PM BLOOD Glucose-258* Lactate-7.7* Na-132* K-5.3
Cl-102
[**2168-7-30**] 09:44PM BLOOD Lactate-3.4* K-5.1
[**2168-7-31**] 05:22AM BLOOD Lactate-1.3
[**2168-7-31**] 09:31AM BLOOD Lactate-10.1* K-5.0
Brief Hospital Course:
79 y/o with PMHx of DMII, CVA, PVD s/p bilateral LE [**Doctor Last Name **]-DP
bypass, CKD & h/o vasovagal syncope who initially presented to
OSH with syncope and was transferred to [**Hospital1 18**] with possible
NSTEMI that was being medically managed due to stage IV CKD &
severe PVD. Pt was also being evaluated by EP for possible
pacemaker placement due to vasovagal syncope and bradycardia.
However, pt had ultimately decided against pacemaker placement.
On the evening of [**7-30**], pt was having a BM & called for
assistance. Pt was initially responding appropriately but wasn't
feeling well and asked for help with getting back to bed. Upon
standing, pt collapsed onto nurse and was unresponsive. Pt was
transferred to bed & code blue was called.
.
Pt was found unresponsive without palpable pulses. CPR was
initiated and first rhythm check revealed PEA. Pt received Epi,
Dextrose & Insulin, next rhythm showed sinus bradycardia in 30s.
Pt received Atropine, and HR came up to 50-60s with palpable
pulses. Pt had already been intubated at this time & pt was
attempting to remove the ETT. PIV had become infiltrated &
surgery had a difficult time with femoral access. Both femoral
groins were attempted for access and ultimately, a right
subclavian line was placed. Left femoral hematoma developped and
groin pressure was being held bilaterally. Pt received propofol
& IM ativan with more appropriate sedation prior to transfer.
.
Initial ABG on arrival to the ICU revealed an elevated lactate,
K of 5.9 and pH of 7.26. However, pt was oxygenating well on
the vent and his ABG improved overnight with IVF. Hyperkalemia
was treated with IV calcium and potassium trended down on repeat
labs with insulin, dextrose & kayexalate. Lactate trended down
to normal range & pH normalized. Pt did not require pressors
overnight and maintained BP well despite being in a junctional
rhythm in the 40s. The am labs revealed at a stable hematocrit
and elevated potassium of 5.8. Pt was again treated with
dextrose, insulin & kayexalate. However, sBP dropped to the
80-90s and HR began to trend down to 30s, pt was started on
Dopamine gtt & EP called urgently to place transvenous
pacemaker. However, pt became asystolic at 8:45am and PEA code
was initiated. CPR was delivered continuously and transvenous
pacer was placed at the bedside. However, despite all
resuscitative efforts, pt expired on the morning of [**2168-7-31**].
Medications on Admission:
ATORVASTATIN [LIPITOR] 10 mg daily
FUROSEMIDE [LASIX] - 40 mg Tablet - [**1-13**] tablet Tablet(s) by
mouth twice daily
ISOSORBIDE DINITRATE - 30 mg Tablet - [**1-13**] Tablet(s) by mouth
twice daily
METOPROLOL SUCCINATE - 100 mg Tablet [**Hospital1 **]
NITROGLYCERIN prn
WARFARIN - 5 mg
VITAMIN A-VIT C-VIT E-ZINC-CU
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Bradycardia
NSTEMI
Pulseless arrest
.
Secondary:
Type II DM
PVD s/p bilateral revascularization
Hypertension
Stage IV CKD
Recurrent Syncope
Discharge Condition:
Expired
|
[
"427.89",
"428.22",
"272.4",
"584.9",
"428.0",
"998.12",
"403.90",
"427.5",
"250.40",
"345.90",
"250.60",
"276.7",
"357.2",
"518.81",
"414.01",
"585.4",
"410.71",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"99.60",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8980, 8989
|
6150, 8582
|
296, 383
|
9181, 9191
|
3142, 6127
|
2256, 2316
|
8951, 8957
|
9010, 9160
|
8608, 8928
|
2331, 3123
|
234, 258
|
411, 1778
|
1800, 2070
|
2086, 2240
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,272
| 118,308
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36208
|
Discharge summary
|
report
|
Admission Date: [**2108-10-31**] Discharge Date: [**2108-12-12**]
Date of Birth: [**2027-2-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic stenosis and coronary artery disease
Major Surgical or Invasive Procedure:
Aortic valve Replacement ( 23mm St. [**Male First Name (un) 923**] tissue) & coronary
artery bypass grafts x 3 (LIMA-LAD, SVG-Dg, SVG-PDA) [**2108-11-7**]
Mediastinal exploration [**2108-11-12**]
percutaneous tracheostomy [**2108-11-27**]
open cholecystectomy [**2108-11-28**]
History of Present Illness:
This 81 year old male had a positive stress test and a history
of aortic stenosis. He was acutely short of breath and had
worsening symptoms. He [**Year (2 digits) 1834**] cardiac catheterization on
[**10-30**] which revealed 90% mid LAD lesion, occluded diagonal an
occluded right coronary artery a dilated aortic root and
moderate aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1 cm2. His EF was
65-70% and he had mitral annular calcification. He was
tranferred for operation.
Past Medical History:
aortic stenosis
coronary artery disease
hypertension
peripheral vascular disease
s/p phlebitis [**3-6**]
hypercholestermia
h/o [**Month/Year (2) 7816**]-[**Location (un) **]
s/p right femoral popliteal bypass [**4-5**]
s/p left femoral popliteal bypass [**3-6**]
s/p right carotid endarterectomy [**2097**]
Social History:
Retired, lives with wife.
smoking: none
ETOH: occasionally., Heavy in past
Family History:
unremarkable
Physical Exam:
General No acute distress
Skin healing eschar medial left foot
HEENT glasses
Neck supple full ROM Rt CEA scar
Lungs clear
Heart Regular 2-3/6 systolic murmur
Abdomen soft nontender nondistended + BS
Extremeties no edema
Neuro grossly intact
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 82089**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82090**] (Complete)
Done [**2108-11-15**] at 11:38:46 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2027-2-5**]
Age (years): 81 M Hgt (in): 66
BP (mm Hg): 116/56 Wgt (lb): 186
HR (bpm): 110 BSA (m2): 1.94 m2
Indication: Aortic valve disease. Atrial fibrillation.
Pericardial effusion. Prosthetic valve function. Tamponade.
Valvular heart disease.
ICD-9 Codes: 427.31, 423.9, 423.3, 424.1, V43.3
Test Information
Date/Time: [**2108-11-15**] at 11:38 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid i-5
Sedation: Versed: 3 mg
Fentanyl: 150 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *3.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *36 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 22 mm Hg
Pericardium - Effusion Size: 0.6 cm
Findings
This study was compared to the prior study of [**2108-11-7**].
LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s)
LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA
or RAA.
LEFT VENTRICLE: Small LV cavity. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Mildly dilated descending
aorta. Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
leaflets move normally. Normal AVR gradient. No masses or
vegetations on aortic valve. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
mass or vegetation on mitral valve. Moderate mitral annular
calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was under
general anesthesia throughout the procedure. No TEE related
complications.
Conclusions
No mass/thrombus is seen in the left atrium or left atrial
appendage. No mass or thrombus is seen in the right atrium or
right atrial appendage. The left ventricular cavity is unusually
small suggestive of underfilling. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve bioprosthesis leaflets appear
to move normally. The transaortic gradient is normal for this
prosthesis. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. No mass or vegetation is seen
on the mitral valve. Physiologic mitral regurgitation is seen
(within normal limits). There is a small pericardial effusion
with echodense material .
IMPRESSION: Small LV cavity size with normal LV systolic
function. Small pericardial effusion with echodense material. No
SEC or thrombus in the LA/LAA. The bioprosthetic aortic valve is
well seated and well functioning.
Compared with the prior study (images reviewed) of [**2108-11-7**]
(post bypass images), there is a small pericardial effusion with
echodense material.
Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2108-11-15**] 18:25
[**Known lastname 82089**],[**Known firstname **] [**Medical Record Number 82091**] M 81 [**2027-2-5**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-12-9**]
10:03 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2108-12-9**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 82092**]
Reason: r/o effusions/atelectasis
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with
REASON FOR THIS EXAMINATION:
r/o effusions/atelectasis
Final Report
HISTORY: Rule out effusion and atelectasis.
CHEST, SINGLE AP PORTABLE VIEW.
Tracheostomy tube present. A feeding tube is present, the tip
extends beneath
the diaphragm, likely beyond the pylorus.
Status post sternotomy. Cardiomediastinal silhouette is
enlarged, but stable.
Left lower lobe collapse and/or consolidation and associated
small amount of
pleural thickening and/or fluid is stable. There has been some
interval
clearing of the opacity at the right lung base. No CHF. No
pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2108-12-11**] 12:17PM 30.1*
Source: Line-quinton
[**2108-12-11**] 02:10AM 7.0 3.34* 10.0* 29.6* 89 29.9 33.8 18.1*
163
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2108-12-11**] 02:10AM 107* 68* 1.9* 143 3.8 107 30 10
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2108-12-11**] 12:17PM 184* 151* 272* 193* 66 1.3
Brief Hospital Course:
Following transfer, workup was completed, including carotid
ultrasonography and vein mapping. Surgery was delayed for
coumadin washout. Dental clearance was obtained. The patient
was brought to the operating room on [**2108-11-7**] where he
[**Year (4 digits) 1834**] AVR (tissue valve) and CABG x3. Please see operative
note for further details. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in good condition for observation and recovery. By POD 1 the
patient was hemodynamically stable, off all vasoactive drips.
He was extubated late on POD 1. The patient developed some
confusion and lethargy with narcotics and was therefore held an
extra day in the ICU. He developed atrial fibrillation which
was treated with amiodarone. Renal function worsened in the
setting of volume overload. POD# 5 In light of Mr.[**Known lastname 82093**]
worsening renal function with an elevated BUN/Creatnine, and
volume overload, a Transthoracic echocardiogram was performed to
assess pericardial tamponade. Large clot and free fluid were
seen around the right ventricle. He was taken to the OR for
reexploration and clot evacuation. Post reexploration he
required epinephrine and extubated. His cardiac rhythm went into
atrial fibrillation. He was treated medically with Amiodarone
which was ultimately discontinued due to bradycardia. On [**11-14**]
patient developed respiratory distress and was emergently
reintubated. He was weaned off the epinephrine and required
Milrinone to optimize cardiac output/index on [**2108-11-15**]. Dobhoff
was placed and tube feeds were initiated. The patient does have
a history of [**First Name9 (NamePattern2) 7816**] [**Location (un) **] syndrome. Due to persistent
respiratory insufficiency, and worsening postoperative confusion
and agitation, neurology was consulted to determine if this
history could be a contributing factor. The neurology team
found no evidence that GBS was contributing to respiratory
difficulties. Also on POD 8 he was found to be hypothermic and
was started on synthroid d/t low T3/T4. He was pan cultured,
all of which were negative. On [**11-15**] he had an echocardiogram
d/t worsening renal status/volume overload which showed an EF
55, normal RV and 1+TR. His milrinone and lasix were
discontinued with some improvement in renal function. On [**11-16**]
he developed increased RUQ pain and his tube feeds were stopped
and he was started on TPN. POD#10 the patient self extubated
and was reintubated due to respiratory failure. His post
intubation chest xray showed questionable pneumonia and he was
started on empiric antibiotics. These were stopped when
subsequent cultures were negative. Five days later he was
weaned to extubation, requiring Bipap for acidosis, which
ultimately led to a reintubation.POD#20 Mr.[**Known lastname **] [**Last Name (Titles) 1834**]
a tracheostomy with #8mm Portex trach tube. [**11-20**] Psychiatry was
consulted for worsening depression and acute delerium. they
recomended haldol and restarting his Celexa. In addition to
Mr.[**Known lastname 82093**] respiratory insufficiency, his postoperative
course was complicated by worsening abdominal distention evident
on CT scan by dilated loops of bowel,gallbladder distention and
pain on exam. Right upper quadrant ultrasound and HIDA scan were
performed and general surgery was consulted. [**2108-11-29**] he
[**Year (4 digits) 1834**] a diagnostic laproscopy that was converted to an open
choleycystectomy for cholecystitis. He was found to have a
severely cirrhotic liver. Due to acute kidney dysfunction, with
elevating BUN/Creatnine, [**11-21**] Renal was consulted and
hemodialysis was ultimately initiated. [**2108-12-2**] Mr.[**Known lastname 82093**]
family/proxy had a meeting with the cardiac surgery attending
physician and Mr.[**Known lastname 82093**] code status was changed to DNR.
His last run of dialysis was on [**12-1**] and his renal function has
been steadily improving. He has since than slowly begun to
progress in which his mental status has improved, trach collar
trials were initiated, along with PassyMuir valve trials,
thickened nutrition in adjunct with tube feeds were initiated,
and he has not required further hemodialysis since [**12-3**]. Video
swallow was done on POD#29 shows mod-severe dysphagia.
Mr.[**Known lastname **] has remained on the trach collar since [**12-5**]. On
[**12-10**] he developed a hematoma at the site of his abdominal
incision. At the time he had normal coagulation studies and
stable hematocrit. The bleeding stopped and the incision was
opened by the general surgery team and packed wet to dry. He
was felt to be medically ready for discharge to rehab on [**12-12**]
for further conditioning and increase in strength, endurance,
and activities of daily living. He has oral sutures from dental
extractions preoperatively. As discussed with his dentist,
Dr.[**First Name (STitle) 1663**], Mr.[**Known lastname **] could be seen for dental suture
removal once he's at the rehabilitation facility. All follow up
appointments have been advised.
Medications on Admission:
Allopurinol 300 mg PO daily
HCTZ 50 mg PO daily
Colchicine 0.6 mg PO BID
Percocet PRN
Coumadin
Lasix 20 mg PO daily
Imdur 45 mg PO daily
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Dressing abdominal
Right flank Abdominal incision - cleanse with normal saline,
pack with moist Kerlix, and cover with Dry dressing
Change twice daily
Please call Dr [**Last Name (STitle) 816**] office if concerns with abdominal incision
([**Telephone/Fax (1) 3618**]
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): changed monday [**12-10**].
8. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Acetaminophen 160 mg/5 mL Solution Sig: Five (5) ml PO Q6H
(every 6 hours) as needed for pain.
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Aortic stenosis s/p AVR
coronary artery disease s/p CABG
s/p evacuation of mediastinal hematoma
Post op atrial fibrillation
Respiratory failure s/p percutaneous tracheostomy
acute cholecystitis s/p open cholecystectomy
cirrhosis
Delirium
Hypothyroid
Acute renal failure requiring hemodialysis
peripheral vascular disease
hypertension
hyperlipidemia
gouty arthritis
h/o deep vein thrombophlebitis
s/p right carotid endarterectomy
s/p bilateral popliteal bypass
h/o [**Location (un) 7816**]-[**Location (un) **] syndrome
renal insufficiency
chronic back pain
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
report any rednesss of, or drainage from incisions
report any temperature greater than 100.5
take all medications as directed
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 2 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr [**Last Name (STitle) 816**] in [**11-30**] weeks for follow up abdominal incision ([**Telephone/Fax (1) 10248**] - please call to schedule
Dr. [**Last Name (STitle) 32255**] in 3 weeks
Dr. [**First Name8 (NamePattern2) 7325**] [**Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 7328**])
Dr.[**First Name (STitle) 1663**], dentist, #[**Telephone/Fax (1) 82094**], for dental suture removal
during rehab
Completed by:[**2108-12-12**]
|
[
"V64.41",
"518.5",
"414.01",
"575.0",
"401.9",
"424.1",
"427.5",
"274.0",
"571.5",
"423.9",
"997.1",
"584.9",
"440.20",
"244.9",
"293.9",
"427.31",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.23",
"36.12",
"36.15",
"88.72",
"51.22",
"96.04",
"35.21",
"39.61",
"37.12",
"96.72",
"38.93",
"99.15",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
14431, 14505
|
8003, 13124
|
337, 616
|
15106, 15113
|
1892, 6782
|
15595, 16166
|
1601, 1615
|
13312, 14408
|
6822, 6843
|
14526, 15085
|
13150, 13289
|
15137, 15572
|
1630, 1873
|
254, 299
|
6875, 7980
|
644, 1163
|
1185, 1493
|
1509, 1585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,824
| 123,533
|
15715
|
Discharge summary
|
report
|
Admission Date: [**2200-6-30**] Discharge Date: [**2200-6-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
biliary sepsis/ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Ms. [**Known lastname **] is an 88 y.o. F with h/o prior choledocholithiasis
and ERCP in [**2191**] by [**Doctor Last Name **], who presented to [**Hospital3 3583**]
this AM with abdominal pain and fatigue. Per the patient and
outside hospital records she had a 2 weeks of nausea and
decreased appetitie. She reported increased RUQ pain, abdominal
tenderness, and weakness. She was able to take her meds until
two days prior to admission when she became short of breath,
with one night of rigors and epigastric discomfort. The
abdominal pain was similar in character and intensity to her
previous episode of cholilithiasis. She denited any biliary
colic or post prandial abdominal pain. She reported no
additional constitutional sysmptoms (fevers or night sweats),
including chest pain, palpitations, lightheadedness, dizziness.
She denied any change in bowel or bladder habbits. She is 2L
home O2 at night.
She arrived at [**Hospital1 32605**] ER with hypoxia and peripherial
cyanosis. She was evaluated for decompensated CHF, and given
lasix. She subsequently developed hypotension and was admitted
to the ICU. She had gram negative rods in her blood, andan
elevated white count 27,400 with a T bili 5. She also had an
elevated troponin (0.44) and creatine (2.13). CT imaging of the
biliary tree demonstrated a 1 cm common bile duct stone with
evidence of obstruction with a small bowel ileus and extra and
intrahepatic biliary dilitation.
.
On arrival to the [**Hospital Unit Name 153**], she appeared comfortable and in no
apparent distress. Her vitals were: T 36.8 HR 104 132/62 17 92%
4L NC. She reported a dry mouth, and epigastric discomfort
after sipping water.
.
Past Medical History:
Past Medical History:
- CAD
- CHF s/p CABG (EF ~ 20% per OSH cardiology note)
- interstitial lung disease
- gallstones/choledocholithiasis: [**2191**] ERCP- evidence of prior
sphincterotomy, CBD 17mm, large stones requiring lithotripsy
- Cholecystecomy
- Bilateral Knee Replacement
- Tonsillectomy
- Right subtrochanteric fracture with subsequent pinning
- H/O GI bleed
- AFIB not on coumadin for hx of GI bleed
Social History:
- Lives alone.
- Tobacco: 10 pack year smoking history.
- etOH: Use to drink 1 glass wine per night.
- Illicits: None
Family History:
No history of cholilithiasis or bleeding diathesis. Mother with
an MI.
Physical Exam:
GEN: NAD
VS: T 36.8 HR 109 BP 137/61 RR 18 93% on 4L
HEENT: MMD, no subligual jaundice. No OP lesions, JVP 15 cm,
neck is supple, no cervical, supraclavicular, or axillary LAD,
slcera mildly icteric
CV: No carotid bruits. Upstroke volume decreased. Irregularly
irregular S1 and S2 with thrill at RSB, LSB. Systolic murmur
II/VI at LSB. no S3. or R. non-hyperdynamic PMI
PULM: Purse lipped breathing, small 3 word sentences when
moving. No accessory muscle use. Dullness to percussion over
right side. No CVA tenderness. Basilar crackles with decreased
airflow symmetrically.
ABD: Hypoactive bowel sounds. RLQ and RUQ, and epigastric
tenderness more pronounced with pressure. No rebound, but mild
gaurding. Pain illicited when shaking abdomen. Positive
[**Doctor Last Name **] sign.
LIMBS: No LE edema, no tremors or asterixis, no clubbing
SKIN: No rashes or skin breakdown across L foot, warm.
NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower
extremities, reflexes 2+ of the upper and lower extremities,
toes down bilaterally
Pertinent Results:
[**2200-6-30**] 11:10AM CK-MB-12* cTropnT-0.04*
[**2200-6-30**] 11:10AM WBC-20.6* RBC-3.96* HGB-11.3* HCT-35.4*
MCV-89 MCH-28.6 MCHC-32.1 RDW-14.6
[**2200-6-30**] 11:10AM PLT SMR-LOW PLT COUNT-90*
[**2200-6-30**] 11:10AM PT-14.5* PTT-34.8 INR(PT)-1.3*
[**2200-6-30**] 01:20AM URINE HOURS-RANDOM UREA N-573 CREAT-48
SODIUM-28 POTASSIUM-54 CHLORIDE-34
[**2200-6-30**] 01:20AM URINE OSMOLAL-367
[**2200-6-30**] 01:20AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2200-6-30**] 01:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2200-6-30**] 01:20AM URINE RBC-10* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-2
[**2200-6-30**] 01:20AM URINE MUCOUS-RARE
[**2200-6-30**] 01:19AM GLUCOSE-98 UREA N-50* CREAT-1.9*# SODIUM-140
POTASSIUM-3.0* CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
[**2200-6-30**] 01:19AM estGFR-Using this
[**2200-6-30**] 01:19AM ALT(SGPT)-214* AST(SGOT)-189* LD(LDH)-329*
CK(CPK)-903* ALK PHOS-129* AMYLASE-16 TOT BILI-3.1* DIR
BILI-2.1* INDIR BIL-1.0
[**2200-6-30**] 01:19AM LIPASE-11
[**2200-6-30**] 01:19AM CK-MB-23* MB INDX-2.5 cTropnT-0.05*
proBNP-[**Numeric Identifier 45281**]*
[**2200-6-30**] 01:19AM ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-4.1
MAGNESIUM-2.0
[**2200-6-30**] 01:19AM WBC-22.5*# RBC-4.14* HGB-12.0 HCT-36.3 MCV-88
MCH-29.1 MCHC-33.2 RDW-14.7
[**2200-6-30**] 01:19AM NEUTS-93.2* LYMPHS-3.9* MONOS-2.6 EOS-0.2
BASOS-0.1
[**2200-6-30**] 01:19AM PLT COUNT-112*#
[**2200-6-30**] 01:19AM PT-14.5* PTT-32.6 INR(PT)-1.3*
.
TTE:
IMPRESSION: Small LV cavity size with hyperdynamic LV systolic
function. Mildly dilated right ventricle with normal systolic
function and right ventricular hypertrophy. At least mild aortic
stenosis. Severely calcified mitral annulus. Moderate to severe
mitral and tricuspid regurgitation. Severe pulmonary artery
systolic hypertension.
.
ERCP:
Impression: ERCP with cholangiogram revealed 1cm stone in
mid/distal CBD with upstream biliary dilation.
Because of the patient's critical illness, the decision was made
not to attempt sphincterotomy/sphincteroplasty for stone
extraction.
Successful placement of 5cmx10F double-pigtail biliary stent for
biliary drainage.
Recommendations: Repeat ERCP in [**2-25**] weeks for stent removal and
stone extraction.
Continue antibiotics for 10 days.
Brief Hospital Course:
# Sepsis / Gram Negative Bactermia / Hyperbilirubinemia /
biliary stone: Remained hemodynamically stable on Zosyn and
Cipro. ERCP was performed, stent was placed as detailed in the
studies above, and there were no complications. Pain was well
controlled pre- and post-procedure with Dilaudid prn.
.
# ARF: Creatine was elevated on admission to 1.9; IVF
rehydration was administered.
.
# Elevated troponin: OSH records have conflicting data.
Cardiologist suggests EF 70%, Intensivist reports EF 20%.
Cardiac enzymes were WNL. Echo was performed and EF was found to
be preserved.
.
# AFIB: One two episodes of RVR during admission exam. Lopressor
was held in the setting of sepsis with discharge instructions to
restart the day after discharge, [**7-1**].
Medications on Admission:
(The patient could not recall her medications, per the outside
hospital records).
Lopressor 50 mg [**Hospital1 **]
Prilosec 20 mg daily
Lipitor 20 mg daily
Lasix 20 mg daily
Cymbalta 60 mg Daily
Magnesium Oxide 400 mg daily
Aspirin 81 mg daily
Stool softener 2-4 tablets PRN
Vitamin C 1000 mg daily
Vitamin B12 daily
Fluticasone nasal spray once daily
Discharge Medications:
1. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 9 days.
Disp:*27 Recon Soln(s)* Refills:*0*
2. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q24H (every 24 hours) for 9 days.
Disp:*3600 mg* Refills:*0*
3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
5. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Docusate Sodium 50 mg Capsule Sig: [**12-26**] Capsules PO once a day
as needed for constipation.
8. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
9. B-12 DOTS 500 mcg Tablet Sig: One (1) Tablet PO once a day.
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day: 1 spray per nostril daily.
Discharge Disposition:
Extended Care
Facility:
Patient was transferred back to the referring hospital, at their
request, to complete his care.
Discharge Diagnosis:
Cholangitis
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 hospitalized in the ICU for sepsis, a serious infection
of your blood, and ERCP. You were started on antibiotics for
your infection and you remained clinically stable.
.
No changes to your medications were made other than the
following:
# STOPPED: Lopressor 50mg [**Hospital1 **] [**2200-7-2**]
# STOPPED: Lasix 20mg [**Hospital1 **] --> may restart [**2200-7-2**]
# STOPPED: Aspirin 81mg daily --> may restart [**2200-7-4**]
# STARTED: Piperacillin-Tazobactam 2.25g IV Q8H day 1 = [**6-30**]
# STARTED: Ciprofloxacin 400 mg IV Q24H day 1 = [**6-30**]
.
Followup Instructions:
# Please schedule an appointment for a repeat ERCP in [**2-25**] weeks
for stent extraction with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2233**]
# Please schedule an appointment to see your PCP [**Last Name (NamePattern4) **] 1 week with
Dr. [**First Name (STitle) 3322**] ([**Telephone/Fax (1) 45282**]
|
[
"414.00",
"428.0",
"272.4",
"515",
"038.9",
"V45.81",
"V43.65",
"584.9",
"574.51",
"427.31",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
8312, 8434
|
6132, 6888
|
282, 288
|
8490, 8490
|
3756, 6109
|
9260, 9580
|
2595, 2668
|
7290, 8289
|
8455, 8469
|
6914, 7267
|
8673, 9237
|
2683, 3737
|
223, 244
|
316, 2005
|
8505, 8649
|
2049, 2441
|
2457, 2579
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,140
| 113,041
|
52026
|
Discharge summary
|
report
|
Admission Date: [**2177-5-9**] Discharge Date: [**2177-5-15**]
Date of Birth: [**2112-12-25**] Sex: F
Service: Thoracic Surgery
CHIEF COMPLAINT: Lung cancer.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
female who is status post right middle lobectomy in [**2172-9-21**] for a T1 N0 M0 lung cancer and who is status post a
right upper lobe wedge resection of a mass found on
subsequent followup. She was recently discharged on [**2177-4-23**] after that procedure.
In the interim, the patient has done well and returns to [**Hospital1 1444**] for formal right upper
lobectomy for the diagnosed undifferentiated large cell-type
lung carcinoma. Of note, the wedge resection and lymph node
biopsies were significant for no positive lymph nodes at the
previous wedge resection.
Previous workup for this mass had provided no evidence of
metastasis.
PAST MEDICAL HISTORY: Lung cancer in [**2172**].
PAST SURGICAL HISTORY:
1. Status post hemiarthroplasty for displaced right femoral
neck fracture.
2. Status post right middle lobectomy in [**2172**].
3. Status post sinus surgery.
4. Status post right upper lobe wedge resection in [**2177-4-21**].
MEDICATIONS ON ADMISSION: Medications on admission included
Prempro 2.5 mg p.o. q.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Family history was noncontributory
SOCIAL HISTORY: Social history significant for smoking
greater than 30 years of one pack per day. Occasional
ethanol use. She is married with two children.
PHYSICAL EXAMINATION ON PRESENTATION: The patient had a
temperature of 98, pulse of 78, blood pressure of 120/66,
respiratory rate of 18, 98% on room air. She was awake,
alert and oriented times three. She had no cervical
lymphadenopathy. Her chest was clear bilaterally, and she
had a regular rate and rhythm. Her abdomen was soft and
nontender. Her incisions were clean, dry, and intact. She
had no peripheral edema or clubbing.
RADIOLOGY/IMAGING: Chest x-ray prior to surgery showed no
evidence of pneumothorax or infiltrate.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
prior to admission included a white blood cell count of 5.6,
hematocrit of 39.7, a platelet count of 228. Blood urea
nitrogen of 12. ALT of 18 and AST of 21.
HOSPITAL COURSE: On the day of admission the patient went to
the operating room where she underwent right thoracotomy a
right video-assisted thoracoscopy, and a multiple wedge
resection of the right upper lobe. She also underwent
mediastinoscopy with lymph node dissection.
Findings in the operating room included multiple adhesions to
the chest wall, and a thickened area on the previous line,
and negative metastatic disease on frozen section. She
tolerated this procedure well. She had 1400 cc in
crystalloid, and a 250-cc blood loss, and made a urine output
of 380 cc. She was extubated and sent to the Postanesthesia
Care Unit in stable condition.
Postoperatively, the patient has remained afebrile and
hemodynamically stable. Her chest tube output has decreased
appropriately and has produced serosanguineous drainage. A
persistent air leak has remained throughout her admission.
Her postoperative chest x-ray was significant for a residual
pneumothorax which has remained stable throughout her
postoperative recovery. The patient has been ambulating and
tolerating a regular diet. The patient had epidural managed
by the Acute Pain Service for the first four postoperative
days and was changed to p.o. pain medication which was
tolerating. Pathology was still pending.
Of note, the patient had a positive urine culture which was
greater than 100,000 gram-negative rods. The patient was to
be sent home on a 5-day course of levofloxacin.
DISCHARGE DISPOSITION: Due to the persistent air leak, a
Heimlich valve was placed on the chest tube, and the patient
was stable for discharge with chest tube and Heimlich valve
in place. She was to go home with [**Hospital6 407**]
nursing to help care for the wound. The patient was to
follow up with Dr. [**Last Name (STitle) 175**] on [**Last Name (LF) 766**], [**2177-5-19**].
DISCHARGE DIAGNOSES:
1. Right lung adenocarcinoma, status post right upper
lobectomy.
2. Urinary tract infection.
MEDICATIONS ON DISCHARGE: (Medications on discharge
included)
1. Vicodin 5/500 one to two tablets p.o. q.4h. p.r.n.
2. Colace 100 mg p.o. b.i.d.
3. Levofloxacin 500 mg p.o. q.d. times two more days (for a
total of five days).
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) 175**] on [**Last Name (LF) 766**], [**2177-5-19**] for chest tube removal.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2177-5-15**] 12:49
T: [**2177-5-15**] 16:08
JOB#: [**Job Number **]
|
[
"V10.11",
"512.1",
"599.0",
"162.3",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"34.22",
"32.29"
] |
icd9pcs
|
[
[
[]
]
] |
3764, 4126
|
1328, 1364
|
4147, 4243
|
4270, 4484
|
1213, 1311
|
2299, 3740
|
955, 1186
|
4499, 4535
|
163, 177
|
4556, 4967
|
206, 881
|
904, 932
|
1381, 2281
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,856
| 195,759
|
15129
|
Discharge summary
|
report
|
Admission Date: [**2154-11-22**] Discharge Date: [**2154-11-28**]
Service: HEPATOBILIARY SURGERY
HISTORY OF PRESENT ILLNESS: The patient is an 89 year-old
female with a past medical history of colon cancer status
post right colectomy who underwent CT guided biopsy of a
liver lesion, which was subsequently confirmed to be a
metastatic colon CA at an outside hospital. Post procedure
the patient's hematocrit dropped to 23 and then to 18 on the
morning of admission to [**Hospital1 69**].
She was reportedly at that time normotensive and not
tachycardic. CT scan at that time revealed free
intraperitoneal blood in both pericolic gutters. The patient
was emergently transferred to [**Hospital1 188**] Emergency Department and she arrived awake, alert and
in no acute distress. Vital signs were all within normal
limits. The patient had a third unit of packed red blood
cells running upon arrival.
PAST MEDICAL HISTORY:
1. Colon cancer.
2. Anemia.
3. Organic brain syndrome, not otherwise specified.
PAST SURGICAL HISTORY: Right colectomy.
MEDICATIONS ON ADMISSION:
1. Multivitamin.
2. Colace 100 mg po b.i.d.
3. Lopressor 50 mg po b.i.d.
4. Aldomet 250 mg po b.i.d.
ALLERGIES: No known drug allergies.
PERTINENT LABORATORIES ON ADMISSION: The patient had a white
blood cell count of 21.1, hematocrit 31.8, platelets 117,
sodium 145, potassium 3.6, chloride 107, bicarb 25, BUN 18,
creatinine 1.0, glucose 109, PT 13, INR 1.1, PTT 25.3. ALT
61, AST 79, alkaline phosphatase 100, total bilirubin 3.2.
PHYSICAL EXAMINATION: On physical examination the patient
was alert and in no acute distress. The patient was
afebrile. Heart rate 75. Blood pressure 158/82.
Respiratory rate 15. Sating 96% on room air. Heart was
regular rate and rhythm. Lungs were clear to auscultation
bilaterally. Abdomen was soft, mildly distended, positive
right upper quadrant tenderness and positive bowel sounds.
No guarding or rebound were noted. Extremities were warm and
well perfuse.
HOSPITAL COURSE: The patient was admitted to the Blue
Surgery Service, but was admitted to the Surgical Intensive
Care Unit on [**2154-11-22**] for close monitoring. The patient had
a cordis central line placed in the left subclavian as well
as a right radial arterial line placed. The patient was also
started on Unasyn for empiric coverage. On hospital day
number two [**2154-11-23**] the patient's hematocrit remained stable
at 33, total bilirubin was 2.3. Repeat CT on that day
revealed large amounts of intraabdominal free fluid and a
subcapsular liver hematoma. Findings were consistent with
the patient's known history of hemoperitoneum status post
liver biopsy and appeared stable compared to the outside CT
three days prior. There is no evidence of active
extravasation at the time of examination. Incidentally the
patient had multiple low attenuation lesions within the right
lobe of the liver. On hospital day number three [**2154-11-24**] the
patient's hematocrit remained stable at 30.6 and was
transferred to the floor. On hospital day number four Unasyn
was discontinued. The patient's hematocrit remained stable at
31.9 and belly examination was benign. Pathology from the
outside hospital revealed a well differentiated
adenocarcinoma consistent with primary disease. On hospital
day number four [**2154-11-25**] the patient's left subclavian cordis
was switched over a wire to the triple lumen central line by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Subsequent chest x-ray revealed proper
placement of the line. In addition on hospital day number
four [**2154-11-25**] the patient received a CT of the chest to
examine possibilities of metastatic pulmonary disease, which
revealed no evidence of pulmonary metastases, but extensive
respiratory motion as well as a basilar atelectatic change,
small pleural effusions, limited the assessment for a very
small lesions. Also of note there was increased number of
lymph nodes in the mediastinum and in particular lymph node
on the left upper paratracheal lesion just below the left
lobe of the thyroid gland, which was slightly enlarged by CT
criteria. Also of note was persistent subcapsular hematoma,
hemoperitoneum and a heterogenous hemorrhagic liver lesions
previously noted. Also of note tracheobronchomalacia. The
patient was doing well at this time tolerating a regular
diet. Belly examination continued to be unremarkable. The
patient was seen by physical therapy and cleared for home.
Of note, the patient's total bilirubin increased from 2.5 on
[**2154-11-25**] to 4.4 on [**2154-11-26**], but began to trend down on
hospital day six [**2154-11-27**] down to 3.7. This change was most
likely due to blood transfusion reactions. In addition, the
patient had a C-diff times two, which were both negative and
no antibiotics were started. On [**2154-11-28**] the patient was
deemed well enough to go home with a benign belly and a
stable hematocrit at around 31.9.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES:
1. Subcapsular hematoma of the liver status post liver
biopsy.
2. Hemoperitoneum status post liver biopsy.
3. Colon cancer metastatic to the liver.
4. Organic brain syndrome not otherwise specified.
DISCHARGE MEDICATIONS:
1. Multivitamins.
2. Protonix 40 mg po q day.
3. Metoprolol 50 mg po b.i.d.
4. Aldomet 250 mg po b.i.d.
FOLLOW UP PLANS: Please follow up with Dr. [**Last Name (STitle) **] in one to
two weeks.
[**Doctor First Name **] Seminara, R.N. has given patient a follow-up appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2154-11-28**] 07:32
T: [**2154-11-28**] 09:02
JOB#: [**Job Number 44124**]
|
[
"V10.05",
"285.9",
"197.7",
"E878.8",
"998.12",
"568.81",
"310.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5059, 5263
|
5286, 5825
|
1088, 1255
|
2023, 5038
|
1044, 1062
|
1555, 2005
|
136, 914
|
1270, 1532
|
936, 1020
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,519
| 117,513
|
46469
|
Discharge summary
|
report
|
Admission Date: [**2148-7-3**] Discharge Date: [**2148-7-8**]
Date of Birth: [**2077-5-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Tegretol / Ciprofloxacin
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right middle lobe nodule
Major Surgical or Invasive Procedure:
[**2148-7-3**] Right middle lobe video-assisted lobectomy.
History of Present Illness:
70 yo F with RML nodule (10 mm) that has slightly grown from 8
mm (seen in retrospect on an abdominal CT in [**4-12**]). Significant
history of asthma and shortness of breath that caused a
hospitalization a couple of weeks prior to visit which resulted
in a chest xray on which the nodule was noted. CT scan was done
that confirmed its presence. Patient is P.E.T. negative despite
history of adrenal nodule. Patient denies any new onset symptoms
though she still has shortness of breath and occasional
productive cough. No fevers, chills, weight loss of malaise.
Past Medical History:
HTN
hypercholesterolemia
panic attacks/anxiety
seasonal allergies
?asthma
chronic back pain
Social History:
distant smoking history, social alcohol [**12-8**] x per week, no
drugs. Lives in [**Location (un) **] [**Hospital3 **].
Family History:
Son w/depression.
No history of lung cancer.
Physical Exam:
Gen: GEN
CV: RRR, nl S1/S2
Resp: Wheezing with mild rhonchi bilaterally
Abd: soft, nt/nd
Ext: wwp, no edema
Neuro: nonfocal
Pertinent Results:
[**2148-7-4**] 05:15AM BLOOD WBC-8.0# RBC-3.51* Hgb-10.4* Hct-33.2*
MCV-94 MCH-29.7 MCHC-31.5 RDW-12.9 Plt Ct-241
[**2148-7-5**] 06:18AM BLOOD Glucose-89 UreaN-15 Creat-0.8 Na-123*
K-4.1 Cl-91* HCO3-25 AnGap-11
[**2148-7-5**] 06:18AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.5
CXR ([**2148-7-4**]): There is no evident pneumothorax. Extensive
subcutaneous emphysema of the right chest wall extending to the
neck is unchanged. There is worsening in volume loss on the
right lung with elevation of the right hemidiaphragm. Right
lower lung opacity is unchanged. Left lower lobe linear
atelectasis and small pleural effusion are stable. Right chest
tubes remain in place. The cardiomediastinum is slightly
deviated towards the right side.
CXR ([**2148-7-5**]): 1. Minimal improvement of extensive right-sided
subcutaneous emphysema.
2. Persistent right lower lobe atelectasis with associated small
pleural
effusion.
Brief Hospital Course:
Ms. [**Known lastname 98723**] had a video-assisted thoracoscopic right middle
lobectomy on [**2148-7-3**] under GETA without complications. She was
transfered to the floor with two chest tubes in the right chest
on suction. Her pain was initially controlled with a dilaudid
PCA then changed ultimately to tramadol with IV dilaudid for
breakthrough pain. Her pain was well controlled. On the floor
she did have subcutaneous air on the right chest that slowly
decreased during her hospital stay. The chest tubes were removed
on [**7-6**]. On [**7-6**] Ms. [**Known lastname 98723**] developed marked hyponatremia to 117
and was transfered to the ICU for monitoring. A renal consult
was obtained and they believed her hyponatremia was secondary to
stress response resulting in SIADH. Her hyponatremia resolved on
[**7-7**] with hypertonic saline and free water restriction. On [**7-7**]
she was transfered to the floor without issue. The patient was
discharged to _________ on 8/____ in stable condition.
Medications on Admission:
Tylenol-Codeine #3 300 mg-30'''' prn, Albuterol 90
(1-2 puffs)'' prn, Carvedilol 6.25', Diazepam 2''' prn,
Fluticasone 110 (2 puffs)'', Gabapentin 600', Meclizine 12.5''
prn, Prednisone taper, Simvastatin 20', Timolol (1 drop both
eyes [**Hospital1 **]), Diovan 160'
Discharge Medications:
Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours)
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Right middle lobe nodule
Discharge Condition:
Vital signs stable. Pain well controlled.
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage
-Chest tube site may drain fluid, so cover with a clean dressing
and change as needed to keep site clean and dry
-You may shower today. No tub bathing for swimming for 6 weeks
-No driving while taking narcotics
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] NPs [**7-16**] at 1:30pm in the [**Hospital Ward Name 121**]
Building Chest Diease Center [**Hospital1 **] I
Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology
For a Chest X-Ray 45 minutes before your appointment
Follow-up with Dr. [**Last Name (STitle) 141**] your PCP
Completed by:[**2148-7-8**]
|
[
"300.01",
"998.81",
"272.0",
"162.4",
"253.6",
"401.9",
"E878.6",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"32.20"
] |
icd9pcs
|
[
[
[]
]
] |
3843, 3895
|
2410, 3415
|
351, 412
|
3964, 4008
|
1478, 2387
|
4469, 4853
|
1273, 1319
|
3733, 3820
|
3916, 3943
|
3441, 3710
|
4032, 4446
|
1334, 1459
|
287, 313
|
440, 1004
|
1026, 1119
|
1135, 1257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,096
| 110,582
|
45163
|
Discharge summary
|
report
|
Admission Date: [**2164-3-10**] Discharge Date: [**2164-3-15**]
Date of Birth: [**2091-1-21**] Sex: M
Service: [**Hospital1 139**]
DISCHARGE DIAGNOSES:
1. Acute-on-chronic renal failure with flash pulmonary
edema.
2. Constipation.
3. Coronary artery disease.
4. Pleural disease.
5. Hypertension.
6. Dyslipidemia.
7. Gastroesophageal reflux disease.
8. Chronic obstructive pulmonary disease.
9. Benign prostatic hypertrophy.
HISTORY OF PRESENT ILLNESS: The [**Hospital 228**] medical doctor is
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**] (telephone number [**Telephone/Fax (1) 904**]). His renal
doctor is Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 174**]. His history of present
illness is as follows.
This 73-year-old male came in with a chief complaint of
constipation times five days and increase in creatinine. He
has coronary artery disease and chronic renal insufficiency
and presented with a 4-day to 5-day history of constipation.
He said he had problems with this before; however, this was
more severe. He reports a decrease in his appetite over this
same period as well as emesis times two. There was no
fevers, no chills, and no sweats. He did have some abdominal
pain. He has tried mineral oil (two doses worth) as well as
Dulcolax without relief.
In the Emergency Department, rectal examination and abdominal
films were unrevealing. However, because of his increased
creatinine to 4.5 from a baseline of about 3 to 3.5 and
bicarbonate of 18, he was admitted for further workup and
evaluation.
REVIEW OF SYSTEMS: On review of systems he had low back
pain. He reported about a 10-pound weight loss over the past
week.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Coronary artery disease, status post an anterior
myocardial infarction in [**2161-11-23**] with a stent to the
left anterior descending artery, percutaneous transluminal
coronary angioplasty to second diagonal. Catheterization in
[**2161-11-23**]; the proximal right coronary artery was 30%,
distal right coronary artery 70%, proximal left anterior
descending artery 100% with a stent placed, and middle
circumflex with 100%; deemed a poor a surgical candidate
secondary to his history of cerebrovascular accidents. An
echocardiogram in [**2162-7-24**] revealed an ejection fraction
of 30%, diffuse akinesis, right ventricle was normal, 1+
aortic regurgitation, 1+ mitral regurgitation. Stress MIBI
in [**2162-5-24**] showed 59% maximum heart rate, partially
reversible anterior defect, fixed apical and cervical
defects.
2. He also has a history of hypertension.
3. Dyslipidemia.
4. Cerebrovascular accident back in [**2162-5-24**].
5. Chronic renal insufficiency with a baseline creatinine
of 3 to 3.5 secondary to atherosclerotic renal disease;
formerly has had some end-stage renal disease one and a half
years ago.
6. Gastroesophageal reflux disease.
7. He is legally blind.
8. He has chronic obstructive pulmonary disease.
9. Benign prostatic hypertrophy; and elevated
prostate-specific antigen.
ALLERGIES: He has no known drug allergies, but ACE
INHIBITORS and [**Last Name (un) **] are contraindicated in this man.
MEDICATIONS ON ADMISSION:
1. Amitriptyline 40 mg p.o. q.h.s.
2. Zoloft 50 mg p.o. q.h.s.
3. Colace 100 mg p.o. t.i.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Lipitor 60 mg p.o. q.d.
6. Rocaltrol 0.25 mg p.o. q.d.
7. Nephrocaps 1 tablet p.o. q.d.
8. Phos-Lo 1 tablet p.o. t.i.d.
9. Tylenol 650 mg p.o. q.4-6h. p.r.n.
10. Plavix 75 mg p.o. q.d.
11. Lopressor 50 mg p.o. b.i.d.
12. Norvasc 5 mg p.o. q.d.
13. Ambien 5 mg to 10 mg p.o. q.h.s. p.r.n.
14. Ultram 50 mg p.o. q.6h. p.r.n.
15. Prilosec 20 mg p.o. q.d.
16. Fibercon 3 tablets per day.
SOCIAL HISTORY: He drinks two drinks per night. He quit
tobacco in [**2161**] but has a 50-pack-year smoking history by
report.
FAMILY HISTORY: His family history in this particular
situation was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: His physical
examination on admission revealed review of systems again
with low back pain. He was an elderly white man in no
apparent distress. Alert and oriented times three.
Temperature was 96.7, heart rate of 77, blood pressure
of 182/85, respiratory rate of 18, and oxygen saturation of
97% on room air. His skin was warm and dry. The oropharynx
was clear and moist. The neck was supple. He had positive
crackles in the right lung base. First heart sound and
second heart sound. A regular rate and rhythm. A 2/6
systolic murmur at the base. The abdomen was nondistended.
He had positive bowel sounds. There was no guarding and no
rebound, but tenderness to palpation in the right upper
quadrant and the left lower quadrant. Rectal examination in
the Emergency Department showed guaiac-negative stool, and he
also had decent rectal tone with an enlarged prostate on
rectal examination. He had no peripheral edema.
PERTINENT LABORATORY DATA ON PRESENTATION: His laboratory
values were significant for a white blood cell count of 11.6,
hematocrit of 32.5, platelets of 406, mean cell volume of 91.
SMA-7 revealed sodium of 140, potassium of 4.5, chloride
of 104, bicarbonate of 18, blood urea nitrogen of 42,
creatinine of 4.5, and glucose of 97. Differential with
83 neutrophils, lymphocytes 6.4, no bands. His urinalysis
showed specific gravity of 1.02, pH of 5, moderate blood,
nitrite negative, 6 to 10 red blood cells, 3 to 5 white blood
cells. Urine electrolytes revealed creatinine of 75, sodium
of 114, osmolalities of 462, with a FENa of 4.3.
RADIOLOGY/IMAGING: Abdominal x-ray was negative. No free
air. No dilated loops.
Electrocardiogram showed sinus rhythm at 83, left axis
deviation, left ventricular hypertrophy, T wave inversions in
aVL, and changes consistent with an anterior septal
myocardial infarction. No changes from [**2164-1-16**].
HOSPITAL COURSE: The patient was treated according to the
following hospital course:
He was given D-5-W with 3 amps of sodium bicarbonate, and he
was continued on the gentle rehydration, and strict
ins-and-outs were watched. Over time, the patient's blood
urea nitrogen and creatinine remained essentially stable in
the 4 range, and on the day of discharge he actually dropped
down to a blood urea nitrogen of 37 and creatinine of 3.8;
which was approaching his baseline renal function. He was to
follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] for further issues related to
management of his chronic renal insufficiency.
In addition, he was started on Epogen 4000 units subcutaneous
twice per week which will be provided by [**Hospital6 1587**] services.
From a gastrointestinal perspective, the patient had
constipation and was treated with an aggressive bowel regimen
including Colace, Senna, lactulose; and he eventually had
bowel movements, and by the time of discharge he had one on
the morning of his discharge; so he will be maintained with
his bowel regimen. It was thought that his constipation
might have been due to either the chronic renal insufficiency
leading to his not feeling well and not eating much; and
therefore not providing enough bulk as the cause. Liver
function tests were normal.
From a pulmonary perspective, during the rehydration of the
patient (he came in on [**2-8**]), and on the morning of
[**3-12**], the patient experienced difficulty breathing,
shortness of breath, with a blood pressure of up 210/110,
tachycardic to 110/150, normal sinus rhythm, with a narrow
complex. Electrocardiogram showed question of ST changes in
V1 through V2. Chest x-ray was done, and he was given 60 mg
of intravenous Lasix. A nitroglycerin drip was started, and
a heparin was started without a bolus, and the patient was
given aspirin. His oxygen saturations were at 78% on 4
liters nasal cannula, and intravenous fluids were stopped.
Pulmonary examination showed decreased breath sounds on the
right side and wet crackles bilaterally, and his skin with
mauled with red and white patches. So the patient actually
responded to this treatment to a blood pressure of 138/80,
heart rate 96, and respiratory rate of 28, and he was satting
only at 92% on 100% nonrebreather, and put out a small amount
of urine. He was feeling a little bit better.
So he was therefore transferred to the Intensive Care Unit
for monitoring of his oxygenation, but since he had been
determined to be do not resuscitate/do not intubate it was
preferred that he would not be intubated and maintained on
100% nonrebreather.
The patient's x-ray on [**3-11**] which showed mild
congestive heart failure with interstitial edema, opacity in
the right hemithorax, with volume loss (increased from the
previous study that was done a few months before), so a CT
was done, and there were found to be extensive diffuse
nodular thickening of the right pleura involving the
posterolateral as well as the mediastinal pleura. His
pericardial irregularity along the right side was concerning
for pericardial involvement. The thickened nodular
appearance of this lesion was concerning for metastatic
adenocarcinoma or malignant mesothelioma. He also had a 7-mm
indeterminate parenchymal nodule in the right lower lobe that
was noted on x-ray. There was also an area of increased
attenuation in the right upper lobe posteriorly adjacent to
the area of pleural abnormality which was consistent possibly
with atelectasis or less likely a neoplastic involvement of
the lungs. There was also mediastinal lymphadenopathy and
emphysema.
It was determined that no further workup of his lung
abnormalities would be done within the hospital, and so the
patient could be discharged from a pulmonary perspective as
it was determined by Physical Therapy toward the day before
discharge that his oxygen saturation was 92% on room air and
98% on 2 liters nasal cannula.
The patient's heart was measured, in terms of its ejection
fraction, just to determine that his pulmonary edema was not
a result of worsening ejection fraction; and the
echocardiogram done on [**3-12**] showed an ejection
fraction of 30%, and a left atrium that was mildly dilated;
however, the left ventricular wall thickness were normal.
The left ventricular cavity size was normal. Overall left
ventricular systolic function was severely depressed
secondary to severe hypokinesis of the anterior septum and
anterior free wall, and extensive circumferential apical
hypokinesis/akinesis, but no obvious apical thrombi were
seen. Right ventricular chamber size and free wall motion
were normal. The aortic root was mildly dilated and a number
of aortic valve leaflets were not determined. The aortic
valve were, however, mildly thickened. There was no
significant aortic valve stenosis. There was trace aortic
regurgitation. The mitral valve leaflets were mildly
thickened. There was no mitral valve prolapse. There was
mild 1+ mitral regurgitation. The tricuspid valve leaflets
were mildly thickened. There was no pericardial effusion.
So, compared with the previous study on [**2162-8-20**], there
were no major changes evident; although, technically the
studies were suboptimal. Thus, his heart had not changed
significantly during this time, and his flash pulmonary edema
may have been a result of hydration too quickly under the
circumstances.
From a gastrointestinal perspective, the patient was
maintained with Zoloft 50 mg p.o. q.d., amitriptyline 40 mg
p.o. q.h.s., and he was given Ultram and Tylenol p.r.n. The
patient was recommended by his renal physician to be taken
down from the Ultram at which he was taking up to six tablets
per day down to at most four tablets per day; which is what
he was discharged on. The patient will need to follow up
with the Pain Service to determine if there is a better
mechanism to deal with his low back pain. However, any
significant neurologic abnormalities were excluded and any
neurovascular problems within his lower back, spine, spinal
cord, and lower extremities.
For prophylaxis he was maintained on Protonix 40 mg p.o.
q.d., heparin intravenous drip while we were concerned for
his having a myocardial infarction; however, he had ruled
out. Again, the patient remained with a code status of do
not resuscitate/do not intubate.
DISCHARGE STATUS: He was discharged to home on [**2164-3-15**].
CONDITION AT DISCHARGE: In improved condition with [**Hospital6 3429**] services.
DISCHARGE FOLLOWUP: He was to follow up with his primary
care physician (Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**]) and his renal physician
(Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 174**]) within the next week. He will need a
referral from his primary care physician (Dr. [**First Name (STitle) 452**] for the
Pain Service followup.
MEDICATIONS ON DISCHARGE: (Discharge medications are very
similar to his admission medications including)
1. Amitriptyline 40 mg p.o. q.h.s.
2. Zoloft 50 mg p.o. q.h.s.
3. Colace 100 mg p.o. t.i.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Lipitor 60 mg p.o. q.d.
6. Rocaltrol 0.25 mg p.o. q.d.
7. Nephrocaps 1 tablet p.o. q.d.
8. Phos-Lo 1 tablet p.o. t.i.d.
9. Tylenol 650 mg p.o. q.4-6h. p.r.n.
10. Plavix 75 mg p.o. q.d.
11. Lopressor 50 mg p.o. b.i.d.
12. Norvasc 5 mg p.o. q.d.
13. Ambien 5 mg to 10 mg p.o. q.h.s. p.r.n.
14. Ultram 50 mg p.o. q.6h. p.r.n.
15. Prilosec 20 mg p.o. q.d.
16. Fibercon 3 tablets per day.
17. Epogen 4000 units subcutaneous twice per week; which
will be done by [**Hospital6 407**] services (the only
additional medication).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], M.D. [**MD Number(1) 7938**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2164-3-15**] 11:14
T: [**2164-3-17**] 06:32
JOB#: [**Job Number **]
|
[
"401.9",
"V45.82",
"496",
"414.01",
"412",
"585",
"511.9",
"584.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3990, 5983
|
169, 451
|
12991, 14029
|
3294, 3841
|
6071, 12461
|
12476, 12535
|
1655, 1761
|
12557, 12964
|
481, 1634
|
1784, 3267
|
3858, 3972
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,539
| 136,505
|
47885+59037
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-6-27**] Discharge Date: [**2129-7-11**]
Date of Birth: [**2076-4-9**] Sex: F
Service: Neurosurgery
HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old
woman with morbid obesity, hypertension, and diabetes
mellitus, who presents with a one-day history of severe
headache of a sudden onset. The patient was able to sleep
overnight, but this morning the headache was so severe that
to the emergency room. She did have positive nausea, but no
vomiting.
On physical examination, the patient was afebrile. Blood
pressure was 154/68. Cardiac examination revealed regular
rate and rhythm. Lungs were clear. Neurologically, she was
awake, alert, oriented, and anxious. Pupils equal, round,
Visual fields were full to confrontation. She did have a
right facial droop from an old Bell palsy. Facial sensation
was intact. She was full strength throughout. Motor
examination and sensation was intact to light touch.
Proprioception was down in her lower extremities bilaterally.
Reflexes were nonreactive and symmetrical. Coordination: No
dysmetria.
CT showed a 6 mm round, hyperintensity in the left paraclinoid
area.
LABORATORY DATA: Labs on admission revealed the following:
Sodium 142, potassium of 4.3, chloride 104, CO2 26, BUN 18,
creatinine 0.7, glucose 98, PTT 20.7, INR 1.0. The CT showed
a 6 mm vascular-appearing malformation consistent with ICA or
MCA aneurysm.
HOSPITAL COURSE: The patient was admitted to the
Neurological Intensive Care Unit. She had a central line
placed on [**2129-6-27**] without complication.
On [**6-28**]/[**Numeric Identifier 41559**], she was started on heparin at 10,000 units
subcutaneously b.i.d. She underwent coiling of that aneurysm
on the day of admission without complications. It was a left
ICA aneurysm that was coiled. Post coiling, the patient was
monitored in the Surgical Intensive Care Unit for close
monitoring for vasospasm. She remained neurologically intact
during the entire stay in the hospital. She did develop
positive blood cultures and a positive line-tip culture,
which was Staphylococcus coagulase positive. She was started
on Oxacillin on [**2129-7-5**], two grams IV q.6h. She will
followup in the [**Hospital **] Clinic on [**7-21**], at 10:30 am.
Neurologically, she is intact, awake, alert, and oriented
times three, moving all extremities. Motor strength is [**6-5**]
and sensation is intact to light touch. She is out of bed
and ambulating. She was seen by the Department of Physical
Therapy and Occupational Therapy and found to be safe for
discharge to home. She was transferred to the regular floor
on [**2129-7-5**] and she remained neurologically stable.
She was discharged on [**2129-7-11**] to home with PIC line and IV
Oxacillin IV 2 gram q.6h. times 14 days total.
Other medications at the time of discharge include the
following:
DISCHARGE MEDICATIONS:
1. Percocet 1 to 2 tablets p.o.q.4h.p.r.n.
2. Lopressor 25 mg p.o.b.i.d.
3. Metformin 500 mg p.o.b.i.d.
4. Flovent 110 mcg, two puffs b.i.d.
5. Albuterol one to two puffs q.6h.p.r.n.
6. Alprazolam 0.5 mg p.o.b.i.d.
7. Potassium hydrochloride 20 mg p.o.q.h.s.
8. Nimodipine 60 mg p.o.q.4h. times 21 days total.
FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 1132**] in
six months and in the Infectious Disease Clinic on [**7-21**],
at 10:30 am.
CONDITION ON DISCHARGE: The patient was in stable condition
at the time of discharge.
[**Location (un) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2129-7-11**] 10:28
T: [**2129-7-11**] 10:46
JOB#: [**Job Number **]
Name: [**Known lastname 1193**], [**Known firstname **] Unit No: [**Numeric Identifier 16223**]
Admission Date: [**2129-6-27**] Discharge Date: [**2129-7-12**]
Date of Birth: [**2076-4-9**] Sex: F
DISCHARGE SUMMARY ADDENDUM: Discharge summary from
[**2129-7-11**]. The patient's discharged was delayed one day. She
is being discharged on [**2129-7-12**] in stable condition
secondary to difficulty with the PIC line on [**2129-7-11**]. The
home 2 liters of Oxicillin with follow up in the Infectious
Disease clinic on [**2129-7-21**]. The patient was stable at the
time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2129-7-12**] 11:42
T: [**2129-7-15**] 09:33
JOB#: [**Job Number 16224**]
|
[
"430",
"401.9",
"780.57",
"E879.8",
"278.01",
"996.62",
"038.19",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
2913, 3394
|
1451, 2890
|
3419, 4624
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,305
| 181,328
|
14240
|
Discharge summary
|
report
|
Admission Date: [**2179-8-27**] Discharge Date: [**2179-8-31**]
Date of Birth: [**2123-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
TIPS evaluation and Redo
History of Present Illness:
56M with EtOH cirrhosis s/p TIPS x2 (last [**2176**]), DM2, who is
admitted to the MICU for hematemesis x1. The patient states that
this AM, he started on cymbalta for his peripheral neuropathy,
and 1 hour after taking the medication, he felt nauseous and
vomited. He vomited a few times, that were mostly bilious, but
at 11 AM, he vomited bright red blood. He states that it was a
small cup worth, mostly just streaked with blood, but concerned
enough to bring him to the ED. He denies chest pain, SOB,
lightheadedness, dizziness, abdominal pain, melena, BRBPR. Of
note, he was admitted [**6-17**] for hematemesis as well.
.
In the ED, vitals were 98.7, 129/73, 82, 18, 97% RA. He was
found to be guaiac negative. He had hypokalemia which was
repleted, and he had an abdominal US with dopplers to evaluate
his TIPS. He was given pantoprazole 40 mg IV x 1 and zofran x 1.
He was then transferred to the MICU for further evaluation.
Past Medical History:
1. Alcoholic cirrhosis - hx of esophageal variceal bleed and
hepatic encephalopathy. He has had 2 TIPS procedures with stent
placement in [**2166**] and again in [**2176**].
2. Chronic pancreatitis complicated by a parapancreatic cyst
that was infected with enteroccocus and coagulase negative. On
vancomycin from [**Date range (2) 42329**] then linezolid [**Date range (1) 42330**].
3. Type 2 DM on insulin
4. Anemia of chronic disease
5. Thrombocytopenia
6. Depression
7. Umbilical Hernia
8. History of delerium tremens
Social History:
He lives alone. He is currently unemployed.Has three children.
He has a history of heavy alcohol use but none since [**4-14**].
Smokes 1.5 PPD. No IVDU, no other illicits.
Family History:
father - cirrhosis
Physical Exam:
VS: 97.7 129/101 76 13 98% 2L
GEN: WD male, NAD, pleasant
HEENT: + scleral icterus; PERRL
CV: RRR- distant
LUNGS: few bibasilar rhonci. otherwise clear
ADBOMEN: soft, slightly distended, no tenderness. + dullness to
percussion. hepatic edge not palpable. guaiac negative per ED
notes
EXT: trace pedal edema
NEURO: A/O x 3; no asterxis
Pertinent Results:
[**2179-8-27**] 02:40PM
PT-17.3* PTT-32.4 INR(PT)-1.6*
PLT COUNT-107*
WBC-7.7 RBC-3.49* HGB-11.5* HCT-34.4*
MCV-99* MCH-33.1* MCHC-33.5 RDW-16.5*
ALBUMIN-3.2*
LIPASE-28
ALT(SGPT)-25 AST(SGOT)-43* ALK PHOS-225* TOT BILI-4.8*
GLUCOSE-378* UREA N-10 CREAT-0.9 SODIUM-132* POTASSIUM-2.8*
CHLORIDE-95* TOTAL CO2-25 ANION GAP-15
[**2179-8-27**] 07:39PM HCT-31.3*
CHEST (PA & LAT) Study Date of [**2179-8-27**] 3:49 PM
FINDINGS:
There are bibasal effusions with consolidation in the right
lower lobe. The heart and mediastinum appear unremarkable. There
is a TIPS catheter in the right upper quadrant.
The focal opacity in the right lower lobe may represent an early
pneumonia or aspiration.
DUPLEX DOPP ABD/PEL Study Date of [**2179-8-27**] 4:26 PM
Doppler son[**Name (NI) **] for TIPS evaluation demonstrate two TIPS, one
of
them is completely occluded, the second one has appropriate
wall-to-wall flow with velocities ranging from 94-155 cm/sec,
considerably higher than prior study, suggesting in stent
stenosis.
REVISN HEPATIC SHUNT TIPS Study Date of [**2179-8-30**] 2:41
IMPRESSION:
1. Pre-angioplasty portal venogram demonstrating focal stenosis
of the distal (hepatic vein end) aspect of the TIPS shunt.
2. Angioplasty with 10 x 40 mm balloon with improved flow on
post-angioplasty portal venogram.
3. Drop in portosystemic gradient from 19 mmHg to 9 mmHg.
Brief Hospital Course:
56 yo M with Ethanol Induced Cirrhosis, Upper GI bleed s/p TIPS
who was admitted for hematemesis.
# Hematemesis: The patient was admitted to the ICU. On initial
presentation in the ED, vitals were 98.7, 129/73, 82, 18, 97%
RA. He was found to be guaiac negative. He had hypokalemia which
was repleted, and he had an abdominal US with Dopplers to
evaluate his TIPS which was initially reported to be patent. He
was given pantoprazole 40 mg IV x 1 and Zofran x 1. He was then
transferred to the MICU for further evaluation. In the MICU, he
was started on an octreotide gtt. Serial hematocrits were
monitored and were stable not requiring any transfusions. He had
no further episodes of vomiting and was tolerating clears
without difficulty. His octreotide gtt was discontinued and he
was transferred to the Hepatorenal service.
# Ethanol Induced Cirrhosis: The patient had a history of TIPs
and these were evaluated on admission. Although initially
reported as patent, repeat review showed evidence of stenosis
and the patient underwent a successful TIPs revision.
At the time of discharge, the patient was doing well, tolerating
a regular diet and was without pain. He was discharged with
follow-up in the [**Hospital **] clinic.
# Pneumonia: A chest x-ray in the ED was concerning for a RLL
infiltrate suspicious for a pneumonia or aspiration. The
patient was started on Levaquin. He received a 5 day course of
antibiotics. The patient was afebrile and without evidence of
pneumonia at discharge.
# Diabetic Neuropathy: The patient's initial presentation
appeared to be related to cymbalta which the patient was
prescribed for treatment diabetic neuropathy of his feet. The
patient was started on Amitriptyline as an alternative
medication. The patient responded well to this therapy and was
given instructions to follow-up with his primary care physician
regarding maintenance of this medication.
Medications on Admission:
1. Folic Acid 1 mg daily
2. Furosemide 40 mg daily
3. Insulin Glargine 34 mg hs
4. Lispro SS
5. Lactulose 30mL 3-4x/day
6. Pantoprazole 40 mg PO daily
7. Pregabalin 100 mg PO BID
8. Rifaximin 400 mg PO tid
9. Aldactone 100 mg PO daily
10. Multivitamin daily
11. Sucralfate 1 gram PO QID
Discharge Medications:
1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a day.
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Aldactone 100 mg Tablet Sig: 1.5 Tablets PO once a day.
8. Lantus 100 unit/mL Solution Sig: One (1) 34 Subcutaneous at
bedtime.
9. Insulin Lispro 100 unit/mL Solution Sig: One (1) units
Subcutaneous PRN.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Hematemesis
EtOH Induced Cirrhosis
Diabetic Neuropathy
Community Acquired Pneumonia
Seconday Diagnoses:
Diabetes
Discharge Condition:
Hemodynamically stable, afebrile and without pain.
Discharge Instructions:
You were admitted for concern for nausea, vomiting and
gastrointestinal bleeding. You did not have any bleeding while
in the hospital. Your nausea improved and appeared to be
realated to taking Cymbalta. Given your history of espohageal
bleeding, an ultrasound of your liver was performed which showed
your TIPS was occluded. This was corrected with a TIPS revision
procedure. You are have follow-up with the liver center on
[**9-14**]. Please attend this appointment as scheduled.
In addition, you will need re-evaluation of your TIPS with an
outpatient ultrasound. This was scheduled for the same day as
your Liver center appointment ([**9-14**]). This is scheduled
for 10:30AM. You cannot eat or drink after midnight the evening
prior to this study.
On your admission, you appeared to have a pneumonia. You have
completed a 7 day course of antibiotics. You do not appear to
have any ongoing symptoms but you should follow-up with your
primary care physician.
You have been reporting foot pain which had been treated with
lyrica and cymbalta. Because these medications did not work for
you, we have started you on a new medication (Amitryptiline)
which seems to have helped. You are being discharged with a
prescription for this medication. Please take as directed and
follow-up with your primary care provider.
Because of the side effects you experiencec with Cymbalata, you
should not take this medication. Please continue to take all
other previously prescribed medications as directed.
You should call your physician or seek medical attendion if you
experience nausea, vomiting, vomiting blood, dark tarry stools,
abdominal pain, diarrhea, shortness of breath, chest pain, cough
or any other concerning symptom.
Followup Instructions:
TIPS Ultrasound
[**2179-9-14**]
[**Hospital Ward Name 23**] Building
10:30 am
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3)
GI ROOMS Date/Time:[**2179-9-14**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD
Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2179-9-14**] 8:30
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-9-13**] 9:15
Completed by:[**2179-9-2**]
|
[
"287.5",
"486",
"250.60",
"458.9",
"357.2",
"V49.83",
"571.2",
"V58.67",
"456.21",
"572.3",
"577.1",
"285.29",
"311",
"578.0",
"553.1",
"276.8",
"303.90",
"E879.8",
"996.74",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.64",
"00.40",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
6871, 6877
|
3847, 5761
|
325, 352
|
7054, 7107
|
2457, 3824
|
8892, 9477
|
2066, 2086
|
6099, 6848
|
6898, 7033
|
5787, 6076
|
7131, 8869
|
2101, 2438
|
274, 287
|
380, 1314
|
1336, 1860
|
1876, 2050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,452
| 165,867
|
37671
|
Discharge summary
|
report
|
Admission Date: [**2173-8-9**] Discharge Date: [**2173-8-27**]
Date of Birth: [**2095-12-4**] Sex: F
Service: SURGERY
Allergies:
Morphine / Codeine / Latex / Penicillins / Naloxone / Ergonovine
/ Opioids-Morphine & Related
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Acute ischemia right lower extremity
Major Surgical or Invasive Procedure:
Right iliofemoral popliteal tibial thrombectomy and right lower
extremity fasciotomy for compartment.
History of Present Illness:
77 F who resides in a long-term care facility was found with
a cold right foot this morning. She presented to [**Hospital 1562**]
Hospital at approximately 2 PM and transferred to [**Hospital1 18**]. She has
been lethargic and confused for the past 1 week and treated for
a
UTI. Currently she is unable to give a history herself.
According
to her husband and daughter, the patient had been on coumadin
but
this was stopped in [**2172-10-26**] due to a splenic bleed.
Past Medical History:
Afib (was on coumadin but stopped [**11-2**] due to splenic
hematoma), COPD, CRI, mitral regurgitation, depression, HTN,
monoclonal gammopathy, bipolar, hearing impaired
PSH: hysterectomy, lumpectomy, cataracts
[**Last Name (un) 1724**]: digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,
nadolol 80', advair, albuterol prn, abilify 2' started [**8-7**],
prilosec, mnacrobid for UTI (treated for 8 days
Social History:
SH: resides at nursing home in [**Name (NI) 1562**], husband and daughter
([**Name (NI) 1154**] [**Telephone/Fax (1) 84462**]) make medical decisions for her
Family History:
FH: NC
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS: Tc=98.5 BP=117/73 HR=85 RR=24 O2 sat=932L Wt=135lb
Ht=67 BMI=21.1
GEN: minimally responsive, thin, was not awake or alert
HEENT: no trauma
NECK: TLC in rt neck, no JVD
HEART: irreg, no murmurs
LUNGS: clear
ABDOMEN: soft nd
EXTREMITIES: edema in left arm and pain when moving arm
GU: +catheter
MUSCULOSKELETAL: quad wasting bilateral, open wound with vac in
place
NEURO: difficult to assess dut to patient Mental status,
withdraws to touch.
Confusion Assessment Method (CAM): (1) Acute onset and
fluctuating course [yes], (2) Inattention [yes], (3)
Disorganized
thought processes [yes] (4) Altered level of consciousness [yes]
TOTAL SCORE: [**2-27**]
Pertinent Results:
[**2173-8-23**] 03:43AM BLOOD
WBC-7.8 RBC-2.84* Hgb-8.7* Hct-26.8* MCV-94 MCH-30.6 MCHC-32.5
RDW-15.7* Plt Ct-350
[**2173-8-23**] 03:43AM BLOOD
Plt Ct-350
[**2173-8-23**] 03:43AM BLOOD
Glucose-101 UreaN-53* Creat-1.5* Na-137 K-4.6 Cl-101 HCO3-29
AnGap-12
[**2173-8-13**] 02:06AM BLOOD
CK-MB-8
[**2173-8-23**] 03:43AM BLOOD
Calcium-8.4 Phos-2.6* Mg-2.4
[**2173-8-16**] 01:24PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
URINE RBC-0-2 WBC-[**5-5**]* Bacteri-MOD Yeast-NONE Epi-0 TransE-<1
Brief Hospital Course:
PT MADE [**Name (NI) 3225**] BY FAMILY
NEURO:
Demented, c/w sertraline and Olanzapine as directed.
Non-pharmacologic delirium prevention/management:
Regulate sleep-wake cycle by encouraging daytime
activity/stimulation and minimizing overnight interruptions.
Provide frequent re-orientation and cueing.
Minimize invasive lines and catheters.
Up out of bed three times a day with meals. Mobilize and
ambulate with supervision as tolerated.
Avoid long-acting, sedating, or anticholinergic medications.
Provide eyeglasses, hearing aids, dentures.
Encourage family visitors.
CARDIAC:
AFIB - NO ANTICOAGULATION
Normal EF. continue with Metroprolol if tolerated.
RESP:
Aspiration precautions. HOB 30 degrees while taking
GI:
Had speech and swallow - aspiration precautions
ground solids and nectar thick liquids
Take minimal by po, just pleasure feeds.
GU:
foley catheter for comfort
VASCULAR:
Pt with acute thrombis
Right iliofemoral popliteal tibial thrombectomy and right lower
extremity fasciotomy for compartment syndrome.
Was on Lovenox while in hospital. This will be DC'd in discharge
PAIN:
Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for severe pain.
Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q 8H (Every
8 Hours) as needed for ATC: prn.
Medications on Admission:
digoxin 125 mcg Q Mon/Wed/Fri, valproic acid, cozaar,
nadolol 80', advair, albuterol prn, abilify 2' started [**8-7**],
prilosec, mnacrobid for UTI (treated for 8 days)
Discharge Medications:
1. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for severe pain.
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q 8H
(Every 8 Hours) as needed for ATC: prn.
5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for prn
agitation.
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) **] [**Hospital **] nursing home
Discharge Diagnosis:
RLE embolis
UTI
Dementia
Afib
COPD
CRI
mitral regurgitation
depression
HTN
monoclonal gammopathy
bipolar
hearing impaired
PSH: hysterectomy, lumpectomy, cataracts
Discharge Condition:
Stable
Discharge Instructions:
Pt was Comfort measures only by family.
Please use faciltiy protocol for comfort measures only
Please use wet to dry dressing changes on Lower extremities
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2173-9-8**] 11:45
Completed by:[**2173-8-27**]
|
[
"917.2",
"296.80",
"458.29",
"585.9",
"344.5",
"294.8",
"427.31",
"440.29",
"403.90",
"496",
"444.22",
"V66.7",
"459.89",
"293.0",
"424.0",
"389.9",
"273.1",
"599.0",
"440.4",
"787.20",
"349.82",
"785.50",
"729.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.09",
"38.08",
"86.28",
"38.93",
"96.6",
"93.57",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5015, 5098
|
2987, 4300
|
389, 493
|
5305, 5314
|
2342, 2964
|
5517, 5690
|
1611, 1620
|
4520, 4992
|
5119, 5284
|
4326, 4497
|
5338, 5494
|
1635, 1635
|
1657, 2323
|
313, 351
|
521, 990
|
1012, 1419
|
1435, 1595
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,648
| 139,902
|
22401
|
Discharge summary
|
report
|
Admission Date: [**2101-3-5**] Discharge Date: [**2101-3-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
85 yo male with PMH significant for afib, CHF with diastolic
dysfunction, HTN, restrictive lung disease, who was transferred
from [**Hospital1 **] for hypoxic respiratory failure. Pt was
admitted to OSH on [**2-26**] with DOE, non-purulent cough, and
orthopnea. The patient was treated with lasix, CHF, and rate
control was attempted with IV diltiazem and BB without
significant improvement in his symptoms. Pt remained in Afib and
on [**3-1**] DCCV was attempted unsuccessfully. Pt was also treated
with levoflox for possible CAP. Chest CT showed new diffuse
ground glass opacities. On day of transfer to the [**Hospital1 **], pt had
increased SOB, RR, and decreased O2 sats. ABG on 100% NRB was
7.48/40/54. Hospital [**Last Name (un) 10128**] also significant for Acute on Chronic
RF, and new coagulopathy with INR requiring Vit K.
Past Medical History:
1. HTN
2. A-fib on coumadin, BB and propafenone.
3. 2.6 AAA by CT in [**2100**]
4. prostate cancer s/p TURP in [**2088**]
5. CAD (details unknown) No known MI
6. Klebsiella Cholecystitis cholecystostomy tube and s/p lap CCY
on [**2100-8-23**]
Social History:
60 pack-year smoking (quit 30 years ago)EtOH (1-2 drinks/week)No
drugsFormer accountantServed in United States Navy
Family History:
non-contributory
Pertinent Results:
[**2101-3-5**] 10:57PM PT-24.2* PTT-28.7 INR(PT)-3.7
[**2101-3-5**] 10:57PM FDP-160-320*
[**2101-3-5**] 09:00PM TYPE-ART TEMP-38.6 RATES-30/3 TIDAL VOL-400
PEEP-10 O2-70 PO2-88 PCO2-49* PH-7.39 TOTAL CO2-31* BASE XS-3
-ASSIST/CON INTUBATED-INTUBATED
[**2101-3-5**] 08:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2101-3-5**] 08:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2101-3-5**] 08:00PM URINE RBC-21-50* WBC-[**12-4**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2101-3-5**] 08:00PM URINE HYALINE-[**3-19**]*
[**2101-3-5**] 06:16PM GLUCOSE-194* UREA N-44* CREAT-1.5* SODIUM-133
POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-26 ANION GAP-17
[**2101-3-5**] 06:16PM CK(CPK)-49 TOT BILI-0.5
[**2101-3-5**] 06:16PM CK-MB-NotDone cTropnT-<0.01
[**2101-3-5**] 06:16PM CALCIUM-8.4 PHOSPHATE-4.4# MAGNESIUM-1.7
IRON-27*
[**2101-3-5**] 06:16PM calTIBC-205* HAPTOGLOB-380* FERRITIN-671*
TRF-158*
[**2101-3-5**] 06:16PM WBC-24.0*# RBC-3.26* HGB-10.1* HCT-30.4*
MCV-93 MCH-31.1 MCHC-33.4 RDW-13.5
[**2101-3-5**] 06:16PM NEUTS-92.6* LYMPHS-3.5* MONOS-3.6 EOS-0.2
BASOS-0
[**2101-3-5**] 06:16PM HYPOCHROM-1+
[**2101-3-5**] 06:16PM PLT COUNT-313
[**2101-3-5**] 06:16PM PT-33.7* PTT-27.8 INR(PT)-7.2
Brief Hospital Course:
This patient was admitted to the MICU for respiratory failure
requiring intubation. The cause of his respiratory distress was
probably multifactorial including CHF, infection, & amiodarone
toxicity. A chest CT showed apical scarring, bullous changes
and bronchiectasis. PFTs prior to amiodarone initiation showed
restrictive pattern. The patient also had suspect underlying
granulomatous disease and COPD with acute volume overload versus
infection. The patient was in the ICU from [**2101-3-5**] to [**2101-3-8**] at
which time the family chose to change their care goals to
comfort measures only. The patient was extubated and died
within a few hours.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory arrest
Discharge Condition:
Dead
|
[
"V10.46",
"401.9",
"276.5",
"486",
"515",
"427.31",
"441.4",
"491.21",
"518.84",
"428.32",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"99.04",
"96.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
3642, 3651
|
2929, 3590
|
281, 292
|
3713, 3720
|
1608, 2906
|
1571, 1589
|
3613, 3619
|
3672, 3692
|
221, 243
|
320, 1155
|
1177, 1422
|
1438, 1555
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
794
| 151,049
|
11740
|
Discharge summary
|
report
|
Admission Date: [**2190-11-29**] Discharge Date: [**2190-12-9**]
Date of Birth: [**2109-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
FTT
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81F w/ DM2, AS s/p AVR, cirrhosis ?[**2-26**] NASH, with 5d fatigue,
decreased po intake, nausea. Mild LLQ pain w/ no diarrhea per
ED, though soft on repeat exam. Denies SOB, but says that she
has had increased tachypnea over last 1.5 weeks. + weight loss,
unsure of how much, but has noticed pants and shirts fitting
differently. + cough over last few months, unproductive. +
long smoking history. No fevers, night sweats, dysuria, CVAT.
Of note, pt. continued to take all medications. Per pt., last
saw PCP 1 week ago
.
While in [**Name (NI) **] pt remained afebrile and hemodynamically stable on
2L NC with persistent tachypnea in 30s. She did have
hypoglycemia to 44, first in transport to hospital, then in ED,
which corrected with two amps D50 and start of D51/2 NS. CXR
showed a left pleural effusion, and UA showed a UTI which was
initially treated with vanc/levo/flagyl to cover possible
pneumonia and UTI. Electrolytes showed non-gap metabolic
acidosis on VBG.
Past Medical History:
1. Aortic stenosis with porcine valve replacement; last EF in
system [**2184**] 43%
2. Diabetes mellitus Type 2
3. Right hip replacement
4. Noninsulin dependent diabetes mellitus
5. NASH
Social History:
She lives alone with neighbor's help. She has a remote tobacco
history, quit in [**Month (only) 359**], one pack per day for > 50 years, still
smoking. No alcohol use. Per her report, no cancer screening.
Family History:
Significant for her father, who died at 50 years from
myocarditis.
Physical Exam:
On admission:
Vitals: T 99.1, BP 111/51, HR 120, RR 32 / 97% on 2L
Gen: sleepy, frail, cachetic chronically-ill appearing woman
HEENT: PERRL, EOMI, MM dry, OP clear
Neck: no [**Doctor First Name **]
CV: tachy, nl rhythm, loud [**3-30**] murmur over entire precordium
Pulm: decreased BS L lower lung on lateral/anterior exa, R side
clear
Abd: soft, non distended, nontender, +BS
Ext: lukewarm extremities, DP 2+ bilaterally
Neuro/Psych: Alert and oriented, nl tone, decreased bulk, weak
thoroughout 4+/5 strength UE and LEs.
Pertinent Results:
[**2190-11-29**] 11:31PM TYPE-MIX PO2-70* PCO2-33* PH-7.22* TOTAL
CO2-14* BASE XS--13 COMMENTS-GREEN TOP
[**2190-11-29**] 11:31PM GLUCOSE-48* K+-5.4*
[**2190-11-29**] 09:35PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2190-11-29**] 09:35PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-MOD
[**2190-11-29**] 09:35PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2190-11-29**] 09:30PM URINE HOURS-RANDOM CREAT-71 SODIUM-29
POTASSIUM-35 CHLORIDE-27
[**2190-11-29**] 08:31PM GLUCOSE-70 LACTATE-1.3
[**2190-11-29**] 08:00PM GLUCOSE-74 UREA N-81* CREAT-2.0* SODIUM-134
POTASSIUM-5.8* CHLORIDE-110* TOTAL CO2-10* ANION GAP-20
RENAL U.S. [**2190-12-4**] 2:47 PM
RENAL U.S.
Reason: ARF EVAL FOR HYDRONEPHROSIS
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with ARF, s/p tx for urosepsis, now w
decreasing urine output.
REASON FOR THIS EXAMINATION:
Eval for hydronephrosis
INDICATION: 81-year-old female with acute renal failure.
COMPARISON: [**2190-11-30**].
RENAL ULTRASOUND: The right kidney measures 9.9 cm. The left
kidney measures 11.6 cm. Again seen is a 4.3 cm cyst in the
upper pole of the left kidney. There are no stones or
hydronephrosis bilaterally. There is a trace amount of ascites.
IMPRESSION:
1. Left renal cyst.
2. No stones or hydronephrosis.
CHEST (PORTABLE AP) [**2190-12-2**] 11:23 AM
CHEST (PORTABLE AP)
Reason: ? pulm edema
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with ascites.
REASON FOR THIS EXAMINATION:
? pulm edema
HISTORY: Ascites with possible pulmonary edema.
FINDINGS: In comparison with the study of [**11-30**], there is little
change. Again there is some enlargement of the cardiac
silhouette with indistinct pulmonary vessels consistent with
elevated pulmonary venous pressure. Left pleural effusion
persists. The possibility of pneumonia at the left base can
certainly not be excluded in the absence of a lateral view.
CHEST (PORTABLE AP)
Reason: evaluate for interval change
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with L pleural effusion, ? PNA
REASON FOR THIS EXAMINATION:
evaluate for interval change
HISTORY: Left pleural effusion and possible pneumonia, to assess
for change.
FINDINGS: In comparison with the study of [**11-29**], there is again
increased opacification at the left base consistent with some
combination of effusion, atelectasis, and pneumonia.
Little overall change.
ABDOMEN U.S. (COMPLETE STUDY) [**2190-11-30**] 2:36 PM
ABDOMEN U.S. (COMPLETE STUDY)
Reason: Evaluate for ascites, other intraabdominal pathology.
Pleas
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with FTT, ascites, history of cirrhosis ? [**2-26**]
NASH.
REASON FOR THIS EXAMINATION:
Evaluate for ascites, other intraabdominal pathology. Please
mark a spot for tapping (paracentesis).
INDICATION: 81-year-old female with history of cirrhosis and
ascites. Evaluate for intraabdominal pathology and mark a spot
for tap.
COMPARISON: None.
ABDOMINAL ULTRASOUND: The liver is nodular and coarsened in
echotexture consistent with underlying cirrhosis. Within the
right hepatic lobe, there is a 2.4 x 1.3 cm hypoechoic lesion
with second questionable lobulated 4.2-cm lesion seen
posteriorly. The gallbladder wall is thickened with a single
mobile gallstone seen. A [**Doctor Last Name 515**] sign was not elicited. There
is no intra- or extra-hepatic biliary dilatation.
The right kidney measures 10.2 cm. The left kidney measures 11.5
cm. There is a 5.6-cm cyst in the lower pole of the left kidney.
There are no stones or hydronephrosis. The spleen is enlarged
measuring 16 cm. The visualized portions of the pancreas are
unremarkable.
There is a moderate amount of ascites within the right lower and
left lower quadrants. A spot was marked for tap in the left
lower quadrant.
IMPRESSION:
1. Nodular and coarsened echotexture of the liver consistent
with cirrhosis.
2. Two hypoechoic lesions within the right hepatic lobe
concerning for hepatocellular carcinoma for which further
evaluation with MRI is recommended.
3. Cholelithiasis.
4. Moderate amount of ascites. A spot was marked for tap in the
left lower quadrant to be performed by the clinical team.
These findings were discussed with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 1833**] on
[**2190-11-30**] at 5 p.m.
CHEST (PORTABLE AP) [**2190-11-29**] 9:33 PM
CHEST (PORTABLE AP)
Reason: please r/o acute process
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with HTN, DM2, with fatigue, nausea
REASON FOR THIS EXAMINATION:
please r/o acute process
INDICATION: Fatigue and nausea.
UPRIGHT AP CHEST: Patient is status post median sternotomy and
aortic valve repair. Cardiomediastinal silhouette is unchanged.
Pulmonary vascularity is normal. Patchy parenchymal opacity is
present at the left base with a left- sided pleural effusion
again noted. No pneumothorax, though evaluation of the left apex
is limited by patient head positioning. Degenerative changes of
the left shoulder are partially imaged.
IMPRESSION: Persistant left pleural effusion and associated
consolidation, likely representing atelectasis though pneumonic
consolidation cannot be completely excluded.
Brief Hospital Course:
A/P: 81yo with ? NASH cirrhosis, DM, HTN, AS s/p AVR here w/
Klebsiella bacteremia, CNNA and ARF, initially admitted to the
ICU and subsequently transferred to the floor.
.
# UTI: Patient initially found to have a positive UA with many
bacteria, positive leukocuyte esterase and nitrite. She was
initially started on Levo which was subsequently changed to
Cipro and then to Ceftriaxone to cover both the UTI and
Peritonitis. Urine cultures grew pansensitive E. coli and
Klebsiella sensitive to all but nitrofurantoin. Patient will
complete a course of Ceftriaxone until [**12-15**].
.
#Klebsiella Bacteremia- Patients blood culture grew out
Klebsiella. She was intially started on Zosyn but after
paracentesis done and she was found to have peritonitis, this
was changed to Ceftriaxone. Patient had an episode fo
hypotension thought to be secondary to sepsis. She was intially
started on pressors in the ICU which were quickly weaned.
Patients subsequent blood cultures had no growth and her blood
pressure remained stable.
.
# Spontaneous Bacterial Peritonitis: Patient intially presentd
with abdominal pain. Patient had an abdominal ultrasound which
showed nodular and coarsened echotexture of the liver consistent
with cirrhosis and had a moderate amount of ascites. A
paracentesis was done which showed 767 polys and the culture was
negative. She was initially started on Vancomycin and
Levofloxacin which was then changed to Cipro and Zosyn. She was
then placed on Ceftriaxone 1gm IV q24 hours. She was given
oxycodone for pain control. She will complete a 2 week course of
Ceftriaxone for the peritonitis which will be done [**12-15**].
.
# Pulmonary Effusion: Pt was initially tachynpnic likely [**2-26**]
attempt to compensate for metabolic acidosis. Pulmonary
effusion chronic after sternotomy. Pt was intially started on
vancomycin and flagyl but discontinued as there was no evidence
of pneumonia. Patients respiratory status improved and did not
require further intervention.
.
# ARF: Patient intially had a creatinine of 2.1 on admission.
She was becoming oliguric, initially thought to be hepatorenal.
She was started on albumin, octreotide and midodrine for concern
of hepatorenal syndrome. Patients candesartan and Lasix were
held. Renal was consulted and felt the acute renal failure was
secondary to renal hypoperfusion in the setting of her
bacteremia, not hepatorenal. A renal ultrasound was
unremarkable. The midrodrine, octreotide and albumin were
discontinued. Patients creatinine slowly improved during her
stay as her bacteremia resolved. Her creatinine was 1.6 on
discharge. No further intervention was felt necessary, however
patient will need closer follow up of her creatinine before she
has an MRI.
.
# Hyperglycemia-Pts glyburide was intially held secondary to
acute renal failure as well as pt not having PO intake. When
she began her PO diet, her sugars were noted to be in the 400s.
She was started on Insulin (NPH and Regular). This was titrated
up for better glucose control. She was sent home on 11U NPH QAM
and 2Units QHS. She will continue wiht a sliding scale. She
will need outpatient follow up for her glucose control and
management of oral agents. She was not sent home on her oral
[**Doctor Last Name 360**] (glyburide)
.
# Liver Lesions: Abd U/S showed two hypoechoic lesions within
the right hepatic lobe concerning for hepatocellular carcinoma
for which further evaluation with MRI is recommended. Lesions
could be HCC vs. metastases. Pt also reports significant weight
loss. An AFP was 2.7. An MRI was not done because the patient
had acute renal failure and her creatinine had not come down
enough before discharge. She will need an MRI with contrast once
her creatinine improves.
.
# Diarrhea: Patient has history of diarrhea on Lomotil at home.
Patient recently started on cephalosporin prior to admission.
She did not have loose stool during her stay. C. diff cultures
were negative x3.
.
#HTN: The patients medications were changed from Toprol XL to
25mg Metoprolol [**Hospital1 **] given intial hypotensive episode in ICU.
.
# Anemia: Patient has a microcytic anemia felt to be [**2-26**] iron
deficiency. She was started on iron supplements.
.
# Nutrition-The patient was evaluted by speech adn swallow
because it appeared that she had difficulty tolerating a regular
diet without an aspiration risk. She was cleared for a soft
solid diet with nectar thickened liquids. She also needs to take
her pills with purees.
.
# Access: A Midline was placed on [**12-7**] to continue her
antibiotic course.
.
# CODE: DNR/DNI
Medications on Admission:
Glyburide5 B.I.D.,
Lasix 40mg three days a week,
Toprol XL 100mg,
Aspirin 81mg,
Lovenox subcutaneous,
Vytoren 10/40mg,
Atacand 8mg,
Senna
Percocet PRN
Dulcolax PRN
Discharge Medications:
1. CeftriaXONE 1 gm IV Q24H
Day 1 = [**2190-11-30**].
2. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) 11U
QAM, 2U QHS Injection once a day: Please get 11U insulin QAm and
2U QHS.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Insulin Lispro 100 unit/mL Cartridge Sig: 1-10 units
Subcutaneous QACHS as needed for Sliding scale.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. MRI
Pt needs to follow up with Dr [**Last Name (STitle) **] and have him order an MRI
with gadolinium to evaluate liver lesions
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Urosepsis
Peritonitis
Acute Renal Failure
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for a bacterial infection. You
were found to have bacteria in your urine and your blood. You
were also found to have an infection called peritonitis. You
were treated with antibiotics. You will continue to receive the
antibiotic Ceftriaxone to complete a 2 week course ([**12-15**])
.
You were also found to have some incidental lesions on your
liver found on an abdominal ultrasound. We were unable to get
an MRI of your liver because one of your labs called Creatinine
was elevated which measures your kidney function. You will need
to wait to get the MRI until this creatinine improved to
characterize these lesions.
We have stopped your Atacand and Lasix. You were started on
iron supplements.
Your Toprol XL was changed to Metoprolol 25mg twice daily.
Your Glyburide was stopped.
You were started on Insulin.
If you have any fever, chills, abdominal pain, nausea, vomiting,
chest pain, shortness of breath, diarrhea, or any other symptom
that concerns, please call your PCP or return to the ER>
Please follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] per your scheduled
appointment in [**Month (only) **].
Followup Instructions:
Please follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] per your scheduled
appointment on [**12-22**] at 3:30pm
Pt will need an MRI once creatinine improves to evaluate the
lesions found on her liver on ultrasound.
|
[
"599.0",
"401.9",
"041.3",
"511.9",
"041.4",
"789.59",
"787.91",
"790.7",
"567.23",
"571.5",
"250.00",
"276.2",
"584.9",
"276.7",
"280.9",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13423, 13488
|
7713, 12307
|
320, 326
|
13574, 13585
|
2419, 3230
|
14823, 15077
|
1791, 1859
|
12521, 13400
|
6957, 7011
|
13509, 13553
|
12333, 12498
|
13609, 14800
|
1874, 1874
|
277, 282
|
7040, 7690
|
354, 1335
|
1888, 2400
|
1357, 1550
|
1566, 1775
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,286
| 150,659
|
21658
|
Discharge summary
|
report
|
Admission Date: [**2179-11-8**] Discharge Date: [**2179-11-11**]
Date of Birth: [**2097-7-24**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
GI bleeding, pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 82 year old female with a history of
dementia, Ehlers-Danlos syndrome, htn, GERD who presents with
melena and coffee ground emesis beginning this am. Patient
cannot provide any history given baseline dementia. However, she
has 24 hr care at home and her home health aid notes that she
has been in her usual state of health until this am with the
exception of a cough which began recently. She has also had
weight loss which has been chronic. This am, HHA found her to
have a large, dark stool followed by coffee ground emesis x 1.
She may have been vomiting last night as well although it seems
coffee grounds did not begin until this am. Her mental status is
at her baseline by report.
.
In the ED, 98.6, 132/61, 102, 16, 95% 4LNC. Guiaic positive dark
stool in rectal vault. She had no further emesis or stools in
the ED. Labs significant for leukocytosis to 15,600 (last 4.4
3/[**2178**]). Hct 32.8 (BL low 30s). BUN/Cr 31/1.3 (BL 0.8-1.0). CEs
negative x 1. CXR showed a retrocardiac opacity. She received
750 mg of IV levofloxacin and 40 mg of IV protonix.
.
Upon arrival to the ICU, patient is without complaint except for
some pain in her back and L foot. She notes both are chronic.
She describes an accident where she injured her L foot but
cannot recall specifics. She denies all other ROS including
fevers, chills, cough, abdominal pain, nausea, vomiting,
diarrhea, constipation, chest pain, shortness of breath. She
cannot recall events which brought her to the ICU.
Past Medical History:
SDH s/p craniotiomy and evacuation
HTN
L Hip replacement
Polyneuropathy
Raynaud's
Scoliosis
Osteoporosois
Social History:
Lived at home prior to recent admit. Lives 2 houses from
brother. 24 h care.
Family History:
N/C
Physical Exam:
HEENT: non responsive to threatening stimuli
Pulm: no spontaneous breath sounds, no breath sounds on
auscultation
Cardiac: no heart sounds on auscultation
Neuro: Non responsive to sternal rub
Pertinent Results:
[**2179-11-8**] 11:40AM BLOOD WBC-15.6*# RBC-3.39* Hgb-10.9* Hct-32.8*
MCV-97 MCH-32.2* MCHC-33.2 RDW-14.9 Plt Ct-388
[**2179-11-8**] 11:40AM BLOOD Neuts-93.7* Lymphs-2.1* Monos-3.8 Eos-0.3
Baso-0.1
[**2179-11-10**] 04:40AM BLOOD WBC-8.2 RBC-3.12* Hgb-9.9* Hct-30.1*
MCV-97 MCH-31.8 MCHC-32.9 RDW-16.6* Plt Ct-286
[**2179-11-8**] 11:40AM BLOOD Glucose-113* UreaN-31* Creat-1.3* Na-138
K-4.0 Cl-101 HCO3-26 AnGap-15
[**2179-11-10**] 04:40AM BLOOD Glucose-85 UreaN-24* Creat-0.8 Na-142
K-3.4 Cl-108 HCO3-22 AnGap-15
[**2179-11-8**] 11:40AM BLOOD cTropnT-0.08*
[**2179-11-8**] 11:45PM BLOOD CK-MB-6 cTropnT-0.05*
[**2179-11-9**] 05:00AM BLOOD CK-MB-6 cTropnT-0.04*
[**2179-11-8**] 11:40AM BLOOD CK(CPK)-47
[**2179-11-8**] 05:30PM BLOOD CK(CPK)-66
[**2179-11-8**] 11:45PM BLOOD CK(CPK)-150*
[**2179-11-9**] 05:00AM BLOOD CK(CPK)-223*
[**2179-11-8**] 12:21PM BLOOD Hgb-11.0* calcHCT-33
Brief Hospital Course:
82 year old female with a history of dementia, Ehlers-Danlos
syndrome, HTN, and GERD who presents with GI bleeding,
pneumonia, and ARF. She died during this admission.
.
GI bleed: She was admitted to the ICU due to coffee ground
emesis and melena. This was most likely an upper GI bleed. Her
HCT dropped from 32.8 to 26.5 and she received one unit of pRBCs
to which she responded appropriately. She had no further
episodes of GI bleeding in the ICU and her HCT remained stable.
Her antihypertensives were held and she was on a PPI. The GI
team was consulted and felt that she did not require urgent
endoscopy. On discussions with the patient's brother and her
health care management the patient would not want any aggressive
interventions including an endoscopy. Her code status was
DNR/DNI.
.
CAP/Aspiration pneumonia: She had a pneumonia with leukocytosis
and a LLL opacity on CXR. She had a cough, hypoxia in the ED,
and significant secretions. She likely aspirated given her
dementia. She was being treated with levofloxacin which was
later changed to augmentin. After discussions with her health
care manager, her brother, and the patient the decision was made
to try to advance her diet despite her aspiration risk as this
was consistent with her goals of care. A speech and swallow
study was not done given that her goals of care included no
aggressive interventions. She was NPO on the last day prior to
her death because she was aspiration on everything she tried to
swallow.
.
# ARF: She had some ARF which was likely prerenal or due to her
UGIB. She was given gentle hydration with IVF. Her creatine
improved from 1.3 to her baseline of 1.8.
.
# Death: Her home caregiver had been talking to the patient and
then walked out of the room for a minute to change a pillow
case. When the care giver returned to the room Ms. [**Known lastname **] was
pale and barely breathing. Dr. [**Last Name (STitle) 174**] was the next person to see
the patient who continued to have copious secretions and was in
agonal breathing. The patient died soon afterwards likely due
to aspiration. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 483**] and I pronounced her dead. Dr.
[**Last Name (STitle) 174**] called her health care manager, [**Doctor First Name **] Hifrhom, to
report the death. She also informed the attending Dr. [**Last Name (STitle) **]
of the death. I spoke with the patient's brother [**Name (NI) **] [**Name (NI) 34547**] and
he declined an autopsy.
Medications on Admission:
Alendronate 35 mg once a week
Metoprolol Tartrate 25 mg daily
Olmesartan 20 mg once a day
Sulfasalazine 1000 mg TID
Aspirin 81 mg once a day
Calcium 600 with Vitamin D2 - 600-125 mg-unit twice a day
Ergocalciferol 400 unit once a day
Iron 134 mg twice a week
Multivitamins-Minerals-Lutein once a day
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
Completed by:[**2179-11-16**]
|
[
"733.00",
"783.21",
"443.0",
"578.0",
"530.81",
"756.83",
"V66.7",
"V43.64",
"790.01",
"558.9",
"507.0",
"401.9",
"438.9",
"578.1",
"331.0",
"584.9",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
6104, 6113
|
3219, 5720
|
292, 299
|
6165, 6175
|
2314, 3196
|
6232, 6272
|
2082, 2087
|
6071, 6081
|
6134, 6144
|
5746, 6048
|
6199, 6209
|
2102, 2295
|
230, 254
|
327, 1840
|
1862, 1969
|
1985, 2066
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,729
| 158,153
|
28181+28182+28183+57580
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2178-12-4**] Discharge Date: [**2178-12-25**]
Date of Birth: [**2100-7-9**] Sex: M
Service: VSU
CHIEF COMPLAINT: Ischemic bilateral lower extremities.
Patient is a new patient to us. He is transferred from [**Hospital6 40383**] with ischemic lower extremities bilateral.
HISTORY OF PRESENT ILLNESS: This is an 87-year-old male who
has a history of a right axillary-bifemoral in [**Month (only) 116**] of this
year who developed difficulties with ambulation 3 weeks prior
to admission progressing to sensation of ambulation 2 days
prior to admission with issues of fatigue and cool feet.
Patient was admitted to [**Hospital6 5016**], where he was
treated for dehydration and electrolyte imbalances, and then
transferred to our institution for further management and
care of his peripheral vascular disease.
REVIEW OF SYSTEMS: Daughter says patient experiences
fatigue, and is not ambulating, and has cold feet x3 days
with diminished activity over the last 3 weeks. He denies any
constitutional symptoms or foot ulcerations. Patient denies
chest pain, shortness of breath, dizziness, lightheadedness,
nausea, vomiting; although, patient is not eating well over
the last several days.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER: Plavix 75 mg daily, Lipitor 10 mg
daily, Inderal long acting 80 mg b.i.d., allopurinol 300 mg
daily, lisinopril 10 mg daily.
ILLNESSES: Peripheral vascular disease. He is status post a
right axillary-bifemoral bypass in [**Month (only) 116**] of this year with a
right 4th toe amputation. He has known renal artery stenosis,
and he is status post bilateral renal artery stenting in [**Month (only) 116**]
of this year. He has chronic renal insufficiency. He has a
history of Alzheimer's. He has known carotid disease with a
right internal carotid artery of 70% and the left internal
carotid artery totally occluded. Patient has known atrial
fibrillation with a paroxysmal episode since [**Month (only) 116**] of this
year.
SOCIAL HISTORY: He is a former tobacco user. He has not
smoked for 30 years. He has active alcohol intake, a case per
week. Last drink was 2 days prior to admission. Patient lives
with son.
FAMILY HISTORY: Positive for coronary artery, stroke,
peripheral vascular disease. Daughter's name is [**Name (NI) **] and is
his healthcare proxy. [**Name (NI) **] is a full code.
PHYSICAL EXAM: Vital signs: Temperature 98.8, heart rate 76,
respiratory rate 18, O2 saturation 100% on room air, blood
pressure 130/80, fingerstick 217. General appearance: Alert
and oriented x3 in no acute distress. Lungs were clear to
auscultation bilaterally. Heart was irregularly, irregular
rhythm without murmur, gallop, or rub. The carotids are
without bruits. The abdomen was soft, nontender,
nondistended. The bilateral femoral scars were well-healed.
On the extremities, there was no open wounds or ulcers. The
left foot was cool pale from distal shin to midfoot. There
was no sensory beyond the mid shin.
HOSPITAL COURSE: Patient was admitted to the ICU. EKG was
obtained which showed atrial fibrillation with a V. rate of
77 without any acute ST changes. The white count was 15.3.
PMNs were 84. Hematocrit was 42.5, platelets 333 K. BUN 81,
creatinine 4.1. CK was 7,170, MB was 150, and the troponin
was 2.1. Patient was...
INCOMPLETE REPORT. DICTATOR WAS CUT OFF.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2178-12-24**] 12:40:49
T: [**2178-12-24**] 13:13:18
Job#: [**Job Number 68482**]
Admission Date: [**2178-12-4**] Discharge Date: [**2178-12-26**]
Date of Birth: [**2100-7-9**] Sex: M
Service: VSU
CHIEF COMPLAINT: Bilateral lower extremity ischemia.
HISTORY OF PRESENT ILLNESS: This is an 81-year-old male who
was transferred from [**Hospital6 5016**], with a history of
right axillobifemoral bypass with a right fourth toe
amputation in [**Month (only) 116**] of this year, who developed difficulty with
ambulation over the last 3 weeks with progressing to
cessation of his ambulation 2 days ago which is associated
with leg fatigue and cool feet. Daughter brought the patient
to [**Hospital6 5016**] where he was treated for dehydration
and electrolyte imbalance. He was transferred to our
institution for further vascular care. Patient has
experienced fatigue, is not ambulating and has noted the cold
feet over the last 3 days, with diminished activity over the
last 3 weeks. He denies fevers, chills, sweats, or foot
ulcers. Patient also denies chest pain, shortness of breath,
dizziness, lightheadedness, nausea, vomiting, loss of
consciousness. Patient's appetite is diminished.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER: Include Plavix 75 mg daily, Lipitor
10 mg daily, Inderal LA 80 mg b.i.d., allopurinol 300 mg
daily, lisinopril 10 mg daily.
PAST MEDICAL HISTORY: Peripheral vascular disease, bilateral
renal artery stenosis status post renal artery stenting
bilaterally in [**2177-6-8**], chronic renal insufficiency with
baseline creatinine at 2.0-4.0, Alzheimer's disease, carotid
stenosis with a totally occluded left internal carotid
artery, and the right carotid is 70%, atrial fibrillation
with paroxysmal episodes since [**2177-6-8**].
SOCIAL HISTORY: The patient denies tobacco use current and
has not smoked for 30 years. He does admit to active alcohol
use, a case per week, last drink was 2 days prior to
admission. Patient lives with son, daughter and has
healthcare proxy. [**Name (NI) **] is a full code.
PHYSICAL EXAM: Vital signs: 99.8, 76, 130/80, 18, O2 sat
100% on room air, fasting glucose 217. General appearance:
Alert, oriented x3 in no acute distress. Lungs are clear to
auscultation bilaterally. Heart has a regular rate and rhythm
without murmur, gallop or rub. Carotids are without bruits.
Abdominal exam is benign. Patient has bilateral inguinal
scars which are well-healed. Extremities show no open wounds
or ulcers. The left foot is cool, pale from distal shin
beyond with mottling of the skin. There is absent sensation.
The right foot is hyperemic from midfoot with diminished
sensory.
HOSPITAL COURSE: The patient was admitted to the vascular
service. Serial CKs were drawn. He was placed on a CIWA
scale. IV heparin was begun. The patient underwent an urgent
bilateral fem patch angioplasty with bilateral kissing common
iliac angioplasty and stenting with ligation of the
axillobifemoral graft at the common femoral arteries,
bilateral profunda femoris and left superficial femoral
artery and graft thrombectomy with bilateral 4-compartment
fasciotomy. At the end of the procedure, the patient had no
pulses in the feet, and the patient was transferred to the
SICU for continued care.
The patient required vasopressor support for low urinary
output. IV heparinization was begun. He was begun on vanco,
levo and Flagyl for perioperative antibiotic coverage. He was
transfused 2 units of packed red blood cells. Postoperative
day 1, the patient was continued on vasopressor support for
his oliguria, and he had a T-max of 101. The blood and urine
was cultured which were no growth. The white count max at
17.6 with hematocrit of 28.8. His creatinine was 3.1. Patient
required 2 more units of packed red blood cells. Tube feeds
were begun. Serial CKs were obtained, and he was begun on a
bicarbonate drip for his rhabdomyosis. His creatinine
continued to climb.
A renal consult was placed. His FENA was 2.2. They felt that
his acute renal failure was secondary to contrast-induced
nephropathy and rhabdomyosis. Patient was IV hydrated. A HIT
was sent which was negative. His creatinine continued to
climb from 3.7 to 3.9. His antibiotics were renally dosed.
TPN was begun.
On postoperative day 5, the patient returned to surgery and
underwent bilateral below-knee amputations, guillotine. He
returned to the ICU for continued care. By postoperative day
1, the white count improved. It went from 14.9 to 13.1. His
hematocrit remained stable at 29. His creatinine remained
stable at 3.9. His CKs which peaked at 7161 began to show a
downward trend to 4107. His MBs were 45, and his troponin
went from 0.30 to 0.28. Because of the temperature, he had a
sputum culture sent which were gram-negative rods. He was
continued on his triple antibiotics. His blood and urine
cultures were no growth. His urinary output improved. His
hyponatremia was treated with IV fluid, and he was placed on
CPAP. Postoperative 7 and 2, the white count jumped from 12.2
to 16.0, and his hematocrit remained stable at 29.7. His CKs
continued to show a downward trend of 1180. His IV heparin
was discontinued, and subcu heparin was begun for DVT
prophylaxis. Postoperative day 8 and 3, his tube feeds were
at goal at 60 cc/h. He was autodiuresing. His chest x-ray
noted increase in the left lower lobe consolidation, and he
was continued on his current antibiotics. He was weaned off
his Levophed.
On postoperative day 9 and 4, he had an episode of
hyperkalemia of 6.6 which was treated with Kayexalate.
Hemodialysis catheter was placed. On postoperative day 10 and
5, his white count remained stable. His central line was
converted to a dialysis line. His endotracheal tube was
reintubated secondary to position of ET tube. Patient
continued to remain in the SICU on postoperative day 15, 10
and 5. The patient was begun on Epogen for his chronic anemia
of chronic disease. His iron was 13. His TIBC was 74. His
ferritin was greater than [**2172**]. His TRF was 57. Epogen 4000
units 3 times a week was instituted, and he also required
free water to be added to his tube feedings of 250 cc q.i.d.
A family meeting was held on [**2178-12-20**], postop day
15, 10 and 5, and was made DNR/DNI. His white count
stabilized at 12.1, and creatinine stabilized at 2.4. He was
transferred to the VICU for continued monitoring and care
since he had been extubated. On [**12-21**], postoperative
day 16, 11 and 6, he had increased mental status changes.
Geriatrics did not feel that the patient required a head CT.
They felt that the changes were secondary to his metabolic
state and history of alcoholism and would just monitor him
closely.
Speech and swallow was consulted. They did a beside swallow
which the patient failed. He continued on his tube feeds and
remained n.p.o. The wound care service saw the patient for
his gluteal decubitus on the left, and specific
recommendations were made which were instituted. On [**12-22**], postoperative day 17, 12 and 7, PT and OT evaluated the
patient and felt that he would require rehab, and at this
time it was determined we might need to consider placing a
PEG since we had replaced the nasogastric feed tube multiple
times and was difficult to place. His white count was 9.7,
creatinine was 2.0. A rectal tube which had been placed on
[**12-9**] for multiple loose stools was discontinued. Stools
for C. diff were sent x3, and this was negative. He had VRE
and MRSA surveillance cultures done which were negative. On
[**12-23**], postoperative 18, 13 and 8, the patient had a
repeat assessment by the speech and swallow service at the
bedside. He then underwent on [**12-24**], postoperative day
19, 14 and 9, a video swallow. The patient did not
demonstrate any signs of aspiration. He was begun on oral
feeds of ground pureed food with nectar-thickened liquids and
pills to be crushed and pureed, aspiration precautions and
food assistance. Case management was requested to
aggressively begin screening for rehab. Patient will be
discharged to rehab when a bed is available. Patient's PEG
was not placed. It was determined to monitor his oral intake
and to see how he does and then reconsider a PEG if
necessary. Patient should have a swallow study repeated at
rehab in a week or so to see if he can progress his diet. At
time of dictation, patient was stable. His medications were
converted to oral route.
DISCHARGE MEDICATIONS: Include albuterol aerosol puffs 4
q.4h. as needed for wheezing, Epogen 4000 units subcu Monday,
Wednesday and Friday, papaverine urea ointment to affected
area daily, ipratropium bromide aerosol puffs 2 q.4-6h. as
needed, famotidine 20 mg IV q.24h--this will be converted to
Zegerid 20 mg capsules b.i.d. which can be placed in water or
pureed food, acetaminophen 325-650 mg q.8h. p.r.n.,
metoprolol 75 mg t.i.d.
DISCHARGE INSTRUCTIONS: Wounds should be dressed with dry
sterile dressings daily, the sacral site papaverine dressings
daily, no stump shrinkers to the amputation site. Skin clips
remain in place until seen in follow-up. The patient should
follow-up with Dr. [**Last Name (STitle) 1391**] in [**4-11**] weeks. He should call for
an appointment at ([**Telephone/Fax (1) 4852**].
DISCHARGE DIAGNOSES: Lower extremity postoperative extremity
ischemia, postoperative pneumonia secondary to aspiration,
postoperative blood loss anemia--transfused, postoperative
acute tubular necrosis secondary to rhabdomyosis with
contrast-induced acute tubular necrosis, postoperative acute
renal failure status post continuous [**Last Name (un) **]-venous
hemodialysis, postoperative hypertension secondary to
hypovolemia--corrected, postoperative failure to thrive
status post tube feed total parenteral nutrition.
MAJOR SURGICAL PROCEDURES: Bilateral femoral patch
angioplasty, bilateral "kissing" angioplasty of the common
iliac artery with stenting, ligation of the axillobifemoral
graft at the common femoral arteries with thrombectomies of
the profunda femoris artery, the left superficial femoral
artery and the graft on [**2178-12-4**], bilateral below-
knee guillotine amputations on [**2178-12-9**], bilateral
amputation revisions from BKA to AKA on [**2178-12-15**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2178-12-24**] 13:27:11
T: [**2178-12-24**] 14:46:07
Job#: [**Job Number **]
Admission Date: [**2178-12-4**] Discharge Date: [**2178-12-29**]
Date of Birth: [**2100-7-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Please see prior d/c summary for full details.
Major Surgical or Invasive Procedure:
Bilateral femoral patch angioplasty,bilateral "kissing" PTA of
CIAw stenting, ligation of Ax [**Hospital1 **] fem graft,thrombectomies of
bilateral PFA,left SFA and graft10/27/06
Bilateral below knee guillotine amputations [**2178-12-9**]
Bilateral amputation revisions from bka to aka [**2178-12-15**]
History of Present Illness:
Please see prior d/c summary for full details.
Past Medical History:
Please see prior d/c summary for full details.
Social History:
Please see prior d/c summary for full details.
Family History:
Please see prior d/c summary for full details.
Brief Hospital Course:
Please see prior d/c summary for full details.
Medications on Admission:
Please see prior d/c summary for full details.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Month/Day/Year **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for Wheeze.
2. Epoetin Alfa 4,000 unit/mL Solution [**Month/Day/Year **]: 4000 (4000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
3. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment [**Telephone/Fax (3) **]: One (1) Appl
Topical DAILY (Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (3) **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Famotidine in Normal Saline 20 mg/50 mL Piggyback [**Telephone/Fax (3) **]: 20 mgm
Intravenous Q24H (every 24 hours).
6. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO TID
(3 times a day).
7. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO three
times a day.
8. Acetaminophen 160 mg/5 mL Solution [**Telephone/Fax (3) **]: 325-360 mgm PO every
eight (8) hours as needed for pain.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Lipitor 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
11. Plavix 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
bilateral ischemic lower extremities
postoperative pneumonia secondary to aspiration
postoperative blood loss anemia, transfused
postoperative ATN secondary to rhabdomyolysis,contrast induced
ATN
postoperative ARF,s/p CVVHD
postoperative hypotension secondary to hypovolemia,corrected
Alzheimers
Discharge Condition:
Stable
Discharge Instructions:
Call doctor for any redness, discharge, or pus from incisions.
Call doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**] >101.4F,
Continue with nectar thickened liquids and pureed solids, with
crushed pills. Continue aspiration precautions and eating with
assistance. Please do calorie counts and speech/swallow therapy
at rehab facility.
Continue physical/occupation therapy at rehab. His lisinopril
(10mg daily) should be restarted at rehab and his metoprolol
dose titrated as appropriate.
Followup Instructions:
3-4 weeks Dr. [**Last Name (STitle) **]. call for appointment [**Telephone/Fax (1) 1393**]
Completed by:[**2179-6-11**] Name: [**Known lastname 11750**],[**Known firstname **] R Unit No: [**Numeric Identifier 11751**]
Admission Date: [**2178-12-4**] Discharge Date: [**2178-12-29**]
Date of Birth: [**2100-7-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 726**]
Addendum:
Patient did well over the weekend. He tolerated his diet of
nectar thickened liquids and pureed solids. However, he
continued to complain of a poor appetite and did not take much
PO. PO intake will continue to be encouraged at the rehab
facility, calorie counts may be required. His diet should be
supplemented with ensure pudding.
While in the hospital his blood pressure has been stable on
lopressor. However, he took lisinopril 40mg daily at home.
This should be restarted at rehab, with his lopressor titrated
to an appropriate dose.
Prior to discharge, his staples were removed from his incision
on POD 14, and steristrips were applied.
Discharge Medications:
**Updated**
1. Albuterol 90 mcg/Actuation Aerosol [**First Name3 (LF) 1649**]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for Wheeze.
2. Epoetin Alfa 4,000 unit/mL Solution [**First Name3 (LF) 1649**]: 4000 (4000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
3. Papain-Urea [**Telephone/Fax (3) 11752**] unit-mg/g Ointment [**Telephone/Fax (3) 1649**]: One (1) Appl
Topical DAILY (Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (3) 1649**]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Famotidine in Normal Saline 20 mg/50 mL Piggyback [**Telephone/Fax (3) 1649**]: 20 mgm
Intravenous Q24H (every 24 hours).
6. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (3) 1649**]: One (1) Tablet PO TID
(3 times a day).
7. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (3) 1649**]: One (1) Tablet PO three
times a day.
8. Acetaminophen 160 mg/5 mL Solution [**Telephone/Fax (3) 1649**]: 325-360 mgm PO every
eight (8) hours as needed for pain.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Lipitor 10 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO once a day.
11. Plavix 75 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 4415**]
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]
Completed by:[**2178-12-29**]
|
[
"276.2",
"E878.8",
"458.29",
"276.52",
"707.05",
"403.90",
"997.3",
"285.29",
"995.91",
"285.1",
"331.0",
"585.9",
"038.9",
"997.5",
"728.88",
"294.10",
"427.31",
"998.11",
"440.30",
"783.7",
"507.0",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.14",
"96.6",
"84.15",
"39.50",
"96.71",
"96.04",
"39.90",
"00.43",
"39.95",
"00.17",
"99.15",
"84.3",
"38.95",
"38.93",
"38.18",
"99.04",
"00.48",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
19988, 20221
|
15036, 15084
|
14434, 14739
|
16885, 16894
|
17450, 18609
|
14965, 15013
|
12840, 14331
|
18632, 19965
|
16566, 16864
|
15110, 15158
|
6270, 11999
|
16918, 17427
|
5667, 6252
|
870, 1267
|
14348, 14396
|
14767, 14815
|
4844, 4969
|
14837, 14885
|
14901, 14949
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,028
| 190,525
|
3850
|
Discharge summary
|
report
|
Admission Date: [**2110-4-28**] [**Month/Day/Year **] Date: [**2110-5-19**]
Date of Birth: [**2040-4-7**] Sex: M
Service: MEDICINE
Allergies:
Augmentin / Heparin Agents / Azithromycin / Tape
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt. is a 70 y/o with striatonigral degeneration, J-tube, trach,
traceomalacia who initially p/w increased secretions, low-grade
temps and increased work of breathing x 10 days. Hx is per wife,
who is primary care taker.
.
Wife reports that sx started ~10 days pta with increased work of
breathing and increased secretions- having to suction more
frequently. She initially attributed this to allergies, but when
it did not improve she became concerned. She noticed that he was
requiring more O2 than normal to maintain O2 sats (generally on
2L O2 at night -> increased to 4L, occ requiring 6L at home) and
was requiring Nebs more frequently (Q6 -> Q4) Feels he has been
lethargic and less interactive than usual. Also reports low
grade fevers, Tm 100.3. Wife thinks swelling in legs has gotten
worse in past 10 days as well. Pt. started on Levaquin by PCP [**Last Name (NamePattern4) **]
[**4-25**], but did not improve with this therapy.
.
In ED received Vancomycin and Zosyn and A/A Nebs and was
admitted to the medicine floor. This AM, while the RN was
suctioning the patient, she noted thick, yellow secretions, and
then the patient stopped breathing and "turned blue" for a
period of several seconds - less than one minute. She called a
code, continued to suction, and the patient began to breath
again, with improvement in coloration. His O2 saturations
rapidly improved to 96%. He was transferred to the ICU for
further evaluation/management.
Past Medical History:
1. Striatonigral degeneration.
2. History of methicillin-resistant Staphylococcus aureus.
([**11-27**] stool)
3. History of vancomycin-resistant Enterococcus.
4. History of multiple aspiration pneumonias.
5. GERD.
6. Diverticulosis.
7. Prostate cancer status post prostatectomy.
8. Hypothyroidism.
9. Tracheostomy.
10. History of bullous pemphigus.
11. History of upper GI bleed.
12. Jejunostomy tube placement.
Hospitalizations:
[**2108-3-24**]: Pseudomas in sputum txt with zosyn then changed to
gent
[**2108-4-24**]: Bronch to adjust trach placement and sputum
[**2107-11-24**]: fever, hypoxia, inc. secretions txt with ceftaz
[**2108-9-24**]:pseudomonas pna, wound infection
[**2109-6-24**] fever, UTI, coag negative staph blood infection
Social History:
Lives with wife, bed bound; no etoh/drugs/smoking. Has personal
care attendent.
Family History:
NS
Physical Exam:
T 98.4 BP 130/52 HR 71 RR 20 O2sats 96% on 3L
Gen: chronically ill appearing
HEENT: PERRL, EOMI
Neck: supple
Lungs: coarse BS throughout, diffuse exp wheezes
Heart: RRR, 3/6 SEM
Abd: soft, NTND, +BS. Mild erythema around J-tube site with
scant yellow drainage. Not TTP.
Ext: arms flexed and contracted, 2+ pitting edema bilat LE
Neuro: regards, opens eyes to voice
Pertinent Results:
[**2110-4-28**] 03:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-TR
[**2110-4-28**] 03:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.025
[**2110-4-28**] 03:45PM PLT SMR-NORMAL PLT COUNT-193#
[**2110-4-28**] 03:45PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL
[**2110-4-28**] 03:45PM NEUTS-83.5* BANDS-0 LYMPHS-7.9* MONOS-5.5
EOS-3.0 BASOS-0.1
[**2110-4-28**] 03:45PM WBC-9.5# RBC-3.48* HGB-10.7* HCT-33.0* MCV-95
MCH-30.7 MCHC-32.4 RDW-14.4
[**2110-4-28**] 03:57PM LACTATE-1.1
.
[**4-28**] CXR - Extremely limited study due to positioning. Persistent
cardiomegaly and increased interstitial markings especially in
left lower lobe, which may represent cardiac failure; however,
early pneumonia cannot be totally excluded. The tip of
tracheostomy tube cannot be confidently identified due to
overlying chin. Please correlate clinically, and if necessary,
please repeat chest x-ray with better positioning.
.
[**2110-4-29**] Lower Extr. U/S - No evidence of DVT.
.
[**2110-5-14**]- CXR - Since the prior study the tracheostomy tube has
been changed. Tip is in adequate position. Lungs are grossly
clear. There has been improved aeration of the left lung base
since the prior study.
Brief Hospital Course:
A/P 70 yo male with striatonigral degeneration, bed bound, s/p
J-tube and trach presents with episodes of hypoxia. His hospital
course, by problem, is as follows.
.
# Resp failure/Hypoxia: The patient was found to have a
pseudomonal PNA, and his acute exacerbation was likely due to
plugging due to his thick secretions. He was treated with Zosyn
x 14 days, and Vancomycin x 10 days for his penumonia, with
substantial clinical improvement. He required ventilatory
support initially due to hypercarbia, however, he was able to be
weaned to trach mask by hospital day #13, and was stable on this
until [**Month/Day/Year **]. An important part of weaning the patient
involved Lasix (as he was significantly volume overloaded), he
required a range of 40 to 80 IV lasix daily until 3-4days prior
to [**Month/Day/Year **] where was transitioned to 20mg PO lasix daily.
Diamox was added(due to a significant metabolic alkalosis, with
serum HCO3 up to 49), and aggressive potassium chloride
repletion (to promote renal wasting of HCO3). By [**Month/Day/Year **], his
Venous blood gases were stable (Baseline pCO2 high 60s-low 70s),
and his secretions had improved. The diamox was discontinued
prior to [**Month/Day/Year **]. He was also maintained on frequent
suctioning/pulmonary toilet, nebulizers, pulmicort respules, and
glycopyrolate.
.
# Hypernatremia - In context of diuresis, the patient was
significantly hypernatremic (Na up to 150). This was treated
effectively with free water boluses on his tube feeds.
.
# Nigrostriatal Degeneration: stable, the patient was continued
on his outpatient regimen of Sinemet, Mirapex, Ritalin
.
Hypothyroidism: Continued on Synthroid
.
GERD: continued on PPI (on [**Hospital1 **] dosing at home)
.
FEN: the patient was maintained on tube feeds per his home
regimen (Comply at 60cc/hr), which he tolerated well.
.
Access: L PICC was placed by radiology. He has required several
flourocopic PICC lines placed, and these have been very
difficult. As such, interventional radiology is reccomending
placement of an indwelling port for future hospitalizations.
This should be evaluated as an outpatient, and placed electively
at a time when the patient is not infected. At time of
[**Hospital1 **], PICC line was non-functional and was pulled prior to
going home.
Medications on Admission:
Mirapex 1.5 mg QID
Sinemet 25/50 1 tab QAM, [**11-25**] tab at 1 P and 6P
Motilium 10 QID
Nexxium 40 [**Hospital1 **]
Robinul 0.5 mg [**Hospital1 **]
Ritalin 10 TID
Levoxyl 100
Unifiber 1T TID
Colace liquid 100 [**Hospital1 **]
Lactulose 30ml qhs
Dulcolax qAM
Albuterol Sulfate QID
Atrovent QID
Pulmicort Respules TID
Vitamin E
Comply Tube Feeds with Promod (1 scoop)
[**Hospital1 **] Medications:
(No Changes to medication regimen, with exception of lasix)
.
1. Pramipexole 0.25 mg Tablet Sig: Six (6) Tablet PO QID (4
times a day).
2. Methylphenidate 5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
QAM (once a day (in the morning)).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
8. Budesonide 0.5 mg/2 mL Solution for Nebulization Sig: One (1)
ML Inhalation [**Hospital1 **] ().
9. Unifiber 75 % Powder Sig: One (1) PO TID (3 times a day).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
11. Glycopyrrolate 1 mg Tablet Sig: [**11-25**] Tablet PO BID (2 times a
day).
12. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q2H (every 2 hours) as needed.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QHS PRN
().
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
17. Carbidopa-Levodopa 25-250 mg Tablet Sig: 0.5 Tablet PO BID
(2 times a day).
[**Month/Day (2) **] Disposition:
Home With Service
Facility:
CareGroup[
[**Month/Day (2) **] Diagnosis:
Primary : Pseudomonal pneumonia
Hypercarbic respiratory failure
.
Secondary:
1. Striatonigral degeneration.
2. History of methicillin-resistant Staphylococcus aureus.
([**11-27**] stool)
3. History of vancomycin-resistant Enterococcus.
4. History of multiple aspiration pneumonias.
5. GERD.
6. Diverticulosis.
7. Prostate cancer status post prostatectomy.
8. Hypothyroidism.
9. Tracheostomy.
10. History of bullous pemphigus.
11. History of upper GI bleed.
12. Jejunostomy tube placement.
13. Hypernatremia
14. Recurrent aspiration pneumonia
15. Congestive heart failure
16. Respiratory arrest
[**Month/Year (2) **] Condition:
Stable - no longer requiring ventilation
[**Month/Year (2) **] Instructions:
1) Continue to take your medications as you did before your
hospitalization.
2) We have added one new medication: Lasix 20mg once daily
3) Free water boluses as directed
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] in 1 week.
Completed by:[**2110-5-22**]
|
[
"518.84",
"564.00",
"V55.0",
"333.0",
"276.4",
"E912",
"244.9",
"276.0",
"933.1",
"707.8",
"428.0",
"482.1",
"V49.84",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"96.05",
"33.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4464, 6763
|
327, 333
|
3098, 4441
|
9743, 9831
|
2694, 2698
|
6789, 7158
|
2713, 3079
|
280, 289
|
7188, 9720
|
361, 1812
|
1834, 2580
|
2596, 2678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,126
| 141,349
|
43148
|
Discharge summary
|
report
|
Admission Date: [**2134-8-29**] Discharge Date: [**2134-9-7**]
Date of Birth: [**2063-8-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 71m who was found down at the bottom of six steps
and noted to be apneic. EMS was called and he was transfered to
[**Hospital1 18**] for further evaluation. Upon arrival pt O2 sats noted to
be
in the 80's and he was intubated. Trauma workup obtained in ER
and CT C spine showed a right c6 lamina fracture and small
associated posteral
epidural hematoma, and hyperextension injury. An MRI Cspine was
also done which showed further spinal cord injury. ETOH level
upon arrival was 238.
Past Medical History:
Unknown
Social History:
Lives alone, independent. Has a friend [**Name (NI) 2563**] and a [**Name (NI) **] that
are involved in his care.
Family History:
Unknown
Physical Exam:
On Admission:
PHYSICAL EXAM:
BP: 88/60 HR: 60 R 20 O2Sats 99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Pupils reactive
Neck: Supple.
Neuro:
Mental status: Intubated, awake with eyes open. Not following
commands.
Motor: No spontaneous movement in extremities, no movement to
noxious in extremities and does not appear to grimmace to pain.
Toes downgoing bilaterally
On Discharge:
xxxxxxxxxxxxxx
Pertinent Results:
Head CT [**2134-8-29**]:
No acute blood.
CT Torso [**2134-8-29**]:
IMPRESSION:
1. No traumatic sequelae in the torso.
2. A 14 mm left upper lobe pulmonary nodule. Given the
background of
emphysema, follow up with a dedicated CT of the chest is
recommended within three months.
3. Hepatic steatosis.
CT Cspine [**2134-8-29**]:
IMPRESSION:
1. Nondisplaced right C6 lamina fracture with small associated
posteral
epidural hematoma.
2. Fracture of the anterior inferior corner of C4 and possible
fracture of the anterior bridging osteophytes at C3-4, with
prevertebral edema, suggestive of hyperextension injury. Given
the presence of moderate spinal canal stenosis which deforms the
spinal cord at C3-4 and C4-5, as well as minimal retrolisthesis
at C3-4 of unknown chronicity, the spinal cord is at risk for
contusion with hyperextension injury. Further evaluation for
cord and ligamentous injury is suggested by MRI.
MRI Brain:
IMPRESSION: Acute infarction in the left occipital lobe.
MRI Cspine:
IMPRESSION:
1. Hyperextension injury in the setting of underlying spinal
canal stenosis results in hemorrhagic contusion of the spinal
cord at C3 and C4.
2. Fractures of the C4 anterior-inferior corner and of the C3-4
bridging
osteophytes, with associated focal disruption of the anterior
longitudinal
ligament. Grade 1 retrolisthesis of C3 on C4 of unknown
chronicity.
Interspinous ligament edema at C1-2 and from C3-4 through C5-6.
3. The nondisplaced fracture of the right C6 lamina is better
seen on the
preceding CT scan.
4. Severe bilateral neural foraminal narrowing at multiple
levels.
Brief Hospital Course:
71M admitted on [**2134-8-29**] after sustaining a unwitnessed fall.
Patient suffered a complete spinal cord injury and occipital
infarct. He was placed in a hard collar. He admitted to the
Acute Care Service and the Trauma ICU. He was intubated upon
arrival. On exam patient had no motor or sensory exam on BUE and
BLE. Triple flexion was noted to BLE. Imaging was reviewed which
showed a complete spinal cord injury at C3, Occipital brain
infarct, and vertebral artery dissection at C3-4. ASA was
started on [**9-1**]. He was transferred to the Neurosurgery service
on [**9-1**]. Patient was notified he would need a Trach and expressed
refusal. On [**9-2**] a family meeting with clinicians, Ethics,
patient, and family was held to determine capacity and clarify
patient's wishes. Patient expressed denial of diagnosis and
prognosis. He expressed desire to live but desire not to live
vent dependent. Health Care Proxy was determined with the
patient's input. More time was given to the family and patient
to discuss diagnosis and goals of care.
The developed copious respiratory secretions [**Date range (1) 29177**] was
bronched with Bal and found to be growing staph and hflu in
sputum was started on Cipro and Naficillin on [**9-6**] he was weaned
to CPAP. He had high residuals of his tube feeds during this
time and was found to have an ileus, he was given multiple
medications to stimulate a bowel movement. He required 2 days of
NG tube suction. In the evening of [**9-6**] he had began having
bowel movements. His neurological exam remained unchanged he
would open eyes to voice, mouth words and appeared to be
orientated to self. He had a complete spinal cord injury at the
C3 level.
On [**9-7**] the patients health care proxy, [**Name (NI) 2563**] [**Name (NI) 64151**], had a
lengthy discussion with Dr [**Last Name (STitle) **] between moving forward with
PEG and trach or withdrawing care. After considering past
conversations with Mr [**Known lastname 3517**] and ethics committee Ms [**Name13 (STitle) 64151**]
decided to withdraw care. He was given Versed and Morphine and
extubated. He died shortly after extubation.
Medications on Admission:
Unknown
Discharge Medications:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Spinal Cord Injury Right C6 non displaced lamina fracture
Acute Occipital Infarct
Vertebral artery occlusion
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
N/A
Completed by:[**2134-9-7**]
|
[
"518.5",
"E880.9",
"041.5",
"305.00",
"276.3",
"041.11",
"997.31",
"434.91",
"401.9",
"806.06",
"560.1",
"806.01",
"443.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"96.04",
"33.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5348, 5363
|
3118, 5261
|
335, 342
|
5516, 5526
|
1498, 3095
|
5582, 5616
|
1041, 1050
|
5319, 5325
|
5384, 5495
|
5287, 5296
|
5550, 5559
|
1094, 1220
|
1462, 1479
|
279, 297
|
370, 863
|
1079, 1079
|
1235, 1448
|
885, 894
|
910, 1025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,247
| 155,530
|
22390
|
Discharge summary
|
report
|
Admission Date: [**2152-2-1**] Discharge Date: [**2152-3-16**]
Date of Birth: [**2111-3-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
aortic disection
Major Surgical or Invasive Procedure:
1. Aortic root repair
2. Celiac artery/hepatic Artery/external and internal iliac
artery stent
3. Hepatobiliary tree stent
s/p tracheostomy
s/p PEG placement
History of Present Illness:
Mr. [**Known lastname 1683**] is a 40 y/o gentleman who woke [**1-31**] w/chest pain. He
presented to the emergency room and was found to have an aortic
disection
Past Medical History:
HTN
hypercholesterolemia
asthma
scarcoid
Social History:
lives with wife
Physical Exam:
VS:T 98.5 BP 148/54 HR 86 RR 18 100% O2 Sat on
35% Trach Mask
Gen: Arouses to voice, follows commands and tries to vocalize
words
HEENT: Disconjungate gaze, L extropia, trach site c/d/i, mmm
Chest: CTA b/l with occ. inspir rales
CV: RRR, nl S1/S2
Abd: obese, NT/ND + BS
Extr: diffuse anasarca, non-pitting edema
Neuro: awake, alert, responds to questions, follows axial and
midline commands, mouths answers, strength; distal > proximal,
wiggles toes, grip strength ([**5-9**] on L and [**4-8**] on R); moves all 4
extremities.
Pertinent Results:
[**2152-2-1**] 10:45PM TYPE-ART PO2-109* PCO2-32* PH-7.42 TOTAL
CO2-21 BASE XS--2
[**2152-2-1**] 08:10PM WBC-13.1* RBC-3.15* HGB-9.5* HCT-29.0* MCV-92
MCH-30.1 MCHC-32.8 RDW-17.2*
[**2152-2-1**] 08:10PM PLT COUNT-201
[**2152-2-1**] 06:10AM GLUCOSE-114* UREA N-24* CREAT-2.2* SODIUM-140
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2152-2-1**] 10:20AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-<1 RENAL EPI-0-2
[**2152-2-1**] 10:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2152-2-1**] 10:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2152-2-1**] 06:10AM D-DIMER-3007*
[**2152-2-1**] 06:10AM PT-12.7 PTT-23.3 INR(PT)-1.0
CTA chest/abd:
IMPRESSION:
1. Extensive Type-A dissection beginning approximately 5 mm
above the coronary arteries with extension into the left common
carotid and innominate arteries superiorly, with inferior
extension to the left common femoral artery. The left renal
artery is supplied by the false lumen.
Brief Hospital Course:
Mr. [**Known lastname 1683**] presented [**1-31**] w/acute Type A aortic dissection which
extending to L common femoral artery and involving the L renal
artery. He was taken emergently to the operating room with Dr.
[**Last Name (STitle) 70**] for replacement of his ascending aorta and his
hemiarch. In the operating room he was started on amiodarone
due to dysrhythmia. Immediately postoperatively the patient was
woken and found to move all extremities but was re sedated due
to hypoxia, which resolved with significant increased PEEP. A
renal consult was obtained due to an elevated creatine and the
patient was started on dialysis POD#3. Also on POD#3, it was
noted that the patient had EKG changes. A cardiology consult
was obtained and the patient underwent cardiac catheterization
which did not reveal any CAD. It also showed that his renal
arteries were perfused. His PEEP was slowly weaned and as his
hemodynamics stabilized his PEEP was weaned and he was
transitioned to hemodialysis. His sedation was attempted to be
weaned on a regular basis with multiple episodes of agitation.
On POD#11 it was noted that he was not moving his left side as
well as his right. A neurology consult was obtained and an MRI
was performed which showed multiple small, bilateral subcortical
strokes. It was recommended that he be started on
anticoagulation, but there was concern for blood in the sinus
and an ENT consult was obtained and it was determined that there
was no active bleeding and it was determined that he would be
safe for anticoagulation. An echocardiogram was obtained which
did not show any intracardiac source of emboli. On POD#13 he was
taken to the operating room for a tunneled dialysis catheter and
on POE#16 he underwent a tracheostomy and PEG, and on POD#17 it
was noted that his dialysis catheter was not functioning
properly and he was taken to the operating room for replacement
of the catheter. He continued to have waxing and [**Doctor Last Name 688**] mental
status and was unable to be weaned from the ventilator. On POD#
21 he was noted to have a rising WBC and fever. He was found to
have Serratia in his sputum and klebsiella in his urine. He was
started on meropenem. His WBC continued to rise and on POD#25
his tunneled dialysis catheter was removed to rule out as source
of infection. On POD#27 a Foley catheter was attempted to be
placed and had large amounts of bloody drainage. A urology
consult was obtained and it was determined that the catheter had
created a false tract. He was taken to the operating room and
underwent cystoscopy and placement of catheter. He continued to
have fevers and underwent a TEE to r/o endocarditis, which was
negative. On POD#28 his WBC continued to rise and he had high
fevers. There was a concern for an intraabdominal source of
infection and a general surgery consult was obtained. His LFTs
were elevated and an ultrasound of his gallbladder was obtained
which showed sludge and a dilated common bile duct. He
underwent ERCP and biliary stent placement, and the procedure
revealed no stones or evidence of cholangitis. His transaminase
continued to rise after the procedure. He underwent a CT scan
of his abdomen which showed a perfusion defect in his liver and
there was concern for impingement of the celiac axis by the
false lumen of the aortic dissection. A vascular surgery
consult was obtained and he was taken to the angiography suite
and he underwent stent to his celiac with fenestration and
subsequently required stents to his L iliac artery. He had been
started on broad spectrum antibiotics and over the next several
days he remained tenuous, however his transaminase, WBC and
fever curve gradually decreased. He was transiently started on
CVVH due to the concern for intra-abdominal ischemia, but as his
hemodynamics improved, he was transition ed to hemodialysis. As
he continued to improve, but was still unable to be weaned from
the ventilator, the decision was made to transition his care to
the medical ICU team and the pulmonary service.
MICU Addendum:
In MICU, after sedation was weaned for 2 days, a trial of
pressure support was attempted which patient tolerated well for
2 days. He was then switched to trach collar which he also
tolerated. He was seen again by stroke service to re-evaluate
his prognosis and neuro status s/p his multiple embolic CVAs.
From Neurology perspective, he was felt to have good
rehabilitation potential and needed only aspirin as an
antiplatelet [**Doctor Last Name 360**] for his recurrent CVA risk. However, full
dose (325mg) ASA will start after 1 month of full
anti-coagulation on coumadin for goal INR [**3-9**] for his arterial
stents placed by vascular surgery. He remains on Heparin gtt as
his INR was yet to be therapeutic. He remained afebrile with
thin, watery secretions in the MICU. He was continued on every
other day hemodialysis without incident. He was noted to have
component of iron-deficiency in addition to his epo-deficient,
chronic disease anemia and therefore was started on ferrous
sulfate. We also titrated up his beta-blocker for improved
BP/HR control.
Medications on Admission:
none
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): hold for SBP < 110, HR < 60.
Disp:*120 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs inhaler* Refills:*0*
3. Metoclopramide HCl 10 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: Insulin
Sliding Scale regular Injection ASDIR (AS DIRECTED).
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Ascorbic Acid 100 mg/mL Drops Sig: Five Hundred (500) mg PO
DAILY (Daily).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed.
12. Warfarin Sodium 5 mg Tablet Sig: 2.5 Tablets PO HS (at
bedtime).
13. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1800 (1800) units/hr Intravenous continuous: until INR
therapeutic.
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: to
be increased to 325mg after 1 month of coumadin.
15. Ferrlecit 12.5 mg/mL Solution Sig: One [**Age over 90 **]y Five
(125) mg Intravenous every other day: to be given with
Hemodialysis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
1. Aortic Dissection from ascending aorta to left femoral artery
s/p repair
2. Embolic Strokes
3. Shock Liver s/p hepatic artery stent
4. Acute Renal Failure leading to End Stage Renal Disease
requiring chronic hemodialysis
5. Serratia and Klebsiella ventilator acquired Pneumonia
6. Respiratory Failure s/p tracheostomy and gastrostomy
7. Enterobacter UTI
Discharge Condition:
Stable
Discharge Instructions:
1. D/C to [**Hospital3 672**] for Chronic Ventilator Management
2. Wean Ventilator as appropriate
3. Physical Therapy/Occupational Therapy
4. Continue Heparin gtt until coumadin therapeutic. Should
Continue coumadin for 1 month and then continue on aspirin for
embolic CVAs and peripheral vascular stents.
Followup Instructions:
-- Please follow up with Dr. [**Last Name (STitle) 70**] upon discharge from rehab
-- Please follow-up in stroke clinic with Dr. [**First Name (STitle) **] in 1 month.
Call [**Telephone/Fax (1) 657**].
-- Patient should take coumadin for 1 month for goal INR [**3-9**].
After that 1 month, patient should start on 325mg ASA daily.
Completed by:[**2152-3-16**]
|
[
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"518.5",
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"997.02",
"593.81",
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"599.0",
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"576.2",
"403.91",
"596.8",
"482.83",
"135",
"482.0",
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icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.72",
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icd9pcs
|
[
[
[]
]
] |
9277, 9332
|
2440, 7584
|
330, 489
|
9733, 9741
|
1357, 2417
|
10096, 10460
|
7639, 9254
|
9353, 9712
|
7610, 7616
|
9765, 10073
|
794, 1338
|
274, 292
|
517, 682
|
704, 746
|
762, 779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,270
| 114,104
|
35862
|
Discharge summary
|
report
|
Admission Date: [**2140-5-24**] Discharge Date: [**2140-5-29**]
Date of Birth: [**2074-8-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lotrel / Adhesive Tape
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2140-5-24**] Coronary Artery Bypass Graft x 3 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
obtuse marginal, Saphenous vein graft to posterior descending
artery)
History of Present Illness:
This female patient has a past medical history significant for
coronary artery disease s/p myocardial infarction in [**Month (only) **] of
[**2139**] with cardiac catheterization at [**Hospital6 22197**] Center in
[**Location (un) 5583**], MA. She presented with shortness of breath and
found to be in congestive heart failure. Cardiac catheterization
revealed a 60% LAD lesion just after the first diagonal branch,
a 100% stenosis of the RCA with faint bridging collaterals,
severely elevated LVEDP of 35 mmHg, severe anterolateral
hypokinesis, apical dyskinesis, diaphragmatic and posterobasal
akinesis. She was noted to have severely depressed global left
ventricular function with an EF of 30%. She was found to be
anemic while hospitalized, transfused with PRBC's and discharged
to consider bypass surgery. The day after her discharge she saw
Dr. [**Last Name (STitle) 59323**] in follow up and was hospitalized at the Lakes
Regional with a blood pressure of 210/110. She was transferred
to [**Hospital1 18**] on [**2140-12-18**] for evaluation of her coronary disease and
possible stenting. Prior to catheterization she was noted to
continue to have a decreased H/H and instead underwent
colonoscopy which revealed a colon mass. Revascularization of
her coronary lesions was deferred until the mass was resected
and she underwent a transverse colectomy for colon cancer on
[**2140-2-12**]. Now she presents for surgical revascularization
following recovery from colectomy.
Past Medical History:
Coronary Artery Disease with Myocardial Infarction [**11-20**]
Diabetes Mellitus-type II
Hypertension
Congestive heart failure
Hepatitis B [**2111**]
Iron deficient anemia
Gastroesophageal reflux disease
Nonsustained ventricular tachycardia
Colon cancer s/p Colectomy [**2140-2-12**]
s/p Cholecystectomy
s/p Tonsillectomy
s/p Hysterectomy
s/p Ganglion cyst removal from foot
Social History:
Prior smoker, quit in her late 30s after 10-12 years. Rare
alcohol. She lives alone in [**Location (un) 3844**].
Family History:
Father died of MI at 67yo and mother died of CHF at 62. She
believes her mother had a CABG.
Physical Exam:
Pulse:74 Resp:12
B/P Right:181/55 Left: 204/60
Height:5'6" Weight:220 LBS.
General: confortable, obese
Skin: Dry [] 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
+ [] midline incision well healed
Extremities: Warm [x], well-perfused x[] Edema Varicosities:
mild both LE / some spider veins
Neuro: Grossly intact
Pulses:
Femoral Right:+ Left:+
DP Right:+ Left:+
PT [**Name (NI) 167**]: Left:
Radial Right: + Left:+
Carotid Bruit Right: - Left: 0
Pertinent Results:
[**5-24**] Echo: Prebypass: 1.No atrial septal defect is seen by 2D or
color Doppler. 2.There is mild symmetric left ventricular
hypertrophy. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
3. There are simple atheroma in the descending thoracic aorta.
4.The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve stenosis. No aortic regurgitation is seen. 5.
Mild to moderate ([**1-15**]+) mitral regurgitation is seen with a
systolic blood pressure of 160 mm Hg. The jet is posteriorly
directed. The posterior mitral leaflet is slightly restricted.
6. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2140-5-24**] at 1030am. Post byapss: 1. Patient is A paced and
receiving an infusion of phenylephrine. 2. Biventricular
systolic function is unchanged. 3. Mild mitral regurgitation
present. 4. Aorta intact post decannulation.
[**2140-5-24**] 01:10PM BLOOD WBC-13.0*# RBC-2.91*# Hgb-7.8*#
Hct-23.1*# MCV-80* MCH-26.8* MCHC-33.6 RDW-14.9 Plt Ct-202
[**2140-5-26**] 03:40AM BLOOD WBC-8.7 RBC-2.68* Hgb-7.4* Hct-22.1*
MCV-82 MCH-27.6 MCHC-33.5 RDW-14.8 Plt Ct-173
[**2140-5-24**] 01:10PM BLOOD PT-14.6* PTT-29.0 INR(PT)-1.2*
[**2140-5-24**] 02:42PM BLOOD UreaN-30* Creat-1.0 Cl-106 HCO3-26
[**2140-5-26**] 03:40AM BLOOD Glucose-93 UreaN-31* Creat-1.1 Na-135
K-4.6 Cl-102 HCO3-28 AnGap-10
[**2140-5-28**] 05:33AM BLOOD WBC-7.8 RBC-3.51*# Hgb-9.9*# Hct-28.3*#
MCV-81* MCH-28.1 MCHC-35.0 RDW-15.1 Plt Ct-210
[**2140-5-28**] 05:33AM BLOOD Glucose-115* UreaN-26* Creat-0.9 Na-137
K-4.4 Cl-99 HCO3-31 AnGap-11
Brief Hospital Course:
Ms. [**Name13 (STitle) **] was a same day admit after undergoing pre-operative
work-up as an outpatient. On day of admission she was brought to
the operating room where she underwent a coronary artery bypass
graft x 3. Please see operative report for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours she was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one she appeared to be doing well and was
transferred to the telemetry floor for further care. Chest tubes
and epicardial pacing wires were removed per protocol. On POD 2
the patient was noted to have a new left facial droop. CT
revealed an acute infarct of the subcortical area. Neurology
was consulted and we appreciate the recommendations. Symptoms
did resolve and the patient was started on full strength aspirin
and plavix- per neurology recommendations. In addition, she
will follow up with neurology in [**6-20**] weeks. Postoperative
course was otherwise uneventful. She was diuresed and beta
blocker was titrated accordingly. The patient was stable for
discharge on POD 5.
Medications on Admission:
Lipitor 80mg daily, Lasix 40mg [**Hospital1 **], Glyburide 5mg qAM, Insulin
Galrgine 30 units QHS, Isosorbide mononitrate 30mg daily, Toprol
XL 150mg daily, Omeprazole 20mg [**Hospital1 **], Diovan 160mg [**Hospital1 **], Aspirin
162mg daily, Calcium carbonate 600mg daily, Ergocalciferol
daily, Ferrous sulfate 325mg daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. 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*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous QHS.
13. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community Health and Hospice
Discharge Diagnosis:
Coronary Artery Disease
Myocardial Infarction [**11-20**]
Diabetes Mellitus-type II
Hypertension
Hepatitis B [**2111**]
Iron deficient anemia
Gastroesophageal reflux disease
Nonsustained ventricular tachycardia
Colon cancer s/p Colectomy [**2140-2-12**]
s/p Cholecystectomy
s/p Tonsillectomy
s/p Hysterectomy
s/p Ganglion cyst removal from foot
Discharge Condition:
Good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 59323**] in [**2-16**] weeks
Dr. [**Last Name (STitle) 665**] in [**1-15**] weeks
Dr. [**Last Name (STitle) **] (or [**Doctor Last Name 78537**]) -neurology 6-8 weeks [**Telephone/Fax (1) 2574**]
have echo and Holter monitor in 4 weeks (our office will call
you to arrange this)
Completed by:[**2140-5-29**]
|
[
"342.90",
"427.31",
"278.00",
"272.4",
"412",
"403.90",
"434.11",
"997.02",
"414.01",
"585.3",
"414.2",
"428.0",
"V10.00",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8474, 8533
|
5059, 6219
|
309, 512
|
8921, 8927
|
3357, 5036
|
9331, 9708
|
2566, 2659
|
6593, 8451
|
8554, 8900
|
6245, 6570
|
8951, 9308
|
2674, 3338
|
250, 271
|
540, 2022
|
2044, 2420
|
2436, 2550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,312
| 191,701
|
8378
|
Discharge summary
|
report
|
Admission Date: [**2167-7-9**] Discharge Date: [**2167-7-18**]
Date of Birth: [**2087-3-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
CC:[**CC Contact Info 29592**]
Major Surgical or Invasive Procedure:
Cardiac Catheterization on [**7-9**]
coronary artery bypass graftx4 (LIMA-LAD, SVG-Dx1, SVG-Dx2,
SVG-OM) [**2167-7-14**]
History of Present Illness:
This is an 80 yo Chinese male with history of HTN and chest pain
on exertion for the last 3-4 years who came in for a stress test
on the day of admission. During the stress test, patient
exercised for 6 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and was stopped
for marked ST segment depression. Due to the stress test
results, he was sent to have cardiac cath which revealed 3
vessel disease and was evaluated for cardiac surgery.
Past Medical History:
coronary artery disease, Hypertension, hyperlipidemia
Social History:
SOCIAL HISTORY: He lives with his wife in [**Name (NI) 16080**]. He is a
retired Electrical enginer. He smoked 2 pcks per day for 20yrs,
stopped 20 years ago. He denies drinking or using illicit drugs.
Family History:
Non- contributory
Physical Exam:
Pulse: 70 Resp: 16 O2 sat: 98% RA
B/P Right:167/75 Left:
Height: 5'5" Weight: 150 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] 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. moves 4 ext / R handed, follows commands
Pulses:
Femoral Right: palp 2+ Left: palp 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2167-7-16**] 05:30AM BLOOD WBC-8.6 RBC-3.06* Hgb-10.1* Hct-28.4*
MCV-93 MCH-32.9* MCHC-35.4* RDW-13.5 Plt Ct-98*
[**2167-7-14**] 06:39PM BLOOD PT-15.3* PTT-52.6* INR(PT)-1.3*
[**2167-7-16**] 05:30AM BLOOD Glucose-113* UreaN-16 Creat-1.3* Na-137
K-4.1 Cl-102 HCO3-25 AnGap-14
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 1955**] [**Hospital1 18**] [**Numeric Identifier 29593**]TTE (Complete) Done
[**2167-7-10**] at 12:15:24 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (LF) **], [**First Name11 (Name Pattern1) 900**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] Cardiac Electrophysiology
[**Street Address(2) 8667**], [**Hospital Ward Name **] 4
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2087-3-24**]
Age (years): 80 M Hgt (in): 65
BP (mm Hg): 129/52 Wgt (lb): 150
HR (bpm): 60 BSA (m2): 1.75 m2
Indication: Evaluate for Left ventricular function/EF/ Valvular
heart disease. History of Coronary artery disease.
ICD-9 Codes: 414.8, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2167-7-10**] at 12:15 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W011-1:01 Machine: Vivid [**7-22**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.9 cm
Left Ventricle - Fractional Shortening: 0.60 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 11 < 15
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.80
Mitral Valve - E Wave deceleration time: 226 ms 140-250 ms
TR Gradient (+ RA = PASP): *36 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Calcified tips of papillary
muscles. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. 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. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Aortic valve sclerosis without stenosis. Mild aortic and mitral
regurgitation. Mild pulmonary hypertension.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2167-7-10**] 14:00
Brief Hospital Course:
Mr. [**Known lastname **] is a 80 yo chinese male with history of history of HTN
and chest pain on exertion for the last 3-4 years who came in to
stress test on [**2167-7-9**] which showed Complex three vessel
coronary artery disease and patient was worked up for CABG.
# CAD: The cardiac cath revealed three vessel disease. The LAD
had a 60% proximal lesion and a 80% stenosis in a major,
bifurcation diagonal branch. The LCx had multiple stenosis with
90% proximal lesion and complex 95% mid to distal lesion with
the distal vessel filling via right to left collaterals. The RCA
had a 50% proximal
stenosis, 90% mid stenosis, 60% distal stenosis, and severe
diffuse
disease in the PDA. No interventions were done at the time. He
was evaluated by cardio-thoracic surgery and was in the cardiac
services waiting for Plavix washout. He received one dose of
Plavix on [**7-9**] in the afternoon.
-Echo was done on [**7-10**] showed : Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Aortic valve sclerosis without stenosis. Mild
aortic and mitral regurgitation. Mild pulmonary hypertension
-Carotid US was done [**7-10**]: Duplex evaluation was performed of
bilateral carotid arteries. On the right there is moderate
calcified heterogenous plaque seen . On the left there is mild
complex plaque seen. Right ICA stenosis <40% and Left ICA
stenosis <40%.
Mr. [**Known lastname **] was takento the OR on [**7-14**] and underwent an off pump
coronary artery bypass. See operative note for details. Post
operatively Mr. [**Known lastname **] [**Last Name (Titles) 29594**] intubated and was admitted to the
ICU for post operative care. His chest tubes were removed on
POD#1 per protocol. He was started on diuresis, betablockade and
statin therapy.
His temporary pacing wires were removed on POD#3. He was
evaluated by physical therapy and cleared for discharge to home
on POD#4.
Medications on Admission:
MEDICATIONS:
ASA 81mg PO Qday
Lisinopril 40 mg po Qday
Multivitamin I tab PO Qday
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 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).
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. 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*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Sternal Precautions
No lifting greater than 10 pounds for 10 weeks
No driving for 1 month and off narcotics
Cardipulmonary Assessment
Wound Care
Medication Compliance
Follow up appointment compliance
Followup Instructions:
Dr. [**First Name (STitle) **] in 3 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] in 1 week
Dr. [**Last Name (STitle) 73**] 2-3 weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2167-7-18**]
|
[
"433.30",
"433.10",
"338.12",
"401.9",
"396.3",
"780.4",
"272.0",
"411.1",
"416.8",
"440.0",
"414.01",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"36.13",
"88.56",
"37.22",
"36.15",
"89.41",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9959, 10017
|
6772, 8715
|
349, 473
|
10085, 10092
|
2023, 6749
|
10834, 11274
|
1292, 1311
|
8847, 9936
|
10038, 10064
|
8741, 8824
|
10116, 10811
|
1326, 2004
|
280, 311
|
501, 979
|
1001, 1056
|
1088, 1275
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,934
| 118,668
|
54890
|
Discharge summary
|
report
|
Admission Date: [**2189-6-30**] Discharge Date: [**2189-7-3**]
Date of Birth: [**2123-4-23**] Sex: F
Service: MEDICINE
Allergies:
morphine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
Ms. [**Known lastname **] is a 66 year-old woman with a past medical history of
prior lung cancer s/p left pneumonectomy, COPD, history of
breast cancer s/p radiation/lumpectomy, multiple recent
hospitalizations for pneumonia, initially presented to [**Hospital1 **] on [**6-24**] with shortness of breath and persistent cough.
She had a recent admission at the beginning of [**Month (only) 116**] for a CAP,
COPD exacerbation during which she had a CTA of her chest which
showed a new lobulated right upper lobe mass invasive into the
airways, with possible postobstructive pneumonitis, highly
suspicious for malignancy. She was apparently supposed to have
an outpatient bronchoscopy, but this never happened. When she
presented to [**Hospital1 **] with SOB, she had a troponin of .28/.24,
diffuse deep TWI, BNP of 1,000. TTE was done which showed apical
hypokinesis, EF 60%. Cardiology was consulted and per notes,
thought she had stable CAD, not acute coronary syndrome,
recommended statin/aspirin, held off beta blocker secondary to
wheezing. In terms of her SOB, it was felt that she was having
another COPD exacerbation with possible postobstructive
pneumonia. She was initially admitted to the floor and improved
on PO steroids with nebulizers, then her respiratory status
worsened, she became tachcyardic and she was tranferred to the
MICU and started on Vancomycin and Zosyn. According to the
notes, vanco had been dc'ed, however was given earlier today
prior to transfer. It was determined that she needed another CTA
of the chest, however, she declined. After speaking with IP
here, the patient was intuabted on [**6-30**], had a bronch at [**Hospital1 **],
and is being transferred post - procedure to [**Hospital1 18**] for further
management and evaluation for possible stenting procedure. At
the time of transfer, the results of the bronch were unknown,
but tissue biopsies were taken.
On arrival to the MICU, patient is intubated and sedtaed,
comfortable on vent.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Prior right lung pneumonectomy for lung cancer
- COPD
- prior community acquired pneumonias
- breast cancer with lumpectomy: lumpectomy followed by
radiation
therapy
- anxiety
- positional vertigo
- stress fracture both
ankles
- Cesarean section
- reported history of a right adrenal mass
- insomnia
- GERD
- diaphragmatic hernia.
Social History:
([**First Name8 (NamePattern2) **] [**Hospital1 **] records):
She was a moderate cigarette smoker, smoking about less than a
pack of cigarettes a day for 35-40 years until 4 years ago when
lung cancer was diagnosed. No smoking since then and no exposure
to secondhand cigarette smoke. She does not drink alcohol, does
not use drugs. She does not work right now. She is married,
lives with her husband. She is physically quite active.
Family History:
NC
Physical Exam:
Admission Exam
Vitals: 98.4 95 158/81 18 100%
gen: intubated and sedated, not responding to commands
CV: tachycardic, no appreciable murmurs over vent
Resp: transmitted breath sounds on left, coarse breath sounds on
right
Abd: +BS, soft
Neuro: pupils equal
Pertinent Results:
[**6-30**] Chest Xray
Left lung is airless and mediastinum occupies the left
hemithorax suggesting prior left pneumonectomy. Right upper
lobe is densely consolidated, and at its periphery is a 5 x 12
cm homogeneous opacity with lobulated margins along the lung
interface which certainly could be a mass involving lung and
pleura. The right lower lung is free of consolidation but there
are septal lines suggesting mild edema.
ET tube is in standard placement. Nasogastric tube ends in the
upper stomach. Right jugular line tip projects over the middle
third of the leftward displaced SVC.
[**6-30**] ECG
Sinus rhythm with premature atrial contractions. Right
bundle-branch block. Possible lateral infarction, age
undetermined. No previous tracing available for comparison.
Brief Hospital Course:
Ms. [**Known lastname **] is a 66 year old woman with a history of non small
cell lung cancer s/p left pneumonectomy and COPD who presented
with a new right lung mass and post - obstructive pneumonia. She
was initially admitted to [**Hospital3 **] with symptoms of
shortness of breath. She was transferred for possible stenting.
She had been intubated at [**Hospital3 **]. On arrival to [**Hospital1 18**]
she was placed on broad spectrum antibiotics given concern for a
possible post-obstructive picture. She was seen by the
interventional pulmonary team shortly after arrival to [**Hospital1 18**].
They performed a bronchoscopy, but were unable to perform any
intervention given the location of the tumor compressing her
airway. Multiple discussions were held with the patient's family
and her outside providers were contact[**Name (NI) **]. We discussed her
overall poor prognosis. Ms. [**Known lastname **] family expressed that she
would not want any more invasive procedures or further
treatments. Her care was transitioned to comfort focused
measures. She was extubated on [**7-2**] and passed away on [**7-3**].
Her sons [**Name (NI) **] and [**Name (NI) **] were both contact[**Name (NI) **]. [**Name2 (NI) 6**] autopsy was
declined.
Medications on Admission:
albuterol 2 puffs q.i.d.
calcium 500 mg t.i.d.
vitamin D 1000 units a day
Tylenol 1000 mg q.6h. p.r.n.
zolpidem 12.5 mg at bedtime
fluticasone 110 mcg 2 sprays b.i.d
Meds on transfer:
Vancomycin HCl 1000 mg DAILY
Zosyn 3.375 g q6
Propofol
Fentanyl
Prednisone 60 mg PO daily
Lorazepam 1 mg TID:PRN anxiety
Escitalopram Oxalate 10 mg DAILY
Buspar 5 mg [**Hospital1 **]
Xopenex nebs PRN
Omeprazole 40 mg [**Hospital1 **]
Singulair 10 mg once a day
Aspirin 81 mg daily
Simvastatin 10 mg daily
Ambien 10 mg:PRN
Lovenox 40 mg daily
Fluticasone [**Hospital1 **]
Mucinex
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"386.11",
"780.52",
"162.8",
"V49.86",
"V66.7",
"300.00",
"518.81",
"V15.82",
"V10.3",
"486",
"530.81",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6589, 6598
|
4700, 5946
|
287, 298
|
6649, 6658
|
3896, 4677
|
6714, 6860
|
3600, 3604
|
6560, 6566
|
6619, 6628
|
5972, 6138
|
6682, 6691
|
3619, 3877
|
2327, 2775
|
236, 249
|
326, 2308
|
2797, 3132
|
3148, 3584
|
6156, 6537
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,185
| 154,723
|
27142+27143
|
Discharge summary
|
report+report
|
Admission Date: [**2105-6-6**] Discharge Date: [**2105-6-28**]
Date of Birth: [**2024-9-26**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Pancreatitis.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
male who has a convoluted medical history before coming to
the [**Hospital1 69**]. Originally, he was
in [**State 108**] in a hospital there after being diagnosed with
pancreatitis. He was transferred to [**Hospital 18**] [**Hospital 620**] Campus in
[**2105-4-25**], where he received some of his treatment.
Thereafter, he was transferred again to [**Hospital3 105**] in
[**Location (un) 1110**] where a percutaneous transhepatic cholecystostomy
drain was placed during that admission. Eventually after
worsening of the symptoms, particularly abdominal pain and
nausea, the patient was transferred to [**Hospital1 190**] for an endoscopic ultrasound which was
performed on [**2105-6-7**]. The ultrasound showed migration of
this percutaneous transhepatic cholecystostomy drain which
had migrated into the stomach. He was then sent back to
[**Hospital3 105**] where the drain was removed. He slowly was
recovering from his pancreatitis. He was started on tube
feeds at this outside hospital and eventually developed a
fever and hypertension after which he was definitely
transferred to [**Hospital1 69**].
PHYSICAL EXAMINATION: At the time of transfer was as
follows: His temperature was 101.7, pulse 105, blood pressure
150/68, respiratory rate 18, and saturations 94% in room air.
He was alert and oriented x3. He was in no acute distress. He
was pleasant. HEENT exam revealed EOMI, PERRLA, no icterus,
and moist mucous membranes in the head and neck. The neck was
soft and supple. His lungs were clear to auscultation
bilaterally. His heart exam revealed an irregularly irregular
rhythm without audible murmurs, rubs or gallops. Abdominal
exam was as follows: Bowel sounds were present. The abdomen
was soft, slightly distended, slightly firm, was tender at
the right upper quadrant and the epigastrium to palpation.
His J tube sites were noted to be clean, dry and intact
without erythema. There was no rebound or guarding on exam.
His extremities were warm and well perfused with no cyanosis,
clubbing or edema. He had palpable pedal pulses. His right
lower extremity was more edematous than the left lower
extremity.
LABORATORY DATA: Pertinent labs from the time of admission
were an ALT of 158, an AST of 150, normal amylase and lipase
at 58 and 58, respectively, and alkaline phosphatase of 638
and total bilirubin of 6.1, direct bilirubin of 0.7.
DICTATION ENDED
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]
Dictated By:[**Doctor Last Name 9032**]
MEDQUIST36
D: [**2105-7-8**] 14:04:28
T: [**2105-7-8**] 15:14:52
Job#: [**Job Number 66615**]
Admission Date: [**2105-6-6**] Discharge Date: [**2105-6-28**]
Date of Birth: [**2024-9-26**] Sex: M
Service: [**Last Name (un) **]
CONTINUATION:
On the day of admission, the patient underwent CT scan and
right upper quadrant ultrasound which revealed the following:
CT scan revealed a complex fluid collection about 10 x 4 cm
with an enhancing wall and multiple foci of air which was
seen immediately anterior to the pancreas and was concerning
for an infected pseudocyst. He was also noted to have a large
right sided pleural effusion. Because the patient's right
lower extremity was noted to be edematous, a lower extremity
ultrasound was performed and no DVT was found on this study.
During the patient's admission workup, it was noted that he
was febrile. Blood cultures revealed negative results, but
the PICC line catheter tip which was cultured revealed
positive cultures with coagulase negative staph. Therefore,
it was concluded that the patient was febrile from line
sepsis and his line was removed. The patient was started on
vancomycin for this line sepsis, and he was continued on
imipenem with which he was admitted to the hospital.
Fluconazole was also added to his antibiotic regimen. On
hospital day 3, the patient was taken to the operating room
by Dr. [**Last Name (STitle) **] for exploratory laparotomy and debridement of
this visible pancreatic abscess at the body and tail of the
pancreas. The pancreatic bed was also drained. A
cholangiogram was performed and a feeding jejunostomy was
placed intraoperatively. Please refer to the dictated
operative note. The surgery was relatively uncomplicated, and
the patient was taken to the surgical intensive care unit for
postoperative recovery. The patient was hypotensive and
oliguric in the immediate postoperative period. He was
stabilized with intravenous fluids. Eventually he became
pressor dependent on Norepinephrine and he was also noted to
have new onset atrial fibrillation during this time. He was
started on an amiodarone drip for this. In the course of his
hemodynamic instability and pressor dependence, he developed
acute renal failure and the team consulted the nephrology
service for assistance in managing this renal failure. On
hospital day 6, it was felt that his large right pleural
effusion was interfering with his ability to breathe on his
own. So this pleural effusion was drained by tube
thoracostomy and was left to drainage. Trophic tube feeds
were begun on hospital day 8, and the patient tolerated these
without problems. Also on hospital day #8, infectious disease
service consultation was obtained to assist in managing the
patient's pancreatitis abscess, line sepsis, in the face of
his hemodynamic instability. Per their recommendations, the
patient was started on Zosyn and the total number of
antibiotics that the patient was on was 4 including
vancomycin, Zosyn, imipenem and fluconazole. An
echocardiogram was performed during the course of the
patient's intensive care unit stay which revealed a greater
than 55% left ventricular ejection fraction. By [**2105-6-15**],
which was hospital day 10, the patient was off pressors, was
more hemodynamically stable, and was still continued on
antibiotics. He very slowly and steadily recovered in his
renal function and his general picture over the next few
days. By hospital day 12, his abdominal wound was noted to be
weeping and quite friable. The wound was opened and packed to
alleviate some of the breakdown and promote healing. The
patient's tube feeds were noted to be at goal at hospital day
15. Cultures of his open abdominal wound revealed pseudomonas
and, for this, the patient was treated with acetic acid
dressing soaks. On [**6-21**], the patient was alert and oriented
and was off sedation and his atrial fibrillation and flutter
had been restored to a regular rate and rhythm. On [**6-21**],
which is hospital day 16, the patient underwent doxycycline
pleurodesis at his right chest to promote the feeling of his
chest pleura and to eliminate the need for a chest tube. The
patient was eventually weaned down on his ventilator from a
ventilation mode to CPAP, but he failed to make progress
thereafter because he was not alert enough to be able to
breathe on his own in a consistent fashion. By [**6-25**], the
patient had made several improvements. His right chest tube
was removed after pleurodesis. Several of his drains which
were draining the intra-abdominal cavity were removed, and he
was extubated as well. He continued to make slow progress
over the next day or two to the point that speech and swallow
consultation was obtained and physical and occupational
therapy services were obtained. On [**6-28**], the patient was
doing so well as to not necessitate antibiotics any more and
these were all discontinued. In the afternoon of [**6-28**], a
code blue was called on the patient because of respiratory
distress and hemodynamic instability. At the time, his heart
rate was found to be 50, his blood pressure was 50/20 and his
oxygen saturation was noted to be less than 75%. He was
reintubated. Pressors were also started to try to improve the
patient's hemodynamic status. Severe and sudden
decompensation of the patient was thought to be due to a
massive catastrophic event such as a pulmonary embolus or a
massive myocardial infarction. The patient was maximized on
pressors and inotropic agents, but eventually was found to
have become asystolic on telemetry. A code was called and
ACLS protocol was instituted with chest compressions for
about 45 minutes with return of palpable pulses and a
supraventricular rhythm. As part of his workup, a bedside
echocardiogram was performed which showed a massively dilated
right ventricle which was consistent with the diagnosis of a
massive pulmonary embolus. Alteplase therapy was instituted
to attempt to break up the pulmonary embolus and, thereafter,
the patient was placed on heparin drip. Late at night on [**2105-6-28**], after the institution of these measures, the family
reevaluated the patient and decided to withdraw care and make
the patient comfort measures only. He expired later on in the
evening of [**2105-6-28**], with the family at bedside.
CONDITION ON DISCHARGE: The patient is expired.
DISCHARGE STATUS: Is as stated above.
DISCHARGE DIAGNOSES:
1. Acute pancreatitis.
2. Pancreatic abscess.
3. Atrial fibrillation/atrial flutter.
4. Line sepsis.
5. Blood loss anemia.
6. Massive pulmonary embolus.
7. Acute renal failure.
8. Gastroesophageal reflux disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]
Dictated By:[**Doctor Last Name 9032**]
MEDQUIST36
D: [**2105-7-8**] 14:44:34
T: [**2105-7-8**] 16:03:08
Job#: [**Job Number 66616**]
|
[
"584.5",
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"038.9",
"511.9",
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"574.90",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"34.04",
"43.19",
"96.6",
"46.39",
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icd9pcs
|
[
[
[]
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] |
9203, 9686
|
1375, 9092
|
171, 186
|
215, 1352
|
9117, 9182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,181
| 105,830
|
40426
|
Discharge summary
|
report
|
Admission Date: [**2123-4-23**] Discharge Date: [**2123-5-3**]
Date of Birth: [**2039-12-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath and fatigue
Major Surgical or Invasive Procedure:
1) PPM: [**2123-4-23**]
Implant of Pacemaker for AV block second degree, Mobitz II
([**Company 1543**] Model# ADDRL1, Serial#[**Serial Number 88600**])
2) TAVI: [**2123-4-27**]
-Transfemoral transcatheter aortic valve replacement with a
31-mm [**Company 1543**] core valve.
-Balloon valvuloplasty with a 22 mm XiMED balloon.
-Thoracic and abdominal aortography.
History of Present Illness:
Patient is an 83yo caucasian male with history of CAD s/p
CABG x 6 in [**2114**], and known symptomatic aortic stenosis. He
reports worsening shortness of breath over the last 2 years.
Cardiac cath revealed occluded SVG to the RCA with collaterals
and otherwise patent grafts. He was referred for screening for
Corevalve/TAVI 8 months ago and was excluded due to large
annular
size. Since that time a new 31mm Corevalve has been made
available. Since prior visit, patient reports decreased exercise
tolerance with ability to walk less that half a block with out
stopping due to shortness of breath. He reports worsening
fatigue, and 10 lb weight loss. Family members report a decline
in his functional status though he remains independent. He
admits
to frequent episodes of lightheadedness and dizziness though
this
is also in the setting of baseline vertigo disease. In addition,
he has known second degree heart block. It has been determined
that he would likely need a permanent pacemaker if having either
surgical AVR or TAVI.
Informed consent was obtained for the High Risk cohort for
the Corevalve/TAVI study. He met all inclusion criteria and did
not meet any exclusion criteria. He was screened and accepted
and has been randomized to the Corevalve procedure.
NYHA Class: III
CARDIAC CATHETERIZATION [**2122-7-23**]. Three vessel coronary
artery disease with 100% occlusion of the SVG to the RCA with
prominent left to right collaterals to the PDA, Patent
sequential
SVG to the proximal LAD and mid LAD; Patent LIMA to the diagonal
branch; Patent graft to OMB1 (that provides collaterals to the
PDA). The only area of potential ischemia in the inferior wall
is supplied by collaterals from the LCA.
ECHOCARDIOGRAM TTE (Complete) Done [**2123-3-10**] at 11:00:00
Echocardiographic Measurements
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function
depressed.
AORTA: Mildy dilated aortic root. Focal calcifications in aortic
root.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2).
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Normal tricuspid valve supporting structures. No TS.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function
is normal (LVEF 65%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area 0.7 cm2). The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined with
certainty or precision (due to the absence of a reliable
tricuspid regurgitation Doppler spectrum) but appears to be at
least moderately elevated. There is no pericardial effusion.
Compared with the findings of the prior study (images
reviewed)
of [**2122-9-4**], the calculated aortic valve orifice area is
reduced. This is most likely the result of technical factors
(LVOT diameter measurement was 0.1 cm larger on prior study, and
LVOT flow velocity was 0.2 m/sec higher on prior study) rather
than a major change in the aortic valve itself.
EKG: Study Date of [**2123-3-10**] 11:44:18 AM
Intervals Axes
Rate PR QRS QT/QTc P QRS T
41 262 98 524/490 118 -21 95
CT: CARDIAC STRUCTURE/MORPH, 3D, FUNCTION Study Date of [**2122-9-4**]
FINDINGS:
CT CHEST: Airways are patent to the level of subsegmental
bronchi bilaterally. Extensive interstitial changes are noted
throughout the lungs, with subpleural predominance as well as
apical-basal gradient, consistent most likely with nonspecific
interstitial pneumonia. No focal consolidation worrisome for
infection or neoplasm is noted. Focal areas of airtrapping are
present.
No pathologically enlarged mediastinal, hilar, or axillary
lymph nodes are present. Post-sternotomy wires in a patient
after
CABG are unremarkable.
Main pulmonary artery is dilated up to 3.8 cm, right main
pulmonary artery is 2.8 cm and left main pulmonary artery is 2.7
cm, findings consistent with pulmonary hypertension.
CT ABDOMEN: Liver, spleen, adrenals, kidneys are unremarkable.
Questionable gallstones are noted, but no evidence of
cholecystitis is present.
No bowel wall thickening or bowel wall dilatation is present.
There is no intraperitoneal air or fluid. No lymphadenopathy is
seen.
CT PELVIS: Diverticulosis of the sigmoid with no evidence of
diverticulitis is present. Bladder is unremarkable. No
lymphadenopathy, free fluid, or air is noted.
Extensive degenerative changes are present in the imaged
portion of the skeleton, but no lytic or sclerotic lesions
worrisome for infection or neoplasm demonstrated.
CTA:
AORTA: No pathologic aortic dilatation is noted throughout the
entire aorta. Mild tortuosity of the abdominal aorta is present.
Extensive calcifications at the origin of the SMA are noted with
potentially substantial narrowing. Renal arteries are calcified
at their origins but no substantial narrowing is present.
Aorta bifurcates unremarkably. Minimal focal dissection/mural
thrombus at the proximal portion of the common iliac artery is
present, 7:180. Measurements of iliac and femoral arteries will
be added separately.
SUBCLAVIAN ARTERIES: Both subclavian arteries are
unremarkable.
The aortic valve is calcified, consistent with known aortic
stenosis. The patient is after bypass surgery. Extensive
calcifications of native coronary arteries are present. Right
bypass is occluded with aneurysmatic dilatation at the mid
portion.
IMPRESSION:
1. Evidence of interstitial lung fibrosis, consistent with
nonspecific interstitial lung disease.
2. No evidence of aneurysmatic dilatation of the aorta.
3. Pulmonary hypertension.
PFT's: Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study
Date
of [**2122-9-4**] 2:16 PM
SPIROMETRY 2:16 PM Pre drug
Actual Pred %Pred
FVC 2.94 3.85 76
FEV1 2.56 2.41 106
MMF 3.87 2.04 189
FEV1/FVC 87 63 139
LUNG VOLUMES 2:16 PM Pre drug
Actual Pred %Pred
TLC 4.26 6.50 66
FRC 2.24 3.75 60
RV 1.69 2.65 64
VC 2.78 3.85 72
IC 2.02 2.75 73
ERV 0.56 1.10 50
RV/TLC 40 41 97
He Mix Time 2.13
DLCO 2:16 PM
Actual Pred %Pred
DSB 12.26 22.54 54
VA(sb) 4.17 6.50 64
HB 14.60
DSB(HB) 12.26 22.54 54
DL/VA 2.94 3.47 85
Impression:
Mild restrictive ventilatory defect with a moderate gas
exchange defect.
The DLCO is reduced out of proportion to the reduction in TLC
which is consistent with an interstitial process. There are no
prior studies available for comparison.
Carotid dopplers: [**2122-7-22**] < 50% stenosis of both carotids
Past Medical History:
- severe aortic stenosis
- CAD s/p CABG x 6 ([**2114**])
- Hypertension, controlled
- Hyperlipidemia, on simvastatin
- Peripheral vascular disease (poor circulation in the legs)
- Stomach ulcers
- Right ear surgery leading to vertigo.
- Possible dementia
- Second degree AV block without syncope
- Diabetes mellitus, Type II with diabetic neuropathy
- Chronic kidney disease Stage III
- Prostate disease
- History of CVA
- vertigo x 8 years
- hearing loss right
- right ear surgery
- multiple skin lesions to all extremities (mult. frozen
removals)
- Right palm/thumb trauma
- low back pain (bimonthly injections)
LV diastolic dysfunction
Grade: [ ] None [ ] I [ ] II [ ] III [ ] IV
Chest wall deformity Yes [ ] No [x]
History of IE Yes [ ] No [x]
Peripheral vascular disease Yes [ ] No [x]
Cirrhosis of Liver Yes [ ] No [x]
If yes, Child [**Doctor Last Name 14477**] Score A [ ] B [ ] C [ ]
History of anemia req transfusion Yes [ ] No [ ]?
Ulcer disease Yes [x] No [ ]
Connective tissue disease Yes [ ] No [x]
Hostile mediastinum Yes [ ] No [x]
Immunosuppressive therapy Yes [ ] No [x]
Previous Cardiac Surgery?: CABG x 6 ([**2114**])- Sextuple coronary
artery bypass grafting with left internal mammmary artery to the
diagonal, aorto sequential saphenous vein to the proximal and
distal left anterior descending, aortosequential saphenous vein
to the first and second obtuse marginal, aortosaphenous vein to
the RPDA.
Previous Balloon Valvuloplasty?: NO
Permanent Pacemaker/ICD in-situ?: NO
Social History:
The patient is a widower and lives alone. He does not smoke and
has not in the past. He has a glass of wine per week. He
exercises with PT and maintains a low sugar diet. Four stairs to
enter his home. One level home. Neice lives 15min
away. [**Telephone/Fax (1) 88601**] (NIECE)[**Doctor First Name **] [**Doctor Last Name **]
Average Daily Living:
Live independently Yes [x] No [ ]
Bathing [x] Independent [ ] Dependent
Dressing [x] Independent [ ] Dependent
Toileting [x] Independent [ ] Dependent
Transferring [x] Independent [ ] Dependent
Continence [x] Independent [ ] Dependent
Feeding [x] Independent [ ] Dependent
Race: caucasian
Last Dental Exam: none recent
Lives with: alone
Occupation: retired heavy machine operator
Tobacco: none
ETOH: 1/week
Family History:
There is a family history of hypertension, diabetes
mellitus,heart disease, and strokes. His mother died at [**Age over 90 **]
years old age; his father died at 86 years. All 14 of his
siblings are deceased.
Physical Exam:
ADMISSION:
General: Weight changes - 12 lb wt loss/6 months
Skin: Eczema [ ] Psoriasis [ ] Skin cancer [ ] Other [ ]
Denies [ ] - skin lesions, dry
HEENT: Hearing aid [ ] Glasses [ ] Other [ ]- HOH right
Respiratory: Asthma [ ] COPD [ ] Pneumonia [ ] Cough [ ]
Sputum [ ] Other : Denies [x]
Cardiac: Chest pain [ ] SOB [x] DOE [x] Orthopnea [ ] PND
[
]
GI: Nausea [ ] Vomiting [ ] Diarrhea [ ] Constipation [ ]
Heartburn/GERD [ ] Other:-stomach ulcers Denies [ ]
GU: Dysuria [ ] Frequency [ ] Prostate [x] GYN [ ] Other:
Denies [ ]
Musculoskeletal: Arthritis [ ] Other: Denies [x]
Peripheral vascular: Claudication [x] Other: Denies [ ]
Psych: Anxiety [ ] Depression [ ] Other: Denies [x]
Endocrine: Diabetes [ ] Thyroid [ ] Other: Denies [x]
Heme/ID: Denies [x]
Neuro: TIA [ ] CVA x ] Neuropathy [ ] Seizures [ ]
Other: Denies [ ]
PHYSICAL EXAMINATION:
Pulse: 65
B/P: 133/67
Resp: 18
O2 Sat: 98% (RA)
Temp: 97.6
Height: 69 inchaes Weight: 185 lbs
General: Alert, pleasant male in NAD seated in chair.
Skin: Multiple red skin lesions upper and lower extremities.
Turgor fair. Hair growth to ankles. Well healed sternal
incision.
HEENT: Normocephalic, anicteric. Upper dentures, lower dentition
intact. Oropharynx moist. Conjunctiva pink.
Neck: Supple, trachea midline, bilateral carotid bruit vs
murmer.
Chest: Irreg. Murmer III/VI RSB throughout. No heaves/thrills.
Abdomen: Soft, nontender, nondistended. (+)BS x 4 quadrants.
Extremities: Trace pedal edema RLE, 1+ edema LLE.
Neuro: A+O x 3, HOH, asking questions approp. Gross FROM.
Limited
ROM right thumb secondary to prior trauma.
Pulses: palpable peripheral pulses.
DISCHARGE:
General: Alert, pleasant male lying in bed, NAD.
Skin: Heels intact. left torso/axilla echymosis improved,
yellowing. Left chest incision clean and dry, no erythema, mild
echymosis, edema decreasing, steristrips intact.
Turgor fair. Hair growth to ankles. Well healed sternal scar.
HEENT: Normocephalic, anicteric. Upper dentures, lower dentition
intact. Oropharynx moist. Conjunctiva pink.
Neck: Supple, trachea midline.
Chest: II/VI murmer RSB, no radiation to carotids. No
heaves/thrills.
Abdomen: Soft, nontender, nondistended. (+)BS x 4 quadrants. (BM
x2)
Extremities: No edema. Groin sites clean and dry, trace
echymosis, right groin palp ridge.
Neuro: A+O x 3, HOH, asking questions approp. Gross FROM.
Limited
ROM right thumb secondary to prior trauma. Ambulated with
rolling walker,gait fairly steady.
Pulses: palpable peripheral pulses.
Pertinent Results:
LABS ON ADMIT:
[**2123-4-23**] 11:00AM BLOOD WBC-6.8 RBC-4.24* Hgb-14.5 Hct-42.2
MCV-99* MCH-34.1* MCHC-34.3 RDW-14.0 Plt Ct-215
[**2123-4-23**] 11:00AM BLOOD Neuts-73.8* Lymphs-19.4 Monos-5.2 Eos-0.8
Baso-0.8
[**2123-4-23**] 11:00AM BLOOD PT-10.3 INR(PT)-0.9
[**2123-4-23**] 11:00AM BLOOD Glucose-153* UreaN-53* Creat-2.0* Na-137
K-4.3 Cl-99 HCO3-28 AnGap-14
[**2123-4-26**] 06:30AM BLOOD ALT-22 AST-34 CK(CPK)-79 AlkPhos-80
TotBili-0.4
[**2123-4-25**] 07:17AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
[**2123-4-26**] 06:30AM BLOOD %HbA1c-6.1* eAG-128*
LABS ON DC:
[**2123-5-3**] 07:25AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.9* Hct-33.5*
MCV-103* MCH-33.5* MCHC-32.4 RDW-13.8 Plt Ct-278
[**2123-5-3**] 07:25AM BLOOD PT-10.7 PTT-25.6 INR(PT)-1.0
[**2123-5-3**] 07:25AM BLOOD Glucose-107* UreaN-41* Creat-1.6* Na-142
K-4.2 Cl-102 HCO3-31 AnGap-13
[**2123-5-3**] 07:25AM BLOOD ALT-33 AST-42* CK(CPK)-66 AlkPhos-87
TotBili-0.4
INTRAOP TEE [**2123-4-27**]:
Prevalve Implant
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). with mild global
RV free wall hypokinesis. There are simple atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
to moderate ([**2-15**]+) mitral regurgitation is seen. There is no
pericardial effusion. Drs [**Last Name (STitle) **] , [**Name5 (PTitle) **] and [**Name5 (PTitle) 914**] notified in
person of the results on [**2123-4-27**] at 915 am.
Post valve implant
Corevalve seen in the aortic position. Appears seated a little
high for postion. Two mild perivalvular leaks seen. Rest of the
examination is unchanged.
TTE [**2123-5-3**]:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
An aortic CoreValve 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. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Well seated, normal functioning CoreValve aortic
prosthesis. Trace aortic regurgitation. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2123-4-28**],
the findings are similar.
Brief Hospital Course:
HOSPITAL COURSE: 83yo caucasian male who got a Corevalve for
severe symptomatic aortic stensois, and a PPM for second degree
heart block.
Problem [**Name (NI) **]:
#. Symptomatic Severe Aortic Stenosis: on dc pt is POD#6
Corevalve/TAVI. Access was obtained with 18 Fr in right leg with
perclose. He got angioseal to left groin.
Pacer was used during the procedure. The first valve popped out,
placed 2nd valve, and had 1+ perivalvular leak after procedure.
He got 450 cc of contrast. He will need to be on dual
antiplatelet therapy x minimum 3 mos ([**Last Name (LF) 88602**], [**First Name3 (LF) **]). We
decreased his [**First Name3 (LF) **] to 81mg daily and the pt was ambulating
regularly s/p core valve.
#. Diastolic heart failure: we gently diuresed the pt, initally
with IV and then later with Lasix 40mg po which we decreased to
20mg daily post discharge as patient was back to preop weight.
We continued lisinopril at 10mg which may need to be increased
after dc. We discontinued patients home amlodipine and htz.
#. Arrythmia: pt had second degree heart block and was POD 10
s/p placement of [**Company 1543**] Adapta PM. No events occurred and the
pt remained stable.
#. CAD: pt is s/p CABG x6. SVG to the PDA is occluded. All
other grafts were patent. We continued ezetimibe/simvastatin,
Metoprolol Succinate XL 12.5 mg PO DAILY and Aspirin 81 mg PO
DAILY
#. CKD-stage III. The pt was tolerating ACE-I low dose. His Cr
was at baseline on dc.
#. HTN. We continued beta blocker and lisinipril 10mg daily.
#. diabetes: We managed with insulin s/s
# obstructive sleep apnea: pt used CPAP mask at night
# anemia: Pt remained hemodynamically stable, incisions sites
were clean and dry and there were no signs of active bleeding.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 50,000 unit Capsule - one Capsule(s) by mouth three
times weekly
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other Provider)
- 40 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth
daily
EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg
Tablet - one Tablet(s) by mouth daily
GLIMEPIRIDE - (Prescribed by Other Provider) - 2 mg Tablet - one
Tablet(s) orally daily
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - one Tablet(s) by mouth daily
HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other
Provider) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth four times
a day
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet -
one Tablet(s) by mouth daily
Medications - OTC
ASPIRIN, BUFFERED - (Prescribed by Other Provider) - 325 mg
Tablet - one Tablet(s) by mouth daily
MULTIVIT WITH MIN-FA-LYCOPENE [ONE-A-DAY MEN'S] - (Prescribed by
Other Provider) - Dosage uncertain
VITAMINS-LIPOTROPICS [LIPO-FLAVONOID PLUS] - (Prescribed by
Other Provider) - Dosage uncertain
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for constipation.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. glimepiride 2 mg Tablet Sig: One (1) Tablet PO daily ().
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
16. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-15**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for nasal dryness.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 81223**]Nusing Care and Rehab
Discharge Diagnosis:
1. Aortic stenosis - POD#6 s/p Corevalve/TAVI
2. diastolic heart failure
3. Arrythmia-AV block second degree, Mobitz II - POD#10 s/p
[**Company 1543**] Adapta ADDRL1 DDD pacemaker placement
4. CAD s/p CAGB x 6 (SVG to the PDA is occluded, all other
grafts patent)
5. CKD- Stage III (Baseline Cr 1.6)
6. HTN
7. Diabetes
8. Obstructive Sleep apnea (uses CPap machine at night)
9. Meniere's disease/vertigo
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 6608**],
It has been a pleasure caring for you here at [**Hospital1 18**]
throughout your stay from [**2123-4-23**] through [**2123-5-3**]. You were
admitted for severe symptomatic aortic stenosis for which you
were extremely short of breath with increasing fatigue,
diastolic heart failure for which you were retaining fluid, and
an irregular heart rythm of second degree heart block which put
you at risk for progressing to a more dangerous heart rythm. For
this, you received a permanent pacemaker to prevent your heart
from skipping beats. For your severe symptomatic aortic stenosis
you had a transcatheter percutaneous aortic valve replacement
with a Corevalve 31mm device. You did not receive any blood
products. You did not have any major post procedure
complications. You have continued to progress in your recovery
and are ready for discharge to a rehab facility for further
monitoring and strengthening.
Several changes have been made to your medications:
1. DISCONTINUE amlodipine
2. DISCONTINUE hydrochlorothiazide (HCTZ)
3. REDUCE your aspirin to 81mg daily
4. REDUCE your lisinopril to 10mg daily (this may need to be
increased at a later date as your blood pressure increases)
5. ADD furosemide 20mg daily
6. ADD [**Year (4 digits) 88602**] 75mg daily
7. ADD metropolol succinate 12.5mg daily
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 1 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 1 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 2:00 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: Dr. [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) **]
Location: CMC-[**Location (un) **] HEART INSTITUTE
Address: [**Location (un) **], [**Apartment Address(1) 88603**], [**Location (un) **],[**Numeric Identifier 86371**]
Phone: [**Telephone/Fax (1) **]
Appointment: Tuesday [**2123-5-11**] 1:40pm
*This is a follow up appointment for your hospitalization you
will be reconnected with your primary cardiologist after this
visit.
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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11,702
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49778+49779
|
Discharge summary
|
report+report
|
Admission Date: [**2154-2-23**] Discharge Date: [**2154-2-27**]
Date of Birth: [**2079-7-7**] Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 yo M w/PMHx sx for pancreatic cancer s/p resection, XRT, and
chemo, MDS, and hx GI bleed presents with SOB, shaking chills
and fever x 1 day. Patient has also been noted to have rising
platelet count over the course of last several weeks, and was
recently placed on hydroxyurea.
.
Patient was last seen in the ED on [**2154-2-14**] with low grade fever
and shortness of breath, and had negative CXR, and was given 10
day course of levofloxacin, which he completed. He states that
he became better after his treatment, but in the last one day
has developed shortness of breath, dry nonproductive cough, as
well as fever. He denies nausea, chest pain, productive cough,
vomiting, GI bleeding, diarrhea, abdominal pain, rash. He notes
no sick contacts, medication changes other than noted above, or
recent travel.
.
Patient was initially evaluated in ED, where CTA was negative
for PE. He received CTX/azithromycin. Due to tachypnea, patient
was then transferred to the ICU.
Past Medical History:
PMHx:
Pancreatic cancer - Adenocarcinoma, grade I, T3, [**3-12**] LN. s/p
subtotal pancreatectomy [**2-19**], Xeloda, Cyberknife, XRT in [**6-19**].
Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years
ago, ringed sideroblastic anemia diagnosed via BM biopsy.
Multiple GI bleeds [**2-15**] angioectasias from XRT.
Anemia
Squamous cell carcinoma in-situ
Diabetes
BPH
Gout
Scarlet fever as a child
Diverticulosis
Social History:
The patient was married, had three children and quit tobacco in
[**2122**]. Prior to that, he had a 30 pack year history. He used
alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived
in [**Location (un) 745**].
Family History:
His sister died of congestive heart failure.
Physical Exam:
VS: Tm 101.7/Tc
Gen: well appearing. Breathing comfortably on face mask.
HEENT: MMM. No oral ulcers or lesions.
Neck: JVD at 10 cm.
Hrt: RRR. 2/6 SEM at RUSB.
Lungs: Bibasilar crackles. No wheezes.
Abd: Anterior hernia. Easily reducible. Soft, nontender,
nondistended. No hepatomegaly.
Ext: WWP. 1+ pitting edema at ankles.
Neuro: CN2-12 grossly intact. 5/5 mm strength. Sensation to LT
intact. Alert and oriented.
Pertinent Results:
LABS ON ADMISSION
.
135 102 21 / 217 AGap=18
-------------
5.6 21 1.0 \
estGFR: 73 / >75 (click for details)
Ca: 9.1 Mg: 1.8 P: 1.9
88
54.8 \ 8.8 / 1340
------
28.2
N:86 Band:9 L:0 M:1 E:0 Bas:0 Atyps: 1 Metas: 2 Myelos: 1 Nrbc:
80
ALT: 58 AP: 432 Tbili: 0.8
AST: 67
[**Doctor First Name **]: 16 Lip: 8
.
UA: Spec [**Last Name (un) **] 1.024. Small blood. 500 Protein. Few Bacteria. 0
WBC. 0-2 RBC. Neg leuks. Neg nitrites.
Urine culture: negative
Blood cultures x2: no growth to date
Rapid Respiratory Viral Antigen negative
.
IMAGING:
Labs/studies:
CXR [**2-23**]: 1. Diffuse bilateral increased interstitial markings
are thought more likely due to edema and less likely atypical
infection, given the rapid change.
2. Persistent small bilateral pleural effusions.
.
CTA [**2-23**]:
1. No evidence of pulmonary embolism is noted.
2. Small bilateral pleural effusions and mild degree of
compressive
atelectasis are noted.
3. Increased interstitial marking and increased prominence of
soft tissue along the bronchovascular bundles suggest heart
failure pattern.
4. Multiple randomly distributed subcentimeter nodules that
might represent metastasis.
.
CXR [**2-27**]: 1) Marked improvement to bilateral pulmonary edema
with mild amount of interstitial pulmonary edema remaining.
2) Improvement of bilateral pleural effusions with small right
greater than left effusions remaining. A small area of right
lower lobe opacification remains.
.
LABS ON DISCHARGE:
[**2154-2-27**] 06:00AM BLOOD WBC-17.3* RBC-3.44* Hgb-9.4* Hct-29.5*
MCV-86 MCH-27.3 MCHC-31.9 RDW-23.2* Plt Ct-923*
[**2154-2-27**] 06:00AM BLOOD Neuts-81* Bands-0 Lymphs-1* Monos-9
Eos-8* Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-249*
[**2154-2-27**] 06:00AM BLOOD Plt Smr-VERY HIGH Plt Ct-923*
[**2154-2-27**] 06:00AM BLOOD Glucose-205* UreaN-24* Creat-0.8 Na-138
K-4.2 Cl-98 HCO3-28 AnGap-16
[**2154-2-27**] 06:00AM BLOOD Calcium-8.3* Phos-1.6* Mg-1.8
Brief Hospital Course:
He was admitted to the [**Hospital Unit Name 153**] for further work-up and care due to
his 5 L oxygen requirement and tachypnea. Upon admission, it was
thought that the pt's dyspnea and hypoxia were multi-factorial,
including fluid overload [**2-15**] elevated BPs in pt with known [**1-15**]+
MR, pneumonia, and possible metastatic disease in the lung
parenchyma. CTA was negative for PE and demonstrated new b/l
pleural effusions. A rapid resp viral antigen panel was
negative. The pt was diuresed while in the MICU and placed on
CTX/azithromycin with improvement in SOB and a decrease in
oxygen requirement. CXR without nodules suggestive of metastatic
dz; however CTA did reveal multiple subcentimeter nodules that
may be concerning for metastatic dz. However, his CA [**66**]-9 was
not elevated on admission, thus making progression of pancreatic
CA less likely. A TTE was also checked which was unchanged from
prior. The patient was called out to the OMED service for
further care where his antibiotics were changed over to po
cefpodoxime and azithromycin.
.
He was also further diuresed while on the floor and his oxygen
requirement was weaned off. An ambulatory O2 sat was checked
which was 97%. A repeat CXR was also checked on the day of
discharged which was significantly improved from prior. While on
the floor, the pt's BPs were noted to be persistently elevated
to teh 170-180s/70-90s. His lisinopril was titrated up to 20 mg
[**Hospital1 **] and he was started on metoprolol, which was titrated up to
125 mg tid by the time of discharge. The patient was discharged
home in good condition to complete a 7 day course of antibiotics
for treatment of CAP. He will follow-up with his PCP for [**Name Initial (PRE) **] BP
check in 2 weeks. He will continue to follow-up with Dr.
[**Last Name (STitle) **] for further care of his MDS and pancreatic cancer.
Medications on Admission:
Medications:
Creon 20 mg 4 tabs daily
Sandostatin - replacement for octreotide.
Protonix 40 mg [**Hospital1 **]
Lisinopril 10 mg [**Hospital1 **]
Sucralfate 1 gm TID
Allopurinol 300 mg QAM
Glipizide 10 mg qhs
Metformin 1000 mg qhs
Vitamin B6 qd
Folic acid 1 tab qd
Aranesp last given [**2154-2-20**]
.
Allergies: NSAIDS; Motrin causes aseptic meningitis
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO DINNER (Dinner).
Disp:*30 Cap(s)* Refills:*2*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Capsule(s)* Refills:*0*
11. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO LUNCH (Lunch).
Disp:*30 Cap(s)* Refills:*2*
13. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO BREAKFAST (Breakfast).
Disp:*30 Cap(s)* Refills:*2*
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
16. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day: for total of 125 mg, three times a day .
Disp:*90 Tablet(s)* Refills:*2*
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day: for total of 125 mg, three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
CAP
CHF
Secondary Diagnosis:
Pancreatic CA s/p subtotal pancreatectomy, XRT, chemo
MDS
HTN
DM II
Gout
Anemia
Discharge Condition:
Good, breathing well on room air, eating low Na/heart healthy
diet, ambulating
Discharge Instructions:
You were admitted for further evaluation of shortness of breath
and were treated with antibiotics for a pneumonia and were given
a water pill, called Lasix, to remove the excess fluid from the
lungs.
You will need to complete a 7 day course of cefpodoxime and
azithromycin as an outpatient.
You were also started on a new medication called metoprolol for
treatment of elevated blood pressures and your lisinopril dose
was increased to 20 mg twice a day.
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) 2539**],
within 2 weeks to have your blood pressure checked.
Please call your doctor or return to the emergency room if you
experience any of the following: fever > 100.5, chills, night
sweats, increased shortness of breath, cough, chest pain,
diarrhea.
Followup Instructions:
You have the following appointments:
Provider [**Name9 (PRE) 4618**],[**Name9 (PRE) 4617**] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2154-3-6**] 9:00
Provider [**Name9 (PRE) 4618**],[**Name9 (PRE) 4617**] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2154-3-13**] 9:00
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2154-5-1**] 3:30
Completed by:[**2154-2-27**] Admission Date: [**2154-3-2**] Discharge Date: [**2154-3-7**]
Date of Birth: [**2079-7-7**] Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
SOB, nausea, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 y/o male with a h/o MDS, pancreatic CA, and CHF with a
preserved EF and 2+ MR who was recently discharged from [**Hospital1 18**] 3
days prior to presentation for CHF exacerbation and PNA (d/c'ed
on cefpodoxime and azithromycin). He was given multiple doses of
IV Lasix during his admission but not discharged on lasix. He
reported that he was feeling better and his cough had improved
until 24 hours prior to presentation when he developed shortness
of breath when trying to take a nap. He also noted orthopnea and
mild ankle swelling. No worsening of his cough and he denied
F/C. He also reported mild nausea with the episode. He denies
chest pain/tightness, palpitations, diaphoresis, or diarrhea. He
has also noticed the development of a rash on his L inner thigh
in the last week.
.
In the ED he was 90% on RA-> 93% on 3L with SBP = 190s. Of note,
pt is s/p dental extraction one day prior to admission. He was
given Lasix 40 mg IV x 1, morphine 2 mg IV x 1, vancomycin 1 g
IV x 1, ceftazadime 1 g IV x 1, and lisinopril 20 mg x 1. He
diuresed 1.4 L in response to lasix.
.
ROS
Pt denied recent fever or chills. Denied headache, sinus
tenderness, rhinorrhea, or congestion. Denied chest
pain/tightness or palpitations. Denied vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
.
This AM, he was slightly groggy [**2-15**] to Ativan given overnight
for sleep, hemodynamically stable without complaints.
Past Medical History:
PMHx:
Pancreatic cancer - Adenocarcinoma, grade I, T3, [**3-12**] LN. s/p
subtotal pancreatectomy [**2-19**], Xeloda, Cyberknife, XRT in [**6-19**].
Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years
ago, ringed sideroblastic anemia diagnosed via BM biopsy.
Multiple GI bleeds [**2-15**] angioectasias from XRT.
Anemia
Squamous cell carcinoma in-situ
T2DM
BPH
Gout
Scarlet fever as a child
Diverticulosis
Social History:
The patient was married, had three children and quit tobacco in
[**2122**]. Prior to that, he had a 30 pack year history. He used
alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived
in [**Location (un) 745**].
Family History:
His sister died of congestive heart failure.
Physical Exam:
VS Tm = 100 axillary, P = 77, 140/61, 16, O2Sat 93% on 2L
GENERAL: Pleasant male, nad, positive temporal wasting
HEENT: NC/AT, PERRL, EOMI without nystagmus, ? scleral icterus
noted, dry MMM, no lesions noted in OP
Neck: supple, JVD 5 cm above sternal notch, or carotid bruits
appreciated
Pulmonary: Decreased BS at the bases with diffuse wheezes
throughout.
Cardiac: RRR, nl. S1S2, [**2-19**] holosystolic murmur with radiation
to the axilla.
Abdomen: soft, NT/ND, + hernia. normoactive bowel sounds, no
masses or organomegaly noted.
Extremities: 2+ radial, DP and PT pulses b/l. 1+ piting edema at
ankles.
Skin: eythematous macular rash noted on inner L thigh.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar
Pertinent Results:
[**2154-3-2**] WBC-29.0*# RBC-3.47* Hgb-9.8* Hct-31.4* Plt Ct-620*
[**2154-3-3**] WBC-33.8* RBC-3.05* Hgb-8.6* Hct-26.4* Plt Ct-589*
[**2154-3-2**] Neuts-84* Bands-2 Lymphs-2* Monos-4 Eos-7* Baso-0
Atyps-0 Metas-1* Myelos-0 NRBC-269*
[**2154-3-3**] Neuts-90* Bands-3 Lymphs-3* Monos-3 Eos-0 Baso-0
Atyps-0 Metas-0 Myelos-1* NRBC-204*
[**2154-3-2**] Glucose-212* UreaN-26* Creat-1.0 Na-136 K-5.5* Cl-100
HCO3-26
[**2154-3-3**] Glucose-212* UreaN-27* Creat-0.9 Na-137 K-4.7 Cl-100
HCO3-29
[**2154-3-3**] ALT-55* AST-50* LD(LDH)-1178* CK(CPK)-32* AlkPhos-294*
TotBili-0.9
[**2154-3-2**] CK-MB-NotDone cTropnT-<0.01
[**2154-3-3**] CK-MB-1 cTropnT-0.02* proBNP-PND
[**2154-3-3**] Calcium-8.1* Phos-1.9* Mg-2.1 Iron-11*
[**2154-3-3**] calTIBC-315 Hapto-83 Ferritn-77 TRF-242
[**2154-3-2**] Lactate-3.6*
.
[**2154-3-2**] CXR
Findings most suggestive of CHF with interstitial and small
areas of alveolar edema. The possibility of an associated
infectious infiltrate would be difficult to exclude.
.
[**2154-3-2**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2154-3-2**] URINE Blood-SM Nitrite-NEG Protein-500 Glucose-TR
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2154-3-2**] URINE RBC-0-2 WBC-[**3-18**] Bacteri-FEW Yeast-NONE Epi-0
[**2154-3-2**] URINE CastGr-[**3-18**]* CastHy-0-2
.
[**2154-3-2**] ECG:
Rate = 76 bpm, LAFB, no acute changes from previous.
.
Echo (last admission):
The left atrium is mildly dilated 4.2 cm. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-15**]+)mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. ? Mildly decreased EF from previous
echo.
.
LABS ON DISCHARGE:
[**2154-3-7**] 08:00AM BLOOD WBC-24.6* RBC-3.42* Hgb-9.3* Hct-30.0*
MCV-88 MCH-27.3 MCHC-31.1 RDW-24.6* Plt Ct-592*
[**2154-3-7**] 08:00AM BLOOD Neuts-87.4* Bands-2.3 Lymphs-5.7*
Monos-0* Eos-2.3 Baso-0 Atyps-2.3* Metas-0 Myelos-0 NRBC-173*
[**2154-3-7**] 08:00AM BLOOD Plt Smr-HIGH Plt Ct-592*
[**2154-3-7**] 08:00AM BLOOD Glucose-190* UreaN-21* Creat-0.8 Na-137
K-4.7 Cl-98 HCO3-32 AnGap-12
Brief Hospital Course:
The patient was admitted to the OMED service for further
treatment and work-up. Based off of the pt's history, clinical
exam, BNP > 50,000, and admission CXR suggestive of fluid
overload, it was thought that the etiology of the pt's SOB was
secondary to a diastolic CHF exacerbation. He had been
previously admitted to the hospital just 4 days PTA with similar
complaints of SOB that was also associated with a cough, and was
diuresed and treated with antibiotics for a community acquired
pneumonia. However, he was not discharged on standing po lasix.
On arrival to the floor, his BP was noted to be elevated in the
170-180s/90s. He was started on IV lasix for diuresis and
standing po lasix. His blood pressure medication regimen was
further titrated up with good effect and he was started on
norvasc on top of an ACE-I and b-blocker. As he had just been
admitted the week prior and had a TTE, another TTE was not
checked. He was ruled out for ACS with 3 sets of negative
cardiac enyzmes. The pt had just completed a 7 day course of abx
for treatment of CAP prior to admission and given his lack of
clinical symptoms suggestive of PNA, including fever and cough,
he was not continued to antibiotics.
.
Over the hospital course, he was diuresed a total of 4.5 - 5 L
and his weight was noted to drop 4-5 lbs. An attempt was made
to contact his cardiologist, Dr. [**Last Name (STitle) **], during his
hospitalization however Dr. [**Last Name (STitle) **] was on vacation. Thus, the
cardiology service was consulted who agreed with the team's
assessment that the pt's diastolic HF was likely [**2-15**] HTN and
exacerbated by poorly controlled BPs at home along with his
known [**1-15**]+ MR. The patient was discharged in good condition and
has a follow-up appointment with Dr. [**Last Name (STitle) **] within 1 weeks time
to check his blood pressure, obtain an outpatient stress echo
test, and further titrate his medications.
Medications on Admission:
1. Sucralfate 1 g QID
2. Hydroxyurea 500 mg PO HS
3. Pantoprazole 40 [**Hospital1 **]
4. Allopurinol 300 mg qd
5. Lisinopril 20 mg Tablet [**Hospital1 **]
6. Glipizide 10 mg po qd
7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
8. Metformin 500 mg [**Hospital1 **]
9. Cefpodoxime 100 mg [**Hospital1 **]
10. Azithromycin 250 mg qd x 3 days.
11. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
12. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Cap PO LUNCH (Lunch).
13. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit T qd
14. Folic Acid 1 mg qd
15. Docusate Sodium 100 mg Capsule Sig: PO BID
16. Metoprolol Tartrate 125 mg tid
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
13. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)).
Disp:*30 Capsule(s)* Refills:*2*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Eight (8) Cap PO QBREAKFAST ().
Disp:*240 Cap(s)* Refills:*2*
16. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO QLUNCH ().
Disp:*120 Cap(s)* Refills:*2*
17. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO QDINNER ().
Disp:*120 Cap(s)* Refills:*2*
18. Omron Blood Pressure Cuff
Discharge Disposition:
Home
Discharge Diagnosis:
Diastolic CHF
HTN
Pancreatic CA s/p subtotal pancreatectomy, XRT, chemo
MDS
DM II
Discharge Condition:
Good, eating low Na diet, ambulating, breathing well on room air
Discharge Instructions:
You were admitted for shortness of breath and were found to have
elevated blood pressures and increased fluid in your lungs,
caused by diastolic heart failure.
We changed your blood pressure medication regimen around and
started you on several new medications, including: Lasix 20 mg
daily, Norvasc 10 mg daily, and Toprol 300 mg daily. Please take
all of your medications as prescribed.
Please check your weight daily. Call your doctor if your weight
increases by more than 3 lbs.
You will also need to adhere to a low salt diet.
Please check your blood pressures at home daily and call your
doctor if your upper blood pressure [**Location (un) 1131**] is > 140 or if your
lower blood pressure [**Location (un) 1131**] is > 90.
Call your doctor or return to the emergency room if you
experience any of the following: increasing shortness of breath,
cough, fever, chills, night sweats, chest pain.
Followup Instructions:
You have the following appointments:
Provider [**Name9 (PRE) 4618**],[**Name9 (PRE) 4617**] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2154-3-13**] 9:00
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2154-5-1**] 3:30
Provider [**Name9 (PRE) 4618**],[**Name9 (PRE) 4617**] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2154-5-1**] 4:00
You have a follow-up appointment with your cardiologist, Dr.
[**Last Name (STitle) **], at [**Hospital1 18**] [**Location (un) 620**] on Monday, [**3-11**] at 1:30pm.
Completed by:[**2154-3-7**]
|
[
"402.91",
"486",
"511.9",
"424.0",
"428.33",
"562.10",
"600.00",
"428.0",
"V10.09",
"238.75",
"274.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
21235, 21241
|
16483, 18413
|
10642, 10648
|
21367, 21434
|
13940, 16046
|
22385, 22988
|
12890, 12936
|
19128, 21212
|
21262, 21346
|
18439, 19105
|
21458, 22362
|
13723, 13921
|
12951, 13627
|
10579, 10604
|
16066, 16460
|
10676, 12178
|
8899, 8981
|
8869, 8878
|
13642, 13706
|
12200, 12618
|
12634, 12874
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,075
| 153,175
|
12267
|
Discharge summary
|
report
|
Admission Date: [**2184-10-4**] Discharge Date: [**2184-10-11**]
Date of Birth: [**2121-10-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Known aortic stenosis
Major Surgical or Invasive Procedure:
Aortic valve replacement (#19 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical), ascending
aorta replacement(28 Dacron) [**10-4**]
Permanent pacemaker placement on [**2184-10-8**]
History of Present Illness:
rheumatic fever as a child has been followed for at least ten
years for aortic stenosis and a dilated ascending aorta. Cardiac
catheterization in [**2174**] was negative for CAD. Her most recent
echo is from [**2184-5-19**]. This revealed severe aortic stenosis
and an ascending aorta measuring at 4.5 cm. She was referred for
cardiac catheterization to further evaluate. She was found to
have clean coronaries. She is now being referred to cardiac
surgery for a Bentall procedure.
Past Medical History:
Mild hypertension, Hyperlipidemia, Rheumatic fever as child,
Severe aortic stenosis, Ascending aortic aneurysm, [**2174**] cardiac
cath: normal coronaries, Back pain, Hypothyroidism, Arthritis
involving knees and back, Bells Palsy [**2177**] no residuals, Thyroid
cyst resection as a teenager
Social History:
Lives with:Husband
Contact:[**Name (NI) **] [**Name (NI) 38313**] (husband) Phone #[**Telephone/Fax (1) 38314**]
Occupation:works in a HR department
Cigarettes: Smoked no [] yes [x]
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-26**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Physical Exam
Pulse:92 Resp:16 O2 sat:100/RA
B/P Right:135/73 Left:137/75
Height:5'3.5" Weight:198 lbs
General: awake alert oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]; long "collar" healed scar
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] [**1-25**] harsh systolic ejection Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds
Extremities: Warm [x], well-perfused [x] Edema [] no_____
Varicosities: None
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit: soft murmur on the left; none on the right
Pertinent Results:
ECHO:
PRE-BYPASS:
-The coronary sinus is dilated. Injection of agitated saline
into Left sided peripheral IV demonstrates presence of a
persistent left superior vena cava.
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No spontaneous echo
contrast is seen in the body of the right atrium.
-No atrial septal defect is seen by 2D or color Doppler.
-There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%) with normal free
wall contractility.
-The ascending aorta is moderately dilated. The sinotubular
junction is not effaced.
-There are simple atheroma in the descending thoracic aorta.
-The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed & appear
functionally bicuspid. Significant aortic stenosis is present
(not quantified). No aortic regurgitation is seen.
-The mitral valve leaflets are moderately thickened. The
posterior mitral leaflet appears restricted. There is mild
valvular mitral stenosis by P1/2 & deceleration slope. The MVA
by VTI is 2.5cm2 and 2.8cm2 by P1/2. Trivial mitral
regurgitation is seen.
-The tricuspid valve leaflets are moderately thickened.
-There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at the
time of the study.
POSTBYPASS:
The patient is AV paced on a low dose phenylephrine infusion.
There is a well seated prosthetic valve in the aortic position.
Normal washing jets are appreciated. There is a residual mean
gradient = 14 mmHg.
There is a tube graft in the ascending aortic position.
Biventricular function is maintained.
The remaining valves are unchanged.
The remainder of the aorta remains intact
[**2184-10-10**] 06:07AM BLOOD WBC-12.3* RBC-3.03* Hgb-8.5* Hct-26.6*
MCV-88 MCH-28.0 MCHC-31.9 RDW-16.1* Plt Ct-351
[**2184-10-9**] 06:20AM BLOOD WBC-11.1* RBC-3.29* Hgb-9.2* Hct-29.2*
MCV-89 MCH-28.0 MCHC-31.5 RDW-15.7* Plt Ct-335
[**2184-10-11**] 05:10AM BLOOD PT-38.0* PTT-34.0 INR(PT)-3.9*
[**2184-10-10**] 06:07AM BLOOD PT-37.5* PTT-66.2* INR(PT)-3.8*
[**2184-10-9**] 06:20AM BLOOD PT-15.3* PTT-24.8 INR(PT)-1.3*
[**2184-10-8**] 05:04AM BLOOD PT-14.1* PTT-28.5 INR(PT)-1.2*
[**2184-10-7**] 02:08AM BLOOD PT-13.8* PTT-28.1 INR(PT)-1.2*
[**2184-10-6**] 01:44AM BLOOD PT-14.2* PTT-31.8 INR(PT)-1.2*
[**2184-10-5**] 02:59AM BLOOD PT-13.8* PTT-27.4 INR(PT)-1.2*
[**2184-10-11**] 05:10AM BLOOD Na-141 K-4.3 Cl-101
[**2184-10-10**] 06:07AM BLOOD UreaN-20 Creat-0.7 Na-142 K-3.8 Cl-102
[**2184-10-9**] 06:20AM BLOOD Glucose-100 UreaN-19 Creat-0.6 Na-142
K-3.7 Cl-101 HCO3-32 AnGap-13
Brief Hospital Course:
Mrs. [**Known lastname 38313**] was admitted and taken to the operating room for
Aortic valve replacement with a size 19 St. [**Male First Name (un) 923**] Regent
mechanical valve and Ascending aortic aneurysm replacement with
a size 28 Gelweave graft (see operative not for details).
Post-operatively she was admitted to the CVICU for ongoing
hemodynamic monitoring and management. She awoke neurologically
intact and was weaned and extubated. Her chest tubes were
removed per protocol. She was found to be in complete heart
block and required placement of a permanent pacemaker on
[**2184-10-8**] (see operative note). Post procedure she was V-paced.
Post pacer placement her temporary pacing wires were removed and
she was anticoagulated with heparin bridge to coumadin for
mechcanical AVR. She was evaluated by physical therapy for
strength and conditioning and was cleared for discharge to home
on POD 7, when INR was therapeutic at 3.9.
Medications on Admission:
LABETALOL 100 mg [**Hospital1 **]
LEVOTHYROXINE 100 mcg Daily
LOVASTATIN 40 mg Daily
TRIAMTERENE-HYDROCHLOROTHIAZID 37.5 mg-25 mg Capsule Daily
VERAPAMIL 240 mg Daily
ASPIRIN 81 mg Daily
MULTIVITAMIN Dosage uncertain
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication Mech AVR
Goal INR 2.5-3
First draw [**2184-10-12**]
Results to phone:PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6699**]
2. captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
3. lovastatin 40 mg Tablet Sig: One (1) Tablet PO Daily ().
Disp:*30 Tablet(s)* Refills:*2*
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
7. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: dose will change daily per Dr. [**Last Name (STitle) 6700**] for INR goal
2.5-3.
Disp:*90 Tablet(s)* Refills:*2*
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
aortic stenosis, ascending aortic aneurysm, complete heart block
PMH:
Mild hypertension
Hyperlipidemia
Rheumatic fever as child
Severe aortic stenosis
Ascending aortic aneurysm
[**2174**] cardiac cath: normal coronaries
Back pain
Hypothyroidism
Arthritis involving knees and back
Bells Palsy [**2177**] no residuals
Past Surgical History:
Thyroid cyst resection as a teenager
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ lower extremity edema
Discharge Instructions:
**DO NOT TAKE COUMADIN ON [**10-11**], dose will be prescribed by Dr.
[**Last Name (STitle) 6700**] on [**10-12**] based on INR**
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:
-WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2184-10-19**] 10:15
-Surgeon: [**First Name8 (NamePattern2) **] [**Doctor First Name **] on [**2184-11-15**] at 1pm # [**Telephone/Fax (1) 170**] in
the [**Hospital **] Medical office building [**Doctor First Name **] [**Hospital Unit Name **].
[**Hospital **] clinic: [**Telephone/Fax (1) 62**] Date/Time:[**2184-10-14**] 1:30
-Cardiologist: Dr. [**First Name8 (NamePattern2) 20069**] [**Last Name (NamePattern1) **] [**2184-11-19**], 10:45am
Please call to schedule appointments with your:
Primary Care Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 6700**] [**Telephone/Fax (1) 6699**] in [**3-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mech AVR
Goal INR 2.5-3
First draw [**2184-10-12**]
Results to phone:PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6699**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2184-10-11**]
|
[
"395.2",
"441.2",
"305.1",
"427.32",
"746.4",
"747.49",
"272.4",
"244.9",
"401.9",
"285.9",
"426.0",
"E878.2",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"35.22",
"37.83",
"37.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7761, 7816
|
5252, 6198
|
333, 542
|
8237, 8425
|
2497, 5229
|
9395, 10653
|
1706, 1724
|
6468, 7738
|
7837, 8154
|
6224, 6445
|
8449, 9372
|
8177, 8216
|
1739, 2478
|
272, 295
|
570, 1054
|
1076, 1370
|
1386, 1690
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,010
| 126,561
|
51934
|
Discharge summary
|
report
|
Admission Date: [**2167-10-24**] Discharge Date: [**2167-10-29**]
Date of Birth: [**2091-7-12**] Sex: F
Service: MEDICINE
Allergies:
Enalapril / Shellfish
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
CC:[**CC Contact Info 107514**]
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
This is a 76 year-old female with a history of LGIB [**1-10**] ischemic
colitis, ESRD, who presents with c/o fatigue pre-syncope, BPs
80's, and hct 21.7 (down from 31 [**1-16**]). She started feeling
fatigue and lightheaded since couple days, also diarrhea x4
yesterday but dose not know if itr was bloody or not, she also
had nausea and vomiting x 2 with minimal amount of red blood
mixed into it. Denies abd
pain. She attributes all of this to a "bad hamburger" that she
ate 2 days ago. EMS recorded SBP of 80. Transferred to [**Hospital1 18**]
where vitals have been stable with BP 134/44, HR 75 99%RA. HCt
returned at 21.7. NGL attempted but pt did not tolerate. She
is s/p 2 L NS with vitals remaining stable. Reportedly she had
melanotic/[**Last Name (un) 30212**] coloured stool. She did spit up some blood,
small amount, that is bright red in bucket. She takes an asa
but denies NSAIDs or etoh.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
.
Past Medical History:
1. Type2 diabetes mellitus - insulin-dependent - diag [**2130**].
2. Chronic kidney disease - stage 5 - followed by Dr.
[**Last Name (STitle) 7473**]. Left av-fistula in place . Gets HD MWF
3. CHF - [**2160**] EF 20-30%, [**2-/2166**] ECHO persistent LVH, likely [**1-10**]
hypertensive heart disease, with mild MR, mild-to-moderate TR.
Followed by [**Hospital 1902**] clinic, cardiomyopathy thought [**1-10**] htn dm.
4. Sensory neuropathy.
5. Onychodystrophy
6. Hyperkeratotic lesions plantar aspects feet
7. Ischemic colitis - [**4-/2166**]
8. LGIB - [**4-/2166**] - thought possible [**1-10**] to ischemic colitis
9. Diverticulosis
10. Breast cancer (invasive ductal, dx [**2156**]). diagnosed [**9-/2157**]
with a 1.5 cm grade II infiltrating ductal cancer of the right
breast, clean lymph nodes, ER positive, HER-2/neu negative.
Presumed remission now s/p five years on tamoxifen.
11. Renal osteodystrophy
12. Hypercholesterolemia
13. TB @ 21 yo, s/p lobectomy
14. Fibroids, s/p hysterectomy
.
Social History:
She is living with her daughter, grandson, his
wife and great granddaughter who is two months old. She is
finding that to be quite acceptable to her. She does not smoke.
She does not drink alcohol.
Family History:
Mother -- breast cancer
[**Name (NI) **] -- breast cancer
Brother -- melanoma
Physical Exam:
On Admission
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
[**2167-10-24**] 06:30AM WBC-11.9* RBC-2.47*# HGB-7.1*# HCT-21.7*#
MCV-88 MCH-28.9 MCHC-32.8 RDW-16.0*
[**2167-10-24**] 06:30AM NEUTS-77.9* LYMPHS-15.6* MONOS-4.3 EOS-1.9
BASOS-0.3
[**2167-10-24**] 06:30AM PLT COUNT-272
.
[**2167-10-24**] 06:30AM PT-12.7 PTT-24.6 INR(PT)-1.1
.
[**2167-10-24**] 06:30AM GLUCOSE-166* UREA N-132* CREAT-6.7*#
SODIUM-140 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
.
[**2167-10-24**] 06:41AM LACTATE-2.7*
[**2167-10-24**] 02:50PM LACTATE-1.2
.
[**2167-10-24**] 06:41AM HGB-7.7* calcHCT-23
[**2167-10-24**] 07:50PM HCT-25.9*
.
[**2077-10-24**] EGD: Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Impression: No source of bleeding found
Otherwise normal EGD to third part of the duodenum
Recommendations: 4 L Golytely tonight for colonoscopy tomorrow.
Clear liquid diet; NPO post midnight.
[**2167-10-28**] Colonoscopy:
Impression: Diverticulosis of the sigmoid colon and descending
colon
Old blood in the whole colon
Small polyp in the descending colon
Otherwise normal colonoscopy to cecum
Recommendations: Suspect bleed was from small bowel source.
Outpatient capsule study
Brief Hospital Course:
76 yo female with hx of ischemic colitis, lower GIB,
diverticulosis, ESRD on HD, presenting with anemia of active GI
bleed with dark colored maroon stools.
.
# GI Bleed) The patient was admitted to the ICU initially where
she underwent PRBC transfusion and an EGD that was normal. The
patient was transferred to the floor, where the patient's hct
remained stable and she underwent colonoscopy on [**10-28**] that
revealed old blood in the colon, diverticulosis of the sigmoid
colon and descending colon and a small polyp in the descending
colon. The GI team believes that the patient likely bled from a
small bowel source. They recommended an outpatient capsule
study. Give her recent significant GI bleed, the patient was
advised to stop taking her asa 81 mg po qd until f/u with her
PCP.
# ESRD: M, W, F schedule
The patient was dialyzed during her admission with removal of 2
liters and then on [**10-28**] 4 liters.
.
# Chronic Systolic CHF: Stable after dialysis.
# DM: Continue outpatient regimen.
Medications on Admission:
insulin
ASA 81
lovastatin
nephrocaps
prilosec 40 qd
renagel
toprol
Discharge Medications:
1. Hectorol 2.5 mcg Capsule Sig: One (1) Capsule PO QMWF.
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day: take with meals.
5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Six (26) units Subcutaneous once a day: Take dosage and
frequency per prior outpatient regimen.
6. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous twice a day: per prior [**Last Name (un) **] and home sliding
scale and frequency.
7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed, possible small bowel source
Anemia of acute blood loss
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: [**2158**] cc per day.
GIVEN YOUR SIGNIFICANT RECENT GI BLEED, DO NOT TAKE YOUR ASPIRIN
UNTIL DISCUSSED WITH PCP OR CARDIOLOGIST.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12898**], DPM Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2167-11-10**]
12:00
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2167-12-1**] 10:10
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2168-1-5**]
10:30
|
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41,281
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|
52794
|
Discharge summary
|
report
|
Admission Date: [**2103-10-14**] Discharge Date: [**2103-10-23**]
Date of Birth: [**2054-8-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
central line placed at [**Hospital1 **] [**Location (un) 620**], replaced at [**Hospital1 18**] ICU and
removed prior to discharge
History of Present Illness:
49-year-old female with a lymphoproliferative disorder (LGL,
treated at [**Hospital1 112**]; last dose of methotrexate [**2103-7-30**]),
hyperglandular autoimmune syndrome (hypoparathyroidism and
adrenal insufficiency), leg ulcers, and asthma who presented to
[**Hospital1 **] [**Location (un) 620**] on [**10-7**] with the course described below:
She was initially thought to have sepsis either from leg ulcer
infection, urinary or pulmonary source, and was initially
treated with Ceftriaxone and vancomycin, which was then changed
to unasyn, then evenutally to zosyn. She had initially been on
levophed and hydorcortisone as well, which were then weaned off.
She has been off pressors for 4 days. Urine culture grew Beta
hemolytic strep. Her wound culture grew Staphylococcus which
were sensitive to cephalosporins. She is transferred to us on
zosyn alone.
.
Also in the differential for her hypotension (and accompanying
tachycardia) was PE, and a VQ scan was done on [**10-7**] which was
low probability, so HR's in the 110-140's attributed to
deconditioning and anxiety. She had initially been on heparin
gtt, which was d/c'ed when VQ scan was low prob; she had been
maintained on lovenox SQ for DVT ppx per report. Also of note,
she was noted to be volume overloaded and received lasix during
her hospitalization eventually requiring intermittent BiPAP as
well.
.
Non-contrast CT Chest (b/c of renal failure) was then done on
[**10-13**] which showed large pleural effusions and also bilateral
subsegmental PE. The patient was seen by cardiology and
pulmonology, and she diuresed adequately, about 7 liters. The
CVP initially was 18 and then improved to 4 this morning.
Despite the significant diuresis, her hypoxia has not improved
much. She is still on BiPAP and requires 100% F1O2 (down to 50%
at time of transfer). Currently, she is on Lovenox,
weight-based, twice a day and Coumadin was started for treatment
of her PE.
.
Her CT Chest also showed that she also has somewhat worsening of
air space disease with pneumonia and significant pleural
effusion and signs of congestive heart failure. During her
course, zosyn was added for pneumonia coverage and vancomycin
has been stopped. Again she remains on zosyn alone for
antibiotics upon transfer.
.
On transfer, she has no complaints. She reports her breathing is
"okay," and she is hungry. 30 minutes after arrival, she was
somnolent and ABG showed 7.45/70/94/50 on nasal cannula,
however, she was back to being interactive and asking for food
an hour later with no intervention.
.
(+) Per HPI. + ulcers (started as bumps last month, now
progressed to disseminated VZV per [**Hospital1 112**] providers)
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency.
Past Medical History:
- LGL on low dose methotrexate, last dose in [**2103-7-30**] at [**Hospital1 112**]
- Anemia.
- Asthma.
- Multiple bilateral leg ulcerations due to reported VZV
- hyperglandular autoimmune syndrome(hypoparathyroidism and
adrenal insufficiency
- h/o cervical dysplasia
- HTN
- h/o seizure
- CKD, stage 1
- Osteopenia
Social History:
She lives at home with her children age 23 and 28. She is
independent. She denies tobacco, alcohol, or illicit drug use.
Family History:
NC
Physical Exam:
On admission to ICU:
Vitals: 98.7 93/68 114 26 97% 50%bipap
General: Alert, oriented (though initially says at [**Hospital1 112**]), no
acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear with no e/o
thrush
Neck: supple, no LAD
Lungs: b/l bronchial breath sounds, dullness to percussion to
mid lung fields
CV: tachycardic, 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, bilateral multiple 2mm
ulcerating lesions on LE, with violaceous borders. RLE ulcer to
tendon. Bilateral upper extremity ulcers as well.
Pertinent Results:
On admission:
[**2103-10-14**] 03:00PM BLOOD WBC-10.5 RBC-2.86* Hgb-10.3* Hct-31.5*
MCV-110* MCH-36.2* MCHC-32.9 RDW-21.6* Plt Ct-346
[**2103-10-14**] 03:00PM BLOOD PT-12.8 PTT-37.1* INR(PT)-1.1
[**2103-10-14**] 03:00PM BLOOD Glucose-81 UreaN-13 Creat-1.0 Na-145
K-4.0 Cl-92* HCO3-46* AnGap-11
[**2103-10-14**] 03:00PM BLOOD ALT-15 AST-19 LD(LDH)-295* AlkPhos-49
TotBili-0.3
[**2103-10-14**] 03:00PM BLOOD Albumin-2.9* Calcium-7.2* Phos-4.9*
Mg-2.4 Iron-36
[**2103-10-14**] 03:00PM BLOOD calTIBC-195 VitB12-1407* Folate-GREATER
TH Ferritn-453* TRF-150*
[**2103-10-14**] 02:50PM BLOOD Type-ART pO2-94 pCO2-70* pH-7.45
calTCO2-50* Base XS-19 Intubat-NOT INTUBA
[**2103-10-15**] 04:03AM BLOOD freeCa-0.88*
Micro:
OSH blood cx [**10-7**]: NGTD x 2 sets
OSH blood cx [**10-13**]: NGTD x 2 sets
Urine cx [**10-7**]: 50,000-100,000 Group B strep
Urine cx [**10-13**]: prelim no growth
Ulcer Skin swab [**10-8**]:
POLYS /LOW POWER FIELD: >25 POLYS SEEN
GRAM POS COCCI,CLUSTERS: FEW
GRAM POS COCCI, PAIRS: MODERATE
GRAM NEG BACILLI: FEW
GRAM POS BACILLI, SMALL: FEW
> Skin Lesion/Superficial Cult Final 10/13/11-1005
Light growth Normal skin flora
Organism 1 STAPHYLOCOCCUS AUREUS
GROWTH: MODERATE GROWTH
Organism 2 BETA HEMOLYTIC STREP GROUP G
GROWTH: MODERATE GROWTH
1. STAPHYLOCOCCUS AUREUS
Target Route Dose RX AB Cost M.I.C. IQ
------ ----- ------------------ ------ -- ------ ---------
------
CEFAZOLIN S
CIPROFLOXACIN S <=0.5
CLINDAMYCIN S <=0.25
ERYTHROMYCIN S <=0.25
GENTAMICIN S <=0.5
INDUCIBLE CLIND - NEG
LEVOFLOXACIN S 0.25
LINEZOLID S 2
BENZYLPENICILLI R 0.12
OXACILLIN S <=0.25
TETRACYCLINE S <=1
TRIM/SULFA S <=10
VANCOMYCIN S <=0.5
.
Images:
[**10-13**]: Chest CT
Filling defects are seen in the right upper lobe pulmonary
artery, right middle lobe pulmonary artery and subsegmental
branches of the left lower lobe. Moderate-to-large bilateral
pleural effusions noted. There are air space consolidations
especially in the upper lobes. Similar changes with associated
volume loss noted in the lower lobes along with compressive
atelectasis secondary to the pleural effusions. No definite
adenopathy is seen. Bone windows do not show any suspicious
findings.
.
CONCLUSION: PULMONARY EMBOLI. BILATERAL UPPER LOBE AIR SPACE
CONSOLIDATIONS. CONSOLIDATIONS WITH VOLUME LOSS/ATELECTASIS AT
THE LOWER LOBES BILATERALLY AS WELL AS BILATERAL PLEURAL
EFFUSIONS.
.
Abdominal U/S [**10-13**]
CLINICAL HISTORY: Rule out gallstones/pancreatitis.
FINDINGS: There is a small right pleural effusion. Visualized
image appears normal. Normal gallbladder. No gallstones. No
obvious dilated bile ducts. The pancreatic is slightly
heterogeneous in echotexture but no definite calculi or evidence
for pancreatitis was seen in the visualized portions of the
pancreas. No peripancreatic fluid or pseudocyst identified.
.
CONCLUSION:
EXTREMITY LIMITED EXAMINATION. NORMAL GALLBLADDER. NO
SIGNIFICANT ABNORMALITIES ARE IDENTIFIED IN THE PANCREAS BUT THE
ASSESSMENT OF THE PANCREAS IS INCOMPLETELY. IF CLINICAL
SUSPICION FOR PANCREATITIS IS HIGH, CT SCAN IS RECOMMENDED.
.
CXR [**10-13**]
IMPRESSION:
CONGESTIVE FAILURE, NEW AIR SPACE OPACITIES, COULD REPRESENT
ASPIRATION VERSUS PNEUMONIA, BILATERAL PLEURAL EFFUSIONS MILDLY
INCREASED SINCE PRIOR STUDY. elevated R hemidiaphragm.
.
VQ scan [**10-7**]
LOW PROBABILITY OF PULMONARY EMBOLISM. MINOR IRREGULARITIES OF
VENTILATION PERFUSION PRIMARILY AT THE BASES.
.
Brief Hospital Course:
49-year-old female with a lymphoproliferative disorder (LGL,
treated at [**Hospital1 112**]; last dose of methotrexate [**2103-7-30**]),
hyperglandular autoimmune syndrome (hypoparathyroidism and
adrenal insufficiency), leg ulcers due to biopsy proven
varicella, and asthma who initially presented to [**Hospital1 **] [**Location (un) 620**] on
[**10-7**] with hypotension and tachycardia which was thought to be
sepsis from leg ulcer infection vs urinary tract infection.
Patient initially required levophed gtt plus hydrocortisone -
both of which weaned off for 4 days prior to transfer. Patient
was initially treated with ceftriaxone and vancomycin then
changed to amp/sulbactam and eventually switched to pip/tazo (?
pneumonia). Her urine culture grew beta hemolytic strep and leg
wound cultre grew MSSA. On [**2103-10-13**] patient was found to have
bilateral subsegmental PE's and large pleural effusions on
non-contrast chest CT (no contrast due to renal failure).
Patient was started on lovenox and diuresed approximately 7
liters. Per report her CVP (via L. subclavian) improved from 18
to 4 after diuresis. Despite diuresis patient still had high
oxygen requirements (50% FiO2) therefore transferred to [**Hospital1 18**]
ICU for further management.
.
On transfer patient was reportedly AAO x 3 with sbp in 80s-90s
(reported baseline) and satting well on 50% FiO2. Of note,
thirty minutes after arrival patient was somnolent (abg
7.45/70/94/50) which resolved without any intervention. Patient
was transitioned from lovenox to heparin gtt. She was given 20
iv lasix with net 1.6L out and oxygen weaned down to 35% face
tent (does not tolerate nasal canula due to nose bleeds). ICU
team contact[**Name (NI) **] Dr. [**Last Name (STitle) 67458**] (patient's oncologist at [**Hospital1 112**]) who
verified that her LE ulcers have recently been biopsied and are
varicella. Patient was not continued on antibiotics as had
alread received 7 days of gram negative coverage for possible
pneumonia without fever or cough. Also had received a complete
course of antibiotics for UTI. Low suspicion for secondary
infection of varicella ulcers.
.
ACTIVE ISSUES:
## Hypoxic and hypercarbic respiratory failure: Initially
presented on BiPAP 50% mask, weaned off to nasal cannula.
Hypoxemia was thought to be due to known pulmonary embolism and
concomitant volume overload. She was given 20mg iv lasix x 2
doses during ICU course with good urine output. She was
continued on heparin gtt for subsegmental bilateral PEs with
improvement in oxygenation.
## Hypotension: Maintained on home dose of prednisone and
florinef for known adrenal insfufficiency. Pressor was only
required at [**Hospital1 **]: multifactorial due to PE and possible
pneumonia.
## Pulmonary Embolism: CTA of chest at [**Hospital1 **] [**Location (un) 620**] done on [**10-13**]
showed filling defects right upper lobe pulmonary artery, right
middle lobe pulmonary artery, and subsegmental branches of the
left lower lobe. She was initially placed on Heparin. She
underwent TTE on [**2103-10-16**] that showed an EF>55% and normal RV
function with systolic flattening and possible RV pressure
overload but no overt RV strain.
Coumadin dosing thus far
[**10-16**] INR 1.2, coumadin 5mg started
[**10-17**] INR 1.4, coumadin 5mg
[**10-18**] INR 5.9, no coumadin given
[**10-19**] INR 13, Vit K 5mg po given (epistaxis)
[**10-20**] INR 1.6, coumadin 2mg
[**10-21**] INR 2, coumadin 2mg
[**10-22**] INR 4, coumadin 1mg
[**10-23**] INR 5, discharged, instructed not to take coumadin this
afternoon, with plans for daily INR checks until dosing has been
established.
## Disseminated Varicella: Biopsies of lower extremity ulcers
showed Varicella. She was treated with Valacyclovir and local
wound care with good effect. General surgery evaluated wond on
[**10-19**] and felt that they are not infected and do not need
further debridement. She can follow-up with Dr. [**First Name (STitle) 44989**] [**Name (STitle) 108877**]
(Dermatology at [**Hospital1 **], [**Numeric Identifier **])
## Sinus tachycardia: This could have been multi-factorial in
setting of PE and possible volume depletion after aggressive
diuresis in the ICU. She was monitored on Telemetry and had no
events. Her rhythm remained in sinus. She was scheduled for an
outpatient cardiology evaluation given her year-long history of
tachycardia.
## Clonal NK cell lymphopriliferative disorder: followed at [**Company 2860**]
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She was previously on methotrexate which
has been held given her varicella skin infection. Further
management will take place as outpatient.
## Adrenal insufficiency: She was continued on home dose of
Prednisone and Florinef.
Medications on Admission:
Oxycodone 10 mg Oral Tablet 1 tab q6h prn for pain
Valacyclovir 1 g Oral Tablet 1 tab po bid for 28 days (THROUGH
[**10-5**])
Prednisone 5 mg Oral Tablet 1 po qd
Lorazepam 1 mg Oral Tablet 1 tablet at bedtime as needed
Mirtazapine (REMERON) 30 mg Oral Tablet 1 QHS PRN
Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) taking 2
capsules a day
Methotrexate Sodium 2.5 mg Oral Tablet 8 TABLETS EVERY
SATURDAY
MAGNESIUM CHLORIDE ORAL 3 400MG TABS DAILY
Cyclobenzaprine 10 mg Oral Tablet Take 1 tablet at bedtime as
needed for muscle spasm
Cyanocobalamin, Vitamin B-12, 1,000 mcg/mL Injection Solution
1000mcg IM monthly
Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation
HFA Aerosol Inhaler Take 1 to 2 inhalations every 4 to 6 hours
as needed; rinse mouthpiece at least once a week
Betamethasone Dipropionate 0.05 % Topical Cream apply po bid
topically
Calcitriol 0.25 mcg Oral Capsule Take 2 cap(s) orally twice a
day or uad
Potassium Chloride (K-DUR) 20 mEq Oral TbTQ mo,we,fr 20meq
MEGACE ES ORAL as needed
FLORINEF 0.1 MG TAB (FLUDROCORTISONE ACETATE) 2 tabs daily
NYSTATIN 100,000 UNIT/ML ORAL SUSP
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours): Please complete the valacyclovir that you have
remaining at home.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. magnesium chloride Oral
14. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
15. Megace Oral 625 mg/5 mL Suspension Oral
16. nystatin 100,000 unit/mL Suspension Sig: One (1) PO three
times a day as needed for thrush.
17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO qmwf.
18. betamethasone dipropionate Topical
19. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
20. warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day: Only
take as directed by coumadin clinic. Only take at 4pm .
Disp:*15 Tablet(s)* Refills:*2*
21. Cut N Crush Misc Sig: One (1) Miscellaneous once:
patient will need pill cutter to cut coumadin tabs.
Disp:*1 1* Refills:*2*
22. Outpatient Lab Work
Daily INR check ([**10-24**], [**10-25**], [**10-26**], [**10-27**]) by VNA to be faxed
to:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Location: [**Hospital **] MEDICAL ASSOCIATES OF [**Location (un) **]
Address: 325 RIVER RIDGE DR, [**Location (un) **],[**Numeric Identifier 8538**]
Fax: [**Telephone/Fax (1) 19406**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Pulmonary embolism
Lymphoproliferative disorder
Disseminated varicella with extremity ulcers/wounds
Pneumonia/sepsis
Adrenal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for a pulmonary embolisim. You are now
started on a blood thinner called coumadin. You will need to
have daily blood tests to monitor a test called the INR. The
goal is that the INR is between [**2-1**]. Your PCP will be the
pyhsician to monitor this blood test and advise you what changes
to make in your dose of coumadin. If you develop bleeding,
increased bruising or swelling of either leg or shortness of
breath you should contact your doctor.
Medication changes:
STARTED on Coumadin. However, do not take this medication until
your PCP's coumadin clinic advises you to.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital **] MEDICAL ASSOCIATES OF [**Location (un) **]
Address: 325 RIVER RIDGE DR, [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 8506**]
Appointment: MONDAY [**10-29**] AT 10:15AM
**A nurse from your PCPs office will call you at home to set up
your time for an INR check.**
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital3 **]
Address: [**Location (un) 108878**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 108879**]
Appointment: MONDAY [**11-5**] AT 8:45AM
**Please arrive at 7:40AM for your blood draw on the 2nd Fl**
Name: [**Last Name (LF) **], [**First Name3 (LF) **]
[**First Name3 (LF) 4094**]: CARDIOLOGY
Location: [**Hospital **] MEDICAL ASSOCIATES OF [**Location (un) **]
Address: 325 RIVER RIDGE DR, [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 8506**]
Appointment: THURSDAY [**11-15**] AT 2PM
|
[
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"511.9",
"482.1",
"252.1",
"415.19",
"585.1",
"255.41",
"263.0",
"279.41",
"403.90",
"707.19",
"052.7",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16280, 16351
|
8084, 10242
|
315, 447
|
16533, 16533
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3824, 3948
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,669
| 121,839
|
50298
|
Discharge summary
|
report
|
Admission Date: [**2113-2-12**] Discharge Date: [**2113-2-27**]
Date of Birth: [**2041-5-12**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Penicillins
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
hypothermia, lethargy
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 71 yo man with h/o cognitive delay, IDDM, and
seizure disorder, non-verbal at baseline, who presented from his
nursing home with altered mental status. Per report, the patient
was in his normal state of health until yesterday, when he was
reported to be "under the weather." This afternoon, he became
lethargic and did not open his eyes when spoken to. His nurse
took his vital signs, and his rectal temperature was found to be
92. He was thus brought to the ED for further evaluation.
.
In the ED, his initial VS were T 86.2 (92 rectally), P 53, BP
122/96, R 24, O2:100% sat. On transfer from the stretcher to the
bed, he had a very wet cough. His FSBG was 54, so he was given
an amp of D50. He was found to be hyperkalemic, so he was given
Albuterol, Insulin 10 U, and glucose, and his repeat glucose was
18. He was thus started on a D50 gtt. His CXR showed patchy
infiltrates bilaterally, so he was given CTX/Vanc/Levaquin for
presumed HAP. He was placed in a bear hugger and he was given
warm fluids, and his repeat temperature was 35.3 and his pulse
increased to 70. His VS at the time of transfer were BP 109/37,
P 75, O2 99% on 3L NC.
.
On the floor, the patient is lethargic but opens his eyes on
command. He was unable to express any acute concerns.
Past Medical History:
Mental retardation, diabetes type 2 on insulin, seizure
disorder, dementia, osteoporosis, dysphagia, aspirations,
psychosis.
Social History:
Lives at group home. Does not smoke, does not drink alcohol. No
drug history.
Family History:
Non-contributory.
Physical Exam:
Admission Exam
VS: Temp 35 BP 109/37, P 75, O2 99% on 3L NC
General Appearance: Well nourished, No acute distress, not
following commands
Eyes / Conjunctiva: Left pupil 1mm < right pupil at 1.5 mm
Head, Ears, Nose, Throat: Normocephalic, dry MM
Cardiovascular: Difficult to ascertain secondary to rhoncorous
chest exam
Respiratory / Chest: Rhonchorous
Abdominal: Soft, Bowel sounds present
Extremities: No edema, warm and well perfused, 2+ DP pulses
Neurologic: toes are upgoing on the left
Discharge Exam
VS: Tc 96, P: 54, BP: 116/60, RR: 16, 96% on RA
GEN: chronicall ill appearing, non-verbal, appears comfortable
CV: rrr, no m/r/g
PULM: CTAB on anterior chest
ABD: BS+, soft, NT, ND, no HSM
EXT: no edema, some bruising over RUE
NEURO: alert, follows commands
Pertinent Results:
ADMISSION LABS
[**2113-2-12**] 04:10PM WBC-6.6 RBC-3.00* HGB-9.4* HCT-27.9* MCV-93
MCH-31.2 MCHC-33.6 RDW-15.9*
[**2113-2-12**] 04:10PM NEUTS-68.6 LYMPHS-24.6 MONOS-4.4 EOS-2.2
BASOS-0.2
[**2113-2-12**] 04:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2113-2-12**] 04:10PM PLT SMR-LOW PLT COUNT-92*#
[**2113-2-12**] 04:10PM RET AUT-1.1*
[**2113-2-12**] 04:10PM PHENYTOIN-21.5*
[**2113-2-12**] 04:10PM TSH-8.9*
[**2113-2-12**] 04:10PM HAPTOGLOB-181
[**2113-2-12**] 04:10PM GLUCOSE-52* UREA N-72* CREAT-2.5* SODIUM-144
POTASSIUM-5.9* CHLORIDE-112* TOTAL CO2-22 ANION GAP-16
[**2113-2-12**] 04:10PM CALCIUM-10.0 PHOSPHATE-5.6* MAGNESIUM-2.3
[**2113-2-12**] 04:10PM LD(LDH)-151 TOT BILI-0.1
[**2113-2-12**] 04:20PM LACTATE-1.2
[**2113-2-12**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2113-2-12**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2113-2-12**] 09:48PM ALBUMIN-3.1*
[**2113-2-12**] 11:17PM TYPE-ART PO2-161* PCO2-44 PH-7.34* TOTAL
CO2-25 BASE XS--2
[**2113-2-12**] 04:10PM BLOOD Phenyto-21.5*
[**2113-2-12**] 04:10PM BLOOD TSH-8.9*
.
[**2113-2-13**] 04:00AM BLOOD WBC-6.7 RBC-2.51* Hgb-8.2* Hct-23.8*
MCV-95 MCH-32.7* MCHC-34.5 RDW-15.9* Plt Ct-83*
[**2113-2-13**] 08:37AM BLOOD FDP-0-10
[**2113-2-13**] 08:37AM BLOOD Fibrino-600*
[**2113-2-12**] 04:10PM BLOOD Ret Aut-1.1*
[**2113-2-13**] 04:00AM BLOOD Glucose-180* UreaN-65* Creat-2.7* Na-140
K-5.5* Cl-110* HCO3-19* AnGap-17
[**2113-2-13**] 01:00AM BLOOD ALT-31 AST-24 LD(LDH)-149 CK(CPK)-22*
AlkPhos-143* TotBili-0.1
[**2113-2-13**] 01:00AM BLOOD Lipase-50
[**2113-2-13**] 01:00AM BLOOD CK-MB-4 cTropnT-LESS THAN
[**2113-2-13**] 08:37AM BLOOD D-Dimer-237
[**2113-2-13**] 04:00AM BLOOD T3-89 Free T4-0.91*
[**2113-2-13**] 04:00AM BLOOD Cortsol-21.6*
.
DISCHARGE LABS
[**2113-2-27**] 06:55AM BLOOD WBC-7.4 RBC-2.69* Hgb-8.8* Hct-25.9*
MCV-96 MCH-32.6* MCHC-33.9 RDW-14.8 Plt Ct-307
[**2113-2-27**] 06:55AM BLOOD Glucose-150* UreaN-35* Creat-1.5* Na-143
K-4.2 Cl-111* HCO3-24 AnGap-12
[**2113-2-26**] 06:55AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
.
IMAGING
[**2-14**] CT ABD/PELVIS W/O CONT
IMPRESSION: 1. Severe bilateral hydroureteronephrosis, left
worse than right, without definite evidence of mass or
obstructing stones. Distal obstruction at the level of the
bladder (from an infiltrative neoplasm), prostate gland, or
urethra are most likely. There is suggestion of bladder wall
thickening on this exam, though evaluation is very limited due
to lack of bladder distention and contrast -- further evaluation
with cystoscopy could be considered. 2. Extensive sigmoid
diverticulosis with surrounding stranding suggestive of
diverticulitis.
3. Trace bilateral pleural effusions and bibasilar ground-glass
opacities,
which likely represents atelectasis, though infection is not
excluded.
Brief Hospital Course:
#. Hypothermia: The patient was found to be hypothermic in the
ED to 86, and his temperature increased to 97 with a bear hugger
and warm fluids. It is uncertain how long the patient had been
hypothermic prior to presentation. His mental status improved
with re-warming.
.
#. Hyperkalemia: Potassium on arrival in the ED was elevated at
5.9. He was given insulin, albuterol, and one amp of D50, and
his EKG at the time did not show any evidence of peaked T waves.
He was likely hyperkalemic secondary to acute renal failure;
this resolved completely as kidney function returned to
baseline. K 4.2 on discharge.
.
#. Thrombocytopenia: The patient's platelets were 92 at
presentation (from his baseline of 250). DIC labs were
unremarkable and peripheral smear did not show schistocytes.
Platelet count started to improve on transfer to the floor and
was back to baseline at the time of discharge.
.
#. Acute on chronic renal failure: Mr. [**Known lastname 104901**] creatinine on
admission was 2.5 (elevated from his baseline of 1.7). Likely
secondary to obstructive nephropathy given finding of severe
bilateral hydronephrosis on renal ultrasound. Source of
obstruction is unclear. Urology recommends foley catheter x 2
weeks. Cystogram did not show any evidence of vesicoureteral
reflux.
.
#. Melena: Patient noted to have melenic stool, guaiac positive
on the morning of [**2113-2-13**] with a hematocrit drop. One unit pRBCs
transfused. NG lavage showed pink blood which cleared after 250
cc. GI consult recommended an outpatient colonoscopy if the
patient has not had one recently and it is line with his goals
of care. After this melenic stool, patient's stools remained
greenish brown and guaiac negative. Hematocrit remained stable.
.
#. Hypoglycemia: The patient has a history of IDDM, for which he
takes Novolin 15 U daily. His FSBG on presentation to the ED was
54, and this decreased to 18 after receiving 10 U of regular
insulin for hyperkalemia. He was placed on a D50 gtt. On the
floor, he received another 10 U of regular insulin for
hyperkalemia, and his repeat FSBG was again decreased at 34.
Patient was initially on D50 gtt and home dose of novolin
insulin was held. Once started on tube feeds on evening of
[**2113-2-14**], glucose drip was discontinued and sugars remained stable
in the 100-130s.
.
#. Right upper extremity DVT: On transfer, patient's right hand
was noted to be swollen. A right upper extremity ultrasound
showed a DVT of one of the right brachial veins. The patient was
started on a heparin drip and eventually bridged to coumadin.
Right hand edema completely resolved. He will need 3 months of
anticoagulation total in the setting of a provoked DVT.
Anticoagulation should end on [**5-15**].
.
#. Seizure disorder: The patient has a history of seizure
disorder, for which he takes phenytoin daily. His initial
phenytoin level was 21.5. Per pharmacy, phenytoin was held until
dose was < 20. Once his level improved, patient was restarted
on lower dose of 100mg daily. He should follow up his phenytoin
levels with his PCP and have the dose adjusted accordingly.
.
#. Hypothyroidism: Continued home dose of levothyroxine.
.
# Osteoporosis: Continued calcium and vitamin D per home
regimen.
.
# Prophylaxis: Patient received heparin products during this
admission.
.
# Code status: Full code during this admission. Given that the
patient is being allowed to eat in the context of known ongoing
aspiration, goals of care were discussed with the patient's
guardian. This will need to be followed up and appropriately
documented after discharge.
Medications on Admission:
MVI daily
Risperidone 1 mg PO QHS
Cholecalciferol 400 U daily
Calcium carbonate 500 mg PO daily
Ferrous sulfate 300 mg daily
Novolin 15 U qam
ISS
Levothyroxine 75 mcg daily
Atrovent 17 mcg HFA inhaler daily
Heparin SC
Vitamin C 500 mg PO BID
Senna 17.2 mg daily
Duoneb q4h prn
Dulcolax 5 mg daily
Tylenol 650 mg q6h prn for pain
Lorazepam 0.5 mg daily PRN
Dilantin ER 250 mg PO qhs (reconciled with PCP)
PeptoBismol prn q6h
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. risperidone 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. cholecalciferol (vitamin D3) 400 unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
5. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation four times a day.
8. Vitamin C 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day.
10. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
11. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
12. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
13. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety, agitation.
14. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO once a day.
15. Pepto-Bismol 262 mg Tablet, Chewable Sig: [**1-8**] Tablet,
Chewables PO every four (4) hours as needed for diarrhea.
16. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-8**]
Drops Ophthalmic PRN (as needed) as needed for eye irritation.
17. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day at
4pm.
Disp:*30 Tablet(s)* Refills:*2*
18. insulin regular human 100 unit/mL Solution Sig: AS DIRECTED
Injection ASDIR (AS DIRECTED): PER SLIDING SCALE.
19. Outpatient Lab Work
Patient will need to have INR checked on Tuesday, [**2-28**] &
results faxed to his PCP's office for review & coumadin dose
changes as needed. (PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (un) 104902**], Fax:
[**Telephone/Fax (1) 23926**], Phone: [**Telephone/Fax (1) 608**]).
Discharge Disposition:
Extended Care
Facility:
Bay Cove Group Home
Discharge Diagnosis:
Primary diagnosis:
# Hypothermia
# Acute renal failure
# Deep vein thrombosis
# Type II diabetes mellitus
Secondary diagnosis:
# Hyperkalemia
# Thrombocytopenia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
# You were admitted to the hospital for altered mental status
and found to have low body temperature, low platelets, high
potassium, low blood sugar and acute renal failure. You were
re-warmed in the intensive care unit and your platelet count
came up. Your renal failure was found to be from obstruction of
your urinary tract causing urine to back up and damage your
kidneys. Your bladder was decompressed with a foley catheter
during your admission.
# When you were transferred to floor it was discovered that you
had a deep vein thrombosis in your right arm. You were started
on a heparin drip to thin your blood; you have been bridged to
Coumadin (warfarin). You will need a total of 3 months of
anticoagulation, as this was considered a ??????provoked?????? blood clot
in the setting of severe illness.
# *****You should have your INR checked on Tuesday, [**2-28**] & the
results should be faxed to Dr.[**Last Name (un) 104903**] office for review
by her covering physician. (Fax: [**Telephone/Fax (1) 23926**], Phone:
[**Telephone/Fax (1) 608**])*****
# It is very important that you follow up with urology to
evaluate the cause of your urinary retention/obstruction.
# We made the following changes to your medications:
- STARTED Coumadin (warfarin)
- CHANGED your insulin regimen
- CHANGED your Dilantin dose
- STOPPED heparin SC
# It is very important that you take all of your medications as
prescribed and keep all of your follow up appointments.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: MONDAY [**2113-3-6**] at 1:15 PM
With: Dr [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 608**]
Address: 545A [**Street Address(1) **], [**Location (un) 538**], MA
Department: UROLOGY/SURGICAL SPECIALTIES
When: FRIDAY [**2113-3-10**] at 11:30 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
Completed by:[**2113-3-14**]
|
[
"294.8",
"486",
"276.7",
"403.90",
"453.82",
"345.90",
"285.21",
"593.4",
"733.00",
"319",
"287.5",
"250.00",
"280.0",
"V58.67",
"591",
"780.65",
"578.1",
"584.9",
"585.3",
"348.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11815, 11862
|
5662, 9247
|
318, 326
|
12068, 12068
|
2712, 5639
|
13732, 14492
|
1891, 1910
|
9721, 11792
|
11883, 11883
|
9273, 9698
|
12243, 13447
|
1925, 2693
|
13476, 13709
|
257, 280
|
354, 1631
|
12011, 12047
|
11902, 11990
|
12083, 12219
|
1653, 1779
|
1795, 1875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,459
| 172,420
|
47829
|
Discharge summary
|
report
|
Admission Date: [**2195-11-8**] Discharge Date: [**2195-11-22**]
Date of Birth: [**2128-11-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
PICC line placement
History of Present Illness:
The Pt. is a 66y/o M with PMH of atrial fibrillation and L
carotid stenting on coumadin admitted with sublingual bleed and
respiratory distress. The pt returned from [**State 108**] noting a few
days of "throat discomfort", voice change and difficulty
swallowing. Per the patient's wife, the patient recently had
increased bruising along his arms but deferred having his INR
checked. While in [**State 108**], he complained of throat irritation
and discomfort. On the day of admission, he flew to [**Location (un) 6692**]
airport and had significant voice change prompting presentation
to the ED.
On arrival to the ED, the patient was minimally responsive with
sats in the low 90's. Anesthesia attempted oral intubation
unsuccessfully due to severe trismus. An emergent fiberoptic
intubation was performed at the bedside. INR from ED returned at
9.8. 2units FFP and 10mg Vit K given.
Past Medical History:
Chronic atrial fibrillation, on Coumadin
Peripheral vascular disease, asymptomatic carotid artery
disease status post [**Doctor First Name 3098**] stenting in [**2190**]
Hypertension.
Hyperlipidemia.
History of GERD.
Hearing loss with bilateral hearing aids
Social History:
Significant for past history of tobacco, drinks alcohol
occasionally
Family History:
No history of early CAD or stroke. Mother with a stroke at 85
years.
Physical Exam:
ADMISSION EXAM:
General: well appearing male laying in bed comfortably
Vitals: 138/48, 77, 97%RA, 20
HEENT: no tongue swelling, op clear, no blood in oropharynx, mmm
CV: irregularly irregular, no MRG
lungs: sparse crackles at the bases. no wheezes noted, no
stridor
Abd: soft non tender, non distended. + BS
Extr: trace edema, 2+ pulses
foley in place
Pertinent Results:
ADMISSION LABS
[**2195-11-8**] 08:10PM BLOOD WBC-9.5# RBC-4.01* Hgb-13.4* Hct-36.6*#
MCV-91 MCH-33.4* MCHC-36.6* RDW-14.2 Plt Ct-208
[**2195-11-8**] 08:10PM BLOOD Neuts-71.7* Lymphs-18.8 Monos-6.8 Eos-2.3
Baso-0.3
[**2195-11-8**] 08:10PM BLOOD PT-77.9* PTT-59.3* INR(PT)-9.8*
[**2195-11-8**] 08:10PM BLOOD Glucose-98 UreaN-19 Creat-0.9 Na-140
K-3.9 Cl-108 HCO3-22 AnGap-14
[**2195-11-9**] 06:45AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2
[**2195-11-8**] 10:59PM BLOOD Type-ART pO2-69* pCO2-46* pH-7.33*
calTCO2-25 Base XS--1
.
DISCHARGE LABS:
[**2195-11-22**] 05:37AM BLOOD WBC-9.5 RBC-3.00* Hgb-9.9* Hct-28.6*
MCV-95 MCH-33.0* MCHC-34.6 RDW-14.4 Plt Ct-121*
[**2195-11-22**] 05:37AM BLOOD PT-14.9* INR(PT)-1.3*
[**2195-11-22**] 05:37AM BLOOD Glucose-90 UreaN-17 Creat-0.9 Na-138
K-4.1 Cl-107 HCO3-23 AnGap-12
[**2195-11-22**] 05:37AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.2
.
[**11-11**] CXR- As compared to prior radiograph, there is increased
opacity of left base, probably atelectasis. There is mild fluid
overload. The tip of endotracheal tube projects at 67 mm above
the carina. Minimal pleural effusion on the left. The cardiac
size is unchanged.
.
[**11-8**] CT Neck - LTD study secondary to intubation. Oropharyngeal
secretions likely related to intubattion. No retropharnygeal
abscess. Prominent adenoid and tonsillar tissue.
.
CXR [**11-8**] - Endotracheal tube just below the superior aspect of
the
clavicles, terminating approximately 7.7 cm from the carina. The
tube can be advanced for optimal positioning.
.
[**2195-11-19**] 12:45 pm URINE Source: CVS.
**FINAL REPORT [**2195-11-22**]**
URINE CULTURE (Final [**2195-11-22**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PSEUDOMONAS AERUGINOSA. PREDOMINATING ORGANISM.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
[**2195-11-19**] 4:45 pm BLOOD CULTURE
**FINAL REPORT [**2195-11-25**]**
Blood Culture, Routine (Final [**2195-11-25**]):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
MICU course:
In MICU, placed on decadron, famotidine, benadryl given
potential allergic reaction to lisinopril with angioedema.
Started on Unasyn transitioned to Augmentin for potential sinus
infection per ENT. On PO atenolol and verapamil long acting.
Transitioned to IV metoprolol while here, then developed A fibb
with RVR into 160's. Patient was successfully extubated and
transfered to the floor.
.
On the floor, the patient was frequently complaining of throat
irritation and dryness. Decadron was discontinued. He was also
in afib with RVR which improved with changing to long acting
verapamil, but which required increased dosing. he received a
additional dose of Verapaminl SR 120mg x 1 at 1pm. Today, he
received 750cc NS at 150cc/hr in the morning for concern for
dehydration. In the afternoon, he began complaining of SOB. He
was found to be wheezy on exam. ABG demonstrated Po2 49. Lasix
40mg IV and dexamethasone 10mg IV were given. ENT was consulted
given the concern for airway compromise. He was transfered to
the ICU. ENT performed laryngoscopy which demonstrated
subglottic swelling/hematoma but open airway. As there was no
stridor, pt able to speak and swallow, it was decided not to
intubate the patient.
.
Patient was observed in the MICU overnight and had an impressive
diuresis of >4L to his initial Lasix 40mg IV. He was also
transitioned to a steroid taper of prednisone over a six day
course. Upon transfer, Xopenex was discontinued for any
bronchospastic component given his tendency to develop Afib with
RVR. Rather, he was maintained on scheduled Ipratroprium.
Coumadin continued to be held.
.
[**Hospital **] hospital course:
66y/o M with PMH of atrial fibrillation on coumadin admitted
with sublingual bleed and respiratory distress concerning for
lisinopril induced angioedema. Ultimately inflammation in the OP
improved and Pt was discharged at baseline. His hospitalization
was complicated by UTI which was treated.
.
# Urinary tract infection: Pt with rising WBC and low grade
temp. UA positive for infection. Pt also with malaise. Note: pt
was s/p foley catheter. Initially started ciprofloxacin but
remained febrile. Switched to pip-tazo. UCx and BCx ultimately
growing Pseudomonas, sensitive to cipro so dicharged on Cipro
500mg [**Hospital1 **] and DC on [**2195-12-3**].
.
# Orthostatic hypotension: Unclear if due to low volume or too
much verapemil. Was on 360mg verapemil. Decreased verapemil to
240mg and improved fluid status with boluses.
.
# Respiratory Distress - Sublingual hematoma on exam in setting
of INR of 9.8 Also consider laryngeal edema vs infection.
Unclear etiology for respiratory distress with ddx of
sub-lingual hematoma vs angioedema though **largely resolved
with patient on RA w good sats. Was treated with dexamethasone,
benadyl, h2 blocker in ICU. Re-inflamed off dexamethasone, so
discharged on prednisone taper. Holding lisinopril as a possible
cause. Dry MM was a major issue, now resolved.
.
# [**Name (NI) 100957**] INR - pt received vitamin K 10mg IV X1 and 2
U FFP in ED for INR 9.8. INR 1.5 on transfer to Medicine.
Resuming coumadin with goal INR of 2.0 per ENT and cards.
Unclear if pt was given warfarin pills at wrong dose as wife
reports the most recent prescription looked different. We ask
the pt to throw away all of his old pills and he was given
prescriptions for all new ones.
.
# Chronic atrial fibrillation - patient with episodes of Afib
with RVR in the setting of holding medications, but also on
recent Holter monitor. Initially had better rate and pressure
control on verapamil XL 360mg PO daily compared to home dose of
240, but hypotensive. Returned to home dose on [**2195-11-20**].
Resuming coumadin with goal INR 2.0
Medications on Admission:
atenolol 12.5 mg daily
lipitor 80 mg daily
lisinopril 5 mg daily
verapamil 240 mg daily
Coumadin
aspirin 81mg daily
Flonase
Advair
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation three times a day.
Disp:*1 inahler* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 nasal inhaler* Refills:*2*
4. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Verapamil 240 mg Cap,24 hr Sust Release Pellets Sig: One (1)
Cap,24 hr Sust Release Pellets PO once a day.
Disp:*30 Cap,24 hr Sust Release Pellets(s)* Refills:*2*
8. Dextromethorphan-Guaifenesin 28-600 mg Tablet Sustained
Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO
twice a day for 30 days.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
9. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
11. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis: Sublingual hematoma, angioedema
.
Secondary diagnosis: Atrial fibrillation with rapid ventricular
response, hypertension, hearing impairment
Discharge Condition:
Good, stable vital signs
Discharge Instructions:
You were admitted with trouble breathing and with a very high
INR (normal is [**3-1**], and yours was 9.8). Because of your very
high IRN you may have bled in the soft tissues in your throat
which obstructed your airway. You were intubated and given
steroids. It is also possible that one of your medicines,
lisinopril, may have contributed to the swelling in your throat.
We have discontinued this medication. Please do not take it
again. Please throw away your old Coumadin pills since these may
not be the right dose. Finally, you developed a infection which
we treated with antibiotics. You will need to keep taking the
antibiotic after you leave the hospital.
.
Please take your medications as prescribed. We have added the
following medications:
- Ciprofloxacin (antibiotic) for you to take for the next 12
days
- Dextromethorphan-guaifenesin (cough suppressant) for you to
take for the next month
- Pantoprazole (acid suppressant) for you to take for the next
month
- Ipratropium bromide inhaler (asthma medication) for you to
take for the time being
.
Please make an appointment to see your PCP in [**Name Initial (PRE) **] week. Please
check in with your doctor's office about monitoring your INR.
.
Please call your doctor or go to the nearest emergency room if
you have trouble breathing, notice more bruising, unusual
bleeding, chest pain, palpitation, weakness, trouble walking or
speaking, uncontrolled vomiting or diarrhea, or other concerning
symptoms.
Followup Instructions:
Please make an appointment to see your PCP, [**First Name11 (Name Pattern1) 132**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
[**Telephone/Fax (1) 133**], in a week.
.
Provider: [**Name10 (NameIs) 28909**],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB)
Date/Time:[**2195-12-4**] 10:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2195-12-22**] 2:00
Completed by:[**2195-12-26**]
|
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icd9cm
|
[
[
[]
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] |
[
"99.07",
"96.04",
"96.71",
"38.93"
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icd9pcs
|
[
[
[]
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10514, 10572
|
5144, 6789
|
337, 370
|
10776, 10803
|
2125, 2645
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|
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|
9047, 10491
|
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|
1752, 2106
|
277, 299
|
398, 1284
|
10667, 10755
|
10612, 10646
|
1306, 1565
|
1581, 1651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,059
| 168,898
|
48138
|
Discharge summary
|
report
|
Admission Date: [**2123-2-20**] Discharge Date: [**2123-2-23**]
Date of Birth: [**2065-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Celery / Bee Sting Kit
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 56 year old female with chronic restrictive lung
disease, OSA, hypoventilation syndrome, pulmonary hypertension
and left & right sided heart failure who is brought him by
family for headache. The patient is on home O2 and
BIPAP. She is also a chronic CO2 retainer with CO2 usually in
the 70's to 90's. She was at bingo yesterday when she developed
epistaxis and near-syncope. She fell and reportedly hither head
but refused transport to the ED for eval at that time. She
continued to have a headache today on the day of admission and
so presented to the ED [**2123-2-19**]. There she had a runny nose,
cough, and received benadryl and compazine. She fell asleep and
de-sated to 60% on room air. She was placed on Bipap and
transfered to the MICU
Past Medical History:
- morbid obesity s/p hernia repair [**6-2**],
- OSA on nocturnal BIPAP (18/15) and 3-5L home O2,
- obesity hypoventilation syndrome,
- COPD,
- pul HTN (PAP 54)
- SLE
- documented right heart failure
- chronic anemia (bl 32), iron def anemia
- asthma
- restrictive lung dz
- HTN
- OA
- Hay fever
Social History:
The patient lives with her family. She denies any tob/etoh use.
Family History:
mother also uses BiPAP, and had breast ca
Physical Exam:
VITALS: afebrile 61 86% 2.5L NC 19 84/43
GEN: alert/oriented NAD, well appearing, speaking in full
sentences
HEENT: PERRL, EOMI, MMM
NECK: obese, cannot assess JVP
CV: RRR, no MGR
PULM: clear anterorly
ABD: Soft, NT, ND, +BS
EXT: trace to 1+ LE edema up to knees
Brief Hospital Course:
.
# Respiratory distress: Pt presented w/ 02 sat in the 60s but
asymptomatic. Reason for acute desaturation not entirely clear.
However, she has had prior episodes of 02 sats in the 60s as an
outpatient (per OMR notes) as well. The patient has severe,
underlying cardiopulmonary disease, which may have transiently
worsened in the setting of sedating medications. ABG not done on
admission, so not clear how hypercarbic she was (her venous HCO3
on admission was 40, which is her ~baseline). She briefly went
to the ICU for close monitoring but no active intervention. She
has been on sildenafil since [**2120-10-29**] (not a new med for her)
and this was continued. Her O2 sat improved without
intervention to the 90s on 2-3Liters. She continued her home
BIPAP while in the hospital in addition to her home inhalers.
Her primary pulmonoligst was contact[**Name (NI) **] to discuss her baseline
respiratory status; and per his report this appears to be her
baseline. No further interventions/changes made.
.
# Recent fall/pre-syncope: Pt reports feeling lightheaded prior
to fall on day PTA. Suspect she may have been hypoxic or perhaps
hypotensive during episode. Her BPs have been in the 80s-110s
here, while off of her BP meds, which she reports taking as
prescribed. Thus, it is possible that her BP has been signif
below 80s while taking her BP meds. Head CT negative, neuroexam
normal. Pt ruled out for MI. No events on tele noted. (Pt has
been on these BP meds for past 6 months) Her Toprol and
Lisinoprol were not restarted given her low BP and this will be
reassessed as an outpatient.
.
# Pulmonary Hypertension/Cor Pulmonale -Pt was on sildenafil
which was continued while in the hospital. Initially her Lasix
was held but this was restarted on hospital day # 2. A repeat
ECHo showed similar pulmonary HTN as compared to her previous
ECHO from [**2121-12-29**]. No further changes made to her pulmonary
medications.
.
# HTN: Pt was initially more hypotensive with SBP 80-90s. Her
blood pressure meds were held. Despite her diastolic heart
failure, her Toprol and Lisinopril were held on discharge as her
BP continued to remain in the 90-110 systolic.
.
# Diastolic Heart Failure: Pt had repeat ECHO during her
hosptialization which showed a hyperdyanmic EF of 75% but
unchanged from her previous in [**2121-12-29**]. Her beta blocker
and ACE were held give her low BP and thought it may contribute
to her symptoms. They were not restarted on discharge. It was
felt she should follow up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]s her BP and determine if the BB could be restarted at a
later date.
.
#Hyperkalemia-Pt had potassium of 5.2 on day of discharge; no
treatment given as patient is on lasix and usually they become
hypokalemic. Pt had appt with nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) 4171**] day
after discharge. I called to ask them to check her potassium
tomorrow. Given that the patient is on lasix and has a
relatively high potassium (that has trended up over past 6
months) she may warrant further evaluation as an outpatient.
Medications on Admission:
Albuterol 2 puffs inhaled as needed twice daily;
BIPAP as needed for sleep apnea;
Flovent HFA 110 mcg, 2 puffs twice daily;
Lasix 80 mg [**Hospital1 **] (does not take when she is out and about)
home oxygen 2-4L;
Nizoral 2% cream daily;
Nizoral 2% shampoo, 1-2 times per week;
Lisinopril 2.5 mg, 1 tablet once daily;
Toprol XL 50 mg once daily;
Metrocream 0.75% cream, once or twice per day to face;
Revatio (sildenafil) 20 mg tablets, 1 tablet 3 x daily;
aspirin 81 mg once daily; Dulcolax 5 mg tablet once daily;
Cheratussin 100 mg/10 mg per 5 ml syrup, [**12-30**] teaspoons as needed
for cough; and nebulizer as needed for shortness of [**Month/Day (2) 1440**].
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ketoconazole 2 % Cream Sig: One (1) Appl Topical PRN (as
needed).
3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
9. MetroCream 0.75 % Cream Sig: One (1) Topical once a day.
10. Cheratussin AC 10-100 mg/5 mL Syrup Sig: [**12-30**] PO every eight
(8) hours as needed for cough.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
OSA on bipap
COPD on 3L O2 at home
Pulmonary HTN
SLE
Diastolic heart failure
Obesity s/p gastric bypass surgery
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with a headache and found to
have a low oxygen in your blood. This was concerning and you
went to the intensive care unit for close monitoring. It was
felt that your headache may be related to the fact that your
blood pressure was low and because you had low Oxygen.
There were some changes to your medications.
You will no longer take your Toprol (blood pressure medicine)
and we stopped your Lisinopril. Please discuss these
medications with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 19039**].
You will continue to take the lasix 80mg twice daily as you were
previously.
If you have any change in your breathing, shortness of [**Last Name (Titles) 1440**],
headache, confusion, weakness or fatigue, chest pain, or
increased swelling in your feet, please call your doctor or
return to the ER. Also, if you feel very lightheaded, please
call your doctor
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
You need to be seen by the nurse this week to check your blood
pressure and potassium level:
Provider: [**First Name11 (Name Pattern1) 2482**] [**Last Name (NamePattern4) 10466**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2123-2-24**] 2:00
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2123-3-17**] 4:25
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2123-3-30**] 10:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2123-3-31**] 9:40
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6561, 6618
|
1875, 5008
|
319, 325
|
6774, 6783
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,461
| 197,319
|
33727
|
Discharge summary
|
report
|
Admission Date: [**2132-1-4**] Discharge Date: [**2132-1-15**]
Date of Birth: [**2089-1-13**] Sex: F
Service: MEDICINE
Allergies:
Wellbutrin / Red Dye
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Intubation/extubation
CVL placement
History of Present Illness:
This is a 42 year-old female with a history of COPD, asthma,
hypertension, and essential tremor who presents after she was
found unresponsive on evening of [**2132-1-3**]. Patient had a
witnessed fall by her family and hit her head on night of
[**2132-1-2**] and was then walking around and responsive after that
and went to bed without problems. She did not awake on morning
of [**2132-1-3**] and was left alone until she was found to be
unresponsive in the evening of [**2132-1-3**]. Was taken to OSH and
upon arrival intubation was attempted with report of difficult
airway and > 10 attempts before a traumatic intubation was
successful. Upon labwork, she was found to have a tox screen
positive for benozs, barbiturates, opiates, and ethanol. Was
given a dose of IV narcan with no change in level of
consciousness. CK was found to be in the 3000s. Head CT at OSH
was limited study due to motion, but report that there was no
acute intracranial process. Images were not sent. Patient also
reportedly received Avelox x 1 at OSH indicated for a right
apical lung infiltrate on OSH CXR.
In the ED here, vital signs were: T 100 rectal, BP 134/97, HR
108, RR 26, O2sat 100%, intubated with FiO2 of 100%. Nebs were
given. They began bicarb drip. Versed gtt. Multiple peripheral
IVs started. Received flagyl 500 mg IV x 1. Blood cultures were
drawn. A CXR was obtained.
ROS:
Patient is intubated and unresponsive to questions.
Past Medical History:
1. COPD
2. Asthma
3. Grave's disease, s/p thyroidectomy
4. Obesity
5. Hypertension
6. Essential tremor
Social History:
*per [**2131-5-7**] DC summary* as patient intubated.
She smokes 2ppd x 25 years, rarely drinks alcohol and has no
history of illicit drug usage. She worked previously as an
administrative assistant but now is not working as she was
unable to perform her duties due to her medical condition since
[**Month (only) 359**]. She is married.
Family History:
*per [**2131-5-7**] DC summary* as patient intubated.
A sister aged 54 has breast cancer. Her daughter suffers from
obesity and bipolar illness. A son is well. Her father died in
his 60s of a heart attack. The father had obesity and diabetes
type 2. Morbid obesity runs on her father's side of the family.
She also has three half sisters, one of whom has seizures since
she was a teenager. She also has two half brothers
Physical Exam:
On Presentation:
Vitals: T: 97.3, BP: 121/69, HR: 96, RR: 23, O2Sat: 98% on FiO2
50% with PS of 20 and PEEP of 5
GEN: Intubated, sedated
HEENT: NC/AT, PERRL, disconjugate gaze when eyelids forced open,
oral mucosa dry, ET tube in place, NG tube in place in right
nare with dried blood around tube
NECK: Obese, supple, no LAD
CARD: Heart sounds largely obliterated by vent sounds and
wheezing; however, no murmur appreciated
PULM: Coarse breath sound bilaterally with inspiratory squeaks
and expiratory wheezes at bilateral anterior lung fields
ABD: Obese, no visual evidence of trauma, soft, no masses, no
HSM, non-distended, non-tympantic
EXT: Warm and well-perfused
NEURO: Opens eyes briefly in response to sternal rub, otherwise
non-responsive
SKIN: No rashes
Pertinent Results:
[**2132-1-4**] 12:26AM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2132-1-4**] 12:26AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2132-1-4**] 12:26AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2132-1-4**] 12:26AM freeCa-1.01*
[**2132-1-4**] 12:26AM HGB-16.6* calcHCT-50
[**2132-1-4**] 12:26AM GLUCOSE-170* LACTATE-4.0* NA+-148 K+-3.8
CL--106 TCO2-25
[**2132-1-4**] 12:26AM PH-7.26* COMMENTS-GREEN TOP
[**2132-1-4**] 12:26AM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2132-1-4**] 12:26AM URINE HOURS-RANDOM
[**2132-1-4**] 12:26AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2132-1-4**] 12:26AM ALBUMIN-3.7 CALCIUM-8.0* PHOSPHATE-4.4
[**2132-1-4**] 12:26AM CK-MB-18* MB INDX-0.5 cTropnT-<0.01
[**2132-1-4**] 12:26AM LIPASE-20
[**2132-1-4**] 12:26AM ALT(SGPT)-30 AST(SGOT)-88* CK(CPK)-3748* ALK
PHOS-87 TOT BILI-0.4
[**2132-1-4**] 12:26AM estGFR-Using this
[**2132-1-4**] 12:26AM GLUCOSE-175* UREA N-15 CREAT-0.8 SODIUM-143
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-19
[**2132-1-4**] 01:26AM PT-13.1 PTT-19.8* INR(PT)-1.1
[**2132-1-4**] 01:26AM LD(LDH)-403*
[**2132-1-4**] 04:22AM LACTATE-2.6* K+-3.7
[**2132-1-4**] 04:22AM TYPE-ART PEEP-5 O2-50 PO2-89 PCO2-46* PH-7.39
TOTAL CO2-29 BASE XS-1 INTUBATED-INTUBATED
[**2132-1-4**] 04:54PM PT-16.0* PTT-31.1 INR(PT)-1.4*
[**2132-1-4**] 04:54PM PLT COUNT-266
[**2132-1-4**] 04:54PM WBC-17.0* RBC-4.11* HGB-12.9 HCT-37.2 MCV-91
MCH-31.3 MCHC-34.6 RDW-13.5
[**2132-1-4**] 04:54PM ALBUMIN-2.9* CALCIUM-7.5* PHOSPHATE-3.1
MAGNESIUM-1.9
[**2132-1-4**] 04:54PM CK-MB-7 cTropnT-<0.01
[**2132-1-4**] 04:54PM ALT(SGPT)-27 AST(SGOT)-59* CK(CPK)-2233* ALK
PHOS-73 TOT BILI-0.7
[**2132-1-4**] 04:54PM GLUCOSE-91 UREA N-13 CREAT-0.6 SODIUM-145
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-33* ANION GAP-9
[**2132-1-4**] 05:05PM LACTATE-1.0
[**2132-1-4**] 05:05PM TYPE-MIX PO2-54* PCO2-61* PH-7.35 TOTAL
CO2-35* BASE XS-5
Brief Hospital Course:
42 year-old female with a history of COPD, asthma, hypertension,
and essential tremor who presented after being found
unresponsive in setting of fall on [**2132-1-2**], found to be
positive for benzos, barbituates, and Et-OH, per husband, likely
suicide attempt. Patient being treated for aspiration PNA and
has copious secretions. Additionally, patient felt to have
underlying COPD and carries dx of asthma so was treated with
oral steroid taper, now complete. She was successfully extubated
on [**2132-1-8**]. In regards to her suicide attempt, patient was
suicidal while intubated mouthing that she wanted to die. After
extubation, patient was delirious. Psych c/s was obtained
initially for management of delirium and for likely need for
inpatient psych placement given suicidality. Pt admitted to
psychiatry that she was attempting to commit suicide, and that
she had been contemplating it for some time. Pt medically
cleared, had repeat S&S eval [**1-14**] - able to advance diet to
regular with thin liquids (diabetic diet).
<br>
# Altered mental status
Pt does appear to have progressive mental status clearing over
recent days, which is encouraging; thus reducing liklihood of
significant anoxic brain injury, for which pt was at risk
considering found obtunded and required 10 attempts at
intubation.
- Speech and swallow consult following. Pt cleared for oral
intake with modified diet. S+S will continues to follow, as
mental status improves will likely return to unmodified diet.
(increased diet today - can be reassessed in psych unit in
future)
- continues to appear more awake, able to ambulate with walker.
Delirium appears generally cleared.
<br>
# Respiratory failure/Aspiration pneumonia:
Likely a component of hypercarbic respiratory failure due to
oversedation from combination of alcohol, benzodiazapines,
barbiturates, and other unknown meds ingested by patient. Also
complicating could be her history of asthma and COPD in addition
to the finding of right lung opacity in setting of leukocytosis,
consistent with an aspiration event.
Treated initially with Levofloxacin, and Metronidazole.
Ceftriaxone was added for better PNA coverage; regimen narrowed
to ceftriaxone and flagyl. WBC normalized. Blood/urine/sputum
cultures all negative.
Aspiration Pneumonia:
- Completed 8 days of Ceftriaxone.
- then 2 more days of flagyl po to complete a full course for
aspiration (had flagyl prior)
- continue Incentive spirometer for now
<br>
# Asthma/COPD flare
- Lungs generally clear today, with good AE.
- D/c scheduled nebs
- return patient to her home meds
- Advair discus 250/50 [**Hospital1 **]; Spiriva q day, singulair
<br>
# Polysubstance ingestion/Suicide attempt: Patient with OSH tox
screen significant for benzos, barbiturates, and alcohol upon
presentation. At transfer to our ED had only benzos and
barbiturates positive on urine tox screen, with both negative on
serum tox. Social work consult obtained, psych consult obtained
as above - are continuing to follow.
- Psych consulted appreciated
- maintain 1:1 sitter
- Patient now considered medically clear for transfer to
psychiatry.
- Section 12 in chart
- Psych consult pager [**Numeric Identifier 68120**]
- awaiting bed on Deak4 - transfer today
<br>
# Rhabdomyolysis: Upon presentation to our ED, patient's CK was
elevated to 3748 in setting of a normal MBI, and negative
troponin. Trended down.
[**2132-1-6**] CPK down to 179 on [**2132-1-10**]
- resolved
<br>
# Hypertension, benign
- cont atenolol
- BP well controlled
<br>
# Hx of [**Doctor Last Name 933**]; s/p thyroidectomy - hypothyroidism
- contin Levothyroxine
<br>
# Hx of tremors
Has been seen and evaluated by Neurology as an outpt in past; pt
has had ongoing sx for past year. Not thought to be seizures. Dx
"essential tremor". No w/u for now.
<br>
# FEN: cont modified diet per S+S, until S+S reevaluates. D/c'd
IVF with good po intake.
# PT Consult following
# PPx: SQ Heparin
# Code: FULL
# DISPO: to inpatient psychiatry today. Pt medically stable.
Patient under Section 12.
Medications on Admission:
*per outside records*
1. Singulair 10 mg every evening
2. Atenolol 50 mg PO daily
3. Primidone 250 mg PO daily
4. Synthroid 175 mcg PO daily
5. Advair 500/50 mcg PO daily
6. Albuterol 90 mcg/act 1-2 puffs Q4-6H PRN
7. Spiriva 18 mcg daily
8. Azelastine 137 mcg/spray
Discharge Medications:
1. Levothyroxine 175 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor Last Name **]: One (1)
Injection TID (3 times a day).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Primidone 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24
hours).
5. Atenolol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
7. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every
8 hours) for 2 days.
8. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
11. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
12. Ibuprofen 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours) as needed.
13. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
Respiratory Failure with Aspiration Pneumonia with associated
mental status change
<br>
Secondary Diagnosis:
COPD
polysubstance abuse
suicide attempt/depression
rhabodomyolysis
HTN
hypothyroidism
essential tremor
Discharge Condition:
medically stable
Discharge Instructions:
Please take your medications as prescribed above. Please
participate in the psychiatric care as outlined by your
psychiatry team. If your breathing becomes worse please alert
your health provider and once discharged your PCP as below.
Followup Instructions:
1. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & VADERHORST Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2132-5-6**] 2:30
<br>
2. *****Psychiatry service to please call PCP:
[**Name10 (NameIs) 78033**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 45347**] to arrange f/u appointment [**1-4**]
weeks following d/c from in-patient psych unit.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2132-1-15**]
|
[
"518.81",
"333.1",
"244.0",
"E950.3",
"728.88",
"967.0",
"E950.1",
"969.4",
"493.22",
"507.0",
"305.1",
"311",
"401.1",
"E950.0",
"965.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11392, 11407
|
5602, 9646
|
288, 325
|
11684, 11703
|
3501, 5579
|
11988, 12496
|
2278, 2701
|
9964, 11369
|
11428, 11428
|
9672, 9941
|
11727, 11965
|
2716, 3482
|
241, 250
|
353, 1780
|
11557, 11663
|
11447, 11536
|
1802, 1907
|
1923, 2262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,137
| 170,312
|
39172
|
Discharge summary
|
report
|
Admission Date: [**2111-3-13**] Discharge Date: [**2111-3-30**]
Date of Birth: [**2049-3-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
PICC placement
intubation
History of Present Illness:
Patient is a 61 yo M with PMHx sig. for squamous cell carcinoma
of the tongue with mets to lung, ribs, and hips who was
transferred from [**Hospital1 882**] ED for hypoxia. He recently moved to
Roscommon on the Parkway. During his initial intake, he was
found to be PPD+. He was seen at [**Hospital1 86761**] [**Hospital **] clinic and was felt
not to have active TB but perhaps a community acquired pneumonia
on CXR. He just finished a 10 day course of levaquin for
pneumonia. He recently has loose stools, was found to have C.
diff on [**3-10**], and was started on Flagyl. At rehab, he became
acutely SOB with spO2 to 38%, RR20, HR 122, BP 86/60, and
T100.5. Per NH, his baseline A&Ox2. He has poor appetite and
refuses most meals.
.
He was taken to [**Hospital1 882**]. BCxs were drawn and he received Vanc
and Zosyn for presumed pneumonia. Labs were sig. for WBC 5.1,
30% bands, 45% N, 14% L, Cr 1.9, Ca 15.9, CK 47, TropT 0.08, BNP
4936. ABG was 7.53/35/57 on NRB. He was placed on BiPap 13/8
with ABG of 7.49/34/326. He was transferred him for ICU care.
.
In the ED, initial vs were: T98.6, P87, BP 94/65, R 22, and O2
sat 93% on 4L. He was briefly hypotensive to SBP of 70s,
responded to IVF bolus. Labs were sig. for WBC of 4.6, 6%bands,
Cr 2.0, Ca 13.4. CT head showed "lytic bone lesions in left
occiput and right frontal [**Location (un) **] likely represent lytic mets.
Pending reformations, but no obvious intracranial extension. No
acute intracranial process." CXR showed Patient was started on
heparin gtt and he was given azithromycin. He has received a
total of 2L NS.
.
Review of sytems: Difficult to obtain due to dysarthria. Denied
any headache, chest pain. His SOB was improved. He had lower
abdominal pain and diarrhea.
Past Medical History:
-Squamous cell of the tongue, stage IV, metastatic to the
zygomatic arch and skull
-Latent TB
Social History:
Unable to obtain
Family History:
No significant history
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented to self, [**Hospital3 **], [**2111-3-2**], no
acute distress, extremely cachetic, dysarthric
HEENT: Sclera anicteric, MM dry, yellow exudate over upper
palate and base of tongue
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse LLL crackles, no wheezes
CV: Regular rate and rhythm, no murmurs
Abdomen: normoactive bowel sounds, soft, tender in LLQ, no
rebound or guarding
GU: Foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2111-3-13**] 07:21PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2111-3-13**] 07:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2111-3-13**] 07:21PM URINE RBC-1 WBC-8* BACTERIA-NONE YEAST-NONE
EPI-<1
[**2111-3-13**] 07:21PM URINE AMORPH-RARE
[**2111-3-13**] 07:21PM URINE MUCOUS-RARE
[**2111-3-13**] 07:21PM URINE EOS-NEGATIVE
[**2111-3-13**] 07:16PM PTT-81.7*
[**2111-3-13**] 09:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2111-3-13**] 09:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2111-3-13**] 09:00AM URINE RBC-0-2 WBC-[**4-3**] BACTERIA-FEW YEAST-NONE
EPI-<1
[**2111-3-13**] 09:00AM URINE HYALINE-[**4-3**]*
[**2111-3-13**] 09:00AM URINE MUCOUS-FEW
[**2111-3-13**] 08:38AM COMMENTS-GREEN TOP
[**2111-3-13**] 08:38AM GLUCOSE-106* LACTATE-3.1* NA+-146 K+-4.4
[**2111-3-13**] 08:38AM HGB-10.6* calcHCT-32
[**2111-3-13**] 08:30AM GLUCOSE-109* UREA N-95* CREAT-2.0* SODIUM-145
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-26 ANION GAP-17
[**2111-3-13**] 08:30AM estGFR-Using this
[**2111-3-13**] 08:30AM ALT(SGPT)-14 AST(SGOT)-34 CK(CPK)-124 ALK
PHOS-139* TOT BILI-0.3
[**2111-3-13**] 08:30AM LIPASE-15
[**2111-3-13**] 08:30AM cTropnT-0.10*
[**2111-3-13**] 08:30AM CK-MB-6
[**2111-3-13**] 08:30AM ALBUMIN-3.3* CALCIUM-13.4* PHOSPHATE-3.8
MAGNESIUM-2.2 IRON-22*
[**2111-3-13**] 08:30AM calTIBC-192* VIT B12-795 FOLATE-GREATER TH
FERRITIN-GREATER TH TRF-148*
[**2111-3-13**] 08:30AM WBC-4.6 RBC-3.64* HGB-10.9* HCT-34.8* MCV-96
MCH-30.0 MCHC-31.4 RDW-16.2*
[**2111-3-13**] 08:30AM WBC-4.6 RBC-3.64* HGB-10.9* HCT-34.8* MCV-96
MCH-30.0 MCHC-31.4 RDW-16.2*
[**2111-3-13**] 08:30AM NEUTS-49* BANDS-6* LYMPHS-29 MONOS-14* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2111-3-13**] 08:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2111-3-13**] 08:30AM PLT SMR-NORMAL PLT COUNT-203
[**2111-3-13**] 08:30AM PT-14.3* PTT-32.9 INR(PT)-1.2*
.
Blood cx: NGTD
Urine cx: NGTD
Flu: Negative
Legionella: Negative
.
CT Head:
IMPRESSION:
1. Right frontal and left basilar occiput lytic metastatic
lesions without
intra-articular extension.
2. Bilateral thalamic hypoattenuation may represent lacunar
infarcts;
however, metastases are not excluded. If the clinical concern
exists, then an
MR is recommended for further evaluation.
.
CXR:
IMPRESSION:
Right extrapulmonary mass, likely pleural-based. A chest CT may
be acquired
for further evaluation.
.
LENIs: No DVT
[**2111-3-27**] 03:57AM BLOOD WBC-13.9* RBC-3.16*# Hgb-9.6*# Hct-28.9*
MCV-92 MCH-30.6 MCHC-33.4 RDW-18.7* Plt Ct-207
[**2111-3-22**] 03:50AM BLOOD Neuts-88.9* Lymphs-6.8* Monos-3.2 Eos-0.8
Baso-0.2
[**2111-3-27**] 03:57AM BLOOD PT-13.4 PTT-36.6* INR(PT)-1.1
[**2111-3-27**] 03:57AM BLOOD Glucose-107* UreaN-19 Creat-0.7 Na-139
K-4.2 Cl-109* HCO3-23 AnGap-11
[**2111-3-23**] 05:00AM BLOOD ALT-8 AST-19 LD(LDH)-201 AlkPhos-120
TotBili-0.1
[**2111-3-27**] 03:57AM BLOOD Calcium-9.4 Phos-2.1* Mg-1.9
[**2111-3-23**] 05:00AM BLOOD PTH-17
[**2111-3-22**] 03:50AM BLOOD Cortsol-18.9
[**2111-3-23**] 05:00AM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND
[**2111-3-23**] 05:00AM BLOOD VITAMIN D 25 HYDROXY-PND
[**2111-3-25**] STOOL CLOSTRIDIUM DIFFICILE NEGATIVE
[**2111-3-24**] STOOL CLOSTRIDIUM DIFFICILE NEGATIVE
[**2111-3-24**] SPUTUM ACID FAST SMEAR-NEGATIVE
[**2111-3-23**] BLOOD CULTURE - PENDING
[**2111-3-23**] BLOOD CULTURE -PENDING
[**2111-3-23**] BLOOD CULTURE -PENDING
[**2111-3-23**] URINE CULTURE-NO GROWTH
[**2111-3-23**] SPUTUM ACID FAST SMEAR-NEGATIVE
[**2111-3-22**] SPUTUM ACID FAST SMEAR-NEGATIVE
[**2111-3-21**] BLOOD CULTURE -FINAL NEGATIVE
[**2111-3-21**] BLOOD CULTURE -FINAL NEGATIVE
[**2111-3-21**] URINE -FINAL NEGATIVE
[**2111-3-14**] URINE Legionella NEGATIVE
CT NECK
1. Patent airway with endotracheal tube in place. Minimal soft
tissue
thickening at the level of cricoid and thyroid cartilage likely
represents
vocal cords, although further evaluation in this region is
limited due to
presence of the tube. A small area of ill-defined density
anterior to the
endotracheal tube just below the level of vocal cord (301B, 70)
may represent synechia or scar tissue or secretion.
2. Left cervical soft tissue thickening with adjacent fat
stranding may
represent post-surgical and radiation therapy change in this
region. Partial
strap muscle resection and submental surgical clips evident on
the left.
3. Partial visualization of a large right chest wall mass
extending into
right lung with multifocal osseous metastasis.
4. Multilevel degenerative disease in the cervical spine,
concurrent
metastasis cannot be excluded.
5. Subcentimeter left thyroid nodule may be further evaluated by
ultrasound
on non-emergent basis as clinically indicated.
6. Partially visualized endotracheal tube, nasogastric tube, and
left
approach central venous catheter appear to be in expected
locations.
Brief Hospital Course:
Hospital course by problem:
Respiratory Failure secondary to difficulty protecting airway
from oropharyngeal squamous cell carcinoma: Intially treated for
pneumonia and ruled out for PE. Echo was also performed as well
which showed normal systolic function suggesting a
non-cardiogenic cause. His respiratory status declined further
after placement of a NG tube for oral vancomycin following a
failed swallowing evaluation. He was noted to have very thick
and purulent secretions from his upper airway and his
respiratory failure was felt to be secondary to mucous plugging.
He was intubated for airway protection. The possibility of
tracheostomy and PEG was considered and the patient was seen by
the ENT surgeon, but he elected to decline this intervention and
to transistion to comfort-oriented care.
C. difficile colitis: Diagnosed at nursing home. He was
continued on IV flagyl. PO vanco was added for increasing
leukocytosis. The infectious disease team recommended a 2 week
course of IV flagyl and PO vancomycin. He was transitioned to
only IV flagyl to be completed on [**2111-4-7**] prior to discharge from
the hospital because his NG tube was a source of discomfort. The
flagyl may be discontinued if he loses IV access at any point.
Esophageal candidiasis: Noted during intubation in the ICU. [**Month (only) 116**]
have also contributed to profound leukocytosis. Per ID team
recommendations, treated with fluconazole, initially PO and then
IV for a 2 week course from [**2111-3-23**]. His oral discomfort
improved significantly while on this medication. Once his NG
tube was removed, he was transitioned to po clotrimazole troches
on [**2111-3-30**] to complete an additonal 1 week course.
Anemia: Gradual drop in Hematocrit. Has some blood loss from
tumor, esophageal candidiasis. Transfused 2 units.
Acute renal failure: Pre-renal azotemia initially that resolved
with IVF.
Metastatic Squamous Cell CA: Per [**Hospital1 2177**] oncologist no further care
that patient could tolerate or would be a candidate for. Pain
management was initiated with lidocaine patches to hips,
fentanyl patch, and po morphine concentrate. Please uptitrate
fentanyl patch (increased to 25mcg/hr on [**2111-3-29**]) and po
morphine concentrate to acheive adequate pain control.
Hypercalcemia: S/p pamidronate x1 [**3-20**]. Secondary to malignancy
vs bony mets.
Latent TB: History of positive PPD at [**Hospital1 2177**]. Ruled out for TB
with sputum negative for AFB x 3.
Hypernatremia: Improved with free water repletion.
FEN: Dubhoff placed during inbutation to allow for gastric
access and patient was transitioned from TPN to tube feeds.
Tube feeds were eventually stopped due to exacerbation of
diarrhea. He may take food by mouth for comfort as desired.
The patient elected to keep the dubhoff tube in place to
continue receiving PO vancomycin and other medications until the
day of discharge from the hospital when it was removed for
ongoing discomfort.
Goals of Care: After multiple discussion with palliative care
and the ENT surgeon regarding option of tracheostomy the patient
elected to change his code status from full to DNR/DNI, with
focus on comfort. He is being discharged to an inpatient
hospice.
Medications on Admission:
Morphine
Flagyl
Stool softeners
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q3 DAYS PRN () as needed for Secretions.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
QID (4 times a day) as needed for dryness.
8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) bag Intravenous Q8H (every 8 hours) for 8 days: Last day
[**2111-4-7**]. [**Month (only) 116**] discontinue if loses IV access.
9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for onc pain:
Titrate dose up prn.
10. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H
(every hour) as needed for pain, shortness of breath: may up
titrate as necessary for pain control.
11. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day) for 7 days: may discontinue if
unable to tolerate.
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
Primary: respiratory failure, clostridium difficile colitis,
metastatic squamous cell carcinoma, positive PPD
Discharge Condition:
Patient is alert and oriented, bed bound at baseline,
hemodynamically stable with waxing and [**Doctor Last Name 688**] oxygen
requirements.
Discharge Instructions:
You were treated for your difficulty breathing due to your
metastatic squamous cell carcinoma of the tongue and clostridium
difficile colitis. You were ruled out for active tuberculosis
and did require a breathing tube as we sorted out whether any
further treatment for your cancer was possible. After discussing
with you that no further treatment was available for your
cancer, the breathing tube was removed and your care was
transitioned to hospice care with a goal of treating any
breathing difficulty with oxygen, good oral care, and pain
medications.
Followup Instructions:
Please follow up with your primary oncologist at [**Hospital1 2177**], Dr. [**Last Name (STitle) 63774**],
as needed.
|
[
"799.02",
"799.4",
"141.8",
"V64.2",
"707.22",
"112.84",
"796.3",
"707.03",
"486",
"518.81",
"584.9",
"198.5",
"263.0",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.04",
"96.6",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12781, 12817
|
7936, 7936
|
323, 350
|
12971, 13114
|
2857, 2857
|
13719, 13840
|
2291, 2315
|
11245, 12758
|
12838, 12950
|
11189, 11222
|
13138, 13696
|
2330, 2838
|
276, 285
|
1985, 2123
|
7965, 11163
|
378, 1967
|
5060, 7913
|
2873, 5051
|
2145, 2241
|
2257, 2275
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,876
| 194,080
|
12074+56326
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-8-23**] Discharge Date: [**2119-8-26**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 58 year-old
male who presented on [**8-23**] with dyspnea despite nebulizers
and O2. Audible [**Last Name (un) 15883**] was heard and his O2 requirement had
increased over the past two months according to history. ENT
evaluated the patient and it was determined that a
tracheostomy would be needed. Importantly the patient has a
history of thyroid cancer with a recurrent thyroid mass
causing restriction of his airway.
HOSPITAL COURSE: Tracheostomy was placed without
complications on [**8-23**]. He did well postoperatively and was
put on Ancef. He has remained afebrile. Vital signs stable,
sating well postop day one and postop day two. The patient
on postop day two starting pureed food with a cough up
without any problems. [**Name (NI) 227**] this the patient was discharged
on [**8-26**] postop day three given the toleration of his food.
The patient is to follow up with Dr. [**Last Name (STitle) **] in one week.
PHYSICAL EXAMINATION: Patient with a tracheostomy. No
discharge, erythema or blood around the trach. Lungs clear
to auscultation bilaterally. Oropharynx no swelling, no
edema.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**MD Number(1) 11390**]
Dictated By:[**Last Name (NamePattern1) 11391**]
MEDQUIST36
D: [**2119-8-25**] 19:26
T: [**2119-9-1**] 10:00
JOB#: [**Job Number 37870**]
Name: [**Known lastname 6847**], [**Known firstname **] Unit No: [**Numeric Identifier 6848**]
Admission Date: [**2119-8-22**] Discharge Date: [**2119-8-28**]
Date of Birth: [**2061-5-27**] Sex: M
Service:
The patient will actually be discharged on [**2119-8-28**], due to
unavailability of getting home tracheostomy care. The
patient is set up for VNA to come to his home no Monday with
oxygen, humidified air, replacement trachs, trach care kit
and suction for him to maintain his tracheostomy at home. He
has had no complications over the past three days in waiting
for this to happen.
DR.[**Last Name (STitle) 1846**],[**First Name3 (LF) 77**] 04-143
Dictated By:[**Last Name (NamePattern1) 6849**]
MEDQUIST36
D: [**2119-8-27**] 15:13
T: [**2119-9-3**] 13:53
JOB#: [**Job Number 6850**]
|
[
"197.3",
"197.0",
"193"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.44",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
607, 1099
|
1122, 2427
|
148, 589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,019
| 190,626
|
51419
|
Discharge summary
|
report
|
Admission Date: [**2126-10-24**] Discharge Date: [**2126-10-27**]
Date of Birth: [**2061-3-30**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left Facial Droop and Left Hemiparesis
Major Surgical or Invasive Procedure:
* Cardiac Catheterization with stent placement
* Administration of IV t-PA
History of Present Illness:
PER ADMITTING FELLOW:
Patient is 65M with multiple vascular risk factors, including
CAD
with multiple prior stents. He had been experiencing chest
tightness with exertion and SOB x 2 weeks. Today, he had a
cardiac catheterization with stent placement in the LAD; the
sheath was removed at 9:30pm.
At 1:30am, the patient was observed by his RN to actively
develop
L facial droop. The patient's primary team was contact[**Name (NI) **] and
found L hemiparesis on exam. Code Stroke was activated at
2:31am.
Initial NIHSS = 7 at 2:45am.
LOC ?????? 0
Questions ?????? 0
Commands ?????? 0
Gaze ?????? 0
Visual ?????? 0
Face ?????? 2 (L facial weakness)
Motor ?????? 2 (L arm drift and L leg drift)
Ataxia ?????? 0
Sensory ?????? 2 (Cannot feel pinpirick on L)
Language ?????? 0
Dysarthria ?????? 0
Extinction ?????? 1 (L extinction to DSS)
Repeat NIHSS performed by the stroke fellow at 4am was identical
to the above except for L facial weakness ranked as ??????1.?????? Head
imaging and labs are as noted below.
Risks and benefits of IVTPA were discussed with the patient. He
has no absolute contraindications to IV TPA, but risks are above
average given recent cardiac catheterization, slightly elevated
PTT, and hyperglycemia.
The patient agreed to proceed with IVTPA. He was transferred to
the Neuro ICU and a bolus of 10mg was administered. The
remaining 80mg was infused over the subsequent 60 minutes, for a
total of 90mg.
ROS:
-Patient denies the following: prior stroke, prior intracranial
hemorrhage or aneurysm, intraocular bleed, surgery (other than
this cath) within 2 weeks, GI bleed.
-Patient initially mentioned that he developed a headache around
the same time that he developed chest pain at 1:30am today. On
further questioning, he mentioned that he has had a headache the
entire day, which he attributes to lack of sleep.
Past Medical History:
-COPD
-Asbestosis
-CAD with multiple stents
-DM
-HTN
-Hyperlipidemia
-OSA
.
Past SxH
-s/p epigastric Hernia repair
Social History:
- Retired truck driver.
- Enjoys salt and fresh water fishing
- Married 44 years with 3 children, 7 grandchildren
.
HABITS
-40 year pack history of smoking, quit 2 years ago.
-Does not drink alcohol or use recreational drugs.
Family History:
-Mother died of CAD
-Father died of lung cancer.
-He has a 30yo daughter with CAD.
Physical Exam:
On ADMISSION TO NEUROLOGY:
98.4 degrees, 114/64, 66, 22, 98% RA
Fundoscopic exam normal
There is a mild left ccaotid bruit.
Heart is regular without murmurs.
Lungs are clear
Abdomen is obese and nontender.
Extremities are warm and well-perfused with palpable pulses.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Not attentive.
Speech is fluent with normal comprehension
and repetition; naming intact. No dysarthria. [**Location (un) **] intact.
Registers [**3-5**], recalls 0/3 in 5 minutes. No right left
confusion. No evidence of apraxia.
Cranial Nerves: Slight anisocoria, left pupil minimally larger
than the right,
sluggishly reactive. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation
intact V1-V3. Left facial droop. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor: Normal bulk bilaterally (note wasting of the intrinsic
muscles
around his left thumb). Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L +4 +4 5 5 5 +4 +4 +4 -5 5 5 5 5 5
Sensation: Reduced on the left arm and leg to light touch,
pinprick. Vibration reduced up to the knee on the right, and
absent on the left. Proprioception is preserved. He has
extinction to DSS on the left.
Reflexes: He is hyporeflexic on the right side, with absent
Achilles jerks
bilaterally. On the left his reflexes are 2s (apart from the
Achilles) Toes downgoing bilaterally
Coordination: finger-nose-finger, heel to shin, RAMs all slower
on the left.
Gait: Could not assess
Pertinent Results:
WBC-8.3 RBC-4.45* HGB-12.8* HCT-38.3* MCV-86 PLT-264
.
IMAGING:
.
CTA, P Head and Neck ([**2126-10-25**]):
IMPRESSION:
1. Findings likely representing changes of chronic microvascular
infarction
in white matter, without CT evidence for acute territorial
infarction; the
CT-perfusion study is unremarkable.
2. Moderate stenoses of the proximal left subclavian and
vertebral arteries,
with otherwise mild-to-moderate atherosclerotic disease
throughout the neck,
and no flow-limiting intracranial lesions.
3. Extensive multilevel degenerative changes of the cervical
spine.
4. Moderate transverse narrowing of the mid-cervical trachea at
the level of
the thyroid gland, of unclear etiology, which should be
correlated with
patient's clinical history.
.
MRI Brain ([**2126-10-26**]):
IMPRESSION: Limited study with only sagittal T1 images obtained.
No mass
effect or herniation seen.
.
CT Head Without Contrast ([**2126-10-26**]):
IMPRESSION: No definite evidence for acute territorial
infarction.
.
Transthoracic Echocardiogram ([**2126-10-25**]):
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 60%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are focal calcifications in the
aortic arch. 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. There is no pericardial effusion.
.
Cardiac Catheterization ([**2126-10-24**]):
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PTCA of the ostial and mid D1.
3. Successful direct stenting of the mid LAD.
Brief Hospital Course:
Mr. [**Known lastname 10083**] is a 65 year-old right handed man with a past
medical history including hypertension, hyperlipidemia, DM, and
CAD s/p stenting who was transferred from Good Samaritin to the
[**Hospital1 18**] for a planned endovascular procedure. He developed a new
left facial droop and left-hemiparesis within hours of the
procedure [**2126-10-24**], and was transferred to the Neurology Stroke
Service on [**2126-10-25**]. He remained on the stroke service until
his discharge on [**2126-10-27**].
.
In the setting of the recent stent placement, the potential
etiologies for the new neurological symptoms were thought to
include cerebral embolism and intracranial hemorrhage, possibly
related to intra-procedure heparin use. However, a stat
non-contrast CT of the head showed no evidence of bleeding,
remote infarction, or early signs of ischemia. While the large
vessels appeared patent on a CT angiogram, the study was notable
for signs of decreased filling of the cortical branches of the
right middle cerebral artery (MCA). Similarly, the Mean
Transit Time was prolonged in the right MCA relative to the
left. Collectively, the findings supported the presence of
ongoing ischemia in the right MCA territory with potential
embolization into distal branches of the MCA.
.
Given the neuro-imaging data and the patient's NIHSS of seven,
IV t-PA was considered a therapeutic option. After carefully
discussing the potential risks and benefits, the patient elected
to pursue the thrombolytic therapy. His symptoms improved
following the infusion. For 24 hours following the
administration of t-[**MD Number(3) 106623**] closely monitored in the intensive
care unit.
.
A head CT repeated within 24 hours of the administration of IV
t-PA showed no evidence of hemorrhage. A transthoracic
echocardiogram revealed no atrial septal defect or patent
foramen ovale.
.
To address modifiable risk factors for future strokes, the
statin was continued with a goal LDL of less than 70. An
insulin sliding was instituted to maintain normoglycemia.
.
Following a PT evaluation, the patient was discharged home.
Medications on Admission:
-Zocor 80 mg daily
-Plavix 75 mg daily
-Aspirin 81 mg daily
-Lasix 40 mg twice daily
-Insulin lantus 45 units bedtime
-Humalog sliding scale with meals
-Imdur 60 mg daily
-Requip 2 mg at bedtime
-Zetia 10 mg daily
-Darvocet N 50 1-2 tabs every 6 hrs. as needed for pain
-Combivent 1 puff daily
-Metformin 500 mg daily
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*100 Tablet, Sublingual(s)* Refills:*1*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: One (1) 45 units
Subcutaneous at bedtime.
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-4**]
Puffs Inhalation Q6H (every 6 hours).
11. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every [**4-8**]
hours as needed for headache for 7 days.
Disp:*84 Tablet(s)* Refills:*0*
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Cerebral embolism, CAD
Secondary: Obstructive sleep apnea, HTN, Diabetes
Discharge Condition:
Free of chest pain. Baseline shortness of breath. Baseline
neurological deficits.
VS: 97.4F BP 148/80; HR 80-90; RR 20 and 95% O2 sat on 2liters
nasal canula
Neurological examiantion at discharge:
Alert and attentive. No aphasia. Slight L NLF flattening, Left
upper extremity 4+/5 weakness of deltoid, triceps, wrist
extensors and hand grip. Atrophy of 1st dorsal interosseous.
Sensation intact to light touch. Finger nose finger intact.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of your heart vessels.
You underwent a cardiac catheterization for the diseased
vessels in your heart. After the procedure, your course was
complicated by a stroke, for which you underwent thrombolysis
(tPA). Your symptoms of left facial droop and left sided
weakness.
After the procedure you have had a persistent headache, which
was felt to be worsening of your usual headache. Your CAT scans
did not show a concerning abnormality.
You were discharged home in stable condition.
Please follow the post cardiac catheterization and stent wound
care and activity guidelines. Please take aspirin daily,
lifelong. Take Plavix daily, uninterrupted for 12 months
minimum.
Please continue to take your medications as prescribed.
Please report chest pain, shortness of breath, groin concerns,
fever, chills to Dr. [**Last Name (STitle) 7047**] or call our page operator at
[**Telephone/Fax (1) 8717**] and speak to the cardiology fellow on call. Should
you develop any new weakness, imbalance, changes in vision or
any other symptom concerning to you, please call your doctor or
go to the emergency room.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 17996**] [**2126-10-28**] at 10:30AM
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] D.
within 1 week of your discharge. Please call [**Telephone/Fax (1) 8725**] to
make an appointment.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] within 6-8 weeks of
discharge from the hospital. Please call ([**Telephone/Fax (1) 15319**] to make
an appointment.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"E879.0",
"781.94",
"427.31",
"501",
"428.0",
"327.23",
"401.9",
"414.01",
"496",
"997.02",
"342.90",
"V46.2",
"272.4",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"88.56",
"00.40",
"37.22",
"36.07",
"00.45",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
10544, 10550
|
6746, 8874
|
357, 433
|
10676, 10862
|
4687, 6574
|
12333, 12934
|
2714, 2799
|
9243, 10521
|
10571, 10655
|
8900, 9220
|
6591, 6723
|
11146, 12310
|
2814, 3083
|
10876, 11122
|
279, 319
|
461, 2315
|
3463, 4668
|
3122, 3446
|
3107, 3107
|
2337, 2454
|
2470, 2698
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,276
| 143,189
|
49035
|
Discharge summary
|
report
|
Admission Date: [**2184-11-8**] Discharge Date: [**2184-11-15**]
Date of Birth: [**2108-6-5**] Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Codeine
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 year-old right-handed woman with a history of high
cholesterol, Sjogren's syndrome, remote ovarian cancer presents
with near syncope, fall, and left-sided weakness.
Pt reports she was at appointment in Behavioral [**Hospital 878**] Clinic
in [**Hospital Ward Name 860**] building today. After the appointment, she went to
[**Hospital Ward Name 516**] cafeteria for "a snack." The food "went right
through me" and she went to the bathroom with some diarrhea. She
then stood up from toilet and reports feeling light-headed. Her
knees buckled and she fell into the wall, hitting her upper
back, neck and head. Currently she reports posterior midline
neck pain but no headache. She reports she is "having trouble"
with her left arm and leg. At baseline, she walks independently
without cane or walker.
Per EMS, a physician was also in the women's bathroom and heard
pt fall. She activated EMS and call went out at 5:43pm. EMS
estimates pt was down less than 5 minutes when they arrived at
5:44pm. Pt is unable to report the exact time of the fall. EMS
placed pt in C-collar and on backboard and transported her to
[**Hospital1 18**] ED where she arrived ~6:30.
ED personnel evaluated pt and noted left arm increased tone,
weakness, and left leg paralysis. They then called for neurology
consult. After doing history and physical, code stroke was
activated, as localization most consistent with right brain and
acute onset most worrisome for stroke (see Impression below).
Initial NIH stroke scale was 8. Head CT without bleed. Pt was
given IV TPA at 2hrs 55min. There were no immediate
complications and no changes in her symptoms.
Past Medical History:
1. High cholesterol. Has had side effects from multiple statins,
currently on zocor
2. Sjogren's syndrome
3. Ovarian cancer, [**2165**]
4. Anxiety
5. Chronic low back pain
Social History:
Lives with husband. [**Name (NI) 6934**] unassisted at baseline. Quit
tobacco [**2165**], previously 1ppd. Has 1 glass wine nearly nightly.
No other drugs.
Family History:
Heart disease
Physical Exam:
T BP HR RR Pox
General: Frail elderly woman, in no acute distress
HEENT: NC/AT, sclera anicteric. OP clear
Neck: Supple.
Lungs: Clear to auscultation anterolaterally
CV: RRR, nl S1, S2, no murmur.
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema, good dorsalis pedis pulses
Neurologic Examination:
Mental Status: Alert and oriented to person, place and "[**Month (only) **]
[**2183**]", cooperative with exam, normal affect, months of year
backward though a little slow, Speech fluent, no dysarthria
however speech extremely slow, no paraphasic errors, naming,
repetition and [**Location (un) 1131**] intact. Follows 2-step commands. No
apraxia, No neglect.
Cranial Nerves: Visual fields are full to finger motion. OD [**3-20**]
OS [**2-18**], brisk. Extraocular movements intact, no nystagmus.
Facial sensation normal bilaterally. Mild left facial droop.
Hearing intact to finger rub bilaterally. Normal oropharyngeal
movement. Tongue midline, no fasciculations. Trapezius normal on
right, decreased on left (~[**2-21**]).
Motor: Left sided flaccid paralysis involving entire body. Right
IP also [**3-23**].
Sensation was intact to light touch and temperature (cold),
though decreased to vibration and proprioception at toes
bilaterally. No extinction to double simultaneous stimulation.
Reflexes: DTRs brisk (3) and symmetric throughout. Toes were up
bilaterally
Coordination is normal on finger-nose-finger on right.
Pertinent Results:
[**2184-11-12**] 03:00PM BLOOD WBC-10.1 RBC-3.48* Hgb-11.6* Hct-33.9*
MCV-97 MCH-33.3* MCHC-34.3 RDW-12.6 Plt Ct-348
[**2184-11-11**] 05:35AM BLOOD WBC-11.5* RBC-3.28* Hgb-11.6* Hct-33.0*
MCV-101* MCH-35.2* MCHC-35.1* RDW-12.2 Plt Ct-332
[**2184-11-12**] 03:00PM BLOOD Plt Ct-348
[**2184-11-11**] 05:35AM BLOOD PT-12.8 PTT-24.8 INR(PT)-1.1
[**2184-11-11**] 05:35AM BLOOD Fibrino-541* D-Dimer-1147*
[**2184-11-11**] 05:35AM BLOOD Glucose-139* UreaN-14 Creat-0.8 Na-135
K-3.9 Cl-99 HCO3-23 AnGap-17
[**2184-11-10**] 04:19AM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-139
K-3.2* Cl-110* HCO3-22 AnGap-10
[**2184-11-11**] 05:35AM BLOOD LD(LDH)-173
[**2184-11-9**] 03:02AM BLOOD CK(CPK)-47
[**2184-11-9**] 03:02AM BLOOD CK-MB-2 cTropnT-<0.01
[**2184-11-8**] 06:55PM BLOOD cTropnT-<0.01
[**2184-11-11**] 05:35AM BLOOD Calcium-9.1 Phos-3.8
[**2184-11-8**] 09:35PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2184-11-9**] 03:02AM BLOOD Triglyc-51 HDL-82 CHOL/HD-2.2 LDLcalc-90
[**2184-11-15**] 06:00AM BLOOD WBC-7.5 RBC-3.10* Hgb-10.8* Hct-31.1*
MCV-101* MCH-35.0* MCHC-34.8 RDW-12.1 Plt Ct-358
[**2184-11-15**] 06:00AM BLOOD Plt Ct-358
[**2184-11-13**] 11:08AM BLOOD PT-12.9 PTT-25.5 INR(PT)-1.1
[**2184-11-11**] 05:35AM BLOOD Fibrino-541* D-Dimer-1147*
[**2184-11-15**] 06:00AM BLOOD Glucose-116* UreaN-23* Creat-0.7 Na-144
K-3.5 Cl-108 HCO3-25 AnGap-15
[**2184-11-13**] 11:08AM BLOOD ALT-18 AST-24 Amylase-39
UCx: E. Coli
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Throat Strep negative
MRI Brain [**11-9**]: 1) Acute moderate sized right anterior cerebral
artery infarction, as previously described. 2) Small left
temporal lobe intraparenchymal hemorrhage.
Carotid U/S: Normal, no stenosis
Head CT: Stable appearance of the area of infarction in the
right medial
frontal lobe with evidence of hyperdensity within it, may
represent
hemorrhage vs revascularised cortex. Please correlate
clinically.
CT Chest/Abd/Pelvis: 1. No evidence of metastasis. 2. Bibasilar
atelectasis.
CXR [**11-13**]: The heart size is normal. The mediastinal and hilar
contours are normal. Bibasilar atelectasis is noted with very
tiny bilateral pleural effusions.
TEE:1. No spontaneous echo contrast or thrombus is seen in the
body of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
4. The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
6. No intracardiac source of embolism identified.
Brief Hospital Course:
NEURO When the patient arrived at [**Hospital1 18**], a stroke code was
called. Her NIH Stroke Scale was found to be 7 (L facial
weakness, arm, and leg weakness). A stat head CT was performed
to r/o an intracranial hemorrhage. None was seen. Because of the
severity of the symptoms, IV t-PA was administered at 2hr 50
minutes post-symptom onset. The patient was transferred to the
ICU for monitoring. Unfortunately, the pt.s left sided weakness
progressed to essentially plegia of the left leg. A repeat CT
was performed ruled out a new bleed. An MRI revealed a stroke of
the R ACA territory and a small hyperintensity in the LEFT
posterior superior parietal lobe, possibily representing a small
second lesion. On [**11-13**], pt. had relatively depressed mental
status and spiked a temperature. A sepsis work-up was initiated
and her Abx were changed from Bactrim to Levaquin. She had
repeat head imaging which showed minor amount of hemorrhagic
conversion of her infarct. She underwent repeat MRI which showed
the infarct o be stable without new lesions. By the day of
discharge, she had been afebrile for >24hrs and her mental
status was much improved with less hypophonic speech, fluent
speech. Her left sided hemiplegia is stable.
Her HbA1c was normal at 5.9. Her LDL is 90, and the TG 51.
Because of the patient's history of Sjogren's syndrome and
distant h/o ovarian cancer, a CT chest/abdomen/pelvis was
performed to evaluate fo malignancy. None was seen. D-dimer and
fibrinogen were high. This was thought to be likely be scondary
to acute phase reactants however a hypercoagulable state is also
a possibility, including cryptic metastases not observed on CT
of chest/abdomen/pelvis. This is supported by very high D-dimer
and elevated fribrinogen.
A left sided ankle brace was placed to prevent contractures
Pt underwent transesophageal Echo - no PFO was identified, nor
were there vegetations, or valve abnormalities. The EF was >55%.
Carotid U/S revelaed no significant stenosis bilaterally.
ID/UTI: The patient was diagnosed with an E coli UTI. She was
started on Bactrim and has since been afebrile.
FEN/GI:The patient was maintained on PPI for GI prophylaxis.
Anemia: Pt. with slight drop in Hct over hospitalization. She is
asymtpomatic and this may represent anemia of chronic disease
however this should be followed.
She was placed on SC heparin for DVT prophylaxis.
Speech/Swallow evluate the pt and recommended: 1.Regular, moist
consistency diet, with thin liquids. PO meds whole with liquids.
2.Basic aspiration precautions, including: NO STRAWS.
Discharge Diagnoses:
1. R ACA infarction with residual L hemiplegia
2. Pseudobulbar Affect
3. UTI (E.coli) with good response to Levaquin (to complete 4
more days, 7 total)
Medications on Admission:
ASA 81, zocor 5, zoloft 25, valium 10hs, prilosec 20 [**Hospital1 **],
folate
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-21**]
Drops Ophthalmic PRN (as needed).
Disp:*1 dropperrette* Refills:*2*
6. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO twice a day.
Disp:*60 Cap(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Disp:*90 mL* Refills:*2*
11. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right ACA infarct with residual L hemiplegia
UTI (E. coli)
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications (take Levaquin for 4 more days)
If you develop new weakness, numbness, trouble swallowing or
speaking, chest pain, or trouble breathing, inform a physician
[**Name9 (PRE) 102913**]
Have anemia followed up at Rehab facility
Keep follow-up appointments with Neurology Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**]
Followup Instructions:
Neurology - Please make follow-up appontment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 1703**]
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Date/Time:[**2185-3-28**] 11:00
|
[
"V17.3",
"424.0",
"300.00",
"599.0",
"342.90",
"272.0",
"710.2",
"041.4",
"440.0",
"285.9",
"434.11",
"V10.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11505, 11577
|
7292, 9873
|
309, 316
|
11680, 11689
|
3862, 6058
|
12123, 12391
|
2365, 2380
|
9894, 10048
|
10176, 11482
|
11598, 11659
|
10074, 10153
|
11713, 12100
|
2395, 2689
|
250, 271
|
344, 1980
|
3090, 3843
|
6067, 7269
|
2728, 3074
|
2713, 2713
|
2002, 2176
|
2192, 2349
|
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